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.)A\. MAcr;-::.:;oi;, M.I
A MANUAL
OF
PATHOLOGICAL HISTOLOGY.
BT
Y. gOKKIL,
«BSISTANT FROPEISOS IN THB FiCCI-Tr OF tUCDICtlTB OF PÀBI8,
AHD
L. UANYIER,
FROFEBBOB IN THB COLLSOE OF FBAMCI.
TRANSLATED, WITH NOTES AND ADDITIONS,
BT
E. O. SHAKESPEARE, A.M., M.D.,
IilRTrKIl OK ■irBiCTIOII ÀHD OFIIATITB ornTBlLHIO IIIBaiKr In TSIDIIiriKIlTt DF
riVITSTLTAiril, AVJt OPHTHALHrCRDftOIOIl AtlD ■ICKOBCOFIIt TO THl
rniLADiLPfli* HoariTÀi',
AXS
J. HENRY C. SIMES, M.D.,
DiHOMTUTon or pATBar.oatoii. hktouioi aud lkctdk» o> riitoloot
IB Ta» rsivIBSITI OF Fll(Il«ILT*Kli.
WITH THREE HUNDRED AND SIXTY ILLUSTRATIONS
PHILADELPHIA:
HENET O. LEA.
1880.
Entered acmrdiug to Act of CocgreBS, in the ye»x 18S0, bjr
HENRY C. LEA,
in th« OfflM ot tha Librarian of CongresE. AH rights reserved.
COLLIITB, PRINTKB.
TRANSLATORS' PREFACE.
The very high reputation acquired throughout Europe hy the Patho-
logical Histology of MM. Comil and Ranvier as a clear and excellent
presentation of this important department of Medical Science would seem
to be a sufficient juatificatipn of the present effort to make it accessible
to the American student.
In France, the work appeared in several portions, at intervals extend-
ing from 1869 to 1876. The earlier parts are therefore somewhat
behind the existing state of knowledge and opinion. Moreover, the
book is very large, and in some portjona difiusoly written. It has been
the endeavor of the Translators, by omitting such passages as are com-
paratively unimportant or have become obsolete, by condensing others,
and by inserting additions where the progress of science has seemed to
call for them, to render the American version a more faithful exponent of
the subject in ita present state, and at the same time to bring it within
the compass of a convenient text-book for the student. The additions
are scattered throughout the volume, and are generally inclosed within
brackets [J. The most extensive changes will be found in the sections
on Sarcoma, Carcinoma, Tuberculosis, The Bloodvessels, The Mamma,
and The Classification of Tumors.
Corresponding alterations have been made in the series of wood-cuts.
In this connection, thanks are due to the Surgeon-General of the Army,
and to Dr. J. J. Woodward, U.S.A., for their kind permission to use
some of the important illustrations in the second part of the medical
volume of the Medical and Surgical History of the War.
The foothold which the metrical system of weights and measures is
gradually gaining in this country, the wide-spread adoption of that sys-
ÎY TRANSLATOBS' FBBFAOE.
tem by the scientists of Europe, and the desirability of the employment
of Bciendfic terms having a veil recognized significance the world over,
have led the Transistors to retain the metrical values whenever dimen-
sions have been expressed,
Fbiladblphia, Janiiary, 1680.
AUTHORS' PRKFACE.
Tue absoDco of a French work upon p&tbological bistolog; luu deter-
mined us to publi»h tbîs book.
Tbe title wlikli yre bave chosen, MamuU of Paihdogictâ Biutotog^^
indicate» tlie object of its publîcattoD, viz. : that of proeenting a brief,
eleineotarj, and succinct explanation of the deticnptions, definitions, and
clusifioaliona of morbid pro>IucU as aeon under the microscope. Our
book lins itot been named J'uihiflogicai Anutomif lfecau»c it U l>a»ed
entirety upon normal histolog;\' — a department of medical acienco from
which «e hAvc borrowed both clasetfiCfttioi» and methods.
This title implies the neceuity of paying little attention to naked-eye
desoriiitioiis, which, indeed, are «o complete ami satUfaclury in tlic
classical works of Cruveilhier, Andral, Ilouillaud, and others, thu it ta
impossible to rival them or to succcsitrully abridge tbem.
The material which lia« been utilised for the composition of this
manual is derived from autopsies and operations in the hospîtaU of
Pari», 80 rich in this respect that a tenth part of the material daily
wasted there would amply suSico for tbo supply of the most actire
laboratory. And her« we desire to exprcM our acknowledgments to our
colleagues, to our friends, and to our chiefs, physicians and surgeons of
the hospitals, by whose camest cooperation most interesting spcctmcnB
have been placc-d at our disposal. The examination of this material was
made by our pupils and by ourselves in our own êpccial hiffirator^ —
our manual being the pathological complement to the histological counc
irhich we have given for four years.
A knowledge of normtû hiitoioffff U indispensable for a comprchensioQ
of pathological histology. Although upon that subject the French trans-
la^ou of the treatise of KoiUker and that of t'reys' ilistologj', in course
of publication, giro full instruction, we have, nevertheless, concluded U)
offer a brief réunnii of normal hislologj' before entering upon the study
of patliological histology. Hence the first chaptor comprises a general
examination of tlie conatimtion of cells and of normal tissues. Further-
more, the normal histology of each organ is rapidly reviewed before
n
AUTHORS' PREFACE.
commeDcîng the study of its patbology. The arraDgcmcnt of this
manunl is, cooB«q[Uent1y, the sauu as that of a troatisc upon oornial
liUwlogj.
General pathology corresponds to ffeneral hittoloifi/, and comprises the
lesions of cells aud of tisaueiii as well a» th^ nature of iaflanimatioD and
of tumors. Tht« occupies the first part.
To tpccial hi»U'}<igy corresponds »)'enal pitlhoîoijy, which is divided
into two parti! : the one. devoted to the lesion» of each of the ti*su<-* and
systems; tlie other, to the alterations of each apparatiia and particular
organ. In this Last part our pupil and friend, M. Terrillon, lias added
his labor to ours.
We disclaim allegiance to any school, belonging neither to the Oer-
man nor to the so-called Freneh »ehool. The latter appellation Ja incon-
gruous, since it« real chief, Professor llenle, is a German. We are
opposed lo such divisions, for tliey woold compromise science itself in
the dissensions of savants — science, a unity indivisible *g truth. In
making oar contributions, it behooves us to justly ai>preciatc the labor»
of others, and to observe our facta with exactness.
Uut little space has been accortled to Aisfory, because in writing for
beginners, we deemed it necessary above all to state simple facts and
ioterprotatioiia wliicb wc believed to bo tnic. The office of a muiual ia
neitlier to relate nor to cricicixo every opinion which has been advanced.
Tlie omission of the discussion of theories and doctrines has not been
})ecause we have coni^dered them useless or barren, but rather becauM
tills was not the proper place to examine them.
It had been our desire to bead each part of human pathology by
introducing a chapter upon rjrptrimentaî pathohnjg. But the former
-will be well understood only when the lalt«r shall have no more mas-
teries to solve. Notwithstanding the fnot that experimental patholo^^,
under the powerful impulse of CI. Bernard and of Yirehow, has alrejidy
had a vigorous beginning, and that both experimental physiology and
histology have tended to stimulate its development, how much remains
to be discovered !
Vxt», Fobrnarr 10, 1869.
CONTENTS.
PART I.
GENERAL PATHOLOGICAL ANATOMY
CHAPTER I.
NORMAL HI3T0LOOT. — CELLS ASD NORMAL TIS9UKS.
Sect. I.— Cell Theory and Slructure of Cells
SilCT. il — Nonual Tissues ......
rial
IT
22
CHAPTER II.
GENERAL PRrXCIPLES ALTERATIONS OF CELLS AND Of TISSL'RS.
Sect. I. — Leaions of Nutrition of ElemonU and of Tissues . . .39
A. Lesions Caust^d by DcHth of Elements and of Tissues . . 39
B. Lesions Caused by Insufficient Nutrition of the Elements . 41
C. Serous and Albuminous infiltrations . , . . .42
U. Mucous and Colloid Infiltrations . . . . .44
Vitreous Degeneration j^^'nxj- Degeneration of Zenker) . 45
E. Amyloid Infiltration . . . . . .46
F. Fatty Infiltration and Fatty Degeneration . . . .47
G. Pigmentation of Elements and of Tiâaiies . . . .49
H. Calcareous Inliltnition ....... 51
I. Infiltration of the Unites . . - . . .52
J. Lesions Causefl by an Excess of Nutrition of Cells and of Tissui's . 63
Sect. IL— Lesions in the Formation of Cells . . . . .63
CHAPTER III.
OF INFLAMMATION.
^jE^T. I. — De6nition of Inflammation .
Skct. II. — Traumatic Inflammation in N on- vaseular Tissues
Sect. III. — Artificial Irritation in Vascular Tissues .
Sect. IV. — Analytical Study of Inflammation in Man
Sect. V. — Clinical Forms of Inflammation
65
55
69
es
73
TUl
OONTBNTS.
CHAPTER IV.
OF TUUORS.
r*ai
Sect. I.— Definition of Tumor ...... 74
Sect. II. — Classification and Description of Tumors .
75
Sarcoma ......
76
Myxona
89
Fibroma
91
Lipoma
95
Carcinoma .
96
Gumma
107
Tubercles .
112
GUadera
126
Enchondroma
126
Osteoma
132
Myoma
134
Neuroma .
137
Angioma .
139
Lymphai^oma.
^ymphadenoma
141
Epithelioma
146
Cylindroma
156
Papilloma .
167
Adenoma .
160
Cysta
164
Mixed Tumort
170
Classification and Condensed Description o
f Tumors
172
Appendix to Tumors
189
Circumscribed Melanotic Formations
189
Hydatid Cysis
■
131
PART n.
DISEASES OF ORGANS AND TISSUES.
CHAPTER I.
LESIONS OF BONES.
Sect. I. — Congestion and Hemorrhage of Bore
Skct. II.— Osteilis
1. Simple Osteitis
2. Barefying Osteitis
3. Formative Osteitis
4. Difliiseil Suppurative Osteitis
Skct. III. — Necrosis .
Sect. IV, — Caries
196
197
200
200
203
203
204
207
CONTSHTB.
IZ
r*si
Sect. V.— Formition of Callus . . . .' . .209
Fnctures Complicated with Wounds
. 210
Fractures not Complicated with Wound» .
. 210
Skct. VI.— Tumors of Bones ■
. 212
Varieties of Tumors of Bones
. 213
Sarcoma
. 213
Myxoma
. 214
Lipoma
. 2U
Carcinoma
. 2U
Tubercles
. 215
Gumma
. 217
Chondroma
. 218
Osteomii
. 218
Lymph adenoma
. 218
Epithelioma .
. 218
CjgU .
. 218
Sect. VII.— Osteomalacia
. 219
Osteoporosis
. 220
Sect. VIU— Kachitia
. 220
CHAPTER II.
LE
JIOKS (
>F CAR
TII.AOI
,
. 225
CHAPTER III.
PATHOLOGY OF THE ARTICULATIONS
Sect. I. — Normiil Histology of the Articulations
Sect. II.— Acute Arthritis ....
A. Simple Acute Arthritis and Rheumatic Arthritis
B. Purulent Arthritis ....
Sect. III.— Chronic Arthritis ....
A. Hydrarthrosis .....
B. Chronic Arthritis by Continuity of Inflammation
C. Chronic Rheumntic Arthritis .
D. Scrofulous Arthritis or White Swelling
E. Gouty Arthritis ....
Sect. IV. — Tumors of the Articulations
227
22g
228
231
233
233
233
234
238
241
244
CHAPTER IV.
LESIONS OF CONNECTIVE TISSUE ANr> SEROUS cavities.
Sect. I. — Normal Histology of the Connective Tissue nnd StroiiH Cnvilies . 247
Sect. II. — Congestion and Hemorrhage of the Connective Ti»«uc . . 2^8
Sect. IIL — Œdeuia ........ 250
Sect. IV. — Inflammiition of Connective Tissue .... 2.52
Sect. V. — Purulent Inflanimntion of the Connective Tissue or Acute Phlegmon 253
Sect. VI.— Chronic Phlegmon . , . . , .256
^^^J^^^^^^^^^^^^^^CÔX TESTS. ^^^B
^Pl
K
*'•■ 1
^H Skct. VII. — ^Tumar* oT t1i« Comicvlivc T}i»ne
. »7 1
^^H Siu-'T. VlII. — IIi^mDirliiiiri^ji of ihc Scroiit Mrmhmiir*
. I»8 1
^^1 Sect. IX. — In<lHmniuticm of tbv Si-rtn» Membruniu .
■ 2»9 ^J
^^m Ili'morriiiigiii .....
KS^H
^^1 Parulcnl ..... é
ssa^H
^^P AdhrMTD ......
ss&^^l
f Skct. X. — Tumon et Uk. Si-roiis Mt>inhrui<«
. ses 1
^^L c n A r ï K II V .
M
^^^^V I.RillONS OF THE UlTSCULAR TISflCR
^^
T Skct. T. — Xnminl Ilintolo^ of Mii>ciilnr Titunic
sn^^H
1 Skct. 11. — Nutriiivc I.oiiion<> of MiirvIv* .
STO^^
1 Aira|>)i}' of MiHfiiliir Fawifuli
. STO 1
^^L Ilyp<Ttropliy nf Miitrulnr FriM-iciili
. 271 ■
^^H Cl<nii)y Swvlliuit of )lti!VuUr F.-uciciiU
. ÏTI M
^^H Fatly l>fgi.<iu-nitL(iii v( MuH'ulur Fascii'iili
. STS^H
^^H rigmi-nUitioii Qrf SluiK'uUir Fascic-iiU
S74 ^H
^^M Vilreoiu Di-geiierntiun of Muh-uIut Ftucii-uli
. 274 1
^^M Ilcniarrh)i|N> of Miim-1m ....
. 176 ■
^^M Embolie Infiirrtinn nf Alau'K'*
. 911
^^1 ïliihipliniUon of (Vllular Kicntrnt* tft th« Siut'olvniinn
. !78
^^H liitlunimntioii of Mi]«'li!> or Myoïîtû
. Ï78
^^H Kuppimlitai of Miih'Ios ....
. 97fi
^^K Cfaronio luUiinimHtiuu of Musclca .
. S70
^^H Biiplurc of Miixclm ....
. S80
^^^ Sxcr. in.— Tumor» of MiitrlM
. »e«
L Sscr. IV.— l'anttiWBof MuM'IcB
. 988
^^^ CIIAl'TKIt
^^^^V LESIOXS Of THE Dl.OOD.
1 Skct. I. — Normal Iliituloir^ of (h« Bluixl ,
. 384
1 Skct. II.— l'iiiliologkal HÎKtology of the Blood
. 387
^^ IlyiInL-i[ii& ...,.,
. 387
^^k l,i-uc!ix'ytmiï .....
. 3117
^^M Li-uccK-ylJiii-inûi .....
. 3M
^^M MrUna-miu .....
. 388
^^U Panuitva ......
. ua
^^K CHAPTER
^^^^K LK«I0K8 OP TnK
^^^^^ Sect. 1. — l'crîcjmiiuia ....
. 300
L lIomorrlinKiri .....
. 390
^^k Drofwy of lhi> l'cricm^liuiii
. 3S0
^^1 IntlAimnntion, Fcricarditi*
. 990
^^H CAn-inooM ....••
. 9»9
OOHTBIilS.
zi
Sect. II. — Uyocardium
Atrophy .
Hypertrophy . .
Fatty Degenention
FigmeDtary Degcneratirai .
CoQgeatioD, Hemorrhage .
Aneurisms of the Heart .
Fiai
. 292
. S92
. 293
. 293
. 294
. 394
. 29S
InSaminatioii or Myocarditis
Fibroid Induration of the Heart
. 296
. 297
Abscetsea of the Myocardium
. 297
Tumors of the Myocardium
Sect. III.— Endocardium
. 298
. 298
Normal Histology ,
Endocarditis
■ 298
. 300
Acute ■
. 300
Chronic
. S02
Valvukr Aneurisin
. 302
Formation of Blood Clots in the I:
lean
. 304
CHAPTER VIII.
LESIONS OF THE ARTERIES.
Sect. I. — Norpial Histology of the Arteries
. 306
Sect. II. — Palhological Histology of the Arteries
. 307
Acutp Kndarteritia
. 307
Acute Periarteritis
. 309
Fatty Degeneration of Arteries
. 310
Chronic Arteritis .
. 31!
Atheroma .
. 311
Calcareous Plates .
. 312
Arteritis Dcformnns
. 313
Chronic Periarteritis
. 313
Aneurisms
. 314
Arterio- Venous Aneurisms
. 318
Arterial Obliterations
. 318
by the Ligature
. 318
by Acupressure or Torsion
. 325
Spontaneous .
. 325
by Ëndartcritlg and Thrombosis
. 326
by Kmbolism .
. 326
Syphilitic Lesions of the Arteries
. 331
Amyloid Degeneration of Arteries
. 332
Tumors of the Arterica
. 333
GONTEHTS.
CHAPTER IX.
LESIONS OF CAPILLARY BLOODTESSBLS.
b1 Hietology of Capillaries
rt»t
. 334
ological Histology of CapîUarîeB
. 335
n of Capillaries
. S3d
itiom of Capillaries .
. 336
□filtratioD, Amj'loiil Degeneration
. 337
CHAPTER X.
LESIONS OF TEINS.
«1 Histology of Veins
. 338
.ological Histology of Veins .
. 839
.
. 339
ombosis ....
. 340
ricosc Veins ....
. 342
^''eiDB .....
. 344
CHAPTER XI.
LESIONS OF LYMPHATIC VESSELS.
lul Histoli^y ....
ological Histology of Lymphatic Vesiel»
n or Lymphangitis
f the Lymphatics or Lymphangiectasia
jymph Tesacls within Tumors
S4S
346
34S
346
346
CHAPTER XII.
LESIONS OF LYMPIIATIC GLANDS.
lal Histology of the Lymph Glands .
lological Histoli^y of Lymph Glands
in
n or Acute Adenitis
enitis .
Caseous, Waxy, and Calcareous Degeneration
jgenomtion
amorphoBis
Lymph U lands
■a
sarcoma, Carcinoma
lea
I, Enchondromn
.iorna .
348
361
361
362
358
354
355
355
355
355
356
356
857
358
OONTBIIIS.
Xiu
CHAPTEE XIII.
LESIONS OF NERVE TISSUE.
Sect. I. — Normal Histologj of Kerrei
Sect. II. — Fatholo^cal HaUAagy of Nerves
Congestion, Hemorrhage, InfismmalioD
Lesions following DiTision of Nerves
Tumors of Nerves
FIS I
3S9
360
360
361
362
CHAPTER XIV.
LESIONS OF THE CENTBAL NERTOUS STSTEM,
Sect. I. — Allerations of the Meninges
Congestion, Cerebral Bheumatism
Inflammation, Cerebral, and Cer«bro-spinMl Meningitis
Tuberculous Meningitis ....
Chronic Meningitis ....
Pachj-meningitis .....
Tumors of the Meninges ....
Sect. II. — Lesions of the Cerebrum and Cerebellum
Cerebral Antemia, Cerebral Congestion, Œdema of the Brain
Melanœmïa, Cerebral Hemorrhaga
Miliary Aneurisms of the Brain
Cerebral Softening
Acute Encephalitis
Abscess of the Brain
Chronic Encephalitis or Sclerosis
Tumors of the Brain
Tuberculous, Syphilitic
Sect. III. — Lesions of the Spinal Cord
Congestion, Hemorrhage, Softening
Secondary Degeneration of the Spinal Cord
Inflammation of the Spinal Cord .
Mjelitis .....
Acute Suppurative
Simple Acute
Metaststic Abscesses of the Spinal Cord
Interstitial Myelitis or Sclerosis
Sclerosis of the Fost4.'rior Columns
, Disseminated Sclerosis or Sclerose en platjucs
Lateral Sclerosis .
Tetanus
Tumors of the Spinal Cord
864
364
364
365
366
367
S6T
36S
36a
369
371
372
375
376
377
378
STS
380
380
381
383
383
383
383
383
384
385
387
387
388
388
^^xi^^^^^^^^^^^^^oÔntËîÎts^^^^^
1
■
■
^H PART
^M
^^B SECTION
^^H
^^^H BBSFIRATOBY An'ARATCS.
^^B
^^H CHAPTER
fAùt V
^^^^H HORUAL uisTOLonY oP nKsriitATOitr Ari-jtnATUS .
889 ^M
^^H
^
^^^^^ riTIIOLOOICAL IIISTOI-WOr Of TIIK IIK^I'IKATOKY ArPARATUI.
'
1 Srot. I. — XiUll FiMio: ....
.
.
394
l C'on^cslioii. HcinorrliuKi! ....
.
,
SS4
^^L Inliammnticin of tlii.- Miieoiii Metnbninc oT ihc KunI F
oxtat
Corvïft
1194
^^F Tiimar* of ihi^ Kuiul Fohic . .
,
S9S
r Skct. II. — Lan-DX .....
,
,
S9G
^^_ (.'(ingi.>]tîoa. At^utc Cnturli or 0At«rrh&1 Ijirjniiptîi
,
,
396
^^B Chrunic CnUrrli, or Clirunit Catun-hnl Larvii^tis
.
.
SOT
^H Diphthvritji' l.nrvniptE» or Croupi ,
*
.
391
^^1 Krysipi'luloiii I.nry nfcitii, Vartnlniu l.nrynititii
.
.
398
^^M I.arynpilia of (iluiidiTa. of 'IVplicilcl Ffvt^r. of Tubctvuloiu.
of Sj-pKïlîï
sss
^^M (.fiiWrnataa* L;u-yii(Eitif, (Kdcmn of tlic (ilatti.i
,
399
^^M IJIcrrot» l.&rynititù ....
.
400
^^H l'fTichamlritii ■ . . é .
■
401
^^f Tuiiiura of Ûm I.at}iix . • • •
,
401
^^ Srct. III.— Tnichea , . . . é
,
403
L IiillailiiiiulLuiin, L'Ii-'i'n, Pi-rfamCious , .
.
. 403
^^B Ciin-îiiuiii», Lrukwiiiic tironths
»
404
^^a C'iUi'ilicatioiw, KxwIoks ....
,
404
[ Skct. IV.— Bronchi .....
,
404
^^m CougMtion, Hemorrht^ ....
.
. 404
^^^ lufliuiiniatîon .....
,
. 404
^^^^^L luwiuie ItroiirhitJ' ....
,
. 404
^^^^^P Di|>btlivritic ilr«iii.'hitît
•
. 404
^^V CljTonii: ttHiTidiiti» ....
.
40a
^^1 DiluUlion of lliv Broiiclii, BroïK'liicetuais
■
40S
^^H (Tlceratioii Ot tilt) Bronchi. Ciik'ificKtiuu
,
. 406 ■
^^ Tumor* ......
. 40% 1
L Skct. V. — Lnnipi . . . é .
-
. 408 f
^^H AnirmiA, llypi-ro-toin, (Kdcma
.
. 40H
^^B rulmonnrj A]io|iU-XT ....
.
. 40»
^^1 Hcmorrliagic^ Infnrrtîon ....
.
. 410
^^M Au>\wtanf. Ao^phy ....
.
411 _
^^B Eiiii>liy *eiiiii .....
. 41« ■
0OHTENT9.
XT
Inflammstion, Fneninonîft ....
A. Lobular or Catarrhal Pneumonia .
B. Lobar or Fibrinous Pneumonia, Croupous Pneumonia
Pneumonia of the New-bora, of AJults, of the Aged, of the
aematons
Abtceu of the Lung
Inflammation of the Lymphatics of the Lung
Gangrene of the Lung
Interttitial Pneumonia
in the Aged
in Chronic Heart Disease
Syphilitic Pneumonia
Anthracosia, Sidcrosis
Chronic Croupous Pneumonia
Tumors of the Lung
Tuberculosis of the Lung
Tubercle Granulations
TubercutouB <»■ Caseoua Pneumonia, Phthisis
Tuberculous Lobular or Catarrhal Pneumonia
Tuberculous Lobar or Croupous Pneumonia
Tubercutoos Interstitial Poeumouia .
Sect. VI.— Pleura ....
Congestion, Ecehj-mascs, Hyperplastic Pleurisy
Fibrinous Pleurisy
Idiopathic Pleurisy
Hemorrhagic Pleur isj-
Purulent Pleurisy ,
Py o. pneu mothora X
Chronic Pleurisy .
Tumors of the Pleura
Emphy-
riaa
414
414
416
419
419
420
421
423
424
425
42S
42S
42«
427
429
430
433
433
439
437
43S
43S
440
441
443
443
444
444
445
SECTION IL
DIGESTIVE APPARATUS.
CHAPTER I.
THE MODTll AND ITS APPENDAGES.
Sect. I. — Normal Histology of the Buccnl Mucous Membrane . . 446
Sect. II. — Lesions of the Buccal Mucous Membrane . . . 448
Inflammation, Stomatitis ....... 448
Superficial or Catarrhal Slomalitis ..... 448
Stomatitis of Typhoid Fever ...... 449
The Lead Line, Argyrio ..... 450
Stomatitis of Eruptive Fevers, of Cutaneous Diseases, cic. . . 451
Scorbutic Stomatitis ....... 451
Syphilitic Lesions ....... 451
Membranous Ulcerative Stomatitis (Diphtheritic) . . . 452
Superficial Inflammation of the Tonsils or Catarrhal Angina of the
Tonsils . . . . . . . .452
^^^^ Sri ^^^^^■^^^oosTESTB. ^^^^^^^^^^^^^^^^1
^^M r«ot 1
^^1 Dipblh<<riu'c Inflninmation ...... 453 1
^^M GMigTono of the Month (Xomn) ..... 4SS 1
^^^ CHAl-TKK ^J
^^^^F AMD ixROriiAei;». ^^H
^H 8S0T. I.— Normal HiMolofO' «I* t1i(- Plmrjux tiiiil Œ^opliagua . 4Sii |
^^H SscT. 11. — l.mloiia of ih« Pharynx «oil (P.«ophnpi« .
451
^^^^^ rhnrvn|:ilif ......
407
^^^^H Rt'ir<>'{ilinr}'ngCHl AbiCcai .....
4A8
^^^^H Œ^nplin^'ilit ......
43»
^^^^^H Foreign Boilim .....
4£9
^^^^H Tumon) of the Pharynx «nd of thu (E«apha)[u« .
4G0
^^B 1
^^^^m TtiB ^^H
^^^^ Sgcr, I.— Normnl Hiftoln^ of thr Stoniuoh . .461
^^^^^j AKT. II. — PitUiological Ilittolog;ir of ihv Stoniiu-li. I.r#ioii( of Niitr
(ioQ
464
4li«
^^^^^^ CongeMlon .....
404
^^^^H I^rfoioiui of ibc Glaiul* ....
Àtli
^^^^^ IjCfioDi of (hir ^'pHl■l!■ ....
46S
^^K^^ Sxcr. til. — Inftoiiinuilion of thv Mtu'uun Alrmbmnc of th« !;
totusch
4M
^^^^^^ Supi-rtii'iul or L']it«rr1i»l Iiiltummuttun of tliv Stoiuavli
4l>.'i
^^^^^H Cluuiiii' CnUirrli of tlir Stuniauli
46li
^^^^^H Croujioti) Gtuiritifl ....
468
^^^^^1 Pvnipliiipi» of lli« Gsslric Muuoiw UoiuUraiiu
4fifl
^^^^H Pklegiuouoiw Gwlriiis ....
4G8
^^^^H LeqIODS CMOscO by CorroMre or Irritnnt A]^n1«
ifiS
^^^^H Gnngrvnoiis Goatritia ....
4G9
^^^^H Siinjilu Ult'er uf tli<> StoiiiDcIl
4G9
^^^^F Siiufle or Pt>rl'oriitiu]; Ukcr of rlic Uuodeimtn
4Î1
^V Sect. IV Tunion of the Stumwb .
4Ji
^^H Sy[>1iilitic Tiimun of lliv Stoinai-li
. *1*
^^^ Hyp«rtropliy BtiuuliKiog ■ Tituior
«I
^^H CHAPTER
^^^^P TaK rNTK^riKE.
^^B SzcT. I. — Nomtnl Bùtology of tho IntCBtitio ..... 419
^H Skct. ri.~Pat>iolu|tii-iil Uiaiulo'^v uf ih« liiteitina .
. 4fl3
^^^^^^ Po»l-inorCcm Chiugca .....
. 4«a
^^^^H Condiutiuii ......
. 4ti3
^^^^H lu&imtnuttoii of the Slocoua Membrane, IntMlinol CkUtrli
. 4113
^^^^H Typhlitii and Pvrityplilîtï) ....
. 488
CONIENTB.
XTU
FA* I
Acute Dysenterj' ........ 4S9
Chrimic Dysentery
493
Cholera .....
499
Unemic UIccratïoDa
501
Typhoid Fever ....
SOI
Lésions of the Inteatine in Hernia
506
Rectal FUtuJH ....
507
Tuberculosis of the Intestine
508
Syphilitic Tunum and Ulcers
512
Fibroma, Myoooa, Lipoma, Vascular Tumors
613
Adenoma, Lymphadenoma
514
Carcinoma ....
<>
Epithelioma ....
916
CHAPTER V.
THE LIVER.
Sect. L — Normal Hûtolc^ of the Liver ..... fill
Sect. II. — General Pathology of the Liver ..... S21
Changes in the Hepatic Cells ...... 522
Lesions of the Cellulo- vascular System ..... 52$
Iiesioni of the Vessels ....... 527
Sect. Ill — Special Pathology of the Liver . , . .527
Post-mortem Changes ....... 527
Congestion ........ 528
Cardiac Liver, Nutmeg Liver ...... 530
Hepatitis ......... 532
A. Parenchymatous Hepatitis ..... 532
B. Furulcnt Hepatitis .536
MftjtKlatic Abscesses ...... 53S
Thrombosis and Phleliiti? of Portal Vein . . , 53T
Purulent Inflammation of Portal Vein or Suppurative Pylc-
phlfliitis . . . . . .'■.38
Biliary Abscesses ...... 540
Large Abscesses of the l.iviT ..... 541
Interstitial Hepatitis or Cirrhosis ..... 543
Partial Cirrhosis ...... 543
General Cirrhosis ...... 544
A. Cirrhotic Liver with Smooth Surface .... 545
B. Granular Liver, Hobnail Litter ..... 547
Cirrhosis with Atrophy ...... 547
Capsule of Glisson in Cirrhosis ..... 54S
Condition of Vessels and of the Circulation in the Liver in Cirrhosis 549
Condition of the Biliary Passages in Cirrhosis of the Liver . 560
Condition of the Hepatic Cells in Cirrhosis of the Liver . 553
Degeneration of the Liver ...... 555
Fatty Infiltration ...... 555
Fatty Degeneration ...... 557
Amyloid Degeneration ...... 557
B
XTui
1 - CONTENTS.
rial
Tumon of the LiTer ....... &59
Angioma, Tubercle
Gumma .
5S9
660
Lukajmic Tumors
SGI
SarcomSi .
fi61
Carcinoma
561
Cylindrical-celled Epithelioma
Cysts, Hydatiil Cysts
Biliary Vessels and Gall-Bladder .
564
565
567
InflammatioD .
567
Tumors
669
CHAPTEE VI.
PERITONEUM.
Sbct. I. — Ii]fla»matii>ii ....
Acute General Pwitonitia ....
Acute Local Peritocitis ....
General Chronic Peritonitia
Hemorrhagic Peritonitis ....
Tubercles «f the Peritoneum and Tuberculous Peritonitis
Local Chronic Peritonitis ....
Carcinoma of the Peritoneum and Carcinomatous Peritonitis
Other Tumors of the Peritoneum ....
571
571
578
678
574
674
576
576
577
CHAPTER VII.
1HE PANCREAS.
Skct, I. — Normal Histology of Pancreas
SucT. II. — Patboltçy of Pancrcaa
Parenchymatous Inflammation
Suppurative Inflammation
Interstitial Inflammation
Induration of the Pancreas
Fatty Degeneration and Fatty Infiltration
Atrophy, Amyloid Degeneration .
Tumors of the Pancreas .
678
578
678
679
579
579
579
680
6S0
SECTION III.
HJBMOPOYETIC ORGANS.
CHAPTER I.
THE SPLEEN.
Sect. I. — Normal Histology of the Spleen
Sect. II. — Fathol<çy of the Spleen .
Atrophy ....
Hypersemia
683
584
eS4
685
Intentitial Splenitis
SuppuratÏTe SpleDJtis
InfuctioD of the Spleen
Kupturcs of tbe Spleen
Amyloid Degeneration
Tutuon of the Spleen
COKTENTB.
mx
rjtai
. SST
. S89
. sea
. 591
. S91
. 593
CHAPTER II.
THE THYROID GLANDS.
Srct. I. — Nomal Histology .....
. S96
Sect. 11.— Pathologieal Histology ....
. &9t
Goitre .......
. S96
. 597
. 597
CHAPTEK III.
TUB SL'PRA-KENAL CAPSULES.
Sect. I. — Normsl Histology . , . ,
Sect. II. — Fatholoj;y of the Supra-rennl capsules
Hypencmia, Hemorrhages, Thrombosin .
Fatty Hnd Amyloid Infiltration
Inflammation, Tumors ....
Tuberculosii .....
599
GOO
GOO
600
601
602
SECTION IV.
GENITO-UHINAHY APPARATUS.
CHAPTER I.
the KIDSEVS.
Sect. I. — Xomml Hislolopy ....
Sect. 11. — General Putlioli^y of the Kidney
Alterations of the Kpitlielium
Tube Casts .....
Alterations of the Bawmcnt Jlt'niUranc of llie Tubules
Lesions of the Renal Cooneelive Tissue .
Altérations of the lilooil vessels of the Kidney
Alterations of the Alntpigliiuu Glomeruli .
Sect. III. — Spetial Pathology of the Kidney
Ana'min
Congestion, lleinorrhage .
Infaretion of the Kidney .
Albuminous Nephritis
A. Cstarrhal Nephritis
B. ParcDchymatoug Nephritis (Large White Kidney)
GU4
G09
609
Gil
GI3
en
C15
ei6
G17
GI7
61ft
619
619
620
621
XX
COHTBNTB.
Fioa
C. Albuminous Nephritis with Amyloid Degeneration . 627
D. Fatty Uegeneration ....
. 629
Biliary Pigmentation
. 631
Jntentitial Nephritis
. 631
Albuminurie Interstitial Nephrit:
B
. 631
Acute
. 631
Chronic
. 632
Nod- Albumin uric Interstitial Nephrit
B
. 641
Suppurative Nephritis
. 642
1. Difluse Suppuration
. 643
2. Limited Suppuration
. 642
3. Metastatic Abscess
. 644
Pyelo- Nephritis
. 649
CatAirhal Pyelo-Nephritiï
. 645
Purulent Pyelo- Nephritis
. 645
Caltmlous Pyelo- Nephritis
. 645
Tuberculosis of the Kidney
. 64J
Gumma ....
. 647
Lymphadcuoma
. 64S
Sarcoma ....
. 64S
Carcinoma . . . ■
. 660
Cysts ....
. 650
Angioma ....
. 6Ô1
Parasites ....
. 651
CHAPTER II.
URIKART PASSAGES THB UBUTEBS, BLADDER, AND URETHRA.
Skct. I.— Normal Histology .
Sect. II Pathological Histology
Hypericmia of the Blndder
Catarrhal Inflammation of the Bladder
Catarrhal InttaTiimutiou of the Urethra
Tumors of the Bladder
652
652
652
653
654
654
CHAPTEIt III.
THE TESTICLES.
Sect. I. — Normal Histology .
Shct. II. — Patholt^i-ul Histolripy
luHammation
Acuto Orchitis
Suppurative Orchitis .
Chronic Orehitis
Chronic Syphilitic Orchitis
Hydrocele
Ha^matocelc
Tumors <^ the TcsUclu
657
659
6.^9
659
660
660
661
661
663
663
CONTBNTS.
XU
CHAPTER IV.
THE PROSTATE,
rioi
Sect. I, — Norm»! HUtolopy ■ . , .
. 071)
Sect. II. — rathologïcal Hittolog)-
. 670
InRammatic»] .....
. 670
AbscFU ......
. 670
Tumon ......
. 671
CHAPTER V.
THE OVARIES.
Skct I. — Normiil Histolo|!y
Skct. II. — Pflthotogical Histology
Hvprncmin, Hcmon-huge .
Inflafaiaation
Tumon
673
676
676
677
678
CHAPTER VI.
THE FALLOI-IAN TL'BES AND ITKRL'S.
Sect. I.— Normal Histology ....
Skct. li. — Pathologiosl Histology
Congestion, Hemorrhage of Fa11oj>inn Tubi'8
Inflammation of the Fallopian Tubea
Tumors of the Kallopinn Tube
IVri-ulerine Hematocele ....
A. Ijcsions of the SIucous Membrane of the Uterus
Congestion. Hemorrhagu .
Catarrhal Inflammation, Endometritis
Puerperal Inflammation
Phagedenic Cleer ....
Tumors — Mucous Cysts, Villi, Fibrous Polypi, Mupous
Tubercles ....
Syphilis, Carcinoma .
Epithelioma . . ' .
B. Lesions of the Fibro-Mu9Cukr Wall .
Hypertrophy .....
ilvoma ......
Pol
.'■p"i
CM
6se
6K7
UHg
GK8
689
68»
69«
693
. 693
. C9t
. 696
. 697
. 697
. 6!I8
CHAPTER VII.
MAMMART OLAVD.
Sect, I. — Normal Histology .
Development
Brolution, Involution
Colostrum Corpuscles
701
703
704
70.1
XXll
C0HTBMT8.
Sect, II,— Pathological HUtology of the Mainiiiai7 Gland . . .706
Acute lolIaniuiutioD or Masticia ...... 706
Chronic Inflamniation ....... 706
TumorB of t!ie Mammary Gland ...... 707
General Hvpertrophy of the Mammary Gland . . . 707
Galactooelc . . . . . .707
Sarcoma- . . . . .708
My^ioma . . . .709
Fibroma ........ 710
Syphilis . . . . .710
Carcinoma, Fibrous or Scirrhous Carcinoma . ... . 710
Cancerous Nodu lea ....... 711
Enccphaloid, Colloid, and Villous Carcinoma . . . 713
EnchondroTua ....... 714
Adenoma, Melanotic Tumors of the Breast, Kpitbelionata . 715
Cystj—Uennoid and Hydatid . . . . .715
SECTION V.
PATHOLOGICAL ANATOMY OF THE BKIN.
CHAPTER I.
Skct. I, — Normal Histology of the Skin
A. £pi<U-rmig ....
B. Derma, Papilla:
C. Vessels and Nurres of the Fspilis and Derma
Lymphatic Vessels
Termination of NcrTes in the Slcin .
D. Glands of the Skin
Sebaceous and Sudorific Glands
Sect. II. — Œdematous InfiltraUons of the Skin
A. Simple Œdcma
A. Œdemu of the Lymph Passages
Sect. 111. — Hemon-hages of the Skin
Sect. IV. — Diffuse Inflammation of the Skin
A. Acute Dermatitis
B. Exutlative Inflammation of the Skin .
a. Suppurative Dermatitis, Simple Phlegmon of Skin
b. Fibrinous Dermatitis, Difluse Phlegmon
c. Fscudo-IlIenibraDoiis Dermatitis .
0. Chrome Diffuse Inflammation of Skin
1. Fibrous Hypertrophic Dermatitis .
3. Papillary lariety : UiRusc I'apilloma of Skin
3. Elephantiasis Arabum
Scleroderma: Atrophy of Skin
Sect. V. — Circumscribed Inflammations of the Skin
(I. Congestive Localized Inflammation of Skin, Papule
7IC
716
718
718
719
720
720
720
721
721
723
724
724
724
727
727
727
728
728
728
728
729
730
730
730
00NTBKT8.
XZIll
b. Lesioiii of the Epidennis : Bulls, BlUters .... 731
Vesicles, Paatules ....... 782
Tubercules . . .734
Circumscribed Peri-glandutar InBammation .... 735
Sudamina, acne ....... 735
KloUuscum Sebaeeam, Pitjiiasis Pilaris .... 736
Skct. TI. — Tendencies snd Evolutions of Cutaneous Inflammatioiu . 73G
1. Hyperplastic InflammatioD : Formative Dermatitis . 736
a. Syphilitic Papule ....... 736
5. Syphilitic Tubercule . . .736
e. False Keloid . . . . ,737
9. Degenerative InflammatioD : Speeific Uleert of the Skin . 737
a. Tuberculous Ulcers ...... 737
6. Dcnnatitis of Glanders : Farcy Granule .... 738
c. Leprous Dermatitis ; CutHDeoiu Tubercule of Leprosy 738
Sect. TH.— Dystrophies of the Skin . .739
A. Tropic Disturbances in the Derma Consecutive to Lesions of the
Nervous Sj'slcm ....... 739
B. Dystrophic Alteratious of the Epidermï», and Analogous Epidermic
Products ........ 740
C. Abnormal Colorations of the Skin ..... 740
Sect. VI IL— Parasitic Aflections of the Skin .741
A. Animal Parasites of the Skin of Man .... 741
a. Acarus Scabiei (Sarcoptes hominis) . . . .741
b. Acarus FoUiculorum ...... 742
B. Vegetnble Parasites of the Skin of Man .... 743
a. Tineu Favosa (Athorion Scliccnieinii) .... 743
J. Tricophyton Tonsurans ...... 744
c. Pityriasis Versicolor (Mjcroaporon Furfur) . . . 745
r/. Alopecia Circuinscriptu (Alicrosporon Audouini) . . . 74e
e. Pityriasis Capitis Simplex ...... 747
APPENDIX. — Methods of Fresertikg asi> Haudemno Tibsues fob
Microscopic Exami.nation ......
749
BIBLIOGRAPHY
753
IKDEX
(G3
LIST OF ILLUSTRATIONS.
no.
1. Segmentation of mammaliaD OTum
2. Diviaion and movements of white corpuscli»
S. a. Pub cells from a gTHQulating wound
b. Pus cells from un abucess
c. Pua celU from an ubsueiis treated with acetic acid
d. Pua tella from a bone fistula
e. Migrating cells ....
i. a. Reticulum of white blood corpusclea
i. Reticulum of ellipticul blood corpuscles
5. a. Muttinucleai' "giant cell" from bone marrow
«I /i ff- Lymph cells from bone marrow .
e, d, h. Lymph cells from bone marrow treated with alcohol
i, j. Osteoblasts from bone marrow treateil with alcohol
6. Cella from cancer, ifaowing division of nuclei
7. Cells from wirrhus of mamma, showing increara of nuclei
8. Transrerse section of tendon
9. Silver-treated tendon of rat
10. Silver-treated cornea of frog
11. Reticulated tissue of lymphoid follicle
1 2. Proliferating cartilsge cells
13. Ossification from cartilage ....
14. Ossification from fibrous tissue
15. Smooth muscle cells ....
IG. M uaeulnr fibres of heart ....
17. Muscular fibres, elements of
18. Nerve cells .....
19. Human nerve libres (medunated) .
20. Nerve fibre» of Remak ....
21. Spinous epithelial cells ....
22. \illU3 of intestilie of rabbit
as. Si! ver- treated pericardium
24. Capillary bloodvessel of mesentery, silver treated .
2â- Papilla Irom a papilloma ....
26. Choicsterine crystals ....
27. Fibrinous degenerated epithelial cella
2S- Irritated epitlielial cells, shnvriiig vacuolation of nucleus
29. Colloid cells from a colloid cancer .
30. Mucous transformation of epithelial cells .
91. Vitreous degeneration of muscle (waxy degeneration of Zenker)
32. Amyloid degeneration of liver cells
33. Corpora amylaceœ from prostate .
34. Fatty infiltration of liver cells
35. a. tatty degenerated ceils from cancer
h. Fatty degenerated cells from brain
36. Corpuscles of Gtuge from bruin
PiOB
IB
19
19
19
19
19
19
20
20
20
20
20
20
21
21
23
23
24
24
25
28
29
30
31
31
32
33
33
34
34
35
3G
37
41
43
43
44
45
45
4G
46
47
48
48
48
^so^^^^^^^^^us^^LLcârsÂTTÔss^^^^^^^B
■
ri«.
MflB
aî. Ciitici fiinpoM ........
49
38. Cclliilnr (trurtuiv aC iiH'1aii<Miii . . . . .
M
SD. CclLi voaluiuiiiji |)ignii-iit .......
40. C3|>illnrv bKioi voavl (vtiit.iîiiiii): inpnent and liKnialoï'lîn <T}«tnls .
41. Canilu^ înriIiraMl wîlli iirHto uf tu(lu . . . . .
M
SI
C3
43. liitlnnivil ortiliijft' ..,..,.
AG
4H. Normul omfiiluin, iiiWi:^ Uvutcd ......
&î
44. *:i. 4'!. Artilicinlly Iiiflnini-<1 otm-titum ....
iT
4T. ]iittiiiiiril i'ii[<illiin of iiKrseulcn*. Bliowiiig ilcUcliitti^iit of Hii vudolWIiul vel
S8
48. OHUi^-mitliiiii: ril> (boiiv (oAviiin;;) . . • ,
60
49. liitliinii'il wli]ii:>»i' li>«iiv ..,.,.
Cl
GO. l'*îbrinoi>i cxuiUt'i»!! ......
ca
Al. l'ilirinoiu ili-gitDcmtn! irpithfliiil rrlls . . . . .
ce
n2. I'u.i<-(?U> .........
«T
OS. Piii oi'lli) lival«''l oitli viiri'jiii tvajfaiCii . . . . .
CT
G4. llloo(lvi'«^-t> ill gniuiilntioii lÎMUi- ....
00
5S. (i rati II Ih [ion liiuie .......
70
AS. Inllumril .'xlîjMWG tiitnic .......
i;
AT. Kuun'l iiiiiill.ri''l]«il Mtvùma .....
î»
M, S|>îmlli>-('i.-lli.-il sureomii ......
8»
69, Liir;^- «iiiiiilk«<i>i-llivl Mjn''>ni.i .....
BU. M\i.-l«i<l tairoiuii Q;iiiiit-n.'U('il MKOIIia) ....
60 ^
1» ^M
^^^Hél. s nnilli-nnil pMi^nJlotl Hvcoma . . , , .
^^^^^■â. (■ ........
^ H
u ^H
^^^**8S, .^Iti'olnr mrponiii .......
84 ^M
tu. AiipiïlilliU' MUi'umH (fmiiiiniimu) ....
C3. CVllulur almclurv of uii-liiriosù . ■ • . ■
89 ^M
97 ^M
fla. CVIla coiitainiug pigmonl .....
87 H
OT. Uvxaina ........
M ^H
es. )lM.*n>n.'a|)ic' nnalumv i>t' int xoina . . . . ■
90 ■
C9. Sllipr-lrvitii-'t Ivniloii of rul .....
« _■
70. TraiiBvvm- «l'i-tioii of Icuilon .....
M ^m
71. FitllXilllH Rioll<t*<-iini ......
9i ^H
72. l'iipillar^' Hlircimn of brciwl .....
" m
73. I.lpomn ........
M M
"4. 7i. C'flU from miiwr ....,,
97 ^M
7e. Colloid vvl\s t'rniii votlulil cuiitMT .....
»8 ^M
T7. Slnimii of cjin-inoiiia ......
9B ^M
7g. IVvtrlopmi-iit of cnrrinciinH of nuimnin ....
»9 H
TH. Silvpr-tTPiiicd rjin-inomn of iniimraii ....
lot ^H
HO. Sl^» of o^irTliauf curviiioiiin . . , . .
los ^H
RI. Eii('(-]i)ialoiil ('■R'iiiutii.i ......
1«S ^
RI. (Vils of coltoiil i-un-inoiiiM . .....
104
63. CoJkiid (■«"■■l'r .......
1(14
84. LVIIiilor inflllrfttion of faily tlimii! nrouod cnrcinomutoiu Ij-mpli glundi
105
Si. Sflihilitîp inU-ntitinl |)iii-uiDUliia .....
10»
86. UummA of lîvi-r .......
103
ST. tiiuiuuu uf kidui-^ ......
10»
8R. Iiiduralinj; lii.-]Kitil!i<, fini »iife .....
. ll<l
89. Iiidurutiii;- li«'|Kiiîtiji, «■iTiiid *tKge ....
. lin
90. Klpliipnt» of milinn liiliprcli! .....
. lU
SI. Softpning of luiliiirv tubeo'lp .....
. 116
Dî. AJilîarr tubi.'n'lt? of pin niiiUr . , ■ . .
HT
9S. ArtL-riuk in llic m^i^-liborhuoil ot * tiitiercl«
. HT
EI4. Vm*i>I in > (uWrelo ......
. 117
1>&. Gintll cell frnin a liilicn'lc .....
. 118
se. Admioid itructiirc of a tnbovie .....
. IIB
97. Uiaot roll frum lutijf in plitliixin .....
. 118
i 98. Tubfrclc in \i\v tahiMiriHh ni il<^iiTii ....
. Il»
1 99- Lymplmljc of iltmin nlfivloil with liiWrclo . . ,
^^ 100. Cuitugo af a ccphidopod .....
. IIO
. 117
LIST OF ILLCSTRATIONS.
XXVll
no.
101. Enchondromatous tumor of metacarpus
102. SI icTOscopic characters of EDchondronia .
103. Mnncle eelU from a leio-myoma
104. Plcxiform neuroma
105. Dilated lymph vessels of picphantiasis
lOG. Reticulated tissue of lymphoid follicle
107. Lympliadenoma ....
108. Spinoua eella from a cancroid epithelioma
109. Elements of a lobu1»ted epithelioma
110. Irri Ea led epithËlisl cells
111. Yariolous pustule ....
112. Kpithelioma of h sebaceous plnnd
113. Tubular rpith el iomn, low power .
114. Tubular epithelioma, hi<;h power .
115. Cyiindrical-cellcd Bmthelioma
116. Papilla from a papilloma .
117. Adenoma of miimma
11H. Adeno-fibroma of mamma
119. Egg of Naboth ....
120. W all of a scbaeeous cyst
121. Head and neck of tseiiia solium .
123. Invaffinatcd echinocoeeus ■
123. Eehinocoeei ....
124. Ostco-malacic rib (bone softening)
125. Rarcfring osteitis ; canaliculjzation of osseous tissue
126. Syphditie sclerosis of bone
127. Caries fungosa ....
12B. Ostco-maliicic rib (bone softening)
129. Ossification of carliliige .
ISO. Cells from fluid of an inflamed knee-joint
131. Elements in synovial tfuid in acute nrtieulur rheumatism
133. Splitting of cartilage in acute articular rbeuniati^tm
133. Arthritis from purulent infection .
134. Cartilage in noibilnr rheumatism .
135. Cartilage in nodular rlieumulisui .
136. Cartilage in white swelling, first stage
137. Cartilage in white swelling, second stage .
138. Cartil.ige infiltrated with urate of soda
139. Connective tissue in a wound dusted with vermilion
140. Adipose cells in œdema ....
141. Connective tissue in an early stage of suppurative inflammation
142. Si I ver- treated pcriciirdium
143. Gold-treated pericanlinni, profile view
144. (iold-trealed pericaniiuni, ïnElamed, jirofile view
145. Transformed eiidothclin of infhinied pericanlium, two
146. Transformed cndollielia oC inllamt-d pi-ricardium, six dav
147. Transformed endotlielia of inllamed porieardiuni, six da
148. Endothelium covering fibrous bauds of adhesions, pleuni
149. Heart muscle in typhoid fever, cloudy swelling .
130. Falty degeneration of heart
IJI. Vitreous metamorphosis of muscle
152. Trichina spiralis in muscle
133. Reticulum of blooil corjiusctes
154. Fatty infiltration of heart
155. Falty degeneration of heart musc'le
156. Pigmentarj' degeneration of heart muscle
157. Acute myoï-arditù in rheumatism
158. Fibroid induration of heart
159. Fibroid induration of heart, more advanced
160. Valves of heart .....
161. Inflammation of aortic valves
I dav
s (parie
s (visée
s (parie
lal)
rai)
tal)
PlOB
129
129
ISâ
1S8
141
142
144
146
147
14S
149
150
133
154
135
15B
IGl
161
163
166
191
193
192
198
201
203
208
219
221
229
229
230
232
236
237
939
340
242
249
251
254
259
260
260
260
261
362
265
373
273
275
2K3
2K»
292
294
294
2!>G
297
297
299
300
XXVIll
LIST OP tI.LVBTRATtO.f9.
•
rto.
lei. Inflainna^on of mîtnil valve
ICS. Rmlocaittill» tla«i tu A-iuiioii . ,
ld4. Vvgftlntioit from bfiiIc i-iidtwiirililii . .
Ills. Small Hrtrrj nnd mpillfti^-
1110. ArU-riolc and (mall vi'iii ....
Itir. Kniiy (kicviirnitiuii ol' innt-r «'ont of kortii
lâH. AotU shuwiii)' mi'UlIc (.i>Ht iiiicmiplvd by rniWyonu) tioiic
109. Swiioii of «rl<Tj- H liour» alwr li^ntioti, iruiwrrriic
1Î0. Seclilin of nni.-rj' 48 boun «fti-r ligHiliiii, lunL'iiiiilinal
171. Sii'lion of urd'ry 48 lioiirt rIVit lijiiilioii, tninticno
17!. Apo» of tlxromliu» ol' fi^. 1 ;o
173. SiK^lioii orf arti-rv 9t lioun nfU-r Ijjraiioii. trniHvi-rw
1 74. Scotiou of Htlery H tliiyt nflvr lijiuiiun, IniriM I'me
m. Sct-tioii of ttU-ry 35 liays iifti-r U|;Mioi>, loiij-itiiiliiinl
I7G. Swtioii of nru-ry W lUvi" «ft»T li^-ntio», lonptuilitinl
177. Sn-lioii of :irlr'r}' 3 monclit utliT li)!niioii, imiKvi-mt
178' SmIioii of nrlirn- l'> dny* after nioiliâiil ligution, loogiluiliiul
179. Artery nhowiii^ nnturol lin'moitaaii
180. Artery tuiituiiiini; H ti-ptic fiiiliolua ,
181. Hi'iiiurrliApc iiifiin'tioii ....
18!. .Sv|iliiltIiViliFHyii'o o!' «ru-fy
183. CnpilUri' fmin miifiitory, «ilTO livalcd .
in4. ItiBamfit ailip<»i- tioiic ....
1H&. Cnpilliin- Sitol Willi hurtiiiiioiitiii rntiHlt nnil itnuiular pigment
IHO. t'ntly <li-||;t'iii.-nil("l Mat[<i|;1iiiiii (tiA , ,
187. F*tly ili'|!('"«''>li-'l ri'iiHl •■HiiilUrk-iii , ,
188. Dilntcil ly>ii]i!> v<-«'i-1* of ■■ii'|i!iantin4i*
1S#- Silvoi^lrfniril «iwiioii of ciuvinoinii of iiiiiiTimn
ISO. Lymjih pliiiitl. low power
191. Lymplifilaiiil. Iiinh iioncfT
193. Lyiiinh elaod, elironic înHitminacIoti of .
193. Ainylfliii ■ji'gi'nrralîoii of aploen .
194. ('i-ll> from lyinpluilk growih of liwr
\B&. l.)iiiplioiua .....
19<>. TubvivuloBU od* lymph jtl""!) ■
llil. .Silvur.trvalcd m-ni> foM-iculu*
198. tirrtv fitire .....
199. Nmtv ganglion from IW^'i )iiutrl
800. KpitlipRomii of ncTïP ....
sol. Kliliafy- lubercU- aroiiuil vemcl in pin mnlvr
SO!. Spftion of »t««jI iu tubwclu
103. Ptaiiiiuunin .....
904. CnjiLliftri' fill<<<l willi hicmMoiilin c:'ry>'ial» .
105. Graniilm' eo»ptm-lr« in brnin «ort«iiiitf>
lOB. Tixnie rhancc iu loftcniug of brain (^nniilnr cor|>iiwlc*)
Ï07. Snrcotnn of limiii .....
SOH. Syphilid of iivnv eviilrot . • . .
SOU. Sit-otnlnj^- ilrpetii-niiiou of >[>iiial conl (laU'ral coluiDiui)
510. Sd'Oiidnry di'gmi-tnlion of ■pinxl corrl (po>U>rior ooliimn*)
511. Sfponilarv ilcenicTTition of tninjil i"onl (potliTrinr roliininii)
81 Ï. Spinnl icIraMBH (poiti-rior i>oliiiiiii>)
213. Spinal «cli-nai». «Iiowinjt iiH'mii(i> of iiturogli»
314. CajMlLiiT UoodvuiH'l in H-krOBii . .
Sia. Anterc^l&teval «ckromii ....
316. PfpmoMMd gaBglionic nerve crIU of rpiiul oonl
317. Broni'hinl lillic of pig ....
Ï1B. KirticuUli'il slruclure of ppUb .
219. Air-cell* of liunuui luti;;, aliuwLiif; I'uitlit'liiitn
S30. Âlut-oi» IntntfomiatioTi of rpithclinl itIU in coryxa
S3t. Fihriiioiia doçrnrrntion of i-pÎTlivlinl ri-lln in ftdsti m^mbranr*
SSi. CVtU from «piitum of nruto bronehilii
. »e
. 901
. SOI
. «OS
. SOS
. 311
. 314
. 3IH
. 919
. 319
. 3Î0
. SSO
. BW
. 391
. 994
. 394
. 3:s
. 390
. 3SH
. SM
. 331
. 334
. .1SS
. 330
. SSI
. 33Ï
. 340
. 347
. S48
. 3J9
. SM
. 3&a
. 3»e
. sac
. 8S7
. S.'.9
. 359
. 3^9
. 309
. see
. Slifi
. 307
. 379
. 873
. 87S
. 378
. S79
. SHt
. 389
. .18*
. S»S
. ISO
. SH«
. 387
. 387
. 390
. 391
. 393
. 8)0
. 398
. 4«5
LIST OV ILLDBTRATIONS.
XXIX
ne. riaa
223. Ttansvenie «ection of bronchus in acute phtliisis .... 408
324. Lung in interstitial pneumonin aiul intra-Hlveolar hemorrhage • 410
925. £mph}-t«ma of lung [macroscopic) ..... 413
326. Emphysema of lun^ (microscopic) ..... 413
221. Catarrhal pneumonia . . .413
32B. Croupous pneumonia (red hepatization) ..... 416
529. Cellular éléments from second stage of pneumonia . 417
530. Croupoas pneumonia (gray hepatization) .... 41a
231. Fetiu pus, shotritig bacteria among the L-orpuaclia . . 422
292. Interetitial pneumonia ....... 423
233. Pigmentation of Inns ....... 424
234. Sj-philitic intergCitia I pneumonia ...... 429
335. Brown induration of lung ...... 425
336. Vascularization and fibroid development of intni-alveolar exudation of
lung (low power) ....... 427
237. Same as fig. i36 (liigh power) ...... 427
23R. Carcinonia of lung ....... 429
339. Bloodvessel of tubercle . . .430
240. Scrofulous inflammation of bronchus ..... 43t
241. Exudation in aivcoti of lung in acute phthisis .... 432
342. Grsv tubcrric of acute tulrenrutoais, lung ..... 433
343. Yellow tubercle of acute tuberculosis, lung .... 434
344. Caseous lobular pneumonia ...... 4.^5
345. Exudation in alveoli of lung in acute phthisis .... 435
246. Tuberculous interstitial pneumonia of chronic phthisis . . . 437
24 7. Inflamed pleura, showing fibriuous exudation .... 440
348. Fibrinous exudation ....... 440
349. Submaxillarv gland of dog ...... 447
350. Papillie of tongue . . . . . . .446
351. Inflammation of conjunctiva ...... 449
353. Silver deposit in gum in argyria ...... 450
353. Section of stomach of child ...... 401
254. Reticulation of epithelial and other cells ..... 462
25Ô. Feptiu gastric glatnl, low power ...... 4tj8
2.^6. Peptic gastric fjland. high power ...... 4(!3
257. Commencing formation of cvat iii stomach .... 4C7
258. Cjst of stomach ........ 407
359. Reticulated tissue of lymphoid follicle ..... 479
360. Villus of intestine, ralibit ...... 480
361. Lymph vessels in vermilbrm appendix ..... 481
262. Intestinal villi ........ 482
36.1. Section of colon in acute colarrh ...... 484
264. Vegetable forms in tVces ....... 485
365. Enlarged solltiiry gland in acute diarrli<ca .... 487
266. Colon of child in acute dyst-iitery, showing <levelopment of cyst» . 4fi9
267. Submucous tis.4uc of colon iu ucuic dysentery . . . 490
268. Colon in chronic dysentery, vhuwing su])erficiul ulcer . . . 493
369. Follicular ulcer of colon in chronic dysentery .... 494
270. Cyst of colon in chronic dysentery, low ]iowcr , , . , 495
271. Cyst of colon in chronic dysenterv, high powpr .... 490
272. Histological ek'Uieiits of eysl-wall in chronic ilysentery . . . 497
273. Micrococci and baclcriH in chronic dysenterj- .... 498
274. Lymph follicle in typhoid fever ...... .lOS
275. Tubercular ulcer of ileum ...... 609
2Ï6. Tubercular ulcer of I'eyer's pntch ..... 510
277. Lymphatic in tulwreulosis of ileum ..... 511
278. Submucosa in tuberculo^JR of ileum ..... 512
279. Cylindrical-celled epithelioma of large intestine .... 515
280. Liver of a three-months child ...... 517
281. Hepatic cells, Isohkted ....... 518
282. Hepatic cells, trabeeula of . .518
^^^sx^^^^^^^^t^^^ftïhSsrîûmovs^^^^
!■
^H
^^^ràm^^^M
^H 283, lujiKtwl liver of raliliit .....
^^M 284. Iii|i<tt<."l bili'T^' t'iiiatirnli of nibint
^1 389. doiidy nvi'Iliii'^ ul' lîvi-r n-IU ....
. 51U J
510 ^H
iu ^H
ÎWI. Vatty inlillnit!on rf livcr rrlU ....
. 32a ■
397. Anjloiit infiltrnlion of lî»-r cflU .
. S3£ 1
38S. Conni'id-J liirr of rimlliii- itiii'iM-
. A90 ■
2tl0. Iiiiliinitliiji inlLuiuiuatioii a( liirr, But rtnff
. MA I
no. Iliitiinitiii}* iiiTliimmiitiun uf iJriT, ctc^lii] *U|lti
. M» 1
391. Itilinri i-xM^Tiriili in irirrliuiLi ....
. bSS 1
M3. ('t'IU m ciri'limiH of lirt-r .....
. 593 ^J
299. l'ntty inlîltriitioii of liior • • . . ■
fi5A ^H
XV4, FnUy liijiltmlian of iivcr coll* ....
. ii$ ^
tSA. Al») loi'I liviT ......
. £58
29U. GoiBina of livtr ......
. ftCO
3*7. Silver (rniltil oiiu'iitiim (tiunii*!) . . .
. m
ÎW8, 3t>!l. InâBBinl nuiKnliiiii .....
. 573
301). Anirloiil 9|<Ii-i-ii ......
. Mi
301. Supm.rciiuJ ra|iMili> (laii)[lttiilinal ■ct-lion)
. M»
S03. Siipru-rt-iiut cuntulv (Iniiisvi-rw: Mi-tion) .
903. 1>in^niiii nf kiiliiv^ giintiiiiil . , . ,
. iM
. «04
30(. llrniii't looj. of kiiltii')' (l»ii-;ili](ltiial) . .
. 009
305. }itnli^hc tiilHi or kiilni'l (luii-fitu-liiiHl) .
. SOS
SOU. I'yrniiii<ltil lulvlitiipe of |>i)['ii kiiliu'v
1 307. Ciiltoiil ilcgciicnition of i-]iitlii;llBt crlU in inivnlitini lU'pliriCii
. eoe ^
61« ^H
^^_ 9UH. lîrinnn 'fH.iU ......
. «11 ^
^^B son. FhII t <■■•(■ ironi \t}u»a}totoa* p<riMH]in|[ .
^^V 3)(>. Fiiny lii-fM-ncnit'ioii or ri-iinl cnpIIlHrii;*
r 911- Falty (iiirciiiTHlinn of 3Jal]iig1tIU]| tuft
^^ 3IÏ. l'rtUrrliuT nopliritis .....
. OIS
. 617
- 6IT
. Oïl
^H SIS. Kiiincy of Hiigiil'^'lMvHM! ....
. GS3
^^1 .114. Aiiitlniil •1i--.-v->ii'nit>»ii uf tlii' IklnlpiphUii Uift and AlTfTntDl venel
. 627
^^H 815. Uriuifi-iTiiiii lulii^ ol' ifirti'K in iilifrtphornu' poiacining
. 680
^^f 316. Fntty ciuti in uriiif ill ]ihc»[ili(ir"iiii |>aiioitiiig
. 630
^^ 317. Iiiicrsiitîul iifphritîi, fiirlK-r iiiian
. 633 ^
3))f. (iRumlulioii uf ki'lm'v ill Itn^jlii'* iliicsM!
«33 ^H
31!i. Maljii^liiiiii i;lii[iii.-niliin uf iiilt-nlilinl lle{ihHlî«
. 634 ^
33». Ilitcmliriiil iii-|>liriti''. ailvniirri] t-Uifif
. 636
3Sl. Iim-r«iitiii! ui*pliriii<, niiïiin«Hl iiia;;i>
. 636
3îa. (.'olloîil ilit^-iii-TBiioii ol' i-niiii.-liiil n-]U in intirnîtial oc-phritii
. 637
323, AMi--rif> froiii Itiilncy of c itonif lt(iy;lit's iliiciwc .
. 63S
324. Kiir)*)!'»] kiilni-v ......
. 643
^^ 3!5. <->nit)iiiH ul kiifiii.'/ .....
. 648
^B 3Î6. San-oma af kidney .....
. 649
^V HS7. ('ntrinoniAlaii* (upîMit of bladder
. 6ï6
' 3ÏB. Tcïtîple .......
. SU
329. SpfniuiuxoiiLi ......
. «M
330. Otury ot un ul<) bitch .....
. 678
331. Ovule .......
. 674
H3ï. Kof of NnSotli ......
S^il. UiwuIdt oi-ll) from u leîo-Riyomn
. BM ^
699 ^H
334. Mntiiniury irliiixl ueîiiui .....
. 702 ^1
3Sb. Mamiuiiry t^liiiiil. iiivoltitJOii of ....
. 704 1
936. Cv\U of iitHiiiiiin in euHv tui-^e of iiivohltton
. 705 ^J
3S7. HtfRinnlx nf liimiHn milk ....
^H
3SH. Inier-ncinii* •|>în<lli>.iTlli-d 'iinroms of niainnia .
708 ^H
339. Kibroiun of niumniii wîili <ii1iiii'd iluetu .
709 ^H
^^ 340. Fîlirontu uf miiiiiriia (pupilliiry) ....
710 ^M
^^m 341. Silver (rv-nt«<l M-etitiu (if l'iLn'iciiliii.i of lUntlluiA
. 711 1
^V 343. IVvolnpineiil i>f oïLiriiioniri nf niNtitina
. 713 1
' 343. Scirrhoii» «■arvinonni of nuimniii ....
. 7IS 1
944. Adiwomi of mamma .....
•
7lù J
^^^^^^^I^HIHH^^^^I
LIST 07 ILLUBTHATIOMS.
XXXI
no.
34G. Section of blastoderm of sd embryo
946. Komial ekin .....
S*T. Tactile corpuscle .....
348. PacioiaD eorpuscle ....
349. Dilated lymph caiiillary of the ekin in (Edema
350- Increase of cell elements of the skin in erysipelas
351. Vscuolatjon of the nucleus of spinous cells ot' epiderm in
352. Variolous Tesiele of skin ....
353. Yariolous pustule of skin ....
35*. Acarus scabiei (female) dorsal surface
355. Group of demodex foljiculorum .
356. Achorion Schcenleinii after treatment with li<]. fiotau»
357. Trichophyton tonsurans from herpes carcinatus .
358. Siicrosporon furfur ....
359. Bair from case of alopecia (mierosporon .4udouini)
360. Isolated spores from case of alopecia (microsporon Audouini)
rioB
, ,
TIG
717
719
719
722
725
1 irritation
726
,
733
.
733
743
742
744
745
746
747
uini)
747
ERRATA.
Page 1T2, in foot-notc, ^br judicial r^nr/ judicîoiui.
" 453, line 6 from bottom, for niyelo|ilastic rtad myéloplaxes.
" 468, " IS " " omi( seldom.
" C37, " 10 " " /or FigB. 342 «nd 343 reorf 321 «nd 3Ï2.
PATHOLOGICAL HISTOLOGY.
PART I.
GENERAL PATHOLOGICAL ANATOMY.
CHAPTER I.
NORMAL HISTOLOGY— CELLS AND NORMAL TISSUES.
Beet. I.—Cell Theory and Strnctnre of CelU.
Before entering upon the studj of pathological hiatotogj, a summary
of our knowledge of normal histology ia given, in order that the principles
which underlie pathological changes may be understood.
Histology was founded by Biehat. It received its further development
by Schwann, who applied to it the discoveries made by Schleiden in the
vegetable tissues. It came to be recognized that the cell, whether aniinal
or vegetable, is the organic unit, pur excellence — the simplest body wherein
life ia individualized. It was then well known that some living heinga,
possessing the functions of nutrition, movement, reproduction, birth, and
death, consist simply of a single cell.
In beings more complex, the cells are surrounded by an intercellular
substance to form tissues and organs of which the cells are the essential
part, still playing the principal role ; but the cells may be so modified, that
they can scarcely be reco;5iiized, if their metamorphoses are not regarded.
According to Schwann the cell ia composed of an enveloping mem-
brane ; of contents more or less fluid; of a nucleus; of one or more
nucleoli within the nucleus.
In regard to the formation of cells Schwann admitted & free format ion
(spontaneous generation) in a primordial generative fluid, whetlier the
latter be found alone or be placed between pre-existing cells (blastema or
cystoblastema). According to him, granules appear in the liiiuid, rudi-
mentary nucleoli; around these new granules become visible, and sur-
round themselves by a membrane to form the nucleus ; the nucleus now
acts upon the surrounding blastema, new granules appear and arc soon
surrounded with a cellular membrane, when at last wo have formed the
perfect element termed a cell.
2
18
CBLLS AXD XORHAL TISSUES.
Kcmxk, wliilc oltttcrring in the ovule t)ic phenomena of development,
fll)Owi;(( titc falliii;}' of this vien. Starling with tlie idea that llie ovule w
H tnic c«ll, the incDihnine of which is the vitelline membrane, the conteuts
the vitcDuB, the nucluus the gunninnl vesicle, and tlit? nucleolus tlio germi-
nal spot, — tliitt nutlior eonttîdercd nil the cells of the t-mbr^vo as derived
from this cell, in llie following manner. After fccumlatioii. the vitcllus
by segmentation is divided into two part*, tlii'*e into two uther part;!.
Which proceaa of diviaioit eoDtinuett until there «re forme<l titmicroiiii atiuill
spherical bodiea. Tliese wgrnentftlion corpusi-lea or new cells apply
F18.1.
FngXMBtT* •(•(•• In Ui taiiiantuliiii of Ih* r*"' «' t^* mtununH araiii. lllfli fovw.
themselves to the internal iinrfAce of tlie vitelline membrane and form ft
lavi-'r (blastoderm), which fouii divides into tliree leaflets formed solely bj
the cells. It is from the cells of these leaflets, and always hj a proceiKt
of segmentation, tJiai all the cells of the animal are derived. In his in<
vestigalions upon the ori^n of issues, Kemak concludes, that all cella
arise from pre-eiiatinj: cells, in one of three ways : by teqmnntation or
diviuftH, by gemmation or hudiiing, and by eiidogenoua formation. Ac-
cordin;; to die present conception of the cell, these three modes are not
essentially distinct, ,
N'irchow npplied to pathology the physiological facte demonstrated by
Remak : he coiisidcreii th.it all ntw funnalion» tif cell» or all neoplatmn
aritf hif a cnnfixamm tirr'l'jimrnl. from prt-rsitfiin-j re//», and thus sug-
gested the ndalion lietween palholnjry and physiology. Kemak, adopting
the definition of the cell given by :^chk-iden and tichwami, recogni;iud a
memlirone, contents, nucleus, and nucleolus.
f^iilise<]uently through the lahors of Max Schnltse, von Recklingliauson,
Kiihiie, Iteale, etc.. the definition of the cell has been much moililied.
Dujnrilin had previously remarked, that inferior beings consisting of
a Bingle cell were not always enveloped by a membrane, hut that they
often consisted of a mas» susceptible of change of shape, to such a degree,
that very long prolongations might bo advanced. To these masses
Duiardin gave t]ic name of MfiWr, and their movements he termed mr-
coaif movemfHti. Max 8chnllxe, iiivn>tigating more widely thesv same
plienomcna, extended hi:* studies not only to unicellular animals called
amwhœ, but als<) to the Cfllidar elements of more complex beings, lie
compared the animal masses ^u-teeplible of movement, to the cellular masses
of vegetables previously known by the name of yrotoplagm ; the funds-
OBLIi TRBORY AflD ftTROOTHRR OF CELLS.
19
nientnl Bu))$tsknco of anitna) colls he cklled pratoplftsm, anil t)iO nvoveawnta
of wltich tliCT arc 8UHUi.-jjti)ilc he itanuid amcHiiiil nutttmenl*.
Numerous celb of tlio lii};her Rniauila am) of niKn, for example th«
white c<ir]Mi«cte0 of tlic Uood aiid eiobrjotûc c«ll8, arc coni|)Qfle<l of |>ro-
riK.a.
Fis- 3.
Wuia wrvxlai (M Irnvft «(111) viiil*!^
^■|4l«Mlll,Ud (Ml» InuIfmriU. <Oir.
® ;9
Fan «dla: ■.(»■■ > (■■■•lalUf «-'saJ ( *. fram
tr«l>t.<,Bl(Mlln(Mllt. \ltl»4^lnli.]
I
i
to|ilasiii, pOBsen no tnemlirane, and prcKent amieboid movcinenM. In
onter that itipse trulj ckaracteri-ilic nuiv(im(.>)iU of the protoplasm may b«
producol. it is necCïsarj dial (he cells be placed in the coiHiitionii of hoat
am) moisture in which thej live in the norma) state. When colored
particlet are found near a cell possessing; tliese movements, they become
cH';)obHl \ty the amoeboid prolongations proceeding from the cell, and
pcneinte into it« intiïHor.
llie fiuion of the amicboîd prolongations, the penetration into the
interior of the cell of colored parliuti>i4, demons Ira te that these cells have
no membrane ami that tiie deliDitioii of the cell given by Schwann i.'« not
correct. It ahauld not be concluded from this, however, thai all cells are
wanting in a membrane, but rather that when it doca exist, it cousiilutea
only an acceasory. The definition of a cell is therefore reduced (*> a
ma*» of prot'tphitm itfhtin'i a nurUiia. [Even the nucleus la not now
considered by some ekUtcd histolo^ts to be essential to a cell. For
th«m the simplest cell consists of a mass of living protoplasm.]
The nucleus of cells appears to be a vesicle, the envelope of which fre>
(|uently hiu a donUe oontonr; its contents are either clear or finely
KnuiuUr or reliculnled. In its interior are found one or more nucleoli,
which ajipear a» clear, round, or angular *\w\a. The high refraction of
the nucle'ili gives tltem the apj>earance of fat ; but the facility «with which
they are colored by carmine, their sohiljility in a solution of pota.s.ia, show
that they are not fat. The latter is not colored by carmine, and is not
dissolved by a cold solution of potassa. A;5ain, the investigations of
Ualbiani upon the oralo «iemonstrate that the gorminal spot is a vesicle
auscepliblo of change of «hape and dimeu'^ion under the eve of the ob-
server. When considering the epithelial cells of tho skin, it will be s«ca
20
(MAL TISSTtBB,
Pig. 4.
thnt their nucleoli nre susceptible of bccominf; vesicular un<lcr the iiUgbtcst
irritittion.
[Ib the white cor[HWcIe« of the hleod, and other celUitar elemeuti*, a
fine reticulum ha» Wen lately tliscovered. The nodal uoiula of ihîa nsti-
culiiiD are sHghtly larger and more distinct lliiiu the minute fibres which
form thu mcshwork. It is iheso nodal
pointa which pi-c to many colU their
^raniilur aspect. This rtticiiluin per-
meates hoth the cell Wl^* and thv nucleus.
In the cell haAj it is termed intra-col-
lulnr, in tlic tiucleus intra-miclciir net-
vfork, llio librilfl of the one heinj; con-
tinuous with those of the other. In iho
mi^shes of this network, bei>îde:t the gclu-
tiniform substance which naturally filU
them, may often be found veritable grati-
ules. When such granules are numerous,
thoee cells ma v be regarded par fxceUenct
as " gramdar cells."]
At it» origin, every cell is composed
solely oft PIA3S of protoplasm surrouudiii); a nucltiiis. Among tbu cells
poïHussing this original structure, no diftoreuces have been found iudi.
eating tliat a given cell will undergo certain ulterior modifications. In
the adult iheae cells are met with only in the blood (while corpuscles),
ill the Ivnipli, anil id Ibe (ittuw which esperieuce a cont'inuoua renewal :
sucii cells cottstitnte the entire embryo ; tiicy have therefore been named
tmbri/onie f«U».
Fig. 5.
H, Wtiil* hiMd-mrvnMlfi. ibnalBt >b
lUI'H-cfllliiiir tnj Ha lDlr4-nn4lr«r r*il-
|il»rJs, ahDBItii ■liuiUr rrdrola. Higli
pi>v«r. (JriiM.)
CtUi rrniiiit><ai*m«orbon'diit1BtlbFlr|wrl6d(iF4cTslepBieBi, n.ft. Maitianglnr "('*»' C""*"
{FrvjV *,f.S- Ljroifb cvtJft frnni Lbn murruw of iho ILbtditf th*nu1uvft')rif,#nBiliied1(i Ibditdrmii vt
Ibf felsflil; c.''.*. iflirlh» icllnu «r iJruhiil id.1 Hun^r Ks pi-icrul. I.J. >i> ralltdnMoblHlirrwinlhn
(^Uif ■ new.boni 4oï, (Itn iba*(th>i of dwbul tipcrceal. Utch puwcc. |Jtiiii<4ir.)
Cells which do not possess an enveloping membnne, and which present
a.)}rolopliLfm with amu;boidraoveracats,are : lai, Thocellaof tiie embryo
CELL THEORX A^D STRUCTURE OF CELLS.
21
before they have acquired a determined shape ; "2d. The cell9 in the
developing layer of the marrow of bone ; 3d. The mother cells or giant-
cells found in the same substance ; 4th. The white corpuscles of the
blood; 5th. Lyraph ceils.
Emhryonic cell» consist of an irregular mass of granular protoplasm,
which may be spherical, measuring from .01 mm. to .01.5 mm, in diameter,
are swollen by water and acetic acid, colored brown by a solution of
iodine, and faintly by carmine which increases the granular appearance.
Tliia protoplasmic mass incloses an oval or spherical nucleus frequently
seen only aft«r the action of acetio acid, possessing a double contour aud
a nucleolus often very small and which is deeply colored by carmine.
Instead of one nucleus, if the cell tends to a retrograde change, there are
frequently several small and angular nuclei ; if the cells tend to growth,
the nuclei are spherical and well developed.
In the developing layer of bone from cartilage, cells are met which ao
closely resemble embryonic cells that there is no characteristic sufficient
to distinguish one from the other. In consequence of the changes which
these cells undergo they become slightly separated from the primitive
type.
The large multinucleated cells, which are found alongside of the fore-
going, apart from the multiplicity of their nuclei, from their great irregu-
larity of contour, and from the buds which they present, possess the same
general properties as the embryonic cell ; the protoplasmic substance
which forms them gives the same reactions. Later these elements be-
come flattened, more consistent, and separated from their original type.
Among the white corpuscles of the blood two kinds are recognized: the
one incloses a single round or oval nucleus with a distinct nucleolus which
re.-iists the action of acetic acid and is colored by carmine ; the other con-
tains several small angular nuclei or a single nucleus which breaks into
fragments on the addition of acetic acid. We believe the latter to be in
a state of retrograde metamorphosis.
Fis- G.
Fig. 7.
CpIIi Trom a «Ancer: ib^ivinfr feU-wali,
CFU-conTaaLn, DLic]el. 4Dil nucleoli^ Lbe du-
X3J0.
All embryonic cells possess the property of giving origin to elements
resembling themselves by the following process. The nucleus enlarges, the
nucleolus becomes constricted and divides, soon the nuclues divides either
99
C8LL9 AND NORMAL TI9SDBB.
Iiy A fÏHure, «rliicli separahHt th« nttclcus into two, or by « kiixl of confltric-
tion whtcli give» it an tiour-gliiss shape. The muss of pmtofil«»m «urroutuU
ing th« two nuclei divides, and two cells arc formed, 'llie Kegmcnution of
the prolopla.^ni doen not always follow timl of tli<! niicleiH, i<o that there
may be n)ai)y nuclei in one eell. Kreiinenily a portion of protoplasm la
separated inclo»ing a nticlcoliis.
Embryonic cells are destroyed or they undergo a series of modifica-
tious which characterize their appearance as seen in the diBerent tissues.
Thtf simplest example of modincaâon of embryonic viemcnis is that in
vhich there is an elaboration of a now substance in the protoplasm. This
is seen in the early dcvclotiment of adipose cells, where tlie protojilniun
ooiitains fut grannies ; in the formation of coloring material in the white '
corpuscles of the blood of the embryo during tlicir truiwilion into red
corpuHcles (^Kcronk and Ivtilliker). The moitt important altération of em-
bryonic cell» eonniiit^ in tlie formation of a membrane surroundin;; the
proto|)lasn). This memhrane is comparable to tlic secondary membrane
of vegetable cells in winch it is formed of cellulose, while in animals it is
coniposiii of an albuminoid mibstaiice (the cartilage cells, etc.). This
nicmliraiio has for each variety of cells some notable difl'crerices. It is
Still undneideil whether the membrane is a condensation of the superficial
layers of the protoplasm or is an excretion of the cell. Whatever it may
be, it is entirely distinct from the protoplasm. As soon as a celt is
Burronndcil by a seeomiary mendirnne, it tiecomos [«o to «peak] per-
roanently lîxed and axsixts in the building up of the tinsues. U h impo.'i.
aible to Hiiidy these fixed etements without consideiiiig the tiâsue which
coDtaioB thcin.
8«et. IL— Normal Tlsmes. I
Xormal tissues may bo divided into three groups. 1
FinsT (tRiirp. — Tliose in which the substance uniting iiiid aepiirating
the cells is charBcterixcd by its form, lU physiiml and chemiciil propertît-a
(connective tissues, cartilaginous and osseous tissues). In these tisanes,
although the cellit have special physioloj^ical properties, relative to the
form»tion and prcse nation of the ti^ftiie, they have no characteristic form
when they are aeparately considered. _
SKnoxti (îROtrp.— The second group includes those tis-iues in whteb ttie]
cell has undergone ■lueh moilllicattons that it is no longer recognised as
a coll, but has assumed certain physical, chemical, and physiological char-
acters. These are the muscular and nervous tissues.
Tlltiiii GtiocP. — It includes tissues composed of cells having a re^Iar
and constant evolution ; the ccllidar elements are intimiitely held to-
gether by a slight amount of uniting substance, the glandular and invest-
ing epithelium for example. Freipicntly their cells have a ctiaractcristîc
shape, and they always elaborate in their interior a definite subiçtanoc:
tlius the epidermic cells form the corneous substance : the Cecils of mucoua
membrane, the mucine; the cells of glands, their secretions, etc.
UCCOUS TISSUE, C0NNBCTTT8 TTSSVE.
ss
PiBKP GmvT. — CosNixriivK, CABTn-Artrfors, and OssBota Tiesre?.
CoxxnmvR Tinsrs». — ^l1io o»nn«etivc tituincit include inucoHa,fibrout,
adivoK, rftirulatrtt, and tlattir tittutt.
'axe foniuttion ai mucmiM tu»ut from «mbryonk tUsue is most Btmplc.
In tlie simple»t rnriety of tliU ti.>^iK, a^ mot with in tho vitreous liumor,
there ia dcvelo[>ed l>ctwo«n di« celU ft hynline Milwbinoc «onuiining a
Urge amount of mucin, while the c^lli remaiti iiidoponilcnl ofcaclt other.
In another variety, that of the umSilical conl, the a-W* bisrome funifnrtu or
BtolUte, anaaiomose vith each other, form a secoivlary memhrui») around
thcnuelvos at the Bam« time that a ;;clatinou3 aubatance is prodiiocil be-
tween them. In thu umbilical oonl of a three montli'a embryo, there are
frci)wc«tly found scvt-nl cells in one stellate space : each of these cclU
oonwtsof adistinctmassof proU>[il(Win«ontainm;;anuctoua. The<te fusi-
fom or itellaie spaces and their content» have been called by Virvhovr,
coniMMtivo liMue corptL^cle^, but the term «houbl only be applied to a maas
of nroloploam ami it« nucleus.
CclU foi
fonuing fihnnin linnif nro nlgo derived from embryonic colls.
Those cells known n« "connective tii»3ue corpuscles" consist of a â»t-
tencd plate of protoplasm inclcâing a nucleus, and lie within tlic fugiform
or stellatd »[inoe containing them. Between tlio walls of Uiis space and
CH'iBt la^St^n of Tona^ rat; alwTliif ap
r>l1i>,iinarln4lin>ulwUh>lli*raMnla. nifk
the cell exists a space (lymph lacuna, canaltcula) in which circulate the
nutritive juices. The lymph canalicular spaces anastomose with one an*
other by tlicir prolongations. Fonncrly it was believed that the fibres
f^oupcd in wavin;; fasciculi in uriwdar and fihrou* connective tissue were
derived simply froiu the cell». Hut Kcichert «nl Vin.'h"w hnvp icliown
that thc«e fibrw are ilevelofx-d in the inleroellHlar suhttnnce, which, at
fint mucotb), \i afterwanls Holiitified and i^ finally separated into Bbrillte.
From tliis ittamlpoiut fibrous tiiuue may be conaiilere<l as a mucous tissue
in a more advanced stage of development. So that all tissues which later
become fibrous exist in the embryo as mucous tissues. At birth, die
umbilical cord and vilreoits humor are the only ])arta which i>erÂist as
mucous tissue. Once fonued, fibrous tissue exporieuces atrophic changes. I
CBLL9 AS» HORMAL T18SUB9.
Ky:- K'.
MrpaarUa. V. Ilnurbi'l malKull wlilali r«>iii»'i lb* Unoi», •■•■ «hitb widi Ibf Ullar («o-llliita
t)i« Ijmph nntll4al>r BTilem. é. M)|rsilH( ir «»d«c1i>g I; mpli e«ll*, ctaepluji lui» ili» ht>u<-hi>it
Fig. 11.
1. U*iiiaUUi1ili>aa>rr«n*l7Dipk>
p«udU adhartblill, bIIIi ill» af Haa
»rqi*Bb«»-itEJd rviuAluinribr Ij-mpb
»IU«, Mi»t4<f Ilia J*(Ur bBVQlr'^ja
lauMlid iiimdillr. d. I-rnii'b iH-
Ml. 1. L'iallndli») BHUflD it •
UetwrkUbD'* kI"4, sbairiiii; iba
•Dtrodndlaf r«UpbUr tUtqn.tn fbv
nietbe* of wblcb ftNa*«u fhaly mpb
pallaUp b- LbHan af b vaa*«t. a,
LniMa of ibp rlkOA. <fV>v.)
of it« C(!lUilBr elements ; tb« protoplasm
shrinks, U tntiisfonneil into n ^raniiUr muss
which ïHrn>uu<l« the niioUus %Un Dtftipliied,
nnil in seen «« an irregular! v «îiaped boiiy (iu
t}i« i]erm, areolar cnimeclive litKtite), fata-
tonn (in tendoai), or lenticular in iiliape (in
internal membrane of the arteries, etc.).
Dunn;; all these chan;;c8 the Ijmph canali>
cular Bpaco prcscnca its shape and sixe, m
is shown by staining with carmino or, better,
by nitrate of silrer.
A'i'pvBf tittuc rc)tiilt« from iui accumula*
tion of fat in tlie wlid of niitcous tissue or
arooliircoTiiiectivf; tis!4uc, which we consider
to be a variety of filiroii» liittiut!. Tiii; fat is
depoiileil within tiie ceil protoplasm, wliivli it
di^tcndd by di.4|ilacing tlie nucleus and proto-
plasm to the periphery.
In rrticiilateJ thme. the cells send off
numerous ramifications, which anastomose
ono with the other, forming a very compli*
catcd network (fi^. 11). A cellular body ia
uot fourni at thu nudid points.
The network formed by the cells and their
prolongations U occupied by lymph cuUa
ELASTIC TI9SCK, CARTtLAftlXOdS TISROB.
25
I
Kin. li.
(lymph f;UDil8, «pWn. Pojor's pfttdiM, etc.), or by eolU and nerve flhrea
(iwiirOfrUa of the Uriiin nnd «[miidI conl).
Kla»tic liêtui' hiiJi u jîreiit rusemW«iicc to the preceding, but it différa
ill hiiring iu mt-nhctt verjr irregular, am] tlicre is onljr found a trace of
Uie protoplasm of «ellii «t « few {iDiiiU.
In all the-te ti.-wues, (lie eiulirjoiiic cells «ml nuclei suffer conaidcniWo
atrophy, luvd ar« reproHeuted ouly by an )rrv;!ular, rouod, or olongsled
DIMS, which cnlort) rc<l by carmine, and resUts the aelion of acetic acid.
IrritAtioti causes all thew celU to return to their primitive form.
(.'AHTiniiisoi'» Tis«.-siiu. — C'nrtilti^nou; tissue, like connective tissue,
occur» in ihc ori^misui undur dilTcnmt fomK ; but îc 'a always f'liind bnv-
ing iiH an essential cliiiraeter Celts entirely surmuixlt^ by a cartilaj^noua
matrin, a inHiHiuirent substanco yielding chmMrin by Ixtiling.
The tnie carlilaf;o cell \e a ata»i of protopla-tin coiiiAintng a uucleus ; it
rarieA mncli in «ise and fonn in the «amo va-
riety of cnrlitiifço.
In livi»^ cartilage, the tihapo of ^e cella îti
spherical, oval, nr lonlioular : but when exam-
incd in naier Kith acetic acid nnd in most other
reagents, cartilage cells are seen to have a ;;reat
variety «f sbapee which are due to distortion.
Frci|iiently I'atly granules or small drops of fat
accumulalo in ttie protoplasm of cartilage cells.
When the fat it rery aburotant, as lu adipoM
oelU, th^ nneleu-i remains, \i well ilercloped, and
occupies a position at the itide of the cell. 'Llie
nocleua is always presenilis .«pbericnl or itli;;htly
oval in flhapc, is limited by a double contour, and
its nucleolus is well develoj*d.
The cartilage ecU does not present any char,
acterisiic sufficient to diaiinguish it when iso-
lated, and it is only because it occupies a place in cartilaginous tisane,
that the name cArtilagc cell is given to it. This cell cannot therefore b«
defined by its physical characters, but only by the pruperty it possesses
of forming around it a secondary membrane of cartilaginous substance
tunned a cap«ule (fig. 12).
When, in tJie deveiopnicnt of embryonic tiiwue, cartilaginous tiMue
appears, the emhryonic cells biicome separated from one another by a
■tultittance at tintl aofl, but |;radimlly becoming more conniitenl, wbicli
has all the cbaraetei-â of oartilnginous subiilance. The formation of this
substance is at tiriit slow, it soon increases and condenses as a capsnle
around llie cells. The capeule may al*> be the result of a new produc-
tion of the cell itself. This is (he rinf-r^ottic variety of cartilage in which
cells and capsules are small an<l spherical. Soon the cellular elements
multiply ; at this stage there are freciuently i^ven two ntwlct in a cell.
While dividing, the nucleus at finrt enlarges, elongate*, contracts at tl»e
middle, and finally separates into two. The division of the protoplasm
occurs after that of the nucleus ; consequently we often have cell» with
two nuclei. Pitch of the new cellular masses posaes^es the property of
formiikg around it cartilaginous substance. Thus in 0» primary cajxiulo
PiallfatUlsK MlllUca Hll* : <,
prmopUitn of tb*nn;iv, ma«l#o.
tetvoAxry urtUl^ (sptitl**; f,
fr'nod «qWlHim, In ..ua t4 lb*
TUlllwa «cn> ■(• «CD IWO BN-
rltl.
»
26 CBLL8 AJÏD XORStAl TtSSUKfll ^^^H
there are developed two necondary capsules, In tnultiplyins, the cells
become flattened against each other, nnd have elongated or prisouitic
fonns. This is/artid ntrtHar/e.
When the iiutriUrv activity is very intense, the cells arc rouud and
1ar<;c, as seen in the osxifvii'.g Invent of cartilage. Pcmmnunt cartiSajre
iu tlie adult co<nsiat« of mediiiin-siied capsules, which fre({uently C4)utiiin
secondary cnpeul«8. Upon the stirracc of the orticiilations nod uiidcc
the perichondrium the calcules arc lenticular, nnd arc flattened parallel
to the iiurfacc while they contain no Aeoondary cap^uW. ('arUlage ground
auliHlance iu the adult is often tntiltrated with a ealcareouH deposit in itn
deeper parto. Tldii iucniatatîon fonns a complete uniform layer in which
the cartilage cells are preserved. It ia called e^il'-i/ieJ mrtiht'jt.
In persons advanced in ago, the costal an<l thyroid cartilages liave their
colls infihrated with fat ami present a mu/y/us deiffnerâliùn of their
funilamental substance, causing the formation of nnfructuous cavititM
filled with mucous material and fatty granules. At these sjtiue points there
alio «nmctiincs cxist« ft ealcarcoku infiltration. tlnitHy, Virehow, by the
action (if a i«oliitiou of iodlno and sulphuric acid, demnn^lnited the pres-
ence of amyloid di-iititer<ttion in Uie oells. Rapidly jirolifc rating cells in
carlila^'e undergoing o-t^ification pre^nt the Kame reaction. Tim «uh-
fltanco, the true composition of which U still unknown, has no connection
with vegetable Atarch. In tlie centre of the inten'ertebral disIcA and
other licamentoiia symphyses, there is found a mucous substance in which
esirt isolated cartilaginous capsules or groups of capsules united together.
Kiii'li capsule iiicli>sc« n (-artiUse celt witb its protoplftsm nnd nucleus.
Tbi* i« Tiiut^'U» rartil-uje.
The suh:«t!»ncft sejiarating the cartilage capiinle» in «omc region*,
AH the lihrouM portion of ligamentou.'* «lymphyiic:*, h&* all the character*
of fibmus tissue. Here the capsules are very distinct fnim tlie funda-
mental substance, and frequently contain secondary cn^isules. This i<
fihro- I'ltrt ila(fe ,
In the cartilages of the ear. in the arytenoid cartilages and epiglottis,
existe a cartilaginous tissue witb very (distinct capsules, separated by a
felt-like ma«s of fibnlbe which resemble elastic fibres, although they
differ fr<:im tlic latter tn their action with acetic acid, which swells tbc
fonnur fibrillaj. This ts reti-rular mrtUaflr.
Where cartilage i» in contact with the pericliondriuin, there is found
in tlie embryo a layer of embryonic ecH»,. similar to tboje «ndcr the peri-
osteum, and from wliich there is a peripherikl gmnth of the cartilage.
Oi^i^Korti Tlt^I^UK. — In osseous tissue, wc bavc the otitro»» gtruettire,
the $Harrote, and tlie vertaxteum.
Osseous tissue, wbich everywhere is the same in composition, con^sts
of parallel lamellie and bone corpuscles. In a section of dry bone, the
osseous corpuscles appear as oval bodies when seen in profile, more round
when seen upon their surface : from their bodies proceed numerous canals
ramifying ami anastomosing with the canals belonging to neighboring
corpniwtes. Vircbow has demonstrated that these corpuscles contain
cellular bodie». By decalcifying a lamella of fresh bone with bydro-
chlorio acid and boiling, Virchow K«(iarated masses having incomplete
branches, and considered them to be osaeoud cells. In souie be was able
^r OESEOOa TrSSTE, BOSB HAHROW, rERIOSTETH. 27
to eee indistinctly the ntfcleiM. The nuclei, howerer, are very evident
vben k piece of îlecalcified bone ta stained vriiti aniline or CArmitM-, aud
tlio cellular nature of tlic osseous corpuscles is plainly dcmonslrateil.
The numerouB cunalicuH ppocceding from the corpuftcles are channels for
cnrrying the nutritive Hiiids into the different parts of tlic osMOud snl»-
Manco, vhich docâ not possess the property of imbibition or cndottmous
in tlic nomml state.
llio boue corptiscles are «;atcd in tlie osseous laniclln;, aud lie pamllcl
to (heir surfacci*. A «ystem of panillel Inroclltc envelops the «urfaoe of a
boi»e,aii() each medullary cavity >» ai^o surroumknt by concentric laDwllw,
wlii<rli fonn si-i.-oml.iry lysteiuK,
The meiltiUnry cavilieii contain the marrow and Moodresaels. Id
nearly all long boneii these cavities are cylindrical, and parallel to the
long axis of the bone. Titer are known &« tiaventian canals, and are
connected by transverse or obli>|ue caualii. Spon^ bones do not differ
from compact bones except in the sise aii<l irregularity of their canals.
The marroiv of hmt is always traversed by bloodreesels. Between
thcMo and the bony walls there are found: Ist, email, round, <;nimilar
cell» with a large nuclei» (medulla cells of Robin); 2d, lar^^c, irregular
cellK witli many nuclei (my^loplaxes of Kobin) ; i)d. adipose veskles; Hlth,
atellkte and anastomosing cooncetivo tissue corpuscles. These different
elemetits exist in varying proportions, in the diflercnt bones, and acoonling
to the state of derolopaient of the osseous tissue. In the bones of the
extremities adipose cells predniniitate ; in the bodic« of the vertehrvc and
etemum, the tnarrou" is red. and contains fewer adipose ceHa. Tho most
important nutritive and pathological phenomena occurring in bone affect
the marrow.
The perhtteum is a fibro-elastic membrane resemblini; very much the
ftponcurose». This membrane surrounds all parts of the bone, stopping
at thi^ hordttr r>r thv articular cartilages. It consists of fibrous and elaslio
tissue, tilt; di^ejMjr portion, in contact with the bone, being composed of
very line and dense fihrillie. The vessels of the periosteum Jire very
numerous, and pass from the deep layer to penetrate directly into the
OBseoua canals. ' ^
Tlio development of osseous (i.«iuc i» very interesting, especially as it
is not formed directly from tlw cells of the embryo, but from fibrous or
cartilaginous masses which have ilie form of the hone. Many patholo-
gists ba^c their general views of pathology upon their understanding of
The fonnation of a pathological tissue from a healthy tissue wbicb
differs from it has been called by Virehon heteroptatia. The development
of osseous tissue from cartilaginous and fibrous tissues is the physiological
type of lieteroplftsta. Virchow has not so considered it, because he
declares that o*m-oim and cartilnjiinoiis tissues are the same histohigioaily,
and Iiecausi? he l»elii;ves that osseous tissue arises bv nutritive changes of
fibrous and cartî lag! nous tissue, occurring especially in the fundamental
substance, which is iiardened by calcareous salts, lie has applied to the
normal developfoent of bone the changes which occur iu rachitic bones.
But li. ïliiller, in investigating normal ossiBcation, arrived at a different
tlieory, which we also have verified, that osseous tissue is always de-
28
0BLL8 AND NORHAL TISSUES.
Fig. 13.
vpIo|ieil sccor(l!n« w the same general Inw, whotiicr from Cftrtilnge, or
fibrous tiititui', or beiicalb tiic pemsteuin.
A. (hni finition /ram Cartilnijf. — The cnrtUu^ cclU proliferate by
tlie mvtiiuds prcviotuljr described ; the new celln nre «urronnded by
sccondnrr cfli^sulcs ; the motliercniwulea,
betii^ fillfd wilh tlii-in, am eiiturged and
«longaiod by mutual |ireAi4iire in such a
tray ax to converge towards the point of
o»iiit<ication.
Tlie fiindamental substance of the car-
tilage appears as if fibrillatod, and is
Boon inliliratcd nitU ealcareoaa nits.
The BMOiKlary capsules arc now "lis-
Holred, the cartilage cells become free
and proliferate, linviug the characters
of embryonic cells, when they may
liavc amoeboid movement». The car-
tilagiiuius ù*»\K is destroyed, but bony
tissue in not yetdcvïtloped.
n)i* new tissue, which we propo-te to
name ottiform, conHiAt» of traheculic
iiieniitted with calcareous haIu, and rej>-
r«senU the gmuit<l Riihtitance of the
«Id carltlaKe. ht thtM' trahffHlte thtr^
are no «elhlar element». They limit
alveoli which communicatc wîtli one an-
other, formin;; cavernous spaces filled
wilh marrow.
This tÎMiic (Iocs not correspond to the
descrijitioii "f "»tr'>'i<t \\iA\i» of Virehow,
iifir to »p<in;/i>lil li-wue of (iu^rin and
Broca. lliejie author* have founded
their deacripdon upon rachitic bones,
whore the calcified trabecular of osteoid
or Bpongoid tissue of these writers con-
tain cellular elements. In the aaal/orni
tittime the vessels coming from the bone
[or pc rie bond ri uni] i)eiietrate into the
alveoli and fonn loop». Tnie ossification
now begins. Along the calcified trabe-
chIic are arran;^d the celU of the em-
bryonal marrow; these nre frcpiently
pressed one against the other, and are
angular. Around a few, which hnve
prolongations, is s«on a new intercellular
sulMtnnoe, which in the osseous substance. Some of these colls may be
partly in Uie o»«eous substance and partly in the marrow. Soon such
cell* are completely surrounded by the osicous substance, and become
true bone corjiuwies. To this fiwt layer of bone an- ad<led new layer»,
always by the same process of fonuation from the marrow. An irregular
VtrltuI •acllua too tita vt ««ll>lii(
lli« mlllaKa: h. «t (on*, r. Ktiiilj.
trUh VP»'U «Dû DiriluIlArj C«tU' ■, /-
UOD^ ?4Uk on 1L«U hrotJ ■>li*rt. ff. CtM-
ILWd c*)>*lli*v itfr««i;*.L la rows, ptrlljr
wilh itiriiiilivn olI.hoiliM. (XDfliT.)
DSSiriCATIOlf.
frimitive mCitlallary spiicv in tins carliU;|;o ts thus trnnafoniieil into a
InvvrsiAu cunal, whtob contains tlio marron- nnil vcah-Is.
lî. (tttifiivti'm from the Prri-'tlewin. — The pri'c«ling ilescriptioD ro-
iatc» b> the <lov«lo|HTK'iit of Ikiim; I'njm cnrttlu^t-, but onci- foniiwl it majr
grow tM'Dvftth llii; {icnOHtvimi. Umli^r tliix ■lu.-mtiranc tlii;n; is foTiitd
daring tliia {ktioiI a Ujcr ai roiiitil or jioljgoiiitl cvlU, vtitti one or moro
uucloi, not liiflV'riiig from l)io cvlU foutid in cinbr^-oii»! nukrrovr. In ihiM
layer, in tmui>vcnM Motion» of bone, «re see» ]>rAjcctiiig Htniighi or
curvet] oA-icoiu i)ec<lle#, tlicir bnne Wing tlie ol>t hoite, aii'l their free
extremity' directed towards the |ierioiiteuin. The mediilla cells are found
ranged along theM osaeoiix neeillea or procc3.<iefl, And w>ine of thi.-ni are
surrounded \>y osseous suksUncc. Here, alao, may the cell be prily in
thD 0AWWI8 substance and partly in the marrow : therefore the proce») of
omGcntton under the pcriosletiiD corresponds to that seen in the second
phase of ossification from cartilage. Hio needles, which corrcspniwl to
vi^rtical sections of lamin»;. gradually increase in me. turn iiiwur>ls, join
one vrith another to form round spaces which corres|)ond to llaviTsian
canals.
C. Onifieation from Fihroug TVMUtr. — I» tlio boiHis of tlie ornniuiD,
tlio 04MOI1S tixsiie » dcvolopc<l from n fibrous mcinbninc nnd from Irn-
beoulx, which grvdually increoM in thickness, turn inwards, nud limit
metlullary (i|«c«8.
[n a humau embryo of two or three month!* ther« arc found oweouB
pUie« corres])onding to each of the 1k>iw8 of Iho cniniiim. These bonc«
tenuinate in the âbrous tissue by needles or procesiieâ. Along (hede
DccdIcJ are found one or two layers of embryonic cells, polygonal in
shape from mutual pressure, resembling those seen under the penoatoum
and in the medullary cavities. By Uie same process these evils become
os«oous cor^mscles.
Pis- 14.
0,«nbliMU Iti-ni Iba paHftal b«ii> uf ■ tmnu rnbryu llilrlata ir»L* oii. a. Btiuj upl*. wUb IW
t*U- n< III* iMaa»- t. L»j*nor»UAtiiii>i<. *. Th« laiMr la im»uioniDbsB« cerpnailo*. iP'jc»'
Anair.)
"Hie osseous needles terminate in the fibrous tissue by a long filament
formed of a refracting and slightly fibrillated substance, not containing
cells. These fibres arc comparable to the trubecul» of the fuodsmcntal
substance of cartilage in tlic lirsc «tage of ossitication, and arc knowii as
'80
>S'A'ir/>i-yit (f/'i-fN; Itiey appear to be die reaull of a condcnutiea of tbt
fiindatnenul substance of tho connective tissue, aud seem to direct tbt
pracowof oesilicalion.
The ombryoDic colls which are found along the osseous trabeculae are
verv evidently derived from tho nci^jhborins fibrous tiasue, tho cells of
which multiply by a process ftiislo^ous to that described in CKftllagei
while tho wall of the conncutivv tissue eorpiucles and tho fundunicntat
xttb^litnce of tho ooiinoctive tissue, anftlogons to the capsules an<l cnrci-
lii<;iiioiis substance, aro diMcilved. Therefore the mme genentl law every-
where preside» in the fonnntioR of osseous tissue, vix. : T'A* gronnd
êitf'flitnre of the txMUf {ran»ulf» of the cartilatfi- CflU, jihnnt» tubttanct)
it diMM-Aftd; fhe trilit protiferaU, hrcomcfr<e, aiui ijive »ri'jin to an rut-
hr>i"nir tintut; the rlrmmt» 'ft' which f^fi^me mirroundad hy a nete fttnda-
menfal «uhttanff, and are thu* trantformed into uete'iu» earpuifttê.
Second GRoirp. — Mt'SCi'LAit and Xkrvb Te^suk.
Mpsculah TissiTK. — This tissue in loan presents for coatideration three
distinct kinds: 1st. Muscles of organic life, consijitin;; of smootli fusiform
cellS) which contrnct slowly and involuntarily; 'lA. Muscular tissue of the
lieart, the fasciculi of whîcli are atnated and
fig- IS. anaiitoinose one with another, and are capable
physiologically of a quick and involuntarv con-
traction : Sd. Muscular tissue of the trunlc and
exlrcmitics, couHistin^ of etriatwl fasciculi non-
Miiiirit(inio*in{i, chiiruclcriin-d physiologically by
II pi)w<T of nuicU and vohiiitaiy contraction.
The flrment» ■>/ ori/iiHlc mutilti are fik^iform
cells greatly varying in length: no enveloping
membrane has yet been recognized, they seem
to consist of an albuminoid substance (muscular
fibrin), transparent, refracting, and amorphous,
e.\cept in the uterus during ^station, when
may be observed a very fine strintion which is
perhafis related to the new function which tho
uterus presents, the ijuicl: movement ucecaniry
to parturitioii, (Fig. 1Ô.)
NeJir the centre of the «morphoiis mass there
is seen au elongated rod-shaped nuclcuit, which
U very distinct after coloring with carmine, or
treatment with acetic acid which gives it a serpentine fthape. The nuclei
do not contain nucleoli. The cells are so united as to form fasciculi, or
membranes.
According to moat histologista these muscular cells are derived directly
from finbryonic cells, the protoplasm of which experiences successive
changes and is transformed into muscular substance, the nucleus becoming
elongated or rod-«liupcd.
T\i>! ma*nil(ir ftt»'^''uli n/ the he-trt are thus derived fromanu»t'inui.»ing
embryonic cells; their fundamental substance is alnays 8(riat>.'d, and oval
nuclei occupy the centre of the fa-sciculi. The anastomosis of tlie muscular
Smu^'iri iifUfplD fl]>n-q from totn^
MDBCOLAR AND NKRVB TISSOB.
8t
fibrea of tlte heart accounts for the s^ner^a and sjncbronîgm of the
can] iac muscles. (Kig. l<t.)
fitriattd muteular i^hret of vofuntary e&ntnution aro developed from
emhryonic cells, «hied arc elongated, the nucleus Incomes oval and mul-
ti)>lK-s, the protoplasm undcr^vs iiutrilivc
cliangvs, which tninsf<»nn it into Mthnlod
Substuiicc, nhilv the nicmhrano of tliv cell
becomes roflisling, reenaiit* aioorphatut, and
constitutes the sareolemnia. Attlie begin-
ning of tin» foriiiatioD, the protoplasm oxfie-
rieikceti. only at its peripheral portion, tlie
change» which produce the muscular struc-
ture ; alirnys around the nucleus there
remains some unclianged protoplasm. The
nuclei arc seen nndcr the sarcolcmnta cod-
atantly surrautMlcd \>y a small fusifona
mass of granular protoplasm.
The lon^tudiiial and tntitsvene atnation
divides the mu*cular 8uli«tAnce into small
prisnu, or »arf>u» tUtifntt of Bowman,
who oomparos the slriie to a uniituji siib-
stanee, and the lareou» tiennent» to the
active ]»rt of tlie muscle. All autJiors,
however, do not agree nith tliis view;
several lii?tologista believe in the old 0)nn-
ion. which rc^iinls tla- muscular Bbre aa
composed of hbrill»; ; the transverse striution of the fibrillic being due
to successive swcllinf^, or to a spiral-like arrangement. Our observations
lead us to admit tlie existence of mtrevu» viettttnt».
h»>L Og Ihf (l||)i> <lis UnilUuf lb«
■Apantv rvlU «lir> Ihult nndri w vji.
hlblUil laiBtVllftl rlla(raullllMllr.
FnavvkUof *lwamtMrj maiciiUE lima, ilrlaMil, ihavlng clwvig* lutppoiltadtrtMlai». X S"-
I'JriV.)
Ntavs Tisst'E. — ^Thc elements of nerve tissue are eeU» and Jihre».
Nervo cells arc quite variable in shape and §ize : they always have
simple or ramifying prolongations which connect them with one another
or with nervo fibres. They do not possess a membrane ; their funda-
mental Bubstauoo if finely granular or striated, nnd always contains a
varying amount of pigment. They all have a large nucleus with a large
32
CELLS A!ID KORUAl. TIS8l'B8.
micleolua. l-'rom ihe micleoliis. acco^^in(; to Frointnniin. arise prolonga.
Uons which pass ihrough the nucleus and body of" the cell inii> its raraî-
ficalions. Ualbîanï believes tht'9« prolongations to bo true canals.
ïlio gray nervous substance contains the ncn-c ccIU, which are there-
fore met irith in the convolutions, in the gra; niASse^ of tlio ci'rcbrum,
tho ccrchclluni, in the spinal conl, am) nil tlie iwrvc gutigUa. They aro
nUo fouml in a few organs tipoii tlic pcri[iheriil extreiniticK of the nervo
fibres.
Aoeonling to Komnk, Kollikcr, and liockhart Clarke, the development
of nerve cell» i* from primitive embryonic colls. According to Heal and
Max ïjchultze, tlie whole of the protoplasm is not transformed, a [loniou
rt^oiaining which surrounds the nucleus of ilie nerve cell. At tlie peri-
phery of ilio nerve cells their substance is striated (arch-like appearance).
A weak solution of carmine colors first the nucleolus, then the nucleus,
and finally tb« cell-body, tlic nucicoluâ bcin;; alivnys most intently colored.
iVfi-iic JîAwK are of two varieties, those having n racdullary flbcath and
those which liavc not. In tho embryo only the latter exist; it ia during
the course of development that the mcdtdlnry sheath is added.
Medullat«d nerve fibres aro separated into two kinds. One variety,
met «ilh particulaHy in ihc peripheral «en-ou» «ystera, i* unifonnly
cylindrical, limited by u atnictundess resisting membrane (ninmlinine of
âcliwnnn, neurilemm»}, in which are men oval nuclei, similar totbo»e of
«g. 18.
Kht* rrlU ream iNs lka»r |»Ti at llii gnj miller at tho niB*sla1laiii ol III* bamu brilB. X UK
the sarcolemmn, but only visible after staining with varminr. Beneath
this membrane the medullary subiilaiioe prcHCuM a double contour. It con-
sista of nij/elin, an oleaginous siib^U-inc<% which, when tliu fibre \« broken,
readily escapes, but it ia always limited by a double contour. We know
NERVB TT5BUB.
S3
of Qo «xplMMitioiii ^y( tliU double coatoor; neither U tUo exact chemical
oonpMiliou of mreliii accurately knowD. In the centre of the myolin
Kg. IP.
Ham» ntrva («It» X^'^'^'*'***^'^'***'* ■'** ar>«,oa* nf
bU oidViattJ. iui4 144 «till irruiVEiua twnlniilM. (fi/vjf-J
Fig.».
Hmkll MtTi' liiMfU frniH the 'ja-
pKiini\iii of ■ ifttjitnisl , iwii 4ftrL tkor-
ilv'Til n*-!!* luhri (u) «wiin ■ imuilxt
.( MrmatTi Sinn (*). (*V«y-)
exists A homogeneous, vitreous, sliglitly 1on;;ituflinnllr gtriiktcd cjlinclcr
(ans eiflindrr), varying; in iliunieter, «ml oipnltlc of being colored by
CBimine when the Kolutioii i* brought, in eootnct iriUi it.
In the other variety of meiliillated ni-rve fibres, obtained by liLtneclin;;
the whit« sulistance of the ceiicrni nervouii system, the fibres are seen as
tnonilirorm fibres, very thiu in some places, and always bavin;;; a flouble
contour. Tlie neurilemma of these nerves is su thin that it is difficult of
demonstration; and it appears to be devoid of nuclei. The mfniiliform
appearance is due to the escape of myelin by rupture of tbo neurilemma.
Il seema to us that, during dissection, the axis cylinder haa been sepa-
rated, and frciuently \s found fjoutin;; in the fluid, having a greater
diameter than the nerve fibre from which it appurcntly came. This is
an artificial appearance, as section» of hanleiteil braiu or spinal cord
demonstrate, Miice there arc never fi>und in the»* preparation* nerve
fibres having a moniliform arraiigeuK'nt or *uch a very «mall dianmter.
The_/Ww* ùf Hi-autk are nerve fibres wilhoMt a medullary sheath. They
arc composetl of an axis cylinder and neurilemma with the numerous nuclei
belonging to it.
Nerve fibres are develojied from embryonic cells, which enlongate,
anastMnose, an<i become surrounded by a membrane to form the iieuri-
lerama, while the axis cylinder is developed from the proto|>la.tm of the
colls by a process not well unrlcrstood ; the nuclei of the ceila remain in
the envelope, «ikI do not oontributo to the formation of the axia cylinder.
CBLLa ASD HOBMAL TiesOBS.
Tbe myéline la 3uW<|iicnlIy produced, and accumulaua betveeu the vÙM
cvliniler and the enveloping; membraue of the fibre.
Nerve fibres [>rociied from mUs, the prolongations of which are con-
tinuous with the axis cylinder. The peripheral terminations of niTTc
fibres »re known only in a few organs ami tissues, constituting special
apparatuses, such as the corpuscles of l'accint, Meissner, and Krause,
terminal plat« of muscles, etc.
Third Groit. — Kpithklial Tissirs.
Cell.4 which I'lUcr into t\ie composition of ejnthelial UoitucK vary much
in sixe and i^hape. Tlicy arc )Kilygonal, aomelimes very flat (laminated),
or their diameters are e>|iial (cuhen) ; others are elongated in the form
of cones or cylinders. A few are poculî«r in shape, and are with difficulty
rcoognixed as epithelial cells when met nitli isolated: as, the ticnutted or
spinous* cells of the middle layer of the rete oiucosum of tbe skin : the
ciliated cylindrical colls in the nir paeengc* and gcnilate ; the polygonal
Fig. ui.
Fig. sa.
Aplaon* «jiUh*1lBl cfllla of ■ rAueiuid
(pllb«110IIH.
SkIIoh •>(■ Tlllutof ■ nl>|.n. iUgb I<r>*ri
celU in the cerebral ventricles ; celU with striated bordera, as in tbe
intestine : cylindrical celU with terminal branches, as in the organs of
special sense ; the cells of tbe cornea and fibres of the crystalline lens ;
cells in the form of pyramids, as in the culs-de-^ac of racemose glands.
An epithelial cell, however, only takes these characteristic forma
during the process of its evolution. Evolution is the chief physiological
function of epithcHa ; «11 their elements are transitory, they arc bom,
develop, and <lic, in a variable period of time. For example, in the
cntancou* covering, there are found, in tbe deepest layer of tbe rcte
mueojum, in contact with tbe papilhc, cylindrical cells, which soon be-
BPITHELIAL TIS5FE.
oomo larger, round, vith tlieir siiifiu!» <!i>ntat«<l, auil grailunlly incrcuo
in «iw iw th«y Approncli tlio «urfucc of the ojâdt-nni*. Finally, (hey arc
flAUoiii't) into dry lituiclliv, ami fonn, hy lli«ir union, lh« corneous Giver,
from wbicli they nrv iK'taclieil by pliy.'>i<rnl aixl chemical a^enu. Hic
buccal epithelium follows the !taint? evoliilioii, excejit the comeouH tran»for-
toation. In (be miicou.i meintirane of the traoliea, the deep celU are oval,
and the euperGcial cells only increase their diameter, assume a diatinct
cylindrical fonn, and hare cilia upon their free aorface. The ce)Ia in the
f^an<ts follow an analogous evolution. It lias, however, been demonetrated,
that in the gbnds. thi.' epithelial cells de»<^[iiamutc iu order to form part of
tfao exorcted substances, and that the content» of the cells constitute ao
ostential part of tho secretion.
If c|nthelinl cull», in a few instances only, possess chamotors l>y which
tliey nuiy he reeognin-d. there arc in the structure of the opiUielial tissue
itself (lie elements for an exact definition, 'llie cells wliieh compoéO
it are united to^^ether bo as to form ma)t)>e« or membranes, «1iivh an
accurately moulded upon the stirfaces to which they adhere. On many
of these HurfaccFi, as that helongin;; to (he ftkiii, the diucous memhmnce,
or tho |^lund«, there ix found a hyaline amorphnus layer containing a few
nuclei, which is the i-atemrnt mtitAntiie of Itowmao. Vessels are norcr
found in opiUielial tissues.
KmwiI (adMlMniin it Ik* pirtiUl iwrlaHlnia <>r t. taai, «Uivr lc«M«L Ll>til (nuu Udlnlo
tlWnuHat (abJuaBI tiltcdnHalh Hifb pow«r. {Otutpman.)
Ttie majoritr of epithelial coverings am derived from the external
layer of the bla^Eoderin, as, for example, the epidcrml* and cutaneous
glands. The epithelium of the mucous iticnibrane and its glands are
aevetopod from the internal Jaycr of the hlnj<toderiD.
Some epithelial (endotlielial) covering», tho#e of the veaseU, serous
membrane, vte., have their ori;^n fram the middle layers of the blasto-
derm. This embryogeuic difference Las led Itindfleisch, His, and Thiersch
CELLS AWD ;rORHAT. TTBSUSfl.
to establUh «listinot pliyi«io]ogic<il ami pnttiolo^ical divi«tonit 'lepcmling
upon the Uyer from wliicU tlio epithetium lia« been dcveloficd. Iliii has
given tlieni dif)ér«nt naines; those ariitïng from t)ie external niid internal
layerti he t«rm3 epitlielium, ami tlioae from the tniildle laver endothelium.
lie believes the diffcroncc of origin alwava correspomU to a different
structure ; the cndothelia consist of very flat cells
united at their borders, «nd form [almost nniver-
Hullv] a ein;;1o layer, as the cpithiTium of tc;«.s«U,
euroiis membranes, articular synovial membranes,
«erous and mucous t(ur«c; the upithclia.on the con-
trary-, have one or several Uvcn of cells varying in
thickiitTS«. Itiit even from this point of view there is
^reat similarity liotueen the two v«rietiv» of epithe-
lium. ThiL-i, that lining tho piilmon&ry alveoli, nnd
which i.4 develojied from the internal layer, h very
thin, and resemlile.i that of «eroua membranes: while
the epitJielium covering; the synovial fringes, and
which is derived from tlie miildle layer, consista of
superimposed layers, and it also sccrctca a li-tuid con-
tainini; mucin. The flat form of the colls of the
cndothelin of His appears to us to be duo to mcchani-
cnl causes, and is explaini;d bv the pressure and fric-
tion of the blood in the vessels, by pressure and fric-
tion of the opjiosite «urfacv« of the serous mi-mbranes.
It «ill he scon, in the study of patholog_v, tlint
pbysiea! condiiions may change the form of the epi-
tbelia. Therefore, the distinction made by Ilia is not
always correct ; moreover, it is fomided upon embryo-
génie facts which are not well established.
Epithelial tissues arc ilîvîded into inve*tintf epîtAe*
h'um nnd >fl't«dHlar cvitheliion. Investing; epithe-
lium consists of stratified layers (laminatea) or a lùnglc layer (^nun-lami-
nated).
Laminated epiUielinm may \m *eimrated into two varieties: 1st. Those
whore the sugierficial cell* are flat, as upon the «Icin, the buccal mucous
membrane, the pharynx, tho œsophagus, the conjunctiva, the bladder,
the urethra, tho vagina, etc. Upon the akin the superficial celU form
tlie coniooua layer, naib, or hair, according to the necessities of the case.
2d. Those where the auporficial layer is composed of cylindrical and
ciliated cells, as in the respiratory mucous membrane.
Non-1aminat«d epithelium is cylindrical or pavement: cylindrical upon
Ibe digestive mucous membrane ; cylindrical and ciliated upon tho uterine
mocoiia membrane, tho Fallopian tubes, vas deferens, and sominal vesi-
cles; upon tho mucous membrane of the small intestine, the colls termi-
nate at their free border in striations; non-laminalo<i pavement epithe-
lium is met with in the ventricles of the brain, in the pulnmnary nlveoH,
upon the aruchnoid, pleura, peritoneum, pericardium, and vesitels. Nou-
laininuted pavement epithelial cells are cubical, aa in the ventriclea of th«
brain ; or flat, as in all the other organs mentioned. In the latter, a
aatisfaotory idea of the epithelium can only be liad by staining with
mvufQUwj at n jiutbd»-
|rt(, tkflcr Irt^lmeiil ^f
mini* ft (IIim: a,
e*n; A. nuelol of tbe
•an*, in^-)
BPITIIBLIAL TiaSOB.
87
nitrate of silver. Wlien colored wttli i>icr<M:armiiH>. the nuclei appear
boiivalli ilto plB(ci*,a»-l soiiK-iimciadistiDctmasaof protoplasm surrounds
tlicni. 'Hie imvIctL* nml protoplasm occupy only a porUoD of the plates,
and ar« motilile^l into ttie suhjacoiit conuectinj; substance. The plate
«eeo» to be tlie result of a secondary exudadou from the active portion
of the cell.
K
-S.
Fnplllana; •kwlBf •■laRltésbir^d pipllla. t*T*n4 br IimUiUd (>t4lti*liBm. (tnn^JUlixt.}
The entire vtueitlar »yM«m is lined hy such an epithelium; it was
fomnerly iM^lievctl that the cajiillarie:* consisted of an amoriiliotu mem-
brane «itti iiiiclui. Auerhach, l-iberth, and Aeby, employing the pro-
cess of von Ilecklinghauiwn to 8how delicate epithelia, have been able
to demonstrate that tiic membrane of the capillaries is formed of epithe-
lial cells, each of which corresponds to a nucleus of the capillary nail.
If the cells cannot be seen by the usual process, it is because they are
80 intimately united tJiat their limiw cannot bo distinguished. But by
irritatiun they become swollen aiul separntcd from one another.
By injections of gelatine aud nitrate of stiver, the eiiduthelial layer in
place» along the course of the cnpillane» ts elevated, without the injection
passing out of the vessels. The cnpillurics are therefore limited at their
periphery. But a double contour of the limiting membrane cannot be
seen, ta ttiat the démonstration of a true memhraue U[K>u which the epi-
thelial cellD are placed i^ not yet eoniplt-te. It \* [m^^ible that the eapil-
lariea are simply limited liy the mirroundiu;; condense-l connective tissue.
This view is founded u)>oii the imposa ibility of i.iolatînn the capillaries
when they are not surrounded by a lymphatic sheath. This endothelium
is continuous with that of the aricriea and veins without any Itue of
demarcation.
Previous to the demon strittî on of an endothelium of the blood capillaries,
von Hecklinghauscn and His had dcmouatrated that the lymph capil*
CBLtB ARD KOBUAl TÎSSUSS.
Iftrics were lined bj nti viulnllicliuiii fonnod of flat urnl losen^-sUitpcd cells.
Von Iteckliu^uiusen observed tluit tlio tympbatic cApillitrie« inuaculatcd
vrilb tbe branobing oangd» of the connoctiw-ciiiuc corpusclM of Virchow.
By suiuing with nitratv of silver, tld» autbor oL^iTvcd lUnl the fundn-
mcntal substance colored bj* tbe de|>oitit wm cbaiiiurllcd by ^tellftt« ipaces
connected togetber by a system of canals.
]n studying the endothelium of serous racnibranes tbe same writer has
Ben lictneeii the cells spacea or atomata, which esUiblL^h a dirocc com-
'^unication between tbe serous cavities and lymphatic canals. The serous
cavities, the lymphatic vessels, and lymrh spaces of tbe connective tissue,
therefore, belong; to the same system. The lai^r lymphatic vessels bave
a much more complex structure, resembling that of veins of the same
calibre.
GlnttdtiUir rfithfUum, the cell* of which may be pavement. cylindrical,
in the form of pyramiiU, etc., also uiidiTgOM a constiuit evolution. Thus
in tlie glands of the stomach, the cells, primarily cylindrical, become spheri-
cal, filled with juices, fall into the lumen of the glands, and are destroyed
while discharging their contents. Colostrum cells are nothiti;; more than
desipiamated cells of tlie mammary acini, and when they are not found
in milk it is because they have been destroyed and their fat sot free in
the fluid. Some cells are not destroyed, but simply empty into the gland
their product of secretion. Thia takes place in the dands of làeberkUhn.
The cells in plands are planted upon a limitin;;, homogeneous, byaline
layer, which does not appuar to l>e formed of cells, but scorns to be a
condensed layer of the (turroiinding connective tissue. The slnicture of
this layer is not well detenmm^d, but almast always Hat nuclei are found
in it.
The different varieties of glands are:^
Ist. Tubular; that is, consisting of a simple tube, so that the secreting
portion of ûie gland is directly continuous with ttie excretory duct; tbey
arc rectilinear, and lined by cylindrical epilbelium (glands of Licbcr-
kuhn, of tbe stonuicb, of the body of t!ie uterus, elc), or are rolled into
the shape of a ball uu<l lined by puvi^oK-nt epithelium (sudori&c glands,
kidney).
2d. Acinous; that is, conm^ng of culs-de.«ac, varying; in numWr,
which 0|K'n into nn excretory duet. The culs^le-Hac and excretory duet
are lined by a pavement epithelium, as in tbe sebaceous and mammary
glands: or the culs-de<sac are lined 1iy epithelial cells in the form of a
pyramid, while the duels are paved by a non-laminated cylindrical cpi-
tlieiiiim, as in tlie salivary glands, Itninner's glands, tracheal and laryn-
geal glands, and tbe pancreas.
In the foregoing brief sketch of normal histology only the e^ential
outlines have bocu presented, [b'or a more particular account of the
natural structure of the various elements and tj^suei of which the human
orgjiuisin is composed, tbe student is referred to the subsequent pages of
this work where the difiorcDt organs and systeou are more minutely con-
BÎdercd.j
tlBBIOSB OP StTBITION OP KLKMBXT3 AS» OF TIBB0K8. SO
CHAPTER II.
«EXCKAL rHIXCIPLBS-ALTERATIONS OF CELLS AXU OK
TISSfES.
TuE altérations of ocIIm sdiI of tUsuea may be divided into two groa^ ;
let, lesions ainiply niitntivc ; '2d, lesions wfiicb compriae tlie foraiatioD
of ucw cell«.
Bwt t— 'Lcdoa* of Vntrition of ElemenU and of Titanei.
They may be divided inw : —
A. l^Monii occJuioni'^l by dntth of Uic «lementa kihI of tho liaaww.
B. Lésions occasioned by iittnfficiont uulrition of the oletnentfl
' (ftlrophy).
(.\ .Serous wnd nibuminotu infiltnitions.
I>. Mticnu.4 and L-oIlmil infiltnilions.
K. Amyloid iiifi I (ration.
F. Fatty infiltration and fatty degeneration.
(Î. Pigmentation.
H. Calcareous infiltration.
I. Infiltration of nratcg.
J. l.es>ODS cau«4)d by an oxcetut of nutrition.
A. l.j»roK3 CACSBI) BY Dbath «p thk Klbmfxts asd ok Tim Ti».
I Kt'KS. — The death of certain elentent« in a pliynological fact and aoni«>
tiniea even a ncceiaary ncurrcnce : for examjile. alinotit all the epjttielia are
subject to an iitces^aut de» | un mat ion. ll 1.4 probable that certain ele-
ments, which to OS appear permnneut, are destroyed at long inlervals, to
be difiirlaccd by yonn jer elemenu. This is aclually seen in the muscle
fibres of tho frog, where, each winter, a certain nninber of primary bundles
are dostrovi-d (Wittich), only to be reforroed in the spring. \\\- may
rca<lily VTievc that analogous phenomena occur in man, notwithHtanding
Uie fact that this destruction and new formation of niusctrs has been ob-
«crvcd in the latter only in grave maladies and during convaleACenee.
W>ien in Dian a largt: iguantity of cells are formed under iho influence of
an trntation.a eenninnumberof Ihcni diebecanse of insufBcient nutrition.
Thia alway:) hap|iens when the supply of nutritive fluid i.i iniiufficlent for
the number of new elements. Of all the éléments of the human frame,
the nerve oella liarc tite greatest longevity; they resist energetically
erory procesâ of deâirnction, and, up to the present moment, a physio-
logical destruction of them ia not known.
IVaili supervenes under two conditions: Isl, from arrest of circula-
tion ; 3d, as a cottSW|aence of iniiial leâions vf cells.
40
ALTERATIONS OV 0EI.L9 ADD OV TIS3UB6.
:
1st. When thont is arrest of circulntioD in & part of the orgnnUm, that
part Alt* and dviormincs tmiui»! it n »iip]>nrutîvc inflftiDnuitioii. One
Bny« tbeD th«t there U itn tKfinr and ijatujrfur ; i>r if & sort of totcraîioi
is cstalilighed. tlie necrosed part deoouiiKWCS, slovfly rcsiivw into i<o!uhlc
HubstAiioca, which Hule by lilUe «re taken tip by the circulation — it\f'trp-
I'kjh mid tieem/iiotii» of Virchow. 'Hie first ]ihenomona utiich follow
necmftia are seen in the moat delicate atnictureit. The blood disks give
up their colorin;; matter ; their fat of coropoiiîtàon e^icapes in the form of
grannW. and finnlly becomes reaolvcd into a ;;ranulariletritii9. Colored
granules and rhombohedric crystals of a bcaiililul '.>ran;;c-r*d. discovered
by Virchow and named biemnloidin crystals, may be seen in the nocmeed
pnrtd. Whenever extnivasated blood escajicB into a natural or artificial
cavity, it undergoes similar a1terutioii«. The white cor|>uwles oflor a
nnieh greater resistance : they ahrivel. become granular and angnlar,
contain u few fatty granules, and the nucleus is undistin^rnisliablcfrom the
protoplasm. Thi.twe regard as a caseous metamorphcHis. Having <>nc«
suftered Uiifl metaraorpboai», they may remain unaltered for an extremely
long time.
Connective tissue, bone, cartilage, tendon, etc., persist almoiit indefi'
nilely in parta deprived of circulation, if the </anffrene is drif- In tliis
case the preservation creu of <lclicate tissues in due to the fact that the
evaporated water of constitution has been replaced by fat, which baa
escaped from the adijKWC cells ; tlicy are deprived of the oxvfjen and water
necessary for putrefaction. The inliltraloii fat gives the dry gun ;j;n) nous
parts the translucence which is seen upon section, while the exposed stir-
face i» brown.
Humid or tnoiM tfangrenf superveneB when fluids are constantly con-
veyed to the nan, as in gangrene after inflammation or obliteration of
tiie veins. \\ hen the parts are deep and cannot dry, the gangrene i:»,
perforce, humid. The fat is reduced to granules, but it cannot infiltrate
the tissues which arc filled with water. :^o long ns oxygen is not sup-
plied— OS in cerebral softening or in splenic infarction — putrefaction is
not possible. It takes pince very quickly, however, on the surface of the
body or in the lungs. Two phases of gangrene slmuld then be distin-
gnislieil, jtiorliHmli-H and putrtfa<ii-m. Kxamplen of tlie first phase
are seen in deai) emhryoK which have remained a longer or shorter lime
in the uterus. Some of these are almo^il dry, and, alter exposure to air,
resist putn- faction much better than any other tissue. In these fuetnses
it is often still i>osaible to recogniiso some of the elements of the tissues.
The red bloo<l disks arc usually destroyed. While corpuscles may still
be seen in the vessels, but tiiey have undergone the caseous change.
Fatty granules and black melanie granules are also visible. The brain
anil spinal marrow are reduced to n pulp in which can be recognised
bodies eoiusistiug of fatty granules as well »s crystJil» of cholesWrine and
nenccells, the nuclei <if which «re no longer visible. The nerve tubes havo
completely disapjK-ared. The |ienpheral nerves are generally very well
preserved; the myvHn, in small i}UHniity at lliis age, has merely become
preci))iuiled as fine fatty granules. Tlie muscular fasciculi of the trunk
and members contain no granules of t'al, but solely brown pigment gran-
ules derived probably from the coloring maiter of the muscles. The
lESrONS 0AÏÏ8BD IIY IKSt'rPICIKXT îtCTRITIOX.
v\g.ie.
tniMcli* fibres thciDêcIvcs, )i«AutifuUy striate'], mav be easily aejwrated into
•Otk» or inl4> mire«H* flrmtnU. On tlio coiitrurj.tbc muscle fibres of (he
kc«rt ev«rjrwbere pr««e»t fuUy j^nulca in ttbutirUiwc. Tbia pres«n'a-
tiOD of muscle \* cownnnU
Th« cells «f (lie liver arc iIoMtroyed, Aiul lire replaced by aocumuUtiooa
of protein an-I fatly granolfs. by fnl erysuils, anil by pi^iient piirticlee.
The unniterouH lubes of die kidney are pretier^eil, but iii the pince of tbe
liiiiu;; cpilbclium exista a granulo-fatly aikd pi^mentarv detriliu. All of
tlie eartitn;;c c«IU contain a few fatty granules, 'i'lie flo-calle<l bono
ooruti!«lcs and the connective-tissue corjpusclefl also are well )>rea«n-e<).
In i/ry i/an.frrnf, the tissues present altemtioDs analosous to thosa
«hich we luivc just cxamiiieil in the maccnited ftctiis. In moitt ifaif
ffrwtt however, tlie mixlitiealions wiiicli supcneDC, rapidly induce de<
OMDpogitJonflfthetÎMueM which ureitouked
with tteriim, or iufiltmted witli pu«. Kren
tlic tou^fbe^t fibrous tisane, n* the tendoiii»,
■fl Âeparatcd into its ultimate Glainentit.
Tbe osseous tissue alone jireM^n-os it»
fonn, and persists for years without alte-
ration. Its surface may be blackened,
bnt this is due to the presence of a com-
binxlion of sulphur «nu iron which nata*
rally takes place.
In moist j^uo^rcnc. ulterior metamor-
phoses of the fftl give riw In cryst-ils of
margarine, of stearic acid , ami of t:hoU-*te-
rine. Tbe crystals of leucin ami tyrosin,
almost always present, are derived probably from (he protéine substances.
Finally bronn or black angular granules or crystals, to which tbe name
of melanin has been given, mav he met with.
lid. The death of tissues may be due to initial alterations in the celts.
This happens in primary fatty degi-neration of rclls, such aa is seen in
arterial atheronia, caries, etc., and in dv;;e ne rations con^jcutive to a
chronic inflammation. A great niimhcr of cells being thus destroyed,
tlie ItMue wlioïo life depeiitU upon llietii must alM die. Divers phenom-
ena result.
There may bo an infUiuimalîon of the siirroinidin;; tiiwno, ami ft genu*
ine elimination of tht: moitified part, as in caries ; the dead tissue may
remain in its place, and become intiUrate'l with calcareou.t salts, as in the
calcareous plates of the aorta; or, as ne have seei^ in tlie skin and many
other pouts of a fictus which had remained for a score of yearn in the
Seritoneal cavity, the necrosed part may soften, fall into a granular
ctrit«ia, and ho at last takcu up by the utrculation.
B. Lesions CAiiSKi>Bv!ssi!Pricriî.NTNirrRiTïos ofthk Elkmbsw. —
Atrofiliy from iunifficient nutrition haa been studied more pnrticularly in
its bearing upoo or;gaiu in gross, rather than in its etlects upon tbe ele-
ments and tiaauca.
Atrophy may be physiological under some circumstances, as in the
dut:tus arterioaus and (hymug gland utter birtb, when the cluiucnta undergo
^w.o
Ftiir uniislH inih (r^tUtt at «Anl«.
Iflrt1i«. frvni hUlvruBIAlullJI d#|r«an« la
^ï ALTBKATIOSe OF CELLS AXD OF TISSUBS.
» fattj. colloî<), or cnkareou» def^noratioii. Thv g«nilal orgniis, yfIiÎcIi,
duriD}; tlieîr pcpioiJi» of aclivitv, h»ve bcuw tlie weal of « lij'(terlro])liy
mon; or Xev» j>rotK>unc«d, lu^iialty ftUophjr in oM a^. Iti ilie atrophir of
tlio ut^rii*, after t^estation, there U probably a mixture of HÎoiple acro|>liy
of tiie «leinentti, ami atrojiUy witli ijogeneration. The ovaries, afwr the
luenopauae, atrophy Ihrougbout their nholn m&ss, tiwl the lîbrous tissue
of ^le organ condenses, Tlic testicles, in iho ogeil, atrophy tlirou^çb a
fatty (le^eoeration of their «pitbelial i-lcmcntâ.
It is thus seen hovr cIum-It atrophy of or;;ans is coiiu«ct«d witli tUe
differont dc^^nunttions of tbeir ulctnonte. Atrophy of the mftminic fonoa
an exception to this rule. Mere, in olToct, after cessation of laolution,
it is obit>.-rv<'<l that the relr»<;tioii of the gUndulur nciui i« nooomnanied
by a «iiDpIo atrophy of the jiaveaieiit coll* which line them. In the
Aged, certain of the glandtt atrophy. Some, as the kidney, become
sUmnketi, the uriniferoua ttibea and their cells are Biualler tlian in tlie
Domial state, sometimes cysts are obserred and the tubes may be seen
to be choked by colloid masses, etc. 7he liver «nd the spleen also are
smaller, and at the same time their capsule is thickened. The miLscIcs
of old people uonstautly present a certain number of fasciculi which are
atrophied and fatty di-geucnilcd.
The type of simple patlioloj^cal atrophy of the elemenu witliout de-
genonition t» met with especially in the omaoiivtian following inanition or
ncuto or chronic maladie). The mmiL-ular fn^cienli leititeM in thickness
vhile prcjicrving their stnictiiro. The adi|>o»c cell)' f^ire up a part of their
fal and contraci, or they hm all of their fat while the cell roiaini* ita
original sixe and is Sllcd with a. serous llnid. The latter condition is seen
in œdema of the subcutaneous eel lulo-adi pose tissue coincident with
omacialion, wherein this tissue becomes ■:;elntiniform and transparent.
Irritation of ccllulo-aili|>oi^e tix^ue idso ends in the disappearance of tlie
fat, but then the protO|ila.tiu and the nuclei are more swollen and distinct
tlihu in the normal ittate.
Accidental atrophies may he the conseijueiico of compre.ision of the
different organs and tissues. Thus in the kidtiey.4, when the {>elvis is
distended into a cyst bv a pyelitis, a hydro. nephrosis, or a tumor, the i-enal
substance flattens while forming the wall of the cyst ; the urinlferous
tubes are discovered to be extremely narrow, with their epithelia atro-
phied and generally also fatty de;;enerated. The same occurs in the
lie pa tic cells compressed by the newly formed tissue of interstitial hepatitis
or by tumor* yf this nr^an. Kvery hypertrophy of the interstitial tissue
of orgaiM su]ierinducf^ atrophy <if the parenchymatous element!. In such
cases, usually interstitial connective tissue and cellulo-adipose tissue take
the [Jace of the atrophied jiarW, fill the void which tJie atrophy has
caused, and it can even happen that there may result, in oon.'^eiinenee of
a surcharge of fat, an apparent hypertrophy of tlie organ. This i» seen in
certain muscukr palsies.
C. Sbroi-s ASb Aluuminous Tskiltratioxs. — We have seen bow, in
«trophy of adipose elements, the cells may experience a serous infiltration,
and we have discovered that this lesion is met with in emaciation and in
cases of irritation. It Is probable that the composition of the infiltrate is
OLOVDl BWELLtSO, FÏBBIITOUS DBOEXERATIOS.
4S
not idcRbcftI in both, notwitIts(iin<ling the fict that nc c«n distioguUli the
on« frooi the otJior solely hy tliv «welling of ihv nucleua and tlio proto-
plwin in inflammation.
Wlienever a Hiighl irritalion exist», 8inc« there is a more abundant
Bup|)>ljr of ntiiritjve tluid to the <>]>ithelinl timues, the opitltolial cvUk swvII
and become filled witli an alhummoua Uiiuid coDtainius; line gritmile^ nhiob
are soluble in acetic acid. This is what had bocu called tfoudy Hu-tUinif.
The nuclei and nucleoli ma; alao preaent similar chants. Thua the
ntKl<<ii« of tlio cells of the Malpigliian layer of tho cpidermii) mav fill with
Ii'|uid and asauntc a form dccidodljr veâeular; this comlidon, although
Tcrr commoD, bas as jet escaped the attention of obflon-crs. (Fig. ii8.)
The Dnwciilar fasciculi undtT^o a similar alteration ; bctvrl^cIl this statA
■lul that described by '/jviikvr nmkr the name of teaxi/ livjeiiemti'/n (aco
fig. M ), every intermodtuie Htajje can be observed. 'J'he naxy dcgeikc-
ntioD of Zenker, perfectly well known in iu physical cliarocters, is
not sufficiently underfltood as to itt chemistry; for we do not know
whether it ta aimply a serous or albuminous infill ration, or is a colloid
tmnsfonnatioD, witli which, as we shall soon iee,it presents certain points
in cotnm4W.
This may also tie said of an alteration of the opitlielia) cells of the
mouth, of tho pharynx, of the larynx, and of the trachea, de-scribed by
E. Wagner, which for him constitntea the essential lesion of diphtheritis.
(See pp. 4â and -K>.) (Fig. 27.)
Fïg.ST.
ng.2d.
fU(b peirai. |«. Wagtrr.'i
BpliktIUI Mill. Ikm tberrtfioimtDB,
dorlB)) tllcbi litiullon. Splu.>u> «lli of
bcnii» VHkuUc lor ■ iHimiDE «r lu* «■•
ttfolu*:^ hnlVi*! DilciJaUBmad aiicrvaluï
In every ledema there is » serous or nlbnminon^ infdtration of the
areolar connective tissue, when the exudation fill» tlie free spaces between
tlic fasctcuii and produces an artificial distension. After destccaiion of
such a tissue, it rétracta and returns to ita normal condition and cannot
then ))C di9ting;ut8bed from normal connective tissue. This process is
entirely passive. These cases must not be confounded with tiioao where
tlic coimeclire tissue dissolves and îa transformed into an albuminous sub-
stance, as occurs in many intlamnadona of tlic connecnvo tissue.
ALTRRATtOUfi OT CCttS AX» OV TTSSHBII.
EullDld OIlllCH'. (J(Ill■^
I>, Mnors .»\l) C'oi.i.rtiu IsFiLTitATioxti. — Wlien « mucous or STnovial
membrane is treat«il with acetic aciil, a white lilameiitoiu precipitate ia
obtniudl whicb doea not dissolve in excess of the acid. Vircliow had
given th« name of mic-m ta iKe substance wbicb is ihua precipitated.
The iimcin \« t-liibonited bv tUe epithelial cellfl i>f the tDUvous or synovial
mvinbraTies. \V« cah iniîeed find in tbe interior of tbem wlU a fluid
prosenliiig the same vharactors.
There i# in the or^nisni a golatinoits roUoid malt«r irhich \» moro
consistent than mucin, and which nl«o re^iilu from a phvi<ii)l'>;;ical motn-
Dtorphosis «f c«ll». It* type i« seen in the thyroid
Y'tg. ■^. IkhIv, Thiscollmd niih^iunce color» reailily by carmine
anil preserves the color: although it is not so intensely
fltainc<l as the miclciis of ceils, yet il is more deeply
tinged than are thi.' body of the cell and the intercellular
enlatance. Acetic acid only slightly or not at all
causes it to swell, and never produces in it a cloudinc»*.
This colloid material is so nearly related to protein sub-
stances that lattvrly Virchow has suuceeded in making
it artificially. A mucous transformation i« r>ften coii-
O^ . J rjk nceteil « itli the soficnin;; and destruction of the ground-
W Bubstance of the costal cnrtîloges in the ajwd. Prom
this sin;;lc fact some observer», Rîndlleisch among '
other», have supposed that whenever the cells of a
tisstie become free, it is by means of a mucous Irans-
foriDatioii of the ground sulwtaiice, bul this opinion very
much needs further obserration to confinn it. 'i'hero is no pathol<>};icaI
mucous or cslloid defeneration which does not find its type somewhuru iu
A ]>liy«ioIof;icul evolution of mucous or colloid matter.
The raucous or colloid matter may be diffused throughout tbe whole cell,
as occurs in the epithelium thrown otl' from mucous membranes affected
with catarrh. This lesion of the w\\ is rec»gTii/.ed by a liomo;:encou9,
transparent, refractive apfwarance, and acetic acid occasions a oloudine»».
The sulatiince tuay preci]>itate and form globular masses enveloping
the nuclei. ]ty the accumulation of this material, the nucleus may be
flushed to tbe [leripbery. The colloid globules may present concentric
avers. Wo shall soon see how they are to be distin^iniished from cal-
Ciireous, amyloid, and fatty bodies. The formation of mucus is exag*
genitcd in catarrhs or auperfictal inflammations of the mucous membranes^ '
anil in articuhir intlftRimadons, particularly in acute rheumatism. It is
connected with a ;;rcaler activity of the old cells, or with the fornintlon
of new element*: these cells are rendered lurgid by the accumulation of
mucus in their interior.
Tbe exaggerated formation of colloii) matter reaches its greatest in-
tensity in certain tumors of the tliyroid body, called gidtres. In some
goîtres there is nothing more than an exaggeration of this formation,
wîiich ends in the production of cysts more or less voluminous, and [loa-
silly communicating with one another. Colloid metamorphosis of cells
may be seen in tlie lymph glandsof old people, and numbers of cysta may
arise, comparable to the follicles of the thyroid gland in the adult. In
the kidney, especially in the ohl. certain cysts are filled by a colloid
aubâtancc, whicb can be seen to come from the epithelium of the tubali.
TITHSODS DEtlBSEKATIOK.
46
The UU4>r dilute nii-l Wcome InnMruriiifi] inu> cvkw, lh« centres of irlncU
are occii|>îfil l>^- a olloiil siihsuiwo festoonnl ul its borders mmI aliniriiig
oelU un-l«rgniiij; thi.'t {«oulinr •lo'ji-iwrfttiou, jti»t im iti llic thjJiMiil glawl.
T)i« gn-oilled tihritioiii) cum» of IIHjçlit'd iliiwwc appear to bo fonnod of
a substance verv anal^i^tui to tliai of tiio «jrsta.
PIj!. 80.
nl*4 rxLlk4Hrs] «tlli, &» Pa« #*rpiii«al«u ; ', ih» «aium mI"1 ni'^n I'j u^iU uriJ. t.é./, ri>ll«
■<■>( rroB ilK dlrldak «f • (tIIbJiImI nil. ihuwlaji itiiTilia tf.t. Xaront d»fin-nui r>li> rra»
■to Uul («VB IB ROT». J. C^UsiItl(sletll,>bnwtV«*<>v>"»'><>*('l**'''- X***-
We cla.*!i witli Ci>!lftir| iiictAmorphoxi» tJic rittfu» deafMeralion of inuB'
oles (,waxy dej^neratiun of /viikvrj tfig. 31 J. In tliis Icdon the muscle
Fig. 3L
à p*niaa«( th*Htea><niwtl*,rniaiB e*Mat iffkiAl h»r. Pnpuntlan Uucil BfUt tniUHal
«)l)> MGllM'* Said. XIOC' "'■■•^X' <OrtM.]
fibre» swell and beoome transparent: tlicv present fractures, tranaverse
aud loii;ûtu<Iînal ; tb« neff suDSUncc which dctvnuiucs these physical
46
ALTBRATIONB OF CRLLS AND OF TrBSDES,
ehansei colors witli cnrmiiK', ftml »ve\U «\ifr\My in ttçfiie «ciil, vrliich caoMS
the breakdi to dna])[ii'ar. 'I'tii^ niteration ia «een in tjr|ihoi<l fev«r and
in mniiy afffciioti» of the iRu.icle^.
In llie epithelial oelU which have experienced the fibrinous de^neradon
of \Va}^cr, the enaoutial Icaion of tho nmco<i2i membrane in diphtheritia,
we t:cco;;niii<> analogous elterntiona. The cells have a vitrcou§ aspect,
are tnmsjwrcnt, show prolonKations. color vcrv t-asHy in picrocarmmato
of aromuiiia, and swell sli^^htly in acetic acid (fig;. 2t). In tumors the
mucouH and colloid transformations of cells arc verj eommoD, and BOrvi;
for the eMtablishtauiit of varietioe ia each of tliom,
K. Amtijiip Inpiltbation. — The name -imi/hiid »uh»htHpr i» given W
an felhiimitioid mat«rial occiirrinf; in the form of itphcrcg with vonc^ntric
laj'ent, or infiltrating tho cell» and tiiMUC* — a mnlt«r which {>oitMAtt«H the
pro|)ercy of staining mahoganjr-red by iodine (fl^l. 3â and SS). llow-
Y\g.n.
Vig. 33.
LlT«r tplU imnmi'il wUb *myloU tDlitttni» :
Hl •tB(l« nlU: A. Mtlt wblsli 1i*i« ouiltevil.
t nrrtu>K.i
ever feeble the oolution of the latter may be, this substance colora deeply,
whilst the adjacent tissue is scarcely tinted brown. This substaooo
exista physiolo(i;ically in the prostate in tho form of granules or massoa '
of vanablo sixe, with concentric layers. It is seen in tho fonn of
spherules in the central nervous system, principally at the periphery of
thd spinal marrow and at the surface of tho brain. Without the use of
iodine it would of^n be impottsible to distinguish them from oolloid par-
tick-».
I'atholugieally, amyloid matter iiifdlrate» divert éléments. In a diffuae
m.ttiner it invade» the cell» and destroy» them. The cells lone their
nuclei, are transformed into amorphous bloclt^, such as are often tieen in
the liver and spleen. The smooth muscular tissue of small arteries and
the walls of the capillaries arc peculiarly susceptible to this dégénéra*
tion. When the invaded cells limit a canal, the bloodvessels for instance,
or the uriniforous tubules, they unit« with each other ami form an amor-
phous mass; tho wall of the canul is very much thickened bv the tumo*
faction and fusion of the cell-elements, so that the calibre of the vessel
or the iiriniferoii* tube is greatly narrowed. The production of amyloid
bodies in the brain and spinal marrow take* place in all chronic inflam-
mations of tliese organs. Id moH ca^e» of chronic Kuppuration, espe-
cially .scrofula, tubercuWis, or ayphilia, this substance i^ ob:terved as a
diSTiiae intiltration in the elements of llie liver, the s|ileen, tite kidneySj
the lymph glands, the vesseU of the intestine, lungs, etc.
FATTÏ lîiyiLTHâTtO».
F. ¥xm TxFii-TKATMx ASft Fattt |)E.!E>r.iiATlox. — Fat tu nift with
the orij^iistii in Ivo Tornis: il uiaj- hc intinu>U<ly ooinbînvd with otliiT
•absUinom, as fkt at comjxMiitio», vtlien it cannot Iw separated excvpt by
chemical meaiu; or it nny appear utxier tlie miorowofM in the form of
grstiute» fliwl jiIolmltf<i.
Tito causes for the vUiMe ap{iearanc« of the lat of coraposition are as
yet not well known. It liaa. however, bewi e^lahliiiheil that to remler
tlie fat apparent in certain elements is to insnre the death of the cell.
Fatty granules arc spherical bodies of variable eizo, highly rcfractivo,
tniupairent, colorless or Hlightly yellow, and they are charocterizod by »
TerydarkhordcrhytrunttniittGd light; thoy arc tnsoluUc in iicctic acit) and
in cold potaiMn (40 parts to 100) ; they dissolve in a larj^e i|uantily of
etlicr awl in (he biiiiilphide of carlmn; thev art- not colnrx'd hy canninc,
but are colored hrowii by iodine and black îjy perosmio acid. When fo(,
recuainiDa in the organism, iit no lon^r subjected to tlio nutritive ex-
chanta, it aeiMnteti into the fatty acidit and choWterine. Stearic acid
crystalliteii into rhomhoidal needleti, iiiolated or radiatin^ç from a point.
The more important crystalis of cholealerino present the form of extremely
thin rhomhoidal plates (see lig. -26 ). The latter crystals color red under
the action of concentrated sulphuric acid, awl blue if they have been
pnvioiuly colored with iodine.
Fat seems always to be deposited in (he protoplasm of the cells. Tn
muscles the depoHit hc;^"^ aronnd the nncleus. Free fat among the ttssueft
18 an indication that Ûic cells arc destroyed or that the examinAtiou ia
made ofïrrdciùccntinn ; in the lutter vase, the fat replaces the water which
has )>een evaporated.
Fat may show ilself pIiyaîûlo;;ical!y or palholcftically nnder two diSeront
conditions : cither it may fill the elements without interfering with their
"^te.fattuoi^umulatioMtT inHltratio»; or the elements invaded by the
fat may be destroyed, /if /y ^</enerati»n. It is probable that in the last
cam the elements at the saoM time experience intlammatory or other
iDodificatioiis which render life impossible,
f^ftitif OT J'nttf/ H'ciimulah'-m OT infiltration ii met with jiJiysiologi-
eally in ailipo«« tissue. The cells of the liver aiut of llie supra-renal
calcules also are often the seat of a physiological
accumulation of fat globules or granules. In the ^^'*' ^'
liver they are n>el with in much greater numbers after
a rejia.'it. In nuntin^ women, as well as in all
female animals during lactation, the hepniic cells are
surcharged with fat, to such a degree tiiat the liver
appears to be the magazine of fat intended for the
secretion of milk hy the mammary gland. The cpi-
tbelia of the intestinal villi are also loadcil with very
fine fatty grannie» during digestion. Tlic cells of
permanent cartilages very often contain phyniological utfr»i:, invunoi»
accumulations of fat in greater or le**er nhuiulance. ■'"»<• -^ '•"/ i»mii».
The nroscDce of fatlv infiltration in the liver of "«'■ X *»- (*'-*
phthisical pnuenta apjiears to he explained by the
impediment to the pulmonary circulation and the diminution of respira-
tory combo»tion.
48
ALTEBATIOSe OF <:GLLS AKD OP TISSDBS.
Fattif lifjeiwration as a physiolosical conditiou U not rare. It is met
with A6 a Donnai process in tke sebaceous, ceruminous. aud mammtiry
};laii(b. til Iho case of the ;;lnnils the fftt clnbornied in the tbrm of ;;mn-
uk-8 nitiiin tim cells is verr soon set free by the destruction of tjiusc
cells. 'Jlio fntty m<.>tttinor)>ho«i«, eXivr piirlurition, vf thv hypcrtrophied
muscle ccIU oftiii.' iitcniit, lliut of the (.-«lU of the tîraufîuD follicle in the
corpuH lutirnm, etc., «r« aUo phyiolopical I'xiiniplc*.
Fnilv degenonition a» n ])iilIiolo;:iL-al !<t«t*' i* eonslantljf observud in
poisoning from [ibo^phoruâ, ameniouA acid, the naît» of anUuionv, the
Pig.».
%
w
Fftlfjr d'tf«dar*Uoa of ^t>' tt. fr.ni • e^aeot: 'k,
rmni III» brail In «bronlr •arwnliif . Tbe Ulwt *bav
ihi: l(iiiv "i:ruiBl>rwrpu»l«"(eui|>u>clHa[01iiNr|,
*u.l aim iti' niaiiarr tnwbleh tliwt iKraDi* lldoM-
F!b. 3fi.
I
tnineral adds, tlie aalta of mercorr. All the infectious diseawa may
present analogous lesions in tiie diflerent viscera. When the circulation
of blood is arrested and the f^irt is struck vrith dcatli, as happens in in-
fnrctions and cerebral softening, the elements undergo this suidc dc^ne-
nition. (Fi;;. 3fi.) In the latter stagi-s i>f nil intlammntory or other
ncoptasniiç, when the amount of nutritive supply i» imt nufficient for (he
projier nutrition of the new cellular i-U-mcntJ» wliicli hnvi' bi'ftti fomied in
great abundance, a part ur all of the latter «ufler fatty de;;eiierati'm.
'Hie destruction of tlie primitive fats, the cause of which we do not
know, iii seen in tbe bone corpuacleti and in the cells of articular carli La ge
in caries and in white swellings. ( Fig. 37.) This fatly degeneration may
be consecutive to a death of the elements caused by arrest of circulation.
This alteration once accomplished, the cells no Ioniser uudcr>;o changes of
nutrition. Similar causes induce fslty degeneration of iiiflaniniatory
products and of pu*. In thenc cases, it seems very probable that the fat
\* «imply set free in the elements wherein it whb iniu<k«d diiriiij: their
life. Tiii* in not tio in poisoning or in infection» di^ieaje». Here tlic
quantity of fat is o^en great, and it itoems that an nnusnal elaboration
of it by the elements Ihem.ielve» haii occurred, ('eriain authors think
that albuminoid substances may, in the interior of the organii^m, directly
give rise to fat, and they even go so far as to say that a protein granule
niav become a fat granvdc. We know no tnicroscopic obsenation upon
which this view is based.
1>I0HBKTATI0X Of BLBIIKXTS AKD OF TISSUES.
tt U M»!] then that tti« (m of cAmixMtition mav become A]>pnrciit untlor
llie infin«Qce of ilie following conditions : &n iinjiedimiMit or in arn.'«t of
nutrition: a suporabumlnnt )iu|i{ily of fnt by the blood, wbicli alwuys
contains it in the phjrBiological state ; a more active vlabontion of fat by
Cirla rai^n*. A ItKcmvui u.'
I. .':!'- 'J. .Ill i.L'ti 'Jti, 1 ucuDB (uU tiiiBe «rpudM TOBUIalan
the elements ; the fat in the elements may not be taken «p by (he circu-
lation with snfficiout rApidily.
1» the case» where tlie circulation is active the rat,alrcndv extstinj; in
the cell», ili:<a|>])t!arj very rcudily, as frctiuently occurs in inSamniation
ami in tbe emaciation of fcven.
it. PlujiKXTATius OF Et-KMKSTS AXi» (if TiSfi'iSi.— liy this phraiK are
uniterslood extremely varieil alterations vfliich consist in ihe presence in
the interior of colls and of tissues of rei!, yellow, brown, or black ;,'ranuies.
'I'hey may be derived from without, ready formed, like the pariieloâ of
vegetable carbon ; they may come from the diaaotved coloring matter of
the hlowl, by infiltratin;; a cell and beinc preci]Mtated there ; or the pig<
ment may be c1ahonit«<l by the coll ÎUelf.
The penetration, from without, of minute purtîclea of carbon is readily
shown by the hluct; pi^nientation of the cells of tlic Hputa wlieo one
breathe.t air charged nith the fiimeti of a lamp. In the phyHiolo;;icaI
conditions niulor which we live, the cells a»d Ihe connective tisi^uc of the
I lungs of every a<iuJl contain mor« or less of carbon. Not only do we
[aee oclU which are entirely formed of sod protophum containing foreign
cranules and little fragments, but also oven those which arc surrounded
Ey a membrane : the penetration of the latter is explained by the extreme
I miautenesa of the particles. The presence of foreign boiliea in cells may
50
ALTBHATtOHB OP CSLL8 ASD Dp -rtSSDBS,
oflentime<i bp accomiti'd for byassumiiis ihat tbey liftve been envoloped
by a cellular i'onuation. Il tu thus tlial Kolliker explains llie largo cells
irliicli, ill the spleen, contain red blood disks, l'"orci;pi particles, for ex-
aniple i-aibon and tliu pigmenta used iit tuttouin;;. urt- usually arrested in
Uie lympL glands belonging to the iuipi-c^iatcd ro;;ion.
ne- W.
Fîg. 3fl.
■■■--- ■:-.îfj ■ ■
C«nalAT ilniMDn 0f B»lnBQ»liiis«*0ii In unjilxtf*- Cfllk ton Ea thing plfin'hl. yr^rn « mtiftnoUf
(SMiHfl.) HlwmianiutllMr. X>^' lit'**''*
The physiological pigmcntatiou of cells hy the coloring matter of tlio
blood id easily seen in the spleou. Kkuients containing red. yellow, or
black pigment occur nonnnUy in tlio splenic pulp. 'Ilie coloring matter
which cniCD! into the conipositinn of the hlk' antl which is often found in
«mall mianlity phy!*i(ilftgicJilly in the liwpatic ri-lU, aWo prubiibly c"nie*
from the coloring matter of the red blood disks which are destroyed in
the liver hy the biliary acids. The formation of the corpus lutoiim in tiie
ofary after the discbarge of the ovule and the hemorrhajje into the
(iraatian follicle, is an example of the production of red pigment which
mav later change lo black, when the body usually appears as a small
alatc-colorcd cicatrix. Whenever blood i» cxtrarasated the connective
tissue cells, the epithelium, and usually all the surrounding cell élé-
ments arc impregnated hy a fluid which contains hseinatin in solution — a
eubïiancc wbtch, hy precipitation, gives rive to crystals of hwmatoîdin.
When the clcmvntâ die their coloring mutter precipitates in & eimiUr
nuinncr.
Pathologically, ])igmeniation was firiit carefully studied by Virchow,
à pr'fji'i* of pulmonary hemorrhage-i. This author saw that thv epithe-
lial cell» which at lirst had become spherical and pigmented by a colored
Suid, soon showed in their interior yellow or red granules, which after-
wards became more and more dark colored, like crystals of hrematoidin.
From this observation he was led to the hypothesis that the coloring
matter of tlie blood, when given up by the corpuscles, first infiltrates
the cells as a colored Suid. lie admitted, however, the possibility that
colored granules formed without the cells may subsequently penetrate
into their interior, Hgrneiit granule» are well chanieterized by their
color. Crystal» of hjcmatoidin are rhomhohcdr»;, of a dark orange-red.
In certain case» their dimensions are »o great that their presence may he
appreciated even by tlit! naked eye : at other times it reiguires the highest
powers of the oiicroiscopo for their recognition. (^Fig. 4U.)
0ALCARBOU8 INFtLTRATIOX.
61
Pig. 41).
In th« normal state, the conDectir«-ti89ue cells of the ohoroid, of the
iris, or tlie pia mater, the (■pitii(>lia1 cells of tbc choroitl, and of the rete
mitoOiadtD of the skin of t)io dark races,
Uio nltl»^l(.^ fihres of the heart uikI tlic
nerve cells contain jn^cnt granules nhicli,
oA initio, are brawn. nn<l ara bj' th&t fact
to bo Jittini^uiAlieii from t)i»»o gnmiil<'3
derived fram the blood. Thcv ara entirely
TOiiivl, and «re evenly ditfiwed lhrotigli>
oat the protoplaitm of tlie cell ; they may,
liovrev<T, nl»<> cxi^t in small niimhcr in
tlie nucleus, a--* ro»\ l>e seen in the mucous
layer of tlie skin of negroes. I'ijjmcnta-
tion in the colored racea is sOTneliow con-
nected with a certain activity of ibc skin
under the influeiKo of the sun.
As a patliolo^ical formation, this pi;;-
meni p«en3s lo he u pe«tdiar clnborotion of
the cells. It may ufipcar at some dintanoo
far from the vosseU, aiul may be black
from the finit. It8 abnormal fonoation
tuay uke place at one titoo in the stable cells of the connective tissue,
simple invlanoHs; ut another, in newly formed cells, &« in mclanodc
tumor», Uie sarcomata, or carcinomata.
Crrtult-iIliaiMttl^lia, n,t:«l«i<K>,
hTMinlKH craKBUi m 4 tu •I» 4 Itiatr
fulor- *, Na4t«f U* «lit, II rpv fuQtkLn-
lav (ruialir HKBtui «Dit ir; luU. d.
Tr«i4l ; ll> lamii II (HD ailt.1 «nil t*é
H. Caia'ABBOU» IsFn-TiiATlox. — The «ilt» which form these infiltra-
tions are tbe carbonates and the tribasio phosphates of linte. These
mita are combined in calcircoits deposits everywhere, except in the oto-
liths, which ara solely compo«ed of carbonate of Unie, Truc osseona
tissue should not he confounded with liwuea infiltrati'd with Uino salts.
In the latter there i* no real or pontianent union wiih any princiftal, for
when the salt^ have been ramoved by acid the ori;^iita] structure of the
tiiwie may lie perfectly seen, an<l there may be no approitch Ut a regular
bony tittsue. The processes of true ossi6cation, therefore, essentially
differ from those of cilcareous infiltration. In the latter, tlie calcareous
salts deposited in the tissues are seen as isolated granules, as sphenitos
witli concentric layers, or in the form of a genuine pctrifaclion. 'Ilio
granules are round or angntar iind highly refractive. When they are
minute and in large uinnbors, they cause a considerable opacity ; on tbe
contniry, when a eomplcio petrifaction has occiirrad, tlio tissue appears
semi-transparent, like araj^oiiite. In the lattercasc, when a thin lamella
u polislied and placed under the microscope, the tiM^tic is seen to be trans*
parant and yellowish, and lacunar openings and gr.-inules may be dunion-
strated therein. 'Ilie oiienin;^ are the sf^incos whieh existed in the primi-
tive structure. All acids mora or less completely di»tolve tbe calcareous
«alts while setting free bubbles of carbonic acid.
Pbyaiologically, in tbe first phase of ossification calcareous granulc-s
are seen in the ground substance of cartilage ; concretions or calcarcoiu
iberes with concentric layers are found in tbe choroid plexus of the adult,
often in the thymus gland during its retrogressive state, and In tbe
méninge of the brain aivl »|nnal iDArrow of th« aged ; petrifactions Home-
times occur in llic prnfound layer of mliilt cnrtîlage in rela^oii witU lh«
<HKeo(ifl tissue, aiitl in tlie coiital and lar^vnj^al cartilagea nf the a^çed.
Never doea the deposit commence in the cell. Imt alwavs around tlie l.iHer
in the intercellular or ground subatance. .Sub-ie-iuontly, tlie cclln lliera-
selves may become invaded, but they usuall.y escape for a rery long
time.
['atholo^^cally, calcareous granules maybe met with when a dead part
remains for a lon;^ time in tb(> midst of living tissue. An vxtra uti^rine
abdominal prtjinaiicy of twenty yt-are' standing, old iiifii rctions. caseous
massos. especially of tlie lymph f;1iii>ds. are familiar t- xnmplca. Calcareous
concretions are seen aUn in the «ecretion» of the -^aliiTiry glands, the
acinoui* glaniU of tlic pharynx, of the pancr«a8,thc follicnlar crypts of tli«
ÎDtc«tinei«, in the synovial mombranvs, as well a^ in the interior of all cyets,
particiitnrly the colloid cysW of the thyroid gland and of the kidney». In
advanced atageit of cbromc iullammaùon, eapecialty in endarteriti», ofViii
calcareouH gramiln» or petrilied plnipics are to be aecn. Tliin melaaior-
pbo»iii supervenes only when the inflammatory prooesa has spent iW force,
or when the circulation of the Quids is much impeded. The products of
chronic inHammationB of the seroiif membranes haro a pecidiar tendency
to calcareous incrustation*, which were formerly regarded as true bone.
In chronic myocarditis the muscular walls of the heart sometimes present
concretions of the same nature. Illood-elots. wlierevcr they may be. may
undergo calcareous iulîllnition. i'hK-liolillw. the concretions oiTcasionally
found iu varice*, have siicli an origin. In old age, around old fractures,
and ill the neighborhood of chronic arthritis, the tendons and even the
muâulea are sometimes the seat of a calcareous deposit of greater or
lesser extent. In nearly all the tumors are freiiuently to be seen caica-
reous intiltralions, rehicli should always bo distinguished from true 03ei>
(ications, which latter are rare under the same circumstanc«B.
I, Infiltrât II IN of the Thatrs. — Tlic presence of the urates in the
solid stall.', undcT the form of jtranule* and crystal», is met with phyeio-
logically only in the urine. In now-born childn^n, however, very often
we find in the slrai;^ht tubes of the kidnvy* amnrphou* urates colored
brick-red by the urinary pigment, and vtMblc to the naked eye iinder th«
form of minute red lines. Here tlie .U>i>OBit occurs in the epithelial
cells of the kidney. Under the microscope the urates may appear as
very fine granules massed together as a cloud, as refracting spherical
grains, or under the form of needle-shaped crystals. The base may be
magneâia or lime, but it is usually soda. The urates arc decomposed
even by the weakest acids, when the free uric acid may precipitate and
form crystals which are «t first rhombohedric, but which often soon
assume the varied form» which uric acid shows by reason of its molecular
dyssymmetry. Uric ucid and the urates may concrete and form calculi
in the urinary passage».
lu gout the urates, under the form of granules or cryatals, are de-
pociled ID the cartilages, the bone», the synovial memhrannt, the tendons,
the skin, and the kidneys, [n all cases the dcpi)sit first fonns in the
cells, which serve as centres whence radiate the free cryataU. The latter
EXCESS OP NDTRITIOS, KBW FORMATIOSS.
I
■
laajf penetratti into the ncishboriiia fmula- ''■f- *l-
m«nuil or t^round Bubatuoou. Ttiv primary
Kir«cti))n ot the cclU tijr tlic uralic iiifiltni-
tioti |>rov-ea ttiitt t)it' t-'olU ]>lsy nn ikciiio
rol« here, and intlicutCM tliut tho prfict-.vi ia
oasenlinlly diflorent from that of OHlcareoua
infiltntioQ. (Fig. 41.)
J. Î.BSI0S8 CaUSKI) by IN EXCKSfi OF
NcTKlTiDS «y Cells and of Tis8iii«. —
When n coiitiniKMl uml uniiAiiallv abumUnt
supply of imirilive uiatt-rinl, etijiecially in
cast?* of irrilatifti). reaches the . cells, the
follMwing pkenoincna may be observod : the
nucletu, which in ceruiu ease« was atro-
phiwl and «arcely riaible, hvpcrtrophie* ; v..o«>«,.,.^ «.-,■«.« ^
tlio nuclcoKia becoioes thstiDct: Uio prolo- m,^ <Deiini*< i.^ am* «r •od».
niaain swells hv aWirption of flitiil; tlii> f*»™ • «ontr p4ii«»i. p. AiiinUr
whole cell. «hiJh ivae tcnKtheiied, flat, or •"'«"••''■"'«"""•*-*- •.-*■"«>■
Terjp- irrcfOilnr, lends to BMume a glolmlnr o.r.,»»i«i.i.d«wi^.M4i.. xw-
fonn. This éUiUi diflcnt from serotis or
albiimJiiouM infiltrations, which are, in wme sort, passive proecwM, for
in it llio phenotDona of cxce^^ive mitritinn consist iu n iiatiiml oxa^gcr-
at«<l activity of itie cells, and tliey oficii precede the multiplicattou of
The cells are phTsiologicallr in such a condition during the period of de-
relopmenl. The cartilage c«ll>f around pointe of osaiGcation become very
voluminous. Tho muscle cells uf tiic uterus, and muscular fasiculi of
the heart hvpcrtroptiy during ;;e«tntt<i»; and the cpirlielial edis of the
luanimnry filiuid V-coiue iiiiieh l»r;;t!r towanU t)ii- end of prcjïiiancjr.
TItc Mi't«C marked exanip!e!< of liyjuirtrophy <if tlie elements by excess
of nutntion are tliose limirn from Ijicu* oWrvcd in the ndnll connective
tissue. This tissue normally contains atrophied cell» which, unJcr the
iuSuenceof a pntliological irritation, soon show a voluminoiu nucleus and
a protoplasm, granular and muck augmented. Kvcry irritated cell, iu what-
ever tissue it may be located, presents analogous plienomt'iia. 1 1 vpertro-
phy of cells from excess of nutrition leads us directly to the study of their
patltological multiplication.
Sect II.— Lesion» la the Formation of Cell».
Cells alone arc capable of multipliaition; the intercellular or ground
eubstJiiKM; is not directly coneeriivd in this phenomenon. To Virchvw
belongs (he Itonor of having been tlie fiwt lo thoroughly appreciate the
' iportance of tho multii>1ieniion of the cellular t-KinciHa in pathological
_ fftcesse*. lie distinguished two kimU of abiuirm»! multiplication of
oelU: 1st, timpli htiptriJana, «herein the elements of the new fonna<
^on differ from tlteir progenitors neither in form uar in function ; 2d.
keUr<ii>la»ia, iu which the elements differ from their progenitors, and
ALTSRATI0N8 Of 0C1.L8 AKD Of TtSSCRS.
conlribnle to the torniatinn of a new tissue. Hyperplasia awl I[et«ro-
plaaia, whicli Virchow regardeii only as patliolojfical conditions, may
exist in the phrsiological state, aa is seen for example in ossiËcation.
In nbDormal hj|)erj>l»sia the multiplication of the colls is effected
always in the name way: the nucleus eireiis ; the niiclcoluâ becomes
ntore voUitninous. constricts itself, ami diviiU's: tbc divieiun of the
nucleus may be ctfcctcil by fission or by constriction ; the nuclcuH then
prcttents the fonn of a wallet, n biscuit, or an bour-;;)aKi( {^ce figs. 5, t>),
etc. : each newty fornicii nucleus ig surrounded by a ]mrl of tJio proto-
plnMo whieh itj<elf divides by scission or «trau<rulatioii. 'Jlius is formed
instead of a single cell two or more cellular elements. Never doe» the
içround substnuce or llie cell membrane participate in this division ; but
most fremienlly, on the contrary, these may sionen or di&solve. At firet
the C4^11 elementâ thus formed do not notably ditler in appearance from
embryonal cells, but tliey may very soon present characteristic forms.
Before leaving this subject perhaps it may be well bo reiterate again the
ftenerai law, thai the method of formation of elements of pathological new
growths is identically the snmo m that for physiological formations.
When a coll prolifi- rates, it gives birth to embryonal or iiulilferent cells.
The lattvr, if thv irritation cease or loMcn, rctunt f> tlicir former condition
and fonn tissue similar to that whcnoe they spring ; if the irritation per-
sist, and be intense, the structure of the original liA.iue is com)il<>tcly dc-
slroye*], tlie embryonal cells hecomc incapable of constituting a <lefiniio
tis»ue and form pus, or they «rganixe into a tissue which has deviated
from Ibe primitive type.
PBPtNITIOS OF IHFLiMMATIOS.
65
CHAPTEK III.
OF INFLASIMATIOS.
Sect. I. Deflnitioa of Inflammation,
ni:i»'KJ^Ë, pain, hc»t, and girdlln;;, as primnry phenomena, follo«o<l
by rewiuûon or imhimtion, auppiiration or ganifronir, have served from
Uh) tomt remote antii{iiity to specify the complex stale undcrstocl aa
inflammiition.
Tnlceii siii-*ly, none of thiiw «i^^s belong cxcltuively to inflnmmntion,
for roilnt-»<, {xiin. and licat ntay be eniMcd by t pasetnf; iwrvoas influ>
rnce ; tiinivfnclton nuiy lie due to ximplu aedema ; iiultirfttion and tumv-
fitction corobiiiod npp<'rc*i» also to lutnorii; gangrene may iupen-cnc
wherever ibe voMcl* are obliterated. Kven suppuration is not constant
in inSanimatio» ; it exiittii often without any other ptionoinoiia, and the
couilitioni of the formation of jmis arc so far from being ntiderotood itiat
it IB Dot yet known if every suppuration is necesâarily due to inSammo-
tion. Il is true t)iat in typictl cases where all these <.'hamet«rs ar« found
united, an in plilc^rmon, inHuumution it very evident, bnt a good delibi>
tion should comprehend every inflamoiutory state.
It ti> certflin that Uie iiiHaminatioTi wlio^u syiaptomaiio ensemble we
see in the clinic, cnnitist^ L-«((-iiiiiilly in an oxaltfl nutrition and furma-
tton of anatomica) eltiiuent.'i. Iti* ilefiniuoii, the ^tiidy of it« intimate
phenomena, »hould be di-nnn entirely from ex|N;riiueiitalion, since by
the application of the simplest irritAnts to tbe ti.isucii of a itring animal
wo can see pro<luced the same chain of symptoms which we recognise id
the clinic as inflammatory.
We would define ioflainmation then, as the t^ie» of pltenomtiM o^
terveil in tistuf» and orgatw analo'fuu» to t/itit whlefi may te praduefd
arti^'iWtti in tke Mme partt htf the aeticn ^ a pUyaitial or ekemieal irri-
tatinff a;/ent.
It I» by the analysis of inflammation produced experimentally in ani-
mal», tJint wo shall eonimenee its study. The principal tissues which we
shall pass in review will be, fir^t, the non-vascular ; second, the vascular.
BM. II.— Traumatic Inflammation in Non-vaicular Tiunes.
If one takes for subject of «xpcrimont the permanent cnrtilsgeii, and
GX|jo«cs a part of their surfaces, in a fortoight the latter will be covered
over by a gray, pulpy layer. Lot a thin section he made so as to in.
elude uiis layer and tlie cartilage beneath. The followin;^ wtl) he ob-
wn'e<l. In the layer of cartilage moot remote from the wound, the
56
fSFLÂMMÏTTOSr
cnrtiln^inous <!lpsulM onninin evils nhoso iiucUn nrc cnaWy rendered \'m-
blc hy a drop of piorio «ciil (fig. 42, u). As wo Advanoo tovuirU tlie
Stctluo of Iu11*ni«4 rarUlHCf. a Thv nornitl nr1IUf«o«Ui ; &» ih« •Mi)<r*ûUri;cil. d- Multiplier
11u« nf r#llft wliblu IbfAr cft|»iil«t; *,fm>l locrtBU In Ibto munbfr vt tbo jr°i"< c«IIb,imi4 4»trilc
tlwsf ili»l1l*n>llfiUr ■uli'ikurf. X 330'
m>ltilii>n or continuity, the oeil naclcus becomes Urger, the protoplasm
more voluminoiia. Soon tliia nutritive irritation ia transformed ioto for-
mative irritation, the nwclciis diviilcs and the surrounding protoplasm in
ità turn also muv divide, in order to form around each nucleus a distinct
mass. Ench ciAl then excretes around it cartilaginous substance in order
to form • new Cftpsiile. Up to this point, the irritation has chan^^cd neither
the structure of the cartilngc nor the proporly which its cell* possess, of
forrotnf; arnund them ciirtilngiiious siiWnticc. This KOnc (fij;. li, tl) of
prolircratiim i.t more or IcAs extensive. Kurtlicr on, the surface of llie
carlilaginoiiH substance is brnken up into festoons ; each of these excava-
tions corresponds to a cartilaginous capsule which lias oj^ned : besides the
latter, capsules may be seen, still closed, tilled with embryonal elements
which have lost the property of forming around them cartilsKiuouH sub-
stance. The gray pulp which covers the solution of continuity, consti-
tutes 111) cmhryoTiiil tissue (fig. 42, e) ; in this tissue hlnoiivesscls may
develop (fig. 4-. i) ; they conic fn>m neighboring parts. The embryomo
ti«^*iu' is fonncd at the exjicnse of the cartilaj^e, while at thu same lime
it destroys the latter.
The ffiitht^lia also con«titule a non-vascular tistiie, usually rcj)o^ng
u|>ou a membrane rich iti vessels. The omentum, however, ia an excep-
tion to litis general rule. The fibrous trabeculie of wliich the Iftltor u
comfiosed vary greatly in thickness. The thickest only, contain adi-
pose cells and vessels. The thinnest have no veisets, aiid are formed by
a single faaciculus of connective tissue. All these trabeculaj are covered
with a single layer of large endothelial cells whose form and constitution
may be appreciated after the employment of impregnation )iy nitrate of
silver (fig. 4:t). In the new-born, the omentum is not reticulated as it
is in the ndult, but foriiM a continuous membrane. It is in ailitlt animals
then, that the epitheliuiii of the trabcculiu should be stndicd under the
iiitluence of irrîtalimi.
An artiticiMi irritation ia excited by injecting into the peritoneal cavity
afewdrojiflof a very weak solutionofiiilmte of silver or tincture of iodine.
Twenty-four hours afterwards, the peritoneal fluid ia cloudy and con-
TRADUATtC IJtrtAUMATinX IS H OS- VASCULAR TIS81ISS.
tains cell ctecnenia : flom« rei^mMing pus corpuscles ; otliera larsor with
one or more oval, sharp bonlered nuclei; butween those two kinils of
cells exist intermediate fonns.
PI*. 43.
PiS.44.
Omaulamutlflrlallr laJlimailiiiiliillrtr IntU^. a. Tr*-
IKnndnit (|iUJi«lul (rtl. t, Tui f'l'ixiMla. p. Itdalkalliil
Urlinirul tram Ih-^ llbroiia Inltrculu t. f. SvdUM bgtilUI
Tlic nitmte of silver iufoniu us th*l tlic epittivrial plates no longer en-
tirely cover the trabecuhi: of the great onu-iitum. .Siiekiii)* to these tra-
beciil:u or between ihein, large, voll-rorined ee!U coiilainiii;; uucU-i are
fouml (figs. 4-1, 4r>). In these elenienla, &II t)ie plieiiumenu of multipli-
cation of cells arc feeii. Where the hypertrophie<l cells »rc adherent,
now by a large aorface, again oal; b;r a point, tbey form salient projeo-
Pig.4a.
Ft|;.4S.
fk* ajitlKrvlj*. PuBrrU* ftn ^iiiIibJ'K'cI \n tli'l^rlb.
a** Ik» trvikla nHtii>tuA wKb 111* Obiuui iimborU'
OiTiaiLiQiD ■rilllf^AlEj' ïafliuirJ ^««1 «ï*
• mliitfil Ihw •l^liLli £4^ afL^r Llii' dp«n»lltia;
Ibu f^oilalhtMitl f^lJ« h«vv ■c«1b brofivfl
■n>ii*i t« lbs aiiiunB intiMFgiit. nair
pFulapImm I* Ut« vnouUt ib*atiilbapT«-
evillllH CB*M. IIUO lh*7 forU' HU nllBt»! OdUf
FifWcpC.boIUIIiiTsiiinMi. X^i^'
tions npon the trftbceulsu. They may become detschcd nnil continue
to lire aid multiply. Tliey poawes no menibrniie, and bitve a sofï gniiiii.
lar protoplasm «bieb i» cspablc of taking the mont varied fonn« and of
giving birtli to atnœ1)oi<l prolongations. The fibrinoi;eiiou» substance
exuded from the vessels, fonnt filnim^nt'' <if fibrin which surround the
cellular olementa ftnd may for a cerl»iii time bold them in contact with
as
TSFtÂMMÂTÎÔS
till- tratiuculic. Pu8, however, miiy b« tb« final product of tlii» ncv
fonniLtioii.
After five or «ix days, wc may «till find clumps of [his corpuwlw or
of otiicr newly formed vclU, floating; in lUo |icritoneal fluid ; t>itt gene-
rally tlie lar)te HwoUeu celU reapjity
thomtielveii to llie Irabocul.-e, tialten oiit^J
present a protoplasm less granular, and'
return to liieir primilivo type (lig. 4"j).
Al iJiis time one finds in tli<r pcriconcal
cavity granular cli'mctibi in a itate of
fatty dc;;<,ncraiioii, for those frw; elc-
nieniâ in the pcriumcnl fluid are plnocd
under conditions not very favorable to
tlii'ir lifv.
We i>binM-ve in these ««impie experi.
mental fact^ two ojipodte ordera of phe>
nomcna, due to the inSammatory pro>
clm;4. Thconeconaistoinanexa)u;eral«d
niitriliou and a formative irrita^oD of
cells : the other in the death, by fatty
defeneration, of the oldest coll*. The
first only properly appertain» to inflam-
mation, ibc other is exjtUiued by the
fact that the cell» are pliioed in vondi-
tioiiiS unfavorable to lifu.
Another cone I uflino follows these ex<
penmenU. It is that bloodveasela are
not necessary to the formaûoQ of pua
corpuscles, and wc may add that in
these cases we have vainly «might for
pus corpuscles disposed along the ves-
sels in the trabecuhe which c»ntoiTi them.
[Trom a hi»lo;;enic point of view,
the blood and lyinj>h vessel» may -ho
regarded as analogues of the serous cavities. The endothelial cell» which
lino tlicse vessels have a liistogenetic origin identical with thai of the
cells which cover the serous surface», and they may he looked upon as
transfumMtd connective- tissue corim^de.*. Instead, however, of receiv.
ing their nutrient supply ami discharging their waste products through
tlie mediation of the lymph, as do the connective- tissue cells covering
the varioiu scrou» surfaces and lying iu the lymph spaces of the organ-
ti*m, the lining endothclia of the bloodvessels arc directly laved by tb«
plii»taa of the circulating blood. We have already seoo that one very
considerable »ourcc of tlie embryonal cells, so numerous in the ti«dues
during irritation and inflammation, is to be found in the increased ftcliritf^|
and proliierutioii of the conncclive-tissue corpuscles and tiieir congener*.
Figure 47 explain» an obwervation reconled by one of us,' which shows
■ LfcIuit VII. T1i<! ToniT Lcctmu. The Natuiv nf Itriwrstorr Innamtiiatiim in
ArU-ri» afiiir UkiHiiti). AL-iipri<i«iiiv, arid Timimi. Ity IMwaM O. i^liakispcarv, A.U.,
H.l>., ilrliverrd Juui- ST, 18T9. Wiuhiugluu, ^nillliïuuisii liinlltiilliin.
X tapin*i7vrihKm(Wni<T}'ciri (Tuf Dlnr
li«ijr« Lnflmnod, thuwtnc ilniAcUrnDni nf int
■MduEbeUkl «n wlkkli \* fluiiilj c*.rrt<-l uff
b^ llio 1iUi>^-rtirr«n1, Ultfli pi»ir4>r. «I C*p<
nti^'f vitlU. I. Lt'iir-nyiif* cilrfciKl Lulbe
«■IU. /.<'a|-1Ila(j MiJiillirlU.tniuiiliraiiil
4Wollfrji«libpmJ«rrln^ Ipi^EIU^- ff.i'tlU vt
■duoUIU. alia laitlldu iini) icn>aiiltr. a,
4, I, 00l0Tlf«4 ft>'|-U(f]«« HOtlO^^Dt 10 tbfi
«kIUl (tli nibrr tiDl)' Wuud liilhii null
by mrtmitl ^\'ita ^^attnUng ih^Ekiifr ; i.
« EorpUAf^la «dbflrwQl Eolbtr pai&lol UEllon at
IVi> fci1)jipeoi «eddibrU^l fi-l]i:a,â hLUa
cvrpuBflt* kdriftriuj; l^^liiJ^ In Ibr iipporend
(4 au v>Anih»U>l cell t. «hlfd la T'XIy
ftitA oat tt-'lu Lia btd by Ibi- kcLkon tti ihi*
rT,J iltakh. The intitw hidlcfelA* thn 4irt<-
ARTIPICtAL IBRITATIOX OP TA8CDLAR TISSCBS.
59
Ihftt Ibo cmlottivliiil lining of tlic ciipillnry kloodvMseU may cxpvrioncv
alterations during iiitlaiutiiaiiftn lùmilur to thotte above (ltiMnl>c<l for tliv
cellular covering of th«' omciitiim. In Arlificiitlly Rxvitvil inllaoMnatioii
of Uie arterie.'i the «n'lotlieltnl celU aro affectoil in tbo mido maonor. I»
the paper already ci(e<l it was pointed out iliat tlic endothelial oells of tlie
vessels shonld also be regardenl aa one of t)ie source;! of tbe colorle^f
olviaeiitâ of the blood present during inSaromation.
.Since what wo know of intlamiuation warranta the belief that tlie
i^rioiiit [diyeiologival processes aro only faint prototjpea of tlio inHam-
>r; proceM, it seems Justifiable to ilraw the inferûnco that, like the
'eoDneotiro-tiHitue cells ciscvrbere. the ondotbelia of tlic vesBoU, parltcu-
larij tho»e which conrey oxygen, niay give origin phjeiologically to
some of the white corpuscles of the 1)lood and lyuipb.
I'he eiidoihelia of itiu vexseU arc probably the niaiii «onrce of the
Urge, granular, colorlou cellit which have of late year» been found occa-
sionally in (he blood of typhoid fever, of reiajitun^ fever, etc.]
tSect. III.— Artificial Irritation of Vascular Titsnw.
O*»rou» ti»me ie very eaxily studied in inflammation. The oaaeoaa
fe^-culm limit space» in which the vascular tissue, tlic marrow, ts the
Hilt rif almost every nutritive or formn^ve lesion.
IiCt us suppose an artificial irritation of a short bone, or the extrcnuty
of A long one. ,
There is al lirat a formation of embryonal tissue at tlie ospemte of the
subperiosteal ineilullary celU and "f the cells contained in the inodullary
spaces. Normally, the medullary celU are free, are not inclo^d in a
fundamental or ground substance. Some are small (medulla cell»);
E others are lar;^, with one or many ovoid nuclei (myéloplaxea or giant
cells). Jlesides iheae, tiiere exist large adipnse cells and fiuiform or
stellate elements. It is from all these different elements that the «»•
bryonal cells arc derived.
In tlie adipoi>« vesicles of th? irritated bono marrow, the nucleus lîrat
hypertrophies, theu divide: the swollen proloplai>ni surroumU i^ach
unclcuii; at tlie same time the fat dlsappi^ars and is replaced by an
albumiuoiil fluid. These new elements multiply and finally completely
fill the vesicle; the» ib* membrane ts destroyed or ruptured and (he
eoDtained embryonal cells become free.
I'he medulla cells a»nime the character of embryonal cells, to which
they are so nearly related, anil multiply. If the irritation continues,
the osseous lamella- adjacent to the medullary tissue are absorbed, and
each bone cell falls into the medullary cavity. Thus the medullary
cavity enlarges and is filled willi embryonal cells, an<l the osseous tra-
bocala> melt awuy under the process of absorption. (Sec fig. 48.)
During this time the capillary vessels undergo very important modifi-
catioita. The cclU which form their walla swell, their nuclei become
more apparent, so tliat on transverso aect'ion one caight believe Uio walla
to be maile of fusifonn bodies analogous to the fibra-plastic cells of
Lebcrt; tlicae cells tlien form projectiona into the lumen of tlie veasel
60
IMFLAMUATIOX.
and may iiTi]>e<le the circulation (jce fig. -lit,/). The bloovl is conpi-
lateii b^' cliroiuic or picric aci<l, used iu lianleiiiiij; tlie tittsue, tlie red und
Fi([. 4S.
lt> iLn rlnhi U mird wOb r«a mriaHttj il»in>, i» wlilcl. il>g lomlni ur ihi («plllirlp* ar» apvB
X3M, (Jtt«4MH*.}
wbiu- corpuscles bciii;; easily distin;;uislicd in tbo lumen of the reme).
But tbc wliilc corjiusclc* do not forin a continuous layer, as ibcy sliould'
iicconling to the theory of Cohnhciro, which will soon be noticed.
In ititf ifuf-iHtdneou» crllular tUëur sittiîlar pht^nomena lake place under
the itillueiicc (if artttidal irrit>iti(Hi. This tissue contiiin» plasmatic cells
placed in and npon the fasciculi of connective fibre», besiilos «orne adi-
pose vesicles aitd lympb cells. I'he connective- limine cor|iiisclei4 (plait-
mntic eetb) at firi>t hy[)ertr(i|>liy to »twU an extent that the shnmken and
lliinncd uucteu») becomes globular, and the protoplasm becomes granular
and very apparent (fig, 4i', e}. After a few houra, the nucleus and the
firotoplasm divide, whence two or more embryonal colls appear in the
yniph spaccg of the tiseue, arranged into clongtiled islands or chiuns of
ccIIh, pressed a^aiuat each other, and limited by the parallel fibres. la
the adipose vesicles the )>ratoplasta becomes visible, the nucleus divides aa
in meilullnry tissue, and the fut disappears. By the continuance of tho
proliferation each fat vesicle is replaced by ft little nest of embryonal cells
(fig. 40, e). Proliferalion of adijiosc cell» is not effected as rapidly as
thai of ibe coniMJCtivc-tissuc corijuscles. The former may con*c<iuently
often be seen in the midst of embryonal tissue for tiome time after tlie
commencement of inflammation.
While tbc cellular elements are tlic ttieatro of the preceding changea,
the fnniliimonia) fibrous sultstauce of the connective tissue imbibes the
fitiid«. the fibrils become less distinct, and may finally disappear entirely
by a complete absorption. According to ItindHuisch, they undergo a
ARTIFICIAL tHRITATtOir OT TASCDl.AR TISSQBS.
61
n*. 49.
luticoiLt traiwritmixlion. However ihi» may be. Uiej lire convorlnl i»h>
a doft ami amarphniu «nbstance. The M«onJar;p* membrane of oolls of
the connective tiMue, if it exist, «iiwippear»
br abeor^>tioii, ami the i>mbryonal celU
hooome free in the mi<Ut of an amori>)ioH!i
ma^. The elastic film'.* cxpcritnce change»
i>on>e«bat similar to thow of ttie connective-
tissue fibrea: they break into fragmenta and
Iwcome reduced to fine molecuW, which in
Iheir tnrn entirely disappear. T^ie vessels
present the «mc alterationx aa were «enn in
the bony marrow; there is an evident muh
liplioiition of the nuelei of their cells.
The different inflammatory phenomena
which we have jnat dc«cribcd arc the most
important, for thoy are seen in the non-
niAcnlar an well a* in the vascular tisâues.
Nevertlieletu, for a long time the circula-
li>^ii ha» been Iwlieved to play un immense
ro'i- in inflammation, a r^ilt whieh Cohiiheiia
by hi9 recent cxpcrimenla has reaffirmed,
while nddin;; facu wltieh up to that time had
scarcely boon suspcctod-
Knttenbriinner and Wharton .Tones had
«tiidicd th(; phenomena of irritation upon
the int«nligilnl membrane» htkI thi- tongue
of the frog, and npon the wings of the bat.
Thev saw t!ie rebels first tontract. aflcr-
wardii relax, and subaetjiiently blood st^viri take plaoe, but they did not
follow inflammation beyond iu firAl »tage. We have already seen that
proliferation and the formation of embryonal tissue are essential parta
of llic iiiflnmmatorr prouosH,
Aug. Wfllh-r. of l^ixton. in 1846, was the first to publish an observa-
tion of the iliH|x-desi>ç of the element» of the blood. His i^tatements were
overlooked. ï^nVo^ueiilIy Cohnhcim, apparently without any knowle<(go
of the opinions of Waller, inittitnted a sencs of experiment», mainly upon
the come» ami mesentery of frog», which tended to iMtahli»h in an
indiihiliihle manner the emigmtion of white btood-vorpiL-^le^ from the
luuion of tlie Wood vessels, and to explain mippiimtion by their eimai* in
immense numbers into the ti^ue involved. Oohnheim commenced at
Erst hy curariztog the frog, claiming thai enrara had no action upon the
1 fiirealation. This claim must be denied, for the poUon determines at
Brat a contraction, then a dilatation of the small arteries. 'I*his jiro-
I cedure, then, is not entirely free from a first cause of error. The abdo-
I minal wall was incised, a loop of inlcHiine withdrawn very gently and
spread upon a gla»s slide, to that the mesentery, when plac«d under the
' microscope, showol very distinctly its arteries, veins, and capillaries.
I The aeUon of Uie air, the traction, or the contact of ncoilles amply sup-
^wplicd tlie necessary irritation of the membrane, Cohnheîm obsen'ed:
^^p«t, ft uK>niliform contraction of tlic small arteries; 'id, tjircc-tpiarters of
AJIrw* il>>*>. tnm » dw> «nniid
In ■ 4a(, U r»f ■«•• ef hMUuji. a.
Ii|iH«> len \ij tka khHryUnn '•' It"
«nil Mirlr rnrmH iitclfl r, nt>
t. RBUfTOUlc nll>. /. ïsellun of ■
tomI vtiltli ba> rubrj-uulc BaUt.
u
ISPLAMHATTOR.
an hour tn an hour after tlic coiiiroeiicemenl of the experitnent the vaina
also contract, the circulation ia reiar<leil, there is stasis id the ea{»llft>
rieH, when the red globulea can be dUtitiKiiishod tmà even counted in
their passage along the larger vessels. We know that the inner sur-
face of the small veins is covered bv an adhesive layer containin;:; white
globules which remain more or loss motionless. In întlainniatinn these
while cells become more numerous utid prewnt ania-hdid nuivements.
While repenting these expcrinicnts, wo have been struck by seeing tbc
aiuielioid ]>rolonKftlioni< producoii only on one «idc of the globule. The
mcehAui^in of this («cnliur doforaiity can be readily olnerved : when iho
white cor]niHcleit remain in the adhesive layer, tliev fix tbemselveii u[)oaj
the wall of ihe vessel, while the flowing blood bends them and lengtbenH
them out: if now, under the action of ilic circuialory ntovoment, thejl
become detached, we see the portion which waa adherent present thd
form of a nipple covered wiih spines. These conmselos accumidato in
the dilated veins. Up to this point we have ourselves been able to oo»-"
firm alt tliese phenomena. Acconliiig to (,'ohnboim, and many other
acctimle observers, many of the cells finally pass through the walls and
escape intii the snrroiniding tissue.
The manlier of cscaçc of tlie eorpuMclea of tlio blood is still doubtful,
Cohnbeiui believes that they go out through Rtomats between lli« ondo-
thelia. lie a.<-iimt1ates the remaining tunics of the vessel to conneotJvtJ
tissue in which there are networks of lymph uhannels and spaces, anj"
lie conceives that the escaping celU work their way along these until
ttiey pniïâ bcjond the wall. The Siime plienoniciia aftpear alao in the
eajiiHorics.
Tlie red ;;totiii]<-s al^o inny i-i<ca]ie from the vessels. We have oh8erve<l|
(he passHgi- iif the rod disk» thi-ou^h the wall* of UiK capîllnries in the web*
of the frog's foot. Some authors consider tiie pbenonienun to ht; physiolo-
gical. U isafact that almost all Diamntifern^ have roihli.sks in their lyin|ihj
Tesacls connecting the lymphatic mdiclea and the lymph glaiid!>. Tbesal
globules have very prohaoly escaped from the blond vessels. The red
globules which have escaped from the bloodvessels are often consirieted,
mummillalod, or fra;.a"iented. Their color, their refraetion. and their setisi*
bility to reagents, contribute to the determination of their nature. Such
altcrei) globules arc found in most intlanimatory exudatjons.
'nic facts advanced by Cohnheim lio not conflict in any manner with
those which we have desoribeti à fir^t/M» uf inflanmiation of cartilage,
hone, and conneetive tissue. The iht-ory of Cohnheim does not appear j
to us to apply to alterations of intlnmed cartilage, because, among othcr^
reasons, the phenomena of prolifi-raiion theretii take place within the
interior of each capsule, which, so far as we know, is a closed cavity,
Nevertheless, Cohnheim would explain the suppuration even of non-vas-
cular tissues by a migration of the while corpuscles, taking as an ex-
ample the cornea. In examining the inflamed eomea of frogs in the
moist chamber of the microscope, Recklinghausen saw the cells of the
lymph «[taces increase in mnnher, and slonlv move along the canals
from one apace to anotiier, in order to accumulate as embryonal celts orj
pus corpuscles at the surface of the cornea. *
ColiDheim refieated these experiments, and fonncd tlie bypotbcais that
IHPLAHUâTORY OOtTOBSTlOir; <33
lho»c ■■k-inenti eomc, not from the so-called comcnl corfiLtclM, Imt rnmi
tiie vrhiti; corpiMcIcs of ttic blood. To dcmoMlraiv Oii« lie injected into
the blom) of (lie frof; a fluid contaiitiog in Kiupeinion extremclj fine
E articles ut nniline l>1iio: he routxl tliat in thv cntieA wlirre the conie»
■d lieen alrendr nrtificiall; iiifliimed, the iiew cellular olentcuLi con-
(lined bhie grantilea ; in these cases a certain miniber of the white cor-
pusclefl within the bloodvessels preBciited moleeiilca of aniline Cthcs«
corpiiscli» are in rcalitv penetrated by f;ranulca in a manner similar to
the (lenetntion of ntiMcwe). He concluded from this thai the colored
white coTjxiwles found in suppurations were orifpnally nothing eUo tlmii
lh« while oorpnsclve of the bloixl.
TUi* conclusion does not apgiear to a» stifficientlj' ri^rotw. After
irritation, the conif» mny Ipcc'une inlillratcil by a laff-e iiiiniitity of fluid
from the blooil. TWi» fluid, li{ildin<| in ^uripennioii the coliiied jariicVs
of aniline, comes in contact with the various cells of tho comea; the
granules may then penetraic them directly. Thus, it t» ]>owil>le to set
np, in ptac« of the theory of Tohnheim, the hypothesis of the direct pene-
tration of tho particles of aniline into pus corpuscles which may be gencr-
a«'d in the cornea. Witlioiu wishing to deny the theory «f Colinhfim,
we hold merely that his exf>cnments may be interpreted by another
hypotlH-sis, and that npon a «jueslion so important it is well to wilhhoM
a positive conclusion. Moreover, it has been detnotistrated that in irri-
tation of the comes the plasmatic colls, or eo-callcd corneal corpuscles,
proliferate, bud, and tuultiply by diTislon.
[Ad cnrly ua 1S1:<, the iliàpivlcsÎA of the white corjwselM of Uiv litooil
had been obsen'ed by l>i:iUinj;er. This observation waa auKi«<|Ucntly
made by at least seven other invest iga tors before Colmheim's socslled
discovery in 18<[7 of the passage through the walls of ihe blood-
vessels of the white corpuscles of the bloo<l, and the construction of his
theory of inflammation and of the formation of pua. Among those who
have confirmed Çohnhoim's investigations by observations of their own,
perhaps Axel Key and Wallis have made the most important studies.
On Ihe uthvr band, the most competent and reUiiblc observers testify in
Uie imxrt positive tenna to the multiplication, under irritation, of tlio
nucleus, and finally of the cellular protoplasm of the various »o-callcd
fix celts, including the endothelia, the epitlielia, the connective-tissue
GOrjiuseles, tlie bone celts, the cartilage cells, the mi»c)e fibres, and the
nerve celts. Id this categorv mav lie mentioned the names of Strieker
and Norris. Oser, Kremiansky, Durante, Kundi-at. l.ang. Kindflciseh,
IIuiob.Kleinandliurdou-Sanilorson.Scwcfgger-Setdel, Remmiug, Kixitor,
Itaum^artcn, Tscbau^ofl', Chapman, etc. J
\nw that wo have briefly studied tho phenomena of infiammation ox-
cilcd experimentally, wc may commence the study of inSammatiou in man.
SecL IT.— Analytioal EzaminatioA of InflammatiOD in Mas.
Inflammation oflera for study hyf'erœmia or inflammatory i^Hi/ettion,
erudatian», ytea formation», and infiamwatorg <Uifetieratii>ni.
1. HvpKBfUU OR IxrLAJiMAToRV Co S «KaT I ON. —When hypenemi»
Fbaa been only of short duration, it disappears after deatli so completely
64
tyvLAXiajiTios.
»
«s to leave no trace beliinil. But, if it has been intense, if it has last»d a
coriain time, the «apiUarics aliow po§t mortem a fulness. Th« Tflssels are
distenflod in the t'ortn of c vHnder» or into fusiform or ampullar dilatations.
Ill fin m m n lory redness has bocn explained by tlio distension of the v«shcIs.
TliiB opinion is most generally adopted to-day, It is probable, liowcvor,
that tliure should be added to this cau«c the fnvt demonstrated by VaXov
and fft. I'ierre, that tliu eoiigeslcd vowk-Is contain a larger proportion of
aru-rinl binod, t* well aa ibc fact that there is often some diffusion into
tlie tisMucH of tlie coloring matlor of the blood. The epitlieliiim and
eotmcctive-Usaue celt» of the hyjierivmio part** often preMnt a color at
limt yellowish or reddish, and occwioiuilly contain pilent granules
w'hioh become more and more black. The latter state of the cells is one
of the causes of the slaty color of cicatrices of serous membranes.
2. Inflaiimatokv Exf!'ATliiS3. — A. Sefi'tiM erudationa. — Tlie exist-
ence of fluid exudations containing only dissolved albumen has bee»
assumed rather than chemlcJiily demonstrated. In reality, these fluubt
almost always contain variable <iuantitice of fibrinogonous matter, of
fibrin, or of iDucus, according to tlie part afiectcd.
H. Mwout extidatiiHt are met with wherever mucus is prodweed in
the normiil state. They contain filaments of precipitated mucin, tvbich
acetic achl <loe» not cause to ilisapjicar. I'his reagent at the same lime
eat»c.<t the apj'earance of a granular preet]ntnte. Mncou» filaments may
form thick layer» ujion the jiurfnco of articular cartilage;*, notably in the
case of white' tivrellingii.
C. FiltriHous exujittions de not escape from the rcssols in the shape
of coagnlatod fibrin. Oenys de Commcrcy believes that the fibrinous
eul>»t»iicc exists in the blood at fir^t in solution, and in exudations in the
state of dissolved plasiuiii, and that this plasmtn eougulatcs into librin
under tlie influence of a substance acting as a ferment. Under diRerenl
terms, .\lexander Schmidt hits advanced a similar idea, lie considers
that there exists a substance whteli he caW» Jihrin";/cn held in solution,
but which jio^^eiise^ the |>ro|ierty of coagulatiii;; wlii>n it comes into con-
tact and combines witli another albuminoid subatauce which he calls
The globulin contained in the red blood disks is a 6brino-plaatic sub-
stance, but all the ti^isuea, the cells in particular, contain it and may
conseouently effect the coagulation of the fibrinogeoous substance.
Ciider the influence of an intense inflammatory congesdon, the fibrin-
ogciious matter escapes from the vessels and coagulates by uniting with
the librino-plastic substance derived from the cells, 'llie coagulation
takes [iluce suddenly and in miccessive hiycr», the «xudat in contact
with the tissues alone coagulating. Kxiidatîons in closed cavities, for
example tlie pleural, may almost entirely consist of coagulated fibrin. If
the»e exudations are drawn olf, however serous they may be, they soon
coapilate, from contact with Hbrinoplastic subntanoea. Very thick layers
of 6brtD covering the thoracic walls are thus often formed. Schmidt
assigns to the fibrinogenous substance a very considerable office in In-
Sammation.
Fibrioous exudations hare a limited duration. Whether dispo6c<l îu
rKfLAMUATOKY BXUDATI0!t8.
65
I
I
fiUnMtitâ or membniDouB layers they soon tiiidorgo a chan^; first fibril-
lar, tbcn ■granular, they finally sufltr a complot« molecular âiâînte;;ratton.
It is not ileinouïtrate^l thnt they nre siiscepciblc of a hi-^bcr orgamxatioii.
D. Jtem-^rrhagie Eiudithn». — Kvcn in the sinipjcitt int) animation,
for iiiAlnnoe coryxa, ri><I blood «IikIch e«CApu from tlic vessel» and tuix vrith
the vxutlcd fluid, sotnetimes i» oonHid«ni)>le quantities, at others in
numbcn iwarcvly nppreeiablc by (he iuicr08Qoi>e. In inllaminition of
tbo »n))cuuinc<>ii'4 cdluUr liiuiuR, at the commencement there is nlways
blood mixed with the young cclla. Its prcseiKe may give to the exuded
fluid a color more or less dark. Tlio glohulefl may hunt or ihe coloring
matter may «tlierinse escape into the Suid and be imbibed by the neiglt-
boring elements.
£. Srnilatio»tt eompogeJ "/ fihrtn and coagulated Mucin, ittelotinff
Cfltufar £UmeNt» {C'rvup-ut £xu dation of German autln^r*). — The
Shrast; "croupous exudation" is applied to «xadatîons •Jeposih.-'l upon
IwMod «iirfaccs in the form of nicuibranvs. This exudation coni^i!>ts of
eoU oIooMnta difforiDg nceonlîng to the part aflcotod, hut it nlsn nlways
oootains fiUmeiit« of fibrin, and somctimett mucin and ontnnglcl pus cor-
pusoles. Theflo fitamenl<« foroi a network in tlio niciilie? of wlitcli arc
found cell element», epilheliiim, pus coqmiicleji. This exudation ih met
vith especially in seraua inflammations and in acute croupous pneu-
monia. German authors atil) confound tliese
fibrinous exudatioiw with the false mem-
branes of true eroup, or the pscudo-diphthc-
ritic membranes of Prvncîi authors.
F. I>ij'hthrrHie and Pfrudn-mmdvaHoMS
ExudtitiiitiK. — Whilst fihnnoul* exudalioiiA
persist aSier death, the fake membranes of
true croup, on the contrary, bave almost
entirely disappeared by tbo time the autoray
is made, or they constitute merely a pulta-
ceoua laver rcrv difi'ereut from that which
Hjt- f*-
ot t^'\a In « Bhrlbnua 4i]cri4iitl4b
is seen ffurin^ life. According to E. Wag-
ner, these false membranes are not composed
of fibnn, hut of epithelial cells uniu-d to-
gctlier, yet easy to separate. After treatin<|
these fal»e mt^uihntnes with a wcnk solution
of carmine, Wa>;ner MW them n'solvo inl» blocks, angular and refracting,
or into branching el^-meuts, interlacing with one another. lie has de-
scribed nuitierotu prolon};ationit of thc^e elements, which he compares to
stag^' liorus, and he has seen all intenoediate stages bctivecn these and
epithelial eotis. In ac<|uirin;; those straii;;o forms the cells become inHl-
trated with an albuminoid substance, lose little by little tbeir nuclei and
their membrane, become transformed into homogeneous ma«8cs which
prcaent numerous ramifications. Wagner admits the Gbrinons de^nera-
tion of the cells. These altered epithelial cells, transformed into bomo-
gcnoouB blocks with prolonged ramifications, fonn in the pharynx nhitisb
layers, thick, opii<iue, and of a fibrinous appearance, beneath which pu4
corpuscles and hemorrhagic exudations are often met with. It \i the
S
66
IRrLAVMATIOn.
Utter wliich funn the reHiliitli eccliymotic i^Unils seen in tlie deep layer
of these false mcmkraDM. In ihc kryiix there »re alwaya many sufier-
im|i(MC<.l layers of these eiHllielial meiubruiies (fig. 51). We have veri-
fied tlie exactnesH of the <lcm:ription given l>y Wagner, but we would
conclude that the cells are lilleil with a mnterial which approaches mucia
r&th«r tbao fibrin. Ttiese e^tudatioos of true croup become deucbei:
and thrown off in proprtiOD as pus or new epithelial coUs form bclowl
thcin.
IxFi^AMMATonr Nkw PoBXATIOKi). — Under the influene» of a slight
Ition, there ncciir» a simple hifpn-phêin of the elenioiits. If the in-
fiunmation ia more intenAe, the ancient ti»i<ue is trniisforiaed into em-
bryonic tissue ; this is what we call an injhtinnKitorii hi-teroiilatin.
In man mtlammalion accords ivith what we have learned from the ex-
perimental study of inflammation in the lower animals. The procès
evolves in the following order: hiffiertrofihii of the HUfleu»; inerea»e,tht
divitinn of tJie protoplasm ; ilvntruelion of the enveloping meinhraHt <
the f^U; ttettrtictioH of the fbrou.» or of the fundmiejltal aubttawvj^
production of emhrtjoiutl tU»ue; forjnalion of new ve*»e(t. At thil
junoturo wo sliall con8Î<ler oidy Rupporation, formation of vessels, graai
Ution ti»«uc, cicatrisation, and the de;;enerationB eonKCCutive to inflam^)
malioti. These <li-<!eiieratioiu take place wium the I'lnbryonal tissue
{iroliferates with very great activity, and the cells multiply and accumu-
ate, with a corresponding Kupply of new vc«aeU.
A. Sttpjmratiun. J*u» Vor/inm-Ir». — Kmbryoiml cell» have a nucleos
round or oval. If the division of the iiiicleiis and the nutritive supply is
well cfl'eoted. one cell regularly gives hirth to two others; if hyperplasia
is active, one finds a few cells with several nuclei. If, however, the
nutritive materials ccaso lo be supplied, the division of the nucleus con-
tinues to take place, but the cell no longer divides. The cell then con-
tains two to five small nuclei. Such cells are pus corpuscles. They
IHFLAHMATORY KEV TOKXATIOVS, TV3.
67
diRer from pmbrjonfti colla otAy br th« number nni] atrophy of their
nncloi. In pus recently fonaed, beaides these pus corpusclcd, eells are
constantlv found with only one nucleus. Tlieae are embryonal cells.
I'm corpuMlvs arc, then, nothing e\»o than embryonal celU with a small
kmoiint of vimlity. This atrophy of the nuclei is constant in all elemenU
which <)tc or arc climiniitctl. Piia corpu«clce may i>xUt in a tissue in largo
niunlwn tritJiout tlu-ir prcMriicc bvin^ reTcalcfl to the naked oyi' by tHo
{ihyinoal charavtvni of Ùw liquid called pu8. Granulatiou tissue, mucoa,
and the »eonilion of «crous membranes normally contain them in gn^fttcr
or leiiaer numbers.
The purifonn appearance of a lt<(Mi<l is ligc to the fact that great
mimhers of small solid corpuscles Roat free in it. Thus the cream from
milk it opaijue like pus, because it lioliU in suAjiension many fatty cor-
puscles: enamplcd could be multiplied. The int«stittal mucua m&y con*
tain in suspension only epithelial cells, and yet to tlie naked eye abs»-
lutely rt-Hcmble pui.
The follovfin;; arc the phvaical anJ chemical characters of pus cor-
ptMclea; They present no cfiîlular membrane. When fresh, they appear
aa a (inoly gruiular mass, irrof^ilAr iu outline, often haring aiiiu-boiil
movementji (fig. .V2). Their nuclei arc not at Brst visible, but vhcn »
drop of wAivr U aildeil tticy «well from .008 to .0(K) mm., which 18 their
Qonnal dinmetcr, to .011 or .012 mm.; they become spherical and show
very ilistinclly, especially after coloration iu carmine, from .2 to 4 or 5
nuclei fn>m .W2 u> .OUH mm. in diameter. These niK.'h-i uxuiilly have
no nuplooli: nevcrthelws, in Botot there exista a refrayling point, which
Foerster calls a puncttform nucleolus. These nuclei resist the action of
Fis.aa.
Pm r*U"t a.Traa n tirtn^l'iitig wund :ft.
v\t.ta.
Fa< nrpiiHU>. I, a.A. U sUfr; •.d.f.sflsr
Ik" MiMa of mUt Mid : S, dhM*« or ■Bt)((.
acetic acid, whilst, under the inBuenco of thî« reajzent, tlie cell becomes
spherical, pale, and remains for some time limitiv! by a very thtn border,
which finally disappears in its turn (fis. Ti-IV !*<»-* corpuscles do not
differ, then, frtmi certain white corpusclcx of the blood.
Theory of fAn formatia» "/ PttK. — Acconling to an oH njûnion of
Zimmennann.puH escaped <Hrcetly from the vessels. Cohnheim affirmed
this opinion while bringing to it» !»up|n>rt the experiments which w« liavc
prcrio(wly dewribdl. But i* pus aluays thus formed? We have to
some extent prove*! the contrary. The epithelium, for example of the
MnKu or mucous membmneii, under irritation divides and forma new cells,
68
nrPLAMMATIOS.
whiclk ihemseh-es may divide, and so on a</ (wn*«(7«w). Wlieii in tlioso
small e.il ce lU tlie nucleus (Uritles without Oiviaion of the cell following;,
we liavc pus corpuscles. &o also cf llio cells of connectire tissue (sec
p, ô,î et leq.}, and of adipose cells, Ilcncc <ite admit two modes of the
fonnation of pus; 1st. by ilic proliforatioii of cellular elements; 2d, by
the escape of while blood ^kibules from the bloodvcesels.
Vus is very easily chun^-d; it undergoes, ncoonting to its age aud
the infliK'tice of the purt» with which it is in contact, many mud ideation s .
FiiU't (Itijfntratinn v/ j'um rorjiutrlra occurs wliciiovor the pua 1» old.
In the intvrior of the ci>rpim;lei>, then, there cxi^t fine, fatty rvfrncting
fjranulo», five to ten in each, and «cetie acid docs not modify them. When
the di.*in to ^ration ia more complete, the cor]>ii!icleii beconu^ distended iriûi
j^rnnule.'^; they appear as dark masitcs under a low ma;;<iifyiiJi; ]H>wer,
meikHurins .UL'i to .0:^0 mm. ; the§e are what are called the eorpii^loM of
Qluge. Theiw corpuscles of Gluge (see iîg. ii5, p. 4^) do not always
come from pus corpuscles : for esamplci (hose of the brain in cerebral
SoAening, and tboso of atheromatons foci of tJie aorta are considered to
be mere asslomerations of fatty granules.
C'uuouf tratm/criti'ition 'it' jntt rfir^nifir» lias already been mentioned.
In this condiUoD the corpiwelca ar« no longer acted upon either by water
or acetic acid.
Pi'juwntar^ injiltmlioH i\f pug corput^lfif happens when considerable
extravasations of bl»0)l accompany the suppuration.
Ctiimremt* Iraim/ormation of pus firpaii'lf* takes place in very old
punilciii foci; ft»d in ^out tlic pu^ corpuâdcà frei|ueiitly conUiin aeicular
ert/M'il)! of' ural^ '>'' gnla.
The terou» acid tramformatioH of /niê is seen in abscesses in bone.
The pus then contains lactic acid, under the influence of whichtbe cor-
puscles BircH, the protoplasm dissolves, and the nuclei become free. It
IS this serous ap)>earaiice, well known amon^ surgeons, by which they
recognize at firtt eight a bone abscess. The simc dissolution of pus
corpuscles takes phicv when it contains n large proportion of water.
}t. XfW Fiirmnfi'in "/ I'ftflii in Jiifl'iiiimnlii'ii. — Whenever inflam-
niation occur» in » vascular tissue morbid plienouiena take place in the
vesseU which may end îii the formation of new branches. These inflam-
matory now formations of vessels serve k* a key for the understanding
of «hat happens in tnmors, and are so much the more tuteresling since
their rao*le of production is very uiul'orm.
l.'nder irritation, the cells which constitute the capillnry walls swell
and soften : if the inflammation continues the nuclei of the capillaries
multiply. These phenomena arc the same aa those already described
for the ciidotliclial cells in peritanitia artificially excited. In iuâamed
tissues the reascls return fi their oaibryonal condition, that is to say,
they arc fonned of embryonal ctdls disposed in rows, and having at the
centre a canal through which the blood circulates (sec fig. 4^,/). The
Bofteneil wall may easily become distcmled or rupture<l by the blood
pressure. How do these altered capillaries become tlie point of departure
of new vesseU? There are several types of new fonnation of vessels:
a capillary loop may enlarge and present a more lengthened curve ; or
the convex part of a capillary loo]i may scud out prolongations which are
URANULATtOS T[SI10B.
69
N
eliHniuillod hy the blood nnil boundot] bj cinbrvoiuil ciOU. nccordm;; to Um)
miittiKT Hii;;;^tcd bj Wiwoiiuoff. Acoonliiij; to liin(lll<tî»cb, certain cull»
îb L-xixInlioiis upon serous mi^iubranos lengthen nix) Ikxarm) <)U|>o«04l in
pctrallol nm;4. betwifen whinh the l>loml from a neighboring L-jijiilUry pcno-
tnites. Mnitllv, in tliia embryonal tUsue, m Meyer ami I'lattner liavo
in<Iicatc<l, wc may alw we caj>iltarieii «rinio^ from i>1aHU)atic cellti follovr-
inj! the ppocc** c)eBcribe<i by KùHîker for the embryonal state, TlioM
eelU and their ansjitonuMÎn^ proloii;;&tton3 beconw bolloircd outorcban-
nelledj the channels are widened by penetntiiou of tlie blood globuten,
and nucleated cells become appHi-d to the «all.
C. Or-mal/ition ti»tin\ — (.ira nidations which by their union cnnstitute
a s<H;aUed pyo;^enic membrane dcvelup most rrei{ticnlly upon uonnds or
inAmniod sumces c«mmuntejiting irilb tlie exterior. It is a general
pbrsiologieal law sinon;; the superior aiiimal«, that (be external and a
part of ilie internal covering everywhere i)ri'*eHt papilliu which arc
Jiing else than ïninll permanent granulalion.4. Likcwiiie in tb<« patho-
^cnl stale, every new formation projecting upon a surface, takc^ thia
pftpillxry form.
ilie granulaiiona ariainj from iDflammatJon coiiûst of embryonal tUmc ;
they are of aoroewbat nlow formation, for a eonaidcrable mass of eaibryo.
liai tissue and of newly-formed vessels are neocesary for their constitution.
tiraniUatioiid furnish the key of the procos» of cicatrixatiou of wounda.
The siKe of granulations U extremely variable.
Pi". M.
Rluad-iHHlaliifniuliilleoi. X •■>' (WJnlk.}
Tliey are generally aimple, hut they miiy bo compound; the latter,
much the more voluminous, j>re!»ent at ibeir surface a seriea of secondary
granulations. The structure nf simple granulations consists at fint of
spherical or polyj^onal embryonal cells, some of irhtch b.ive a very distiu«t
uucleus of .OOô to .1101) mm., others have several very ftraall nuclei. Among
these elements capillaries are formed in an embryonal condition. This
initial sta^e dues not usuallv last lou^. Soon acerlain number of the em-
bryonal cclla change their {onn, become angular, send out prolongations,
and unite by anastomoses of the latter, thus constituting a network of
plaMButio ecDa. The rao^ihes of this network are filled with amorphous
lundamental sulwtanco in the midst of which remnin imprisoned the round
cell* which are distiiuH from the network of the connective tissue cells.
Uf Uie cells embedded i» tht> futidamenuil or so-called cement substance,
some are embryonal cells with a single nucleus, others are cells wilU
ro
IK7I.AII1IATI0!*.
several miclci or pw eorpoMloa. In bonea, granulations contain in
addition «omo giant cell» with nialtiple nuclei (s«o fij;. -i). In many
of the cl«mciit« wliiuh «re obtaiited hy scraping );ranu1ùtiuu ti»«u«, atnue-
boî<l movements are visible. T1i« 4uaDtity of pus corpuscle* i« variable.
Ib'Up, wUlk rtjiiMAfj Jrkp>i*<, wbi'ti^ wtlU run«^<iof fe U>i>£Lini1lnHl \%y*ttit re\U AtiT^t^lug in ItlelE* ]
■«•t frfm vlLLLi» vutWBtiU. c^ BflK^naiujt nîILd rIcKlrfrlitfonuitiiun lu llta Jenp Uy«r» 1»pLadl»4*U
tl»id«^^ d^ ncAtrldtl llMim, 4, irampIHe «ptibi^ElAl ««tprliig ^ Ih' «vntntJ lA^«t nf Mil* enntlivl ctf
Mrrui-I (olli. /. Ïauii(«ii|(bc1lkl «lit. y. X«naut<liiT>mriUiUD. X 3oO, (Afn'(fMnr*.|
being gencrallj greatest at tlie beginning- It alao varie» acconUng to
the general and local pathological condition of the patient. Oenerally
when the granulations atv h«althy tlioy arc reiidish and contain few pus
cor{>nscles, nlivii they are unhealthy tlit'y are usually pufiTy and gray
and inclost! a large nnuiher of pu« corpuscles. In the proportion that
thu )^anulation:4 contain pus, to luako use of an old expression. Ui«y
«ccret« it on the surface. How do the piLt cor]>iisi.'tiTS roncii the surface?
Are tiiey simply proiluced there, or have they waiiilcred from the depths
of the tissue? Up to the present lime we have no direct proof of this
migration; but the pus h sometimes ao ahuudant in a short time at( to
lead to the aunpositiou that at least very many of the elements come
from the intenor, either by aid of their amoiboid movemenU, or hy the
inSiicncc of a current in the fluid which tends toward the surface and
which the capillaries may jwssibly establish in the granulation. Aa
evidence of Uie possibility of the lattvr, «o know that afler activcly
I
imlatiiit; n flc»U woiii»] wo may nt some colored dropR exude from tlie
■Hirfiicv: in tliu fluii) DuinWni of pus ror[>tL$c1e3 exist which have ev'i-
dvnllj bven washed out of tin; tiinuc. Ncî;;hboriDg ji^mnuUtionâ unite and
their reasels coiDinunicatc. As ctcatrixatiou advances pus is do longer
formed in tlie interior of the (rraniitatioti. The cement substance of tJie
;;raniilat4on tiRiiiie condcnxeK, the vmhryonnl cells bcoomo »pindle form,
fibres of connecttre tissue are develoiwd, fiouUy tite ncwij-fonncd 6brou«
tissue by virtue of its eontinue<l contraction gradually le«MM and almost
disappears.
D. CimtritotioK or ffealtnff of nVunds.— A wounKl may Ueal by first
or second or even by the thinl intention. Cicatrixatiou consUts essen-
tially in nil caxes. in tbo formation between the lipa of the wound of an
embryonal ùmmc nhich suliBct|iienlly becomes converted into adult t4iMue.
A lolution of continuity gives rise to hcmorrbaj^c from the divided vessels,
«rhieti is soon arrested. The cxtravaeatcd blood coagulates as does also
the blood in the «aiùllaries opening upon the solution of continuity. The
coagulation in tlie tatter extend» an far as the finit collateral captllanes.
The blood conlinueti to circulât); in that part of tlic raitcular net which
remains permeable. The bonier^* of the wonml undergo a formative
irritation which ends in the filliiij; up of the lo«.i of subtitance with em-
bryonal tissue. The permeable capillaries in ^e neighborhood of the
cat surface present the changes which we have alreaily indicated for
these inHammationa, proliferation of their cells and sonening of their
walls. New capillary loops coming from the old modified veeaols advance
their cmirexities towapi similar loops from the opposite side. If tlioaur-
faces of the wound are maintained in contnct a vascular communication ts
establiâliet) by the union of loop» from op[>oi»itc sides. Then the solution
of continuity is filled up by a smalt i[<iaiititr of embryonal ti»(ue, the
cells become stellate, anaatomnse and form a iieiworic; the cement or
intercellular substance aofl at first soon becomes fibrillar and a» résistant
as the old tissues. Such is union by first intention. However rapid the
union may bo, it is not so simple as some authors have thought.
In union by second intention, granulations begin to vegetate upon the
surfaces which cannot be kept united. Fi-om the sixth to the eighth day
they constitute a membrane eomposcd of granulation tissue, the vesseb
of one granulation anattomosing with those of the ticighboring bud. As
cicatrixation progresses the embryonal tissue becomes tninsformed into
connective tissue, as in tlie previous case. Ilie mode of healing is really
the same in the two cases, only, in the second, cicatrization is slower, and
tlie tifaue may experience the divers accidents incident to suppurating
wounils.
Union by third intention differs from the preceding only in the depth to
which tlie tissues are divided, in the greater di.licuUv and xlowneM of
union. Cicatrices of inHammatory tissues have very diverse iasues. In
tlie skin the cicatrix is composed of fibrous tissue ut which fat vesicles
600n appear in the deep layers, but never in such numbers as in tlie
nonnal state, moreover the fibrouit tissue is always very dense. The
fibrous and elastic tissucH of the skin arc reformed and the papillie may
be more or les* perfectly rccongtnicted, but never so the glands. In
many caaea of destruction of the derm, as in variolous pustules and syphi-
72
IXrLAMUATtON.
litic ulcers, where the papill» have been dcatroyerl by the siippumtion,
they «r*-' not perfectly rcsonoratofl, and tlie reaullinj; cicatrix iriimiiw
BinoOvh und doprc-sMct. The t-piilcrinm reforms. Do iU cells come from
the iU'ighboriii)r cpidcrni. or Jo Ihoy form îndopeudently at tlic surface of
the granulation ? Jïoth modes appear to u« to be p'roved, for, if in a
wound underjçoing ropoir, tlic nevr epithelial covering mo8t frequently
starts from the old cpidcrcnis and i» developed from the periphery tonartU
the centre, tieverthclo^w'* i^lnniln of epithelium aI»o form vithout any direct
connection vfilh [he old epiiermia. [According to Billroth, it is only
wlten n remnant of the rele Malpighii remains that iit1en<U of epithelium
form upon granulating; aurface^.] Tlicie nen- epidermal colU may be
tlio tranHfarmed embryonal cells of the superficial layer of the granulalire
liniiiie. The cpiderm of cicatrices in alwars thinner and more subject to
de-'<(|uanintion than is that of the nuij-hhonng lisauca.
llony cicatrices will be studied à pr"p"» of bone. Cicatrization of nerves
will be discoMCd with the diitcuses of die peripheral uervoua sratem.
To formulât* the general law wliich prmdcit over the ulterior tmnsfor-
mationi) of iuHamed ti««uc: Whi'Mfvrr arlijii'ial or palh'tlnijiml irritation
h't» ilflrrmiueil a i/niu'th of fmWgonal rlemenl», i/ the irritation ceaM
this nrw tjriiu'th aiwitytt Iftulti to rr-turn to thr "ri'jinai /orrn (if the
tiatue H'/iie/i trrrni it» <t matrix. Thiâ tendency \k eiipcoialiy noticeable
in irritation of ositeouH tisiiue. when very freijuently byperostoses Mid
fixostosoH reitutt. Another still more iinj>ortant law has relation to the
9C«t of the new embryonal tissue at the time of its alteration into a ]>er-
manenl tissue. Whatnvr maif be the ttri'fin of the emfir'/onal ttfsue it
All» a tendenirif to repr"dwcf the- tittuf. o/ the région where it i» teatfd.
Thus wlien a bone of a young penranis extirpated the emhryoiuil tissue
which rtplaee» it helps to huild up a piece of bone similar to that which
is removed; vi'-e rrrrâ, tbt-rt- are cases where fraj;ment8 of cartilage or
of bono introduced under the skin disappear after several niontbs. They
are transformed at first into embryonal tissue, then into fibrous tissue.
There is not a simple absorption, for, as we shall see when we come lo
study necrosis of bone, an osaeous fra^mont does not become absorbed,
lostead of absorption by necrosis there bas been, on the contrary, a
gnperabmidant formation of elements which first determine the metamor>
pho»is of the bono into embryonal then into fibrous tissue.
4. Dkueseratios Coxskcltivb to Isflajimation.— a. Fatty Dr-
gentration. — We have already *een that the disappearance of fat from
Uie adipose vesicle» i* a result of inliamraation at it-* heginiiing. Per
contra, fiitty granule* appear in cells develojied under thn infiiience of
irritation whenever these elemenU are more numerous than necessary for
^e reformation of the primiûvo tissue, and when tliey are in too large
numbers relative to the nutritive supply.
In irritations affecting the parenchymatous cells in the so^alled paren*
cliymatmLs inflammations of Vircliow. tbe elements, after presenting some
phenomena of prolileraiion, become infiltrated with fatty granules. So
also of the proliferated elements of conneelivo tissue.
B. tiiiM'irene. — It presents («po essential form». In the Jirtt, the
gaugt-enous pans arc large, and arc eliminated entire fts eschars. This
IBFLAMllATOBY BXVDAT10S8.
GS
V\g. EO.
Sbantts or membninouB Injrcrs tliev soon imder^ n clian^: fir^t fibril-
hr, tlMo lïTaoïiliir, thoy finally sufli-r u complete mak-cular àiûntoeration.
Il is BOt lii'inoiwlraU'd that they an; smccptibk- of ii liighcr orj^Btiuation.
P. ffrm"rrha;ric F.ruJntionn. — Kti-n in tliu Himpltsl îritliinimHtion,
{ta iidtatico coryr.a, rixl blood dUks e^capu from the vcjwds and mix mth
tb«! Muili-d fliiiil. eoinotimes in considerable quanlitie«, at othcm in
DomlM» scarcely appreciable by the microscope. In inflammation of
ibo «alicutancoHit cellular (1.1.111», ai the commencement tli«re h always
blood diixc^l with the young celU. Ilii presenoe may ;^ive to the exuded
fltid a color more or le»H dark. Tho globuleo may bur^t or the coloring
mtier may othorwiae escape into the fluid and be imbibed by the iieigl
hmng elements.
E. Eruditions, comp»»td of Fibrin and eoaffttlated Mhiuîh, iinr/onny
L Cfllittiir Element» { t'roupouM Fxitdatitn of German avthort). — The
H^pbravt "i.-roup'ius exudation" i» applied to exudations deposited upon
^KfBlt;' ill tbe form 'jf membraiie«. Thi«i exudation consîsls
^nd ' rin^ nceording to tlic part nReuted, but it ulsu always'
footain» liiamcntf of fibrin, and soniclime» mucin and entjint^led puH cor-
puicleii. Theiio tilumvut» f»rai a network in the m«iilici> of which aro
fottoil cell clvtnenla, epithelitiui, piu corjtuHeK-M. Tliis exuilalion in met
wiUi ciq>eeinlly in serotu întliimraation.i nnd in acute crou|)om pneu-
mnta. German autbora still ooufound tliesc
dbnoAUS exudations with the fnlae mem.
hnnei of iruc croup, or tlie pacudo-dipbthe-
ritie nH-mbrane» of French authors.
^m P. lHjMheritii- -m'l Pti-uii't-memf'mncmf
^ft£niii/'i/(uN)i. — WbiUt fibrinous exiidations
^bj^lt after death, tlio fal^ membrane» of
^I^P croup, on the contrary, have almoHt
«ttirely disappeared by the time the autopsy
b m&oB, or they conâtitnte merely a pulta-
ceoiu layer rerr difl'erent from that which
L^ seen during life. Acconling to E. Wag-
^Ber,theM' false membranes arc not composed
^of fibrin, but of epitbelial cells united to-
i^eetlicr, yet easy to separate. Afl^r troiitin;;
JBlieM.- faine nicinbraues with a weiik solution
gPwe&nntnf, Warner MW tliera rv-solve inui blocks, angular and refracting,
or into branching elements, interlacing with one another. He has do-
•eribcd numerous prolongaUons of llieso elements, which be compares to
ttaga' boms, and be has seen all intermediate stages between these and
^fcpithelial cells. In aciiuiring ibc^ie strange forms the colls become inGl-
^Brated nitli an albuminoid substance, lose little by little their nuclei and
Blheir membrane, become transformed into homogeneous masses whic'
" jiresent numerous nmilicaUoDS. Wagner admits Hio fibrinous dogone
(Mm of the cells. Tlieso altered epithelial cells, tmn>tformod into horn'
mteoos blocks with prolonged ramifications, form in the pharynx whiti-ib
nyers, thick, opanpic, and of a fibrinous appearance, beneath which pus
corposcles and hemorrhagic exudations «re often met ivitli. It is Uio
of flbtin Ell II flbr^non* uinJittictaj
66
INFLAMilATIOX.
latter wlùcli form tlic re<l<Uiih ecchymotio inland» ae«n in the d«cpla]
of lliese r«li(f tUL-mbranea. In llie larynx tliere aro alwaya many bui
înt{)Oi)C(l layers of ilieae epitiielial raembraues (fig, 51), Wc have vci
rtic. il.
nbrmsiis a*Kaii<r(t1iiB ot pàoucni apltktUftl «lit. Bltili psntr. IK m^ ii(r.>
fiod the exactness of tlie description givon by Wa;^er, hot w« would
conclud» that the ct'lla aro (iUed with a matcrinf which approaches mucin
nithcr than fibrin. Those cxuiiiitions of true croup become dctnchcd
and thrown oil' in proportion as pu8 or new epithelial cell* fun» beloir
them.
S. Inflammatokv Nkw FoniiATioxif. — ■Under the influence of a sUeht
irritation, ilicre occuis a simple hiffierflima of llie elements. If the m-
^Animation ia more intense, the ancient tissne is iransforraed into em-
bryonic tissue: this is what wc call an inftaminator^ htturoplatia.
In man inliammation accords with what we have learned from the cx-
pcrimcntnl !«tudT of inflammation in the lower animals. The process
evolves in the following order: h^pertroj/hi/ of the nudfut ; inrrfu»r,tht»
diviti'm nf the prnfnjitatm ; destruction of the ew:h}>in<i mKtiU/miui of
fJle tvtl ; JrftrwtÎDti. of tfir fihrnu» «r of the j'tnid'tinental rubftatu*;
tirridurti'iii of emhrjinnnl t'ltuHi- ; /"rmati-jH of «cw ve*»eU. At this
iuncturu we shall con-iider only suppuration, formation of veiiseU, granu*
«lion li.sAue, ctcatriKalion, and the dc;;eueratii>ns conaecutire to inSam-
matjon. These degenerations take |>lacff when the embryonal tissue
firolife rates with very great activity, am) t^ie colls multiply and accuniu>
ate, with a corresponding supply of now vesseU.
A. Suj'puniiioti. J'us (''jr/futclv*. — Kmbryonal cells h*?e a nucleus
round or oval. If the division of the nucleus and the nutritive supply ix
well effected, one cell regularly gives birth to two other»; if hypcq)U«i«
is active, one finds a few cells with several nuclei. If, however, tl>e
nutritive niateriaU cease to be supplied, the dirîsion of the nueleuâ con-
tinues to take place, but tbe cell no longer divides. The cell then con-
taina two to 6ve amall nuclei, Such cells arc pus corposcles. Tbey
ISPLAMJIATORY SBW FORMATIONS, PU9.
6T
■lifipr from embryonal cell» onlv Hy tlie number nnd atrophy or their
wctei. In pus recently fonued, betiidefl these pus oorpusolea, cclU »re
coostwitly found vitli only one nucleus. TheM are embryoitnl celU.
Poa corpuscles are, then, nolhiiii: else than embryonal cells with a sniaU
touunt of riuihty. This atrophy of the nuclei is constant in «11 elemotita
which die or arc «.-liminated. rua corpusclea may exist in a tissue in large
niuulwrs «ititout their presence being revealed to the naked eye br tho
phyticni olinrncters of tlie lii|uî<l cnlled pus. Umnutalion tissue, mucus,
ud til» Morotion of «orous nfmbrenes narmally contain them in greater
or kster numbers.
Hi« puriform appoamnec of n lîi|Hi<I is due to the fact that groat
nunberB of small solid corpu»cle« flout free in it. Thus the creniu from
milk is q|iai|ue like pus, Wunuso il holds in suspension many fatty cor-
iniscles: exaronlei could be muliiplSed. The intestinal mucus may enn-
tain in suspension only epitlielial cells, and yet to tlie naked eye «bso-
lately resemble jiiis.
I'he following are the phvsical and chemical character.* of pits cor*
jujHcK's: They present no cellular membrane. When fresh, ihey appear
as a finely gninuUr mass, irre;;ular in outline, oflen hating aniteboid
morcmentM (fig. .'i2). Their nuclei aro not at first visible, but when «
drop uf water is added they swell from .008 to .U(ll) mm., which is their
n»riual iliameicr, to .011 or .01- turn. : they become sphencal and show
[Tory distinctly, especially after coloration in carmine, from - to 4 or !>
nuclei from AHVZ to .OOS mm. in diameter. These nuclei usually have
nucleoli: neverlheless, in some there exinU « refracting point, which
Kucntcr calls a puncliform nucleolus. Thejie nuclei resist tlie action of
Pl,r. ft2.
éo
Vip. G3.
© ® © © i^
£»
^■ïî-
CI?*'
#
Pmi «all*: rt-fTOBH jrriïetHUtif WA1I4I4) ; t,
ir«»l#^ itlrh ^ilaln *4*iXt aold; if. fmrn *
l»D* S-Iila lawndat ', t, nlgnUag lalU.
]>ui foppDMlH.- I. n, s, la «IMC : I, ii, I, «dar
lb.' triina tt aedlE Hid; I. dlrldaii at bkc)*).
I ytteh<iiB.l
ac«ln acM, whilst, under tlie influence of this reagent, the cell becomes
', [wle.aivd remains for some time limited by a very thin border,
.iially disappears in its turn (fis. ô^). Pus corpuscles do not
iiffer, then, from certain whiu- corpuscles of the b!o<id.
Thf^-rg of the Formation of J'n*. — Accordinj; to an old opinion of
Immennann, pus escaped directly from the re-'tjM'la. Oobnheim affirmed
lib opinion while brin^in;; to its suppiirt the expérimenta which we have
previously dcsirrilK-d. But is pus alwoy* thus formed Ï We have to
extent I mtniry. The fjiithelitim. for example of the
isor mui i-t, under irritation divides and forma new celb.
68
IXPLAUMATtOH.
which thetnaelvea maT liividc, and bo on it*^ iHSiitum. When in
smallest cells the uucluua ilividca without dirUion of the cell followiDij
we have pus corpusoW^. So alao of thv l'cUs of connective tûsue (s
Îi. ôô et net).'), and of ndipoïc cells. Ilcncu wc xdmit tno modes of t .
ormution of \)»»: 1st. by the prolifc ration of cellular eiccucuta; 2d, bj
tJK- escape of whit« blood jj-lohulcn from the bloodreMcls.
Pu« a rcry vanily chaii<:ed ; it nmierjroos, kocording to its »<^ and
the iiiHucnoe of the paru with which it i.i in contact, many modifications
Falfi/ (te^rnfrali'm of j-u» /•orjiun'titi occiin whenever the pu« I» oI«
In the intenor of the corpii-iL-IcA, then, there exitit fine, fattv rafncting
granule:*, 6ve to ten in each, and acetic acid doe^ uot modify tlieni. Wheti
tlie di^InteKi'aUon is more complete, the corpiiâclc^ become didiended with
l^raiitilea ; ihcr appear as dark masses under a low niu;j;iiifjing jwwer^,^
meaaurins .Ol.i to .1)20 mm. ; these «re what are called the corpuscles oCJfl
fllu;;c. These corpuscles of GluRO (see 6fî- <ÎS, p. 41*) do not alw»ya^
come from pus corpusck-s; for example, those of the brain iu cerebral
softening, nnd those of atheromntou» f'wi of the aorta aro eoosidcred to
be mure a^^i^lomerations of fatty griimdvi>.
Coft'/an lrttn»/"rm'tli'in <>/ yu* orpntrlrt has already been mentioniHl.
In this condition tlw oorpuscles ore ito longer act4:d upou citlier by vrat«ç,
or acetic avid.
I'i-jmi-iitiirif infiltration of pu» corputrh» happens when conaldonU*
extrnvflsaliona of blood accompany the suppuration.
('.ilmrf'ii* lr>t>i*firriii'itii-n ••/ pus mr/ntn-frt lakes place iit very olii^
purulent foci: and in ^»ut the pus corpusides frei^uently c<.>utjiin aeîcular
erifHtaU of urate ff êoda.
The semut acid tfamforinatSon of pit» is seen in abscesses in bono.
The pus then contains litctic acid, under the intliiencc of whichthe cor-
puscles swell, the pn>topltwm dissolves, and the nuclei become free. Il
IS this serous appearniice, well known ammig surgeons, by which the/|
rccogiiize at first si;;ht a bone alMc^i^s. The sttme dissolution of piig^
corpuscles take^ place when it contain.'* a lariçe |in>[M>rtion of water.
)I. Xfw f'Tiiuition of V(n»elK in /^«rf((wffwih'"«. -^Whenever inf]ai»-|
mation occurs in a vascular tLt-sue morbid phenomena take place in tliej
vessels which may end in the formation of new branches. Tlie.se iuflam»!
mat<»ry new formations of veasela serve as a key for the understanding]
of wh.it hajipens in tumors, and are so much the more interesting since ,
their mode of production is very uniform. J
L'ndcr irritation, the cidls which constitute the capillary nails swell'
and soften ; if the inflammation continues the nuclei of the capillaries
multiply. These phenomena are the same as those already describedi
for the endothelial cells in peritonitis artificinHy excttcd. In intlamcd)
tissues the re««el» return to their embryonal condition, that is to say,
tliey arc formed of embryonal celU dinposed in r'>w-;, and having at tho^
centre a caual through which the blood eirculatfs (see fi;;. -IH,,/"). The
Roftened wall may easily become distended oi' niplured by the bloody
pressure. How do these altered capillaries become the point of departursH
of new vessels? There arc several tyjws of new fonnation of vciwels:
a capillary loop may enlarge and pre.sent a more lcnj;theni;d curve; or
the convex part of a capillary loop may send out prolongations which are
d-
dl
ch are^
URANUtATIOi; TtSRUK.
C9
fhioMiled t)T th« bloml and bounded by embryonal cells, according to the
atnaer suggested hy Wiwodwifl". Accordiiis to KiodtieiBcli, certain voWa
h vxwUtions ïipôn aeroiu membranes lengthen and become disposed in
ftnllel TOWS, between wbicb the blood from a nei<;l)bonn^ cuuitlnry f>ene-
inl«s. KÎDalIr, in tltia ombryonul tissue, as Meyer and I'Isltticr liavc
iniLicat^d, we may also see ca]>illitriei arising from plastnutîc cells foltovr-
iii2 ttie proee&* described by Kitlliker for tlie embryooat ittAtc. Tlicso
nil* «iid their 9itia.<!tonio9iit<; |>rol<>n|iutioiu becoiuo holloweJ out »r chitn-
trllnl, the cbauiifls are thiilened by |M^netratii>n of tlio Mood globules,
iiul niKrteutod eclN b«come at'iilied to the wall.
C. Uritnuhti'in ttMur.— (^inintilatJODS «rbich by their union con^tilnte
■ M>-c«lle*l pyogvnio roembraae develop mojit ffei[iicnt]y upon womid." or
blUned »urfaeeg comiuunicating with the exterior. It is a general
pIiy«in)o^c8l law among the su]>eTior amni^ila. that the external and ft
[art of tlio intenial covering everywhere present ]>:ipillw whiob are
MlUng ebe titan small ]>crinanent granulalions. likewise in the paibo-
bipeU 8feit«, every now formation projcccin^ uj>on a surface, takus this
(apilUry form.
The granulations arising from înflammatî<n) consist of embryonal Rustic ;
they are of soinewliAl «low formation, for ■ considérable ma^ of embryo-
mi linsu'- anil of m^wly-formcd vessels are necessary for their constitution.
linniiUtiiUis fHrnlKh the key of the process of cieatrizatiou of wounds.
TIh> siw of granulations is extremely variable.
Rg.M.
*l»4.v««al* la rnsslallau*. X *"• tBtllnlk.)
Tliey are generally simple, but they may be compoan«I; the latter,
much Uie morv voluminous, present at their surface a. series of secondary
pvoulations. The structure of sitnplc granulations consists at first of
epWrical or polygonal embryonal cells, some of which have a very distinct
Doclcns of .(Ki^'f to .(*(>(> mm., others have several very small nuclei. Among
I these element-'» capillaries are formed in an embryonal condition. This
initial stage does uoi usually l»-it long. Soon a certain number of the em-
brytmal cell* cliange their form, become angular, send out prolon^tioiiH,
ami unite by anadtomoses of the latter, thus constituting a network of
tilasinatic ccIIb. llie mesbcs of this network are tilled with amorphous
fnwlanMntal substance in the midst of irbich remain imprisoned the roimd
eelU which arc distinct from the network of the connective tissue cells.
Of tJic cell» embedded in the fundamental or so called cement substance,
are embryonal ccUa with a siugle nucleus, otliora we cells with
^am are
70
ISFLAMUATIOtl.
sevcntl nuclei or ptu corpusek-s. In boiK*», granuIationB contain il
addition some gisnt cells with miiltîplo nuclei (itee fi;;. 5). lit mnny
at the cIcmcDts whicli iirc obtuin«d t>; scniping granulation ti»«uc, atnw-
aid movements an; visible. The quantity of pua corpuscleH is vurtabk.
fHlldu IhniDgb l)i«1iririlerarii bmlluc tnifiiiaiir rnnnUIUix. n. )lr«i*lloDnrrD>. A. OrkaDUtlia
«lunii, HtlU ca|>lllin? Iimpi. ahu» iHllt runslil uf • lunniludliiil Itjtf-I eoltiilicroiliiii Inliiltk-
tla*D«i' ff' rifAEf^dAl tlMai\ t. C<>mpl«l4 epUhqUAl «uiwLiik; lb» t4-Dir*1 lA7^r o' oallt mwlta 4^
Mmladcalli. /. fousg cvl'ligtUI »1I(. y. Xuntodllirgrnntlitleii. X >'*- (tfli'IttiUr*.) '■
being gencrallj greatest at tlie bepmiing. It aUo varies ucconitng to
tlic ^("lierai ami local pntholn^ic^il condition of the patient, (jcnorally
ivlifii the granulalionA are healtiiy they are rcddLtli and contain few ptu
f corpuscles, when they are unhealthy ihey are usually puffy ami pray
and incloae a large number of p«3 corpuscles. In the proportion that
the granulations contain pus, to make uso of an old exprea^on, they
secrete it on tho Burfacc. How do the pus corpuscles reach the surface?
Are they «imply produced there, or have they wandered from the depths
of the tissue? Up to the present time wc Lave no direct proof of tids
mi^niti'm; but the pus is sometimes so uhundant in a short time as to
lead to the supposition that at least very many of the cU-incnts come
from the inlerior, either by aid of their aiiuchoid movements, or by the
influence of a current in the fluid which tends toward the surface and
which the capillaiies may poi^ibly establish in the granulation. Aa
evidence of the possibility of the latter, we know that after aotjvel/
CIOJlTBtZiTtOir OF VOOSDS.
H imtitÎD" a fiesb wound we mnj see aomo colored drope exude from the
H Mrfivo: in tliis fluid numbers of pus corpuscles exist which have «ri-
H deiitiv been washexl out of the tissue. Nei;;hboring grnnulutiotis unite si»!
H Atir (resAeU commuiùcutc. As cicatrization advances pus is ito lou;;er
■ foniMol in Uio interior of the };ranulatii)n. The cutncnt subâtnnue of tlie
^ jnnoliition tissue condenses, the embryonal cells become Kpindle form,
I tbres of connective tissue are derclujieil, Rnalljr the ncwlj-formed lihrous
j; linae by virtue of itM continued contraction graduidly lesitens and almost
l' (Ëiappean.
ij I), i^i^itrizaliimor Htafitti) of Wounii». — A wound may heal hy first
•VMCoad or even by tlie thtnl intention. Cicatriisntion oivmi^tH esaen-
Iblly in all casea, in tlie formation between the lips of the wound of an
I nVrvoital tissue which subHe((Uontly becomes converted into adult tissue.
A «ofiition of continuity gives rise to beniorrhai;o from the divided vessels,
lUch ts soon arrested. The oxtnvasated blood coa^^latea as does also
thcbtood in Uic capillaries opcnin;; upon t^« solution of continuity. The
ct^iilation in the latter extends »h far a» the firet collateral capdlarics.
IV Uootl continues to circulate in that part of the vascular net which
Rmoins permeable. The honler» of the wotind undergo a formative
imtalion which ends in the filling \\\> of the Iom of substance with em-
^ brjooal ti^ue. The jtermeable capiliaric't in the neitçhlmrhood of the
I eol duHace present the changes wbicii we have alrnady indicated for
^■Jbase inflammations, proliferation of their cell» and tto^enin^ of llieir
^|BilU. New capillary loops coming from the old modified veascU advance
tbcir eonvoxities towafl similar loops from tho opposite side. If (lio siir-
^eesoT the wouml are niainluined in oontiict a vascular communication is
Mlablislied hy the union of loops from opposite siiles. The» the solution
L "rf continuity is filled «p by a small ^uaulity of embryonal tissue, the
H ceils lieconie iilellaie, anastomose and form a network; the cement or
^ iutenMïlIiilar suh^ianco ftol\ at fmt soon beeomes fibrillar and as reaislant
as tiie old tissues. Sucb is union by Unit intention. However rapid llie
onion may Iw, it ia not ho simple as some authors have thout;ht.
In auioit hr second intention, f;ranulations begiin to vegetsto upon the
surfaces whien cannot be kept united. From the sixth to tho eighth day
they constitute a membrano composed of ;;ranulation tissuo, the ves«ou
of one granalation anastomosin;; with those of tho neighborin;; bud. As
cicatrization progresses the embryonal tissue becomes trunsfornied into
connective tissue^ as in the previous ease. The mode of healing i* rwilly
the same in tito two cases, only, in the second, cieatnxation is slower, and
the tL<«ue tnaj experience tlie divers accidents incident to suppurating
wounds.
I'nton by third intention differii from the preceding only in the depth to
which tlie ti^uea are divided, in the greater diScullv and slowness of
union. Cicatrices of inflammatory ttaaucs have very diverse issues. In
the skin the cicatrix is composed of fibrous tissue in which fat vesicles
soon appear in the deep layers, but never in such numbers ns in the
Donnai state, moreover the fibrous tissue is always very ilen^o. Tiie
fibrous and clastic tÎBsucs of the skin are reformed and the papithe may
bo nu^rc or hiw perfectly reconstructed, hut never so the glands. In
many cases of duslnictiou of the derm, as in variolous pustules and syphi-
IXFLAHMATIOK.
I
lilic ulcers, vliora the papillœ Iiarc tteon destroyed by the Buppuntion.
they arc not perfectly rei^iiemtu'l, Mtd the m^ultin;; cicntrix reuiM
smooth ati<l de)>re.«««'1. Tho opiilcrmis rcfonns. Do its colU como frooil
the neigh lioriiij5 epirlci-m, or do ihey form imlcpernlontly at the surface oi
the granulation? Both miilo^ H]>pcar to i» to be prorod, for, if in
wound undergoinj; repair, the new epitliclinl covering most fnv^ucDtl
BtATts from the old cpîilerniiâ and ifi developed from thtt periphery u>wanl
the centre, nevortheleas islands of epithelium aUo form wilhonl ui>y direct^
connection wilb the old epidermis. [According to Billroth, it is only
when a remnant of the rote Malpiglûî remain*) that inlandii of epithdiiim
form upon graDulatinji; surfaces.] These new epidermal cells may he
tho transformed embryonal cells of tho superficial layer of the granulative
tissue. The cpiderm of cicatrices is always thinner and more subject to
desquamation than is llmt of the nei^hbonn;; tissues. M
Bony cicatrices will he studied d pr"p"fOl'hoivi. Cicftlrization of nerves*
will be dincus^ed witli the discifcs of the peripheral nervous system.
To formulate the general law which presides over tlie ulterior transform
mations of inllamed tijwiie: Wliciii'Vfr artifinal or pnlhuhiiiienl irritation
Arts iletrrmitifd n iir"N'th 'if mihri/nn'ii ehtnf.ntt, if thf irritation etaté
thig nrw ijf'iwth nftfti/» tfnd» to nturn to lAe tirii/inal f'inn of th«
tittue H'liifft K'-rcf J ng a matrix. This tendency la ea|«ciBlly tioticeablo
in irritation of osseous tiaaue, when very frequently hyperostoses and
exostoses result. Another elill more important law has relation to the
cent of the new embryonal tissue at the time of its alteration into a per-
matient tissue. Wliatfivr innif hf the 'tritjin of the embrifonal li»»ue it
hds a femifiirif to nprxiiuri- thf Imnf of thr rfjinn whrrr. it it tralfd.
Thus when a bon*- of a y»uiisç per*iiiiis extirpated the embryonal tissue
which replaces it help» to htiihl up a jiieco of bono similar to that which
is removed ; i-jc* vena, there are cases where fraj-raenls of cartilage or _
uf bone introduced under the skin disappear after several months. They ■
«re transformed at first into embryonal tissue, then into fibrous tissue.
There is not a simple absorptiou, tor, as we shall ace when we come to
sIikIv necrosis of bone, an osseous fraient does not become absorbed.
Iniitead of absorption by uecrosis there has been, on tho contrary, a
superabundant formation of elements which first dt-terniiiM; the mctamor-
phosis of the bouc into embryonal then into fibrous tissue.
4. DROBNEHATION CoXFEfrTIVK TO IXFI,AMWATr(l\. — A. Fatt^ Df-
generation. — We have already seen that the disapjiea ranee of fat from
tJic adipose vesicles is a result of inHammaliou at ilit beginning. Per
contra, fatty granules appear in cells developed under the influence of
irritation whenever these elements are more numerous than necessary for
the reformation of the primitive tissue, and when they are in too large
numbers relative to tho nutritive supply.
In irritations atfectinK the parenchymatous cells in the so-called paron>
ehymatoua inflammations of Yirchow, the elements, after presvntiug somo
phenomena of proliferation, become in<rated with fatty granules. So
also of the proliferated elements of connective tissue.
B. OamjTfVf. — It pre.*cnts two essential form». In the firtt, the
gangrenous port» are large, and are eliminated entire as eschars. 'Hits
CLIKICAI FORMS OF I HFLAMMATtOX .
rorm in M«n wli«n sliisi* in t)ic inflimed part, su)>s^|ucitt to cda^latioa
of the tilooil ill lh« vom«1», occutm, from arrast of circulation cauMcl hy
prewure ()a« to the ttccumulation of the oxudalion around tbc rcsscla.
SucI) conilition^ are cominon in vvrr aciitv inflaminatioiu of o&^cous
I tÎMiio. In all kikIi ca»e9 of gan^r^iie tlif mortifioil part act« as k rur('i;{n
body. The irntat«<l anrronnditijç [larts give birlh to embrjronal tissue.
^ P^imUltoiu) aixl pus. By llii* m^iiiiA the necroHed ])art i» ixolatc'l and
I removed. A KCi^m^/orm is that of a«cotidary molecular )çin;i;rene. It
» met wiih in the ulceration of |)Iiat^denic' chancren, in hospital gan-
jf;rvne, etc.. also in the iliplithcritic ioflaniatation of German aiithom.
Ill iw considered to bo the result of an infillnilion of ilje tissucs hy ]iiis
land fibrin, which, by compression of the vessels, prevent a sufhciunt
afflux of blood to the affected p<art«.
S«ct, T. — CUnioftl Forms of InflamButlon.
useful, and an anatomical classification of the <liflfereut forrog of in-
latton is ha»cd <i)iou the form of the le»ioii:t themselves, u|<on their
seat, their ilei^ree of intensity, and their cause.
I. C'')>iJt:s!'iVK Ist'iaMMATioNs. — Such are hypeneimafl, cutaneous
erytliemaa, erv^ipelaa, every acute catarrhal inftaramalion of tlie mucous
iDiembram-s, riieumatîc inflammation of the joints, etc. In all these
IciiotM ne always find with the congestion, vhicfa predominates, prolife-
rations and miwou» cxudutioiia,
II. K.\itDATivB lxv].AMMATioSfl. — Wc bavc alrcftdv conwdered ihem.
As many forms should bo recognixed as there are distinct e^ndatjons.
Almost all tlie-ie exudations are mixed in character, and contain fibrin,
olbninen, mucus, and pus ; almost all enter into what the f ierman pbysi-
dans call croupous exudations, such a^i acute pneumonia, pleurisy, peri-
carditis, pcritoni^, etc.
in. i'LKi'UiST Ixn.AMMATl0.s«. — Appertaining to this Tsriety are
purulent infectious disesBcs, etc. In these cases pua shows iwelf overy-
when! with mi cxtrnordinary facility and in abundance. The phenomena
of congestion arc much less prominent.
IV. Uvl'EB PLASTIC OR IsTRIlSTITtAl, IxFI.AMMATIOSB. — Soch ape
:irrliodi.<« of tlie liver, of the kidney, interstitial pneumonia, sclerosia, etc.
V. <r.»x«UKSOT:s IxKtAMM.tTlo'xP. — Scc «hove, pa^e 72.
VI. TiiiKR<:n..irii Avn lyAScnus Inkt,amm*tioss. — (Foorster)
VII. l'«KL-iK)..\lK)iiiRAXOfs IxKLAMMATiuXS. — Such are the Icsions of
le croup, etc.
74
CHAPTER IV.
TUMOUS.
TuMoao dift'er from inflaramatory piwluct» hjf their tcndency to pcraist
and enlarge, while intlainmaury neir fonnatâona t«n<l always to (lUa]>-
pear or to rQ|>rodiice iho tisâue of their matrix.
8eet I.— Defiaition of Tumor.
Ilio word ttiiwr, swelling, from the moat remote anli'iuity hiks boon
applied in medicinu to tlio Dion divorce produutioi». TUi» dcËniliou
undorwcnt a inodincation at the hnnd:» of iht! pthological analocii»l«,
who applied the t«rra only to every abtiorninl itiraefaclinn which could
bo demoitatrateil at the autop^iy. In proportion as the liUtoIogical atmo*
ture of tumors iiaa become better known, the group of tumora has been
circuiQiwribed.
The following is tlie definition and cltiasificatioD which ve have
adoptcil: —
Wo would dcsi^ate a a tumor ei'ery maim miwtituteii hy a new/nrma-
tiim (^nftphuMf Ajikin'/ « t^tuieni^tf Vt pi-mUl or tu iniyreatr.. Tlii* defini-
^on comprehends two term« which we ought to analyie; the neoplasm,
its neruHtcnce and increa^te.
Neopla^mii are subject to two ireuer.il lavrri. The first was announced
by J. Mliller: Tht tiatua whifh J'oria* a lumar hat it» tj/ite in a tistue
tf tie organism, eliier wA^n tht tatter in I'lt an emhri/oiutl ef>»Jitlttn or
in a ttate of eompUte dtvfhpnunt. 'ITie second ia from Vircliow : The
celtular elernent» of ii tumor are derived fr^in thu pre-exi»tirt;/ ceU» of tht
m-t/amem. Vtrchow ailds that theif are derived from (Ac cellt of tke eon-
Jieetive tifsue.
[Ii#tolo<;ist8 to-dav arc inclined to admit the law of Militer. The Inw
of Virchow i» true in lt« first proposition, hut the second pro[iosilion i*
not tenable, for the ccIU may be developed irom epithelial or other eeltii-
lar elements.
Tiie word nejiphnn, which we have made use of in the definition of
lumors, should neither include effusions such a« escape into cavities, nor
the retained products of secretion, etc., which Vircliow wroiij^y, a« we
think, looks upon as tumors.
The tefond term of our definition, the pergtatenee and inereate of
tumors, oompletoly separates those neoplasms from inllammaiious. In
the latter, wiien the neoplasm forms it organtxes and reproducer tiasue
similar to that whence it sprung, or it disappears little by Vutlo. by EOppU-
ratioii or caseous metamorphosis, otc. This ia a fact so important that
. W« insist upon it.
0LA83I?ICATtOS AÏD DESCRIPTION Of TUUQIIS.
75
I
Tninon olwy in a gcocral way the laws which regulate living tissues,
rvvi'rtlicloss, to Bom« oxt«nt, thoj live an independent life. They ptmiem
their own proper circiilntlon, they extend, they grow at the «X]>cn<Mi of
the ti<Muc upon whkh thoy arc implanted, ho a« to constitute au entity
within an organism more compleU\ For ex»m|)le, the patient with a
liponut becomes cinacial«d without «icing hi» tumor diminish. A malig-
nant tuoMr grows rapidly, while tlio patient falls avay and ùnka into an
incnrahle cachexia.
It is not known that tutDora pOMteMi nerves, unleaa they may be consti-
tuted by nervous tiA*iie of new formation (neuroma ) : they want, conse-
iiuently, those regulator» of the nutritive functions which connect the
cliflerent parta of the same living organism with a common centre. This
abeenoe of nencs impressed Schrceder van dcr Kolk and prompted him to
make tho following experiments : ho cut the nerves of a dog'tt paw, then
prodnced a fracture of it : the callus became exuberant and fonocd a
vorilahl« tumor of granulation tissue. This fact would suggeu Uie iui-
porUikce of « M>rics of researches for the purpose of lenming if the
exaggermtcd nutiïtion «if » part of thfl organism, ««[«rated from iu regu-
lating eoutre hy intcn-ti|>tion of th« n«n-e tubes, oould determine the
|irodiiction of a tutoor.
Beet II.— Clauificatton and Description of Tumora.
The lavr of Muller suggcsta to us a classification of lumon. Our clusi-
fication will he bused solely upon the analogy of tumors with the normal
tisauea. either in thoir adult or embryonal state. Thus we will admit
thoao which are Roalogous to cmbryoiul tissue, to fibrous tissue, to carti-
la^nau.<i tÎMue, to oss<^otu Usstte. etc. \V« will employ, as often iM poaai-
ble, word« forme^l by tlie nidiciii of the normal tiitsue, U> which the
tennination 'otui, vmitta will l>v added. We will study successively llie
following group» ;—
FittiiT tiBui-f. — It comprehenda ttimor» whose constitution ia analogous
to embryonal tissue. To them we will apply the «ord Mritotta.
Skcosi» Gnori'. — It includes tumors eon*lit«ted by a tiMue. the type
of which is found in connective tissue. This tissue may be mucous, the
tumor is then called a myxoma ; it may be fibrous, it is then cilled a
fehroHUi or an innoma: it may be adipose, it is then ejillod a liiioma. In
certain eaikis the tissue undergoes a liy|>ertrophic al^erration, which mainly
affecU tliG volume and number of its cells, this is mitmnoHM, which should
be belter named ntvflar fihromn ; in other «as«s tlie cells atrophy, as in
tiih^fU, niffihilitie i/nntmaia, glnmlrri.
TuiRD Giiorp. — !t comprehends tumor* constituted by cartilaginous
tissue: eneii'imir-iinnla.
FoUBTit (>uut;i-. — ^Theae tumors are formed of osseous tissues: ottto-
mata,
FtPTll Groitp. — Tumors foroted of muscular tissues are divided into
two kii»ds according as thoy are composed of striated or unstriated fibres :
m^Qmn ttrio-cfilulare, and myoma teio-eeUulare.
76
Tenons.
Sixth Gkoi'p. — ^Tuinoii oonsislini; of nervoa» tiMtio comprise i
TnrU'tic:» : nciir"ma madultare, wliicli contain norve cell» ; ami neurt>,
fa»nfrHlata, which contain nerve tubes.
Skvkntii (iituui'.— In thi« group are included tunioni formed of blood-
Teasela: anr/iomata.
Ki«mT!i tinoi:!-, — Comprelienda tumors constituted by lymph vesalfls:
an;tio-{i/iHf}hoi><iila, nnd those wtiich roproduco the structure of lymplmtic
glnnds, adrHo.iifiAjihoinata,
ÎJl.MlI OU'Jui'. — Tumora formed of new epithelium, dindcd oceonling
w th« cells nre in irregular masHoti, upon pnpillcc, in cul(i-d«-;tac, or in
newly fonned cavîtics, into four kinds: epitKeiteina,paiHlltnria,utien0ma,
Bnd i^ffta.
Tenth Geoup. — .Vir^rf tumor* : they contain a grcal variety of Usauca.
The foregoing i» ]>uroly an unatomicnl clns^iftcaticin, nnd doeH not
respond to tlie legitimate do«re of the olinieinn; in fact no anatomical
clarification can do so at present. I'he malignancy of » tumor depends
upon the continued formation of a grcal 'pmntity of embryonal éléments,
by whicli the turoora very rapidly increase.
TCMORS COKSTlTfTKD 1ÏY EMBKYOXAL TISSUE.
Sarcoma.
i
We will at first study the generic characteristics of tumors analogous to
embrvona! tissue, then we will discuss tlio characters wbicli appertain
particularly to i-iicU itjiccies and variety.
Syxoxvmr. — There are no tumor! which have rwcivcd more different
denominations than the sarcomata. J. Millier ti-nned ihcra jil'ni-ul/rnmi-
v'/id, lichert called tli<>m f!Ar"-/>/t«ft<T. Ohas. Kobin thought that fibro-
pla-<lic tinnor^ tnhould be .teparativl from certain ones which had, with
the former, numerous atialogiesi, hut which differed hy the round form of
their celU ; ho nam<-d them einf-rynylniitie Imni'V». Paget gave to the
fibro-iiiastic tumors the name of reeurrin'/ fikrifid, and classed with ihem
certain tumors having a structure simitar to the marrow of hones, which
he named mi/eliict titimrs. The latter were called by Chaa. Uobio
tumor» with medulla relit and tumor» with mi/éloplturt. Finally, Vtr-
chow separated from sarcoma somi? tumors which, till then, were clasM.
fied with them, and to which he gave the name of glioma and pgammmna.
DKFisrrtox. — We define earcomata aw, tutmr» e«ttjitilut*d fr_y emftrt/-
onal tittuf, «tmj'lr- <>r undergainy "nr. of tin- firtt modification» throu'jh
whieh it pii*»'* in order in Ivcim*^ adult ii»iinfi. Thus, as embrvona)
tiMue i» transformed into fibrous tissue, the spherical cells lengthen and
become fusiform, and an intercellular amorphous substance is formed.
Tumors presenting an analogous constitution are »<trc'nn'ita. If sarco-
matous tissue has its tyjie in a physiolo^iical state wc should find it» ana-
logue also in a pathological condition durin;^ inflammation. In cicatrizing
granulation tisane, we meet with all the phases of connective tissue.
Certain sarcomata have a similar structure. In inflammatory tissue
arising in the bony marrow, cells like those of the bony marrow show
OENBHAL DBBCKIPTIOX OP SAtlCOUA.
UietDselvea, and often even Iionj tnbcculœ tn course of development are
wen ; identic*] appemraDccs are met with in tlie (issue of certain »iiri-i>-
nntous tumora (sec Gg. â). Ttie only difference between the sarvo-
Id a Aug iu profrt** ot b'tltaf, ii-
^|4<«« Jtfl 1'^ \h* Ati*>rvltim Iff lb*
til ttu-ttt i : ihay iM f4aod lUI*d
wltb u«wl7 fond*! ttHAldl r. a*^
tAflA^til «ïlh cf*iJ*l*r fffOlopUatt Ï
tAHDl wbick btvtnbrroiila vaU«,
iMtotw umI inflammatory tissue is that wo
may rcco^tzc a different beginning and
em) for each.
While as a general nilo, boUi in inflam-
natorjr tiMue and in «arconui, when tlio
prooeiMaa are «low or chronic ttie «leaicnta
arc large, aiul when tticj- are active U>c
eellit are mnall, the elemeiit<t are luuallj
larger in sarc'>ma than in .'<tm|ile inBamma-
Uen. Moreover, the form of tiie cells in
saTComa, is not very rigidly dependent
opon its seat; thus, sarcoma aprin^ng from
^o skin or a ^ai»d may show larf;o (nant
cells similar to tliose «tiicb are dcvelo|ied
naiially nn'ter the influence of intiamimition
I in bone. The cvlltilur elements coik^tilute
■linust tbe entire man of sarcoma.
I Okxkrai. I>EScRipnox OF Sarcoma. —
Vbc eelh orsareooia include iho most varied
p)mtt. Some are «pberical, others are ir-
regular, witli nmltipte proeeBMS, which
■omelimefi anastomose. They possess one
or more larf^e round nuclei ; many of the
latter are fitsifonn (the fibroplastic dé-
nient of Leber! ). In cranial tumors the
cells arc often flat and oxtrenifly thin; they rrvi|uent1y are lar;;e in
n» attd pOMC'» a central lenticular nucleus ; aeen in profile they appear
as a fibre, showing al it« «entre a lengthened nucleus (see Psam-
moma).
We «ee tJien that iJie minr|>liology of the eelU of sarcoma \» very com-
plex ; the «ixe of the elements may vary from .00-5 or .0U4> ram. np to .00
mm. The iiLnicture of these cetU is very simple. They po^t^em one or
several nuclei, eitlier spherical or oval, varvin;; in aiie from ,00.'i to .0(13
mm., and in number u|i to fifiy. The nucleoli arc usually shinin^ and
small, but they may exceptionally aci^uire a diameter of .OU.^ mm. Nuclei
are particularly numerous in the large giant cells or royâoplaxes. Around
tlu' Tiucleiis exi-its a granular substance. Examined m a neutral medium
llie nuclei are always disiinct. but when examined simply tn wau^r, or in
wnit-r »li);htly acidulated witli iicetic acid, they become much more sharply
defined. These celts have no membrane. In certain eases the albumi,
noid grannies of the colls so arrange tliemsclves as to produce an appear-
ance of Biriation. As in embryonal li.<4ue, the cells of sareoma are very
sensible to the action of reagents. Ilccaudc of tlieir friability, when the
surface of fresh tumor* is «craped, the elements are often ruptured and
thfi nuclei set free. It is tliin presence of free nuclei in the scrapings
m
7S
TOIIORB.
which hu l«d certain htStolO|psto to ailmit tlic «xUti>iiec or free nuc1«i in
lb« tumor itocir. On Mcouatuf the rurioly in form and diinonuon of
the «lenienta of rarcomit, «imI tlieir non-ohanctcriRlic appe»ninc«, the
WLHtomicnl dia}ÇDo«is of the tumor cwtnot safely be made by examination
ciilv of (he scrapingn.
ll 18 the arrangement of the element» mid their relation to each other
and w the vessels, which furnish distinctive characlera. TTie cells are
placed close together, they are in contact or are scparatctl only by an
extremely small amoimt of int«Kellular or comcm substance, «rbich is
amorphous and very soft or, perhaps, indistinctly fibrillar. BloodrcsseU
always exist in ;;rcat numbers in sarcoma ; they are in direct relation
vich the cells, or thi.-y ar«> surroundt-d by fasciculated connective tiitstie,
as is occasionally tbc case with some of Ùie lar^ vcwvls. (Seefij^. r»7.)
The bloodvncMls are not rcj^darly di4]>o«ed. Their arranf^meni, and
tlio Mrucluro of their wall» are very similar to thoite of iiiSamnwtory
tlisuo. They arc, therefore, <lifficult to separate from the mass of the
tumor. When, after Imving hardened one of thctie tumors, tliin sections
are made, tlie lumen of the veHselii h seen to be limited hy round or
fusiform celU. but rarely does one discover proper walU appertaining to
these blood channels. This is an esscnlial point, for joined to the ccnenil
disposition of the elements it distinguishes sarcoma, and explains the
rupture of the blood vt-asflls, the extravasations, and the blood cysts ob-
served in these tumors.
[In his excellent lectures on sarcoma of the long bones. Dr. S. W.
Gro»' well tsprcMKCN what iw miw nlmosl nniversally rcf;anlc<I m a
characten.ttio of the n^lntion liotween the oelluUr and other elemenu in
sarcoma. According to hîni the cell.i are eontaiiied in an intercellular
substance which U hyaline, granular, fibrillated, or alveolar, and irhich,
along vith the varions degenerations to which these tumoM are liable,
famish a basis for subdivisions. Moreover, in accordance with the dimen-
sioi» of the cells, the sarcomata should he separated into small-colled and
large-celled, a distinction which is most useful, not only bocaux the sixo
of 3ie cclU influences tlic coBsistencc of tumors, but particularly because
it has a special bearing upon the prognosis,]
Spboib^ .txn VA&iii:r[i»< of Sakcuma. — ^Thcso are Wed npon the form
of Uiv cells, their cement substance, the vessels and tlic ultimate tend-
ency of the tissue. \ sarcoma iloe.* not always consist of a stnjrle vnrieiy
of cell» ; all the forms previon^iy indicated may be met with. In reganï.
ing tlie charactem of the elements for the piirpo:*« of cUu^ificatioit, we
iniLHt not only demonstrate the presence of certain cell forms, but we
should also take account of the relative proportion in which they are
found. The intercellular substance is sometimes semi-Buid, in this case
the cells are generally round, at other limes it is solid, the cells may
then, from mutual pressure, assume varied forms. If the cells are com-
preaaed laterally in every direction, tliey become fuwform : if they arc
compressed in a single direction they are fattened. Upon the fonigoing
basis the following is the classification which wo propose: —
' Amerlcsn Joarnnl of t)it> M«>li«iil SriviicM, I*Iiilsdflp)iim Juljr, 1879.
E^tCBPnALOID SARCOUA.
^
wprcir». imtvplialinil [or r-nitiJ-rvUfil^ nari^mia,
%l tiptfitM,j'a»eicuialfti ["r »i'intlU-fvlUii\ mtroouiOt
Hit t/tein, mi/doid [or yidNÏ-wWwTJ Mrmma.
4fA uj'rrU», 'rMÎ/ttin;! mir-yinM.
i(/i tj'fi-irt, iiii'fi'riil/iie tarfimti (pasmnioioa of Virchow).
To the fore;;oiiij; wv ought also to add, as distinct spccîea, the three
following forms: —
iUh ffiffirt, U/xnHat^uë larvoma.
I'ifA npfrifty meltma-tarmma.
Thciw difforcDt tmiiors ma; rniiir »t tho place of tb«ir location, or thcv
may bo )>n)]«goted to remot« parts of th« orgnniua, th« rwurri»'; or
acoondar;} growlh» rcproiliicing tJie structure and nuturv of thit ori^iul
(un>or. In «acli of tlieso {irincipal H{ie«ie« of sarvotna, le«oiis of uutri-
lion imiy pve rise to varieties, ritich ledona ar« :—
a. Fntlt/ (IriimeratioH.
b. Jnftireth».
C. C'tttfrf't* Irantforutation.
A. t'vrtttation >•/ fih/ftJ-ct/tl»,
e. InfltrmmaUiri/ pAfn-jjnena.
We Bba)) Dov stuu; in detail each of tlie preceding apeciea.
RouxiH'KUKh Sahoim A. — Fonncrly it was confounded with carciaoiBft
under tlio iiaiiie of *iic<'|iiialoiil cancer. In France it waj" often spolcen of
as an cmhrjffl|>l.iKtio tiimor. I14 encephaloid or pulpy appcaruncu is com-
monly well utarked ; itit color is usually gray, and it is more or less trauti
lucent. The primary tumor often
very{|aick]y attûns anenormous aiae.
There may be owtastaâia to ibe dif>
fercnt ornns, especially tbc lungs.
The vessels arc volaminot», often di-
lated, and varicose or ancurismal :
these then appear to the iiaiccd eye
as little re^t points; tinallT, they
may niptiire and form little cysts
fillêil with fluid or clotted blooJ or
«itli mucus holding i» suspension
degetM>r»tecl clen>cnts; (lie rupture
may aUo ^ve rise to eccliymoses
or difl'use henwrrliaj^s. Motit fre-
f|uonily, when tliese hemorrhage.i
occur the red globules are prc^rved
and there is no pigmentation of the
ncijjhbflring etcmi'nts. When per-
fectly fresh, tiic tumor contains a roduj .ic^ii.4*tM ■•wnn^ «. n*nur
juiew which is perfectly transparent, laana». t. tttmrijmm mnir btii»ii«j «i.
Tirvntv-four, or fony.cijîlit houni •-'*■"">•■ ^"*'"t^«"'<""t'"*' ">>-
alter deatli or ablation, liowover, an ,j((vr/.i.e«.>
K?. S7.
80
ftliunilnnt juic« of whit« color, snd r««tinUliiig that of cancer ii obtained
hy :4t,Tti|)iii);, vhich ctrcunutiineo is due to tlio cndnvoric lii|uefiiction of
the i[iti'rc<.>llulftr itub«ta»co and to the fluid ttiu« foraicd liolding in «u8-
peit^ioii umny ccllMlar oleinonu.
The cells of eiicephaloiil Mrconia are genemlly stnatl nnd round, or
more or le^ia irregitlnr. Tlieir nuclei are large ikud incloae from one to
tbree nucleoli, whicli luav be vehicular. Tliey seldom have the diversity
of form of culls of carctnooia. In these tumors there often is to be
found a certain <iuantitir of olil prc-existont connectivo liasuo.
Iteiiide alterations in nutrition, those tamors often present in their
oldest portiotia ftranular cornusclos and an inBltration of ibo elements by
fine fatty granules. SomctiiucJ> portions of the tumor have undergone
mucoiiH or calcareouH degeneration, or they muy have b«eome infiltrated
with red or hluck pigment. In these cases, to the tenu enevphaloiil
sarcoma, which représenta tltc rfpoeics, a term which woidil iiidiciite thi«
partial degeneration should be added. One might say, for example,
eHivyih'ihnd utrevma with /lartial mueouit <ie;/^w-rnti'in.
Ihc scat of encephaloid sarcoma is very variable: it is seen in the
aViii, subcutaneous cellular tîaâue, hone, muackM, iu the glands — particu-
larly the breast and testicle. Of all the aarcomuta [except the alveolar],
this s]iecies is the most malignant: it recurs very fre<[uently. and \>y
metastasis invades a great number of organs.
SptMiLR-OELLEii Sarcoma. — In this species the stnictiiro of the «m-
brynnal ti&suc is more nearly relate<i to coiuiective tissue. It is the
fihro-plitstic tumor of I.ebert. 'J'uroors of tliis class are so common that
they iiave been regarded as the type of sarcoma. From their trans-
Kg. 5S.
Thin Hrtilnq (.r m ritflitfblfti^ «jirrnDiK faplb^lc.
(b« f^ll• liKTf >i»B «lunMd b]t ■•oinf. u
(bal tbair ludlililaal furMt aKtiiptnai; M
■ba rigbt. IbfT w* In Ihilr uU<m4 tUt* nf
«pptAllloD, «ucb ]Lt u<idH It 4f«D Ib b lUa
luccnicy and tlieir fasciculati.'d aspect they have been compared with
miucular tissue, whence comes the iinmc sarcoma (Besh).
The cells which constitute fasciculated s»rcoma are fusiform, and are
terminated by two lengthened exireuiilies which sometimes ramify. They
JjYBLOID SARCOMA.
8t
■
I
■
arc of variable size, their mean length heioe from .Oln tn .O-H ram. : but
tber BMT aoc|uir« colosaal diinensionfl, reacliinii even .1 mm.
Th« tiB8U« of fasciculated sarcoma ia very^ simple: tbe cells are 'luite
or nt-arfr in contact with each other in such a manner thai tbe 5|Hmlle
exIromtUfs of one cell ar« apjilicil along the i>clUc« of another; theae
ill trnli<;i ta tiof; veils form real laeciculi, which miiy be pnralk-l nith each
othrr or msj- intercross. The ilin-ction of the rcsseU U tliu sarou aa thai
ofthoeclU. (Fi]^. TtS.âïl.)
TTm) periphcr») limit of ttiMO lumnr* \» soiaetimea «harp, sometimes dif.
faae and eontintioiM willi ibe neigtiboring tiit:<uc#. Their incr«'»)f<- tukcs
|ila<te at the {mrlphery, at miv time irre^uliirly, at another liv the f'lnun-
lioN of diniincc and .-iiihencal l»biit<*ii. Their vohime i* varinblu, but they
art> uaitally smaller tiisn cncephaloid aarvomata. Nevcrtbelesii, in the
limbs tiiey often grow from the perioateum until the^ reach the size of an
adult hew). Tbe«e tUDora contain no jnice in the fresh etato; but the
(lay after tbe operation or later, after ca<lavcric cban^fen.a email «(uantity
mar be observed. Very often. fascictda led »aa-omaia arc waled under the
penosteum : they vxisl in bone, connecUvo l4S4Ue. and muscle, in the
breast, tbe tcnticiu, etc. Ity secondary deposits tbey may înrade all the
oriinns.
In the mamma- these tumor* and those of the prccedinj; species are
aocom|inmed by n praltfenition of the cetl^ of the t:l*i><l»lar ucim to
such an extent tliat Billroth has reco^^ixcd them m a sdparaic variety
under the lume of adeuo-mrconui. In Kratice tlie latler arc often called
»deiionifti.i of the Woast. Many tumors of different spccioa hive been
confounded in the brcasi under the name aden^nut!
î^arcomala of the mammnt present two forms: they constitnte a maai
throu;;h nhich the acim arc Tv;^ularly disseminated; or the sarco-
matons tissue, through pressure upon the nulls ef tlie ducts and culs-
dc-*»c, forms projections into their lumen. Thow projecting vegeta-
tions are covered «îth e]>ith<;linl cell*. The lacunar cy>it» thus formed
have varying dimenfiiouA and prcneut, u|H>it netHion, irregular, stellate,
or semilunar opening», the etiitbeiial celU ivhicli cover the oppoaitc
walU oflen being in contact. TbeHe canities may appear &s large spaces
which separate tbe tumor into as many lobes. Ily scraping the cut
surface of these tumors of the mammw an abundant milky Uuid is ob-
tained. In sarcoma of the mamm:e and of other regions there is never
tnie adipose tissue in the midst uf tbe morbid ninss. We shall see later
that this funiishes an excellent eharaeteristie for llieir differentiation, by
the naked eye, from carciuuma, in which, on the contrary, adipose tissue
is preserved.
MykloId Sakcoua. — ^I'heae are itoft tumont, the cells of which arc nearly
in oontact and are very similar to those of the preceding species ; a certain
number of them, however, lend toward a more stable organiiaiion by
surrounding themselves with a membrane, and their conlour i* more
regular and more distinct, âomc elements are round and spherical like
the cells of embryonal bony marrow; others arc fusiform; large, flat,
irregular, giant cells are seen, which are filled with ovoid nuclei (see
fig. 5). We thould remark, however, that the latter cells arc not peculiar
6
82
TUMORS.
lo mydoîâ wircomn. Tiiey are fmiml in Etmall numbers in other sarcoira-
tous tutuors. Finally, »aiii« qvW» in Uieae tuinora reociuble iha angular
Fig. «0.
UrtMi unaiu*; >bo«lii( (jiliidtBgtiid itUnKBll*. Ulah fint. ibnwa hjrDr. Skak««r*«n !••
Dr. K. W. (In-. B» 4mff. i'mn. Hit. trtmeti. laij. ItT».]
clenicnta vliich re<>nh from rociprocnl pressure, nrxl which Gcgenhnu<>r
huit iiii)>ro[ierly exiled oateoblasls. Myeloi'l sarvninata are nearly aluayil
luc»l«il ill tlip bone». They are usually limited lo a siugle boiw, whicli
they may destroy cotii[)l<;(fly.
Fig. 61.
rorltKD Dt ■ ■•(Hod from ib> bonlaref ■ fplndta- uil g1*B(-c«ll*I •treoni at Iba ttmr ibtiDIa,
■huialDKlxluwa' UilnxiiU, «htlh dlmpjiniii >l lh>nn* (lit* b^shinrilllgil. imd «rov. w IliaoUi'I
hxiii)»>iiloD. Til» Mill ■|>i>ILtil(u(ha loBii l<urd>r af II» m)«iiilit ■naim.tiluU.uid u> taiatt-t
s** l4un«. vbtlv ihn arubi «ail* tt|ipU«i] W lbs upjrvr *df * «f th« btmf iriT^ml* ocenpj thi- iiguiioa ^
»t lloBihlp'* >MuirK tid «le «lUif («aj lb* bVM. Ihor nielli, lb*T*("n, bi ash larninrl <
I
I
OiP>stPr[N') Sarcoua. — ^Tliis spMtcH (tilTrrs fmm Uic frecoding tumnn
only in the U'tulnxiy of tliu (7)i'inrn(jt to prodiico omcous tisauc. In lliU
OttMous tiaâiii- it is rnrv to fiml tioiiy lamcll»; nrtd Ilkvcrsian cnoals.
Ttio anwll tainora of tlio iletitAl arobes, wtiich nru called opales. &r«
«onintimos mydoul, 8onK'tim«n owiîfyin^ sarvoinatii (fio. G}). It mar be
AtVeil wlicihflr lliCMi'imicAare osteoDttUorMrcoinata: kc linvi>cliissifii!<l
tlicnt iiH sarcomata, becattse tUey have only a tcnilonoy to osailication, their
osnficution i» never complete and nenaanent.
'Hic little tumoni irbich ant callci] Bul>iin;;iial c:toi3itot<eii are ideotioal
ID ntriKture and nature to that of c|^ilif. Itotli may reluni.
The tumors of this spvciv« arc seated, hy ]>referei)ce. in the short
spon;;/ bonea. When thi-y arc on the long bonex, thev are almost alwava
located in their epipliywal extr<!n»itios. They »U<nM be carofullv di»-
tin^^uidhed from {•rowths «iniply iiwriut^d or permoaleil by calcariwus
depoaita. The latter hare only tlie form of neeillea, disponed like osae*
otia trabcuulm, and cannot, witli the tmlied eye, be difleruntiated from
bone : hut under Hw microscope, it in neen that the intercellular Hobsiaiiue
is iiicriutt-d with calcareous salts, tlial it is opa(|Ui-, and prfsents sniall
round or ovoid cavities witlioui processes which serve to lodge the cells
of the urcooia. [Many authors make no distinction Wtwern ossifying
and calctfjiug sarcomata, and rcgani both as hij;hly Dalij^nant.]
(tl<tOMA. — Virchovr has ^vcn to thesie tumors tb« name j^liomata,
because their consistence resembles that of j^lue, and as he found
their tissue similar t<nti:it of the neu-
roglia, he has svparaled them from Vif. BS.
«arcoma.
These tnmont contain cells from
.QOtJ lo .01 '2 mm. in diameter, oonsist-
ing of a iiiideus .■iml a very âmal) mass
of prolo(4asm surrounding it. After
the ;;rowth is hardened in alcohol or
chrnraic acid, certain of these cell*
are seen to po«seas fine processes by
which they anastomose and form a
reticulum HimiUrtothatof n<!uro<^lia.
This reticulum can sidduni be seen
in tlie fresh sUte, ami is, ai least in
part, prob*hly artificial. Wo may
a<ld tliat similar forma of cells may
be seen in other species of sarcoma, fliiona. muh *«»«(. (HimffiM.)
sfter thorough Itardeninj;. It is
then not charaotcristic. In the mvshes of this network esiat small free
cellt which, by ihcir characters and reciprocal r«rlations, recall those of
encephaloiii sarcoma. Beside», it is rare that one of these tumors 18 con-
stituted throH;;hout its enlirc mass bv such a reticulated tissue ; very
freijuenlly islamls are oWn'ed which Iiave tiie structure of eucopbaloiil
or fasciculated sarcoma. We reco^niae, then, in the giiomatn only sar-
comata whose tissue bas a tendency to orjEaniiation into neuroglia, 'l^ho
censro of these tumors is generally in siwh a state of fatty degeueratioo
that, at first wght, one might hesitate .between volunùnous cerebral ta-
84
lK.-rcli>s rir «»rcoii)»ta. Tho tmmiIs of a Klionnrcomn oft«n {Kraeewt lymph
she» til Ï.
1 Hio-.iftrcntnnt» nri- fouinl in the brain aii'I npiiiul mnrron', koili in tlio
graj' anil in the wliiui «ubmaiic»; ; tlit-y nia v ilevdop «loiii; the cranial
iiervcH ami in tlio relina. Viraliow re|Hir(.'' an oWervation of a glioma in
tlie cortical HulititaDce of lb« kidney-.
[AlvKoLArSaucoma (à%reoma earn'tiomat^e»i>f Ttiu'lfinm-h). — This
species of sarcoma appears, bolli in a clinical snri hiâiolngical point of
vK'w, to occupy a middle };round or eonoocting linli, as it von, between
the earconiata and tho carcinoinata. These tnmors poesetw an alveolar
structure. Their alveolî mai' Iw lar;;o or small. In proportion (o their
KÎKe. the ftlvcoli arc oociipîod hy one. two, or three lur^çc cell», or tbey
contain Iiir^ niimbere of iimall cclU. The celli< ar« usually of the
type of cmbryontil cclU, altlii>ii;;li Uindfii-isdi dwUrcit that in {««mo
ca<te;« they are opitlielioid. Acconlinjr to Killrotli, from the «ixc ami
arranj;ement of llie celU, il u often extremely diffiotdt to di>tiEi>:uÎ!ih the
growth ftxtin « carcinoma. Aocordin)^ to S. W. (irocu, rouudiMi heapâ of
Pif. 63.
y
Ali>diirMiwu*rtv4piii>. tibiL X*M- lEtUnlhA
umall cells are seen contained in the alveoli or spaces of a conneetirc-
tiîfsHu meshwork. At certain poinl-s, the roa&ws of ceils are interceded
by delicate bands of connective liitsue, which are ;iivcn off from the alve-
olar walls, and which divide the larjjer cell clusters into smaller ones.
Tumors which possess this slruciure are excessively rnscular. and are
often tho scat of mUsatiou and a bellows murmur, which have sometimes
eausod them to bo confounded with aneurism duriii): Uf». JhEé con-
siders that in the very m«cnlar tiimom of this kind tlio walls of the alve-
oli are formed by th« ckpillaries. Wvhcr believps that in the vaMnlar
tumors tlio xtrocim iii d»e to the oblilenitifni of the blooil channo);^ aadi
their convention into !<olid fibres. Aec<ii\ling to <9roAji, and in this he ^
agrée» witli Itillrothandourselve», the point* which distinguish tliis form
of *arooma from carcinoma are : liTHtly, that the cells are intimately con-
nected with tho walls of tho alveoli or the ressela which form them ; seo<
ondly, Uial, by pencilling, an intercellular sabstanoe like that met vriHk
PSAMHOMA.
85
Hit l7mpha<l«no)'l Torni of tumor U <Usolo3«<l,' the Bbm of which arise
from the nlviralnr walls vrhich incloso thcgroujt* ofcHlo. In otiicr worils^
in alveolar ^tnrcoma, the strxrma ami evils nri; iiitimntcW iiitorwovcii iitto
a MiDglv tj«iiu', wht-rcus, in cnrumoma, tliv culls and stroma arc cueîlj
êeparahlo iiif> two iliittiDot tisstic».
Thi* fonn of tHmor i« raro. It ha.* hpcn ftiumt iti the akin, in tnnicles,
ill hone, in the Irmpli i^lnmU, aii<l in iho 'luml coveriu); of tlie s|Hnal
eortl. It h iiecoml in mali^tmtiQy only U> the oarciiminnta, and, like the
latter, it. as a rule, aeoondarilj invalvej the lymph glands. \(elastasea
are rre>i(uent.J
AsflloirtHli; Sahooma (^Pnamnuima of Virfhow). — In Iho form of
ita cells, this very curious groirih <loes not es^eutially differ from the
prcciMlin}; epecios. These tiiiuoré contain" cerobral miiiiI," and the nhy-
stoln;pcal typo of their strticturo is nivt with iii the uhoroid plexus. They
are siH-u only nithiu tlto crauial vault, in the arachnoid, and in tlie pia
anil dura lunter.
Sud) sarcomatn aro aoft, easily crushed, and contain no juice. Their
color ia gray, and ihey are roorcorkiu upnque; ihey are otUn su^
Muuded by » fibrous cajMuie. The colU comprising them arc liât and
ng. 84.
abfloUlbVf vaRDmK l^BAumoiiiA). A- l*«UL«<1uIU.*«*ii In nirfjiFB Mo, In proAU M ft, X^W^
B. V»*cqlAr kad. rnii[4jiiii|> ■ rdlo4r«oii* cl4br, a. C, V#«««l inûlErfttaJ vr^ih «Ajc«r«oiu MlU, «nd
pir***ft11»i( At « « nl£*r*4qB cdacf«Ilan oj/pavoQ^f lli bndtfhda, X 1^*
thin, of colossal dina-nsions, and of irre<pilar form. Viewed in face,
tlicir border U so thin that it U dîtlictdt to follow, and the nucleus at the
centre appears ienlieular; sven in profile, they look like a libre or an
extremely long fuKiform coll, the centre of which is occupied by the
nucleiij. 'Hie cells reiemMe the endothelium of the veins, but they are
not united at iheir edges. These neoplasms are distinguished fpiai all
epitlielial tnraors by the fact that the vessels are in direct connection with
the cells. This relation never exists in epithelial gmwilis.
The bloodvesaelâ arc numerous and are easily Isolated. Xo matter
what may be the siie of the vessel, the wall is entirely formed of cells
eimitar to those which constitute the morbid mass. The^e cells are only
loosely nnited: ihey easily allow the blood to ooïo out between them.
Hollow buds (or diverticula) are constantly seen, which communicate
villi the lumen of a veeao). These little buds grow and become pedun>
86
TVHOnS.
culated; i\\e flattened and conoentricalk ifi-'^poitef] colU nbtch roinivwe
theiQ become ÎHcnuted ffith Oft1c*reouii nalta. TiiU procci^ of iiitiltra-
tion is identical witli iho ]>Uysiolo;;i<;al modi tics tiona of the vessels ot' the
choroid picxua. When tlie calcified bmb liavc not broken tlicir connec-
tion with tlio vcssola, the peduncle and n part of the vcesd- null are ohen
incnistcd uith citlcarcoiiH salts, and buTC become homogeneous and vitre-
ous. (I''ig- ti4,C) After s'-pji ration frointlieir attach ment, tbese Iictlo
knobs majr somewhat reiwniblc a "wili nwt" of epithtdionia. Tln'y may
or may not bo calcified, and the tendency of liifiltrati'in by ealcareoug
salt» scpurate* thi-m from the epidorniic globes or "cell nesia" of c|ii-
tiielionm. lii other jiarw of the body, jiarlicularly in ibe ihymiis gland,
wc meet viixh concentric sphere» whicb maybe calcified or not. and wliicb
aUo are appendages of the vesel-walla and have a Himiiar origin. .
Mvxo.B,\iiTOMA. — The mucoid dcgenorution of the cell» of sarcomAf
associated or not wilh fatty degeneration, ends in the destruction of the
cell» and ihf fornmtioi) of cavities more or lew largo, filled with trans-
parent geliktiniform matter. Tlie»e cariUeiii have a variable volume.
Tlic whole tumor may 1u' riddled by them, and flonie antbora in thÎA case I
call the growth a cy^lo-iiarconia. It is only when the degeneration is
very marKed, extends almost throughout the whole tumor, even the most
recent portions, anil parctcularly when the secondary tumors present the
same appearance, that we wouhl name tbo tumor a myxo-sarcoma.
Lii-oMATOUt; Sarcom.\. — In (hia form, vbich id not uncommon, the cella
are intiltratcd with globules of fat without boiitf! d^^troyod and withont
ceasing to function, a capital distinction which dificrenliatee this form of
sarcoma from that in which the cells are uudergoiii}; fatty degeneration
and cousetjuent destruction. Those cells which contain many oil globule»
may be much enlarged, with their nuclei crowded to the pcn]'liery. Tho i
cement or itit^'rcellnlar substance i* very slighl, and ibe cells are close
(ogctbor. 'Hie tumor U^ometime.tfoft, and the surgeon, when examining'
it by the naked eye, may he disposed to call it an euoephaloid cancer.
It is usually very large, and it may occasion secondary formations with
iden^cal characters.
Mki.axo.sarcoma. — Melanotic sarcoma hns it» usual point of de|)arl'
ure in the eye or skin; but it may aUo primnrily a^ijicar in the lymph-
glands. In the developing inmor, all of the celli* are not equally pig-
mented; variously colored xones maybe seen, white, gray, often semi-,
transparent in the youngest points, black in the oldest points, of sepia or^
slate-color in intermediate epois. Sarcomata of this species may be
black tbrougbout their entire mass from the commencement.
The colU of these tumors are round or fusiform, their disposition and that
of the intercellular substance is variable, but, tbey correspond tn a general
way with the structure of a fasciculated sarcoma. (Sec tigs. ti5, ti6.)
What coiwtitntes tiie specific character of these tiimorv is the presence
of black griiTiuK's in the interior nf the cells. The granule* are black
from the first, and ihU forms a distinction between dark melanotic pig-
ment and the black pigment wliich follows hlnnd extravasation.*. When
these black melanotic granules are round, tbey may at firjit be confounded
with very fiite fatty granules ; when ihey are angular, tbey are more
DEVKLOPMEST, BXTBS8I0R, BtO.. OF BAROONA.
«7
rcftdily reoogniied. Thcâ« ni[^uunt-«fuiiulv» oft«n unite into onmll rotiud
cluin|ia sorroundc^l bv n briiliutit tnuv, which i« noUiing cIm tUau a de-
posit around thou oï albuminoid inntcriBl.
nit>c&<
Pifi. «4.
(AhmN.)
•HMiM oribeUtar. X aSO. («rwa^
Tlie melanotic granules arc first formed in tlie protoplaam orouud Ui«
nuoleua; aften'ard^ they may invade the micleua iUclt'.
'Hiis morbid growth lias u Kn-at tondency to occasion secondary inva.
«on of Uic distant tissues liy similar grontlis. The name of mvlano-
Mtcoaia should not bo applied to thoao sarcomata in which only blood
cxIraratiKtioiL» aud their M-(|iiolai arc found.
Papiiiary Sarcoma. — Thî» docs not constitute a species, but a form
which any sarcoma lunr assaino when it grows upon a mucous or cutaneous
surface. Wo have alrcaity indicnloil that sarcoma of tho mamma hoe •
tcudt-ncy to send hnds into tbo lumiiut of the acini and gulactopho-
rous cauals. Sarcoma of the Hkin, wliich is the type of this variety, at
one time preMnt^ nvffa upon the surface, at another papillic. Through
pnilifo radon "f tta-ir element*, the pnpillfc of Ûw skin undergo a con-
sidoraMe hyperlrriphy ami eve» jjiveolf lateral Itiida. They arc corerud
with epi>)ermifi, the cells of which are more pigmented than in the iionnal
fltate. fn certain cases, ercn the celU of the RarcoiDatou» papill»; arc
also altshlly pigmented: it is jMHsiblc that such may he the commence-
ment of a melaiio-sarcoraa. hut in the most of ttiese cases the pij^ment
appenrii to be due to ecchymoses. Tiifsc tumors generally increase slowly,
hut at any moment they may take on a rapid growth and cause secoml-
ary fonnationB. «
pBVBt/tPMBXT. EXTKS'SIOS, SN'D GKN'ERAUitATION OP SaBCOMA. — The
development of Har>.N>ma. like thut of mnst tumors, comprehends three
terms: 1st. the development of the primary turner; 2d. the extension of
the primary tumor; -Sd. the formation of sccumlary tumors.
let. The manner of Uie development of the primary tumor is very
simple, ft «lioidd be studied, by preference, i:i tissue of which the struc-
turc is rery different from that of sarcoma. In bone*, the dcvclopmeut
of sarci'uia \* exactly the same an that of inflammatory ti$»uc (p. t!U).
In teii'Ioii.t the endothelial celU. so atrophied iti the norm-il stntc, swell-
their nuclei divide and suj'round themselves witti distinct musict of pro-
88 ^^^^^^^WBW^^^^^^^^^^^^
boplasm : the cmbtrODal ttWs, thus fomicdtbocomc dÏMpMvd in long rows, '
wliilo the inti-rcvllular enbetaDcv <lisn|i]>can. [To iheso [ii'olil'cr>it«d <
CDiIothdinl cfUs. titc witttc blooil coqjiiMios uml tin-ir ilorivKtioDS 8boul<l '
pcrliii|» K- niliii-il to form tbe nuofibmiii.] 'J'Iius rvsiilu nu embryounl
{mut which is «imiliir to Uml of enco])bttloti] Mtrcoma, but wliicb lany
become bj- oiodiRcaiion of vdU and iiitracclluUr «iiWtaiicc, « fasciculated
■arvom», et«.
2d. Increase of tb« primary tumor takfrs iilace: a. li;/ rhf profifera-
li'dw of ilit •iii-n rhtiirnt». b. lii/ ettii(inti"Uit iiivarioit'ij' Oic iu-i-jfi/>orinif
tittue. A smooth, roj^dar, j>eripberal outline ia an indication that tbo
tumor is no longer extending; by an invasion of the neiglihoring ti»«uc,
If it is not âbaryily liuiilcd from the i)art« wiiicb surround it, the inrasion
is atill continuing. Whon th« growth is extending, we sec, under the
Ducroscope, muKHcs of einbr^'onal cdemvtita in proei-»» of formation at tb«
cspcnite of the noriDal elements of the i^urrounding lUsue. 'V\\ii mode
of invasion »bould suggest a grave prognosis, but We» grave, h('wevcr,
than wlien morbid masMs isolated fi'oui the principal tumor are to IfC
fonnd in tlie lii4«ue arouml the growth: the latter mode w what bi tenned
interrupted or {ihi-'iNtititivu» invan'm.
'.it\. When nL>w tumnnt of tlie Knme nature a» the primary grovth are
developed in dîritaiit organs, «e say tliai {hey have become ijcueniliitii ;
«e call this metuntati».
It is precisely npoo this property of metastasis that we have based our
classification, Sarcomata as a general rule do not invade the lymph
glands Ij eccomlnrv metastasis, tbey become generalized through olJier
channels than their lymphatics, probably throngh their bloodvcsselt
whieb are often in an embryonal condition and easily ruptured.
pROOSosiï 01" âARC4)UA. — 'Die gravity or malignanty of sarcoma, aside
from the scat and tlie volume of the growth, îm dejfeudent upon its ten-
dency to extension and meta^tanitt. Sarciymn ts m'rre or Ua» grave in
proportion at it» urr/anuittion it more or U»t Itiwered.
According to their malignancy the sarcomata might be classified as
Lfollows, beginning with the most malignant: — alveolar, cncephaloid, me- ^
F Unie, cidloid or mucous, lipomatous, then fasciculated, ossifying, etc.
KarcomatA which present true osseous tntbecnis are less to be feared than
those «btch have simply undergone calcification. The more pronounced
the tendency of sarcomuta to pro<lucc perfect tissue, the more the organi- i
nation of the latter will he elevated, and the less grave they will be.
TliuB among the myeloid sarconmta tboM' which actually ros^-nible Umy
musses will be more benign than those in which we will tind parta re pre- <
senting the tissue of enecphaloid or fasciculated sarcoma. It h important
to take aocountof these complieations and of their prognostic value;
they explain why, for example, the tumors which Aome authors sdll call
myelo-plastie enimot always be regarded as benign.
Virebow, who has not made a distinction between ossifying and cal-
cirying sarcomata, says, in a general way. that tbey are very grave. In
loalting tbi« dit^nction we arc led to say, on tho contrary, that ossify- 1
log sarcomata, aa epulcs and subungual tumors, are, as everybody knows,
benign; while fasciculated sarcomata incrusted with calcareous salts are
HTXOMA.
89
grave, the ^nvitv resahhig not particiilarlv from tliU calcîficatioD but
. from die fact (liai they are faiwtculatAd aarcoinata.
Iflto-sarconut U grave aolelr by reason of itfi seat and extension by
tinuous or dÎHcnniinuou» invasion; it rarely if ever oci'ision» mc-
taes. We woiiKl ^y tlie nAinc of ptiammoma or «i^iolilhic snrv'imn.
[Alveolar sarcontn possesses a ^rcnt teiulcncy to mctiuUMS) and of «II
Uiv sarcomata, it most frvqucDtly ttivadcs tliv aeighborinj; lymph glands.]
11— TUMOHS OF WHICH THF. TVPK IS FOUXO I» THE
DiFFEKE.NT VAKIETIES OF CONNECTIVE TISSUE.
^- Uiv S
^^^H i»T Clahs— Myxoma.
^^^ttKFixiTioK. — Myxoma is a tamor formed of mucous tissue. Iw defi-
nition is involveil in that of mucous tissue. This tissue forms the umbilical
conl ; it persists aficr birth in the vitruoiis humor of tlie eye, but in the
embryo it is met «itli in varioui» parts of tbe body, Mucous tissue in
the embryo u observed as ono of the first pliascs of development of the
eniliryonal into fibrous and ndipoge tissue. The tumors constituied l>y
it «ttjrfit, therefore, to hy described between lliose foriiK'd of embryonal
tissue and those coiwtitiiteil hy fihrouA timtue.
I'liywologically, miicoui» liniwe presents two forms: l«t. Round «ells
isolated in the midatof a mucous intercelhilar suhftanoo; '2d. Stellate
and auastomodiiig cells, suajicnded in a similar intercelliilar aubstaiKe.
It b rare that myxoma prcseota one of these two forms alone.
Dfi^cRiPTiux OK My^uua. — Myxomata are trambling, gelatiniform
tumors permeated by vsssels which are readily seen and isolated; when
one scrapes them, no milky juice is obtained, but, on the contrary, a fluid
ùrailar in appearance to a solution of ;(um arabic. In this fluid, rod
Mood disks which have been forced from the torn vessels are seen, to-
gether with cells of various forms, round, angnlar, fusiform, sometimes
possessing; proceases. The cells may contain one or more nuclei; they
are pale, and their contours are not dis-
tinct, because tliey are seen in a .«ub-
' stance who«e index of refraction nearly
^H «qusU their own.
^B Kre»bly examined, a targe meshed cap-
illary network is seen, in the walla of
^_ which ttie nuclei and the outline of the
^B endotlielial cells can be readily made out.
^V lietween the vascular meshes is mucous
^P tiasue, in which are suspended large pale
^^ fusiform or stellate cells, which aiinstomoso
I with each other by their processes. ( Hg.
Besides this net of plasmatic cells, the
mucous fiuid contains round and «mall
cells [leucocyte*] which hnvenoconnectJon
withtlieirneigbbora. The prc«««nce of the
cell-net is rendered very appareut by the
Pig. «7.
of Ibfl AFia, fcbovLnif tbe cKiiriiC!Lvrl«Ue
lIiû ft ffW leitr'H^]'!'*', *ad ont o' tv«
k
90
TDUOES.
ai](lition of ft nolutinn of iodino or ptcro-can»m&t« of ammonia. \le<ài
Uiesi^ eleinenls, the innrktil lutii» ifinti cam tftiiiA elastic tltirea aii<l »<lif
«ells. Such are the general ctiaracWrs of tumors of this group. ^See
Spsciks akd Varietibs of Myxoma.
IfiT SPECIBH: I»PBE Ml[-x<iilA. — It is composed of miicous inwrcellular
substance, tiirougli which arc •caltorei) ve««eU, «nd routnl ftisiform And
atfllUte «nastomosing colU.
2i> KPKoiKEi: MrwMA uontaikinq a coxhiubraul^ quANTirr OF
RUSTIC rillKKS.
8ii spBoiKii : LtFOMATiili;^ UYXojiA. — The adipose tisane which charac-
Erixus this opecieARiay hesoahiitKlant that it «ill be difficult to determine
liothvr VQ have to do with a myxoma or a li|>oma.
VIp. «.
JffltÊUlta StdUtdfrft
SMUtr-eifl
Mjumuf
'ZfijMM
Le^ttMMU ttfXf»'
Cicntl
BcHÏdfs th««e three species which may present the »p]>earancen above
indicuwd, myxoma may iindi-rgo tho following alteratiims in nulrilion : —
a. Tli« ve«»el* may rupttir»'. an accident vhioh doea not occur so fre-
i]ueiitly M in 8an»ma, tieuause tlie vessel walU are sot softened ; we have
then hemorrhaific mtfxvma.
h. The elementa of the tumor may iinder;:o mncoux molamnrphoaia.
The cellii arc auhject to alterations »omenhat similar to thoae of tho coUa
in other tbsuea.
The elements, so degenerated. diaint«Krate and form a dotrilus ; tliorêj
thuH re.4idt cystic cavities tiili-d with mucous niasee*i. and it is |>articHlarl]
from the surface of these cyata that the heraorrhnïc» occur, (ifneralty,
fatty degeneration complicates these lesions, and a part of the tnmor
may thus become transformed into a cyssic cavity. This variety might
bu termed a cysfVn myxoma.
rlBROPS TDUORfl. FIBROMA.
I
I
e. M^'xoroata ftrc pupilliry. pt-iluiiculakvl, nni], nhoii tlioy »f>rini: rrcmi
• mucfluMincaibranciiiiditrvWutvil iii a. uiucouncurityiara alHo |xily|)oid.
[Theoe polypi, |^win<; from tliv c«lli)lnr liMue of tlio iduoouh niembniiie
'oftbeuiwal foiuw, are covi^reil by ctlint«dc,vliiidricnlcclls,ai>i) ofle» oon-
[I'Uin liTmrtrophi«d gUniliilnr uAks wliicti tlie luticouii incml>raiie contuiu,
d. Mucotw polypi may influme nn<l even ut'-enite, efi;>eciBlly wlien
[they project externally. In tlic tnci of inflatuination tbere is a Imnd.
formation of tlic mucou<i tiaaue into rmlrtfonat lÎMiir,
t. Myxoma may Iw the seat of <fa»ifre>ief either limited or general.
Thfl 8BAT of myxoma is vanaMe. Tber are cncounleR-d in tbe pla-
ccn». and analogous proiluctionA occur along the umbilical cord of tho
'foetus and of the Dcw.bom child.
MyxotuHta occur by préférence în locationg vrhcro cellulo-iidipoec tiiMno
exista; they are frcijuent in the subcutaneous tissue nnd in the miiscl«8.
Ill nerves, they are olWii multiple, developing from point to point along
llic Muntc of A poripbeml nerve. Ascending along bucU a nerve, tliey
mav even reach tlie crauial cavity.
ft I» reraarlcnblo to note the power of resistance which the peripheral
nerv«9 offer tn the compression and invit-tion of these tumora. The nerve
tubes usually uwlerg^o no appreciable nucrilivc alteration. In tlie brain
myxomiita often form greenish ttiniom. The various glands may also be
their seat. They are occasionallv fotiud under the [«eriosteum, and are
met with also in the bones, UBoslly in the short bones, where Uiey are
generally conneuted witli the periosteum. In the skin tlioy may often
assnme the papillary form.
Anatomical Diahxosis ok >1v.\(]JIA. — The differential diagnosis ia
very difficult only when we attempt to determine whether a tumor is a
«arcoma with mucous motamorphosis, or a myxoma with islands of embry-
onal tissue. We may ho guided by tho fact that in parts of a sarcotna
which have suffered colloid metamorphosis, the cells are destroyetl : in
the remainder of tbe sarcomatous tumor the proper «tnictiirc can l>u
recognizcil. The presence of elastic fibres or of genuine adipose colls
immediately suggests a myxoma.
pRO« XÛ8I3 OF Myxoma . — Myxomaia are generally non-malignant. En.
tirely removed, they very rarely return, Thoy almost never cause second-
ary formations, except in the case of multiple myxoma of nerves. When
inwmplotcly removed, they redevelop with a new vigor, like every tumor
irritiiied by surgical interference which is not effectual. Mysoma may
increase in sixo at tbe expense of the neighboring connective ti)^ue which
has first become embryonal, or it may enlarge by the proliferation of iU
own proper nin.ts. Virchow has several tim«s seen these tumors form
mvtaxtatic formation.
It i* probable that their gravity or Ijoiiignaiicy t* pmportional respect-
ively to tlie amount of embryonal ti.'Mue and of elastic or adipose tissue
which they contain.
!» Claks.— Fibrous Tumors. Pibroma.
SrsosvMB. — Tlicsc tumora have received the name of fibroid and
ttUtmvid. When tbe tumor was very hard, J. Muller called it asteatoma.
92
TUHOHS.
Vcrnonil propowd thentraeof /iVfr-^ut'i, which isnow Ecncmlly emplojed,
niul wiiicli define* the tUBiw as w«ll porhaj» as lh<; won! iniwiwt, given
by I'ftgot,
Dffixitiok, — The definition of fibroma is eupplicd by tbat of fibrous
tin» lie.
Tvf« rarioties of fibrous tissue, that known a« deii#e while fibrous ti»-
»u«, and tluii iieeu in the inner membrane of artcrie*. will tenre as a basis ,
for the deacription of two vorreepondiiig varietio» of fibroni».
Fig.W.
Pig. 70.
lirftbrLf^il euri<ii*ii^I<^*, Im^ZuaLhj; «p^pf* wHkli. lf<fl
blu«.an nMunltf niltxl «Uli UndUoni rHcl-
«nil. tll«h powar. (OsrymMr.)
*
tn order that a tumor may be called a fitirnma, it is not »u<ficient thai
it contain connective tissue and vessels; it is necessary Uiai il contain
nothing elso.
DiacuiITlox OF FliiROUA. — Fibromata are tumors which are dry, hard,
firm, and pearly, pink, or white. When they are scra]>ed with a razor, the
edge of tho instrument detaches small distinct fragments. In a thin sec-
tion of a fibroma, one will see bundles of fibres which intercross in every
dirvction, as in the skin; some of the fasciculi will ho seen lenfTlhwise,
others in cru«s-»ociiuu, still others obliijucly. It will be impos«iMf to
mi4cou:<true ihi» disposition, cspucintly if the sections are colored «lith
ciirmine and treated with kcetic acid. One will then sec very distioclly
ft network of plusinslic cells itmon<; the bands of fibrous tissue. ThcsQ
buudft are t» bo di:<tiuguiMlicd from bundles of spindlc-cells or smontit
inii:«cular tiiMue by the fadt that the nuclei of the fibres «re not in their
interior, but are up<jn them.
(«enerally there are no el».«tic fibres in this tissue, and this is one im.
portant point. Vesaelsare not very abundant; they are found especially
in those parts of Uie tumor whicli po^ess a loose connective tissue, and
tboy consist of arteries, capillaries, and veins.
Wc will describe two species of fibroma.
1st SI'BCIt»; FlHKOMA WITH H.Al CKLl.S AND AN AMimniOUS PUNDA'
MBNTAL SUiiSTAM-K. — We oi'tcn sec upon serous mcmhr.ines— especially
(lie peritoneum wliich covers the liver, and, above all, the sple«a — hara
PAaoiccLjiTBD risnoMA.
■Hpdl; sdmII, diapOMd in plnue, in villosilicfl, or «mall ^Inbiilnr
RWoi corMin suthorv bitvc (U-Mrili<Ml à fivtff^i of ficrilicpntili^ «txl
pnritiplviiilis. TIh'm tumore nrc at times Hiitiencd ii{MJti tXm convex jtiir-
fac« of th« or^n ; oUicrwiRO tK«y form promiiivncM, coiMiHtinit of «n«
nr more lobul«ti clotwl; unilt'<l \ty intvrmotliatv liMtie, or ncAttor«(l orcr
tb« «Mrfac« Hoiii« ilinunce «pnrt. To tbe naked evo, (licj* have a groat
^_ r«Minti)an«o to canilajfe ; tlie v are tratmliuent ami uliglilJjr yellow ; they
^P out vitli diRicuUy. but do notcrenk under l)i« knife like cartilage. Tlicir
^^ nrp an liard that thin nectioni) can readily be made in ibc freab condition,
nie latter examinecl in water, witboiit recourse to any reagent, show pnr-
allel lamcUœ separntod by openings. After itlainiiig wiib carmine, cella
j can be very ili»tinetly seen in tlieae open apaces. The cells are ll&t. Iinvo
An «longatêd nuelcua, aiul proceases «bich nnastsmose witb nci};hboriu;;
L^ cells. The«c propsratioiu very rouch reBcmblo tiiose of the cornea,
^P and, OD this account, lUmlBetsch called tliom corneal fibromata. Hut
^^ tlHiir fundamental subtitance U difforvnt frum that of the comoa, for
L it i# ainorplvouH, It probiibly con^i^ts of gtrlutinc. Thettc fibromata do
^K tint cdiitnin vetitiuls. Tlioy arc very frisjuently tbc seat of calcnrvoiu
^1 infiltration: the tiiwue tlicn bvc>tDe« y^Uoi>,0])a<|ite,and «olid. A genu-
^B intt petrifaction may, however, take place, wben tbey ar« tnitslucent and
^^ ittony. 'Hie ]>(>trifaotioD may occur in superposed layer». Such are the
formations ii\\\<:\\ the old authors called OMseotia platcii of tbe pleura, peri-
tiineuin, etc. The calcareous infiltration of tbeao tumon alnaya coin*
iiiencca at their cenire.
ill (jfKL'iK)': Fa^i'R'I'uthii KiiiuoMA. — To tho naked eye, thpso tutnore
liave a characteristic aspect. Thoy consist of an afi^lomuration of a
number of Gnn hard lobules. Upon iiection, the centre of each of these
lobules forms a conical prominence, and tlic fibrous bundles wbicli com-
pose the cone arc interwoven in a concentric manner. Several niniilar
|qbitlv« «re miite<I to-^etbcr by a loow- coiiiieclive tUxue, permeated by
vcJWoU whicli suiiK-tiiuvj, but not alwayi<, penetrate tlie interior of tbe
lobule. I'nder the micrOM-<>|it>, the buudW of fibrriua tissue vfaich com-
poM the lobuIeH are seen to intercross in every conceivable direction, and
V> contain celU which form a network, as in young or adult connective
liasRie.
Tbe varieties of fasciculated fibroma depend upon modifications of
nutrition.
In some, the fundamental substance is infiltrated with scrum, as to
a,
œdcma: the tumor is then called mr>f-
{iuoitt ^roma (Molluscuro nmptex).
(Fig.n.)
h. In other cases, a mucous mct»-
morpbosts of tlie fuiutamvntal «ut>-
staiice and of the ci-ll* may cause a
jiartial destruction of the tumor by
tlie formation, in rioinu, of cysts filled
with détritus— .l/Ntfirt J fifmima.
c. Except in thoM fibromata which
have ft syphilitic origin, fatty degene-
ration is rare. iSypbilitic fibromata
't
rift. 71.
Fibrtia* moilaicDn. <F!ir«k«>.>
94
TDUORS.
•often 111 tilt! centre. nnil t!iroii^Iithî(><l(.-';oni.Tiition. united witti the miKOÎil,
nay ilUuppi'nr. Wo dn not ctaiuuf}' tlic«u tumors with gumioaUt wbicb
have n ik'fiiiite tiintolo^^ical cUnrncter.
d. C'ftlcarfoiiK infillrntioii \i ho frcuiu-nt 'm these tumors that few
flbronuita escape it «iitin:!^, after tlu'v liitve existed for a long time. It
hej^nd at tlio centre of tlio lobule, tlmt i^, at tlie point most di«uiil from
tlie vessels,
Tlie tibroim ti^ue wliicti exists [o a jireater or testier extent in cotabï*
nuiou with lipoma, mj'xoiua, carcinoma, etc., is only an accessory ele*
menl in titem, and should not therefore cause a classiHcation among the
fibromsta of any growth in which the fibiyiuB tissue holds only a ealwrdî-
Dfttc p'MÎcion.
«. When fibromata bnvo (lie funn of a peduDCulated polyp, thcr may
from irritulion îiitlanic, ulccrutt), and, like every euppumting wound, beal
by iininuliition.
Tiie ni:vEi/>i>stKST of fasciculated fibroma is not well underatood.bucniiM
generally tliey aro remowil onlyitfter they have completed tlieir growth,
when tticy are KtatJonary and ttieir process of development is dormant.
Foereter stales that tliere are inlands of embryonal tissue in fibroma
which are incrensint;. It may bo snpposeil from this fact that each lob-
uli? may possess an indejwndent centre of development.
The SKAT of fibromata is variable. They are found in tlie skin and in
the subcutaneous cellular tissue. Ujion mucous membranes they arc ob-^_
served less freiiuently than are myxomaia^^^H
The retro-pliaryn^cal polypi form a» ex«^^
ocption to this rule. In the muninia-, tlicy
ary seen umk-r two form* : the urn- consti-
tutes li 8in;;l(.r ni]i.^s which prcsentdt tlie
character of a fasciculated fibroma (fibrous
bodicii of the mamma, Ornveilhier); tbe
other is diffuse, and is accompanied by a
proliferation of the epithelium of the culs-
de-sac and ducta of the ^land. The canals
enlarge and become trans fornwd into
genuine lacunar cysts, into which vascu-
larixed fibrous vegetations, covered with
opitbcliuiii. may project, (c, Fig. 72.)
Fibromata arc frequent upon the pcrios-
t«iim. A point in their dilfcrenlial diag-
nosis from «arcotiia of the gKrrimteum, which
Yirchow in^intM upon, i^ that the former do
not penetrate into the bone, but are limited
to its enveloping membrane.
'Hie ANATiiMicAi. niAi3No«iâ of fibroma ia
easy; sarcomaandmvxoma, in thoircystio
f-anetiea, are the only tumors with which
certain mncoos fibromata could bo con>
founded : but an examination of the parts
external to the cyst will furnish the data
for the solution of the problem.
Fl«.72.
■'.'ïdfltUiï Bbnmtnr Ihthrt^il. Fl-
'IfMi I'fvUlioui |>ia}(c>|g( lulu lb*
tpiihvJiDiB ■! r. HDil arr .Uugdfd of It
At a : b, coDAccliTft (Imilq ooryQAClvt.
LI FOU A.
95
Pswi.sôsis. — These turoora are /u-ni;i» niid gcnorally singlo. As a
aXo, tli^v do not return after lbeîrci>in)>let« aklaiion. lûvtro-pUaryngvitl
Bbroiua any form au exception to tliia law. Molluscoid Sbromalii li&re
cvruin mnli;;iiity, by reason of llitir extension or tbcir consiOcmble
'ilic tibramau, as a class, are more iunoccDt than tlic inyxoiuau.
te.
h
9» Clash. —lipoma.
SY:tONV)itt. — Cruveilhier ha» projiosed the vonl atiipoma. When the
ponwiilciico of tliG tumor was lirnt ami h»nl, it wu formerly cullcil a
itatmna. Cruveilhier named lUe Utter adifo-jitirmna.
I)KnsiTl"N", — 'Hie definition of lipoma ia based upon the cellulo-adipose
sue which constitutes it.
We «lo not rcco^ixe as a lipoma the masses of «dïpoM tissue whicb
tplacc an atrophied or^n, nor do wc tldnk of lipoout when conjùdcring
lio proMnco of a large ijuatitity of fat lu the omentum or other parts in
IpcrsotM with an cxotigenited corpulency. The name should be limited to
ttbnormal ui reunite riU-d ma««cs of udipOMc ttMue baring, to a curtain ex-
rti'nt, a vitality imtcji^rn'U'nt of the mst of thf or;:ttni*in. Tlii* iitilcpHtid-
lent viliiUty î* dcuioiwtrnk-d by tbc fact that a piTMon curryhig one of ilieu
amors may become emaciAted without seeing hin tumor dimiuisb in volume.
DR6rRiprio:i OP Lipoma. — In the phyMolo^cal «tate, tlio adipose ves-
uU are collected together in limited masses or lobulea. These lobules
are also met with in lipoma. They contain very large adipose celU,
«hicb are aarrounded by an enveloping membrane ; the nucleus of these
transformed conocctive-tissue colls is very distinct. Both the lobules and
the cells arc much larger than in the norma! suito.
The naked-eye aspect of lipoma perfectly resembles that of tbc aub-
eutaneous adipose ti««ue. lin pceuiiar struc-
tttro gives it n soflnrss and false fluctuation
which is characteristic.
The tiie of li{>omat« is variable ; Mmelimes
the tninors ar« of olo^aal <lim«n«ion:«.
]n yV.nit, these growlha are lobulntcii and
have eitJier diffuse or very sharply liraite'i
boriera. 'llicy often form poîyjioifi elevaitonit,
and may aometimea hare a pedicle. They
nay be single or multiple.
Concerning their location, lipomata are fre-
quently obaeri'cd in the ar«olar tissue of the
elcin. They bare bucn seen in the mucous
membrane. Tpon serous rocmbmnes, adipose
|)olypi may exist in tlie nonnal stole; such are the epiploic appendages
of the large int^stinv and the fringes of articular synovial niembrsnes.
Tkeao may be the starting point of lipoma.
Lipomata may be found in niu^ruhr tissue. Here the miiMular fasci-
culi remain normal, wbteh i» not m of any Mher new formations Heated
in muscular tissue. Lipomata of bones are rare.
In tbe mammary gland», the new tissue U disposed around tlie galae-
Fig. 73.
LIlKJint. ^.>Hni uf 111» («Ht c<>alala
96
ItophoronscanfUa and the iinni, vtliilo t)».- or^n prv^crrct iU form. Tt
I nw; acquire a volume uml wviglit so cnonnoiu tliut it la iiii]io»i)>I« for the
patient tu walk.
Spbcibs and Vabibties or Lipoma.
ISTSr&ihS: P(tHKi.ivi>MATA are compnserlof uotliingels* than a'lipoBo
tissue, with a verjr small amount of couiieclive tissue surrotmiliii;; tlie
lobales ; the latter are large, and give a distinct sense of a cbaracteristie
false fluctuation.
âi> itfiirih's : Myxomatous ufouata. — The myxomaboiis tisoue i« found
in the lobules between the adipose vestcle«.
Siiwi'ECiE!': KiBBors LiriiM.iTA. — 111 tliem the interlobular connective
tissue is very abundant (adipo-fibnxnft of Cruvoitiiier, niid »tentoum of old
autliont). hy tàtt naked eye, it iniglit bo confounded with fibroma
and carcinomu.
4ti! iti'Krit::^: Krkctilk mpouata. — The vesaeln may be ver; numerous
and ilU tended.
Xutritive alicratinns in lljutmit wliich are worlliy of study arc: —
a. FaUii tle^ifiifrntion: the adipose vesicles rupture and become re-
duced to fine granules ; the tissue has then a çray opaque appearance.
ti. Oaityr*nf is possible in lipoma, and is most trc<iiient1y seen in morbid
masses arising from the pcritonoum or synovial memhrane. e. Calmr^au»
inHltratifti may occur. </. The lipoma may inflame, in which cusc emhry-
onnl tissue is fonned. the fat of the adipose vesicles is partially abftorbed,
whilst the tumor hecomea harder.
Dkvki,i)p«kst of Lipoma. — Since it is in the plasmatic cells (connective-
tissue corpuscles), whether Ihcy are new I y -formed or pre-existent, that the
fat first appears, they may be considered to be the starting-point of the
morbid growth.
PUOONOSI* OF LiPuiiA — These tumors are grave only on account of
the volume which thev rnny altuin, tho iiitiammatory accidents which they
may determine, and by reason of their location.
■ivn Ci,A*^» — Careinoma.
This class comprehend» tumor* which by their attpcct and gravity ap-
pear to he )icp(irut<Ml from th<' nther f<irtnit of tumors, the type of wliieh ia
in the eouneclive tisane, lînt lu'vertht-le**, they properly belong with
connect! vc-tiasue growtJia, hecauAe of liieir onjpn, their mode of develop-
ment, and their constitution.
Sï.soxrJi*. — The word earnnama corresponds to the terms alveolar,
scirrhous, encephaloid cancer, etc., but the synonym is far from lacing
absolute.
DErisiTl'JX, — The word carcinoma, employed at first in Germanv in
the same vague sense as cancer, has of late received a more precise defi-
nition, ba«od upon histological structure. Nevertheless, it has not yet
been sufliciently defined, for to.day many of the German pathological
anatomists do not consider carcinoma and epithelioma as absolutely
di»lii)cl. •
I
ORXEKAL DEfifRIPTtOy OP CAKCtltOMA.
OT
W« wonlil <lelitio cnrcinom» iu Ibe foUowing terms: —
I'arnHnma it a tumar eojn/H'iu'ii nf a Jihrou* ttroata UtnitÎHif altM*>U,
whhh falter 61/ r'/iHiiut'ii''tli'ini' witJt iinr <inother forma ftirtrH'iH* t^tttm;
fArw nIrfAi (in* fillfii teiih free ftll», trArVA art KparateJ /r»M Mfh
lAhtr onlj/ hif It jitiiti mort or Ue* ahuudant,
(ÏBNBRAt Desckiphox OF Carcixoua. — ImI »« stmlj e«ch of IhcMe
two paru — tliL- stroma and the cnnknts of (he alveoli. Tti« ceils eon-
txiiiisl ill itiv ulriK>li in tho midst of nii iiilercellular fluiil Mtlmtance con-
kliuiu-, witli the latter, the milky juice "f cancer. Tlii^ mill;^- juie* U
•tly *']iio«M;ii from Uiv cavuniotM tiii^iio, or t» reailtly ohtaiiietl hy scrap-
_ When Olio examine» tlii« lliiiil uii<ler the micro<icoi>Q, thcrv is alwavA
obwrved a considerable number of celU which preHout an incoDCcivablo
variety of fonn atxl dimensiou. Some round and uninucleateil are small,
me»iurinj; only .01^1 or .010 mm. ; others, «((ually Hphvrical, are more
vohiininoiu, rcachiii;; a diainoter of .OâU to .040 min.,aii'l even more.
Often (hoy are jmly^onal. with obtuse or vvry 8haT]> angle*: such are
the c«lls «iih sharp caii<UI extremities. Nothing can be more varie<l
than lliese fonus. Certain of thes« ecIU ap[N.'ar l^at when they preAcnl
their surface, and ihin when soen in giroltle. They may ho len^hcne<l
into th4< form of a spindlo at their extromitiei, like the cclU of fascicu<
latml Mrcoma. A polymorpliouii analogue, alttiough less pronounced,
may be met with iu sarcoma, as we have seen.
These cells iiicloiie one or more nuclei, aomedmos as many as 15 or
30 in a «iu^le cell. The nuclei Arc targe, oval or spherical, aotl contain
one or more nucleoli, luually voluiuiDOus.
Kg. 74.
Flf-T*.
^H^f
Cdlafrcn k nncar-. ihssUR call-
aii«l«ld|irUla«. {M-utJUtMl-}.
"When tliey arc very Urge. the nucleoli appear as vesicles. The noelet
often have a double cotilonr. Tlicsc forms of nuclei and nucleoli are often
met with in the cells of sarcoma and even sometimes in simple inflamma*
torv growtlis.
Tlie cell.i of carcinoma arc polygonal by reciprocal (rwwure when
they are contained in a cavity with only a very siuutl amount of iutcr-
cellutar fluid substance. The anatomical reason of ibis form of the cells
7
SIS
TOKOBS.
Fig. 7i!.
ii! tliv BUDMï tts t)i)it nhich dotemittioa tlic pavcmont form oF the cvlU of
mticoti* lucnibrniieA. From tliU iinulogir of f'oniis «omc autlion liavo
conclu<lvil Mil aiinUi^ of iiHtiirc. niitl liiiv« empWed tlic torm i^pïtliclial
or cpithclitiiil for tlic desipmtioii of tlio cdIIs of cnrcîtiomii. These colis
<lft iiot npfieiir to have k projicr meinhniiio, aii't thc_v iin.- not closfly uiiîto).
which featiire-H i«Iinr[i)y :><'|inriit<.- thcm from <t\\* of ('|iitli(-1tiim.
Besides the foi-e};oiiig varintioii^ of fon», wliicti nrc innro nr less 4ii«
to pressure, the celU <>f ciiri:iii<imn fXi>ericiii'e <iircra other al lorra lions.
Tbey are subject, like other uell», to all the changes of itutritîoa, such
18 Tacuolslion, vesiculalion, mucoid degeneration, fatt; defeneration,
etc. These nntritive alternlioti» jiive rise to varieties (see fig. 7ll).
The Hlr-ymii, the second eswiitial constituent part of
caa-inonia, is ohtaincl in fraKniL'nts by scrupins. or tty
making II thin si'ccion iiivl afti-rwaide brnsliiiij^ unuy
the eoiiti'nts of thi; alveoli.
It consist!) of liUroiie Iraliecul»: united together and
forming a contiiiiioiiit vrlmle. Kncli trabectiln represent»
^'— v^ ' «lie or more liu-cii'iiH of coniicctivf tissue coulaiiiiiig
f \ /^\ pla.tniatic (;e!l*. The latter become distinct wlien. hr
V^ ^<é**v^y '■'"' addition of acetic acid, the fibrils liave swollen and
^~Y ® ) y-. become Iranspurent and liomogencous (see fig, 7T).
^~y^ ^^ It is especially al the nodal points or points of union
vv' of tratiecul.-e that the plasmatic cells «re scon to con-
tain one or more ovoid nuclei. In thcuc fibrous ira-
liccnlff arteries, capillarica, and veins fonu » very
ri'gultir TH-tw'irk.
Do carciiioraata possess lynipliiit.ics? Scbm.-der van der Kolk has in-
jected them, and Iliudtltiisch thinkit that they form cbanueU around tlie
Ô
®
P
I Collttil inlli. rioin ■
itloK eauccr. ttl»-i-
FSj. TT.
PnelUfd i>tt«iB*«t («rtlBra», dioHluji slnrn. TU* niiuMi i>f nlU nukln la Km*. X^"^
bloodvessels, analogous to the perivascular lymph sheaths of the nerve
centres. Wo shall soon return to the consideration of this point.
DKVei.Or>»ENT OP OARCIBOIIA.
Will!» » very tliin seuiton or » carciiionia i« <'XKimni.vl,ît tnivybc inm]*>
ined UiAt itie atrcoli nri> p»rre«(ly clotioil vuvicicit, butnlivn the srution i»
tliieker, it U verj retxlily Heen that we have to do nitlt a c«wnt»u« tis-
sue, the caritiea of wbieli cotninunicate with one nnotlter.
nKVKi,orME\T or CiiHiNOjiA. — The devclniMiient nf cnrciitnma bring!
m to its niiliirr. Let iis boo what trana|iirep in ihe dflvelojimeiii of «ar«
ciiioriia ill the mt(l«t of Ihhiv tissue.
Wi- otiHi^n'O at tiret jii«t what tnk«a (>lacc in the inBammatorj process.
Tli« phviiomciia of rarcfviii)^ or condonitin;; ostviti» c<»nslitutc tho/r>f
phaitr gr perio-l of bi-Kilnlioii of lU'vi-l opinent tif cnroinoinii in hoiR». î^oun,
bowever, ttic f mbryon»! murruw bccoriius triiiisfoniioii into fibrouit tissue ;
ttrwf'i fibutt: or fihrùv» yha»t.
It ia from thiii newlv-fomieil fibroiw ti«>iie that carcinoma \i il«veIopo<I
bv a peculiar melboa. This tJsaue po)i«e«MS a ftindiitneiital fibrillar
aabstaucc contai Din;; plasmatic or Ivinph !«j)acc», «ilhin which the evil»
enter into proliferation nn*l fçive binh to 'A, 4, or 5 aroall cellti. The
lymph spaced }*row in sixe and constifiite irregular nivcoti with canalicnlar
projections nhich anastomose with those of nei^hborin;; sjwiccs. 'Ilicse
(tpace» aftiT further culiir^cment Wcomo roiiudcil.nn'), ut the same time,
Ibo w\U multi|j1y and grow in tbeir interior. Tbiu the cavernous tiwue
of onrciiioma i« formed.
FI». ■«.
p*ri<ln|»nnni «r raipinniiia 111 ihi> immBi*. A. i.jm'jt, «pmi nbl'-k vnltrj» hf Oi* iniiliEplmllia
■r Ihltr triU 1 at r. xhm-} ha» ]iti>*mcil llii-li lUfiilar fuln , alif, Itiay bale IMkiris ipliall»! and
laiv IIkis IIk »lt*»tl at tui^bobil X'^'
In thv maminary ;:lnnd an Bnalo<;oua dorelopment is observed. The
trabeviilic ut' connective tissue nhich enter into tbo composition of the
glnml nixl which from tlience radiate into the nci-^hborin^ tissue, become
nran; charged uilh juice than in tbc Donnai state, thicken ami Soften.
Upon a tiiin section, it \i ili«oovvre«i that the lymph spaces are in proce^
100
TUMORS.
of Dill nr-p^ni (.'Tit. nnd Ihnf tbcy end, by the |irolifcrntioii of the oclla which
th«y ontuiti. in tin- fm-rnation of curriiiomiUoiis uU'i-ul).
Thii! ililatatioii of tht: lymjiti (t|>itc<-* litki» plaov nttliout ilcgoncntUon
of tlio fiimUiinenUil vuWtnncc whicli, on the contrary, I>i;corh-h more dcuM
under tht! pntfsnri? w hicli the contents of the alveoli exercise upi>n it. Tlii«
pressure, exerted regulnrly in nil ilîrections from the centre of the nlvc-
c]\ti, is tho cause of the sphcricitl or rounded form of the alveuli. (^Fij;.
7H.)
Ill carcinoma of the mamma the adipose tisAUois preserved: the tumor
((TOtTS at the expense of the connective- 1 issue tnthccul»; ivhich separate
the lobules of adipoito vesicles, while tho latter for n long time rctuaio
intact in the midst of the nxjrhid mass. These islaniU of fat, an>;ular
and dis.4«iiiinatcd irregularly over the section of n tumor, have euaM«d
lu miiiiy a time to form, hy the naked eye vxamiiiiuion, an opinion
which lias always heen verified hy the microscope.
At the itame time that these plieiiomenn arc transpiring in the fibroux
trahecidie, the epitiicliiim of uniue of the canals and acini proliferates,
on account of an adjacent irritatioiV. Tho acini become dtntended with
cells, and hypertropliied to such an extent that one mi;^ht be ioclined
to believe in a direct relation between the proliferation of the cells of
the epithelium and the development of carcinoma.
It has even been claimed that a carcinoma is a new gland destined to
«liminalc noxious clémente from the organism, just m the kidney elimin-
ates uri-a. The faUily of tlii* conception is demonstrated by the fact
that, instead of a thorough ablation of the morbid ma»s producing an
intoxication, it is the only remedy which offers even a small degree of
safety to the patieni.
It is upon the existence of this now epithelial tissue in the acini and
j^tactuphorous canals of mammie which are the seat of carcinoma, that
is founded «hat analog* may exist between the tatter and tho glandular
syttem. The force of this analogy is dostroyvd by the proocas of de-
velopment which wv liave related. In epithelioma, on the contrary, we
never see epithelial tij«uc developed in the inu^rior of lymph simce:', but
un embryoual tixsue in the neighborhood of pre-cxiittent epithelial ti>^«ue.
pWhat oharaoterines carcinoma is it» development in the iyuiph space» of
the connective tissue, and the mammary gland does not escajie this rule.
[.\l the present time most patJialogiats, and es|)ecially ibe (ienuau, are
inclined to consider carcinoma as of glandular or epithelial origin rather
tlian as developing from the celUof the connective tissue. In support of
the fonncr view, {(indtteisch says, '* the majority of carcinomata proceed
primarilv either from the epithelial clad surface of the body, from the
skill nuit mucous membrune, or from secreting glands. They depend
upon an abnormal growth of the epithelial tis.'tne." liillroth, in his work
on " .Surgical I'athology," " maintains a strict boundary between epitlio-
liat and oonnective-ti».*He cells," and says, " true cai-cimuna have a forma-
tion similar to that of true epithelial glanils (not tbc lymphatic glands),
and whose cells are mostly actual derivatives from true epithelium."
This writer even goej so far as U» say that " it is impossible for an cpithe.
liai cancer to occur primarily in a hone or lymphatic gland." Waldcyer
defines carcinoma aa an "atypical epi^ettal neoplasm." Uirch-llirsch*
:
DRVELOPUKyT OF OAUCINOMA.
101
fpM also acce))te UiU definition of WaWcyer for tUft hisU>ffm6i\a of
Hcirrhun: )<ut ilcscribes as cn([oth«liiil cancer a Uimor <l«v(;1opeii from tho
«tflfitlK-Ithl <:«IU (txistin;; in tissues, and Uiorcfoni of comivctivc tissue
origin. S. ijamufil, Cohnlit-im, Kli'bs, mxl l,uck«, nil consider caroilK»-
mau to have Uicîr origin only from njûtladîml c«Us, «ltd iiol from the
contieclivMiMUC c«lU. Kudiiew, of St. I'etcrnhnr;;, ui hi» vork on
general nnd iipecial paiholog}', L^xpreH^o^ hiraAoira» tielieving in tlici «jii-
tiielia] orison only of carviiioma. I'erha]» all of ttieic diverae omnion.s
preaent a pan of Hie truth coucemin;; llie nature and origin of carcinotaa.
Bui dies* are wroblemu mliicli shoulil not. in the present statp of our
knowledgi?. W lïojpnaciirallj" decider!. It rcmuins for future invertigutor»
to doicriiiliio tJw relative influences of proliferation of the onncetivo-
Umi».' corpuscles, of the cndotlii-lial cell, of the epithelial cell, vrhcther
K)ai»)ulnr or inrestiu;*. of tho wxniloriu;^ whltv corpusclct, xiid of tliu
infective power of cerUtJu elements, upon the f^-nvMs luid the i-xtcnsion
of carcinoma.]
The iHi-rivisr »/' tlit tumor i» either by Ui« growili of iu own mass or
by invasion of iK-'i;:li boring tLmue. One fiiid.t a proof of the growth of
oircinoota Ity proliferation of ita own iL^'tue, nhen upon sections of hard-
ened pieces, one recognizes in the iraheculœ of" the fibrous stroma,
1yiB|)liatic spaces, nhich arc distended nith cells, and which are in pr<h
oeu of conreriion into caruinomaloiis alveoli.
Fig. 7».
a. AlifuU of ib> urclnuDii HIIdiI «lib «(]!•. i. I:]iin|.li ipH»! iliuwu Ig ifc» gbisn, utH» afiar
Growth by invasion of neigiiboring tissue is i^ontinuDiu or diaeantinu-
ovs. Wlutt is meant by thctte phruites hns already been explained à
propos of «areouia. lloili of thcte modes «re common in carcinoma.
Tlie i/enerulizalion or the scooodary production of tumors in dia-
t02
TCUOHS.
tnnt parts is alunjrit, in carcinoma, prwoilecl bj » liv|>crtn)|)h,v witli inilu-
rnlion of Ilie l^-Liipti glnii<U iiiln wliicli l)i« 1,vinphnticM from tlio hiinor
eiii|)ly-
Wliy in carcinoma t)ic jiatliolo^ticDl tiiiHtie which itioiit easily bii>1 most
constantly <le to rmincx lesions ot' l)ie lyinpli glamls? It is becatise iJif
nli^rtili fif t'arei)M>nii fmrnttnifnte wlththf Ijfmjthtttie ventl» of the t*tm»t
and «f the Hàifhborin'i ti»»ue.
Thin truth is dotnoii8iratfl<l Xty tlio stmJy of preparntions made by the
impn'i^iitition of nilratt- of silver. ( Fig. 71*.) Tliis is & fact «f tiio j^at-
c«t imjiortancc, ami wliU'h ju^tiiics the aiialo>;\' cltiiincil by us between
(.■arcitiomn anil tomicctivc tissue.
Ill caivinnma thv fibrous tiuuc pro«cnt« a hyperplastic aberration of
certain of itrt clcini^ncx.
1'he lymph ^InmlH in carcinoma ;^n«rally, though not always, exhibit
the structure of tlie primary tumor: but thoy may untlergo Biin).1y a
fibroiifl transformation. It U in this fibrous tissue that the alveoli will
form if the orij^inal growth is roprotluccd. Tins fact, which is often very
cviik-nt, has escaped llio authors who have prec«do(l us. It has foru8
great si;;nilicauco, for it adds to the support of our view of tlic uattin» of
carcinoma.
SPBcrKs ASt> Varirties op Cakcinaua. — ThcM species are based
neither upon the At^ nor upon tlie form of tho ctfUs : the latter, in effect,
are mually small in a young carcinoma, and, on the contrary, voluminous
Fit;, so.
BtlrrlioB* ntnlsomi. CiKloon» tlmtilitt Bi*iBmn, o. r>---i
Pitllr fofnrJ carr-Lhtjiiift U*«ur. r\ Cvmiuvu'lu^ oli-Atrlial'
of Ult nlMl^n vl AinimA and mitt \ti nfLrrhiiH. d, H^Uff! r '
' .1* 4f {<>nf#r r«n«. 4.
>■ (In-r ■ »|.nu«UUOa
in a carcinoma in full licvelopmont ; tlieir round or polyhcilric form is
solely comn'cted with the greater on lesser tjuantity of iniereellulair
fluid. It is upon the amoutic and tho condition of the «troma that tho
species of this class of tumors dei)end.
BXrBPII A LOIÎTDÂHÔÏHÔMA .
103
1 WT SpBcfKs ; Fimioin CvnrrsoMA (S>niniir!').— When di« trnWouIw
of tlif Himinu arc thk-k in proi>ortioii u» Uil' me or tlic alveoli, nixl are
minMnt, nif Iiavi» t<i ilo with » Imn) or xcirrhoiu carcinoma. The HbrilUr
t8]^>ot of tlu> tmU'cula* i» not marki'il ; tltii) ti^auo coiHlenwa. becoincfi
li«in(>i;eD('»i» m*<i rtTnictiiii;. SoraotinicA a ratt;r ilcgcnQration of cli« qv\U
ill itio iilv«-fll) is sc^-ii : tilt? cells may break itonn, llic fatty Kraimles
net free in the iulorcellular tliii<l are tlien Immi' airay by tlio lymph-
aiicï ; tho fibroua ti<<suc may t)i«ii contract »o tlwt tlie alvci^li winch
contait! only a very small amount of 6ui(l and sook fatly gniuuli» be-
come almost efliced — the cnnililion of nfr<>/(AtV WrrAwj. This atrophy
is sc«n in some jxiint^, vapvcially in tlic central portion» of t)i« ffrowth,
which thpii yiclil no jiiici-, whili- the pi'ri|ili«ry of the tumor shnvn alv«oli
contatnini; iKith ct-lN ainl juico, Tho lymjili gland* are very «juickly
involved in tlii» form of tuinor. Uy iti-condary mi;tA<HaaU the growth
coiiatantly but hIo» ly invnilo* cnuM nf the or^^ana and ti-i-iucs, whilai the jm-
tnary niorhid rniu^ luay incrouo ouly wry alowly or not at all, or inay
evfn uiolor^o atrophy.
•2u Sfix'iKi?: KN<-EPiiAtjiiiD OR Mbiuju-arv Carcixoma. — In this form
of carcinoma the fibrous irabtculre arc narrow in proportion to tho di-
ameter of tbo alveoli. Till- fibrous ti&suo U not very reiiistaul, coii-
M'lpiently hcmorrLn;;ea remlily ih'cut.
Upon section the «uri'ncu of the liinior
sofi and diventelv colored — molded
lyi^i-white or pink, and red, yellow,
:■ hrown.
The primary tumors grow much more
rapidly in thi^ form than in scirrhus,
but then melasUAia is lesa extensive.
We may distingnUh teveral varieties
of encephaloid carcinoma; —
The yultiiffOM» form, m which the
tit'iic io soft ami the alvcoU are i^o volu-
minous tliat llivy can be dist)n;:^ii«he<l
by tlie nakei) eye- Hy prrsBurt- the
growtti exudes a very thick and al'unilaiit
juice. The erertih hiratnli}iie \i often
iMociatcd with tlie preceding form: in
it, the bloodvcMels, which are very
numerous, beeome dilated into diver-
ticula or aneurUmal sacs, viaiblc to the
nakeil eye as little red pointa : tJiey project into the alveoli, and may
rupture, anil ;;ivc orî^n to blowl extravanttons therein.
The softness of a» cncephaloid carcinoma mar be ontirely due to tho
presence of only an extrenu-ly omnll amount of librous tissue, the akeoH
themselves being small, bui »epant<>d fnun each other by tbin trab«cula!.
Chan^e^ in tht: nutrition of the elements of carcinoma give rise to the
three followiu;^ forms: —
:{ii Spkcehï: Licujutuus Carcixuma. — The cells in the alveoli become
filled with fat drops and resemble adipose colli of connective li«Aue, but
iir It* (limll Uii lb* tbiiiga» <H tbtli
«kllL ■■IbaUIUraaillmniiniUU.I*.
Thn Ui(> «plltiallil •tII< iir 'unmcdïlHï
lOJ
roHORS.
there are no Iiandi nf conn«clive tisane
which hold tliem u>;;et!ier Tiiesc lumora
so <;roiit1y rci^cnililc lipimiita tlint tb«7 amy
bLTomlilv iiiistukcii for ihu latter if tli«j ara
not c»rcmllv Htii<lii-i). In tlicw ouce the
celU arc iiotiWstnijoil. Via have won rd
exainplo of mciai^tuitU of tliiit spccim of
carcinoma whi^rt- all tlic tiecoiulur^ tumors
preaenteil the jiame oharacteni.
4tii rii'iirit»: Ci)LU»ii> CARi^i;(t>NA
1'\m metAinnrphoaia of tlie oella of tlits
apccie» of carcitioma givea to it « char-
actvriftic gelalinifonn asjivct vrliicli ia r«-
proilticpil ill the ei-voii'lnrv forinatioiis,
Colloid onnivr lins al«) ln-i-ii ciilkil <UiV"tar,
which is an objcctiouiiMo wo^l.lKvttiiM- nil
c&rciiiomBtn nrt* alveolar. The aWuoli of
colloid coruiiioma d» ttot e»^eiitia)ljr diHcr
from thow of the other apecieii : their tta-
T)Ocul»! art awn cn^ilv neen oiil;f bec&UM
the alveoli are filled «ith coll<nd matter,
which i« more or less transparent. (Fiss.
7ti,82, 83.) The cells bt-come loaded with
drops of colloiil matter. Wome «plicrical, vesicular, niid finnlly dc«tro;ed.
Those which rciuiiiit are aomeiiin.-« colossal ; tliuro arc tlicu otây a few cells
fdUvFivlii'i'l I .'11 1. a. A Unr*
4. M*tl>«i Htl. e, C>1U luAllralnt
Willi nllolJ williir. ». ('(II alJril
«Itli • mllgld 4MP. «. t'ltli inJaHil
U ■ dlak la pnCMu u( 4«lrii«iati.
Flg. 83.
Cslldd I
»e«vL abowlnc lb« Inner mlT*<iJI. wltblo «hteh l«rmiula«d thvffvlftHftoa*
in CAch alvcoloK, in the midst of a fluid al«o colloid. The alveoli tli«in<elv««
■re distended liv thî* fluid, ftnd hare a rcziiliirlv spherical form. .\it \»
the Cti*K with «11 colloid de^i'iieniti'ms. ht;n> also there in united with it
fioine fatty de'.îeiieratioti of the cell.'». The Ktromn of the tumor occasion-
ally may he ao Utile moitified that tlie lilin.^ of the connective tissue are
Tery distinct ; at other time» the irabeculte are (edematous, and their fibrila
HBLAKOTIO OARCINOUA.
lOS
an separated W a amnli amount of Hui't. They nlao may hnrc uiulcri^nc
eolloi'l mobimoqilio^iâ, ami )iavc 1>c«n doalroyal or v«ry rniich iliianw).
One ibcn finds an aurrautiious canity, fefltooiie'l at it4 jH!ri|i)icry, simI
ïlioniiif* very fine întercroâsing Gbrils, the reroaiiiîi of tliin Iniliecutiv fonn-
in« arvM of rcx"!*!" circlM (m« fifi. 1*3); a immlier of sncli «nfraciuous
cnritt«s, with Bumo more perfect alvooU sro collMt«d together into a lobule
bonlcre4),lM>wov«r,by ImiihIh of fibrotM tissue. It is this disposition which
enu)Ki)< the naked eye appcnranoc of alveoli, and whicti has sug^jestetl
tlM> namp " nivcolnr euivinoma." The forcKoing alt«rations aw some-
ùm^A aocomiKinii'd by dibitation of tbo vesseU which nay nipturv and
givi* rise to «xtnivn.^a lions «f blood.
5tii Spkcius: MKi.AXo.('ARfiNoMA. — U is more rare than mclano-«ar-
ooma. Ilie celk contained in the alveoli arc in contact with each ollieri
and present in their interior melanotic ;2:nitiitle». Th« tnib«caliv may also
be intiltnited by the same granules, wliich are then dejwitited aroiiud the
Jila^malie cells whicb tliey contain.
Indepeivk'iitly of the forc;îoinK characteristics, whieh are reproduced in
ih« >M-con<lary f»rmatii>n«, many cnreinomatoiis tumors may present modi*
ficatiuiM of iiiitriiion which «crvc to «etabliiih varieties in each of the
preceiling tijweieM. Theso art: —
a. Fitlty lifjrHfrnthn. — All cardnomstA. cspwiallv at their centre,
|>reseot traces of fatty degeneration. The parts thus alwrcil are yi-llow,
toore or less dry. and ojiaipie. The d<'^riiiunition may also affect tlio
plasmatic cells of the stroma ami the ctiiiilliiry wallit. <.'oiiM^cutive to
tmch a dei^lruclion of portions of the growth there resnils a retraction
of the tumor, fn the secondary deposits in the serous membranes, as
in the liver, this atrophy is chanictcrÎKcd by shrinkint; of the central part
of the tumor, and iimbilicatioii of the surface. In the skin, and {utrticii-
larly in tlie mamniit:, the atrophy shows itself by a dopresdou in the
rorm of a hard and callous cicatrix.
Rg.84.
6, C<ueoHt M'ianuyrphogU. — In all tumors of rapid pro^rcs^, e:»pe-
Ctally in carcinoma, ohtiteration of the vosàels may occur, when there
often reaulté a caiteous deguneratioo. In the portions of Uie ma^i de*
106
TUMORB.
or iii.i_v ocTii
privvd or blooil, ulceration amy take |>Ihco wlien tin- liiinor h Hiiiierlîcial,
or an iiilarction result Trhen it U dccji ^eaUii. Thede iufarutioiiâ also
bocouic cafleous.
<•. C<tlrarf»u» infiltration i« very rare in carcinrttna ; nevertiieleaa, nu
the vidnitv of bones the stroma laay oX|>t!rience tbi» ctiaiij^o : tliia is wfaafcf
Itait Wuii wriinglv called aa^ifvin<; carcinoma.
il. tnH'iiiii'iati'iH itivl ul'-^ntli'iu of •■arriuoma may follow Irauiiiatism
or iii.i_v 'HTiir ill tlir onliiiary srowtli of tli« tumor. ■
caoi-'fi w« oIiBcrve îii iho iu'îf;lil)ortiooil i)f an uWeralioii an
[iroUfcralion of the cellular Henicnl* cnntainu'l in tin» nlvi-oli, tliu
!uu pri'M-iilitig nil till! oliaravtcni of ombrjonal celU. The
■Ireoti ilifagijioar hy liccomin;t l<"t in a mnxH n( cmlirvtirml tissue, in tlie
binidtit of wliicli are ^tîl! fftuiid a few of tlie lilirou» tntbeciiliR of the cancer
Pstromn. Thi-i itiHnmtd tumor. ea|iedally at the tturface, is extremely
Tiuctilar. A similar embryonal ti-ana formation is never observed in the
cells of opithi'lioiua, as we aball see.
«. VtUoiië t^rfiHi'm't. — \VbDt«ver loay be the species or variety of
Careirioma. when it affecte a cutaneous or nincoud surface, w see griuin-j
Utionit arise «oon aftur uW-ralion. Thc«c villous bmU have n iniichi
greatvr length than in a simiilc ulcerHliim : they are nuiiii'rdii.i, andl
nreined closely together. It i* these which have jiivcu I" the tumor thii
|main« of tîHouh carcinoma. The vesceN which the villi contain majrl
ntavc omall aneuri^mnl dilatntioiH, tind may he the |>oint of departure of'
bcmorrlia^es more or le»* conKiilcrabh'' and re[«alcd.
Anatomical Diagnosis of Carcinoua. — It is very difficult hy ib«
naked eye. Carcinoma has, in effect, hcon confowndcd with all tb«|
malignant tumors, an{l evcti with infarctioiia until nicounu has been tiad''
to microscopic analysis.
The preaencfl of the so-called caiicer-juicv is not a sufficient charao-
teri^iic, aa we bare a1rea<ly «et-n. ;\nd nu i)hall iwe that a similar fluid
is found in soft ejiitbelioma, and in lymphatic tumont ; tiih is §o aUo of
infarctions and sometjines of ti.i.tuc» attacki'd by a diffuse suppuration.
The cells of carcinoma have of themselves nothing cliai-acterislic. It
is necessary to discover the presence of an alveolar stroma, and of
clum[<s of cells contained therein. It is not from the study of scrapinfcs,
or of the Juice of carcinoma, but only by the microscopic oxunii nation of
Ibiu sections of the tumor that wc can be assured of the pcculiiw nintc-
Inre which we r^tcOf^nixc a» carcinonia. Tlur >iiicd:il alveolar arningo-
meiit of the stronm of carcinoma, will always diElcrentititeit from sarcoma,
in whicli we may perhaps meet with fibrous tntl>eouliv parallel with the
Teaaels, hut neldom regular niveoli.
An atrophic scirrhua mijïlil be taken for a fibroma if we did not rec-
ognize the alveoli, whicli may he more or less efl'aced in the atrophied
portions, but which are unmistakable at the periphery of the tumor.
The [litTeroriiinl dingno^a from epithelioma will be spoken of when
considering the latter.
l^mjNosia or CAJici!fOMA. — The termination of carcinoma i» always
fatal; hnt thu duration of the disease and its malignancy vary accunling
eifHHA.
107
ïta Umî itpcciv^. TIitM Uiv ptillncf'oiis nr «iicephaloùl form moat rapidly
. kCi|uir^^ a contti<tcm)i)<- voIiiirk )>y inviMÎoti of the m-i^cliboring tissuos.
IScirrhus. eapeciitlly llio niropliic ïiirictjf, i» rcniarkuWc for Iho slight
I tendeucy of the primary tiiiiior to <-^t«-i«l, fir tlio >>l<iwtiv>i» of it» pr»;;n-tui,
and rapccinllT for lite coruiiDtjr «f iM j^cniTiilixatiofi, irliidi ia cxtciisive
ID proportion as t)ic ittAease is older.
it K difficult to «Iccide irbctlicr the Hecondary meUstani» in dkttc closely
' eoniivctcd wiiU tlic parlkular variety of the tumor or with ita loug dura-
8f:\T.-~0nrcinoroatn may develop primarily in all the oreai». hfTtMi^
aro iiiuHt frix|acnily mouUhI iii tli<; ;{laii(b and in the viscera wbk'li aro
lined «itlt luuoouii membniiic, partîcuinrty th« stomach, ttifi utenia, thq
mainiDa, etc.
Here ends the «tody of a data of tumors chamct^riwd liy a fiypcr^
tfopiiic aberration of the cellular clemenU formed in llit- Ivinpit ?[<iici-8
of the conneetire tissue, the ty[>e of which 19 in tliv conncctivit iiKHno.
W» now propone to examine a aeriea of tumon* in wbich ilio same eli-inenta
atrophy. 8uch aro aypliilitic growths, tubercular formations, aixl ^lan<
dor', 'nurse tlircp sppcica of tumors have this in common, via,, tliateacli
of them is connected with a general constitutional disease.
Otii Ci. ANN. — Ûumma. *
In an anatomical point of view, the mosl charactoristic le«ioiM of
Sjpltilis are gummata. Kvery syphilitic prodiict is not a gntnina ; most
of the lesions of syphilis present no analoniic^tl iliâeronce from tlio^e
cau?c<I t>y jiimple inflammation. The lissions deiermineil in connective ii^nt
by hard chancre, do not esdeniially differ anatomically from those wbic))
inflammation produces in the same tissue. The celU resomble those of
iïrantdation tissue: they are embryonal, round, or fusifom) ; some corre-
spond to pun corpuscles. Thev are situated in the midst of a fundamental
tubstancc, nmorphou» or fibrillar and rm^itiint, to which the chancre owes
ibs induration. If there l>e unytbin<; which may ilisiin^nish the tissue of
clmncri- fnmi iinliniirv i nil» minatory tissue, wo think that it will be found
in this lundniiMfnlal sub^tanoc-
Whcu imlumted clmucre heaU, the enibrvonal tissue which form* iu
tiase. tends to form adult connective tissue. All the proilucU of (he first
period of consiiiulional syphilis, and all the malformations ol the second
period, consist of inflammatory tissue which poaaosses the property of
refonnin;; the old Itaeue, and which may leave no trace behind. This ia
00 more true of lesions in the skin than it is of lesions of the same sta;;e
in the deep parts, for example, in the parenchymatous or>{iius, the peri-
osteum, and tionc. Therefore the division of syphilis into primary,
Mwoniary, and tertiary pcrioii», whcRi the wonl secondary is applied
to cutaneous syphilid*^*, and thv word K-rtiary designate» lesion» of lli«
bones and the jmreiichymHta. dot-H not. n]>|i<-ar to us to he correct.
It would he nearer tlio truth, from the anatomical point of view, tf w^
TOMORB.
ehnulil term tfondftrfi ttie mirt-ly inf^iiminatorr Ii'nioiis of evphilis, nnil
terti'trn th« lat«r losione wbicli manifest thcnMolvcii uiidisr ibe form of
For u goofl iiiiik-rstniiiUn;; of tlio pHthologiciiI |ihonnim*ua of ^y[ihiliB,
it «fill \i<! xwvf^-vws to stwii_v «liiil occur* in encli tiwiie iiml «acli organ.
Ill tin' boiH'* wo olwpn-c. ciit^miiornry villi iho necoiidarv acoi-leiiw,
the rliuumntoiil fininit of KicoH : lti«y are not iliic to peniianent le.iion.t.
L«tcr wc we maiiife^lei) chronic inflainniations at the surface of the boned
(j)RrioHtitiii and reauliing perioatoses). or more deeply, oateitiH, which may
at firi»t lie rarefying, but which subsequontly ends in the condeiwalion of
the osseous tissue — (lie ohIiterntioD of tho Harersian canals, tlie latter
occurrence often detorniining necrosis. At a later epch veritable guro-
mala may form.
In the liver, at fintt we have iutenttitial hepatitis, cither ;;enerAl or <àf
camscriWd, but always chivntctcrized by n new foniialion of fibrous tisuM.
l^tcr ;;<'nuine j'nnimatA appear.
In the twlicte w.- also hare to do with interstitial fibrous pmdi)ct«,
afternanls with ^uminata.
In the hin^ an tnremtilial syphililtc pneumonia mity be <lifliiM> or cir-
cnuwcrilied. Tliis lesion of the liinj; liss reeeiveil ilifl'crent naines. Iiorai»
and liohiii called it epithelioma of the lung: it is the vrhtte hejiutiita-
tion of Virchovr, which other authors regard aa gumma. Il is neen
in new-bom children, and up to llie age of ten or twelve years. To
a certain degree ita characters ap-
4 Fig. St. proaeli the stnicture of the luiij» of
the embryo. In syjihilitic pneumo-
nia the înter-lobulîir eonmsilivc ti*-
ttue enters into proliferation and
present» n larj^o i|uantity of embryo-
nal celU; the alveolar walls «re
thick while the narrowed alveoli
are lined, and even filled by t'pU
Ibelial cells, whieli are of the pave-
ment form in contact with the walls,
round in the centre of the alveoli.
As the process progresses the ejM-
theîial colls become fatty degene-
rated,and suhseipicnlly broken down
and ahiirirhed. while the rmbryoiial
interalveolar \\*»\w rapidlv organ-
ise« into fihron* tî»siiu. 'fhus rc-
iiultic a small fibrous tumor. In
this tissue a gumma may ultimately
develop. (Kig. H.").)
Syphilitic fihromata, such as have
already been mentioned in the liver,
testiclt, and Inn», may show themselves in the akin and other organ».
Ordinarily they exactly resemble fibromaui. and mav undergo similar
«(«generation». There i» nolbiiig in their structure wdich could charao-
teriH them as true ^umiiiata.
«fphLUIICIiit^ndlUl jtnaBiu'^aUrVofii «ptw-buro
chilli- 4- l'rDUf^tnUQfl t«nii*0it«t UAfld«nr Iha
Xuwt- 6. pAi*m«Dt o«n> ■rr»air«d ftr^artil ih«
■litall, a. I'm iphirlMl «1I> U \\io iilwIL
«. Y»*«i>. xax.
D88CUIPTIÛX OP OUUUA.
[ Autlion an not in accord as to the position wbicb syphilitic (^mniata
■houlil OCCUPY anwui! tutnor».
Pesckiptios ok Gtmma. — (ïtimmnta nw tiinioraof vnrinWcslM', which
an; »n difFiiMcly Joioivl wiih tlit: riv^i^liKoriiig CiKj»it<.'ii ihul t\wy ptMMtM no
«Itnrp botiii'larjr mhtch cnn Im: rvco^iixoii, and for ttiix reaMD thejr cai>-
Dot i>v tMiuclt'atc^l. NuvvrtlielL-A)!, they Ion» an elevation u|xi» llic surTaoo
of organ* wlien.^ tliey are de*eIope*i. ï#c«ii by tlie naked eyo, u|>on wo-
tioD they Bpfiear to W c<>ii.<ililute<l by a jimkish>grav, more or le.<u va«-
oular liwn«, «itliout Jtiict-. Ttiis al>tionc« of juice, joiiwd to the firnmea
nf thrir tiiiAtip, at oik« âc])arates them frooi granulation tiMue. Kxain-
idiiig »cr:i|ûiigA we fiud colls of Tarions FonDS and siiu-'s : a. embryonic
celU; b. fuaiforrn or irre»ulnr eotls; f. smaller atrophic coUs, ntvasuring
.iHtn or .(Kiij nnn . almottl entirely R1I«H by their iiuvletu, imck«d ctgoo
to^etlmr in a K>'aii)ilar fit mla men ta I sulMttinou. But die elvincnttt Ihua
obtaiiH'dby serapin«arvix>tsulfioivnlfnrthe raoognitioiiof ;;ninii>ik.mi1<-«((
vc also lake into a»;ount th« characters of tlic rem of the tiiuiie, and tho
pnMeiM »f devclopiiient.
rnder t)ie n>icr(Mwo[K>, a thin aection from a gumma in prooew of evo-
lution, preMnt« a series of itodulett, each imtweRflinj; itit own centre of
formation, (Kij;. 8lî.) These no<lu)es are nwre or toaa >liiitinct, and are
Fig. 87.
'""^J^^^^SI
waniHbiDt (nirrh fnn llt«. a. Crnlnl
kn>. fr-fnti-WolRnaalaltHUHH. r.lUiHi.
Thflpirl;hrnlp«Rl«*(an«ia>*t«iMR>snk
lu Ik* kllagjr, ibiiHlaril» •iu>II'«ll*<Kni>aU-
Una iiHua !■ lb" inunubiilat Uiioo. X a")'
reeognixod by the fact that the cclliilnr clement» of their central portion
are antatl, and have fallen into a luok-culnr detritus, whilst thoac of the
periphery arc larger, rouiul, or fusiform, and are confounded with the
neighburin;; embryonal tisane.
'Vhc nodule» tucRucKes are very irregular in their fonn an<l their
dinwmionii, avenging from ^^ to ^^ millimetre in diameter.
The hhiixlveâwl» penetrate to the periphery of each nodule, and may
ramify there. They arc pvnnoablo and contain blood even when tho
centre of the nodule U in a state of atrophic de^neration. (rummata are
very radcular while they are developing. The intcrnodular embryonal
or fibrous tissue always ia rich in vc^ielit.
Gummata in process of evolultoo are rarely found upon the post-mortem
1
no
TPMOBS.
tahle ill tlic ndiitt, but
bom cliiliircii.
froquciitly Bcvti at Uic aHto|i^rj> or new-
The duvcloiimcnt of giiinnio w of gri'nt intorcnt. We recoguiae t¥fo
ntirxCK ihn'r )• ■ •ukII iwlird iBlJittitUH. t. I.Hslaa or lamlatinlti «••all- X^'''^ {INiufc
periods : Th« /k»; ;)A(1«^ cannsts in the prdlifcrâtlon df conductive tiinuo
or «f no nnulogouii tisimc — ^for example, iho medullary Hubstancc of bonv.
Ilfiirftttiitf In ll«Biautlofe of lltv, **eaBd ■Ufr. it. Hiidd baad* of a Hbrvo* HBnMH» ilatat^
Vlllcti It t«7 rtfli I» (A**!* irtlliogi dltilnrl «ill», uil i> lioundfil (owmdi S bj an IntfiroruJ
Ufti u( TOitOf CDDUcelli* lk»Df. I. UrDUi» ul »tBl of Iht III» slfh Ibrti p>tliib>i)' lanllrudl
In the liv«r, in the first plnee a miihiplicntioD of the clcmenta of the
interstitial connective tia^tuo takes pluce ; but tbiit iutcr«titisl hopitlilia is
I
■
k
very «lifTerent to that which one fiaAa in onlinnry cirrlioflùt (a» «eon in
fijT". Ht* nud Sit), In ainiplc cirrlio!ii« there is « jirolifi'mlion of tl»e ii*-
teriobular connective tissue in sucli a manner tb»t the lobules are B«pat-
nieil from cacli ottier l>y wido baoil» of new connective tissue. There is
* consecutive atrophy "f the hepatic lohulcs.
Id 5V[ihilitic interstitial lit-piitici». clic proliferation of the cells of the
Mwinectirc ti»ue lAkcs plaeu it'^t oriiy betne^u the hcjialic islamic, hul
alto in their interior, aloa^; the capillaries up to tlictr entrance into tlie
ecnlral vein. It naturally results ihkl ihc trabccnhv of hepatic celU arc
«Tcrymherc surroumlcil by cell* of new formation diapoAcd in rows.
This coiKlition is iwcti a» w«ll in ih« now-bom child m in the fictiu uul
adak.
When ^umnuila are about to he develo|wd in the liver, Ihi* formation
df embryonal ttiiflue takes ]>lace cither throughout the or;;an or in liiiiiicl
pointa which are to Itecome the seal of the tumor. The new liiisue,
which accuraubiles in masse», become» riitdled with numerous vessels.
Then commences the •fdH-/ jihnrf of development of gummnla. The
cells multiply, ■limini'^h in siz^'. are compressed against each other, and
then- are thus prmloeed. in places, little nodules or irre;;uliir islands, in
which tite central c<*lU are atrophied and «^nular, while the peripheml
mIIh are more voluminous and present the character, of nmhryonnl celltt.
The fuwhiment»! eutwtance is va^iely fibrillar, and resembles conuec-
Uve tiiMiM).
In Itone, m ivroliferation of the cell» of the marrow occurs, and there
Kflulta an embryonal tissue which fills the o&ieoiu canaU. The o&seoua
trabecule become thinned and absorbed, thus giving rise to latije medul-
lary spaces in which the gummatous nodules form, by the same manner
of growth M in the liver.
(lummatB arc developed in an analo^ns manner in the skin, in the
»nl)Ciitiincims adi[>o>ie ti^ue, and elsewhere.
Their ultoritir uliemtions have in)l yet been well «tuiltud. In ^umma,
mueim» uK-unioritbnvi^ is never seen; but, on the contrary, a peculiar
easeoiu state, charrie te rixeil by it:« conni^tence and duration. This c»n-
aistence sufli^efl for the differentiation by i)i« naked cy« of ^ununata,
which arc always hard,even when caseous, from infarctions and tubercles,
which frequently soften when tbey have reached the caseous condition.
Gummatn of the liver which have exbted for ten or fifteen years,
often exhibit siut^ulsr characters. In the midst of the liver which may
have preserved, around ihc gumma, ita physiological condition, we find
angular miU!H.vi of a whidsli or yellonish-whitc tissue, which are very
den^c and hard, vrhich creak under the knife, and whtuh are surroundei)
by fibrous Umu«. At these [•laces cicatricial depressiotis exist.
'niese maw«« may exist at the surface or in tlie ilepth uf the organ ;
their extent may W nuch that the liver i^ ilivided into two part» by the
new tissoc which ':>oc.'upies itit centre. This yellonish-while lardaceoua
tissue, studicil in extremely thin sections, kIiowj the characters of gum-
matous nodules which have undergone defeneration.
Between and around these angular masses exist fusifortn or stellate
groups of fatty granules, regularly disposed in concentric circles, am]
ecparated by a fundamental fibrous sulnitauce. One might, at first si^^lit
113
TDUORS,
Wliï've Unit thc)tc grnup«orfftUygninu1e«corrcs])0ii<IoTilin'1;totlie pUt-
(iiatic celU; but «tu'lyin;; xUtm morr cIcMvly wi- »ko Unit Riaitv Itclong to
spaces, more or IcM Ivngtliy «mi wnioliDic» niile, nli'ich reprisent tli«
di6|>0Ai(ioii of Uic Ivinpli cJtiuilx in the fitiroiiA tiitniie ; nrnl we »re niilii in
couclmling that the (t|iiietrs lilk-d Itj- these groiifitt of fatty ^raiiiilci» are
lymph veswia atuffe<i witii the fat resiilliii;; from the .Iccoinpositiou of the
niorbi<l maflH. The tissue between aijil aroiiiul these aii;^lar kniaceoiis
masses is vascular, irhile the entirely altered nodules themselves have no
vvssuis.
Is this peripheral filirout tissue of n formation contemporaneous vriib
thnt of tlie nudulra, or i« it devclopeil suWeijuently ? The Utter eas«
i» the more probable. However Uiis may be, it is by nivdiis of the lympfa
lVCSScU that the prodnot« of decomposition of Uio nmlnlc* are abitorbeii
when, after yielding to proper treatment or to the processeit of nature,
the (Çtimoui diminiNbes. We have proof of this re;«orption in the circum-
Stance of cicatricial I'ctrac^on of giimmatoiiiS products. And «e bave a
positive proof of the absorption and disappearance of gumniaia in th«
.akin and suhciitnneuus (issue, a disappearance which n<ay or may not
'bo followed by cicatrices, and which is easy to observe any day at the
clinic.
8rat of Gumma. — After the skin and the snbcutuneoii» oolliilar lixtuf^l
the or;*nns which are most frcijucnUy the scat of >;ummata nro first tha
liver, then tlio kidncvs— where the phenomena are identical with ibortc in
Ibe liver — the testicle», and Uie liones.
Tito ASATuMirAL uiAiisosis uf jitimmala is easy: they cannot be cou:>
founded with fibromata when carefully esamiued; their differential iliag>
no»8 from tubercle we will speak of à prop»» of the latter.
The PROUNO^is of Kummata is j^ravc, because tbey <lcslroy tlic tissue
where they are developed, and finally convert it into cictttrieial tissue.
It is therefore readily eumprehendcd how, in the dîUcrent organs whero
tliey arc developed, they disturb or suppress the funcUons. Their grav-
ity, however, is very diffciTiit from that of curcinoma, for they do not
give place to secoiidury foniitilions; iind they may be arrested in Uieir
course or even be caused to disajipuar under proper treatment.
Grn Ci^sH— ToberonlosiB.'
The (piestion of tubercle, brislling with contradictory opinions, îa i
oWenre, but li^ht coniuienccM ti> dawn upon it. KoninTly, every eas60ll
mass «as called tubercle. [l.aenneo*s Uiesiit concerniu;; the gray granu-
lation and its chanjie into yellow tubercle spread a welcome li^ht over
the nature of the entire process. The re^mblance of the lesions in dif-
ferent or;ians was explained by the axiom that there was «^«dy one |^thiu8
— a phthiitia tuberculosa. Lacmiec's views soon spread widelv; but oppo-
Ùtioii to Uiem, never entirely tiknced, has been more vigontu every
> Tbt^iiuliJvDl iDaltrr iritliiD tli« brnrkirlii Uni mainly hivii nbi tr net rd «1 moat vMlmliiu
ttojo Rlndâi'liiv)i,.\(tli'l<T TiilH'ti-iilonla. /I*'iii»i-n'> r_vi'li>)in~li» .if Mi-ilk-liiiv ficui Wcxxl-
W.inl. Mi^ll;*) nii-1 Surtciiwl HNtvr/ v( tli<- War •>[ lliv KcliL-Iliuii, umxiikI Mril!i«l
Volume, Bnti (rain Wagncv, Manoa) vt (iviivint I'atlit-logy.
TIIB8IICVL09IS.
m
^
' year since 1H4-I. Tlic objection «omwiitly urgeil tij^iiinst Iactiivcc's «loc-
trini- wftM llinl mottl, if not nU, t)ti' iHicm* miuiHeM found in plitliim-al
hm'Z» nif «tmj'ii' prwliicw of inHiimmiitirm.
Virolin» fotiiiileil h »«'«' Hoctriiio, Oint itn jimccji^ vet» 10 be callctl
tubercular uiil<;.4-i gmv miliary gmnulcfl were fflumt. Vhetay masses
coulil he formed from tliielceued pun, and other cellular forma tioiiji, u
well M» from miliary luberclea. He aluifwl entirely removcfl pulmonary
plithiâia froiD tlie domain of tuWrculosis, and considered it to be allo-
j^thor a choesv broni;ho.pueaiDonia,
Thiw the ciiain that imd been fonn«d of tlie tuberculous nlttbîsis of
dilTiTetil or;;anB by I.aonnec and his followers «as broken, and th« m0)>t
important link — jniliDonary nhthisia — wait alu>;;ether taken away.
NieiDcycr was thu first clinical t«acher who boldly adopted the neir
dootriiM}.
The exprrinwnlal patholo-^iM now took up the question. Villemin re-
virH tbc old opinion of tin: inf^-.-tire character of lubtTcuWi».
\.oug Iti'fore, Itnhl had pronml^atod t)i« idea that miliary ttiberculosU
waa a " rytsorjuion iii*i!a«iî,"
Virvbow ba^l fiecn ttiatinalmojl all casesof acute dinteminated miliary
tubi-rcutofiiii, chee.iy masMs could be found somewhere in the body, it^u-
ally a cheesy lymph ^land.
In the cxporiiuenial inoculations, therefore, it «as interesting to note
that in aome cases the miliary tubercles wore found in greatest number
around a choeay focus, as if ihv latter wore the point of inoculation and
resorption.
In this way, the miliary tubercle tost snmewbal xtn character lu a pri-
mary Icdon, aind iieemitd r.ither to be n result of resorption and depend-
ent upon certain anterior condiliiins.
Waldciiberg demonHtrati^d that " in certain animals" tlie manner and
matter of the inoculation are of no conges pie nee. Xexi. Cohnheira am!
Fiaokcl proved that "in certain animal*" it was not necessary lo inocu-
late at all, and that the formation of a focus of suppurative inflammation
in I rabbit or <;uinca-pig was aufScicnt to render the animal tuberculous.
It ))ecan>v evident that the species of animals cmpkiycd for cxperi-
taent \» a mattvr of importance. In rabbits and gutnea-pi^, any focus
of irtinilent iTiHiimmiition is vcrv apt to puss into the cheesy condition.
ft seems very natunl. therefore, to siippoçe that the predisposition of
these animal» for tuberculudis is a conscipicncc of their disposition to
cheesy intlamniatio4i, and that Ruch aiiiuiaU become inoculaleit from their
own inflammatory producli'.
Thus far reached the experimentm on animals. Their principal ohjeot
was to demonstrate the infectioiut nature ol liiherculoflis. and the exisit-nc^J
of a tuberculous virus, which, like -typhilis, could bo transmiit«il from one
person to another.
A TciT remarkable and significant fact is the great similnrity between
the predisposition of "certain animals" for tuberculosis, and the almost
exclusive occurrence of tuberculosis in a special K<^uip of persons, the
«crofulous. It is a characteristic of the constitutiounl disease called
"scrofula,"' that all the iiiBammatory processes run n peculiar courue.
Therv is a well-marked tendency to protntction ; tbo inlîltratiuu dîsajipears
TUHOKS.
TQiy gradiifilly or it ri'mnina Btntionary niiil iinJcr^os ro;nvwivo "tti
DiOTphoM» of « cliiH'»y i-lmnicUT.
Virobow fini cftlU'<l ■lifiition to the [iicdoainnnt celUiltr clinrnctiT of
thft soroltilous exiKlntioii, nn'l iu liv[ivr|)la«tic nature and to tliv low
vitality of tb« celU which coinpoHv it*.
UiiiiiHcUcli ndiled that fr«»li scrofulous exiulalinim contain relatîvcljr
lav'/e colls with glUtctiinji; proloplasni, and a iiucteiia in the aot of ac^-
tuvntatioti, or conCaiiiiuu; a double nucleus, lie received the îiapresalo»
that the mij^raiii)^ white blood corpuscles in ecnfulous persons have
a tendfiicy to {"row Inr^'er on their nny throuj-h the connective lissuo.
Thi?_v i^welt up by tho imbibition of albuniinouti «ubstanceo, unt] by this
very swelUiij^ iliv and slowly dei^ciienite.
riK 90.
in*me»Uarnl>liiry labnntr.abUlnrd fc^uwa'sr. I. l.irtnUbtrcl* «llv i. Smtll tnhttU «IW.
.1. Xai1ui:«Dau> •■II rurrriMi»!». I I'laa inrilitd Iitlvork Irim (h« lDI*rlM ol altUtf lub*nl«, Ih*
The consci I nonces of this peculiar anomalv of ve|ï«tsUoD are felt in
ftll ihfl înfianitimlious of scrofulous persons. In scrofnlous cntiirrh atten-
tion liHs ton;{ been cslled to the abundance of cells and thv thick,
(juickly-dryiog character of the secrctioiis. In this form of ciitarrh iho
exudation corpui'cles Hi; »" thickly together that they form n layer ex-
tendiii}; to the epitheliunt, awl there is an infiltration with round cells
exieudin;; deeply into ihe submucou:' tlwiie.
Many "f lhi-«! celU ;;radiislly wander to the free ^«urface aud are east
off. others pa*H into the radicles of the lymphatic ve.isels, while still others
undergo a granulo-falty degeneration. Their detritua is {lartly min;;led
with the lymph which Hows from the inHamed tract inlo the neighboring
lyniphittic glands, and [mrtly t'ornis an element in the secretion, in which
fine grannies, possessed of molecular movement, arc constantly found.
It s><emB that tbe fonnntion and transportation of the tubercular poison
)H eflecled by the formation and transportation of this deiritu».
In scrofulous inflammation there is a remarliaUe tendency to [ternianenl
intiliralion of the alTected tissue. In simple influinniatiDn the infiltration
is a temporary condition which terminates in jiuppnruiion, in organisation,
or in resolution. In scrofulous inâamuialiun lUv only termination U a
TDBBRCVLOSIS.
lis
N
eelliilnr infiltntion of «onncotiiro tissum, which converts tbem into a bkrd,
dciiir, j^yisli, semi-iriiniiliitieiit nuuw, wliicb conslibUes tlie acnitt of tlie
l>rooc». In liuch « matt thi> MooiIvmsuU bccoino ooclu<t<>J, nml Uicti
necrotic i»roc***c* eniiuv. There \* no cvidcnw; thai this scrofnlouD intïl-
tnttioii is cajntble of noy olhvr lliim tlt-jj^noralivc vlian<^. 'VW\« <ic;:i.>in'-
mtion hegim as a cl»'*?sy imnnfonnatioTi, f\r*t of the centre, then of the
entire iufiltmlioa. After the cheesy dogencnttion, caltùËoatio» or «often-
iny may follow.
TliP final •lc)^ncr»lion of the acrofiilouî infiltration i* oHected by a
chemical mptninorphoHi-t, which convene it into fat globule», albuminoii.t
frmnulcs. nml n i|iianiity of soluble suh^lances which cannot ho seen. All
thCAf- su)>«t.inccâ miiHt nec«aaarily be ahsorbcil.
Now, when «c consitler that ocrofnlom penons nre cspi-cially [ireiiis-
powd to tuberculosis; thnt tuborculoels nitnlly ercr occurs exce]>l in
•crofiilouH persons: that tubcronlouii phthisis i* only ft combiiiaUon of
flcrofuiotift inllammution uikI luhvrclcs ; and tlint in tlic scrofulous an
inflammation brin^pt with il Ihc ri^^k of luberaiilo^iit, wc «an hanllj fail to
see that in certain men, as in certain aninutlti, inflammation runs a pecu-
liar courtie. The cheosy inRamniatiouH and aupptiratinns of nnmeroiis
membranes elabontle a f>oi<ton wIiIl-Ii. wh^u ab.4orbed, proiluoo.^ tuhcrvles.
This conBlitut«a the real relationship between scrofula and tubencutnsts.
The tubercniar ]mison, in moat cases, is tlins manufactured by itio |)ativnt
liimsclf. and it has not yet been demonstrated that this poi^n can I>e
tmnsmittcd to perfectly healthy persons, ao tUnt the disease can hardly
be coiuidcrcd m parelV infi-ctiom.
There in f\nt scrofula, tlivu a cachexia from the absorption of scrofuto;i3
prodoots. I'he intensity of this cachexia ia only partially revealed by
the irruption of miliary tuhcrclei).
A scrofuloui cliild ha:* n protracted arthritis, from which the joint
becomes the seat of a .toftening caseous mass. The <letritus in contact
with the deceased synovial membrane is absorbed. There results from
this absorption first a local then a genera! lulierculoiia.
In another scrofnloos child, a catarrhal intlammation of the small inte^
tino is excited, the adenoid tissue of the mucous membrane becomes infil
tnit«d with cells, which subsec|ncntly brcnk down and are absorbed by
the lymphatics. Then there are produced miliary tubercles atong the
eourse of the lymph rcssels up to the mesenteric jilaiuU— Aioo/ tuler-
tvl'>»it. or the vims may puss bcyornl and infect the «ysteni, when ^neral
tubr.real'-n» IS esl^ibli-nhwl.
UindHeLwh niv] ijchilppel bvliero that scrofaloua ^ands are alvsjs
tuberculous.
The lymph glands in luberoulosts, as in tlie case of malignant ttimom,
are the situations in which the new growth is developed in tlie clearest
and best defined manner.
In tubcrcnkais, as with nuilignant tumors, the snolling and ohstntclion
of the lymphatics may cause the disease to remain for a time localized in
tlic -{lands. We know that for many years a scrofulous gland niay
remain as the only trace of youthful scrofula. It ts eminently proper in
such cases to extir]»te such a ^Innd in order to prevent the gradual
ial'cetion of the whole bo<ly with tubercles.]
116
ïi'uona.
PiK. 91.
Tun ASATOMY OF TniRitCLES. — Miiiarv tiiVrclos of tin- «he of a
millet Bec<l are inFroiiiont. Tiioiii- of tho mho of k p(i)i|>y ^ei^l nrv more
common. Even tliv snmllcitl noiliilea vitiblv to tlic naki-d eye are made
up of still smallur iioiliilc:< — *iibmilinry tuWrcli;». Tlie latter raeattiire
From i to 1^ of a milliiutitre in <liiiiiieliT, no itml fmm forty lo filVy of them
must be s^fflomcrated to make a nodule as large a» a poppy seed. There
are no definite limita to llie .line which mny he attained liy the agglnm-
«rmtioD of suhmiliary tubercles. Nodules as large as a pea or even a
wnliiut are not uncommon.
Miliary tubercles or gr»j frranules arc haol, and fonn a relief;
tran.^pnretil when recviil. they soon bi-come opa>fue and yellow at tho
centre, Tliey arc most Fri-iiueiilly surrounded by a red<lish «-a^icidnrixed
xone. They may be dincrvte or confluent When cimHuent tlu-y fonn
yellontsh niaMe». which are tDtpoMiblc to be differentiated by the unkeil
eye from caseous inflammatory foci.
I'ndcr the microscope we oOeii meet with cells n* larjço ha m earci-
noimi, and containing a great number of i)iicl«i ; tbei-e are oflen al^
fusiform ami embryonal cells, but the elcmencn which predominate are
very email cells, measuring from .004 to .ixi!) mm.. t)ie nuclei of which
are surroiindcil by atn--xtremt'Iy ^raall amountof pro.
toplasm. Tho latter are embryonal cells undergoing
atrophy. The reciprocal arrangement of those cells
is very important to study. In euvh submilinry
granule cnn be distinginshed a peripheral proliferat-
in;; XQiic, in nhicli cxlit multinuclear cells (^unl
cells) and fibro-plajttie or spindle-form elements — a
sone sometimes roncb more extensive than one would
suppose at first view; and a central portjon (fig. ill)
whcro the elements become closely crowded, and
atrophied in proportion as the centre is approached,
anil finish by failing into a granular detritus. All
these clenicnl*i acerete around them a granular or
lihrilliir funditinental jubslanee, which afc^^lutinatcs
and holds them very firmly united together. By reu.^on of atrophy and
molecular destruction of tlie elements, the centre of the small nodule
beoomcs opaque and friable.
The vessels of the centre of the nodule are never permeable. This
bloodK-asni'ss is the cause of the trau^lucency of the tubetvle. A» ex-
aniiriiiticiii of tht'se vessels shows that their ohltieralion is effected slowly.
The obliterated vessels betray themselves by their contour: their
lumen i* filled by a coaguUim of granular fibrin. In the midst, and
«»j)ecially at the border, of the granular contents of the vessels are found
white bloi»d corpuHclos (A, fig. 94), elements which are distinguisticd
from the adjacent elements belonging to the tuberculoua granule by their
larger siae and by their regularly cireuiar disposition within llio vessel
•rails.
r [Besides the cellular, granulation-like tubercles, such as arc met with
in inoculated guinea-pigs, there is n fibroid tubercle which is most fre-
quently found in sypbilitic-i. and a lympbadenoid tubercle, which occurs
in the scrofulous. Itap[iears then that the iiklividual constitution noi
(ïu" I'l" 111" t'rnj [i"iIuL«B
Injiri Iha litnif tb t CAA« of
ktpfl Lb Ibr rvulrf- (tHA'
fframmaMr,) <9r(tn.|
■
TRK AKATOUÏ OV TUBERCLES.
otily exerlit nn ii)l]iioni:« an the prediaposilioD to ïtM>culitîoti, but also ou
tb«'rorfaortb« Uikerele thus produced. Acoonlitig to «onto write», a
Kg. 92.
Kllliry inWn'a In IM pla maUr. Tba d«ll*d llu IddJett» lb» Drlirl°>l •'>■ it II» ■ii<«n<aUt
Hiliil'. i. Tli« lrB|>li>Ui itMlk. V. Til* blvtiliwHl. r. rfulit'iulun a< *Un>B(i «Kbla lk«
•hoib. X HA
tal)«rote-;;raun1o con«t»u of reticulated tissue, inclosing in ita meshes
certain cclluljir clumouU. It hu, on tbid account, buvn termed a cyto-
»«.•
Ltsftlidliai Tinr of «I (iMrtola «( in* pU
■■lartllb» <unn*k»Kaiii or lb* (•nilll'ir*'
Mlffkborb'wd <if • mbfrflï*- a. Kltfuiculk uf
l]r»pb ibmb ii yroiirimiloD. i, Cnu bi^
M«B)at BBMbUr llinsof tk* middle mat.
XdW.
Iti al'iiii. 11. Tutich'uiir liime. i, wbUr blwd
latpaariot. Tbcirti L« boFB ■ loWMh baVOlTlbC
Rente growtb. In t,lie word* of Wagner, the reticnluniiï^nerally similar
to tbat wliicli h lountl tn iiunual reticular caniicctive tinuc, «xcept Chat
tli« fibre» of llio network are sautewliat broader. At tlic poriphcr; of
118
TtUORB.
the nodule, the filtres are uauallv broador anil donwr »nA llicir course U
nearly oiivuUr, do sa to form a kind of girclli; around ttie wliulu tubervlc.
Kx. M.
UDltlguclMttdftDd bnuicliid cell! |Kl«DI-Br11ii| (n»u > nriri
f*VH»Mfe'ftiTii«11xctfQlLimuuk with ikdAilBuolil rrlifqliL»
Fig. n.
A rurilon at * (i«j alllM) In*
bnicUnf tl-F liinr. •t««la« tkt
I0rttm.i
(Sco fi^. 95.) Thi* roliciiliim i.* void of l>i"()dvc<»cl*. mil in Uic jntmeest
tuWrcIvs it M ver^ »cittit^' and ^oft. Tlic reûcuUitn il)l;l<>.■^'f c<dliil»r
ciiMiienLH. Iteitidox :(nitill rotiui] celU,
F'g- 07. very HÎroiUir to lencocvteit, and more
tniuiite an;£ular Wliea, tliere are aluo
8«en — usually in tlic centre, rarely in
the periphery of Uie nodule — one or
more «o-cMeil /•■'ii/nurleiir •jiant •tH»,
(Kig. S"!.) ^l'J^^■ol-cr, cells are con-
stantly foniid of nil tnlcnnedint); «ixc;
tliey aro viulot1i«!inid in character. A n-
ihora are divided conceniing tiio si^iifi-
cauco and tlie coii--<tancy of ùiv pres-
ence of so-called jfiaiit celU iti tuber-
cular jirowthfl, some con*iilering lliem
as a constant and essential character-
istic of tubercle, others denying ihe
oxtstciàce of true ;:;iani cells in thcs«
fonnationa, while still otbers fail to
recognize in tbeir presence or tlieir
eoiistiiution a peculiarity of tubercle.
It li»-* lii-CTi iilrcaily luciitiunoil ibal
ttieae so-called giant cells are not uiirre'pii-ntiy fourni in inauy olhur
formations.
jL luulllCbatlDHird r^tl, frum Iho liiiv Iri
■ tAtt uf dliriïiild (ihEhUW- aliufrllbi; a
ïëttf onmliffrif obelpl with brtfbt aaelf-
TUB AXATOMT OP TUBBftCLKS.
lia
Acconling in KiTnttlci.'icli, lln" size of llie UiWrclc cslls in scrrtlulous
tntiorvlu i« imuHtutl. thev are tnice or Uire« liintia aa lsr;;o as a vrltilu
Wood cor{itinlt>. At tKe name time they are more lii^ihly rcfnictivo. itivir
nuclei are siiarply defined and often shininj;- The tiucloï ma/ he !•«;;-
meiited, hut do iwt go on to the formation of ci>lla ; thi-v «iia|ilj |midiic«
iDullinucU'Dr colls, sometimes ;^nii[ cells. Iti ttiia way Î* i^-otliiciil a
|ii.-L'uliur lar^* celk-d ;;erminal ti^ue (Me tig. t>0), wlitdi lUndtleiwli
rCK»i^U as a specific (Toiliici of »cri>t'nlou» tuticrvnlrMi.i, IK- onnsidor*
tissue to hv the acme of tin* proceM, iihich i« m>t.Alway:i renchod. Ilu
thiiik« that tilts lai^ celled tiuuo it^iially lornu ilie middle portion
of Uif Mtibmiliary nodules, while ai llwir pi-riphery there prevaiU a «mall
celloi) inHnmniatory ;;r»wtli, which gmdiially Wcoraeit cotititiuoiif with tlie
iiomial coiitifctivv tii'.-'iie.
Ill liii titudy of tulK^rviiloâis of the intesttuea, WoodwanL' ^ivea a so
R£. flB.
Bsall latMreldBlba nbntiein al Iha lli'iin. X )^- '- C>*tnl BfUia [I)roiptiaII*l mimmm:
II I* «tiiBv^ klib (naulhr flhfiD. io vlil«h LjrmpiivM 4l«Diftki»,uduu LheikrrlrlrvrT.Qaitvibiiltl «Ik.
ttrt labtdilbi: tnJitaEioii* dT % lJriiUiii|( ^nii, Hud ikl h mokII bniDli «fn AJ»fi v^vn. In ik*ht'4jn
■ntatJ ih'<«ntr4l Afnrr, art" n'tm*-r^n» 0piiii»1>f oa^loBl^l vnddtbvL i hi r^ilït. Llko iV>*r kudicftlvd k4
fr- Ifaofifi of 1hP«« c^lU^ r, ■ «ackuIa Ijiij» r«rEik»l< TKor* tr« ■!"* piiin«r<]a* ij'm|>b«Ld nit» *irrnH|>
«i toqr It ludtialtJ &I f- A amnll ■«la,.', iiftt'i«« EhrvUgh Ih* m4rcln of tl.« lul.rn^I^^ Trar*.» uf ft Ab-
f1iUr«,l HbnttfljT* d*aDp nHitfi«t* H«ft w<r7'*ta»r*aiu*l.1«tb«t*virftL nMu^v.liHirttiaiha'UiiiffbU.
(PrvmpbM'-Blenicrftrh. b/ ïinnu J. J Wumlmnl. IT. s. \naj. I'opind (tva (b* xfon.! bhI;**!
laliiaHatlhelUdlalaodSBrclnl Hiiiurf «t ih* nraiitib* B«tiflll<iii.j
clear, and. as we th'mti, ■^enrrally ncctirato description of the oiiiiuie
anatomy of lub«rclc, tluit ne have inaertcd it hero almost verbatim.
' UhIImI »nvl Sun[i«Hl Hl»l<irj-»if lli>- Vftr of tlif Rrbclllot], part mcoiicI, mixllral
voliimv, J. J. Woodward. Sarguon I'. S. .\riny, ]>. ."iflj.
120
TUMOnS.
Accordin;* to hire, the smallest, prcBumabl}- tlie jounscst, tubercle granu'
latioiis in the submucous connective lUsiic are from ,^b to g|a of aa
incli in tiianii-ur. or even 1ar;?i.T. Tlic sections of these ftW sonenilly
ruiiii<Wii or ovul in form, uml liountlcil by n <lLstJiict1jr rvco^^izablo vx*
tcriml wall, like tlmt of u Mnull vein or lymphatic resM-l cut across
(»cv fig. !tS>. The space within tlii>i bciiniilBry i* usually filled with ft
granular or iivli^tinutly fibrillated material, reHcmhlinj; coafpilaied fibrin,
entai);çliii;; in itM «iiliâunce a inimher of cclU; some rciwinMiti}; «tmlo-
llichal ele[DC-nt<4, am) the»» uiuially lay on the ))(-ri]>hery ; otherii, ami
these llic roost numerous, ordinary lymphoid cells. Ouwide of the limit-
ing wall of tlie central ti;^ire the ^çranulaiion is made up of two kinds
of cells: large, oval, nucleated cells, corrosjiondin^ in size and form W
the snollen cndotliclial elements seen in shronic inSammJtttoiis of the sub-
iniieuus connective tissue of the iiiteslino; and a swann of small n>u»d
cells resembling ordinary lymphoid cleiuenta. The relative nuinbor of
these two kinds of ccIN varie* very gntaily. The small round oolls
occur sometimes in modeiiite numbers, cliietly on tlie {wriphery of die
jiranulattoii; soiaetiuiert they infiltrât» all [lart-i of it, and arc so nu>
merouA as to obscure tlie targe oval celU, which, however, with a good
'*.
'•y:-:sj.-
■Ml ruiH b^B >hri]»k tnitjr fniu Ih" «mil «jp lb« t***'<l. If^vlnf % *|ia«4, k, Iq cbc vkliLiff of th»
•tqtffKl Jjrtaith'Itc til* «««Uoii p^Mrtl ibro-i^h é ti>dou» n4J«Iv. #. Tho aufrouudkai; nkOhngilT" iMo*
Imkr\vr«pb« \if Kuryroa i. J. vrnvdirAnl» V. K- xntty. t^ttpifd troto iha ftewad iti<dl«U tMlan* of
;
immersion objective, can generally still be reco;*iiised between them.
A II these elements lay in the meshes of a fibriltawd reticulum, continuous
with the surrounding connective lisjue. WoodwanI is inclitiod to inter-
pret the significance of such a figure as above describodas a section of a
J
ItKâBNERATIOXS OP TUBBROLB.
121
ic veBsel. a^einjs:, il) thin, vitli Virchovr, rather tliao with Coniil
invier. who rcj^r^ it aa a hlooilvca^cl.
For him. a lar^c fibrin clot. comjJctcly lillin;; the rossel an<I cntan^Uuf;
Ci-lliiUrc'IcnMntu in it« interior, fornm ihc round or ontl fi;;iirc avvit m tiio
ovntn- of tiw youn;; tuhcrvk- ^miuilutioiij. It ts cwy to U(i<k-r#t»n<l lh»t
SOUK) of thouc fipireit, if «hrunkcn l>y the potont infliiencf of oliromic ftcid,
wiitilil bear a ittriking rf«4>mhlaiic<; to th« <lo«cri]ition of giant cell» (fijç.
Oil). He, thervforo, reifanU tlm Hovalled f^niit ccIN, in inttnlina) »iid
peritoneal Inbercle^, a# Ëgurea r«»ultin^ from the action of chromic acid
on seclion.4 of )^-mpluit>c veiuoU HtnfTed with cofti;nlat«:d fihrin and cells :
and thinks that the larjce emlochi'Hoiil elenientit of ihe primary lulxrrcle
gnnulAiion outside of the central fij;ure, are formc<l b_vcwlar;;cnient of the
tixlothulial elemonte of the lymph spaces in the connective tisane. The
di«cej- metamornhosis of the tubercle granule appears to comniencc in
the contents of the centml lynipliutic, but it speedily invadrs tho ifljaoi'nt
exterior elements, and then all trace of a wall )« lost, and the central
|ioriiun of tho tubercle appear* Micnply occupied hy a -jruniilnr muM, in
which dhriveUed nuclei arc imheddi-'l. Ho believe* tliftt the devcl'>j>nH'ut
of 1» minute lulxtrele Atart« hy th»; fommtio» of a fibrin clot ohsiriicting n
stnall lymphatic vessel, and dint the lymphoid elomcntit groufied around
the veascl at tlie (loinl of otHtniction, are pmlmhly a Hwami of migrat«d
white blood coqtuAclcs, while the lar;çe emlollielioid cell>* arc produced by
tiie gradual enUr^enient of the fixed eorpuacleii of tlie area of eonnectiro
tisane involved,]
Varibttbs of Tcbkrclb. — ^Tubercle {granules are discrete, or by tlwir
union they fonn diMiuct laasses of the «zv of a pea, a hazel-nut or walnut.
IHfTttf. tubercle gniniilea are «orrounded by a iwnc of proliferation in
which ve&teb exidt; lliiii red zone inake» the •granulation itself very |iromi-
nent, for the latter it Ï* aniumic, :«einitninsparent, or opu({ue.
CoHJiHfnl ;;ranule:i are unit«il to;;cther, oft«n in great numbers, witliin
a common cnvelojiing mnsA of embryonal [i.**ni». Kaeh of the nodules
proiicnbi at the centre an atropliy of ila etemenis, ftimilar to that which
occurs in jïummata. In each granule the rei»eU are early obliterated,
while sulM«>|ueiitly th« Teasels of the surrounding embryonal tissue are
aUo clo;frd. iVfter that, th« tubercle gi-anules, being no longer separnicd
hy a ra^^cidar »>ne, are lost in u common anEcmic ma^^a, in which it is iro*
]>i>Aiible hy the nitked eye to recogniKo tho iinlividual nodules. Very
soon the whole ntaK« become* unifortnly opaiiuc, and niny soften at tho
centre or tliroughoul. TIumo casroas nodules, when they are luuat«d îu
the lungii, are often rejMrtcd, eren hy experienced ubservcrs, as caseou»
)»ieumonia. The lun^ are not tlte only orgtuts i» which confluent tubercle
may
he met with.
NlTTHmvs Mo«iFio.*Tto\8 OP Timiiiinj;. — Tubercles appear not to be
[capable of an absorption similar to that of syphilitic gummala. The cica-
trices which aiicecud them always result from a mortification and an elimi-
natin;; ulceration. We oHen find, however, at tlie apex of the Itmga
caseous foei filled with a suWnncc almost solid and calcareous, isolatc^l
in Ibc raidst of an ludurateil tissue, Itut it is impossible to détermine tho
TUMORS.
origin of »iieh foci, wliic^ mity 1ie ri!iimia'< of infarctions, of abaoeas, or
of ililAl»ti«ii4 of Immclii Kv]>arnicitl from llie rent of IJie bir^possages, m
vr«ll at omlrixed tubcivuluuA cavitieti.
/'rti>''<Mii it';i<-ni-rati"H is coiisUint in every olil tubercle. It has Itcco
attriWte<l to oWiteraûon of the vessels; t>ut we fimi also a dc;;cncriiti;iD
of tlie same ktiid in ^iiinroata, tli« vcaacU of wliicli romiiiM jwrmciblc.
The caH«oii3 siatc of tii1>ercl« instead of ima^ nccoin]uimc>l )>j indura-
tion, as in ;'umma, ends in the soficniiig of tlio tubercular bum, ami tU
conversion into a focus tillud with dotriti» nnd fr<;e eli-incnbt which may
diHuhar;^ into n mtionus ciinal. and \>w rupliieed liy un iiWr or h cnvem.
If llic liibcrciilar mass reninin incWcd in b dvc]> parenchyma, it nmy
mi'Ier^o drsiccution and eiitcUSaitinn.
Dkvklopmkst of TitMRRCLB. — Tubcrclo i« nlwaya developed in the
miiMt of an emltryotial tissuff in such a nmnnc^r that the tuhcrcic ^franule
is constantly sarrouinled by a »one of proliferation. It arises from the con-
nective tissue. Thus, in the Ucor, the granules developed iu the inter-
lobular tissue are always procoded by an interstitial hepatitis. The
development of tubercle i^ranulcs in tlie bonus is jireueiled by an oslvitid.
that is to say, by tbo formation of embryonal tissue in the nivdulUry
cavities.
Ontinol tubcrwle originate from epilhelial cell-i nx well »« fwm the cou-
neciive-tis$ue element» ? We nurselve» have obnerved the epitbvlial colls
contained in the alveoli of the thyroid body proliforatt- ami take part in
th(.' coMstiliiùoii of a tubeanilou» noiluli-.
In the Umg, the tiibert-le ;;ranule eommonly spring from the inter-
lobular, peribroncliial, iLud ini^r-alveolar lïbrous lis^ue. Hut ne also
m«ot with tubercles wiiich oucupy the interior of several alveoli, the
clastic septfl of which arc still preserved, In such a case the embryonal
tiiHuc projects from the alveolar walls into the interior of the alveoli, and
it is possible that the lining V|iitholium takes part in the formation of the
new «mhryonal tiwue.
[Accordin;; to Hiudfleisch ami nearly ev«ry other writer, it is froai tlie
fixed eelU of the vascular connective tissue sy^ttem that the miliary
Mihercle oriiiçinate^ — the enilotheliura of the hloodveitM-U and of the
lymphatics, the endothelium of the serous membranes, and the fixed con-
nective-tissue corpuscles. Many of the more recent authors rcKard the
formation of a giant cell as always the first step. On the other liaml.as
wc have already seen, numerous mvestigators not only fail to rccognixe a
dpccinl si;;nificance in this cell, but some even go so far as w deny the pre-
sence of true i^iaiit ecll». Kimltleisch thinks that a ;;iant cell is DOthing
more than an cnlar;;»'! endothelial or connective- tissue cell, with an
increased number of nuclei; and he has found them constantly and
lias oft",'» useil them as "jiijtn.postJt." In the smaller tubercles he has
luualty found them at the cenlre, in the liir;;er at the periphery of the
crannies. He .states that uo special reliance can bo placod oo them,
for they occur in non-tube renin r new formations. He reganU the
greater omentum as the most favorable tissue for investigatimi. Here he
roco'jniites the smallest tubercle as a nodular swelling; of a sin<^le non-
, Yucular connective- tissue trabecula, and says that tliis swelling is due
DEVKL0PU8KT OF TVBEHCLE.
133
•141 (!■
■fe»nc
I ft 1»
entirely to a growth of the fixwl coiinceitvc.ii«uc cclU, »iiii of tlie
eiiilottioliAl L'tflU iipuii llii; tnibeculn. lit- iil»o ailinitH Uint ttiv eii'Iotlio-
liiini of ttii: Iyiu{)ti iin'l l>l(io<J cnfiilliims itml Iui^t vi.>sm;1s pmlilcraic iiikI
may mif-ply tdi- cv\U tor the fornwlioii of s ImIktcIi' f;rnniiliili"ri, ami tliat
thr «rnllji of tin? ciipillurivM in ilic iirt)^li)>nrhootl of the tiilM-i-uli,-'' Jttv in a
•tuti* or [iniliffiration, recuUiuir in a jiartial olrlitcration n{ iheir lumen.
1l' l)clio^~vs tliat <rhen a tuhcrcle litu« passeï] tlic firal ^lajcc of ica ilovel-
noiit, it ititHf bccotueii an irrilatit of t}ie connective tiasiie in wliieh
, i« flitiiiilvol ; and that from this time on, therefore, the proihiola of oniî*
narv inflainiuntjon hecotiw iiiixeil witli llie Hjieeilic tuljercular [iroilinrls.]
With refl|>eet to the iuiimale nature of the tuliercle p-annles, (liferent
^opinion» have bee» advancoiJ, Foerater ran;^s tlicm anton;; tumors con-
^■titiilcil by lym|ihati<; oclh. KiDdlleiwh deâcribeaa reticulated liMuo in
^Huborcle : but wo cannot ruco<;nixe in this anytliing else than an artificial
^Kardeniiig of the inivrcvllulnr substance. No snch tiiisu« can )>e seen in
^Hio frcsti state. Virchow nlso conaidcni tubercle as» l]rin{>)iAtiG product,
^^hth<, for him, friimmaut arc nnah>-{ons to "ranulation tissue.
F Wo nm unahh- to admit such a radical diiiiiiction l>ctwc<'n luherclo
I and ;;umnm, hut coiii<tder both as a kind of fibroma in which ihe «ell
lletiiont* arranged in n«lulo« atrophy tit tlie «entre of the lattrr. There
k no rccof^iixalde anatomicxl diffenince, if accotnil be nut taken of (ho
Hitt« of t)in obliterated vei»eU in tubercle,
f [No(«ith.*landiiig the ureal ooiiftict of opinions, not only concerning
Bic minule anatomy of the suhmiliary tubi>rcle jnanules. but al*o re.
jnnlin;; the aiiJit'Mnioal hiMorr of the funeral disorder comprehoixtod by
lie term tube run losts, the folloviug propo«îti(Hts Diay bo coustdorod U
rltrately well established: —
Finit, tliat the di«eM« w of an infectious nnturc.
8«cnnd, that the inlectinj; matter may fw produced within the nr)ranii<m.
Tiiiril, tliat it has a cWe asMOcinlioii nttli the ciiiteouf de<:euc ration of
nflauauatory product<(, and tiie Hul^i^ipient liquefaction of tli«sc casuous
prtxhicM.
Fourth, that certain animals as well att certain men (the sorofuloiR)
peculiarly prone to the caseous deftene ration of inllammatory foci,
to self- in fee I iou ibroufjh the absorption of a s[iecifio tubercular rirua
ifaich appears to be vitalised, if not, indeed, generated, by tlie li'juefao-
'dh of s«uh caseous maasea.
Fifth, that the formation, caseation, and subsG<|uent partial liqucfai:-
m of intUumiatory foci appears to constitute what may he regarded as tho
St active or f.rimarif êtwj* în the production of tuberculosis. There still
n» to be mu«h doubt conoemin); ttie real inoeulabilily of tuberenlosis
Dm one individual toaitotber. It iHTory probable that it is only certain
redi»}--jMd individual (the sorofulona^ «hof undur ordinary circum-
ancea, are capable of being inoculated. Kven in them, while tub«r-
Josis has unitoubtedly been excited after an attempted inoculation
iritli caseous or tubercular matter from another iiuiividual, yet, in similar
nimals, the i^iinplc establishment of a caseous inflammatory focus fol.
lowing tlic introduction, under the skin, etc., of innocuous foreign bodies,
wnw to Im- an i-iiually cfliciont method of producing the disease. The
IK of heredity appears to be most potent in oeauûoniug thu pr«dispoâ-
124
Touoets.
tioii or s<vc>illi-<I fcroFalons Blat«'. Nrvi'rtli«^1«M, comlitioiw of hyj;îiM)P,
of cUinuU', uDiI of ri-<rîn»n orv ponrcrfiil in «ountcraciiiig or agi^reivKliug
thu inlicriu-d temltmcy, kiiil, iii Ùto absence of tho Inttor. Ùwy inay
occKHÎonnUy b« ]<iiltt<;iuiit U> «rij^iiinu- n ncrofnlout ilinthesis.
iïîxth, tlini aiimlly tlio vînin |in>')iicos an irrluiioii (specitic?) of nome
of die eclliilar oK-rk-iiLh wiili which it comes in cotiUtct liuring iv* course
thronick the lympli fia.-*.-ia;;i-s w tlii! nei;;hboriiijç lymphatic gUixU- — an
irriutiou vfliicii ivAitlti* in thp swcltitii; ami j>roliferaûon of tliu endotltelial
elciacnlâ, a choking of tlio p3a»a>!:c-. an am-at of the Ijrmph. ltd coa^jula-
tioa, aiul the formation of a bloodless iio<la)e presontirif; tho characters,
alrL'ady doAcrilwd, of the submiliary tubercle ■;raiiulo. Tbv infecttoj;
viriH may be arrc-stcd by tbe obitruciion of the lociil lymph |MiUis, and
1h! prercnted, cither for a time or cRi'ctmilly, fn»m «ntorinj; tin* ^-m-ral
circ<i1atiou and caiisîn;; an outbreak of the 'Usca^o in diiiinnt piirtt.
Ti)i» is the teeimd pkaM in lli« [troccfts. and baa been ternivd lixat
tulicreuio»h.
Scvenib, that when tlio virim reaches the general circnlation-^eilhcr
by pai.'ting boyomt llie lymph clantU or by directly entering; ilio nei;rhbor>
in^ bIoodre*»els. aa Î* freijiienlly the case when ibe liver becomea infected
from foci in the intestine-i, and occasions an eruption of miltary taberoles
in other and more or lesa remote lontlities — the potsooiog luu become
general, and there ts ;/eneral tufrercutoni».
Ki;;bth, that, once formed, tubercles themselves, by (Jivir caseous
do;!encratiou and Hiiuofaction, may form foci for secondary infcetîoti.
Xot nnly liKM l)ic tniiismi^Mibility of tuliercul'isiit by inuLiilatiuD bfcn
iinpjHirted liy many invivtii.iiitciH. hut sonu- reet-nt <'x peri men (era are of
the opinion that the disease csu he eummutiicited hy the food. Viseur
has seen tuherculosi-t prodiiceii in tiie cat after feeding the animal upon
tuberculous material. O. Itallinger experimented opon herbivorous and
carnivorous auimaU. and found that, by feeding with luborculoufl matter,
tbc herbivora become infected. He failed to find tho same result with
the fev L'iiniivora vhich be fed. Uerlach found that tuberculosis can
V- produced in animals by tbc use of the milk of tuberculoid cow»; and
Kleb« believed that the jicncnl tuberculosis thus prodncdl usually bej;ins
with an intestiuut catnrrb, which leads nent to tubercular ntleelionv of
the Diesent«rio glands, and «ubse>)uently of other organH. Without
expres.4in[ç belief in the )io^^bility of infection by feeding, Woodward
reuarkd that so plaiuibly lta.<t the affirmative view been ur^ed. The
tierman Society for the Preitervalion of tlie I'ublto Health, in June,
1S7.">, adopted are solution declaring it to bo their opinion, "thai the
results of the inoculating and feeding-experiments with the flesh and niilk
of animals affected with tubercle justify tho assumption of a dangef of
infoctiou to man, and therefore merit tliu greatest consideration by tbe
Military police."]
[Srat op ToBKBfi.E, — According to Wagner, tubttKlU riions a rary-
ing fre<iuoney, in individual orgaiu, accorliiig u> the Aga oF tlu> attacked.
In I'Ai/JntM itoccur» mrt*l «ft*n in the lymph glands, in the lungs, in tho
brain, the spleen, the tirer, in the int^'stinal mvicou.'' membrane, in serous
membranes, and in boues. In aJuU» it h found as » I'riiiMri/ affection
PROOXOStS or TVIIRRCLB8.
iy r»r most frwjiwntty in the Iung« : more rnrely iti thi* lymph j^Umls,
iriimry or<:9iM, f^-nittils, kimI inU'rtinnl canal, ffec-iminrili/^ii occurs ia
almool all or;:ai)3, oliivlly in tin- lymph vt.-»<«l(i nutl gUmlit corrtBponding
to Ihv eont of (hi- iiririmry tesioii. TuWrt^lc hii« ttcvor bcvn seen in cut-
ùIb^v, in tl)u fxu-mikl iiiiiMli-«,or in thv gixrat vcmvIx. It ha» been v«ry
nrtly owt nith in tin- |>liiiryrix, loiwil]t,<jcH<>]<hi>p>», rniiinfttOvariM, henrt,
tongue, Mtlivnry gl.iii<U, tliyr'^ii gland, and ^kiti. Nnt ii)frci|Uonily,
Uiliercle i-'^ ultiuialcly develo|)e(l in many new formations, especially in
le M*e racmhi-aited formed upon fleroun aienibran«s.
Writcrit have vanoii^ly pbced the location of tubercle in iho walls of the
bloodvesseU. in llieir luininn. in their advenlilioua »Keathâ, in corrc-
lins poeitîona iit the lymf^atic vessels, upon tlio scrou<i surfaces, and
lymph s]««o3 of tho connective-tissue frame «ork of the organism.]
ANATOMictL DiA«:<0819 OP TiiiiEKCi.Eâ. — The rvco^ition of the tsO'
[ated tnWrcle ;;ranule, when it in sufficicnlly lur^, i» very easy by tlia
itakcil eye : btil «hen the tubt-rcU-s are coiiRiii-nl', and have tinderf;unc
ciu>«r<u4 drgriKT.tiioii thron^hniit the entire duum, it ta i(iipo»<ibli' to make
a ilia^noitft in ilii« iiiitnnor. It iH aometimes very diffiotilt to diittinguisU
by the tiniiiilcil eye. ovntluenl tubercle jçrnnules from jfuminain, wlientlio
latt«r nm in iiroocMof forouilion. Ijion micruscojuc examination.4 of thiit
sections nuidi' after hnnleniii]! in alcohol or chromic acid, etc., it will be
leen that in tnhcrclea ttieve»«cli< are entirely obliterated, or are occluded
by a granular maK.4, wbiUt, on the contrary, in guniinata they are empty,
or cohlain red blood disks. Wheii gummau are old, th«y fomj firm
caseoits, lanlaceoua, manca, in which the vcfHel« arc obliterated ; tbcy
are ahaqdy limited, and nrv îmVfMed in a thick, firmly adherent,
fibrous tiMue, which present» the chnnictert iilreaily iiulicated (»ee page
lui* if m-'j.). On the contrary, the oaseou.* mas4e»i resultinir from confluent
berele* do not have the same wltdiiy ; they break ilown into a grumous
p, and are Hepar»te<L from the aurroundiiig ti^aue, which simply pre-
KntK the chnraclcra of inflammatory dfuue.
pRooKiwis or TuBERfLts. — ^TUe RTave prognosis of t«berculoaia ia ao
cU known tliat it is scarcely necessary to enter upon it at all. The
Bodeiicy of tubercles is to defeneration. Wo may ask if the tubercles can
healed, nml if they always act like certain mnllpmnt tumors in deter-
ailing, at a distant point, the fomiation ofnoduli-f «intilnr to thcnisi-Ivcs.
Clinical analysis, anil tho results of autopsies, «how that nniall I»0-
kted tubercles may simply nTulergo a cuseons degeneration and remain
Boat indefinitely in the midst of indurated ninme* residling from an
Qterstitial pnwuraonia. [We know that generally tuberculosii* in man ia
related to «crofula. (.'onceniin;' the nature of scrofuia we are alili very
norant. One fiuidamental characteristic of tiie disease seem» to he a mi»-
dlKirlion between the volume of the blood and the weight of the body.
here is a deficiency of blood-sunply. Dependent upon this condition
(ista an abnormality of the entire vegetation, which is especially evi.
ent in the course of any inSammatory processes which may ariae.
lereditary scrofula usually manifests itself at two periods of life: in
irly youth, before tiic seventh year, and again after puberty, between
128
TDM0B8.
llie ajîes of tw«nti^ nnfl thirtv year». The other reani of life Rw iwrt
h^ any mrans exempl I'mui (hi- liitea^e, but it is ira|>ortADt to remember
tltat hotwoen the as;ea of ten and fifieen years there U a (lorioii of com-
ptmiive immunity. It U <lurin>; that porioil tiial we may hop by care
ami treatment to oblilcraie the traces of previous scrofnlons lesions am)
to prvparc against fiitiirv ones.
L'jKtii what tills pi-riu<hcity >tc)>cnH^ it i« hnril to say. Its c«U8« mar
probably with reawm be «>ujitit lor in thr ilisproportioii, durin;; the (li-vol-
0)>mcut of the iii>liviiliial, between the volume of blood and tlie weight of
the bixiy.
A^ one of llie eii»entia1 features of the progrès* of the tubercular pro-
oesiwfl is in the nniemia wliicb cbaracteriïea it, m one of tlie firint aicps
toward recovery is an increased blood supply. The be^tt treatment for
scrofula is to iucrease the volume of the blood, and the best treatment
for scrofulous or tuberculous infiltration is to produce ami sustain for a
time a moderate local bjrpeitenija.]
ÏTII Cijuw.^^lsndui.
In inlanders, as in syphilis and tuberculosis, «r« observe two orders of
lesions: the one purely iiitlamtnatory, the other constituting speoitic ood-
utea. The inllaramatory lesions in this affection are essentially suppu-
rative.
The now formations in glanders liavc a great similarity to those of
tHhcrciilofti», t)f spontaneous orij;iii in the horec, glandciï is observed
in iiinn only after contagion from the former.
The anaiomicnl iIcmc H plions which have been f^iven of glanden krc
irautinjç in the histolo)iicAl details which would enable ua to give a coin-
pietc histological account of it.
Ilk man, as in the horse, the disease may commence by a primary
tumor and ulcer, which are soon followed by Ivmphanpiis, accompanied
by abscess and acute or chronic suppuration, ana the discbarge of a serous
pus.
The nodules of glanders, in the horse, arc formt-d of itmall cells in the
midst of a substance vaguely fibrillar; the cellulur clcmciilK atrophy at
the centre of the nodules, and it is absolutely impossible to distinguish
nue of ttwse nodules in the hoMe from a hitman tubercle. We do iiol.
therefore, cotnprtihcnd why VircUow has ranged tubercle» among lymph-
atic formutioii», and ghkiiders noKing tumora iVinneil of graiiidatioii tissue.
Death is the cotiKUnt terunnalion of acute gkudei-a-
ni.— TUMORS II.WlNOTIïKntTYl'K IN CAItTII-AUINOL'S TISSUK.
Ed chondroma.
Dkvinition. — The encboudroinata being tumora tihich have for their
Ijffies earlilaginoiLS lissjie. their definiiion is drawn from our knowledge
ot the latter- it is a^lrisable to separate from euchondroma certain
cartilaginous productions which spring solely from pro-existing cartilages,
and to which the name redumdrotft has been given.
DKSCBIPTrOM OP BKOnOXMtOUA.
1S7
DKSi'Miiaiox.' — KiichonilromaUi, profierly cnllct), never arUe from pre-
exUitiifC cjirtUaginouH iUmic. In tliciu «e ateei wiili every concrivalilo
form of cartilage* ; vc fiii<l a)Ao anolli«r rariciy which iitia no cxi»tei>C6
in man in llic {Jivsiolozical state, but which mav he .lecn in lh« ccplialio
oartilaKv of cophslvjxtda. I» these animals, the carlilnr^o cclU instcA'!
of iHrin)* incloeed m » capâiilc. present |nKilongationa bv «liich thojr
itnn^loi»o«o witi) each nthcr, reROmbliiig tli» plasnuitic mU of the con-
ncctivfl ttMuo. iSto fig. liKI.) Studying tlie ilevcloptDCiil of thisvDiÎAtj
rxf, iftci.
rlllar* of k tprhai'ipid :
111*11 Ul tlik>Uu«ii. X<1'' I''''"
• lit IbftalU. r. r«iidk>
««rtiU^ro, vr« Icam that the capsules which primarily surrouiid th«
jCelU beefiiiie penetrated hy anastomosin;! processcn which they itcnd f»
Hie iiei;;hhoritij; cells. This rcadiiifss of the CMpi'iiU'» to he thus intverscl
is rcmaricable. I^tor, the capsules bccoiiic iiiili»iitict and ili*a[i]M!nr.
iThese cartilages Df the cephalopoda have their «xact analope* in certain
nchDDdromata.
Id the adttlt, cartilaginmiK tissue \i Toid of IdoodveAAel.t ; it is so abo
of tiioet canila^noiiH tnniort. Hut it may liapjien that a cartilaginous
maw bccoows vasctilarised at it» centre, whilnt new Isyen of car^la^
[fonn at the surface. (îeiierally, t)ie ]ioinU where the vessels peDCtraie
iften ; in this way the tumor heeoniL-s reduced to a cartilaginous shell
[incb:<in^ a cavity filled with a vascularized medullary maw.
It i:? ntrc that an enchoudroma consiatin;! of a Bin;;le lolio attains a can-
liderable «iic. When the? arcof larse size, thcv arc formed of a number
1S8
TUMORS.
of distinct cartîtn^noufl muses, tvhicU arc separated hv connective tîn^iie.
Most frt.'<i<icntly tin-fv moHM arc splierica). tiiU somctiinos ihej tiave irreg-
ular lurms; tlivir voltiine is viiriablei in tlicKiinK- liintor some liave tltc aixe
, or tliiï lieiid of a pin, whilst ottient r<>acli tltc diniviisioiu of a pi^^con's
I Ogg. it niajr al«i> tinp{>en tliut in oi^rtiiiii liimoni (lie eurtilnj^iioiis loWs
bavc not the «ame «truvlnre ; *ome heing fonneil of hvnline i-Arlilagc,
others of miicoui cartiU)^!: certain oik-h have the structure of liliro-
eanilage; ntill otiiere of carûl»;^c nilb raniiRed ccIU. 'riiese liitferciit
lobes are generally covereil uilli n liUroua envelope, wliicli acta an a peri-
chondrium and in nhich the ves.sels nni ; bcucnlh it. we find a layer of
lenticniar capsules flattened parallel wiili tlie suil'acc: deeper, spherical
ca[>siitt'H exist, and at tlic centre lar(;or capsules, containinK man; gener
tttioiis of secondary cu]>«Hlfs. are to be seen. It is in enchondrouia that
we hnd the largcai cartiUi binons ea])suli-s.
VARlirrtKS. — We meet with »um«rou« varieties of cnchondroma, soido
|^t»c<l upon llie lissiivd which form ihem ; otherâ upon inoiliticiitiotu iti tlio
' BUlri^on of these tiH-tucn.
a. VniMiufiir liyiiUnr tnrfi'inâmma, covered «filh an enveloping Gbroua
oajKiule, containing at the flurface lenticnlar cnpnle^, and at the oentro
ea{>Aule.4 similar to those of adult permanent cartilage.
/•• J,vhaLtUd h'tuline eHch'mJririmi, in which a mirober of lobules similar
to tlie preceding arc separated hy connective tissue.
e. Certain fvmig of b, in which the lobules arc separated by a vasci
lar fibro-cartila^c.
d. Jn grimr fiieli'tnJromaln, besides inlands of welUdevelo[wi) cartilaj^e,
more or less considerable maaae.* of embryoimi tiiwiie an^ found, nitxrd
with the inteniodular Ëbroùa ti.isiie or with the embryoual card la);i nous
tissue.
Should wc, with Virchow, consider those tumors as chondro-earcoma?
We think not, for the ciubryotia) tissue seen around the cartilaginous
islands is simply the matrix whence the new cartila;;inoiis tissue is formed,
and represents the first phase of the development of cartilage.
f: The fibrous tissue which «-parâtes the carlila-pnous lobules is wime-
times predoiiiinniit. Virchow maices these a distinct species, under the
name of '■k-rnHm-jifir-nut.
f. When eiichoiitlromaia develop in ghind^i, we always find the fibroui^^^
tit^ue, which sejiarates the cartilaginous iitlanit.t from the cub-de-sac a»d^^|
uland ducts, in a state of proliferation. Wv shoidd wot reganl tiiis as an^^^
fOdnto-ckondnitHa, for the proliferation of the elements is only secondary.
The same may be said of every tumor, of wbalevcr nature, developed in
a jjland. Itc^dcB, when an cnehondroma dcvclo|>ed in n ;^1and extends
■beyond the latter, the extended portion presents no such adenoid appcar-
'mnce.
g. Certain cncbondroniata developed in bone may form an elevation at
the surface of the latter, while invariiibly remaining overed by anusseom,
layer, which ia somelinivs extremely tbin.ol'tcii inicrrupted in places, b
is alway!< covered with jierii^teum.
A. 'J'be cartilaginous lisnue of enchondroma may give rise to osaeonsi
tiwue. The latter has uâually only a transitory existence, as we shall eoe
DBTBLOl-VBIIT AND HODIFtCATtOKS 07 SXOllOSnitOHA. 139
la profioB of devel«pntG»t, Tlio.T Havo bo«n called '■imtXyiN// euehimdro-
naf ii.
i, l^nie L'nuhonilroninM arc not Tortncd in lobule», but in » diffiito niAW,
Eofteu preMiiting th« vluimctrrs of rmltryooal cartilago. 'V\m variety Li
Pig. if'l.
Fig. 101.
lll«I*«iipl« «banettn of uchosilniaa. Ill|b
chiellj met witli m lionca. Diffvtr
enrftojuh'nna. (Sec fi;;. lOl.)
,/. Tliore cx'itl lobulalutl viwhoDdro-
miitA till; fiiii'laincnUi) stibjtanco of
«hioh U iiiucouH at Uic c«iitrc of sonio
of ibe lobule». In tliL'^c tniicouA ]miM»
tlie capâulea are preserved, but tiicj
Boat free in a surrounding fluid, as U
observed normallv at the centre of lh«
intcrverU'bml disks: often, also, the
Cellular «lenient* are dwtroyed. In
jome caws the cartilaginous lobule may retain at the periphery a résistant
ayer ainl be transformed into a cyst, Viful'i-ehnmlronut of Vircliow.
k. Certain enchondromata con«i«l ]>artty or entirely of cartilaginous
l^ssue with ramified cells, as in ccphulnpoiû. Kttnhtnilmma with rami-
M '•'•««. (Fig. 100.)
I. OÏXtn these différent form* of encbondroma are rariouflly combined.
In reality, tlie majority of vnelioiiiiniiData are of m/^c^JcODatitnlion.
Seat ok ExruoxDRoMA.^Knchondromat'i, as we have said, never
8prin;i from cartilage. They may be locateil in all the organs, but thej
are developed more fr«iuently in the bones, in the parotid gland, in the
testicle, in the skin, in the subcutaneous cellular tissue, in the lungs, etc.
In the glands, very complex forms arc fr«'|uently net with, the different
Varieties of cartilaginous tissue being often combineil. The ■rpithelium
the enl»-de-sac and ducts prolift-raU's and finally undergiK-s divere
etrognide metamorphoses. In the muscles, the connective tiwuc nI<Hi«
irticipatc» in the nen- formation. The ftiTtctcult aiiffer fatty de^'enera-
>fl, alropiiyand diiiapjteariafler having commenced m ith a multiplication
the nuclei of the sarcolemma.
Dkvi^uji'ïikst ami rLTBRtoR Moiiu-^'ATioxs OF ExciioxuKOMA. — The
lovelopment of enchondroma never takes place directly at the expense of
180 ^rWAh^. ■
an adult liHStie. but invariably after thfi transition of the liitt«r into emlirjM
onal tiftfliio. Wbcii cudiondroma spnn<^ from boni'.wc fine otieerre pb^9
nomens siiuil&r to those of oslcit». The pinWvonnl cflU tlitu fonni'd
soon become ecparatud from encb other hy the iiilerponition of a triiits-
parcnt Bubetaiicf. The iiciJsciMit nssi'ou» irabemihe |>ri'»oiil notcb»!» into
whicli iR'wlv-fomicil I'liibrvoiiiilpU-mMit!' jH'iK'tml*. IntheoliiMt [lansof
this tmhrjoiial lipwiic the culln iire wi.lely sc|ittrnltfii b^ ii I'liinlatneiiul traM
I parent cnrlilagiiiouH «lub^tniicL', in Audi a tnxmior as to form n littli> i.^Uixl
of cartilage at ibo c<!titre of an eiilarjfod meitulUrv c-av'tt^. Around
l\»» little otn^t) of cartilu^ti* th« embryonal celU proliferate «bile llie |>ro-
«eo» Dr conversion of bone into inedulla advances : at the same time, tlie
I bone trabecule are Bh^orl)ed and neighboring medullary cavities are opened
into each olber, so that a large cavity is formed at the centre of which a
cartila>;inoiu nodule is found. The latter Increase» in sïsc by the gni'luul
inclusion of the embryonal cells which mirround it. Lnter, th« ndjoinin;*
cmbrvonal tissue is transformed into libruus tissue, and thiw U ooiistitutcd
a veritable perichondrium.
Analogous phenointna arc produced when the enchondroma spriug»
from connective tissue. Islands of embryonal cclU are found; at the
r CxpCDsc of these the growth of eartîla;;;e tolionA its Anlinary ty(>e of
F development. In certain cases, «ben the fnmiattve movement in very
slow, the fundamental librouii anbiitauce of the coniiectivo tissue persi^Li ;
thns libro-carlilage is formed.
After cartilagiiiou.t islands become surrounded by a perichondrium,
their increase is effected by a multiplication of cartilage cells in their
interior. The elements of tbeac islands being habitually very large,
every phase of this multiplication eau lie very ejisily followeil in ihern.
From their very beginning, enc hoi id ro ma ta may exhibit nutritive modi-
6caltons. Thus, when their increase is rajiid, ibeir cells may become
infiltrated by a hyaline sub.'ttance not well determined, yet named amyl*
oid by Virchow, becaniteihey take an orange-yellow color in a very feeble
Bolntion of iodine.
The cells of enchondroma contain fat when the tumor îa stationary.
It freijuently happens in points where interstitial growth ia very marked
that the celU may be simply infiltrated with amyloid matter, while in
olber places this substance is replaced by fat drops. Fatty «legeneratinn
is i^ometimes observed in the curtilage cells of enchondroma, when com-
plete destnietion of these elements is the result. It dctenniucs an arrest
of development in the jmiiUs alfeeted.
When ciilcari-ous infiltration takes place, it almoijt never ocoura at the
periphery of the nodulos, but always at tlii^ir centre. U may present
tvo different conditions, according as it accompanies a formative move-
ment analogous to ossification, or as it is distinguished, ou the contrary,
by a calcification which invades, at the Same time, all the secondary cap-
sules. The latter does not differ from the calcareous infiltration to which
wc have previously alluded.
In the Qrst case, there occurs an evolution comparable to that which
take» place in ossi6cation. Tbo chief dilfercncc is that in enchondroma
the embryonal marrow may: (a) remain in the embryonal state; (b)
give origin to fibrous tissue; (c^) become transformed into adipose tissue,
ORTEDID TDUOBR,
m
Bach âa the marrow of a long Irono; ((?) in soinfl rare caswti, give mo
'to oaa«oas trabccul», which liav« onlv a temporary exi^tcitce, aitd which
aometinM distipnear *j;ain in onlcr to ;five place to marrow.
Il'RuiiNOi»!!?.— The method of (ievelopmenl of the tumor «liters into the
pro^nosij of an etichondroina. If the morbid maas ta sharply limited
lor surronwlcil by dense fibrona tissue, constituting a real perichondrium,
tnti if it ilcvclops eolfly at th« exprns« of it« own ok-roeiits. xu i^rnvity
in nlij^ht. Ittit if, aniiind the tumor, one mcvtê with tracts of cnibryoitui
tiiutuc or of dcvi'loping eariiliise, the K''**''ty '* miwh greater. In (he
latter COM!, till* tumor tuny return aftvr extirpation, and it way oven bo
genemlited.
Oi-TKoi« TiUDHs. — ^Undcr ihe name of osteoid tumom, osteoid chon-
tdroniata,.!. Mbtlcrha^ described tumort fonned of tiâ^me anaIo;;ouA tothat
>f bone, hut ]>osji«saing really not all the cbaractcra of the iaCler.
In !<todyin/ tbe.deielopoi^nt of bone in rachitis. Virchow, after anal-
yziii;^ the piirtiiiilar tisane itesî^:naled hy llufi and J. (îudrin under the
jjsamc of H]>on^oid, called it osteoid tissue, and considered it a« osseous
tissue in process of physioloj^^ical formation. We are obltj^-d to antici-
tte h«ro some of the history of rachitis, whicb we will describe biter in
petnil, in order to explain the constitution of osteoid ti>^ue. In rachitic
bone* «0 often find under the periosteum a tii^uo nnnlo^jout lo hone, in
the owiform traheculx-, instead of eoiitaiiiing bone corpuscles and
■llel lanKllic, show angular corpuscles in the midst of a guhttunce
which is homojieneou!), or nbiob Uà* distlnelcalcaipcous j^ranulca scMlered
Ithroui^h il. Instead of beinj: tieparated by medullary tissue, these ira-
lieculie arc situated in the mid^t of a fibrous rïssiw which U permeated
ly vessels, and iho lymph spaces and cauaU of this tissue freely com-
liiuiiiciktc wilh the an;;ular corpuscles of tbc osteoid trabeeulai.
Fn>ra l)ie jirei:ediii;r, an osteoid tumor seems to be coustitiited by trft-
Veculie of variable iliriicnsious ami form, composed of a rvfnictiii;^ homo-
geneous or vaguely fibrillar substance, ofw-u infiltrateil with «aîcarenii»
, Kranules, and containin<; snpdar corpuscles ; these trabecule are nepuratcd
iDy fibrous tissue, in which course the vesKcls.
This osteoid ti««ne, however, doc« not solely compose the mass of
liamors of thin name. They arc almost ulway!< dotted with islands of car-
jlttf!c, aiid infiltrated in places with calcareous salt^. The cartila;;inous
»reas develop in the inter trabecular fibrous tissue, and in this case alone
ihouhl the name otteoid eHe/umdrfiina be applied to them.
Calcareous infiltration in some part of ùiese tumors is almost the rule,
olated calcareous {granules are deposited in tb(> fundamcntnl substance
jf the traljeculw; ; nevertheless, the corpusdes surrounded by this deposit
lo not bceome bone corpuscles; whether there be only cnlctireou* infillru-
ftion or complete petrifaction, these eor|.usclcs show only few and imper-
fect processes. The fundamental substJince never become;* laTuellati.'d.
These osteoid tumors may form a single :nass, oi- they may be lohu-
itcd: but they never ptvseni the lohulnted arrangement so markedly aa
in ordinary enchondroma. They may attiiin a eou^derable volume. They
ire very malignanl, and are freipiently reproduced in a great number of
>rgane.
J
l82 TUMOKS.
A iiflki'il fje «xnininnlîon can FurDish iio Bi^ni> i'lmniclerUUo of tlic
I lumonc llicir n)<|K-ct it, in «ITcct. vory like thnt of siirooinit, fibronui, or
ienchun<]roiiiit. TIk* iiti:tt<'inic)il diiigiioas of Uiiê it]iecics of Uimor mi»t
be made liy tlic micro*i:o])C.
IV^TUMOIIS FOKMEI) OF OSSEOUS TISSL'E.
Oiteoma.
The ostcotnata are tutnora in «liicli are rejiroduced tlie different Tarie-
tiea of osâcoiis tissue.
We will divide tkem, according to the nature of their tiasue, into three
spccice: —
^ft. F,h»rn'itfi i-mttoma. — Virchow found, at the îutcrnal surface
the cniiiimn, ««[enmutu c«m[)0t<rd of concentric lumelliv purullcl to tlti
eiirfavc of the tuiimr. In \\\v Inroi'ltn?, lionu corpuwlea were *ei*n wli"»e
catialiculi w«re nlino^t all directed lownrd the ])cripbery, iw in the ileutul
ceitioiit. No vcsmI» could be di«iingui«bct).
'1(1. Camjutet oftromit. — These tiiniftr* are formed of onseouii tiii$iie
ninilar to that of tlie diaplijoiA of lon^ bonca. The osscouh aiihstniiue
is diapoaed in lamellie concentric to the vascular canals. Tbey <iifl"er
from the diaphjrses of long bones in this, that the Havei-sian canals in-
stead of bcin;; parallel bave a more irregular course.
3</. Sfonyif '^(eoma. — These osieomata may consist of spon^ or
areolar tissue. The medulln fonnn the greater part of the tumor, and
bas various ch«mclers; it may ho i-inbryonal, geluùnifurm, fibrout, or
Jipose.
SnAT .\XD DrvbTvOI'mkst. — Aoconlîn;; to their place of development,
we dblinguish two large ):ntu]i.'« of osteoninta. The first comprises lb
irhich are atlached to boties; tlie second those which arise at ft distance
from them.
The Grst loay form at the periphery of the bone — exoattma; or io its
m ed id lory canity — tnoatogi».
Ex(ï?T03ES. — At the surface of bones, tbc exostoses prc«cnt IlarcreiRQ
Canuis whicli have a direction <;enenitly perpcmliculur to that of tb«
Haversian canals of tlic old bonc«. The periosteum is lifted up br the
tumor, so that there Is a perfect continuity between tlio bone and the
cxoAto)(i#.
It is ea*y to explain the perpendieularcourse of the llavemian canals.
In exostoses, when the subpiTio:'t<-iil tiiMue ii« trausfonuediulo hone, it is
the periodical vessels nhicb determine the direciion of the Ilaversiao
canals and the dia{io»ition of tlie lamella. These vesseU are, as we know,
perpendicular to the surface of the bone.
Lxosloses may be divided into tpîiJi^neaî and pareneh^tatou».
The fpiphi/iial exostoses may be met with in all the bones. On the
vault of the cranium, they arc generally due to syphilis. Upon section,
the new and the old bone are ^en to bo perfectly distinct, a fact which
hcrctororv has escaped pathological anatotnista.
OSTKOMA.
133
Hiua, under tlie exottto^ia, we very rcidily ilistin]nii»h the oM lainellte
in layers pnnillel U) tti« xurfnce or the oM boii<^. C|>'>ii t\ia long l>ouM,
these cxo^loses hnve the same ilU)io!)ition at) ujmi tlie cramutn.
The dcvclopcDcnt of tlicse exo<iiose!i takes place under the perineleuDi
from a pralifcration of m meflullar^v laj-er. itie bony tnil>ecu1iB gener-
ally form in the ihhiI «siy. but m som« rare casoâ the exoitcMU U covered
with It comiiiuotis layer of cartiUgo, from which the bony tissue then
■U'vcIo](i.
J*arrnrhyriui(-<u* cxo«tO<M8 «rc tlioso which urine in tht depth of the
p, and ill tlii> following manner : There is a ramifyinj; otu^ilis rexulting
iti the conveniou of an orea of bone into inflamouttôry mixlullary lissuo,
which latter become!* the point of departure of on exuberant omcous forma-
tion.
In thia caae, aho. the old tisane can he eanly distinsuinhed from tlie
new, for here, too, the Harer^ian canaU liave a general direction jier-
poiidicutnr to dial of the canaU of ihc old boue.
Kioftosos are formed at all a^es. Soioetimea they fonn upon the epi-
physes while the person is still ;^wing; they are then oflen multiple
sud ityinnietrical.
K.vui^TOSKii are formed liabltnully of comiuict tiftsuo, and encroach more
or loM u|io» the central eaiial of the bone. They consist of simple iiodulM,
or the formation ntny be difliHi^
Nut all of tho o»i«oouit formation» which arl«e at a distance from hone
arctuniont; ne»crihele*s, «<• describe them hero in order not to omit
them entirely. They may ftrine in divers tissues of the orasniam.
Certain carliLig-?» frt>iuently uiidcr;;^ osseous metamorpliosia, solely from
the pragresa of ajîe, as tho cartilages of the larynx, the trachea, tho
bronchi, and the ril». In the thyroid cartila;^, we observe this ossiB-
cation in tlie n^'d uiidin the pitticntd who have HulTcrcd from luryoj^tis,
particularly tuU'roulnr lHryn.;ili». Iti the latter it is an irritative process
consecutive to intliinimtUion of the mncon* nicmbrane. At the end of
the ossifyin;^ pri);-!.-*», which is identical with physiological owification,
the cartila:;!» an^ more friable tlinn i» tho nonual atate. ^iinilar phe-
nomena are observed in the trachea.
In the coftlal cartilages a!»i6cation is slower, and tt Is im]>eded by
mucntts metamorplioAJH. Cysts tilled with mucous matter and the debris
of eella incapable of orj^aniLstion ofien form.
In cases of chronic rheumatism osteomata often sprioj; from the diar.
throdial cartila;;es and synovial frin;^. Similar tumor< may form upon
tendons by hcjiinnin;; at their prjint of attachmunt to the bono, ami ex-
tending, in die form of long needles or stalactites, within the tendons and
often iDti) the attached luuscIeK,
In the connective tiïwue of the arachnoid or of the pia mater, little
platL^!> oftt'Ti exiHt, composed either of conneodve tiame, incrusted with
calcareous «aits, or of true bony tissue.
The choroid coat of the eye may be transformed into a bony shell con-
(i^tin^ of bane corpuscles and of osseous lamelUe.
Kokiunsky has spoken of the frc<|U0Dt présence of osteomata in the
bieepd of the infantry and in the adductors of the thighs of the cavalry
of tlie Austrian army.
I
:
TITMORS.
Oeniiine bony pUto» have been fouml in the pericarilîiiiii, niid oven in
the iD'iaciilar tissue of llie heart. Hui mont of hucIi I'ormatiotia are lilirtnu
U^uc inci'uxtcil MÎtli calcareoiia salts. We cannot agree wiih Vircliow
that bony I'latc-i form iu vessels afl'ccteti willi cliromc ointarteritw.
Ill the skill, ojseotis shells somi'timos dcvi'lop arotin'.l the i;ian<U.
At tlio inilurate'l summit of lnberciil'>us lim;;^ osseous proiltictions often
are prcaenl in tbc form of nce4K-$ ami ru'liatliig nmssi-«, which huvc Weu
described bv iliflcrcnt nuthora. l^ieir ori^ii has been attribut*»! to tlic
bronchi III oitrtila^e».
We have heen iiblo to satisfy oursolveii that their development titkcs
place at the exixmse of the new connective ti**iie of interstitial pneuiooniii.
Ojaciiii^ Irahectihi; hi proce;*» of forinatinn are itiirToiiii<k-d by an em-
bryonal tiiuue, from vrhioh their development proceeiU in tlie oniinary
manner.
Besides the osteomata of the arachnoid and pia mater, the central
nervous system tnay be the seat of tumors of the same nature ilevelo]>ed
in tho nerve subsisnce of the brahi.
Obostuma. — O'l'iil'itnatn arc tumor* fonnctl of dental tissue,
Vndcr this uamu hnve been de«'ribed: —
1ft. K\ OS to se* caused by inflamtiuition of the niveolo-deiitjil jieriostenm.
The ccmi-nt of the teeth, » geniÙTie osseous tissue, is in imiuedixlc retution
with the periosteum of tli« ah-cohis. Under the intliienue of periosteal
iullamniation nex' layers of cement are added tn the old.
liX. Ni'Wf formations of enamel and of ivory may occur either upon tho
neck of the loolh or upon the cement. These lumore resemble little dni[ii
of wax.
."id. A spcci.it tiitiwr of the maxilla, eousislin;; of one or more normal
or dcformt'd tcvth, Homutioies grouped together in a congeuital malfor-
mation.
It λ iiecewary lo add to thif group of ndontomn, tumors in which teeth
iinplniited upon lu.i^ous plate.* are met with in dermoid cyst^, etc.
U<lontomiita are not asually vuluminoiui tumors, nor ara they grave.
v.— TUMORS FORMEI» OF MUSCUl-AR TISSUE.
Hyoma.
The structure of myoma has Mb type in the muscular tissue of tl»e
economy.
At present we iltstiii<;uisli two kind» «f myoma.
IsL Tumorv vontainiug striated muscle fibres. Myiyma *tri<>-cttMare
(rhabdo-m^iima «f Zenker).
2d. Tumors formed of smooth fibres. Ln'tf-mffoma of Zenker. Mjfoma
with uiistriated cells.
1st. Myoma STKiocici,i.rLAKF:. — These tumors are rare and tre con-
genital. In dermoid cysts of the third variety of Lebert striated muscle
fibres are often found: those are complex tumors, not myomata. In
other tumors which develop in the foetus, and which we shall .soon dc.^ribo,
striated muscular Ëbrv4 arc freciucnt but the morbid growth is too com-
T.B[0-ljrO)fA.
lU
I
ft
lex to be onllcd a tnvonin, «ml iu c)mritcMri»tic« of development am) of
stnictun; tiaaipx it to a .letMinito i>lBec.
ib. Lkiouv'Iua, or Myoma with SW)Otii Fiiiriu. — These tainorit
mav juvaent llieniMrlven under the form of an irregular, dilFiwo inaiâit. witli
ill-delined bonlers, or may stiow a verj diatiitct lobular form. Tlii-^ liure
s fle«li; or fitiintis aspeci, Tlie musole eelb offer tbo same eharacbera m
in the physiolo^cal titatu, and ma; be grouped into fasciculi or inembmnee,
or inaj bv ieolalnl in the midst of connective tissue. The foMcictdi arc
separated by vonnectîvo liuue in wbicb run the bloodvuMolit ; the latter
never [loiictratc tlio luutciilar fusoîcidi tlK-mH-lws.
Whpii ilie musculitr elemonbt are i^oluted, t!wy are recojnijted by their
•(|iiti>lle form, and their rod-Hhape*L iiucleiif in the eentre nf (he coll.
l^eio-niyoma may be formed of faaciculi vhicli may all nin in the same
direction, or which may interlace. The section may take tbom trans-
rersely, oblic|Ucly, or lons;itudtnally. In cro» section the «ells appear
Willi a more or teas circular outline, wilb the nucleus appcarinjî as a little
roand spot in Ibe centre, liul ohlii|uely. the celU may prosonl a more or
Ins oral MClion. In lon^itmlinal section only do the luufi-uliir elc-menta
ml tfa« fumiliar spimlle form, irith « central rod-sh&ped nucleus.
]C*>r«l*r**]U Fro» ■ I*lii-i*;aai». A. r«ll> Hparnud by tba leliBii at nllrls a(U,SB p»r ntA.
M. k htt*ttr4 KclUu r.>Ioi^ nMh hiiiIii* and itnud «Uti iMtltr »ild. m. LattKlludtiully tui. h.
tntitT9t9*ïj ini unrUt, I- C^ubucIivp-UMue stilts
A very interoMing properly of myomata is their contractility. Upon
tliis property {rreatly depends the varyinfç consistency which ibt-y posseM
at the moRientnheii they are examiueu. 'Phis phenomenon is p^irlictdarly
noticeable in the myomata which are commonly called fibroid bodies of
the uterus.
The VAitiKTiKS met with in myomata are: —
lat. Xon^oèulaUd m^^omata, fornii-il of a homo^noous fleshy mass.
They are soft, {losjtcss voluminous muscular celU.
2d. L'thnl(ilf<i M^imuita. — They «oniiïtinit;» hdvfl lttri;e K*^P'''n ve**«ls,
like the Mleriue muuhcs and iho hepatic vein*. In certain very rare cases
the dilatation of the vessels Li such that the term trtHih has been applied.
Sd. iSihtxrttiu» injiltrtilion is freiiuentin these tumors. It commetiees
ti tlie centre of the lobule ; sometiratts the inliitration is only into the
oemeni substance : at other times, complete petreFaction of this subttanos
and of the muscular elcmunts occurs at the centre of the lobules or
186
TOJtOHS.
I
tbroii;;hout their entire mas?. Tliia tnuisforowtton is pnnicularly frc-
quont in the uteriiio m^oniiitH wltk-h project U)Jon the pentoneal §iii-t'ac«.
4th, Fiilty inptmtkm of the cells is Komelituus associated wiUi cal-
careous iiitiltriition.
«til. Mw-'iM» mrtamnrph'iti» i« frDijiiently sssocint4.vl with dilftUttton of
the voMnel» in myoimita. It iiianifi» the iJe*trncti"ii nf a certain Dumber
or elometitn «ml thu formation of cavities or mucouii cyat«,
DKVKmi'JiESTOK MviHiA.— Sometimes in tiie fihrotis tJ^ueofthc Ininor
And along the muscular Umdlea ialnnila of em^ryoiiAl tissue are ace» ;
the contractile cclU mar develop in the aame m.tnner a.4 in t)ie embrjro
from a direct traiHlurmMÎMn of the enibiyonal cells. Some autlmrs have^
thought that the pro-csiating muiulo cells may multiply by dimion.
True myomata arc alwiiys ^eatbli in the muscular tissue of organ
life. They arc met with most freiiucutly in the utcnis, where they tmy^
appear as an interstitinl ma««, lobulatod and cucysle<l in tbe midst of tli«
uterine tissue, nr as polyps projcetîn;; upon the surface of tlio perito-j
neum, or into the uterine ciiviiy. Their structure in thee» en«o« eoasiaifl
either of yonn^ nni.icu1iir ti^isne, ur of a muscular tissue iuvnilod by
reeiintly-f'^rmed connective tissue, so abundant and predominating that
tlie ifi^wth mti:Ut almost be considered a Rhroma, if, in nttmin;;; Inmorn,
ve did not subordinate the commonest tissue to that which (fives the
tumor its special characters. The muscular tissue is of new formation
in these tumors.
In oltl men the prr^tate is often the seat of a new formation of smooth
mui^ular fibre», either diffuse or circumscribed in the form of tiunora.
There also exi^t myomaia of the scrotum.
'Jlie digestive tract présenta lormationa of the same nature, in the shapOl
of [Kilypi. The latter myomata, like those of the uterus, are at first
interstitial, but after a variable time they become pedunculated, and
project at one time into the visceral cavity, at another time into the peri<
toneal cavity.
The anatomical diagnosis of these tumors is impossible without the aid
of the microscope. With ihi» instmnu-nt their recognition is generally
easy. In doubtfid cnses, reconnic should he liad to dissociation of tbo i
Dtnsclo cells with iipedîeji, after the u«e of nitric acid. An important point]
to be obi»erve<l, when .itudying the tiasue in section», \n the shajic and
rolativo position of the nuclei.
Tlie rROdvogiB of myomata is not f;rave nnless by their seat and their
volume they iletcrmine lesions of the neighboring tissues, or offer obstaclea
to the proper function of important organs. Thus a niyoma of the uterus,
may compress the blailder or the rectum, and occasion congestions aodj
hemorrhages of the mucous membrane, and other uecidonts. The pcdun-
«ulated myomata of the intestine may give rise to symptoms of strangu-
lation.
KKUftOMA.
TI— TUMORS FOKMED OP SERVE TISSUE.
Neuroma.
NouTODiata ar« tumont coiiHdtiitcd hy a tisane of new forrmtioi), of
which the type \s fouixl i» nvrvc lîïituv.
In Iho normal stale, m>rrc tiMiic [»n.-icntt two ililTcront variviies: Ist,
roAdiilUrT 8u)M'tai>c<\ fouwl i» tlii> grny <.'«iitr(.>it of tlio i'n(;c]>)inlt>ii and
fipiiial nwrrow, con«txtiit<; of nervo cellit and neuro^li» ; 2d, fns<;icuUl«d
DcrrL- limue, tlic type of which ia met with in the ])eri|iheral norves.
Thc^e two fornix of nerve tL«iite «tisble \i* to di:<tini;uii)h {wo kinds of
neurotfinta: Ut. Medullary or j^xii'ilinnic; -d. t'iHciru1at«d n«)irt>ma.
li^T. Mtmt't.i.ARV Nkiimm*.— Medullary or gansliotuc ueuroouita are
rery nn: and of small imjiortance clinicatly. Virchow h&A descriWl
them in llie hraiii and aninal marrow as ftti;;litly pnyecliiis tumors. They
muât not be confoundea with heniii« of llie marrow, '.nieae tumonj, of
the color of the gny nerve substance, contain nerve cells, neuroglia, and
vessel -I,
'lliey may form in (ho corpora striata and upon the surface of Urn
ventricles. Sanj;nlli ha* described, in con;?onital cnecplialocelc, tumors
fomvc-d of gray suIisUur'v. in some dermoid cysts vv at«) find masses
of Cray nerve substance conlainitig nerve o«lts and ncuroiilta.
2p. FAPriniMTKi) NErRoin. — At the commencement of this century.
(Mier (of (iciteva), under the name of nouroma, inclwlcd all tumor» i>eated
alons; the coumc of nerves. Tlieac were imxH freiiuenllv niyxoioam, u
we have already learned. Tho wonl neuroma is still ottcn applied by
sur^^eojia to every tumor, whatsoever may be its nature, which may hap-
pen to be seated aIon« the course of a nervo. In the terminolo^j em.
S toyed to-day by patholo^sts, this word should be exclusively used to
eeii^ate tumors constituted by nerve elements.
Tho foBcicuIat^rd neuromata are then simply tumon constituted by
nerve tubtdes of new formation.
The name of fiit'/ul ntur'-ma haA been iiiven to certain little «ubt-uto-
ueons tumor», «imply on account of the great pjiin which they cau«e.
Dtipnytren called tiicm painful fibromata. They probably contain nerves
which arc compreiiiied by the new coiniectivc tÎMufi.
Vemeuil baa described, under the name of pli^xiform ei/Ihulrieal nm-
rwnta, an ioterc^lin;; affection of the nervous system, characterized by an
alxnvlaut iiro-luction of fibrous tissue between the tubes of one or more
ne ne- bund les, so that the ncnos have aur;mente<l considerably in size
while preserving tlicir cylindrical form. This afFeclion is not aceornpa-
nted by a new fonuation of nervous elements, and it should tu>t be called
a neuroma.
Genuine f««cîcui(ited neuromata are very rare. They are always seated
upon the track of a nerve, and ;iro in every ca:<e fonnod of ti^Mue similar
to that of the nerve. They are genei-ally minll and fonued of a siiii:Io
lobe. Upon a cut surface, their tis.sue apjieant fibrous; it is dry, and,
when the débris obtained by scrapiniJ is examined under the microaoopo,
dro[Hi of myelin may be observed. By dissociation, one succeeds in iso-
lating some nerve tubes. A magnilied view of stained sections ahowa
138
TUUOKfi.
ncrvo tubc^ in gront numbers, dicer^clv intcHxcoil An<) separated from
each olher by coiincctivu lUttiie more or le^s rich in cell elemenU.
Accoriling W vlietlicr they contain nerves of double contour or filirea j
of K«niiik, Vircliow divides thtm into two
Fig. IM. dUtinct spccieB, designating the first lu
mf/elitiir neuroma, the second &s amj/flinie
neuroma.
The ^EATof these neiiromnta is «xtrcrnelj i
vftrikbU'. One of the most interoHtint; xk-
rieties is seen often nt the out «xtremities
of nerve» in nnipntution. The end «f the
nerve bec»me«, in these ciute:», the point nf
ill ; niiire for the >;r"«lh of a little p.vri-
1 iiji nmirir. «liich nii;;iit he conaidei-cd at
firstt sight as a new formation of tihrous
tissue. Valentin and l.ehert have fonnd
iu them a Inrjjo qnantity of nerve lubes
with double eontonr. In dissecting these
luiuora, a bundle of nerve tubes is seen to
penetrate » little snellins. Within the
latter the norw tube» intc-rlnee and form '
siniitwitir» and loops; it is difficult u> de-
termine if these tubes are oontitmonit with
those of the cut nerve. The rery <lcntie
fibrouH ti^tue uhicli separate!) them makes
dissociation and isolation of the tubes trou-
blesome, and the winding course of the lat-
ter makes it difficult to follow them in the
seetioTi for «ny considérable distance. Wo
shall soon see. while stnilyinj! the plieno-
mena of cicatrisation of nerves, that llie embryonal tissue of the cicatrix
lias the tendency m produce nerve tubes.
Intitead of being single, there may be numerous neuromata alon^ the
whole course of a nerve ami it« divisions, along a plexu,*. or along allj
the nerves of a considerable nart of the body, 'I'umors of the optiu i
nerve, which have been callea neuromata, are, according to Virchow,
mostly myxomata.
The .w'AT^iMiCAL DiAONOrils of ncuToma, difficult in the amyelinic ra<
riety. is simple when they possess double contoured fibres.
In order that a tunmr should merit the name of neuroma, it i« not suf>
ficicnt that they eontaîn nerve lubes ; it U neecisary that the number of
the nerve cells or tube» iK i»uch as to iniliunte a new formation of ncrvo
elements.
FKOd.vosiiJ. — Neuromata are u^tially grave only by rcaaon of tJicir
■eat, by the jiain which they occasion, and sometimes by their multi-
plicity. These tumors are never capable of secondary reproduction in
tbe different tiHsucs of llio economy.
Tw# pumrnrin D«aromi. (ffrunf')
ASOIONA.
lïîï»
VII.— TUMORS J'ORJtF.O OF BUH>I)VKSSEt8,
Angiom».
AnjiionntA are Ininon tlio iypo <iî vihmc Etrnotiiro i« iteen in tbfl n»-
TUoy Itat'p )>«en ileoijcnntei] a» «reetile (union ttj I>ii|Hivtrpn, as an;;i>
OSM or ecchjrfiMtna by Alibcrt. To merit tlie tmme of tumor, it U iwoes-
Bftrr thnt the viMi^els which coiii|>oa« t}iciD ithall bo of new romutioD. A
simple dilatalion of oM vcsmU sboulil not be c>oikaul«re<l as an angioma;
anourUui sbonl'l not W c1ass«<l amoiij; iliein : varin^s. or <)ilatalion with
hypiTtropliy ol' the veinows walls. bIiouM aUft he i]i.xtin;;uiBlie'l from them,
anil tliu same miiv he said of arterial rariccB.iii'scnbuil \ty Virchov with
the «iifriotiiata uii'lcr t\ie name of att'/hiaa racem-jgum.
Wv (iUliii^niiflh two s|K)ciGa of aniiiomata : —
l«t. .Vf'/Jtji/r amji-init, in which ihi- neft-ly-formcl vflsscl» wliicli cODlti-
luiv the tumor arc »imilAr to norniiil arlorie^, veins, and v.i pilla rien.
'M. Cai'fTH'ott an'jioma. \n uliich the l>Ioo<l cin-iilHics îii n liwiiiiar
»ji>leiii atialo^iu to the cavoriiou» xv«teiii nf «n-ctile or;î»n«.
lisT. SiiiPLE ASniojiATA Ccongi'iiital mi'vi, toiiiri;:wl«''e''l «how them-
aelvrii un<)er the form of [lolypi, or of Rat, ittif^hlty olcvnteii tumor*, at
one time efEaceil. at auother tiwollen. 'lliey are red or violet, am) are
rMUflllv localei) upon tht' face, around the orbit. or upon the neck. They
IJMentjally consiat of capillaries of new formation predentin}; rc;;tilar
NmpuUnr or varicose-like ililalation^. These vessels are very tortnous
nn'i '.icnvnilly havi; a corkscrew uppcuranco. In a section of the liititor,
the walls of thrso vcnacls arc ob»crv«tl to bo very rich in nuclei «ixl to
have tt thicknex» of one- or two-hundrcdths of a millimrtre, while «ill
preserving the «impie iftructure of ca]>ill«ric». The veswt» are imbedded
in a fibroux or eellulo-adipOKe Htroinn. Thctic tumor» are coiij^cnilal and
are very common. Tliey may <liHa)>pear in the fmt monlh.t of life.
2d. Caveexoc!: ,inhii»mata (Nievi cavemoRi, erectile tumors) are con-
stituted by an creclile tisaue, the cavities of which are filled with blood.
The bluocl circulates verv ac^vely iii tlieao caverai. Their vessels form
a direct communication between the arteries and veins, thus taking the
place of tbv capillary system.
Wo study in nn«toitiata —
l»t. Thr Irahemlit which circurnscribc the c»vcmî. They are formed
of dénué fibrotM iIm.mic, in which pliismjitic element» arc to be iVistiu-
gni^thcd after itialniuir the JWetiou examined. The Irahofidie may alifo
contain arooolh mititcle celU, or, when the tumor originate» in mu.'tculnr
tistuie, they may even exhibit atriated muncle llbrctt. The irabeculiQ may
also contain fat vesicles, and they may somctimeH poiucts vessels which
have the rotation of rasa vasorum. In one case, Ksmarch was able to
trace nerve tilnmonts iu tUem.
2d. Thf rvUi which pave these cavities are similar to tho eudoihotium
of veins.
âd. Thf hhi"<i contained in tho cavernous spaces is similar to that to
tiic rest of the vawular system.
AlVr an incision of an ungiotim which hoA boon rvmoved, tlic blood
I
1-ÏO
cscap&a nnd thcri? remuiu a Bfoagy tissue, slightly coiitractiMl. If, ob
thu coitiRirj. liie blood is OOft;(ulBlcd vu nin&ïo, lis nlicn the tiint4>r i«
plucod entire ïd alcohol, a nm^DÎdccnt nuturnl ii^cction of the cuverni
18 seeureit.
AU theMo tumors arc not erectile.
Til the iictivc i>Kvi:i.<>rMKST of xnf^onin «mbrjronal liuue and noriMl]
cni'illanuii nri.' first prntluco) : #tibitei]U«titly, ttieiw voueU become diliit«d, '
Soon iho dilatod cnpillnrie* come in eotiUiut wrilh *ach other; wide com-
tnnniontion» arc cttablinhcd, and tlicre reAiUttt a (]a)iillary nyslem with
lar);« cax'cniouH ililntaliotui. This method of fonnalion baa beea (leoton-
Htratcd by Vird)ow in oavernoUA ausiomJita of the liver.
Cavernous angioma may undergo lUvcra nutritive alteraliona. The
walU of the vessLda may become the seat of cali'ni'eouit concrétions, sintilar
to those Heen in the choroid plexus mid in anj^ioHthic sarcoma. Cyst*
fillfd with a serous fluid hnvo been ob«ervvd in nn<;i<>mata. This modifi-
catioa is explained by the isolation of a vai^ciilar bud, and the subsequent
coagulation and mctamorpbosis of thu blood which it contained.
Can these inniDni he converted into carvinnmata or san:«mutaï J.
Millier thinks that he bas «cen mnli]j;n cavcrnou* an::iomnt« witli a ten-
dency to extend, aitd wbioh have even been followed by inetastAseit. Cer-
tainly sarcomata and carcinomata with dilated vesieU act in this iiiauner.
Many pid.-iatile tiimora which bave been dia^fnosed as ercotile ttiinors,
aneiiriiim of the hone, etc.. are really nothing else than sarcomata or
carulnomaia with very widely ililatcd ^vessels.
The tumor may be '(/»ff"M*e,'that is, not separated from adjoining tissues
by n shiirp limit ; «r it nmy he ••irfumfcril'rd or ev«n surrounded by a
gonuini- cHfisiile.
Acconlinj; to their skat, angiomata may be divided ioto internal and
external.
Kxteriinl an^^ioniaLi are located in the tissue of the derm or in tJie
celhi!o-adi|ione suhcutaneous tissue. When they sprinjt from the adifioae
tissue, Vircliow calls them tipoifenna». and yklehoi/ettui» when tliey ariae
from the vasa vaiorum of the veins. They mav extend into the inter*
muscular cellular tissue, and even into ebc bone itself.
Internal an;;iomata have been observed in the liver, the ktdneya. and
the spleen. The an^pomata of the liver are the modt common. Their sixc
varies from that of a haxcl-nut up to half the sixu of the liver. Nolvrilh-
«taiidiiij; that they project upon the surfact! of tbc liver, they generally
d" n<it augment it* volume, for they are developed at the expen*e of tlio
hepatic *uh«tance. When they are surroumied by a capsule, the hitler is
pierced by vasi!nlar openiii;;*, Armmd them the hepatic substance is
nomial, but is âe|>arated from the tumor by a none of coniioctive tissue in
a state of proliferation. It ia in this proliteratln;; tiitsue, when the tumor
is increasing, that the work of development proceeds. Kuplurea of an;:io«
mata of the liver may occasion a peritonitis, An;;iomata may retract
after spontanoous coagulation, and give rise to cicatrices.
Scbuh has published an imperfect observation of an angioma of the
luuiç.
Their anatomical titAOSOStsi» cnay. Wo^ould be careful to exclud«
an erectile carcinoma or sarcoma. Around au angioma and in tiie inte-
rior ire find only tlie norauil tiiumett of Uie pri inviclct. It will Nomc-
tiiaes be <liflkitlt to «lifferentiali^ an an)cioiim from b lei» inynin» witti ili-
Ifttod vessels; but hero nlso die «xialence of n verj greai mmiWr uf
miisclff colls will remove doubt.
PiiouKOi^rs. — Anj^iomata hkv« no gnivitjr otlier Iban that which maj
rmull Trom their Mat and extent.
VIII— TI'MORSTHF, TYPK OF WHICH RXIST8 IN THE LntPHATIC
SYSTKM.
Lymphanf^oina, Lyrngthailenoma.
There are tno kindfl: lat. ti/trtjifinnirivmata, tamors eonsiiinted \yj a
new formation of lymph vessels; 2. Lffmphadenamala, tumors wliich
result from a new fonuatioii of adenoid tissue, similar to tliat of tiie lymph
glattdx.
IsT. t.vMrilANfliDMATA. — Thesp tumors, constituted hr ncwiy-formej
lymph vewtcU, are fix-i|Ueiuly oonfoimded uitb «imjile ililntntions of the
pre -cxii) ting veseeU ; pcrhni** tin- existence i>f lym|iliikn;;i<>itiii, in Ihe «triet
meaning of tlii* definition , may be «unewlmt iloiibtfiil. .Snmc author*
have observed xnch tiini'ir* developed in subjects inlinbiiinK eomitrie*
where «)e|>li!intin.ti» Arabnm i» frenueiit. but there is nothing to »h»w that
in them we have not a !>iiii|>li: clilnt>ilioii of prv-cxislinj; vesMls.
Tbc u<letutlfii»}'h-relf of Néliitmi, etc., in which the dilatations ex-
tend H^ far as lymph glanda, should be cli83«d vitli lyoipban;rioina.
Lympliaiij^iomata are soft, fluctuating. comprcMihlc tumora. which may
or may not be adherent to the i;kin. They are constituted by networks
of lymphatics, which communicate with each other u» the bloodvessels in
cavernous tiiwne, and which may even o[ien extorniilty and allow lymph
to eseiipc. The histolofiy of Ibese tumors bn« not been fully ■•tinlu'd.
Th. Anger ilemonstmted that tbc dilated lymjthatioi show a byjierlruphy
of tlieir walt.eau^d by an increased
Dimdxrr of smooth muscular fibres.
He was unable to see tbe endothelium
of these dilated vessels.
Virehow ia inclined to associate
con^iiilal bypenrophy of ibe tongue
and of the lips will» lymphangioma.
In these hypcrlrnfiliifs we find di-
lated lymph ve^çiels containing a tluid
8liuh>«ons to lymph, awl locate<l in
the midst of a deiiic fibrous tissue.
{Fig. !".'>.) In the connective tissue
which fnmw the niti>i' of the «welling
of elepbantiasi* Arabum. we meet
with irre;:idar laeunic filled with n
lluid similar to lymph. The devel-
opment of this elejihantiaMs is pre-
cedeiJ by n series of ''anjiioleucitc*," and
is iie|>cndent upon the latter.
Fig. Id».
l>1lHmJ \jmyU yrmmr\* En ■ cua *>/ vltphan.
Ilft>l* of tbn ftk^D of Ihft |«>iiU, 0. Lf iQpb «*«•
*«l. II. FUI tiiituihrlltui of ibf fond. e. En-
brf ADlfr r'}Dn4-<itit« tl*iin« ai lb» tuoor.
the formation of the lacunte
142
Tl'MORS.
SI) Ici- 1,
till* i»
Certain p»Ie and cnrapre-ued coii;;ctiilii1 tiimora of t)ii> nkin, considered]
08 Ivmjiliatic iiievi, »liouM iio cl&«âeU ammi^ lymnliîLugioinaUi.
'Ji>. lAMi'KAitKNuMA. — l>yiii|il mile noma U conaist of t,vni|)liadcnoi<l tia-
sue. After Virchow and Bennett, in 18-1.'), discovered leucoc^'iliœuiîa,
the attention of observers waa drawn to peculiar fonnatïons in tlie lirer
and some other organs. In t)ii- liver tlic hepatic cells and lobules were
separated by newronttd clement») locnt<rd in tin* connective tissue. llieM
eelU were regarded as wliitc hlmul e-irjiuddcs, wliieli Imd npniiig from
the connective tissue by pnOifemlioii, .-mil the fonnnli'in» were looked
upon n» a [«lint of snpjtly tor new nliite IjIihhI corpiwclea. In the kidneys,
i-n, and lyinjihatic glamU, analogous productiotia verc iutorprutvd in
S8ino manner.
A* early »« IHOt, llodgkin had studied a fatal disease charaoteris«d
by a prn^rejaive hypertrophy of the spleen and lymphatic g)an<U.
I.aier, ItonfiU discovered that the Ivmpli plumls and the spleen could
]>ecoinQ livpei'tropliied while the blooil coiitiiined no more white globules
thiin in the nnrjnal stale ; in these ciiseM iilso the jireviously indicated new
formations were found in tlie liver, kidneys, etc. Trousseau itamcd this
diseaso itdeema,
Kor us, leucocy tha'mta and adienin constitute two rariotii» of tlie same
morbid process: the essetitini legions of the <liiTereitt orjjam are the sant»!
in alt eases: they are lymplmdenomuCa, or tumors which rcproduco tho
nilenoid tissue of His.
'riie DEVixiTiON of lymphadenoma is based npon that of the ti«(ue oC.j
lymph gUnds, and in the reticular conneo-
Vi%. Itl6.
1. lt«ilCiLUI*<[ll«ii« rran * Irnipt'
oldfvtndaof Ili4 jftmitorm iLp)i*ii<(kK
af tbr rriTbhn, tvith ih* vjiIaih of
tOOtbrt, ftbil f«ijibla* of tbi^ tjriitph
erilt N. Mull ar tbr UIMt !>■•■■ btta
r*iDa»d trllDiUlIx. It. Ljnipb «••■
•*l. 1, LoDitHudlBiil •■rllva or ■
naHdin^ r««TtrulBr li«np, la iha
IBitabi?4 of wh1?li KEB acvD lit* I^utph
nil* ». A. Liimtu vl • ou*), t,
taanaf lb*(ls*d. <Pr*f,)
tive tissue of the intestinal tract. (Kig.
lOfi.-)
We should apply tlie name lifwphadtwtK
only to tumor.^ eon^tllutt^d hy an adcnoidij
li».4ue of new fonnatimi. and not to olhcrj
alterations which accompany teucocythi»-]
mia, and which will be noticed in the follow-
ing description.
Di:siiLii-rit)X. — Lymphadenoroata arc tu-
mors of extremely variable sise, from that
of a millet seed up to that of the head of a
ficlns. They almost always have ill-de-
fined limit*. In the lymphatic glands they
resemble a simple hy|)crlrophy of these
orgaiii), hut when Hcvenil adjoining glands
arc involved, they are confounded in a eom-J
mon mass. Tlicy have a decidedly enceph-l
aloid aspect: they are soft, gray, with r
points which correspond to dilatations
vessels and ecchymoses : tlicy «omclimc
present opaque, cheesy portions. Tliese
tumors yield a very abundant milky juice,
exactly like that of carcinoma.
This juice consists of a fluid in which
flonts small round cells, having a mean dia>
U3
meter of .010 mm.. anU containins; » single nucleus : larger colla meamtr*
tuR .U2<J nun., contitttiin;; several nuclei ; a tew of ihc cells an still more
Tolutniuous aiul lomlvd with iiucIpî.
In tlic rc<J<IUh-bmwti or ^'cllow points of tliv tiimora thest celts conUin
I>I<hkI pi^ineitt of (liHereiit tints, Tliere iirr itW to b« sevii in the jutoo
rflftt vriU «it)i uvnl inicU'i from th« vvsavl wiilU, Itemile», red iliik» and
'ftw nuclei of i)tn«r«iit sixo, the l»lt*r re«uUiiij; from the rupiure of ili«
celU witicti contained tliem. Ity examining the acr!i]>iiij;3 or tlie juioe
atone, these tumors cannot be d in ti liquid lied from futrcoauita auil enee]>lta>
loid carcinomata.
For tlicir recoRoition, it is nrcossary to study thin sectioiks which have
been jicncillcd. 'l*lio reticulated stroma which forms the reiil basis of
these tumors is Uien very cvidonl, ftml is seen to be tn conueetion with
ttio capillarÎM. (Slh- Iî;^. 107.) In the ciise of adjcniu iliv hliioilve^teU
arc filled with gh)bulc» which do not color by carmine. In leucocy-
thiemia, on the eoutmry, the dilated ciij^tlnrirs arc filled vriih white coV-
pwtcle^, wbieh am readily i>tninvd by carmine. Capillaries full of vhite
bloud-corpuAclcA are aUo met with in all the or^aiu, aa that by this
characterialic alone we can dia^iOiW! after death the leucoeylhiemie coii>
dition.
tiKAT. — Lymphadenoma of the lymph glanda determines a con^dvrablo
increase in the sise of the follicle.^, which nre compi'ciiscd and modified in
fonn. The connective tissue of llio medullary part seems to have dis-
ap[fenrcd, in onlpr to make room for the hyperirophicd cortex. Upon tlio
cut «urfuuc open «pace» are seen, which correspond lo the Kwplialic sinuses
envelo]iinj{ tJie follicle. Kveryvihrn^ the enlar;;ed ^laiid.i prenant this
same structure ; ihey arc entirely coni])osed of liie modified conical Aub
BteiK-e.
The thymus gland, even at the h)^ nhen it has undergone almost com*
Eilete atrophy, may in leiicoeythiemia or adaenia réassume iu orignal
imn, and become the seat of adenoid tissue.
The spleen may suffer an attcradon simitar to that of the lymph glanda.
The le«iou is in the Malpigbian bodies, which corre»|iuud to tiie folli-
cles of tlie lymph glands.
'Jlift liver preitcnts many distinct alterations. Tlie one which is jiecu-
liar to hiueocylhwraia consist!» in a diltmte njwplexy of white blood cor-
puscles. The whiti.^h i.«lands, which in the liver have been reganled as
caused by a hyperplasia of the connective tiitsue, result in this cane from
an accumulation of white blood corpuscles ; the hepatic capillaries allow
the escape of a larj^e ciuantity of white corpuscles, which spread them-
selves belwccn the liopatic cells in a limited or ditl'usc manner. The
liver cells undergo fatty degeneration, and may be thus destroyed. We
bare, then, not a formation of adenoid tissue, but a real ttpoplexy of the
white corpuscles of the blood. Besides these «mull products, there are
in the liver (genuine new formations of reticulated mletioid tissue. I'cr-
baps the extnivasAted white corpuscles above mentioned may bo the
starting point <if this new tiiuiuv. In mlicnia it is almost certain that this
is itol ao, and that there tlie origin of Mie lymphadenomata of the liver
must be altribuud to a hyperplasia of the coiniective tissue.
In adicnia, we have cousuntly met with a notable hyportrophy of the
144
TUMORS.
liver, eonncoted with a conpcstivc ililitinlion of the ve*«eU. Tin» kidnejwl
Iiri'M^nl two Itin<U of Icr^ioiH, wliicli un in erery respect «imilar Ui t(»«e of!
th« liv<T. In till' imic'iuH iiK'iiiliniii<^ of tlie Ktomacli and iiitt-Kiînes Ivdu]
phaitiMioiiiiita arc frciiiiDiit. Their iinlure may be atiggeatod to tlie uaVed
Fig. 107,
Fnm ntnmntt ctt/sftlrtajtrrffy/iarlllk'i •
eye, w which they appear u emboiued, gray tiimord, nnironnly co1(m<t
or spotted with ecchymoses, soft, and nlcerated at their centre. In their
neighborhood the mucous membrane is thickened. Under the microMope,
and iti [icrpcn'liculnr hccIioo, th«ae CumoM ahoir the tnhular ghnds with
grnmiUr contcnti-, Ik-twci-n the latter and below them is a reticulated
tiif.*ae of new tbmmlion, charactt-rized by lar^o meshes, thickened tra-
kecnlic, iiivl a few niictcntcd nodes. The glands of^n cntirtdy disappear,
leaving oidj adenoid tJHitiic.
The tumor* of the ittomacli are often extensive and 3 to 4 centimi'tre»
in thiL-kiietu. Tlieite larj^e lyraphadenomatJi may be mistaken for other
kinib» lit' turaont: their noftness, their ulceration, their juice, may ea^itly
cause them lo ho confounded with encephaloifi carcinoniata, or with epiihe-
liomaia wiih cylindrical cells, if use is not made of the microscope.
I.ymphadenoniata of the lar^c and small intcstinea ;;eneralty present a
very ijrcai similarity to thosv of the stomach, ituc wo also find in iho
intestine small acuminated tumors resembling very much the hyportro-
phtcd follicles of typhoid fever. When these arc slightly ulcerated at
their cpiilro, they show A dwpri'Mcd area. One might think that tlicro
il* niraply a hypertrophy of a suliinry follicle, hut this is not so. In
these little tumors the jçlanda of litcherkiilin are surrounded by ft reticu-
Uto<l tissue of new formation.
TUU0B3 HAVISn TEKtS TTPB IK EPITHELtAL TISSCB. t15
Tho lungs iniT be the seat of Ijmpbadcnomata ; so abo amy the bones.
Lvni|>UiiHcnofiM la common in the divcn or^^ns which we have just paaaed
in rvncw, l>iit it mtiy bi' met with in other p»rt8 of the orgnnism.
llio DRTEixirMBNT oT tlitMC Uimors c»u be well stit'lifd only in origans
Ttben adenoiil tix^u^; does not nntnrnll^' cxtHt, in t)iv livur, in the ktdncj's,
in the bono», for example.
The fintt pliMC of thoJr ilovetopmcnt consî»ts tn tlio production of a
msaa of embryonal tissue al the exjicnae of the intenttitinl oonnoctivo
tissue of the organii, of tlie marrow of tlio bones, and perliaps of tlie
white btood coq>u9cleB which have escaped from the vesaels.
In a second phase, some of the embrvonal cells put forth niimeroua
prolongations which come in contuft wiiii each other, unite, ami form a
complets network. The traheculic of this network are at first thick and
«oft; little hr little thcjr condense and a«<ume the character of a retica*
1at«<l fliroma. Tliose embryonal cells which do not undergo these cbnngoa
roinnin imprisoned in the stroma and form lymph corpuscles.
I.ymphnitenomatn are «nhjecl to diverse wo»lPlc.\Tii)S« of their tisane.
DiJfuKf lirm'rrrint}fr» ate frequently otwerveil. They may bo limited
to the tumors, or they may sometimes occur in titMuej and or^ns where
the new growth i» not found. The latter ia the case particularly in leu-
oocytliieniia.
tHfaretimtt are common in leucocythiemia. It is not known whetlier
they exist in adie»ia. They are charaeteriised hy whitish, opa(|uo, caaeaua
islands in which we still see the structure of adenoid tîaaue, but th«
latter )iM snifered atrophic mmlifiiratimiM, alToctinj^ at one time the Btroma,
at another tlio lymplici'l celU. 'Ilie vesseU are then traDtfonaed into
grannlo-fatty tracts, opa<iue to tran.-imitted ligtit.
Tlie niAn\'Oâi« of lymphadenotna can he made only upon pcnetlled Mc-
liona, when the truly characteristic reticulated stroma is revealed.
We will not dwell upon the l'Ruo.suî'iîi, since it is alwaya in subjects
«ho have succumbed to tlic generally rapid progrès of the disease that
ve find these formations.
IX.— TUMORS nAVIIfG THEIR TYPE IN EPITUEtlAt, TISSUE,
In the skin wo hare a structure showing the variations which the
epithelial cells can experience under varying physical conditions. Wo
do not think that the di«linction created by [lis between endothelium
and epithelium can be accepted ah absolute ; iiud the opinion «f 'HiieiXih
that all epithetia «print; tn^ «n epithelium seems to us contradicted by
what takes place in the formation of the epithelial celLi which cover
Sranulalions and fislulae. It is very probable in this ca.se that the epi-
lelia aie derive<l from embryonal tissue.
The hiatorv of cancroids demonairates very positively the formation of
epithelial cells in parts which are void of tlieni in ttie normal state; for
example, in the medullary tissue of bone, in the lymphatic glands and in
muscles.
in tumoTf, cpitliclial tissue niny astume different characters which give
I liae to aa many dialinct classes.
10
146
TCDIORS.
1«t CloM.-^^cv opilhdial tissue hiirin;:; uii nrrangeineat into UL
or TnassoM, which do not taku tlic slmpv of dc&uit« orjjans. Thono ai«'
t}nthtll'i>ntUa, properly «p<.vikin<;.
2</ Via»*. — Kpitiicliul tiMuc ouvtrrin^ pnpillu; «aoh arc papillomata.
Sd 67<i««. — Kpithelium «rraogeil as in {;lnnd«; «iicli arc ii>V4-M'>»i'ir<i.
4tA C'aai. — Kpitlieliura preaenliiig a c^-»tjc cavity ; these arc cff¥ts.
l«T Ct^oH— Epith«lioinft.
Dkpixitios asd CiJiBBiFinATiox OF Ki-fTiiEi.ioM.t. — Kpillioliomal»
arc iitso ile^ignaleil iimtor the name of ettn/^roid-, epithelial caiin'r, or
t/iilMiiil niri-iwima, Iiy (ierinan aulhoni. The pntyadfttoma and hfter-
a'i">iie tumors of several French writers are nothing else than certain
varieties of epithelioma.
Tlic c^'lla of opithelioma are disposed lo Mratifieii layers — Pax'KMKST.
ct:i.i.i;[> Ei'iTilKLloMA ; or they arc t-yUndriml and generally form only a
sin;^e layer — CïusimiCAL-uELLEU kpitjiiu-ioma.
Pavk«ESt-cei,1,e1) Kpithemomata present several spodes; —
1st, L»hulnU<i fi'ithfll-'mii, in which thcif is ini epidermic ovolation,
2d. The cpîdennîc évolution \» wo longer decided and the cell» of th«
lohnlo having sulTi-red deiticcntion have become corneous. £}iit/ntiotMa
xeitk fin'YMlric CfU-tiftifii.
3d. The fihrous liwiiie which forma the stroma of tho tuowr » «Imid- '
tielled by caviliea in the form of tubes filled with pavement cells, which
show no epidermic evolution. Tuf'ttlitcd epithvli-imn.
Cri.lNt)KlcAU-cei.U!i> ei'itiiklioma present only one species.
l8T SPECIK8. — LOBCLATED PAVEMEST-CgLI.EI) El'lTllELIOUA.
It is this species which has sen-cd as a type for the classical description
of cancroid. It is usually seen on tlio skin and tho mucous membranes
covered with pavement epitlioliiim. It present* to the naked eye a gran-
ular aspect; a cut surface «hows n gray or pink ti^ue, upon which
opaque or tmnslucent poinl» and fihroiw tract» appear very distinctly.
The consistence of the timior is unenual, very friable in certain points,
more dense in others. Usually iu ti^nue may he broken very easily,
which led Cruveilhier to give ii the name of fraijiir. enncfT. By scrap*
in;; these epithcliomata with tho edge of a
Kg. 108. scalpel, a grumoua opaqno substance is ob.
tained, which does not mix with water.
Cancer juice, as we have seen, is readilv
miscible with water which it renders uni-
forridy turbid. In the scrupings wc 6nd
cclisof varied foniis: some resembling tho
epithelial plates of the mouth ; others pos-
MAfing one -ir several |irolongation!< ; they
appear fusiform when Keen in profile, and
flat when seen in surface ; sonielimes sphere
ical cells diiilended by a colloid vehicle,
Bplasa* •ptiliill&l eeninf •«■•trwll
LOBCLATBO PA VEMBST-CELLED Bf ITHBLtOM A. • 147
«liicli contmcW by tlic addition of «etic acid, arc oI»Mrv«d; rarelj. wc
obuin in itii« nmy d(.-ntat« cells liko those of th« nus miicosuni. (Fig.
108.)
Very often in Uie grumous fluid thus obtAÎncd wc find ^lolw^ conipo^cil
«f p|iidern)ic evils di:*posvd in concentric layers, like llio Ifnvr» of un onion
(r, b, fig. 100); the» ara Uiv cvU-neets, the pearly liodicii, tbe opideruiii:
Fig. 100.
f
^V Itx» RBslai. nxai«ioilwrl(h<(koiriu*r1IB*(lalpt««l4li r«^ btdlw ( »1I-m>uj. o. CïMhtd
^hervs. The c«»tre of these «phcreii in sfiioe on»e«coiitAÏns colloid colls.
Tlicy may xIaa {Miueu cells wbich contain a considerable number of nu-
cW. (Fig. IWJ.a.)
'V\i\i*, we Hee tltat by examinin^ç the scrapings from a cut surface of
8(icti tumors, some indications are fumisltcd suggestive of the nnturo of
tite tissue. But, for a coin])lel« undi^rstanding of tlic morbid j^rowth, it
is necessary to study thin sections which iiave been cut from Uio titntor
in Tarious directions. If the svction be made perpendicular to tlio sup
lace, lobules formed of epithcliuni and evnnixted together by band.-* of
epithelium an- si-eii. In m-ctioiis parallel with the surface, only trans-
verso cut« of i««liitvd lobules are visible.
Tbe lobuli*» »re formeil of epithelium similar to that of the epidermis.
At their periphery, tlie cpittielium is composed of cylindrical cells ini>
pUntei) pêrjwridicularly to tbe «all of the lobule. .\» we adi-anco from
tbe periphery tonards tlte ceutre of the lobule, an cpidonnîc evolution
148
TVMORB.
Plu- no.
stmilnr to tlinl of the »kii), ia oKierved; that ia to s&y, we find first a
lajer of cylimlrical cells, Inyers of dentate cells, then flat comeoTia cell»,
which heconiing dry form an epidermic globe at the centre of the lohnlo.
The mode nf forrantion of these cell-nesta is th«« easily undcretood.
The lohulea are separated from one another by a Htroma, Benertlly
oonsiatîng of connective tiasuc, which scn'cs to sustain the urt«ric«, ca)>il-
laries, and veins: these vessels never pcnetnite into tlie epithelial mait-ses.
Lobulated pavement epitheliomiita )ire«enl varielio* according to the
faistoIo;^eal alterations of the stroma. The strum» may be composed of —
a. Kmbryonnl liwue with DumerouM vessels;
b. Mucous connective li»»ue ;
e. A<lult or fasciculated connective tissue ;
d. All those varietiea of tissae combined.
Aliemlionii in nutridon of (he cells of epithelioma permit of the recog*
nition of two varieties : rotl"il^ and corntnu».
They are annlngona to what we observe in the epidorm, where the cpi-
ilenuiil cella, instead of drTin<;, become colloid when there is an irritation
of the skin. At the commencement of the
alteration the ilenUit*.^ cells, from an iii-
creimcd nutritive supply, show a vc«icnlar
state of their nucleoli. The nucleus itself
becomes distended by the transformed n^^
cleolus. Thia nnwJihcaiion is observed in
the cella of lohulated epithelioma. Soon
the cells themselves become vesicular and
tilled with colloid matter ; they may then
open into each other and forin iin areolar
system, of which the trahecul»; arc formed
by flat ei>idermic ceils. These elenicntury
lesionx. which are seen in ve.iidcs and pus-
tules of the skill, also sometimes appear in
epithelioma. In the latter, the most com-
mon modilicationa consist in a colloid
drop which replaces the nucleus, or the colloid matter may be formed
around the nucleus in the protoplasm of the cell, and crowd the nucleus
to the periphery. (Hr. 110.)
Both the colloid and corneous transformation of the cells of epitheli-
oma may be present in the same tumor, which is rare, or one may exist
singly, when we have colloid or corneous epithelioma.
liobulated eplthelt'>mata arc subject to «/•vnifi'in. This idceration is
caused by disiiite;{ralion of the epithelial cells, or by gangrene following
obliteration of the vessels.
In the first case, the cells constituting the lobules easily liecome de-
tached from each other by softening of tbeir cement substance, and fonn
a grumous mas* which can bo s(|ueezcd from the tumor by lateral pres-
sure upon it. The proliferation of the connective tissue at tlie surface
of epitiicliom.ita may be intense enough to give rise to granulations. We
have then a papillary surface covered with epithelium, as in the adjoin-
ing figure. (Kig. HI.) A partial or a total gangrene of the tumor
ift brought about vrhon the epillielial lobules iucrcasing iu size press upon
EpUhttlKl »U»> froMi lb<< rrin ninpf-
Mm, durliif 'liihi IrrliMloo. DviiUU
«alia of ibD vif'dvrniK. Ihv biiolrl nt
whlFh ImobKoluBlMkuliil b/ •.lUk.
(]i>nDrTh«iiqc<l«ioIii«- A.QDfinftliitifflQua
«dA ni]et«iui: ^.llllhl»4 qd«Io<p]ua;?,
■iMniioa-
tOBVLATBD PATBUKST-CBLLBD EPITHKLIOUA.
14»
»bi obliterate the neighboring vesaela. This U seen rery FnKiuonUy in
tviDorfl of the neck of the uterus.
Pi». 111.
VfTtlnl ml nf III* rK* BDa"»"» •< ih'larikilotKil n •miMn» pntinU, if, r. OadilH raSHj hfiba
tMlfilkc Mki< of ihfeill'.tuil. >l lti>»vs Uia«. llltiliriib |iiit«r(ii)>«l*t. a,«. Bplibslid «Hi.
*k MMu mil (MlaUUtf !"■ wpUMlw- X V».
Bkvkujpbknt. — Xjobulated ejwthelioraa hM it« origin in the epithelium
of the skin and mucous membranes, or in neighboring embrj'oual tissue
of new formation.
Rindflcisch entertains tlie opinion that the ne» epithelial tinuc ma;
also be ileTclopcd bj- tlie appsition and metamorphosts of young and
small coll» in the connective tissue at the border of the epithelium. We
admit (he orrcctness of this opinion in many case^, and think tJiat tbe
fact i# to be oxplaineil by a sort of iftion Je prttMnrt, or epithelial
infection. We reco^^nixe iu this an occurrence analogous (o that which
is seen in embrjona! tissue when, irrespective of iti4 origin, it is trans-
formed into bone in die neighborhood of bone, into mii«cle and nerve
when it is in oontinuity with those tissues.
Lobulated epithelioma is u:jually developed by an extension of tbe
rclc mucoeum at the bottom of the inlcrpapillary projections. The epi-
thelium pcnt'tniteB the dorm by u growtli of new celts, formed very prx>b-
ably from adjoinin;; embryunnl cell.t. In fact, the tissue which Is in coa-
nection with the newly-fonniMl eitrhelial pv^s i« always an embryonal
tissue. These epitlielial offithoots bury tlienij^elves in the derm while
presenting constrictions from jioint to point in such a manner as to afford
a lobulated aspect. Hpillielial shoota may also often arise from the lateral
portions of old pegs. The epithelial massea may originate in the hair fob
licles. The epiihelia of the siieath multiply, the hair «oon falls out. the
limiting membrane of the follicle disappears, tbe surrounding dcnno-pap-
lâo
Pig. ns.
Prgltraratlan df Ihs rpllliatui ctl* ot ubx-
truat (liuili In ■»<'!>( rpllhpilau*. a. ItfA-
ihi'IUl »ll> In l'raiM <il iiiiilHpInlIuu. i.
e*b4<'*on> ("111 aitnl wnb fol. s, AdJulBlsi;
(•aBMII''t II*tDl>. X ^''"^
illarT tUfiue U penetrnteH b; epithelia] hwh, nnd the pr(ic««) is llien tli«
same HA in tbc preceding case.
In th« sebaceous glands, which normally present only one or two
periphenil Uyer» of pavement epithelium, wbilo the centre of tba
acinus U filled with fat cells, we see :
at the beginning of epitbelioma (he
pcriplieriil piivcmcnt oclla ÎDcrcnec id
number, and the limiting membrane
of tlic ginnd dii>9ppcjir. In this way
the sebnceou^ glands Arc transformed
into Inbule» of e|iitlielionia. (Kijç.
1112.) The pbenom«na which tak«
place in the Hudoriftarokis glands are
more intci'esting. In the develop-
ment of epithelioma from tliem, we
observe at first an accumulation of
cpitheliam in their interior; their
central lumen is filled by the new
formation, the whole sudoriparous
tube i<: disUrnded. and the limiting
niftuhriitie noon disappear*. The*e
cylinders of epitlieliuni invade the
siirroinidiiig «mliryniial liMue by
sending out epilholial buds; tbey
nnaflioiuose and form « network.
They consist of small pavement epithelium, and, bv ulterior modifications
in form, they heoomc kibiiluted. Finally, the lobules may become iso-
lated. [The gnnvtb of an epitlieUoma of tbc skin, according to the in-
vestigations of Kocitlcr, tnkcs place through a proliferation of the eitdo-
tlielial lining of the lym]>hatios of the part.]
Whatever may he iLi beginning, lobuJated vpillielioma may continue to
increase in Ni7.e by the growth of ita own maiw. Many bi»toIogiMttt (hiuk
that an cpillielioma continues to grow without cen^ution. Where the
progrès* of the tumor is very rapid, the neigbhoring jjarta ahow, in the
papillic, in the hair follicles, and in the glandi«, the .same pathological
phenomena as have been mentioned respecting the geneaia of the tumor.
The muscles present at first the same modifications as those which
characterixe iiiflamnuition. The fasciculi are rarely intact : they usuallj
show the result* of compn-ssion and other interferences with their nutri-
tion. They almost always present a fatty infiltration or a vitreous nieta-
morphoùe. The epithelioma spn-ad» through the embryonal ma» which
haa taken the place of the fasciculi, and which has sometimes extended
among them a very great distance.
Osscoiw tii«ue ]>re3enta aiialoj:ou« lc«ion«). An in inflammation, we
have the formation of i^tnbryonal marrow and the destruction of the o^ee-
itu lamell». It is in the midst of this emhrymial ti.isue that the epithe-
,al formation takes place, and it is frotn this new tissue tlial the epithelial
nodules grow.
P^pilhclioma may be generalized by the production of secondary nod-
ules at a distance from the primary growth, in the nearest lymph glands,
EPITHBLIOMA W[Tn COKOBNTRIC CRL1.-NB8TB.
^■mk^Bgle of the ja«, in epitlieliAma or tlie Up, or in tlie internat
VHOJnr, M lli« lun^, liie liver, the kiili)«ja, CK. It «lioiil'l i>e stitteil,
however, itiat fwcomlarv fonHatiouH iu the viMem are very nre, and
their hjstvtogical dei'elo|iment haa not yet been well studied.
PHOHX06I8 OP l^niiLATKi. Ei'iTiiKtiOMA. — Tlic f^vitv of lohulated
epitlic)ion»ta Taries greatly according w die Dtructiira of the lumor and
ita K«t.
The nifl«f ifmrf nre tiote whi'-h fn>»»tê» a ttroma rntinlif embrtional,
and lioK tn wAiVA at ihe p<ri/>/irrj/ of (Ac tuut'ir iht iMHMf^tivt tiêêite
jiraunit fke tamf em/'t-t/oua! c-nniUiion. iSuch an Appearand aigiiificH
that x\iK epitliolial m»«< i!< mpiillv extcnilinjr.
The pnrw of tin- Ix»! v where the «Ivvelopmeni of an e^ûthelioma ia most
mpi<l are UiOm wlik-h are mo^t abnndanlly »upptied with lymph vessels,
ihoae where the hlood circulation ia most active and which are raoitt ex-
pOiWid to irritations. The lips, tlie tongue, the eyelids, tlie neck of the
uterus, «ic, often exhihit epilheUomata whose progress is ae rapid and aa
promptly fatal aa is that of the most malignant careiootnata. And vet
tlieir fltntcturo is idcDtical with that of epitheliomata of the nose aiitî of
tfao chi.i-t:. which remain ({iiiescent for t«n. fifteen, and twenty years with-
out inducing; grave accidents or incrensint; in size. Kpitheliomata of slow
progress «ouietinics ehon a cicatrix at their centre while the tumor M
aprcading at the borders. After liaving remoiuud stationary for a long
time, tliey may suildenly commence a more rajiid marcli. This fact showv
that llto malignancy of'a itinior is oot ao closely related to ita biAtologicnl
atruclure aa to its seat and its mode of development.
2d Species. — EpiTin^uouA with Ooncentbic Ckli^xkih'B.
Thesetumore bavoscertainsimilarity tolobalatedepitlieliomala. They
are lohulated and often encysted, 'j'heir cut surface ia dry, oimcjue,
whitish, slightly shining, like cholcsterin.
There may be a few crystals of chulcsterin in these tumors, as there
are sonH'tiract in the softened p<iiiit«of tobulalcd epitheliomata; but their
•lûuing aspect is nsunlly due to <U'siccatcd C)>idormic lamell».
By «craping, we obtain small pearly grainit, vi^^ihlc to the naked «y«,
having a regularly round outline, or siich as would be presented hy «cveral
lobules united by enveloping concentric layers. 1,'nder the micro.-*oope,
these little granules very much resemble the spherules of the choroid
plexna and of angiolithic sarcoma: but they contain no calcareous sails.
When they are colored by carmine, one sees, in their exterior layer,
united enidermic cells showing atrophic nuclei stained rc<l. Beddes
these epidermic pearU, isolated cells of corneous «pithcUum may be
obeervcl. In Mme cases, spangles of cholcsterine are also visible.
In thin sections a tissue chamcterixcd bv lobides wliicfa resemble
Qtosc of lobulated cpilhclioma is nlmerved. nut when these lobules are
attentively examined, it \^ seen that the epidi-miic evolution is stationary.
Instead of there being, at the periphery of the lobule», layers of cylindri-
cal and Mralified pavement epithelium, we observe only a single layer of
Bal cells, Die nuclei of which are atrophied; the whole mass is seen to be
Ifi2
tCMORS.
transformed into coroeoua celU, Tlieac pearls arc sometimes conipletclf
separated from each other, somelimeH united by very fine jicdicles, which
are also formed of comeotu ccllfl. Bclwrcon the loWes tha» cMMiUited I
esistH a dcDBOvaiin<;ctivctift»uocontaiiiin<;no VL'««ols. (KoorsWr.) Th«M
tumors arc so rare that vc have svcn only thn^c examples.
I)K%'Ki,ûi>»iRNT. — i^inoc ihcy have ttc^uirci) their full d«v«topmcnt and
have lict-ii for a lou^ time stationary at the timi.- of their ablation, their
hi-^tolo^'ical lievelupim-iit is not known. But Uieir «milarily of location
aii'l siruciiire to lol>ulat«d epithelioma warranta h oonjeclure of a aiimlar
gênent a.
i'HouNOSie, — These tunom are very benign, but the reason of tlieir
beniguaocy is not understood.
8d SpKCIBS. — ^TUBULATl!» EPITIIKUOMA. '
Tubulated cpitheliomata have received different naine«. lîillrolh has
dMOribed, under the name of ^i/littiiroitut, inmnn which appear to be
related to them. Kobin has clarified lobuUlcd and tuhtilated epitheli-
oma and carcinoma, as well n» many other kind* of tumor», under the
hetiradcrni'- hitH-rf. Broca ha« named ihem /«'li/aili-jiamii.
The epttheiiomata apriiiging from the ^udoripamuâ glanda and well
de.icrihed by Venieuil. enter, in pari, into this species.
Ukkisition. — 'l\ibulated epitheliomata may be defined as tumors com-
potied of plugs orcylindere composed of jiavcment epithelium undergoing
no epidermic evolution, anastomosing witli one another and imbedded ia
a stroma, which con^itt» of emhryonul. mucouM, or fibrous tissue.
The first «tage of dwelopment of lolmlutt'd cpithelioinau from sudori-
paroiLS glands gives exactly the sami; pictnn' which tubulated epithelio-
mala present iu their tilate of complet» development. Hut it should not
be inferred from this that tubulated epitliciiomata are cancroids which
have conuQcnced in the sweat-glands and have been arrested in the first
stage of development. They may appear in organs which have no sudo-
rimrous glands, as in the uterus, even in paru; which have no glands at
all. as in the lymphatic glands.
J Desciiiitiôx. — These tumors are regularly gphericul. or oroid. f pon
a cut surface, they show a tissue resomblia^ a ;;]and or a sarcoma, out
the naked eye is insuflicicnt fur a diuf];noiiis. They yi(dd no jutec by
pressure. IJy examining «crapin';». we may acquire some idea of their
structure, pvegments of cyliiiders compcsKd of piiveuimtepitheliuin are
thus oht.iined. These cylinders unmeliriies are branubed; tlieir bodies
are regular and generally |iarnllel; tlieir extremities are limited by
irregular sinuous edges, the result of breaking. The ceils wbieb consti-
tute them are small, of equal siae, and limited not by a sharp, but by a
dentate border in such manner that with a slight enlargement and a poor
cbjecuvc, their boundaries cannot bo easily dis tin }>ui shed. (Fig. IV-i,
B.) In the scmpings, besides these cells, we also find fusiform cells,
free nuclei, and the cells or perhaps tbc fasciculi of conneetivv tissue.
But the various eleuient« funiîsbed by scraping are not characteristic
of tills species of epithelioma, for, at the commencement of the develop,
mem of a carcinoma in a gland wc may encounter in tlie scrapings frag-
TUBULATED BPITBBLIOUA.
1&8
neota of epitltclïum prosenting the fonn of solid cylindcre, which perhaps
bfloDg to Itn irritated gUnd of th« rt'givii inviwlffi.
Upon thin section» we 8«e anaatomosiag cjrliiuloN of pnvenwnt «pitho-
liuDi, imbedd«d in a stroma of variable conatilutioD. Be«aus« of the
Vif. 113.
L HntlDa «f ■ tokoliUd «Mlhtlisn». n. Ï4il<l oxltadon fonnod if piTtnosI <pl(bt4iiiia. k
Stnaa cbuiK>tl*4 bf tBb» vhkb 1adf> lha<rlluil*r>. x *>- B, Ei'lttialUl cill> fruoi ibii hds
la»**. U«U(*4 nlikswiof ili«-l*at*ilaiitat >plD» trj aumof ntiicti tbtjrkn oulltd (utailiochy
8pinDu^ ^urfiicc of the efnthelin, the Wrdera of the cells are not rery «lis-
tiuct, giilir^K Hiti suction i» extremely' thin. The stronut 19 lUaally fibrous
and very dense; but someûniea it i^ miicoa^. In thiii cqucour tissue,
surrounded on every side by epithelial pluj;^, the ptaamntic cells (con-,
nective tissue corpiwclea) are sometimes degenerated anrl destroyed ; a
HtUe cavity is then formed and 6lled with mucou!) fluid. It might be
ima^ncd that ihofe cyslic cavities come from a dcgenoratJon of the cm-
thclinm, while, on the contrary, thcr rrsutt from an uUi-Tution of the
etnintn. Itindfletsch has given to similar tumors the name of cgitie
tpithftiomaUt.
The pavement colls may undergo colhtiJ degeneration.
lliese tumora may also «how in certain poinu an epithelial evolution,
there may be more volumiiinn» lobule.'*, with corneous cells at ilieir centre,
a dispusiliou which cstahlishes a relation between them and the previouâly
de9cHl>ed tubulated ejiitlielioma.
Sk.\t asd DuvKfji'MEM'. — When tubulated epitheliomata arc seated
in the skin, their development is from the sudoriferous glands. This
origin was observed a lon^ time ago by Vemeuil. Because of their
1&4
lOftS.
114.
derolitpment in the deep layers of the skin, lh«BC tiimore ulcerate mora
8lowly than tlie preceding species, .\niong the oaroerous Uimoni of the
DURinHe form --rly described under tlie name of curciDoma, some corre-
spond exacdjr to (hv description of tubulntcd cpUbelomn.
Mnnj of tlicse tumor* «fter liavin): attained
a certain degr«c of developmonl reiimin st
tionary. Snmetitnea th<^y continue to iiicreasH
in me. In tlie lutter case the epitUelialcytia-
den terminate in cuU-de-sac in the midst of i
embryonal timne. Their extension ia eOecte
by an epithelial metamorphosis and *WO^
dition of tlic cells in the adjoinin;; connectiv
tissue.
l'Ko<ixo?ifi. — The srav'ty «f these tumora
is less than that »f lobiilatetl vpithrliomnta,
but they often return after remotal. The
lymph «lanits arc sometimes invaded by sec-
ondary formations of identical structure.
Whftii they are located at the neck of the
uterus, their progtmsm i* m grave a» that of
Otlier forms of earcinomatou» or epithelial
tumom in this region.
\Vithtubulat«d epithelioEDtita we vroald class
certain very rare tumors described by Itobin,
Foerstor, etc., which present a very peculiar
amtUEcment. 'Hiey are constiliitcd \>y i'[«-
tbelial plug» imbedded in tlic miiUi of
fibrous tiagne, and showing at their centre refracting ovif'>rm bodies con>
necteil together by prolongation*. In the interior of these bodies Stella ta
fi;Ziires are sometimes seen. Koentter called these tumom epilheliomata ;
Kobtu cla.iiiified them with bis heteradwnic tumors. Ordonex regarded
the lar^e oviform bodiea as sporangia, sometimes containing spores similar
to those of mushrooms.
Sh In nf ■ l»b>i*«f rpllhrllnin».
n. Ol.llj|U4 ««Ttïuii« ^>r oy11uil«rB of
*t>illi*ll*l nILi. t. rilinai •Itnna.
4tii SpKctEs. — Cyl[sdiiicaij.ceij.ki> Kpithkuoma.
T>ii«;overeil by Bidder, this particular kind of epithelioma bas been
deccnhpd by Focrster, by Vircliovr, and wc ourselves bave unalyxvd and
piiblirtlied tt large imriiKcr of caacs. These tumors wore formerly entirely
coiitViiinded \tilh epitlirluid and colloid c it re î noma.
They are characteriied by irregular or tubular cavities juived with
one or more layers of cylindrical cells, and separated by a stroma whidi
may be fibrous, embryonal, or mucous. Their cylindrical cells arc similar
to those which cover certain mucous or glandular cavities, and are always
implanted perpendicularly to the wall, (Fi;', WA.)
Tb« aspect these tumors present to the naked eye is variable. They
nifty appear us round masses or, in theinteutine and stomach, as nummular
priiniim-nees of varyinj; number and diameter; they arc in the latter ease
u.'tually ulcerutcd at their centre. When, as is olteu the case, they are
reproduced in the liver and other organs, they have altogether lb«
CTLtNDRIOAt-CBI.LBD BPITHSLIOMA.
cyv itpp«)ininco u enceptinloul cxrcinoouttA. Genemllj
ri«h in a mitky juM«, «ml »ott. tint thi« mf\no8s tni juico
uv probabi}' in great part <lue to cadaveric nlturatinn. Post-mortom
aon^ïniiig being less rapid iit winter tlian in 3umm«r, tliequauUt; of juice
varies accordingly.
The flnid ofilained bv scraping is docidedly {irumoua. The elenienU
contained in tlio juico are cylindrical cells. They often have a double
oonlourM border at their free extre-
mity, and some présent at tiii« end a
Tesioular dilatation. Thov are uan-
Flg. 116.
ally rtonsatcil, but some may be po-
lygonal and more or Ictw irregular.
They jiotwcM on« or more ovoiil nn-
clei, conuining o»u or more brilliant
nueleoli. Often in tbe juiee several
cylindrical cclU are found united at
the ittdt^a, and ^honing their double
contAured free border, an ohject in
itself sufficiently characteristic to jus-
tify one in af5nmn;j; the presence of a
cylindrical enilhetium.
Tlic histological nature of the tit-
mor must be lcanic<l by examination
of tbin flections. In the latter one
«illncv Uibulftror irregular cjivittex
iMved witli cylindrical <>|iithelium.
Tiiese tubes sih) npace^, wiiich some-
tiuKS are sinuous and present papillie
at their surface, appear to have no con-
nection with the neij^liboring inlands.
The latter may, however, become hy-
iwrtrophicd, and form a very distinct
layer upon the eurfaco of the tumor. The celU are directJy planted
upon the struma, without the interposition of any basement membrane.
The free surface of the tumor is often Uie seat of papillic, which are also
covered by cylindrical c|)ithc1ium.
If the tumor lia^ completed ibs development, the stroma i« f;ener.illy
fibrous. Hut it \* vClen embryonal, and in certain eases it is entiiely
mucous, aa in myxoma. The stroma ntwnys carries vessels, which are
abundant and, if the stroma is vmbryonal, nnnlovitiiK to those of sarcoma.
L'aually small in amount, the Mroma may, on the contrary, predominate
and constitute the hulk of the tumor. The vessels may aometimea under-
go dilatations which are fretpient in the mucous form.
A very important and very common variety iscliaractemedbyacoll<Hd
transformation of the epithelial cells. The latter become transparent
vesicles, and fall into the bimen of the cavity. Cylindrical cells are then
oWrved to limit a cavity Ëllcd itith colloid matter and the (M'tris of
cells. At other times the cells which Uno the wall are ibeinselvcs com-
pletely degenerated, when the cavity no longer possesses the character
CTlloilHnl cflM *vI<I»|1kd» tma Its
i. Insll t]r.ll( ntldo llnartwllh cjllndiiml
Ili« flbl .a <>f tW4> *dJ*>lalM fw1tl44 AI *t
iQUrnt lUu («itiiin. lu ib« inUrlgr of vut*
ami*. Éa ftn ftiaDt|>lii>a* niiM «auislui
lae
TU Mon s.
ofnn cpîtliQlioiiuiirîtti cTlindrical celU. Fatty degeneration of the coIIm
is hnbitually aHaociated willi the colloi<l metamorphoaU.
'Iheso epithelioma ta almost invariablv ulcerate wlien they are aeaieil
upon the mucous cavities, especially io the atomsch where the digestive
and corroding acUon of ilie K*slric juice ie active. At tbc surface of
taiDOre locntcd in the stomach, wc oltcn find coa^uln of black blood in
th« vesM'ls ; this coagulation itt due to tbc actio» uf tbc gastric juice.
DBTK1.0PMENT. — It 18 probable that these vpitheliomaMarc dewlopMl
froin the [;laiiiU by a procciis artalo-^ous to that which lias bcon atoned
in pavement e)>itiieliotan, but up to tlic prcMiit till the phawa Iiaro not
been ïboroughly followed.
Skat. — Cylindrical celled epitiicliomala, with the exception of thoAC
of the ovarjt have never been observed hh a primary growth anywhere
but upon mucous menibranea covered with siwilar epidielium in the nor*
mal state.
In the ovaries we haro seen non-cystic tuinors resembling carcinoma
to the naked eye, which were in reality epitholiomats with cyliodrical
cclla.
Certain polyp4 of the nasal frntsfc correspond in minute structure to tliis
kind of epttholioma.
Seconilnry formations identical in structure with the primary turooni
»re niel with. especially in the liver. There havt- Iwen published obtwnii-
tioiu of secondary nodules in the luiijr> and bones. As they are usually
located iu the iut«mal organs, ii is generally impossible to diflerentiaie
them, during life, from the variotis forma of carcinoma whose fatal pfO'
grcsB and mulignnucy they, moraover, simulate.
UiMisosis-— Their anatomical diagnosis is usually very easy. They
should be carefully tliâcrentiatcd from medullary carcinoma when they arv
aofV, nuit from colloid carcinoma when they have undergone the same dcgeit-
«rutit>n. In lliosi* secondary fonnatious in the liver which have rapidly
progressed, the centre of the tumor is softened, the epitbeliai cells are
dissociated and loaded with fatty granules ; they have lost their charac-
teristic form, and they entirely fill the alveoli. The forceps breaks them
easily, and reveals au alveolar stroma similar to that of carcinoma. This
similarity is such that, if one is not guided hy the younger peripheral
portions, it will be impossible lo make a diagnosis. In order to dis-
tinguish n colloid epithelioma with cylindrical cell» from a colloid carci-
noma, it is necessary to study with the greatest care the recent poi-tions
which have not yet usisumed the colloid aspect. \Vc will speak of the
diffcTcntial diagnosis between these tumors and adenomata and papiUo-
mau, à prirp'M of the latter.
Cylindroma.
[Kindfteisch gives the following account of this peculiar and rare form
of tumor, ilenlc called the morbid growth a siphonoma, Hillroth a
cylindroma, Meckel a tubular cartilaginous tumor, Friedreich a tubular
sarcoma, Foorsicr and the most recent examiners regarded it asa mucous
cancroid. Notwithstanding the widely divergent opinions concerning the
Papilloma. 1S7
future of tti« titmor, U Is prolmUv tliiit the ilifTcrent Author» hurc mfer-
to the Bamc kirul of new Tornuttion. Tbc di'vclopmcnt aniforinlj- id
fsun; tiftcutWy in tlic vavitv of Uic orbit ftiul it« surroundings, «cvins
to wnrnint tins asxumplion, wliilv On- diffcnmcwi of 0|miion coDCvmiiis
tin- miimU' sttnwture of the growth mnylH- I'xplniuei) tiytlie circumitUtiice
tliftt former ii)ve.4ti;*nlont occupied tliemnrtve*, liy preference, witli the
roost (lecHllar rattier tluui with lli« most e«ietitial cliaracteri^ilicA of the
tiet^liuim.
The toMt peonltar prodncts are certain hifaUni- maws, which may be
i»olat«4l b; teaaing. Their peculiar outline is striking. Beiiidcs pcrlcct
epheree, cviindcrs are met with as also arc club-shared and cactii»-like
figures, 'fliprc is often BDappcaniDcc as if these hyaline bo<Iica branched
111 various dir<*ctions from a common point of itnion. Huganliii'^ the
nature and development of thcoo bodies, the opinion of Ilittrotli that
tliey should bo reganled a« [lertraMutar mucous tissue-sheathe or liicir
fragiuenu, wii» the mont wiilcly entei-taiued until Koester, aOer carefully
«iidyinj; the Mnietiire and growth of llie whole lumor, advanced the
bypothivi'' that the hyaline jipheres and cylinders are tlie prmliicl of a
secondary hyaline metainorpho^kig, which the cell trahecultc of a cancroid
of ^le lymph vessels undergo. According to tlic latter author, we have
in all these cases to deal with a cancor-like proliferation of the cellB
in the lymphatic network of the part afTocled. The endolhelia of the
Irmph vessels multiply by division and plu;; up these vesaela. Uyatiue
jcgenenilioD begins firsi in the axes of these cellular cylinders, llio
hyaline mfltt*r thus formed may collect together into «phericnl or cylin-
drical miwscs. Thi» hyaline ilegenuration beginning in the axis of the
vegnels may end in a total ilestmction of tbc endothelial covering (the
peripheral layers of celtrt), when a relatively large hyaline cylinder
Afwears imhedded in the connective-tissue stroma.
Tlie eoiidiiion of the bloodvessels in the axes of the hyaline cylinders
which Ktndfteisch saw most distincUy in a cylindroma of the brain, is
explaine<l by Koester by ^le well-known ensheatiiing of the bloodvessels
within lymph sinuses.
Cylindroma ia a tumor which readily recurs, rarely exhibits metastases,
and should therefore be classed near the cancers.]
So Claw».— Papillom*,
IThtie ttimors arc not coneidered by all pathologists a» worthy of con-
ttitntiiig a sojiarate group. For ns, the definition of papilloma .■ilioidd
correspond with that of the papilliv themselves. Tt is known that the
papillK are constituted by connective ti.isue serving as a support to
vessels which terminate there in a network of capillaries or in a single
tapillary loop, and that tiiey are paved by an epithelial covering. These
normal excrescences upon the skin and certain mucous membranes, are,
io some cases, coverea by stratified and corneous layers of permanent
epithelium — in oiliors, arc paved by a mucous epithelium.
These two normal forms afford ns types of two apenei of pnpillomatti
^•—com«<nit jxipilloma aod mufout papilloma.
PaHIIoiM: ihairlud * «IdkU >i1u(si1 imrllta, «utoiad I7 IhiiUbiimiI aplllwltu». (Mii^|M«at.|
For u tiinior to 1>e called a pftpilloma it i» necessary that the paptllic
shall lii^ formel) nf connective tia»ue, and that the epithelial lave» which
«over thorn .thiill lie disposed as upon normal jiajiillic ; moreover, that Oio
Imwi wliicli co!i:^titutea tlie hase of tlje ppillit âliall nut form a ymrtion
of one of the Sfw-dal liimora pruvioiuly described. Cnro must be taken
not to confound papîllomata with ourconiiila, fihrODiiitu, cnrciuoinala,
epithelium a ta, etc., which present ut their surface pupillury proiDiiicnce^,
and which c"n*C(|uentlj «hoiild »inipl_v receive the qualification jMi'illitrji.
IsT HPBriEs: OoRNKots l*Ai'ii.i.oiiATA. — Tht'y constitute a numeroiu
Yariely of tuniors. Mait nuthor^ include horriH, warts, and comA.
Comn !H!at«d upon tlie toca are caused 1>t repeated pressure or irrita-
tion.i. They commence by a liypertro[phy of liie papillie ; rhe comeoua
layera of the cpiderm soon e.xerl pressure npou thoao mpill% so as
depress and hury tliem like a nail in the dermis. Tho lattor atro{4iie«,
the adipose tissue disappears at the point of pressure, and somednics
cvon there \» formed at thia poiDt a mucous l)un<a in the subcutaneous
cellular tiniiuo.
In tctrt», the papillw liypcrtrophy, rewetate, and ^wa place
secondary papiHis ; tht- coveriiis:, cuniposcd of cell* identical with
of the epiitermii«, vnvclo]i!t the whole papillary \n\\*i \n a, common,
«mooth layer ; or a certain number of the iiapil'Aj arc separated by an
vpidermal covering common to each group. The coiuiective tissue, which
is permeated by bloodvessels, is less abundant as we proceed from tlia
base of the tumor to the superficial secondary papillae,
Jïôrw» may be considered as warts, of whieb the epidermal cells are
întimatety united in the same mauner as iu tho nail*. They are ob-
served upon different re;;ionH of the skin, but especially upon tlie face ;
they arc also encountered in dermoid cyata. The corneous epidermic
CelU are not dc«{uamatcd, but they arc preserved iu many i^upurimpoecd
^V PAPILLOHA. 159
Ujen. There thua result hard, more or les* long nppcndng«s, fonoMi
of imbricatoil layers uf comvoiu epitliclium.
' Certain congenital furri nUo ooiutitiito wrttwui /MptllaiiKtla. Tliey
tn f»rmci1 of papilliT limplo or compound. '11ic«e con^citiul tuiiM>n« arc
BAtiH'tinM-it very 'iiM'i>ly (liginenwd.
2t>tirKi'lK;^: MiK'oiH ['APtu^'MA. — III thiMc papillotnaUi thepaiulln; are
simple or coni)Nmitii. Viiloas iwjiillnmnta, in vi\t\c\i (he papillie re&emble
by iheir lenjttli >iul lenuiiy itito.Minnl vilH, are iioi iiifrei)uentlv net with.
Ttieae tutnortt are usually «imply comprised of papillie ; out tumors
often exi^t where the papillK are combined with cyeta or with liyper-
tro|))iie3 or new formaliond of j;tan4-i. At present we are only conovrued
with true paptllomata. but shall »oon be occupied with tumor» complicatiHl
I by adenoma and {Mj^ilUry cyata.
Ttiff papilliD nrewnt for sludr two parts — tho papillary body ami tho
epithelial covonng. The papillary body has tho form of bnde, more or
less voluminous, pviujs; origin to a j^rcater or lessor number of secondary
and tertiary papillie. Its variable form is dependent upon n new fonni-
I tion of vascular loops. It consists of connective ûsauv in «bîch run the
vesselit which terminale in loops at the extremity of (he pnpilhe. 'I'lio
([unniity of coniMCtive tissue is sometimes so sli»lit that the epithelial
covcriti^ sooms in some eoiie.'* to rent directly uf>on the vesHela. In
pa|iilloma(a of recent and rapid development, for example, in certain
cauliHowcr fun^^i of the j^enital organs, tlie body of the papillte is formed
of embryonal connective tissue.
I'be vessels of papilloma are arteries. capiUai'ies. and veins, which
possess their usual structure. The capillaries are often dilated rv;;u-
larly or into ampulW, aii<l their ruplure fionirtiuii-s give» place to hemor-
rhages which escape outward, or rcDMiin iinprinoncd in the papillary )iody
am) become transfonncd itito pigment. The vefl!>eld of tb« pa[>ill)t; may
present bud» and undergo calcareons degeneration.
The villous pupitliv are j;enerally nimple. and ibey may attain a con.
Hideriible length, eapecially when they are laterally compressed against
each oUier.
The epithelial covering of the papillte is different according as it is
formed of pavement or cylindrical celU. In the first case, a great
number of layers of cells undergo an evolution identical with tluit of the
Malpighian layer of the skin or of the buccal mueous tncmbrane. These
cells arc dovi-tuiled into each other, and the superlicial lavera arc flat-
tened, l'apillomata often possess a covering of pavement ccll«, while
the mucous membrane wheiMe they spring is covered witli cyliiulricul
epithelium. These pavement celts are frei|ucnlly ve^cular and in a
state of colloiil degeneration. When the )mpilla is invested with cylin-
drical epithelium, there is only a itingle layer.
Dkvku'Piik.st. — Mucous papillomala generally spring from the villi
or papilla* of the mucous membrane, but they may form where there are
no papiKie — for example, in the ventricle» of the laryns. The minute
phenomena of Uiese hypertrophies and new formations have not yet been
followed very closely, but the analogy of their structure with that of
inSammatory granulations support» the suppoùtion that their mode of
formation is simitar.
100
TrMORS.
Morefiver. inflammation may be the cause of the development of papil.
loma, as is often the ca^e around callous «kew, etc. >W i»nnot, how.
ever, very closely aHsimilatc papillomata n-ith ffraDuladons, for the latter
t«iid to heal by organiiation, while papillomatA tond to persist indefinitely
M tumors.
Skat. — Wc find pitpilloniatA seated upon nearly nil part« of the cuta-
neoiu and miioous surince. lu the Urynx they n're generally combined
with adenoma.
Often tipoh the extents I irenitnl organs, so-called CAuHtlower paptlliHj
mata develop. Tlicy may be very small or may reach a eonMÎderabl^
81». We are obli^ted to extirpate tliem, and yet it often happen» that
the irritation attendant upon the operation causes them to return — aal
occurrence common to many forms of tumors.
I'apiltomata aro observed upon the serous euHàces, and especially
upon nrticnlar membranes. We have seen pa]>ilUry now formations
sri»in<: from the wnlN of the rcnlriclc» of the brain.
|)ui)xoi)|tt. — The diftgnoM* of papilloma, very easy in ecrtuin typical
bMi», i* j^'nenilly very difficult, and must be btùed upon ft very careful
fexami nation.
For the recognition of a papillomit we must find at the base of the
papillie noitiier alveoli, nor gland ducts, nor tslanda of epithelium.
The cells situated between the papillie must not be taken for lobules of
cfqthelioma; this distinction is easy to mahe, for the latter penetrate
deeply into the dermis or submucous tissue, whilst the most profound of
tht' intorpapillary colls of papiiloratt are upon the name levul as in the
normal papillii;. Diagnosis is ca»y only when examining good prepara-
tions.
PROflsOHts. — Tlie prognosis, generally very benign, can heoome grave
only by reason of the location of the tumor in parts where it may inter-
fere with vital functions.
Can papilloma become transformed into e])ithelioma ? We do not con-
sider it impossible, but, up to the present, we know of do oliservatioo
which proves it.
Si> Class.— Adenoma.
Thtn tuinors correspond exactly with the glandular bypcrtropbiei
described by Lobcrt. They have been cunfmuided with many other
tumors, under the niime» MdciioiiUpolyiidcnoid.hctt'radenoid tumore, etc.
For as, adenomata arc tiunors which offer th« same structure as glands.
Normal glands are divided into racemose and tubular. We also have
two species of adenoma: Isf. Aeinout aiifitonut ; 2d. Tubuhir adenoma,
containing cylindrical epithelium.
1st Bi'Kfu:^: Anxois aiiknoMat.^, — tn the mamma, Cruveiihier rec-
ognized them as fibroui boiJU» ■>/ tfu- hrfntt, Vclpeau, before their struc*
tuR' w[i8 nndcrstooil, named them fibrous tumors, afterwards adentni
tunwr» : Lebert, tiifperlmphirt of the mart!m<t ; Broca classified all tilSM -
epical tumors of the preceding authors among adenomata.
We have very often examined tumors of the breast which have bocn
ADENOUA.
ICI
«liacnoMd *a xdenoid bjr Velpeau, and «n.< Imve found them to bo fibromata,
aarcotDaU, m^-xomata, or true adenomata, the latter very înfre>(|nviitly.
Pl|f. 117.
Aduuiiaa vF UiK BiaM». X*^ |lla>tlM>«t.)
Adenomata of tlie breast are small and are tiauall; blended with th«
nuua of tho mamma, wliiUl tumon wliicii are sharpljr circumscribed and
Fig. US.
Ad«a»-lbraniâ of im«n>. ShovliiK d«« fiatliKit gland •iruotflr* 4ndof oonsmilKtlHiu.
X too; r>lucr4 !(• (Onn.t
lated are generally fibmmata, rayioDUita, or sarcomata. Their ane
t-ariod from that of a hazel-im: to that of a walnut. They do not inclose
cysu. the presence of the latter, bo far from charact« fixing adenoma,
eliniinaie» tliem entirely.
11
162
TUH0R3.
Tlipy nre compoaed of «cini dwjiosed near tnjt«ther, M|»ral«d onlv 1._t
a «mnll iiuaiilitj nf fibniui lis^iie ; Uio ncîiii arc limited by a very 'iistinct
membrane, whidi îti \i\wA bj a very regular pavement epitlielium.
The jrrowili of these luinoni U very slow, aiul they arc neror general-
i8c<i. nie pnssihiiity of their transformation into carcinoma has been
'mooted. But vithoui obdcrvationa the tjncstion cannot bo positively
Other acinous ^^lands may bo the i^iCAT of aoinuu»! ndt-noina. Lcbcrt
reported «uch tumors of the parotid gland, as well as an analogotu hyper-
trophy of the lachrymal gtntid.
'i'bc arches of the palate and the pharynx may bo the scat of tumors
canMrd liy a conndvrable hypertrophy of tlie acinous glamls of the regions
either ciTCunwcriticd and .*ntivTil under the form of tumors, or dilTutie
a« a uniform tliickcidng of the mttcouji membrane. The nolo difforonco
between »nch tumors and tlie normal parts ii that the glandti here «re
hypertrophied.
In the i)tA(i.\oi;iâ of aotnoiui adenoma, they ahoulil be aoparated from
all new products which, by develo|iinK in the ueishborhood of glainla,
determine a proliferation of the epithelium of tlieir acini.
In the tumors which wo have described up to the present, we bare
«en that every new formation atlecling the stroma of a «land is, at a
certain moment, nc-companied by a multiplication of the epithelium of
the culs-de-suc find of the excretory ducts, followed by a dilatation of
these cavities and by various nltorior modifications of their contents.
For example, every cnchoiidroma of the parotid delemiinc» H orolifcr»- ■
tion of the glandular epitlielium, and yet no one thinks of ranging tlie^fi^
tumors with adenoma.
If the elands hypertrophy at the commencement and during the period
of formation of tumors, they also underf;o varied modiRcation^, such as
fatty or colloid degeneration of the epithelium, alteradons which end
sotne^mes in cysts or in hypcrtropliy of the acini.
Moreover, when » srowtb containing very many hypertrophied ;;Ui)du(ar
acini, a sarcoma of the breast for in<stnni.-c, returns after removnl, tho
new tumor no loii_i;er contains -rlands— an evident proof that there has
been no adenoma, and that the hypertrophy of thi- glands in the primary
tumor was accessory. If the pritnury tumor bad been an adenoma, it
would have returned with it^ primitive stnicture.
It is by a full knowledge of the iftructnre of other growths with which
they may be confounded, and by an attentive examination of each piece
that we iihsll succeed in recogni/jng true adenomata. The latter are to be
diagnosed by the condition of the int^racinott^ ti.4^ue and the tmture and
diflpoution of the new acini which arc entirely like those of the aR'ected
gland. "We should add, moreover, that no tumor is more rare titan this
species of true adenoma.
S^.si'BciEs: Tviiiii,.*B ai>kxomata with cvlindbical cbu*. — They
arc very common in tlie tnucoiis mcmbrnnes which possess tubular glands.
The tumor is so(^, generally slightly trunslucid and somewhat vascular.
Its surface has the name color as the mucous nu-mbrane. Upon section,
it yields no milky juice, but rather a mucous fluid, in which tJie micro-
ADRTIOHA.
Fig. 110
BCOjte rareaU c;lini)ric:il ocll«. i^olnud or unîtc^I in baiuU, or round or
ejrlindrical ocllai pr«iteiiitiv); n trdiiHparunt i;lobtile at their base.
Tbin soctimid from hanleiiiMl pioce» preicnt diScrent upevt« accord-
ing u the gland tobcs are aeen lougiludiii»)]; or traiwvoncly. Id the
longitudinal §ectinn<i, the friand tubes oft«n iihow lat«nil bwU or )>ciiiiini3
)>i furcations, tcrmiaating at the one end in the muoou* m^mbrano, where
they open; at the other, in culii-de-uc aituat«d itt different doptlia.
Tliaw tubes are generally 90 closelv jmckod a^ainit one anoiUer that
tlwro Menu to be no fibrous strama. The epitlielium which line» tlie
tnbe« i» Tvr; diMinctlj cylindrical; the cells are two or tliree tinKj
«i long as in the norm^ state: it is espcciallj at the level of tlie dilata-
tion of tlie ;;Unds that one observes the colloid drops which we have
mentioned. The tithes cut transvorscly appear as circles, with a ceotnl
lumen and a border of very ruf^iiUr cylin<lrical cells.
Dilatation of the tulK'.* con«titiitiM tlic first phn«c of the fonnation of
ttie cyata filled «itli ooltoid xuK^tance, which arc cotumon iu this special
of tuiDors. A nearly phyflii>lo;;ical tVDC
of thoM! cyatA exi^tti in the "e;ti;s of Aa-
botli," resultin;; from modifications of the
t4ihul.tr jilands in tlie oincoua membrane
of till- uterus. (Kig. llil.)
We in)t «ufrei)uently find hyperlro-
phicHof the gastr»-intestinal mucous glands.
In the atomach, the hypcrtropbied glands
màj become tmnafomifld into cvitbt of
reientiofl Rimilar to tlie egj^ of Nabotli.
Tlie mucous membrane may he speckled
irregularly or in limited spots by vehicles
more or less lai^, which occupy the
place of a tubular gland, or one of iu
portions. The hypenrophied glands and
the cystic vesicles fonn a litttle tumor
which often is peiluncuJHtcd. thus constituting a polyp. In thv uterus,
tbeM mucous polypi may at length project into (be vagina, even as fur as
the vulne. In the uterus, as in the stomach, these byjierirophies of
gUnd« often unite with pajnllary new foruiation* to form compound
(ucaord, villous at tlicir surface, cystic and glandular in the re«t of their
raaw.
Analo^iui lumoM grow in the rectum and tar^e intestine. TIte strnma
of the tumor is fitirous in the fully developed portions ; it is embryonal
in the mints where the gland is budding. If such a tumor of the rectum
protrudes from the anus, the investing cylindrical cells become trans-
formed into sqiiamoua epitbelia, which may oven becone corneous at the
surface. In the projecting parttt in contact with the air, the glandular
depressions are filled by stratified pavement cells; the interglandular
projections then represent pa|)illiv, so that one see« a layer of tubular
^and* become transformed into a layer of papillte covered by a aqun-
nous epitlielium.
In Ute utenis, be^de« tiie TC.<>icular tranttformation of the glands
which we have indicated, we observe globular productions principally
tn Bt Xi>>>«lk of ih* «tflnul maiviii
nFmbr*sri>ribs»r*l( ulart. ». Svhaik-
^1 dIUliuii *'t " f land, lh< oriaet «pan.
164
TVHORS.
charaotorizod by a hypertrophy of tho ^Inmls of the neck. Th«M tuOKn*
Arc small, aiul tnelo»«(l in the ciirit; of the ni-clc, or tticy pAs» throagh
the 09 into the vninnti. T1ic«c growths, dcwnhcd tiiulcr the tmine of
nKicouHorutero-veHicularpolTpi ( I liiguier), either pivi««ntlhGiippeiinince
of a red maiM, iinft., «pecKled with transparent vei>ioIe» vrliose itiiu! rariea
from tJie fûxe of a millet seed to that nf a grape Heed, or ihev show the
form of flatteucil ^anulationa. The last form show at tlieir surfaces
jirominencee ami depressions, whicti recall tlie arbor viUe. In their
etnifture they present a striking aualo;:y vrith the mucous membrane of
the cerrix, only all the elements have become mrich hyportrophied.
The stroma of these tumors is babilu&lly formel of a fibrous tt»sue im-
f related with Juice, and pernioated by numerous dilated bloo<l vessels,
t oceitsionnlly contains «mootJi muscular eh'iiu'ntt. In thU case Virchow
thinkit that the tumor ithould be ranged timou;; the inyumata.
The»M! uterine polypi, which are oorerccl with cylindrioul epithelium in
the cervix, present in the vagina n pavement epithelium ; when tliey pro-
jeet at tJie exterior, a rare occurrence, the epithelial coverinx in comeoua.
Uut tbene mutations iu the form nf the superficial epithelium does not
extend to the cells vfhich line the ducts of the tubular jçlands, nor even
tn the dépressions, analogous to the crypts and folda of the arbor vine,
which these polyps sometimes show.
Among nasal polypi there are those which arc so like the cystic ade-
nocna of the uterus, that it is impossible to distin^^msh diflereiiecs in
structure. Cases arc also occasionally encountered in which the glands,
lined with cylindricul epithelium and dilated intv cjsM, estnblUh A per-
fect j>iiiiililude with the ju-evioinly described uterine lumora.
.\asal polyjii. however, arc most commonly constituted by raucous
tinoue, when they belong anion^ the myxomata.
Diagnosis. — -The only tumors with which these adenomata with cylin-
drical cells may be confounded are cylindrical-celled cpitheliomala. In
the great majority of cases the dia<;noBis is ven easy: the regularity of
the glands, their opening upon the mucous surface, the presence of cysts
regularly limited, establish the diagnosis with certainty. Rpitholiomata
with cylindrical cell* never piVKcnt small regular cysts; besides, tliey
show uherruliiin» in the form of the tubes «ml their «ells, which »ep»rato
them from the normal type- Moreover, they invade the profound tissues,
while adenomata, always superficial, have the tetidoncy to a»j>ume the
form of polypi.
While the nttiii.soi-is of epithelioma with cylindrical cells is very grave,
that of adenoma is very benign. Adenomata are never generalised, but
they return after they have been incompletely removed. [According to
some authors adenotuatu arc occaeionally subject to metastases.]
4TII CukBs — Cyata.
For us cysts are glandular aberrations which, up to a certain point,
have tlicir stnictiiral an«li>;;ies in glands comiKiscd of closed vesicle», as
the ovury and the thyroid hody of the adult.
Cym consist of a connective tissue membrane, an e]>ithclial lining, and
»
^V CTSTS. IBS
cnntento wtiicli ar« fliuil, colloM, or iiebftciïoiifl. Tliev ohouM be oare-
tdllj disdiiguisiieil from mticoui) de^neratioiui accom[ianied \tj ttie formt-
Ua» of cavitieâ at the c«nire!i of the divers tumors wliicti we liare
itlread; studied : in ili^se cases, really, we find neither * {>raper nieia-
lirane iior an epUiicUal litiin;!;.
The process of tlio formation of a cyst is not so simple as may be
imagiued. By tying thi- duct of a Rland, far from obtaioing a cystic
dilatation, we may dclcrminv its atrophy.
TIic structuTO, the m<ldl^ of development, and the vnrietîes of cystt arc
so different in their different «pecics that it is împoMitilc to giro a general
deecription of them. Heiice we piuut at onco to tlioir varieties of nature
and of «vat.
We would divide lliem at first «ceonling to tlio nature of their coii-
t«ntit, into two groupa:^
1*1. .W-rtrttHW r^ttê.
Sil. Muevu», »imm», a»d colloid rj/»t».
IST. SBBACEOue Cypts. — A'lAiiVfw* ci/Ht: arc KÎmpIf or dfrmoiil. The
fint eonsiitbi in nn accumulation of ejndermal cotls or of the product of
accretion in a hair follicle or in a glandular cul-ite-sac.
1» the scbaccouti cysw we fiml: —
a. TlfO«; little »liiii*h graina projectiii;? upra the skin of the race,
especially at the externa canthua of the eyelid», which have keen cnlled
milUt •/raitu (milium pnljiebrare). They contain au accumulation of
l)i« eptdenuia which form» in the hair folliulcB.
The orifice of the hair follicle is obstructcil and inviiiible; by incising
the little ^amilc w« cause the t-scapc "f an epidermic sphernlc. These
little grains are true cyst» of retention. Ttiey arc extremely common,
in »ome persons advunced in yenra they are confluent upon the eyelids»
and they form there an uninterrupted whitish layer, like plaster.
A. C'lnifdonrty little elevation» lormud by the retention of «cbuni in tho
hair follicles: tlie orifice i* pervious to «iioh a degree that hy pressure
the oontenln can Iw tupieexvd out. In this sebaceous material we often
find I^enuxirr fofliiruhrujtt. ijometimes an accumulation of sebum occa-
sion* an inflammation of the follicle: pu^ globule.* nre then mixed i^ith
the epitlielial cells and oil drops, which fonn tho sebum. It is thus that
a pustule of acne form^.
e. Wm», so frei)uent among hairy persons, also consist of an accumu-
lation of masses of epidermis and sebum in the hair follicles. Tliey
attain a much greater size than the i>receding; even as great as that of
a hazel-nut or a pigeon's egg, and they arc habitually fiattcncd and
lenticular.
According as their contents are fluid or solid, they arc called melicerotit
or ateatomal"N» tvei)9. The nivliccrous substituée is a lluîd-like honey,
constituted hv a great 'ptnntity of free fut and isolated e|>idernuil cells.
The mort- solid contents of steatomatous wen» contain tite mtan elemi-nts,
but there are more epidermal cell* and less free fiit. In them the fat
undergoes the same transformation.^; no longer subjected to nutritive
changes it gives rise to crysinU of stearic acid, margarin, and choies.
terio, which are constantly met with in greater or lesser ({uantity . Often
166
TtlMORR,
Pis. 120.
Upon the Btirfac« of a wen in sc«ti a «lark tlc]>resaed point, irliîcli ia titaj
ori(Ic« of a hair follicle. The ç\fl i» located in the subcuiaitcoufl tisaue.
The derm wliich covers it is tliinned at the surface : its napillœ arc flat-]
tened, or they have even ilisappearcd, vrliilc the surface is cotwcjucntly
eiuooth, and tlie sebaceous glands are also atrophied. Conwmiii'î the
structure of the cyat itaelf, there is proscntt-d for consideration first \ls
fibrous wall, which ii« formed by con-
DL-ctirc tisi^ne wttli flait«nod cvlli) (figij
ISO, 'i), and pnrallvl laycn of a ftUMla-
1 ft û il 1 mental .suhiitiince' — a ti-tsue identical
7 1 "^ n Ji BM^LiSfcJCiX, with that of the inner tunic of arterid,
I \ù M i/VffiBl^SSjn V and that of fibroma — with flat celto'
(see p. 92). This di.ijiomtiou la
caused by the pressure e.\ertcd upon
the walls by the incessant accumulation
of vlemenis contained in the cyst. In i
this membrane then» arc no clastiel
fibrO), but tho 1att«r exist in the nei-di-
boring tissue. Fatty, atheromittoiis,
and valoarooua degCDcrations an; verv
common in this connective tiiutiie wall,
which completes the ]ir«viou«ly rocit-
titined analog)' of this membrane with
tlie internal tunic of the arterieit and
with the corresponding species of
fibroma.
At the internal face of this mem-
brane exists a strntilled pitvcment ept.
theliuni, which experiences an evolution similar to that whieh is observed
in sebuceoiis (•land:'. The cells in contact with tliv wall po«scsa )arg«.J
nuclei siirniiiiiiied by a small iiuaiility of protoplasm (A, fig. 120) ; and"
"t is probabh' that it is hen- that the new e<'lls iiici^.itiintly form. In
eerlftiii cases thf fatty evolution i.* very sli>w, uiui tiie layer of corneous
cells, in which the nucleus has cotnpleiuly disappeared, is thick, and often
detaches itself from the wall of the cyst, and forms a shell consisting of ,
whitish, slightly translucent, almost cartila^iniform tissue; it Is at thai
interior of tliis shell that the meliccrous or ateaiomaious contents are
found.
d. Dermoid '-i/Ff», which, like the preceding, contain a steatomatoua i
matter, aro developed ouuidc of glands, and are cbaractcriied by a wall
having a structure analogous to that of the skin. With Lebcrt, we may
recognize the three following vurielies: —
1st. Tho first variety of dermnid cysts is that which verv strongly
resembles wens ; the sole difference relates to their wat. 'fiieae cysta
develop in regions where aehaceoiiâ gland» have tinturnlly no existence,
and they never present orifices.
2d. tn a second variety, the cystic membrane, together with papill»
analogous to tliose of the derm, [fos»esses sebaceous glands and hair fol-
licles. Thasc hair follicles give origin to real liair. In the interior of
these cysts wc find matted hair in tlie midst of sebaceous matter.
A ^ff ttt*l urU^hQ vi (II* Wfttl aT lb« ■rbi'
Drvu» i]rit. u. ribniui wall it cjtt Ka-
ne t^tnm. «. Ei-liholiil ctlU. ». Cani*iu«
MlK 4. SrlKoono c^Ila. X >>0-
OTBT».
167
îltn* Af the CVKt wall may give nw to warU, cundTlofiui, nnd linn».
latter (leveloivitig from the ilee|i«at portion of iLe cyst wail, ami in-
beyond of tlie
til
enraging in Htxe, mav îonn a projectn
manner that we liave to do wttli a bom aurrouudod at its base by a caljrx
formetl by ibe cyst.
It*!. The third variety of dermoid cyal of Lehcrt is more complicated.
Many iliflerent tissues — and even organs, for example, lecth — appear in
Uw wall of the cyst, whose ontctits arc tlic sami; aa in thp otht-r variulies,
vii., Mbum, etc. The teeth are found id a dutitul follicle surrounded by
fibroud tissue, or tliey are implanted upon bone of varied «trttcture.
Their disposition is very im-^Inr; tlicir d«velopment, aconrding to
Kohlrausch, does not <liflcr from phy«io1a;;ical growth. TUc«c t«elli —
caninff, molars, and incifors — have tlic «haractera of the firMt nnd second
dËtilition. There may tic one or more teetli ; in certain ca»ca, llieir
(iiimtitir ia sucii tliat K«il and Auleiirieth once counted a» many aa -iOO.
Thiit olMen'ation is niinous to the hyiioCheAiH of mapy aulliord, that one
of these cyat^ indicate» a fuitat incliij>ion at this spot. For, if there had
been a fwtal inclusion, it is incoioprelionsiMe why the teeth vould be so
Dunwrous. Instead of a bony plate aervin;; as an insertion for the teeth,
aometimes only an osseous border rpprcscntin;; an alveolus is encountered.
Teetl» and osseous tissue in the form of plates are the commonest
occurrcnoe* in Ac wall of these cysts ; but there may be al*o long bones,
cartilaj>e trre;^lnrty disposed, maascs of striated muscle, and even nio-
dnllary ncrvv^. Wu have seen cysts of this kind where this iRTve tissue,
uhuraclvrizi'd by sronll ilQiibh'-coutmm'd nerves and nerve celts, was con-
tained in a fibrous pouch adjoining <)A>it>ou') portions. Nothing is more
irregular than the <lijfiO!>itioii and relative t|iiantity of these diverse tis-
sues. In places, the wall of these cysts presents plaques which have tJie
same structure as the skin, po^tsessing papiuie. sebaceoum and sudoriparous
glands, hair fotlictes, and hair ; at other points the «all is thin, smoodi,
âbrous — analo^^us to that of cysts of the first variety. The volume of
these tumors is rariable betnceii that of an c;y; and that of an adult
heart. Their mode of dcvelopmait is not understood. It is only known
that they arc conf;i'iiitnl. Tlie most freipK"«t seat of dermoid eysts is
tJie ovary and the testicle, but they may bo met witli also in all th«
other organs.
2d. Sbkofs, ^lucovs, axd Colloid Crarfi.— The second group of
cyald is characteri/.ed by their conteiiLi, which are serous, mucus, and
colloid.
Tla-y may develop: a, in natural serous cavities — for example, tendinous
or periarticular bursie : b, in glandular cavities ; o, they may arise any-
where.
a. Serous cavities may be considered as spaces in the midst of the
connective tissue which surrounds or;;ans ; they are lined witii eodotlie-
Hum, which may desquamate, be destroyed, and reformed again. We
should not be surprised, therefore, to sec regular or Irabeciilated aoci-
dental cavities, lined throughout by eiidotbeliuni, develop at any point
in loose connective tissue.
Physiologically, the membrane of serons caviljes secrete» a serous
Huid which Is taken up again by the vessel* with great facility. This
Ifi8
TUMORS.
facility of rvHorption t» dcmonstritteil 1>y tlio mpiil Ji^fipprarBncc oT iii-
JccK-il fluiiU. Itut, if the Kcruuit Dit'inbntnv it ii>ll»ii»;<l, tlio nmorption of
an iiijectvd fluid in impoeaiblo ( Kiiiiltlcl;<i;h >, itm) ihv irritittion of the
«eroib* uiembraD» (lewrinincs «n ftlniiuUtit ^ecr«ti<ni. Kvcn u xlii^ht
irritation U flufficieiit then to tiauxfann a «eroua bur»» into » vyMie
cavity. 8ucU a tranaformation of a eiulicutaueouii aerouA bursa i» known
AS a hgyrofiut, and may be called a tumor because of tta tett«leucy to
peraiai iiidefioit«ly.
Tlie cystic membrane of « hygroma is j^encntlly thick, and formed of
a dense connective tissue i>f tJirtiln'Onoiis appearance. According; lo
Virvliow, it siiould always be- lined by a pavement epithelium. 'I1i«
Huid cotitvnU are transparent or Hli;;htly clouded by dctaclic*! cells ; Uicy
sometimes coiiUtin concretion» very irre^tilar in form <rice grnius'), oou-
sistin*; of coiiccntric Inyers tviltioiit n spécial InsUtln^ical siriicture and
of wliicli tlie origin \* diversely understood. Velj*»u constilcr» thent as
fibrin ; Virchow thinki* that they iiHw by a buddiriï' t'niin the oys* wall.
The ghrath» of teiiiiftu* mav prettent (be greatest similarity of structure
with imbcutaiieous serous btin»fe. Tbey poasej«i, according to Cio&'teliti,
little depreflfiiouB of the surface, like tbe linger of a glove, which pene-
trate into the surrounding connective lÎAàue. An obliteration of the
neck of these depressions may give riao to little cysts. The name of
•l<in;ifi'/n» has bccD ;;iven to them, and ihey are observed especially at
the wrist and the buck of the foot.
Hydroceles of ihc tunica vaj^inali» and hydropsies of (he articular
serous membrnnc may be classed with the pree>cdiu|> cysts ; tUcy ap[»car
to have an analogous origin.
Thette occurrences serve really as intermediate links between the [tfO'
ducts of chronic inHammatJon and tumor».
i. Oysts develofied from gUndei are very numerooa. The thfirmd
hJif is aloioet a physiological location for ihem (,see Thyroiti lîojff).
1'he GraaHan /"llickg of the ovarif are often lilied, even iti new-born
children, and before mcustmution, by a large (luantiiy of fluid ; this
constitutes hydropsy of the follicles. It is probable that a large number
of ovarian cysts nave such an origin ( b'oerster).
The viW'iHi yUititiê ••/ tlir lifs become transformed into tittle trans-
parent cysl-* "f retention. The buccal mucous membrane may be UfUd
up by volumintiibt cyslrt resulting from the distension of the duct« of
Wharton and Kivinus; the l&tt«r swellings arc dosigitatod under the
name of runuUi.
In the »t'iiiuifh, the luttHliitr^ and the tnichfa little mucous cysts,
either isolated or agglomerated, often result from distension of tlie
tubular or acinous glands.
The ^t'vfr sometimes contains cysts inclosing bile or coloring matter,
or simplv a serous liuid. from distension of llie biUary ducts.
The kidney is very frequently the seat of variously produced cysts :
congenital cysts, sometime» very voluminous and very numerous, duo to
atresia of tlie impîllic, according to Virchow, who !ias found urates in
tin- fluid of these cysts as we ourselves have also found it in cysts of the
«amc kind ; serous cysts, observed in tlie adult, some following Bright'»
disease, others duo to intcretitial nephritis, and sometimes contaiotng •
CT8TS.
Î69
MrOQS fluid, at other tinicH n colloiit concretion. Tlicj- nro (Icwloped hy
dtstADsion of tbe uriDifvrou^ tiOws or of the cii[isuIcb oftlio {;loiDi.<ruli.
Titc trsticU oTlea HbOK« Minilur rormiilioiM otibtidc of tbo };liiiiil, aming
rrom tbo hydali'lx of Morj:u;^ii, or fnKD distension of iite Muiimferouii
tnbos. Tlioir timd frciiiiondv L-oiitain» H|>crinatoxoa.
Sijtuc c^'Mic fonnntionii of the utmiM are aluioat normal, as tho Im-lica
«bich liHvo been called fi/y» of Nitt'-itli. In the «tamiutr, cjrsu somo-
linws exist which, acconliiig to Vircliow, are developed from the galac-
tofihoroiu d»cb>. Thev are Jilted by a caseous detritua analogous to
milk, and are aoroeliiuea io di.iwnded that, before oponin;; titcin, one
would imagine tltat he had to <lo with a solid tumor. Similar pro<lucttf
mjr alJO Hhon themselves in various tumors of this glnnd.
e. Ctfttti no longer resulting, like the preceding, from the distension
i of prfl-eicistint; cavities, may arise under the follonin}; ciruum^ljiiivcs : —
' lei. Id the suhcuUuicou* tissue at ono tinw cyst» pos8es« a thin mem-
brane and contain a Mrouti fluid ; at another they have a much thicker
vrall. and are then irregular, anfractuous, and paved by n cylindricnl
ciliated e]>ith(']ium.
'li\. MuUilocular cystâ may appear in rausole*, tendons, bones, the
brain, etc.
3d. In titeovariea. where they are very frequent, these cysts constitute
a variety designated under tlie name of proliferous cysts. It is not cer-
tain, however, that at tlieir origin these cysts arise from » Graafian fol-
licle. What has lead Koerster and some other authors to consider tliem
as foriDcd of many cyets, is thiit their wnll at a given moment it^Of
forutiB now Dy»t«. No ouv that we know of has ever studird the initial
formation of tliCM cy«t». It is po«t>ilile that they mny be dovdoped
from the connective tisane of the stroma of the ovary, ju-*l a« secondary
cy«të BCCTO to «rise from the cmmective ti.t.tiie of the tvalU of prttnai'y
cynt».
Tbene proliferous cysts are mnst frequently encountered in the ovary,
but sotuetimes also in the great omentum. Tliey are all muUUocular and
bave characters which dUttnguish them from all of the preceding varie-
ties. ITicy poasess tliick walU. which are îndcpenrlçnt or common to
several cystic cavities; their inner membrane resembles a mucous mem-
brane and presents «t its surface papilla: or villoaitics disposed in tufts
or budding masses ; finally, in the walls of those cysts wc bnd secondary
cystt.
' The tissue which sepurAtes and unites the difTen-iit cyst« \« mo»! frv-
quentiy a young and very vascular connective tissue, entirely embryonal
in 0ome places. In some cues, we have found nmco\u tissue therein.
The papillic or villi vegetating upon the inner surface of the cytU are
«mple or compound; tlieir arrangement U often extremely complicated,
their body consi^iU of embryonal comieclive liiuue; tlieir vesela are
numerous and often dilated mco ampuUie, somsiim^^ they rupture and
give rise to ecchymoses. The latter peculiarity explains whv the fluid
contents of llic cysts are often luorc or less colored by the coloring mat-
ter of the blood or even by vxtravosau-d blood ilaolf. The papillie and
the inner surface of cysts are cov<-rcd by epithelial cells, sometimes small
and cubical, but most frequently cylindrical, and the latter may bo
170
ciliatcl. In the dîHercnt layers of llie walls of the cvsts, particoUrl^ ,
in llie papillary layer, little cysts are often seen from llie suce of & pin-
head up to that of a bucl-nut, exactly similar to the preceding.
The contunls of these cysts is a serous or colloid fiiiid, wboeo color ù
extronii'ly variable ; somedmos colorless, it is often rvi or dark brown,
It contains oAU regular or deformed, in a state of colloid or fatty dege
«ration : free fatty ;;raiiulea; sometimes crystals of chotvstcri», in siich
considerable tjuuntity that they nay be seen iu the Buid by the naked
eye.
In the colored fluid aro encountered red blood di^ks, variously altered,
granule:*, and crystals of liwmntoiilin.
The iir:vKi.iH'MEXT of »ecoi)dary cyaU has been studied by Foerster
and WiUon Kox, who have reached different conclusions. Koersier
olwerved in tlie wall of primary cysts islands of embryonal cells, tiie
oost liitcrnnl of which underji^o colloid degeneration and are destroyed,
rwhilo the perijiberat remain and constitute iho epithelial covering of the
cystic cavity. For Wilson Kox, the secondary cysla always form bo-
tween the papilUe, the villi joining together by their free extremities
form at their base cys^c cavities lined by the same epithelium. 8nch ia
tiie mode of development that can hti eiisily observed. We do not wish
to deny the mode of dovelopnicnt indicated by b'<x'r«tcr, but wo Iiairc not
been able to follow it conipleWly, We liave neen round islawls of em-
bryonal ti«^ue in the wall of ey*w. but we have not l>eeu able to recognix»
the tramforniation of the^e i-^lands into veritable cysts.
Thcae lumora are very analo;;oua in structure and nature to ademmatai^
and papiUomata. In fact, if one examines a [;ooil preparation of the waP'
of oueof tbeseeyats, not knowing when? it came from, one could hesitate
between a proliferous cyst, an adenoma — such as those of the cervix
uteri or of the nasal foseic — a papilloma, and even an «pilhcUoma with
cylindrical cells. They also pn-sent j;reat similarity in structure to »ar-
comata devploped in ;;Sand». But when one examine» the whole tun»or,
doubt is no lon;;er posslbli^ ; it U readily seen to be a ttimor de-icriWd by
all authors under the iinmo of proliferoai cyst, a tumor which may attain
each an enormous developmeni as to induce death, but which is itérer
generalized as are aarcomnLi and carcinomata. We aliaîl aUo find genu-
ine cysts in die following group of tumors.
X.— mXED TUMORS.
In the fœtus or at birth, sometimes voluminous tumora are found, con
stitutetl by an embryonal tissue which has undergono euch an evolution
tliat nearly all the tissues find their representation.
We have observed two tumors of tins kind located in the peritoneum.
In the midst of ao embryonal tissue uontiiinin^ vessels with embryonal
walls, these tumors present: 1st. Striata n m iide fibre» iu the pnicess i>f
development; id. Embryonal cartila;:e ; Sd. Bone developing; from car-
tilage, the two covered respectively by a periosteum and a perichondrium;
4lh. t'ystit possessing a membrane well defined and covered by a layer
of pavement epithelium or of cylindrical ciUated cells; ôth. l^ong chan<
I
HIXED TUMORS. 171
nelB fiUed with cyliadrical epithelium or with lobules of pavement epi-
thelium. These tumors could not be regarded as fœtal inclusions, since
there was no form recalling a fcetua. The name teratoma, as proposed
by Virchow, does not appear to us to suit them, for they have no deter-
mined form recalling & superadded being. They have, on the contrary,
the form of an enormous embryonal bud, which enjoys the property
possessed by embryonal tissue of this age of forming all the organic
tisHues.
These diverse tissues, muscular, bony, etc., present a degree of devel-
opment much less advanced than that of the normal tissues of the sub-
ject bearing the tumor.
As the new-bom children soon die, it is not known what might be the
niterior course of these productions. These complex emhryohal tumors
might rigorously be considered as sarcomata developed in the embryo ;
bat the multiplicity of the normal tissues which are met with in them,
especially the presence of epithelial, cartilaginous, and muscular masses,
separates them from sarcomata such as we have previously described.
172
TCMORE.
CLASSIFICATION AND CONDENSED DESCRIPTION OF
TUMUltS.
Aiiiu>u£ii un Viiicuuw'ii IlisTiiniisKTic B^siK, moM tu» Lbctuku or
I'Har. Jawu Trtoji, I'.iiv. Tmsa., «tc.
Br II. V. FOKUAl), B.M., M.D.t
I. Tiimon composed of connective tUsuo substiincc», mid vhicli [»ro-
coed froiD the connective ti«dui: group (Hitftoid Tumon).
11. Tumors composed of miLscular tjasue, and which proceed from it.
in. TuiDOM compared of nerve tissue.
] V. Tutnore, the es«cnti&l constituents of which proceed from epitliclium.
V. C^atic tumors, com])09ed of a closed sac, with more or less fluid
contents.
VI, Mixed luniors, due to comlnnation of the different forma of tumors.
VII. Oranulntioii or îiifoctimit iiimoR!, which letiologically and hiatolo-
gioa]ly stand very near the inflammatory new formatioi».
I. TtMOIW COMPOSKI) OF COXSECTIVE TI.tsrB Sl'BSTASrES. ASD WHICH
PROCKBD FROM THK OONSKtTIVK TISSCE «ROUP (.HlsUiid Tumors).
FiimiMA.
Phy»iohffif<il Tj/pf. — Connective Tiasup. Areolar and fibrillar.
Ornerai Mw-fm-o/iÎT C/iunn-trrM. — n. S'l/t Fihroni'i: whitfl, reddish,
or jcUowiah in color: Bort; often papilla; on surface; sometimes multiple;
occaaionallv polypous form.
fi. Hard Fibroma: white; sometimes pale reddish and glistening; ex-
ceedingly hard and dry ; creaking under the knife when cut.
Itoth show even to the naked eye concentric fibrillation; uinally have
a limiting capsule ; reach often enonnous eixc ; usually round in shape ;
often lohiilntcd. Orowth slow. Sometimes they arc very vBMular.
Cavernoiu tihroids (see Ketrograde Changes).
Mii'T^enjiie 0tnr<ftfrt. — u. Suft Fihr-'ma: Prototype in (loose)
areohic connective tissue.
I. Iltird Fihr^uut: Prototype in fihrillar coimectivc tis»ue.
Both are made up of the elements of cicatricial tissue ; connective lîa
' Tlif oicnltono*, jiiilk'ial »n-,niit''iii'--iit. ami (nliHim (if Ihi- fallnwitiB rtusiflmtinB]
havtf Uul lu, Willi tin- conscut of ih<- noiltor. lo lulvtltntc ll. wilh but Tory ItttU i
obaiig«, for thu oJaulflcalinn nf tumun |ir«»vi>l<>J by Cornll «nil Bftiivlm-.
^ OLASBIPICATIOK AND DBFCRtPTlOS Of T0MOR3. 173
6bmi tnil thoir nuclei; latter more dUlinct bjaeetk«cid. The fibres «re
mmi^'d in bumllc:*, and extend in every direction, without anv ilefintte
amngeiDent, often concentrically ground the bloodvcsstls. I'hey iwii-
taifi nsually but few vesaeU, anJ Ihoeo aoiD«tiiiK8 have no detînt-d walls.
Utat. — I'litis, Kiibmu«otis, and avbaerous tiMuee, faeciw, inttTsiitial
tiBsne of or;;an3, intcrmuïcular connective tissue, pvnosteuni ; in utenu
oRen iiilerminKled witli niyonia.
Aii^. — Middle nn*I advanced.
A'tif M r* . — Ben i )n> .
Comi^Mtili'-H». — Myxoma, lipoma, saroomft, chondroma, myoma (in
Dtenu), anpomn.
Rrtr<"jrtfif Vhtn-jr». — Fatly, mucoid, cavernous, calcareous, ossifica*
tion (rarely), pigntentn^on.
Remark», — N>fl fibroma when difftue »nraewhat rescmMeii in stmcture
ele|))iauûadis araburo. Inflammation is somecirac» observed m fibromata.
Myxoma.
Pht/uoloifiait Tffpt. — Mncoits Tissue. Fonnd oonnaDy in the sab.
eatsnooos connective tissue of the fœtus, in the ombilic*] coni, and in tb«
ulutt in tlio vitreous btimor of tlie eyo.
Qrnrriti Macr'>»t>ypic 0iitracteT». — Round, lobnlaled, usually circum-
scribed within n capsule. CoiMisteiicc : soft, viscid, «lelatiniforn), fluctua-
ting. Cut surface of pale reddish or ^rmyisli color ; 8h(*win;{ iutertcelion»
by (Minitions ef fibrous tissut-. Yield» a u-nncioui, translucent lii]ui<l.
Ctrowth pretty raiiid ; sixe varioui^. ftometimes enomwua.
SftfToscipie Ciiararters. — Itoundiah, spindle- shaped, and stellate celU
united by their prolongations, imbedded in a hotnogeneous, translucent
stiiny matrix, in vrbich, alW addition of acetic acid, appears a fibrillar
or (granular preci|>iiatioii of mitHn, Hands of fibrous tissue containin;;
few l>li>0(lve$«vls are ocexsionally seen, and ;;ive a somenhat alveolar
appcaranue ; red bloud-corpuscles from the cut vessels and amoeboid cells
are also present.
Nfit. — Adipose tissue, chorion (uterine hydatids from placenta), thigh,
baclccheek, labia, scrotum, aMlla, nose, marrow of bone, mamma, sheath»
of nerves (multiple form), bmin and membranes, parotid glaud.
A<je. — III iiew-born and adults.
Mature. — Considered by some beni)£n. Recur t» fturwvery ftc«)uently;
and the 1i|K>matoaii variety especially often infectious (S. W. (iroiwj.
ConAittaJioit*. — I.i[ioma. sarcoma, enchondroma. fibroma.
Retroffmde f^unyeg. — Fatty, fibrous telaui^ieciatic.
Remark». — Various tumors may contain myxomatous patches, circum-
Kribed or diffiise, but the term myxoma is limited to tumors wtierc tho
described appearance predominates, (W appears to be the primary alter-
atiou.
Glioma. (Syn. Ncuroglioma, Glio-sareoma).
Phytloloifiatl Tgpt. — Neuroglia.
Guneral Miirr-ittyiftie Ohararlrr/t. — ft umiaily oocupics the place of a
portion of the atlaehed nerve tissue, which retains it* normal shape, only
1-4
TO HORS.
peiliap oiilirficii, never M-hIhwI. It U softor and more glistening, hut
lint) tltf m\w color iin<t ft|>[ii>a ranee as brain substanee: sometimes mul-
tiple iifion nerves, lîrowllk alow, readies oocaflion&llj* lar^^ sixe. Never
involves the memlir&nes of brain.
Mhrnf^fif ('haraeter». — Uoundisli, 8pin(]le-sh«pe, and rarely bmI-
Ute celU in a granular matrix seem enlircil^ lo replace the nerro tiasu*.
Sometimes ;^ivea the impresaion of a genuine hyiiortropliy of th» oorre
ol«ment« ; or may appear as a circumscribBd sclerosis (scleroma) but moro ■
frefjucntly diffuse: corpora aniylacea arc sometimes seen. If tlierc b«
«iilateil lilooilvcesels and extravasatiotis of blood, Virclion call« it a tivmor-
rfaa^ie glioma. ltesumblv« sarcoma.
Smt. — Itmiii, Hpiiial cord, nerves of special sense« (opticus, retina),
fiuprareiiai c«p.»uli;, Macrum. J
A-if.^~iyc(MTH at alt ages ; more frequently in childhood. I
Xttlure. — S«mi' malignant ; unfavorable for the patient through preiw>]
arc, and tendency to extend by continuity.
Comhinntion». — Myxoma, sarcoma, lib'roma, hemorrhagic cysts,
Rftr^nrade C'hanye». — Fatty (yellow softening), cystic, CRMooa
(green), calcification, ossification (Wagner).
JifiiMrk». — Itecencly. KIcbs s,n<X Colinhciin regard the glioma aa a n«w
(^wtli of true nerve tissue, classifying it with llic neuromata. Most
authors consider it a variety of sarcoma. j
LlI'UUA. I
Fh^nM'trfifiil Tifpf. — Adipose Tissue.
Gcneml Mticr-txrrijilf iJlinriteUm. — Round, lohulated, soft, sometimea
fluctuating, usuallv encapsulated. On section, the usual appearance of
adipose tissue. May reach enormotis size; may be multiple. Growth
slow in beginning, but later, rapid. Have on surface sometimes puru-
lent, bud-smelling ulcers and granulation tissue, frtm cxtenuil irritikltmi.
Mii^ote-iph Çharai-tFT».^~GcW» and lobules both larger tlian in normal
adipose ti.-<siie, I'tbcrwise idontieal. Blood vessels in the fibrous septa.
If stroma prédominâtes: lAfiuin fi/iniKiim.
>Vc(if,— Subcutanftftiis and tiubiiiiicoiw tiiwues, h^ck, neck, stomach,
intestines. More rare iu intermuscular connective tissue, peritoneum,
membranes of brain, cortex of kidney, liver, lung.
Age. — Adult.
Àfature, — Benign .
C^juhinatioHt. — Myxoma. Sarcoma, cysts.
Retr-'ffradf. Chtn-iti. — Xot common. Culci.icadon of the fibrous frnmo-
work and septa may occur; also mucoid and 6broid degeneration.
Hfiiiiifki'. — Lipoma is the most common tumor. Sometimes hereditary
an<l Kyiiimetrieal on two sides of the body. Occurs more frc[ucntly î»
emaciated than in fat pemons ( Birch- Mi rachfeld). In starvation the
«ntire normtil fat in a («rsou may disappear, but never in a lipomatouii
growth (Virchow).
CllONbiiouA (Syn. Enchondroma).
I'kgtiolofpcal Type. — Cartilajji
inous Tissue.
OtABBIPICATtO» AUD DBBCRIPTIOS or TDUORS.
Getterti} ^fif^r^iKvfiir Charat-tti-». — Uâuxllv roumlish. lobiilatt'<l, vt-ry
firm Mil) bnnl.cxcvM tlie mucoi<l rarictV) wbicli rcsoniMcs thu tnyxomntn.
(>it BCcUoti, mi Ik- white, hkrd clastic resistance. Usunlly «)M'|ue or yellow
HpoM an* Mcn. which arc ilue to calcification. If (.'onnectivc tissue in in
exc«w, it has to the naked eye the chantctcr of fibnuna. 1'h« titmor
cansi«t8 MiDOtimes of îiultvi<liinl lolmle^ Iiomvl (ogcilicr l>y filirou.* t*uuo
into one tnu8. lirowtli often rapid ut puberty; reach «emctiiuv^ eDOr
moufi siso ; often multiple.
Oaieoi<) choiidronuita, «s pear-shaped and fu^rorm swelling!i, nay
rencli enonnous aixc.
Mii^'Himfii/- CAKfti'-fi^».— Iliatologically four kiniU. correspon<IiiiK to
the four kiiwtfi of tionual cartilage: l,hTaline; 2, liMmui: 8, reticular;
4, niuooid ; the latter variety is rare. Tho cells are round, oval, spindle-
shape^l, or stellate-fantastic; according to variety, numerous or few, in
proportion to the bomogeiieous or lîbrillated tnatiiit. Very few lilooit-
Te«sels in the band» of fibrous tissue which often intersioct the outtrix.
giving it an alveolated appcnrance; nom- iu the interior of the hyulinc
tobulee. Tbv most cointnon Is the rciicuktcd variety, retninding of tho
alveolar structure of some csrcinotnatu . All fonns may be foun<l in une
■pecimen. Hyaline cartilage is usually in islands surrounded by the
fibruii» or reticulated varieties.
Variety: Osteoid choiulroma. Ilij^hly refracting, donae, homogc»«o<»
tmtrix, iinil Inciinic with tiborl proce^sc». Tho celU «maller and witliout
capâiilc. Itecomes true bono after impregiiaUon nilli lime salts.
Srat, — ^l'hree.rourUis or four-fifths occur in osseous system, mually
witliin the toarrovr ; one-fourtb in connective tissues (fibrillar variety).
Favorite seats: tubular bones, lower jaw, scapula; less freejuently,
parotid, testicle, mamma, ovary, bronchial cartilages.
Scatof osteoid chondroma, between bone ami pcrriosteuin of long bones.
A-t*. — Any age, sometimes congenital ; usually early life.
Mature, — Benign, but not always.
MetastastK M>metln)c^ occurs, especially in lung.
V"iMmttii>MS. — Sarcoma, myxoma, oalcoma (iiometinies with a bony
capsule).
Sarcoma.
JlHroifradf- ('httn;iet.- — Calcification, ossification, miicoid, fatty, cystic
(degeneration easy because of scarcity of bloo<Ivcssels).
Osteoid chondroma i* converted only into bone.
liemtirk». — Birch-lliracbfcld and others consider the stellate cells in
the enchondromata not as cells, but as little cavities or B[iaccs, The
same has been asserted of those iu the cornea. According to C'ohnbetm,
enchondromata never grow from pure cartiliiginous tissue. Their devcl.
opment proceeds in bones from encysted particles of cartilage which
bate not ossifie*) (Yirchow).
I BiilroUi olassifies osteoid chondromata among tlie sarcomata.
^ft USTEOMA-
^H J'hgm'itoffifal T'y/»!.— Kone.
^H Qentrai Miumtwfie Chanteter».—'V\\c first two varieties are harder
176
rruMORS.
tnd emootlicr tlian tlic cncliondromata. The liim! nml fourth <>-fineti«8
liitve stich conmst«iicc &s thuir names tmliciitc. Kxosto»i#, n huinolo;^iu ;
o«too]>liyt«, a lii;l«Tolo;^uH bony j;ruiTth. Mn>- W niultiplo. Growth
rfow ; may roacli »he of cliiH'* heml.
Mi-v'igro/.ie Vhnrartrr». — Slnicture oorresponds eillier to oompiict or
eanc«llAt«il iionnal l>oiic tiiuiie.
Vnricties: 1. Osteoma elmmalum (rare), ivory-like and wiUioul
]>1oodvcfl8ek ; 2. O, dumin; H. O. H|ioi\;;ioHum : ami 4, (). inefluUoanm.
Stat.' — Itonea (perioaleuro), marrow, fibrous tissue of sofc parU (rare).
Ajit. — Karly life. Congenital ï
Xal lire. — Beii i gn .
CitmhlnntiuH. — Sa rcom a .
lirmiirk*. — Ostcomata arc nim-infiamtnator^ tumDra vhicb codmM
mainly of bone tiïKUO.
LrUPnoMA. I.VMPII.ll>KNOMA.
F/itffifit'ii/ical Ti/pi: — Cytogcncoiw Tissue. (Lymphatic glinds ai>d
narrow of bon«.)
Onural Mncratofne VhnrartfT,^-a. Soft liympboma: soft, brain-
like conaisiencQ. On «ectioit, gray i^th- white in eolor. Vit*M juice.
Setr«ral hypertrophied glands may tniile and form a linnor of considerable
use. Growth rapid.
h. Hard Lymphoma: conslatence harder; Hinaller in sixe, and slower
in development.
Miir'/sfyipir Cfiarartere. — ^Type of normal lymphatic gland-structure.
Two varitttiv»: —
a. Sift Lymphoma: the cclhilar dement* (lymph-cells) aro incrcawd
in »iii> and number, wbilut tJie conneutivy tissue of the follicles appears
only as a delicate relicnUim «ontaining tliu thickened bloodv«s«cl«. In-
filtration of surrounding striictiirex i» 8ometinie« notic«d.
I>, Hard Lymplioma: cellular elemenU diminished and compresiied by
an ovcrc;rowth of reticulated conneeiive tissue.
Soit. — Mediastinum, cervical jjlands. More seldom axillary and in«^
guinni glands.
At/e. — Early Ufc, before tbirtv years.
Natitrt. — ^Ttio soft variety nmte malignant; the hard, comparatively
benign.
Hi-m'irkt.^-Wcrv: 18 understood an iJiopatldc hyperplasia of non-
iuH 11 m ma tory origin.
AxiiioMA. (Tt>l*'an^ecln«ii,) CftTamous Tumor.
J'hyti'A-iil'iiiil Tiffe. — Itlomlveasel Tiwiie.
{ftn^rat Miteru»c-)pie (Jkumrt^rr. — a. Angioma s^impTex: bright red,
slightly elevated spots: «mail lobulated. May become a prominent Nwvas
(a truo cavernous tumor).
h. .angioma cavemoïta : dark red, hard, sometimes eucajwuled. Mod-
crate siïc. Growth slow.
MiûT<>»f«fiic C/uinvtera. — a. An;;ioma simplex or plexiforme, a tree
hypcrtrojdiy of capillaries without increase in number. The capillaries
CLASS I ne AT I ON AMD DESCRIPTIOS OF TCltORS.
17T
are wii)eae<l an<l leuiïthenec), and sometimes tliickenod; b«ld togotb«r by
snutll amount of corawctiv-e tUsue.
A. Ansinma carernom bss, as its prototype, the stnicturc of the
corpus cavomosum penis; rcticiilated nu-«hwork of fitirous liaeuo liued
by ptMlothfliuQi and filled with lilood or limy concretions.
[Comil and tUnvicr do not regard a simpl« dilautioD of prc-existitig
T9s«cls as a true aii<pomn.]
SfU.—a. Angiomn «tmpli'x: externa) int«i;umeut; more octdom mn-
'eoua memhranfiii. k Angioma oaveniom: adipone tisjiue around btood-
veMela, liver.
A;/f. — a. A. simplex: often congenital, early life. 6. A. cavernosa:
old iieraAiu.
Aitture. — Tteni;in-
OimffiuiUi"»». — Sarcoma, Lipoma, Fibroma,
iUtrograâe Chattpet. — Mucoid.
LyaruASGioitA.
}*hgrir.ln<fif.ii Typf. — I.Tmpliiltic Vcsseb.
Gfitrrnl Miff>*'-i'ir c'/inni'-frre. — Produces rcticnlar etcvatious of
tile vpitbvlium of the «kill.
UeprooentA: CoiitEctiJud Macr(i<;loisia (large tongue); Congentlal Hjr-
pcrtropltim of cheeks, li|M, and eyelids.
Mieroitvfir t'hara>Hfr». — A d'ilalation of pro-existing lymphatic vi>«-
sels and lymph Hpace^, iitmilar to diialatioii of varicose veins (only here
lymph inroad of hlood in the channels). I'artitionod glmcture liri«d
with endothelium, and coutainin;; lympii-like fluid. CavernoHs Lymph'
angioma (Billroth) has the type of erectile tissue.
Smt. — Adipose tissue around blooilvcescls, liver. In clepliantiuis
arabum.
A;i*. — ^Young pc^rsons. Always congenital.
Ifittxtre . — Beni;iii •
Hemarkn.-^ï\iWi.^X by some to be a cauxe of chytnria wlien involr-
iog lymptiatics of kidney (cliyloiu urine). Here belong alao, according
to Kleba and l.Ucke, many cystic hygromas of the neck.
SaR(!OUA.
Phtfm'hgieal Type. — Embryonic Tisane, Uie elements of which never
become mature.
Accordinf! lo Kindtleisch. the prototypes of sarcoma are the different
sta^s of intlammalory ti^uc.
Billroth oonsidors as prototype not vxctiuivcly the embryonic state of
connective ttssiie. but nI»o that of nerves and muscles.
Genrral .Ifitrvtrnpl'- Ckartwtrr». — Tlic different varieties of Sarcoma
have, in their general character, many peculiarities in common. Most
of tbem grow rapidly, and «omelimes attain enormou» stxe. They are
all very vascular ; m»y become erectile (f^mil and Uanvier) and piilsat-
iiig tumors. Tliey are usually round, oncspsuled tumors, though they
frei(uentiy infiltrate surrounding structures. Some^mea tbev present a
fungoid growlh. and in rare cases a polypous form. The color de[icnds
upon tiie vascularitv, hemorrhages, and pigmentation. On scraping, the
IS
I7â
cut sarfiwe u«untl;r yioldi a clear juice contAining few c«U«. Tliu ii-
the cnsc if the tiinior U removed during life ; if post-tuortum, thu jnieo
will be iiiilkv (C'omil ami Kanvier).
A . — a. H"und-cflUd Sartvma. — A yellowish or rcddiHli, hotaogeneotw,
clmtlic, ^tl, uAttallv encapsuled masa, reaemliliiig the roe of fnlie». Un
Ucnpiiig, the cat surface yields juice, perfectly clear, and containing a
ffew CO tu.
k. /.ymjiJiadewiiti rounâ-ceUed Sitreimui. — Soft consistence, very ra»^
cutar. Ou section, roddisli, resembling tlesb, often hemorrfaagea »eeaA
Keachea large sise. The 1arg(K:vlli-<l variety is more brain-like, and la
rare. Thc«c tumon were formerly clasHud with medullary cancers.
LipomatouH and m^'xomatouM Sjireoninuv give an appearance correitpond-
ins to the degree of the combination ; they may coexist and reach
colossal ate.
p. H'nind-<^U'-'Î Ali'C"hir Sarcotiux.^K rare form of tumor. Iliglil^
rascular, and friMiuently jmlsates. '
J3.— A. Small it}iirtdi«-<^lied Sttrfmta. — More or less firm in cotisinlenoe.
On «cctioii, preHente a lasciculaled appearance. Often fungusdike pro-
jections. Size may I)e large. Met with more fre<iuently than any oiber
tSaraoma.
T b. Larffe npimife-cellgd Sarcoma, — Consistence softer than the fore-
going ; attain larger siio ; often encapsulod. i
OeUoid Hareoma. — I'yriform and fusiform tumors, «rliich toay readH
large sixo; voDsietence rlen«c.
V. — yffiehid (i'arcvnid.— Moderately finn in conilsttncc, eometiiiiW!]
excecdin<:ly vascular, giving riae to distinct pulsation, 'iliey freqneiitljf
Usve a bony capsule, wbicli n^presonts new.tormed bone from the perioa-
Iteum : or tlie capsule is membranous or osteo-membranoiia.
D. — Mflatnitin Sarcoma. — ¥\na in consistence, ûxe moderate, gener>
»llj mnlliple. J
J*itaotnuintn. — Occurs in small, hard nodules. I
ilicroneopic 0 fiarac/er». — The Sarcomata arc tumors comnsting of »
tiisue wiiich, throughout its growth, retains the embi^onio type* If
stroma at all exist, it is formed, as arc also the nails of the bloodvessels,
of the same san.'omaton« Ussnu-i. There are three principal forms of
eella : 1st, round, resembling those of granulntion tissue ; 3d, «pindlc-
shaped, resembling those of young cicatricial ti«»ue, or yonng, smooth
muscular cells; and 3d, myeloI<l celU (giant cells), made of a nucleated
protoplasm, analogous to the giant cells (Myéloplaxe^) met with in (he
marrow of bones. In aise the cells vary conniderably in the different
varieties. The intercellular substance exists usually only in a minimum
quantity ; it is either fluid and homogeneous or may be gelatinoid, or it
Ï resents a network of adenoid tissue, sometimes apparently fibrillated.
'he blùiidvit»»<fl» are numerous, and present simple channels running in
every direction, having w) dUtinet tcnih; this is peculiar to the Sar-
comata. Sometimes two or more forms of cells «re met with in one
tumor, but osually one form prcdominatis, which determines the variety.
A. litntnd-eelled Sarcoma (Sarcoma gloWcellulare). Varieties :
a. Granulfttiondih- S<trcjina (S.globo-cellularc simplex). Resembles
tJsane of granulation. The cells small, round; nucleus very large, con
CLA8SIPICATI0K AVD DEBCItTPTION OF TUHOKS.
179
I «a
pred with tiie bcmU amount of tltc protoplaitm of tlie c«li. Tlic cetl-
poiljr ia very ti«nsluc«nt and sodiuUdic^ iiiviaibic, tlie intercellular sub-
■tanco span»o and trnndparcnl.
' /', l.iimyhitdmiml r-mnd-c^lWd Sanyma (S. lymphadcnoiJce molle):
Mils iniWWi'd loosuly in a dclkato inlcpcelluiar, translucent network,
■aggeatin^ tho rotienliim of adenvid tin-tuc of lymph follicles (aI»o stmoture
«f '* proud f)ci>U" [caro luxanan»J). ilesidee tho colls, the rcticiilum
containit fluid, whicti nccouiiU for «oftnef» of these tumors. The ruttculum
can be ileuKin-^lrated by hruftliiug out tJie cells. BloodrcMcIs iibiindant.
Sul'varietieii: I^ryif-etUed, rou>itt--vlle<l SafyiKi (S< t^lobo-tnajçnï
cellulare). Cbaracterixed by approximation of ct'Ils to e|Mlh«ltoid ly\ie,
reacliinj; the siiw of large cartîla^ cells, and by an intercellular rctiou-
e*i network, with proportional meslics.
Sarmma lifromatwh^ is derived from this variety : part of the cell
becomes infiltraiod vitli fat; Inrjje and eiunll fat edlit nn interuiingled,
the fat cells arc not uniform as in Ijipoma. Also Surr-ynta m^r'imut'/ilc»:
matrix bavin;; undor^^ne mucoid ile<;ene ration.
e, Alvt">itr r-'unii-^'fttj HarmiHa (Saraoma mediilaria or Carcinoma-
todcs). Snuill nutMes of round cell* are most intimatelr surrounded and
imectttd vith an alveolat«d stroma, made up of spindle-shaped sarco-
lis celh or of delicate fibroiu ti*8ue (S. \\ . Gross). The most intî-
union between tbe cellsand the reticulum isan important dia;^H>stio
int of difference from the Cancers (Billroth). Tho cells arc larger than
lus cori)useIen, have round or ovoid vesicular nuclei and lustrous nucleoli ;
«in;; irregular in «hftp«, tb«y âppronch ver; much tli« opithetial type.
IBindâeiscb considers it a canocroua dc^enorution of sarcoma.
B. SptHJlf-e^tlftt Sarcoma (S. fum-cellolare). Varieties:
«I. Small uphidU-eflUd Sarcoma (S. fuso-cellulare durum) (" Kecur-
renl fibroid," of Paget, " Fibroplastic tumors," of Lcbert, FiHciculatcd
larcoma). The cells fusiform in shape with oval nuck'i, Jirrjin«;e tbcni-
■elves, with very little intercellular substance, into tjundlcw which paw in
every direction. RcitmUe spindle cell» of recent scur* and .sometimes
those of young Leio-myoina.
ft, Lartje if'indif-<rlhd .S<trmma (S. fuso-gi^nto cellnlare). Diflera
from the foregoing in the lurge «ixe tjf cell». These may reach g J^ '"ch
iin width, and when muginlied '2W titnea may reach ttiree times diameter
Df field of microscope. Tlie cell» have large oval nuclei, with one or
bore lustrouit nucleoli, l'uually the cells are granular, and occasionally
frcy are ittellate. Kindtlei^ch recognbes three varities: radiated, foil*
Itfid, an<l trabecular.
iSubvaricty: OHwid «ar cvnta, distinguished by calcification or ossifi-
cation of tlie matrix, and conversion of the cells into bonu corpuscles.
C, .Vi/flmd •Sarenmii (Giant-celled Sarcoma) i* characterined by large
lis, olW» up to -rjj of an inch in diamct«r, considtiug of a mass of
[nrotoplasm containing numerous (thirty or more) round or oval nuclei.
Theae celU may occur in any variety of Sarcoma (Billroth), but usually
are confined to tbe Sjàndie-cell Harcoma of bones, to which the name of
iO»t»/.Mtr,-uma is ofttn applied. It is known as Epuli», when springing
Srom the perioateum of iJie upper or lower jaw.
180
icHons.
D. Mfiaitnti'- Sariyima or Mplanoma (Surconm ptf;Ricntntuiii). Any
0D<^ of tliv varieties of surcomii may be t)i;;nit.-iili-<L ( liillrotli), but nrast
rrci|iifiitly the ^lU-eolur jinA spindlo-Htixpeu :>nrL'oinnta un ihiw colorcil.
Tlie pi;^ncnt, oitlior black or brown, is usually coutAiiicd in thi- cvIIa;
rar«Iy in the intercellular «uWuinc«.
The toriii J'niinin-mi is a[i])li«d to Sarcomata containing conc«MtricaI!y
fonncvl niUHSL-s nf lime.
S'iit. — The most common aeattt of the Harcomnta in geneni are : skin,
«uhctiLtncouA li.t.'iue, iniermiiitcular connective tissue of mediastinum, eye,
]ieriO!)t«um, marrow of bonea, sheatlia of nerves aud ressels. Secondary
growttis: lunc liver, heart.
A. — Ilounu-cclled Sarcoma,
d. Small rt/und-ftlUd iSarrotna. — Periosteum nn<l medulla of bone»,
ahcntbs of nt-n'c-eentrett ; occasiuually skiu, mucous and serous metn-
bratiM iind ^lunds.
A. Lt/iHi'h'Khtu'iii muitd-rflUd A'arooww. ^-Subcutaneous, subfaciiil,
and intvnnii.'tcubtr canneciivo tissue, moitt fretfucntly of tliigh; lymphatic
glaiuU; periosteum aud medulla of bone*.
Sart^fmit IJ}"nmiii»ifa. — Loose connective tûsue of the extremities,
gub]ieritone3l connective tissue.
r. Alfeolitr r"U}iil-c--l!f<l Sarfoma. — Marrow of bones, eye, subcu-
taneous tissue, skin, intcriDiucular counective ÛMue.
B. — Spindle-celled Sarcoma.
a. S-nall «pindiccfUed tinreoma, — Fibrous membranes, shcatlts of
vessels and nerves, subcutaneous and submucous cunocctivc tinue, peri-
> oet«um, marrow of bones, breast.
6. Jjarift Hjntuili- relUit Sitrr'nita. — Kascin; and fibrous membranes,
periosteum, marrow of hones. .Mine rarely in interslitial tissue of gland-
ular organs.
Otttoid Sarcoma. — Grow from the periosteum and more rarely va soft
parts.
C. — Mifehid Sarcoma. — Nearly always connected with bono, origin-
ating in the marrow.
It. — Melanotic Sarrnma. — Choroid of eye and skin.
Prammoma. — Meninges, choroid plexus, on the spinal «ord, and 00
nerve- trunks,
Ayt. — Before the S5th year, on the average.
AnfKrc.—'Kecurreiivv in low is almost constant. Metastasis is aUo
very freijuent.
All varieties of sarcoma arc mati^mut. The round-celled or medul*
lary and the small spimUe^eelled darcDiiiaiu. especÎJilly tliose which have
undergone myxomaiouadcj^eiieruiion*. are the most malîgiiam of all tumors.
The giant-eellcd variety is the least infectious of the sarcomata: while of
the varieties, due to changes in the cells or intercellular substance, or in
both, the melanotic, osteoid, lyrojihadenoid, aud alveolar are eminently
malignant (S. W, Gross).
V"mbinfil{->nf. — The round-celled with Upoma, Myxoma, Fibroma,
Chondroma, lilioniH, Osteoma, Lymphoma, Angioma, Cysts; the spindle-
colled with Fibroma.
à
CL&S8IPICATI0X AXO DKBCftIPTIOM OF TUMORS.
1f)1
lîftf»'ir,uh Chan^t. — Fatly, myoxfttnaWos, wliuiKiMttitw nnd liemnr-
rhn^v, citloificatioH, ossîficntioii, ovNtic, pigmontary. l')i« flarconuta may
liirc'tiiuc iiiHaini-<l aw) may MU[i)>tiniti.'.
IlriMark;- — Billroili, Klehx, ittrcli-Ilir»clifd<). Colinliciin, Cornil, nml
ItAiiricr ail )iOi>iUrdy o|i]ioi« itie view of Uiiul&eisdi, ihat saTi»iDaU>tu
Lvll* eau WeoiDe ilevelopc^I into true fibmua tiasiie. Connective tisatiOi
if met witli in tlietie tuiuora,is reganled«3tfa« remaineof tb« pre^xùtiog
Donnai stnicture.
The QcWi arv j^eneratly fipimllc-stinpeil iii sarcomata of hard couBiHt«nco
«•lien cnniitresH.»! from :ill »i(lo« ; ilicy urc Dut if oompri'MC-d in ono iliroo-
tjon (C'oruilan<l Ilanvior). Fiat cells i» profile may apgwar spindle-shaped
and UTvn like fibrils.
Jtiffrrfntial Dùii/nanM of
>fulasta«t8 tlmitifrh hloodvcuols,
«ml a» a nilo does tiot affcot ttic
lyinphati« )(lan'U.
Ori};iiiat«i* primarily in d«cpor
EltructuKs.
Is <it;li]«ni lieredtUry,
Average before the thirty-fiflb
Ljear.
FrimarilT0iicapttu1cd:lat«r,boir-
Dr,capsulc frisiiicntly pvnutruied,
land tbe cidlii infiltrate surrounding
[•tructurcK.
Kardty ever containi* fat.
Sarwma/ram Citfinoma.
Mi'tasU«# through lymplintic» ;
usually alfecls lymphatic glands.
Originates primarily, always su-
perficially ^Samuel).
Is hereditary.
After the thirty-fifth year (onlv
in kidney and prostate met witli
er«n in «hildron).
Never encapsuled. The cells
primarily infiltrate and penetrate
freely the eoaneclive tissue lyinph>
xgiaee.t, not bound by any limiting
membrane (contrary to Atlenoma).
Nearly always contains fat.
Acetic acid and caustic potash di^«solve sareomatous and embryonic
ells ; hut do not acton muscular cells. Diagnostic point for leio-myoma
ï(Rndnew).
f Ceuiraily growinjt «arcomata are les3 mali<ntant: those of jjcriplieric
grovth are more mali^iuit ; the softer and the more rapid in ;;rowtli, the
owre tnalij^ant: mosimnli^innt arc themelaiiomala. Uarely is eachexia
observed as early as in cancers, thonj;h it may present itself late in the
disease, especially alVvr recurrences, l.iicke considen Uie sarcomata more
mali;pianl than the cancers. Sarcomata occur u.sually in healthy, well-
^nourished |ii!r«ML< (HillrotJi).
In curly life sarcnutata occasionally grow so rapidly that tliey have been
^misukcD for acute abscesses (LUcke).
II. Tl^MOItâ OOUPOSKU OV «L'SCULAR TISSl'B.
Itoma :
/i'utfnl'y-mifim'i.
J'hjfëioioffieal Tyy^f.— Striated Muscle.
18â
TrMOBS.
Ornerai Mnfrn»rapic Charaetem. — The pure titnior \» exce«<lingly
rare in maD. Is soroetïmcH found in comltinniion nith otlior tumorn.
Mia'i't'^'l'îc <'bnrtt<-ier*. — Voimj^ striati'ii moiicle in (hia rnrietj hu
beon observed lo consist of sinatc<i and siiindlf-sliapeiî cflU and lîureâ.
Seat. — Hxclusively in tho genito- urinary tract (Coliuheim).
Ane. — Conseniial ï
Ntiture. — Bcni<;n. Mctastn«is observed în tbo pigmented varie^.
Coitihination». — Sarcoma, rociniiotie ssrcODia, imrcinonia.
Jtefroitrnih C/ifinyf». — l'i^raontatîon.
Rcnuirk». — Occun inoro fix-^ucntl^- in unituaU (KolesutlcolT),
Ltia-myoma.
}*fiy*iitl"<finil Typf, — Smooth Atu!*cIo.
OfHtral Mif-ffm/niT Cliuritrtr-r».^\'ùTj; niiicli resembling fibroma ;
firm and round, usually a limiting capiiule. On section, grayisb-whitc
or pale red ; concentric and radiating martciit^. Sixe from tliac of fist
to pregnant uterus, (iroirth slow, eoinelinics multiple.
fl/irffr\'j'ic Cfi'irnrUrt. — Include smotili miHcular elements and eon-
nective tissue in varjiiig proportions. Muscular celU either iu bundles
or separated.
iSVwt. — I'tcms. walls of ceeophagus, stomach, intestine», prostate.
Af/e, — Advanced.
jVW ure. — Boni ^ .
Comfiinati'tn». — Ft b roma .
Itetrograde Chmujn. — Calcifiention, mucoid, cavomous.
JEemarX**.— Originates only from pre-exialin^ mu.scular tissue.
UI. TUMOBB COMPOSKl» OP XERVK TISSCE,
Tiii'B Neproma.
Phii»i"hifieal Tifpe. — Nerve Tiuuo.
Gmentl Ma/^rotcoiiii^ (Jharifi'-rt. — tlbrillar neuroma. Small, hanl
swelling, white in color ; somctiincA nodulated. On spinal oervea ofteu
multipK-.
Oan^iioiiic neuroma. Has been met with once or twico.
Mirmn^ifie tluiraeti^». — Hard and soft variety, awordiitg to amoc
of fibroui" tissue.
J. Kihrillar neuromata, subilivided int<i :
a- Uomjiosed of medullated nerve fibrils (myelinic neuroma).
4, Composed of non-mcdullatcd nerve fibrils (amyelinic neuroma).
2. (îangHonic neuromata, composed of ganglionic celh. In both tlie
connective tisane stroma often predominates over the nerve elements.
Stat. — Fibrillar neuroma. Frequently on cut nerve-ends in amputa>
tion stumps.
Ganglionic neuroma. Dermoid cjats, brain ond sjnnal cord.
A'je. — Adult.
JHnturr. — Benign, cause great pain.
C<imhinatio»*.-^-Vi\\o\a&, myxonin.
Urtrv'/niiU ('A'in;/ft.—y\iic(i'ui.
Jieuutrkt. — IVotluce often severe pain.
OLASaiFICATIOB AKD DESCRIPTION OP TDHORS.
1R3
d
Bm'kIm th« neuromau, the glâwlnlsr canccra arc often peciiliitrly
pninrul ; lint, gcnenlly, any tumor maj produce pun if presaiiig upon
a part rich in *eik#ory iH'rvea.
IV. T0Mm8, TUB ESBKCTtAL cnx(tTITUKXT8 OF WHICH PBOCKKT) FROM
TKL'E GI'ITUEUUM.
CLAvr« (Conw). Cosxu CUTANBDii([Iom5). Onychoma. Ichthyosis.
Also fiome Corneous WarU.
PkifMoloifinJ Tit/M', — Surface Epilbelium.
Gma-at Maero»eopie Charader: — R«acb conflideraWo nse ; vary in
color.
Mkrtttrtnnc Charaettr». — Com*. Tlicy aro all simple cjntbolial
hypertrophtee.
Hom«. Consist liixlologwally of «pitheliiim alouo.
Onychoma, llyi-erlnipiiic now formation of niiil-tiiMiH-.
ItfhtliyoKix. IIyi>t^rtiv>pliy of e]>i<li'rinis reacinhling «cnloe of fish.
Sf<\l. — At any {tart of liody.
.4//r.— <.)ft«n oongenilal.
Xature. — Benign.
Jitmark». — Cohnlieim regards as Uie sole «aiue of corns the local
hyperemia occurring during the dme when pressure (the shoe) upon tlio
seat of the com is remored.
Papilloma.
Gmrral Jfarrof^pte CharaHrr». — If einglo, proiluc*? simple contcal
olfvations. If dendritic, produce a fungous, oflon vascular mass (cauli-
flower-like K'^"*'^*)- ïf many deri;li>p<.Nl logctlier, may form a tumor
of con*iil<:!niMi- >>izG.
Jlitrd yaviU-imit. — Kopn<4«Ht4 the denilritic irarts, Uie pointed con-
dyinraata. Veiwreal warta.
S»ft P'lplll-ma.^The dendritic growths in mncoitu ni«mbranc8.
Mierr-ncj/nc (ftarnrfiT*.— Iw physio! ogie* I prototype U tlie papilla
of the skill and the intestinal villus. W e find the same conical projec-
liona repeatedly branching, made up of a basis of vancular connective
ttsnie, and covered by epithelium. Sometimes the stroma and more
rarely the epitheliom predominates. The epithelium, being nolumnar or
squamous, corresponds to the kind normally present in the part. There
are two varieties:
JTard Papiiloma.
S«ft PnpiUoma (more vawctilar).
>y<nf. — bkiii, [H-nii«, Rn;;ers, Aims, lahia, bladder, roctum, uterus, milk
«luctit, «toniflch, vagina.
yul urt. — Uciii^.
G-rnif^nation». — -SaTComa. epithelioma, cnrv^inoma.
Itrtroi/rade Chant/t». — Ukeration, hemnrrliagc.
It^mnrt», — These growths are purely i(iii>erlicia1,bul sonve times, when
ulcerating, they ponctraw the integument, proliferating into the cutis,
thus beconung epithcliomata.
\Si
TUMORB.
Gl.AXI>ULAR HvrrUTRni'HIKS.
]'liy»iQl)tjiral 7y/je.— <jliin<lular Kpitlielnim (of ibe difiérent glandular
orgnns).
(feneral iifa«rvfeornc Charaeter». — Kepreaented b; mamiaarv gland
during lactation. Ilyjwrtrophiea of one kidiicjr or of on» of tlie liv«r
lobes. Deviations: Ilyportrophy of muc-ous glands incautrrb ofetoiaacb,
iuU'itincs, ao'l ri-spiratory passaji;es ; sweat and si'baceous ;;laiuls.
Mierrfyipi'^ Vharartrr*. — I'hjsiulogical typo aod arraugcnifiil is fully
fii'csi-n-cd yi)\ilv both tiic stroma and tbo t-pitbvHal cU'incnts liyportrupbicd }
ocal byp<iq>lasiu. Conucclivc tissue of follicular sacs tliiukciied.
Al>BXOMA.
J'hi/ifiuloi/ieal Tjfjte. — tiiandular cpilbciHuia of the different glandular
organs.
Ornerai Mncr"*fopU ('liitrnriert. — Lobulaled, sharply circiimacribe
by a thin capsule ; nodules replace portionii of the (^land structurel
tiiey iuvalve. Ou eectioit, wliite ; lh«ir racecooae structure is sonivtiuioa
visible to tlie nakod eye. Hard, elastic ; tbos« originatiui; from t;laati
lof mucous mciDbmncs &rv usually soft, aud attain frc^qucnlly polypou
and cystic forms.
Mirrotcff'tc Cfiarat^i'rt. — Coluniiisr or si^uocnous cpithcliuin, resting
on a basi-mciit niciiibraiR-, fomis tubes, imbedilcd in a niorv or leMd
vascular stroma, like normal structure of the niiimma aud similar içlamU ;J
but arraiigumi.'nt loss regular, the epithelium ]u-oHfi;ratvd aud tiliiug tb«|
lumen of the tubules.
.Vmr. ^Axilla, mamma, liver, sebacooua and sweat glands, thyroid
gland, rectum, nose, uterus, ovary, testicle, parotid (polypous forms).
Atfe. — At puberty.
yat ure. — mnisu.
Cam/tinationê. — Sarcoma, fibroma, carviuoina.
KetrvifrrtJt Chamje*. — Katty, colloid, mucoid, cystic.
Ranttrke. — ^Always develop from ]>re-existjng gland-structures.
Atyjnatil}/ CoHatrueti^d Tunuira.
Epithelioma, Caretttoma.
Sqdamoi'h KptTiiKUoMA. (Syn. Canoroid, Kpidermal Cancer.) Va-
rieties: Lobular Hpilbelioma, Tububir Kpithelioma, Pearly Epi-
thelioma.
I'hjini'Aiijictil Ti/pt\ — Surface Epithelium, a. .Sijuanioua.
General M'irroêccjiii- t'harticli-rt. — Present different appearance, ac-
cording [o locality. Tboy arc fini^roid, if proceeding from a cauliflower
growtb ; otbcrwiso present flattt-ucd indurated elevations, covered with
diied, odorless secretions, s^jmetinius depressed in the centra. Fre.
quentiy have the apjiourttnce of an tdcer, with indurated edges. On
section, pri-sent a grayish-wbtce, tinu, inelastic, sometimes friable, dry
mass. On s-pieeziug, a turhid li'piid, and in many cases a very charac-
teristic curdy material, worm-like in shape, resembling " eomedone-s,"
can be expressed. The pearly bodies in exceptional cases can be seen
will) Uie naked eye.
0LA8SIPICATI0R AKD DSSCHIPTIOR OF TDXORS.
185
Mi'Toteùpic Charaettr». — afuamoua «pith«liftl cells (rormtn); itsually
A l»rgor inn)w), arr*ii];«i] into eimplv or bmnclivii vylindors or coti^s of
^nrious leii};i)i, wtiich penetntlo a vasculiir connooUve-Usaue jiUonta (llie
nrij^iiinl culU or fibrous bâtis of tlio mucous m«mlirane). lu the c^limlcrii
tliK «'j'itliijliiiiii krrtinges itself oftvn coiici'nirically (otitoii-like) into pecuiinr
neslSt t)>c so-called (learly bixliesi. Older lay«ni of ejtitlielium, when
fionpreiised aiul dry, liave, like tlie pearly D(>dulea, often a homy yel-
lovish appearance, llie celU in ^«neral are lar^, bave one or tito
constantly largo nuclei, and large aiiining nucleoli. Sorrated opitbolial
oella have been observed.
ShU. — Skin and mucoiia membranes, lower lip, tongue, prepuce,
KTOtutD, labia, «yclida, cheok, uteruâ, bladder.
A'je. — Advanced.
i^Wwcf . — Mali;^mnt, bnt not always. Mctastaititi mrv.
Rrtra<fradt Ckanytê. — Futty, otberainatoiM ubscesMS, calearooiw,
onvooa.
CYMSI'RrrAI, KpITItELIOMA.
]'hif»iol.,.iintl 7'i//»'. — Surface «pithclium. ft. Columnar,
itrnftal Marrogrt/pic Cliaraftr)», — Fungoid or flattened eleralioiw of
a TiurTuco, often witli n depreiuian in the centre. C'oi).4ia>teuce soft,
i^tiinvit gelftitiioiiA ; lij^ht colored. May form exteimivc growths.
JHi'-r'>t'-'>/'ir Charitileri. — <Jo]iimtiar e|>itlieliiini (analogous fi the
normal) ami a vaHcular eouneclive-lUHue stroma arranged into orgauixod
pafiiihe, wliicU j^row in every dircctiou, mostly inwanlly.
■Vi'^if. — Only mucous i>urface8,larynx, uterus, bladdcr,elDiaBeh,rc<!tuin,
Itrcr (from gall-duct«).
A ^e. — Ad va need .
JtWure. — Mctastflsia has been observed.
Ci'iahinnti-int. — Colloid c»tiecr.
Jiftr->;tni<lr Chitnyrt. — Colloid, fatty.
/{•■initrh, — .Ml glandular cancer* -best considered nodificatiORS or
degenerations of a single type (Tyson).
Itireb-l liTscbfeld confident the glandular cancers as of no more defined
alveolar structure than the ejiiiheiiomata. Indeed, all the ei>itlielial
elements in the other cancers ai-e fonueil into variouniy branching cones,
which fienetrate and separale the stroma in a iiimtlar way as in epithe.
Iiou>ii, only more profusely and irregularly. Transverse sectionâ of
these cones give the alveoiated appearance, which can be obtained in
epitbelioom by making sectiona horizontal to the surface of tlio tumor.
Uabd CAHorsoju. (Syn. Seirrhus, Simple Carcinoma, Connectivo-
Tissac Cancer, Chronic Cancer.)
Ph^ti"i'"ji'--il Ti/j'F. — Glandular Epithelium.
Ocnerit! Mocrfitrajntr Cft'ir<Wi-r».— More wr le*a 6nn and banl (nc-
conling to »gc and dovclopniuut and i>fciili;iritii>s of locality) ; sometimes
dvprvssed in the centre. On section, gravL-sh-wliiie, glistening surface,
intersected with f!bn>us hands. Central [>ortion hardest, lowanls the
j«rij)hery softer. Oo scraping, yields a milky juice, rich in cells.
186
TV MOUS.
ifîer»Bcopif Chitractfr». — Bolh Scïrrhus and Eiiceplialoul ooniri#t of
epî(li«1ioîi] cclla, mthin a vascular alvoolatcd connct:tive-ÙMUv stroins.
1^0 cells are irre^ulnrlj packiiil in tlici varioiulj stxvii Mvcoli witliout
niiy iiitorccllulnr substance. Tht- cdk nrr uAiially ■>r coiMidenblc aizo.
vftrv imioh in sliupc, and (iBvt- prominent nuclei nnd nucleoli. Tliffre if^
iwl.ioni n line of demarention hinwwn the c«iicemii!i ^rovrlh and ilie i«iir-
rounding norinul structure ; tlie Utter i* gnidiiali^' infiltfmt«d hy c])ilhe-
lial cells. (Hence the nmlignnnc>' of these tumora.)
In scirrliug the iitroma pre<iominal«!i over the epithelial elements,
llic trabeculn; of the ^ttroma are usually made of broai] hands of vas-
Bular fibrotui tisane, forming comparatively Hmalt, often narrow kIvcoU,
vrtiich the epithelial cells are closely packed. The proportion of ihc
stroma and the epttUelium differs at different portions of the tnmor. In
typical development there can be rcoofpiixcd four xones : Isl. the peri-
pheral— developing tone; 2A, fully developed epithelial ne«ta; «td,
partial retroj^esâivi- metamorphosis; and 4th, the oldest centra) part-
cicatrization, atrophy.
A'fat. — Mnmnia, ])yl'>ru8, œsoplia|*ns, rectum, tiver, glands.
Ai/t:. — Advanced.
ynr»rf. — Mali;niAnl. MctMtiidis.
Jtrtrt'iivitU <%tH'ifti. — Fiiity, fibroid, caseation.
Itftiuirlc». — Knoephaloid cancer* are invariably of epithelial orijpni
I.e., glandular carcinoma. A certain large number of the scirrhus be<
longs, nnipiestionably, to this class, hut a fow have their origin from the
tû.<iii'S of the middle blastodermic layer (endothelia). Comil and.
Itanvier believe carcinoma to orij^iuate from the connective tisuM oor-J
puitcle».
Soft Carcihoma. (Syn. Enccphaloid, Medullary Cancer, Soft Cancer, ^
Acute Cancer.)
J'hijêlM'jhal Type-. — Glandular epithelium.
Ottifritl AfaiT'tfmfne <7hara<rfrr». — More or lc*3 lobulated ; soft, bnùD^
like consistence. On section, presents a white, pulpy, often bad->im«11ii;
ma!** : frenuuntly extravasations of blood ; central [wirtion fre(|uently fatty^
degenerated. I'icatrization never occurs. Milkvjnice ia discharged, or
can be easily expressed. May reach considerable size.
MierûHcif-ic l'huntfti'rn. — Here the epithelial elements predominate
over the stroma. The trabecu!» of the latter are thin and delicate ; they
are very vascular, form large oval alveoli, loosely filled with epithelial
cells.
I'hcro are all intcrmediato staffs between enccphaloic! and scirrhua.
Sent. — Salivary glands, niainnin, testJclc, Ovary, prostate, thyroid,
nose, liver, kidney.
Aift. — A <1 vanced .
A'lturr. — Most malignant. Meta^tasis.
Jtrtroi/radu Chamje*. — -Fatty, colloid, cystic, mucoid, pigmentation.
Itenuirk». — Samuel describes an itcuttr miUarif tr<ir<-inii»t$, aooompunicd
by high fever, etc., perfectly analogous to acute miliary tuberculosis.
CtASBIflCATION ASD OBBCRIPTION OP TOJIonS.
187
Tki^aniukctaTIC CaIICEKOUa. (Varioty of Encoph«1<>iil.) Ooo form
of Kuni^B Ha>iit&to(t«s.
Qenenil M>u:r"iu'Of>ir Vharadfrt. — Con8iricnc« Bofl, color dark reil ;
fVe<|nciit)y pit) rcnchv matous hemorrhages, and pigmented spota. M»y
roach Iiir^ «\zv. Cvi<bt.
Mifroaciijii'- C/mrii'-ti-r*. — Iti ihU variety of cancer, the vascnlar dcvel-
opncut |>rcdoniinat^s. 8otueUn>e3 the stroma is entirely tnado u|i of
tn>ciilar rami 0 cations, forming in aome places dirorticula.
iVivif. — Stomach, intestines, rectum, matnma, ovar;.
A'ft'-- — A d 4-ai>cei1 .
y lit Htf. — Maillant.
Rvtr^grade i'/iitnifrt.—Cyitic.
COLbutD CA!(CEn. (Syn. Gelatinous Cancer.)
Gênerai Mnirroteome Charaettr*. — rrcsonts a sofl, gelatinous, lobn-
ed, ycllovri^h, bad-SDH-lliu^ muss, intvnwtetcil nith hands of fibroaa
ac. Surface fro<|iii>ntly covcri-d with hydatid-like vcKidei.
JUicTfitoopie Chanirtnrr. — A cancer (often Bcirrhii») Iiariii* uiflcrgone
oolIoM degeneration; lin« a rery limited ra#ciilnr Mipply. In the large
alvfoli, iliKteiitlcd by the colloid matter, arc seen a few remains of epi>
thelial vellif. The colloid cancer cannot be conaidcred a special variety
of cancer.
A;!-^. — A "1 ra need .
A'atur*: — Malignant by extension in continuity. Ha metastasis.
Retroffrade C'k/iH^t.—Cye.ûc,
EsiK)TnEl.iOMA(î>' (Syn. Endothelial Cancer.)
J^hi/noloifiral Type. — Endothelium.
Genemi MtKtvtnipie ChitrifUrn. — Similar to the f;landular cniKer« ;
Fera from them only by ori^nating from the emlothclium of lymphatic
fcis anil lymph spucei». Kare.
.ViVr^)" <-.)/'( c Chttni-.-tirrt. — Xcst* of clrwely-packeil pro!ifi>ratc-d cikIo-
thelial cell» are inclosed in ah-eoli made up of a va^ciibtr conucctive ti-'t.'tuo
Btroiua. The hi»toIo^cal character of the cellit and nlroma is very similar
to that of tnie canceni.
lS.'«I^. — îîkin. memhranes of hraîn, pleura, perineum, tymph glands.
Nature. — ^[ali^nant.
Itelroijradi! Chaude». — Mucoid, fatty.
Rtmarkë. — Some consider the eniiothelial cancer as a variety of sar-
coma, others a» a true carcinoraa. Samuel considers it identical with
the alveolar sarcoma.
Cn-LSIlllOMA.
Pbyainhiiiiyi} Ti/pe. — Uncertain.
Gmeral M-irf^'-'ifi" Chtmricr*. — Resembles mynoma. Found some-
time» in other tumora. The hyaline masses are, perhaps, perivascular
sheath:* having underj;nne mucoid degeneration. Ka<l«r re;;ar<ls it as
the pro<)uci of secondary mucoid metamorphosi-t of a cancroid of the
lyuipli vessels, (jrowthslow; sixe moderate ; rare.
188
TDM0H8.
Mierotctme C^ractert. — Pn-aonls peculiar cyliiidric*], spht-rical, or
cluWliapou bjalinc mB8»e, contaiuin;; atellaU- or ru»ïronii cells, and
liarin;!; in thvîr ct'iilrc one or more cnpillury I ilooil vessels, luuully of Ur^c
«hif. Between and around these hyaline romiutions, wliiclt nsuatly ur«
iiiilied<le<l in n voitniM'tive t.îs«ne struma, are Mtuated sumetiincs lyin|iliuid
■jiiid riiier C])itlielioid eullji,
iSr.it. — Orbit ami iici};lil)oriioo(l of javfs in the «drcntitia and Mood-
vc^Mil». MixiNl tiiiuort in the parotid, dunt mat«r, peritoneum.
J^'itturt. — Hliglilly malignant.
Hfnutrk*. — Waldcyer call» the cjlindroma a plexiform aiigio.aarcoina.
Kîtulfleiscli snggeats the name cancroid (cancer-like). It never aHecu
lyiiipli j^iauds.
V. CvsTic 'IVmobs, nift<Ie up of a closed sac, with more or less fluid coo-
tenta (indnding also the Dermoid cysts (Virchow's TcratiMm)).
I. Ci/»t9 formed bj/ the aefunnlation of fuhttanrt» witJiin (Ar raPttUt
of )>re-eritlinif gtructurt».
A. Uetentios Cvsts. — Cysts resulting from the retention of normal
secretions. These inelodo —
a. Hfharftua C;f»ti>. — These are formed by the retention of aecre*
tioTu in the sehaeeouA j;1ands. Sucb are comedones and]
athcmmatoiis tumors.
B- M»f"ut Vj/»tjt. — These are formed by the retention of secre-
tions ill Ihc glamb of tuucotia mcmhmnOH.
y. Cffst» from lilt- rttfufi'in of «e:Titt!i-M» in other part», includ-
ing— Raimla, from occlusion of the salivary ducts ; Kitcy.sted
Hydrocele, from occlusion of the tiibuli teàlis; CysW in the
mammary RJand, from obstruction of the lacteal ducts; Simple
and some ompoimd cysts of the ovary, from dilatation of
the Graafiun follicles; Simple cystâ of the lircr and kid*
noys.
lî. KxtnATroN Cysts.— Cyets resulting from excessive secretion in
cavitie* uiiprtnidcd with an excretory duct. Tl)c«e iucliidv
ItuRtte, (îaiigUa, Hydrocele, and many cysts in the broad
ligament.
C. Extravasation Cysts.^ — Cysta rctullin* from estravaMtioa
into closed cavities. 11ie»o include lliematocele, and sooifrj
other forms of sanguineous cysta.
n. Ci/tt» nf inilf/'i-nil'-nt 'iri-fin,
A. Oysth kuom SorTKsiNii OP TtssuEa. — ^Theae arc eapeoîalty
common in new formations, as in encbondroms, lijioma, sar-
coma, etc.
B. CyST.S FIIOM EXPANBIÙX AND FUSION Of ShACBS IS CoNXKCTIVB
TissuB. — These include —
a. BurKte, originating from irritation and exudation into the
tissues.
S. iVr/wN» cffit» in the neck (often congenital).
T- Mantf eompuunâ ovarian cyttt.
I
I
■
OLASStPICATIOX AXD DRSCHIPTIOX OF TDHOna. 189
C. CT8T9 PonMBD AROCSP FollKtnS BOPIF^, KxTKAVASATKHltLUdll,
a:>i> rAnAHiTtid.
D. Cox<iRXlTA].<JvSTi;.— 'Dieise include many Dermoidcyata. Thoy
Kppenr often to l>e tlic retaainii of ltligbt«d ova. Tbey con-
Uiu fatty roaltera, hair, teeth, bones, etc.
VI. MiXRP TtlUORlS, DtIK TO COUniXAT(0!i OV TIIK IUCFKHKNT TYI'ICAL
AND ATYPICAL FORUS OP TUMOKS.
VU. Oranui^tiox oh Ixpxctiodh Tumors, wbîch letiologically and
liifltoloKÏcallT fltaiu! very near to the iiitlainniatorT new ioruia-
tjotui: fubercle. Glanders, Syphiloma, Lupus. Lepra ; Lyniph>
oma, of some infectious diseases, as typhoid fever, scarlatina, etc.
AFFKNDI.X TO TUMORS.
Af^er tlie definition which wc have jiiren of tumors, we dioald XKDgfi
among tliero neither accumulations of pigment under the form of oirvun»-
Mribed masses, nor hydatid cy&ts. Vie will hrietly describe them in tiiia
appendix to tumors.
SlUPUK MeLANIC Ma!!HKS CIRCVMSrRIBKD I» THE FORM OF TtMOHl!.
SvxoxvMS. — These «»a\>\c melanic mames have been very frequently
eonfounded with utelaitotic sarcoma and carcinnina under the name of
melanosis or melanoma. We do ifot nie the term ttinijile melanosis to
characterise thejc masses, became the radical of the word does not rep-
resent a tissue.
Defi.xitio.n. — The melanic masses vbich we here have in view are
distinct from melanatic sarcoma and carcinoma in this that the niclanto
granules do not aecumulaie in the cells of new formation as in the latter
tumors, but they infiltrate the prc-oxiating normal clement*. Melanic
pigment ;^nules auoumulutc in the cetla of nonual tlsHUc and destroy
tbcni, and if tlie ucciunulittion continues, the tissue itself is destroyed
tnd replaced by a nodule or a tumor softened at its centre.
We i^ve the namp of melanic niiissos to those accumulations of pig-
ment ooourring at the sum« time in great number at different points of
the organism. Tliey are distiri^uUlied from pigmentary inBUrations of
the skin, tuci-i mnUnii, and frotu the pi^^neiiliitioii ivhtch is sometimes
met with around vessel.* in the nerve centres, hy the fact that they
destroy iJie ti&iues and are generalized in all the organs like tlie most
isalij^ant tumors.
Dlslrii'TIu.v. — CoRtrary to the habitually slow progress of simple
mcUnosts so common in the horse, productions of this nature in man
become genertiliEed with very great rapidity, and cause the death of the
patient. The progress of the malady is suoh that one is often cmbarras.tcd
I, know if a primary mass has determined a secondary infection of the
190
TUM0E8.
organîaiD, or if tlie nmnerous masses wliicti are observed proceed fh)m
tlic influence of the same general caune.
Ttiese melanic masâca bave variable dimensions. Tticj are «liarply
bonlc-red, and tlieir periphery présenta no intermediate tones ol lessening;
color,
WIh-ii tlicy rcuch the the ofttn almond their consistt'iice isttsuallj soft at
the ct-nlru, whilst at the puriphcrjr tliev still preserve Uto firameaM of the
tissue u'horeiti tlivj »ru ilcvtOopud. The lar^^ost contain at their centre
a gnimous fluid, in which the microscope reveals nothing tUc titan
metntiic granules. K»r the microscopic examination of tliv i>eri]>hcral
parlii which are ^-ct firm, sections mnat he made after hanlenin^. We
Rnd the elements of the original tissue infiltrated with melanic granules,
vithout any indication of a cellular new formation.
In the subciitancAii3 cellular tissue the plasmatic (connective tissue)
cells are infiltrated with pi^imcnt.
lu the peritoneum the melanic granules are deposited in the plasmatic
corpuscles exactly a» in the skin. In those trabccuhe of the ereat
omentuni which contain no vessels, eïnùlar piginontatioD of tlic ««lis la
seen.
In the kidney the depont of pigment takei plaoe ni>w in pntcht-s.a^ain
in littl'^ black granules. Sections of tlita orj^an examined nmler the
microscope show the location of pi^eni in the cellulo-rnsoular tis:*uo
and in the j;lomeruli; the epithelium of the tubuli remains intact for a
lon)t time.
We have also seen the mamma present patches visible to the naked
eye. The pisment was fonued not in the connccliro tissae, but in tlic
duels and i» the acini of the gland, in the protoplasm of th« epithelial
cells around the nucleus.
'i'liis ]ngment has been found deposited «tod id the muscles of the
heart.
From these fact« it is certain that the formation of pî^nnent takes place
at the same time in the cells uf the connective tissue, in the cell;* of tlie
epithelium, and even in musctilar fasciculi, and that the pigraeni does
not come directly from the cfiloriii'; matter of the hlood. It i» not a
^rople penetration of the pijfmvut, but h the reault of on action of llie
cell.
This morbid product can only be confounded with melanotic sarcoma
and carcinoma. From the naked-eye examination one may sn^jACct a
simple melanosis, if wo do not find between tlie black and the healthy
parti a xonc presenting tints of intermediate coloration, t^uch a ;p^a-
tion of pigiueutation is almost never absent in melanotic sarcoma am)
carcinoma.
Hut, to arrive at a precise lii^tological dia;piosis, it does not suffice to
Mvrapo thv tumor or to examine the elements obtained by dissociation; as
we have already said, it is necessary to make thin sections.
Oencralination of the melanic masses is very rapid, and death follows
in a few montiis.
Ot-ASSiriCATION ASI
I0R8,
191
Hydatid Cvstb.
<)«scri)jc
k
Pig. in.
10 in th« gciwnil pan of Ibis manuiil Iwonuïe tliey
may he mol witli in nil the organic nnil ti^ucK. llic oUier liuiuan p»ra-
sitcR which hav« 8)iocinl sen» will be inetitionc<I àprop^t of the tLis^ues
nwl or^iitiit wboix'in thi'V »r<.> fouml.
l>i:i-iNiTri)N. — llyilittiil cyst», which owe their name to tbe aqiieoua
fluid which they contain, arc csiientially constituted by vesicular wonoa
which repiviteul a phase of llic dcvetopmcnt of taenia.
In roan two varieties of hydatids are found — cyetioerci and ochinocoeci.
Ci^ntii-trd are always wn;;lo in their cyst, while ochiuococci nre con-
taÎDod in the primary cyst in considerate liumhcr. They proceed from
various spocic^s of t^tùa, hut most frequently cytticercu» ee^ÎH^o»a!
(Uudolphi) appertain tu tieniu «<'/iNm.
T:t>nin solium, u wen in the «mall intestine of man, ia a ribhoivcd
I «onn, whitL&li, aud Mv«ra1 ynnU lon^ ; it 'a com>
powd of jointe, th« am*]|ost of which are near the
I neatl, while the largeat are fonnd at the opposite
extremity.
I The head i.s nliont the size of the head of a pin
I (6g. 1-1). l'[Hin it, besides four suckors, a little
tubercle or proltoscis is to he seen, whose base is
^_ surrounded by 24-48 hooks disposed in two rows.
^B The jwnte bepn iaunodiately bebiod tlic head,
^f «ikt iocrease in sise progrcsotvcty down to tbc
H extremity of the anintal. The rtn^, which may
^ actfuire a breadth of 12 mm., are fiat, and each is
an iudiridual hermaphrodite. The oriRces of the
male and female genital organs are unite') in a
alight pmrninence at the lateral border of each
joint. These organs are composed of sinuous
ducts which repre*;nt the uterus ami ovnries —
the latter fillcil with ovi. The male apianttus
eonsisbi of a falciform penis and a seminiferous
duct. The fecundated egg in the mature joint» contains an embryo
which already posst^isscs six liooklets. The last joints become detached.
^m Tbcy are filled with fecundated eggs, and are eaten by animals; tlie
^weggs baring arrived in the intestine loose tlieir envelo) ing membrane,
^B the embryo is ItV-rated and tntver^e^ the intestinal membrane in order
^F to pass into dilTcreiit parts of tiie organism where it becomes cytlin-rr-uf
tvUtiloêiw.
It'ysticerei cellulosie, very rarely observed in man, appear in the mus-
olea, in the pia mater, ibe brain, under the conjuncdva, in the chambers
of tlie eye, in the rodna, in the pleura, the peritoneum, etc. 'i1icy are
generally encysted. The cyst is formed by a membrane of connective
tissue supplied by blootl vessels. This membrane is wanting when the
cystieercus is situated in a cavity- When the membrane is incised the
cystieercua presents itself as a rouiid, transparent vesicle, from 8 to 20
mm. in diameter, 611«d with an aqueous fluid. At its surface is a little
depressioD. By pressure upon the vesicle the body, the neck, and Uie
I, H«<l lad B«k i>r it,«
rU. t, iri»!* lii>(,kl>M.
«,«, I'uchtr». 2. Au Ito-
\Ufi biukitt. a. rnt
192
htuA of tlic niiiinal %n Huktft to protru<lc from its cau<lnl ri-siclo. Tlie
head ii) vxncily Oic •amo M thtt of tbo tiviiin ; thv neck and thv hvdy uf
tliv uiiinin,! preaont folfU without tiistinct rings ; there are no j;entt*l
For the complete development of a tajni» it i« ne<^88ar5 tlint tli«
«j*ticercu8 pasii into the inicittinal tuhe of another nnimnl. The tirnia.
$o[ium of man î.i moiit fre>|uontlj ilenred from the cvRttoereuii containedj
in pork. CvsticcrGt celIuIo.4te are not the only npeciea met with in man.i
Cjslicerciis from iirnirt afinthôtria», from t<rnta *erraf<i, etc., have also
been occaaionally obacrved. While the precedini; cyHticerci are rare in
man, the echïnococci are. on the contrary, more common. The latter ;
have the same relation to irenia €ehinoro(Xue as the cysticercus ccllulosa']
liaa to tho tœniii «iiliinn.
The Uenia eehinocoociu, of which the exixtfliice is douhtfnl in nuin,
lives in tin- înlostînc of the doj^. It difler» from the t-rtiia t-ftiiii» par^
ticuiniiy by the «mall number of its ringit; the ihirti or fourth from the
head already poH^e** ova, mid bet-omo detached.
Th« ova of this tienia having reached tlie intestine of man lose thcïp
«nvi'IopiiifÇ memhrane, and their embryos migmle to the serou» cavities
and tlio parenchyma.-). They are the point of <leparture of cvsu» whichi
arrived at their full development, are coustitutcd by an aaventîlîour
nemhrane of fihroua tissue belonging to the organ anocted, and by on«
'or several vesicles either free or some contained within others.
Thc*e tmnaparoDt, trembling vesicles, giving to the hand the peculiar
KHsalioD known as the hydntid crepitus, arv sphcricid and of v«tj rari-j
able size, from that of a hiiy.i;1-niit to that of an a<lnlt head, 'lliey containi
a trnn^ipa^cnt niiueous fiiiid coaj^ulating neither by heat nor by acids.!
The nifinhnine of the cyst L» gelaliniform ami traa^jiarent, and is formed
of thin superposed leaflelA, wliîch can be separated from each other hy
âÛBSeution, and which roll up like clastic morabranea. llndcr the micru-
K0p6 these leaflets appear to be constituted by lamclira still more fine,
Fig. 123.
^5- 1S3.
InnflotMO «hlDOnFcaa. dsUobrJ fNn
Bflitll«oi>(al. |<7ru>)
amorphous, and separated from each other by beaiUifally distinct parallel
lines. The most internal is iiuuied the germinal membrane, and it boars
upon its free surface the cchinococci, which appear to the naked eye as
little whitish grains. A certain number of tliem are detachud and float
ECQiyOCOCOI.
Ids
in the l!ui<l. In one of titeso large vesicles we often And smaller veskles
of iiteiitienl Mrucltirv.
Kcbinoeocci (f«« figtt. 122, 12H) nre formed of a caudal vesicle adherent
to tlin gcmiiitnl membrane, i» tlie midHt of wlitch one finds the body ODd
bead of the ikiiimal inragiiiAted &.« in L'T^ticerci. The diameter of
echiimcocci varies between one- and two-tenths of a taillimetra. Tbeir
head has a pmlMwcU. a double row of hooka, and four encken). ïlic
body of the aninuil contatnii calcareous disks.
Hydatid resiclea do not always contain ecbinococci,t]ie germinal mem-
brane beins absent, or the animals havin<; ceased to live. In the latter
ensp oni^ fîndâ free booklets in tbe hydatid Huîd. TliiTi variety of sterile
hydatid cysts has been cspeciully dcsi>piat«d under the name of aceplialo-
cysts. Sometimes tbo vcsieles prewiit a very thick wall, formed of a
oonsidembic number of superposed lamollao, and their central cavity is
verr sioall,
f^ticrly bn« been described (Friedreich, Vîrohow, Ott, etc.) a va-
riety calteil inultil'iruhr fi^Jatid tntnor, characterised by the presence
of a great niunber of very small miliary cysts disposed in a fibrous
stroma. These tumors are extremely rare in France. Kach of tliesc
cysts contain» one or more hydatid vesicles enclosing cchiiiococci or a
few hooks, and always shoving the membrane peculiar to hydatids.
These tumors at first sight very much rcsomblc colloid carcinoma, with
which they have been often confounded ; but the microsco{w removes all
doubt.
When hydtttill ejtta harp completed their development and still remain
in the organism, Uveir different constituent partit sulfcr considerable modi-
fioatiom. The fluid is absorbed, the echinococci slirink and decompose;
tlie hydatid membranes contract, rupture, and break up into leaflets which
Boat in a fiuid rich in the salts of lime ; in cysts of the liver the mem-
branes are rendered yellowish or reddisb bv the presence of the coloring
matter of the bile and of the blood. Tlie ailventitious membrane beeonte^
thicker, retracts, and undergoes fatty and ciduareous infiltration. In
one case of cyst of the livor, we observed a genuine formation of a few
islands of osseous
and vessels.
tissue containing bony trubcculse, medullary tissue,
PAÎÎT II.
DISEASES OF ORGANS AND OF TISSUES.
CHAPTER I.
■
LESIONS OF BONKS.
The Imioiu of bonee «re im(>orlant, not oiilj liccskusc tlicy Hrc num«r-
oim aimI vftri«t), )>iit «spccinlly bi'cakisv tlifir ea»y iI«t<.-nmnaCÎoii, tlicîr
«xacl dcvi'Io}>iin-m, ami ilieir nppreci«bk eroluiirtn niitj- giiMe pntUoIo-
ginta iu llietr invotti};» lions of otlior tiMnce, ami DUgge.it t» them general
coiL<ii<ler»tiom coiiceniiiij; patliological Uiaiology. Tliereforc, *re h»v«
b«en leii to coinmenco in tlie (>»«ooii4 sjgt«m th« stu<lv of the altentiona
of tlie v&rious liidUfls of tlio orga»i»iii.
A etadjr of the development of oascoua tjsauo is necessary for the
uti'lc rata Doling of most of the pathological c)ian;^oâ which occur in bone.
Bniic U iiol the result of a direct transformation of connective tissue or
cartilage, Ibe cellular elements of which first proliferate in order to fom)
the embryonic marrow of bone ; some of tlie embryonic cells thus formed
8ub»e>iueutly hwome bone eclls.
AoMDg the embryonic cells of the medttllnry suhttauoo of bone, those
which »re iioi converted into bone cell» undergo changes which :(e]mrat«
them from iheir primitive type. Some apjiear to have a limiting mem-
brane developed around them, other» become adipose celU, a number
asnst in the foroiatiou of a true connective tiiuue, a-t may be seen .sur-
rounding teasels of considerable calibre and between the adi[H»e cells of
the mcdulUrT spaces or canala of the long; hones ; finally, some of the»e
cells do not divide, while their nuclei multiply, thus forming the so-oailed
giant colls (myéloplaxcs).
Almost til of the pathological changes which take place in bones have
tbetr starting-point from the celU of tliu embryonic marrow, or from the
eelb which have undergone the raoilifiuutions above mentioned. The
bones of young persons, ami those of the niluU which cont;iin embryonal
narrow, tn the sternum and bodies of the spinul vyrtehne, are particu-
larly liable b> nutrittre or fomialive pathologiuil alteration». Moreover,
diffcrcut parb* of a hone are not ei|uûlly subjccl to disease; the youngest
portion, the nujwrficinl or suli-|)erio!iU'al, and that which form» the ex-
tremity, eiifiecially duriug the growth of the bone, are localities mojt
frequently attacked.
196
LESIONS OF BO^-ES.
Sect. I.^Congestioa and Hemorrhage of Boae.
Congestion of hone h inauifeitt^'il to the naked eye hy a red coloration
of the innrrow. In order to diatinguiâU it, it i» necessary to know tlie
normal col<ir of ttie marrow in different bones and at different periodu of
life. In the oteniiiin and bodies of the spinal vertebrw. the marrow is
rod: where we have bone in process of formation.» similar color is seen.
In young persons the oniphysia in the proximity of the ossifyinîî carlitage
presents a tnie phy8iolo;j;ical conf^-stion, while in the older portions of
the bone the marrow is fatty and resembles, in color, and transhicency,
adipose tissue. As age ailvance«, tho marrow in the bodies of tl)o spinal
vertebra; atuI in the sternum loses its red eolor ami becomes lî^ht«r. The
rod coloroftlic marrow i» not always due to a congestion, and to <Ii'tcnuine
the cause a liint^dagical examination \a nccC'txiLry. It is wecit that the
bone containing fre*h red marrow shows not only the capillaries dilated
by th<^ ncoumulation of red ooq>nscle3, but more frei^iiently the conges-
tion in accompanied with an abundant increase of the medullary cells,
and a variable absorption of the fat; there is even at times ditfuse
hemorrhage, when the red eoqtuscles are found mingled with the medul-
lary cells. The red corpuscles which have escaped from the vessels
slowly iindor;{o changes, which cause them to have their coloring matter
set free, and tu iuiîltrate the non-culorcd clcmenls. It is in tlieso cases
that the young cells of the marrow contun granules of luemaloidin.
The red color of the marrow in bone may bo due to congvstîont to
hemorrhage, and to the alaliiiii;; of the medullary elements by the color-
ing material of the blood. I'lie red color of the marrow may be due to
a new formation of veiiseU, hut in this case it is not a «irajtle congestion.
Simple or complicated congestion of the medullary substance is met with
under numerous conditions — osteitis, caries, various tumors, rachitic,
ostco-malacia, etc. It occurs with great readiness, owing to the vessels
of the marrow not being supported by a resisting tissue. It is seen
even in simple physiological changes, as above stown; it ia present
during ossification, and it acconipunles the formation of new vessels
which oflcn permit tbo red corpuscles to cscajtc into the medullary parcn-
chvma.
Ilemorrhage» are froi|uent in the p|iongy tissue of bone and under the
pcriost^'um, on account of the vessels in those hicalities not being well
supported. With traumatic injuries, such as contusions, wounds, aii<l frac-
tures, should he placed those lesions «here there is a charigi.> in the walls
of the capillaries, as tieen in inflammations, and in other active new for-
mations. The wall of the capillaries, formed at this lime of embryonic
cells, baa become so soft that the red corpuscles easily escape and are
found in the medullary parenchyma. In a third category of cases, osseoua
apoplexy is connected with one of those general diseases in which hemor-
rtiagea are easily occasioned: cachexia, purpura, Icucocythiemia, etc.
Almost always, when hemorrhagic foci have been foand In the different
viscera, there arc similar foci to be seen in the epiphyses and under tho
periosteum.
08TElT[a.
lOT
Beot n.— Oataitii.
'im{i1« irrilaUon of (i bone, sa ilciitiilation, injnrj, the prC8<-nc<> nf a
foroi;pi tK><lv,etc.,cnii*«8 it to Hinlcrgo «tvi-riil chnngi.'^, wliioli c"nslitul«
ft patholo^onl comlitioii «Ic^ijinati'il o«Unitii. Th« irrilatton cntincs an
ïncrea9«i] actinty of liiv cellular olcmunw of the bon«, nud Uio Iceions
wliicli follow arc «imply iiconKei)uetict>, 'tlteM le«ioiu do not eMCiitiiiUy
(lilTer fconi thn^c wliicfi are [troiliiced in other tiuuet hy flimilar oausoa,
Bucli M we have .ttiiiticd utuler };ciieral inflammalion.
If a hone of ai) animal i.i ileim<loil ami the wound kept open, in a fev
days there is seen upon the deniidod surface an ciilar^emcnl of the
Ilavoraian canals through ahsorplion of the osseous subatancc, while at the
periphery of the denuded portion, beneath the perioateum. ihorc is found
a layer of nowly-rormcd bone, a démonstration that an irritation causes
ftt tm same time both absorption and };ro«'th of osaeoos tissue. In order to
aiwlentand why tiie ^Jitne cause produces simultaneously a diflcrcnt effect,
it beooDMs necessary to study the histolo^cal phenomena of oHtcilis.
The Gnt cbftn{;e ohtMin-cd in a bone upon which artificial irritation has
been employed, is the formation of embryonic c«lls in tlie medullary
npaoM, in tlie llavcntiAU canal», and under the perioateum. The» cells
rasemble tlioso which fill tho primary medullary apac&s during the devid-
opinent of bone from cartilage, or those which are found under the peri-
osteum widle the bone incrcasea in thickness. Irritation of a bone re«iilia,
tlicn,in ita return to an cmbrj-onal condition, and herein we find an appli-
Oktion of the general law which governs irritation of any tissue.
There are two changes which follow the formation of embryonic tissue
in the medullary spaces and under the periosteum: A. Tlie rnlarije-
mrnt of t/tf raiuiU or medullary splices hy absorption of the osseous tissue
wbicb limits them } B. TUt j'ormatitn a/ new ^rn^mt Cra/teeul<f.
A. — The enlargement of the Haversian canals may be easily seen.
Tlie osseous lami-dtte nre found eroded in such a manner as to form notches
{ llowship's lacunar) filled with embryonic cells. (Fl^. 124.) The bone
corpuwlea at the edf;es of tho notches open, pcrmittiTi;; the contained
cells to escape and join the cells already oceupying the medullary «paces.
Gradually the osseous lamella; disappear, and adjoining Haversian canals
unite to form irresw''»'' spaces in which the eiid.ryoiiic marrow proliferates.
Several Iiypothe*c» have been adv«nc«;d to explain the cause of the ab-
Mtrption of 0«s4roiM ti.sAue, but as yet it remains in great obscurity.
Killrutli havin<; noticed that the -terons pus coming from an oaseous
abitceits eoolained lactic and phosphoric acid, was led to think that th«
solution of bone was effected by these agents. The fact, however, that
the «ction of pus upon fragmenta of dead bone which form seiiuestnc in
cades of necrosis, is very slight, Is sufficient to overthrow this conjecture.
ItindBeisch aupitoses that tlie absorption of bone is precedtnl hy «
raucous change. In some preparations wo have noticed along tlie side
'-' I osseous tracks undergoing absorption, areas uf a suUtftuoe brij^hter
U)8
LBSIOKB OF BOKSe.
than the nc'ighljoriiig oeseons tisKiw, wbtoh, howeror, »pe nothing mor
tkmi obliquv ciiu of tlictfc portion» of the bon« in procexx of aliaoq)lioQ.
Virchow thinks that the bono corpuitcles «nlarge, c)iang«, and caua« a
solution of an areti of the osseous substance corresponding to the carti-
Vit. va.
iloftrnlDit "f biiiiu. tplrnU uf I~<iif friiin ihe •iwnr)' ■abilu» sf tn «tM'iniIaiiIo rib- a, Xr>miil
MMODi llttRB. A, ItmlMacd uiirotLiiliinB. f. Iliirnun riuiil. if. Mfilnlltrj tpMM. Thfir«t«
tolhr ililil U Blind Willi ri'il mi^dnllic; Hum-, Id «rbitli ih« Inmlmiul ihi oitiillulM ■» orta-
Iftginons capsule from yfbich the bone corpuscle and its tcrritorj arc
foniK'd, and hasen ujion lliis inter))retation his ilieoi-v of cellular tcrritorj.
At the present ttm? such an explanation cannot be admîtled, .«iiice we
know that boue corpuscles do not proceed direct); from cftrlilaginous
capsules.
(). ^Veher and Volkmann consider the abgorpdon of osseous tissue to
depend upon a fatty defeneration of the bone corpnacles. Tliej have
confounded caricB with rarefying oatcitis. Later it will be shown, that
true caries is the only disease in which there i» a fatt^' degeneration of
ibe bone corpuscles, and in which the diseased part dies without being
again absorbed.
The bone corpuscles which nrc fnmid at the boundary of the inflamed
part, are frctjuenlly observed unbrokcTi ; ttie cell within beinj; slightly
increased in «ikc. Itnrely do we observe any signs of proliferation;
never in these cases <lo tiie corpuscles contain granular fat. From these
stntenietila it is very dithcult to understand exactly in what manner
«1)isorption of bone takes place during osteitis. It is. however, prol^ble
that, in accordance with the opinion of Virchow, the bone cells play an
important roll in the process, since in those conditions where this cell has
lost its active vitality (caries and necrosis), Uic solution of bone does not
occur, notwithstanding the bone may be in contact wiih elements similar
to those which, in ordinary osteitis, fill the enlarged medullary spac«a.
OSTBITta. 19fl
B. — Tlw formation of new oaspoua tmbeculje taVes place at the eipcnse
of llif pmbrvniial colls, which were dcvolopod «luring the flret sMRe of
the ititinmniation. Irritation first prpfmrcg the matvrial)» fnr osnificution,
liul tJicâ* niatcrialB aro not iitilixcl for ihe dcvt-Iopment of new o«s<roti8
trsheculw until the irritation hus lost its firal intcni<itv. llniH, it is nol
nl the fiointa when- the inflammation is intense, that jwir othWOUB tissue
U fonned.but in tho«« parte nnly wliîch ailjoiii the iDflainmaiury focus.
The «uVperiwueal marrow i>os8e«»c« in the highest rtepwe the proj^rty
of forming bon?. The rapiditv with which oitseous ti».^ue i.t fornied
heneallt the periosteum, niuler the inHuonce of imtatiAn, h tnilv aAto»
ishinj;. The manner of ils development iloea not difler from tltat olMerved
in i)liysiologieal OH^ifiaktion. 1'he trahecut^e spring from the oM bone
and traTene the eniUrvonic tiiuue ; along the aides of these trabecutie are
seen numerMis celU, which become angular : some are partir imbedded
in tlie yoimg osseous snbatance, which is formiu» around tiiem. It is
not iiece9<tary that the periosteum sliould coTcr the lion?, in order to hnro
a new formation of osseous tissue upon it« surTncc ; but the preMTiatimi of
the perioateum, and especially the rcawls of tJic under «urface of the
periosteum, which enter the tlnvcrsian canals, nMist gn-atly in the fonn-
ative action. TIte ext«mal surface of bone i* not the only part in which
we have a new formation of osseous tissue during inflammnlion. When
tJia inflammation has been alleviated, the atifractuouA cavities which have
been exoavated in the Imtir are very won filled bj layers of new oiweoua
tiMue, vbtoh are devchipcd in a :«iim1ar manner as upou the extenial flH^
face of the bone. Kven the metlullary canal, if the irritation attaclcs the
central medulla, may also become the seat of new osseous formations.
The relation between rarefaction of osseoiu tissue and its formation,
or between rarefvinj* osteitis and formative osteitis has been clearly iiidi.
cated by the foregoinjj. In infiammatory rarefuclion of bone, the male-
rials for rebuilding are already prepared, and tJiey arc employed by the
organism at the moment the irritation lower» itt intciwity. Wbilir, on the
contrary, if Uie intensity of the irritation continues, the surface of the
bone ie covered with f;ranulation tissue and pus.
These granulntiims are formed directly from the marrow contained in
the enlarged mcilutlary canals, and (hey ^hnw, aa has been ol)«erve<I hj
Troja, that at tlii^ time the o^seou» tintiue included between several
canals has been »b»orbi.-<t. Tliiii absorption continues until the whole of
the deniidett surface is covered by a granular and very vascular sofi layer.
A general description of osteitis having been given, we may proceed to
the atmly of the several varieties, neither making special chapters for
acute and chronic osteitis, disiincnons nioro interestin;; clinically than
in a patholoj^cal point of view, nor considering nrpantt«ly pcrio«titis
and osteomyelitis ; periostitis being in fact simply a superficial osteitis.
Histologically every osteitis is in reality an osteo-myelilis,
We will describe sepnratclv thnpU intt-ifi», rtrrfyinn <tiitfitit,f9rnui-
lire 9eteitit, and tli^uted phhijmvifnt» ottâti». Caseous o«teilis being
always connecte)) with caries, tuberculosis, and gummata of bone, requires
no special description.
200
OP BOIJBS.
1 . ScMFLE Orarrn.— 'Id conaoiinencc of contusions, injuries, fractoresg
, wounds, etc., when not followed by necrosis, we have octurrin;; the ph«>
iDonwna as previously described. I'he beet oxatnplo is ec«u in the ex-
' tremity of tlio stump of a bono eight or t«D days afUr amputation. In
this caw the murnjw under the periosteum, in tlic ilHvcr»ian vsiials, and
in a portion of the medullary canal, bccomex caiKryoido ; tli« perinstriinij
is coUgMted, sligiitly tniuclied, and infiltruicd ; it i» easily dotaohcd fronu
the bone, from which it is :<i.-pnnitud 1iy a layer uf round or angularoellH
rc«cmblin^ lbo:wi of the vnibrvonic umi-row. The ilavut^an canab aitl
enlarged and tilled with similar «lenient^; these oauaLi anastomose oiMJ
with the other, ronniiig an anfractuous lacunar syâtero. The Haver-
ainn canals, which opon upon the cut surface of the bniie. ar« visible to
lihe naked eyo as red points, or opening from which project small HeahjJ
rgranulations. We see at the same time now osseoua tTabi-culiv forn'
beneath the periosteum from the embryonic marrow developed under the
influence of the irritative process.
The^e oDHeou» formations never commence at the point where the irri-
tation is most active, that is to say, upon the cut surface of the bone andj
in the mi(l«t uf «ii|>pun)tion, but jtortiv distance above. When tliv nlumpl
is conicnl, ami the huuo projectin", the lateral portion! which fonn part
of the Wound do not then pre»ent any tracer of OMifieaiion, while a litUo
higher up a new formation of hone i» «een.
The snh.|ierioât«al o^eouii fomiation«, coïncident with the abaorptioQ^
of the old hone, should not be considered as indicative of an '«aieo-|
LKenetic property of the perioâteum: they iu reality epriiig fi'oiu the em-
pbryonnl elements which have their origin beneath the pcrioHteum and in
Uie Haversian cutials, under the influence of irritation.
During the cicii tri za lion of the wound newly fonnod o««eoua Uttstie is
aUo prodneed, both in the enlarj^ed Havcraian canals and in the medut-
larr canal. When recovery is completed, the medullary canal is obliter-
ated by an osseous plug, and the extremity of the bone consists of a
round taam of coiiipact o;<seou« Htsnc covered by a new periosteum.
\ ^imjde osteitis terminating iiirecowry.isatthebej^inningararefyin];
but suhseijuently becomes a condeniùng osteitis. Therefore we have do
more reason to term tlie inflammation of a bone of a stump undergoing
sappuratioD rartfi/in;/, than to give (o this same osteitis the name of «vk-
dènnng when the stump is cicatrlxed.
2. RAUEFYlxii Osteitis. — Inllammationof bone in which the ati
tion of the osseous substance is a prominent feature, and in which
enlargement of the Haversian canals continucH until the complete disap-
ncaruncc of the bone, is named rarefying osteitis. This variety of oateitis
IS peculiar in the absence of any attempt at new ossification : the new
embryonic tissue generally protrudes externally, is covered with largo
fleshy granulations, and discharges pus.
Karefying esteitjs, as above described, is a disease not frenncntly met
witlu It oceiin» in the short bones of the u|jper mid lower extremities,
either as a result of injuries, or following a continued irritation, as a
perforating ulcer of the foot. In the latter disease especially several
pUalangea may completctv disappear without ttay oecroais, yet necrosis
ift fiçiiorally met with dunng the course of a per^onttin;; ulcer.
Till- dis«a»ed bone ia TouikI at ibe IkXIooi of a euppuratiii'i «iiiuH, the
wklls of nhicb aro covered wiih Deshj ^^rauulatioiu. Tilt's^ lur^c red or
gray ^ranuladoiiSi rich in secretions, arc connected wUli the Murruce of Uio
booo by inflwDinatory tissue, nbich is oontinueil into tlie enlai^d oweous
caitab. lliis intUminatory tÎMuc is chanict«rixed by granulation tissue,
dejcribed on pm-'C TO, and resemble» very niucli Mme <^ the bone sarco-
mata, hut in this rariety of osteitis a siippiiration i» esUhlished at tbe be-
ginning nf tlie disense, and is cuittitiuvd nnlil it« lerminalion. Again, tliia
osteiti:! difTer^ fnitti the sarcomata in the iHiSHÏhility of a spontaneous re>
covcry. Tlie inaauiniatory tisstie which iicrve» as a hasis for tho Beshy
granulations, developed in tlie iKidy of the hone, at timeB entirely Bar»
rounds pieces of bone, so forming living iteiiuestra:, which possess vessels
coming from the embryoital marrow, niid are coDseciueutly cspalite of
Plg.lîS.
L
Wmntjlag iMl4mt. CwiillcnnullaB ut lb* qiunoi tlMa«. X^^^ (tWlm«Mi.|
being absorbed. It is iiecossary to guard aj^ainst confouixling these
living sequestne with ihc dead eei|ui'j<tru: found in necrosi*, in which
there is an absence of vessels. The absorption of osaeoiiji tissue in
rarefying osteitis, occurs in s simtiur manner as iu ordinary osteitis;
202
Listons OF SOMBB.
the process only being more intense and continued ; extending from
the suppurating fociw until both estrcraitica of the bone arc reached.
When tlic epiphTsis of thv bonfl is absorbed, there is produced a suppu-
rative nrthritis. There rcniaine no trace of tiic bone or cnrlilnge. except
ptThiipH a thin, 0])a<[itc, friable lamella, formed bv a cnleifiei) layer of
the dinrthrodial cartilage, which may be readily recognized witli the
mioroscope.
X. FoHMATiVK OsTKiTiM. — E^ry oslei^s vhioh terminates in recovery
deterininea a new formation of oa^eoua tissue. This nev formation la
Bomotimea effected before the cessation of tlie osteitis. In a number of
cases the ossification ends before exceeding the limits of the old bone;
Yf hiMt it should not be considered a formative Oîtcitis. In other case», tb* ■
new formation is oxuberani, eiceeda tlio limits of the old bone or causes I
it to become more dense; the disease is now designated as hypenMto«is,
exostosis, enostosis, and condensing osteitis, all being includi.il in formik-
tive osteitis. Every osseous formation mu«t not be coniiidered ft.t tlto
result of an osteitis <,see Oslvoma, p. 18'.i). The Ion;; duration and slijçht
intensity of tlie inflammation of the born- are the usual caiisea of fonua*
tive osteitis. Therefore, it occurs especially in deep and chronic abscesses
of bone, in necrosis, in syphilitic osteitis, etc., these diseases, as wo know,
being characterised by their alowneas.
Now osseous formations may be developed upon the surface of the
bone under tlie periotteum, in the bodif «f the bone, or in tlic vK^nHnry
Cficify.
It. Upon the surface of the hone we meet with that variety of fonna-
tive oMeilis, in which the inflammation has been of long duration and of
slight intensity. The irregular osseous majtses are named uMr^fliytr».
The trHbccuIiK and veeseUof these Kujicradded parts always have a direc-
tion different from those of the old bone, so that they are readily distin.
guished one from the other. In making a transverse section of a long
bone covered with osteophytes, the Haversian 'canals in the old portion» ,
of the bone are cut transversely, while those in the new arc mostly cut '
longitudinally. The direction of the Haversian cauais follows that of
the vessels ; for the oateo- peri osteal or granulation vessels coniv from
the Ilnvrrsiun canals at the surface of the bone, and it is around thescj
vessels that the new osseous lamella: are formed, as in tJie physiological
08.*ilicution from elements of the embryonal tissue. The new bone with
its Hnvorsiiin canals thus formeil is ingrafted with it« vesseU perpen-
dicular to the BurtWo of the old bone.
In the formation of oateophytea which are occasioned by inflammation,
cartilage is never found.
b. Formative osteitis occurring in the body of bone causes it to become
dense (condensing osteitis, sclerosis of bone, ebuniation). This change
Ï8 habitually [ireceded by an infiammatory rarefaction, traces of which
«re readily found with the microacofie.
If the embryonal elements contained in the cavities enlarged by the
iiiRamination do not undergo extreme irritation, they assist in the fona».'l
tion of new osseous layers, which cover the old eroded trabcculic ; w
DtPPUSBD SUPPURATIVE OBTKtTTS.
203
thHt the chftntctcri^tic boumlnry of ran-fyinj; osU'îtis in recognixH in n
T^r; <lMÛiict iDBiinor in boi)i;s «tliich hnvv tiiulcrgoiic rcponteil nttnutu
or «bunwtion. When tlic irnutivi- uciion continues for »cv«ml yvarain
tbn «âme bone, «a, for vxkinplc, iu cases of iii-cro>tii« or dc«j) alMee«aM,
tliere occur» from limv to time inlla minatory otit^^wlliti, These bonei
gi'n«r»lly attain cmi.suU'rnhle sine, doublfi or irijile the iionna) ntate. At
th» ttm« their Htnictiirc presents n verv great tiregiilarity. The aysteiw
of lamelln are arnttiged iu sii uno^ual manner.
Pig. ]2«.
ftrrblHU* Ultntft ot Ibe (Caoul bot», a. KiAvlitf tpMn of Ihv AlpU*. e. Tb* hb* tf utM
Biiiih •■rrwcil, I, lunj «obitus». X''-
Eburnstion of oaseotu tissue cnuaes not only a narrowing of the llav.
crsiao canals, but in some cases complete obliteration of some. (Sec fig.
1 ïtî.) A necrosis then enpcrvenea, on account of the arrest of the capil-
Ury circulation in the bone.
IT. Formative osteitis in the medullary canal of boDO is Hcldom observed.
However, examples of ifitt ossification of the medullary substance of
Ixine in consequence of osteitis have hi-en reported by Troja, Té, ion,
Broca, OlHer, etc. We have ourselves commun icatcd to tlie Society of
Biology a case in which bone wa« formed in the intorior of the incilul-
larr canal of a necrosed bone.
Finally, in am])utaiioiifl re.iulti<ig in recovery, tht? meiluUary canal i»
always closed by a compact oiiseous plug, the length of which varies.
4. DlFPxi.SBi> St'PPrR.^TlVE Osteitis. — This variety has received the
names of oatm-myAitia (Chossaignac), of phU-jmonom prriottili»
(Giraldi<),of rpmAyvnil osfeiW*. etc. We believe this disease to consist
essentially in a «iffusea suppurative inHammation, which may be located
in any part of the bone, under the périoste uni. in the stiperficial layer»,
in the substance of the bone, or in the central mi-dtillary .«nbfltanc<.-. A»
it attacks yonng persons especially, and as the phenomena of growth
of tlie bone takei< place under the perio^itenin and at the epiphyses, the
physiological activity of these ]iarts favors a more intense inflammation
tbaa in the other portions of the bone.
204
LBSI058 OF BONES.
The primary and ]>rc(loniin.iut symptom of the disease eonsists in the
ra{ii<l fonnatioii of [iui>. If an incision i^ nimle under tfae iMriosteutn,
about twenty-four or forty-ei^lit houra after tbe beginning of tbe malaily, •
a punilcnt centre is usually opened (Louvel). It is in thetie casee of
rapiil and cxtcn^ve auppuraiion that we find tliobone necrosed in itawhol»
extent, detached from its epipliyaoa and perioateuin, and floating in a vastj
abscosH. A purulent inliUration of the spongj' tissue of the extreiultieB B»i*
of the medullary tUsue is uow found; from such n (juantity of pus accuumlat-
in^ between the (mwous walls of the llnvoreian cnnals and the vvihmiIs, tho
latter UK coispresifcd un<l arrest completely the virculation of ttie hlood,
Cftusini^ a necroMs. It is CMctitially a «uppurativo iuSninmation, and the ;
pusi» tliconly inâaronmtory new forroutioti. Karefactiou of the OMvoitisub-
etaiiee it never obi^cncd iu lh«sc ciuies. The uveromtd h»nc has the appear- j
niic« a« if it had hovn macerated in witu-r. S> intense or ext«nsive a sup- '
jmrativc inflammation of heme seldom occurs. It may be limited to the
neighborhood of an epiphysis; an abscess forms ti])0n tlie surface of tlte
bono, which, when o|ieno<l, ooca;Mon3 a series of anatomical changes in
the diseased hone, varying according to the case. In the less seiionai
the inSammation being superficial is followed by the same lesiona which '
occur in simple denudation of the l)one,uamely, rarefaction of the osseous
tissue succeeded by formative osteitis.
In another class of cases, Uic suppurative inHammation having invaded
tlie medullary canal, openings by wliich the deep abscess empties itself '
arc produced very slowly and by a process yet unknown, openings eitlior
ill the middle of the diaphysta, or in the proximity of the epipliy^ii^. In
the^e cases the irritation is intense at the centre of the bone, widle at the
[icriphory it is very slight, but it continues upon the surface as long as ;
the inflammatory action at the centre lasts. As a consequence, tbera
are formed under tine periosteum new osseous layers, vhich, being placed
one over the other, cause a considerable increase in the diameter of lbs
bono. This peripheral formative osteitis is produced according to tbs '
process preriously describod. A partial necrosis is a very frecjuent result
of suppurative osteitis, when the latter is limited.
Beet, in.— Heerosii,
nth the majority of authors, wo give the name necrosia to mortifti»-!
tion of bone which occurs in eonîei|uenee of an iiijiirtf or an OtUittt.
Necrosis is occasioned by arrest of circulation, most frcquentlv owing to
eomprcstion of the vessels in the Haversian canals by pus or oy osseous
new formations. The mortified bone in process of elimination is itamed
a sequestrum.
French surgeons separate the scqucstrEc of necrosis from those of
curies. When speaking "f caries, it will he seen that this distinction is
legiliinnte, not only from the naked eye chiiracters, but also by the pro-
cei* of formation ns revealed by the microscope. At prêtent we will
consider ni-erosis pr0]ier.
The fraj;ineiits of bone in a compound comminuted fracture are named
splinters. Those which are removed by the surgeon or eliminated by
J
HBOIIOBIS.
205
•iipfnimtiflii do not merit coraidonition hero. Nocrosin of the stunp
«ftiT ntu|uitnUon occun« «rhoti tlic infUmraiition of the «n<t of th« )<an«
ia inu-iixi;, or when ilio Kmo projects ooiuïdorsblj'. À priori, it i»
diffiouh to undemtiiiMl why » tliin lajrer of thff cut Iwno in not aUava
nmroaed. After tlic l)one hntt l)c«t) !innn, henorrhiige is arrested only
in cmtaciinence of tlic coa^ulatinti of tlic blmxl in the &n)aU vessels of
the bone close to where they have been divided. The tione cells situ-
•ted hero arc deprived of tlieir ordinary mcaos of nutriUon, and if lh«y
continue to live until the circulation is rc-esubliabed, they must hftv«
other iravs of obtaining; nutrition, or durin<; a certain length uf timu they
exist without il. The bloo<l pliuuna which i? found in the wound may M
t Nource ofnutrilionfor these cells.* In a conical slump, wht-n- the boM
it iu contact with ihc drC8<ingFt or external uvr, mortification of ft small
portion of tlie Iwiie very frctiuently oocure.
The coiulition of a denuded bone i» a wound resemblee exactly a out
bone. When tiecrcMiiit follows an injury, a i>ufi|>»ra(ivo osteitiii, or B fnnn-
ativo nsteiiifl in which the lUvcrivAii iriimili^ are obliterated {aee p. iiVH),
the (ihenoraena of sefiaratioii and elimination of se<|uefttrge are tlie foU
lowin;:: —
The i»ece of mortifyins; bone acta aa an irritating foreign body, occa-
sioning around it a rarefyinR osteitis, and there are acen developed j^nu-
latioiis which inclose it. The Haventian canaU in the neighborhood are
enlarged hy the prolifération of the marrow and the absorption of Ui«
OMCons lamulljc. I'his absorption continues destroying the living trnbeiï-
uliv and aW those in wliich the vessels arc obliterated, until the canala
communicate one with the other. The disappearance of the tmlwculw
entirely isolates the seipicstnim in the midst of a ^ntnulatin^; marrow.
The re-iult of chU process is tliat the !ii><|uestruni is bounded by a tiinuous
surface, the prominencea of which corre^jiond to tlic vascular distribution
where the circulation has coaw'i.
The procesa of elimination diRcrs acconling to the situation of the
Bequostmm. If at the periphery of the bone under tlie pcrioateum or at
the end of a cut bone, it is very soon aepantted and surrounded by
pus ; upon the surface of a large wound, as an amputation or denudation
of the bone, the mortified part is eliminated ivithout difficulty. If there
is no wound comniunicatiug cxt«mally, s deep abscess is formed, which,
when ojiened, cither spontaneously or with the knife, the se(|t)eslnim
ciami>lelely detached, i» dlscharj^d with the pus. But, when th<t entire
bone or tJie diaphysis is tmisformvd into a se<(uestruni, the subperiosteal
marrow proliferates, becomes embryonic, nurl occasions the formation of
new osseous tistiue under the periosteum. The new osseous layers {çradu-
ally grow thicker until the old necri>*ed bone is inclosed in a new bone,
from which it is separated by a layer of granulations, llie sefjuestrum
is now said to bo invaginated.
The invaginate-l sequestrum is never in contact with the «nvelofMng
bone. The latter is covered with a layer of granulations which con-
stantly forms pus. AVhen the pus is not readily discharged by fistular
openings, it accumulates, desiccates, and undergoes caseous trunsfonna-
tiOD.
S06
LESIONS 07 BOKBS.
i^ntiic writon Admît tliat thi» necrosed bouc nay lie absorbed and
gmilunlly diiappcar bjr tiiv action of the pus. Tliey («se Uieir opîiûoa
pupou tlio inuiiunlîties and depresMons «eeu upon die surTace of ti>e
Hlii«i*irum. \Ve cnnnot conacul lo thU manner of view ; for, if ther bad
examined wttli care several aei|ue3li(Q wliich bad Doaoerated for a Iods
^me in pua, tlicy certainly iroulil have found upon iheta some smooth^
surfaces. A micro^icopic examination of a section from ibcBe surfaceal
hows the peripheral lamella) of the bone. We have foond them uf
Bveral sequeatrsa which had maceratod thirty years b pas. So Uut tb*1
F solvent power of pus for bono is very slight, it it exists at all,
Sei|uestrœ and the bone froto which they come proiicut ilifTerent cbar-
actcitt accordinj; to the cuur^t' ami cause of the necrosis. In Acut«
siip))iirutîvc osteitis the seiiueïtruni ohovrs the normal structure of UiAj
Lmif. or the Iwions of rarefyiiii^ ««Intis. In a alowr fon» of osteitis,
occurs in syphilis, in phoi^phnnu nia[ch-iniiker:<, etc.. the necrosed
stiows special liMioii». 1» sypliiliiic necrosis, so comrooii in the bones o(
the oraniiiin, llie se<(uestrum resembles a fragment of nonnal bone botb
I externally and internally. At times it pre.ienta here and there a loas of
^Bubstance, givin;; it the appearance as if there was a rarefacljon of the
bone. Uiit, if a section is made throujth the mtdillf of the aefjue-itrum,
it will be found that the diploij has been changed into a compact ti^ue.
An invagination like that which occurs in long boneâ is absent in Hald
ones; there i» in the latter a new osseous formation which takes place
at the edges, and incases the eei|UC4trum as a watch-^laas. Formative
[Osteitis in syphilis is geuerally of eonadcrabk- ojtti-'nt. Tlic diploo of U»,
uranial bones becomes more compact, and ujion their external surface^
small liv])erosu>Aes are met witli.
A microscopical examination of theae sei|uestrii; show» the medullary
cavities of the diplcij replaced by very narrow canal.4; and, in _
preparations, it is seen that this transformation has taken place in con-
BCiucnce of the formation of oaseous tissue, which, being deposited layer
by layer in the interior of the canals, has narrowed them. The new
osseoai layers may be so arranged that the lumen of the canal does
not correspoiiii lo the centre of the original canal. This process con-
iinuio;^, the cunal may be completely ob1itcrate<l, so that at the centre
of the concentric layere, instead of a canal, there is found one or more
bone oorpuacW. (Fig. 12»».)
Necrosis of the ma.nillary bones occurring in persons employed in
manufaotunng ])hn!<phorii.s mntcben funiisbe:* seiiucitnu which arc dense,,
eburnated, and freijuently present u{K)n their surface sjiongy ontvophytes]
which may be easily detached. In those parta of the scuuestnim wlncbl
belong u> the old bone there are found the lesions of condenititig osteitis.
The density of the osseous tissue and the formation of osteophytes in-
dicate very evidently that the necrosis has been preceded and prodiwed
by a formative osteitis of long duration.
êiMM.
»
Beet. IV.— Oftriet.
llip disL'fue of tliG OMuoiu s^rstom dcsignnud ss caries U very itulefl-
nit«lv (lvGn«'l hy intbolui^iotd.
Among sur;^'inii*, ocry i>'ippurnlion of the otti^ooiu tÏMiie, aocompnnied
with f;re«t friiiliiUty of this lii>suc. U cttri(i«. In order to dia^^'^ite ^l^'^
dUeaae tli(?v întroduco, tliroii^Ii tlit- fietidar opuiiin^, n probe, vrliich breaks
do»n the bon«, [»TO<ltioing a crackling sound, or £'"»;! *" ^^ ''^■''1 *^
ei|uivftlvnt seuiiaUon. I*ntho1uf;i«t« thenvMlvea <lo not a;;rco upon tito
anatomical character» of tlii^ dUeoM. Tbe <ieriiian.i eoiplov Ûw won]
cariva to ilcHÎgnate everj rarefnclioii of hone. Virchow bclii'vcs tlio
dtangva which take place in tW hone afti>r amputation, the lou of wib-
«taiKo in the cranial honoa oansed hy xyphiliûc gutnoiata, to bclonj* to
caries, liillroih considers " the tenn cariefl M alwolutcly synonymona
with chronic otUeitla with sohilion of tlie hone." He descrihes several
rariolies according to location, whether iutemal or «xtvnial, aoconiinjç to
tiio aapect of the diseased parte, if vascular (caries fun;;osa), if iiuite
auiemio (atonic, torpid, and caeoouâ caries), also a necrotic cnriM.
Ilieirarioiis lesions described by different authors under carie» arc con.
aecutire to an initial lesion, which consist in tke drttrm-tive j'alti/ <lo-
gentrnti-m of th< reUi CHtmnfd in the hmc furpuii'-lr».
Personal investigations haw led us to recognise two distinct stages io
caries:—
In the first, tkt hone nlU undcrgo fatti/ Jegmeratvm «ith<mt any
prfrimit injtammatori/ aet!'>n.
In the second, the cellular elements of the osseous trabcculm haring
died, tliey constitute so many hhoÎI foreign hodiea, whifh niri-man
arountl them a mppuratht innammatmn.
Thiii xeoond stage — in which the osteitis présenta special charactenii in
conaci[uenc« of the cause which has produced it — i» the only one which
has been described by vrriter».
Cariefl generally occurs in the proximity of the articulations ; it is
alirays aocompanied or preceded by a chronic affection of the joint —
iphitf neeftinff. The epiphyses of an artlculutloii altjteki^d with a recent
white swelling are formed of very thin trulwciilio surrounded by an adi-
pose marrow. By a stream of water wv are nlile to wasli away the fat
tissue sn<l isolate the delicate osseou.t relicuUim, which, by microscopical
examination, is »e<^n not to liave undergone any lo-Htt of aub^tanco, sucb
as the eroding or notching occurring; in osteitis. Their tliiuncsa at this
time can only be explained by a regular absoqxion of their surface, or
hy an arrest of development — a satisfactory hypothesis, if it occurs in a
subject whose bones are growing. It is in these trabecnlw that arc
found the bone corpuscles metamorphosed into granular fat with atrophy
of their nuclei. This fatty degeneration of bone cells is found only in
caries.
The characteristic alteration of the first stage is continued into the
second. New lesions now occur, which are appréciable to the naked
eye, and correspond to th« aiuitumiciil description of curie* a.* given by
the old surgeons. Those uhuagus are of an inflammalory nature ; their
I
S08
BOHBS.
prodnotion ecems to bi- conncctcil with the prosonco of naneroaa âttd'
trobeoulta irre<;u1ar1y M'Attcreil tlirou^^h (he usscnus lUsao, nod caoMd hy
fatty dcgonorntion. Tho mcdullury tiubittaticc bocontv* very vimcuIu- ;
the a(li{H>ftc aiWa diMfijipcitr, and nrv replaced by embryonic cellii ; sap-a
puralioii U estahl'itthed ; lliosc bone cells, not completely d«8trojed by tfa(
Fis. 127.
CarlH ranjvn, X rnf usnt Of boat «iih Itoir.nip'i iHunia taà bmc torpuielt* «■■•I«In( Ibb
X SO. IRinilJItimh.)
ffttty defeneration, become active, and tlic ossooti» «ubittaDce which soi^
rounds tbom ia liriucficd ; tbe necrosed o^isi^uus trabeculse become free,
«nd arc Burrounded by granulation tÎ8su« form(.'<l by the cmbrj'onîc mar-
row. Entorin;! into the coiwtitution of the granulations arc numerous and
diliitod captllarioH, which when occurring id fi«tulnr track» or ftrtivulnting
cavities may attain considerablo «ixe. Kuplun- of these dilated blood-
vessels may occur, cAusin;; interstilml or cxteniHl hemorrhages. Tliese
lar^e ^ranulAtions form what are known as fungi.
îiimilnr gramdationn, but smaller and connected together, exîot in the
enlarged areolar spaces of the epiphysea; flometioneii inclosed in thi»
tissue are found osseous trabeculie. the colU of which &re infiltrated by
fat. Id some cases these small islands of osaeoua tissue are necrosed ;
the KrannlatioDB surrounding them penetrating oven to the centre of tho
trabceulfD of which they arc formed.
The charactere of tho seijuestrjB of caries are entirely different from tliose
occasional by a simple osteitis, for they arc compi>se<i of trabceuhe under-
going fatty eiiange. thin, but not notched ; whik- the sequestra; of osteitis ■
«IwftVK present the characters of rarefaction or of infiammutory sclero«ia,
«ml never contaiu fat granules in their corpuscles. If fistulnr openinge
are established, small trabeculre and larger fragments are carried by
^^^^^^^^^^ roRMATiox OF oTTSvo^^^^^ 209
eiippiintîon to tho exterior. When anfractuous caritio^ exist linn) by
(;ranulittioii tissue, whi<:h ^rA4)iiallj' iiiKlvr);ov« tibrouit orgatiiuiinn, tlicre
u fonncil a kinil of cyst uontAinin>; iiifpii^^iiN) or cxkouh ptu, frv'iurntlj
muMkoD for an old (uWrdv. Iti nUl luxl Htippuratinj; white «wellin^s
ibcr» mrv nt tiinex olwcrvuH i^lnnii», «i-veml i;cntimoti*H in extent, finm-'l
pf n tiBillv or^snize-l libroti* tiwsiii! which la aiulo^its tn that wliicli i»
aeeu nrourxl <i1il ti^tiilur oiieiiiii^^H leailiiig to a diaeasfi'l bone.
In cariei). the embryonic marrow or graniilative tissue may nnderf^
caseou» tramiforinauon in portions of the niaâ'4. lliia change \» probably
owing 10 vascular obatruction, ami has frcijnently been con^dered to M
of a tuberculous nature.
Inflammatioii supcrrcning in a bon« attacked with fatty docenoratïoD
hju a reparative ettV<ci; wlicn. by the procese which has beeu indicator,
it luui êuccci-dcil in eliminating all tho iiecroscd fra<nn«nb«,nncl it bccooMS
leM int«iUM, rc;;enerntion of the ti««uo be^^ins. Itiit previous to tliia,
Ihure are exuberant formatioR^ in t)ic ncighborin;; partti of the intlnmma-
tory centre, under the periosteum, especially around the fi»tuUr tracka.
The nvw sul>|>i.^ri'Kttval layers, gootelimeii thivkenivl, arc formed of thin
lawclliu xli;;hlly i*<'}tarateii from each other. The carious proecases IkiÎii^
very irregular, some pana are eliminated by the I oug-coti tinned suppura-
live inflammation, while at the aame dme, other parts show only .aliitht
inflammatory lesions. In the firiit, eburnation is freiguently seen, while
ID die other, rarefaction still exiau. Thia ebamatîon may even lead to
true necrosis.
In a bone affwtcd with caries tbr counc of the lesions described ia
not iduntieal in diflttrxint [lorlions of the hone. Only during the first atuge
do*'!' the entire cpiphyatit present the «ime appearance in all it* i»rt«.
I>uring Uie necoiid Hta^e, the o<i8eou.s tl^ue varies in the conststenoc and
Gotor which i.4 con«dered, with good reason, to be characteristic of caries,
âome parts are yellow, translucent, slightly vascular, with fine OKScoua
trabecûln^ (6rat stage) ; other part.^ arc vaj^cutar and tight red in color ;
scHDetiiues whiiish and opac{ac (carious change, tor]»d or caseous caries of
Billroth) : here and there spongy sequestrae are imperfectly detached, and
surrounded by blooding fungi {iiecrolic caries of Billroth) ; elsewhere are
islands of ebumatud osseous substance ; finally, upon tho surfnce of the
hone newly-formed omoous layer» exist, varying in extent and tliicViiess.
From tliia ilcsuriplion of caries, based upon aeuurate observations, it
eaanot be eonsiiiered a simple ost«iu«, and if inHiimmation plays an im-
portant part ill thi* disease, it certainly doe» not perfonn the principal
one. The primary fatty degeneration of the bone w\h, altliou;^h oflou
not marked, is uevenlielesa the true caaie of all these disturbanoes.
Sect. T.— FormatiOD of Callu.
The word callus is employed w indicate not only the cicatrix which ia
formed between the fragmeuu of :i tVaciurcd bouL-, but also the neopiaam
which precedes it.
ïbe anatomical phenomena of the formation of callus are complex and
M
SIO
LESIONS OF BOXKe.
wrvc K» K connecting linlc betn'M>u tJic ii)t!animittorv ncoplMinii and lliow
vhich ci>n»iitute tumora.
FriicUirci* m«j be diviiled into ttirc« «laafles: A. Tliose wliidi ooni-
nunicnte with the external air (compotuid fractures); It, Tlio&e not
complicated wtti) noimdfl (simple fractares); C. Tboso which BUperrene
in conseijuoDce of a losioo of tlic bone, which randors it friable (cancer,
rachitis, etc.).
A. — Frarttir^» mnipliMtfâ tvith wcunil» (compoun<l fractures) are the
noHt simple in a liistolu<;icHl jioiiil of view, those in which bone is most
rapidly producod. Tliu chaii^us occnrrîii;^ are idcniionlljr thv same aa
in osteitis; at all the irritAt«d points of the i^urfaoo of tlic solution of con-
tinnity, the marrow becomes embryonic and undergoes changes «imitar
to tliose of « simple osteiti». Under the peristeum the new embryonic
marrow tioon forma os^eoiui tralicoiilic; five or nix days after the accident
tfiey mav be found. The llavemian canals opened hy the fniclure are
enlarged through the absor|>ltDn of tlie oaseous substance limiting tlien ;
the ve^els and marrow which they contain contribute to the formation of
the j^ranulativc tisane. The marrow in tlio central modulUry cavity
undergoes the same mod ï fient ions, a 1th on;;!) more slowly. Thus, over the
whole surface of solution of continuity there are formed ;;ranulalion3
which enlarge and hy uniting together constitute an embryonic or inflam<
matory tissue, in the midst of which osseous trahcculsc are developed,
as in the physiological method of ossification. The neodle-likc pointjt of
the old hone seem always to net a* a biife for the now owteous formation,
(irowingin every direction, nniting one wiili the other and with the opfioMte
fragmente, liicy limit the spaces filled with the embryonic m&rrow. These
spaces are gradually narrowed by the addition of new osseons layers,
and consolidation ia brought about by a 6rm adhesion between the two
fragmenta of hone.
In cxperimcDtx made upon small mammifcra;. tt frecinentlT occurs
that the suppurative indanunation is limited to the part which is in con-
nection with the external wound, while the deeper part of the fracture,
not in contact with the itir, Mimrtime? presents cartilaginous masses. It
will be seen that this formation of cartilage occurs in fntctures not oom-
plicatiîdhy wounds. Suppuration nvt confined to the surface of the ossi-
fying parts, is similar to that which is seen in suppuration caused by a
sei)ucstrum. Tlie formation of callus in this case does not essentially
ditfer from the formation of bone aa observed in uecroMs.
S. — Frai'turft not nmpUrated trilh wintntla (simple fractures), both in
man and animals, give n»e to a cartilaginous callus, which later be-
comes ossified. Until the time of tho excellent work by Cruveilhîer, the
formation of callus was interpreted dificrcntty hy different writera.
Their theories may he classified into three groups : 1st, that of Duhantel,
who derived the callus fi-om the penosteum ; 2(1, that of Ucllor, in which
an osseous fluid was exuded lietweon the fragments; 3d, that of Troja,
according to whom the ends oF the fractured bone put forth granulation
tissue, which is afterwards ossified. According to the last theory, cica-
trization of the bone is eR'ected through the graimlation tissue.
MBIIATÏO» Oï CAtLUS.
211
By oxperimento, the reoultx of vfliicli were observed hv tlic miked eye,
Cruvcilhier <Iciiioii.«tn>tL-<l thaï cfllliis " U fonneil hv tbe «Sflifîcalion of
nil the Aoft partA wliich sutrouinl the fragmenta." Id bis de9cn[>tiou he
addctl ihnt il îs ihe connective tissue which contrilmtes to tbo formation
of tl»e cnlIiiH, whether it be îti the mtisclo or periosteum.
The only objection to this doctrine is that it is not general enough, for
the marrow contained in the medullary cavity and in the Haversian
canals may furnish the éléments of couaoHdatton.
The first phenomenon occurrin;; tn coiiscijiicnco of n fnoturc id a
hemorriui)^, which undcr;:çoeB all tlic chan;;<^» of an ecchytnosi*. Tlie
extra vaxatioii i» generally of such extent aa to grstdually tnanifest itxelf
uniiur the «kin.
Soon cUHnj^eidw to irritjition are [iro'lHced in the ^uhpcriosteal marrow
and in that coniained in the llavemnn canals. This irritation reaching
the perioileum ami neij^hboring connective tiitaue, occasions the forma-
lion uf numerous cellular elements, ho that in live or six days after the
fracture all these tissues, snolh^n and rich in cells, assist in the formation
of a peculiar mass, of firm consistence, hut not yet cart i la gi nous. Under
the periosteum and between the two fragments, ap])c!ir» a thin pulpy
layer which, when examined with the microscope, is found to consist of
cells, varying in shape, like ttioso of the embryonic marrow ; in the midst
of lliCM' cells red blood corpuscles and blood pigment are seen. The mass
of peripheral embryonic callus is entirely sepnrnicl from tlic hone by
thi* l»ulpy layer. The peripheral mas* is bounded intemnlly by llie
smooth pcxrly aurfftco of the p<>rio)tt«um. Whon the eurt'sco of the
bone b completely stripped of tlie preceding pulpy layer, tlie Ilaveràian
canals appear in the form of red jraints or lines, like those seen io the
beginning of osteitis.
At a later period, about the eighth day, the cellular elements of the
ppriphcral callus In the course of formation arc increased to such an ex*
tent thai Uie fasciculi of the connective tissue and the cla:jtîc fibres have
almost enUrely disappeared, while the bloodvessels especially at the
margin of the eallus have become greatly enlarged. It i» at thi« time
thai the ceil* of the peri]>heral callus are found to be imbedded by a
cartilaginous substance, while the cells of the peripheral marrow remain
always free. At the period when the peripheral callus is cartilaginous,
ibe bone itself is entirely free of cartila;;e.
From the icnih In the fifteenth day, calcareous infiltration takes place;
it is seen in disseminated spot» in the proximity of the bone. This
infiltration, however, is preceded by a proUforation, which is similar to
that occurring in the physiological ossification of a short bone. There
arc sevn large cartilaginous capsules filled with secondary capsules which
open one into the other ; afterwards the calcareous incrustation of the
cartilaginous substance which separates them takcii place in su«h a
manner as to fonu areolar spaces wldch communicate with the [teriosteal
marrow, tJie vessel* «f the old bone senilitig out prolongations into
tliem. Osseous trabeculic an^ soon dvveloped, the base of which is
alwayii implanted upon tlie oM bono.
~ I most of the ciises that we have studied, the first formation of true
(loeit not take place about the enda of the fragments, but near
S12
LBSIOWBOF Boms.
the superior or ihfi-rior inargiiii> «f tlit> cnllii.i. W]ii)c hone )8 f<Hin<1 at
the margin of the ciilluji, the forniaCioiiof ciinilagiiiooitivâue \i extvutleil
between the two fr»;^iuonla.
Kroro tlic lil'leentli to the twentieth rlay, the callus ofTcra a firm reaiaUj
ance, hill aIthou)*ti the inass Îh ao1i<l throughout, it necessarilv l>as do
^become true osseous tissue in every yam. The porlphenil jhortiona. infil.
rtrate'l «ilh calcareous salt», are not rcafhcd bv tho ossificalion ; it is vtry
prohiiHo that Ihcj arc absorbed wîthont iimk-rgpinf; tliie change, while
the latter is compk-tvd in the proximitjof the bone between the two frng-
snents. Here ttic new omoous iImuc developed from the i»tenite<)iate
Cftrtilngr <;rudiially becomes dentte, forming a «olid di«k, which divide
the medullary euual into two pari». At a ranch later period and hj
proceRi) imperfectly uudcnitood, ihe OA^ouf< difk ia perforated in onler to
rc-ealabli.-ih the primitive medullary canal. When thia alow procès» is
elTectcd.tlio peripheral caIIuh has (liiiap|>oared, so that in Bome casen it is
witli diSicnIty anoid fraciurc can be reco;niixed. Therefore, I>upayt7en
was right in naming peripheral callus provisioual.
We said that all the adjnccnt soft parts contribute to the formation of
calhit. Muscle is no excoptiou to the rule, as has been pointed out by
CntveilLier, yet the fn»cioiiH of the muscles take uo part; the iuterfiw-j
eiculnr connective tissue alone is the active element. The primary fa»-
ciouli undergo fatty mctamorphoei*, atrophy, and ^raduiilly dîi'apiH'ar.
'I'hu* two mi.-lhnd.-i for the fonmition of callu» are (ib*cr*'i>d, de[>eudiDg
upon the nature of the fracture, whether it lit simple, or acoorapanied
LVitfa an external wound (compound). In the latter, oitsi&catton takes
Jace directly from the embryonic or granulation tissue, while in the
Ibrmor bone is formed from cartilaginous tissue, as occurs in physiological
osmficatton. In the present state of science it is impossible to cxplùn
this ditTcrunce. The prvsencc of bone acting upon innamcd tissue caniwt
be the cau^e, since it is the same in both cases; nvither can it be »_
different doj^ree of irritation, for in formative osteitis, whether acut« of
chronic, the formation of cartilage i.s not oh.*erved. When in a fmat
mammifcra the bone ia scraped .lo a» to o|>en the medullary canal, tha-^
loss of substance is supplied by an oafteoua tâ.saue of new formation,
which is not preceded by cartilage, even when the wound has united by
the first intention.
Sect. TI.— Tumors of the Bonet.
All the varieties of tumors previously described are met with in the
bones ; but tho.'*e occurring most freijuently are the sarcomata. In study-
ing the seat of tumors of the bones, an important distinction should be
made according to whether the tumor is primary or secondary. In the
first case, it is gi^neraily the hones exposed to external injuries which
are most frequently affected, as the tibia, frontal, maxillary ; while the
bones most frequently att.'kcked by secondary formations are tlie Sjiinal
vcrtebne. sternum, and riha. that ia, tho.*e in which red marrow iini
found. Soft primary tumors, of rapid proj^reas, which are developed'
in a booe, invade it gradually by <lcalroying tlie osaeous tissues as
i
»
tlioy |*mff. The proccM or abwrption of t))« mscAitii tiwuo iIom not
eMi'lilisllv iVilfvT from ihM occurring in .IcBlructive »nU>îtÎH. HniltrTOHM
Um>k* u iU'veli>p*riI in the mi-ilulliiry cavitio;*, fttnl fau>(i';« the «oliiuon of
tbe flweous lamelln- : tlio cl-Uh contaim-il in the C4tqiu«ol«8 become fro«,
una are ad<Ie(l to the ninss of embrvonîc ttfl.4iin. l'h« morliiil tissue of
the tumor doed not touch the osseous (ratiecitlie, hut is aejiaratod Trnm
them hy a la,ver of erohrvonio tissue, from uhicb tti« tumor ta devel-
oped, lu some case? the morbid proceâa is extended as far as the ex-
U-cDiiti<-a of the bone ; but there, as in osteins, it is arrested at the
CJiicilit:d Cflrtilnjnnous kycr; sclilom is this barrier cro6Md. Never*
tbelcMH. there is j*eitera1If found at this tjiae • chronic arthritis.
^(e[■I<tntit: fonnnlions are iniicb more common tlian Is usually «up-
posetl ; ftutop«ies mu$l be made very tkorouj^dy iti onler to discover
(hem.
The rnotjxnsis nf tuinant of tho bone» depends upon the untitrc of each,
and w« have nothing to add to what ue have itaid à pr-'y» of tmiKir» in
j^euenil, except to say, that the mnhdiary system Wing contiiiiied
thniujfh the entire bone, the tumor* are, therefore, very easily difl'u><ed,
and ail ojieratiun limited simply to removing the apparent tumor, leaving
intact the neighborinjj osseous tisauc, is generally followed by a return
of the growth.
Vakikties of TiiMOne ok tub Bomb». — Enrejthahid or vnnâ-t^Urd
utroima (m;c p. Tl') ocGurs frequently in the bones, attains coiisiiU-rable
size, aiul it of rapid growth. It 1« fnsjufntly erectile in it« nature,
and then give» rise to symptom», which clinically resemble aneurism» of
tlie Iwne:^. Itiuintetime» happens that <liUtation of the capillaries may
be so extensive that (liey open into one anollior an<l form a large sac.
In tiie interior of these »8cs there are found thin, soft, and Boating
ahred». the structure of «bich resomblea that of llie morbid tissue
which exists at the margins of the sac. From a nakedeye examina-
tion carelessly made, these sacs are liable to be eoiwi.lered aa aneurisms.
Mucoid uietatDorpbosia is also seen is these tumorâ (see p. 8t().
Fatf-icular or »pindle—^lkd iaftmata of the bones arc more com-
mon than the preceding variety. The fascicular character of the tumor
is more or le** complete, and gives them u variable consistence. It is.
at times difficult to disiinguip^h between encepluiloid sarcoma and fasci-
cular can'Oina, esin'oijilly in cascs, not uncommon, wherti both varieties
of tissue are found in the same tumor. The soft fascicular sarcomata
are found roost often in the body of the bones, while the bard have a
preference for the [leriodteum. We constantly see, in the fascicular
sarcomata of bones, large multinuclear cells (giant cells), which here
actjuire tlicir largest dimenaions : but the presence of these cells alone,
does not aullîce for the recognition of a variety of tumor, oeithcr does it
indicate the benignity of the growth. These cells are mat with in every
variety of bone sarcomata.
Eucephaloid and fascicular sarcomata arc very often invadeil by cal-
careous infiltration, which does not change the gravity of tlie tumor.
The infiltration is generally in the form of nodules or friable Irabeculie,
S14
LBBIOXB OP BOSBB.
in *rhich arc foiin<l cells from llie morbid aaas, inoWed m small cantîes
without prolotigsktions.
Donea afTccted with aarconm are very eaaily fractured at tlie aeat of
Ltlie tiiinoi-. From the sarcomatous tissue ttiere arc then developed small
qslai^U of cartila;;e, which do Dot uniw to form ii firm callus ; hut their
presence seems to indicate that the fracture act* up-m the morhid tissual
m the same manner as a simple fracture upon the iicij^hboring connective
^wue.
Mffthiiî tnreoitMta are nuitc rare. Their tiMuc rcMmbles the embryo-
nfil marrow «f bones, and présentât similar histological char»ct«r8. ft u
^composed cliiclly of round cells, distinct and larger tlmn in itie normal
fttatv. The mullinuclear colU (giant cella^ are not ver^- numeroii«. In
this variety of tuinora, the valU of the bloodvessels are not embrjomOri
but appear normal.
Onsi/jfiH;! mrfomata are a veiy common variety : tliey form almost
all the epiilet), the subungual, and most of tumors knoirn in France by
the name of tumeur» à tnnHophjiy». Hovfcvcr. all the tumors whicn
Aur;;eons dc!>i^ate by this last name do not currvsponi) to the o«aifying '
■arcomatn. for fascicular sarcomata may contain nuineroiu multinuclearj
bells (mvéloplaxcs), nnd thi-y should not be confounded tvitli the former,]
Tor they arc relatively non-iiinli^mtnt, while the fascicular survomnta aro'
docidc<lly inali;;iiaut. There are found in the boiice other rancties of
wrconiatA, the Upomatoua and tlie mffan')ti'y, the lost fts m«t*Mutic pro-
ductions.
Myrnmatom tumùr$ of bonea are met with in the form of rouod masses^
diatinclly limited. They are genorally developed under the perioâteam^
and cause an absorption of the hone upon which thoy lie. We have
never seen them infiltmle the osseous tissue. They should not be con-
founded with a nutritive lesion of the marrow of bones, which is seen in
CAchcxics of long duration, and is chnructerixcd by a gelatinous appear-
ance, due to the absorption of the fat from the adipote cells, which is
replaced by iteruin. This lesion i« analogous to that which occur» in the
$ul>cutaDeeu.t cellular tissue in the name cases.
We have seen an example of a li^'/ma of bone. The tumor was devel-
oped in the substance of the tibia, and riuJte large, llie Inbides oCj
adipose tissue, instead of being limited by tihrous bauds, were separatedl
by trabeculœ of osseous tissue.
Kvery variety of carcinoma has been mot with in bones. Well-
authenticated primary carcÎDuma of bone bns been seen, but secondary
or meln^iatic is much more fn'i[uent. Hunl carciiiom» of the breast of
lon^ duration, is almost alwnys accompanied by secondary growth in
the vertebral column. The carcinoma is seldom larj^ ; mo«t fre-
<]auntly, the os-teous tissue is «ubstituteil by the morbid tissue, for
example, the body of a vertebra may ho almost entirely formed of carct-J
nomatoiis tissue, without its shape being nokihly changed. There may'
even he considerable atrophy of the hones without either nlceration or
wearing away. When carcinoma develops in one or more vertebral
bodici, a loss of sub>itânce occurring, there is caused a convexity of the
column, as seen in I'ott's disease. The development of the morbid
product in the body of long bones or in their extremities, gives rise to
TOMOBS OP THE BOXES.
215
epontUDCOiig frncturog. There is tlivii seen n Mooilj fffuition, bat ncvor
hAv« we \tttn iMk^ to tliscoviT tlio U>n«t atlvni]>t at ossification. The
irritation cauMal by tlio fracture oo<;Mions ii tranitforiDation of t)ic noif^i-
borini; liH^iic into c]ireinnRuil«>iig tis«ue. For tbo dcvulopoicnt of car-
dnoiu» il) Wno mo p»^ !)9.
Tubtri-tr» of boiH-H iin> mot vith in the spoDsj Ussno of Iodk noii short
boDOfi, but their favorite ho»1 is tlio bodies of the spin&l v«ncbn«, Uie
stenium, am) the riha.
In the atlult, the iue<!ullary substance of the flt«mum, ribs, and hmties
of the ren«brjc. is red. iuclinin;; to a violet, and very slij^htly translucent ;
it coQsisIs of the ordinarjr celk of the marrow, a few adipose celU re;;u.
Urlv<)tâtributed,and bloodvesscU. around vhicb there exists a thin laver
of ontinar; connective tisane. A tuborculous ^^anulation, situated in
such a ti^uc, has such decided chanictors that it is impossible to mistake
I It. It foTTDs a circular spot of one or two millimètres, frcqupntl; a little
; imgular in ito contour, i]i)itc amcniic. and elî^htly trunshicciit. The
centre is often opA(|uc, while at ibt circumference the marrow is deep
red. The tubcrcnloiu notlule cannot be felt with the finger, owing to tlie
prcwnce of o«)eoti« tral>eculH.'.
Tiihercleit of boneii are of two kinds: iliMi-miuittfil tiiliereHiou*
ffranulitli'-nit and eonfiumt tuhfri-nhu» i/mnul>tti'in».
IHêMemiHati'il Taf>i-railvu» OranutiitiitHt.—A micnMCOpic examination
of a Idberculoua granulation, remored with the aid of a needle, and
placed under ihe microscope without being covered with a thin glass,
' appears, undtT a power of l.V) diameters, to he fonned of medullnry celil
only. But this is n<tt true, the tubercle is only cnvclnjxid by the cells
of the marrow ; for, if the granulation U pvncilk-d, it is not di^fintc grated ;
and if DOW examined, after i<tight pressure by a thin gta»» cover, it is
seen I» cougist of very small nucleated cells in a granular or very .«lightly
fibrilbiled substance. If tlic granulation 'n caseouit at the centre, it in
there 0{<a<|iie.
Tht.* meiho<l of examination, however, is very unsatisfactory ; in order
' to study iho iii*siie of the granulation, and obtain good results, tliin sec-
tions should be made from the diseased bone. A granulation included
in the section presents the following characters: at itâ periphery, the
marrow contains no adipose cells — the bloodvessels arc dilated, and bavo
no connective tissue around Ihcm; this zone of irritation fn-qucntly ex-
tends some distance into the spongy tissue, where the osseous trabecuUe
larecnxled as in ost^-ilis. Not oidy aronttd the granulations «re tlie
I phenomena of irritation to be seen, but at distant points, from which it is
I rational to aiipiK-se that the irritation has preceded the appearance of the
gntnulation». In a woni, osteili j precede.'* tnbercleit in hones. The tissue
of the granulation is composed of small refracting cellular elementi,
.which diminL*b in aize gradually from the periphery to the centre.
[These elements are imbedded in a reaiatiog granular substance.
'''■nthient Tuf-^ful-u» Gr'inul't(i'H\g. — It is very probable that many
Vol the changes described by Nélalon under tuberculous infiltration belong
[to confluent tuberculous granulations, hut his description muy serve also
for caries with caseous change of fat, for cbumatcdsci|UcstrH;,or for some
syphilitic gummata. Without the aid of the microscope it is freipiently
216
tKSIOKB or BOMBS.
impos^iWo to reconnue a Iwion sa tubercular. The j^raiiiiliition U the
only fharflctcrislic product of tubcrcuIoBis, and thus caiiiwt be <lUtin-
giiifihcd with th« unaided eyo wbon tlio dUeaso is confluent, A Urge
mitnbor of tiibcnruluus f;rnDulKtir>n8 forming; at oticc in tliv «Hlïm mmlul-j
lor}' cuvity Dcvvr bfcnni« so lnrj;c as tbc diHi<cniiiiatP<i );rnnitUtinna {I
llicy viTv rn]iiil!y imdvr;;o itie clicecy Tncta[iior)ih<ifîii, nniJ csum; a Mimilarl
ti'uti!<f»rmoti»u of tli« iiiterjiOBed medullary »ulj*lanc«. Ajtnin. the de*l
veloijuu^iit and «truciure of the tuliorculou» granulation are alwaya Ui©
Game, whether dii>»eniiiiated or continent.
Tuberculous jcranulalions when developed in hone occasion an oblitéra-
Ltion of the vetuek. Therefore, if several ^i-auulationa arc inclmled in
|Die same picdnUary carity, occupying iliflcrent posittone, it la evident
tli:tt perhaps all the vascuUr brnnclics of this cavity vrill have their
circulation anx'sccd. The Hpon;^ tissue, nol containing «ranulations, but
I Surrounded by the tubercles, is alsostrikin^lvai winic. Thepkrtsof bone
'where the cir^utution has been nrrcxted iinJer;;a caiiCous transfomuttonr
for thu eanie reason that infarcti btcomo cheesy.
Freijuontly ilie aroolw, which have l>vcomc caseous by oblitemiion of
tho I'esJiel», an- iliflerent tVom those which linve underjçoue the mine modi-
fication by a breaking down of the tuberculouH granulcH. In the firtl, tlic
adipoae cells are not destroyed, or their place is marked by groups of
stearic acid crystals ; in the second, the adipose cells have disappeared,
leaving no trace, from the fact that oaleida has preceded the tuborclee.
The caseous metamorplioiiis of the marrow claims consideration.
L forp iinilcr<;i)in;; I'aciy dcj;onoralion it becomes at first trausluccnb,
Foiedullary cells appear to «brink and unite to^tlicr — lhi« «tnf^ ia
•hort duration, and is »cen in a very liniiled ai-oa, and it i* soon followed
by the caseous metamorjibosis. it i:^ not posntiblt; to detenuine where this
change finit occurs, whether in the marrow or in the tubercle.
The osseous irabecnlic included in the caseous mass have seldom]
undergone either condensation or rarefaction, Kslemal to the tuber»!
culoiia formation, it is not customary to meet with any considerable
alteration of the osseous tissue, except rarefaction.
The bone corpuscles do not participate in the caseous change of the
Duirrow, (heir nuclei become irregular, but around the latter there arc
no fatty ;:niTiules. This may bo learned by colorinj: with nnilino red,
I which distinguishes the caseous tran>ffurnmtion con scijueut upon confluent^
I tubercles, from that which accompanies curies. In oriea the bon
corpnsdiM brcaV down by a fatty degeneration, while the portions of
bone invaded by tubi-rcu1osis not reoeiviu)^ blood are necrosed, and <dimi-
nation lakes place at the time the crup^on ia completed in a part. 'Hie
élimination very probahly is produced, as in a simple necrosis, by
means of a rarefying osteitis, which occasions the absorption of llio
oaseotia trabeculœ, and even tlic dc'velopmcnt of a granulation tissue.
In this manner is formed a cavity in which is found a B0<)uestrum sur-
rounded by pus.
At the pr«-s«nt time, when there is found in a bone a canty lined with
granulation tissue or u smootii membrane filled wîtti pus or cheesy mate-
rial, it can be logically considered of tubercnbius "Hgin only when there
exist in the surrounding tissue tuberculous grunulutions appreciable to
TOHOBB OF TUB BONES.
k
Hw uaatdod «ye or witli tlic microKoopc. A ReqnMtnim of spoiij;/ tÎMU«
■umunilei] hy pa or iiifihmud with caseoiu matter sliouli) be attnlnited
to confluctit tubcrvivs only if disKfiniiint^i) or ooiiâiu'iil grnnulos nrv pm-
•i^Dt in tlic unrroiiiidii)): hone. Indocil, «iinplo »«tuitiii, caries, imt pitn-
nutta tnn V rK-ca^io» niotlilicRtiona of tlic ooNr^'un lt8»ue. to the ututidiMl
ejc, ftiintlar to confluent luberclcii »t their time of erolutjou or elîimn&-
tion.
OuiHMoia of &.)i>e> are found in the luinie localities as tubercles. It
shouM, bowflver, be remembered Uiat tlie bonea of the cranium oerer
contain tuberculoua gmnulationa, while tliey are a favorite scat for );am>
nmca. Anatomical observations of ;.'un]iiiala of hones are rare : atlhou;;h
clinicatlr vrrjr frc<i«cut. patients sohiom die of sjrphilts. Two f'lnns
occur: in one ihi-y uro limited, resembling in appearance and Consistence
a hard Burtoma ; in ibc other they iu6ltrate, aa it were, the omoouh lis.
sue, and it i« to tliia latter variety the name of gummatous osteomyelitis
is fàven.
('irntmn^ihfd pimmata of the hones of the cranium develop flr«t
un<ier tfie )(erierantum or beneath the dun mater, and sometimes even
sîmultnneouily at both of Iheite points; growing in the form of n oooe
into the oaseous tissue, in wtiiub they occasion a proi;rc«sive rarefao-
tion. l*liey underj^o albuminoid degeneration, and. if we accept the
description of Virchow, are slowly absorbed [probably under the influ-
ence of appropriate treatment). In their place there is fonned a stellate
cicatrix of osseous tiiisue derived from the fibrous tissue. Allbough it is
•c«n from the di'^cription ereu of Virchow thai theae cicatrices corre-
ffpond to old gunimata, yet this author dcsi;^aies them by the name of
dry »}fj-fiililir eariea. It is rery evident, fiom the description j'iven of
caries, liiat there is notbin;; in common between this lesion and that due
to syphilis. Tliis ^inciiiar loss of substance, truly characteristic of
syphilis, is limited by a sclero«ed osseous tissue, and at times by flat
osteophytes which surround tie eentral depre«iioii.
i>i^^'tiNedguraiiiata of bones are particularly common in the subcutaneous
partA of the osoeoas system and palatine arches. Their formation takes
place under the periosteum and in the corrosjioudiiig o^ueouA tissue at t]ie
same time ; at first in the form of a soft, slijçfatly getattnous, red tissue,
mon becoming firmer and opuipie. Upon section of the bone at tbia
«tajre u whitish surface is seen, of cheeay appearance, similar to eon-
fluent tiiburcles of bone. But a very evident difference may already he
recogniiM-d : under the periosteum there exists a pulpy layer, also whitish,
over a *pace corresponding to the bone lesion,
A mioroMOpic exaniinnlton shows the osseous trabecu^as, as in rarefy-
ing oateitts and the enlarged medullary spaces, to contain gtnnmatoiia
nodules (see p. iiOO). In these nodntes the bloodvessel* have remained
permeable, differing in this re.'pect from tubercles. At the margin of
the Kurama are seen all the characteri.flios of simple osti-itis.
What ultimately becomes of these dîfl'used gummata of lionnit? .\n
answer to this (jiiesiion hy a complete series of anatomical data wouid
be desirable : but, in their absence, the clinical and anatomical observa,
lions may he referred to. It is well demonstrated that gummaU, for
esampte of the tibia and sternum, may entirely disappear under titio
218
LESIONS 07 BOSBB.
tnlluencfl of anti-syphilitic Inintment. or leave in their plnce hypernstoaes ■
analo^oa to those which accmnpaiiy circuiDMnbed guintuata of tho
cranial bonea. Again, syphilitic necroaia is seen in which tlie sefjucstrief •
instead of being ehumattjd. aro excavated with numeroiu cavities lill«d
with a ca&coTis dctritua at tho time of cxuminatjon, and which prohatty
pn-xioiiirly coiitaioed gummatous tistiuc. Virchow believes that over/
iiyi'liilitiu nccrosit haa a like ori<:in; but, from what has been lutid con-
c<'niin;; nccrosisi it is very corlain tliat tlie «Iculh of bone results frv-
<]Ut-nt1y from a condcnitinf; oMtciti» or «clerosis, coii^nued until the oblité-
ration of the vascular caiiiiU i» aocomiiU»hed.
(f/inNilrtmatit arc developed more frei|uently in the osmioiis iiamae tliaa
in any of the other tt^xucH. They should be named jieripluiHiiromtitit when
seated under the perioftletim, and tn-hondr-imula when iteveloj>e<l in the
substance of the hone. I'hey may be diffused or lobulated ; tlie latter
form is the most common.
ICvery variety described at page 128 may be met with in bone, for
example hyaline chondromata, lobulated chondromata containing fibroiu
trabecule or libro-cartiln(;'inoiis, ossifying clioudronata, muoous «hoodro-
mnta, with raroifyin;; celU, etc.
These different tumors are developed u dcsctibcd at page 129. In
regard to their pro^nosiii, see page 131.
Ontumata or tunion* of oiweoiis tissue, are named c](0stose«, hy[ter-
oflta-tes, or osteo|>h,vt«s, according to the shape of the new formation upon
tli« surface of the bone (sec p. 1^2). The name enoatosea has been
given to the osseous formations developed in the medtdlary canal.
In leiicocythromia, ti/mphatir tumor», or lymphadonoraata, have been
found iu bone. In a case published by ua in 18tî7, the tumor was quite
larj;!!, consistinj; of a whitish tisani- which, when scraped, exuded a lact*-*-
ceiit (liiid. containing cell» analogous to the whit4.i blood corpuscles. In
some localities the tnmor hod undi'i^one caseous imnsformation. A micro-
scopic examination of thin sections showed the reticulated stroma of
adenoid tiiwne. To the unaided eye, the tumor resembles a carcinoma,
JCj'it/ifllrjiiiaUi 'if hiint».^ll is uncertain if there is ever a primary
epithelioma in bone, but iia extension from neighborins tissuus is not
uncommon. An epithelioma of the lipa may extend to the bones of the
jaw, of the palate to the palatine epiph vais ; an epithelioma of the extrcmi-
tiea may also extend in depth and reach the underlying bonca. The de-
velopment of the morbid mass Is by epithelial pegs, which penetrate and
develop iu an embryoino tissue fonncd at the expense of the osseous tissue,
a» in osteitis. (See p. It'T-') Tubular epithi-lîojuHta arc met with in bones,
being not nnconimoii in the niiperior maxillary, and they are then consecu-
tive trt tumor» of the soft ]ialaie or maxillary sinuses. A case of cylindrical
epithelioma has been re|>orted by Oawrilofi'; this ia not surprising when
it is remembered that these epitheliomata behave as carcinomata in their
generalization.
(.yufg are sometimes met with in bones, presenting the uaual cbatactcrs
of such formations,
OBTHOXAL&CtA.
Sect. Vn.— Oiteomal&cia.
Tnt« o9tKimalana is n. iliseiLH- « liKli moi»t frcniicnflj occurs in women
âft#r Bwc or more Inborn; it is cliuractprixeil |iftrticiil»rlv by a nutritive
lésion of the bniK>s, wliicli rr»ult4 iu lli*; ftlntgrption of the calcan-oiM
wlt« of tbe o«Mi>iu HiihAtanc« nud the tioliitian at the osseous trabvoiiln;.
At tliu .tjime tiiiift, important chan;^» occur in the marrow. During tbe
first stage, the bnn«» retain their niice ami pmsont no rarefaction, jrct
the» may be cut with a knife. At this time the middle of the osteons
tmMcatae still contains calcareous salts, whil« tlieir cif^cs arc deprived
endreljr of them. According to RindtluiMb, it is this last portion alone
Flj. 12S.
N
HvHailftf of Wtt*. Splcnlftof Imba from IbtapoDtjialitUDf* of «a ««MdiAfctftr'' rlb^ a 5ornAl
*f^if*t* thAftf bl tt fln«d vlth r«.l iDr4uLlftr7 cIhq*. lu vZilfh iho luuilu^of tliv c^ptlUrlo* knvp4B.
tbat is capable of being colored by carmine. Tlie vessets of the marrow
are congested with blood: the adipo^ie cells less numerous than normal;
in their place are found round or irregular, sometimes fusifonn or flat-
tened colls. Soon there occurs in the marrow diffused hcmorrliaKe in
the fono of ccchjmotic spot». These hemorrhages may also take place
beneath the périoste uni.
Id the second Btafî^'t ''"î bones become greatly deformed, they cither
bend upon then^idves or fracture, and it is at thi» time that such extra-
onlinary ilcformilic» arc *<tcn. In thin second p-riod, not only «re the
OMcou* tr>ibe«iilm decaleilieil in their entint thicknc.-<:t, Imt they are al«o
even in great part absorbed. The enlarged m^^dnllary cavities are Itllcd
by au embryonic marrow having tlie appearance of the «jdenic pulp, 'flie
coloring matter of the blood is constantly found in the medullary cells in
the form of yellow, red. or brown pigment. Thia pigmentation arises
from tlie bloody extravasations above mentioned.
k
sso
LESIOHS OF BOXES.
FrBOttire» during tlio cftune of tliis disoiiM »ro not generally iioJI^H
noverlbolpi», nulhont hnve reported cMe» in which lliere haa Weu fd^^H
tiun nf catluH; bul it i^ onlv nheii the iliseoAe ia iri '[iroc«S3 of reoan^^|
We liitve not yet been able la j^ivc any «ati^faclorv explanation of l|^|
LilecalciËcnlion or abgon>tion of ibe osseoiix tjs.'<iie. I'ho formation of ^H
i. acid capable of dissolving tbe lime salts has been suflpni:ti-d, but tlitH^|
\6 not known. Weber has found free acid in the urino of person* l^^H
in^ with this disoaxe. Itindfleisch beliovoa tlial tht- culcareon^ sal^^^l
dÎMolveil by the action of an excoas of carbonic acid. The venon^^^H
uei^tion of thu marraw that occurs dtirinp;thofirHtHtn^i>occa»iom ^^^^^l
The blood, charged with carbonic acid, \a in contact nitli tho M^^^|
trabeculiv and causes a solution of the caluarcoiia 8all«. This, Iiov^^H
is only an ingenious theory. "^H
SeniU agtf/poront, aUo described m Mnik otte-ymattma, is & ruefi^f
tion of the oj^eoiiii tixtiue by an onlnrgetncut of the inodnllary spacClH
In Ibia diiieaite the frinhility nf the bones ig owini; simply to tlioir T^t^fl
Lfaodon ; there is not a softeninjc of the hones by decalcification xt i""*^!
I osteomalacia. Acooinjoinyin;^ the rarefaction there are important inodiM
I fictttioiis of the marrow, presenting some analo;;y to tho«e oc-cnrriii}; id
true osteomalacia. There is also, to a croaccr or less extent, dtmipiietlfl
(Uico of the adipose cells, and a formation of cells similar to thoae oH
embryonal marrow. Xew.ty-formed young connective tisHiio is at tia^J
found in the mcdull&ry spaces, ■
The bones most frciiticnlly attacked with this di»e««« nre tlie ribs ufl
verlcbne. The vertebral column becomes curved, tlio ribs nre fractUTM
by the sti^lilest effort, anil, what is very sln;;nlar. they arc afterwarofl
firmly united by the formation of a cartilaginous callus, which aftcrwnnll
is ossiiîed. I
Fatti/ ogtenporoti» ia a rarefaction of the osseous tissue which is »eefl
especially in the epiphyaes of long bones or id short bone». It ii» ohaig
I acterieed by an ahundant formation of adipose cells in the medullary
Spaces ami in the Haversian canals The osseous traheeuhw of tho spongy
ti«:<iie at first become very thin, and finally disappear. 'J'he bone is re-
duced to u parchmcntdikc aboli, pierced by numerous vascular openiags.
This dt«ease is met with in chronic aifcctious of tlie aniculations niib
immovable joint*.
b Sect. Vm.— Raohitii.
Rachitis is a disease of the osseous tissue ocournng only during the
development of llie bone. Characterised liistoloeically by disturbaocea
of nutrition and of development of tlie tissues which contrihntc to ossi-
fication; these tissues are the epi]>hyseal cartilage, the periosteum, and
the marrow. It is a very common afl'ection, especially in lai"ge cities,
and principallv among the poor.
I>urin;; the first stage of this disease thcro is no doformily ; in order
to ascertsin how frefjuently it occurs, tho bones of every dead child should
be ex«mine<l.
Three periods of this disease aro rocoguiied: first, one in which ik
RACillTI?.
Fig. 129.
ftre not defonaed ; aeoonil, one in which dcfonnitiM «xist ; «ad
Jlj.a diird, îti wliinh the (li»emM<l bon^s an cotwrfidiwtl.
If th« histological Icsiona only arc conaidcrod, thero is not any very
ttkf\ iliffervnco butwetu thi.' first ami second periods. Tbs aanw pn>
o>iiliiiue«. extends fiirlhcT inti:> the
B, a»d duti-rniines ntotlificnttODs, ap-
Mv u|Ki» the livini; subjfct.
J»'i>rm<il otri/icatioH of caTtilag^ occur»
jiilwity. (dt-e i>. -JS.) The
1 'Hiic oArula;;o swell, while
cnfMuiu •urrouinlitig them beoouaes
borical : llie cells nfterwarda divide and
itwIiiMcd within Hecondarv capsules
I such k mauner that each primary cap-
' I coiitaiu.1 from four to ten aeeoDdarjr
Icanuka. The pfimary cnlnrged cap-
[hiIm ans clonçatcd 1>T mutual pressnri!,
[m u lo OQDTor;;f towanis the point of
ItMificatiuD. 'I'hf liiyer in which these
I d>ui^>i takoM jilaci* is bonuilc«l hy two
I jattllel linex, oiio to one nnd a half milli-
■MrMfltNirt; tlii« layer is spparetit to
' lb« «naiiled cyo by iûi trnn:«1uceticy anil
tJHitlh color, nud is fomid between tlie
I odseoos ami cartila^nou^ tû;JU(^.
llajerhaabeeDhadlyiiamcd byBroca
[timdrMd, which wouU indicate that it
: of a tiasoe oidy huving tbe ap-
■(rf* cartila^, while it U in reality
I of prolifcmtinj: cartilage.
, rschitiif bi7;*tiu, there are seen
tida layer moliiiuaiioivt which are
stinncd during tliC duration of the
lafleetim. With tiie unaided eye it is
[•een fi be increased in tbicknesa to the
, of sererai centimetres ; instead of
; nguUr, it is upon both sides very
Sometimes Tcry Iohr prolon-
I extend into the Wnc. frc^jucntly
I that tbey are separated and form
tmS islands. The layer is also fur-
by medallary cuiaU, containing
' bloodreewls.
nicniecopic examination of this
, ' abows a strikinj; analogy to that
I«»ented by the physiological proliforatins layer of cartilage. In the
* iwd layer, however, the primary catwules are much more distctuled
I coatain a greater number of aooondary capsule» which are larger
II in the normal. Beneath this layer and contiimotts with it, there
t a red vaecuiar and s|>ongy tissue resembling a hone that has been
Vcrtlnl ■•citon fnin (dft «( om\tj\ot
porilaaor ih(i dliiphjrtU of 4 mvlat*"»*^
fMU t fattl Hir. a. <>ni«i>d huViIadw
ol th" nrllUii* 1 ». uf ban». *, KtiBlr-
lamtt bunorflli 111 pruSI*, luarr or !•<■
lrn)>oil<l<^<l I» IsKmlUlnr •ablanr*. <!■
NfdnUirr nanni In pi«M«of PicsktlOB,
«iiUtMwli ud nfdallsir Mill- <-/-
noua •aJUastbvIt broil Mt4ct. ff. Car-
tllac* oapaaln arnoxail la rvwm. pudj
«UbitLruakautall-lHirlla*. (JTSUar.)
2S3
LKSIOSa OF B0NE3.
pArtinll J noftened by an acid. In order to untleralaiKi the Bignitk'attN
till» la^er, it i» neccsaary to recall iu a few words tlie tissue eKistiii); hi
ill B p)i_v a iu logeai condition.
Iti the physiological state, beneath the proliféra ting; cartilnsf. !• *■ <!'
[ » thin layer, fonued of areolar tissuc, tho trabecol» of w '
poaed of the fundamL-ntal substance of cartilage infiltrated v^l-.a _
aalta ; the »lveoli cootaining cnibryonal marrow ond vcsmIs. Bci
tbifl the tnio omvous ti««ue is fonncd. To this Uyer is gircn the
of ossifonn, bone-formiii^.
In rachitis we ilo not tliiiik ntth Hroca, that it Î8 a simple increaM
thill liiyen' i>r boiiii, but tliere i.* formed upon itsaitrface » peculiar ti.
to whieli (luurin gave the name of t/i'-nii-iiit. TM* iiK^ue, which
exCentU from the msrgiu of Ibe cartilaj^ to the •liaphyf^ia, fr*M)i
invading both, is red, foriiied of alveolt of very irregular dinwi
it appears to contain much blond, ita consistence is thai of a fine s[
or better, that of tlie osseous tissue of the epiphysis, which hae
incompletely softene<l by an acid. The boundary between tliis spo .
tissue and the caKilage is very distinct. At Umes small islands o(^ _
line mrtilage «re found in its interior. On the side of the old UiitcV
is often impossible to indicate exactly where it ceases.
At the periosteal surface, the spongoid layer, especially at tlio
of the diitphyfis. is mingled with a tissue forinen of oeseouit Unwli
separab^d from each otlier by a soft tiMue, of wliioh wo will prc««at1|
■■peak.
I A microscopic examination of fn»>h sections of the traboculie of tl
\ tpongoii) tissue shows angular corpuaoles arranged irregnlarly in n grai
[ uiar non-laminated substance. These corpuscles, larger than boue cof
[nasclcs, do not preaent any anaatomoeing canalicuU at their mari^n*.
To understand the importance of the tissue which form the-sc trabec»la^,
their fonnntion from hyiilino curtilage must be traccit. There is ()ien
seen starting from tiiis eurtilnge a calcareous infiltration of tlie segmented
fundamental eubstancc which separates the Urge eorpHMles; (liis cal-
careous infiltratiou extend» to the secondary capsule (which never ia the
ease in physiological os»ilication); it results in the whole cartilaginous
tiitsue being invaded by catcaruous granules, which remain distinct,
, that is, separated by cartilaginous tissue whioh preservea its fiexibiliiy.
[The secondary capsules are not dissolved — an essential dilterenco from
I physiological os.4ttication. At the same time that this calcareous incrust-
tatîon occurs, tlie vascular canals of the cartilage arc vnlarged by the
^dissolving the calcified tissue which surrounds them, untdng with each
other and opening into the medullary spaces of the old bone. By tbeii^
union they form a cavernous system to tte later studied. ^Ê
The spongoid tissue is, therefore, formeil of trabecule representing
portions of cartilaginous ussue infiltrateil with calcareous salt'*. These
irabecube. when young, |>ermit the cartihigc with its cajwules to be dis-
tiiiguiniicl — -the margins of the latter, however, are diflicull to recognixe,
owing to the eatcareoiis incrui«tation. In older trAhecul»;, the capsuiea
are entirely hidden, but in order to niabe them visible, it anflices to dts>
solve the calcareous sall^t with hydrochloric or chromic acid. It may
happen thai these reagents do not reveal the présence of cartilaginoas
KACBITIS.
Cnl«fl, Init dieclMe only angular corpuscles arranged in a fiin<lam(tntal
taitec «liicli Menu hoiDo^neous atïor the solution of the calcareoua
ilu. Nvvrr in tlicM tniboculir cftn be recognized uxsoous lamellae,
a laiuinjiwl oppenniticc roeoroblii)^ that scon in osseous traboculs
it«<l bvxciiU. Tlii' Apnvc'S which tlivst! truWciilivof thespongoid tiesuo
ii»l cohtiniie to viilargc ir tliv pm^^i-M pt-nUHl», which is th« 0])|>o^to
I nonuiil o^MficAtioti, when) tlie mvdullnrv )i|taoca arc narrowcil \>y nvw
P0U8 lavcrs. The marrow ooulain«<l in these space» in at first soft,
1. anil bv inicmsoopic exnminatioD la t*een to be oompoiieil of rouml or
~ ilnr cAU. some of w hich nre pigmented, and to contain numerous
corpu^lfB. Itut ill the older modullarv spaces, the contents are
oODsistont, the cclU become stellate, and sepamted by a sJiglitljr
Blatcd fundamental substance.
Tin» Bttvmpt at fibrous organisation of the marrow, takcit placo not
tmly iu the uK-dullury cavities formed ilui-iii<; the evolution of ruchiljs,
Wilt the oM m.trfxiw contained in the sponj^y tissue, in the Huversiao
nuU, in the (.■■■iitrnl canal and in the suli-peri osteal marrow.
Ill live mcdulLirv canal, the peripheral layers of llio marrow are those
«itirti are the moat modified. While the ccntnil portioiiH of tlie marrow
trt re-l and fluid, composed of emhrj'onic marrow, the peripheral portions
m organized into a kiixi of young connective tisHue, which has the
Iplttanncv of a tncdutlary membrane. It is posiiihle that it waa tliis
«tuition which led the »hl anatomists to admit tlie exltitence of a roe-
Aillarr membrane.
The layer of marrow beneath tlie periosteum, which has been men-
IWiT'l «cvenil times, is Gban;;e<l at the commencement of the disease into
imft couticctive tissue ; later it becomes more solid, adheres to the «mder
lurface of tlie periosteum and to the hone, m that its reparation frmn the
boM is much more diflicuU than t» euMtoniary in youn;^ [tersona. This
(Muiective-IJssue layer, truly suh-perioiiteal, at times aci)uirefl a cousitler-
tlile rliiokness. Xi undergoes a very ititerertting modification, the nature
of «hivfa ts not determined, consisting in the appearance of waving refracU
iug tralwcul^, anastomoùng one with the other, which come from a ti-ans-
fonuttoD of intercellular substance of the young connecûve tissue.
These trabeculie arc the analogues of Shnrpey's fibres, which arc seen
in tilt? osstficalion of ihc sopondary bone» of tho cranium ; thoy differ from
tbem iwwevor by containing cells in their interior. The tissue which forms
'liieee traWcuta; is considered by Virchow u» repri^scntins the first pluiso
I of ossification, and isnaiucd by him osteoid. Sections of this tissue made
pffieudicular to ttie axis of the hone, colored by cannine and treated
with acetic acid, aliow stellate bodies, with an ana-itomoniii): appeamncc,
tlimughoui the whole thickiiesa of the preparation, hoih in the refracting
trabeoulfe ami in those parts which look like ordinary connective tissue.
In ihe refracting trabecultc the stellate bodies eeem larger ami have a
more distinct coniour.
When rachitis of a hone is Tory much advanced, there is fourni beneath
the osteoid tissue tldn lamellae forming complete cylinders around the
bcme, and separated from each ether by a soft and vascular connective
tiaaae. TbcM lamella; which are formed of true osseous ti^ue, are
spongy, and the cavities which they contain arc filled with young con-
224
LBBtOXS OF BOMBS.
nectlve tissue. This sinj;uliir form of tmao is a result of a Gbrons
formntioii of the old marrow, with partiail ahaorption of the pa-vioa
fonn«â boM.
A* the (liaoMe procuresses the mnrrow in the Haveraian canals m
goeii fibrouH tTan»f'>riiiutioii in the wholo thickiieM of the compnct )«rt j
the <!taphy.4iii, nt tlie »uiiie time the ««jcdiix trnhceultc arc abïurlioil, i
the bone cells become free. A boni' whiob has timicr^M such chai
loeeH ita rc^istiii): power, maj become curved by the vrcifjht of the
or auBer iiicnnijilete or complete fracture.
In a fracture, the callua ia entirely conipoaed of osteoii] tissue, aa
ogoua to tliat which ia formed under the periosteum. The calli^i
osteoid tieaue is generally very large. It is not necessary to innst i
the importance of this accidcittal new formation, resembling exftcUv i
which IS formed uoiier the periosteum in the natural course of thut i
Cftse. We have acen old callus in racliitts, but produced when the di»
waa progrcning, nnd the union was etTectcd by true osteoid tissue, i
not formed from oMCOus tissue.
It 18 not yet known what changes are proiliicetl in l>ones affected '
raohitis when the recovery supervenes through oaaeon» oonaotidida
Some believe the recovery occur» by n aimj>le deposit of calcareoia add
but this hypothesis is not supported by any histological evidence, anl *
not in harmony with the plieuomena of physiological ossitication.
LB9I0X8 or CARTILAOB.
CHAPTER II.
LESION'S OF CARTILAGB.
ÎAUTiLAeism^s tÎMue is a living tissue capable «f undergoinj; a serlc*
firiutary n)t«nitions. lit the a<lulc, in the normal state, it never cmi-
vcseels. Ncvi'rthclcsa. ii is siucepdMe of experiencing lesions of
ilktioii (HOC p. ô.*>), besides lesions of nutrition which affect the cella
F the intcrcdlulnr euhstAnc«.
. VmitniM vf nutn'tifii which affect the colls of the cftrtitniic arc : —
». K&tty ile;;L>iiernti(>n, which should not be confounded with the fatty
&1iniii<in conatautiv met with in the cartilnf;e« of ndidl».
TliLi fitty ilegeriemtiim caiwus the dentli of the oclhilar element* of
eanilaiie, ho tliat in a ciu'tiliige whore it is present, there in K«en,
id of tlie capitule and cell, .«mull collections of I'atly grauitlea. The
llcrmediate fundamenlal flubiitiince U mfteued, often orncked. This
ilioD is pritn&rv ; it docii not belong to intiaruinatiou, wliich iu car-
tge ia characterized by an oppodte phenomenon, tho di^appc avance of
• lu contained in the cells.
!>. InGttnttioD of iiratcM, which bc;;ins in tho cells of tho cartila^, has
i ■lrea<iy mentioned, page 52, and will be folly explainccl under gout.
Luiou of nutrition which affect the fuiidamenlal substance are : — •
t. Hoooid degeneration occurs phyiiiotti^ically in the co-tud earlilnges
' p. a), and may occasionally occur in other oarlilagea ; il ia usually
IlKompaoied by a iiegmentatîon of the fundamental substance.
4. Calcareous infiltration, which U the reverse of infiltration of urates,
s always in the capsules of the cartilage, and extends into the funda-
bial substance, never inrading llie cells.
f. lafiltratioD of uiates into the fundamental substance ; it consists
I the fonnation of crystalline needles of urate of soda.
Iauok» from irritathn of the cartilage are expliûncd by the modifi.
ons which occur at the same time in the cellri, in the c»|i:iii1e.^, and in
:csniln;^n<>us substance. In most ciktrs, aà the cells within the cap-
nlccare divided, they generate around them new cartilaginous capsules;
I it abo happens at timeii that the celk which reauU m>m the oivision
" llie old cell» have lost the properly of forming nevf capsules, and then
ey renuin in tlic state of embryonic cells. This Ian phenomenon ia
en in cases where the irritation is very intense, or when it Is associated
Iriih calcareous inliltraiion. 'Die embryonic cells which result from this
nliferatioQ remain as such, or they become the point of ori^u of an
Bi-uus or fibrous new formation.
Them lesions arc essentially similar to those occurring in cartilage in,
proximity of points of ossification.
[ Tdc phenomena resulting from this process vary a little, ace
IS
236
LBStOKS OF OARTILAUB.
the car(jlag«a «ffectet]. In the diarthroilial articulations the cartil^H
arc free at the articular eurfacc, and «re not there vovcrcl hy a v^Ê
chondrittm ; there is then ïrcn upon thi« tturrani a M'rivti of alteniti^H
which will )ji' (le«enbed under acut« and ehronic arthritis. ^m
Whvii the eartiliigei aro covorvd hy a fihroits nerohrane, as tbeaS^
Ia;;ei« of thv lar^'nx, the oostal cartilages, and the inUin-ertehra] ^l^L
the ocIIh of the cartilage multiply, and ai« surrounded nUa^-n hy tt^M
dnry capsules, giviug rise to the formation of new luasiicfi of canU^H
It then almost constantJj iiapi>enii that the irritation lermtnates in a <^M
OHsîfication. This ia noticed parlicularl^v in the ihvroid cartita^^B
vnung {wrBona auffering for several years with phthisis : the oâsifio^^
IS liere caused by a proecsa similar to that of physiolo;;ical ossificalil^l
A sli;;ht continuous irritation of cartilage always tenuinalcd in 0flN^|
now formations. The facility with which the ossification of prolifenl^l
cartila}*e occurs explains why, in fractures of the costal oarùtant^l
callus is freipiuntly entirely osseous. It lias been previously stntt^^H
ill fnictures of tlio costal earûlages, the îrrilntion stipi'rveTiiii); at tbM^|
of the fragmenitt occasions iuBaiumntory chanj^s. Tlit^ fuixlntuental afl
etance is infiltrated by caloareous mIIa; the primary capsules are graifl
enlarged and communicate with one auotlier; the cetU become lh^|
the interior of these cavities; the formation of marron and of ^^M
takes place in a physiological maonor. The fonnatiou of osseous tii^|
in fractures of cartilage is truly a singular occnrreuco, for» mbpH
chondrial rosections, made by M. I'eyraud, always gave him cnrtil^|
nous regenerations. Suppuration of the wound which extends into ^|
resection does not prevent tlie regeneration of the cartilage which tlH
place from the preserved perichondrium, the tegeneratinn contribulin^l
form the wall of the abscesa. Therefore tiuppuratioti does not prmnt
the new formation of cartilaginous tissue any more than it does the fo»
maiion of osseous callus id a comjMund fi-actttre.
There are tumors developed from pre-existing cartilago which ui
comj>o8ed of cartilaginous lissue. By their slow devolopmont aod theii
animportance they arc entirely separated from chonaromata proper
Theeo cartiia'^inous fonoations arc named occhondroscs. and nre foun
most freipiently in arthritis, under uldeh they will be described.
XORHAL UtBTOLOGY OF THE ABTICCLATtaN'S.
227
CHAPTER III.
PATDOLOCICAI, ASATOMY OF THK ARTICULATIOXS.
Sect. I.—Hormal Hitlology of the ArtlonlKtioni.
PntvioutS ta be^nniiig Ibc nnatoimcal study of articular alTections it
exppilÎGUt to Kire, in a eoiicW manner, the structure of tlie most
Drtant parts which enter into the composition of joints in a normal
tie. Tbo cavities of the (litirthrodini a nictitations arc limitoii by the
faces of the curtilages and the synovial membrane. The elements of ^
be 'liarthrodlnl cartila^^cs havt' an unvarioil arrangement. When a
svrnto «ectioii of tiicst carlilnges is made, there is seeii a nnmhcr of
Friin[a>sH layers in n-jmlar onler. At the free «urfacc the cap^iulcs
' flat uvi lentieular ; beneath these the capsuti^s are roim<l, containing
I «ily fine coll like the preceding ; deeper the capsules are len;'lhe«e<l jier-
1 fmficularly to the surface, and contain two, three, or a greater number
*f Baofindary capsnloa placed one behind the other. The enlarged pri.
■arr capsules form linear series which are continued into the deepest
liTtrs, where there is an Infiltration of calcareous salts, uniting the
hjnfine eartita^e with the o«»cous tissue. Ail the eclU contained in the
ales at the surface and in the middle layer inclose granule» and even
^èôp* of fat. 'ilie caloiGeil layer i» boimded on the cartilage side hy a
■uoi» line ; on Uie bone side are hollows and prominences, in which fit
ppilbry p elongation s from the extremity of ihe bone. In the centre of
tMh of these osaeouH ;>a]iâllie there exists a medullary and vascular cavity
B Gommunicaiion with the medullary and vaacnlar tissue of the spongy
nbetance of the bone. If, therefore, the plasma of the vessels goes to
the hyaline cartilage, it must pass through the osseous layer and the layer
j tf calctBed cartilage. Yet these last layers do not contain canals, and do
|a«tappear perméable ; so that tin- nutritive miiterial reaches the cartilage
fin son» otlicr way. Very probably the tintriment comes from the fluid
«lûch hatlies the articular auifacea, and widcli 'a exuded from the vessels
of the «ynovial ntembratie.
TV «rnovial membrane presents for consideration a plane stirfaoo and
a Tilk)u« «iirfacc. 1'he plane Hurface is composed of layers of fibrous
tiMDe intenuiugled iriih numerous elastic fibres, in continuity with the
I ptmrticular connective tissue, and lined with a single layer of flat epi-
ft thelial cells, resembling those on the large serous memliiranes. The villous ,
Isarfiiceâ itamed aynonal fringes, are especially seen at the points where
^raic membrane fonus folds in order to pass from one surface to another.
Bïboir Uaae is constituted by two supporting layers of the smnviftl
^Btembraue, rescmblin;; tbo peritoneum where it forms tt"
Between these two layers there are found loose coiineellw
liposc cvllsi and nunwroiu bloodwsdeU. All of i.
228
PATHOLOaiOAL AKATOHY OF THS ARTtOOLATtOMB.
oT their tliinne^a ami transparency, my be exaoiined by cuttius'
synovial fringe from iis l>asc. If the vessels are a little c<onfieBtcil*
large sise of the arteries ami veins is noticeable. The capilUriwi
ft v»ry donet- pk-xua at the free extremity of the synovial fnngi.-a.
From tlu-se cxtreroitics proceed bodies of various sbapea; some
fiUfomi prolongations made up of sn axis of connectîvo tissue, aix'
«red by two, tliree,Dr morolAyore of epithelial cell». 'I'he latter »:
ridftil nith prolongftlioiw wtiich join llieni together, ami contain rm
the ni«Dibmti« of which proocnts a double contour. This epii)'.li<iiai
resembles very closely that »een upon the oboroiil [iloxus. At tim
prolongations have the f\A]ie of a citth, covered witli ft similar I»;,
epitbelium; tlieir axis formed of connective tissue frcjuently cont-ui»*
cartilage cajisules. VcsacU are never found in the prolongations. A)
their hnse, «bich is generally wide and continuous with tlie synorii
fringe, there nn.- seen one or more vascular branches.
The phyBiolo;!ica! function of the synovial lrinj;es Is very imports»
The cells nhicli cover the prulun^ations are the true organs (or sic
the synovial Huid, and the Ur^v and numerous vessels found n
fringes carry the material for this secretion.
The synovial nieinbntnc does not cover the surface of the diarthr
cartjlngea at the pointJi where the cnrtil»<^os slide upon one anotlier.
The synovial fluid is a very omiplex li<|iiid containinj^ albuntou, imieîil'
in largo proportion, and a futn]] quantity of fat, which, under the tuicro'
eoope, appears as gmnules and âuiall drops. Kpithcliat cells xikI celltf
resenjbliD;^ white blood corpuscles are also found.
Tlie varieties of arthritis are cii-i*ff arfhritit, chrxmii' arlhn'tia, «fW»-
lou» artliritis or white swelling, and youfg arfÀrtWs.
Sect II.— Acute Arthritis.
A. — SiMPLii Aci'TK Abthritis axi) RiiEi'UATic AiïTiiBins. — Trail,
malic arthrilia in man very probably presenbi the same leations hiato-
iogically as rheumatic arthritis. The anatomical lesions of the latter do
not difl'er from jtraumatic arthritis artifteially provoked in the higher
animals.
^VlIen an inflamed articulation is opened, there Sows from it a viscid
ropy fluid, the amount and appearance of which vary according to the
decree and duration of the inHammntion. In eomc eases, this fluid re-
sembles the normal synovial fluid, hut is more abundant ; like synovia, it
coagulates by tlie addition of acetic acid ; it contains a laigc number of
cellular elements, some of which resemble pus cells, other* much laT^cr,
are round, and contain one or more vesicular nuclvi. In llio protoptasn
of these cells fatty granules are generally seen, which aometimes are very
abundant, and the cell then has the ajipearance of a granular body (cor«
puscle of GluRc). The synovia is more or less cloudy, depending
upon t)ic number of cellular elements and the degree of ibeir fatty
change.
There are usually seen in the liquid mucous flukes similar to sputa.
These flakes are transparent or slightly opaque, and present all tlieint«r
ACUTE ARTHBITia.
2âd
ilegnM between miicnua nn<1 )>iirulcnt apitU. At timiM> ihvte
bn t (rrester couHistonoo. xiil ulit-ii cvumitK^il uith iii<.< iiiJcn»-
M founii to coiitAÎii till," C'-Iluliir i'li;mi.'iit^ iitmvc munti'im'"!, nfjU-
tim omI) other by j-ranulct or titiri!.i bittUud in tiie svnovia, 1 he
»pfioarftiM« of the tlakeiiilej>eiidfiu))oii the iuiiub«r of cells ttiej'
In «orae ciuen or acut« rLieuinatmiQ, where the inflanimaiion has
Beveral anictilaiionii, or onlj' a t)iii;;1e one, itio articutar cavity
illcl <rilli a creamy [>U4 analogoiLi to tliat of an &cut« abscuss.
,lfe HTuonal meioliraoo is injeciml, llio capilUrics an; ililaleil into
ir or apiniUe-rorma. The cella of the synovial rriti.îes prvHonl very
ei«n9 nf multiplication, Iboir nuclei become vehicular and show
or more bri^^it uucleolt. The nuclei are seen in the process of
ingtaud s^nie celb jmjscsi iw lujuiym tvii or twelve aepaniie nuclei.
Fig. 13tt.
Fig. 131.
• ■■•■IvdiB It* mbJiiI tnM (rim
||l*unnlUUa M Ika «us of • ii-t. Uii
L fnititntf la «rdtrM MHa > nii-
lUt* ■■■uuutia». a. Mstbtr-etllt.
Hnr<lv> nita. e. CatU whtcb d«
^ iruir f.4. Ph* «m^bmIm. v- (-'•■I'
I Iva itiuM. III()i |Kt»«.
Is aeulff trllciil»r rh'uti>jiU>m- d- I-krKM^all- /,A,
lïrïDnU' libj^lic» ffn'i<n*n]4-k of f*Ingv) r^tqLting from
ibfl fully ilvufiurraUu II 'if t'rlU. r^ Urap'of frao ^i-
a, <'<}rpEiBErLQ rv>aml>Lia^ ]m« itr l^mph- r- FtbrladH
nlli'iili^iii. Miuiigllr^ï «*U(, fall)* grtiBlvi, asd I«t
énipa. Hint! iiuwot.
In > case of «cnlc arùcular rheumatitiai exarotned twcnty-four hours
sfirr death, the ejHihelia) celU of ilie i<yiiovial fringeH were much more
Iniuparcnt, tlieir nuclei were 3t>en without the aid of any reaj^ent, and
ïLiTTOunilin^ them were some fat granules or small drops of mucin. The
«it«]ie of these cell» in man ia always spherical ; they may aClain a large
!; their nuclei are vesicular, their nucleoli round and refracting, giving
the shape and dinicasions previously aacribcd to tbo cella of
r.
Generally, in tbi^ form of artlirittt», the cotiEieclire and adipose tissues
not notably changed ; but, if the inilnmnuition hti» ooaUniK") ■• '■■'."
ne. thv lesidUM of itiHamed eoniti^tive tisHue arc tlii»-
Tlie synovia] wembrwie 14 DOt tlic only ix '>
220
LBSIOKS OF D0SB8.
KrftcturM duting tlic courac of this digcMe arc not j*enorii11y unitM;
nevertliolesa, Butbor^ Uaro r«port«i1 CMes in wliidi tlivrc hax Won fonun-
tion of cnlluii: but it i* only wlien ihe diseuo i» in prooe** of recovery.
We have Dot yet been able to give any sntinfactory explaniition of the
decalcîlîcatiou or absorjttion of ilie OHiteoi» ti««ue. Die forroatîou of »n
aci'l capable of ilissolviu;^ tbe lime »alU haa been !iuH|jecleilf but tbe acid .
is not known. Weber ha» foimil free aciil in llie «rii>e of persons suffer- \
in^ wich tbU disease. KinJfleiach believes that the calcareous salts or«
ili#sulvc<l by tlio action of an excess of carbonic acid. The renons con-
gestion of tlio marron that occurs during the first stage occasions a tttaaU.
The blood, charged with carbonic acid, is in contact with tho omeoiiftj
Irnbeculie and cuiis«s a solution of tlie calcareous suite. This, however^ 1
Ï8 only an in^vntou« theory.
Senifi- '•ttf.ufmroti», also described as tetùle otteomaiada, is a rarefac-
tion of the oDiteous tisRua by an enliirgement of tlie nivdullary spaces.
In this (lijteaiie the friability of the bones i« owing itimply to tbeir rare-
faction ; there is not s softening of the bones by décalcification aa in true
odtcomatacia. Accompanying tho rarefaction there are troporCant modi-
fications of the marrow, presenting some analogy to those occurrin;; in
trutt osteomalacia. Tbere ia also, to a {çrealer or less extent, disuppear- J
anco of the adijxise cells, and a formation of cells similar to thoiic oCj
cmhryoiinl nian-ow. Newly.formed young connective tissue is at time*]
round in the mt-dullary spaces.
Tbe boncx most fr«(|U0Dtly attacked with this disease arc tlie rib<t and
verKbrw. Tlic vertebral colurao bccomos curved, the ribs are fractured
by the slightest «(Tort, and, what it wry iiin;;tiliir, they are aflerwanta
firmly united by tho formation of a cartilaginous callus, which aftcrwanUJ
is ossified. '
Fall;/ otteopùrofi» is a rarefaction of the osseous tissue which is seen
especially in tho epiphyses of long bones or in short bones. It is char-
«ctcrixed by an abundant formation of adipose cells in th« meiluUary
bpnaces and in the Haversian canals Tho osseous trabcculicof theitpon)çy
^usue nt first become very thin, and finally disappear. Tlie bone is re-l
duced t") a parrhnu'iu-likc shell, pierced by numerous vascular openinea.
litis disease is met with in chtouic afi'ections of the articulations with
immovable joints. I
Sect. VIII.-Kachitii. 1
Rachitis is a disease of tho osseous liîwne nociirring only during the
developineiil of the bone. Cbaracteriited hiit'>lii.:i(.'any by diâturbanee^ij
of nutrition and of development of the tissues which contribute to oesi*'
Acation: these tissues are the epiphyseal cartilage, the periostenm, and
the marrow. It is a very common afiection, esjjecially in largo cities,
and principally among the poor.
Hurins the first sta^re of this disease there is no deformity; in order
to a!>eertnin how frequently it occurs, tbe bones of every dead child should
bt" examined.
Three periods of tbîa disease are recogniacd : first, one lu which the
J
RAcnrTis.
»
221
awl
rig. laa.
^K fori!
h
1>ones are not (Icformcd ; Moond, one in wliicli defnnniticA exint ;
fiitiilly.a third, in which thg diM-as«d booca are connoliilawd.
If the tii»u>lo^eal logions <nily arc considered, there is not nny very
mftrkni] diffcronce hclwiiin ttio tint and second periods. The sane pro-
ceM continues, «xtvndH fiirlh«r into the
hour, and di'lormiw* modiricatlon*, ap-
|>reirinhl<' ujioii Ute living siilijcct.
A'annal "«vVRivrr/"n oï cartils}'!' oocim
iritli great re^ilaricy. (î>eop. 2H.) 'Hie
cella of enibryonio cartilage swell, vthilo
Uic c»)i8ule Aiirrouiidi»;; them becomes
spherical : ihe cells afterwanU diride and
nra inclosed within secondary capsules
in such a manner tliat each primary cap-
solo contain» from four to ten secondary
capsules. The primary cnlarj^ed cap-
■nica aro olonj^ti-d hy mutual prossnrc.
M an to convvT'e tovranU the point of
osflifîcation. The layer in itbioh these
ehangoit Ukoa jJaoo is bounded by two
pantliel linea, one to on« and a half tnilli-
metre» apart; tliin layer is apparent to
the unaided eye by itA traoHtiiceiicy an<l
bluish ciilor, and is fniind between the
formed Oâseotia and cartiU^fiitous tissues,
Thia layerhaa been badl v named by Broca
chondritidf which would indicate that it
eonsista of a tissue oulv havîn^ the ap-
pearance of cartil^^, while it i» in reality
formed of prolifcratinj; cartila^.
When rnchitis begins, there are seen
tlii.i layer nwKliGcatiomt which are
tinuol during the duration of tlie
affection. Witli the unaided eye it i.t
seen to be increased in thickneu txi tiie
extent of several centimetres ; instead of
being regular, it is upon both ûdea very
ïiregalsr. Sometimes very long pwrfon-
gations c.\iend into the lone. frei|uently
so thin that they are separated and form
siDall island*. The layer is also fur-
rowed by medullary cauls, «ontainîng
dilatisl bloodvcsMls.
A. roicro«copîc examination of this
layer «hows a striking analoj^ to that
presented by ttie physiolojrical proliferaling layer of cartilage. In ihe
dUeiuctl layer, however, the primary capsules are much more distended
and contain a greater number of secondary capsules which are larger
than Id the normal. lieneath this layer au{l continuous with it, there
exists a rc<i vascular an<l spongy ussue resembling a bone that has been
V*rtU*l ••«lion tnta ligt «r ault;rli(
Tnnlaovf lti> dlapbr>l> ••> ■ «UluHa,
r»n armul atlf. a, ilmtd ■■I»tuM
of ih> «ttlUt»^ i, tri bou. t. Hfwly-
lottap4 bn»* e*LU la jvrofll*. mart or t«Aa
luil-rdJ^il La lAtFfRallalar kali*lann^ if.
M«d(t1Uf7 fABkl tn pPMHi*' Afnaatlan.
«lib itu^li and aaiiUtrf **1U. t./.
0aa«f*n4 0D lb«lrbrv«d tMjittt- g. €a^
ttUg* apan'f* ■rnBiiKl In nwi. t%tiXi
vllh^miLkHMLI'lUdiw. fJTBlKr.)
232
ïlBÏÔSBOfBONl
pnrtiutly sofl«nci] by an iti'M. Tii onler to umlorstaïKl the ei^iilîcimcc oT
thiii layer, it is iK-cuitsury to recall in ft fvvr wonla Uic tissue vxisUu;; Itcra
ill II ]>hyeiulo<!:iciil comlition.
In t)ic i>liyAi(ilo^ctil ittntc, hencath the proHfcrtttinfç cartilage, in foind
ft tliiii layor, forined of areolar tissue, tlie trabeuul» of whtcli are wtn-
posed of the fundamental ïiuliHtftiice of cartilage intlltrated with calcareooaJ
saltii ; the alveoli containing erobryooal marrow and vesaelii. Iteneathl
this the tnie osseous tissue is formed. To this layer is given the name
of ossiform, bone- forming.
In rachitis vre do not think with Broca, that it is a simple incrvaso of
tthin layers of bone, but thorv is formed upon its surface a peculiar titwio,j
fio which Gatfrin gave tiio name of »fntH,f»<l. Tiiis tissue, which oftelt^
extends from tlie niar;^n of the citrlila^ to the diuphysis, frci|UOnUy
invading both, \« rvd, formed of alveoli of very irregular itinK-iuioiis i
it appears to eontain much hloml, iw ooiksistvnve is that of a tin« spong6|'|
or botter, tliat of the osseouH tissue of the e]>iphysiH, which ha« boeiH
ÏDComplotely «oftcncd 1>y an acid. The lonndary Wtween tliis «itongoiiU
tissue and the cartilage \», very diiltnct. At times small inlands of hya-
line carlilaipe are found in its interior. On the side of the old Itone, it
is oflvn impossible to indicate exactly where it ceases.
At the periosteal surface, the spongoid layer, especially at the margin
of the diaphyais, is mingled with a tissue farmea of osseous ]am«)MBji
separated ^m each oUicr by a soft tissue, of which we will presontlj^
speak.
A microscoiHC examination of frueli soctione of tho trahccuttc of the
spongoid tissue shows angular corpuscles arranged irregularly in a gran,
ular non-laminated sulutanoe. Tliese eorpuscle.<, larger than Imne cor-
puscles, do not present any anastomosing canaliculi at their margins.
To understand tho importance of the tissue which form these trabeculie,
their formation from hyaline cartilage must be traced. I'liere is then
seen starting from tliis cartilage a calcareous intiltration of tho segmented
Lfundamental substance which separates tho large corpascles: this caU
EjCarcous infiUruliou extends to the secondarjy capsule (which never is the
BBOse in physiological ossification); it results in the whole cartilaginous
>iissu« being invaded by calcareous granules, which remain distinct,
that is, separated by cartilaginous tissue which proscrvcv îtx flexibility.
The secondary capsules are not dissolved — an essential diflcrcnce from
physiological ossification. At the same time that this calcnreons incrust-
ation occurs, the vascular canals of the cartilage are enlarged by the
disAolviug the oaluiticd tLssne which iiurrnuiids them, uniting with each
oitier and opening into the medullary space» of the old bone. Ky llieir
union they form a cavernous system to be later studied.
The a|K}ngoid tissue is, therefore, formed of Irabeeulie repreaenting
Lportions of cartilaginous tissue intiltrated with calcareous salts. These
^rabeculie, when young, permit the cartilage with its capsules to be dis-J
tinguisbed — the margins of the latier, however, ai-e difficult to recognise^
owuig to the calcareous incrusmtion. In older trabeculte, the capsulea
are entirely hidden, but in order to make them visible, it suffices to dis>
solve the calcareous sall« wiih hydroehloric or chromic acid. It may
happen that these reagents do not reveal the presence of cartilaginot
HACHITTS.
223
IcA, but (iijtclo«c onl; atigulitr corpuDcl«!i nmnged in a ruiiilftmiiital
suUuiiice which seumit bomoj^eneous After liic tiolution of Uic calcareoiu
salu. Never in th«fle trabeculw nn be recogiiineil osiiteouti Iftinelln,
or a 1aminate<l annearaiice resembling tlut aeen in oeeeoua Iralieciilie
tmatnl l)v aciits. The sjiacefi which these trabecnlie of the apongoi'l ti^Hue
bonnJ oontiouc to enlarge if the procese peniste, which is the opposite
to normal osi^licAtioD, where the medultarv emces arc narrowed by new
oesooufl Uycr8. Tho marrow contained m tneae epaces is nt first soft,
red, aiul by microscopic examination is seen to be composed of round or
angular cells, some of nhicb nrv pigmented, ant) to cootuin nuuicroiia
blood car]>iisclfH. Itut iii the older medullary spaces, the contents are
more consistent, the crlU become «tellate, and separated by a slightly
Sbiillaled fuixlninontil suhittitiico.
Tbia attempt at fibrous or^anixaUon of the marrow, takes place not
only in tlie medullary cavities formed duriiij; the evolution of rachitis,
in tlie old marrow contained in the Hj)on^ tissue, in the llavenuan
ànaU. in the central canal and in the fiiiKperiosteal marrow.
In liie me^lollary canal, the peripheral layers of the marrow are those
which arc th« moet modified. While tlie central portiune of the marrow
arc red and fluid, composed of embryonic marrow, the peripheral portioits
arc orgiinixed into a kind of younj; connective timue, nhicb has the
nppenrnnce of a tnednllary membrane. It a posriblc tliat it W114 this
condition which leil the old anatumisttt to admit the existenco of a me-
dullary memhraue.
Tlio Uyi^r of tnarrav beneath th<> perioat^uro, which has be«» men.
tioned severs! times, is changed at the commencement of the disease into
a eofi connective tissue ; later it becomes more solid, adheres to the under
surface of th« poriostoum and to the bone, so that its separation from the
bone is much more difficult than is customary in youn^ persons. UTiia
con m-ciivc- tissue layer, truly sab-periosleal, at times acquires u consider-
nlilc thickness. It undergoes a very interesting moilifi cation, the natunJ
of Tihich is not determined, consisting in the appeanincc of waving refract-
ing traWculiu, anastomosing one with ttiu other, wliich couie from a tran»-
formatiou of intercellular substftiice of tlie young oounvctive tissue.
These traheculK are the analogues of Sharpey's fibre», which arc «eo
in the ossification of tlic seomdnrv bono^ of th<- cranium : ilicvdilTer IVom
I however by conUiining celli* in their interior. The tissue nhicli forma
trabeculae is considereti by \' irchow as i-epreseniing the firàt phase
oT wflificatiou, and is named by him osteoid. Sections of tliis tissue made
|>erpondicuIar to the axis of the hone, colored by carmine and treated
with acetic acid, show stellate bodies, with an anastomosing appearance,
"^rougbout the whole thickness of the preparation, both in the refracting
"ftbcculic Hiul in those parts which look like ordinary connective tissue.
Fn the rcfnictlng trabcculas the stellate bodies seem larger and have a
more distinct conioiir.
Wb^n rachitis of a bone is very tnuch adx'anccd, there is found beneath
the osteoid tissm- thin lamelliv funning coniplclc cylinders around the
bone, and separau'd fnun each ether by a soft and vascular contiective
tissue, 'riiesc lamellic which are foniit-d of true ossvoil* tissue, are
spougj-, and ilie cavities which they contuin are filled with young con-
I
224
ctivc .tiesao. Tbîe s'lni^ular fonn of tissue is a result of a fibrous
ïomiAtion of the old marrow, with partial absorption of the prt-viouBlj
ronn«d bonil.
As the diMAM progresses tlic amrrow tii tlio Havvrsiftn citDftIs under-
goca fibrous trniHormatioii in tlic whole thickiie» of the «ontpnct pftrt of
^tb« diapbjr^i-'t, at th« same time the omooos trabeculic are alûorbed, wai
>ie bone celU become free. A bono whiah has uiulergoDe such ehangt
loMs itjt ri»iiatiii2 power, ma; become curved by the weight of the body,
or sufier incomplete or complete fracture.
In a fracture, the callua la entirely composed of osteoid tissue, anal-
ogous to tliat irhicb is formed under the poriostcuni. The callus of
osteoid tissue is ;;enerally very large. It is not neciMsary to insist upon
th« imoortatiee of ttiis accidental new formation, rosomliling exactly tbali
which IS formed under the penoiitcum in the natural couree of tliis dis-i
We hare sctn old cnllus in ntchitii<. but produced wlivii the disc
r«u pro^resHing, and the uuiou was effected by true osteoid tissue, rati
not formed from osseous tissue.
It is not yet knonn what ohan|{e« are produced in bones affected with
rachitis when the recovery auporveDes through oaaeons eonaolidation,
^ome believe the recovery occurs by a simple de|Ki«it of calcareous salts;.
But this liypotheais ia not supported by any hiaCOlogical evidence, awl isj
not in harmony with the phenomena of physiological ossificntioD.
LRSIOXS OF OARTILAâB.
225
^
^
I
CHAPTER II.
LESIONS OF CAKTILAGE.
CAKT[t.«<)i.v<trs tisane in a living tisane cap&ble of utMler^oinj; a aeriea
of primarj- nlternùons, In Ui« adalt, in the nonnal staU>, it ncvt-r cun-
tains vessels. Xevcrthcless, it is susceptible of L-xperiinicin<; k-sioiis of
irritation (see p. 6ô). bcfltil«s lesions ot nutrition wbicli aft'cct tbc colls
or tlie intcrcL'llular substance.
Lftiotig >if nutriii-JH wlitch affect the cells of the cnrUlagc are : —
n. Kutty (lugeiH'nitioQ, which shouM not be confoumleil with the fatty
■nriltratioH coustautl; met nitb in t)i« cartilages of «dutts.
Thi» fatty degeneraiion cause.* tlie deatti of the cellular elements of
the csrlila;;e, »o that in a cartilage vrlicre it in jire^ciit, there is seen,
indiead of die capaule and cell, iKmal) collections of fatty grannie». The
interoieiliale famlafoental substance is softened, often cracked. Tbia
alteration is primary ; it does not belong to inflammation , wbich in car
tila^G is characterbted by an opposite pbenomenon, the disappearance of
the fat contained In the cells.
A. Infiltration of urate», which begins in tlic cells of tlic cartilage, has
been already inentiimed, page .V2, and will be fully explained under gout.
Lesion» of nutrition which affect the fundamental aubittanco are :^
c. Mucoi<l degeneration occur» physiologically in the coalal cartilagea
(see p. 44), and may occasionally occur in other cartilages ; it ia usually
accompanied by a segmentation of the fumUmental auhsLincc,
d. Calcareous infiltration, wIiil-Ii is the reverse of iniiltnition of urates,
begins always in tlic capsules of the cartilage, and extends into the funda-
mental substance, never invading the cells.
t. Infiltration of urates into tbc fundnmuuttd substance; it consista
in the formation of crystalline needles of urate of soda.
Lttiotif front irritatviH of the cartilage are e3(plaine<I by the modifi-
cations which occur at the »ame time in thu cells, in the capsules, and in
the cartitannous substance. lu mo*l i!a.<«e.'<, as the cells within the cap-
sules are divided, they generate arouwl them new cartilaginous cansules ;
but it also hanpens at times tliat the celU which result from the division
of the old cells have lost the properly of forming new cajisules, and then
they remain in tbc state of embryonic cella. This last phenomenon is
sceu in casus where the irritation is very intense, or when it is associated
with calcareous inRltration. The embryonic cells which result from this
proliferation remain as such, or they become tlie point of origin of an
osseous or fihnms new formation.
These lesions arc essentially similar to (hose occurring in cartilage in
the jiroximity of pointa of ossification.
The ])henomena resulting from this process vary a little, according to
226
the cartilaKC3 affected. In the diarthrodial articalatîons tb« cartîlazes
arc frcf at tht- articular eiirfacc, and an; not there covorwl by a peri-
chondrium : thcro is then Mt'n upon this eurlaco a scries of altérations,
which will he il«scribcd under auuttf and chronic artliritia.
'VVIion the cartitngcs nru covered hy a filirous membrane, a« llie carti-
lage« of the larynx, the coital cartilages, and tlie intervertebral disk»,
the cells of ttie cartilage mullijily, and «re surrounded alwaya by »eci>i»-
dary capaaica, giving rise to the formntion of neir inasnoa of cartila;^.
It then almoat constantly h&pneua that the irritation terminates in a true
Oif^iBcatton. This i§ noticed particularly in the thvroid cartilage of
voun^ persons eufleriug for several year» with phtliisis ; tlie ossiHcation
IS hero caused hy a process nmilar to that of physiolor^ical ossification.
A slight CO DÙnuous irritation of cartilage ainays terminates in OSWOHB
new fonnations. The facility with wliich the os«iticiition of pndifvratiii;
C-nrtila;^ oceura explains why, in fractures of the ooetal cartilages, the
ealhia is frei|ucntly entirely osseous. It has been previously stnttxl tliat,
in fractures of the costal cartilage*, the irrilution supervening at the end»
of the fragments occa.iion» iutlamniatory changeit. The fundamental sul>-
slance ia inhltrated by calcareous aalta ; the {irlnmry capHulcn are greatly
enlarged and conimuuicate witli one another; the celU become free in
the intonor of these cavities; the formation of marrow and of hone
takes place in a pbyeiological manner. Ttic formation of osaeona tissue
in fraeturcs of cartilage is tndy a singular occurrence, for, subneri-
chondrial resections, made hy >l. I'eyraud, always gave bim cnrti1agi>
nous regenerations, iiuppuration of the wound which extends into the
resection does not ])revent the regeneration of the cartilage which takes
place from the pi-eserved perichondriutn, the regeneration contribnting to
lom) the wall of the abscess. Tlierefore suppuration does not prevent
the new formation of cartilaginous tissue any more than it does the for-
mation of osseous callus in a compound fracture.
There arc tumors developed from pre-existing cartilage which are
composed of cartila^noas tissue. By their slow develojiment and llioir
unimportance they are entirely separated from cbondroniuta projicr.
These cartilaginous funiiations arc named eccliondro«CB, iiml arc found
must fre<iucntly in arthritis, under nliicb they will he described.
HOBMAL III8T0LOOT Or THB ARTIOULATIOXS.
227
CHAPTEK III.
I
PATHOLOGICAL ANATOMY OF TIIK ARTICULATIONS.
BMt I.— Honnat Histology of the Articnlatioiu.
Prrtioo» to beginning tlic imtttotnical study a{ articular nfToctïoQS H
is cxiicilicnt to prt^, in • coiiuisc maniwr, tlic «tnicttiro of th« most
imjiortanl ]iart«i which enter into the composition of joint* in n normal
slat*. 'Hii- cavitie? of the fliarthroiiiat articulations are limite<l by the
surfaces of the cartilagca and the synovial membrane. The elements of
the (liarthrodial cartilages have an unvaried arrangement. When a
transverse «ection of these cxrlilnjie.'i is made, there is seen a ntimîier of
superimposed lavers in regular order. At the free surface tiie capsules
are flut and lenticalar : beneath these the capsules are round, containing
only one cell like the proccdin)* ; deeper the capsulea are lcn;;thened per^
pcndicularly to the surface, and contain two, three, or a greater number
of seooDdary cap^uli-x placed one behind the other. The enlarged pri*
mary capeulcs form linear série» nhioi) arc contintted into tlio deepest
layers, where there ia an infiltration of calcareous salts, uniting tlte
hyaline cartilage with the osaeoos tioâue. .\ll the celU contained in the
capsules at the surface and in the middle laver inclose granules and even
drops of fat. The calcified layer is bDun<te(l on the cartilage side by a
sinuous line : on the bone side are hollows and prominences, in which 6t
papillary prolongations from the extremity of the bone. In the centre of
each of these omvous papillic there exists a medullary and vascularcarity
in communication with the medullary And vMcnIar ^Mue of tho spongy
siiWlJtncv of the bone. If, therefore, the plasma of the vcwels jçoes to
the hyaline cartilage, it must ])aM throu-;!] the osseous layer ami the layer
of calcified cartilage. Yet these la.« layer* do not contain canals, and' do
not appear permeable ; so that the nutritive material reaches the cartilaj^'
to some otlier way. Very probably the nutriment comes fi-om the tiuîd
which bathed the articular surfaces, and which is exuded from the res^els
of the synovial membrane.
TI»o synovial mcmliranc presents for consideration a plane soiface and
a villous surface. The plane surface is composed of layons of fibrous
tissue intemtinglcd with numerous claetlu fibres, id continidty with the
periarticular connective tissue, and lined with a single layer of flat epi-
thelial celts, rcKembling those on the large «crou» membranes, 'llie villous
surfaces named synovial fringes, are especially seen at tlic points where
tlie memkrnno fonns folds in order to pass from one surface to another.
Their base is constituted hy two supporting layers of the synon&l
membntne, resembling the peritoneum where it form» the meisontery.
Between the*; two byem there are found loose connective tissue, groupa
of adii>03e cells, and numerous bloodvessels. Alt of these, on account
I
I
PATHOLOGICAL ANATOMY OF THB ARTtODLATIONS.
of their thtmiPse an'l Cransparencj, may bi> exnmîn<^i1 hy cutlin;; ihv
synovial frin^^v from its ba&v. If tïiv vessel» are a little uonj^stvtl, the
largi* size of the arteries and veins is noticealik-. The capillarios fonn
a vcrv dfiiee i>1exii« at tlic frov extremity of tliv synovial fringo«.
From thc-M extremities prooecil bodies of varioua abftiwo ; aonte are
filiform prolongatious made up of an axis of conneclive tinawe, and eov-
«red by two, tlirec, or more layers of epithelial celln. The latter are pro-
vided with prolongations which join them toother, and contain nuclei,
tlie membrane of which presents a double contour. This epitlieliuro
Kftemblea very closely that seen upon the choroid plexus. At tiiMS tli«
prolongations have the shape of a elub, covered with a similar layer of
epithelium : their axis formed of connective tissue frequently contains
CBrlila;;c capsules. VtsseU arc never found in the prolongations. At
tbcir Ituse, which is generally wide and eontinuous with the synovial
fringe, there are seen one <ir more vnsculiir hriuiches,
The pbysiohigical function of the synovial fringes i» very important,
'ilie cellrt which cover the prolon^rations are the true organs for secretin;;
the synovial tluid, and (he large and niuuorous vessels found in the
frinj!;es carry the material for this secretion.
'Ilie synovial membrane does not cover the surface of the diarthrodial
cartilages at the (mints where the cnrtilu^cea slide uiion one (mother.
The synovial fluid is a very complex liquid containing albumen, mucin
in Inrge proportion, and a small <piantity of fat, nhicb, under tlic micro-
scope, appcant ns granules and small drops. Kpithelial cclU and cells
roacmbling white hlood corpnitdes arc also found.
The varietiesi of aithriti» are acuti nrlhrifi», c/ir-tnic arlhritit, »tr»if'tt-
hue arthritit or white swelling, and yout'jf artliritii.
Sect II.— AoQte Artluritii.
A. — Simple Acute Aktoritis and Rhei'Matio AitTanm». — Trau-
malic arthritis in man very probably presents the same lesions Imto-
logically as rheumatic arthritis. Tlie anutuniicat lesions of the latter do
not (Ufl'er from Jraumatic arthritis artificially provoked in the higher
animals.
^Yhcn an inflamed articulation is opened, there Hoirs from it a viscid
ropy fluid, the amount and appearance of which vary according to the
degree and duration of the itiflnmmation. In some cases, this fluid re-
sembles the normal synovial fluid, but ia more abundant ; like synovia, it
coagulates by the addition of acetic acid : it contains a targe number of
cellular clcmeuts. some of which resemble pus cells, others much larger,
are round, and contain one or more vesicular nuclei. In the protoplasm
of these cells fatty granules are generally seen, which sometimes are very
abundant, and the cell then has the upjioarance of a granular body (cor-
puscle of Uluge). The synovia is more or lew cloudy, depending
upon the «umber of cellular elements and the degree of their fatty
change.
There are usually seen in the li<[uid mucous flakes similar to sputa.
These flakes are transparent or slightly opai)ue, and present all the int«^
ACOTB ABTBRITIS.
229
^
fnp<l(iit« ilcgroes between mucous ami purolcnt spuu. At timcft Uieae
ltakf« bav« a j^reacor con^iistpncc. anl vrliou examined witli Uie micro-
KA)>v arc fouii<] to contain ttic cellular dem':)nt4 above mentioned, sena-
nti'd from «kIi otitcr by granule or fibriU bathei) in the synovia. Tlic
piirifonn appcirancu of Ibo flakes ilcpcnils upon the number of cclU tlie;
coiitiiin. Ill «onte cum-s of ««uie rhvunaiiadi, whfre tb<i intlaraination has
altackeil several articulauoru, or only a 8i.Q^« on«, tlio articular cavity
i» nUeil with a creamy pii« analuj^oiis to that of an acute ab«K48.
ïhe ayuovial membrane in injected, the capillaries are dilated into
lullar or sjùndle-roriat. The celU of the ay no vial l'rin<^e!i present very
i evKlent signs of miilliplicalion, their nuelei lieome veniciilar and sliow
one or more bri;;bt nucleoli. The nuclei are seen in the procéda of
dividing, and aomo cells pojacs) as many as ton or twelve separate nuclei.
Pig. 130.
V\g. 131.
Cell* nttalard In At »iid°d diilil frnn
fn\mr c*<\tj li4Tlnif ti»»rj opiflfld tanr
* |fr^ik4'utl7 La ordAf ta «aa** t >iir-
ttt laliaiisUlDii. a. Millier'»! !•.
Ivn^Mi^» t^ii*- 1^ r«IN whl^h Alt
■ (lias lb* lulant «llhuDI Ihr •4i]Iili>a
' W*l>r- »,<f. Pu» KirjIllMl». Ji, Cslll
>lDmD* Hnil a^rlb<mi Siiki*« <lt lb* t}-iiuTl«l Abld
Id fill'' jtrtirnl&r rhpnui'Ll^Or it^ Lkff* cxU. /, fr'
enuuUi budift i»F|-iuci«or ainnti rnaliiaii fi«m
U^tf fnli^ di^k'vPPrhtioii of fptU. r. Ii»p> «f fir* tnu
ft. <'nrpg«a)« n*0mhllnir pu«ar l/mpb. f. Klbrlnoa*
nUcaluni, (nUiiiilliiK nil», flttf i;niinl«, sbiI Cat
dtr>p>- llt^h pnwr.
a MM' of acute articular rluMimittism exninîncd twonty-four Wurg
Inftcr death, the epithelial crll« "f the synmial fringe» were much mire
I tmxparent, their wuclci were s.r^Mi willitnit the nid of any rea'jent, aud
eurronndin-^ them were souie f:it ^raimWor small drO|H 01 mucin. Tho
Ishaiie of tbeae cells in mm) » always apherical ; they may attain a large
lake; Iheirnuclei are ve^ticnlar, their nucleoli round and refracting, ^fiving
' theiD the aliape aud dimeiistona previously ascribed to the celU of
I cancer.
Generally, in this form of arthritis, the connective andadipose tissues
I arc not notably changed ; but, if the inflammation has continued a long
I time, the lesions of inflamed uoiiuectivc tissue are then seen.
The sjuovial awmbriuiv ts not the only part of the articulation which
S30
PATHOLOGICAL kSATOMY 07 THK ARTIOtTLATIOSS.
nav be affected in acute arthritis ; even in sIÎKtit attacks, a modification
of the diarthrodial cartila;;e is coiisi&ntt/ seen. For this rcawn, vre
object to the names of svnovitis and st1^raiDeniD|riti8, given by Volkmann.
Wo <lo not think thut in acute inBunimations of the jointa the ajnovial
membrane is the only part uffc-cled.
The le«ioni»aiwiiy)' présent in the cartilngc canrnt of a nutritive trrit*-
lion and n proHtV'raiion of the cartilage cell», whicli is very ri.ia<Iily «ppr»-
cialed, itince Die arrangement of the «ellular elements nod eapuiles in dtar
tlirodial cartilages ia very rejiuUr.
As seen in tranaverse sections, the superficial lenticular canali
which Inclose the cellular elements, nat very diiitinct in the normal state'
(eee p. 2-T), are the first to bo intluenced by the inl1amroa[<ory irritation.
The protoplasm of tliese cells Hwelli', the nuclei increase in sise and
become vesicular. A very diittinct nucleolus apneare; tlie capsules,
which were flat, bccomo spnerical. (Fi;;. 1:12.) By the application of
picnc acid upon fresh pieces, all these changes are rendered v^ry mani-
fest, as i» e.\m the division of the nucleus which involves the scj^ncnta-
lion of the jiroloiilasni. The capitule may at one time contain si-veral
«ells, but soon each cell is inclosed in a secondary capsule, so that the
lenticular capsulée of the surface which, in the phyaiolofçwal statefj
never contain more than a single cellular lams, enveloj) now two or a.
greater number of secondary capsules. Most writers who have remarked
this phenomenon (Kedfem, V. Weber, etc.) in chronic arthritis only,
have taken the secondary capsules for the cells. This mistake may be
avoided if » flolnlinn tjf iodine 19 addivl, which colors thu jiroMploani of
the cells brown itnil giws a lighter color U> the secondary capsules.
Acai* ■ftlentAT ibtaiuitflaiii- Ci.iM; U>wl ^': : r::» tvmnr. (ibt^q* «putting np4f IWotrlV
Um. a ahrid -if ihgcmtillifaluiogil taat, MDUiBing * friaiwrf Mpanli, In vblch tn—tm Miami
This increase of the superficial cellular elementt generally does not
incKnle the whole extent of the inve^tln;^ cnrtila;;», hut i^ seen in dis»em>
iualed spots. The same irre;;ular distribution of the lesion is met with
in the deeper layers, which mny be affected in cases where the arthritis
is intense or of long duration. When these layers arc implicated, the
cartilnse pre*enti» changei* appreciable without the help of the microscope,
consisting of swellings which to the finger are not so finn as norma)
cartilage, and when cut with a knife do not olfer much resisUtnce. Fro-
quently there are seen upon these prominences clefts, or villi presset]
against each other, or even shreds free at one of their extremities and
adhering to the cartilage by the other, several millimetres or even a
ACt'TB ARTUBITtS.
weDtimetre Iwi;;. In some rare cams of acute mono-articnlAr arthritin,
ulceration of tJic cartiln;(c hns Wen sc>cn, not tiimiUr to tliat occurrin;; in
vrlitt« sHL-lling or chronic arthritis, bnt a true- lo« of «ubsMiicc ft8 n rv-
*ult of a ntpiil brc»king down of thv cunila^ Diatrix.
A microscopic cxBminiition of h vvrlical «ocùon from the tumefifid
pATt of tti« cartilage ik-mi>n«lTnt«« a n«w fonnaUon to have invaded tlio
deep U^^erj and even the calcified layers of the cartilage. The ncir-
formed oelU an<l the formation of secondary capi)uleii do not differ froni
those described in the superficial layers. Since the primary camules of
tbo midtlle layers are arran^^cd in a linear maitocr and preasea a^inst
.one another, they are elongated and form rows perpendicular to the
[surface of ihc cartila);«, while ihe lenticular capantcs of the surface
tro filled with sccondury capsules, forming lines wfaicb have a i^roctioa
[parallel to the surface.
The proliferation of the cclU is always accompanied by a segmonta-
ktioD of tJio fundamental 8uh«lAnce between the primary capsules, caii^ng
fatriio jMirallcl to tbo long axi« of the jn-iraary «apaulvx (nee fig. ]'.V2).
'So that in the deep layera tUi^ scgrnvnt lincation \» per[)eiiilicular to llic
surface, while in the superficial layent it iit jiarallcl.
In an advanced s[a)!;e of the disease the striie give rise to cleHa, which
dinde the cartila^'e. as if an incision had been made with a knife. These
[incisions are parallel to the surface in the superlicial layers, and perpen-
dicular in the deep layers. This change in the cartilage may be con-
founded with the villous state of chronic rheumatism, frocn which it
notably diffeiy, as will be later seen.
These clefts which end t)io «cgmentalion of the cartilage may ecpa-
Irate it in shred.'< parallel or ohli<iue to the surface, and may therefore he
' larger than the thickness of the cartilage. Very freipiently these shreds
Unclose proliferating cellular elements. When a true ulceration of the
cartila;i:e supervenes, the fundainc iit.il substance sofiena, untlergoes a kind
of liipie faction, and the proiiteralcd cells become free.
From this description it is seen that in aculo arthritis the diarthrodial
cartilftgcs are affected as well as the synovial membrane; lesions. aro
I produced in the cartilage at the same time as in the synovial membrane.
I Vet the hyperniniia and exudation, which have their origin in the vessels
' of the synovial mcmbnuie, pluy an important role in the inflammatory
I lesions of Uie cartilage. It hn» been shuwn that the superficial cell* of
I tliQ cartilage are the fir^t alfected. This may ho attrihuiod .to the cir-
Icumstance that they are in direct connection with the exuded liijiiicU,
tfrom which thev draw their nutritive material. It has been seen liiat
[tlie nutritive material of cartilage is not derived from the vessels of the
[hone, since tbo calcified layer of the carUlage prevenia it. The cellular
I elements of cartilage have in arthritis an individual aclirity; fop, al-
rthongh all may beiijU.illy surrounilod by tholiijuid, yet all do not eigually
par^cipate in the proliferation. This is very important, because at the
prci^ent time there arc some pathological anatomists, who are inclinuil to
■^aeny anv creaiivv adivity to the cellular elements in inflammation.
B. — K'urLENT Arthritis. — By purulent artbrili» i» luidcrstood, not
nippurative artliriti.s, snch as met with in acute rheumatism, in tj^iunntic
anhrili.s, or in suppurating white swellings, but only iho^e rapid and
232
PATHOLOQICAt ASAtOJIT Ot THE AETICCLATI0S8.
ntmnilunt forniatioiis of pus, su])puriitioiis which aru not lit proportion to
tho ottiLT ill till ininiitory phi'noDicnit. This fona of ar^lintiii la tteoii io
purulent inrMtion, in puorpersl fvvor, in malignant 8ii»ll]wx, glandert[~
etc. The synovîul membrane snd fringes arc iDorc or less injfctis);
Honi«times to the iiiiftidod eje the ftltorntions in the cartiU^e cannot bo
diiittiii;j;itiHlit'<). The pramineut I««on comble in • rory Ur^o quantity of
]>ii.4, »uch nn met witli in an abscess. In tJiese caM9 it is very evident
that we cannot explain the foniiatlon of the ptis celU by a simple pro-
liferation of the epithelium. The procès» indicated by Cohnlteim may
account for it, although it is difficult to conceive liow such a great oiuii-
biT of pus cells can come fi-om tlie blnod, since in purulent arthritiajj
several articulations are aBeci«d at the same time, anu inSammatioiu i ~
the same nature arc prêtent in otlii-r organs.
A(lk>tll>fFoiu piTiiJcni Inftrllni. r. PiiBik'7 «imbI* giltd wHb tit» (vIIl <I. FibiUlargt nurix.
■^ Prtiimrj' dtp^ult ujivucd ii|iou tb« tottat*- A- ^mlJar cB|iiaZ« ■■ Iht prtrvitLEig. In «t^nb f h« fvn
|MliB *r« ftrrftD^vd ku à riiv, Th« np]>flr t*A «Jf« tboin* « porukfDt Uyer opoa ibv iturficv of <h*
rHilllglti
In a few ca^e.t of purulent arthritis, lesion» more or le»8 advnncoil of
t^ie itiarthrodial cartilage are found. In one case of purulent infectioa,i
Ui<^ i-ani I acinous covering had almost entirely difiapjieared, and only %{
Bmsli part of the surface of one of the condyles of the femur was coveredl
by cartilage. The rest of the nriicnlating surface belonging to llio bone
was simply covered by the calcific<i layer.
A caicroscopical oxaminntiou of a vertical section of the remaining
piece of cartilage, plainly shnwed the process of tho disappearance of the
cartilage, and a direct t run s formation of its cellular elements into pits cor-
pusvtes. Tho primury ciipsulv» were elongated, filled with free cells, the
secoiidurr cap«uW being dissolved, aud forming long rows, perpendicular
or ftbli(]ue, to the articular surface.
The mo.st superficial rows opened upon the jturfnce into a purulent
mass, which consisted of elements not differing from those contained in the
elongated rows. These cellular elements had the diameter of pu» cells,
«ere spheroid or angular, and inclosed fat granules, some bad even becoioe
CHRONIC ABTURITIS.
233
granulsr coryuacleii. It «as ver^ evident thai all the pus cclU, fillio;; tlic
articuUr cavity, were not derived from ihp cartilajïcâ, but that « grcM
Dumber of iben had Uieir origin from it, U not lcs£ certain.
BMt ni.— Chronic Aithritis.
A. — HTDBAiiTHKortie. — Authoi^ wbo have studied articular âisenses
bave not ngre»! upon llie place hydmrthroais should «ccti|iy in t)ie na^o-
lojiical list; xonve, as Blandin, Ilonnet, BillroUi. Volkiatiin, place it
aiDon;; the inHaTutnatitiia ; oUien, as I>u{)ii vlreii, Nélaton. among dropsies.
Tilt." difference of opinion seema to be owio^ to the circumstance that
various articular affections are known by the name of hydrarthrosis. In
rcadin;; over the reports of the autoraies, among others those of Dupuy-
trcn, Blandin, Brome, and Bonnet, it is found that there are tn tlio di»-
eased joints lesions which bolou;; to acute or chronic rhcuinatii>n), .fwh
M oongcHtion, thiclivnin^ of the synovinl membrane, hypertrophy of the
fring^-s. and fy«n ulceriilion of the cnrtilu;;'' ; in other caMH, on the con-
trary, tlierc doc* not exist any lejiicm ni'juvciiiMc to the unaided eye —
the »ynorial membrane i» smooth (Dupuytren).
Opportunities to study the Icsiunit in hydrarthrosis seldom occur;
penooB auflcring from tlic diseftso die only from some other intercurrent
aJCection, and at the present time, wo know of no hi«tolo<{ical examination
except of the li^guid obtained by puncture. There are found in this li<|uid
cpitholial celU, dear or conlainiiif; faily i^raniiloe (Voikmann), but these
element» urv met with in normal eynovml fluid, ami their presence doe»
not fumisti anything positive of ttic nnture of tliv disease.
I
B. — CllBOSIC ABTHRtTIS BT CoNTIVTITY OF THE IsPI.AMMATIOS. —
This forra of arthritis is very oommon. The articular cartilaginous
covering U very notably aifected, while the synovial membrane does not
present any appreciable lesion. The diacnse supervenes in llie articula-
tions corresponding to the two extremitiea of a bone attacked with inliam-
mation, or a rapidly growing tumor (sarcoma, carcinoma, etc.). When
an articulation is invaded by a suppurative inQsmmation. as seen in the
««■cond pcriwi of white swellings, and when the corresponding bones are
affected, then the neighboring articulations present Uic lesions to bo
described.
The articulating cnvily does not contain more than tlie normal amount
of fluii). The synovial membrane is generally slightly hyj>enemic; iW
Triaitfi», however, may present a very marked congestion.
llie cartilages, and es|>eeial1y those which corresf>ond to the diseased
bone, are more or less deeply eroded, the surface ia bare or covered by
» connective tissue of new formation. The shape of those erosions u
tisnally very irreKtilar, their size varies, they arc located chiefly at tho
periphery of the cartilage, thus reaching the margin of the synovial
mcmbmne; but solitary or confluent erosions arc frci{uently seen i» tho
centre of the cartilaginous surface. The loss of cartilnge at tlio periph-
ery is often replaced by a vascular conucctive Usauc, which is con-
234
PATHOLOQtCAIi A:(AT01IS OF TUB ARtI
tiiMioua with tlio stuoviaI membrnDe ; but wben it takes plitce in tbo
contre of the «irtiiage, it remains bare, or ia filled by n eoft iniiM.
An cxaminatioQ of tbeso eroaiona, made from nvrpciiilioulur Acctiona j
of tliu cartitaf^o, shows that the loss of substance ts due to « Holnlion of
ttie vurcilngi? in coiiec<)uenco of the cellular prolifvrfttion. Thin appeiiraJ
to be u iflovf process, afiiectin;; layer after layer, so tliat the ciijwule* in
the proximity of the ulecmtion, exhibit only phenomena of jiroltferation
aiialognuj to tho#e described in acute arthriilK.
The margins of the parts where there hud been A loua of Aul»tance «re
festooned ; each carity of a festoon corre*ponda to an opened primary
capsule, the cells of which have become f^e, and have floated on in the
synovial liuid, or remain and form a collection of embryonic colls, which
His np the cavity caused by a breaking down of the CBrtiia;;c. lliesc
cells may give origin to an embryonic connective tiwne, especially trhon
the erosions are in connection with the conncctire tissue of the Byno\ial
membrane ; the veaaels of the aynovial membrane enter into tlie luiildlo
of the embryonic naauc, and afford an excellent opportunity for tlic ittuily
of th« development of new vessels.
Seldom in thi» form of arthritiH îs the inflammation so active a» to giv» I
rise to suppuration. Tin» latter occura. however, in cams of intense «up-
purative osteitis, whtrti tlie hone Ia absorbed and replaced by (granulation
tiiune; the cartilage also disappears, only tlie layers of tlie calcified
porUon remaining. This condition is see» in ditTii^ed phlegmonous
osteitis, in deep paronychia, aud in some cases of destructive osteitis of
the plialttngcs which accompanies jierforatiu); ulccra of the fool. ,
C. — CiiROSR- Rheumatic A utuiutis. — Alsd calli;d arthritis deformans, I
formative, or proliferating^, nodular rhouinatiniti, nn-ri-u» i-'rtr thiili». Al-
ihouïih the name! nodular rheumatism, dry arthritis, aiul m'/rlmê amx
tmitli» arc ^tven to distinct clinical affections ; yet the anatomical lesions
and evolutions are the same in those different maladies. They are
easenlially characterised by a villous state of the cartilages, by a hypo^
tr-Jpliy of the synovia! fringes ami by ecchoiidroaea or oâteophytea in
the circumference of the carlila'^inoiis covering; these serious legions
arc not accompanied by any notable effusions into the articular cavities.
The lesions of clironic rtieuroatiam differ acconiing to the articulations
affected, and according to the sta;;t> of the disease.
In the phalangeal articulations, for example, the changes consist in the
pnigressivc disappearance of the centre of the cartilage by the villouA
traiHfnmmtion, which will be described later; afterwards small cartila-
ginous ncjiluU'» (ecchou'lro«e-*) arc develojicd at thy margin of the car-
tilaginous covering. These give to the digital articulations a peculiar
appearance, which has cause'l the disease to be named nodular rfaen*
matism. At a more advanced stage of the disease, the central parts of
the cartilage bare di»ap[>eared, and the eccbondrowes have become ossified.
In these caaos the articulating surfaces formed by an eburnated osseous
layer, hare lost their original form, and present furrows or grooves, which
may be determined by articular movements.
Ill the large articalatioiis, as the knee, there is seen the samo disap-
pearance of the cartilage in its central p>rûons, the same formation of
■
CDBOSIO BHKCMATIC ARTHllITTS. 235
marginal cc^hoociroocs. But the sTncvinl frinsf« aiKl intcr-nrtieular
li-^itnivtits undergo onsMcrnblc nioilifiatltons. TUo friugos mrc liyi>«r-
troptiifd ; tlioir villi enlarge and fonn doomlari,' villi, wliicli have rweiveil
tKc name of dendritic Tosctatioiw of tim s_vnf>vinl n>i<ml>rane. Tli«He new
formation» are aocompnnied by great ra*i;Hlftr dev^lopawnt.
llio ;>ynovi«l villi ^nerally Wcomo carlilaicinmi!), and form spliorical
or oval roai»C9 of vnryin); me, reacliing sometimes lliat of a hazcl-nm,
eonttected by a pedicle at times very tliin. Tlte pedicle may bo broken,
and (lie mass act free, thus rorniitijç an articular forei;in lioJy. Iii son»
cases the cartilaginous forniaîions are iiifiltraU'd with cak-arcoiis itatti. or
tbcy present to the unaided eye all the cbaract«r8 of a viwcular lio:ic.
TiK-re \m also Been in the articulations a ooiwidcraWis hyportropliy of the
inter-articulnr li^ments «kiclt asitnme tbe character)) «f carlilagiiiotw
tissue.
The eccliondrosM, which are developed around llie arlieulation, later
undergo o«aeous transformation, ami m form compact or sponjy o^teO'
phytva, aomeiimcs ooloeeal in sixe, am] v«ry varied in shape. I'hc moat
rcninrkable example:* of these osteopliytv» are seen in the articulations of
the hip, in tlio disease deaignatod Mi'>r&iitii c«zir »riiilit, a form of <lry
arthritis. The tendinotis insertiona. which honleroti tlie articulations, may
become a atartinj; point for the formation of osteophytes, and in tht-se
ca«e the diseased articulations present the most singular deformities.
Whatever may be the artiodalion afl'ected, and in every form of tho
fflcaac, the liistolopcat process is the same.
It consiab! Msentinlly in a proliferation of the old eortilago, and in A
i>cw formation of C)irtila;i;c in the Ubrous part«, therefore the name de-
fining:; it heiit i« proUfrratinif arthritis.
'llie liistoloi^ical lesions in chronic rheumatism have been studied by
Redfem. i.i. Weher. \'olkfnanii, etc. These authors have distinctly seen
what takea place at the centre of the cartilage in pnasing into the viHon»
state : t>iit they have not understood the change in the cartilage at its
periphery rcsultinj; in tho formation of eccbomlrosos. Throughout tho
whole extent of the cartilsgc there is seen in perpendicular sections s
multiplication of the cells of the cartilage, with the formation of cansnles
around each. Tlic enlarged primary capsules contain a large number of
secondary capsules. Very olten these secondary capsules form groups
enveloped in a conmion capsule. In Other cases, the primary capsule is
filW with small round capfule», which arc not held together. Former
writers have taken these round capsiile* for true e«-ll8. Tliis error niny
be avoided by the employment of a Aoliilion of iodine, which coIori tho
prolnplasm of the cells brown, and leaves the secondary cap«ule» nncolored
or slightly tinged.
The primary capsulée on the surface become globular and much dis-
tended, finally rupture and open into the articular cavity. The cap-tulea
of tho second row and those located dccfjer can enlarge only pcrpcndica.
larly to the surface of tbe cartilage. As they are arranged in a linear
manner, they open one into the other and form parallel rovF«. These
different altenitions arc similar to those seen in cartilage In proximity to a
point of ossification («e p. 28).
Upon tlie surface, the vnlttr';od primary capsules gradually pour tlioir
I
PATHOLOOtCAL AXATOUT 07 TBlf ARTICULATtOÎTS.
contenta into the arliculftr cavity, and the rows, deprived of their
st-cmirlary capsules, contain oidy synovial fluid or cellular debris. Tb«
ftiudamental subataoce of the cartilage, included between the spaces
left crupty by tbe lallin;; out of tlieir elements, remains for a lon^ time
in tbc form of long or short villi, floAtiiig iit tbo surffive of the ctrtilago.
Thi'si! fitameiiitt, i^vitumlly very Ihin, arc constituted Ȕmply of tbfl
funilanivntnl substancu of the cartiln<:c, or tbcy contaiu a few cartillige
cap*iili's. These liwt are fouml espeeiatly At Ih* free extremity of the
villi which are cluWlin[wd. The filnmentâ vary in length, appearing Bomc-
timcM a millimetre long. Tlicy arc perpendicular to tlie surface of the
joint or Mi)çht1y nbH<|ue ; one or more »wellhigs may bo seen in which exist
primary capsules containing secotxlnry capsules. (Fiff. l-S-l.) .\s the dis-
ease «avances, the cartilaginous lilamenl>), deprived of their cells and
Pig. 134.
suhmitled to the articular friction, j^radually
dixappear as far as the calcified laver of tlio
cartilase. This in turn is worn ofr. and the
iniilerlyinK bone wears away by the articular
movements, and nndi-r^joc* tliiriuilS'm. Tlii*
is obitervoil pnrliculndy in chronic arthritis
occnrrinj; in locomotor ataxia.
En the majority of caMH it is difficult t«
know how the eburnation of the Hii]>er6cial
layers of the bone occurs. Yet we have ob«
served some facts wliioli may explain tbia
process. While the superficial csiwnle* of
tiic cartilago are filled with new cvltnlar olc-
UH-ntd, those situated deeper, found in ood-
iiection with the calcified layer, niwlergo
ttiiîilogou* changes. In enlarging they «xtcwd
toward the bone,Hiulcam«e the absorption of the
calcified layer. Tin- omcous trabeculic, which
separate lliera from the medullary cavities,
are in their turn absorbed by a process similar
to that seen in osteitis, and finally the enlarged capsules open into the
medullary spaces of the bone. The cells contained in capsules are emptied
into these spaces, as the superficial capsules are emptied into the articular
cavity. As a consctjucuce. the medullary spaces which bonier on the in-
vesting cartilage are filled with ncwlyformcd cells developed in the cartil-
age— L'eiU prevfiiiingiilt the characters of embryonic marrow, (Fig. 1?.^-)
The suhulion<lral i>»»eou» layer which contains the embryonic marrow
is thin, and, to the unaided eye, ap|^>ear« as a red border. Thi* layer
is tran»<formed into the ebumated lamella hy successive metamorphoses of
(he embryonic cell* into hone cells, by a process of «wi float ion similar to
that occurring in the physiological state. It is probable that the uiel^
morphosis of the subchondral compact osseous lamella does not always'
take place by the process mentioned. It is possible for the infiammation
to extend in a dîroct manner into the spongy tissue, and occasion aa
inSammalory cbuniation.
In the other portions of the epiphysis the marrow is highly fatty, the
IruWcnIw of tbc hone are thiu, being easily broken with the finger,
>Li[tiiLiir rbanm^Ilain, 9Kir1%s9*'1
■ bf 'nilUiift- t. Unrliorttpinlts
tllad wub ttroa^tirt «v>al«
fthuut I'r open liilD lliv flf ILcalHlluu.
i. Spliiiluf nil lit llM Dilrli. X
OHROXIC RHKPMATrc ARTHBITI8.
wlii«)i miiy penetrate ilecply into the sponRy tissue. These thin (rabec^
ulfc, uixler ihi^ microscope, are very rcgitUr, showing the OMe«us cor-
pusoloA conuiiniiig colla but no fatty i^iiulcs.
Ëochondroaea tre not charACt«ristic of ehronic rlioumatisni. They
an «ometimes met wit)i in oUif r forms of urUiriti» vrbich hjive u e\i>it
coiine, dtie to Hcrofula or gout.
Kvery notable proliferation of car- Fig. 13S.
tilag«, vlicn it attncka the margin
of the inveatin;; cartilage, causes
the fonnalion of nodes. The con-
trni portion of tlie cartilage si this
ttnw «IwaysdiMtppcars by k villous
tranaformatioii. Tlien-forc wc have
th« lUBQ ditoiiiie (Iclcrminin^ ujion
iho Mme «rliciiiar surface, n tlls-
«ppearanoe of a great part of the
iiiTCAting cartilage, an<i at the .tame
time an exuberant ]iroiluction of
cartilage. These two leaiona, how-
ever, are cauaeil by the same hi^io.
logical procesé. The ditfcrcnce
whicb exist» between them comes
from the circumstance that the mar-
gin of the articular cartilai^c id
covcrivl by the synoviiil mcmlininc,
aiwl Uiat the prollferuteil i^kiiii'iila
collect beneath thin membrane in-
»t«a() of being ilischarged into the
articularcavity. A vertical aection
of one of the ecebiindro5e« shows suc-
«esuvely, first a fibroos tiwne membrane, then fibro-cartilft;;ioous tissue,
and finally pnjlifcmtin;; hyaline cardlage. The fibrous membrane, which
is in some cat^vs di*tiiiL'l1y vucculnr, varies in thickness, and is diri-ctly
continuous with the synovial membrane and periosteum. Beneath is
seen a (ibro^;artitaginous layer which uiiit«s it to the hyaline cartilage.
This hitter incloses large capsules with secondary capsules, forming by
their union a complicated System.
Thi? ti-taue has a very close analogy to the carlilnginoua layers which
precede ossification in the short bones. The ecehoudroses, however, become
omified in time, the ossification always beginning at their baae. and from
the old bone. The process is similar to physiological ossification (see p.
28). TTic osseous tissue invades the ecchomlrosis, which finally disap-
pears, in order to give place to a spongy or eburnatcd osteophyte. In
chronic rheumatism, the OBt«opliytc is usually fburiiated only upon the
surface, while in the deeper layers it i» spongj- mid coiitiiiim a mt-iIuUary
ttssuo which is fatty, as in tlic other portions of lUf ln;«d of tlie bone. The
bvnndary between the old an<l new bone in osteophytes i^ always very
distinct; these osteophytes hi'lun^ to the epiphyseal extstoses.
llie synovial fringes heotne vnscular: the adipose lisiiue that tbev con-
tain disappears, and is replaced by embryonic cclU, which accurauUttng
jfddujïr rli'itiMiillijii. llvC[i lii,4F nf tU« 'ftrll.
eiinKinInc wTuulnrjr npislu. e. OpaoUc Into
288 PATUOLOniCAL AVAtOUT 07 TDB ARTICOLATIONS. ^^
Lgivo rifle to tlie secondsrj dcriiiruic vegetations. Some of the emlirvonic
rcellâ contained in ûie vej^otations lorni cnrtUaginous tissue, tlie [)crij)tiera!
ccliâ form a layer continuouâ with the fibrous tissue. The cartilaginous
lOodulea so produced may bo small in eïïe, but very numerous ; Uiose ■
Docated at tho base of the synovial frin;{i>« constitute by their union thick j
l|)Int«H, which extend a varying (li»taiice upon the synoriat membrane ;1
pothcn, situated in the villi of the friti^os, are fnstvited to the synovial!
EDombrano by a pedicle varying in Icn^h aiul thickness.
TlicM' tiodulcJt of cartilage may undcr^^o calcareotis infdtration, or crcn
a true oi>HificatJon. This latter Ia alway» accompanied by ooitiiiilenblo
vascularity; we hftve met with cariilapnoiia nodules faiit«ned to the ayno- ■
tial luembrane by a very thin iredicle, and which have undergone lorji
Lcoraplete oasitieatioD, but then bloodveaseU were includo<l in tlie pedicle.
F!Fre(]Uently these suspended bodies, whether cartila^nous, calcified, or
osseous, are detached, and become articular foreign boiiies.
^~otwithstanding that this articular disease is accompanied by an exu-
berant foroiation of carti]a<iinou8 tissue at first and osseous altcrwardSf
it never occasions osseous ankylosis, dilTering in this from other fonns of
ehronio arthritis, which, however, do not rvsult in osseous formations of
sucli large dimensions. J
TIki immobility of articulations in chronic rhcumati^im ofWn depanMl
upon the osteophytes, or iu very rare ciuieH u{>on a fibro-cartila^tinoud (ranK-
forraation nf tlie synovial membrane, and even tipon a fibrous union of the
two articular surfaces bared of their cartilage.
J>. — ScHOFPtoi/S ABTnitiTi9,ou WiirTE SwKLUXo. — Up to the present
ftUFji^ons have described white swelling without defining it either clinic-
ally or anatomicnlly. Their descriptions indiiilc several forms of artic-
ular ilisertse. Clinically they designate under the iiamc of white swelling
all chronic articular atTcctioiis having a tewleuoy Ut suppurate, or wliieh
are suppurating.
The i^wellin^ ami the pallor of the integumenti aUo enter into tbe elio-
ical detiniliou tliat ha.4 been given hy them, altliougU they reoogniie,
that in certain stages of while swelling, the skin and subcutaueoos tissue
may be the seat of an inllnmmalion accompanied by redness.
In this disease ihey have pointed out all the possible alterations of tlie
synovial membrane, of the cartilages, and of the bones. Bonnet is the
only author who has endeavored to find in white swelling a constant ana-
I tomic!il chanicter in the existence of fungous granulations of the synovial
Inacnibrani; and bones. liut these granulations do not exist in all the
iMagtfs of white swelling, mid they do not diflbr from large gianulatioita
rdevelopcd elsewhere.
In the clinical course of this affcotion there are generally two periods ;
the first long, characleriised by uneasiness or slight pain ; the smoikI iu-
dicated by the cousopiences of suppurative intlammation.
The anatomical lesions of white swelling differ in the two atngesof tii«
disease. In the firet stage, tliey consist in a fatty degeneration of the
cells of the cartilage, and very often of the bone cells of the epiphysis.!
Id the second, the parts which have died from the fatty degeneration'
occasion around them an eliminaiive inflammation (arthritis, rarefying
SOROPULODS ARTHRITIS.
2S9
tiiU, HiiiiptirnUnn, grnnulstions oT th« sjritovial memUrane Antl of the
e, caricii, alisceai of Wiie, h^peroatosU, sclerosU of the bone, itecro-
flis, ctironic ptile^un aod circuniacribed abscess).
T'A; anatomietil lii^ltHition of white itetlHn'j ia Inited upon thé initial
lenon, vil., vpon the initial fatt g dvgetir.ratioH of the crilulttr element*
Hf the eartilaife and hone. The other Itaton» Mong to infiammatioH.
Fir»t SlA'je. — Wtiiti- swelling in mIiIoid seen in the first stags ; how-
ever urc liavo hiul the opporUinUy of exnniiiiing two case* iluring iiuppu>
rativG inflaimnaiion, ami were aul« to rocoj^iixe tracca of the priniarj
Icsioits in the cartilngos and l>onc4. llic synovial membmno apiwnreq
«Itervfl ; vol tlie Bjrnovial flukl was not wore abundnnt than in the normal
stale. In one case there was found upon the surface, as veil as upon
the cartilage, a concrete mucotu exudation, graj'iMi and gelatinous,
which upon section showed a very Iiandsome network, in the meshes of
which was found a liquid subétance destittite of cellular elements. The
exudation was adherent to the surface of the cartilage.
Tlie cartila^fs had preaerved their polished surfaces : they were
slightly oi>!v.iiie, and baa lost a little of their elasticity. V«nical s<tc-
tiona examined under the microscope show all thi- layera succvsaivoly
described on page '2'27. The cells contain fine fatty granules, and some
an completely destroy«d by fattv dc gene rati on. 'lliis change begins in
lite auperficial lnycn> and gnulually extends to the deeper ))nrt«, at times
aflecting the whole thiekncM of the investing cartilage. Oonerally the
changes are nol ciiually iltstribiiicd over the whole
of the cartilage, not difl'ering in ibis from other car-
tila^noUB lesions : one part of the investing carlilago
may Iw completely transforroed, while another is
modi6cd only upon the surface, or oven does not
present any alteration.
Tin- fatty degeneration terminates by the complete
destruction of tlie celU contained in the cap«ulcss,
wherein are found only fatty granules, the nucleus
of the cell having disappeared. At the same time,
the fundamental Hubstaneo of the cartilage is soft-
ened, and does not resist the movements and prea-
anre of Uie articulation. After dii» process, the
eapaules containing only faily granules, are deformed
and irregular in shape, aa ^own in fig. VM'i.
Frequently these louons extend into the second
stage, and even ^vhcn the cartilage has undergone fatty degeneration
throughout ibi entire thickness, it may persist without experiencing any
other modification.
The epiphysis present* the lesions of the first stage of caries. There
ia a gn^at thinness of the osseous trakeciiW, the cells of which have
mostly disappeari>d, ami undergone fatty degeneration, while tlie marrow
ig yelloi., slightly vnsctdar, ami fatty. Tlio periosteum «nd soft ]»arts
surrouiuling aie articuhtUons appear entirely healthy.
Seeftttd Stft/fe, — The lesions of the second stage vary according to the
iolensity of the inflammation succeeding ilie mortification of the cartilage
Fi(. laa.
dfl^bar«Uoii of lti<i chFtt
laga Hll*. Illsb pamr.
240
FATQOLOOICAL ASATOMY OP TUB ARTICULATIONS.
Flj. 137.
and bone. The synovial mcmlirunc bi-comcs viiwular an<I thioVi-niil ; its
BdipODU tissue iliMppOAr.'* in onlor to ^ivt- pluut- to an vmtiryoiiic ti»e<ii-,
winch fonas grnniiUtion» and produces pus whieh is disohai^ged into tlie
arlJciiUr cnviiy.
When iho diaeflAe is more advanced, nfter (lie destruction of die carli-
i l&ge, the extremities of the hone arc «cen, uIho covered br gnuiulaiinn
tissue which ia confounded with that of the synovial membrane. If an
tternal opening exists its fistutar track is also lined with these granula-
l^tions. In while swelling the granuladona arc speciality named fitngalin};
or fungiiH. Those very often rest upon a semi-transparent, friahle. very
vascular layer of tissue, which may become lanlaceous in coDsisicncy
vhvn the supiiuratii*'!) ceaiKCs. Siibsequcntlr this tissue has n ten>leucy
' lo complete organisation, l^omctimes these fungous granulations undergo
pft COMtous nietnmorphnsis. The structure of the grannlaUons varies aocom*]
ing to the dejjree of iheir evolution (,«cc Caries, p. 207.)
The changes which supervene in the cartilajte arc not always the same ;^
where the investing carlitage liaa undergone fatty degeneration of its
cells throughout its entire thickness, it acts as a foreign body. It is
sot^ned, so that, by the articular movemenia
which still continue, it is detached in large or
small layers, which either attached at the border
or perfectly free, tloat In the arliculnr cavit^^
The granulations develojied in the cpipbyseil
may uplift and also rletiich the cartilage.
Wlii-n the investing oarlilugv luis been onl^
partially involved, the deeper layen, which
generally escape, present in their eleraenb* le-
sions which produce localized thickenings, ul-
cerations of Its rilloua surface, new formation" '
of fibrous tissue, and oven ccchondroses. Al
these lesions arc due to proliferation of the
cells of the cartilage, which during this evolu-
tion of an irritative nature, do not present fatty
granule».
The superficial layer of cartilage hani^
become inert ilirongh ilie iloitimction of its
cells, the cajisules of the deep layer filled
with secondary capsules, and arranged iu
long row*, cannnt open upon the surface of the joint. At the »aaie
time that ihi^ proliferation is inking place, the fundamenial sulKttance
becomes transparent, and is segmentated parallel to the axis of the
rows. It ia this process that causes the increase in thickness of
the «iTesting cartilage, which in filuces may reach seven millimelred.
These hypertrophies are gcneruliy limited, and, besides exuberant carti-
laginous portions, which fonn regular islanrls, there is seen granulation
tissue or fibrous tissue in the process of organisation, or again ulcerated
cartilaginous surfaces. The^e surfaces preneut villous filaments, the
shape and development of whicli are the same as in chronic rheumatism.
In some whiit? [>«elliiig^ which develop slowly in the second stage,
there arc Men marginal ecchondroses, less perfect and more irregular than
or Ihttifnmi'tnrjr p^rlnit . mothr t
opiiil» rurmlniMW» llll<>4 vltb
Il IbrllUMd. X i""-
OOPTY ABTHBITIS.
241
»
in rlironio r1ipuiunti.ifn. Tlioir origiit and MruGturb aro, hoKuvor. tlto
Mtov in Wb dineaiie:!. Titi>y are derclAjied («ncatli the tbickcii«d t)l^
roii« lis-tiif. «Iiicli tiai« taken the place of ili« Hynovial memhranu.
When the cartila;:!' has )>ecii miacd cd masse hy the ;^im1ation tiwue
uf the lionc, or when it lias been deetpayed by the villous degenemtioa,
it di.'tapi'cars, ami ia rejilaced bv ;;ranu!a[ion or cmbrvonic fihrctua tistue.
lu the first case, the articulation is transformed into a true bUmcm,
lined hy a ]>yo»eni<! membrane, whtvli, when the pus is dîsdiarged ex>
temally, is covL<rud with vej;cta(ioiM.
Insti^ad of tiie articular cavity, ihcro e%w\« a cnntinuoiis tayor uf ea>>
brronii; ti<«iie, which iinitrs aiwl Mjniniles the two oamoiu surfaces of
the articiilalion. In thii> youtig ii«niL' ojisenus trabceulic derelo^i, and
cauM> n L-ooipU'le eon»)! id at ion of the luo honea. 'Hiis U a fftvorablc
niellind of t«nniiiatian for the disease, yet os»eotis ankylojix toay «xist
witliont oe«*alion of the auppuralion.
Tilt- leaions of the ejnphyses in white awellin^ conxiBt of caries, and
all tiie eonâe(|uence9 that this disease induced. It h daiibtful if tnie
caries iii ever develowd far from an artieulution (Volknmno), and it is
fre<(uently accoinfiantcd by the articular chaii;{cs of while swelling. To
«hat haA been said of caries, it should he added that the gran it J a ti on it
oflou form prominences in the artictilar cavity, «ft«r tlio partial or com-
plete disappvaranco of tlic cartila^. The ca«eou« sc<|U0Rtrie or tlic
small sciue^triRoroarie-sraiyal^ohu di^har^cd into the articular cavity.
In the mtl part4 adjoining the artienlation, in the connective tissue,
ill the sheaths nf the (vndona, sml in tlie teinloiis tliemselres, thurc an
»een .til the lesions of chronic inti animation, ll is especially arouml
tlïO Ei^tular opeiiitigs that these new inllaniraatory formations are manî-
fe»t; there is no essential differcniio between these different lesion.^, and
those which occur around a necrotic bone. However, at the beginning
of the second stage, there is seen a piiffinesti of the connective tissue,
which somewhat resembles cedema. This wdoma will be studied under
coDDective tissue.
£. Goorr Arthbitis. — Goaty affection» of the articulations, like
scrofulous arthritic, are divided into Ino ^lage^. In the first there is
seen a simple nutritive te-sion of the cartilage, of tlie .'«ynovial membrane,
»oi) of the nnrroundiug fibrous t>»sue, which in tlie Hecond stage excites
a true intlAnimution.
Fir»t Ulaift. — The legions of this stage consist in an infiltration of
nmt« of wda, generally in the form of needlo-like crystals, into the car-
tilage, the synovial membrane, neighboring fibrous tisHue of the arcàcula-
lion, aud even into the periosteum and wreolœ of the spongy tissue of the
epiphyses.
In the cartilage, at first tho urate of soda is deposited in tbo anper-
ficial portion, never upon the surface, as an examination with the unaided
eye would seem to show. When the articular surface is examined, it
appoanlike a chalky and polished layer, usually glistening although very
opaque : at times scarcely perceptible riilges are distinguishable, and
are very irregularly arraDgeu.
IS
34S
PATBOLOaiCAL AKATOilY OF TUB ARTIOULATIORS.
Fig. 138.
A perpcndicnlar section of the carliinj;o showrs that the tlppoail only
occurs in tho nx^l »u|>crfi(.-iiil parbf ; i-xamiiic<l nitli the mici'oscopc, verjr
ofti-ii thi* timlo vf mih\ U foiirid to hnvi' scctiimiUtod in such larp;p ([uan*
titles ihiit nothing but kii oprnjuc »ii<l ){miiiiliir honU-r citii be di4tin<riiiiliixl.
Whvrc it Join» tlio <1e«per paru, tjie noe<ll<.*-»linpcil cnrsuls aiv u-eo
ntiliating from » centre, which in («■ncrally n ciirtiUgi' cvH. Th«M
nceillc-iihaped crvMals, which are from five
to i*ix [Dilliiii«troA loiif;, lire either rectilinear
or ciirveil. When the <lL'|K>>iit of uratcH it
eoitfiiilernhle, and all '.he ne«clle-like cry.ttals
n<)iato from a centre, the mass rc»eiiit>let
vcrv much a thom-appte,
'i'o aecoriain if the <Urk bonier ujxw» the
surface of the cartila<*c is not simply a
«IcpoHÎt formed upon thr !iurfac«, acetic aci^
or potAMa U employi-il. The (>alta ar6l
gradually <li««olvea, an<l it is scvn that they
are dcpo»il«<l in tlic carlilngo. The rca^nt
act« upon «aoh group of cryMaltt from the
]:H>riphery to lh« centre, ho that iho fuixla-
inenlnl stuliHtanoc of the cartilage uiaj; W
completely deprived ofitK unties, while tlitt
in the cells remains. When acelio acid 1*^
used, at the same time that the urate of Mtfai
dinappeara, there is seen the formation of
loxcnt^e orhcxagonal. transparent, audcolor-
lesi« crystal» of uric acid.
To till- nnaiilisl eye, upon tlic counoctît
tiatuo of the synovial memhranc. are seen small whito opaque itjiota,
Cfttued by a depor^it of urate of soda in the interior of the membrane;
although very superficial in appearance, these deposit» are very inti-
mately connected to the Ëbroua tissue, and CAnnot be reiooved by
acrajiing.
The synovial fringes, li<^anicnts, periosteum, sheaths of the tendona,
peri-articular connective tissue, slicathâ of the nerves, external sheaths of
the vessels, and the <kin itself may be be inraded by analogous depodita.
These di'pijisits apfwtir to be bctneen the fibres of the connective tissue»
BO formed tlint the «hitv and npaijiie mass cannot be isolated. In t}ieir
centre, be«idc« granules mid erysiuls of urates, are found fibres of con-
nective tisHuc.
When the peri-articular deposits of urates attain «uch n sîxc as to be
observed ilurin;: life, they are called a l-i/'lai» {rknlk-tt'im'). Very often
in the centre of these chalk-stones there iii found a white pulp, which
being removed leaves a cavity, the wall of which varies in thickneax. Wing
comgtosed of connective tissue infiltrated with urates. The soft chalky
mas* contained iu the centre, when diluted with water, shows very
beautifid needle-shaped crystals of urate of soda.
In a tecimd ttat/e of the disease, considered only histologically, the
cartilages through the irritation occasioned by the presence of the urate of
Ttfllml Hrtli^D at »d BrilmlHr «tr-
■ nrfwfpf fbacartllifov. v.«,. Aiuvr*
■,CaT«vl«*i>cidnnlliieatrn>- X''"'-
i
»
soda, iinder^ cliangea whioh HhouKl be considercd of an inflMiuiiintory
DAtnre.
TtiU irritation of t)ie cftrtilagea is reco^^ited, with tlie unaided eye,
by a |>cciiliar aprwrarance of t)i« deep carlila^ioous layer, nol intiltratcii
with urates, ami by ecchondroses. Beneath tlie superficial layer, in-
cnistrd with urates. tli« cartilaj^ is mure tnit^sparent tban customary,
and presents a bluiiih color, nhcu studied liy a pcrpcndictdar section,
"niili layer rarie* in Hei>lli, at times being; thicker than the nortiuil
inventing cartiliise. a;;uin il may W scarcely fcen. Sometimes the entire
iuvcMing cartilage may be infiltrate<l with unites or have completely <li*-
apnearetl.
By a nii«rowo|He examinatioti there is seen in the bluiflh layer a
proliferation of celU with enlargement of tbe |>riiaary caiisniea, which
form tuw.t botaeen which the fundamental ^utixtance haa tiecome trans-
narcnt and segmented. The^ phenomena of irritation, which are much
kaa marked than in chronic rheumadsm or in scrofulous arthritis,
never lead to villous degcno ration, because the superficial infiltrated
layer becomes inert, and does not permit the enlarged capsules to open
into tlio articular cavity. Therefore there is at times a true accumulation
of new cartila^^iitous elements, and consequently a hypertrophy of the
cartilage.
Tb« dimppearanoc of the cartilage is cnuseil by t)ic prof;re«<ii<rc wear-
ing away of the surface of the cartilage inliltmtetl with urate.*; there
is a l'>ss of elai^ticily; it doc* not rv*m tlte action of friction. 'I'he
opposed surfaces are worn away by the articular murementa. This may
be dcmonetralcd in preparationa after the action of a solution of potassa,
when wc sec at the surface of the cartilage the round or elongated
capsules perpendicular lo the surface — a very clear indication that tho
superficial layer foniied of flattened capsules has completely disHpp<'an.-d.
This wearing away of the cartilage, however, only occurs in the very
movable articulations, while in those less movable it is not seen even in
chronic caaes of gout.
When the cartilages hare disappeared there remnins in their place
chalky matter, which *4-|ianites the end of the Vme#, or, aâ we have
seen in one case, there \* a true omncouh iinkylnsis. In place of the
articular cavity, the areolie of !«|>i>iigy ti.i.im-, which contained urate of
soda, were seen to have enlarged, so that the iiiterarlicular line was
only represented by a white mark. .\ longitudinal cut of the bouea
ahowed this singular arrangement very distinctly. The ankrlosis evi-
dently resulted from an osteitis limited to the extremities of tïie bone«.
These are not the only conditions in which the medullary ti:<»ue of
bones may be infiltnited with deposits of urates, They have been found
in the ejctremttics of bones, the investing cartilage of whicii hm been
presened.
Formative trriuiion of carriage may. in gouty nrtltriti», as in other
font» of arthritis, c*u»e the formation of ecelioiulrose». generally these
ecchondroM-a are .'^mailer than those in chronic rh(nimati.im, and the peri-
articular nodule» in gout are chielly due lo chalkntoncs, yet they may
he considered partly a» ecchondm«e».
Uouty arthritis is never «uppumtive, but aonielimea very chronic
S44
PATHOLOGICAL ASATOMY
h
cl î mi II» ting âupj>urativ« inflaïuiiui lions are seen in the neighborhiKxI of
aulicuciincouâ dial le -stones. Tlic pus colla are tlteo assoctauid witli
grAnulee and crystals of urates.
The two stages that have been Riven to the tiisU>Io;;ical tcaions of gout
ar« not so diâ^uct us tliu prt-cedin^ description would load oiw to fluj>-
jioBi>. The •IcpositJ' of urates mav occur in prolifcraûng citrula<;us ;
for the pniniiry uu[.<3nlcs eniitaiiuiiR n lar^o' miinWr of «ecoiidary
CAp*uIc^!( iiidicitti! vcrj- pusitirely » formntive irritutioii, at;'! tlte largfr^
splioricul eajisuW have an uniilogoiui :>îgiii(ïciitioii, and way contain crys-
tal» of iiraw of «oda. From the clinical «ymfitoiu» il i« very probable tlial
tlio dciMKiit continue» during the whole course of the di.^eaiie, and tluit
the «Itacka of gout have nome connection with the inRninniatory exten-
sions alongside of llie joints. It Li known, from the nliservatioua of
tisirrod, that there is no cxcosa of urates in the blood durin;; the attacks;
and it is proven, at least in birds in whom Uie ureters tinve bc«i
iigated, that infiltrations of urates arc uot dcpondcut upon an excise of
urates in the Mood.
Beet. IV.— Tomors of the Articnlationa.
Trimary tumor* of tin' .iiiiKiuri-i^ wliiih cmi.-'ûtute the irtieulationa arc
extremely rare, if wi; rxoi'jn tUv ecclioiid roses wiiich are produced in
Gon^eiiuence of an arthritis.
f'r'-h'm-tfoifi ori;^inatin|i; in the interrertehral disksi, however, do not
seem to be connected witli inSammation : their cause is not known.
They are fnund at the autopsies of subjects generally advancivl in age,
and usually several «re present. The mtcnertcbral disk is a'lherenl to
the body of the vertebra in the same manner as the rliiirthmdial carti-
lages. l.'i>oii each o.s«cou8 siirfaw there is seen successively a layer of
calcified cartilage, tlicn a layer of homogeneous or segmcnled hyaline
cartilage, which limit:* a cavity filled with a mucous utits». The verte-
bral «cchondro.iea are developed from thij hyaline cartilage. Ther ap-
pear in the form of two ma^we» held together and separated by a layers
of fibro- cartilage, which indicates the inter-articular line. In subjecls'
advanced in age these eechondrose;» are frei|uenlly ossified, ai»d the
osteophytes ofWn are separatod into two parts by a longitudinal plane
in which fihroniartilaginoua tissue atill exists. It may aUo happen tliat
the fihro-cartitaginous layer has undergone ossification, and then the two
vertehrul bodies are consolidated.
J. MHIler has pointed oat in the articulntions ii form of lipoma whiohi
he call* Ji-mlrilic, ehiiraeterixed by a number of lobules se|>amied from
each other in the articular cavity, yet united liko a hunch of grapes.
J'hysiolojfically, the ^ynoviid fringes contain adipose tissue ; the den-
dritic lijioma may simply he an exaggeration of this. The affection is
Tcry rare ; we have never met with it.
Tuhcn-lea of the Symmiil Mnnhrnnr. — There is another neoplasm ■
the synovial membrane which seems f^i he more common, although it haïi
not Qft«u been described. It consisU of miliary tuberculous granulations
TUÏtORS OF TUB ARTICULATIONS.
245
N
of the synovUl memhrano. Virchow simply mentions it. Kfist^r bas
colle«t«<l a Tow cnsc». hut has iioi yi't publi^hf<t thorn. 'Ilii- i>rcpn rations
he ehowo*! u» in WiirlKbur^, nnd a cuiiP of ihe «amc nature that vtc have
rince won, irill serve w lor a ilcsoription of tubcrclM of the synoviiil
nwnlimno.
The articulur cavity contain» \nw, t)i« synovial inciDlirAn« Ic Ihickcnec)
snd etiangoit into a piility layer rescmhlinj; a pyogenic msmhrano. iu
vtiic)i an» Men it^-miintn^pnnMit or opa<|ue gmnulalionti. Hy mitting
tlirougli tlio ni4'mliran« tiiene gmuulatioiu are seen thron$chouc iM entire
thielcneaa. Thi'»« itiWrctitoiu granulationfl are foun'l diA-ieuiiitatcil or
confluent, translucent or caseotis, pos.tesaiii;; aU the elmractcrs pointed
out on pa^^e 112; Iwtvccn tlc^ ^çraniilationa cmUryouic tissae exists,
trnvergpil by dilated vessels. The «Upose tissue has disappcanfi).
Tlic CRTtila^, to the iinaiilcd eye, appears normal, or it has lost its
elasticity, and its §urfacc is not smootii. In the case that we examined,
the lesion? of ucnte arthritis were found ; the most siiiierficial ]>or(ion
of the carlilii'^u vsiê softened und M;;;mcnied ; tlic ni<y<t «iipcriiiMnl eamulcs
«wmod to have di8np]x>arcd, and tJterc was n prolifcmtion of the deeper
capoales.
llie spongy tissue of the epiphysis waa not rarefied, differing from
ja ieen in vfhite «welling, and the bone celU of the trabeculw did
lli^iintain fatty graitutes.
It is certain that, up to the present time, the arthritic ivhicb aecomna<
nice ttiis tuberculous new formation and its results have been confounded
witJi scrofulous artliritls ; yet tliese two affections seem to us very
distinct. 'I'he aymptomatelogy of tuberculous artliritis is entirely
unknown.
Tittnort hiieinff ihrir Ort;rin in the Ntij/lif/nrinif Part* and I'nttt-
tmtini/ int-t tfif Articular ('^ii'itif. — Tumors of die bonen, and especially
sarcomata which arc the m«»t common of ail, seldora penetrate into the
articular cavity. The calcified laver of tJie cartilage does not ao readily
absorb MB does the bone when irritated by a neoplasm : sometimes, how.
ever, this layer yields, and then the morbid mass sjrows into the articular
cavity. This penetration has been prece<ied by all the phenomena which
have been previously described uivlcr chronic arthritis by continuity.
In some person». and purtîcularly in children, there is seen a liw* of
eubMlance of the nrlinilar surface, cut out as if by a punch, vsUiblishing
a communication between the joint, and a cavity of varying sixe ex-
cavated in the tij»ue of the epiphy:<i». Tlie ot»cou« tissue which limits
tliiii cavity is rarefied, filled with granutadon ti^ue infiltrated by pus, or
is condensed. The surface of this cavity is lined by granulation tissue
or by a caaeona layer. In the interior of the cavity there is found
pus or caseous matter more or loss concrete. The arlicidation contains
SOS, and all the changes of suppurative arthritis are seen. All surgeons.
IdlaloD especially, have coiisiden-d this lesion to be tuberculous in it*
nature.
The histological examinations that we bave been able to make upon
tbi* :<ubject have not pi-niiitted m to form a definite opinion, for we
know, at tlie present lime, tliiit caseous degeneration is not ucce»Mirily
24t{ PATHOLOaiCAL AHATOMT OF THB ARTIOOtATIOBfl.
spécifie. In the osseous tissue which surrouada tiie opemogs ve hare
only found modifications belonging to osteitas.
The margins of the perforstiona in the carriage show a proliferation
of the oarcilage cells as in other oases of chondritis.
It is necessary, therefore, before coming to a positive conclasion,
to wait for new oases where the changes are more recent, or cases in
which, by the side of the old alterations, we may find points presenting
the characters of tubercles of bone, aa has been seen in Pott's disease.
KOHMAL BISTOLOOT OF THS COXXBCTIVB TISSUS.
247
CUAPTER IV.
XHAXCES OF THE CONXECTIVE TISSUE AND SEROUS CAVITIES.
Sect. I.— Ifonnal Htttology of the ConnecliTe TUsoe and Seroos Cavitieo.
Bv injecting with a hyjxylcrmtc Ayrinii;c ii«ruin of the blood into th«
i»ibciitaiieoiid cellular ItitAue of an adult maainiifera, a portion of th«
iImiic will t>e diHtcndet] m the form of a spherical ball ; the site of thi.t
mas* .lejwiKU upon ihi' .|iiaiitily of llie 1i>]ui<l injected : onco produc<fd, by
furtber injection it may be enlarged to a considerable ai»«, Thia fact
alone domonstnites that there are not in the connective Umuo spaiies ana-
logous to those wliich Kichat «IcsiRiiaWil by the name of celle. The con.
nective tissue consists of innumerable filamvnta of great flflxibilîtj. When
fluid is injected with »oinc pressure it cnnaes them to be compraMcd, they
are then closely applied one to the other at the border of the ball, whore
tbcy finally aurrouod a sort of cy«t. Thi# kiud of liinitin); membrane of
the Kpherinil ball ÎH formed of fibres which «lidc one upon the other, so
tbat If we inject more lliiiil the ey^it U enlarged, but always has a spheric
cat form. A few filament» traverse ihe injected substance in diHerenl
directtoDs, so that it is inclosed in meshes, and upon section tira ma»
presents a gelatinous apfrcanince.
A microscopic examination of the infiltrated portion of the œdomatous
hall, removed with scissors, shows the presence of filamentit which are
fasciculi of councctivo tissue nml elastic fibres. The fttscicuH of eonuec*
tive tissue are lon;;itu>linally striulerL ; they seem to hv formed by A col-
lection of fibriU, and arc therefore named raiciciili. Thi'y appear w«vy
orsiigjta»; their diameter varie» greatly, and caraiine colors them red.
After the act40n of carminé, if examined in water or glycerine to which
aeetie or formic acid hits been added, they swell, lose their color and
fibrillar appearance. The swelling is not eijual at all points, and there
are seen constrictions in the form of rings or spirals, which seem to be
caused by a kind of fibre, stained red. lleulo has named these fibres
annular or spiral fibres, and eonsiders them to bo elastic in nature.
Klastic fibres are found alon:; with the fasciculi, and are character*
iïed by their refraction, tbeir perfect cylindrical shape, their anastomoses,
and their rci>iHtHiice to the action of acetic ncid.
Between the fasciculi there are foutxl two kind.* of cell* : one, placed
along the fasciculi of Ihe connective tiMue, are lar;^, Hat like Ihe endo-
thelial celU of the serous membranes, and contain a nucleus, also very
flat, in which one or more nucleoli are seen. The other cells are found
free, anil have all the cbaracteni of white blood corpuscles or lymph celU.
In normal connective Ussue all the fasciculi touch and slide ea^ly one
ui)un tlie other.
248
cflAsaEs or Tns coN^soTirs tissue.
Prom the preceding doacrîptîoii it is cK*nr tiist the ecllnlnr tissue lany he
considcrcil as x viist <:avity travL'Koil I>t ffi^ck'iiU which arc oolttiiiucil iiitoj
llu^ «Viii, npiiiiciir»K-s. pcrio*tciini, etc. — llii'w ffiMicult «liding upon ftnti
atintlivr, a* tiic opiw^iu- j^iirfiiw» of a serous cavity. Hotwecn tlio rH8CÏ4
ctili tlioiv U foiitii) ill tlic phyMi'ln^cal fUVc a Rtiid in wliich arc Mu^pondea
l^tiipti cell», niid tlii'itiiiiliudrappeartt to he Ui« Mine aa that of the jymphil
In the âerotij CAviticn then; if aim found a fluid DOntaiuing the aftDM*
element». It; pitysiolagical expérimenta has b«en rccojzuiiwd a dirrct
commaiiication of thc!<e minute serous cavities iritii the IjriDptiatic ress«la.
In the frog, the <iniall lymph ^paceaofthe subeulaiicous wllular tiasii*
arc replaced hy vast sacs, named seroiis or lymphatic sacs, travvrMid bjrJ
fihruiiH hawU with muscles and ncrvoB. By injcotinj; into the lymphatMH
1 8ae$ of the fro^, fine particles of c*>lm-in;r iiinterial, they arc roitiul to (mI
' taken up by the lymph curpusulus and curried into the hlood (Cohnhfin'
and iU-cklinghauscn'). In the serous cavitjes of nainmifetU! i^iiniliir phc-
noiQcna hnvc keen olMcrvcd by Keckliiighauscn, who Iia»*tiidie4 the suVj
ject very attentively. Vfhtn milk, red Wood cell», or particles of colnredi
substances are placed in the peritoneal cavity henrath the diaphra^nJ
tliey pads throuj^h the endothelial layer hy mcanii of small oriftcol
(etomata) between the cells, and eut«r into the su)>crlicial lymphatics.
Fine particlea of colored substances injected into the subcutaneous eel*
lular tiBsue of man and maouDirera soon reach and accumulat« iu the
rCorroBpondin;; lymphatic glands, but when tliey arc injccwd into the
ililoodvesseli! lliey do nut pans into these glands (LaugorlianV). These
jdifiierunt physinhii^ical fad» deiininstrati- vitv ]M)silivt'ly thu relations t>e-
'tween coiiiieotive tissue lymph spiice.t and seniii* cavitiiM.
A physiological or accidentai liiibculaneous mucous bursa results from
the fasciculi of the conneclive ttsaue heiiig separated and pualied aside
at a certain point, where tliey are closely pressed together and form a re.
sisting membrane. Generally mucous bursK are traver3c<l by connective
tissue fasciculi arranged as a membrane. The internal surface of the
cavity is lined by an endothelium nhich forms a complete or incomplete i
covering, the cells of which do not difler from those found upon the
fasciculi of the connective tissue;. The sheaths of the tendons are analo-
gous to serous cavities, they are lined hy a single layer of flat endotlielial
oelis. The external layer of connective tisane fibre» hleixls with the sur-
rounding connective tissue.
The large serous cavities (the pleura, pericanliura, peritoneum, and
arachnoid), although very complicated in their anatomiOal stnicturo, are
all of the same histological type, and very simple; a laver of dense
connective tissue lined by a single layer of flat endothelial celU. The
aixe and shape of these cells arc very variable. The connective tissue
which constitutes the wall of serous cavities contains vcrT numerous
lymphatic vessels, the most superficial hi.'in;; immediately beneath the
eudolbelium (Recklinghausen, Ludwlg and Suhwciggcr Seidel.)
Sect, n.— Congestion and Hemorrhage of the Connective Tistne.
Simple congestion of the conneclive ti«ue is freipiently seen during life
wilhout leavin:: aiiv trace after death. Vet when it occurs in connection
\
I
well
^_ con(:
■ Ti
TlHKI
OOVCRSTIOS ASD HEMORiinAOK OF COHKBCTITB TISSITI!. 3-19
with influnnulion or h«morrhii;!c, th^ vc**el* of tUe conneciivo tûaiw îa
tl>PCikd«v«rar(iofti>it fiximl tillod with tilnix). Kv roraovin^ n piece of lh«
congo#t«(l ti*<uo, uwl exuniiiiiit); it with the lukroscope, the capillnnea
sn? A«vii filli^d with ro'l Wood oorfiuscK'^, wliicfi twenty-four lioiira after
■leatJi n{)p>Ntr cri'iiftted. The cxfiilbrioa, eajx^cinlly m iiidaionMition, iiro
wvn re^tUrl^ diUted or iDDnilifomi. There may be (edema witli tlie
conei.-stioD.
Tlie effusion of bViod into the conn«clire tisntc is rer; cowmon; it
iini iu oontusinns, noiinds. f^OM-ral dtsoasc» whtuh arv acooinimiiiiMl 1>y
iorrhsj;ci, cic. Tho lilood i.'8CU)>in}; from ihevcxH'ts rai» bctwrcii tin.-
'ntKii'iili «f the coiinectivtf tinmif ami scpiirntcB thcin. A wicpo^copie
exniiitiiittion of « section in whioli tlii» lesion hi»» oci-Hrrwî, shows Uie
fnncicnli of tlic coiinectivo tiiwncout lonjiitHiltnmUy «r imn«rer!*ely.9e|«i-
mt«<l from excli olh«r; tlic spaces filled with blood, n-stim1>ling very
nucli a c«v«mouii nngiorun.
Fig. 13».
TrAixT^'** ■«^lïfB ùf Lb« qDb<uL»n4>oiift tJ*BDf *•! % Aot In t movni ilu»i«il «lib v«raiin4ii. a. Cod
l^Jirïllï» (lusr «III ■maif*i< (o f •<« h»lf rttcioi «oimil Ito fi^tleoH, », of ih* ■nooittlti- Muna
vUcta fc4t« bcrDifl* IrvbapAHiil from the jkCdonef stfr^nn^ a'- CatiAQ^llT* ll««hlr a*ll> ««vl Inlt^-
^.ti>^lD4il]r' t- Lfinph rorpuvAl'-a liiaLtf»lj<d «Itb itrmUiflb. «liuaUi In lb» lnUr.fjM«ltqiKJ a^r**.
(kirh intnl'rit»! ud lllIcU wlili ■ (nuuUi tiiidnliuii. Tli* uumtBll'* lliHaaMUi bonaun «•
liAler, Trithiii tvn days, the extra vacated blood has undergone consider-
able chauffe ; llii- fitiriii which ton^çulalfs around the blood corpuscles
ami supporta them «-itperieiice* a molcfular mciamorphoei». The red
corpuscles are de^itroyed, and the products of their decomposition arc
; found — grannUr liieawtoidin or at leaat an nnalofjoiis red matter, yellow or
IVrown granules derived fi-om the hiemoglobin, albuminoid ;;ninulcs eom-
jing pmbfihly from the [iar<>;;lobin, and finally fat f^uiniles.
Ai the »ume time that tlit-^e metaiuorpho^'s are taking place bi the blood.
CdANSKS or THE COSKKCTIVB TISSCB.
thfTO occur in the infiltratei] connective tiwue chut<^s of an irrtutirv
nnttirc.vtliicli tcnninntc hy ulimiuftting ft)l tb« producbt of decom|KiMiti'>ii.
WliiU! Mood coll», coiitniiiinj^ colorcil gmiiulos whleU ihejr h»ve iiliwirln-J,
are very nutiwrniis, Tlioy ftftcnrnnls return to tlie blootl or lyii))ihntic
olrciilnlion, ami curry with them the contained j^ranule^. The tiat orfixe^l
oeiU of the connective tissue ar« swollen and contain foreign grannies. It
i» to the^' tiro hii«tolo;;ical phenomena that niiiat be altribiit«d the complete
diaapjiearanoe of ecchymoses, and also tho |>ordisteDt pigmontation of
Bome cicatrices.
The iliflercnt colora of an ecchymosis, mible to the anaidod eye, are
due to the hsmu^lobin : at firet soluble, the latter ix ;;n>iluully changed
into colored grtoulcs nnmeil hwmatotdin or loelanin. Thcttc i^ntnules
act tow;iril« the surroundtu;; living elements like fine- colored ])Brticle«
injected into the connective tUsuc. They cause an irriuitioii which
detennini.'s the Appeurance of numeroiH white blood cclU, which finally
absorb and carry away the stolid (crannies.
1'he irritation ]>rodiiced hy the colored jrraniile» ulnch come froin tlie
blood, varies in intt-nAÎty. Sometiraca it [wssea away iinperceived, a^n
[.there iit suppuration and an ahacesa.
Sect. III.-(Edema.
nistolojpeally (cdcma is cssooiially cbaractcriwd by an elTusion of al>
biiininous fluid, which take» place between the fibrea of the conocciire
ti:(HiK' iind Ki-panitc't them from one another.
When >i;deiuatou.t loose eonnoctive tisKwc ifi iiicisied, instead of a denw
felt-like li^xue, there is !teen » gelalinou.i, transjiarent, trembling maiKf, m
the midst of which are found small collections of adipose tissue, thin white
marking and red traheculte which , correspond to the vessels, litis
appearance results from the retention of fluid between the Bbres of
the connective tisane, as water is retained when imbibed by a piece of
cotton. If a fra^nont of ojdomatous connective tissue is exaniined with-
out stretching, the fasciculi of the connective tissue and olastie fibrca
COntriKt, and uxpul the fluid, and the tisstie returns to the normal state.
That this is due to the contrnotion of the fibres, may bo proven by placing
the fragment in fluid, ivlicn it i.^ found that the tissue does not again be-
come filled with the lii)nid. Thii property of the connective tissue fibre»
is retained for a long time notwithstanding their dl^ti-iislon, and explains
the easy and continual discharge of fluid from |)Unoturcs uiiule through
the skin of dropsical patients. The fluid which flows from the ptnicturcs
is transparent and albuminous ; it neither coagulates sjKiutaneousty, nor
after the addition of red blood corpuscles, which indicates that it docs
not contain fibrinogenic substance, and therefore it may be separated
from intlarumatory fluid. There are always found in an edematous fluid
a few white hloix! cells.
A hislologtcul examination of this infiltrated tissue shows the fasciculi
of the connective tissue separated from one another. In the spaces
fonued by this separiition, there is found a fluid which contains white
blood corpuscles or lymph cells, more numerous than in the physiological
œtiBUA.
251
ï
cotuUtion. Ttic cells appIiiNl nlong tlio fucoioulî, tlio fixed c«Us of llio
tissue, Are mort> or leM sirollrn, contain n vcr^' ili«tinct nucleiiii an>l re>
fraotîti^ ^ntnule«. In tho corapotùlioii n( ihfitte granule» Uiere i» Tat ;
t>nt it ÎR iMl pcrTeclly forined, Miice chrotnic, acetic, ainl picric aciila have
t tlie Mme reaction npon tlicm a^ is obt.tirie<l n|>oii |>iire fat tçnniilea.
'hcw r««gontj> i)imiiii.t)i llicîr diaincleni ami increase llteir rofniction.
It I* probaMe thattheiie granules neeniii the cells of connective ùsaue sre
a combination of fatty principles nitb an albuminoid substance, and that a
sefMiraiion ia proiluced by the aciilx.
Sometinies in the coUa of (dcinatoits eonn)<<cti\'e tissue, there are seen
colored ^ranutcs, briifiit yvllow, vcrv tnmll and often nn^^lnr, fomicd
posoiblv from tliu coloring subsluticv of the red corpu^ck-s uf tlio bloo<l.
This pi<;mentation of the comiccliTetisKiic fibres and lliu elastic fibres dees
not undergo any apprccialilc change.
The bloodvessels which traverse the ocilematouH parts are filled vritb
nil oorpnaclcs, tho proportion of white blood cclU i» increajwd. In some
eaMt tlie red carpuwles are so nnme-
rou» at»d so comprewed one against ^if- ***•
ttie other, that they cannot be ilitu
tingtiiahed, the vessel ap]>earing a» if
injecte'l by a homogeneous raasa.
The vessels are very readily recog-
nized, ami they are soparaled by the
fluid as are the fasciculi of tJie eon-
ItHBr of ■ iloi- ArlllrlBl iFdtiu, i>culu«4 tjr
UtialRtg gr Istwlai «aia uA ■Ktlob n[ 111*
*<lHllc, a t-f mpTi «arjiBi«1fl Ili4l<mc4 wllb
ar ibo HiL t prolupUiBiliilIlnifd «lUi Mtj
nectii'c tiMue.
The adipose eelU, in œdema, gen-
tmlly uiulcrgo a change. When
enin is artilicially produced in the
there 'm *een a fatty degene-
ion of the protoplasm sitimted be-
I tween the membrane of the vesicle
I and die central drop of fat. So that
ItJie adipose cell, instead of being
Ifonnod of « single refracting maiis,
rhaa surrounding tho central drop of
[fata cirok- of ^rnnnlcs.
In the caclivctic uudi'inas the fat contuinvd in the cells has undergone
I partial absorption. This uccurs, for uxunipk\iu phthisis. Tliere is also
«onïctimes seen a breaking up of the fut of tlic adipose tissue into deli-
cate little dropii. This change of the fat is due U> the presence nf an
albuminous fiuid within the a^poite cell, and is analogous to an artificial
einuIsioD of fat with albumen. The nuclei of the adipose celU are nlnays
very distinct.
Formerly it was believed that u'deina was ibe residt of a stasis of the
|1>load. The physiological theory of Lower was accepted by all patho.
Is. lie said that when the veins are obliterated, the blood cannot
pass from the arteries into the veins, its serous ))ortion passes through
the walls of the vessels, as through a Biter. However, Hodgson did not
see œdema result in man if a vein was ligatod. IHic tlicory of Iiower was
abandoned «hen Bouillaud showed that iu most local dropsies there is
S52
CnASOES OF TUB COVSBCTIVV TtBBnS.
an oblitcrntion of Uic corrcK]ioii(1in;; veins. Ycl clinic*11jr >t U men tliat
there arc i]ro)>»ii>ji «itliuut nblitcrntion of tbe veinâ, and again a vfin
may be oblitorat«d without drnfay occurrin];. In aittmala tbe simple
ligation of a vein does not pmduce droptiy, aince tlic collateral (.'irciilniiou
ia nlwavH sufficient to prevent tlie prc^^uro of tlie blood from cxcd'Hlin;;
the limit of reaiâtnnce of the trails of tho vcsseU. But if u|Kinanitiiiiiiil
io which a vein ha§ been H^tvd, the vuHO-niotor nerres an- ilivided, tlic
arteries bt-ing ilitat^-d. a greutor amount of blood p«ssM into them,
and the prt-ssnre bccumi-H niiflioiviit to cause lliv tranittKlntion of Mrum.
This exaggerated pre^nre is tlio true chum of dro)>#y : if the pn-saure
is «wfficicnt. ti-ilema in prodiiwd, iniirpendenl of obliteration of tlie
vein». V.vtrry irdema, except pcrlmii» cacliectio adema, may be referred
to the Willie cji«.«e.
The obliteration of the velna ma? ba regarded as one of the cauiies of
dmpây, ttince it increases the blood nreaeure in tbe corredponding capil-
laries ; this obliteration produces oedema in cases where there is at the
same time an atomic state of the vascular system.
In rodemas which are very rapidly developed, llie large cells of the
connective tissue are infiltruted irith a greater amount of fatty granulea
lliaii are the cells in au œdccna which has slowly formed, as in dueauto of
the heart.
Sect. IT.— Inflammation of ConnecKTo Tiua».
When the .*iilii;iit,')n<-"ii.* ftumeotivo ti^.tui- lia* liPên divided by a cutlînf
instrument, an intlauiiiiiitiûii i!t proiliiced which terminates in recovery, ana
eon.ititutea tlie proce.i.s neces-iary for the recovery.
An open wound of the connective tïs.^ue, after a few hours, has its sur-
face covered with a thin t-ravish o|Wilescent layer, plastic lymph of J.
Hunter. J. Hunter, his followers, and the French surgeons, up to the
present time, have mainlnined that this plastic Ivniph is derived trum the
vessels by exudation, is susceptible of organisation, and of the formation
of the different tiwucs met with in cicatrices. There arc found in this
{jray layer GUincntK of fibrin, white corpuscles or pus cells, niwl red blood
corpuscle». Iteiieath tliifi «njmrficial layer the fasciculi of the connective
ti.*i*ue and the blood ciipiiiarie» are separated from each other by th«
same opaleMcnl sub»>tauce, so a* to constitute n kind of membrane, con-
tiniiou.4 and e.tlremely thin. Krom thi* description it is seen that at Ihe
moment when this so-called lymph becom>a ï>olid, it contains cellular
etementa. At the present time these facts might be explained by the
white blood corpuscles passing out of the vessels, and the coagulation of
the Ëbrinogenie substance (Cohnheim). Yet this explanation is not suf-
ficient, for it is very p'ssihio that the lymph contained in the lymphatic
vessel*, and in the meahcs of the connective tissue, plays some part id
these piicnouicna. It bas been mentioned, that the white or lymph cor-
puscles are found free between the fasciculi of the coiuiective tissue.
Again, the conditions for the funnation of fibrin are far from being per-
fectly understood. It is only known that the plasma of the blood ab-
stracted from the vesseU. coming in contact with the panigiobnliii(KUhne).
and other substances contained in the hi^ttulogical eleincntii, takes the
AOUTR PHLBOMOïT.
253
»:
■
mth of fil)rin. What is difficult to uii'lcrataii<l is, why the blood plaatna,
l^mpli, aod senim of the piM-icanliuni, which uoniaiD the 6briiio);«nio
NtilMtAHco, ncvvr give on<<;in to fibrin in th« living or^jsnisiii, altliou(;h
tlicM- tlui'Is arc in contact with ckinente ooutainiiig the fibrino>plat)tic
siibxtancv.
Tlio pbeaoinona of superiivial oituilnttnn, which iit first nre slight^ soon
berome ox«ggerat«d Aiid suppunitivi.' in uhitni<:t«r. 'Ha- ooiinvotivv tÎMiiu
«UHtnitw great ino«)tficati«iis ; lo«u sevenl millimetre» of lhickn<:s«, iiUu
it» fascicular appearauoe, beoouiug pulpy, tratuluoeut, aiid has tiie lutturu
of euibryouic tissue.
Tlicrc are atill faiiml fn>« the Mcond to tlie third dny aflvr a sintplo
wniiud, fasciculi nf tlic coniMOtive tinne in this einlirvonic layer.
They are sroaller, less disiitictly fibrillar ; ihey do not appenr env«lo|)ed
by a api-cial layer which limits ihcm, aixl which causes thcui to swell
im;;ularly when acted upon by acetic acid. They are separated by round
or Angular c<<lls, consis^ng of a mass of protoplasin containing a mtcleiis.
In BWMt case» there are not found, in this layer of embryonic tissue, any
Inrgi^! (Tat cells of the connective tii!«uo.
The infiltration of connective tJMue by a notable (|uantity of round
elcnu'iiti*, geuurally extends uh far a« two milliinetreA to one centimetre
from the R'llution of continuity; but ibis infiltration can only be recog-
^itwd with tlio microscopo. In this periplieml x«n« tliere is very mani-
festly seen a swelling of the flat cells of the connective tis«tic, a dirisïon
of their nuclei, and a coii*ci|ueni pralifcration of i!ie«e cell».
Fr<iin thifl (lescrijnioii it It seen that Itic abundaiil production of ncir
cellul.tr clomonta. belwecn the constituent parts of the connecûve tissue,
mav come from two sources ; the passing oui of the white blood corpuacles
aad the mnltiulicaliou of the colls of the connective tissue : but science
has not yet uoon able to determine tlic influence of each of ^ese pro*
ccesc« in the phenomena of the reparation of wounds.
It has been M'en that the fasciculi of the connective tissne, comprised
in the embryonic layer, have lo*t their fibrillar xtAte and are smaller,
lAt«r no trace of them can he fonmi. The granular layer n[wn the sur-
face of iJie woimd, or pyogenic membrane, formed only by the cells and
capillaries of tiie embryonic membrane, give* origin to granulation iiK.iue.
Sect. T.~ Furalont Inflammation of the Connectire Tiane, or Acute
PblegmoQ.
CThe name [urulent inflamna^on, or acute phlegmon, ts chosen, since
in rare cases where the disease terminates by resolution, there is never-
ttieless a great number of pus cells in the meshes of the connective tissue.
The evolution of acute phlegmon is very rapid ; redness, increase of tem-
perature, swelling, tedema. and the sharp pain, are all simullam'ously
manifested. The histological changes occurring in the connective tissue
during the first stage, can seldom he studied in nmn. Phlegmon artifi-
cially produced upon animal«, is probably identical with tluit occurring
in ma», and may be satisfactorily examined. In onier to excite an acute
phlegmon in a dog, it i« oolv necessary to inject a solution of nitrate of
364
CBASOES OF THE OONXBCTIVB TISSDB.
silver into the connective tU^ue, After ten or twelve lionrs there i|
cetlemaious and painful awellin;^ of the region. The connective tissiu
lias become gelniinou<i, the ves^U arc ilitatcil anil filled niUi btood, at
first there appcani to be no diflerenco between this tissue and that of
<ctliMnu. But the tlui') ilocs not Sow so rootUlj oe in oedcm». and there
U k noutablv ditTerciice hutwccn the two leiiions. Anion^ the fasciculi
of the «oniiectivv tiMuc M-paratcd from each other, there arc iicen, n» in
[«edema, nmncronft whit^ corpuscles or pu8 celU, but lliero alw exisi» a
[Jbrinous reticulnin, which ia never Kcun in «impie wdema. Moreover,
Pig. HI.
PdrOouuf k L>#rp«aiUculiir'4i^1l«ii Ihroujih I1^« «iLbninDQakatiinorlltf iIbiiia af ib« It in», la «nt4
«f &Cfit4 ôjteatt^rj «liowLfi£ Dip eppht^i^* uf (ouui^fliva Il*4d4 \a m Mfl^ tttg* of ««ppar^lf*
iDllimiriiliriu. X <^> '''I": lr'»p)> aplX** *n lllnUi], mul l^luir rraa 111 lh>H inil iulli*il«( |q
Ibfllr williLtr* aunifimn* ratind*! uiirI«A«Bil «tlU (itluml «ii<1^Lb«]liim),AadHU'}ft iiiitbb«rnr amilUr
IFl^iii * pb^l<^iiilcroj(n|ib. ■>/ Sur^fuii J.J, WiHitlwiirU, IT. ft- Arm/, Cnpt*J frvjb thm tK^fiil aitdic«l
Talantirfib* Slwllal ud HarfioiJ llliUiTorib* Wuof ib> UalidtlaB.
there occurs a Inie acute inflammatory 'cdcmn, which vcrjr probably is
fiOnneoted with the aame caii»e n« œdemii, from the circumelMwe that
there renultt a paralysia of the vewclx.and f^reater pressure of the bhiod
on the vascular fty^tem. Tlie Moml cnpillariesnre dilated and filled with
blood, causing an increase of tem[>eraturc of the part. At ihis Bttge the
I
^^^^^^TTTFlTilUATIOII OF OONHBCTIYE TI880B. 265
fnMiciilï of iJir coiiiirctive lUtmc Ao not present iiiiy xpprrviahlo diikngi-a,
TLioUrKO Hnlc-lU swell, boome splioricnl, «onic voiitaiu two nucli>i; tliûr
proM|ilft!*ni iit very grnniiUr, nnd erun gninuIrD of fat tomy bo «liMiiij^Uliecl.
Ill» tint «t»gia of [itilejcmon is chanci^riuid hy tb« fomuttoii of biime-
rous i>uR cells and a fibrinous extiibitlon. 'i1ic pusoelU increase in uum-
tier ami tlie (ibriu bccomca more abundant ; titi» material cxtnmU between
tiic tibrea and consolidates Ihein; the infla minatory tumor becomes firm,
fpviiijj; a sensation of resistance to the fingers. There is no fluid nreseut
which may be displaced aa in œdeina, and it is to the presence of fibrin
filling the iMfthe« of the oonnoctive tissue that the limiting of the phleg>
mon should be attributo<l. in cuta where the course bas been slow.
In man, this first stage is f'lUowcd cither by rr»olution, tntiuratt'on, or
tufipuniiiuM. When resolution is produced, it is probable that the cs-
caprd white corpisclea are take» up by the lymphalica, citlivr in their
nonnal state or afWr havinj; tuidcr^rouc » molecular séparation, and that
the fibrin and exlrarnsated rod blood cells experience the saoie change.
ln<luration without suppuration has a v«ry cIo»e analogy- to tlie indur-
ation which succeeds the opening of an almccs* ; the histological clutnges
are |>n>l>ably the same in both case:». There U a proiluotion l>etw(-cn the
fasciculi of the connective (in^ue of new cellular elements, while around
lli«m there exists a new fundamental substance, transparent and of »ott
consistence. Later, the cellular elements present a fatty degeneration,
and the new tissue is absorbed.
Id eirery phlegmon pus ccIU arc formed in the meshes of the con*
nectivo tisstK. When their production 19 very olnindant, the conncclire
tissue fasciculi urv wparated or undergo inflammatory softening and nb-
aorption, tiius forming a pnruletit collection or »u aW«s«. The phleg-
mon is now said to have Kuppiirat«d.
The pus of a circumscribed ])lilegmon is creamy, homogeneous, and
does not contain fasciculi of connective tissue. Examined with the micro-
acope, the purulent Quid presents: 1st. round cells exactly resembling
whit« blood corpuscles containing only one nucleus ; 2d, colls of the same
diameter possessing several small nuclei : :îd. similar cells with fally gran-
nies varying in amount; 4th, large cells inclosing fat granules, the granu-
lar corpuscles of Glugo : 5th, red blood corpuscles perfect or broken.
The sac which incloses tliv pu« is anfractuous and lined by a layer
similar to that which is formed the Mcond day upon the surface of a
wound- Hero the fasciculi of the »oftcnitd connective tissue are united
together hy a layer of coagulated fibrin, in which are seen pus cells.
When the abscess is ojieiiod by the surgeon, the pus escapes, the wall»
of tlic empty sac coming together are united, and there resulL^ an indu-
ration which persists for a fen days, (ieuerally, the bottom and mlvi
of tiie absces* granulate and form pus, when the phenomena are those of
a simple wouikI.
In diflused phlegmon, the inflammatory changea are so intense that the
layers of connective tissue have not lime to undergo inflammatory absorp-
tion. They die and act upon the neighboring parts as foreign bodies.
Properly speaking, a diffused phlegmon is a true necrosis of the con-
nective tissue, and is very similar to a suppurative ostco- myelitis.
When the purulent centres are opened, there are found mingled with the
856 ODAXQBS 0? THE C OinfnTTVmTBS tl K .
■jnus mocorftted ehrccU of connvctiri; tîisïuc, «ml from Uie bottom of the
'^tbic«»g float gfray filacnuntoiiii niiusi.'^.
If the pstioiit d'lM (luring tliia stAgo, «n iiiciiuon nuidc lhrtiu<*h tlic
Tili]i>^iiio[i i>tiowi* till* wholv uf lh« CoiiiMlctirv tiiHUlO of till- part t<> Im; in*
hltrAteil with ^ruin, blood, and a varying utnouiit of |his. In the iiiitUt
of tliv infiltraud re^nn thvne are »cl'>i whitish, o;iiii|Hc, filaiDOOtons
muAi'j>, free or adherent, formeil of luortifieii ooniicctive tiuiie, the
whole exhaling an odor of gangrene.
A histological cxaminatioa of thÎH gangrenous connective tisane offers
for study a fibrillar idilss. in which it is difficult to distinctly recognise
the fa!>ciculi. In the midst of the separated fihrils tliere arv sevn alW
ninoid granules, yellow or black pigment, fat grnmiluM. aud fat dro)«,
these last coming probably from the ii'liposc tissue. I'liu shreds of oonncC'
live ti^ue vthioh are detnchvd and flout in the pus present a similar stitic*
turn. The otfect produced hy inuceration in the pu» is the dissolving of
the uniting sukstunce of the fibrils (KUt-nulitlam of tlie ijonuuns).
Sect. TI.— Chronic Phlegmon.
I
The name chronic phlegmon is git'en to intlammalions of the con-
nective ti^due of long duration, charafiterized by a lardaoemia induration
iU'>ual1y accompanied by suppuration. It is not a primary disease of ihe
connective tissue ; it accompanies chronic affections of tlic bone or of the
vascular system.
Soinelimes the thîcltcnîng of (he connective timuc i* Considerable jiimI
8imulHt«-s a tumor ; but the tnuiefaction i.* never clearly circumscribt-d,
it blends with the nei^Iibonng healthy parM, so that it is difficult to
■s«ign any definite limits lo the lesion. t"[ion die iturface of the ^kiii
th>Te may be seen either ulcers, tistular openings, or pa]>illary hypcr-
tropliifS.
Upon making an incision into the morbid mass, the tissue presents a
tardaceotis appearance, and a serous or opaque fluid flows from it. Care,
fully examining the surface of the section, distinct fibrous portions are
recognized, which correspond to the tendons or apoucuroses; parts trans-
lucent and inliltrutcd nith fluid, as iniclcni»: irregular, opa<|ue, aud
purulent spot») ; dilated congested vessels, and lieinorrhagic poinbi.
In order lo study with the micrOKcope thi* complex lissuo, it is neces-
sary to employ sevurui inetlioila. The elements obtained by leasing •
tresh jncce are pus cells, gruntilnr corpuscles, and cvlU larger tlian
those of pu«, of varied .«hape, rovitul, ftiâîfnrm, flat, irreicular, similar lo
those seen in a sarcoma. IWiden tliese cellular elements, there arc weft'
fat granules, drops of fat, and fibres of connective tissue.
In thin sections after hardening; the tissues, tliere are found fas-
ciculi «f connective tissue running in difl'erent directions and separated
by collections of cells. Some resembling white blood corpuscles, others
larger aud fusiform, representing the fixed cells of the cmncctive tissue.
In theae sections the bloodvessels present embryonic walls, and are sur.
rounfled by an irregidiir moss of pus cells. At times small spots of atro-
phied adipose cells, with a multiplication of their nuclei, arc found ; tbey
arc ^jeuemlly sepuratod from one auolhvr by collections of embryonic or
»
I
TimORB OF TUB OOBITBCTIVS TI99Vi. 25T
colU. FitinlU'. at some pointe oftho ])ri'pnnilîo», cells o»nlo);oti8 to
OHu uf a Hitrcouu |in»loni!uiilo mul Tornt collcutiano vtrrvin)^ in «he.
It i» «eon from Has ilt'M;ni>tioii that tliCR' is ixi rutKlamviilal (URorcncc
between the structure of iIi'ik iiiQrl>i<l ma»» «tul time of M>tuc SArcoauta;
it would )w irajwaaiblc vt >liH:ingiii»li preparntions of ititise two UaHuci)
Fcli-cted from Ihosu wlik-h L-lcKt«ly rt-.temble each olWr. Bat if :i com.
tc an-l (-ompunktive aiialytiiit of 'lilfcreiil portions of these ui>oplasiiia U
]e. (lilfiTcutia) charactent are hooii found. A Mrcoma, for cxnni]tle,
Ica^t irbcti not inSamed, does not coutain purulent sfmU «a does a chronic
phk-^uon ; annin, in a chronic phlegmon, the constituent elcmont« of tlie
tiiHuv iwreiift A much lont;er time than in a diffused sarcomatous l^imor,
Sinci' a chrouic phlegmon is occasioned by a cauKC which mav «cnerally
Iw dtrlwnniiiLil, such as a white swelling, a diseased bone, etr., while the
cau.4p of (he ilevclftpniciil of a siirconiii is unknown, it is almost always
easy u> make liie diiignoitî^ by constduring all llio iitfonitatiou funiixhed
Uilli clinically and j>atholo^ieally.
Another very important diffcrcnlial character i$ f^iven to iis by tlicra-
peutical Burgery. When the anatomical cattle of chronic pblei^on is
rvruoted, there is recovery. When in a surgical operation, an amputa-
tion for example, tJiare is eomprUed in the tiap some of the indurated
tissue of a chronic phlegmon, the i-eaulting cicatrix is rej>ular, while if
Karonnuiioiis purls are left the tumor again grows with renewed activity.
Sect. Vn.— Tumon of the Connective TiMue.
All tumors without any exception may be developed in the connective
tissue, but it does not follow thai the cells of ibe connective tissue are
the only source of these neoplasms, as Virchow has maintained. It
lias been previously shown that almost all the ncoplasma constituting
tumori, at their beginning comisi of an embryonic masa, which is the
origin of the new tissue. The method of formnlion of cmbryonk tiiwue
from connective tissue is the same in a simple intlnminatton am) in the
V'^inniiig of a tumor. The cells which form it are probably the while
blood corpuscle» escaped from the vessels, and the cells of the connective
tiMue multiplied by divi«ion.
The most fréquent tiimon of the loose connective tissue are those which
have their analognes in the varieties of this ti^tue.
The epitheliomala which are developed in the connective tissue always
have their oi-ij;in in the inter-pajiillary epithelium, or in ibc embryonic
tissue in contact with pre-exiitting epithelial masses. All other tumors,
the osieomata, chondromaia, etc., may also bave tbeir origin in the loose
connective tissue.
ycrous cysts of the connective tissue are always lined with endothelial
cells similar to thosv of the serous membranes, and of the eouneocivc
tissue. Their waill is formed by the fibres of the connective tissue placed
one u[)On tJie other ; between the fibres there arc found fiat cell» arnin;;e(i
parBlM to the surface of the membrane. The development of the:>e cynts
bas not been studied, but it îa very probable that >t Ls tbc same as tliat
of serous bnraie.
IT
ffîS
l%CB.
There hnvc bct^n Mon in suHcuMneouei connective tissue hyilatida with
echinococci. The mother vcâicnle is tli(>n aiirroun<le<l bj* a coiii])lete coi^
neetive tissue membrane containing nnmcrous vcesvls.
Sect Vm.—Hemorrhagea of the Seroui UembrAtiM.
Ilic ftlu^rntionx of the iiemii.4 nuniliriinv^ an; hero stuilicd, on account
of tiit-ir aiialn;ty willi tlio» orcoiiiit-ct.ivi- ti.tHiid.
IIomorrhn;;e.i of the aerous iui>uihrai)eii nrc comioon, Huch aa memn^oall
h omorr liages, [)eri-iit«rino hiematocolcs. and hHeroatooeleii of tlie tunioc*
vaginftUa, The elfuscd blood coagulates, undergoes the inetaniorpboau
observed in all blood extravasation, and occasions an inflammation of tha
scrou! niumliranc This inflammatiDn is j^nenlly slow, and docs not
cniisc 8ttp{iiirntii)n. It produces cxudittions and new formulions in tba
form of falHi- iRomhniiii.'^ upon tlif hiiH'ikc, or bande and adhir)>inns 1x-
twucn llio two surface» of the neron» membrane. Ilie rvtroj^radc chan^^'s
of the etfugi'il blood consist in the dinapiicnranoe of tlio risl cells, the
elimination of the htemoj^lobin, the formation of bnimatin granule» or
crystals of biemotoidin, the hi-eakin;; u|i of fibrin, etc.
In traumatic hemorrha^^en of the serous membranes, notahlv in the
hemorrhages of the peritoneum following a wound of the abdomen, the
hœnHttin which eomes from the ducoroposiiion of the red blood cells is so
abumUnt that, upon opening the alidomen, it appciini as if soot had been
spreuil ti|>on the great omentum and intestines. L'pooi the great omen-
tum the black matter i^ seen in the form of very deep brv>wn oprnjue
granules, spherical or an;;idar in shnpe. Tliey are located in the white
blood corpuscles which fonn collections between the fibres of the reticu-
lum, in the endoilielial colls lininj; the fibres, and in small groans of cells
that surround the «diposo ti-*suc, whicli the_v partly conceal. I'pon the
intestines the peritoneal cndotheliinn is also inKhratcd with black gran-
ules, and has the appearance of the epithelium upon the clioroid coat oC
Mic eye.
The absorption of the ha'matin frrnnules from these locations is effected
probably as in the eonnectiw tissue, by the lympltatic vessels, ihrouj^h
the intermedinlioii of thv- whiu- corpii.scK-Ji.
1'iie piieiiomeiia observed in llie peritoneal cavity of a rat in which
deltbrinated blood has been injected, are the following: spherical swell-
ing and proliferatioTi of the endotlielial cells of the serous membrane ; tlwj
IMmeli-alion of broken or entire red blood cells into the interior of then
cells, some of which are detached and float free in the carity : afterwards"
the formation of pus cells and a fibrinous exudation. The rod blood cells
undergo changes, first studied by KindËeisch, similar to thoee seen in
blood when heated to 40^ C. They are dccoin)>osed into spherical, re-
frftctin<;. colored granules, easily iwognincd, and their diUcrcnt stages
of dlsiulegration may be seen.
INPLAMXATIOK 07 SBKOUS MEUIIRAXBS.
8«ct IZ.— Inflnmination of Seroni KembruM.
Tbo eesontinl c1ian<^a aict with In all infliunnwlioiis of Hw urana mvia-
bninvs Kro cxuil»tion« itiid iiiulli[!li(\ttioii of tlic «ndotholini colls. Tlic
oxni^Ations of in8aiDc<l Mroiu nu-m1>raiii-i« itliriiys contain fitirin. Ttii# la
not iiiieKpe<:t«<t, «tice the flui<l of it^rous cavicio» in tti« ph/tiio]nt^ail
fttato oonuin* • con«<lcrnble <{tiai)lit)- of rilmtio;;pnic iiubiit»ucc. In ilio
acnte iiiflamcmtionR of HcrouH iiiemlintnct*, the fliiii] in tlie cavity becomes
more abtLitdant and still «ontaiiM a larger amount of fibrinogenic sub-
atance.
llie fluid obtained by puncturing the clieflt darinj* on inflammation of
the [Jcurn, U at first clear an<l fluid, but if exposed to the air in a foir
boura it becomes a gelatinous mass. This change was first observed by
Virchow, who concluded that tlie fibrin doe« not exist nlreiidy fonne<l
ill the oxudatioii, but that the latter only contains a substance stii<ceptîMc
of becoinih;; fibrin under ihe infinetice of Uie action of tho air. Tlii-re-
fore he itnnicd this «ubstnncc fibriiioj;uiiie. Yet it ia oertnin tliut the
action of tiie air i« not the only causc that dcci-rmines the ooagtilalion
of fibrin in this fluid. The addition of red blood cclU or even tho itennn
of the blood after it haitcoagiitatoil, uUl immediately occasion tho a{i|iear-
aiice of fibrin in the exudation. Thene are very iinjiorlaiii facts, since they
explain ihe process of the forinaliun of fibrin deposited uimu the surface
of tlie inflamed serouBmembrane in the form of lamiu.'e, while the distended
cavity contains a clear fluid. Yet the central fluid may presfiit some
fibriiiou* flalccs, or may coagulate to a greater or less extent tlirougliout.
Fig. 14:^
Itwiul ■BttUxllasi «f vlcwnl perfcudlBD nf atni, tUtHtrwUd ud bl||h pomr. {Cki^Mit*.)
If the fluid exudate<l Îk abtinilnnt and clear it is termed serons, althnu^^h
there always exist» upon the surface of the membrane a layer of fibrin
varying in thickness. In this serous fluid there arc fonnd suspended
many puA cells and red blood diiiks. When concrete fibrinous layers
exist upon the surface of inflamed serous membranes, and tlie exudation
260
is OP THE COXXECTIVB
Véoee not contain cither blood or pus cctU appreciable to tbc unaîiU-<I ejif,
tlie «xudation U termed Ghrinotu; when the cxwlAttoii contaitis bkwjd, ilia,
named bcmotrhagîc ; and puruk-iit, whvii it voutaine a large amount of fnai
Kg. 143.
pMlltf Tldv of nirmtl «■kjnlhfll'in nr ticHorJIon at k l«'l, irxlvit «Ilk t>)<l ; 111* cuJorlKUsM
• liiiiriui: >t llic uii|Hii siIki. Tbc iMIaU »ILa baJon «n nBiia<ili« iIiiki* MF^oxIt*. Illfh pvHTT.
'r\ie Jifirinmi» exudttton formed upou the atirfaco of «croui* menibranea
rnrivs in iw armn;;cmeDt and microscopic api)earatice. Wlien receul
the «tirface i« seen to be redcuUtcl. liavin;; very smull mcihes with alight
dcpre«ùon«, at lir«t tbio, bat soou ttiickoned by tbo deposit of new layers.
Pcvlllii TUwaraiidslliolUsf ptrinnlLuia ofu»'! urciitjr.fuaf buan bjamaj. Oald daUvd.
lllfh pi}<v«i, {Chapman-}
It is yellowish ■;^rny, scmi-traoKparcnt, gdntinowt, Mft, and friablu. It
can btf dotacbi.-d with tbc nail in thv form of «bred», «hioh when broken
liavu a clear fracture. In tlii; perieardium the fibrinong cxndation has a
special arrangement, its surface lias been compared
t» a cat's loiij^ne ; it i» villouH, covered with granu-
lations or »tired!t ; this arrangement is produced
by the agitation of the fluid caused by tlie move-
menu of the heart. When the exudations are
chronic they become smooth, opaque, and are fonnod
of layers placed one upon the other, wkich may be
separated by dissection.
In order to «tudy niicrosoopîenlly the stnicwre
of thi- fibiinous exinUtiun, and the chan^^es in the
KubjacentHcrous membrane, several methods should
be employed. The nK>«t simple con^ii^ts in renM>\'in};
shred» of t^e exudation, and examining them after
spreading ujion a jflf^s slide. Whew very tliiu
there is seen with low power a very beautifitl retic-
ulated arrangement: from a central thick point
trahecultu of fibrin radiate, increasing and dividing towanU the periphery.
When the exudation is thick or chronic, this reûculatcd amingeroent
cannot be distinguished. By tearing with needles there are found cells
varying much in shape and size. Some resemble white blood corpuscles,
Tr*i»rorui''tl sn.lHhall*
of p»rlfiikl porir^rdlnni ot
nuf. Iwu /\t.jt liiiliniiid,
OvM irwud. Bl|b pavor.
IKfLAMUATtOX OP TnS SEROUS MEMBRAXKS.
261
gcnenlly conlainins larj^c. ov»l, rcry distinct tiiKlei, will» one or more
Wj^it, largo nncWIi, similar to the nuclei formcrlv coiuitlcnvl chnructer-
isiic of cardnoina. Other ccllii wliich contain nuclei itrv tint, rc«oroli)ing
«n4)otU(>liml cvUb of lh« «vrouii ni<.^nil>rnnM, others powoM long pmlon'rn-
tinn» nnil niinH-roiif nuclei, nrc ftht, rcscmhiing multiniteloar coUk i>f hono
miirr»ir (roj-(î!ii[ilftxc*. Kinnl oulU). l.nnglianK hn» pointed oui lliese Inat
colU «rouii'l tuWn.^iiiou.1 ^ranululionit of M>roiM inembranen ; but we have
found (beoi in »)1 tlio tihrinon^ intlammnttons of scroua membranea.
Fig. 146.
Tnùttinùtl (ndnikslU of tIm««i ptrloitdlam «r Iniit, nli •Ut> iii«iinrit, Oold tritlM.
To jitiiily tlic itituation of those cell* in the exudation, the relation of
tlie exiidaliou with the suhjaceiit menibraue, and the chanseii in the liiller,
rertical sections are to he made at1«r hardeninj;. 'Ihcy show upon
the flurfacc of the serous membrane a layer of amorphous or fçrsnular
fibrin, limited by > Tery distinct although sinuons contour, Rcncatli are
seen succesaivo layers of cells previously described, and fibrin arranged
differently according to the case. Usually the fibrin forms a network,
the flattened meshes of which limit elongated alveoli containing the cells.
The limit of the serons membrane is always very distinct, the exuda-
tion is simjilyapplicd to it* surface, and i^ »epiirnlcii from it, at intenni»,
by collection» of endothelial cell*, forming teviTa! Inyers, and wiembling
the ccIIh found in the alveoli of the cxudntion. It i* very probable that
all the ccll« come from the proliferated and detached endothelial cells of
the «woUcn »crouR membrane.
At present we can lo;rically infer that the endothelial cells, mwlified
bj inflammation, act aa ttic flhriuo-plaâUc substance, and determine the
OHASoeS OF THB COSHBCTIVB TIBSUB.
formation of Sbrin from the fibriuogenic substance of tb« primary fluU
CXU'lalion.
Thv Hiipcrllcinl clasUc layer of the serous mcmhrnne is in nKXSt caset
uiicliiiiigi'd. Butwcon tho fasciculi of tliQ subjacent oonneott» tiaaii
Fig. UT.
«I'li'jlt-fvrvi m'l \Tr^a$*A in iw* to formiiwrg or lot" ooai^»! fultc jpenbnkB**- Oold u<*l»A. _
there are ac^^n nimu>roii4 celU, normal m ch¬er, wmîltr to white blood
corpusdeii or ljm)ili cc\U. Itenide» lho.<ie,dU^noUy limited circular ellip-
tical or cylindrical sjiota are observed, which are only the transverse or
longitudinal Beclions of ilie lymphatic vcaaela of the serous membrane
rfillcd with lymph cells, Erocst Wagner recently, in studying fihrinoM
picuritis, pointed ont the filling of the lymphatic vessels witli (ihriii, and
concluded (but thit> obstruction of Ibc vessels interfered witli the absorption
of the exmliition ; be aW mentioned the existence upon the surface of
serou:^ nicinbruiie» of largt! colls with many nuclei, which ar« fonud alao
in chronic inlliimmations (Uoliitan»ky). We have oursolves oltscrved
the lymphatics tilled with fibrin, and a;;ain, in pericarditis and fibrinous
peritonitis we have jiroven the exi^lonc^! of mmlificd epithcdiul colls la
the mass of the exudation, and the dilatation of the Ijmpbatica by an
accuranlalion of lymphoid cells.
JIem"rrha<fie infiammnllmg of serous membranes are characterised bjj
the preseucc of « varying amount of blood added to the fluid or fibrinous'
I
?CItlJLB.1T IMPLAMUATIOK OF THE SBROUS HEUBRAXBS. 263
citnctutio». Jli'tiKMjii Himple flbrinoufi iiittemmfttions toi Inw h«iiM>rrb»gi«
it)tlai»inniiniL« tliort' are i)i.itiii^uk)ieil niany iiilorn)ediatc fonns. tu the
nwwi HiiT){<lp lli« filiriiioii!! «xu'latkin U stii>I<l«'<i with ecclivinotic ti)>ol3,
Mpcciiillv verv 'li^tinct u])Cin tlio uixler aurHu-'c of tlie exiidalion, at ibe
tnoioetilnf iie))Aratiii;: it. Al otiior tiincfi ttic Glirinoua membrane h red
t}irotii;hntit iu entire extent, anil the «eroii^ surface of the exudation is at
tlie Mtmo time colored by the blood. Ttii-ae hcmorrtiagic influnatations
are very ffv<)wcntly connected with th« formation of n«w rcesels vrliich
develop upon the surfncc of the Herons lOL'mbranc. and pcnctralo as flab-
teiivd i^nntiliitioiM into tlic uiiiler portion of the exudation. The newly
fornwd vciweU hare an vuiVryonic wall, nml arc surrounded by nn ein-
bryniiii" tiw«e; tliey l'i>rm bmiicliex which mdiiito from ft central vc«si«l.
ThuB in hciDorrbnjpc iniMiin-çiù» (pachyniMiin^iii*), there are at limes
found upon tlic internal surface of the dura mnter, Hmall nummular red
pnlL-he«, which u]ton vdry careful examination present fine vaiwiilar lufl^
an>i Jtnuill ecchymoses. Tbe^e small palchet), rudiments of ne v membranes,
if extensive, as is frequently the case, may be readily detached. A ver.
tical section of the dura mater ihroiigh one of Uiese pointa shows the
continuity of the durai ve&^els with those of the new membrane.
In hcmorrhnj^ic iuBammations of other serous membranes, sometimes
ther« is oWrved, as pointed out by KindHeisch. in the middle of the
exudation, the new formation of vessels, the friiiblc embryonic walU of
which eiinity toni give rise to livmorrhaijcs. Ihit in eases where the
exuilnti'ui i» inlîltrate<l with blond, nlth»tt<!h ve^Kel» an- recoj^nixod in
the cxtidadon and false membrAiic, it is difficult tA determine if the
heroorrtia^e proceeds from the new or old vesaels. ^\'hen the process is
chronic, the false membrane a compoaed of embryonic tissue and veseela,
with layers of interposed fibrin of considerable thickneas and is batkod
in a bloody exudation.
The bloo"l effawd into the exinlstion undei'soea the nsunl chalice* tcr-
tninucin;! in the formation of ^rnnulur or ery^ialUne hiematoidin. When
hcmorrliii^ic inSammations result in Buppimttion the fluid within the
aennis cavity contains pus, which examined vlo$ely wîtli the uimidetl eye
prewnbi red granules consisting of large crystals of liivntatoidiu isolated
or in jzroujM.
llemorr)va-^c inflammationa of scrotu membranes ocour particularly
in alcohol drinkers, and in tlie inflammations connected with tuberculous
and cancer.
Purulfht itiflammftlioH» of the serons membranes are primary or
secondary to a fibrinous or licmorThagic inflammation. Thus, m son»
fibrinous pleurites, where a primary paracentesis thoracis gives a sero-
fibrinous linirl, a second punettire made several days after the first will
give pus. I'rimary purulent inflammations, however, are much more
comnioii ; they oiicur tn puerpéral fever, purulent infection, ^lander^,
rhenm»ti:>m, ete. (.ienernlly in tlii* affection the or;;ans Covered by «
«erouA membrane contain melatitatit; ahscesseit or some legion of th«
blood or lymphatic ve»eU, which will he conxidered under tlie vascular
syatem. When the ooune of the purulent inflammation is very rapid,
the serous c^ivity is filled with a recently formed pus. and there is no
solid exudation upon its surface. The vessels arc dilated, their walla
S64
CHaSSEB of tub COXXBOTIVB TtSSUB.
lenitiryftniv, Hml the connective tissui- of the Boroiis ntomlinini^ !« îniiltratoil
r«iih piia uolU. It is ahuust bcjronil doubt Unit the pits cclU cumi- from,
tilt blood and tliitt th« cndotlicliiiai of tin) iiemns Dicmbnino InkcM bnt liltM
niirc in their j'nxluctioi). In man, the clinn;;!.- of the «ndolhi'lia CHnnot
be followeii ; »it the time «f the «xuniiniiti™, they an; either not Toim'i or
«re see» in tlic form of ïlired» com|MH«d of granular fiittjr cells. I'wi.
ally yellowiih (lnke« niryin^ in i*ixe atut .«hape arc found, forming a 6brin-
ouii network, t)i« mcslivit of which are filled willi pua celU genorally faltj
and granular.
If the course of the purulent inflammation is less rapii), a fibriootis
«xiidatioii \s oeen upon the surface of the serous membrane, the stnicturo
of which ia exactly eioiiUr to that of tlio procedinj; âakes. The number
l4>f pus cells is hero so ;;real that tht-y complvloly conceal tiie fibrinotttJ
Foetwork. The lymphatics and t)loo<hvfi(ielif of the serous inemhrano pr«-1
$ent at this time the skiuc chan^ej »s in fibrinous iiitlitmnintion.
Lf the purulent inHanxnatinu nccuni after a nimple fibrinouN indatnnia-
tion, at tlie autopsy there a« fouml very thick faUe inumbraneji infiltrated
with piH, vascular ^raniiKlioiiii .tiinilnr to those described under heinor>J
rhagic inlluin ma lions. Almost always red blood-diskii or pigmented ntatterl
derived from them are pre;«eiit.
The piw formed in serous cavities very rapidly undergoea nutritive
changes: the cells are filled with fatty canules, and when the fluid haaj
been partly alworbeil, they become caseous. This caseous pus forms
yellow opaiiuc masses havin;; the consistence of putty; formerly it was
boonsidered to be UiI)crcii1oii;<. When ttic fixa rcmninfl in ft QmA sUttc iaJ
Etlie serotis cavity, it« cfUnlar elementii are destroyed, at least in ei^an
lipart. There are formed, a» in tlie caseous contres, crystals of the fattn
'acids and cholesteriti; at limes pigmented granules and l^a^matoîdJu cry^l
tals are present.
>?olid fibrino-piirulent exudations undergo the same changes as pus
cells ; they become caseous, shred» arc detached from their surfaces and
float in the serous cavity. The shred» and exudations, yet adherent, are .
composed of a granular substance produced by the molecular se}>aralioD^
of the fibrin and of collections of fut j^aunles, of crystals of fatly acids,
of cholesterin, and of bliiod pifjnu-nt.
The serous membriine at thi* time is considéra hi y thickened and vas-
cular, or it resembles carliiaj^-. It consists of purnlltd lamellio of con-
nective ti^ue, between ivhich are found flat cells; tlii« indurated tisxue
is in every way similar to libromata with parallel lamella) and Hat ctlls.
This new tissue i» very liable to calcareous i ililtration, which forms hard
bone-like plates, varying in regularity and extent. We have never seeiH
bone coqiuscles in these bone-like plates. '
A thickening of the pleura is especially seen around oiasses of caseous
pus. Sometimes the change is limited t^) a single portion of ihe seronsj
niembrune. thus forming a ey^t with thick walls containing caaeoan
matter, around which there exists, in a few ensos, a gelatinous trans»!
parent material studded with opaijue spot.*. These chronic encystecl'!
pleurisies have an aniilop^us arrangement to old hydatid cysts. The gela-
tinous material thai they contain is nothing more than fibrin, .
TUMORS OF THE SBttOUS UEMBIIANES.
265
/f^perptaMtic or mt/ietirv iHjtamtHatiom of avrous ituMiilinini^s «re cliar-
acU'riied bv a ;:roiTCli of cmhrvonic ttastiv lrnvri¥c<l liy Mooi^voiuieU,
which is dennitely orjinnizcl ami j^ivca rist' to thickciiii)>^ or iii)h««ions.
Ailhc^toti!! occur in the f'>rm of baatls, or Ihcy rniiM? ii ooiiiplcKi fusion
or th<- two opfioBitu sirlcs of [he serous mctn)trAi>i>, fro<iU('Utljr occMioning
tlir olilttontion of the ecrous cavity.
Tlifl nilhosivc iiiflntniDationd occur ttltcr iiiflnmnuitioiiii «1ii«h present
the mlhwivo chnntcter from the beginning, or lliCT follow fibrinous or
iniloiit iiiflamnMiionH; but very often it i* »n\<n^\h\e in oM adhesions to
Stvrmiiie t)i>-ir oripn. It is i>rnbable that many of tiiom are of con-
genital ori^çii), and may be conncoted with niBlfomuitions.
In a feiT aiiu>|K«i<-» there are found upon the surface of serous mein-
hmn*9 Mivd C'^pecially the picun, soft va.wnlar grof lbs, composci) of em-
bryonic tissue and vessel*, the walls of which wmitt entirely of celle;
some, acconling to liin<lfleisch, present considerable len<^h. These
growths as they <leveIop meet with similar formation* from tlw opposite
surface, are united, become tibrous, and so fonn band.i, very varixble in
form aiwi extent. Their surface is now covered with
flat criilotbelial cells similar to those upon the rest nf
the «erouB oviiy. (Fij;. t48.) When the adhesion
is complote, there ts found between the two serous
surfaces a homo^ii«ou5 layer of fibrous ti«sue
which blends them into a single membrane.
Thickening; of a ser"ii!< membrane, or hypcn'hwtic
infinminalion a)'[«ars to liave the same orif^n, but
a* tile new formation is limited to a ain;.{le surface,
the growth doca not terminate in adhesion. If it is
very slight, it is termed a milky spot, on account
of the whitish uppeanini;c, due to a fibrous tissue
comjiOMd of su|)erimfiiii"i-d and pHnillul lamiiinï. If
the new formation i a thicker, it WTistitiitesthe cnrti-
lagcdike plates previously doHcribe'l, In (be niilky
and chonaroid plates the bloodvesnel.'* arc very fen-
or entirely vanlins. At times the chondroid plates become iitfiltraled
with calcareous salts, and then form solid '■ cnrapacf s," which arc met
with in the pericardium, pleura, peritoneum, tunica vaginalln, etc.
Fig. IM,
KidnlhetlHia cnTttlBt
Ibdbniu ^IM1« «blrt
null* oppnlir ■iirfMnaT
lb* |>l«qr«&ri4r riiBAiniih
Sert. X.— Tomer* of the Serons Membrane».
Priniary tumor.* iif the «eroiis membranes .wldorn occur, while second-
ary tuu)or:i, tbrnugh extension or gcneralizadoti, are frc(|uent.
Primary tuniont of xeruus membrane* are those of wliicli the type U
found in couiieclive ti^ue: fibromata, lipomata, myxomata, saa-omaia,
carcinomaia. and tubercles.
The most frei(uenl/Ar'/M<i of rterotu membranes ia tlie laminated fibroma,
or corneous fibroma. (See p. iVi.)
At certain pata of several of tlie serou» cavities there are seen viltoue
appendices fonncd of adipose tissue and vessels covered by the serous
CIIAXaSS OF TUB COXKBOTIVS TtSBUS.
■ncmknino, like the finger of a glove. Suuli arc tbu ■.■piploic uf^tultcfs
of the intc'Stim-ii. tlic folds of adipOHii tit^ac of Hie )iuntoiii!uni, tiii* villi
of tlic plvurn.titiil tho synovial fringco. These <.vlliilo-ii>liix>»c'U{>]M-tiiii<.'es
uiro aiilijcct to li_vp('rlri>iihi(!» aw\ ooiislitutt" lite '/'■Mt/rif**- lij-itnn(ii, iht .
psvolution ofnliicii \* »tow. In tlioHO kahip a)i[icii>lico« iducoum ur tiliroul'
tiitAiie miiy form, vciiiKtitiiling pi^iltincululeil mi/jMntattfu* or JibrvmaUnu
tAiinors.
Aliliary ( ti Acr ''u'ou n i*)'» /<[/'>»« of ne roui) inenibraneaarecommon. Tliey
are primary or are aa.iociale'l with a generalisation of miliary ttibervii-
loiiia. or are developed in the proximity of tuberculous foci of organs
covered with n sîtoua monibrane. The gramilaiion» are prominent, len.
ticular, whitish, traoiiUiceiU. non- vascular, eanwliniea opni|ue at itieir
centre. The smnllvst arc scarcely visihltr to the miaiiloJ eye : if they
are numerous, ihcy join nt their borders aiul form areas varying in sîbo,
with si<rnit«d edges and uneven surfaces, 'l^e neighboring serous mom-
hmni; is congested and ecohymotie s}>ots are seen very oftvn upon (ho
peritoneum, either red, violet, slalecolor, or black. They arc generally
upon the visceral layer of tlie serous membrane, but arc also found upon
the pnrii'tal layer.
Tuberculou!* grauiilatiotij of serou.t membrane:* arc very ouporficial
, ft])pcnring at time» a^ if placed u[>oii the aeroiiit membrane. Tticy nut/
laUo be oitiiated in the membrane, and in diiFerent layers of il, wUen
Fit acipiirea coDBÎderahIc ihickne^H, and preoeiitd the Htnieture of inters
Itlitial inflammation. In the [leritoneura, and e»|>cciaUv in Ibe great
oin«iitiim, sonji'lim«H the liyera sre united wijether. ami the destroyed
trabocula- replaced by a solid mns» one to iwi> centimetres thick, funned
of tubereul(>H-t granulaiioiiK, imbedded in a soft and vascular tissue. To
the unaided eye tbiit new formation may be uken for a eoncer.
The evolution of tuberculo.*!» ocoanions iu soaie membranes tliflereot
varieties of inflammation»!, fibrinouit, liiMnoirbagic, purulent, or formative.
Frenuently, when the tuberculous erupdrm is i-ecent, the entire surfai
of the aerouii membrane h covered with a thin and train parent fibri
layer. This is easily deiaL'iie<l from the membrane, and often l}ie tuber»''
culoua granulations arc separated witti it. The surface of the serous
I membrane, at the points where the granulations hAVo been, does not
I appear to have uudergone any loss of substance, whou the false tnem.
brane is removed. In other cases the fibrinous exudation being very
abundant, the tuberculous granulations are not at once observed, so also
when the exuded fluid is hemorrhagic or purulent tliey are concealed,
and aiU'r removing the exudation, the surfxce «f the serous membrane
should be washetl, when the granulations become ajvjMreMt,
Chroniu luberculouK inflammations almost always cause soft vascular
granulations, varying in extent, covered by an exudation, and iu the
lissuo of which tuberculous granulations are developed. Tbiit granulation
Ussue may undergo caseous degeneration. In theâeoa.ses iho connective
tissue of the serous membrane is thickened, soft, changed into embryoni
tisHuo in which exist numerous lubcrculoua granulations.
In lubercidoais of serous membranes there arc also formed upon the
opposite surfaces of the membrane, bands or filamentous adhésions, wliich
may be invaded by tubcrculotis granulation».
TVHORS OF TUS BBROOS lIEUBRANEil.
267
Bnlous grnnuIation$ of •erous mcinhraiwii, At Uieir be];înmn){, itra
ffmrmwi of small cellular tiemeut» crowded one a^ftinst the other, which
i»re gnidiialljr coiitlimoti-i wi'.h the celU situated upon the surfnco nf
1 the membrknc or iu ila deeper larer. These super&cial cclU are simiUr
Ito tboe« praviouBlv described in tibrinoua exudations. Tlicj are round
I or flat, Bome reMo seireral mUliiDetrca in sue, nud are fillud with nuclei
(;;lnut colls).
Wlioii ibv (iibcrcutoiu «rnption is nbundAnl, the conitccttve tissue of
Uie wrous mcmbrauo tM chuti;;cd ; belweoii iU fasciculi there are found
[ embrjoiiio ci-lU in vnrjin^ iiiimb«r«. Tho lilooilveMtds aru dilalv<l, aiut
tlie Ivinjiliatic vcsjm.-Ii' iilied with Ivmpb corpuscles.
Tlie exHilnùou which aocompniues tuherunlous granulations, preMiits
tho cli«racier« tliat have been ^lu'lied under inflammation proper.
The thickenings and )tranulation.<i developed upi^n the surfacsof sorous
membranes infiltratc<l with tuberculous ;jxanul.tcions, are cnmpoaed of
embrvonic tissue coutaiuiii^ cnpilUnod whose walls are formed of anollen
cells. When there is a development of tubercles in thcao granulatâoiu,
tlie feeaela Gorres)K>nding to the tubercles present the modifications which
hare been explained at pa^ 116,
The ilcrelopmcnt of tubcrcidous gmnutatioiia upon th« surface of
serous membranes, at the bej^inninj; of their evolution, is not always
from the connective tissue of lhe«e meiiihrano^, for tliere are fouixl, Iwncath
the tnlMTvhft, wll* which appMtr to be derived from the endothelial layer,
end a^nin the lituùna of connective and «lasiîc liAHue of the neroua mem>
brane Las not auflered any loss of substance. Do the cellular elements of
tho granulation come from tho endolholium of the serous membrane, from
the while blood corpuscles, or from both of these sources? At present
it IS impossible to decide. Yet IlindHcisc-h maintaiiK^d, nt a tîtue when
the emigration of t^e white blood eorpui^les was unknown, and also very
recently, that the proliferateil endothelial cells wore the |wint of origin
of tubercle. It is very probable that these cell* take part in tiie forma-
tion of superficial granulations, but it ha* not been demon:strated tliat
they «loite arc the origin of them. ^Vheu tlic tuberculous i^anula^ons
are developed in the ileptli of the connective tissue of serous membranes,
or in the granulall>)ii tissue, they spring fi-om embryonic tissue, which
may be derived either from the jiroliferated flat cells of the connective
tiisue or from whit** blooil corpusctea.
Primary ritreinoma of serous membranos is very rare, but secondary
carcinoma, by extension or generalixaiion, is very ircnucnt. Of all the
primary caremomata which bave been obwn-ed, the most common is col-
loid carcinonia of the periton*'um. either u|)on tlie peritoneal surface of
the liver, stomach, or in the gr<-al omi-nlimi. Ft present the form of gela-
tinous plates with vuscnUr marLiu;*:* .tiid "f ecohymotic points. It is
"ifeloped from the connective ti**ue of tlie serou» membrane or tho sub-
''Wrous connective tissue. In the great omentum tlie reticulum is trans-
formed into a flat ma^, having none of the structure of the omentum, but
only that of collotil carcinoma.
The other varieties of caivinomata have their origin in tbc organs cov-
ered by serous membranes; whileincreasin;; they form round mn.^O» which
cause inilammation in the serous membranes, tbc exudation of which is
almost always hemorrhagic.
268
onASflBS OF Tns oonsbctivs tissue.
Wlion there exiitts a carciiiomatotH ma^ formed upon a aerouo mee
lirniie, there are getu-rallv ilevelopfl nmund it smaller, separate, imtn-
mtilnr HeconcUry miiA^e^, having an iimhilicnte'] central depression. Ttàa
depression ia occasioned by a graiiulo-fatty degeneration in the cenlr«,
antl hy an active development at the periphery of the nodule. Th«
lymphatic vessels which pass from t)ie morbid înasees fre(|UODtly form
upon tliD sorous membrane hard, knotty, whitish conU, 8ejAratc<l or
arrangi-d in a reticulum, while email granulations are developed near them.
The tissue of the serous membrane artiuDd these dej^nerated lymphati<
and f;ranulations is always very vascular. The bloodreescls itre dilate
and linvc embryonic wullit.
Viilimlrii'ttUetUMfpilhelioma may extend to the seroua membranes, but
it is very rare. Frc<]uently an epithelioma of this nature developc^I in
the intcMine^, stomach, or biliary pitssagea, causes aecondary formations
of con-tiderable siiu; in the liver, without the serous membrane being
involved.
Sarcotitatft, »(/uamou9 epitheliomntti. and cfiondr/wiatt, arc ^-ery seldom
met with, and *re secondary formations in serous rnuiDbnines : tlic ù»t«>id
tttinor» are propagated more frequently to serous membranes.
MOHUAL
TISSUE.
269
CHAPTER V.
CHANOBS OF THE MUSCULAR TISSUE.
Sect I.— Bomal HiBb>Iogy of Uaianlar TlMue.
^Vk have divided muHcleH inlo three «Ibilinct kinds: Isi. Rftpid and
voluntary coutrxctjug muscleii ; '2à. Uitnliac muscles, in which the eon-
traction 13 npid and involuntarv ; Ad. Slow «od involuntarv contracting
muscles.
Voluntary mu»clcs c«enlialty consist of strialoJ muscular fasciculi
(lescribeil on jmgoSl. Tlic fusoicuti are arracij^cd pamltcl one to the
other, bouiti) together hy oxtroim-ly thin fibiv!> of connoctive tissue so
M to coiutitute dii<tinct i^roiifis known m iiecoiitlary fasciculi. Thcsv
seooDrlary fasciculi arc not »»rrouu<)cd by an amorphouH continuous
membraiiu simitar to the sarcoleininu, which surruumU tbo primary fas-
ciculus.
Between the secondary faticicuii arc placed tlie arteries and veins.
The iiipilliirics pooelraw ilic aci-ondary fasciculi and arc dtaipilm«d be-
tween the primary fasciculi, tbrmin;* elongated rectangular meshes which
envelop in ihcir network the primary fasciculi. These capillaries are ab
way»«ituateil extenial to the «nrcolenimu. The entire muscle is cnaheathed
by an «poncurojibt formed of cWc connectJve-tiiMue laniellic, which can be
separated, as iihown by inji-cliuf^ a lluid into th<- muiiclc beneath the
a[ioneuro.^is ; the fluid will pass through the aponeuroiti;» to the cxtvnial
surface of the muscle. A fluid may, therefore, penetrate tliroiigliout the
whole ext4.>nt of a muscle between the primary fasciculi, tiic conneottvc-
tissue fibres and vessels. Consequently, a rauscle possesMS a vast inter-
stitial laciumr system belonging to the connective tissue, and which i^ in
counminieution witli the lymphatic system. All muscles have tendons of
insertion, h was believed for a long time that the primary fasciculi of
the muscle wore directly continuous with the fibre* of the tendon.
Kulliker, howcTur, hai «ecu that when the muscular fasciculi came
obliijuely upon a tendinous surface they were not continuous with the
tendinous fibres: but he per8i!il«d in believing that in vases where the
tendinous fibres have the same direction as the muscular fasciculi they
were continuous. Weiîmann, in studying the muscular insertions by
chemical melhoda, found that a solution of pota!<h demon^traled the union
of the muscular fasciculi with tiie tendon by means of an organic cement
or uniting substance, wiiicb under the actinn of this reagent is softened
and afterwards completely dissolved.
270
CIIANOKS or TIO: MUSCULAR TISSCB.
Sect. 11— Nutritive Lesioni of lffa>ole>. I
The lesions of the uriiimry fnscïculi of miiHcIcti conHtst in chaiif^s of
imlrition of Ihe miuciilitr tisttiie, or in a division of Uie nuclei of tli« «ir- '
co)i.-iiiiim an<l of the protoplanm whieh HurroimiU tliem. It fre<)uently 1
occur» that the leriionn of nutrition ai-e accompanied by a iliviaion of tka 1
nuclei of the tian^lemuia : yet tlietie two phenomena fire not aInaysas»o> !
ciateil ; there may be multiplication of the nuclei of the sareoleiDtoa whh' 1
ont any nutntive change in the tnusoular faflciculi, or, vice versa, very
advanced modlRcatiaiis may occur in the contractile 8ul>fitunc«, without
any alteration of the naclei. .
Athopky op Ml'srCLAR Fascicui.!. — Atmphy of nmiicular faitciculi
noay coincide with gennral utrophv of the muscle, or itith the préserva tioti
ana «vcn îiicrenM of the sise oi the whole miucle, when there i» au
increase in thickness of the connective and ttlipose ti**ne. 'Hie varioua
tumors of miwclea alirays cause »n atrophy of the muscular fasciculi.
The muKcular fasciculi of the entire hodyare ati-opliied in emaciation.
All the fflHciculi of a muacle may he affected at the same time, as in in-
fantile paralysU, or only a fen- are attacked hy tlic atrophy, as occurs toi
low fehrilc diaoases. It is not certain that in the phyaiolo^cal 8tat« th«
mmicular fascicalî of man are not renewed, since in the adult very con-
siderable difTercnccii in the diameter of the fasciculi of a muscle exist.
Some are scarcely the ouc-hundrcdlh of a millimetre, while others nieasnro
tlirep, seven huiiilredths nf a milliini'tre, and even more. In lliu aged,
this rliffi-rence is mori; marked, and there are constantly found in their
mu^^clcs fasciculi containing fatty granules, and other* also undergoing
•trophy.
The atrophy is simple, or is caused by some of the nutritive changes
irhich will be later studied. Usually these changes at the hoL^innhig
occasion an increase in the stie of the fasciculi, the atrophy occurring
Bub3e<|uemly. The airopliied muscular fasciculi are very variable in
Bixe and shape. Any fasciculus in the aduit not exceeding the four-
hundredth of a millimetre may be considered atrophied. When the fa»i-
ciculi have an average diameter of one-hundredth of a niillimetre, th6j
atrophy is consiiierable. Finally, the sarcous substance may have «ob
plctely diïnppi-arpd, at least in some of the fasciculi ; the latter are rep.
resented only hy recliHnenr filaments fonnwl by the sarcolemma, empiy
and shrunken. In an extensive and uniform atrophy of muscles the
Rtriatiun of the muscular suh:^tance may be manifestly preserved in fas-
oicidi measuring only the three-thousandth of a millimetre. These fas-
ciculi possess nuclei, and opposite each of the latter the fibre prcseuts a
slight swelling. This variety maybe seen in progressive muscular atrophy^ 1
in infantile muscular paralysis during its second stage, and in all atrophies
which depend upon the nervous system.
In some case» of ulnb-foot and infantile paralysis, the connective tissne
at times has so increased that it more than compensates for the atroptij.
of the muscular fasciculi, so tliat the muscle truly atrophied, in it« esse»'
liai elements, is considerably larger than in the normal «tUe. Tliis^
fïÏBliPSÔÏÏÏÂBP A e 0 1 C KLr .
271
I
itwrttaitr in hiw in r^iwcinlly shown, when nili)KHto tisiiuo w fonnwl in
great Kbuiulnnvo I'otnccn ilic atro|>liic<t lauMukr Gbrc«.
In tumor» of tlic niuMiHeti tli« rlcvvlojxnent of the nfopUam oconn in
irrrpilar inasitcf ; Uic miLtcular fiu^ciciili have undergnive Ktm)i)tjr in a
[Mit nf tlioir c<Hir!te. whil*! in the reniaiivler of tht>ir extent, the^ naj
huve prctwrved their jmroarv site. It thus happens that tho mtisciilar
fasciculi an.' liivideil into irregular segmcnlfl tho extromiticH of which
nre rnnwleil or tapcriii;!. Generally in their prcwrvcd portion the mus-
cular fibres present numcrona nucH.dietfeminated inagmnuluntuhsunco
«hieb replacva the striie and which resembles cells with many nuclei.
Hïi'KimiOPliY OF MusrLBS. — Hittnlopeal atndy of (he hypertrophies
ifi very difficult. When a niu«clc increaae» in "i^v through phy8iolQt;ical
or |mth(>l<i;;inil exeiviM!. it i* difficult to dcWniiinc if ihii" hyjiertrophy he
due to a iH'w foniiatinn of muNUnlar fa^eicuii, or to an enlargement of the
old fasciculi. The difficulty '\» due bi Ihc fact that tlte faaoiculi varjr
v«rv much in sine in the same inuule in the norma) ^tat».
In eaav« where the hyporlrnphy of a inuaale is owing to tlie formation
of new muscular elemem,-». llie phenomena of new formation can he very
well Men. It wni^ in such canes tii.at Hardeleben studied the origin of
new mm«ular fasciculi from cells of the connective tissue, in a hyper-
trophy of the inicrcoslal muscica occasioned by a prolonged dyspooca.
A new fonnation of muscular fn^ciculi constantly occur» in adults suffer-
ing with an acute tiisoasc ; boidc of the fasciculi arc destroyed by nu-
tritive chiinj;c5. The physiolopcal restoration of inusclf:». «iVr febrilfi
emaciation, is due, not only to an inerea«e in aixe of tlie shrunken, yet
unaltered fascicult, but also to a fonnation of new muscular fasciculi
which are develo(ied between the old. The.se phenomena have been
Studied by Zenker in several febrile dbeaaes (typhoid fever, scarlatina,
etc.). (See U. fig. l.'il.)
The same vear Colhcrs demonstrated an analogous regeneration of
muscle followmg trichinosis. It is always from the cells situnldl outi-îde
of tlio fasciculi, that nre ilcvclopcd the no». formed muscular fibres. The
nuclei of these cells are multiplied, their protaplasm is increase<l, forming
blunt or tapering prolongations; this nucleated mass is vert' similar to
the large giant cells of bone marrow. Neighboring cells unite at their
extremities: thv substance which forms them is transversely striated,
ftnd takes all the charact>;rs of striated muscular ■«uiisiance.
Increase in the size of a mtisciv is not always due* to an increase in
aiise of the fa.sciculî. or to their new formatiiMi ; it may result from tli«
production of connective liasue, of adipomo tiitsue,or even to an abnornui]
developinent of blood or lymphatic capillaries. Hypertrophic paralysis
of muscles has been previously mentioned ; congenital hypertrophy of
the tongue is princijally due to a considerable thickening of tl>c wn-
nectivv tissue of the organ anti a dilation of the lymphatics.
Cu>0i>ï SWEUjxo OF TliB Mr3Ci'L.4K Fascicit.!. — This is rery often
the first phase of fatty degeneration. In this alteration the muscular fas-
ciculus is more opofjuc than nonnal, its substance contains ntimeroua fii.e
granules, the striation is not distinct or It has completely disajigieared.
272
tHE Musi
Fig. 149.
Bj tlie action of ncctic aci'l tLc Bu<^ gniiiulcs in iho fawiculad diu{>po«r:
tb« fibre becomn transparent, and tlie striation is less distinct tliaii i» n
nonoul fiucicuUiH treated by Ibc same roai^nl. ^ooKlimes tlie aeotie
uci<1 in caiutiti;; the fioo granules to diaappear,
inakcti viiiiblo other transparent and refracting
f;mniil«i<, of n Tatty nnlnre and varyinf; in nutu-
ht-r. The naryolvniiiin U Aê triin^jArent as eu»-
^^ MJ^M tomnry ; the iitvbm^d nuclei are itornul, or
^^Bi fr^B l>i'e-'"'tit «'gfi-* of )irulifcration. Wlteiiovcr this
^^^E^ W|«-.-i' granular condition of miiflclcs i« accompanivd
^^^H mltlt a proliferation of the iiuoici of the «nrco-
£-*^
loincDa, parmicliyoiatotia tiitlamination \n prv-'tont.
This lesion nmv bo observed in intUmmnltoiiii
of RiH^clcâ, as in suppiimiive inirn-muiicular
pblc^Dou; but it 'a also rcco^nixcd in e.
whore tlic inflammatory niitur« ia doubtful, ai
in nil the aeuto general low iliïcasM (typhoid
fevor, eniptivii fcvçrs, purulent iiifeciion, etc.),
In grave fever* this el"iidy «nollin;; i» freipicntljr
aceompniiieil with fatty or vitreoiw Inuisfo:
lion. (Fi;;. loi.) Fmiitiinl care -liiouM be cxcrcioed in the preparntioB
of muscle in order to Mudy tla- histological cbuigw of thia iransfonnstion.
Fattv DicaoRRATiOK OF MuscLKH.^In children and adults there are
alirap found some uuâcular faaciculi, wliich contain extremely Gdo fatty
HgfMiUr Hull* nt 111* hHrl.
r>uw ■ «tu of •■(*■* typlold
(«nlllUf at tit *tf>a aa-l iba
iM* of Ihtir «UUIIra. X *"(>'
|0r«r».l
Fig. IflU.
/i'-T' a
\ ■
^x
Aral* fiilT <l*(>nKnil»D M ])i>trl n'nJ ol)i»r moMlH. n. U»il- h. Kotiat *h4anit>lf. n« «hslfiif ]
grannlrï, visible ufu-r the action of aectic adii. Thewt granules are very
few, and a careful uxamitiutiou u neceseary to discover tliem. But in
MDSODLAH ATROI-IIT.
i>Ii1 a^ tlie numlwr of ;i;fitnu1o- fatty fasciculi i!i more consi'leratil^, nii'l
Uic fnacicitli cotiUiiiiiiig tlio fatty ^raiiule.t are larger, so tlmt it ta aoi
oeoosMr; to employ acetic acid to ilUtin^uUb tliera.
1Vr« always exist» in muscles a certain amount of fatty material in a
state of soluMo combination, the base of vr liich is prohably an albuoiinoii)
eubsUnc« ; it is not then viaibU- witb ilic microscope. SL-parated fat only
IK acvn in tiic fonu of an in»ulublc product : microscopic examination dooa
not tfic» r«Tcal the amount of fatty material contatiwd in tli« muscle, but
only that which is seen in a nvutral Ktat4.^ A chvmiual analysis of a
mu»cIo in an arera;;:« state of fatty det^neratinn. therefore, docs not
funii-th iDoro fat than comes from a pliysi<âogieal muscle (ItindHcisvh).
Yrt th« |>resonc« of a large number of fatty granules iu a muscuhir fa«-
cieuluA, always indicate» iui|Mrtaiil nutritive tmublu, .liiice the fat iu this
statu cannot be utilixed for the work of the niuseles a^ can Uie fat in
coinbinatiou ; it, therefore, interferes with the function of this tissue.
Muscular fasciculi, which have undergone a fatty degeneration, are
mo^^ friable than normal, and retjuiro more care in preparing them for
microscopic examination. Tho fatly sraimlcs of the degenerated muscular
fasotculi present a certain resularity in ihcir arrangement, being placed
in lonptudiiinl i^crics in thu priaiarv fasciculi. They rcmlcr prominent t>v
their presence ihc longitudinal stnation, whili- the iransvvrsc strintion is
very ranch le^s ilistinct, and may have even disappeared. To distinguisb
tbeae changes it re'|uire« a power of at Ioamc '250 diumcten.
n>o nrcolemma retains it* transparency. The nuclei arc rery dis*
tiiKt, and the protdpliism âurrouwding them \s granular and fatty. The
de;:cncralii>u be;;ins in the protoplasm immediati'lv around the nncbi.
It is very probable that tho fascicnii which have undergone fatty de;;e«.
eratiou may again pctuni to thi-ir physiological slato, if our conclu>
aions are based upon vhat occurs in frogs, in whom during winter a great
manv of tlic fasciculi are fntty, which in summer return to their normal
eoDoitioD. In man, honcver, freipiently the fasciculi which have expe-
rienced thi» change are destmyed by a process the different phases of
which cannot be well folhiwcd. The fatty ^rniinle:» become more and more
abundant, the fasciculus bt-comeR opa<[ue, the slrialiuu cannot be distin*
»gnished, an*! al the ctkI of the process the sarcolcmma sheath is filled by a
fatty ;^ramilar ma.->s which gr.iilually disappears, leaving only the shrunken
aareolorama. It is chiefly in tumors of miiacles, am! in callus when it
invadea the muscular substance, that these madiËcalions may be inicsti-
gated in detail in the human being.
In infantile paralysis and progressive muscular atrophy, tho mnscutar
fasciculi may nt part or comjilctely disappear from the effect of fatty
lie gene ratioti. Fatly degeneration is also met with in fevers, in puru-
lent infection; it is very decided in mctaslaUc inSammiitions of muscles,
while in white infarct! consecutive to arterial obliteration by an embolus,
«e have found the muscular fasciculi free from fatty dt; gene rati on. In
niyo*it44 or in the neighboriwoil of woun<ls, at times s<.>nie of tlie fibres
ftre seen in a state of fatly degeneration, but only in the midst of the
embryonic tissue ; iu the svirrounding (Hiru, aliiiough there niny be a
Ê formation of new cells between the muscular libres, tlie fasciculi
degenerated.
:
2T4
or TBB MCSCCLAB TISSUE.
In paisoning bv i)hoapboni3, aiwnic, etc., fatty degeneration oF tibe
miiBcK-s id rer^' evident.
I*ioMK!(TAiiY Dkgexbkatiox. — Thcfp arc found phTBioIoRiwIly in the
[.eanliiK; mueclfi, but «nlv patholopcally in other dihhi-Ioh, rouni] ur iin«ii-
Ilir •;riinuki>. bruwn in color, »ituatv(l umior the Mtrcolcmma, or in tlii'
snbitMnoo of tbv oitisolc fibn-. These ^niniile^ pruhiihlj c«in« (mm n
tniii.->f'>nnatioii of tlio coloring matorial of the nntiick', anaJogouii to that
of tlic blooil, ami which mu; he designated as miHcutar hicmoj^lobin.
Thia trnii^formaiion of muscular hicmoglnbin into pigment happem
when ttic rnuitcle dte« in the liviu); organi.tm (ttie heart being of oouree
excepted), for example, in infardi, in metaaintîo ab«eomeB. A fucttu,
which baa remained in the uterine cavily some weeks after its death, alsO
contains pigroeutar; granulea in its muscles.
Vintiioi's Deurnkuatfox. — We have described this altcrntton on
Ipage 45, and j^avo it thv name of t"Vr<vMi Jr^rnmitMn, which Menu
t» UK preferable to wttxi/ ^iven by Zenker, who first discovered this lesion.
This c'liuDj^e of the muscles shouM not he confounded with a modification
of the muscular fihre [iroclucod by the method of prc[ianiti»ii. The vitrcona
metnmoTphoi^Lii coiui^iit» in a trun^furraxion of the miiMtihir siibsuiice;
the latter loaes il« iitriution ami heeomcM liynliiiu an'l tran^gareni m giutê.
In the firrtt 8ta^e the miiiicular faaGit.'ii]i are increnaed in Bi:be. tliey retain
their cyliudrical regularity, the nuclei of the sarcolcmma are more dii^
tinct than in the normal alate, the sarcolemmn itself doe» not appear to
bave undergone any cbanj^e. The nuclei of tiic fibres and the proto-
plasm which siirrniiiids them entirely escape the vitreous change; they
appear upon the hoino(;eneous fasciculus as a ili^tinet granular mass.
Carmine color» the vitreous substance quit»; inumsely. Acetic acid
swells, without diwolviug it. This substance is very much more brittle
thnn iiiuitculiir HuliAlnnce, and if the preparation in not made with great
care miraeroiLi and irre;{iilar fractures are canned. When a small cylinder
becomes separulitd hy fracture, it h iitolated from tlie neijchboring fraj;-
menta. and the folded sarcidemma upon its Hurface aeema to he shrunken.
The sareolemma by compressing the broken extremities of tJie frag-
menta, gives them the form of a cylinder swollen in the centre, resem.
blingaaroallcafik. When the preparation has been made with great care,
the vitreous muscular substance retains its cylindrical form.
The number of fasciculi afTcctcd by the defeneration is always limited.
All the muscular fasciculi of a mu»ele are never found metamorphosed :
therefore an examination should include a «^oup of fasciculi, rather than
an isolated primary fasciculus. There are seen bnmo^eneous and tran-
sparent fasciculi presenting; at tbeir cd^-s n charucteristic npjicarancc
duo to the refraction of tlieîr substance ; others are normal or fatty de-
generated. By the side of the vitreous mu.teular fibres, which have lost
their physii>loj;i«al properties, there are found others intact and able to
contract.
The changes which we shall now discuss are moat marked in chronic
vitreous metamorphoses, such as found in the proximity of tumors, or
better in the chronic phlegmon w hich surrounds tlie oaaeona fistular ojien-
VITREODB UKTAMORPIIOSIS.
275
itigs roltnwiniï cariea, DecmaÎD, or whiw «welling. We nre not Harrantod
in nffinnin;^ that tlu' pecuUnr ap|iearance of che^e faiiciculi U 'lur [•> the
niftli'Hl of prepamiinn. Tlie viirwus «uImUiicb, unJer tiie influence of
(1)0 innTcmeiiU of Uic muKular fibreH vrhicli remain liealthy, lias cxperi-
encpil n true breakinj; up into fnt^^monu, and is sopantted into blooks,
whieh in thmr arrBn>;ement eometiines re««mble the stones in a wall.
At tliA tarmination of the proce&s, the fra-^mi-nts become ^^ilually
0Hwll«r and foraa grauuk-s, each oimi of which still jxMaeoKes tJio o]>tical
Pig. isi.
4
.■ie-!*r»!»fci.
I)
^'
■■®^
j'jf^''' "'t^^
32S2
\
P.-^,
V
-a
^^^ 4 Tba pcUfllat tttntsU fm>t l> iba VsU «f k bamnrrbtvlc Inlutiloa i^ lb* nclui nMointui»
' ti*B(irv !■ KM4* a' ir&r1*i>, («*lft1i iltyvf «iivtlan. X SU- u^ ft. r, if, flr«qtilo^<tlr««q« rr*irniiïQ(4
A. AklTtlUa or nokcJt* u « ciit««oiat futm In lh# ti«tçli1hiTlM>»4 nX a hKiD^rfrhtf p into tta« nilK«
ftW'ïititiiitB Lk « r«*e af pbibltU Stcib>n twnivcrtotolli* mmcoUr d'Or**. " TLbfut wb«*v ■IrUlnl
f'-kiMiTH «r« ir%a»tftVioA \a ft.ri ur Lo it\o tbtd vlLrtoaK HiihiUtif*, A- Ftbr* rnntftUlDf muarqlur
nUt )■ p>>>r«« i>r<<<i*)s;iMai. r. Xatmul Bbrta. 4. <>lltil»«Ua«ai>, Urgnr mil rn^'x riligji.liiii
ibu nHBil, ««aulaol Ik iti* liiur.rurltalu ni>i*erilva ■!•««■ X 3»0, t, Th* lut<r <U»iiu(d)
* X "*>' Boi dtlliirHii riMin ■ImlUr «l<iiu*nu balanclog w ih* maicla Sbran ilmniiialiri,
l> Ibta ni>B<elkn,«M ■!•<• K>R. 31 •
chararterH of tlie ritriwug snbatance. At tliis time absorption begins,
the sareolemma foMsupon itAolf, its nuclei become lariçer an<i more nunM-
rou», many of lliem presenting the signs of multiplication by ilivUion.
This proliferation of the nuclei of the sarGotemma seems to be a phenom-
enon conaecutivo to the do"ei>cration.
— *
276
CIIA!tOBS or THE MPSCULAR TISSUS.
In the gr&ve fovore, who» a certain nutnher of the tnuscular ra«cicuti
have b«en •Ivatrovvd 1)t tliU alteratiuii, tbcro ocvum a now lormatioti of
inii»:ii1ttr libret>, and & cumpleti^ re^^enemtion of the musclo, 'I'ho celU
«f the uoiinvctiri- ti»>tu- »<ljacctit In the iliscased fascieuli ara cnlarf;e>l,
their nuclei limlùply withmit <H»-iîioii of the celt», they uftcrwanb bc<:otn«
clongatoit ill the direction of the fni>eieiili. uml buforc Ihcjr hftv« Iwl the
chftractcr of eelU in onler to heuoiue ]>riinjiry ratteiculi, they i)n'i«;nt » v^'ry
manifeM .ttrînùon. This development doe» not vioitntially differ from the
i)hysinl(>j;icAl development of i^lriatr'il nmwle. Muitele^ attaeke*) hy iIi'h
etiion are brittle and are fa'<itieiitly nipunvd. The change» occurring in
eonfle<jucnco of rapture will be better iitmlt«d under lieinorrhagea of
ntuiiole.
The aiu»e of this degeneration is local or general. In the former ease
it is localised at the scat of the aflectioi) which occasions it, ah a tumor
[of a muacle, an abscess, or a chronic phlegmon. When the disease
f aupen-encadarin-^a fever, it id ni'>st frei|uently seen to attack the anterior
'muscles of the thi[;)i and abilomen : yet it may oceur in any locality.
To the unaided eyo. it i» vcrr difficult or even impossible to rccoj^M
this lesion. Zenker ha» pointed out a special color analogous to fish flesh :
but this color may be seen in muscles which do not prcsonl the tlc;^-ncnii-
tioD, no ihut a bistolo^ical examination is necessary to detenuine it.
ItRM>muiiA<iK^ iir MfSi7LKK. — Simple oonjçeîition of a miiwle is mani-
fciteil by ili!>tinct .li^nii upon tl)e cadaver only in the nci^iborhood of
inliammatory foei, of hemorrhages and of infarcti.
By the old I-'ronch and (îcrmans authors, hemorrhages of nmscle^ were
designated hemorrhagic infarct!. This term by no means implies the
idea of a primary arterial obliteration.
Hemorrliages in tliu muscles rimy be eaused by contusions, wounds, rup.
turu of muscles, or they nmy depiiid iipon a grneral hrmorrhagic affec-
tion, jiiicli as purpura, «curvy, liomorrha};ic fever», Icuencythicinin, etc.
If till' heinorrba;;e is recent, it foi-m» in the mnsele a dark-red mass,
very difTeront from the light-red color of the miwelc. This mass, the
extent and «liape of wliich is very variable, may lie limited or diR'ui^ed.
Ak the blood coagulates, the muHcle at thi.4 poîiu become» more con.^iiitent
and lo«es its elasticity. Tlie naiLicular fasciculi contained in the part
liave not undergone any alterations, or [lerliaps they iiave become granular.
In order to study the relative relations of the bloo>l and the muscle
fibres and vessels, thin transverse sections are to be made anil colored
with carmine. It is then seen that the muscular fasciculi are separated
by coHections of red blood disks. In these collections and between the
fasciculi the blood ciipillHries and vessels of larger calibre arc dilated
anil filled with red blood disks. Thv bli>ud coagulatvs in the vessels, as
well as in the interfascicular spaces, in eonscijnencc of arrest of the cir-
culation.
When hemorrhage follows a rupture of a miincle, the blood ooagidates:
the torn fiMciculI of tlie mnscbt project into ihi.-t coagulum, aiitl the
blood to a greater or less exi«iil peiioirales between them. 'Ilie roo.*.
cular fasciculi now present various .ilicrations dejjcnding more or less
Upon Uie cause of the rupture ; sometimes they are in a at&ta of vitreous
^
KUDOLIO IXTAFCTIOX 07 HdSCLES. 27T
^■n«rfttioi), or futtjr mctamorphotis ; t]ie miiacuhr fascKuli at the point
wh«ro thvy arv ruptiinid, liare alwavH iiixlert^ne complete fktt^ liej^ne-
rncioii. Tlii^ U frei[iiontlv seen in tlie recii musclea of tiie abdomen <lur^
ing tYjilioiil fever. In rujrture of the muscles, nit the hloodveaaela in-
clinU'd ill ili9 rujttiire contain a clot, in nhicU if (he Icaion is recent the
rwJ blooil cells are well preserved, or granular if llie lesion ia old.
Xh« blood thus efl'uacd into the muscle seems Co be absorbed with great
facility. The muscular morouifints certain!; have considerabl« influence
u|>on the inlra-muscular lymphatic circulation, and, con!M)i|uently, upon
Uie transporuiiou of tnau-rinls whioh arc derived from the changes oc<
curriu}; in the extrava^^atod blood ; liiit as yet nciiht-r upon anitniiU or
man has the nu'lhud of this abeorjition been dulerniincd. It i» known,
however, that the elTeet of severe contiiuonA, irhich are alwaya aocom-
paniod witli coiniclcrahte intra-mnscular hemorrhage», may disappear in
a few days witJioul leaviu); any trace. The changea ocourrinï in the blood
do «ot differ from tho«e deHcribed tinder hemorrhages of the connective
liaaup. 'llic extiavasated bloa<l ex|)erienc«B the usual metaraorpliuAOK ;
at lirai it ooagulales, then decomjioaes ; the tihnn undergoes moWular
changes, it becomes soluble, or broken up into very tine granules which
are taken up by the circulation.
The production of muscular hemorrbagea raries according to their
eauoe. When they are the resutt of direct injury, such as muscular
rupture, fracture of bones, contusions, the torn vessels permit the blood
t<) esca)K: until by its coajpilation it occludes the ruptured vessels.
Hcmorrha^fli rnny also be due to oblitcratidn and thromboaia of the
veins, when the arti.iml pressure tranituiitted to t)io oapillaric» i» suf-
ficient to cause their rupture. But the «hliteratiou of arteries, either
l)y thrrmibftTtis orcmbolium, cantint cause intra-muscular hemorrhage, any
more tlian cau lij^tion of iin artery.
The phcnomeiui of nancular hemorrhageii in general dtseaaea, such ai
purpura and the hemorrhagic fevera, are not yet known.
Embolic Iscirctiox dp Mr«cLES. — Tme embolic infarcli of muscles
thave been seldom aeen. We understand fay this term the alteradon con-
I lecuiivc to the obliteration of a muscular arteriole and its branches.
■ Thia lesion differs from hemorrhagic infarctt by the absence of offiised
blood. Metastatic abscesses, such as have been described under inllam-
inationa. shoulil not be conlo\iiidcd with embolic infarcti of muscles. We
have only met with two examples of this legion, occurring in consequence
of emboli from endocarditis and endarteritis. In these ca^^, in the mus-
cular substance, were found whitish, slightly opaiitic, eonc-sliapcl massos,
which were in very distinct contrast to the red and translucent muscle,
Micmscopic cxuminiition of these parts showed that th(^ muscular fa»,
cicnii had very plainly preserved their str'iation ; they cout-iined no fatty
|f:ranult's, but tnclotted only n few pi<;iDent )^ranule-« derived frnin the
f muscular haemoglobin. This pigmentary chantée is similar to tliat occur-
i ring in a fœtus dying before its expulsion. The changes in the blood-
I vessels nill be studied umlei- iufarcLion in connection with the vascular
i ay a te m .
37»
CUJ
or THE
rissuB.
Ml'LTTPLICATKtX OF TÎ1K CKI.U'I.AR Kl.KMKSTl' OF TIIK .SARCl.I.KMilA,—
This is prpecnt. ft* ulrcmly siiown, in vitreous ineMmnqiliosi» hikI even
ill >;rumilar truii.<iformntii)ii. Imt it nUo oocurs flonwiimcs m ft »e|<armt«
l«HÎon. In the inilauinmtioii of k muscle following a wAunil, in tlic pn>X-i
imilj' «r luniora, for example an cpitltelioma of the lip or (ou);ue. tn noraal
foriDK of [larnl^v-'^i^. anil inammak aftertlieilit't<iionof a nerve, tbia leiioal
lA *i-eii. When a iiene is lUviiie'l in an animal, fifweii days or thiro^
■«««!(» after the operation, the only lesion found of tbe musclca is an
Eâncrease of the nuclei of the earcoicmma : the; become larçer, diviilc,
nnd form elonsat«d groups (Vulpnin). In thew groups fim nuclei are
'arranged in Hortes in a granular protoplasm. This is tiic usual meUiotl
of proliferation of the nuclei of tiie sarcoleinma : the nuclei remain in a
coiBDivii nia«s of prmoplnsm. Only in exoeptiona) cases do wc m-c thai
protoplasm isolntcil in di-itinct nm«Ms around each nucleus, us in tlic Ivstl
BtAge of the vitreous change. In epithelionui the multiplication of thcl
, oellulnr clcnK'iits of the «arcotemma is often very markMl ; while nt the <
iMmi: time there is more or less atrophy of the fHMtculi, »o tliat tlie
nuclei and their surrounding protoplanm are very distinct, tlccause o^
tlic ro tend it u nee of these éléments to e]>ithelial celts, some writers iMlievsl
Uiat they contribute to the fommiinn of the cells of the epiiheliotna, Imt
we have never seen anything »hich could justify this conjecture. It lias
I not been posilively determined that the proliferation «if llie c«llular cle»
' monta of tbe sarcolemma take part in tho formation of pus cells.
IsFi,AH>iATiox OP MuscLES OR Mtositis.— THc tnosi Simple and most
«asily studietl intliimmation of miLscles is that follnwin;; vrounds. If ■
l-moscle is divided in a wound, there arc seen u;ion the cutsurfaoe all the
I phenomena of the formation of granulation tissue. The new fonnation
Itftkcs place in the midst of the inter-fasciculsr connective tissue; it is
' effected by tbe production of embryonic tissue and the grovtli of vessels.
The embryonic cells are found not only ujon the surface of the wound
but «1*0 between tho primary fasciculi, at a dej'th varying acconliug to
the intensity of the intiammation and the stase of tho process. In
contused wounds, as also in ^^unsliot wounds, tho extension of tho embry-
onic tissue into the muscle reaches scvoral ccntimetre-B when the wound
U suppurating. Upon an exainination of a traosverse section of on
I injured muscle twelve days after the accident, there is seen first a layer
I formed of embryonic tissue, in which dilated enpillarics wiUi embryonic
walU form loops. Beneiitb this layer, the thickn<,-ss of which varies
from one to five raillim<trfs, there is found it swcond where the eaibryouic
tissue encloses alri>phied primnry fasciculi, which, instead of all hiirinj;
, thiMsmc direction, ns iu a normal muscle, are very irregularly armn^ed ;
I tWir size varie» from .U! to .OS of a millimetre ; only their longitudinal
I fMation can be distinguished, they appear to he coiis^tuteil of fibrils
uleparatod by au exudation, 'i'he nuclei of the sarcolewma midtipliod to
f excess, form jrroups or series one upon the surface, the other in the centre
f tX the fiksciculus ; the aarcolemma seems to have completely disappeare*!.
Around these fibrils, which aro tbe remains of the fasciculi, the embry-
onic tiMue »howa the beginning of organisation, and ]>resenlA a reticidum.
CBROMC INFLAMMATION OP 1I080LI8.
279
I
i
i
k
tfae fibres of which, nt auiny point». Arc minglol wilh the mitficiilar fibrils,
90 tliat till- linu «liviiliii» mie l'n>m Uiv otb«r U not verv «Iktinct.
l*iusinK to tilt- licffwr I»,vctn> of tlii» tissiM!, ilie interfascicular con-
ne«livD tiMuo contain» fewer cell», ami Uic ntraplty of tlie muscular
TsMicuH i» mil m lanrloil. 'Hie fasciculi show oiil^r an increase in the
^unlhl.•r of die iiucloi of llie sarcolemoia, which, in a traoaveree cut of the
I1Ï, foriuK a heautiful circle arouml each fasciculus. There are alstt
id in wvera) |ioinu of tlie interfascicular connective tiwuc, free
spherical c«lla containing broirn granulée of hsniatin. ThÎ9 «hows tliat
thrre have heen hemorrha^ into (he deep layers ; their ri^olntîon lakeit
|>lacc according to the proceaa explained under bemorrhn<^-3 of tlie coif
u«ctive tissue.
I'he changes that have heen dcscrihcd as occurring; in a fiini|>lccase are
seen, with sli;;ht variations, in all inHammatioiut of uiiucles. Final m:ov-
erj* takes place bv the organixutton of the eoibrvontc tissue at the
surface and its disappearance bctwocn tlio fauriculi. Yet tlii» Ai<n|)leaiMl
natural course aay bo «omplioucd by accidenu— heiuorrhage or âiip.
puratton.
StPPtTlATios OF MilsoLKS. — Sup]>uralian of nnscled may be either
diffiutixl or limited. Limited suppurating foci may W met wiih in the
proximity of wouikU, or lliey may he connec[e(I with purulent infection,
etc.
MeUsiatic abscesses froro purulent infection difFcr entirely from white
embolic infarct!. Their size varies trtini a hemp seei) to thai of the
list. The pus contains the debris of uoiini^ctivc lisxiie and di# in It! grated
muMiilnr fasciculi. The purulent focus is surrouiuled by a greeni.'th
brown xone, i» which the iiiler-fa''ciculftr oonitcctive tissue t* found infil-
tnteil with pus cells ami ri'il l)Io"d corptiscleii, and in «hich t)ie muscular
fasciculi oonUii» fatty and pigmentary ^nimiles.
In diffuaeil inflammations, which are very often seen in the divided
Htnsielefl of amputatifliix in purulent infection, or in inflammation of the
pmas mande, the punilenl Irilillralions occasion faity degeneration of the
primary fasciculi, and tinally their death.
CuK'iSic Ï.XFIAMMATIOX OF Mt'scLE». — Thtfi follows as a secondary
clianj^e around articulations aulfcrin^ wilti «chite swelling or chronic
rheumatic arthritis. The lesion is aUo met with in the pn^xiinity of puru*
lent Gstular openinj^ from carious or necrosed huue. The alu^nitions
of the interfascicular connective tissue conflit in an hypcrtntphy iluc
to an exuberant production of cells and an exudation; tlie cut .«urfaco
of the muscles, iiist^^d of presentin;;, to the nnaiihsl eye, the character-
irtic fascienlar appearance, when cut Iranitvenfly resembles marble,
fihrous li»i>ue when <Iivide<l loTi^riiudinAlly : (he inunde ha» lo^t its natural
color, it is whitish or li^ht red, its consistence i» increased and ilâ elaa*
ticity Li partly lost.
The changea in the miiscalar fasciculi vary : some retain their etna,
tion, and the nuclei of the »arco)emina are more numerous than normal ;
others have underjy>ne cloudy swellinj; or fatty degeneration ; tinally, in
a few cases, moat of the muscular fasciculi present the lesions of vitrvoos
degeneration.
CnASQBS or TBR UVSCVLAII TT88CB.
Most vrritore still claiu with chmnic iiillniiiinntion, tfao fibrous nodules
Bliil OMfOUR formations which Are proiluc«d hy itit- repeniPi) i70<iititfiioiis
anil rrivtioiis coiini-c'tO'l with ninny occupations. ItDkitAnnky fir<l dis
.Kribcril tli« oiMvous formatinns in tin- liiccp* of eoldi^tn wlio cxi'rcirtJ
'miih ttio niuskvt ucc-nnling tu tlic (icrniAu im^thod, ftiid in thi' atldiKlonJ
of lior^t'nicu wlio remain a long tim« iu the saddle.
RrPTUHK OK MuKci.KS. — Ktiptiires caused by contuwxl wotiniln are not
here comidered. only those ruptured conncclc'l with Rii»cular conirac-
tiona. If the muscle is healthy, iu order to produce ft nipture it require»
1 considerable effort ; hut it" it ia diseased the accident inav readily occur.
rill low irplinid fcvcrfor example, where the nntsclesare degenerated, the
recti muscles of the iibdoDien may be rnpliircd by the effort of the pntient
to sit np in bod. It îâ vspeeiuHy this rupture that hns beeu analonilcally
etudioil, for most of the other ruptures are foltuwed by recovery of the
the patients.
Kll]itun,^ of tho recti muitcleit of thfl alMloinen in typhoid fcvop noM
frei|ueiitty occnrn wilhnut the pbyHiciaii being aware of it, and il \* only
at tlio autojisy thitt the lesion is di.'icovered. It is tlien seen tliM the ni]>-
ture i» very irregular, the s]iaco between the two I'ragments is occiipieil by
a clot of blood, generally dark rod-brown, with 0|ui>|ue whitish strtalioits.
Where the muscle is cut longitudinally, there «re found at the ]>oinl of
rupture and for an extent of one or more centimetres, a brown coloration
and stiflncir». The blood clot is I'omicd of red blood corpuscles contained
in II fibrinoiis roliculuin, iind it imdernries the diftV'rcnt inodificntions Been
in ii\t<-n'tilial heniorrhagft.
The muscular fibres, at the point of division, present a very ad-
vanced fatly de;:ene ration, or viireott* mem mo rj dim is. Itet«een lh«
nnisciUar fasciculi, the connective tissue is infiltrated with coagulated
blood and the bloodvessels are also filled. If the miiwular fasciculi near
the rupture are compared with those of the same muscle situated further
I'Off, it will be Been, that in the latter very few of the fasciculi are in a
Btat« of fatty degeneration. altimiiKh many of thero may have under^ne
tho Wtreuus metamorphosis. While, near tho rupture all Ihv fasci-
I cult contain a <;roat iguantity of fatly <;ranii1es, and trie stiiatton has dis-
rtppeared. It is then very probable that the fatty degeneration, at least
for most of the fasciculi, is consecutive to the rupture.
Sect in.— Tumors of Mtudes.
Sarfoiuala. — IVimary sarcomata of muscle» we have ticver seen, but
tumors of this nature develog>eil by continuity are very frequent. Tb»
moatoommon of all is the fascicular (^ spindle celled ) s«rci>t»a. There are
also seen round celled or enceplialoid sai-cooia. liponialonA sarcoma, mu-
cous sarcoma, erectile saTeoma,nnd melanotic sarcoma. 1l is unnecetuary
to Rive a description of these {iilierent tumors, wliich, when developed in
muscles, present the structure already described in the chapter upon tuowrs
in general. Tho development of the morbid mass is always by the forma-
tion of embryonic tissue in the interfosciculnr connective tissue ; titis cm*
brjonal tissue compri'sses the ])rimary fa^riculi of tlic muscle, causes an
TrMOAS OP TUB MC8CLK8.
281
^
[Btropliy aimnle or accomiianied hy a faUy d«(^ii«rfition. The latter form
" ftirojiliy IS MpeciallT in^t wiib wliere tbe development of Mrcodialonii
DC is rer; rapid. It \a alao seen io exubérant callm nliich iuvades
les siiii which durinj; a ccrtaio period of it* development pro-
ie )>tnict>.ire of a snrcotua,
F!hr"m<tlii. — Simple fibromata of muîclM arc iisiiall}' tlie retnilt of a
nrchantral irritation. The«e tiiniora once developed ceavc to grow, aiid
oau*« rcry little fimctional trouble of the nnii^Ic.
.Vi/jvmiata and tAym-itfi are met with in muMles as simplo or com-
bine<t timiora, the latter nami-d li|>omitton^ inyxnmatA. They arc found
roost fr«.[uetttljf in the muscles of tbo tonj;iif, lifw, and buccal walls, but
are liable to occur in the other muscles of the body.
Oammnta of mu^clcâ, »lihoii;t,'h thev 9i>hlom occur, are very well knonn
cliincally, but have uot yet been studied histologically ; they have beeu
fount! in the cardiac muscle.
Oti'i-iMo»Hn(t.— Carcinoma of muscles is secondary by extonsioD or by
n»vtiMtjiei« ; it is developed in the int«<rt'a!K:icular onneclive tisMuc with the
luaual cburact«ri!itics of the evolution of carctnomn, while the primary fas-
ciculi uifler;^ «mple atrojihy with multiplication of the nuclei of the sarco-
temni», or the atrophy is associated with fatty dcgenomlion. Kiteeplntloiil
awl Acirrbous carcinoniaUi are most frcijucntly met with, but the other
varietieii are found. The extennions of a scirrhus of the mammary glands
to the ]>ectoral or int«rror>lal munoloi^, «nd of iin riiecphnloid of the ntenis
to the (Ho&A and iliae muscles, are to be particiiUrly remiuibcred.
Kjithfliiinuitn. — epithelioma of the orhii^ularitt oriw miiacle occupa
almoât conHtantly iu au epithelioma of the skin and mucous membrane of
tlic lips- It is here tliat the study of the development and growth of an
epithelioma into tbe muscle is most frcijuently made. Before the «pi-
tlielial pegs have pi^'uetratcd amon;; the primary inuivular fsïcieuli, there
is formed in the interfascicular eonnectivc ti»suc a growth of emhrynnic
tissue which wpanites ihem from one another. A few of the tnwiculi
may remain iu hundleii, but they are always few in number. There are
always seen in them a hypertrophy andauinci'easeof t)ie nuclei of the :»r.
colemma, while tlic sarcous sulxitancc U generally atrophied but retains ita
charade riiiltc sitiation. It i* iu the embryonic liwue developed Wtween
the fasciculi tliat i!ie epitheliiil pegs advance deeply into the muscle. The
musclt-s of the tongue are attacked in a similar manner in epithelioma of
this organ ; these tumors belong to the lobular epiiheliomata. A tubular
epithelioma developed primarily in the antrum or nasal fo6S« may also
spread to tlic muscles of the lace cither in a diffiised or circumscribed
form. Epithollomata by extension or metastasis may invade other mus-
cles of the economy, notably the heart.
Eifh'>jnir"ni'tta may invade the intermuscular connective tÎ8.snc, a»
occurs in some cases of cDchondroinata of the parotid gland and of the
hand.
OttronmUi of muscles causeil by mechanical irritants have been con-
sidered on page \i^'■i. In the proximity of articulations affected with
very old chronic inflammations tJierc is at tiroes seen an ossification of
the tendons which extends to the muscles, forming nodules or apiculie
situated iu the middle of the muscular mam.
282
CHANGES OF THB «ITIiCULAB TI88U8.
A tfjiifmata of muscles, either flîmplo or cavernous, are not rcry mre ;
tliey »li«uKl not be cotirounded with varices.
Beet IV.- Paraiita of the llu«le«.
There arc foiinil in the mnsclcB of man only three kindx of |»nutitc«( tha
cj'Sticcrei. the vcliinococci. and the triuhinw.
In tnim tlie uy^ticcrciiH in niusclviii is nrc, esp«cikllv in Fniwc. The
|iAni4ite <lou» not give ritie to an^' symptoms (hirin>; life, aiul it in onljf
acciik'iiltilljr <li«covere<I at the aiito)wy. We have had un opjxxrtiinil^r of
exaininin}r thir mitscivs from one case. The oysticerci «era within wUitiiih
cyeta «a large iw a muall jwa, Hituated between the muscular faaciaili,
am) Hiirrounded by a fibniiiit membrane. The cjflticerci were infiltrated
with calcareous granules, but we were able to Bnd their heade, suckers,
and booklets.
Very few ob§ervatJoni« of hydatid cysts of muscles have Wen so
thoroughly made as to leave no doti1)t of their nature, lliatologjcal
examination of the parasite has been made only in a small num)>cr of
caws : the wall of the cyst, showed that they were formed by tb« vcht-
nococci.
Tri'-hinip ( Triehinir »/nrali»). discovered by Owen in the muBClct (ainl
by i.vidy iu pork), tire rcco;;ntxed a» email worms ooile<l up and conUiiued
in cyst». The cyst U situated in the interior of a muscular fasciculus, or {
in the tnterfaicicular connective tissue; it is oval or le mon -shaped. These
cysts are scarcely visible to thv unaided eye as ttmall «hite points, lliey
Trirhlu arlnll* all«d ip and n#rti*i 1b > aottalu fMIImla.
have two envelopes, one formed by the sarcolcmma or connective tissue,
the other l>clong« to the animal. In one cyst there exist one, two, or
three of the anininl^, coiled ufiou thentaclvcs. The worms are charac*
t«riiei) by a transverse striation. a mouili, ftnu». and digostiv« tube. Cal-
careous intiltialion is met with when they arc old and obscuree the cyst.
The trichiu.'i itself becomes brittle the neishboring muscular fasciculi
undergo i^ranular metamorphosis. The irriUnionrcNultin;; from the pres-
ence of the cyst caU9e« a vascular new fonmition at its uircumferenco.
In the muscles, tho trichina; are sexless ; hut being swallowed by a
PAHA9ITEB OF THE MVSCLES. 283
mammifera and reaching the digestive tube, they become free and eexunl.
The malee are l.â raillimetres long, the fenialea 3 mitlimetres ; their
anterior extremity tenniaating in a mouth and containing the œaophagus,
Ï8 elongated and pointed ; their posterior extremity ia blunt and rounded ;
the sexual organs are placed in the middle third of the body and are
simple; the testicles are in the posterior third. Copulation takes place
in the intestinal tube, and a few days after, the female produces a. con-
nderahle number of young. The latter perforate the intestinal walls
and wander throughout the whole economy; finally, they lodge in the
striated muscles, with the exception of the heart. At the insertion
of the tendons, the trichinne are arrested in their migrations. They
become encysted in the muscles and occasion nutritive changes in the
fasciculi.
BtOOD.
CHAPTER VI.
ni.(>oi>.
TriK oflici.' of tlie WooiJ in disoaa^s of tli« ves»wls ami heart i» so iin-
portAiit ihfil it is irDpos«t)lT! to iindurHUiid the lc»iou» of tlic»e Dr;^iii'|
niltioiit having ^^lixlii^d the Ijtjutil which fill» them.
Thi! iiiiuruMojiio alleratioiki of the Mood will only be studied in lliia
chapter.
Sect. I. - Koimal Histology of the Blood.
Th« morphological ekmenta of the liloni) in the normal atate are red
and «hile corpusclca: there are abo found eleineiitarT ^ranulea which
Boat in the senim, and «hen the blood coagulates, a reticulum of fibrin.
Crvstalfl arc formed either sponuneougly or arti6cially.
Il'he red corpuaclcs of man arc disks slightly depressed in Ibetr centre
upon both surfaces: whvn seen in profile, thoy have the form of a bi*
concave lens ; mccn upon the surface, their centre is dark and the honler
bright, atJO'irdin;; to the pnsilioii of the objective. \Vh«n the ohjwtîvo
is nearer tlinn llit: point of distinct virion, the centre i:< dark; when it i«
beyond the jK)iiit of ilinlinct viMon, it h bright. The^ detaiU arc {pvca
that the depressed centre may not be taken for a nucleus.
The higher the inHgiiifying power employed in examining red cor-
puscles, the less they ajtpear to W colored. Vhua. with a power of 800
diameters, they have only a very sHj^ht yellow tint ; in profile, they aroi
more colored th:in when seen u|ion the xtirfucc. The red corpuscles ar«
not of uniform diameter, yet they rary very little; their avcra;;c diam>
vter is .OUT mm. Besides the' dÎ!çk-«hape<l corpuscles, there are often
found sphvricnl red eorpusck-s hurin;^ only .00;> mm. ; thcîr tînt is tlarkcr,
which is due simply to their shape.
[Tlierc un- hc»idc» the spherical red corpui*clei* of .OO.'i min. in diam-
eter, e.i]«-'(:iiilly ill the blo"d of ihe veiiie pornw, variable numln-n» of
very minnif spherical ;;ranule.-t, vthnnte eonaiitution ap]>ears to K> idenlioul
with that of the Ittrj^er red eorpuAcles. The aise of these small spherical
bodies varies between a minute dot scarcely visible under a magnifying
power of :{Ml) diameters, and .(R'.'i ram. Some authors believe lliai they
come from the broakin;; up and division of the red blood disks in the.
spleen : that diirin;; the passage i>f the splenic blood through the liver k '
]"nrt of the proper tunclion of thi- hitler is to complete their destruction ;
and that their presence in considerable numbers in the genera] circulstioD
is an iriilicHtion either of a dÎMease of the spleen or of the Urcr, or por>
hap» of both these hfemopoieiic organ».
Of late years several authors have testified to tiie existence in tli«
KORMAL urSTOLOOY OF THB BLOOD.
^i
V\g. I&3.
«11 1iitrjk.f«tlaUr *bJ «-A Lniri'imrUtr
Inllf'rliLn. t. Elll|"l»> '"'"•"I '•(■'■'A
01(11 |>iiw>r. fKIHm.t
iRoriml red blood corpusHed of it certain nmwmt of contractile power, am)
1 one or two liavc oven nffirmcif the pn'*cnco of » j^nuiue uuclvu» iritliiu
the onli[iar<r biconctivc ntl l>1oo>l <lUk of iniiti.
It now «t-vin;! to 1)6 i>st«blishcil thitt in.tleftil »f the red blood corpuscle
ht'm,i coin|NM«d of n boiDog^ncomt, ^Inictiirelesa inaaa, as nus formorl;
Utuglit, it a coiwtitiileii b; a delicate reti.
CuUim nhicli perviules the entire inaai of
' Ibe eor|niwle, an<l which holds in \U iDtnute
meabeii the hoino;;e neons tiiiiH vrhich con*
tsina the coloring and other inaUers of these
corpn^elea. This retioul.ile'l struciiire ts
typically renri-sented in fi;;. IM. '•. Al-
thou;;h the illustration i^ a reprotliiciioii of
tlie reticulated appearance of a nucleated
ollip«oiilred blooilcorpuwleofa batra'jhiati,
yet, «xcepùng the nttclou», the enai! con-
dition hM been fre>|nent1y r«co^nixed in
the bloiwl of mail.]
A t the margin of the drop of blood under
the tliin gta-ia cover, where it ha.i driei) by contact with the air, ilie red
eor|>u»ck>a bIiow notches, the extent and number of which vary and in*
creaM nroportionally as the dryiii>: progreasea. When this change i^
much advanced, the re<i corpuscle becomea apbeiic*!, appears ct-eiiat«d
or covered with spines; it is in this form that Uie red Mood corfiuscle
of Ihc cadaver is oft«n found. When the drying is complete, the rod cor-
pu«;lr» form a cmcked niii»».
Water aot« ujron the re<l corpuscle.* by remoring their coloring; matter
and caiLdn;^ them to become Hpherlcal; their diameter iii reduced to .005
mm., and they become no traiutparent that the fiehl umlertbe microxcope
muflt W shaded, or tliey niuat be treated with iodine in order to render
tliem risible.
The cohriii;; maicrial of the blood dissolved in the serum is named
hiemo;;lobin ; it is soluble in larjjc (luantitic* of water without being
decompoM-d. The spectposcopo detects it in very weak solutions: in
cotvcentrated solutions it cryxialHics. Crystals of bicmo^Iohin are ob-
tained by several methods, all bavin;; for theircnd the dcftrnctiou of the
corpuscles and the libcnition of the hicmo^^lobin vtilbout the aid of wat<T.
The crviitaU are of a boaiiliful red color when lookdl at en mas»e: their
form varieii in ililTerent animala, in man it is that of rhoinboidal plates.
Ry the action of aeiil* or alkalies on hiRmoglobin, there i« formeii a
new HnlMtauce nanted hiematin, not cry-ttallisable, hut precipitated aj
darkish granules. Thiscombinea with hydrochloric acid, forming a, crvju
tatllxable salt known as liiemin, but it is really bydroehlorate of hiemaiin.
Ilsmatin is of natholo-^cal importance, since it is formed from blood
^^ extravaaated into the tissues. Il« formation is slow. The varied colora-
^H tions of ecchymoses, as has been shoivn, arc due to the slow transfonnation
^* of hsemo^^lotun and his'natin. This chaii;!c is much more rapid if the
blood pastes into the digestive tract, espcciully into the stomaeli, where,
^H by tlie action of the gfMlric juice, the hijcinoglobiu becoiae:* hfojiatin with
i
I
1
286
i;real rapi'lily : tliU U tlie reason of the color of Mack or mBbnMtc *-omit,
aii'i the browu color of ecchymoses of the stomach.
\Vh«n tlie blood remitins anions t)ie tissues, there is fottofl bc8ul«« tlic
hueinatin another substance, which haa not been productM! artificially and
tlif coinpoâiiion of which is not known; it isnamcdhn^matoidtn. Itoccnr*
us ^irumilvs or rhombic crystals of a beautiful oranKc-rivl, *n intcn.w tliat
it ri-iiiiiiiiit brilliant umlcr very hi;;h powcrit. It is pariicuiurly in ciwyMed
iK'Hiorrha^^-», notably thotte of the brain, that tlie noM beautiful i«pcci>
nivM of these crystals are met vitb.
The whiu eûrputrlft are seen as «pberical hodies or have an irregular
contour; tbi^y are simniilar, aiul nnder the microwope have a ^ray tint.
Prolongations of vnriixi» KhapCH are somelimeit seen at tboir borders.
Ill the froj^ and other cold hloodod amniaU, these prolonjaiions are ri-ry
dintinclal the moment the blondis drawn from the vessels and suliiiiitted
to examination, but become more and more prominent aa the obsvn'alion
is continued ; they change their ahape, form secondary prolonKaliona, and
again return to their ori;^nal form, thus presenting the anxuboid move-
nenta. The white corpuscles possess the projierty of scinin;; the bodies
which arc near them and causing ihcni to penetrate into tlieir inlerinr
{Itcclilingliausen). This phenomenon can be directly ohservcd under the
iniomscope by mixing with a drop of froa's blood a «mail amount of gran-
ular cuniiinc or vermilion. The absorption of solid particles may aliw he
studied in the organi«m by injecting into the vancular system of a frog
or a wnnnbliindcd animal fine (mrticlcs sunpendedin a fluid, and examin-
ing the blood of the anituaU a few minuter nfter the injection. The white
corpiusclea are then âeen to have in their interior grains of the injected snlj-
suncc. The rc<l corpuscles never contain any of the injected particles.
The power that the white corpuscles have of absorbing solid particles
when removed from the organism, shows that they still live, altliough the
conditions of their existence seem changed. These vital manifesta tionn
may be prolongcil for a lung time if the blood is protected in a suitable
incliuni.
[IVxidcs the ahove-mentinnod while corpuscles found in the blood, tbere
are occasionally seen other oolorivsa olemenl.-'. There arc a certain
numlierof larger, more granular, and Ics» mobile colorless! cells, met with.
In the frog, especially during the spring, a few lari^ ellipsoid, slightly
granular uni- or bi-nuc1oated colorie?» cells are found. Klements very
similar to the latter are found in the Hood of the splenic veins of mam-
mats in health, and in the general circulation in some pathological states.]
The whiu^' corpuscles arc much loss numerous than the red. In a
healthy man there is one white to three or four hundred red. 'ITie
numeration is <liflieult : therefore, to cstimnlc the physiological aa well
as the pathological proportion, it is well to have some rajwd method.
By the action of water the white eorpusoloa become spherical, trans-
parent, and in their interior apjwar one or more nuclei. If the action
of water is prolonged the cell i* ili**olvei|, the nuclei only remaining.
Fifirin iloe» not exist ready formed in the blood. Tlie theory of Schmidt
whieh jirevailt at the prévient time is accepted, although not yet per-
fectly demonstrated. This author admits that there is in tbc blood,
be^des albumen, two other albuminoid sulistances — fibrinogenic and
■
PATBOIOOICAL UISTOLOGT OF THE BLOOD.
fil)rii»opliiittic ; mid tliat s rery nuiiuUi iiuntilîtj of the ItliriitopWtic
eubsC»nc« ia sulficii^nt ti^ cWi;:« into ftbriii a lflr-;c amount of tlic fitiriiio-
tjifiik* HiihHlaiici-. The fibrini)|>Wiic fttitinuiico i» fouii-i in tlic reil Mw»!
I cnr|)uitc1ce, ntitl tin- filirinoji^tiic exisW in tho pliuinn. Thrse iwn sub-
fsunci^ liiiri; Wvn extnic[<-d fr«tn ibe blnoii, bill it is not kiM*vfii if by
tuixiii^ ihcfD 6brin will bo jtnxluueil. It in poAitivcly knnwn, however,
, tbkt m] Moo<l cor]>u»cleii a<lde>l to certain exuded Suids — ^tliat of jdeiiritis,
I for exttinple — <au4e the rormation of librin. Blood collected in a vessel
[in a few momeiita forias a inasa or clot, vlûch at first sccuratel; re]>r«-
I Bents ibe volume of blood urairn. without anv change in its appearance.
But in a few liours the clot is contracted, and surrounded by a U-nion-
I colored or fili;;htlT red scram. When ttic formation of tlie clot i^ «low.
I as in inflanunatory diseases, the red corpuscles, btin^ deit»cr tlian the
other constituents of the blood, fall to the boUom of the vessel, fti>d the
superficial part of thccoagulum is colorless. 'Fbo colorless portion of the
clot presents relieidnlcKl slHio and wbttisb spots.
Microccopk exBimnalion of (ho clot demonstrates that the coagiilatioo
is dtiP to the formation ofcyliudrieil fibres aiid granular larainw anaAlo-
luoNÎii^ eiie nith the other, constituting a network, in tlie me^hea of
which lire red blood corpuwrle» and sicruni. llie diminution in the sizo
of tlie clot is «wing to the contraction of the fibrinous reticulum, which
retain» the red globules, but penuita the escape of the Huid portions.
In oriler to recosiiiie the fibrinoiu reticnluin, which is concealed by tlie
red blood corpuscles, the clot should be hardened in alcohol, and thin
weiions made, which, nftcr moceralinj; in water, shauM bo p<'ncill«)il. 'IV'
«rater ilissolvcs the red corpuscles without actiiifç upon the fibrin ; the
latter ts seen as nn irre^ilar aiia-ttoHin.iin}; reticulum.
In the oolorlew f>ortiotiit of tilowly formed clot« (he fibrinoit* reiiciiliim
is more di#:Unct and regular. The small «hitiiih 3\inUi found in (he color.
Ii:sw jiorlion immediately above ihe layer formed by the red cor|>uscle3
consist of collections of white globules contained in a fibriikous reticulum.
I
Sect. It— Pathological Histolo^r of the Blood.
The alterations of the blood in disease arc numermu; they are almost
all recognixed by chcniiail analysis, but a few arc distinguished by the
microscope: the latter only will be here coufttilered. They consist in
variations in the number of the e<>r|>nsclË», in the jireseiioe of bodies
which do not exist in the blood in the normal state, aiul finally iu ihe
coagulation of tjie blooil in the interior of ihe heart and vei»el(ii.
Chmtitn t» Oit uuml-fr uf (hrfutelt». — The corpuscles of the blood
may be diminished in oomparison with the amount of serum, the red and
white remaining in the same relation, constituting hifJrfBiitia. If this
change is very decided it can be rcoogniied by t!ic unaided eye in a drop
of blood place<Ll upon a glass slide. Kxamined niicroscopically tJic sinull
number of corpuscles contained in the blooi.1 is very evident: but the
elements preserve their nalunil shape.
The name Uuorj/i.}»!» (Virobow) is given to a transient and «light
increase in number of the white blood corpitscle^. 'Hii^ »late is met with
288
BLOO».
tin acute rnid inflammatnrv discawit, pneumonia, phIe;;mon, prrfti)>eln!i,
Funallpox, and the otiier oniplive iliâeaaos, etc. InâicaJ of Ihree or four
white corposcles in the fieM of the microscope, five, six, or twent;r '^'^
BOCD. '
Lfitivri/thœmia (Bi>nn«t), or leuksmia (Virchow), U a diaeaae char-
aeteriscâ by r persistent nnil ^{rowing ini:rctt.so of the niimbcr of whittj
blood corpuscles. Towunls the eixl of the iliscuse the white corpiiMjIcMI
rare as niuncrons or uveti more »uiii<-roti« tbitu the red : the hlood is paloJ
[ vilhotit liaviiii; the wuler_vap|)cnTiincc seen iii h.vihiwmia. When n prcp^i
[ aration i« exmniiicd without the ft-lilîtiuii of wnter, the whito corj«*cles
are iie«ti ait ;;niiiular l>oilie:< vnrviuj; in me from .OUT mm. to ,1)1:2 mm.;
afler the aihlition of water, tlieite corpiuide* swell, become more trnoi*
. juireiit, and in »orao a single ajiherical ntideu:) i.i di^ttiiguished, in utlienU
I two or more nuclei are seen. Virchow has deacriheil two forms of leucocy-J
lUiiemia, one, iu which white corpuscles containing several nuclei pretloouJ
I nate : the other, in which uni-nuclcaced corpuscles are more uumerDuaJ
He rccognixes a loucocytlucmia connected with hypertrophy of the spleenj
and another with the lymphatic glands. This distinction cannot ho nuunJ
tftined.forif till' blood of :i leuonoythicmic patient is examined sereral dajM
in succession, it i« found tliAt smiietiniex the corpuscle» containing several
nuclei predoniiimte, and ngain those with a single nucleus are in excess.
Hc^ide^i, this distinction of Virchow which i» founded upon tlie analog^
of the white oorpusclei with tlie cvlU of the spleen in one case, and witli lh«'
cells of tlie lymphatic ginnds in the other, is not admissible at the |)re#ent
lime on other ;;round.4. It is known that the glands or new Irniphoid orgao^
contain, in leucoeytlionna, elements larger thuii those of the splenic pareiM
chynin. Again, in Icucoeythiemic patients, the changes of the spleeilJ
of the lymphatic glands, and of other lymphoid orgatis tnost frv<[ueDt]7^
occur at the same time. There are often formed, iu patients siitTv^riag
with this diseuse, new lymphoid organs (see l.y m ]ili adenomata, p. 141).
A few writers have described in leuooeythtemia, beetles the ordinary
vhitG cor|)ii:tclc, red corpuscles contiiining a nucleu», and which Uiej'J
'consider as iutermediale éléments hetween the white and red corpuscles.^
Ve have searched for these iniermediaio corpuscle» in several leiicocy-
thiemic patient/* without ever finding them. Many of the white corixi».
cles, «specially the largest, contain very small, araher-colored, spherical
granules, grouped arouml the nuclei. This can be explained by the
destruction of tlie rod corpusclos, particles of which have been absorbed
by tho white corpuscles.
Mffanœinia. — This name signifies the presi^nco of particles of pigment
in the blood ; this change is swu when the spleen hns experience*! frc-
4{ucnt attacks of congestion, especially in malarial poisoning. In the
cases that we have observed, tlie pigmentary particles existing in tliu
blood, were round or angular, deep black, varying in diameter from ex-
treme smallnesit to ,008 mm. or .OH!) mm.; they were all coniained in tin
white corpiwcle]*, or enveloped in a colorless granular zone, which very '
probably represents tlie protoplasm of a white corpuscle.
At the auto|Miy of persona dying during the presence of this lesion,
most of the organs, especially the spleen and liver, are foundof «grayish-
slate color. Éxaminin;; thin s.-ctioni ffom these organ;, pigmentary
FATHOLOQtCAL HTSTOLOST OF THE BLOOD. 289
granules sre found in the white corpuscles containeil in the vessels, in
the cells of the vessels, in the cells of the peri-vascular connective tissue,
and ID the celle of the parenchyma. The splenic lymphatâc glands are
also pigmented.
Pathological pigments act in a manner similar to inert granular matter
contained in the blood, vermilion for e.tainpte. If vermilion, in minute
particles suspended in water, is injected into the blood of an animal, the
granules are taken up by the white corpuscles and carried by them into
the different organs; they pass through the vascular walls, and are
finally fixed in the elements which are the seat of pathological pigmenta-
tion. It is probably correct to consider that melanœmia consiste of a
pigmentary change of the blood in the spleen, and a carrying off of the
pigment in the blood by the white corpuscles.
The pigmented corpuscles are generally larger than the non-pigmented,
and are liable to accumulate in gome of the btoodvedsels, and obstruct
the circulation. This does not cause true embolism, as maintained by
Frerichs and Virchow, but a phenomenon analogous to that of stasis of
the white corpuscles in leucocythsemia (see p. 148).
[^Parasitei. — According to the investigations of many hlstologists there
exist in the blood of persons affected with some diseases (the infectious
in particular) various forms of minute organisms which are thought by
some to be the germs of contagion, or in some way to bo more or leas
directly the cause of disease. These are micrococci, bacteria, filaria, etc.]
19
IIEAKT.
CHAPTEK VII.
THE HEART.
The auntomical chaugeB of the three coMtitwent part» of tlic liwitt,
will lie Miccessivvlj described ; the pcriearduim, the mvocArtliiim, nrxl Ihft
enilocanlium.
Sect I. Perieardinm.
HuiORBUAGRS. — llemorrliugus of tlic pi^ricnnliuin nre of two kiixlpi:
1st. Ecchymoses of the mumhrniic ; -il. ïlciuorrlugcfl into lite ciituj of
the pcricnrdiuin.
J-^t-chjim"»'-» uro more frequent upon t!ie visceral tlmn npon the paricul
lKj«r. When reeeiu, thev Are itceii na Icntickilar spota of a uniform re<l
lint; sometiinei* Ihev are continent, forming spots vnryinj; in extent, with
«iuiioiis mnrjçinii. Thene ecchymoses are not nccain]i»iiie<l by any înflain-
malory phenonK>na. They occnr in asphyxia, leucocytlnemia, 8cUT%'y,
etc., or they comjiUcate inflamnuitory legions of the pericardium, nben
ttieir description helon<:s to hemorrhngiv perienrditis.
JtemoTrlirt;/rf înlo the pericimliiil sac nrc coiis«cutiv« to inSaiDointion
or to n rupture of the heart or a large ve^iel covered by tlw rwcer«l
layer, for vxiiwiple, the rupture of an aneurism of the asceiuling portion
of the aorta.
T>RorKy OF the l'ERlcAittutM — IIïi'Bo.pKKRAKDnM. — The i|uan(ity of
fluid found in the pericardium iweniy-foor hours after death, always ex.
ccedd thirty j;ramiiifs: When the lluid if- very much more abundant, aa
19 9c«n esj'ecially in fitscs of general dropsy, there is said to bo dropsy of
the pericardium. In the fluid there csiçt epithelial cells, separate or in
shreds, which usually contain fatty K''a'"des. Vt-ry fretpiontly during
summer there are also seen, in the pcricurdial fluid, articulated and mo-
tionless bacb^riu of iinusnul sieo.
Oaset are sometimes founct in the pericanlium of «uhject« which have
commenced to undergo putrefaction, hut it «hoiild n"l neeessHnly be con-
cluded that tiiese gnitc* have existed during life. Tlte existvncc of a
special pueumotosi» should therefore be rejected.
Inflammation ok the Pbkicakdr'M. PERicABDiTts. — Kihrinoii»
inflammation of the pericardium diflers from fibrinous inflanunatiou of
other serous membranes only hy the appearance to the unai<lcd eye of
the solid exudation. Generally it covers the whole surface of the peri-
cardium, but may be hmitod, especially at the base of the heart whore
tixc ftorla and largo vessels have their origin. The exudation is found
IXFI.AMMÂTION OP THB rBSCCiRDtlTH.
291
njjon liritli vtMCvml nnd [itin«Ml siirTnccD of tlur ccricurilinm in n Inycr
which 111 <rav« prcsctiw u]>oii itit surface |>tiiill]trv iiromiiieiicv». 'l'U<:*e
proini»«itce9 nre not tni« (lapiilie, ti* the conti«oti>'e Xi^me iin<I vcasfila of
the nerouii laetnbrnne do not Torin ariv [lart of tlicir structura : tlitn u dam-
nnsinitctl hy detacliing the faUe lueiiibrAite, which is perfecllv snvooth
at ita union niih the [tericardiiiin. The tal.ae membranous soli'l exixtatioa
conaidts only oi'librin, cclU from the enilotheliiim and pua corpuscles. Ilic
piifiillarv proloDjpi lions of the free surface are flattened or clon;iate(t and
much varied in ahapc. They are acen eve» when the layer of fibrin i* «x-
tremuly thin. Tb«ir formatiou is duo to the iDovemcn(« of tltv )i«art in
tli« (lericariliuin at the lime the fibrin coagulutcs. Fibrinous pcricKrditia
occurs in actitc nrticuJar rln'iiniutisni, piieumunia, «oarliitinK, ainalljiux,
Briicht's i)iwa«e, etc.
ffemtrrha</if pericardili* is met with in tiibercnlo^s, cancer of the
lung, and in cachectic diseaiie ; it diflem fmm the preoodin}; letton, only
by the presence of a greater number of red blood cells or tlte product* of
their dccomponitiou (hieantin, hniiuatoidin) in the finid and soliil pAriioits
of tlie exudation, lu ibis disease the demarvattoii of the serous uieta*
bmne and exudation is not so «listinct as in simple pericarditis ; the dilated
veawds, with embryonic walls, of the serous membrane penetrate into the
fibriiioits exudation as loops ; they are seen surrounded by embryonic
^cellri, and from them hemorrliagea escape into ihc exudation as ecehj-
noacH.
In lulnrreuhu* pertcnrditîa licmorrhagci arc more frequent. Tlic tu-
t>crcul(ui<) ^runulKtioii.* mHV he in the |icncanlium, or in tlii! viifiuutiir part
of the evudadon. Wlieu the jiericardiuin aiil exudation are iiililtratcd
with numerous tubercles, caseoiw transformation of the exuiiitiou may
occur ; tbc altered exudat may then be partly separated, and form irrej^u-
Ur firay or ochre-oolorcd masses, free m the cavity of the pericardium.
By raicroacopic examination there are found tatty ^ntnules, granules of
hsematin, or cryalala of hicmatoidin, if ibe disease is chronic, there are
also caiuareoos granules.
J'uru/rtit perirarditit doca not occur so often as the prccedlnj; affec-
tioiu; it ia chuructoriicd by the presence of a lar;;c quantity of pus,
which causes the fluid to have a creamy appearance, aud the fuUe mem-
brane is rendered opaque. Tlie purulent exudutiuu may undergo acaaeoua
and calcareous chitiij^c a.^ with the bemorrliit^ic e\uilatio[i,
Adhe.*ions of ibe pericanlium foliowirig iutlummiiiiou» are not very
common, esjiecially if compared with those of thi^ pleura. Incomplete
adhesions are effected by lamin» or filaments of taseuliir cimni'ctive ti^ue,
generally situated at the base of the heart boiween the visceral and pari-
etal layer opposite the aorta and vesseU; they are aUo aecii at tlie apex
of (he heart.
Complète adhexion of the pericardium obliterating the cavity may result
from ft reeoguiiced perimrtiitis. or it may be found at the autopsy without
baring gi*en any symptom of ita formation during life.
Ill* prnniini;nt pntthcs formed of laminated connective tissue, which
are seen ui)0» the visceral layer, may be considered aa lesions consecutive
to pericaniiti*. As haa been explained on page 113. this tissue, in the
pericardium as in other Organs, may undergo calcareous infiltration, thua
202
IBART.
forming calcareous plates nbich vxrv in extent and somollmes send pro-
longations into tho cariliau muscle. Usually tliu calcurooua j^ato is noc
(Icnu'lvd in the cavity of Ute pericardium, but is covered by » tliiu
layer of filrous ti«aiio.
Mitktf yalAes liave hoen considervd by most nritcm m liaving ad
înniiiiiriiiitory ori^ii: tlicv nro smooth, opaque, uid of pCAtly aspect, go»or-
iillv I'onniii^ n sHf^lit ckvatioii upon the surface of the membnue ; tlieir
sent i;t {)ariicul»rly u[M>n tlio anterior tiurfuce of llie vonlricic, (lii'y ar^
rery varial>lc in »ixe am) {tosseiis irregular HinuouH margin.4 ; they are
very frenueut (,-!■'> in 15U autopsies, Uixot) and cousiat of lamicuil«d cou-
nectivc lisaue with elastic fibrea.
i'rinwirT etireitioma of tJie pericardium is very rare. Ilie secondary
form is hotrovcr ijiiite fr<.--|uent. It tarons into ihc cavity of tbo pen>
canlium, causing a poricanlitis, generally heuiorrhagic.
Sect. II.— Uyocardium.
Atrophy. — Atrophy of the hrart occunt in ^iienil atrophy of tlie mws-
clc« of till! economy, in ciiclivctic disi:ii«v» of Iroij; dur»tii>n, in phtliiHÎii,
ai the tvrminiilion of typhoid fever, eto. The form of Ibe heart is not
Fig. IH.
~.J:
r>l>}' Inltllmllnu <•! hvatl. A inKl.m fnin nt uotr "xlcriial poKloii nf Ihr Itfi le&lrttla at Iha
hnd, •)iu»1ng rb» aruH lb of Ul Iidih'-ui: ih> uiiiKuUrni't». Tb'BhmimtuwiiivpUBMalrapliiW
«■d cftmineiiclDf to tiadtrfA full; unt^nvrpbualt- X '^ (4?rHi>>J
cban;;ed when the atrophy ia ;^eneral. The coronary arteries, which do
not take part in th« atrophy, are toriuon» and prominent; at sonte parts
of their course the visceral pericardium iâ seen as a membrano eounect-
PATTT AVD FISUBFiTAItT DSOBXEtl ATIOX.
a^
I
1^:
Bus lliL- vessels to the heart. The alrophjr aiay he »o (»roat as to cause
hirinklin;; of the jwricsnliMio. Soroo authors beltirvc tli&t ihty hure
Mcvn in titrophy a iliniimilioii of thu six» of Ihe mnwulsr fihres. Iliit Uiio
[!■ wry <lifficiilt to upprvciatc o» account of the f;roal viuistion of tliuir
tiliitincicn.
I Atinpliy of thi- heart miiy «xi»! with an iibiiinlsnt fonnation or«'Iii>«<e
ItiiUiK! bcntiitth thu visceral p^ricaniiiim, m ihnt iiotwith.^taiKJiii^ thi-
kanliiie idiimIq k airophicil, the heart at fir^it 8i;;hl ]>r«iietitii it^ normal
lue; hut if the or^an U cut in[o, the a'lipoae tU«iie nitder the ]icri>
PHMinm ii fnun<l to tie conaMomU^ Ihickcnei). [rre;;iiUr |iroli>n;^tiana
of thiâ tiïHiio exti'ini heinccii the fasciculi of the canliac muscle. Thia
Iciiiou reH«mhleâ fattj: infiltration of volunlAry muscle. (.Kig. 1n4.)
HTPEBTHOpuy. — Hypertrophy is connected with exagiiertttod work oi
the lieart lu diseases of the orifices or vessels ; the ohjcct of tho work is
L to overcome an ohntacU- to the couKe of the blooil. 'lliereforu. nio^t
^flen only » single ventricle is alTect«'d. (or example tho left ventricle in
cliause» of the aonic orifice. Hy()crtmpliy of the left venlriclc in atntphy
of the ktilney has ticen referred hy Traulie to an anali)iou« cauM. This
coincidence of hypertrophy of Ihe loft heart, and of atrophy of tho kid-
ney is an incoiilê«tahle fact, hut in the «xplnnation t;ireu hy Trautw, it
i* >)illiciilt to undenttntid how the inconvenience to the circulation in mi
few vcmcIm can cause such an enormous iucrcaso of work in the licarl.
Myi>ortrophy i* general or parlai. The i)ha[ic of the heart t.4 not
notably chanfîod in ;;eiii>pal hypei^rophy. In hypertrophy of the right
ventricle, the apex of the heart is not so pointcfl as normal, it is en>
lar^d ; it is formed by Che extremity of botn ventricles which are upon
tlie same level. In hypertrophy of the left ventricle, the apex is formed
by tlie loft only. In hypertrophies of the heart tlicrc i* always seen a
t)iict;onin<; of the enil'Kardiinn. The miwouUr fibres of the hyperlrophied '
parl.1 either do ni>t present le»ion]i of nutrition, or they have undergone
fatty {ligmenCary dejçencratîon.
It ii not yet known if the hypertrophy is due entirely to an inorease
in the nzo of the miwular libres of the heart, or to a new formation of
tlieso fibres. In hv[iertro|)liy of the heart the plienomena of develop,
ment of new muscular libr«3 have never been obsor\-cd, so that ilie first
hypothesis is the more probable.
Fatty DKiiENKUATios. — The heart is more frequently the wat of fatty
degcnenttion than any other muscle of the or;;tnism. When all tho
miuwtes of the body are submitted to the same iiiflueTices ca|>able of pro*
noiog fatty de;^nenitioii, tite heart alone may be nttac):e<l. In a fœtus
lying in the utenui and retained f"r more than a week, tlie voluntary
muselet* arc not in a «tale of fattv dc^reue ration but the fibres of the heart
*
are; there are, however, im|)ortaiit charj^e^ produce<l lu the voluntary
muscles — the colorhi;^ mailer is separated in tho form of black granules,
which are located beneath the sarcolomma or in the substance of the
pnmary fasciculus.
Fatty <lei;eneration «ay occur in a hypertrophîed or atrophied heart,
t is seen in poisoniag by phosphorus and arsenic, in i;ravo diniases.such
294
ttKART.
Fîg. 15S.
■illftiitid-X^»''-'^"»"-'
lie tvphoiJ fever, smaDpinx. )eucocirth»>inia,elc.,in euilocaixlicî» snd prri-
cunlilM. Tlie ilejçeneration may involve the whole of ilie inynrnnliiitn
or only a [tart. To ihc unaided eye, ttie ctiait;tcd
portions a ppctir Rray or yellow, and by llieir opacity
arc distin;!ui!ilicd froDi the licnlthy parti), wlitcli are
sli;4htly translucent and of a more decided red tiiil.
Hut it ia not possibli- always to rccopiiiie fatly
dui;vnenition without the did of the microscope.
(FIe. 15-1.)
Tlio iiiiL«cnlArfa«cieutiprc»eiitvery Tnrioil decree»
of fnlty degeneration. At times Ihei» «re ^tid
only fine jzramile» scattered over all the fMcieuli,
but not raaAkinj: the Ktriation oonipletcly; n^in, the
fatty de;:eiie ration may he so far advanced liiat the
fasciculi of the heart reaemiilo cyliuderâ which are formed entirely of
fatly grannies.
Ptii-MKNTAHV Di;«KXi:itATi(>.v. — III the oornutlslate, with the adtilt and
old persons, tlie miiscnlar fuHcicnli of the heart at tiinea present around
the nucleus, spherical yellow or brown granules, the naturv of which is
still undetermined. Their color has enused them to bo regarded as formed
of a piitmcntarv «ubotancc^ derived from hiCTuof^lobin.
In chronic di«efwc» rcmiiltiiig in rinai'ialion. and in senile weakncas.
the atrophied heart prciieiiw a brown cobir, and its iniwcnlar faMieiili
conlain n greater (lusiitity of tlit'se f;r!inule:it)ian in tho iiorinsl conditinn;
the piejeiice of iliese granules accounts for the brnun color. (Fijç. Ii>tî.)
In melanosis, there is found a piv'Oientary infiltra-
Hg. iftB. jIqu f,f tjip heart which diflers from the preceding by
the black color of the granules, by their scut in the
en mice live tissue and in the muscular tissue at the
»aiiic time, and by the localiKalion of tbe dégénéra*
lion in small circumscribed points or spots.
COSIJKFTIOX, l[EM0RliIlA«8, ASD IHPI.AMMATtOX
OF TiiK Mvoi-ARitirji. — t'oniffttion of the myocar-
dium may exist during life, but it ha.t iioc been |ioitt-
lively demonstrated after denili. HfiHi'rrhay*», on
the contrary, leaie evident traces and they are cer-
tainly preceded by congestioD. The heraorriia^es
are gcucrally seen «s small «cchymotic apote, «au.
ally scaled upon the internal or oxtomal sarfacv of
the heart. /,''■'• Ay »i"*f« occur most frequently in
all diaenscs which tennlnate by K.«pliy.\ia (diseases of the Itinpi and heart,
in poisoning: by plios|iliiiru.'«, iirst-nic, etc., in lenCQCythmmia, in purulent
infection, and pm-rperat f^-^'er). The blood escaping between the mus-
cular fibres of tlic heart soon coagidalea, so that tlie small ketnorrhagio
nia^ forms a bard, red or brown nodule, of theater consialenc« than
the neigliborin*: parts ; the muscular fasciculi included in this mass have
experienced fatty degeneration.
There arc sometimes accidentally found at autopsies blackish spot^ in
i\nt\ r,J Ih* hrnlt. MhilV.
Inir I1i« VTtnnlf* of ply.
aiiml ittid llttt «lrii|i|ij' of
lh« Alir*^ Tb«'llttl^^^■Tt
|q kowv pkrit Budr-rKogn
•I*. X»"^ (Orrm-.i
AXBrRlSMS OP THE HBART.
S9S
(Ut« m^ocartliiim, wliioh vcrv prolnM^ come from olil hemorrbages, flince
in (li<-.4« puiiiW tiic interraMÎcular cniinec[iv« lUsue conuins cclla inlil-
tratoi nitii |>i^iueuUry f^raiiuleH, nnd ihe neij^iibûrîtig muKular faaciculi
un also pignteuted.
Iiarge hcmorrtiAgcs of tlie heart occur in niptarcs of the mj-oc&rtlium
leilher priinarjr or consecutive to fatly de^cnoration or to aneurisms. A
nipture tino to fatty «Icfjeneratiou U siii^te or multiple autl alwfays occurs
from within outwanU ; it is irregular, and if d4-atli is not îtutanUineoufl,
the Mooit infiltrate; the muscular ti»«ue in n (lilfu»e<l umnner. If the
rupture >Ioe» not exteml as fur a« the pericaHiuin an aneurism is fonocl ;
but tDMt frC'inentty tlie rupture breaks through the pericanliutuantt lill«
tbe sue with iKtrtly utia^ulatvl Mack bluwl. The fatty de^eneriition i»
■Iwnys more decided in the proximity of tlie heoiorrhajcie foeu:».
Anruriiitnii <il' thi; Âtitrt an found especially in the interventricular
iteptum and at the apex of the left ventricle. The aneuriiiinii of the
xcptiini and baiie of the heart are generally tbe result of the exlennion
5 of a valvular aneurism, the origin and structure of which will be later
studied. Those of the apex of tbe heart, which occur most fri'-iucnily,
are probably consecutive to a fatty de;;cncnitionoran inltammaiion com-
bined with endocarditis and myocarditis; but all the changea of an aneu-
rism occurring in this locality cannot be follonod, as in the aorta, and it
is only ttirou;;h rcasoniug by aualoj^ that the method of their fonnation
can be understood.
At tlie apex of the heart, tlie nncurism is isoen as a ano varyinj; very
much in nhé. from a haxel-nut to that of the heart itself. When the si^e
of the iiac ÎH very itmall, it h included, aa it were, in the walU of the
organ, and can only be recognised liy opening the heart and examining
^B it» internal surface.
^P The communication between the ventricle and the cavity of the aneu-
^^ ri^m is by a funnel-shaped apcrtun', or by an orifice in the form of a rin;;.
The wall of tbe aneurism is firm nnd ri^d, so that the aneurisnial sac i»
not emptied at the time of the ventricular systole. Yet the stasis of the
blood is not sufficient to form laminated clolo, as takc^ place in aneurisms
[of the aorta. At the autop*y, there arc very often found in the «ac,
recent Ghrinoua ciot«. Where the aneurismal »ac i» Anfractuous, there
are suen •hn»<' fibrinou.t clot* adherent to the w»ll.
The internal .surface of tlie sic iâ usually âmooth; sometime.* it is
irrc;;uhr and anfractutius.
A histological examination of the wall of the Aneurism shows layers
of flat cells, which seen in prolile appear tliin and fusiform, owing to
their centre being awollcn by the nuclons. These cells arc separated
from one another by connective -tissue fasciculi and bloodvessels. The
entire wall of die aneurism may consist of this tissue, but frequently
only the întcniul Hurface of the ^c is of this structure, and there arc
found in the exl'Tnuil jmri ma«culnr fibres of the In-nrt group<;d in small
fasciculi or isolaleil among the layers of Itat cells. By examinin;; n fre»h
piece of the aueuri«m:il «ac, it is possible by dis^^ection to obtain tbe flat
cells. They accurately resemble the cells of perfectly formed connective
tia^ue. Isolated anil floating; in a fluid, they pn-sent surfaces and borders
ftud folds which imlicate that tliey are flat cells of extreme thinness.
nSART.
Th*ir contour ia sïnii'iu'i aal sometiroea sliows prolon^pilions, which arc flat
lilto ihc boily "f the cell. The form of thcM ctOls ami their arranci-meiit
ill Uycrt pnrallcl to the internni surface of Uio nneiirism, nre iluv to the
pr»'i"»urc exertcii by the Mood fierpciiiliciilarly to tiie wall. The snintt '
ccUn iiikI ti««uc arc foun'l in Kticuri$in!i of the srtvric!). The nncuri»)R«1
pniiliiwil hy im «xtensiun of vaWtilar utienri«ni« nro gonerally ililluiwtM
or the Kdc iM wry iitifniciuous and (wciipied wîtli irre^iUrly arranawll
doll). Thetw nneuriitiui, locjttcil most fr«<|iicnily in the intcrrentricuhtr
aeplum. caiine ilti ilv^trudinn nivl ii commuiiicatioii of the t<ro ve»lrii:le!t.
The (UiiiieM are toni orseparnu^d in auch a manner that tlic ithre<lt) ara
forced iiiro the riuhl ventricle, l>y the Mood pacing from the left
ventricle into the ri;;iil, the jires-^iire being alronf^er lu the fonner. The
mtiâcnlar fibres at the luarijin-i of these aneurisms, which are gODerall»
aculc in their course, are torn and are fatty degenerated.
Infiammatiim of the mi/oitirJium ia not belicn-il by us to l>e pcculiariy
chnrftotcriwid by a fatty degeneration of the mnitcular fibres of the heart,
fill' ilii.< di->;ei)crntion may «xiat in a number of nfl'ectioti« of the heart or of
geiieiitl di»easi'« which hare nothmj; in common with inllaniinntiuii. On
the other haml. fmty dr;.fncmtion of the mii-'citlar fibre* i» iml «eon in
caae» of well-marttNl niyooanUtii< cbaraclcrixeit by a growth of Uie eoih
nective tissue of the myoc-inliuin.
The miueular fibre» bocoinc fatty in (uyocardilis only when (hey ar«
comprosaed hy exudation.^ and pus ctdN; for exuinple, in abwe-» of the
heart. The fatty de;*eiieration does nol difier then from that seen in car-
dine hcmorriia^ïes. This inclines us to dtiiiy the finreiichymaioua myo-
cArditis of Virchow, which ia characterized by a faity dcj^Ciieration of
llie mn^leit of the heart.
Plff. 1ST.
wmJlf la Ihi* 4lTwi(lvn of lilt nnv'^'Ur lll.r«, tkowUir itat f r^ualAr ■ud «von^a ro««nu>u of lb*
Bl.'t*. HD.! ih<- prL»irklnf<u4't of Ibulr imcl'L ft- A lrui«ir*r*4 •*cUdD, ab^Kliif th« <MllA4ftr lutJltftlt*«
ol (b« lulntnuieiiliudtiiit. X i**^ ((Tthn.)
Myocanîitia occur.4 aa an extension of endocarditis or pericarditis, or
as a manifestation of purulent iufecUon, when it is characterized by inira-
muacular abscesses.
AII8C893 OF THE HEART.
m
[Fifiralil ïtulurtifian ttf tht ITtart.^ — ^Thi* i-nin[iiirntivelv rare coim)!-
lion w prolialttv î» tiH«t cMO* • t*!m\\ ftf iiivocaHiti!'. Tiie cimnjro i«
c)innict(-nï.<r<l liv llio 'l4>v<.-l'j)>ini'nt of ii lilirilUlfl itMiuo liotncni tliC liiiiti-
ottUr eli'RK'iitii. 'riie pnvc^M cointixMtcvK in l)ic iiitornmsoulnr *f\Att
aronml tUe blood vckkc la. (V\^- li>i<.) TtioHo lirconM! inlihnttvd vitli
oelU, which lend to hccome developed iitto a flhrillitii-d .itnicture. 'Die
growth «r ivevf (issue gradtuillT extends Wtween the Inutiles of musvulnr
fibres, BO dint iiltinmioljr each fibre may be furromided bv a micl of
dviue fibroid tisaue, (Fig. lâft.) The muecular fibres llieiDselvea, owing
ri|f. iss.
PljC. IÏ9.
WM^kMh.
.'^m ■
rl^r^'4 (■•lintilon uF Ih* hniii. A Ihla
VW'tSi liijutsilwi of Ih» lini'1. » «Mk-tt frtui Ik*
tolljr d'K'iKtmlaa. y,'UM. tOrtrn.}
to tlie residtiuj; iiitcrfewnce with thi-ir nutritive supply, atrophy, iinderiçn
tjr dcj^n«ratioii, und «i* gradually n-iiîaiiod hy the fibroid jçrowth,
TtTj freijiiently the c^^lluiar naltirc of the growth i& not seen, iJie uewr
tU«uv heinj; itîmply iihroid.
l'hii* fibroid induration of the heart appears in most casea to ho induced
by iiiHamiDatory procewies commencing; in llie peri, or endocardium.
When secondary to pericarditis the ehan;;e is usually mo*t advancod in
the mope external portions of the cardiac walls, and r. commmdy aift-cb*
both the right and left ventricles. When, on the other hand, nn eitdo-
earditis is the prccunioi' of the indurative process, the ehan<;e \* more
marlitvl in (be inlomtil musculsr layert, and inasmuch n.» in!lainmat<>ry
procetwe* in tbp eiKhicnnliitni occur almost exclusively in tlie left canliac
caritic», the left vcutriclc i» iirincijially invidved. In other caseft the
fibroid growtli a|i[H.-ftrA to he the n-uuU of «vithilii*.
'i1ii# lemn i.t hy no mean» iinifunnly tlisirihuled through the car<ltac
miLwIe. Il «hould he rcganted m the re-iult of a chronic inflammatory
procéda, which rai;^ht be termed clirouie myocanlîtjs. It ijiteriepes aot-
lerially with the movements of the organ ; il therefore is one of the most
grare of cardiac diseases.]
j4A«(Vsa» of the heart occur but seldom ; they vary much in «Îkc,
from a pin-liead to a hazi'l-uut. The pus ■$ found between the mit'vcular
fibres of the heart, or is enveloped in a ïonc of ciuhryouio tiiwue. In
< Abstracted rrani Qrven.
Heart.
t)io foriDcr, the muscular subiitAnce in tlie prnximitjr of tlie ft1»c«»4 U i>\
a sinle color; the [tiu fonoing the absce;*» cmitatnd dd1>m of rmiacular
faoi-icnii, if the suppuraiivc inSaiDinaiion ia recent, lu the sUte^coIored
lone surrouuilin;; the small noit-cysted ahsecsses are found fattv ami pi;*.
meittarr -^niiiules in the tuusoular fasciculi whicii are se[>ftrftteu hj bluotl
C(ir|HMeK->t, pus colls, and brown granuien.
Thcri.! lire soniittiinirs fourni in the suhstnuce of the heart cmcous'
«ncyxted iiumbos, wlûoh KocrAter considers ks the result of an old mrta-
morpho^ed ab«cc»8. Thei-e are a few record» of uufrnctuouD e«vitic«
excavated in the cnnliac muscle and opcuiri>r into the left v(>ntricle;
thefic have been considered »-■« iih^uc^^'eA, wbieh have opened ami dis>
charged their coulent^ itito the circulation ; such eases shoulil be inter-
preted as auenrUnu following endocarditis.
TfMOIi* f>¥ TUB MvtKïARDiVM. — Gumniata Iiave been doacrihed ia th«
heart filicunl, Virchow) aa also secondary nodules of «arviitonui «pd<
epithidioma (l>a»et, Uonvillc). UeckHnj;hausen has published a caaM
of striated niyonm in the heart of a ncw-bom child. Thirty cases or
hydatid cy«ta of the heart, due alurays to echinocoeci. luive bcvii rs-j
ported. TiiCM! cysts may form a promtneuce iu one of the cavities oi
tlie heart, may rupture, or even become free without rupturing.
Sect, III.- Endocarditis.
NoKMAL HisTOLOov. — ^Thc endocardium lining the wliole internal sur-
face of lliR heart presents for con^idenition three layers : tsl, tiie cndo-
tbcliuni forinin;; a sinj^lc layer of flat cell» ; 2d, a layer formed by
flntU'ned cells separated hy ii laminated fundamental substance; Ai,ik
layer fonned by elastic tissue and fasciculi Df connective tissue.
l.-<t. The first of these layers disHii|«;iir» twuuly.four hour» after death.
"id. The layer of flnlteued cells i.-i very thin ii]tnu the ventricle* and ,
both -iiirlace-* of the arterial and aurlrulo-veniricular valves ; it ii* thicker
upon the auricles, and more so upon the left tlian the rij^Vii. The flattened ,
celU are thin, and generally pMWM prrdonga lions which vary in number;
they contain a lenticular mieleua, a little swollen at the centre ; they are
arranged parallel one to the other, and are flattened in a direcdon parallel
to the internal surface of the en<locar>liuin.
The lauiinaled fundamental substance which separates the celU is not
reduced to fibrils by macerntin;i in bnryta-watcr, as i* the ca»« with
ordinary c'lnuRctivo tissue ; it seems but sH^^htly fibrillate'l atnl almost
hyaline. This layer, like the endotliclial lnyer, is continued without
interruplion upiiu the sujicrior and iuferiur surfaces of tlie valves.
Hd. The connective and clastic tissue layer of the endoearvliuin raries
the mast, accor<iing In the different re;^ions of the heart, and so con.
fiiderably that, for example in the apex of tlie left auricle, where it is
most developed, it is about ten times thicker than upon the ventricles.
This layer is directly continuous with the layer of flattened cells on
the one side, and with the connective tissue surrounding the muscular
fasciculi on the other. Figure Hit) represent» at the left, a soctioa of the
KllDOCARDIUX.
390
veotrtcttlnr endaeardiuni, sbowin;; Uic flaitcncl colls, a : (h« filim-<>tajiue
Uycr, h ; an') the conriL'CÙve tlsauo wliicli sorren as n iiivxm of union
(o the DiUAL-ular fibri-s. <■. It consjjits <A wit» niiil olaMic lil>r<-ni the
Inllcr aru wry fim*. an'l iiro arniii^fl in U_vor» luirnUcI w ttie surface in
till" I'ndocnnliuni of thi- auncKs ; tht-y arn wry Clone logellnT aivl verjf
nutncroiu. It i* tlif«j fibre* wliich pv« tlic a)in<|u<>. Krayisii-yoUow
color to the «urfaco of tin* Ivft auricle in the normal comlilion. lu th«
Uy«r whi«h llicw Hhrea form in the vciitriuiilar cuilouatxtium they are
not 10 uloM u in tlw aurioluii.
Thp l««r* L> Iti* Urt i*pr«>*iitt 1 Wfllnn if lh***nlr<<-iil*r*Bilat«M!un; tl th»MlrAni» l«Rlt lb*
Jl. Mr l'on fiT AH Knri^c tKlv«: d, lnyfr o1 ût,i c^i^* sf ihu 4pp#r Ucr <ff Ebp vtlt* ; oa ttin fpjiatn*
>U*, fij* abiM Uj'r or IÏJ» Unrr or vfotflcaUr fft'Odf ITivihIi* : r. ^» ftbr^«'U<lk lAyet t>rififf pur-
d*a«f tliaf-4lv«iU«ld*d f mai Ibfl ftorU : /*/', A^r^vliivllc Uji^r «■/ Ihv t*Btrkulftr |i0rl)vo pi lb*ntlv#,
XlM
mprtHsU ■••Hiua of ihr «huU of * ralia uid ll> IsiartlDu HI ibo nbriua Ha> «f lti«a-iiUr m,
tm** oMh^a rii<v^ rn. niin^ •Itftttr I'lriinn iti-riToA Fmhv ibq Éoria; j»i dhru-frJktilv |>«nLi>ii «JtrtVfd fron
lb> tauLiKnltr abdiHahliuiu : u, *U*dr Bbrc*. ^I'i^
The fibro-«lastic tisave of Ihe ralres is arranged in the followinj;
nanncr: Cpon the auriciilo-vootricular vali-oa. tho fibro-elaaiic Uyerof
th« amides is continued somewhat tiiinncr upon the superior surface of
the vaUe. The fibro-elaslic liiyer of the ventricular cmlocsnlium is con-
tiuue*! upon their inferior surface ; it is very much thinner than the pre-
ceding ; and it is from it, «t the free border of llic vnlvc, tliat the tendon»
proceed, enlarging to their «ri'cin from the pajtillury miiscW. The two
elastic layers at the centre of the valve are separate'! fniai each otlier by
N very thin layer of connective tt^ ue. In a tranitven>e .>>cction of the
valve we (iii)tiiigui»h, at ita periphery upon the flU|>erior ami inferior !«ur-
faceii, the layer of endothelium and flaitenod coUm : then the two layers,
superior and inferior, of fibro-elaiitic tissue, the superior lieîiij; thickest ;
UkI. lastly, at the centre a ihln lamina of connective tis-^ue. It is aWaya
the superior or auricular surface of the auriculo-vcntncular valve nhich
is iirst and to the i^rvalest extent altered in valvular endocarditis.
The arterial valves nro formed hy the rentricular endocardium upon one
side and the internal membrane of the artery upon the other (fig, 1<H1, B
nnd C). Beneath tlio cndotlieliuni vxi^ta the layer of flattened cells {B,
300
nEART.
â,ti'), nhicli \» erervwlicro contimiouii, and U reflected at the freo boHor
of ttii.' valvce : this layer ia thicker upon tlie ventricular surface, if. than
«poll the arterial surtacc. d. The fihro-elastii: tissue of bolh laniiiuf id
very Ihick at the ori^jin of the valve ( '', w) ; it forms the support for (li«
valvo, but very uiieiiiialty — acconliiig as we (:OTi«i<ier the port vthich
eomos from the fihro-elnslic tissue of the veiitricninr cnilocanliimi or
from tliG iDtcniftl membrane of the artery: it i;»[)stitittcg fuur-fifUii* of
the thickness of the valve. 'Hie fibn-eliwtic tissue in nrrangol m that,
beneath the Inycr of flattened cells, thcro in foniid a very thin layer of
connectivi- ti.<iiie hi>oii the inferior or ventricular iiiirfaci>, and a thick
layer ii\im\ the .iiipcrior or ari«rial surface of. the valve (ti;;. ItîO, /{, e);
beneath the^e layiT.i exist two layerd of fibro-elaatic UaHtie, separaie>l
by a thin lamina of connective tissue.
Valvular endocarditis 'is rooflt frenaontly localised upon the intentai
surface, near the free border of the arterial valves, in the layer of ttat-
tciied cells, which is hero thicker than upon tlic external surface (A, tC).
Ksiioc.iuiitTls. — A'-uU rn'l"--inliru occur» in nrticiitar rlieumatidn,
in piterperal fever, in tliu eniptive fevers, etc.
Of all the cavities of the heart the left ventricle i« the on* in whieh
the lesion is» most frc<|uenlly met with, Mjiccinlly on the aortk and mitral
valvc-^. and, o-i uill be «een, it 19 ufion the auricular iiuffaco of tho mitral
and trii!iii>]>id valve^t, and ventricular .lurface of the aertic valvoit, that the
Icwinn fin*i appeal-^. 'I'heolder pathnlogieal anatomîsis acconled an exng-
{•cratcd iniportincc to redne*« ; but. exeopt «rhen it presents itself as a
vascular arborixniion. the redness indicjite^ simply au imbibition. This
redness is seen both upon the endocanliiim and the internal membrane of
the vessel* ; it is due to the impregnation of the membrane by the coloring
natter of the blood couiinj; from the red corpuscles, which linvc beea
Fig. lai.
ng. lOi.
IltflHIIlinallan uf «nrlk VftllAA, Tba o«flirr
■ Ifefl* of Ibc pi^r««<. SlioW'Cijf (he hUtiAtltiD
iHSnininiiiriii i.f Do raiirU «tin. TIkcMfllar
■ tiiilo i>f I.U<' I'tic-**. V4Ît* »«ii trfm ikM %ntin'
destroyed ei^cr by an infections ilisease or by a rapid decomposition of
tlie cadaver. Kmlouanlilis i» esseniialiy diaracteriwîd by ve^^elationit,
erosions, »n>l ulceration of the endocardium, sometime? causing perfora*
ti<>iis and laceraiionit of tho valves.
Vcj^etatiun^, Hliich cotutilule the essential phenomenon of endocardii)
^
BSDnOAnotTIS.
nro nt Uidimi cxlremcly Himill and iiiiQi«rotis, m Uiat Itie nwrotirane, to a
rarjriiig vxlvnt, bits n iMu;;honc<l iippcariiiite. 'l'Ue»e ttuutll ve^fuuiions
ma; bu iiiiifonnlv «cnuurad over ii large surface of Ibe auricin and loft
reniricle. The; uro won in tbis state at ttio beginning of endocarditis ;
Fig. 144.
an at* vl tl» •■(«•■•■• al iba urlio
tvlta, «hUk hr nVMfef »a ih» sbJi-
•kKlNM lwl*w ku |>iu4iifi»4 ■ iiinmut
lalMNMaUtry inHNlatlaat (i).
lent* >a4<aifri<il*. A (naalallsa Inm Ik* tallnl
tdn. (lluiBlitt a auilaiiut ■••lalniii iir«H HiaiuilWt* ■<
but if tlie diaeaac, no PHttter how mild,
lias continued, tlie rej^tatioiu are ctn-
sidcraMy inr-fcr, and rony bceonw ba large
us a pea. Tlii-ir form rarira vcrv much ; it
is conical, niimimilar, or resembles a lasf^
berry. Some of the gr<>ni)8 of rej;ctationa
are very irregnlar, at times arran^ol on
ibe bordent <>f tbe aorlio valves or on tlio
border of the auricular surface of tlic mi-
Ital valve, nour the iiwcrlion of the tendons, reaemblinft very irregular
wreaths; their »eat \* determined bj tlic limit of the vascular netvork
of tlie honlcr of the valvi.>«. I'pou the aortic ralvea, thoy are not seated
upon tlie eiXge of the valves, but a little distance from the border. It is
chiefly in an endocarditis of rapid course, as in puerperal fever, or very
severe acute artieiibr rheumatism, ibat this arrangement ts ohïcn'ed. 1'he
lnr|;c«t vegetations are seated only upon tbe valves or upon the fibrous
«one of the cardiac oriHcea.
If tlie course of the endocarditis is irregular and slow, tlie vegetations
are very uncoual id siee. In chronic form*, the vegetation» are not so
pmmincnl — toey rcat upon an indiiratAd base, arc harder, cartilaginous,
and ofti;n opa^f ue ; while, in the acute fomiR, the recently formed vege-
Utioii^ are soft, friahte, and semi-transparent. The irari»liicency anil
friability of recent vegetations cau^teil iliem for a long time to tw con-
sidereii as consixtin;; only of fibrin ; yet their attachment to the wall
should have bani.itied Ibis hyiiothe^s. When they are removed witJi the
fingers, the surface of the membrane ta not «en, but there is a tear, which
very distinctly demonstrates that the vegetation is part of the niembmnc.
A microscopic examination shows this relation most satisfactorily,
Si-clion* from acute endocarditis exhibit vegetations formed entirely of
embryonic c^'lls separated by a very scanty amount of aiiior]>hoiw «ib-
alance ; this tissue is continued into the en<locanliiim henentb, and forms
a Koiie varying in extent around tiie vegi-ialion. This «one of prolifera-
tion should he carcfnlly studied, in onler lo understand the formation of
vegetations on the endocaniium. tt U seen that it is not distiikclly
limited, but that there is a progressive multiplication of new cells, as one
J
SOS
BRART.
ftdnnccs from ilio periphery (inranls the centre. Tlie new farmatioD
takes place in llic layer of âutteuc) cell», tlie Hat celle iiUo xesUtJn;*, Imt
it iR by no nenns diMnciiislniteil tlmt ii few cellular elements <lo not cuaie
from nnotlier »uitrcc, for oxnmplv, tliv wliite IiIocm] voriMutelcs. j
The vejçelatiOTi* are covered l»y a thi» liyiiline loyer forriK-fl of flbrin.^
In ffironi'- enii-'axnUli* tlie vrgelatiuiis hove a tliSerent ittntrttinr; tlie
cellular elutneniH, in.tteuil of heinj; rotiiid, are elongated <>r tlaiti-iiv-l,
separateil by an iiitefx:ellular fibrillar iiubatance, always very abuiidnnt,!
which gives them their carlila^^inoua conaidteuce. Tbe intluratcd plates*
opon which they are implanteil present an analo^iu Btntcture ; in a
wofii. thcae vegotationa ami their base rocall the structure of the in-
ternal layer of the endocaivlium. According to what is kiiowo of the
LORUHC of all inBammatary proilueta, it may be nffirmeil, that all iii^luruti.il J
rami prnmineiit plates have at lir«t buen soft ve^^etAtions which have ultt-i
nately undergone a fibroiw or^niaation.
lu the tetiduns of the imlral vulve thore are seen the phenomena oCj
acute and chronic cndocanliii*. In tbe fornior, the lendone soften, Wcomu
Lfrinblc, and may rupture. In chronic eiulucanliii.^hy[M>rlrophied chonl»
ptenditieK are rn-i|ii(-iitly met with ; they are diniiiti^bed iu lv»j;tli, rigid, of
eartilaginnuH conmitMice, and iiiiiootli upon their surface. J
The soft vegetations of eiidocarditin, instead of undergoing changad
which render tbeni lihroua, may, from the constant passing of ttie bloou
over their surface, be torn into fragments, an<l they then arc seen an
ahreds. The cause of the friable nature of these new formations is owinn
to llif jircjit abiinilancc of cellular elements pmdmxd hj the very aciitaj
infliiiniimtiiry jiroces*. It al»« at time? occiir* thiil the increased forii>a-l
tion 'if cellular i-lcment^j re^uU? in a fatly nu'lnmorpbosi*, on account of
iii^ufHcieiil nutritioi) ; «o that all the growiii;^ ti^^ue becomes a gmniilar
nia»s ; there ihcn remain.t an anfractuous ulcerated surface, formed of a
tittsue in which are found granular fatty cells, frae fat granule», and
blood pigment. The portions lom, .loftened, and seinratcd by die circu-
lating blood, are extremely amiiU. and may be carried into the capillaries,
or ihcir siie is such that they arc arrested in the arterioles, producing
septicipmia and embolism. This entire morbid process has received the
name of ulcerous endocarditis, but it docs not constitute a distinct variety
from other acute forms of endocarditis.
WiU'uiar Aneuritnië. — The lesion described as valrular tncuriam
{Tbiimam, Foerster, Pelvet), is a eonnciiiicnce of acute eudocanlitis
aflectin;; the valves. Tbe nmltipliuatiun of the cell», their embryonic
HtnK*, the softening of the int<rrcclluliir ïubvUmce, and the disa[qiearancc
of the ela.-'tic fibre», phenomena connected with endocanliti», caune the
valve to lose ittt power of re»iHtnnce, and it is not able to snp{)ort tlie
blood pressure. Wlien, from the action of acute endocarditis, tlie soften-
ing rapidly extends to all the layers of tbe vaU-e, the latter is at first
distended, but is soon ruplurod. When, however, thi action of the in-
flamniation is slower, the valve having losi part of its resisting power,
slowly dilates without being ruptured.
Vah-ular aneurism has so far been observed only in the left heart,
upon the aortic and mitral valves. In the aortic valves, the orifice of
the nnuurism is always upon the superior or arterial surfaces; in tbe
TALVOLAR AVeCftlSUS.
808
mitral valve, the oponiti;; of the orifi«« is always «ipon Uio iiiffrior «r
ventricular aurtace, Ttiis arrati^cment \* ownig to tliu Woofi prcttmre,
wlitch is oxeriol when tiic valves arc <.'1n«e(t from Mow upwards in tlie
veiitrk-lc at tlio uionMiil of t^iv ventricular «vst/)le, ani) from almve
«lowiinanU upon ttiv aortic valves at the mnntent o( ibo diastole of Uie
'ventricle.
'J'w4» foniia of tli«se aneunsiUH arc met with : IhI. A valre aofleue^t by
' ihc iuflaamatory procoM, may be diiitended tliroughout, and remain in
tliis condition when the inflainnintioD ceasea, llie li.isued again rcj-ainin;;
tlit'ir primary lirnnie^^; 2<1. Tlie endocarditi» coiilinuin;! in t^ie iiotile
, mate. '>ne or more vAtve.i (ire^eiil u[>on a part of itieir Hiirfaco soft aiteu-
' ri^iuial saea, romitl or funnel sliapcil, or thoy show raj;v;od tears, 'rhvsc
lesiona tmv oxUt at the same time upon two neighborin<; valves. An
irregular tearing of a valve ia very often seen, the shreds ol which project
from the vcntriuular side on the aortic mitral valve. These shreiU are
ni};ge<t, (H'tyisht and covered hy a tliin layer of (ibrin.
A liistolo^iical examination of the shreds shows ibem to conDÎ^t of
Doclet and rouiut cells in a mass of -iniiKihir substance ; tlicro in neither
Coniiis:livv fibrillar suWtancu nor eliistii- fibres. 'I'his same tiasue, how-
ever, is always see» in the walls of recent aneurisoal sac«, whether they
an; iiktact or ton).
bpherieal or funnel-tthapod valvidar aneuri*™* without any tear are
Fre<|uenlly, if the sac has not hetn niiUnrcd into a great numlier
^pieces by the blood premire, it is mm «> a greater or less extent,
^c have seeo, lor I'samplisa fuuncl-shaiied anetirism of the aortic valve
prcai-niing a single perforation at ils exu-emity.
Acute endocarditis, by the vegetations and ihickenlnj; of llit* endo.
cardiuni upon the oritices, is a cause of oarrowin;; (stenosis), and by the
rupture ot Ihc valvular aneurism, it may occasion insufficiency. Theae
letuuns, however, arc more often produced hy chronic endocarditis.
A series of lesions of the heart, occurring espwially at llie orifices,
are coniieeted with •■hr-ml'- rnihu'itriUti* ; some have for a chuso acute
endocarditis, which has passed into the chronic slate ; the others arc de-
veloped slowly, and are seen in alcohol drinkers, old peraona, in lead
poieoniuKi ''^■
Chronic cndocaniitjs is essentially charactoriited by cartilagc-liltc,
translucent, or ojni'iue thiekeiiiiig». In many iniitancea the indunttions
coutain calcareous sali.s and hec'iun; like bone. These lesions an- es|ie-
cially seen in the fibroat xone of the orifices, and in the cbordie tcndineie,
aiHl valves ; they are very analogous to the alterations occurring in ewl.
arteritiii defomtans, and it is probable that ii|>on the endocardium a.t in
the arteries, primary atlieroma exerts some influence.
'llip le.'iions of the valvea, in chronic endocarditis, have the form of
globular or warl-likc ve;;ctations, seated fjenprally upon the ventricular
unrfnce of the aortic i-alvcs and upon the auricular surface of the auriculo-
T«»tHcular valves. The chordae tendincte of the an riculo- ventricular
valves are increased in size, indurated, and shortened ; the fibrous zoni;
limiting the orifices is hyijertrof'hicd and indurated. When the heart is
dilated by blood pressure, the fibrous rings of the orifices fre^juontly cx-
{leriencc a similar dilatation ; or they may prcdciit a notable narrowiuj;.
I
804
nEAtiT.
Tlic vftlvc» llieiD»eWe« iriftj bo lliivc or fowr tiiiK-n tliickcr tlmii iiorrnnTT
Their liwiie lias liecome rigid, tlieir borlvi? fitmi irn'giiliir «ncUin^s.iiitd
llier Art! sW tliickenoil at llieir in^acrlion, wiiere they ftro vonnvcUil to
tlie fibrous zone, wiiich preiMnlo no analogous imlurntioti. A« a rcfult,
tiie ^neral form of the orifice U ^realty modifieil. There mny ex\*i at
tlie Bamc time insufficiency anJ stcDosis of ilie orifices, iiiiiiiRici^itcy froii;
rigliliiy of the vulves, stenosig from Uie new formalioua yrowiiig ujMal
their biii-<ler« : it is very rare to finrl sienoi-ifi nilbout inauRicieDev.
Pcrjieiidicular seetioTisof the in<liirate<l liiMuc slionconsîdcrnblc changea
from the arran;;emt'iit of the iiorriiul en<locar>Iiutn. Instead of finding the
gucceattive layeni which have hecii described and which are so charaGter-
tstîc for each part of tho valves and orifices, there arc seen oidy irro;*ular
layers of flat cu'lU '««■]>nnttcd hy a fibrous substance and iri-e;;ulnrly di».
trihuted elantio fihre.i. SunietiiiicH th« oclhilar new forma tin dm uhich
hftvo caused the irregularity of titriicture Iiccome the stnriiiii; (loiiit '>r a
new organÏMtion tending to rcfiroduce the jiriinary tissue, hut never pvr-
feoUy succeed. The origin of the:^» new fnrmations ta always tiie layer
of flattened cells situated under the endothelium.
There are always found in this imperfect fibrous tissue small points of
fatly degeneration. These points, uniting together, may form atltoro-
matous foci filled with grauiilar detritus; liiese atheromatous pointa may
be stationary or they have a tendency to open upon tho surface.
The fonnalion of ca1c«i\-uiis (;ninu1cs and plates is very often seen in
(he iuduraied tissues of chronic endocarditis.
Il in vfTj ini|iort«iit to know if the indurated tissue, dcToloncil id the
endocardium and valves, undergoes cicatricial contraction. The ;nvat
narrowing of the mitral orifice, for ejiarople, can only tie exphtined hy a
process of this nature, but it is impossible to follow the process from lii^
tological observation.
TUK FoRMATiox OF HijooD Clots is tub IIbahi.— Fro(|«ently at the
Mutopsy the left ventricle is found contracted and empty of blood, except
pH be u lew filamentous clots between the columnK cameie of the uiitnJ
valve; it is only in cases wlicre tht* person diw of syiicjpe. that the
ventricle »rreste<l in diastole at the moment of death contains blood and
t clots.
The right ventricle ia fre<[uenlly distendeil, and tilled with coagulated
blood, chiefly owing to the agony geaerally being accom]>aiiicd by
asphyxia and hinderance to the pulmonary circnUtion, which jirevcnts
the right ventricle from emptying itwlf. Iho anriclea, on account of the
feebleness of the contractions, are always filled with blood during life
and occasionally after death.
When the heart ceases to beat tho blood contained in ita cavities is
slowly coagulated — much more slowly than if it ts exposed in a vessel.
Tliis has been established by the experiments of Brlicke, who remarked
that blood from the cavities i<f u heart removed from the body of an anima
coagulated only after several hours, a phenomenon which he attribute*
lii« influence of the endothelium of the endocardium. It is now known
that when blood coagulates slowly ilie red corpu.->cle.t, which are the
heaviest part, settle to the dependent portion, while the sui*erficial portion
rORMATIOir or BtOOD OLOTa ITS THS HRABT.
SOS
»
k
destitute of corpufwtea coaj^ilates into a colorleefi fibriDOua masa. Tlie
etol is tlton formed of two hTpr8,on«siiperficiul. li;;lit in color. coBBisting
of Gbrin ÎDclositi;' acniai (bulfy coat), the otlaor deeper, colored red by
the corpuscles. Coa^ilatioD taliefl piscv iit this manner in the heart «lien
tlierv is & nouille i|u:intitv of blood in its caritics, and the subject has
remaiiH'^l in the same position some hours previous to the autopsy, upon
tlic back for example, as is usual. All large ctots of the heart arc then
cnlorloM upon their superior portion, while tliey nrc cruorio upon their
inferior «urfaoe.
These clots are considered by lamt physicians to be formed during tlie
a^^ny ; on account of their decoloration, they have accorded to them a
vital ori^fin, and have named tliciu acdve clots. What we have said in
reference to the modo of formation of these clots is snfficient to demon-
strate that this interpretation is erroneous, and it ia useleaa longer to
insist upon it.
Some ctots nkcrit the name of aclivo clots, if by this word it is under-
stood Ihotc which arc formvd duriiij; life; they arc the fibrinous coagu-
lationit developed in thin layers upon the surfaco of the denuded endo-
cardium in endocanliti», or upon ve^tatinns of the orifices, or upon tlio
torn valves, 'Hiese clots are white or yellow : ihey contain wo red blood
corptiftclea, only layers of granular fibrin and white corpuscles. Aceonl-
ing to the tlieory of A. Schmidt, which ia generally accepted, their
formation results from the condensation of the tibrinogenic substance of
the blood in contact onlv with the inflamed wall. The slow coagulation
for this reason does not include the red clémente.
Other tarifer clot» are fonned by « sloiviiig of the circulation of th«
biwxl, a« occurs in «;tystole, ei^pecially that produced hy an impediment
to the pdmonary circulation, and in hypertrophies of the heart with
diUt talion.
'lliese clota vary in size and form ; they generally cover the eolumoie
cameœ, are adherent to the wall, and are uniformly yellow. If they are
not very old. they may ho separated into lamellfe by tearing, and their
central part does not didcr in consistence from the superlirial layers. If
they are older, their superficial part is more consistent, while their centre
is soft, and forma a granular mass. When the chan;;cs of the blood have
been great, as in hemorrhagic smallpox, puerperal fever, poisoning by
phodphorns, etc., heart clots fornted after death arc soft, friable, and do
Dot conttin distinct layem, while in k-ucooytbicmia tlie dots are hut little
colored, and there exii»w hcside^ n fluid which sometime» ha» the ajipear-
anoe and consistence of pus, a$ Virchow has observed. This in due to
the enormoufl ijuantity of white corpuscles contained in the fluid.
806
LSaiOKS OF THR ASTERIES,
CHAPTER VII r.
LKSIONS OF THK AltTKKlKS.
8«ct. I.— Normal Hi*tology of tbo Art«ri«*.
The arteries itrcscnt for «xaminntion an interoal. miilille, and extercal
COM.
'Die intenial coat of Inrse Arterie» canatsta of two parte : lac, the endo-
thelial layer; 2J, a thin layer lyin^ upon the middle coat.
The endotheltiû layer may be demoDairatcd by menna of nJtnit« of sil*
Fig. 1«.
A' Mr*ic<idr»;tfM uivoilirADv «tUl nlih tun* uortol. »-
IVWbuOj^d of the iniila iiUxniliilii, A- IfaciH <it ih«
nmcnUr Rht* rvlU- <■- Xiinl«l wlffain tb« *nm1]
la ih* fltii«hli>b v>^*hI«- from hqmin ('rata, x ^no.
V\f. I BO.
r\
lif;
vcr. The polyclonal very flat eii<l<-lhelial celU are tlien limîtpd bv a line
black Willi InitmtnÎHcd light : ihcy all contain u flai nucleus, round or
elongated.
PATnOLOOICiL HISTOLOâX OP THB ARTSMM.
307
I
The nU>-endotkelial latftr ta fonacd of flat ccIU îrrcguUrly 8t«Unto,
containing flat nuclei, and of a fibrillar substance running longilndiuiilly ;
it ilocs not contain vessels. In the Hninll urterioi lhî« layer ia »o tliin
tliat it ie only reeo^izeil by the longitudinal striation, and by tlie prctt-
vncD of a sinj^le layer of flat colls separated from one anatber, and wbicli
can only b« ili«tinctly rooognited aft«r the aetJon of nitrate of silver.
'Flio midilU r^itt of tbe large and médium size arteries consists of elastic
latnintu and fibres forming by their anastomoses a continuous system in
which are found smooth muscular libres passine in a transverse direction.
Next to tbe internal coat, the middle coat le umiced by a thicker elastic
lamina and also more refivcting than the others ; in transverse sections it
has a festoooed appearance. The rcco;^ition of this lamina is rery im<
portent in pathological investigations: we have named it tbe inlcrHot
elaatie lamnia of the middle cjiU. [Most authors regard tbis clastic
lamina as the external layer of tbe tunica intima, reoogniting three layers
of this coat.] In the external coat elastic fibres mingle with the fn«ciculi
of ttio connecUTc tissue in every direction, to form the framework of the
ttmioa odveniitin.
The external coat is traversed by arteries, cajnllaries, and reins {ra»
rnsorum) and, by lymphatics whose lumina appear as cleftH when cut
transversely. Small nerve trunks and isolated nerve fibres are also seen
in tbis coat. The small arteries possess a middle coat fanned by smooth
.nuBcular cells arran^^ed tranaver&cty, constituting a continuous mumbrsne.
^91ie tunica adventiiia of these arteries consists of very fine fasciculi of
connective tUsuo having a goueral longitudinal direction.
Sect n.— Fathidogical Histology of the AitoriM.
AttTKRlTli*. — The inflammation of arteries presents for consideration
many vnricti«tt when oxaimnod from a p.itiiolo^ical [loint of view. The
inflammation may be considered in reference to its location in lai^c, me-
dium, or «mall arterie.s, and in the external, middle, or internal coals;
atlieromatous and calcareous tumefaclion also enters into the history of
arteritis; finally, spontaneous aneurisms and the obliteration of arteries
by a clot followed by organisation belong to arteritis.
itt. Acvte AUTitRlTls. — ,\cute endarteritis or acute inflammation of
the internal coat of the aorta, has been seen by in several times as an iso>
latcd lesion. To the unaided eye, it is characterized by a swelling of tbe
internal coat in tbe form of prominent jiatches more or ivis extended, with
a contour somewhat n-gular and generally circular. The i*inaller oiiesarv
rcgulariy round, and present a sharply raised surface ; others, larger, more
irrcgidar in their contour, are evidendy formed by the confluence of seven!
small round patches, and exhibit prominences and depressions ufmn their
surface. Thoircolor iâli;;hired,transparent,or opalescent; theircoivsist-
ence is elastic and soft aa jelly ; they have been named gelatinous patches
of the aorta ; llieir surface is very seMom ulcerated. These patches are
fre<[uently accompanied by a somewhat analogous change in the neighbor,
ing internal cont, so that tbis membrane appears saturated with fluid
tBSIOKfl OP Tn8 JIRTBRIBe.
Cntn.<)luceRl, light red, or colorless. In some cantos wliere tlie emlartc-
tilU vna very iDtense, we have been impressed with tlie jialeness of Uie
internal oat, and, a^mo, we bave frequently met with an intense nMlnMS
of the vessels and endocardium, dnv solely to imbibition, without any
histological tnwe of ondarU^ritis or endocarditis : it is suffieiont, how-
ever, to allow an urtcry to macorato in water olort-d bv blood, in order
that its primarily pale surface may become red by imbibition.
There is freiiit^ntly «eeii in endarteritis a rou|;hcncd appearance of tli«
internal surface of the artery, due to an irregular tumefaction of tlie
■nternni coat, and not to a falling off of the cmlotiieliuRi, aa has bcea
Buppoted. Alt we hare already mentioned, lhii« endotJicliiim is normally
deslroycd within twenty-four hours after death. This is no leas true
also of jiathiilo^cal conditions, both upon the smooth surfaoca aa well aa
upon thoiie which are roughened.
A vertical section of these patches is seen to have a color and semi-
transluccncy similar to tliat of the surface, and to the noatded eye
their separation from tlic middle coat is distinctly reco^ixcd.
The elements constituting^ these patches can be separated wttbout dlA*:
eulty, by dissection with needles. Large shreds of the internal coat mar]
also he stripped off: this coat i« transjureul or slif:htly striated, and is^'
caaily separated into thin laminn, a d«m»ustmtion that tlie cells of th« '
eoat arc arranged in layeni parallel to the surface of the vosel.
'riie elementii forming tlie patches are round or irregularly spherical
cells having an average diameter of .01 mm., and in which a nucleus is
|teen upon the addition of acetic acid. These eleini-tita have all the cliamc*
Pters of embryonic celU. Larj^i- fliitloned cells with several prolongations
containing at times two nuclei, are also observed ; they exist normally in
the internal coat. Examination of the tissue by dissociation showa
round cells, which are wot free nuclei, as has been believed.
On microscopic examination of thin aectionn, the patches appear u t\
thiclieuing of the internal coat. With low magnifying power, the gres
thickne.xa of these patches can be appreciated hy comparison with the
normal poiiion of the internal coat and with the middle coat; for tln-y
raiay be a hundred times thicker than the internal normal coat, and
f*two or three times thicker than the middle coat. Witli a power of one
hundred diameters, which permits the whole of the preparation to be
seen, the cellular elements arc found to be verv numerous, arranged
in lines pariillel to the surface of the patch, and atminishîng in numbera^
as the middle coat is approached, offering a verv striking analogy to the
phenomenon which take* place in inllamcd diurthroilial cartilages, where
the cells at the surface are also the first to proliferate.
This cirrum*<iince. of the mullijtUt^tlhn iif the tlrment* at the tur-
/aee 0/ fhe internal coat it peculiar to aeutf emlitrtitriliii, ami B^tratr»\
it/rinn eHclarterltîa with a temleitctf to atheroma where the pmlifemliim
occur», a» we »hall itee, in the deepe»t hyer ^;f" the internal cmU. Tht
tame di$tinetion maif he made in endocardilia.
At the periphery of the patch, where it is continuous with the internal
coat, the changes in this coat may be observed and the process of form* .
ation and growth followed. Even in the tumefied portions there is seenJ
apon the surface of the internal coat a great number of round celliitarj
I
■
I
PATUOLOQICJIL UI8T0LOOY Or TDK ARTERIES. 809
clementa, wliile deeper t}i« fUtteoed coUb with their lenticalar Doclei u«
still found. I'pon the surface of the natch th» elcmetits ure very near
together, and seem w touch. The nuclei arc biscuit- or vrallet-shnped —
a precursor of the division which is to occui^— and scries of two to five
aoclci in contact one with tho other nro seen. Townnla the deep lajcrs
th<- ground sub^lnnro i<: more abundunt. ntid the groups of cclluUr elc-
menu nrv ntorv sejtnriiUjd fnim one nnotlier.
lu netitc eiKliirteritii, nhere the new elements «ro found upon llio «ur-
faou of tlie hitentiil memhrane, in order to explain their forioation, the
theory of (.Vhnheitu, acconling to which the wliite corpu.4cIe-t emij^rating
ool of the ve.sseh constitute the products of inflammation, does not readily
apply. A careful study of tiiese elements distinclly dcmonstnted thai
they eome from a division of the fixed cella of the tissue.
Tlie jtelatinoua patches of the arteries at times present superficial and
funj^uid ulcerations, which are covered by a thin Inycr of adherent fibrin ;
this occurs more frc(|neutly in valvular endocarditis than in endarteritis.
^9 «emt-transparent, soft, fibrinous layer is often uniformly red in color.
And striated, or it is so in patches. It cannot be dcterniitiud without mi-
croicoptc examination whether the structure is fibrin or the modified
inienuil membrane. 1'he parbt corajMsing the traiuparent layer, whea
stndied by diasooiatJon, are iteen to lie numerous round, small, nucleated
cell»; by their «liape alone, it is not possible bo determine whether these
embryonic elements come from the pmliferati^nof the cells of the internal
membrane or from white corpuscles of tlie blood. But if sections are
BUul«,it is seen tlint thoy consist of fibrin inclo«in]> cellular clementj. It
is veiT probable that the fibritioj^cnic substance of the blood tstransfonnod
into nbrin by the action of the fibrinoplastic substance of the infljunod
parts, nnd tliat this lihriu incloses either the white blood corpuscles or
tlie proliferated and free element)* of the discn^cd surface.
In every caite of acute endarteritis there exists a cotiHiderahle thicit-
ening of ttie rxtfrtnil fvat, a furrittrttrili», correspond in;; to the whole
extent of the diseased part. Its tissue becomes bomogeneoua. j^el&tinou»,
light red or amher color. Microscopic examination of sections sliows
considerable thickeninK and a now fonnation of cells between the fasci>
coK of the connective- tissue fibres.
Tlio middle -yiiit does not j;encrally present any alterations in acute
endartentis. Between the in<^?t acuic emtitrtcritis and that which ulti-
mately becomes a chronic endnrtcritis, every intermediate staf^c is found;
all the phases of the lesion may be seen in the same section of au
art«ry.
Aeutc periaTteriti» ehnraoterixed by a purulent infiltration of tho ex-
ternal coat, occurs in phlegmon. The inflammation is most freipiently
limited to this membrane, or it nccsstons only a slight lesion of the in-
ternal coat. In ttiis case the middle coal, which is not modified, is suffi,
ciently reaislins so that there does not result any serious interference
with the local circulation, and the artery performs its functions.
In arteries of medium size and smaller, sponinneous acute endarteritis
seldom occurs; but in granulation tissue of wounds, arteritis is common,
for example, in the fun^^id tissue of paronycliia, and in chronic ulcers.
By making a section of these tîssuua, a small ur[«ry is seen as a red ])oint
SIO
LESIONS or THE ARTERttS.
surrounded by a translucent and tliîck circular xone. If Ùwn i» in
utt^mpt at dùiâccijn;^ out the nrtery, it will be found very difficult to fol-
low, 00 account of the external coat beioji; infilirated with fluitl and in>
flummatory clement^, and blended with the neijihborin;; cotinectife tintiiie,
forniin^ with it a lar«Iaceous mass. The dissection is almo rendered) diffi-
cult, because of the friability of the vcMi-k, and the Bli;;ht«at traction in
iitllicienc to cauao D rupture. It is cdpcuially tlies« art«ries which «re
difficult to distin!;ui«h from tlio noigUbonng nerves, ou account of tlMÎr
nnkod-eyo re»einbtftnce to a solid conl.
Ili^toIoglcHl crxnmi nation of the di^en^cd vensol and ita mirrotinding
tissue ahowH vegetations of the incenml coat, that i.i,of all th«ti»lloincloMHl''
betW6en the internal Hurface of the vesHel and the first «iastic lamina of -
the middle coat. These growtlis consist of round or flattened cells i>e|«-
rntod froiQ each otlier by a small amount of intercellular sultstance. \e*-
eoU comiog from the tunica adventitia may penetrate into this tissue and '
form loops. This vascularization is seen very often when the middle ■
coat it! trunBranDi.vl into connective tissue. The external coat formed of '
fasciculi of conneetivu tisduc and elastic fibres \s subject to phlozmooovs i
lesions, that is. there is a formation of embryonic cells between ito fibrM
and an ahsoqilion more or less eomplet»; of the elastic fibres.
'i'lie mid<lli- coat in thi* fonu of art«riti.t docs not remain inactive ;
proliferating eloni^uted «elU of gmootb muitcle are 9>een, while the elastic
fibres are bi-oken down and alnorbed. Finally, the different arterial coata
are blended to^^ether in areas varying in extent.
Under the inllacnco of infiaminnlion tlic several ti»sue<i which constitute
the arterial wall tend to assume a structure like that of the intlamcd inter-
Dal coat.
Where the growth of the internal coat is sufficient to himlcr or
arrest the circulation of the blood, there is a coagulation of it constituting
one of tlie form» of arterial thrombosis.
2d, CilKONIC ARTinuTis, Kattv AsnCAirABKors DeiibxkraT[OS asd
ATiieitouA — The lesions of chronic arteritis are analogous to tlie pre.
ceding, except that they arc complicated by fatty de<:eneradon, atlieroma,
and calcareotia transformation. Atheroma and calcareouA infiltration
are always accompanied by arteritis; but this is not the case witii fatty
degeneration which may occur separately, and which we believe to be one
of the causes of arteritis.
PniMARY FATTT PEr.ENBBATIOSOP ABTBBIKS ÎSSCCn chîofly m the aoH»,
immediately above the aortic valves, whore in almost all adults thoro are
found while, ojiaiiue. tttriatcd patches forming a scarcely perceptible ele-
vation- Tliese palj:hes may he considereil as tlio first stage of fatty
degeneration which, with atheromatous and calcareous patches, in some
a^od persona extends over considerable space. The while or yellowish
patches shouhl be studied principally by longitudinal sections, or by de-
taching shreds of the internal coat. In these shreds are seen small col-
lections of granules and small oil drops, tVeiiucntly having the shape
of the flat ramifying cells of the internal coat. (Fig- 167.)
In transverse sections it is found that the fatty dcgcn«nition is i>ot
limited to the internal coat. The neighboring layers of Ui« middle coat
are attacked with Uie same fatty degeneratiou.
h.
PATUOLOOICAL niBTOLOflT 01* TBS ABTBRTSB.
N
^
I
Fmir 4*(«»mli<«*f IhalBlareil «qui »< 1L4
OTflf 111* IIHLntf ai«iitbnQ' ol lb« Tf*«**l 1 jrrj
oulMulg*. kixl Ibr •lidittmclm) d( hi li 11m Ik-
llBC XVO- Itfnm.l
Tn ihc inicrna) coat the fnt i;rana1«s fonn fUtunvd or rii«ifnnii \tiytn in
vrliici) remains of nuclvi arv sometiiiwii dLMingutihed ; tlicy are rocog-
nixed hy «taînin}; nil with carminé,
while uic fat )rnintilc« «re not Wg. 1«7,
ctilorci), M(wi of tin: »]Mtà do not
cmuin uucloi, tliey having diaap-
peareil lij: ntro)>liv.
In themiddlocoat. tlic fatty cran-
nied are arranged between the fibres
anil elastic lamin». and wbon they
nr« very abundant the mn^ular elc>
ineiit« cannot he iliiétiii^i«hed. At
tbo mar»in« of the fatly dezen«nto<t
patches the nituwtihir culls, which
atn be «till reeo^rnixeil, ari' intil-
tnte<) with gmnii)tf«.
From these facta it may he con-
cluded that this lo;Mon occa^iioi» the atrophy of the cellular olemonts of
the tiâ^uo invaded ; there is a fatty necrobiosis in tlic full acceptation of
the word.
CiiiiONic AiiTEUlTls. — When a part of the arterial coat« hae under;:on«
the chan-^ that we have described, the necroMd portioai deteriniiio
around tlium a hIow irritation, pnnlucin;; in tluH manner a chronic vitdar-
teritis.but this is not the only cause of chronic endarteritiit; it may appear
from the lirai or follow an acute rlieiiniatiaro, pacrperal fever, alcoholic
endarlericis, etc. The lesions of chronic endarteritis, whatever may be
iw origin, are always complicated bv a fatty denencrnlion of the artorial
coata; they lenninate in the formation of athcromatoua foci and calcareous
plates. It is important to make as complete analysis as possible of all
these phenomena in order to demuDstratv that they follow a f«tty dcgcno-
ration which occasions arteritis or succeeds it.
In acute arteritis which is not very ÎTitcnw, the gelatinous patches
ihemteive* inclose rainitied cclU coatnining fatty granules, 'nds fatty
matnmorjihoi^is continue» when the InlUmmalion lose^ itd first intensity ;
moot all the cellular elemcntK of the patch are )^enerally Sited witli fat,
instead of hein;^ ne mi- translucent the patch becomes yellow and
HUe. The fatty dejreneration continuing, the groups of granules
lich at first had the form of the cells are fused together, and there
results a small patch, visible only with the microscope : later it enlarges,
and hccomcs evident to the unaided eye as a characteristic atheromatous
tocos.
This athermnat'/uê foeuê is situated in the tldckcned internal coat ; it
is largo, «uperGcial, and Jl» honlers are irrejçular. When it remains
intact it is separated from the current of blood by a thin, carlilagedikc
jjellicle which is formed hy the most superficial layers of the intenml
coat. The pellicle ia tense yet movahie; at iti periphery there is fre-
■[ueDtly seen a swelling formed hy a thickenin;^ of the internal coat in
such a manner that the slightly <lepressed centre of the atheromatous focus
has been compared to aa umhilicatcd pustule of smallpox.
When an incision i« made through the centre of the atlieromatous patch,
312
LBSIOKG OP T[LB AHTBRIES.
Ihe knife, »ft«r dcin;; arrested hy ilie hardoess of the internal layer,
openâ iv focus from vrhich escape» a thick whitish pulp; examiDcl nith
tho microacope it ia found to conâist of numeroiu cbolcslvriD crystals,']
fn-c fut granulos, compound granular corpusclu», and crystals ol fatty
nciils.
Tlic athoromittouH foci soiiietîmcs open, durin); life, into lite artery in
Coti»(,-<|Ui;i)»T of the thinue«# of its coatx and under Ihe in6iiuni*v of the
ni«i:liaiiical force of tli« circiilmion ; the npouiiig any be either a umII
slit or have a sttellatv ith»p«. Tlie atberou&tou» palp then paueg out tnlo
tlie circulation, and the blood enter» into the cnvicy. I'he cententi and
edges of the nlheromatous focus are now colored yellow, brown, or black,
from the transfonnatioD of the hemoglobin.
Such ruptures of foci niay be the beginning of aneurismal dilatatiora^j
which will oe considered later. In aeetions paxsing vertically through the^
atht-romntous focus and its bonloni, it is found tliiit tlie bottom is foniK-^t
by till! inncrinost layers of the internal coal, whicli présent the inoditti'a-
tions of endarteritis with fatty degeneration. The n)»st i^ujierliclal
layers of the tniddlc coot shew the modifications of jirimary tatty de-
generntioD.
At the edgea of the ntlicromatons point the swollen jKinions presenl.
mieroMopi.e athernmafju^ toci lodged in a refracting slightly fibrillar
Bubatance; further from the ailieromatoua focus there are found nuclei j
colored red by carmine, and surrounded by fatty Rrnnulcs. The funda*
mental substance is made up of a fibrillation rery much like that seen io
illic centre of tho costal cartilage; and again, the fihrilliir mass limits
pmall cavities which contain cellular elt-menls recalling tlie cells of carti-
lage, except that they potites-i n'k capsule. It is a kind of chondroid, but
not carlila;cinoiu, transformation of i!)e internal coat. If the utliero-
Diatoua evolution occurs slowly, while the cella experience liie fatly i
, metamorphosia, the fibrillar fundamental substance ia infiltrated with
kalcareous granules. Those granules at first discrete, are later united
together, so that tboy form tmbriated, semi-transparent, friable, slightly
elastic plates.
Tftf rtUcarffUi fhfeê are seldom completely exposed at tho surface of ■
the ve«sel ; genuruUy they are eovoed by a lamella of the fibrous ttssua
of the iuterual coat, 'lliesebard laminie are nt times extremely tliin, and
«re destroyed by the movementa of llie circulation ; or tliey are tlnckeiicl
at the edge, and the thin layer of tissue which covers tliem i« rupuired,
forming irregular slits through which the blood enters and occasions a
deposit of black pigment.
Since the calcareous plates are transparent, friable, and but little
elastic, by the unaided eye they am easily distinguished from osseous
tissue, which is resistant, opa<iue, and i)uile clastic. Under the micro-
acope the structure of osseous tissue is never seen: irregular masses
with clel^ and dark stria; are found in a very transparent sulHtiauco,
which does nftl present cither the lamellar arran^-ment or ressete of bone.
The eltifta ami striie have no analogy with Imne corpuiicle»,
L There are frcipieiilly found in [lersons advanced jii age all tlio prec«(Iir^
Resions united, and accompanied with the dilatation of tlic rmne] ; ttw
PATIlOLOelCAL flISTOLOGT Of THE
313
name nrteritt» i}efnrm<tn», liu b««n ^Tcn to tlitS complex pathological
con'littfln.
\Vh«?n th« aorta in removed and open«(l, its increase in sixe, tho irre;;-
ildaritv of it» dian>et«r, the in«finaIitic-9 of itd surfAce, ati'l tiio rariotr of
*ft« lesions that aT« discovered oy careful examinai ion, are vorv xtriliiu'*,
Th« 1«eion8 are genernllv more decided and older at the origin of Ui*
aorta, than in the rcmsin<ier of ita len^^th, and thej aro contîniiL-'l %» far
t* it« main dîmions ; it appeare that the change had it« ori-^in in the fintt
portion of tlif iiona and pro;;rc««ivel_v invaded it. Ahovc the aortic valvcn,
Mpiiiitlly indurated, there arc found calcnreona plate», separated by cloffai
or iinhricnted one upon tho other, sonietiincs limited at iheir periphery
hy a swelling due to an endarteritis. The** calcareous platen very often
extend to the coronary artcrie*, 10 the innominate, to the carotids, and
to the sahclavian, invading them to a greater or lea» extent. The origin
of llicae arteries fioni the sorta almost always preaent^ a nearly perfect
bone-like ring. The arch of the aorta is the portion the moat dilated ;
it fre<|uenlly has the form of an elongated funnel. In the thoracic
aorta tliei-e are found eatcarcous plates, open alhcramatouB foci, alhoro-
matoua pustules, trunsliicid orsomewhatopa'juecartilagcdikc plates. Tho
«hajte and thicknotA of the cartilage-like plates vary. The excrvscenccs
which tJiey cause aro nuinmnlar or ve^rctating : they may he covered with
loyew of fibrin winch projtxt in the direction of the blood curr«'nt.
When there exist upon the inner surface of the uortn thin, calcareous
TitrcouM plates, formed iu tl» rigid and hypcrtnipliiod internai coat, or
extewUiitf over the atlifromalftua foci, they often hrtak, forming very
narrow slits into which the blood infiltrates. This blood undergoes the
usual pigmcntarv metamorphoses, and occasions black or melanotic
patches varying in size, giving the diseased part a peculiar appearance,
The preceding dcMription is particularly appropriate to the aorta, but
tbu same lesions are seen in tlie medium and smalt-sized arteries, where
the calcareous transformation is found fro')Ueiitly in old persona, in tho
arteries of the mcmhrane* of the brain, in the coronary arteries, etc.;
it occurs in the hypcrlrophied internal cont at 6rst by a chrouic
endarteritis, 'fliis endarteritis is histolopcally charactcrixed by a
multiplication of the celU of the internal coat, and by the formation of
a slightly fibrillar, resi^liii;;, intercellular substance, which ROO» gives to
the membrane a cartilaginous consistence. 'Hits cliondroid tiiiiiue may
develop regularly in the internat liftsue in such a manner as to diminish
the calibre of the vessel, or its development is greater at some point»
than others, constituting prominent plates or projections into the lumen
of the vessel. In consequence of this lesion, the blood is arrested or
«ufBciently retailed so that coagulation take^ place.
Tlicsc arterial coagula or thrombi cause (;angrene in the extremities,
softening in the bmin. and fatty degeneration of the heart when they
occupy one of the coronary arteries.
Kvery endartoritis of long duration is accompanied with a thickening
(if tin- f xttrnial coat, niUi the production of numerous cells between the
fasciculi of the eonneetive tis^*iie — s Mr^niV pert-ttrteritit. •
In the dilatutions of the aorta accompanying arteritis deformans, there
314
&8SI083 OP THS ARTERIES.
ÎS a coiintniit clUnppcarniice of th« middle coat at some points, wlioa
linjortrophied iiiternut coat is iinîcud f> tlio «xtcrnal coat.
I'ho portions of the destroyed middle «oat (ire replaced bj oonneclivo
Ltieeue from tlte proliferating external nod iDtenutl coati. Fijiuro 1<>8,
Vrom a section of the aorta, allows un interruption of lliîâ nature of tlte
middle coat ; it is seen as a bridge of oonneclive tiaaue placed between
tliv interual uad external coata.
FI){. lOd.
SmUo» of ib< unnim» i^ulal vt*rii ik« ■nldilli' li]><rl>lui>ii'api«l b^tioUirnanlf-OHMlt* Um*
A. lirMtiial nxubnua, d. KWtnti in«*1>ttn*, r. MUAIt «onl. d. Vtual la Ilia mllil *( Ik* i
t>r7aii>l ilHs* wblch aoltu iha •XMrnil ud Ulcraal mm*, y IM.
Vessels mav penetrate tlie 1>and of connective tissue, aa obown in the
drawing, whigh explain-t bow ilie internal coat may become vascular.
The destruction of ibe uiiddle coat i» tlie oidy cause of spontant-oua
aueurisms of the aorla.
In tlio ilisHi'pi'araiicc of the middle coal, the destruction of tlie clastic
Sbres i» pn-ceded bv a decomposition of it^ elemenlA into «mall refraet-
in^ graimle-i. ThL- external coat is ao modified in its structure «a to
nve the hiitological characters of the altered internal coat. It ii
fermed of Hat cells parallel to the axis of the veswl, and aeparated
)>y a slightly fibrilhir fmnlnmcntal subalancc. This alteration may be
'attributed to the pressure exerted by the blood upon the irriiaie.I con-
nective tissue of the external font, when unprotected by the elastic and
resisting? elements of the Kiid'llp oat. These very lutercstinj; phenomena
arc seen in the clyrelopnu-nt of every spontaneous aneurism.
8d. ANKUBiSMi). — Authors bave divided aneurisms, aecoriling to tb«]
ihape of the sac, into riffiiutrinif, /uti/orm, ntu-nform, rraUr-Ukt, at\
eitp-êlia/ifd. They have aUo been claaiufted, aoconlin;; to ibe structure •
the wall of the sac, into Iru/r ,t>i/- uritm, formed by the dilation of thai
three coatA of the artery : mix''<l extemai attetiri»in, formed by th«^
eslemal coat, the other two coats being torn; and mûvj iitterttnt
aneuritni, in which tbc sac consista of only the internal coat, forming
a hernia between the two torn or separated external co«ts. F«iat\
anrurigmt arc thos« in whieh the sac is compodod only of the neighbor-
PATIIOLOUICAL niStOLOQT OF THE AKTSKtBS.
Z iitMiica of tli« vessel. aAer the iJestruction of its walls; «iid, finally,
tiintfi-tiuif aneuritin» are those in wliich, the internal antl midille coata
ibi-ins torn, the blood infiltrâtes betveeu them nod separates them to a
ler OP less extent.
tithors who have adopted tlitM otatwificntioii hftvc relied up(m inatOB»-
ical principles, the niajorilv of which nrt- fKlite, as we have tleiaonstrateil
in a I'ormer work. Their error is owiii;; to the fact that tlwy cotwidoml
Hie foniiatioti of «ncHrixoi-^ as the result of a sinple mechMuoal action
exerted upon » heallhr artery.
SpoiiUiicous aneimnms «re alwBys developed in arteries which have
been for a long time the seat of iiiflatnmatory lesionn
It has heen »een that in the formation of the most simple aneurism — dila-
tation of the aorta in arteritis deforroans — the internai and external coata
arc greatly chani^d and hvpertrophied, irhile the middle coat has par
tially disappeared. Therefore this aoeuriatn cannot be considereil as a
trae ancunsni. since the midille coat is at places absent ; and it is not a
nixed extvnial or mixed inleroul aneurism, since botli the external aiul
internal coats are at the same time moilifii'd in thi-ir structure aiu) are dis-
tended. It is the same with every other fonn of spontaneous aneuri-tm,
i.lliat the anatomieal elassificatien of autlior^ should he rejected.
All Rpofitaneoas aneurisms are believed by us to he the mme hiittoloj^-
cally, that ts, their sao is formed by the intentai and external coata,
modified by inflammation and dilated by the blood pressure, tlie miildle
coat having disappeared completely or in part.
Fnrif'>rm aneurisms are produced hjr a circuiMcrilied dilatation of an
artery, in which a limited portion ts distended in a uniform manner.
Tlic arteritis has extended ru^ukrly over the entire surface of a portion
of the rcssel.
If tlie arteritis is located only upon one «de of the artery, or there
Mtain» it» greatest intensity, it destmys the middle coat, and the dilata-
tion oecurs solely at thi.« point, forming a mn-rit'orm aneurism.
finally, small aneumtii.<) commnnicaliii'' with the artery by a sharp
edge — the sac of which is rcgulnrty hemispherical in «hape, mont fre-
quently sitaated at the origin of the aorta, and which appear to be formed
by an opened and distended atheromatous focua— are named cgttogetùo
or «aHliaped.
DtêMf^tng anfHritmt^ described first by I.aennec, owe their formation
to H rapid dilatation duriiiz an ciiduri«ritis. Laennec supposed that,
after the nipture of the intenial and miildle coats, the bloo-l escaped
between tliem, disi«ectiu^ the cxtenial coat. But l'eacouk has demon-
strated thai tiie hlooil is diffused cither between the hyperlrophied
internal coat and uiid<lle coat, or between the laminie of the middle coat,
l* hy ai ologi cally, the extenval coat if formed of fnscieuli of eoniiecUre
tissue which slide one u^nn the other, and i» incapable of retuitiint; the
blood under the arterial pressure. Several hive»tigaton*, liiill and
Duguct among others, have verified the views of this Kn^lish author.
Every circumscribed, sacciform, fusiform, or cup-shaped aneurism pro-
ccnts for consideration Uie membrane or wall which surrounds the sac,
and the Ktratijifd flntt which line the internal surface.
When tui aneurisinal sae is ojienvd, there arc found fluid blood, soft
816
LEsiojrs or tha artbrics.
cmnric cloU of recent formation, and Uminre of clastic, (îriyisli. or tntiul
luccat fibrin, presenting grayish opa-jue striœ, ami sepiiratcJ inW> Itmrtn
1». Tbo last of Ihoeo lamina can be dotaoheJ from tlii' iutcraal surface
of the sac.
Fn->|uently it occnrs, espcvlallr >n the Iar<^> nnouTii*m« of the aortA,
tlinl ill ihv n)o»t external liimiiin;, iiniiiely in tlio^e which :kro in cmttnct
with the «nils of the niiciiri^ni, the fihriii hii» iimleivoiie a gmtmlnr
(lege lie rati on. These Inminiv at lîr.<l Ixtcoine opa.|iie, aft«rwartiH hrcak
clown iiit'> JeiriitiH; liere anfraotuous cavitieo filled with an atheromatoita
puin are formed in the tibrin.
The «rrangenicnt of the âtratîfiei lamiriie in the interior of the sac
rarim. In the most siin|>lo caitoa, particularly in cup^iaped aneurisms,
i the larers of lihrin form lamellnr [ilnced one »]wn iho other, the most
' external of which line only ilie buttom uf the sac : those forming after-
wEiHs are )ar;;vr, only t)ic most inlvntal rtuch thr neck of llic sac.
These lamelliv conse<{iiently vary in extent, the Kniallejt l>eiu); the mas^^^
cxt^ninl and the Iar<;e4t the raiMt internal. Tlii^ arrangement marll^^H
the pni;trcw*ive growtli of the aneuriiim ; tlie oldest deposits, that is, lli*^^
tuo»i t^xlerDal, were formed » hon tJie sae was small ; the suceesive layer*
are more and more extensive in projiorlion as the sae increatiea in siie.
In the large aneurisms, the onler of the stratified clots is not so sim-
ple; the changes are scon to be miicb more abrupt than in the pre-
ceding.
The InminiG of fibrin arc much more rosisting and thinner tho more
cxtcnini they arc. In thin iiectioni^, recently m)A::iilatr<I lit)rils of fibrin
are ni>t found, but irregular laruiri;is between whti:h «mall collection.-* of
fnlty granules and blood pigment are seen ; it is these coltectiom whieh
form the opai|ue striie. l.acunie resembling canaliculi ure aim observed.
In these clota, a true organization in the sense of a tisane is not seen:
neither living cells nor vessels are observed ; but after the action of cu^
nine and acetic acid, bodice colored red are noticed, facing the rentuna
of whiK blood cells con6ned in the coagulated fibrin, in the atheroma-
touH pulp, which is sonu-tiincs sub^ttituted for the luminie in contact irïtb
the witll of the sac. thtirc exist albuminous and fatty granules, crystals
of cholesterin. ancl ciiseous while corpuscles.
In thin sections, the membrane of the aneurisiiinl »tK appears in some
préparations f'orme<l by a single ussue, the slruotiire of which Is the
same aa that of the int«mal coat of arteries moditied by intlainmation.
At some [loints, the middle coat is very thin, and the external coat
has boeome like the iniumal; in other preparations, there are fount)
only some irro^lar pieces of the middle coat, enveloped in tlie tissne
of the aocunsuial sac, which has taken the characters of the internal
inRaincd cent. When the different regions of the same anourismal sac
art- studied carefully, the middle coat is found to have entirely diiap.
peared aroiiitd the niiddtc of a fu.^iforui aneuri:<ni and at the bottom of a
I sacciform aneurism; irre;;ular shredi< of this cout are met with tM (be
' non-dilated portion of the artery is approached, and in the neigtihortiood
of the neck of the sac, the middle coat is thin but continuoiL-t, or is inter-
rupted only by small foci of vascular connective lii»ue iuterpo#e<l be-
tween the external and internal coato. The new-formed tii»ue, which,
PATHOLOGICAL RlSTOLOâY Of THE AftTBBIBB.
P
partiall; or «ntirelv, constitutes llie snc of atieunAiu^, coasista of \ajcn
of flat cells sepamtei) by * ali^flitty fibrillar substance; it uncter^es the
ntn« alterations as the tissue of chronic cudnrtcntis. namelv, fnttjr do*
Kenvntion, alboroina, and calcificatjon. Old am-urii-mal oace are «t
tinics fonucd by a solid, incxtcnaibic, calcareous slicll.
From what Iia« bf«ii previoiuly mid of chronic vixlartvntiif, iind of
[Uic Mtructurv of the «neuri.trmil »%e», it is very fii*y to understand the
Jdevelo|Muent and growth of aneurii«n)it. Of the different eoaw of the
^arterie:* the middle one only, by ita elastic and contraoulv elements, is
able eSbclually to reaiiit the blood pressure. When, from tlie combined
^«Bects of endart«ritis and periarteritis, the middle coat has diimi'itvarcd
coRsequonce of the fatly degeneration of its mu^cuJar fibres, and from
[the granular breaking down of its clastic 6brea, the resistance of ttie
1 vessel becomes insufKcicnt and it is distcndnl. This dilatation does not
Isrrcst the formation of morbid tisane ; neither is the thickness of the
liralls of the eac in inverse relation to ît« extent. Sometimes the wall
of the »ae, at Ica^l in point», is much thicker than all the united coats of
► the primary vessel.
The wall of the aneurismal »ao may, honevvr, become thin and break.
This rupture is followed by an escape of blood into the Deifrhboriog tis-
sues. The leaion has been named a false consecutive aneurism.
One of the most iut«resting points in the anatomical history of aneu.
risma consista in the changes occurring in the surrounding parta by the
1 extension of the sac. In aneurisms, especially of the arch of the aorta,
where the bones cannot be pushed Midc or separated, thp latter undergo
& very singular l'>ss of xuh^tanre, which the older anatomists explained
by roeclianical irearin^r away. When the aneuriitmal sac extendi and
comes in contact with the «temum, ribs, clavicle, or bodies of tlie ver-
I'tebrw, excavations or a loss of substance limited by a red va-wular
1 surface result. Sections of these bones, to the unaided eye, show the
' characteristic lesions of osteitis: enlargement of the vascular or nic<lul-
lapy spaces, and the formation of embryonic marrow, are recognised by
microscopic examination. The osseous liimellic are irregularly eroded;
^^ftnd the marrow formed of youn;: cells does not contain adipose vvsi-
[cles. It is, therefore, not a mechanical wasting nway, but a vitnl
-process, through which the bone ilisappears. The mecbanical action
oecftffiOM an irritation, and it li this that causes the absorption of the
bona.
The irritation excited by the pressure of the aneurisraal sac causes
the neighboring organs to unite to it, giving rise to infiammalory com-
plications. Inflammation of the organ at the point of adhesion is added
to that of the wall of the .sac; softening of the tissue, and a perfora-
tion are produced. In this manner aneurisms of the ascending aorta
nay open into the pleura, pericardium, trachea, oesophagus, superior
vena cava, pulmonary artery, right auricle, or ventricles. Adhesive in-
Sammations of the tieij^hboring organs at limes may extend to more
distant partK ; thus, a phlegmon of the mediastiinim, catarrhal and ca-
«eoHs pneumonia may occur in aneurism of the thoracic aorta, and phleg-
mon of tlio subcutaneous connective tissue arise in aneurisms of the ex-
tremities.
IBSrOSS OF TBE ARTBBIBB.
Artfrio-ffnou» aneurUm consisU csst^tiatly in th« accidental and
direct vommnnioatiun of an arlorjr with n vein, characlprixod particularly
bv tlie dilatation of the vein ami tistially by the presence of an inlcrme-
dinti.> sac. To tlic uDuided eye, the vein gradually takes the vharactent
of ail artery.
Rg. 16».
ParlMa "t a Er«citvf<r*4 ■■^fiioDor ili* r*aii}r»l rtrttrj otu A»^ Shan't tti^t tljfni«r#, RlfT^ |»vw*r
nicElaii 1>»<«>I Jnil ibuis Ih'latrl et (ho bultom at th> Mi»j<]-c1i>l trblrh hai ftll4a as) vkllt »aad<
Uii[. nail «hl(h b» Doi bi-'B dnwn. a. Adifniltin : uni nii^r>h iril lornix ■< ihl* I***!. <■.
il'Ji' mil |i«n«pt1ltlr «lE^rviln «- KLuilo r#liti of Inllmji. imaJler**! /^s Tiilclt Ihjvf «f ^UfWat
r*U>»<laialj Hdhorluif II* «Acb iilb«r keiU ld ihtt ■UbILo ]47«r of tb« lulliiid. Tt«ttiig «kjv«4 1k«it
nil! I» lis In Ihc mala fmlnllirli"!!! In iih<nti<r. I.V»»t*«f*ir(.|
Arterial Oulitckations. — The rooât simple oMiterationa of arteries
are tHo^e jiroduced in conM>i|u@nce of wounds, tiy a coagulation of the
blood in tlie small arteries, or Ky the surgeon ^ligature, torsion, acuj)re*-
sure, cauterization).
ObliUrati'm of Ari^f» hy the Li'jnturi'. — ^Thc phenomena following
the ligature of an arW-ry are very oaxily oltservcd in aniiiial«. Twenty-
four hour* after lyitij^ the earoiiil or femoral artery of a dog, there i»
formed a clot in the central end as far as the firnt cullateral branch. At
this time the endothelium of the internal memliraue pre.tents importaiil
nioi lili cation H : the cells are swollen and granular, containiuj;; a spherical
inicleu4 and frctiuontly several nuclei. The lolloivin;; days a thickening
of tlie internal coat is seen, especially in the proximity of the ligature,
dial is, all that portion of the artery compriseil between the clot and ibo
first elastic lamina or internal elastic lamina. The latter, which in trans-
verse cuts is seen as a clear, refracting, and festooned band, \» a very
important point, indicating the internal boundary of the middle coat.
The thickening of the iiiiornal coat i» formed almost entirely of cclU
entanglvd in a complex manner: they appear fiiMi'onii, but are in reality
dntleiied cell». These cells exactly resemble endothelia, or cell* of the
connective tiaaue swollen by inflammation, Tiiey do not differ from tl»
celU found in acute endarteritis. On the eighth day tlte internal coat
puts forth low elevations, uipplcdike in form, which are ])articularly well
marked at the point of ligation, and are seen very distinctly in traasrerae
MCtJons : in loii<{itudinal sections from the level of the upjier point of tlie
coaj^ulum Co the place of ligature, there is seen a gradual tiuckcnini* of
the intemni coat. Ity the twelfth to the fifteenth day, the lupplc-Iikc
elevations originating in the neighborhood of the ligature have increjiscd
in licight «11 the cardiac aide .of tlie ligature, and penetrated into the blood
PATHOLOGICAL RteTOLOâT OP TSE ARTKttrES.
319
cliit ; in sections iher nppcar as complete circles separated by the btood.
TUvs« circles, rcpriMcDting transverse sovtions <^ the «lerations, are
ns. 170.
V\t. 171.
A l«a||1la>1lBkl H«(las tt thrnmln» IB
in*t Vlltlarr. L«w pa««. It. kill rn-
■WW. M.Mnlu.p, PUitlftlaUi. Iiiiinii.
é. Il|.u4 Tint. Ik* IktM \nwtt pOKI"»
iitulaftl'd- /- Ap» «f blood Hut. If.
B»4 ar Bb'la. iii<llln(ll<> ■■Ini'a rlalln
ibt i***-l «kTJa rather LinhUjvn vttr
<U*, UomIj ia lh« olhar, (. ^inall vaL
^
FurtlnD rvf UmaiT*r*f liirlloB pcwlof lkp«q^k lb*
pUBi^' porilon of 1 0141 Id t^i4 Niix.rsI *n*tf of ■ dog,
pHptraUvu 4H hi>OF* Afl»r llfilu». Ulfb p-wrr- r.
CatUkU'l'Hu*, abuwlujc (fII la?r*(k*t^ n. AdvutlUk,
Alan ihoifrlDf InrrfitiA nt q»ÏL #lvinval*, b«( dvC ir»4flE.
*ltf. Ht- &l«OI*, la lu lofipr lajtfr tlivr« «t« rva^
•Idtnbl* «all |rpt]1f*rmttiiq, doI tltnvb Id Hiv r'll, r,
Volila or t1a<(l« Itfar r>r IbeIiih •Itll nrj •l<.ili>c( •nd
kljthtvrvfntiTi**, j«i*hi>vlaar ■ iloff* of farnituD wbl^
ctPAul b# to illtllatll/ >*«b Itt jtratiEvr pruvimtloDa.
4. |[|uiliiliiiirlafri>intl)«lBf>rutd>bllB>.iiol (ob'fblj
r*fnfli¥^ cr »o frvo frvu eoruiliia iUiikLnic ■* ihu ;■!*>
raJlDn- p. Tbn nllnUr •lanrsla of Ibt plullr tlat,
«lilirb, nitrn a-iutrMfx) b^ iifi«4l««, cartmTfPUA lu <tnl
ItuB Hbd chHrmctar talLh ft«^l}ea Bud ^FnlirtnitaK ?&•
dotJi«llii. iMut'-ifMim )
fonneil of colU wparatei] by an intercellular eiibsUince, and contain
rery distinct capillary vcflsels filled vfith blood ; the voHMib run parallel
w Uie aWB of the elevation. In longitudinal sections it is found that,
at the place of implantation of tliesc elevations, the middle g«»t of
the artvry has disappeared, so that they appear to spring from the ex-
ternal coal ; their vessels come frtmi an extension of the V(ua vu^yrum.
The several elevations oi»y unite one with the other, and there then
remains no trace of the clot, or there is found between ihem clefts filled
nitlideeolored red blood corpuncle*, granulea, and a few while corpiwcles.
It Li very probahle that such preparaliona suggestcd to (). Weber the
idea of the or^zaniKaiion of the clot followinj^ the obliteration of arteries.
This liTpothesis, the fallacy of which we have demonstrated, cannot he
maintained in the presence of the above simple cxpi'ri mental analvsia.
Ilowover. when wc cxnminv the fi;{ures given by <). Weber, and by
those wbo adopt his viens, it is seen that the socalied or^ntscd clot
extends as far as the internal elastic lamina, xo that tlie internal coat
MnJ itA cndutheliiim have completely di»appeared or are oonfonndcil
with the cloi. Hut il has been seen that at no jjeriod of ihv nrt«nal
obliteration is there any fusioD between the internal proliferated coat
820
LBSI0K3 OF THB ARTBRIS3,
ind the coagulated Hlood. N«Uhcr can wc n^^e wilh Itnbnoff, vi\m
ku euileavoreil to dvnioDiitnittt tbut ttic clou urc truly orgiiiii£«<l, ImC t>jr(
Flu. JT2.
Fig, 173.
Apax of 111* ihnmbat ripnxraisd •■
/, 111 BlfUMlîw. X aiO- 't. T"pu(tlilf*
IdialUdU^ pofiiiia or the Lhn>u1k<i> jtf,
hs- 17l>). /, UiWT tinluin chf Ihtf buill^
CfBfaiit tl'X oiiiiUiailiii ilin tpni. /'.
Ul<1dk alrtfam, /". t>p[rBr «(rftltia^
TUa wliiba curpnarUa «n '««a »TWi&lx
■VHlc^rqil ADinnglhercit 41*k*, Had * fev
4«kI"IJidlÏ4L fvllt BT4 iuUnn^uclvJ Willi
1119 «lb« •ItUOD». {$*llitl(pMn.)
•TCIIuu ur ■ iliruiuliuMiil f'Hionl *>wr]r *f & 4>f, N
tiiinTn ■ft«t llfilDti. Tb" M(*m pHHd IbruBlli lb*
aia«\iet in* pltatk «lot. Ab *U*apt m ihHM ()>•
Ikrumbui f luiu I» MUfkintnl M lb* iiMfUl «nil b<J
bHn ■nv»u[uil]r mtila. lUut rarfvrailait «llbumi li
■Id of uvcdlat >iJiM->Kl*ileB a( i)>« c*llt «hlih v*n
sail ibd tmlaii. u. AiliaulUU. ■•■ 1I*i1>l «, tluWl
laldi uf luUiDi prrlHIlj- daaai-t. nad ■li<-wl<i( h r*<
DM nocb, If itiij. Isudaccr Iviiiint bnutlug duab.
p. I'Ttl-arkil lot«B|[*-*hA|i0 «#1U 4f Ibv plaMlvl
tloD of ILo <tar«li|]ji»^-tb«lr «iitllll», fn«
A process difTt-reiit from that ndvancod hy O. Weber. He supposes that'
tiie wliite corpuscle», wliicli appear in great numbers in Uie externa) coat
Fig. 174.
rartTuB ef Iramtrr»' •■(Hon of ih<" irmnr»: nrt-rf ni ■ lins, n [fij'i «ft«r Iftninr». III(Ii pou
s. Jkdx-Dim*. I». HtdU. I. ElxllT U;9iurijitliiis tllU «hirply dcOuvd. p. OnDiiliilIaai *pr1
Id* [mm iIk iBkMur«lli d>i<l<:pud fn»ii lbs c<IIuI>.i>1dbii'BIio1 ibaiulln» , lU*r <«a>M »(•!«•
t^llB. Ibv dlFKIl^ip at who** ^ouH all* Lu IbA ninlu I* p4»tKUt>l |4 Ibnl nf lb* «xln 4f tb« gruihlAftlHO.
Tb> luifm of iha ri«nal*ik-D li (ui*ro<I vlib am: nr two U/oriof fpllb*llold«ll*L sol Ibc tllchlMI
»\fo vt A A«plM*fy liaop vvuu^'jtIdii lb* *it]* «f ib« jirnuulail^h, ai>r lb* It-MI (rA»*f a t*4*4l I* b*
fl«*D ■ayvbarr Vn lb« l[ia*r 1*^ *r« ot ibn rnvdU i-n phrtaf la •■nd ■ tuaviu Ivop Lbn«ch ib« «ditilc
l*rot«rib* loliat. TbeM«oJ vk<iiippllwltnialb«upiu&tl*rT*lw<< ll>« IIiiuDbda. (XAoiIiijmu».)
after ligAtion, pass through the itiMdle and internal coata in onior to
enter into the blood clot and asgisi in ite organization. The exjieri-
menta of UubuoCT vf«r« made upon the veins with a double ligature ; ver-
HSALIXO or ARTERIES ATTBR LIOATURS.
331
nrilion wm gprea<l upon the wound. After a few A&y», white corpuacles
couuitiing vermilion hml [aaaeil througli Uie viMa of tlie veiiitel ati far ns
tliQ clot. 'Hiia fact \a uni|ueationa))le na regards a doiiMe ligature of the
veind. We hare repeated this expeniuont with Huocesa ; Wl never iu
till? singlo lij;aturfl of «rlerics and veins, when the Imttom of the woiukI
has bei'n covered with vermilinn, liave we seen tho corpiisfles containiuj»
Teniiliun piua thmn^h the walla of tho blood vessel. Durante a^niu
reiy carvfuUy performed diests experiments, and arrived at tho same
conclusion. Ile admits that, in the double li<;aturo of veins, there is n
DMrtMiis of tlio coatK of the vessel s. and tlint the white corpuscles then
|»M throu;rh as the; would p^metrate an inert ni«mhran«, the elements
of which arc separated by ihe mortification. We fully aec«pt his views.
We. therefore, believe that the defiwiie obliteration of atteriea iu con-
•e<)uenoe of a Ii;z;Blure is due to » n<rw formation, the origin of which ta
an •rteriti*, consecutive to the tTainntitic tei«iou. The blood clot disap-
pears by a series of retrograde chan^fii similar to those experietwed by
the blood «hen it has escaped into the itijues outside of the vessels.
n«. 17S.
Ldi
i- -f -^
Had Hci)i>n of fduortl iiMij of n t<<t, V ilijx ■ftor llfular*. Tka tilagd ot al>ilnoai> rlnt
L a)i|in«4l ttiim LU prlijitiivc puttiloa. Luw ttowtr. u. jtitvvbElII*, tit, M odLft, r. tlu*n4
rorltKx* al alia olltnunf «bo'*iri1>larr>t>|>|>»nniibT«lirùanr! unihuxad. I. Thiekiinail
nil* tar p«v1lbB of Intima an « l«ir«l with bZWHl dot- t- V«ri«4a luIbrtfilliil&rll^iQoatrbfaadof Ik*
titrtj «him Ibr llgitiir* vioppllad. I*. I>atv< lutuUl irnnk vIiKh •uukllthi» lb* auailBuiuita
*t aifriial Twalt aUti IhoM «lILIn (hn oMauiial Flul. p. Ttn^muhlj > ucBlkriud plullctlol.
' t^«lTif rvrntuHncl^K ^^urwntt InnitfûnntUuii. Thn Uliribaii» or bl«il alot (if. d'l «till «bava
kaarrcBilH* laiBoUMian. uiJ aibiMU no all» af appruubliit vnlulHlluu. (SAotupnaiw)
(The observations of one of ua* confirm in many reapecti the foregoing
views of the intimate nature of reparatory intlammatiou in arteries after
ti;^ature, yet in some important points ttiey not only diverge from the
statemcntJi of Comil and llanvier, but also are in conllict with the writings
of nearly every other author. It has been thonght beat to briefly relate
them here.
' TonM LectorM. I,npln(nVII. Ri'pnrntorT Intlnmmntlon in Arl«rini*n<irl.iKxtiirp,
Aonprmontn, Anil Ti-mioii. H,v K. O, Shiik™fHi:iri;, A.M., M.I»., of I'liiloilplphU.
SmillisoiiSau InatitatJon, Wublugtou, D. C, ÏHIb.
21
883 LBStOtïS 07 THE ARTERtES. V
When a Bin;ile ligature in the continuitv of an artery of a dog i» ap-
plied in the ordinary way, tlie following phenomena arwe.
Soon nflcr the blood inchitled between the ligature and the firet col-
lateral hrHiich above is pUcod aeido froin the circulation, a fibrinous
coa^iiluin bc^^ii» to fonn at the bottom of the nrterial cup. Thii» coaguliim
t» not homogeneous, u« Kimllh-inch, Itiltroth, ami others huro tleclnn-il ;
neither <loe» it at once fill the calibre of the occluded vessel np to the
flriit collateral brunch. The fibrinous clot i« built up little bjr little fron
llie bollom to the lop by the luperponitioii of «uccesriive portious (</, fig.
170). It mav ret|tiirc hours and even d»;s for the formation of the
entire fibrinous dot, and its apex mav never reach aa high as the level of
the first collateral branch. The general outline of liiia blood elot ia that
of a cone or a spindle blunted at the end near the ligature. The cotiati>
tutioD of the separate portions of the hiooil clot, which liave been de-
posited at int«rvals, is not booiogeneous, but it presents unnùstakable
evidences of lainiuution of a peculiar kiml. 'the separate portions appear
to be com])Oscd b; coils of a cylinder consisting of coagulated blood — tha
coils arranged very much like those of a ropo or distilling pipe. Thi«
curious opler of deposition of the successive portions of a blood clot wn«
Vfttohed, during life, in a small arieriote of the ton^^ue of a frog. B;
thia observation it was learned that the serpentine slratification of the ol«t
above alluded to was not an optical iUn-iion, but a genuine fact. Soiae,
not all, of the completed blood clots were capj>ed by a stratum of homo-
geneous clot. In llils stratum of homogeneous blood clot are to be seen,
Bcattered nmong the ivd and white blood corpu^^cle, a rariable number of
swollen granular uni- ami poly nucleated endothelial cells (see fig. 1Ï2).
Here we may r«-niark that by a homogeneous clot is meant one in which
the hbrinous reticulum incloses red and wbitc blood corpuaclca scattered
evenly throughout the entire extent.
Uitulflei.'ieb stjiteit that the moiit convenient method of pre|iknii|g a
1ijçate<l artery for microacopic study, is by making thin sectlona tnuw*
verse to the axi;» of the vessel. Oar experience leads us to prefer, in
the main, sections longitudinal to the a\is of the artery, alùiough in
every case transverse sections should also be examined. It is perhaps
from exclusive examinations of one or two cross sections which passed
through the upper part of the blood clot, that KindHeisch bas formed his
erroneous conclusions concerning the structure and tbo formation of the
arterial thrombus after HgutuR-. Otherwise it is difficult to understand
how such an experienced microscopist could so conipU-tely fail to recognixe
the varied constitution of the arterial plug, which in fifty or «xty ob.
eervatioiis wo found to be nearly constant. (Only in one or two instances
was the clot homogeneous, and in these cases, even after the lapse of
some <tays, there was not the slightest indication of a reparatory process
at work.) leaving for a moment this curiously constructed blood coagu-
lum, which for the sake of distinction we term the fibritwua dot, let us
turn our attention to other objects.
So soon as the ligature is tied and the liquor sanguinis in the Ugated
Teasel is nearly in a stale of stasis, the element» of tbo tunica intima
begin to increase in number. The lining endothelium and th« subjacent
cellular elements very soon present the appearances of an acute cnilsr-
HSALIXn OF ARTKHIES APTBR LIOATCRB.
323
I
»
I
teritiii {p, fig. l(!!)). Roth the emlotliclia ami the other evil» of the inner
coal rajnilly multiplir. This inflamraatory cotxlition u moot mwrked in (li«
.nei;:h)iorlt<KHl of the ligature and shows itaelf by a graatlj inoreaset)
thicknesa of the inner tunic {p,6g. l"<i) The evidences of thi^ acute eiwl-
krt«ritts grvluallv {^row less and less marked as the fir^t collateral branch
Î0 apimwched. I'hc irritation aeldoni posoes Itejond thi-i point. The
butt or bsM or the Hbrinouê eht is moro or less closely attachent to the
nu» of colorless elements fortnin» the swollen and inSamed tunica
intima, by meat» of filament* of fibrin. Similar fibrinous filaments also
osHally nttiKh the blood clot to the inflamed liintca intima at one side
(«ee fijt. 17<>t; itomviime* the fibrinou» dot is firmly attached on all sides.
The swollen and iiillnniod tuiiiat intimn mifjht be conwdcrtnl as a cu]>,
within which the blood clot is (ilnccil, and to which the latter \» attached
at the bottom and !K>metiiae« also at the sides. The walls of thi* cugi aro
tliiuuest at Die top and tliickeal al tlie batlom. This cup we hare t«nne(l
the pl'Utir efot ( p, fi;^. 1TU>. Dissociation with needles and flul*ei|uent
staining with .carmine show that the mass of the plastic clot is composed
almost entirely of large, grantitar, uni- or multinucleated memhranele^s
cells of various forms, mainly due to reciprocal pressure. Tbey arc
nsnally flattened and more or less endothelial in appearance (see fig.
17^). Among these larf^e firanulnr endothelioid elements are a con-
Kderable number of lymphoid c<>ltfl and a few red blood corpuscles.
Tbew clemenu are hchi l<>s»'tlicr more or lews firmly by an intercclltilar
»u)HtUi)c«, which \a sometimes stmctureleM, sometimes grunular, and ocoa-
Monally sii^hiiy filirillar (li;; 171).
Jn a few days the walls of this mass forming the plastic clot hepn to
bud and put fortli granulaûons, which soon till the spaces orijtînally
kft between the blood clot and the walls of the cup in which it is lodged.
A little later still, these granulations have increased to such an extent
that tbcy must bave room. The space required for their growth is fin-,
nislieii at (he expense of the blood clot. If the latter is cmly feebly
UUdied at the tiides, die lalvrni filament» of fibrin which form the
Éttschmenta are torn loose, ami the blood congulnm is uplifu-d bodily and
ptuhed before the growing plastic formation.
In this case, but little alteration is seen in the fibrinous clot for a long
time. Kren at the end of twenty-five days there is no sign of organi-
tation. (See fig. 17.Î.) If, on the other hand, the fibrinous clot he fimdy
bound to the walls of the vessel, the granulations from the tunica intima
invade the cracks and crevices of the blood clot. The latter gradually
softens and wears away through the pressure and absorbent power of the
enlarging gramilations, and after twenty or twenty-five days there ia
often ■>» trace of its presence except sonic accumulations of pigmentwid
hUy granules between and u])on the granulations. These granulations
have much the same structure us those upon the surface of orilinarj
granulation tiftiK. They are o<ivt!red by a layer of endothelial cells,
8ucb as line<i the surface of arteries. Their base is up>n the elastic
lamina of the tunica intima which, up to the twentieth or twenty-fifth
day, ia still ]jerfectly distinct, forming a sliarp boundary between the mid.
die coal of the artery and the prolil'erstiou of the inner tunic, {e. Fig.
174.) There is usually no indication of its perforation by a capillary
LKSIONS OF TOB ABTBRIE3.
Pig. 17B.
loop from tlic Tosn vKBorum, as hue bcon clnimcd bj Comil anil Runner
and otlicr iiiv«flti{;aton). Ncitlior is tlio &xw o( the "ntnulntion oconjiii
iy M CB[HHary vesKel. tintmilntion« ^ronin*: in opposite diractions m*^
DUiet and fonn a union. In tlii» niunncr it cnvoniou» tiMiic i» foni>cd,in
thu spncr* of wliivh, up (o the cif-htli or
t«nUi dav, «ows llie arti-ria) Wood from
the open lumen of llie ve»*i;l «bore the
throntbua. After th« aixth or wrenth
dar. varices of capillaries bepn to form
at the bottom of the plastic clot ; they
receive thoir blood from the cavcntoit<i
space)) a bo vp moiitioufd. At the aaoH
time, capillary varices form in the em-
bryonal tiMsuo of the outer coatfi of
tJie vessel in the neighborhood and at
the location of the lignttirc; they re-
ceive their blood from the vfl*a vaaoniiu.
Ill a few more day«, the two systcnu
capillary varices form a communicatï
ivich one another by means of ana.ito>
moainK loops vrhich pass through ibe
injured elastic layer of the intima at
the point of ligation. Up to the lime
of the cHtitUishmenc of this anastomosis
in the munniT ilescrihivl, the capillary
and cavortioiiii cirv'iiiaiini) of thv I^UhxI
of tlie plaittic clot iit iiu le pendent of the
vasa vasorum. After this time, there
exitits a free anast<>mosis, alntoat exclu-
sively at the bottom of the pWtic clot,
rarely, if over, ihrougb its aides.
Fig. 176, after 0. Weber, very well
represents the blooil circulation of the arterial xtump some weeks after
ligature. The tissue of the plastic clot, now progressively amlcrgoes a
Vig. 1ÎÏ.
'■■^5^>j
LoiiffltodiuAl iocUdd vf Ih4 llvnibrati «ud
of th« VTutiLl arUrr^r ft Jl-y^, tUy ûaymutimi
III* >|i|.t1'stiDii gf iho ii(»(arF, Nhoniiiir
*n4 tbvkf criDiiiiniilciilloiiB wtlh ihti tvA Tk
X. Kiuruftl «At KSd vua tatorum. X ^
|0. Wtbn.)
rrvH 1)14 («aw.MFlt>a ot U KTtarttl IliraiubBa or tbrra Bantlii. /. Lnmlita of thhI* !• lb*
tbtomliUi. Tho (ixiia irpriaKoiDii a> nJliiie ilir Inuietaf Ike tntrj it uu.I<ir((dBi ikantvtuHa
aaUinaiplKi'la uf Abros* if»iie, x ^««L tlUn'I/ltUch.]
change nbicli has been tcnncd cavcmoua mctamorphoais (fig. ITT), while
the ncwly>foniied ^granulation tissue experiences the cicatricial eontno>j
L
SFONTANEOrs n«M03TA8Ifl IS THt ARTRRIBB.
325
I
tion ooRunoD t6 «Il sneb producu. Itv idc«m of tlii« cK«tri«iiil netaii>or>
pho«» tlie oblïtomted trury witti its oîi.4truetin« thronibax fiitally contracis
tuto A «mail band of oonnoctivc U«<tu<>, i» wliich no trace of Uio fom>er
structure of tlic re*t«l can b« ilUcorend.
From UiL'»o ol>i>ervatiniia tt «ppean tbnt the ffirmou» Mot doee not
orgnniïio u luu lieen «)nM»t univcr^nlly t'cltevcd of late je»rs, but tbal
it suffen no other clmn^ than that of il<>struction.
The injury of tlie arl^ry U repaired by a cellular tts§ae (the fi'titif.
rhtl), which is furnished by a prolifération of the tunics intima, and the
new elements of repair are, in great part, derired from iho fixed ccU*
of that coat, both the «ndothelin and the GtcUatc and Hat aWs of UiC deeper
Ujora. A einiiUr (jn^cess sccurcH tlie obi lU'^ rati on of tbo vosmI anor
Mnpreesuro and tor«ioii.
Befor» ending tlii« brief ahgtmot of the brochure from which it is
tAkcn. ktuntiot) '\t direcud to Gg. 178, which partly vxplaitts itself. This
Flj. 178.
I
1 Ikranhai. W iltp '^i- *^"*' mudllrd V-guina. Lniif IibIIbi] ca|. La* ti»w*r. Aflar IIrhIu*
AI A, £b« Aftffy Vft4 mtiitrA »DiJ Q4Dipf*u*>l ^\ ^' b'lwtvn Ih* »tiii» ot t p4jf vf farr*T«- a. Adr44-
llll*. H- MnlU. e. Ciltnlu iIhuv, p. CtlliiUc (ainiuilun m buiuni «1 r)«[. uaa-orvnolivil, ta4
■PI.u<lill]r nol luntrltisii meb un iKr«iniilk(i>>i niHallr !• n It'e iU;i>; ll»i.>li(> m%if>tr of (pIU
■IbUu t* «hi» bisvd Hiriiiucli*; *u\T ■ f'V •tlih-liniJ rr)!' m ■raiirnl ihr^ndi li. tai) «o
|naBli>U*a> (prlsilar fnm it p>ii*luU Iks cniim "( Itit lirDlunlril (M <>() Iniii.nlliMlr i>bo<«-
Atf'.y IlisfvUan lUjroiiib of il» Uitmmi J idikt lir^n ef ibi mrdi*. Ai t.. nlhiir tho |i<>lii<ul
caBr****biB, ■ U»d tlut Ilk* Ibkl ■! 4^ rciM. bal titiiiJllDK nnud Ilt41iplatsn>u(. iS/«ii(U)iBir«.)
observation idiowed that the reparatory iiiflammation was most actÎTO,
not at t)ic point ofIt;;aiion. but at the pftint of compro.<>«ionhy iho forceps.
At tbiii Utter level, the tunica iiiiioia by the eighth day was iio much pro-
liferated and granulated aa to occasion a complete obstruction of the lumen
of the artery, while al the point of li^iion the larta presented the ap-
pearance of a process of elimination of the thread, without any tendency
to repair.}
SrosTASKor? Odliteratios of AntEitiKS. — When an artery of small
calibre has been divided hy a cutting ia-itriiim-nt, there U first a jet of
hh)«ii ; if the Mct-din;^ \* «pDntanvoiifty arretted, the obliteration of the
vessel follows, by the formation of a clol in tlie artery, as far as the first
826
LBStONS OF THG ARTBRtKS.
KCollat«ral brancli. The onpii of this clot is in the oonUici of the 1>1<
Tïilh the connective ttnaui; nlicath i>f the nrtcrv at tlie jioiiil of <liriaio<ii.1
The artery rotmctn wîtbiti it< Hhenlh hy virtue of ita own ela.sticity.
(Sec* 6g. 171'.) Lntcr, tlie c<>a;;;ulufn acta
Pig. ITU. M a foreigu liody, oocaHioiiing around it a
ve^tating endarteritia. forming thus a cica^jj
trix by the aame proceaa a^ above described
Oblitkbatios op Abtctie» bï K.vDAa-
TElilTl* AND ÏUR0MII108IS. — EniJ«rl«riti«,
consecutive to the obatriiction of an nntrj,
anti the coagulation of the bloo«l, hat bctHi
deacribeii : but acute or elironie eiidartcntil
may be the cause of a ci>ai;iiIntioi) of ik
bloo«). If at auy part of n nic<liuiD-six«d i
small artery— a» tin! arterit-s at Uie hmte o(
the hraiii, or titojw of ibe extremities, etc.—
the internal coat is the seat of eleratJoa*
due to acute or chronic eudarteritis, tbai
vessel being almost completely eloew*! by
these vogelaiioiis, the btood coagulates on
the cardiac side aa far as the first collateral
branch.
In clironic endarteritis with atheromatous
and ejilcarcous change, tho ciirtila;^--1ike
ve^'tatioii« are at time» quite lnri;e, «»]>«-
cially in tlie boMlar and coronary arlcries,
canning; almost entire arre.st of the circala-
;ion in the vessel and the formation of a coa;;ulum. 'l'hère is tko dniibl
that, in these caDcs, the coagulation of the blood has folloned the oburuc-
tion of the artery.
In wonnds, ulcers, and chronic nhlepnons it is frequently «en, in
sections made for microscopic examination, that the internal coat of the
arteries ha* swollen so as to eoniplctely.obstruct the calibre of (he vessel.
There may form in these elevations vascular networks, so that, at soma
point», the Kame apji'tarances arc presented which have been de«cribed
in connection with the lij;ation of arteries.
In the .*raaU arterie.* there is another cause for the coagulation of the
blowl which is very important ; it ia the arrest "f the circulation in the
'Cnpillary vessels. When in conïte<{uence of an interstitial suppuration,
of a catarrhal inHammattan of the lunj:;, or of an intt^i^titial hemorrhage,
the blood is arrested in the capillaries by the pressure of the morbid
product and is coagulated, the coa^uhmi extends backward into tlie
arteriole to a point corresponding to where the circulation is effected
by a collateral vessel. An arteritis occurs at the point of coagulation,
and may be th« origin of a rupture of the vessel and a hemorrhage,
or tlic cause of a «omplclc obliteratinn.
Ohrtni<-li"ii of Arterirt hff Emf-oliiim. — In the arterial obliterations
previoiwly studied, the coia;îidation occur at the point of obstruction;
this phenomenon is named thramhvsi». But when a clot formed «taay
Xolanil l'ainuiUiU. Tlis 4Jili1>A
euJ* (<f|*»f tUfl ■'t'fy ntrofl WilLiln
iJi»U(ii«h tba nAUbr^ *rt ibn c«uil.
hI, tii.l La llju Hfl'ty i,x*rU ib) li|> lo
Jif'idff.- Ijfnyh it pnii'fi4 okiL frikin 1I14
d)*Mt.l «Onu 4f i'n^ TMA*I. iuA hj
or lb* iMMl lakH plat*. (.roDH.)
syswm. eBpi>cially in the veins, has bevn do-
bv ihe klooJ current >iul thrown into t)ie arterial sj'slem,
n<n>pMl in an arterr too enutll to afTonl it ft pasmge; this is tcrn>G<l
emh/ligM, and tbc inij^ratin;; clot has rcceivod àic name of em^ofii».
■ Fi>r example, aa n rCHult of tltL> cDiigulftlion of the bloml in the femoral
rein, it may happen that thi« venoui dot (ihriunliux) «hnll become tin-
tacii«4, ptiaa into the iliac vein, tlie inferior vena cava, the ri^ht auricle
■ anil ventricle, an<) the {uilmoDary artery, where it nay meet with a rami-
tication too small to alloir it to pa»a. It i» then arresteil, and finally
b«com«8 an emfi^JuM, and cauaea arterial obatruction hj embolism. In
this example it is easy to follovf tlie most important phases of cmboUsm,
since dunn^ life there Is the certainty of obstruction in the femoral vein,
and ;;rout hindrance to the |iitln>onary circulnlion caiisinj; ntpid death.
At the mitopey, there is found in a branch of the pulmonary artery a
clot which hait cortaiidy not been fonned at thi« point, for it prcoent» an
outline entirely different in shape and diameter from that of the obstructed
artery. The olwtruoting clot is whiuitli or yellowish in color, it may be
foliled upon iMelf, an<l have branches which do not correiipond to the
nimificatioim of the pidinonary artery. Fre<|»ently it ia surrounded by
a recently formed cruoric maaa ; but aa t>iis recent clot liaa much lean
eonsbUmce than the embolua, and as there is not a firm adhciion, it
may be easily separated from the old cloi, when it will bo seen that the
embolus had the form and calibre of the vein in which it waa nrimnrily
contained. Such is the simplest and mo«t easily veriGcd caae; out when
tfav (oigratini; ctot ie very email, or when it is reduced to very amiill
pieces, and tnmspnrted by the ciroulalion, it it ofl*n impossibUt to find
tlie embolua, the exi!«tcncc of which is supposed only from the lesions and
*tfae symptoms.
Thia theory of embolism has been employed without sufficient evidence
to explain a series of analouiical changes, such as the alwcessea of puru.
lent infection and puerperal fever, in which the existence of migrating
dote hare not been dcmonatrated. It is not enough that the blood
may coa};ulate and the circulation stop in the arteries of the focus, in
onler to bo able to aRirm thstt then- has been an embotuSi Indeed, as
• before mentioned, evory interstitial hemorrhage, and some inflammations,
eause an arrest of circulitiion in the capîlhiries and consequcntW arterial
thrombosis. Virehow, by employing the word mfarrtun in order to dc-
Bignale certain le^iona following einbdiitni, ha.-« helped to throw great
obscurity upon tliia cjuestion. Itefore Viivhow, tlii.i word wn# applied to
a aeries of indefinite changes, in particular to ]iai-enchyniaii>n!< hemor-
rhages. Laennec called the foci of pulmonary aitoplexy, hemorrhagic
infarcti. îïince then the doctrine of embolism has been generalised, and
thor» has been a tendency in science to connect with embolism everything
the older writers called infarctus. It ia incontestable that a certain nnm-
ber of infarcti have an embolus for their origin, aa in the kidney, spleen,
liver, etc., when there are Been white, yellowish, anicmic foci, having the
shape of a comi with the hnse turned towards the surface of the organ, and
which represent the di^tribiilion of an arteriolt;. At fir^t it would seem
that this ti^^ue diit'ered very much from that of the organ affected, but by
examining sections with the microscope, there are found all the constitu-
S28
LBBIOKfl or TUB ARTERIES,
eiit part* of th« orgitn, the elcmonto of which bure und«rgoa« fntty At^
^fwi-AUnn, niid the vc«*el« «re fillc<i hy a i^mmlnr maiia ilerivei) froto die
C'ii\;i;u1iitt^il hluod. U U only nt th« m&r;;iii of the Altered [laru thnt
iutlnmm.ilory leiiioDH are seen; they exteml bkit a very short distance.
The-ie iiifarcti are aaaocinted with vnlvular endocarditis, both ulooronaj
and voji^tatlng, or with valvular aiieurisin.'i, or with chronic cndarli-ritis.
FragmcDts of the inHnuied vascular wall or hUrinous cloU liave bc«n
torn off and carried aloni; the arteries. The loss of etibatunce from tlio
Tiilvos may be seen in §omc ca^s, hut seldom ia it possible to disoover
the infarctus in thu mi^raiod clot.
The obstruction of an arcvrr by embolism is followed by various Icnom, ^
vtliich oiny hv demonstrated by experiment. If a «ingle artery of KtnaU '
calibre i« oh«tnict«d l>y un cralioliw, there may be no lesion viaihln to the
unaided eye in tlie vawular territory of thin art«ry; thu cîrciilalion ia
re- established by aiiaxtoniosis, and the embolus acto much like a simjda
li;^tiire. Ity iiitrodiioiiig into the jugular vein of a» animal a single
embolic fragment, as a small ball of Benlitig.irnx, it passes into tlic luug,
and there is not observed any pulmonary Iceiion appreciable to tlic mi'
aided eye for several days alïer the experiment. Ilut if fine powdeni,
whii-h may be again rccognÎKed (a.4 starch or lycopodium) are injected,.
conj^L'stions, hcniorrhugcs, and iiiHammation are met wiiU iu the luDglJ
after a few daye.
Fig. ISO.
■ (..j^pp^.^yj^gj^M^
TimntKn* HF<iiiiitrr>4lEl irltrr pIsttEfil bjr >ii*nil»t9inriitpUc ortfla tamti^T' ■"forr dntk.
rmffl ■ a*r of u)c.-r«iiat aiiduwriLtiW, I.4W poHO'. a- Clnl. A, tat^n»! oa». #. Iut«tnii1 «lH4ti*
i>r r«i4««iF4iPi1 ini?nil>nkiiv. 4. HIJ^Ep (an*«uijkr tout, t, Oul*r tlitAllc niflii)br<4«. /. A4T*tt^Tlft
trowJfi) v>Ib •l.iioruiil Du<l«i «nil j^i»|Hiriii>aiiUl7 iblcktsad. /'. lUjtaa «f tHt TUatnJn. if. ttU
lUryaul.)
The tieipielnei of embolism in the artoriea of the extremitjefl and a!! the
other organs vary according to the sîkc, number, and nature of the em.
bolifl fra;iroentfl. Necrosis nr niortitication occurs when there are several i
embolic fragments distributed i» iho arterial system of a limb in such ftj
manner that collateral circulation is impossible. In organs whore the;
vascular territories arc limited, a single embolic fragment may pnxltLce
tiie same effect, as is often seen in the kidney, spleen, liver, and brain.
SHBOLISU OP TRB ASTSRIE9.
3S9
N
But in llie «xtremitieii a single einbolua dwâ not eaaae gungrene aoy
more tliaii a li^Uire Joe».
If ilie cm)iolii3 has irritatinj; propenloa, like almost all ooU'l foreign
bo"iics, it causes in llip part where it lodges a suppuncivp inflammatiOTi,
nliicli <locs not differ from that occnsioticil hy the aaiiK' foreign Uoily if
introrluccti into tko cellular lixsue, am) a {jhlfj^nDoii in tlio result. 'Die
walls of tlie artory at tjie \io\al where the vnibtflii» ia «tuitlt») are pre«M-il
upon; they «iifl'tT necroMis or piinilent infiltration, nifl the infliinimutio»
of the nei^iborinif connective tX*»\if appear» to l>e tlie result of un ox-
teiMioti of the primary lesion. (Ki|:. IS».)
When the ombolwi U derive'l from the or;;am!im, for example, a Hmall
fihriiioiiNclotooinin;; from the heart, it obMructe the artery, aixl ocea^intis
A cosj;ulati»n of the hloni) aa far as the Itrst collateral branch. The ol>>
lit«rBtion of the artery does not diR'er from that following tlie application
of » ligature : it is elfocted by the proc«sa of endarteritis, while the
collateral circulntion rc-eaublialies the course of the btoott.
In umboli^m of the artciiea of the kidney, liver, or brain, the initial
secondary phenomenon i« a limitcl sweilini; of the part supplied by the
obliteretd iirtcry, and the tuniefie<t part is bluish-red in color. The
blomt «ecumulato» in ttiis area, stAgnates, and later coa;;ulnte«. .\t this
tine the lemn i» u:<unlly eonc-fthnped, and is called a red iufaratu«, which,
eODHMtng of the vlcni<-nt« of the organ ami coagulated blood, form:* a
Gfetew natifl. This blood ex[>ericiice« the changes which have been pre-
viously studied, vin., eranular decomposition ami the separation of the
coloring subst&itce in the form of pigment. The pfuvnchymatous «ellukr
elements undergo fatty degeneration: the infarctus now becomes yeb
lowish-white; it still retains a firm consistence, and contnicting a little is
somewhat smaller than the red infarctus. This yellow infarctus consista
of a iiuwii within the organs tso distinct, that it couM be mislakeii for a
tumor if it were not cotie-shapfrd, with the base tumeil tnwanU the [le-
ripliery of the organ. A micrmcopie examination of tlie morbid liaaue
reveaU the texture of the organ: the vcRseU are found injected with a
granular mass due to a transformation of tlie blood, and the parcnchy-
Eoatoua celts of the organ are infîltraied with falty granules.
At the margin of the white infarctus the vessels of the living part are
dilated and filled with blood; the connective tissue is infiltra^d with
white corpuscles; frcrjuently in this portion there are found interstitial
hemorrhages ^'arying in extent. The parenchymatous elements, the
epithelial cell» of the uriniferons tubules, or the hepatic cells for example,
present mulli|>le nuclei ami at times fatty ileg<'nerJition. In the kidney the
tubules contain fibrinous oa«ts, blood, and sometiincs white corpuscles.
In tlie thti\l stage the white infarctuA is softened ; the Aoftening hegina
at diecentre, as a result of molecular destruction of all the necrosed parta.
This molecular detritus is then t.iken up by the lymphatics of the con-
nective tissue whicii acta as a cyst wall around the dead part. This
occurrence is very much like that described as taking place in caseous
gummata. (Sec pp. Ill, Hi.)
Sometimes the soft<-ned infaivtus is infiltrated with calcareous granules
■od deskcaUon takes place ; there is formed cither a dry atheromatous
DM», or a true petrilaction.
aso
ISStOVB OF THB AATBftlES.
Fitialtjr, all the necrosed portion mAy be ubaorbod ; thoro mnaiDit
iii^tvml a HtdluM i'imtrix. The dunth of a purt of an or;^n, witliout
ti'uc ipiiigrenc, has been Je«enl>cJ by VîrcUow under tlie name of nfrr^
liuti».
['VW voMuUr eogoi^ement of Uifi embolic ftrea was fonnerlj mpposed
to be- due to Uie inoreaaedsticu which \» thrown on di«eolUterAlvpMels.
Tlie itiveAti^^tioiii* of Cohn)i«iin, however,
show tiiat it \» mnlly mainly owing to the itn-
tiairment of the vitality of the walls of the
hlnndvea&ela, and the consectuent cxuilnlion,
emi;;ration, and ultimate n«croais of the vaa^
ciitar ualls. When tlio force of tliv blw»)-
sti'cnm iu tho artery is annihilated by ih«
impaction of the embolus tliere is a Ixtckwanl
pressure and regurgitation from (h« voiM
into the enpilUnctt. so tliat there i« proiltiec<d
consiilcrabic Tcnoiu engorgement of llic last-
named vo«:iei8. There is tliux • HiibHtiiution
in the ca|>iUiirie^ and small arterieA of venoi
for arterial blood, and owing to tStot tho vi>^
lality of ihene vessels becomes impaired, and
hemorrhage results. The infarction conw-
qucntly doea not occur immediately after tlio
tmpHCtion of the emholu», but ouly alVr th«
lapse '>f a certain time.
The sub«e(|nent cliangtis which take place
in t)iv infarct ilepcnd upon its «ixc, upon tiiC
extent to which the eirctdalion in it is inter-
feR'd with, and upon the nature of the emhohiA which oaosed tlie infan;-
tion. If tht- infarct is xmall awl tho embolus pottemes no infeclit'e
properties, the ooagulaled blood may gradually become decoloriited, and
tlic mass undei^o a gradual process of absorption. The infarct tlien
changes from a dark red to a brown or yellow lint, its more external
portions becoming organized into connective dasuc. and the whole gnul-
ually contracts, until ultimately a cicatrix may be all that remains to indi-
cate the change. If. however, the infarction is considerable, the moloc»
alar disintegration jiuit Koft<:iiing may be so extensive e.s to convert ths'
mass into a pulpy grunuliir material. This may «ubsoquently dry up and
become encapsuled. In ull these secondary changes which take plocc in
the infarct, it« most external ])ortions arc «urrouudcd by a red lone of
hyiwriemiu tiwuu. This is exceedingly characteristic.
If an emt)o!u^ poi<sesses irritating or infective properlie«, as when it is
derived from a part where putrefactive inflammatory changes are going
on, it sets up inflammatory processes botii in the vessel within which it
becomes impacted, and also in the surrounding tissues. These inflam-
matory changes fre<|Uently lead to the formation of absoessca, whieh are
known as emb-iUc abscegae». The formation of such abacoues nuy
oaaociated with more or less infarction of the embolic area.
fHif run of A If^norrhtc^' Iti-
«uil-iint \t>. r. Vrlir mini witb
■ ■vfOQiUfT thrAifihm (Ihy 1,
CimrDof lAfiirf-l wbJcK L, basoin.
lot! dlilnlvvrau'rl. ï. Xtrm ot "X'
Itaf ft«»1iail.. ^- Ant of wllftbtnl
brpitsBiliL (0. ITi&M-.]
STPniLlTIO LESIONS OF THE ARTERIES.
381
I
Smiii-iTio LEitioxs OP TiiK Artkriks. — Cenain chnnges in the
ivrvf-ntl arteric» tiave biwn Pf»o«nily described by Huebner m clinrac-
terislii: or 3y|)lntU. Tbeao tibkiii^efi have be«n brought prominontly boforo
Englisli palhobigist* by I)n». Irreenfield. Harlow, and others, and iho
inrvfttigationa of the first named of these obacncrs would tend to render
it probable th«t nimilar ehnn};ea occur in arteries in other eitantioiiii.
In the cerebral arteries the chan^^eii prndiiccopiicity and marked thick-
onlh;; of tlie vesael, with considerable diminnttnii in iu calibre. It 't« ibis
diminution of the lumen of the vcsael which a especially oharftoteri:ttio.
When transverse sections of the rei^elH are examined niicro«CA]>ioaily,
the [iriiu:i)al change is seen to be situated in the i>i>i<-r cent. It i» well
sliown in the acco[npanyin<< dmwings made from specimen:» of Dr. Har-
low. (l<1g. Id2.) Ttiii coat is considemblj' thickened by a cellular
ng. isa.
SrphlliUi* dl«H» at «Mbml in^nfa,
A. »«Bta< af «Mdla (PNl.Ni ci*?. inaiTr»* Hriii's — I, (blckmail IbdhmM: >, ■ndalballan
^, B«lftbrmH fauaaINU; nt, muactiJamjal : a. adinrfMILUr X ^^^. rW'lu<''<l l>
P, SDAll an«T7 of pu OQAlf r, Irmnaivr^aB^^Oria. Sb<jiv1uif llikha^d lunar ««I. JlmloTibf^J litrqvti
rfaaaiil, md Mntldtnttta liBllrilliiB at adTamtllft. Tbauikljr of Iha faaasl la nccnpltd lijr ■ rivt
IT tk<«Bkiia|. X «»> ndo»! I-
growth. Th« growtlt, which is limited intcmally by the endothelium of
the vcMe) (fig. 182, a, *), and exienmlly by the membrana fenestra (G^-
182, A,/), cioMly resemble» ordiniiry gramilation ti*sue, conisix^ng of
numerau» small round and .tpindle-ithaped cclii«. This tissue afipears
gradually to undergo partial develojitnenl into an imperfectly fibrilialod
structure.
In a<lditjan to thia chan^ in the intima, the outer coat is abnormally
vascular and intiltrated with small ccIIk (fi<r. 1S:Î, a, a), and thia cellular
infiltration usually alao invades the muscular layer (fig. 182, A, wi).
The result of these changes in the inner coat is to dînûnish very con-
833 tESioxs or tbb arteries. 1
Md^rabl^ tin? liiniffn of the vc«*el {fi^. 182, ii); Rml the conscqiu'R*. mtrr-
ference witli thv circulncioii fri'<|ucntl,v ]eaii« u* uoagulntion of Uio klmWi
(ifarombosK) ami cerebrnl noftcning. j
Ur. (iroonliëld'n observations, au alrcmly ntalei), t«n<1 to uliow tbtn
atmilar arterial clian;^3 occur in other jmrtd, and that tliev aocount foH
the <le^eue ration of a^-philitic giimmata.]' ■ I
Amvloiu Mktamoki'Hos[8 or thk Smau, Autkriks, — ^The genirrfj
cliftrscterâ of the amyloid tranflformntion of the arterioles has ht-t-n pre.~
viotisly <lc-scribc(l at pa^e 4(i, vrhore we have insisted that the midille coiit
of the email arteries is peculiarly dispciHed to this dei^encration. Tlio
amyloid siitwtaitce ts first infiltratcil into the muscalar elements of the
vewel, tlic«e elements ri'tnin tlieir form and relayons, so Uiat liiey «r^
Kcognixed «hen iodine 'm emiiloyed ne a reagent «lone, or in combination
with sulphuric a«id. Kometiiiie« the orgao treated with iodine shows itn
arterial network m distinctly oiid so perfectly colored tliat il ap]ieâra an
if injected. I
In a very advanced Ata^e of thi.t nietamnrphoaia the muscular cells are
fused into a single ma-ss, and the wall of tlio arterjr seems to bo consti*
tutcd by a homo;:eneou3 and thickened tube. The calibre of the vesMlj
is lessened, and this may be to such an extent as to arrest the circulatioa*
of the blood.
The organs most froquently the scat of amyloid degeneration of
arteries are the spleen, Hvor, kidney, mucous membrane of the intestines,
and the lyinplialiu glandn. This arterial 1e-«iou which is associated iritfa^
a similar tranciformation of the parenchymatous cell» of these organs, is aj
consef|uence of prolonged suppuration, of phthisis, of syphilis, etc. I
Tt!M0K3 OP Tlis Aktkkies. — Primary tumors of the arterial system
consist of a new formation of arterial tissue as seen in dilatations aud
elongations of arteries in situple angiomatn (see p. llti)), and in u pecu-
liar essentially arterial form of angioma — the arterial varice.» or varieosO J
anciirisiTi. In these tumom the arteries are dilated, elongated, Uirl(ioti*,1
and thickened; they present mimerou» anastomoses and partial ililatA-
tion*. They are most frequently located on the temporal and occi[HUl
arteries.
The arteries which are connected with iiome tumors, for example in the J
breast, thyroid body, etc.. are extremely hypertrophied, and there ofteo^
occurs a true new formation of arteries at the same time that the tUDMr
grows. This new formation appears to take place by a transformation
of the capillaries into arterioles and larger arteries by the formabon of
smooth muscular elements developed from the embryonic cells surround-
ing the vessel. Iloirewr. this evolution is very difficult to follow, and
there still remains great uncertainty upon the subject. J
Tumors which grow rapidly ar<mnd arteries of a certain calibre, occ»-^
sion (he phenomena of an arteritis ; namely, a vegetation of the internal
coat, a di«ap{iea ranee of the middle coat, and an embryonic state of the ,
fixterual coat. At times the artery may be obstructed by these ve^l*-^
■ Abttr&ctoii fruTii Gnwu. I
TQH0R8 OF THE ARTERIES. 833
tions, or by bemorrhagee which occur on account of the weakness of the
walls of the vessel.
These lesions are obseired especially in sarcomata and carcinotnata
of rapid development ; the tissue of the tumor is seen to grow into the
vessel after the middle coat bas disappeared. When the circulation is
impeded or iatemipted hy these lesions of the arteries, the parts sup-
plied by them mortify ; if the mortified portion is superficial, as ia the
case in tumors of the neck of the uterus, there is softening and ulceration.
If the necrosed mass is deeply situated in an organ, it gives rise to a
caseous focus.
Tuberculous granulations are very often developed in the tunica ad-
ventitia of arterioles. The result ia the obstruction of the small artery
and a coagulation of the blood in its interior.
334
CAPILLARY TB9SEL9.
Fig. IS3.
CHAPTER IX.
CAPILLARY VESSELS.
Sect. I.— ITonnal HUtolog?.
CaPH-I-^RY veasela are câscntialiv fomieil of Hat cells united at their
OilgCfl, urnl arrangeil so aa lo coiistitutc cnuals ansntotuoiing one witli llie
other to form a network. Thcv Imvc nearly tiie Mme siructtirc in all
organs and tissues, but their 3i»o and tlio form of
their network vary in each orj^an and tissue. 'Die
capitlaHes itni surrounded nith fasciculated or n-
ticidnted conneetive tissue, or thei,' traverse spaen
whicli do not coiititin conneetive tissue, which arc
siinjih- !jni|ihatic «paces. In fftwcieular connective li*.
sne, the cafjillaries covered with flat celU are louiul
8iluate<l in the !>pace9 of tlie connective ua«iie along
ûde of the fasciculi, without adherinc to the latter,
and the lymph of the coiinculive tissue is seen In direct
relation with the vnsculttr wall, go that in renliiy a
c»)iillnry of the connet-tivf tisane is located in a lyiuph
sjittce. This arnin^^-nient exist» not only in the siit)-
cut»neou.< ueltutar tissue, hut in the skin, muacles,
iierveit, and in the celluhr tis-^uc of orgaik*;. In tlie
lymphoid organ» (lyni]>hatic glands, lymjitialic folli-
oleâ of the intestines, tije tonAiU, etc.), ^e mpiUaries
are covered with a dense fibrillar layer, which cornea
from the libriU of the connective tiaaue. The lymph
contained in tliia tisaue is separated from the blood
by two layers, the cellular membrane of the capil-
laries and its investing reticulum.
In the (glands the capillaries which arc found iu
connection with the ;;lnndulitr acini, and which conse-,
queritly are very iiniwrtnnt in the function of seorctioii,
are sitnatx-d in tlie lyniplmtic sp*oe which AurrouwU
each «ciniis, and tteparnte^ it from itë uei^UhuT. 'I'he «ame arrangement
U seen in the lymph ximi.teci of lymphoid org&iiH.
The ca]>illarie9 of the nervoua centre.-; are aUo iiurrannded by a lymph
sheath. When a capillary occupies a lymph apace it ia alwaya covered
by an endothelial layer, and ia connected to the wall of the apace by bamla
ol connccUve tissue, varying in tliickneas.
From the constant existence of lymph spaces placed between the capil-
laries and the constituent elcmentâ of the ti««ucs of organs, it is seen
Capniiuj from tbd
iH4aeDi«r}r of t, fuliieft-
piir, ttif IfihliiTriTiL b^
blini* of all trr ; 0,
tell; ». autlH at Iha
inFLAMHATIOK 07 TBB CAPILLARIK9.
tlint lties« elements nre not iii iliroot oonnectioii with th« exixled plasma
(if (lie bloml, but (lint tlie plniuna cacnpcfl firat in(o the l;m[ili Hpace!), ani]
is tlienc« taken up by ihe elements badied in tbe Ivinpli. It inuiit not he
concluded tioverer IVom this nrrangement that (iie exuded fluids hare
no effect upon the functions of iheae elementâ. It haa been !>e«n that
the mnditicattoiiB of tbe flat cells of connective tissue in œdema are eon-
giderahly influenced by tbe serous exmlation. In concinsion, it is not
the blood which nourishes the elements, but the lymph derived from tlic
blood.
Sect. II —Pathological Hiitology of CapUlariea.
IxPLAMMATIOx OF TUK CaPIUAUIES. — ^In the first part of this manual,
although we did not entirely reject the resalts of the experiments of
Cohnheim, of the passing out of the «hitv eorpuseles from tlie vessetsi
yet vtc rosened sunie doubts peganiiiif; Ihcra. From repeated experi-
ments, «e lire eoiiviiwed of ihv emigrntion of the vthite corpiisctes (dift-
pcdvsi"). 'Hiis dinpede^i» oeunni not only in intttimmutiou, hut aW in
cong^ittions, (L'dema, and in the [ihydiologicnl state. In inflammation,
it in tnie, tlie phenomenon itt exaggerated,
like all tlie phenomena of nutrition. In- Pig, tM.
flammation la indeed nothing more than an
exaggeration of the noi-raal processes of
nutrition, and inflanimatiou has therefore
been nttrlbntvd to the irritation of tissues.
Tlie inllummatory phenomena present in
the capillaries i-oii.>ti.ti in a modification of
their whIIk, and in the formation of new
capillary vessels, which always take their
origin from the old.
There ia first observed in the capillaries
a swelling of the cells and their nuclei ; the
cells which were flat, homogeneous, and
could not be distinguished, now appear
granular, and when viewed in profile are
fusiform and distinct one from the other.
This arrangement is capi-cially appreciable (,_.
in transTcrse sections of the vessels in in- ,,
flamed tifsuo. (See/, fig. 161.)
In the mesentery of the frog, which has
been exposed to the air, it is much more
difllcult to see the swelling of the endo-
v.tJ — -^-.^ ~™Zi^
Mifjii Want rruU t ir*f «iuu.1
In « dof . In pM(-r*H or h'Ktmif. 4.
r*i rt*Mf9 ^.' lbP7 %im ft»qiid AIki
roBiiili'il with iiimaulitr ptMatittia . r,
tmlrji.iiH t»ll> ; /. ««Iloii of ■ •ohI
which tav «mbryoulv n*n«.
tlielia. The separation of tlie cellular ele-
ments of the capillary vcssela permits of
their dilatation, and favora the pitssing out
of the white corpuscles, the red corpuscles
and the fibrinogenic plasma. It is in inflammations of long duration,
occurring upon free surfaces, that the diliittitiou of the capillary vesseU is
particularly marked, as in catarrlial inflammations of the mucous mem.
336
Bue. In these cases tlie «ipillftri«s rcmnin full of blood a(Wr death, and
Tonn the red arborescent spots, visible to the unaided eye, wKile the capil-
LftricftnotdÎHcnei'diire ulwuys oiripty of blood on ueoouot of tlic contraclioD
timy exporienec, after denth. Tiiis circumstoncu alonv ilcnioustrttcs tbat i
the TCsmcls modified hy inflninmntion have lo4t on« of ibeîr uxMt ïnipor
projicrliea, cliistieity. Tlie inodificnlion of the vttiW*. joined with bu in-
crease in the lilooil prea:<nrc, fre>|uently cnuHea rujitnre-i, nbicb nre very
common in the brain. In .loftening and liemorrhagie of ihiit ors;an, lliero
are often seen small red pointa or nodules which conaiât of a dilatation of
tlie capillaries, sometimes nith rupture and pRiision of blood into the
lymph sheath. This latter lesion has been named dissecting or miliary
aneurisni of the capillaries.
Tiie return of the vascntar walls to the embryonic state ap])«ars to be
the starting |>oint uf the new formation of cnpillarics. It oiay be addcJ,
tiiat llic most usual mo<le of fonnation of numerous now capillaries cod*
titUs in the production of cellular diver^cula, which spring from aa ,
inflamed capillary and extend to a neighboring capillary, or form loofi
th« two extrcmiiic.'i of which being attached to the wall of tlie s&mi
cajullary. Thene cellular cords are afterwards hollowed out for the
pasaage of the blood.
Nii-miTiVB T.ESioss OF TUE Capillahies. — The most fretjaent lesio
of nutrition consists in the falty degeneration of the cells of the capillaries^
It may occnr in all organs, but U especially common Id the kidney and
nerve centres. It is always eccD whcD
nutrii.ion tii much teâ^ened or arrcste^l,
and it accompanies fatty degencrBtion
the neighboring; elements. Pliyfliolo]]
eally the capillaries of the brain of aduluj
freijuently contain a few scattered refract-
ing granules. In cerebral softening, the
capillaries are loaded with fatty granules,
which at some pointa give to the caiiiliary
the fonn i>f a dark grnnidar cylinder.
The lymph shciith at this time contains
blood and granules uf ha'inatoidin (Gg.
38a), which indicates that the degencraioltj
capillary Ims been rujitiired. At otbef
timet the lymph sheathâ are dilates! ai:
contain granular bodies, in which almoat]
always ii nuclfua may be found if the rej
ration is treated with picro-carminate ■
ammonia. These grnmilar bodies in\
either lymph corpuscles loaded with fatty
granules, or siniilaHy altered endotheliul cell» of the lymph shentL.
Following experimental division of nerven, the ciipilluries of the peri-
phery undergo fatty de f^cnc ration, and griimdar bodies arc found in
their neighborhood. In irifaa-ti consecutive to obliteration of the arteries,
in chronic inHamniation with fatty degeneration, in Jtrigbt's disease of
f\g. iss.
Cr^aUliKif hjvinkTiHin, i IFv^ dink*.
color- A- JfcnrDfJIkrvltB, ■ fnw c^mLtLu.
tai; imnular plgmvni idiI crjitila d.
Clfiulf pf hHuiiMdlii. /, Occlnaed u-
pnkmrj'; It* Iuiii..n !■ n^^n 011*4 «r.li rvi
BOTRITIVB IBerOHS OF THB OAPILLARTBfl.
337
N
Fig. 18(i.
Fig. I ST.
"UiP ktdnejp (fi^- lM<i. IK"), nrnl in porltonn of tumor* wflikli experience
the aamo ch*nge, ItiU fattj degeneratioo involves tlie cells of the c&pil-
tftrivs.
I Calfvireoua infihratxan is widom scon in tlie cnpillarieji. Nevorthcloaa,
I it «minetiniM occnrà ciihor in the form of granules, or in plaiea, particu-
K Urij in till- angiolitbic earcoauta (psammomata) of Uie dura mator.
!■■ tut* la lt>« kidu*; tn > oh >r Sitglil'i iIIvhi*.
Ut^a«- (-1^4 «.f Url^UI'k 4i«««h« of lb*
Aoothcr common Iohioi) of tlic cnpillarios a amyhid degeneration of
their ccllit, whîcb cliditi^e« these vcë>)clit into vitreou« tubes. Thi« nii-ta-
iDorpliosifl iit espu-cialljr ^'vll marked in thv cupilUries of tliu Muilpi^liinn
bodies of tlie kiilney. Si>melimc:t it \* *c«ii limited to the*c capUlane»,
while in tlie other organs tlie amyloid alleration begin» most freijiiviitly
in the arteries.
VEISS.
CHAPTER X.
VE1XS.
Sect. I.— Hormal Htatolo^y of the Vein».
TllK idrcc conts nhich arc ;tcneriiUy atimiltcl as W-Ionsing tn voiii»,
on- not nearly bo ilistmct as tlioso of tlic arteries. A;;ain, vi-ins of the
eaiiic cntibre ilo not have the «itinc stnicture in 'lifforciit iv;;it>iis of ttie
boily : tite iDvisciilar and elastic olccuoaU pn-iwiut uvïtlter thv eamv ar-
ninï^cmciit nor thv «amu tUickitcu.
Tlic internal «oat of wins m lined with flat pnly^onal ciidotlieliat cells,
«liorler than tlioao of the ai-u-rio». Tin- intetiuil uoat proper ooiutsts of
ilnl cc\U .teparnted hy a Hbrillar iiiilKitanco.
The itiiddk- coat hcjçhi.-i intt^nially by circular ela^ilic fibre» or laininic.
fit has already been atati,-d for the artoriea that tliit) internal oWiio lamina
IS re;;aritcd by mo.4t atilhom as the oulennost layer of die tunica intima.]
From this primary clastic lEver ariflc elastic fibres, which form a net-
vork. In this clastic rctiviilum arc found eoiootli muscular fibres uqi^h
''fionuectivv-ti.-s^ne Oisciculi. The lino of demarcation bi.-twceu the uiiddl^^^
and t'xtenml coal i.< not clently luaiked, bnt all tlmt i«rt of the vein
which oontaina miiscidnr fibi-^n may be conitiiiureil tut the middle coat,
and those veins which do not contain muscular fibren (siniL^es of titc dura
mater, aui)clavian veins, veins of Ihe retina) we sbnuhl say patse.! no
middle coat. The middk' coal of reins of larj;e and meilinm calibre de-
.nianiU a special description, at least tor souio of those veins whkli are
inoàt freauontty the scat of anatomical alterations. _
The clastic reticulum fonns near the internal coat a close network^^H
w hich becomcH gradually looser as the ext^'riial coat is approached, wher^^H
the elastic libre» arc blended with th'isc of the latter. Tlie muscular fibres
ill this coat have a longitudinal or transverse direction, uccoixUng to the
vessel inider considéra lion. Thus the inferior vena cava, Hie portal vein
and renal veinfi prévient internal circular fibres and externa) louptudiiial
fibres ; the femoral and popliteal veins j>osse?ut an internal lon^iitudinal
layer. In the saphena veins, the imiscuiar coat is .still more complicated ;
tliore is seen an internal lou;;itudinal layer, then a series of Iraiisver^
and longitudinal fibres placed one upon the other. The veins of the
neck present only a few scattered muscular fibres situated in the eUstw
meshes immediately external lo the internal coat.
The valves of the veins, in the normal condition, are extremely Ihio.
Tiiey are formed br a duplication of the internal coat supported by a fe#^
elastic and connectivc-ti»su«i fibre».
The ram vafvrum arc found upon veins, especially wliorfl Uiere is
connective tissue, and they penetrate into the middle coat.
I
tRrLAUHATtOir OP TRIRS,
Sect. II —Pathological Histology of Teins.
IxKLAUMATiox cpf Vkixs; Phi.kuitis. — Hpontancotiii plilebitia i« i»et
witli orit/ in tlie rciita of the ut«rus in consoijuenco of pru^uanc/. I'hie-
biliii rr«(|u«ntly complicate!) inttamiuation of the surrouixUng connective
tia^iie, or it ia seen in conseijiieiico of woitniU, of li;{ation of veiu.i, or fol-
lowiiis a prinury coa;nilalion of tlic hlooil in their interior.
In injuries of the veins, the coa;;ulation of the blood and the phlebitis
occur at the same time, so that in these ease* the phlebitis is at least in
part dependent upon the thrombosis.
AVIten a lîf;ature is applied to a vein, an operation almost entirely
«bkiidonod in surreal ])ractice, the blood coa;;iilat«)i in the peripherat end
a« far as the ftntl collateral bmnch ; there i# also a clot formed in tlie cen-
tral fnd. During the liwt few day» there a ob«ervod only Kwelling «ml
roiiltipUcatien of the iMidothelial cell», but Hoon the «iitiru int«riinl coal
thickenji from the foniiatioii of ii^w culU, and forms elevations espvciiilly
well marked at tlic place of the lî^taturc. Later the elevaliouii liecoiae
vascular, unite together and obliteration of the vein takes place aa in arte-
ries. The clot does not appear to bo organized in the veins any raoro
than in the arteries; it undergoes a granular change and gradually dis-
appears.
rill." simplest wound of a vein is that occurring from the operation of
lilecdiii^ at the bci»l of the arm, includin<; the vein and i>ikin ; it hcnls
by tlie fintt intention. As previously describcl, this mode of heiilin^ is
not ai'compliiiheil without inflammation playing au tmpctrtant role. A
tliiii clot remains between the lip^ of the wound ; the following day tliere
LI «een a redness ami slij;hl œdeiiiali^u-t swelling of the skin; ahtinl the
fourth day the scab which hatt formed upon the incision fatU off, and the
cicatrix ia completed. The bistolotry of these simple phenomena has
not yet been studied, but it is probable that the union of the rein takes
fJaco as in connective tissue of the skin, by the interposition, between the
ipe of tlie wound, of an embryonic coancctlre ^ssuo and its orgauimion
into ordinary connective tissue. (See p[). 71, 2i2.)
ttHicn in consenucTice of a sup|>urutiiig wound or of a phlegmon located
near u rein, the connective tissue of tbo external coat of the vein juariiei-
pate» in the inflammation, there arc seen embryonic celU or pu* corpus-
cles between the fawiculi of the connective tissue of this coat. The
external, mid'lle, and internal ooatd of the vein may ulcerate and ba de-
stroyed, by means of the same process which causes the formation of
an alirjcess (softoning and necrosis'). This is observed parûcularly in
a phlegmon of the a:icilla, of the groin, and of the posterior mediastinum ;
fre^iueiitly the ulceration of the veins i^ accompanied with a coa;;ulaiion
of the blood in the interior of the v-^sscl. The danger of a diroct intro-
ilnetion of pus into the circulatory system is prevented by this coagula-
tion of the blood. At times, however, the clot does not completely plug
the vessel, and then septicn;mia and pyicniia supervene; agaîit the clot
already fonned may undergo further niodlfi cations, it may soften in th«
centre, and form on the cardiac sîdt.- an anfractuous canal which connecta
tlic suppurative inllauimatory focus with the vascular system. The loss
uo
of Mibetanco, seen in such ca»c» in tlu- wall or tlic vciiH, rarics ÏD «xtMt,
and tlitfircxt«rnit1 surface is llicn blcmk-d nicli thcgurroiiiiiling |>UI«>ginonoiu
tissue ; the tc«»c1 does not contract but reraaiD» open when out. Tht
«xl^rnnl mftr;;iii of the part where there is n loi» of utiltstxiice, is blei)i)e<l
vritli tlie iiiihiraU-il or fim^oid liiye.r liiuitiii;; i\w |iuniU>nt ttxti*. 'Die
internal mirface of the vein rIiovs tlie loiu of auWaiice to lie timico'l hy
a more di^lmct mar;^iu, although the (UlTerout coata are infiltrxit^il wilh
pus, ami con8c.|Hentlj thickened or pnrtiallv necrosed. Tliis infiltration
of pus is seen under ilie microacope, in sccUons of the vcnoua wrall. The
process in tlieso cases bcin^ rapid, organized vegetations upon tUo internal
coikt of the veins are not found.
In woiinik of the veins such as occur in amputations, all the hlood be-
twevii the point of division and the neari'*t valves Hows out, and this por-
Uon I'f the vein n'niaiiis empty. A clot form» ahovc the valves a* far as
the first collntera! liraiich. Tiic empty e^truinity of the vein partici)<at4?«
in the intlamninliun of the wound ; there oceurit adhesive poriphlebiti» and
etidophlcbitiH Hk« that wliioh follows a ligature, and obliteration of liie
vessel is tlie result.
From the preceding description it iti seen that coagulation of Uie Mood
accompauicR pldebiti^; until a few yoara past it was believed that every
coagulation of tlie blood in tlio veins was caused by tlio pblelntifl. V'ir-
chow endeavored to show tliat primary phlebitis is extremely rare, and
that when a coagulation is seen in a vein witli phlebitis, tlic coagulation
bas moi<t frci|uently preceded the tnllammutio». This Uieory. which
eeciat to 119 too poiMtivu,' haa however been accepted hy most Oenn&o
paihblogtstit.
The causes of venmiii ffiromlifniit are of two kinds : a slowing or arrest
of the circulation, or changes of tlie internal coat of the veins.
After death, the bloodwhieb has collected in the vonouR system coagn-
lates. It is important that the pathologist should be able to recognize
these post-mortem clots in onlcr not to confound them with those of
, thrombosis. They are met with eiçpccîally in the large veins, in the
v«na cava, ilîue and fcnioml. These po^t-niortvm clots occupy onlv a
small part of the calibre of the vewel, never filling them eomplelely;
they do not adhere to the wall, and after opening the vein and removing
thv coagnlum, it is found that prolongations have entered the «ollalenil
branches. These clots are red-hrowu streaked with yellowish-white, or
an? in part fibrinous and eruoric; the whitish or pink portion is seen
always in the superior layer, the rod in the inferior dependent («rt
according to the position of the cadaver. In the same vem these clots
present great inciiuality of thickness, duo to the presence of ibe valves
and tortuosities of the vein. They have the consistence of fibrin and
may be toni into laminn;, or they are curdled. The latter variety are
seen especially id poisoning by phosphorus, arsenic, aod in infectious
diseases.
The arrest or impediment of the circulation which causes thrombosis
during life is due to a weakness of the heart, or to a local interference
of the capillary circulation belonging to tlie vein which becx>mes tlie seat
of the thrombosis.
Such, for example, are all asystolic cardiac lesions causing the forma-
<
TnnoHBosta or tbiss.
341
^
tioD of cloU in the ri^lit b«art and Urj^e veins ; th« direct Action exerted
by lij^atiire», by Uiinow, I>y abAceitae^. by coin{)resiùon of llio gravid iiienifl
upon the iliac reinti, etc. The retardation of Itie lilood in variooso dila-
tetiona may aUo "be a canse of tlirombosU.
Thrombosis of the pulmonary veins in [ineiimonia lii due to the pro«-
Burc escrt«d upon the capillaries by the exudation vliich diiilentU tUe
ftlreoli. 'riironiboiis of the veins of iho kidney and spleen, in caaeotia
infareti, etc., is from the arrest of the capillary circulation. It is t}ie
same in leucocylbicmin ; the capillary circulation bein^ interfered with
on Kcconnt of the ;;rcat number of white corpuscles, clots are rca<tily
fonnei) in tlic veins.
When ni] artery \» obstructed by an embolus, the blood is arrested in
tlie cnpiliaries; it docs not circulate in the veins, but there coa;;ulatcs.
tiuoh are the phenomena alway» tieen in embolic tnfnrcti of tbc liver,
spleen, kidneys, nnd embolic gangrene of the exiremiciiM.
The venouii thronibtia fitU completely the calibre of the resweU: it it
adherent to the wall and terminates at the cardiac end in a j>oi»t or
groove. It is formeil by a series of layers joined together, the mast
superficial of vrhich arc the most recent, and may bo still cruonc, wliile
the central and middle layers arc gray or yellow. When the dot h old,
there is freiiucnlly found in its centre an anfractuous cavity filled with a
pariform, vrnit* or opai^ue detritus.
A microMopc examination of this detritus shows numerous white cor-
puscles which hnve cxperieiiccil cationtion; they iirc irregular, present in
tlieir interior fatty granules, anil do nut contain any apparent nuclei.
IJetiideii tlie:je corpiu-^cleii are found granules, which diiiappear by the
addition of acetic acid, and free fatty granules. A section of the clot
shows red blood corpuscles at the peripheral portion of the thrombus,
vbicb can be siill recogniaed, senaratcd by rcticiduted layers of fibrin,
in which arc seen white corpuscles. In the interior of the layers, the
fibrin fonns closer laminie, between which an.' seen granular collections
varying in siïo and shape, containing pigniciitAry musseii.
'fhcrc arc alwavs in the thrombi of veini numuroii» white corpuscles,
n phenomenon which cannot b<i attribntiil either to a new formation or to
a migration. It bus been seen that alway» when there is a retardation
of the circulation of the blood nt any p.irt of th« vascular system, the
white corpuscles arc there uccumulated. i^ince thrombosis t-i preceded
by a retardation of the blood circulating in tlie vein which is the seat of
the lesion, it U iialuml thiU the blood coagulating under this condition
should contain a greater number of white corpuscles. These are free
in the centre of the clot, which ia the oldest part, because tlie fibrin there
nndergoes a granular change.
Tb« disposition of ibe thrombus into concentric layers is due to the
primary clot being formed h\ the blood coagulating in a body in the vein
and undergoing a shrinking by the contraction of the fibrin. There thus
is formeii a space between the clot and tlie wall of the rein, which is
soon filled with blood which circulates, ulthough slowly. The oMigula-
uon of this last blood is followed by a new .shrinking, and these phe-
nomena are continued until the rein, completely distended, is ajiplied so
accurately upon the clot that the circulation is arrested. Until the clot
TKTV9.
onlirely fill'* the vein, it » frcinientlv retaineil wlicrc it i» formed fiy pro-
loiigutioDS wliich it xemU iiit<:> the collatvi-»! veiin: tliU peculiarity ox-
plain» why lli« clot ia not always delaclKtd and tiirovn into iho cii\;uU-
tion in order to form emboli. At iliit) time tliere arieee in the venous
«all » ^erieH of inttsmmatory changes, the first of nhtcb consist in the
■welling and proliferation of the endothelial celU. The iutenuil coat
soon participates in the intlamniation ; there arc formed new cellular eic-
tinenls which produce cicrattonii (endophlebiti^) : the «xUrnal «oat also von-
tainB new ctUuUr element» between ita Rbrus and is DOtkUy swollen (peri-
phlebitis), (ienerully the miildle eout io not moilifieil ; yet, in eftMs wbcro
the inflMumation i» very intense, n tnie suppumlion of Uic coatd of the
vein niftv occur, and involve even the middle coat. Throinbosi* nwv l*e
the origin of an ali^eciM of the extorual ooau of a vein.
Su])puratioii 'n far from being the uskial termination of tbroraboKia ;
somelimes the clot iit partially or completely detached (nm the vein, and
the circulation is re-established in the peiiplieral vein and carries the
thrombus on to obstruct a branch of tlie pulmonary artery.
'I'lic most freiiuent termination of venous tlirombi is the permanent
obliw-ratioii of the vein; vegetation» of the internal coat and absorption
of thu old clot consecutively supervene, and the vein is traiufonned luto
a fibrous cord.
•
Varicbh, Varicm8k Vriks. — The term rnriVvA i« applied to dilauiioua
of tlie vein» accomjianied by j)CT»i«lent modifications of their wall. 1'ha
word vftricea 'n not absolutely «ynonymous with phl«becla«cj, for simple
[dilatation or nhlebectasiD may be seen, for example, around tumors, wi(b>
[out there bein^ any varices. When the tumor is removed, the simply
dilated veins retnni «gain to their primary condition.
Varices are observed «specially in the superficial veins of the inferior
extremities. In order to see the arrangement of varicose veins, they
«bonld be dissected for their entire extent, when it is found that they
are not only dilated, hut elongated, and fonn numerous curves. The
calibre of the vein is very irregular ; fusiform or «mpulla-Kke dilatations
are seen. Their walls are not uniform in thickness, wldch can only lie
demonstrated by oj>cning the vein. The valves are found to be insuSi-
cient, or reduced to loops, or flattened against the wall, or pArtiy de-
stroyed. There is frequently noticed at the position of the valve* a
con»derable thickening, in the form of nodules. The internal surface of
. the vein presents longitudinal nrommencea and depressions, which aj)[K>ar
' as iorgitudinal foM*. The wall of the vein is in plaoe« extremely iJiiok,
so that, in transverse suctions, tig calibre remains gaping like that of an
artery.
Sometimes there are seen, in chronic vnrices, calcareous incnutations
in the form of jilale.*, nodules, or »pber*.'8 with concentric larere. Exam-
ined in the fresh stale, sniiill calciircous pliitcs are not visible ; but, whoo
the altered veins are dried, the calcified part becomes very evident by
ita opacity and the prominence which it forms while the uonual parts
contract and become transparent.
Calcareous infiltration is seen in the form of sphere:* or phlebolites ia
the varicose diverticula. An extensive calcareous indurati«a several cenli-
VARICBS, VARIOOSE VEIKB.
S43
h
m^tiTfl in len^h, \» Hl*n ttomctioM'» observM, tb« vein being tntnsfonned
inlti K calcareous ttiW' with tlio raniiticatinn.» atHO varioofle.
When llio variccii ar« old am! jçrenily «levcloiied. the ililaled veins,
doiiblin); upon themiielres, fomi cavernous ttiniorfl «itli lar^ me^hea. so
that a seetiou of the tumor open» n ^reat number of caviùos, filled with
Iiloo<l ant) commnnicating one with the other. Tho veins constituting
this tumor cannot be isolated b; disâoction.
Around all old varices Uie subcutaneous cellular tissue has uticK-rKone
clironic inflammatory morlificationa ; it ie in&llratrd with fliiiii, vcrj
vancular, and of ]anlaciv>us consistftnco. This tissue mav t>e tiic jxiiiit
of orijpn ofcnllotis nk-cn! and of osseous formations, :>omctimi-«i'K(i-ui'itT.
A lii^tiilrt^lcal «xuminatiiin of the walls «f vnric»se vein--* xhowH, in »
varying; degnn;, an alteialion wliich con»8ta in a nen forniHiion of
fibrous tiMue in th« internal pnrt of the middle coat, ae))ar»ling the
muAcular fawiouli of this coat which are theot*elve!i hypertrophied.
The internal coat is not evidently hypertrojihted, and usuallv does not
present végétations upon itA fiurface, unles-i it in at the position of the
valves, or when there is a thrombiti. In section this coat appears as a
bond, which colors slightly by carmine, and possesses two or three rows
of lenticular nuclei.
Beneatii this layer there osists an elastic network, tlio meshes of
lioh are formed by largo fascicidi of connective tissue, generally
a lonptudinal direction. It is these which cause the longitudinal
upon the internal surface of the vi-in, visible to the nnaiiled eye.
!?e ra^etciilî are eovert'd with large connective-tisaue eella.
Nc.\t to this internal layer of the middle coat, the thickness of which
is always considerable, come faMicuU of muscular fibres, which, when
cut transvet^ly, appear under the microscope as a series of clear
circles presenting in their centre the section of a cylindrical nuclotis.
The Iur<;e><t of the muscular fasciculi are elliptical. Those at the uK>ist
exteniui part of the middle cent almost always are circular in direc-
tion, and nm at right antics with the longitudinal fawciciiti. These
fasciculi are ^parated one from the other by connective tissue, »o that
there is a continuity of connective tissue from the internal » the ex-
ternal coat, from such an arrangement of structure, it follows that
the muscular elements may he easily separated one from the other, and
that Huids can penetrate into or exude from the vessel, which explains
the frc>|uency of «deraa and chronic iiitlammadon in these cases.
Between ttio fasciculi of connective tissue there are frequently found
granules, or collections of granules, of a beautiful yellow color. They
are composed of blood pigment, and demonstrate that the red corpuscles
of the blomi have infiltrated this tissue. The thickness of the middle
coal, changed in this manner, is two or three times greater than normal.
TIte dilatation is not confined to the principal vein, but exieu'U to all
its branches, and especially to the vam V'im"ritiii of the venous walls.
The latter are much dilated, sinuous, and their walU are ihicVened. In
Bone cases «here the dilatation is more decideil, a vci-nel of considerable
diameter is seen in the midst of the middle coat, and may often extend
to its moat internal [mrt. KitKilly, the tortuous dilations of the vtua
344
vaBorum, ntlilod to tin' ililntiittoii of thi- principal fvsxcl, f)rm very oon-
plex «avcmous luiDcfactionM.
Tlic «ftlonreoiu pktv* of the veins «re ilcvelopod in the fibrous anil
intenml jMirtion of the miiMk- coat. Al tlio bcgioniiig they coialsl of
firatiiilt-», ilfjiofliteil in llie faHcicnIi of tlie conneclive tisane or between
tliem; ttieae .toon unite niul form trnti.t parent ))late4 with granular Mrt«.
In certain [larta of llieîr course, varicose veins are fre'[iienlly siiimile-
shajie or splierically dilated. Their wall is then very tbin, and seclion»
including tlie diHcrcnt layer», show a proceas analogous to tliat of ancu-
risDial dilatations of tlie arteriw. ITie muscular coat hait partly or com-
pletely disappeared, and the internal and external coat« bicndin;; toge^icr
alono constitute tlie wall of the tumor. The wall« of the dilatations nuy
he so lliin as tn rupture, am) «five rise to be[norrha<^8.
Th*' indurated ctniiiective lixsue and the hypcrtropliied skin near the
rariue* present Ui tin- iiiicmsoopo tho hi-tt>>i'i;;ical clmngc» of chronie
inllainmatioii and elcplianlianifl. Ulceration >n due to the uniting u>j;eilier
of irninll fluppuralinji; foci which open and form an iilceratin;; wound» with
indurated borders and base similar to the subcutaneous cellular tissue
attacked with chronic plilej^mon.
The extent of these ulcere ia sometimos considerable. In tho midst
of the Burrounilin;; lardaceous tissue smnll jioints of suppuration are
found near the nicer», the rcmuining part of the tissue bcin<; infiltrated
with white corpuseli-s, which colk-cl toj^cthvr to fomi the small ubttcesses.
The inflnint nation ol\cu attacks the surface of bones, eau»in}: the fonna-
tion of Dcw (iHsuoufi tissue, in itic nliu])c of osU^oph^'tcii) which ut tiiiwa
are very large.
TtiMORS op Vrin8. — Kxoept tl>e uigiom&ta, which are dereloped in
their wall, and which have been described at pages llt'J, 14U, primary
tumors of VL-ins do not occur.
iH'Condarv tumors of veins occur frequently. Often when a vein Is
surrounded hy a malignant tumor, carcinoma or sarcoma for example, iu
walls arc coiiverled into morbid tissue which sends vascular elevations
into the calibre of the vessel. These elevations occasion an impedîmeot
to the circulation anda coagulation of the blood, when they are found en-
veloped within a clot. Portion» of the elevation» may be deUiched and fonu
emboli. It is very probable that the geiiëralixation of certain Narcomala,
especially encephaloid sarcoma, occurt* hy the tr)ini«[ioi'talion of fragments
of this nature. Tho fragments of morbid ti.-wiie, carried away by the
circulatin;^ current, are engrafted in the diiferent or):ans, particularly in
the lun^s. and become the origin of secondary formations.
Thus from primary tumors developed in the general venous syelein,ia
the testicles, in the kidneys, in the extremities, metastasis takes place
DiOKt fre>|ucn(ly in the lun^, while in tumors of the stomach and intes-
tine» the portal win iind liver arc the usual seat of the metastasis. Tlie
sarciimnta appear to us lo be generuliKcd through the venous system, and
the carciuouiata througli the lyniphutic system.
PATrtOLOOICAt UISTOLOOT OF LTUPIIATIC VBSS8L8. 845
CHAPTER Xr.
LYMPHATIC VKSSELS.
Seot I.— Noraal Histology.
TllK Btructiire of lympliauc vesseh is bo like that of vciiw of tlie samo
cnlibrp, tliat it is uonocosaarjr w repent itio description. But while vtins
have tlii-ir ')ri;;iti tn the capillary network, tho lymphatics liavc Ibeir
•oiircv from the tÎMues, ami <lo not liircctly coniTminicatv trïtli (he va»-
cnlar aystcm. The lyrnpliatics empty into the subclavian veins, on the
'■ left itido by the thoracic iltict, on the right »iile 1>y tho right lymplialic
I duet.
One of the most intere*tin» anH most disputed <iue3tionfl is the origin
tiie lymphatic ve.'<^el.4 in the tiiinne». When they were fltitdieil hy
HH of mercury injeetions, it wa«i believed that tho reticulum thuit
"^hjecteit naH the only origin of the lyin|)hatic system. Uut since tluidu
which are much more penetrating!; have been employed for iujecliug, it
h&B been found that ft sroat number of vpsjcIb, not injected by the
» mercury, arc rendered viiible by these fluid*. It is only necessary to
iBso a hypodemiic syringe, introduced into the connective tissue, to
demonstrate that the lymphatic vessels communicate directly with the
iTrnjih splices of the connective-lisstie system «f the body, (tiec fig. 10.)
L it has been *een how the serous cavities arc apfiendage^ of the lymjdiatio
F tyslem, inasmuch as there exista a direct communicadon between these
cavities. The lymphatic ve-ssels of the «erous cavities are situated very
SuperBctalty under the endothelium, so that any pathological change of the
serous memhrsiieà cannot occur without tho corresponding lymphalicd
experioncin;; at the same time an alteration.
Lymphatic vessels forming a reiicuhim are always foimd around
arteries; in many organs this reticuhim is very extensive. The spaces
of this network arc in conmi uni cation with a lymphatic sac, which partly
surrotinds the artery as an imperfect fthenth. The lymphatic sacs are
then C(piivalent to a peri-arterial retieutiim. This arrangement of peri-
' vascular lymph sheaths was fintt observed by Oh. Itobin, iu the arteries
of the brain.
Sect. II,— Pathological Histology of the Lymphatic VesaeU.
Ljfmfhangiti» or infiamnuitioH of the lymphatic vessels has aa yet
been studied histologically only upon the surface of serous membranes,
in the brain, and in the uterus. In pleuritis, pericarditis, and perito-
nitis, sections including the exudation and subjacent serous membrane,
S46
LYMPHATIC VESSELS.
veryilUtinctlyslioH-litmiMinof lymphnlic veiwcincntiiiHilfcroiittrirpctioM.
Theite ve^ticl-i are liilnted ami contain a liiiliAtaiicc itiiuilar u> tlint of Uio
exiidatjon upon the flurlnce of tiie aerou* mem^rntie, voiiXMtiiijç of )iu» or
fibrin encloajng pus corpuscle!'. Tlie endottictiuiti of tlie ves^eU U nivnyii
awolten, 'to»<|iiainatoil, and pralireraied ; the wall of tlie veti^l in inlil-
tratnd with new eleiuoiils and eve» pus coq>u.'wlefl.
Tlic lymphatic sheaths in the l>rain, reprcaeniing the troe lyrophalic
vessels of tno organ, show in encephalitis, id cerebral sofienin^ and hi-m-
«rrlm};cg, a séries of chnogcs which nmy be easily studied. They consist
ill the production of granular pus cor]>nscles, and in a proliferation witli
dcsijnnination of the endothelium. Generally, these lesions are accoinpa*
iiied with an escape of red orpti^cles, which give rise to blood pi»nH-nt
nnil crystals of bunnatoidin.
Ill (lie chi-onic forms, particnlarly in chronic «otVeniiif; of the bmin. the
niiicli di^ii>ndi--d lymphatic itheaths prenentan endothelium loaded with fatty
eranuleii, and contain numerous granular corpuaclce and ptu corpti-^cU-s.
It is probable that the granules resulting froia the breaking down of the
foeiiH of softening may be taken up by the lyraphaticii and gradually
removed.
Li puerperal metritis, the lymphatic vessels found in tiie horns of the
uterus and in the broad li;4ament, are freijuently seen dilated a»<l tilled
with pus, and the coats of the lymphaUcs are infiltrated with pus cor.
pu^cles.
Dilatation of the Lymiihattct (^Lj/mphan-jif^taBi»}. — In elephantia*
818, in congenital enlargement of the ton;pie, the lymphaiic veswls arc
dilated without any very eomiider-
"''*- able moiliticaiion of their structure.
Their endoliielial eelU are enhir^çed
and readily recomiued. The injec-
tion of the vessels is always easier
than in ihc normal state (see p. 141),
Ittêiant of the hj/mphatie P'eêèrl»
m T»mi>r». — Tuberculosis of tlie
lympliatic vessels is very fre<jiicntly
«een upon the serous membranes
(pleura, [fvricanlium, peritoneum).
Upon the visceral peritoneum, oppo-
site a tuberculous ulceration of the in-
testine, there are often found knotty,
opa<|ne, white cords, which nuliate
from the indurated base of tlic ulcer-
ation. These cords, which form ele-
rations upon the peritoneal surface of the intestine, traverse the mesentery
as fur as the neighhorin;; lymphiitic glands. Cpon their surface tlierc
are freipiently found prominent tuberculous granulations ; if a transverse
seeliun is made of them, a white or yellowish opaijue auhsiance Hows
out. The contenu of these vessels consist of white blood corpuscles, of
larger corpuscles 6lled with fatty granule* (ind of free fat granules,
liy a microscopic examination there are found all tlie phases of de-
velopment of tuberculous granulations. In the first stage the lymphatic
DUftlfd l^mpb TMjidU In a ttmo nf ^Iniihitn-
tU4U4f tbo «klQ «f Ib« fpiitB. A. l-^iupb T«<-
Mt. K FUI asiliitlivlliini ul tbc tttHl. e. Sni.
brf 011I4 fioniMilvv i1.B«d« at lb* lumor.
rATDOLOOIQAL BTSTOLOOT OF LTUPKATIO VRBSBIS. 347
venels sre found filltH! with wïiite blood corpuscles, and celU Tarjin;; in
shitpe coining from tlic enilollietiuni of iLe v<:s.M;la; the wall of tlio vcaacl
find the neighborin;^ cnnnective tisaui; arc infiUrat«d to a pvftt «jctent
witli emtirj^onic cells. In the second stage, tlio cclla groujied in tlic wnll
of till- iTmphntics and in the connective ttseuu form with the oxiâtîti;; cell»
of the vrsacld, a nodulo havin;^ all tho chnrnotvrinticd of a tiibvrcnloits
granulation. These nodules sitiiatt^'d ulon;; thi- coiiriti' of the Ivmphiitio
vcmcIh arc located at inoro or Ii-ss regular inivrvulii. In manv caiteH they
ura cloM' together, or arc ontlucnt with neighboring gratiututioiw whtcli
have dcrelopi'd in the connective tii^ue, thuii forming in places ft collec-
tion of granulations.
When n carciiiotnn excites an irriiation in the lymphatic vciwek nhich
come from the tumor, the latter form hard cordai, ij^ndunllv increasing
in sÎ2i>, at tiiac4 becoming ait large as a croH'ii ifnill. Kor example, in
a hard carcinoma of the mammary gland, where after repeatc<l attacks
of angioleueitea thev terminnte by transforming the lytnphatic vessets
into hard conU, true sctrrims.
Pig. 169.
u-
CftKlnoBii Df mAmmtrj gixn^—lUv ftrvnaâ atibvEitirvar th*Hfldr|-.ii lUlnvd vLlti ullrat* r>r «ILivr-
a. Alt#«li <rf lb* fArflaoiuA BlirJ i«nb ««lU. b. Ljrmph «iinr^a ■U<j«d to Iho Dbront nitav ^nitr
tr«atn«Dl bf Etlnu tt allfcr. r. L^bijiIuiU» (bowing ■lint •UtnlDf ii( lb* «IvVImIIbiii.
In aocondary carcitiomala of the lung^ and pleura there are at times
Men npon the surface of this itérons membrane nodulated and indurated
lymphatic itetworks, gray or opatjne in ajipearance. I'pon the vessels
90 cnangci). there are sometimes found small secondary carcinomatous
nodules, and a transverse cut of the vessels causes a millcy fluid to exude.
The same degeneration of the vessels may be seen in other serous mem-
branes, notably tn the peritoneum.
From the description which wc have given of the evolution of the car-
cinomata, and the communication of the alveoli with the lymphatics, it is
very probable that the cells of the alveoli penetrate into the lymphatic
vessels and become tho starting point of their transformation.
848
LYMFIIAIIO GLA.XD8.
CHAPTER XII.
LYMPHATIC GLANUS.
fiect. [.- Normal Hutology of the Li^mph Olandi.
Lymphatic glaiKU are organs situAk-il nions t'"ï course of ihc \ymj ..
alio vCMfls. if tlieir titructure la juiigoil acconlini; to tlic iteBcri|>tioii of
wriler», it is wry comjiticatcd, but in rciility il i* very »iinj>lc. The'
gUuiU nre Burromuled by a eapaule of coimeciivc ti.'i.'ttic, whioli docs not
COiMtJtiiU: n close nitmbrane, but ia only a layer of conrnx'tivf tissue in
Triiich tlic fiiâcicuH form u denser structure llian in onlitutry conucctiro
FSg. 190.
fiediim at imill lymphailc lUnil. hkl/ itlrtcnniiBlKHllr iflien. wllh liia wnnr trt Iha Ijstit-
1h*itniiftiip*; I, v|iTb tiftïwrfi Oi* fvCttcltii or HlvDi>]t of Ihfl «ofilc*! pirl ; c, •*r»t*B» *f Mpu** ik*
nttulHir |»iti<iii. .|<<«ii i<> \iir liiloD ; it. iho folllil'u ; i, l/Tupli'iuli'i o' d* meinMtrt nu»:/,
dlB*iH( Ijnpbklle tlrstni* wlilch «tituuud Ibg Fullkla*! unil A»w iLii><ik1i ibt Inlpnilw* bI (b*
ttBSue. From the inner snrfact of the cnp«ule connectire-ti^sue wptt
pene'.ratc ibc gland and divide It into follicles. In tht-se iM;]>ta, m «vU
as among the connective tÎHïue fibrcH of the uHpsutc, arc fri-<|nent)y found
a varying number of Hoiootb muscle fibres. Tbiscap^iili; is traversed by
bloodvessels, and by tlic lymphatic vesoeU which ont«r and those whiut
paiM out of the ginnd.
The iiffercnt lymphatic vewels wlien ihey reach lW« gland penetrate it
at ditleretit \H>\nto upon the mirface, and empty into a syi4t«m of cavitiea^J
The efferent vessels form di»tiuct canals in the hilua of the organ, *fhor
they pa.-** out of the gland, 'rhis system of cavities which corrosponij
to Uie «inuses and tympbatic paths of His is [lermeated by the art«rk
and veins of the gland. From ihe wall of the bloodvesseU proceed email
KORMAL aiSTOtOOT OF TBB LVUPU 0LAXD8.
^
I
fiwcictili of C4nnvctiv« tLssu«, vhteh <ltriilc ami nnnstoiuoAC with nvî>;;h>
boriiij; fftscknli, rnmiin^ a c<»m[>)ct« rotUnilutn. nhicli hislologicnll^ ilqes
not iltfTcr ci*«<>ntinllj' fmm the firent ftijiontuin, fxcopt thut the trfihL>«tilie
ni'liato ill ait direolionii, while in the (Çieat oiDcntiini the triibwulii- are
filnccil in ihe n*inff piniii. A section of a glnnd, cntting «n arti-rv truns-
ventely, aliowit ihe vessel to t>e aiirroimiled by n rin^ from th« margin of
which proceed, in a radintin;; rannner, roliculnled fufoiciili of comx'Ctivo
tissue. These fibres gradiiallv become thinner the more diManl they ere
from the «rtery.
ITio fibres of tho rcticulntpd connective tissue, which pa-e through tlie
lymphatic carity of the ^land, never poaeess nuclei in Ùieir interior, or
ÎD their continuity, or at the point
where they cro*s one nnoiher. Fig. isi.
Th««« fibres (ire eoveruil with flat
cmlothelial c«ll« «imilar t» thoMO
wen npon the small Irabecitlic of
the great onienttini. All the cavi.
ties arc filled with lymph extremely
rich in while corpiidclea, ho that the
rcticulam can only be seen after
peitcillins thin sections of tho
eland. If a lymphatic glaml is
injected with a solution of I'rusflian
blue, by mcan« of a ptmcturc, the
fluid filin all thi< lymphatic Etyslom,
and pA.^^eH out throujçh the efierent
veiiaela. If the organ ia now di-
vided, it ia found that the colored
fluid occupies only a part of tho
^land. which portion remains to he
dcseribeil, nnA corresponds to the
follicles and follicular conlsof His.
The follicles arc very <IUtinct in
the Inlands of the mesentery during
digestion, being ^tlightly translu-
cent, while the lymphatic paths
previoiwly described are fdled witli
chyle, and form opa4ue noues. The
follicles are round upon the free sur-
face of Uie gland, while at the bilus
they form one or more sinuous pro-
longations, which properly bclung
to them, although they have been given a distinct name,/(i?/KM/ac -vrd».
We dfTsignutc all the follicles, a« above diiseribed, by the name ol'/o/fi-^U'
lar ri/»ti'm, while for the pKKMges tbroujth which ôie lymph travels wo
employ tho name ctivurtv/u* fifnifihatie sj/Kdm. Tlie latter corresiwnds to
the art^rieti and vein* of the gland; tho former, the foUicnlar system,
correspond* Vi the blood capillaries. The foUiclo differ* in structure
from tlie tissue which forms the cavernous system only hy the greater
thiuiieM of the fibrils. The capillary network of the follicU-s consists
r>-in]r>n Af m«diiU*i7 ■abti«ni4a «f ariiiUivn
glAitil uf All t>x- X -^^- *'- MtJiLUirr «ab.iRitfa
of ntno'^imrf» 1L.Aij«« And It r*« L^l"!'!* fvr|'b,cl**.
A, ^n)H«arUI Ijntph |iftih if*ieTv«d If ■ r^
tl^nlLiBD let wtlh ummfroiLi jtuMlvnivtlitc pTo-
lonKJitlflna, ThA I^inph curitn.f Ira hit«r Liku
•xetdtltvlj at aafetr1p«d nia»U S1>m. |/V«jf.l
850
LYMPHATIC OLASDB.
of Ur^e regular m«s)ie3. A transver^e ticclioii of tlie capiltarieii shows
tlicRi aurroiiiidcd by a ring Trom which proceed fibrils, which anaslo-
mo&c and form a reticulum. Tbere are neilbor nuclei nor cells iu the
fibrils. iioV arff thojr found in their continuity nor at the nodal points
of till- fibrils. This obiuirvation is •titl'cii-nt from that of other his I ol ovists.
Tliitt conchnion hus been arrivvil at by the cm ploy m out of c<Mic«ntra (<.■<{
fier'n: ui-id in orAcr to hftrdcn the ^Inn'ts for inakin;^ sections. After
nmccmtiiii; in tbts reagent the relicitlnted connective tissue can be sepa-
rnted, so that their remains not n single c<^llidar element, twithcr in tlie
lueobed of the stroma nor in the fibrils. If the ]H'nuitling )im not heca
complete, there arc iieen upon the surface of the BbriU or At tlieir points
of junction, flat nuclei connected to Ihe fibriU by a layer of protOftlaam,
the extent of which we do not yet know, lu acute irrititions of the
Ivinphatic glamle, the removal of all the cellular olementi n uuch easier
tlian in the normal state.
The boundary botwoon the follicles and the cavernous lymphatic system
is made iiuilc distinct, cither by interstitial injectioiis of i'fussian blue
fluid, or by an incomplete pencilling. The nicshcs of the cavcmoa»
system bcin;; larger, ami the cells less numerous than in the follicular
syxtem. the pcn(ûJlin;r remiiveS them first. \\M there is not seen between
the*4! two system* a tnu' limitin;; lueuibrane. It may, however, be ex-
perimentally demoujitratcil tbnt there is « naiurul communication iK'tweeo
tlio follicle-'< and the cnvernous sy.4tem of the ^lanis. Ity întrmlncitig
vermilion, in fine |iowil>>r Husjieniled in water, into the connective tiKiue
which surrounds lUe sciatic nerve of a rabbit, and killing the snimal
twcnt>'.four hours after the operation, the lymphatic vessels which pro-
ceed from the région where the vermilion has been introduced arc found
filled with the red substance, a» tf they had been injected, and the lumbar
glands also contiLin vermilion ; the latter is especially seen in tltc caver-
noni .system of the <|hLnd, mci that the follicles appear n[)on the snrftoe as
white circles .lurroimdttd with rod honlers. In iwetions maile after
hardening the gland in picric acid, all the particle<< uf vermilion are ^een
ÎU the cells, whicii latter are of two kîndn ; lymphatic corptiMte-i, and
endothelial celU which cover the lîbrilii. Some of the grains of rennilion
are also found in a few of the lymph celU of the follicular systetn. In
the physiological transportation ol the chyte through the mesenteric
glands during di^^esliou, fatty granules are found not only in the spaeeu
of th? cavernous lymphatic system, but also in the cells of tho folUcnli
aystem. yet in a, much sinillcr proportion. It is then very probable that
the me»bes of the reticulated tissue of the follicles are in eommnninitiou
with the reticulated nieshes of the c«vcrti<i\i* system. It may be infer
therefore, that a lymphatic gland is notliing more tlian a com|Aicatc
lymphatic cavity or serous cavity situated along the cour*e of the lymph*]
a tic vett«cls.
'I'be afferent veitaeLi enter into ibis cavity at different pointa, and the
cfterenl ves-swld pass out after being collected together in the hilus, whei
tbey are ])laced alongside of the arteries and veins, which latter [loasa
distinct walU, while the efferent lymphatics arc simply canals excavated
in the connective tissue and lined by an endothelium.
rATnOI-OOTOAL BISTOtOOT Or QLAnDlt.
351
liaK been previously stnU'-l
into tlie lympltatic ;;liiii<l8
It hns also bi.-«n ti«cn tbut
6«et. n.— FftUioloffioal Hbtoloffy of OUadi.
P[<(MKXTATlos op Gl^si>3. — Frcqucntlj tlwîit i» Kceii a liliiok color-
fttioii nf thv pvri -bronchi II I lymphatic ■;liini)s in tliv kiliilt anJ in old penom.
A simtlkr coloration may nièo be seoii in other ^liinila. wltvu the rojiion»
from wliivli their afforent vvsselit [irouoed have bv«ii tlie «out of infiltra-
tïoM of blooil or fontigii granul&r malt«r8. TIiuh, when colored povr'lor.4
httve l>e«n introduueil into the iikin, a» by tattooing, the Gnmspomling
lypiphatic glan<U present colorei] particles id tlicir interior. H the
cotorei) auWances exist or are incro<lDce<l into the blood inateatl of
being depoaitol in tlie connective tiaaue, pij^ciitatinn of the glands does
not take place, or it is very limiieil. It
how rapidly colored particles penetrate
«hen itepositv'l in the counecllre tissue,
vheii bloo<l escapes from tlie ve»:«el4 into the tissues, it UDilerj^oe» a
scries of m«tami>rpliosue which tijriiiinate in the formation of volored
granule-s; thvsti arc taken up by (he lymphatic vcssuU and ue arre^tad
in the ^laiviU.
The eoloretl particle* foiiu.l in glanrU ar<e of two kiivls: they come
from the bloo'l, or are forui^n to the oi-;^.-iiit:im ami are iiitroiluced into the
]^BiKluliir parencliyioa lhroit;;li the lymphatic pa^^;;eit. The (irtit are
yellow, re<i, brown, or black, and are round or angular in sliapc ; Home
wiitem (Uebiiamen) have found crystaU of htematoidin. The second,
fonned b^ opa<(ue substances, appear always black or dark to transmitted
light.
(jlumls iiiKUniteil with pi^ncnt are tttato-gray or dark-gray, marbled
with white and bliu^k. lu the latter ca^o the [»gnu;utation is iH-stt^l
e»p<^'cia1ly in the ciiveriiou^t lymphatic system, and lh« follienlnr i>yMteia
w \k** colored. When there are only a few dark striiu in the glaiub,
they «xcltiitivcly oiicupy the spaces of the caveriioti-t system.
The gl&nda alfecteil with pigmentation are generally larger an<l more
onnsiatent Chan in the normal comlition. The increase in siie of a ghtml
by pigmentation may be demonairaled by esperimenl upon animals ;
it is thus seen that the kI&ikIs corre spoiling to the lymphatic vessels
communicating with the pigmented region, are twice the sise of the same
glands on the opposite side of the body.
A few of tho pigmcntated glands arc hanl, and present a dry, glisten-
ing surface upon section ; no juice Minle» under pressure.
ThoMT latter glan-U have experienced, fmni the slow irritation caiwcil
by the presence uf the pi>rrni-uLiry .■(uliAianee, a true fibrous transforma-
tiou. iiy inicr'i.'i':i>pio exuiiiin^ttion, it i^ found that the arteries are sur-
rounded by a thickened fibrous zone, and that the interfascicular celU
are iufiltrated with pigment.
The reticulated fibres of the cavernous system are hypertrophied ;
their endothelial cells contain Kramiles of pigment ; the lymph cells also
contain them. The follicular system is no longer distinct from the
earernoos systom, and everywhere the gland has tho apnearance as
described. The rcticulate>l tissue may have eoinplctely uisappoarod,
and only the pvri-vascular connective tissue infiltrated with pigment may
852
LYMPHATIC GLANDS.
occui)}* the entire or;;an. But these are examples of complete trans-
forniiition, whioh exi»l onljr iu old peraons or in tb« leeioKs of minora*
pIitiii»U.
The fjinnils which arc only sligbtlv pt^cDUtcd. as the bronchUl
glnnils ill n case of piiciimonm for example, prissent very diffcnnt chiir-
oclerM. Tliey are hypertrophied, and rich in a juice in «hii-h are
found mnall sphericxl ecU» cotitniniii^ yellow. n.'<l, or brown pi^nent
granules: in a mere ndvniieed nltenition.all the pigmentary graniiW are
absolutely hinck. In the juice there also exist larjte, ramifying, or
aneulnr cell.i contAitiing several oval nuclei and grains of pigment.
Id thin sectioiiii, the cavenioti^ system isi found to be the principal
seat of the [iii,^ieniation. and, besides the pijjmeiitaleil Ivropti cells. oUier
Btnaller eoloriesa cells are seen. There also exist colored j-ranules iu
the endotlielial cells of the reticulated fibres. These cells are alij^hlly
swollen and more readily detached.
Inpi,ammatto.v op the Lvurii Glanda; Acutb AnKNtTti;. — loaanwd
lymph glands are nt tJnies considerably increased in size ; they have a
tontleiicy to become fijilicricid. "r, if thi-y come in contact witJi neighbor-
ing glnndi" C'lually liimefied, they arc Huttened one agniiut tlio other.
The HurrcHntdiiig coiiiieciive tismie i» the scat of an intlammalory wdenui
wilh congcstidii of the bloodvessel», which fre<tuently causes small cvchy-
moses. In intense adenitis, thr ledcmatniis cotuiectîve tissue pri^se)lt«
small pundcnt collections, or an abscess ; thits the lymph gland may
be BiirrouLided by a layer of pus.
In the ginnd iteelf are found altorationa which vary according to the
Stage of the inflanimalian. In the first ppriod. there w congestive and
influniniatory ccdetna. particularly well marked in the cavernous lynipliatic
system, so that the follicles and fotlicnlar cords are much more distinct
tban usual, on account of their forming whitish, Ofia<|u« apots or lûtes
upon a slightly translucent ground.
In a few cases, the hygiertemia and extr.^t'asatinns which accompany
the tnDammaiion occasion an increase in sixe, and a red or red-brown
coloration of the whole parenchyma of the gland, resemblinjç tlie tissue of
the spleen. Such is the lesion generally seen in the bronchial glands in
pneumonia, or intense capillary bronchitis.
At a more advanced period, the distinction between the two systems
of the gland is not apparent, and, by scraping the cut surface, a very
abundant juice is obtained, as in soft carcinoma. In a normal gland,
twenty-four hours after death, it contains a slightly milky juice, analo-
^us to that obtained from an cnccphaloid sarouin. Hut, in the ca» of
inflammation, the juice is much mure abundant and more milky.
Under the microscope, this juice in inllaminatinn presents numerous
lymph cell* and large endothelial cells, containing one or more nuclei-
The latter cells are swollon, and resemble the mitltinucleateil cells of
the bono marrow (giant cells) ; yet they are not so numerous, and they
contain fewer nuclei than those found in certain forms of a chronic nature,
which will be studied later.
InHammatioD of a lymph gland may continue until small purulent
points are formed in its iiiteritjr, or a single purulent focus is prodnced.
CHROKIC ADBKITtS.
8S3
n«tDorrltage3 nay »\ao occur, And the blood then lufiUretes into tlio
paranohyma of th« hiRamiMl ;!ltiiiil.
The corpiiacleH which arc found în the purulent foci do not notably
diffiT from the Ivmph c«lU ; llicy frv-iiu-Htlj: contain fatly sniniilcs ; Inrj;»
graniiUr corpuscles arc also mccii. An examination of an inliiirnvd
glnnd, hardened iti picric acid and piMiciUeil, show*, in tlic first period
of ihe inSammation («welling and rvilcm»), the cliangcs in tiiv odlo
which have hiNfn alrondy dcMribed, e^ipccinlly tlto Bnelling and the
m 111 ti plication of the nuclei of Uki endothelial colU. The Ktires of the
Cftveniou.s system are tumefied ; îii.ntead of appearing fonucd hy a homo-
geneouii snhAtance, they are seen to be constituted by a fibrillar and
granular material. The fibres hare reached five or six timed their
normal diameter.
In th« follicular substance the fibres are less swollen and doBot exhibit
a fibrillar structure ; they are simply strewn with granules.
When the inflamed lymph ;;lrtnd rcscmblos tho spleen in color, the
capillaries of ihefollicularHyMU'mare very much dilated and filled with red
Mood corpuscles, and helwiN'u the lymph elements which fill the meshes
of the MrMoa there are seen small collections of red corpuscles, or red
conkiisoles arc disseminated between the lymph etemenU.
If the adenitis has fipne ou Ut suppuration, there are «e«n snail col-
lections of pus, irregular lo»s of subAtance, at the marins of which the
ÎiroMM of deatniclion of the fibril:) of the reticulated «Ironia may ho
blloved. Theiie fihrib are swollen, ."iriftened, and finally form a granular
detritus, wliich \s ahsorbeil by the nei^iliboriiij* lymph cells.
Acute ndeimis is Bcldom primary ; it generally occurs in lymph glanda
vhoso lymphatic radicles have their ori-^in in an inflammatory focus,
or arc in eommumcation with an ulceration. It is very probable that
the inflammation of the gland is then <:oiincct«d ttith a transportation of
irritating sulwlances, elaborated in the infiammatory foens or coming
from the cxt^riiir. I'neumonia, bronchitis, soft chancre, ulcerations,
«specially «f the inleittines in typhoid fever, etc., may be ciu-d as ex-
amples of iiil^amraations which cause adcniliii. Adenitis is also seen in
infectiou-i diseaseâ (scarlatina, âinalljKix, etc.), diseasei* in which there
are verjr probably virulent substances carried by the lymphatic pa«-
•agea.
CllKOXic Adenitis, — The changOH following chronic inflammation of
the lym) h ;;landa are simple Gbroua induration, simple caseous or acrofu-
looa de;;oneration, and finally calcareous infiltratious.
FihmK induration of lymph glands occurs frequently în the bron-
chial and inguinal glands of persons advanced in age. uenerallv it ui
accompanied with a slight hypertrophy and ingmentation ; it consists in
an increased thickness of the fuTiviiwcular connective ti«sue of the cav-
emoos system; ihkt reticuliiled tnibeculjc of the cavernous spaces are
double or triple in sine, and at iminy point* Uioy appear fibrillated.
A varying amount of atrophy "f the fultic-uhir parenchyma is obscri-cd ;
even it» complete disappearance may nccur. I'^iually there are found
amail irregular diMeminated areas of this tissue, located esjjecially at the
periphery of the gland.
854
ITMPIIATIC OLArrpS.
Fig. 102.
fUo'l, Ktin«l»t IhS hirTHX In lh«
tKODi. null ilicJiDiluuiiD» lu I lia amu-
Wr «r IL* Ifiniilivld »ll*, X ^i**
l</r«ca,|
In «'^'■A'/'W* perema th< «nKûrj:;oini.-iit nf tlio lympli glands iriitcb
occurs ill €Oti»C(|Hcnce of OKtftri^iil tiifliiiuiiintiuiui of th« mucous membrinM,
or or ciitnneous eru|>tion*, (erminiite» in a
ile;;en«ratioii of the previously liypertro-
[itiied gUnilit. In the Grat stage the Icaiou
apiteara in llie form of Rmall wsx-like
poinlA in the cortical aulistance ami in
the parcnchyma. In the »ccond 8taf;e,
tlioHe points fuse togetbcr and form a
«liitisli, Dpnnui', gnimoua mass, t)ie con-
sistcnco a»il dryncM of wliich vnrv aoconl-
ding to till' nffe nf the K-HOn. When the
iilloriifinii in "f lonj st4iii<)in<;, ihr hv[>er-
trnfilii«d gliinil becofoo» trnusforiiied into
n ilr^', non-vawiilnr cluilky auttiitance,
rcaiUly liroken down, and ta envelojied by
tlie capsule of the gland, which in tliis
cnHe forma a cvstic membrane.
Calcarooua translarmation aupen'enea as a last Bta;;c of thia lesion.
Fre((ucntlv in old persona, tlie gtanda are found to consist of a fibrous cap-
aille containing a eliKbtly lobulatod calculus connected nith iho t-apsulc by
fibrouit filaments which penetrate into its interior. The calculus is fri-
able, or it may have sufficient consistence to rebound when thrown upon a
hard surface. It is «cldoni, however, that the calcification i«»o complete;
gi'iicralty, the ciilciticii glaiuU inclose only one or niorc small nuuHM, ttie
aise and ahape of wbicli vary much.
These difierenl ilfi/eneratiiiit» of lymph glanda may be de«gnated by
«8xy, caaeoua and chalky, or calcareoua degeneration.
Pencilled aecûoua of waxy degenerated glanda abow that it ia im-
posBibk' to separate the reticulated stroma fi-om the degenerated spots,
wherein all the clemciita are fused together into a scmi-tmnsparsnt D»8B
in which the histological forms cannot be distinctly recognixed. The
waxy jwrtions are oolored by piçnx'arniinatc of ammonia.
When fatcvii» degeneration supervene*, there frequently remain parts
of the gUnd in which the wnxy change is still seen, and in which all the
intermediate stages muy bo observed. Ca!«oous transformation coiultts
in the fatty degeneration and molecular Reparation of the elementa re-
maining betwenii the waxy partit. Caaeoua alteration may alM> take
place from the first, in con.tequence of a tatty degeneration. By pen-
cilling a section of a caaeoua lymph gland, the stroma is found more
or leaa perfect ; the Bbrila are thinner and less flexible than in ihi' norma!
glan'l. The caseous, slightly angular blocka separated by pencilling arc
formed of fatty granules (caseous lymph corpuscles), granular corpuscles,
and crystals of fatty matters.
In cbe ehalkji transformation, the reticulated stroma cannot be dîstin-
guiKheil,!in<l the mas» cHcrvesees upon the addition of hydrochloric acid.
The calcareous ureas of lymph glaiKls do not possvss the stmcture of
boae. Kxamincd in thin sections, they arc transparent and present fis'
sures and irregular striie. They are partly soluble lu hydiwliloric aciil,
givinj; off carbonic acid gas.
TBJlOnS or THS LTUPn a).AXDS.
355
Amtloii> DKOR>iERATlOK or Lymph Glands. — This lesion is m«t
witli in coniwetion wiOi oimiUr clinnges lo the spleen, kidney, tirera—
tliBt is, in cwhexiefi willi a nuppuration of long daration. It occasions
A unifonn hyjiertropliy of the gland, which latter, upon section, pre>
sentR over ttie entire surface, or in iu cortical substance, small, aemi-
tranaparent, grftv pointa. By the application of a aolution of iodine.
Fig. 193.
I
t*itpn*t Irm 19^ IrllU lliit ■JjKfedl aonaftl aiilcDlf ((«ant b. *)iuwlnir lli« IQrvBfe*" la tl» «ad, la nJ^aj
fall*. Ilk* ogtlHetawoT ttafwllt.et «lilib Ui« lotpaaol* l*«iupM«d. X*^- ltf»«i.|
these poinUi arc colored a m»lioeanj-red, and somcttmes whea sulphurio
acid is added thejr become violet, blue, or green. The lymph oorpoaelo»
are traii.->rormed into »iiiall, boinogeiicoiiA, atigidnr, and trniif)[tarr-nt lilouks.
'Ilie capilUry vc^tels and arteries undergo tbe amyloid uliati^e that has
been previously described.
Colloid Trass FoitM,wiox, — We have several times met with a trans-
formation of the lymph glands, the cause of which wc have not been
able to determine. It cousi^ts in a colloid appearance of one or more
^(lands similar to that of the thyroid body.
By microscopic examination, the degenerated parts are seen to be
form«d by a «erie^ of alveoli, varying in «ixe, filled with a refracting
«wlMMuee »iniilar to that fotind in the alveoli of the thyroid gland. Tlie
Alnoli are »eparated by fibroiw irnbeculiv, and freijiiently prê»ent at
their periphery row* of spherical cell», some of which are vesicular and
contain colloid sub.siiincc.
ThtA change i^ without clinical imjiortanee, and is especially seen in
old persona; it appears to be dependent upon an arrest of the function of
the gland.
TtlMOlt?. — Sarcoma of the lymph glands, except one variety which has
been named by Billroth adeno-iarcoma, is always a secondary paihologi-
cal product. It« occurrence is not so frequent as carcinoma and opitho>
lioma. It has been seen that carcinoma and epithelioma are propagated
especially by the lymphatic paMsgcs, while sarcoma is gencraliBed by
the bloodvessel system. This is due to the circumstance tnat the alvcoU
of the earcinonia are connected with the lymphatic system, while on tlie
otlier liandf the developniont of sarcoma occasions an embryonic trans-
formation of the vessels, and at times a vegetation of the morbid tissue
inio ilieir lumen.
ITUPHATTO OLAMDa.
^Vlicn a sinrcoma i» forinet] in the neigliliorhoo'l of lymph gtandii, the
CotiliniiouH development of the luinor may cnuse llieir iuvolvetueot. when
their capsules and ^Uinlular parenchyma luav preiwnt â niimencal in-
crease iu their cclU and a rettulliu^ trans forma tioii into sarcomatotis tÎAdtic.
A'lenu-»arco>na. tlie tiosition of which in llie cladflilication of tunwra
has not yet been defimicly dctcrniincd, and which rony be a variety of
carcinoma, is usually generalized through the lymphatic ras»ag«s; it
causes the successive alteration of a chain of lymph glands, a chfti)<^
characterized hy a connidentble hypertrophy of the invaded gland».
It hn^ a» i>nac]ilinli>id appcnmnoc, and it contnins a lurgir (quantity of
Juico. in which nrv seen large «ulU of variou* shapes, po«M«»i»g «nonaoua
inicli-t. Sections of these glands present fibrous traheeulti;, from «biali
^.lU.
Fig. »e.
;**"-?i-^
Call* fnw k Irnplutls rfv«ll> is U*
liver. TkiH* l« ih« Irlt *r* Ihf •>rilla*r|'
Irapk orpDigle* «hiirli «uuxlluiFd lU*
fr*4kar purldf Ihv £f4w1h- T4 III* rfgbl
«tK anntf* Iff llk« lAPftr «l4n»oiiu. X ^^'
(Omn|.
-"■:«
no4t<xiiaaiD. MbowlnE ■ off tlilck*»»! net**-
lum, oiihlD Ihr inaabn Bl wïlrb lbs l/ny-liuld rIU
■njniaptd. XiiDX lOrHi.!
ari»c a fibrillar reticulum ivltli large meshee, the fibres of whtcb aro lined
with flutcell».
C'ir'-iiviiiia nf the lymph gIan<U i« very common; carcinoma of the
niamiimry ^land i» ulmoKt always ai<>»ociat«d with what iit called an
«iigorgement of the axillary gland«. Thefie engorged gland« are either '
small, firm, and of a librons appearance, or they have exactly the aspect
of the primary tumor. u[>on section. F'ihrous induration of lyinpli
glands always precedes the formation of the charactcrbtic canceroiu tis-
ane, as licsL-ribed at page 102. The histological process of fibrous in-
duration is very simple. All the fibrils of the ri^'ticulum, both in the
cavernous and follicular systems of the gland, are hypertrophicd in such a
Dannor that the nlvoolar spaces gradually become smuller ; a few ontir*'ly
^disappear, and the lymphatic passages of the gland are alnioitt completely
obliterated. A gland so altered is, for a certain time, a barrier to th«
propaf^tion of cancer, .\ gland which ha» experienced thi» primary
fibrous change, later presents all the characlcnt of carcinoma, and be.
comes itself a new centre fi>r the infection. When secondary carcinoma
of lymphatic gland.i is rapidly developed, the lymph elements included
between the fibrils of tlie reticulum take the form of the so-called cancer
celts, while the fibrils grailually increase in thickness in order to form the
stroma of the alveolar tisiiue, which characterises carcinoma. (See
p. Itil.)
Tulerclea of the lymph glands present tlic same characters as ia
TDBXRCLES OF TBB LTMPK OLANDB.
»57
•ullHt >Ui:>Dl(ba T^VM** Bbv«la( lb*
•o-ulUt (Uiit-<all. X>»- iOmm.t
Other orf^ane. They an; iligactninutod or contlut^nt, and are ilcvclopod in
ttiv follicular or cuvcmous ityxU'ms along the vessels. To the uuaided
e;« tli«y appear in the form of ^^raiiulntions, gm/, semi-transparent, or
opaijiie at tli«ir c«titre, or in small spats in which arc seen the primary
KraTiulatioiiit, will) ano[)ai|He point oceupyingtliv centre of each. Granu-
uiljoiia in a tiiWrculotiA jçlaiid cannot always be distinguished by tliv un-
aided eye. A hîâtologioal iituily of
the j^land can aloue determiDe tlie
nature of the alleratioo.
From a pencilled section of a lymph
gland aflfectfld with tubercle, it is im-
|)<>Milile to (UBen;;a;;e the stroma from
tlie tultcrcle. Tliosamc««ctiun« colored
«ith pierocamiiiiatc of ammonia, show
iu the peripheral layers of tlie tubercle,
ami Aoinetinwi* at iliittnnt [Kiints, lar^
flat celts, containintt numerous nuclei.
These cells, (Kiitited out by t'oerster,
and afberwarda by many other writer»,
bave been considered as giant-celU.
They are evidently irrilaied and
swollen endothelial cells. In the most
central portion of the tuberculous nodule the reticulated stroma bu du-
appeared, the lymph cells have become i;radunlly smaller; they an
muted together by ft now intorccIlulAr sulKttanccr, »nd fonn nilh it ft
eaaeona mats in which the elements cannot be di^liucily reoj^uixed. In
the centre of the grautilalioii, at the point where the caaeou» degenera-
tion has occurre<l, the celhdar elements become free. A central loss of
snbeiance is thua occasioned, 'ilierefore, we cannot understand hoir
Rindfleisch has been able to maintain that the tuberculous granulation is
formed of raciculaled connective dasuc, since the granulation developed
in diis tissue begins by tranâforming it. In the tuberculous granulation
of these glands, vessels arc found varying in site, according; as they are
located in the cavernous system or follicular tissue ; Lhe^o vessels are ob-
structed by a fibrinous congulum or by white blood corpuscles.
When the granulations are confiuenl, all portions of the intertuedtary
parenchyma of the gland undergo citscous i ran sfomia lion, and the entire
organ may be alTeoted and assume the character of a ^crofulou.* gland.
Id many ca$ea tlie differential iliagnosis between a tuberculous gland and
a »cmfulou8 gland h imfioijiible, either to the unaided eye or with the
mîcro»co|ie. But, when the tuberculous cvotutiou is rapi<t, other granu*
lations may he developed alongside of the caseous mass, so that the
tuberculous matter can be distinguished from a simple caseous dégénéra-
don.
A'ifvhili» occasion» intlanimatory hypertrophies in their different forioe,
inclu'itng caseous dcgeiteration. Oummata of the lymph gland have not
yet been studied.
Etn-hnHitrumatu of the lymph gland* .leldom occur; they may iiivolvo
tlie glands by a progrc*sive invasion or by continuity.
A58
LYMPHATIC «LANDS.
Every varielT of epilhtliom't may be met wîtli in the lymph glands;
tlieir (leve! opinent diffei-s from lliat of carcinoma in ihal tlie first epithe-
lial Dodule usually be;iins iu a part of ibe cavernous lymphatic system,
MndÎDg it* pegs id different directions, while the structure of the gland
is yet pivserved. These pegs are surrounded by embryonic tiaaao and
always present the structure of those of the primary tumor.
UISTOLOdl
IVB8.
350
CHAPTER XIU.
NERVE TISSUE.
Sect. t—Vârinal Kiitftlogy of th« Nerrek.
ymtVSâ congidt of nervu filirn» wUlmiit mciiiillnrv .«iil^^tiuicF Or fil»re«
of R«iiiak, Aiiil iiorvo 6hm witli n doiiUlo contour or mi^'lullated nerves.
The Utter are limiMd by an ext<^rior Htructurele^i envelope of exH'cme
tliinn«M, known as the membrane of Scliwann (neurilemDia). TliU mem-
brane doc* not form a conliuiioi» cylindrical shealli, aa previou.tly biN
Itered; il présenta at regular distances constrictions in tbe form of rings.
These annular constrictions are [^aced upon the large nerve fibres at
Vig. 197.
Fts. 199.
PI». l*7.~X*iT*(ucku1ninf ■ boom in» lmp™BB»>l"a wKli illi»f nitrtu. l^ni' •ileoitotbniltl
r*n* &r* •fvn rnir«c1ii< Kt «arfur;*, TJia nipUitillan of ibfl •mall {vrnw \4 Bwa t^ r*tfr*arv u> IJjb
•trtrtiBX tiaf. TH. Whkle >ali*Utif« or ^rhviiaii. Ttod^rod |r«h«pftr*n( bj glftw^t- ry. AxU
fTlibdrr «hUhn J>ibI SaIht Iba U*»! dT IbA bjtek of lb* inautmr coatlrictluq, pr«Htiu tbv tltljtof
FrVMbio, tllgb pnvtr, {{Stfytnlfw.]
Tig- lf94^€ltratt*tp\ù ntiTVft ftunUoa {nm bfiqrtoT ttaf. Htjih powor- {Okbrfifmr«r,^
distances varying from 1.3 mm. to 1.5 mm., and upon smnllor fibres .8
mm. to 1 mm. : lh*_v limit segment», culled tnti-mnnular fi-'/mi-Hlt. At
the centre of each of tlicse segments, and n|M)n the inteninl .^urfaee of the
invinbrane of Schwann, there exists a flat oval nucleus, tiurroundcd by a
layer of protopla-im. Kunnin;,: through the entire length of the inter-
annular segment is tlio axis cylinder, the esTtential element of the nerve
860
SERVE TieSUS.
fibre. TtetwecD tbiH axis cj'tmder and the membrane of S«hKann, It
by iw layer of protoplasoi, is foimii tlie medullary sheatli.
The iieunlcninia and medullary slieath are organs of protecdon for t
axiH cylinder, wliicb aloue a]>pc&rs lo possess the function of con^lncti
the norvoos itnpressions. Ttic nuiriiivo iutcrchangos occur at the atinuUr
constriction)). (Ki;^. lî'8.)
Tbc iicnc fibres are grouped into bundles in order to form a atm.
Thi.-«L' bundles vnry in diameter from .UôO mm. to 2. inm. ; tlicy are
Hurroiiixlud l>y a Iniuinatcd sheuth similar to tb« A[>onrunHi8 of muscbii.
(Fig, 1H7.) The bloodvessels earryinj^ the blood for the nuurielimunt uf
tile nerves, after forming it network in the jieri-fasciculnr cuniMCtire
tisane, [lass tbroiigb the tatninat^d sbealh of the fasciculi and form a net-
work in the interior of the fasciculi.
Beet IL— Pathological Histology of Ntrvei.
J
C0SOE3TI0X, llRMrmUllAnR, AXD IXFIAMMATIOS OP NsKVES. — Coo-
gestion of norves fri-'juuntly oceurs, eince îl is seen in all ncrros wbicU
lomi a part of an inllaintnnlory fociis, often extending beyond tlic focus.
If the nervt's involvt-d in a wound are disuceu-d witli c»ro, they are
found .-«lijihlly Hwollen, and upon thuir i^urfiwe are wen red liiM» running
longiluiliiinlly which indicate the congestion existing dnring life. 'ïht
nervt'S in wounds, in cases of tetanus, have been principtly exacniiied,
and, by some, it bas been thought that their congestion was the cause of
the convulsion. Hut this Is certainly an error, since congestion may bo
observed in nerves in almost all wounds where tlierc is a slightly intente
in H animation.
In coiigettion of nerves, the hyperiomia can l>c rccognixed with great
fadiity in the peri-fasciuntar vessels, as the nerves are dii>tinct from the
itnrnnindingparld. llypcnemiaof the intra-fascicular Te«éels also exists,
but it is not always easy to recognize with the unaided eye, for it ii
necessary to tear tlie laminated sheath in order to aee the vesseU filW
with blood. To judge of the dilatation of the capillaries, transverse cuta
of the nerve should be made,
In inflnramations of the fingers, the nerves present a congested appear-
ance, and It is very probable that intra -fascicular hypenemia of the
nerves ia an important cause of the acute pain accompunyitig these
lesions.
Congestion of nerves occasions an increase of the blood pressure and
a scrou.f exiidatioii into lh« peri-fiMcicular oonnociive tissue ; frvqiicntly
niilinry heninrrhages are also produced.
Infîniinnatioti of nerves characWriKeil by congestion an<l serous exu-
datiim freipicntly occurs; but su]>purative in Ham mat ion is rare in tlie
nerve bundles. The laminated sheath forms an almost in»iii|>embIo bai^
rier to the difftision of pus into the interior of the fasciculi ; ihia, ncrvea
included within a Buppriraling focus — tlie peri-faacicular tissue of which
is the seat of bypcrœmia, serons exudadon, and even suppuration — frc*
fre<]nontly preserve their properties, I^tho nerves in a purulent focus
arc examined with tlie microa'opc, it is surpiiûng to find the nerve
LESIONS FOlUHriNO THB DIVISIOS OF SERVRS. 361
EhrM itomul. The rosistnncc of the nerve* to the <tiflriL«ion nf pu» into
their fflMiculi is in pnrt duo to tiw hmiiinUxl «heath, «ixl in part to the
nuiaeroiu Anai«tonio8e« of the veiisHs, either in the peri-fftscicular cmi-
•.nrctivi' tiMuo or in ihe iiitra-faMiciilar conuœtive tisauc, which iosureti
tlie imii'nendonco of Uic circulstion.
Inflammations of loii;^ duration and neoplasm» of contînuou» derelojy
mcnl aflect ttie nerveit to a creaicr extent. Suoh cellular new formations
ext«n<l into the peri-faxcicular connective tiiaue and between the laiiiin»
of tlie taroioated tiliealh of the ncn-e fasciculi, separatinj; and compre»-
Bin^ ihom ; the nen'e fibrea undergi) bclovr this point a Mries of changes
ùmilar to those seen in the peripheral end of a divided norvo.
The nerves of poraljKod extremities in chronic hemiplegia, aouom-
paiiied with rigidity. prcBont a very muiiifc»t increase in sir-e, which nay
tn'ivMBc doiiWe that ol the healthy nerve. In auch civsc». tlie norvc fibrea
lia«-e retained their normal structure, the hypertrophy is due only to a
ttliielteiiing of the connective tiiutiic.
I.KSlOKt* Foi,ix>wiNn TUB Divîninx OF Xkrviw. — By experimenLt upon
liùmals, il in [lOMihle to follow the différent phenomena which follow in
C0Dae<(uenee of the <)iviM»n of a nerve. The opportunities to study iheni
I in man are rare, although, in war, wounds of the nerves are common ;
bat the vroiinded soon die, or recover and experience ft aeries of symp-
toms similar to those which may be produced in ftnimals auhtmlted to
txpcrimcnt.
Some uritPis, Foeistor aniong othpre, spenic of the immédiate imioD of
nerves. Vury probably their opinion is based upon men- clinical facts,
«och as the rnpiil ro-e»tj>bli«hment of the fii net ion of a neire after divUion.
Recently, Arloin^ and Tripier have explained thi* by a complementary
Dervoits action exerted by the recurrent peripheral hrancliea; t^ey have
supported their interjiretation by direct exjierimenl.t.
In animaU, divinton or re.*ection of a nerve ii never followed by îmme-
diate union. Therefore, it may 1»; doubted if it ever takes place in man.
When a nerve in a» animal ha:* been divided, the peripheral end
undergoes a special degeneration, and after a variable time, not less
tlian three months, there is a restoration of the nerve and its function.
Tliere i» by this time a union of the two enfls of the nerve, by a pi-ocess
which ii« not included in any of the methods admitted by siir^-ons. It
lit neither immediate nor secondary union, but A special hîsLolo^cal evo-
lution which has not yet been definitely dpteniiined.
■ Four day» after division, in a mammifera, the [icripheral end of the
serve has loat its neurility, and from thii* time ihe de jçene ration liefpns.
When a nerve is destroyed by certain processes, its |ihysîolojçical pro-
perties may disappear immediately, and the defeneration aUo soon fol-
lows. Thus, by the action of water upon a portion of the sciatic nerve
of a rabbit, causing its destruction, de;ieneracion and loss of neurility
may be occa*ioned in about foriy-eisht hours.
fhc dejrenentiion of nerves consists essentially in a se^cntation of the
owdullary stibrtance, which continues until re<;cncni^on be^ns. 'Xliis
H legmentation terminates in the formation of fine };ramdes, which lose the
Hdtaractera of medullary substance and take those of neutral fat, «ucb as
362
HIIVB Tie SOB.
found in the or;^^ism. Reduced to fine fatty graonlcs, tUc medullary
eu)K<tnDCL- gradually disappears, by an intercstiot; proces8,Bcvonil leasts
of which »n not yet kDOwo. From eighteen to twenty-five «lays after
die division, there Btitl remain, in tlio nerve fibres, at ci-rtaïn points along j
tlicir course, oblen;; masses, formed of vyVinderB of the nH-dullary suV^
stance, n few myelin drops and fatty granules, while in otlier \»ni of the
fibre there are only scattered fatty gronules.
A jwrtion of the medullary sulwtJnnoo e«CR))e« from the nerve fibre by J
traversin;; llic sheath of Schwann. The fatly granules become free'
among tlic nerve fihrei*, and form granular corpiucle^ similar to those met
with in the pcri^vawrular lymjihatic aheathii of tJie brain (corpuaclee o£j
Gluge), in simple softening or liemorrha^^e of thiii organ, and which ara^
very probably lymph corpTiscIe§ loaded with Catty granules, and are
again taken up by the lymphatic circulation.
The cells forming the walls of the intra-fascicular vesaels «bo ooiltaia
nnmerous fatty granules.
In about twelve to eighteen days, when the wound of the cellular tis-
sue and intfgnment is united by the first intention, the two ends of tliO J
divided n«rve are joined by u slightly opnline line of cicalrioial liasooi^
which proceeds from tlie i>eri-fasoioular ttsMie of the superior end, to
hk-ml with tlie iwri-fascicwlnr tissue of the inferior end. The easential
pnrti nf the nerve an.i not yet connected, their path is only marked out.
A microtwopic examination of a tran^ver^ne section of the peripheral j
end of a nerve, twenty-one to thirty day» after the operation, présentai
most of the uervc fibres without axis cylimleri); it ]s only in n few fibrca, 1
the diameters of which are considerable, thnt swollen and mispliiet-<l a^ia ;
cylinders arc found. Twenty-five days after division, the nerve fibres
bave therefore lost their essential element, the axis cylinder.
The proximate cause for the degeneration of nerve fibres in conse-
quence of division, i* yet unknown. Wnller taught that the nutrition j
of nerve» depends upon ganglionic celU, which tJirough their connection |
with the nerves net as trophic centres ; thus the nen,'os degenerate I
when they are separated from their centres. The motor roots of the '
spinal marrow have their ti-ophic centres in the spinal marrow itself, while
the posterior roots have their trophic centre.i in the spinal ganglions.
Thus if both roots of a nerve are divided in the vertebral canal, tiie peri-
pheral end of the anterior root and the spinal end of the posterior root j
alone experience granular dcgenemiion. If a mixed ncr\'o is divided all
it passes out of the vcricbrnl canal, degeneration occurs in all parta^J
which have been separated from the centre. When regeneration lui* 00- '
curred.that is, from the third to the fifth month iifterdivision, the peripheral
end exhibits under the microscope slender nerve fibre» containing normal
medullary substance, alongside of degenerated nerve fibres which are
not coinplct^Oy destroyed. Waller thinks that perfect new fibres are
formed in the intrafascicular connective tissue spaces, SchitT, Vulpian,
Keiiiak, etc., believe that it is the previously degenerated fibres which
Oj^in become regenerated and assume their former structure and function.
TtJMons OF TUB Nrkvks, — ^Besides medullary and non-medullary neu-
romata (see page Hi"), fibromata ^seepage Ï'I} and myxomala (see pmgie ]
I0R8 07 TBB KKRV8S.
sns
SO") — which were formcrl; nAmud iiçiirorant», aDiJ are slill by the French
sur^eoDfl ao ile>ignatc<I — nrc met with in nerve», 'litis tiatii«v(ss(.-m[iloyi^d
at a time vhen [MtthologiHta i1t<l »ot recognise the tru« nature of the tumor,
but it should now be rejected.
Ff(t.aoO.
T' f.
N.\:.
■«n» fiuni ihsKUnit. Thainurfuiiniilai iiuu" ■■ in prD>iimi>il bj ihv BDiip1i>iii»',wI>lrh mftlM
4>t>lu^ In tb( Irniph ■)■■«• •utrDutdlDit III* Hcondn'j liusdl» o( »«*<•. Tli* iivtv* »!•> n ur*
Ml la(alt*d. X •"-
Carciiwina nml cpithclionm are gmicrullv stcii In non'es an th« ej£t«n-
sion vX « tumor primarily il«voli)[icd in a ni-ifjhlioring tiseuc. Tlio pcri-
fa»cic)dar crtmii-clivc tiitne i* fimt invudml, th« laminated sheath is
•epanitcil by thft new formntiou, the nervi- fibre* undcrj;o fatty degemi-
ration and di.iapiioar. Ko<>ist<^r \\ti* observ*-!! (inmary CHrcinoniata of the
nerves, which at the beginning; were the «iKeof a lentil, and in developing
caused complète destruction of the nerre. (Fig. 200.)
CRXTRAL KCBVOOS STSTBX.
CHAPTER XIV.
t'KNTKAL KKltVOUS SYSTKM.
Sect I.— Alterations of the UeoiiigM.
TlIK alterations of the cerebral and spinnl tncnin^ca bcïti'; ttnaIo]|;(Nis
they will t)o described together, but thoec ultcmlions pcculinr to the ]ms
mater and dura mater will bo indiciitc^d sepuratuly. The arftchnoid ts
only ail «ppi'udago of those two membranes.
CosuKSTios ANi> Inflahmatiox OK THE JluxixcE*.— Very fr<i)Hent
in the pia mater, the coii^^stioii rarie* in extent, and may be actire or
passive. Active congestion, when intense, causes the dc»({U«auitton of
the cndrtthelium whieli properly conHitiites the arachnoid, «ud t]i« exud»-
lion of (ihrinoj;cnic fluid with white b]ooil-corpi»clea.
In rerft-rtil rhtumntitin the )>ia mater ia congested tlirou^hout itj* entire
extent, and pre^^ent^ patches or t^mall spolA, upon the surface of which
tlie conseation U more intense, and ma^ even go so far as the eflusion
of blood. The spots are rermilionred m color, an if the blood contained
in ihfiir vessela was highly oxidized. The laminse of the arachnoid and
the pia mater so changed show uniform or fusiform dilations of the blood-
vessel», around which are fret|uently extruvasated red blood corpuscles.
The choroid plexus is found to be congested, as is also the vrfum in^-
The tlitid contained in tho large cavity of the arachnoid, in the ventri-
cles, and in the suharnchnoid «pace.4, i» increased in ijuantily. In this
fluid numerous cellular element'' are found, large granular epitlielial cells,
whil« and red blood cor|iu«cle», although it may not he notably turbid.
Whencei-ebral rheumalism baa existed for twemy-four hours or longer,
tho Huid contained in the arachnoid, ventricles, and sub-arachnoid spaced,
is more abundant and is cloudy or even slightly purifonn — appearancea
due to the great number of epithetia] cells aou vhit« blood corpuacles
which it now contains.
Tin; conilition is not peculiar to rheumatism, it may be met wttb in all
cerebral congestions acennipanicd with delirium, vA those eauscd by pneu-
monia, variola, typhnid fever, et«.
Primary r,-r>hrfil mt-iiinyitif is extn^mely rare; it may be caused by
insolation. Inflammntion extenditig over the whole surface of the ner-
vous centres, or curfhra-xpinnl meningiti.t \« generally endemic and
usually occurs in armies or hospitals.
The inoHt freiiuent form of meningitis is that which followa tubercuhMÎs
of the meninges, or tumors of the meninges and of the brain. It ifl
characterized by the presence of pus upon the surface of the pia mater, by
TOBBRCULOUS HBMKfllTIS.
365
tticipTiinj; and opacity of the connective ti-tHuc of this metnbnino. an<l
by the accumulation of paa oorpusclea aroumJ anJ along the vessels,
where the connective tissue is most ahuititanl.
nio ve^seU appear to the unnided eye surrounded by an opaaue «me.
Whi-n Httidicd with the microscope, lymph oorpusclea arc founa located
in the Inose connective tissue siirroumling thcin, these elements besi<Ies
aceiiTnnlale in tlie lymphatic sheath of the vessels, and envelop them as
n cajBule.
The iU'ro-puruI<-nt fluid found npon the surface of the membnine is
someiinteit very thin, aud accumuhiU's in the anterior and posterior sub-
arachnoitl spaces, or it may he tliick and mixed willi fibrin.
When the meniugiti^ is intense, and has Instted several days, the pus
mixed with fihrin forma under tlie visceral arachnoid a continuous, opa<|ue,
yellow layer, thicker in the sulci. The vessels are partly imheddeil in
this false membrane, an<l are seen as red lines covered with a film. From
a section it Is found that tliia fibrinous layer may even reach five mitlime-
trcsinthickneesover theaulci. The false membrane can be removed, and
the firny substance beneath is seen marked with red points. From each
red point one of the vessels which penetrate into the nerve substance has
been detached, and it is found to bo surrounded by a purulent layer and
at times with escaped blood.
In cerebro-sjnnal meningitis, a similar exudation is found around t)ic
^nal marrow and poiiD. The pus occupies the nracliuoid cavity of the
npinal marrow and the meshes of tlic spinal pia mater; but it docs not
peiwtrate beneath the fibrous part t>f tins mcnibraac. The gray sub-
stance of the sjiinal cord presents a pink color to the naked eye. Slicro-
Bcopic examination of thin sections does not show any modifications of
the nerve elements, only a simple hypenemia of the vessels of the pi»
mater, and a few pus corptisclea between tlic connective tissue fasciculi
of this membrane, f^ometimes suppuration is so rapid that the amount of
pus is considerable, even when the symptoms of the disease have existed
oaly a few houn.
TuBKRCiii.nrs StKXfxniTlP. — This is analogous to that (iescribcd muler
purulent exudation, but differs from it by the presence of luherculou*
granulations, which arc generally located along the courae of the vessel
in the pia mater.
Frequently, at an autopsy of meningitis, it is thought that ^e men-
ingitis is acute and primary, because evidence of granulations are not
at first found. It is not rare, in these cases by careful investigation, to
recognise abundant, hut small granulations, which have escaped a care-
Iflw examination. In order to find them, the pia mater is removed at the
points where the tubercles arc usually developed, which arc the fi»iurcs
of Sylvius and the anterior peduncles of the cerebellum. A shred of tlio
membrane should be washed in water to scpamtc the adherent fni^nenfc» of
the cerebral pulp, when they are seen as small whitish granule». This
examination is not suthcient, the pia niater should be spread out with care
npoii a glass slide, when with low magnifying power the granulations,
which could not be recognized by the unaided eye, are now perceptible.
The study of a single granulation «hows it to be formed of a collecùon
866
CSSTRAL 1IBBV0O8 SYBTBH.
of young or emhryonîc ccIU, developed in Uic lymph «hcftlli of Uie Mowl-
vcMols, mui iici^iiboriiig comi«ciivi3 tiwue. The larger gruniilatton*
encroach upon the iiflighUoriug ti«iuo, an'l completely fill up the lymph
sbea^i (Bg. 2(Jl). llie ve«iiel which ia in the centre qT tlie granulation
Kg. Ml.
Nllltrr tnb«dt La Iba p(> outfc. Th* dslUA llo» lotirai* Ih* »fl|l<al (In of Ik* UlwaBIU
ts4iil*. i. TKe lr»)pli*ile iliHlb. T. Tk< blooi] ntHlt. P. t^vU'wUira «C «Umtaii wUbIa Iba
it obittructed by a fibrinous coa-^lmn. Onliuarily the«c collections of
cellit aix.' found nt the bifiiroition of a »miill vM^el, nlicrc the lymiA
ahcath ofier^ a gn-ater exccnl of .^turface. Kinally, it is not uiiuïiuil to
notice ii(>on the »Aii)e ve$;iel ^veral grunala-
doiis placed at intervals, giving to the r«ttcl
the ap|)earance of a string of beadit.
Tho ncoplasoi i^iiito often has the forra of
Ffg. 303.
.~."*
-^
^
a sheath, surrounding the vessel for sooae
extent by a tissue composed of small element»
prosHcd closely ono ngain»t the other, situated
in the pia mater and lymph sheath.
In a gJvM many cases of tuberculous men-
ingiti^, the pia mat«r and arachnoid covering
the iipinal marron are strewu with granula-
tions.
aUfd wtin ïr»ul>r dbdn. n, fa.
bvrev Ur 114*ur. A. WLtte bio^it c<ir-
|>oaeli*- Tbvrr in birv k InbimL*
lUToiTlsa lb* <«*Ml. X *"*•
CilHONic MKsrNdlTis. — This form of men-
ingitis fre<|uently occurs, especially in di/-
fused meninfio-eiicff'hatitiii, an anatomical
lesion corresponding to the aympton» of gene-
ral paralysis of the insane. It is cliarnc-
teriied by a new fomiation of connective tissue, wiiicli occasions thick-
ening of the pia niaier. The walU of the bloodvcMcIa undergo the sane
thickening. 'Diokc- which itre imhcildvd tn the cerebral palp adhere
to this Hubâtance, so that it is torn when the pia mater is rooooved. To
this alteraUou of the vessels is added a proÙferaiion of the connective
TDUOBS OP TDK MBMROBS.
367
•
tisHtir' or Uio brain, ft (UITiuimI îiiterstiliftl «nccpliftliti.t, ani] an atrophy
with pit£mi'iitatiou of tliu cvlU of Uic corliua! \myer of the convolutions.
In n fow rare ciwe» there exiiits a special degeneration of the iralU of the
bloodvessela. 'DiUle^oiijdca'cnWit hy MagnaDumlorlhenameof colloitl
d« se ne ration, appesra to consist iu a chronic endarIeHtiâaii<l periarU'riti».
ïleningitûi of the dura uiacer is Darned jJiu-ki/meninf/ilii. It u always
chronic.
Upon the intcroal surface of the inflamed dura mater ther« are formed
small plevationa or buds, possessing vascular loops, wliich are contiiiuoiu
with the pre -existing; vesesla of die membrane. Arouixl the vc»8eU awl
to »)niv extent ujmn the surface of the membrane i» devi;Io{)e<i a new
fomuition of connective tissue, which con^titiiteK a thin and very vaacular
false membrane. When the IntUT is recent and wry thiu, the blood>
veitMls have embryonic ualU ; they are fnigile, fre'juently nipture, antl
allow tlie blood to escape into the tisaue »f the faUe membrane, giving it a
dee{>-red color. I'hi^ may lie mi»uken for a iiimple spot of blood, if in
scraping the surface of the iluru nmt«r it i.t not detached as a 6ne pellicle.
Aller having removed a portion of the membrane, it is carafully placed
upon a glass slide and examined with the microscope, when then* is scoD
a dense network of bloodvessel.", between whoso meshes exists a new con-
nective tissue containing extravasalc*! red blood corpuscles.
When the false membrane is older, there are found arouml the blood-
resseU collections of rcd-hrown blood pigment, and crystals of hiuma-
toidin. Kn^iuenlly the membrane is formed of several parallel layers.
If, in conscijui'iicc of ruptures of ihc vcsscIji. a (iiinntitv of hhwd cifcapcd
between Uie layers of the false membrane, there is formed a blood cyst,
named hœntaU'ina <;f' the dura nvtter. 'i'his lesion for a long time was
believed to he due to an etlusion of blood ujion the surface of the dura
mater, surrounded by a layer of fibrin which became organised into
a &be membrane, encysting the blood.
Pig. 303.
Tumors of the MBsrsnes, — Fihuomata. — PacoUonian bodies may
be described as hbromaui. They may be developed in great numbers and
form tntc tumors, capable of wearing
away Uie bones of the cranium.
Th«i>e bodies are composed of lami-
nated fibrous ti«!tu«, with flat cells,
analogous \a thojie forming the fibrous
patches of the spleen, and arranged
concentrically (fibroma willi Sat
cells, see page 92). This stnicture
is readily recognized, yet they are
often mistaken for tuberculous granu-
lations ; tliey are frciiviontly incrustcd
witJi calcareous salts.
True fibromata adherent to the
dura mater are met wttli, but they
are rare.
Cgtt». — There «re
found in the choroid plexus small mmuaau. ic/xninm.)
■e frequently
plexus small
868
CBNTKAL MBRVODS
acroiis cysts, which are iJeveloped from the vascular diverliciiln ; fltuilapj
fonnutioiiâ arc met witli in the meflhes of (Jie jiia mater, c^peciall^' neafi
or witliiu the fourth ventricle.
Tulienha. — They onlinarily exist only in the pia mater, bnt they iD»y
bo mot with in the false membranes of the dura mater.
iSaromatn. — They fre':|iieiiily occur in the liura mater, and. tikt
those »r the brain, niuy be of two diflcreiit rarictics: ;;lioms (ncuroj^ii
sareoma) jicencraUy devc1o]R-d alon;; the course of the cejJialio nerves ;
and psammoma (nngiolilic sarcoma.) (See pp. H3, Nû).
Otn-tHinnatti iind JCjiit/ttUomaCa. — These ne«f formations arc very
rare in the luenin^^.
All tumora of the mettïngo.i may perfornte the boneifl of tho craniiitn.
Sect. II.— Alterations of the Cerebrum and Cerebellum.
CVrclirnl ai'^einift is characlerixed only by a p-il-rncps of the norro
substance, without ony appreciable modiècatioa of the clemcntA.
Ckrebral CoxflESTloS'. — Cerebral convocation which bn» continuod
for Home lime always leaves characteristic traces. There ie a very de-
ciiled ÎTijecùoti of aft the vcMcls ; the convolutions are pinkish, inorea«c4^H
in siïe, and closely preyed agaiiut the dura innter, which appears stretched ^^B
sometimes the convolutionn are ao flattened one agaiait the otlier tlinl the
denresâiona separating them are almost eflaced.
Upon the surface of the cerebellum reddish points or patches are at
times met with. The surface of a section of the cerebral substanco
show« the cortical substance to be ^rnyish-pink, and the whitv substance
kto be spotted all over with red point», which corresi'ond to sections of tlv
'capillarie» filled with blood. When these red points are numerous ani^
very close together, the hrain appears speckled.
Microscopic examination show^i in place» a pigmentation, collection» of,
pigment granules, seen especially in the lymph sheath of the amalf
vessel». The accumulation «f red or yellow pigment is particularly
abundant at the bifurcation of the vessels, where the sheath is soparatoa
from the vascular wall by a considerable space.
The nerve cells and clomenta of the neuroglia arc not much altered.
In the colored spots, the nerve cells do not seem to have undcrjç^&e any
change. Repeated congestions, which accoinpiiny diffused nieningtven-
cephaliiis, occa-tion a pi^mMilaiion of the nerve cells. The congeslej
state of the brain may be caused by cerebral contusions.
(EiiEMA OF THE Rrai\. — By (^udema of the brain U implied an acen-
œulation of fluid in the cavitic^t of the ventricles and in the subarachnoid
cavity, accompanied with amemia and a softening of tho fornix. 'Ih«
oidy histological lesion found corresponding to this condition is simply
imbibition of senim by the cerebral aubstance.
The principal cause of oedema is pressure upon the veins of Galen.
The soliening of the fornix which coincides with an accumulation of semm
iu tb« ventricles, occurs, as a rule, in case» of tuberculous meningitis.
CBREBRAI. lIEHORHnAOR.
360
I
Mrlavxmta. — Ti:Î8 nmiitf is given to ft «pectnl ^ncrnl Ickiod, wliicli
i* churacurixei] by th« ftcviiniiiliition uf pi;;ai«iil <^riiniilL-a in the capil-
larii'^ or servntl orgki», «it|ii-ciiilly the bmin nnd liver.
Niimcroiis cupillnrioA are fre<^uoiitly nhntructo'l bj tbeae accamulations ;
at some points tlie sraall xrterieii are dilated in tlie fonn of aneuri^mj
nn<I arc alM filled nitli lilack pigment. This legion often Bupervcncs <lur-
ing low tvpca of intermittent levers in which thorv in considerable altera-
Uon of the spleen.
CKKRttR.ti. IIrmorrhagr. — Ccrcbrallii'morrUagM arc soiDQttmMcauMd
hy chaii'^cs iti tlio blood, as occurs in gravu fevers, in variola, in scurvy,
k-ucocyiha-mia, «le. ; »om«liin'.'» tticy are due to uhan;;i;« in the heart ami
bloo-lvea^el*. Hypertrophy of the heart coincident with an ailieroinatoi»
induration of the wall* of the aorta, inlemal carotid, ftnd branches from
the arteries at the hiue of tlio brain, ha^ been ro^nrded a^ a very cora-
tnon cflutte of cerehnU benvirrlia^e. [n ihe^e oondilionit (he flow of the
hloo'l, driven hv the heart at each ^y^tole, 1.1 Jcrktu'^ or irre;j;ular, ami is
not traiiaformea into a ooutinuou>t current by the action of the elasticity
of the arterial walls. The jerkin;; taipulae of the blood transmitted to
the cerebral eapiltarie.<i is very probably, in some instances, a cause of
dilatation of the small vcasela and of their rupture. But the ci'xt fro-
quent lesion preceding; hemorrhages, and which may he rcganled a«
their proxiaiatc cause, consists in anourijinal dilatations of the soiall
arteries and capillanct^ of the enct^'pbalon.
Two distini^t forms of liemorrliji;^ are met with iw the brain : capillary
hemorrhage, and that where tlie oxtravasatod blood is collectetL into a
mass, or so called focus.
OapiUarjf heinorrhitf/e. or capillary ftpoj)loxy of Cniveilhier, is either
locate^! in tho convolutions or in the central portions of the brain. The
part of the brain where the lesion occurs is soCtenod and strewn with rc<I
points, which at tin^t si(;lit rvtcmble small drops of dark ami con 'filiated
blood. When tlie cerebral tissue around these red points is torn with
needles, it i* found that they correspond to vessels, which may be fol-
lowed and isolated for some distance. Around tlie very tlark red points
the slightly softened cerebrnl ti^tiie if colnred red or pink.
One of thcjie heraorrhapc points» examined with the microscope «howfl
at first only a collection of blood, Imt by careful washing, it it* found to
have ill its centre a capillary ve«el, the lymph sheath of which is dis-
tended and filled with bloo-d. nie red corpuscles have also eiwaped be*
yond the lymph sheath, among the nerve libres which have been separated
and broken. Ksch of these small hemorrhagic spots is therefore com*
pised of a ve^^ol and its lympli sliL'Hih disti^iided with blood, and of ao
int<-rstitiiil hemorrhage into the noighhoring nerve tissue.
A fatty detjeneration of the wall of the central capillary is frequently
ohserved ; the lymph sheath is cimiiderably cnlnrge<l; but the rupture
or fissure through which the blood passed out of the vessel 1» not usually
found, nor U the opening of its sheath recognised through which infiltra-
tion of the elements of the nervous tissue occurred. The shape of tbe
dilatation of the Hheaih varies; it may he cylindrical, fusiform, orspheriual.
870
CEMTHAL XRRV0U8 SYSTEM.
These different forms have been deecribe<I aa diraertinff Annimma of the
CApillariea.
riie nerve fibre» arc torn and Mparated, but, when tlw c»|iillnry
henorrhase is n-cont, tliey have not undorKone any d<.-<;i>n<;rniion fxco|it
tile breaking ii|) of the m*.-dullary «ubstanco into «mall ilrojw. I'litieikts
riX'(|ueiil1v die during tlie fintt jienod of tlie hemorrhage, bul, vrb«n tlirjr
.«iirvivc ttiitf i^tjtge, Iherc is found in tlie circuuferonuc of tbc vsmhIat
idiUlation yellow or brown blood pigment, free or contained i» the whi
1)Iock1 corpui^clcj. These latter &1ho contain fatty granule-^, derived (Ttta(
li« medullary tiubiittincc of th« destrojetl nerve fibre», Tlie blood
ttained in the ililaled vosïteU baa become hro^vn; blood |)iginent may ai
Hie seen in the imerior of the veaiielei or in their lymph aheath.
The small poiutfl of ca|iillary apoplexy are brown or slat«-color. and,
by microscopic cxaiDinalion, are especially characterised by pigoientarr
transformation of the colorin;* matter of the blood. Brown or blacV
pigment granules, and even crystals of hiematoidin, arc found in tlie
white blood eorpusck'S and in th^' lymph sheath of tin- vessels. Tn the
shi-ath and in the peripheral ni-rxc tissue, granular corptisc)e« are seen.
Itoiind lacutijt; n^ Urge as the head of a pin, i>r cyliinlriual «jiacea
rtravcrsed by the altered bloodvessotit, are aUo frci|uently observed in tliia
lesion.
Hnmrrliaiiif t'vn. — .\ hemorrhagic focus may follow Uie nijitwre of
a large artery, or be the rpiiuU of the coniluencc of numerous points of
capillary hemorrhage. The lymph sheath diKteiided by blood may
I rupt\ire ; small loci thus t'oroicd func togiMhor. and intimately mini^lQ
with the cerebral substance. "Capillary hcmorrbagc may then precede
a true hemorrhage ; it is the first stage of a hemorrhage which later
aecimiitlates to form n focus" (Bouchard). Frccpiently there arc fomui
around heniorrhitgic foci, even the largest, a number «f small point* oi
foci of cttpillury hemorrhages.
If the heiiKirrhn^i- necur at. the corpus striatum or tlialamu.i optiouii,
the lilooil may break into one of the lateral vi-ii trie lea.
A Jiemorrhage in the conical layer of the hi-ain near its surface,
gradually siircading as the blood eacajtes, may force a passAge titrovgh
the cerebral substance and uplilï the pia mater, or even break through
this membrane and escape into the large cavity of the araclinoiJ.
The most common location of hemorrhages is the corpus striatum,
thalamus opticus, and more lurcly the white aubatiiDiM. They are also
met with in the cerebellum and pons. Hemorrhages sometimes occur in
Several foci at diflerent times, but are generally unilateral. When the
quantity of blood is considerable, it breaks through into one or more of
the veniricle».
Large extravasation» occasion a tumefaction and softening of the
cerebral mass, and a tlniteuing of the eonvohiUons of the bemisj>bere
which iâ tiie aeat of the h-sion, to iiucb a decree that the existence of
the lesion may he suspected before mukinj; a action of the brain.
When the accident occurs only two or three days previous to death»
the blood and clot are red, as aUo the «alls of the focus. This is the most
favorable time to Study the condition of the vessels which surround the
focus, and to investigate the direct cause of the hemorrhage. For this
CBBBDRAL SEUOnitnAfiK.
871
thomothodofClinrcotand Boticlmnl should beeniploj-od: theintcmitl snr-
faoc of the foctu is c*n'fullj- clenned, tbe clot \i reiuov^iil, uid the part ho
prepared is placcKl in witt«r, which i» renewed irttli cnrv. AfWr « tew
dnys of mitcenition, the cerehnl Huhstnnoe is reduced to ii delrittti, which
maj be washed «wsj bj a flmall stream of water, leaving the vessel*.
These TCssels are placed up»n a glas-t slitlt? aod exaniitied. KrMitieiiil;
there is found a ruptured aneiinHm, belo!i;:îti^ nat to a capillary, but to
an arteriole, whicli ctplatna the )ar;^e sinount of blood and aixe of tlie
fociiH. Finally, there may be rccos"'^'^'!- "" Charcot and Bouchard
have pointed out, a dilated, ruptured arteriole within a lymph sheath,
■too raptured, and, to the interior of the arteriole, a fibrinous clot coii'
tinnous with that of tbe focus — a most palpable proof of the cause of
the hemorrhage.
Tbe places of election for those aiicuriains are, in tlic order of their
fmiuvncy, the thalamus opticus, the corpus Htriatuin, thv cvrebral convo-
luttona, and the pia mater.
These Binall aneurisms, described as tnitiar^ OHeurimH» by Charcot
&D<1 Bouchard, are, according to these authors, due to arterial soleroisis,
particularly to periarteritis. They iiuist ii|>on the point that hemor-
rhage* arc generally caused by miliary aneurisu» and periarteritis, while,
on the other hand, Hofteninji ia mo.it usually connected with endarteritis
attd atheroma. But it Is to be remembered tliat the leaions of periartcritia
and atheromatous cndarioritia are very often united.
In every case of cerebral hemorrhage occurring in old poreons, there
are found, disseminated in the substance of the brain, miliary ancurismt,
which in developing have excavated spaces in the white or gray sub-
stance.
A hemorrhagic focus, formed by the rupture of a large vessel, or by
the union of iteveral small foci, distibcos the lacerated cerebral substance,
tlie nerve fibres of which are broken. The wall of the focus is formed
directly from the cerebral pulp ; it is ragged and stained red by tlie
Mood.
If the patient doea not die immediately after the accident, certain
tnwiifi cation s take place in the hemorrhagic focus. The escaped blood
undergoes the transformation that has previously been described: the
fibrin coagulates, the âuid is {^dually absorbed, and the coloring mate-
rial of the blood passes into the state of rod or yellow granules, which
finally* become bronn, or form crystals of ba>matoidin. During this time,
the wall of the focus becomes smooth; an abundant formation of new
connective tissue springs from the elements of the neuroglia, and forma
a true fibrous membrane, which is visible a month after the oocurrence
of the hemorrhage.
The isolated nervous elements undergo fatly degeneration, and the
medullary substance is reduced to granules.
Secondarily there is produced an inflammation, which terminates in
the formation of fibrous tissue in which are foun'l fatly granules an<l
grannies of hœmatoidin. Thus the wall of a focus may have a consider-
able tliickness, a structtire which consists of connective tissue in the process
of fibrotte organtialioii, and may inclose crystals of hiematoidin, pigment,
872
CENTRAL SBBT0U9 8T8TBII.
Fi|i. an.
"^^M
and (granular corpuscles. After four or five years, or longer, the Tocus
OODtract» niul forms a ciciitrix, irliioh sometimes doc4 not sliow any traco of
eolornlioi), but most frci|iu<iitl^' {iri.^!>ciil.« numerous eryitals of hmmaioidii).
At times a cyst remains, filled with a lemon-colored tliiid iiml limiuvl hy i
fibrous menibrane. These oy»l« are difficult to dilTeri'ii tinte from similar
«y^t* ivliicli are lh« result of softening, of which the metliod of fonoation
«ill he later described.
In the majority of caac», the cerebral tisane surroanding the focus
undergoes a series of moiUiications, which consist in the infiltration of
the coloring mittter of the blood between
tlic nervous dctncnte, and into the lympli
tihrnth». The liittvr now contain irre;;u-
larly sliiijicd red Mood corimscles.f'mnulei
and crystals of liiviontoidîn. The gratiulci^
and crystals are ui<ually conlaiiM^ wittiin
the u'liile c<ir|iniiclrti. It h (o the existence
of tlie*e grannies infiltrating the cerebral
nuhsLnnce or situated i» the lym|ili ciheAlb,
that tlic ncn'oua tissue in the {>roxiQ)ity of
the hemorrhagic focus owes ita ochre color.
This colored zone, varying in extent, is
opa'iue. on account of the number of sranu-
lar corpuecles It inclose* and which are
cont4iined in the lymph sheaths. The
granular corpiwelesfrenucnlly contain [«j;.
mcnt granules. These bodies are notliiug
more than lymph corptiscles loaited witli
tlie fatly granules, which con»e from die
broken down nerve elements, and which enter the lymph passages.
color- é. 3Ctariijft1ic*]]a, ft trw cvulAkn.
Crr<ul>ar haintlBlitlii. /- <>i>fliidFil M-
pllUry.lu luiiiiu t> Htu UMnt'Ii inl
irftjialftE pLguirnl iinl rry^UU. X ^^'
Ckiibbieai. SoFTEMKa, — Cerebral softening may be the result of
emboli, of an arterial thrombosis consecutive to atheroma, or of an
obstruction to the arterial circuladon caused by atheromatous or other
lesions of the vessels, etc.
JCviMir iSoftcniuif. — Fre(|Ucntly, during the course of an attack of
articular rheumatism accompanied with cardiac lesions, or in consequence
of an atbcroniat'ius dc^cncrution of tlic walls of the large vetsvlsi, thoro
suddenly occurs hcmiple;;!». This accident is the result of a» olMtmc-
tion in one of the vessels of the brain by an embolus, the origin of which
is to be found in the diseaitdl heart or large veiueU.
The left middle cerebral artery is more freijuently obtttrncted than any
other cerebral ves.iel.
T'he first phenomenon manifest in the parts which the vessel su|)plios
is a stasis of the blood, followed by a more or less rapid falty degene-
ration of the Civils and nerve fibres. Notwithstanding the constancy
of the histological lesions which characterize theae auocessire changes,
the altered part may present to the unaided eye very varied appearances.
In one variety, the elements simply undergo a slow fatty degeneration.
The medullary sheath of the nerve fibres is segmented and transfortned
b
CRRBBRAL SOPTBMTXfl.
373
Fig. »5.
into small tat drops. Tbfl n«rve colls an alton-d and deatroyed in s
«iiuil&r manner.
An analo];ouH chan;^ occurs in th« protopltum of tli« neuroglia ele-
menu, wbicli arc traiisformed into true graiiulikr corpuMloa. It tias pm-
vi<iiL<l V Im-vd slioiTD thnt uU gmnuliir corpiiwlcs
coai« Trom living cellular clomvnts, v»pcoi»lly
wliiti; blood corpuiwles, nbicb nb«orb fbttjr fçran-
uloti. lliercforo a nucleus in nlnnyi* Touml in
tliew granular corpuwlea, vrben treated «ilb
picro-oarminate of ammonia.
Finally, in tbe ve^floU filled wilh coagulated
btood and fibrin, tbe blood pi^tnteitt h precipi-
tateil, and tbe fibrin beoomea granular. The
vc^eU are now Blled with fatty graoulea and
]ù;;ni«nt.
i'hc repletion of the vessels fully explains why
the bej^nnin;; of tbe process the diseased por-
ID. wbon it is supurficial, is lumclîcd and misod
Dvo tbe k-vL-l of tlic Hurfact' of thu brain. Itut
to soon ait tbn altered elements experience a inie
rétrograde ehitngp, tbe infarctus becomes dry
atid Kloirly ontnict^. Kre<inently the fat is
cltangod into margarin ami stearic acid. Tiiexe
new Bubslaoooa are found as round boilieit, «biob, from their opacity,
resemble granular corimscles : btiteiamined witli a bi^b power, tliey arc
seen to be formed of immeroua needle-sbaped crystals umtcd together.
Fig. SOâ.
OhrAutt wkda MflMilBf it
Iha b'Alft ; •huwIbiT I1)*irrwui|'
Ur (DtpDielH (iMip»uln sf
Abiat, Had Dl trmmlfl*. of
«lileb iIiK KfliBH •aliM*t«a
!• MD^SwI. I>H at («0
ntrvB-Mlli) tn alig *tiilbl«.
Tl,»* rbitiiii* Ib n-ninlnii of Ihsoolnl urttt luliMuict. Iilii(»mniitk. J. Vtiial. B. B. C.
■M*4. llGnUltaii.l
'Hie cerebral pulp, tbua dried and collapsed, is yellowish white, OMi|ue,
aikl firm ; but the solidity is oidy apparent, for. it is readily broken up
3T4
CBHTItAL KERVOUS SYSTEM.
I
bj a Btream of wnter. This mricly i» «.'spccinll v mot witli in the inrnred.
loi'alcul ill tlic ccrolirul Biilwlancc iiciir the siirfiicc 'il' dur lirniii.
The avc-uiiil variety of Irftiwfnmiiitiini of infitrcti is «harnctoriiuid hy '
ft gruniuus sofU^iûng of tlie centre «f ih* (ItMCUocd part, cspeeiallj seen
in the white «ubstAnco of the brain. There occurs » tnie lt<(ueractiftii of
the centre of the infarvtua, fonning a cavity, with irregular wallit. fille«l
with a wliitii^h tiuii] rcicinliiiii^ chalk aiv) irater. Kroin llic internal .sur-
face of the cavity project numerous Rlaroenta, which float i» its interior,
ami which are formed from the >lâbna of the veaaela tliat hav« reaist«d
dcj;;eTieralion, If the wall of the softened focus is examined, th«r« are
found the deiritiis of tiic ncrvoua elomonta and some granular corpusclei).
The vessels themselves are covered with the same fatty granules : hy
ahakin;^ in water, their surface is freed from this granular d<Shri«, and the
following peculiarities are observed. Tliey arc empty or filled with blood
or ft yellow grnDiilftrmH»». The lymph islu-nth surrounding them is dilated,
generally in n very irregular manner. In the iiiu-tior of Iho sheath are
econ ooll« loaded with pigment aiul fnlly gninnW (granular coqiuselex),
and the detached or partly adherent endothelial cell.4 also contain a few
fat granules.
The softened foci may cicatrixe hy a proceai similar to that described
for the apoplectic foci.
A portion of the fluid is absorbed, the elements of the neuroglia which
surround the focus untlcrgo proliferation, and there is formed a limiting
membmne varying in thickness, in which are seen many reescls. Finally,
after one or two yean there is found a true cyst, flllcd with ft transparent
seroug fluid ; the walU of which dilTer from tho^e u hich are cauited by
n)inplectic foci in not containing a notable amount of Mood pigment.
'liie infarcli which involve only the surface of the convolutions, pre-
sent analogous modifications, but les* marked. Sometimes they become
softened and are transformed into a soft, diffluent patch, nresenling a
peculiar yellow color, suggesting the presence of hiemaloiain, although
no trace of it can bo found.
A smsll stream of water is sufficient to completely break down thc«o
yellow paWhe». The si«e of a patch may be so large as to oxtenfl over
the entire surface of a cerebral lobe, Sunictînivs they are dried and
sunken, Jiml uppi-ar hanl. But the résistance is only apparent, for tbey
nmy be lUjiintegniied hy a small stream of water. The cerebral conto-
lutioiis stretched, flattened, and yellow, still relnin a form which recall*
tlieir normal appearance.
S'lftfiihi'ifniiit Athnroma and Arterial T/irtn»l«ttig. ~~lt is generally
the result of atheromatous disease of vesjtels, beginning usually in the
arteries at the base of the brain. The endarteritis causes a narrowing of
the ealibi-e of (he vessels, and the blood stasis which then resulis, oc-
casions necrosis of the cells and nerve 6bres. Sometimes the irregu-
larities of the intenial surface of the atheromatous arteries, also deter-
mine the formation of thrombi which obstruct the vessel. This takes
place, for example, in eonsenuencc of an acute or chronic endarteritis
of one of the arteries at the base of the brain, when prominent elev».
tions or veget«tioni< project into their lumen. These vegetations mar
separate from the wall of the vessels, and, carried along by the circula-
BBCBPHALITIS.
375
tion, bMomc ttio cause of coa^ilat4nii of the blnm] in the vetseb tiioy
partly obstruct. The le^ion^ of the cerebml AiibuMnoe in ihem oa«e«
are sitniUr to those in an infarctun, only here tlie disease of tlie walla
of the veMeU \i primary.
When the legion is recent tliere ia observed a snperficial aof^nin;; of a
pink color, invoking perhaps a nn^up of conroluùona : if iho changes nro
more chronic f/fU-'tc, gift, or A<ir'/, drv and sunken p<U«kr» are present.
In obronic softi-nin;^ of the convoltitiotis. tUeir form is prosorvcd, althou;:^
tliey are ntropliicil in tlie htj^hcat de;;rcc. Tbc pia mater is atdi'tnatoi»
over their surface, and fills up tiic loss of substance caused by tlie
Atrophy.
As in old embolic infarctions, jtoft^uin^ from atheroma is ofteu manifested
in the centnl [«irtion of the brain, by a fnciw fitlid with a Horon* liuid, or
a fluid rvM'iiiliIiii;^ chalk and water. The liiitological tc4io[i« are tlie saoH
as in an infarclu».
ENi'SfllALiTrs. — Encephalitis, or intiammation of the brain, occurs in
tlie form of diffiised or Girctini<icribed iiiflainmatory neoplaaraa ; the latter
constitutin}; al»ceases of the brain.
The brain substance is sometimes red, when the cHange is described as
rtd infinrnnutlorif »i>jy«ninf^ by some authors; again it ta yollow, «lue to
tlie ahumlancc of pus cort>u«cles, this is the white or yeJUio »<>flrni»_i/ of
autliom. Tlic hiHtuto;;iciil process of inflammation of the brain, bait been
expvrimenlally sttiiiied by Bouchard and Haycm. They produced the
diM'asc by dm direct action of forci<;n hodic» or ohoraical subttanccQ upon
ilie cerebral tiamie. They aihrro that in inflammatory softening there
exisUi a proliferation of the cellular element» of the nenro;;lia. It is,
however, very probable that some of the new cellular éléments are white
blood corpuscles from the bloodvessels. The new elements are collected
into masses, varying in size. Accumulations of new elements also are
found in the lymph sheath, bocwoon its limiting membrane and the wall
of the bloodvGSS^-U. ThoHC elcmcnrs are nothing more thau white bloo<l
oorpiucles accumulated in the lymph system.
At Uie same tinH- ihitt the neuroglia participates in the inflammatory
new forDUition«, the nerve elements undergo fatty degeneration.
The iiiflamniiïtory process studied by expertmentii, u similar to pri-
mary acute iiiflannunlion. Thi.i may terminate either in an abscess or
softening of the et-rebral sub^t-ince. The color of the softening may be
either yellow, whiti-ih, or red. due to hemorrhages in the lymph sheaths,
or to intense con^eâiion of the capillaries.
Subacute intlammatinn of the brain may bo idiopathic, and at the be-
ginning occupy the centre of a hemisphere. It may also develop spon-
taneously in the foetus and new-bom obildreii, a form describnl by
VirchoK Kf tlifuted enn;fenital rnrrphalitiê.
In this lesion, acconling to Virchow. the cellular element* of the neu-
roglia, fir»fi pnilirerate and undergo fatty degeneration. Thi- ntrvoiw
«tcnienbs also bL-coniv granular. Ther4! re^tiilu an abiiudant production
of );ninnlar oorpugcles, and a true Hofteniu;;, to which capillary hemor-
rhages give a pink or red color. But the-te statements do not seem con-
clusive, and the appearand; may be simply due to the normal fœtal con-
87 fi
oesTRAL NliKVODS STSTSM.
dition nf tlio hntin. In Iho foultis, a» in olil pvnMM, tliv vcs.'iaU of tk«i
brain pretient granular oorpu»clcs upon tlicir tturfacv ami îii llivir kdvc».1
tïtiniia stieatli.
Kncephniilia U obn«ri'ei] ii])on tiio aurfaee of (ho oonvolutïois in tnb<>i^ ^
ciilous nieninizîtbi and in diffused meiiingo-euMphalttis (general imraijraùj
of tlie insane).
In tnU-r'lr» itf the memn'if'f Uie snrface of tlie convolutioDS, eape.
cially at the base of the l>min. shows conaiderable coneeiition willi pro- j
liforittloo of tho ni-uro^Iia, followni with sot^ning. rhea« facta are
casiljr dcmonstrnttd, and thi- lotion should not bo confounded with IocdI*
izL'fl wdvina of tbo base or fomu^which ts due to prt^Beur« upon the veins
of (lalcn.
firff'n»fil mrninf/o-rniypfialiti» is charm; terixcd by «evoral Icsioni,
Tiiiich uniu-d occottion a peculiar itoUmng of the Rurfacc of lh« cudvoIu- '
tionx, readily fleen »ith the unaided eye.
The pia wnier and the ressela, nhich are itnhedded in the graj sub-
stance, are thickened by the increase of dieir cellular elements. The
Dicmbrane is separated from the brain witli difficulty, carrying vitli it
pieces «f the {tray subatancc, which adhere to the thickened walla of
tlie vessels. Those are frc(|Uontly congested, and there is found in
the lymph sheath surrouiidin;; them ml or yellow pic;ment, the result
of a destruction of the rod blood corpuscles cscajwd into the sheath.
FimtUv, the brain tissue presents the altcnitions previously described —
Dtultifiticnlion «f the element» of the neuroglia, degeneration <>( tl)o
n<-rvouii elvineutt», and aoftening of Itie gray Hubgiatiee. lliese lestona
are limited to the cortical laver or gray substance of the convolutions,
which may be easily removed by scraping, when the white substance U
seen dialinct and 6rm beneath tho Hoftened ^■'av substance. Tiie white
snb^tance has ev4^n been considered more dense than normal, due to an
increase in the neuro;^Iia. The entire surface of the brain is implicated
in the disease, and the cpcnilynia wnlriculonvu is also altered mkI
thickened.
Freijuontly there exi»t «mall transparent granulations, risible to the
unaided eye, prominent upon the siirf'ace of the ependyma of the vrn-
tricU-.t, parliculurly the fourtii ventricle. These granulnlions coiwUt of
embryonic elements traversed l>y a few capillary vesaela.
The nerve cells are atrophied, but the successive lesions, described by
Meschede as occurring in them, coDsistinK first in the granular state,
then pijtmcntation, and finally atrophy, seem very doubtful. It cannot
he said that they do not exist, hut it is very difficult to define them, since
the physiological state of these cells varies according to age, s«x, etc.,
even in the same jicrson.
Af'itysi of thr- lirai». — Ah^ccM of the brain occure in purulent infcc-
lioi), whatever may be it» cause, and in traumatisms.
It niay also sujiervene in consei)uence of oxteitis and nccrOMS of tho
bonCA of the cranium, especially in tuhercuhiurt osteitis of tlio petixnn
portion of the temporal bone and syjihilitic necrosis of the frontal bone,
fhe abscess is connected with the purulent focus of the diseased Wne,
or it is devolo[)ed near the focus without any direct oontintiDi«ation with
ORROaTTO R!)0KPnALlTI8 OR SCLEROSIS.
377
it : tlie dura mater, for exnmple, may remain întaut 1)olwi-«n tlic hImocm
in the brain tinà the dîscivaed bone.
Abscesses of the braïo arc generally amall in mm, nnd are fonowl by
the same procoea as in oilier or^ns. Thcv may be HÎn<;lc or dix^eminate^l
ÎD crvat Dumber^ ihrou^^^liout the cerebrnl Hiib^tance. 'Iliey ar« cliarac-
teriicd by a yellow flnid, «omctimcs ropy aiui viscid, containinjç nuntei-oug
cvlhilar cIiMiients, and inclo««d in n aiviiy ntth irregular walU. We
have obwrveJ i-vverat Bil}:)ce«M>M of the brain in which the fluid was ropy,
inucoiis, aiul coiilainvd granidc* of iDucin not acted u|ion by acetic acid, and
very «iinilnr to miicoaa saliva. I'he walU may thicken by the fonnation of
oouiicclive tiiaiie etemcntii and become fibrous. They at times discharge
extenially, or open into one of tIic ventriclea, or remain us puntlent cynts.
AbwesMflf the ntxe of a hen's «■•{•. bare buen found after death, never
having cauaed pain duriuj; life, or a trace of cephalalgia.
CllBOXic EscKPnALins on ScLBBosifi. — Frequently primary in the
brain, this lesion may also follow an aualo];;otu altemiion which l)c;;ah in
tin Bfinal cord. Two distinct periods or stages nay be ndiuitted as
diaraotcrianj; ita orolution.
In tJic first stajrc, the rapid niulti)<licatioti of the element* of the neu-
roglia give» to the cerebral ti^'^ue a soft con^titence, almnat gelaliuoua,
«iDilar to that seen in liHiiue.<i compo»ed of embryonic elements.
llie secotul »Uigf is remarkable for tlie airophy of the new clemeuta,
and the development around them of numerous Ghrils, vhicb are ex-
tremely fine mid interlace in every direction. Tims, the cerebral tiivno
ia hard, resisting, and if cxnmined witli liï^h magnify tnj; power the fibrils
are seen to form a true nt-twork, in the midst of which nre found atrophied
nervous clemcnU and sniull round or oval nucleated cells.
In the same brain hotli stages of the disease may he found.
Idiopathic eelerosl* of the cerehrum nnd cereWltHm i* met with in
idiots, cretins, and sometimes in epileptics ; most freipiently the leiiioii is
then localized.
Wiieu the disease involves only one or two of the cerebral oonvolu-
tion^, ibey are at first found turjjid, semi-transparent, soft and ^eUiinou9
I» the touch ; later they are small, not prominent, and so bard ^lat the
nail can barely indent them.
Tliis scle)-osis almost exclusivelv invades the convolutions. Tliero is
seen a lesion of the nerve cells in tiic convolutions, which we have several
tiinea noticed ; it consists in u very evident removal of pi^^nont from them.
Tlie cells arc ab>iulntely free from pi^nent, and tninspiireiit, ii little atro-
phied although ibcy preserve their angular sliajw. When tbe legion is
very chronic, and the tissue very hani, the nervous elom<tiits, both cell»
antl libres, are neariy all atrophied or have complotely disappeared.
There almost always constantly exist, in sclerusin of the brain, upon
the surface of the alrtijihied convolutions and in llielr substance, nume-
roiiA disseminated cor]K>ra aoiylacea.
Finally, with sclerosis may be classed the lesions of the brain, occur-
Ttn;ç around cerebral tumors and particularly lar^o tubercles. There
oceura a new fonnation of embryonic tissue which atrophies and is re-
placed by fibrils, exactly as in the second stage of sclerosis. Cbronie
TUMORS or TUB BRAIK.
S70
t]ii*in. Ry making a section thron;;!) tlioir cvntrc> iiicltiHiii;* the
h<)in<* tissue, it is mcd tliat tlio centre is vetlow aiti) soft, Kiel thftt
(•«^rijitiL-rnl Inyor ^rny and M-mî-trDuspnreiic t« ilîrectiy (nititiniKiiis
tJi« c«rebrel tiaiiu«. Tliv portion of bruin wliivli HurrouiiU^ the
1 --fti'l .-Sï;;-;,
I (%t(tif il ib« n^itmrl^. ft. The Hoie «l^ùxol* '«Kj* J«^r<Lp'4rn^, if rurll^xi if ■ ililn •ADI>«a
'-Maqv4 iKhlft*d rvU* (Bru «mMtvA «mang ibp nprvA int'Ha, b Mid^la inuc, DBmn^i (•KcliKÉvaly
MwioM t-j tui< knucha4 «tvuelo iiili«l mlih > f«w r..ouil wll«. il. Iilii-ilv^.u!, luiil/
«■in4by «luu «f f l«4«l&r «fjlt. t. Ç^ntiaX pi^rtkûo ofBidul''. 'ni>"iiUDg irT r^mid ^timaltn «dllii,
ttUrete, preMntd nil the stages of active neuroglia prolifération. !.ar^
«ill «ith Bcvcral nuclei, as well as change» of the vohagIs are met with.
It» TCMoI running into n tubercle is carcfiilly examined, itj» lymph «heath
ùfnund t))Ip*l nith nmiieroui* embryonic elemenis, united together by an
inten:i.']Iiilur nulutaiicc, whi^ii it \» yel in the midst of normal nervous
tlpoiMit*. A« in>on as it penetrates the j;ray, se ml- transparu m Zfiiip of
tbt tubercle, the sheaih suddenly dilates, and tiie entiro vesstd apponr*
>t>re« times its nonnal ûze. Ueacliing the central part of tlie tubercle,
I it H lost in a roasa of granulo^fatty degcnem^on.
Throngbout their whole course m the tuborctiloiis mass, tlic vessels arc
,, ot*tfacted hy fibrin.
JK Tubercle of the brain may appear as a singk- tumor. Very often
HtiViciilouB granulations, disseminated or in gruuj)» arc seen at their
KFnflieTj.
P^ An examination of cerchnil lu)>crvk-!> «itb the microscope revealii the
**M charactcra, tliv same arrungemL-nt of structure, a^ found in tubercles
380
CRNTItAL XBRVOUS STSTKN.
of oth«r organs: sninll edit» united by a gniniUr siih^tanotk
obliWraletl iy fibi-in, (rraiiular <li'gi.>iii.'mtJon of ihe i»lemenu iu [
tral iiari of the tumor, cic.
2<fur-imiifit. — MediiUary or f^n;;lioui<' iteiiromata, tliat is, ttunont
dftting of nerve cells ami neuroglia, hare been seen upou tlie stir&wj
in the mibsUnco of the brain. (î^cc page 1i!7.J
Cj/»l*. — ^Theae oflen develop from the vosscia of the choroid [
the; arc nerous and tranaiiarent. It has already beon seen tluU
may ro«ult from eoftening of « hemorrhagic focoa, or of an «M i
farvtioR.
Sect. in.-P&tltological Hittology of the Bpinal Cord.
CoNOE8T!os. — Congestion of the apinal cord occur* during i
and inflammation of the iipinni meninges, in typhoid fever, in MHiei
of rliciimuli.^iii, in fetirilo diseMes, and in cfimnic lesions nf the be
It is cliaracttinxed by distention of the vesoels. Sohruler van dcr!
has advanced the opinion that, i» every cnse of epilc|>jiy, the nie>li
oblongata is congested ; but tliia lias not heen suflBciently establialie<l|
observations.
IlKMoitRiUfse. — This ledon ib very rare comparatively to that of I
tin; however, it is sometimca met with, and is eluinictcrixe-l by|
_ itrava«ation of Hood into the gray substance. T)»- hemorrlinj
nauftUy seated in the s'^a.y centre* of the conl, and it may exleod
dislauce (IScenlimetros, lùonvillc).
Acconliug to Charcot and Ilayem, Ihis le»on i« always conMCUll
to myelitic.
Si'FTKXixo, — A softening which follows an arterial embolos w m
atheroma of the veasels of Uie spinal cord seldom occurs; the le«niit)
limited lo a re^pon of the organ varying in extent.
The color, consistence, and structure of the softened portion tsrj
ojcactty in the aainc manner as in the «voral forms of cerebral softetiioj
studied above, so that a minute description is not necvMary. Soin«tin>^
the softened part is diffluent, whitish, and opaque, giving upon aectiofii
milky Suid ; or it may he dry, yellow, shrunken, and atropliied; tib"
hardness is only apparent, for a «nmll xtream of water causes a it«parati<>
of the elt-Tiieitt», whicli, mixing with the watt-r, f;ive to the latter a milk
appearance. In both ca-^e:* there are found, by micro3co[ùc examiiu
tion, as in the brain, numerous gr.iiiular corpuscles coming from tli
granular destruction of the medullary substance of the norvo fibres, 4
well as altered veasela the lymph aiieath of which is filled with the san
elements,
tioftoning of the spinal cord is very frequently seen in cases of «oo
pression by a tumor of the spinal meninges, by an osseous tumor or b
chronic affections of the vcrtchric, as in I'ott's disease of the spine. I
may also be caused by a disease of the brain, which ha* destroyed
large portion of a uurcbral hemisphere.
ÏOMDAItr DBâKXBItATIOS OP TBB SPtSAL COBD.
tdart Dkukskratios of TiiK Spinal tViKU. — Wlienever a focu»
lin^ or ticmurrliage or any oxlent exista in tlie uorjiu» »triiiliim,
tial«niu3 opticus, or upon tlie aurface
onvolutinns, the white fasciculi which
I this part to the periphery undergo
with fmty degeneration of the moduU
«tmico.
enbral jicditncic of the dÎHcased sîtlo
Wid alrophicil : the pyramid shows the
rophjr and change iti co1ur, >h> thut the
bod; in atorv t'rominent upon this
oti the opposite aide.
' tlie decusnatinti in the pyramids, it
ide onmaite to the cerebral IcKion, and
Itérai columns of the spinal cord, that
nces of the nerve fibres are continued
Ting extent.
wfu-ned portion of the lateral column
»*<i to iu most posterior region. (See
, fig. 209.)
in hemorrhages or softening of the
itrialum, nccoiDpauied with destruction
intenial capjulc, that these secoiidury
ling lesiotu of the i*piiial con) are most
StMBiUtr <l*caDgni1oH> of iba
fcphLial vorù- A, (/ i," worv 'il»-
(ftltl'U /n.lnM c4*Bor 411 i-\A 1<*«UU
(if 111" rlfhl l>mila|iliarr Tlia
•baJu>l |>i.rlliiii> Isiliinia 111" lom-
OifU at IliD BBft-iiilAr/ .l<-(*itvr4'
Hall. I.. Lnoa(iaai>r Ili4 allr^Lllun
In Llifl I«ri l&tonj ciiliimii ft lUa
fptirïobl njflan. 6'. Tlia viiJiia
l»*lnu Id Lltd d*ttim\ i^gi-m. b"-
Th* ump Jpvivd lu tbv litij.lrbr «n-
ftp^utl card la th« .tvrnaL «nd hkm*
bur ratldu bvlav a \>a\bi wUara
111» io»rn>w WH comi>l"'i!'j' lio-
■tr0^p4bya>ini.n*«Li>ii,1b^kJiiidad
part* rafr^aiMïL lb* lnra;I'.D aaJ
ailrni %\ lUu doacDudluf dauuDfr
IBIl^D.
n the secondary degeneration is con.
le, it may be recognized, upon section
fresh cord, by the unaided eye. In
leaboTO nieiitioncd the white substance
some gray or yellow in color. But
ly, in onler to localité the sea,! of de-
ion, il is necessary to harden the cord and examine it microKop-
intiona mawlc from the fresh cord show, in iheno areas, nume-
àDuIar corpitsoles po«M«»inga nucleus, element'* which are fi-cc or
)d in the lymph sheaths, and an ntrophy or ittniost complcto dis-
■nce of the nerve fibres. In ease:* where the disease could he
back for a considerable time, the granular corpuscles were found
!8 numerous, and there existed a greater number of neuroglia cdts,
■yonic cells, than in the normal condition; there was, in a word,
iDflammaûoD of the spinal cord in these regions.
n the spinal cord is injured by the pressure of w tuherculnusi,
I displaced or destroyed vertebra in I'ott's disease, there gener-
lows a very complex process.
umtion aiul chronic iuflniumation of the tissues which surround
lased verteline and !«piniil meninges are always present. Tuber-
punulations of the meninj^ett are sumetiiiius »i.-en. These influm*
and irritation» by contiguity of the spinal cord explain the fact of
rfreijueDcy of wftening in I'ott's disease of the spine, while in
863
CBHTKAI. HBRVOCS SYSTEM.
Fl«. SIO.
the great^at <tUptaccineDU of th« Tortcbnl cnluuin CBuHOtl I>t
tbe fipinal conl remains intACt bvcanxc ttii.' spinal menin^cA srv nuti
Id i'otr'a dUeaw of Ilio spine, nml in «II taniors eiliier of lix \
hrx nr the awmbnnen of iUv spinal cord, which occasion an mi
tion of tlic tDL'ningvs ami a softening of the
tlio latter i» itoft«i]0(I, whitish and o|m)U«, i
lowish, for a space comspondiog to the at» i
tumor.
When the spinal cord ii thus ilcstrovvd in ai
tncnt, the ymrte of llic npinnl cord Hitnatt^l A
and below undergo changes which, «cconlîii;; Ml
ioT08ti;j;atioii8 of TUrclc, Itouclian), and itUTWlv
»ocm to be constant. They are a* follow»:—
The posterior columns show n ttvcondarv iv
ration almost thn>ui;hout tlieir entire exl«at
fi;;. lili») above tin- point of flofteiiing, while
only the lateral coluniiia «xporieiice a chaRA \
Rg. iW, r, r\ ami r"): tliu alteration cotisuiii
falty dcKenernlioii of the ncrvo fibres, in
atrophy, and ill lti« presonc« of nameroas,
corpusvlefl.
The extent of tbe lesion in the posterior odlti
gradually lapera, Hit «no oeconds llie oorH.to
It tormiiiates in a tliin filnmciu in the niiitilri
posterior part of tlio lioaterior coluiuu. ( FLt. iit^i
c, ^, c", and c'".)
Tlio lesions in the anterior ootunuu toRnîiuH?
a1»o iu the sanic manner as ono descends the totii.]
theii^Sfftt ix nearly (he same as that of degcom-J
lio» coiisecutirc to a dv»trnciioD of a heauspbtf^j
lliat lii, the posterior part of the lateral cotunmi.
A sarcoma which we mw in the nerves of ■ '
horae's tail, had compreit^ed and degenerated tbt
nerves at the point of ibc inmor ; in thia case tbe potnerior eoluiiir.' '
the cord Iind undergone a similar de^-ticration tliroughout it* ' :
Icn._rth. (Ki;£. 211.)
What i* the caii«e of secondary degenerations asocnding in tlie ]-
nor columns and desccmlinf; in the lateral columns Ï It U cerlaiiiiy ,- "
nected to the circumstance that divided nerve fibres beoonK granular i>^
the part separated from their nutritive centre. The experiineiit« of
Waller have shown that if the motor norvcs or anterior root^ of spinal
nerves arc divided, their peripheral [wrtion» dcgencrale, while the central
«mU presenilis their connection with the mrve ccUh of the anteriof
coniiiu of the sptnul conl, remain nonual. The same ex{>erimentQr has
shown that the legion of nerves pursuci an opposite direction when the
posterior roots arc divided; the part of the mots remaining in connec-
tion with the cells of the spinal ganglia is normal, while the M'tiaitire root
which penetrates the spinal cord becomes granular.
Thus, the changes which arc seen in the nerve fibres of the apiual
cord, in these cases, are explained by a separation from tbcir trophio
of lb* |>M«rliii™l"niin 11 f
IU< apUtl lUh'MH In ■
cut) ■! U> Ii>»Ti [igrilua
gt ihn iliinal »(laa. *.
L*4Ei>fi tt tbv pnttrrior
oaluRiB* 10 tb« J0f**l fv-
(inn ilino Ihe pelai ut
«bot* Ifu viifldtlrq, •*'.
c'^. Iff«l'>[i ii'<* onJ Ivo
«xtoDBlto Ta itntpuf IIdo kl
tb« ErivJcml rajlob l«
InvfrHil.
tlicru still remains much obscurity about this fjiiestiftn, enpe-
^rulutioo to tlic gourde of tbo ncrvo libres in ilie Hjiiiinl coUimii.
^Ibsof physiological oxpcrimiinCs made by Viilpiau tn elucidiito
lliqn do not w^nc with tiiosi' ;;ivcn by pntlkotogiatâ. lie did not
• in piwlacing aftcundiri^ tind dv»:t.'tidiiif;
f (lio Bi»iii1 vord I» gutiK'ii-pigi or pij^cotis Viit.:ii\.
JBMmotion of a ««gnietit of llic »|iiiinl iiiiir-
!
I diwMe whtcli wiU be described as t^léron
àe», in which the gray centres and white
M th« spinal oord are irreguUriy destroyed,
ff degciionittoiu of the nerve fibres are
In coticludca (hat the secondary dc;;eticra-
it solely duo to the sv))a,ratioii ot' the nerves
If cells, but ho l)uliovc« that the ciiubnge i»
M peraistonce of the irritation.
^, when an «xaminAtion of the spinal cord
"ffotn persons who have previously suffered
ton of tlie tliigli, or from animais which
I the Dciklic nerve divided, the secondary
}X the spinal cor>l may occur not only in
trior wliifi columns, l>ut aUo in the anterior
'aitd in the celU of the anterior comua.
\)
of 1l*<< itatier^ot «iluiuu*
of lUtf •I'lnal inarfaVF fo a
UBrvatirf a, bon^VltLll d^
i^Mi«B* of fh« |iu*(tri4r
«latiimn b)f lh« Um i-àtl «r
4' Tht «Amu I«]uu HI Ihp
npjtf>r part of iho tnmbftr
eolBiKfliii^DI. if". Lptiun
In IUp dttrvAt HifioD, p*"*,
TIlD hlllDA tPlioh Lb ih«
irrs. — Under this name may he lU'Scribed
( of very diflerent pathologiciii sUiit'*, in
ere exists acnte or chnjnii; intUmmation of
irai elements of the spinal cord. Ily the
tiiiiit is understood not otily true îiitlamma-
kracteriït'd by the formation of new elements, embryonic cells,
H>dcorjiuscies or pus corpusoîcs acallcred between the elements
ird, but also increase of the elements and thickcniri>; of the ueu-
|K>wn as schfoti». Certain atrophies of the nerve olcmonta, nhich
b the only lesions found at the autopsy, ore likewise dependent
luBmation.
Imppuratine mtfelitiê may occur in epidemic Mpînal mcnin;;itis,
BetgUCiKC of niccrattoa* of tho fHicrum which involve the spinal
tcr. The myelitis is then aupurticiul and consecutive to the
M cases of gangrenous ulcorulions in the insane, the puriform
b8, Uie inflamed niumhrunes, and even the surface of the spinal
fiiao the characters nnd odor of j;an;;^rene. This lesion may ex.
kr as the medulla ohlougiita, pons, and inferior part of the brain.
Keltic iil-*c()ifeÀ may occur in the spinal cord from purulent ïnfec-
^ey do in all other organs.
ttKuU nijrr/ifin, non-suppurative,iâ at times diffused, tnvolviuj^ a
ible extent of tJie axis of the ;;ray substance of the spinal cord
relitis) ; soiDetiowa it is localised. The histological Icfiionsii
I
S84 CENTRAL NBRVOITS STSTSX. ^H
botli varietiE-» are the name m in encephalitis. The modullarj ixAtll^r.
U mtUeaeA ; it^ calor is whitiah. (>ink, veltowisli. or chocoUh'. ■K-ptiJ'
upon the congeatinn of the vessels, «nd aanben of rod corpuHcli-s cHifl"
into ihc Hoflciied part. Points of eochjmoaos Kiul (iMteniivd vcmch iM'
fiotuetiuiea be H<>en with the unaided cro. Ity luicrocKOpio CJUunÎH^B
there are found ^rnmilar norvc litire», miini.'r'>us whito blooil corpdli^|
aomu normal others filled with liloud pi;;aK>nt, fatty grmitul«», wad gn^H
corpua'Ws. The «ame clemcuu cxint in tlie poriv»»oular lymph sh|^H
This foroi of tiiyvlitis, when it is diflfiiMil and general, exteiuU fi^^H
dislnncc from ihu cc-nlml inaits «f the npinal cor>i. and, accord^^l
CliarcotwidHaycm, iliii intheiti'ca.-'t^sihatiiciuorrhaKCHof tJic spinali^l
occur. It in certain that in the conl an in the brain, sofWnin;^ "^7^1
the cause of hemorrhage.*!, but it w difficult to decide whicb ie the- prim^H
le^on, for primarr hemorrhaj^H also oocauon a softening of tlie tiJifl
and infiltration of the neighboring tissue with whitv blood eoqMUclH
pigment, and granular coqjuscles. This variety of the disease ts rajnfl
fatal. Ix)calixed myclitif may present further modifications, suÀH
complete de genu ration, separation, and atrophy of thv partd wliere ^M
lesion is located, in which ease it exactly reacmldcA limited clm^|
soltenin^. B
The leëion» ilescrilied i\» chnraelvriittic of myelitis, the importance «H
nature of whieh have not yet been determined, are :^ fl
iitt. Hypertrophy and varicose condition of the axis cylinder of ifl
nen'e libres, observed by Krommann in fielerosii), aftârwahU verifid |H
several authors ; (Charcot haa seen thi.^ condition of the axis cyliuJenH
recent scute myelins. H
2<1. A coloesal hypertrophy of the ct-lls in the anterior comua of tH
spïtinl uord, observed by Charcot in the same conditions, and appurifl
to be due to the same cauac. '
3d. Foci of granular degvnerntion, described by Ijockhart Cbiie,
con^iiiitin^ in irregular ma^w*. ivliich seom to come from a coagulation vf
albuminous fluid ountaining >;raiin1es. These masses are contained ^
irrt'gular cavities excavated in the iipinal conl. As these cavitic» lA
aeen especially after hardening the cord in chromic acid, and as, oo lIP
other hand, the least traction is sufficient to tear the medullary fibrci.it
seciDS to H9 probable that tliey are produced artificially.
4tb. The numerous ami excellent works, which have recently h*»*
Îublishcd in France by Charcot, Vulpian, anil their pupils, l'révos*
oiïroy, etc., demonstrate that there exists an atropiiy of th« cells and 0
the anterior comua of the spinal cord, in infantile piiralysis, in i^uort
spinal parulyinis of the adult (Duchenne). and in pro^t«sive mnscuU
aCi-ophy. Charcot is inclined to believe that this atrophy \» due lo
primary myelitis, limited to certain groupai of colls in tite anterior connu
which opinion ha:« been ado|ite() by Uajardin-Itoaumetz. Labonle, Kng»
and Dainaschino, regard infantile piualysis as caused bv a myelitic wit
proliferation of the cellular elements of the neuroglia. l'Ile» very inl«
e»tin" observations do not, however, seem to us sufficient to eatablbh i
a positive and definite manner the jiathological anatomy of the precef
ing diseases.
Jnterttitial Myelitia or Sctervtis. — In this variety of myolitis tbc ce
60LBBOSI8 OF TDE POSTBRIOH COLITHNfl.
SB&
Clunai.l
elriuents oC UlQ neuroglia nre iiicroaiteil, this tb»uc ûi llitcltened ami
rvt tihre* if» iecotnlaHlv «tr>>j)hii.'l. The lesion occurs t'ii.<(Ut-iitly
i|>tiial corâ, ati'l h limili-ii to cciiuin rej^ons, giving rise to specifti
m» ilefKïiKlîug ii[ioii tJie localioii of tlio disease.
!iua »flrrotia of the potterior column» Is the anatotnical lesion of pro-
'vc locomotor ataxia : i/i»»emtnatf<l telerogi» (^eelêroen en plaiiucs)
larly (lisiribute^t corresiioiiiis to pnm-
, with contraction or relaxation of the ^''K- 213.
kimI trt-mtilin;;», etc. ScIero§i« has
fc'iiiiil localiicvd in the lateral columns
«w, httfvtl flrr-ttK («i-léfoiv rufxifie'').
Upon the siirfuGD of llio 8|n»al eord in
Bif iivuco of a chronic m«iiiiigiti» (^sflérfiê
ttlnire).
iScLBlIOtflSOFTIiK I'niiTKRIDR OOLUMNB. —
ay dri/^ntntli'Jit of the jjosterior col-
^«een in all CRiies of uron^Hsive loco-
»bur ataxia, ia cliaracteniwd tnacroscopi-
lly by « gray color and n peculiar trans-
lacj of tlio posterior eolumna, ïlie pia
■tvr IS almost alnaja thickened, and very cloflcly adherent to the dis-
Ifuvl portions of the oord.
Two different stages nmy he distingui^hcd in the course of this alter-
Itlûm.
At the li«(;inning there cxistj> an increase in the number of the nca>
'rtglii dement.*, «nd the diseiwcd |*art« appear slightly tumefied ; in tho
(Kood sta;;e there is atrophy of the cellular (■lenieiils of the neuroglia,
lhirl:cinnK of its fihroos tisane, ami atrophy of the jjoslerior coluimia.
A small portion of tho scmi-lran§parent gray suhstance of the dis-
eutd part prepared from a fresh cord, after teasing in water, présenta
■ ikc first sta^ numerous embryonic elements possessini; a round or an
ml imcleus. These cellular elements arc imbedded in an amorphous
pintttar substance. The nerve fibres are preserved, as also are the
wrrc cells in the anterior an<i posterior coniua. Tho vessels in the
fiieaited region hare tbcir lymph sheaths dilated, and tilled with granu-
lirlymplt coqmscles.
Thin transverse sections of tho cord, stu<lied microi*copically, sliovr the
Biero-lateral columns healthy, and the posterior columns altered. In
iit fonner, the nerve libres are seen to be regularly separated from each
cdtcr by their partiticma of neuroglia and hy tho vessels. The neuroglia
potenta at interrala a few «nail cellular elements.
In the posterior colnmns, the nerve libres vary in diameter, some
ut Tcry small, although still retaining their axis cylinder and sheatli of
udallary substance ; others are normal in slxc, or larger than in health,
•od their axis cylinder may bo considerably hypertniphied. Itetween
lU aerre fibre», the nenro^lta presents linear or round collections of
Miill elements, the nuclei of which are alone visible.
Ufigitudinal sectioiu of the suioal cord, where we are able to compare
as
386
CENTRAL KBKVOIIS EVSTBM.
Fig. 213.
_Jh(i ,pMt«rior colamns with the anterior colunini, show the Mme I
''fmn'detaiU.
Id » luoro advaiicvil fftiigc of tlie lUsense, the postonnr cohiniM|
fused togclhor bjr the fonii«lioii of now eonrwctive (issue in thej
lunler, irhîcU, in tiie nonnal eomlition iJipfl
tli'iM fiaxurc, anil tieparalcfi them one fmaj
oilier. This connective tissue acte w civ
tinsiie, and intimately aniu>s tho two cota
which nreviouHly were only in cuntaet
each other. From thiit fiiHion as vieil iiaI
the considerable utrophjr which nil the'
filirca under^, there result a very lu
atrophy taii shrinking of the entire pwd
coluiona. so thitt the posterior comua of I
gray 6uh«tAnco ar« brought nearer togoti
(See fig. 212 )
IVansvefite sections show that tlic noil
fibres are fleparated by n tissue whicli
low power appears ;^nular, but with hig
power it is found eomposed of very fine interlacing fibrils, with a fo»
atrophied nuch'i ut îiitenals. The nerve fibres art- thin, hut tliein
cylinder alnay:' exint^. By some authors it is ninintained that the
eleniuiib) have disapiieured when the sclerosis has reached this suge ; I
Pig. 2H.
)l(il«ni>l* ut Spinal rnrd. 1
III* ^iiL fiiuUtit tli# barto-fllirH-
Ai'ptarkBia of (ipllLjirjr b1uudi»ul> In >o rarlj iUi(i of ««IefuIi. a. 3C*a(lat*f h<«A*1
vhlch *It iinl rnufh hl[^^ft1. d. Inftvw khJ pioUf^ntlf^a uf (hq ^■nruiml** «1U, lllfl p****
they arc always present, and may be demonstrated In sections coloi
with carmine ; when tho lesion is far advanced, the fibrci^ niay be
to their axis cylinder, the medullary sheath haviD<{ entirely dtsapf
A peculinrity of these scleroses consists in a thickening of Ûie
of the capillaries and small vessels. This thiekoiiing is due to a |
liferation of the elcnicnt» which constitute their walls; they beet
rigid, and their calihre is diminished. .\t the same time, nun
coqiora ainyliida are otiserved in the' neuroglia, aloiijpnide of the rf
and especially beneath the fihroits membrane of the pia mater.
The pia mater coverinp; the poatorior columns also participât
the chronic inflammation ; it is thickened, and becomes closely adhci
to the spinal cord.
The posterior roots of the spinal nerves have become transparent
80 small, that, instead of being donblc the sise of the anterior tool
TUMORS OP THE SFIHAl. CORD.
8fl7
' are in the ««mial condition, the; arc only half the size, or even
III locomotor ataxia, the lesion is not alwava liDÛtotl to (he posterior
m; it soRMitinics riR-roacheB a. little upon the conti^oue cortival
inn of the liiU'ral vottimnii.
» gctMTnlly in the luniWr rcj^ion that tlic lesion of tlic posterior
■nti it ol'lcft and most advanctril ; the ilorM»! nml <!t.-rviciil rc;nons
naualljr Ioha diweiMeil. The tuhnTvnhi 'jiiii'lra^aninii, th« oplio traebi,
1 Uie optic uon'es thenieulvcH mny he iitrojihiiul, ^tayî^h, and :<emi-lraiis-
ent : at times, oven Uic hypoglo^^l ncnc inuy i)r«;.iciit the itaruc k-s'iuiii>.
n«. 2IS.
Ftj. aiG.
Mm Uol xtMotlm. |Cftar«al.| lialiteil c&HjiIion »!■• oribfi •plml Mil. ■bailing
1114 tartuiit •Uq«a vf âi<A:cn«rmili>D, a >«nn«1
b»rv« cet], TUh lU pral^ugBlKina and oqrl«<lK.
f- A HDrt* CDU aim «hmAlbv Ita bf BUflipi, bill tUm
latter irn iitmpbLcd, Ami tbo hud^ uf Lb« call ki «o
be ««ru. i^/.d. K»F*« «ellt »1t11 wore feTi^:***!, r,
ff^ XffV'' it*1Ja m^irakTlproil ; l^ti> hma I^itt Ibcilr ^iv
luuifetiou*. ''. 1 iifirfi «ell lu <hp IibL «EAff «r i1*.
(■BmlluD, Ibii «ruunlit dIidieoi Ii bicn^Lnf uj-iula
■mall (Mgnesl*. Iligb ftyrti.
I Wb symptoms of locomotor ataxia may be due tit a k-Mnn confined
iWirely to the posterior columns. In an observation made hy i'ien-et,
ft«*e columns vrcro only altered in close proximity to the posterior
Minna.
The cells of the ttpinal f;aiiKlîa, and those of the gray centres of the
ffin»! conl, »[i])ear «hwlut^-Iy normal in the majority of cases.
Hilh re-'ptcl to the white columns of the cord, (iit*eminiUe<l tcfcrrttit
fKl^M en plac()iies) and hilrrâl trUmfit (sclérose rubani?^) arc his-
tiidgically identical willi the above-ikitcribfid lesion, the only dilforonee
tbtingtlie pitrts involved. [In lateral sclerosis, in diâseminatcd seleroois,
[in progressive muscular atrophy, and in some other spinal lesions, the
Hrre cell» of the ^ray comua are cither primarily or scc"iiihirily '" "
i!«d. Soiuo of tliese nerve-cells onder-jo » cloudy swelling. « hich ifl "
1 by pigmentation, and granido-fatty degcnui-atiou. The final
8TH
CBNTUAL NERVOUS 8YS7BM.
pncf plinlîtis is s«cn as a concentric luno, fn.'<(uetitljr of considerable tliick*
rn'SH. Dtirrouiidinjj ccrcbriil tiimurK.
Fig. SOT.
JMOBS 07 THB Bbais.— .S'orwBiata. — These oecor in two tUstioct
ioa,lbu «nmc n» in the méninge*. Tlie neuroglia sarcoma (;i;1ionia),
ami the angiolithic sarcoma (peain-
tooma). (bee pp. ttS, h5.)
Fibromata. — FibroDuta of tUe
brain are rare. Wu have ha<l Uic op-
portimilv oF etuil^viui: onv, wliioli wag
lou&ti'd m the white «ub^tatico of (lie
ri;;bt verobrnl podunclo. It watt ex-
tremely han], ancl composed of fine
waving fibriU.not changed by aceli*
acid, ami »na\\ nucleated cells.
A Hfitniii, [larl of which was os-
ûliei), bas been reported hy Benj
mil).
Cixrcinamala seldom occur in lh«
brain ; sarcomata haro frc()aoiitly
been confounded with them.
Wc have observed a fMjiUhntta of
wneidcrablc eize i»itiiat<'d upon the
cpcndyma of the tliinl vcniricto, awl
projecting into tlie lateral ventriclot
through the foramen of Monro. Thi# budding niasji, engorged viUi a
milky juice, surrounded by softened cerebral tici^ite, could have been mi»-
taken for a carcinoma, ft consisted of a cautitiower-like (çrowth, formed
of veswts more or less dilated, covered with pavement cells, which in
desqu a mating gave to the fluid ite miiky appearance.
[tS^/iliUitic altmitiim» of the bloodvcsHols in the brain have already
been mentioned (see p. 8H1), Clmrcot and Gontbnult describe a «yphil-
ttic teaion of the brain aulutunce which cH^cntially coiwist* in tlic forma-
tion of <liÂ<>Gmiija1ed or confluent Mmall nodutv», either u{»n the «urfaoe
or in the depth of the nerve ct'nlre*. Tliese imduief umially jirenent
three aoneti. the histokt^itnl chai-flcterii'tii-» of which will be understood
by reference to fig. L'U». The initial lesion Hoems to affect the con-
nective tissue corpiisL-lcs of the neuroglia. They first hypertrophy,
then cither fatty dcgoiiemte and di-iappear, or, after the irritative hyiwr-
Iropliy has re.tehed it» acme, the progrciuivo alterations comnio» to irri-
tated connective tissue elsewhere may «u|ier\cne, vîï., ciaitricial on-
traction, etc. These jinthor» «re not [rositivc whether there is nii nvtunl
new fonnation of hrunchcd cells of the ncur"Ldin, but they declare that
aueh cellti are proMent in gn-atly iiicreused numbers.]
TufH-rcltK.-^Ui external appearance, tubercles of the brain resemble
Barcnmalous formations. Instead of being small, like tuberouloits granula-
tions of other organs, they may atl.iin ttie sine of a pea or even thai of
the fist.
Their external characters are generally marked. They arc hard,
compact, and so blended with Hin brain tissue tliat it is not possible to ena.
IB-
TUHORS OF THE BRAtX.
379
•ImM Uinb Bj mtking a Miction Uiroiij;h ilieir uvnln iitclmlin); the
«omonfioft Mmuo, it U 9u«ii tlmt tlio contre m yvllow nml aoft. wkI thkt
[their ]>eri]>lieral layer iiray nml .■>onii-traa'4{iaretit îfl ilirwtly contiiiiioiM
ntth Ùie cerebral u»<ue. 'ilie portion of brain wUch surroutuU (lio
SrrtilUlfe UtlDBor ili« mm* »Blrw. J. BlfmraH rrom B. a. Bnn«b*d ctUt. with •>li»i«l,
ti-lf«ttlnff lo ihfl upitmrll*- A- Thd avmn ■(^iDi'ui* Fmly itaj|*b#r*t«d- AT- Purllnn *it « Ihtb «p^lfio
I^Evq^^^'U^B^I^f pl>^"'^''i**iL'°^^lii th*^ pi>Ttrt oMtt" br4La- <T. Kk^fibI i<ia« ntirlf ûoni^il Ja vtiLfh
. nUrc«t nialllMl nlla trr •uturni anjouK ti^" iix"* luhsi. k Hlddli luuc. iliiiml ricluilitly
0OT«*4 b; ft uiiua «f rrtbiUâr nil»* t- Ç«ulral iigrU^iiuf ovdulv, cgiiakBilDg of Fvuml ^niablv otllB-
tulwrcle, preacnts all the stageii of active neuroglia proiireratioD. I^arce
cells with several nuclei, aa ueU aa changea of the vesaela are met wiw.
If a vessel runiiiuR into a tubercle is caret'iillv examined, its lymph sheath
' is foiinil filled witli numerous embryonic elements, united together by an
intercellular substance, when it is yot in the midst of normal ncn'ous
clemenlA. As soon as it penetrates the gray, aerni-tranaparent zoia' of
the tubcrclG, thu sheaih suddenly dilate», and the entire vcHoel uppears
three time» its normiil «hf.. Keachinjz the central part of the tubercle,
it Is lest in a mna of granulo-fatty ile gene ration.
Tliroughout tiieir whole course in tiie tuberculous mai», the vessels arc
ohslrticteil by fibrin.
Tubercle of the brain may appear as a jiinj^le (nnior. ^'^ory ofwsn
tuberciilous granulation*, diiseminaled or in groupa are seen at their
periphery.
An examination of eerehral tubercles with the microBcopo reveal» the
Bame ctiaracter», the same arraiij;ement of structure, as found in tubercles
8R0
CBMTRAL NBRVOUS EYSTEU.
of Other organa: small cells uDtted hy a sramilar sulwtance, rcsseÎB
'obliterated bv fibrin, granular degeneration of the «Iem«»iâ in the cen-
tral part of tn« tumor, etc.
yeammata, — MaduUarjf or ganglionic neuromatA, that is, tnmora con-
sietinj; of nerve cells and nourof;li«, have bo*n eecn upon thv «irfaco anil
in the snbotancc of the brain. (Sco page 137.)
Cfftlt. — 'nicsi- oftfn develop from the vt-sstlg of tlic choroid plcxua ;
thc-y are Hcrou« and (riuH|iarei>t. It ha» atn.Midy bc«n «con that cyoU
way rv*uU from sofu-ninj; vf a bemorrliagic focus, or of an anja of iu-
farcliou.
S«t. in.— Pathological Hiitologj of th« Spinal C«rd.
CoxiîEgTiox. — Congestion of the spinal cord occurs during oongestioo
And inflammation of the spinal meninges, in tvphoid fever, in aoae casee
of rheumatism, in febrile diseaaos, and in cïironic lesions of the heart.
It is charactcriEod W disu-nsion of tho vcawls. Schrtilcr van dcr Kolk
has advanced the opinion that, in every ciiae of epilepsy, the m«<tulla
ohloiigata is congested ; hut this has not been eutEciciitly eslablishwl by
ol)«ervulions.
IIi:uoKKnAtii;. — This lesion is very rare comparatively to that of the
brain ; hnwevor, it it) sometime» m«t with, and in ebaraeterisiod by an
extravAjiation of Mood into the gray Kubstancc. The hemorrhage ta
u»na]ly seated in the gray centres of the cord, and it may extend some
distance 0&i^^"timctrcs, Liouvillc).
According to Charcot and Ilayom, this lesion is always consecutive
to myelitis.
SoFTESlxo. — A softening which follows an arterial emholu» or an
atheromu of the vessels of ttie spinal eonl seldom occurs ; th« lesion is
limited to a region of the organ varying In extent.
The color, ooii»i#tenco, and !*tnicture of Iho Roftenc>d portion vary
exactly in the same maiiner sis in the iteveral forms of cerebral sol^niug
studied above, so that a minute description is not necessary. Sometimes
tho softened part is ditllueut, wbîiish, ami opai^uc, giving upon section a
milky fluid ; or it may be dry, yellow, shrunken, and atrophied ; Uie
hariiness is only apparent, for a small stream of water causes a separation
of tb« «lemcnta, wbiuh, mixing with tho water, give to the latter a milky
wpearance. In both eases there are found, hy utîcroscopie cKamina-
tiou, as in the brain, nunieru\i» granular corpuscles coming from the
granular destruction of the me<Uitliiry sulistance of the nerve fibres, as
well as altered vessels thu lymph sheath of which i» filled with tlie same
elcmenW.
Softening of the spinal cord is very freiiuently aeen in casea of oom-
pression by a tumor of the spinal meninges by an osseous tumor or by
chronic affections of the verlebrie, a» in I'otl's disease of the spine. It
may also be caused by a disease of the brain, which kaa destroyed a
large portion of a cerebral hemisphere.
8S0OSOART PEOKSSRATtOIf OF THB SPISiL COHO.
881
Fin 20».
I
Swo.vpAiiY Deobnsr.ition of the Spinal Cord. — Whenever a fixjiw
of Huftcnin;; or hfitiorrliiiffi- of nny vxtc-nl cxUbi i» the corpius suialuni,
in Uii' lliAlamus o|>ticiUi or ujwn the surfuco
or tlio ooDirolutioiii«, tlio itU'Hi: fnxckttii whioli
go from this pArl to tiiv iwriplicry uiKlergo
atrojihy witb fatty <lej;ea«mtioii of tli« miMlul-
larv i4iih^tiinc«.
Tlie cerebral peduncle of the «liiiiMiwd aide
19 gray and alropbied ; the pyramid ^howd llie
same atrophy and change in color, i^o that tlio
oliv&ry body îa oiore prominent upon this
than upon toe opposite aide.
After the decussation in the pyramids, it
Û Uic *i'ie opposite to the cerebral li-sion,and
in the lateral columns of the «pinul eord, that
the changes of the nerve fibres are continued
to a varying; extent.
The softened portion of the lulerni colttmn
Is continod to it<4 nioitt posterior region. (See
It i:^ in hemorrhages or iwftening of the
corpiifl Htriaturo, Rccompanted with deistruetion
of the internal capaule, that the» secondary
dciicending lesions of the spinal conl are nuMt
tniirked.
When the eocondary degeneration is con-
«ideniblv, it may he recogiiixed, upon section
of the frfc<h cord, by ihe miaidcd eye. In
areas above mentioned the white sulMtunce
become gray or yeilow in i:oh)r. lint
_ 'rally, in order to localîxe the seat of de-
generation, it ia necessary to hanlen the cord and examine it microscop-
ically.
i'roparations made from the freah conl «how, in these nreiw, inime-
rouB granular corpuscles possessing a nucleiLs elements which are frew or
eoDlaincd in tlic lymph sheaths, and an atrophy or almost complete dis-
appenrnnce of the norvc fibres. In cases where the disease could he
traced back for a considerable time, the grnnular corpuscles were found
to be less numerous, and there existed a ;;rcatcr niunbcr of neuroglia cells,
or embryonic cells, than in the uonnal condition ; there was, in a word,
dirotiie inflammation of the .spinal cord in these regions.
When the sphial cord is injured by the pressure of a tuberculous,
carious, displaced or deKtroyod vertebra in Pott's di^ea^, there gcuer>
ally follows a very complex procu«^.
ï^uppuralîon and chronic iuflantmatiou of the tUsuea which surround
the diseased vertebra? and Bj>inal meninges are always present, 'l^^^".•r-
culous granulations of the meninges are sometimes seen. Tlieso influm-
matioDs and irritations by contiguity of the spinal cord explain the fact of
the great fretj^uoncy of softening in I'ott'a disease of the spine, while in
■lilaul vurd, t. V t," war* ol»
iiijiplt tr-an 1 riiia of cb dU ImIm
o( Ih" tliibl Ii«iniiph>-n. ThB
■bAdil i^ttitti» tmit\cttr 111*' \t*r^
Hob. I>. LunUao oI ih* ■lloului
In ib« un UMnl (olnraa si (h«
cvmeftl rfgIdD- ^- lUù aitu*
l«al»ii la fhf du/iftt rr^fion. v.
1TI9 ta^na l««l«q la lb« Idliibftf fa-
Urcrmanl. Tha 1br«« prrpBra.
tii>Bi«. r'. p". (b** amlu» t< lft«
■ P|0bL C4nl lu Iha lUnal «ail luut-
tikf TVflon bfl'>w ■ polDi wlior*
lb<* mamiw «■* »>vi|ij«uty 4*
Mivj^Uj «mpn<Ml'iD,iliii4ba4«d
pan* TtfprHaal Ili4 LocaU<<a «ail
eiiltai al iht dtknadiag ilff^a»-
fallna.
8S3
OBKTKAL ïrCRTOns BT8TEM.
I
Vig. 210.
the i^atost diaplaceEwnU of tlio v«rt«1>rnl column csused by ractiilts,
the spinal conl reiiiaiiui intact becaitnc Uii' itpinal Rienin);<>8 are normal.
In I'ott's disease of tlie njÀnc, an<l in nil tunion I'itlicr of tlie verte-
brte or tlic rocmbraoea of Uie spinsl conl, «tiich occuion an inflamma-
lion of the meninj^cs and a «ofivnin;; of the cord,
the latter is solWnei), whiti^li and «piii|UG, or Tel>
lowish, for a spac« oorre^puiKling to tlic «xc of tlt«
tumor.
When the spinal cord is thn* dwlroyed in a seg-
ment, the parts of the spinal cord ^iuuttcd above
uiut below undergo ch»n;;es which, acoohlin^ to tbe
investi^nlioDs of Tiirck, Bouchard, and (>unelr««,
seem to bft constant. They are as follows: —
1'he posterior columns show a secoudary degcite-
ration almost throu^hont their entire extent fsee
fig. 210) nhorc the point of softeuing, white below
only the lateral culmnns experience a chan;>e (see
&g, 2m, <-, ■■', and (■"); the altération consists in
faUv dejieneratio» of the nerve Hbrtm, in Iheir
atrophj. and in llie presence of nnineroua granular
corpuscles.
The extent of the leùon in the jMMterior colnmns
gradually tJipei*», as one ascends the conl, no that
it u-rminates in n thin filament >n the middle and
posleiior pari of thu posterior colmnu, (Fig. ÎÎIU,
e, /, <7",mid^".)
'Die le«on« in the anterior oolumns tenninate
hUo in the same manner o» one descends the conl ;
theiKseat U nearly the same as that of degenera>
don consecutive to a destruction of a hémisphère,
that is, the posterior part of tlie lateral columns.
A sarcoma which «e saw in the nerve* of a
horse's tail, had compressed and degenerated the
nerves at the point of the tumor ; in this case tlie posterior columns of
the cord had undergone a similar degeneration throughout its entire
lenirth. (Kig. 211.)
What is the cause of secondary dejjcne rations ascending in Uie poste-
rior columns and descending in the Intcral columns Ï It is certainly coo-
nected to the circumstance that divided nerve fibres become granular in
the part separated from their nutritive centre. The cxperiroenu of
Waller have shown tlint if the motor tten'es or anterior roots of spinal
nerves are divided, their peripheral portions degenerate, while the central
ends prescning their conneciiou with the hiTvi- cells of the anterior
eoniua of the spinal cord, remain normal. The «apie experinieiiter has
shown that the lesion of nerves pursues au opposite direction when ilic
posterior roots are divided; the part of the roots remaining in connec-
tion with the cells of the spinal ganglia is normal, while the sensitive root
which penetrates tlie spinal cord becomes granular.
Thiu, the changes wliich arc seen in the nerve fibres of the spinal
cord, in tbcse cases, arc explained by a separation from tiieir trophic
Ibv ft|iUb*L 1II4FF4W ÉU *
«r Ihr donil KVlun. t-
fthdtD ]«■» «lUatl**- t",
e^, hP%Wtl 1#M »dJ l44t
•XUaalK Ui |>r<i|wriluBa>
HTELtTIS.
883
*
I
I
I
Pirsii.
erlls. But there 8iill rcmniim Diuch otHtcuritj about tlits «juestimt, eH{i«
ciitlly in n-txtio» f> tlic coiini; of tlie nervv fibtva in the spinal cohimn.
Tlio rociilt« of phynologicnt oxporiin«nt« mudc by Vulpian to elucidate
this i|ueitt)o» do not agree witli tUo«! j^iven hy patliologidts. He did uot
toooeed in produoin); aflC«iiilin;; atxl de*cen<ting
lesiAi» of Uie spirinl cord in guinea-pigs or {ligeon*
li^' ttie destniotion of a segment of tbe spinal mar-
row.
In the disease which will bo described as tcliraae
ru filtiqueM, in irbich the i^ray centres and white
columns of the spinal cord are irregularly destroyed,
Mcotidary degcnemtious of the none fibres are
never seen.
Vulptnn concludes that the secondary dejienen-
tion i» iwi «olrly due to the séparation of the nerve»
from ilicir cells, but he believes that the cliBuge is
due to the porwatence of the irritation.
Finally, when an examination of the spinal cord
is made, from persons «ho have preiriously suffered
amputation of the tiilgh, or from animals which
have had the sciatic nerve divided, the secondary
Iflsiofu of the spinal cord may occur not only in
tfa« posterior white columns, but also in tlie anterior
eotumna and in the celts of the anterior comua.
(Vulpian.)
Swiailarj d«c««fnil(ig
nl Ik* pa*<*n*r MlaiuBs
Qf ihe »t>la*l Burrow it «
<4»* nf OtUlftthliXI ^f (bfl
BVIM'or* Iwric'i Hit. 4.
■.Hiast a' lb* r*M*rtor
«luuD ot lb* l4« purl of
Ihv Imnlfhr rulariT'infliil,
d' The HIE* lailuu <I Ike
DppHr j>*rl it tb* Inn hat
VltlBFf tniirnj. il", t-lt'iilU
Id Ib^ d<jr«Al ti%\tn. ti*^'.
Tlla M»a ■••lOB Ib 1h«
«nloal raUrcMnciil.
Myklitt!:. — Under tbi^ name may be deaeribed
a serieti of very different pachclogieal Mates, in
which there exist» acute or chronic inflammation of
tbe several elements of the spinal cord. By tbe
term m^etiti» is underttood not only true inflamma-
tions, cbarscterûted by the formation of new elements, embryonic cella,
white blood corpuscles or pus corpuscles »c»ttered between the elcmenta
of the cord, bui also increase of the cli-mciit« nnd lliickomn^ of the neu-
roglia, known as fl«ro»ii. Certain atrophies of the none cK-incnts, which
conxtilute tlie only lesions found at tbe autopsy, arc likewise dependent
upon inflammation.
Afulr gufimrative mi/riiti» may occur in epidemic spinal menin^iti»,
or in eon«e<|uonce of ulceruliun.* of the saeruni which involve the spinal
dara mater. The myelitis ii llien sii|>erlicial and coiiiiecutive to the
meningitis.
In some ca-ies of gangrenous uleeradona in the insane, the pnriform
exudations, ttie inflamed membranes, and even the surface of the spinal
«onl,assumc Uie characters and odor of gangrene. This lesion may ex-
tend as far as the medulla oblongata, [ions, and iiiforiur part of the brain,
Mttattatie aktcette" may occur in the spinal cord from purulent infec-
tion, as they do in all other organs.
SimpleaTute myt-/i((«,non-8iippurative, is at time»diffu.*ed, involving a
considerable extent of tbe axis of the gray subitaiicc of the spinal cord
(central myelitis) ; sometim^^s it is localized. The histological lesious in
8fi4
CENTRAL KBRVOUB BYBTBH.
botb vtrictifrs tire the sBine us in cneuphnlitts. The mcdultarj iBbataace
is «oftonod ; ilo color is whitiali, piulc, ^vHlimitli, or chocolate, dtpendin];
UJ10I1 thu eongcriti»!! of tliu v<.'»>cli>. ntid iniailtUM of rttl corpiuclM e«cKpe<l
IDU» thv itoftviioil part. I'ottiw of I'ucliymoticit nnd lUnutuIcd vc«im1« 111*7
Bomeliiue^ be fl»on wHIi th« unauled eye. % micro«oot>to oxumirialion
tliere are fouiH grautdnr nerv« )il<rG!t, tmuKtmiLi white blood cor)>»3clett,
some normal other» filled wiUi Vilood [)i;:tnciic, fatty gr&iiuW, aixl gniiiular
eornaaclea. The same elciueiiM exi^it in the perivascular l^mpli slie&tha.
This form of myelilU, vhcn it ia 'litTi»ed and general, «xtenda for soaK
diaianco fnjm tho central Diaaa of the spinal cord, and, according to
Cliurcot ond Iluyem, it is in these «tses ibat hctnorrhaf^a of tbe spinal cord
! occur. It is evrtain tbat in the coni as in the brain, softening inuT be
the esuso of hcmorrhajrus.but it is difficult to decide which is the primarjr
lesion, for primttry heiaorrha;;es also ocuasiun a softening of tlie tis«iic
and infiltration of the nei';bbonii;; tii^^uc with wUili» blood corpufctoi,
pigment, and granular i;or]>uMlcs. Tlii;* Tariet; of the disvAAi! is rftpidly
fatal, i.ocaliiced myelitic luiiy present further modificfttiooa, suob lu
complete degeneration, aepnration, and utropby of tbe parl^ where the
leaion ia located, in which case it exactly re^einblea limited chronic
softening.
The lesions described as characteristic of myelitis, the impoftaoce and
nature of vfbich have not yet been determined, are : —
1st. Hypertrophy and raricoso condition of Ibo »sis cylinder of llie
n«rve fibres, obiorvod by Frommonn in sclerosis, aftorward» verified by
Revend anthora ; Charoot has seen this condition of the axis cylinderv Id
recent acute myelitic.
2d. A colossal hypertrophy of the eell» in the anterior comua of llie
spinal cord, otuen'ed by Charcot in the «ame conditionii, and appearing
to be due to the same caiue.
^d. Foci of granular degeneration, described bv I^ockhart Clarke,
consisting in irregular maeacs, which seem to come from a coagulation of
albuminous fluid containing granules. These maaaea are conuined in
irreguhir cavities excavated in the spinal cord. As these caritica are
> «een especially after hardening the cord in chromic acid, and as. on the
other hand, the least traction is sufficient to tear the medullary fibres, it
seem:* to n.» probable ttiat they are produced artificially.
4lh. The nniiiorous and excellent works, whicL have recently been
Suldiahed in France by Charcot, Vulpian, and their ptiptls, VrévoA,
offroy, etc., demonstrate that there exists an iitropby of the cells and of
the anterior coruua of the Hpinal eoni, in infntitilc paralysia, in gvueral
spinal paralysis of the adult (Duclienne), and in progrea-iire muwular
atrophy, Charcot ia inclined to belîpve that this atrophy ia due to 3
primary mvelitia, limited to cerUin groupa of cells in the anterior corima,
which opinion has been adopted by Dajaniin-lteaumetz. Laborde, Hoger,
and ]>amiutchino, regard infantile paralysis as cauaed bv a myelitis with
proliferation of tho cellular elements of the neuroglia. 'These very inter-
ealJng observations do not, however, seem to us sufficient to establish in
t positive and definite manner the pathological anatomy of the preced-
ing diseases.
Interstitial yfytUtiM or SeUroei». — In this variety of myelitis the c«l-
eOLSROStS OF TnS POSTBRIOR flOLITMSfl.
385
'
lular olecMDts of the ocuroglia aro incrcasoil, tlii* tmw \* tliickcncd aiul
till! Dorvc fibres are MconiUril^' iitri>j<)iHr<l. 'Hii' Icniou occur» fn'tjucnUy
iu thv b|>îiaI oord, ud>1 i» liuitlv<t to cf'riitiii r«)^oiis, giving rise to a]>eeial
eymptoros ({«pctuliag npon tlio location of the diitcKae.
Tliui gelerttaSt qf the futttt^rinr rtilutnn» ta the anatomical lesion of pro-
(rrvssivc locomoUir ataxia: <(i»itrmin'tlf<l nelfronf {sctênse en plaijuea)
irrct^ilarly ili8tribat«<l corr«A]Ki»'U to jiara-
ulenaa, witli contraction or relaxation of the Vig. 213.
limlM, and trcmblingit, etc. iSclerciiii liasi
been fotind localiE«<l in the lateral coluiona
alouo, lateral n-Urotit (»tlirotf ruàmiie'),
and upon tli« eurfac« of tbo spinal conl in ; -I^Hl^F^ ^
tfon£«<|uenco of a chronic iiiooingitiB(,«<'fA>i>M j_ - J/H^^BF^ --^
annulaire).
Sclerosis op the Posterior CoLrMSS. —
Tlic yrtiff ii*<jtneratvm of llie ]>o«tvrïi>r col-
nmoa seen iu all cattcs of progrossivi,* loco-
ntolor ataxia, is c>iarncleniM.-(l nucroMOpi-
cally by a graj color am! a |ii'ciiliar tniia-
lucciwy of the pooHerior columna. Tlie pia
mater ia almost alway» thickened, and very closely adiioront to tlie dis-
eased portions of tbe cord.
Two different stages may be distingiiialied in the coursie of this alter-
atioo.
At the be^^inniii;; tbcre civîitts an increase in tho number of the ncu.
roglia clenivntif, nnd the di«eii«ed parts appear aliglitly tumefied; in the
second 8taji;ti there i« atrophy of the cellular elements of the neuroglia,
tbickeniug of it» fibrouï tissue, and atrophy of the posterior columns.
A small purlioii of the .lemi-trauspan-nt gray «itbstance of the dis-
eased part prepared from a rri-.'<li conl, afu-r toa^iiii); in water, pre-M-iita
in the first stage numerous embryonic elementa poMesaing a round or an
oral nncleus. These cellular elements are imbedded in an amorphous
granular substance. The nerve fibres arc preserved, as also ai-e the
nerve cells in the anterior and posterior comua. The vessels in tho
diseased re^^ion bavc tbeir lymph Hheaths dilated, and filled with granu-
lar lymph corpiiKcles.
Thit) traitsverMo sections of tho cord, studied microscopicallv, shovr the
antcro-latcnil columns heidthy, and the posterior uoluiimt altert-d. In
the foriiKT, the nerve fibres arc see» to be regulwly sc|iaraled from each
otlicr by Uivir purlitions of neuroglia and by tlic vessels. Tbe avuroj^ia
presents at intervals a few smalt cellular elements.
In the posterior columns, tlii^ ner«'e libres vary in diameter, some
are very small, altliough «till retaining their axîâ cylinder and sheath of
medullary substance ; others are normal in siise, or larger than in health,
and their axis cylinder may be considerably hypertroplitcd. Between
the nerve fibres, the neuroglia presents linear or round collections of
small elements, tlie nuclei of which are alone visible.
Lon^cudinal sections of the spinal cord, nhorc wc are able to compare
866
CBXTRAI. XEKVOrS STSTBU.
Fig. 313.
the posterior coUirona with the anterior eoliimiM^ etiovr Hie samo liMtoU
gical details.
In K tnora ndvaTiceil »\tigv of i)ie dÏMiae, ttie pottt^rior colutnnD «re
fused to^lb«r hy tliv fortiintion of ii«w connective ttsaiie in ttin pia
mater, wliicli, iii Ûte normal oiiditioti 'lifw into
this fiaaiirc. ami separates t}iein one fn>m the
oilier. Thia connectire tissue acu aa cicatricial
tissue, and intimately unites the two columiis
which prcviotLsljr were only in contact with
each other. From this fiitiion as well us from
the eonsidernblc atrophy which nil the nerve
fihre* uihUtj;", thi-re result n very ttotalde
«trophy iind «lirinking ol' the entire posterior
columns, !>o thai the posterior comiut of the
gray snh.tUii)ce are brought nearer together.
(See fig. 212)
Transverse sections show that t]ie nerve
fibres are separated by a tisaue which with
low power «ppcare Rraoulnr. hnt witli higher
power it is found composed of vorv fine interlacing fibrils, witli a few ocal
atrophied nuclei at intorvols. l^he nerve fibres are thin, but tlieir axîâ
cylinder always extsM. By some autliors it is maintained that the nerr»
elements have disappeared when the sclerosis has reached ttiia atage ; but
Slltttttt III B|>liiil Cunl. A
liiw4.4>ir L ht of'v refill Vvtwt'm
Ihc out cuptBof ILd Dvrv^AUjvi,
A[>ii«in.iice «f HpnuiT blood «ttxsti Ik aa («fijr ■!■«■ of ■«Wnttn. a. Xn«U1 <4 aadaltalla,
whidh uro sol moch alUrtd. tf, lum&aAHbd pTuilrATbiLva bf Ibo ponaicnlar c*U«. Illfk pvmr.
they are always present, and may be demonstrated in sections colored
with carmine ; whf n the lesion is far advance! , the fibres may be rc'inced
to their axis cylinder, the medullary sheath having; entîr^-ly did» p pea red.
A peouiiitriîy of the-tc sclerose.* consists in a thickening of the walla
of the capiltaricA and ttmall ve^itels. 1'his thickening is due to a pro-
liferation of the eleinenta which coiiHtitule their wall»; they become
rigid, and their calibre ia dimini.thed. At the saroe lime, nnmerous
corpora amvtacia are obaer^-ed iu the'neuro;;lia, alonjîside of the vessels
and especially beneath the fibrous membrane of the pia mater.
The pia mater covering the poaterior columns also participates in
the chronic infiammatiou ; it ia thickened, and becomes closely adherent
to the spinal cord.
The posterior roots of the spinal nerves have become transparent, and
80 sinall, that, instead of bi-ing duublc the size of the anterior roots, as
TDUOKS OF TQB SPIHAL COtiD,
t))i>y Ate in Ui« Donnai cotkHuod, the; arc onl^ half the shte, or «ven
In tocoiuotor xtaxia, tlic lesion ta not kIwhts lintitiid to the posterior
eoltunm* ; it mmetiniOA rncronctiv» n little upon tlie i-onli;;iiou« eorttml
portion of the lat«ra1 column*.
It IK g«nonillT in tb« lumbar rvpou llint the lc*ioii of ttifl iHiRttrior
columns is ol<le^l and rootit advmice'l : tho ilrmal ami cervionl rc^iow
are nauall^r 1^3^ ili.>wa.4ed. The tubercu)» i|iiadragemîna, the optic trncbi,
ant) the optic nerves thcmflolvca mav he atrophied, grn^iflh. and etc mi ■trans-
parent ; at times, even the h^pogloâ^al nerve may |>resent the same legions.
Pig. 21 A.
Fix- 2l<-
Aiil>ni taltnl Mieiotto. |C*iir«vl.t UoUw4 [*iicllvnnl1iaf ili>iplsal«Hd.*kii«la||
Its i*riuiu lUfrri of dfttBeniluB. n. Soiad
aitrvD coll. ivLth it* pralaiigftU'}ii« anil nntUui^
r, A n«rtv tri\ «tJll «hw^ùg M« lirtnfbf^. but thn
1al4fT *in »Eni|ilil<?E]-*«^ llio bvilj vt IJ»A cell t# •«
1l1l*d with (nt«F'<l gr4nulM tlllt rll« UUtirDit f^JJbal
tw«4«D. 4«/,dr, Xfrr* f«Il« tlUI vii>r4 »ltf:pilr r.
^. E(*rt«e«Lt>flirrntll«rtd, thaj hatr J4ti lïiirtri»^
loDKkOfli» ft. « Deiro r*ll In Ibr Ibu •lag*i>r 4*.
(flDFnlt^a, lltBiftBiiul&t *i4Bt«Dt I* brf&iknf uf talo
(lull tngtunu. Ulgti paint.
Thv syniptoms of locomotor ataxia m&v be due to u lenion confined
entirely to tliu posterior columns. In an observation made by Fierret,
ihfv*: colunma werv only altered in cIom proximity to tli« posterior
com lia.
The cells of the spiiial ganglia, and tliose of the gray centres of the
Bpinal cord, apjiear absolutely normal in the mnjority of cases.
With respcot to the Yfliit« columns of the cord, liiMeminated scleronia
(sclerose en placiiiic») and lutfrdt g^ffmh {scldro«e ruband*^) arc his-
tologically ideuiiiial «ith the above-de.wrilied lesion, tlic only differeiiee
being the parts involved, [In lateral Aclerosiâ, in di&*<-minated «ulcrosia,
in progroiwive muscular atropliy, and in some other epinal k-sioii«, the
nerve celt» of the gray cornua are either primarily or ifecondarily in-
volved, îiomc of these nervc-coll^ undergo ii cloudy ««ellinjl, which iw sno-
ecfidcd by ptgincntution, and gr^tiulo-fatly dcgencraUou. The final result
S88
may be a narked fttropli>- of tliosc «Icin«»U or tlicy iD»y break up into
small fmgnienta nnd lotAllv «lisafiiiciar. (Suv iij:. -I'».)] Tlio coimw:liv«
(lsiiu« surrotiuiliii}; the oi'ittrnl cmial, in th« iiikjoriiy of com* of «cloroMS,
is in a ntAle of prolifération, and th« «atukl iUâlf ùt lîlled and (]i)Uciid«d
with epillieriat oclU.
In telanue, Dcmino liat) 'Ie3cnl>od leflionn aimilar to t)ifts« of sclcrcKtia,
dtSAcmiiiatcd throughout the etiliro ttjùnal cord. Michaiid reco^'ntE«<l
analogous nnpcaranccs — in pnrticular, a htpertrophy of tlte neuro;;lia
elemc-nta whreli arc found in the gray comnuBSurc surrounding lîic central
ivanal. Uur «xaminations of anulo;;ous cases ithoircd only a normal con-
dition ÎD this locution.
Ti Jioitfi or Tni; Spixal Conn. — Tnmor* of th« spinal «on! very teHom
occur, hikI. nlicn met with, are generally located upon llio meninges.
Tliey do not differ from tumon* of the lirain atnl cerebral tneningct.
Lanoereaiix lias reported a ft^r"ua fuimrr, developed in the central canal,
oceunyiDK a part of iti* leni^tli. We, abo, have seen a small fibroma
developed in the pia mater of the spinal cord.
Glioma and psammoma may occur in the spinal meninges ; tuborclea
also are met with in the same structures.
In the inferior part of the spinal canal, frequently in old persons, tb«
arachnoid and pia muter present calcifying and ossilying patchoe.
PART ITI.
DISEASES OF ORGANS.
SKtrriON 1.
RESPIRATORY Al'I'ARATl'S.
OIIAPTEU I.
NORMAL HISTOLOGY.
TilK reitpirttriry .ipimrnditi coni^iatii of a ajatem of ramiRed pniiiia^s,
«likli u:nninitl« in tlio lii')gi<, an arrangement aometbin^ like the ilueta
of acinous glawU. Tlio different parts comprise the largnx^ the tntvhea,
the hronchi, and tiie air tvticle*. Tlic tooutli and th« pharynx apporUin
more particularly to tbc digestirc spparatux, and tbcir lesions «ill be con-
sidered under that liiiad. The nasnl fossn;, however, may be properly
reckoned lut a part of the rettpimtory appomtiu.
Several portions of the natal ffinm- present a difTepence in stmcture.
The anterior entrance bristles with linirs stiff enoiij;h to nrr^t entail
foreign bodies* sii:«pended in the air, an<l \s covered with a .«trntilîtrd pava,
ment cpitlielium. 1'he nasal fosiuc, properly named, are lined by the
Sfhneidrrian membrane.
The Srhneiderieiii memlrane poaâoasea over ita entire surface a ciliated
cylindrical epithelium, and, throughout the greater part of ita extent,
18 thick and very vascular. Moreover mncoua j^Iands arc imbc^Idcd in
it, and empty upon its surface. The olfactory re^pon is especially
remariiabte for the tcrminntiun of the olfactory nerve*. In this region
Uic mitcons nieinhmnc in thickest, and presents a yellowUh tint. Ita
«ftll*, cylindrical and implanled upou the connective tissue by a fili-
form raniifying extremity, do not always jiossess vibralile citin. Tlie
mucous glands are reptacct by tubular glands analogous to those of
LieherktlJin, nhich contain oellii infiltrated with yclloR or brown pigment
grannies. The pale nerve filaments of the olfactory nerve terminate in
a long, alim rod, situated among the cylindrical cells. Upon the courae
of these terminal nervous filaments, which are a little raricose, ia often
found an ovoid vesicular nucleus.
ITio larynx, the trachea, and the brontki arc composed of a mucoos
3!)0
APPAKil
Dwmbrane, which covers thoir intonml tturfiicc, of « fihrocnrtilapnoiia
frameirorfc, ot" alriatcd and iinstriaU-il niui'i'k'S, of v<'HKe!i< awl of nerrea.
The mttifoMt memln-ane upon tlie cpî^^Ioilis nmJ Uio inferior vocal conla
is covered with a stratified pavement epiUieliiiin! upon the rest of the
laryngeal cavitf un well as niton the trnche* and bronchi, it présenta «t
Fig. 217.
frlsr ftlnooin* •CEllun v' •. bronr-tiliil iiilir fniin ilis Dit. lia*lii.( a ilUaalarar «koai I^Mili of]
•slat» X il^ a, Kiinrnil Ktini» l>r>r. A. HutruUt lnjrir. f. In(«n*l Ibroat lafar. il. Bph
Utfllni ÉafAT. /. Obu vt ilie luiMUuiliiit; •Iiwll.
iu tiurface cylindrical cells with vibratilc hairs; at the termination of the
bronchioles in the pulmonary acini the opittielium bectunea aqnunous.
Beneath the epithelium the corium of the mucoufl mcmbnin« U com-
posed of two layers ; immediately below the epiihelium in tiic laryux and
trachea the first layer is mainly comiK>«ed of «luetic fibres, and it is limited
itileniuily by a thinbomogeneou^Iuyer^.nil mm.) upon which arxi planted
the cyliiidriciil cell». At the ttalient jwirt «f the inferior vocal corvl dierc
arc niimen>u« pîii>illjii wiiich resemble lliose of the palmar aMjH-cl of finKcni.
They are covered by |iavement epithelium. This superficial layer of
ibi! chi^irium coniiiata everywhere of reticulated conneciive lt»»ne, tike
that of the small intestine. This layer possesse.i a few closed rollielea
(SO-^^), exclosively located in Iho mucoua membrane lining the reu.
tricle and larynx.
'J'hc second layer is eompoHcd of fibrous tissue and elastic fibres, which
lod;i;e the aeinonx ;;liuids, itn<l which connect the mucous membrane with
the mii»elex and the cartihige.-t.
The mticoti* glaiuU of the larynx, trachea, and bronchi are very
nunieroHS und are racemose. The rounded nciin of tlieM glands con-
tains pyramidal cells with the base applied to the basenent membrane.
The cell nucleus is at the base of the pyramid, and the protoplasm U ,
clear aud contains mucus. The ducisare paved irith a cylindrical >'pitli«-l
lium. The structure of the fihro- cartilaginous framework of tlic larynx
is that of ordinary fibrouç and cartilaj-iooiia tissue, except that tlie body
of the epiglottis and the curtilage» of aautorini and of Wriaberg consist
rOtOOY OF TUB LDKO.
391
of roticulaled <'itrtilnt;(>. Tlic lilirus nf the «rouiwl ^ulMlnncc of tli« car-
tilsgo* Hfi! <.'»iiiiim<>u« nitli thr cIakUc libres of tlie piiKOtu ini'iiibnnv.
Thv rings aiui pUKs of tlic trnclivit ami bronchi «ro rcpre4<.'ut«il by onli-
nary byaltnc lurtilago. THp lij^nmi-nM nhioli unitv Ùiv onrtiUges are
chiefly oo(DpodC<l of vImùv li^uue.
Fig. SIS,
wMi- Kllk Ik* UlUr l>ttui I > '( lb^ tuli»i>'Ilultt nalKOrll. b XhiIbiu •< * (Ub4<i)a(
ffllbvlUI oil rmu ihs ilnniK '1 11 •, ^>>wi, alx'Slrif lb'* >iilr»uu>l«t ntl*i>rli, *, R«dtillj>|Ml nil
of tt# BIMvalVy frf 4 114«t. rOQUIfiiUtf I A A hj'4llft<- Kr<lun<l ■dbB1Alir«& )ll*11U«0f flu* ibl« bquill**
— InlrfccdIaUl HlwatK— t» «n-auitlna «ilh it» IdIik nnitm nfim»K, d. CtanMllr* lixa* col-
fmitttram d*>«I'>t<4b"1. •btvlbciDiirilnrljr l|j"liiir>-T<>lliilEi ut'ivtik if tbrlliKiil ilukf*'
Ua*irr«aa<l Ht^uucr. lb*(Dt»THIaaJ> Intsll»' Imtnilii^ giro»»'*, inil !• ilMmiiMMrd mihlb*
aor< il'IfcdiB l«m-Aiirl«*r r*41fildiVi '. <'flbl«l rf'lJ tnta (be «loioarh at k iisvi alrtvlni lb*
lalnk rrllaUr *f<iB'»tli lu c«"D*cti<jq vrl4h AbriUst U» lalr^unt^far bh*** li, lb« »p^r put Wlte
«•tll*tlt«Mlr iwolUabr mBiini. <Xt(fii.}
'Hie nrnscU-s of tlio rcsiilratwry passaRea arc atriatei] in th« larynx,
DMtriaUiil ill tlif trachpii nixi hnmchi. The distribution of the hlootl an'l
lympli v«8scU in tliv diflvreiit layers of thu mucous tnembrtkiie praiscDU
Qothiug unHsiial.
Tiie tiifcriur Inryngnal »crv« is compo«H of piirticulariy large fibres,
while in the ^U|««rior laryngeal Ihe nerve fihreii arc fine. Upon the ler-
miniil plexiis of Ihe laller, microMopic gaiigliit are to be found.
The Ihii;/i suit]>ended in the tlioracie cavity by the bronchi and trachea,
are ooropoaed of lobea and lobules. The bronchioles tenninatc in tlio
primitive lobnles or infundibuln. An infundibulum 14 constituted by a
group of alveoli commiinicatinp; willi each other by a romnvon CMvity, in
which the bronchiole tcrniiiiaics. The form of the infundibulum i^
conical : the uir veùcle» or alveoli wtiivh can»tituto it are round or )>oly-
çonal ; tlicy may not only be t^upcd together in tlic iufundtbuliim, but
ùiolated air cells may occasionally appear u])on the bronchiole itself.
Uiwn a tbin section of an inflated and dried lun^ the alveoli present
the fonn of pound or oval cavities bonnded by thin «i-pta of connective
ttMHC coDtainiiig elastic fibres. T\m extremely dilivtublc fibrous fraiiw*
892
^l»AKATue.
rork of tbo Inng, which is continuoiiR viUi the irnll of tlio tenniul blOB
Ohiolos, serves as a support for blood and tyroph tictworka, its woll m to
the iKirves, and also iitforrU a basement tor the pulmonary cwtholium
which linos tho alveoli. In the terminal bronehiolc^ the epithelium vt
email, very regular, and of the pavement variutji' ; upon the walli of the
air vesicles a [Mivcuient epithelium mny be deraonstrated hy staining a
rif. 21B.
AlrKsUaar tiaunn limit villi luioisUwItr ivpu. a. EiiiihflliUD. >. KluUi Inbtvola.
t, Xfuvbriuuu» trail «lib flgn alMiit abr«i. ((TftrrtnMr)
section of fresh lung with nitrate of silver. These cells are thus shown
very roadity in Che fro;; and Hciinll niummifnra, but the same treauuenl-<
docs not work very succeosfully with iimn beenuso of the extreme difficulty
of securing an autopsy soon enough alVcr death ; in new-bom infants,
however, the ei)ilhelitira is very easily *een. The cells uniformly cover
the walls of the alveoli, and their nuclei are placed opposite the meshes
of thi> vaspular network.
The bloodvcjtsela of the lungs are derived from two sotircos : from the
bronchial arteries which are distributed to the bronchi, they arc the
nutrient vessels; and from the pulmonary artei-y whose ramifications are
especially concerned in hscmatoais. The ramifications of the pulnMnary
artery form in the inter-aWoolar septa a network with extremely fine meshes I
which are .004, .005 to .018 mm. in diameter, while the capillariM
forming them are from .006 to .01 1 mm. wide. In the state of contraction
or scmi-iiiflaiion of the nircoti the*e vessels are tortuous, and they elerate
the floor of the alreoli into ridges corresponding to thyir course.
Tlie lymph vessels of tlie luugs «re very numerous. The deep lymph-
atics arise from the walls of the bronchi, and of the I>]oodvc.«#els, particu-
larly the pulmonary arteries, and, according lo Wiwodzufl'and otlion, TroD
the walls of the air Tesicles also.
HORMAL HISTOLOGY OF THE LUHQ. 398
The pleani, the seroaa membrane of the thoracie cavity, prenents two
portions; the one, the visceral, covering the surface of the lung, is thin
and conaiats of & layer of loose connective tissue invested upon the
external surface with large flat pavement cella ; the other, the parietal,
is also lined upon its Free surface with similar cells, and on the other
Bide is conlinuouB with the connective tissue framework of the intercostal
muscles and the ribs. The parietal pleura is thick and consists of two
layers of connective tissue, the one loose, situated immediately under
the endothelium, the other distinctly fibrous and containing a large number
of elastic fibres. This membrane possesses blood and lymph vessels,
nerves, and according to some histologists a few smooth muscular fibres.
886
0B:CTRAL XBKV01T8 6YETEM.
Fig. S13.
tlie posterior columns nilb the hntcrior columns, ehow tlic Minr hi
gical •Ictails.
Id a more a<lv»ii<:c<l Mnge of llie ilUenae, tli* po«tl^rior colunM
fused together by tlic fonuation of new connective tisittm in tH
mnter, vrhicli, in the normal cruxiition <1ÎÉ
tliin fiasure, »n<l separate» tliem ooe rrOJ
other, lliis connective tissue acts as cicad
tissne, and Intimately nnitps the two «ri
which previously were only in cuntacM
encti other. From this ftimn as well at
llic considerable atrophy whicli all the]
fibres undergo, then.' result n very n
Atrophy and «hrinking of tli« entire |Mq
columns, so tliiit the po»l«rior conma 4
^ray siib.^l»ncc are brought nearer toe
(See fig. ■212) "
Transverse sections show that the
fibres are separated by a tissue whicl(
low power appears i*rBnu1nr, bnt witli t
power it i» found composed of very fine interlacing fibril», with a tei
atrophied nuclei at intervals. The nerve fibres are tliin, but tlitA
cylinder always exisis. By some authors it is nminlaincl that the
elenientH bave disapjicarcd wlivn the sclerosis lia» reached this singl
AcWalU uf Bplsiil rati. X
IriDawWHNlgn. ali»irinrriiu(h
lb* 4ut 4>u.laiir tbe Lsrip-flbr**-
Fig.m.
Aii|>isnurr of «|i)1UrT li|gpilv*titlt la ui hi!; •■■k< at »l«n*l>. a. i(«ael*l*f
vh^cb trr iioi maob «tcrrad- cf, lufitAffl an J i>iulir*"Kili>i «f tbr ^vrvAKoUr mU«. ttlgti
they are always present, anil may bo demonstrated in sections i
with carmmc ; when the lesion i» far advanced, the fibres may be t
lo their axis cylinder, the medullary sheath having entirely dlsnp
A peculiarity of these sclerose» consists in n thickening of Ù
of the enpillaries and small vessels. This tliickciiiu<; is due to
liferalion of the ehtmeiif^ which constitute their walls; tliey
rigid, and their calibre is diminished. At the aarae time, no
coqwra anivlacia ara olwerved in the* neiiro^çlia, alongside of the
and especially beneath the fibrous membrane of the pia mater.
Tiic pia mater covoring the posterior columns aUo particip
the chronic inflammaliou ; it is thickened, and becomes closely ad
to tbe spinal cord.
The posterior roots of the spinal nerves have become transpa
KO small, that, instead of being double the sUe of the anterior
insparw
criorrtj
TD110R8 OF TUB SFISAL OOBD.
8fl7
are in the uomin] condition, they aro onl>- hitir tlie Mixe, or ervn
In locomotor ataxia, tlie lesion is not alwn^H limitci) to the poRtrrior
lutniis: it EoiD(>tiincs encroaches a little upon the conliguouA cortical
Ktioii of the tutcrai coluioina.
ill is Kencrallv in the lumbar region that the lesion of the riosterior
lamii» is i>lil('*t ami most advanced : the dorsal and cerviL-al rc;iiona
u«iuiU;r U-iw dÏM-AMid. Th* tuborcula quadra ^cmlna, tlip opiic Iracta,
ltk« optic nerves thoinflcl vos mil V U-nlropliied.<rniyisli,»nilHcaii'trans-
'.; at tiiDC^fCvcn ibehiF'poglossal nerve may proseiit tlio same lesions.
V\g. 315.
Pig. Ï16.
MUntaMnI MlaiMla. [CAdr»r.) IhIiIkI i;iin(lldn wllipf tbc ipliKl nurd. ■Lmilttx
tbri fmrliiii4 tla^«« at At^fnutxtioa- d. Tritiumk
DAF<4 tqtl, h I 111 iu prvl"bjt*tiua< and ngrtpnK^
^ A narvn cvtL atllL khoHlni,' It* br»Q<h'*, but Lb4
lalUr «rs aimphlod, taf th* Nailf a' Ilia nil !• w>
tiled itnu f'klgrrd friudlt* Ibtl 1b« niirli-u* tiiimi»!
ba*(WB, t,/.iS. >*rird c«ni »UU uiktic «Itvad- Ct;
^. N»F*4 c'll* [ui>»Al(#rod : lljfijr iiAïf* lo'l iholt pn>-
loBiiiillvui. A. «nrrrxnll lu llio lui Xx^g »f da.
g«>i«titl"D, lh'*^anu]*r«[t4Diiiil In brtAklPif uplnltf
■uill rtt«iiiul>. UlKh piiwtr.
Tbe svmptODU of locomotor ataxia may be duo to a Ici-ion con&nctt
«D'ïfly to tii« posterior colnmaj. In an ohacrvaiion made by I'ierret,
|the» Golumna were only altered in close proximity to the posterior
feornoa.
The cells of the xpinal ganglia, and Cbose of the gray cenlrcN of the
pina) cord, appear absolutely normal in the majority <'f ciisi-.«.
With respect to the white eoltiinns of the c'>^l■ iVurininated êclerotit^
clérosc en pUcques) and laUnil irUr-inië («cl^nxsc niliai!de)j
oltf;^ciilly identical with the above-described lesion, l)ie ^^
riBg the parts involved. [In lateral sclerosis, in '
[irogretisive muncular atrophy, ami in »ome
prve cell» of tbe {p%y cornna «r« i-ithei- primat
Dived. ÎMHiie of ihest- iit-rre-et-ll!" iindi^rp* a t '
eded by pigmentation, and granulo-fatty dc^'
388
thuors op the spiral cord.
tony be » innrkcil ati-ophy of tliosv olcinenU or they amy brook up
email frafiçiiicnU ninl Wtally <li»:i|>tiriir. (Hcv fig. -160] 'n»* conmi;
tisKiif surrounding tlio cviilntl vaiinl, in the in»j»nty of csisc» of tcUt
\» ill a HiHiu of {irolilorntioii, and tUo eanai iUcIf i^t tillcii aud di>toa
u'itit <-])itiii'lial ccllii.
In r<fdMH«, Demmo liaa described lestions similar to Ùioee of sclcr
dissetDÎnaCed tlirougUout tlie entire spinal cord. Micbaiid reco^a
analogous nppearancca — iti particular, a Ii5pcrtf0]>liy of iho D«ur
«IoidcqU which are found in the ^r^y coiDiniBsiin- surrounding the ce
canal. Our exaintnatioua of analogous cuscs showed only a nonuul i
ditiou iu thill location.
TuMnttsopTliBSplKAl. Cord. — Tumors of the spina] oord very nclj
occur, aiul, when met with, are genemll; located upon tlic mrmnseAt
Tiivy <lo not diflfcr from uiinoni of tlie brai» and cerebral ni«niiij;es.
l^nccreaux baa rejwrtfid a ^fiftmn» tumor, dcveloiied in the central cana.\
occupyinj: a part uf its IciigUi. We, also, have aeon a sinall fibmaaa
developed in the pia mater of the spinal cord.
OHbma and psammoma maj occur in the spinal meninges ; tuberdoa
also are met irith in the same structure!!.
In the inferior part of the spinal canal, freauontlj in old persoBH, dk<
arachnoid and pia mater prosont calcifying and oasil^ing patobe».
PART III.
DISEASES OF ORGANS.
SECTION I.
RESPIEATOBY APPARATUS.
CHAPTER I.
NORMAL HISTOLOGY.
1^ respiratory apparatus consista of a system of ramified passages,
•bicli terminate in the lungs, an arrangement something like the ducts
of acinous glands. The different parts comprise the larynx, t\\& tranliea,
t)ie brimcki, and the air vende». The mouth and the pharynx appertain
"wre particularly to the digestive apparatus, and their lesions will be con-
sidered under that head. The nasal fossie, however, may be properly
Mtoned as a part of the respiratory apparatus.
Several portions of the nasal/ossœ present a difierence in structure.
The anterior entrance bristles with hairs stiff enough to arrest small
fwign bodies suspended in the air, and is covered with a stratified pave-
ment epithelium. The nasal fossEe, properly named, are lined by the
Scheiderian membrane.
ITie Sehneiderian membrane possesses over its entire surface a ciliated
cjlindrical epithelium, and, throughout the greater part of its extent,
1! thick and very vascular. Moreover mucous glands are imbedded in
it, anri empty upon its surface. The olfactory region is especially
remarkable for the termination of the olfactory nerves. In this region
the mucous membrane is tliickcst, and presents a yellowish tint. Its
cells, cylindrical and implanted upon the connective tissue by a fili-
Ibrm ramifying extremity, do not always possess vibratile cilia. The
iniicous glanda are replaced by tubular glands analogous to those of
Ljeberkuim, vrhich contain cells infiltrated with yellow or brown pigment
granules. The pale nerve filaments of the olfactory nerve terminate in
a long, slim rod, situated among the cylindrical cells. Upon tlie course
of these terminal nen'ous filaments, which are a little varicose, is often
found an ovoid vesicular nucleus.
The larynx, the tracJiea, and the bronchi are composed of a mucous
sso
RB8PIRAT0RY APPAKATV8.
membrane, which covers thoir internal surface, of k fihm-cartiUn
frainoworlc, of 8tnnti-<l nnd unstriiitri] inii»v1es, of vcîmcU hihI of
The muffou» memhmnf upon the epiglotli» «ml thf inferior vftOil •
is covcrihl with a strntificil pavement Q|)itlielitim: ii)ion the reati
larjriigeul cavil^t as well a« upon the trachea and bronchi, it preacuW
Fig. S17.
I'ttI nf II tnuttarw •Mllfu si ■ btgii''hUI tubs fiiim ihr Pin, IiiitIi>( t, dldnglat a( ahtM b«M^^
tM iHh. X ^*"- "' Kiifrnnl tXnaii,' \tjf . i. MuHnUr UgrM. t. ln\mt\t\>rti»*\»fti. A.1t~m
Uwll*l ■■jw. /. Ou: vl Itin •urr'iu Bill lit sItkII.
ttft surftice cylindrical cells with vibratilu haint; kt the termination oftbo
bronchioles in the pulmonary acini the epithelium becomes mjuanwas.
Benenth the epithelium the corium of the mucous membrane ia coïb-
poscd of two layers ; iimnediatcly below the epithelium in the larynx awi
trachea tJie first layer itt mainly eoiiiposeil of elastic fibres, and it is limllP''
iuleniiilly by a thinhouioj;ein'(nn biyer(.011 mm.) upou which are plant»."'
the cyliuiintal cell.*. At the nalienl psirt of the inferior vocal cord tbcr*
»rc numerous papilln: which re*emblo tli»«o of the palmar aspect of finger*-
'J'hey are covered by pavement epithelium. This superficial layer o*
the chortum consists everywhere of reticulated conncclivo ti«sa«, lilïC
ihat of the sm.iU intestine. This layer pns^Me.i a few cloMd foUiele'
(JtO-ôO), exclusively located in the mucous membrane lining tbe vci
tricle and larynx.
The second layer is conipo»ed of fibrous tissue and ela!<tic fibre.*, which
lod^e the acinous <;Un<)8, and which eonuect tJie mucous raembnne wiUi
the muscles and the curllla^s.
The mucous glaiiils of the larynx, trachea, and broncbl «ire very
nnminoiui and are racemosL-. The rounUitd acini of the«o inlands eon-
talus pyramidal eells with the Imi^e appHod to the basement iDonihrane.
The cell nucleus is at the hase of the pyramid, and the protoplasm i*
clear and contains mucu^. The ducts are paved with a cylinilrlcal epitlre-
lium. The structure of the fibro-canilaginous frameworli of tlie larynx
id that of ordiuiiry fibrous and cartilaginous tissue, e.xe«pl that tlie bwiy
of the opigtottis and the car^lagev of Santorini and of Wnaberg conflit
oi I
te I
,1, I
NORMAL IIISTOLOOY OF TUB LDKO.
[^ffiinlatod canila;§e. TLe fibres of tliP Rrouod substniicc of tho cnr-
I 4P8 cODtiuaous with the clastic fibres of the muo"»» mcmbmne.
[ling» ukI pUtea of tbo tracliea bdiI bronchi an- repro^ontiMl by onli-
IkjruÎM cartiU^o. Tbv li;;aincnt« which uiûh; the curcil«g«s am
Ijcoapoeed of tUstic lisatic.
Fig. 318.
"^
t»Hii>»r>mhn«IW«luiii i.f «If ptalapl»-iii »Bd docTmii. n. CaloniTKr ■|-lllitllil sgll prcMdiil
Ml «kit! lUMr iMJIii rrwio'ttllnni -f lb" lulrmT<"Ili>Iu nilv^tk. « Xiiglsui ^r i glx.Jiilar
•lUiIhlitlirnimlholSBiitdiaf t anwi. ihiiitliiu ilin lnt»'niiclD*rii»in>itk. f. KniiMhilUl t<ill
' ■)• HUctttctf of « tnrt, «aqUlQlUri \a « hj-allltr rruuiij »jb*[La^4riL tiUlU'af ti^t abie I'uuilloi
^ks^flrtlaUr ■^iBOik— lb i^onni'rlïoD villi th« liilr* im^rlrvr ncI1r>fk, d CiynnaclUn I1i.aii« istf
l^fl^t>-«iiK*^4<"f7 0f o^vl. pbfwlaa tary clvarljr IhTlDirk^rrltiilHr D^luofkitf flhrltiitiird t!]'î1lrt'
i^(B<W nWt*&«». Ibo lormfpT «ixctDd» iDiD Eh^ litnnthtH vrnfHaac*. mnd 11 rilf>rk>bfi«c{'-d «ilctalhi
MiUUtis imo'Dailm mlesluuj. i. liirMni cfII rr<iiu ih« •lumguU at n nxwi •hnirUif ih*
, *BMiiiolu MtvarK I* rnnnHtiLin «Uh Dhillial lh« tuKii'iiuclMr oatirMli. Ibii upjior piil oftba
The nuiid'^Ied of t)ie mspimtorv {laeaa^cs are striated in the Inryn^,
' Muted iti ihe trach«a and bronchi. The dietribution of the blood aui
I In^pl' vessel'' in the different layers of the mucous membrane présenta
I nmsag uniianal.
rte inferior laryngenl nerrc is cooiposcd of parliculariy large fibre»,
Hile in ibe superior laryngeal tlio nerve fibre» «re fine. Upon the t«p-
i uisat plexus of tlie latter, microiwopiu gaiijjiia are to be found.
Th« iunffë «MpODd«d in th« thoracic cavity by the broni.'bi and trueliea,
composed of lobes and lobule-'). The bronchioles terniinule in the
'prinii6vc lobules or infundibula. An infiimlibiilum \n coiL-ititntetl by a
poop of alveoli coinnmmeatin;! with eaeh oilier by a eommon wivity, in
lliieh the bronchiole terminates. The form of the infiindibuhnu iii
eoical ; the air resides or alveoli which conBtitute it are round or jtoly-
DDal ; ihey may not only bo grouped together in ihc infundibulum, but
olated air cells may occasionally appear upon the bronchiole itself.
Upon a thiu section of an inflated nnd dri^d lung the alvcoH prL-sont
form of round or ov»I eavitieo Iioimiled by thin siipta of connective
containing elasiic fibres. This extremely dilatable fibrous t'ruuic-
UB8PI&ATORY APPARATUS.
work of the luoç, which U cnntinuotis with the wall of iho t«miîa>l
chioloe, flcrvea as a support for Mood am) lymph tiflworlw» as w«ll u-fl
the nerves, and also affords a basement for tlif pulriiunar^- epil
which Unes tlio alveoli. In the terminal bronchioles the ciHtladiu
Bioull, v«ry n.-;;ular, and of thu pavomeni varictT : upon tlie wnlU oft
ftir voflictcs a puvomeat opithclium may be doinoiiatrat«d bjr siAÎnii
1^. 31B.
llr-nllaor Iiuid>o Ubi; with liiienl>*oI» hjim. a. EpiiholJnm. t. XImiIs tulmtil».
f. >I*iitbn>iiaii( «>11 slib lu* «IhIIc ttrtK. |Ckr|WDMr.]
seotion flf freah lung with nitrato of silver. These cells are thus aho''"
very readily in the froR nnd «mall nmmtnifrra, but the same treami^"
does not work very suct'cjt»riilly witli man Ijccniisc of the extreme difficu'*-'
of securing an uiitopsy *oon enough ftftvr death : in new-bom infaii *^
however, the epithelium is very cjutily «e«n. The cells uniformly coV
the wall* of the alveoli, and their nuclei are placed opposite the mesl»^'^
of thi- va*ctd«r network.
The blflodvcsael.i of the Kings are derived from two sources : from li*
bronchial arteriea which are dislrihuled to the bronchi, ihey arc th
nutrient vessels; and from the pulmonary artery whose ramifications ar^^
I especially concerned in hicmatosia. The ramificatiomi of the puhnonar^^
' »rtcry form in the inttT-iilvL-olar septa a network with extremely fine mesho^
which itre .004. .000 to .Ol!lt mm. in diameter, while the capillaries
forming them are from .006 to .011 nun. wide. In ike state of contraction
or »e mi -inflation of the nlveoli these vessels arc tortuous, and they elevate
(lie lloor of the alveoli into ridges corresponding to their course.
The lymph reaaela of ihe Innga are very inuwrou*. The ticop Irmpb
«lie* arise from the walls of the bronchi, and of (he Moodvciwels. particu-
larly the pulmonary arteries, anjl, acconlinj; to WiwodsolTaikl oihers, fro
the walla of the air vesicles also.
HOBHAL BIBTOLOGT OF THE LDHO. 398
Re jjeara, the serons membrane of the thoracio cavity, preneots tvo
rtioDB: the one, the visceral, covering the surface of the lung, is thia
flonuBtB of a layer of loose connective tissue invested upon the
tenal surface with large flat pavement cells ; the other, the parietal,
ftbo lined npoo its free surface with similar cells, and on the other
k is continuoue with the connective tissue framework of the intercostal
lies and the ribs. The parietal pleura is thick and consists of two
lyers of connective tissue, the one loose, situated immediately under
ne endothelium, the other distinctly fibrous and containing a large number
tt elastic fibres. This membrane possesses blood and lymph vessels,
HTves, and according to some histologists a few smooth muscular fibres.
FATaOLOalOAL HISTOLOOT OP RRSPtRATORT APPABATDS.
CHAPTER II.
PATH0UHÎ1CAL HISTOI.OCY OF THK RESPIRATOBT
API'AIIATITS.
Sect. I.— Haul Fosste.
I
CoNOKSTto.v : llEMOituu.Miu. — t'on^psiion of tlie nasal taasK in the
initial phenomenon of inflatumalii>ii or hciuorrliat;e. I len>orrhage or e|)i»-
taxia is either primary, ns that wliicli is seen in yomij; mibjecls, or Hecond-
ary. such as in typhoiij fever, scurvy, etc, Wc ilo not know the lesions
of tlic vessels nliich explain tho hctnorrliit;;cs or ïtiiUcato thcïr proximaie
or rcmottf cause.
INFI.AMMATION OF THE MCCOCS MRMnSANK OF TUB NaSAL Fos8 J ;
ConvSA. — A<!iil« coi-yza is a conj^tion aooonipanieti by a Hcrous oxud»'
Uoii. The first (ln>(>a of this exudation are tranApar«nl, yet they alrira<lj
contain lymph corpuitcle». The iinmeiliate pr<-»eiicc of these corpuscles la
llio serous iHacharge of corjKa occasicus llie ausjacion lliat they are
whilo Ijlood corpuscles escaped from tho bloodvessels, rather tlian the
Erotluct of multiplient inn of the epithelial cells. Xevertholess, we have
ore n very good oj)pi>rtunity for,»tudyin<; the metamorphosis of the epi.
tlielial elements. The eylindncal cells liccomc i;lobu)ar and divide in
Kucli ft manner that the part* have the diameter, the form, and the reac-
tion* of a pus corpuicle, yet possess vihralilc cilia, a fact which very
strongly suggests their origin, {f.j. •/, fig. 220.) Such cell^i become ■"
taclied and mingled in the exuded menim wiiii ilie numerous lymph cor-i
puscles which have escaped from the hloodvesseU, or have formed in the
deep layer of tho mueous membrane. They give to the exuded Huid
mucous, cloudy, or puriform appearance, acconling to the number ofeell
elemouti held in suspension.
An acute coryza, uf a secondary cbaracttT, is obserrcd in the exau-
thcmata, especially in rubeola, in erysipelas oî the face, in diphtheria
and (;lan<ler«. Kacti of these disea:s(-8 may mitnifcst itself upon
mucous membrane of the nasal fossto by the local character and the pro-
gress which cliaractcrixe them upon the cutaneous surfaces.
The acute ItiHammation may be arre.ited, or it may bisiocnc chronic.
Chronic coryxa and frequently recurring acute atuictc* determine a thick-
eniog of the submucous tissue, as well aa of the connective tissue of tlie
nucous membrane itself, which lias been pointed out by authors as a
sible origin of polypi of the nasal fossie. It may aUo be accompanied
by ulcerations ana even by small abscessed in the submucooi tissue.
Itarcly do the periosteum or the bones become involved.
Chroikic corysa of a specific character, or vtana, ts seldom obserred^
TUVOBB OP THB XASAL FOSSA.
8W>
except in the scrofuloiti or th« sypliiUtic. Prorouiwl lesions of the mu-
cotu OH'inlmiM nod of Uic «uVmucou^ ûmuo, lUe alccntlin;; (^inmata, the
Decro«tt of the bonea wliiuh fonu th« skeleton of the nose or of tiio roof
»
NtMu lnii>ri>n»>llaB «foil*, frnm knUrrhil <(i(liiiBniiil<QBari)iMlr|iuM((* a. tht»»»rtMt
<j>\t4ntal <>l)>. b. Fui c->ri>i»tl«. e, (b* •(»> i«l*d op»» ^7 u*tu arU. •. ■!,/. Crlli »>bIb(
rrvn 111* iKliIoa «I ■ riflli'lrlnl «11. «Mwluji cliM. f, 4. Manou dt(*urr>tt4 «11* tjum lt«
■•Ul fHacLu «vrju, J. Cfllnrltlrdailli. •hflHln|[fiiid«t>ai>n) c>ll>. X^^-
of the palat«, RÎV© ri»c to perforation* of the vault or of the «rchea of
tfa« palato. to tbo dischnr)^ of frk{;iiicut8 of bone, an<l to sinking of tlie
nose, etc.
Ti'JioBS OP TiiK Xa3al Fofls*. ^fiieiiti» Polfff», — ^[ucous poljfn,
i;«ncnillj fniiutl in the ftnt«nor portion of the ntsAl envîties, ara «ingla
or mtiltiple. Their pedicle is more or io*» thick, their form is ilutcrmined
hy thnt of the envily in which they are locateil, tU^lr sixe vnrieit from
that of » pea to that of a walnut. 1'hey are soft, of a tremblinj; inucoua
appearance, and are easily torn.
They arise by a localized increase of the corium and submucoat tis-
sue of the mucouii membrane, which latter covers their whole surface.
When the latter ia liosselatt-d and irregular, the mucous membrane dips
into th? di^prcs^iaus.
Kxani)uin<; a thin section of thcïo tumors, itisecvn that their free sur-
face is bonlercd with n stratified layer of ciliated cylimlricwl epithelium,
and in some ca«c« glands opening upon this free surface are t"! be observed.
TÎK-w; glands may be considerably hypcrtrophicd or tliey may hare under-
gone cy-ftic dîlatâti'>n,etc. To thi« variety of tumor appertain those of tl:«
antnim, described hy (ïinthlàj. In certain mucous |)»lypi of the nasul
fosxn;, 01) the contrary, ire do not meet with glancU. The roucoat tisAuo
which forms the maj» of the tumor is very vascular. In a gelatinous or
mucnua ground substance are imbedded, besides the vedscls, connectiTO
tiseue cells, which may be round, fusiform, or stellate, often having pro-
PATHOLOOtCAL HiaTOI.OOT OP RESPtBATORT APPABATUB.
I' OMKt> vhicli may unite to fnnn a cellulitr uetwork, aiul in raryiDg sniDiuit
ftlso buii'llcH or fibre» of couneclive tia:itie. A Ai.rikiii;; uliArHClcmtic nf
these tuiuoni i^ that the portion irbicli may j^roject bevond tlie iio»tril
poasessea a coveriug of atratifled pnvement epithelium.
Fibroua Polj/pi, — The fibrous polypi of the uasal foasie arise from the
ponostoum, or thcv may hare their ori;;in even in the bones. Thejr
usually hoTo their point of attAchmcnt in the pogtcrior portion of the
cavity. They send prolongations in every dirvction into nil the cavities,
fitliiïr bendin*; around obtttacle^ or breaking tliroii};!) thvm, i-idar;;iu^ thtt
nasal fos^K, ti>inntii<;or destroying the Itonct», and penetrating by noir
way* or by tiatiinil cii>cnin<;s (,thc «pheiiu-palaiino eanals, for example),
into the sitmseFi wliicli iturround the na«nl fo»8tc, Mpwially tlie lygo-
[matic fosHie. They consist of fibrou» tUsue, and according to MuroD,
they poiuiesji a considorahle number of capillary reiuela witli embryonal
vails, liable to hcroorrha>;e.
Among the polypi of the nasal fosa;e there occur genuine papHlomata.
These arc composed of numerous compouni papill.«, compresiiéd acaintt
each other, or perhaps united by a common epithelial covorin;^. Tlielr
stroma is fibrous and vascular, and their thick cpithoUal iureâUDcnt con-
sista of pavement cclltt.
The t/trt^'imnta raiiy have the same scat and proj;re«s, and it is poniblo
that many tumorji described as fibrous jKilypi of the nasal fossic may in
reality hav« been saTcomntn.
Primary farfinomu of tlie tmsnl fo««re h very rare.
I'ai'emeiit-'vllfti rpitfielioma, starting from the akin of tbe nose, the
check, the upper eyelid, the edge of the noetril, or the upper lipa often
invades the nasal fos«te.
There is a form of cyliDclrical<elled epithelioma primarily developed
in the uasal fossic. which by the naked eye cannot be distinguished from
■ mucous polypi (see p. 154).
Polypous growths arising in the antrum ol>en project into tlio nasal
fossitt : they u-iually belong to tJio class of tubular epithelioma. These
' polypi are implanted upon a batie of morbid ti«sue, ami titeir prognosis
r u very grave.
r Sect, n.— Larynx.
CoNOEsrrov, AcrrB Catarrh, or Catabbiial LAnïKoms. — Acute
catarrh is primary, as when caused by an impression of cold, or second-
ary, ax when following a febrile exanthema (scarlatina, nitx^olu, ctc.).j
Couge.ttive and inKammaiorT redness, accompanied by swelling, is ob-l
served hy the laryngoscope during life ; but at the antopsy ibe laryn^
mucous membrane is pale, a circumstance which is due to tbe large r|ii__
tiiy of elastic fibres which squcexc the blood from the tissues after death*!
The changes in the mucous membrane are the same aa in coryza. The '
sputa from larynsiti*, and from tliy respiratory pasoages in general, rarel]
contain norma) ciliated cylindrioLl cpitboliiim. NovorthelcAs, examine
wi »i'(t(, these eylimlriual cells exhibit evidence of proliferation (a&o ]
220).
Kindfletsch has indicated the following mode of formation of pus cor-
' DTPHTHBRITIC LABTXQITI8. OB CROUP. 89T
|ia4clcs. The connecbvc ti-L4iio corpuscles of the mo^t )tu[>crfi<;tal lnvera
of tlio mucous coriuni proltforate, become globular, Ukl auiiiiBle<l hy
aiiMvboid morcineQta travel between the cjUiiilricnl cells to tbe surfaco
of the membrane. It is the eame course which, acconlinj; to Cobnlieiin,
tbo wantloriuj; irhito conni«;liM purauL- after escaping from the blood*
resscls. It \s nnilcniablo that iu Ur^rogitis tbo stroma of tlie mucous
membrane is infiltralod with Ivmpb corpuacW, «spuciuUy along the ves-
8cl«. TliU a seen ]»rtU'ulnrly m the nrytvoo-epiglottilian folds, in the
lurvn^îtiM «f nihouln.
The glitmU of Uiv niucoiu membrane arc aflecte<]. Their i;ulsHle-«nc
onlttrgo, an<l (Ik- cell'* which they contain are swollen. [ii the lumen of
tlie ouIviIe-<tnc au<l of tlio excretory ilucM exists an nbiimlant mucous
fluid containing piL» corpuscles and swollen celU. ThiM state eorrespODds
In a hy]>ertr»jiliy of tlie glands, appreciable lo the naked eye. Uy pros-
sure a drop of muco-pus can be aqueeEod from tlie orifice of the gland.
Later, if tbo suppuraûon of the glanil eontinuoa, the duct am) tlio eiils-de>
aac arc destroyed, and there only remains a small erosion or round slial.
low uker.
Ciiitoxic Catarrh of tuk Larysx, or Ciirosic Catarrhal Laiivx.
oiTis. — ^I'his aflection may follow an acute catarrh, or it may be the
consequence of a clironiv grnnulnr or tubercular pbaryuf;iùs, or of an-
other iliwase of the larynn . Tlie luucou» membrane is eongcsted, brown,
or grayish. It secretes a mucous or piinfonu tlut'l. The membrane is
thick and it!t jflniids are so iiy|)erlrùphieil thai the diiiu&sc has been called
glandular awpna. Tliia hywrtrapiiy of iho glantU may be observed a$
a senuence of the same conaition in the pharynx.
In inflammations of 1od<; duration, the connective Ussue of the
mucous membrane proKfcratvs, and there results a thickening with a
tendency to the production of végétations and of papilUe more or less
numerous, which may be limited to the inferior vocal cords, for example.
In a marked degree of development, these vcfjctotionB may constitute
small sessile or [it'ituiiculnlv-d tumors. These modifications of the mucous
corium are accompanied hy a transformation of the epithelium, which
beooiues straliSed and si|uamoiu, not only upon the vocal cords, where
it normally exists, but upon the other Aurfaccit, which in health aro
covered with cylindrical cells. This is the ao-callcd dermoid metamor-
phosis of Koerster.
DiPiiTHKRiTie Labtsoitis, OB Cbohp.— It IS eiUier primary, or is duo
to an extension of the lesion first developed in the pharynx, or in the
loner portions of the air passages. It is especially met with in children.
It begins in a local catarrhal inflamination. which soon is followed by the
appearance of false membranes. Those fulso membranes are whitish or
grayish, more or less extensive, mure or less thick, disposed tn aupcrim.
posed layers. The deept^sc layer in contact with the mucous membrane
IS the most recently formed, whilst the superficial layere, the oldest, dis-
integrate, and are thrown off. The false membrane is more or le«e resist-
ant. It may be thick, tenacious, and dtlTicuU to detach; or, on t!ie con-
trary, soft and easily reduced to a graimlar or caseous detritus. Tlicso
Pig. 321.
398 PATIIOLOmOAI. BISTOLOOT or XSi^PIRATOXT A7PAKATD8.
differences in con«îst<;iictt ilepeml Bololy upon Ihc «gc of Uic fnluc incin-
l>rant^. At tliu auUipsj of cliililron wlin cxpovlonito h Urge iguMiitit^r '>f
tvugli false inembrADo, it in A-^toniitliiiig to Bitd «IntiMt itotliiiig in tlie
larynx or trachea «xocpt »orno itiiti;^iiilicaiit pulpy ilctritua.
Tlio cxplaitntion nf this poculiarity of thia fal!<« mernhraiie liaa already
rboeii pven wlitle ilcâcrihing t)ic modilîcations of tiic epilht^litim in tlieâo
i ipecini inllnuuuationit (nee pp. l>>'> and •>*{). Tlic faUe tDembranc expelled
by conf;liing often furmshos a mouM of tlio parts upon which it waa located.
Ill ttic larynx, it may extend over tlic oniiro surfaco of thix c»vity.
liUtotogically thu falso membrane conmiits of fibrin in the form of
filaments, of pti« coqtuwirs, and of epithelial cells. The latter, whether
tliey arc derived from the eîliatcd cylin-
drical epitlielitiiii or from the i^vemenl
epithelium of the inferior vocal cord«, art'
modified in form und chemical componi-
tioD ft» hua been indicated at p. t>lt. De-
veloped at tlio expense of the nuperfieial
layer of the epithelial covering of the mu-
cous oiombmne, each layer last fonm-d is
pushed forward as new cell» ami pus cor-
puwles form under it. They never eoa-
tain bloodvessels in their interior.
Beneath the false membranes the mn-
eous roombr*nc may be bypertroptniil, red,
infillrated, atid softened, and often tlie
are found between thèse two ti>embrai>ei
blood extravasaiions. But moat frei|uently
the subepithelial eoniicclive tissue is intact,
even if the mucous surface appoitra uuevei
anil ulceniti-d ; nevertheless, this tissue is
sometimes intlanied and there may then
exist very superficial ulcerations.
We find in the false membrane» spnre.'^ <>f microscopic fungi, upon tlio
nature and explanaûun of which there Ik mucii disagreement.
Diphtheritic laryugo-tracheilia may exist in the chronic oomlition.
EnrsiPBL.ATOi-3 Lakyxoitis. — Krysipelaa of the face and of Ifai
pharynx, prop!ij;uicd to the larynx by continuity of atnicture is oba
tvriïed, as npon the skin, bv an ina-nse redness, and a pufliness of the
mucou.« coriiim. The cellular tii^ue of the mucous membrane may b«
^distended with serum as in an oedema of the larynx. This condition hat
been followed by faUd suffocation.
Variolous Lauvxhitis. — In confluent variola, the larynx and indeed
tlie mucous membrane of all the air piuwi^es are the seat of postules
nwre or leas numerous. The pustules of the Inrynx have, generally
apoaking, the same form and evolution a» tlio^e of tlie skin.
When the pustules are very nunieroiL'4 they unite into groupe, and
^10 epithelial layer, dej^nerating over an extended surface, furau a veri-
IthBtlnl «lia IB dliililbfirltic tstui
L
IXDEMATODS LAIIYIIQITIS.
Sft9
tiiMo r»l«e mi'mbrkno which in ctruin cases niip;ht bo conrounded irith
the inh« membrniie of croup. After the slioddittjï of the epitlicliam tlio
pimtulo empties ilMlf: tlio mipcrficinl layers of Ûi« mucous membnuw
Diny continue to i>ti)ipiirnle ; there is then forDwd an ulcvr moro or loM
dee|i niul irre^lar.
More severe iiiltnmrantionit, alMcemcs, Mid even perichondrilcs have
been observed toward tlie end of tliid prooes*.
IjABYXCITI» op Glaxi>ebs. — The lemon of the mticouii membrane ia
eharnctcrizf^d by the preflouce "f small miliary ahsc*»aes, ami iiof by ■jraii-
ulitiioiks such as nn- bccd in the nasal fossw and air paa9a;^ea of the
borne. Uroups of tht.'sc ahscfsses unite and give ri^e to ulcerationa.
I LABTîîflms OF Trwiorft Fbvr». — ^The lanmsiiis'of typhoid fever is
I more orleee jçrftvo. Almost always a superficial catarrh of tlie larynx
I accompanies Ihe catarrh of the bronchi nnd tiBchea, bnt sonwtimes ulce-
L ration», vfeli dowribivi hy l^tnii*, mny he iccntvd upon the arytcno-epi-
^K glottic Ugami'uu, iipoii the epif-Ioltiji in tlio m-ijihlwrhood of the iiryU'uoid
^^K cartilagea, at the ttame time that they arc found in th<^ phitryn.t ati<i in tlw
^^HOqBoptiaf;)!)). I'ericliotiilritiii or an ivdenialou» laryn^iii^ may result.
^" iS'iffiAUif betray» itaelf in the larynx by catarrhs, mucous patohe:!, deep
or superficial ulcerations, and all the accidents nhich may renult Ihero-
from, as perichondritis, œdema. etc. The mucous patches result fmui a
dreuiBscrihed irritation of tht- mucous membrane characierine.! by a slight
elevation and u thickening with proliferation and swelling of tilt- epithc-
liura. .\ll profound «ypbiliiio Irsion» of tlie mucous membrane occasion
a proliferation and a production of connective ti^tue uitually much grejiter
than in diiteasc!) of the larynx due to otlier causes.
Tultrfuhir jMrtfuffifiM aiiio varies iu character, according as it may he
maiiifcs'.ed by a simple catarrh, by laryngeal tubercle», ulceration», or
peri chondrites, etc.
•
(El>FMAT0tl8 t.ARÏSGITI»; ŒOSMA uP TUB (ÎLOTTIf!. — ^This lesiOD
wbetlicr it is primarv, or is consecutive to one of the affections already
mentioned, to i^cneral anasarca, or to traumatism, consists tn a aeroos or
pruriform infillmtion of the submucous connective tissue.
'Hie ccdcma is most frequently limited to the upper part of tbe larynx.
'Hie arytcno-epi;:lottic folds, swollen, œ<lematoui<, trembling, and semi-
transparent, tend wobtitcrate the openiti;^ of the larynx especially during
inspiration. Tlio arytenoid region i!i<riJematous,n« i* also the epiglotliit
atiu bsM. .Ml the other part» of the mucous membrane may, however,
be the seat of a similar swelling, llie œdema ia uaually caused by an
ulceration or a perichondritis.
The mucous membrane is livid or rosy red. When incised, a notable
quantitv of a puriform or a transparent serous fluid escapes. The micro-
scope shows this œdematous connective tissue to be composed of fa^IcuU
of connective tissue separated from each other bv a transparent fluid con-
taining granules or a reticulum of fibrin. In this fluid large cells, more
or less grnnular and (tistciidci), are alm> found, as Well as pus and h\obA
corpuscles, the i|Uttiitity of pus depending much upon ulceration, etc.
400 pathoÎS
ISPIftATOI
TARATES.
l'ijjKiiorM Lahyxihtis.— Acconling to their cansea Uryogeal u1«cr9
Tary mucti in theiv forai and grarity. We bave eeea an intenM catarrfial
laryngitis determine the deslructire suppuration of a inticous f^iv/i—f-tlli-
eHiar ulceration, such as is frequi-ntlv seen in the laryn-jitis of nht)ii»)s.
In typhoid fever, the deeper ukere with vertical walln and goncrailT fillotl
vritli a caxeoii^ detritus, ori-^inate, in all prolwbility, from ft typlioit) ne*
formation vthteh has for its »vat a gland fuUivlu. UlcomtiOM duo to
variolous pn»tules and to «rpliilis B.r« «bftUoirer, and more or \tm «xt«n>
«ive : they result simply from a destracUon of tbc vpitlteliftl covering.
Tliu «xpoited coriiim of the mucous membrane in co«g6*t«d, nmre or le»
gramilar, and moistened with pna.
In Urtiaiy fi/jifiitit, the bottom of the nicer is covered with granula-
tions «nd the aubmucous liasue is thickened, indurated at times, and very
rasoular. Syphilitic ulcers may extend over a large aroa of the tnuooai
membrane of the larynx and even of tlio trachea. When muted wpi>n
the ejàglottis, tliey often cause a loss of the substance of ito free Iwrder.
They fn;(|uent}y gtve rise to new formations of connevtivu tisstwt vege-
tatiuj; in the form of polypi. These ulcers may heat, but the new con-
nective tissue hft« a great tendency to contract like cicatricial tissue and
«aiuc deformities.
Pnlmonarff phthim is much tite tno»t common cause of laryngeal
ulcers.
'L'he ulc«rs start from a very intense laryngo-tmcheitia, and Qsually
extend into the trachea and bronchi. The mucous membrane is nsually
much coDf;estcd, and ia covered with muco-pus. Upon the noD-ulcorated
parts tbc layeiv of cîlinted cyliudrlcal epithelium are still prescn-e<l.
The lesions which cause the ulcerations nre complex: fir»t there form
tuberonlons granulations, primarily developed under tiie epiUielium, more
or les» numerous, isolated, and confiuont; then follow follicular uhxn-
tions.
In the place of the ginnd destroyed by ulceration is seen a little cup-
shaped circular depression. Theae ulcer* enlarge, and may reach 2 to 3
mm. in diameter. Their floor is grayish or rosy and is slightly de-
pressed. Thcv may unite with each other and form a large ulcer with
festooned borders. It is rare that tubercular granules cannot be seen
upon the flour or ed^cs uf these ulcers. Tlic vocal cords at their jtoint
of union, the corN themselves, the arvtcnoid cartilages, tlie epi<;loltis,
and the interior of the ventricles of Morgagni, are tiie most freipient
seat of Itiese ulcers. The ulcers extend in depth u well as super-
ficially.
'i'he exposed fibrous tissue of the vocnl corils may itself bo eroded;
the free border of the epiglottis, also, frctjucutly presents loss of sub-
stance, involving destruction of the cartilage.
The submucous connective tissue arouml the ulcerations is much thick-
ened by a new formation of embryonic cells, or it is infiltrated willi
serum and pus. These lesions affect the function of those portions of tlio
larynx where they arc located.
The muscle» arc aho sometimes invaded. The inlcrnmscular connect-
ive tissue may be infiltrated, and the fasciculi themselves undergo fatty
degeneration.
TtlMOItS OF TUB LARYKX. 401
iilfitn nnil hInicvmcs of thv liirynx maj câii^ic u {icrfonttiuii,
II tliu |>iM mttjr «how itaolf in the .-xitwittiineoiu tittiuc nixl diwhnrKu
eittciriorly, or it ni»; empty into tli« ccs<>(iha^U8. The«c perrorattrjQit nro
almost «1w«y« nccompnaied by perivhomlritîa.
rKHic'iioNnRiTii^. — SiippiirAtive inH&mmatioti of iho [tenclionilrhira of
lite cartila^v* of lti« Inrytix ni«y ariae apontaiicotuly, but it ia idoaI frc-
i)uenlly caused l>,v extetiûon of th« inflaiDtnation att«TKling dc«p ulc«n
I of the larynx. XererthfiloBa, it appears to have be«n very frettueDtly
DbBerved in typhoid fever.
In Mvere laryngitis of ton;; duration, when the submueoHS G«llular
tissuo in nrolifcratvd, the tiisuu which surrounds the cartîtag* ia alUirod
in a siinilur manner, nml the curcilu«es themselves undergo modifications
of tmtriliun. At one lime u cak'ureous infiltmtion of tlieir ground «ub-
atanoe aiul tif their ciipi^iiles i* oWrvcd ; nt another, a genuine ocsiGco-
|tion may W ite«n, with ih^ fornuitionof tru« bonecorpUMcloKiOUt. Thtfse
MOtM of tlic uarlita)^» nre not infreipiont in laryuj^enl phthiiii^. The
bpiiZlutli:* is ofl«n intiltratcd with iratcareou» ii»\la, but it doea nut oaaify.
The irritation of the [wrichondrium and of the cartiln^, nhich ia
■nanifeAted by nroHferaliona, is of iUelf an additional <:aus« of au]ipura-
''irc ]>ericliondntia.
The latter in characterized by the formation of mi5 corpuscles between
^the pcrichondriuiu and the eartjla;;e. The pus uotaohes and separates
the perichondrium from the eartilago, which, isolated from it« nutrient
metnoranc» must ncci-ssaril; mwrtify. In tlic necrosed cartilngw of
typhoid fever, we have wtm the fundamentiil !<uUUnce of the cartilage
very granular and (ho carlilage cell.i Imided uilit fntly granule.-). The
aluceaa by which the cartilage is aurrouiided spreads amon;; the sub-
mucous tissue and the articulations, and {Ktints upon tlie larynx, upon
the plisrynx, or ujiou the skin. It is not alow to open and to discharge
with the pus, fragments of eartilago, often calcified or ossified.
Inie cricoid cartilage is most frerjucntly affected, next comes in order
of frequency, the thyroid and the arytenoid cartilages. In the first two
eases pcrt'oratiun takes place cither upon the Inryngcal surface, or upon
the cutaneous side, and then there may result a subcutaneous oedema or
occasionally an emphysema. When the arytenoid cartilage is affected,
the perforation is into the larynx, and tin.- laryngiMCOjW will therefore
reivder tlic diagnosis of this lesion easy iluring the life of the patient.
V TtiuORB 0? TiiK Larynx. — There are a few recorded obseri-aliona of
mtfxonula or mucous )>olypi of the larynx, resembling small cystic ])olypi
and formed of mucous tissue covered by a thin mucous membrane. Tliey
vcre seated upon the base or the posterior aspect of the epiglotUs, and
re «entiiclcs of Morgagni.
Fibrtnnattt, or fibrous |iolypi of the larynx, arc much less rare. They
spring from Uk connective tissue of the mucous membranes. They arc
generally «mall, from the si^o of a hemp-seed to that of a pea ; they
increase slowly ; tliey are se«silo or pedunculated ; their usual scat
^i« upon the inferior vocal cords ; they are hard, resistant to the scalpel,
^■tnd their substance presents all the chnruclers of fibrous tissue. Their
402 PATUOLOBtCAL UTSTOLOOY OP RKSPIRATOBV APPARATL'S.
surface U Bmootli or irregular, ami is covered by several \»yen ofAtnti-
fied pavement «.■pithcliuin. The nature of tbifi epitlielium U alwa^c Uio
niDO. Soinotimes the aiirr&co of these polypi is ulccntted.
Ttt&ereieê of the Inryiix nr*'. wlioii encountered in antouues, aimuyn
found UMOciatvil with pulmonury lul>crcul(isiH. but it is posaible tbftt tulter-
ctilosis may c-otmnence in tbv larynx. Tu)ii-ivlc <;rAnulos of the larynx,
denied by 1 -itiii*, have been pliivcd beyond <loubt by llokitatvaky, Vtnchovr,
Foeritor, etc., wid Ihey are coiniuoii eiiou^li hr lîicni to be easily etudiod
.ID their different tttaged. At their coinmunceRient, they appear m» sniall
ry or whiliflh salient poinlci, ami are diiitingui^hed from «wollen glands
the fact that they have no deprei<.4ioti at tlio centre. A lliin fti-ction
rthroHt;h one of these nodulea shown it to be covered by a layer of oylin-
Idrical epithelium, and to coatlflt of an agglomeration of elements which
rcbaracleriite all tubercle ^nulea. These granuletl developin the Hiif>er-
ficial Inyor of the mucous corium. They are discrete or confluent, attd
are usually less numerous in the larynx tlmn in the trachea, l^ler,
when the granule has become caseous, the epithelial investment ia tost.
At this time a granulation may sometimes be seen projecting from
the midst of nn erosion of the mucous membrane. The gninulo itself
L'Diaj bo etiminatc-d in frftgmenU, with the pus which the ulevnttitig sur-
rface sccretu». The bottom and i«ides of a tuberculous ulcer consist of >
tissue, more or Icm titick, composed of tubercle granules.
Primary r/trdnoma of the larynx h extremely rare. There are, bow-
ever, a lew recopled obiter va tioiut of eiiceplialoid carcinoma oommvncinfl
ill the larynx. The tumor shows itself under the form of rose-oolor
nodules, which lift up the umcous membrane, develop rapidly, invade th
submucous tissue, the connective tissue of tlic muscles, and rapidly cause
death.
Ef^hnnJrote» and oit.eonvtta have been met with upou the totemsl
aspect of the cricoid curtilage.
I'ftvonieiit-cellod rpilhrtunnii develo))^ in the form of granulations and of
condylomatu which Hprin^ from tl)e nurface <>f the niiiuouj membrane,
and are coven-d by a ihii.k opa<pie secretion. Oniiiiiirily it i* easy (O
Ltcc that the tumor sprln;<s from the anterior wall of the i>:.w>phagu^
'from the pharynx, and that it projectn into the larynx only after liavin
penetrated ita fibro-cflrtilaginous framework. These growths correapon
exactly with the description of lobulated epithelioma (see p. 14l!). Tha
surface of thcde vei^etntiona is covered with cylindrical epithelium, 01
Lmorc frenuontly with the piiveuient variety. The vegetations may be
r uloenited and their epithelial cell» disintegrated and mixed with the mucus
whicli coven! them, thus forming an opanue fluid.
Kpitheliomnt» must not be confoun>led with papiUoniata of the larynx,
lind in order to avoid this error it A<»:* not suffice to examine screpings,
but sections must be made after previous harrlening, and must be well
studied.
The papillomata, ito freipient in the larynx, are covered as ve shall
soon aee by layers of pavement eiiithclium, and these eleroentd are fouMJ
in lar;:e numbers when one sludien the papillomala by the scrajungs.
The faplUomala or pajiillary polypi of the larynx are growths which
are most fre<iuently seen after tubercles. These tumors have a cauli-
lirPLAMMATIOX OP TRB TRACHEA.
flower apitcanncc, nnd présent * taen» of primary ant] secondary ^raitU'
Ut)ou«. They iniiy «onsii»! of a nmntnir of fine salient villi. 'Hiey bftve
ft ^rvAt temlvncy id i*pri.^a<l, htit tbeir l^a.'W U rery diiilinctly pe<lunculate<l,
mill tlieir vegcl«liotu are loiij^r ntnl more distinct frotn eacli other than
iu «nnïinoDUi and epithelioma. Moreover, ncitlier Uie tonucct)v« Ihmic
of itiL' mucoiiA membrane nor the submucoiu cellular tissue ia ioradod
by llie morbid growth, while the contrary ia true of the last^mentioned
tu mora.
Ttio favorite seat of papiltomata ia at the an^^lu of junction of th«
inferior vocal corda or upon the cords thcinaclves. Their atrueture is
titat of all papillomata. namely, primary and accondnry pupilltv, conaiat-
inj; of a amall i|uanlity of eoimeciivc tisaue wtth reaaol», ami of a cover-
inji; of atrutitied pavement cpith<.<liuni.
A'i<»'*m'tt(t or ;;lamliilar polypi. Hypertrophy of the glniids in the
larynx in chronic eatjirrhal laryn>^tia liaa already hetni nienlioncd. 'Hivm
Iiypcrtropliic» arc, properiy «peaking. i*mall adenomnta. 'Hiey may, in
very ran: case», ("row unite prominent and become pedunculiited, 'llie
ciil«.d«-8nc of iheae hypertrophied gland» are larger than in the normal
state, but their epithelium pre«entft the phytiiolopcal form. At the aur-
face of these tumont we alinosl alirays find papillary excrescence!!, and
bynerlrophied ;;landfl are i|iiite constantly met wilii at their ha^e, ao that
polypi of the larynx are very fre'|nently mixed tumors iu which itiavorjr
difbcult to say which predominates, the papilloma or the udenomtt.
Secondary lifmiJiaJen'/mntaoT lenka;mic ttimora hnvc been several tituea
observed as iniiill soft flat nodules «eatcil iti the tiirynx, trachea, and
brotichi. Their seat, according to Virohow, ttt near the mouth of tlie
^awl.i or upon any other point of Ihe mncoiu raeinhiiine.
I'anmSU». — Young nematode worin.t have been found, after death, in
tlie larynx and bronchi.
Sect. IIL— Trachea.
Inki.ammation. — Thedifferent varielie:> of inflaramalions. the acute,
chronic, diphtheritic, variolous, syphilitic, and tubercular, which have be«n
de^ribed, à nrofft: of the mucous membrane of the larynx, pre»nt the
«ame anatomical characters in the trachea.
Tuberculous and follicular utrer» of the mucous membrane are very
cotUBMHi, and often very extensive and aorpi;;inoua. They are especially
toc«t«d on the posterior wall of the trachea and in the mncoua membraue
between the prominence of the cartil&;;inous rings. Sometimes a deep
tilcer communicates by an anfractuous fistula with a caseous abscvas of a
nei;;hboring tubercular lymph gland.
Perforatim» of the trachea may result from ulcers of the œsnpha^a,
abwees arising in the adjoining connective tissue, cancerous growths of
the lymph glands and of the œsophngus, aneurisms of the arch of the
aorta.
CariHHOma ncrcr originates primnrily in the trachea, but it is not very
unusual to see in the cclluUr tissue of the mucous membrane secondary
403 pATUOLOdioAL nisToLoar of respiratory apparatus.
surface i» smooth or ii-rcxnl»'". anil is covered by several layers of mnti-i
fied pavcoKint t-pitlidlium. The oaturc of Utis e|)ithelium » alwayn thtd
same. Sooictiincs the sitrfncc of tkoso polypi U ulcerated. i
Tuterdi» of the larynx arc, when encoutitored m autopsies, always
found s««oai«t«<l witli pulmonary tiiWroiilosM, bul it \s possible Uiat tuber*
eulnsiit may comnmiiue in the larynx. Tiihorirtt- jirjinulM of tlic larynx,,
deiiiod by i.niiis, jiavo been jiluced beyond doubt by Kcikiumsky. Virobow,
Foerstcr, etc., and tbey are tomnuni enoui^h for tliem to ho easily Mttulicd
in tlieir diftcrent àla8:ea. At their commenoement, tbcy appear «« Nmall
gray or whitish salient poinu, an<t are diAtinguinbed from liwollen jçlaitdi
by the fact that they have no depression at the centre. A tbin st^ction
through one of these nodules shows it to be covered by a layer of cylin-
drical cpilheliiim, and to consist of an agglomeration of cleuienlci whiol
cliaractcrixo nil tubcrclo ;;ranules. These granules develop in the aa\ieri
■ ficial layer of the mucous coriuin. Tlicy are discrete or contliiool, ami
aro usually less tnioicroua in the larynx than in tlic trachea. I^ter,
wlivii the f;rannle has become Gascons^ the epithelial investment is loft.
At this time r ;;rannlalion may sotnoUmcs be seen projceiin;; from
the midst of an erosion of the mHOOiH mombraDe. 'Hie groiuilv itself
■ Diay bo eliminated in fraiinicntM, with the po* which tbo ulcemtin<' Mar-
mee aeoretcii. The l>ott.>iu and *hiv* of a, tuberculous ulcer conaiit of a
^tano, more or lean thick, composed of tnhurclc granuleit.
~ "Primary careinotna of the larynx ia extremely rare. There are, how-
ever, a few recorded observations of encepbaloid carcinoma commencine
ID the larynx. Tbc tumor shows itself under the forni of rosecoloreu
Dodules. which lift up the mucous membrane, develop ispidly, invade tbc
submucous tissue, the eoiniectivc tissue of tbc muscles, and rapiilly cause
death.
Scchimdr'itrjf anil ottfonuUa have been met with upon the intenuil
Mpect of the cricoid ctirtilajce.
I'avement-celli;il efifhtliomu develops in the form of granulations and of
condylomata which spring from the surface of tiie mucous membrane,
and are covered by a thick opaijue secretion. Ordinarily it is easy to
see that the tumor springs from the anterior wall of tJie œsopliajius, or
from the pharynx, and that it projecta into the larynx only after bavinf
penetrated its fibro-cartilaginous framework. These growtha oorrespooa
exactly with the description of lobulnted epithelioma (set- p. 14tf). The
surface of these vcj^ctations is uovereil with cvlindrical epithelium, or
more frequently wiili the puvciiii-iit vnriely. The vc^tations may be
ulcerated and their epithelial cell" (li^lute^nitod and mixed witli the mucus
which cover» them, thus formiuf; an opuipie lluid.
Kpitheliomata must not he confounded with papillomata of tlie larynx,
and ill order to avoid lhi.i error it does not aulKce to examine scra)>ings,
but sections mu.sl be made after previous banlening, and must be well
Studied.
The papillomata, so freijuent in the larynx, are covered as we shall
soon see by layers of pavement epitiieliura. and these elements are found
in large numbers when one studies the papillomata by the serapiti^.
Tlie papillomatit or papillary polypi of the larynx arc growths which
■re most fre4UentJy seen after tubercles. These tunion have a cauli*
IXPLAMllATIon OF THE TRACHKA.
I
I
\
I
^
fiowcr appcftranoe, at»t proMut a xam» of primnrv atxi ««condftrj ^nnu-
latioiu. £\\ty nuv conitUt of n immliur of fine guiliont villi. They linre
» )!rcitt tvniletiuy to »]>reail. Imt tlicir Im.sv is v«rT dintiiiotty pei]uiiciilnteil,
mit) tlii-ir vcgetatiOD.t are loii^fer ami nioro dHtiuct froia each other than
ill c>in.'inoiu& ami e{>ithclîoiua. Moreover, neither the connective tÎH»ite
or (he iniicoiiii luembrane nor llie submucom cellular itssue is invaded
by the morlid ^rowtli, wtiile tho contrary is true of the lasC-mentioQoil
tamors.
Tho favorite aeat of papillomata is At the an<;lc of junction of th«
ioferior Tocal conls or upon the cords thcnist-lves. Their etracturo U
that of all p&pitlomikta , iminely. primary and «ccoiidiiry papillto, consist-
ing of a stnall <iii>ntity of connective tiHsuv wHh vchbcIh, and of a ciiv<.t-
in<; of «tnttified pavement epithelium.
A<lfH4>miil<t or glandular polypi. Hypertrophy of tho glnnd« in the
larynx in chronic caUtrrhal laryn^iti« bn.» already been naontioncd. Theiio
hypertrophies are, properly spenkinj^, Hnial! adenomata. They may, in
very rare ea»cs (;row ipiite prominent and become {M'limculnied. The
cul»-de-3ac of the^e hy|>crtrop)iied glanda are larger than in tho normal
state, but their epithelium pre.ieots the physiological form. At the sur-
face of these ttimora we almost alwavâ litid papillary excrescences, and
bypertrophied glands are i|uite constantly met with at their base, so tiiat
polypi of the larynx are very freqaently mixed tumors in which it ia very
difficult to say vihich predominAtes, the papilloma or the adenoma.
Secondary lymphadfH-m'itii or lciikH.'nnL- tumors buvc been sovcnd times
oWrvcd ai graall soft flat tioiluics seau'd in the larynx, tracht-a, mut
bronchi. Their «-at, acconliiig lo Viruhow, îm m-nr the mouth of the
glands or upon any oUier ))oint of the mucoat mc^mhrane.
I'<ira*iu». — ^Youiig nematode worms have been fi>un<l, after death, in
the larynx and bronchi.
Sect. III.— Trachea.
T*(rLAMM.\Tlo<(.: — The-different varieties of inflammation», tlie acute,
chronic, diphtheritic, varioloua. syphilitic, and tuhereiilar, which have been
described, à orop»» of the mucous membrane of the larynx, present the
tame anatomical characters in the trachea.
Tuberculous and follicular ttlfer» of the mucon» membrane are very
COBunoii, and often rery e.\ten»ive and serpiginous. They are especially
located on the posterior wall of the trachea and in the mucous membrane
between the prominence of the cartilaginous rings. Sometimes a deep
nicer communicates by an anfmcttious Bstula with a casoous abscess of a
nci;;)iboring tubercular lymph glaod.
J'tr/orali'm» of the tracheii may result from ulcers of the œsophaf;ug,
aWvM arising; in the adjoining connective ti»8uc, euucerous growth» of
tlie lymph jilands and of the «ciKiphaj^, aneunHms of tho arch of the
aorta.
(\tr(in(nna never orijiinntcs primarily in the trachea, but it i* not very
unusual to see in the cellular ti««uc of the inncous membrane secondary
404 PATUOLoart
Î.<»IY op It!
Ari'ARATUS.
carcinomatoua noduleti wliich xre licmiâphcrical aud inoro or low volu-
mi no us.
Secondftry Imhemi'- growths bave «lao bciMi mot wîtii.
In the aged tlio tnicbeat cartilagirâ arc 8oniL-tiin«s calcified mmI OMsifivlt
and may present exostows, Kven an intimate union ol' two or inorw ring*
may be vstubliiibvd by fonuation of bone-
Sect IT.—BrouolLi.
Conomtiok; IIkkorriiaor. — Congestion of tlie bronclii precedes uid
aocomjianies catarrhal and other inflammations of tticae tubes, and a
present in almost all diaeaaeii of the air paiaaj-e-i and of the heart. It 'a
'observed also in many fevers, such as the eruptive fevers aiw) typlioid
fever. It le characteriEcd by redness and liilncss of the Vf-sit-N and
Bwelling of the mueous membrane, and most freijucnliy, even lu pawivo
congestion, by a secretiOD of mucus. The inner surlace of tlic bronchi
is red, often u dark maroon color. Kccliymoses may appear in tbe
mucous membrani.-, particularly in the e\untlioniatn, in typhoid fever,
in scorbutus, And in asphyxia. Then the broiielnnl mucus contains a greater
or leaser number «f red blood gtobuK-s. Large bicmoptyMS arise from
ulcerations of the bronchi, from puhnonary cavities, from pulmonary apo-
plexies, or from rupture of ati aneurism into the bronobi.
BnoNCiiiTifi. — Catarrhal inflammation of the mucoos membrane of the
bronchi, cither acute or chronic, is excited by the same causes aitd pre-
sents, in H gcni>ral nay, the same histoloj^ical •:han;;cs as doi'S that of the
larynx. Limited to the lar-^o bronchi, it is nut dungerou», but when it
invades the small bronchi it is ol^cn fatal, especially in children aiul in
the hff.'d. In these grave ease», the bronchitis t* rarely simple ; it is com-
{>licated with lesions of the piilnionary ]iarencbyma, such a» congestion,
obular or catarrhal pneumonia, atl^îecla«i>l, emphysema, and lobular
I gangrene.
JitUtme hrt'Hfhiti» of the small broncbt, or capillary bronchitis, may
be such that tbe inRammatory thickening of the mucoiu membrane,
added to the products of exudation, prevent the air from reaching the
pulmonary alveoli. In other cases, the diseased bronchi, very red upon
Uieir internal anrface, which is covered by a puriforra mucus, appear to
bo dilated. The connective tissue of the mucous membrane is thickened
and the bronchial tube is more rigid than normal : the natural longi-
tudinal rugic of the mucous membrane, which result from the contraction
of the muscular tnnic of the bronchi, become elfacvd, and the internal
«nrfaee of tbe bronchi is smooth. This condition of tbu bn)ncbial tubes
is most fre(|uent1y seen iu broncho-pneumonin. In severe bronehitU,
whore the secretion is muco-punilent, the cylindrical epithelial cells hare
dc»i|uamated, the glands are lilled with emhrynnal celU and pus corpus-
cles.and tbe surface of tlie mucous membrane, may present an un|iolished
aspect, due to the formation of microscd]iic papil'»» or granulation^^.
Dif^'hlheritic fironehiti* is seen particularly in children, as a complica-
tion of croup. It is then generally associated with pulmonary congestion^
DtLATATtOX or THE URONCfll.
40ft
Cslla flvn til* •polnni sf ksW
hroHtillU. Bhovlst <hf mloaM
itiU*. ïaïuv of Lb« «4lU ftlvo wb-
anA witi) more or less cxtonslrc nrvfts of 1*12.322.
hrnnc h Ik pneumonia. In uliilts it t» not a
vtTir riirc «omplimtion of broncho-pnctiraoiiia,
or of iteiiw pneuiDOiiin.
Chrnnir ttrfiufhiti», otïnn related, a8 cftii!i<!
or effect, to empliyiiciiia or to <li!icaiie of the
heart, is characterineil Hv a violet or slatc-
jfray color of (lie surface of llie iimcnu-i mein-
hnne. The connective tisane of the latter
is fro*inentIy thickened by the formation of
fihrooj tissue, which may vcfçetato at the
eorfocc uti^cr the form of smiiU pnpîllnry
excrescences. The niuciu secretcil mnj «c
transjareiit, f^elatiiiifonn. an<) itmnll in iinaii-
tity, or it may be inuco-]mrulei)t, or it serous flui'i may be exuiled in great
a I'unilance.
Chronic bronchitis may be Acoompanicd by liilatatim of the bronchi
ami by uicerationa.
DtiJtTATtos OF TUB BROsrHl ; BuONciilKt'TASFS. — ^The dilated bron.
chi. the mucona membrane of which is thickened by acute inflammation,
reailily return to their normal condition; but under the inftiK-nec of a
chronic process, such as branchitis, chronic pleurisy, chronic pncitmonia,
these laocs remain dilated. Almost ulways thc^ tissne which surrounda
the dilated bronchu» is induratad and present» the characters of intersii-
liai pneumonia or of piTi-hroiidiiti*. 'llu' dilataitonof the bronchi may he
cyliudrical and uniform ihrongliout their hMi;;ili^a rare fonn. One or
more bronchi whose diameter i» thus increa.*ed sometime» terminate near
the pleura in an ampulla. There may he several cylindrical or spindlcfonn
dilatations alon^ the course of a bronchus and its branches, as is often
oliserved at the apex of the !un;;8. The dilatations arc connected with
one another by brnnchinl tubes of normal diameter — the ninnitlform dila-
tation of Cruvcilhier. A third am] most common furm is an ampullar
or sacciform dilatation, gt-nrnilly »injile and frenucntly very lar^v.
Several of these ampullnr cnlarjçementa may conimnuicate with one
«notlH'r by the intervention of bronchi more or Icm dilated, whence may
result the convcrs^ion of a lobe into an alveolar mass, the cavities being
sep«ntt«d by shrivelled and indurated pulmonary tissue. The favorite
location of thexe dilatations is at the peripht-ry of the lung, and there
always exisfc* in the*e cases a chronic pleurisy, marked by the fihroiw
thickening of (he pleura. Beyond the dilatation, the bronchus and its
terminal branches are atrophied, or some of the bronchi may be con-
verted into cysts. Wo sometimes find cystic cavities, more or less volu-
minous, at the apex of the lun-is; they arc lined with a mucous surface,
and contain a nuieous tluid. They have been considerc<l as bronchial
dilatations, isolated and closed up by the obliteration of the )<mull
bronchus upon which they have been formed, Sinuses exist independ-
ently of bronchial dilatations. They should not be eonfoiinded with cer-
tain space» which may exist between the phura and the faW fibrous niem-
braite^, which are due to chronic pleurisy. In the walUof these sinuses
406 PATUOLOOtCAL HISTOLOQY OP RBSPIRATORT APPAHATUB.
in the luog proper, the pulmonary tiMue is readilv rccogniuble. Tiw-te
cavities somodni<?s reacli t!io volume of a pijieon'n egg. anil wlicn iIict
Bre incised, tlieir areolar wall presents the appearance of tlie lung of a
Tbeintcnmlsurfflceoftbcbroocbialditntationâ, it) recent cases or vrheD
they arc not coiiipticated by ulcération or by ^an;;rciMi, is lined by a
miKous meiiibmni.' which, tvitliout intornijrtiini, is cohtimiouïi witb tliut of
Un' Donnai Iminclii coiiiniiimcntiii^ willi tlio iliintiil |M>rtion.
Tlie broDi'liial iiiiie»iL'< iiicitibriiiie '\« in ()iii< liH'tiiion rufy, gmr, or
Hlnty, mnciotii, Kliiiiiiii;. nml tbin. The ^flntuls arc «mall and ntroplned :
Ibe oiirlilages are also to be (•oen. as well as llif nlicf of tlic niiiM-nlar
buiuUcH, wbich are far from forming a continiioii:< nicinlinine. Ity micro-
scopic examination, we leani Ibat tbe cylindrical epithelium Ia well ]ire-
served. Tbe aiihmncous tisfiiie, usually ricb io cells, has Iwl ttie greatcvt
I portion of its clastic fibres, wbicli have been atrophied and destroyed Uy
ttlie repeated inflammations. Tbe bloodvessicis are sjnnll and tlie capillary
^nesboa are large. The muscle fibres are dissociated, hut are ti'it <le>
Btroyed. Tbe disiipiicarance of tbe eliistlc fibres bere.whîUt tlioy are
preserved in the nei^bbnrinji jniluiouary tiMUe, furiiisbcs a {lussiblc
explnnatioi) of tbe dilaiiun of the tube.
The niucotiA nicmbruTie of the <libitationR iit not always tliin ; it may
happen, on the conlniry, that iti» ertuneetive tmxw amy he thicker than
itornud. There i^i tbon a hyperpla.iia and the elastic fibres arc dci«tmyi.vl,
Ikt in till» pi-eceding ease.
I'lie absence of elastiuity of tlie bronchial tubes, tbe induration of the
suriMiuiding tissue, iiitt'nttittal pneumonia, chronic plcuriscs with adbe-
aious. are ihe patliogeiiic causes of dilatatio».
Broncbial dilatation iit exlremely rare in pulmonary tiibcrcutosis.
In old dilntminn» or when thi- mucouit im-inbrane i» the sejit of an
I înteni^e purifonti eaturrb, «t llic .■'ame time liiat. the sis:retio» clianges
cbarncter tbe uiueon.t niemhrane rc'ddenit, lu.'ieii itt polish, becoaM>» very
vascular, thickens, and, as in chi-onic catarrh, prcHents small |]«pillary
vegetation»!.
When tiie formation of pus is very abuwlant. the epithelium desc[uam-
«tes and an ulcer of varying extent and iteptb is the result. The inflaïu.
roation, tbe suppuration, and the rciention of ihe pus impress upon the
cavity and Its contenu new ebaracters, wbich cauao tiie cavity to closely
rescinblo large old tubercular cavities. The mucous membrane no longer
exists ; and the only remains of tbe primitive structure of the bronchus
is a mas» of embryonal tiswue. Tbe surface of tlie cavity »ometîmes is
covered by a gniyi.*h adherent iayer formed of connective tissue in jwo-
eccs of mortification. 'I'hts U a sort of tu/mr^'-ial and curable ijangmte,
which amy be compared to tbe death of conncotivo tissue tti phlegmon.
The puriiienl contenu asaume a browniii'b color, a fetid odor, and a cer-
tain fliiiility. Tbe pus corpuscles are tilled witii fatty granules, and
crystals of margarin and cbolesterin are often found. >lixèd witii water
in a glass, tliis pus readily dissolves — an indication that it contains little
mucin. Similar oharacterislies apporlatn to tbe sputa.
The lesions which belong especially to dilatation of the bronchi, or
«bich are caused by them, have a slow progress, ïlw wall of « dilated
TI7U0RS OP THK BBOHCnf.
407
k
bronchus may CKlcîfy. More rre<)ucn(ly Ihc lironehi (dilated ami îsnUtei)
from Ihe roin of llio ftërinl tree, are fiUetJ wHU a IrowtiisU nearly solid
maiKit of cafieoiiK ptis ; after having removed tiie contenu, tlic structure of
the hrODChial wall in recognlKablo.
l'UîEiiATios OF THE Bronciii.- — l.'lcors of the Iironclii may ba jçlandu-
lar and rery superficial, or they may he due la au iii[«iiso 8U[^ratiT0
bronchitis accompanied by points of purulent pneumonia, as in purulent
infection, typhoid fever, ete. : at other times they ouiv be caused by
rarioloMs pustules, or by pulmonary syptnlis of ihc new-born ; but Iticir
Bio«t freipient cau^c is pulmonary ;:^Ti;;ri-iie bihI tuberculosis.
'lliese different causM tniiy octa«fin pi-rforalion of the hronchu» from
witliout inward, jurt an well as ulcers may caiwe perforation from nitldn
outward. Aneiiri^mx, nmlijiçnnnt tnmorN, pleurisy. sii|ipunittft» of the
bronchial lymph ^luniU, may ul.->o he iinndtervil anion}; the causes of ]jer-
foralion of the bronchi.
Ti'iiuns OK TiiK nunxnii. — Kipoma lifta been observed hj RoUtansItT
in the suhmucoiie collular tienne and forming a prominence in the lutl
broncbue.
Caicificathn and true otgHt'ition of the cartila^s is not extreiucly
ntrv in a<;ed subjeec« of chronic bronchitis, at the division of the trachea
and iu the prinuiry bronchi. These tuhc-s then livi'ome ri';id. A Kimilnr
proeeu may appear in the small bronchi, hut it iloem not iR-ce«*arily fol-
low that evtTv osiiGoiu Hpi<ride, whîtrh i:! aiTidmitaily ffunui in the Innpi,
I should be eonaidered lu connected Mith oHsiticaiionti of the bronchi or their,
cartilages.
Careinotna is never primarily found in the bronchi, but it mav reach
there by extension from a tumor of the mcdiastinum, the lung, the œso-
phajjus, or the bronchial inlands.
TuheretfM of the hi-onchi are vcçy common, and the Icjnona which tbey
dpti'miiTie here are very easily studied. Tubercle j^ratmlc» have the
Nunc dinpoifitiou. the same orijitn. and the fume t^nnination as in tlic
larynx and traehen. llic alveoli of the puliiKmnry ti««ue «urrciuudiu}; tltiK
di^eaited »y>nt. heoomr filled with proiUictK of iiiftammatory oxudation,
and couitlitule a itnialt lobule of lobular pueiiiiioiii» («ee tig. 228) which,
when the .imall hroiiehnn in ulcerated and destroyed at any point, will
soon become a minute cavity.
Tubercles in the bronchi give rise to an acute puriform catarrh coin-
cident with the suppuration of the no<luIes of ttibercular pneumonia and
the rapid formation of a laree number of mnall cavities ; or, m the case
of nodules or lar;:e masses of caseous pnciunouia. we may have a caseous
bronebitis. l'p<}n Mction, tho bronclii apiwar completely filled by a
drA-, gray, or yellowish exudation, which is apjMircntly cohervut but is in
reality friable.
This ca.4eoiin mttn» nf onmjiosed of granular pus corpuscle* and of gran-
ular and deformed epithelium, which become reduced to granule» or to
amall fragments. The latt«r were at ono time described a» tuhervle cor-
Duscle.1. Examination of thin section* shows the mucous niomhranc to
reduced lo iu connective tissue which i» difTuselv inllltrittod with
40R PATnOLOOtOAL HISTOLOOT OF RBSPinATORY API'ARATUS.
nomorous small cclh (tiihcncular peribronchitia), nr th<! celU mav form
roundi«h nuiSMa (tuliercular granules). Tin* cadoouit piiii aix) opiUieliuin
Pf«. 33.1.
FiItmII- BiiowlDit lb» lvl«ili>l>it rli»r%ii*tot |i» p'tluiunUT ooualMxIai. t. Ca<UTuIbPiii<hueuB-
lalUii(alllll*iiineui. k A bl>»d<«>sl. x '*<>■ '•'•"•■I I- ((rrwi.)
contained in tlifî lumni af th« broncliiiH in timo unfTor a titok-rtilar ili8tn>
Miction nriil nrc «liniiniiUtd, ami the ^nmc may hn]i{i(iii nitli t)iu caAcoua
infill^Ikt«^ in tiio walU of tlic kroucliUH, thua accompliitliiug tliv dvstnK-
tion of tiiC latter.
Sect v.— Innj Ï.
AniPtnia, — Pulinonnry aitiKiiii» inti^- <-xi»t in the ^nerul anœmia duo
to cholera i>r to iitstoinii; ciw-'tiesijis ; or it iiiiiy be caueed bv eotujire»-
sion and atmiihy of a more or le«t< coniiirWrable portion of the Inn};. Tlie
orpin U cxtroTin'Iy pale, the vcsoels arc void of blood, but tbera is no
oilier iimrked U-niim.
Ilvi-KK.F.MiA ; ŒuEMA. — Hypcriemia of the lung i# rre<qii«ntlj met
with al aiitopies. It is present in moKt of the ncut« febrile dtwasee,
and ill nearly all afTcctiotiH of tlio heart and lun;^, aa one of tlie loxions
wbkh precede» and aceompnnioB the a;jony, Tt exLtta nearly alway)* in
severe bronchiliH, bronehi>-pni'iimi>iiia, pneumonia, typlioid ferer, loeiUlc*,
emphysema, ete., and in iliAeitKcs of tlie bctirt.
J^io congested lung in red npon tlic surfiice and ii|)on section. Ecchy.
rntows, more or lex» l*rj^ aii'l iiiimfroii«, are freipientlv oWn'ed under
the pleura, iii all congtwtiotiM <:nii.'«>il liy iktpliyxia. I1ie stibstMiice of
tlie ItmjM i* filled wiUi n red or rosy fnilby Huid. 'Hic enpilUrj
reswii' wbtcli stand ont upon the alveolar walls are filled and turgid
«ritb blood.
irniler the inSiience of c»n;^stion, whether it he active or rtawitve, the
pavement e|nth6lîtim which covers the surface of the alveoli bMOmo
sirollcD and granolartaud uiidorgocs a aeries ot* uutritiro changes. Hie
I
•
I
>
I
POLMOSART APOPLEXY. 409
pavement «elk Iwoomo jrmiiulnr or vpsinilnr luid i-ftcii [ireaeiit n v^llow-
isli color due i» tlic ixmeuittioii of iliiouilvcil lifciiio^loUiii Trotii tUo lilootl
|il]t!ini:t wliicti lillit tlie air TwiclcK. Tliiit fluid i:* mmk irniistomicd into
Wnialin, tints «kuttîti^ tlio dohOLiitiun even iii the inu^rior of ilie colla, of
;;rni)ulcH, at first red or yetlow, Iml later lirowtiinh or Mack. TIimiï
wIIa become spliorical. delAched, aiul fall into tlie fluid which thu n1v«o-
liu contains.
ItetvTfcn œdnma and congcslion of the lun^ there îs no ifltitrp line of
deonircittion. In Wth caavti Ûie Iun;*ig i)tHti<nde>) niul liiri^r ttuiu uoroial.
After incision of tht' orjjaii, wo can Bi]Uecïc out from tlic ewl siirl'ftcc a
iTrtaiu i|iuiiitit_v of fmtliy fluid. It is said tiint tliorc in ruHi/tiftion
when tlie color of tlic surface if red and tli* cscupiiij; lliiid ir« red or pink ;
tliat there U iriifma vrlien ttie Iliii<t i» tr.inM|iar\Mit and eol(irIc>).i and the
long itAolf ia jmle. l'assiic or }iv|>o^tatic conjr^'^tion or (vdcnia of the
lung is coinnioiil^v located in the iiiKt^-rior lionlcr of the lovrer hibe. It
ÎK ofleii purely cadaveric, «hen it i» iliie entirely to the graritation of
tie Mood during an<I after tfie tnoroeiit of death.
Tlie dietioctton between con^iestion and true inflainnmtioii cannot he
sltarjilr drawn at the hc^nning, for in congestion, in the jilacc of tti«
cells of the alveoli which have dea<|iiiiinatcd new cells rapidly form:
there arc then, a» in pucutnonia, new formation, of elemontei, ami excape
from the vesucl* of white Uood corpuscles ns well as liipior san;riiinis.
We uW fiml. in simple congestion, n fine mcshvrork of fibrin with red
and white hlooil coquisclon; hut theite elements are not numerous in
simple eoii^eatioi!. whilnt. on the eontmry. they rapidly form iit groat
numbere in the eon;[cstion which (irecedc» pneumonia.
When a portion of a much oongested lung is at the same time deprived of
air it looks like ticsh, and the condition han been termed camitication.
Chrvnif hjfperœmio is followed by more profound changes. IV'e hare
already wen bow the epithelial cells may become pigmcnted; similar
aitl^ntions may occur here. The distended capillaries of the wall;?! of the
alrcxdi exude into tlic alveoli and their septa a highly -col end fluid; the
coflnective-lis.<uc cells stvell by imbibition, and pigment granules are de-
posited in and around them. The amount of this pigmentation is the
greater the more repeated and iiersistent the cong('i>tion. It» greatest
intensity is seen in diseases of the heart accompanied by great impedi*
ment to the pulmonary circulation.
When the hypcriemia of the alveolar walls is very intense or a long
tiioe prolonged, the connectiTp.tissne elements have a tendency to pro.
liferatc and fonn nen- fibrous tissue, principally around the bronchi and
the vcMtcls. This thickening of the pulmonary tissue \s really the first
stage of interstitial pneumonia.
A dark color of the lung may have a cause other than that just
dewnbed. It mtiy be due to the penetration into the ultimate ramifi-
cations of the bronchi and into the parenchyma itself, of line particles of
diuit.
Pl'lhoxary Ahoplrxy. — This lesion \n most fre<pi«ntly met vitli in
affections of the henrL, aWve all in those of the mitral valve; it Itsoinc-
tiiDca oonnected with the eruptive fevers, witli scorbutus, etc.
410 PATHOLOOrOAL HIBTOLOOy OF FHSFIRATOBT APpTrïTÏ
When llitf jircssuro in th« cui>illari«» of thv liinjjt in nitiuli nii^nnoiKo*!,
««jH'ciiillv in (Nissivc cut>^c«tii>n, bwiiku tin- (.■loiikitite |ireviouc(l^' de-
ecriljuil, wc liiire tUoDc of tlic blood filling tin- nlvouli.
Fi£. £24.
Il»r<ilnii at Iiiuk ullkclitd uMbtwaitllin* »llh lil«»tl(lkl pBciuntnil» Mil iwlaiHarj hswirrhw*.
Tha villa "I Iba ilimll If* ililckrord ; In ihg aliv»!) »• itru Unr* naad plf waled Mlli, |>at«-
ntiii »1I>, mill rtd Uiud dlabt. X IC*'-
Tlii' pilent granulœ which fill the Inrgc granular nnd TMiciilnr clo-
inc-ritK, «lik'li liiivo been already deiicribed à jrr"f>»i<tccnif^e*lÀonf»n
yellow or red, or, it' tho apoplexy is old, thev are lilnck. We may imate-
tiniw find in tfiesc colls crystal* of liiematoutiii. In the ap«ta of («d-
moiiary apoplexy we tiiut these mime i^raiiulur c-leiDcnte Htispended in a
reil tnucotu! fluid, in wlûcli a liir;;e >;ti»ntit3- of blood corpiifcles is »]aa
Been. The nlveoli nnd (lie U'nnînnl br'>[ieliiule« emptrin); into them are
eonipletely filleii with coa^uhitcd blowl; lliv iiir i» expelled from tliem,
nnd the eut surfwo of the liiii*; jirweiitfi n molllcil a j ■pen ranee, which in
due to lliwe riiii.-ill coagula, Th<' di»U.-iii'i<>ii "f the limg by ihe^o coagula
ni»l Ihv nl)!(eiice of ftir oRer to the nak«d eye tlie appcuranc-e of a
ke}iutir.»t)on.
ilie cajiillariea and the bloodveaaels of the whole of the <)i»«aMd por-
tion are full of blood. The nrtcriea and veins mljointn;; thfi iipftplot*tio
apot are also obstnicted by a coafpdnm, whieh is red if recent, or whit-
ish and hard when old. The estravasated blood probaMy come? from
the capillary network of the alveoli, either by rupture or transudaliou.
The iiake<l-eyo ch»ractor« of the alteralïous of tho lung in pulmonary
apopK'xy m»y present two different aspccto.
tut. Ilrmiirrha'fic. Jn/aretivn •>/ Laetine^.. — Wc find in this case one
Or more fimi jmiiiU of a brown or Mpia tint, Kencmlly so well circiun-
«erihed that there is a shftr|iline of demarcation U-tneen the hard nodale
and the healthy or conj^e^tteil tisane which itnrrotiiids it. Cutting into
these {foints, we observe that the surfaire of (•ecti'Jn \» dark colored iind
{•mniilar, and upon pressure exudes a ;ery ^niatl (jtiantity of tliick
blood, free from air bubbles. The swrroundin;^ tisane onlinarily ia
»oft and crepitant, but it may sometimes present a slight «anguineous
infiltration.
The must freijuent sent of tliDSO itdarctious Is at tlie centre of the
ATBLBCTABIS — ATROPHY.
411
I
I
Snfimor lobe, or id tti« n«i^iborhoo<l of tlio root of the Inn];. Thov Arc
niK» often 8tii>orfieial, iiiiii riait occupy tlii> xlinrp l>or<lcr of the lui)];.
Wlicii t\Ky nrtf lociitctl iiiiiiiwiiiitciv U'iicatti tlic plriini, Uict fonn «
«iijtlit eti'viilioti. Tilt" i>!cuml covering i» iiifliniu-<i, iiml t'rc'nionily pre-
(wtiU A fiiUi- filii'itioiiii tiK-mbraiio. It tlicii «ncn liiipj>L-Tii> tlmt tiiort.- In a
Horo-fitiniioibi <-ffiigii>ii, iimnr or lovwt iiiîxi-<l with Moml, in tlie pleural
cavity. TliiH «IFuiùoti may l)C iu> coiit>ii)erahlo as to coiii]>rci>» tlio lung,
tliiu rcndenng tlie (ti.<>covery of the [M>int!i of infarction difficult.
2d. Localittd Apaplrxy. — >Vc somelini«ii enoounler in the l«n;( a
mass composed «f ooagwlnted and fluid blood, surrounded by Btirod" of
torn niiliuoiiary ti-uuc. It \» a rent npoploctic foi'iui, just »» wc nicct
witb in llii> brain. If ttic anopK-xy is located »t thi.^ âurf»c« of ihv lun<;,
tliv pli-uru often ruptures, «nen tlii> Llooil t-sciipcs into thv plciiral cavity.
Tliis fomi of apupluxy is rapidly fatal,
ATBLBCTAHtH. — ^Tliis Winn, which consists in the ahsolute aheoncc of
air from tlie alveoli, Ib met with in capillary hrouchitin, in broneho-
pneumonia, and in comprcwiion of the lun^ by a tiunor or by a pleurisy.
Tlic alveoli no longer contain air, llicir cavity is elTaccil. and thoir
waIU arc in contact. Tlic iDO!>t extensive ut<-1(M.-tasis of the lini^ is titat
which is caused by the coinpr(^»fi"Ti rt^Hidlinf; fi^m a iitiilalcrul pU-iirisy
witli great effusion. The compressed lung, in the latter case, is sur-
roundeil by a much ihickeiicd pleura, which prevents it from fully ex-
pan<ling again, oven after inflalion. If, however, wo remove the lihrous
em'cl'>)>e, we can rcadilv a.i.4ure ourselves that the pulmonary parenthyina
is intact, for the alveoli resume their form when the pleura which bridles
them has been removed.
In atelectasis, the alvcolî may be altogether empty, or they may con-
tain in thrir interior n Biiî'l holding in siispciisiun large, spherical, gniiiular
cells, like tlnwe fourni in congestion.
The nffeeted tissue is flesh-likc, and sinks to the bottom when plunged
into water; u|iiin Kcction, it presoiit** a violet-iyrd color; it is dry, l')ii>;h,
fimooth, unilVtnn. and it iii not indented by digital pressure. Tlii.* coik-
dition very «ell corresponds w that of the lung of a child which has not
('et respired. It is most fre-iueiiilv eiicnuutered at the periphery of the
ung, at its sharp borders, diasominated in jioinls which are freijuentlv
small, as in hroncho-pneumonia. In this case, the anatomical lesion is
the rcstilt of the obstruction of a small bronchus or hroncluolc by a plug
of unicus.
Inspiration is too feeble to cause the air to penetrate ; but the expira-
tory force, which is dm» only to the elasticity of the lung, remaining
unabated, the air is gnuhially cx])cllcd fnim the alveoli supplicij by the
obstructed broiicbni», and atelectasis follows. The !«arae result cim be
protliiced in much the same manner by compression of the lun^;.
FaUe pleuritic membranes, or indiii-alion of llie intiame<1 pleura, render
the dilatation of thU portion of the lung im|>oi<sibIe. Tlie altered jior-
Uona of t)ie huig may, of course, also bo the scat of tubercles, tubercular
pneumonia, cavities, etc.
Atropav. — .Vtrophy of the lunj*. generally limited to one lobe, when
it is caused by a pathological lesion, is the oon80([ucnce of compresaioa
412 PATBOLOOrCAL BIBTOLOOY OF BBBPÏRATOHT APPARATOB.
by n tumor, by a ploiirisy. nr by bronchieetatJc cnvitiee. Tin' atnijJilwl
part tbi-ii pn-Hcnts tbc changes of interstitial imi-unKinia. T1ii« is iw uIim
of Honilo atrophy wlilcli is ffenerally liniittro to tliL* m|)OX of the orpiii,
mill >t^ iW^iii'iitly a^nociaU'il nitli iniliirati'iti iin<l )ii<;nK-ti tali nil. Knipliy-
si'iiin elioiiM hIbu be uotii^iikrvd a» u ri<rni of pnliiioiutry ittropliy.
Eut'iiveKUA. — It was for a laiig time bclit-vcil tlint, in iHtlnxmary
FeRi]>byHi:itm, t)j<.> alveoli had jsiinply bcconiL- i-i il it !*;:«■ il. It i» now Ik-toikI
doubt tliat, ill this afTcctioii, tlicrc it lUi atrupby of a ovrtain imtubvr of
Fi{ ssa.
Hi«(M<opl4 rinr at tattviUntt tlnrt*«braa|g mpltp'BM. «d<*n*t4 lUf*. (HtgatUt-t
till' alvoolur wall;», which often l«atU to the dilatations wliivh are so large
in cin[iliy#cinHt(iiii> luiij^-
I'txiii tbc wall.-* (if iarj;i> Giu{>hyit«rantniij> dilatatiotu th«rc nrc to tw
seen, under the inicroscojie, the venli^a of tlic sejita of thoM alvt:oli
vhicb have been converted iulo a ftinjrle cavity. Wy evamiiiin^ tbin
ftections of such a lung inflated and <lried, or thin pieces of (In- fpe.xii
lung, it is oaay to see that tbc inleralveolar seitla are oOcii jwrforitieil.
Thin is tbc finit stage of the process : tbc dilatation is liuûte^l to the
iufundibuliuD, the central cavity of wbicb is enlarged and confounded
willi tlio alveolar cavities, of which the walls are more or less atrophied.
liTbcn tlio CDipbyscmatouH infunditiiiKmi u bicatcd beneath the pleura,
the iilwone*; of the resistance of neighboring tissue pernûts of a greater
dilaution. 'Plie targest liilfttjiliiiii» nr vesicles, which may attain the
vohime of n haxol-niit or wahmt, arc line to an int<>rconi muni cuti on of
aiUoiiiin^ infuiulibula. TliiA is the motit advanced Kta^c of the disease.
In certain case» of em]>bysema. especially in the old, at tlie apex kimI
<Hi the anterior borders of the upper lobes, the lung is converted into
lacume which communicate with one another, so e.vtcnaively that prcAnure
unon one point causes the air to move in the interior in slmost every
direction.
The mechanism of the perforation of the septa has been the subject of
various iutcrprotatîoas.
Wc consider that the employment of silver staining has demonstrated
the existence of» pavement cpitbctiuin lininii the alveoli.
After rvmoTÎng with the scissors the thin wall of an em]>hyscmatoivi
SHPHT9B1IA.
wsîclc i>rojectîtig lieneath the pleure. an<l AtuiiiinK ita inner (mrfatf with
a ilolutioD of iiilvcr, tlie pavement epitliolium nliicb Waas ttie uniitbyoe-
natous dilatation ie vorv disliuctlj visible. Kxaiiiiiii-d. in tîtu, m pre-
parations uncolnrcil by tbo sllvor, tbt- cpïtlicHuI colb often exbîbil fauy
^ranub-s in tbc pruiupUsm urounil lh<; nucluiis, just aâ lUnJflt;tM.-h lias
fi;;un-d.
Flg. 226.
I
llif ■(<»• U Um rUbi ftnd above npnmU k bithlf niBDlBad «law of ibe wmll i-f > TolmiiiK-r
•l**ala> la ■ eut at tniphriDuii. urior Vlllsnils. Tlt ;irrpitailUB tbswi lofinl pnrnmiiii».
Tbo licim la ib>I«fi iii(ri>ui Slndil<ilu[i.iu>4 •W» '■ii/cnanUa tritnn<l Ibtciatleiiif ihailcinii-
fmttbf *bd iklruph^taf lltau*. Hj^ b pavraf.
Tlio tliinned «opta aUo présent iu tboir tliWkiie^:! aivl ii|H>n timr Htir-
fa«e ovoid naatwe* of fattr granule.4 wbîch arc derivt-d from a de^^i^uira-
lion of lboB« elenwm.f, or peiliape of [lie ceiU along the capillary vcîEjela.
It y j>ra1iablo tliat thiâ granular degeneration in a great measure causes
tbe small perforations of the cellular sejitwm of the alveoli.
Senile cmpbyseraa is especially characterize*! by nutritive lesions of
the lungs. There is no rc^i^on why repeated bronchitis, disease of the
heart, etc., shuuld not be considered as initial causes of these lesions.
While wc know that crou]), wlnxipinfr-coufîh. and broncho- pneumonia of
children may tnid>>iihii'dly ;:ivc ri»« to tlic «flection. In these maladies
tb*- infuiidibulu may hv d^li^^■d hy effitrts of ei)n;;hiiif; and of rcspirotion.
While the pnieesw of their fonnntion i:i acute ami the hmiidiititt nrmain»,
tbe «mptiyiiciiiatoibt vacuoles »r ve-ticle!* are filled ntth nnicousor muco-
pu».
Upon the walU of large emjibysematotis ditatatioiiji, ]>articular1y in the
old, a |»gnientation ahiug tbe course of the htooilvcssels is remarkeil. We
have vainly sought in these v^acs for atheromatous alterations of the ves-
wlfl, vhicb have been supposed hy several authors to explain tbe idio-
pathic production of cmphyscnm.
The wall of the cavities presents ridges formed by the bnodlce of
414 PATHOLOOICAL UIUTOLOGT OF RRSPIRATOnT APPARAT09,
elotttic fihrc* wliich ln'lon;r»!(l to llic efl>cf<I itlvooli mkI wliidi an- now
a])])lic(t a^itiii^'t tliu ttitornitl wiill of t)ie ililatatiun.
If the «ii)|>hyA«ma oxi»! ovvr a lar^ cxWiit of llio Intig or of a IoIm
the circulation U truiiHtilorablv ciifeebl«(l; lti« iliM-aneil |igirl in uiuuiuk
while in tlinsc ]»tru which Imvc rein«)iictl healthy the tisane U red, ccilc-
malouii, and gorgi'd with lilood.
Kiii)>l)ysi>iiia shown iwcW by preference at the apes »n<l at th« ant«rinr
and interior border» of the luu;:. as whitish or ;;r»^ proniiiK-iKvs. ifune-
times even as !<phcrical vesicular appcndaj^i^H filled with air. Thv dis-
' cium:-<1 portions are «oft and clastic to the touch.
When the greater ptirlio» of the liiiij: i» itivtdvcd, the orp>n appears
hypcrtrophicd ; it filln the plcunil eavitr and dur» imi collaixH- when tlic
llioritx ill i)]i(Mii-d; it may dc])n^'^ liir liver hihI ijinpiacc the hvart.
Kiii[ihy.tciiia iniiy givo vim to pi i<>iimti thorax by nipture of a venieitlar
dilatation.
Iiiicrlobnlar eropliyacma may extern] to the mediaïtinuin, to the neck
and to the Aul>cnlaneoiia cellular tisane.
Finallv, interlobular emphyaeraa by reaaon of the penetration ofaîr into
the Bubi>lcural cellular tissue from nlpWre of the alveolar walU. gives to
the vvHienl pk-iira the apjietirancv of ii uieiDbraiio npHtVtd by foam. These
vcaii'ulîo are eiisily liinpUccd by prcsitine, and moved from place to
place under the plcunv, a cburaeteriMtic which distin^uiiihes tlii» form of
ciujihvM-nia.
The tiioxl frc>iuent cAU«e of ein]>hy»enia is aitthmti, w}KM)pinR-cou}:h,
and In ^n«m) all the di^cUHCi* of the che»t which are «oc<>inpanicd by
cou;j;h and by violent efforts at expiration. It is almoâl constantly coin-
cident with senile atrophy of tlic lung.
IsFLAJiMATios OF TliK LtJN(ï ; pNEUMOSiA. — On account of their
diflvrent causes and their van,-in}! mode» of action upon the different
tiiutuea of the organ, the fonns of tnâummution of the lungs are niimeroue.
We will first describe tiiow forms of pneumonia which are parlicularly
ciuiracteriwd by an iiiteralveolnr uxndution. After that we shall con-
sider those fonn» of iiitliiniiniition which essentially consist in an
alteration of the fibro-vasculur framework uf the lung.
A. IjOBFUR or C'atarrhai. Pskumonia. — 'V\i\» fomi of pneumonia,
alao described -m bronclio-piieuaionia. is nioctt fre<[ueully eniised by an ex-
tension of iiiflauuuauoii from the bronchi to the bnuioMoIvs and the air
cells into which they eniiny. Hut this extension of the broiichitiit is wen
only in certain lobules of the Imig. It is es|)ecially frtxpieut in ehib
dren, hut it is al^^o met with in adults aifected with typhoid fever, laeaale*,
and in pfathisia pidmonalis.
llie lesion is ^enendly <lis3eminatcd in small areas of the «ae of a
liaxcl-hnt or walnut, hut nevertheless it may uniformly invade a lar^
portion of » lohe. Under the influence of congestion, liie vessels Iieoouic
turpi), and the epithella of the alveoli swell and present a granular
l>n:ito|ila.'<m nhtch freifuentlv contains two or three nuclei. These eel b
becoiiit; fçlohular and fall into the alveolu*. Moreover, a considerable
number of while corpuscli's, with qtiautitîca of scruui, escape from tha
LOIlULAtI OR CATARBBAL r?lBUU05IA.
Culiiirhiil (laraauBlk. Proa ■ dbm b! wmtc
*
III (mkIv easels inio tlio aK'ooli. but tliii latter arv tivver m tti»t«i»)e(t tu> in
loliar or fihrinou» pnoiiiuonia. The epUlu-linl eleniciito wliieh nre fminil
detached and suspcitded id the Suid wlijeh fills tlie niveoli, l>t;!Ûd»»
silfîerîti;; the ehnti^eH ahove îtnlieiitcd, mn^' cx])eneiicc U division of ibcir
prnt'^ijlitsiii. t\m» fiivi»;; rUe t/y tlie
prtwiiee of eniliryonnl eell" ei>ii- P'B- ""•
Uiitiiiij^ "lie or mor»' imolei — eliaiigvit
gituilar to tliu#e do-»cri1)e<l itt |m^
67, r' 1W9., (1 /H-rt/M» of itiflaiiiinH-
tioii of tlic gri'At utiu>iitiiiu. Hut
bero tii4> phciioiiieim nre more eom-
plex, because of the ]>reactice of the
white Idood c«rjiiL*oïes which bare
escaped from itie ve&iieU.
Vio recognise lliree stages in this
fono of pneumonia.
i»t Siit'/e. — The altered pointx of
the luHf! are rod. |iri>miiieiit, «Ujihllv
or not at all creiiilant, and from
Uieir cut Hiirface n red, cluiid}',
sli'^lttly foamy tluid atay ei>cH[ic
npon pressure. There iit no diittiiwt
line of dcnkkrcation liotweon tlieite [mintH ami the Hurrotuidinf! parts vhich
are cMifriviotl. Thii> it* th« ulage of eii^r;:emcnt or iultaminat^iry hv|>er-
xmn. ubich » on!)' oue degrm more ulvaticvd than con<^8[ioii alawly
d«Bvribcd.
MiL-nx^copic examination of the rc<l, lurhid flnid whidi upon [1n.^«(u^o
escapee from tho cut surface will show lar^^ nutntien of |iit.t cnr]>uKclt:s,
and thin sections made after lianlcninf; the iitaained lîs«ue will iihow the
alveoli filled with thente eleni<^nt«.
2ii tSlni/r, — Tlie alveoli cotitainiiig the éléments and the fluid pre-
viously iiwlicat/rd no ivujier ineli^te air ; tlie amount of Mood in tho
vo«<4d.-t in diiiiiiiislivd hy reiwoik of the ei|tiilil>riiuu eistaUitilicd ï)ctweou
conjçe^Ktioii ami exiitlatton, between intra-al»eol.ir prcsaure and the pres-
sure of the Mooil: eoincident with tliU diminution of tho quantity of
blood, the aflecl«d lobules liocome less colored; tiiey present a pink or
gray appearance. If the lun^ arc forcibly inflated, a small umomit wf
air can yet be made to enter the diseased alveoli, when the lobule will
asaume a Bomowliat normal appearance.
id Staf/e. — ^Tfao pus corpiuwies whivli hnve nut been cxpcelorutvd
rapi<lly underj^o a retroi;nide metflmnrplio«i«. At first gruuular, hy
reason of the eoinmenoement of a fatty dertniction. they «urn Wcome
deformed and broln'ii tij», ttieir molecules w^parate, and are sulioeuuenlly
eliiniiuited in tlie form of a f*tly emulsion, which is prohahly taken up
by tlie Idooil aixl lymph veaMd^.
When the catarrhal pnciunonin terminate:* by resolution, tho pulmonary
e^nthelium re-fonna and again lines the alveoli, a furtlier analogy with
tl>e inflammation of the great omentum ile^cribed on page &7.
In certain caoea the lobules remain lalc yellowish, often appearing as
granules of die site of a millet-seed, which somewhat resemble tubercles,
41G PATHOLOUICAL UI8TOL0ST OF RBSPIRATORY APPAHATOS.
but «lien tlior are iiicU«il, in.ttca<l of being fwlid bodie» like tiibtfrc)c«, a
fluid cscai>frt from llicir i-t'ntre.
Tlicri'' ulways oxiate a pleuritic exudation ujioii the plcunl oorvrin;; of
iiffcct«d tubulw.
B. Lohaii or Fibrisou» Pxki;mokia ; Cnurpou» PNKiMoxrA. — '
irn>u>l'>;;Ica1 phvnoiDODa Arc much tbe same aa tiwae niol wiili in thv
ceding r'>nii of infljunmnti'Hi : but the exudation, in ndililiuii to tii« oilier
coniitiliiviiUt, ctiiitaiiis tibriii; llm Utter i^ at first tluid, but mwh cuagu-
latet) and Imid» in ittt nivshci) the clcmonlD a1roa<); imUcated.
A» in the prcui-diiig variety, three ttagn an.- distiitgtûshed : iM,
eiisnrgeraent ; ^d, red hepfttisaiion; 3d, gnj hc[Mtixatioii or jmmloui
infiltration.
Flf.a!8.
• I.». '
Ovapgnant Obrlimi* vvoo""")!*. Aid li*(«liuUiHi. Showldi Iba IbrlBiins nitfiiUiii !>«•■ at
Ihm fBltàoaut nliiull. Iniluilac wlihli I» unlipii niinnruai l>nni]r|*>. «hioh in »lm*r rtm-
■vDcltif Iv fifi4m<j tttij iD«Eiknkr»fpb<<>k, A f«v I^aoor/IH *rr tint iwa «u Lbv UtdoIat vmlU, m4
lk> alifalH •pllbcllan l> iHvllankad xn»»!*'- XVÛ. <OTWa.)
\H Sliffe. — The firot stage, iu vhich there is a very intent eougestîon,
ia obaract^rized, in a histological point of tiew, by fuhiUM and varicose
dislenmon of the capillaries of the alveoli, by the aitcrationit in nutri-
tion of the celU already mentioned, by ilie ewagie from the veii»ul« of tlie
fluid of the blood together with both red and wliile oorp«ucl««. Tbv
LOBAR Oft riBRINOUS PKSCHO:fIA.
417
pulmonary pnrenclivinn, of a broirtiisli-rotl, is licavîcr Hnd more com]i>u;t
Uisti ill the tionnitl ftaUi, it liit» luitt it» i'l»«ticity, sitd creintiit<>4 l>ut little
andvr |>r<;ti:tiirv. U{iaii itrc-tion, tUiHv i^fcniic-n tt »vro-WMij;uiiioleiit fluid
M yet a liitU fmtliy, mul jmnioiH oftlie engorj^ed (irt.'«)it> ntill float when
Iilunged intt) uaU'r. Thin firat Htage laitUi frum twenty-lour Ui forty -«ight
lonn.
2d Stage. — ^The exudc<l fibrin cospilatee, filla, and distends the a1v«oIi ;
and th« lung is coiiTerted into a solid mass. The tnnii; sc«ids aiif;-
mcnUfl in roltunc, and upon its extom&l sorfaco the ribs have left their
imnrint.
Dk' Itint^docs notcri-'pitaU'; it is firm to the touch, yvt is at the sario
tinw! verj- friublc: it is heavy mid sinks in water. The cut surface pre-
w-'nte a ^mnular uspecC, which is slill more ]>roiii>nnced when the jiidnio-
tiary tissue is loni. 'J'liis aspect is due to llic relief fonned hy the infiin-
dtbiil», which nre filled with fibrin which, on account of the prcM'tice of
red blood diokti, îa red.
If a stream of water is turned upon the cut surface for the purpate of
washin;; away ihe blood, red as it is at first it soon becomes gray or
yellowiBh.;;ray, the natural color of coaRulatcd fibrin.
By scraping the i^urfiicc of section we obtain small grayish jn^nulations,
which fiimiab a complete mould of the infiiiidihLdum and alveoli.
When these coagula are examined in *Uu, it is found that tlicy com-
])]ct4>ly fill and distend the alveoli, and that the walls of the latter show
no other ihickeniuj; than that which results from the engorgement of
their vesselii.
The exudation contained in the alveoli is composed of a reticulum of
fibrils of fibrin, which ineloses in its meshes altered epithelium and large
numbers of white and red blood corpuscles.
Pig. 429.
^^lèK
r^lalar ■tantôt* fniB thaunul ■■*■■«( pntBiBOBU. /, fi,l. I^inntpimolo*. a,«. Paruinl
Miti. 4. r>i*iDODi «II *Ilh («a ouilal. t. V»lia1aT»llL (SiynuIiti.J
Th© bronchi contain a traiis|iHreiit, viscid, finid exudation, and eoagii-
l»t«d fibrin similar to the preceding. Tbc»e coagula do not complvlely
lis FATHOLOaiCAt niSTOLOOT OF RSi^PtRATORT ArrARATQS.
I
fill the tubc«, tliey may hn found in the H[iutn, vrliich Arc kIho more nr
Ira» mixei] with hliioi).
'Die MCi-oiid ntit)^, nfter liaving ooiitinueil on «n average from tliree
to five (lava, icnoînatca hy rewttulioii or li_v iia*wiii;t into suppuration.
The fitiriii dcpoiiited in the alveoli passes I'mui the fibrillar into the j^an-
iiUr state, and the coH eUiucntjt are then i'l-ccd aii<l easily displawd ; tlie
solid exudation has hecome tiuid or Homi-tltiid. At thi« time the |ms
corpuscleit or white cell» may bceonu- granular or VMiculnr, inav <ltt(intt>-
gralc and be nbëorhed or expelled nitli the Hpulu ; thin is rv-solulion. Itut
if, on tlic contrary, the pii» eorpuwlcM contimie to form, if as oflow hai>-
potiB llier hecyinc even more rupiilly prixlnced than iit the coinuH-nce-,
ment, the piieuuioiiia will piiw< (<■ the hUi^o of purulent infiltration.
3i/ Sla<f*. — In this ntiif^o of /ray or purulent infiltration (gçray lu
tjuiùon), the eut aurfaee iii paie /niy or yellowish, and tlie graDa
R])peitrance is lets marked. If ihe luiig is sigueeEed, there ooua out
a diick reddish-gray pus. The tissue is very friaMe, which condition,
in the second, and e^iwcialty In the third stage, is due not oulv to the
frialiility of the cxu<lation but also to the t«n60 state of the tbiu nallfl
of the infuikdibula.
Pig. ao.
Cn>B|i&qi or flbrtbuua trurniaotili. Qr%y hr^%lit%tiaU' ShovlD^ tb* UrB«acniBaUn<A 4f ntti
«l«n°Du wliliiii DBo i>f Ih>i i>iiliiin>iiit7 iliroii, vhl«li la un* |»>rli hti* u>d*rt«dM n*h «lU*-
■liafaitf dcctsinlloB iliti ibeir di>|iDclli>uDtllB«*n*« luBfr lUllila. X*"*- tOrnn.)
When acute lobar pneumonia reaches the tturfuee of the lnng> it ia
always complicated with a certain arinmnt of pleurisy. The videra]
pleura in covered with a thin layer of false membrane, which is slightly
adherent and prcMutti u dull and downy aspect. This fabe membrane
eoiuialë of n fihrinoui? network lioldinn in >M meshcB pus corposclos
Invad «ndotlicliid celU, which arc tlut, swollen, or proliferating. Thi
ABS0E6S OF TttR LVXQ.
419
fiilw nembranofl very rapMIy hecomo \'i»flculariKid. Vorr rarely do w«
Snd any iiotaMe <iiianticy of Huid (.-ftViHioii in tt)c pl^-nrat cavity : the <^«(-llpe
of mich a fluid is. in effect, especially characlrrificic of ordîmiry ii«ute
plourisy, w.-|)ic)i iiiny nomclimes complieate piifuiiioiiin. and vrv then dMig-
nut« the ufft-ctinn u6 a picuru-pneunioniii.
lite slight thicknt-tw of Uiv viseorn) pltturn, scarcely .OH of a niilli-
metor, iinii tlie direct eontiection of itd cireiilntinn with that of tlic coiu
tiguotiit ah-eoli. nradily explain lliiii conittniit complication.
Inveriiely intoni>e iniliimmnlîonit of tlie pleura nuy involve tlie adjoin-
ine (mlmonary tiit^iiie.
Tlie lymjihiilicii of the surface of the lunR arc conatantly inHamcd in
pneumonia. an<l are tilled with an inHammatory exudation, stmilar t» that
which distends the alveoli. In catarrhal pneumonia ihoy contain swullen
endothelial cells, ^hile in fibrinous or cronpons pnctinionia tbcy are
choked with fibrin, irhiti.' corpuseles, red blood disk», and n few endtithe-
lia. In these eiustse the deep lytnpliatîc» «re extremely difficult to dis-
tin)i;it>»li under the mieroscope. bcesiiisc of the identity of their i.Mnlenl«
tn ihofto of tlu- alveoli. Hut there if not the .«nine <Ut!ieulty in recag;niic-
tng iJie tiii[ierfîciid lyniph vetuteU. The whole lymphatic system liclong-
in}t to tiie affected jiorlioiis of the lung, including the reawUi of the
hronchi and the lymph jçinnds at the root of the lung, always present
evidence of inHammation.
In the N<7ip-/K>rN we soroetimcs meet with a peculiar form of catarrhal
finetimonia, which uniformly involves one or move tohc^, or which remains
Imited to tohule*. It may involve aveoli wliicli have not yet respired.
In ehiUtrtn a little older jnienmoiiin is onlinarily lobular or catarrhal,
mill «cvimipanicil with iiuuierouK jioiin." of ateleeUuii!! ; iteveHheleKM
children may iil.'U) he attitckeil with erftii|Kiiii> or fihrinoua pneumonia.
In adult» )tntMinu>Tiia is almo»1 hIw;iv.-< ioliar or fihnnous.
In the aiffd ite may nie^M with lobular pneumonia, but the commoneist
fonn ia that of the loWr or fihriuoiia or croupous variety, and of all
acnte disea^es which attack man at this time of life it is the most fre-
<|ncnl. Id the old. croupous pneumonia utViTi fidlows an uiuisimlly rapid
coiirw; ; frc-jucntl y patienta succumb upon the fi)urlli dity of a jiiieuinonia
while, at the aiilojisv. the lun^ shows a ^riiy or purulent Iiepatixivtioii.
In lung» affected with rmphtfiema, the large sixe of the tihriiioutt
granule» \* remarkable.
I'atienlx .tufft^nii}: with cardiac trnuhic present a special form of pneu-
monia. It may be catarrhal or fihrinons. lobular or lobar, but is almost
always of slower |)ro^w)w than tiie onlinary acute pncomonia, and ia
com[>licaled by an intense ctmji;eation, which may even necomo apoplectic,
or redult in veritable a^mplexifomi inlaretions of the lung.
Ptioutnonia may terminate in absoea» or gwigrone.
AbS€8»« of tiik IilTRa, — ^Thia termination of the thtnl sta^ of pneu-
monia is rare. Abscess is characterised htst»lo;;icatly by the destruction
of «everal of the septa, thus causîn<: an intereoiumiinication of sevei^l
alveoli filh-d with pu;*, and the forniiitinn of a small anfractiiou.t cavity.
Several adjuiiiiuj; infiindihula may in like manner form cxMnmuiiications.
FATHOLOOrCAL nifîTOLOOT OF RBiiPtRATOBT APPAKATU8.
T)io ntiilceaa in tUen larger, and if it happens U> break into a broucJiua
and einjity îtiiell', a vomica in e.ilabliiihcd.
If the aliaceas be HUperficial it may load to perforation of the pleur»,!
and the estaliliahiDent of a pyo-pDoiimathorax : or. us not infn.'4|iu-ntlj
happens, the two surfaces of the pleuru may adhere at this [xjiiit, anil tli«
abscess break throu*;!! tlie intercostal inusclvfl and form an external
fistula.
Metastatic abscLissos of the luii^. smch as are commonly seen in purulent
itifcetion, in puerpi-ral fever, in ulcerative endoeunliti», in typhoid fever,
ete., are ('hikni<,-t<'nxi'il at the comme nee men I by «inali conj^ttte^l foci
nf catarrh»! pueunionia, of tlie oîie of the head of a pin, seated moat fre-
ijuentlv miller the pleura. Aii they increase in aixe a amall, at firtil
acarcely perceptible, point of tiuppuration becomes risible at the centre.
This rapidly onUrgeâ as the nodule of metastatic intcumonia, with it*
aurrouuding are» of apoplectiform congestion, cxteiids. Very soon tho
ptis corpuscles, instead of boin;^ comprvMed within l)w infnndibtilai
constitute M purulent focus which is due to tllO destruction of Uic septa
between infundihiila.
'IIk'jk' nodulutt of catarrhal or pnmlcnt pneumonia iiutt«iu] of Iwinj;
diKAominated may become conttucnt, «hen they fpvo rise to a larj^er
area of catarrhal pneumonia, the border of which isi aiuuoti» and lobuUtvd.
If circulation continues in the part thiL'4 altered, there forma an abaoMlï.']
but if the vessels become iropermeal)te by preaauro of tho iutTa-alveoIar
exudation, the entire portion mortifies, and there is thus ]iroduccd a white
intnrction of an irregnlnr shape and of a eascoiis consistenoc, surrounded
by a iiuich congested ïoiie, in which diffuse li«inorrhoKes often occur.
In tlie caAeom spot# the conteiittt oflhc nlveoli consist of nothing else
than the déSri^ of ceil», fatty granules, and oryjitals of tlic fatty acids.
We can still dincern the limits of the alveoli, but tlieir vesaelii arc no'
longer recognisable. \t tlie border of the caneou^ areas, the alveoH
present the ap|>oarances of catarrhal or purulent pneumonia and of apo-
plexy.
W'hat is the patholo<ry of the pulmonary Icaicm in purulent infection ?
I» it su embolus, as Virchow imagines, or is it an mfiammauon due to
another cause ? We were the first to disclose that tlie lesions of |>uru<
lent infection might not to be attributed to emboli but rather that they
proUihty depeml U]M>n a certain ferment, which in tlic form of niîcro-
phyt«rtor bai-tt-riarirctilating in the blood or lymph ptisugM, det^^nmnes
a local irritation. ThÎH view wu* devrlnped almost itimultaiieuusly by
two of Virchow's pupils — Kleljd and lleeklingliam>cn.
The pneumonia of ;;landera U a purulent pneumonia, of which tlie
charactcni rcsomble those of metastatic ahaceaaea.
Isn,AMMATKis OP TUB Lymi-iiatics op TiiK LuNo. — Wo bare pre-
viotuly seen that, in pneumonia, the lymph ve.^aels are constantiv in-
llained, and are filled by the same exudation which the lUvooli contain.
We may, therefore, recognize, as in pneumonia : Ist, a catarrhal
inflanunation, characterised by swelling and multiidicatton of the oiido>
thelium which line.* their intenial wall: 2d, a filrrinou» or croupoiia'
inllammatioR in which the luuilna of tlic vosseU are filled with pua,'
OAKQItENR.
421
I
9rT>uftc1eti and fihrin : and, 3d, a purulunt inRammation, such m i« ami
«itli in punilciit itifcctiun.
InKummation of the «uporficinl und deep lymphaticfl of the \w\g i»
raroly met with indcpcmleiil of pni-iiinonia and jitcuriay. Neverlliolcsa,
> fow obïCrvtitionH huvv bcvti publUhcd. I'liosc lyuipliatigitos wliitrh tre
ooiwccDÛve to «inccni of tlii? stomiich, to Ixnnph&donoDmta, to STpliilitie i^^
«•«e of lti« vtoiniicU and liv<«r— nil lp*ioii« «liicli Iiavf occaaionod jdliTnliona
of (lip hroncliinl lymph glniidH — arc particularly rcunarkiiMc «ii acvoimt
of tlip OHormoiia dîi^tciiition of tlic lymph vf^.ivU, tus well n« of the cnefoiu
condition of tlie central fmrtion of ilie <;xiidnli<>n which tillit them.
Upon the tturface of the liin;;. the lymplmtic^, having the apjwarmicr
of whitisli or yellowish moniliform cortU. of a diameter from ^ to 1 and
2 mm., mark out the interlobular network; theae veissels increase in the
as the root of the lun^ is approiiched.
In a thin section of the Inn;;;, thoy are seen in the interlobular !>epta
and ttlonj: the bronchi and binoil vessels. Examined in the fresh condi-
tion, Iwo layer* of eU'mcnts arc onlîiiarily vi«ihlc within the lymph ves-
itcl: the OMC close ajiainut the icJfMC-l nail, nnd eomposed of muneroua
laycni of Hwollon, poly;tonal, moml>nti)cles«, «ndotheltal cells, with «
gnnntar protoplajim and large ovoid or spherical nuclviis; tlic olhor,
within the firnt. eonsiAtA of a ca^eotm, opaijiie, yellow ooagulum, fonncd
of lymph corpuaclea which show a jf ran ulo- fatty degeneration.
O.isuiiBXE. — Pulmonary gangrene is sometimes a sequel of pneumonia
or of [Hilmonary liemorrlia;;e. It appears to ht- most frequently con»
nocted with oblitoration» of the piilmoimrv or bronchial arteries ; or it la
«atuMMl l>y infcclioiL* diM'ajios — typhoid fever, anthrax, etc. ; or it may
be the re-Hull of a wound or a perfunttinii of the lunp. Gangrene, in
conm-otion with dilation of the bronehi, ha.* tilready been mentioned.
I'lilraonary gangrene présents two anatomical varieties: iti»eirirum-
aerified or diffunf.
Ifit, CSreumterihed gangrene usually présenta several di.tse mina ted
foci in one or both tunjrs.
These gangrened or softened spots arc always found to be surrounded
bv zones of lobular or catnrrhiil pneumonia. In fact, they are almost
always preceded at their «eat by « localiKuil catarrhal pneumonia.
Kach of thés*' noilnW of lobulur pneummiin which lin» tcniiinatod in
gangreni; pre!»«nU at it» centre » umaller or Inrj^cr anfractuous cavity.
if the latter i« very cxtenaive, veiiselH are often olwerved to project into
it. It is filled by grayish, gntmous fluid, and it mav communicate with
a bronchtis; both cavity and fluid exhale a very fetid odor.
When one of these indurated foci is cut open, three distinct zones are
seen. The Ist or central zone is formed oi a grayish débris or a con.
cut pnip, while the eavepious wall which bounds this softened mass
I of a deep vinotu tvA, TIk' 2d zone consist» of hopatiicd pulmonary
tiMuo, gray and friable. In these two xones all the vcmcU are 61led
by ft fibrinoiw clot. 'Hie Rd or peripheral none is continuous with the
xarrounding healthy jtarts, and prexents tho lc»ionK of catiirrhul pneu-
iDOnia in the second stage.
ïbe second or iutenuediate sone, which is about to mortify and b«
422 PATItOLOOICAL UISTOLOdT 0? DESPIRATOIIY APPAR&TOS.
alinûitated, liîstologicallj prcsonte tho folloving cUamcterUtîcs : tti«
tissui> ï« bloodlciuf, conUtinâ uo air. and prc-tcDte u ^ray, ulif^htly traiu^
]mrvnt u^jw^t. L'iukT ttic microscope, wc find in tbt' alvooli Inr;^,
^Oiind cells contsiiiinj; fatt; gmiiulm, ami suspi'itilcil in a lluiil whii'lt coik*
nnïiw puH vorpiiM-W. 'riiv»e lnrg« gmnnlnr <.-or]»)>>cU-!i nxtutlly Mil) voM
tain a niicU-iu. Thov givo to the alveolar conU'^ntit llicir o|uu:tly Midj
yelloniitti ccilor. T)ie vcHneU ara lillei] witli e(>ugulau-<l filirin. Tho
tissue tliiiA hepatiï»! îa dUt«ndcd with fluid and is very friable. It is
met with in all the varieties of pulmonary lEan^rene at the limit uf the
pTilrefyinj; none. an<l it is often ohsen'ed in tubercular pnuHmunin which
la }:uin<; to teimtnato in an ulcerative itcHtruction.
The solid ^^y's'' déhris which covers ihe wall of the ulcerated cavity
contains the rcnmtiis of vct>«c1» inid ola»tic fibres which still adhere more
or IcM intimntcly to the ndjoinin;; vxtvnial xonc, and which, uivlor tJie
niicrtiHcdpi-, may be fotuid to be oontiinious with the saiue elements of tlie
liei>iitiu-d jjortiim.
riic his» of :(qbitlnn«( in this form of ganj^rene in explained briefly, ■«
^follows: I'litrefnction and molecular destruction commence at the )>oint
'where the ^ngreued |>iieumonia comes in contact with the external air,
namely, at the centre of the lobule which is supplied by a broiiehiu.
This destruction extends from )x)int to point, and the jirtMliietA »F
caitareric docomimsition. to;;ctlicr with the fluid, remain in the ulcerating
cavity until expectorated.
Tlio contentM of the cavity arc now a ^imniis mai9B, oonatsting of a
fluid in whioh tliuit |>uh c»rpuiicle.4. larj^f! celb infiltrated with fatty
graiiuWs, filimieiiLt of connective or cla-itic iImuc, pigment granules,
black, orange, or yellow, derived from the colorin;; matter of ilio blood,
and. finally, cryMala of the ammonio-ma^^iesiau phospliate^. of mar^rin,
of louciu, anil of tyrosin; wo may also meet with fungi similar to
leptothrix buccalis, and with swarms of vibrionea and bacteria.
The sputa ha^■c a characteristic oilvr, arc Keiierally gray and pun-
form, and aiv slightly c^lorc-d by blood. Tliey may present nil or \»Tt\
of the elements oiiuuieriittid in the |)rec(-diiig jntragraph. Mixed with
" rater they separate into three layer», like llie «xiieetomtiou from bron.
ihiec'trttic cavitii'-^.
The iitfected lobides, when located under the pleura, exalo a fibrinous i
pldnriMv ; itnd, when the gangrenous cavity enlarges, it somotimev oponi
into the [ileiiml cavity and occasions a pyo-pnoumotltorax.
2d. Diffuêe {xanijrene. — It may be the termi-
nation of the tliird stage of croupous pneumonia.
In the honw it is a frequent ac4|Uet of pneumtHiia,
and i« the tMiilt of a coagulation of fibrin iu ifaa
bloodveaaels. In man this form of gangrene teaj
be the eoniiequeiicc çf an obliutration of a larga j
brtuieb to the pulmonary artery hy an vmbolus.
The roortifie<l portion of tlic lunjr '\% more ex-
tonsive and more irregular in outline tluin in «tr^
'"".r\ "T'"* *""; ciunacribod gangrene, but the minute pn>ouM«a,
tba fv »>rpiutiM. X •»■ ""^"" "1*'^'". and Ihoir rcsulU are the same. The
(«TMB.} ulcoratcd cavities wUicli result from this fona of
Kg. 231.
IKTERSTITtAL FKEDIOXTA.
I
Dgrono are anfrnwluoiw, are vory Inrgo, are 1>ni)]i«d by vawiilar
niit nm) contnin an icticroiu, wroui*, or jmriform tlutil in whicli injrisdi
«f 1)aot«riit jurrnrm.
In corliiin citM-a the gangrene liad a |>ori|>h«ral location immediately
umler tLe pleura, wlion llicro very rapi^lly re.iulbi a [>yo-piictunrii!iorax.
Iktemtitial Pneumohia. — Under the nam« of interstitial pnoumo-
nt» wo sha]) describe seroral couditioia of the hing wbicli have very «lif-
f«rent cauMcs, niid which arc far from bein^ i\\c eumc in an anatomical
point of view, but which ou^ht to be coniçidcred to<(cther bccauxc thcjr
present a character m coiniiion, nanwly, iiiRummatory lhick«iiiii]^ of the
Sbroiu framewnrk of the lung.
Wlial chitraclorlxcH interstillal jmemnonia h, ilierefore, the inullipli-
cation of the coiiiioctivc-tiitfiiie ideiiieuU of the pidiiiotiary m-pta. The
process iii generally chronic, most fre(|uent1y the thickened anil indurated
ptilinonary tiâduo is at ttie same time pigmented; it lit colored tdack,
or elate gray.
lotcrstitial piiriinionia is partial, when, for example, it is occasioned
by a limited lesion, by old caverns, hv miliary tubei-cles, by dilated
bronchi, by a healed abscess, Ky a chronic plcuritiy, etc. It involn-s an
entire lube or is ;tfnrral, when it is due to an acute pneumonia or to tlto
penetration into the Inn;; of minute particles of cnrbon, stitc», or 9te«1.
In tlie different «nrictics of ii)t<-nititial pneumonia, the aiintomical phe-
nomcna which iM}(''>m|)iiiiy the thickening; of the intendveokr and other
septa, not being the saiiie, we nhitll be «bligwl tu describe them separately .
Fi)t. 332.
lal*i*II|lil pB'iiiRiiiiU. From ««h of tD-»niHl "rlrrnanin" i>t itio Innc, la «b<cb lb' 4i-«u«
wtM tiiiU*r«n1^ Th^ T^r^arhl wpr# wneh 4\l^t»A, »nd Ihcrt vit * cùiapisC* mlrttuo* «tr ■iif <r*#ffliiB
tb«4f*. TbK dnw lac abuwA Ibrt now Sbru^u acl«*(td rrvwLb. bntti la tb«iiJT4><>lM w4Ub and la lb*
laUrlobnUiltaHi), •l«'lbopl«awiUilaa. Ai ii*dlTld«d ■•«h1 !• uta. X ll»*- (Ore».]
The phenomenon constant in all the forms of intenttilial pneumonia is
iho fibrous induration of the pulmonary tissue. The alvt-ol»r .<epttt arc
very thick, hard, and of a Sbroiis aspect. Under the microscope a larger
number of small cells are seen in the septa ; at the commeneeuient of the
nwrbid procès» they ant round; later they become slightly len^lliened
PATHOLOOrCAt HISTOtOOT 0» BKSPIRATORY APfAllATUfi.
and flattened, and are situated between fa.?cicuti of nevrljF-^foniket] oonnecl-
iv<! tinfiuo,
Tlic cavitj: of the alveoli, at first only diininielied, enda by beeoming
COiDpIftely obliterated. Tlie enonnouitly thickened walla are then in con-
tnct, and tlic wbulf of tlie iiffceted ])ortion of tlio Iniig haa under;;on« a
fibroiiK tnini*f'irni:Uii)n. TliU i» very often obnorvcd in tb« subpleural
portion, and at the ujx^x of t)ie Inn;; m certain chronii; pleurite«.
Tliis altered tiMuc creakt under the knife, and, 1» tlie eye and tlie
touch, presentjt all the oliaraeter^ of a fiWiiw tiiuue. The niicrvifoope
reveaU a more or lexn abundant pi^ncntntion of the connective tiiitne of
the iilieoli, especially around the ve.'vMdd. The hitler ])rwent very niweh
thickened wall-^. wliicli «hade off very gradually into the adjoining: fibrnuA
tiiMiie. The arterieti are not obliterated; upon Bectîon their tununa »re
fiaping.
a. In the afffd there exist» a condition of the lung, ao freouont that it
uould possibly be re^^arded a^ |ihysiolu»i<.-a1 ; it consists in a shtfy indum-
lion ot the apicett. The tissue is hard, eliwtic, non-crt-pitunt, and black;
Fi«.2S3.
^^ upon the aurfaco it aornetimc» preccnl* depressed cicatrioo» of the pleura
I and denae fibruiw adhe«t<iii#. Upon xeclion wc «eo » dense tisstie formed
I of very much thickened wptji iiinitin^ç retrauled alveoli, or on the eon-
I trarv "we observe eiciphy.ieuiaioim dilatation» tiurronnded by a dnnmi
tibrouB tissue which i* inlillraied with Idack pigment. Often there alio
exist, in thi^ inidit of (his librauH tioaue, caiieoUB or calcareous nodule»
lodf^ed in niinnto cyatïc cavitiea, which if cylindrical mav be continuoua
willi Ji brouctmii. Such cavities containing caseous or cafcareoua matter,
which is nothing else than altered pus, have been rcjîardod by roan;
writ'-rs n» healed tubercles. If this tw true sonictiui»!, it \» unqnestioD-
able that they uiay also be the rvinuinit i>f any <i)d morbid prooom, such
an bronchial dilatation, pulmonary ab»c<!Kn, infaix^tion, etc. In this fann
of interstitial pnoumonut, at th« a]ivx <>f the luugit vo soiuetiiaeft mc«t
witli spicules of bone, already dc-icribed at p. 183,
■auUfrAOf (bo pVjIlVBUl lu tb« mWwiBr «lUi, bad »oaiid (he bluadr«a»l v. X Va (0^VM.|
BTPniLlTIC PSKIIMOSI*.
42S
A. SiffAilitic PneHmtmia. — In tliw variety, wliicli w« fiml nlnutMt *x-
clusivvlv in tliD nt'w>boni, the luti^ ofTun* no tntve of pi^i'iiution. Thv
intvn>lvi-ol:ir DCpta art- oxtrcnK-ly
thick, ami tlicir «clliiUr «Icmont» •''K- !!**■
lire n»iunl iiDii ^•mbryOIli^!. Fitiitltj
tito alvciilt, aUti«u;^li iiolnbly diinin-
iiihoil il) !<izc, lire «till purmonlilv,
nnd Uivir viiiIId are covered with a
very evident |iavcmeiit c|iitlieliuin,
which »l tlie centre of the alvcoUia
f)eL'f>niea spliericnl anil ia tlicD infil-
traie'l with fatty K^anwlpa.
TIic iiakcd eye vxamination ena-
bles us to rvco;^iize the deitaity mid
th« rMtstancc of t)ie disen^cd ])»r-
tioD. Upon the cut Kiirfnce we *e4i
tistiuc, wliitïr i>r griiyisli, of fibroua
appearance, difficult t» tear, or to
cut with the fin)fer-nail.
Ill tlie«e nôduli>9 of ayfthilitic
pneumonia, veritable gummata may
be devclo])cd. In certain ca«iM tb«y
are accompaniod by a surrounding
bronchitis or catarrhal pneumonia.
e. In rejicatwl cnrif;e»lion of the
lung follo-'iii^ hemorrhagic itifarc-
tion, in a sjiecial form of miliary mbcrcnioeis, and especiallv in ^ironie
dictate of the heart, ve often find partions of the lung indurated and
Fig. 23S.
•nUI>ll«liiMntM>«lpu>Bmiiil*fniinanDV.|ii)rB
ehlltl. d. I'relKonilliii («Tin*g|iTfl 11»dq i>r Ibt
Imifl^ A. PAVourul'CalLk urntbftd tintiipd Iba
■IrHll. a. trti iplirrli;*! r*lU Id lk« dvauU.
lirîl^
PéÊi
Pr*V* t«4vrft0aQ af llip tm>iï. ibottlnf tbA ^buamul Qqmbvr of ivoklvD plfnaDttd «f n^ftllJit
flttU f4i«rlfig tbtalfalir »*{[*, th* loer**** of «douoctlvd t»4it« jifouud lb« bloudf«i4Dl. a. tad tb*
liuw*i|<i*nlilr uTplfDitul. A. The ■l(wl»UTllf. X*'"'' [QritH,]
black with pigment, which present the same loaîons of the alveolfir trails
and of the contents of the alvcoU as in the interstitial pneumonia of
luinors or antbracoeiB.
PATnOLOOrOAl HrSTOtOfiT OF HBBI'IRATOBY APPAItATOS.
rf. Antiiraeoititi. — The Ictiiana pixHluccd in the liinpt of iiiin«rs, in«tal-
founders, ew., liy minute |)arltcle« of carbon are at first tliose of bron*
cbitja; after that, a special form of interatitia) pneumonia whicli tvrtni-
natoe in iiU'crations and t)ic fonuation of cavities.
One or liotli lungs arc nltcro) more or \w* Dxtoiisivcly> The iliscaacd
portions ur« dense and of a sliitv or black color ; tlicr (ïcnt-rall v form a»
elevation ii|>oit the swrfacc of the lmi»tt. Ujwii «-clioii of the orpin, t)ic«e
induriilvi) pnrtion* offer a iiinoutli, shining, «oliil surface, ■<lnt«-i;ray or
hliwk, or of II brilliant ebony wlieii the Icwoii i* very pmnouncml. In
the hitter cnoc llif tiogcr irtiich toucbort it it* ttoiled black, anil by fcnip-
ing with (he iu:al)iel a thick fluid of the uime color m ohlaineil. The
bronchi contain a dark uiiico^ptiM, am) thd Hjjuta prévient a similar
aspect.
Thin section» examined nnder the microscope abow the interalvcolar
sopU very much thickened and containing minute hlack particles dispoM'd
along the vessels, in their intomal coal as vrcll as in tho cells and Wtwcon
tbe tihres of the connective tissue.
In the interior of the contracted alveoli there are nmnd cell* of tl»e
site <>f pus corpuscles and liirj:er, which contain «hLik gmniiliri<. Iii the
fluid iti which these cells arc aus{)onded the same dark crantdoH are m'cn,
and they nrv enilowcd with the Browiiiaii movement. Tlicite granules* are
either round or irrei^idar and angular. They undou)>Icdlv cnnaint of tbr
du.it of rarlHin introduced by way of the air-pa>ua)tes. This dust cannot
penetrate the layer of ciliated cylindrical epithelium which lines Hi» air
nassnge!!; bavin;; reached the air-ean, & destitiamation of the epitlieliuiD
IS excited by their irritating presence; it is then not difficult for (be fine
particlea to penetrate into the loose connective of the septa. Ttie ])us
corpusclce absorb some of these particles, thus sccnrin;; a dlscliar;^' by
the sputa. Others, by an oppomte rouM', ent«r the lymph circulation of
the lun^ and rcacti the bronchial ghuKls. Tbe ine«cnt«rtc j^landi* may
»I«o lodge »omi' iif tboiie particle» which are swallowed witli the tiputa,
and iheKe (çland# are ummlly cTihir^i.'d.
In the last stage of the niorhid pn>cess, tlie hlack and indurated por-
tions of the lung may ulcerate at their centre. 'I'liua, carems somewhat
aiialo<roiis to those of pulmonary ]>hthisis are formed.
Artificers in iron and stoci are subject to a similar form of pneumonia
(iidfro»i»), but here the coloration is brown, instead of hlack.
Workmen exjioscd to the dust of silica may be affected in a similar
way.
e. litAiir or eroufiout pnexinwnia which ha» passed into tJie ehronie
staff is extremely rar«, but it is soiactinic* met with in hospitals for the
aged. Oliareot distinpiiidieji three distinct fornix by their color— ret),
Eray, and yellow hejiatixation. We believe that this difTerence in color
IS due, in the one case, to the effusion of blood into the alveoli, and in the
otiiers. (o the abundance of fatty granules which are contained in them.
In these cases of chi-onie pneumonia the inieralveolar s«pta are thick-
ened and more or less infiltrated with dark pigment derived from lUo
blood. The alveoli are filled with lar^c spherical cells, containing lig-
uent or fatty granules as well as lymph corpu<:cles and, in sotuo caaes,
red blood disks. Cavities have been uccusionnllv met with,
I
I
TOHons or thb luxo.
427
rOreen hxA seen three casei in vrhich, tteatde the growth of tUe alveolar
walU. the intnt-aKeolar «xitdation proilnctjt were iinilvi^ing AbroicI mct-
aiiioq>hosia. The alveoli yrere foutwl tilled witli a fihrinoua tncshwork
containing Icncocytes, soiaewkat similar to those met wiUi iu red hopa-
Flg. 2311.
Cbrsnig pBaanaiila. VueuUHnllBg moi ttbrald (■«•iDpnonl «r laM-altMla* •ludstlim pro-
dutlt. D loud •«•ni* tl* t«°D In lh« timtillan (irniloAla.irhlrh MnudTiu»!* omiiuDIiltaU «lib
lbo«* la Lïi* 4tTf4Ur wftlU, Th« alTvoUrinllB trt bIao IhUktbrd Ifjr 4 AltrvbiicJ««t*d g-nnrtb-
ligation. Tlicy dilTered however in thifi respect— that many of tlie cells
«ere long a»d D|>iiidle.j4hai)ed, ami hloodvestieU were dUtribulcd amonjiat
thcfo, vrhich bloodveniieU comnmnicatcd with tho^c of the alveolar walls
(figs. 28ll, 2j17). The alveolar walls were also thickened by a fihro-
nucleated growth.]
In ftll the forms of intitntitial pnctiroonin whieli wo have pai(»cd in
review, when the lesion t» «'iited nt the surface of the Iwng, il i« aeutun-
panted hy a chronic plenri.-ty eliiiracl«r-
iw;<I by a cwiisidcnihU- fibnuii* thickeniiig. V^g. 237.
TmoRS OP THE Lrxo. — ^Almoal every
kind of tnmor has been obsened in the
lung, but the most common ami the moat
iin{iortant are tubercles of this organ.
We will dcscrihe with tubercle the di-
verse le«iotis of the lung which accom-
pany tliem.
tîtrcnia lia« been met with in the
lung only a8 "■ecunlury umliiK-s :iuccMd-
ing prininry tuirxirH hwaled elsewhere.
In these «oeomlarygrowthd in reproduced
the structure of the original tumor. Their
development may atari in the alveoli or utn«j«>.>i*r >>u4>iiuii prv<ii>vi> (Fijt.
in the mieralveolar septa. *"' """• "■'«'■'r mwi»»^. *hivut
In tnelanic sarcoma the only difference *"• """«•'** 'i;'"*"' ,"'"•'*' "'•/!'^
18 that the elements "I new toniKition are (i,.ph>b1h. x*i>. (Onn.)
infiltrated with blucfc cr bniwii grnnulc».
iSimplf mrtnuir twitorii (itee page 198), reproduced in tlie lungs are
entirely similar in constitution, both to the nakctl eye and under the
Ch»«i(' I iii><<uL4. A ;<iiiiii
"f Iha
•ti8 PATIIOLOfllOAL HtSTOLOtlT OF RERPERATORT APPARATV8.
micrOHoopc, tn ttio interstitial pn«ninnnia of miner», except that the WucV
granulea are small and rountl. instead of angular.
A Rielanic tumor of the Inn;; may invade tlie hones of tlie vortobr»1
column in such a manner to destroy the bodies of one or more of th«
vcrt-t'liriK, thus giving riso to a variety of Pott's diaeitse.
Fifiromatit of tlic lung have bucn olisorvcd by Rokttaiwky M «mall
har<{ miutHcs of tlie e'nc of a pc» or liaxel-nut, and tlio samv patltnlofpxt
liH» oecii tipomata from the sise of a lentil to ibat of a foa, «ititaled l(e-
nentli the vint-cral plenr».
OrifiniitUt are im-t with in liinji!t afFected with int«rstitinl pneumonia.
We bare soon an example "f nsK'oid tumor of the Inug cbaracteriiu^l hy
tlie Irnii.ifiinnation of alveolar septa into osseous tissue.
Jinch'Kiilr-nnata have been seen in the lung only as secondary fonoa
tjons after the development of an enchondroma in another organ.
Primary Carcinoma of the limg is very rare. It is most frw)ucntlT
onc«pluiloid, and is found mon- often in tlie right than in th« loft, but it
may invade both lungs, the ont' aftor Ibo otlior.
It commcncf» by nodule» which i-iilar^e and form one or more ruu«<u-t>,
invitdtiig tli« greater part of oui- or mori- lobe». Tlie vimiernl pleura over
tlieac nodules ulwnyn presents a considerable thickening, which is due to
a care i noma to UM trannfurinatiou.
Upon ciittiii); into the diseased partj*, it \* common to observe whitish
island.^ or granulations similar to those of the bepatir.cd lung. se|»ratei)
bv pigmented septa of lung ti^isne. These islands are due to the stuffing
Of »n infuiidibuliim by the eareiiiomatous eloiiionts. In scnipin;; the cat
surface with a scaljK-l tlieite granulations arc removed, and a milky fluid
is obtained.
A mienwcopic examination of thin section» shows the alrcoli filled by
large spheriiral or polygonal cells cDiitnining Inrg^ tuually oval iitMlci,
with distinct nucleoli. Tho alveolar vinWit are very friNjucnlly pri'serriNi
intact, or they may be somewhat ibickoued by the furmatitm of small
rouiul cells between their fibres. Their vessels are gorged witli blood.
There is therefore no stroma of new formation in carcinoma of the lung,
but the fibrous trabecule are conadtutod by the altered inter-alveolsr
eepta.
Carcinoma of the lung may givo rise to ulccnttJons or caverns, vhidi
are sometimes midlijtic and in direct communication with tbc bronchi,
llsemoptysi» may then »u|H'rvene. and the patient expectorate the disin-
tegrated tdomenljt of the wall:' of the cavity with the cancer juioe.
Xodules of secondary carcinoma of the lung present tlic «Juno struc-
ture aa ia found in the primary growth wherever it may he located, and
whether it be soirrhoua, cnceplialoid, colloid, nielanotio, or any othOTj
variety.
Colloid carcinoma, which is comparatively common in the lung ae a
sequel of a primary tumor of the same nature developed in the muoom
membrane of the alimentary or biliary canals, presents itself under th9
form of small transparent grains, surrounded by the wall of an infundibu-
Inm. These grains tmitc to form small spherical nodules : here ahm the
stroma of tliu tumor représente the fibro-elastic framework of the lung.
Tl'BBRCCLOStS OF THE LCKQ.
429
ft
ft
ft
The j;roiT^ of cftrcinoma of the lun;; thcrcforo notably diflVrs from ite
habitual modo of development (ace {mgv W et wq,),
Vie- 23e.
J. tnUet or anciphilaiil ainliian* ol lb* Ibb* X >"- 0- Vltirtti* •lisBi* «atlubc ot lli« «slU
at UM ^Inennrjr aliKll. c- l|iiihaJlkl Italnf of Iha alHoUr walla vllb ih«lr ttgouiioDi. ft.
*l>nU>«aiIV-
It. Kfllli'llal KitrlDg at Bil c*ll> X *K'- «- 'l»-olar wall*, t. R|ilihvlUJ cull*.
M, Kplthdltal toTtrlitK of o^lhidrltfal «alia X 3^- f-fiit^rliit «a^D* at prtM^lujr Avar*'
J>. P^Iif^nilfif c*]U af thii llHtafl ai^llhellmn X ^'^^ t'^iitrlaii tama ai pm^ifdJqK,
ff. BaflliiDof aWoDflililjilaiid X ^' '■ RalUolaUi) tlHoial Ibf rolllfll. t. C)r|lail()«»l rcKhutluD
Ualag a i|iw« Id Um tavtEauaa lltaya. f. A ailld a^Ubatlal pruloof aUoa poaaLraLlnc latu tbn totle-
mlatUiaQt. (JKibuMt-l
In a certain number of cs.!sea of sci-omlury ciircinoni» uf (he lun;;. we
have been able to dcmonstmtv n vvrr uctlvo ptircictpntioii in the iiroplaem
of the superficial lymph ro««e1s t>i thv plrtirn (i<i<!0 below under eaneer-
oofl j^niilatious of the pleura).
TirBEitm-oiUls or tiik Lrxo. — However perfectly demoiiMmlod and
indi«putaMe the unity of tuhereuhwi* may he, we ulioiild not i'xjn>el to
find in tnhercitlonH hm;;;* iiimjile lexion*. or those iihicli nre ulwflv» the
mme. Beside the initiiil »ii<l oharaetoristic resinnA, we invariuhly meet
with tlie ordinary or apoeitic inflammation of the hronchi, of the lung, of
tltc pleura, of the lymph };landA. 'I'heso diverse atiiiociatt'd leisions may
even become predominant in an anatomical or clinical point of view. Yet
480 PATIIOLOOIOAt nrSTOlOQY or RBSPIRATORT APPARATUS.
by their progrcaa and tUeir evoltition, IiT llicir fl])ccial pUysiogimmy, by^
tlieir tfMidencv to the caaeoim Rtate »n<l Ui morliSvatioit, tlit-oc iwltn^niirjr
intUtinntnlions properly belong to tubcrculosis. Wo sliiill lliiTcfor« <iv-
Bcrilit' umtpr this hca-l linili ilip tubercle ^raiiul&tioDs of tlm lnug, and the
lesions of iliifl organ whieli art excited by tht-ni.
TUBBRCLR Graxixatioxs. — Wv dn not pro|io«tf to roilcrate livre the
dcHCriptimi which hiuhpcn ;^reTi at pa^C tl'2^f »rq., hut we mttHt coiuiider
nioro ill detail tlic mode of origin and of evolution of the jçmniile in
tin- liinj;. Tin- scat of thi? tuhorcle gramilo is at the bcpnuing vnriahle.
In order to ifludy it we miLtt itolect a lung ubich is aowii with very fine
miliary j;r»milOA, ^<> Kinall n.« to ho cicarcely vLiihle to the naked eye, but
wbicli i!an be bolter appreciated by the touch.
Studying a projicrly prepared ecction we observed that tlie minute
granulea omy be aeated : —
1st. Around the vesseU. There is thon an ■ccumiiUtion of eoibryonal
element» in their adventitious nhentb, and in the adjoining connective
tissue, such &s is represented in fi<;ure 234. As the figure indieates.
the lumen of the vessel is obliti^'ruted by a gnimilar mass of fibrin, in
which soiwe white blood corpiweic» can bo
ogiii»e<f. The udvenlitia and tlm Kurr'>und-1
iiig eonnectivo tixnue are the Heat of un e.tii-
bonint i)roductiou of nuclei anil of Hinall cellH
held togetiier by a fibrillar or aiuoq>houii
intercellular siibslanco. This uen lis-uifl ia
eon till imns with the ihiekcncd walls of th<n
iiei^îhlioritij; ulveiiit, whieh arc lined by
MHolh-n [iHvenient e<'lls. These legions of the
wftl!:« of the vi'weU and of the alveoli together
couHlitiUe a nodidc.
2d. Around the bronchi. TIte sdven^tia
of the peribronchial veaael» take:i »»
a part in the neoplaiua as doe» llie con
ncctivc tissTie of the bronchiu. A very
minute granule may occupy only a part «f ll»é
periphery of a hroncbus, or several granulea
unite around it in such manner that the entire
peri]>bery of the bronchus niay bo siirmunded by a aouc of euibrvoual
tiiwiie in the midst of whieh exi.tt Hcvonil groups of eteiiivnt« wUcfi are
iiiiieh compressed and atro|ihi('il at their centre.
The bloodvessels in tubercrtloits nodule:* are nlway» obliterated, and
tltey are very fret[uontly in the same state in the xurrounding enibryotuj
tùme («eep.llfi), Tlie lumen of the clotie<l vesaol i.-i occupied by granu-
lar fibrin, and in tninaverse section between the coagidum and the reswd
wall a row of white blooil corgmscles and of endothelial cells ia often M-eii
S see fig. 23H), The while corpuscles may also occupy tlie centre of the clot,
n most tnbcrcle.t the walls of the vessels are very easily distinguished.
But if the centre of the tubercle hns undergone caseous degeneration the
rcMcl wall U also altered, and is very indistinct and readily confounded
with the caseous mass wbtch i<urrounds it. If the ['R-ccding alterations
Tr^QiTrno AACII^D *t( • i«t«al
tllul «lui RturnUr Obrlo. ti. Td-
htfrolirlUaor. t. WblWhlniil rnr-
IxitsliK, Tli*n la hat> t lubcrolt
IsIulrlDg lUg '■•••I. X *>">■
TCBBRCLB ORASPIATI0S8.
431
tre not rcco^^ixe^, one <locti not know to wlinl Uic kdiaII gmniilnr dwm
conlwniiig niicK'i, uiiti uoouiiviiig lui ill-ilofii)(.-(l citrity ■■> itiv mi<litl of tlie
Bodulc- i« line. 8chii))|icl liii^ iK-Horilivil iht-vv luiiriitiM u giant cells,
wUicU ho ri.'guit]» ax characwrUtic of tiili4:rvlv.
1ft certain csmm the wnall broiiuhi lire envwlojwd in a great extent of
iJicir coor?* liy » cjlinilcr of new emlirvonic tJiMiie. Such a peri-
bronchial cj'liiwler i* the nltnoHt contitaiii lorm of the siuaU and recuot
granulations ot'glamlcr» in the horM.
The lunten of the bronchux iw gfiiierally filled with larj^c eclk, round
or irregularly polvhedric, nii'l a caUtrrhal or caaeous hroDcliitij» eompli-
cates ihu tubercaïou» ]icri-()roncUititt. The wall of the broncliiLt »how«
a tUiiUv containing nuiaoruua emhrvonal celU, which pcrLa[M) i» continu-
Fi». 340.
N
•tN/DW«aloaintai(laBarkbm<bii«. »MtlMarft*n>II t>ma<liB(4f ■ markrdif •r»faUa>thll4.
lltBbftltj*H ti hron^bltL*, which t*rnl4i4>«d la nllUrjF tolttm^atB' Thft itc#p?r tlro«larci ot tbe
kn>arhUI «nil or* •■•u lo b* «tlcnalirlT loOlinltd atU «lit. >ia>l *t mhlrh utr turf/rt IbmD Itioi*
B«l «llli tn Ihp Le«ii «it«fk*Lvn LfiBUrftliunof hoillhf IHttiunutlaL TbA luflUrktJvD aitauflB to «■<!
tinila* l!>« «illi «r ILo k'TjAf^tl 4lTf.]M. vUkh %n u«a «« ibfi ii|-r«r pnrt al tb« ilmntut;. Tb«
•■ritf "( »)• biunchui RiBUIn* • IllUe iui)<ii>. n. X IW. Hdnnil |. (On*».)
0U8 witli neighltoring nodules of similar elements, perhnpn with t)ic walls
of nn adjacent alreoliui which 4iare been thickened by a siniiUr new
formation.
Figure 228 tihowg a bronchus, the latnen of which i» filled with «limilar
contenta, and the walh of which proscnt at different point» a tubercle
granule surroumlcd by pneumonia.
Hd. The granules may be foatcd in an infiindiboluni, all the alveoli
of vhich are tilled by the new formation ; whitiit the iiitvralveolar septa
mar atill bo recognixcd by their eliutic fihres. The whole mass forma
a fittle nodule whose centre \» already undergoing ea^eous atrophy,
«hill) the pcri|>henil aJvpoH cviutuiitly ]jre»v»t the letionii of congcstîoo
■182 PATIlOLOaiCAL aiSTOLOQT or SBBPtllATOBT APPABATUS.
aiii<l of f.iuirrlinl IiiflnrnmiitioTi. WiicncP oonw tlic «WnM-iite of tlic ^miiiila
wliidi till the ulvcoli V '11ii« \n n ipuifliun vcrv ilifficull to aiuiwor. It
U posflible Uml tlirc« utadcn of fornialioii itn; ui-livu. Tiivy m»j cooM
mg.m.
Acuta pblbltl*. UMwlBK»B*or tkctlTfoU lUtd wÉ>b npllhtlliil •lantBU.Md aarksdwllmtar
luflltnlkgor tholtMlu w*l). X W. («MaJ
from a thickeuinK of tho sept», from » proliruratiun of die ognthclium, or
they may bo (U-rivfcl from lymph oorpuitglv» o!t(;jii>(!(l from Uic vessels.
Iti citsvif of iiiiliiirv ]>)itlii.-<iM, tubercle grannlcH uIho are iirviwnt at the
«urfiice of cIk.- liiog, niiil form [irojectioim u))on it : lliey ara )ocati.'il Id the
rii*ceml i^h-iim. Tticy arc abofotinil in the bronchia) mucong moiiibnine.
At thi' pfrioil of ertiption of miliary iihthisis there cxinn an int«iiM
congeatioii of the whole lung, a catarrhal pneumonia more or le*» este»-
dive, anti there are soon joined with thcae, new Ic^iona which eoii>tt«t in
ulcerative iJestruction of small bronchi and of nodutcA of lohular pneu-
monia.
All the parte invaded by the liiberclc arc deprived of their life by
obliteration of their vciwels ; the cellular element* become granular, till
tissue becoming dry, and, like all deiid tissue, it is subject to decomf
tion, which soon manifestK ifj-elf at t\n< point* where iae nir ponetrat
Kirtl the <-i>iitcnL-« of the bronchi, next lb»; hroncbial wills, then
point to point the altered pulmonary tissue, expérience a molecular dc-
compoailiou which reitull^ in eliminalion.
This complex process is what we understand by tiiberciiloiis brondio-
pneumonia, in which small caverns very Hoon fonu at the extremity of
the bronchi. These losses of substance are bordered by a xonc which
contains tubercle t;ranu1es surrounded by pneumonia, and, since here
also the hlood circulation is impeded or arrested, this lone ofTera a yellow
or gniy a^jiect, and the infliiinmatory products undergo caaeous degenera-
tion. ÂI the peripbury of ibîit xonc the pulmonarv tisKUe is congested,
and prt-Muntft the lesions of catarrhal pneumonia in the first or aeoond
stage.
When both lungd are invaded throughout by a large uumber of di»-
TDBBROIILOVft CATAHRIIAI. rXSUHOMA.
433
wninnud mïliitry ttil><!rcle«, <Ie«th rajiidlr «ii«ueJi. But if, on tlie ooil-
tnry, Uio tnlioMi.'* are nmcli m«Tçi itifcrrlc, » loii^c^r rlnnitioii of the
iliwAM jienniLi ut' the utiHi^rviitioii of a fcfwn of jirofouiiil alurittiniis of
the loiig (laroncbymit, which we (<hn]l dow [iam in review.
Ti'BKRCt'iACe OR Caskous Phbi:mon[a. I'liTii I sis.— Pneumonia plavs
■ cnnai^lerabte rûlf in moflt c*â«a of pulnionar;r (ihihiaU, and most of the
lenions olwened are caua«d by it. It manil'esU itself by inHammatory
liypenemia, by catarrhal or croupous piipunioiiia in the fiist sta^c, vt-rr
Sflon followed by thi- va«<.-ouâ mctaiDurplio»!!: of ihc iw^idation. It li
always prettrnt nmniul cuvittcH in proe«tw of fomiation ur onlarpNtivnt.
L«t lis now describe «uccosxively lobular pnvtunniitu, lobar pnuniuDiiiii,
and intvmtitiat pnvmnonia, whiU> iiiilictitiiig thvinuintomical coiI8pi[uciici».
Tul'irrcuhu* Lnhular, or Catarrhal Ptirumonin. — 'Hie two first xta^ea
diffi-r from those already de»cril)od at yn^f- 414 mily by the i)rciH'nce
around the bronthi or in the infiindibuhiof tiibervle ^ranuloA. \el these
graiiidea. beeattae of the granular degeneration of the pneumonic nodule,
mav not be recognizable.
'rhe siac of these small pneumonic masses ia extremely variable ; they
may W limited to an infundibulum or a primary lobule : they may com-
priac a secondnrv or a tertiary lobule ; or they may attain the eiae of
n hazel-nut or walnut. In otiicr eascti the caturrliul pneumonia '\» dilfusv
and oioro extensive.
Kg. 34S.
.J ■:<-
A (MiUMn tnf lnhinlt mm tba la«B U •«•* n^MiiM lahtrgulanla. Tb* wboMotikaiubrrcta
!• •bowB la Iti* itniwlDf . kBil It li otiilaailj «uUIBiol Ur^tlf ot lal rib«l(iDlar i>tii4>eM. % 100
ntvttAlait- itfrm.}
Very soon thotte pneumonic nodules pa-ts into the caiieou8 state ; titey
•olidify and dry up; all Ilic elements of the exudation become granular
and agglutinated by a .lUghily transparent granular âuWtauce whldi
23
434 PATnoLOdtCAt niâTOLoar of rbspiratort AVVXKATts*.
shiiioti like fibrin when acetic acid in adilod. To the uakcl ej-o. these
foci apfwar gvtiy and homogoneons. They are friable. They constitute
wlial Jiai'imec called miliarv luherclos.
Tin." (.■Icmciits contaiiii-'d in the alvooli consist of pufl corjnisclfs, roiiiMl
or slijjhtly angular by comprc^iou and filled l>y ]>miein or fat ^fraiiidcs.
an<l of rouiiil or poly^oiuil vrllt of
vnrinlilu size, preâentîiit; one or
more nuclei whiuh have »1m> «uf-
fcred tin- «nine falty dcjieitpra-
timi. The cell tiiideiw i# not
whollv lisiMe, for tho clement»
are ali.iiduU'ly inert «ltd dead.
TlieM> dead «lemenbi Itreak uji
into nnuill fra^^mmiU often angiu-
lar, whieh licbcrt liafl nained tu-
he re le cor|uiflelea.
In these mope or loua extensive
foci of ]>iicnnionia. as has alreadr
heen auid. the h)oodves»elii are
ohlitersled by eoa>;uUted (ihhn.
Sometimes the nodules |)n'fent.
firat lit the centre or λ itet'enil
]ioiiito :it once and finally ihrouf^i-
om their entire niaM, a yellow
irolor which in due to a Urjferqitan-
tity of fatty granule»; thin Îjk tlie
crude yellow tnhercle of authors.
Tho corresponding bronchi al.
most alwayx present the altera-
tions which have Wen studied at
pape 407. (Fig. 223.)
Tliese foci of piieumonia «onu'linMr» very «(niekly pinw into the pnni-
leiit condilii)D. When they «re very nmnerous we have i>nc of the forais
«f acute plithi«i#. Upon Opening the lung a htrge numhcr of tliein are
destroyed, thus fonning xtnall cavities in oomiimntvation with tin- hroiwlii,
111 lliÏH form<if tiibereuliictis, perforations of the vijiwral pleura arc not
iiifiivpieiitly met with.
When theiie jmeiinionic lobules are located at the surface of the long,
aficr having ^i*en riae W a locnliee<l pleurisy charactertxed hy thin, soft,
false membranes, and a thinning of tiie friable wall of hefiat)Ji<ed ttiuue
wliicb sei>arates the pleura from their carity, they may break through
into the pleural cavity and occaùon a pneimiotharax, Ihe fluid cHiuion
and the air cause utelcclasis of a lobe when the f ileuri^y Is so recent Uiat
there \» not sufficient ttiickenin<: of the viscerul ]>lvum to prevent the
retraction of the pulmonary tissue.
In fwh a compressed hihe multiple lewon» are oWrvcd: there an?
iuhereic grauules and nodiilf» of jxieumonia in different .«tatçci* inilnshled
iu a congeMv<l »n<l atelectatic [lulitiouary tiiMue. Several tiinent we liavA
aeen even recent porfiira lions closed by exudations and plcuritio uew
forinntiuiu*.
,1 txiitlna nf ■ end* jvUnr labcrcl* rnni Iha
lung Id > iiiv at aralB lakaraalail*. KtooliiK 1N«
<l-i>i.rriiliiin of Ihs «Elf*] ^rtloB* it (ba nvduli
e. ftoJ (]■■■ I'^llvUr ililrkonlrkf or ih" Aliwtlu HkUt
VI 1 ■«»miiUluii> Klllilu 111* iltiuUr «tUlat itl
TltBBRCULODB CROUFOUS PIIBOMOMA.
435
tliU form of (ihthisia baa hcen (nkcn as « type for the geneni <)eiu.>rip-
tîon ffliîch Liwiioec, Luuis, Cruvcittiivr.d o^., have gtveu of tubeivk.
Fig. SU.
i/^r.
■f
)
■ ..^.^
•acUnBiif > B<i>l>ili< I'F ■ liiii( (aaitlttl villi ifVMO» InbnUr pifninanlL n. ruluiautrf «Itroll,
tlM*llkulklaiiiui*tof7*iaiUlMn. t. T*mln«l liniafbuvpanlBi liiW » lafBadltuIaa. X**>
Tulfreutt'tt» l^lttr or Oroupu» Pneumonia. — Tlii» f<inn of piiciinionla
offers for c^Huitteration an evolution very tiitiibr to llial of conuiiun
vig. za.
A«W pkttiUli. fbtwlof aoror lli*ii|T«ll «ll*d wKh BtiFlinni «tmlitlsa «a-l l«w«flt*.*ad
»in*Mliilul>ll1irikll4D*t lh« nloulir null. XWt. lOrttn.)
croupiis iHipunioiùfl. It differs from tlie 1a(t«r only l)y it« groator oxtoiit ;
it may involve n Ijirjic [iiirt of u lt>bc, ^r an i-utire loin', or evoii nliiioil tlie
vliolv of one Idiig. ïiiv Ktagv of red bepatJtatioi) i» nijiidly reavJied, but
436 PATIIOLOSICAL ntSTOLOOY OF RESPIRATORT APPARATUS.
k
it '}» niro I» fiml a rihriiiouH exudation in the nlvvoli as «olid u m onlin«r7^
crotipuuM |ineuinunin. {
In tlioir {WfKuigi-' tn the ciuteniui «oDilitimi th« <liiicasv(I portîani» lieconw '
<1et-ntorei], anil ihc cellular olementA of iW exiidalion whicli •liiitcti'U the
alvfi'ii hecoinc granular anil (trv. The cut tiurfuco of ihe aitcrcil lolw
is sliining, fliuontli. uniformly gray, hoinogeneoiu. <lry ami lil<«>iiless ;
the bronchi arc tilled with the snmo cxuilatinn as that which filb the
alveoli, and the vessels are choked with coagidated Sbrio. The pulmo. ]
nary tissue is harder than at the coraniencctucnt of the hcpatixation, aud J
iiotwithstatidiiii; thut it is easy to tvar, modorately thin sections van he I
cut without hardening, Tlii» is the type of the ffrai/ i»jittratioH of
Lai'iiuvc.
In other caw* the heiMitiiicd jiortion jjroiteiit» to the naked eye a ool- ;
loid BKpvct; the lung is infiltrated uith a trembling gehttitiiform inatorial
(ih'htiniform in^Urati'm of I.neniiec; <oUoiii. eaavous (incumoiiia «f
Ulinon). In thin .«eetionti under the microitconc, the alvei>li are seen to
contain a colloid siihstance ana1o^otL4 to that of the thyroid hoily, rea4lily
colored hy carrainGt li^sidefi numeroiitt cell elomentfl Home of which ar«
vesicular. This exudation soon under^es a caseoiifi metamorphosis.
Instead of being gray, caseous pneumonia, which is older ai>d in which
tie granules arc more abundant, ofi'crs a yellow color. Save in color,
the appearance is the same as in the gray infiltration, and the constittition
is also similar.
In certain eases of this kind of pneumonia there are no tubercle gran-
ules to be roco;imKert Dither liy the nuked «yp or by the micmwnfw.
Il may bo that they have been present norertliele««, but in coufletguence
of ca^eoutt traiiRfornialion have become iiiditttin^uishable.
Aeconling to lirancher there is always in ca!<eous pneumonia a certain
amount of interstitial pneumonia in places.
Considerable masfics of this tuberculous pneumonia may remain un-
changed for a long time, when the lung continues impermeable to the air
and to the blood.
Cavities are farmed in this variety of tuberculous pneumonia in the
same manner as has already been indicated. ^Vbcn the loe» of substance
has reached the nonnal pulmonary tisfuc the destruction id arrHtcd and
the furrounding tissue is indurated by a chronic inflammation, accom)«-
nicd by the formation of connective ti**ue in the intcralvcolar nepta and
even at the surface of the cavity. Upon the latter we find sntall vascu-
larized granulations beneath tlie pulpy or puriform covering which line*
Uiem.
ITifire 9ometimi>it exii^t also in this layer of granulation, small anourifflus i
which arise by ililatatton of the branches of tiio pulmonary art«rv, which
softened by inllammatîon, become distended by the blood, Bv their
ru|»ture, these aneuriums often give rise to fatal hjemoptysis. V'esscls
and lar^e bronchi often extend across targe cavities ; such trabeculie arc
also covered with a layer of granulation tissue.
Later, the inner surface of the large cavities is smooth, almMt as if
it were covered by a mucous membrane.
The interstitial pneumonia, aided by the chronic pleurisy, the 6bniti8
induration and intimate adhesions of the ,two wall* of the pleun, when
TOBBBCtLOVB IKTBBSTITI&t PSBOMOIIIA.
tlii-y arc located at lli« apex, m a rule, cnwc marked «uM&viculnr
dc[ire**i«iiit.
<.!«iiititiiiiikiitioi» maj be c«tal>liii))C<I between tliv cavities and a caoeous
lym|i)i ^laixl, or l)OtWG«n a i:arity mid n vertébral jtliKceiM in Pnii'ii rlia-
otktc. The cavitiflH dmjt oven be et'!t«)Ukleil exutriorlv by a cMltineous
fiittiila.
Because targ« maaaes of lolnir pneumonia are often found, in «bich
no tubercles are to be sc«n, the attempt has been made to et^ilabliAb a
form of acrafuIouB pneumonia independent of tubereloa. But. wlicii the
«hole of the lun^ '" oxnmined, we almoat always 6nd very distinct gran-
nies in other part* of the orsiin or in the pleura, citlier viscenl or costal,
or they mav be found in the periloneiim or elsewhere.
TxiUmiioHt InttritUial J'nfumonia. — We liave [irerioui^ly seen tliat
intv»titial pucuinonia often is prcHi?nt at the apex of the lung, arciiwd
rig. 24&
until •(«pllbsnki c*lli wll&la>b«*JiHtar«iU]'- Tke UIMt u* wiilBrituiBg nlrign»lv« ebàMM
large tubereuloiw eavitieji. [n tbo*e indurated and often idaly or black
■HUM we may find very elinmcterÎMtic tubcrele granules, wliich prolv
aUt remain a very long time without sutTering de.itruution.
But there exitita a form of tuberculosis in whieh the granules, however
numerous they may be, are everywhere surroundetl by a pigmented
interatiljal pneunioiiia. The tuberculous proccis is then more or les»
rapid in its maroli : but there is no very great tendency to tlie det«r-
mituition of a lobular or lobar pneumonia.
ITie general distribution of tubcrcnloua lesions of the lungs is such
tJiat it is the apices which nre usually first invaded ; in the slow form of
tliis disease, the apex of one lung may be attacked a long time before
that of Ihe other is involved.
Tluw we find, for cx«ni|il>', in the rîf^bt lunji. somewhat lar^o cavitiec
at the summit, with intenlicia] pneumonia, and a pleural moiabraiie very
438 PATIIOLOQICA^HtBTOtOflT OP RBSPIRATOBT APPARATOB.
thick nnfl filirouH; tlic inidilli; l«l>n iicpimmim i'xtrn«vc iii>iliil(;:> of cMCflMi
pDeiimonia vrilh cavities îii (imcv** of formation «l tlicir «onir»'; mid Ui*j
infcnar lotte may cihnw a nuuw of loliar piiiimufliiin in Korcnil xUgM,^
without tlierp yet Wing eiivenw jjrewnt.
Ttic pleura of the tVo Itviit lobcn lA {ierlia|ia corercil by a fi1>rinot»
fXuiUtimi aiiiî inav bIiow tuliercio ;;ranulea. In tlie other Inn? there
may lie s few lobiileH of cn«eoiis rniotiiuoiiia. one or two amuH eaviiie-i in
tW ii|iper lobv; in (lie inferior lohe. eoii»estion and §onie tu)>orck> jn^n*
ulv»; tubenjle ;;ninulot( nuiy lie vltt nuinorotia njion the loft jileura.
lliin i» a cominoti ly[>c, hut nothing is more variable tlia» Ihv form and
Uic dititi-ibutioii of the lexiotu.
liirilCHcI of r>iili(inliiinliii;! tht^ inRaminatorr Ie?iinn)i to the tnWrcIo
u]ti». Nieiiicyer, Buld, and «evorHl other ('lenniui writers, rejçknlcMoons'
inieiinioni» a.' a jioAsihlc cotuxH|iienee of every acui« [ineuuionia or pd-
niotiary lieninrrUngeH. Moreover, for them, ttdierclcA arc iiothinj; elM
tlian the result of an infection following the destruction of the ca^eou» foci.
This theory does not well stand examination, for tliere arc cases where
ati even Niemeycr and Ituhl admit, minute rpsearcKce inad« Upon the
cadaver of putiento who died «f j^enemt miliary tidiereuhieis of the Inng
have faiK-d Wi «liow a Htnfjle au'i.'oui' foeii». We are then obliged to
admit tlial the hyjxithejiiK of an infection liy absorption of * vMvotu pro-
duct of iiiH annua tory orij^iii cutniol apply lo every case.
In chronic phthiiiiii, it tteenu) to u» much more natural to itocord lo
tiiliua-U- an oripn and [ii-o^rcait uialogoua to that of all ttUDDrs. In llio ,
latter, whatever may be their nature, sitrcoaia. carcioonta, epithelionta,')
etc., the tumor grows at it« periphery by little masses which are united
to the tumor, while the central portions — the oldest — have often onder-
f^one an already niliiinced dc^-iivratioti. In thv development of tubo^
clc, the i^anic niarcli id ol>»erv<-d.
We caimiit. therefurt-, »ntn>cnhe to the idea of the dualism of tubercle
aiuitained by many j'hyrtician». in piirtieidar by Virehow, iiecording loj
which tubercle granules, on the one hand, pneumonia on the other, oon- '
Htilnle two distinct processes,
[For various opinions reganling the relation of caaeoua foo to tubei^
cles, see article Tuberculosis, p. 112, et teq.]
Bed TL>-Pleura.
W« have «ufficiendy explained the general pathological histology
Ûtt aetwu mcmliriuieif (see pp. 24H-2IjH) to enahlc us to avoid rejteatingf
src the detail» "f ibeir micniscopJc lesions li prijing of the pleura.
Imntit all that ba» liecn Maid ndativc to serous iiienibnines in general
applies to the pleura, and we Khali liave to relate hen' only wimt c^iKNiialIy
appertains to it. We shall see that, in most cases, tlic le:ùoiiA of the
pleura are subordinated to tlio^o of the lungs,
CONUEâTios; Ecai\M08E8; ÏIvpkrplastic Plkcrist. — (j'ongeMionof
tho visceral pleura is always present when the lung is congested. Hie
CnBONtC COXOBSTTO» OF THK FtKimA.
I
Wontlveascls vliicli Wlon;; to llio tliin traiiM[»nreiil luycr «f coniKfclivf ti»-
siK* nliicli fwrnis the visconil |ilctini lire filled nml ilUu-iKied wiili iiloml.
By ren*i>u «f tliin Ir;mi^|iiri'iM;y ol" tin- vist-enit ini'mljniiic, tlio iiiK-rloliij-
Ur nepui of tin- tiiii^r fvi-rvwln're )i('nm'»t4!(l by tlie liWd mul lym|tli
v<-(i»c1b an- ilixlinct. Tin- {lulygoiinl «)inc;ei>, w)ik-h rcjircM-tit the ^mwi
nt tli<* I III hum III ry lolmliM at lliu mirface ol' die liin$i, arc, in fvalilr,
liiuiti-il by wliUinh or |iipneittcil ImiKlii. Tlio naked eye very caiiily
r««»l£iiiM*ji in the^w hnml» blooilvetweli* more or lowi filled with klooti, and
lyin]>ii vcw«l9 which are quite as large ns the interlohulnr \ciiia, and which
are very -luiierBcial and trniisparciit. and presciUiii;:; tliin dalt«iied nalk.
When the pulnioiinry coii^eatimi ia very îiiteii»» and there is dyspiitta.
hiip|>etis in diseuse uf the heart or of the liin^, or there is an a«)ihyxia
to utiy other muse (disease of the trachea or hirynx. stibiiK-rsioii,
'trtnui;ïulntion, etc.). we fiiid at the surface of the parielul [ih-iini sinnll
cccliyuoees, punctuto or liuviiijc a dinmetvr of one or more niilliiuetres.
Thetie «.•chyiiiosest are chantcturiKed hy nu eMmva-^ntJou of ri-d hItHHl
disk» into itie connective ti.«ue of the jitoiira. \Vheii the ecchymose*
arc rii-eril, there oote.i frnin them at the free iiiirl'a«e of tlie |ih-iir» a.
iia »;; II i noient fluid, and ihey form a slight elevation. Soon after their
formation, the extra vacated hlood diwVa hecimie modified : they are trans*
fornieii into red-brown and black pigment gniuulc«, and the ccchymotic
spot, at first red, subseqiiently turns sUte-brown, and finally black.
In flutopeics in eases of heart disease, or in cniphysctna or an intense
dyspnata, it is rare that we do not find scattered «ver the visceral plfuni
n lai-^i' number of sin;ill eechyinnses. Monie of which iiri' red and rciwril,
while other* are dark hi-oww, and «till citiiei-s ai-e shite ei'lor or Muck.
The effect» of a ehrùnii: congeuthn of the pleura are kIiowu especially
in a more or less marked thickening of the membrane, in the formation
of vegetations, small villous growths consistuif; of connective tissue, and
often also in a hydiothorax. The pleura is whitish and untransjiarent.
This condition is Irefjucntly but slightly marked, and considerable practice
ifl necessary for its recognition, for the visceral pleura thus altered is gene-
rally only very slightly thickened and it preserve» its pliabililv and
folish. rho opacity of the pleura is (hie to the thickening of its hhroua
undies as well as to tlic tnmeractiuu and proliferation of the flat con-
nective tissue ceils.
Carefully cxatnininj; the surfine <r tin jih-urn, especially at the ante-
rior lionler of the lunj; and at tin lnu |i id^e "f the lobcw, in similar
cases, wc often reco^nixe small pnyeelioiis aiinhipuis to «nail r<rd graiiii-
laljoits, or long villous growtlis, or filaments, which uiiiu- the two lolws
and hold them in contact. The constitution of these papilhc and flhimentA
is that of connective tissue: they are supplied with bloixlvesscU and arc
covere<l by endothelium (page 2t!.5),
These slowly -produced lesions should belong to chronic pleurisy i-ather
tlian to congestion; but the pleurisy cannot be recognîïed during life,
because it docs not of itself present distinctive signs. These lesions arc
produced by con>;e«tioii with chronic irritation, and there ia no doubt
that even eccliTmoses may become the point of departure of such fibrous
firowths. In fact, there sometime» exi«l«, beside» email ecchymoses, little
whitish vleratioud of the same fonii and dimensions, which arc nothing
PATHOLOStCAL HIBTOtOOY OT SCSPtRATOBT APPARATD8.
tW than Kiunll fihronuita. Tliev are exactly- .limilnr to aualoji^iiH îmlii-
rntiuii» »f itie tibroufl on[i«iule »t' tlie sfileo» (soe pajço '.>:!} and, like Uiu
latt«r, the y luay Honieliinc!* have the appoaratice of cartilage.
Ttiiit chVouio consefltion, tliese slow inflammatory Rrowths, may be
aQconi|>aiiif<I by an emiaion of flui<I into thu |>k-urnl cavity, a bydmliiorax
more or lees almndatit, hut ;^-i>frally coiifimvl to thu ionor [Kirtion of
thie cavity. Wlinri^ tl>i* cfjiulon vxiitht, tlu- fatno fibroiw merit) inUM.*»
whii'h unite the parioUil ])li.'ura with the luii^ arc (vilvinaUmé, and présent
tixv u&tuU appuarouce of coiini-ctivo tiwuv in llial atjite.
FiFntsnus PLRtmifT. — In every acute iiitlnmnuition of tJie pleura
tliere is a tibnnmu exiiilntion and a ivxi^ulation of fibrin ii|>i>n th« free
Burfave of tbe inembran» and moat freinicntly aW in the tiiii'l exudml.
Biit we dcaignat« a» liiiriuons ])leuriHy that in which the intlainvd men»-
brane Is covered with a layer of fibrin ai the sam? time that there is in
tlic pleural cavitv a fluid wbich coagiulatea into a gclatinitbnn mass when
exposed to the air.
The fibrinous exudation is not fownd upon old fibrous mombranos which
Kg. 247.
^."^ --^
lpB«ni mal lira u' IhA dIaplirBwujBLLc ^Uuek - armwlac
111* i.Etior''ttr AbtLboiiH Ih^it. Or UuhfaUf rnBlof dit
pliraifin. 4. Mu1ii4raaa 1i««nQ. e. A^r^ui mtiubfimD' 4^
L^mpb C4rpaj«t*t mai Ûimmtmttw ai
thru In ■ Ihrluoui aiadsll» ap»
lb> plauts; u. Iha TorpaKlH ■•■
bind to>çether oppoHite surfaces of the serou» cority. For the dfpo<>ition
of fibrin it is necessary that a c:"ii.*id<'nihlc [mrt of the pleural surface
be free and that the cavity contain .sonm ipiantity of fluid. Kor exam-
ple, in the drv sc mi. transparent and finiy hopatiKatiou of tiiherculoiw
pneumonia IKclatiniform piionmonia, etc.), one sees u(>on the surface of
the pleura a layer of fibrin which is al one time extremely thin and Irans-
Karont. and at another time thicker, because formod of aevomi layers.
;cmoviu<; one of these very thin layers and examininj» it under the
inicroscoiie, vte observe that it is formed •••t hands of fibrin, formin;* a
meshwork, *n arranju-il that the principal iraheculre correspond to the
plciind vosst^ls sitnnted hcneatli.
Kn4iu ihi-Ke principal imhocnlic arise cxtrenicly thin fitanienta. which
form a very regular reliciiUini, iitcWin^ the swollen epithelial c«ll.-> and
pns corpuscles. Beneath this thin layer of fibrin th« rwAeU of llie
pleura ap]>ear snollen, and the pleura it^lf lia4 a noii-tnuisparent appe«r>
rlBRIKODS PLBUmST.
I
ince. Th« l«tu>r may «ven be «nlirely opaqtw nnH HligliUj UiicL«ii«d,
K conilitiuii wlik'h i» ()ti« iti (li« jirawTicv of wliite blood corpu»cl«« bctwixnt
Ihv fibrrtt of uoimcvtivc tbiiiie. Tlie reticulated a|ipearni)c« of tlie tliiii
fibrinous fntiio membrane i.t visible to the naked cvc ; if the membrane
la tlticker, tbi." reticulated a8|iect in nn langer marked, and tlic «rrange<
eineut described at page 2tiy is tlion seen. This fibrinous membrane ia
very friable. In pleurisy associated with f;elatinifonn tiibvrctilous puou-
monja, the fluid exudntiou is gunerally small in amount.
Ill acute croiiiKius pncumonîu. when tt i» peripheni), tlicrc always
exist* K more or Icwt thick fibrinoni* exudation which is itccompanied by
a rery small <iiiatilttr of fluid oxudiition. The faliw fibrinous mem-
branes are then >i«inetimc4 nmre iijia<]iie and yellow than in the precedinf;
câ»tf — n fact relatcif to the ittafje of ttupjiuration or of gray hepatiiation.
In this owe the pleuritic exudation contains very many white corpuHcleft,
»n<l tlie elements are often granular. Afier detaching the false membrane,
upon the surface of the visceral pleura the vessels are found congested
anil prominent ; they may even project above the surface in the form of
vaticular vcgetaliouâ. It is upon these vascular loops that the fihrinoufl
exudation is thickest. Tlie pleura is itw-'lf thickened and infiltrated witli
whit« corpuscles.
In this inflammation, which bus extended dir«etly from tlie lun;^, the
imrielid pleura may esca])c ; hut xuoM frc<|ueutly it shown exactly the
Kiimi- liitioiM, although the circulation in thin [lart muy bo nlt^t^ether
diffen-nt from that of the pulmonary pleura. Perhaps it is the irrit-iting
action of the fluid i'Xiidulii>n wliioli excites inHammation in the oxtenial
leaf of the pleural membrane.
The idiopathic pUurittf which follows an impression of cold, for
example, is variable in it« termination and in the nature and abundance
of the effusion. It i» always characterini.'d by a layer of fibrin de-
posited upon the pleural surface. It i^ almost alway» unilateral. Gene-
rally, towards the ctgbtli or tenth day, it ha* reacbwl the maximum of
effusion, the amount of which varies betwoeu J to IJ litres.
Both the parietal and visceral plcune are at first eongested, and very-
soon (during the first day) they are covered by a thin layer of fibrin ;
at the same time tluld is efliised into the cavity. The effusion increaaca
during the SHCceedinu days, and the layer of fibrin thickens. Fre4Uontly
Hakes of coagulated fibrin float in the fluid.
The (iflceral and iJic parietal pleurœ are always affected. Thin vertical
sections show a large quantity of white corpusclos between the bundlos
of fibres, increasing iu numbers aa the free surface is approachod. The
bloodressels project upon the surface in loops. The Ij'uiph vessels con-
tain the same element», as do the spaces of tlie connective tissue, as well
a» Coa;ndated fibrin occasionally. The lun-i itself doc» not entirely
escape the infliimmatory process. The su|H>rficiai ulveoli arc inflamed;
white blood corpuscles, n« well n* swollen or desipianiated epithelium,
fill them. Tliiis we have a secondary pneumonia de;)Ciulont ujwu pleu-
risT, as well as the opposite seipienco.
Having reached it« stiite of full development, simple pleurisy enton
upon tlie period of resolution, but the reaolulioii is uaually eSMted wrj
442 PATBOLOQECAL DIBTOLOaT OP RBSPIRATOBY APPARATOS.
the- plivsiciiin doc* not intoricre. Tdc MlHwing i» wluit tnin*^^
pires dunti;; tliit' [icri'iil of R-Ki)ttiti<iii : littlo hy liitk- the tliiid offii>i"ii ii
tnkcii u]> by llic Iviiipli vo-Ki'vl:' whicli Itocome gii'nuentile ; tiii* I'liUi' iiit-ni>
l>ntiiL-« iiu<lurgo fatly (Io)£(.'iii>riitioii, &» aLio i)u tlie while Ulood cnqmMlvd,
wlii'ltivr Uh'}' he ill the fluii] or in tlic fal»« membranca. Occastuiully
the olTuitioii <liAA|)|ienrs with creat rnniility, iu* liappons often in itcuu
articular rlieuinaiii^ui. aitil the uilw fibrinou» DK-mhrunes mav alao i[uicklyl
Hoflei) and he absorbed «itbout learing fibrous odliviùoiis, but tliis U vx-
tremcly excoptioiml.
Most frc"(iKriilly the vlsccml nixl puriot»! plcurto remain ttncktynciiL
Cn<lcr tho laver of librin. fonniLtions uf embryonal eoitni-<;tive tiiwuc nntT
ncwlv*fortnod vojweU constiluti: smull ]ia]>illie which project into tlic fitUc
memhrikDcti, uniting th«> Tixceral and eoi>tid ploiinv.
Tin.' trnbectilie nï i.-inl:iryiiiiiJ ounnective ti*;mc, provided wiUi vriwvUi
liavin;; enibryoiml wulU, jiinh forward into the t'aUe membranei) unlit the
o]>pi>»ite !>urfiice i^f the pleuni U reaclieil, when they unite witli sîuiîlar
tiiwiiv from that Aide. These tmhecniiv or^nnixe and derelop into dcnsa
cuntivctive tissue in proporliou as the fibrin diùnlegntes aod U itl^
»orb«ci.
When fibrinous pleurisy remains a long time in resolution, it IcavMj
behind it orgnnized iind permanent filamentous or lamcdW iulhesions nfl
(ireater or leï^cr length, or there is aluiost ft direct union uf the twn
pleurro. Tlie iturnti<>n '>f lljo«e phcnunieni consecutive to pleurisy it
variable : it may be xi^ iiioiiiIik or n year or more. Wc theu say ilial
ihi" ufutc pU'uri*y han become chronic.
In certain simple pleurisies with simple iieroiis effu.iion, lasting for <nie
or two months aiirf terminating in death due to some other caiwe, we fiml
llie visceral jileura thickened and covered with a thin layer of fibrin,
without the intervention of a false fibrinous or cellular meinbraitc
uniting tlie two surfaces of the serous nicmbratio. In such a case the
effusion is abundant, the lunjr )j< compressed (sec Atrtectati», p. 411),
and the vinccml pleiim, briieath it» layer of fibrin, is nc^istHnt, uu^h
retjiins the lung in a jienuancnt state of rctniction. It is the falM^^f
mombrane whii;li binda down ihc or-pin «nd prevents il« dilatati'm.
SonietimoA a part of a lol>c or of the tHirdi-r of the lunjr, Uius bridled,
form-t a projection and aasumes the shape iif an udder or « finger. By
iuci.-iing the thickened pleura, taking care not to wound tli« pulmonary
parenchyma, the latter can again he inflated and made to resume ite
original form. If a thin slice of the lung, tlius conipreitsed, i* ])hK'4il in
water, the alveoli take their former size; one may then l«e a^ured
that, in this coniprcwion, the alveolar walls are flattened against one
another, but without alteriition of their epithelial or other tissues.
Idio}>athic fibrinoni^ phuriKy may be aeconipanied by a very abundant
serous efi'ii;«ion which may be poured out so rapidly as to roach three,
four, or five litres during the first week, nn<i yot not provoke very pro*
L sounc«d febrile symptonw. Clencnilly the shreds of false membranes ii|,
^tbe Buid are iu inverte pro[Kirtiou to the amount of the fluid effusion.^
Those pleurisies in which there i.i very con^ideniblc cfiusioD of scrun
are wmeumes related to tlie comme nccnieiit of a tuberculosis whose fint
manifestations are seen in tlie pleura.
^ POHCLBNT 443
r During; tlie formntum nml orfianizntion r>f vmbryonal tÎM>ui' upon tlio
Mirfiic*' «f ihe pleum iicciiluiiM inny nriiw i'rf.m an o\itl)critiit foniuition <if
vr«M>l.t l>oili iijMfii tlio .tiirfiive d' tliu j'ii-iini aiuI iti tlio or<!itiiiiu-'l litl>>o
ini-mlirain'ii. Tho n<-w ve^ifi'la ])0)t.'*fs.i embiyounl and «onMiMjiicnily vory
I'rialile miilLi. Tlic Mnoil leiimon \st lii^li i-noti^li lo oniLie oxli-iitiLMitiiiti
of red blood dUka; eccliyioo<ios of the t'uhe membraiicit, anil HtAÎmiig of
tliese nKwbrftnea hy the coloring niatU-T of tho hlowl ; dotAclimonbi of the
racmbnutos and finally «flnsion of blood into the pleuritic fluid. llieM
MCidcnta «omclimwrt Impiien in ïdiojjatliïc pleurisy, but tlicy are then not
vtrj imrkcd. They occasionally occur with greater intensity in tlio
pVurisicK whioli uccoinpany itubiiciitc articular r)icuuiati!-m. Itut their
tnosl ci^imnoii can:»i' in tniwrvic orcanc*'r<>f the )tu!m<iniiry pleura, in wliich
h'iiîorrh'ujif j<lfnri*n iit incutt grave, Th'J pleunil cavity t« llicn filled
by blood held bclueoii Kucci^i^Hivc layeni of newly-fonnotl fitUo niem-
bnne. Theite nuiiicroui^ lainelliu arc i-cil, cousttHt ot' fibrin am) va;>uulur-
«ed embryonal lU-ine, Imtli of which are infiltrated by the elenieiil;' <if
the blood. Tlio blood hciu under^oeâ the alterations wbicb aro coiumo»
to it clavwhore.
Aiiotlicr nccidont to be feared, even in simple plonrisy when it is Jn-
(«iise. is giif'i'uration. Wo have aeon that tliu layer of fibrin which covers
the intliiinc'l plcnra always coutnins a lar;;c ([uantity of white corj>u»cleii
between the filauicntd or lamella of fibrin; that similar cells iufihraie
tli« Knjwrficial |K>rtiitn of the thickened |iK-uni: and tluit lar^c numbers
of these are aUo found in the trnn^iparent or 4i;;htly clouded serous fluid
which tills tlie pleural cavity. Undi-r the inthience of unknown canfc/t,
or after repeated punctures, etc., eimple pleurisy may become purulent.
Then in a short time while corpuscles become extremely numerous in the
fiuid aud in the faUc mcmhrancg. The fibrin breaks up, becomes infil-
tinted with pug corpuscles, and the fluid effusion becomes cloudy and
thick. Tlie latter prci^rntg the aspect of serous or phte^nonous pua.
lliis accident, happily rare iu simple pleurisy, is lauch more common in
Keomlary p)euri.'>y. It is Momi-liuics met with in tuberculosis, albumi-
nuria, gout, and almott conHtantJy iu {lurulent infection, etc.
PtRi;i,KXT Pi.Ki'itisY. — Pleurisy ta purulent at the outlet whenever
there is located upon the surface of the lung a raeUistatio allF>c•^'<!(, a puru-
lent focua or a purulent lymphangius. that is to say, an infection fullow-
ing a sur;îical o|HTatioii, a large wound, confinement, etc, A local pul-
monary lesion may also be the starting point; for example, a lobular
gangrene seatvd beneath the pleura, one or more small tuberculous
cavities su]>erficially ifituatvd. The purulent pleurisy may then be
excitvd provided (lie pleura he not so thickened and indurated, as to
Oppose a siitficient barrier lo the propn^ation of inti animation. For
tltc Mioe reason suppurative pnenmotiiu niny pvc rise to an eflin^ion of
[ Uic name nature. In the preceding example?, the purulent pleurisy is of
__ ulmonary origin. It may also originate in the |iariel(d pleura and suc-
i ceed, for exaiDjtle, an abscess of the liver opening throuj^h the diaplirugni.
Wounds occasioning fractures of the ribs coingdicatcd by perforations
I of the thorax, also often ^ve riae lo tlie afiectiou.
444 PAinoLoaicAL niSTOLooT op rrspiratosï APPïnATrs.
A purulent «fTtwioti itt verv ofïen followed l>v Rerious diaordera uxl by
death.
The ]>ii3 aci|uir«(( in înfe<;tioiia pleiiriav a repulsive fclîd odor due to
decomposition, without iliere necessarily havîiij; l-oen cither perforation
or pulmonary gangrene. Cniveilhier has sevi-ral times seen ;::an<^-i>ou8
mortification of tlie parietal pleura, nt one time following a plourûy from
puerpcml fever, at other times dcvi-lopcd from other causes.
After punctures of the client, find repeated iiijt>vtioHs of irritante and
antÏMoptics. the pleun becomes tmnsfomied iitto a prro^enic nierohmiM;.
Granulations form uiid orgaiiixi-, and eîcatrixation in eflecUil hy tlie union
of opposed nurfaees, hy (he pmevM explnined at fiage 71.
Purulent pleurisy often ht.it« a long time, even months and yeam. It
may terminate l>y a 8[iontaneoua external evacuation of the ]>us through ao
intercostal sjiacc. Thi» termination is usually preceded by an osteitis nith
caries or necroùa of on? or more riba, and it is preceded by an oedema
of the skin. At other ^mes the pus may discharge into we bronchi,
through the diaphi-agm into the peritonetnn, or pns4 into the modisslinuin
or niniig the vertebral column at. far as the psoiu muscle.
Wlion a tuV-rcular or giingrctiou» canity or an nh«roiw has ojieneil
u[>>in the pleura, beifidrs the nuppuratioii there in aluo an owape of air
into the pleural cavity, n pifo-jineumutharoj:. The vomiwosiiioti of (he
lung then reaches iu maximum.
ClIKO.Nlc PiXL'KISY. — Chronic inflammation is eolablUhed at tlie otit-
BUirt, or it sut'cceda an BCttt* plaiirisv. Tlio liv|>er|)la^lic pk'urisy pi»,
viously described is. in reality, a pleurisy which is chronie from the
beginning, und which manifests ibself by the foroiation of connective
tissue, embryonal at first. The jiroceiiu! torminateK in libmus thickening
of tlie pleura, in filamentous or membniii'ius adhefionc, or in a eioni|det«
obi i te lilt ion of the pleural cavity. We jtl.*o meet with pleiirioie^ chronie
from the first, which follow chronic lesions of the lung or pleura, ao, for
example, certain cases of tubercular pnciiinonia. tumni-s, etc.
The chronic pleurisy which succeeds an acute fibrinous ])leuri8y and
which is marked hy the fibrous transformation of false membranes, is
most frequently the natural method of healing. It often hap]>ens ibat
these false fibrous membranes or the thickened visceral pleura do not
much interfere with the expansion of the lung or the inoremcut of the
ribs. But, when tlic effusion has bcrt^n eonsidenible, when the false metn-
branca have been very thick, and absorption iiit< not fora longtime made
much )>rogrcsi<, the or;;iiiiixed false mcuibianes and the tliiekvning of tli«
fileura seriously imjieile the dilatation of the lung in inspiration. TlieM
also membranes form a solid union between the walls of the pleura ; and
in proportion as die fluid is absorbi-d and the apace which .lejiaratm ilie
two leaves of the pleura narrows, the contraction of the false mcmltrauea
draws the costal wall toward the root of the lung. The thorax which had
been dilated by the effusion contracts, and the ribs approach and touch each
other, especially at the lower part of the chest, so that tlie diseased side
become» nuich sinuller than the healthy side. The slioulder becomes
depressed and the vertebral column may even pre-sent a certwu degree «f
scoliosis, with the concavity towards the affected side.
tUHORS OF TUB PLBURA.
UH
»
I
When the plotirnl ciivity is dividi-d into uoinpartmonto by faUo mem-
'hranet). a ci>nfllil«m)>Io portion of tJic effusion rvmiLÎDM viicyiiUid vitkin a
poucli formed l>v the falac membrnnef.
In chronic ititerâtitial imeumoniii, tht> viderai [ileum \ê ii1wiij« ^atly
thickf-'iicd^ snd whatever he the cauiie of the pneuiiionm, the plt^untl lc«<m
is tliu enme. The plotira fennn a fihrnuA cihell, <kiiKe, elaiitie, white or
Rrny, sUiîhtly vascular, from 1 J millimetrea to 5 or more uiilliinotre» in
thickiK-M. Thi« ÏDCxteiuible tiasTie is formed of vrnvy huodleti of con-
iMjeUve-titMue fibrc-A. and prciients the usiuj chaiactere of comicc^ve tissue.
In vertAin point» this ti:»»ue may be codematoua.
Fibmii» itidiinitinii "f the filcura \t generally seated at the apex of
the lunjc Vfhere tlio two .turfitcre» aro ni»ual)y found firmly united. It ia
im[)Oi»ihle to remove the lung witliout (tcpamting tiie periosteum from the
When the lunj; liaa been removerl by séparation of the peririiiteuni and
I pleura, white band» are seen which correspond to the punition of
ribs, and which consist of the thickened iieriosionin intimately iiiiÎK'd
with the newly -formed conneetive tissue of the jdeura. The correi>|)OiMi-
iiig ril« imiy even jiresent the characteristics of a coodevaiog ofiteitiH.
I» chronic pleunsy we sometime» find more or leas extensive calcare-
HM platOK, which fonn a kind of cuirass, now upon the surface of t)ie
unj;, aj^in at the surface of the parietal pleura.
When ft ^up)>iirative pleijri*y pa.tM^t into the chronic stale, it is associ-
ated with lesiont) itiinilar to the precedinjz. There may olvo be cu«oous
motamorjiho^is of the pua, losiomi of the ribs, such as exootous, pcHos-
tâlU, neurosis, etc.
TvMOBS OP TUB Plbvra. — The commonest tumors of the jdenra are
tuirrde ^rtinulatinns. When they are few and recent, they may pre
"we to a ncnreety noticeahU' [^ileuritic itiHammntion: hut they are always
cooniTianicd by one of the foruw of pleiirijtv nireadv described (pages
f2t!5-:itW).
Fibromata of the pleura preiwnt the form of small ve<;ettitious. ol
vhich ve have already Hpakcn. Tliere may he in itoine of these vegeta
tions onoufïb adipoae tî^'^iie to justify the name of UjMirux.
Carrinoma of the pleura very frefpiently follows ii8 development in
the lung or in the bresist. In the latter it ia propneated hy coiititiiiity
of infection to the pectoral and intercostal muscles, then to the iiarietiil
pleura. It is very easy to see upon the surface of the visceral pteiir»
the lymph vesseU inflamed and trunsfumied by the earcinomatoua neo-
plnxni. The*e ves»els may be genendly or only partially aflceted; their
calibre i* dinlended by a more or le*» solid «hilish or yellowish mass,
oonaisting of [Kivement or fpherieal endothelial cells. Careinoinutous
rranulalions of the pleura are small and hard in scirrhous, bnt they arc
lar^r and often dciiresaed at the centre when they are iiecoiidary to
an encephftloid. When these nodules in the coital pleura are deep
aeated. they may press upon the intercostal nerves and produce neuralgia.
AH the various forms of carcinoma have been met with in the pleura.
iSquam&u* epithrlioma has been ohsened in the pleura from an exten-
sion of the disease tn the skin. .Sarromala and enchondromata have
also, but very rarely, been found seated upon the pleura.
SKCriON II.
DIGKSÏIVE APPARATUS.
CHAPTER I.
THK MOUTH AND ITS APl'liN DACES.
HoBMAI. HfHTOUlilY OK THK lirWAl, MUCOUS ^[KMUKAXI!. — IV I.HCCmI
WKotw nu- 111) I ratio, whiob i» directly cnntiiiuovis vitli xUc skin, like the
ftXUnial )tit«;;u(ueiil. comprises: tst, an i>i>ithclinl covering ; 2d, a «iMptr
Inv^r coinpoHcil ot'cDnnoclivo anil clastic tissui'. containing veins, vr«8i'lfl,
nnd glands, and supjilioil with |iii[>il]cG ; 3d. ■ decptr layer of loose coiw
n«ctive tissue, which is more or Icm cloi^ely connected with the miisvlce.
The mncoiis membrane, properly called, or thf mucomi chorion, ii
directly continuous with ttiv ciitiineous denn. It prrscntK n]ion it« sur-
face numerous pnpilliv nnnh'^nw with Ui*)«> of the okin, hut presenting
pi'Ciiliar fhai-acU'rinticH upon the longue. Over every jart of the roouth,
except the tongue, the papillie arc bo numerous that tiicv touch at iheir
ha^e». They are iiuhciidcd almost everywhere in tliick layers of strati,
fled pavement epithelium. In contact with the papillre the cells »rf
criindricat or ovoid, and arc implanted pcr])cndicidar to the surfitco of
the papilla. Above this layer of cylindncal cells, the cpîtbcltum îs sod
and an;:^ilar from mutiinl pressure, «bile at the surfiwe large flxt cells
with ntrophied nueb-i exiiil. 'Hn-se cell*, like those oftlio skin, are in a
CdntinunI ntiUe »f ile.''i|u.ini!ilion. The epithelium ii« very |fenneflhle to
Uiiid, an i-^senlial f')r the senïie of taste.
The mucou.i derm is so closely united with the dental nlvcoli. am) irilb
the bony portion of the palate, Ibai it represents the ]>en03teum of IbeM
bones. In the tongue it is in connection with the extremity of mi»ctdar
fibres tbroujfli the intermediation of the lingual fascia. Upon otlior por.
lions of the mouth it poir^esscs ft Umiteil mobility.
Tbo glands of the buccal rançons mcrnbnuie arc : Ist, acinous mucons
glands of a round and boswlatcd t'orin, and of a diameter varying from 1
to 5 millimetres. They «re found n|»>n the inner siirfu»! of the tif«,
upon the mucous membrane of the cheek, of the roof of (he mouth, of
the pidatiiK^ arches, of the base of the tongue, hehiiMl the lingual V, anil
in iht^ vicinity of the calciform [inpillw ; '2â, glanais at the «jk's of tli«
tongue forming upon either side an elongated glandular island, whoM
excretorv ducts, to the number of five or six, open upon each side of the
frtennm linguœ.
'iliose glands are formed of su excretory duct, consisting of a Itaws
MORHAL HI8TOL0GT OP 8D0CAI. VIIOODS UEHBRAXB. 447
■ont iDcmWoftc of eoiineclivi' ti«f)i(>, lined hy cylimlncnl ix'll«. Tlie
"«Ml»livi*iinw of ilii# rfuct wlikh urininaU) in the |MTifiinu or «pborioil
^Ijlaixiitliir vfsk'li'i» or cuIx-iIv-hiic, »ri> goiiorallv (MveJ \,y largo omcouii
pelt) HÎintlar to those of tlie siihliuj^iml gliuiil.
Fig. *w.
Tlip Mklivnrv giaiiil.* wliich *inpty ujMin the buccal muL-oug nK-tiiliranc
kre iMiit^ true ted ii|>on tti« mm^ iiio<)i-l nn tlie tnucoue ginnilit ; tUcir voliiinv
iwhhî liera We. Their cui.-uk'-wac ilo not iippear to [hwjiw* a *iKcm\
iii«rul<raii«, but onlv a delicate eiilicle of flnt or sleHatfl ceils. Th«- ceils
which line them are of two kind» ; in the suUingunl gland, and in » pari
of tlic acini of the submaxillary, they possess a nucleus and » cloudy
prolopliLsm which arc located next to the wall of the cul-do-Aac, in anch
a miinncr as to ktarc the rent of the cell clear. The general form of
Itiitfse cell* is conic»! ; their hase, where the niiclenî- and jrraniilar proto-
|ilii«m are fmiiul, is jilaccd at the |H'ri|ihery of the cul-de-sac. itbiUt their
puinUNl inner extrvniity i« towiinl the centre of the nciiins. In the parotid
Knd ill luiwl of the iieinî of the suhnmxillary the i!id»-de-«»e eoulain granu-
Ur cell» with nn oval nucleus. The excretory dnct^ luxt lined with cyliD*
drical cells.
Tlie muanim membrane of the tongue poaacsites three varieties of
papillie: —
Ijàl. Fungiform papillie. recogniied as little red elcvationa upon the
anterior half, at llio anes and al the edges of the tongue, liave for their
bane an deration of the mucous chorion studded with secondary conical
papillie. Thoy ar« corored with a soft eptthdinm, and in their interior
vessels and nerves rumify. The lutter tvrrainatv in special gustatory
orpuw.
âd. Calieiform or circuravallate pnplUiv, itix to twelve in nnniher, which
form tlt« lingual Vi fu« conipoAed of a central papilla depren^ed at llio
448
TUB MOlITIt AKD ITS APPENDAGES.
apex, snrroiindi'd 1>^ a lesa promliiont ring mhîcli cïnninucrilx-s tUc
rof Uic ]>n)>illa. Both urc liuilt upon the «sine nioilo) os ll>c fuii^fenn^
iijiilla, iiDil i-oii^iit of Hovonditry jnipilhc. Imving tlic sami* Htriicliirc.
r'i'fm
Pig.2M>.
Til* IbN* klBiUol pii|illl»a( Ik* loBKac
3i). PUifarm or conieftl papillie «onajst of elcvfttioa4 of (he derm, and
ttic/ are fumiâlicd al the aununït witli smaller clcvationii wbïch arc thin,
e]on;^tcd, snd covered by a common nnd imlriual^il cpillielium, whicli, ut-
iiitnatii)<; in pointt-d <-xtri'initii>s,givi's to the end of tiic puplIU the appear-
ance of a very Une bmsh.
The buecid uiiieoii» piembranp présenta mimerons lym^ /otliflf».
Upou the tn.-ie of tlie tongiie Himple lymph fotlicleit exumd from tlie limit
of the lingual V to the cpi;i;Iotti«. Thn simple follîelei* coimixt of a ronnil
promiiieneo, which présents a doproAfiion at \Ut centre. The muooiDi mfnt-
hrane over tlic surface of the follicle, and in the ceittral dépression, pre-
aenla itA ordinary layers. Beneath the mucous membrane the follicles
ftrc accn to be formod of a rcticulutud tisaue, such as has already he«ii
described (p. MS). Tlie tonsils arc composed of the same kind nà* foUi*
clea united in a hir^^c ansa.
Lymph vessels run throughout the mucous mcmbraiu) as well as blood*
vessels Bud nerves.
Pathouxjical Ai-TintATioss OF THK BpccAL MPCOCT Mbmbrase;'
âxoMATlTls. — Stomatitis, or inRaiuination of the mucoiui membrane of the
mouth, Î8 variable, atTordiiig to the decree of infiamiuatton, &ocordiu|Ç ta
its cour»e, acuordin;; u* the depth of the layers affected, and acoordiug tol
the part which is attacked.
■Sufierji'-iitt or entarrhal tPimalitii is characterized, as in other mueoii
membranes, by a loss of the superficinl epithelinm. soon replaced by new
cells. In the simplest irritations of the mucous membrane there is
always a formation of pus corpuscles at the surface. The rapidity of
the pussu<;c of these corpuscles to the surinvc of the mucous UMinbnine
u such that, in the action of spcakinj;, after a half-hour or an hour's
ALTERATIONS OF BUCCAL MDC0U3 UEUDHANK.
449
cohtiniuince, the tliick and froiliy saliva contains a Inrj;* f|uniitity o(
tlit-M! ck-iDvnu. Pus or lympli corpuscles »|-e always fuuiirl in the
■mieux vhivh surrounds a canoiu to«tli incnistcd «itik tartar, ainl llicre
An- aC tlio same limv large numbers of vibrios, bacteria, «le.
Fie. 3S1.
I
R
Cllankai laBuiBdina »t lh« conjaatlirs. iliawlac 4baa(M «r 1)ia crlIkilMl ibJ «iiliariUbtll*!
Huu*. «. Brlltaihan. K Sib*|i11l»1lal «faiixili** n>.af. ibirvIiiK Ik* priillfar*llat «r Ih* ryt.
tbHluB. an4llt**tU<Baf Ibar^aiiK *)•»•&«• «tlbli lllai|il<b«Wiil <«ll>. i KI»4JitUtk,}
Superficial stncnnlitiit, twiNtiloi* llie rixlnt^it-^ of tiie macoua m«inhmn«, îs
nftvh acuomfianiol hy <tnmll white !iu)<erlioinl [iiitclies. wliic)i are ceen
|ttrtÎL-iilarly upon tUc (wierirtr surface of tlie liiw, upon tlie altvolur
muonuH m«mbriine, and upou ih» arches af tlie palate. This HKulilicaUoa
of tlie color of the sup«rttcial epithelium is sometimes seen in the stoma-
dtis of typhoid and other feverâ. It is almost constant at the commence-
ment of mercurinl swmatitis. It Is duo to the fact that th« superficial
epithelial cells are swollen, cloudy j^nular, ami opa>|tie. Thc«i white
patches, which have nolhinj; in common with false membrane» or with
eypUilitic mucous patche», diitappear when the diseased cells have re;?i-
larty de»{uaiDnted. Hut if the Winn i^ more profound, as in mercurial
atomatitie, if there ar<^ pan corpuflole.t in large numbers intiltratin;; the
epitliclial layer* and colleotinj; between the latt«r and the papillte, there
ITMulU a genuinit Muperhcial ulcer of greater or lesser extent. At the
' ^ le lime there i* profuse salivation.
Mercurial ittomalilis. when it is intense, in aceonipanied by pharvn-
)i[it4s,and.jierha|â.by ulceration of the mucoua Euembrane of the pharynx
uul of tbe base of Uie tongue.
In the atomatili» of ty/ik'tid feivr, vc somotimefl observe round ulcéra
apon the iutenial surface of the lips from 1 to H mm. in diameter. In
the onlinary form of ihe stomatitis of ncule disease*, the tongue is red
at its point and ed^es, us well lis in the vicinity of the fungiform papilt;«.
It may be. on the contrary, dry. dark, and crackdl in the middle and in
front i>f the filifonn [iai>illiv. ^I'he dryness is caused by breathinji thron-^h
the muulh.while the mucuun membrane is inflamed, and the corneoun cidl«,
instead of being; tlirown off, accumulate at the surface of the filiform
jtapill». Tlie dartc eolor is due partly to the loiI;;meDt of foreign par-
ticie.'i from the air, and iiartly to the présence of extrarasated red blood
29
I
TItR XOOTH AKI> IT8 APPE.^DAflBB.
disks. Bi'twi-cn llii-so papî11:c ihcru (irc iometîmos orcvici;i which c^n-
bin white or nui hlood ^{lobuloa. In ty|>li«id frrcr, thv arch of Uic
paUu is alaa congested, dark ri'il, «mctoth, dn-, or coron»! «itli Mrinf;t
of iiiitoiia. 'Jlie more or ivn» aliened, opitiiuo, aod «lnii}:,v bihcib whi<:h
the patient reJ<,?cU is chnraclori^tic cf this fonn of fobrilL- AtoniMtitîii.
StomittJtl^ due to Kjiociiil c«U8oa posscnea pculiar charnvter». lliiu
labial aod buccal horjitM bef^ins in the mouth, as it does upn the «kin or
the ]i))3, n» veiticli.'^. Hut, ujmn the mucous membrane, DieHe venicles
remain n much shorter tin» titan upon the skin, (for their structarc,
' see VeHtclcd and Fiutidea.)
Tlie lead line upon the gums around the teeth is due to the presence
|.of fine metallic i^ranules in tlie cells of the deep lorors of the derm. It
U visible at this location jmrticularly became of the Ihiunvss of the
mucoiu membrane. This deposit always occasions a more or less intense
degree of stomatitis.
fylr'/ynVi.— I'rof. W. Popper, of the l"nivcreity of Pennsylvania. Iiks
lately rc^^itUcd nltcntioii to a line at the ed^s of the gums sonvclimea
scon after the c»iitiuu<.'d use of silver or its salts, and has vlainwd tltat
the presence of this silver line is » valuable premonition of an approach-
ing saturation of the system by the silver, and a warning to «upend the
RaFlltiB «f Eain Itarangh th* *>ln»>l Ilnr, «blch.urqMlnn ii> Dr. Vm, rtq>p*r, la • fMnMalUaa I
«rirjrla. ilmiflni ill»r di>p^>ll alunn (ba connruf lli- ilmp ••»<1>. X IW ••• AaWrtar ■put*-
r. Iajm i>f rjliu«lrl<<4l f^lK /. Klbrout kolrttAUfv ur turn. y. A f«v Mftfli f run;*, à^f^itui
■lonf <b* ,«*■«[■ Vf tb« p«pUlJt. k. l>Ark gr^noUr dfi>u<lt cuvri^bf kud or^b^jrlii^r tb* wu*l i*an*>
(SH Tmu. Call«K*or Plifiiclkui oF |-blUd>lr)ilt, IHT,)
vae of the dru;; in time to nrevent the silver staining of the skin com.
inonly known as arr/i/ria, i'hiâ line is caused by the defiosit in the
deeper )iortiun of the mucous cerium of the Kums, of metallic silver in
the udvontitimis sheaths of t^« bloodvessels, and in die neighboring dsaoe.
(See Fig. 252.)]
p
^m ALTERATIONS OF BUCCAL UUC0U8 URMBRAKIi. 4fil
^^BB0irH}>tiv«/eetr« mAtiifc^t th«ntselve» njion the buccal mncoi» menu-
orahe hy i^ruyAion* similar lo those of tlie skin. 'Ilic r^diwsa nf the
rottcottii loi'iiilirane, in tlie prav« form* of Acarlatina. ofton followA a
des>|uaiualioii of the nitpertictal cjûihelitim, under tlie form of a soft,
whititih, pullaceous membrane. When the epilhelium of iho tonpic des-
quamAtes, the Ungual mucoii-i membrane becomes rod and shining and
aiuoulh. This deB>|tinmation is alloj;olher cUaractcristit of scarlatiiui.
Cutancoiia diseases, such as erzana, pfmphiguv, eri/tipuhu. are 8oni«-
tàmt» accompanied by similar eniptiona in ttic mouth and pharjnx.
Atnon^ cdronic Btonatitea coDn«cted with ctitaneoiu diseases, fiwreal
ixi.wiVwi'ji may be mentioned (iuhthyo»!» of Eiij;li8h authors), 'f^i'u Icnion
u charactt^rized b_v whitish iiininmiDnted palehes seated upon the ton;^
or clieek, the inncou" iin-mbranc "f wiiich is cracked, flie epidermic
layer «lion the disea.-«cd part i» very thick, Uw papillpc tlieinHolve» arc
hypertrophied, and the derm of the miicoii» membrane in Hcleroxeil.
i'he cnicka are nothing eine than an exagération of the normal folda
and furivius of tlie membrane. Tbii* le.'tion is iteen around canuroidii.
A localiiced stofDatitis with hypertrophy of the papillie and subacute
or chronic inflnmmation of die mucous corium around the t«elli is not
iDfrc«|uently met with.
S^rhulit^ tt'imatitiâ is distinpii^hed by intense con^iestton of the
mncous mcmbmnc ami a tendency to hemorrhages ; fun<;rias surfaces
which readily blood aï'o to be seoD upon tlic gums at thoir Junction with
tlie tcvth.
i^The »^/»Ai7if/<' Ie»ir>n»ti{ the buccal mucoiw mi-mbrane arc the mw^jw»
MWf^f*. and tlie deeper tiloeratioat which follow ^itmiiiata. Recent
noucoiu patches manifest theni»elved by the wliito. opaque, or |>carly
color of the superficial layer of the epithelium : an aj<|icarance which is
due to causes previously explained. If the mucous patches are ohi,
they iletcrmino a thickenin;;; of the mucou« membrane lielow tlie altered
cpithelitim, and they arc thou slightly prominent. If they are not
elevated, they offer to the touch a hardness and a marked thickness of
the mucous membrane. Their common scat is at the corner of the lips,
where the mucous membrane is white, while the eiitsuieous portion of the
jwtch is crtvered with n oilorod crust; at the honk-rs of the tongue, whcro
they are ovoid or elonpuivl in the ilircction of the toiiKuc ; iit the tip or
wpon the hack of the tongue ; anil upon the tonsils. But they may appear
upon any part of the oral cavity. We have often had opportunities to
examine, under the microscope, muoomt patches fmni trin«ili< which had
been removed during life. Thin vertical siections, inclmiing the pntcbe*,
showed the Utter to he seated upon the mucous membrane which cover*
this «land. The epithelial layer «as thickened ; Bome of (he su|nTfiri»l
epithelia were swollen and vesicular ; the papillie of the mucoiH conum
beneath were hypertrophied. It is to this hypertrophy that the promi-
nence of the patches is dufl. The enlargement of the papiil«s is due to
the presence of a lari^c number of cells.
The more profound Kyphilitic legions of the mucous membrane begin
by an induration of the eorium «nd of the eubmiicons tissue, hy deep
Dodule» or gunimata which very soon ulecratv. Their favorite scat la
I
453
TnS UOCTB AVÏ> ITS APPBNDACGE.
the roof of tli« moiilh nii<l tl)C arctiv» of tlic jmliik'. the (niistld. ftiul the
tAiigUi'. T)ic j^uniinntA «f ibv iikIim of Uiv jiAlntv bo^in li,v a tunicftc-
tii»i, with iiiiliirntion i>f tho (;uiiii<h!Uv(< tiiuuc, whicti utilfoits ihv nrvhr^ ;
they often cxuiii^ n pi-rf'inici'm, tliu» I'ftrvliii;^ n c mi in uni m linn l>i>tni-fn
the inoutU ami naaal to»'iu. (iuuimntii of the tongue art! very <liflH:u1t to
differentiate from tnberculnua ulcers.
MfmbmnMi* uieeraiive ttwnatitU (diphtheritic of the Qennan autlinr!t)
is clinracierixcd bv a diffuse iulîltration of the Ivmpli lacuiiaa of the dem
widi pTis and fibrin. 'Hie enpillary vcsHels of the affected part are OOin*
pres^i.'*! by the c-xud:itioii itixl eirciih|tioii coascs so eoiiip1c[elr thai thf
piii-t tinder-i'ios an iilecmtivo vtiminution nhicb «uoeeeds ihix nwrlificalioi).
The Hiicevvdiii<: iik-erntion invadea the det-p layers in such a nuinncr tluit
the edgeif are vurtîcnl. The l>ottom of tlie nicer i» gray or ibvrk gray,
saniouvt, futiil, and covered by an opiK^nc gray pulp. If the bottnui *uf
the uiocr \» eieitiiei], we see detiiehed from this .tnifiuio irregtdar (iUments
fonuc<l of the di}')riM of elnntie tibri^H, eoiincelivi'-tiwoic fibrex, and of
ves.-ol*. These nlcemtionn are ordirmrily bn-atpd upon the lips, cheok^i
«nil guni.i, and éiouiettmea upon Ûw pabite ur ioiu->iU.
Bnporficial inflnmimtion of the tonsils or catarrhal auffina of tht
toHfiU docs wot essentially differ from a. similar inflaniinaiion of tht
buociil inombrinio. The mucous inombrnne which lines the dej:<ression
and tlie dtc[i c-rypt* being hyportrophicd. con2csic<l, œdcmatouH, aixl
iutiltnit^'fi with aii inflanimiifdry exn.[iilion, there n*n\u an eiilarstiwiit
of tlie whole };ltkiid. The de^i^nauinted vpitlielium aivil the nutcous HuiJ
loaded with white corpuscles nccuniidnte in the crypt» and fonn a pnlla-
GOiHis ma^A which appeal's at their orifices in the form of gray p(Miita.j
Thi* accmiiiilHiion often hart :i fetid oilor.
If the innamiimlion is more profonud, the tonail is much more «wtdlen
and the cmitonts of the crypts may form an abaoena, nhiub very rea-lily
opens of its own iiceord.
These catiirrhnl inflammations often repeated in young lymphatic «iib-
je<;ts almost always cause a persistent hyportrophy of tiie lymphoid li^ue
of the tODStls.
IHphtherUi'' inftainmatinn, «harneteriKod by a f«l<e membrane, thin,
gniy, not vi-ry ili'n.te, hut udhiM-ent U> the siirfiic« of tlie non- ulcer» ted
niiivniiM miMidiram- (see ]Mtges 48 and <i'>), iâ not often found upon the
niucoii» uuiiiihi'iine of ttie moutli, e\ce)>l npon the loiiiiil« anil Uiu paUti.-,
Siipcrfidal shreibi, which are with diiliculty detached, unite to form a hard
and adherent layer. The fiwt false membrane being reiooved or artiS-
ciiiUy detached, a new layer is soon i-ofoniied, or there are stralifi<»lioiis
of these diphtheritic lamellie. the olde-^t beiii;j; the mo«l superficial. The
uvula ia olWn eovereil hy ihe»c productions; the tonsils are niore or
lesa inraded by thrm, and the disc.-ise nmy i.-xt?iid into the nasal fo-^oe i
larynx. These false incnibnines may iK,\iisionally be seen even upon i
mucous membrane of tlie cheek» and the 1i|K. In thisafTcetion the lynpb
glanda of the neck are often liy)<eririii)1iied ami iiiffamed. Ustnllvlban'
is no ulceration beueatli Uie diplitheritic uiciuhranes.
TUMORS OF THK MOCTU.
458
I
Oanifrrnr of the month (nrnna) frcfjiwnlly etiocecMis iiifitetioiiM di».
MMA, Micti ax nilieola. vnrinlii, j^angroiic of tlio hiHg, etc. After Imviiig
commonceil in the <lei'|> btvem at the Imrcnl iuiicoma iiii^uihntne, it niny
progressiv^lr iiirnde tlie aulijaceiit layert ami tcmiiiiatc in li»tiili« of the
check or in suppurative deatnictiotm «hitli corniironiiite even iJie lilooil-
TCMi'U of tho paru Large nia*aes o( ihe tonsil and of the aiirrotindiiig
tonntrctivo ti»fui- may be dcstroyeil, or iIip gangrenons ulceration allKoiigh
Biiiali limy yxtffnd deeply. lu lliis manner an eroaiou and [lurforaiion of
llie cxtfriial cnrotitl artery may be oecaâioned.
(iaiigrenc makes ile ajtpctiriiDcc prtmnrily on the lips and on the tonstl))
in mali;n»ut piiKtiilc, an fxtri:nicly infcL-tioud di^L^nso caiwod, according
to Davaioe, by ibe prciH'ncc of hnclcria.
These diverse aiijiptw, fmrticidiirly the diphtheritic, are wmctinws
aocontpanieil hv paraly^i^ of the palate, irhicU îa itself fidlowed l>y nior«
or lew extenflive paralysis of other parts of the body. Awrording I»
Ohan-ol and Vnlpian. tlie nerve tiihes of the motor norves of the arthi-j*
of llic pfilatc arc altered and proaeut a granular deg«neratiou of tlicir
myelin sheath,
TraoRS. — Persii^tent htfprrlr"[>fttf of limited arena of ihe buccal canty
i» not a rtirity.
Hypi'rtrophy of tho lip* and oflho tangue (ni.-tcro-gloMia> consist in a
tliickening with new fornuiiinn of conncctive-ti^iie vlcmout», at the sanwi
lime iliat llicre i.* a very rewarkidde development of ibc lymph spiK-cs.
These spacer, lined by a flat endothelium, are filled « ith nennn eontniniug
Duiueroiis lymph corpuscles (Vircbow, Itillroth). I'hese levions exaotlj
correspond with lymph tumors of the skin.
We have met with a hypertrophy of tlie arch of the pnlnio, caused by
ft considerable hypertrophy of the acinous ^IiukU of this region.
Vi/iUf of the ducts or ^lundnlnr cuUtie-jiac arc frcfjuontly met with
in tlie lunuth. 8inidl cysts commonly exist in the mncuus membrane of
tlie roof of tlic jiaUte in the new-honi. The^e are small, nhitish, round
grains, cotiUiiiin}!: a lurj^t' quantity of flat bimtjllatfd epithelial cells,
aîiDÎlar to those of tiui month.
lianiiln consista of small cyi'l-i situated beneath or upon the »ride«
of llio tongue. They often coiijiUt in a dilatation of the ducts of the
submaxillary or sublingual u;|ands. When the duct becomes cysiio Ihe
j;lan<l atrophies. A few of these tiimore belong to s cystic formatioi)
developed in the cellular tissue, anil they are analogous to pouches of
the miwous membrane. These cysu contain an albuminous fluid in which
tliere i* siunelinic» mucin.
S-ir^jmntix arc very common in the punis and maxillary bones. Epulis
has been (icscrihcd a» a variety of oMifying saR-mna (pp. t<2, 83).
The tumors of the periosteum and niaxill»: which have hecii de«:riwd
hy Unhin as tnyclopliutic, myeloid tiunors by I'li^ct (myeloid sarcoma,
p. 82), are very cimumm. A henijçiiity bad been assigned to tliein,
which their rapid gniwtii and in some cases their re prf" ludion at a dis-
tance make riuestionable. Cystic formations, mucous motamorphodis,
e0usions of bloo^l are not infrequently met with in these tumors.
Oficasionally Jiaromata, hard and apfaerical or aeasile, are found in the
464
TUB MOUTU AND ITS APPBNDAGB6.
connective tisBue of die nrncoug membrane corering tim (onitila. Fihrons
polrpi ttprinipii;; from the bui-ilar apa)>hyeis of th(< oc«i|nlal boue niur
extvti'l ill riiriou» directions uti<l Rmillv roiicli tho mouth.
Lip'tmata mm iwinottiiK-9 sci-n under tlio innous niombratiu of tlic
ctii-ek, and «oiuetimi» at Uiv tip of tho tongue uud po»tvriur a«j>ccc of tbe
lips. , •
AHffi'>matit often exUt at the fVee border of tbe Hp«, otfpeoinUy in per-
tom will) itnDor from ilisonlera of tUo oirvuUlion.
Carrineima is Hometimes met with in tlie tonsibi and in tlie parotid
glnntU.
Hmtheîioina wilti pavemcnt-«elU anil pearl liodies is very cotninon U|nn
the Up9 «nd ton^if. It sometimes shows itstdf at the junction of tlie
mucous membrane and skin, under tho form of a horn, from • few milli-
metres up to u centimetre in leii;{th. After tlieir «blation similar growtlia^
may return, like ^emdnc enucruitls.
Jxi&iat mneraitt w seated almost alvrny» ti]M>n the lower lip: ttic tui
commences at the most supvrfieial |>iirt of tlie derm by n ncir fnnnatinn*
of epithelial cell* growing downwantii from iho miicou» layer of the epi-
|derm, frvm thelinir follicles, orfrom tlie i«etiiiceoii«glandii, and penetrating
ileeply between the papillfs of tlie derm. The tuiunr i)prea<la (Kith n{MiaJ
the rtkin and the labial mucous membrane. It is coverc<i upon tlio exte-
rior by a dark cniat which, when it falls, exposes an ulcer or a gninu-
lating surface. U cxten<U rapidly in depth and sujierlicially. and fron
it epithelial lobult-s arise which penetrate and destroy the inferior in)ix>1
illnry boue in front of anil hunealli the alveolar p^M:es»e8. Dcatli U Ui«
lUual Miguel.
Cancroid of the lon^pie much resembles that of the lips botli a«i to iti
Utnicture and its rapid lermin»lion. It usually commenoetf by a swelling
P>f tbe mucous membrane at the aide of the longue.
7'iiMar e/iithelit'i)ia has been met with several times upon the arch of
the nalato and iu the antrum (see p. 1.S2).
luherde of the buccal mucous membrane commences by one or mor
small ^rannladons situated at the surface of the derm, which soon bceoiM '
opa<|Ue and vcllow at their centn-. They miiy he located at the tip iw
^e border of the ti>n;;uc, or u|>on the tonsilx, tbe iiR'h of the pulutc, tltft.
base of the tongue, or the pwlenor wall of tlie pluiryiix. Theae new-'
fonuutions ulcerate, anil tbe ulcer in ni;:;^d, iiml |>erli.i]itt granulating
upon il* surface. The edgen are irregular or ft-stooiied, and show, when
on the tongue, a hyjierirnphy of tbe pnpillte which is very remarkable.
The surface and tbe subjacent tissue are very rich in embryonal cells.
Tliaon has seen at the bottom of an ulcer of the tongue, very small and
tery characteristic tubercle granules located in the connective tîs^uoj
nhich separates the muscles. In a ease of hvpcrtniphy iritli ulceration^
of the arch of the pulate in a tuberculous patient, oljscrveij by lieniuK,
we saw, besides a few but easily rceo^iized tubercle f;ntn»le<t, an inSam-
tnatiou of tho connecdve tissue, a hypcrtro]>hy of the acinous glands, and
a fatty Jcgeneriition of most of the cells of their cul»-*le-.'<ac.
l"p to a certain jMiint thc«e morbid growths may be ili.it in jpiUhed from
gumm:il.-i of the lon^^ue or palate, becuu.'>4- (luminatii form ma^'teii of larger
BJxe, the centre uf nbich are camou», hard, and yellow. l.'j»ou a histo-
PARASITKB OP TUB MOUTH.
45.')
logical examination of anch ;;rowt}i3 we do not tiee verr minute tubercles
like lliOAe seated between the miiscular bundlcn ol' tlic toiicriie. It imiat
he avowed, however, that with our present knowledjçe it would hedifficnlt
to DUike ftn anatomical diajfnosia between gummata and tiibercles of the
bncvml mucous membrane.
Leprous nodulea sliow themBclvcs upon tlie busft of the tongue a» upon
the MKin, and t«nmitatc in ulcerations «bicb maj extend to tlio uvula.
clou
H UpAl
I
PAliAsrrES. — Lfptathrlz bunali» (Rol)in) cxi^bt normally upon tb«
pnpilliu of thi? tonpie. It voj^utate» ttiiunifr the cpilhcliuiii, and is eliarav-
tuniu>d l»_v a felt of vcrv (ii>lic»i« Ion;; and .-«ti-ait;!!! lilnmi'iit.-<, arixing in a
cloudy rtiilintuncc which i* thc-ir iimtrix, mid which i.« bcated among or
upon the nlt«red «uperiicial efùtheliiim.
1» the nnictut and particuUrly In the dental tartar between the teetli,
ides leptotlirix we always find vibrios, bacteria. s]K>roa of rrppttroeett»
rerevititp which live and move amonj; sofleiied and ducomposiiis rmginent^
of foo-l. There are alwavs to be found also a certain number of hinpb
vorjinscleii. These parasites aru swallowed with the saliva and are found
physioloipcally in the fnstric juice.
Of ftll th« parasiics of the mucoii» nicmlirnnc nf the month the most
iiDpoft&nt and Xhv most common is the OfHum aUnfan* (Koliin), which
ooiistitnte» the whitish patches and granulations of thrttth, Thmsli.
which \» chanicteriscd by email whitish jjcmin.t or »ofc pulgiy patches
forminj; a slight elevation upon the surface of ibe mucous memhrniie, is
prt-wnl under different circuDatanoM. In new-bom children it is par-
ticularly due to the milk taken as food, and Is of little importance. In
children, aâ well as in adults, in the counto of chronic diMssos it is a
troubleaome indication of profound disCurtmnce« of Dutrition. Accord-
iDg to Uubler. its development is connected witli an acid elate of the
onl nticoSi an acidity which m itself due to the pretence of fermun^ng
sacebarino or amylaceous matter. Under the microscope, there is seeo
to be imbedded i» the midst of u frrannlarejiitheliura, the elements of the
poiaaite, viz. : 1st, u mycelium composed of trunks and very numerou»
tabc«, fiittulous, jointed from point to point, and filled with molecular gran-
ales floating in n colorier protoplasm (Quin^iuaud) : 2d, vesiclca and
tporea, which arc found at llie extremity of the tnbes. These oval or
spherical spores arc very numerous and sometimes of considerable siie.
llie lubes and ajwres of tliruah adhere only to the superficial epithelium.
In many cases patches of ^ruah are funned upon the pharynx, a;soph>
agua, and even in the stomach.
There are some rare records of cysticerci having be^n found upon tho
lip; cyste of these parasites bavo been met with in the muscular tissue
of tbe tongue. Hydatid cyst£ containing echiuococci have also been
aeen m th« check.
456
PBAHTSX AND œSOFHAGUS.
CHAPTEB II.
I'HARYNX AN1> ŒSOPIIAttUS.
Normal and Pathi>i/ioicai, IIistiii/)iivuptiik Fii.MtVxs ANli(EBOl>n-
Aiiva. — ^Thc nalU of tlie pliarjnx and of ihe a'>o)>l)a^uri possess four
Invert). Iftt. At the periphery a filirou§ envelope compo9e<l of bnnillea nf
fltinn«ctive tmae nud elastic tihres : 'Jd. A thick muscular laver coin)>oâ«d
iu the pliarvns of the coiiBtrictors »nd levatora, nil »trist«d : in lh« ic!io]>li'
af;u3 consisting of two lavvrs. of which the cxtcninl is lon;;itudiiial, th«
iiit«mal circular. The lonj^itudiniil tihrci^of thr u;t>opUii<nH. aoniv arinîn;;
from the inferior constrictor, other» inserted into the cricoid carlila^-, arc
striated in then«ck. lii tliv thomx thero arc niMed totliectmular (ihres
tt (irat, ufterwnrds to tho longitudinal fihrvn, hmidle» of «mooth iniivcioaj
irbicli Iti'coine more «nd more niitueruns as the Lc«ophasus is dewcndfd.
The longitudinal hundlea of itie œ^ophagiiii flend expaiiaioiiêi (o the tneheAi
the norta. and left bronchus, etc. ; :id. A laver of submneoiM connective
tisHiie ; 4th. A mii<rotia membrane, the structure of vrhiob varies koconi*
inn '*> t'l'' location exaiuioed.
Ttif mucoiii^ membrane of the pliurynx niay be divided into tvro vçry
different region». Below the jiostcrior pillar of the arch of tlic jmUl* I
the phar3'ngea1 niiiont--' cucmbrauc positcKscs nidi men ta r,v ]Miptlla> and i*
covered l\v ]iHveinenl oiiithrlinm like that in the month. In Uie superior
portion, on the coiitrarv, tlial is, upon the posterior ait{)cct of the tiviila
and nrche.t of the pahitt-, around tlie orifu-if.t of the Knntacliian tube, ab|
Lthe jKutcrior orificea of tlie nas»l fotwse, and u)>oii the whole vault of (lie]
'pharynx, the miicoua membrane ia invented with a ciliated cylittdrtcal
epitheliuni. Here it possesses uo papillœ, but it contains a large number
of Inlands.
The mucous membrane of the œsophajîus, like that of the inferior
portion of the pharynx, is lined by a stratified pavement epithelium and
It is furnished with conical pa[)illii!, which ttrv much more developed
than those of the pbwynx. Thraughout the whole extent of tlie pha-i
rynj;o-a;sophagcal mucous membrane there exist numerous follicular and
r^iccmose mucous glands. The first may he simple »r onijiound follicles,
«nd are more frwiuently met with u|ioii the mof of the pharynx. Thcj ■
iforcn at Ihe orifices i>t' tho Kattachian tuhti a continuous layer sever
liiilliinetreit thick. Considerable uumhem of them are fonnod iu the
vicinity of the jioxteritir 0|>eningâ of the naiial fnd»ie, on ttie {■tH'terior
axjiect of Ihe soft pnlate, and upon the walls of the pharynx in the
nciiEhljorliood of the e]>i};lottis.
The mucous glands, which are very easily seen by the naked eye, are
met with in the same locations. They are very numerous over the wholo
LESIONS 07 TOB rUARTNS AND ŒSOPDAOUS.
4â7
of ihi' pMtcrior wnll of thti pliurvnx ; they become much \6a nuDicrous
m» tlie (i;]S0|ihagu8 i# a]>pr»nclicil.
Tlio bloodveMcl» f<inn in ihc jiUarynx a verr rich network wiih elon-
gKted m«shes. llie voMolar «u|>)>lv of tlie u*-'^|>hagiu is mtich \e»a
_ abunHnnt.
H Tb« nerves of tlie pharvngeal ani] wsojihageal plexus postieftâ ganglion
Heclls.
L««ioi)s of the Pharynx and (Biophasiu.
I
rilARTXniTis. — InflniiiiiiiitionH of the oral :in'l imsnt cnvîtlcs finrc a
griMtl tcnilfncv to l'xtmiJ to the pharyngeal imicoiiif nti:inljr«in.', tmt there
are t)evvrili«]c«M numenxis i'>xccpti'>iis to thisniK'; for while inflatniiin-
tioi)8 of lli« lonitiU aiul of the arches of the ])nlnto like tho^c proilucetl
by variola, scarlatiim, etc., with tho greatest rcadines» i-xtend to the i>os.
tcrior surface of the palate ami t» the poAh.'rîor wall of the phnryiiXi
tho .laom la nul true of the aphthou.t, phimhic, luereurial, nlcero-men
Itranoos, and »corbitlic iiiflammaUoiis, whose neat is almost solely limited
to the lipe, cheek, and alveolar mucous meiubrano. Moreover, pharyn-
geal inflammationH present pecnliariûea which depend u|mn tlic structure
of tho mucous memhrano of the pharynx. In this ealc^orv are to be
placfid thtf K-sioiig of chronic inflammailous of the gluniis m granular
pharyi>;?tiK.
8u|>crficial or catarrhal inftinmwilion of the pharynx mo«t rreijuently
Toltow^ exposure to i;oId, and succeed» a coryza or a tonsillitis; it is char*
acterized hv rednetu and a muco-pundenl sci^rclion from the surface.
In vtiriota, the pu.ttule^ formed in the pharynx have not the aarae
solidity aa tho«e of the oral cavity; the epithelial cuticle is so easily
detached that, instead of well-fonned pustules, »e usually see nothing
else than whitish spots or patches formed of softened and dcec|uuniuting
epithelium min;;lcd with mucus containing pus corpuscle*.
In mf-fola and in ti-arlalÎHa, a punctate redness of tliu pharynx iii
nlmuBt constant. Scarlatinous pharyngitis is peculiarly j^rave, and very
frc«|ucntly it gives rise to a supcrlicial pulpy vxudation. The surface of
the itnicous membrane hec"ni«» covered with a soft white or gray pulpy
layer, which is fonncd of iloApiamated epithelial Cidl.^ and muco-pus.
Be«idt-ti, in incarlalina aixl in rubeola, a diphtheritic memhranc is some-
tim«8 olwervcd.
Srgtiftlaiow* phiirynijitU present» characters siinilar to those of the
same form of stomatitis. It extend.-) to the pharynx from the nasal fo&se
or from the mouth ; it may descend to the inferior part of the pharynx
and reach the epigioitis, the aryteno-epiiclottie foMs, and tho larynx.
Di/>/irf<fritic- i>lntriin;/iti« fre((uently follows the same inflammation of
the ton:^ls anil of the palatine arches. Bceiilcs covering the potttvrior
aspect of the palate the membranous patches may invade the niwal foMic
and the posterior wall of the pharynx. So also when the diphthcritis
extends Irom the larynx. (For structure of the false membranes, se«
pp. 65, 00.)
TgpiiDid fewr frequently dcicrmines tumcfactionM of the closed follicles
in the loRor portion of the pharynx. These swullinga which have (he
•158
PHARTNXf AXi> ffsopn^aus.
same nppearAticc aa th« «loscd i«olfili.'d fotlk-W of tti« small intestine are
Ujonslitutod l>v an infiltmtion of Ivmph corptuclcs in» the follichw and
FBurronndin^ connective tisMne. TlietrulcenttioncomniotweMattlie pointed
Donion of the little tumor and apreadd over the whole iiifiUnite<l musd
rite«e Wious liabitually coincide with typhoid Larjngitis whiob has hMM
dvHcribi-d.
.Sffi'liiti» mnuifeste itself in the pharynx by muc(Mia patehea and deejt
dlcoi-nttoiis preceded by induration of ilio Biil>m<ieou3 connective tiraue,
Land by giiiunitita. The character of the ulcers has been nlrcady ithi
Iscribod. The disorders cuueo) by thcttc ulcere coikslst chiefly in a thick-'
lening ef the whoK' mucoiis membrane in their neif^bborhood, in pcriostili»,
■in 1(»^ of .itib^tancc, and in cicatricial contractions, constriction audocclu-
UOn of the Knïiluchiaii orificeii, etc.
Oritnular phitrymjiti», whici) is nometiincit cotinect«il with olironlu
cutancuuH disease and often with phlblsis, or with the habitual use of^
Lalcoholic stiniuli, is mast frei|ucntly a chronic process characlerixed by
ralterations of ihe closed follicles and mucooa glands of tlie pharynx.
Cpoii the coiigoBtod surface of the pharynx the glamls i)rojeet R»re
.prominently than in the normal state. At the centre of the glanduiarri
Iciaineiice, the excretory duct of the mucous glands is oftvn surroundwil
by a whitish rim due to the dcs>|uamatioii and swelling of ttic cpitheliall
cells ; the enlarged duct sometinics contain» a puriform mucus. TborM
may ho ouporficial ulceration aftectiug an entire gland. A similar inaamJ
mation attacks the depreavions of the mucou« membrane :^ittuilo<I at tba*
centre of the agrainaicd follicles which exist in the upper part of the
pharynx. The tumefaction of the acinous glands is due simply to a hy-
pertrophy of their culs-do-sac, caused by u swelling of dicir cells and tlic
enlargcMH-nt of the I'ollieular glands, a hypertrophy analogous to Chat of
the t'>ni<ii». When tiic IcMon is older, glandular atrophies are produced
by ulcérations limited to a certain number of the glands nix) follicleaij
, 3'he mucous membrane is irregular, thinned in some placeswhere tliere ara
I imall cicatrices, thickened in others by persistent swelling of tlie glambJ
The bloodvesaels, pariieularty the veins, are diitended and very risihien
they may form genuine pharyngeal vtirifcs. We may find cystic dilM
tatioD-t arising from acini or ducts of the glands, small calcareous concreJ
tions KCftted in the glands, and irregular papillary vegetationa of ttrin
mucous orium,
Chri'nir- jiharifnffitU ia sometimes related to the pre^enc^ of tuberclea
winch may ulcerate and forip ulcere similar to those of the tongue.
The vault of the pharynx, so rich in closed follicles, often presents snelu
an iiiHanimatory swelling of these follicles and of the muooui tucmbraUH
which covert them, that the orifice of the Kustachian tube is obotructofl
and a ]>assing or jienniinvnt ïmj>airnK'iil nf hearing is the cousequeiKV^
This hiipjjeii.t eitpecially in scarlatiiiu and typhoid lever. Certain case*
of deaf- mutism appear to have tlieir esscnUal cause in these ob«tnKtioiu
of the Ktistachian tube.
Hftro-pliartfHi/ml i^mf-»» U sometimes produced by an exteiuiîon iqj
depth of a very intense inflammation of the mucous membrane, as is 9omeil|
times seen in scarlaûna ; occasionally it is caused br ttie local action of a
ntntic poison, or by foreign bodies deeply imbedded in tiie mucous mem-
asttVBAonia.
459
I
I
branc of llie pharjux; most froiiiiLiiUy ite oripii ts n primary discnM of
the periosteum Dud tlic body of llie v«rlcbr«) (mrivs of tlio rDPtebr»,
PftUV diM-asc). All nbnecss nliiob lilttt up tht) mu<:o(i» nwiobrnne »
I niurv or hs» Inrge, awl hoi* a toiii]«ncv V> extend around the pl)aryu}j:eii1
orifice nUcre it may occn«iou an œdema of the ^çlottia, or alonj; llie
u:«o)>bagiL't into the posterior mediaiiljnnm. It may open spontaneoiuily
into the pharyngeal ca\ity, or it may discharge into the air paâ!«a}^8.
*J1i«ee abeceasea, especially in children, are frciiuently fatal.
F (EeOPU&tilTES. — The œeophagna ts often inflaoicd from the same
canMS ae is the pharynx, but miicli letM frci|twntly. It i* probidite that
tlic iwiiMitioiie of pymgii correspond to a A\^\\ deforce of cntarrh or
RupcrBcial vongcfttion but wc cftimot bo certain of thia^, for cciiopbitgeni
congvwtiou i« not neon nt the «ntop«y, becauM« of the contra<:tioii of tiie
miiwlef and of the tliickneiM of the pavement epithelium, whicii is more
\ or 1e.4.« H>>flened and macerated po.«t mortem.
•SitftrrHiri'il infiaotmiUirm occadioncd by the febrile exatithemata i»
miich le.-M pronounced in the œiiophagu» than in either the moutli or the
pharynx, employment of emeiics mav occasionally cauHO the fomiutioa
of small pustules, followed by superGcial ulcération.
An intiammalioD of the (eeophagiis ix sometimes met with in scarlatina
or rubeola ; it may also be consecutive to a gangrenuu» pharynj^ti^. [>iph-
tlicritic fulitc membranes may form uj>on tJie «urfaoc of the mucotu men-
brmne. 'ilinivh 1ms also been oliMt^-ned upon the «urfaoc of the owoph&gus.
Other cauaea of œsopha^tia conai^t in the effect produced by very
vano fluids, such aa tea, etc., and by irritants, such as irritant and cor-
rosive poisons. In the first case the intlammation is superficial, and is
chiiractoriicd by vascrdar redness with tumefaction of the STibmucous
connective tissue, and swollin;; and desquamation of the layer» of epittie-
liuiD. It) the second ease, when the caustic a<;entK have rcmiiiiied in vcm-
tact with the raucous membrane of the ie»u]>hagus, ufti>r iniiùbîiioii by
Uie epithelial laycn» and the connective tissue of the mucous membrane, an
eM.'bnr is produced iiiul is fallowed by nn eliminating .'«uppurative inflam-
mation. The mortiliod tiiiiue, after ii.t elimination, leitvcs an uleer, Ihe
bottom of which may hi- formed hy nniscular fibres covered with ;:ranuta-
IJonti.4sue. 'llie .lubunicous tissue and liie connective tissue which sepa-
X^xe^ the muscular faiiciculi are intiltratod by embryonal cells. Later, if
tiie patient recovers, the ulcer will cicatrize, and upon the surface of
tlie cicatrix new epithelium will form. Contraction of the ucsopbagca)
canal follows with all its consequences.
fonit/n hodift arrested in the œsophajçus determine not only super-
ficial inflitmintition of the mucous membrane, but alHo aimait always
lacerations and cxcorinilons, and in this way catue an ab»ce;i8 in the sub-
mucous tissue of the ccsophagus. which may break into the canal of the
fillet, into the pleura, the mediastinum, or into tlin air passai^es.
Sffphilig very rarely a0ect« the mucou» membrane of the œsopha;;u3.
All the inflammatory lesions which profoundly aflcct the submucous
eotineclive tinsue of the (csophajtua are followed by cicjilricial contrac-
tions of this canal. These contr.ictions are often multiple, yet not very
extensive. Ojjposite the-ie coutractions the muscular coat is gencritlly
480
PHARYXX AKD CBSOniAllCS.
thiek<>ne>l. Above the eotwtriction ihe œsoplingcal canal is diUtcd. The
tnoHl frequent wat aI' cmipXrklion in on a level with ttie larjDX, ami at
the inferior or eardiac etui >tï die iiMopliajuii. All of tiie abovc<ni«uûoii<^l
' lésions inay be developed in intra-uterine life.
TtiMOKs OF •run Pharynx axi> of tub (B'Suphaous. — ft'eiw-myoD
«mull ami round, orij^inatin^ in the miisciilnr coata of th« icso|)hasos^
Eaometimcs form projOL'tioiiH upon tlic «urface of tliu rancuus mcmliniiie.
yUty may iiKaiii tlio the of a pcH, but i^t-ncrnlly caum; no disturbance.
Juipomnta Imve hocn mot wiili in th« (cscrphuguit. I^hev may roach
tlie «xe of a liasel-ntit, and project into the canal under the form of
poI/P"-
nniall et/*t» of tlie mucous ^lanilii are met vitli in the œaopliagi». T1i«y
nay occasionally roach a very oousidcrable sixe without necessarily occa-
I aioning serioiia difficulty in de;:lutitton.
Dtrmoid rt)t(e have twice been seen in the œnophagos and pharynx.
JWkrc/i« arc very rare in the mucous iDomhrnno of the w3ophas;its.
Cardrtt'iM't very rarely cxiRts ae a priinnry tumor of tlic phiirynx.
In tlio œ«opba^uii we do not believe that it ever originates as a primary
i growth. It invades the wsopliagus by extension from adjoining part«.
siioh aa the lymph glands, collular tissue of the mediastinum, etc.
Pavtmrntfrthd rpithrliomn ftppears in the plinryiix as an extension
,frORi a primary growth in the tongue, or in the a-sophagus. It not iiifrr-
quenlly occurs in the cesophaj^us .v< a primary growth. The favorite
location of the epithelioma is at the middle portion of the o?30pha«ia,
opposite the lower part of tiic trachea aod its bifurcation. 1*he neigh*
boring lymph glands are early invaded by the e|nthelial elcmcnia, but
they preserve their form and thoir ca|wnk'.
Hy its propagation to a<ljoiiiiii^ purtin, an<l by the prof^ressivo dostrac-
tioD of the growth, oesophageal ciincrutil ends in a perforation of tlic
trachea or of the left hruiichi», or in an opening into the oMMliustinum,
accidenta which are rapidly fatal.
KOHMAL IltSTOLOflT OF THB STOMAOH.
4til
CHAPTER Til.
THE STOMACH.
Sect. I.- Normal Hiitology of the StonMh.
IK Atoinaoh prosonU for conaide ration tliroe tunics, vbt. : (he tnucoti<«
fBi«nil>nne, the miiAculnr coat, and the periloucal covertug, tivM to-
I.ecUicr liy connective ti»aiie. Tlie
l»tt«r U most altundftnt in the
mucous membrane, between the
BupcrEcial glandular lajrer and
■ Uie muscular coat.
The mucous membrane of the
stomach ia normally pale when
inactive, pinkish or red durin*;
ttli^e^tion. When the orjsn is
empty ihc niL-mbranc prcnont«
longil«<linul Tohls; diiring dîiten.
«on it often prciicnLt ridges,
mnmmitlnry elerntionA, ani) irrog-
uliir folilt), which are mainly due tft
enntraclionH of the smooth fibres.
in ihickneflit incrennes as the
pylorus ia anproachot).
K The Klxnas of thi^ atomnch arc
" of two kinds: lat, mucoua^ïlands,
occupy the vfhole pyloric region,
«nd are also met with, but in
smaller numbers, at the cnnliac
fend of the »toniuch : *2il. [Kîptiv
ginndis, which extend ovvr the
Yfhole funiliw an<l middle rejçion
of the stomach. The firet secreut
the muctis of the «tomaoh ; the
■ '•econd the nastric juice.
Kvcrywhere ii|>on the miicoua
«itiface, tubular jjlands exist par-
«llel to each other, and perpen-
dkutar to the surface where
they empty into small depressions.
Each of these dcprosHions re-
li ■ 2ft3.
rnnJai, H- i'''»^iiinniiF<tpUli«'l|iin)r (- r*pikîlkn4
lib»*, 't. Siibii>iiT>iai t]i*u4. «. ClftuUt iiku>rul*r
ceives iho di*char^*5 of two or mon? tiibt;^^. Tlirsc fimnil superficial
r deprv«Moti« arv JK'purutod from eucli oUicr hj clrculur f roiuiacDCCA of
i
463
STOMAOB.
the mcmbrano, which in rerticnl flection app^r aa ulightly clernte'I
conical papilli». Thetie elerntions an<l depresiiioii» are covereil l*v a
BinfiH» umnUtrnipted laver of eoMet-shap^ crUn<lrical cellH. Tltcw
c«liâ present a protopfasm and a nuckus situated at their point of
Fig. 2M.
C«ll><h«B ni (kann»l«*artk*pml«plii>a*ad «ntUni. a. Cvlnnnir «plibalUl cati pfmMM
«llh illla. IIi> liilct t>alo|i pruliiBj[*l1ui»»( th* luln-vlIuUi ocliinrll. i X&tl«ai ol * (Itiiidiir
«f :t)>«ll«l f«1l f'4»ii ikp BtnmMh at ■ itdwl, »liH)if1p>f ihi Jnir«.(iuaLe«f UAlSArk, t. HaUaUi*!!*! tM
— Inln-rrltnlai DilwutK— In n>a<i"rliuD villi lli« Imn-iiuclHr sslirirk. 4. CoBiiKllr* ItoM ««■
|>u-<ls fruni mi'*! 'ii'if --f ifvi. •UntrlBK v*i>r i^loacl; ibxam-rallaUi' aMmrk ot IMIa anO iti> lif»
lliii>R»ca.t >ul»Ii.Bi>; III* formai tilradaliitu Hie ImnfUrd |>iai»Hr*, «lid (• »!»* «wit-J mi> iM
vote fl«ti«)ie hitr>.uut>**r T^Ucalnin^ r. (ïi»lktDt «tl rrnn Ilia atouiBcb af > bfwi »Lawi«f i^
lain cAllaUr oatwur't Ut ft>Ti nerf I'm viti nbrlltof Iho lAtrfrBa«l«tr atl^vrk ; I&4 ttpp*( pftriof i^
#«]| It ifr'Bltjr airnll4u by mu47u>- Ifi'/'tii-)
iniplantstioii, whilst the remainder of the cell, moulded into the shape of
I & goblet, coiitaiu.4 a transparent rouou». which i» contiiiuonK with tiic tliin
laver ofiniicuti that itaiially covei-^i am) adheres to the mucoii» surface; at
otlicr tiiiieii the free extremity of the^e cclU. instead of heiu;; hollowed
«ut. ifl closed h_T an extremely tliiii membrane, (e. Eg. 264.)
Tiie mucus which covers the surface of these celb poasMM* the re-
action of gastric juice (Beninrd).
This superficial layer of oclU and the subjacent tissue of the mucooi
membrane arc altered with the greatest rapidity after death by th«
action of the gastric juicte, which, by a ea-^avcric digestion, macerates
tl>« elements, rentiers Uiem (ran^iparmit, and finally dissolves tiiem. Be-
caiL^e of tliiit <li;^sttoii, the mucous membrane of ttie stomach U rarelj
obtAined in a fit condition for histological study.
The peptic >;lBiid9 consist of cvlindrical tubes which tKnuinale in
depresaiona above indicated. Tiiey possess no inde[>erident scpsnt
membrane, hut they arc limited by a layer of flat conneclive-lijiKuc cells.
Thev possess two kinds of cells: 1st, the peptic cell, deMTibcl by
Koliikcr, which is spheroid, granular, and cloudy, and contain* at itt
centre a !<tnaH round nucleus. Tlie«o cells, whose granules eoii»i*t
protein material, arc placed along the tube near its limit in such a maa
HOAUAL BISTOLOQT OF TITK STOSIACn.
ner m to produce small entnrjïcmenw where they arc locatdl. Tltcy
color (lui'ply with carmine and aniline ; "M, the other cells found in the
ftptic lubes are conival. with their base at the periphery and their njwx
at tliv oviitrc of the tube ; ihvv arc finely granular, aud are iiitimatvly
unjtotl with each other.
Fig.sss.
¥\z- U6.
P<t<Ir ■*•<''< kI'BiI- o. CamnoB^sd i.K
lu thirt iTkBih». r. Tanulail cau Hllb
■phtfOldal alK&J «till.
FDrlloB «r t>u^ of llin MCH mon hi^hlj uni
*l II. 9. liiL*«ijipDi llt'■nl^Flln^' ti Utic rl*"'!-
From this disposition of the cell» of tlii* peptic tubes, we aociir<iin;;lT
sec, in a section which passes tniiisvcrM-ly U' one of the tubir*. two or
more round ffmniilar cells nt the piiriphcry, while the remainder of the
circle is occupied by conical cell* whose borders convert towards tlie
centre of tlto tube, havinj; there & very «mall central lumen.
Each of the tubes i,* surrounded by a narrow zone of connective tissue,
lh« fibres of which follow the general direction of the gland. The two
or more glandular tubes which empty into the same depression or crypt
of the mucous surface are separated from similar ncighborin;; group» of
tubes by a greater thickness of connective tissue.
The mucous glands of tlie pyloric region are aUo compound tubular
danda, with a general resemblance to the peptic glanda. They are,
Dowever, more voluminous, their tubes arc larger, snd they contain only
afflBg1« variety of cells — the eoinco-cylindriciil. Tnese wlU approach
in structure those of the surface, but their frei- cxtn'inity i* not iwtially
g<>blct-shaped. They arc very long «ud narrow, their nticlciu is ovoid
464
STOMACH.
nnd <!lnn;;iilc(l, ahi] titc ccntrnl lumen a much Urger than tluit of lli«
peptic gtiimU.
Tli« gkii'ls vfliich wo have jii#t dewribeil cAinpnHe by far l>ie ^reftlt-iit
part ol' tUn glumluliir or !<U[>crfii.'ial limits of the stninach. Ttiey are
acparaleil from endi otlicr l>_v interlacing bnndleti of coniKCtivo ttfutie,
vtiiti uliicli, at tht.' lower part of the ;:laii<]ii)ar ciil^deaac. ^mootti mus-
cle filtres are intcnningld. Ttn'se muscle fiUrea oven penetraii.' betwet-B
the ^laniU nearlv lo tlie surface of the tncmlirane. Thia ootinectivi- tU«ae
is well siipplieil «itli a very fine capillarv network. Tlic rapillarifB also
forDi a snperfitiai network ioitnoiliatoly boncath ihr epttlielintn. ftmuud
the orifices of the Klanils, aii<l at the summits »ï the f"M« whk-h lîinît the
«lepri'Btiimi. The capillaries of this ïiiperfieinl netirork are lar^'cr llian
thoM bolHoen the tiibiile».
Tli« «rUrioles wliich supply these network» of capillarica ooine fro»
the f!«atri<; nrteiie*. from the splenie, from tlie right ^Atro.«pi|)(oi«,
anil frnm the pyloric.
The 1yniphnti«!i fonn two iielworkfi : one aituAt«(l beneath the i*nU-<I«
MIC of the |r(^|itie i^landii, the other in the Hiibmucouii tissue. Tnerv en
beâidca an e\t«mal network beneath the peritoneum.
1
Seot. 11— Pathological Anatomy of the Stomach. Leûons of NutrltioD.
Ist. AN.fiMlA. — Antumia of the mitoutt membrane of the 8trimiH.'h Li
vcpy unfavorable to the nonnnl seeroiion of the giMtlic juice, It is
prubahly ihe ii.iual cause of ()y.4|)t>{Mia iu clilornciiEt.
2d. CoxiiKSTtox may be re^rded aa a jihy^iological phenomenon of
normal oLcurrence in the mncous membrane of the siomacb during dij^s.
tion, and essential to the production of the f^aHlric Juice. But it is also,
in certain cases, the first stage of a catarrh of the stomach. Under the
infiuetK'c of normal or physioloftical conKL-ation, wc often sec ru|>turfS
of the csipilluries nnd ecchymoses in the siiperfidul layers of the mucotiD
nii'mbriiiie. The latter are «tnall irregular jiatcbes, often diflicnlt to see;
pomt-times, on the eontrary, they nm nslar<;e asn sbillin<;, red at first, then
rapidly pH>>:'inK '« red-brown, «late^^ulor, or black. Very dark occUy-
moL-M-.^ aitf not infreipiently found fit the itiimniit of the fohl.t of wurouit
membrane; they are elongated in the direciion of theite folds. Tii«
pressure at the base of the folds causes the blood to he retained at their
Humntit. At other limes there are small, round, leitiicular .4|M>bt of
eon;;estion, situated upon a more elevated plane than that of the ameo "
tissue which surrounds tiiem. Localized anemia is due to contraetiOD ■
tJio muscle fibres. Sometimes the spola are seen to bo slightly dej
at the centre without there bein<: actual loss of substance ; the depr
is eaiised simply by contmetion of the muscle fibres.
Ttie ehan;^' of cdor which these ecchymoses may undergo is so
that they may pax* from red to black within twenty. four hours from
time of extravasation. Here aW, as elsewhere, the extravasaled blonl
may decompose and j^tve rise to pijimentation or to the infillnition of the
elements by blood crystals. In the other tisauea of the economy, llie
Ixri.AllUATIOt> OF UtCOUS UBUfiltASB OF STOMACB. 465
lueuitnorfihosiii of t)ic Mood is novi'r so rapid tis in the Mtooiaoh, where U
is subJL-uU'd to tiiu action of thv ;;iwtriu jaicv nml Kut]>1iur(!tt«it hyiirageii.
Ttiu di;;i.'«tive nctioti of th« giuitrio juive upon tlioKu [lartK of the iuuodu»
memliraiw which, by rcnsnn of prvsHurR of ttio inliltrated celU ami «x<
tnviMfttO'l tilooi], lire no l»rip.T iinuriHhcil liv etruulating blooil, luity be
coniuclorod nit a iiocuiMv oun-tc of the itimjite ulcers of ilio stomacli.
When ileath «uildciil^ intvrvenoH during llie courfic of di;;eation, when
tlie AtomacU contains not oidy Ruid but aUo a large i|uaRtitjr of gastric
juice, the name digestion of the mucous membrane ensues as is seen in an
experimental digestion : this post-morlem di;jcsti"n is nuturallv more rapid
io a warm ihsn in a cold eeaaon. Thas Boftcncd. liic mucous membrane
is reduced to a pulpy detritus uniicr s stream of water. This alteration,
which is post-morteni, was for a Ion;; time dcsoribcd as an inflamtnatorj^
U'«ion, under the name of white, red. or slat/ softening, according to the
difTvreut colors which the mcmliraiio presented. 'This post-mortem diges-
tion of the mucous membrane îs met with i» the «Icpendcnt part* of the
atOKoach, particularly in infanK* who often die while the stomach i* filled
with mille, an emini-iitly fermentable fluid which very much favors oada-
veric digealiou. (t ia po^ilile that in cerUtin cadeti inflammation may
coexist with this softening, Imt even then the result is certainly due iD
the main to cadaveric decomposition.
ad. Lesion» o»- tub Gi-axds. — We shall describe a apeciesoPMrophy
and of hypertrophy of the glands when wc study chrouie gastritis, but
wi> should mi'ution at this point » lesion of the K'aiKl» wliicli we hiivfl
hail au opportunity of examining several time*, nunudy, u fatty di-gcnc-
ration of the epithelial cells following phoiiphoriis poisoning. W*e do
not refer to tlie local action of the poison which déterminent gangrene and
ulceration, but it ix the effect of the HVAtemic intoxication nhieh n-.^ulta
from the absorption of a tiinall ijuanttty of tliiii suhAtanee, to which wc
would call attention. Coincident with tlie fatty degeneration of the liver,
kidneys, etc, the cells of th^ glands of the mucous membrane of the stom-
ach arc filled with fatty granules, and tlio glands theraaelvos are more
%'olnminous than in the normal state. The mucous membrane is thick, yel-
low, opai{ue. Virehow compares this alteration to an adenitis of the glands
of the uiitcons niemlirune ; but the infliimnialory nature of thi» lesion is
very doubtful, for we can «ee only u «impie fatty degeneration.
4lh. I.KSloxs op THB Vkssklh. — Atlii-rtinui of an artery of the atom,
ach is not very rare; it may cautte ulceration of the mucous membrane.
-■inti/loitt degeneration of the arteries has been mot with, but always in
association with a similar alteration of tlie arteries of the intestine.
Etect. m.— Inflammation of the Uucous Membrane of the Stomaeh.
^K. Ut. SCPERKIorAL OH CaTAKRHAL ISfUMMATIOX OP TltK SïOMArH. —
^H^'IBan it is almoi^t impossible to recognize tlie slight degrees of gaitlric
^^SMarrli which in all probability constitutes the anatomical lesion in dys-
pep«ia. The «uperficial layer of cells, as wo have seen, is very readily
46»
BTOïlACfl.
destroyed after dcftlh, the himra of llic c(^ll.i of th« gtaDdsateittndtnd
rerjr doubtful by reiaon of airuilar cliangcsi, and there n tlie Hun« difll-
CuUf in studying the histolo)^cal condition of the ftuperficiat ooniicclivo
tisaue. It is necc^earv to resort to the stmly of intiamiiiation artificially
produced in the stomach of animaU. We hare cxaiained a iierieii uf
Lltomacbs of dogs, where irritation of the inner surface of the orKao
Ibad been produced by a venous injection of diSbrent eabetancea. The
Istomnch was found intensely coii;;estod in various placM and covered bv
'a mucous or mttco-puruleut si-crct4on. The ^nslrîc juice, when it u
cloudy, contaiius a lBri;e quantity of white corpiiHcles besides llie super-
ficial epilhelia, whicli are almost intact or are filled nith mucus.
In the conge»l4-d iirejut thin aeotionA show, under the mioroacope, a mrj
marked dirtteii^ion of the »iiiperfiei»l capillary network found at the erests
of the intcrglandutnrproniineneeii. Tliene prominences are more aulienl
thati in tlie normal state. In the tiasiie around their cagiillary vc
extravanations of red and white blood coq>u9cle9 are often recogntK^d.^
Whence lesion is not very pronounced, tlie epithelial covering remains
in place, but at other points, where the inlerglandular fohls are more
tumefied and the connective tissue around the dilated i-eesels is muchj
infiltrated witli the csc^d elemouts of the blood, the epithelium is «oi
pictely absent. The depressions of the metiibranc into which tlie glandril
empty arc narrowed or even entirdy closed by the swelling of the coo
nective tissue which «urrouwU them. They neverthelexs reUiin Ihcîr'
cellular lining. Neither the mucouM i;lan<ls nor the {«jitic glands present
llterAtioDs,
From the foregoing, gastric catarrh artificiallv produced Heems to con-
sist essentially in congestion of the surface of Uie mucous membrane, in
the repletion of tbe superficial capillary network and the escape of liuid
containing red globules and lynipb corpu«elU!>, in the cedematous and ecchy'l
motic tumefaction of the interglaridular prooiinenee», while the glands of
the stomach appear to take no active part in (lie morbid process.
In man it Lk impossible to demoniitrale all these histological conditional
yet the redness of the membrane, the eccliymones, and Uie character of
tlie fluid secretion, indicate with suthciont certainty a su{)erGcia1 catarrh
of the stomach.
In a whole series of infectious febrile diseases, such aa pnerper
fever, variola, etc., wo meet with a grayish paleness of Ibe glandular.]
layer of the stomach, which is more or le$g mammillatcd. The glandular
celts arc swollen, cloudy, and filled witli fine fiitty or protein granules;
they are in contact with each other, and their outlines are indistinct. In
(lie sidient folds, the glands are enlarged : they are in a state of fatty
degenemtioTi analogous to that which we see in the liver ami kidneys of
the 8ame siihject8. It is possible that post-mortem liecomposition plays i
part in thi.t i^teraUon of the gland cells.
2d. Chhokr- Cat-ikkh ok tuk STO.<HAi:it. — The lesions of chronic ^u^l
tritû extend deei>er. Tbey are not limited to the superlicial layer of th»<f
nmcoos membrane: they also invade the glands and the submucous con*J
necdve tissue, even tlic muscular layers are often altered. In cirr
onHOMO OATARRH OF THK STOUACO.
4BT
^
lh« liver, in all afvctjon* accom{)3mcd by ftn tmpeHtmont to the «in:ii>
m ill the portul vci», in «orne dittea^iei of llic heart, etc., the mucous
ïmbrano of the «tomnch h often tlik'keited and of a red, broun, or alale
color. The thickeiiing is increaseil ia some places into circiiro.icribed
soft p-ay exerescence-i. se[iarated from one anotlicr by shallow furrows,
iht» ^iviii;^ to the mucotia membraiw S mammillated aspect. L'pon a ver-
tical section through ilicso places wc wc in the raised portions dilated
glaoda, filled with a more or less irranular c))itbeliiim. Tho thinned
pan» correspond! n;^ to the fiirrons arc, on the conimry, remarkable for
the atrophy of tha ginud whose walla are thickened, and which contain
Pig. 317.
Fip. S5».
P(. «T.— CoioiMiMlagAinDMtoii of fTaUtrioiiiinrlInnaf Ighgtu n'ttidi M t »d e. a Tbitk'Bet
ni*iii1>i4ii4 UrallwiB- if- FMly iluirDiiiBrKLtuu «t trouieuli tt iab^.
t^g- ZSiV— Cx"Uor «IDDitffb flilril wit^ ficplmiiiiiLr ApiLbtiUum- d- A'ljii'ttiil lab*. Ilm nbtAaE* vf
•hich »t* UflirtoUc Uit; 4>(*a<raaaa. t. ihltkaDad utctbrt» llaluui.
fatty fçranules and a few sraniitar cells. Tlie elevations are vellow and
opaque when the gland cells contain manv fatty granules, 'ihe suhraii.
coiw connective tissue is everywhere thickened, but especially is this so
under the furrows previo<isly mentioned. The color of the mucon« mem-
hrane is gray, red, or slate color, in spots. accor-Jing to the congfsicd or
pigmented condition of the elevations. In almost alt these ciscs of chronic
gistritis, by a carvful examination, nc find upou the Murface of the nicm-
bnuio very tramtparcnt «hining points resembling «mall air bubblos.
These »r« cy«ta fonncd by diatciKled glanda containing a liigblv refrac-
ting viscid aiuciis. 'J'lic wall of this dilatation ia lined by cylindrical
epithelium, and the contained nmciia incloses a few s{iherical veMcitlar
cells. These cysts are hnhitually surrounded by glands which present
one or more dilatations of their culs-de-sac or ducts, so small that they
escape the naked eye. At the same time the mucous membrane is
covered by a thick layer of gray, viscid, and very adherent mucos.
If the chronic intlammntion persists long enough, from the Sbro-
Tascular tissue which separate» the glands of the mucous membrane,
STOMACH.
YC^tflQtîoiw pivijcct in th« «liapo nf vtllntis p<owtbit, nt thu «jntrc of
wliich am to be fouii<l Ioop« «f capillaiy rcMcU. Tlii- cj)in<lnc»l o]>i(h<--
Ittim i# not to bo Dccn upon tlici 8urfaeo of thcic papllurj groirtli*. Tor it
ifaDi* off within twenty-four lioura nfti-r clmtli. When llifftc i)a[iilliirjf
Pgrowlli-t have Kttniiied an elevation of half a mttlimctru Oiey give to thu
inumal tmrrace of the stomach the villous aajicct of th« «inall inteatin
After ileatli, itic^ are often filled wiili granular coqmaeleii. They are
most frei|Uenlly found near tiie pylorus, hut (hey may appear over ft
great part or the whole of the sastric mncoua membrane.
Vory often if the chronie inllamniacion por9Χts, the villosities cnlsreo
and unite nt their base, thrir extremities remaining free ufion tlio snr-
fiiuc of the bypcrtrophied nuieous membrane. As a conflC4|Ueiicu of ttiitf
condition of tlie piipiUns. the cscri'tory duels of the ^diiitde become o'
atructoit. The ^land» Uien MulTer « total ninijiliy. nr tiie eiûtbolium coik'
linuea to form in the ciiU-<le-»iiC, white the ktler enlarge a»d preacnt a
»phorical dilatation wbieh in thin sortions ha* the upjicaranov of a ^nall
cynt. The inner wall of tlie*e «mail cy*l« is lined by a layer of cylin-
Ldrical collii. while the lumen is occupied by n Huiil l»nde<l with spherii-al
feells. In other cases the ■jlanda send prolon^^ationei deeji into tlie mucous
membrane, and the thickness of the glandular layer of the membrane
may then be considerably increased in places. These culs-de-eac may
also Iwcooie cystic like ibo others.
From this partial tbiekenin;; of the mucous mt^mbninc there may result
u small tnnior (iCMile or peu une ill a ted. In the hitu-r case we have a p»'ly-
jiuN whiue naluiv siid coitsiiiteiice dilTer aueonliiiK u it u oompoHn) of,
jihrons ti«<uo and papill»!, or raucous cy^tci or these different structu
knnited. Mucous polypi are remarkable for their sofincsd and llieir tran*
"parency.
This chronic irritation of the raucooa membrane associated irilli glan.
dular dilatations and irith smalt polypi b more fre^uoDt in old persona
than in the youn;*.
Tumors dcv<^li>ped in the inticon? membrane of the stomach determine
ftTOund them a similar chronic gastritis.
Chodpoits Gastritis. — It is very rare, and supervonea only in getvenl
dipbtherilis. The false croupal inemhmncs rarely cover a large extent
of tliu mucous surface; ihcy arc seldom seen in small patchoe.
Pemphigls of the Mucous Memurang of the Stomacu. — SnperBcial
ulcers which have «uccceilcd very transient bullw developed upon the
Lfsstric mucous membrane, have several times been met with in i^eneral
rpcmphigus. Their color i» often very dark, for they arc the scat of mi-
nute hcmorrba^'c* ivhich may bwome intensely cohired. The blo-id still
couUiiiied in the vessels is u.'«unlly cougulatvd, and dark in color. We
have several times had ibe opportunity of «xumiiiing these ulcers. In
one onsG ibcy wore covered by a browni.sh pulp containing a lar^- niini-
bor of spores and tuhci of viiiitnit aibieat» (tbni»li). Tlicse ulcvrs sooi ,
cicatrize.
I'liLKCMosors Oaj'tkitis. — Thin form of gattritiA.onlinarilycoimdered
as a secondary or metasutiv iiiHamuiatiou, complicating lypbus, septic
^^^^^V SIMPLE TLOER 0? THE STOMACH. 469
Dila, purulent infeclin», juierjjeral fevor, nn<l finally f^encral {Hirulent
pcritotiilU, loay be excited hy the local aciion of poiion, aoiila, or cani-
ties. It is an extremely rare lesion.
'Hie interj;lan(lular an<l siibmucoiiB connective tissue of the storaacli is
the flcai of a Oiffiisc purulent inlilcralioii. whicli iisually in a HilTuse
nannor filin the lucume of tin* connective lisxue. The purulent intiUrate
inriulee ako ihv intortnuirCulAr nuil subeeruus connective tif>8ue. and ex-
tends to thtt pcnU>ni>id coat which generally inflames tliron<;hout lU whole
exiont. The diRcrent tissuv» of the atuamch arc fitleil with puit. llie
tbickneiM of tlic^e tissuOH i» to reiuarktilile that often the walU reaiain
rifçid ATid do not culhipse.
The miicou» membrane finally beoomes tliinned and at points [terf»-
^ivinj; n.^e to sruiII openings throuj^h which the pus rexdily
'miKfM inU> the cavitj of llie stomach.
Lksios» HKODrcKB iirCoRRoeivE AXi> IbuitantAukxts, — The inges-
tion into the stotnach of corrotiivesuMiniate, of sulphuric acid, of arecnio,
of ammonia, of potassa, etc., is followed hy the formation of brown or
black eschara, surrounded by a vivid areola of injection, and followed by
all the phenomena of inHaniraation. The removal of the eschar rcveafa
a loM of substance or a perforation, which is fullowcd by pi'ritonitis.
Pbospliorus when sivullowcd in sutBcient ([uantity proilucoa loailly the
same effects.
It is probnhic that theoa«c« of t/anffr^NDut tfattrHtti cited by authors
are all rolati^t (u ixiiMuningH. Ilouevf^r. Kleha citea the case of an inraDt;
which, consecutive to a gangrenous inflammatioD of the pharynx with
swelling of the cervical glands, presented at the orifice of the stomach
B«Toral round gangrenous spots surrounded by a purulent eliminative
inflammation. Tbe same author states that with malignant pustule of
the longue, in tbc hog, similar gastric lesions are otuerved.
8[Mpi,B UU'EB OF THE Stomacii. — Simple ulcer is ch-iracteri/ed by a
loss of substance, more or less rcgulnrly circular, witli edges so sharply
cut tliBl the mucous membrane ends at the ulcer wtthnut oflering a mani-
festly granulating or i.-vcrt«d bonier. The bottom of the ulcer U jiale,
fibrous, gray, and is habitually covered by a layer which is in process of
molecular destruction through the aodon of the gastric juiee.
These Iojcms of âul>stance are due to a genuine digestion of a limited
portion of the stomach in which the circulation is impeded or entirely
interrupted. At the begitming, the ulceration involves only tin- mucoua
membrane (Cruveilhier). It commences by an erosion of the follicles;
later, the fibrous tissue is invaded and destroyed ; tbc bottom of the
«leer is then cunstituied by smooth muscle fibre*. Tbe latter in their
turn disapjionr little by Hulc, and there then remains, of the wall of the
stomach, only the peritonenl tunic. When this final coat is eaten away,
there is a communication between the cavity of the stomach and that of
tbe peritoneum, or ti>e bottom of the ulctir is bounded bv the neighboring
organs with which tbe peritoneum, at this location, has lormed adbeaioDS.
When Uic mucous and submucous tissue, and suhs(.'t(uenlly the mus-
cular coat, are destroyed by the process of erosion, wc have an ulcer of
470
STOMACn.
greater or lesser aise, vritb sloping or temced sides, the bottom or the
apex having a tnuch smaller diameter than the intcmnl orific«.
'I'lio shape of the ulecr corresponds to tlie area of tissue nourislie<d by
an arteriole ; it forms a cone whose base is upon tlie miieous siirfac«.
Upon the sbarply-ciil stalls of the ulcer sniiill arteries, and u; the ttottoa
of it ont or more larger arteries arv almost nlvrnvs seen with a [Jug of
connective tissue in ibeir Inmeii. Patients affected with this lesion often
(lie from proftwe heinorrba^^es. The cause of tlie»c bleeiling» i» readily
appreoiat«d ; in the arterial stump nhieh has funii#hcd tli« MimmI we Mta
a {)ost-iDorteni elot. fl^^
Tbe extent of these ulcertt i^ extremely variable. When t)»e Iwitom
of the ulcer ia formed by adjoining organs, the tiiiHue of tlie latter
inay somelimes be eroded to some extent. When the ulcer is located
upon tlio groat«r cunature of the stomaeh it may enil in a perforation
and a funeral peritonitis, or an inflammation of the jwritoncum localiseil
by adhesions. The nicer may bo single or multiple; it may be located
upon the lesser eiirvature. at ibc pylorus, at the enrliac end, or upon
tbe posterior wall of the stomach; more rarely upon the -greater etirv^
ture or upon tbe anterior wall of tlie or^n ; it may even invade tli«
lower end of the ifsophapis or originate in itic duodenum.
When a thin suction Uirougli an u)c«r ia examined, the wall of the
latter ia found to coiiHisl of tlio pre-existing lisstie. 'llie conncetire tis-
I tue is only a little thickened, but there ia neither juloo, as in cancer,
Isor new products resembling neoplasms. 'I*he glandular layer at tha
[limit of the iitoer shows tlio tubes mncli k'nj;thened, the inlerLdaiiilntar
connective tiissue richer in polls tlmn in the nonnal stale; the epithelial
cells of the i^nnd are not altered. Beneath these glands the connective
lissne is thickened somewhat and is rieh in fiinifonn or rointd cells and
fibres. In this li«suc, at the boiler of tlie ulcer, lesionit of the vestel
valU, consisting of a aclerotle tliickcning and coutnction of their calibre,
are constantly found. The ualUof the capillaries are sometimes eon*
verted into a thick refracting substance, which stainit deeply in carmine.
In one ease we found some of the lymph vessels of the submucous tissue
filled with lymph corpuscles. In this same ease the connective tissue
showed in spots a colloid metamorphosis ; in these spote there wore thin
reticulatod fibres of connective tissue, bounding very small alveoli con-
tainin-; a colloi<l suVt^nce an<l some lar^e round cells. When the ulci
ha» invaded and piirtly destroyed the niuscular eoat, bundles of smooi
muscle i^roject upun the wall of the cavity in tlic form, as it wer«,
bnnhes of irregularly cut filnmenl«, coti»isting of diwmcialeil contractili
elements, which may be normal or be in the various stages of faUy d'
generation. The âuhjacent mu.scuhtr tissue aliio sometimes sbowa
fatty grauutes in the smootli mui^cle fil>res. In thia tisaue, and in the
fibrous septa which separate the muscular laseiculi, as well as in the peri*
toncal connective tissue, the arterioles are altered in the same manner
in the submucous tissue.
hi a number of cases, a perforation has formed a communication
between the cavify of the stomach and an intra-pcritonval abscess, aîi
ated posterior to the stomaob. or between the latter and the liver.
Spleen, or thi- diapbrsjjm. Itarth has seen a simple ulcer of the anterior
I
I
SIMPLB on PRRFOBATtriO ULCBR OP TUB DOODBSOH. 471
wall of tlic rttuiiuKih in which Uie aiit«rior wall of the abdomen »ixl the
poawrior f»cc «f tlie eiisifomi cartilage formei) iU bottom. Tlic carti-
\tgfi had suAered a lieâtniction of ibi perit-liondnnin at tlii» point, and a
partial oro^on of its substance. Cniveilliier lian st^en ulc^n open into
the transverse c«1on and the third portion of the duoilenura. Ho Ua.-i
also reconied the cxtraonliiiary observation of an ulcer of the .itomaoh
ooDnnanicatint*, throu-;;b the diaphra^nii with the Icfl bronchna.
Tbu aDatomtcil dia^piosis of this Ic«ioti is easv ; the absence of a pro-
jc<;ling border, the drjness and hardness of the bottom of the ulcer, and
thv ntwenco of a lactetwonl juice in tlit- tissue, which forma tbe floor and
th« borders of the oroiio», diffcrcntiato it from carcinoma and all oclier
morbid gTowtli«.
Tho healinj; of ulcers i.4 jx-issiblo. We not infr«<)iieiitly lin'l at autop-
sies nnal) cicatrixed uleent iiiolnted, or aii.'Wiciittoil nith utcen in process
of development, in a i{uiei)cent fltate. The cicatrix which .<)ucceed« a
omall superficial uWr. which ends by henlin^i, is bonlered by a puckering
of the raiicoua membrane, in conaei|uence of the contraction of tho cico-
iricial tissue, but the )iart de-iirojed is not replaced by mucons membrane,
and presents ncillicr "lands nor epithelial covering. If there has been
during life a layer of epithelial cells over the spot, they are no longer
present tvrcnty-four hours atVr death. I^arger cicatrices may very
rewUly become tho seat of a new ulcerative process (Cruveilhior).
Fatal termination of the lesion inny bo induced by hemorrhage or by
jtcrforatioi) of the stomnoh. The»c two formidable acciilents, and espe*
cially perforation, are incomparably more frË(|Uenl in aimple ulcer than
in canc«r of the stomach.
Wliat is the cause of simple ulcer of the stomach ? It ia rea.ionabIe to
refer it to a molecular 'teath of the tissue, to embolism or to tlirombosiit of
one of the vessels. Such is the hyjioiheais which has been advanced by
Virchow, and which is supported by a number of clinical observations
and experimental researches. On the other hand, ecchymoses and capil-
lary «mboltsms. when they accompany ulcerations, give rite to a very
■npcrfieia] mortification, which doos not involve the deep tissues. \Vc may
admit, as a gen<;nil law, that the legion is cause*) by an arrest of the cir-
eulation. Atheroma of tlie arteries may in itome cascA be recognised as a
cauKe of ttic trouble. The i[uality of fooil, alteration of tlie gastric juice,
Hiibstances which havi^ a local action upon the stomach, aa, for example,
alcohol, mercury, etc., may alao enter into the etiology of tliiit disorder.
An uIc«ralion once establishe^î, we mav suppose that the continuous action
of the gastric juice, together uith sclerosis of the small arteries, which
diminishes the aMux of blood and conse>|UcntIy the nutrition of the purt.
is sufBcient to prevent complete cicatrisation, and to occasion the accident»
observed.
Ebstein has noted a case of ulcer of the stomach following trichinosis.
StuPLB on PEnFonATiSQ Ulcbr op trk DrooBstiM. — Wo mention,
in this comiection, simple ulcer of the duodenum, which ri-sembles in
cverii' resjHtct the same ulcer of the i>lomnch. It is much more frvijucnt
in nutn than in woman, iu the proportion of ten to one. Its tisunl ^eat
I» in tlie lint i«rt of the duodenum ; it is often seated on botli sides of
1
472
»T«MACH.
the pylonifi, and i^ inoro common upon the antorior wall Uinn iifixi
the posWrior. It i» often acvonipanîed b; a iiurtiul obalruction to tbe
Bow of tlic tiilo nnd of tlic pancreatic juice. When it t«nnirwt?B in
lienlinz nnil ciciiCriiuition, if tliv ciCAtnx io li>cat<!d at the pjlorus the con-
Iraclioii L-ause» ilitutntion of the fltonuch. with livfcrtrophy of its mus-
eutitr ti^-xii;, vomiting, i^tc.
Ifi-niorihage aixl ))«rr<)rAtion are to bo ilrcadod in this cmc m well u
in ulcere of the âtottmcli.
8«ct. IV.— Tunon.
LmiMATA. — They am raw. Thejr may ariae in the raucous me.
hrane, or upon the serous covering.
Sarcomata. — Prinuiry aarcomn of the stomach ia rare. Virclw*
mentions a tunior of this kiiul locat«il at the K-sscr curvature, awl iropU-
cutîn;; all t)ie lîtisucA. There was in the Hainc case a sarcoma of the
ovaries anil of the peritoneum.
pApnxABT OB Abbnomatoub Tumors. — Thejr have «lrcB*Ijr been
; described in speaking of glandular hypertr»pliioâ in chronic giistritÎH.
IiYMPiiADKNOMATA. — They afc Hometimefl met with in caitos of «plenie
or glandular leuksemia, and to ailtvnia. Thoy have the same aapcvl ai
cancer, and Form soft vrbitish ■p^nulatin^ tumors, yicldtn;; a lacteacent
juice, and ulcerating at the centre. Microscopic examination alone can
reveal their nature. These tumors may have a considerable snperliraal
extent, and may reach a thicknesK of from 1 to 2 inillinicterB, When
ulceration haii not yet taken place, vertical sections sliow the different
layers of the mucous membrane. The glamlulnr layer i* still preserved,
and the glnndti tteero much longer than i^ormal. an appearance due to
development of the connective ti.sttue which iturri>ni)ds tlieni. This tisane
is intillrated with lymph coqniitcles, diajioaed in longitudinal fteri<!# be-
tween the faacicuU of connective tisane. The e]>itiielinm of the gland» is
preitt^rved. lleneath the glands the much ttûckened connective tissue is
infiltrated with lymph corpuscles, and in thin, pencilled nectioiis, adenoid
tissue is very distinctly visible. The muscular coat contains lymph co^
pui>cleti hetirecn tbe muscle libres, but these cells are much more numer
oil* in ihe int^^rfasciciilnr Imiiilles of comieetîve tissue. When ulceralio
occurs, the U'm of xub.^tsiice aU'ecb* the glandular layer, and in place of
tlie latter «e observe very irregular granulations.
TuBKKCixs. — ^Tliey arc very rare, and are met with only in a general
tubercular nlceratiou tjxtendîiij; throughout the intestine. They present
the same appearance and follow the same coiirae in the stomach aa in
intestine.
CAlx;ABl«>Dti IxFiLTRATlox. — Vircbow has described under thia nan»,
a lesion which consiats in an infiltration, by the salts of lime, of a limited
SYPHILITIC TUMORS AND ULCERS OF THE BTOMACn. 4T3
I
portion of the miicnuii mombnine of the stomach anil llie correopomling
gUixIii. Ulceration huit <iucveeil thiH inltltralion, for it occasions a
Buperficial destruction of t)ie itwue of the mucous membrane.
Myo-pibrojiata. — ^Tumors constituted bv biiiKllcs of smooth mtiscle
fibred and connective tiaeuo aro eomctimos met vtitli in tlift atonutcli.
Thev are. both as to their structure and their dovi-iopnicnt, comparable
to myomata of cbi^ litems. Arising in the miisciihr coat of the utoauicli,
timy timy projvct cither u)>o» the mucous memliraiic or upon the »erou6
surface.
1st. The myomatJi which proj<(ct upon (he mticfii» membrane arc morM
frequently Mated in the viuinily of the pylonw. Jty the morement of^
the food, they may be drawn into that orifice, ami even project into the
diioilenuin. These |ioly|ii, cwcred, &» they rany he, by hT]>ertropb)ed
mucous glanda, may present a mucoiia nr myxomamua appearance.
2d. The polypi, compo^d ttf muscular fibres and fibrous tissue, which
|>rajcct upon llie periloneum, are generally hard and small ; but they
may «ttain the size of an almond or a walnut, and may sometimes under-
r^ calcareous ÏDâllmliou.
SVPIIILITIC TlIUORS AXli rLCRRS 07 THP. StoMaCH. — Patliolosist»
record scvcml observations of ulcer» and of hy|wrlropbicd thicltcninjç of
iralls of th« stomach which they connect with syphilis. Hut most of the
these reconU are indeliiiitc. Thitt is not so of m ca*e reported by
Klebs, where there were nicer» of the stomach ami intestine associated
with gummata of the liver. We ourselves have seen a case of syphilitic
tamor of the stomach accompanied by very characteristic gummata of
the liver.
Alen;; the lesser curvature, and in the nci);bborhood of the pylorus,
the mucous membrane of the stomach presented prominences of flattened
nmbilivatcd tumors, from 2 to » centimetres in diameter. Over them
tbc mucous membrane was prescrvcil, but it was thin and adhervnt.
Id a vertical section, tlic thickened ami altered sutiuiucous tissue pre-
sented a thickness of 8 to V2 millimetres. This elevation, formed of
tliickened submucous tissue, was perfectly distinct from the muscular
layer sttitated below.
The muscular layers were normal, or scarcely at all thickened, while
the anhmucoufi connective tissue was hypcrtropbied. Thi» connective
tissue was of fibrous consistence, very dense, and yielded no juice by
Benping. Its color was yellow.
The pylorus was constricted. There were no adhesions of the stomach
witJi the liver; but. at the lesser curvature, the peripheral cellular tissue
was adherent to ihe indurated lymphatic -glands, and there was a hard,
white, stellate cicatrix scon upon the «urfaee of the stomach.
On microscopic examination, tbe };landuUr layer was studded with
erect and oblique villous or papillary elevations. These villosities con-
sisted of hypertrophic granulations "f tbe coniioctiw tissue which anr-
rounds the tubitlar glands. The fçlands were sepiirated from each other
by thickened and hardened eonnective ti^'tue. 'i iio^e gland tubes ivhich
were found at the depressed centre of the elevations were narrowed, aud
474
STOUACn.
Uie excretory duct waa almoal complewrlj n'|il«co<i Uy '•" "
Over tlio Kf'-'aW"' pal "f llie luwir lUe wntiiiml ciiliKle .
were nearly normal. Only at the cenlre of tlie tumor nvn tint
and less easily distiiiguishcd. Under a high nutgnirying (mww,
appeared to Ik; covered by flat colla, and (o ^ IbrracJ of
tissue, eoutiiininf; hctvrcfln it« fibres round cœbryonal c«IU aid
granulrs. Tiie gland tn1>L-# were tw?cn to contain a few stull
epitliolinl cc)))> which did not form a complete layer. Tlw! ttiwuli
tatioii» of the plaudit eontainod eclU whtoli fumishod a oonpttV
and which were v»iiicii1, havinj; a thin wall irith a ilitiihle conMr,
clear or cloudy mncous conlentd. The tivue which surrouaM
glands was dense, «nd coniaiued elastic libres, connective tissiu
and small round celU, and was permeated by nuineroiu bloodTCudh
'I'he ^uhmiicnu.t lÎA^ue, which, a» has been said. constituted tbe wM(
minoiiceof llicnewformatian,waâdenHe and closely felted, and [w
bv arterial, venoua. and capillary vesscU filled with bto<»d. lie
elastic fibres and connective tiiwuc fibres, among which existed la
bon of sroall, round, or slightly clvn};atod omhryonal evils. In
to tlieao elemoiita so arran<;tid. there were also found groups of suikll
in the midst of a ground substance of small itniount and of j^rantilar
pcaranoe — i»laiiils of embryonal tissue. At the deprcMcd centre of
liimoni, their mbrauetius tissue, «■> to si>eiik, reached tltu surfaee, for,
we have alreuly seen, in thin area the glandular layer wu in gr«M
Atrophied and converted into connective tissue.
lu the muiwidnr tunic (he bundles of amootli muscle fibres
separated by banda of fihroua ti^ue, between wliich wore round n»-
bryoiial cellt) : but ihcee celts iiere not met wiiti in bho inKrior of tk
bundles of tnusdc f bres, winch lutter were in a nearly normal oODJiiico.
In the peritoiK-a! connective tissue, w« found the same new foraaiin
of cellular clcuieiiL-".
This ca»o, in which the lesion was characterized by flat tuann t^
sombliii^ lîhroiis gninniata <leveto|>ed in the submucous connective IhnM,
leaves iir) doubt of the syphilitic nature of the neoplasm. It enabk« «
to understand and to acknowledge at the aame time the existence, in Ifat
stomach, of ulcerations of tlio same kind.
In this same case, the lymph glands of the lessor curvature were vtty
large, white, and infiltrated with a lactescent juice. The juice wt™
freshly examined contained lymph corpuscles and swollen endntliernl
cells, some in n state «f fatty degeneration. Tliin sections of these lviiip*i
glands showed the lymph canals extremely dilated and everywhere filW
with very large and more or less spherieul endothelial cell». The rociiiA'
lary tissue also presented these large cells in its me«hes. The s»n**
alteration also existed, but in a less pronounced degree, in the rcticnlnic*^
tissue both of the follicle and follicular cords, and there was alsi» a rer^
evident inflammatory thickening of the fibres constituting the reticiiliiui '
The hi'onchial glands bad undergone the saioe alteration, and the retm*'
tion of the lymph, and the conseijuont irritation of [he lymph vessels,
were nianit'ested by a chronic lymphangitis of the auperficiai and deep
lympliatics of the lung. This is one of the forms of chronic sypliililt
Adenitis.
TUB 8T0HACQ.
lUtnioitA OP TtiB SroMjtoit. — Gnnc«routi tiimont of the stomach are
DOUUDon, ntul, Uowen-r rliav-rcnl in slnictiiri; th''ir vnriotie» may bo,
prenont u> the imked eve tunch the fiinie allied, ami llio Aaaw ] nngress.
ptuiloM ciirciitftiiiii, for exatniile, oaiinot liy the naked eye alono he
iKuiiilie>l from ovlintlric»! uelleJ ej:iiciieliftma, which ia very common.
Uflercnt varieticii of carcinoma irbich api>ear in the stomach, may
«kei), accorilin;: » iheir fpCi|ueDcy, in the following onler : encci)hâ-
carcinoma. fibrous or scirrhous carcinoma, colloid carcinoma, and
uniic carcinoma. The almost constant location of these tumors a at
lylonis, and the losxcr ciirvaliire. and ihcy arc aljo occasionally toutwt
«cardiac end. Tlicy have a ;;rcat tvn lency to ext-ciid upon tli« ad-
ig f'ortion of the posterior wall ; more riirely thoy ailimncv upon tlie
rinr wall. Mid M>mctime« thoy inviidir tlio vrholc ext«nt of tli« stomach,
iiiumntoiiy j^wtiiM he;^in in the nvihiniicon^ ti^iie, and in the glandular
rof tlie Mtomuch. Upon » vertical Heclion it i» seen that the j^hm-
r layer ta Uiickcned, it) itliL^htiy traaiijarenl, and that the prinei|Nd
I which causes liie jtrominence of tlie new [;rowth is fonncd hy the
r of submucous connective tisfliic. Eve» in very small tumom, by
KDg the surface with a 9cal|>el we nhlaiu a milkv juice. Micro>
le examination of thin sections throii<;h the morbid (growth, jiraves
tbt submucous tissue already shows caiviivimiKons alvi'oii tilled
colls of a new formation, whilst the ;:laiidtilitr layer exhibits its
It mtiob 1ent;thcucd and filled with cylindrical or cubical cells,
ooniiective tisi^ue which se]iurrtti.\i the gland» coubums a Inr^c niim>
of embryonal celln between it^ fibres. From this intcr^rlaiKliilar
;jroDal dssue may jtrow prolongations which extend beyond the nock
le glands in the form of |)apillary vegetations. This formation of
lary vegetations is common to all new formations in the mucous
branc of the stomach.
the neighborhood of the cancer, the mucoiii< membrane is usually
cd : it is red or violet, sometimes softened or mammilluted, and it
mtit the indications of chronic intlumniation, frequently with intense
eiitAtioii. Small retention cy^t» of the jrland* are also often met
It in very rare t« find the mucous niombraiK- in a healthy condi-
iround (he cancerous nodule.
lien tliere is ulceration, the ulcer is of variable siee. If it is seated
le pylorus it may have the form of a ring, Clceration may
entariiy re-establish tlic course of tlie food which had been arrested
te contraction of the pyloric orifice. The edges of the ulcer are
ited, and sometimes looïcncd. Its bottom is habitually fuuj^ou»,
ly, and covered with detritus ; or if the whole cancerous growth is
y destroyed, the muscular tissue is exposed or partly destroyed, or
' may even be a p<^rforation.
irforation is incomparably mon' rare in these tnm<ir« than in simple
'. The oiiwcular tunic adjoining and in the noighlKirhoad of the
r is always hyperlrophied. This hypertrophy may extend far be-
tbt! location of the tumor, it may involve the whole muscular coat,
çuueittly ha|)peti4 when the new growth aRects the pylorus.
ilomach ol'ten forms adhesions with the neighboring orj^ns and
r[.on die peritoneal surface miliary cancero»
STOMACH.
rouiuikh fuitcliea of tJi« same oatnre, and siirrowiiJed by a '
ailhosivc [icriioiiilis, arc i>rtcn fltou. Thcae ail licii ions, !T*t|wn
Mivc atid son II- ti m (.'a coiisistiu;; of ciincoroits tWuo, may arrvM ibvtrii
of tlio ulcération, in <k-pt1i. and jiri-vi-nt ttit- dischar^^o of iln-
U'utK iiilo t)i<> [ii-ritnnriil «inly. Soroctitnoii thi* siunwcb eontaintt
fluid, litit iiKidt t'rf<|iicnt1y it vonlains n thick, dark inatorial
cwffci> j:roiiii<U, wUidli i» ejected in the iu!t "f vomiting.
Tlio iyiiipli );liiTid« of tin.' Icnsor ciirvniurc art always altered.
Hocotxliiry »odul«e tire ofu-n lomul in t)ic iiL'i);)iboriDg organs.
VaUIKTIBS OKCARCIXOMAOFTlIlîSTtHIAfll. — KnetpiMlai-i '
always primary, at an« time prcs«nta tb« ap|>enmice nf a liiuit<
witb an irregular granulalin;; Hurface, cvortetl Itnrdcra conslituv
the bottom of the ulcer — by a soft, vascular, trhitiflh or [linkwJi
ricb in juice : ut anotbvr time it extend* over Uic greater part or cii
tbr whole of tlie nmcuus nti-Mibriino.
Hiiito1o]i;ical cxiitiiitmtioii HlL'>nfl, at in cvi-ry enrcinomatou* ttim^r. i
alveolar iitronia, i>iirroii»(liii^ ma»*c« of Inrgv Hat or lobular ci^i
varied tann («e« p. OtJ rt vr^.). Secondary noduloa in the tivcr («iBJ
very miickly in this variety of tumor.
7V/'t«.'/iVW<jf(> etirrinnint, or etirrittoma htrtnatodt», wbloh »i
rarii-ty of onccphaloid carctnamn, présenta in the Htoniacb large i^lib
tJons of the veMfU, and is reraarkablo for Ibe facility with vliick '
«ins «re altered and invaded by tlic neoplasm. In fact «ben the pflv !
toncal surface of tlic tumor is examined wc remark opposite the potinM i
of tbc ulcerated portion, lar<;e dilated vesMli^. We have seen l«ooi«i
in wliicb these veins were tillcil with a whitish jtiico, contaiaing etils '
aimil&r to tliow of the tumor, and numerou» small red points aad linfl
«hich were iiotbinj* elue than minute dilated vessels. TheM aiorie
vessels projected from the inner wall of the reins. This conditim of di
Teins extended as far as the portal vein. In one of these cases Ac
trunk and the hepatic branches of the portal vein were eatlrely filMbj
this singular vasculariscd new formation.
Primary tcirrhnut of the stomacti is more rare. Ercn secondary «if-
rhous is a rarity. I'bc tumor i:< haijler, nodtdated, tc«s rich in juice wl
less vascular than in encephnloid : but in itx ulceration, its propagi^
of nodules tu the periloncuni, to the glands, to the liver, to the paacnw-
etc., it entirely resembles the latler. It devclo^ts in the suboniootu <•»-
ncctive tissue.
<'-ill"id ciiranoma is not uncommon in the stomach. It is chancttr-
izcd by tlie j^latiniform appearance of the tisane of which it is eoatpoiev-
Many tumors which present a colloid aspect are far from being c»!*
linomala. for freijucntly cylindrical-celled epitbeliomata present a coH"'*
Detamorphosis.
Kpitheliomata. — Cylindrical-celled eiiithelioma is the moat commt^j
of all the primary tumon of the st(.>miich which formcriy were tenor
cancorous. It present* here thi- same nuked eye characters as encepha^
loid ciireinomn, and the name vxt^'usiuii, by secondary nodulcf, to Ui
liver and to tbo lymph gUnd:i of the lesser curvature, lis bvoritc scat
i
UTPERTROPUr or tUE Ml<8CULAR TISSUS.
477
* ' ■■ pyloriis, in tin? region of tlic mticoux gl""^*' Nothlnj; is more
r. lo ilcU'rtiiiiic ils nature liy ai<l of ilic inicrojtcope. l'|wm lliin,
KCtioM we find wide ilcpWBsions liavinn the j'i-iuthI form of till'
laiKla. nniJ lino! by ii cvlindriinl i-intlu'liiim. Tlir»' tiii'vit arc
rcgiilitr, loii;^cr niui wider timn IIkidc of tlie imicoiL* j;lnD'l>t.
11 preMiiit llic fi-riii of ciivitie», frvim the vmll of which )iit)-'illia
t;tr loops oovervcl with tlie nainc cyliiidriol epitlteliiim |)r»jc(il
ihf liimeti (»ee {>. IM et nf/.). Tliere h iio doubt tliAt tlicae lumora
:u»tc ill tlie luueous çlaïuU, but they pro;(resaivcly invade ihc deoiier
benenth the mucous membrane. Al the bordera of lh« ulcer Ibe
gtntwtB arc TOiicli p|oii;;aled, and there is a new fonnatiou of small
cells in the inlcr^flan-luinr connect iic tissue. The lymph ^^landa
lesser curruture havo alvrsya been involvud in the miaea which
ve wHii. They presented cavities bnvin;; a form tletcrmineil by
of thfl lymph oanala : these i-avities were everywhere lined by
lliiidrical e)>ilhctinm, nm) slioned villouiii growtb» 8pnn<;in^ from tliuir
■face, ftiid eovered by ihc wiine epithelinm.
Tie secondary nodules in t!w liver mid other or^^ns, «onietime» met
:. are nUn constituted by a tissue in vrltieli tubes, or itninll round or
ilrical uavitie», always lined willi tlic aauie kind of ei»tliclium arc
I Blomach the primary tumor often under^oe-t. in part or in toto,
! degeneration, so t!iat at finit Hi;^hl we nmy imagine that ne liave
itb » eolloiil carcinoma. The jioints which haves {•clattniform
fvnrance contain cells which iire round or of an intcrmoitiate thape
Dt«(-<'ii «pherical ftnd cyliiidriual. They arc tilled with a transparent
iMbeiUiice, and arc more or le»« dustroved. The cavities which tliefle
line have at the same time lost their cylindrical form and become
berical. Such tumors are recogniKi-d in cyliiniriciil-ccllod opiiiu'lio-
Inta by the structure of the parW of the primary growth wiiich have
|m* safiêred the above metaroorpliosia. or by tiie fact that the lymph
J^mU or the secondary nodules present the appearance of the typical
Parrmntt-celhd epithelioma is very rarely met with in the stomach.
It in al<ray« secomUry, and folloivs an opithclioma of the mouth, the
twj^, or «-itofih»;^!». In the observed cases the secondary foirnations
io ilie mucoun mumiirane of the utomach presented hiiitological character
liiMlar to lliose of tb« primary tumor.
UvpERTKOPiiï OFTIIK MtiscrrLAR TirifiUK. — We here dcacrilte this al-
Inution which is ordinarily camted hy chronic gnslrilis, because it acoom-
Kies almost every tumor of the stomach, and hecanse it had very oi\en
D mistaken for a tumor. In section tite ihickeued mii.sciiliir coat prc-
Bents a pale gray nçpect, is hard, semi- transparent, fle.-ihy. and permeutcfl
bï ihickenc-l. parallel lumellic of whitish conneeli/e tiwne. which com-
taniiicnte to it a honeycombod appearance. The hypertrophy may be
limited to tlic n«!iglibortiot)d of a cancerous mass, or it may extend more
L Or less throiii^hout iJic entire muscular tonic.
a few ulisf rve^l cases, • connidurable hypertrojdty of the muscles of
niacb, accompanied by nnrrowinj; of tti« pylonv Ote cause
STOMACB.
of di-ntli. The laaton may appear to be primarv, because at the i
neitlier » tumor nor an ulccraûon oï the aur£tce of tlie BtoOACh it (
It U probable that in such ca«09, it U alwaya cons>e«ati«» to i \
cftturrii, or «omtrtimc^ to a aimplf snmll ulcc-r which has heaM.
located at the pylorus, as is rrc<{UfitlI<r the case, it narrows th«i
and nil «nonnonit >lilutiitioii of the stomach may «luue.
Hypertrophy »f the mnsciilnr wall» of the sbcvnach may rcsahfn
oh^tnicùotu) and local irrilaiionn caiiHCil by foroign bodies.
Microscopic «xamitiation of t)ie muscular timxe of the titomacb, ii
of simple hypertrophy, shovrs the mu^icle libres thicker and
than normal. When the hyperirophy is in the nei;j;hborbooL) of a '
there ia a swcllin,; of the cell» of the connective U^auo inierpose-l !>«»«
the bundles of muscle fibres, and at ihe same time in some ntinh
lymph corpuscles are also to he found holwccn the cnnective tissue fib
The mnseic fibres themselves are hyjwrtrophied. There is an œdeo
and inHntnmatory swelling of the muscular tunics caused by tlie pr
of the tumor and the great vascularization of the part.
txsi nisToLoar op tqk lvtestlve.
479
FiK. ass.
CHAPTER IV.
IXTESTISE.
Sect I.~Normal Hiitology of Uie Intestine.
u. Intk;^ink.. — I'be scaall intestine ia «ompoaed ot several iayera
nbranes which Arc, front without inwanU: tlie )ieriloi)Puin. formed
cells and connective lisauc : two lajr«rg of smooth muac-lc, the
st4:nial lon;;itadinal, and the most internal circular or tniiiisvcrse;
e mucous membrane, h is the latter which we have especially to
er.
mucous membrane of the small intestine, contintioiij at the |i_vloru9
M of the stonutch, forms in tlie dneilemim tiiid jt-jiinuin the trauii-
lemilHiiar folds or mlvniic uonnivcntf*.
> mirfaee i« covered witlt villi which
) it a, velvety a]i|>earance. Thewc villi
[tremely numerous in the duodenum
jimam (ôO to ilO to the square line) ;
liioinish in number Id the ileum (40
). Throughout the whole extent of
nail intestine the mucous membrane
i» tubular glands or LiebcrkOhnian
IS, «hioh have .«ome rcitembtance to
of the HtoiMAch. Moreover, In the
portion of tlie duodenum, racemose
or glanda of lirunner, somewhat aind-
tbo salivary plands, arc found. In
in from one end of the small inlcAlïne
other, closed follicles arc met with;
lay be teolalod (solitary follicles) or
tied (Pcyer's patches).
connective tissue of tlie mucous mem-
is a reticulaW'd li^aue (Hi*), whether
ocalol in tlie |)aj>illi«, between the
, or in the deefier ti^iie. Thi.t con-
1 tissue is covered upon iUi surface,
ir it be of the villi or of the crvpta of
kflbn, bv a laver of flat endothelial >^''«-r.i.i»u.»«c.>b.i).»ph
Debore), upon which are implanted L.«p**ii».,i«*, if«».)
till;; evils, irhich are cvlin>incal e[^-
^f ^îvlmJrical vipîthclium which co' »^holo of tJie free
the mucous mcnil.iruttu vonAiat* tlljnilbcring
ihcT, eoiituinin^ Mil ovoid m hctr froo
1. TCoUiTDlKadlittavrrotn ulympli-
t^Hn ft. Ma*lat ihe lAlEtr h4t4 b<#i|
LLfrb*r)tùUii'< cl^nJ. «towhu iht
IKTKSTIXK.
Vil!. 2WI.
bonlor a ptnto of Blight tliickneHS dniJ vertically atriatel. Tkailes
cell», Koblct cells arc; met with from poiut w point. Tbe IstWr ele
which have bocn consiilercd m fat aosorbentâ, do not Appear to bare
otiior fiiiictioii thnn the nvcriMinn and (lischai^c of rnucus.
11l« iiitt'ctiiifll villi cnvrrcit l>v the eifithdtiiiD jiiDt deecribrd hfti
vartnlile Iciij^th. Tli«jr are IravcrAeil oy ■ raâcular network Prn
vapiilnr^' uiothcd contiuuuux, oii tha
HÎilc, with one, two, or three arterial
which [icnctrotr iho villuA, and mi
other, with 1 vein. The reliciilaleil
sue of the villiM n\m |M«i(eu«a
mnsole fil>i-es <liii)<0]ieil lotifjittidinkll^
aiithnrii describe «h^vh^rniti n
the villi — a tiinj^le central vcMel
long slender villi, and for the tliick
Mventl Ivmph rcaseU. which form ai
iDOHe« with each other. Ucbovi; dei
the existence of the cculntl lacml,
believcH that the 6ttt ondothelivm •i^
Rcrihcd a^ beloti;;in;{ to the IrniphattG i)
nothing else than the ondotheltal ivn*.
mctit of tile villus. The fatty panic
fiwt enter llie cylimlriol cell*, um»
into tho n^ticiilaliii i«j>iices of the tn-
uective linsuo of ihe viliuit. and dinice ire
collected anil trans pr>rted by the bctmU,
Un tlii^ account, tho villi «re the i>i«it
important agents of intestinal ab>WT|C)M>t
Oi well 11» from the fact that tlicy nmltiply t}ie abttorbin;; surface.
Tlte plaint* of lîniimi?r, sitn;itird mainly in the fin»t part of the it'-
doiiiiin, arc vory nuiiiiT"iw beiwwrn the pylorus aiid the nioutb <f tli^
diictiu c«iiiniuniH ch<ile>l>ii:hu:i, hut are much more rare ill tbe reM « tb
diiodeMiim. They are visible to the naked eye.
The tubular j;Iands or folUcles of l.ieberkUhn are found thmoslinul
tho whole of the amM intestine, and are iittiialed between the villi-
Thcy, as well aa the villi, are absent only at the points where tbe clt«d
Ctdliclcs are located, annrnd which points they form a corona, bo liat
the projection of the closed follicle is really a dopreasion below the Itnl
of the surface. Tliese tnbiilar glands are formoctof a Biiuplc eyliwlf»»!
tnhe, which is sometimes a little dilated at the inferior extremity. Tk.'
are inticli »hortcr and narrower than the tubidar glands of the stoiMck.
They do not appear to have a liistinct membrane ; only » «nglv enl*
t)i»lial layer Jt«|iamt«s them from the surrounding connective ti«ji»*'
The tuheit are lined by cylimlrlcal epilhelituu «imihir in tjial upon t^'*
villi, not always «o long, but often goblet-siiaped. Their fuitctioa is
aecrete muons.
The cloHod folliclea of the intestine are lymphoid gland* aiialogMis
tliose of the base of tlie tonj;ne and of the toDiiils. They oaiiaist
reticulated tissue inch>sing lymph corpusclca; they are imlaled aa
the jejiinutn, the ileum, and lar<;o intestine, or they are agnûnaied it»
NtcUoD »ra Tlllu'dt* nblill. High
pnBnr. (KlrUlitT.t
Ml
tf
J
KOftMAL HISTOLOGY 0? THE I^ÎTESTI^B.
481
li«8 which are situatc<l oppositu tlio nttnc^imont of tlie me8Ciitcry,and
■^»t«il in the lonstli of tlie intestine (I'ctlt's patclic^). The I'vycr's
Bfipear in the ileum uml arv ropcctallj well developed in its
»r end.
HoltUrv follicles reach the «iirfnoe of the intestine at a point
ïre there an, as a nile, neither tubular glands nor villi ; exceptionally,
rever, tJic iatler ouiy he preitent. Upon the surface of the' I'ejer'a
Bhes the villi and glands form a corona around each follicle. The
of the i!*<ilated follicles 'h spheroidal ; the follicles in the Peyer's
ttches are compressed against each other in such a nay that tlieir long
iaiuecer is vertical to the surface of the membrane. These follicles are
ell supplied with blood capillaries, and are scparaiod from the conuect-
tissiie of the mucouâ membrane by a condensation of the reticulat«d
lie, but tliey have no real envelopin;; inemhrnne.
The fatty particles and the Ilui<l« of tlie «niall intestine taken up
\tiw villi, arc first uclc<l upon by ihv reticulated tiMuc of the muuons
prg. U\.
^^yiiAir7tlw,r t^ttiun IjLroitp'I] titr « ad J iiE [l>0 t*ri>F?ift1E» TartiLiEiiriiilB | ins<i). a «.^Lftail nf Lla1>Vr-
B»**«U •unoiilidliLA bal nvE ti»Q4lnIta^ Ehflrirllkla*, Jll(£ Art idhu I1l4 Imrg* cffcruU v«n*U
BM*d wflh nUn. iOirptmtir.l
lemhrane and the cloned follicles, and are then emptied into tlio lymph-
tic «nuMM and vessels. The latter, indi-pondcntly of the laet*!als of the
Elli. form at the surface of the mucous memhnnu- ft superficial plexus.
Inch surround!* the tubular }:laiid^ and the follicles, and communicates
ilh tlie -liiiu* at the l)a.*i; rtf tht- follicle*, in wliich arise tlio lymph vc^.
M «hich perforate the muscular wall of tiie intestine in order to empty
no Uie subserous lymphatics. There exists, besides, a lymph ploxut
rith lar^e meahea, ai described by Auerbach, situated between the tco
31
4T4
STOUACll.
:li« excretory duct waa ftlmosl con)|>t«t«ly replnow] by connective tiiwti«.
(K'vr the Kf^^lcr [>art of the tumor i).e unainal ciils(-<!e-»ao of iIk* gUnds
w«re nearly norma). Only ftt tbe centre of the tumor were Ihcy xcnioe
and lese easilv distinguishod. L'nder a high magnifying nnwer, die villi
appeared to he covered by Bat cella. and to Iki fornica of «onnective
tiaeuc. containing between its fibres roimd embryonal coUa and fatty
granules. Tiic gland tubes wore seen to contain a few small cubical
cpitbttlini cells wbicb diJ not form n complete kycr. Tbc terminal ilila-
tatione of ibc glund» contained cells which furnished a complete tiniuf'
and wbicb were eoniciil, baving a thin wall nitli a donblo contour, aiuf
kclear or cloudy mncoiu contente. Tbc tiiviuc which iurroundcd the
'glands was ileiwc, and contained «laslio fibre*, connective ti««uo fihrett,
and Mtnall round cclU, and was pcroieated by nnraernuii blnoclvcAttclM.
The !iiibmiici>u!i tissue, which, a» ha.** been itAuUconflCJtuted ibe w hole pro-
minence of tlie new formation, was den.io and cloiiely felted, and penetmti^
bv arterial, venooa, and capillary ve»ieU filled with blood. It contained
efastic fibres and connective tissue fibre:', among which existed large iiutD^
bers of small, round, or slightly elongated cmbryonid colls. In addition
to these elements so arranged, there were iilso found groupa of small cells
in the midst of a ground substance uf small amount and of granular ap-
pearance— ii*lanils of embryonal tissue. At the depresMd centre of Uie
tumors, tlieir submucous ti^iue, so to Mpeak, reached l)ie surface, for, as
we have already seen, in this an i r1,. L^hmdnlar layer wa« in great part
atrophied and converted iut>> coum i i.r lissue.
In the musculnr tunic the biindlea of smooth muscle 6bre9 wok
separated by banda of fibrous tissue, between wbich were roand em._
bryoDai colls ; but these cells wore not met with in the interior of
buniltes of muscle fibres, which latter were in a nearly normal condilic
In the peritoneal connective tissue, we found the same new fonnstk
of cellular ttlements.
TKi» '.Tisi'. ill which the lesion was cliaractcriBcd by flat tumors re-
sembling fibrou.4 gummata develojied in tlic iiubmuvouïi conueclive tis«uc,
leaven no doubt of the nyphilitic nature of tbe neoplasm. U enables us
to understand and to acknowlclge at the aame time the ext»tencc, in the
Stomach, of ulcerations of the same kind.
In thi^ flame case, the lymph );land-i of the lesser curvature were ^erj
(large, white, and infiUraled with a, lactescent juice. The juice wl»ei
I freshly examined contained lymph corpuscles and swollen endoilicliall
cells, some in s state of fatty degeneration. Thin sections of these lymph
glands showed tbc lymph canals extrcmelv diluted and everywhere filled
with very large ami more or less spherical endothelial ci,-IIb. The n>ednl>
ilary tissue also presented these large cells in its meshes, l^ie
ptslterotion also existed, but in a leas pronounced degree, in tbe rcticnlal
tissue both of the fcillicli^ and follicular cordj, ami there was also a tcit
evident inflammatory thickening of the fibres constituting the rcticnlam.
Tbc bronchial gland» had undergone the same alteration, and the reten-
tion of the lymph, and the coii«e>picnt irritittion of the lymph ve^Ael;!,
wcro manifested by a chronic lymphangitirt of the superficial anil deep
lymphatics of the lung. This is one of the forms of cbrenic syphilitic
adcniti*-
L
CARClrtOUA OP TUB STOUACO.
476
Caxciîioua of TllE Stomacii. — Canceroua tumors of th« stoinitcli arv
rery common, and, however difTcTcnl in sinictura thrlr varicticg inuy Iw,
tlipy prvHcnt to the iiiikril eye miidi the »iuw ii«|)eol-,«iiil the *»uw )>n>^roi!«.
Encopiiiiloi<l varcinonui, for cxAwplc, cHiinot by tbe niikeil oyo ftlone hv
di»liiiiruUh«J from oyliitiirical cvlk-i) epithelioma, which i» vcr; cotumo».
The ilifTercnt variclicit of oaruiiiomn irhioh appear in the stomaoh, nuty
l>« ranked, according to their freipiency. in the fol!owin;( order : eiicejilia-
loii) i-arciaomn. fibrous or scirrhous carcinoma, colloid carvinoma, and
melanotic carcinoma. The almost cooAtant location of these tumo» is at
the pylonu, and the lesser curvature, and tiicy arc also ociaaionally found
at the cardiac end. They have a ^reat tctitcncy to extoiul upon the ad-
joining portion of the posterior trail ; niorv rurolv they advance upon the
anterior wall, and sometimud ihcy illvadl^ (lie whole ext4.'nt of the stomach.
Carcinomatous growths begin in the submucoiu* li«»uc, and in the glandular
layer of the elomnoh. L'])»ti a vertical «oction il t* «evn that Die glan>
duUr layer is tliictc<-ned. i^ slightly triinsparcnl, ami that the principal
inaas which oatiaea tlie jirDUiiueuve of the now ^^rowtli is funncii by the
layer of Huhmiicous connective ti«)rtiie. Kven in very sniall tumors, hy
scraping tlie surface with a scalpel ire obtain a milky Juice. Micro-
scopic examination of tliin seclioika through the morbid growth, prove»
that the submucous tissue already shows carcinomatous alveoli filled
with cells of a new formation, whilst the glandular layer exhibits its
glands much lengthened and filled with cylindrical or cubical cells.
Thti connective tisKue which separate» the glands contains a large num-
ber of embryonal cell." between it* fibn-s. From tlii» interglundular
embryonal tissue may grow prolongation.* which extend lieyond the neck
of (he glands in the form of papillary vegetations. This formation of
papillary vegetations is common to all new formations in th« mucous
membrane of the stomach.
In tho neighborhood of tbe cancer, the mucous membrane is iisiuilly
altered; itiared or violet, somciimea softened or mammiilated, and it
presents the indications of chronic inUammadon, frr<|ucntly witli intense
liigmentation. Small retention cvjts of the glands arc also often met
with. It is verj' rare to find the mucous membrane iu a bcaltliy condi-
tion around the canccrou« nmlule.
When tliere is uU-eralion. tbe ulcor is of variable eÎEc. If it îa seated
at the pylorus it may have the form of a ring. l"lcemtion mav
momentarily re-establish the coime of llie f<Mid which bad been arrested
by the contraction of the pyloric orifice. The edges of the ulcer are
olevatmi, and sometimes loosened. lU bottom is habitually fundus,
bloody, and covered with detritus ; or if the whole cancerous growth ia
nearly destroyed, the muscular tissue ie exposed or partly destroyed, or
tliere may even be a peri'onition.
Perforation U incomparably more rare in those tumors than in simple
ulcer. The muscular tunic adjuining and in the neighborbood of the
tumor is always hypertrophied. This hypertrophy may extend far be-
yond the location of the tumor, it nin.y involve the whole muscular coat,
as frcpivnlly happens when tbo new gn>wtb affects the pylorus.
Ulie stomach often forms adliesions with the neighboring organs and
surfaces. Upon the peritoneal surfiice miliary cancerous nodules, or
478
STOUAOn.
rouiutixh patches or the tume ntttiiri.', ami surrounded 1>y a prolîfonttîng
ftdtivsjve puritoiiitiif, aru often «ocn. Tin'**? ndlii-xionH, trt'-iiu'iilly excii-
nve nnd soDM-timr» cmisintinj; of L-niiccronit tiMut-, iiiiiy «rrrat tin- trxu-nfioii
of tlie ulceration, in deptli, and jirvvent tlio d'lMhargc of ilu- ptNtrii: con-
tenu) into llii! jKfntoneat Ciitiiy. Snini-tinx--! theatotnacliconUiti--* Iml liulv
Quia, but nioai frei]iiciitly it coiitains » thiolc, dark nwleriiil reriMiiblinjç
coflec ;;roimds. wliicli in ejocttd in the act of vomiting.
Tlic lymph glands of tlie Icssvr curviiture are atwaya altered. Fiaally,
secondary noduks arc often found in lli« neighboring organs.
A'^ltlETlBi' OF CakcISOMA OFTltK STOMArii. — Enrephttloid Cari^nnma,
filniiy» prinmry, «I one time prcsenW (he np|H-ar«uco of a limited \i\ckt
with an irref^ilar {granulating i^iurfnco, cvertetl borders conxtitutcd, tike
the bottom of the ulcer — by a jioft, va-^cular, whitish or ])iiikiMh ti»su«,
rich in juice ; at aiiollier time it extend» over the greater ]»rt or evun
tlie whnlv of the raucous membrane.
lliiiloloi^ical examination shows, as in every carcinomatonn tumor, au
alvenliir atroma, surrounding masHcs of large flat or globular cells of
varied form (sec p. ftl et ttq.). Secondary nodules in the lirer form
rerv ijuivkly in this variety of tumor.
TtlanijifcUHif ntrnnoTiut, or Mrrinoma hirmatotlfg^ which is only a
variety of eneephaloîd mrcinoma, pnrM'iiti^ in tlic stomach lar^- dilata-
tion)? of tlie vesstd», iiud i* remarkable for the fucîlity with which the
vein» are altered and iiivadeil by the neoplaiim. In fuet when the pi-ri-
toneal xurfacf of the minor i^ examined we reiuiirk opposite the poiilion
of the idceraled portion. large dilat«d vossoli-. We have seen two cases
in which these veins were filled with a whiùsh juice, cootaioinK cells,
aitnilar to those of the tumor, nod numerous small red points and lines
whiL-h were nothin;* else than minute dilated vessels. These minute
vessels projected from the inner wall of the veins. 1'his conilition of ibc
wins extended as far as the portal vein. In one of these cases tho
trunk and the hejiatie branches of the jwrial vein were entirely filled by
this sinjrular vawularixed new formation.
J*rimary teirrkuut of tlie stomach h more rare. Kven tiecondary scir-
rhous \â a rarity. The tumor is bai}ler, nodulated, leit» rich I» jutoe and
less vascular than in cncephaloid ; but in its ulceration, itn [«ropagation
of nodules to the peritoneum, to the glands, to the liver, to the pancreas,
etc., it euUrely resembles the latter. It develops in the sut>mucous con.
nective tissue.
Outlaid earcinnma is not uncommon in tiie stomach. It is character*
ind by the gclattnîform appearance of the tissue of whick it is vom|M)ecd.
Many tumors which present a colloid aspect arc far from bcin;; car-
cinomatn, for frequently eylindrical-ci'lled epitheliomata present a colloid
mctamoqjhosis.
Ki'iTiin.iDMATA. — Cyrmdrical-celle<l epithelioma is Um nMt comma
of all the primary tumors of the stomach which forraeriy were terme
oaneornus. It presents here the same naked eye characters as «nceplu
loid Riifcinoma, and the same extension, by secondary nodule.t, to tfa
liver and to tho lymph glands of the les^^er curvature. In favorite
UYi'EKTftOPUY OF TB8 ItUSCrLAR TE83UB.
177
»
U at the pyloruB, io ihc region of t!ttc mucoiu «lands. Nolhiu<: is more
«aojr tliAR to ilctvrmhic lU niitiin- liv aid of t)ic inîcrowopc. rp'>n tliin,
vertical «cctiutia tTij: fiml wiilv ilvprv^ioiis havii^ the jiencntl fonii of llie
iniicoiw glaitiU, ami liiivl bv a uylindriail ojiitU'liui». riiortc liiW.t are
ou}y \et» regular, l(>»;;er ami wuUit thnn thoM! of tlie uiuc^us jilamUi.
'ni«v oflon present (tw tmm of enviUi-*, from ifit «rali «f wliicti ]iii)ii1lœ
or vMoulnr loop* uov«rt^i] with the itanio cylindrical epilheliuni project
into th« lumen (aee |i. 1Ô4 et «r'ty.). There i» no ilmiht that these mmora
originaM in lh« mucous glaiiilH, hut thoy pro;'ro.')aivcly invade ihe dcofior
lfty«K lieneath the mucou-i meaihraue. At the borders of the ulfcr th«
mucouB clatuU aro much Alon;;3iic<l, an<l there is a nuir formation of aniill
round ««lis in the interglaiidular uonncctivo tissut-. The lymph ^landd
of the lesfior curvmure havo always been involved in the com» which
wi> have eevn. Tbey presented caviUes having a form ilct4>riniu«d \)y
that of the Ivmph oanals : thene cavities were everywhere lined by
oyliiblricnl epithelium, and showed viUous grontlu Hpriugiug from thuir
turl'ace, nud covered by the same epithelium.
'llie ftccoriilary nodules in tlie liver and other organs, sometimes met
vritli, are aUo constituted by a tissue in which tube*, or small ronml or
cylindrical cavitieii, always lined with the same kind of epithelium are
iml>cdded.
In the stomach the primary tumor often undergoes, in p«rt or in loto,
a colloid de;;eneralion, so tlmt at 6i-8t sight ite may imagine that wc have
to do with a colloid cancinuma. The poinu which havo a gclsliniforw
ap|n>ar)uioe ooittain cells which are round or of an intenncdlate shape
between spherical and cylindrical. Tlioy are filldl with a trauKixirent
aubstance, and are more or le** destroyed. The caviiie» which thej*e
celts line have at the same time lost their cylindrical form »ii<l become
spherical. Such tamors are recognised b-t cylindrical-celled epithrlio-
maia by the structure of the paru of the primary gronth which have
not siià'ercd the above melamorphonja, or by the fact that the lymph
glands or Ihe secondary nodulea present the appearance of the typical
tumor.
Pacemfftt-ceUed epitheUoma is very rarely met with in the stomach.
It U always secondary, and folloirs an cpithcliomn of the mouth, the
tongue, or icsophagus. In the observed cases the secondary formations
in the mucoii.i nivritiUrauc uf tlie stomach presented histological characters
similar to those of the primary tumor.
IIypkhtropiiv oi' THK MiiflciTi.AR TissuK. — We here describe this al-
teration which is ordinarily caused by chronic gastritis, because it accom-
panies almost every tumor of the stomach, and liccaii*e it las rery often
been misUilien lor a tumor. In section the tiiickeiied muscular eoiit pre-
sents a pale gray aspect, is hard, semi-transparent, fleshy, and j)ermi.-nted
by thickened, parallel lumell» of whitish conneetiyo tissue, which com-
municate to it a honeycombed appeiirance. The bvpertrophy nuiy be
limited to tlio neighUirhood of a ciinccrous mass, or it may esleud more
«r leas throu^iout the entire muscular tutdc.
In a few «liserved cases, n coiuii dp ruble hyptTtropby of the muscles of
the .tlomach, accompanied by narrowing of the pylorus, tuM bccu the caaae
4T8
STOMACH.
or di'ttth. The lesion mar appear to be primorv, bec*nse nt iHo autopsy
neîttivr n tumor nor nn ulcorat^ou of the surface of thv stomucli is fuutM.
It is proliaUe tbat in suuli cn*et, it is always consecutive to a f;Hstric
eatarrn, or sometimes t« n slmplo smtill iilc^r which hiui hi-ak-d. If it is
located at the pylonu, iis is fr«<)tii'iitly the cuse, it narrows tlic orifice
an(] an enormoiw dilatation of the «tomach may eiidue.
Hypertrophy of the mu.'tcular wallii of the Htoruach maj rewilt from
ob.tt met! 011)4 ami local irritations caused hy foreign bodies.
MicroNcopic examination of the inuictitar tiâ^ue of the alomacb, in caacR
of simple hypertrophy, shows the muatle libres thicker tnd mtich longer
tlian nonnal. When the byporlro|iliy is in the neiKhhorhoO'I of « tumor,
there is a swelling of the cells of the connective tissue interposed iictween
the liumllos of muscle fibres, and at the sunie time in some numbers,]
Ivmph corpU'^clc'i uro also to be found between the connective tissue fibres,
'i"he muscle fibres themselves are hypertrophied. There i« an œdemaious
ami intliinimatory swelling of the muiieuliir limic!» CAiitied by the prcwiDCO
of lliv tumor BU(1 the great vascularliution of the part.
KORMAL niSTOLOQT OF THE INTESTIMK.
479
CHAPTER IV.
INTKSTENK.
Sect. I.— Norm»! Histolojy of the Intertlne.
SuiLL IsTESTiXB. — The small intestine is composoil of several layers
«r tncmbrnncs which art-, from without inwards : tiie peritoncuto, foniKd
of flat cvHo ami comii-otive tiMuc; two layers of smooth muscle, the
iDMt exccrtinl loii^itiKliiial, an<l tho most inlcmal circular or trausrcrsc;
«till the miicoiis membrane. It is the lutter which wo have cs[>ecially to
OOORider.
The niucow» membrane of Uie ttraiil! int««tin«, conliniiou* at the (lylorug
with that of the atoranch, form.i in the diioiK-num and jitjuniim the tranit-
verse semilunar folds or valvuhu connivenle*,
and its surface ia covered wilh villi which P'k- SSf-
give t« it a vptvely sfipearance. These villi
are extremely numerous in the duoiienum
MkI jejunum (jiU to !tO to the square line) ;
they dimiuixh in numlier in the ileum (40
to 70). Throuj;hi>nt the whole extent of
Uie small Intoiitine the mucous memhmne
contains tuhular glands or l.ioberktlhnian
follicles, which have some resemblance to
those of the stomach. Moreover, in the
upper portion of the duodenum, racemose
{glands or glands of Brunner, somewhat simi-
tar to the salivary glands, are found. In
addition from one end of the small intestine
to the other, closed follicles are met with;
they may ho i»oliited (solitary follicles) or
agiuinated (I'eyer's patches).
The connective tis-tue of the miicou« mem-
brane is a reticulated ti.-i.iue (Ili^), whether
it ia located in the papilln;, hotweeu the
glands, or in the deeper tiisue. This con-
Dcctivc tissue is covered upon its surface,
whether it be of the villi or of the crypts of
LieberkUhn, by h layer of flat endotiielial
cells (Debovc), upon which arc implanted
the inTc«tiii^ cells, which are cylindrical epi-
thelia. The cylindricul epithelium which covers the whole of the free
surface of ttie mncou» membrane eonai:*ts of lon:^ cell» lau-rally adhering
to one another, containing an ovoid nucleus and presenting at their free
1. R«Ll(TaU(fl1lua*fToai kljupb.
■Ill «t Ihs r>bMi.ii<:h Ibii iirMrin tl
ipaih'*"» mil romniH* <«r Ui^ Ijmpli
ranitïT^kl Hniflrl.iltjr' ^- l-jupb vtt.
LWbdrhuUn'i fjAEiJ. «huwluu Ib4
■ DrrounilLDg ftldnlar tl-'inf', In the
0*I1b k. a. I.nmo» ot m t«4«*l, c
LyuutQ „f iheiflftatl, IFft^.t
480
IHT>STI»E.
vnri»
Pig. Siio.
border a p1at« of slight tliickoefia find veriicxllj' .itriatcd. Btfsiilea these
colls, ;;oblet cells are met with from point to point, 'fiie latter elemenu,
vhivli have bo«n consi Jcrcti as fat absorbentâ, <lo not afi|ie&r to have any
oUiLT function than thu secretion and diâchar^e of luucua.
Till* ititvi^tinul villi covered by tlic cbitlieJiuin just dc»;nbod bavo a
riablu Irn^th. Thi'j are traversed ay a vascular network forinin<;
capillary mushes coutinuotui, on the one
»ide, with one, two, ur tlircc arterioles,
wliioli [>un<'truto tlie villus, and on the
other, with a voin. The rt-ticulnted tia-
euu 0Î the villus alM poasesoe* smooth
miiHcle fibre>dis)>cifloi] longitudinally. All
Bulbors ileiicnhc ehyliferoiifl veawU, in
the villi — ^a sin^tle central vessel for the
long nloiidc-r villi, aivi for the thick villi
soveral Wm(ih vcsttek, which form anasto-
modca with eacli otlior. Itehove deiues
the existence of the central l!i<!leal, au.l
believes Uiat the 6at cndotlii^liiiin ■!«•
scribed a« bcloi));in;; to the lyniptiatiu is
notliin^ else than the endolbrltal invest-
nietit of the ritUis. The fatty parucloi
fiMt enter the cylindrical ct'lU, tlicn jiaM
inlfl thi^ reticiilau-d :i{Hice!( of the eoti*
nective tisftue of the vilius, and thence are
collected and transponed by ibe lactcals.
On this account, tne villi »r« the Dioet
important aj^nts of intestinal absorption.
as wdl ns from the fact tliat they multiply the absorbing surface. ^
The ;;landt( of Brunnur, sit»at«il mainly in the first part of (he duo^^H
dcnuin, an: very nuiiivn>ii.-> betwei?n the pylorus and the mouth of tbt^^l
ductnit coiiiniiiiii.'t cholcdot^hii», hut are much more rare iit the rost of tbe
duodenum. They arc vi^tihle Ut the naked oye.
The ttibular glaodit or follicle:! of LieberkUhn are found tliroa^thont
the whole of the small intestine, and are situated between the villi^^H
They, m welt as the villi, are absent only at the pointa where the elosedl^^|
&lliclcs are located, around which points tliev form a corooa, so that
the proJecdoD of the closed follicle is really a depression helow the hsvel
of tiic surface. Those tubular ••lands are formed of a simple cylindrkil
tube, which is sometimes a little dilated at the inferior extremity. They
are much shorter and narrower than the tubular glands of the stomach.
Tliey do not appear to have a distinct membrane ; only u single cndi
tliclial layer separate* them from the surrounding coDneotivv tisSMiil
Tlic tubes are lin^d by cylindrical epithelium «iniilfir to lliat upon the
villi, «ol always »•> loiij;, but often gnhlet-sliaped. Tlieir function is lo
secrete muous.
ThL' closed follicles of the intestine are lymphoid gland* analogous ta
thoito of the base of the tongue and of tlie bon«lfl. They oouust
reticulated tisiue incloiinj; lymph eoq)U8clca : ihcy are isolated as i
tlic jejunum, tlie ileum, and largo intestine, or they are agmiaated i
tf*<l1<ll(rfkTltliIiariin>hUI. Illfb
INWt*. (Wrrntir.)
XORHAL tllSTOLOOT OV TDB IXTBSTIXE.
4»!
4
paiclieii wliioh are siluated opposite the attAcliroent nf the mef)entcrj',an'l
elonj^aleil in the lenKlh of Uie intestiue (Fejers paiches). The I'eyer's
iiaichea appear in the ileum and arc eapeciaDy well dereltped in ita
ower end.
The solitary follicles reach lh« ftnrface of the intestine at a point
where there are. a^ a riitc, neither tuhnUr ••lanrU ii'ir villi : exceptionally,
however, the lutler niny be preweiit, I'pon tlic Biirfiicc of the I'eyer's
Mtches the villi nnd glnii(I« form a corona around each rullicle. Tho
form of the im>late<) follicle Î* spheroidal; the foUiclei in the Peyer's
patches arc compressed njininsl each otlier in such a way tJiat tli«ir long
diameter \* vertieul to the stirfnce of the membrane. Those follicles are
welt supplied with blood capillaries, and are separated from the conneot-
ive tJi<-'<iic of the mucous membrane by a eon'lensation of llie reticulated
tiasue. but they liave no real enveloping membrane.
The fatty particlea arul tlie fluids of the small intestine taken up
hy the villi, are first acted upon by the reticulated tiasoe of the mucous
I
k
I
IVrf [uîlrslir ii'ci: irj Kirnm^Jk [hi' mil nf [Im priiri'-"»!!* ï/*rmiri*rml" immij, ii li Iaul] vT Lli?^"r-
—*t nmtit •nnDVniUnt bnt uol pvnairtilg^ Itai falllElvn. AI d >!• «hb tha !«'(« «■«Ptot 'TraMli
r-«'M*d>tlk nl»>. lOirpmttr.i
membrane and the closed follicles, and arc then emptied into the lymph,
atic Eiouscs and vessels. The latter, independently of the lacteaU of the
rillt, form at the surface of the mucous membrane a superRcial plexus,
which surrounds the tubular ;;land« and tho follicles, and communicates
with the *inus at the ba*c of the follicli?*. in which arise tho lymph ves-
si^bt which pi-rforatc tht- musculnr wall of the intestine in or.ler to empty
intrt the !»ub*en)m lyiiiphittici. There exists, besides, a lymph plexus
witli larice meshen, at described by Auerbach, situated between the two
31
ISTK9TIÎIB.
iniuculnr la}-«ra. The anburons Ijrniphatics subaetiucntly pass between
tli« two Ixvcrs of t}ie meacntery at ita actachmont to tliv iiituiùiic.
Tlie bloodvesaelfl form in the mucous membrane very rich vnpillnry
netit'orka, in the villi, around the tubular ;;Umifl, and in the cIomH ToMicW.
The muscle librei tiw «upiiliiit by
Kit:. 2(K.
Tvu Istntlul lUll BiculliJ. lOnty.)
enpillArieit forming a picxu» witli
i-longot«il m«itli«».
T)iv norveit which come frum
iht- [iiieumui^iistriv arnl great sym-
putJi«iic forai two plexuses in tlie
inl«iu'uio : the firiit, iliscovcnid by
Iteroak and Meissner, awi situalei)
ill the aobmucoHB eomievtivv tisMe,
iâ formed of jjai>};lia a»d palv nerve
fibr«8 vhicli arv distribtited to the
smooth muscK-s of tliu villi kbd
mucous membrane; tlie «ocond,
(liscovtTcii by AuerbacU, i» foitml
between the two layer» of muselé
film-!». It aUo I» fonuenl of gan-
'flie lutt«r arc ilii)ti-ihut«d to tlie iwighlforiiig
|[lia awl smooth fibres,
mitiicle».
1» ltd general plan of oouM ruction, tlic larfff tntetttnê differs little
from the small inteaUne.
In mAi), ttic mucous membrane îâ fumi.slied neither ivilli rilll n»r
I'eyer's patches. The elostd follicles are Ic^s numeroiiH, if wc except
the ileo-accal appendix, which is very rich in theitc follicles.
Tubular glamU or follicles of Licberlitihn arc to bv foiinil over the^
wliolo surface of the larjii! inti:-«ti»e, and their «tntcturc here is the sam^^^l
as already described. They are only a little bwgftr tba» in oUior por.^
tiona of the intestinal caiuil.
Beneath tin- layer of tubular glands, llio connective tissue of the
mucouH membrane more resembles ordinary loose eonnociive tissue than
reiieulated tissue, and shows a layer «f muscular libres. This muscnlar
layer, which exista here as in Ibe small intestine, is placed iiuincdiatrly
below tlio tubular glands. The inner third of the solitary follicles is
intcninl to the plane of this muscular layer; die outer two-tliints is
extenial to it.
The solitary
small iiitentiue,
follicles, lesi> numerous, but larger tliftn tbosv of tlie
art- placed in a layer external to that of tlic tabular
glands. The layer of tubular glands is wanting at the position of tite
cloised follicles. There conM-i|ucntly result» a di^pression of the mucous
membrane corresponding to the scat of one of tht-se fullicW.
The Ivmph vessels of the large inlvi<tin^- are far from being as abo
dont as m the smnll intestine.
The bloodve^eU and the nerves present the same general dispositioo
as in the umall intestine.
Tlie mucous membrane of the large intestine is directly continaoas,
at the lower part of the rectum, with the mucous membrane of the auu*,
INTESTINAL CATARRH.
I wliicli lMl«r, in il* "inTeadneiit «f pav^mont epitlielium biw) iU pnpillic, is
niJ> lA tlir> itkiD, The aiial mucous Ri«mliniiM posMiMfls aebac«0(i«
i'lut no liaini.
^
Sect n.- Patttologictl Hiitelog? of the Inteitlne.
Po6T>HDliTRM ciiAX<iBS Are aUajs met with in the intestine. In the
maioriiy of cbsm tin: iduooi» iDciiibrnnc is pnle. unil Îh coverc<l \>y a
thick Uror of opMijuo mucuM wliich cnn bv rcmovcil by scnipinj;. Tiiis
DMHHU is n pr<xluct of cadnrcric ilcoomponition. The ccll« bci'onte <lii-
tsch«d an:l oiixi'^l utth the miionA which »t the moment of Henth norm.ill;
OxiMU At the «urfiive 'if the m«nihrane. Ttii^ fluid h ii>ora nh«uiihint in
tli4»c pari» of tii« inteoUne where the surface U multiplied 1>^ tlte villi,
tliAt i», in the mhaII int«(itiiio.
The follicleti of l.ieboi-kiihn Are htibitii»1ly altorcil; their colU gciw-
ntllj have beooine detached from the su[ici-tit:iui part of the gland, thi»
oauniiij; the latter to Appear shorter than it is in reulitjr.
Th« connective tiMue itself is softened, and there is often a «juitc
a<lvanced digeittion of it, especisllv in ohildren who die of diarrltoea.
Sometimes we meet with perforations, purely and simply post-mortem.
In thcM, neither the thinned nm) [lartiiilly dostroyed {>ortion, nor t)io
adjoinin-; p)trt« offeni a rcdiiesM or iiitliimmatory infiltration of the con-
neelive tissue.
When the vcâteU are full of hlood at tli« moment fif ilentU, thoy nf^-^n
preitcnl a brown «r alate color. I'he cochyinoacs and tlie couge«tJona
which aocooapaiiy ulcerations also show this change of color.
CoxBEjiTlox. — Congestion is present in all inflammatory and other
affectiona of the intestine, as well as in the case of stasis of the Wood in
the portal vein. It is characterized by a more or less abundant secre-
tion of altereil intestinal fluid, the composition and the cburactem of
which wilt be described à pr-tpitg of intestinal catarrh, and by a redness
of the nucous membrane which remains after drath. On Account of the
action of the tntestiiui) jnice, tbi>< color iii itomotime^ brown or slate color;
but it is pa**\hh that thr chnii^ of color may be altogelber posl-inortem.
When cotige-*led [xiim* an! ex.-imin4>d under the tnicrowope, the capillaries
of tht^ villi .ire nceii lo l>e full of Mooil, which ii« not tlie cane normally,
and the -tniH^rficiiil eapillarieii which describe meiilies «round the tnlwa
ami orificea of the iilamU are aluo filled. At the ptiints where the
mucous membrane is slate color, the villi, deprived of their epithelium, as
tliey alwavs are twenty-tour hours after death, show a larjje i|U»iility of
brown and lilack pi^jmeiit ^raiiulca. Tliis lesion i^ couatant in intense con-
gestions of tbo small intestine which have continued tor a conaidorahle tjnio.
Ixfta muatiox of tub Mwoi* ^Ikmiikaxe ; Ixtestinai. Catarkh. —
Catarrh or superficial inflammation of t!ttc mucous membrane, aeuociated
with an exA^:^crated secrvtion, is very common in the intestine. A
numl>er of different causes may pn>d)iee it, and the <|uality as well as the
quanuty of fluid varies in diilcrvut ca«e«.
I
4IU
IKTESTISB.
Fargntivea generally exdte a local irritation of tlic intestinal mncous
membraiw, whether they are adminiflleroil by tho mouth, the rootuin, or
rcocli the intcstino throii;;h the lilnod circulation. When thv mucous
inemhniiK.- «f the intestine of animals, under the influence of purgatircfl.
i» examitic'l, it ih found coii^e!>tt-d. and covered by a muvns moro abun-
dant thiiii iiornml. rich in lymph corpuscle», and contwniog also MOH
cj'lindricHl coll» with clour am) vesicular iiuelci.
It U poiMiblc aUn thnl cvrinîn dinrrliuiiu may b« due to exaggerated
perifltaltie movenietitf, which interfore with abtorptimi of tli« int«st4n«l
Said b; causing it to [irogreaa too rapidly in iti pa9U^ downwards.
Pic.S63.
- C
y
^ -x-^ r
-/■C--
Dlinrui of k pirpvKlicaUf ■riilvn at a Tdlnn >» ■ MMaC aaut* 4liink<H. >b*i>ti« iMaMNHaaM
«f Ih* KUbuiarua* Iir^t. Xi^'^ A. Miimna iii«nbnoe: », Folll'lnut l.libttkckn r«>b(4 «pan
by ibfr awanDvf iiiiw oldntbni* in ihn «itvpirM ituuv- a. Mutcl^af brflifka i\ vnbrvthBBou an-
aarUt* II»bi. D, A •hibII aiuiy. K. A •niiU tsin aiLrruanrleiJ bi a •■arm uf IjBfAild i-UmaU.
V- Afi«14^nlal raalA la tbi MpIltPii. (Fmid a i^bnttvEulDrq^raph l>]r tturiffHb J J^ Vp'na>l«ar4^ e I'
Ami- C<i)-I''<l ('OU <>>■ kKUUd médical <uisiu*gl tb* Utdlcal aD4 «urnltai aiMMj at ika Wual
Uia KabtllUB.)
A. MorcftH, after having placed two li^^turca around a Wp of intes-
tine in a dog, e»t ihe nerves supplyin;; thin portion of the gut. aul
observed the included portirtn of inie»line fdl up \Nith an nbnndant fluid.
This Huid, which Mareau at fir^l thought to be [)h y it illogical in(e»tiiiâl
juice, différa essentially from the latter; it contains much le«» oi^aie
matter, whil.<<t, on the contrary, it fluspendo lar;^e numbers of lymph oor
pngclea. It i» not normal inteaiinal juice, but h the secretion from a
icry ÎTiiense catarrh, lïy its dp. gr., by the tiuantity of organic matter
and 3altB vhich it contains, it very much rascmbies the fluid of the dtar-
I
rliœii of cUolcra. I« lliiit catarrh due solely to the nection of the iwrves,
or i» it c«tuw;<l tiy the wounding of tlie tneMiiler^ aii<l Ibe intostino?
TliU problem doe» not ap|icar to \is to be satiisractorily aoked.
tl ii easy to excite more intense or purulent catarrhs in animak hv
tlie injection of irritante iolo the rectum. In kittens thus injected witli
a weak solution of nitrate of ailvor or tincture of ioJino, the large intes-
tine waa filled with pus at the «nd of twenty-four or thirty-six houni,
I yet wo found the cylindrical epithelium in position. In somo 8pot« most
of thfl evlindrical cells which covered the villi and lined the jçUnds
were f*ol>lct-slia{>cd. Neither endogenou« formation nor division of
nuclei wn« objerved in them. It \» probable, therefore, that ail Ibe
lymphoid eelU of the purulent secretion had escaped from the vessels
and pasiied throngli the epiilielial layer. The.te lymphoid cells were
numerous in the superficial connective tiisue of the mucous membrane.
In man, the had quality of food, the abuae of fmita, or the non-
sppropnation of aliment, tiie iuHuenco of cold, errors of diet, indigoa-
Vig. StM.
Hlavta HfeUbla foriDi (ron DtrBitl TflMa. XIMi). a. Sr>b*nMl*l«n«aU(iitittnc4»ai). >. Rat.
Uli* hoilif ibudtrlal. r, I'Uhidi'IiUt'xiiihjhiI at doili Ilia liimtMag. d. TuroU-llka lalla. (I'fiiD
• p1iotfru^m>0i«i>A ^r ^UTV"»» J J- W«04]viird. V.f, Amv, C>i|>ltd from th4tr»tai]iii*4lJa«l vuluuu
«f Ik* ll*4l<al ud tturgtui Uliwrj «I lb> Wkr of lb* IUbaUli>a.|
' tion, «t«., «re the mo«t fri'^uent causes of oimplc catarrhftl ^arrliooa.
Inferior organisms (bacteria, etc.) are often found iu tlie feces in largo
IKTBSTINS.
nuiiiWrâ, anil Uiej frer|tioiiUy oxifit in the Htonlii phj Biologically. In t)i«
dtflerent caéi«a the tiutii diiwharjie 'n wat«r;, U colored vellow or brown
br the hile, Aitd conuina Buid fecal matter. In this fluid a very small
number of cylindrical colU is suapcnded.
In suppurative peritonitis, and especially in pucr])eral fever, tli* small
intestine xurmundcd by the peritoneal c-xudation is whiu'ucd; it ha» a
cluuily ur milky asp«-t. The mucous uiciiibrane is nlijitsh ami opa-pii':
it apjicars to be «nuked with pu», an<l it i» covered by a thin layer (vf
purilurin fluid. Wu have U> do here with a [lurulcnt catarrh ucckAioucd
by continuity of *trucUir«.
In a «ucee^ion of chronic catarrhs of the intestine, fxirticnUHy the
large intestine, there a snmetimea formed around the hardened substances
(feoal matters, scyhaK > which irritate the intestine, a layer of transpar
MMoifluid mucus : at other times, these matters are invested by a laye
of purifonn mucus. The more or lees tenacious mucus, in the form of
false membranes and long filaments, in these cases, may, at first sight bo
mistaken for fra^onti! of mucous membrane or for nanisites. Tiila
transparent or opK({uc mucus always contains many cylindrical cells, aij
well usa variable number of lymph «orpucle». In tlie«e forms of chronic
catarrh the abundance of the fluid secreted Î8 not always pro]>orl(onalAl
lo tlie irritation «f the niucon* nienihrane.
ï>iuiiile ciitarrh of the mucouK membrane ii rarely accomiMuiie^l «rca
by superficial ulcerations.
In chronic catarrh of the intestine, we observe another series of alter-
LKliona which cont^isi in lesions of the tubular <;laiid3, which may be atro-j
' pUiod or hypertniphicd, or present the appearanec nf mucous eysts, as ifcj
the stomach. The ;;lands are markedly hyjwrtruphic^l in portions of UmJ
roucou.'< uierohrano, where, under the intluenec of an intense irritation i
the conneelive tissue, villous prolongation» «prin>; up between tite ^huxU-
In tlic large intestine, for example, where villi iln not normally exi»t, we
see, in the chronic catarrh of infants, ve;^talious of the inter^laiulubr
L connective tissue. Here, as in the stomach, increase in the Icn^tli
Pthe glands is brought about by development of the connective lissH
which surrounds them. The portions of the mucous membrane tba
thickened at one point may form an elevation, which later may tiecaoH^
pedunculated. Thus are produced those papillary glandular polypi so
freciuont in children, which sometimes become the starting-point of an ii
vaf;inutio«. The luncous contents of those glands which arc dilated an
cystic have given rise to the name fur tiiesc small tumoni, of
polypi.
Catarrhal inflammation of the inleiiiinc has received different names,
according to the location of the morbid process, such ai duodenitis, in*
flammaiion of the ileum, typhlitis, colitis, and proctitis or iuSammatioB
of the rectum.
Simple or catarrhal iluottcHÏtig has rarely been seen independently . The
flwclling of the mucous membrane of the second fiortion of tJie duodenum,
and in particular of the ampulla of Vater, causes the closing; of the
canal of Wintung, which connects the ductus communis cboledocnus trilh
ISPLAMUAT[o:< or THE ILEU».
th« internal surTnce «f tlio intestine, Mtil occAsiotiH retention of biW atul
iolerua ad n coiuci|uenco.
In iUiti», or inflaiDDUttion or tlic lower end of the sninll intvittine,
besidea the common anatomicil «igns of cAtarrhal inflaminntion, we
slninâl onnstantly observe » ttiinef»clion of the cWei) follicles, botli
thfi soliurv and those of I'ever'm giatcheii. This Icsiou is «specially
narkvJ in cholera, in t^-phoid fever, and in lb« infocttoiu maladies, in
F>a. 2-:;..
.^^.-s
liU(nB ol t ptriiMiilIrBlH •tftlna ol ibP limn, ibnirlag «iiIi>ik<mI ■oliiaij ti*nà, lui (Heur
«cvt« iUTTbsa- X^- '^- Uufvit* oiDiitlfnDff, «Uui^inj llin folliel'v uf LielxfMûhn, rt, ;>qkh^ apart
bf Ika alHi^onaal (ovlb ot aAniiotil lli>u*- H. MqqrU of BrucW*- C, SubmafDnairoBaffftLTtllataa,
aWwinc •rtlloai at kloodit4irl>. a> al (. aid tiaté arrldcDul rMil>. a> al t, t>. CItraUr lajroTOf
alin iBiitfnIar roatof fb* ralakltaa. B, LadNtlndUiak la^vr. f- ^iil-parlbjaaal rotipacilv* ll«aPa' 0-
l*arllaafajii. B. BalatiT* «bliurT «land. Th* wll>af ib» atriitidiuni. a-ii-DnM tlituc asil HilSiarr
Hlanl la Ibl' Jim rain arsninrli «itx^rralrJ U iIMi auil il eiana por.»|ii>uiJliitI; (iw la nniiili*!.
iVnm ■ pboio Dili-r^jcnph b^ KurKwu J. J. WaiKtirar<l. r.H. JLFmjr. Cipl'd Inm iha xcouil ni)4lcal
nlnMof UaMadltal aad Earcisal Bliiorf »( Ui* Watef tb* Kaballiaa.)
the exanthemata, puerperal fcrer.ctc. The isolated folliclea, which nor.
Dially do not form a ocnxible relief, project upon the tturface as little
round grains; thcv arc more than twice their normal size, their surface
ia pale, and thrir sc-cUon presents a gray or pinkish mo mi -transparent
upect. Hxainitiin^ oiiv of these little clevaliDiu iiiulnr u low aini^iiif^-
ing power, we see tii»l it in «orered, except at tin- apex, l.y the rilli and
the glands of the mucou« membrane. The hypertniphy of the follicle ia
due to the dtsteniiion of îu relteiilated meahea by lymph cor;>ii«clK8.
Kr scraping tlie cut nurface, we often find swollen granular eiidoUiclisl
cetla with two or more nuclei.
This tumefaction of the isolated folliclea, which is aeon in most diar<
hosaa, is more risiUe at the end of the ileum than in other jforlions of
488 ^^^W IXTS8TTXS. 1
UiL' inti-«tinc. Wcitune tli<-sp rollicles are gencrallv more numerous h«re;
but it i* obitervc^ uvvvnliek-«« tlirou^'hout tlic whole iatcatinal canal, iiti
ti\e litrs^o as wvll im in l)io RinuU inU'stmc. Wliorc tlio onlargemont oU
I'cyi'r's fintclios ti? rt-rv mnrkoil, ft» in ftiiltiirn, tin- liv|frtri>i)liK-<i folUclen
nmy end in tikcrniioti. Wo will ifimly nloi-nittvi- intliiminiitiouti of th^
follicIi-M iitidtrr typhoid T^wr, uni cosoous iIcgOTivmtion uitilcr iutMtinal
tuberculosis.
TtfphUtia and Peritfijililitit. — TjplditH ii« nn inflanimation of tbe
rcnutfonn appebilix. Wlieo it is Uiteni^c it is aa oflen accomjiianit'd liy
nn inflnminaiion or llie iieisLborin;; («riloneuni that the two iiitlnniin
tiwiB have ;;fiiera!ly been describod together. No oilier )«rt of tlie
t<s'iiinl canal is more diHjioscil to loilgmcnt of fecal matter or forel;^
bodies, a ciix-uniKtiiiicu wliiuh ex|>]Ain8 tlto fnxiucacy of intUtuinatory
legions of tliia appendix.
When these forvi;;» bodies remain a certain time. Ibcj nro babitualli
covered by a coat of tripb- plioftj'bntcs, and lire convcrtt-d into sml
cnkidi. Wlivtiicr till" a|'|<endix in iiiHiiniod apoutaiicoiuly, or. b« is mo
ODinmon, t!ie inflnnimution in exeit«il by the prc8«nee of tliew; forvign bodic
tli«niucou» membrane flecr«teA n fmrirormor mucomtHuid; it is Ibickvne
more or lesa conjiestcd, and the thick layer of closed follicles, nbich it'
poaa«88es, présenta uiceration^. The entire ap)<eiidix ia distvndetl and
mucb more voltuninous than in the normal slate. The infiltration and
tliickcnin;; of the muous membrane prevent the contraction of the raiu-
rculftr coat, snd render it« einptyiti<! or chaiiiie of position impoeaibtef
Since the inflammation of tbc nmcoiu membrane very often i« propagat
to the »«roii» siirracv. the c«n;teiited peritniivum beconw» covoreil with a
tbin layer of fibrin which itt penetrated by v<r:tselit, newly formed cmiiwc-
tive tissue re^iults, and the iuunobilined appendix forms adbesioiu with
tlie parts ndjoiiiinij;.
Thin peritonitis ia usnally not grave, but is from tbe comtnencienMi
limited and adhesive. Most frerpienlty the appendix is bound down to
the ctecum, when there is a resulting; atrophy. At other timed il is
[ united to the ulerns. to tho bladder, or to the ab-iominal wall.
An nicer startin;; in the mucous membrane may penetrate the other
coatâ, and extend into the îtillammutory tiHsnc which forms th« adhenonSrl
It is thiu that iliac ab«ci-«se« are »ometinK-s funned. So also GstuW may
be established, which m.iy or may not comninnieate with the caecum.
Infianimation of the tarj;o intestine IS rarely observeil in îla wholtj
length. It moiil fr*niieiilly originates at Ibe «igmoid flexure or in th»
rcctHm. I'roctitiH or inflammation of the rectum ia primary in aporadie
or epidemic dysentery, and is ttien accompanied by ulceration. It ofWikj
follows liiRUiorrhoids ( ha^morrhoidal catarrhal tinx), foreign bodi>
arreaterf in the folds of the mucons membrane, syphilitic disease of
anus or rectum, fistula in ano, mucous patches, nleeratious of icrtiar^l
svpbilis. In cased of cancer of tbe uterus, even when iho walls of
rvotum are not invaded by the neoplasm. tJicrc is usually an inflammi-'
tion of the neighboring part» which excites an intense catarrh of tk«
mucous membrane of the rectum.
ACCTE DTBBSTBilY.
480
DrsKVTimr. — D;rMntcry is m ulcerntive infl«ma»tion of th« Inrf^e in-
tMlin«. Im favorite scat U (ho wctiini ntxl ^i;;moiil fl<'xiirc. When it
is very iitlen^r the Wnioii» fi»coii<) nml *iirt;i»'l Uiixiiiiçhoul the large Jnlcs-
lini'. Tlic varicti^!» of this «ITovtiaii ilo not differ mucli aimloiuieall}' ; ibey
luuiiilj vnrv in their vouric and ititcwaitj.
ArcTK DvsKNTKRV. — In the mild form of acute dysenterjr th« sur-
face of ilie niiicouA membrane h very red and much coDg«st«d, tuA there
»re small <NM;bymos«a. The lesion wliicli exists throughout the »thol«
extent of the rectiim nnd the ncij^hborin;; paroi of the sigmoid Hcxurc,
is )Ar(icutariy marked upon the salient fohU of the mucous membrane.
I'he mucous membrane is thickened, and the lymph follicles fonn arsliof
it-:. . ■ .
I
th> i|U*<li> «< UtbMkihB pU'kad *|4ri Yy ibaiwuni at Ifnivbuld «lia Ib lb* idcuolil Uxor- U.
Mntr^sar HrAtX*. C- Submaola* ^aaiwirllT* Il»]i4. wllh «tim*n>it» Ijrmphotd «l"iwa1i Df4r ihp
iiwili II r Bfill**. >n Iti* wolrcof Iha pl*n |l>alv<4ii ll lad Dl l> au noImt^Hl uliUir IViItlrli. In
«bl«h **T«nl ejMta lurmt «rfr^T. Tba *ia<h1(t Q^aiin Jitftt litlttw III* «nUriitv^ f land Uh lfiiï|»h
•IM* (rn>a * i')ui>|j>-n>l(nHinpb by Xairou J. J. Wniidiraril. D, ■ AriDf. fovlail fntia Ib«*c««ili4
l(*4lc>l t*lua» of Ibe MMiral ■nil Sunlal IlltUrT of ih« Waro( Ibc Kcbrlllgu.)
Upon the surface. It U covered by « stisht mucous exudation which
ratemhles the white of an eg^, or is nurifonn in Hfmts : tliiâ mucous i»
nsaally streaked nith blood, or colored uuifonnly re<l by the latter fluid.
This exti'lntion in frci|Ueiillv passed in the stools aecompanicd by tene.-raua
and bunuug of the anus; it constitutes the characteristic sign of dysen-
4fl0
INTBSTIKB.
tery. At the end of a few day» sinall vertical walled ulc«rs alreidv
exist, or tliere are irregular aud shallow tosses of substance. These
losses of flul)atance are tilled with a IniDapnrent or cloudj; inucii^, «nd
have the appcaranco of bein;; deeper than thcjr really arc, by reason of
the f^niniilntioti and thickeniii;; of the surroitndinj:; mucon» nivrobranc.
ThCâi! Ifsions arc very limited in the simple form of dysentery. Micm-
■copie oxa mi nation of the snollvn portions of tbo niuootu membrane
shows thi> following conditions: —
lit. In the ^landtilar layer the turgid vcwel» are «Mrrouwled by con-
MCtire tissue, iiifillnnied with lymph corpuMloa, and the iuI«rglait<luUr
Pig. 2«7.
\
*^/
\
' «■•• at iftraurj. X '*^' ^* UHrlj glrvnUr <(m*I i« iba Itti »a balow iba muta tt Iht
ftiiU toaaoiftll ti**tj. Tin Unc*t allipilcal tatm u th* lUhi It • <*lii ftrrttl aaalltr mad»
at* tat WMu IS oik-r pan* of itii- a«l<]. Th< «>BMa-ilt> iliauK ibnvtliuiii l> Is>l(nlr4 nik Ij*-
pbolA al«l□^ar*. ^Frtim ■ rholkj aiiTr.}j^n|>b t^ àifc^va .1 J, W^^wkht. I'- i- Army, i'a^ad
tnm Iba ««funj mvdldal Tvtutnii of tînt Mr4i<Hl HBd "vtgWtl Hti^urj «t Ih" War of <a« lUbtina»^
is«]>ta arv incrensed in t^^nitlh, as well as in tli idleness, by this inftainiDa-
tioii. The -ïlands of LirhcrkUlm uiulergu an elongation or a comprrsMoa
with ftlt4-nialin^ dilauiionH and COiitroelionK, as in tlte stonaeh. Tbe
«pillivlliuu of the glauiiâ is preserved in eifu, and the cell» are gotieraJlj
ACUTB DTSBMBBV.
491
. tioA oujviilinped. With rea|tect to the «urfsce epithelium,
: M uselCiW to look for it tneiitj-fotir hours hhcT death, Wt we mn,r be
ire that it ix iii a M^lt: of jiariinl de^'iuarantioii dunng Itfo, for it is fouod
lin tlie HtuoU at tlie coiameiioeinent of ihe dysentery.
'2d. Around lie vcsmiU. in the Hiipcrlicial layer of connective tiMiio
located iniinediateljr beuenth the inlands of Liobcrkithn, where llic vcs«i'l«
forai the plexns from Khonce tlie cApillarie« arisc, the lymphoid evWi nro
«xtremely nonieroua. (See Fit;. -'iV ■) There is an inâaoïraatory iiitiUrution
accompanied by thickening of the connt'clive ti^ue beneath the glandit and
tronnd the closed fulliclcs. The lutter on^ iiUo HwoUen niid filled with
■ lympli corpuscles, Mnd they project upon the xtirrnev of the uiucouh nurm-
Bbrnne. They sonen and break down in the centre, and their destruction
Vu followed by a follicular uleer.
H In Uio«c points where the v«rj abundant infJammatory exudation—
H coiiitiMtnfç of lymphoid cell* and a fluid containing fihrin — ^inRllrate!) the
connective tissue to the point of compressing the bloodvessels, there is
pr<)<luced a genuine mortification of the tissue supplied by resâels.
This is precisely what happens in the layer of connective dssue snb-
jscent to ilic glands of l.ieherkfihn and around the follicles. These
more or lesa extended lamell» of the )!landiilar layer are detached by the
Buppuration which takes place beneath them, and arc thrown off in
1ar<;cr or smaller fra;^ents. which arc found in the oracuatiooH.
■ When the mortification affects a portion of tlic ;:;Iandiilar layer, ihero
results an nicer whose Dut irrc-pdar bottom is f;cnendly hCJited at the
summit of the fold of tho niombrniie. Wlion the slough affeotti a lyinpit
follicle an<l the surrounding tisaue, a small circular tdcer follows it3
elimination.
[Ilcers once formed may continue to extend by suppuration of the
adjoining infiliraled tissue, and, even when circumscriWd, their surfac«
secretes pits during tlie whole time that the dysentery remaitis in the
acHte stage.
I This stage may end in repair of the loss of swhsiance. by ^nulation,
cicatrixaiion, ana its results, or it may pass to the chronic staj-o.
Buch is Ibc slightest form of tlie disease, which, in ccrtaiu cases, is
T«ry limited.
I.
*'
f
Intente anutf dggfntery exhibits the ttaniu p"*''™' plienomena ; but the
nortnd process is much more active, and the lesions arc much more
general and extensive, involvin<; the j^nrater part or th« whole of the
larjre intestine. At the autopsy of pittients whu have nuoeumbed during
the acute stage of an intense dysentery, the ulcere are deeper, much more
extensive, and are scatti-red over almost the whole surface of the large
intestine from the eieciim to the anii.-t. The surface of tlie ulcers ia
coTcreil by a débris of the superficial layer of the miicous membrane,
infiltrated with pus, and not yet detached ; or it is granulating, and red-
brown or slate color from the docomfiosition of pulri<l blood. The walla
of the niccrs arc sharp cut. and are bordered by swollen, very coiççosted,
ecchymotic. softened mucous membrane. The ulcers may be so cxt«n-
*ivc that there remain only island; of undcstroyed mueous membrine.
In the preserved portions of mucous membrane tlte glands of Liubetr-
408 lSTSSTi:iB. V
Iikttbn are foaiiA with tfacir lining of cylimlrienl celb ; buttheiv gUnila
tre irregutar nnd dcfonnei], comprt-ssi.vl lit^rc, diHt«i>de<) tltor«. The
1>loo(lve#s«l« whici) iiurr(»iiiii] tlii'in nro I'lionnous nnd are j^rgcit witli
blood. Aroiiiiil ili«m, the connective tmue contaius maww of lymph
oor[»iiaclei< ami ûtamcnts of congitlnted filirin.
'I'iie ^ubgiitndtiUir connective ti^iiijc, wliich fomig the bottom of theaa
ulc«râ, throughout it^ whole thîckiicad i-i iiitiltratod by an inflaiDtnatArjr
exudation composed of roimd cells and Rhrin : the bloodvessels are di»-
tundcKJ with blood, and their walls arc in an einbrjroQai condition. Tlw
lymph vossela aro filled by very lar;;c and awoUen endothelial celU
(KcUch). AH the layers of the sutunucous cellular tisane are uttered
t<> Huch an extent that wc have a ccnuino phle^rmon below the (glandular
I layer. The connective tissue is double or triple it» UMiiil thiclcrwM, and
itfl moit «upcrhciid portion beneath the glands is in plaeeH Intiwfonncil
into lacuiiw of pus, nhtch isoliite the f;landular layer and render ita
destruction inevitable. Thus it is not very rare to see patienU ovncuate,
with the MtooU, cciwiilcmblo fraiçiuent» of the inticous iii<:tiitir»iu>, either
in tlakc* or in oyliuilcn which nuiy even reach more than a foot in
length.
It «roubl «eem almost unnecejsnry to adil tiiat thoae ctMa of dyaenter_
in which the leflion.i are ho exten:!iive and »o profound tenninato fatally,'
by asthenia, or more rarely by perforation of the intcâtine and pentoo*
itis, or by hepatic abscess.
An aamimtioH of the »t'>\>h \<a acute djuntery h an imtiapenubli
«omplement of the fore;{oin<{ study ndutive to the state of ttie iutMtiw^
At the beginning, they are constituted by a snu^ (|(Utatity of glairy,
gclatinnu» Huh)it«nce, Innipy or re^emliling muowis 8]nitB. Tbiarauoia,
has been compared to the spawn of a fr.)g. It is often colored wit"
blood, either evenly or in «treak^. Micro^opic examinalion shows in it
^lymph corpitacles, red blood disks, cylindrical cells, niucoua corpuscles,
and numbera of infusoria. Such appearances characterise the first
perioij.
When nlccration commences, the evacuations consist of a serous fluid,
colored rod by the blood, in which Doat whitish membranous fragntonls,
sometimes actual membmnous cylinders, which are composed of the
superticial hiyer uf mortified mucous membrane. By a microscopic
cxaminution uf these âukes or cylîndent, we rccugniiie in tlicm fragmenta
of the ghinds of Licberkiihn, or even »crios of these glands unit
together.
When the elimination of tho«c fragments is terminated, the stools con-
sist solely of an ichorous, puriform, or noroiis discharge of a gray, slate,
or sanguineous color. Thi« lluid, accreteil from the surface of the utcer-
atioDS, conutins a large quantity of lymph cells and red blood cor
puaole*.
The other organs contained within the abdomen ofton suffer a second-^
ary involvement: the Uadder is generally congested, and may be the seal
of an acute catarrh : the kidneys aro sometimes attacked with catarrhal or .
interstitial nephritis ; the lymph glands in the lumbar regiou are hyper
CBBOSIC DYSESTERT.
493
trophied and consestc<l; the Hple«n enlarged and softened; Unatlr tti«
livor is often aflWutd bj' congntiOM andabMees(8ee liosions of llie Liver).
Thv small intcatino not int'reqiiontly présents traces of « more or Ivaa
intcn«c nUirrli, or it, as vrel) m tite atomacbi may be atropbiod from
inanition.
CllRAXlc DYflKXTSRY,-:— Chronic djriwiitcry siiocvods an acute djNcn-
t<>rf , or the in Rumination maj follow a chronic course from the oitt«t»rt.
Tbo chronic diarrliuia* of warm couotrioé vhich, by their pro^tM and
hy i;«rtnin symptonialic characters «an be distiii^ui^bcd from «hrontu dys-
entery, do not dilTur from the latter in an anatomicui point of view.
l^rptalMaUroMIOBarMloBla natarcbmiila drmtH?, akowlBf ■ •■•■II niHrtrtil alcar n.H.
!■ Ibvtrnlfftdr wblch ào Iiil*rl*al>lki7 folllri^. 1, pr<>l>ud**At ■nilliiilr<iLlppl'-ltk4 *l«T*|toa. Ilftlf
4l>fraaivjillc^ X ''*- *- MuruBi pumibnBv- B- 1Iq*«U at Rnlokd, C, Sahmnriiu* i-vuukUto
Hmuc; *. 8B>n nln* oui uioh. P, Cltcnlir. K, I,>>a(l(y*Ma<. BOiisalai oiUi it ih" li>w<uiin:
l&iH ■» dlrtdtd by U» SBlnii» «r u arMFT-"' ■^■B <^* MmmmIoi whlik laatwnpwiM l<r> ti^Id
•( raBaldtntil* tlM. «nd ■■rrnaodnd «lib cnaoviidti Unat. (Pmg> plii)t»4iilcin|[»p1i bj Surftss
J, J, W<iu4wiril, r. B. Amy. <'uplad rntm lb« •Hund midlc*! t«Ibb« W tb« UMlMl led sstflMl
llli(ai7"r(h-> lU hull Inn.)
At the antop«y, the miicouit membrane is found to he swollen in placesi
and c«n;;Mtcil, very red especially in lbo«c parts which horder depre^-
sions Minnlaling iiiceralion at firM flight. At certain points, in reality,
where the nakdl eye receives tbw impression of genuine losses of suV
Staiicc, we find i)ic f^IamU of Lieherkuhn prettervcl am! a simple promi-
neaco of itei^bboring [tarts or a jjranulation of llic cellular tissue irfaieb
INTBBTIIÎE.
ïpamiea the glande. In other cmtei there if an wtasl low of tobriktiee
by ulceralioD. Ttiese ulcers compromiite only ft pBTl of the gUnilular
layer, or tJiey )>en«tratQ aafar a.t the ittihjncentcelliiUr lU.tuc. Tbe «itr-
face of tlie^c ulcers ia brown or iilate colored, and «[ion it we roeogniw
by the naked eye more or less regular openinjçs wliich lead into Uie foU
liuulitr depressions which are more deeply sealed in llie midst of tli« same
eubmucotu cuuneclivc tiMue. From th«se minute cavities a concrete roa-
CU8 einitlar in appcnmnoo to frog «pnwi» may he scjuceied out by pressure.
Thi» i^elatjnoiiï mucus «hen freshly cxnminvd shovrs cylindrical celkt
nuitily cup-dinped, di>t[ici«cd around (he periphery of the idjms. The
centre of the sL-mitluiil mass contains fusiform, elongated, ovoid, or spher-
ical cells "hicli have undergone n colloid metamorphoiis. When treated
ng.san.
A. Hncii. mriplinB*, !<• nt'-r : .-r.< l.'-imfid 1>y rilimllun, B. Muutrof Bclicll*. C. ■•»■■•
bUi iLi:i ijrxlf lonii dotind (ri>iu ItiK ilKud* !•( LlrKisrKiitiii iPiau ■ i>luiM-Bl(Risnrk liT ***■
(wn J '. W.MiiwB'<l. I', S, .iTn>T en|i''*l '"'■» ■)» •*™b'1 tnoiliisl loliiiu* «r O» Jlidliwl uAim-
by nitric or uectic «cid tht; muens gives an opa'jue precipitate. A Uiin
Sbdioii c<iinpri*iiix fit the same lime the edge of the ulcers, llic ulcen
thi-oiNclvct, and the cnvitie^i tilled with mucus, présente the following
k;)pearance<: —
lat. In the congested, swollen, and oelcmatous parts of the mucous
membrane which sejiarate the ulcers, the ^Innds of I>iebcrkahn are rcty
long and *ide; they are separated hy connective tissue pcnneated by
veaseU distended with blood. Below the ^'liinduhir layer, the superBctal
niueular layer ia normal, and the cotiuvclive tiMuu is siiuply hypcniMuic,
OHROXIO PT3KXTI!nT.
496
while its cells «re larger Uiaii in the lutnnal iit»tv. The SMiian* of fol-
licles |)retiont ab cUifitical or circular (Hilliiie.
:M. In the ulceni, tlicre are oiiljr vciitigea of the tubular glanii»: only
the lover third of the glanil remains, anil in Hocae place» the glatub are
eDtircl,v absent. Their remaining culs-ile-aac contain cjlindrical celb.'
They art- gc[>anile<l from each other hj connective tiiuue infiltrated with
lymph corpusclcB. and below theni the sub;*landular tissue is etjnally rieh
in celld. There is an appcamncc as if in the nlccrated portion the eupep
ficial layur of the niucoua inonibmne baa been cut away, wbilo the intcp
l^felMlular Connectix e tissue bus been destroyed at the same time.
Ftg. 270.
I
Pwf tknlM MHIm Itntnnh »CT»liif 111» «loo. it thwptt dyMaUry. X 30. A. It Iha pnlol it
wbIA lb» raiMiil* of Il.t «711 tiHUBH ronilaaaaa wiih <h« lnir>t purl i^ ih» «lindi ol LlBlwtkOliii.
B. OIukUIis iru* Sllisg Ibi (tmn ptrt uT U» t)n: Iho •rlloo ■>! nlobol in laiajr plvtaoiuiu] Il
M kkriok itri/ thiiii Itif e^imll*. C, MiioM*. D, Hi-rl* i>f Uillckf. K Kobnucoua R-nntcUii
tU««* U-dUnMil, aa]HT4ftU; In lh« H^l^ltbvrkuiï^l af (ba oiuxU oE Drfaf^* »i«l Id Lh" pnnrat of IL«
nnt*t r^^clot. wllh «vftrniA of l^mpbulij «tll«, T- f'inuïikT mnnraitr mtXof ih^ pdIud G. LodiI-
Indiaal nn«cul>FHai. D. KabpnUugail Munndit il«ar. ifran » |>hnM.ul<iuenpb b/ ^un|mo
J. J. Wwdwuit, D. K. Amj. CapM tma tli> Heiiad mullul tvIohu •>( lb* ]lgdl»l nud Sar|{l<al
■itlorr of lh< B«biHlan.>
3d. Hio» always open on the surface of the ulcer, folliflnlar depreH.
sions or losses of substance risible to the naked eye and filled with mucus.
They open by an orifice which is often rery narrow an<i irre;iiilar. The
uuDCular layer of the mucoua membrane is penetrated by their neck, but
496
INTESTINE.
othonvirte it aan be traoed above the small cavity, and bctvie«n it «ml tli«
raucoun Biirlace. There may be a sinjçlc caviiy or ihere may be sovcnl
placed lo;2;ether so aa ta be either entirely or only partially separated br
tracts of iibrouH tissue. These caviiios are filled with mucus vrliklt a
bouinlcil at tlip peripliery by a layer of cylindrical cells. The coHtents
are rou'lily di-tnc-bi-d from the fibrous wall. The mucus nuty retract ami
form a knob atiuclicd Dcar the neck of the follicular e.-tvity. it may then
swell up and rai^e tlic mirfacc of Iho mi>coii:t tnembrani'. At ftr»l aighi.
tliis cojt^ulated muciw, wicJi it« foldg, its depreuioiid, uid iu elevatioiu,
rencinbtc» a racemose gland.
mg. 271.
VliittlimnritTt\<taTntTliti A la r<i. i:<>. •li.>wtT>K : .il>UFItd (Uail tabutoa n»BJ tj
■ totvmnkr tpLfhAllnm kïmlL&r ir> iIiai uf ili^ irUfid» **t I. x t^- T^* «^ce Ih<v««ii ikt
RUad Islxi In l> allM wrih • >,-nniiUr Uont Jrutrij igaii'.U'<i niih IjnphiiA* mrt). T1i*4«ltnur
gnoalu niUinuin In (l>i> IgiTiar of (ht dIUtiil iD<-n1t>. In vlUrh l^mpho)-] <I*iuiiU*m I>h humr-
pholo-rjilprufTftpb bj SorfeMaJ. J. WvAilniifd. U. s. ArmT, <''i '".'t^t* «««tad »i*i1teal r»l— *
ortli>lf»dlHl udSurs-oM Itlturradli* W» «ruw Bdiitllluii.)
The wall of the above eaWties is formed of eoniicctive ti^Miie, between
the fibre» of irhich are to be found iihite corpuwle^ and sir&iteu Sat
ci'lli». It is paved with cylindrical cells which form a lining aoinetiiiMV
entire, at other times iucomplote. These eytindrical cells are almoit
CHROKtO DYSBXTEKV.
497
iiU CHp-slmpcd {îM-e fij;. 272). In those cavities wlicro tlii-y exist only on
H part of llic wall, tiu-y nre seen only «t tlie *uin'ri"r [art. rn*nn.'at Ilic »ur-
ftcc of the meaibrKiie. lu thow piirw of the huII where the cylin<lric»I
©ell» are wanting, the eonnectire tiwne b very ahumlniitly infiltrateil «ith
white cnq]ii)tcles, at»! there i* an inteiicie de-itriictîve iuRammatioii which
prevontfl the inresting ejûtheliuiu from reattachiDg itself (see C, 6g. '2,12).
lllMulatlMl •Irnaiilf nr lb* «ill nt cfMi m<l4lM lo otinnlt ij—frf. y «A A. (lohlal-
h* niiir.
C, P*f(l(i(ur ■ «ill at aB^I ttvm which (t> CTllsdrlMl hDi ti»a bien d>Uili*4. r, KmbiTOiilB
tttlls •noUoc tnt ka lh<< iiia«ou> «uirnlt. ■(. Vne lit «nil*, a. IIIotiiltstHl Allol •'■ih isd
R. Vwlciilar tvlii of th< unMiit MafnM.
A Dior* or U-s» extensive zone of the civinK-ctive tis«ne wliîuh SHrroumU
;;tfie»e eavilie« filled with iiniciis, is infill riH4.'iI with lymph cells or ym uor-
.ocleji. Opposite ihe*e cavilics the glandular tube» have mually ilis-
sjipeAre'l, or tliey have been reduced to their culA-de-tiac, or they hare
become hypertrophied and dilated in such a way that their inferior ex-
tremity, filled vith cylindrical cells, ha» divided into two oc three cule-
de-sac.
We believe that the previously describeil glandular foUicleH generally
occnpy tbe place of the destroyed closed foUioleB. They have the itame
locution, the same relalions with the glandalar layers and the superficial
mnMcnUr luyer, and the same form as the closed follicles. Moreover,
Kti hitvtr «een in our histologicat prejmnitions clfts<;<l follicles in process
~ Mftening and de«triictioii. wden a section of onr of these sofu-nin»
àtlîclei haa been pencilh'd and the lymph corpi^cles whieh fill the reti-
culum have been brnnhed away, we see that the reticulum is alisi-nt in
points and that there are larj^e space-i bounded by areas of the reticulum.
Should these softened portions of the follicloa break open and communi-
cate with the surface, we would have the eavities which have already
Iwcn ilcscribud; cavities which would soon be fitted by the intestinal
mncus and pnrcd by the cyliudricjil epithelium of tlie surface, or of the
idjoining Riucous glunds.
K mi
k
Kl
ISTESTltlE.
Once formcJ, the foUkulnr caviuott ciiliir^^e >iy llic destruction of Ui«
tcptn ; tlii'V may rcftch n dianioicr of -1 or .'■ lum.
Th« «ulimucous coniicutive U«itue h thickencl nt the «anH< time; it
» fibroiiH and cootaiiiit lymph vemch Blk-tl nitli swollen ondotbelu
(Kelc^li). Tlie iiiKammation i « freiiuetitly propn^steil to tlio OOntMWtive
UsMue vrliich se])arates llie inu^ular layers oî tlio îuteiiÛM, and it may
extend as far ad the subseraud tisAue.
Fig. 373.
PdrtWn ol iwipoaiKeiilar Hsllaa Ibnmjth Ibi' "-r-lMr in n i-iMor dlphllHrille il]r**"^'7- X***-
Tbs Still U cruittd odltfiucii- bf ■ MvttT Kh» ^>iini>r ulUnf nut n( III) (lnaiUat UttertOhal tt
wbLrh Ara irvtr»! mlPr^cwcou* |Ef^^u|i> niid n uiiiiblivrof Ti>il'llk«' Ivm*. Tft« rMlvtftWttUI"
aHni^tJ «lib mkmdoffniit. wllh a f^iir nd^Ukr «InmvnU nn^r th* ndfta qf *h« «flKral ATlIT^
irtntD > l'hulu-inlcnic*)'!! bj SuriKii J. J. ITugilii'inl. t'. i. Ariirjr. Cu(i1*d(n>ai Ih» wr««i mailtil
»Ibui at Ibo ll«dln>l uiil MucRlal KUbsrjtat (br Wit of ib> Rrbsliiau.)
Till» fibrous thickening of all the layer» «f tlii> large inlcntino is llie
CK plu nation of an apparent hypvrtropliy »f tliu intL<(.'tilnr (imuc, and
leads to the irai informa timi of ttiv intestinal canal, e^peoially inît« lower
portion, into a tube with nearly ri^iil walU.
This conrlition is met with especially in eases of chronic ()y»nti'ry,
with extensive ulcerations which have been healed and replaced by a
dense ami solid cicatricial tissue.
I
I
I
CItOLEBA. 4P9
Upon ihcflo cicatrices, where the iniicoua membrane h&n never «ntirely
Tc-fortiiL-'l, polypous oicreaceiices »rc often found, coiisUtiiig of fibrous
tM^iic or of a fil)n>-inucoua structure.
Till" rvacuntions observed diiriD;; Ihe course of th«e dian-hœas and
clirouic iljscntfrics arc vorjf variable. When there exists an acut* con-
dition, they bccom« raucous and contain blood or a little pus; ordiiurily
tiie; arc serous, abundant, and of a yellow, grocn, or brow» color.
The diarrbiea i« not always constant ilnring the whole course of the
duease ; it may be temporarily stupcndod.
CnoLBRA. — Cholera, an infectious disease in wbicli the most of the
or<:an8 are altered, U%» for its fîrit mitni Testation the signs of an inles*
linal catarrh whiuli correspond to a pathological state of the smtill inlea-
tiiie. Thi» is why the pathological anatomy of this disease bas its place
in the chapter on the intestines.
.\t the a\itop«y of paticntit who succumb in the stage of cyanosis, we
find the ^mall inte.itine very much cons^itted throughout its length, but
|iarticu1arly in the ileum. The mucouii membrane prenentu a pink, lilac,
or red color. On account of the fulne^ of the capillaries an<l small
veins, the summits of the foMa are especially colored. The mucoiH
membrane is thickened, turgid, and œiiematous ; the intestine îh dis-
tendcd hy a large <|nantity of a whitish, cloudy, odorless iluid. in which
are Huspended small opaipie flakes (rice bodies).
The epithelial coverings of the villi and of the mucous membrane des-
quamate afWr death, but an examination of the etooU during life does
not indicate that there is an abundant loi« of the epithelium during the
choleraic att.ick. The chnidine^t of the fluid i^ due not only to lymph
cells, but more particularly t^ the presence, in larj^e numbers, of proto-
organiams like those met with in putrefying fluids.
llajem and Raynaud, in the last epidemic of cholera (1863), verified
the ohMrvatioM made by Pacini. Oavaine, etc., of the presence of in-
Tuaoria in large qitantity in the stools of cholera, but without finding,
among the ten rarietics at least which were present, any which are spe-
cial to cholera. There were varieties of three kinds: bacterium, vibrio,
bactcridiiim (Daraine).
We find besides collections of spores in great number?, of themselves
alon* fonning the greatest part of the wbiti:<h flakea ; they ]>robably cor-
respond to the imcrni^iiTHt of tiermau nulhora, and do not apjiarcntly
differ from yeast. All these proto-organi-tms exist in the atooU from the
first.
The specific gravity of the atoola, compared with that of tlie intestinal
fluid obtained by the process of Thiry, is very low; it runs from 1.004,
l.OOii, up to 1,013 in certain cases.
Chemical analyns shows that organic matter is not very abundant
(Bccqncrcl). We find urea or its decomposition product, carbonate of
amraoTiia ; it is this which renders the fluid alkaline. The proportion of
the alkaline chloride» and salts is sensibly the same as in health. The
eholeraie stools a)iproach very closely, in chemical analysis, to the fluid
ObUined by A. Moreau in the expérimenta above cited.
Very rapidly after the o»»et of cholera and the ooounencement of the
INTESTIXB.
nlKÏil pcrioil, the clonetl follicles of the mucoua morabran^ of the small
inU-Htinc. cspocially those of the lower portion of Uie ilcmn, are swgllou
ami look like small pearly Rraiu§ of a n-dtlish')^; or gray color.
'Hii' ultvrntionit of the mucoiis membniiv and of the submucous cog-
Dcctive ti«su(.\ studii'd iiitdi;r the microscope, urv much more profouitd
«ltd more jnlcmto than the uiikvl vyo woulil loud us to suppose.
Thoy were ilcscribi-il by Kvlscli imil Reniiul in the opi<leinic of 1873.
tie connective lissuu of the mucous aii-mbmne is very thickly infiltrate^
with lymph oolU, while the conneotive-linsue fihrca are ipute dUtiiKt
lateiH
tiiwC^^
ThU new formation takea place in the înterglandutar and HubJHcenl con-
nective tisiiue ; it is. not limited lo the small intestine, but may extend the
whole length of the intestinal canid from the pvlorus to the aou3 ; it exists
als'i in a variable amount in the intestinal villi. The ;;Iands of Lielwr^
kiihn usually show epithelium only in the lower pari of their culs-de-ea«
(in part a p(>*t-mortem change), aud they arc oluin distended by luaflus.
The bloodvessels which exist id the supertioial part of tlie mucous mcffl-
brauc are <list«-iided with bluod, and their nulls are in an embryonal con-
bdition. The siimc is remarked of the vessels of the submucous tissm-.
The lymphatics are tilled by round wiU or by their swollen endutho-
lium, which is de.iiiun mated.
The closed foUicli;* present the lotitons already desoribod à prapty» of
" psnreniârîe :" their centre has some tendency to soften, and tlteir vcU
I Ittlar elements are fatty degenerattid.
The muscular tunic is normal, but the subserous connoctivo tissue il*
byper^inic and is infiltrated by lymph corpuscles. There may even tw
An irritation of the sennis covering whicb shows itself by thin falMi
fibrinous mendintnes exuded upon the surfucc.
In a more advaiicttd »tage of tiie lesion, when the autopsy is made
during the period of revuUioii, we sometimes find follicular ulccn
situated at the location of the isol.ttt-d follicles or at the seat of Pever's^
jialchi-s. The mucous membrane is less coi));ested, except ,t)iat at ccrtaii
points a («rsistent hypersemia is observed, and sometimes u|H>n tiie to|
of the folds of the small intestine there arc even superficial ulocn.
[These ulcerations mav involve the deeper tissues to the extent of per.
'foratiun (Ilamentycky In other cases the intestioe is tiiinned aDiij
atrophied.
Tlic phytiical characters of the intestinal contents are entirely dilfereat
from those observed in the first stage. There is no longer a rice-water
fluid, as in tla- fimt peri'^d ; tlie intestinal Huid Is colored by bile ; of
it is strongly ling<^d by blood. The large intestine contains solid matut
or a diarriiucic lluid.
Altérations of the blood are noted in a very high degree during tba
fîr<t or algiil stage. The blood, from loss of «eruni, has beeome so thick
that it does not circulate freely or does not How at all. Krom (his Iom
of scrum it results that the number of red blood globules is rclatiwly
iiBiuch increased, and the white corpuscles are increaaed in the same
pordon. The red disks are viscous ; a large number of them pre«ent i
volume much less than normal. There do not appear to be any pnt» j
organisms peculiar to tlio blood of cholera.
This viscosity of tlio blood in the algid stage appears to be the pria-
TTPHOID PE7BR.
501
I
il enu«« of tli( (liwrdcr of the kidney, consiatin>; osdonliullv in the
linutton or even the Kiippri'Mion of the secretion of urine. The nrino
kins nlbumen nuA ua^ti*, nnd thv cellx of thu tiibtili nrc (;rnnulnr {ic«
Leaion of the Kidiiej). Tlie cell» of th« livop «uffer n similar «Iterntion.
When reaction i* eMMhitfd tlic itenim ;;ra(Uml1y rolurn^ to it« normal
quantity, and the mimlier of the blooi) corpiiitclL-A in a given voluatc
rapidly diininishcâ. Tlic rleep color of the urine cau^ci* the suppnttitiun
that a Urge number of the red liislta ha« been >lestro_vetl. .\l iliiii time
the blood always contain*) an abnormal ipiaoûty of urea or carbotiali; of
amnioniti .
It 19 during this period that we observe the muldple lesions of the dif-
ferent or;;an«, wliicli Arc, in part, under the inl!ucnco of uneroia. Such
lire pulmonary conKTHtions. bronchitis, larynjrilis, pleurisy (sometimes
purtilciil), (cdeniH. congt'i»tion, and cochymosis of the pia mater ; and, in
rare cn^^cti, «u]ipurutioi) of the pnrotîd, cy^liti», pyelonephritis, etc.
™ l'R.ffMlc Ci/^KRATioxs.' — There arc developed in the large intestine,
very rarely in the lower part of the small inte-ttinc. iilccnxtions described
by Trciti as related to tirieinia. 'I'hey are ])reccded by & caUrrh and
by li<|uid siooU wliich are alkaline, aud contain a large amount of car-
bonate of ammonia. .\t the commencement of ulceration, the «tooU oou-
tain a little bWd and iWhria of the mucou-i membrane. These ulcers
H follow R mortification of portiona of the raitcotia membrane and the ex-
" pulsion of the slou;^)is. It is a species of ganj^renous dvsentury in
which the iiiti^ttinat mucous memhrttiie \s neither ninteriallv thickened nor
congested. The*e ulcer* whiub originate in the closed follicles and tJieir
surrounding tissue may «prend until Ihey reach a diameter of several
centimetres. Their long axis is generally pivrallel with that of the intes-
tine, and they vary in number. They may heal and leave superficial
cicatrices, elate colored and smooth ujion the surface,
TïPnoT» Fevub. — The intestinal lesions of typhoid fever «re Incatud
in tlie lower part of the small intestine : it is seldom that they involve
the large intestine. Four stages may be recognized: l«t, the cutarHial
period; 2d, the period of swelling and ulceration of I'eycr's patches;
Sd, the period of abatement; 4th, the period of cicatrization. These
four periods correspond more or less ehiscly to the four weeks during
which a typhoid fever of medium intensity lasts.
1st. In the fir!<t period, which u^iuilly lasts four or five days, the
mucou-i membrane is crtug.'*ted, and it weeretes a grenier or less quantity
of diarrbiral Unld ; the closed follicU's, b"lh the isolated and the agmi-
nated, especially those of the lower part "f the ileum, are swollen from
the beginning. The isolated follicles form small, pinkish, semitranspa-
rent, pearly prominences ; the l'eyer".s patches are tuntelied, and form
slight elevations,
2d. In the second period the hypertrojihy of the follicle* and of the
Peyer's patehcs increases. At auto]nies made on the lifth or sixth «lay
of the disease, wc have seen the isolaied follicles looking like hanl,
prominent, conical nodules, fi^om ;i to 4 millimetres in height, while the
I'eyer's patches were similarly thickened
rsTESTtKB.
During the secontl wtHik th« Pcjor's piitchcfl nc&rcst ihe cwciim. tltat
ds to My, thoso wbk'li uru Gr»t afl'cctcd nnd now most alU'rv^l, nlrc»>ly j
pwgin to ulocrato in one or two point» of the rainc {Hitcli, while lii{;)i<-r]
n[i in the ileum tlie^u iintcitei* nre not yet iilconttcil. I'lmn cutting I
tlirougb an Uolnteil folliele with u «cttlpel, we »ee l)iiit it» ti#«u<! m wliitiHl), 1
nnty, or slightly pink, of a 8<it^ con^iAtence, itu<l Ia mniilar to the tiasu* j
*ot lymphatic glnuds. It yields a cloudy lluiil hy acni]>ing. To thai
nuked eye them in »» Aliaq> limit l>etwe«ii the follicle and the surround^
ing tissue, an appearance which .luggesta a pat1io)o;;:ic3l inliltration botbi
of the foltiele and of the adenoid tissue which surroundj^ it. The follUJ
ctes of IVyer's patches present simitar appearances. I
The number of altered patches varies from two or three in the neigh. |
[liorliood of the ilccciecal valve to twenty, to fifty, extending up the inie»>|
^tine. In tho!!o caseti where the lesion is most intence the jMtch is hyper-'
tropliied tltmughout, and is very much thickened, li ovsy form an
elevation of 2-~S millirootres, sometimes even more (linrd patches of j
IjOUIa), When tlie lésion is le«t intense the dossil fuUicle.-» do not foniil
•0 great a relief : Ihe pntchcs then have only a Amnll number of theif I
follicles diseased, and the patch i* not swollen over ii^ whole surface {aottn
patches of Louis).
The hard patches and the very prominent follicles are the iDOSt favor»*
We for microBcopic examination.
At autopsies made twcniy-four hours after deatli. the cylindrical ci-lls
of the surface have been macerated into an opa-iuc, purifortu fluid which
eovflra the surface «f the mucous tnembrane. B; gomiung the «ut tar^i
face of one of these swollen patches, wo obtain small fraiçaienl» whidt*
after treatment with picro-carmine, show a large nuial>or of tymph celU,
some containing a single nucleus, othcra several smaller nuclei. 'Hiere
aUo are to he found in tliesc scrapings numbers of large, swollen, spheri*
oal or polygonal or flat cells, with a granular protoplasm, and one, twa^ J
or throe ovoid nuclei. These large cells are nothing else than the swollen I
and inflamed endothelial cell» of the reticulated tissue of the mucoua J
membrane and of the Ivmph follicles. These elements are siuiiiar to*
tliosc ohaorved in the leukemic products of the splecu, and in lynipli-
■denomata.
These cells, which have been called typhus cells, luul regarded as
special bo typhoid fever, have no really charactcrtjtic feature*.
Thin sections through the now ulcerated patches offer the following
details: —
(u) The villi, instead of being lengthened ami distinctly separated .
from each other, are increased in width, at the same time that they appear j
shorter, and have the tendency to fuse tofjclher at tiieir bases. riii»|
modification of form is due to the fact that the tissue of the villi ts infiM
trated by small round cells or lymph corpuscles. The fusion of the villij
is t^uch that the surface of the patches examined under the niicroscopin
ap)K'ars to be slightly undulated, while to the naked eye it appears alto-
gether smooth. J
(A) The tubular glands arc increased in Icugth and width, as we \»ni
LiW>m the normal parts of the mucous membrane over upou the surface of '
|tbe patohes.
TVPHOt» P8VEH. 503
On tlic mucoiH mMnbrnni? in tlie itcighWrliooil of tlie ]*ejer*4 patchci,
the villi &K very 'iistinct nud tlip i^rwwili in «mall. On thai covering; the
fatclii.'s, ibe tilli arc funoil t»^ellier by n miiM of embryonal tiMite, aiid
they «ro warcvljr wpamtril even nl t)icir extroroilit^H i the (;lan<l!i of
l^eberkUhn hare double or triple their ii»ual lengtli, ami their transveree
di»m«ter la increatted in the same pTO]x>rlÎDn.
The cylindrical «[lithctium of ibo liyi>ertrophied glands is loDger than
tMmml. The lutuen of the glauds coutains free rouud cells, or deformed
cylindrical celU.
The intcr-glandutar and subjacent cnnnrc^vc tii>sue is tnfillratcd by
aaiall round cells : the tissue of the villi is Altered in the same niatiner,
TticïC lésions of t)ic villt and of the glands are the ttante, whether they
arc seated in the I'eyer's pottchca or located around Ui« i»o1atc<l follicleti.
(ir) The profound layer of the nntcoua membrane, vhich fomt* the
greatest part of the hiirilone<I gmteh, at first ptreMent^ a homogeneotu ap-
pearance. It U penetrated by bloodveasela which are much distended
with red and ohite blood corpuscles, (ho latter in much greater num))era
tbaii normal, and the ailenoid ti^iie which Hurrounds tlie folliolea b in-
filtrated wicli embryonal elements. These embryonal cells are disposed
in concentric circles around tlie vessels.
Such is the structure of the hypertrophied patches in typhoid fovcr ;
we see that it coHsisu essentially of a proliferation of the adenoid tissue
(rilli, closed follicles, and deep adenoid tissue) and of the connective
tissue of tbe mucous nienibntiie, while the tubular gliinds H[>on the mit-
face are at the same time liyportrophied. Thi^ lejiion of the glandit of
IjielierkQhn )ip|>ears to us simply secondary to alteraliona of the connec-
tive tJ^Mue which surrounds theni-
During tlii.i second period of the diwase, the ulceration always begins
in tJie patches and follicles nearest to the ileo-ciecal valve.
In the hard patches it is easy with the naked eye to uee the process
of ulceration by mortification of a more or leas extensive portion of an
isolated follicle or a Poyer's patch. It is the most elevated part of die
follicle or I'eycr'a patch which first mortifies and assumes a yellowish
tint, due to the imbibition of the intestinal fluid. The mortified part is
soon cut off from llic rest of the morbid tissue by a narrow border,
then by a furrow, and it is subsequently eliminated in $n>»ll (moments.
Almtglide of one of thc»e small eschars, slill in viVu, oihcnt are seen
which are almost completely expelled, leaving in their place an ulcer, (ho
bottom of which is filled up little by little.
The liard patches »ucce««ively present new points of sloughing, and a
total ulceration is thus eRbcted in small islands which are attacked one
after anoUier.
The isolated follicles present at the commencement of this ulcerative
process a small slough upon their most prominent part. The slough is
thrown olf, and there results an ulcer which occupica solely the centre of
the follicle and which progressively spreads by tno invasion of the whole
of (lie diseased tunic. Those ulcers often have a great tendency to ex-
, (end in depth, sod notwithstanding that they bare a small diameter they
504
INTBSTISS.
imy eM UinMigU the masealw walls and pcrfomte tbo acrous imbJ
bran«. "
The mflaminntioii »f itic muoou» mcmlintnci ftntl of ite collatar tissue ia.
in TucL, propagated U> a ooit-iideralile di:)>lli, nu-l tre find lui tiilillration of]
lympli celU in the connective ti.-s^ue vrlikli iic|>orato8 tlio two mnwtJârJ
lasers and even to the iiiibâoroiis tissue. J
The peri lone um opptaiie a hard patch iii reddenet]; all tlio voMOll^l
particularly the small veins, art- dilated and tilled with blood. OpjxMlM
patches tn process of idc«ratioD the sorouA inetiilirane h aoinetiiiK^I
thickuitcd, and it presents uray or whibsh opai|ue spot», slightljr pronû* J
nent. looking to the- niil(e<l ejrc like tubercle ;;isiitilca.
The purit»n<-uiu may «how a considcniblc iiitiltmtton, and npon ttio
turfaoe of till- perîtoïK-um oppiwiic the tilcoriitioits thcrv mar «xtsfcJ
«hitiili sp(>l4< vimbk- tu the imlced oye, which consist of an aji^^lonMtm- 1
tioii of cmbrvonnl cells imW-ilded in a fundftincntnl amorphous sitb«tAnco.|
Tliev are to be di«lin;piiiihed frora tubercles bi-caiuw there are no distinct'
nodulea, or pointa of caseoua de^^ene ration. 'ÏWin formation \» oftveml
bv a laver of endotlielial cells, and it Hoein» to be due to » proliferation
of the same cells.
It is certain that this cellular infiltration of «II the tunin of the inte»>d
tine, and the consci|ucnt sotU-niii<; and friobilitjr of the fibrous buiKlks ,
are conditions which favor ulcer-ition and caiiw the tendency to tlie in-
vaùon of deep piirtti anil to perforation.
Tht soft patches and the hy))urtrophie'l follicles which accompanj
ttitiD, uautlljr ulcurnlc in thuautne nmiiniT m tliu Itnrd patches; onljthc
eschars arc le^^ visible, and there is a diâiiiicgration and moleoular elini-
nation of the superlicial parts sooner than the destruction en maa»e oFJ
the more extensive portion. "
Partial reaorption and removal of the neoplasm of the soft patches mtiy
be cflccted without a genuine ulceration. The fluid mixed with lymiÂ
corp\isck's, which the previously swollen follicles contained, may bo taken
tap by those blood and lyuiph vessels which n-rnain permeable; ami the
"follicles may thus become effacvd in such n manner us to produce rrficw-
latfd i>(tlr-Jis-f{[.imUj. I'pim tho^urfaue of the»cpatch«M tbede[H<os«ioi)ttl
correspond t^i the folUclf» atn>pliied in the foregoing manner, while thft'
reticulum formed by the coimeotive tissue still infiltrated with cells re-
mains elevated. I'pon thin sections of these reticulated juktcluM, madt^
liuring tlie i>eriod of repair of the ulcer, we find in the sujierlicial layerl
villi and glands of l.ieherkllhn, the presence of which proves iJiat tlieru
tias been no ulcerative descruclion. Xoi infreipiently we may see one'
or more follicles transformed into a small abscess from which a drop of
serous pus escapes when it is opened. Ksamining, under the micro-
scope, a thin section through one of these follicular nbscesaoe, it is «en
that the pus has been removcil by the handling: there exists in its place
an empty space in tbe midst of the follicle. This space is bor>iered by
à6Un» ot' capillary ve-MOls and fine meshes of reticulated tissue. Tfa»J
walls of IhcHe small folli<riilar abscesses consist of a connective tissue the'
fibn.-* of which are pale and granular, while the [teripheral connective
tissue contains rows of suuill cells (fig. 274).
Sd. The third period, or third week of the fever, represents the pro-
TYPHOID FBVKR.
505
of the ulc«i»tion of IVycr'a pntchru which lm»e cant off «11 the
thickly iiifilttntcil with tliu roiini) aAU. Thtt less allereKJ Uh-iua
«rliioh forma the wMi uiul (lie hntt»m of the ulcers ia very much con-
geflte<), and may present granulation». The «tnhryonal state of tbe tosmI
walla prédisposes to hemoirlinges. Thin i^, iu fact, the period during
Kg. 274
bronft tb« pirlphrri' "' * Ijrtnph CtilllcUltia m-<iii< <7x'>>"<<t 'MfT. Tiit Hnlnl tmrll» !■
• r-t I nil mr iliieHi. M Ibi n)>ii«( pmi of BjcuiE ei|iUlti7 •ctiili mid tn* »ll> in lli«<ail<r
'irhich proftiM hemorrhages take place. It i» rare that ru]>tnrc of the
TCMMeU and heiDorr)ia)res are met with during the seeiud «n-ok, yet ihrjf
may {uiHsibly occur at the oomroeiiceroeiil of the eliniinnUon of the toor-
(ifieil jiarM.
4th, At the «ul of the third period, commences the process of repair
which continues during the fourth week. At the bordera of the ulcer
there commeDceK an irregular formation of t^uimlutivc tisfluc, which little
by little spreads over the iilcenited surface. As this tissue condcitMS
the bonlers of the ulcer appritnch, and the cicatrix form». But complete
cicatrisation is very slow ; <piite six wi^eks or two tuoiiths or more from
the 1wKinnin>; of the di?iea.ie we .ttill find nmall ulcerated places. Ihiring
cicatriïalion the cicatricial tiitsue becomes pigmented almost conntanily,
^and this pigmentation remains for years.
B Microaeopic examination of the cicatrices shows that all the tinsue pre-
viotuly attacked by ulceration, thai is to say, the whole surface of tlie
inucoua membrane of the patches, is replaced by a connective tissue with
parallel loDg;itudinnl tibros which arc separated by a large number of
round cells interposed between them, 'i'here is here no vestige of the
closed foltictcs, of the glands, or of the villi. The vessels remain dilated
with embryonal walls, and aro often «urrounded with black pigment. If
in the cicatrices we aonaetimes find the remains of a few villi or glands,
it is becauM nil the ti.-<.tiie of the nmcou» membrane had not been attiicked
by the le«ion; in these case», the piitclie» have been only partially
tinvadeii.
The ulcers of typhoid fever do not give rise to constrictions of the
intestine.
The t^mph i/landa of the mesentery are conat.antly altered, and in the
same manner as arc the closed follicles of the intestine.
The tpleen is always aifcctcd: it is hyperirophied, pink or red, moat
[frcqueoUy pale, soft, and engorged with lymph corpuscles. The MaU
606
IRTBSTIXE.
pinliiun tioilîps, nt oDOtimo visible, at utiotlitTtiiiMiinvUiblc, arcgenerailj
sonivwhiit uiilnrgcd. (av« Spivcii.)
We linvc it1iH.-a<lj itcen tliiit t)io l'hartfiiï anil larf/nx ath fminoDtljr
ftlu-Txtil ill tlii« (Ii«ca8«. The lanjt intrtti'tr is ntrelj affeotvd : wiicn it
in iiivniU-il, ita lesions, conipfirablo tu llioM of the sidaII intedUtie, nuy
be lociitt"! in tlio civcum, colon, or rectum.
'i'iie livff aiid kidm-i/» are almost always the seat of an intereiitial
intiammation, wliicli will bo examined vtlie» these organs are studied.
The mimrtf» very often, if not always, aufler a fattv or waxy dcRon*-
ration. This ia especially bo of the miiscics of the abilominal walls, am),
on this ftccouDt, they mav sometimes rupture during ijuick movcmcuta
in bud. (See Kif,'s. 14y,'l.>l.>
The cardiac inti^clc doea not escape. In conseijuence of this dcgene-
rition, which usually happens ilunii;; the Initt period of the diseue. the
cai-iliiu; tnuscle is considerably weiikciK-il, and its contractions are inter-
mittent.
W'e finally meiiti'>n the hypostatic congestion!! and iuHaaiiBationa wbicii
ta nay occur in moat of the or^ns— the lun^, the brain and its envelopes,
' the spinal cord and its membranes, etc.
Such are the lesions of typhoid fever, of which the initial leaton is m
the intestine. In the primary sta^ the lesions are congestive and in-
flsmmutory, whilst they arc retrograde and accompanied by enutoiatioD
and nnntuiia in thu later periods.
Lbsioxk of TtiK lNTKSTt:<t{ IN Hbrnia. — In inftamtd hernia, llic sac
may not contain âuid. Under other circumstance», it contains a seniiu
fluid which is transparent, pink, or even dark-red and aaogiiinolenl,
and in which tal^e membranes exist. The serous coat of the intestine
is almost normal, or it is intenselv red, as in acute peritonitis, when it
Ç resents a whitish opacity or false membranes and vascular papil!»).
he study of the condition of the mucous membrane in such cases has
not been tboroughly made, but it is probable that it also is attacked by
a more or less intense inflammation. l;^malI abscesses have been found
between the intestinal tunics. If the hernia is not reduce<l, this infiaoi-
mation of the sac niul of the intestine terminates by fibrous adhesions
between the two, and by thickening of the sac and of the coats of the
intestine.
In atrimi/ulaUd Iterniti, the color of the serous surface of Uic intestii
is of a darker red than in intlammalion. It is ecchymotic, brown, :
preaching violet or black. The stranjtulated loop is tense, much lar
than normal ; later, when perforation or ^ngrene threatens, there nny '
be collapse of the included gut.
The serous covering is stretched, and presents eroeiona at the seat i
strangulation. The subserous cellular tissue is Ui« scat of Mood iat
trations and ecchymoses. Later, the serous membrane is covered by a
fibrinous exudation, and the sac contains an inflammatory fluid which is
oolore<l by blood.
The contents of the stranf;ulated loop consist of a somewhat abu
mucous fluid, oi^cn reddened by blood, or altogether hvinorrbigic.
I
BKOTAL FISTDLA. 507
be pro'tenc in ^mull iiitantity, but ttivre \» v«r/ ntrelj an; frcal
,tm:. Ill fuel, die Huid U «iicti n» i* «xud«d during & ver; intviuM;
' catarrh.
1'he mucoua meinbraDe is muck congented from the ))«>^»iiiiig ; very
Boon it |>resent8 ilie analoniienl signs of a very intense iuflamniAlion in-
Totvinz all tlie slructures. Tiio much congested villi are aKoUen, soft-
ened, friable, and shortened; tiicv Qiaj- even be united toother b; a
pwudo-Dtembrane. Tbc closed ^llicles, both isoUled and agminated,
are hyportrophted, intiltmtud wi^i tlitid, and ulcerated at the centre.
The» lesions are espucially pronounced at tlic ttcat of slraoRulatioii,
and particularly at the junction of the Htranj^lated loop with the supe-
rior end of the int«atiiie. 'i'hc latter it distended with inlc«tinal matter,
especially \>j gas. The iiitiannimtiun of tlie mucous membrane and of
the serous covering spreads to the upi^r end of Ibe gut, ami, in certain
oases, there results a general jieritonitis. The lower erul of tlic interline
Ï» diminished in calibre, contracted, and it also is ttie seat of hitlammatorjr
levions of the mucous membrane and serous coat nhich are le»s intense
than upon the superior ond of the gut.
When the coDBiriction persists, the impodimoot or the arrest of the
circulation at tbc point of compression dotormines a progressive de.
slniction of iJie intestinal wall, which is effected bj a sort of molecular
elimination at the [Miint:* I'-f constriution. This destruction is secured
irititout the gangrene exk-nding beyond the «ubitions of continuity; the
tunics appear ns if they bad been cut niecbauically ((iossehn). The
alteration begins at tlie superficial layer of tlie mucouii membrane, and
progressively invades the submucous tissue, the softened muscular tunics,
and finally the serous membrane (Nicaise). Save in exceptional cases,
section eilends from within outwards. The perforation may be very
small and diflicuU to see, or, on the contrary, it may involve the greater
part of the circumference of the intestine.
Another termination of intestinal «trutigulatioii, much more rare than
tbc preceding, is t!''"i^'''^"<'> which may appear in supcrficiai spots, or
wliich may allect at once all the coats of the intestine. The gangrene
ly be located &t any {loint irhalever of tlio strangulated loop.
The le4toiu4 'if the intestine which are observed in strangulation of the
ileum by bridles, by rings, by the accumulation of fecal matter, by
[invagination, etc., are, generally speaking, the same as those just de-
Hribcd of hernia. A strangulation by invagination may terminate hy
the expulsion of the gangrened intestine, and a union, end to end, of the
intestine ; or it may end in perforation, peritonitis, pernicious adhesions,
and almost aUays cicatricial contractions of the intestine.
Kbctal FiSTi'ia. — ^Thc fistula; which follow periproctitis, that is to
my, inâammation of the coimeetive tissue around the rectimi, may be
«cparated, according to their location, into two varieties: Ut. Those
which are seated in the ischiatio fos-'^iu or lower pelvi-rectal space,
and which arc consecutive to suppurative inllainmation of the adipose
linsue #0 abun<lant in this region. They are almost always complete,
is, tliey open ai one end into the rectum below the levator recti
ole, wbiUt at ibe otiier end, after a more or less tortuous course,
i
808
tSTESTISB.
tlicy open upon the iiltin. 2A. Superior pe)vi-recta1 flatnlie ftre almont
alwftyii external, lli.it U. tliey open extemnllv ami not into Die rectnai
( Po/.xi), Tliey Imbitiially prc-ieiit a superior pouch or ampulla wbivti
secretes pus, anH which is loealc<l above the levator recti. Tliev Tolkiw
a Buptiurative itiHaramatioii of the cellular tixsue of lliia region; ibe
ampulla which remaiio <lDes not poMew a free vent bec»«9e of the muKb
vhich is situated below it. These fistulic alwnvi airen<l very hîgli up
along tbo rectum, from which they arc separated by indurated counoctive
tissue.
Th««e different varieties of fistula have it common cliamcti^rtstie in
this, thai ihey are ohandled out «f connective tiKSue which is indurainl
by cbrnnic inflammalion. The ti-Xulous chntuieU, when they uro n>eeti(,
ooDHtilute irre^içuUr .litniHei), hounded by suppurating ;;ranulatiotia. When
they are older the fiHtulouii canaU are lined bv a mucous loemhrane with
firominent cells, and more or less distinct papdl» which p048«8a vascuUr
uops, and a covering of atratilicd epitholium, exactly similar to that of
the mucous membraoe of tla- anus, Tliosi) liscuhD *n often present in
intestinal tuberculosis.
TcBBnctiL09ls OP THE IsTRPTlSB. — Tlie tuherculous leitons of the
intestine, like those of typhoid fever, hare their preferred seat in the
lower part of ttie small intestitie, but they do not remain confined to lliat
region ; thej generally extend over a wide extent of the ileum, the jeju-
num and larger intestine, including the reoluio.
These lesions arc char»cterizod by tiiberelo «ranulps and caseous and
ulcerative inflammation of the isolated and a;;mi!iai«d lymph follicles aa
well as bv inflammation and dostructioti of the surrounding connective
tissue. From the mucous nieintiranc, which is their point of origin, thej
extend to the deep coats of the intestine, and involve the submucous coik
nectivc tissue nmi the lymph vessel* of the inlc«tinv. as well as those
which lead from tiic intestine to the lymph s;lanil» of the mrsentcry.
We deaeribe together the lubi-rcle grannies and tJie tuberculous in-
flammations of the clo;i«d f'olliclcii, hecauiie these two varieties of the
same process are almost constantly seen associateil with the luberculout
inflammation» of the follicle, the tatter sometimes even preoodtng tlie
tubercles.
Tubercle granules of the mncouH membrane of the intestine begin ai
small round ie mi transparent grains which project above the surface, «mt
which mav be located in the connective tissue around tlie culs-de>s3M: of
the glands of Licbcrkiiho, or in tlie connective tissue of the villi,
Wlien a thin section passing tlirough such superficial tubercles is
examined, we see two. three, or a greater number of villi, with small
round cells filling their rcticntnted tissue. These villi are united to-
gether at the base, while they are still separated at their free extremity.
They are thickened as wclf at their free extremity as in the points
vfhero ihey are fused together. From their nniim and their infiltration
bv small cells there results a solid excrescence of the superficial portion
of the mucous membrane, having to the naked eye and under tlie micro-
Boope the form anil the structure of a tuberculous nodule, 'llic tubular
gUnds, compressed and occluded by the neoplasm which surrounds then.
TCBBRCUL09I8 OF TQB I.fTESTIKB.
609
■I firat still preserve tlieir iiornml cjliixirical ccll^; t)i«jr arc Wiit aiid
ilintortcd, and can no lon^^er freelv «mpty thoir itccrttorjr prodiuibt upoo
die iniriacc of the raucous rti«mhran«. Lator iKe €01111% ol' the Uiliercle
eranulo tiecomca opai|ue and caiteouH, and iu elemcnU atrophjf ■■xl
Decome filled wiib Rik> granule). The celU of ibe tubular (;laiids expe*
rieoce a BÏmitiir kinil of degeneration.
When tlie tubeiiile graonlc begins in the tissue bt-low the tubular
(^awU, th« whole is covered hy a layer of ttlunds and villi. The latter
an), ae îu tho former case, the seat of a hvpertropliy ami an increane of
tlicir Ininsverse diameter. The glands of Lieborkiihn arc eloii^ntod and
filled with urlindrieal eetU, and the villi have tlie Wndency to unite tu-
etiicr aud form granulation tiïdue. At the bcjjimiiug, the «{tccial
Fig. 275.
vljli II* tnboUr ^1*Dilt pr>'h<-d ap4iTl hj wt fe'«aHiLi[Anoii ai IrmfilioJd «l^fai^nu; 1l« vUll nTvfttljr
bjrptrt'vlilLkrd' 0, muscla uf BrprltA. O, *itl-niU«aq* <oDii(ieU«fl (Ittuv luatlnLt.1 ttWil llfuiplioM
«•n* «a4 ettmibiaj « bnrnr>iir of lubitmliq la tnrlnb* ht&i^fu : Lu 1»Jo^llfn*.^i• 41tAl*d. i>, 1^, F.
rHptdUvlj the DlTcai^r *ii<l li»avLiii<lLuAJ inuirqlLf cLiti vl ihc UIo.i^dc aaiI i'rrlioa*uia. i7, t^vHf
flf tbt Blr*r; f, uDkofl*n''d mlirtr<t«. ; ihA ivn leltm bvL>tr tb* Intrrrn^lir* ;>dLeiI Id tubtrelA. In ilta
MMtT* of wtilfiti fp^nlUr dial fi>nn« nn. «««o {J^-nxpli Tf<*4e]a ful 4^rb>*«, itlAut nU*!, Thpir ar*.
b«a44««» nrunM lulwclt* vbkb «tv nvl LriUrnl r f lubar*.'!*. wJLh «mlr*! nDfli^qiq^. Lu whlcb tmit
tS Ihe tbr^tj ID»»» hfc» UlkD ooL *". «nfuntj tuh"»'!*. whii44 ciivLEk' form !*■* »f iho ul*rt^
(Fr^m A pbt)(a.i>iWrvifrAph iff ^urirruD J. J. W.iu4wHrrl. T. 8. Army. Copird fhiiD Ibc •»<4u4 moillc*!
nlaiM of tbd Mcctleil laJ ânrficul llUtory of lb* Wtrol tba l[gli«llloii,]
ftnflaii
inflammation A of the cloned follicles in tnberculnais do not differ fmm
lie "psoremérie;" but soon the folticle becomes raoi-e and moi-e en.
_ d, and presents at its centre a whiliiiU or yellowish opacity. The
follicles tliua liypertrophiod are longer, leaa dense, and softer than tha
tubercle granules. OlWn. in picking them with the point of a needle,
there exudes a little cloudy, whitish or yellowish fluid, holding îu suspcO'
sion granular lymph cells, and large spherical cell» containing two or
three nucloi and faltjr grauule«. Kuuniuiu^ thiu sections of these litUo
I»TB3T[SB.
Pttf. SÎ0.
tumors, wt' sec ihat tlicir jieripln'ry i» more sliarply scpunited from tbe
Eurronndin;; tiuuc thnti i« the ease witli tiiWrclu, nml we Mni>etitn«« eb-
servo tbv eoiitent» of the follicle tmnxfoniH-il into n soull nbM«M.
Tlieae «mall folliciiliir nh^cuiwes firojecting into lUc Uimi*ti of the înle».
tinul cube, poweM on tliat ^idf a thin wall, wliich readily niptnreH, wtien,
the contents dUclmr^iug litile by litlle, there r»r!«ill<i mi ulcer which
enlarges. Several altered follicle.'* located at one time in a I'eyer'a patch,
at another time iu another point of tlie miicouH membrane, aim n^
rounded moM freiiuentiv by a diffuse inllainmaiion of the aubmocous coi>-
nective tissue, ana At tW same time by an intlnmmation of tlie villi aail
glands, unite lo form an elevated patch which soon ulcemtes tn one or
tnoro points nhere the foDiulcs arc most diseased. It is io this way tint
ulevrs of the nmcoiis nn-mhranc in tuberculosis are fonucd. When one
cxuiiiincs with the microscope the edj^es of these ulcers, someUiing of the
Mime lenions of the villi and of the glands is seen as Î8 met with at the
Burfaoe of llie «wolleii pnlchc* in typhoid fever. In reality the villi are
ÏRrtly effaced hy the svreUiii;ç of their H]iiees atii! fusion of their bMM.
'hey are iuRltrated with embryonal elemeiitu, and are tmnnrormed into
lar^e j;ranulattouH which unite together. The j^aniU of I.icherkilhn are
tnoiiifiod in form, in some places compretued, in olhertt dilated, purlieu-
larly iu iheir culs-de-^ac. They are filled with cylindrical cells which
ar« generally larger tliao normal. I'pon the border of some ulcere in
V full suppuration, we see villi IraDsformed into
large, very vascular granulations, separated
from each other by deep rtcpressiota, the rfr
maiiw of tuhuUr glands, lined by a welLpre.
served cylindrical rpithelium.
When the tiihercle grnmiles are confluent,
iheyare surrounded by lesnotu of irritation of
the mucouA membrane an<l aubniuoous ttwiue.
and an ulcer »oon appears at the points first
invaded or where the circulation is arrested.
I'Icerntion is most frcnuently effected throttgb
the mechanism of molecular gangrene.
Whatever may be the mode of ulceration,
the aspect of the ulcer, its ulterior course, and
its coQseituciiccs are the same.
Tuberculous ulcers of the siuall intestine
have a round or elou^atcd forro. Tlioir lon^
axi* is longttud'.nal when in ilie Peyer'i
patchen ; but. outside of the Fever's patches,
in the jejunum, in the -«mall intestine, and even
in the ileum, it ii> geiierallv transverse. Rii>d-
fleisch regarda this predominant traiwverso
form as due to the fact that the granulations
follow, by preference, the walls of the bloo<l-
vessels and lymphatics, whose counte is genr-
rally transverse. The sinuous, irregular.aiul
more or less serpgiiious borders of thesr ulcers are thickened and [>n>i»i-
ncul, and contsiu tuWnrIc granules or altered follicles, eibseous in tiieir
t
à Qftinb^r of «tniill tiiti«r«ii]Ar
■Icm lu ft wttf al^ifbiEy tMvl(«u<<l
r^fr'A pftleli- >hliiriil m\t*^
K*vji J, J' WoudwfenJ, r. 8. X'taj-
Gf^pttd fTnih Ihn ««wild iitviltcftl
HLtlary ti/ tb* Wir «f Iba lUbflt
TUBEBCDtOSIS OF TRE ISTESTISB.
Cfintre an'l Aiirroniuleil l)v t)ic a1>'ive described iiil!amm!tl»ry legion* nf
the villi aiii ^Innils. Their floor is altto coverivl with y^ray or vrhiti^h
nodules, witicli are mostly tiiliercles in procesa nf elimination. Kleljâ
coiwidera lliat these wliiii^h j;niins are aUaya lymph ves-sek; tt is n fact
thai ilie Wftll of the Ivinph vesseU is ul^n a starling- inint of a tutien-le
grnrmlc. (f. I-'ig- 27.».)
WlicD Kc examine the pcrilonoal surface whlt-h corresponds to the loca-
tion of the ulcor of the mucous monibrano, wu always sec a certain uuinher
of minute tubcrele ;;runulcst sotni-
tmnit)iarent or «lishlly optique nt *%■ S''-
the centre, forming an elevation
upon the surfnee of the seroiw
membrane. The lytnpli veMeL*,
which emerge at this [wint to
empty into the lymjiU glands of
the mesentery, ap])ear aa large
knotted cords, of a whitish or yel-
low)sh>whitc color. At different
points they present prominences,
due to the tubercles vrhicli are de-
veloped in thuir nail, and nhen
tliey arc cut there often eu^apes
from them a whitish caseous, «emî-
fluiil, ma*», Thi.* growth in tho
interior of the lyiuph veueU iit
coEDpoeed of swollen, granular, en-
dothelial cells and of lymph cor>
puscles, which arc often granulo-
latty, whence residts the opacity
of the mass. Tliin sections of
thc«e TCMel» made nt difTcrcnt
pointe show the vessi;! wall» infil-
trated with round eelU, and at
poiutit in tlio course of tlio vessel
the aectioiiH show one or more
granules developed side by side
in the walls, whieh at these points
are much hypertropbied.
At the same point^^ the lumen
of the lymph vessels is most fre-
quently very much lessened and
irrcpiinr. and is filled with gran-
ular lymph corpnscle».
[Dr. J. -1. Wciudwanl belk've* that in the intestine the tuborclcs spring*
from the lymph pa-i'iagcs, ami that llie bloodvessel.* are rarely, if ever,
prinwrily a Reeled. J
Tlie different layers of the connective tissue of the intestinal wall are
the seat of tubercle granules, and ulceration is e(fecie<l by the pn>L'e»4
with which we are already familiar. A complete perforation of the in-
testino may be «fleeted by tlie spreading of the ulcer, but this accident
BuellDB Ihronfti tb* lunSB of ft Ijrnpbâik la ih*
iabBUfUH «r ihf Lkaa. hi Inburcnluili at Ita^
klHt, X UO. * (tigBlm ttbria tlol o, la wbl^
both Irmfbom luJ «ndiilhdul rlrmrait •!• In
badiltO» ftilhcn, an->b««kd«lit Lb« Hftllkuf h Iruih-
•tic «*udL In whifflu lumen, b.b. toonra'.il «ii.liul>«.
lui evil, Uttne^ SJoilldF «kDii>«<tiIft «pprar tq ih«
CouniHTllrB Uatua ififrDnqJltij; Ihv Tf<ual. ntllh ft
anmlvr of 1rm[bUo1d f+IU. ono 4^r «liUh U Ibtll-
cAii^il »L il. ( Vr«ui 4 pbot.-iiilcrs'rrAL'b by Sntitfoft
J. J. W.mllwt'i. U- K. ilrmjr. On|)lnd tmn\ ih*
•p^p4 m«0[d Ti>l(Lm*4rih«M4itlf«l ftnJ SulxIctE
HIaKiFy at Iba Wftt of lb* BabalUuB.)
512
INTSSTINB.
I H nre, because pulmonnry lesiotiH or tiiliei-ciilou'* inllnniinaliniis of tliv
eeroufi cavitîfifi oocadion (k'alli before tlie inteiiUtial k-i«iiiii> hnve ro«clied
tlicir termination.
Sonietiuica the inflamniHtorv and tuberculous infiltration of tlie mneow
membrane is so great tli»t there may reault in conse<)uence a narrowiug
of the intestinal canal ainl its con9c<|uence^.
Ttibeiv:ulous ulcers of the rectum may b» locftt«d at the anns tnd
"invaiU* the uoimcotivc tiasuu of tbe Burroumlin^ rc^^on. It is not
'sitry to u<ld ibtit in tulierculnitid of the intestin» the mucous utembmno i
the Hoat of A more or liMs intense catarrh, with hjpcrsvcrction of Buiil.
Pig. 278.
'>-*'/>:/iî;>
a ' 'i
fnmtlm*. *iidiilti«fUl oUkf. ÙU0 uf wtalcb U la^ichUd bj «. «nd numi^iDqi lympbvld «Univ^it. 11
, Irhlflb mrr Ikdtoilvd bjri^ ifrntu * pbolo-mlartfnpb by Hor^nici J- J. VTcodvArd, I'- ^- tknmf.
Caiil'd ttnm Uie imob<I medical idlnma at llit ll*dltml uul Surfliwl KUMtir*' Ik* ffw «[ O*
Sfb^Uan.)
IRie tuberculous ulcerations which have just beeo diMcribcd are often
eoBReeiitive to tube re ti low* ulcere of the lun^, and maj be caused by
patieniA swallowing; the sjiuta. Tliey occasion tubercles of the peritoocu
IfinpbatJGa; but tubercles )in ma rily developed in the perilonvum on)/
ver^r rarely give rise to iutestiual tuberculosis and ulceration.
SypMlLme Tttlioiis asd Uukhs, — ^The ulcerations of the intesline
wbich follow syphilitic j^ummnta are not umch more fref^nent titan those
of the slomuch. There oxist, however, several very conclusive obserra-
tions which pluec their occurrence beyond doubt.
Th«s« ulcur* are oharavterised by their thickened cd^es, which some-
tiiuit« caiitain nodules ca«eous nt the centre; by their iMttom, which
yields but little pus and wliicli consiste of a dense tissue, yeUowisb>graj,
of fibrous coTuiatenoc, and which corresponds to » cîcntricinl fibrous
thickonin'; «ml elevation of tbc scrmi« uiornhrnne. Tlii« iniUiratrJ fibrous
tissue is inlihnitci) with sninll rotiinl vt^'liiiliir vIcnivitU. Tbc l>i>iniiniti<;
of tliOM growthK has oot been precisctj ilrconDinri] : tii thi* »^atH\ intes-
tifto they may he seut«i1 in ihc lym|ili t'.iUidc» "f IVyer's paU-heit, bui if
tUiey «uirt in liie uhweil foUiulc» ihey nlno invmlo tiie n«ighborin): tixsiic.
Th« Iyin])hatic8 which «merge ugio» tlie seroua surface are altered awl
knotted.
Accofdin;^ to the opinion of (rOBjicliii and others, the extensive ulcers
of the rectum accompanieil by indiiraltoii of the connective tissue, and
sometimi?» by considerable contractions, are not characceriatic of syphilis.
Theac ulcere ditfer from those of chronic dysentery in this, that liioy are
bonlcrc'l by a narrow rin;;. and that they occasion constrictions, whilst,
»on the contrary, rather a dilatation of the rectum is observed iti dys-
entery. More frei^uent in woman than in man, they succeed chancres of
llic anus, mucous patches, or condyloinatu.
tFiBUrtMATA. — Fibroma ori;;inatinfç at the mirfacc of the intestinal
mucowt lui^nibrane is rare; in tin- chronic fonn^t of dyi«eiit«ry, we find
small fibrous polypi around the ulceralion.4 of the rectum or anu», where
they aa^uine the fonn of papilloroatA.
A production of librouis tisâite i^ aasociatei) with adenoma in certain
[mucous polypi which present a development. of papill» at their surface.
Fi/rro-iiij/"ina. — There sometimes exists at Oie serous surface of the
iit«itino small sessile or pedunculated tumars, composed of tibrons tiMue
'I bundles of smooth muscles. These tumors do not diifvr from thosa
formed upon the Herons «nriace of the stomach.
Smalt tif-tfiuiia may form very rare growths beneatli the mucous mcm-
ae of the intestine.
H tioD
■ofti
Ktomi
■the
VAK(a'LAR Ti'MORB. — Dilatation of the veins or phlebeclacy is not
infreipient in Ibe large intestine, especially in the hiemnrrhoidal plexus
aroniid the anus. Varices are often found in the smalt intestine, form-
ing an elevation of tlie mucous membrane. The causes of these dilata-
tions are all those which determine a blood stasis of the different branches
of the portal vein : cirrhosis of the liver, iliseasc of the heart, abdominal
lors, increase in siie of the uterus, efî'ort^ of parturition, constipation,
the efforts in defecation, etc., all eausis which impede tlic course of the
blo«<t in the hicmorrhoidal veins.
Hn.-morrb«ids consist, at the commencement, in a simple dilatation of
the veins at the bonier of the anus, and which form there a «li^bt pro-
jection, .^t the same time the vt:in!« .tituated hencath the rectal mucous
membrane, above and below the spliiiicter, are dilated. Later tlie^e
dilatations increase in ttÎKe and become distended under the form of little
lumps by the etfarla at defecation. Rupture at some point of the dilata-
tion, consequent hemorrhage and catarrhal irritation of tlie mucous mem-
brane of the lower part of the rectum are the usual serjuctffi. The cellu.
(ar elements of the altered veins experience the same alterations wbich
have been described à frnpm of varices (sc« p. 342). The connective
tissue around tlic veins may thicken, so that ncigiiboring veins arc united
k
as
i
514 rxTEsTiXB. m
by an indiirntetl tifuue. A section of one of these tumors reserohlee that
of a vanx. All the otvitiea ilo not coairaunicale «lireotly with the prin>
cipat veasels (blin'l htQmorrboiilii). Calcareous iufiltrationa of tlio walls
01 the dUooâud veins arc sometimoB observed.
Ai>K\iiM,\TA. — Theso tumors cutMcd by a hyportropliy of Iht ^lodft-
lar luyor of tho mucous mcnibratic aru mraly met with in Uib mMlI in-
U'j*lin«, bnt they are very oonmion in tlie rectum, whore they fonn muirtmi
pofffpi, which arc very frc.juent in children. Their type is tlte fKilypu*
of the stoinAch alreaily deitcrihod (see {>. -lliH). Their conitlituent psru
are only a litllo more rcji;utarly di«tpoRed than in the fltomach. Thew
polypi may be the cause of an invaj^ination of the lar;;? intostine. When
they project externally throujjh the anal ajierturc, that part of the in-
vesting layer of epithelium, which ia in contact with the air, (.'han^^cs
its character ; the superficial cells which wore cylindrical, likc< those of
the intcstinu. become flaUciicd and pavement shaped, and the surface of
tlio jNjIvptis assumes all the characters of the skin, except in remaining
red. This peculiarity is observed of all fonns of polypi which project
extomally.
LviiPHADiixoMATA of tho stomach and intestine have be«n studied in
the Rml part of tim manual (pa;{e I4'2). It is especially in the lower
portion of the small iiitetttine near the ileo-ciecal valve, that theae tumort
have been ohnerved. hut lliey may be aeated anywhere in the lenf^lh of
the ga^tro-iDtestiual tube. In two cMei of Picot and Itendti th? oev
formation of adenoid lisMUc bad invaded all the layers of the intestine
and the mesentery, and there had rt'suluîd an enormous tnmor. 'Wvtt
lesionK of the intoistine and stomach usually coincide with other adenoid
neoplaomA of the lymph glands, the spleen, the peritoneum, ihc lini<^,
the boiie#, the skin, etc. Lymphadtenic ulcerations and lumom of the
int^.itine to the nnked eye, re.tomble encephaloid growthtt ; their cut iiur-
face yieldn a juice by scrapinj^, and their extent, their (hickneiiiit, their
progressive invasion of the neighboring tissues, their intestinal tunic»,
and their peritoneum, and the defeneration of the lymph gland» very
closely asaimilato them to tumors which have formerly been called can-
ceroiu. Notwithstanding that they may bojiin in the closed follicles
sod Foyer's patches, tho lymphadcnumatous inËltrittions and ulceration)
preWnt totally different naked eye appearances from those of typhoid
fever, for they do not remain limiicil to the IVyer's patches, but, on the
contrary, cxtvni) imliflerently to all the stnicliires of the mucous men>-
branc. They are habitually transvers.-, wiiiU> tin- lesion* in typlioid fovtr
kre longitudinal. They cannot he conronnded with tubercular ulcer*,
because there always exi:tt in the latter tuberoular nodiileii or inttamms.
tiouR of lh« lymphoid organs, which are caseoun at the centre. More-
over upon the peritoneal surface, oppoute tubercular ulcers, we always
find Amall semi -transparent granules, which are wanting in tlie disease
we are considering.
Under the microscope it would bo more difficult than by the naked eye,
to differentiate the swollen Tcycr's patches of typhoid fever from loukai-
CAHCINOHATA OF TD8 INTESTINE.
515
nil: )>rotlucûoRS. Tn both caxcs in effect, prcviotia to iilcunition, the tiimora
#liuw A Mttiiliir infiUrntioii of tlie villi, a Iciij^thcninj; coropresMon niul
emWiiing o( thi' tiilmUr t;lAii>lii uhicli coutnin n niiicoiu or grnnuUr
e[»(hi>lium, a.t well m ^ vellu)&r infiltration of tli« ri}ttuulat«d «ubmitcoiu
OaKCIXOMata. — Primary carcinoma of tlie tnte.<itin« ia mcoiuparnMy
more ntr« tliao tliatof the stomach, but when itoccura it preMnts entirely
the same charactors aa when found in the aiooiaoii. It is often secomlarj
to carcinoma ori;;iiiatinf; in neighboring tissues, the peritoneum, the aterufl,
the bladder, ete.
Tlie rc;;ioTi8 most freiiiicnti; alTected bj carcinoma are the rectum, the
hepatic (lortioii of the traTi»ver»o colon ; the c»cam, the duodcuuiQ, an<l
J4'Junum are very rarely attacked.
AWrMw» and tn^yhnl'i'l are met with in the rectum, tlic firet more
freiiuently than die second. The tumor may be developeil in the ricinity
of the sphincter, or eight or ten centiiiiittroH above it. Tlie growth MaT\»
in ttie Aubinucoua connective liiwue. The .«ubmucouA infiltration •.-vcendit
in an annular form completely around the circumference of the inteiitine,
and occasions a eonstrictton.
The grannlatiog appearance of the mnoous membrane, ita ulceration,
tbe extension to the deep layer, the hypertrophy of the muscular coats
of the rc«tiim, tbc infection of the lymph glands, are in every respect
comparable to the le«ions in carcinoma of the stomach.
Authorn record the frC([uency of colloid carcinoma of the rectum.
It is certain that tumors havinj^ a colloid aspect, are not infrci|uent
in -the rectum and other parts of the
intestine, but we chould not consider
tliat every colloid tumor, with large
alveoli filled with gelatiniform mat-
ter, is carcinomatous. As wo have
already seen, cj/linttrirttl-i'elUd epi-
theliomit may sufter a colloid dugene-
ntion.
The cancerous tumor may ulcerate,
and in this way an ohntniciionof the
lumen of the gnt may be partially and
momentarily removed as with similar
tumors of the pylorus, and the ulcera-
tion may cauao a perforation of the
intestinal wall, an accident which hap-
pens more rarely than in thy stomach.
Occasionally carcinoma may show
it^-lf in the intcBtinii under the form
of multiple tumors.
The secondary noduh?» which orij;-
inate from carcinoma of the inte^iue
inrade the [teritoneum, and generally
aI»o tlie liver, with a marked predilec-
Pig. 270.
Cxiinilrlnl r*U«l ariihe'lKin* frum llii
i>ng LsUiUd*. X I-*'- "- Flbr^ni •iruna.
b. Sinhlt c/itld«ktllE«a Illicit «lib r^lin^rktut
tbA uulun «f IwD ftdJutiiLuj: envUIUB. At ff
lb«r* It « oooilMoilaii, * Irucaf ili* nrialntt
tBl«riB«dUI* «rpluin^ Ib llie lulvrLot flf i4ui«
«*<ll1uUaiiBIiigrpli«a*Biiua«BUliilB{c*lla.
510 IKTESTtKE.
tion. Tlicjr are also found in the other organs, the lungs, kidueyti, ete.
The neighboring lymph glandd are alwayn altvrad.
Epitiirliomata. — Cylindrical-cclk'd cpiUioliocn» i« ono of the OM»
'iBoni'Et liiiii>ir« of ttio «mnll iiitestini;, tlio Wrgy iniuAiiic, and tlie njotun.
It hiw (m^oiwlj- tlii> jtanio naked eye and luicroiicDpic (.-liaractvra a« in
the «toiiiaoli, and it hn» al»o a similar Hlarlliijc point. ( Kij;. 'ITV.y
Epitlidioma tvitli pavement cell» and aplierical cell uefltd, ta sotovtim»
met vridi at the anus.
TUBBRCULOSIS OP THH TKTESTIXE.
««tilt preserve tliwir nornml ejlimlrtoni coll»; tliey arc Lent »nd
«te<l, aiid can no longer freelv euijit)* tlieir necretory proiliicu ujioq
urfm» of (be intK'ous memhmne. l>a[cr tlie centre of the tubercle
^ tieconws opa(|ue and cadeoua, am! ÎU elemeiiM atr»[)liv nrol
pe filled wicli Bne >;ranulea. Ttie cclU of the luljular gliinils enpe-
» a similar kind of de;;eiiGration.
MR tfa« tubercle granule buj^ns in the tissue below the tubular
|g, th« «bote i» covered by a layer of -^lamls and villi. The lulter
w in tlio former cane, ttie Hi^at of n liypcrtrophy ntul un incnrnse of
tniuverve diameter. Tlie glutnU of IiK'borkiilin tire cloii^ntcd and
wilfa eylitulrtcal c«llr«, and tht- villi luiw the tendoncy t» unite to-
Mii form graiiiiluliou Usaw. At the bv]$iiiniiii{, tlie Miieciftl
Fig. 27S.
«fjil*4- it, mu'eLv I't Britclre. C, fahm[tritii* 4'viitiDcIlTc <Uau4 liiflUmei] wlIU I7»pbt>t4
id •akUtmqf m nmnl'iir of tul>#4vZ<-< In tatIdui »i4f m : tE* bUioiifntBDiji ftiiiiaii. li.K, y,
\tmly Iht t\rfalht «D'l ]i>a^Ufi<hi>4l itruirulAr t'liiil uf Ili« luli«4titie ii4<t pvrll<iu«TJiu^ fT, f^illf
!«■( ; f. uotofl'd^'J luliitrirEd* ; lb* Iwo Nnara VidUh- (Si lawfrailcv jiaiEit Iv liibarclu lu Itm
K «ti'rh pMiMiM- ni<t fnfmt »rn i-wn (Irmph uruali ml mrrn», giunt t*U»). Th<.m nr»,
, «DftAktil lubflrtLp» wblfh kfr iiDl Iriltrnd : t' lbli«r<ln «Ufa <^r]klr*l *4jf[iin]iiC Iti wKLfb pBft
t^r**j »*•• fa" f^n'u out t^, tof <*poil ïulrfxclt* -wfafli* r^vlltn fi-nn |f*Tl vt the ul^r,
I ^lrt<^4>>ltr*ijr'*i*b by f^iàtyrtu J. J WovJvferd. T. H. Aro^f . Co|>khJ from Uk4t*oaaJ jntJtr^
■t ■!■• Had)»! nod «urglul IIIiterT of Iba War ol tba KuballiOD.)
imatioriA of ttie closed follicles in tubcTculoaU do not ditfer from
t "jipuirenlérie;" bm soon the follicle Wcoiiit-s mf-re and more en.
I, «nd présents al ita centre a whitish or inwiah opscity, 'ttie
«s tlms hvpertrophiod are loii^r, I» *- than (he
pie granules. Often, in picking * needle,
lexudes a little cloudy, whiâgh o lupcn-
{ranular lymph celU, and iar|i "» or
lei aud fatty granules. & 'e
ISTIBTIHB.
tUBMra, «« «CD tlint their periph«r;r U man shttrpW iiciwnttA (i
Burraunding tifsuo tlinn i« the ca»c with tnhdrck-, n'ml «c noma»
■erve (be coni«nt« of the f<>IUcl« tniiHr'>rni«'<l inlv n ftnall «htem.
Those Kmall folliciilxr AkweKsex pi-<)ji^:tin>; iiitti the liiimii ofthl
tiiinl uitie, jiCKiAeiiH on that mA« a thin wall, which ri>ni)i1v ni^itiun.
tlio CDiiteulA (ligictiarj^ing little hy little, there r«itult« an iikoH
enlarged. Sevenl altered follicles looatei] *t one time in a I'evfr's
kt another time in another point of the mucotis membrane,
rouiKleil mo§t fre({uentlv by a diffuse inflaiDmntion of tlie Mboneoi»
iicctive tissue, and at the snmc time by an inflammation of tiic riffi
ginnds. unite to form an clevati.'tl ]<nicb which Boon uWratM in «ut
more points where the folUcW arv moi^t discaaed. It ia in thiii way
ulcers of the miicouM membrane iu tiiberciilosie are formed. Wlifii
exftniiiies with the microscope the ed^^s of these ukcrs.aomeihingiflS*
anmc leciona of the villi ami of the glands i* seen as \s met with at ike
surface of the AnoUeii patches in typhoid fever. In rcniity tb« villi M*
mrl)y effaced by the Awelliui: of their apices and fusion of thi^ir iiawi.
They are infiltrated with embryonal elementtt, and nro tnntiforiiied ini»
lar^c granuiaciona irbich unite together. The gland* of 1 Je1>erili)iD m
modified in form, in some place» compressed, in others dilated, partKO-
larly in their cuWde-sac. They are filled wilb cvlindrical mIU «tiiei
are generally larger than normal. I'pon the bonier of aome idcon ii
full suppuration, we see villi transfomieJ in»
large, very vascHlar granulations, «'!««»)
from each other by deep dcpre««io«s, tlie re-
mains of tubular f;1ands, line<l by a ir«ll-in-
served cylindricil epitbelinm.
When the tubercle ;;ranulea are coaflnnn*
they are surrounded by leaious of irritatitorf
the mucous membrane and §ubmucous tiMW,
and an ulcer aoon appears at the pointtfcwt
invaded or where the circulation U arre«wi-
Vlceration ia moat frequently effected llin«*ff
tlic mechanism of molecular ^ngrcnc.
Whatever may be the mode of nice rail *-^^
the iispect of the ulcer, its ulterior coun»,*'^^
its consequences arc the same. ^^
Tuberculous ulcer» of the «uall intesiir"^^
bave a round or «■lousateil form, llieir lou^ ^
loTi^itud'.iial when in the Peycr.
Hfi. 270.
h El "' r "I «riiiLii LiLr»'irii1ftf
ulrrr* III ■ «vrf vhifhUy Ibickaocd
IPiwm ■|>ti<iiO'<i>irrrncni'ti tifHut-
tniD J. 1. Wi<DdK*r>l, I'. S Itraxy,
Copldd fmnt Ihf^ •iHviac] niodlciLl
■IMatj or (ba War at llw Rabal-
ItOB.)
axH \i loTi^itud.iiat when m the Feycr^ i
)>atches ; but ouUide of the Peyer'* patebes^^
inlhe jejunum, in the small intestine, and even ^
in the ileum, it is nonerally transverse. Rind-
fleiach regards this prédominant tran;^verse
form as due to the fact that Ui« grR'"d»tioi»s
follow, by preference, the w»lls (if tlie bl
vessels am) lymphatics, whoise oourM is gc
rally transverse. Tlie 8innou«,irre pilar,
inoro or les» serpi^nous borders of these ulc«rit are thickened and pnwiî
neut, and contain tuburi'le granules or altered foUiotea, caseous iu ih'
lions
TDItBRCDLOBIS OF TOE INTESTINS.
sarroundiMl hy the atmve ilfiftcrihei intlninmatnr)' lesions of
à t^laiMla. Tlieir floor h also covered willi grav or whitish
iliich are inostty iiiberclos in process nf elimination. Kk-lis
^al liiese vrliiti!«h ^niins are al>T.ivs tymph vc<i9clâ: it i» ii fact
rail of the IviDiih vcsseU is often u slarting-jtoiut of a tubcrolc
exatniiiu tlic peritoneal surface which corrcspomU to the loca-
te uk'cr of the mucous lucnibraDo, no al way» B0« a certain uumbor
e tubcrck- i^ranulvit, Hcmi-
m ^.\
^■'
j'-
ent or «liRhtly opn<(iic itt ^Us- !WT.
ro, fonuing an i-lcvution
e surface of the Merourt
W. Ttie lymph vcitneU,
merge at thia [loint to
rito ihc lymph glanda of
entory, a]i|)ear as lar;ie
eordi), of a whitish or yel-
]iit« color. At 'lilferent
liey present prominenLXB,
it tubercles which are de-
in their wall» and when
I cut then! often e«cape«
m a whitixh cnseoii^, nemi-
kS«. This {irrtwth in tlio
of the lyuipli veMcl» is
d of swollfn, ;:^ranu!ar, en-
l cells and of lymph cor-
which are ofU-n granulo-
kencfl results! the opacity
nukSB. Thin geetinns of
easeU maile at 'UfTcrcnt
inw the v('S!<fl wiiIIh infil-
«ith rnuiiil cflls, and at
1 the course of the vensel
ions xhow one or more
I developed side by aide
alU, which at these points
h hypertrophied.
le aame points the lumen
ftapU vessels is most fre-
vcry much lessened atid
r, and is filled with grun-
iph oorpuHcles.
I.J.Woodward believes that in the Jnlesline the tubercles fipring
I |ym|>h paivtagea, and that the bloodvessels are rarely, if ever,
J affecteil.]
iflerenl lavera of the connective tissue of the intestinal wall a
of mberc'le K^'fulcs, and ulceration is cflected by the pn
Ich we are already familiar. A complete perforation of I
aajr be efi«cted by the spreading of the ulcer, but this a*
Sectbo throufh thi lunMin of ft Ijipphirlc tn thi
ftiihujitro»!! of Ihi^ fUuiu, in tiilif^rfiilv^t «f Ilia
1(11*1. X 'W- A Ermi>ii!i' DbFlii Fliil u. lu nliU'll
bnlJi txmpUoJd *tk<t vueI^iUhIiuI '.'Uniiaia D-rv Ibi.
hftltli^A. mlli'Tf' 'H\ ^110 *i4f lo Ih*^ Wftllpiuf a Ljrnbh'
■lie VO»«t«1 tTE whijpij LuinviEi fl, h^ ioaMfll'f'à ifllilitLhd-
tlnl cii:L]4 lin tjcf, Alpillfef pEfiiifnlA Appi^it' Id Ifiq
MbD^cIJ** 11«4i.fi AurroiiQ^Tti^if ILv v«av-I, villi n
bumhur of jj-[iL[iliiilil cpIU, ona vf wEikh In latii-
fiAL'il AI if, I K^nin h phiiti'inlcT^'Ifrjitah bj S^ur^Aia
J. J. WjuilifBiJ, V. &. Arui/. Cnj^'ii^d fr^in Ih*
■npjqil riinilir*! mlnmn of Ibo Vfhllfjvt Biiil Hd'^caI
UUMi74t Ihi Wv vl ia< BcbtUlOB.)
512
IHTSSTINB.
is rare, beosuw pulmonnry loxions or tulicrcnloiu infltiiiini«tion« oT i
Mrom oavitÎM occasion <k'nUi before thu intestin»! lofions have tvac
th«ir li^rruiriiitioi).
.SniDOtiiiif» tliii infill nimiitor^ niid Uiberculous infilLnlinn of the
int-niltrnne is so great thtit there may r«4ult in coiu>e>jiieni:« a iiurovî^
of Die iiuoi^tinat canal ati'l itâ conae'iuences.
Tiibei\:u1ou3 ulcere of the recUun may be located ftt the anw toil
invado the connoctivo tiasuo of tbe aurroundin^ region. It b noti
sary to mid (bat in tuborculosU of the intestine tho mticouâ nKflibrauM
the ei'at of « more or liws intense catarrh, with bjrporewretion of i
PofilnD <4ihe tnbnaovM tM Tlclniif >irtaliar«nl*rnli)rT<>rth>t)*aiii. X*'"* ■■*>■• aMiksisIi.
^■intil«q, «Di|nib«IUl 4«n«l.aa'"f (Th1«h U luiltAAltil 1*7 n.mid niimorviiA Ijrnpbald alitmtitU. tv4 4^^
«bleb ■» liillsiKd I7 h. tFrt-iD ■ |>linM'iii1oh>tmi>b bf Snr^MB J. 1. 'Ktot'mt.it. V. ». Atm^^
C^l«>l from Iha ■tcitud Biadli^iil vvIubm of tlx Xidlnl tnd tuMlMl HUUIT «' tiM Wu tt <b^^
H*brlligii.r j
The tuberculous iik-f^Tntlons wbicib bavc just been dcAcribcd are often
cons«;utivo to tubcruulouM ulcers of the lun<r8, nnd may be CAUsed by
ftativnts swallowing the sputa. Th«y occasion tubcrcle« of the |>criloneM
yinphatius ; but tubercles [iriiiiaril y developed in tlie jteritoucum only
very rarely give rise to intvittinal tnbi^ruuloai* and ulceration.
Svniti.iTic Ti:»oiKi aku Ui.rivRii. — ^Tbe ulcerations of the intutinv
which follow Hyjibililic (^uniniata are not much more fre>|uent than tliose
of the »l">mach. There exist, however, several very concluatvc obsen*»-
tionn which place their occurrence beyond doubt.
Tfiese ulcora are chnracterixed by their thickened odgoH, which iMOb-
times contain nojtdes caseous at the centre; by their bottom, which
yields hut tittle pus and wldch consisto of a dvuse tissue, yellowish-gray,
VASOOLAR TUMORS OP THB INTESTtKK.
513
fibmufl consbitenoe, and which correajmmU to a cicnlriml fi1>ruii3
iekeiiing umI elevation of the «eroiiH meEubrAiie. 'Hii^ imliiritteil (ibroua
ssne is infiltrated wiUi i^iuall rounil cellular elemenu. Tlie 1>e;^iiiiûng
tlieae irrowlhH has not been precisely delermiiwd ; in llie small intes-
ne Uioy luav be soated in ilie Ijmpli follicles of IVj^er's patches, biii if
icy start in the closed fotlicloa thoy also inrade the neighboring tiasue.
'tip lyinpbalica which emerge upon the serous surface are altvred and
uottml.
According to tlio opinion of Ooisdin and othcr«, the ext«n<iirc nicors
if the rectum aot'ompanivd by indiirution of the eoimix!tive tinsue, and
KKoettmeii bycwnsideruhlocontrnetions.are not chnnicierisliu of *yphili>t.
rbcM iik-cni differ from those of elironic dyiteiiicry in thi», that tliey arc
kotdcrc'l by « narrow ring, and that they oocamon con«tnclioti«, whilst,
M die cootmry, rather a dilatatinn of the rectum is observed in dy».
Mtery. More fre'|iient in woman than iti man, they succeed chancres of
! anuii, mucoua patches, or condylomata.
1 Fibromata. — Fibroma onginatins at the Burfaoe of the intestinal
Kous membrane is rare; in the chronic forms of dysentery, we find
nil Bhroiu polypi around tho tiiccrations of tlio rectiuu or anus, where
the form of papillomata.
^^^ luotion ol' fibrouH tis-^uc is iisfiOfintcil with adenoma in certain
mii^n'! i>olypi which prcaenl a dcwlopmcnl of piipillm at their surface.
t'iKr'i-mif'iinit. — .There *omiaimci* exists at tliv wcrom Murfacc of the
inteittiiie small semile or peduncutaleil tumors, comgiosed of Bhrous lisitue
sad buudlcA of smooth muiicles. These tumors do not diiler from tlioM
brmed upon tlie seroiui surface of tiie stomach.
Small liiftmata may form very rare growtlis beneath the mucoua ment>
lïïne of the intestine.
PVabcclar Ti'MOR». — Dilatation of the veins or phk-bcctacy is not
llr«<{UODt in the lar^c intostiTie, especially in the hiKinorrlioidal plexua
round the am». Varices arc oft^n found in the small intestine, form-
ic an olcvatton of tlic mucous membrane. The causes of the«e dilat»-
fKw are all thosi' which determine a blond «tasu of the different branches
r Uie portal vein : cirrhwi* of the liver, dUea^e of the heart, abdominal
nnorii. increase in siae of the iilmi.*, efforts of parturition, coiisii|iation,
ke effortfl in defecation, etc., all causes nhich ii)i|>ode tiie counte «f the
loo<l in the hiemorrhoidal veina.
rwraorrhoidfl consist, at the coramenccniont, in a simple dilatation of
veina at the border of the anus, and which form there a slight pro-
Wtion. At the same time the veins situated beneath the rectal mucous
titnibrane, above and Itolnw the sphincti-r. an; dilated, f^ntor these
ilatatinns increaw; in size and become dintcndeil under the form of little
imps by the efforts at defeeation. Uiipturo at some point of the dilata-
on. cot»ci|uent hcmnrrha<^ and catarrhal irritation of tho mucous mciD-
r»no of the lower part of the rectum are the usual seijuelss- The ccllu-
\T olenKnts of the altered vein* expc^rience the same alterations which
mve t>e«n described à jir'if-* of varices (see p. :i42). The oonnwjtivc
hMuv around the veins may thicken, so tiiat neighboring veins are uuiiei*
SÏ
514
IMKBTINB.
by >tt in<lurat«<l tÏKtiie. A «Mlion of on» of t)icw^ tittnori re»euMi< (tn
of a varix. Atl thu cAviUes do not 00(amuTiicikt« ilireotly with tlw |i{||
cipal vt-A.4i;N (blîml hajmot^hoiil!)). Citluareoiiâ itiRhraiiona of liie >ilH
of the (iiaeaADcl veîiis are soneûaiea obHerved. M
Aukxomata. — Tbeso tnmora cauaed by a hypertrophy of the dÉJ^^^
lar layer of the miicoiu membmuc are rarely mi:t witli in the "B^^^^H
testiiio.but they arc v«ry eonimoii in tho rectum, whi're tlivj fonni^^^^|
polypi, which are vcrv tro<|iiciit in childron. Th«tr type is tlw pm^^|
of the atomauh a.lrcaay described (see p. 4i58). Their constituent F^l^^|
are only a tittle more rej^tilarly ilisposed than in the Htomach. Tbc^^H
polypi may bo the cntixe of an invagination of the largo intestine. Wte^J
ihcy project «xtornnlly throii^^h the «nal aperture, that part of tbr ifrVJ
veittiug layer of epItlicHum, which is in contact with the air, ohuM^J
ita character ; the superficial cellR which were cylindrical, like thase^H|
the intestine, heoomo Battened and pavement shaped, and the i^urfiM^^|
the jKilvpti.i aA)4iimcs all the characters of the skin, except in romaiaii^^l
red. Tbia peculiarity is observed of all forms of polypi which fCM^H
extenutUy. ^H
I.VMriiAi>B.\OMATA of thc stomach and iotc«tino hare been «tmM ii K
the first pArt of this manual (paj^o 142). It i^ espeoially in tlic 1i)«rr ||
tiortion of the small iiitextinc near the ilco-ciesal vairo, that itiew tvmn V
lavc hern observed, but tlicv may be «eutvd anywhere in tlie leu^çtliof ■
the ga^tro-inlcstinul tube. Jn two casus of I'ioot and Uemlu the »• H
famaatjon of adenoid tiiiAne had invaded all the layers of the tntwliw H
and the mesentery, and there had reanlied an enormouB tumor. Tbwt ■
lesions of the intestine and stomach nsiially coincide witli other aJeiioiJ I
neoplasms of tlie lymph glands, the apWn, the peritoDcuia, tlie Wfi I
the bones, the skin. etc. Lymphadsenic ulcerations and tumors ef th« 1
intestine to the naked eye, resemble cncephaloid t^wtlu; their cut ^ai- I
face yields a juice by scrapin», and their extent, tlioir thickness, the** 1
pri);;res«ive invasion of the neif^hborins tissues, their iiitoAtiiial uiDUf*T
and their peritctioum, and the degoni- ration of llic lymph glamU velT^
closely assiinitat4! them to tinnors which have formerly been called ca^^
cerous. Notwithstaniiitif- that they may bej^n in the closed folliel^^
and I'eyer's patches, the lymphadenoraatmui iufiltxations and iilceratioD^
present totally different naked eye appearances from those of typbow^
fever, for they do not remain limited to the I'eyer's patches, but, on Ib*^
contrary, extend indifferently to all the structures ot the mucous mem-
brane. They are bahttually transverse, while the lesion» in typhoid fever
are longitudinal. Tbey cannot be confonn<led with tuherxjular ulcers,
because there always e-iist in the littter tuben^nlur nodules or inflamma-
tions of the lymphoid organs, which arc uiisoous at tlic cenbr«. Moie-
ovvr upon the peritoneal surface, opposite tuhercular ulcer», we always
find small semi-transparent granules, which are wanting in the diuaM
we are considering.
Under the microscope it would he more difficult than by the nakod eye,
to differentiate the swollen Foyer's patchesof typhoid fever from leukse-
OARCINOMATA OP THE INTESTINE.
5t5
io proiliictintu. In both ca»c« in eflVct, previous lo ulcemiion, tlio tumor»
ow a cclliiliir iufiltriitioii of the villi, a lengtheutnj; ooinprcMion and
alK>:«rtitig of the tubular iilaii'L* which contain a mucoutt or (^r&iiular
lilhetium, u wuU an a cellular infiltration of the retioulated eiubnmcous
le.
I
Fig. Ï79.
ABCISOMATA.' — Primary carcinoma of the inte.itinc ifi incomparably
ore rar« than tJialof the stomach, but when it occurs it presents entirely
le fianic eharactcr^ a» nhon found in the stomacli. It is often secondary
I earcinomu originating in neighboring tiitaucs, the pcritooeum, the uterus,
it liladder, etc.
Tlie regions most freijuvnlly affected by carcinoma arc the rectum, tbo
tpatie portion of the transrerse colon; the ciecum, the duodenum, knd
ijiinum arc very rarclv attacked.
•^rirrhuM wid r»r--pfuil"id are met with in the rectum, the fir«t more
:eiiu<-iiily than the xecond. The tumor may be developed in the vicinity
r tlie HpliiricUrr, or eij;ht or ten ceiitimetreg above it. The ;z;rowtb aiarta
I tlie fiubmucoua connective riitsue. The Aubmucoux infiltration extends
I &Q annular form completely around the circumference of the intestine,
bd ooc«aions a conatriction.
The granulating appearance of the mucous membrane, its ulcorntion,
be extension to the deep layer, the hypertrophy of the njuscular coata
i the rectum, the infection of the lymph glands, arc id every respect
ip«rablc to the lesion» in carcinoma of the stomach.
'Author:! reconl the freipiency of coIUiid ciircinoma of the rectnm.
a certain that tumor* having a colloid aspect, are not infrt-tpicnt
n the rectum an<i other parts of the
>Bteetine, hut we nhouM not consider
tbtt every colloid tumor, with large
iWeoli filled with gelatiniforra mat-
l«r, is carcinomatous. As wo have
dieady swn, ejflindriml-ivlled epi-
iffioma may suflcr a colloid degcnc-
ttion.
The canccroiia tumor may ulcerate,
nd in ÛM way an ob«itructioti of the
imcn of the gut may be partially and
onientarily removed as with similar
ttnorv of the pylorus, and the ulcera-
911 may cause a perforation of the
itestinal «all, an accident which hap-
>aii> ntore rarely than in the !<tomnch.
Oocaâîonatly carcinoma may show
self in the inlertino under tbo form cxHo.i»..! «iw .i.iii..tii.in. fn.™ ini
I multiple tumors. ^,6»,lUr.l..«.ul-.uo.,.-l■...TJUJr.«l
Toe secondary nodule» winch ong- .puh^iiiim, r. kjmii, m», <r>n.iiinuii b^
ate from carcinoma of tbo inteiitine "■• ""'"" «' '"" ■«ijo'I'Iue fmuii. At it
ivsdc the peritoneum, and generally ,"■-" '■"';■■■'«•■'-• • '"■"•■' "" -;<■"'
l«o the liver, with a marked predileo- wmiHUuiuiMphoiiiiMMeniMKiwoUt.
CJ..
irOlMAL BISTOLOQY OF THE LIVBH.
61T
CHAPTER V.
TIIK r.IVF.It.
Seot I.— Nonnal Hutolog7 of the Liver.
Tub liver is cotnposcil of lobules in which ilio lirjiiitic ci'lN an' plnceH
tin connection with tho hlood of the porliil win. I.iirgo iiinl rik^c'iilnr,
fdi'si^R-ii lo clalioratc the Mowi of the [lortiil vein in its passade from llie
atcstinn. «plccn, nml heart, thft liver also secretea bile and [ioi»e«.tes a
I of excretory rlucb. It is aurroiinded by a librottH membraDe, tlie
^pnula of (Tlis.''on, which U covered by the peritoneam; the connvc^ve
itiKoii- of t1ii!t cajMiile accom|i»nie3
I
I
tlio vessels as tliev penetrate be-
tween (lie hepatic lobules.
Although the hepatic lobules are
not *1I of the same sixc and shape.
yet tlieir intimate structure is iden-
tical, and a single lobule niar be
taken as n Upc. for the description
of tlie entire liver.
Strwturr nf a Htjiatity Lohuh.
— The hepatic lobules are spherical
or polygonal in shape. i>f n diameter
one to one and a half millimetres;
tl>ey «PO appended to the divisions
»of the hepatic vein as glandular
lobules to their excretory duets.
The principal extra- or inter-
lobular bmnches of the he]>stic
vein give ori;;in t« very short
smaller branche» each of which
enter» a lobnle, and i:« named
intra-tohulftr hepatic vein or cen-
tral vein of the lobule. At the
centre of the lobule, the vein di-
ÎDto capittariea which radiate
%rda Aie periphery of the lobule,
and anastomose with one another
Fig. 280.
I.w*r of DhlltJ Lbrfnn nmnlhi* olil, b«rit^D'i1 Ln
rtruiiik ■t^<I. The hciml!* olli lit ullli ItiTii
nqvlAi »rv «fipiirftliKl Ftvin Ihf c^i-UUrr waXl bj a
•utnil ifii"vrDiD|f «pAPp. Til" o«rlllafl«4 iqjp4a-
fair rnliirlf** rorpM*o]<i*, A f*** ^lonjrnlvil niif^lM
of thp r4p1>tBr/ wmll BTn «n-D- Within thf* Jlurif
(•tiion of ■ W\»if auailCDlu* !■ «ou i«> id].
iatritlnr.)
b? short transverse branches. The
duDteter of these capillaries is .010 mm., and they are separated by an
average distance of .Ol.'i mm., forming a network with meshes elongated
, in the direction of the rediatinj; capillaries. Communicating at the ceo-
1 tro of the lobule with the central veiu, the capillaries at the periphery of
5M
UTBB.
the tubule rec«ire the hloocl of the portal rein, and are directly oonliini>
0U8 witli the sDiall interlobular portal veins. These I»lt«r are placed in
the prismatic spacer formed between the lobules, and ponctrate the latter
al their surface, so thut each lobule receives its blood from four or
fivo branches of the portal vein. In the same intcr-lobolar prismatic
«paces which receive the portal vein, run branchies of the hepatic artery
and inter-lohulnr biliary canals surrounded by connective ti>uu« in con-
tinuity with the eapiulo of (rlisaon. The capilUricH of tlie hepntie
artery are espeoially deiiigne<l for the nutrition of the walla of the portal
rein and inter-lobular biliary canaU. They are found especially at tJic
peripliory of the lobulea, where they anaotoroofle with the caiiilUries of
the iohule.
The lobules are in contact one with the other, separated only by the
mmiticatjons of the portal vein, biliary canals, and inter-lobnlar hepatic
artery, accompanied by a small amount of connective tissue ; their capil*
larics are intcrmediuie between the portal Biid faopatic veins.
In the lobules, the spaces between the mMbu of tbo capillaries aro
entirely 6IIed by the hopntie cells. ^^H
The hepatic cells are small bloclcs of soft grannlar protoplasm powea^H
ing one or two nuclei, round or ovah The shape of the celts Is readily
iDoditieil by the proasure of the capillary vessels and noigttboring oelb.
When exumincd isolated, the cells arc seen to be Hatteued, polygooal,
F>s. S8I.
'Fig. 382.
-0mm
liBlaUd bapitte Milt, a luil >i Domiil. bni I)
llidBM nil pufUelv*. « Calla <■ i*rl»iii alftf**»!
ttUj dr(4a*riilluii- iOiutkhIu.}
E«ir-
Jl.^A.*^
Purlli'O af Irmlwnli at btfaltc «lia.
UniDaa. \0aTptK4rr.)
k
with four to aix sides, or with irregular eilges ; one of their aurficea b
generally notched where it is in contact with a bloodvessel. Kxaniincd
in thin sectiona, each one of the hepatic cells is seen to be in oontacl
with five or more of its neighbors, and to touch one or more blood
capilUrieti.
The granular, semi-fluid, protoptasmtc mass of the hepatic celU tn-
([uenlly contains fine yellow ;j;ranulei of biliary pigment or red-color
granules which arc derived from the blood. They also iucloM gtycog
MORUaL UISTOLOdï or TUB LIVKR.
1)19
r
granules, nliich may be colored by tincture of iodine. During digestion,
tiie cells «t the periphery of the lobule contain fat.
The cella do not possess a separate membrane, but thuîr granular
ibsiance is densei- at the surfncv of the biliary canuts, and t'orms a
in cuticle, scrv-ing as a wall to the canals.
OoiMidcrcd in their mutual relations in the lobule, the liepatio cells,
toconlinji to Kberth, ap|>t'ar to form series or cohimns radiating from the
centre to the periphery, nnd una«toinojting tmntiveraely.
Tlieic network!* or trahtcuUv ;j' /iffiatir rtU» are eompared to the lubes
containing hepatic celU which are met with i» some animaU (fishes and
reptiles). This apjwarance of trabecule ia due (o tlie general conlÏKura-
tion of the capillary network, as demonstrated by Hiring and KùUîker.
In man and the higher mammiferro, there is no membrane comparable to
a glandular sac which incloses the hepatic cells and separates then from
the capillaries. In the rabbit (liiSrin):). the bepalic cells adhere to the
eapillariot, aiuL do not scparat« from them nht-n a piece of the liver is
placed in alcohol or chromic acid, rcngenU which cause the elements to
shrink. In man and <lo^s, the hardening notion of these âuîds sepa-
rate» the cells from the wnlU of ibo capillaries.
The hepatic lobule abould liien be considered simply as a (wntinuotis
of cetU channelled by a capillary network, the cells being arranged
koconling to the form nf the vascular meshea.
Tlie biliary veaaels have their origin in the hepatic lobule by a net-
work of fine eanalicnli. which form narrow meshes, and are in contact
vlth all the hepatic cells. This network connects with the intvr-lohular
biliary canals which ui:com]mny the branches of the portal vein.
Vig. 293.
Fig. SM.
lajMltl U*nof nbUL Tb* •Ii-n.lri l.llnrjraliaJtruI)
KD*. «ftcb al Ihn iD«ah<.« oi «hleb iATU.>ir* h bv|4-
nnrb «Mm hlwjd »pin>HH> tn hIk igan.
IiiJii?I«4b>ni>rTmi>*llrHll of rmb-
till. a. Bllliirr «okllenll. ». 11».
pKil« r»Ll4. r, KntiiLi bllL&rydDft*
%l barder of labnl*. 4, illodd tm-
tUUtr. (CUrptHtrr.)
The biliary intradobular canaticuH or capillariea have a rectilinear and
[regular course ; their diameter i;* -dOl.S mm,, white that of the me^ihes of
tlie network varies from ,0I4 to .1)17 uim. in the rabl)it. They have no
cells in tiieir interior, and tLt:ir wall is formed solely by the hepatic cells,
62?
lttbh.
tlie aurfnce of wlncli Ix'enmci' con(lcii*c<l at thin [loint aimI font» a ton of
cuticle. The iikmIioi* i>f iho 1>ili«rv ciiiinliciili arv «loiifçatvcl i(omeirl»t
like ihe blorxl L-uiiillnriefl. I'lie c&tiàliculi (laiw Wtveeii the h(.']iKlic eclU
in such a inanuer that ihey do not come in eonlai-l with tlip ca)>ÎIUrT
Lltitid system, from nhich ihoy are sejiaraleri t>y at leant hall' the nitrt'nce
' of a hfpalic cell, llio meshes of the biliary canaliciili are ]>oly^onHl,
followin;; tii« shape of the hepatic ceiU. Kacli cell in coiisojueiitlj iu
i-oiitavt with a Wood cMpillary by m angles, and by svvoral of it» surfaces
villi the hiliary ciijiillariett.
At thi- iRTiphery of the lobule the biliary capillaries uiii«! to fom
xiiini'Mhat uarruwer networks, which empty into tliu ]>vri-lobular iMliarr
Curiiil.i. ^^^
The j)«ri-li>litilar hilinry canaU have an entir«ly tlifTereiil iitriicturej^^l
They are formed of a thin enveloping membrane, in the interior of wbtch^^j
is found a complete lininj; of cabical epithelial celU provided «itti a
rninid or oval uucleus. At the centre of the canal exista a narrow
Iiuneii for the How of the secreted jirodncta. These are Ime excretory
ducta which are in connection with the biliary capillaries, which tatter
have no cellular lining in their interior. It is the hepatic cells wliich
njnvBent the secreting c«'lls of the bile, which, being secreieil by llw
liopatic cells, Gnl enters the small lutra-lobular caiialicuH, theu paswM
into the peri-lobular canals.
î>uoh arc tbc essctitial «lenienti* which i^nter into the corapoaition of •
lie]intic lobule. It n-niains Ui consider the connective titwie ami lynpb-
aticîi of the lobiUei*. The eonnecltve tissue wliieli coiuph from the
capiuie of Gliaaon, and the faaciculi which accoinpany the interlobular
\ vessels, penetrate into the interior of the lobule aa very fine fibrillne. It
I ia connected with the wall of the cnpiUurie^, forinin;; in places a kind of
adventitial or it is spreud out between tbc cai>illancs, forming a reticu-
lated tissue. The existence "f flat eoniicctive4i»suc cells applied tu
thi'se fibres is ijin^ationable. By it.* union with the Iilood atpillarie*, tbc
reticulated connective tissue form^ in the lobule the frami-work vbidi
aupfiorts the ht-jiutic cells.
The porijiberul oonuectivo tissue of the lobule does not always eon-
atitut^ a couiplelc coverinjz; at times, two lobules are joined at (heir peri.
i^ery without any prolongation of the capsule of Glissou being inierpoded
between tbem.
Upon the surface of the liver, the capsule of tilisson can b« derooa-
«trated to consist of two layers: one serous, formed of loose connective
tiHsue covered by the endothelial cells of the [tcritonctiui ; the other,
. deeper and thicker, is in connection with the hepatic lobules and consi:
of a close and dense fibrous tissue.
The existence of lymphatic veMels in the lobtde has been admitt<Nl by
Madjiltavry, who, in injecting the biliary veiifleb, produced extra\*asa.
tions located around the blood capillaries, between them and Ihi- hi'[iniii:
cells. In similar cases, the injected substance has been seen by Kijllik
to flow into U>e ]>eri-lobular lymphatic vesscla which accom|iany
! portal rein. It ia certain that in tlie cat, dog, and man, the hepatic
cells are easily detached from the capillaries, and it is those peri'Vajouhu*
space* which .Mautiillavry regards as the lymphatic lacunie. Iléring îb
OE!rXRAL PATIIOLOOICAL AXATOKT OF THE LIVER.
i
\
lop|<ow^ to tliiii view nnH savâ that in tlie raUbit nothing of a Rimilar
UMure exista, lti« hepatic cellâ adhering alwa,vs to the wall of the
r The peri-Iobular lymphatic vessels oneistof trunks or networks, whieh
'Boeontfmny the portal vein and arc united upon the surface of tJie liver
with the BupeHiciiLl network situated under the pi-ritoneum.
Nerve Ëlamcnta have not been met with in the hepatic lobules, and in
the latest invention tions they huvc on); hcvn foUowvd into the walls of
the iiitcr-lobular portai veins. [l'Ail^r liait thought th«t h« conld troci:
fine n<>rvv filnincntj* into the periphery of thi- lohnlvs, and occasionHlljr
oouM cvvn M« a communication with an hepatic cell.]
Tint hillarjt rxfvii'iry duct». — The biliary capillarief» of the hepatic
tobtile empty, ha wo have seen, into the interlobular canalii. The hitler
acvonifiany iJie ramifications of the portal vein, and join to fonn tarter
trunka which follow the principal branches of the portal vein. As they
{Mas out of the liver, two principal Crunks unite in the transverse tissure
to form the hepatic canal, which is continued partly as tlie durfun vim-
tntuNia fkofetioÀu» (common biliary duct) to the internal surface of the
duodenum, and partly aï the cn»lit^ du-t to the gall-Uiidder.
Bonder these principal divisions, th^Tu ext»t accessory ramifications
which unite with the two branches of llic hcpnCic cnnal in forming
* network in the tninsverse fiesnre. At difft-rent [loinu upon the sur-
face of the liver, the biliary cftnitU divide and aiia>*tonio:ie in thi.' conne^-t-
ive Ltfuue; thuse entering the left triangular li^atuent extend to ttie
diaphragm.
The interlobular biliary canals are composed of a membrane of co».
nective tissue. The smallest have ft lining of cubical epithelial c«II»,
while the larger canals arc lined by eylindrieal cells ; in the smallest
intcrlohubr canals it is difficult to sec a membrane, and their colls are
fretpieiitly tittttened; the fibrous membrane of the hir):e mid medium
eue canals contains smooth UKisciilar tibren. All thc»e caniils arc pro-
vi'leil with snmll simple or eomponiid f^lund», farmed fiy round or elong-
aie<l rc.'çicle:^ which optm into the biliary duct, and have a lining of cells
similar to those "f the duct.
The epithelial linin;^ of the hepatic, cvitlic, and common biliary ductx,
and of the gall-hladdcr, conïtiotit of a stîn^le layer of long cylindrical
cells, the nuclei nf which are oval and elongated in the direction of the
celU. The subejaihelial connective tissue has a very abundant network
of capillary bloodvessels.
The gall-bladder has, beneath its mucous membrane, a layer of con-
nective tissue traversed by fasciculi of intersecting smooth muscular
fibres, giving rise to an alveolar appearance. It is covered by the f>ori-
toneiun upon its external surface, and possesses a network of aubsorous
lymphatics.
Sect, n.— General Pathological Anatomy of the Liver. 9
[Commence the study of k-sion? of the liver by a •tencral observa-
the pathological anatomy of this organ. Oenoral pathological
&22
LIVKH.
ftnatomy » OM oF tlic most important braocbea or ];;ei>eral pntLolnsr,
and each organ majr be looked upon u having a genorol patbologj whicU
ppoMrlr belongs to iloclf.
Tbe situation of ttic liver with reApoct to th« course of ibe blotxl
loaded witb the materially of (lig«Htion, it« consi-qiicitt relation to intvs-
Uinal diseases, and the large amount of bVioil which ciTiliniion^lr poesa**
Hirougb il,reuderiirerv liaMctolesiotissRuondarv l'>inle»tiiinl»i»âs|ilcaÎ8l
niHcases, and to the alterations of llie blood in utl •it'ii^r»! disoasrs which
'[Çroally derange the organism, or wbiob change Uic eoiiditioM of the cir-
culation of the blood.
Therefore, excepting* traumatic affectîona, it uay be aaid that tbe Si*kty
majority of hepatic aSectJouB are secooiUrj to otlicr general or local'
affections.
In warm countries, where dcranj^t'menta in the functions of the liver
arc f)0 common, the more intense follow intermittent fever, yollow fever^ I
dysentery, alcoholic cxccMes, etc. In our climate thoy are secondary to '
intermittent fever and dysentery, but arc always lcs« serious than in trop-
ical countrira ; the most intense hcpatio alfeclions hero met with are duo
to alcoholism, low types of fevers, ty)>hoid fever, variola, scnrlatiiut, etc.,
and to purulent infection; or they are occnsioneil by aflecliuns of the
biliarv oniials, the lobules being sometimes secondarily affected. Finally,
parosiU-H may aUo cause secondary diseases of tlie liver. Affection* of
this organ ar<^ found to be altnottt always detitoro|>athic.
In order to have a general idea of the lesions of the liver, it is neoe** i
»ary l" study the anatomical aheralious which its eiemiMiiary paruj
undergo: that is. first, those of the hepatic cells which make np tbo '
greater part ; nuxt, tb« cellulo-vascular tissue, and tinolly the biliary
canaU.
1st. C^ngtr in ifiv Ififpatip Celle. — It bos been Men tliat the shape
of the hepatic cells is polyhedric ; that they onuiu a nucleus, and ex*
ceptionatly two nuclei; that their j^raiiular protoplasm mntaiiw alW
minouo Hiid glycogenic granule.-*: that nnujctimes, in the nomuil state,
they are pigmented and fatty ; but under t)io iiilluence of the »eveTa)
morbid stat<-it, tlieir constitution is greatly moditied.
Their shape is very easily altered by pressure ; in the normal condition
Uiey arc frequontly moulded upon a cajrtllary. by one of their ekeavated
aurfaccs. From the pressure of tumors developed in the liver, the cellsj
may he tiattened in one direction, so as to have a resemblance to con>^
nective tissue with tamellu) and Hat eclls, like those of the internal coat
of artortes or the capsule of the spleen. :>con in profile each such cell
resembles a fusiform cell a little thicker at the position of ib# nucleus.
The hepatic cells assume such uu appearance when comprenscd by Uie
^ssue of a gumma, by a tubercle, by ft scirrhoo» iiodulo, hy a hydatid
cyst, ct«. All the cells of a compressed lobule tukv tlu^ saute shape;
this results in the entire lobule being flattened and spread out around^
the tumor.
Ill conse(|nence of the softness of the protoplasm of the hepatic cells,
the entire liter may be cbangeil in its fornk by the comturossion of an
abdominal tumor, ur of au effusion of fluid into the peritoneal cavity.
I
OIIANOBS I» THK KSPATIC CELLS.
Kxtcnial pressure from corwts also changes the normal shape of tlic
liver. In ihU case, tlie baac of the thorax Wing contracted bj th«
constriction, tlie entire liver is pushed downwards, ita superior earfac«
bcvomea anterior: this surface, smooth in the normal condition, is in-
tli-ntvd, am) presents depresùons corraB))onding to the rib»; the inferior
bonier of the liver, which nixv extends below the faloe ribs, is at times
turned up l<encAth the rib« in foltowiti^ the uohvcxity of the abdominal
irftll. riiosc deformities become permanent in conscijuenue of the
alTOpliy of the lohule» coniprc««ed in the fuldx of the hepatic eurfscc,
and from the thickening of the CApttule of (ilisson at the mme points.
Similar defomiiticH are very fre<|Uont in old [lersons, in whom the back
lit arched, and in whom the inferior bonier of the thoracic csvity com-
presses the anlerior surface of the liver.
The sliape of the cells ia also frequently modified by blood preasure,
sa in diseases of the heart an<l Whji^ nith increased blood pressure in the
rij*ht auricle. an<l consci|uently in the inferior vena cava. The pressure
in tlic infi'ri<ir venu cava is directly transmitted to the bepaiic vein and
to tl»o cvntral vein of tbc lobule. The capillitrieM are necessarily dis-
teitded, and conseijuently the bi^'patic cells are compressed and 0att«nod.
At tbe same timo, from the inlltience of the .Mirrounding blood pressure.
tliey arc infiltrated with tlitid coiitnining coloring sulMiance, and have
in their prolopla^m red-brown grannW of bieniatin. The pre^^urv con-
tinuing, they become more granular, griidiially thin and atrophied, itnd
may even comiileteiy disain*ar, so that, in ]<oiuts of the hepatic hibule,
tltc distended vessels &r« not soparatod by colls. Those arc the esaen-
tial lesions observed in cardio-pulmoiiury aâecûous, and ptutîcularLy in
lesions of the mitral valve.
In tmuut hepatic eoi]i;estion8 not accompanied by any impediment to
the blood circuliitiun of the liver, the ct-lls arc hyftertrophied at the be-
ginning. Thin oecur» es|>ccially in (he licpatic congestion ohsened at
the commencement of dittbelctt. The liver ia now mitfomily congested,
and the cells arc lartJicr than in the normal state; they also contain nu-
merous granules of glycogenic material. The entire organ is hy]>crtro-
phîed. Later, the cells are loaded with fat granules of medium sise, and
the liver remains hy|>erlrophied or retunis to its normal sixe.
In all cases of increased hlood ]>rcsâuro, the cells experience analogous
lesions: increase of nutritive activity, when the blood circnlatioii is
simply accelerated ; atrophy, on tbe contrary, when the cells are com.
prested, when there is an obstruction of the How of blood through the
h«patio vein, while the pressure is the same in llic portai vein ; pig-
mentation of the cells occurs in both cases. The nuclei of the hepatic
«ells are usually unchunged, at len«t there ia no atrophy even when the
compre^inn exist» in a high degree.
.\nother «eries of modification* of the cells occurs in all acute and
febrile infectious diseases of great intensity, as typhoid fever, puerperal
fever, rariola, particularly hemorrhagic variola, scarlatina, measles, ery-
sipelas, etc., as well as in acute tuberculosis, in certain poisonings, aiid
iu fatal jaundice or acute yellow atrophy of the Hvcr. This last lesion
bas received from Virchow the came of parenehifmatoua htpatitit, cer-
524
rfeR.
Uvar froDi ■ et*' <il •.mit rhnmtUira
«un hl|)l 1Siri1>ii(iluti- : lb<<«l<i( llisawdl-
nb^fd'H IKk (<» 1>(> «Imual IniJtaltdituUkilib'a-
tainly not a gooil term, «ince the signs of inflmnmfttion are litit rt
evident, and tbc term parcnch^'niatouA U open to (;niii:iMii.
Then; «cure in all then* affections, a clinnjre in tlie nutrition of ibe
celU, in connoquence of vrhich tliev Wcoine cloudeii, more aphvrivul, and
liirgtT thnii tionnat. The coniaincd
Vie. ii^- f^nniilca ol)»cure tbe nnclcuii of tli«
cHI. However by staminjiwitb picro-^
carmine, or cm|>loïin;; acetic acid
nuclei may be made «riilent. KxMiw'
■nation of ibc cwlls very often [trore*
half of them to notuieMH two nuclei,
some ovL-n containing tlirce or wore.
If tbc ci-Hs of a normal liver j)reMi
two nuclei it is excoptional, while hci
it is vcrv uotnmoii, and therefore abij
normal. Jiesidcn ttieae large cell» in'
ft stnto of eloutlff MPtHinj. there are
seen, in tlie tlitid nliuuned by scraping,
otberii without a niicleua ami âioall,
the i>rot«i>la8m of wbicb ta soft and
permibi the nuck-its to i;»capv ; free
nuclei are also fonnd. It is very ptol>-
able, thttt the protoplum of th« cells, af^r awolling and softening, be-
comes frugnieiUed.
^uuli is the letiion found in the first stage of fevers of low typ«, altliough
it \it not known to what actua! change in the l>loo<l \i correspooda, yet it
is evident that it k rclateil to tin* inlV-clioiiH nature of the ditteasc, and
lo the elevated temperature of the blood, and that ii ahoulii be oonaiii-
ered as adding to the gravity of the diiieatie. At a more advanced
period of the disease, there are found in the cells nnuieroua fatty graoalcs,
and a true fatty degcticrution of the li^er. as observed at the tenmns-
tioti of typhoid f<-vvr. In other diseases of tliia grou)>. csgwcially in
hemorrhagic jaundice, t)ie cells are atrophied, and broken down, they are
infiltrated with yellow granules of biUarjr inattcr in connoclion with »llm-
minoiiM and fatty granules. Inhales, or portion>( of lobuli^s are re])laeed
by the débris of cells. Post- mortem decomposition very probably jJays
an important part in the aofteiiing of the entire organ, which is «o very
extensive in this le^on.
Acute yellow atrophy of the liver is not tbe only form of pnroMhyT
matous hepatitis in which the uu11m are infiltrate*! with biliary pigment.
In the liver of peraona dying frtim hemorrhagic variola, there ia found a
simikr k-siuu. The organ in now large, soft, and of a uniform ffrayiab-
yellow color. Nearly one-half of the hej<atic cells have two nuclei, and
are cloud^'l with albuminous, fatty, and pigmentary granules.
Tiiu uiimerou» general febrile diseases all cause a parenchymatoas
bepatitiit. Although in them this losion may present ao evolution, ami
an inleii.sily slightly liiffercnt in the several diseases, yet they may all
he connected with a similar nutritive derangement of tbe hepatic cell*.
This scries of nutritive alterations of tbe cells in parenchymatous bcp*-
AHTLOID DBORXERATIOX OP THE LITBR CSLL8.
fi26
I
PiR. 280.
I
I
litis U «onnecMtl with a chaugc of the blooil in infectious fevera, which
jifl aa yet little known.
An analogous prnuulnr change, followed by destruction of tlie coll», is
[otwerTcd at points where tin- blood circulntion is int^rniptccl (by emboli
lor thrombi), und whi-n tbu cuUs arc compri>««od by suppuration.
MGond Mriea of nntriiirc changes is seen in chronic cachectic dis-
pnlmonary phlhi«is, prolonged luppuration*. «crofula, c»nc«r.
ste., and 18 eharaciorizcd by fatti/ infiHratioH or amyloid metamorpAvêi»
of Uie hepatic cells.
y-ilty iH<nition ooniiifitit in a surcharging of the cell by «mail oïl
dropH. Very rre<|iiently in the^e chronic cachectic diseases, tlic nucleus of
tlie cell is preserved, and therefore the hepatic cell
is not destroyed. It ia simply surcharged with fat.
The protoplasm of the cell contains either several
email drops of oil or a single large drnp, which occu-
pies almost the entire cell, and it is seen as a circle
of pmtoplaem surrounding the fat. In a part of the
protoplasm the nucleus is seen well preserved. The
appearance now very much rexeniblc* RiIipo«e celU of
the subcutaneous tissue. This \i tcnne<l an in61lratiou
of fat. since the inicleiw is intact, and since the cell
is not destroyed, while, on the contrary, the de;ieiie-
rated cells filled with alhuniiuous and tatty granules
in parenchymatous hepatitis are broken duwn and re-
duced to débris followed by a death of the cell. Each
fatty infiltrated hepatic cell becomes enlarged, con-
seT^ently there is a hypertrophy of th« entire liver. A phy si "logical
intiltradon of fat In the hepatic cells occurs during digestion, and at the
end of parturition.
Avtylnid dnjtnfrationt which is found in analogous pathological con-
ditions, aljo affects the hepatic cells, transforming tiiem inio small blooka
of a transparent, refracting mibsCance,
easily broken into small cubeii. The
jEranulcs aii<l nucleus of the cells have
disappeared. These small masses of
refracting material are colored brown
by tincture of iodine, and frequently
after the action of iodine, when treated
with sulphuric acid, they are colored
violet, blua, groan, and gamct-red.
Besides t^o two great series of
general causes, infectious febrile dis-
ea*e« and chronic cachectic di<«ease«
which «0 greatly mcxlify the hepatic celU in eonscquencc of changes io
the hhiod, the elements undergo other lesioii!» «econilary to a disease of
the liver v^hieli does not have its begimiingin the cells. Thu*. in reti-n-
tion of hile there is foiinil an accumulation of pigment in thwr interinr;
in acuie suppurative intlammutions, they are de^lniyed after having
LlTnr-f^U* In *&rlatii
•U|t*( a( [tity iDlUlr».
1 1 LID. X i""' litlaJ.
Fig. 287.
J
536 tivBR. 1
become granulitr; in ctironic cirrhotic iiiflnminiitioiM and iii lumoro. tlte^r
niA^ prcflciit u11 tho series of nutritive chunk's.
iîti. I.Ttùm* of tfir Crtltiht'tiitrular StftUnu — It \» ilifTiciilt to jW]m-
ratt- the IcAiotiii of the coiiiieotivâ tiiuue of llic cu[miiIo of <ilU.'i>m sur-
muiuling tlif iiit«r1otnilar hrniichc^ of the [lortal vt>in nml he|iiiti<r Hrter5
and penetmtiu]! with tlie cnpillaneB into the lohiile, front those of ihc
wall of the vessela. I( ia aroiuid the lobules and in the neighboHiood
of the portal vessels that the changes of the connective liasiie bv^in,
Thev arc uhuhIIt due to the presence «r foreign sahistancos in ihe ]>oruil
vein, which do not exist in theiiomutl ^tate. or of normal elentGiitx, nhirh
are found in abnormal ijtiantity, The^c suh»(urice« oocosinn, \>y ihcir
C'lntaet with the vascuhir wiklls, nn irritation whicli ts irutisinitted to tltc
neigh boriiif; connective tiitsiic.
Ill leueocvthieimii, for exanijilo, the hlood \a lowled «ritli numorotm
white corpn»elci*, whieh interfere with the oircnialion in t)ie veiWeU
and i-auae an increase of pn^iiure and a retudling diapcilesis of the kit-
cocvlea into the connective trasne. Thus otwnr true infarctions of white
corpuscle» in the connective tiaaue Burrounding the ^nuill inU'rlolmlar
veins of the portal vein and around the capillaries in the hepatic lohnlp.
In chronic intermittent fever with cachexia, when the swollen and in-
durated spleen is attacked by inteivtitial splenitis, when the wliite cor-
puscles contained in the lacuna: of splenic lisMUe are loa<le<l witli hlacl:
pigment jrraiiules (mehuiiemia), the lilood of tJie portal vein contaiiu
manv of the !*ame pi^mented lymph cells. The wal! of the sirall inter
lobular portal veins soon presents a black pigmentation of ita cellular
elementfl, and the pigmented lymph cells pass out of the vessels and
infiltrate the connective tissue i;urroHnding tlie interlobular veaaeks u
well as that accompnnving the capillaries of the lobule. TliOro !« aUo
generally found u lliicliening of the interlobular connective tissu*- ; it is
influtucd and infiltrated with lymph cell», some of which are filled with
pigment. This i« a variety of cirrhosis or chronic thickening of tlie con-
nective tissue of llie liver.
'Flic iDOitt rri»(ueiit cause of cirrhoni» of tlie liver ts akotiolism. tti«
irritant probably aclini; directly upon the vascular walla and upon Uie
coiuieclive tissue surrounding them. Alcohol is found in the blood, and
especially in the blood of digeation. The liver is always congested
after eating. partic\darly when large (juantitiea of alcohol have )>een im-
hilicil, and it is very probable that the presence of uloobol in the blood
acta upon the wall of vessels and through them upon surrounding con-
nective tissue, producing a chronic inflammation. In alenholic mrrhosis
as in malarial cirrlioHis, the hejwtie connective lisiiue Ik inllamed, there
are found in the developing «tago of llio disease numennw lymph cell*,
situated between tlie fibre.* of the connective ti«aue. There soon occur
a new fonnalion of fibrous fattcieiili an<l a sclerosi» of the vascular «alUI
which blend with the fibrous tissue. This atage of cirrfanaia continues a
varying leiigtli of time, and torminatee in a cicatricial contmciion of tbo
new tissue.
In purulent infection following traumatism, when small metastatic »\t-'
Bcesaea appear in the liver, not only do lymph cells occur Id grcatCI
POST-MORTEM CHANOBS OF TOR LIVER.
527
in tlip normal (ttat«, Imt tliere are also microscopic genua,
'tibnos, spores cominj; from (lie part lintt aflectcd and carried away in
tlte blood, lu auuipue» made a very Htioit time after death, durinc tlie
war and under npi-cial oondîtionH, in a very low teroperaHire, U-lon the
freeting point, we have seen small luetastalic abscesBPS containing; besidwi
^fte Ivnph cells coming from the veawln, the previously mcntioiid tnicro-
facopic eerma. Moreover lliorc occum-d during life a true putrid fcnncn-
I'tRtton 10 th«8« abaceases, âemoii«tratud by the prettcnce of ga» bubbles in
fctlieir ÎDterior.
Lfginn» n/ the VftfJê. — Tlii- vesticl» are altered oithcr primarily or
Ljteeoiidarily. Among tlic primary legion» i» inflammation of tb« portal
», in wfiicli till' vaj^cnliir iniiik i^ found, at tlie autopny, filled with piia
p>r coagulated fibrin. Ttii« affection also Acetira a;»ai(e<|uencoof iiittfAtinal
[Icsioiia: ily^enteric ulcerations of warm countries are fre<[uently tlieir
Ltource of ort}:in; at otiier times they follow general affections, and often
lit Is imi)ossiHe to find anv primary leMon wliich haâ ^ven rise to the
fl^blewlis. ('|ion opening a liver aflect«d with this lesion there are
, {bund ft varying number of sniiiU purulent colleetiona, true canalic-
alar abscesses which have the shape and direction of the brancboa of the
(portal rein.
In cïrrlioHÎs nitd other chronic atTuctionB of tlie liver the walls of the
portal vein are changed tn well n* oilier parU of the organ; Uic cellular
Cottt «Ji«w« a very niaiiifettt cirrho^i:*.
Vascular liimoM lu-ldoin occur, yet aneuriRins of the {mi-tAl vein hivfi
been met with. Induration of its internal coat and atheroma have occa-
sionally been seen.
tMore fronuently arc observed what are desi>;nated as htemie tumor»
of the liver — small red neduks which form in tiie hepatic tissue an island
of cavcmoua tissue.
Sent m.— Special Pathological Anatomy of the Liver.
PMT-mortrm Chasob». — At autoiwies, the liver \* generally pnlc,
jukI more or lea* bloodless — the Urge vessel:; only containing blood,
Sartieularly tbi? branches of the hepatic vein. 'Hie siniill vcji^els and
ranches of the iiortal vein conktiu very little blood. If a large fjuantity
of blood is founJ in the vesiels, tJie liver has been congested during life.
The absence of blood in the small vessels of the liver U explained by
the circutnslaDce that the bile destroy» tin' red corpusclca of the blood.
This disappearance of the red globules explains the itpparcnt nnarmia
anil [lulenesB that is to freijuently met with at post-mortem vxaniinatlons.
The liver may also be fmind tn/tmeif; «ometinies after the death of an
animal, the protoplii-im of the hepatic veils becomes «olid, so that one or
two hours after deiith, the liver lit rigid ; but thi^ cocidition iIÎMippcars
afteKa few houra, and nhen an autop>iy is made twenty-four iioim after
death, the liver is soft.
The diffusion of bile occasions another phenomenon, which consista
^eventually in a yellow-greeniéh staining of the parts in proximity to
6Ss LI r Bit. V
till- K*iII-bIi»iI<li.T. particulnrly llic intcatino. There Uan not necMnrilj
W<tn liny rupture of the f;all-blai)ikT or any otiicr Icinoii beforu (Ivadi.
Al'lor (lentil tlu- Durfiict' of the j;all-1>la(l<lpr and cabala U Rrc«n; under
tlic inicroK(.'o{)o th«- i>|>ilhclia1 ivlU an' nUn colorvd grei'n, but thU ts ovvnr
Beoii in livinj; aiiimiiU, for tliey arc iiornmlly trntuparcnt
I'ulrei'nctif'ii also omseH cîiuii'reji in the hepatic pareiwhymn wrhicb
mav lei»] to error iit pntholnj^ioal invent igatioiiA.
There are produce'] in the Huida of the eL-»»omy, pnrtioaUrly in tJie
blood, constant nietamorphoiiefl. I'utrelaclion develo|M itulptiuretied hy-
drogen which united «tih the iron of the blood, and caii;^cA a greeni«li or
bWkish dotting of sulphate of iron, vhicli Uas hcoii taken for patholojponi
lirions. This orror however may very readily be avoided bV the um of
ferro-cyanide of potassium, which forms the characteristic color of Pru»'
aian blw.
Another giiiu>i' of error, which liari been deMritied M a patliolo^pca)
lesion, its thnt in '>onie ca»v» of imtrefaetion there i» a formation of gM,
which ctiliect* in tlw ti^Mue of the iiver, and i» acutnnimnied by ttvnim;
upiin niakin); an incision into theite little cavitie.* the gtv* escape», and
only tho rtiiid mnceutii remain ; tlic^ little csvilie* liuve lumti incorrectly
deMrrilicd im cyHU.
CoNtiKëTlON OF THE LiVBR. — C»nj:e<>tion ia a very frer^tiont leoiou,
since it ia met with at the beginning of aloioat all di^ieaseti of the liver,
ami in diseases of the heart and lun;^ it is almost the only anatontioni
ChiuiRc observed in the nrgaii. IJotwitli8t»ii<lin<; tlie IVcqiiency of co».
gestion, every enlargement of the liver is not necewarily due to an
increase r>f blwjd. The iniliul eimgestioni» often followed by very diverse
legions, fatty degeneration, cirrhotic hypertrophy, etc- etc. We ouiko
two division» of hejialic co»]j;e»tionii: in one the initio] canse i» an orer-
Rllinj; of the |H*rtid vein ; in the otlicr an increased blood pre«sui« in tbo
hepatic vein.
l*t. After eating, the jiorlal vein contains more hlood than at any
other time during the day. After a lar;;o dinner, during which co«»id-
eralile wine ha^ been imbibed, tlie blood of the intcalinal and rtplenic
veins, loaded with the absorbed fluids, is emptied into the liver, which ia
congested and enlarged. Tlicre is now felt a sensation of fulness in llie
right hy]>ocbondriuin, or at times sn uneasiness, or actual pain. From
Una filling of its vessels the liver may increase one-thini its normal use,
I vbich may be deroi^nstrated by |H'rcii**îiin. There is here an exaggera-
tion of a physiologieul function, the ehiborittiou of the intestinal blood
by the hepatic eland. These errors in diet, when repeated, or when
tney become linbitiial, may, by the eonllcninl congejition, lead to cirrhosis
or g^uit. Wrilent u]ion fçout h;ivc pointed out thut in iminy cases the
disease is prt-i-eded by a hepatic congestion, ('ttnge.ition of the liver
from a too niln^i;;enûus and too alcoholic diet is an important faetor in
the {general alteration of the blood which Murchison t«nia uriewnna
(uric acid diathesis).
Great heat is a cause of hepatic congestion, and sometimes of exag-
^rated secretion of bile. In warm countries, this is a common ooudition :
but heat alone is not the most energetic agent; alcohol has aUo an
im/wrtant intluencc, and so also has malaria.
CONtlESTIOS OP THB LIVBR.
539
I II tenait tent fever, àyaeaiery, xymolic (iiaeanes wlikli exert tlioir spe-
cial action Mjioii tli* or;;aiiB supplied «itii the hlooii of the jiortal tein,
an! tlie most general causes of ]ie|iaiic congestion in warm countries,
congestions which there ]irccede either pigmeiiiai^ cirrhosis. especisHy
lueUnieniitt, abscesses of llie liver or the various dc;!enerattoDa of this
organ. In pernicious fevcni n section of the liver is uniformly red ; at
tiovM ecchymows bciicuth the cnpeiilc are sui.'n. Hepatic con;^tion
occora at the boginning of iciero-luemuturic fever of vrsmi iMmiitries,
of bilinua intcrmitlenti dcscrihed hy l>iitmulau, of dioetiM* in which the
secretion of l>ilc 'i9 so great that tlie iMvUertt» t'omit, au<l void by the rectum
one to two litre» of bile diirinji twenly-four Imure, while the biliary
coloring mattcrA infiltrate the hejmlie ti»<ue, Hkin, etc., uid altered red
blood corpuHoW are pnued in great numbers witli the urine. The con-
gestion of the tirer U m extreme that the tiiune of the gland is eccliy-
miMed, anrl freijuently small effnsiona of blood are seen beneath the
capitule of (rlissmi. .V section of the liver shoira h tissue uniformly red;
the blood flows from the small vcsaela and distended large trunks. The
histological appearances are nearly tlic same as those observed by Grie-
singer in Kgypt in bilious typhoid fever: congestion at the beginning,
followed by biliary and granulo-fatly infiltration of the hepatic colls.
In tlic latter stage ilic liver is normal or diminished in sise, ito color is
y el 1 0 wish-gray and opaque as in yctlix» fever.
Something of a similar nature is met with in our climate, altliougit of
less intensity, during extreme heut and fmm other cnuitcs, suoh as improper
diet, alcoholism, etc. There may occur wltli jaundice, bîlioai gastric
derangement, vomiting, bilious stools, coincident wiih an increase in the
siic of the liver and a febrile state of short duration. This is an in-
creased secretion of bile with hepatic congestion, and should be distin-
guished from another variety of simple jaundice, also frequently accom-
panied with congestion, which is due to an intestinal catarrh, with catarrh
of the biliary passages, and obstruction of the latter by plug» of mucus.
Most of tlie low infectious fevers of our climate, variola, tjphoid
fever, erysipelas, etc., nro acoompanicd at the beginning by a hepatic
ooogestion which precedes the cloudy :twelling of the cells, and their
fatty ilegetierntion. Thi» is a tfandient state, soon marked by the de-
generation of die cells.
2d. When the caiu^e of hepatic congenlion is an increase of the blood
pressure in the hepatic veins, it generally manifests itself hv a distension
of iho central veins of the he|)atjc lobjlea and the capillaries of the
lobulo Dearest [o the vein, so that the inner half or the inner two.
tliirds of the lobule is red. while the periphery is gray. All cardiac
discuses, but particularly those affecting the right and left aoriculo.
ventricular valves, stenosis or insufficiency, aortic aneurism, chronic
diseases of the hmg, emphysema, pulmonary induration, chronic plcuritis,
tnbcrculosis, etc., iu which the cardio-jiulnionury circulation is interfered
with, have the same result. Yet if the itsphyxi» i» very iHpid, as occurs
in p'iisonirig by carbonic acid, the congestion, insteiul of being limited to
the central part of the lobule, is jioneral.
Congcttiou of cardiac origin conlinue» as long a» the cardiac disease ;
34
S80
LIVER.
from it follows a series ftf nutritive lesions of tlie liver, hcginnlng witli
a hypertrophy, and terminating in an atrophy of the org»n.
Hypcrtropliivd and toii^Mtcd ninlinf Ihtr presents •* finrt a "month
enrfnvc ; itic vitpsuk- of (îliMion is thitiiied by diittcnrion ; ujwn ninkin^
a HOcliou «f till? organ, the lobuK'A appear Inrprr than normal ; in their
cciitml Koiie, ofcupyiiijï one-half or two-thinU i>f the lohnle, tliey lire of
a very uniform ilecp red color, resembling mahogany red, while their
poripberal xone is gray and npiW{ue. At the pitinbt where the ttention
piuae^ through and parkllcl with the divisions of the hepatic vein, tliore is
8een a leaf-like figure with red hranchcA .lurroundird hy gruy xonea. If
the aection is made nerpendietilar to the <lirectioiw>f the hepatic veins, tlierv
are seen reguUr cipclea having red contrée, while the periphery ts firay.
This distribution of red and gray in the same lobule is evidently what
caused M. Andral to believe in the normal existence of two difTerent »ul>-
stunci-s in tlie liver. The coloration liiis been cotnparetl lo tiiat of. t)ie
nutmeg, and the lesion lias been numcd nntmeif liver or rttrdiac Ui<er.
The latter name is not absolutely correct, «itco the leaioti aliu> otxurs ia
pulmonary diitea^'e».
An exftininatiim <'f u thin section of such a pathological liver allows at
tlie centre of the red jiart the eoniral vein much dilated. Sometimes ils
opening may he «een with the uiiiiided eye. The remainder of die rvA
region of the lobule luiii the capillaries very much ttilated, two or tlin-e
Vig. 28S.
SmUoh of* panlenof * btptUc lobnlr Ua sua of MDiwIliia ■In* locudlM^iMu*. Tk*
»ll>. k, %n ■liopbM. «hllal tb* up1lln7 TEUfl>.jr. un (trslljr 4lla1«d ■■4 ill*4 VUk **•>!
«arpii»l«^. The htpatk ttlh bavt vniuclj dlftApip'tF^d a1 lom» |Ki1nla. ■• atl. X Da
times larger than normal, and filled with blood. The hepatic cell» bo-
twccn the dilated capillaries arc flattened and atrophied. They ]ioâscs*
a nueli-nit, but their protojilasni is finely -ïrannlar. and very frt-<pteully
contaiiiH br<iwD pii;m<'iit <:mtuiles of Iteniutin. Crystals of t:senkatoidta
have been met with, .ind wnie ctdls eontaiii yellow granules of bile pig-
ment. These may he found in t)ie centre as well as in tlio poriphenl
recoil of tlie red pi^rtio» of tlie lobule.
ooitoBSTiox OP rns livkr.
581
its peripheral pny portion tlie IoIihIl' conswt« of capillitries, noniml
I (fixe or oniullcr tliiin tlic pnrcoiliiifr, nnd of futty infillrateii wUfl.
he w\U coubtiii lur;:^- ^ratiulv» t)r oitc or iwu uil drops which distend
ind giv<! tlu'in n «phcricnl xhiipe.
Siwh is itu- firnt iHiij;« nf tlir iMiflii; the hepatic Mood ctintouih the
eiitr»! v«iii iind ci-ntrjil cHpilliiripi nf Uu- lolmlo, tlit- cells are intilirnlcil
with the coloniig tnalu-r ol' the hhioil. iitnl atrophied, «hilt- the |K>rittl
Mood fltagiialea al the jieriphery awl stirL-liar-çes the ptrripheral uells
with the tat derived from digestion,
tOtlicr Ipeiona &oon follow : the dilated capillaries, nf^er the more or
lesâ tttmpliie destrrictioti of the celts s<^panitin;; them, may eoino in ooii-
biot with Olio nnoihcr : their walls ar« separated only hy (he itornuil
coiiiiectivc tiwui- surroiimliiif; them, ami perhn|M> hy (tntti-i»?d hepatic ctdU
f«till p(wn«!t!*itig M micleuH. Tiicse dilated ciipillarie.*, filled with hloml.
Tonii in the n-d portidii. at its centre nr irregnhirly disseminated, sninll
'fi>cr which very nmcli resenihlc hiemic tumors of the liver, but, in die
latter, the vasciikr eavitiei» are imich larger,
rpon section of the nutmeg liver, ihc red pointfl appear as dÎMliiictly
Tolieulated spaces, whose tne^hes are filled with Mood corpiiecleji.
I^aier, the liver, originally hypertrophied, become* «mallur: it in atro-
phied (red atrophy). Its aurfai» ia now* little gramilnr. Ujion section
of the organ, the lobules appear smaller than nonmil. The riN) siilistance
eeeiM at fintt more nnetpially distributed. aUhoH';h it is still in realitjr
falnap limitei! to the centre of the lobule ; but the lohnle» hoîng smaller,
tlic dilTerenoe in the color of their centre and periphery is more dïBîcuU
to appreciate by the unaided eye ; again, th&tv is now always a new
formation of connective ùsit^ie around the central veins of tbe lobules
and the aub-hepalic vein ; this timsuc is also noiformly colored red. Sec-
tion* of these livers, examined mtcrojopically, presoui a zone of newly-
formed connective ^«sue around the central dilated rein. In thi* zone
of Bbrillar ti^ue tliere exist cells with an oval nucleus. The hepatic
cclU arc atrophied, finely granular, and often r«-duced to a mass of
albuminous and fatty granules. Tne capillaries are ni)t always so much
dilated a» in the preceding stage. Tnis state const itntt-s a sclerosia
around the hepatic vein, or, bettor, a peri-phlebitis, a thickening of the
external coat uf the vessel.
In such cases a true cirrhosis is said to exist, coraparahlc to cirrhoeis
of alcoholie origin ; the lesion is not freijuont. Recently, however, at
tlic autoiisy of a woiiian nh" dittl with stenosis and double insufficiency
of tJie mitral and tricuspid orifices, we found the peri-lobular vewels also
surrounded hv a aone ot' silenisis. There was around some (im! all) of
the interlobular branches of the portal vein, fibroid connective tissue con.
tnining cells of this tissue and forming, upon section, small circles inclosing
both the hcjKitic arterioles and small branches of the biliary canals w hicb
aceomjmny the portal vein ; but the new connective tissue did not form
|ierfcct ciixic* around each hepatic lobule, as seen in well-marked cir-
rhooin. This red atrophy «f the livcr'hiif U-en differently interprctt'd hy
writers. Kolcitansky consider» it a method of recovery from acute
yellow atrophy of the liver. This does not seem prolwible. since le-
coveries from acme yellow atrophy ttelilom occur, and an exaininattou
583
LtVER.
of the clian^H in the liver of aiiimals noïsoned hy phMpbonts sltowg a
com|)lct« ru;;oni-mtii>D of the hepatic celts after tlanr destruction hj fatt^
de;ï<Mienttion. m
As a coiis«'|iii>ncenf lii'iiiitic con gestion, from >itiwi«of thvlilnnd «itlied
in tlic lii-nrt or in t)io vcii'iiis fjniiiclics and cii|>illuriv« of the livvr, tlioriy '
is nl ways Ifreut intorleri'iira witli thv cîrciilatiun «f thuoe orj^iu.tliv vetioiiH
blood of nliicli tlowK inlo tintiiclic^t of lliv jiortal vein. There rc;«ult
ntU)Çuiiicoufl eii^nr;ii;ËUR>iitit «f the Mploou, atomiich. intiMtiiiefl reaching tlie
. rectum, ofleii iintduduj; varic(>^e dihitiitioiiH nf the vein» of tJieac parts,
' varices of the inferior j)ortioti of the «aojiUajciia. of the soTeral parlft of
tlie intcaUnes, hemorrlioidfi, etc. At limes ecchymoses are wen. [larticu-
larly in the mucoufi memhrane of tlie stomach. When these j>athol«<;ical
occnrrenccB exist, there is present during life chronic catarrh of thcstomach
and intestine, a condition characterised by loss of appetite, vomiting,
MiarrhwB, at time* by a yclluwÎHh coloration of the sclcrcilic, and finally
by a certain amount of ascites. These symptoms arc alnays pr^'cent. in a
varying degree, in patient» nflected with cardiac lesions and red atniphy
of the liver.
A very curiouit and unfreipiont phenonicnon in «ometimea oht*er\'ci) io
similar cascK, which consisiii in apiil^uilioiiof the liver. I'lieae ])ul nations,
»yiu'hr>inoii*) with the venoua piiUo of the heart, were referred by 1*oUib
to an inaiiflicioncy of the tricuspid valve.
Con;;ei"tiou of Ihc liver may be due to traumatism. Sometimes the
injurv is so severe as to cause a liruisiu^ of tlie hepatic sul)«tanee. «ith
ecdiymoses, and even resultant abscesses. In the rare atheromatoiu
Icaions of the portal vein, infiltrations of blood are met with after p«'rfo.
ration. There may be an ancunsniid dibitation and rupture of ihe he-
patic artery of which I.eberl has reported an example.
Thus, it is found tliat o»n;;e!itiûii of the liver occurs at the beginning
of all nutritive lesionii of that organ, iuttauniations, cirrhoses, luraon,
etc., and it may constitute of itAelf a permanent morbid state, partku-
larlj in cardiac diaeuea.
IIepatitis.
Three principal varieties of hepatitis are recognJxcd: partnchgmat'nii
Jiefatitia. especially charaelerixeil by le^ious of the hviiatic cells, »u^h-
rative hepatitii, and tnturttitial fiefatlli» or cirr/iotit.
A. PABBScnTMAToua IIbp-mitis. — The word hepatiiia althougH i
jectionable because suggestive of inflammation, vhich in reality n
perhapa have no existence in some of these cases, has been long used by
writera. It is on tliat account that we retain it.
Of all the variêties of ]>itrcnchynmtous he|>atitis, the best detennin
is tliat knonn as acuU j/rltuw atr-iphg of tJie liver which corrvspouds
symptoms to grave or heuiorrbagic icterus, typhoid ictenu». The symj»-
toms of tliis atfceiion. which fre<iuently begins as a simple jaundice, and
afterwards breaks out with fever, hemorrhage», delirium, and coru, toop
temiiimte in death.
These syniptoiDS, however, do not always oorrespond to acute yelloi
PAREXCUVMATOUS J1BFATITI9.
533
I
I
atrophy of the liver. Tlu-y arc »cva in u iiumbor of liver ilî«ca8C« nocom-
pnniod with rcte»tii>» of Iiilc, According to wniie writer*. i<ometinK« in
iiltnpiithio iclenis followril by (rravc Hymiitoiiw. there nrc fouiul nt the
aiilo[>Hy none of the chamcterUlic Ittflioii» of a^uie atrophy. In oiir ovrn
otise nations, however, we have atwayx found the characteristic levions,
when a fatal idiopathic icteniH had been the cause of death.
In patioim. observed during tbe short duration of their disease, it may
fcc demonstrated that the liver, of normal or increased size at the liej-in-
nîng of the nialadr. diminishes in volume during the course of the afteo-
tion. At tlie autopsy, the Hver is more or less atrophied, aceordinp lo
the dnnition of the disease ; it is Mofier than nonnul : the greater the
atrophy the mnre the softeninp. The ca]K<nle of Glisson may he pinched
u)> between the finger*. When the liver i» lakcn in tbe hands, its soft-
netw and llnbhine:4K can be bc»t appreciated. It feelii like a Hemi-fluid
inasA. The color of its surface i'< like yellow oebre; upon section tbe
. oolor and softness are found, and it present" a homogeiicoits sur-
virin^ to the liepatic Inhulcs heiii;; uniformly colored.
The gall-bladder and Hilary canals contain very little bile, or bile
which is slightly colored, or at time* evon colorless. Microscojiic ex-
sminntion of the fluid obtained by scraping, shows a small numlier of
hepatic cells of normal size and shape, outuining fine albuminous, fatty
mid numerous yellow biliary pigment granules. Most of the cells are
very much smaller than nonniil ; their edges are thin; they are broken
into fragini-ntîi, and the grannhir |irotopla)tni of tlic fragmeifts contains
felty an<l biliary granules. In places where tlie aofleninj; i.t very great,
none of the hepatic cells have retained their physiological shape «r sine.
The fluid scraped from these places contains only small masses of granu-
to-fatty and pigmented substance, in the centre of which there is not
always a nucleus. The latUT luvs been set free through the softening of
the protoplasm of tlie cell as welt as by the niechnnicnl force employed
in tlic method of preiwiration.
Acconling to moMt piithobigio.al anatoniists, the peripbcml connective
tiiwue of the lobules iind thul' accompanying tlie capillaries of the lobules
nndergoes au al bumi no- fibrinous infiltration, in which are found escaped
lymph celU. niis întlainination of the perijiliera! connective tiiwue of the
lobiile is the initial k'liion of atrophy, aceordinii to Winiwarter, who ho»
seen a patient who died twonivfour hours alter the beginning of the ilim
easc. He also thinks, with Ilolm and lliittenbronncr, that the segraent-
stion of the hepittic cells loadi lo their triinsformation into connective-
tissue cells. This we btdicvo to be an error. Wc have never seen
tliickeiiiug ot iioiublc iiiflamiaation of the pcri-lobvdur connective tissue in
this disease.
At, the autopsy of one case, we observed around the hepatic lobules the
network of biliary canalx penetrating into the external third or half of
the lobule. In this ca.*e tlie acute yellow atrophy was chronic and had
reached to a very advanced stage in the destruction of the hepatic cells-
Thin sections showed the canals in the midst of a fibroid tissue. The
i hepatic cells had entirely disappenred, and there remained only tbe capil-
lane4 and fibrous framework of the lohule. Tbe larger inierlobular bi|.
iary canals were cliamctcriïcd by the csislcncc of a structureless mem-
asi
LIVBR.
1>rfiii(> lincil liy flm&ll cubicitl «jiitlx'liiil i-clltt. From tlicKe ennuis anuillefl
caiiiils liad tlicir orijtin, hi wliîcli the nioral>nin« ka» more difBeull l0 9e«^
anil wliicl) were lined ami eutirelv titled niUi tlie raioo cubical or more
fialWaed celU. Tlicïw canaUi formed a vcrv distinct uetwork in all tlxiM
paru of the lobule from nbicb ttie hepatic cclU had diiuppearcd. ami
their celU, triiich neither ooutuiiied {•ij;iiieiit tior fat •granules, wcrv dt»-
tinctlj §tai>i<.'il with carmine. Thi-y ciinhl nut he miHtjikon for hi'pntic
cMs or hlvodveHsdfi. Thiu do nions t ration of intra-lobiihir biliary c-aiiaU
in man ita* of ituiiorUuice, siiicl- u]> tii that liiiic t]iey had not Uieii bccti
iiijcutvd ill thv normal »Uiii, and their structure had Won unknown,
althouj;h it hud hcun believed tluii ihcy did not dilTer fi-um (hoKC in Uio
tamo location in nniin:tU. Were thet^ ctinaU nonuiil, and vUihle only in
coiiNeijUciico of the di:«n|i[ica ranee of tlie hepatic colls, or were they allereil
CikiiaU dilated and Riled wilh ejiithelinl cells irhich do not nomially exim
lliei-eï Wo are inclined to accept the latter view.
Another examination of a liver from a caac of acut« yellow atrc^iy.
slowed the celU, aUhuugb granular, to be infiltrated with pijpDent and
partly atrophied, but not destroyed. I'hc biliary cunaU did not (irisent
any alteration; the peri-lobular connective tisituo was neltlior thickened
uor inBatncd.
The hlnod in tlil« Affection id very mucli richer in corpunclon than in
the normal cimdltton ; it nit only eontitiiH a larger i|itantity of urea than
[ihvKiuUij^ieal bliiod, but aku a ({iiantity of the le^^ eoinpletoly oxidiiwd
aliiiiminouH [>rodiicM, teucin, tvrosin, and xanthin. 'I'heHO «ulMtancca
tfxist ID cousiderahlc amount iii the blood of tlie veins of Uio Itrcr u
'well as in tht» K'-'fCi'l cireuhition. The liver dons not pcrfono it« baeaa-
topoietic functione, the incoin|>lete combustion of albuminoid substODOM
loaves a residue — lenuin, tyn^in, and xantbîn.
These nuine »ubstane«s are found in the uiine, which \s aomctiuiw albn-
Diinoiis, contains leKrt urea than normal, and i.t loaded with Vdc and the
coloring; 9>ii I lii tancer of the blood. 'Hie nrino, tinted by the cidiiring
matter of the blood, does not always contain difltinguL-diable red blood
«orpu.wlea.
The spleen is constantly swollen and softened.
The heart is Dabby, its muscular tissue is in a state of fatt; deg
ration.
The kidneys are always altered in icterus ; the epithelial cells of tfatj
tubules are, in places, infiltrated with biliary itranules, and the Ciihulc
Contain bynline casts, in which are incloinul biliary granules, and n hieh are
covered by pi^iinented cell.'*. .A^in, in many eases in whieli alhuinlmiria
Diny or may not CxI^C, dnrin^ lite, the ecUs in Home of t)ie tubules of th>J
cortical «ubrtWnce are fmind in a stsie of fatty degeneration. In othfff*
word», there exists a slight catarrhal or parenohjraatoiu nephritic.
These lesions of the solids and fluids may seem to cxpbiin tlie sjnp-i
toms observed in grave icterus. They consist especially in the allcraiia
of the blood. The latter is poor in rod corpuscles, and it contains bili-
ary coloring matter, and a quantity of im|Jerfectly oxidized albuminous
products, whose presence is due to the fact that the liver does not per-
fectly perform its fuDCtluns, and also that the products resulting fn>m tlw
destriietioi) of the hepatic cells are taken up by the liquor ssnguiuis.
K
I
The iMÎons of the sp1c«n, kidnoys, ftml heart, arc tlie result ol tUU
ohuigcd composition of tlio blood.
Tbe symptonu of griivt,- ict«niii liuvc bo«n nttribut«d to uncmSa, tmt
thoy »r» very (lifTorfiil from tlio Inltor. lUvy have been Altribuwd to
cbolieiiia or cbok'toxiviniit, or poiiioiiiti}; hy tlio bite, ft tlieory buod upon
the b,v[iothc«is that bile does u»t jan* iut« the biliary paauged, and liiat
its nuiieriiiU ncoumulntc in the blood. Kut, if Ihia were true, ever;
retention of bili^ tihould girerijw to the fiitni« [ibenontenn. Finally they
bave been attributed to iioiaoning of tbe hlooil bv cbolesterin (A. Kliiiij.
The choleiiterin. a product produced from tbe nutrition of the brain, id
eliminated by tlie bile : in conscijuence of the suppression of the function
of the liver, it accumnlalcâ in the blood. But the same objection may
bi< a[>|>tied here as in the ca<=« of cbolœ^iia. Vulpinn re<;ur>U ^rarc
icterus as the result of a poisoning of thu blood by numerous products.
due to tbe derangement of the bse nalopoietio ftiDctinn of the liver, to
Itic presence in the blood of several principles re^uliiu); from the dcooin-
{Kwitiori of nitro^eniitcd and biliary :tikbiit»ncei(. TlicM chan^cit in tbe
coTn)iowition of the blood occonnt for all tbe nen'ouit phenomena of icterus
and the heniorrbnges, a» wel) as for the anatomical leiilonfl of other viscera.
In rejçard to tbe initial legion of tlie liver, we are without a aatiflfactory
explanation of its caune.
Orave idiopathic icterus may be connected with acute yellow atrophy
■H wc liave seen, iind with pftrenchytnatous hepatiùs. observed in certain
Iioi*niiiii;f« aiifl in grave typhoid fever. Tiy a number of its symptom*
and lumtiiniiciii lii»i<m«, phosphorus poisoning is closely relateil to grave
icterus, lint in this poisoning, falty def»iieniti<in of tbe cells predonii-
iiateti. In {loiitonin^ bi antimony and a rite id c, tlie cbanjçe in the hepatic
cell» ia comparable to that produced by pboHpboruH, but in leas tntenite.
»Tbc infectious diaeaAe», the iclertiii, wiihbœmaturia, of warm countrie.i,
the febrile disease», sueb an pneumonia, tiiherculosis. present different
de;;reoaof parenchymatous bepaiitis, which vary according totbe diMwe
ftikd itd intensity. The lesions of j)areii(!hym»tou* hepatitis are comparable
B^to those of acute yellow atntphy, hut they are less intense and less per*
Hmttly marked. Thus in icterus with Jiieniaturia, the liver, after having
B ]>een congested and ecchyinosed, parses to a state of fatty degeneration of
B iU( celU, cbftraeterixed to the unaided eye by a yellowish tint. Tbe same
B^ ^^^ ^'*'^ i(i yellow fever.
In tbe liver of typhoid fever, there is frenuenlly olaerved at the
middle or end of the second week a condition of sol^eninjç, which coin-
cides with the cloudy swelling and lesions of the cell.* previously de-
• scribed. Later the fatty degeneration predominates, and somctimea,
ftt the end of the disease, instead of the surface heiug uniform, the
lobules are red at their central part and grny at the periphery, in coiise-
quetice of a stasis of the blood in the hepntic vein, due to the feeble
contractions of tbe canliac imiscK-. I'lircTicbyinatous hepatitis, as met
with in our clim»t<'. gt-ni.'rally present.'* )i state analogous to that seen
in tbe liver in typhoid fever, with a greater or W« intensity. In many
cases the blood U more or le» altered in Che name manner a:* in grave
icterus, by the relentîon of imjHtrfectly oxîdixt-d albuminous Nul>stttnces.
mù
LITBS.
At tbe «Htrt]H_T tiior* is fdiini] u aitnrrhitt or » «li^jlit pnrcncliynisMus
nephntin, ]iiti'liitpH iiccompnnii'd 1>v uUiiiiiiinimu, itml thi;rv itrv pMraiiehy-
inntoiL>4 Iciiioiiii of the mH«ciiln,r ti^uc of tUe lioitri nml voluntAnr iwmcIm.
B. PuRULKNT IlKPATiTitt.^-Thin varietT of he|iAtit)it in olMrKCt«riu<il
if}n the prcaence of purulent foci, Acl<loni tiunu-raiin. eîtiior mn»1l »ii<l inuU
Phpie, as û mont fref|ueiilly otii^ervcd in our climate, or lai'tçe, nu nwt «ith
in wum countries. In warm countries alrscesses of tUe liver froiuenily
■ are the t«rtnînations of hepatic con-cation and <lcrang»)Dcnt of tlie biliary
Iseerction: they nccompany dysuntcry and intermittent fever.
Mrtattatif AhtrtMtea of the Lixrr. — IVinileiit infection, «crcre trau-
matSi*»!, sur<ncnl opcrationi», imi-rjeral fever, dy^nitory, soimiimm
typhoid fever, and variola in the ■•upiiiinitive Mtnge, etc., «re reoogniied
I M uiniieit of thiM lertinn. In tlie Intter di^eiises small miliary fthMOSM*
^coexint vrith |iarcndiymatouK hcjiatiti.i. Their ttejpmiin); in ohftraeter-^H
i&ed by a Mood-red eeeliymotio coloration, or Ity a yellowi»lt colo^^H
I limited to a hepatic lohide. In the deep red part, due U> a tilling of^^
f»II tlie capillary xeswels of tlie lobule with blood, there soon apfHears in
the middle of the lobule a small nhit» point, which is a small drop of
pus scarcely visible to the unaided eye. The pus increuaea, und auppti-
rnlion soon invader the j^atcr part of the lobule. 'Xliin itectioiM itbow
ttic capiilarr vewel» filled vrith red and white blom) corpusclca. ArouiMl
the cnpillaneK in the aecompanyin); connective titvue are wen wcaïa-J
while uiorpuitck'». These cellular eU-nientn snrrnnml wid comitre^ ihc
hejialic cells, and cause them to become ;^-aunlar and atrophied, and to
break up into granular fragment*. Their nuclei become free, or renain
surrounded by a small amount of protoplasm, in tbe midst of puaK:orpu«-
cles which till the ^acea botwoon the cnpillurios. The latter soon
undergo alt«mtînn, soften and dixinte^irate within the suppurating fiKiw,
and no trac*- of them λ found when tlic process haa luvolvwl tiie entire
lohuie.
The HujipurHtinj; foci inereaxe in aixe by union with tiei^bborin^E; foci.
I B» as to form lar^r cavities filled with pu.*. Around the «uppiinting;
' point» Uio liver i« generally fatty, yellowUh, and opa<|ue.
Such are the changes wliich indicate the beginning of met«Rtatio «b>
Boeeaea. An investigation of the anatomical cause and manuer of fom»
tion of these abscesses may now bo considered.
During the psmt fiftfcu years the theorv of embolism a'lvanej^ by
Virchow bus sufficed for most writwr». This theory of embnliiin 6ii|v
poses that in c"n»e<|uenci' of fibrinous OHirulations fonned in a vein, atnl
«ubwsquently triinsported by thu circulation, Kinall fminneubt aru arrested
in the nrt«riole.-< and capilhirie^, and an aluiceiM cuMie». Itul, in tliH
liy|io[he.4itt, local auicmia, by the intt^rruJlIj«>n of the pa.«tajçe nf tlie hlixxl,
ahonbl precede tlie «upimraiion in ttie jinrt aftV'utt-d, yet aecoHinj; to i
I f i-evioujily deseribed anaioinicukl faoU there \n no «uch •.audition. Tbt]
I congestion was explained by an increase of the preswure in die olbiterel
TC8wla; but this collateral conKcscion was innufKcient, and wsuviely
proven. Again, a coa-^ulum is seldom found in cbe nutritive veaael of
the suppurating [>art; moreover, tbc coagtdum may be a thrombiia,
eituK«i1 liylbe suppiiradon, inaleai] of on embolus. Wlierc a vciw], nrW-
H rial or venous, is fourni in a pumlent fociis, tlio vmll of il»* vvmcI 19
■tnllam<><i, iiifillraKil with lyrapli cells, and its cnlibre i» filled willi coagii-
Blftlcil Eilirin. The rlemonslmtion of the presence of un ombolus u, there*
H fore, doubtful and difficult.
B In the doctrine of cmliolisin applied t" nietn*t«tie nlisi-enses of the
™ liver there nrisM another difficulty, the vxplnniktion of the fonnation of
the niiipnting clot. \Micn, for example, ihere is a. wound of a lîinh m
A point of punileiit infection, it \» in a peripheral vein that the primary
fihnnous clot foriiw to lie eRrrie<linto the ri^çht auricle, then into the pul-
ntotutry artery and vein, then into the l«fl heart, and finally into the liver
hy mean» of the hepatic artery : hm in this Ion;; courjfc would tin- fihrin-
ous particles noi be arrested in the capîUaricsof the hin;;? How explain
*Uic formation of alMcesscs in the liver when none arc found in llic lung*
Tlie theory of embolism as the cause of hcputtc absccwte» can oidy he
applied to the branches of the portal vein in suppiii'iu'i that the ah«:t*sses
have their origin in a lesion of ihc organit from which arise the nidiclea
Kof thÎH vein.
W Tiie theory of diapede)<is, or the piu«in;; of the lymph cell throujih the
wall* of the \"e»»cd!f in anppuration, hpw ;;iven a fatal Mow to the doctrine
tot capillary emholixni eonitidereil m the cause of mutAotatic abaceisct.
More recently, the \'iew has been advanced tliat in peripheral suppu-
rationfl there exist microscopic germs, «hich are curried away by the
blood which contains more than a normal amount of white corpu^^de*.
TVm inferior urftanisiM and white corpuscles iii^ airesti'd in thtf urgaiis
and occasion tsinnll suppurating foci.
■ No organ of the economy i« «> muidi preilispnsed tn purulent infection
B » the liver, and expecinlly when the pririiiiry seat of suppurating foci is
Bin the tionrN, fuirticularly the bone* of the cranium. Magendic bus at-
B tempted to explain thi* marked tendency to suppumtion of the liver
B '1 wounds of the head, by saying, that in wounds of the head there
is, Uirougli the coniminii cation of the blood with the superior and inferior
»»ena cava, a |K>ssibiiity of a reflux of blood into tho superior vena cava
as faraa the hepatic vein. This hypothesis ia contrary to our kiiowledjie
of the circulation; but it may he admitted that purulent infection ni
favored bv the arrangement of the osseous vein». It may also be inferred
that the dtapedesis of the lymph cells and micwicyt)*!» contained in the
blood occurs more easily at pmnts where the eirculatirtn is slow. The
(hepatic circulation, uompriding two venous Hystern*. must necessarily he a
«low one, and perhaps thi^ is the cause not only of the frcuuency of ntc-
bwtatic ftbi<ce»!«eH in the liver, but also of all socondarv infectious carci-
nomatous, sarcomatous, or syphilitic {[rowtliA. Such is the explanation
proposi-d by Klebs,
ThmmliiHis ami inflammation of the external and internal walls "f the
branches of the portal vein should not be overlooked in the study iif
hepatic abscesses, since they are very frequent and ver> tni|x>rtant occur-
—^ rencea. They are met witîi under tho following condition» : —
Ist, Tlirombosis and phlebitis of the portal vein are observed consecu-
tively to tho formation of luetastuticab^vj^eâ. Kor ctample, an abscesa
i
£.»
k
of tlie liver about as largo as a pea or hnzpl-niit, formctl t>v tlio onînn of
eevtriil Diiliarv aWcsaes, haa its wall l)imtt.-<l by <:(iiiiii.'ctivf UibtiK*. ninl
at iwverttl (lointM eotiiiccU'd with one or murv lur^v itili^rlobtilar bmticlm
«r tlii.' [Mirtiil vein. Hon' tlit- coiincctivi* tiMiicnIiich fonn» ttie «xtcnul
coat «f tlif vein i» iiifiltnvtod wtitli pii* corjnwclo» : at tliU point llie jiori-
|>h1o)iiltii, by c(>iitiimitv nf tho iiitlaitivtl liMmc caiiitt-.'< nii ctMln.{iIi1i;iiili*
and a C'>ii;tiiIittio)i <if tlit- blitui) in thi; interior of the vein — a tlirombiiii.
'I1ii-i iiitiliriktioii of tlic |>t-ri)itiorul voiint-ctîve ti^iie of tbe int«rlobuUr
vi;iiiâ and tlie rcrtiilcitig kii|i])ii ration, exi'.biin.i ibc cxten^inii of ttic ab»c«MM
to lli« noi;ïhboring parlai ; but the tbrombodis aitJ pcri[ili)el»tis arv purely
scvonUnry lesioua.
2(1. 'Hie tbmmbojiU <if a bmucti of the portal vein may W priniarr,
for example, in conM'i|uou<:v of a i>lilebi^s of a branch of tbe nK-m'itierk
vein, in mleatinal ulceration and the iDt;^tioii of a librinotu clot into
tlio brnnclie» of the portal vein. When this clot U nrrodto) in one of the
hcjntic hmnches of tlte portal vein, it occaiiions, by the obstruction of
the ve.-i>tel,nn interference of the blood circulation in a number of lobule».
It acU as nn enibciUi» unil u foltoned hy thrombnuiH of ibo ]>ort4tl vein.
There occur.^ in the purl where the eircnlationi:* arro:iit«d,neiÙier intense
ci>n;;c.'<tion, nor beniorrbat^e, nor pn^, ils :'een al the bojcinnin^c of miliafy
metnâlaijc abaceAnea, but a local anit-iuia of the part «liicU is drier.
l^rJiycr, and whose cells lave undergone a ^ranulo-fatty de gene ration.
'J'licru is simplyan infaretns, similar to those observed in the spleen and kid-
ney of old persons, or scfii in the coime of valvular dUea»et> of tlie livart.
Ill the liver, ibedc infarct! arc not followed I>y «uppiiration iiny niore
than they are in the kidney. Similur infarct! of the liver arc very tinfre-
quent. a ciri'iiui.<tinicv explained by the fact that in the liver, when ilie
];ortal vein is obliterated, the hepHlic artery may continue to nourish tlve
aH'ected part, while in the kidney and sj leen ibem exists only one kind
of uourishin;; vesseU, the renitl and splenic arterieo. At least in onr
clinmti^' emboli of the portal vein seldom seem Ut cause abscesses in this
way. In warm couniries. however, several writers lielicve tJiat the larjî«
ubsicsses may he duo to softening and molet^ular destruction of a jmiX of
tbc liver in wliicb the small portal veins have been obliterated, Tor example.
in the same manner a« lar<:c pulmonary cavities follow the tnortification
(if u eonsidombk' amount of hni;; in caseous pneumonia. We liave had
no persiuml experience relative to this mode of formation of larpc ab-
scesses of the liver, iinil llie observations collected in warm coantncs arc
nu e\act eiKiugb to uonvlnci! u« upon this point.
Md. I'urtdent infiammalion of tlie portal vein, nr nippurativi' pj/lt-
j)hUhili», it better known to us. This is a disease <iuite common iu our
climate, and we have been able lo study several examples. In lliis
aHeclion the âui>puration takes place within the jiortal vein, the internal
coal of wbieli is intlamed and supjuiratin;;. This lesion is the origin of
ahiiccs^es found in liic liver in tbose eases. The abscesses do not arise
by emboli, but by a suppurative pblcbiti?.
'Hie cause of these suppurative intlaiiunatioiis of the portal vein û
well known since the labors of Daiice, C'ruvcilhier, Froriclis, etc., have
am
liccn puhli^lio'l. We kiKivi ibnt a1inn.it iiltiiivii |iylL'-|ili]<.!biti*iaaecoii(lBnr
(ti ulu«r)iti»i)ii nl' the itite.'<liii€i), ei)[iem]ly of tlic lar^e intestine, in
tv]>1]lttis and il^rHentcry. E^otIletiulO.') it ban been occondarjr to an aWcAS
of the aiiWn and a phleliitî* of tlie i)]i1cnic vein. In one case il w»s
provolioa l>y a fisli lione, wliich caiiw from the stomach or «tuwU-nuia
ami )>*il;;i.-<l in tlie [lortnl win. A fililclntis of one of the ufTi-rcnt
liraiichv8 of llip trunk of iho vein ext«n<b to the trunk unJ heiiatic
bninolioï of this veil).
Whun the trunk of tlic portai vein it opoiwd, it Î8 foin») fillud \>y a
fibriiioiiD coai^ulutu or by a purifonii fluid which i» continuel] into tlio
ticpatic bmnchc« of tlie [iort.il vein. In the more iteriou» ciuieK, the
innjoritv of ihr Urge bmndu-* of the vein are fillfil with tliiek iiiia
luixod with ^nmulur filirin ; tlic- niUhrc of tlic di*CHwd resi)i.'Ii« apjienrs
enlarj^d ; ami in Mcvenil ]j>rl» of the liver, along the brandies of the
middle and tuuall HÎitvd veins, Inie oval, round, or irretcular ahsccBses
are found, tlie walirt of which, inflead of heing fonned b,v the coat« of
the vein, arc coitntituled by the heg^tic tisiiue after the suppurative de-
struction of the vascular witll.
Thin sections pernendicnlar to ibe direction of the portal vein, at a
point trher^' it is filled with nua, inL-lu<lin^ the vein imd n(,'i;;!iborinj;
parte, show the inlernal coat ot the vein thickened, roii<:licned, mid iiifil-
Initcd with lymph celU The middle coat Is eipnilly chau;£ed, ti* im ako
the cxt«nud coat. The peri-phlebitis exteixls to the perijiliond connec-
tive tissue, the fasciculi of >^liieh art^ i>e]:iintlcd by lymph ctW*. The
sffcUih^ (if the vftiouK witUfl ami ffurruiindin^ coimcctiri! tiaaitc c»umb
the vein to lie considerably increased in size and to comprei» the
uoighborin;{ hematic lobnlefl. which are flaiteued. as well aa tticir cells,
in a direction perpendicular to that of the pressure.
In the parts where the abscesses are larger in diameter, tlie stipfm-
ratin<; fociL^, having first destroyed the ink-rnnl coat of the vein, form* a
cavity filled with pus. The middle eoat residts a lon^^er time, but is ulti-
mately destroyed by a eontiniuition of the suppuration, which i* now
limited l>y the inflamed connective tissue of the cxtenml coat and the ift-
durat^-d hepatic connective tissue which surniniid» il.
By llii» :>uppumtive and doslrnctivir |irin;e-« <if the wall» of the vein,
the ]>yle-phlt-biti» may ocvnition abAcest^iht which for a time are limited by
the neigbborin); hepatic lobules. This is especially seen in the small
branehea of the |Kirtal vein, since here the venous walls are less resisting
than in the larjje trunks.
Around the abscesses, where the vcnows wall is partly or completely
dcstrovcd.and further jilon^ the course of the diflcnsod venous bnincbe»,
tlierc IS always a new formation of embryonic connective tissue, which
ticcom])Hnies the »miill divisions of the portal vuln and etirroumU theoi
like a sheutb. When, therefore, a thin section of a liver containing
abscesses \* examined, the pnxnintic .siiae^;* which neparute tite bibule*
are fv-titx to be ntplnced by u uirt^ulnr xoiie of comieclive tijum- infdirated
with round eelU, in the iiiiddK> of which pass the inter-lobuiftr portal
branch, the iuterdobulnr biliary canaltculi, and the branch of the hepatic
arlerv .
MO
LIVKR.
4lli. Tho portai vû'ia is not the onlv vcsttd of the lîvor whîcb ntay ie
the sont of tlimmboaia and iiifiaminatiun. Itcccntly vfe muilict » speci-
men nf iiictiuttfltic u)«CfS8e9 of the liver secoiidurir to a fitiil pnniityuhia
(wtiitlow). Thv iibgceMsoi; nienaiirei) from 5. 10 to là niilliim'tr»
in ili urne ter. Tliey contained ii yi'llowîsh-grBV detritus fonninl of
jrriiiiiiliir ii(!|>iittc «-11» iiiid pli» corpuscle*, tjurroiinding llicm were
loixili-it, wliii;li, to the uiiiiiiU-d cyt\ uppenred yellowish i» color, and
infiltmied «ith ptiÂ. Thcne lolmk-i* rot;iiiied their shape ; the blood
ca)iillariei) and hepatic vein.<), the ceiitml vein of the lobule-t and inter-
lobular vein», were filled and diiitended by white oorpuacles «ud coa^>
latod fibrin. 'Hie he]mlic cells of the lobulea were somewhat atrophied,
Bnd, in places, the trahecula) of bcfa^c cells were represented only by
cells compressed and Battened between the ntifîbljorin^ ciipillaries.
There were lymph cells and tihriii in the capillaries, yet thert^ «as M
Mipptinition of the siirroiindiii<; cunnt-ctivc tissue of tlie capillaries. Thi«
wiw ix'itdily appreciated because of the preservation of th<' capillary
walls and their endothelial lining, which scpAmted the viuwular con-
tent.'' from (he bepaiic cells. Between the wall of the cnpillitricK hik! the
atrophied hepnticcelU there were uNo lymph eor|iiiiek'.-' which had jaiued
out of the veiwelit, aj> well u* ^rAniilar fibrin. Tiie intra-lobular veina
and tlie enlar^^d small brandies of the hepatic vein were aUo distended
and filled; tbeir walU were also infiltrated with lymph cells. Tbere
was then a phlebitis and thromliosis of the hepatic vein. Tiie peri-
lobular branclies of the portal vein and the heptic art«ry were normal.
ir Kc admit, which is very pritbahlc, that tlic initiil lesion of ibo
abscesMiit has been the same as that of tlie neighboring pari*, «e
reco;;;nixe »it a cause of these »l)i«cesseM a tliromboai» of the eapillarie*
of the lobules aixl of the he[intic veins, followed by atrophy of the
hepatic cell» and a supiiurative detitructioii of all the parta deprived of
blood.
5th. miiary Ahtftitf». — Almost the only eausc of inflammation of
the iniicoiis membrane of the biliary iMssascB is the presence of t-iliarv
cnlciiti in their interior. Tlie Mnull calculi resembling sand or fine t^rat^cl,
calculi which are irregular, nnj^nlar. formed of ptf^ent, cholesteriu,
and ealcan-ouK sall^, and which exist in the hepatic canaU and tlieir in.
terinbular branches, apfiear alone to have tlie power to eioit« Mtarrli of
tlieme eaiials.
(j'alarriial inflammation of the biliary paa-^ages in the liver varies m
intensity : sometimes it is limited to the secretion of a slightly turbid
mucus, colored by the biliary mntcrial. and is accom|^inie<l by a certain
amount of dilatation of the canals which fre(|uently iiave aiapullar ca-
larfK^ments alonj; their course. The fluid contains lymph cells, cylindrical
cells, biliary pigment, and fine ^niuules. It ii in inflammations of llii*
kind that biliary absceiwes of Ibe Hver most freipieiitly occur.
Ill other cases, the intliimmatiou of the biliary ;«.'<<«£ <;e<i in very intense,
and tho dilated canals are completely and uniformly fillinl with a thteic,
whitiiih, opnt|iie fluid, like muco-piiA or pus. Only pua corpuscles mi^l
be eS]>coted to be found in this fluid, but these round cells are very much
lesa numerous than arc the cylindrical colls of ttie biliai^' pai»agos.
LARflB ABSCBSi^E!) OF TBX LtTSR.
S4t
ThcM cell» «re frviiucnti v nllcred ; ih«,v we infiltratud mmI dUtondei)
with a luiicouit flmii, or tiiey coiitniii Hovi^nil nuclt-i.
In Hooie livvi'ii thiijt ftllvrcd, tlie licimtic iliiclii art; fi1l<^<l uitli {hl-*, «ihI
•re rrei|uently an lurgc a^i the fin^r. at fimt .it^ht a)i|)oanii^ Iiki> a)>-
aeeaaess dcvcloiicd iii tlieparencbjiDa.llut upun opeuiii;; ilii.'iuuiircfii11;,',it
is Mvii tliat the piis has not paaaed hcvoiid iho ualU of the biliary |iaAa>
•gM. U ifl in tlw Itss intense and slovfcr inHainmaliona ratlicr îlian in
thi'sv liMt ca«cs8 of inti'ikâo iiitlnmiuntion, tlutt wc hnvi; mot with hiliarjT
sUkciwv«. The i»viti<-s nrv foruicd hy iIiIatAtion« of tiit- tiiliary diiois,
atwl ore filled vithcr with inucuii or iinitio [>iix or jiiu. Th<^'ir wall i» i-ilhvr
«nootli niid consistât of th« nmcniLt mi-itilirnui' of tho duct : or it «.vniiiiitte
of ct'niicotive liwuo of new ronuation, ihr wnll of Uio duct hiivin;; liwiu
dcstmjrcd \ty Hujipunttive inflanunatiou, while the neighboring <M>nu«clivo
li$>aiie is infiltrated with tymph cclU.
The 6uid within Ûie alûce^âes always contains, besides tlie ljrin|iJi eclU
and biliary pigment of a sandy nature, s varying number of cylindrical
cells. Il IS theiso frco cylindrical evils in tlic fluid of the absoeits «hich
«re chftiTtcterûttic of it. In true pnmlvnt abeccMt-L» of the hepatic Hvd>-
eluncc, ntrophiod, gmmilar and fatty, licpatic cidU may bo mt-t with, but
cylin<lri4»l celts arc not found. Another anabtmical cliaract«riâtie of
tliVM ahwesscs m, that tliey communicate wttii the biliary canaU.
I^tTfff. Ah»eft*rt of tht Livtr. — Idiopathic alwocowuit of the liver of tt
large rtixc. are scMum M-en in tliU climate. Whether ihey arUe from «n
emIioluA or Uiromhus of the portal vein wliich compIet*Iv iuterruiil') the
•circulation, is not yet sufficiently known. 'i"hc necrosed tissue ia aubete^
quently softened, and is surrounded by a purulent inflammatory xone, m
Buch a manner that the iiocrosod and lilooillcss part is ultimately trans-
fomte<l into a lurgv abscess.
Any of the acting cihwch wliicb have Wen prcvioiwly mentioned may,
in warm climates, be followed )iy the formation <>f large absccsMs ; even
intcnnittent fever*, longK-oiiUiiued eongeiitioiu», or imperfeut secretion of
bile may in wann countne» develop alie<ce«Aea of the liver.
Theiie ahtice*»C!) have irregular walU which are formed of hepatic tiaaiie.
The thick pua cont;iiiied in them ia yellowiab in color and granular, ia
oompnsed of lymph c^rpiiacles, and altered hepatic colls. A few pulpy,
sofWnetl fntgmenia of hepatic tisauo infiltrated with pus are found adher>
ing to the wall of the abscess. This is tlio first stage in tlio formation
of tlic abscess, Later the surface of the cavity becomes smoother, when
all the stippurative parte of the liver are solïeiied and detached ; tJie tn-
tcmnl eiirtaee of the nb«ceiw \» Uien fomieil of embryonic connective
tissue, which surrouixls tbo alwce*» and ext«^ni|«, for *>me dii«t»nce, aloug
(be bniiichfs of tlic portal vein and in ter- lobular ti.t^ue. This wall of eow
bryonic tiscue in more or lea» vaacular. and its aurface ia more or lea»
irn^^iilnr ; at time.< itti surface présenta true graiiulatjona ; it then oo^
jllituiea a soft pyogenic membrane, analogoiis to that which covers ulcers.
~he abacesii may aubaeijuently increase in aiae from the suppuration of
the pyogenic membrane and surrounding inflamed connective tissue. As
this tissue is continuous with the [■eriiihcral connective tissue of the por-
ul vein, there is always a peri-phlcbitis, and jfeueratly also an ciido-
i
542
LIVBR.
plilehitis. with the formation, n( Uip iiiHamcct point, of a fil'rinotw dot.
All this ii)W)i<.- nmjr hu entirely destroyed bv tin* snp|itirnii<m. in Hurli h
manner tliiit the abeccao nmy W vnlnr^vd hv h later»! extcriiKiou uloii^
thf limiicheï of tlic portal vein. It i^ Jilso reii'lily "imienftooil h«w a
phlebiliâ may he exoited Micoiiditnly in n bntiich of lUv portal vein, itud
becfiinc Uif iitsrtin^ point of one or more nceondary «bst'CMfi* in tlie
proximity of tlie primiiry nbweitd.
The inturn»! «all of the nhm;«i«« Ï8 pay, or pinkialt^jcray, in color.
Criiv'cilhier has seen (raiijrrenoiia ahHCeuea. It in pnssildi.' that a true
giiii^'i'oiio due tn iniemiiititui of the circulation of the h]ood injiy be prt-
Bciil al the liejpnning nnd in ihe later staseH of the abscesjes ; hiil (lie
changes of color in the connective tia5uo ana glandular tissue surrounding
the abscessM, described bv writers, sliould be luistrualed. ITie slaty or
;;reeniBh colorations are almost alirays the effi^ct of post' mortem dvoom-
position which occurs so rapidly in tropical climates.
AVIicn till' abscess cense» to eiilar;;c. the pyoj^t-nic membrane become*
smoother, more fibrous, and the tiei;;liboritin cunncutive tissue is thick-
ened and bi-comcs more denwr. There it now a true fibrous membrane,
which is froqticnily '[uite thick nml lou};h, formed of laycm of connec-
tive iiK«ue ; we have in thi* ciwe a true encysted ab«cci<s.
In the more chronic abscesses the pus varieii i» color from yi'Iloniiih-
brown to L-hocolate, dejx-ndin^ upon the amount of blood, and the fatty.
graunliir iuliltration of the lyinph cells.
These large abscesses may be located in any part of tlie liver; bat
they are more freunemW found In the rijrht lobe, and especially in its
lhici<er part — that is, at ito right extremity, or npon its superior stirfaoe.
near the diaphragm. Tbey have, like all collections of fluid with euual
pn-»nun.' upon their walli", a tendency to uwtinif a spherical shape wiieo
they are clii-onie. The hejiaiic liwue i» easily pushed aside and flat-
tened hy the ]ireiwiire of the alwcesw.
'I'lie amount of tlnid, an h ell a^ the sixr and number of absce«sc9i.
raries very much. The largest are generally Hiugle ; they may coiitaiii
from 100 grammes to one or even two litres of fluid.
By its development and progreas, an abscess at the f^riplierv of tli« liver
has a temioncy to open spontJineously ; most frerjuently it [wintii upon the
superior surface of the Hvcr at the diaphragm, or at the liorder of tli«
tnic or false ribs, or a little below upon the aMomimil wall. When the
abscess is covered only by the c:a|isule of Ulixson, and Is thus connected
witli the peritoneum, there occurs a local peritonitis, and the irrescnce o(
the a.b«c««» ta soon made known hy the oudema of the abdominal or tho-
racio walla, and by the sensation of fluctnation. If tbe aWcss no*
breaks into the conneelive tissue surrounctiii;: its wall, it may oi-ension tbe
fonnation of purulent sinuses, which may |!a-'«s alon-: t)ie false rilig aiwl
extend ujion the side as far as tn the .ixilhi, or anteriorly to the middle
of tbe thorax. These collections of pus should be soon o|)enetl, or if the
diagnosis of alwcess of the liver ia well established, an adhesive jfritoai*
tis and opening of the abscess ^ould be caused by the application uf
Vienna paste.
When tbe alisces* points at the diaphragm, it may oecaHÏon beneath
the latter an adliesivc ]>eritonitis, and an adhesive plcuriiis above it, with
ISTBRSTtTIAI. IIBPATITtS OK OIBBilOSIB. fi48
mift itt the «naie {loint, m> that th» cAvitv i>f the almoei*)! may,
tlie rIcMriiclivc im g ipii ration of the (lia|ihrA^in, inflniiieil jileiira suitl
IB, cnramuiiicAte with the cavity of a lironchu». Thin termiuadon, na
well a^ thiit e.iWnially tlirau<f;h the ahilnmiual wall, ia one of the mmt
forlnnale, not more than one-half being fatal.
But inât«ai) of causin;* an mlhemve plcurilia, tbc hepatic nlise«M may
iioii a plouritis with co:iJiIilerikb1e «.fusion, when the aVce*! jwrfo-
the diaphm<;m, nixl !» eni]iticil into the ]<li>iir:il CAviiy. Thin
iiirnlmit pli; until'' niajr ncciision n piimnioiùa ami a [ii-rfortlioii of tho
iiii^, thrf>iij;h which ihi- nb*o ■«< iti^iy be evaiiiiivleil. Mm thi* luotlioi) «f
evactinlinii of the pu* it not «> favornhle n.* llic precoiiinjt, since it leii» ed
behiii'l u pK'tirilic vnvity which t* only iniperfoutly omtitieil. uiiil otU-ii a
furiileot collection, hi'ivrccn the iliajihnigin and the liver, remainH. In
tht-»c iieveral cavttio» arecont»iiie<t a famous fluid and gases, which give
llie same phyflical nigns aa pyo-pneiimo-tliorax.
The ahacesse-i may aUo o[ien into the periloncnin iinil excite a fatal
perit(>niti9; or into the stomach, the duodentmi, or colon. They have
very rarely opeiieil into the pcricardiviin, causing immediate death: or
into the biliary canals and blailder. which is very forUuiat«, since from
here tho ptw may e«ciipe into the intestine.
Finally, the liver in;iy be ulccrtilcd when it fomw part of the hnjsc of
BUtrie uk-cr. From the effect* of the giielric jtiice the hepittic timiie
il hrokcn down, an<l theru reKnlta a 1«« of ouh^tunce. The trahtrcnlic
of connective lijistic, which extend from the hiisc «f the ulcer around the
neighhorinj: hepatic lohulea. are hyperiropbied. iViuH constituting a kh\A
of localised cirrhosis in th« proximity of the ulcer.
Jntemtitial Hcv^tlti» or Cirrhttlt. — Tnleratitial hepatitis or cirrhaois
is characteriKed histnloj^ically by a new formation of embryonic or adult
connective tia-iiie. To the imnided eye it 1» «con as an induration wiih
hypertrophy nr atrophy of the organ, generally accompanied by a
granulhr condition of the surface.
The leiiionn in interstitial hepatitis are very variable both u to ex-
tent and eau)>e. IKfferent <:&*<:* of ctrrhosii«, at limt t>i;;ht, may h*vc
I little reiterabtance one witli another, especially if jitdjicti from the jihajw,
color, and siiie of the oryan. This, however, ia so of all chronic dLiWaKtui,
which develop slowly from different or \'ariotijily acting causes.
I
I
I
I
Partial CirrhoMt. — Interstitial hepatitis is associated with a ntmiher of
tumors and lesions of the liver. It is then often limited in extern. Thus
all tumors consiatin;; of tibroua tissue, such as lubcrclca. gununaia,
6hron!! cy<t^ developed around hydatids, abscesses, angiomala, etc.,
Src aiirroundcd by a new formation of connective tissue which is eon-
tinuon:f with the interlobidar connective -tissue septa. When, as at times
occurs, an eruption of miliary tubercle or of email gummata in new.
bom children is diffiwed throughout the Uver, there ninnrally follows a
rariety of cirrhosis, whii-h rxtt:nil* through the greater \mrt of the orgnn.
Sometimes, in elironie iiiflamiuiition^ of the biliary «atiul.< or jiortal ves-
sels, the connective tissue which accompanies them is also seen lo be
inHamed and thickened. This occur* in inflammation from tlte presence
J
944 ^^^^V V
of vnlciilt in the Inliftrj ooimlit, in p;io-iililc1>ili8, vtv. Wv have HvronI
tiincrt iiI>$«r\-o<] CMCS of [ngtncnttxl lit'cr, in c(>iw<ri|ueiiiH< ot ualari&l
cnclicvia ami nwlnnn^inia in cliililrL-ii. [ii two v»m.*rt (hv Mum] in the por-
tal VL-iii wai4 loaded with white i:(>r|iuiti;lcH L-outahiing lilack piguivnt. In
oite llie wall of the interlrilmlar Ijmnulin.'i of the \ionn,\ vein w»it tliick-
ened, capec'uilly tlie externnl coal, in wliicU were aeen Hat itr iHcllaU
cclb cnntainin;^ black ])i;;;iiu>nt. Tlic t-onnective lisiiue arouiul i)ie lobulea
waa atoiosl every wliere more marketl than normal, and was also fn^uKuted.
In anotlier case, «11 the bnincli«a of the portal vein were aurromuled by a
snne of L-mbrymiic connt-elive ÙMne containinj; pi;;ni4.'nt in a few of the cell*.
tUpun section i}i tin- livi-r, t>[uidl istunds, rich in round colla, were flt-cii,
I In till.- middle of thv^e inlands was found the suc^on of a small vein.
This tiiiiy ln' i^xplnined hy llie irntalion of tlic vascular walls which was
caused 1iy the ]>\nc\c. pigment carried by tlie blood, und which vxtcndvil
by continniiy of tissue to the neigbbnriiij^ connective tUsue. llto pig-
nieriti^d embryonic celU which were fonnd in thiit tissue may itUo Im
considered as {li^ men ted whit« corpuscles ettcapud from the port&l vewfit*.
My reviewint; the cases in which chronic inRammalion of tlie connect-
ive tissue occur» somodmos around the biliary canaU, someiinics around
the branches of the portal vein, in pyle-phlebiiia, in malarial cachexia,
gnmetiniea around the hepatic vein, as haa been meutioncd under red
atrophy of the liver, it is Hccn that there vxiata a variety of cirrhoaia in
yrhicU the xonosof new connective tisane aurrmind the branches of the dif-
tferont vascular systems of the liver. The [mitid veins, biliary catuila, and
he|mTic voinx nmy thu» he auconipiiiiicd by slieftths of fibroits tîiwue, eltlicr
in u portion or throughout the whole of the liver. Thoae partial cirrlM>*es
are very frequent, and upou aoction of the liver are characterised, to tbe
unaided eye, hy small grayish points or zones which snrround the veaaels ;
but a more minute examination is necessary in order to de te rnu ne whether
it is the biliary cajtals or the bloodveaaels which are tbe seat of tlie leaîon.
Qentral Otrrkoti». — The cirrhoses which involve the entire liver are
generally due to alcoholism or to syphilis. Sometimes they folluvr intor-
iDÎttent fevers, or a residence in wann cUmatvs, in patienta in whon
alcoholism has had considerable iniluencc in cuiuioction with fever or
with dyseiitc^ry.
From the ctTcct* of repeated congestions, and of the irritation causi^I
by the ]ihsmii^ i;f alcohol throuj^h the branuhcA of the ]>orta) vein during
dij^vstion, there re^mlt^ a |>ermanent inflammatory state of the conitective
tiMiie iu eonlact with the vascular walla. Around the interlobular ves-
sels, in tlie prismatic spaces which separate the lobulea, ibere are now
secnarcas of tissue neb in nhitecorpuaclos; this tissue ia continued around
t)jc entire lobule. This alteration takes place at tbe beginning of all
the difti-'rcnl varieties of cirrhosis.
It is difficult to believe that the lesions of all cirrhotic livers foUov
the aamc rc;;nlur courte. In & niunber of casvs tlie liver is smooth apon
its surface {fifpadfU ylal-ra of Klebs), and is cither hypenrupfaicd or
normal in size. In other autopsies, the organ, either mucli bypertroplûvd
or of ordinary size, ha8 a granular surlace. ïluallj in cases wliidi
CinitHOTIC LlVXIt WtTH A BHOOTR SCRPACB.
545
MiTve M B tv)>i> for ilio tïrot desaripdons of cirrliosia, iho gUntl i» both
atro|i(iied atxl j^rauular.
To llieae differeocos in »izc and sliape of tlie liver, are to l>o added tlic
cbaiij{«ii in the lipjintic cet)», irhicli arc aometioitij fatty, AoraeMnws infil*
tratod with bile or blood pigment, causing a red, ^'ellow,or gre«iù»Ii
coloraàon of the liror.
A, Cirrhotic Liver with a tmoMh tur/aee. — ^The Iivcr tnay have pre.
served \\k uonna) «jnc and Nhnpo. The Burfaco is smooth, and. upon aa»
tion.it pretent.f viirytn;; n)i|>onrniicc« : sonti>tim«H it îsof a uniform jellow-
isb-brown, or ii ofTern yi.'llovii.th «r gmy poiat». or the pcrijihiTy of the
lobules preseuli» reitdi#U line* which bcooinn gniy imd scnii-tninsfiari'ni
«[ter wMhin^. The reiiittanoe so the )iro«»nre of the nail w vkriubW, at
times the liuue iii lirm, or it breaks down ijuilo readily. lu exnminin);
ttiiii Acctiooa vrith the lulcroaoope, the prismatic iipacoâi whioh separate the
Fig. a«9.
liKliirmii£ luSikEiinïll^a af Ibv n««r. trM «Utra, 4- Luntv of latArtabnUr thavU la vb«a«
- «adni» ittf* ii > tisill uilwJ lollmUim. (. Lmalnk «( tmialDbnUr twMli. X **"'- (Mud-
lobules are thickened and show round embryonic cell». When the prdoCM
is recent, as in newly born syphilitic children, or in adults where death has
resulted from some other cause tlian the liver leaion, the peridobular tissue
\è slightly re^istin^;. since it is composed mostly of cellular elements and
ooiituina few fibres. Wi- have examined several cases of this kind in
chtMrcn, and have st-cn cuibrvouic tissue foliowin;; the oapitlarics of the
iKirtal vein in the interior of the lobules between the hepatic cells. There
I» now a diffused hepatitis involving to a certain extent the lobules as
well as the interlobular tissue. In the variety of syphilitic liver described
by (lublcr (miliary interstitial hepatitis), the wuftll nemi-transparent or
yellow gra nidations, which are seen by tlie unaided eye, consiitt of a cob
ieelion of sniftll enibryonie cells. They are small gummatous nodules.
Frci(uently there is seen in the liver of newly bom children a similar
35
LTTRR.
nakc(i-«ye nppeftrance, wliich is dne simply to a Fatty i1cgeDer»lioii of th«
bepatic coll».
Tlio cirrhotic Hvor with a «inooth surface occumtiR in adtilts, may or
mny not bo liyrortropliicil. It is •finivmWy iiuliiriik'il hiiiI rtreixCM jirfMiin.-
by tlie nail. I'lii» i« owint; to lh<.- ncn conni-divi- tÎMitc wliicU Hi*|inniU-s
the lohiilc», being ili-iisf, uikI coiii^ititinj' nf fibri-*. Wliilf ibv frinblf ùi>*w
of ri'coiit tirrbcwi» i» t-mbryoiiic, i-omposwl <•{ vc^.m-Ii' viitli imbr^onic
wit1lo,atifl rouiiil coll» «ilh n »ofi fibrillnr iiitvrci'ibiiiir )<ulK*laiici'.'lhf tin-
■ue of uliroiiic i-irriio^in coiivtf't^ of » dviwe, fibratis Mil>itlauc«, coiniKMwd of
longitudinal tibre-t or of a Inminatcsl network of filireR. BetH«v» tbc
fibres arc fourni âa( collit, an<i freijiicnlly »\»o nuniL-rouH round ci'lls niuil-
ogoua to lyuipb cnrpnM-leH are ac«n. jioesemiin;! a niii;:Ic uucIi-lis, and
situated between the fibrca, or in round, oval, or cloncato') sjiacvs
with the fibres armnged in a network between them (llayeiu). In
tbis dense tUeue run tlie bloadvcMoU belonging to tbe interlobular
tl«B*. wblcb l> i»r rkti la I»>eli ■Ulium dMlDcl «iU>. tnil i> < inrdt k bf <■ tM'f^
raixeil Urn at idbii( rDon<ic(Ii« iluuu, V Uroap* dI lubnUa al iSm lliir *ltb rbalr r«lr&«T
tollinHd Willi t»i. X »"), tSti-iJIrUel..)
brandies of the portal vein ; their wall blends with the acleroA«d timne.
This kind of tissue is very abundant iri cirrhosis with bvftortri)[ihy, it
more or less re;;ulHrly surrounds (lie hepatic lobules, in sucli nuiniier tlial
upon scttiiin wide baml» of it are wen between the lobulca. The laitlor
are frequenlty lluw itepttriitt-d utid llieir wlUiIar paroncbynta cncmadusl
upon, either at the edge of the lahules, wlierc ^rnu]'» of hepjittc celU are
iitolntcd frcnn ibe rest of the lobule, or even in the niiiMle of tbe lobule
where Ruch isolnto) groiip-i may be formed. It ^eiwrally follows the
eonrso of the intra- lobular ca pilla ries, ami, by eonipresjiiiiu, causes nii
atrophy with flattening of the hejiatic eell.-', which are thi» ami j^ranulnr.
At other times tlie lobvile is divi<ied by one or two haiuLt of thick fibmiu
tissue, and the groupa of iiepaiic cell» which remain hxvc s kjiIicHmI
omi ne.
CIRR1I0SI8 WITH ATnOPIlT.
1.0
^f In cirrltmis with livfieitropliv, the liver ia (Veijuciitly mnnotti aiwl îit
coit«iiI<>m)>lr inorouM'd i» »iw, hut in otiior ciute», il i» 9f>in«wh»l irrvjirit-
lur, lotitiluti'd. or j^nimilur upon iu siirfucc, while the organ is aW
IenUrged ntiil granuUr.
a, Granufar Liver; ff-Jmail Liver. — TliC «jmntilar state, which
always indicnics a certain amount of contraction of the newl^v-fonned
tàamv also always coincides with an cxcfSfi of fibn» and a density of the
tiasiic.
A» has heei) demonstritted by Cnivcilhîer, the granulations orcirrhosiii
hiivc at time» the wixc of normal lobiilf*; at «tliera, they «nj larpcr or
snutUer. Ho tliou);)it that cirrhofiiti conflicted C8)ientiallv in an atrophy
of numerous lobnle«, occasioned by precsnre from thickening; of the
fibrtHU li^siio, while *<>mo Inbides were liypertrojihied iu ordor to tuk«
the piiMio of th(>:>« which wcr» atnijihied.
The atrophy of the hc|uitic lobulen is only apparent. When a lar{^
Imle ifl examined, it* ccllii are alwayi* chan^icd ivnd nitwi fr()i|Uent]y difr
tended by oil drops. ITpon section of the liver, the cirrhosed gninula-
tions— that is, the hepatic lobules — when they are in u stiitc of fatty
iufiltntinn, hare a yellowish-faun color, from which Lacnnec hax named
the disease cirrhosis. They are aurrounded bv banda nf a aemi-tn>n«-
parcnt. ;;rnT, or pink tissue, the color dcpcndinif u)M>n the amount of
blot»! and the libr<)U»stnicture which con«ititntes the essential lostnti. If
the liepalitis \s tlilïiwed, extenilin;" throii^hoiit the entire lobnte. the jierl-
lobular connective liKsiie is cmlinu'iu.'* with that of the intt^rior nf thi»
lobule and caiirioi he M'p» rated froiiiit; but, if the lobule is not implicated
in tlic libruu.4 ihickcnin;;, and especially if it i» inliltrated with fut, it may
easily be eiuiclcaled from the siirmundîn^ fibrcuLs ûssue. This c"ndiii<in
haa been tully described by (rubier, who remarked tiiai the l»r;5er;;ranu-
lations arc mo«t readily separated from the fibrous lin^ue arnuiid tlii-m.
But these lar^e granulations, which to the unaided eye npf}ear hoiuo-
gvneoiu and formed of a single lobule, are constituted by a number of
liepatic lobules, which have their connective tissue almost normal, while
the entire group is surrounded by a thick fibrous envelope.
<yirrh'im$ with Atrophy. — The cirrhi;t<ed liver klropldes in proportion
' to the duration i>f the diseii*c and to the organisation and contmction of
the ne*ly-forme<i fibrtiiis tissue. It may contract to two-thinJs, nne-lialt',
lor one>third it8 nonnal Kixe. The granulaiion.t seen upon \\* «urfage
or upon section of the organ are generally regular and .«mall, yet at
time« they are (piite large. The fibrous connective tissue separating
the lobules is very resisting; it is impossible to tear the hepatic )iart>n-
chyina by pressure with the nail, and the new tissue is also clastic, m
that the organ may bo siretthed witbant ruptnrin;^. Connective tissue
fibres predoniinale in the new tissue, and between these fibres no collec-
tions of embryonic cells are found. All the cellular elements interposed
between the fasciculi of fibres arc flat or stellate and provided with a
flat nucleus. The liver is usually arnemic; its lobules arc fatty infil-
tratcl, and yellow, or tbey are colorcil by bib- or blood pigment.
When cirrliosis duo to iiiaUiria reaches iho atrophied stage, the thick-
LIVKn.
«n«(l coimcctivG t'ltwuc, and «Hpecialljr llial arouml tlic branche* of '
portAl vein, is ihe scat of black pigment graiiiileti situated in tb« '
aecdre-tissue celU.
From tlic nreceHiiii; deacriplion. it la seen Ihat tlie strucWro, the dU-
tribution and aidouiiI of ««.'loroecd tissue vai'v vcrv mucb sccordtng to
I the condilion of tbc liver at the lic}{iiii)in^ of the cirrhosis, whothor in the
Bmoot)), liyiwrlropliicd, ^^raniilar, ur atrophied Hror. Since (bv dÎM-iutHl
organ i« Mccn kitt mxv und mily at a corlaiii jioriod of the evolution of
the di»i'ii!>c, it c-'uiiint W positively "ffirmod ihiit tliv c-oiiditiou found at
llic autojiay liiw hwn pn-cedwi or would have been followed l>y certiiin
diflerciil »tA};t;i', yet what if kiioon ro)tiiTdiii}ï the ehaii^it of eunneutite
' tii<»ue iLUtliorize.-t iiti to I.c-liove that llii.t li.'i.-'iii- in tlie liver is at ftret en-
hi-yoiiic, and aflorward* becomes* deimv and fihroiis an<l tendii to contract.
It may also be inferred that cirrhosis with hviiertrojdiy, uliaraclenxe^l by a
^reat abundance of embryonic connective tiaâue, représente the firet stage
of cirrhosis.
The fihrouf rovcrlni/ nf the liver is alway» tliiekened «ml difficult to
detach in cirrliosi». To the unnided eye tlie projeeliini» of tlie cjipsule of
<JIin»oii, pellet iiui II ;; deijdy l>el«»'en tlie p'wiiidHlio»*, have a whilislt or
pink e<dor. I'pim tin- ■«urfjice thei-e are wen extensive cicatricial deprc»-
«iouK, both in «yphiHtic and nuii-siyphilitic he)i«ttiùs; but ibey itre never
K» lieep, so hard and piiekered n^ choae occurring in «ypiiilitic jçummata.
The he|ialic periloneuni in cxce]>tionally iiitaet in well-markeil eir-
rboitts with livpcrtmpiiv or atrophy, hometinio.t, and in canett where
tliere is a slight peritonitis, there arc seen, upon ihe surface of the liver,
e«peeially in the depression» between the lobes, small granulations or vi|.
lous filiiments scarcely visthle to the ininided eye; soiDelime» there are
fibrou», laminated, false membrane", which float free upon the surface or
which are attached by BilheMiini* I'l the diaphnijim or nei^iboring organs.
Occa!»ionally ihe-ie Mm- nieiuhnuies «re eovereil with Rbrin. The i^K'ri-
toidlis, wlion it i» somewhat acute, may he general and may fre«|ucutly
occaiiion slate-colorod or hlackitih eeehyiiioseji.
When a thin section, porpcndicnlar to the surface of the cajwultr of
Glii^on. and including tlie small vegetations upon the peritaneum, is ci-
aroiucd microscopicallv, there is seen a thickening of the ca[iaule which
is formed of horiiontal layer« of eontieetive tissue; upon it» iturface lite
vegetutions of the serous iiieiubroiie are olwerved to bo coiilimioai nitb
the connective tÏMiie "f the |>eritoneiim which covers the capsute of
<.ilis«on. The vcgeUilIiHis ure sometimes sessile, soioetintes long and
lliiii; they may ditiile and suhnlivide at their free extremity, or onîtc
with a neighboring tilauient to form an arch.
Theite vegetaiious are eompotted of famculi of eonneetiru tissue, sepa-
rated hy flat celU, or at times one is fonned of a itiiigle fastricnliis, vei
fine, very long and slender. Most of the large vegetations emiluin blms
vessels, the «mallest do not always possess ihciu: ail are eoveix-d willi
endothelial cells, which are collected in thick layers mion the jiurface irf
the vegetations. These cells are swollen, thoir protoptasro h» increased
and more grnnular than in the normal cclU of the )M>riton«um; tliey
resemhlc the eiilarj;ed eiidotlielial cell* of the intlamed peritoneum.
\
CCRCULATIOS Of THE LIVER IN OIRKllOStS.
549
^B TliP resacU of theao ve;ïotation8 and a^)iiN«ion<; arc filled with th« in-
^■joctiiig fliii'l whi^n it is thrown into tliu portiil win. l'lici^« vojrotaûtHW
^pofccTi fonii thu ndlinfions with tho nuî^hliuriiis oi-^ii« and tliiui fitvnr the
ivliirn of the blood from the portal win to tlid hcnrt \ty a collateral
^^cifx-'ulntJon.
^" Conâitinn af tht Ve.*»^h and of the Oirailathn of f A« Lher m Oir
rhoêin. — -lu !K'Htecirrho«» with enibryoiiie tissue, tlie interlobular branches
of the portal vein are surrounded by round oells, which are Ihotighl to he
leneoci^leA, and niiroerotu round ccUsiiililtralo the extenial coat of thfue
vcina. In the lohulcs, the connective tiflsue nhich accompanies the cap-
illttrios is infiltrated with the name clemcnta. The capillarie» and small
kloo<lvciwt«ls experience the same chanijo as in inSamiiiation; tho cells
I forming; their wall are swollen; tlii'v become embryonic, and th» linitue
h«» m »oftnc«s and frinbiUty which it did not prcvii)u«ly (toiMiess.
The [leri- and intradobular port«l veMtd» ami small branchi.^ «f the
he)iatic artery fuuiid in tlie connective tiviuc or embr^'onic litt-iue of aent«
eirrlw^in, may In; greatly dilated, And cntue a lar^e |Mrlion of the liver
■ to rescmhle erectile tumors.
In the cirrho.*ed jHirtionR, in Bome place» there exists a true eavemona
tissne, the irregular lanunne of which are, like the capillaries, dilated and
filled with blood. The walls of those vascular sinu<!es are formed by
the no>ghhonn>; connective tissue and their intenml Hiirfacc is lined by ft
liiver of flat cells. The same lesion is foinvi also in a number of hepatic
lobule.t; the capillitTiett of the lohuleit heni^ eiil[tr<;ed and fil]<-d with
» blood, atrophy am) fnltj degeneration of the hepiuic eoUs hy oouipre.iHton
from the dîlate<l vetiselx follnwK. It seems that the pre.tenee of soft em
liryonic tissue favors the dilatation of ihe vessels. The branches of the
portal vein and hepatic artery are permeable t« Mood, while, on the con-
trary, the circiilttlion in the capiliariea of tho lobules is impeded ; the
pressure of the blood dilates the smallest vessels which remain permeable,
(«specialty when they arc seated in a soft embryonic tissue. It is under
.Buch conditions and in sucli a tissue that vavcnious angioniata of tlis
liver are developed.
Later, when the cirrhotic ti»<su« has Wcome <lcn!ii> and resÎMting, the
bliiodve.4it(-lH are still very nunieniufi »nd tarife in dinmi^ler, with walls
■ fonued only of the neighboring connective lissuo. There are a few
sinuaes which ai-e channelled iu the indurated connective tissue, the
walla of which are Wended with the neigblHirinji tissue. In the wall of
the interlobular branches of the portal vein there are no contractile or
elastic elements to force the blood into the capillaries of the lobules ;
their external and middle coats are wantin;;, there remains only a layer
of endothelial cells lining a canal which is neither contractile nor
elastic.
it ii« easily understood how insufficient i^ the circulation of the blood
with the portal vein in thU coiiditioii. The cardiac impulse and m it
Uri/n are scarcely present in the vein» from the intestine and upleen which
nnite in order to form tlie trunk of the portal vein. When the hepatic
branches are deprived of elasticity and contractility, it is evident then
that the blood must paas willi difficulty through tlie capillaries of the
550
LITBR.
I<»l>ulee. This i* wluit occurs <lur!n;* life, aiul cnnscH t)ic iiit^Hcr^iicc tf
tliu virc'tilnlioi) in tliv portal vi;in.
Till" cniisiia uf as^itcs un- : l»t, tlic prcrcHins Mntclnrai nlwnitioi» t)f
tlio Willi iif liwêc limiiclH-!' pf ih<- porul vein indiirlod i» tlir arrlioiic
t\nf»Q ; '111, tlic (ilntriurticoi uf ii iiuiiilior of €il]>illnri«'# of llio loliiilc tiy
ext«iisi»h of the cirrliiX'iL'* to tlic celluln-vit.-iailnr ti.'<-'4Ui> of tlie lobiilo;
Ad, the ohHtriictioii ol* a tiiiiTilK-r of iiitvi'lolmlnr hranolies. I'hromtii
have heou found to h ^ruau^r or \ea» extent in the portal vein in oir*
rliosis. Aocnnliii^ to Ritidlleiitcli, the Uooii of the hofmtïc artcrv haa
^ ft proesure eridenti v very nincli above lliat of llic Idood of the pori«l
ri'ii), nnil takes the place of tlie latter in all ptirts of the scleroeed tiwne
where it i» oMiteraU-d, »t> that the (•yelcm of blood canals of the cir>
rhotie tiAtiiic in tnainlv Hupptied by artt-riid blood, tt i« from tliiB
arterial blood that tli« bile in idahorati-d. Tbi« pro[>OHitioii iwcqh to W
to» poititive, ivfter hnrtii;; Mtndiud sitrL-ral injetitioits whi«h wo have nnuk
into the portid vein in >^ue!i «wc». The iiijocled fluid ]uw«cd very
rai'iilty ihnm^ti i\u- vrwiid» at tlie periphery of the lobule», aiwl from
ihenue it {laA-iud into tho accvDMory |)oruil v<-iiL^, nud into t)u< voiiu nf
the adhesion.t whidi iniitttd the liver to the diaphrajnu ; Wt froi|»eiitly
the eapillarieii of tlie lohule» wore injected ibroujfh tho portai vein.
Ill the later itt4kgeii of cirrl)o.4iit, that blood of the jiortAl vein witk'h
doc» not pa88 throii;;h the he|iatie lobules, escapes partly by the vc^imIs
which traverse the adhesions formed («tweon the liver arul dia|i)im)nn
(Kiernan), ami puitly by the ;ireatty diluted system of accessory portal
veiiw de«Tib.'d by Sappey. Sappey, from hi* invejiti(.iitionif. conolndw
that tiie blood of tin; porlul vein i», in cirrboMis, returiie<i into the infe-
rior vena cava by the g«;atly dilated «cc«8Sory portal vein», after
bavinji; oceaitinned dilatation of all the ana-'ttomosinjç veitm. mdNnita-
neoiis aVoloiuinal. inlenml tiinminary, etc. A itinail vein in tho siL3i[ien.
sory li;;anient of the liver, and in the atrophied umbilical conl, ix of
Epecial iuijiortancc. It exteTids from ibc sinus of the [)onal vein lo llie
femoral artery, sometimes following the subaponeurotic veins, somctimea
the subcutiincous alKlominal veins. Tho direct current Iwneatli liie skin
U evident by a sensible thrill i^iven to tho hand, and a tnurmur peroo^
tible by the stethoscope (Sap|H'y). The manifest insutficieiR-y of this
Oollat«ml circulation for the hlood of the |M>rtal vein explains the ascites,
which grndually increases notwitlistatidinj; the aid of the nocewor; portal
veins.
In a case of cirrhoni» examined by ui*. thprc were found bclwecn the
ke|utlic lobuloi), lai^e, cylindrical, lymphatic canalji. inoaittirinK from
.2 to .5 ram., situated in the middle of tlie i«clero.se>l li»<ue, and filled
and distândcd by lymph ceils.
The biliary jia»»aije» are not always changed in cîrrhoisis; eitpecialtr
is this the case with the lar^e vessels. The bile is normal in appear
ance; it is, bowevor. generally more watery and less colore<d than ia
thu physiological slate. It is secreted in sufficient amount, a fact which
was remarked by Bichat in tiinaors of the liver, which he desoribnl
by tho name nf «tc"t"m»t«, and which have licen earefullv Dot«d by
every writer who hu» studied the pathological anatomy of cirr^oeia. Tli«
DILIARY PASSAGES OF TKR L[VBR tS CtRRIIOfllS.
551
h\\
unttMo]
>lc clmn^c; ,vel tli«y ii»v lie diluloi) in
ililntntion, wliidi liu coiujmrcn to tlii;
« (to not ueiwlly pre^cut HDy
in [iln«c4. (>u1)l<-r himtK iipun
tliirt ililntntion, whidi liu uoiujinrcK to tlii' dilalutiou nf tin) linitn-lùal
tiilje.i ill oirrho^iti «f the liiii;{ or iii[or:<tî(ial [>iieuiiionia. T)i« cnnai^,
tiiali^ikil of beinjz ililuled. raa_v )>c (l'uilnictod liv the cicatricial li^^ue, and
a rel«nlion of liUe occitiiioued in the tnuaU iiitorlobular canals ami iu the
hepatic ccUh.
In uirrlioais with ao ahundaiit formation of sclerosed Ussno, the inter-
lobular biliary caimb. with tboir liniiiK of sinall cnliical cells, art well
prWMin-cd. Instead of tiiidin^. in the ccllulai- zune tiiiiTiiundiii^ a lohide.
a «iiij^le biliary canal accompanying each of Ibfi iiittirlobuUr branches of
the |N>rtal vein, as in the normal state, thero is «eun, throiij;hont the
kreiultU of the selcniscd xt»\e, a xystein of iiiinicroii« biliary oanaU
~ mJitf^ a network. In itortimix where one or more lobiiloM have com-
J or almost entirely di»it|)|i(!nred and bccoiin* n:]ilnoed by dciHC
ëonneutÎTC tin.iiie, the latter 'm triLverncd by a ximilar network of biliary
canal.4. fonnitig fln« mesheii within tlio lobiilc, nnd »l the {ieri]iiiery pre-
xentin^ lai^er canal:*, calling tn mind ibu distribution of the inter- and
intra-lobular biliary vemieU. Tborvfore we believe that in cirrhosis, while
tli« hejnlic celU are atrophied and replaced by fihroiu tissue, th« biliary
canals remain, and become very distinct. It is possible then that the
biliary caiiab seen in cirrhosis aro only normal inter- and intra-lobn.
Inr canals mailo more distinct in consoiiuonco of th« atrophy of the
imrencbyma. Only the interlobular biliary Vl^88l'ls in man arc well nn-
derMloini; they in«a)inre fmia O.OtiU to O.U2i> mm. in diameter, am] fios-
seA« a baiieinent mi-mhraiie lined by a layer i)f itm:ill cnhical cell». In
aninialA, the inlrahibnlar biliary canalit have been well .'«liKlied ; in them
Ihey conaiâlof delicute canaU wot |>o.«4c.<'<in);ci-IU, and they measure from
.lH)l:i mm. to .W-IH mm. in diameter (see «nf*->. This system has not
been satisfactorily studied in man. The biliary canals so numerous in
cirrhotic tissue in which they form a network, are very similar in
diamclcr and constitution to the inti.-rlohular canals, and do not corre-
spond to the description of întmlubulur canals of animals. The meshes
which they fonn in the new ((ulero»ed connective tissue, are also Inrzer
nt linw!» than the iiarn>w ini-«heii of the intrahdmlar caiiaU of animals.
It i» not a f]uestiiin Hinijilv <ir iiorniiil caiinls madi- ajiparent by the diiiap-
^~ trance of the bepaliii culU ; hut it is aU<> p(i.i.ijble th.it, at the begin-
''niDg of the cirrhosis, the prc-exi^tiii^ canals, situated lu an intlarnnuilory
tissue, increase in length and luimber by an extension of the epithelium,
which nominally exists in the peri-lobular canals with which they com-
municate.
When the thickened connective tissue which separates several lobules
in cirrhosis with hypertrophy is examined, there is fre(|ucntly seen, in the
centre of the area occupied by the connective tissue, one or more large
biliary vesst-ls surrounjed by ïoiics of embryonic tissue consisting of
round eelU. lliere is now a true i nil animation around the cunalieuli. In
the interior nf tlie latter there i^ found a rciw of eytindrieal celU and
tiiiuitar d<^.«i(iiiiTnaled colls fiHin;;; the lumen of the vess^-1. The vessel is
generally dilated, and there is a true caLarrhal inllanimatiou of the
Lives.
mterlolnilrur Iiilini-y iluete, vorv prntiablv ^pcotidiinr to the inBnmmtioB
Aod tmliryonic KUte of ilie coiUK-clivo tÎMiie of the liver.
Exaniiiieil with a liiffh [)ow<tr,tli<> iietnoi-k of Mliiiry ciiimliculi titunteil in
tlie ncnl_v fortued cuimeulive tissue, \» neon to Ih.' vf ly rr^iliirly nmtii|ii>«1.
In tlic centre nf fibrous tii»iie bund», niu «ne nr tun cnniiln haviiiff » di-
ameter of O.dtiO lo 0.(UO mm.. coinjileUdy iiin-il niili ciit^ciil «r cylin-
drical colls leaving a central lumen, empty or fiUfd wiili detaclied cell».
Tbcac canals have a distinct wall, and aiv surrounded eiliier with foiiimI
celU or flat cells |-laceil Wtween the
" fibres of tlio dense connective tiasoc.
Frnm these princifial canals |iroo«id
oitlicr a smaller network of caiutU which
still retaiu their complete f|ii(hcliiil
iinin); and a distinct hysHne wkII, or of
rery onioll cjinnU filled with elonfniied
ccllî' [jlaced end U> end. llie c.nn«iii
lined with a com[)lete epitliclial lining
and mciuiuriiif: 0.0:!0 mm- in iliainetcr,
can readily he followe<l into the iniiials
measuring; not more than O.OIO to (I.I105
InlTFlnbulir l'Illarj nsal. r. Vsrjr •malJ
nUHlluulnn PDmmaBktllBjf wnh atttri hd-
«llpulk Hitt loium* Kb4 tiD»4 iruh r«>il<
plmnl rnd loinil, Tlio» Hunllcull ouititr
Ibid liiyer widi. a, r*. a", d. CaDatetii*
n««av nrpnielv. X ^^■
mm. in diameter and i)Oi»es«in}{ elon-
gated cells. These cells consist of |>ro-
topl.ism and an oval nucleus. In ll>c
smaller caimU. they are nlacod end lo
end: their proiopla«m ami iiiivU'iiscxMiw
ph'tidy filling the luoio». Sinnng tlie»c
eamiU filled either wilh rown of ehxi-
gatcd cell» or hy a single row of the
Mme elements, their nature may he
mi^UikiMi for blood ca|âllarieii. Kut tlie
fadlity nith wliieh their continuation
with the lar^ canaU lined with cuUcal
or cylindrical epithelium can W demon-
strated removes all doubt. The smallest
of theae canals running around tJie cir-
cumference of the lobule» form a very fine meshed retîculuiD, much tiai^
rower than that of the large biliary ducts completely lined vitb epithelial
cells.
From thc*« fiictd it may be concluded, in regard to the doTclopment of
thesu netn orlis, ihut hy ihe formmioii «f embryonic coniicctivv tissue
around thi- caiml», and in u(iniie<picnce of the new formation of oclls in
the interior of the interlobular hiHary canals, iioly formed vpitladial
cells ])Cnetr.ite into tho intralobular canalicular nctworkit, which in tlie
normal state do not contain them. (Fi^. 2{*\.) There is Ihe» a tnn».
fonnation of the smallest canaliculi ; tliey are dUat«d and tilled witli epi-
tlielial cells, Tho cannla noaront to the healthy part of the lobule haw
only one row of the coIIh which fill ttiem, while tiiosc canals in the focet
altered paria have a complote epithelial Hniug.
lu regard to tlie circulation of the hile. the catarrh of tho ïnterlobiili
canals, tho filling of their luiuen with cdU, as well as the oxtot
COXDtTION OF Till! UBI-ATfC CELLS IK CIRRHOitlS. 553
into tlic luliary canalicnli of cells which <ti> not iioriimllr contiiin Uii'in,
offor an olistacle to th»- (lischiirtn- of the (►île. Thcrv-fon- on ku-nw,
mon' or 1cm intfii8i\ nl tiines siiÂÏL-tent to occiMion un infilirution of the
veils of the lobules ttitli bile, is vhi«crvi><l nliiiost alwujrs in cirrboHÎH with
hjrpcrtrtiphy.
Tlie prccoilinK Wions of tho hiliitry cnnn1iiMi]i ftrc also frci|iiciillr Aceu
nl [loinU wiiire there iit locnl (.'irrliotii^ from any vaiue. U'hey hBv<> nbo
been olnierved îu :«v]>htlîtio cirrhosis.
lu (he hepatic Inhiiles colored a deep olive green, Bucli «a are met with
in some caaea of cirrho-ii^, with retention of hilo, there are seen in the
small intralnbular canal.4 dark-!;reen contenu, while the e:(tralohnlar
canals have a palogrecuish-ycllow color. A thin section cf these lobules,
examined under a high power, shows in the interior of tlie straight ami
anastomosing; canals small cubical fragments, hard, resistinj;, snd of a
dvcp green color. We Ik-Iivvc these canalicnli to be intralolmlar biliary
canals contnining «niiitl calcnii «f i-"loring nmtt<'r, very probubly dejiofiied
in llic cctl». At til the inti-rlobulnr cjuiuIm. their eubieni cell» lire wimv-
tilDM faintly eohm-il gnten from piiKl-morteiii im)iibition, for (lie rol!." of
the biliary eu nal> iire colorless during life, but bueonic imprcgnalvd nith
bile after death.
Condition of thf Hepatic CtU» in Cirrlmtiii. — The hepatic cells pre-
twot alteralions whicli arc very variable, and are evidently secondary to
changes in the connective tissue. In fact the connective tissue
ItgWtn always of the same nature, whilst, on the eoiitrani', the liver
cells may be ai one time nomiid, or only slightly gmtnilar or fluttetnil and
alra]>bied by compression ; or tlic cells intty be iufiltriited with biliary
Suiule.'i ; but must frcpionliv they ure tilled and destroyed by oil glo-
lea. They may contain red or black |iîgmeiii, nr may have undergone
amyloid degeneration.
Fig. SSA.
Clrrhoal» nf Ihi tint, A itii. ..,.i...i. li.i:. .[-i-l.-i (nffilnii of ooe of Ih» Ii»piiclf Ubol»».
OVt^ï lb« ■■« cfQVtb 4f AvonntLvr Lih«a«, AhLl Lb« n*7 la «liLub II lurglvna tb» ln[»rv4lJitltT uiU
laadekwoa uruphy uf ths lli>r (aiJi, x ^"<'* (dmnii.i
The hepatic cells may be found noniial not oidy at the commencement
of cirriiosi», which shows lliut they have but little to do willi the origin
IITBR.
of tlic iliHciMCi, l>iit tlio fnmi- livallhr «littv of t1ifM' ci-llrt mav «Iao Iw pre-
«eril ill vi>r_v ailvniwci] nml very iiiU'nifi' iitm|iliic eirrli<wig. 1» Uii- IntMrj
CAW, Aliiion^h iiiHiiv i>f lliom hftv« iilsii[3]>c!trcil. nml «one «f Uh'tii hmrfll
houoine isulntcil i^itlK-r jiiii^ilv «r in ^n>ii|irt uiikiiij; th« i>clerwo>) oniitM^ctiv«
liiwitf. yet llioKO nliich rt>nmin riiiiv have a noniiitl nncleti» aixl jirnlni'laâm.
Wltili- tmi|i-i-;*oiii^ airojiliy from ihc [treastire exerted \>y ihU |ierilt>l.iil«r
and iiilralobular cotineciive ti.ixiic, the Hepatic c«tU ofteu [ireservi' tlieir
orignal form. In otlicr cjiac», wiion the pressure ia eserciscii only îit
one dircciiu», tliey become âittcnod apiiiist each other. W« h»v« alrcudy
Kiren the facility with which entire lohideit may chanjj^ form undor pre»-
sure.
When the lohnU-s arc colfircd Kwifii. n« ie the ciwe in retention of liilp
am) p'lienil ieteni< "hich siniictiiin'» ««oiii]imiii.-» atmphic cirrhosis, »nd
not illfre^|l)cnlly uImi iiyiiertn)phi« cirrhtwi», the hepatic cell* contain bile
pigment intiler tlie foiiu af minuto grnniilett, ami in oertain ca-ipa tlw
entire ecll ih colored Itright ydluw. In carefully treatiiiiç tiie prepara-
tion with nitric adil the cell becoiueti more intensely colored and aHsniues
a tcreeniflh-yellow lint. Tlie <(auie ri-Hnli \» obtained with tho solution a(
iodine, lu these colored cells ihei-e may W at llie same time an accu-
ntiilulinn of colorlcsH oil drojis. which diâtonds thotn more or less. It is
ill thcM- i-jii^es of reteniion of bile that we find the intralohuhir biliary
canals filled with the small greenish concretions which we bave prevtoitsly
dcKcribeil.
1'lie aliernliou of the cells most commonly met with in cirrho:*ttt »
fiitty iiitiltraliDii. At tin- «ine time there are cell» more or less înfij.
trated with Viili- or blood jii;:nitriit. It is the latter alteration which givei
to the entire lobule the yellowish or brownish color regar\led as cbarM-
tcristic.
The red pigment is often pre dominant. The ceils then contain brown
granules iiud h!Qniiitin. and the lobuIcH present a loabo^ny-brow» color.
This C'lniUti'jn of the hepatic cells is anal(><:oiis to what is »<-vn in nutmeg
livt-r, duo t'l incroiijie of blood pressure in the riglit cavities of tlic heart,
mid ill the Kiiliheiialic vein:*. ,
In cirrhosis we liitmelimiM find portions e^doreil black. We ohoiild not,
however. niHtake a cadaveric change for «luch an alteration in c<^or, for
the red pigment readily tuma black after <leath. Man; obeerd'ers have
spoken of the presence of black pigment in the connective tissue, or in
the hepatic cells in siibjecta who have or have not suffered dunnj; hfe
with intermittent fever. As we have seen above, in ehnmic malarial
[Kiisontug the pigment is especially fotinrl in tbe whit« blood gtobalw
and in tho more or less abundant connective tissue wliicti surrounds tbe
vessels.
The complication of cirrho^ia of the liver with amyloid degeneration
of the eelU and of the vt-i««eU iK infreqncnt. It may oocaiuoiially be
met witli ill (liftciiic* which lead to amyloid de>:eiieradon of the i'isu«ne.
Iiarticularly in syphilis ami in prolonged mippo rations, whatever may be
their cause. The spleen ia generally hyfwrtropiiied in cirrhoisis of tin-
liver ; sometimes it ia even indurated and affected with cbronic inSau-
Dtttiou of the connecdvc-tiasue trabeculiie and of tbe aplenic capsule.
FATTY INFILTRATIOK OP THE LIVEB.
555
I
DKtiENitRATiux o¥ TUB htVEK. — Wfl havi> fllrcndy sloHivd tbv olWr-
Htiona of tti« hepatic colli» in ani}'lui<l uml in I'utlv iti'^^npnitioii, Wi>
«ill ROW atteiu)>t the i)oscn)itiuu of the nuicru^copii; di«tri1>ti(ii>ii of tlie
Uttiou with respoct to the hoputjc lo)>ull^,
Fatly Ii^}i!trali-m. — Tlic ncfiiimiliiti'>ii of fill in Uie livor lias no con-
DCClioii witli thctiuduu itvvi.>Ii>]>nii.*iit of tlii< [iiiniiiculii«»i|i[><iaut>, oroliositv.
Oh tlte contrary, tlic Hnbjccts who |)ro*eiit at the autopsy a fatty infil-
tnitioii of the liver are gencntlly einamteil frinn the effects of a Ion;;
chronic ■) iiio nier, 911c li ns |iulniuiiary jihthi^in, caries, scrofula, or tliey arc
n prey t'> cariliac iti.seaxe.
We ithall sec, in fact, that impeilimenta to tlie circulation, diamums of
ttie chiwt, etc., have a ^reat înBueiice ujjon the production of ilic hvpatic
legion which we are now conaidering : and that, instead of tliv accuinulu-
tio» of fat in the liver indicating a richness of the economy, it sitj^vstâ
an inahility to consume the hydrocarhoua which como from digestion.
I
Puif Indlnllnn at Iti9 llnr |>liiftTt. A. A hsiiallc «II «ouln'HK Mnol til ilru|i>. A. lod
#rmjial«ftaf IbD ijimn bbiuh ; 9. buniml nnettUL y xiD. fl. 9\Uy InBLImllnq at ht^nt eAlladtir-
la|lMlaUi>D^ l>rppafBlluB trHlnl bro«ult «rU. Tl>' bi-IIb, •■,••( ttm t»r1pliory nr tb* lobnlt» an
tornikJ: Ibr cajli aT thu tnjiErtiiif tbvLnlmlK Ar* nili*il with ilriïVS Ah *t»l>'*<l l>Lji«k with ^«Dik' a'M ;
A, iMotnl itlD. X <C- ^- Fillf InHlinil"» uf Ibn hIIi ■! Ilm )>«rlphi»ir of ihu lobnln : h. milinl
Vfla » ^. |H4rUL ««lb : fr, nllji aF lb* pArlphorj fkllj' LnAlmml ; d. qarviHl cslU In lh« nnlrftl portlOQ
•t Iha Ivbol*. X ^
There w, however, an exception to tliis nilc, namely, the physiological
accutiiiilatiiiii of fat in the liver before and duriii;^ lacLiiton in mamniiferi«.
I» women in ]mrtîciilitr, from the establishment of lacttition to its ce^ua-
tion, the he{))Uic cciU of Ihc centre of the lohulo are tilled with large
fat dro]« (lUnviiT, de Siiirfty). In the central half of the lobule the
LITBR.
ViK. 28-i.
c«lN wtiicti siirround tlie ci^utrn.1 vein are loailed with Fat, nlitUt itiow
M tlio |H;ri[)herj contain iicfinrelv anv or uone at all. Thia coitsi'lorablv
i|iiiiiitity of fnt, eviilenlljr held in reserve for the fabricatioo of milk, m
■l4>])ftiiiteil n* near a.» possible to tfae blood vbioh will go directW to Ui«
iK-art. (B, Fig. -iH».)
In most <ir the oilier partial fsitty infiltmiions of the liver, the fat i#
located at the peripliorv of the IoIriIob. TiiuH, in thi- phjri'iolo^icid
procosses of digestion, only a very thin jieriphvral «one of Uic lobules it
infiltrated. (C. Fiji. 29»!)
In all patholajrical ea^ts, fattj infiltration i< »ecoiulJkrr, and it mav
occupy to a ;treatcr «r letwer «xtent tht- pi-riphcry of the lohule, or it
may involve tlie whole hoptttio lobule. TIius, for exninple, in the ex-
ternal half of tliu lohule, the cellit here, instead of rotninintï tiieir nonnal
pnlyhndric form, haro become spherical and voluioio
noiu»; tlii'ir nucleus, still pi-eserved, luw been dis.
placed to the periphery of the cell. The irells thus
altered \-ery much rcteinble au ordinary fat vesicle of
Adi|inse tissue. The periphery of the lohule inlil-
trateil in this way, after death, aiipcars ansmic. K™.V
or yellow, and opa<tii© ; whilst m the centre of the
Orsgy lobule, on the contrary, the hepatic tissue pre*erve4
^^ ltd brownish or rosy color, and the cells arc nornul
or coutitin a few scattured fatty granule*, or eoiue
brown or yellow pi^^raent ^inumle*.
The distribution of the Icsioii i» ilelonnint'd hy tlw
iinpt^dinient to the cSrculittion of Ihe blood in tlie
liver, by «insis in the capillaries of the p0rt.1l vein,
and, at the same time, by au iiimuf&cicut biematosis.
Piilmounry and cardiac affeclions work the same result, which la tJie arrest
ill the Vivvr of the fatty maieniil carried hy tlie portal Wood in di;!esiiou.
In the nutmcj! liver which is met with in car<liac disoues there is a
new ch'tneiit nddeil. as we lime seen — dilatition of the central vein awl
capilhirieM, and a pi;;montiiry intillmtion of the cells at the centre of the
lohule -
In chronic jiiilinonary diseases, and e»|wci»Uy in phthisis, the entire
ho]>atic hihiile is most freipieiitly in a state of fatty infiltration, 'llic
same condition is ohservcd in the cachcxin--* with chrùiiie supjiuratioi
In the latter Ciwes, we have the most eompleti^ type of fatty intiliralioi
To the naked i-ye the orpin appeiirs hyperlrophied, because all iiii eel
are increased in sizi- hy tlic aifiimulution of fat. Its color ia uniformly
eray or yellowish; it*« ed^es are ohtiise and thick; it« consinlenoe s
douj^hy, for it conuins a large quaniity of oily Htiid ; and the eajHuIe
of (Jlisson is stretched and shiuy. It greases pajier, and. witji the naked
eye. we can see oil dobules iu the scrapings from a cut surface. An
anatomical diagnosis is very easy.
The circulation is slili carried on in the«c fatty infiltrated livers, but
it is evidently impeded in the capillaries by the pressure of the swollen
cells.
The biliary secretion is sometimn vitiated, «ecordinir to Frcricha.j
In fact, the heputic vvlli! are not placed in noma) conditions for
Ltt<-r.ii>IU la **(|i>ni
«IJkjM af tKlly liiQII'ik.
lion. X »■>- iXt'd-
JUIich.)
\ IK
nlM
^ AMYLOID DEGEXERATIOX OP THE LIVBR. 657
secretion of bile. The Urge l>iliary cAiiaU may be fouud empty op
coiitiitiiin;; only mucus, uuil chc ;;nU-ljlu(tHcr fillcil with a mwiotis and
pall- t>ile. In the liik- tlms liwolon-'I ami iiii[xjveriithvil the coli'riiij;
□Mittvr iti vrtintiti^. but thi* bilinry iiciiti^ fitill vxiat. Finnlly, in thcitr
OTilnrt;i-(l fnttv infiUriitciI livcrv ii v^iiuolunn <lilii(Htioi> of the bilinry
canals and u cutnrrhnl coiiilitioii uf thoir niiicoiu mcmbnine bare l>«H!n
noted.
f'ltlh/ Dfijnurfiti'in. — Beni<k'a tliMC fatty Jnfiltrateil Hvcin nlwerved
in the course of chronic c;»cln-ctic discnsês. lh«rfi i» a tot»lly <lilTcreiit
serieii of heiwlic It-nions which liTininnU" in .Mlif dr;ienrrati'in ; it ia
tlie scrieti of parenchymatous he|iatitc*. In tlie^, tlie cclla are tilled
willi minute protein or fatty granules, and they tend to fragmentation
and (le«truction. We have Already called attention to the distincttou
between fatly infiltration which does not kill the cella, and fatty degene-
ration or nccrohioBi» which ri-!<ult8 in the death of the clement^. Among
tlie parencliyiiiHtouii hcpatitcit. those which follow poisunin;; by pliO«-
phonis, by arsenic t and by antinumy.otc.. arc chamcturited by aninrked
fatty degencrnlion of all the hepatic ccIIh. At a certain «la^^ of phos-
|)lionc (loisnoning, the liver doe« not much diflor from ihiif or^jim in the
state of fatty intiUratirm of the entire lobule. The cell» arc oomj.letely
filliNi with granules and i>iiiall oil dri<[>«. The orjian iji of normal tuze,
or i* iiti;;hl1y tumefied, j;r)ty, and opiugiieou the eut surface; is fropietitly
con^'c^te'!, and >if a doii<£hy MoftneMn, The kidneyf* are almui<t ahtaya
in A complete atftte of fatty degeneration at the same time.
Amyloid Veffeneration. — .\myloid degeneration of the hepatic cells
(!«c anU) conitietâ In the more or tesa complete infiltration of the cells
by a peculiar translucent, refracting substance, which poaooKses the pro-
perty nf filing iodine, and of staining mahogany -brown by a weaV solu-
tion of iodine. This dark-bri>wn mahogany color is somctiiueit »ll«red by
snlnhuric acid, which may successively cause a change to green, blue,
violet, or red, or to only fine of these c<dorK. Tlie he|inlic cell» become
tnuitfomied Into itmall vitreous Mocks with ohtuse angles, or into aphe-
roids. The cells thus altered are united toj^ther into t<mal) maitsea,
which may present irregular fissures. In these cells nothing remains of
tiieir normal siructurf, neither nucleiL*. nor fatty granules or drops, nor
pigment granules, nor glycogenic matter.
This amyloid degeneration commences in the liver, in the terminal
branches uf the hepatic artery, and the capillaries belonging to tliem.
Tlie interlobular branches of the hepatic arterv penetrate the periphery
of the lobnlc, and break up into e.ipillaries which anast^unose with thiise
from the ]V)rtal vein. The amyloid degeneration of these arteri<ilei»
traiuforiiK them into liiiual-', with hard refracting walls. con.stJtuted by
cellular and niust-uhir dements infiltrated by the aiwvhiid sub.*l»nce.
The adjoining be]nitic culls »re those fir»t attacked. It rejiults. there-
fore, thai the lesion is limited fit first to u middle Kone nf the lobule, yet
nearer to the periphery than Ui tlie centre. At this stage the lohule is
divided into tiiree «ones, a very narrow peripheral zone, the cells of
which «re in a state of fatty iutikrallou ; an iutermedialo zone iu a 8tat«
S&8
LIVKR.
[of amvloiil de^^ncntion ; ami a central ïone, of wliïcli Kk- ctlU mai
he iioruial, may be filU-d with fatty granules, or may Itc infiltrait will
red "1" voîiow pipucht.
Wlioii llio la-iiiHi i.t iililor iiml mow ailvanci^l. the whole hepatif lohulc
ia dcReiicraled, But il i» ran- that the ulmle i>f ihc liver hua iiii<Ier;;«iio
amyloid de ;ifiie ration. Tbcre nre in-ariv aliviiVA [larta of |ohule« at
cutirc lobiile^t which «re sitiijily in u state of fatty iiitiltratioQ.
Fig. SOJJ.
T- Inlmti^btiliir vtlu*- Tbv liter v«ll>lo tbtcfatr*! ab>offtor(ba l<ibiil4>««r«liitlIrMt4l «ub «toflc(4
■BtlMi. X '■">'■ iltlnd^Urh.t
Th« lesion may extend to the h('[iHtio veiiin and to the hmnches of itie
portal v«iiia, in which cntv tint hihiih' in entirely Iraiisfornivd.
[n the last three exanifile* of iimyloid liver which »e hiivi,* examineil(
the lesion was limited solt-ly lo tlie ven.-ieU, In one of ihvs«, a case
Hplenio leueocytlsQnii», only the eai>illariea of the he|ialJc lobuka «err
arfectci] by the amyloid de^neraiion. The hepatic celU were a little
atrophied from the thickening: of the capillary walls. In tlie two other
example» all the vonseU of the liver, the hranehes of the jwrtal rein, i<(
the hepatic vein, a* well a.-» the capillaries, were simultaneotLtly affi-flteth
When « thill section of aiich an altered liver is stained witli the two
varieties of Laiith'a tnelhyianiline, tlic violet eolor decompone^ into
two tinta, a red violet, which is fixed by the amyloid el«mentH, and ■
hlue violet, which is imbibed hy the normal cells and fibres. Iloffinann'ï
violet presents the same reaction. Upon préparations thus obtained it
was eaay to assure one's self that the hepiilie celit were iionnal in the
three cases, or were dimply atn.iphied. Tlie endiilheltnui of the vessel
alM> almost always escaped the iiiiiyhiid alteration.
'i'o the naked eye the amyloid liver pru»cnt« nearly the aopvct of the
fatty liver ; it has a dcngliy constntence ; i* aniemic, jimy or yollowùb-
^r»y ; it« ed^e» are rounded ; ita sixe \» nonnal, or U Kli^hlly or some-
times greatly increased. But when one makes a large, moderately thin
I
TDMOBS OF THE LTVBR.
«ectini), aitil cxiiminrH it upoo » glrnu plntc hy Iraiuiinitled li;;))t, it is
aeeu Umt tt jirewnu more nr lc«t voii4i<luralil« nreiui which are vitreoii-i
aiitl traii.4(iaratii. Mort^over, when tincture of iodine, or «ven a vroitk
Hotiilion of iodine, is (lonred over «ucii » âti^ttou, |)orlions of lobuluâ nr
entire lobuleH a«aume » characteristic dark iimho);Hiiv hmnn color,
Most frequeiitlv, when the liver is invadtil. the sjiiccn nnd the kidni-jif
arc alio similarlv altered. If ihc kidneys arc not iimjloid. tliey iilwayit
present u •;runulu.fatty dcKi'""'a'"on of th» epithcliuni of tfa« wicreuiry
tubi-ft.
llic etiolo^ of amyloid dciîfn«mtion offers many pointu of n»tm-
blarici> to tlittt of fnlty iiililtrntion of the liver. Amyloid d<');4-ni-i-alion
may ti« met nith in nil the cachectic dUeaMcn with clinmie au]i[mrnlion,
in tiilMrcuhi.'*)», ncnifiilii, vypliili», in cancer ttotuetinic». U offert) thin
|>oint of re.iemhlance (o cimjiK' fatty jntiltmtiuu, that inanition or ema-
ciation arc the Hole clinical symjrtonis.
Ti:mob« «F thk Livrk. — We have already «poken of tumefactions of
the or^n occasioned by acute aujipurativc intlammniion. by chronic in-
flanuDation (hypertrophie cirrboni»), and by certain dejïeneratîons,
hypertrophies, limited or penoral. wrhich have not infrequently received
tb« cliiiieal ttcsignatioo of tumors.
Anf/ioma, — Cavomoiu an;iioina is a tnmnr not infrequently ohnerved,
but wliichoiily wry rarely utIainM a notuhle viihmie. Mo?l fninieiitly
one olfserveit at the wurfiire of the livvr a xiimll, Kplierical, ^ilieiit tumor
beneatli the cajmule of (îlistinn. It is dark-red ui>on the cut i<urfaoe. and
Uood eecupes while the ^matl tiiroor contracts. It consists of an areolar
cavernous tissue, the cavities of which were filled with blood. For their
minute examination they should he placed in some bardonin;; afjent
before tbey are opened. Upon tbin sections tho cavities arc seen filled
irtth bliio'I; thcv arc limited by thin trabeculie. which separate adjoin-
iii'; caverni. These trabeculie are formed of dense fibrous tissue, and
arf corere<l by a layer of endothelial cells. The tumor is everywhere
iturrounded by u w>ne of embryonni connective tissue, in which cour»o
the dilated vckvcIs which ommnnicate with the previously mentiune<l
caverni. 'flicM! caverni intercominunicati' with one another; they origi>
nale hv a dilatation of the capillaries of an embryonal tissue of new
formation. These tumors may he injected from the hepatic artery.
TuhereltE. — Tubercle granules are very common and often very nume-
rous in the liver of patients who have succumbed to an acute miliary
tul>erculoMS. These granules are so minute that they arc seen with dif-
ficullv by the naked eye. The liver is an»mtc. yellowish, and it is
oidy Ml examinin» it attentively in a favorable li;;bt that the small semi-
transparent f;niins are seen between the lobules, (jranules locfited in
tlic capsule or upon the periwneum aR- more easily disliii^nished. The
miliary (granules in the substance of the liver are seated in the connect-
ive lisisue which aceowpanies tho portid vesseU. Cpo» a thiu section,
these vessels arc found either in the centre or near the penphery of tlie
granule, 'i'liey are accompanied by a new fonnation of embryonal tw-
560
nue wtiicli cnvtlons tlie grnnule, aikI which, where the Utter in vern
rcceiil, U not «omij^ i)iAlm;i;mi«h*;(I Trom it. There U canfle<|iieuUv a Doit'
of i»t«riititial he|ialitiit, which accompauiea tuhcrculosis of the liver.
Later, when the granule is oKler it consista, at the centre, of ucro|i)iif^
cellular ctementa, and is very rewlily cUstinjriiishivl from tho MurroanM
inj; «.Tiilirvonal tissue, Thojf do iint tlu-n iliffcr from inilit»rv tuln'rclura
(tlsi'wliuru ; they rarely csfccd I-IO milliini'trfe in iliameUT. Thi><«|
of thv lar((cst size are fomicd hy un a^glo mi; ration of Miveml tniallcrl
one», inni iiri- ea*i'i>iis atid ituft. Tiiberc-lcs in tin' liver are «niuvtiincM
^soeiutfd with liiherek-K of the peritonouni in ohildren.
(7Mntm<it(i,— Whciiconiiidcrinj^oirrhoKiawehriefly jrare the cliara«tvrs
of interstitial 8y|>)iilitio tie|>Htiti:i. In tlie tertiary jieriod of syjihili^ (he
liver 1!» often the «eat of ^ummata. These rai>rhi<l ;;rowths are «.-oiisii-
tuted hy an ii^;;lomeration of two, three, or rnore siualt neoplasms froni'J
the aiie of a millet seed to that of a small ];ea, of an angular or irrepi-S
larljf spheroid form, of a yellowish color ami very firm conwiirtenw.
These small rcUawish masses arc hoand to;^thcr and surrouiKlmL
by a ihiukeiied zone of dense connective tissue, whieli form< a emumon^
Cftpeule. There thus results a sphcmid tutnor from the KiiH> <>f » hazol-
nut to thnt of a walnut, or ;^i>Htcr, which tn nxualty located at the
bottom of n cicatricial depression «f the surface of the liror. There
often exist several of the*c coloniw of minute ipiminat», surroundvd hy
tlieir tiliruu.^capstde, either u|>on the superior face or. aa is more ootumon,
ii|K}ii tiic inferior aajiect of the liver, or iu ihe de])th of the or^n.
the cicatricial depressions the capsule of (ilisson is thickened, and all
always aliio there arc fibrous «abeaions which unite these ]>oint< wit
ticighliorin^ surfaces. When one examines a section passing; throuzh'
such a cicatrix and tliv «^roup of gumnmtit which are fourni at the
bottom of the depre-ssion, one sec* a cirrhotic thickeninjr of the inter-
lobular conuective tissue around ncighhoriiif; hilnilt-s, ()f nuch s nature
.tiliat one recognises a partial cirrhosis as nlway.* iK'coinpanyiug gummjr,
ftuinor^. What obaracterixcs f^uinmnU to the naked eye and difleren»''
tiatea them from aJI other proiiuets is tiieîr dryness, their yellowish
caseous condition, joined to their great hard-
Fiji, aufi. nesa and to their elasticity, so dense tlwl they
: cannot he tont hy the finger nail.
" The volume of ttie liver affected with gum-
mata is usually found niucli diminished at the
autopsy, because the lesion is then old anil
4 the jicri-hepatitis. as well as the cicatrices fot
loninj^Uic cnibryonul fonnation;», have c»u»e4|
.811 atrojiliy of the organ. Bol si the
ir .^ - mt-neoment of syphilitic hepatitis thin;;» "^J'j
, J lie idto;iether difrereul. The liver may
r 'n much hypt-rtn>j>hied iu the congestive anil
onniMiDii* fT>i»ih tnn iu«». ttcutc iiitiwinmniorv period of syphilitic hep-
«. c.ai,.irori'....ori,™»ih.B>u- ^^\^;^^ Aceonling to Lancereaait, Klefc
ripc^r.. «,.auiMt-a II...... r. «'"' «o™e Other auUiora. hepatic giummWl
Bitfod.fui.1. x>M. may be reabsorbed while leaving in divtr
CAT!CIXO»A OP TUB LIVBR. S61
]>lBce cicftlricml de(>rc»)iona. l'h«re U no donbt tliat caaeotia tioduleiA
■ ina_v be partially abaorbed. We {icacriWil (pas*-* HI) lacune Riled
wilh fatty ^raoules aroim<l tlie caseoua ci-ntri" of K<uiinuita, which waa
rvganlod as lymph voHMcld nctiii;; as alworboiitit : but it io ilifficutt to be-
lievu tliftt tlioiicw to mm ti oil» can di»i{ijicur conipK'ti-Iy. The connue live
tÎHi^iii- which surrtiiitKlti tbcni CAtii>»t, iii any ca»c, di^fajipvar.
CoiiCLTiiiiiR their mructuif.Mlit ^luiunutUi {iri^»ciit iii tlicir CM»tfOU8 contra]
portion «mull cclltdnr cli'in«nt« clo^'ty (lackcil together and tilli'd with
Kmiuute gntnulm; the ven^cli* in thii imrtioti areolilil^rateil. Ardiiiul tho
jrijllowuh Cftwoiu portion lacimie i-xi.-<t in the connective Hfnue xtniilar to
the tym|ih A|mceii and tilb-il wilh };raiudeâ. In the ])eripheral tibrouii
Koiie are hundle-i ol' t<ni;^h cuuneclivc tiiii^ue, between tJie fthres of nhich
are celU sometiines roundiali, somedinea Hat, and in which ecleroacd ree-
sol» courae.
The more recent giimmata of thv liver, of which wo bavo ^veo a
description (p. lUD), a^- constituted by »^inuU niicniseO|iic nodnle8(a, fi^.
^JG), the centre of which ha» already iiuderpmc an ntr<)|>hy and a tatty
degeneration of the celln, wliiUt the round cell* of thi; perijibery are
confounded nith the ni-i;|liboi-iiif4 embryonal lissuv. A large giniiinu i»
rnniKHwd of colonies of tliv«i- minute nodidci*.
Lukttnie Tum»rit. — In leucocythienita we may find in the liver Hcvernt
rarietieH of IcKionn associated with a considerable flwellin^c of the or^an.
At lirAl tbem arc xumll extra vasatioiiH of while blood corpui'cles inui tlie
hepatic tisâue, cuiucd hv an obstnionon of the rnpillurivs by the n-hit«
corpiuclc^ whieb distoni them. Moreover, in 1ymp:»i U or epl^nic aden-
itis, now formations of lymphatic reticulated tissue arc oftt^n taet with.
Tlieao new fonnatioiis of reticulated tissue ajipear bclweeii tlic lobules,
nrontid the perilobular vessels, and especially along thv Course of the
branches of the portal vein.
t
Siirerimii. — Sarcoma vi rarely met wilh In the liver. It iit always of
•econdary formation, «si^cially following melanotic .tarcuma.
ITp to this point, the Lnmorii of the liver which we bave passed in
view— lu berciez, jçummaia, leuk^emic tumors, sarcomata — «re all
secondary, cavernou^t angioma being die only exception.
ICarrinoma, — Carcinoniats and cpitheliomata arc very rarely met with
■» primary tumore of the liver ; they usually follow similar tumors of lh«
tloimich, of tlio intestine, of the rectum, of the peritoneum, of Ibe lym-
phatic glands, of the uterus, the testicles, the breast, etc.. or of the gall-
binilder. 'Jlie gall-bladder and biliary pHSsagus niiiy be the seat of pri-
mary growths which secondarily involve the whole liver. Iteca\i&e of a
coiiniderahlo development of the cnncemiiJ* fommiioiin of the liver, while
IjUie legion of the gattbladder is of sniall extent, or i^ not even «uspected
or flouj^ht for, iin inexjierieiiced obMfrvor might readily believe that he had
to do with a prinuiry growth, whilst, on the contrary, it» real nature is
that of a secoiKliiry lum»r.
Secondary caicluomata of the liver are peculiar in the fact that they
3S
HVRR.
ftro fiflcn (if rorv eait^ffffllfiAo tnzv, whtlu the primnrr tnmnr, in ilic
stomiif)), fw <-\nmjiU>, nut^ eoniiïtit of un ul<:vntto<i L'iKujtkttloiil, (warcvljr
iu( lllr•^■ ni' till- hollow ul' tin- Imnii.
Of III! lliv (>r;;ftii!» of tlic eeniiomy, llie livtr U the niiTOt fpe'Hiciit ^i-it
of necomlai'V careitionin. Ami, «iiice it ia h Inw that llio tM-ct>tiil:ir_v I'-irrii-
alioiin ri'iinwliice more or less elo«*'l_v tlic slriiclure of the f>riiinrv ■.;r>i»th,
it follon.1 iliat tre nhould expect to Shil in the liver all the ram-ties of
nrctiionik.
I'rintarg e«retw>ma of the liver prcsfiits a hoinof^neonfi miws of oon-
mdcniMe sixe, at the centre of which thi-r« is no vestifte of hc)<«ti<!
tienne. The central porlioii imifomitjf ilegi'in'rmti.1, \* yellow awl ofuique.
AroumI the tiimm- secondary cnrcinnninloii» fiwi nri* ilevctopeil bjr îrifiw-
tto». ThcM.' tiiiiiora yicM ti niitky juice iipfjn ■«I'ccion, awl preMDt> umlor
tlic iDÎcrPscopc, the ty|ûciil structure of cftrtiwoma.
In Mfondary carnnnma of tlic liver, in«itcu(l of fin<Iing a «ansi<lenl>l«
homo^neonit ma»*, oom]>lelely ii\i|i)i1antin;4 the atrMcturo of ihe organ
where il i* foiind, as in the [treceilini^ exain;>te, we liml tuually a lar^
niinilier of islamU of ilic morbid ^rowlh. nearly of the sams age. and
very uniformly scattered through the entire or;;;an. TIteao aecon-lary
noilulen of <i|ibericnt form have a volume which varie« between thai of a
millet seed and that of a hazel-nut or nalmit. If the primary ;anwth is
very near the liver, in the stomach or pall-Waddcr for instance, thai jiart
of thr orpin adjacent to the orij^nal tumor will lus os a rulo, most
altereil.
The nodiili'îi (U'vc'liiju'il »t the surface of the organ fnnn a liemixptierical
pmji'cti'iii, thf half of the twmor being covered by the capttule of <!li:bU)ti,
whilit the other hjtlF is imbedded in the substance of the liier, 'llie centre
of the projection is generally umbilicatod, boeauae of the fatty degenera-
tion and atrophy of the contra! elementJi* of the tumor.
A liver affected with primary or secondary carcinoma ia ;!;enenilly
rery much enlarged, especially when the ;;rontli U ciKcphaloid. It ex-
tends much beyond the inferior border fjf the ribs, and by palpation "C
may often feel the inei|nalitics upon the anterior surface, and the infenw
bor>lor of the or;^n if tliD pcritoiicul cavity bo not too much distcmtcd
«ith fluid.
We will «tudy here some of the pecidiurities «f carcinoma nhich Wloii;t
to it« location in the liver and to its development there.
One very remarkable character of cancer of the liver is Uiot llie tntnw
may invade an<l fdl the ditferent branches, the trunk aiid nei^btxma:;
divisions of the port;il vein. Wo have several limea seen aMociatnd »ilh
a telangiectatic cancer of the stomach, a carcinomatous formation of the
same nature in the portal vein.
In this variety of carcinoma the net work of telangieclattc capillariei,
and the isolated spherical ancurisraal dilntutions are very easily reeo;;-
iiized by the naked eye as rinuoiis lines and isolated red jmints. In
those case^ which we have seen, the ulcerated tumor of the stomacli
scst«d near the ityloru:* presented ii[>on ltd peritoneal flurfaco lines or
tortuous conia of tlie siee of n crow or gooM (|uill, which were nothing
else than the afferent branches of the (lorfnl vein, which could be easily
followed up to the trunk of Uie vein. When opened, ihew veins appeared
CARCrXOMA OF TUB l.IVRIt.
563
filled with a soft cardnoinato)!!! j^roirtli. like tlint of the priouir^ tunwr,
iDwhicli ecstatic capillaries conM l)e «en. These vessels prikjoctiii^ intA
the lumen of tlic vein, were ofleii 'Hiite lon^, Tlie wall "f tiie vein
altliow^h iiifiliratcil with new «.-lenients was atill reco^jninaWe on lln^ |ieri.
toiR-al siiic, bui on the Bi<lc touunls the ulceration it was coiifoiin<leii niih
the cnreiiiotiiatoiis ti<»uc, in (net it was totally transfornieil into alveoli,
filleul with ci'lls. 'ilic alteration of the veins wae not liniitod to this
location. Tho trunk of the portal vein ami all of itit afferent branches
ninning into the Uvcr were lillcil hy a «itnilar growth.
In other ca»e« a carcinoma of the lymph ^^lunijit, whether primary or
•«couilary, or of other ti^iAue» in the vicinity of the jiortal vein, tnvailcs
the wall of the vein am) thus reachvti the Inmcn of the ve»->el into which
it soiidi* projections. At the jioiiit of invanioD the endothelium of the
inner tunic ju-oliferates, and the cancerous tiifjtne project* more luul more
into the lumen. Later thi.t cnncerouK liMMne may Hoflen and hreak down
under the influence of tlie blood, and beooaie ilt^tnched and form ;;eiiuinc
emiioli. These cancemiuendioti, arretted in an interlobular branch, may
beeooie tlie point of departure of secondary tumors.
The neoplasm occuj>yinj{ the portal vein mavi at a ^ven moment,
ulcerate, and there may thus result a complete to» of substance in the
wall of the vein.
In several observations of melanotic carcinoma of the liver, reported
liy IJemian autlio», the capillaries uf the hepatic lolinlcs were filled
with the cclltdar clenicnU of the tumor (radiated cHrciiioriia of Itind-
fleiach).
l.ast]y, «e have met with an example of iieunndary melanotic carcinoma
of the liver in which the new formation at first sij^hi appeared to be
irrcijularly infiltraled throufîhout the entire orjjati, l'[)OU lliin «eelions,
examined under the microscope, it was seen that most of the vessels
belonspng to the portal vein had a much larger diameter than normal,
and were of cylindrical form. Their wall was the seat of a largecelle-l
infiltration ; their inner membrane presented coonoctivo tissue eravktions
infiltrated by the same lar;;e cells. These regular elevations filled tho
whole cidibrc of the vcsacl, or left a central lumen occupied by free cells
and Wood. The cellular elements wurc more or less pignu^ntcd. .\lnio«t
all the ve»sel>i were ult^^red in ihi* manner. The hepatic arterie» were
not the !tcat of rto intense a cnreinom.ttouis endarteritis, hut they alxo
showed in their inner niembntiit- hivers of iMvlothclial c<dU, Home of whicji
nere pi^ented. ^ome of the lobules were entirely triinsformed into
carcinomatous iitlnnd.4; the corres{>ondin;; interlobular porbil vessel»,
althoo)di recognizable, were alTeeleil with the previously described endo-
phlebitis. The central vein and iu radiatinji; capillaries were nearly
healthy. Btit the network of hepatic cells was replaced by neats of
cells with larjpj nuclei, largo nucleoli, and a protoplasm for the most part
pigmented. The thickened connective tissue which accompanied the
vcsmIs formed the stroma of the carcinomatous alveoli. The intor-
lobnlar biliary cnimis were also to be rccogniiccd, hut their swollen
cubical cells were replaced by large cells with lar-^c nuclei and highly
refracting nucleoli, and their calibre was increased. It would be dilficult
5A4
LtTBR.
to 8IN) a more bcniitiful cxmnplo of Ihv pnrlioipniioii of all |nrtâ of tin*
liver in tlic tlovdofimeiil of u iiimor.
Wc iH!«d not ni-w«!iiiril_v conuluilc, however, ihtt tlie luiuil dorvlop-
mvnl of iwi-ciiioiun is efiectc-<! by llie lilliii;; of tin; vc-itiK mid cit)<illnriir«
iif tite liver. In the (nv»t«At immbei' of caiw.'i, ini|i:6il, tW recL'iil tuilînry
tioiluleii are iiostod in th« perilobular coiiiievtive tii»ue, «round tlie nmll
divimona of tlic pana] void, uid liiev ame from a nev forinitton ofcella
letweeii tbe bundles of conai>ct3ve tissue Sbreâ. flie veins, tUeu, mow»
ûmes present un inânmniiition clmractcmed bv tlic fortnstion of nuin«rotia
endotbelial cM* upon thuir intt-mnl surface. Tiiis alteration of tlic ves-
sels mny alHo bo rvoo;;Tiixfd »s a «ooondnrv lesion.
Riii'ltleim-b luoks niioii the beputic evil as the slatting- point in tbc
UBUtil dovelopmont of cftreioomn of the livvr. Wc do not bvlivvv lliât
ttiis mode of d«v«lopment is tto wmmnii.
Wbiic we lire co;^iiKani of some fnctst concerning tlie dcvolopinvitt of
' CftrciiioiDft of Ibe Hver, manr ((ueslionA vet remain uiutolved. In jwr-
> ticiilivr, tti« role of the Ij'inpb vciwel»! at tliu commenceriKMit of iheMr
growths has never been tliorou;:Iily studied. It has Ircen said (bat the
celti* of hepatic cancer are a reproduction of ibe struciure aiul the form
«f the normal «.dis of ibo liver. We liavo been unaldo to recognize mcb
■ »n aiialog;^. Tiio «Us of ejii-ciiKUun of the liver possess the same «hai^
I ac-terà as they do in otlier locutions, nnd rrsemhle the hepatic cell id
no tiling.
C}/liitdrini!.^fUeii f'i'ifh^lifma.-~i'yVmilncA\^\UA epitheliomt {«e
p. 154) is not iiifre<|uently met with in ibe liver aii a Hccoitdary fortiia>
iioi) wliioli follows a primary ;^rowtb of tbo name nature in tlio sioinach,
tbt small inleaiine. ttie reclum, tbe gall-bladder, etc.
To tlie naked eve, this variety of tumor offers the same characters u
cncephaloid, tbal is to say, it consists of nodules more or less volumiooiM,^^
and of a soft consistence yicldin;; an abundant lactescent jiiico. It maf^B
also assume the a))|jcaranve of colloid cancer, by reason of a purtial or a
very extensive colloid metamorphosis of its cells — an appcaranou which
the primary growth al»o presents. In order to detcnuiiie the oaturv of
these tumors it i* nocetwary to lianlvn them, nnd suhwpioiitiy examine
tliin sections. The iilveoli are found to ho lined by a single layer of .
cnbieul or cyliiidricul cellii. These elements nnd tbeir ai-r»ngeiaea^^H
faithfully reproduce tbe alructiire of tbe primary tumor, ll is noî^l
possible to demoiistrale an isolable membrane around tliese tubular
lormattons. They are simply limited by tlie neighboring connective
tissue, llie centre of the tu^ea shows a disUnet lumen or cavity. Tlie
colloid portions of the tumor present tbe same tubes and the same cavi-
tie», but tbcy arc lined hy a layer of cells which have undergone a col-
loid metamorphosis.
Tids epilbelionm with cylindrical celts has bcvn described uitdcr tbe
name of adenoma by Mverul authors, piirticulnrly Uindlteioch. In our
personal experience, these tumoiv of the liver hiive always been second-
ary. Wc readily ailmit the possibility of a pritaary e]iilh«lioma of tbe
liver, but this i» no reason for re^itnling as au adeiuima a growtii wbiof
is absolutely identical in âtnictur« «itb a cylindrical-celled e)Mthel>
I
I
I
I
IIYDATtU OT8T8 OF THB t.[VEH. 56S
It would he more loircxl to coosiiier the fonnation as an eptbeliouia Af-
iini0])c>\ from tliii bii't'lin,; anil (he new foniiiition uf bitiary canab, In
'nwt t^if thf obsLTtutioii; |<uhti(ihi-il In Kranoc uixlvr the tiainc of aik-nonia,
vrlion the nnatotiiical <li>tHil« an- cluarlj' givvn, oiiv rcvo^ixov a tmti of
Uy|icr trophic or atrophic vlrrhosi» vrîlh Inr^c graimlacioii» oil the sur-
face of the liver. A genuine iiilfnuma of ihv lirer ittioul-l ri'proiliice
the structure of the hepatic lobule*. Then how can we cli!itiii;;ni«li
the lol>u(es of new fornintioti from the nornial lnhnlesV Thi» at lin't
Nght doe^ not. to 11.4, seem {)Oii.«ihle to 1)0, ami we lack undoubted ex-
xmples of such titmora for Htu'ly. Thoae uhich hare been publi^he'l
unuer the name of adenoma by Rimlfleiscli ami several othur <îermHii
atithora are crlindrical-cellcd epitholioniata primarily developed in the
liver, or aro oxatnplea of carcinoins in which the ceila of the tumor hare
apjicared similar to those of the liver. Fur tho^e i^oIaCed nodules \i\xta
the surface of the liver projectinj^ kenuitth the capsule of Glissun, which
present the structure of u hepatic lobule, thcv are les« to be con^dered
adenoinatu tlian vices of ilcvGkpQicnt and voolormatioD, and posseee only
a purely tcratologieal intercsL
Seroua ct/al» of tlie liver arc very probably never anything uUe than
dilated divertieula of the bile ductal, which may tieconic t«>lated from the
ducts wherever they have anfleii. We have (leveral times exainineil cysts
located uj^on the surface of the liver, and containing minute biliary cal-
culi. The intcnml covcrin;; of ihvao cysts conùiits of a sinj;Ie layer of
flat vpithrlial cells. The connective tissue which surronnds them is con-
tinttoiiit with the jwriphcry of the a<ljoiuiiig lobules, and constitutes a sort
oflocal eirrliditts. In this sclerosed tissue tlie biliary canals show the
aime lesioiisi a* in cirrhosii*. Serou.* cysts of thp liver are very rare.
They are surromided by connective ti^ue, and are liui'd by a prominent
epitbcliom. We ohoidil not commit the error of re^anliii); as cysts of
the livcT the caviiie» which are sooictimeti found in the centre of cancer-
ous tumors, or those which succeed abscesHes. Advanced putrcfuction,
leading to the <levelopment of vesicles under the capsule of 4îli«Mn, con-
taitiing air and a little fluid, might at first view occasion a misLike.
Hi/Jalid Cfftt*. — CystB eontainin;;; echinococci, which are not nncom-
mon in tin- liver, usuidly constitute a voluminous tiunor, commonly projivi-
ing upon the cunvex suH'nce. Sometimes they are seated iu the dejith
of the organ. We find in procoeiliii}; from without inwaixls : Xst, A thick
flbmus envelope or adventitiotiit membrane, thv structure of which is the
same as tliat of lamillated libroiu tiHsiie. T)ii> fibnins membrane is con-
tinuous with tiie connective Umuc surroundin|Ç tlie lobules, which ig
increased to such an extent that there is a localixod cirrhosis at the
periphery of the tumor, and the lobules here are flattened by pressure.
îîd, Ititemal to the fibrous envelope, is a periect hydatid membrane, in
recent formations, spherical and tenao ; in old crat^, alininkon, wrinkle<l
Riid ruptured. This membrane is characterized by its regular lamellic,
pnnUlel with cnch other, fonned of a hyaline amorphous substance, witlu
out any cellular elements intorpt>«'d between the layers. Within this
membrane, of which tlie sharp fraelurc, the separation into lamellae, the
66Q
LIVBR.
TitTCOiia ami tremVling aspect can be confounded with notbin;; eUe (see
)>I>. I'.l2 ami li^8), are fnuml dau^fbtcr vesicles, also li&\-iii<r ii similar liul
thinner membrane, a volume varving from that of tlie heiul of a lar;;e
pin to that of an egg. Itiese daughter voslclcs art- vorv n-irnlnrlv e\ibtr-
ical. Tliey i-ontain non-al)>uminouf> a<|UL'ous fluid, and smiill grnnnlw
whicb are nothing cIhc tban ecbiiiucot'ci. Of^n tbrto vesidvA contain
nothing: — tbojr art- tlieii «tcHlc. ât\. Tbc ecbinocoCGÎ iirpsnmll v<i«culitr
wonnK, furinvd of n I'liwlal vvsiclc adber«nt to tlie ^rminal mcDibniue.
In the mid*t of tlii* vcnîtle tin- bod.v and head of the animal \* found.
'Th« h<.<nd :<Iioi>:m » pi-obuacis, four Mucken, and a doubl« row of hooka
(*pe \>. li)i;).
Kobiiiococci arc tJie vwicular worms of TVfiiiti rehhioeocrutt which
doea not live in the inteftliiiea of man, but is common in the do;;. I'hv
Twnia ectiinococcu» is remarknhlo for the iimall number of its rins;s.
The egjçs of these worms, discharjied with the fecal mattar of the animal
ill which lliey Hie, arc swallowed with the water and food, and arrive
in the stomach of man where they lose tlieir eiivc>lo[i)n;; membran». The
«mbryo thus set free (wrforatcs the membmnos '>f the stomach in onlcr
to lod^ itself in the neighboring organs, and to undergo tbvra tbc
woiid [khiisc of ils dei'elopment.
When the hydatid cyste reach their full development, and ttill romatn
in the liver, they contract, and the hydatid membrane)" rupture. The
fluid i» thon thick, o])ni|iii,'', and rich in the italis of lime; it is n-ndcred
yell<>\s' or reddish by the pretence of the colorin;; matter of tlie Inle and
of blood. The ccliinococci no longer exist, they aro broken up and de-
stroyed : yet we may still rocogniie the hoaklcts in the fluid. It is not
uncommon to find at the autopsies of patients who have not presented any
symptoms of hepatic disordcr^ — at least in the latter years of their life —
such cysti of the sÎEc of a list, or greater. Tlii'ir fibrous membrane is
contracted. In one case which wc examined it had undergone a genuiDO
ossification, with bony tralM-cnbo, bfmc nmrniw, and osteobliMl:!!, etc.
A variety of hydatids of the liver, dcMribfd bitk-rly by Kriedrcîob,
Virehow, etc., oon^i.'itM of a jnultil'H'ul'tr htfilntiil finwir. Tbcvc tumorS'a
are comptwcd of siraall hydatid oysta dis|>0!ied in a fibrous «trona.
cyst contains a characteristic membrane which someliraes incloses ft per-'
feet echinococcus, sometimes only its hooks. Such tanora very nuicfa
resemble, at first fti;>'bt. colloid carcinoma, with which they had been
long time eonfoimded. Microscopic examination will immediately
move all doubt.
Hydatid cysts in process of growth, instead of atropbring and sbiivek|
ling up, mar reach a volume so great as to require surgical intertereDC*!
At other times, they may esun- adhesiun» between the surface of Ifad
liver and the dinpbrugm, tlii; walk of the stomach, ibe «mull intestines,
etc.; and they may open into the pleiirn, the lunga, tin; bnnwhi, th*
stomach, the int^-^line, the gall-blinblcr, et«. fhio caw ha» W'<:n eb-,
served of a {)erfoniLion into the jiortal vein. When ibe ojieninj; tak<
place into the peritoneal cavity, there rcàull» a fatal peritonilu.
I
ISFLAMUJITIOK OF BILIART VK99BLS ADD OALL-BLADDBR. 567
BlUART VgïSEIS AXD OALL>BtADbBft.
l:trLA)[UATfO!i. — 47ftUirrlml inflaninuitîon of t\w galMUdder frniuentlv
U caiKtA hj th« pr«)ii'ncv of bilinry calculi, which act as forciRn IkhUvs.
Yd cnlculi ilo noi nlwayi», or usually, occasion irritation of its int)«ou«
m«nihran«; in old women, with wliom cnlculi arc tto frc<|iicnt, tticinten«1
m«tiilirati« of llie gall-bladder is often inlnct. At other tiiDM, tl is in-
JMted and contains a [lalo, stringy, imn'oiw hile with piw coq>ti*cles.
This ia eflpecially seen in connection with inflfvinmnlion of the hilîarjr
canals. The mucous membrane k thickened, roiij^licnod. and «cdematoufl,
instead of bavin;; its ordinary ihinnexs and delicate villous surface. In
a mora intense de);n« of the Ic^oti, there are found one or more ulcers
npoii ihc mncoufl membrane, especially at the inferior portion of the gall-
bladder. These ulccmlion*, when they are ra|>iilly produce<l by a puru-
lent infiltration of the connective tiisue of ibe mucoua membrane which
extends u> the mtticnlar layers, may occasion fatal perforations of tJie
|)«riu>neum and an escape of the cafculi into its cavity; but this, how-
ever, is a very uncommon accident. The ulcers, «hen thev exist, arc
accompanied only with a local irritation of the peritoneum, which is seen
upon the externa! surface of the ;;nU-htAi]der opposite the point of dis-
ease, where are Tound fihrinonit f»l«e membranes, or a fibrous thickening
of tlie serous mcraliranc irith ndhoionx. Iiocal péritonites with adhe-
sions have resulted in communication:* "f the ;»ftll-bUddcr with the duo-
denum, with the colon, and even in biliary fiittulic, opening externally
through the ahilominai wall, calculi having been discharged by these
several pcuiitagea. ' In all thcBe cases the intlammatinn extends to the
cystic, hepatic, and common biliary ducts, causing an icterus. While the
presence of calcuii seldom occanion. these fata! results, they frci|Hently
cause a thickening of the mucoun membrane of the connective tissue and
muscular fibres, comparable to tJic hypertrophy of the urinary bladder
caused by cnlculi in that or^an.
Lotus, Amiral, Kokilaiwky, etc., have described an infillmtion and
gangnoous ulceration of tJie nincnus menibmneof the gall-blnddtsr ocuur-
rii^ in cholera, typhoid fever, and puruletit infection.
Catiirrhal inllammation of the common biliary, cyxlic, and be^iutic
ductal frei(uentlr occurs either srionlaueouitly or in conseiiuciice of an
inflammation of the duodenum, when it causes catarrhal or simple icterus,
.\l other tiroea, it i.i due to biliary calculi coming from the gait-bladder
or formed in the hepatic canals. Jtiliury gravel or small fragmenta of
calculi are the most active causes of this inflammation. Kvery stage
has been observed between the swelling of the common biliary duct
limited to the ampulla of Vater. or to the neighboring portions of the
duodenum, where it arrests the flow of bile, in simple icterus, and acute
svpparative inflammation. It is ea^ly understood that the (edematous
swelling of the ampulla of Vat«r and conm'ciive liwuio around the
common biliary duct at its duodenal exlremiiy, may he an ohxtAcle to
the flow of bile ca[>ahle of producing jaundice, h is seldom that an
autopsy demon.^trati:* this lesion in simple icterus, hut the oK^crvations
by Virohow and Vulpian are such as to leave no doubts as to the pailio-
LIVKR.
1
■ M
logical conilitian. W'Mi (li^ ooh^c^tinii Ihere is nliecrved an ex^ilitM
ofnmcua. a mncoiLA I'lii;.'. More inu^tisp i?itlniiinintion, froiu llie prrwm
of biliiiry cnlciili. oMends to inoat of the bili«r_v cauaU in tlii- li»tr.
The mucous iiicnibrane of llies« cnnals is covereil with a iniMf<ima
imicuit. or tlio latter is reiulercfl clomly bjr Uie presence of ilc«>|iuinMl
cpillirliiil ccll^ nnJ im!i> corpimclBB. The canaU arc dilntvd. their ntortw
mcmlimuc thickL'Tio<l. as is nlso the connective tissuu surroumtiii^lltM*;»
Huch CAM-» iimjxillarililntacioiiG tire l'oeil IÎikvI with miKOiit mcinhnuit.llil
fiUwl oitlRTwich a inucoiii^oi- (iiii-iforni thiiil. Tlictliliitiiticms. wImcIivmj
ninth rt'xcnihU' j-nmll tib'-o.-sft-». nrv (ouwl (hnxi^^h iKo (^iiliro flrgaa,vr
liiicil with II iiiiicoiittintMiibraiti.', uixl coiituiii ninny c,viiii<Iricul cclU, mixH
with lymph ix-ll» und blood i>î<;ii)<![it, or gruinit of hilc pii^oent.
In the mo«t iutcas» inttainniatioiw, the cotiteiiLi of th« tniloh dihlc^
bilinry tomcU coiMi«t <if ii)iii<)uc and tvliitish iniico-{>tiii, but po«se« >
certain viscidity iIi»! to tin- uincii'i, as in muo-purulent tiputa. Uf
aiunnnt of this pus in s>iiueli(nes iio ;:rcat tliitl, upon nialcins n «ccûoiiuf
the liver at the aiilofi^y, there is the appeanmce of an uhecoM. Tht
numerous cellular elements in this pus consist of uyliiidricikl ciuthcto
and lynjph ivlls. In intense intinmrnation of the btlinry cmuiU, tlitrew
always obsened durinj; life, fcbrik- nyniptonu* uhich arc inlcnnitt^i'tw
tyiw. The intiainmation may terminnlu i» «iippuraliofi or a |>erfi>r*ù*
of the portal vein, and may oociuioii perforations, peritonitis, etc., vih^
the cidciili act us forcij^ liodieft.
It is probable tlmt, in cunsopionce of int«ns« inflammation of **
caiiatM, nurrowinf; ttiul even complete obstnietion of the Itc^iatic *^
connnon biliary diiut^ are pro<luced ; soroeltmea, as in llio case referre'^^
by Andrnl, fibron* cords have replaced these canals. ^^
At times. fiapilUry excrescence* of the mucous membrane of the dr ~-^^
are found, in coiJsei)Uencc of intlamiuation : thi^. houever. is unfn- | i'
Wlien s Uise cnk'nliis passes into the cystic duct, tliencc into tin '■■
mon duct, it may be arrcsteil in the lutter at its entrance into tJie di
dcnuiu where the duel is narrow. If it experiene^s any difBculty in
passage, the contractions of the duo« and ^It-hladaor give rise ^^
hepatic colic. It may also result in more serious inHamniatory accidct^^ ^
if it remains fixed in the canal or if it is encysted. The bile may t^
2
■111-
oo-
it»
w
rf^
arrested in it^ |ia«sage, occasioning jaundice; and, again, the inflam»^ ^^^
tion of the mucous membrane and submucous tissue caused by contatf^'ri
of the calculus, may extend to tlie nci;;hborin;; organs, especially to tb» ^^
peritoneum. There frecjuently results suppurative inUammalion or Ilia- " ^
ited sloughins, which terminates in perforation. If the calculai ha**"^^
been «rresled near the duodenum, from the niortâficatioii of a |H)rtio<n *^
of tlie mui.'Oii:< tiicmbnitie and wall of tlii» jwrt of the intt^xtine tln-rc
occurs, as a favorable tcrini nation, the p^.vii^e of the cak'uhii' into tlie
intestine; but if the iierforation is into the ]it'ritoueuiu,a fatiil {wrilooilia
is the result.
The biliary ducts, and parUculariy the small interlofaular canals, ex-
perience in many of the diseases of the liver, lesions due to Uepalic
disease or Va irritation by conti;;uity. Sach arc the alterations described
in cirrhosis ; in acute vellow atrophy ; such are ttie inHaminaiory irrita-
tions oocuriing in the large and small canals included id catvimiir
TCMuna OF TQK OALL-nLADDER.
fiQO
orsihiAtiNl inthi'irncî^îliborhflocl; «iich ari' thv niniloraU'catarrhiil
iw, iKiliile<i "lit hv 0. W'y»*, in pois'niiiii; hy pIioophoni8, uiid in
^-iniit'iki)' li(r]iatiti!*. iimi wiiicli «xi»!, with j;"»'! i^*-*<n>. i» siilJJiU-
ir(wtitU. Ill till' luirt'DclivnintoiiM la'piititi.t of juicrpcral fovâr,
C. etc., vrclinroiiecii an inlilt ration nf tlie {mn-vtiscular connective
itb h'n){ih cell», and at th« Mine time a catarrh of tlie amaW
tanalH included in Die iDtlaniod tisane.
! inSanimacory leaiona of t!ie liiliarv caimls. which end in sn
(t secrotion of mucus, and the forrantinu of cells which fill thum,
i with the piiasa^e of the hile from the heimtic cells to the com-
iirr <luct. In hepatic tmnoii) iho intlaiiici) biliary cnnalo arc
f flattcucd, UDd comprossod, cauùug complete retention of bilo,
ma.
ler result of inflammation of the hiliary duct« — which is, how-
friKiurnt — i* hcmorrhnni; from thfir mucous mo m h nine, occur ring
jtlly in cirrliosis, carcinoma, or simple inflammation of thi- livi^r.
Iiajî* may aUo wcur in c)iisL>i,|aoncC of ahucw*.-!» of the liver. In
c|>ortiril ity Lebert. hcinorrUage followed the rupture of au aueu-
the hepatic artery into the ga)l>blailder.
KS Of TllK Gai.i^iii.aij1)Kk, — Accordinjc to llokitanHky. a new forra-
i(li[)Ofle tissue is found in Clio euhperitoneal coniicclivc tissue of
■hladdcr in obesity; lliia ia, however, iiifre<|ueDt.
ureiors develo|io(l in the mucous mcmbi'anc of the ^nail-bladder are
nnta or cylindrical-celled epitht^liomata. The history of carcinoma
^U-hladder i« relntiv<dy of recent date, yet it is not ti very uii-
feclion. It may he primary or secondary; in the latter case it
S caroiiioiiia of the liver. Ktumnch. intestine, or neijihhoring
I'riiiiary carcinoma of the pdl-hladder i^ mont freipiently a col-
;inoiDa ; at other lime^ it ha.^ the appciininco of enccplialoid, and
rely it bclonj^s to cicirrhiis. ItA anatomicnl form h very similar
■ocurrii)}; in the intestine. Generally, indeed fourteen timcâ in
the gall-bladder contains one or more calculi: the fewer in num.
lai^r the calculi. The bilo is somottnics colorleaâ. or it i^ thick
wo; it may contain mnall fragments detached from the tiimor.
face of the f^a 11 -Id adder at the diseased point is uneven and iViin-
for now frirniation» >»sume the villous I'onn in the gall-htudder,
in the urinary hhuldcr. The tumor invades a part or the entire
surfaco, which is increased in tlilckne.'^. and upon section shows
ÛRSue, or a whitish ti^^ue inliltrated with a milky juice. Tlie
r the niucouii membrane and MuhmucouH conu<-ctive tiKitu» may
0 the muiwular tii-^ue, which latter i^ itInay.-( Komewhat o-dema-
1 liypertropliied. 'Ilie cavity of the gall-j^iaiMer in (generally
d, but mav be diminished. The tumor fn-'iuently cxtendti into
ic duct anil common biliary duct, the mucous membrane of which
«ted, »nd tiie calibre contmcleil, occasioning retention of bile in
fltic canals aiwl interlobular biliary ducts. Biliary cyst;^ may
■nm this condition, whicli is always accompanied bv jaundice.
ly Ihe )u;|>atic »• with the altered {rali-bladder. is
tlie I 1} liver may be studded with
.170
LITRtt.
no liileH hai'ing thestnifliirv nriiir primarr cnix-inoma of itii' calUi
lu 80ID6 autopsies, in vxniiiiiitii;: tliu liver iiivinlri) chfiii;;!)!!!!! bv
split^rical undules, varjin^ in me, l)icr« mav be «oni« )ieail«ti<m in
lievini; that tlie noiliilcfl arc aixiondarv to Ote iilcorauon o( tliv
blaitdcr; but nhat occurs in bepatio cnrctnoina, ftecomiary to tlialof
HMiDiicb, should m&k<> ti» aibiût tliat llio naiue coiinretioo mat ciisi
twccii the bejintic noduIeH ami the ulceration of llie inucoae Durinbi
(if llic ;;all-lila<l(lcr.
Tbo iifigbboring Ivmph glands arc always alterwl and trancfoi
and tbo (luodonum, coton, nnd eren the stomach tnny lit- itivadi^l \>y ■
cinoina which hn^ Its beginning in the ;!n1 1 -Madder. Tbcw «it
or<^iis ar« then uiùiod \ty carciunniatnns itiid fibrinous adhcMun*.
))»tclic« in the Mtomiu-b and tiitcistino arc «luallvr awl inore nccoi
the ulciTS of tlic gallbladder.
Till- •|ii*"ttioii whwlbor the carcinomatoiH ulcer jirccMcit ll»e fornistiniiof
the calculi, or whether tlie latter oxi«t primnril;, and prtMlncc tli« tQMt
br irritation, ix doubtful. We are inclined to believe the first b^
thetti;*,
liîâlolflftically, the »u)>crfioîal nou-utoeratod granulations are otnrri
by llie cylindrical cells of the mucous roeiiibrauo. and are roost frui|iiotii!_i
conatituted by a simple, very vascular embryonic tissue, S'-imiiiwi
they show the alveolar structure «f scirrhoiM, cncopbaloid or oo1l«H («■
cinoma. Tlie ulcerated portion of the tumor is deprived of all eptbtliil
covering. The alveolar structure of carcinoma is best sccu in tbc^n
thick snbmncons tissue. In the muscular tissue there is fin>l Mfnu
inlilt.raiion of eiiihryonic cells, aftcrwanl.t a true cart-inomatoi» timit.
Uyliiidrica]-('clle<l epitheiionu of the gall-bladder, to the uitaided ti'.
doe» not diffiT fiwn eiicepbaloid ; the iiislological characters af ft*
tumor are alwolutely iliu same as tlioae previously described uiuler ctI*"'
diicnl-cellcd tipithelioma of the liver. It gives rise to fiocoii4lary iwM*'
in tlie liver, as does carcinoma, and baa the esioe symptoms and l'***
nosis («oc p. 1Ô4). In the piiMished obsorvatiooa of G|>ithelionui ' "^
were also fomul calculi in llic gall-bliiddcr.
PBBIT0NITI6.
5T1
CHAP TEK y I.
PFRITOXKUSI.
I Van First c'rtnct'rnin* etperitnentnl iiitlikminfttloD
tho«« in rdutioti to nlteraliong of ibo «orou» niem-
I Part S«conil, nui^' be ajiplieil lo iniicli of ibe pathological liU-
■Ahe ]>ericoiieuin.
MïlTlîi, — PeriUinitis io acute or ciironit;, general or Ifwnl.
peritonilb, seldom primarv (rheumatic), ia almost always the
trautnatisiD. a conHwion or woimci, or of a lesion of one of the
overc<l by this serous nn-inbrano— sucK as perforationfl of the
i or of tbo stonuich, fopci^pi bodies entering; the peritoneal cavity,
iap of ubsccsji's into it« cavity, «iipeiiicial inftaiimuitioi)» of
>VcriMl by this i^eroiw iniiiTibnitu', lymplianj;iti8 and phlebitis of
18 and it» n|>peni|:i;:e^. iiietnutatic iih««c!t.«c'i of the liver, elfl.
<«■ i/rnfral i<rril">iiti* the vasciiliir injivtion of the visceral pen-
is very intense, and ia accomiianied from the beginning by a
purulent exudation, more or less abundant
tlic roeahes of tlic great omontum. in the Fig- 2f*T-
'e tissue of the serous membrane between
S and npon il* surface. The parictnl peri-
» hIho imp] i I.' n led, as are also the digèrent
tlie omentum and mesocolon. Fibrfm» »d-
Xfry rapidly form between the parietal and ~r
layers, mid between the different organs '
1 in the abdomen.
rjieral peritonitis, when the autojwy U made
ree days after the bef;inniiig of the disease,
tal layer of the peritoneum is found thick-
infiltrated with pus, it is uray mid opaque
and united in places, either lo the great omentum or to the
I, by soft fibrous false membranes, infiltrated nitli pus. The piu
into the cavity of the ahdorneii usually collect'* in certain locali-
n the pi'lvis around the apjiendiige* of the uterus, etc. The
ind thickenoil great omentum, at the priinli* where lobules of
nind, is somelimeK adherent lo the surface of tho inte^tiiiea, or
■OD ilacif; it présenta the appearance of a flosby, red. irregular
sred with pus. When the great omentum ia exposed, it \» found
to the intestines, especially to the small intestine, from which
I difficulty detached : it almost always also adheres at several
the abdominal wall by its free border. Beneath tbe omentum,
tinal loops, swollen sad di»tended by gas, arc united to qqq
«rl Willi flUoiT ol illirr,
«IiiiwliLir thf uaUijiaf of
lb» fnil.'thfflUI fnTi-rlOf
ttX lli# c^-imactlvo iWtiiA
liKliixratB. X 'iM.
572
rSHITOïtEUH.
annilier by filirin iiifiltratod wilh pua. formini; l'UIipr n tliîck Ujffri,
gra_v or yvUowinli.giny inft««, which fills np ilir Kimcco )«t««ni
tiei^hViritig toop«. Tlii» tliïuk, flemi-solîd exiidalioti varii.ii ioiM
It in (lilliovilt to »«p;Lriit« ttic united intostiiia) l<in|jd witiioM
Fig. S»8.
Vif. sn.
Il lUufir» fk^ atrlilf^UfcJ crila lu prorfiH vf i-r-'llf^
f«ltv4 BJid In Ihn ttitti iJtfUrrilBK Ht^mfliot rroro
kiiil ihua n^nlu c40i>Ml«it wUb Ik* ItitvAi tnb*»
Oaioatan ••ilBrUlly UlwH' tti i
•n>H*il ib* tif^Uà tkf ■>!* ib* 'r
Ibr m.di.llirMiil vlli k4t* M'l>
■Plillrrl u lb* ItiniM InWrtiia
rroti'i'lxiii ItlM* f »••■•' IkM u n>:
«dln,- tliiHM. ■■•! 11.(17 (ara «• ilHU I
|ilsUtrpLlti«lulla*«MiiiMl. X».
Mme of thoîr wntls. «ïncc tlie inlcBtîtml coat* tlii'm»clve« un in&l
wilh Bui<l, mill iiri' pale im<) sofU'iiivl. ThiH imtoun iiifiltrttioa or
înt^flline aW extends m ii« mticous surface, whk'K ia at times vuhm
or congested, and perhaps oovorcd witb a puriform mocuâ. The m
faoeA of the liver and sple«n ci|uaUy present an intense super^niili^
flammation: here the peritoneum is infiltrated with pus, and the e»!»
sides of these or^^ans are thickened and opiu(iic. Thf re alvars niM^
eithi-r iijion the apiiendaKes of thr uterus, upon the «iirfacc of thi~li'«T
or other or^nns, i,rniphan;;itcs. p)ilehitcs. or superficial abscesses, «liid
are the slftrtinz-poînt of ihç purulent peritonitis.
The pt-ritrtneal exudation in^ittxid of being small in quantitj, i>i«i\M*
and tlbriiio-jiuiuleiit, fw in the [ireecding example, rnav it» nwre alioni-
ant, nero-piirulont, with flake.* of free fibrin in the duid, or cnni^l
serous ; in the latter there are also alwavs fibrinous Sakes present.
A histolo;;ical examination of the great omentum demon*! rales ^*
same appearance, as described in Part First, under artificial periioii*'''
(see p. AO). that is fibrille of fibrin, lyin;^li cells and large, swolW'J
fn"aiiu!ar cells, with one or more nuelei, located in the mealies of rf^
oineulnm. Thoru i» nn infillnition of lymph celln and fibrin between t^
fibres of the connective tissue Uiroii^hont the thickenod and optuiuc mc^
bninei<. Accnmulationg of these lynipli c<'lU arc |iartieiilari^' se^
uroiind the ve«*<ds. The «ame increase of round cell* is ob^Tvwt ar<Mii^
the vessels in the adijiose nodules of the great omentum.
The liver and kidney.t arc jiale upon secliun, and their eclls ar*'
generally fatty.
The fluid exudation into the peritoneal cavity may contain bloml aMo-
olated with fibrinous serum and pus, and there are geuoralljr at lite aanifff
ciiRosic pBRtTosrTra.
■ eccliytiMWes, wttli iiifiltratinna of bloful into the sabperitiineAl cellular
We. itiit thU vxrictv of peritoiiilla uaually has u special cause, such
lancer, tulwrcle.or cirrbo«is of tlie liver, »nà it i« not acute in tlii; same
■e as the |>rece(liiig variety.
mbt t«rRunation of acuto pvrilonttis varies. When it docs not mpidly
Kin death, tlic Cfcnpcd tliii<) bi.-ooini.-f absorhi-il, embryonic comicetivc
Pitt form» upon (lie (^urfuec of the pvritoneum, ami vessels of new form-
ion Imvin-; einliryoiiic walU penvtratv into the fibrinoid false nem-
|IH.*«. These fal«! ra«nibnines lhu^^ orgimiued form ailhoition» between
ktnu'l anrfaues, an'l, at tinier, cnu^e ili;:eiitive troubles, by the intes-
beeomin^ iminovablc, contracted, nr tixod in an abnonoal poitilioii ;
bamU of uilbL-ttioii formed benveen tlie visceral and parietal peri-
Buni may he the cau-ic of internai airangulatinn.
other ca»eii acute purulent peritonitis tcrminaiea, after the absorp-
Ik of a ])onion of the exudated fluid, by a kind of caseation or inanis-
'an of the pus which coUpcis in one or more points upon the pcnto-
These collections become encysted within false membranes. An
caatioD of this piinilent fluid miiv be eftected by a perforation of the
stiue from KÏtbout iuwunU, or it ttiny even be discharj^ed through
walls of the abdomen. \Vlicn the suppunitinn causes an opcniii);
. of the iiitcAÙnc and of the abdominal \fa)l, there results a fecal
•U.
Inte lomt peritonitiâ ia traumatic or idiopathic. In the latter ca^e,
BRemlly foUowM an inflammation of an organ covered by the ])erito-
Kiia. Wh«n an iiitUiniiiation reaches the Biirrac« of aiich ati or;;aii, tlie
Bnioneum is always intiamerl : therefore, a local pcritonîlis is fre [uonl
^lesions of the liver, j^all-bUlder, splceti, in diaphragmatic pleitritiaf
aetritis, in inflammations or tumors of the appendages of the uterus»
cystitis, in typhlitis, etc.
C/rtural chnrnte peritonitit follow* acute pcHlonitis, or it is chronic
om the beginning. In the latter ca-^e, it i« «oi.tom that it cannot be
ifcrrcd to n chronic periionual or inteuinai lenion: tiiburi;iib)?is, carei-
ba of one of the abdominal organa, cirrhosia of the liver, disease of
I iivari, malarial cachexia, etc.
A» carcinomatoiu) peritonitis is superlicial at ita beginning, a» wuH na
it» «tibsequent deielopment, there are found upon the surface of the
ritoneuiD larj^e cells with largo nuclei and enormous nucleoli, which are
ingiel with the lymph eells and fluid exuded into the pcritoneiil cavity,
refore. aomeiiroeâ a carcinoma of the peritoneum may bo ausijcoted
ra microscopical examination of the fluid obtaiuei by an explora-
jy puncture.
iThc lesioDB of chronic peribonitid vary much. Thus, in chronic peri*
inici^ following acute pi-ritoniti*, then* are found njlhuslons between the
ilestinal loops, or bctvrcca the loops and neighboring organs or ab'.loni-
a1 wall, eoiisifting of filamonlouK or hintelbr fibrous tissue. Com*
letc obliteration of tlie jicritoneal cavity may occur, jiwl a» oblitemtion
f (he pleural cavity ot^en happens in pleuritis. That life may be pro-
aged eron when ttie intettinei are contracted by the interfcrei: < > '
■Taction of the new fibrou.t ti^ue, is seen in the autO|)iMes nf '
574
PERfTOKECM.
sons who, for n niinilier of yivirs. hnvi; livi^l witli thïii k'«iftfl. At MflH
limet), tli« itictiibntnos CAiiiift ol' n fvw utiiiti]>ortiiiit linixiii or eolliI^^^|
Impious, in «btch caic tli«n) it uiUAlly no titiiil foun^I in lli« jicnibH^H
Til cardiac ilUva^ei, in cirrhoi]^ of the liver, airl in niiUrial oacben^H
with hvperirophy of the itjiWn.n tnie[i«nt«iiiti:iiloo«iiot ovcitr, iMMÉâ^H
is a ^erouH ettiiniou or aicileiiiiHMad. Vei. in [nire a-tcttic efTuÛMij^^^l
nro can«tuntly observed some lesinnn, which roay 'lofiend Mfum n euw^l
inflamnuition which is secondary and which con^i»t« in tliickeniiiKs of lli^|
ca]x<u1c iiml peritoneal covering; of the liv«r and splc«n, aud in «KRtH
visnccs or };raiiu1aùoiis of tlip i)«ritoncuni of the liver in cirTlio«i8.orifc^
pori-sploiiic pcritoii«iini In malarinl cachexia and canltnc diseasM. TIinS
new Ibrmntioiis of coani-ctivc ti««ue may jusclr lie constdorc^l uit InKtiH
»r ohroiiio pcriloniùs. Again, the pnrictul pcritonvnm may )••-■ thkkfnid-M
nnd frC'ltiviitly tl.crt; niny Dxiiit Dttivr (;vidfm;c)< u]>nit the oniriiiua nlH
iiiiv'tiiH':' lit' dii-onic pc'iwniti*. In I'irrtiOi'in of tlii' liver there i*ni)H
often B tnic ^uliitcHlo orchmiiie peritonitis with the pre'iincc nf fihnwMH
flftke« in the eiïiiti« I fluid, a^ well a» hlood. The xurfauc of tW pen»-^
noum, either upon the -tiirfacc of the liver, or the iiiet«entory, or iat«4liBei, ■
is cmered 1>y flhrinoua faUe uiemhranes, or very va^eiilnr organiie>l nwa- ■
braii(-t, wliicli are accompanied with sul'ijeritoneal ecchyipows. fit- M
(jiwiilly Here occurs a peculiar heiuorrlia^ic |ieriUinili!< in Iiyperln'flitfl
etrrho<ii!i. Abdominal puncturoH do not ap|>ear to develop or aj^nnltH
indammaUons of the pcritoiietim. H
Hemorrhaffir pffH"nitU, which is chronic or subacute, aa seen iii(tj|«(^fl
trophic ctrrho»!!», in articular rtieiiuiHti»iu, in tnbcrutilo«s, in Bninit'lH
diiti^afic, irtc., is characterixed by vascular new membnincx, which ii tm ^
MJ^ht re-'«ndi1c »\k»* of blood, and nre similar in apjearnncv to tlien* I
tiK-mbrBiie!' of jiachymeiiin;'iti!t. These new tncmbraiies cover a prt "t 1
the whole of itie [>arietal [icritoueum, the peritoneal surface of theiniK- I
tine», and in a general manner the whole peritoneal surface of the pd<û.
The membranes are simple and thin, forming a sinj;le layer, or ibeve*
sim of Huierimposed hycrs separated by effused blood: liie eniWj««
tissue compo^in;; them niny also be infiltrated with red blood corp^^H
When these membranes are thick iind ecchymotic, the Suid effusaflP^I
the abdominal cavity always contnins blood in considerublc quanntf.
The connective tissue suhjaeent to the new membranes is also soniciim'^
the seat of infiltrations of blood. 1» this variety of noritonitis, now itA
then the entire »iirfncc of the peritoneum has a darV brown color, u^
the effused fluid has a chocolate bue.
Tuhtrrh» of the Pêritamtim and Tufinrttvhm» Prriiimilit. — Nothing
ia more varied than tlie ili^tribution and consequences of tuWrclesof tks
peritoneum. Tubercles of the )}eritoneum may he discrete and nunierout,
or there exist only a few, very small, semi-lrauspareni ^rnnulatioit* upon
the intestinal peritoneum, opposite tuberculous ulcers of tlie intt^ttinal
mucous membrane. The lymphatics, ramifying under tiie periKMKHioi,
are seen to be inflamed and tnberculous (see p. .tII); at this j"dnt there
are sometimes found traces of peritonitis, fibrous faUe membranes, ».
weak adhesions.
■ CHRONIC tOCAt PBRITOXITtS. 5TS
Hpnt when the entire pentonciitn, or n. greater part of this aeroua nwm-
^■ne ia t'overeil witli miliarv ^t-aiiulalioiiM, uc have a very difl'cretit
Hkearance. Soraetioies there rvmultH a periioiiitis cliaracterixe'l 1>^ con>
■KniMe ascites, the efliiise<l Hui'l being lenion-colorpd. transparent, nqiic-
■l, ■III) rioiT an<t llien containing ftakes of fibrin. Tbis occurs wlicn
Bt >;rsniilatioiiB are small, and ^rben llicy are seated upon th« surface of
Bt seroiu nM^mbniiio.
BAi other times the peritonitis is aiorc intense, cspeeially vhcn the
^piitilitions are fotiixl deep in the ooiiiicctive ti^iue of ihi.'' |ieritonetiin
Kl in it« folds. Tlic oiei^cutery, jireat onM'nttini, mid niesocolnn have
Hbcrculons ^iran illation» iiol wi\y wpon their «urtaw, Iml hetwwn their
nreml Inyer» ; iIiIk ntuwn a thickeninj; of tiuriiv mi^mhrtinoitM f»l<l^, for
■• ponulation!) are àiirruundeil hy an i;m1jryonic linttue with which tlioy
He ooiitimioiis without any tine of deniarcaiion. 'I'liese membranes may
Hjuire a very great (hieknetia. The great omentum or mesentery,
Km) of being a thiu membrane, may measure one to one and a half
Hrinietnifl in thickness. Ttie great omentum is shrunken and drawn
■wsnls the transverse colon. The mesentery is aUo drawn towards ita
Bfi iiiM-rtion. curryiii':; with it the mass of small intestine. The loo[i8
B this inttrstiiw arc a;;-!;lutinated to ciicli other, and, as the nbdomen
Bntains a conitiitcrublc amount of serous fluid, upon pnlpation of the
Blly, the im]'n.-«>ion is obtuiudl of a very Itir^rv clastic tumor situated
Blow the umhihcus, and formed hy mnny intestinal loops united
Pgi'ther.
The efliiMd tiuid in this viiricty of tubi'rculoiw peritonitis is of a
changeable nature ; at first lemon color, it may become puriform, and
contain Sakea of lymph, while fibrinous false membranes are formed
ttpon the peritoneum. The fluid may he absorbed and the abdomen
tbtniotshcd in sise without losing its elasticity The cfl'used pu» at times
tmllcctfi in OTIC or more points at the dependant pari^. becoming encysted
by faW membranes, and cvcntnully becoming caseous.
Kin some varieties of tiibcrcuhnw peritj)nitis the intra-abdominal cffu-
Iwn is bloody, and tlu- lubcrcuhius granuhuions of the surface are
nsually «urrounded by ecchymose». There «re al*o freipieiitly seen, in
tliiii benu>rrhngic form, vnwular new mcmbnine» which contain tubcrcu-
hwi granulation.*.
k Tubercles upon the .lurface of the peritoneum in cliildreu, rarely in
alts, may, by the union of several granulations, reach the 8ixe of ntnall
peaa, or ho as large as almomls. These large tubercles scattered over
the surface of the mesentery, omentum, parietal peritoneum, etc., upon
■crion. appear yellow-ish and caseous.
BTbc lymphatic glands, cither those of the mesentery or those above
pe lesser curvature of the stomach, or the |>elvic glands, are always
wore or Iom implicated in the tulH-rculims process. Tliey contain
nbercle granulations, or they are in a condition of caseous infiltration.
Bhen the glannls are very large and euseoMi' tlic ]v«iun is namvd Olftt
mt$ttUeriea; this disease is oL»en-«d > '-••d. ^^
Ition of an organ cootaineil
riic itiRs^T
linplv.
598
1.1 V BR.
1ugic*l condîdon. With the con;;e!iuon tliere is ohgerred an exwlation
of miicua. a mucûiui |ilu^'. More iuWnw intliiinmation. froio the pniwiioc
[of hiliar; cxlctili, oxtcnda to ntost of the biliary cnnala in tli« liv«r.
[The mucous memlirane of (bese canals is covered with a tranii|)ui-i-iti
[mucus, or the latiLT is rendered cbudv by the presence of dcf^llllllnIa«•l
^<t|»tlielial cells and puc corpuscles. 'I'hc cnnnli arc dilated, their muuotu
mvinbntiie tliiukcnod, as is also tlic connective tistiue surro»ndin« thfia ; in
eticb onses nnipnliur dilatations nrc i>«fn Unod with idiicmus mcrotirams aiid
filled either nitli A mueotutor purifomi fluid. The dilautîon*, which vcr,v
nmdi resonible xmall alutees^cs, anj found thron^^h ib« entire organ, an-
I Jined with a mnvDuM membrane, and contain mnny cyliitdrical celU, mixed
KttU lyinjib Dclla and blood )ii;c<^ent, or grain» tf bile pi^^meut.
In the nioaL iiileuiie inttaramatiociH, the contenta of the iniu.'K dilated
biliarr vej»eU coniiii.H of opa'pie and whitish mHco-piia, but posaoRa a
certain viscidity due to the inucu^, as iu id tic»- purulent spiiia. The
amount of this pus is eomotimcs no jjreat that, ujxtn makins a section at
Ihu liver at ibo auio|>sy. there i« tho appearance of un arnceas. Tba
uunK-rous cidbilar elements in this pu« L-<iii«ist of cylindrical epithelium
and lyiuph cells. In intense int) animation of the biliary canals, tliere arc
always obsened during life, febrile symptoais which arc intennilt<^nt in
typo. The inflninmation uiuy termiunie in mippiinitinn or a |ierfomtt«4i
of Uic portal vein, and ui»y occasion perforHlioti!<, (K'ntonitts, etc., when
tlie calculi act n,* forei;;n hodiea.
It is probable tbal, in conAcipionce of intenae î nil animation of (be
canals, narrowinj; and even complote obstruction of tliO liopatic and
ommon biliary duct« are prwluced; sonictinics.as in the caac referred to
by Aiidral. fibrous conls have replaced these canals.
.\ t times, papillary cxcrescvnceit of the mucous membrane of the diKU
a«! found, in coiise-iucnee of intlnnimnlion ; thi», however, is unfropicnt.
When a liivge eak'nl'i* pajwe.* into th<' cyxtic duct, thence into the cem-
luon duel, it nmy hi- arre^ted in tli« httler at it« entrance into lliv^ duo>
dcnniu where the duct ia narrow. If it cxpenence^ any difficulty in its
pasukfice, the cootractiona of the ducia and fiall-bladdcr give tim tdj
iiepatjo colic. It may aUo reault in more serious inflammatory accident
if it remains fixed in the canal or if it ia encysted. The btlc n»y b>
arrested in its passage, occasioning jaundice ; and, a^in, tbe inflamma-
tion of the mucous membrane and submucous tissue caused br cont
of the calculus, may extend to the iiei;;hboniig orjjana, iispecially to '
peritoneum. There frei|uently results suppurative inflammation or lim-
ited sloughin;^, which tonninutes in perforation. If tbe culculiu has
been arrested near the diKxIenuin, from the mortification of a poniou
of tbe mucous nieud>mne mid wall of this part of the intestine there
occur.i, a»i a favorable termination, tlie paaaage of the calculus into ttie
linteatine: but if tlie perforation ia into the peritoneum, a fatal jieritouili*
is the reault.
The biliary ducta, and particularly the small interlobular canala. ex-
Îenence in many of the diseasca of the liver, leaiona due to hepatic
isease or to irritation by conii;;uity. Such arc the altérations deacribed
in ctrrhoais ; in acute vellow atrophy ; such are the iuflamntatory irrilM
tiou6 occurring; in the largo and small canals included id carcinomatou
I
I
I
I
TUUOHS av TUB (1A1.L'BLADI>ER. 5C9
mnsKes, orititiixtodin tlieirneittliliorlmofl; iiiicli are the moderate CA ta rrh»!
irritHtKiii!*. [lointed out by 0. Viyaa, in pniiontng hjf phoeptiortia, nnj m
[lareiiohyiuatoufl hepatitis, ami wltkh esisi, wiili good reuson, in «iipfiw-
raiive liepacitis. In the parencliyniaious hepDlitU of puerperal f*v<y,
smallpox, etc., no luivo seen aii iiitikrntion of the pen-voMutar Gonn<.-cliv«
tjsaue nilh lymph cells, nii'l nt the Kuine time a cAtarrli of the «mall
btlinry uannlti included in the iiiHnmed tissue.
Tliesf iiitliiiiiiiitibiry lesion* of the hilinry canaU, which emi in an
al>iin<lniit secretion of raiiciin. and Ihe formaiioii of c<jII« which fill ihem,
interfere with the piis.tage of tlio Kite from the hepatic celU to ihc com-
mon hilinry duel. In he|wlic tumor» the iollamed hiltary caiuiU are
tortuou!!, Sallened, and compressed, cauiung complete retention of bile,
«od ictvrus.
Anotlu'r result of inHammation of th« biliary dncta — which is, how-
ever, infrequenl — is heniorrhaige from iheir rancona membrane. oocnrring
iMtcasionally in drriioais. carcinoma, or simple inflammation of the Uvcr.
IleiDorrhaKe may also occur in consci|uenee of abt'ceif.'^es of the liver. In
a ca§e reported by Leberl. hemorrlin»e followed the rupture of an atieii-
rUm of the hepatic artery into tlic gall-bl»dder.
TuMonsoFTttKGAia-BLADDKn. — Accofdint; to Ilokit«u)«ky,«new fonn-
Atton of adipose tÎMue i« found in the milipcritoneal oonneciiv« tisauo of
the Ktll-'di'ldor in obesity; lUU i^, however, infret|uenl.
Till- tiiiiKir» devoloF>ed in the mucous membrane of the gall-bladder are
carcinomata or c vlindTicJil-celled epitheliomaia. The history of carcinoma
of the ^ll-btadaer is relatively of recent date, yet it is not a very un-
usual aflectioD. It may be i>r!mary or secondary; in the latter case it
follows a carcinoma of the liver. stoma,ch. intestine, or uei^hboriu);
glands. Primary carcinoma of the sull-hladdcr Is most frct|ucnlly a col-
loid carcinoma ; at ntber times it hn» the appearance of encephaloid, and
more rarely it beloiifç» to scirrhus. Its Anatomical form is very similar
to that occtirring in the intestine. Generally, indifd fourteen lime» in
fineen, the j^all-bladiler contains one or more calculi ; the fewer in num-
ber (he larger the calculi. The bile is ftometimes coIoHch^, or it it* thick
and brown; it may contain small fragmenlji detached from the tumor.
The surface of the gall-Uadder at the diseased point h uneven and jrran.
nlatin^, for new formations assume the villous iorui in the gall-Madder,
just as in the urinary bladder. The tumor invades a part or the entire
mucous surface, which is increaaed in thieknesa. and upon section ahows
colloid tissue, or a «hitish tissue infiltrated with a milky juice. The
Sfsion of the mucous niembniTic and submucous connective tissue may
CXttnd to the muscular tissue, which latter is ulnays somewhat <cdema-
tout and hypertrophied. Tlic cavity of the ^all-j^ladder is ^enerulty
incrcACcd, but may be diminished. The timior ff'iuently extends into
tlie cystic duel ami common biliary duct, the mucous mcad>ranc of which
is infiltrated, and the calibre coiitriictcd. occasioning rvtvntion of bile in
tltc hepatic eanal.t and inlerlolmlar biliary duetit. Biliary cyslit may
result from thi» condition, which is always accompanied by jaundi^-c.
Generally the hepatic tissue, in contact with the altered ^all-bladder, isi
invaded by die carcinoma^ aud the entire liver may be studded ttitli
A70
LIT8R.
noilulealiAvini; tho structure of llie primary carcinoma of the gklMiliuMer,
In M>ine nutopaies. in exaniininji; the liver invaded throughout b_v !<uch
sfihencal nodules, varying in size, there may be ootM lieaitation in \»-
lieving that the nodules are scconilary to the ulceration of tlic ;r»ll-
bladder; lint what occurs in hepatic carcinona. secondary to tliiu of the
stomtieh, should make us admit that tlie sanie connection may «xist be-
tween the hepatic nudules and the ulceration of the inucotu incmbranr
of the •latl-Maihli^r.
'nie neiwhliorinj; lymph ;;1and« are nlwiiyg altered and tran^fonnod,
and the duixlviium, olon. ntid i.îvcii the utomaeh may be invaded by a car-
cinoma which hiw its lK';;iiiriiiis in the ;tftl|.li|midcr. ThtM Mveral
organ* are then nniied by can^'inomatoiw au'l fibrinim» ndhesionfl. The
patches in the xtomach and intestine are «mailer aiul more recent lluui
tJie tduen of the gall-hladiler.
*ni<> i|uefliion whether the carcinomatous ulcer precedes tlto fonnation of
the calculi, or whether the latter exist primarily, and prvxiuce tlie ttiinor
br irritation, in doubdul. We are inclined to believe the first bjpo-
thesis.
nistolo^cally, the siiperlîciBi non-ulccrntftd granulations are cororvd
by the cylindrical coIIk of the mucous meml>mne,aud an- moKt rre4|iie»tly
ConHtilated by a simple, very vascular embryonic tissue. Sometimes
they show the alveolar Structure of scirrhoiw, enccphaloid or oolhnd car-
cinoma. The ulcernU'd pivrlion of the tumor is deprived ofall epithelial
coverin;;. The ah iviUr utruotiire of carcinonu im bcM seen in the vi-ry
llii<-ti suiimiicouji ÙM\i6. In the mui«nlar tissue tbor« ia first seçn aii
infiltration of enihrvonic celb. afWruanls a true carcinomatous tissue.
Cylindrical-celled epithelioma of the };all-bla<ldor, to the unaided eye,
does not differ from encephaloid: the hi8(olo;!ical characters of the
tumor are ahsolutclv the same as those previously dewrihcd under gtHd-
drieal-cellcd epithelioma of the liver. It givt-s risi^ to secon<iary no-Iules
in the liver, as does carcinoain, and has the same symptoniï and prog-
nosis (*ee p. 154). In the published obxerratioiis of epithelioma tl>ere
were also found calculi in the gall-bladder.
PKRIIOMTtS.
571
CHAPTER TI.
nf.î87.
pi:kit().n'EL'M.
TiiK i^winrks maile in l'art Kii-THconceroinj^expeninental tnRatnination
of till- [loritoneum, aiiil ltioa« in relalioii to alterations of the serous mem-
braties in Part Second, may he ai>p)ied to rouch of the patholo^cal UU-
t«U>gy of the peritoneum.
pKKiTOXITts. — l'eritntiîtîa is acntP or chronic, froncral or local.
Acut« peritonitis, sclilnm pnmiirv (riiL-umatiu). is nlmust alway» the
result of trauinati«m, a contuMiOQ or «omul, or of a lesion of one of the
organs covvrcd hy tins sorons itiembrftiie — «ncTT att perforations of the
intestines or of the Mtoniaeh, forei;;ii bo<)ie> entering the |>eritoneal cavity,
tlie opening of itbM«Mioa into it» cnrity, superficial intlanimationH of
organ» covered hy thi« «oroo» inenihnine, lymjiha uveitis ami phl<-biùs of
tlie nteni.t and it.* appciidii;^^, nietaiXatîc AhAce^'en of the liver, otç.
In ri/^titr ifrnrrttl /ifrif'/nitin the vasKular injei-tiou of the vi-tc«nil peri,
toneum is very intense, and is amompanicd from the be^nning hy a
GbrinoHS ywrulent exudation, more or less abundant
between the meshes of the great omentum, in the
connective tiiisuc of the serous memhnine hetvrecn
its layers and upon iu surface. The parii-tal peri-
tonciiui ii< hIm iniplicaUrd, as are al*o the diAen-nt
layers of the omentum and nictocolon. Kdironx ad-
heaionA very rapidly form between the parietal and
vi.iceral layen, and between the different organ»
contained in the abdomen.
In puerperal perilonitis. when the autopsy is made
two or three day* after the beginning of the disease,
the parietal layer of the peritoneum is found tliick>
eneJ and infiltrated with pus, it is gmy and opa<|ue
ID color, and united in places, either to the great omentum or to the
intestines, by soft fibniiis false membranes, infiltrated with pus. 'Hie pus
csca{>e<l inti> the cavity of the abtlomt^n usually collects in certain tooali-
tics, as in the pelvis around the appendages of the uterus, etc. The
injected and thickened jiçreat omentum, at the points where lohiilea of
fat are fonnd, is sometimes adherent to the surface of the intestines, or
folded upon itself; it pre^ntA the appearance of a fleshy, red, irrcgidar
massGorcred wiUi pua. When the great omentum is exposed, it is found
adherent to the intestines, especially to the small intestine, from which
it is with ditfieully delached : it almost always also adheres at several
point' to tlie abdominal wall by its free border. Beneath the omcntura,
the intestinal loops, swollen and distended hy gas, arc united to one
3fiintall aiu*uEunt, Mtslo-
«d «*Uh nltntU at Blll^r,
lb* qDc^uthtlUI cvt'riilg
of ih* rnnaasUT* iMo*
tHliVCBtB. X ''^
6T3
PBRtTONBUM.
MifttliM by fibrin inGltratod witli puft, forming eitlier a lliick Uyisr or a
grny «r yetlowUligmy masa, which fill.* up iln> sj-accs beiwtvii Ui«
ii<'i;;Iihiiriiig loajts. This lliiuk. aemi-sulid cxiiilatimi viiriM iti Aiit»iiia.
Il it difficult to ««puniU) the united inlentiiDii loojnt nitlioui rupturing
rtg. 198.
Vit. iOO.
Il «Uitw* tup ifllhfWtt r^lU 1» pror*»*ar |<n>ur«-
t»lioii Km4 in Ibo tet vt Aeihf\\\^i lh4iDtrLv«B ffvu
Ihc If nliHuLs. Pn> n>ll> «rs Imhi-diUi) Ui (b* Klirto,
kcid Hint rHDHlH raiiit«cl4d «UL [h« flUrvd* 1rftl>H-
fila, Xl%
Om«n(an urUlcUtly
Umi fi»il'-1TiBJ1flL vll* haifl oitiln l^ia—
«ritll<-l to ih0 Ai-rk>i)k ImbtfBl*. TWIf
cwltuE tl(nni.i«rl ibcifuria aBdiMii «•■■
pl*U ■tiUballnl IbthMwU X »».
wattio of their wnlU, ainco the intestinal coats ihemiiclres «ro infiltratiil
with fluid, anil are pale and softened. This seroiw iiifiliration of ihe
iiiti-rttitic; iiUn oxU'int» to its iniicou» juirfnee, which is at linw;» aiucmic
or congvitti.'d, mill pcr1in|M eovorvd with a puriforin mucu-i. The sur-
fa<t<-.i of ihe \\\^.T iiiid «plueu «>]ually prenont an inU'itse superficial in-
flaiiiniatÎAn; here iho peritoneum in inhllrated witli pus, and the cap-
ii)des of these origans are thickened and o|>a<iue. Tbcre always exiiiu,
either upon the appendages of the uterus, upon the «urfaw of the liver
or other organs. lymphansiUrs, phlel.iies. or «uperiicial nbscessM, which
are the stitrtiu'-iwint of the purulent iwritonîtis.
The pi.-ritoncHi exudation instead of bein<r small in quantity, opaqae,
and tihri no- puni lent, a» in the preceding example, may be iDoro atrand-
ant, sero-punilont, with flake» of free fihriu in tiic fluid, or «ntirclf
«eroux ; in the latter there arc al»o alway» fibrinous flakes prc»cnt.
A hi.ttoln;;ical examiuatinn of the ^reat omentum deutmuilrut*!» the
samfl appearance, as described iu l*arl First, under ariiHcial jK^ritouitis
(see p. 5ti), itiat ia fibrillie of tibrin. lym/h cells and Urge, swollen,
granular cells, with one or more nuclei, lociitod in the meshes of tlie
omentum. There is an iufiltraiion of lympb cells ami fibrin tietween the
fibres of iho connt^ctivc tissue throu^^liout the tliickeueil aitd opatjue mcm-
brano!>. Accumulations of thuac lymph colls arc jxtrticulariy necn
an>utiil the vf«»<d». The same increase of round cell» J* obnortod aroand
the vcweN in the adipose nodules of the great omi-uluni.
The liver and kidneyit arc jiilIc upon ei-ctiou, and their cvUs an
generally fatly.
The fluid exudation into tlie peritoneal cavity may contain hlood aswi.
ctated with fibrinous serum and pus. iiud there are goitcrally at tlic Name
CnFOSIC PEBITOXITia.
I
I
I
I
I
time «ochymows, with inriltriitinnit of lilnoi] into tlie siitiperitftneni Odiliilnr
tiiii>iK>. But tlib variety of {luriumiti^ iioiially )ia« a upeciitl cnu80, ttucli
tw cHticer, tubercle, or oirrhosis of the liver, iktul ii is not aculv in tin; Mine
Ceuxe as the |>recei1ing variety.
'file termination of acut« pericoiiilia varies. When it Joe» not rapidly
«in) in death, the e8ca)>e<l fluid becomo» absorbed, embryonic connecUve
ti>iaue forms upon the surface of the peritoneum, and veadels of now fona-
Btion having embryonic wallfl pcn<>trat« into the fibrinous tnlae mem*
branes. These fnlsc membranes thus or-fiinixed funn adhesions 1>etween
inflaoifld surfaces, and, at timc«, caiiae di^-stive trouMcf, by the intes-
tinoa beooming iinmovahlf, eontraoted, or Kxeil in an abnormal ]x>siljon ;
the bands of udln-Kion forni>-d between tlie viitceml and parietal peri-
&>neiini may be the cause of internal .itrangitliitixn.
In other caneii acute purulent periionîti» terminates, after the absorp-
tion of a |)ortton of the exmlated tluid, by a kind of oaseation or iiispis-
tation of the pus which eollectt< in one or more points ujioii the perite-
oeum. These collectione bocome encysted within false membraues. An
evacuation of this ]mrulcnt Utiiil mjiv be efl'ected by a [«rforation of the
ihce»tine from without inwarls, or it may even he dii^cbar^od through
tiic walla of the abdomen. Wbei> tlu- ^iippiirHtion causes an opening
botli of the intestine and of the abdominal wall, there results a fecal
fisUiU.
A/^utf heat )>trit'tnUit i* tmiirontio or idiopathic. In the latter cam,
it generally follow.* imi intlaiiiinatiini of an organ covered by the perito-
neum. Wiieii an iiiUanitnaCioii reaches the surface ofauch a» nr),;aii,tlio
fteriioneuni is always intinmed; tlicreforc, a local peritoniti* is frejiient
in iesiouii of the liver, gall-ljltiildcr, spleen, in diaphrn;^uiatic pleuritia,
in melritt.s, iu intlammaiioiis or tumors of the appendages of the utertu,
in cystitis, iu typhlitis, etc.
General ehrotiin perltoniti» follows acute peritonitis, or it is chronic
from the beginnin;;. In the latter case, it is seldom that it cannot be
referred to a chronic peritoncul or intoWinal lesion: tubercuWis, carci-
noma of one of the abdominal organs, cirrhosis of the liver, disease of
the bean, malarial cachexia, etc.
As carcinomatous peritonitis i.* superficial at it» be^innin;*, as well as
in it» »ubsei|ucut developniL-nt, there are found upon the surface of the
peritoneum large eelU with iar;^ nuclei ami enormouji nucleoli, which are
mingle 1 with the lyui]>h eellituiid l!uid exuded into the jieritoncil cavity.
Therefore, sometime.4 a cai-ctnonia of the peritoneum may be suspected
after a nûcroscopical examination of the fluidohtaiuel by an explnra-
torv puncture.
The lesions of chronic iicritonitis vary much. Thus, in chronic peri-
tonitis following acute pentooiUs, there are found adhesions between the
intestinal loops, or between the loops and neigh borin;; organs or abdom-
inal wall, consisting of filamentous or lamellar fibrous tissue. Com-
plete obliteraiion of the peritoneal cavity may occur, just as obliteraiiou
of the pleural cavity often happens in pleuritis. That life may be pro-
longed even when tlie intettinvt are coutractod by the interference and
retraction of the new fibrous tissue, i^ seen in tlie autopsies of old per-
574
PBRtTOHSOM.
sons vtho. Tor a nuiiiWr uf veitra, have lived with this Ic^inn. At nilinr
times, the ini.'iiiUriiii<.>s con^i^t of a few uDimportaiit l^nn'l» or cvUulnr ml-
h«Moiis, ID whiuli CAW there it ii^iiatly no tliiii] fourni in tb« jwriloitMil
cavity-
In cardinu (iîiîawiï, in etrrliDils of the livnr, nnri in nulariti cncliextn
vfiih hyponro|i|iy of tht' siitciiti. n tnie |H>nuiTiiti.H <loc*ni>t occur, Imt Ihere
i]> a ^crtiiH etfiKiuii or iiioiti'-.'i iiHte.vl. Vet, in {ivire ascitic effiiflioii. there
are oomlniilly nhserved r«i>nic leaioi», which mny dupend upon a chronic
inSammatinn which in secondary and which conmsts in thickeoinga of the
fia]Mule and peritoneal coverinjj uf the liver and spleen, and in excrtra-
cenccH or ;^anulati(mâ of th<> ptrritoneum of the liver in cirrhosU, of the
peri-apleniu jieritoncuin in matarial cachirxia and c.irdinc discaseâ. The^e
, new formations of connective tissue may justly be e"ii§idered a» traces
of chronic peritonitis. A^in, the pnriulii! periioneiiin may hv ihiekcnrd,
andfre<|Uoiitly tl.ei'e may exi^it other uvidcnccs njion the omeiiluiu and
iole'tines of chrome penlnnili*. In cirrhntiiit «f the Urer th^-ro ix very
ofWn a iriic stihaenli!! orchronie peritoniti!*, with thv pr«^enoo of filmnoas
flake« in tJie offiwc I fluid, a* well an Mood. Th« Knrface of the peri
nciiiii, either npon the Mirl'ace of the liver, or the nissentcry, «r intculine!
U covered hy lihrinoii:* faUe niemhranes, or very vascular organised raei
braiieit, vhich are accompanied with oubperitaneal ecchyoMses. P
ifiiiMitly there occura a ]:eculiar hemorrhagic peritonitis in hyportroiibic
cirrhosiit. Abdominal piinclun-s do not appear to develop or aggravnte
in (t am mations of the peritoneum.
Iîott<frrh(fjir pfritonitis, wliicli is chnmit or eiihacnte, m Been in liypcr-
trophic eirrliosi», in articniiir rheuniHtiini, in lube re ul «iris, in Hrigbt'ii
disease, etc., is charaoieri/eil hy vascular now «leinlinmc», which at fini
BÏjîht rc'emhlc »\iiiUt of Idond, and are similar in apjeamnce to the new
menibranei* of [lachymenin^itit*. Theite new mvmhranes cover » part or
the whole of the parietal peritoneum, the [leritoneal diurface of tjie intea-
tincf, and in a {general manner the whole peritoneal Hiirfacc of tlte pelru,
The niemhranea are simple and thin, forminjt a tdiijile layer, or they coi».
si^t of mi|erimpased layers separated by effused blood; the emhryonic
tiriHue comjioain;^ thcni miiy also be iiititirat«d with red blood corpuscles.
When these membranes are thick and ccchymotic, the fluid effused into
the abdominal cavity always contains blood in considerable qnantity.
Tlie connective tissue subjacent to the new membranes is also sonietJnM»
(he scat of infiltrations of blood. In this variety of peritonitis, now and
then the entire surface of the peritoneum ha» a dartc brown color, and
the cfftised llind lias a cbocolnte hue.
las
1
T^litrrli-n lit' thf Ffritoneum and Tufifrnthn» Pftitoniti». — Nothing
is more varied than the distribution and consequences of tnbereW of the
peritfineuin. Tubercles of the peritoneum may be diwrelc and nuineroas,
or there e.xiat only a few. very small,. lemi-lrauKjiarent grannlaiion» uimb
, the intestinal peritoneum, opposite tuberculoid ulcer:* of the ttiie<tinal
Riucoiia membraDC. The lymphatics, ramifying under tlie jtcritoiteuni,
are seen to be inflnmed and tuberculous (see p. .ill); at this point lliere
are sometimes found traces of porîtomtîa, fibrous false membranes, and
weak adhesions.
»
CHROSIC LOCAL PERtTOSITia. 575
But when tlie cntirt" pcritnnoMm. ht n grcaUT piirt of thi* «««« tni'in-
brape is covered «fiHi mttinrv (;raiiiili>ti(mi', »f liavo ■ vury diffiTuiit
apneamnce. SnntoiiincM llitrn- ri-fniltf a |writ<itniu cliarnctt>nic«il Uv con-
siderable nscitfB. till- cfliD'cil rtiii'l Witi^ k'riii>ii-i;"l"reii, tniiiapnreiit. a<i«e-
mu. Mini n')w aixl tWii C4>iitaînin(f AnVvi of tilirin. TitU occurs wtivn
the ^nnulaiiotis are «ion)), and wlieii ibey are sealed upon the surface of
the serons mnmbrane.
At other limes ibe peritAnitia is more inlen-ie, espDcially when tho
granulalioiks are found deep in (be conneclive lissuo of tho iwriwiMJUtn
and in iw fold». The mMeiitery, great oiiKintiini. and mesocolon Kiivo
tuberculous j^ranulations not only upon their surfui-f, but bctwtvn tlioir
several layers ; this catts«a a tliickenin;; of thvsc mcmhranotu fold», for
the granulations are surrounded by nn embryonic ti«iic with irliicli they
are continuous without aiiv lino of deiuurcjition. Tnvsc ineuibrancH mny
&oc|uire a rery •p'cat thicknes*. Tlie great omoutuin or mcM-ntery,
instead of beiiij; a thin membmno, may incsturc one to oiie au'l a half
ccntiiiietren in ihickne«t. Tn« great omeritum \* shrunken and drawn
looanl» the tranKverw colon. Tbe m«Mntery i:> iiU» drnirn mwanl» its
fixed iniiertion, cnrryiu}^ with it the moss of tttiiall intestine. The loo|is
of tliiit intestine are njçï^liitinaled to each other, and, as the abdomen
conlains a considerable amount of scroui fluid, u|>oa paljntion of the
belly, the impresaiun is obtained of a very large elastic tufoor situated
below the umbilicus, and formed hy many intestinal loops united
together.
The eflii^d fluid in this vaiicty of tubcreiiloiiB peritonitis U of a
changeable nature ; ut finit lemon color, it nuty hwomc puiiform, and
cofituin RnlteK of lymph, while fibrinoiw faW mi^mbninea are fonuetl
upon the peritoneum. The fluid may be alj^orbed and the ahilomen
diminiHhed in sise without losing iM elasticity The effused pus at tintes
colWtM in one or more potntii at the dejieiidant parts, becoming encysted
by false membranes, and erentually becoming caaeouâ.
In «ome varieties of tuberculous peritonilii* the intra-abdominal elTn-
sion is bloody, and tbe tuberculous granulations of the surfaee are
usually surrounded by ecchymoses. There are also frequently seen, in
this hemorrhagic form, vascular new membranes which contain tuberco-
lous granulations.
Tubercles upon the aiirfaM of the peritoncnm in children, rarely in
adalt)i,n)ar.by the union of several granulations, reach the »ir.c of «mall
pcAS, or be as large ns almonds. The«e large tubercles scattered orcr
the surface of tbe mesentery, omentum, {larietal ]>eritoneuni, etc., upon
«cction. appear yellowish and ca«eous.
The lymphatic glands, either those of the mestentery or Uiom above
the lewer curvature of tlie etORMeh. or ilie |>el('ic glands, are alvrtyg
more or le» implicated in the tube real oua process. They eonlnin
tubercle granuhilions, or they are in a condition of caseous infdtratinn.
^Vhen tlie glands are very lai^ and caseous, the lesion is named tafieÊ
meuiUerica ; this disease is observed in scrofulous children.
Chrimù- heal ptrifonitii Is gencntllT tho result of a chronic inHam-
matiou of an orjjan coutaiud in the peritoneal cavity, For example.
'
fi76
PBIItTO.VRQM.
inflninniktions of tlic upp(!iuln<;L'S of the utvrua occasion the adliminii of
the Kullopiftii Uibc to tlio uterus, by âbrïiious forniatiuits in the liga-
iDtiiiW nrotiiitl tlift tube ami ovnry, etc. Foreign bodies in tku peri-
toiietiiii iroMiing from the alimciitury ciinM, afïor ■ pcrfoi-ntioa lîiuiiM
bjf niiliesioiis, uterine fibrou* pol_v)4 bocoia'm^ free in lln; iiUloiiicu,
]W(lutiouUl«(l or ilt'taclW ligxiniiitoi or |jii]>illoniatA of ttic otucntiim,
extra-uterine |)re^itaticii;A, etc., are hUo cixmm* of cbrcmic local peri-
lonitiii. It ia eiipccially characleriKed by lihriiioufl wlbeitioii».
Tubercles, when they are developed only at oike jiarl of tlic (>eri-
tonvum, also at first occasion a local peritonitis.
Carrifioma and (hrntMirmtoat Pfritoniti». — Primarr carciootna of
the pi-riioDcun] geiicriilly begins in the r>inomun). It may "be encepbaloid,
scirrhous, or colliii<l. 'I'lic Ut [er occurs most fre<|uuiit1y,aii<l at times cou.
IrSliCutcs a larj^v tumor, iuvoKin;; the entire pcntoiiuiiiii, the omeiituoi,
' meeontcry, mesocolon, mid the peritoneal coverin>; of the sujierior sur-
face of the liver. 'I'be »h<; of the tuuuir filling \\w nbiloioen is such
thai it ha» been friitpicntiy takei) for a very large cyst of tlic ovarv.
Thi- structure of these coUoiil can;in>^iiuitA dω not nialvrially difler
from the description given on page IU4: there are .'«een in tlie oli)«r
portion of the tumor large alveoli filled witJi sgiherical ait<l large traos-
parent vesicles having sereral concentric circles, Jlut in the luoro recent
portjons there is a very remarkable abundance of extremely fine fibrillar
tbrouA tissue, inclosing betf^eou the fibrillie a colloid substance with or
willioul free ccllit.
Secondary carcinoma of tlie peritoneum occurs in confle<|uooce of
|8Îmilar tumor» of the stomach, intestine, liver, or of titt nteros aod its
' ftppenduj;u9.
At first it is usually seen a^ a ditfused nodular tbtckening of the con-
nective tisane of the peritoneal covering of the diseased organ. In a
caroinoniu of the stoinaeU, the gastric peritoneum shows eitlier nodulei^ of
a similar nature or a diH'nse infiltration ; generally, the lympli ve«Mls oFa
veins jiroceeding from the tumor of the stomach, and passing to iht
liver or neighboring lymphatic ;;l;nids, may he seen ramifying under the
peritoneum at the sent of the lesion. An invasion of the«ntir« serous
membrane by the carcinoma follows ; it is seen covered with numerous
■ granulations or sm»1] tninoi-s, varying in sine from a millet seed to
pa small pea or larmier. The smallest of the»e granulntions. especially
when the primary carcinom» is a scirrlnw, to the unaided eye veri '
much resemble» tulniicle» ; a microscopical exHinination, however, wiT
remove all doubt. These new formations resemble Ûm primary tumor
iu structure.
Secondary oarcinomata of the peritoneum are always accomjiaiiiei] by
a variable nuiDunt of peritonitis, i^metimes thi.'re la simply an abdomin
elfusion. the tlutd being lemon color and varying in amount: or itco
tains Sakes of tibriu. while fibrinous exudations are found upon the surfaodl
of the peritoneum. .\t other tlaica carcinomatous formations of the peri*'
loncum are accompanied by the development of vascular new membranes,
consisting of embryonic connectivo tissue : hemorrhagic peritonitis nuy
now occur. These new formations of connective liasae occasion adbc '
TrMOKS or TUB PBBITOrtBCU.
577
I
'C«n the orgnnit ; the adhesive bandit ihenimtlvcs Itiiallj niKblga
iremtmntous iDetntuurphoHi^.
Finally, varciiiomaloiia {leritnnîtîfl tnay develop into an nciite purulent
peritonilU. Tliis occiii-si when the diseawd or;;an a]>ei)S into' the jieri-
toneum, or when the destruction by purulent softeninK of ihe carcinonuitoati
tumor in nn or^an occasions the lormation of a pnrnîent t'ocua located near
the surface of the oruan ; this is especially observed in carcinoma of the
uterus and it» appendages.
Other new formations or tumors of th« peritoneum are very unfre-
qucnt; they are (i^u/maia, having their origin in the epiploic appendages
or in the adipose tiMue, situated under the jwrietul peritonoum, or tboy
coimiiit of variouM fom» of cyst«, pnMiferotint:, dermoid, etc.
At the autopsy of an old noman, w« foiim! ii|K>n the peritoneum of the
<lia]ihragin Pacinian eorj'UMflrê projecting in great nuinbere. They mea-
sured one, two, and three millimetres in length, and were arranged in an
arborescent manner, -leveral being united to a single jiedicle.
Jljfdatid (i/»t* containing echinoeooci sometimes exiitt in Ihe porito>
neum. They may come from the spontaneous opening of a similar cyst
of the liver, or Ihcy may be primarily developed in the great omentum,
or any other part of the peritoneum.
37
Pa:ïcrba3.
CHAPTER VIT.
PANCREAS.
Sect. I.— Normal Hittolo^.
THK pancréas. nnalo;roiis in iu structure nrnl fnnelions to tlie t«1ivary
glfUiiU. ta siluntcil trnnsvcrgely in Iront of the vertebral colutiiii. between
the H)>levn un<l iluodoiiiiiii. It conoist of acini nhicli cninU' tlieir )>r'»lu<:t
of eec-ri'tion. tht^ pitncrvatic Jiiico, throu;;h ihv can») »f WirHim;;;, ittto tlia
nni|tii1la of Vatvr, in the si-cond portion of the diiCKlciium. Thvrc exista i
Kcutmil «xcrotory uanal coming from the hen<)of tU^jiancreati, and npi^ninj*
HOparAtely near the fomier. Tlie acini or jçhiiiiliihir cuKiIe-i'ac an» from
.04-^ mm. to .UCO mm. in iliam«tcr ; thoy liave a very tbi» mi'mhratie lint^
by [lavement celU, the |irot(i|)la.tro of wliich beurtme.t i;ratiular by the action
of acetic acid, ami i* dissolved by an excess of this acid, 'Hie excretory
ducts, tlie ibin wall of which consUtH of connective msne and elaatuB
fibres, are lined hy a single layer of small cylindrical epithelia) cells.
When these ducts are injectvd with a eohition of l'niïsian blue, with
«ontiniiokis and slight jirewure, the injection at first jiciielrate!" Into the
central lumen of tlie uuls-dc-sac, then into n ^yjttem of canals fonoin;; a
complete network around the ^landidar colls. TiiU nelvrorkof caiialicidi
is coiiiparnbie to that of the intralobular hUiary canaliculi.
The acini of the ^land are imbedded in a nia^ of adipose tissue, which
contains the bloodvessels and nerves. The bloodveiaels and lympliatks
liave the same arrangement as in the satiiary glanda. The nerves oome
from ibo great eympathctic, consist moatly of fiiw Gbre«, and accompany
tht vessels.
The pancreatic juice ts ctesr, lîmptd, slightly viscid, alkaline, conlaim
albuminous materials, and poseo«sc« as an esscutiid projx-rly the powerta
emulsify fati* i it also acts like the saliva ti-aiisforming into sugar the sidv-
lacenus suhslances; llnally it ajuists in the digestion of nitrogenous sub*
Stances. Therefore the pancreas is one of the most tsteniial glands in
intpstânai digestion, if it is not positively necessary to life. When the
pancreatic juice does not reach the intestines, the fatty substances are
incompletely digested, and they are found in the feces, which are geue-
rally lifjuid (tatty diarrhœa).
Sect. II.— Pathologieal Aaatomy of the Pancreai. PareDchymatoiu
Inflammation.
According to Hoffmann the pancreas is always altered in typlioid fever
in the same manner us ibo liver. There is seen during the first week of
the fever a wry intense hyperemia of tbo connective tissue, while tlH
FATTY DliaENERATTOM OF THS rAXCRRAS.
570
g1«n<lu)nr celLi are hjrpcrtro|thied. In th« seeonH wMk, tlie cells contnin
Revcrnl nuclei ; t)K'ir protoplasoi becomes fiilcil with fatty granuleei, wliiclt
obflcure t>i« iniclei: llie ooubtur of the eel I a iit not very deciileil. Ttio
hyperuwpliy of the iw'mi. «îiich results from tliin leBion, cauaca pressure
upon the bloorlvasaels. am! an anemia of the intt-rsiiti») connective tissue.
It is very probable thitt u eitniUr lesion «xiats in » number of infectiuita
diseases.
Stij'/'Hralive infianiHMtit» of the pancr^fts acldom occnrs; it i» met
with in the form-of iliMeaiiiiittcd ractfutntic nb^iL-f^wA or ilitTiiHo) siijipurii-
tion of the giMid, or aa ui intlkininntjon cxtcinliiig t» the i'iirr<iiiii<liii;r
oonncQlive Umuv and lympUntic gUnd* Tlic pnncrea* may be utii-rnuiidr'l
by Ml nbfloeM, which niny open into tlic peritoneul cavity, into ihe ittio-
deiiuin, or into Uiu slMnauti. Tlie»e slwccHoe» «boiild not be cotifoundei)
witli cyxta containing a wliitiah pulp, wliiob are aometimes foiin<l in tbis
organ.
Jnter*tili<il Infiitnnniiliiin may occur in tlie connective tiasne of the
pancreas. 'Hie few caiscs of ihia lesion which have been nporteil show
that the heail of (he pant^roas joins in the chronic inflamntatory Uiicketiing
of the connective tissue which surrounds it and the duodenum. Thi* is
ol^en seen when a biliary calculus is arrested in the duetiut communis
choledochus near the diKidcnuni and muses a chronic inflammation of all
the surroutKlini* coniK-ctive tissue. In caiM!* of twmon» of this rc^rion. or
in simple ulcers of ihe pylorus or duoileninn, etc., the pwcreatic duct is
cither uonnal or contracted.
Induration «/ the l'nntreat. — We have fretjuently examined psn.
creanes, bard and of a f[j*y color, in which the ;;laiidular acini vere
perfectly marked out. This condition has been taken for scin-bus. In
our examinations we found no very appreciable lesion of the or;nin.
Its appearance would suggest to a beginner only the idea of cnttccr.
Accorain;; to Kkbs, it is possible that there may be a ptirenohyiniitoiis
inflammation similar to that of typhoid fever, or a new fonniition of
acini (an adenoma), or, as Vulpian bctteves, « thiikeiitng of the connec-
tive tissue of the organ. In cases of induction «een by us, tiic acini
were large and well develoiicd, and appi'ureti normnl. as ilid alHO their
cells ami connective tissue, yet the latwr presented no adijioHe ttsHue;
on the other hand, when the pancrea» i* mti. and the acini are ?<niall
and atrophied, a hoU and very abundant adiposie tissue takea tlie place
«f the glandular parenchyma.
Faltv Defeneration and InSltration. — Fatty infiltration of the epithe-
lial cells of the glandular acini, and a new formation of adipojte tinsue,
should not be confounded with one another; they are distinct changes
which bave nothing in common.
Granular faftit ({((feneration of the efuthelial cells of the acini is
seldom seen, and the conditions under which it is found are not well de*
terminH. Wc have seen one example in senile marasmus. It is proh-
able tliat it may be fmnvl in a immber of cachexies. When there i* an
obMniction to the discharge of the pancreatic juice, tlio glandtdsr acini
680
rAHCRKAS.
«re ntro|iliieil, and tlieîr cttlU filloil uUU fntty granulcK. Atrophy of the
paneront) m&y he a i;oTiae>|ucuc« of tliu inUy 1 1 e^ ne rati ou of iu itvîni.
Fatty ihtillratiol) ot the cannectire tî».4ite vtliicli iiiv«Hla the panvreM,
ami penclr.itt-s nith the vessels Iietweco llie loltules, is a «luiie fre<|iicDl
leiiion. Wbeu from nicohotisiu, from clirooic diaeaâes of the heart, from
di:k)ietes, from hindrance or urrtst to the How of the pancreatic juice, the
ttlnndtilar parenchyma hua partiully or entirely cUasppearetl, it may be
reploecd by adipotte tisttue, which le dcvclopeil tti the fibrous stronia of
the or^jun around its resKoU mid glandular diict«. The ncoly-formeJ
ndipcise tiMuc rcscinblei* very closely the «hape of the gland, and at ttio
uut'iiwy there may he found a mass of ndipOM tûnw having the size,
seat, iiml oonfij^iirnlioii of the panorea*. ]>re4eiitiiig at it« centre Uie canal
of Wir»iiiig, without tliere Wing a cingle normal acinus.
Atrophy of tlie pancreas may occur from rarioua eauaea: 1st, from
nresaure from without, exercined upon the glan<l hy ncighlMrin^ inmom ;
2<l, fVofo pressure from within, bv distension of cysts, eauseit l>y eoncrv-
lions in the excretory ducts of the gland: 3d, from granular fauy de-
Cencrattoii of the epithelial ccUh of the acini ; 4ih, from intonuitial
inBaminatJon, and, aceonlin'; to Kolb, esiiecially hr ota^iB of blood in the
gland in consv<iuence of chronic di^caMis of the heart, liver, und lungs.
>lunk and Sylver have each «ee» a ease of atrophy of the pnncrea» in
diabctc-s. Sometime:* the atrophied neini are replaueil by adipose con-
nective ti.'««ue, which forma around them; .«omeiimai there i» no incruftM
of fat, hut the acini are found in the midst of & loose coniiMlivd tiswue,
and the nancroaa is mueh atrophied both Id appearance and realiiy.
This condition is frequently associated with calcareous concretions, or
with a whitish pulp contained in tlic ducts.
ylini/hid Pf'jrnrmli'in. — Acc.onling to Rokitansky, the cells of the
acini may undt-igo amyloid degeneration, The« cases arc very rare,
and cvi!ii iloubtfiil. The veaseU of the paiicrcM have wvcral times l^'en
found in a ftate of amyloid degeneration in connection with «imilur con-
ditioiu of the liver and spleen.
Tl'Moiui OF TUK Pasceba». — Tubereulovi» of the pancreaa m «el
occurs that Cruvcilhier was inclined to doubt ita existence, and believ
thai the casts regarded as such are only a caseous alteration of the nei;^-
boring j^lands. The lulicrcukiHiB of the pancreas is always secondary to
that of the lung» and peritoneum; the miliary tuWrcle granulations are
developed in the connective tissue separating the adni. to a case re-
ported by Aran there •tofi a tuberculous caseous mass in the acinus itself.
St/philitir ffummala are very seldom met with. Klebs baa seen
gunim.itu in the pancreas of a fuutiu of six months which had syphilitic
legions «f till- lungs, liver, and kidneys.
In a case of Ij/m/ihoma of the stomach and eorresjionding lymphatic
glniid» reported bv Lépine, the right half of the pancreaa was enlarged
and compressed, but not included in the tumor formed hy the gl&odi.
Instead of normal glandular pancreatic tissue, a section shoved a soft,
whitish tissue resembling an encepbaloid. The pyloric region, liver,
I
I
I
I
CTSTS OF THB paschbas. 581
ilîaphrii^, Qn<l rijîht lung were iiivolvd, ft* well as ihf pvloru:», pitncrcm*.
ami tviupliBtic ;;liini1><. Ttiv morlùtl Us^iic of tliv i>totuacU, liver, «ud
]}«ncreaif uiw t<iriii<.-'1 of relic lUiiU'i.! l;t-[ii(ihktic tiiuue.
Citrnnomit. — C'areinoina of tlie [tancreait is iiifreqtieiit. It may he
primary or secondary. From ihe AlatUtic» of Willt;tk, of -lli" casi-s of
carcinoma. \t were carciooma of the paucrcas, the majority being eccoud-
»ry. Primary carcinoma is most frequently devdopet] at tbo bead of
the pancreas, very seldom at the left extremity or middle. As nrimary
carcinooia of the pancréas very soon extends from ibc bond of this or-;na
to the neighboring part^, to the duodenum, lymphatic glands, duct», etc..
it U very difficult to determine its origin ivheu a tumor including tht-so
organs iii found at the autopsy.
I'riinnry carcinoma may W either scîrrliou», cncepbitloid, or colloid.
It may hegt» by one or more tiimon» which uro unitei), when a portion
of the gland i» hoo» transformed into a itiitform cancerous mast«. When
tlie lumor U limiti-d to the head of the pancreas, the canal of Wirsung is
contracted; it leaiU from the duodenum into an indurated tisiiue vrbieh
compresses it, and the disuharge of nancrealic juice is prevented. If the
loft half of the pancreas is not included in the lesion, but continues to
BccreU' somvwhat altered juice, the excretory ducts are dilated in this
portion of the gland, and form cyst*. The subserous connective tissue,
the muscular layers, and tbo submucous connective tissue of the duode-
num, as well as the ampullfl of Vater.and ductus communis choledocbiis,
Mon bMome involved, and there frei(nent1y re^ultji a narrowing of the
duodenum, perhaps conMderable. followed by an icteru», etc. The cxl«n-
ÛOQ to the lymphatic glands may occasion pressure ujion the vena
porta; the infiltration of the subperitoneal connective tissue terminates
ny compressing and narrowing the aorta. The stomach is very seldom
flccoadarily invaded by the tumor. Klehs and T.iicke have reported a
primary colloid earcinoma of the pancreas innhich a secondary dropsical
and cystic dilution of the oinentuni was found projecting prominently
hetow the transverse colon. This secondary tumur of the peritoucum
bfl been punctured during life.
Secondary carcinoma of the pancreas, due to an extension of the car-
cinoma from surromidiii;; jmrbt, the «toomch, tlie duoilonum, the liver, the
lymphatic glands, is seldom seen in the form of isolated nodules, at least
when it is not a melanotic tumor; generally the new formation of the
pancreas ia rlirectly continuoiL^i with the primary cancerous mass. The
nea^l of the pancreas ia almost always the Krst region invaded, and it i^
unusual for the entire organ to be degenerated.
Cylindriesl-ceUed eyitheiioma of the pancreas has been once seen by
£. Wngner. It probably followed a similar epithelioma of the mucous
membrane of the duodenum.
Sxrvonut of tbv pancreas has been met with only in the forni of a mc-
lanolic tumor.
I CffU», — The only cysts of tlie )iaucrcas are those which result from n
dilatation of the excretory ducU of the gland. A tumor, such as caret-
noDA of the head of the pancreas, or of the duodenum, or au encysted
PANCIIBA8.
biliary cnlculu^i, oK^tfuctin^ the ampulla of Vater ami catuîii'j an iiiflaio-
matory imluratian of the durmiitiilin;{ connective tusiie, or puDoruxtic
^concretions obstructing the excretory duct of tiie pancreaa, ovcnnoD
obatnictivc cystic ditatatiou of the duct. These dilatations, xomewlist
regular, with proiubfiraaces along the principal duet, have the form of
ktacculatod or spharic«l dilatations, in the secondary ducts vhich ]>ewi'
r'tPftt* M far aj? the surface of the gland. There dcTolop in the loft or
middle portion of the pancréas prominent tumors, vrhicn appear to be
«phcrical cy^ts bounded hy a niutnhraiie: but, upon section, there is
klwtiy« «con a commiintcntioii with the principal duct by a narrow pauu-
,eze. The sac-like dilautiont nnA the irregular dthitutioti of the canal
*cf Wiwung contain either u wliitifh chulky miicitH, n'nder«d opaqiw bj
tlie ttaltji it conlainit, or true concretion*, usually friable and white.
'Xlie^te cyAU of retention and cxIcuVi are not unfVeiiuently met with.
In a CA-ts recently observed, the large di1ate<l excretory eaitaU contained
an opapte, thick, white pulp, white and irregular friable calcnli consixl-
itig of ])hosphat« and carbonate of lime. Tiie internal sur^e of the
canals was lined bç a single layer of very thin flat cells with irregular
edges, provided with an oval flat nucleus. The wall of the canaU was
I thiekoncd, fomiud uf supurinipofcd layers of lainiiutlcd connective tissue
Mparnted from one another by flat nucleated cells. These matlificatioos
ill tlio structure of the wall and the Mliape of the epithelial c«lU were
cviilcnlly due to the présure exerted hy the «elid concretions. To tfae
unaided eye. no traces of the glandular acini were Men; the Mcrttiug
atrticlure of the iiaiiereai was replaced hy adipose tissue. Micmwjopic-
«lly. there woro seen in the fibrous trabeculse of this lisjue, only ibe
aioall excretory canals unchanged and provided with their cubical epi*
thvlial cells.
The sixe of pancreatic concretions is very vnrîahle. Thoïr presence
muy cause an acuto inllutuiuation and even the formation of an abecesa.
SECTION 111
CHAPTER I.
THE SPLEES.
Beet. L— Normal Histology of the SplMn.
TllK Hpk-t-n, nil as^ymmotricnl viMciiliir Mooil fitiinil, coii^iuLt of a filirotm
«nv«lo|)o (cApiiulc) ('"veri'd \iy ilii> iit^ntorioiiiu, "I" u i^ofl ri'<l |iareiicliyiiia
conbtinin^ «in^ciiil liiiilio.-< niiiiicl ^fa)pi^)iiiiii ci'irptiitcVii, of vesseU, and
of iiervM. Till? «jiletiic imlj» is formi'l of reticulnli;il tinxue. Tlie fibrous
iii«uil)nine (cii|iaiilc) of ihe itplc^ti is very re:»i!*liiiK a"'l «leiiae, formed of
parallel lamitiie of coiiiieciive-ÙH.iuo filircM ami olaalic fibres; between
Uiea« eleiiieiita a few Bat cells are int«r|)oi«eil. FibrouH tissue trabeculie
tariite from iu inner surface an<l form miineroiis parlitioiid travcrsiiijj tho
spk'niu tifisne. This fibrous tissue alno aixonipanie^ the vessels, tirtcrio»,
Hiiil veins, forming a fibrous sheath for tliem. These trnbcciilK c<m*li.
twtr tlie fibroiw Mtroinit of the organ, Tlicy oontiûn sinocillj iiiii:«c<ilur
Bhrem in thortti niiimiiN wbidi bav« thoin in tb<- ciiiwilt; (iiiiiny mainoni-
fenc). In nmn, the ])re*eiice of itmootb niuwtilar filirct in affirmed ttj
some hbttologt.tw (Krey, Meisiier), and denied by others (Kolliker, (ier-
lach, Henle).
The splenic artery and vein enter the orsan at the hilua, surroiindod
• by a fibrous shealh provided by the capsule. This §hoath la thinner
than the arterial wall, but thicker than the venons wall. Each of tlie
principal branches of the splenic artery divides and forms bninchinj; tufls,
• which do not anastomose with those formed hv the neigbborin^ arteries.
Whvn thufc branches have a diaroeter of .3 mm. to .4 mm. they are
separated from the reins, and have along tlieir coorsu the Malpif^hian
bodies.
Tho Malpighian bodies or eorpiisclcs of tho spleen are sphnricnl or
oral in !iha]>e, giiirroundin^ an arleriolc ; their diameter varies from .2
Dm. to .7 mm. They are always intimately conitectoil with an arlerinle,
which passes through their centre, or near their jieriphery, and which
eends into their interior small arterioles and a network of capillaries.
These corpuscles consist of a reticulated tissiie. similar to that seen in
the closed follicles of the intestine. Tho meshes of this tissue are coD'
nectol with the sheath of the arterioles and capillurics; the mesboB at
the periphery of the corpascles aro narrower and the fibrils are nearer
liut there is no Inio membrane sepuratiuf; them from the splenic
e\i' retieulum of the pulj) is cuntiiitious with tlic rutlculattid tissue
■pusclea.
583
SFLEEir.
The coUuIar elements contAined in the mcah^e of the reticulitted
Arc lymph oeWs, botli small ttu<l Urj;*, provitlei] with « nucleuH ; tbt^
lurgi'st contain i>i;;iiicnt ;;rimiik>«, or cvvii rod blooi) coqmscleii.
The Malpighiai) corpuwU's of the Mplvcn tl» not iiicloM rcini>, whiV
the «picnii: pulp ii> tntvenud hy a very <ii.-n«u und ithtindaiil voiion* nvt-l
«work. A tliin. MCtion of th« splonic pulp «howit ttfctioni* of stoall vciiu
very close together, fonning the OMcnlinl cleruent of the p«ilp, and aepa-
mt<-d from each other hy a reliculnted ti»due, with very fine Rie!itii>s atid
filaioentA (intervawular cords of Itillrotb). The veina have no distinct
«all, and are limited by a thickening of the reticulated tissue ; they are
lined by larjçe fiat endothelial cells.
Tbe cellular elements contained in the meshos of the reticulum of the
splenic pulp are the same »s tlios« in the reticulum of the Malpighii
corpuscles. From tlio above description the corpuscle* may be comgnr
witn the follicles of the Intestine and of lymphatic glands. The wliolll
0ple«n may be coniparei) to a lymphatic ginnd in which \hf medullary sat
atanoc is rcjilaced by a cavernous tissue ; the veins replacing in the sp]c
i.tbe pori-foUicular spaces and tho lymphatic caiwls of the glands. It it
' evident that tlic lymph cells are able to paita from the reticulate<l tiuue
into the hlood, anil from the bloo<l into tlie reticulated tissue.
'i'be mode of connection of tlio arterioles and corpnacles with the veo-
OUH network of the pulp is not yet accurately understood. Ilistologista
have not yet agreed upon the manner of communication : some beliemg
that tlie arteries are directly continuous with tbe veins : others admit tbe
existence of an int^nnfdiary oapilUrT network ; and. finally, othvi^ think
the communication takes ]>lacc tnrougli the spaces bounded by the fibrous
network of the splenic pulp. Tho blood in the splenic vein contains a
greater number of red corpu«cli-s than the bloocl in the artery (Mftlussex)^^
therefore it has been inferred that the mowt essential function of the
ajdeen is the formation of red corjni^clei*, altbouj^h the hlood |iigme
found in the lymph cells, indicale--< llic destruction of a number of ihea
elements.
The lymphatics of the human spleen are not very abandaitt ; they ara
found in the capsule of the organ, and also follow the arteries into the
substance of tbe spleen. It is very probable that tbe lymphatics of dMj
arterial sheaths penetrate as far as the Maipigbian corj*u«Ies, but their
relation wiib the reticidatcd tissue of tbe spioeu is not known.
The nerves of tho splcrn, consisting of large nnvlulluted fibres and
numerous hbres of Kcmak, come fnitu tho sp^ ^^ic plexus, and |)cnetrat
the organ in company with the arteries. Tney may be followeti upon'
the arterioles as far as the corpuscles, and, aceonling to Kcker, terminata
in free extremities.
Sect. II — Patholo^ of the Spleen.
AiRopay of the spleen is frequently seen in old persons ; it generally
is associated wiih a nbrous thickening of the splenic capsule. Tlie pareo-
chyma of the organ may also be induraterl, but usually it is of normal
consistence. It is generally pale, antcinic, at least when there has been,
I
KYPRRXMIA OF THE SPLEEN. S86
ig lh« lifv of the pAtient.ehMific <IiseMO ftocompAnicd with intcrrer-
UM-nf t)ic' ctrcnliitioTi of the Mooil. Tlic tliivkcning of th« cupsulc of
nJiefpkcn coimUu in the fDrmalion of laniimv of coiiiii'ctive tiitgue, wpn-
wted hy flittc«tl4. Tills tiuue is rdm&rkiiMy liani am] resisting; fre-
, qucutly it is like carlilagi* aiul intiltrnleJ with oalcareoiis xalls. A
'clironic inttammatinn of tiie periloneiim upon tlie iiurrace of the capsule
'laiKays seen, and n«w formationa in the shape of ;;ranu1»tionâ are pre-
Mit; thcv ar« li&rd and non-vascidar, are lu the form of patcfaca or
Coating Blaments.
HypRn.ïMrA of Tnn Splbes. — Congealloii of the splcon occurs in a
nitniticr of very different Diorbid states, itnd al«o i« tlic first staf^i; of the
majority of discfiM-s of the «pleen. No orfjan i» more prone to c»ii)^s-
tiona ; but the ^tnictiire of it« ImheculiB ami uHp>u1e, whieh contain
elastic fibres and Hiuootli uinsi-uUr fn^ciciili, is sucii that it i^nerally r»-
tiims to ita normal condition. When, however, tlie cause of the conges-
tion is fre<}ucntly repeated or permanent, it is not the same, tiiere in
then a (lennanent increase in aise. The hyperiemia may be acuta or
chronic.
An acme t«m|)orary congestion occnrs in all infectious febrile diseases,
such as eniptlv« fevers, pyi»mia, erysipelas, etc.. and in ji number of py-
rcxiiv. There nociir» in this congestion not only a filling of ll»; ve^cls
with blood, partic-nlarly the vein» of the splenic pulp, but very prohaMy
aldio an intemiption of the blood-inakin;^ function of the spleen, nud the
I formation of whlto corptiacles and the dostrticrion of red ones, beside the
changes peculiar to each disease. The precise alteration of the splenic
blood following each infections febrile disease is not knovrn. lu most
cases of acute congestirc hy|)crtrophy Mien in infectious diseases, the
spleen is soft, and its pulp is not of a iloep red color, hut is pink, IwcaoM
of the numerous white corpuscle* contnimnl in tlio hlood.
In inlerrnittent /ev<-rs tJie spleen is tumefied dnring the fever. At
first, the hy[>enemia passes off durinj; the apyrcxia to return with each
access of the fever. Soon, however, the tumefaction bi'comes permanent.
Splenic conxesiion in these fevers is always accompanied with destruction
of the red blood corpuscles in the spleen, and pigmentation of the splenic
tissue. When the disease has continued for some time, and a malarial
cachexia snponcncs. the spleen is not only congested, but is also indu-
rated, a cirrhosis witli pigmentation.
• Tyithoiii ffvtr is one of the infectious febrile diseases which moat fre-
quently implicate the spleen. This organ is almost always hypertrophied.
reaching at least twice its normal sine. Tiie congestive hypertrophy
varies: it may increase to four or six times it» usual volume. In the
adnlt, the increainc in size is less than it is in children, for in the fonner
the capsule of the spleen is denser, thicker, and conseipionUy less ex-
tensible. The capsule is thin and tense. A section of tlic organ shows
it to be infiltrated with blood, brown in color, or more often pink. Hie
ilalpighian corpuscles are sometimes very apparent ao<l large, or ihey
are invisible, a fact due very probably to [losi-mortem softening. Ttie
coniùstencc of the spleen is generally less than normal. AVhen eKamined
A
SPLKCX.
laûoroacoiMeallv in the fresh state, the ccltulsr ck-menl» of tlio xjA^nie
palp »re founn surramiilo) liv rotl corpascli;^, aa xUc tcotb or tilWouUi
(lay of thi' disease ; tlio swoUon Ijrinpti cl-IIa, witli granubir «ad aoft pro-
toplasm, frc>(uuntly liavc Hcvoral nuclei. Many of Uio lyinplioitl cvlU
conUiiu ont or toort.' rcil corpusi;lc«, The nuclei of tlicdf iympk celU
arc very distinct. Tlic ii>il curpuscWs vrjtliiik titu protoplasm nre sonw*
times uoniinl in »ixv, and easily reco^niiwil by ihf^ir «liape, llteir color,
anil iho UomogciMOiu appearance of llieir struoluK ; sometimes thvy
are small, meaiuriii;; only .004 to .004 mm. ; aometimes they arc gnina-
lar and aro only recignixed by lb«ir color. 'Hie Urge endothcltal cella
of Iho veins always appear normal to i» ; but Hillrotfa liaa described a
proliferation of tbeir nuclei in typhoid fever.
The number of lymph cclU coutiùnini^ red corpuscles is considorahlp
in typhoid fever ; from a drop of the pulp obtaiuod by scrapinj;, at loM
one hundred may be counted.
When the fever terminât*-» in recovery, the spleen dîminishoé m
its cutsnrface is hrown in color and not much coD|{est*-d. Mivrotcoi
examination does nut show the cells in a state of prolifcnttiou ; but
lym]>h cells contain fatty gmnules (Fu^rKtcr^ and red pigment.
The lesion of the f\Aven m ly|th<iiil fever is therefore not a simple con-
geflion ; it scemtt more like a parenchymatous iiiHammatiou, a» there is
a proliferation of the lymph cell». On tlie other hand, it itt not a simple
intlammation, since there is,as an eiittenttul phenomenon, a de:»truction of
tlie red corpuscles which are taken ii|> hy the lyiu)ih celLi.
In very intense con^restiona due to iuleriuitleni fever and typhoid fever,
there arc also found true licmurrlia^ic foci, and in many eases ni|>Utre« of
the spleen. In typhoid fewr soin(.-titues splenic infurcti are met with.
A chn>iiic coiigujttioii is alway» ohsened in diseases of the liver ae-
cam^iaiiieil nith interference of the portal cinuilation, and i» disease* of
tlie heart with iihslrnciion to the venou--* circulation. Thfl pr^S'ture of
the blood is increasei) in the splenic vein in the^e di.4ea»e«, and there
results a blood stasia with congestive hypenrophy of the spleen. Di».
eases of the heart are not so apt to cause intense hypertrophy of the
spleen as chronic diseases of the liver, particularly cirrhosis. Generally,
chronic congestion is accompanied with some amount of interstitial sple-
nitis with induration and thickening uf the capsule, with or without [>ig-
iDcntation of the etcniunts of the splenic tissue.
In •■hninir ilUfaxr «f the hctrl the spleun almost always has its oapsnie
indurat<:d and tliickened, and upon Its iiirraee exist small vegetations with
free extremilic«, or fibri>us cartiluge-like jiatches. The sine of the splecu
is normal or is increased. In old jientoiis it i« smaller tlian in middle
age. The splenic tiitsue presents the color of ventuiii hlooil ; it beiromua
paler npon exposure to the air. The cut surface is smiwdi and somcwlial
firm; by scraping it yields some splenic pulp. By closer examination
there are seen u|>on the deep rod surface fibrous trabeculae and vessels
much more distinct than nonnat. The truboculio are thickened and have
a greater number of connective-tissue fihrc^s, than in the normal state. The
artoriolea arc firm and tlieir wall thick; their inu-nial coat is fre<|aontly
the scat of an endarteritis, especially when there are atheromatous
lesions of the aorta ; their oxtermtl coat is also thickened. The rcticu-
siaaj^
I
Utoii tmne of the pulp atiH cor|>U9cle8 is u^uiilly not thicki-ned.
capillarr aud venous sy^^tAm; of the or^au atv Alluil witL blood.
In dwoasca which caiHO an iritorforuncc with the circiilnlion «f the
niui porta, c*pociiilly '■irrfn'sU, iht- »pl«i'n it much hypiirtropliiod, atid
IB ai 1ea«tdo<ibiv ittiiormxl sixc; n« in the iiriNiodiii^ cn^u, the onpsiiU- is
UiicVcnvd, aud sometimes covered with numerous vej^etaliotiA ; there it
aU<> ascites with the itiiba«iile pcrilonitii* irhit^h so frei{uentty accompanies
th« uirrhoi^Ls, The color of the cut surface i^ blood red; the tîbrouti tnr
bee 111 le are thickened.
Niicroscopic examination of the nplenic palp obtained by acrapin;; the
fresh spleen, fre-^ueDtly ahowa lymph cells containinji brown or black
pigment surrounding the nucleus. The endothelial eolla of the veins of
tfa« pulp often have pigmïnt granules in their protopU^m. In thin
MctîoDs these veins are found lar;;er thiui nonmd. Tlic tnibecuhc of the
enpflido and reticulated tissue are ifinnil or 8lij;htly tiiickened. Iq (hvite
OMO«, therefore, the hypertrophy of the spleen 'n c«]H!oially duo to a dis-
tension of the reins and ft sli^çht thickening of the Bbrous trabeculK. The
IjiQph cells are oot more numerous than normal.
IxTHKHTiTr Ki. Si'i.KN'iTis. — Ohronic conge^ition^ of the aploen terminate,
as above stated, in a new formation of connoclivo tiaaue, which may he
considered a^ indicative of an inflamuialton or alow irritation similar to
that of cirrhoiii of the liver or interaiitiat paaunir>ma. This lotion is seen
in a more advauued and intense di'^rco in m ilarl'il •■i(:hfx-iit than in any
other disease. The spleen of porsoiw who die with Ihi* cachexia varies
very intwh in appeantnce. Sometimes it i» red or pink upon section, or it
nay be of a brown or slate color, and the trabconUw as well lu the sjilenio
p may be dark broirn. The diiTerencf>i in color depend upon the
lint of pigment contained in the conuective tîasue aui in the blool of
the spleen. An aimnsi constant lesion in intermittent fever which has
lasted for some time is a fibrous thickening and induration of the eapanle,
which is also covered upon its surface by inflammatory productions.
These consist of prointnont. very dense, frcquenily cartilago-likc granula-
tions, and of (ibriHar-like vegetations or fibrous floating false ntembranes.
The false nienibrunit» are vascular, while the fat granulation* forming small
fibn)mAtu with l»iniii»U-d layers (see p. 92) are non-vascular or only have
very ffw ve.«eU. Ttiesijie of the spleen i* nlmo^t alway» incren^od. A
Ïigmented spleen may reach 20 to ^■> cetitimelre-i in its largest diameter,
hew spleens are indurated, but not to such a degree as is a eirrhotio
liver. Oq examination of the pulp obtained by scraping from a red or
pink spleen, there are found a amitll number ot lymph cells containing
pigmentgmnules: ina spleen iniuratei and pigmsnted there are found
many lymph cells inSttrated with the pigment granules. These gran-
ules nri!< cither small, brown and brilliimt when they aro cxaniin?d with
higli power, or they are large and dark, or perfectly black. They are
contained in thi? lymph cell^, but are also sometimes free in the blood.
The lymph c«lls gijnerally bave only one nucleus. Tlie large endothe-
lial cells of the iniermd coal of the veias also fre >{u en tly contain hrown
or bUek pigment, but in the form of line tyrannies and net large grains.
Microscopic exaiuinations of lliin sections show the (ihri>u« trabeculis,
H very
I
J
588
8PI.88X.
coming from die capsule, tliicltened to a varvini; degree. Tlivre \» a
new formation of connective tissue fibres in theMi bands. Tlic Mitt]>i^bian
corpuscles lire tisuiilly vcrv distinct. The retictdnted tistiuo of Uie c<ir-
I piuolett and pidp undergoes chan;:es, wKidi erioenttaUv oouTiiHt in a )4g-
iDimtalion i^f tijc )_vmph cella contained in tlie meslieii of tlie r<.'ttciilnni.
Tlie cell*, liowi'ver. witliiii the roticiiluin of tlie c^trpiiscle* are le» pig-
momcd ibmi tlmsu in tlie liand* of retieulateil tiittue lietwœn tlie veioi
of the ]mlp. In thi* portion of the Hjileen, the npleuic vein» liavi; u|)oii
their intemni surface iili^htly pigmented or normal endothelial I'ells,
I and in their lumen nitmeroiii* Ivinph eelln deeplv pi^cineuted anton-;
the while Wood coriiusoles, These veins have their lunwn dilatod, if
the procfâs is recent, and if the or^an is slightly induraicd: they an»
normal or i-ven contracted, if the sjilcen is indurated aiwl the lesion
olirouic. The reticulated connective ti$«ue separating; the veins from the
I pulp is very dei-nly pigmented. Examining this ti«ne witb a high
power, it is fouitd that the color is due to the Ivniph cells nitliin lite
retienhim. These cells arc geneniUy hiack. Wien the collidwr ele-
ments are removed fniin the rcticulal«<l tissue, llic filainentit which oom-
{>o»e the rt'lic'iilum are usually not thickened to any notable extent, Wl
have upon their surface very line pigment granules. In sjilcena which are
greatly indurated, tJiese filament» may he two or three times tlikkerand
more rij;i(l llian in the normal state. Yet they are alwara fioin|)o6«d of
fibres, itnd Imvo no nuclei at their inteKections if the section is very thin
ftod ««11 pencilled.
The enlar^nl arterioles, nrterieg, and veina of the spleen have their
wall* thickened, indurated, and intiltnited with pipueni, e«|M!cially in
their peripheral none. Tlie connective tijuue forming ilio large fibroua
traheculte alun have a targe amount of hiack jùgment in the proioplaMa
of the cells and around tliem.
The lesion of the spleen in intermittent fever is such aa to essentially
consist in a destruction of the red corpuscles, and in the formation of
I black pigment from them. This change is not confined apeeially to
malarial fever ; as has been seen, there is an absorption of the red
corpuscles by the white blood corpuscles in other infectious febrile dis-
eases, typhoid fever, for example ; besides, chronic congestions of tbc^H
aplcen, particularly in cirrhosis, terminale in induration ukI piginct)tatio|^^|
of tJie cells. Hilt tlio exagiçeraled pi^nuntation is l'^j'ecially nurked
and constant in inalarinl cachexia, and it is in mia:<m^tic infection that
tnelaiueniia or black ]>igmenlation of the wbit« blood corpuscles occurs.
In refieated congestions of the spleen, and iik interstitial aplenitis, it
bai been seen that there occur a tliickening of the ca|>sute, and a new
formation of connective tissue upon its peritoneal snrfaco. nie folds of
peritoneum fonning the gastro-splcuic omentum, tho pbreno-<liapKrag-
matic and pancrento-splenio ligaments aro intiamed, resulting in an inti-
mate union of the spleen with the neighboring organs by false membranes
which become org»iii7.eil connective tissue. Tiiis Jilir'mê pm-tplenitii
is most rre<[iiently th<- oonAC^uence of primary changes in tlic sple<-ii,
but it may nl.to be the evidence of » general or local peritonitis from
any cause. In intermittent fever it is always pre«enl to a raryiug
«xlcnt.
IXFAttCTIO:! OP THE SPI.RK!C.
589
I
SrPPtntATlVR Spr.KKlTFS. — Large almoeasca in the «[tleen are very
Mldom seen ; tlti>v nmy be cau»e<I by contusion» of the s[ilenic region,
bj fracture of tiie ribn, etc. In a few ca»3 the cause of splenic aU
.icesses fourni at autopsies, is not Vuovid, yet, duiinj; life, iliey may liare
occasioned very inleuse febrile Bymptoma. Iii otiicr cases, also rare,
abscesses of the spleen have been seen in liubilitated persons who have
had fi'vers or have lived in a malarial country.
Suppurative aplonitis occurs in thrco fortns: —
l«t. As a ilifTuscd infiltra tiuu, so that a cousideribV part of or tlw «ntire
eplenio parvncbyma is softt-ncd, grayiih-white or pink, redueoA b) a pnip
or pus; the blond and tlic d<Sbri« of iho li**iie of ibe nrgan arc mixed
tO0)lber. Lestoiiti of this kind have bwD described as yangrenou»
2d. One or more absoetses of varying sise have formed in the tifiaue
of the spleen. Thete abflCCSees are a result of traumaûi^m, of phlelntin
of the splenic vein, or they are metastatic ahscossea, or a conse'iuenee of
fevers of low type (typhoid especially); they may unite and form purulent
foci, which are separated from the normal tissue of the spleen by a
pyogenic membrane. Absue^^ses of this kind may attain considerable
sue ; tiicy are generally encyatod. and their pyygcnic membrane becomes
fibrous. In some cases the capsule of the spleen is thickeneil when
they are superficial. In other enxes — the ctipctule being it«clf invaded
by the suppuration, and fibrous arlhe«ion« being eittiibli^hed with the
neighboring organs — an ab^^cesa of the «pleen may o^n-n into the stonineh,
or through the diaphragm, Into the pleura and lung, or it may discharge
through the abdominal or thoracic walls. In some cases the abscess
communicates with the splenic vein, and, finally, it may work iu way
int« the sub-peritoneal cellular tissue as far as the pelvis and open into
the vagina.
8d. Metastatic abscesses occur freqviently in the spli-en as well as in
D^cr organs ; they arc met with in pytemin, in puerperal fever, in acute
locardilis, in phlebitis, etc. They are I'wtited esjiccially at the ppri-
phery of the spleen, their hose toward» the capsule. Their number is
generally limited ; their sine varies from a hemp-seed to a haxel-nnt or
larger. They bejttn by a small dark-red colored sj)ot; pua is »oon seen
in the centre of this area, which gradually softens, becomes fiuid, and
forms a small abscess.
The pathogenetic conditions for the formation of these metastatic
thMWases fre<)uent1y occasion at the same time suppurative perisplenitis
genaral peritonitis.
IsFARCTtox OP TUB SpLEKS. — Thc splccn IS an organ io which infarct!
«re very frequently met with. This is explained by the fact of the
.ic artery having it» origin from the aorta, not far from its arch,
'mi by the absence of anastomoses between the branches of the spleme
artery. When, therefore, the aorta is atheromatous, and fragments of
fibnn enter into the brnnehes of the artery, the portion of the »iplecn
receiving its blood from the olwtrucied artery is the seat of an infarotu».
It is not possible for the circulation to be re-established by collateral
veasela. Infarcti should be carefully distinguished from metaslalic
590
BPLSBX.
al>9ce<»e8. Splenic infarcti are si>en in atheronulons ehan^a or the
aortn, of tlic aortic valves, of the Apteoic arterr, in endocanlitis, tvs.
Their she »m\ number varv. A spleen may In- enlirelv invaded by the
leeion, or tlivre mar )>{• onfv one, two, or tlirec sninll intarcti, the sixc nf
s liazL'l-nut or wuliuit. 'J heir form is cbanuih'rii'tic, and usually re-
> semblés n cone, tlu- lui»c townrdti lliv surface of tlie orf:an and the apox
towfinis the Iiibis. Wlien a larf^e extent of the splee» is involved, ih*
splenic artery or «cvenil of it» branches are eomplelely obturiicird by
an adherent clot. At iho lieginning, tlie cnt Mirface is deej» tfd.
> almoiit black, owiu]; to the blofld UariDg coapilnteii in all tlie i«mi«l) reim
and in the arterieei, f;ivin(; to the nliole the color of venous blfxxi. I.a[<>r,'
wlieti the fibrin has become granular, when the corpusclea and fibnii are
transformed into a granular fatty aubetanec, the color of the section ts
grayish or yellotcitih and opaque. The eoonistence of the infarcttiâ ia al
first much greater than that of the normal spleen ; later, the part be-
comes «ofler. srmi-fltlid, and yellow, and has a dou;:hy feel. The soften-
in); may occur in sudi a manner that u portion of the infarctus is sur-
rounded and partly separated by flui<t. The healthy i«rt of the ïplevn
limiting the regiiin where the eirviilation ts arrested id congealed and
inflnmed, hut suppuration never oeeiiw.
From the cimiplelc obi*truotion of the arteries, from the coagulation
of the blood in all the vcHiielti of the altered region of the apleen, and
fnini the rciiulting necrotic sotieiiing, thiii process amy he compare<l to
tliat of ;;aiigrene. The mortification i-" owing to the ariesi of the circu-
lation of the blood. But here, as in the lircr and kidney, the mortitici-
tion occurs \vitliout any commimication with the atmosphere, and there is
no putrefactive or f;angrenuus odor. Anatumicnl lesions uf the s{dccn
com)inmble to putrid ganjEnnie may occur, but mily when a portion of
the nmrtified spleen is furroutided by the pur" fnim a peri-.*|ileiiilii<.
Microscopii; i-xaminntion of recent infiinli shows the veaseU simply
distended with coagulated blood. Soon the lymph cells contained in the
ret.icidum d' the fihriu of the clot hecomi? fatty degenerated. The fat »e[ia-
rate» and forma round collccdons of crrstalti of fat acids, which, with a
Ion power, appear as opaque bodies. The lyoiph cells eontuined iu the
reticulated tiasue of the spleen uit<lerf;o ca^-oiis de<;eneratioQ, while the
elements of the blood tn the vessels pass through the changes pn-viou^ly
described.
The trabuctdie of the reticulum in time exi>orienoes a molecular de-
struction, as do »I»o a uumlior of the lymph cells, and there results a )wr-
tial or extensive sofu-niug of the infarctii». and the fonnation of A pulpy
mass, in which are found granular cells and albuminoid aud fatty granules.
The infarciuit is at first awolien, later it contracts, and there is seen a
depre*«ii)n ujion the surface of the spleen.
The cajiftule of the spleen i» almost always affected in this lesion.
At first it is congealed, afterwards it presents villi and vegetation*, is
thickened, becomes denser, and may even undt-r^o a kind of cakification.
Aa the infarctus softens, the fluid portion ia absorbed by the healthy
peripheral portions of splenic tissue. The loss of substance is, in pan,
replaced by new-formed connective tissue from tlie capsule, nhicb ia here
Siinl in I'lirt lij' a fiUnm-i j;rowlh of th* nciglihoriiig splonic
riiilly, n tilirouH cicatrix reiilnco^ Ihv iiifarctiLs.
Ill tlie»c cica(ric«.4 nf ttie ^[tteen, r«cogiiixL-(l l>v a ilepre!»ton ugioii lli«
siirfiico uith tliiokciiin;^ of tlie capHulo, there U generally calcificMion.
K^nniiiintion of ihe calcified tisnuc iIoe§ iioi sho» tnio onWobl&âbi with
tlictr canalicular prolongations. A rlecalriBed iiei'lioi) shovs smalt cavi-
ties, wliicli re]ire«eut the sgiaccs contaiuing pre-cxistiDg connective liaaue
otflls.
Kflpccially in itifarcti. hut ali>o in tlic majority of indurated 8])1ecii9,
titlicr from cirrhowa of the liver, or iliseftrtes of the heart, the splenic
•rterie» are iniliinil^il, and their wall* conxid^'raWy thickened, due lo
ctulartoriti* and pi^riurteritis, with or without culcart'ous incrustation.
Ki'iTi'RRti or Till! Sn.KËN'.— Trauma tie or spontaneouii rupttires of tli«
spleen sometimes occur. When tliÏH accident takes place, it alnio»t always
happens in spleenit swollen from coiigeative or inflammatory lésions, tt» iu
iiilermitteut fever, typhoid fever, cholera, syphilis, etc. Tliey are met
with a« 8u[«rfici,i] or duep fissures, varviiij^ m sixc. and arc scaled in all
parts of the or;;an, panicnlarly ujxtn the external surface, in the lar^e
lon^itadinsl Ssaure. A clot of hlood is found at the M-at of rupture ;
ihiif ch>t is sometimcs continuouH witli a cruoric mass which surrounds
tlio entire or^^n as a lar;^ clot. Hemorrhage into die peritoneal cuvitr
kt ttmi.-s occure, resnltiu;! in rapid death when the anmunt of hluod is
conxideraMe, or wymptoms of peritonitis if the escape of hlood ocour«
gradually during several (hy».
Amtloi» DecKNeitATlox. — Amyloid degeneration of the spleen ia
seen iu two forms : in one, it is limited to the Malpighian corpuscles : in
the other, the aoiyloid degeneration is diRusc. In both variotie-s the
spleen is liypertrophied, sphcricnl, and of d-nighy consistence ; its capsule
in stretched, and in freijucntly thickened by new formation of connective
tifi*u« ujmii il« surfuco; its edges nre thick and niiinded.
In the w'r** mirU-ty the Malpighian corpuscles are seen, upon section,
lo he increased in sixe, ineastmitg from one to two millimetres or more iu
diameter; they are somi-transparent, conMiKtinj^ of a hyaline WiKtance,
which is colored niiili<>j,*any-red by a solution of iodine. The ap])earai)ce
of these large numerous corjutnclex resembles boiled sago grains, and the
lesion is termed a m-fc Htilten.
Sections of an amyloid spleen, colored by iodine and examined with
low power, show tJial the diseased parts are appended to the arteries,
or arranged around these vessels. The degeneration ia host studied by
staining with the violet of methylaniline, which colors the anivloid infil-
trate violet-red and the normal parts blue. (Sec p. i'^3.) 'l^ie wall of
the arterie* wtiich pass through the diseased eoqiuscles is intiltrate^l or
normal, la two vn.'H-s we found the arteriiil wall unchanged, while the
walls of the ciipillsries and most of the elcmonts of the splenic cor-
puscles, the lyniph cells ami reticniated tissue, were infiltrated by the
atnylmd substance. The degeneration of the lymph cells is iieen by
tearing the corpuscle with needles in the fresh «tato; in thin iieciions, the
lymph cells of the corjmscles are vitreous iu appearance, spherical or
4
•
3
S92
transronned into smaU îiTo;'iil!ir blocks, or nre nnited to one atiotlior ami
h»vc lost their nuclei. Wlitn oKamiDed with high poirpr, Dioist of tlie
BbriU of the reticulum, in tlic di«oa»«d cortiusclc«, are sœn iofiltntcd
nilh tb? amyloid »ubsl)iiK'« ; the «upillorjr wiilU arc uIho id the Mune con-
oid d(t*n'ntlloii of lb» i<pl>«a~"Hta iplr*!!." A iwRldnnf nntof Ih*lalltn4*l XilrkbUa
Mr1'll•Il^>a, «nil tl» 4dJknDl «urunl iiilnuU iltms i. KhuwiUK iti* InsnaM la «tin tiii, la *■••;
p4TU, Ib«4uatpM>«De*uf (b« («lin, itf vblrb Lb> «rpuktl« la fainj?«4«d, X^^ iO^ttm.)
iliiioii. A# nil tliceo pttrt«, Ivinpli ciOlit, rvticiilum, iind «-«lis of the capil-
laries, hftvci loiidcncv to bUnid tojreUKT, they form l)onu>;;eni-oiis auisae
«litch are obannctled by iinrrow civfttt forming a network; tbiit i» a iMit>
work of capUlnriL'a uhicb biive tbcir ltin:i«n increaitcdi iii which l)ic vtido-
tbelial cell* and corpmnclea of the blood are preserved intjict. In ruecnt
îiiv<isii;;nlîon8 lumle with the violet of mctb^laitilinc the eiidotlielium of
the capillaries van always fomid to be nornitil.
Till- iiUiTi'il Mulpi^hiiiii coqmsclos an- much ci)Iurj;cd. and m aoiM
plftL'i'» ari' n.lniOKt in contact with orif another, only sc[taratt-d by bands
of normal tipl^iiic ti*!*iie. Vi^ry freiiuciilly it i* not only the corpuscles
which arc infiltrated with the amyloid AubMance, hut the veiiK of the
pulp near the corpuAcle aho have their nail tiHghlly thickened and di»>j
eased. The endothelial cclU of ihcHO veins are alway.4 normal. Tl
calibre of the veins is not changed ; the reticulated tissue tturroundiii
tlicm, and the lymph cells of tlie reticulum of die pulp are generalljrl
unaltered.
llic Mtcoitd varifty of amyloid degeneration, general and dilTuse infiU
trutiou of the spleen, is very probably only a more advanced stage of lll«
leMioii which began in the ca{»llunei> of the corpuscles. The spleen is
niiich hvpt-rtrophiod, and npon «eelion i* homogeneous and vitreous ii
a)iiiearHiicc, according to the amount of infiltration. 1» portions where
the lesion is at its acme, large maiuiuji of the spleen are pale, «niei&tc,
and waxy. The circulation, although interfered wîtli, is nCver entirely
interrupted. In very advanced amyloid infillradon there may bo foci w
suppuration.
In three cases of complete amy1(nd infiltration, that ve have recently
«tudicd, all the vcsaels were alteréil in s very high degree, although per-
meable to the blood. The cnpsulo and trabecula; of the organ were
tjiickened ; they were travcrsctl by ji few capilluries, the walls of which
were diseased. The Mulpighïan corpunelcs were «mail and imperfectly
colored red, in such a manner that a uoTie of normal lymph cells was
klways found at the centre of the corpuscle surrounding the artery.
TPMOnS OF THE SPLBE.'«.
593
The veins of tlic pulp wore implicated, th«ir walU wore much thkkened
I by the <U';;eiii.T»tioii, nlthouch tlirir ciililiro rciniiin<.*d normal; & vorjr
distinct iku'l iionniit cn<Iotlii-liiini wn» »<^n in tlioir interior which lattor
oontain«(l Irlmxl cor;>ii«c1eii. Tiic rcticiiliitcd tÎMuu ithicli unîteil the veins
of tlie pulp wttti *omiiii[iioji nnrmal, or in pnrt amytoii]. Tlic lexion, tliera-
fore, Hffecteii alike- tlie fibrillar network, which wiiit rerv thick, ami thu
cells conlAined in itit roeHhe^.
In diiTuited infiltration, the splenic pulp, an<l «specially the walls of tlie
Bmall veins of the pulp. appeared to be tlic ei^cnlial seat of ilie <legenera-
tion. The two varieties are not alvrays distinctly separated, and nothing
varies so much as the intensity and itust of the lesion, according to each
parliuular case.
TrUOUfi OF TIIK Sp1.EB!(.
I
I.Kt'CocvTn.fLMit. — lleiierntly in lencocythiemia an<l lynphadtoitii,
tliL' Hpluen is intilirated with iiumoroiis white hlood corpiHClM, and is
very notahly hypertraphied. Itnt this hypertrophy is never ho great
in splenic leucocythremia. In this form of the disease tlie spleen may
ac-iuire a diameter of twenty-five to thirty centimètres.
The increase in size is due to the hypcnro]>liy of the Malpighian cor-
pnscles, nhich may become as lar;;e h» a haxi-l-niit ur walnut. A iiectiou
of the ur<^n shows numerous ;^my or whitifth ikhIuIcs, sometimes yellow
nt their centre, and yii-lding a juice hy «craping. Tliu nodules, formed
of a homogeneous li»*uc, are ftt'iiaran-d from each other hy red xones,
rrei[Uoiitly s» narrow that they appear to touch at their jieriphery. Th«
celliilitr elements oht^incd by scraping the ^i-ay {loritons are lymph cells,
the majority containing a ^tingle nucleus; some. Iir>wever. are larg«,
measuring .010 mm. to .020 mm., granular, and containing several round
or oval nuclei.
In large and thin sections of these spleens, examined with the micro-
«cofWftbe whitish nodules are found to corresiwnd to thcMslpighian cor.
puscles; while the red xotics which surround them corrcsjxtiid to the tissue
of the pulp. The hypcrti-ophied Malpi^hiiin corpuscles consist of a reticu*
latc^ tissue, with fine meshes filled with lyinph ctdts and krgc proliferating
cells. The arterioles passiu;; throu;;li tiio*e forpuscles have an excessive
infiltration of white corpuscles into their walli<, s» that a transverse cut
of the arterioles shows iheir lumvn »urroundi-d hy » circle of embryonic
tissue. There results a series of t<injill t-iiihryouic nodule» around the
arteriole which travcnes the uew-f»rmed reticutaled ti.tsiie of the cor-
puscles. The meshes of this reticulated tissue are formed of Bbrils,
mostly thickeiH-d. In the central jiortions of the corpuscles, which are
yellow and opaque to the unaided eye, the lymph cells have undergooe
a granular fatty degeneration.
At the periphery of the hypertrophicd corpuscles, in tlie red «one
which separates them from one another, the network of smutl veins ia
seen which characteriEe» the tissue of the |iu!p of the spleen. This por-
tion of the spleen is evidently atropiiiod from the compression exerted
by the Malpighiaii corpuscles. The small veins are slightly enlarged,
3S
694
SPLBXy.
the; contain many lymph cetU, «nd their endotbelium is small. Tbere
are found only a very few )ym[»h cfllla which contaiu brown pignn^nt.
Tt'UKRCLEs. — TiibiTcIr* of ihc flpk'on arc frci{Hi-tilly mt-t with as seconcl-
dry gran 111 all onia in chililrcn. but ibcy iiru very ecldotn sccD in adults.
8on)i'lint0)i numcroiM Isr^c disst^minuCvd niiliary gramilaliona nro found
in ttiu splenic )mr«ncbTinii with ibvir ufuiil charaot^ni soiiM'tinK)* \tiT^«
lUMHCii, the mo of a small pea, an; mot with, fonnod by th« iiniofi o(
several ca#«oiui tubercles. Tubercles of the 8|deen arc never iiHiniirv.
The point of 1>cginning of the miliary gramilationi), according t > Itillroili
and Virchow. \a tlie reticulated connective tisatie of tlie pulp. The bamb
of thin rcliculated tissue separatinii llie veins become tbickeuod, and pre-
eent now elcmeuts; at the same titnc the endothelial cells of tlie veins
show a multiplication of their nuclei. Fœreter, however, has seen iho gran-
ulations develop from the fibrous tissue which forms the trabecule da-
parlin;; from the cnpsulc of the organ ; ho haa also seen them in the
^Ialpighian corpuscles. The iJifliculty of anatomically diagnosing tuber-
culous granulntiont), is on account of their shape and sise. TliDSo. with
the lymph cells which thoy inclose, f;ivv them a rosenibhince to the Mai-
pi^hian corpnscle4. Hut in tubercW the centre bocomea cascou*, and
the cells are infiltrated with fine granules, and atrophied. Again, tlie
small vesseU and cajnllaries which ]<ai8 through the {{granulations are
filled with ;;ramttar fibrin, lymph cells and lar;;e endothelial cell.i, and
they are obliterated, as has been mentioned under tubercles in general.
The elements contained in these obliterated vessels liave been taten in
Gcmiuny for^innt cellsof a special nature, and characteristic of tubercle.
Some tJernian writers, howev(T, are reconsidering this wrong inierpre-
tatio»; yvl, without any reference whatever to the description wo have
given of tbem, or notice of the criticisms upon giant cells by Thaon and
(irancher iu their thesis upon tubercle.
SYrHii.iT!c Ti'Mons. — It haa previously been remarked that the spleen
was hypertrophicd in syphilis, at the period of sypbiltlic Infection. Tliis
tumefaction of the spleen is especially evident in new-bom children suf-
fering with syphilis. The organ may also be indurated and cirrhotic,
with the capsule much thickened, and covered by fibrous formations: or
the spleen luay be in a stat« of amyloid degeneration. Finally, tnie
gummata may be met with, which, however, arc infrecjuont: thoy should
not be coiifouiided with infarct!, which arc also found in syphilitic persona.
Carcinoma op thk Splbks. — It is doubtful if the spleen is ever pri-
marily affected with cnrciiioma. Wc will not pfisitivel/dony it, but tlie
cases reported as jirinuiry cnrriiutma are wonting in liis^lolugical details
Buflicieiit to convince us of their carcinomatous nature. It cannot be
diagnosed by the naked eye or by a microscopic examination of scrapings.
The stroma of carcinoma, and details of the structure of .wcondary fonoa-
tioDS in the glands and other neighboring organs are necessary to sup-
port and demonstrate the anatomical diagnosis. We have never seen
primary carcinoma of the spleen. Secondary carcinoma, on the con-
trary, has Certainly been mot with, following tumors of the stomach,
CT6TB — PARASITES OF TUB BPLEES. 595
mammary gland, liver, brain, etc. These formntions are seen aa nodules
or in6Itrations, which rescmhle the tissue and cellular elements of the
primary tumor.
Cysts. — Mucous cysts of the spleen are extremely infrecjucnt. An-
dral reports a case where there existed several viaicle», which he com-
pared to cysts of the neck of the utema; Leudet saw ii large cyst divided
into four or five compartments by fibrous jartitions lined with a pave-
ment epithelium ; Magilelain reported a case where the internal wall of a
unilocular cyst was smooth and covered with hard patches, formed of
carbonate and phosphate of lime and magnesia. The fluid was estimated
to he about 3 litres, of a yellowiah-brown color, albuminous, and contained
lymph cells, red blood corpuscles, and eryatala of cholcsterin. Fœrster
mentions, in the collection at WBrtzburg, a serous cyat of the spleen,
as large as a hazel-nut, with curtilage -like walla. The mode of develop-
ment of these tumors is not known.
Andral reports having seen a dermoid cytt of tlie spleen, containing
fatty material and hairs.
Parasites. — Single or multiple cysts in the spleen containing echino-
cocci have bece very rarely met with. The hydatid sac may be the
seat of daughter hydatids, as in the liver. They are most frequently
developed in the peritoneum, which covers the organ, and are pedun-
culated, projecting into the peritoneal cavity. They are generally seen
in connection with analogous productions of the liver and peritoneum.
E. Wagner has seen an example of Pentastomum denticulatum, surrounded
by a calcified cyst, in the human spleen.
696
TnVUOID OLAXD.
CHAPTER II.
TKYKOiD GLAND.
Sect I.— Normal Hittologr.
TiiK divroiil jçUni], the ruiictiuD of whicli U unknown, U conntnicted
vcrjr muuii like llie racoDio«c glan<U, except that il [losscssps no excrelorj
duoU. It consinU of c1os<?(l spherical or obton;; ;;lunita1ar vi^siclca, wiûch
join to form roiiml or oblong lobules, si-parattcd by bnmU of connective
tissue, thicker thnn t1io«c Mpar»ting tbo vchicIv!!. T\w lobules grouped
to^t'tl'cr form liir^cr lobi-t «iirraiiii<)«il by n capsule wUicb is oontinnotut
witli the fibrous cnpsitle uf the giniv).
The vesicles hnvcfiilinmolvr of -Olô mm. to ,llil mm., and ooumiitof a
hyitli»e mi'iDhmiie, lined with a layer of finely granular poljgouiil e|<itlii'-
linl cell* measuring .IKH» rara. to .(HH mm. The centre of the cIom>(I
onvity i.'* oouupieil by an alhiiroinoua Rui>l. A colloid sulutanee is M
frequently fourni, iu.'iteaii uf this fluiil, that it may be cont«idered aa a
uonniil coiidilioii. The colloid dejieiie ration of Iho celts in tlie thyrad
glanii ia very easily followed. Between the central colloid aaas of tlic
vesicle nnd its epithelial lining; are seen one or more layers of celU,
which arc round, have lu«t their nucleus, have a vitreous appearance,
and which gradually blctnl nith the muss of colloid substance which
occupies the centr*' of the follicle.
Ttu- bloodvessels of the uland are very numerous, and come fn«n the
thyroid ve:(iicl4. They break up into h rich plexus of capillaries arotuid
the follicles.
Sect. II.— Pathological Histology.
The lésions of the Lhymid ;;l«iid are extrciiiely rare, irith the excep-
tion of goitre or Iiypertiophy of liie thyri>id budy.
GoiTRK. — Hypertrophy, commonly known as [îoitre, con.<tistti in a
bypertrophy and new formation of the glandular auhiitance. The follicles
enow a more abundant formation of epithelial cells than in the normal
state ; they arc enlarged and send off prolongations or lateral buds
which form new follicles (Billroth). The hyjiertrophy of the isolated
follicles, and the new formation of follicles is sometimes uniform through-
out the entire ;;land, or it is limited to a few lobulc«. In the latter case
there results a tumor united to the ;;land, and situated upoa one of it*
sidea, or a tumor which has a tendency to separate from the gUnd. '^t
gland i» froipiently lobulnted by the great hypertrophy of somo oT iU
supcrGcial lobules.
0AItCl:ïOXA OP THft TIITROtD OLA:iD.
*
I
I
■ Imi
Freqneiiclj tlit> v<'«ic)c« <lo not a|)precialjl v <Iifl'er from itie noniutl fltnte ;
altlioti^ tlii'v nrc iitcrriMei) in »i£o, yH itieir lining of opidielial (x\h
and tlivir fluid or colloid contente ift verj similar to that in the phvaiolo-
pciil state.
Tlie disteiir^inn and Iiypertrophy of each of the gliui'lular veatcles
can^a the formation of sannW cvâtd, and ;^rci: a certain softiicM to tliu
hypertropliie'l jçland i*"fl (fUrr). A Bii|tcrficisl oxaniiiintton of these
goitres, by the unaided eye, would lead one to coii«i<ler tlieui a» large
cysts; hut a microscopic examination showt) the pr<r«enco of veviclen,
somenhat enlarged, the partitions of which are distinct. The formation
of the cells and of the fluid or colloid siilxtance continuing, the thyroid
body is tnui<ifornicd into a nmkitiidc »f largo cyst^ and Uic entire ^anA
beeonie» very voluminous (fi/êlic •jnUrt).
In many other cjikch, t)ic capitlnry vCMelii and small arteries are
dilated ; the large arteries a1»o un<Ii'r;ro a change analogous to that seen
in cirsoid nneurinm.-!, giving ri^v to a puliation in the tumor ; the capil-
larie.i project iiilo the cavity of the follicles, and betnorrhagea occur
therein; ihene are ternie<l iinfurinmitl <ioltrta. The veaeela arc some-
times incriiji(e<l in j>lacea with calcareous salts.
At other lime-i, the connective tissue of the gland Is very evidently
thickened and the gland is mostly formed of fibrous tissue, nhich prciiite^
upon the follicles and finally takes their place; this ts termed a fihrntiM
ffoitr*-. In old persons the fibrous goitre gradually hccumej» hnnler in
COf»e<|ueiwc of the calcification of the connective tissue. This calciS-
cation u limited or it inrailen the entire titutor [calajinl i/vntre).
TUBKitci.KS'. — Tuhorcles of the tliyroid gland have been described in
Part I. The development of the m-n- fonuatiwi from the epithelial
cells and connective ti^^ue of the gland has been pointed out. These
tubercles are of very unfrei[ucnt occurrence, and do not diSbr Ifota
tubercles of other organ.i.
Caroixoma. — Secondary carcinomata of the thyroid boily ai-c seldom
met with, and we know of no histological description. I'rimary tumom,
dewribcd as encephaloid cancer, are also very unfreiguent. Tlicy arc
large, and by their invasion of the neighboring connective tissue, they
liavc a tendency to project into the cavity of iho trachea and eesi>ph!igus,
mug ri*e to tiie same symptoms as a cancerous tumor of these cavities.
"leir hirtiological description has not been given. The foth>wing ease
Been by us. lead*, to the belief that the primary tumors of the thyroid
gland are epitbelioinata ami not carcinomata.
A patient, in whom an 0|>itl]elioma of the (esophagus had been diagnosed
during life, presented at the aulo^Mty soft granulations infiltrated with a
milky juice, arising in the connective tissue of the neck, and projecting
under the mucous membrane of the (esophagus, which over their surface
was raised and thin. The connective tis!^uc. inRltratcd with large cells,
having large nuclei and brilliant nucleoli, resembled the tissue of an encc-
phnloid carcinoma, except that there were no regular alveoli of new forma-
tion, it being simply an infiltration of the pre-cxitting ti»s\K by large cell».
The thyroid body presented a similar alt^ralion of it» tissue which was
infiltrated with a milky juice aud cootaiiicd the same large cells.
598
THYROID OLAND.
An examinntinii of a MoUmi, nftor lisr'Ieiiin;^. fltiowed tliat tUe ilogeiH'
nle<l porliuna of the thyrotil bod;,- hail the same j^onernl arrangement ss
the nornuil pnns, an<l tliat the nen foruiatiou consisted of a iruiafomft-
tioii, iH »itM, of tlie epitlielial c«lU of the follicles into lar^e distinct
colls provided iritli Ur^e nuclei and nucleoli. In most of the clian^vil
folticli'^e the cells were arranged in a single layer; they were im[ilKntcil
initni.-,li.iti'ly tipOD the ccllulo-vascuUr tissue which surrounds tlic folli-
I cl*Wf and their nuclei were oval in shape. In some of the follic!«H tb«
cells forincd several lajcre, nm) there niis a de8i|nanui^on of the larg«
G«)ls into the cavity of the follicle. The wall of the follicles frequently
)iiid one or more fine cellnlo-viMcnhir ve;;i' union» projcctin)^ into their
cavity and <'nvore4l hy a Inyer of cell* similar to tho*o above dedcrihed.
The vegetations c»iiCAim-d omhryonio cells, w did the [>eri-folltculnr ccn-
necllve ti^ttie. Thi^ întiliriiiion wua not very uhnndanl, and the interful- ,
licular parUims were not tiiickened. At the hotuidary of tlie iinplant^^^f
tion of the ej)ilh('Hal eelU npon the collntar lii^ue a krer of llatteneo^H
Cells with flat nuclei were seen, which in tliin aectioiis had the appearance
of fnsifonn celU.
The change from the normal follicles to those most altered «us easily
I followed. The celt!» in tiic normal follicles were hypt-rtniphird. the col-
' loid sulwtnncv conuiined in the cavity of the follicle grA<luiUlv diinimtliei)
and liiiaily hecame ahsoihed. nhen the epithelial cells had beeoine very
large and wen.- tletached from the wall and set free in (hf cavity. TIiom
altered follicles formed islands, in which the degenvralion wm visible lo
the unaided eye; hut even in those islands which were moM disewwd,
almost normal follicles could he found which Mill contained the eolloid
■ substance, and in wliich the celU «ere .«li^^htly liyfiertrophied. The
[ eeptum of celluto-fihrous tiȉiie separating two alveoli iVeH|ueiuIy had upon
[ one side a row of normal or almost normal cells, and opoo the other side
a row of large cells.
This mode of development of the tumor is allied to carcinoma of the
lung, in so far as concerns its origin from the pre-exisling epithelial eells
i» the normal cavities of the org/m. The vegi-lHlion* which projwi inio
the interior of the follicles, and ;vhicb are covered with m-w celU, are
analogous to those ohsenc'l lu the galactophorou* duct« included in
tumors of Uie nuimmary gland.
In re^tartl to the nnture of the tumor, we consider it an epithelionia,
in which the hypertrophted p re-ex idling and ahundant cells are cylinilri-
cal when in place, hut irregularly polyhedral or round when free. As
the neoplasm of the connective tiii.^ue does not form inbes lined with
cylindrical cells, hut consistai simply in an inliltraUon of large cells be-
tween the connective- tisdue fibres, it cannot be considered a cyliudrical-
oolled epithelioma. On the other hand, it is difficult to class th» tumor
as n carcinoma, since the new formation of connt-citvo tiasue does not
have the regular appearance of the stroma of carcinoma. It la a variety
of epithelioma intermediate between the ty]ies which we have oscd
establish the elassilication of tumors. It is well known iJtat
LMOlated cases of tumors cannot be placed under the dcjuriplion of a
^definite type; they establish the connecting tiiika between one variety
and another.
or T&B BUPBA-RBXAL
Les. 599
CHAPTER III.
SUPRA-RKXAL CAPSULES.
8Mt. I.— Normal Histology.
TliESR <jr;;an» nre «liieii lo tin- ;iL«cii)nr IjWiI gUoils which have iw
' excretory liucts; their function ia eiitirrly unltiiown. They consist of «
fibroii» cnvolopc coiitintious vfitU llie
•^c- S"*!- fibrtiii» ntroiim of the gtniul, iiiiii of a
corti<.-nl tiiid i:ie>Iiillarv.'*uKttaiic«. The
cortical iiul>HtanL'<: in man in iitiually
yellow anil opaijue, dueta the ]>resenco
of fat in the cells; it io composed of
cylindcra running from llie perijJicry
townnis the centre, and formed of
cylindrical or polygonal cells. TliCite
Fig. 3CS.
V«rllr«l «ulun if luiin-'ninl npioUat
*■*. VDlnmntr Uyar. d. L>rai "t lawru»!
«•tl nia<*v4. «. )l*lill»7 nulHlaii*, /, Mus-
uilïTit'EfliiU l><i<lr jhiiiiiitiii, it^ FrmiitHwarb ol oott'
cortical cylindcrH liave no hiiwinent
membrane, and are limited only )>y the
connective li.tsue which fonnu the stro-
ma of the jflancl. At the intcmnl
boundary of the cortical ftuh-itanee, the
cells are larj;e and filieil with fatty
granules, jçiring hero a more marked yellow color, which extends to the
whole cortical substance when the celts are inHltrated with fat.
600
SUFRA-nSXAL OAPSDLBa.
The tDP<!ii11arv substance abo potMSMS a connective tinsuo str
composed of ihiu fasciculi whicli forin a netirork of round and narroi
mcaiioe). In tbU network ir found a tioc granular eubatunce <rith |m
an^odar or branching celU, provided with a nucleus and aucltolus eonie-"'
vfliiit rescmblinx nen'e cells, from which however they ought to b« >it«-
criniinntcd. Bclwoeii the cortical and medullary sutistADcv, (.■ailareric
di>C'>iti|ii>sition fn>i)Ui.-ntly cau^ies n softcnin;;, thu»' separating the two i^ub-
»lai)cvi< hy a brotrtii»!) Hiiiil containing bloud and lsr<^e cvll^ filled with fU.
The numci'ous libxnlvt^'dHeU dt-rivcd from the ptin:nie,cii.-liac,*nr) reoal
arteric4, at first form a plfxiin n[ion the capsule, then |)(m4>lrat« titto tite
Riedullar)- ttulMlance, and form ciipillarir plcxuites in the luetliillanr and
esiieeially in the cortical suhflaiiccti wh«T« they surround the cortical
.cylinders. The rein« follow the same coiirtte. The lyinphatict have not
.'M yet been aufficienlly studied. Tbp nerves, very important oh aecottnt
of their number ami the size of their tnmks. come from the semilunar
};an;;lion and renal ptexua, Tiiey arc accom|)«nied by nerve ;iau;d>a
eoDsistin;; of bipolar and multipolar c«lls which are found in the nwdul-
lary eubetauce.
Sect IL~Patholoff J of the Supra-Renal Captulot.
Hypk)i.r«u asp HRUoRRiu'iic. — Canffftthn» of the supra-rcnnl cnp-
8uIm frcipientlv occur in newly-born cbildren and in early life, hut are
met with in tlie ndnll nnlyin chn>ni«' di^ieiuv^ of the heart, «itii ootuidor-
able hindrance of the venous circulation.
Htm-irrha'jf» of the suprarenal capsule are not very frequent; they
occur always in the meduUarv sub-tiance, vrbicli is softer tlian tiie cortical
eubslanco. The escaped blood collects in foci in this portion of the ^liutd
and may he considerable in amount. In a case reported by Bayer occur-
ring in an oM woman, thv capsule was tninsfonneil into a sac fiUvd with
a brownish lluid weighing two kilojiramnics. Several other caseti of %
similar character have been reportt'd. Imt generally the hetuorrliajfeK are
not larger than a pt>aorba»id-imt. The--«c colb-ciion* of blood may. nhen
the latter is absorbed, develop into a eyst containing a serous fluid vary-
ing in color. There arc no special symptoms which may be referred to
this leeion.
Tiiromumts. — Klcbs reports a case of thrombosis of the cortical sub-
Stance of the suprn-rciuil capsule in a case of pytcmia occurring in %
woman in conMipiencc of a resection of a bouc. The cortical 6\ibslanrc
presented ^wtU of « brownish. y «dlow color, in which the capillaries wt-re
obiktrut:t«d by libnnous coagidalionit. The epithelial cells of tlic cylin-
ders were completely fatty degenerated.
Fatty and Amyloib IsriLTRAXtux.— The infiltration of the epitlielt:
cells of the cortical substance by small drops of fat is itonnal in
therefore it is difficult to appreciate a patholoj;ical infiltration,
amyloid infiltration does not often occur, it involves only the vessels >
the medullary substance and not the epithelial cells. It kaa been ob>
TOMOKS OP Tlie SrpBA-BBSAI. CAPSITLBB.
COl
Hrvei] onl^ in connection villi similar lesions of ttic fljtleen, kidney, «ml
liver.
IxFtAMMATios OK TUB Supka-Rksal Capsi'LR. — Purulent inflamnm-
lion of tl» 8U|>n-n-na1 capaulea very aeldom «cciifs. The suppuration
nmy involve the entiro organ, the cellular clcinenw participating in the
inBstnmation, or it may be circuni^crilicd. Thv vueoti^ metmyorpliOtfis
wliiirli rcitultfi from tliin proct-if.* ham hcvn tiik«n for tw hero nil joiI ion, Tlic
nhuixlitiit in-w fi^rniiition of coiini;ctiv« li<<ue, tnio cirrhoai* or fornmtivo
KiilKicutii ■>r clinimc intlamnuition of the glitnd, oucunt more friM{uently
Ui*u suppuration.
tvHiyns.—Surrtma lia^i hoen met with in ehililren as a primary tumor.
Ogle, citeil hy Klehn. hn* <)eiicnlie<l a cano of «arcoina a» a whitish inasa
in both <iii|im- renal capiiiiteii. I'rimary melanotic flarcoina lias been seen
by Ktiiisinaiil, The tumor was as large aa an Biliilt heml, metaatatio
nodulus followc'I, and death resulted from an embolus in tho pulmonary
art«ry.
Oartrinoma \s primarv or secondary. Tl>c-se tumors {generally hare the
clinrHctvreofencophaloid, and may be very viwuular. The primary car-
vimimata are very rare. The proximity of llw kidney to the «upra-renal
glaml prediipoees it to the iwvanion hy a cancer nhich hat it* origin in
Uie kidney; a cancer of the rectum may alsii «extend to the ^laud.
Klelw reporta a eaac of epilhAioma, which iuvadt^d, at the oame lime,
the thyroid body and supra-renal cnfMiile, very prnhably be>;innin;; in
the thyroid body. The cell nesta of the new formation in the capsule
I had, ni their cenirca. HtratiFied calcareous concretions.
An example of syphilitic ijummn of this or^nn lias been re|)ortrd hy
jBnreiisprnn;;. It coii*i4te<i of patches of connective tii»-*\ie with cmbry-
Otàe cells, the centR'S of which were in a itlatc of case^'UD dcsencration.
Tlie*c fntches were seated in the nicdnllury jiuh^tance, which wa* but
slightly modiGed, The surface of the •:lan<l wa« .smooth and lobuialed,
the consistence Ann, and the thickened oafiHule wa.« adheroni, not only
to the cortical substance of the or^çan. but also to the surroundiu'; par».
A flection of a Klan(i very much altered, present» no trace of its nor-
mal structure. There cxiaiA in îta place a firm and hard ti«suo, in the
midst of which are Men caaeoua massea varying in sixc. The cortex is
frequently transformed into a firm semi- transparent grayish tissue, while
the central portion is yellow and opa^pte. Sometimes the caseous por-
tions arc distributed irregularly through the entire gland.
Microscopic examination of the gray and senii-tmiMpari-nt portion.i
fkows Oidy a connective tissue infillniU-d with round lymph cell*. The
fibrous stroma also contains connective ti-i^iie cellit. Tho yellow and
caseous parts show atrojihied lymph celU lilted with tine albuminous and
fatty j^rantdes ; no trace of tho j(land elements can be found.
'ilie further metamorphoae.i of gland so changed are various : some-
times the caaeoua («ortion i* softened into a pulpy detritus ; sometimes
the softened focus farms a cyst containing cn^eous pulp, or a âuiil which,
to the unaided eye, resembles pua ; at other times calcareous points arc
602
8UPBA-RBSAL CAPSDLBS.
found. T\\c a1)»orption of th« Hui<t paru am) Uie calcification eoiDcidr
with tlic fonniition of (lenx« fibreii arouml Oie csIciGcd |)art<t.
Aawcinted uicli chronic i nil a m mal ion termina ting;; in Ûi« caKemta state,
and whidi in manv poinis resembleH luberculUaiion, tiiere are also seeo
acute and subacute inHamniatioDS terminating in fot^i of suppuration. These
ahsceHses sLouM not be i-onfounded with caseoiia aollânîng ; the; contain
}>Qa characlemeit by numerous aiid free Ijrmiih cells,
TuBKRCllLOMfl, CitROKtO Ilin.AllMATtO:!, AR» CAgEOrS I>E<I E.t Kit A-
Tios {v\m'iWN's DtPEAiiR"). — Vi'v dnM to^rtlicr tubercle of the gland
Bitd chronic interstitial iiiflnn)mAti<ii)!< wliicb «'TTuinatr in cimous dc^ne-
ra^on, becnu»e these lesions prei>ent, aiuon){ other ^ncral and im|>ortani
points, a Ajmptuin nhicb accoin)iiinies the anatomical lesion moft fre-
ciuent in Addison's ilisea»e — pig mentation of ihe »kin.
7'iifvrftet — either as miliary jirranulationt), nr as collrctiotia of fçntnw^H
Ititioiis the size of a hemp seed or a small pea, and comptclel^ caiieoii»—
are ijot uiifrc<|uent. Tlicy are eons«cmiv'e to » ptdmonarv or other
tuberculosis, uud occur in one or both eiipra-renal cajieiili's. the miliarj
crannlatioiis, whelher in the cortical siiWance beneath the ca|8ute, or
disseminated through the ;:land, do not difTiT from (hose fonnd in other
organs. They f-cncrnlly liegin in tlic cortical substance, becoming larger
by uniting together; their centre bec'imi>« caseous : they may invado
the mcdiillnry stil»tiince; tbey are surrounded by un embryonic tissue.
When large massesi exi»l, the entire slan'l may be trnnsformvd into a yel-
low caseous tissue, at times softened and pulpy ; or, while the centre S)
yellow and sofi, the periphery may be hard, Bbroiu, and gray. In this
complete transformation of the gland there remains no trace of the normal
atrueture. Tliis condillon is treijueiiily found at autopuea of patients
who died having the bronxc color ilcecribed by Addiaon.
Tbo lesion most frequently observed at autopsies of Additon^t ditrate
consists in A jUira-tyietvut mrtttmurphngin of tho glftnd, or a chronic inter.
Btitial inflammation, characlerizHl by the new formation of conticctirc
[is»ue, the central part of «hieh is in a state of cnsci>u« degeneration.
It i* liifficuit, from the eases, to say whether we Imve to do with a
tuberculous legion or not. By their ap{>^iirancv ami degcnenilion, the
ghnds âo changed are similar to serofulotis tympbatic glandit; but duubt«
still exist concerning the nature of iho dtseaac.
In this stale the gland is increased in sixe ; it may reach twelve
centimetres in its greatest diameter: its shape ia oral. The Bofteoed
portion mny be transformed into a serous cvsl.
Tuhen-ulosiiÇ, and chrmiic in flu m ma lion »icb eaopous degeneration, a
lesion closely allicil t» tlm former, con«titu(e the greai majority of affections
of the supnin'iiiil uHjisuhrH iissocmted with jVddison's disease. The two
ca)>6u1cs are usually affected in a diflei-ent degn^c ; sometimes one ia found
normnl.
We will not attempt to explain why tlie lei>i»n of the capenle« produces
the chnraoteriatic symptoms of Addition'* di«east% that is. tbo pigmniU
ktion of tlie rct« mucoaum of the akin umI mueou» membranes, the
TUBERCLES OF TBE 8DFRA-RE1TAL CAPSULES. 603
anœmia aocl the digeative disturbances. The physiological explanations
vhich have been given are far from satisfactory. The leaiona of the
nerve centres of the supra-renal capsule and of the great sympathetic
probably in part account for the phenomenon of pigmentation. It is
also to be remembered that, very frequently, leaiona of the capaulc are
found, 9uch aa cancer, tuberculoais, and even a caaeous inflammatory
state to an advanced degree, without the skin being pigmented. Accord-
ing to Klebs, in 141 casea of lesiona of the supra-renal capsule, the skin
was colored in 100, and in the remaining 41 no coloration was present.
But, on the other hand, Addison's disease — when it has been care-
fully distinguished from the melanccmia of intermittent fevers, and from
the cachexias with cutaneous pigmentation of tubercle and cancer — is
associated almost invariably with a very decided lesion of the aupra-
renal capsule.
The changes in the other organs, observed in Addison's disease, are
very varied and multiple ; but pulmonary tuberculosis and scrofula are
most frcijuently met with.
SECTION rv.
GKNI'rO-UKIXARY APPARATUS.
niDld ut F(TT>lii. n, B. K*r(fn ut
ncJiilliirr*n)u(u(t. C. C. C. Lovi»
ol N>Bl>. I>, », I). «iniifhi inhiv
Inlffa, f. T#rwlti« tien itf •tntfbl
tntw. (Orag,)
CHAPTER I.
THE KIDNEYS.
Honual Uittology ftf the Kidoey.
TiiK kîilncv, the fuiictioii of wliicli in tke
secretion of urine, haii for excretory raauges
' and receptacles tjie pelvia, ureter, blad<ler,
and urutlira, Wlicn iw (itirous enveloi* is
removed, tlie surface appears tnaminillatei] in
the child, but in the adult it is emouih. A
section made in tlio l»ng diutiietcr uf tli«
orf;an «liontt it to consist of two subsUinci-s
differing in sliape and color: the cortical and
medullnry. The latter, also termed tuhtdar,
forms llie pyramida of Malpijilii. The eorli.
cal suhatauce is gray or grayish-pink, trans-
lucent, and in greater amount ttian llie
medullary substance. In it are seen the
Malpighian tuft» as small bright points.
The pyramids orcones of Mtilpighi are red-
der, and terminate in a lonnt at their free cx-
tri>uiity."hereiheyareeovi,'re(i bythcnmc<Hi8
membrane '>f the cnlyce.t. Kroni the apie
of ilies>; conea the itrine (!ow<i into the pelvi*.'
An examination of a kidney in which tlie
bloodvetiseU are injected red and the uri-
niforcua tubules blue, shows to ibe un-
aided eye that the cortical substance is
colored by the red injection. The Malpi
hian bodies are seen as small red points in
this part. Tiie uriniferous tubules fitlfl
with the blue injection radiate from the
apex of the Malpij;hiKn cone« in the pyrv
mids. afVrward.-t paHS into the eortic»] sub-
stance and constitute Iho iiifrnmi'tt nf ftr-
rein or medullarg ray». 'Jlicir course is u
follows. (Fig. 308.)
J
XORMAL HISTOLOOY OP TUK KrDXKVS.
60S
Tliey have their origin in iho cortical guhatanee around a ?ktalpif;)iian
glomerulus, the eapaule of wliicli is tlirecil^ contiimou§ with the inem-
^rane of the tubule. The Miilpi<:;hian jjloinemle^, as nill be soon seen,
eonitist oiil; of u tuft of «mull vesiivU arising dircctlv from t)io intortubti-
lar ftrtoriofl of tliv kidneVi nnil are vutîrcly surrounded hj a c«p«nlar
momlirano. Opposite thv entrance of the itrlenole into the i'a])«ulo,
there iâ jtecn a narrow oriâce by which it coinmnnicale^ with the uri-
niferou» tubule. At ita origin, the urinifurou7> tuhuk- U irinding and
larjçe (convoluted tuhulea of the cortical subslAuce). After forming a
number of tortnoaitie», it narrows, lakes a reciilinear course, and is
directed towards the substance of the pyramids (dettcendin^ limb); sAer
Ïrocccding in this direction for some distance it forms a loop (loop of
lenie), the convexity of which i« turned to the apex of the pyramids;
. it now ascends (asceudin^; limb), following a directioo parallel to that of
Fig. 304.
Pig. 300.
I
'dc^cendin;; portion, enters again into the conical substance, a;^in
dilutes, becomes convoluted, and is aj^ain contracted before pacing into a
«traight tubule. This latter (collecting tubule ), the direction of which
a rectilinear, (ind which at first run» in the cortical substance, then in
Uie medullury tuibstaiioe, receive» by the way sevcnil iscihtcil or united
tubuleA; the»e branche* become gradually iiior^ numeniu^ na the apex
of the \falpighian pyramid tit approached. The eolteetinj; tube finally
opens at the renal papilla into the pelvis; the opening is large enough
to be seen with the unaided eye.
The diameter and structure of the tubule vary in the different parta
of iu course from the glomendufl to its termination iu the renal papilla.
The glomerulus measures from .IS mm. to .2mni..its shape is spherical;
the convoluted tubules of the cortical substance measure from .(MO nun.
lo .DUO mm. ; in the loops of llcnlc the tubules are not more than .Olii
mm. to .02(1 mm.; most of the straight tubules measure ouW -OSO ram.
KID5EVS.
to .0-10 mm.; by tUfir union at the t«nnînal extrcniH; of tlie collcctinj;
tubule Uiev Kc<|uire a diameter of .1^0 mro. to .'2Wi mm.
Tbe capsule of llie glomerului* U x thtu hyaline membrane which is
easilr wnnkled by ihe action of water ant) (iilutcd acids. It in liitetl
upon tliP intirnal surface by a layer of liai pavement cell» which are
directly continuous with the cellular lining of (lie convoluted tubules.
Fig. 306.
T^«ll»«^fl" trelloB of iiJTaiiililiir .[il..!-!"'- Il 1 1 11 H'/ Ml I'll, III. 1 i.r...!' .1 «Mflk •" 1k)r^«4^
€ulaciu*a, ItDfid VIUl <|ikllf<llumuf BboFlor r/Uaiit'a. « tbd il, Rvut^'a I«vp4 pbI ««Na*^ t. frlw^^
thmU tui atmu. Z>. CaoatMi» lltiucitnniBil tubtuoro. lUgti lonr. Idrag.)
The convoluted tubulca, the loops of Hcnle. and the slraigbl tube»
alao poHsess a hyaline membrane which may be wrinkled like that of
the glomeruli, and wlildi, ncconling to Ludwig. po»s«S8es nuclei placed
at inlenals. In thy lurp- colleciinij; tubes of the mrilullary substance
I.udvrig says this scpnnit« mcmbrunc does not exist, but is blended with
the neif'hboring connective ti*»uo.
The cpithelini linin;; of the tubule» is modified according to the differ-
rnt pointa of tlicir coume. In the convoluted tubnlc» the pavement ccUc
Approximate the fonn of a cube, huving around their oval nucleus a
clouded and granular nia.i« of proioplanm. The aeparalioiM Itetween
tliese cells are acarceiy visible. The celU show, e.«]ieeiaily where tliey
are implanted upon tlie hyaline membrane, 6ne ^triationf^ [icr|iciwiiaiiar
to the hvalinc membrane which have been considered as small minnlc
canaliciili. These special cells, the description of which has been given
by llcidenhain, have, accordiiiR to this author, the function of elaborating
and separutinf; from the blood tho solid substances which enter into the
composition of the urine. By their striotimi they very much re«cmhle
the ceil* in the excretory ducts of the salivary glands. They do not
present any distinct enveloping membraiw. Tiieir protoplasm, which cos-
tains very line albumiooufl gmnulcs, becomes more clouded when acted
upon by water. The cells are regulariy arra»j;ed witliin the hyaline
membrane, so aa to leave a central lumen, through which the urine tlowt.
They adhere one to the other more than to the membrane of the tubule,
DO that in preparadona from a fresh kidney they are oft«o seen as oyliD-
NORMAL. rnSTOLOOy or tub RID.VErS.
6«7
I
A«n iinving t)ic form of th« tuhulea. Th« liyaline membrane of tlio
tiiliulv' tA then aecn foUled and adherent to the renal tUsuc. In tlie loojjs
of Heiile the eptthclhiin hecoinîs tbtn, flat; the [»rotoplat>m is much rc-
ducml, and the nuclei of the cell» project into (he lumen of the tubules.
In the convohited tubule connectiu;; the loops of Itcnle witli the
struight tubulos, thi: cpithctium n'^in becomes ^wnllcn iin<l «rnnular: the
vpillieliiiin haa the same cbaniutcr in the stniii^ht tubnlos. In the col-
k'cliiii; tube* the pavement and cubical cell* gniluul! v become very Ion-»
find cylindrical ; tWy are impt»nted (HTpendicularly upon tlie wnll ; lln'ir
larf;e bgMc it nttaohed to the membmne, itliile their free thin extremity
projets ii[)on the lumen of tlie Inbe ; their largest diftmeter 13 '>.02 mm.
Ac the Htnnii jiapilla' they are directly continuous with the cells of the
miioous membrane of the calyces and ]ieh'is.
Such is the course of 11 uriniferous tubnte. The relations between
the cortical and medullary anbslance of the kidney may now be consid-
ered. The collectînî; tubules eniptyin;; at tlie papilla ascend and divide
as far aa the cortical subittance. where thoy send off the straij^ht tubules
known by the name of WfihiUnrt/ rat/» (pymtnidH of Ferrcin), which re-
ceive ihe convoluted tubules emunntiii^ fmm the glomeralu», aft«r thc*c
tubules hnvi' formed in the medullary substance the loopH nf llvnle.
Gaoh medullary ray i» composed of Alrai;;))! tubules emanating from the
collectiu;; tubnli.-'t nixl the atoeodin;; ami descending bninche^ of Ifenli-'s
loop. The oonvotuted tubidc^ and the glomeruli in continuity with tlie
siraight tubules of the cortical substance, form in this <iubstanee as miny
secondary pyramids as there arc medullary rays. the base of these pyramid*
bein^ turned towar»!î the periphery of the kidney.
The bloodics.tels present » special distrihutinn. The rctinl artery
enter» at the hilui, and there divides; itJt division» run between the
pyruinids, and give off branches at tlie boundary between the cortical
substance and the pyramid», at the ba«c of the latter. The intertubnlar
arteriKit ari^c at this point, pass directly into the cortical substance per-
pendicular to the surface of the kidney, in their course i;ivin;( olf at inter-
val* arterioles wiiieh enter into the Mal)>i;^hian tufts. The afferent
vessel of the glomerulus divides into a number of secondary branches,
each presenting fi'ee loo|)i upon the surface of the glomerulus. The vea.
acts proceeding from these subdivisions are united into a sîntflo trunk
(oSeretit vessel), which passes out of the glomerulus alon^de of Ihe
«Seront vessel.
In the ijlomernlu* the small vessels possess a membrane containing
iiuck'i like the capillaries. These vessels arc covered npnn their cxt«r-
nid surface by Hut cclN, so that the cavity of the glomerulus is a closed
cavity lined thrf"i;;houl with cells.
The efferent vessel, after pas*inj:oiit oP the glomerulus, is separated
into capillaries, which w* a fine network surround the glomeruli and
uriniferous tubules. In the same re[:ion that the inlertubular arteries
are given off to the cortical substance at the base of the pyramids,
the renal arteries glie off other very small arterioles, wliieh pursue
an opposite course, and descend into the pyramiils. These arteries are
Straight, haviug loops with the convexity turned towards the papilla of
KIUNBYS.
the pTrumids, and ecpnrating into captUarÎM wbieh ieooni|Mny llii»
Stmi;;lit tubiilva nnd collectin;^ tuhra.
Till- h\i}>n\ of ihu capillar^' vpssoU nearest to tlie surface of thf kidiK-y
U eoUoctcil liT vt-noiw trunks, vr liicli come from th« nurfnce of ib« kiilnojr,
wlii-rc iKe^v fwrni tin' aU-Uiiuid veins (sbirs of Vi-rhcyrii); lh«K« tiHiliit};
fonii nu iiiti^miViuInr tniiik, wtiich iIcsvcikU îiilo lliQ «ortioitl sulwiUnce
{iiirHllcl irith the 'mtATtiitniliir nrtvriiM. Tlio intt-rtitlmlAr vi-ii)!i receive Uie
M(io>l from nil the ciiiiillnrii-^ nf th« cortical !<iil)i4titnc«, y\vi em|itv iuto
lar;^c vein» âitiiali-il at tlii- Winitnry of iIil* mvdiillarv :iiid cortk-nl sa\>-
stance. Tlie veitw nrHin;; "tn tlio •iiilMiance «f the pyramids have a course
parnllcl to that of the Hlrni;;lit arleriea, and also form loop* with the con-
Texity towards the pagiilla. The veins of lb© medullary eiibstiincv ar*
always more dcvulopcd, and ({enerallv more tiu';^d. tliaii the artoriue of
this portion of the kidney : nt nutopsii-» the pyramids alniosl always w
found of u drep red, even trhen the cortical substitiicc ii^ pale.
Till' n)0.*t imjitirtmit part of the cirC'dnlion of tlic Mood in ilie kidney
is till? ;;lnmvndii» ; it i» here that llit pren<tin; of the Mooii in the biflheft
(I.udwifi). and that the );TeateMI amount of tluid ntalerial from the lii|Uor
jtiitj)tHiui'* lusses from the intcri'ir of tlie ve.ivicU into the uriniferons
Uihule». It is in the cortical Kul^lance tlial the convolutions of the
tiiliutes are more marked, and con!ie<|uentlv the urine remains a longer
unie in this region; here alone the ;;Kimeruli are located: in tli<r
tnbules of tliis substance are elnboraleil the materials which are swept
away by the current of Buid coming from the glomcrulns. Thus is ex-
plained the pbyHioloi^ictil function of tbc kidney: it i» almost always
affected by patboiopcid modificationc of the orj^an, which in the cortkal
suliiitance acc{mre tbeSr ^reaieiit intenitity mid Treipiency. Althmigli it
is simply a structure for the |>aiiita;u;e of the urine, ibe roeduHary sul»-
stance participates in the fituelions and paibology of the excretory mWs
with which it is immediately continuous.
The t_^mf'luitie canal» of the kidney are readily injected and demon-
strated in the fibrons capsule and bilus. An injection made (breugli
these canals penetrates into the entire orjian, even into the gmiimc-
tivc tissue surrounding the uriniferous tubules. In tiie kidney, as in
connective tis:>iie in ^-neral. it is difficult to separate the study of the
lymphatic xy^itein from that of the connective tissue. Ilie connective
tissue of the kidney is unei|ita1ly distributed; llie fibrous eaf^utule in
formed of fasciculi uf iiiterlacin<; fibres, and »eiids fibrous probxij^tioii»,
which accom)i»ny the vessels of t)ie cupi>ute into the cortical sulistauce of
the organ. The capillary vessel» of the connective tis;<ue olTer little re-
sistance to ibe iieparaiion of the capsule from the kidney. At the
apex of the Maipi>;hian pyramids the eonuective tisane is quite ihick,
and easily de nionxt rated ; here the wall of the collecting tubules is
foiroed by this tissue, not having any iiiter])Ofled membrane between it
and the lininn cpitlieliuni. Surrounding the glomeruli, there is also a
very distinct layer oi' connec6vc tissue. Throughout the remaimng por-
tion of the orj;an ibe sti'ucture supporting the vessels and surrounding
the uriniferouK tubules is very delicate, and is blended with the vessels.
The connective tissue i» the kidney is, as everywhere elw, ]>cruMnt'''t by
spacea containing 8nt cells, and commuiûcatîng with the lyiuj^mtic vessels.
(lENERAL PATUOLUUY OP TUE KIDXEY. 609
The pelvis, calyces, and iiretur. oxcreWrr canals of the urine, are lined
bv a niueouf) membrane without ;;laiiiU. Thcliniii;; ct>itliclium ts fomied
of several layers, [lie most siipcrlieial of whicb is pavi^-oieiit, the middle
I cylindrical, ati<I the deepest tonneil of Hat cells. The pelri* and ureter
;ftro fumislicd with muscular nml tibrous layer*.
Sect. II.— General Pathology of the Kidney.
Tlie moat essential lesions of the kiiiu'y and the moat extensive are
thnte which nccur i» the tubulea, and particularly in their epithelial
cells.
Altérations of tub Kpitiibuai Cblls. — Lesions of the epithelial
i cells of the uriniferoos tubules vary aocordin- to the repon under con-
fiideralion. The jrT&iiiilar and striated pavement celU of the convoluted
tuhuk'A of the cortic.i] substance are those which are most fret(Uviitly
aflecwd. They, and the renal connective ti*»ue nW, nre swollen and
eaturatvd with urinary (liiid, when the hitter is retained in the kidney, in
consi->iuence of an obstacle situated at some [loint altm;^ iho course of
the nrinnry pasitase«. They become larger, more spherical, swollen,
and j;ramil«r (clouded swellinji), in renal conge*lion, in the first stage
of Bright'.* dÎHoa.te, and in every minaient albuminnu^ nephriti.-'. If
the elemenU are now examined in water, their nuclei are concealed by
the lino ;;ranuloâ. Ily the Addition of acetic acid, the albuminous j;ninuleii
disappear or clear up. and the nucleus of the cell appears: at tinips two
nuclei are present, and there frequently remain small fatty gr.inidcs in the
C4'll. Fatty !;ninules in the renal cells do not exist in the norniiil state
either in tlie child or adult, nUhon';h they aro found physioloipciilly in
great numbers in si>me animals, us the d»^. Kre<)ueiiily in ol 1 jMrreons
fatty ^unules are fimiid in some parts of the ui-iiiifi-rouit tubuK-» of tliv
eonical substance without any n^naldinease hiivin^ exiiied. Willi thcto
exceptionti the pre.*ence «f fatty jtranules is patlioiopcal. Fre<(uenlly,
eiipecially when these granules exist with the c1oii<ly swelling and albu-
minouii infiltration of the cells, there is present one of the forma of a
catarrhal or albuminous nephritis, of varyin;;; intensity, which invoices
the escape of albumen into the urine. In certain poiaonings (photi|>honiB,
tutpliuric acid, arsenic, icterus, etc. ). and in some cuchexias (pulmonary
» phthisis, etc.). the ceils of the kidney may 1>c loaded with granules and
fat drops without any alhumeu having been present îii the urine.
Theae albuminous and fntty granular renal cell* may be seen in nil
parta of the kidney, but it is in the large and convoluted tubules of the
cortical substance that they are generally found. 'Wi* lesion also affects
Ilcide'? lo"p. Ill the stndght tubules of the in«dti!!.iry rays and in the
collecting tubn!i;<, thu liniu;; epithelial cell* are le*.* frcpiently the seat
of a fatty granular change, for these are especially the excretory ducts
of the urine, but llieîr lumen is often filled with altered, spherit-nl, and
granular cells, which come from the cortical substance and are eliminated
vith the urine.
As a conseuucDce of repeated congestions, the coloring nutters of
33
k
610
KtDJIETS.
the blood may jmss into th« interior of tlie urlnifcrousi tubules fttifl eauM
a pigmontation of ihcir c«ll«. There are llien seen >rcllow or brown
granules infiltratin}; tJio pavemeot cpiilielium of the convoluted ttibulen;
the cells may be tlotached rrooi the vail and fall sepnratelj or in fntj;-
mentcd cylinders into the lumen of tlio tubules.
In run»! iiiHiimm^itions, indic'ritod by ihc presence of albumen in tlie
urine, the cpitlieliul cell» are ctoutly, contain two or tJircv nuclei, and
are snid to he in a aUUts of prolifenition. ' Tho renal cells in the nonua)
state, liowevvr, Domotime^ contain two nuclei. In inSatDawiton accom-
panied l>y a ili-.4i|unniiitiiin, tliere if, couTitunt reproduction of new celU,
a* in de^ipiamilive nojihriti*, for the bynliuo wall of tJie tnbulo is
alwayt rc^iiliirly \\i\f'\ nitli ci-ll.s. It mi»t he nilmitted, therefore, that
there in a eotntant celluinr fontiation the m<-irhaiii»<m of nliich haa eacap^d
a». We itill a;;aiu refer to cellular proliferation of the kidney vhtn
considering garcoma and carcinoma of thL^ organ.
Uy virtue of thcxo olemcntiry le:«ions. which belong to tlie intlamma.
tory procesa, there is a series of moililîcationa which result from otian|R«
in nnirition of the cells, or their intillntiion by different aub-ttaiwe*.
Thus, ill overv case of iotcnis, whjilever may be the cause, there are
found in the kidiicy mmie i>f the uriniferoitg tubule» who»e cells contain
yellow or gi-cenisU-ycllow granules powesnin;; the renctious of biliary
oolorin<^ matter. The oclU thus altered remain t» gitn or are free i»
the interior of the tubule^ or they form eloii'^ted inaKseit moulded in
the cavity of the tubules. When bile ia jireM-m in lar^ie amount in tha
kidney, crvsLil* of bilirubin are found either in tlio l-vHh or in llie oon-
nective liiviue. I'nder other circumatanccs.BaUsiufiltraie tlio renal cell*;
the latter become centres of crysUtllization and of microscopic or lar^r
calculi. This occurs, for example, in newly-born children, when the
renal parenchyma is oli4triicb>d with umtcof soda, or when, in the goulT
diathesis, the same salt infiltrates the cells of a number of tubules and is
dcpo-xitcd in the form of needle-like crystals.
The ealcarcons Halts, alkaline carbanntt-s and phosphate-*, also may bo
deposited in the epithelial celU of the oafisule "f the glouienili. Tlie
latter appear in the cihape of small ojiaqtie and
hard granulea upon the surface of thf kidney,
where they are scarcely vUihIe to tJie unaided
eye. Fnrihcr there are found up<*n the surface
of free cells in the urinitcrous tubules, crystal*
of the tribuic phoaphates or of the oxalate of
lime.
Tlie cells of the kidney may atrophy aikd be
destroyed. For example, in a renal infarciai.
when tiie circulation of tlie blood is arrested in
a part of tlie organ, as in a raetnstatic absceas,
the cells become fatly and hreiik up into jtrao-
ular molecules. When a purtion of the kidney
is compreitsed by a pelvic calcul»*, or in chronic
pyelitis with retention of urine and distension
of the calyces and pelvis, the atrophied tubules contain only small or
granular cells.
30T.
Colloid <l'c*Km-fciiottar<bvvpl-
lb<l(*l erllt If ■ gilulfprnut lu-
butfi m iiiur«liil*l ii4i-Srl11«- a,
ConutcllT* llitue. t. KflU"*!'*!
UalBg i.r Ilia hilm, r. Cvlloll
t*l>t. t. I'nllslA fHl «Mil cnn-
MnlrldUjtir*. X^*^.
CASTS IK TUB URTXIFBROHS Tl'BDLKB.
611
^
Frefjticntly in advanced stages of lïris'it's ilUeaae, especiall^if In collmd
cyata, but also in the ojien urinifemuii tubules, cells are sc«n wliicli have
become colloid, refracting, round, or with the angles and ed;;es blunted
(Fig. 3il7). These cells are deeply colored by carmino, but they do not
give tlie tipecial color by iodine and sulphuric acid which is character-
istic of amyloid degeneration.
Finally, the cclk at times present an amyloid infiltration, and arc
transfonnod into eninll vitri-oiH blocks, which gîrc the charnotvrislic color
vrilh iodine and sulpliiinc acid.
HvAUSK AS» oTHKii Capts wHirn AUK Fon.MFP i\ TOE rmxirERors
TiiBCl,itrt.^[u inoHt of ihv c<!liul;ir altemliontt, which will tie t-dtiisidered,
there oceure n s«crclii>n of an albuminoid, hyaline, vitreous substance,
in tltc interior of the uriniforoua tnliules ; this substance encloses, or hik»
u|M>n its surface, cellular element) more or less changed. The shajte of
this albuminoid coagulated substance is cylindrical, so that the name
ca^tH or cylinders has been given to them. Thoy aro found hy mi.
oreeco]>ic examination of the sediment of urino passeil during life, ami
therefore they arc very important in a diagnostic aud prognostic point of
TÎOW of diseases of the kidney.
Hjl. 30S.
OitfOuta
o™«À>C '■**'■'
raat ^
We must, however, not exaggerate the importance of casts. Aa
Charcot lin« correctly remarked, ciwt» formvil in the convoluted tubules,
where the lesion i» generally thr wxmK im|H>rtsnt, pass "ith difficulty
into the urine if they are Komenhnt I;irgc, it being nccrsaary for them to
travemo the narrow tubules of ltt!nl(''.'( loops. It is certain that casts
formed in lleide's loops sometimes pas« into the urine, and it Is probable
that narroiT casts formed in the convoUiled tubules of the cortical sab-
stance may also be washed out by the secretion of urine.
lliere are found in urinary sediment collecUons of granular epithelial
cells, containing fatty or transparent and colloid granules. The.*e cells
aro joined together by a homogeneous or glightly canular substance difli-
KIDXEirS.
cnH to sec. but neviTthcK-ss obvious, eince tho cclU do not separate one
from the oilier : these «re ffiiOietiai ca»t4.
Id urioe nearly norma], or when the kiJnojr is alfectoH by a eongeeUon
or slight cutarrh of Ihc tubules, there exist very pale, narron casta,
fortucd of a Hnv gmiiiilur, sufc. amorpliou§ iiiutvrial. the exiges of which
are not bouiKled by a dark line. I'Vc>|uently upon their snrfiice tlicrt
arc n-niil epilhelium or lynipb corpaselen. I'or n beginner these cast* are
difficult to rroognixi;, owing to ttieir il(.'licacy kikI trans|nn)»cj. Tbejr
arc goiierully vury long, mid fonnod by an albuminoid nuitcrial, analo-
gouii to mucin. Tlic*e are muivm« rti«f«.
Tho majority of casMi seen in diteaseo of the kidney with albumin-
uria, are formed by a lioniogeneou.-t, hyaline, eolloii) material, without
granules in their iul«rior. Their edfce» are well marlie<l bimI nhadcil;
ttiey are not Uattened beneath tlie gla^u slide, and rolain their cylindrical
tthape. Their emU ai-e rounded and tliciredj^ea arv dark. Their sliapv
varies, as also their length am] diaiDcter ; fre<|uently tliey are not wore
than .05t> mm. to ,100 mm. Ion;;, but they may roach one raiilimcljv in
length ; at times they resemble a eork-scre», having the shape of llie
convoluted tubules in which they were fonned : some arc very narrow,
a fuL-t rendily explained when seclions of tliu diseased kidney arv
examined, (dt they are frctiuenlly found in the interior of the tubules
of llenlc'it loops ; othcm, very large, ar« formed in the collecting tubulin,
Thfir diameter varie:* fnjni .00.5 luni. to .040 inni. 8amctiinei< vitreous
cMtS are neon with transvernc fiiwure». TheNe are Ay<i/tic mjjir* ; their
»ub.staiicc i-t Boininvliat hard and roâiMiiig. When Ihvy arc iiuiDcroiu,
thev always indicate a ncrious form of ltn;;ht's disease ; if ihey are hard
anti dark-liordered, tliey indicate a chronic Bright's disease. They aro
not changed by acetic acid ; they are readily eo)or«i] by most coloring
maleriaU, by uannînc, or by the coloring material of th« Uood, 9o tli»
when blood i» mixed with tlie urine in Bright's disease, they are yel-
lowish-brown ill color; tlivy are al«i colonwl by iodine, which, however,
is not »0 niftrked a« in |iart.t of the kidimy which b.-ive undergone amyloid
dcgcnei'ulioii. (?af<t.4 in amyloid degeneratiou an* not colored violet-red
by the violet of niethyline, which demonstrates that tlicir substance is not
amyloid material.
Hyaline easlH are mostly covered eitticr with granular cell:*, or traiM*
parent and colloid lymph corpuscles, or a few colloid epithelial cell*. lu
granular fatty degeneration of the epithelial eelU of the tubuK^, llie
cells arc also granular upon the surface of the casis. aud fine fatty
granules may form a complete cortical covering to a hyaline cast.
These cunts may at time« present n))on their surface, or in their inte>
nor, granule» of urato of soda, orcrystaU of tribasic phoe|)tuites, or oxalate
of Itiuo, or uric acid.
In regard to the chemical nature of these productions, it is known that
ihey Are compoited of albuminnid matter, hut it is not definitely kuown
of m hat tlii subilaiice consinU. 'Hieir hfimog^-ueoint .itntv. the abtwtnco
of Gbriilalion, their retdMaticL' to acetic acid, sejiarate them from fibrin,
altliough they are fre<{ueiitly termed fibrinous casW- This name \»
the more inappropriate, since true fibrinous casts are «omctimes found.
ALTERATIONS OP nYALINB WALLS Of TUBULES.
an
I
I
Tlic caHtA present in ftmvloid degenerntion Ho not iliRer from the precis
diiig hyaline casta.
Accordinji to ar.me authors, hyaline casts arc forrood by s simple exu-
dation coming Tram the scrum of the l<looil, filtered through (h« inom-
branea of the vascular «alto and tuhults. According to itîmlfli-itch,
there occurs a colloid transformation of the coll*, wlitch arc ugglutinalc<l
on« to tli<^ other in the foi-m of castX) or t)ic colloid substance escapes
from the «Us. This opinion is opposed liy KleV». It iteem» to us im-
probable tliat hya1in« casts have thu orij;in in the majorily of case* of
rec«nt Brighl'.* di.-wui'C, since lh«^y ure fouini niilimit smy coltoid change
of the colls being iliscovorcd when the kidney \it directly examined. Itut
w« have seen, in several cases of chronic Itright';* di.4eaiie, colloid meta-
mnrphoACH of the c«IU aroinid colloid cants, am! the participation of the
eel!» in their formation seemed t" us very evident (see fig. 30"), cape-
eially in the colloid cysu of an atrophied Bn;^Ul'H kidney.
In jaundice from whatever cause, there are found in the urinary sedi-
ment hyaline casu colored yellow, and covered with yellow granules
awi with epithelial cells containing bile pigment, or,
i of hilivtrfdin. The hyaline
Fig. 309.
Faiiy ci»l>lo>lbniiila-
aa we once saw, crystals
citats, in caaes of jaundice, are nnnicrous, yet not
any or hut very little albumen is presieiit.
In poisoning by phosphorus tin- cuct* in the uri-
niiry sediment are peculiar in boing composed of
u };ninulnr mas» cnsistiiig "f fatly nmli-cule*, con-
8eH(uently differing from the usual casts of llright'a
disease. These are /nlty en*/*. In intense con-
]*eBtion and hemorrhage into the interior of the
oriniferous tubules, there is a coagulation of fibrin
wbieb is carried out with the urine, and a true fibrin-
ous cast is formed, characterized by fibrilliir fibrin
vhich swells by the action of acetic aciil, and which
contains in its interior red and white Mood corpuscles.
Instead of Wing in the form of small cylinders, the
fibrin may present small masses, «ith indistinct edges. Red corpiiflcles
are seen in these musses of fibrin. The urine preserves the red cor-
puscles, bnt change:* their shape ; they become jjranulnr or crcnated upon
tlieir surface or excavated.
^Ê Alteration» of thf Hi/aline WnU$ of the Tuhulr*. — The hyaline wall
^B'of the convoluted tnhides and Menlc'n loojuj i-i ii^ually preserved in renal
^pdiseasM. In Bright'» disease, with granular fatty <legeneration of thu
^^ cells, when the hyaline nails are isolated, albuminous and fatly ^ran-
nlea are seen upon their surface ; these grannies are not in the sub-ilancc
of th« membrane, it remains intact beneath them. .According to Hind-
Beiscb, the hyaline wall of the tubules is thickened in chronic altiumi-
nous nephritis.
Thi* mcnibnine in suppurative nephritis, and in tumors developed in the
mnal parenchyma, diwapiH-ars : in ititer¥tilial nephritis it also completely
disappe.ir* at points where the lesion is far advanced, when the boundary
of tiie cylindrical cavity of the tuhulea is foraicd by the thickened con-
voi tiie
614
KTDKBTS.
nective ûsaue oFthe kidney. Riixlfleiitcl) lK>liev«3 lliAt the hjaliiw wnll,
in the Tiormal comtitioii, is |Men;eil l>v poriM. wlticti |)era)it tlie lympb
cclU cooiiii;; from llie rewels to pnf» tlirou;::!), either to ooiiiiiitiiti' tiie
epithelial celb of the tubules in tlie unrinal atute. or to fonn itti' ccllulnr
clémente of pus in rcual &iij)]>uration. Thest- jiot-eâ have not yet been
aatisfactorilj doiuonstraled.
In amyloid de;;ci>ci'niion, the hyulini; wnlls of the tubules, tn somu
cases, become very tlùck, kikI aru iuliltrntvil with the amyloid sub.
stanoe.
The jifttholojîiciil clinnges of the celL« in the liibuVit, those of (licit
hyaline wall, and the e:(itilntiouH into their Uiiuen, have beon o'lwiilcnil.
W e now {>aiw to the changes uiulfr^'>iie by the iiriniferoiLi tubules as a
whole.
The uriniferoiui tubules may be nniformiy dit^tended ; tfaia occura ia
ratsBtian of urine, and a urinary inlilcration of all the elements of the
kidney is the consc4ueiiLx- ; » similar distension U seen in the fir<9t aUs«
of Itni^ht's disease, when the vpitlielinl eells are swollen and eloudy, aixl
the lumen of the tubules eontniim n liyaline exiidnlion, dv^uamatCil cells,
blood, etc., when the entire or^n is increased in sixe. Rut soon, in
Dri};bt's disease, there occurs either ob<itnictio» of a numWr of tubulei
by their cimtenti* which «scape with difficulty, or iutcrxtilial inflaninu-
tioii« which occasion at a (iiirl of the tubule an obliteration or a )H>rma-
tu-iit narrowing, whcit tlie tubule ))reHuntA above the (^laeb: irre^^lar
dilatatioii-4 or true qvûu of rutenlion. Tliefli» eysta are i,'t>ni' rally fonued
from the urioifcroua tuhulos : from tlio same uauso a ilisicnsion of the
caraule of the glomerulus may take place.
Total obstruction and even complete atrojiliy of tlie uriniferoos tubules
ia observed in comprvssi'Mi of the kidney from witliin outwards by dis-
tension of the pelvis and cnlycei*, in the «evenil varit-tics of pyelo-
nephritis. There is aliiuist aUayM associated with thi« condition nn inter-
stitial nephritis chiiraclei-i7,ed hy tliickeuing and induration of the con-
nective tissue.
Lf$ionii of the Connectiee Tia»iK of the Kidnei/. — The connective
tissue of the kidney ia not very abundant, yet it is certainly present,
eapeeially in the parts that have been mentioned.
The lesiana which this tissue undergoes in nephritis arc varied, accord*
ing to the cause of the disease. In simple con;;e«tion, tbo cells nf tbc
connective tissue consume a greater amount of nourii^ing fluid than in
the normal state ; their nucleus becomes larj^er; the proloplasm of the
cell is granulhr and distinct; Uie entire cell is enlarged. If the con-
gestion is intense and peniistenl,aM occurs in carliac diseases, uspeeiallv
in lesions of the mitral vaUe, an extravasation of tlic coloring uialerial
of the bloû<l may be manifested by pigment granules around the cells in
the fibrous stroma of the kidney. Almost always, in these cases, the
connective tissue cells proliferate and increase in number. The inter-
tubular septa are therefore increased in thickness. The cellular elements
which compose them belong to the cells of the connective tis-tue. The
cellular stroma of the kidney Is thickened, more rcslstiuj; tliau normal,
AI.TBRATIOSE OY BLO0D7I1888L8 OF RtDXET.
615
and the entire organ seems denser. Such is the essential lesion of
iiflpliritts in heart diseases, the con^stive and interstitial ncphrïûs caa»-
in^ an organization of new elements in the eonnvctive tissue.
• In welt-niarkci) I{n;;h['e disease with C'.>ti;^-iition and renal inflkromo-
tion, the eonnectivv tissue pre^i-iils inllnriiiiiitl'irv te«if>iis, ufiich at lirsl
CODfist in the presence of ihiiiictoiu round cell» (cnibryonie or lymph
»Gvlts) in tlir laoiiniu or lymph «'[«lem of the contioctive ùsstie. Thi-sc
cvllular eIriuentA are «vtn in i^d! itepta between the tnbnles, and iti the
lii«ne mirroiindiiig the glomeruli. Thi» lesion in not nlway» preiient, and
it varieit in diHereut portion» of th« kiilney.
iDo thefle elentcnt^ come from a proliferation of the fitted 8at cells of
tlie connective tift^we, or are tliey while blood corpiidutea or lymph
cells? This is difficult to dotermiiie otherwise than by furmin;; a hy>
potliesia biutod upon analogy. It is possible to suppose that there oeeiirs
here ft diapedesis similar to that observed tition the peritODcal suroos
membrane. Later, when the kidney is atrophied nnd contraeted, in the
tasi stnge of Bri;^ht's ilisease. tliv embryonic ti^uc is orgaidxed, and
l>ccjmc* vi-ry fibrous and dense.
In ndvane«-d stages of l{ri;;ht'# disease, and in renal atrophy due to
chronic pyclo-iiepbriUM, ihe int4.-nititiai induration of the connective
Iti^ue reacheti its highest degree. A inw denne fibron» twiic at thi»
lime sejmrale* the atrophied seeretin^ c1emeiilc«. The fibroii.4 capsule
elo^ly adheres to the surface of the kidney, which is granular and
inammlllal«d like a cirrhotic liver.
Small metaetsttic absecsiieH, or dilTust^d giippiiration of the kidney,
should also be ascribed to a primary lesion of the circulation and con-
nective tûsuc. Consecutive to capillary emboli, or to the transportation
of putrid or fenueniin;; mntcrials by the blood, there are seen one or
Diorc red milinry wchymotic points, the centre of which *oon becomes
whitish and puriform; afterward» the entire small uni*« î» triiu^fonned
into a miliary uhsees*. During thi» proee.M the vessels «re at first
■ turgid, next ihe int«T[ubular connective ti»»ue i» infiltralvd with white
corpuscles and softened; at the same time, the epitliclini cells of the
tubules become granular ; lu soon u* tlie small »li«cess is formed, there
are found mingled together in the purifunn fluid while corjiuscles and
granuhir epttheliiil ce!l.t.
I Such are the leiinna of the renal connective ti«ue in the different
varieties of inflammiitiou. This tissue may be infiltrated by the urine,
and ill a manner become «ideiuatouB from retention of this fluid. The
urine then difttendâ the laeshes of the connective tissue aa well as the
lumen of the renal duett).
Tiiroora of the kidney, fibromata, tubercles, syphilitic gumtnatn, car-
cioomata, have their origin and are devclojicd in tlie connective tissue of
the organ : their be^innin^î is marked by a thickening of the inter-
tubular partitions, which arc intiltrated by tlie new cellular elements.
Altfration» of the Blondpfuwh "f ihr Kldnri/. — Tliu renal arteriea
are frer|uently the scat of obstructions caused cither hy a migrating clot
(eml>oliis). or by vegetations due to a chronic arieriiis with atheroum.
Xbese le»iona are located eiUierio the renal artery itself, or, which U more
61» HlRW!#a. ^^^^^^^^^^
rtiotiunon, iu one or more of iu principnl brandies, at Uic bouixlun,' be-
tween t)iD corttciil ami mcdullnry «ubotaiice. Tlie result of tbvev suvi-r&l
procei**o» is one or more iiif'ftrcti.
Aciit«, Aiibiu-iite, or obronie nrtcrilW may occur in th« kidnej %i the
hsaioo time thai there cxiitUt a flimihtr sunlo of ibe whole urterial tyateai,
[on account of senility or from any other caiL«e, or it iDHy bo eoH«ec«-
' tive to an emholus uhkh ocL-aHJoiiA au irrilAtitm liuiitci) to oiti* or inore
branch oâ of the renal artery. It does not iliRbr from an arteritis uccurrisg
elsewhere.
Acute inRammatimi of the reiial arterioles iadoveloped in coreic^jiience
of oerlain forios of albuminuric nephritis; for example, tlial which fol-
lows scarlatina. The wnll of tlic small arieriolos, mi-iicularly thoM
«liii-h i>upp1y tlie Malpi^^hiun gtonierulcs, shows a considerable iitcniaaeof
the nuclei.
I lu cbroiiic alhmninoiiA nephritic, the walls of the arterioles are lliii-k-
tcne<1, tin is al»» the CL'llulitr tissue of the ort:»»; tbis chango occurs ia
^flverv inteDititial ncpbriti», whatever may be the cause.
Oiironic arteritis, cbaraeterixcl hy tbickening, iiuluration, tortuous
[Slate of the nail and narrowing of the calibre of the arierie»), iiltitnately
loxi#la ill every ca^e of inter-stitial nephriti.i, as well as in general s<'nile
'atheroma. In a section of the kidney, the lumen of the arterites rciuain*
open, and the course of these vessels is marked to the unaided eye by
opa<}ue lines. The same characters are observed under a low ]ri>wer of
the microBcopo, nhen a transverse or longitudinal section of the vessels
I Ù examined. The external cont and the moat externat part of tbe inid-Ile
^eoat present an opai^ue appearance. This opacity sometimes is due to the
presence of fatly granule», hut rnoi-e often it \* owin^ to a great tmmlKT
of eliistio and connective-ti^^ue libres, which tutea'cpt the <)ircct ray^
of light. The intenial coat almo^tt always undergoes a itoiable thicken-
ing, which i» seen in trsnsver.te cut<i of the arteries, 'llii^ lliickening,
caused by a new celluUr formation, narrows the calibre of the vewvls to
a varying extent. Kiidarteritis is always well marked in the arteries
obatnicted by thrombi or emboli, occurring with old infarct! of the kid-
ney, and it is a!wa.ys present in part* of the kidney which have become
fibrous in conscnucucc of int^-rstitiul nephritis. The arteries are the
favorite scat of amyloid dcgencrutioii of the kidney.
AUf ration» of the Mfilfiiyhian Glomeruli. — The small Teasels wbicb
arise from the divinion of the Hffcront artery, frojucntly exhibit in
Itright's disease, and especially in Kcai'l:<tiiiou« nophritie, a multiplica-
tion of their nuclei, (ieneially, in albnuiinons nephritis, the Sat cells
which line the wall of the capsule are shhUch, granular, and even con-
verted into true granular bodies, irpon the iiurfacc of tlio vessels of the
glomerulus, granular spherical cells, or nuclei also filled «ilh fat ^n-
ulc^, are seen. Tbe.so elements remain upon the vascular biogw when the
glomeruli are removed by teasing: by wa.'<bitig, the vascular vail is
«eon to contain numerous fine fatty granuleji. (Fig. -ill.)
in renal atrophy following a compression which in pointa arrests llie
circulation of the bloo<l, or in an inleratitjal nephritis, the gloun-ndi are
atrophied ; tlie blood does not enter them, and their vessels are atrophied
I
[.OOT OP KTDNBT DIABASES.
and form a smnll filiroua hall. When the cnpaule lit ilÎAteiiiied hy urine
or by a colloid subalance, the entire gloraeruluH U traiinforiiwd into »
cyst.
The glomeruli nro gcncrallv the first portions of the renal vascular
8y«t^-[n whidi urc attackt'd by lh« anijloirl degeneration.
Tho ri'iial cajiillarieH arc with difRculty evpamted fruoi the eonni-ctîvc-
tiuuo ritroiua, mid m order to Btu<ly their Ivsium^ thin scctiunii of th«
Fig. 310.
Fir 311.
FaICj d»g4ii»ran«D of <h* IftUnnbol^r Mpll-
ITtttJ dfcrafUlDB at Iba «plllarlM Vf i
XolplKhlu luO. X»4.
kidney are examined. In regions vhîch arc the «eat of infarctî, the
i'»|ii11ancs arc (.■ompJoU-Iy obstriicti'd, cilbcr by fibrin aiid blood, or by
their iiietiimorphos^-d produce. In nlbuminoii^ m'plirili* in the slus« of
fatly ik'gern' ration, their walls as well as the int«rfihrill«r )acun:c of the
connecuve-tiiiitiie utroma, present cells and nuclei infiltrated with fatty
^raimW. (Fig- 310.) finally in iiiltirsliiial nephritis their walls be-
come thickened by the formation of new ul«menttt. In lymphadenitis,
the canillariea are aometimea Riled ntth white corputtcleA, and a rupturo
of their wall, or a simple diapedesla, may catise an intiltra'.ion of ibvac
olomenl^ into Uie cbnnuctivo tissue.
The lesions of the veins of the kidney are lhrombo«ia and acute phle-
bitis: both cause the esca]>e of albumen with the urine. Chronic plde-
bitis is characlerîjied by a ihickenin;^ of all the coats of the vein, by a
Dcw formation of connective- tissue element»: in interstitial nephritis, in
the last at«gc of Bright's di»a8e, in pyelo-nephritia with renal atrophy,
and in »M iiifareti which have become fibrous, it may occasion a complete
obliteration of the veins.
Sect. III.- Special Pathological Histology of Sidney Diieases,
ArtAJIIA. — Anrcmia frc^iicnlly occurs in all chronic cachectic dis*
ea«c«, pariiculurly in cancer and the last sta^c of tuberculosis. The
kidneys are pale, and of a grayish color, the cortical substauco more so
618
ETDIÏBTfl.
ihim lli« ]>vniinïi1ft, whieh indcM nr« innlci;*!!. Tlicy lire .tnioofh upou
Uioir *iii-fi»cv, nnH are g«n«rAlljr bhiuII. Frttiiu'ntly, wlien Uiero i» fceiirrali
ana^tarca, tliti ki<Iiiey» aro iiiKIlraud with urine, ami arc normal în sisOfV
or (li.'Oeiiilttil. When an o1]i«tiu:le to the cncape of urine exista — Tttr
example, when » cancer of the hlailder or utentfl coiDprefue.4 the tirclers
or iiililtratea their wall ana civii^a n narrowing of these jkum^ch at «J
given |>oiut — they hecoaio tlilaleil aliore the olistruction by ibe <:oiiti»iiL'df
ace un ml at ion of the urine, which is thus dniDOiM up in the Viiliiey and
infiltnttc§ the Ivmphatic connective tissue of the organ. The kulticy
()Ocoinc!i tiMisc, Ùte capsule smooth and stretched, whilu the orf;a» ts |m1«,
very acKtiiic, and inKltratcd with nrîne ; the urinitcroiis tiibidcs, e«p0-j
cinlly t]io«c of the cortical siihutAnce. arc larger than in the normal sttU^fl
Tho cells of tlie tuhnles arc not changed. I
CoNOBSTlox; HliMonRîiAOR. — Kciinl conjfetttion i» ft^cn, in tlw Uvtfl
Blate, ill poinoiiinji; l>v en ulSi arides, in the fimi jicrioil of fevers, Ole,, aiifl
in the chronic stale, i» all di^eafei* which are attended with a diflicult^
of tlie return of the t-euoiiA htood to the heart. It is also alnajra pm^j
ent at the lieptinin;: of the several vaiiolics of nephritis, J
L Congested ki'lueys are ;;eiierally lartîer than normal ; yet they nttjj
rnol be pcrcornihlv iucreaHed in size. Their capsule is easily detacbea.l
I'he Burfaco is red, and the mucli dilated stellate veins of Yerheyen are
prominent. The cut surface of the origan oiliibits » dlfliisc redness of 1>ulh
siihsiniices, the medullary more so than the cortical. In the latter, there
^irc :«cen, with tliu ntiaiilcd eyi!, red pointit whJdi Are dur tn » tilling of
Ithe ve.<>elM of the )^l<Jiiieruli. The pink or red color of the cortii.-al i>ub-
ntance dejiendii u))an the amount of Mood in the ca]>illary veaseia. Tbo|
'deep red color of the medullary subiitancc is owing to the fulueds of ibfl/*
renal veins.
When the blood pressure has been considerable durin» life, ruptorej
of the vessels, or a iliapcdesis of the red corpuscles from the vessels of tli«
Lfilomeruli may have happened. There then results a true renal hemoiJ
Fniago, bavin;; its origin in the interior of the glomeruli. The hlooin
escapes between the vascular tuU itmt the unp«ule of t)io glomerulus,
vrhicn is slightly distended; from thence it putsvs into tlie lumen of ilic
convoluted btbule» of the cortical iinhKtaiiee, then into llic loops of Heulo,
into the straight tubule.i of thr> medullarv ray», into the eolleciing tu-
bules, and finnlly into the iielvis of the kidney. The con^.ttion baring
Lreached this intennity. the kidneys are found increased in nixe and «eight^J
pDpon section the glomeruli are very disiinetly seen as small red sifoln,!
and surrounding them red torttious vessels, which, at first, are taken for
enormously dilated capillarieSj but they are only tJic convoluted uriiiife-
rous tubules filled with blood, as can bo seen by nicroscupic examination,
which ïhows the lumen of tliv convoluted tubules filled with red Uood
«'irpu.iclc». At the ])enpbery of the tubule the e[>ithelial cells arc bmb,
eitSier normal as to shape aiul etnicturc, or flattened by the pressure eiiJ
erted by the blooil. The flattened cell:* form n hriglii l>or<]er in uucoloredl
seciiuna, and in carmine fltuine<l seclion:!, their iioclc-i, instead of being
round, are »cen flatteiied and elongated parallel to the wnllof thv tubule.
Tlie glomeruli which are the scat of the blood effusion are surrounded by
I
*
ALBVmXOUS HBPKRITIS. 619
conrnliiteil ttibulc» which, at timcH, are enormotialj ilintended with blmxl.
In other };louienili, iu»teni) of blood corfiiiatW, thc-re is foiiiiil a coagitluin
of a hyaline substance colored yellow by the blood, and arranged in con-
centric laycre. These are true fibrinoua concretions in the interior of ibe
capsule, similar to certain cysts existing i» inti-rstitijl ncjihritia. The
blood csca|ji-d in llic intt'rior of the tubules undei-<;ocs eevornl vhmigM ittU-r
it conquîmes, forming; hieaiatin ;;rnnuli;s. brown pi;;nteiit which infiltrute»
the dct(i|uainatc<l ojiithelial cells. The blood is discharged with tlie co>
afntlated fibrin in the furm of fibrinous casts cnntnining ri-tl corjiiisclos,
or coveroij nith |>i^mcntt'(l vpithuUnl celU. Those ea«ts are sometimes
jr«llow from the pre.teiice of the coloriu); niattvr of the blood.
Conjtestion nith renal a|)0)ilexY or lu-iiiorrhajçe is Doinetiineit olxwrved
at the be^^iniiin^ of a nepliriti.s and in otiier rare clrounutaitceii where
the blood {iressure it) very hi^h.
Prolonged passive con;;estion of the kidney, due to cardiac disease,
almoBt always occasions more serious lesions than does simple cotigcstion.
Tlie kidneys are sct>n to be very red, indurated, and by microscopic
«xaminatiou present the characters of interstitial uephritis — that is, in-
Creoto in the sixo and numbur of the cells of the cotinectivc tissuu, and ft
fibrinous thickeiiiu^ of the stroma. At timu.^ in i^ueh n kidney tlic vpi-
tJivlial eclls of the tubules arc also tilled with albuminoid and fatty gran-
ules. Passive congestion is generally accom[ianied by the prv^once of a
timall iiuantity of alhuiuon in the urine.
iMfAUiTms OP TiiK Kit'NEV.— The itifareti defloribed as rhoum.atio
iie|)lii'itis by Ilayer, arc associated with valvular leaions of the heart, and
with aortic ciidarteritis, lesions which frequently occur in rheumatism.
T\k infarcti of the kidticy arc very similar, both in frequency and cause,
to those of tbc spleen ; tliey arc found upon the surface of the organ, at
finrt deep red in eolor. and slightly clcvateii. Soon they bw^- tlicir rcd-
luiSS, and becocw! yellow; their periphery is snrrnuinietl by a iwme of
congestion. Up'in section «if tho cortical snbstniicf, the infarctus i* seoo
to be conical in shajw, with the base toward the [wriphcry uf tJie orjçan,
and it occupies the entire va4cular territory of an arteriole.
Microscopic examination of the altertid j>art .«bow.t that the c^llarj
Teasels of the kidney are Riled with an opif pu; siilistauoe rich in granules
of b^eraatin and fat, etemeuiii which come iVum the fibrin and blood cor-
puscles. Tlio epithelial cells are granular ami opaijue; ihey are alM
înËltrated with f»l ;;ranules, and are disinle;^ rating. '
Gradually the malcriaU resulting from the molecular destruction of
the alfocied part are taken up by tlic circulation and absorbed, the infarc-
tus shrinks ; instca<l of being elevated, it is now contracted, and in it4
place there is found u depressed, librous cicatri.v. A microscopic exami-
nation of the cicatrix shows n dense tibroiu; tissue, the vessels »f which
are in a slate of chronic atheromatous iutlaminatiun ; no trace of the
glandular parenchyma remains in this fibrous mass.
Auil'MixfliK KiiftiRiTis. — Ueniil lesions which occasion the presence
of albumen in tbe urine are various, and the iiiiniitity of albumen escaping
from the kidney ia alao very variable. Tbc word nephritis, by which theââ
620
itDSsra.
several conditions of die kiilnpy arc usually ctinractt^rîzcd, Ïb not cntiroly
ealiafector^ : for, while there is a nephriiia «ith c'>D;<p»tiDii, wiili i'xas»i,'-
rated tbrmation and destiuamntion of cptthetial colla in catarrhal noplinti»
lUid ill the first slaj;^ ot parcncli^voiaious nephritis, it i« difficiitt Ut mw
Hmy truces of inflnuimation in the litrilicr sia-fcs of tlii« di^oase. It Ji tbe
BMno in amyloid di'fïincrntion, which Îa nlwny» acu<Hn|Miiiii*d l.y the
Btrwcncv vf ull'tiiiH'iiiii the urine, 'flic reiwl loMon asuoointt-d with alW
nnintina wliich >»'«t niurils the name of ticphriti«, is iiitontiilisi nephritU
^(reiiiil eirrhowis, or pmly kidney).
Vftrivlies of nlliiuninoiis neptiritis, coRijiriiic caturrMI vefihrHig, j>ar*»-
rhymntoH» tiff/triti», amjfhid ijfffrnerittion, J'ntlg tlfjenerativn^ Mid
inUT*riti'tl m-pfiritU.
r mil receiiiiy, interstitial neplirilifl wa« considered to be simply k late
Hinge ill the évolution of parencliyniatous nephritts. Such WM iho
ueaching of Hcinlianlt. Viivltow. and Frcrichs, wlm placed (he clmneos
'of llie rcnaJ epithelium in tlie lirst rank. Deer, and shcrvanlo Tnuibe,
liowcvcr. have drawn attention to tlie participation of the eonnvetire
I tissuo of the kidney in the inllanimntinn of acute or chronic nlhuminoiM
Inephrttiis ; and Tniuhi' ri't;(ird(i the la!t<.T n» «wentinlly a» inierstilial |>r->-
U088. The Kii^lijili wrili'i^, Wilk», llanddeld Joiicd, Todd, etc., hat»
nnslMed upon the cliniciil and aiiatomiciil dilTi*reuceii which separate paren-
chyinatoiiA nephritis (lurge white kidney) from interetitial nephrilts
(grannhir contracted kidneyj. The moal recent works upon this auhject
puhlished in France l>y l.^corch^, KeWh, and Charcot retain the division
tuade by the l^n>;lisli'wrilera, whether scpnrntin;; incrstitial nc])liriris
from Bri<;ht's disease, as LiSchorché; or with Charcot, making it a 8]>cciil
variety of Hrijrht's discaeo.
A. CATARliJlAl. NVi'HRlTlS (TraHSinif Alhtiminiu» Ki-phrili», A'm/iw-
fifiat yephritU). — 'llii^t renal le»ion i» met with under a nuniWr of
ditfereiit circmnstancei): frnm tlie etTecl^ <if cantharideit, in low lypca
Bvf fevera, in typhoid fever, in cholera, in )>neumonia, etc. It may
fie more nmrked in the excretory ducts of the kidney — for example,
in fioisoiiiii^ with cantharides when it ia ncconipanled with pyeliti*
and oatarriial rcdnefts of the pelvia and calyces. In this case, oven
when the nephritis aucceeda an indammation of the bladder and ureter, by
prcasin-; ii)'on the summit of the Malpighian cones a oonstdonibk (|uan-
tity of turbid tiuid may be forced out. Thit> ttiiid contaîits fatty p;rann-
l;ir I'pitlieliiil cell», inucons or hyaline tniniipureiit «iid wft ca»tw. and
lyiriplioid cells. The iiitlaiiiimilion of the nincon» meiuhrane of the jndt'ifi
I and cwlycM ill nlw chariictcriKed hy n tmliid nnicou.* ilmd, coiilainiii);
I lym|ihoid celU. In other cusv», the eleuieuts of the kidney rMkrticiiUrly
I aflecled arc the ccll« of the convoluted tubules of the cortical ttutiettHnce,
which have undergone cloudy swellinj;: itoinelimea in the conTolnled
tnbutea and in lleule'ii lonpâ a granular fattv degeneration is found.
This latter state is more especially seen in the low types of fever».
To the unaided eye, the kidney is hut litlle^hanged; it is somcwliat
b larger than nonnal; ita cortical substance ia pale, gray, or yellowish-
' gray, and slijjhtly o|)ai(nc ; ita consistence is soft ; tlie capsule is teiiM,
J
PARSXCIIYUATOUS :«ErnR[Tis.
631
and easilv Hetaohed ; th« «urfaoc of th* orgiin i> sroootli. In ihe 8Wll«t«
reins of V'urb«yen, anil in tlie gloincnili, tUo vcsmIs nro generally full of
blood.
Pig. 312.
I
■■■■■, I* HM* or Iha Iub«t U» *pltb«lla« kM IkHea out darlMg (b* pnimtalliiB ol (b* «dlon.
X ». lOnn.)
Thifl mriely of renal lesion i» u«n«llj- Mcondarv, ia acooin)>Anied wilb
» very sihaU iiu»ntjty of «Ibumen, nnd tvnntnaU-s in ra|Hd recovery.
B. PAHBSCHYMATODS Net-ltRlTis (^Di(fH»ed ^ephritit, Pn>f"Hvd
jVp/'An'fM, Ijaryt White Ki'lnry). — >FarencbyiDatouâ neptirilb affecta
CA|iooially Ihe cells of the uniiilVr(>u>< tul>ulrs of tbc <.-orlic»l suWtance.
They becoine anollen, ami Knimilo-fnlty ; (hey dr-«<|iL!iinaUi, are elimi-
nated, bein^ rcpliioed by oiltors, luid nuiuoroi» Jiyaljne caata eacajw
«ich Ibe urine.
TI>G coses nbicb «re cla»ied as parencbymatou OC|dintia are very
difterciit from on« anoUier. Itecovery is the rul« ; tb«ir coiifm Is very
rapid, lasting from eij;lit «lays to three weeka. aa in scarUtinoua albii-
miuuha. In tbeai, besudea the inliltration of the <;onti«clivc tistuc and
gluiDoruli with lymnbatic celUobaert'ed by Kleha and Kel:>oh. tliere aru
alway.f cloudy awelling and fatty degeneration of the e|Milieliutn of the
tuhufe* of the cortical substance.
The albuniinoua nephritis, more or leas pei^i^tent but generally
curable, occurring; during prcffniincy or at the lime or after delivery,
aocompaniod or not with ecUmpsia. con^i^ts in a fatty dej^pnoration of
the epttholiuDi, comparable to the chaii^os seen in scarlatina.
Front the effects of encernivc drinking, or the aelion of moisture and
cold, there may result cither an intense albuminou.t neptirilis which termi-
nates iu rceovcry after a week or several nmnth*, or there may arise a
I alhiiininiirin terminating in deatli in HevLTal mmitbs or year.''. The
u»use» may, in conseajueooe of a different intensity of action or in
A
flSS KtDNBTS. V
t,ooiue(|uence of epccial prcilis])ositiona of «acl» person, produc* lo*inin
[varjinj; in inccnsily and general diankcter, but etiU cotnpunible witk
one nnother.
Then- niT Homv iIÎmiwcs in wliich, if albuminuria occurt», Iherv 'a
altiioil itlw:tr# a similar condition of t)io kiilnvy foiiTul. Thtid, i» tho
pitnrticliymnloiiA nepliriti« of iliiihctic piiticnte, as ne luive sevvral timet
seen, the kiilnry» were normul in sixc, xiwioth, and prefteiitiMl n r«li;;lit fatty
dcgeiitTiitiim of their epitlieliiim, but it vfas diRiiac<l nnifitnnly tlif(>u;;b(>nt
the entire cortical Kiiti»t;iiico. In Uie albnininoiM neplirili:' of pbthii^i^, tbe
kiduuy 13 gcncmllv smooth ii[)on it* îtiirtaco, wliitc, ami np>>|iie ; its aim
ia normal or slightly increased ; tlie fntty de^^cnerittion of the celU h vcrr
decided, either nnifonuly or in palcbivit ; nior^'over, there frc-iucnlly
oocura, at tlie name time wttli tlie legion of the cells, an amyloid degene-
ration of the vessels and walla of the tubules.
In rerv intense albuminuria, terminatin;; in death, ami causim) by
moist cold, there is usually fonnd a tariff wlii(« ki<turi/ (waxy kidney),
Eniootb upon it« surface, considerably increased in size ; upon section,
one sees opuum- yellow lines formed bv the convoluted uriniferoii*
tubules, which urc filled with a fatty detritus; tliere ar« SfitiietiuiH
Men, upon the surface of the kidney and scattered tbrouf;h the cortical
suhntanee, yellow and opaijue efut», rarying in sue front a nuUvl- U a
Iicuip-sced.
FinAlly, in Icad-poifonini;, in gout, and in some chronic iMMtn disra^ec,
tlie kidneyx are Hniall, anil are [;rann1ar ujum their «urfaco, w als'i u|ioci
1 1 section of the cortical aulwtance. AHsociiited with llic faltv di'ijenera.
' tion of the cells of a varying number of lubulea, atrophy and interrfiitial
nephritis are often encountered.
From the above descriptions, it is evident that — although relate*! by a
common symptom and a common lesion, namely, the presence of albutMB
in the urine, and the fatty dc;;eneration of the cell* — jmro itch y matons
nephritis is far from bcinj; always the »aine. A similar diversity is also
observed in all the chronic discjv.M^>s due to a variety of cauncs.
After Brighl's discovery (l*^iI7). patholofiisln were inclined to regard
' fw one disease all renal cnauges found »t aH(0(>sîes of nlhuuiiuuric pa-
tient». Accoriling to Rayer, the lesion* presented mx dlMtinct varie-
ties ; the first two belonged to acute alliiiminou* nepbriii», and tlie
others to chronic albntniiions nephritis, t'rericlvs a<lmit« otdy tbn^e
stages of ]tH;;ht'g diiteniie: the ^rst stage con^iists in bypcm^niia ai»)
clouily swelling of the cells : the second in fatty degeneration of the
epithelium ; and the third in the destruction of tbe epithelial celM aitd
atrophy of the tubules and of iho entire kidney.
The cflect of such a classification of albiuninous nephritis îa to cause tbe
erroneous impression that the several anatomical states regularly snccee^l
one another, white in reality we bare to do with a class of cases distinct
fnim .me another by their cans* aa well as by their patholo^cal anatomy,
but nevertheless somewhat similar.
laL At ihr hipnnimi of every nlhnminoiis ne]>liritis, the kidneys are
congested and increased in size at the expense of the cortical substance.
The caj)«ule is easily detached ; after itn removal, the renal surfuce ap-
peurs rcJ-brown or yd!owisli-{;niy, congc»tctl unifonuly «r ïu palclie*.
'riie {lorlions «fliicti art? m>l rcdiUucd by the ilttitcnsion of tin? vossoU
•ro f(ray or yellow isb-^ray ; ln'iici* we Imvo & martited «ppennince. Uy
making a section of Uiii orgaii aiul wntthtiig it to n-iuorc itie lil'io'l. llto
trncei> of coii^^eHiion are noticeable ; small red |iniiit<t imiicnte (lie l'iilnei»
»or the voâsela of the };Ioiueruli ; liie recD»iuiii>; fiortion of Ihe entire cor-
tical aubslance îk ihickened and yellowish-gray iii color.
When the le^iion in more advanced, the cougeation of the cortical
substance is diminitthed, and the yellow -gray color prcdominatea ; Bayer
correcilv tcnna thia stato inflamiDatory anieniia when the part \a cl«arfd
tof blood by washing. I'hc Mnlfii^hiun ;*loiiieriiti arc ecen by the unaidi-tl
eye, as brilliant and traniluccnt points, for they f;vnerally runijiin
[lOratal in tlio midot of a tisnue which has become opiii|iio.
Microscopic oxaniination ntUi low power dooioii strates, as in cjitarrh&l
nephritis, numerous opa<|iie and distended nriuifcnuis tubules of tlio
cortical substance. Thi- ^lonicnili sometimes contain smnll blooil effu-
iion* l>ctwcen the vessels iiud cap-
sule, a» in all intense coii;:estion? of V\e- 313.
tthe kidneys.
Kxannnationu'ithhi^lier power ttliovra
tlie tittiulei^ filU-d witli celU clouded
liy albuminous and fine fatty granules,
and cont.iining in their lumen hya-
line casts. (Kijj, S1:î.)
I The altered «lis of the eoiivôluted
tubulea arc usually in st'fx ; the
lumen of the cnlar;;ed tubuU-s con-
tains hyaline costs. The cellx, how-
ever, may not retain their iiomial
«onncction wich the wall of the tu-
bules ; and they nmy accnmnlate and
distend the uritiifttrnus tiibuleii into
the fiirm of varicoKc dtlatalionn. The
term duMpianiativo nephrilin is eiB-
ployed by .Johnson ami miit Ku^^Ii^h writers; the word is not jrooil,
since it seems to indicate that the uriniferous tubules poascM fewer cells
than in the normal state, while they are, on tlie contrary, distended by
mltered epithelium.
B I'he large number of hyaliue casta and their supposed fibrinous nature
" induced lleinliardt to compare Bright's disease to pncuinouia; and Vïp-
chow gave it the name of croupous nephritis ; but the fact that the casts
are not chemically composed «f fibrin oppose» tlie^ie views.
The niitopsies of persons dying after delivery or scarlet fever, in which
alhuminurin has existed for a short time, usually do not show all the
coiivdiuied tubules changed to the inline degree. Some are normal,
■-Otlicns have a granulo.fnity epithtdtuui,and a few tubiile!< of the eorticut
H substance are filled with cells entirely fatty. In siarlatinous nephritis,
Htlio glomeruli and connective tisaue fonnlng the wall of the capsule aiij
the intertuhular partitions are infiltrated with lymph cells. In ihc same
conditions, if the albuminuria i» conûdcrablc and has lasted a long time,
TntiitT4r*r t4«Uoa of a kMnej la 4 t^t* ot
nrlfkl'a illtHM Tks »ll> UbIbi: U>ii (uIxt*
6S4
KIDXRTS.
the nholc or tlie corlicxl auWtance M«aen(s, to tite uoaidd ej», r
narVcil o]ineity, anil mo-it of tlie Uilmies of tlie re^inn ehnw ft»m vj»-
'thelial (icgeneralioii. Tliis Htago of tliL- discaiw may termionti- m re-
covery.
2i). When R iiersiatcnt and more afirioii« nlKuruintiria cxiaM, siicli ai
Be«ii ill j>hthi»i», in ah-ok'Alem.J'rum r^'^/. etc., tlio prcccilinj; Iciiom are
more |>r»iii>uticcil. The kidnoy U i^vm'rnlty ii)cri-a«uit in sîu, hut may
bo normal, «nO'Hh upon tlio «tirr«c<-. lis well a» upon section ; the ctrlkal
■ aub^Cniico i* ycllowi^h-wliiic in I'olor i\w\ very rvidently «pa<iue ; the coo-
si.^tciicft i^ Moft ami (l»ii;j;iiy, l>ut nvvcrso lUbbjr ax iti catarriinl ite[i)intis.
The cortex of tlir kiilni^y, at ^t*\ view tiM^niK anicmic, but Ihe et«llaii!
veiiw of Verlieycti however are Rlleil with hlood aitil ihe nloineruli an*
congesteii ; ttiis appearance ia caused by the opacity of the (ubulcs. The
re*l raedullary fliibntatiee is traversed by yellowish and opaiiiic HniMi,
foUowin-^ ilie direction of the straight tiitiules. ihe loops of f lenlv and
the colle<:tiii;ï tubules. The mncons membrane of the prlvis and calyuv*
is tliiekeiied, slightly opaiiue, nneemic, or pro«cnt« a v»rico«e didtviMoa
of the veins.
The histological vxaniînalîon of thrge k(dn«ys ohonid b« mndo in tlie
fresh state, if llie lesiims «f the C))ttlieHiiiii are rlcuîn-d to be «ell seen.
In [bin section» oxaniiiied in water with low power, atmnst all iho convo-
luted liibiili-s iiiipcnr opniine niid dark by transmitted li^ht, white and
ftl*o <)|>a<pu- by reHt'ctcil li;;lit, because of the fst lliat they contain. Thes«
Inbiiles are frefjuetitly varicose and larger than normal. The loop* of
Hcnle are likewise tilled with granular fatty cells. The condition of th*
8traif;ht tubules of the medullary rays varies; sonie are normal, others
contain free fatty colls. The collectin:* tubes are generally ivormsl,
and their cells unchanged. The Malpi^hian (ilomeruli are usnally clear,
yet 8^^tlK•tinn.^'( they prewiit in places an Opacity, due to a f;riinnb>-fally
de;;enenili"ti of the epithelium which covers them and lines their eapsiJe.
With a hi.:her pi)wer, the e]>itheiial cell* of the convoluted tiibutes
appear filled nith fine and larger fatty and albuntinous ernnnleo. They
contain a nncleits seen by coloring with picro.carm>ne. Their shape is
frcfpiently ohun):ed : some are larire and spherical, separated from the
hyaline mcnihrane. and occupy the lumen of tlie tubule as large granular
bodies; oiliers are irrej-nlar without any definite shape, onisistiiij; of
nasses of fat and albuminous granules i^urmunding a nucleus. Free fut
and albuminous grunulcs are found in the lumen of the tiibalcs with
hyaline cast*. These casts, the substance of which is iisually perfectly
homogeneous an<l vitrifins. «re covered upon tbcir surface with cells or
fragments of eranular fatty cells, or with a gmniitar layer which com.
pletely conceals them. V'ery rarely granule.'* are found in the albumi-
nous imv«.«es which form the ca-<is. Numerous cittl^ are found througli-
out the whole course of the tunnies. The hyaline mcinbraite of the nri-
niferouB luhules is atill recogniKable, it has cx|>erienced no change, but
when isolated it is seen lo have upon its inner surface fine fatty granules.
I'hc arterioles and capillaries are genemlly normal, but it is not
unusual to sec upon tlie surface of the small vessels of the glomerulns.
Mid butirvciL them, a minifcit m^tUiplicalioa of the nuclei and colU, be-
\
PABSXcnTUATOFB KKPHRtTIS.
625
longing either to their wail, or to the connective tiasne interposed Wtween
tlicin in the tut't of the glomorulna. The endothelial celU, which line tJi«
interna! surface of the capsule of thp ^{lomcmlas and tho eurfnco of (he
vascular loom, »re granular, fatty, de;{entrmt«d. and swollen, frp()ncnlly
detached nnn spbencal tin gmnuliir corpuscles : (hey al«o contain n nucleus,
By jjfiicitlitig a section, tlio ca)>illnnes nnd cells "f the riwcidnr tuft are
frci|>iently t'unnd contitinin^ tine fnl }!nttiules. The connoclivo tisiiiic is
gvnenilly intact. Yet when thin M'ctioiiit are examined in the fnwh «tato,
and iiencillcd to n'movo the e)ticholiuin, very fine fatty gratiules in tlio
prrit<>|il:i.->iii Tiurroiiinlin}: the tiucleii.t are often seen in the eomieetivo tiiwue
cells, or in the colU of the external coat of the amall vesseU.
3d. Incxamiuationsof very inteuflcalhuminuria.eBpeciallT that resulting
from (ho effocu of cold, the ccUa of the kidney are found in a suie of iitoat
decided fatty de;;ononttion. The or^^n is tumefied, nttaininj; double ita
normal nei-'tit or more; it is smooth u])nnit«sTirfacc, nnd is yellow nr ••ray
in odor with line» and spots of a diH'|HT yellow and more opai)Ue (largo
fatty kidney). All thr prcvioiwly dewrihod lc!'l<iiin arr inloni^itiL-it.
F'lr exiuii]ile, (lie convolnt^'il tiilnile* of the cortical siiMtanoo are dit.ited
nnd tilted witli fat. at koiiic points appearing to the umiideil eye a» small
yellowish opaipie 1im^«; hy their union these form small i>]iolj( nf tho
same color (i>jja'(uo non-elevated granulations of Itright's disease).
K^lie kidney is flalihy and solt; îlti vesseU, rariicularly the stellate veins
Haf Verheyeu and the glomeruli, are filled » ith blood. The cortical ciul)-
HMaiue is extremely liiiek, aod it is to this tliii'kne«s that is due the
^rlncreaw in size of the or^ii. By microscopic examination, the convo*
luteal inbulcs, varicose, dilate, and opaque, are seen to be filled with
a fatty emulsion, with lar;^ free jimiiular corpuscles, derived from the
«pittielial cells, and with granular ca«t«. The cajisules of the glom-
eruli contain the same elements ; (he walls of the vessels of tlie glomeruli
arc generally foinid to be in » slate of fatty degi^ncration. The connect-
ive tissue of Ibe kidney, which is not in a âtate of proliferat>'>n, is infil-
trated wiili very fine fatty granules. A lliin section from a fresh kidney
pencilled, (ibows that the very fine fatty granules are located ufion llie
• surface of the Blirils and capillaries ol the stroma ; hy continuing the
pencilling they are almost all removed. The small lacunse of the con-
nectirc ti^uc between the fibrils and cnpillnrîes, cnnstitutin^ the con-
nective tissue lymphatic system of the kiilney, are filled with very fine
fatty };ramdcs ; the cells of the comicclivc tissue are also filled with tlic
tBairie kind of granules. The employment of osmie ncid is useful in
atudyiiig this variety of fatty dcf^nenitlou.
The hyaline casta bave the same characters as those previously do-
■cribed. The lobulesi of Henle are fatly degenerated. A few of thv
straight tulmles of the medullary substance e8c^>e the granuln-fatty
change. 'Hie cylindrical celU of the collection; tubules are found in the
aarae unaltered state : nevevtlieless the lumen of these tubules ia occupied
by round granularcelU filled with fat, by fragments of cells, by free fatty
granules, and by hyaline or granular casts. This variety of fatty degene-
ration of the kidney in Bright'a disease differs very mucli, in regard to
the fatty degeneration, from that caused bv phosphorus poisoiuug.
U
D'itf KIDXKTS, ^M
Tliin Urge, Binootlit and wbîtc kiiln«y i.i irilli JilEcuUj dUtiiigubfarJ
from BOOM) amjFloid kidneys by th« unaided eye.
■tth. Ill B Binall number of caràiof diitatet, in a Te»' cases of arttiritii
d^fiirnintm, o{ ;/\iul , 'y{ {minary iilbiiniiiioii» nppbrîtis from nmist cold tir
&looli<>li«ni. nt tlic »ut<i|»^k'a, kidnev» urc fnunil whicti bv ibcir viMciitiul
Iiistolo^nv^il t(rHio)ii> rr»PiiiMc liut)i of the [irx-ut-din;; vxriftifs, btit «likli
diBor in r(-;:anl to »ixc and «liiipe, bcin); normal or iflijjiitly atA>[ihti'd,
and preMUÙng Ufioh tbcir «urfiiuu [irnmini-nt nnd nidi dvfiitcd graitub-
tionii.
Tliii) gmtliologicnl IcHÎon of ttie Icidtiov mrt; )>c cIiijuliI botKcen lypical
pareiichyiiiaton.i iie|iliriti.4, that \*, .'«iiiootii mid large kidney, and inter-
stitial nc[ibriliii or j^ranular cotitraclitii; kidii''y.
The caiHule of the kidney may he ea.iilv <lctached, or, n>ore frequently,
it carriea with it a thin layer of the cortex of the organ : the surface of
the kidney stripped of its capiidc prcaentâ slijjhtly prominent, ebarrily
raiïod stnnll ;:ranulntions, Uic siïo of a millet seed ; their color is yellow
or ycllowtsh-whitt; and opaijuc. Tlicrc exists at their cirrumfcreucc a
depression, in whidi the much con^îciited etellato veins «f Voriicvttii are
found. Upon «i-vtion the iti>rf»ce of the cortical soWtonce prtaenu
granulii lions aiial<>j;ouH to thosv neeti upon the surface of the otf^n;
Ihey are heinwphi?ricid <m . njiied, ycllowiuli in color, and nniciuio,
vfhile tins vessels and glonn'iuli uliioh surround them are conj^'iM^d.
The promitieiil and opaque j;i-nuuliitioui( upon the surface, and the routtd
or elougited spots, alâo opH(|ue.âeen upon tlic cut nurfitve \a tlie curtical
substance, arc the pyramids of Ferrein or medullary raya, the tubulca of
vhich, both strni';ht and convoluted, are tilled with fatty granular dcgcD-
erated cells, and arc distended or nonual in sise. The contracted tisaat
Burroundin;r thorn upon the Kurfflec of the kidney is composed of atrophied
nod fibrous glomeruli, and of a fe«r atrophied convoluted tnbtdes near the
glomeruli. The connective tissue enveloping tlicse glonKrutt and tuhuhni,
on the contrary, is thickened, as in intcrstitiiil nojihriti*. The MtrD|>tiied
gliinioruli have Aonietimcs undergone lihrons degeneration, ^mieiiuies
they are filled with fat and caluarcoiia granule». The atrophied tabules
contain small cells infiltrated with fine fatty granules.
The (;ranulo<fatty lesions of the convolttted and straight tubnlea «hicli
retain tiicir nonnat size, and the hyaline casts, tiave the same character*
as in the preceding jtsthological condition.
AVheti the atri>pliy i» very decided the thickened fibrous capsule of ilie
kidney it aluBys nbserved to adhere closely to the aurl'nce of (he cortical
substance, which in some plai'cs presents depressions, with a very finely
granulated surface. At other [loints exist elevated yellow granulations.
The cortical substance is partially or entirely atroijliied. It is verr
difficult to say in such cases whether there ii a pareiichymatoui» ncphritu
in an advanced stage, in which the convoluted tubules, ori^ually di)nt«d
and filled with fat. have afterwards become empty and contracted, or
whether there is a primary interstitial nephritis.
The atrophy of numbers of tubules and glomeruli, the fibrous trao»'
fonimtion of the latter, the fibrous thickening of the capsule of the
glomeruli, the lesions of the arterial vessels, etc., are the same in both
[MODS RBPQRtTIS WITU AUYtOID DEOENBRATIOK. 627
Feases. Th«ae leaiona will be Htudîed in more deui) irhen considering
-intentitii) nephritis.
C. Ai-uiMiKOfs Nepiibitis wrm AmuoiD DBOBsnuTiOK.— In the
numerous «isos of diiivIoh) dcjienflration of th« kidney, tbftt we liave
cxamincil. wv liitvc slwayii seen Ihu eitmu •nitnulnr fatty iiltvnttioiM of tlic
cpitht-liul uotU of Che tubiiles u» in piiruiioh/mntoii» ncphriti«; there
wera iiIh) rIwajm h;r<>Hne cimUt, gcncritUy hitrd imd vnxy, itnd tlitr ninount
of iilhitiiivn in llio iinTic wiu conKidcrable. In other wonlx, then* uus
nlniivM nn iUMOcintion of pa re tie hymn to lu* nlbuininoiw iiophntix, with
H|i«i.'iiil ItMioiiii of the veitiiels xnd walU of the tiihideK which ctiar.tcU ri».-
amyloiil de^eiieraiiou. We are, moreover, convinced thai |>arei)i:hyniii-
I tons nephritis proeciles amylojrl defeneration. Wo have never met with
amyloid degeneration of ilie kidnev. «ithovit there being pareoohymntoiui
nupliritis, nhile we have frcituentty seen in tuberculosis, for «xam^Je, an
nmytoid spleen, with pa reiic hymn tons nephritis without amyloid change
of the kidney. There «iih in these cases a» amyloid lesion of the sjileen,
and an amyloid d<rt;fni'nitiini alvriiys bc):pns in tlie jipleeit, there is no
donht that the kidney would hare been attacked Inti^r, if the patient had
I lived loiij; «iioujzh.
'Ilic ^hn)>e and oixe of the kidney vary : at times il if very Inrgro, and its
«urface tAurnooth; itj'ca[KiuleiiieaMlydetii<;hi-<l,k'avin;i:a.-<nrfa(!cu'hiteor
yellowish-while, and, to the unaided eye. rescmhlin;; a larjje white kidney.
In this cn^ic, the amyloid defeneration is not far advanced, oidy n few,
or. perhaps, ft considerable number of the 4Malpi;;hian glomeruli being
altered.
At other times the kidney i« nomuil in siic, rcsemhlin;;, maeroecopicallvi
the «mooth and whiti; kiilney njmn it» stirTucc. It i» now usually much
Fig. 314.
lati 4f ih? waIUoF ihf irf**cl.ih4 «klk'Kciiiabi uf ib< c«ij* uf ilfV tJrvuUr mutcnUr t*«t- mad (bf>
B{0IMMJ
alt«red ; all the glomeruli, most of the arterioles, small vein», and baso-
ment membrane of the (uhulcs are infiltrated by the degeneration, h 'inallv.
in rare caseM, the kidney is atrophied, its surface granular, iiA eaji^ulc
'
«28
KIDNBTS.
adhcrcitt. The organ is changed in tlic tiighcttt degree l>j- infîltmtio» of
tliR ani^ldii) {lubMaDce. It \» vcrv {iraluiMe tlmi nti-opliic)) anijioid
ktdiitivA are only an advaitced ata;:o of a le.<<inii vrliidi livjifin.t by a
livperiroiiliv more or leas inarkcil, 'Ute to a jmreiK-li^vuuitou» ii«|>liritta.
I'lie aDivioiil lesion may lie recognued l>y the onuiilei) eve only wbea
it in very marked, iliat i», when tlic ^'(""^'■uli are large and viirtoiu in
appearance. Wflien tlic medullary substance, and espeeially tlie apes
ot' tbe Malpighian pyramide, preocitu a similar liyaliiic U0)ivcti accon^
pniiie<I by a ecrtain (leimity of lisi^iic. But ic may aUayo be m-»;;-
nized witb tlie naked vye ulien a suluttQU i>t' iodine i» |ioured upon tli«
eurlaeu of a eectjoii, tlio diseased pnrbt becoitiitig îniuiédialely reddîdk-
broivn iu color.
Amyloid dcf^ctieratiou liiui het» Htiidied genemlly (poge 44»). and alto
under li<»i»n« of tlie liver ami spleen (pa{[c« A->7, n91).
Wben tlie leaion is alight it is limited, a.4 aliove mmitioned, inther to a
part, or to all the loo|i§ of the glomerulus: almx^t all of the gloiuerali
are more or less attacked. In these cases, the reaelion of sulphurie acid
eni|>li've>l after the coloration by iodine, gives ibe tnocit dixiile<i rlTi-cts,
vieliling a scries of coloi>i — grccti, blue, violet, and finally red-brown.
Wo have recently studied six specimens of amyloid kidneys, hnvin;;
colored them with the violet of nietliylaniliiic.alW |>reservation in alcohol.
In three of these kidneys, the amyloid ehangc was very extJinsivo;
all tbe arteriole!*, the ghmieruli, tbe «mall reiuf, the hyaline wall of
some of the eouvolut^d tubule.t, nearly all the tubules of lleide. ai»<l the
ttrai^ht tubuleii; woru iiiBllrat^d nitli the amyloid mibalaiice, am) eolorpd
re<l, while the parts remaining normal wore colored blue. Iu the glo-
meruli, the walls of the vessels wore very tliick and stained red. The
I^aioi) attacked their inner layers ; the connective tissue uniting thes«
vessels showed its fibril* ami cells colored blue. The Hat cells which
eoTered the vascular )oo\»s of the jçlomendi were nomuil and blue.
The cells lining the capnulo «f tbe glomcrubw were nnnniil and verj-
distinctly blue. The eajwular mcinbriiiu' it.<elf was j^-nerally nnnnal.
Transverse ttection.t of the arteriolei) abovred their endotbt'liitai very
distinct, uoi-mal, an<t blue in color. In all the emiothelial cells of the
alten'il ve:t:(el)i, tbe nucleus waa ]<bviiily vi^iible ; itit etlge was luarke^l by •
blue lino, and the nucleoli and granules of the prAtophUm wore aUo bine,
nie internal coat, iho laminae of cIilhIic fibres, and the siaootli miL-tcular
fibres of the middle eosil were colored red ; the former wer© swollen. Whca
the lesion was not so far advanced, only the internal coat was degenerated.
The external coat is usually not ini|)lieutcd : its vonncctjve-tissue cells and
fibres were colorei) blue. Yet sometimes a few fibres colored red wera
seen, while the comioctive-tiswue cell* retained their blue color. The
lesions of the jimall veins of the pyimmidit are nnnlogous. and arc well
marked. Their endothelium is preserved intact; tbe reii blood conmseles
and lymph cells are blue iu color. In the convoluted tubules of the cor-
tical sulisLince frequently tlie hyaline membrane is seen tbickenciland n-d;
but tbU thickening by amyloid degeneration is much luatv deeideil i»
Ilenle's loofis, and particularly in tbe straight and oi>llecting tulwles. In
a transverse section of iho latter, where the hyaline meiuhnitc is of
doubtful esiatcncc, there is seen, as in the others, a thick zone, colored
I
rexl, liinicin^ their liimi^ii. Wittiin llii; hf(i]in« memhrnne. th« cpithnlial
eelU of tbtf ilitTi-ront titbule* are (biiiul in (lieSr normtl pn^iuoii and
colored Wiie. Ttieir l)iue color is lowered hy n dark tint wbicli is prolia-
bly duo to tlie cells heins ;;raiiulo.fnil_v. as in everv ullmminoiis ne|ihnliH.
In Uic proparatioiis from the itiree much dc;;cneraled kidneys, none of
UiC epitlielial celU had oxjMtiienccd the amrloid traoiformation.
Till! j>pitlivlitil uvlli! of the convoluted tubules were fre'iucnily fiatt«ne4
by th<' [iresdiirc «xerlod upon tbcni by tlit lii;;hly ri* frac tin g hyuHnu ca^ta
eontoiived in tlit- ceniral lumen of the tiihiib'*. Many of Hvnlr's tubules,
and most of the i^triii^ht aud coUeetiii;; tiibult^M nW eontninod byalinc
easts in itieir liiraei). Tbc castit were «Iwav^ Idiie iti color, more lU^eply
tinted tban llie eelU. A auction of a tubule, then^fore, prc^sent^d tbree
very decided colors: the red color of the membrane and neighboring
connective tissue, the modified blue color of the epithelial liniut^ . and the
deep blue color of tJie central cast. Among the coUectinR tubules were
Keen red stained sections of Ileiile's tubute«, and loops of small veins
containing blood corpn^iclci^ and cells colored blue. The connecC>>'e
liMue which separated the transverse sections of tubules «as olored
bliw, but wat travcrsi;il b_v capillaries with red wall^. The sections
of kidneys which ne have made, lea>I us tn believe that the hyaline
enKLt, which aro fonned as in chronic albuminous nepbritiit, arc not
constituted by the satne .«ubstance that infiltrates the walls of tlie titbules
aifl vessels. We can aUn s»t, that, in these cases at least, the endo-
thelium of the vessels, as well a^ the epithelium of the urinifoTOus tubules
and of the tnciobranes of the glomeruli, arc not iavolvcd in the amyloid
dcgcuoratjon.
D. Fatty Urokskhatios. — Simple futty dcfrenoration of the epithe-
lial «elk of the )yi<lneys i« not generally accompiinied with albumiiiuria ;
there are cases where a small amoutit of albiim>;n is present in the
te. lliuB, in some cases of p»i-'«>uiii;; with phosphonu, alliuminuria
U observed, while in others it is not. Fre<juently there is in old pursona,
in tuberculosis, and iu several ottior cachectic states, a partial fatty de-
generation of the epithelium of the tubules, wi^out the c|aa)itv of the
urine being changed. This m»y have some analo^^y with the physiological
fatty condition of the cpiihclial cells of the renal tubules in several ant-
ID^, particularly the do;; and cat. Poisoning by arsenic or sulphuric
acid produces a fatty change similar to tbut of phosphorus, but less
intense.
The kidneys of a person poi*oned by phosphonu are ty|>ica1 fatty
s. 1'he organs are itomcwhat lar^ijr than normal, iu conse>|nence
anîncreain^of ijie cortical substance; the capsule is easily removed; the
e is smooth, opatpie, and yellowish-gray in color. Sections slww
aane uniform, oj)a>iue color throughout the cortical subitimcc, which
w îa frei[nently congested at the same time. The rat-dullary sub-
stance is deeper red. an) presents a certain opacity when its blood is
removed by washing. The mucous membrane of the pelvis is nornid.
Preparations studied under the microscope, show iu all the tubidcs of
the cortical substance a filling up of the protoplasm of their cell» ami the
IiimvH of the tubules, with numerous fatty granules, generally larger
kidncTS
KIbXRTS.
than those oUerv«(l in paivnchj-matoua nepbritis. The legion is iinironulr
uxtvixlod thi-ou^h all the convoluted and loojicd mbulos; the stmi;ihi
tubuk-s of the conical substance are also altered, hut their t.-]i)tli('liiiiu
coiitiiiiis k'ss fat than does that of the ooitvoliitvd tubidc^; the iumiiu
ui thete tubes ^v«8 passa;;» to iiiuuer'HiB free ^rutiulf«, granular fatty
cvlU, and granular cnats, nliicli couk^ fmni the tubules higher ii|>. Tbr
liniii]; of the collecting tube» iit almixtt itornial. In the luidnt of the
much cliiiugcd cortical suhstnnco, l)ie gkuiiuruli ant ahtoliilulY iiuntnl;
their vcMtvU, and tlie ilat uoIU eoveriut; thi-iii, do not *\\avt any faltv
defeneration; neither ha vo lliu ewlotht^lial ciiLi of the <;n|Mu1r exfiFn-
onced ativ chau)^, Th<! connective tÎKMie surrounding tlie tnhuteA and
cupillaric» it al^o i|uil<< normal in cite cortical Mibstanco, differing in this
from the fatty degeneration occurring in parenchynatouH nephritis, whem
tliore is alwaya an increase of tbia limuv. In paronchymatous uvjihrili*
it has also l>Gcn seen that the connvetiw tissue, the KalU of the cajiil-
laries. and tlio glomeruli were alwB^a infiltratod with very finv fatty
granules.
AVhen poisoning vriih phosphorus nccusion» lh« presence of nlUumrn iu
the urine, the prolophisiii of the epithetinl cellti ID iuftltmtud with alhu-
miiioid granules in connoction with the- fat granuW, aitd t)i« evils are
genomlly snmller than in the fatty condition witliout albuminuria. Iii
phosphoric albuuiinuna the coiuicciive tissue and reoaols of the gtonw-
ruli are norcnal, as in tbo latty form without albuminuria.
Fig. 31S.
Kifi. 316.
UHnir^rvD* Itibp» of Ilia i<f>rl1n^ «dW^pc*
frvEB IhA htLihnjrof ■ nuci-nlbiiiniiturip lorJn at
F>ll/«»«M Id ftllfa[ij)b4UB ifcrltt^ Turn m mM
•ft |>liuftj<li'jrvuB ivLkoulA^.
I
Casta fotmd in the sediment of the albuniiuou!! urine, duo to phcâphoras,
are peculiar in being oompo^ed of a grannhir niaxs, containing fattv
jn'anutes. while in itright's disease tiiî» lunu nf ra;^M i* very rare. The
fatty granules seon ii] the latter aHocliou are only upon the nurlaco of Um
inist« whieh are hyaline beneath.
In fatly kidneys found in phthisis, in alcoholism, and in oltl persons, tliis
]mtho]<igicul change is almost always coraplicateil by some other lesion.
In phthisis and iti atcohulism, parenchymatous nephritic gcnemlly exiMs:
in old [lersoni* thrre arc sl'cu, with atiophy, a dense state of the coiiuec-
tivc lj#»u« and atheromatous lésions of the arterioles of tlie kidnvv.
ALEUMIKOUS IKTBBSTITtAI. SEPRRITIS.
631
I
I
Tn every varicly of irWru», tlw coloring miilwr of tlie biie {«ssea
înlo the iirimft^mijM tul>itlc-«i. Wlivn iW L-liitiiimtion of ti'tliarv |>ig'
Dieiit i* vi-ry f^n'iit, llicrc h [1rn<\iK^\ it Hjiecinl inrencliytuAtouH iiiHam-
n»lioii of l)i« kii)ti«y, nliich we will describe here, f'mce the cpitlii-lisi
celU allow a )tai'tiii] fatly dc gene ration. Jauiii)icc<l kiduevâare Mi;;;litly
larger than nonual, ginooth and yellow upon tlicir snrfftco. Tho yellow
color is varied with ;;n)emBh lines; the cut eurfaco proBents it similar
appcarftiice ; to the (iimidcd eye tJic tubiilca arc seen to cotititiii Inlinry
pi^^nmit; they nppcar tu greenish -yellow liiiuA. These yellow tuhiiK-*
lire found both in the corticnl MiilMUnce and in the EuWtHiiM' of the
pjisnids. By pressure upm tlie pyn>mi<U. ihert- Hi'wt out iiu ivteroiw
nrino, contaiiiiiif;yello<» cast.* covered wiUi cpitlieliiil uell» iiifdtmtL'd "itli
biliary [n|p)ont.
Svctiotis of tho reual aultstaoee nhow, in iwme of the tnbules of tlio
corticJil stiloitaTice, not in all, a ^ranulivfatty degeneration of the cella;
the f»ttjr jennies may he very lar;i;e, ai« in jioiaoiiing hy ]>ho)iplioruA ;
(he same eelh contain hiliarY pi^ieiit : eomelimes crystalaof Uliruhin
em wen within the cells. The inturtuhulnr ciuniccEive tiitHtie also Ehoirn
bUtanr pij^ment and hile crjstJils. Tlie lumen of the tubules at times
contMiM free celU, and hyaline casta. The circumstauce thut the urine
of the ]alieut while living shows these elements, is an evident proof
that the reiud cells contain biUarv pi;;mi'nt during life. This lesion of
the kidnej is seldom accom]>aniea by marked albuminuria.
iKTERfiTlTlAL Nkphhitis. — TntiTslitial ncpliritii*, dianK'tcriwd liy the
formation of new connective tiiisue, embryonic or fibrous, hj fibrou»
slrojJiy of the slomeruli, and hy fibrous and inflamnmlorv induration of
the vascular watU.with atrophy of the renal tubules, is a lesion met with
in many different conditions. It may he general or partial ; it may or
may not be accompauied by albtuniuuria.
AlBUMISOUS ISTERSTITtaL NSFUBITIS. lit. Artil« or StlhrtniU. —
Wo have previously seen that in some case» of pit roneliy matous nephritis
there is a im>w formation of small cvlh and nuclei in the vascular tuft of
the glomerulus, either at it* centre or nijou the vascular loojw. When
tliis foniuttion is very abundant, the vascular loop» ure nut iwparale;
they fona a compact ball, in which the .^inall vessels of the jrlomerulu»
are fuaed together by an embryonic connective tissue inlillrated with
lymph celU. This condition baa been well described by Klobs in scar-
latinous albuminuria.
Ketscb Itas reported several case» of scarlatinous nephritis, in which
the j^lomeruli, the connective tissue surrounding them, and that scpantt-
ing the eonvoluted tubides of the corticul sub«Iaiicc. were infiltnited with
BiUBomus embryonic cells or lymph corpuscles. This lesion is uecom-
panied with a grunidu-fntty dejrcrieration of tbv e]>ilhelial cells of the
' tubolcs.
Tlie infillnlion of the renal eonnectirc tissue with white corpti»olM
awy be comtidered, from our knowledge of the evoluUon of conneiitivc
K liM*ic,as the fiisinlage of aninlerstàliaTuephritî:3,which after continuing
B foow time tenuiuates in the formation of a t^ctorotic tissue; but we lack
I
I
682
KIDXBTS.
pOMÎ^Ti^ cvîdi'nev of tliis clmit^. Scarlnlinoiis ii)tminiiiHriA vuAi în re-
covtry, or temiiiiiile* în lU-atli în tlu- fintt st»)rn, *« tliiit wc tio noi know
of Miy i.'xiini|ilf wliiTi? «Il iiUmniiiiiiria "t tlii* kind lias Unniiuiu-d în
obronic intcrstitiiil ni-]>liritin with »lro]>liy «f tlic ki<t»ejr.
Ki». ÏI7.
IiMntiUtt n*{ilirliU. Tb« tarllot •)•«• of n* pmtMa. Shawlat Ib* *^1sl*r IntltnttM si tL»
lauKDlioUr «ntiKcliirt Tliiii», Tb* <it>libtllïu haï (ktUD out ot Mm <]t II» InVat 4iirUc Iki* r**-
paniUiiior llixHiMi. X'>""' ICnc'O
2d. Chromi" Vari'tj/.^ln tlii» form of albiiniinoiu iivphrilis the Iciiîney
is gL*noru1],y ^miiHor llian iionniil ; tiic nninutit of ntropliy, however, \-nrieâ;
al time» i( i* Sîi'arcely oIh^ rviihic, nr the «rgaii may he reilwceij to one-haif
or oiitï-thinl iti* orditmry .<i£C. Both kidiieyi> timy be Ltiually atroj^iie^l,
or one mjiy he half a» larj;e a.-" tlu- ntln>r.
Tiic fihnius oa|«iilo is thii-keiieil, dense, and adherent. In poroorinR
it, a thin irregular layer of (he cortieal au^wtance ia alwaya separated
witli it, vfhich, iiotwittiataiidin^ its thiiineii«i,aliTayscontains manyallrred
flomenili. Beneath the ca)>su1c, the surface of the kidticy w jîrjiniilar.
he ;;nLnidntione are funned by the hases of the pymmids of tVtrrein ;
they vary in size — the more atrophied the kidney, the smaller Uie ^rninn-
latioiut; they maiMnre from one t<i one und it half millimetre» in dixin-
eter. When the kidney Im* readied the In*l sta^e of atrophy, it« Kur-
faw i* finely ^niniilnr. TliO wntnil i>firt of a {^raniilatinn, exBininiMl
in section, i» either i>{ia>)UC or tratwiuwnl; the latter condition is iiitually
seen in very much atrophied kidni-y!<. 'Ilie cortical sulicttance, liotD
upon tlie fltilifltance of the kidney and hetweeu the Malpighian pyramide,
is lessened in ihickiiesw. When the atrophy is not very great, it pre-
sents, upon section, round 8|M)i3, which are dift'ereniiaied by (he eidor
of their centre diHcriiiK from that of (heir margin. These simL* are
analogous to the Kranulationa uiJon the surface, and represent trans-
vemc (lections of the pyramidit of Fcrreio. When the cortical itnb-
Rtsnce is gn-ntly atrophied, the granulations are visible only iqMvn the
surface. They are always separated, upon the external ptirt of the
kidney, as «ell u« in tiie prolongations of the cortical substance between
1
ALJIUMIS0C8 1XT8R8TITIAI. HRPHRITIS.
633
I
the pyramid.*, hy n tUsiit' mliich i« more va«riilnr ihirn tlie contre of the
emiiiilntioii. Tlic atr»)<hy niiiy he Miich Unit tlie t)iiel(iuM« of t)ie cortex
IH reduced to «m- millimi-lr» i^i- Ichs. The iia-<liiltary .«nlntliiiice i»
always Ies.4 tliaii tionunl, liut ex|ierii^iicoa a tlimiimtiou in niee n-liitively
much less limn thnl ol' tlie cortical layer; iL iit ^unerally i:on;£v.4te<l,
mucous DiciDliranc of tlic [lelvi» and calyces \a congested, tlie aub-
mvcoiis li!;«uo is dense nnd thickened ; somcHinos the pelm ami calyces
»rc dilated. There almost always exist cysu, «isîMe to the unaided eye,
in the cortical iinbatancc. The cmiaistencc of the kidney is firm and
dense. Such are the most im|>ort)int macroscopic lesions.
In an extrpmi; de;;n'c of nlrojihy, a varyiii;; cxteiil of the Itiilncy is
atrophied uikI in places the cortJckl sulMtance lias almost dUiippearvd,
the «orreit[)onding pyramiiU am nlco reduced in nine. At the«v places
the cortical eiilittlitnce is finely ^ninular upon the Hiirfacc, of a doujçhy
eoDsÎHteuce, of a repilar pink color, and hy careful oxami nation wtlh
oblii|ucly incident light it is seen to lie 9<eim-traii:<[iiin>nt. Thlft terni-
(rans]>arency is due to a formation of niimoroim small cysU. iioine of
which are visible to the unaided eye. Iict u» glance now at llie histo-
logical detail» of the foregoing de^cripttou.
Flj. 318.
a -
Btelloa Ihponflh a ft^nniMoa \nt\HntfM BrIjrhi'M dlHiAap. Tbn (rmniilMlAft ffrtTÉTPIlfltff
Ih* wbilA vt lb« IJ|li( ptrrlUo i^r (bv wiira of tb* dtfim, n. lubnLr*, 4, floincrull Ifl tt* wml^
Hoa. c «', f . Ampblxl labnlo ud glan»rDli g| ili* tarnuBilliii; nsaJ raiepelijiu. x tt>
The (;ranu1utioii ix <hie to the fact that the uriniferaus tuhultt^ ocunpT-
ing tlie centre are uominl in »/■>• or even dilated, while those at the peri-
phery are atrophied, »-■< are nW iiuiiit of the ^l'^ncruli; al the name
time, lietween the«e atrophi(>d I'lemeiit», the conm-elivc tissue »lion-s
nucneroiiii cellul.ir I'li-ineiit^ and newly-formed fibres. In order to fully
understand the atrophied portions, it is necessary to turn to the normal
eu
RIDXKV3.
atntfituro of tlie kidnejr. Tlie collecting tubule» divide nnd luMivKto
vhile imHHing into tbc cortical tfulratanve ; tlio rcmiltiii^ tttniight tubole*
tlic» g» to tlio ceulrt' of each small pyramid, givin;; off UteraHj dodvo-
lutc'l tiiKuIw. wliich, uOcr ibrining llcnlu's loops, t«rininal«- in ilic InA
convaluùoDâ of the tubule wliiclt viitorvinto tlie i-»peule of a glorot-ntlu*.
Kacli of thcKc small pyrainiil» (of Fvrreiii) of the cortical subsiaDoe pofc
ecssM at its ccitlrQ straight ntid couvoluted luUiilcs; its periphery cod-
tniiis tbc convoluted tuUulcs, wliicli nro coiititnioutu witli the capsulra of
Ihc gloiiicnili. It in lliese lust elimiciif.-», tin- glonu-nili ami coiivolut^ij
i^tubuU'», «liicli are atropbied and surrounded with thick coiiiK's.-tivc lÎMue.
and it i* here tb«t occurii tbo atrophy with co n true t ion.
When ft section is exauiinod with the microacojie, tbrre »ro Mm,
«round the glomeruli, laminated concentric zones of cAnnoctivc liMiw,
between the laioellie of nbich exist flat, su-llnte, or «nail rouitil cell*.
Williin this comiective-tissiiu envelope, tbc f;loineriilua lias Hn<lnrs>tne
cban;;oA. Its diameter may W only one-thini its tionnal site. The riiiper^
ficial portions of kidney» alfcuted with interstitial nephritis gciwrally
exhibit nuracrutis glonuTuU locatvd very near tngctbcr, oning to the
iitroi>liy of the tubidei» mliîcli separate them. There is no part of Uw
kidney «here the leMÎon is more marked than it in immediaudy beneath
llie rcniil calcule. The cajaule of the gloraerultLi iii usually vrrinUed
Kig.319.
*■ iHiliWd (Innrrnliiii fmn lb> nit»r* Bf a kMi»T •(•'(fd *tia lawtalMU «vplirirUL a.
lft1HB«nt lh< ««(nlcarrlnklnd nait tuld'd )iy IM «11011 it •tIJulAttd niar. t. V«4(lf*i rt
«nd thickened; si>metimcs it prciMïnts ooneentric fohU whicli tniiT b»
iake'ii for concentric and [larallel biyen* uf coniieeiive ti^^iie. But if, by
tea.#hi;^, tbc j;Ionicrulus itt i^olnte^l while still »Hrromide<i willi il« cap-
sule, it I» Keen that the lalt«r becomi'ji distended, uiifidtlcd, and bms the
appearaitce of a rumpled membrane, which tms bee» contained in a KjMce
ALBDHIKOl'S INTERSTITIAL XEfltHlTIS.
6â5
I
amull for it ThU membrane iti made vorjr diatinct bj tho action of
acelit; acid, which canaeti it to awcll. Figure ;it'.t repii-sents n j;1<>"ib-
rnlus iaolaieJ and treated l>v acetic acid. The mcmbnini- wiiich iWioed
the concentriu lawyers and circular folda around thu t;nttiithtr msiiM in lU
interior is distended and presents irre^lar folds, while Hicliin it uro 8<>on
granulitr cells and calcaruons K'^nulcs. At times, in vcrv thin Miotionn of
liidnt-ys attacked with chronic int<-r»titinl Icxioiiit, the «tructiirclesa ca[«tile
of the ^Imnerulus is seen to be distiiiclly tliickened, Ua»ing «jmn ita in-
tvrna] surface flat cells with oval and pmniim'nt nuclei. The hjfaUno
meDibrniie i» not nlwnvs [>r<'*orvi-<I iti intc-n«iitia1 ncplirilÏA ; fre>inc»tly
th« irall of the cavity is lornied hv tiio neighboring connccttv« tissue,
l^ii'i ficoura whvrc the itew formation of oonueclive Uasao 18 taoat
abunilant.
The arterial ttift of tlic glomcruliu is difltorted ; its vascular loops are
iinileil hy a thick connective tissue containing cellular clement^. It
grailuallv alroiihie», and refircsontâ at linies an almost honio^îi-mviug
mas8, irregular at the periphery, and in which Iht- vessels canimt always
be recD"niEe<t. As the atrophy incnases, the vaçouliir infl cimtiiini» 1ms
embryonic démonta: it consists mainly of n few sluUattr colls in n inatut
of lihrous tissue. Upon the surface of this mass which repiv.tviitA the
gloinerulus. and upon the internal Mirface of llie niembrnnc of the
gtoDtenilus. tht-re exist t^itular cells contnining some fatty or calcareous
|Çninn1i-s. Krfi|ueiitly tho entire cavity of the cajMulc is distended and
fiUed with granules of this nature.
The whole of the glomerulus now appeara. to the anaidcti eye, ns a
BOtall. ycltnw or gray, and opaque point ; to the microscope, a» a sinatl,
round, dark, and opaiiuc mass, which efforv-csces upon the addition of
acetic acid.
Almost all the glomeruli are more or less altered, and the (ubules
proceeding from them undergo an analogous atrophy, while the eotntec-
live tissue surruunding ihera is notably tlnckencd hy the formation of
oclls and connective tissue fibre». The nhrinking «wl even total dîiu
appeurnnee of the convoluted tubulus near the glornendi, in the )ieri|iheral
w>iH> of the granulations, causes the latter to come almost in couUct ono
with the other.
8»nietiinea glomeruli are seen, Uie vesseU of whicli are atrophied,
while tlie ca]»ular canity is filled hv a colloid substance. These are
colloid cyatA developed in a gloiDcrulus. In these cysts there still re-
maiti, upon the internal surface of the capsule and upon the surface of
the vascular tuft, a few flat cells.
The tubules, which retain tlieir nonnal diameter in the centre of the
granul.itions. contnin tionn.il cells, or fatty, gntniilar, or colloid ceils,
and their central lumen inclose» hyaline or olloid cast«. At other
times they contain numerous blood c<»rpu»cle.'<. In the firel case, the
centre of the granulation is «oinl-tmnsjiarenl ; in the second, it is o)ia(|ue
and yellow or red. In the »tm|ihieii tnbnleit the cell.-* are Nuall, they
liave lost the charaderii of secreting celU, and they are also xomewhat
granular, (ienerally iwme of the cell» of the tubules are fiile<l with
bloo^l pigment, and, with a low power, give a chin-atteristic yellowish-
browD color. The membranous sno&ttis of the tubulea are normal at the
636
KIDKBTBi
centre of the granulation». Tn the iitro)))iip<l lti1iuk-« tht' DKinkmno \» al
tinifs absent or Uemted with lh« m^iglibori»^ cutiitcctîvu lt««uo,or H naj,
bv thicker than iu the nononl slAte.
Fig. 320.
laUntitUI Biphtttlk A rerf «dnaiad •■■*•■>' 'b*i>T»f>H. >l>nB<a( Ih* Urf* iBogal «f IbraM
AptlhatUfii which WA» c-.aUliivil let >uin* ■>' Lb* ludv* Um £*ilea «u( lu Ibo fnpfttfttW* ut "
The MHlpi<;liian pyramitU do not pri'«ent itiicl) marked lesint» ; tho
alrojihv of llcule'it loojnt uii<t of the «ollecting tnhiilen, and the tliicken-
in;; of liio connective ti^iic, are not so great. At times there aro foiiml,
US in tiic cortical ^ulmtance. numerous hyaline casta which luuro or leas
fill the collecting tubc<t and loo|» of Henle.
Pig. 321.
f,-
I
■,;i"i^>;.
, ..■ y-y
lbi-«« mmû iftflK A. f-rWi-n .>f nn ^ r. '<i.i rirLitiff-rniii Ibiln ojfiTittiitiif la »■ jiiisfa ■ rull«U
txtL K à urifi1fBrou4 lubv tlcii^J wLiU nii'i'^<i-^.i ■[ liltrlLim. An<l a1«a fTumt^aifiK ■ rollpid «aal.
l^rUlfi>i4aA (abt- '- Put i«IIb UalQjf ft ejit JuntiflJ Lr a illUl«d IttbnlvwbMb h*1aU« ft «u1t«ll
•utj^tftuf. d. wlLlL ftpQwo^'lc Lft^tn ftfld ft ««d(nl sT4Biiiftr mu*./, «abtltllBf «f (nuvlfta of kav
In ft mope n^lvanceiî sttage of înlemtîlîal nepliri^ft there t* ^j^rTi, na
above mentioned, a homogeueood aemi-traikfipareai lL«»a«. Exiuniimtioii
ALBITMrMOUS [XTKKSTtTI At NKPllBITIS.
637
Fig. 333.
iritli the microAcajie nhows only atrophied glomeruli, manr of which
Iiave no characieriiitics Ity which they can he rocofnii^ed, some cjMs,
swn only with the inicroBCOpe, mid » few urinitVrotut tutmlvs cwitiuntiig
colloid casts.
Tlic f;loincru1i xrc reduced to small i>phcncnl linlU of fîbrou» tis«nv ;
die niicrowopic c\»ts are at limefl «a elonx* u»j;ctlier, that n section
tliroiigli the fliirTnce of the kidney i»how» tliem coi'crinf; the niirfac« lid
«nidi cluster» in contact one with tin- otlier. Tliey are filled with a
yclloninh or ctdiirli-sA refrnctinj; colloi<l KiilMtnnee. They Are iindoiiht-
eilly ilevelo]ied from ihe iinniferouit tiihulcs. Ity ihe wd»;,» of tln'.*c cyst»
are scon sgcIioha of greatly alropliiod iiriiiiferoiia luhideH filldl uiili
CAlIotd Koaia. The cysta freiinciitly contain in iheir centre a colloid or
fïranular cast; and by exannuin:; a secdon, not too thin, and varying
the focus, the caat« in the interior of the cysta are eeen to extend into
a nriiiitVrotiH tutinlc. (l^i^- &'Zl.)
The atr<:ipljie<l uriiiiterotu tiilmlcs mid the cysttt which ramnin in the
niilitt of the new connective ti««ue have a vi'ry «tniilar strut-taro. In
trun»vt!f«e fcclionit very narrow tuhnleit itre w^en wiili » thin hyaline
menitiraiic, upon the in»i<le of which is found attached n single layer of
cuhicnl or pyrninitlal cells, pnn'ided with a
round «r ov«l nucleus which is colored by
carmine. In the lumen of the tuhiilo there
almost always exists a colloid cast. (Fig-
Thu colloid eyst* hare the «me «Inidnre.
There i* found tt hyaline meinhriiuc applied
ajcainit the conticctive tiitsue nlnch hits ;:mwn
thick around it. In this tissue, tlie cellular
elements are flattened and placed in tlie direc-
tion of the fihres. following the concentric form
of the capBidc of the cyst. Cjion the interior
of this capsular membrane there is seen a com-
plete lining of cubical cells in the small cyst»,
and in the more distended cysts the cells arc
ali-{h(ly flattened, but in both always containing & nuckMi>i. Within thi»
fir^t layer one or two other layer» are wen in which the c.dl!< have no
micli-n», «re upherical, tr.HWpa rent, and are transformed into »ni.ill round
DMi^M^rt of colloid "ulistanoe. We thinh it is by thf fusion of these ele-
ment» that the colloid snhitance filling the cyst is formed. This tiuhsia nee
IS floint-tinie^ homogeneous, aometimes granular, or it foi-ms slightly yel-
low, refracting, transparent, concentric layers {d,j\ fi;f, &i'i, fig. 34S).
Acetic acid swells the mass, causing the concentric circlta to disappear.
In the centre there is seen either a tnio colloid ca>-t — ohler, more re-
fracting, and yellower than the peripherni layer* — or a small collection
of yellow gianules which arc derived very jirobahly from altered red
blood corpixsclcB. This description warrant» the belief that, after the
inflammatory destruction of tlie normal cell.'» of the convoluted tubules,
there arc developed cells, not having the characters of »ccrcting cell»,
but assuming; the cubical or flat ftirra ; and that these celU undergo col-
loid transfoniiatioD and fuse into a colloid niaas, which ia itkcreaacd hj
riiUL<iii<i"irtii«r>EiH>b iff Uifvpt'
tbtlul pril4 4f É urlnUrrou* lb'
I'dI* in UiUnlliUl nrpbrlll*. a.
t'liniiveilmiitSF. e. tiiihi^lu)
UaliiK of IL* tiiW f, ColMâ
c^liB- f- ratLuM ii&,i vllh ton*
tenlilc Inftn. X >^-
688
KTDHITI.
t)ii' depnsit of 8tioc«asire lavers, while at ttie anme Ume new cell» at the
periphery îiccomc colloid. In tliia conception of the fonuatio» of (he
colloid coiitonW of the cyals, th« centre and cculral layers are necessarily
tlic oldest formed.
Th«8e cyiit« are iiol alwuys onstîlutcd l>y the distension of > sin;;le
bibulv : .«eviTol nynU may iiiiitt- tu funn one, when the connectii'v tiasue
tnrnniiiding Hcvvnd tubule» d(ïvelo|M into a thick covdupc couttuon to
tliein nil.
In an atrophied kidney we once ohwrved « cyi»t. nearly one cfliitirwtrc
in diameter, Mtimtcd tii liie inidAt of a liK^ue hllc-d nitli nnall colloid
cystH. The wall» of tiie large eyst were formed of tiiick layer!» «f very
dense flat lamell» of connective tissue, reseuihling thnt fitrnwd in tliv^
fihrous ttiickenin;;» of the capsule of the aplecii, ami havin); a cartiU;i
noua appoarancc. Tlie ttuid contained in the cyst was Uiivkened by
nits.
By tea»in|; and tearing; the renal tiesuo transforoied into colloid cysta,
the small cysW are ohtaiiied iitiiled to;;etli<;r hy narrow WihIs of lilirotu
tissue reM-mhlin;: a itlnii>r of hendd. It is very pr^lmlile thai iht-y an
dev<'loped one helow ihv fltlwr in the course of the rame uriniforous
tidmle, Ijiit the fihrutiA lissue niiitint; them docit not always hare tliv cha-
racter» which helong to an atrophied tuhule.
Fre4]uently, in granular and atrophied kidneys, there are foiind Ruall
concretions of the urateit: they are seated iu tlie iiiilielaiicc of ilic pyra-
mids rallier than in the corlcx. The white concretions are cliarHct'Tistic
of ffouty nepltriti», and ttro formi>d of itcicular crystals of urate of soda.
ng. 333.
Kbtfvlbi; Lhit jfFr41 rhl^Vrqtatr kt' th" tAfbAl IvniiitudlaAJ Bti.l riUroiU cIitqIat BtiocuUr (hi, 4
oribsoour abrnii* «int. t. I'nniorMi »rlli>n of anDIlirr ■(••■1 Itia tlttM*. U(M ■■ •*<■ lU
Utlektnlngofthariicnl» BuitcuUf «nil iilrrual Rlxui» oui. X*"- |Or*n>)
The red concretiona are due to aiDor;ihou!) urates. Botli liare (he name
location, and at first iill cither the coUectin); tnhules nf the Malpi^hian,
pyramid, or the strai;;ht tubules of the cortical sulintancc. 'llic ilc)i"«it
^ontinuhi;; to increase, invndes the ncigboring connective tissue, aiwl Ihi
larger concretions include u ^roup of adjacent uriniferous tuhuleci which'
are filled while the connective tissue is at the same time intiltraletl hy
the same sail».
The vctfsvl* in Uiis variety of nephritis constantly experience very great
ALBIJMtXonS INTBRSTITTAL !(EPIIRIT[S.
039
ZïOJiâilUilUtÊâtflM. To the iinaiiled 6ye, the art«rice are seen awiit-
tttd^ tliîok^ned aitd vlp\\, not colluiiains «lieu u trnnsvcMC iwction is
iiut'lv, (Çeiiemlly tnrluoita if ihe section is U'lij-it'i'limil ■ Thcite Iv^giM
bave bec» ixiintod outam) known for a ton;; liiiic, Iml wiiliiii tin- ymti few
yeAn tbey have been llie sutiject of •Ji)^cii«(i<>ii)> nnion;; »vvei-iil K)i^lî»li
writers. Jatmaan refers tlie imluratioii of (lie nrtcriii) wiill.t tu a )3V|ier-
Irophv of the muscular cont. «liik- Gull aixl riutlixi r«;;af>] it aâ a ile[iosit
of a tivnliiie libroiil or hyulinv i^raimlitr mtn» ititiltrntiiig tlie walUof tite
«rtcriolcH and capilUrii-a. Wv cannot accept tlie oi)imon of cither, for,
in llic ciwe* wc have «ecii, the nrteries were only affected by chronic
artcriûs. When thin »cetiiin.4 arc exutninod with low (lower. the arterioles
show ibeir wall ibiclc and ri^id, preiienling in their external and middle
portion:» a dark coloration due to the great abundance of clastic fibrvâ.
The external and middle coau )K>i»esa the numerous cellular clenient«
tieen in arterial sclerosis, and there is usually also an ondartvntiM
eharacterixed by the proUferalion of tho cells included between the last
e1as[ic lamina and ibc internal surface of the vessel, 'flic calibre nf Uie
arterioles is dimiiiishcd: at the same time their wall is thli-kencil by
chronic inâaiumation. The wall of the capillaries returns to the embryoitio
stati', and tlic veins are attacked vfith chronic pldvbitis.
Such an; tbc aitatomical characters ol this disvsM!, which is slowly
i1«vclopcd, is aocompanic-i) with variable and slight albuminuria, with the
voiding of large ipmniiiie;' of urine, with litlle or no cedcina, and h gene-
rally aiMociatrd with bypcrtr(>)>hy of the left ventricle ocoasioneil by the
diSicuIty of the circulation in the kidneys and a consequently increftud
pressure in the aorta. In all the caacs of atrophied kidneys that wo have
examiocd, wo have always seen in some of tbc tubules less atrophy than
in others, and a grannUr fatty degeneration of tbc epithelium, similar
to that observed in parenchymatous nephritis. Ctinsci|ucntly in ibvsc
two varieties of albutnimnis nephritis there is an alleration of the reiiiil
epithelinni common U» both. Ti> distinguish between iuterslitial nephritis
and parencbynialoq.* nephritis (large white kidney), il rnunt be remem-
bered liiat in the latter, the connective tissue i» normal, tho epithelium
of tlic tubule» U primarily granulo-fatty, and the surface of die organ is
smootli. The symptoms diller aUo, fur in ihe latter the course of tlie
disease is more rapid, the alhumiuttrla is very abundant, the iiuantity of
urine is less than normal, and the <»<lema is always very decided.
The preceding facts appear to be well establtshed. and the two distinct
groups of symptoms correspond with two well-established distinct lesions.
But before concluding from these syndromes two distinct diseases, or
even two distinct varieties of the same (Uright's) disease, it is necessary
to be certain tliat tbc granular contracting kidney never begins in parca-
cbymatiiu.i nephHli:i. Now it is preciselv this ipieiti'in which dues not
fieem to be certainly ciilahlishcd. 'llic laststagew of inieniUtisI nephritis,
the atrophy, tlie lihroiLt thickening, etc., arc well charaoterixed ; but
what changes does the kidiioy undergi> previous to these stages? This
is difficult to understand from the descripdons of autopsiées given by
writers. There is only seen at aHtop.ties one anatomical phase of the
disease, and it cannot always be said what were the preceding changea
or what will be those which follow. The first stages of granular contract»
uo
KIDS BY s.
ing kidney ^ven bywrilera are, especially: 1st, coiig«Htinn,accfliDpaniei)
by a sli^ïiit hypertrophy ami iii<luration ot' the ârgan. a lemon ooiiudod to
both, and we will not consider it : '2d, coiijiestion and inSltnttioo of the
vidlutar tixHue and lynif-hatic «(laees by white blood corpuscles or ombry*
oiiic cvlU. This is ubsi-rvcd in H:nrlatitia, «here the epithelium of the
tiibiil<-?i i* fatty ;;niiiuhir, while the vclhdur ti^ue is inilaiDi'd, ultliough
Atvopliied iiite«tinul iie]>)iritiH may nut be the cotiM;()UeiK*e : <t<), there
a» tt tibrftii» nrf^uii nation of the connective tisjiite ; the aiito|Niii'S cited lU
heh>ii;riii^ lo till» stage, tthowcd the iiidumtion of tlio kidiwy of enrdinc
dinotiriei. In this CM« the coniioetive tiiuuc k thickened, niM) organ-
ized ail a condie([uence iiF the btoixl atus.h in the kiiliii'V. Itut is tliijt
lesion one of those which may lie fnilowwl by the airojihied ami granular
[ kidney of Itright'ii diaeaae Ï Wo doubt it, ^ince. in nearly every autopsy of
cardiac lesions there is found tliia cyanotic induration of the kidney, which
evidently has existed a lon^ time, while the atrophied and granular kid-
. nOT is relatively rare as a direct result of a heart affection. But in
' ftCKiiowledgtRg the probability of the existence of establijihed li'*ioiw oorre-
Spondin^r lo itymjiloins in the fçroup of iilburaiin'iis nephritic diiteiue^, we
will not venture lo way. that firannlar iiii>T»titiid nephriti* never follow»
an initial ]>»reiicbynia[oui« nephritii*. Il M|i}><-iir« lo iLt that tlie differ«nc«
in the typvM nf albumineux nephritis dejiends eijx'cially ujioii the inteniutjr
of the pro'lucinjf cau'e and of the lesions which are tbeconseipieuceof it.
. For example, :u the result of eold, there is produced an albuminuria
' which di'vclojw t|uickly and tenninatett in death. At the autopsy there
is found ft 1ar;;o whito andemooth kidncr: th» intcngitv of the ti-^ionbai
killed the patient. Would this saute kidney later have been atrophic),
if the patient had lived long enough? The pathologist who would judge
without having before hi* mind ûie evolution of the legion», would very
certainty M'lxinite the recent infiirction nf lite kidney, which in prominent,
red, or yellow, ami the cbroniu infaretus which ia repreaentcd by a de>
prcMcd and fibroiL'i cicatrix.
AVheii the exciting cause is slow in it» action, for example alcoholism,
wo may have cither a nmooth kidney or an atrophied and granular kid-
ney j Ôie lesions being limited, and slower in their changes, the connec-
tive tissue is irritated at the same time as the cells of the tubule. When
the canse is constitutional and \'err slowly developed, a» gout, the lesions
will be limited, and at iirsl not very intense, and a tyjMcal granular con-
tncting kidney will be found at the autopsy. Itut it should be rcmeo-
bcred that there always occur», in every case of albuminoiw nejiliriti», a
jçreatcr or lesser chnng*? in the renal epithelium; when it ix «{ttedlioiiable
if the Ie*ion of the tubnlcs if primary or secondary, we do not believe an
aiii4»er unu he arrived at, except iu the two extrême» of these rarieties
of Hri;;ht's dttease.
The kidney may bo attacked with inlerstilial nephritis at the same
time that the liver i^ affected with eirrlio^is. 8ucli a complicaiion ta not
nro in alcoholism and fftat. The t^ngliiih writerii insist upon this coin-
. cidoncfl ; it is probal>ly tnore common with tliera titan upon Uio coutuuinl.
t^Grainger Stewart observed cirrhosia of the liver fifteen dmcB m a htiB-
dred cases of interstitial nephritis, and Dickinson once in aevon. Charcot
ill vitin;j these cases reports that in five or six caaes of interstitial pocu-
KOII-Ar.ilPMt!i(OHS IKTBRSTITtAL XEPIIRITIS. 641
tnoniK (fihroid plitliUi^of Sutton) he liik> lwic« «eva int^nljtinl ncplirilis
«itli albuminuria.
K. Ni)X-.u.ui'Mi,\in*s IxTEBJiTiTtAL NtrilKiTl» — fieiieral or partial
intcrâtiiiut nej^irilis is frei|iieiitlT seen witlmut albuniiiiuna, wlikti in
eviil«nc(.* that an inttnmtnatorv lesion ol" the c^nrtective ti»»ue of the
kidncjp boH 110 direct connection with the preflence of albumen in the
' arine.
tioncntl intcnttitinl ni-phriti>ç nithoat nlhuminunn 19 o^Mtrvcd in the
Benile »lHt« with chronic iirtontis, and tn chronio calculouo py«lo-
tiephriti:).
I» !*eniIo cachexia with nthcToma of tJio aorta, moro or low g«ncrul,
the kidneys arc iHiuillv hanl and small ; their capsule in nn>r« oiihcrent
than ill the normal MtAte ; their ^itirface i^ Rneljr granular; Mmctiiucx it
nreijcnta infarcti in différent ata;^» of evolution ; the cortical «ulKitanco
IS alrnphied and pale, while the nieduUarr auhntAnce h C(iii;;e.4t<-il mid
nearly norrnal in amount. The renal arlenes are «cleroiied and har^l.aa
in inicrstitSnl nephritia. K\amined with the microscope, the connective
tiiiitue of the cortical substance ia seen a little tliickeiied ; a few groups ot
vlomvruli arc sclerosed and atrophied sa in the preceding lesion ; there is
an inUTMtitial nephritis, hut it is chronic, not very intense, and the tubulea
ftn- ^■ucmlly nornml. There is no albumen in the urine. I» calculouB
pyelii-nephritiH, the utrnphy of the cortical siihi^lnnct- îs still mire marked:
the iiitlnmnijitioii of the tissue iif the cajhuIc and iK'i;ihl"priii;; or;*au is
such, that there may occnr a pen-nejOiritiA, cither acute and jnindenl or
chronic, with the new formation of connective lixrtuc. The Aitrroundin^
cellular adipose tifiHUe may adhere so intimately to the capsule, that the
whole forms a single mass, in the midst of which the kidnev is found
almost completely atro|thied, compressed from without inwards hy this
chronic inflammation, and from irithin outwards hy distension of the pelvi-i
and calyces filled with calculi and pus, A microscopical cxaminalinu of
■ tJK'se kidneys shows the vessels sclerosed, and the renal connective tissue
fleiis*^ and thicker than nonnal. The urinifrron» tubules and t^lomcnili are
vftry nittcli atrophied ; tin* latter are transformed into small fibroid muMca,
aw in /ninular intt-ntlitiul nephritis of Ilri;iht*8 <liseasv. The most ex-
treme dc;;ri*e of atrophy of the kidney i» seen in some ca«!s of pyelitig
and (;alculoii.<4 hydivi-mtph rosis, in whicli the entire renal wuVtnnce sim-
ply form» tlie wall «f tlie cyst, while the pelvis and ealyoes arc enor-
mously dilated. The^e varietieit of very chronic and atrojibied int«r-
Blitial nephritis by their causes, by their lesions, hy their symptom», and
especially hy the absence of alhumînuna are very far removed from
those forms which are included in IIri;;hl"s disease.
In interstitial nephritis without albuminuria, the tubules contain
iK-ither hyaline nor colloid casts; the epithelial celts arc seldom fatty
de;;cncratcd, and do not exhibit colloid degeneration so frequently as in
utbuminoiu interstitial nephritis.
I'artial int^rgtitial nephriti» is soon surroniidin;; most tnmont, ftnd
Mpecinlly those of a connective tissue typo. For example, around gum-
mnta, the tii^'ue of the ;;umma. which is primarily developed from tlie
fixed oKrmeiits of the renal connective tissuo, extends from the tunuir ua
41
13
KtDNEY.
thick partitions wUicb scnaratfi Uio tubules and gl»m«niU. A^ain, tulicr-
culoiis jj;ranulatioiis of tlic kidney arc, at lli«ir bc'^iiimng. onlr a cillcv-
tiuti of ciDlirvonic corpiuclos arraii^od in tho coiiin-L-tive uekw of tlio
kidnev— -I'lciHcnts wtiicli. »cciimiilatint;. occilsiod ulrupliy and •r^iiidt^
ftttty di'stnicttoi) of llit- i-t-ll» of tlic tubult;», mid ditçii|>]ifaraikC«' of ihfl
luttvr. Around tutifruiiliir ^runulaliou»', tliv renal <.'onni-ctJv« ûfimc »i>pta
arc thickened by an intjltnition of :finiilur vinhryouic or lyiufih curi>iM;lc«.
Sioall filiroiui tiimon!! (fihroRuitn) ni-o rarely found in llic bunun kid-
ney, hul tliey are more fri-inwnl in ihe dog.
C'Antraeted eîentriooH, which nrc clinractcriitcd by cnnitiderahlc ilopret^
sion of the cortical ^iiirfiico of tho kidney, and which tollovr oM infafxrli
occoflioned by an euibohiH or thromhus or by atheroma of a renal arteriole-,
arc vcrv distinct exmnplca of partial inlor^litial nephritirt. lii thiit caâv,
after all the clomvul* within the infarctus have bceomo degenorated and
absorbed, a tnie fibrous cicatrix tak«s tlkcir plac«.
SLTniiAtlVB NsnililTtfi. — There arc two foniw of Kiipimmtion of the
kidnvy : it may b<- diflniiv or in the form of mctai'tiii.ic iil<He<-M.
Ist. IUffwef Sufimrittion. — This <^iccur» after c>iniii»ioni>,irauiiiati«nu,
iiifluminritionM <-\teiidin;; ahing the \X»i\\v of the excretory ducttf, c«niwd
by calcidi of un: [itjlvis or ureter», retent4<in of uririe, in uieritiv carci-
noma, diiriu}^ the coiir»c of Apirial dii«c»Ae, «tc. The IvHoii vuricit in
«xti?ni, it may afli-ct one or both ki<liK-yii.
The or^au i.-* at tii^il congested and swollen, a consideraMe amount of
blood i'scfipes upon makiii;; n ecclion of tiio kidney ; by waghin-;. the
rcdnci!^ tC^-ucridly ditninishe», but tnie ecchymoses remain, either as red
or a* Aaxx colorvil »|)ot«, due to blood exlnivuxations into tlic cotmective
tis!<ue of the kidney, into the vupeule «f the i^lomcridiiA atid into the
nrinifi-mii.* Lubnle>. Inoorreaponding poinU, the fibrotw cap«tdc «f the
kidney is dyejily injcct«'d, prewntitif; vii.-*ctdnr arborcMierww, and cv«i
red or slate colored etx-hymorteM. Wht^i there i.-< foimd Much a dvcided
congestion of the kidney at autojuiie-t, there in usually at tliv «smc [loiut
a colloetion of pus, eillier in the form of one or more al)4cea«c4, or of
purulent collections within the pre-existing cavity of a renal cyM. Kr»*
tiuontly the suppuration Is an acute condition comjdicating a chronie
lesion of the kidney, esjiecially a calculous affection or retention of ilrine.
The ^cnend sh ape of the kidney is retained; it is iiierea^ed in Mxe,
and it may bccom|>letely iufillrntedwithpiu: when the capsule is remove*)
the surface appear» yellow and ojtaijue. The cut surface aUo is yellow
and optu^tic; ujton pressure, n thick pint i-xu<les. Al^r washing the
«iirface of u «i-ction, tliv nina) tissue i« sœn tnlïliraled with pus and is
very friable. A microscopic examination of a thin section shows the
pus corpuscW in the cellular tissue, and in the interior of the tubules of
Uie kidney. The puriform iufdtrulion mont freipieutly uflecta the cortical
substance.
Sd. Suppuration in foci. — At^ome autop^uea, fnui U seen collecteil
into suiall and disseminated foci, and care must be exercised in discrimi-
nating them from melaatatic abweaiies. When these ahscestma arc recent,
they contain a thick yellowish pus ; the wall of the sac is formed by the
SBPPnRATIVE KBPORITIB.
643
»t«Mely congcKteil renal lisBue. Wlii-n llie foci nre chronic, the pus is
tuorc nr IcsH i]ecoiti|i<iiieil, thickened l)V the presence »f viiKiireotu Mtlbi,
or it IS serouM and fvltd. 1'iw sac raa_v coD^ti^t of » true membrane of
connective tifwiie. In kidneys which are the ae»t of ihese chronic fwi,
there are almost always found other lesions, as {lartial atrophy, irrc;;»-
[larities of tlie surface, cTSta, etc. It ia possible thai these purulent foci
Fig. 2-ii.
/
^i^^'i-v
«•y, after the nhwrption of the piw, give jilsce t« kctoh* cystn; hot at-
tention should he directed to the i'nct that in kidncyjt in which serous
cTst« linvt- i-xisted for a long lime, ono or more of the cyi<t« may hecome
6lleti with a turhid jmrifoim flnid. This occur» in retention of urine
rullowcil hy an intlunimatlon of the kidney.
A very freipient error consista in mistaking ft distension of the pelvis
and 'calyces* hy pus for one or more atiscesses of the kidney, 'ilie dia-
t«n:<ii)n of the jielvis and ureter may secondarily occasion an atrophy
of tlie entire kulney, whose siihatance then fonns the wail of a wic filled
with pus. When atisoessea of the kidney are very large, they an- );ene-
rally connected vich a suppuration of the pelvis. Tnie atiscewes in the
. kidney are, however, quite frc(|uont in suppurating pyelitis, which ig lui
occasional cAUse of nephritis.
The sujppuratin;; foci of the kidney have variable terminations. When
only the apex of the pyramiils is involved, the foci may ulcerate and form
irregular ulcers, which freely discharge into the pelvis. C'vstê or cica-
trices, followed generally hy atrophy with a condensation of the organ,
arc the consequences of small abscesses which hav;u healed.
Large absccst^es of the kidney may open: a, into the polria and bo
entcuated with the urine, a comparatively favorable t«niiination; h. into
a portion of the iutcstincg ; c, upon the exterior, pantiug through the
(144 ^^^V V
abdominal walls, copccinlly iii the lunidur TCf^ion; <!, into Uio jH'ritoiwal
cavitv.cnH^in;;» [leriU'iiitix rii|iiillT tutui; <!. tlirnugli thv i1ia[itint;?n. into
the luii^, and bmiiclii. Ruyiîr »iiw n c&tti in wliivli th« Uvur vtiis ulct-r-
Rttfd mill fornii'd thtr wall of an mWckm. wliicli iuvtilvrd licilli llif liver
and llio kiilncv. A r<[i)oittc nbttcoM, coitimitniuuing wiili u ptinilvnt him:
in tlic ki'liicy, liiw Iievn reported,
III «ovtTiil ciwcit iiii|>{>iiriitiu^ nujiliriti» «h-iiw t<i have tenniimlcd l>y n
true tpKij^reno of ll»! kiilney; but it «Wuld be rememliorei) that jiAMt
innrtt'in (U'v(iiii|)0.'<ition of the kidiit>}' is verj ra|)id, and otiglit not be cou-
founded vrilh ganfrrenc.
8d. Mrtnttalie Abtfttte». — Tliese are uxunllj found with nnalof^u
Iciiinna of the lungs, livor, tic. ; hut thoj may oct'iir solely in tlio kidney,
aa o(t«n bappong id affi.-<:tiotis of tlio gcmto*urinary juaasagcs, aud some-
timoB iu typhoid fever.
They can usually be studied in difl^-rcnt i»tAi^« of dcvolopmcnt in tli«
Bame kidney, especially when they arc recent. After ivniorinfj; the
fibrouM capsule, tlien' arc found *i]nni the «urfuee of tlie kî'lney mnall,
cireular, iniliarv, pr-imineiil nggbinieratioiw, m»iw deep retl, otJiers while
or yellow in tlieir centre or thron^houl (heir wlml.- inatis — the latter
beiii); (surrounded by a itone of cimj^-i^tion. The uniidl foci are bi^t for
dtudyinjc under the microscope the bepnning of the su|i|tumtion. A KC-
tion jMiiv^in); throu^fli the iiHiIni of nn a^^loine ration uf snuill miliary foci
demoiirtlraioH that they extend into die cortical and iiiedidlary «uh^tsiwe,
uaumiiig nn nrraiii^rinent wliicli recills the distriliiilimi ul* a renal arte-
riole, or, better. 'nienf the pyrainidsof Ferrein. The«eiiiC;loineratioiuiof
ttninll nlmee^ue» biive in f;eneral the shape of a Cono with tliv bgiac towards
tliu periphery of the kidney.
We cloM' lui'tiwlatic absei-saes with the pnratitie ttrphiitit, A&Kiri\yeA
by Klebi*. because the most n^cent writ<-r* nixm purulent infection consider
that the tmeteria come from a »ani<itiR rtitjipiiriiting fnou* imtiead of
bein^ conveyed by the bloml, as occurs in puruleiil inrtetitm ; the small
Alg» and s]!ores pass along ihe urinary imA-utxcj' in tbiti form of iiephnli*.
Siarlins from the htadder or pelvis, the infecting particles anceiid into Uw
cortical siibittanco by way ot tho urinifcrous lubule». Their preiienee
occasions irritation, and fatty degeneration of tho epithelial cell», aud the
escape of lymph celU eitlier into the uriniforous tubuleâ or into the con-
nective tiwue of the kidney. The abscesses which are the result «f ihîi
inflaiiiniation have the sninc seat and shnpe as metastatic abeoosses.
Wv readily ncknixvled^^ that, among the many causes of metaataiic
alwccsws of the kidney, the presence of ]>arasiteA coming from tbo bladder
in catarrh of it» niuc"iL« luenibrane, «r carried by the blood in infectioiu
disea:Keit, may be riK'Oguiïecl a.i mie.
The hyaline co-hIs in ]>arii!iitic nephritis, rcjircsented by Kleha, and
observed during the life of ttie [latient, present u[><>u (heir Nurfncc spores
and parasitic algte. The great abundance of liacteriH a<lhering to Ihe
casts coming from the kidney irould suggest iliat they atw fonued in the
kidney during life, and that they are not depodiled at tlio time of the
entrance of tlie hyaline casta into the bladder.
PTKL0-XEPIIRIT[9.
645
PïBLO-îtKPUBiTis, — There are many variiMiM of pyolo-nopliritis, Iw-
twcvn X Hupcrfici»! and tvin)">rary catHirlinl {lyclo-iiL-plirilU, siktIi as foe»
aftvT \viicntina hx cnntiisindvs nnd a 8ii|i|iiiratin' pyi-lo-ncfilind», of »
chronic pyi'litU vausod by the lïxiatcnce of culcult found m lh« pelvis,
culy««», ureters, und kidnt-yn.
^Kr CatarrAtt pffeff>-nf]^riti» it) clmnieterizod liy a rednow of ihc nnicous
^HBAnkmne lining tho t'xrivtorv paaita^H of th« urinn, hy a desipiamation
^FbtiiI vt-ry aUundniit formation of ttit- fpitln-lium of t\w miicoiii* nwnibmne
I of the |n-lviti and calyco», and liy a notaMo tliii-ktmiii^ of iliin in«mbnin«.
The urine con(aini«d in llie pelvi» hold^ in itimpcnflinn dt'^iiwrnatcd epi-
' thclial cell^ and lymph ccIIa. The collecting and ittraight tubnles of the
H pyramids luirlicijiale in the i nil animation.
H When the lesion ia more intent, the fluid exuded npon the surface of
^B the raucous raomhmne contains librin wiiich coa;;;ulatciJ and forra;! a mem-
^B branc or lihrinotis pntchp» njion thr ifurfacc of the \k\v\s iind calyces
^P (^p»fmi'-rniriHl>rtiKnus ]'i/fiHif), TIil'«c cavities are now diUtcd to a
varying vxieitt.
Acute purulent p^rlHi» may lie met with iliirin;! the cinit*o of chronic
dise>S4'!i of tlie bladder ami urethra, ha.iicniu^f thoir fatal lerminntion.
It \n iiV*o frL-<(ttently met with in nt4'riiie ciincer nheii the ureter anil
bladder are iiivftded, and in pnrnU'nt infections. The amomil of pus
accumuliiteil in the |ifkis, when there exists an obstacle to Ihc e*ca]«
of the urine, may be considemhie, Tiie connective tissue of the mucous
inenibrnne is infiltrated with lymph eclls, If the diseuse has lasted for
some time, the muooii< niCHibrutic of the pelvis is irrctudsr, and it« sur-
face presents «mall vaj<cular ît""" illations, formed of embryonic tissue and
villi, which float, when examined, under water,
The apice* of tin- pyramid.^ alt» «u^^mrntv, mid ulcerale. Thi'» cimdi-
tion 18 u(>ua)ly complicated with aUUeMK or i)i(fu«e t>nppiiralioii of tbo
kidney.
Cii.-onic purulent pyeliti» is sometimes accompanied with considerable
effusion into thecavitv of the pelvis, causing larye cystic tumors when an
obstrucUon exists in the ureter. These large sacs contain, with the fluid
pus, ammoniacal products, inspissated pus, soft white calcireous matter,
and calculi. The submnciuis tissue is thickened, and the tumor contracts
adliomoRs with the surroiindinj; orjçans. The secreting structure of the
kidney is naturally atrophied, spread out. and flattened, so as to form the
wall of the cvst. The pyraD>i<U are always flntt^-ned. and do not fonn
elernUons. Notwitb^tamling the fihnnw thickening of the wall, the
latter Diay ulcerate and eaiwc an opening I'ilher intrt the intcittine, or into
the lung after parsing through the diaphrngin. or iiit» the siihpentonoiil
connective tiitrine, «hen the piL< appears under the crniiil arch. Ab.*cei<ses
of the liver may he developed in the neighborhood of llie sac, if the right
kidney is the one affected. Peritonitis or pleuritic may be tlie ultimate
termination of the diaeaae.
ft
I
Oateutotta p^elitU. whieb is essentially chronic, is occasioned bv the
^presence of calculi in tlie iwlvis, calyces, or ureter. Multiple calculi are
616 KIDSEY. ■
rgeneraHj* snuill ; wlicn tliere oxUu a single calculu», it cithi'r is tiin)ilo
or ia Fomicd bv tlie union of scvonJ. The shape of thv calculi U that
of the caviticfl which they fill.
Thcâ« culoili arc most fr<;(|uentlT coin|:oscd of uric ncid, iimlcs, oxi-
1]lt« of Unie, niiiiiir)ulo-mii;;ncdium phtMphnto ur ]jlio«pbat<: uf liiuo, cvtitia,
etc. Soinotimea tiii.'V onsiiit of sl-vitiiI Hubs tat icv».
In calcitlou» pyt'litis tin- liidticyM are ftlway-H aflfevtod hy interstitial
nephritis, cyHtx, vi-rv iniirkoil atro|>h_v, «to.
Tlio inucoiiii nicaiiiraoe of tlif pelvis Hnd enIyo«i< ]» alNO alway» mocb
dialled : it le iliiokcmxl, filinnw, infiltJ'iUt'il iiji<«i it« surface wiUi valcarMOS
«alt:< nhich fnnn a »4>rt uf ttiipurticial iiicnistation, or it may Iw ulcemtcd.
Frcim tli« elfecu of calculi, or any other nlMtacle to the pasasfro of
nriue, there may ho doveloped a hitdr^>-nffihT"»i$. tliat is, an accumii-
latiAn of urine in ilie pelvia aiii) conaiderahlc disCenainn of UiU ruMTVoir.
TruKncuLOSis oy tick Kiksey. — Tuberculoais of the kidney is primary
or secondary. Primary tuherculo^ifi is not of very frf>|Ui-nt occurrence ;
it may afieet one or butli organs, hut one alirays to a j^rratcr extent than
the other. In kidneys but little altered, whether in prinary or m'cod-
\ dary tubercnlosic, the hi!>t<ih>fpciil structure i»f ihe tubercle can )>■■ Im-iU
Btuiiied where the grniiidatii^nni nre miliiiry. They ordinarily bc^u in
tbccortical»ubatance,alunj; the arterioles wliieli sepamte the pyniuiidi> of
Ferrcin, or npon ihe surface of the kidney. Ther« «re seen along the
arleriulM of the cortical .iuhiitancv, longitudiiml j-dwd Dr fironpit of tnWr^
oulouH xrauulaùun». Hach of llie^i? fnii- ^iniiiululionti conùstA of a portton
of Lhan;icd kidney structure ; in it tlic intertnhidare«Uulo.v»SGa1artta8no
is thickened and infiltrated with small round cells. The epithelial cells of
(he tubules become ;;ratiulo-fatty, »nd the tubutoa arc compresaed by tbo
abuntbmt cell fonnatîoii in the fibrous partition which surrrnuids then.
The centre uf the unmll granulation beconH-s caseous. Nei;rfiboririg
g nm III II til) I IK fine toisether, funning liirger tniuM^, vrhich «re m<nally lo-
cated ut the union nf thtt cortical with the medutlnrv Huli^taitcc. For a
more minute dettcription of tubei-culi)<ii.-> »<.■ refer to jiart fmi (m-o p. 1 12).
Persons vlio die of primary luherculosi* of the kidney, always pre-
sent a very complex morbid can<lition of the ge ni to- urinary organs. The
cortical and medullary substances are the »eat of large caiseouti tulior-
culous maKseâ. The greater part, or even the whole of tJic kidivey, may
be invaded bv ibis new formaiion. Tlie pelvis and calycos are dilated
and filled witli caseous pus. or with a scmi-tiuid jinlpcontniniog maasea
coming from the desiruetion and elimination of the ulcerated part£ at the
extremities of the Malptghiaii pyraniitbî.
When the distended cnvitie* of the pelvis and cnlycc» are washed
tlivro are seen npun tbeir »iirf»ee elevated tiiherculoiis granulatioiu,
either ilMoreie or forming iv eontiiiuoiis layer. A section <d' the mucous
m<Tmhriino abowa tlial the mucous and suh-niucoiid connective tissue is
very thick, often raea^urin^ one <>r ni(irt> cenlimelre«. It i*. tnuufonned
into an cinhryonic li?.-ue. in which exist one or more auperdmiiosed layers
of tuhoreulouB granidationa. The mncou» membrane 90 altered ««fre-
quently ulcerated, the pus and the detached frapwntfl, which are the
restdt of the ulceration, fall into the cavity of the pelvis.
Vn^iip.4|ia urotor is ponueabli>. the urine L-arrie» iiway tlio proi]!»;!» of
roppumtiOTit i>n<l lia^ »ii unpi-nranci- chttracti'ristic of ronitl tiil>i*n:ulo»ÎK :
it It intimntdy min^lcl with i-iL<.i.-<m« pit» iii») fliiky oj>gii|iic <l4SI>m, which
»rc ilrposiU'il iti a tliick chimly IrtyvT iit i\h: bottom of the \-«»»>:\ in which
it i* hfcirixi. KxniiiiiK"! with thv iiiicni.-it'ftpo, tliore aw finiiid Ivimih
cHli» lou'ti'il with I'lillv ^niimh-.*, ii few MixhI o>r|>u*clw, aii'l di^brin of con-
iicciive lis.iiiv infiltmttiil with Hiiinll nixl fntt^' gtrnimlar celU. Tlie urioe
ooutaina albumen, m doe» all purulent urin« ; but it i^ impossible to con-
found it Mtth onlinary albiiininoitti urine, which ia clear, and contains
numorons hvaVme cauM, while iu luhereutoui urina tubo casw arc nlmo^t
always absent: if they ilo exist, they «re few in number. Tbcw char-
acters «f the urine, with the pun and renal tumor, afford a means of
diai^iiuifis. ■
Tbe ureter is generally alfectvd with llie Mime tubcrculou* Icttionn a* i*
the miicim>i raemVntiii; of the pelvi*, but iiutead of bein^ç dilute.!, ib< lunicn
i-t frcpieiilly cDiUracted, pcnnitlinj; the iirino to [(ana only with great
tlifficulty ; it may be complohdy obtitrueled-
lu the further iita;;eii of renal tuborculoùti most of the le»<îon^ of chronic
punileiit pyelo-nejibritis are observed: calcareous incrustations at some
pans of the mucous membrane of the pelvis, abacessee of the kidney
which have a tendency vi become caseous, a tumor varj-in» in size due
to the distension of tiic polvia, perforations openîn;» into the poritoiwial
cavity and intestine in consequence of tuborculoua ulccraUons of cbe
muicous Diembranfl,
In m;in, r«;nal tiibcmiloîtîît i.< very {iftcii oxicnilcd to all tJie excretory
duct'* »f the urine : tho urciier, the bhidder, and (lie niucoiLs membrane of
the urethra. The griinnlalions are sealed in the connective tissue of these
mucou.t membrane^ nnder the epithelium, and deeper in the subioiicaus
tissue. It is accotn|>ameil with a purulent catarrh. The prostate, the
inal vesicles, the vas deferens, and the testicles arc also sometimoa
i^nqndly invaded by tuberculosis. A special variety of tuberculosis
limited to the ;;ciii to-urinary or^ns may therefore be recognized. In
the female renal luhca-ulosis is much more rare ; it may alxo be compli-
cated with ;;ranu)ations of the bladder and tuberculosis of the Fallopian
tubes and uterus.
t'inully, the patients usually die from a {general tuberculosis in the
lungs and inte-stiiiM.
(JirMJiATA. — <inmmnta of the kidtiey nry seldom occur. The kidney
of syphilitic [«itient.i tnav, however, be affected with albuminous nephritis
and amyloid do^^e ne ration. We have reported a marked example of
gummata of the kidney occurring in connection with amyloid change of
this organ and with gxiromata of the liver. The ginnmala of the kidney
were numerous, twenty iu numltor, isolated or grouped, varying in sine
from a hemp seed to a small pea, very ebarac-tenstic to thu unaided
eye, by their fibrous density, by tlietr caseous degeneration and by
hardness. They were all located in the cortical substiiiico. Kxamined
with low power, tlicy were trans[>an!nl at the periphery and 0)<a<iue
and caseous in the centre. The new formation von.iii«ted of embrvonio
_ muc
■ tiasi
018
KIDXEY,
Pi«. sa.
«aa vr»WIS In lilt ililoT, abnirllg ltl«
unikll-cglii'd (fiiml^Iuci ii»u> In ib«
iHMltUbBlllt IIhB*. X^^""'
coiiiM-olid" tissHP iI('ieli»iiC(J from the pr
(.•xialiti;: filiriiiw n»rtiti«tw of tlic kiilneyjj
'nil* j;l(>incnili wero rury oaail; rwîognii
boUi iit l\\v. iK'rii'licral fiUroua tissue. Hod
ill th<! cvntrnl chacaus xoiie of tlie Uimor.
Ill ilie ]ieri|>licntl xone the now oinlirvmiic
coiiiic-clive lUtiUP purrtiuiiileil ilic elitl visi-
Me Imt alroj'liied uriiiiromiis tii)>iilfti.<
Tlic tiflsue OÏ the t'luniuata did iiot iJiffi'f"
from lluit of similar fonaations bvcii in tlm
livor of the eaiiu) caeo.
LvMPiiAiiKMOMA. — Tlic liiilncyB ma:
111.' tlio Hi'iit i)f ei-comUrr fonuatioim
listing of adenoid tiiwue. Tln-so snmll liimorH <Iu not diflvr from U»i
«en in other organs, especiiiUy in the liver, Tlicy are dovrluitedl
ID tlic conitecuvc ti^uc. Ituleix^ixk'tit of ihrRc tiiinor» there exist
;«H«« wlicrv nil acciim<dalion »f wliito lilood citriniKcliM i» ticen in tlie
(MeU of llie glomendi, in the cajiAule of the t;lonieruli, in the capiU
luric* of llie intcrtuliular connective li^^ne, and liolwce» llie fibres of tlie
latter, in a word, there ia nn accumulation of lymnh celU in nil (lie
giniitl arterioles of the glomcnili, also in all the capilian' vessels of ilip
kidtiev, and a diHtisud infiltration of tlicfic same cleRieiiis into (lie cellular
frniiu'work of the or^an. At the same time, tlie epichclial celU of the
tiiliules iindiT^ a -ïrannlar fattj iK'gt^iio ration ; tlie lumen of the tubulM
sometime» coiuaiiiit collection» of lymph celU, or hyaline esHl«.
Sarcoma. — We know of only two cases of sarcoma of the kidney.
Tlifse cases were tumors of consideralile .siée, occnning in younj; chit-
dreii. The centre of these enonuoiis ajiherieal tumors was softenetl in
one case; there vas considerable infiltration of hlood into the substaiKo
'Mid into the lacunie of the sarcomatous tissue. The renal capsule which
1 everywhere surrounded tlic tumor was tbiekcned. The kidner was
flattened upon the surface; imdcr the capsnle, at some points it showed
to the unfii<led eye and to the microscope the appearance and simcnire
of the cortical substance. The sarcoma was eertjiinly developed in the
suhstanue of the pyniniid?!, at the [loint of union with tiie vortical mib-
fltance. The central part was soft and friable, showing all tlic charueterv
of round celled sarconix, with vesseU liiivin;* enibryoïiic nails in one of
the CMW», and fascicular (spindle-cell) sarc"ni:i in the other. In lioth
leases the dt'velopment of the sarcimia could be followed from the eenlre
to the periphery. In the fascicular sai-coma it liad extonded into the
cortical suhntince along the coarse of the arterioles. The circumferei»ce
of tJie vessels and the iH'i;;ht>orinj; connective tissue around the urinifer-
Otis tubules exhibitc<l a new formadon of round or elongated cells, with
fusiform nuclei, interjjoiwd hc-twcen the fibres.
In the second tumor, the ptirticipntion of the cells contained wittiin the
nriniferoua tiibuU'S, in the lonnalion of sarcomatous tissue, could eery
easily be sludied. The elements of the tumor were developed both in
the connective tisauc ami in the inteiior of the uriniferous tubolea. Upon
1
SARCOMA OF TUE KIDKET.
649
thin sections rnndc from tlll^ pvriphcnl portion where th« kidnej vn* not
deBtPoy«d, urinifcrouH Uiluloe coulil lie scun in iliffcreiit dogrcca of xllera*
tion, eornt- rct»iuin>: tlii-ir normiil sixo, tlii-ir hvaliin.- nienibnint^. and a
sin^e Ujcr of opitlicHiil telU, with » c-ntrnl «iiijuv Iiidku. Alon^^idc
of tticw nornml tiilmlea oilii-r* wt-rx- wvu hiivin» ii tlinmvu-r two or llirce
time? eiitiirfïvil. or even more; tlie tivniiiio mcnihrttiie could still \tQ
rfcognizutl ill thoM! not gri.-fttly dilau'd, l>ut it was nantin;; in tlic tnncli
«il»rged luhwlea. In the firat the e|iilheltul cell* fomn-d two or thivo
I
^rffOB tienut fonrftltand lo1>alA« fn iltn mT<1«i of tfti^mutuna lltton TUa lobule M t U >n*Q ^nlr
l« pitrL TItp lbFC4 olb^r» prr*«bt «u i<iu|iEjr iDtnim 1A. ill Lhd ■'•vrttl ]fejr*r> «f «pLtbtllkl «111.
Tha Ikieriubulac tli*QQ t* ftHa to «DtUi «f oLotaly rro«4*<l «jiibdl* cvLI*. X ^^
BUporimposed laypi-3. The lajcrB of newlv -formed cells consistod «f ele-
inentH smaller than normal : thcjf had lost the charactcnt of st'crftitig
eell^ of the kidney. hitvin;i only un oval nucli^us, surrounded with a nmall
amoniil of protoilasm; it wns nece«!«rr to add acetic acid In order in dis-
tin;^ii«b the nucIeiiH from the protoplnsm. The «mail eells, «rniii;;ed ill
thick layers, were oval or cdongatcd, liavinj; their Ion;; axis peqii'iidiciilar
to ilic wall of the ttihnle. 'Fhe centre of the tubtdv sboued ;m open
lumen. In other [inrt*, the tuhides were only repR!*eiited by large,
irregular gipaci'it, without anv Irnco of n liynline inemhnine ; tlie^te spaces
«ere filled with round nueleatod cell--*, hnviii;^ the diameter and all tlio
characters of emtiryonic cells.
Both the normal and tiie enlarged tuliulea were separated by tlnck
hnnde of a tisi^ue comjioaed mosllv of c«l!s generally oval, seated in n
fibrillar tissue parallel and coiicemric to the border of the tubtilo;, tliv
whole constituting a tissue very characteristic of sarcoma. Tlie periph-
eral sarconiattius tissue «f the small urinifcrotiB tubules was relatively
den.'ie and fUwe; hut where the tubules were enlar;{ed, and filli'il with
round cellx, tlie «iirrotinding itnri''imat^)u» tissue was much mon- frinhle.
lia ccUa were ruund, and tH fibriU fonncil a much looser network.
KIDXBT.
TliCHO two cjuw» very c1«Arly cittnMirih ttie oxiatence of primary sar-
comn in cliililrcu. It i» v<>rv jinibiiMv iliat itonio of the ttimors of U>o
kidney in cliiMrcn, jniMi^tieil a» caticiM^. may Itave Iwen saroonnita.
C.AitrixoMA or Tiir Kidnkv. — lUnal cxroinnma may 1»« primary or
secondary. The latter is doYelo]io<l in nmlules, moat froijucntly li>oat<'<l
in tliL- cortical substance lioncatli the cajxsule, aod lias tlic Btniclurc of ibo
priiiuiry tumor.
Primary carL-lnonin is of iiifronti«ut occurrsncc. Loealci) gvnorAlly in
one kiiliiuy, ihi- tumar may coiulitute uiy of th« varictim nf carcinoma ;
tin" mr-'flt cMtiinnin i» cnwiilmloid, i-spfciiilly lu-matoid carcinoma, <^•ll<>i(l
curcitKinm îi* iiii>rr frciiiH'iit llinn »cirrliii». Tin- inviidi-d kidney rnlnr^^ca
to a varying t-xti'iU, «ml it* wriylii iimy bo four nr five limm grcau-rttian
nonnal. Tin.' xliaju' iif tlu- orjtan if gi?iii'ndly retained, M> that Hie corlicnl
and me<!ul]ary [lortionA may be rccojriiiiEi-d ; yet who» the entire kidney
is not involved, it ir* nuwily in tin' gorlical aitlwtance tliat tlie lesion a(i-
jieai» to liave ori^inateil, Tiie morbid growth is diffuse and nniform,
or il bas tlio form of irregular nodules, iwiiaralcd by tbc altcn-d. but
still recogiiixable renal parenebyma. The pelvis and calyco» an- invidi-tl
by extension of tbe tumor. The tissue of the kidney, alonj^idi- of lb*
rnnccrotu nodules, is at times tlie ^at of a fibron« tliickcning and alro-
phicil inlcntitial nepbritis ; if com)>rc^cd by tbc tumor» tbv clomeruli
nndcr;;!» the «imc atrophied fibrous tmnsfonnation n# in inti'ivtittal
ncphrilis. At iitber times the ejillielial ev\U of tbc nriniferou» tnlniles
are fatty dcj^eny rated, and the hloodveHselii art' ;çrputly congcutwl. Keiixt
bemorrbafîes, a fn'(iuent symptom of these tumors, occur on account of
this extreme congestion of the ronal sulmtancc, aa well aa from the carci-
uomatous now lormatioitH ujion the siirtaeo of tbe pelvis and calyces. In
portions where tbc tumor invades tbe normal tissue by extension, Wal-
devor has isolated cylinders of epithelial ceils growing from the nrinifcr-
ou* tubules, and extending by diverticulse. Robin bad indicated tbe
metboil of devetojinent »f epitlielioma by a now formation of renal epi-
tlielinm; but he ODnfounded, under the iinmc of cpithetiomata of the
kidney, not only carcînomntu, but also other lesions i>f the kidney, par-
Ucularly Brijrbl's disease. AOer the invoJttiïations of Waldcyer, ob-
servations publl-ibed by Neumann and others, have oonfirmeil the inoilc
of development and extension of the tumor by budding of the epithelial
cells of the uriniferoua lubules. What we knovf of the developiuent of
tiitiiors in glands, and nbal we have described relstire to tlie origin
of renal surcoma, incline ns to believe that the epithelial cells, as well
OS the connective tissue, participate in the development and citeusion of
carcinoma.
Tbe structure of the tumor doc» not differ from the descriptions given
of thv several varieties of careinomnta. A pecnliiirity of bmmaboid CD-
cepbaloid of tbe kidney is marked by the presence of very numerous,
enormously ilikited eapltlary ve.-^-'els. Tbe renal vein is «omelimes the
Ecat of cancerou.t thrombi, which may extend into tUo inferior vena oavs.
CvsT8. — Cysts of the kidney are very fre(|uent, and their vftriettes
are numerous. Colloid cysts occurring in the cortical auh^tance during
AKQIQUA — PAKA8ITK3 OP TriK KII>!tBT.
651
P
i
trlvRiiced ïnteTHtî^al ue[i)iritU Imvc nlriMt'ly l>c(-n coiijtiilfrcd. Cystn of
t)io Karoo nklurc fDMowing tlie iliKtt^iifttoii nml fillinj; u|> of t)ic va|i4itli- of
tlie gloinemli li_v th« ^amc oiUoiil inateri»!, may »No l>e iiu-t nhii iiiirli-r
Die 8MD0 circiiinsiaiiccs, hui ilicy are not ao fr^i[ii(riit at> the prwediiig.
Cysts containiii;; lilirin coapilalcd ami Inininaiod u|ion t)ie interior of the
capsule of the t^loniiTuli in kidiievs ^reallv coiip-sted are oliaerred,
vflii-rt tliurc his been primarily an escape of blooit into tlie cavity of the
glnnicruluit. In Bnj2:l)t*)t ilieeiise eysts may fonn by ililntation of the
iiibnlo* in the inocliiUary Mibstanoe. Tin- bisti'b.iKical eliiwaclcre «f these
varielif* iif vyU linve been alremly suffieii-ntly stmiiid, and it only rc-
inain.-> to driicribi; c(>ri<;onitril nnd «rrriiiK cvts,
r<>nj!:4'iiital eysi,* are ul limo.» w> mmii-ntn* that the kidney i» filled
with them ; their »it>ù and that of the or^m nmy be !><r ^ruiit its U> ofler
an oliâtacle to the delivery of the child ; they eoniain u clear Hiiid, which
in unne, prevented during fœtal life from escajiin;: by the excretory' dttcta.
TbcBc cynlfl have their origin iu iho glnmenili; the eaii^iile of tin- latter
ia much dilated, the vascular tuft in atrophied, and llatleued agaiimt the
wall of the cyst.
i$«roii» cyatB frwmcntly occur either in perfectly normal kidneys or
in the kidneys of old persons, esiKviidly in senile atrophy of these or;^ns.
They contain a clear Hiiid, and are small »nd numerous, or larger and
fouer in number. Their mcide of orifpn and devehipment is more difficidt
Ut di'teiniine than in the prcci-iliti); variety ; they nmy be unrnumded by
jxirfectly normal riiial tiiiitue, and in them iberc i» no trace fntind of the
atrophied vascular tuft of the i^loroerul! an there is in llie con^nilal
cysta; they are lined with a layer of flat epitlielium. It is probable
that they are developed in the connective tiiHUe by ttie enlargement of a
lacunar lymph space of this tissue.
Dilated eaiyce» which penetrate between the pyramids, should not be
taken for cyttts of the kidney.
AsnioMA. — Tliere are found in the kidney» small tumors constituted by
capillaries, dilated in such n manner that ibe entire tumor represents an
erectile tjflsue, with cavities IiIIvmI nith blood. Thesv tumors are analo-
jtoMS to similar formations seen in tlie liver, but never iioi|uirc so jjrcHt (k
sixe, and are without any pathological importance.
pARAeiTKS. — In Europe, the moat important panutiteit are the «ohi-
Bococci. which, however.seldom occur in the kidney; when found in this
orgnu, they resemble both in structure and details those deaoribod under
the livwr. Sometimes they break into the pelvis. A very few ctum
have bei-n rejiorlcd of eysticerci and strongyli existing in the kidney ;
I the latter live in the pelvis.
I 'Ilie diâtoma i« a vnriely of renal parasite frequently met with in
Êlt exiatH in the embryonic .-«tHte in the urinary ptusa^, in the
1 in the renal vein. It riccnsioiii* in the kidney pyclo-ncphritis,
wards, very probably, the hematuria endemic iu that country.
652
EXCBKTOnr DRI.XARY PAeSâtiSS.
CHAPTER II.
EXCItETORY UKINAKV r.\SSA<;KS.
irKETURA.
lllETEIt. Bl.APnER.
IfoRMAl. lIlSTOLoov. — Tiic urfttcr conoUu of a [loripiii-rnl filiroo»
moiiiliram^, of a miiftculnr 1iij^«r of oxtcrnitl transrvrM nnd inlemn) loti;n-
tinliiml fibre», »nd of ii mtR-o<iji iix'mlimno. This motnliraite w tliirt, ntid
cK'âlitttte of ^ilniidi^ ; ibt ci>iilii'1ium is lamiimt<'tl, (lie dfe\i colU are smnll
anil roiiml, the middle cvliixlrical or conical, and t)ic iiuporfioial («dy
gotiat or flat. Tlic Madder lia^ lieiieAlli iu peritoneal lair«r of Hltroiu
tiâàiie muscular fii.aciculi, tlic inoiit duj)crlicial i-uniung lon;;i(udinnl, and
Iho iniomsl having a tranaverse or circular direcUou, The foroKT arc
rartly continuous with tlie urachus. Tbe latter do not fonii a pcrfwl
layer, llic fibres interlaciD;^ form a iictnork, nhich cuum*» a «Ii;:))! uitovi>i>-
iiCdtt of the mucous membrane; and nl the nrck of the hlaiMi-r ihvy are
leoiitinuous vrith the intenml sphincter. At the inferior part of the bla^
'âcr in llic tri'îoiK', himndi'd in fivitit bv the uroibra, and bidiiud by
onenin^ipi of tlio ureters; liere tlie fiUruuH connective tissue and thick
elastic fit>re«, which exist in the rugie of the n:iucoa& membraite, also have
tninjicled with them many muscular fibres. The mneous membrane of tii<
bladder, pink in color, is composed of epitheiial cells, forming several
layers, moie nnmcrous than in the ureters: the mo^st superficial are tlal
and lamiiiated.tbe deeper cylindrical or conical and round. At the nec4
of the bladder and towards the fundus there arc fwuiid small, pvrifoTm,1
simple or afy;rcgiitcil j^lands, lined by cylindrical epithelium. Tliere arc
no iMpilla; ufion the mucous niemhraiif of tlie hladiior.
Ihe mucouH ui<-mbran« of the iiriMhra is i-ed and vascular; ita epittie'
lium i.4!<imilar hi thiitof the bladder; il has, both in males and in femalea
nuQiei-oiis large ghkuds, (he </7am/* of l.ittrf. about one millimetre
diameter ; their ol>liiiiie ducts are from two to four millimeUvs long, an
are lined with cylindrical cells, which secrete mucus. Tlie snbmuc
connective tissue fortna a membrane rich in clastic fibres ; this membmne,
in the prostatic portion, is intimately united to the proMat4:, aud to tlwj
cavernous body in the spon^v portion.
PATIIDIXKIICAI, HtSTouMir. — ITi/f>rT<rmi<T of the mucous membraM
the bladder is obitcrved i» certain poi!>(iirui^, by cantharideii fftr ex-
ampK*; it also «xisti* in all acute and chronic inllammation^ of tbe tilad*
der, whatever may be the cause. In old persons, in diseasea of the
■i)Mnal cord, or as a conseijuence of tumors of tlie nei};hboring pans, there
lere seen ecchymoses in the submucouH connective tissue, at tbe base of
the bladder, and especially at the orifice of the neck, This same rep«
of the bladder, is, in eome persons, the seat of varicose dilatatioDS of T
CATARRRAI. TXFLAUMATIOX OF TUB BLAPDBR.
653
veina, vhtch auty be tlic occiuinn of nhnndaiit nnd re|>e«ted licroorrhagM.
liiematurtn, however, ocean Diore rret|iteiid; froni fungous or papillary
tniDors.
(\ilarrfnil infltimni'itiiu of tlie bladiler, Cftiiwil «ithcr by «inthn rides,
or by nn extension of urelbral cstarrh, by atony of ttte libiiliicr. by strio-
tiire of ttie urethra, by swL-llin;' of the prostate, by ttftVctiotut of tliv Hpiiutl
con), by (.-nleiiH, «tc, may he cither ucut« or chroiiio : it preMiiiU tlic fiimo
bistnlo^cnl diiinges, which have been ecverul ûnivï de8cribi>d in connection
wilJi untHrrhi! of tlie miicoiis membrane». Tlie prc*eiieij of numerouA
lymph cellK in tlie nrinc givrn tlic btter » milky or turbiil apjieuranoe,
nnd there h nlwnvH an nhumUnt mnco-punilent deposit in it. In intense
inSmaonlion limilet) to the boM of the blttilder, there are seen, with the
unaided eye, small prominent resides, resembliiig small pearls, which
contain a iranspiirent or iili];blly turbid, or mtico-purulent ranciLs. thcvare
tbo small elands diat«nded by an abundant mucoos secretion. 'Iheso
hyporlropbied glands are spherical in «hapc and from one to two milli-
HH-trM in diameter : they are local«d either in the inferior part of iho
trigone, immpdiately Whind the orifice of the nrctlini, or in n circle
around the nook of the bladder. Tne imion;! incubrane iiirronnding
them may be deeply congested. At <»lhor limes intoune iiillnininatirin of
tlie bladder camte» the formation of prnmint^nt pApillte upon it<i nurfiice.
AVIien the caturrh has lanted for «oinc lime, tlie irritated subinucou» con.
nective tissue become* denwr and thicker, while the mitscidiir fibres of
the wall are hy[iertro|)hied. The eievt^lioll^ of the iransverae folds form
crypt* into irhtch the nineoiu moinhrani' j^ink^. Tho bladder eaiinot now
be easily or complcloly emptind ; the urine remaining is mingled with
pus corpuscles and soon undergoes alkaline decomposition. Bactorin an
developed, and urinary calculi are formed.
Inteiue acute iuHanimation of the bladder may occnftionslly temiinAte
br sujipuration of the submucous conix^clivc tis-'tiic; by idcerntion of the
overlying mucous membrane, thi» unhmticoai nbucess may conimiiiiIeat«
with the interior of the bladder, which fortmmtely is a very uiifre<|ueiil
lesion, Aaa conseijuence of this process there may result a perforation
of the bladder, a peritoneal [«ri-cy.ttic intlammaiion, a communication of
the blwlder with the cagina or with the intestine.
In other cases, (he violoncf of the inflammation, the paralysis of the
bla<ldcr, the retention of urine nhich i'c<inltt<, may occasion n gangrene of
the timcoiu membrane. The membrane is brown or in patches black;
its surface is irregular, an<l covert^'d with a di^bris iiicrusted by tho
salts of the urine; the bladder contains a brownish fluid consisting of
pus, mncti», fragments of breaking down mucous membrane and blood
corpuscles. The coiisoi|nences of thi* legion are destniclion of a portion
of the mucous membrane, in61tr]ktii>n of urine into the neigbbonTig con-
nective tis-sue, urinary abscesses, local or general peritonitis. I'yelo-
nephritia also ia frc(|uently a conf*eipience of severe cystitis.
Chronic cystitis is otWn accompanied by vesical calculi. Tho latter
coote from the kidney, frotn the pelvis, or they may form in the blad>
der. Thoy vary in size, are free or are inclosed in one of the crypt»
formed by the folds of the mucous membrane. The calculi consist of
uric ueid and urates, of ammouio- magnesium phosphates, or of carbonate
h
KXCnSTORY DltllTAItT rASSAABB.
of lime ; very sclitoin tliej are composed of xanltiîn. Tliey arc attciwiwl
liy a clirvinic catarrh of the blailJer, and a pyeto-iiopbritia U frwiuonlljr
present in the kidiioy and pclvia.
Ulcerating uysiitis occurs in pyfcwia, Irplioid fcvor, low type* of cniii-
tàvc fercrs, etc. A limited and »upcrfii:ml portion of the mucoii" moio-
braiiL' ititittratcd by nii i-xudacion cutaiKiocd of i-xlravasaK-d lymjili cidlftJ
and fibrin, ix «oftuncd and ilcdiroycd by an nicer witli a f;ntyi'>li baMJ
(diphtlii-riliti ulceration of itiv Uennitnv). Vnriolonii jtiixtiilett liav« bedd
noticod both upon thv mocouii mumbran* of the blaildcr and urutlira. ■
Urrthriti*. — The catarrlial iiillaiiiiuHÙon of the ur'thni cAnjwuutire to
iberpes, to the |Hii*.-iiiij; «f instruments, or to mi infettin^ i.-oition, is nene-
Prally acute. In the latti?r (true Menorrhagia), it may continue st^vcral
montlis.'aitd it ia ac>.^uipanieil with a Bcri«s of accident», Uie roost serions
being stricture of Ùw urvtiira. Tbo bteunorrha;'!» is localised in th«
anterior region, the fo^sa naviculnris for example, in tlic 1>ulbou4 portion,
in tlio prostatic region, or it is f^cncral.
Tlic formaiioii of lymph ct-li4, the dcW|iiamiitioii of epithi-tiat ccIIh, the
Lprcwncc of blood corpuscles, the vnitcular congestion, etc., arc lite saiiMJ
Pnpon the urethral miicon» membrane as upon all mw^oiu* mt'inhrativa;'
When the in H animation ii* very intense, it extendi in a varyin;; t-xti-nt to
the subomcoiis cunncctire ti»suc, and may spread to (he «rectde connect-
ive tisme of tho corpus 8|)ODgio«um. Soiactiaies there résulta an iiiHiun-
mation of the lym|>liatic vcaaels of the doreal rej^on of the penis, vhun
beneath thn iikiii are seen the lines and cords of lvm|J»ngitifl. When lh«
L much intlamed submucous coiuiective ûmue is infiltrated with lyniph (xWi,
land the tissue of the spon«y body is also involved, tliVM; piirti* are not
Idistcnded by the blood during ttic erections, vrhk-h arc no fr«'i|ucnt and
'painful in acute blcnorrhagio (Konorrhu;»). The t-mction give» ri«' to
an villa rgi^-nivnt of the cavernous body and gUn», while the miicouii mein-
bmnc of the urethra reinfiinit unchanged. There then re^iultii what a
termed blcnorrhagie conliJi;, in which the cord ia formeil by the uretlira,
the arch by the tntitefu-d eavernon.-i body and glana.
A very inten.ie bleuorrliiigic intlnmmation of the nrethml mucous mm>-
branc ia at tiiuei< limited to liie xlands, and the surrounding contKctivc
dssuc, causing an abrtce^ either ill the fossa navicularis,or inthcglandsof
Cowpcr. If these absccwes, conuining a varying quantity of pus, open
through the nkin externally, they do not occasion sucb sonous re«u)t«i a»
when they rupture into llie urethra. In the latter caw, there occurs an
infiltration of urine, which may extend to the connective ti^rmi' of the
perineum, if a counter-opening through the skin \t not early roadt-.
Stricture» of Uic urethra arc generally caused by fibran» orgaitixaiion
rand contraction of a part of the inflaoK-d submiicou;» connective liMtit
LChronic blenorrlia^a occiLnionK vegetation» amdogoua to grauulatit
tissue, vrhieh c»u«e a sinuoiu or irregular urethral canal, and a chronte
catarrhal intlammntion at tlio point of di.ieasc. Hard fibrous nodole*,
creaking under the knife, arc sometimes found around tho urotbn, at the
base of the glaas or fossa uavicularid ; they compress tiii: can*! and
eouatitutc strictures.
TuMORâ. — Tvhtrmhm» of the bladder and urethral mucous tnem-
_ bruDCS is soinelimcs ohicn'ed, especially a^outated aith the prerionsljr
«U'â<.Til)c(l tu})ffl0ffllips of the gcnito-urinArv nr^piia, U prcoctiU tho
Mmo chamcteti! as upon other mucous mu tab ru ne». The liibfivuloiM
f;runuliitiuii8 dfV(rki))C(l ujwii tlit^' surfnui- <>f tlic iiiiic'>u« iiK-iiiliriiii«, »n<t iii
thv counoctivv ti(U)uv, occtufîou u purir»nii cntitrrh, wîtli pui-uloiit ami
Ciuti'OiiH Hvcrvti»!»). Tlic tuVtrcK-i' iimy lit- gmuinjii îiito |>atclii.'ii, aixl
uiiiU-<I l>y Ail onilirvoiiic lis^ttit.- ; iii(i1oi;iiliir 'murtïticatioii nf itic ]>arU
wliicli liiivo liccoiui.* uiineoi» give* rise to ulccrïi varying in eîxc ami depth.
t'HehomlroMala tiav« lieeii rcjwrted by OixloiiL'S atitt Landctta in t)ic
walla of the liluddcr. In tlie c)ts« of Landctta. the tumor was due u» im
extentiion to tlie wall of the Madder, of aa cuchoiidrituui from the hotiva
of ihc pelvis,
J'lil-ill-maia (vcsii:»] fungus) of thv UaildiT occur frctjiivnlly, and
piay tie of considi-rnUe size. Althmi^li tliv mucous incmbrauc of the
bladili-r dovH not uunnally po»si-M pupiUie, tlicrc U a very jurent tendency
to thv new rormatioii of viMcuhir ]iH|)iltic in vvvry irrtt&tii-v [trucoiis. The
favorilL- suit of these papilliu which form true tumors of variahle sire, is
ftmuiid the nock (fiitiilus) of the hhidik-r. At limes they form i!|ion the
Hurfacv of th<^ miicouK iticiuliratiC a nîtij^lc tiiaiM, or acvoral (lUseiii ilia ted
tuiiior^ ; they are very vanciilar. When examined under water, long or
short liatr liki' tibrila aud wavy )ia|iilli«, aiiitstom<jTtiii;{ or free.-are seen
floating fre«ly in the tluid. 'î'hey cousiât of connective tissue, in smidl
siDOiinl, forming a sopriort for Ibo capillary vcsmÏs, which travers the
pajiillw^. The ea|')ll;kner) and small vuASt^-U haviii;; a thin, embryonic and
easily torn wall, tcrniiiialc in loo|« ul thr toj' of the pa))il))u. 'flic
pspillic nri^ covered with a thick laver nf epllhi'lial wll*. Tln-se .laino
celU, f»rm<;d in great iihuodaiice, fiii u[j the (*|.act'n romaininj; between
the liiviKionH and iinbili visions of the pajâlla; of the new tomiaûon. The
epithelial cells break down into a turbid, muco-punilent fluid which infil-
trate» the centre of the tuinor. Papillomata spring from the submucous
connective tissue with which they are directly continuoua. This tissue
does not present much pathologieat change, in this respect diHeriug from
carcinoma and sarcoma; it is sometimes sli;;htly thickened, and contaitui
more connective tissue and lymph cells. An examination of the biwc of
tho tumor and of the connective tisauo from which it was dcvolo))ed i^
necvssarv in order to diagnose between a papilloma and a carcinoma,
for the latter has u tewlency to become villuii.t ujioii the aiirfacc of llie
bladder. Theae ;;rowth» occasion a catarrh of Hie bladder, as well as
abundant and persisteiil hemorrhages produced by the rupture of th«
capillaries from very slight mtclianieal cause», such as tlic effecta of
micturition, for example.
Instead of having the [lapillary form with long hair-like filaments, th«
pai^llomata may be more compact and dense ; they may be seen as single
or multiple nodules, consisting of embryonic connective tissue, forming a
compact and prominent mass upon the surface of the mucous membrane.
Ciircin</inij of the bladder is pritnary or secondary ; the latter n.'«ult»
from a direct invasion of the layer» of connective tissue and muscles of
iho bladder by a neighboring carcinoma, developed primarily in the
uterus, rectum, or in the prostate. The mucous membrane is aÛerwanU
invaded, and tJierc are then developed either sessile carcinomatous bmla
nith lurge and prominent hemispherical base, ordeudriiin papillary vege-
656
EXCRKTORV rRISABY PAS3A0ES.
FIS.3ÏT.
tAtions implanted upon n L-aivinoiimtoti» lia^e ; Ui«m vegeutiotii
sommrhat BÏmiUr to tlione of pajiillouui.
In the vesical tumora occumog ho frenuently 1)V the extension of i
carcinoma, the mucous meDil'raiic of tliu bl9i<ltlur U uiucti iiiflataeil, etp
ctully where U » not tbe «eat of cancerous prodiuitions. Its suriWI
iiitcnsely red, in coiisojiience of vascular confçesuon, aud there are fi^
<l«eiitly seen proniiitent vehicles rormed hy the vesical glands fill«d «i^
transparent niuetis or muco-pua.
I'ntnurv cnivitioma of tbe bladder U usually eneoplialoid, very at\i
U it ecirrliuH. Tnv form it assunieit is variable. When primary it mdc-
times iiiGltratcsthc en tii'c mucous uwisbnM,
or it« ^renter part, especially the fondai
and neck. The mucous mcnbmM au
have a tliickiw)» of one-)ialf to one cm-
iiti'iro ; tlie luiinciiliir fibre!* are liyi^rln»
j'liicd and tlic coimwtive li^sue m alio lliiek'
encd. Tt)U whitiiili or jiinkiali surface «f
tbe mucous membrane i^ ulcerated in [ntt!t«t
of rarvinK '•'"e. and covered hv aniall lilloiu
proccaaes. A section of ibe diseaaed j<>r-
tion présenta a whilisli tissue rielk in a iinJk;
juice. At otlier times ilie mucous mcoilinM
miiy bo c)ia»;;ed only at one point, partie»-
larfy in tbe trij^one. tienemlly carcinonu
of the blad<lcr is rillous, that is, patchet
of tbe dcseiieratcd mucous membrane ut
ovcTvd with tufts nf tflougmted vascnlir
villi, ciivored with vpitbeliuiD, and travurwd
c.ni.»i.....»r.rUi.o(>t..bUdd«. by enpilliiries, which do not differ from ilw
villi found in pa;»Uamata. But in caRi-
noma the basis of mucous membrane »[ioii which the \-illi are implaattd,
is fonned of carcinomatouM tÎ!>.-<ue, which extends deeply and cawM •
thickening of the wall of the bladder at tbe seat of tbe lesion ; tko alt
tissue is MfflOtit always white, soft, encephaloid.
SORUAL UISTOLOCIY.
6Ô7
CHAPTEK III.
TESTICLES.
Beot. I.— Normal Hirtolojfy.
The teaticles, •urrounded h\ tlie tunica va;^iiinlis. which conatitulos
their 9«r«u5 covering, present for oiwiduiation a fibrous DK-inbratK* or
tunica albuginea : ami a pareiichynia irhich
e86«ntiallir consists of winding cimaU, ^' 528.
termed spermatic tubes which cxcn-te
tfac i»]>cnnatic fluid which piir-iics into
tfa« i-pididjTDiig ; finalSy, vessels aud
The tunica vagiintlU con»iHt4 of two
Kycnt: thcone|uiriotal,iiic»nii<-ctiouwitU
« Mrotum ; the other visccrnl. covering
the tiinica albugin«n and cpididvini^.
It is formed of connective tissue lined
witli a layer of flat coUm.
Thw visceral layer of the tunîea albu-
ginea is a thick, dense, fibrous uu-nihrunc,
which wild» fibrous prfilonj^iitioiis into
the (Mtiulu to unite directly with the
fibroiu trabeculte «f the organ. The
moot important and tliickcst of these
proton j*a I ionrt \* the corpm Hi^hmoria-
nam or mediastinum tesli», a thick layer
of close connective tissue which esists at
the posterior part of the testicle, and
throush which pass the tubes going to the
epididymis.
Tlio parenchymal or (glandular sub-
stance of the testicles is composed of
tabes which divide and subdivide, ana«toraosîn;î with each other, in such
a manner th;vt when a mimlior are collected together they form cones,
the «Duill end of which mlers the corpus Hi^hmoriatmni, while the en-
Ui^d extremity is placed at llie periphery of tlie gland, where the tubes
temiiuate by a free extremity or loop. At the small end of the cone tlio
taben become rectilinear, unite togetlier in order to form a network iu
the corpus Highraorianum {rtU leirti»). In this network seven to fifteen
vata tffertfitia are formed, which i>erforate the tunica alhu^iiiea, and
pass into the epidid^nnis. These efferent vesseU, becoming narrow and
tonuous, form another series of cones (coni vasculosi), which constitute
the head of the epididymis. They unite into a duct, the canal of the epi-
43
■miiïtmeiitadbs Ibdu. |I7riy.>
600
TSSTtCtEB.
can lie mon durinti \ite, h tlie epididyinitU ând acnte inflammatMiiof Ifat
tunica vit^inaliH which cûnalantlj accompanv orchiiia. When then oocan
a l>I«tinnrrhngîc orchîtin, the intiaiunutioD cxtciiilH by the vas ieUrttt
and e]iiil't<lvmi!), and readily reaches the tunica vaginalis. TImi epidil^*
mia is lirot afflicted ; it eikiar^es and lltiid escapes into tho tunica tip-
ualia. Till» titnicn ]>rcsonU all thv chiinictcristic^ of inHamiuatina <( I
serous membrane, that is. an vseapc of fluid with fibriu, lymph eclUtitd
blood ccir]>usclcs, and a prolîfunition of its ondotlicltal c«lls.
Simple orchitis ofton diifnpjH^ani without Icavinj; any tnicM; but, iadv
ttions of the cvUiitar lis» tie which «urruunrls the hcml or other parts cf
lie epididymis not mifreiiui'iitly remain. These iiidiimtî<>it«, fonac^ of
hard and contracting cictitricial ti^ue, erniiiire** the excretory diKi;
there result» a narrowing or an entire uhlitcration of tho duct, aod toa-
Bei|uenlly a sui)|)reMion of the I'nnclio» and au atrophy of one of tbt
t«8ticte3. A similar le^on may be produced simullaooously in tb« Mhcc
organ, when impotcncy must necessarily occur. Seoondary to inflaua-
tjon of ihi! tunica vaginnhs, there are found fibrous vegotations upon il*
surface, in the sliape of villi or ;ptuiulations, which may be well oitrkei
These will he considered under hydrocele.
Suppurative injiammaiion of tho parenchyma of the toaticic mIiIm
occuni. It is. however, observed in traumntUms, hcing either loeat w
general. Ws ia form«i] in the cellular tissue, probably in the lymjilnliei
of the f;land. Soiaelinics suppura^ve inttanunations of t]i« lymptiatio
or veins of tlio oord occur.
Chrosic Obcbitis. — There are several rarieliea of chronic inflio-
matiftu of the testicle. It may invade at the same liroe both iJie tcstiels
and epididymis, which are increased in sine. According to the descrij»-
tion of Fœrstcr, the lesion consists of an enlargement of th« Beminifcren»
cumils by the ei-lls forniing in greater iihundance than in the normal state,
niid by »ii intillration of all the cellular tissue with an inflammatory tx^
dati'iti. Tho fibrous trabecniiv are thickened ; tho testicle an<l ejiididj-
mix lire indurated and hoi<H«'llaled. Upon the cut aurfacc the thickened
filirnus irabeeulje are visible, and between them a yellow hoino<;cneow
ea^eoiis maris (rri^i-uus orckltii) is seen, in which traces of the seminifer.
ous tiiliCA are only occasionally found. 'J'liis lc«lon has some re^emblauce
to tubercaWis, with which it is frei|uently confounded. According to
Virchow, it has no connection with tuberculosis, but follows a traumatic
intlammnlion or an extension of a catarrhal inflammation of tbe urinarj
passa i^es.
Another variety of chronic orchitis consists in a chronic inflammation
of tlie interstitial tissue of tho testicle. The size of ttie organ U aonw-
times increased, sometime» normal or even diminiabed. Seldom ia an
atrophy of the substance of the testicle observed. Sometimes this
chronic Inflammation ta aceomjtanied with a aup]mration which occasions
the formation of one or more abacesses. 'Hie ahsce«te» may remain
stationary and be surrounded with a fibrous or calcified eiKyattng :
brane ; or they may extend and open sjiontaneously.
By a solution of continuity, a hernia of the testicle may oocnr ea
nalljr as a spongy, vascular, awi gcaiiMUi.™^ mass, in which the altctvd
HrDROCELS. 661
Miniiiiferons tubes are found surrounded by granulation tissue. The
gnnalations consist of embryonic tissue. The lesion is termed benign
funffus of the testicle. T'le mass gradually diminishes through suppura-
tion, and recovery takes place by the formation of a cicatrix.
The surface and connective tissue of the epididymis, as well as the
serous membrane of the testicle, may be the seat of chronic inflammation
with an abundant formation of embryonic tissue ; the latter may pro-
liferate and form elevations like the granulations of fungus of the testicle.
The granulations of embryonic tissue formed upon the tunica vaginalis
after gangrene of the scrotum should not be confounded with benign
tanjças.
Benign fungus, that is, hernia of the inflamed substance of tlie testicle,
in which the connective tissue of the testicle is changed into granulation
tissue, occurs under various circumstances : in acute purulent inflamma-
tion when an abscess has been opened; in tuberculous orchitis, and at
times in syphilitic orchitis.
St/philittc chronic orchitis consists in a new formation of fibrous tissue
between the seminiferous tubes. The tubes are separated from one
anotlier by embryonic or fibrous tisane, and are atrophied by pressure. In
some oases they are almost reduced to their enveloping membrane, and
have in their interior only a few atrophied granular fatty cells. This lesion
may affect either the entire testicle or only a few lobules. A thickening
of the tunica albuginea and tunica vaginalis is also observed. The tunica
vaginalis may present either vegetations or adhesions. This variety of
orchitis usually coexists with syphilitic gummata, but may occur without
them.
Htdrocblb. Hydrocele of the Tunica Vagittalis. — Although hydro-
cele of the tunica vaginalis has been placed among the dropsies, it should
be considered aa a chronic inflammation. The lesion seldom occurs in
general dropsy, and the fluid in the tunica vaginalis contains a consider-
able quantity of fibrin, as occurs in all inflammatory exudations ; fre-
quently there are formed fibrous productions, new membranes, and ex-
crescences upon the internal surface of the serous membrane. This
disease is characterized by a serous or fibrinous exudation into the
tunica vaginalis, resulting either from an acute or a chronic inflammation
of the whole serous membrane or from a varicocele. The amount of
fluid varies; it is generally clear; at tiroes colored yellow by a few
blood corpuscles ; there may be present crystals of cholesterin, swollen
endothelial cells, and enough lymph cells to give it a turbid appearance.
In some cases of hydrocele there exists a cyst of the epididymis, which
may rupture into the tunica va^nalis ; in the latter case, spermatozoida
are then found in the fluid of the hydrocele.
The internal surface of the tunica vaginalis in recent cases is smooth,
but the connective tissue of the membrane is always thickened. Id
chronic hydroceles there are always found very evident signs of chronic
inflammation; there are superimposed, upon the surface of the tunica
vaginalis, either the parietal or the visceral, layers of new vascular mem-
branes. These formations usually consist of a dense, hard connectire
TRSTICLBB.
tijAiio, HÎmilnr to tlint L^overin}! ibc siirHicc uf tl)i' )i|ilecii iii ehnmio jmi-
HjileiiUiâ. Tlicse dcuso fibrous fonuationii also, aa upou tlie Mrfoor (i
am aplecu, funn elevated [latckwi with a carllUi^inouâ appearance, «r d»t,
eomctimeH clevatoi) nodules, or evou villous projections ; tboy etaigent
parallel layers of lamiiuilMl connective tissue eepatmtcti hy flat Mik
EoL-livmoscfi are frcigucutly seen bcncuth Ihcm. Wtvrt-cn the imnuat m>-
ueotivv lisstie itnil the new ti)jroii» rununiio». Vej^cUttiuiifi aitil rwl
«Icvatioiu», having tlte bIimjio, seiiii-tran«i>ureiiey, aixl ilennliy at nill
pcarU, Riay tiucumo free in Uie HOrous cavity, in tlio «amo manner u «nth
fon^ti^t ImnIIvs aro fonnod in tho artkiilntiona. Tliou' IhmIIm in thi
cavity of the tunica vuginnllK are forinod of conceiitho inyern of liniiu-
«lc<i coiinoclivc tAnfuv sepitnili^ij hy Bat ccIIh. Tl>e»e diflerewt vanciiu
of new tormalious may be inhltralCKl niiti cakareoi» aaltj<. 'I'hv totictc
surronndod l>y nuch a thickeiioi and contracted tunica Tagjinalis atrDpbwt.
Dydnxele of tlie tunica vaginalis is frei|uently coin]ilicated vitlirr vilb
e;8t8, or other varieties of hydrocele, or witli a scrotal hernia; it nat
be the origin of a suppurutivo or intense tnl):inimiition of ttie tunica v»;i.
nulls; it may also be complicntod wttii a hœmatoocle, thai is, an ttayt
of blood into the cavity of ilie tunica vaginalis,
C'tnifemtal Ilydroc^t. — The peritoneal hoc nhiob aooompanie» Iki
cord and te»ticlo in It» dcM«nl into th« acrotutn, inittvad of tieinj! «Uit^
nttod above the te«ticK>, to form tti« tunica va^iuills, retuoiiut upi-u, inl
the serous membrane «urroiunding tJie (cotiule communicatee dnrlni; lift
with till' [KTitoiica! caviiy. ThL-refore Hwid in tJic |«eritoDi'aI cuviiv vm
pass into tho tunica vaginalis, and Quid in tho tunica vaginalis may alt»
pass into tlie peritoneal cavity. Freiiucntly in these ca«es there is u
inguinal hernia.
which accompanies tlie con) ia not oblit^tML'tilRKi'zliDut i >-x.
tent, but remains open in »ome psrtof il« eonrae, t«i nd
below. If tiie^H* part« become lillc<l with Huid, thi-: 'i-
bydrocele of the cord. Several cynM nuiv thus occur along the i
It hap])ena,al times, that an oM heniial aac is obliterated, and u.. ,....-
longation of the peritoneum constituting it, instcail of remaining eolUpied
U filled with fluid. There then results a dropey of the h' ' l.icb
should not be ixuifouixleJ with a cystic hydrocele. Cy '>f
the cord, or hydrocele of n hernial sac, frequently ccnii{>)ii,ttU-â siiU[ilc
hvdmccle of tlie tnniea t'aE'inulis.
Other cysts which have U'vn for a long time c<^nfo«udi-d with simple
hydi-ocele, are »i>rrmmie eygiu (spermatic hydrocele), ;•.■(--
at tlio superior part of die teaticle. Uliene cvsts, aomci
are filled with a turbid Quid, conuuitlug with ine living or -a-m:
toxokls. epithelial cells similar to those of the nomial apermat
'Hiese cysts may open into the cavity of Uic tunica vapi
fretiiH-nily at (he same time tlic seat of a hydrocik-. In
moile of formation, the hypotlicsisof a new and itidepim
the cyitta has been advocated hy Paget. According lo I
of Gooaelin, Luschka, etc., it is more yrebablc that
II.- i,-.„^i
ori^n from a dibitation nf pre-exU^nj; ducts. Tbeir ticat is exactly the
poiut where the tu'ies of testicle and those of tlie epididymis are 9ep«-
rau'ly developed during the emhryonic period, although aftorwardu
united ; here aW arc found the useless tubes comiug from the Wolffian
Iwlv which fouBlitutc the oe-tan nf Giraltih.
BSiidrpi'itdent of mil the foro^oin^ vani-ties of cyf^ts met witli in hy-
^■ccli'A, there i» often found an wdematoiM iiiiillrntton of tlic con-
^■tivo tiMiio of the raiwuliini aWrmn:! of llaller and organ of (liraldâi,
^nt truo cjTfttie tlilatAtion of the uaniil'! of the latter.
TT^KMATOTKLR. — It has been seen that, in chmnic hydrocele, the tunica
vaginalis i?i covered by new mcmbranoti-i forinatioiu^, arranged at tiroes in
su|ierimnosed thick fibi-oiis lavera supplied with veasels whose rupture
causes tlie ecchymoses often found in this formation. From the frictions
Or contusions, to which tlicse largo tumors arc exposed, there may occur
an osaipo of blood into the cavity of the tunic* vaginolis. The tumor
fornH-d by [his blood \t dense, ham, and non-fluctuatiiie ; the cavity of
the thickene<l fibrous tunica vaçinulîs îs filled with a chocolate orhrowii
fluid, a color <Uie to tlie presence of Jisint<'{;niliiif; blood coqmscle*. I'pon
the fiurface of the membrane and in the sac, blood clots and coagulated
fibrin arc seen. Microscopic examination of the fluid shows fibrin, red
blood corpuscles, swollen endotlielial cells containing blood pigment, fat^
gmnules, and frefin«>ntly also crystals of cholestcrin. If the escape of
blooil occurs when there has previously been a large amonut of tho serous
fluid of a hydrocele, there U no coagulation of the fibrin in (ho fiiiid of
the l)n.-matoc«Io. The testicle \» geiicrnlly atrophied beneath tlie thick
layers of new membrane. An ewape of blood may also occur in a cy8t
of the conl.
InliltraiioHS of blood into the connective tiaaue of the testicle are of
anfreijiient occurrence. They sometimes, however, give rise to a hroma*
tocele within the testicle. This rare legion hiis not yet been minutely
described. With Coyne we have had the opportunity of stuiiyiug two
cases. There was a very old laree bsmatocele in the tunica vagiimlig.
At tho central portion of tho testicle an old, partly diifcdored clot was
found, nbout the sixc of a small apple; Uic clot w** tnvr!-— i '■•■ -'..Is
with IhicV walls. In the jwriphcrai layer» of the clol " :»-
Kd seminiferon» tubes. The : ' ' " i ■ i' '
ented tlie lesions of papcnchv:.
terized by an abundant formattun of round embt .
Tumors or tue TiaTiuLi:.
of
H^xcnoXDROMA. — Enchondronn
^ftvriilly foUows tr;>i
^^1, both with thi- 1;
of variable siec, or ai* n
Ïl;knd, iMit it may involve : ;
'be testicle is îivoreased in WEe, ~
the cartila^ouuH tissue is nsiu.tj
661
TB8TICLE8.
sarcoiniitous tissue, nlitle cy&is esiiit in the aubstanco of the ;;lanil. E»*
chondroma does not always consist solely of «arlilaKinous tiiwuo.
From tho otMervationx of Pa^et ami Virulioir, i{ Hias Wen a«etruiMd
tbnt cartiliigo may develop in the interior of the Ivinphaticit >'( tlic Mût\t
ami |in;»ent the riimîfrinfç ithapc of the«! |ms«it^e!'. In one cwc. i»
ported by l*n>;*'l> *he tumor vxlendvd ulonE; the eficrmntii: cord, iuio tU
iliac Ivinpli ^landn, into the lym])hatieâ of (h« inferior ven» can, tw
tlio lumen of which a eartilaginoiLi niiiitii ]jrAtni(lcd a^ fnr Kit the pulioc»-
ary arterv: aud the lung al-w pre.'iented twcondarv tiiniora of tbefaat
nature. [Secondary fonuUona are not extreuely rare. The mnt
favorite «eat of tho Bocondaiy deposits is tbe lungs.)
FiBKOMA. — Except the hard, often calcified fibromata, which «i
fonned upon the Kurtnce of the tniiica \ik;^nalis» or which oii;rinBtti iaa
fibroiia hypcrlmpliy of tlie tiinie-a albiifî'i'f'i '" hydr»>ceK", fihrnuuiUAr
the testicle are xery rnrelv seen. However, Fwrater rei«ortH a ra»cia
vhicb a (ihrous tinnor <lcTelopi»g in the tuniea tlhuginea pntjected ixM
th« substance of the tcnticlo.
SaHcoha. — Sarcoma witlioiit cyatic degeneratÎAn is not often nwt wiâ.
It occurs in the testicle or enidi<lynÙH ; the sland is unifonnly enlargtd.
not lohukted ; tho tunica albuzinea is not involved, a small amount »
fourni ill the ejivity of the tunica vaginalis. Upon aection the ti««
ia Bofl, fleshy, vascuhkr, hoDio;;encous, and infiltrations of bloo<l :■■'
ijueutty aeeii. Examined with the microscope, these tuoiorv sotm i
approach the myxomatA in tlicir TundHinonlnl stilistance, wliich iuitip>l«
Urge fusiform celb, or Mmsll round celU. Fatty «tegeneration, and blood
extravasations at tiroes gite a caseous ai)]>caraiice to purtion^ of tbe tumor.
In a cuse of Lebcrt there nai* a repi-oduction of the neoplasm in the lyio-
jihatic tçlands of tho neck and in the pleura.
In another variety of sarcoma, which is frc^inently combini'd with
enchondronia, the tumor contains cysts varying in Mxe. Those an i-i/Htt
$ar<t»maUt, which, after remaining localized for a time, at lon';t]i hreal:
through the tiiiùca albii^nea, ana become ^nernlixed, and mnli^nan* in
type. Cystic sarcomata have been, up to tbe prissent, confomwM «iili
malignant cyst:* of the testicles belonging to a grou]) of tumors difieriug
in structure, nature, and prognosis. An anatomieal enamiiizition ^
malignant cysts of the testieic demonstrate» that they are onlike sarco-
mata. Malassez ctnclu<lci< from his investigations, that ihcy are a f«ca-
liar variety of cpitlieliuma, and he names IJiem myxoid epiUieUomata.
In a targe cystic .larcoma, n fibrous or sarcomatous tissno, in places
spindle celled, in other [lart^ round celled, fr^ueully bavin;; small
arvftsof cartilage disseraimitedthrongh it. is interposed b'' ci-
niferouE tithes and cyats. The cysts rary in siïc from a a
haxel-nut, and arc titled with a serous or colloid Quid- Tin.- tumor w »t
firrt limited by tho tunica atbuginea, and there are found porr— - "' " •
testicle unchanged. Occasionally the growth begina in tlte
From the histological descriptions, particularly Uiat by Foets*
appear to originate by an enlar;!enient of the «eminiferc
ktter are lined by an epithelium, which becomea detae
TCBERCLBS or THB TE3TI0LB.
f;«5
[«vity with cell* ; these «olU undcTjïO mucoiiH licïcncrfttiw, nrwl nrP Imns-
|fi)rnM.-(l into a homo^i'iiiMMi» iiiiict)i<l tltiiil. l*ii[iillary cxoreswnci-* civored
|«rtt]i r|>ithrlium (irow fmin the «alU «r the cv»l« into their inlerior. Tlie
»nt«>nw of llic cyM, iii*ti;!i(l of hcing miicou» or serous, simoliincs ns
etnhh' ihc caMeouii matter of ik'rinoiil cysU, The epitlioliiiia of ilie
sroiift cvhU is formed of tint, cyliiKlric»! or cilifitod cylinilncal cell»,
associated with the aarcomntmia and cartilaginous tissue, there arc often
bund in tlie stroma, new formations of Btriatoil musculai' fibres.
1 «cveral cases of sarcoma and cystic 8BrcoBui,coniplicHt«d with «nehon-
»nui, Nepvcu hna followed the process of cidArj;cmont of the scmini-
torous tiibm, and has pointed out the pr«smcc of small pearly globules
1 nvsu) sitnalcd io the cavitîu» of the enlarged tubes. The«c globules
r«re formed of corneous epithelial cells.
»e<-iiia to US Ihm the neoplnsin termed a cystic sarcoma ha» often
sn olnsMtl u'itb tnmorit which difTor from it in their course and histo-
jical fltniclure. It is probable that clinical and anatomical investiga-
tions wit), in the fiiluro, determine a distinction between them.
Malasscz has recently published some obaenations upon this subject,
in which the cystic formations, sitaai«d in the centre of the lexticle, were
BCparattd from tJie parenchyma of the tc«tjc1e, which was pushed to the
criphery id contact with thu tiinifa albajïînea. The cysts surrounded
\>y an almost normal connective tissue, which contained a few lymph cells
between its fibres, varied in size from a pea to a hax^hnut. Smooth
muscular fibres were found in tliïs connective tissue. The Internal sur-
ce of the cystH, cither smooth or presenting viltoiiii projccbona, was lined
(ilh cells varying; in form; polygonal and Hat, cylindrical or ciliated and
able I- shaped. These several varieties of cells were found united into
ciaps in the sanw cystic cavity, I'he cells found in tîie serous or mucous
luid of the cysu resembled those lining tlio intoniat surface ; many had
pcomc spherical and undergone a fatly degeneration. In no part couhl
MnlaMez discover a change of the normal seminiferous tubes into cysts;
Pmreover, the cy*ts had no similarity lo the seminiferous IiiWs. Heiu-c
e concludes that there is a new formation uf epithelium and of curiiivs
Ik'd nith miicouit cpit}ielium, and he proposes to call the DcopUsm »
tffi^id fj/ithelivma.
■ CfU
TuHEBCLES.— Tiihercles in the testiol» vmv be
of tuWrcnloaia of the genîto-unnary orgMW, pr<-^
ring in the hin):s. It mi»y begin m thv
IB the epididymis or vas deferens whit-b ;
The testicle at times presents very >i
«rcclv visible to tbo unaidi^I '■'•■■ "i
.giiialls and in the connectiv' '
permatic canaticuli. The mil
CMVoiut nt their ceiitm, and fon >
appearin** like a
of the gr&)Hdati<i;i
amining die caunlicnli of >
fibrous waits of thtt eanulK.»-. ...^ ■■
666
BSCBBTORT ORIltARy TASSAOBS.
tntiona implnntcti upon a carcinomAtotu base ; these vegetotiofu are
somewhat similar to those of papilloma.
In tho v«etcitl tumors occurriog so t'rciitiently by the extcn«iou of ut«rine
cnrcinoRiii. tlic mucous membrane of die bln/blt^r U much inflamed, eitpe>
ctiiDy where it i« not the si-at of i-anceruu» producûons. Its surface is
intensely re<1, in eoniteiiiK-iice of viiscular coii}; option, and there are fre*
<[ueiiily !iecri jiroiuinoiit veticlro fvrmi-d hj thv vesical glands filled with
transparent mni-iis or tnuoo-puH.
I'riiiiary carcinoma of the blmldcr is usually enccphaloîd, very setdom
is it ituirrliud. Tnv fonn it a#»nni«9 i» variable. Wlien prirmrj it snnw-
time:* infiltra cvti the entiro tmicoua munibruio,
Kg. 3*7.
or iu ^rviiter |iart, especially tliv fuDdui
and tievk. 1'he »)uo(>us inembraoe in»y
have a tbickneim of one-lialf to one venu-
inetre ; tlie muiicnlar fibres are hyporlnv
phied and the connective (i^iiue is kIm tliivk*
ened. Ttie wbitiiih or |>inkifih surface of
the niHcoufl membrane is ulcerated in |iatolic4
of varying si»?, and covered by aouill villuiu
procefisea. A scciion of the disvaaed por-
tion presents a wbitisli tissue rich in a nult:;r
juice. At other times the miwotis mcaibratw
may bo changed only at one point, gmrttcu-
larly in the trigone, tivnvntlly carctnotna
of the bladder \tt villiiu<i, that tit, patchcji
of the dcjiÇeoerated mucou.i membrane are
covcreil uith tufia of elongated ra-tciiUr
villi, covered with epithelium, and travonkid
c»Mi«.«u.o.i..rm-o(.i..i.i«id.r. hy eaiiillaries, which do not differ from the
villi found in papillomata. But in carci-
noma the basis "f mucous membrane upon which the villi are impUmcd,
«is formed of carcinoraatouH liflsuc, which extends deeply and causes a
r^thickening of the wall of the bladder at [lie scat of the lesion ; the new
tissue ii almost always white, soft, cncepiialoïd.
HOXHAL UI9T0L0t)Y.
65T
CIlAPTEll III.
I
I
I
i
TESTIC1.BS.
Beot. I.— Hormal Histolo^.
The testicles, Burrouiittod hv tlic inuicn rii^^iiiiilis. wliich onittitutos
their serous covcrinj^, prvsciit lor fniiiiKi ration ii lUnxms lui-mltmic or
tunica nlbuginea : nudn imrtiiiclitinnHliicti
«SMMilittlly coiisisu of wiinliiig ciin»U, f>«' 3âS.
tenuis) «])erm«lio tubes which «xcrute
tlie i({iernialic Hiiiil which pa«)tc9 into
tlic i>|»(lidj-mtâ ; finally, vessels and
nerves.
'riie tunica vaffittaltB consists of two
laycra: the one parJotal,in connection with
the scrotum ; the other visceral, covering;
ttic tunica albui^nt'ca and epididymis.
It i» lormod of connective tissue liued
with a layer of Hat cell».
The viiiceral layer of tin* tuniea alhu-
ginea is a thick, dense, filirou» membrane,
which iiends fibroai prolon^atio:)» into
the testicle to unite direoth- with the
fibrous trabcculœ of the organ. The
most important and thickest of these
prolongations is the corpus IIi;^hmoria-
num or mediastinum testis, a thick layer
of clo»e connective tis«ui'> which vxiKts at
the pMterior part of ttic testicle, and
through which pa«« the tubes goiug to the
epididymi*.
Tlie parenchyma or glandular sub-
stance of the testicle* is compoited of
tabes which divide and subdiride. anasinmosing with eac'i nt)icr, tn such
t manner that when a number are collected togethiiir they form cones,
the smalt end of which enters the corpoii Hî^hmorianum, wliile the en-
larged extremity is placed at the periphery of the gland, where the tubes
terminate by a free extremity or Inop. At the small end of the cone tlic
tube» become rectilinear, unite together in order to form a network in
the corpus Ilighmorianum (rete tettU^. In UiU network seven to fifteen
vatn ftf'fre-ntia are formed, which perforate the tunica alhu^inea, and
pa«s into the epididymis. These efferent vcsscU, !iecomiii>; narrow and
tortuous, form another series of cones (coni vasculosi), which constitute
the bead of the epididymis. Tliey unite into » duct, the canal of ihe ejâ-
V«nl<sl MclltfD it Malli, ititfwlai Um
65S
TESTICLES.
ns-ssv.
iliilyniU, whicli run» tortuously nioii;; tlifi ixwtcrior border of th« t^elicU.
And after Ixting reH«;t«"i fmiii IjcÎdw it]>waT\l Wi'oini^ti coDliiiu«iu wiili the
vas deferens. The wiw/wiVVmu» ruf'f» coni^Ut of a Uiick, doiwc, fibmas
m«m1>rnne, com]«o«ied of Uinitiiu of fihrotis tisniie, sofianiuJ hy flat cotinrc-
tive tii»sue cells, rponlhe ititeriinl siirfnccof tbisiiieinbrnoe there e\ÎM»
a layer of polyt;ons1 celU, wliich may bo oonsidcrcil m aii cpilWIiuot.
In tlie Itimcn of the tube there are spheriRal celU, seminal cc\U, and
vesicles, conlniiiiug one or more nuclei, and
wliich give ori;:in to llie apcrraatosoida. Bm
the gmnoa toxoids çwUlom become fre« t» Uic
t€Sticfc: it is in the vas deferens that the sper-
mutic tluii) reaches its tmttarity.
The speriiiat()z»idK (irritent a swoUan porlion
orheAfl.flal and {lyrifun», vi houses?» in |»n>fil«:
and A tikil nhirh i« i>xtroni>vly tliin, and Mhîch
trrminittvn St it« free «ticmity in » tilnnu-nt
i«<'iirc40y Mjiprmul'le with the hi^ht'^t [lOMm of
the niicroAcfljie. '['tie tait is connected to tbe
head )iy a niiildte piece. The iDOveu>enla of
spcnuatozoida are very lirely, and th^'V may
coiilinuo for screral davs in the genital orgaiu
awl utenw of female animnU. Water arrests their movoiucnte ; they are
aoceleraled or may he re-established by alkaline Bolulione, by concfninied
solutions of sugar, alhumcn, urea, t-tc. Acids, on On- rontrurr. nUi]! tlivir
movcmeDte. Cold {xiraly»-.t tlu-m, Imt afu-r lieing oïjioseil for tlin-r «r
four days to 0'^ (C), tliey may l.e revived Ity heal. 'J'hf e|>ithetial liuinft
of the efTerent vesseU of tlic e^iididymis coil-ùsih of cylin<ifical ritiat«d
cells. These cell* I>fi-oiuee\tri^iiieIy lonj^and uarrow": theirciiiaaUoare
very long in the e|rtdidymiA, ami in the beginning of ihe vas defert-ii*.
In tJie efferent canals, in the cpiilidymis and in the vas deferens,
tliiek layers of muscular 6brc~s are seen.
Id a portion of the epididymis, f;eiM)rally at its inferior part, thwre is
frequently seen n suiatlr elonjated, cylindrical body, Tfitli a free ex-
tremity, which lias bcvii named by llaller the ra»ru!itm altrran:
GirMiti has dcscrihnl n «mull oriian siiimtcd at tlic Kiiiierior border
<^the testicle, liolweeii the liody of the epidi<lyiiiis and the vas deferens
(orj^an of tjîraldè'), niiich coii.ii.-iu of aeviirol loooely connected whitish
itodultfs; e«ch of tlie latter U composed of the conroluiiona of a tube is
the form of a gl'>mi9rutiis. The interior of these tubes is lined with a
pavement ejiitlieUura ; they represent tlie remains of the Wolffian body.
The arteriole* of the testkle come from the spermatic artery «hicb
follows the conl ; at the head of the epididymis, one of its branchée
enters the corpus i Ii<;hiiioriaoum, while other brnncbes pass to the anterior
part of the testicle or pass al»n<; its surface, an<l penetrate into the
testH-lc with the fibrous trabceulai of the tunica albu^inea. Tlic veins
follow the course of the artorica. The ncrvp«, not nuuiorous, come froia
the spermatic plexus, and reach the testicle with the art«riira. Their
termination is not known. The lyniph.i(ic«, in which the suhva^nal net-
work iit verT abundant, penetrate, acconlin^ to the investi^tima of
Ludsig and Thoma, into the testicle, formjnjj a network of targ« — — >-
AODTB OBCUITia.
659
I
wbicli eiirroiiii<l the seminal cannliculî. Thcr arc Imrd with an endothe-
lium. The ratt ih/fr,-m, m fyl'milrical rcctiliiwar tube with thick waits,
B coiittTinution of the tnil of the vpi'li'ljmi^, n t-omiKutoil of nu cxUtninl or
fibroufl membrnDC, of hycn of smooth muscular fibres, aiul of » nmcoiu
mvmbrAiK*. Tbc mnecniur fa«cicu]i form tieTcrnI layor», n miil<)lo laver
of circular fibro», bolvrcen an internal «ml an external lotigitudina) layer.
liiD miK'Oiu mombnbiio preMi^nCA a number of Inngitudiiml fohU, Hie
connective tissue of the mitcotid raemlirane has in iu external part a net-
work of numerouB ela^ttic; fil<rc<i. The epithelial lining consista of a r>in;;le
layer of parement cells, containing some pigment f^ranulee, whioh give
a yoilow color to the surface of the mucous mombrano.
Tho feminal vfticle» arc nothing; elso than ai)poiidagos of the va8
deferens, whieh terminate in a blind cxtremilv, ihey are cotiHtruotcd
upon die name general type. They coimist of a fibroiu memhrains con-
taining eniootb mi»cn1ar fibre*, which penetrate between the ililfttreiu
OODvoiiitions of the mnoous membrane, and unite them. This mcndirane
is thinner than the thick envelope of tlic va4 dcferenii. The ain|iiilln
aivd dcprenioMi wbieh form tbe mncotiH membrane of tlie seminal ve.^ictes
contain a traa^jiarent, riâcld fluid, in which exist the apermaloaoids.
Ttie mucouH membrane secretes a special fluid which enters into the com-
position of iJje apermatic fluid. In old persons there arc found in these
or^rnns colloid concretions formed of an albnmioooa substance.
Tbe ejit/nilat-'fit dart* h&ve thin muscular walls, which are thinner in
the profttale. Their mucous membrane is wrinkled like that of tiio xtu
deferens.
In old Rg*, or fivm the effect» of di»eaae, such tm advanced tnhercn-
lo4t«, dixcat^eti of tlie spinal conl. with marked emaciation, etc., the xper*
■oaltc canalicult become atrophied, and then contain iu tiieir interior fatty
degenerated cella. A section of tlic testicle now presents a vcUowiBh-gray
oolor and an opacity duo to the presence of fat. insiea'l of the xwinl
|Mnlcisb-^y anpearanc*. Yet fttplay iiaa seen liring spcrmatoxoids in
Û10 spermatic fluid of old men, eighty years and older. Atrophy of tho
spcnnatic tabce, and the fatty degeneration with atrophy of tiicir eellit,
are constant oocurreiiccs in the majority of legions of tlie testicle in which
tlic tubes arc coinprensed, as occur» in chronic orchitis, where there is a
fonoation of new counectirc linsue, and in tumon which press «i>oii the
parenohvma of tlie testicle. Btmilar dégénéra lioiLt arc «een when the
Spermatic vcaaeLi, especially the epididymis or the va* <Ieferen!t, arc
compreesed in such a manner that tho excretion of spermatic fluid i^ in>
(«rfered with by an impodiment to its ejection.
Sect U.— Pathological Histology.
Inflammation". Acctk Orchitis. — An opportunity to anatomically
8ti»ly the acute orchitis which follow.'* biciuiorrhagia or traumati^ns
seldom occurs. It is probable that the testicle prenentii an aidciuatou^
infdtration of \i» connective ûasiie, followed by all the conse>|ueuce3 of this
condition : that is, irritation of the cells of the connective tissue and in-
Bammation of its lymph passages. The prominent lesion, and tliai which
i
6S0
TMTICLB8.
oiui bo Mvn ilurin;; life, ia tlic «pîdii1;,-inîtÎ8 nod acute influninntion of tlte
luiùcn vAginalÏH which consUntlj sccompany orchilit). Wlicn Ui«re oocun
R bletinorriingic orvliiUs, the inflnmnuttion extvtxb b; ihc viw dâferens
ftinl i-}it(Ii(lviiii!4, Ami rc«tlily n>ncliei> the tuuicii riigiiMlis. Tho epidiit;-
wis is &ntl aft'ecKd ; it etiUrgea and fluid e*ca]>C9 into the tunica va^-
naliji. 'Hits tunica preaetitA all the charact«riitticf) of inHammattoa of t
eerou9 membruie, that ia, an cicane of fluid with fibrin, Ivinpli o«lU, ni
blood corpuscles, and a proliferation of it») endothelial cella.
Simple orchids often diHapjicars without li-aving any traces; but, indu-
rations of the cellular tisiiue which surrounds the hcxd or olhcr part* of
the cpididvmio not unfrequcntl^' n-main. These indurations, formnd ot
bard and contracting cicatricial tissue, compress the «xcrctory duet;
there results a narrowinj; or an entire obliteration of the duct, «nd con-
Mttuently a «upprcvaion of the function and an atrophy of one of tlie
testjoleg. A iiimilar lesion may be produced «imultnneoujtly in tito other
or^nn, when ii)i|intt-iicy iniu>t necessarily riccur. Secondary to înfiainiDa-
tjon of ihe tuiiicu vaj^n.tliit, there an' found fibrouti vc^etatJonH upon iu
nurface, in the aliape of villi or granulatiom, which may be well marked,
'i'hese will be considered under hydrocele.
Supjturaltve iitfiammatifm of the parenchyma of tJie testicle seldom
occurs. It ia, boweTcr, observed in trnuiDntiiimiS, beini; cither local or
general. Pus is formed in the cellular tissue, probably in the lyin[>)iatios
of the ;;lflni). Sometimes suppurative inHammatioos of the lymptiaues
or vrins of the cord occur.
I Chromc Orckitik. — There arc sercral varieties of chronic inflan».
HÉMion of t!ic testicle. It may invade at the same lime both the tvfticle
and epididymis, whicJi are increased in sixe. Accortiinj- lo the de»cri[v
tion of Fœrsier, the lesion consists of an enlargement of the aeminiferoua
canals by the cells forming in greater abundance than in t)ie normal state,
and by an infiltration of all the cellular tissue iritli an infiammatory exa-
dation. The fibrous trabuculfe are thickened ; the testicle and epididy-
mis arc iudurntcd and bosscllated. Upon the cut surface the thickened
fibrous InibecuW arc visible, and bctirccn tliem a yellow homogooeous
caseone ma»s ('istwus ovkiti») U twn, îu which traces of the seminifer-
ous lubes arc only occnMonally found. Tliis lesion has some rceemblnDce
to tuberculosis, with which it is fre'iumidy confoundcfl. According to
Virchow, it has no connection with tubcirulo^i», but fitllows a traumatic
inflammation or an extension of a catarrhal inflammatioD of the urinary
passages.
Another variety of chronic orchitis consistai in a chronic infianimatM»
of the interstitial tissue of the testicle. The sixe of the organ is some-
times increased, somctimea normal or even diminished. Seldom is an
atrophy of the substance of the testicle olxsened. Sometimes ilus
chronic iuflammution is accompanied with a auppuratioD which occasions
the formation of one or more abscesses. The ilocesses may remain
stationary and be surrounded with u fibrous or calcified encysting mem-
brane ; »r they may extend and ojien spontaneously,
By a solution of coniinnity, a hernia of the testicle may occur exter-
nally as a sjioii;^-, vascular, and grauulating aam, in nhtcii the alteivd
HYDROCELE. 661
seminiferous tubes are found aurrounded by granulation tissue. The
granulations consist of embryonic tissue. The lesion is termed henlijn
fungvB of the testicle. Tlie mass gradually diminishes through suppura-
tion, and recovery takes place by the formation of a cicatrix.
The surface and connective tissue of the epididymis, as well as the
serous membrane of the testicle, may he the aeat of chronic inflammation
with an abundant formation of embryonic tissue ; the latter may pro-
liferate and form elevations like the gramilations of fungus of the testicle.
The granulations of embryonic tissue formed upon the tunica vaginalia
after gangrene of the scrotum should not be confounded with benign
fungus.
Benign fungus, that is, hernia of the inflamed substance of the testicle,
in which the connective tissue of the testicle is changed into granulation
tissue, occurs under various circumstances : in acute purulent inflamma-
tion when an abscess has been opened ; in tuberculous orchitis, and at
times in syphilitic orchitis.
Syphilitic chronic orchitis consiste in a new formation of fibrous tissue
between the seminiferous tubes. The tubes are separated from one
another by embryonic or fibrous tissue, and are atrophied by pressure. In
some cases they are almost reduced to their enveloping membrane, and
have in their interior only a few atrophied granular fatty cells. This lesion
may affect either the entire testicle or only a few lobules. A thickening
of the tunica albuginea and tunica vaginalis is also observed. The tunica
vaginalis may present either vegetations or adhesions. This variety of
orchitis usually coexista with syphilitic gummata, but may occur without
them.
Hydrocele. Hydrocele of the Tunica Vaijinaii». — Altbougli hydro-
cele of the tunica vaginalis has been placed among the dropsies, it should
be considered as a chronic inflammation. The lesion seldom occurs in
general dropsy, and the fluid in the tunica vaginalis contains a consider-
able ijuantity of fibrin, as occurs in all inflammatory exudations ; fre-
quently there are formed fibrous productions, new membranes, and ex-
crescences upon the internal surface of the serous mcmhranc. This
disease is characterized by a serous or fibrinous exudation into the
tunica vaginalis, resulting either from an acute or a chronic inflammation
of the whole serous membrane or from a varicocele. The amount of
fluid varies; it is generally clear; at times colored yellow by a few
blood corpuscles; there may be present crystals of cholesterin, swollen
endothelial cells, and enough lymph cells to give it a turbid appearance.
In some cases of hydrocele there exists a cyst of the epididymis, which
may rupture into the tunica vaginalis; in the latter case, spermatozoids
are then found in the fluid of the hydrocele.
The internal surface of the tunica vaginalis in recent cases is smooth,
but the connective tissue of the membrane is always thickened. In
chronic hydroceles there are always found very evident signs of chronic
inflammation; there are superimposed, upon the surface of the tunica
vaginalis, cither the parietal or the visceral, layers of new vascular mem-
branes. These formations usually consist of a dense, hard connective
S62
TESTICLRB.
tissue, ûmiUr to tliat covering tlie Btirface of llic Hpleen in vhronw peri-
«jilcniiU. Those tlciiac fibrous fornutttonfl nlso, an u]k»i iU« xurfncc of
Lliv Tifilccu, funu <-levalcil [iRtclie^ witli acartiUgiti'itia a|:i|>earnric<-. ur tint.
soBiotiiiieA «levatoil iioilulea, or eroii villous jirojcctioiia ; tliej iniiuiis» i-f
Ïnralli'l U^'crM ol' Ianiiiuit(>d connective âsôue ecparawd bv Hal cvlU.
!vc)ivrooB«H are Ireiiuently scfii beneath Ihcm. b«cween tiie tiomial eon-
neclivo tisauc ami tno new fibroii* fonDUEion. Vi<ii;Dtatioiis ftml ivunii
elevations, bavin^ the ohnpe, seini-traiigparoncy. and iletuity of small
pearU, in*y bceoiue free in tlie HCrouti cavity, in Uio ruiuo manner u eaàt
toroigii Ixxlie^ are tonncil in the itrliciilntion^. Tlietc IxxliM in th> ^
vavity of ttiv tunica vagiiutliit arc formvd of concentric layorx of UmidH
fttdl comK-ctivc tiiwiie Heparatod by Bat cellii. Tlieac dift'vrvnt varioti^l
of new fornixtion» may he iufitti-aled with calcnreom ultA. The teii6cl«
surrounded by Huch a tJiickeuud antl contracted tanica va^nalis atruphim.
Hydrocele of the tunica vaginalis is fr^ifuouily cotoplicated cither «ith
cysts, or other varieties of hydrocolc. or with a scrotal hernia : it may
be the origin of a euppurativo or intense intiunnnntion of the tunica vagi-
nalis; it may also bu complicated «itli a ha:iiiutoci-W, that is, an escape
of blood into the cavity of the tunica vaginalii).
Oangnnltat Kgclrocitt.'—'The peritoneal »ac which ocooin|ianivit the
oord nnd testicle in its descent into ibo .tcrotum, intitcad of iM^ini; ohlilv-
ntod above the ti'stich-. ta form the tunica vaginalis, rcmaimi f<|H>n. simI
the wrona membrane Aurronii<liug the tentiule communkatcs dtiriii;: life
with tlie porilontal cavity. Thtrcfore fluid in tJie ^ritoocat cavity may
pass into the tuuie^i vaginalis, and Quid in the tunica vaj^inalia may also
pass into the peritoneal cavity. Fret|ucoi]y in these cases tliore is an
inguinal hcniia.
Ct/*fie Hi/ilr'irfU. — It wHBCtÙKS happens Uiat the peritoneal sac
which acmnipatiies the cord it not obliterated throu^çhout it« eittin- ex-
tent, but ri'uiaina open in eome jmrtof ïu courue, being closed alxive atul
below. If these partd become filled with fluid, there ia formed a cystic
hydrocele of the cord. Several cyata mav thus occur along the cord.
It happens, at timea, that an old hernial sac is obliterated, ai>d the
lon-ïation of tlie peritoneum constituting it, instead of rctnainiiij; colla|JiM _
is titled with fluid. There ihon results a dropsy of tlic hernial sac, which
should not be uonfounded with a cystic hydrocele. Cystic hydrocele of
the oord, or hydrocele of n hernial sftC, frv<|U0Dtly complicates simple
hydrocele of tlie tunica va>(inalis.
Other cysts which have been for a lou); lime confounded with (drnpl*
hydrocele, are nj'ermaCU- rtftl* (spermatic hydrocele), generally located
at the superior jiart of the testicle. These cyata, sometimes very lar^,
are filled with a turhiil Suid, containing with the living or altered sfienna-
tozoiiLs, cpiilielial cells similar to those of the iiormal spermatic canab.
The»c cysts may open into the cavity of the tanica vaginalis which is
frequently at the same time tJic scat of a hydrocele. In regard to their
mode of loi-uiation, the hyp ocbesis of a new and independent formation of
the cysts has been ndvocah^'d by Pajiet. According to the investigations
of Gosselin, Lusdika, etc., it is mure probliblc that they have their
TUMORS or TBS TESTICLE.
668
orifpn tmm a ttilatation of prc-«Ki8tin^ ductit. Ttieîr »cat t» exnctlj? lli«
point nrliere th« lubes of t«iiii«Ie and tlnwe of the otiiiliilvintit are sefio-
ratelj dcvelnped during t)ie emhrjonM; perioil, allhough aftorwsirlii
united; here aW are found the otelf»» tuhe^ ci>ining fmin the Wolffian
body which eoufltitulo the on/a>t cf (finiifif*.
Independent of all the foregoing varieties of cysw mot witli in hy-
drjci-lcs, thcro is often found sn ccdetnalons infiltration of the con>
iMCtivo tJMMc of the vn^culuRi aberninri of Ilaller aod orgsii of tiinldej,
or B Inu) cjatic diUtution of the caiialii of the latter.
H.SMATOCBLB. — It hu be«n iron that, in chroniu hyilrocole, tlic binica
vaginalis it «orerod by new mombntnous fomiit lions, aiTan};oI at (im«a in
Hii)>«rim[M>t«d thick fibrou» layers anpplicd with veaaels whose nijitiin.-
Ci\iLr«A tlic ecchymoses often found in Ùii? formation. From the fricii»i).-i
or contusions, to which tbe§e large tumors are ex[>oâed, there may occur
itn escaira of blooil into the cavity of the tunica vaginalis. The tumor
foniifd ny Uiia blood is dcn»e, hard, and non-fluctnating ; the cavity of
tlie thickened fibrous tunic» vaginslis im filled with a chocolate or brown
fluid, a color due to the prCMnce of dïsÎDtcgratiiig blood corpuKlos. Upon
the surface of the mcnihrano and in the «ao, blood olot« aod coa^^tlaied
fibrin arc «ccn. Micro«copic examination of t)i« Buid shows lihrin, re<l
blood O0T]iui>cle«, swollen endothelial coUx contninin}; blooil jiigiuent, fatty
granules, and frecjucntly al»o orystalii of oholosterin. If the escape of
blood occurs when tlierc has previously been a large amount of the serous
fluid of a hydrocele, there in uo coa^liition of the tibnn in llic fluid of
the hematocele. ïîie teâlicle ia generally atrophied beneath the thick
layers of new membrane. An escape of blood may aUo occur in a cyat
of the cord.
Infiltrations of blood into the connective U«sue of the testicle are of
«nfrcpient occurrence. They sometimes, however, give rise to a hicnm-
tocele nitliiii the testicle. ThiA rare lesion has not yet been raiiiiicely
described. With Coyne we have had tbe opportunity of studying two
eases. There was a very old large hiematocele in the tunica vaginalis.
At the central portion of the testicle an old. partly discolored cïot was
found, about the sixc of a sniali 8]>ple; tlie clot was traversed by vessels
with thick walls. In the peripheral layer* of the clot were fotmd sopa-
rated scmîniferoaa tubes. Tbe Doigliooring substance of tlie testicle
proitented tlie tenons of parenchymatous ami intcntitial orchitis, chaniv-
lerized by a» abundiuit formation of round embryonic elcmenttf.
TtMORS OF TUB TbSTICLK.
EscnoSDftOJiA. — Encbondroma of the teiiticlc i« not rcry rare; it
generally follows traumatisms. Tho hyaline cartila^tinouA ti.4.4iie is easily
MKu, both with the unaided eye and tbe luicrosoorie, in the form of nodules
of variable sixc, or as a diftused infiltration. It generally occupies the
gUind,l>ut it may involve Uie cpididymi*. eiilier primarily or aeondarily.
The testicle \» increased in jiixe, sometimes it is very large, but in this
ca»c the cartilaginous tissue is usually found in the midst of a fibrous or
661 TslVI^LNi. ■
^ftrconiAlous tt-iHue, wliilc cysts exist in the suWl/incv of the ^^Isnd. En-
cbondronin does uot always consist s«Iely of vurtilaginous tisaav.
From the oWn-ations of Paget snd Vii-chow, it luis W«n ssccruineil
tthat carUlago may (k-velop in the interior of the Winpliiitics of llic ti-*ticle
I^Rnd present the riimïrymg sluipc of Ûtvf-o pn««ii^cM. Iii one ciwc, r«-
porti'd by I'lim-t, tli« ttirnor extendvd nioii;; tlio «pcrmittic conl, into the
ilinc lyni|>h ^liimlj*. into the Iyni)>hAtic« of (he iiiferi*ir vena cnv», into
I the lunu'ii <>f which » cnrùlagtiioni^ mics |ii-otni<lci) tu far as Ihf [iulnion>
' iiry aricry ; and the hmf; aliio ])rc;Mnt<-d aecoudary tiimora of the RBoie
nature. [Sccondary farmntiona ai-c not extremely rare. The tnost
favorite seat of the sccondarjr deposits is tbe lungs.]
FiuiiOMA. — Kxcopt the hard, oOon calcifii-d fibromata, whioh ar«
fornii-d upon the «itrfnce of the tunica vngimilis. or wltich orif^iiiatt- in a
fihrouM hypertrophy of the tunica allnigiiiea in hydrocele, fihrimuitn of
the testicle are very rarely seen. However, Fuirster reporta « owe in
which a fibrous tumor deveio|niig in tliu tunica alhugioea projected into
tlie substance of the teetiele.
Sarcoma. — Sarcoma withont cystic degeneration is not often met with.
It Otictirs in the testicle or entilidyniis ; the gland is unifomdy euhtrged,
not lolmUted; the tunica albuf^inea ii> not involved, a small amoimt is
found in the cavity of ilie tunica vaginalis. Upon section the tissue
\» Boft, fleshy, vascular, homogeneous, and inGltnttione of blood are fro.
4uentiy seen. Examined »filh the microMOpc, these lumon» somctiiucs
approach the inyxonuil» in their fumlamentnl enlutanco, whieh imWdi
L large fusiform celht, or sninll round celU. Fatty degeneration, and blood
extravasations&t tiineiigtveaca^eoii.snp[)carahi:e to portions of tbe tumor.
In a case of Lcberl there was a rcprmlviction of the Dc«plasm in the lym-
phatic glands of the neck and in the pleura.
In another variety of sarcoma, which is frequently corobiiH*d with
eiichoiidroma, the tumor contains cvsta varying in size. These are ri/ttie
mrr-omat'i, which, after remaining localised for a time, at longtb break
through the tunica albuginea. and become genernliied, and malipinut in
type. Cystic sarcomata have been, up to the present, confounded with
[ malignant eysta of the testicles belonging to a group of tumom differing
in structure, nature, and prognosis. An uuatonit<-a) examinaticHti of
malignant cyst« of the testicle demonstnit^^'S thai ihey are unlike sarco-
mata. Malassex concludes from hi» invent i^tiona, that they are a pecu-
liar variety of epithelioma, and he name» them myxoid cpitheliomata.
In a large cystic sarcoma, a fibivus or .«arcomalous tissue, in places
Hpindlc celled, in other partit rounti celled, frequently baWng small
area» of cartilage disseminated through it, is interposed between tbe semi-
niferous tubes and cvsts. The cjatA vary in size from a hemp soe^l to •
bazel-nnl, and are hlled with a serous or colloid fluid. The tumor is ai
t first limited by the tunica albuginea, and there are found portion» of the
* testicle unchanged, t.k-casionally the growUi bcgiiw in the epiditJymi».
From the histologie*) descriptions, particularly that by Kcersler, tlie cviKs
appear to originate by an enlargement of the seminiferous tube»; the
Lttcr are lined by au epithelium, which becomes detached, filling the
TrnERCLBS or trb testicle.
A66
"* wril^Tfitli cells : tliese celU undergo miicooa dci^ncnttion, and *rc trane-
(inraed into a hoiito;*c»eoiis mucoi,') âa\A. PHpillarr cxcronccncos vovi<rc<l
vritb i?|iiUiclium ^rovr from tlic walU of tlic cyHa into tti«ir int«nor. Tlie
contents of tbc cyst, hiKtoai] of bcinj; mucouti or «crotiii, Aotiietim»» rc^
eombk- the caseous miiiU'r of dcrmoiil cy«t«. Th.; cjiitlieliiim of the
serous cjTBt* is formed of flat, eyliniiricBi or cilintoil cylinilrk-al oi-IU.
Asoociated nicli tli.^ MreomaloiH and cartjlngttious lis^^uc, there arc often
found in l)ic «ttrnmn, new formationn of 3lriat«d inuacular fibre«.
In «veral cnsea of snrconiji and cystic sarcoma, complieatcd wjtb onclion-
dronia, Nepvcti ban followed the process of enlargement of the scmim*
femus tubi», and has pointed out the presence of small pearly ;;lobu1es
(cell nesta) situated in the cavities of tbe cnlargod tubes. These globules
were formed of corneous epithelial cells.
It seems to us that the neoptasm tonnod a cy«tic enrcoma lias otten
been clnased with tumor» which differ from it in their coiir»e nuil histo-
logical «trueturc. It is probable that clinical ami anatomical inve»lign-
tioa* will, in the future, dct«miine a <liiiit4nction between them.
Malawea has recently jmWisheii Mme otiservations upon this subject,
in which the cjstic fonnatioii^, situated in the centre of the testicle, MCre
iieparated from the parenchyma of the testicle, which was pushed to the
periphery in contact with the tunica albuginea. 'Ilic cysts surrounded
by an almost normal connectire tissue, which contained a few lympb cells
between its fibres, varied in sixe from a pea to a hazel-nut. Smooth
muscular fibres were found in this connective tissue. The internal su^
face of the cyst», cilber smooth or prescntim' villous projections, was linwl
with cell* varying in form; jiolygoniil mid fl:a. cylindrical or ciliated and
goblci-shaped. These several varieties of cell* were found united iuio
groups in the same cyi<tic cavity. The cells found in the serous or mucoua
6uid of the cysts reseml^ed those lining the internal surface ; many had
become spherical and undergone a fatty degeneration. In no part could
Malasscz discover a change of the normal semiidt'crous tabes into cysts;
moreover, the cysts had no similarity to the seminiferous tubes, llenco
he concludes that there is a new formation of epitbelinm and of cavities
filled with mucous epithvliuiQ, and be proposes to call the neoplasm a
mgxoid epithftioma.
I've EBOLBS.— Tubercles in the teatlclo may be the first mnnlfv^talioD
of tuberculosis of the gcnito-urinary organs, preiious to a dcjfi*it oecur-
ring in the hinji*. It mny begin in the testicle, but more fre<iuenily it
is we epididymis or vas deferens whicii is fii^t affected.
The testicle at times ]ire«enta very small gray miliary granulations,
scarceW visible to the unaided eye, which are iteated upon the tunica
vaginalis and in the coimective li^ue of the teslicio, surrounding the
spermatic canaliculi. The miliary granulations, at first gray, become
caseous at their centre, and form lobulaled groups, the centre upon section
appearing like a caseous ulcer. There is no douljt that the development
of the granulations commences aroimd the spermatic canaliculi. In ex-
nmining tlic canaliculi of the periphery of a nodule, the laraollœ of the
flbroua walls of the canaliculi are found separated by an abimdant dc-
660
T83TICLBS.
|)osit of flnuill tymph cclU, so Uiat th«re U ooiwiilcntlJc tlitckenÏDg or tlie
nail at thin point.
It U this accumula lion of amall c«IU in the coniMietiro ti^Mue of the
wall nhicli causes tiie limited ewelliii^ of ttie granulation. At tbe suaw
time tlio luinon of the tabo is enlarccd at tliis ]ioiul, and not diniiuisliei),
. as mifîht be c-xjiocU'd, by a fortnatioii of graimlar epithelial colls united
\ lu i.-iiL-h oUier l>y a ;{riinular eubetuiico. Tliia mole of dovclopment of a
I tubL'rvulous ;^rii link t lull of tbc tvstïcld, iDVMti|^tcd )>y Malas^ti-i, ts com-
' parable to thi- di-vi-l<i]>incti[ of a granulation aruuitd a >'ft»i'l of the pta
inat«r (moo pp. 11it,H7y). The wall of lh<r lu)>o i» exteniaUv in relation
witli tlie lympliativ;», and in a limitod portion of it« lon-^Ui \» iDGItnttod
wi[)t Iyni|ili e«lU, wliîle ibe corresponding iiilra-caaalivtiJar i<pilliolia ac-
L cumulate mid become caHcouD. A thin nectionof a Ur»(tclc inKltrativ) by
I tuberculous ){i-anuladona in process of development, preoontu aii mcuiuu- _
I Inlion of ^mall lymph cclU ionnin;! a circular zone around a HeminiferoM^^I
' tube, tlo lumun of which is enlarged aod 6lled with cusccmis enithelii^H
colls. Tlic lumina of the lymphatic» and bloodToswls iodudcil in thr
tissue of till- ^^ntnulation, are tilleul with fibrinous coaf;ulBtiona incloaing
in their »rattulnr Mululance, lymph corpuscles aiid eudothelial colla.
. Around the granulation the coimective timie trabecnla; sopftratiag die
[tubes, also are infdtrated with veils
I Itin Hi,-clion of a larger granulation there ia alnayii seen in itx contre
• CAsuoiut area, which corrcÂpouds to the lumen of a eaiutliculuii tilled
with ettlk; only the centre of llie granulation 'a caseous, wliilu in tlie
jfcripheral zone of proliferation the seminiferous tubes arc atrophied bjr
pressuri;, and narrower than in the normal state.
In a recent work on tuhereuWis of the tcstJclo by Tizxoni and Osule,
they conclude tliat tlio alFeetion begins by u new formation <.if Uic epilbe*
liutuof tbe lubes. They describe librinoua coagulations unitin;; the cells
of the lymphativ vc.«.4el.<«, and tlio collections ofca^cous eptlbelial cells of
tlie tubes in the granulation u giant celli« ; thitt error of intorprctution
vc liare several times previously explained.
When tubercles of the tesljcle become stjll larger, they are united
['Into grotijia, the centre becoming caaeoua and Mfïened. Tbe aoftening
[and suppuration in the centre always correspood, at tbe be^nniDg,lo the
lumen of an cnlarRod seminiferous tube ; hut when the canty extends by
ulceration, all the tissue's, without distinction, bceome caseous in the cen-
tral part of Uie nodules, and undergo a molecular de«tnicbon. Ther«
are fre<|ueiitly soon upon section seveml caseous centres united in a
common destruction, «o that tbo cavity is turrouiulcd by several graoo-
lations.
Tubercles are fre(|uently localized primarily in tlie epidtdymi», n.
to^tis, or vaa deferens. In tlte ras deferens and in the epididymis,
tultenekM are seen generally ad multiple noduleà arranged along tbe
tu))e. The large nodules, which are two or throe tiroes tbe diameter
L the canal, and oval or Hiihcrical in shape, consist in an infiltration of tha
'irall of tbo tube by sniull lymph cells, while at the same time the epithe-
lial lining of the mkicoiis monibi-anu prolileratcti, and noneioiis crauol:
cells fill the dilated lnuKiiof the canal. Tbc same lesions occur in tbes»'
Urge duett as in the seniiniforous tubes of tbo testicle. The yel-
LYHPHADBKOHA OF THE TESTICLE. 667
lowuh cafleouH «ontcnU of the duct M tlie jioÎDt of dUeasie &re »ort«n«d,
aiid s ite.^trucùve oufiriirniion, with caaeoua iilc«r.ttion of the walk
takes place »t tti? »nme time. A porlion of the wall may be deali-oyotl,
ant] n cliratitu înHa minatory process occiirriit;; in Hie noi;^boriti{; conitcc-
tivc tisiuo cauflea adhésions of tUo diae!i*i*d puns to ihu skin. There «ro
seen tii<tular cutaneous openings of the Rerotum, conimuni«ft(iiij: either
with the epididymis and cord, or witli the tMticlc ; tticy coiii^txt of n
fuDgons, emhryoDK dsauci ^in'rollr pale, and diMltartfc a «mall ipiautity
of grumoua pua. Tabcrculosis of the epididymis and eon) I» freiitienlly
complicated with talxTCuloais of the seminal veaicles, prostate, bla>lder,
or the entire getiito-urinarv «yntem. The lewon %ho frefiiieiilly omcikU
to the neighboring lymphatic glands, and finally to tiie luugs, which are
generally aflcetcd secondarily.
Stphilitic GcuiiATA. — Interstitial syphilitic oichitia has boon pre-
viously described ; it remains to study •{ummata of the UHrticlt-s. whivh
arc always accompanied with an interstitial and peri-orchîlis — that is, a
fibrinous thickening of the tunica albiiginea and rnginalis, fn.-<iuuntly end-
ing in intimate union of the two «ertms surfacca.
Aceonling to the di'«cription of Viruhow, gnmmata be^n by the for-
mation of dcuHc, librouM, ealloua fasciculi from the tunica albu^nea aixl
eiirfaec of the gland, penetrating Itetween tlie lobules of the testialea oa
oonicml fasciculi, or large masses having a spherical or lobulated sha]>e.
nils fibnut tiwue taking the place of the aeminiferoos tubules, which are
completely atrophied at the eurfaco, becomes lutpr the wat of yellow
gummatous tumors, located either in tbc tJiickciR-d ttinica nlbu^^nea or
in the fibrous tissue developed in the testicle. These yellow gummatous
maasca are nothing more than the caacous degencraUons of the pre-fonncd
fibrona tissue.
Sypliililic gnmmata are very easily recognised and differentiate*! from
etlier legions; tliey have been described by Curling as chronic orchitis.
The hardnoH of gunimaia, even wlten they have become cai^^outi, the
great fibrous induration of the substance of the testicle where the semi-
nifemuB tubes are atrophied and separated by fibrous tissue, disUnctly
discriroÏDatea this lesion from the tubercles in which the cxmious foci are
soft, suppurate, and have a tendency to open externally by fistular tracta.
Again, the induration of the epididymis i^ less frequent than tlint of the
testicle; also gnnimnta of the epididymis arc more rare. The large
tubercles of the cjiididyrai* and vas dcft;ron«, which arerery characteria-
tic, arc more common tiian taberelei of the testicles. Sypliilis of the
testicle, in consequence of the complete atrophy of the seminiferoua
tubes by the precsitre of the connective tissue, entirely arrests the frnio*
tion of tlic gland, 'lliere i» no positive evidence of suppuration or an
extendi o)>t'tiing of gummata of tlte testicle. This eatablishes an essen*
tial dilferetice between tliese formations and tubercles.
Lyhphadbxojia. — We know of but one case of tymphadcnoma of the
testicle. It was described by Mnlussex. The tumor of tlio testicle was
formed of a typical rctictdatcà tissue, the meshes of which were filled witli
lymph cells.
S8
TB8TICLB8.
Carcinoma. — Oarciiioma is ono of Uic inojil frc<|uent now iM'0[ilfttire«
of tlie tcftlicIeH. It in nrininry ; almost n«v«r wcotiilary. U M:cunt
only in one testicle ; it bej^iia bj RCparate noiluleii, or bv a ili1tiL>c<l ii^
filtrntion, irhicli rapidtj- exteiitia, and acqiiiret) a larj^ iixe. Tbe tnmat
Igcncrally beginB in the ti'sticle, but the opi.lidymift is almost always
wou involvej. The now tissue bcRin* around the B«minifi.-mus wSes
in tlic connective ti^ue of the gland, which is tranefomict int/j a carci-
I iu>inaio)u Hti'oiiia ; in the tllsotscd portion the fieminifurous tubes arc
airojiliit'd, and filled by the new fonnation. In the centre of tlie
ttiinor, tbe oldest and mont diseased part, there are no truoes of the
tubes remaining. When the Himor ha« hail it» origin from tlio tronira!
part of the testicle, or from the rete tetitis, or from the oorpu.4 llijilim»-
rianum, there is always seen at tlic periphery of the growth op]>osite to
the place of its development, under the tunica albuginea, a gray and
opu()uc. or pink layer, which consista of the seminiferous tubes pushe-l
asido and compressed hy the now tissue. Theso tubes arc atrophied,
Kiirro\inded by new very vascular connective tissue, and they cannot be
drawn out. f he distended tunica albu^nea is intact. Later, howcvvr,
I thU tunic is invndcil by the tumor, and prc«enl« exoresccncc^ of tlio sanw
I nature; the epiilidymi», the cord, the pelvic antl reiro-i>critoneal lyinpli
glands arc aUo involved. From our inve^^tigaticns the )>«niini(croiH
tubes do not seem to be the jioinl of origin of carcinoinA ; yet Birch-
Ilirschfeld has isolated seminiferous tubes, which presented ncw-foniwi)
protuberances, increasing rapidly a^ they penelrated into tlie ntorbid
mass. According to lliis writer, curcinoina of tlie testicle has its ori^n
in a new fonnution of epithcloid ulcnicnU in the interior of the semi-
niferous tubes. We have not been able to verify tlii» mwlc of develop
ntcnl, and do not Leliere that cairinoma is developed in tlie tubi;», but id
tJic connective ti«»ue, by the swelling of the connective tisiiue cell», and
tlic new formation of large cell*, which occupy the connective tissue
spaces between the fasciculi of the tihres and the lym[))iatic cavities.
The most freijuent variety of i^arcinoma of llie testicle is encephiib-id;
the .surface, upon section, is while, doughy, and, upon pressure, oxinlea
a larjjo ipianiity of milky juice. To the uiiiiided eye. it is impossible to
confound this tumor with a sarcoma, which contains juice only when it is
undergoing cadavcrie decomposition. Sometimes an cncephaloid pr»-
scnts a great development of capillary vessels, and is then terrace
bii:matoi<(-earcinum& ; it is then very friable, and the conucctivc
small in amount. Hi^ologicnl exnniination of this variety of carcinon
of tlie testicle presents very distinctly all the cliaraeteristics of sueh
formations.
ijcirrhus of tbe testicle is extremely rare ; several writers deny thai it
ever occurs. îlepveu has studied and published one case of this variety.
Melanotic carcinoma (or melanotic sarcoma) has been noticed as a
sccondarv tumor of the testicle.
Many case-s of tumors published as cancer of the testicles, with iosnS-
cicnt Instolojiical details or oven without microscopic examination,
tion the presence of cysts ; others report tlie coexistence of carcinomK'
OTBTS 0? TBE TESTICLE. 669
with cystic sarcoma, and admit that a sarcoma may be tranaformeil into
a carcinoma. These are very interesting points, and as yet remain
unexplained.
Tlie testicle is sometimes the eeat of dermoid cysts and cysts of fœtal
origin.
iîoth striated and non-striated muscular fibres have been found in
connection with sarcoma of the tcâticle.
There are reported some very rare cases of hydatid cysts with echiuo-
cocci developed in the epididymis and tunica vaginalis.
070
PROSTATB.
CHAPTER IV.
PROSTATE.
Sect, I.— Konstl Histology.
Tub prostaw ia an organ compoepd mostly of emonUi muscular and
coimcctive tissue fibres : this tissue is traversol by glands wliieli njieo
at tli« sides of the rem montannm in the folds of tJio nretltral mucoos
mvnilirauc. At the inferior portion of tlio prostato, in thv depressions
of lliv ginnd. pii«9 the ejaeulutory duct«, which open in the inferior part
of tlio pro«lAtic portion of t)ie urethra. The vent iDonUnuni or premi-
tionci', lihajx-d tike & orevit, din-ctod from above downwards in tlie middle of
th« prosMlie [xinion of tli« nrcthm. prc«cnts bi-^idos at it« middle part a
slit-like deprea^ioD or canal, uaowd the utricultu prostMicoi or nutle
uterus.
The jjlanda of the proatnte. which open by ton or twfelve orifiec» on
each side of ilic veru monianum, are remarkable for the lenjtth of their
Lj08inl«, for the small imoibor and llio glcndcrne^s of the f>lnndnlar vi*gic1ce
ruonMi lilting them. Thci't'! vesicle» ore lined by a layer of eylindrîcal or
polygonal epiliieliul ct'llw which eoiitain brown iiignientury granules. The
«xoreiory ducta are lined with the «amc variety of epilheliiim iw thej
uretliral mncou») moinbrane. The tiiiie»u.t mendirane of the uale uter
\m8 an analogous lining of atraiilied cpitliolium.
Sect. II.— FaUuilogioal Histolo^.
lîiFLAMMATros. — InGtiniiDatian of tho prostate occurs niost fre*iueDlly
with bICnnorrhagic catarrh of the urethra and neck of the bladder, but
it RUty a1»o he «pontaneous or traumatic. It is acute and s1i;;ht orj
chronic, «lid ia atwociated with the formation of abseoww. The latl
Lvariety Ls more often seen at antopsie». I'atient* seldom die of non
Ï undent pro^tatitii* ; therefore, a hypothesis of ils nature must be formed. 1
'be ;;land is flupi>osed to lie congeiited and (edematous; it aecret*'» an
abundance of mucud with pus eoqiuacle» ; and its ducts and glawlular
adui take an active part in the iutlnmrnatory process.
pTQtMie absvraafs occur most frec|ueui1y as a result of chronic inSam^j
nation» of tho mucous membrane of tho urinary passages ; ther arsl
either «mall aud Humorous or of eonsidontblc nize. The entire prosiaier
rnnv bo Ir&nafomed into a large «ac &lled with pus, which bceomej thick
and caseous if the legion \» of long ilurxtion. These alwcesiKs may be>
come surrounded by a dense cystic wall infiltrated with cakareoui^ salts,
or they may open into the urethra, which is the most frev|ueat termina-
TUMORS OP THE PROSTATE. 671
tion. But an opening m&y take place into the bladclor, the Beminal vesi-
cles, the surrounding connective tissue, or into the peritoneal cavity.
Tumors. Hypertrophy. — The increase in size of the prostate is s
physiological fact occurring in advanced age. The venous vessels of
the gland and perineum are dilated; the fibro-muscular tissue becomes
thicker and denser ; the glandular vesicles are hypertrophiod and multi-
plied ; and the prostate is enlarged cither uniformly as a whole or in
some of its parts — the right, left, or middle lobe.
Prostatic concretions or calculi are also fretjucntly met with in old
persons. They are formed in the interior of the glandular acini or
ducts. Their size varies from .004 mm. to .005 mm. up to a half
millimetre or one millimetre in diameter. The smallest are round or
oval, refracting, and colorless ; they consist of a hard colloid substance
difficult t« crush ; with tincture of iodine and sidphuric acid they offer
the same reaction as do parts affected with amyloid degeneration, and
have been described by Virchow as due to amyloid degeneration. The
larger calculi arc more resisting, yellow, yellowiah-brown, or darkisli-
brown in color, and present concentric layers ; escalate or phosphate
of lime may be deposited upon them in laminœ, when they become very
large. The glandular acini and ducts dilated by the calculi are filled
with a mucous fluid, so that when the prostate is the seat of numerous
concretions, which is often the case, the gland is transformed into a series
of cavities which give it the appearance of cavernous tissue. These
cavities are lined with a cylindrical and polygonal epithelium, several
layers thick. The calculi remain in position and do not produce any
symptoms, or they are passed through the dilated excretory ducts, and
give rise to inflammatory troubles either in the prostatic ducts or in the
urethra.
General or partial hypertrophies should be placed among myoraata of
the prostate, due to the new formation of a very dense, grayish-white or
pinkish tissue, consisting of smooth muscular fibres and newly formed
connective tissue. The glands of the prostate also increase in size at the
same time that the cellulo-muscular tissue is developed, and there is seen
a new formation of glandular acini. Such a growth might be considered
as a mixed tumor or adeno-myotna.
A ijeneral hypertrophy of the prostate due to the formation of new
fib ro- muscular tissue, is not usually uniform, but commonly forma nodules
or elevations, which frequently project into the urethral canal and offer
an obstacle to micturition and cathetcrism. ïlie enlargement is not al-
ways symmetrical, and there may result a lateral displacement of the
urethra in the prostatic portion. The consequence of hypertrophy of the
prostate is an increase in the calibre of the prostatic region of the ure-
thra, but it occasions at times great difficulty in the passing of instru-
ments into the bladder, because of the development of nodules projecting
into the urethra and often uplifting the neck of the bladder.
Partiid hypertrophy is characterized by the nodules which form upon
the surface of the prostate, very similar in structure to the preceding,
and generally developed around hypertrophied glandular acini.
(TTS prostate.
TrBtntcLC!;. — Tubcrcolosia of Ibe pixHtate ofien accompwiiea thnt of
Uie other genito-uriiuirv or^oB. Tht> luberculoiu (r^nulauoiu derelnpe^l
in the coaneciit'c tUeuc, in the proiiniit; o{ ibe docts aud gUndiUar
ftcini. arc diffused or grouped togeth«r,»nd tliev do not differ from Uiow
fomid in other or;;Mis. CdMovs «oftoDÎng, uh'vration uf thv gUndoltr
dueu, and central soiVininf; pvfl rise to atvemuus foci «hicb soBMrtimca,
hj thio nK-diuiu of fi»taltr pUMge*, opon into tiie bladder and rcctaa.
Carcinoua. — CarciiUMDa of the prostate Heldom occara; it may b« pri-
DUtr;,-, nr woondar; to » jiriioarjr liiwor of the rcvtuoi. 'Dte Buwt frv-
i|ueiit varietj i» eticepbaloid. The diseMCd ghad ]>rrijcoU intn tlie urr-
thra or neck of the bladder, aii in unipte hv|ier(ro]ihj. 11ip wallii of
the bladder may be s«coiidarily involved. Accordiog to 0. W'vi. car-
cinoma bcgioa hy a new formation of epitheUal cells eprin^ng fn>ot the
epitlielium of the glandular iube«, the stroma of the gland remaining
almoat passiTe.
KOttHAL UISTOLOUÏ Ot TUB OVARIES.
t>73
CHAPTER V.
OVAItlES.
Seot. I.— Normal HisUilog^.
»
The orary consists of ft cor>
^cal ami medullarjr «nbstanefl.
Tlic cortif^it $tA»tanee w
limited Gxtoriislly I>t ft port-
toncftl I'ovflrin;*, whioo is lincil
ujKni il* *nrfin;o with a InytT of
cylinilricul cetli< nml ncoiiii«ctivc
ti»itue layer bolon^^iiig lo the
periloneHin. The latter layer,
bowerer, cannot he aeparated
from the tunica albuginea, a
d«n3« filtroua mcmtiranc, which
oompletety surrounds the or^nti,
and accompanies th« vos^'-li en-
tering ttie liilun. Henenth tliu
tunica albnginea ii< neen a }!niy-
tsh layer, abncni only at the
hilus ; it coutaiiiR the orisac».
The latter are so uuiDeroua in
children ami young women that
Sappey eatimntus them at about
anillliun; they coni-istof a mem*
brail»; lined with epithelium, and
at the centre of this vesicle,
which U spherical in shape,
there la found a larpj ci-ll,
which is tiie ovule. The small-
69t of the oviitacA contain a
ûngle ovule surrounded by a
iDaao of cells which are in iuime>
diate contact with it. As the
orisacH approach the cortical
substance, they become larger,
and in their further evolutitui
they are filled with a fluid, and
are visible tti the unaided «ye,
when they receive the name of
Qraaiian fvlliclts or vesicles.
43'
Fig. »C.
folllflaa^ J, OM''' rollklo. r- Pnlltfdrf-a* dikkn with
**t' /■ Ki'UbvUiim of* BaitfQil «cf in ih* torn* toUU
fin. ff. TqbI» HhrnM 'olIlfivLl. A^ TuJii<s v^'F^^'^
FolJltaU. 4. EpULat^uv at lb* folt^fl* (Btfinlifinii
fnuttl"«â>- I- V«**-1b- m. Oil lubM ot thq ptr*
«TarLamU iva^ tfcUt>a. p. Tiibtfntini1*pra>*lDnurtb«
|i«rBlu*l*pUb*Uiunlp|«tba«r4TUDllMd«- tStrtctf't
6T4
ovakies.
The Grufian follicles nre «Ivrars fnum) in jrreM numben in clùMrvti,
Jtmmg girl» ittid womoii; lli«y cotiMiNt of «n internal tunic nml »n ciHtlxs
i«1 lining. At a point of th« qiitJii-liil lini:i^, tli« cclU ronnin;; il arc
e»llecte<l tojKlher in » hr^r nwwwi {llif pr<Jiij--r-iu» <iiitk), enrelopinf; on
ovule vhich ha» ac'iuircd ilA ci>iii]>lete iI(tvelo|imeiit.
Tlie wall of the follicle consists of two Invcra of lonfie conttective tÏMue :
the first (Slifaut faemliraNe) contains the mmifioations of nrlenolea and
Vfiniili.>8; the aecond, more internal (l'inferKo/ inemhntne) 8up|Wrta tlie
capillary UIooiIvl-sscU. The two layers composeil of rctictilatea connec-
liri- ti^UL* possL'Sâ miinoroiifi cnnncHitive-tiasiic cella. ^Vitliin this is mci
n iiiriiibmni; consislin;; of a ïtii;;lf layor of large cndolhclial colls (Slav-
juiinki). 'riii« nicinbran<.- is lined with a layer of javement c[>it)iclial
colls (granular nioitibraiie). The iiavenietit culls are Haall, incasuring
Vie. 331-
4. TrUiuiiUlrtnlliniiisDl frain * r»la> kl lli*<'(tilh mnnlt. if. Pr-.tinldUIMlltMrMW* nkUI|
f^ ttvia t pti^on : A « ■'>if>^iThiii o^dr' ohe from ■ntnr. R. C^^éi B\ifmmMJ of otAr^ vf tmmy
BitnitawM. r Aij rn al ttiyt aoimril. O. iuttn Irtm ■ roliicUuriinl>l>li.l mis. la dlmmttat-, m,
mfithi Ham vt ttto "«uni: ^. i^AiaUf «trlAU^ too* |<*]lii(il4it; tf« 4*riDliwl tovlal* ; il, irtmlMAl 4i*<l
r.ralk. lliKh powM, |«I>lrlw.i
only .OiXt nirn. to .1)1*2 mm. in diamoter. and are prondod witli nitclet.
Whi^re liiv tayfr of cells in ltiickf«t. that i» at the proli^'erout disk, tiiere
i» foanil a completely develn[>^d ovule. Tho ovule is sitnatcd in the part
of the follicle loint removed from the oirariaii surface. The pc«i of ibe
cavity of the follicle is fiileti witli » Siiid holding a few ce)U in siupen.
Bion.
iLpon exaroiDation of the orule after separttting it from the C«1U of the
NORMAL UISTOLOGT OF TUB OTASIKS. 675
proligerouii disk, ît is fouod to he t ver; lar^ anherical cell meaanrinj;
.1 ram. to .2 mm. and can be seen hy the unaidoa eye It consists of a
capule or rit«lline membrano. This inembranu is very thick, homogo*
Deoiis io nomen, b\it ia some miimnls traversed by cnmlîculî. Th« idms
of the ceils tenDe<l vilolliis is x visciil m.iss contsînin<; nlbunrinoas And
fatty <;ranulO'S. The nucleus of tiie coll or ;;ermi»ii1 reside (tomcIo of
Pnrkinjc) is also spliericiil, from .020 mm. to .0-48 mm. in diiunetcr, and
incloses several nucOui nutii^d gcmiiiinl spots.
Indc|)eiidciit of this nitcleus there always exist* s second tiHcleu»,
discovered by Itxlbiniii, and named bv him embrro^iieiiMis veriicle, liecnnse
before the fecniidation of the ovule it is the centre of nutritive chants
wbi<;h take place in the vltellus.and because it remains after feciin<1ation.
Itnlhiani has alao seen the gomiinal spots change their form, and he re>
garda theiu as contractile wsiclcs.
Wlien the GranliHti follicle has reached a centimetre in diameter, and
projects from the surface of the oviiry.it ruptures and empties its contents
into the Fallopian tube during thv luhido-ovurian con^stion which aceom-
panies inenstniatinn. It ts, however, an error to believe, that every
Uraafian follicle niplure:* upon the «urfacc of the ovary, for nnnicrotu
follicK'* iimlergo involution and ntrophy before the evolution of the menses
and after their i;e)i.4ation. It aUo apjicarii to be dcmountrated tliat ovu-
lation may occur uttliout menstruation, under tlic intlnenoe of an ovarinu
congosiioo oocarioTietl by a grave type of fever (typhoid fi'ver, variola^
Again, it has been proved that fecundation and gestation have occurred
in some cases after (hf menopause and witboat «ny return of menstms-
tion. Itut notvritfastandin^ these facts, which are exceptions, it is doteiv
mined that, as a ^neral rule, meuslriiatio» corresponds with the pasaing
of an ovule by tlie Kallopian tube into the uterus.
Tlie ovisacs, or primordial follicle» containiii<i the ovule, come from dis-
tinct i^landular tubes which exisit in the orary of the embryo. Aeconl-
ing to i*tlu;;er, they are formed by an envelope lined with n layer of
finmll epithelial cellii, which represents the granular merohraue of the
Ornafian fnUicle, and inclose at their centre a aerie» of nidimenlary
ovules. By the growth of these omles and their surrouniling connective
tissue, the tubes are partitioned by the connective tiHsiie, and divided
into separate very small se^mentn. Kacii se;;ment now contains an ovule
surrounded by a xonv of ejnttielinl colls, and constitutes an ovisac.
When the tiraalian follicle has emptied its contents into the oviduct,
it undergoes a scries of change», being transfurmed into what is known
ns the rorfut fulram. Tliesc bodies diffor aeconling to whether the
follicle correspondu to a fecundated egg or lo a «impie menstruation.
The first or the corpus hiteura of gestation Ia large in aiïc, and very
slowly uiidergor» modifications. It njipearii a^ a prominent point u[>i>n
the surface of the ovary, where i» seen the cicatrix which follows the
rupture «f the follicle. Upon section there is .leen an oblong or spheri-
cal cavity, which acnuiros its greatest sine two or three monthti after
fecundation, and is tilled with coagulated blood or a Moody mucoua fluid.
This cavity is lined by a wrinkled yellowish or whitish, very vascular
thick lonc: outside of this limit between the corpus luteum and the
stroma of the ovary, there exists a whitish and very tbia fibrous mem-
i
676
OVAHIBS.
brano. Tiie jcUowieh uni vrinklt-d iiintr sono comes frotn a tliîckeoîng
of thv iiitcmit] layer of the flbrou« luoinbranc of th« Gniafiau fnlliclv.
Tliv ttiivkoniiig, in whMlt tlif «pithelium iloc» Dot itpgwar to {iartH-i|i»te,
U duo to an imnwii^v miiutier of cell* roHulting Trom llio |>rolifiTiition of
tlic von»eolive-li8sa« elcmentit. Among thc«e cells nutnv )>eci>m« very
' 1ir);e, containing a large »ucl«u8 an<I a ereat r)iiantiiy of fattv granules.
It in the latter wbidi have given tlie foldet! membrane itti yellow coloc
aw) opacity. The thin libroua membrane of the corpus luteum re
senta the fibrous moiubrane of the follicle. Tliis now formation of
bryonic tissue contiiaiea (luring ^{csution ; at the aame time the blood
abeorbod, as also an- tlic fatty Kramiles of the wrinkled membrane, Tbe
corpus lutcum diminiahcs in size, aiwl becomes denser. At tW tinto of
delivery il measures about nine uiitlimetrvs. Later it ;;nHiually atro-
phies, and is transformod in[<^ u yvUowishnhite or dark pif^tneoted
fibrous i'icalrix, which never entirely disn[>pvara. Ilie viiriotis colors il
[ireMents arc due to th« tmiiofortnatioti of tlio hicmacio whit.-h it eoiiiaiun.
When the corpiu lutout» comm from « simple nieit^ttruntion, it tt
generally xmall from tbe bi;;;iiiniii;:: the phenomeua occurring in tbe fol-
licle arc tbe aame &» aliove dei^ci-ilred, but the cliangeii are very ra[iid,
80 that the corpus Inteum disajipearx completely in tlte oounui of one
and a half or two months.
The mftlullarif tufithmre of the ovary consista of a dense, fibrous lis-
enc, which is continuous, in th« Uilus of tbe ovary, with the ovarian
ligament, and sends prolongntiona as far >a the fibrons catwule of the
«rgftii. Hero are found the largest bloodvessel* and lympbatii'» which
enter through tbe hilii.s. Tbe arterie-s which are spinl, first run in the
central ooiineciivo tissue, afierwaViis pikts to the surface of the ovary, fol-
lowing the iibrous fasciculi of the organ ; vein^ traverse tlie connective
tisane, aa alao do lymphatic trunks. The external fibrous ntcnibrane of
tlio (irantinn follicicâ naa a very abundant network of lymphatic ve«M)8,
The ci>nnDctive dseue of the roeilullary suliâtaucc contains aome faaei-
culi of smooth muscular fibres.
Tlie ncnes come from the ora nan plexus, penetrate into die organ, and
follow the course of the arteries. Their termimttion is not known.
The broiid hgunient beneath the ovury I» travi;rsed by vioding and
raiiiifyiiig tuhen. TliMC dnct« have a membrane and are lined by an
epithi'liuiii. Tliey are coti.'iiilered n* tint remninn "f the Wolffian body,
from wliich the ovary is developed. Tbe winding ducts we nanwd
Koaciim tiller' s organ.
lied.
da
>duH
Sect. U.— Pathological Histology of tbo Ovarr.
TIypbr.cmia: Hëmukuiiai>k. — <_'<>iLL:i':>!i>.iii and hemorrbage of tbe
ovary are monthly |>hyïiiij1ot;ical "ci.-iirTi.'tic:e^: each menAtruAtioii and
opening uf a Orantian loUivk\ :i> li..s lio'ii socn, necessitates a i^rr in-
tense congestion followe>l by u lii^iiiorrhuge. Ovarian congeation abo
•IwayK fxists during the acute )wrio<Ls of low forms of fevors. (Oubler.)
Congestion of the ovaries U excited by the causes of congeation of tl»e
genital organs of the female, by exceâ^M in coition, by goetadoQ, by lalior
I
INPLAUMATlOif Of THE OVART, OTARITia. 677
«nd ita coase(]uenc«8, hy motritia, etc. Traces oT cliroDic con;;eation,
cati.4«d 1)y imppdimcnt to the How of venous blood in cardiac- diseawH,
arc met vriiti, and in the same caeea tliore may «xiat an induration of the
ovary due to the new lormation of iodnnttcd connective tisane.
From a very intense conf^*tioii of tlie orary (Uirinf" menstruation or
between the nifiwcs, there ninj- occur an t'lcajw of blowl into one or more
Griukfiau follicle». TIh> ovary i# then enlargeil. and upon section, t)ierc
arci seen, in it^ indnrati-il |iarencliytna, several follicloa which are lîllvd
witli eoafpilnt«d hlood. The^ie IViHieles vary in me from a pea to a cherrjr ;
the eoajçulfttcd blood which dLitends th^'m iti darlc brown or black, and
nnderjtoe.i the usual chan;res. Tiiese [lathological [iroducia are easily
distinguished from corpora lutca ; in the normal state there is never more
than a «ingle follicle which contains blond, and it is that of the last men.
etruation, the cicatrix is also easily scon which corresponds to it H|»on the
surface of the ovary. Patholo^cal h«morrha<;e, on the contrarv, occurs
in two or three folhcles of one ovary or tn both ovaries, us well >n the
deep OS in the supi-rliclal follicles. Follicular hemorrliagcs sometimes
occur with chronic peri-ovarian ndhc^five peritonilij, or irith [lathologicBl
adhesions of the Fiillopîan tube which prevent the normal nipturing of
the folliclcx. In !4uch cases there is at the same lime n caltoii» thickening
of the ovary and retrograde chan^^a of the Irraatian follicles, which are
soinetiiucs Ailed with a mucous tissue, or have tiecome droiwucal. When
the ovary in free frvim adhesions and when hemorrhage occurs in a «nper-
licinl follicle, there may result a rupture of ita wall and a more or leas
abundant hemorrhftfjo into the pôritoneal canty.
Inflammation op thb Ovart, Otabitis. — During gestation, the
phoDomcna which occur in the ovary are iiiHammatory, and constitute,
what may be tiirmed, a physiological intlummiitioti. The parenchyma is
tumefivd, and tlie circnlation more active, owing to which the cor]>ns
lutemn of gestation is of unusual site; the cells of the connective tisane
are lar^e and cloudy ; there is also a greater number of migrating lymjih
celU; the smooth muscular fibres are more swollen ana longer, and
comparable to the same elements in the wall of llie uterus during ges-
tation.
From these nutritive changes the organ is disposed to a more or less
intense pathological intiammaiion after delivery or after an abortion.
ITiua it IS almost exclusively in women recently delivered, that acnte in-
flammations arc met witli, or they may occur in connection with metritis
and peri'Uvnrinn peritonitis. The lesions vary in iutcn^fitv* In a slight
fonii, the ovary is saturated with flnid, nuil then; is an mfiUnition into
il8 c<uin(-otivc ti.'<#ue of uumenxiM lymph cell». The fully developed
Uraatiau follicle.^ have in their interior ii turbid tluid, souiciimes colored
by blood, and containing a ^rent tiumher of epithelial and lymph cellit,
there i.* in fact a true catarrh of th»- cap.tulo of ilie follicle. When the
inllamntation is more violent, a.t in pelvic [feritomtns following delivery, at
the same time that tliere is fourni a very inleuse congesQen and new
Bbrinou3 membranes ujmn the surface of tiic ovary, there is a more
abimdaat formation of lymph cells collected into whitish lines or small
abscesses in the stroma of the ovary. At the same time the Graafian
OVAHIES.
folIiolM frei|ut!iit]j oontain a sero-puruleut Hui<l. Finxlly iu aevtn
pncrpeml luetm-fieritonitis, the ovarjr ié found in t)ie mUbit of pus niid
\ udae membranefi ; ita tissue ia uiiicli congeât^d nnd îttt follicles are alt* ajâ
fiUe<t with pua.
Wlieii ovantia is aocotnpanïod vith a peritonitis limited to Ilie true
{lelvis hy fibrinous and connective- tissue adiicfliona, the ovary aay be
ouud in tbo middle of a uircumscribed abaceaa, tlievontcnta of which may
lie »lMorhed or opeu into lh« rectum, bladder, etc, I>at«r, the orarj
• forms Grm inttinat« or filautcnloua adbesiotia witb the neigliboriiig organ»,
. and it« function is destroyed.
Tlie foriDutiuit of tliv hard ami dcntie RbrouH tissue wbicb follow» n-
pCBleil ovarian coii;;estiuns, and the retro|:rad<' evolution of t)ie (fnuifian
follicle», may be considered ai ruiiultd of a cbrunic tntorxtiliul ovaritis.
In old vomen (be ovary is altoMt always bard and calluu»; ît«i filiroaa
capsule is liiickoued and indurated, like Ibe capsule of tli« 9ple«ii; ita
cortical layer Is absent, and the (irsalian follicles or cor])ora liitea of
previous pregnancies are seen only aa cysts with bar^ and contracted
fibrous walls. I'hese ovarieti are small or atrophied.
Tlmobs. — Enfhomiroma of the orary bas been twic« observed by
Kiwi»ch: iu one of the cases, the rif^bt ovary had a<H|»ire<l tbe site of
tb« list, and naa transformed into a byalino and bard carlibi^nous mass,
ëcanzoni has seen on» casv of au onchondroma in tbo middle of a fibrous
tumor of tbe ov-ary.
TahfTcJi'» n{ the ovary are selilom seen; Romi'titDun lliey occur villi
tiibtTciihwifi of tbe other genitourinary orjiiin», es peel ally in cliiblren.
Tbe livai of the tul)crculnus granulations i.i either in Uie peritoneal covei^
ing or in tbe pnieochyma of the ovary, more freipientty in tlie former,
the parencbynm being relatively less affected. They present (beir usual
eb a l'acte TH.
ilummaia are also very rare. Iiftnccreanx cites two examples, without
bistolo^cal details. He considers as syphititic. a dense fibrous state of
tbe ovary wbicb bo has several time» observed in women sbll meo-
atruftting.
Lymjihaâtnama hits been seen once by u« as a secondary tumor.
t'ihrc-miiomtiiit of the ovary are coinjuirable to UiOM of Ûie uteroa, bnt
they occur much less fn'i^iifiuiy llian the tatter. Tl>ey are «omvtitncs
seen as small cpht-riciil tumur» Wated t-ithcr npon the surface, or iu tbe
substance of tbo ovary. Sometime» they fonu lai^je bard tumors, tba
size of the fiat or larger. A very Urgo cystic myoma baa been cxamined
by H9.
â'oT'vmia.— •Several ovarian aarcontata liave been reported ; they
inried much iu siïe. Villard has reported a round-cellc<i sarcomatous
' tumor of die ovary, with cy.^is containing a hloody finid. In other cases
' serouji cyst» have been develojied in tbe sarcomata.
Varcinnmit. — t'arcinoma of the ovary is eitlier primary or secondanr;
it may follow a carcinoma of tbe neck and body of the uterus, of to*
reclnnj, or of a more distant organ. Tbe new fonnation is then generally
small and nodular. Yet we have several times seen a diffuse and complete
oVABlàH overs. CTd
inRUrnUon of th« «nUro or^nn 1>v secondary noilulcs nliic-h oinaDftt«(l from
a carcinoma of tfac ulorus, uml extended to tlie nei^htiorin^ organs.
Primiiry cnrcinonia, în uomc ctwvs, attains a very Inr^r eize, ue largA as
nu ndult'« liead or Inr^or; most freijiienlly it bc-Ion;^ to tho eiicc{))ialoiil
varit'ly. One «vary only is ihe neat of a largu tumor; but tlie otlior
nin.v W in a losa decree disemted. Ovarian medutlnrj- «arciiionui ts a
tumor varying tn eoiiAistvitce ; it \* imtiatly tinner itiau in other organs,
bMaiuo of the fibrous ^iructure of iKe ovary, lly scraping, an almndnut
milky juice i^ obtained. Tlie cut surface ia white or ;;rayi3ti-wliite, nni]
opaijiie. The fibroiis cap.tule of tlie ovary id generally involved if tbe
carcinoma is not very recent, and there are tlion found upon the cnpside
regetationa cousiislin;^ of careiiioniatoiis tissuc. The peri lone u id, cilher
in n limited part or ihrou^tlnnu ii» entire extent, very soon participates
in tha Jc^^cne ration of the ovary. We have several times seen cnormoua
tumors with cancerous perit«nitis in youn;r persons. Tho structure of
enccpbaloid carcinoma of the orary docs not much differ from that of
typical cnccphaloid : besides tbe connective-tissue fibres, the trabeculie
limiting: tlic alveolar spaces sometimi's contain smooth muscular libres;
the epithelial colls^ arc arnin;:ed without order in tlie cavities of this
Htroma, or they nm placed |>cr|4'ndiciilar to tha wall of the cavities. Tho
vetMels are Komelimes of lar^e fisc, constituting a hiematoid cancer. In
earvinoma, as in other tumon of the ovary, cysts are fountl, which liave
formed witli the tumor, or have preceded its derelonraent. Usually,
vegetations formed of carcinomatous tiitflue project into the cavity of
thne cjrsu.
Primary carcinoma may be coUoid in character; this variety, however,
is not »o fre<|uent as scirrhus.
Secondary tumors of the ovary offer the «ame «truclnre as the pri-
mary formations. For example, eylirxlrical or jinveoient-oell epithelioma
of the ovary, oconre secondary to tumor» of the same nature developed
in llie uterus.
CyhiidrÎLal-celled epithelioma may, «ceoiviin;; to the investigations of
Rindtleisch and Kleb«, be developed primarily in the ovary. In a case
reported by the latter, a reproduction in the cutaneous wound followed
tlie e:(drpation of tlie tumor. An examination of the cutaneous tumor
sboweil it to consist of gland-like tubes.
OVAHIAS CïSTS, — Of ail the new formations and diseases of the ova.
rics, cysts arc the most common, and the most important iu view of their
development and their results. The ovary and kidney arc organs in which
these formations have the greatest tendency to be developed. It has
already been seen that cysts may form in tumors of the ovary, aud it
now remains to describe cysts proper, which vary much in their develop-
ment and nature.
I. Ifr-'i'iiti iif the Ormfian FoUirlrt. — Itolcitannky ha» shown that the
Graaliau follicles may be »o distended by a serous anil limpid tluid a» to
form small cystic cavities, the sixe of a small bean or hazel-nut. In an
ovarian tumor coro)>osed of cysts of this site, this author has shown that
each one stiU contained an ovule. The cyst» from distension of the folU*
c1g« are generally small, and the tumor id seldom larger than the 6ât.
680
2. Unihmhtr f';i»tt. — A single ovari»n oyst îs aomctimea Been of votj
laiWKixVfiiiidiiiiiiu-'IsiiniilTbjanallcouBiBUngof tiicporiiuneiiloovvrini;.
uid of ft Inycr of Iniiiinatva connective tUnue, vrhich ia itive8U'4t inUTtixlly
fay nn opithelial lining. Thv^v tumors ura onsidcn-it u tlie result of a
dropsj aix] diliiteitioii of u ningle UrimGHu follido ; but wu liBvt> iio pom-
live |)roorof it. On the contrary, tUcy «pikmif to reHull from the funion
of «(cverat cyiiiR into one. This occuni in n {«culinr manner, by meiiftt
of llie cvfltic degeneration of the ovary, of wlticti vc Have ^ven a dcrtcrip-
tion ia part firat (p. ItïK)- Kverjr variety of oyata niay auppiimte — tliat
is, they tuay have in their interior a sero-piirulent or purulent fluid,
caused either by poncturing or by other irauiuattsiD.'i, or occurring in
the course of general scplic diseases or ateriue iuHaniniatioikS, especially
after delivery.
3. Pr-li/rr^H» Cyit» ; Gelalintiu» or SfnilHoculitr Cifita ; MtfroU
£j>itlir!i-mit. — These eysts are niiiltilocular, and ^n«rally contain a
luucoiu fluid. They arc very large, and formed of B«v<>ml cysts coti-
; Uitied in a eommon enrelopi',or united by a detuv nnil abundant coiuKic-
livc tijuito. The walls of the cy*U are also formed of oonnectivc tisiuc,
in which spiral arteriei« and very large vein.'* cour*e. llie layer of cod-
nectivc tisiue nearest to the surface ia formed of lamellae, like tho«c of
the cornea, separated hy layerx of flat cells. The inner membrane,
which is almost alnays tlie seal of iiajiillary or warty Tegetatioiw, is lined
with a cylindrical epttheliuni. According to Malaases. tlic opittieiium ia
implanted upon a membrane formed by an endotliclial layer. The cylin-
dricutl cpitliclium very frc<(ucntly cxperioaccs a partial oroomplcM Dincotu
degeneration. Some of the relU becnintt gublet sliu|>ed, being reduced to
s cup with iliin walU, coniaSniug a nui^li'ii» al the fxiint of im plantation,
while the cavity of the cell cont;ûii.t and continues to secrete a mitcoiu
fluid. Other cells become spherical, and are filled vith mucus. These
cella may be destroyed, and fall into the cavity of the cyst, thua iocrca.i-
ing the amount of mucous fluid. f>omelimes ciliated cella have been met
Kith.
After the action of nitrate of Bilvcr, there arc seen upon the internal
surface of the^' cysts, roarkiuga which indicate the open extremities of
the goblet cells : after removing these cells by pencilling. Ihe large endo.
thelial cells which arc placed beneath are nude visible by thv silver solu-
tion. By this process the eiidoihuliuni of tlie capillaries in the wall of the
cy#u I* displayed, and the superficial [Kisitiou of these vessels is ren-
dered very evident.
Tlie coiitent.4 of the oyst consist of a mucous or gelattnonii fluid, which
coagulates by the addition of alcuhol, swell» and U tatiiic trans]>areiil
bv water. fitria> are seen concentric with the surface of the cavitit-i.
The cella which are found either have no deBnite order of amt^^roent,
or tlioy arc in rows parallel to the stria) of the mucous mass. These rows
consist either of gohlei cells arranged in layers, as if they had been
de«i|uamttt«d. r i'> < pithclial cells, or of branehing cells with many pro-
longations, ri'r iiJliii^ ihc cells of mucous tissue, nltliough there lonv l>e
no formation of mucus in the interior of the tumor. Collectîona of fatty
enerated cells arc aUo seen.
Chemical analysis of the Uuid, according to Mchu, shows » large qtwo-
degeii
OTARIAV ctsts.
681
I
tity of alhuroon, inetalbumen, ai»I panlbitroen ; it is the h(t«r which
gives the Sniit \ts gelatinous conai-iteoce. Kichwald has found also nlbu-
minous peptone, mucin, and mucous peptone. These diffepenl aubsuncea
are products of the filtration of ttio ulbninoo of the blood, and of th«
elatmration of the caUce-like colla.
The contents of c.vsts Itnod with vory viuculnr nlli are frequently luixod
with blood, which (pvcs thcni A brown or cboeolute color. There maj also
be preMont in diein numerous I vinph celts, or oven puit, C8{)eciiUljr lut »
rcWt of traumntiiimH.
The cysu may communicate with each other hy n spherical opening
which i.t found opposite to the place where the principal hlooilve»icls are
situated, that is, where the wall was priourily thinner and less vascular.
There ia no evidence that a single primary cyst divides, forming two or
more; while, on the contrary, die appcarannes of commuuicaliog cysts
show thai two neigbhorin;' cysts hare opened one into the other, iti con-
^Bomnooe of a thinning <ind niptnro of the separating parution.
I Tlw connective tissue which separates several eritts. usually itself con-
tftins smaller cyst«, which are in the process of dcvolopim-nt, and pruMiit
tlie same structure ae the preceding «vst« ; as these cyot^ increase in »ixe
they project into the cavity of the principal cysts.
In none of the cy^I-'*, even the smalle.tt in course of development, can
ovuleii or pmligerotiA disk» bo recognized ; therefore the liypmli&^is of a,
:£0|nH>t*on of the cysts bv the di^ten^ion of pre-existing GraaËan follicles
t he accepted. Neither is tliere found any trace of ovisacs or
Ornnfian follicleâ. tho ovary bom;; eamplcicly tfnnsformed into cvfts
analogous to those vro have described. The entire absence of ovariao
follicles sertcs as an argument for writers who, like Virchow, Waldoyer,
etc., explain the genesis uf multilocular cyst* by changes of the oraiian
tuben, which are described by l'Au^^cr in fuutal life. There «re muK
points of analogy of structure, and the comjiarison is ingeniotui; hut
there is no jirool that the targe or tiie more recent cysts have their origin
from the ovariun tubes of fœtal life.
We have described in part first the structure of vegetations upon th«
wall of cysts. We adniitted die possibility of the development of second-
ary cysts according to the method indicated by Wilson b'ox,thatiB, by the
union of villi, which in uniting fonn closed cavities. The more recent
investi^TJàons bv MalaS'Sez weaken this view of the mode of formation. He
hn.s seen secondary cysts form in the villi, appearing at first as a small
collection of cells, the most central of which become mucous, and aro
destroyed in forming a cavity, around which the paricud cells become
epithelioid. Tliis mode of fonnutîon is compamblc to that which has
been described hy Focrster. From a later investigation Mahu»C7. was
led to believe that there oecurj in these tumors a new formation, a tntv
epithelial heterotopia, a peculiar epithelioma, and from the fact that the
epithelium has the property of forming a mucous secretion, he iwmes it,
as in the corresponding cystic disease of the tesdcle, a mt/xoid ejfi-
thelioina.
When the cysts are old or during their peiiod of growth, they may, in
consequence of peritonitis, he intimately united to the neighboring [larw,
rendering the oporatioD of ovariotomy very difficult and dangerous.
«82
OTARIKS.
Oeiieriilly a single ovary in iliwnioii Bhi] fom» tlic lai^c tumor; Im
liie oilier may prcAeiil a few siiwll CTSts in procès» of tIerelo[iti»em, m'
Uial the larj^er ovai'V Wiitj; reuiovecl, the oeuoiiil ovary become» in its
turn tiie Hcat of a largo cystic tumor. Very i>l<I tumors liave a 1i))ro-
carti]n;;tnoiit< tliickeuing of iheir walla, uliich latter ar« frc<|ucn(lT îd-
cnistcd with caicart-ous salta. either in the coimoctivo tissu« rormin;;
tlicin, or upon the intonml surface of tlie cyst, or there mar br foaij
upon thin internal surface n whitish pulp formed of 4lcgenorati.-(l faWy
colli!, caicarcouB granules ami cryauil* of chok-stcriii.
TiioKint of this kind are not f;cncralizi>d. lu adopting tlio luime '
tnyxotd-cpithclioniu, proposed by MutasHcx, this circunutunoo should '
rcmvtiihi'rfd, as it is diflcrvtit with other varieties of e]>itheUomu. SvM
nry fonnatioiis of thcsu cysttt in ttiv gliindj» or cUvwhore liaro Dover
met nith.
T>ttnMoip Cysts. — The ovwieg arc one of mo*t fr^'niieiit «««la for the
formation «f dvnuoiil uyHt» of the third varimy of Lehert; ihej are nl
limeit very large, n» large aa an adult' it heml, and Imxe in their interior
hkir, teeth, eta. We liave uochiug to add to the deâcripUoD given in
part first. (See p. ICtî.)
NORMAL niBTOLOQT OF OTIDDCia AND UTERUS. 68S
CHAPTER VI.
FALLOPIAN TUBES AND UTERUS.
Sect. I.— Nonoal Histolofrr.
Oviducts or Fallopian Tubes. — These are the temporary ducts of
the ovaries, sen'inj; for the pas6a<;c of the ovule. The fimbriated ex-
tremity is applied to the surlace of the ovary at the time of the rupture
of the Graafian follieIe,and it receives the ovule wliich passes along the
tube to the uterus. The ducts consist of a peritonei;! covering, which sur-
rounds them, of a layer of fibrous and muscular tis.^ue forming their
Tvall, and a mucous membrane. They present for consideration a fim-
briated extremity which is attached to the ovary by a short ligamentous
cord, an inferior and narrow part traversed by a canal which passes
through the muscular tissue of the uterus at each lateral comua, and opens
into the cavity of the uterus by a very small orifice scarcely large
enough to receive a fine bristle,
The lumen of the tube in its free portion is large, and its mucous
membrane is longitudinally folded like that of the vas deferens. From
itâ free extremity to its uterine orifice, the mucous membrane of the tube
is lined with a ciliat«d cylindrical epithelium. The movements of the
cilia cause a current in a direction from the free extremity towards the
uterus, assisting the progress of the ovule, but not that of the sperraato-
zoids. There are no glands in the mucous membrane of the oviducts.
Uterus. — The uterus presents for consideration the body or superior
part, and the nock opening into the vagina. It has a cavity passing
through it from the fundus to the os, which is narrowed at the union of the
body with the cervix. The uterus is covered by a layer of connective
tissue and cells belonging to the peritoneum : it possesses a very thick
wall consisting of smooth muscular fibres and connective tissue. The
muscular fibres are difficult to separate. The superficial layer is com-
posed of fibres running longitudinally and transversely ; the first form
a thin layer extending over the fundus and the anterior and sujierior
surface of the uterus ; the second a thick layer wiiich extends partly
into the round ligament, the broad ligament, and tlie oviduct. The
middle layer, which is the thickest, consisU of longitudinal, transverse,
and oblique fasciculi. The most internal, like the external, is very thin,
having intersecting fasciculi which form circles at the orifices of the ovi-
ducts. The transverse fibres of the cervix constitute a true sphincter.
In the cervix there are also found some very superficial fibres in the folds
of the arbor vitte. The muscular fibres of the uterus and Fallopian tubes
are short except during pregnancy : they are separated hy a large quantity
of dense connective tissue couuining oval cells.
684
TALLOPIA!) TCBBB ATtn OTERCS.
The mucous nicmhrano of the titenia is intiinately united with th*
mtiscular layer, from which it may he dislinguished by it« lighter color.
'Xhc deep liiycr of the mitcous moinbi-ano is formed of a connective tissue
cuiittiiuiri^ c»n]ic«tive tissue corpiucles hann^ oval nuclei, and smooth
niiwi'iiUr fihrcs ; thert are no vlftstie fibrca. Tiiu liuinjj cjiithoHum coo-
usl8 of » ain^tc layer of cilinteil cylindrical cclU.
The niovemcnt of llic cilia i» m n direction from witlKnit inwanU.
The gland» of the muoou« membrane of the civvily are sim)>1o or bifur-
cated tubular glandïi, analogous to the gUncU rif LioberkUlin. They are
lined with a cylindrical epiûielium, and open upon the mucous membrane,
either singly «r two or three together.
The mitcous membrane of the cervix of the uterus, inntetid of being
smootli as in the horly, presents folds which unite to form the arbor vit».
These folds, and the entire mucous membrane of the cervix, are covered
vith villi. Bctivecn the folds are seen crypts, which, aa well as the
cavity of the ccrvjs, contain a viscid and transparent mucus. Upon the
surface «f the folds are found utricular déprécions itituaCcd between the
villi. In the bolt<im of the crvptif are the njienin^s of aeinou8 glands
(Sapjicy) of coiididerabk' «i/.e, anrl conipiirJvMe from ihvjr sbajx' to suba-
ceoutt j;1andit. The acini of thcst- gliin<U are lined with elongated
cyliiidrifttl cell*, and they are filled willi a viscid mucus.
The itujierficini epithelium of the cavity of the uleruit is a single layer
of cylindrical cell». Some writers describe them as ciliated ; other» deny
the existence of cilia. Ninety has seen ^Met-shaped epilbclium u]>cia
the surface of the mucous roerabraiie of the cenix in a fœtus at term,
and examined immcdinteW after death. In this case the epitbcUum of
the cavity of the uterus ilid not pOMvs» cilia. It is probatulo that the
mucuji ill the cervix of the uterus i* secreted by the cylindrical cells of
this cavity ; jn« a« in the inle.Hiiml lining, the cell» which sec-reto mucus
»lwayA a]i[>ear a« goblvt cells, and are e^jiecially found in the folds of
the nuioni.i meinlirane, in the erypti^, and in the glands. Konaut has
found gohlt^t c«IU in the layer of cells lining the ovula Nabothi.
There are freijuently seen in the nonnal state in young peraon», bat
more oflen in advance<l age, spherical cystic dilatations of the glands in the
cervix of the uterus, coutaiiUDg a mncou*
Pig- 83- fluid ; they arc named eggs of fiabolh
(ovula Nabothi). The fluid contents of
the ovula Nabotht.aM uUo the mucous fluid
of the cavity of the ccrris, consist of
mucin and «triic, which are apt to be
taken for fibrils. Cylindrieal, oral, anil
spherical cells in a state of muoous de-
^^^ generation are found in the fluid, eitlier
.^Allif L^H^ ID rows parallel to the slriie or irregularly
amnged. Irregularly shaped cells witli
ramifying prolongations are alto seen,
ttt *f ^'b-ib 9f ih. vMi«i luiK^iB. dnd iïcnâut believes that ho has been able
-> ,i,uu.« .1 . .u.d. Ih. =H.c, V». *? f""»" l"--»-" ^^ development of mucous
iBUaia. c. TvbuUr f lud. X ^' tlSSUe.
^
u
NORMAL HIBTOLOOr OF UTEHUS. 685
The oiucons oicmbmiio of tho cervix vomplotclv chiin;;^» in Appearance
anil 8truclar« ut tlii; poiut where it i» roficcU'il ovor the iiim-vit^iiial ppomi-
niïiicc, funning the wa uteri. In thw iittra-vugiiiiil portion of the cervix,
the mucotis membrane coiwiate of co&iwctive tissue foniiiugiiitpillie,«hich
lie bonontli a linninatcd pavement epitheliinn.
A similar arrant^emetit of the iimci^u.'* tnemhraiie ami epithelium exists
over the entire surface of the vai^ina. The hard excrescences found
upon the surface of the vagina are nothinjt more than prominent papillary
formations covered with lauiinatod epithelium.
The arterial vesaels of the uterus run in the muscular substance and
form capillary networks, which ramitjr in the mucous membrane and
muscular layers. The veins arc without valves, very large, have thin
nails, and follow the same course as the arteries. The lymphatics arc
Tcry numerous ; they probably originate in tho mucous membrane, and
form upon the surface of the nterus beneath the peritoneum a clo4C net-
work which conimunicateK with the pelvic and lumbar glands.
The ccUulo-vaMiular tissue of tliv broad ligimienU contains smooth
murieular fibres (Rouget).
During menstruation, tho very notable increase in the sixe of the uterus
U due to the coniiiderable afflnx of bloo«l into its ti^ue, and to a awellin^
of the mucous membrane. Thii* membrane during menstruation eiperi-
mcee great hypertrophy; it becomes softer, anil the glaniU are readily
isolated, measuring fri^ini two t<> six millimetres long and .OT'I mm. to .090
mm. wide ; the connective tissue of the mucous membrane is swollen and
contains numcrtiiu tymph cells. Hie vessels arc dilated and very abun-
dant. At the same time that the menstrual blood is diechargetl. the
epithelium of the cavity of thv uUths i« almost entirely cast off. Klimi-
nation of the glaiuU and of slireds of exfoliated mucous membrane during
nenstruauoii arc pat)iologieal lesions.
We ha^e fre.juently had an op[>ftrt«nity of examining the products
discharged during menstruation, coinciding with xymptoms known as
jmfudv-membraHouf d^tmeuorrhtta. They vary, at times consisting
simply of coagulated fibrinous clots, which are with dilficulty passed
through the onfice of tiie os uteri when it is very small, as is frctjucnlly
tlie case in females who have never borne children. Microscopie exami-
nation shows the fibrin in a fibrillatcd slate, inclosing in its reticulum
numerous lymph and epithelial cells.
In other eases there are found irregular slirods eontiuning capillary
Tessels with embryonic walls. In the midst of connective tissue infiltrated
witli Irmpli cell». There are also frequently seen fnignient« of uterine
glamlH, or entire glands. This is a genuine discharge of exfoliated mu>
co»s membrane. The mucous iiK-mbrane may l>e expelled entire; tltis,
however, is not a fretiuent occurrence.
In a thini and larger series of cases the products cnnaiat of the débris
of tiie decidua, which are recognized by the villi of the chorion. The
surface of the discharged membrane presents villi, which are easily
demonstrated bv placing it in water ; the villi are formed of branching
cylinders containing vessels in their interior, and covered upon the surface
with epithelium. There is atiio found, if tho membrane is discharged
entire, a smooth portion or a cavity containing the embryo. Wo arc of
m
TALLOPIAN TUSB8 AKD UTRIlCe.
tlic opinion tlint tlitsc eues of villom ilrsmonorrtiica arc nlo'ft^ii uno-
cixtcil with till) |>ro<luctt of conception, xnd vrith t)ic roombrnnM cum-
8f)0i)i1in<; to su cmtir^o of two or three ncelcH, or to tlio iolorml which
B«p«r«l4w two menstrual period».
The ohaiiges wliioli th« iit«ni'« iindcr;^*-^ iliiring fetation «Mpcciallv
affect the »roootli niiweulrtr fibre*, tlic vessel*, nmi tlie imi«ou« mcmhraiie.
The great lijf|icrtropbj' of tiic niusculnr lajrew i* citM*«i1 I>_v Ihfi increase
in siie of the preexisting miHcntnr fibres, ami by th« fonnalion of no»
fibrcfl; the old filireti bemnie ten timea longer nnil five tiniei* wi<Ier iban
normal. The formation of new tibrott occurs |<artic-ubirl_r iliinu;^ tho first
montJis of gestation in the iniemal la^orx of ilic tnuKi-nlnr coaia.
Tmineijîatel V after conception the mucou» membrane Ihickei». becomes
looser and retldcr, and the fold» are more prominent; it is infiltrated
with embryonic cells, and ita glanda are hjpertrophied (tnie decidna).
Where the ovum is located, the mucoua membrane is transformer! into
tiif uieriue placenta. The placental portion of the mucous nK-inbrnne
forint granulations which sarround the onnn. and constitute the decidua
reHexa. The cylindrical epitlieliiim nf the mucous membrane of tlie
cavity of the uterus completely disappciirs ui:on the decidua. The nia-
ooiis membrane of the cervix takes no part in this process ; it preserved
il^ epitlÉHium, and soereles n miicotis plnj; which fills the e<Tvieal canal
diiriiij: jire^iinncy. The bl nod vessel* of the iitoru* iimlorg" n parallel
[growth with the miweuUr wnll». AflfT delivery the true deeidiia is
completely eiiot off; the e\j>idnion 'if lli^ pliiceiila leaves a grnitiiliiling
surface which breaks down, and is aluo rliscbarged. The internal sur-
face of the utenia no longer eontains a (race of mucous membrane, but
consists of a soft, pulpy tissue, in which, amon^ embryonic connec-
tive tissue, are found hypertrophied muscular fibres, vcwwls and cells.
The latter, which are connective tissue C'lrpusclea. arc swollen, flat or
sphcriciil, iiviil or stellate, freijucntly very large and i^nular. cnnlaiiw
ing one or more nuclei, and are often in a state of fatty dcf;enoratiiio.
Tlic histological phenomena conntitnting the rx'generation of the nmw«9
membrane, have not as yet been sufficiently stmlied; it is very probable
thai the regeneration is a »low proceas, *\wf the wound, which corr».
B[iond< to the ]tlft('riital insertion, remains \-i.*ible M-veral month* after
delivery. Slavjaii*!;! has n-oeutly described papillary vej^tattou!* analo-
gou*in structure to graiiulnliim tissue, and an infiltration of the »u|>eTfi-
fiial layer of the mucous membrane wiili lymph cells, in a young woman
Uiree months after delivery. The surface of the mucoua membraoe am)
that of the vegetations was desliuite of epithelial cells. TliO utricular
I glands, well fonned and prtïsentîng their normal arrangement, were filled
with romvl cells.
Tlie muscular fibres rapidly return to their ordinary sise after having
preseniecl numerous fatty granules. It Ï8 probable that some of them
are rleatroyed by fatty dogeucratjon.
Sect. II.— Pathological Histology of the Fallopian Tabes and TTt«ru.
COXDKSTIOX ; HoiOKnUADe OP THE Fai.i/)pian Tcbks. — ITypereemia
of the Fallopian tubes, occurring at the same time in the acveral tiasucA
I
»
tVVLMUtATtOV or TUB FALLOPIAN TtlBX. 087
which compose thom, is ol)«i>rri'(l <ltiring mciislruAtion, after excessive
eoitii^n, and in acHW nfTculions ortho uU-ni».
IlfiHorrhaije* of tlii> tnticiiUK nicuibrniiu of the Kallopinn tiiliefl. an<) cflTii-
■ions of Itlood into thvir liiinon, rnr Koinetimeit a result of hypf nvmia, find
other piorhid condition». Thn» Kokiutitiky reimru two cxach of liomor*
rhage of the Fallopian tubes during lliecnurM! of tv)>hoid ferer ; another
in » reoeiitiv delivered woman who died of picuritia and hepatitis: a
fourth, due to retroversion of the uterus. Barlow has seen it in purjmra
hiemorrhaj^ca ; Scaiixani in menstrual congestion ; Puoch in a youn^ pri
with meaalea.who died of a hemorrhage from the FullopiantubcrnpKiriug;
into the peritoneum, and causing a faljil jteneral peritonitis. To tJii.'»*
roav aUo 1>o added rupture of the tube in exira-utcriuc tubular prcguaiiucs
(m« I'eri-uterine hœniatocele).
Ikflammatio» of TiiK Falloi-ias Tube, Catarrhal Salpisoitis. —
Catarrhal inflammation of the Fallopian tuW oceura frequently tn eonsc-
(|ucnce of inHiHTimatory and catarrhal affcctioim of the ^nitid ])»ssa|^8
durin;; iniictiviiy or after liclivory. The tube» are fiUi-il and dixtended
by turhiil miicui* or pit»; they nru tortuous, with irrejçular dilnlatioiut.
This leiiion ix frcipiently accompanictl hy a GOii<;cslion of tlic u%-nry, and
almost always hy iin irritation of the neishhoriu'; jicnioneum, by n true
snlwrulr or chninie pelvic peritonitis with adhesions; iwmetirae» hy an
acute Kud suppurative ;>eritonilis. The tnhe now gonentlly ndhcrt-s to
one of the nei^hhorin|t nrj^nns; usually it is the uterus, rather t» the
inferior part of the boily, or cervix than to the fundus. The lumara
fonned by the hvpertrophy and wlhesion of the tube are generally re.
coguiacd by vaginal cxatnmation.
In acute inflammation of tho lube it ia increased in size. îta mucoux
membrane Is very much con;!e.sted and thickened, it^ longitudinal folds
arc effaccK), the fimbria) art- 'ibliterated. and its lumen is Blled with a
imico-puruicDt or opa^pie Huid. This tluiit. examined microscopicailv.
ia Keen to contain oidy distorted, ;r'aimlar. cylindrical epithelial cells
and lymph corpuscle». The coonoctive (îisauo of the mucous membrane
is inhltratt'd with lympli cells.
tuHiimmiiliou of the Kiillnpian tube ig most inteniie in pnorporal tneiri.
lis ; it, in nlwayi* aceimi|iHriifd with phlehilin, lymphangitis, f^cneriil or
local jierilonitia, false membranes inliltnttcd with pus, and purulent effu-
sions.
In chronic inflammation, the adhesions of the tube to Dei)ihhnnn$;
organs is always observed, the connective tissue of the muoou.* nicmbniuc
is thickened, llie ftuid in the canal is either clearer and mow .serons, or
more opai(»ie and more caceous than in the prccodinj^ case.
Chronic dropsy of Uie tube should be considered as a species of inflain.
mation. The tube may become as large as a child's head, and the more
or less numerous sacs situated one after the other along the tube, con-
vert the canal into a Gcrics of distinct cysts, that poruon of tho duct
between the cysts bein;; obliterated.
The fluid from a drojwy of tlio tube may be discharged by an opening
of the duct into the uterus, from which it passes out by the vagina.
This, however, is a very uufrei^tivnt termination.
3
^Rjg FALLOPIAH TUDBe AXD UTEHUS. ■
Tduom of the Falloptax Tuues ; Tcbekculee. — ^TuWrcnlodia of
th« genital organs of fcmalea U not an unfro<|aent i]iB«a«e. llio tnhtr-
coloiu cmnulations of tho pcritoni-um, VF-hicli covers tlie tube, are aoooo-
E anted or tuberculous tioilulcs ujion ihc surface of tlic mucous nH-inbranc
Avinft tlicir ori;;in in tbc euhiuucuuD coniiectivv tissue. At the miim!
titno llicrc is produced an intense catarriial înH anima I ion of tixv nxicons
BR-mbraiiv. The duct w dilated and liUetl wilti piw, whicli at finit u
mucous or muco-punilent, but soon becomes cuscotu. Tlic Hurface of
tin- muconf menibninc also now [ircscntfl a eascnis dejieninttiini i>f tbo
niiilule.<, witb enibrvonie ti»sne uniting tbein. Tbe éoiiwwlnit lliickewd
luveriif emliryoiiic liBSHD studded with tubercutoai» fETanulatiiui!* «Iii<.-h
occnjiie» the i!iubimicouii tÏMiie, is in a voiulition of chiwoua de;^tivratton.
llie tbtme of tbe wall of the tube situated between the ttibcreuloutt pori-
tonvum and thickened subimicnui< eonnectivc tiniue is ahn infiltrate^l nilb
lymph «ell.". IIiuh reitiiU;> a eonniderablG tliickcnin];; nf the wall wliich
remniii» ri^id after divi.'>ion. 'r\w tube so changed in Ur^c, nodulated,
fR->|iii'nclv t'lrlu'iiix, and adherent to the uterus and nei;;h boring organs.
Tubcrculo.'iia luny bt-^iti in the tube, and freijucntly. tliroujjh a va^iivnl
examination, the timt.- of ilH ontiot mar be roco^nixcd \ty tuuion of the
tube ami by the pelvic perilonilts ^thich acc»m{)anies it.
Carcixoma. — Carcinoma of tbe Fallopian tnbe is never primary, it
especially follow» a primary lE'§ion of tlic wall nf the uterus, when the
eareinoma i« iliffiised<hrou;{bout the internal wall. In c-areinnma of tbe
neck of the uterut, tlie most freijucnt Uicutloii, tlic tube «Imoiit always
rcmnin» intact. In it eii#e of secondary carcinoma of the tube, wo fouiul
till' I'l'ritdtii'iil eonl iiiucli tliickent-d : the fimbriie, also infiltrated with car-
cinoma, were o{ien and fîUts) KÎth a milky fluid. 'Iliere waa aUo peritonj.
tin, frotti which the patient died It man very evident that the carcinoma
of till' tube had been in this i:a*e tlie cause of the jwrilonitia. Generally
carcinoma of the tube <levelope<l by an extension from tbe uterus is com-
plicated witli a similar lesion of tbe ovary. Rokitansky haa seen can-
cerous vegetations in the lumen of a tube already dropekal.
Cysts op the F-^llopiaîi Ti^iie. — Cysts developed in the wall of tbe
tube arc very common, but ustially small. Their iimxIc of formation is
not yet entirely known. Vet there is one frequently found at the fim-
hriat^'d extremity, which is re;^arded as developed in the closed extremity
of Mtlller's duct, the ftctal or^an from which tlie tube is developed.
AîKtlbtT cyst is often fouml by tbe *ide of the preceding; it is at-
tached to the bmad lijcamcnt, rcpre«entin^, accordiuj^ to Vireliow. the
reniaiiii» of tbe primary excretory duct of the Wolffian body. Tbi-*c two
cysts become an lartte as a cherry . Iteaidcx theao cyats, othertt are foiutd
dovelit[)ed in the ttihe^i of IlosenmUUer'H orj^an ; finally, tliere are nooie
nhich âeeiu to have their origin simply in the subperitoneal ti»9ue of the
tube and broad ligament.
Pbri-utbrisb U,eMATOCHtH. — It has been seen that by the rupture of
a Graafian fnlticle there occurs an effusion of blood, but the amount of
blood is very small. More abundant hemorrhages take place from the
LKSIOXS OF THE UOCOUS UBMBRAXG OF TDK UTIROB. 689
rapture of large varicose venons veiisela of tbc broad liKsmenta, hy a
hemorrhage rroin the Fallopian tube tlurin;; a rocnstruat flux, or by a bom-
orrliage in conaeouence of delivery, or from a rujrturc of tbc tube in
(ixtra-iUorine tubular gesiAtions. In the latter tb« bciDOrrtmgc î« uausfrd
t'ither by a rupluro of tlio varico«e tubulo-ovarinn veîtis, by a rupture
of tho ovary, or by a itolalioii of continuity of ibc tube, or even by
tbe rupturu of a foetal cy«t. If tbc bciQorrIin;;« in very great ilvath is
rapid, either by tbe amount of blood but in tliv peritoneal cuvily, or by
B Bubacutc pcntoiiitis which reiiullH. But if tbe inlrA-|)eritoiieal effusioD
it U**«, and is repeatrd At wveral mciiitninl pcrioiU, the blooi] collecU in
the lower part of tim polvit {Mritimcul <:«vity, ami oocanioriH an itiHaiii-
matlon of tbe peritomuin, nreupiscribed by a false membrane (a tilooil
tumor). Tbt« tiuimr may be felt through the vagina, and conâtttut«s a |>cri-
til«rine hœmatocelo, which ik of much importance clinicallv. Itcruulx b&-
lievea that tlie Fallojiixn tubcii have considerable to do mtli tbe produc-
tion of hemorrbajçe into ilie peritoneum. Acconling to him, blood coming
from the Fallo|>iaii tube escajics into tbc acroua cavity whether there may
have been a primary hemorrhage in the tube, or from both uterus aad
tube, or whetlier there ha^ been retention in the uterus of the calamenîal
blood during several months, m occurs in cases of imperforate hymen
in youn;; KÎrls. It must, howerer, he remembered that the lumen of the
tube, etpeeially where it pa«sc«t through the uterine wall, pnrmitfi the
p*«£tt;^e of fluids from the cavity of the uterus into the tube with diffienlly,
ytl tluit it may occur ban been dcnion^truted beyond doubt in neveral
obMrvattom.
Virchow, on tlio other hand, hnn stated, tliat vascular new membraoes,
due to ]>rimary or secondary inflammation, may form \i\Km the surface of
tlie jieritoneum, and lliat these new roemhranea may ihenuelven be the
ori^n of blood clfiL»iona upon thoir surface, or in the loose conneetive
dsaiie constituting them, aa occurs iu (ho new membranes of pachyme*
dngitiB.
Whatever may be the origin of the hgematoecle, it conatitotes a tumor
located posteriorly, upon the sides, or all around tbc uterus, and which
may ttc felt through the vagina. Tho envelope of the tumor at 6ret
coiw»ts of fibrinous false membranes, afterwards cellular, which separate
tho tumor from tbc peritoneal cavity. It contains coagulated or fluid
Mood, varying in color aecording to tbe ago of the eflusiou and the
chemical changent it bos experienced. In time, the blood is absorbed and
ttie sac oontract<< by meaiiit of tbe organixatiou of the oounectire tissue
which surrounds it. During the escape of blond, indammatory and oven
purulent foci arc sometimes seen, so ûiat peri^utcrine abscess and bscm»-
toeele are very similar in their seat, causes, and symptoms, and rosy
complicate one another.
A. Lesio.vs op tub Mccous Membbake op tkb Uterus.
CoNOBSTIOX, Uemorhuaub. — Congestion of the uterus due to venous
stasis is very common in diseases of tbe heart and lungs with dyspncea.
The mucous membrane of tbe cavity of the uterus is bluish-red. and tfav
cavity itself contains a very small (juautity of bloody mucus. This leùon
690
ILLOPIAS T0BE8 AXO UTERHa.
U frcinfntly soon at the autopsies of old [lersonit; it ntiW Acciirs from
preesuro u]>oii the uterine veuous p]e.\iLs l>v luiiiom, ejt|ieciallv filiruns
tumora of the uterus and its appondagee. I'liysiologic*! Uentorrtiti^
of HMKutntatiou arc not includeti here, but wc ahnuM miintion
menstrual hcmorrhuRcs of the utonis, which cannât he discliarycd fast
eiiau;{h, or arv retained in coD8c<|Ucnce of a uarrouing or obliivrntinit uf
tlio orilicfl of tho cervix, or li_v an iiujicrtoratc hvuien. In thccv cnsw
t)»e FallopÎHu tuhe îo ulso fillt-d with hloud, anil somctiiuvs tlic' I'Iixh]
esMpM into the [ii^riluia-al cavity through tiic tubes (see J'rri-utcrin*
hœmatoetU).
Catahbhai, Inflammation' (TnUrivtl .Veln'tiê). — Acute eatiirrtial in-
inll:ii:iniati«n of the inut.v>iu< mi'iiihi-uii^< 'ioc»r*,<'ithor in coii»o<jh«'ih.H' of*
va^nilis, aiid jinrlicularly wîlli bleiinorrhiigic vaj^initix, or in i'Ouhciiiii'ik.'o
of a local onijitioiuii the cervix of the utenw.or it occur* iti ccrtiiiti gom-ml
ocuU! iliacases, aa typhiiit, or it h more commonly «Mwcintod witli a number
of pathological couditinns, scrofula, tuberculosis, ttyphiliA, etc. In many
caaeH, the only cause is chlorosis, or disorders of ineiistruatio», or the r«'
mote conseil lie lice s "f parturition. Catarrh of the mucous membrane of
the cervix causes Uie formation of a fluid hnviii;; the mucous constitution of
the Recrelion of the ccnix, but iiislciid of bein;; transparent, is puriforiB,
resembling; muco-purulcnt npula. CatJirrb of the mucona mcmbratte of
the cavity of the uterus u clmniclerixcd by nn abundant fluid M-crctioo,
mora serous than thai of thcccrvix, andof »nc<piu|ueitnd punfonnap|>e«r-
ance. In tlu'.sc Ir^^ioiiH, there la an iihundatit fumiatioii luid drwiuaaiB-
tion of th« epithelial celU, a^ well as an escape from the vesael» of lymph
celU au<i uUo of a few red b!r>od corpuscles, contributing to the ervornbo-
logical clenit-ul^ in the catarrhal tiuid. A turgescence of the vessels of
the mncoiui membrane, and an in<mtiou of its tiuuc witli scrum aod
even witli lymph cells, accompany the secretion.
Chronic intlanimation foUotrH nn acute attack, or it is from the fir«t
chronic esjiccially in unsemic, tuberculous, or scrofulous persons. Ilie
secretion of purit'onn muciw, with its diScrences in the conix and carily
of the uierns, the state of xeroti» infiltration and of vascular oongi-stion of
the mucous membrane are the siunc »» in acute inflawinatioo ; but there
is in addition a scries of more profound changes in th« mucoiw uembrane,
rich as the fonnatlon of ovula Nabothi in greater numl>er than iiomul in
the cervix, hypertrophy of the jiapilh», fiolyjioua excresceitces of the cer
Tix which are lonnoi) of vascular connective tissue, soraetimea of mucous
tissue, having the elongated shape of the cavity of the cervix, or reraaifr
iag small and sci^iiile. The former are fre(|uentlv seen projcctiug fmia
the 04 uteri, and may reach several millimetres m length. Amooz Uiv
small polypi, a few contain, scattered tliroughout their tissue or only at
their extremity, eggs of Naboth, protluccd by tho accamuUtion and re-
tention of a mucous fluid in the glands in the folds of the arbor vii.-e.
^miill tibro-nmcoua polypi occur much less frcijuently in the cavity uf
the cervix ; yet they nmv he developed hero, but are tbcn »iiiall and
scwiie. We linve »omeli[ne« seen upon the mucous membrane of tbv
cavity of the uterus small ovula Nabothi scaltereil over its entire surface.
In intense chronic eiiturrh of the mucous menihnknv uf tlie cftrity, then
p
CATARRBAf. INFLAUHATIOR OF TUB UTERDS. 6fll
i» a v<Tjr liccided brownish-ped color of ihig membnine, nml upon presauro,
there id Hcnn to «xiuie & piirifonn tliiiil froni tlie jilandulnr orifices.
Ooiiit<'eiitiv«lj tn these Hevcriil ]>alliolo<*ii:al conilitionii of the uterine
iniicoiiH RM'mliranc, tlie mucous iDcitibranc of the vaquai portiou of
the wrrix uithiu view is nlwnvs attci-cd to a varving extent. Tliiia in
cntarrh of the cervix or caviiy, when the catarrlial fluid flows in nhuii-
danoe froiu the uterine oritiee, it remains in contitct with th« lips of t)iu
oe nleri, especiallv the posterior, and there results at finit a superficial
erosion, afterwards a true ulcération, which rlcstrovs tlio epithelial corer-
in|*, particularly in the middle of the posterior lip. In elironie states,
there is ut tliid jioinl a ;;ri>wth of the papillic of tlie mucous ineinlimiie, in
the fonn of siunll gmuulatioiis composol of enihr,voi)ic vomtvetiv^- tivue
tnvened bj vessels.
I'hcw j;ranulntions are pink <>t red. Who» repair tahe» place thev
«ro covered with ejuitheliinn, and eonlract, on account of tlie etnlirvouic
tisBne becoming fihrouit, fiiuill^r becoiniujç buried under the epitheliuni.
In tboae etaet favorable for the Alu<ly of their development, it is seen
that theiie granulalionii have their ori^ii in a proltfemtire inllammation
of the papillae which normally exist under the laminated epithelium of
this portion of tlic mucous membrane of the cen'ix,
'riie mucous membrane of ttie os uteri mar be the seat of numeroua
cru]>tions, Bitch as vesicles of herpes similar to thow occurrin-; upon tlio
TuKa and prepuce, bullx of pemphigus, eruptions in conm-ctii>n with
«niptive fevers, simple or indnrateil clmncrc, mucous patches, vegetations
deteloping upon the stirfncfi of mucous piitchf>i, etc. In iiei:<indiiry .^yphilia
tliere are almost always found a redness of the cervix and a uterine
catarrh, tiic latter ])ani«idarly when there are several mueo^s patches
upon tlie surface of the cervix fullowing erosions.
In chronic eatarrii of the cervix, the mucous membrane of the intra-
raginal portion frei(uent!y contains eg-;? of Naboth. The catarrh of llio
nterus {[uile often extends, as has lieen prt'%iously mentioned, to the
mucous membrane of the Fallopian tubes, and, hy extension alonf; the
latter, there may occur a subacute pclvic-peritonitis.
All onfreqncnt result of inflammation of the mucoiu membrane consists
in ft narrowin;; of the internal 04 and cervix. The purifonn or scro-
mucniw catarrhal fluid tlicn accumulates in the cavity of the utenix and
distends it. The mucous membrane atrophies from pr«>ssure, and ihe
miiMulnr coat is generally tJiinneil. We have seen this lesion very often
in ohl women, and it is probably the result of a senile atresia of the
corvico-ut4:rine orifice.
When tiie inflammation of tlie mucoun membmne is very violent, tiiere
is an infiltration of ib< mucous membrane with lyntpb cells and fibriu, in
such abun<L-inee that su[ierficial monificadon or ulceration may be the
result : ibis is oliaerved in tvphoid fever and low types of eruptive
fevers, but not in every case, it being an unfre-iuent complication.
These inSammalory lesiona involve only the mucous membrane, aivd
do not extend to iho fibio-museular tissue. Yet it is possible, from the
severity of a chronic catarrh of the cervix, that it may, by the congestion
of Ibc deeper parts of the mtieoos membrane, by the fonnation of fibro-
■nacwM polypi, cause also a more intense nutritive activity of that [utri
692
TÂtZOVÏATI TDBES AKD IITBRIT9.
of the tDu.tciilar parenchyma in connection wïih the mucous n)i'i»hran«.
Thij" sc«roa to t»e one of the eauseo of hjf perlrophy of tlic cenix in woinep
who have not had children, but the abuse of coitus taust nbw bv tak«n
into account.
PrcRPERAL IsPLAMMATios. — Pucrpop»! endtHDetritis bo^niiii);! imme-
diately or a few (lays or si-vcral week» ftftvr dclivcrj' (poHt-ptierjipnil
tmctriljtt) i» Dcver «miilc ; it extends to ihv pan-iichyma, to th? vvooaa
BÎiiuie«, to tlic lymphatics, to the peritonval vovoriiig, to the Fallopian
ttibc«, etc.
'Die iiIltua, n^ hm bocn ulrmdy mfutiont'd, i« in all [tn pnrtA rorr
touch altereil by partiiriiion, ami, by this increaite of pby9ioli);;i«til
aotivily of all its eleinenUi. it is prc-ili^pntied lo acute iiiHummatian, ubicb
ill reality iii onlr an cxaegeratiou of tbtti activity. All parta. thi-it, are
liable to particrpate in tbe puei^icral iofluDmatiou. The miuculur con-
tractions, tratimatisras, mn ni pul niions, and opcratiouit during •U-livery,
especially the nomid rcsHltiiif; from the removing of thu plaeeiitA. arc
the principal eoneurritij; and excitin;* cituacs of the influnmiAlinn. 'llio
putridity of the cOht«nt«> of tbe uterus, the phlebili^, llie lym|ibnn^ti«,
the condition of the bloinl which curries infecting xytiiolic germ*, arc the
caitseâ of tho febrile phenomena «o rapidly tcrniiiihtiitf; in tiumeniu
rovtiulatio iibacesses, general peritonitiK, and dvatli.
At tbe auu>p*ie8 of women dying soon after delivorr from metro-
peri toi lilt», tbe uterus is found relaxe<l; it^ vrnlU are llabby and satu-
rated with fluid, white pug or a fibriiio.puni1otil coaj^lalioD alnny^ fill*
to a greater or less extent the venous aimiscH which tntrenu- tbrin.
Tho mucous surface of the uterus is dark red, and a jxilpy wfïening id*
the uterine decidua or a purifurm sanious fluid saturating tlir sofleited
mueotis nK'mbrane is seen. At tbe point of placental atlacbiuenl a vege-
tating surface is found foruied by villi of tbe mucous membnine. At lJi«
projecting portion of tbe villi fr('i|wently exi«t «mall fibrinou* clot». 'Hie
entire placental diwk is soft, ptit]>yi infiltrated with faui»u« blood mixed
witli a purifunn fluid, nnd lia.-< a very nIFentiire udor. Fr«<[uently this
portion of tlic mucous membrane is gaiigrenovis, dark-brown in color,
and is detached in s-hreds from tbe membrane by a small stream of water.
Homedmcs, at the same location, there ia a grayish falso membnuie which
soparatea into lamcllte, and beneath which the tjssne of the mucous
membrane is red-brown. This diphtberitic or gangrenous false mem-
brane at times extends over the entire uterine mucous membrane.
WbcD tho fluid obtaiued by scraping the surface is oxacmnvd with tlie
microscope, there arc found numerous lymph cells. From tti« deep
layers of the înliUnitcd mucous membrane wc obtain, by «cmpiog, a
small 'luautity of fluid which contJiins, with lymph cells, large, swollen,
nnd grniiuUr fatty cells of the connective tis.we. The neck of tJie uterus
itt Moftcned, ntddl^h-bbie, puljiy ; al«o often covered with the iiame gray
morlifii-d fal^e tuendinine, beneath whicii the tis^'uie is greatly congested.
Tlio same gaugrenous b-»i»ii fre<|uenlly exista in patches upon the vagiaal
mucous membrane and upon the vulva.
The cavity oF the venoiiit sinuses is free, or it contains a purifonn
Buid, or a coagulated, soft, or pulpy semi-Huid eabstatice, mixed with
I
I
TUBKUCLB8 OF arOOUS MBMBRANB OF TTERDS.
Ijmph cc-lk, Riid fiwollon, gniimlur, cndotlitliiil colU. 'flic wftll of th«
venous siniui-s in the iitvriii*: niusculnr ùf*ne bus ihu uppusniiwo of an
endo- Aiid pori-phliOfiiU.
The Inrge vciiw ivrw frcqnviitl v fiili'd wiOi pus or filirin, nnd tlie liroail
ligAnienU lUu-ays coiiuiii a var;ring ainoutil of |>il^, collected into jmru-
lent foci, aitiiatod in the connective Us-huc or in the veins.
The auperlicial lymphatic vessels of the ut«nt» Are sniDOtimca flllod
with pus. The periloneiiin which corera the utcrua is nln'ay.<) the fieat of
ail intense inBammatiou, wilh rcduesa, va^ciilariiation, ami fonoadnn of
false 6brino-p(iriform m«tuliranes, and irith a purulent infiltration of ita
connective tisHuc.
The Fallopinn tube and the ovary arc similarlv affected. Finally, a
general rapidly fatal peritonitis occurs; metastatic nbdcvsscs arc formed
in tho luiipt, livvr, kidney. t^'Cc. In the metritis which occurs some
time aflcr <li'livcry. the phcnomona do not have tin* sftnie intensity. Tho
utonu i» contracted — at IcaAl so far that it does not contain lar<rç cloM
or fragments of placenta; tlio venouK plexuses have Had time to contract,
and the decidtta i» in greater part eliminated. All tho [tarbt »f the
uterus and its ap{>enda]ce9 are less vulnomhle. Metritis under th^se cir-
cumatanccs, however, is always more inteiLie tlian in the non.f(ra%iil
organ, and ia frcrjuently accompanied with peri-metritis. There results
a local perilonitis. circumscribed by false membranes containinj; a pnni.
lent collection, varviuft in qnanticy, which is froii«ently aIisorl»cd when
the amount is small. aomelinicH there occurs a phlegmonous intlamina-
tloD of the broad ligament or of the cellular tissue of the iliac fossa.
Phn'jfdenie ulcer, characteriied by a progressive destruotjoo, with a
gangrenous a}>|>earuice of the cenix, causes a Iom of subsUince, so that
Uie inferior portion of the neek, and even of the body of ihe uterus, and
neighboring portion of the va^pnal mucous membrane are iieslr<iy<-<l to
such an extent as to foi-m a fetid canity with K^ngrenous walls, and caiwo
a perforation of the bladder and rectum. This ulcer, we think, siioutd
always be referred to carcinomatous tissue or cpitheliomatous ulcers of
the neck.
Tcjrons ftEVBtopE» ix tiie Mccocs Mkmbkask of the tTTEiirs. —
Jifumv3 '■yj»'*, fanned by the retention of nnicus in tlie glands, and known
** *'SX* "f Nuboth, have provionsty been described; at tiinuB they may
become as large as a pea or cherry. I'Uli, which may citiat upon the
internal surface of the mucoiti* membrane of the cavity of the uterus, have
also been mentioned ; they aUo occur very l're((uenliy as vegetations and
JibroH» pofi/pi upon the surface of the cavity of the neck. These fxïlypi
arc very vascular, and generally contain in their subslance or upon their
surface oj^ of Naboth. which cause thorn lo be named muemu j>"li/pi.
TuberettM of the Mwcoa» Memiratie of the L'teru». — Tuberculosis
of the utorinc mucous membrane sometimes occurs in connection with
tuberculosis of the other female ircnital or^jans. The lesions of the uterine
mucous membrane ar« in evcrytliing eorapaniMc to thono of the muon.-t
membrane of the Fnlloptun lube». The surface of the mucous membrane
of tho neck is the seat of a pn>fiue catarrh, with the production of a
RM
rALLOPIAK TCBK8 AKD CTBRDa.
thick, j^ramous, opaque, and ca^ooue piu; more rarvlv tlio carit/ nf the
ut«nu \a aflectcil in a situilar mttntior. The miicotis menibrane ot' the
cavity prc«ciiM ^rnmiiatîunti at first evinî-tniiMpurtMit, lutvr becoming
j<>llou- mill Dpofjiiv, un<l tinitiii*; iii patches varyin;: in »iu;. Tlii- fu\t-
cpitlii-liul ounncctîvc tisane i« tW initial Mat of Uk- Icvînn, hut Ihi- ilcop
tiMu« or ihe niuocHW laeinlirnne it invmlod bj nn nhtiiulant fomintiuti of
enihrvonic connective tissue and tuburctilou» granuUtioiw. Tlivrv roaulw
a genera) Ihiokeninjç of lh« .luhinucouit c^itnectire tiwme. Tlie aanw
leflion» may hei>e«n in tlie neck of the uteruH.and al ilii()rifi<.%; but Ihej
are alwAjfl more limited. Th« ^eUtinoua mucoua Huid i(eortrt«d by the
cervix in ihÎH diAcimo i» loaded with a gmmous. oi)a>|u<>, yellowi-ih, semi*
solid dé^rÎA, due to the ca§caua de^etioration of the pua coming from the
tuberculous portions of the cavity or neck of the ulorus.
SftjiitilU frcqucully attacks the corrix in the form of chancre and
mucous patches, us also in the form of indiiratioDs and deep ulcers of
the t*Ttiiiry |>criod.
Carrinonut. — I'riiiirtry cnnrinonm of the neck of the iitcnia is very
frciptently met with; the vuriety is almoMt alwavH ciicophaloiil. Tims,
iu titirty-four MiKTimcn^ di^teniiiiied hictologiciiUy by iu iu I81IS and
18t>-l, all belon^i-d to tbitt variety. Some jiatholoponl anatomists, bov-
ever, mention isolated cnsefl of Kcirrlioui* and colloid caroinoma. Hut it
must be retnembered thnt carcitioioa, vihioh al the 1>e){iiitiitijÇ aeeuL'* bard,
beoomea soft, and has the appearance of encephaloid when tlie tumor
extends.
CnrcinoiDB of tlio neck bc^ns npon one of the Wja of tli9 M (tt«ri,
which is indnruted, hypertrophicd, and soon presents ujmhi its surface,
especially upon the side of the orifice, uiid at the free border of tiie lip,
soft and vsiwular vegctaLii)iiK. The op]iot«it«- lip, iu its turn, licoomes
hyportrophied ; there rciiultA a dilatation of the orifice of the neck, pCT<
Qiittiug the linger to enter; ami the n bole Hurface of tlte cervix is covered
with vegetations. The infiltration of all the vaj^inal portion of the ct^n ix
produces a peripheral excrescence of the neck in the shape of a fun^«,
the end of which projects into the vagina. The suhjaceni cellular tiMue
of the va;pnal mucous mi-mbrane which surroimds itie 09 uteri liecotnes
indurated to form, with the cvnix. nodules and granuUtioDS.
Tlie carcinoiiiA always appears to hove its origiu in the submucoos
ooinipctive ti«me, ito tbiit the mucous membrane of the cavity of the nock
and of the vaginal portion remains for some tinie normal upon the surface
of the tumor. Soon, however, this membrane ulcerates, and the can>
cerouA noilules cause the fonuntion, upon the surfacv of the vagina, of a
fetid fluid, which accumulate» in the fold», where il is mixed with the
va^^nal secretion.
The carcinoma extends to the muiicular wall of the neck at the same
time as to tiie peripheral eonueplive tissue and to the auVvagiiial ii«(riw.
The uhvrntion, which is accompanied liy putrid luotst gangrene of all (he
priuuii-ily invaded parti, is followed by a loas of substance linuted by a
portion of reliiined carcinomatous ti&auc. There is now seen a com.
picte interruption of continuity of tho vannai mucous membrane and a
tranaveriw section of ibe inferior portion of the neck. If this nh-fratiiig
cavity is examined under watvr, there lioats luto vîcir a con.-iiderabk
CARCEXOUA OF TIIK UTERUS. 695
auftndty of wliitiah or gny fitamcntou.'i tatxs of gangronou'i cnnnectiTe
ttasae. These are the vessels of ihe ulcerated part of the luntor, which
rcuinin attAchc<l to the portion not tcI ulcerated. Upon iho walla of
thv^v veMUiU, the microscope shows colls itnplftiiicil pcr|H'iii!ieuIiir to their
axis. I» the f^nty or slate-colored filameiita tlic velliiliir elemeiits of
lli« vesM'U are in a state of fatty <lc;;eiieratton, anil their walls are in6l-
trateil with bruwn or hiaek pigment, due fi tlio awlnmorpliosts of ibo
coloring matter of the hlood. In directing and separating the»c vomvU
at the point where they peneli-alo the maiM of tlic tumor not yet ulcer-
ated, it i.* fmiiul that tln-y oonlaiii in llicir interior a deposit of fihriii. or
a tlieoinhiiii formed by lar^^e cancentuK colls. The veinA, largi- in m»-,
very often contain vegetationn or similar formationa which ]»krily fill
tbcDi. Theite ibrombi are evi<lently thi> eauiie of the mortification of the
new tissue, which ia hastened hv the putrid décomposition of tlie iliiida
accumulated in the va^jinnl ciila-fîe-eac.
Ity the new formation continiiiii;; to extend to the nei3;hboriniî parts,
the whole wall of the neck and a ^i-eat (utrt of the unll of the l>ody of
the utcnts are involved, tliickencd, infiltrated, and softened, and contain
the milky juice of encepbnloiil. The walls of the bladder and reetum
arc aUo inva>lcd: n perforation of one or Ixitb of these cavities may
result. .\ fistular opeuiiifi; between tlie blailder and vn-iina is always a
special cause of rapid putrefaction of the pnrUt inviidcil by the curciuoma.
Ttie surfaee «f the nicer may »nmetimej be covered with pliospluitic and
calcareous degiosiM from the salt» i>f the urine. .\t oilier linu'!' the floor
of th^^ ulcers of the uterus and raxinji is. at the time of death, fortned of
normal tissues, alt that portion infiltrated by the carcinoma having been
destroyed by a gangrenons slougli. The erosion now baa the appearance
of a simple pha;;edciiic ulcer, uute«s there arc found villous granulations
or nodules saturated with milky juice, projcctiuj; from the surface of the
perforated bladder or reclmn. Wlu-n the latter ur^ns nre not perforated,
but have their dwp couueetive ti^iuo infiltrated or only co»gc»t<'d. their
mucous membrane pre^^nts tlie ebaracleri^ttie sign^ of a very intense
catarrh. The deatriiciion of the utcruiii may lie so j^i-eattlutt the fundiis
and cormia only remain ; but the portion of tissue left may be normal,
and the Fallopian tubes unaltered.
If instead of hej^nning only at the neek, the carcinoma bejçins there,
and at the same time inliltrates the whole muscular ti&sue of the ntenu*,
the ulceration of the cernx does not present the same characters: the
uterine tissue, thickened and inBltratcd by new formations, measures two,
tlirce, or more centimelros, and not unfrt^quently the Fallopian tube and
ovary are also de;icnoruted. The latter organs, on the contrary, escape
when carcinoma be^çing at the neck ulone,
In tlii'jie two varieties of tJie lesion, when it is chronic, the snb-perito.
Deal connective ti*»ue of the true pelvis i^ generally thicliened and indu-
rated, and ill jilace^ very closely ailherent to tln> d^mmus wnll. This
hardened fibrous tissue, without any trace of carcinomatoiu du;;enenitioD,
is especially thick and bard at the poste ro- lateral wall, and compresses
the sciatic and |>elvic ncnc». The fibres of the latter are in a state of
fatty degeneration. Pain ia expcrioncecl in the diigha, in almost all ciwc»
of uterine carcinoma, aomotimcs the cellular tissue ia degenerated, aa
^096
FALLOPIA» T0BBS AUD ItTRROB.
veil lU tlie iM'lvic «ml liitnliar lym|iliati<; glnmls. MeUsUtic depoiiiu are
fret|ucntly found, «s]>eciiiil_v i» the lump» wwl liver, invasion of ch«
arclcr« occaitiatiii a reieiilioii ot uritie. nti<l uritiotia iiifillnttioD and auKiuia
of llie kidiievfl. The cellular liiuue of the tironil lignmcnl and iliac I'lKsa
h frei)iienlly llie seat of piintlent collection.'), mid tiiially before the death
of tlie ]>fttient a ijtineral poriwnitiii nia_v occur. In tliese cases wo hare
ohiierved a plilcbitis and a caret no oistUniâ Ivrnplian^itis. Ilistolofooal
examination of the chan-jcd uterine tisauo shoirs, u io every earcinotna,
a stroma of small alveoli, filled with polj-morphou» «lie, (îcin-rally ar-
mn;;ed without order; somotinics thoce at the poripliory nnj iinjilautvd
KgidnrW upon the wall of the 'alvcoUi». The stroma, cotnposwl of c<K>-
< noctivv tÎKïue, freipieiitly contains »Uu itmoolh nuiitcnlur Shn'O.
Eliithfliomn. — There nr« two dii^tinct variclic» of primary o|iillieli»-
ma «f the inncons inembrnni? of the uUini»; thv pavcmctit-celled c|nthe-
liouia, uith or nUhinit c|>itheliBl jwuri», and the cyliiidrical-ecllod epithe-
lioma. The fin«t variely occur* much more freipiently than tlio awwond.
From what viv know of tlie loc)ilir.atioti of these tumors in iceneral, they
appear to have their ori>;iti otdy in niuemia uiembranei* xhich possesi a
covering of cells simitar to those coiisthiiiin;: the new formation. Thiu,
, upon the vaginal portion of the eer^i.x i.t normally found a covering of
laminated pavement oclU, while there is a layer of cylindrical cells apou
the mucoufl membrane of the cavity.
These two varieties of epithelioma having their onKin la tlio cervix,
cttnDot bo disliDf*uishvd from carcinoma in the same locality, eitlipr by
their pliyt>ii-nl eigne during life, bjr Ibcir color, bjr their cuitroc, <tr bj
their severity.
At avit»]isies it is very difficult, and fretpiently impotiaible, with tlie
unaided eye, to make an anatomical diagnosis between the varieties of
epilheliouu or between them and carcinoma. V^Undrieal felled ffiilif-
Itoma is a tumor generally verv soft and infiltrated with juice, reaei~
bling a very soft encephaloid ; it also has lacunar cat-itiea filled with
milky juice, which are visible to the unaided eye. Tbe alveitar spaeea
contain cylindrical cells, and their walls have numeixiua eanllary loopa
projecting into the spaces covered with cylindrical cells. In the thr«
cases which wo have seen, and in which histological examinations were
made, there was an extension of the tumor to the neiglihoring parted
to the glands, to the bladder utid rectum in one cose, to the sciatic and
crural nerve» in niiutbi-r. In one iiU the tis«ue of the nti-rus was invnilcd.
aa were also the lymphatir vi-ssels upon the ]H>riluiiCHl surface. There
waa no «econdnry propagation In more distunt )>arts, but a nnailicr of
well studied cases of geuer.'ilixntion have bi-en re|iorted.
J'avtiiiietU'CelUd eintluUoma, which in about onedialf the cases po»-
seiases pearly botlies, presents characters by which it may sometimes be
recoginzed with the unaided eye at autopsies, I'ortions of the tumor are
alightly vascular, having the opa<4ue, waxv, and apparently firm appear-
ance, which is in contrast with its friabifity. L'fion sec^on its surface
is dry : and by pressure small grumous, vermiform, opaque, white jdug»,
consisting of collections of pavement upitbclial cells, are squeesed out.
Microscopic examination shows a tubular or lobular typo of epithelioma
with pearly bodies. In the first variety the tubes Slled with epithelium
LBSIOKS or MUSCULAR VALL OF TUB CTEBU9. 607
«re eitlier very larpe or very small, imJ the cells arc also snutll. Il is
probable tbat the tul>cs arc fli-rolo|i<.>(l from tiic ciilit-dG-sac of tlic glands of
the nock of the uunuç, ))iit thi« i» not ci^-rtain. The tissiio «uparab»]; the
tabea consists of the fibro-miiwiilnr ùsmv of the ntenw. Tlii."*e oiiitlieli-
omftts are ri'pro'liiecd with their ehAractcristic stnictiire in the gtandn,
ill secondary iiodulcs, located in the filiro-imnculnf (issue of the uterus,
or upon its perilnucal surface, ami in nodiiU-n develope*! in the layer» of
the hlnddor and upon it« mucoiii) tttirfacc. Idit melaslattc nodules of these
cpithuliomnta, eiiliiatod in or;;ann distant from tlie uteras, aeldom occur.
We have never neen theiu, but they have beeo reported by other piitho-
hp»U, esnecially Vtrclioir.
Ulceration with its several conserjnences, eepccially gangrene of tlie
altered part, is the eame in epithuliomata »a in oarcinoinata. In pav«-
tnent^relied epithelioma, the diseased part of the neck may entirely dis-
appear. Tlie noighborinj' organs arc neither so frei|uently nor *o ex-
tensively infiltnito<l with the ni-w fonnation as in carcinoma. Kjiithelio-
mata are apt t» be liikcn for a «ini]>le phn^o<lenie ulcer. Tlie tnttkr «hould
always be carefully exuinincd for irjice* of cpitheliomatoim structure,
both upon the vaginal surface of the ulceration and in tlio pelvic and
lumbar elands.
The difTerent varieties of carcinoma and epîtlielïoroa are usually de<
velfl]icd at the time of the roenopaune or a few years later ; yet they hare
been observed in youngwomen from twenty to thirty yeareofage. The
tumor of the cenix does not prevent fecundation, parturition. or ilclirory.
After delivery the lesion of the uterus progresses with great rapidity.
B. LKStOSS OF THE FlBUU-ML'gCULAR WaI.L.
The fibronrnsciilar wall of the uterus generally escapes involvement
in catarrhal intinmmation, and it is markedly affected only in puerperal
inSammaiion. The veinn are attacked with inflammation, and abscesses
may be developed in their wall.
Lesions of the uterine wall mostlT consist in a new formation of
smoo^ muscular and fibrous tissue, wbicb occasions cither a gcucnil or
a local hypertrophy of the wall. A local hvpertrophy when sharply
limited may be regarded as a myoma. The différent fxrms of diffused
fibro-muscular hypertrophy of the wall uro included by miiny writers
under the name of purcuchymatoun metritis, which is certainly not a
good terra, since tliey arise generally by a slow proce»*, consisting simply
in a new formation of smooth muscular fibres. Vircliow eon*i<ler> this
growth as a hyperplasia of the uterine fibrn-nuiscular ti^^uc, wliich is a
much better name; and he describes it with the myomnla. There are
according to this author two varieties : the one soft and resembling the
uterine wall shortly after delivery, a comhtion due to it^ vasculariiv and
abundance of muscular fibres, and the softness of the connective tissue ;
the other hard, compact, not very vascular, and containing numerous fasci*
euli of dense fibres.
These \'arieties of local hypertrophy often follow delivery, especially
when the nock Inis been torn. The subacute inflammation succeeding
goch a trauiiiatiijui, the new formatiou of conuccttvc tissue, and the active
I
F1I,1.0P[AS TVBB8 AN» UTBBOS.
nutrition of th« |>art, «11 retuni or prevent th« TaUjr dogencntioii, mnd
f>tiv))ihf of ihv musclfis, aiiil ncvaHion n fibro-niUDCulnr liypenroplijr or Uit i
neck. I
SimpiM)!! coiisitK'nt the ctiftng«8 of the niii»<'ulnr fibre» ilurin;; andj
«fier jfoslittioii or greul impnrtntice in tli« ox[ilanatioti •>{ j^ncnil andl
IdCiil hvpurtrflphio^ nnd nlmithie* of tlie uleru». In tlie foraHT, lh«
Binnll tiliri-3 hyperlropbied hy the jieittAtion reronio so, or, at lea^t, iheir ,
Atrophy or involution i» iinpodcd; in the latter the tihysiological airoptijj
«ntitiimoA, causing a pa tlio logical, goneral, or local atronhv. Tbis in-
gcniotiA view ninv explain a c«rlAiu number of caaes,Mpecially in ;;<;ncral
or lorn! Iivpertropliics follnwinj; delivery. Itisali^o true that pre-existing
mvomaia of the uterus majf increase very rapidly after a prejpmncy.
UturiuD myomata, however, arc observed in you»;; ;;irl«, or in wikdoh who
liitvc never bad «exnul connection, or have never borne childnin. WflM,
n><;nrds the formation of niyoinata a» a result of activity of ibe utenuj
while the »r;9»n in doprivi-d of its phy«n>lo(4Îcftl function, which iit genla-
tio» ; for example, when miirried women do not have children. Yet local
IrfUid ;:rnerid liyp'-rcrophie* of the ntenw arc aUio seen in wonK'n wlw
Ehiive bad cbildren. Local hypertrophy of the va^ii^l portion of tlie
neck is very frc(|ueiit in multipara. 1'hc Hps of the twck arc lar^e,
irregular. And bosflelatod uj>on their tmrfaee. The hrperlropby may
occnr upon cither lip, giving varioufi iibapeit to the neclc. The mocout
membrane of the cavity of the neck in changed: it hss lost its cylindricalj
epithelium and is covered bv Inmiunted pavement cells. Goiiorally theru
Are soeii, n;>on tho altered lips, nvula Xnbolhi, or folds, doprcBsinns, auu
small euvitics. or suc4 with elevated purlUtonif, which give tltc apin-arance'
of a hypertropldod tonsil (Virchow). The mnuoiui membrane of the neck
tassiot» in the fonnatîon of Ihi» byperlro]rtiy by the developnicnl of the
povula Nahothi ; but hypertrophy of the lips ha* also been iiecn, in the
sbajie of elongated fle«by proUingationm, )>roiecting even from the orifiofrJ
of the vajEinn, and covered by a thin mucous membrane with pavemenin
cells. The vaginal portion of the neck mav he generally hypertrophied
to such an extent aa to cause a prolapsus into the vagina as far a» the
Tulrar orifice. But prolapsus is more frcfjuently cavised oy a hypertrophy
of the entire cervix, the supra-vaginal poriiou as well as it» vaginal piru
Tbis mode of hypertrophy of tbc ni-ck frcnuvntly occurs; the ccmx i^
then very long, and project» into tho vagina either by an elongated or
by a club-shaped extremity. In these ease», the uterus may remain in
position, and be of tmrmiil bîïc, or it» U^ily may lie byitertrophied as
well as the neck. When, however, the body of the uterus is normal in
sine, it may he ilrnwn into the prolapsus by the weight of tJie neck. Thii
byp'-rtropliy of the entire neck has l>ecn met with in women who haru
never carried children, (ioneral hypertrophy of the whole uterine watE|
is not so freipient a lesion as locaj hypertrophy.
Mt/oinalfi are the most frequent, almoat the only, tumors which hare
their origin in the muscular wall of the uterus. They consist of fasciculi
of smooth muscular fibres, intersecting each other in every direction. A
general description of this class of tumors has been given in Part First,
which wo will not again repeat, as it is equally appUoble to tho ateriiK
HTOUA OP THK DTERUS.
699
myomata under consideration. We will give only the peculiarities of
their development, seat, and anatomical conaequenccB in the ateros.
Fig. 333.
llDKcalar cfllU fram it Ii^1o-nij'>iDfc. A. Celli ««panted by the ftctlon or nttrle %t\A, 30 prr cid(.
B. A hftntflnad lectldD eolotfld vLtb CArmiue ibi] tnaled with icAtLc ao^. m, LoDKlLudLaatJ/ cut. a.
■rM(T<n«lr eat unclai. (. Coanaeil<re'llBiB« eatpuicl«>. Higb power.
They begin in the muscular wall. They are generally at first very
vascular and soft, later becoming indurated in con3ef|uence of the
fibrous organization of their connec^ve tissue. Sometimes the intra-
parietal tumor.4 are very small, round, and «[uite hard. At the be^nning
the fibres of the tumor are directly continuous with the neighboring
fibro-muscuiar fai^ciculi of the uterine wall. By their development, these
tumors project either upon the external surface of the uterus, when they
are covered by the peritoneum (:iubparieUil tumors) ; or upon the intentai
surface of the uterus, when they are covered by the raucous membrane.
Frequently they are pedunculated in such a manner as to be united to
the wall, cither by a large and vascular or very nam>w pedicle. Myo-
mata projecting into the uterus are frequently called fibrous polypi. The
subperitoneal tumors, not being impeded in their growth, acquire a
very large size. They are usually multiple, even when of considerable
size, and very often there are, at the same time with subperitoneal
tumors, intra-parietal tumors and polypi projecting into the cavity of
the uterus; at times they are so numerous as to cause a change in the
shape of the organ. It is also sometimes difficult to find the cavities
of tlie uteriLs, owing to the cavity of the neck being entirely cut ofi"
from that nf the body, by intra-parietal myomata projecting at the point
of separation of the two cavities. Tue several degenerations which
have been mentioned in Part First, as occurring in myomata, may also
occur in this class of uterine tumors, especially the subperitoneal. A
carcinomatous metamorphosis of a uterine myoma has been seen by us
in a case of carcinoma of the peritoneum. Virchow has also observed
carcinoma in a myoma.
Myomata projecting into the cavity of the body of the uterus are
either hard and fibrous, or formed of a softer mu^^cular tissue, redder,
more vascular, anil having large vessels ; their ablation gives rise to
hemorrhages difficult to arrest. The former of these intra-uterine polypi
sometimes occasions considerable and repeated hemorrhages of the mucous
700 TALLOPIAK TUBSB AND UTBRUB.
membrane. It is seldom that a polypus of this variet; is developed in
the wall of the cervix. When a polypus having its origin in the body of the
uterus projects into the neck and passes through the lips of the os nteri,
its mucous membrane is changed, becomes thicker, and is covered wiUi
pavement epithelium. The projecting portion covered by mucous mem-
brane sometimes in red, inflamed, and ulcerated. The mucous membrane
is entirely destroyed in spots varying in extent, exposing the muscular
tissue. The neighboring mucous membrane fonna a sharply cut border to
the ulcer ; it is red or red-brown, and much inflamed by contact with the
irritating fluids of the vagina.
KORMAL BISTOtOQT Of TUB VATilVM.
701
CHAPTER Til.
UAMMART GLAND.'
SNoRXAt IIiSTOLOOT. — The mammary kIoi)i1>^ ^^t- organs common to
I etiM, bitt it IS only îii the fc<ma]«, and &t tho utiil uf ■icstntioii, that
tixey rcncli thoir porl'cct physioU'^liciil development. In the miiU- tlicstf
or];A)ui rL-mniii — oxci-pt in vvrv ritrc in«(anci.'«— A# rudimentury Hlriio(tiro«,
ncrvr attaining llinl phjitiologicul or hiHtvlogicAl perfection met nitli in
tlio foiniik'.
Tin; ^rmiii of gland» to which the manimn: belong is (he racomose,
or it is Iwiter to ilcitcribe each gland as consisting of several race-
mouR glaiKU, tiince it the» not empty itself by a iiingle diiot, tint there
arc found n]ioiiiiig u])on the Htiiiimil of the nip)>lc (iftc«ii to twenty
minute canak or yalitctophorou» duett, which are the outlets of as many
raccmou» glandit. Thu collection of glands or lobules is flnrroundcd by
a ma»s of ailipose tissue, and che nipple is the only point where tlis
glandular structure is in immédiate connection with the skin. Here and
under the arcula there is an absence of fatty tissue, and instead of it
there is found a layer of «raooth iiiiisuular fibres.
Followiii}; the course of the excretory duct« into the gland from their
opciiiu)^ upiKi the nipplf, they are seen to dilate, at a |y>int corresponding
to the hase of the nipple, into sacculated receptacle» known as the «tie-
cult Iririiferi. Occasionally recurrent branches are ^pven off under
the areola, which collect the secretion from the small glandular bodies
in this location ; these glands, however, may have their own excretory
ducts which open within the areola (tilandulw aberrantes of Moll^
gomery). Below the dilated portions, the excretory duct« again be-
come narrow, dit-ide and subdivide until they ultimately terminate in the
vesicles or acini. Sejiaratin;; the lobules wo have tirn stroma [>f the
g1an<l or the pcri-Iobular ami pen-acinous connective tissue. Thi« eon-
m-ctivc tissue is a vontimintion uf the subcutaneous connective tJs^ne,
and like the latter contains iii it« meshes the udipOAC tissue of tlic
gland.
Tlie hislolot;ical structure of the ei^cretory iluct* is distinctly seen in
a transverse section. Kxtenially the wall of the duet consists of fihnllar
connective tissue, the libres having a circular direction, and interwoven
witli this layer are elastic tissue fibres; no proper muscular layer is
present, but scattered, nuiooili, niuscidar fibres are described as existing
in the connective tissue ; im]ilaiited upon the wall of the duct is seen the
lining epithetiiun. consisting of columnar shaped cells, and sopuraled
' On aemnnt nf th" tmixirlsnoo uf this orj^aii in patlialojiical ttUtologjr, wo ]itv«
wrili.-n n mort c»teuiltil iliiiariplioii of Its liiatologj' tliau llist gUtn \if t'ornll ind
Knuvlcr.
702
MAMIIAItT OLAKD.
334.
tuva», •kuwlan iiia*fti(>
»f peljbwirle uplihctlun.
from the fliirrouiul'ing uoiinL^ctivc tÎMUC bj uno or nwro laycni of end
thcliitl ocltit.
pMsing b) t)ie 8«creùn;; portion of tlio gUiiil, tJii- glnmlulnr voMclrs
or ftciiii are «phcrical or iivriform in i^lm|ic, wpiiruU'il "iic Tmm the
Qtlivr Ijv tlio )i(:ri-aciiioiu> comiwtivf tissm;, »ikI arr *iirromiilf<l hy the
PH-mtiraii» |)ro]>ria oommoii to j^biDdulHrxtruclure!*. A sc«liun ncroM «d
aciiiiiit ilfiuoiis trille;* (lie Boor to be Uikn) by t
layer of |»i>lylie<iral i-pithelial celU, containing n
central nuoleiix, averaj^ng aliout cine>thir<] of tbo
entire breadth of th« cell. In » profile riew, m
may be seen at the periphery of iiio swMioii. the
cells Br* fonnd to be obloii!- or cubical, Iiavin^ a
height uboiit one- half itit-ir bn-nUtli. As llii' w\U
BpprT)»cli till- oullt^t <}{ the acinus tbcy gni>]ii;illy
aasume the columnar shajie, rttscmliliii;; to a certain
C]tt«nt tlie ccllx liiiin<; tlie cxcri'tory diK't. Thi-
Cftvity of the aciniu \» (illtxl «itli fat globules
and debris of cell*. Kxaminvd iluriii;; laeution
tlie acini arc found to contni» the clcnientH of
milk det)o«t«d between and within the fpiiliilial
celln. By removing the lining; e|ùtliclinl <:clN i>f
tlie acini, there in seen a re;;>dar arnin^i-ment of
ilclicfttc libres, forming polyhedric apacea in which t}ic bniteri of the
opitbdial oelU were }>iaccd. Between the lining t-pithelinra and the
mciDbraiia propria in a sinj^le layer of very lliin cndotliclial cclh.
Immediatcly outside of the mcnibnma propria i>> Ri.ien n rcrA' delicate
ele»r sonc. in nhich the cells are very few or very imliittiiict; external
to this structure exists a second layer, cuii.<iKtiiig of a tiiisuc in which the
cell» arc more nuai«roii!< and arranged concentrically to Ui« «oini, liariog
the uppearaiice of a »econiI meiubrana projiria u> tlie acini. The connec-
tive tis<iii- natiiri' of iliiii laver îa evident from the circiimtitance ihat
there is observed a gradual intermingling of its tissue with thv (ibrunii
traheculte, which form the framework of the gland.
A varying number of acini are grouped together into lolmles. The
latter are separated fi-om each other by more or lesa tliick Innda of
fibrous tissue, usually containing fnt.
The blood supplied to the mammary gland comes from tho Gii1>cataoeo(ia
connective tissue vcwels, entering at the under surface of the organ:
tbo largest pass upwanU towarU the nip^^Ie, givin}^ off branchca to the
several lobules an<l <lui;Ui. Jtoth the acini and liacU are fouiKl to be
surrounded by a capillary system, which is jwirticwlarly distinct durÎDg
lactation.
The lymphatic system of the mammary gland ia rcprcMnted br a
number of lacunse or lymphatic spaces, fheite lacunw arc situat<^ in
the puri-acinotis connective tissue, separated from llic acini by the dense
«one of connective tissue previously described ; they oommuntcatr with
lymph sjiaccs and vessels running in tho interiobular bands of oonnectire
lÏMue; their shape is irregular, triangular, oval, or elongated, fi«<|uent]y
appearing a^ a «vparation of the connective tissue fibres, hut, upon do**
examinaûon, tla-y are sec» to have an external wall of connective tlanie.
KOSUAL niSTOLOGT 07 TU8 MAMH.S.
« tnidclle lavcr oonsistin;!; of vl^ry tlolîciitv vWlic tiwiio fibres rûtnmg ft
reliculucD, and «n iutPmal lining of rmlotlioliB) colU. R_v itivang of an
interstitial inji'ctiun vith rni8»iuii hliiv, tlii' fonn of llic lvii)|i)iatic»t inny
lip (Icinoiistrntcd. WIkmi itio »<'ction i* iniidc in the ijirectiim of tite
princijial vt^wls, Oic im';iiiliir liu'Uiinr spwes are seen filled wîtli the
lUJCL-icil âuid. Oilier i^wtion» :ibow canal» tilled witti the fluid which
orcHcnt a Ivadud apifcamiice, the conUrKlioun representiug a modified
tonn of vnlvc».'
Tho nijipU- and nreotn are peculiar in heing erectile and of a darker
color thiiii the aurrouiiditi^ Akin, and containiii); in their EtriK-ttirc iiutMr-
oua nntttriped muscular libres. The direction of ttit fibres in the formt-r
ia ohieRy lon^iiudiual, with intorsecting band^ ; a few long! tiidi mil bmi-
dles are aUo seen. In the areola thu c<iursc of the fibres is ino#tly cir-
cular. Nuroorona papilla; arv funnd in tho skin of tho nipple, aoine of
which belong to the raiicty known ne Itictilu papilln. kjcboceoiu glands
and hairs arc present in tlie areola.
No Mitiijfactory învoifti^ation of the norvou» ayateni of ihe mauuuary
gland lias yet hcvii mnile.
TItc firat indication <>f the niammary gland is seen ahont the third
month of intra-ntvrine life, con!>i«liiig of an ingrowth of cells of tho rete
mnciftum, surrounded by the fihrouH ti^uo of the akin. At about the
fifth or Mxth inontb, by a process of gemmation or budding, the nnli-
mentary duct^ of llie lobules are apparent, springin;^ from the central
collection of cella. These Imda are increaacd in size by a ci>ntiniiation
of the cell prolifcralioii, but as yet thcrp is do attempt at the develop-
ment of the secreting ncini. During childhood, and until puberty, the
increntfi in the number of duct« is very idow, Itnt at puberty, in the
girl, there ic a rapid increaiic in their mimbpr ; while in man, on tlie
other hand, there li no further ilevelopmeul, except, in extremely rare
caacii. there may even be an atrophy of the existing ducle. TIte begin-
ning at the formation of tho secreting structure of the gland, the aeïiù,
ia noticed in the femikle at puberty. Yet it is only during the super-
vention of the first pregnancy that the gland attains its full development.
The gland retaina tlua structural development during the child-bearing
life of tlio woman, becoming somewhat emaller in size and losing a few
of its acini during the period» of physiological rest. When the ineno-
pfttiM U reached there is an entire disappearance of the »ecreling acini,
and die ^and returns to its embryonic state, fatty tissue being suljstituted
for the glandular tissue.
niis ïiow of the histogenesis of the mammary gland, from tho rtte
mummnt, has been accepted by must liiatologislii. Keccnlly, however,
Charle.'t Creighton, of Oambndge, Kngland, in his work upon tho
Phyn'A'iijy and J^at/tulnif}/ "/ ilin BrMml. advaucea the opinion that it
Ù) not the epidieliai but the connective tisaue layer of the embryo fr«m
which this oi^n takes its origin. His conclusions, drawn from many
investi gâtions upon the subject, are as follows: —
" Ist. Tliai the mammary acini of tho guinca-jMg develop at many
sepante pointa in a connective-tissue matrix ; that the embryonic celb
■ l.al)b£ uid Coyne, "Tuinrars bonlgnaii iln («In.''
704
MAMUAKT 0LA9D.
from wliirb tlioj develop *r« of the Mme kiwi that give uri^n to At
siirrounilitig fat tîxâuv ; aiul that llie [irocesA of developnient of the aan-
jD*Ty aciiii n stop for step the same as that of the fat tobole*.
** 2d. 'lliat the ilucts of the mamma develop from the Bamc taatrix-
tiuoe iiv direct u(;;n^gatioD of the em))rvoiiic colls alon;; prc-<leU;n&iaed
littvfl ; llmt (lie ducta develop id the individual gniiwa-gu*; before tlw
acini, mhrruao, in the ph^logeootic eaocoMion, IM docta are » luer
acitiinitioii,"
From (he sarao writer wo have made tlie following extnet of lûa twmi
upon evolution am! involution of the ronmnia: —
"An examination of a glaud in tite nate of well-advanee'l inv
<rr raitiiig period, always pnacuti the dnots and bloodveiMeU vsiy <
tinctly. bceaiiie of the retraction of llie glanduUr subalance. !th« mintite
structure of the neini is of a ver; definite character, and oocurs witJi
^reat aniromiity, TiiL'ir nine is about one-fourth that of the acinut
dtirin;; lactation. Iiutead of the oelluhu' elements lining; the acini being
\ô to 2U, tlicre are only about half a doxen, and, insu-ad of forming a
ne. 33S.
B. r»n utittt of ■«• (torllr ^htt Uh «iI «T )ii*liil1«a, ncsDUllva or lk« «Hlkallani <■ *M>.
X *■). D. CrUt tram Ihs miinuii i>t ■ sit h1b< ritji »n*t iMMtUm ; lli« tubal* uMiiaKtf ihra •nil
rsUlanI II» 'oil tljaiBdnD. hul ll> «pllhalllt Mill ptCHaUd Ihi ■liomlM M •■•■ to tk* tmt,
nOMiie of polybedric cellM, tliey eon»titate an irregulAr «illcction of
naked nuclei s-aryin;; in Hh»pe— a certain number are oblong, others
«rescentîc or triaugulur, uitd the more round or oval «liow a nucleoltis.
<^. fig. 885.)
"The examination of a friand in an intfrmediate state, that in, durinji
ttie intcrvul bi-twi'i.-n full evolution and iromplâce involution, will jrtve m
the §te]ij (if the priKOii» through which involution îa reached. A inainnia
of a eat that ha<l truckled ita young for sixti'en day», and had then U-cn
kept apart from them nine days, upon examination, showed moat of the
NORMAL HISTOLOQT OF THK UAUHX.
705
ftnc4 uf »U occuj^ylD^
Ihs ctvltlrn or mc\ai In
an early Htn^o of Ihto-
Inliaa. X '"<'' t^'rom
[hfl Bnnj« Bl'Pclmeil A<
lobules to be as large as in the condition oî full evolutjon. The acini
were also of much the same shape and size as in the secreting gland.
But their cellular contents were very different. In each acinus were
found variously shaped cellular bodies, usually corre-
sponding in size to that of an epithelial nucleus ;
also, a number of ring-like forms of a grayish un-
stained granular appearance, with the variously
shaped cellular bodies placed on their periphery,
were seen. (i>, fig. 335. C, fig. 336.)
"The significance of these appearances is better
comprehended from another preparation. (B, fig.
ÎJ35), Here the acinus presents a profile view of the
epithelium, which shows the cells arranged as a com-
plete circlet adhering to the circumference of the aci-
nus. In many of the acini were seen irregular collec-
tions of cells free in the lumen of the acinus. In other
parts of the same preparation were observed cells of
which C, fig. 336, is a drawing. The cells in êitit
arc vacuolated cells, usually possessing Ibc thin and
mostly uncolored rin^ of the vacuole (?ignet-ring type).
Other cells undergoing the process of vacuolation are found. There is
thus a gradual transition from the perfect mammary epithelium to the
forms that characterize the various stages of the involution processes."
The secretion of the mammary gland formed during its physiological
activity is milk. Anatomically considered, it is a fluid in which are
suspended vast numbers of fatty
globules, in other words, an emui- ^'g- ^3'^-
sion.
Examined with the microscope,
there are seen numerous, distinct,
and separate oil-globules, varying
in size from 0.002-3 mm. to O.tiOOO
mm. By the addition of acetic
acid, the globules lose their indi-
viduality and coalesce, forming
large oil-drops; therefore, each
globule may be considered as a
minute drop of oil inclosed in a
delicate membrane of some albu-
minous substance, probably ca.sein.
Themicroscopicappcarancoofthe
fluid secreted during the last days
of gestation, or immediately afier
labor, the colostrum, contains, in
addition to the fat globules, other bodies, spherical in shape, from the 0.0151
to 0.0504 mm. in diameter, composed of a collection of oil globules, held
together by a cement, and sometimes containing a nucleus; they arc also
said to possess the power of contractility to a slight extent. These
bodies are known as the colonlriirn rorpunrles.
Frequently the mammary gland of new-horn children secretes a milky
45
^-r-n
0
70(t
MaMHABÏ aLAND.
fluid, in nliicli arc fonnd globules of oil. Tho bisiolopcal |i1ieiwaHnon
is tlie stiiDO as in die accretion of milk in wonieii ( Sînélj- ).
Milk ie sapposod to lie either a metamorphoi'ia >if tUv lining colls of
the xcini, or a produce of tleso eame cells wiihuut tlicir (le«truoti«u.
Tb« Utter view u mo«t probably- the corivcc one.]
V\Tao\jm:cAh Hiptoumt op tiik M-iumart Glakd.
h
thf
Lrtn-K lxFi.\M>HTi.is OR Mastitis. — Inflamtnation* ofthe owmnuiTy"
jion an; oxireim-lv viiriwl; tbi\v occur after delivery, dunag the fint
TreekH of Inctalion, or ».■> a result of coiitiisioiiH or tumor».
luflnnunatioiui of tlic areola of the nipple, eliappiii;; of thv akin, subcu.
taneoiia abaceMe* of tlie areola fre<]uentlT occur during the Itrat dttjra of
nuniiu);.
KrvHipclatous infiamniations of tlic skin covering tb« gland are fre-
(juenlly seen either duriof; lactation or in consequence of ulccratiuj;
tumors, and in the latter it occur» capccinlljf iu the lyinpliativë, recog-
nixed nith the nnatilcd eye by redncHu alon:; the course of th« aubea-
laiieous network of lyniplialicn. The erysipelatous inllammatio» my
1m! follotred by true Hiilwiitaneous phlei^niououK abwMses. Ilecumnj^
H»bcutaii«ou» lymplian<;iti8, due to an ulcemled carcinoma of tlio t>rea«t,
somciiino)! tomunatoit by a carcinnmnlouii degenenilio» of the wall of tJi«
1ymphatie!<, which are then tnuiHJonnfd into hanl and toniiouA eorih).
i'areiiehymaiouHor ^^landiilar inRamiuatioiu of the tniiuiniie arr deejwrt
and hejjin either by a retention of the tuilk, or hy a purulent inflamma-
tion of tho couneclivc tisaue which Bcpamtes tho lobule«. ITieso puru-
lent inflnminatione are generally seen in nursing and recently •Iclivered
womeu,very seldom tn pregnant vromcn.
The abflcoflses which t'oriii in tho gland arc at times rery nurncroos awl
often rccurring. They conUiin the rlenioiitM of milk, mixetl with lympli
cells, and, when ojicned, may rci^idl in a milk liïituia, if a itiuus or lar^
gulactophorous duct i« included in the supiiuraliou or cut with tlie knife.
l>uep or «ubmamraary aliitcess may he prtKluccil from the sauac cauM's ai
tlie proceilins, hy the extendîou of the purulent inflamouition tu tlie
loose oonneclive tiRsae whtcli acjiarates the gland from the Bbrous luoia.
It is certain that thcitc submaminary abscesses arc produced by ioSai»
mation of the Ivmnbatic minuses ana inucouu bureie ; pus rapidly collecte
in a sac beneath the gland, and raises it up.
Occanoually eubmummary abscesses lollon the course of cold aU-
flcCBses, antl instead of having for a cause an acute inflammation cxIcimI-
ing from ibo breast to the deep connective tissue, tliey follunt lesions
of the ribs or st^niuni, from scrofidous or Inberculou* curies, or frrnn
abscesses of the same nature which are developed upou tiie intenuil sur-
face of the ritw or Ktenium, mid which sul«c<iuently perforate the inlcr-
eostal spaces, aiHi project into tlie iuflamed submaiumary cuniiceUve
tiwue.
CitROXic IsPLAUMATiox. — When mammary abscesses recover, they
giro rise to indurations consisting of organiied conw^clive ti-uue of new
formation, which may increase in amount, and constitute filiroiu tumors.
LKSIÛS3 OP MUSCULAR V ALL OP TKE UTERUS.
R9T
fdro tsitlwT very liir^c or very Htiuill, ^ml llio eolla are niso «mall. It is
jfrolmMc- Unit the tiiic» nrr rlfvctiii'nt rrom tlic ciitn-de-sac of tlic glniuirt of
llkt nock of the iili'nw, tmt tlii» in not o-rtnin. Tlie ti««ue *<!j)aralîtijÇ tlie
Itiibcs cotiùi^ts of the (itim-miisi'iilnr tii«^ito of tlic uionttt. Tlie^ epitlieli-
lematn arc reproduced willi their i;linracteri.4lic structure in tiie glands.
An wcondary nodiilea, located in the fi h ro- muscular tisaue of the iitenis,
tor uiwn iw jieritoHOal auHaco, and in nodules developed in the layers of
Jthe Madder and upon ita mucous surlace. But metaalatie nodules of these
epitheliomAla, situated in or^ana distant from the uterus, seldom occur.
F We have «ever seen them, but they havo been reported by other patho-
logists, especially Virchow.
Ulceration with jt« sevend can»C(|ucnces. especially gangrene of the
Filtered part, is the mnn- in epitholiomata as in cureîiioinata. In pave-
neiit-ci'iiod cpilhelionm, the diKoaaod part of the neck may entirely tlia-
iipl>ear. The neijrldiorinf; organ* are neither so frequently nor m ex-
tensively inhltrntt'ii with tlie new formation as in carcinoma. Kpitlielio-
mata are apt t» he taken for a simple pha^fidonic ulcer. The latter Ahould
alwaya be carefully examined for IraceH of epithelioma tons stniclure,
' nth u{Kin the vaginal surface of the tdceralion and in the pelvic and
lumbar iflanda.
The different varieties of carcinoma and epithelioma are usually do-
"oped at the time of the menopause or a few years later ; yet they have
nt ohsened in young women from twenty to thirty years of ago. The
[tumor !•( the cervix does not prevent fecnndation. parturition, or delivery,
iftcr delivery the lc:ûon of tlic uterus progresses with great rapiility.
B. Lksioss of Tns Fibbo-muscular Wall.
The fibromuneular wall of the uterus generally escapes involvement
I'lD catiirrhal inllammation, and it is markedly alfecled only in puerjieral
1 inflammation. The veins are attacked with inflammation, and ahscemea
imay bo developed in their wall.
1 Lesions of the uterine wall mostly consist in a new formation of
'smooth muscular and fibrous tissue, whiuh occasions either a general or
i« local hypertrophy of the wall. A hical hy|icrtrophy when .«harjdy
limited may be regardai a» u myoma. The diffiTent form» of diflused
, fibro-mu-fcutar hyjiertrophy of the wall art- included hy many wriiera
I under the name of parenchymatous metritifi, which U certainly not a
' good term, since they arise ^ttenerally by a slow proce,ss, consisting simply
in a new formation of smooth muscular fibrea, Virchow considers this
growth as a hyperplasia of the uterine fibro- muscular tissue, which is a
much botter name : and he describes it with the myomata. There arc
jaccording to this author two varieties: the one soft and resembling the
Interine wall shortly after delivery, a condition due to its vascularity and
|kbundance of muKcular fibres, and the softness of the connective tissue;
he other hanl, compact, not very vascular, and containing numerous fusci-
îuli of denae fibre*.
Ttic*e varifitte* of local hypertrophy often follow delivery, • ■ ' "v
[vhen the neck has been torn. The subacute inflamiuntion ft. ■ . :^
eh a traumatism, the new formation of connective tissue, and Ibe active
698
FALLOPIA» TUBES AND UTSBUS.
nutrition of tlie pnrU all retard or prevout ttio fittty (logei»nti«ii, ul 1
)ilro[ihy of ihc mu»cl6it, and occasion a Bbro-iuuscuUr h;pertrofA; «f Éï |
neck. I
Sim|>sflii cnnaidora the changes of the miiscidar fibres dnrinj; mè
httet ^eslitlion of grmt importance in tliu vxplanation rjf j^-nvnl m»!
local hypertrophies and atropliiefl of the utcnis. In the foniu>r, 4«
Binall fiores hrpcTtruphied by the ^MCiticm n^niain ««, or, at letM. ihw
ntropliy or iiiiolutioii i» ini|H.'(ti-d: in the Intt^T tlie phyeiological alr«<|^]r
cuiiliiiiif», enuxin^ a patholojiical, gcnvml, or toonl atro}>)iy. Tli'u in-
gcniotiii rievr may vxphtinn certain number of caMSiOKiMtciitlly in ppinni
or liiail hypertiiiphics following delivery. It h nho true that (Hre-irxiiitiii;
niyoinatn of Uie uterus may inoreai«e very rapiilly after « |>rcg:iiitDc;.
I'teritie niyotnata, bon ever, arc obaerved in young jtirl^, orin women wh"
bave never had iicxual couin'Ction, or have never borne cbiblren. Wri
rcjtardB the fonnation of inyouiaia aa a result ol" activity of the menu
while tlic organ is deprived of its physiologieal function, which is isest*
tion : for example, when married women do not have children. Yet loctl
and pencral hy{>«rtrophieft of the uterus are also seen in women «b«
have hud children. I>ocal hypertrophr of lb« vaginal portion of the
neck id very freituciit in multipara. Tlie lî[i« of the neck are la^s^■,
irrt'^iiliir, and bo«m'latcd upon their surface. The hy|H!rtropby m«j
oceiir «pon cither lip, jitring varions «hatieslo the neck. Tiw mticoos
mem)iraiie of the cavity of the neck is changed: it has l<Mt its cyliixlrictl
e]nthelium and is covered by kminuted pavement eclU. Generally there
«re seen, uynn the uttered li|«, ovula Nabothi, or fold», dcproMions, ami
nnull cavitiea, or sacs with elevated |wriJlions, vhicb pre the ap[*eanuice
«f a hypertrophied tonsil (Viruhow). The rancou» membrane of the neck
assietfi lu the formation ot thim hyperlroiAiy by the development of tiM
ovula Nabothi : but liypertrophy of the lips has also been seen, in the
sliajw of elongated tiesby pmloiigutions, projecting even from tbc orifice
of the vagina, and covered by a thin mucous membrane with pavement
cells. The vaginal [lortton of the nc-ck may be gcncnilly hypertropMed
to snch HTi exu-iit as to caiwe n ]>robip«iis nito the v*giiiii us far as the
vulvar on fifC. Jlut ]>rolap«us is more IVivjiieuily ca«»e<l bva hy|»eiTrophy
of the entire cervix, the supra-vaginal fwriinn m well as it« vaginal part
This mode of hypertrophy of the neok froipiently ooctirôi; tlie cenix is
then very long. an<l projecia into the vagina either by an elongated or
by a eluh-shaped extremity. Id these cases, the uterus may remain in
position, and he of normal size, or its body may be hypertrophicd as
■well as the neek. When, however, the body of the uterus ia nonunl in
sixc, it may be drawn into the prolapsus by the weight of the ne«k. ITiis
hypertrophy of the entire neck has been met with in women who hare
never earned children. General hypertrophy of the whole uterine wall
is not so fre<pieiit a lenion as loeij^ hypertrophy.
M^omida an; the mo.^l fre4uenl, almost the otdy, tumore which hare
their origin in the muscular wall of the uterus. They con.ti.'tt of famiiculi
of smooth muscular fibren, interiiecting each other in every dinrclion. A
general de»cri|)tion of this class of tumors has been pnn in Part Kir^t,
wlilch we will not again repeat, as i[ is eijually applicable to tb« iitcril
HYOllA OF TUB UTERUS.
699
mvomata ander consideration. We will give only the peculiaritiea of
their development, seat, and anatomical consequences in the uterus.
Maicalir eelti Trom & IMo-inToniii. A. Celli ■ep^inli'd bj tha ulJon of nllrlc «Id, W p«r rtaL
B. A itririnta iMtloii colored vllh «rnilne noi Iresled with icelic lold. m. LouKl'adloàLljr cnt, m,
tnbivAnvlj cat oafilAl. t. CanuflcLlva-tLMna earpqeclai. iU^h powen
They begin in the muscular wall. They are generally at first very
vascular and sofl, later becomin^r indurated in consequence of the
fibrous organization of their connective tissue. Sometimes the intra-
parietal tumors are very small, round, and ijuite hard. At the beginning
the fibres of the tumor are directly continuous with the neighboring
fibro-muacular fasciculi of the uterine wall. By their development, these
tumors project either upon the external surface of the uterus, when they
are covered by the peritoneum (aubparietal tumors); or upon the internal
surface of the uterus, when they are covered by the mucous membrane.
Frequently they are pedunculated in such a manner as to be united to
the wall, either by a large and vascular or very narrow pedicle. Myo-
mata projecting into the uterus are frequently called fibrous polypi. The
subperitoneal tumors, not being impeded in their growth, acquire a
very large size. They are usually multiple, even when of considerable
size, and very often there arc, at the same time with subperitoneal
tumors, intra-parietal tumors and polypi projecting ïntc the cavity of
the uterus; at times they are so numerous as to cause a change in the
Bhape of the organ. It is also sometimes difficult to find the cavities
of the uterus, owing to the cavity of the neck being entirely cut off
from that of the body, by intra-parîetat myoraata projecting at the point
of separation of the two cavities. The several degenerations which
have been mentioned in Part First, as occurring in myomata, may also
occur in this class of uterine tumors, especially the subperitoneal. A
carcinomatous metamorphosis of a uterine myoma has been seen by us
in a case of carcinoma of the peritoneum. Virchow has also observed
carcinoma in a myoma.
Myomata projecting into the cavity of the body of the uterus are
either hard and fibrous, or formed of a softer muscular tissue, redder,
more vascular, and having largo vessels; their ablation gives rise to
hemorrhages difficult to arrest. The former of these intra-uterinc polypi
sometimes occasions considerable and repeated hemorrhages of the mucous
TOO fALLOPIAH T0BB8 ASD BTBBDB.
membrane. It ia Beldom that a poljpus of this variety is developed in
the wall of the cervix. When a polypus having its ori^nic the body of the
utorua projects into the neck and passes through the lips of the os uteri,
ltd mucous membrane ia changed, becomes thicker, and is covered with
pavement epithelium. The projecting portion covered by mucous mem-
brane soraetimea is red, inflamed, and ulcerated. The mucous membnne
is entirely destroyed in spots varying in extent, exposing the muscolir
tissue. The neighboring mucous membrane forma a sharply cut border to
the ulcer ; it is red or red-brown, and much inflamed by contact with the
irritoting fluids of the vagina.
SOHUAL mSTOLOGT 07 TBE ItAMMX. 701
CIIAPTEK YII.
MAMMAItV nLAND.i
'NoBMAt. lIiSToLonv, — 'riic mamnmry gland» arc orgw» common to
li M'XCit, but it i» only in ilie f<;iinili', iiml at tln> cmi of sMtut'"". lliat
boy reach llii-ir ]>erle(;t jtliysiolDgicHi ilevt-lojimont. lu the niiik! l\w»c
orgniiA re mam— except in very ran* intttanccm — x.4 ru<liincii1nry iilrucliires,
n«ver nttaiuitig that pUysiolo^cnl or histolftgiL-al {loi-fectioti met nith in
the le ma le.
The group of glands to irhich the manim)» belong i» the rncemoae,
OP it is better to describe each glaiul as consUtiiig of several race-
mons glands, since it does not empty iUicIf by a single duct, hut tborc
are found opening upon the summit of the nipple fiflot-n to twenty
Ditnnt« canals or galaHnphorous duett, which are the outU-ts of as many
racoDioiu cflandx. Tine collection of glands or lobules ii> surronmled by
B nui«s of adipi^ise tiMue, and the nipple is the only point where the
^Lgliiiidutur «inicCitrc i» in immediate connection with the i>kin. Here and
^uimlei' the arvolu tliei'C is an abfonce of fatty tissue, and instead of ;t
^Bborc is foaitd a layer of smooth inniKitlur fibres.
^B FoUoving the conme of the excretory ducte into the gland from their
^PD])enii)g upon the nipple, they arc tieen t» dilate, at a point corresponding
^to the base of the nipple, into sacculated receptacles known as the «(<■•
ûitli Iti'^iferi. Occasionally recurrent branches are given off under
i^e areola, which collect the secretion from the small glunduliir bodies
liu this location ; ihcBp glands, however, may have their own cxcretitry
iucts which open within the areola (OlandulsB abcrrantv» of Mont-
[gomcry). Below the dilated portions, the excretory ducts ajçain bo-
wme narrow, divide and subdivide until they ultimately terminât* in the
'vesicb.'S or acini. Sepamtiii^ the lobules we have the fttroma of tho
gland or the peri-iuhnhir aixl |ieri-«oinou» connective tbwine. This eon-
n<'cti\e ti.-'.-'ue is a continuation of the snU'iitaneon,* connective tissue,
and like the latter contain.^ in itii incHbe.-) tiie adipose tissue of the
lland.
The histological structure of the excretory ducts ia distinctly seen in
[a transverae section, Kxtemally ttie wall ol the duct consists of fibrillar
aectiTc tissue, the fibres having a circular direerion, and interwoven
iritii this layer are elastic tissue fibres; no proper muscular layer i»
present, but scattered, smooth, muscular fibres arc dencribed OS existing
in the connective tissue ; implanted ujion the wall of the duct i« seen liio
iuiiig epitlivlium, conai^tiug of columnar shaped eclU, and separated
' On KMonnt of the iinpir.rlan*i^ of lliin orgnii In pntholosisal Iitftotoirjr, w* liu»»
firritl*« a ninro «'xIhkIviI ditci i|>ik.ii v( lit tii>ti«!(ij:y tlmii ihai givuo \jy Coruil iiiid
lanvkr.
702
UAMMAItT OLAS».
Fig. 334.
t^tlj «iinad»! aalRa* of
Uf |Kl]rb*dit< >)>Uh«tlllIII.
rrom tlie flurrounding connoctiro ù«ute by une or more Iftyera of enflfr
ttielml cell».
I*as5iiij^ to tlic «rcrviing pdrlion of the glsti^, tlii' };landu]:ir rej^irla
tit sciiii are sjihi^rical or iiyrilViiro in shape, 8c|JiiraUHl out- irwrn ilit
utiier \>y the |>eri>aciuouH connecdre Ussuc, »nd are surrounded l>y tb«
inviiibrÂim propria common to jilunilatar BtructuroH. A M-'gtion »croM an
acinii^ dcnionsiniU-s the floor to be lîufd bv &
laver of polyhedral i*piclii-Uiil colU, vonLninitii; a
central nucleus, av«nt^ii^ iiliDut wno-tliird of 1I14
entire breadth of the cvW. In a profite view, ai
mar b« m>en at tbe (lei-iphery of tUo «ection, tlM
celb arc fotind 1«> b« oblong nr cubical, liariog a
height about one-hnlf their breadth. A-* the cells
a[)proacb the outlet of tbe actnuti lliey gradually
assuKie the colmiiTmr <<h»pe, rcaonblin;; to a ceiiain
extent tbe celU litiin;: the excretory duct. The
cavity of the aciniu is tilled with fat i^lobulea
and débris of cells. Examined durio;; lactation
the acini are foond to contain the elements of
milk deposited betnecn and wiihin tlie epithelial
cells. Br removing the lining opitln-hal cells of
tlic acini, there i% seon a re<^ilar arrau^-tuent of
delicate fibres, forming {wlyhedric Atpnces in which tbe biiocv of the
epithelial celt» were placed. Itelwecn tlic lining epithelium and the
riiem\>rnTin propria lit a single layer of very (bin eiMlotiielial colli.
Immediately ouUide of the aicmbrana propria is seen a very delieate
clear zone, in which the cells are very few op verv indistiiwt ; external
lo this âtnicturc exists a eccoiid layer, consisting of a tissue in wbicb the
cells are more numerous and arran;^ed concentrically to the acini, having
tbe appearance of a second membrana propria to the acini. The connec-
tive tissue nature of this layer is evident from tbe circumstance that
there is observed a gradual intorminglin^ of its tissue with tbe fibroM
trabcculiu, which form the framework of the gland.
A varying number of acini are grouped together into lobnlea. Tbe
latter are wparated from each other by more or Iv.tA thick bands of
fibroiLi tift-sue, usually containing fat.
I'he blood supplied 10 tbe mammary gland corner from the snbcataiicoiu
connective tissue vessels, entering at the under surface of the organ ;
the larROst puss upwards towards the nipple, giving off branches to the
several lobules and ducts. Both the acini and ducts are found to be
surrounded by a capillary system, which is particularly distinct daring
lactation.
1'lnr lymphatic system of the raamniiiry gland is pepR-scnted bv a
number of lacuna; or lymjihatic »]iaees. lliese lac unie arc sitoalcd in
tlie peri-ncinou» connective tisHUC, separated from tbe acini by tbe denae
«oue of connective tissue previoualy described; they communicate^ with
lymph sjiaeea and vessel» running in the interlobular liaiid» of connective
U*suc ; their shape 18 irregular, iriangular, oval, or «longau-d, fr^-inu-titly
appearing as a sejiarntion of liie connective ti«i(uc fibre», but, upon close
examination, they are seen to have an exienial wall of connective tisane,
a mUMIc tarer conaixliu;; of v«rv delicate «liuitic liasuo fibres fonDÏn;; a
rcticuliiin, and an internal lining of endotholial cells. lï_v moans of an
ioter^litial injection with I'nissian Wiie, tlu' form of the Ivinpliatic^ may
tbc dcnioiistnited. When the section ie made in liic direction of the
prinei|>iil vcsacU. the in-cfudur laciinnr spaci-s arc Been tilled with the
DJected Ruid. Other scetioiis ïliow canulii filled with the fluid wiiieli
cut • beaded a)ipciirance, the coustrictiuus repri-gcntiu]; u tnudificd
of vftlvta.'
Tiic nipple unci areola are peculiar in lieing ertsjtile and of a <lnrkcr
ulor llinii the i(iii-n<ini<liii;4 •«kin, and containiiij; in Uieir Hlriiclinr ninner-
; uiiiitriped mnicuhir iihre.*. The dirfL-tiini of the fihre* in the former
liietiv t»n^iliidiniil, with iiiloisectiu}; lutiid.'* : ii few louj^it.ndintd bun-
)les are alflo seen. In the areola the coiirxc of the fibre!) i^ mostly eir-
^oular. Numerous papîllic are found in the skin of the nipple, nome of
which belong to the variety knotrn as tactile pnpîllœ. HehaceouH glands
^»nd h«irs are present in the areola.
^f No sadsfactory inveattgaiion of the nervous system of the mmnmary
' plaiid lias yet been made.
I Tiie first indication tif the miimmury gland is seen about the third
^■montli of iulnt-uterine life, censi^tin;; i>f un in};rowth of cells uf the r/tn
^^mumgum, surrounded by the fibrous tissue of the skin. At ubout tlie
fifth or itixtli mouth, by a process of ;;emination or buddiu);, the nidi-
mentary duct» of the lobule» are apparent, ^'prin-jinj; from the central
collection of celU. 'llieiu! bmU are increiiued in *h6 by h coniliiuatîou
of the cell iiroliforatioii, but as yet there is «ii aitt'mjil at ll»^ develop.
mcnt of the accretinjt acini. During childhood, and until puhertv, ilio
increase in the number of ducts is very slow. But at puberty, m the
jirl, there ts a rapid incrotise in their numbpr ; while in man, on the
ioiher hand, there is no further dcvclopment, except, in extremely rare
TcHw», there niity even be an atrophy ot the existing ducts. Tlie begîn-
lliiug of the fcinriHlitm iif the secreting structure of the gland, the acini,
lis noticed in tlie fciiiiiU' nl puberty. Yet it is only during the super-
Tentinn »f the firi^t jiregnancy that the gland attains its full devLdopmeut.
The gland retains Uiis Mtriiclural <levclopment during the child-bearing
»life of the woman, becoming souii-'what smaller in size and losing a tew
of its acini during the periods of physiological rest. When the meno-
pause is reached there ia an entire disappearance of the secreting acini,
^ and the gland returns lo its embryonic state, fatly tissue being substituted
Hd'or the glandular tissue.
^^ This »iew of the histogenesis of the mamtnary gland, from the rett
mKCJifum, has been ucei^'pted br most bistologists. Recently, however,
Charles Crcighton, of Canibndge, England, in hts work upon the
I'll }f *{'/('> ffff ati'l I'ath'jlvyn of the BreagI, ailvance^ the opinion that it
i» not the epithelial but tJie conneelive tissue layer of the embryn from
ishicii this orgiin takes its origin. His conclusions, drawn from many
I inve^tigation.'i ujx-n the subject, are as follows :—
" 1st. That the mammary acini of the guinea-pig develop at manv
[separate points in a connective-tissue matrix ; that tiie embryonic cc lu
' Labbi and Coyuf , " Tumour* Wiiijpies du «wia."
lOi
IdAUMARY QtAXD.
from H'liicli the; <tov<>lo|i arc t>r tbo Ham*.' kiiMl that give «rigin btk
suriMiiitiliii;; fat tissue ; and tbal tiio firocc»; of di-vvK>puiuiit of die tsaa-
mary uciui is step Tor steji tlit- snaie as dint of tho fat lobulbi.
" 'itl. 'I'hnt tlic «inclH of tin.- tiiuntiiia develop fmin Uie satou nairù-
tiiww) by direct «^^^regation of tli« embryonic coll* aXonj^ pre-detcnBte-l
lineti ; tbat tlio <iuct« dovolop in tlie individual guin«a-pig In-fuiv tU
acini, wlicriiu*, ia the ]»IiyIogcnctic «uccc^t^ioii, the diicu arc a liwr
acuiiisitioii."
From the «ame wriler we have iuad« the following ostrn«l of his vitvt
apou evolution ami invohttioii of the mamma: —
"An examination of a gland in tlie Btatc of woll-advaiMMxI iiiroluti'in,
or resting period, always preaonta the ducts and hUMMlveiwcl* very di*-
tinctly, because of the retraction of the glandular substaitce. The miuut»
structure of the aciui is of a very di-Jinitu chanicier, and occurs with
fjrcal uniformity. Their gxso ia about "m'-fourth thai of the ocîuu
during lactation. Instead of the ccUiilnr cleiiiont.'* lining the acini bciu;;
15 to 24), there are only about half a doxon, and, io-itead of forming i
n«. 33S.
B. fmui iidrinr at •»•< •turtlr allir tba (DJ of iMUtlOD. TinAluU» *r the «ylUalUw U HI*,
y *w. D. Cp||> froni ihi> BiKibuin uf * »l olu* inf tn*t Urutiun l tli« Ivlinls Ma)«liili« Ik's «II
nialDDd lu full aiiNtaitun. liai lu f|.llhfl>(il cflli ff'Mtri ilm aliaialWa M mm la lb* cu.
X^« f. jirt>-«'«B<*'>'*>>K>«iluwiiii>Wit. X'^- (t"-"#Af*it.)
inonaic of polyhedric cells, they constitute an irregular collection of
naked nuclei varying ii. shape- — a «eriain number are oblong, otliers
cresceiLtic or triangular, and the more round or oval show a nucleolus.
{JÇ, fig. 885.)
" The examinntion of a gland in an intormodiate state, ibat is, dnring
the interval l)eiwi.Tii full eviihitioii and com]det« involution, will pive ns
the «te[)8 of the ])r«ccs» through which involution is reached. A mamn»
of B cat that had riuckled ita young for sixteen days, aud had then been
kept apart from them nine days, upon examination, showed most of
the I
NORMAL HIRTOLOQT OF TRK MAMMA.
705
lobules to be as large as in the condition of fui! evolution. The acini
were also of much the same shape and size as in the accreting gland.
But their cellular contents were very different. In each acinus were
found variously shaped cellular bodies, usually corre-
sponding in size to that of an epithelial nucleus ;
also, a number of ring-tike forms of a grayish un-
stained granular appearance, with the variously
shaped cellular bodies placed on their periphery,
were seen. (i>, fig. 335. C, fig. 330.)
"The significance of these appearances is better
comprehended from another preparation. (J5, fig.
335), Here the acinus presents a profile view of the
epithelium, which shows the cells arranged as a com-
plete circlet adhering to the cireumferencc of the aci-
nus. In many of the acini were seen irregular collec-
tions of cells free in the lumen of the acinus. In other
parts of the same preparation were observed cells of
which C, fig. 836, is a drawing. The cells in tilu
are vacuolated cells, usually possessing the thin and
mostly uncolorcd ring of the vacuole (?ignet-ring type).
Other cells undergoing the process of vacnolation are found. There is
thus a gradual tranaition from the perfect mammary epithelium to the
forms that characterize the various stages of the involution processes,"
The secretion of the mammary gland formed during its physiological
activity is milk. Anatomically considered, it is a fluid in which are
suspended vast numbers of fatty
Fig. 337.
fcbpfl lit ceJl acrui^ylDg
tliv CK¥lLti^bor «clnl In
lulloD. X -■*»■ (flora
Ihe uiDC apoclLDea «■
S.) {Crflglitu»,]
^■^l-'^-l
00.0 -*■
■s a
0
globules, in other words, an emul-
sion.
Examined with the microscope,
there are seen numerous, distinct,
and separate oil-globules, varving
in size from 0.0023 mm. to 0.Ô090
mm. By the addition of acetic
aoid, the globules lose their indi-
viduality and coalesce, forming
large oil-drops ; therefore, each
globule may be considered as a
minute drop of oil inclosed in a
delicate membrane of some a!bu-
minouB anhatance, probably casein.
ThemicroBCOpicappearanccofthe
fluid secreted during the last days
of gestation, or immediately after
labor, the colostrum, contains, in
addition to the fat globules, other bodies, spherical in shape, from the 0.01 51
to 0.0564 mm. in diameter, composed of a collection of oil globules, held
together by a cement, and sometimes containing a nucleus ; they are also
said to possess the power of contractility to a alight extent. These
bodies are known as the colostrum rorpv»cIe».
Frequently the mammary gland of new-born children secretes a milky
46 ■
!•
ïiMM;^^
colon Ira ID corpuidfla^
70A
IIAUMARY OLAKD.
BuUI, in wtiich arc found j;Iobuleâ of oil. The liUlolopcnl |)li<niaiKt(it
U tbo sitniu US in tLi' sccreliou ofintlk in womcu (^iiiéi^).
Milk is Bupposvd to V' i-iibor a nictainorplioHts nf llio Uniii;; ctll» ((
tlic iK-iiii, or x product of tliese sbdk- cells wilhout thvir desmclMi.
Tho liiWiT view 18 ino«l probably the correct onc.J
Patholosical Histology op tub Mamjiahv Glasd.
ACCTK lN-FLAMUAT:t>N OH Ma5TITIS. — llllIllRtmittioiM of till' nOMtti;
rrgiou are extremely vnried; th«y occur aft«r ilulircry, during (he fait
uerki* of lactation, or UA a rwult of coiituaioiu or tumore.
Iiiflammalionii of the areola of the iii|ipl«, «bnppiii}; of Uie skin, subcii-
taueous absceaaea of tlie areola frequently oecur during (be first dajiof
nursinf;.
Eryaipclatouâ inflammalioi» of the skin Goverin;; tlie gland are tn-
t|Uonily Hoon cither during lactation or in eorueifuonoo of ulocntiu^
liunora, and lu iJie latter it occurs especially in tlio lymphatics, nn/f:
nixod with the unaided eye by rodtiess along the coura<^' of the aoW
tnneouB nutwork of lympliatic». Ttie erysipelatous intlammatiou aij
bi- followod by true nulicuuiiteuus pblc^ionoi» absoOMCs. Recvrritij
Kiibi'utaiieou» lynipl)ai);;itis, due Uy an ulcumtvil carcinoma of (he breut,
Mmeiimcs torminautn by a carcinumatoux dcgenerittion of the «rail of tbt
lymphalioA, wbioh arc then transfornK-<l into hard and tortuoiw conU.
Fa re noby ma I ou A or (^UmluUr infiamniatioiwof ibe umiuuiiv arc i)ee|>tf«
and bej^in either by « reMntiou of ihe milk, or by a )>uruloiil iafluuM-
tioii of the connective tissue which separates the lobules. These pun-
lent inflamniations are generally seen in nursing aud recently delivered
women, very mldoni in nrcffoant women.
The abscesses which lonn in the gland are at times very numorous aoj
often recurring. They contain the elements of milk, mixed with lympli
cells, and, when opened, ntay result iu a milk fistula, if a lûnua or Inrvt
gnlactophorouH dtict is included in the suppuration or out with (he knife.
l>eep or Ktibmamniary aVocw may be pniduced from tin- .-Mtiue vausc« m
the preceding, by the extonston of ibe pundent inlliimmation to tlic
loose connective tîs:iuc which aepnratcs the gland from tlie fibrous fascia-
It ia certain that these submaiumary alKtcesMa arc produced by inJUm-
mfttion of the Ivmnbatic sinuses and mucouH burste ; poa rapidly collects
in a sac beneath the gland, and raise» it up.
Oûcosionally submammary abscesses follow the oourw of cohl ab-
toes^o*, and instead of baring for a cause an acutv iidtaiumation exleuii-
■U from the brea«t to the deep connective tissue, they follow lesions
Wr the rihd or itternum, from scrofulotis or tuberculous caries, or from
abecosacs of the Aame nntnrv which are developed upon tlie internal sur-
face of the ribs or ^tcnnim, and which subsemiently p«.!rforat« the iutcr-
cost«l spaces, and project into the inflamed eubiiiuinuwry coiuiectjvv
tissue.
CnROXic iNFLAMM.vTrox.— When mammary «iMMKa recover, they
give ri*e to indurations consisting of organixfil connective tissue of nc*
formation, wiiich may increase in amount, aud constitute fibrous tumoiA.
TtlHOns OF THE UAUMAHV iJLAKD.
roT
The raiMca of gcucnil clironîc iiiflMDOMttton or clirontc nustitia are rery
obscuTv. Ttienp is Tormod un BlMtomial amount of fibmiu Umuo, mmI a
gciicml iitiluratioii of nil thv iicw-formed titwiiv wltidi si'[iiir»tvs tlu) ttdni.
Thù anutoinkitl alterutioii is uftoii coufouitd»! with gviivral hjr)>vrtro-
pliies or with fibromaut of tlio j^and^.
TuuoHs OF THE Mamuart Olan».
The essential his(oio;j;icaI etiaractcrs of tumors of the mammarv jjlaod
have been descriWil in l'an Kirst. under tumors. We will here con-
sider their fjencral history, an«i complete their descriiiliuii niiicroscrtm-
cally and micro&eopicaily. Tuinora of the breast occur almost exclusively-
in femali's, bu; may also uxveptioDaUj be met «îtli in niu1c«.
GSVERAL îlTPSRTRoritv OF THE Maidiart Oland. — l'h«r« m>m«umes
occur», ulttioujfhaoldom.conHidvrabk' liyportrophy of tliv mammary ;:1nii(Is
in young girla afUir (mlicrty. or in young women roiisevutive to nariuri-
tion. Both bnasts may be affected at the same time, or ouly one. Xltc IctV,
more freiiuuntly tiian the right, may aluin an enorruous sixe. The coDStst-
ence of the gland is normal, moderately firm in young girls orduring getla-
tion; when the hypertrophy has existed for some time in young women,
the gland liecome^ soft and flabby ; to palpation it gives a sensation of
lobuwa which are movable. The skin is normal, or sli^^htly ihickeneil,
but not adherent. The glands in the axilla are not enlarged. L'pou
section of the gland, tfacr« is seen a ^ray tissue, with yellowish lines or
lobnlM; but there is no juive. Microscopic examination of the tissue
hIioks an abundance of connective tissue, which i« denae around the
iobnU-s of tlie glnitd. Elastic tissue also is found, 'llie canaU and acini
of tlio gland are eitber lined, aH in the state of re«t, with nmall cclbi
forming a single layer, or, as in the first months of gestation, their cells
are larger and granular. In every ease ihe canaU are elongated, in
order to keep pace vith the hypertrophy of the connective tissue, but the
alteration is principally a fibrous thicl>emng of the connective tissue, and
not a leeion either primarily or principally of the epithelium. Sometimes
there are lobules of fat in the gland, but generally they are not present.
Manse obser^'od that the galactophonjus duels were much dilated, so
much so as to receive the extremity of the finger. Hypertrophy of the
mammary gland consista mostly of a new formation of hbrcius ti&suo. In
most connective-tissue new formations, the glandular ducts and acim are
dilated : this dilatation is analogous to that of the biliary ducts in cirrhosis
of tlie liver. By the same prOMM, small cy»U> may form from the n'ten-
tion of the glandular products, when a galactophoroud duct is isolat«d in
the middle »f fibrous tissue.
GALAcrocG[.B. — Galactocele is a tumor caused by the accumulation and
retention of milk in a part of the mammary gland, eitiier at its centre or
periphery. Its development coincides with lactation, and it may spon-
taneously disappear after the cessation of this function. 'Hie milk is
either normal, or curdled and creamy ; it is contained in a single sac, or
partitioned by bands, (pvinjj it au alveolar appearance. The sac com-
70S
MAMUARÏ OLATtD.
tnuDicate» «îtli » numlwr of »ecr«tmg lolxiles. From tlir (lc»cri|itîoa nî
tlieae tiiinore whk'li )iavc been piiMUticil, e;t|>cci»llv tlint \>y Kor^t, il
Heenii thnt the evMic sac id noilittij; roi>re tlian a itUate<l j^nliK^topliorous
canal, wbîcb caïuiot diwluirgfi by the uîpple the milk it coiiUiiua.
Sarcoma. — Tumors of thU class vary in bîm. TIicj- do i>ot at their
beKinnin;; aJliorc to tUc tUtin, liiit Iat«r ther hoooine attached, and, &ii a
rule, they do not infect the neîjiliboriniî lymjitiatic glands, llie entire
, ninuiinarv j^land may W implienu-d, aitd ttit-n- tg a very large tumor, or,
I for a lung liiQO, only a liuiited portion in afTectoil. In tJie former case
I (lie dcvclojimuiit of the tumor if untfonD, the skin itt Htretclied over it.
Ronivtiiti^H ndliereiit; in the latter, there vxiitt one or more tumors, wbieh
]live th« glaud a lobulat«d appearance. A flection of the Uiinor, after ita
removal, ))n.-»enls a .-«oliil, uniform, gray maiw, w ilh nome viwirular jxirtione
Acattered here and there ; older partit ar« ycllowisli in confcijut^'nce of a
fatty ;j;ranular degeneration. There are jiUa '«eeii several dijititiet nuuwc«.
aejiarated from each other hy 1cm chaii}:od portion» of the gland. In the
rinorc altered portions, the glandular tubes and acini are ofïen pre«vr\'cd:
they are hT|)ertTophied, hue not cTStie; frequently the acini aro waatiu);
in those ]>ortiouH, which are devclopcil only from the connective tmat
and peripheral mliposv tii-suo of the ^tund«.
When the fHirv pland is involved in the new fornuition, there U an
incr^aitcd fonnatiun of epithelial cells, a distension and lillin;; of the
dncts 'ir fcatactophoroiw siiiuiic» with fntty (ief;eneriitcd eclUJiavin)! Ihe
ap];etirance of milk corpuscle.t. More frciiiiently there w found a mucoua
Huid. Cyatâ are often olcerved in Mieh case», or rather arborescent cicfu
representing cavities and acini into which the neighlioring urcomaious
Usdue buds {(ov Histology see Part First, page 81).
Flu- na.
tqUpaelBBi •plalla-nlUd hcwoi* at aimnti} |U>d. ibovlDg (b« dfaloiMJ mIbI IUH «ilk
Tfltgv'alid ||luidaJ*r*pnb*llan)< lll(l) faovr. ICnIfUvn \
Sarcomata of the hreast are very easily dîstïn;;utshe<l from carcinnniata
by the entire absence of the ccllulu-adipo$e tissue — it hai; been iran.'-
fonned into su rcomatouï tissue — and by the lymphatic glands of the axilla
not being infected.
The most fro<pient variety of «Brcoina of the mammary gland is en-
cephaloid ; tiw f:ucicular sarcoma is aUo of fre-iuenl occurrence. Thede
MYXOUA 07 KAHUA.
709
tumors oflen return after ablation. When a cjstic sarcoma has been re-
moved at the first operation, with the entire breast, the recurrent formation
)8 found to be a sarcoma without cysts. This is explained b; the whole
of the gland being removed at the first operation.
Secondary sarcomatous nodules of pleura, lungs, bones, and otiier
organs are somottmes met with at autopsies of persons who had been
operated upon for sarcoma of the mammarj gland.
Myxoma. — Mj;comata of the mammary gland are not unfrequently
seen ; they differ from sarcomata only by the nature of the tissue com-
posing them, for their situation in relation to the glandular acini and
canals is the same. Cystic myxomata are tlie most frequent (for His-
tology, see Part First, page 89).
Klyxomata of the breast are essentially benign tumors ; tliey do not con-
tract adhesions with the skin, and at times may be completely enucleated,
appearing as if contained in a serous membrane which separates them
from the surrounding tissue. In a case recently seen by us, the large
tumor, a papillary myxoma, presented in its deeper portion large masses
situated in a serous cavity, one wail of which covered the nodules. We
Fig. 339.
■^%iU;^
tf<!S0ln11uQV, HLkJi power. {L^lftbi a.o i Coyne. i
had here to do with a large serous bursa, the anterior wall of which be-
longed to the tumnr, while the |>03torior wall was in connection with the
connective tissue situated behind it. The cells upon the surface of this
cavity were thin and Sat. From this arrangement we were led to think
that this serous membrane was the serous cavity or large lymphatic
lacuna situated beneath the breast, for it was impossible from its location
to suppose that it was formed by galactophnrous canals or glandular acini.
It is very probable that the clefts and cavities into which the new forma-
tions of fibromata, sarcomata, and myxomata project, are not only the
TIO
UAUUART ola»d.
F<g. UO.
galiictophoraiu duels ftinl tiuinimnn' acini, hut rrc<|ucntlT ilso dit ljrtii]>h-
Btic luctiDte ileooribcd by OiraKI^) aiiJ Cojik (mco p&gc IST).
FtHRf'MA. — Amnng fi)>K>iniita nay correctly he c1it»M-<l f^rn-nil liyirf*r.
troptiy of tbe inaounury gliuul, Kiiw? thi- irrholc of thv new formation i*
fihmti» timuc. Tlier* «l^o exist filiroouu
in whicli Uie bronat ii* of c<>n:4Î<)cmhIc
liardneftA, and tml lttllvi^ntnr)^il. Inatoail
of Wtnt; jteoemi, filiroina of iho hrea^i taux
)k- limited to a [iikrtot' the ffland. iin<l furni
a tumor varying in »\ze, gcnernllr -hiuII,
hard almost Atony, and Itavin;; no intinuite
adhi^sions lo the neij^hboring tiasiica. Tliew
tumors have th« same amn;!ement as sar-
oomabt »nd myxomata in romani to the
glandular ducts and acini. (For Ilistiln^
«ec I'lirt First, page 01, and figs. ;{:('.), ;!4o!)
SrpnrLl? — Apparent srptiilitic iDdnrS'
IJotis of tlie breast have Wen met «ith.
whifh have dtt4iip]>carvit with anti^yphilitio
trefttineiit, there have tx-on no histidoi^c*!
examina tinn.s of theiii> loMmiit. Wv know
of no exam|>k- of (uArrWi'« occurring in I
•ant tyalic; IVty «n c.*0rDi] bjr Uielr
•|4lk*tl>iin «I t,*R4 ■» d*iiad«d at II
■1 It ; A, HautMlf a ili>n< coipuirl».
mamiDary gland.
K
CAitcrsoMa. — The several varietiea of
carcinoma urc- met with in tlie mamiaary
«land, occurriii^ ne a primitry Ivsion : acir^
rhoti;t, cncephaloiil. and c(>lh>id carciDotna.
h'ilf'Kt nr »eirrh'>Ht earnnoma be^ns
by a hard generally sinaM t«mor followinj; a different course acconlini;
to the case, 'niii.«, it mur extend with great rapidity, beeomin<;udhemri
to tlie ektn, invadin;^ it an<l presenting hranching proceMi*j<, or it may
extend in ramifying; and anastomosing lineti which are due to the ctii-
secutive change of the superficiiil lymphatic vessel» ; at other time» there
are Heen small nodules developed iu the subcutaneous cellular tiwite and
in the «kin. We have twice seen very largo and hard Ivmpltatic veMcl»
raising the skin, and extending from the ttnnor to the axillary gland. A
microscopic examinatioD in one of the cases proved that the periphery of
the lympnatic vessels througliout their entire course consisted of a ear-
ctnomatotis tissue with alvcoti and characteristic cells. We have alreadT
indicated the connection between the lymjihatics and the aivcoli of cann-
t]oma (sec p. 101 ).
Iq THpidiy growing (ihroiui mrcîtioiniila, the tikin la not only indurated
in #mall patches, bnt also aa deiiHc hand» : the opposite breast in iU luro
laay be invaded (enni^er en nurattf of VvIjx'aM), and goncraliitation of
the tumor gradually nccnrs in the pectoral inii*cle*, in the fihrmis tJMue of
the axilla, in the riiitt, in the intercoiial uiii»clei<, in tbe pleura, lungs, etc.
In a number of cases, e9j>ecially in old «oin^n, the »virrhui« is atrophied.
CAIICI50UA OF TUB UAMIIA.
:n
Th« tumor remains siniatl. (lie brosflt uliri veiled, the nipple retnctod : tb«
axilUry glanda are mrnlvcil, liul onlv after four or five vcurj orlonj^cr,
anil there are observed neither secondary nodules of the skin nor sciwrnl-
ixation in ihe internal or^au*. It ia the eeeondarjr fvrnuitii>ii!< whicli
cause dealh. The cancerous nodules found in tlie organs and tiiMuci' are
remarkable for their smallness and hardnf!>s, and vrhich b_v n c»rclc)is
iiakud-eyo uxumination roajr be confouudcd with tubcrctdftus grauulaltonj.
Pis. 341.
,^f^
àW};
»
CartI D<>Biii nf nimiii«TTilÉn4— (h»(ninn4 •nhiiiDri. nf ill* MOllot «ulnrit ttllh DllrMrot •(■■».
n. A1<«>1^ ^f tha rtKHLEtErmih hWvt vlih cvILk. fr. Lyiiapb *piic«a iihitwa \b Iha fllirnii» Utao* «Avr
IrtnlJdtdl br iiUr»t« of tll¥«r^ ^. L/uiplLHIIcA thovlnit >t1t*r «UJqJdk uf Ul4 «nilottiolluiii.
Wben atrophied Bcirrhua ulcerates, whicli frequently happens at the
munkeu, retracted, central portion of the tumor, there arc seen, upon sec
tion through the borders and base of the ulc«r, the phcuomena described
in part 6rst under inflammation of carcinoma. (Sec p. 106.) Tlie uU
cerated and inflnmed part siiows a lar^e innM of inflamod tissue. It»
borders and buKc presvnl alveoli,- thickened oonncctîve tis-me, and cell-
clumps of cArciiioiiia.
Fully developed mammary «cirrhuK, upon «ectio» preaentjt, instead of
a smooth, white, and .«lightly juicy tissue, thfi Hinuwii of large gnhcto-
phorous duct» ftllvd with a yellow iith-wliit« fluid, or with an 0)>aip)e yel-
lowish or brown caiteouH material eonaiating of fatty granular celU. The
ilitet» of smaller calibre are al»o tilled with granular epithelial cells, an<l
are recognized by the unaided eye as arborescent lines, which can be
followed aa far aa the periphery of the tumor, I'pon thin section» ex-
amined when fresh, it iaseen that the glandular acini arc filled with large
cells provided with a large nuclcoa and nucleolus. In hardened tiuuors,
sections of the central or oldest portion of the formation show tlio ducts,
distinguished by their enveloping membrane, coutaiuing upon their inter-
nal surface large cpithcloîd cell» arranges! in several layers, and at the
centre of the duct, in its luiucu, a eollecbon of fatty cclU distinct from
712
llAUMAHT OLAMD.
tlio liiiiii;; eptlieliuni. Tin- pre-oxistin^ Diaintiuiry acini and c(mticctiv«
tissiiv lire ImtiH forint' J into carcinoiaiitous alveoli containing larj^u cvlU.
At lh« ]>eripherj at the tamor, in iho imrts mora rt^untlv attoclceil, tbc
c)iiitif:;<-8 in iJiv glandular itnd connective li^suflM mav )»! foflowvil. Tliu«.
al^ii^Ki'le of A normal glamlular lobule, the cvlU of which Arc unlv
|lliglill,v sirellon, ant) llie iici»! larjccr tliitn when in li hUIu of rest, an
on luWlewi the aoiiii of which are iliscciKli'tl by IttrjEC finely grnntilar
CcIIm poiwcMing large nuclei aixl nucleoli. 'llieiM? aciiii fltill retain their
enrelo])ing membrane. The t»l>ule, ao chanced, hecoiuoii much largvr
than the aurrouudinx lobuleLi. At the came time the ]>eripheml connect-
ive tissue liae itji cells more distended and tno/e numerous than nonnal
irilh proliferating nuclei, and the lymph apaces are filled vitli cell») of
ll>ow fonnation or 1jrinp]> colla. The coitnective tiasue is transforrued into
tcarcinomatous tîssno, by the new formation of cellular elemental in it«
cavities. Id time the membrane of tlic acini dt)Utp{>earR, unit all the
rreiitinting tifi^uo ia riddled with alveoli filled with larj;u cclU. The
ymj)hatic vettseU ara in their turn involved and contnin tlie same ele-
.rnoul*. (Fig. 342.) When the Hoirrhii^ in old, the fibrous tiseuv is
PlE.342.
Pi«. 343.
II(TMe|i»»'"IunlaDUBU tliiRitnaM- «. tjavi SclnIwB*aK4atM*(lb>raniUI-r*Mi.
tftetr ubub ■ulMina l>r ilia miiiUfllcill"!! ■•( ibalt Tbt Jimlliw aiFunnnf iIh ktcui iiixm-
ctlla ; ale. Ibtj havo vmotrid limit aniiii III fonn: at picj hf nnoasJ railftna ■mnr* at aa-
4, ibiflianb'aaiitatrliadetlaiidfgruiilifnlliaaliMU tttaUit nIM. X *">■ (Oi«<#&ii>i>.)
•(outlining. X UCL
very thick and the alveoli are small. In the central part of atrophied
carcinoma tliore exista a fatty degeneration with atrophy of the ccUa;
the dense fibrous tissue aUi> oontain.* fatty ^ruunlcs.
In this variety of carcinoma lli« lyinpliutie ;;lnnda of tlie lixilla
alwaytt indufutod. They are frc<|ueiitly cliaii^^ed into fibrous tisme («
page 175); the connective tissne in tiie axilla, which accompanies the
nerves and vesaels, is also extremely hard, and presents at [wiut» car-
cinomatous alveoli, and especiaUy a new fonaauon of deiuse fibrous tiBsuc,
^ CARCIXOXA OF THB HAïlVA. T13
whidi compresses Uio vessels ami ncn'<!B, iott-mipting tlic circiilatiAn in
tlic urt«ricâ. which arc filled nitli organizLv) thrombi; tliv pwnibraiic of
the arteries is folded toii^ituditmlly.tlieirviilthrc is coDtntctcd, sikI horms
tjmcs entirely oUitcritlt'iI ; thus iiii a'dvmu of tlto ana i» caused. Tlio
jeripheral tnd of lln; ci'mf>n.^**ed nerve» i» in a staW of fatty dogenera-
tioii. The axiUurv IviiijihntJe {rlimdâ, ntuiolced willi cnrcinoiuH, shovr
tlint the tunior is deveU>j>ed in the mesihei* of the reticuliuo; in the small
iDedieis of t!ti* reljeuluin thfl cell» are much larger diau Irmph oorpuaclea,
and there arc two or throe cells in a mesh. Those cells )>o«aeeiS a distinct
gniiitilar |)r<ito|ila3n), saturated with fluid and contain oval nuclei, re-
aenililiiii; the cells of tlic tumor ; tlioy are rery probably the Hat celts of
the reticiddtod tissue, swollen and proUferatod.
KnftjihahAd carcinoma forms, in the breast, tumore generally \xr^f.T
than the preceding, and {^rowing more rapidly. The skin, in time
invaded and thickened by a new formation of embryonic or eareinoniatoua
ti»uu in its deep laycm, shows upon it« surface enlarged papillie, in-
filtrated with lymph cells, and eonutininj; lur^e re)W.*U. The^e changes
of the «kin pri'cede llie ulcerations. The nki-m. cuventd with very vas-
eular granulations, and spreading to a varying extent, fre<|u<-ntly give
rise to repeated henorrliagvoi >iC liniea CAnsideruhle. Hemorrhage may
also occur in the hard variety of carcinoma, hut i» always more frecjuent
and more abundant in the ^oft (eucephaloid) fomi.
A eeetiou of the tumor presents a i^oft, viucular, grayish-whîte tiesne,
and yields a very large (jtiantity of milky juice — posse;^inf;, in a word,
all (ho chani(-[«râ of enL-cjihaloid. The development, the extenmn to the
neighboriug tissue and to the lymphatic (glands, are the same «.* in
iFcirrhus, with this diflrereui.v only, that thu new Itssnc alnyiys has the same
ebamctors as the primary tumor.
Colloid carcinoma is not so frequent a» the preeeding varietie».
t'illmiê Ciirrinoma. — We have «everal time» aeen a tumor of the
mammary gland, which re»<niililed a carcinoma in its mode of extennon,
ita infection of the lymphatic glands, and its generalisation, but which,
however, differed from the preceding varie ties in tta histological structure.
To the unaided eye its appearance doefl not perceptibly differ from cn-
cephaloid carcinoma ; njion section there flows an abundant milky fluid,
and there are seen caviiies and cysts nhtcb arc <)uite large, measuring
OD»-lialf to two or more millimetres, which are filled wiili a milky juice,
and contain dendritic filaments. Some of these open cavities arv only
galactophorous ducts filled with vegetatiou», which may be easily detached
witli a needle. These dendritic vegetations, removed and stiuiicd with
piero-carmiiie, show under the micro«cope a very beau^ful bntuching
arrangement, 'l^ie princifial trunks divide, fonning long divided papillte,
terminating by free, elongated, or eluh-nhapod extrf milieu ; all are tra-
TorM^d by capillary vewel.*, which terminate iu loops at the extremity
of the pniùltH.-, and are «urrounded hy a very small amount of connective
tissue. They are everywhere covered with prUunatio or cylindrical cells,
fonning one or more layer»; die first layer is implanted perpendicularly
u]K>n the surface of the papillae, and Uie cylindrical cells forming it arc
pressed one against Uie other, elongated, granular, dif^tinct. and provided
with an oval nucletu. Tlie more superficial and detached cells are larger,
i
714
MAXUART aLA:<D.
Lpnsfintic. or polygonal, more distinct, and Kiivf n inor« swollen and
Murgcr nuclou», mid oni? or inon* Urgi) mmlei. The latter cell» liecurae
[free in th« fluid contnined in ihe cavities, and invlerjio fatly granular
[dej^tiomlii^n. Ky Htndyiti-: «lection.* Tmin hanleued ajiecimcna, tlic vUl-
f 0U« TP^i'tatiotw are ^ceii itii[ilaiitc<l n|ioti the fibrous wall of these cavities,
and growiii;^ into llieir interior. The internal anrface of llic cavities i«
lined with the saine variety of cells as the vegetations. The majority
of tlie cavities are dilated galactopborous ducU, filled with ve^i-tattoii*
which jTTOw from their wall, and extend along the canal, which tliey
{lartly fill. The ;;landular acini experience a cyetîc enlurgeinent. their
wiilU covered by epithelial cells arranged u in the canaU ; and tliere
also fret|uently exist vcgctntions pnyecting from tlic wall int" thf cmity.
The galactophorctiw cnnab have a dtdtiiict «aU. and the neighl">rinic
connective tissnc hatu its fibres Arranged cnnucntric around lUeai. lUit it
is not Uiv Kume with the acini, the hyaline memhmne of which disappears;
J thoy arc «nrroimded by a connective tissue transformed into alveoli whieb
> are filled nith Inrjçe swollen colls havin;; a lar^ ovat nucleus.
These tuniorii may he oonsideri-d a* ei<itiioliomala. This ojiinion is
lisaed upon their jimlmhle orijjin from tlif surfaee of the gahiei'iphorou*
canals, and from tlie shajie of the cells resembling those of the cylindrical-
celled epithelioinata. Vet the infiltration of the neighboring connective
tissue, changed into ahcoli containing large cells, resembles carcinocu
more than cylindricaUceUcd epithelioma, in which the epithelial fan&a-
tion^, when tlicy invade the connective tissue, have the form of vylindrinl
tu!jes ennliiininj regularly nrrnii;;('d cylindrical cells. For tlie^c reawiiui
ve have phiced the^e tumors ainon^ the caroinnouitn. llum-n'r, this
variety, like sevtml other mammary tnmor!«, is not yet îtalîsfactArily under-
fltood. and further invesli;^ation is necessary to determine ttieir exact
nature. We cannot too strongly recommend to those making a claasîfi-
calion of mammary tumors, the examination of the tumors which return
in the ciciitrix after the complete removal of the gland, for (hey give
rooit iraporiant information of the nature of the primary tumor. iTie
degenerated neighhoring connective tissue and lymphatic glands shouM
also be carefully examined.
From the foregoing deseriptionx it is svi-n, that in fibromata, myxomats,
sarcomata, and carcinomata, the initial lesions in the gland and excretory
ducts of the breast, have a grent mmhi^v ; for example, in nil the«
tumors vcgelatiomi grow into the intfrinr of the gataetophorous ducts,
and cysls have their origin hy the distension of the ducts and acini.
Tliese cysts and vegetations are not. therefore, cbaraclcrislic of any
particvdar tumor, and in order to determine the nature of the new foro»-
tion, examination of other portions must he made — that is, of tlio co»
ncctive tissue, which is in each changed into a special tissue.
Enciios'droma. — The encbondromata of the mammary gland %rc ren
rare tumors; a few only have been reported. In a specimen met villi
by Wagner, there were found cartilaginous masses in a carcinoma.
Cnlcnroo us or osteoid indurations may he met with cither in au en*
ehondronia or in nodules of fibrous tiHsuc.
i
CYBTS OF THE MAUMA. 715
Adesoua. — The eharacterj of adenoma of the breast have been ;;ivca
ill Part First (see p. 161). They were for a long time eonaideved by
Ve)peau as synonymous with benign tumors of the breast, among wliîch
«ere confounded fibromata, my.'iomata, sarcomata, and true adenomata.
Melanotic Tumors of the Breast. — See Part First, pages 329, 330.
Epithelioma! A, with pavement cells and pearly bodies, are seldom
met with in the mammary ^land. Tney occur especially as a new forma-
tion, having its origin from the skin in the region of the nipple, where
are found numerous and large sebaceous glands. These tumors do not
differ in their mode of development or extension from epitheliomata of
the skin, and especially those of the lips.
Cysts. — The cysts occurring in adenomata, sarcomata, fibromata,
myxomata, and carcinomata, have already been described. We have
now to consider cysts due to the retention of the secretion of tlie galac-
tophorous canals and acini. Their causes, as yet not welt understood,
have been associated with the partial obliteration of a duct from the
fibrous atrophy of involution of the gland, from cicatrices following an
operation upon th ' breast. The majority of se ro- sanguineous cysts are
associated with tumors, such as sarcomata or myxomata; yet they may
follow contusions.
Several cases of dermoid ciftt» have been reported, especially that by
Velpeau, which should be classed among the dermoid cysts of the first
variety (see page 304); another, reported by Albers, contained hairs in
the midst of a sebaceous mass.
Hydatid c}/»t», with eehinococci developed in the connective tissue of
the mammary gland, are aho of very unfrei^ncnt occurrence.
SECTION V.
PATHOLOGICAL ANATOMY OF THE SKIN.
CHAPTER I.
Seet. l.-Normal Hiitology of the Skin-
TllE skin is formed of iwo la,vera, lite e/'iiitrtfn'» iitiil tl-'i-ina. Tlic
eiMdcrmtH consist» of cells uiiitoi) as in other e|iithclia l>; nii iri(t'rc«lliiUr
cvmcDt, and arranged in luypra covering the surface, «ml dcteIo|>cil from
the «xternal or corneous luyer of the blasto<lon».
■nllOB or tb* bUalndanii at ui amlirTa flff^l boB» «n« lucubdJu». A. BflMwl or •■ureal U|«c
B. MonlilaM 4>r mldilli Itfti. O. llfimbUw or Itiwa*! Ujtt.
The derm dovclopcd frcim the mid<ll« layer cODsii^ts of ivtniicetivc tTssa«.
Il contains the ve*si-|i mi<l inost nf the ncne torniiimliim» of tlic ^kia
In tliis iiK-tnlintiif arc to Ih- ttiiilifil thi- Mali'iyhian rrtr- mucifum amt
conuouf rpidfrmit; l/ir tieruia ami fnpiUot; the vettel»; fAf jwnw
and the tfiuRd».
A ■ El'iDTTRMii). — A vertical :<octi<ii) of tho Kkin shows the ii«|»U» u
inegiilar fe»toon« eovereii with tin- cell* of the Malpi)i;htnn rct« mucoHum.
The ci'll!> til the laver next tu the [iti)>illii; are prismiitie orcjliiMlrica], snd
arc im|ilante'l perpcndioular to the navy surface of Ihe dt'mi. TlicBf
prismatic cells have at their hase iiiik'iitaiîons or notches, iulo which art
]. laced prolongations from the derm; upon the «ides lliey art joiiicl with
the adjiiceiit cells hy extremely fine serrations, which fil in corre.tj Hindi n^
itotvhesof the neighboring cells. In this deep layer U depoi9ite<l around
the nncici the ptjiacnt which gives Uie color to the skin. Above ihc
layor of pHi^matic cells is found the retc muoosum proper, ooDst^ting of
several rown of iwlyhcilral cells, wilh vesicular nuclei surroaoded by n
bright mine. At their (wriphery the cells are indciitHtcil.or have spinous
procesiiea which unite them to similar ncighboiin^ cells. In tliia maouer
DOKMjIL DIBTDUT of THB KPtDKKMta.
ri7
tlir ilotitatc or spinous cell» of tlic ret« oiucofiirn sccra to be so|>arat«4l
from oiw stioth«r by »n ititonitttiiil u«mci)t (KitUul-sUitie) fonDcd of
)>ri)liaiit grnntilfis Avjmrnteil nt înlrn'ale b; tl>c spinous procvsses whîcb
are iiiit(«<l u> encli otlicr in tii« mitUlte of Uio intvrcvllular spucc.
Vlg. 3411.
V^rUf^tl it^t]m> of tli0 ÏIUIA1B l' lu r Ill Imynr of «tiJiEiriLiiij». *i i -iiamw hiriilniB.
j/r. (trmlnru «rmualnamn. i- Rrir mtiei»din ■ail ptj<llUrf Uf rof fjr^u*^^'''-^^ rvlli f VkfILJ* ■>'
aklB. il. Tuitllo (vtimxlt, f, «(tiiHuat iiliiiil. /. lUU-lalb. p BiMIor-pIll. Jl. ConTolultgi)
ut >«rai«t>i<d. <- PirlDim tatiiuiels. J. Panulcolui idipiMa*. t. Tiieiila) loop. L«w«t p<«w.
Pulljr iIlkjinUBinsIlc- (AvkHnp.)!
Between tlie rctc mucosum nmt ttic i.'i:ïd«niii ; there exists a special
lawyer; it ia the rtratum 'jrayiutntum, un'l is formod of cloudy cells loaded
with allmminoug jTranules. I'icro-coniiine colors it deep r^^d. 'llie cell*
which form it are without spinous prr>ccs^s, their imclcns appears percep-
tibly atrophied, and the body of the cclU is loailcd with numeroun ^ranuloa
which are deeily colored with carniim-. Tliey are feebly united to one
iitiothcr, and conâiitute a I'lightly rewKiant Kone hotwcen the rctc muco-
tVitn snd the ttratum luridwi, whi>*e cells arc firmly joined together.
Imnifdiaicly cxteroal to the tliiii granular zone is n transparent none,
the stratum lucidnm of Scbriiu, «onùtting <ri' several layeri of very thtu
< Oni ibnnlti art, dan ii^ Dr. llnhHiii Tor lil* muMniy In pcrRilKlnfr Ihn qiip of ililii
*xc«illr^l rcil, fnnii n (trawîiiB r>{ Dr. Vîiti lliirlinp!ii, in adviuirt- of il» apiiMraiii:* In
tbi> avwDil alUi«ii at Dr. Tfalirlng'a trnrk on tliv tJihi.
L
718
TOaL ASIATOIIT OP THE SKI».
boiDosi'neoiifl transparent i-pithdml Males, in Aome of winch traces of a
alnff-iili»]>i-[| nuuk-us cnn W- K«c*n. Therefore, when tlicrc i« oMtgj^rated
pressure \i\iou liny part of the «kin, ncting from without iiiiriird!> or within
outwunls, tlic epidcrnii» i* ruadil y «oprirnte<) from (ht-f^Dulnrxiiir.niKla
ve8t«Ie in prodncvd. Laiij^rhanK iiM n-ciiitly o»n«iiIere<l the gntnulnr et-lU
of thi« n-f^nn iM embryonic celU, from which tin-<Uveh)tkMi tliecfU.-* of the
cpi'U-niii", thu deep portion of the rele inuco^uiu having no part in Ibn
process. Thi» hy|Hil!i<^*it is wron;;, hecause the jii-osreftaivo atrophy of
the nuclei may he followetl in tlie epidermu: layer, and the conicoun
layer i» rrurnrui«d, as will be shown, wttb ^al rapidity when tbe granu-
lar wine hiifl been raised by a vesicle.
7he nuist auperfiml layer is the corneous epidermis, diRcrin;!; in thick-
ness iM:cnrditig to the rt-^ion. l*]>on the surface the protoplasm of the
cells ifl dry, is tran»r'>mtL-d into kenkttn, and t)ie cell« arc reduced to thin
plat4'«. which hcoome gra>lu»lly thinner, and fonn «trntA. tlie euperim-
posed layer* of which are iiittiiuiudy united together. When the e"r-
neouH celU liave been maconttcd by jiotasra or «umwnia, they are MCit
to bo polybedml, cxtrenwiy thin, frei|uently riiowin^ iroprewtions of the
ndjnccnt cv]U, and often having at their centre only a rudimentary nnclei».
'riiiît iiiipn-nition present» the fonn of rectilinear ridges, which project ta
dîReront ilirecliona from the siij>erior and inferior surfaces of the cells,
h. Okrma; Papii.l.'K. — The derm consista of connec^re tiaaue which
has the uppcarance of a dense and resistins; membrane. It supports Uie
layers of the epidermis, and contains the ^nds and vessels of the skin,
as well as the nerve tenniimtiiHiii. It is fonned of eonnectivc tissuA
fasciculi, unalogoiis to tho^c «f tend'»), whiuli intentect each otbiT in
rarionit directions, forming superi»i|H)!wd layers. There «re i» it nun».
roVu elliptic fibres, anaatonux^ing so a« to form &n eloDgated network,
embracing tb« connective tutsue fascionli like the nie«he« of a net. la
the jxapilbe, thin elastic network is especially ahundant, and in part con-
stitutes the solid stroma of these eminences. The pa)ûl[fe form under
the rvtc mucoHura a series of regular nipj>le-Iike projections, being more
or leaa pointed. They contain loops of capillary bloodvesseU, and a few
nerre tenui nations.
C. Vessel» axd Nerves of tue Papili.* axd Derma. — Each papilla
contains one or more loops of a capillary bloodveaee) which a^cen-l
verticjdiy in its substance in order U) form n tuft. Tlie afferent arteriole
below tbe base of the pApilla subtlivide» into capillary branche* which
aiui.-tloiiio^e. and form» inuncdiutely beneath the epidcnuie, without pviie-
traliii;* it, numerous loops. The cflerciit veinule anims fnno li>e capil-
lary loop» of tlie piik]>il1u nnd follows a course parallel with tliat of the
arteriole. Jtene^lh the papillary zone the superficial veiiu» aod arteries
form a longitudinal network with elongated meshes, frocD which are
Terticnlly given otf the vascular tufts of the [lapilla» and anastomosing
branches which run through the derm and form a communication between
the superficial network and the arterial and venous trunks of larger
calibre which occuny the deep jxirtions of the derm, and which snpply
tbe network with irregular meshes which surrounds the convolutiotu of
tbe sudorific gUnds.
TB8SEI.S ADD NSRVKS OP TAB SKIS.
719
Tlic Ijfmi'halir iv»»tU of the <li>riii are ilirideil into intra-ilermie fatil-
larùt uiitl imalt 4ei-/f trunk*. Tlie ca)jilUrius orig^nxtc in the aU'lIale
clefW fonuixl l>y tliv HcgianitioiiH of Ùie inlorsectiiin oonneclive ùssuv
faACtciiIi of tliv ilvnu»; thcj arc liiuilcd Ity a fine clastic network, aud
arc lintil witli t'liiliMliclium.
Thfife cu pi II aril" It aiipear to communicate freely w itii the moshra of th«
<icrni; they are nothing eU« than ihc gle1lat«il si>aci's of the coiiiicctiv«
tissue L'haii^cil iuio clefts and channels to form tlie lymphatic ])a*wtg('«.
These [lawagoA have s. distinctly cannliciilar form nl tin- bouiularics of
die iteim ami subcutaiwoiis adipose tirauc. Here the «mull Iym])hiitic
trunks are Acen passing obli<|ueLy into the deep portion of thu dorm, from
f If. 34T.
'V///;
''■■ p
r. VipAll bvrt* of Ibfl fiiiplllt.. 4fr tt* Iwo brLLebei
tmùatng ^n «pic*! Tt>IU 4r<>aTi<l (bo cvri uhIo. '.
Afrfnl IcnilniilK-u «r une of Ilio It»—. U. Jl IditllD
Vlg.^M.
» Piriilnn fjijiEifls with iM tjHtm gf
TApaDlra ■nil <Ml(r»l CAVtlf- 9- XH^tltA
tv^ï. A, Klbrudi ilft'dD Vf ib« ttam vn-
lattgtA frùfei th* bpQr1I«nma. n, Park
«IUIC4. ad4 «xi'D'Ung «lo»( the axi< ra
ih< appoalia rBil »btn li In tisi] t/j ■
inbFNnUT nlarffant, llt«b iHimi,
vhich they continue into the fat or follow the fasciculi of the connective
tissue which separate the adipose lobules, or are insinuated between them.
A transverse section of these passages is not now alellatc in outline, but
circular, nod the lymphatic begins to form a true vessel provided with
Tulves, not differing from other lymphatic vessels of small calibre.
t90 PATHOtOflTCAL A!fAT'>MY OF THE SEIX. V
Terminitti'in* pf Xenvv i*i (Ae .S'friH. — The «onsorj nerves t«rininftt«
in Bpevtal budics [ilnvvd in Uio skin: the taftUr rorpaaften and J'ai-inian
cor/mxt-IeM. Lnnj^i-Huma hna âi*cn vcrj finu nerve librills pusin;; be-
tweoii iliv cHb of Oiv rcU> mnc<>siiin and cominiinicntiof; wit)i i^li-ltnte
Corjiii«tli.*»i »ait(cr*-d here ftnd there lielwevn liie «ptiinn^ cell», fonnin;; a
nctnork siiiii1.-ir to itml ile^crilicd l>v Cotinhcim uh existing in tliu rpîlhelîuiD
(pf the Cornell ; Ùnim iiiveKtigalioiii» hnv« ticon cunRnned bjr Pmleopagir
Kud 'I'oitwa.
Tlie taelile oorpiii«cli» are found in tlio papillic wlierc they «re !><•[»-
I rtte<i from the rencln enly liv biindlcn of eonneelivo ttwite fMcieuli
They are in immediate vicinity to the deopent Inyer of cell» in the me
mtit-oAura, and eoiiAJai of an eiilarj^mciit, rihujicd like a fir cone, fonoe^l
of trniiM]iaretit cells ( l.aii^er)ians) so united as to leare no eaivity al
the centre of Ùw cor|>uiic1e. At the base of this smnll orpin is seei)
a nen-« fibre, tbo intcraninilar segments of which gmdnally boome
shorter. By spiral turns tliis n«n-e passes around the cellular m.iss
icitliout penetrating it. Detneen the H]nrs1 turns of the nerve fibre
pnivided with it* nicdulliiry «lieiith, upon the surfncc of the c«ri>U!K'le.
fine filnnienti nre seen, whieh )ui^» around irregularly like ihrvadn n|>ou
a bo)>l>iii. These filaments arc protMibly of a ncnnus nature, an<I ;;ivo
rise to the characteristic tntiisvvreely striated appcaraucv of tlic tactile
corimscle».
The tactile corpuscles may lie formed of a single segment or super-
imi>ose<l se^^inents; they are found frefjuently double or triple. Kiteh
rUgpient is fonn«d in the «nme manner m a simple corpuscle, and récriiez
» special ner^e fibre (Thin), fre<|ueDtJy coming from a single oerre,
vfhich is bifurcated or trifurcated al the base of the corpu«le at the point
of an amiular enlargement (tlanncr).
D. Glaïtds or ths Sk[X. — Cntil towards the frud of tfa« third month
after conocption tbc surface of the skin baa remsinetl perfectly Km«>.>th.
It then assumes a definite »rmii[;etiient ; the connective tiwue of the
derma forms numerous granuialiou'» mhich elevate the rete mucostini and
develop into the papil'ie, while buds from tlie rete roitcovum sink into Ike
derma to form the tAiietou» fflanJ», the êvdvrijie jflandê, and the hairt.
Seharfftiit Olandtt. — Ordinarily these glands are, in pairs, atlachc^l to
the haira which they lubricate : they are wanting in places where liie liair
doea not exist ; thev are inclosed by a bnâcraent membrane which rej»»-
8ent« the superficial layer of the derma. Within thid tirat layer are seen
one or two rows of cubical cells implanted upon the basement membrane,
llie cells of the central layers gradually undergo fatty transformation,
»« tliat in tlie centre of the gland there is seen free fat or epidermic cells
in tiie procei>4 of granular fatty degeneration. The sebaceous glamts
are aurroun'ied by u network ol' bloodvcissels with narrow meshes which
envelop them like tlic meshes of a net. M
Sudonfie Gla»d$. — Theae glands are developed from epidermic Iruda
or granulations which sink vertically into the derma, and ndi themselves
into a glomerulus or convoluted bodr. 'Hiis latter ia aittuitcd in tJiu
CEDBMATOUS INFILTRATIONS OF THE 8KIH. 721
deepest portion of the derma, in the midst of connective tiasue surrounded
by adipose vesicles and capillary bloodvessels. Later a cavity is formed
in the tube, which in a section of the skin of a new-bom child is seen aa
a narrow lumen surrounded by a row of distinct prismatic cells, implant«d
upon a thin wall. The excretory duct ascends vertically into the derma
and reaches the eptdennic layers through which it passes in a spiral man-
ner. In its dermal portion it is lined with cells similar to those of the
rete mucosum, and in the fœtus these cells, like those of the rete muco-
Bum, are loaded with glycogen. In some regions the duct is provided
with smooth muscular fibres longitudinally arranged. The sudorific
glands seem to play an important part in the development of a number
of cutaneous lesions.
8eot.II.- Œdematou Inflltrationi of the Skin.
Œdematous infiltrations of the skin are of two kinds, and include;
Ist. Simple œdema, which simply consista in the eftusion of an albumin-
ous serum between the connective tissue fasciculi of the derma. 2d. In-
jiammatory œdema, caused by the accumulation of lymph, containing
coagulabte fibrin in the interstices of the same fasciculi. We consider
these two forms of œdema in one paragraph, although pathologically
they correspond to two aeries of phenomena essentially different.
A. Simple Œdema, Serous Infiltration of the Skin. — It is known,
that when the pressure in the capillaries exceeds a certain limit, diape-
dcsis occurs and œdema is the result. The increase in pressure may
take place from two causes: either because the passages which carry off
the fluids are not free, in consequence of a venous obstruction ; or because
the contractile vessels are in a state of atony.
It is to the latter cause that primary œdema of the akin ia due. The
elevations of urticaria, and of papulous erythema, are nothing more than
small points of circumscribed œdema. They are always accompanied by
extravasation of blood. The fluid poured out at the time of the diape-
desis, always contains a number of red blood corpuscles. Hence, in
cutaneous œdema produced by the paralysis of a nene, the akin at the
location of the lesion sometimes has all the colors of an cccliymosts, and
the papulse of urticaria, for example, may have a hemorrhagic character.
This variety is dcâcribed by Willan and Rayer ds purpura urtican».
The papuiai of urticaria are a type of local œdema of the skin. The
white elevation corresponds to the iuBltraCed portion of the derma,
the pink areola to the vascular congestion which surrounds it. Tne
redness always precedes the appearance of the papulje The white
color is due to the interstitial distension of the derma by serum, as may
be demonstrated by injecting water into the skin witii a hypodermic
syringe, when there is formed the pale pniriginoua swelling of urticaria.
The pruritus from hypodermic injection, comparable to that of urticana,
is in reality due to the action of the water upon the nerves.
The white spots upon the surface of the skin in anasarca, isolated or
running together so as to form networks, very similar to those of urticaria,
46
722
FATIIOLOOICAL ASATOUY OV TRB SRt^.
Ffg.SW.
show tiiat the denua \s invaded hy tlio 8uhj«oent OMleaui. As soon as tItU
passive and difliiSB cutauoous œdvma occurs, the skin los«a iu emootii
sppuarancc, h bceonic« iDUDunillatcil ; rre\]iiciitlv. nver thii cli-vatioiu; the
«jndormi» U pliwttoit; finally, the cplilonnis maj L'xcoriaie, when a tliin
ecmm, which is m>t «pontniieoutl v coii)^dnblt' in the nir, floire out. This
âiiii) contains the anatomical ctemviitfi ulnriiy mi-t with in ucdoinatoiu
âiiids, that i», white corpiisclcH and n few red disk.*.
A Uiin rertJe-al section of the ekin, when in ilm ]intjiolojpcal Ktate,
shows the blood vcji<«l(i rer^ diitlincl, engorged with hlood and snrrouiulnl
with white corpiLtcIeii. lu the derma are Hoen, between the conuectiti;
tiwme fasciculi aeiiaratcd hy serum, white corpuscles, in greater iiumWn
than in normal BKin, Tiiey I'renuenllv form collections or irreguhirlv
disseminated foci. The lymphatic capillaires are ver// mueti dïtaud, niA
instead of appearing as narrow clet^, as in normal skin, tliey arc seen
as largo stellate, open spaces ; tlieir diameter frequently «xccoiling tliat
of the largest hloodre^sels of the derm.
Tliis dilatation of the lymphatics is always present in a-dema of tlic
skin. At a time when the histologicnl «trncliirv of connective li««u« was
not *o woU uiwierxtood. Young de-
Mfibcd ft» (Ulalttl It/miihiittrëy Inrgi-
spaces filliil witli fluid, circumscribed
br thick fa-tcieuli of connec^ve tiiuiir
an<l ]nrUtàoncd by a delicate network
of oonneetive tiasue fibrea. TliMe
spaces, having; no proper walls atid
communicating one with the other so
as to form a trae caTcmous system,
were Cftrreelly considerol by Voong
a« the #eat of cutaiicom ludeina, bat
wore incorrectly reganlenl m lympli-
atio ves!*olt< {fig. ■S49). These i>pncei>
iici-urately correspond to iltc descrip-
tion given hy Uanricr of the oonnee-
tive tiasue distended and aenareteil by
t!ie scriun of œdem» ; and they by
)\o means resemble lymphatic capil-
laries, which are not spaces parti-
lioiK-d by intençcctiiig connective tis-
sue fibre». Tin- lacunn: of Young arc
merely the connective tissue spacea
of the derm .■(wollcn and dt^tonded by
tlie fluid of (cdeioa. Tliereftirc Young
had imagineil rather than dein-m-
Btrated the dilatation of tlie Ivmphl
tioR in oedema. If, however, it ïs admitted that the connective tl#aue 1
nothing more than n partitioned lymphatic sjiace, the conception of thiii
liiatolojinal remains correct, and in oedema the transuded aerum oitllects
in the raeshea of the connective tissue, that is, in the radicles of the
lymphatic passages.
Diffuse œdema frequently attacks the skin of limbs which have been
nM of «dtoii.. a- Civlrjr <if tha tfu«L A.
I» »n4alli*niiD. r. il, r. CslU *nd tkt(<i»]|
ur ibc i-uusMtlis tixUB la Ih> mldd ol whlcti
1h« tjlnlih ImrOki La tdf^t'O^
^g (EPEKA 0» TIIK CtJTAXEOCS LTMPn PiSSAOSS. 72S
for a long time anistrcous. It iit «elilom pnmttry ; in ntMT-tioni cliildren
it nlwajrs commeaee» «idi «(loma of th« subciitAneogit cellular tiuuc,
and conalttutea a sclcrod«m)ii.
We have seen that œdema U aocom[>anted with seroufi «xuilation, witli
nucoeroiia white corpiiaele» and a few rt-d blood corpuHclcH. If the defi-
nition that Cohnbeim bas given of indamniation ia con-ect, there should
not be any dilfcrence anatomicivltjr between inflammation and uedema ; tf,
on tht contrary it i§ admitted, that irritntioD and proliferation of the fixed
celts of the tissue ore also necossarjr in order to cbaracterixe the beg^n-
nin;; of the ititiammator; procèdes, œdi-ma remains distinct from inflam-
nwtion.
The phenomena ho cIokc to inflammation cannot continue for a long
time in tiMues withunt a chronic inflammation rvs'illîn;;. Therefore the
history of a chronic œdema and chronic dermatitis are intimately con-
iiecie<l, the fonn«r always by it-t Ion;; duration canaiiig the latter.
To rejioat, when the OMlecna of the skin 'u, oocasiont-d, cillicr in conse-
quence of local nene pxralyn», or by the extension of a subjacent ucdema,
tliere are -teen: 1st. Serotialraiiiiudationa forming an intoriitilial injection
of the derm ; 2il. Mij^raliou of white blood corpuscles and a few red
disks; yd. Dilatation of the lymphatic passages, the enlargement of
nhich is in correlation with the elimination of the cedematons products
to such an extent, that in some cases the dilated lymphatic vessels are
irritated alon^ their cour^, and are seen as white cords. Tliis always
occurs in an intense <xdema of the skin of an entire limb, a«, for example,
in phUymnia alha di<hn».
B. *Kt>KMA OP THE LvMpn P*BSAnKS. — Tliis has been described by
several writers, especially by Vircliow as feuwj'hfe-fmagia, and by Kind-
Heiach a* fympkan;iieiytatif pachydermia. \i times alao, when, in con-
ae(|ueDce of a |>rotonged œdema, the lym]>hatic canals and the corre^j^ond-
iiiglympb glands, for a long time irritated, contract in the same manner
as a cicatrix, this variety of œdema is often seen to follow anaAnrca.
Bio skin is hard mammillated, reddish-brown; upon nunctiirc, there es-
capes a fluid spontaneously coa;;ulable in the utr ; and in sections of Uie
skin, after baracning in alcohol, the derm i» seen filled with lymph wliich,
afVr coagulation by the alcohol, remaiug in all the interstices of the
fibrous ttasue, distending the meshes like an injection of gelatine. The
lymphatics are gapiug and filled with lymph clots; very freijuently this
variety of wdema rapidly occa«iotis in the .'«kin a chronic dermaciUs,
which extends to tiic subcutaneous tissue and add» to tJie rigi<lity of
the skin already ongorged with fluid. The cellular infiltration is as in-
tense as in .simple oedema, only, instead of an alliuminous serum, it ia
lyropb which 61U the lacunar spaces of the dorm.
This stagnation of the lymph dependent upon the impermeability of Iho
lymphatic glands which have usually become fibroiis, froijiicnlly occasions
the appearance of varicose lymphatics in the skin. The œdematous in-
duration observed in tlicso cases bas been considered, by several denna-
tologisis, as a variety of elopbantiasis. This name may be retained, if
it is applied to every cbronic infiammation or induraliOD of the skin aa a
generic term.
J
PATnolOaiCAL A!tATOHT OF THE BKIK.
Sect m.— Hemorrhagca of the Skin.
In the skin, ai> iu other bssues, hemoirliageii may be oocanoBfd
mpturo of the capillnrii-s, or by the passa;;» of tbe blood «orpiiHclea
through Umr dclicutc wnlls; tlieiattor phenomenon U termed dîa|>oileaia.
Xlo>Dorrh)if;c« caused by incisions of the skin or tlie divi^on of Urge
. TCWcUwill not be lierc eoneiderad; only intcr«titinl hemorrlmgus swl
'tiicir evolution will bo described.
Wlii-n, IU * coiiKe({Ueiicc of a coritiiston, the itmitll vesscls of the ikin are
ruptiiretl withoat tearing the deno, the red und v,-liît« corpaMlei> nf the
l>loo(t inliUriite llic oouneclive tisauc. There results & hemorrliiigic focus
of irregular outline. When tlie exlrariuintioii \* large in amount in a e'lt-
^eum^icnbect area, tlie blwid neparat^a llic fasciculi of the dtnu, infiltrates
the liuhcutatieot» a<lipo!ie ti^iue and forms a \Aooil tuinor (luematocele).
In other casea, under the influence of 8yittemtctliâeat«e«,oF«hich Hcurvy
ii« a type, the exanthemata and purpuriu being well-known oxanipha. tiie
hemnrrhaftes spontaneously lake place by diapedesis, and Uiejr diatiihu-
tion ia probably deterDÛneil by a special nerve pnralyaia.
The blood, once cacajied into tlie tissne of the denn, undcr;toeéi retro-
grade chan;§es. The hlood plasma is first rapidly absorbed. Tlio eolor
ing matter of the red cor|>uselea is afle^ra^ls ehaiii^cd into bwmatiu.
the hcniorrha^ic s])"t liavin;* now u dark tint; the broken-down corpuscle»
arc taken up and transported by the migratinR cells and arc de)>o<ri(e<I
as pigment in the neii^hborin;^ lymphatic glands, or in tlic protoplasm of
the fixed cells of the denn. In this manner there results, in regions of
the #kin which have bcitn the sent of hemorrha^, a brownish or yellow
tint, which reni.iiiiâ for a variable period, which doe» not disap^tear hy
pres-turc,aii<l which servea as a diagnostic sign of previous hemorrba^es.
With n-s])ect to that singular form of eutaneotts hemorrhage called
htrmalhi/JrufiK or Mood sweat, but little is known anatomically. It
forms in drops which soem to exude fi-om the orifices of the sweat glands.
It ia supposed to come from the vascular network enveloping their gland».
When the blood breaks through the rete mucosun, elevating the epi-
dermis into bulhv, or penetrates already-formed bolls (hemorrhagic pem-
phigus, etc.), it cxperionccs tbe same changes as if it were in contact
witli tbe air ; it coagulates iu a short time, and forms with tbe clwaltid
epidermis a scab, vrbich suh8o<iuontly disappears by demjnamattoa.
Beet. IT.—Diffase Inflammations of tbe SUa.
TiifTuifr infi(Minm<tli'tHf "f ihr itkin an- tliosf which liave spreail over
a large surface i>f this mv ml mine. Cirmiitf-rilH-d infinmmatiouii i>ccupy
only very limited partj«, and their evolution throws a certain light njon
tJie pathological anatomy of the ]>rincipal elementary lesions of the siâa.
A. CosaBSTTVE ISFLAMUATIOX UP THE SkIN. .\riITB 'DeKMaTITI».—
As a type of dermatitis, we lake one of the most freijuent inflammatiotia
of the skin — trytiptha, which seldom passing to suppuration, permiu oa
I
COItAGSTIVE IKPLAMMATEOX OF THE SKIS.
72S
to follow step hy stop, from its beginning to its complete recovery, tlic
process of uoiigMtivo licrmiititis.
When the skin ntta<:kL-il bv crysipoliie i» tnciMtl, it i* found tliickencdf
oii^orgcil with fluid) nud lyiug upon a firm ndipotic lisitur, nhiuh «ome-
ttmi^H appean 08 compact as congOklod fut; tlio scrum which flow» from
O'*,
M
^jviljri
I
)- ■■faltfnslloo nf lhii»dn>BMeU*»U>tn*c*Iliaf Iba «^Id III *C7>l|'*lu. o. ('«tntftlx^tluuv
flUrv*. b^ K.'ooaptll't^ti^a* ovPpnHUa lu |>»(w«* at 4lfl*toii ; llinjr ar* tniicrh mor* nuudfoua Ebitu
ttûTmjil : in buuo ■ Urf* «'^nnlAr iin'l'iii U hour-fl^** La khàpf<, rvaitj tu dit Id*, lb nlhfra thf
feOcUiiB ^M -lltLilfd. r. Wbkt« bLuod-cdnitiM^tM, Lu inm* pUtA4 thirjr «m Imbtdilf'J In th« yrtlinlAr
•inituina. t. Tnntiorv (wIlaB af ■ lyniili ripinirjr ur ihs Ibidiu tlHqa. u. TmuoinM oMllaaa
of QannAcaK-Itfauit UacUiiU. 6. EDdi^Ibcllniti wllfi tiirx« t<uktilihr uDcJtDn monldtd np«u Ih^ Irr»
■iltF tiirlk» of tbr l/mpb iium. «■ raa»iilf ■llun* c«r{ii)'eti'>. .1. hyrnvh «iil'1>T lanlut^fd
l^mthh «puwT of tb« dvriB Iti Iba l>«ftBBliif af njnLptUA, d. Lum^u, t. kadalEieUiJm. e. L*(u
cgcjl»c4ll*<M4«MUd tbalfuipbtrMW BndlmbaddadlD*i|iiiaBlu>xiidilliia. lligA povtr.
the cnt surface is rery sli;;htljr fibnnoua, contains numerous white cor-
puscles and a lew red corptiacles, also some conuecuvv-ussui; cells, the
protoplasm of vrhich has become active and graiiiilar.
Upon thin sections, it is seen that the derm i« infiltrated with vhit«
rATUOLOalOAI. AKATOUT OF IBB SKIS.
Llood-corjiujiclos (Vulpïati), «litch nrc oeukII^v ptikccil oIod); ttic course of
tliv l)loo(lvo«8dM (VolVimftiiii uixl î>toutlncr). At poîiiU vrhoro l)ic er^stpc-
1*8 is in coiirM of iWvulopmoni, thnt i», at ihv mjir>;iti i>r titv iL-ilvionlouii
swolliii);, tlic tninsvorsc »rctioii fiî the vc«sl-I8 Appear» Mtirrotiiulcl by ^
circle of wliiiv c«rpu0clc«, wliilc in tlio m<.'»liC4 of tlic derm only a hin
ftr« found.
Aootlier Icwtlit; for Uie «ollccUng loj^cthor of lh« iuaUntiti;; wliitr
i>rpUKle« is Ui« neii^iborhood of the Ivmphacic capillnrieM (lyinphmii:
apaceti of th« dorm). At tlie Hatne time thkl Uic whiC^' corpuncli'» tr
aocumulatiiijï aioutid tlic cotmectivt^.ttiuttic spac«8, t\\v cndmlicliu in rod
of tlie Ivmpliatic clcfui are seen .inollen and grâtmlar, iheir nuclei <livide,
and liie ccllit des<)uainat« (fig. îtnU). In otlier poiutA Ibe lymnlialics are
filled with embryonic cells, resembtinf; iboite wliicti liavc inftltrateil the
ilerm, and tbey appear, in lon^tudinal section, as long tortuous cellular
rbanda.
Later, the aubcutancoua lymphatics in tbe adipoM tisBoe are filled wit
mij^ratiii;; cells, wliich mW arc abundant around the vesseU and even inl
their walls, (îeiicrallv in inUinâc congestive inllummation llie cellular
infiltration exteiuU into the panniculuii adipomu, an^l separates it« red-
ctes. This infiltration is the principal cause of the in<lnration of tbe skio.
The circuit of these changes is that the white blood -corpuscles escapaj
out of the vessels b_v diapvdcflis. with n slight fibrinous iTansuitationj
they F^preiid into the meshes of the derm; anemartls to pass to tb>
lymphatic radicles, to be tnkcD up liy those ve]<«elfi, which carry tliem tO
die venis. This ii the process of unieioa
tous inflammation, and it 'a probable tliat
tlie evoliiiionH of Uie wandering celts are
but sli>;tiilv diHerent in acute «dcma of th(
skin. of wliich ]iapulous ervUiema fumtufac
a type. Itm beside;*, in coniçestive tutiaii
mation, there ia seen a proliferation of the'
fixc<l conective-Ussue cells ; tlie nuclei di-
vide, they arc surronuded by a (^ranatar
nnd active protoplasm, and contribute to
«irr:; :C-/™::';r ;;:r; «.« production o.- the embryonic element
tnu a[ lit «pidgrinii. ih> noti»! uc whiuh fill the dcnu. lu congestive det
•Met. h«> bitume it^ituur b/ ■ titj, ihjs ti.>ii<|oiicv to thc proliferatioD of
d,u.,oo »f .h. """'"i»- ; -. »°™>' the fixed cells is much less marked than is
ci«iu>; >i.'i,*a»>»*4>itD<o<i>uv<«r thc phciiouicnon of innltnitioo by diape-
ih* HO* aUfTiuaii. »i):iipD*n. dois. tVom tlils circumstancc, resolution
uMuitlly may take place witliout leaving in
tbe ekin any appreciable trace if the inflammalory process. Thc red
blood-eurpuïclcA iiifiliralod into the derm at the same time as thc white
eorp)i<^-1es, undcr;;o tbe same changes as in «echymoses, and catuw ilw
formation of a yellow spot, which disappears Mme time after the inflam-
mation. From thecffcctsof inflammatory congestion, thc cells of tlie rcte
iDiicoiumare iit«o changed in their vit-ility. tbe nucleoli are enlargeil (fig,
351). coinprewinx and atrophying the substance of the nucleiLs, and th*
Cell* die in corwe<iiiunce of ttiis atrophy : they do not secrete the cement-
lu^taiice which in the normal skin joins them to the neighboring cells
Fig. 3S1.
I
ESDPATIVa IKFI-àMMATIOSS OP THB BKIK.
nnd there i» a i]e8qunni»ti&n of the epiilermia. Plilycteniilcs and abacesaes
vihicli majr suoc«ed coii^eMire iiillnuimation of tlie skin will be described
further on.
In this vanety of Infldmiuation, ihe congestion playa an împortnnt part.
It is aecompauieii «rilh an exuviation, which cnnslitutcs thi- inflaiiirauiory
iBdema and contains a ffarj-itij; amount of Bbrojienic suhstaiiee. But the
exodarïon is not ordiimrilj depoaitcd in the in(.>sbeB of the derm, as oocurs
in the following variety of inllamuiatious,
B. KxpDative Isflammatioss of thk Skin. a. Suppurative Der-
maliti». Simple PhU'jmon of the Shiv. — Tbis constitutes a rare termi-
nation of diffuse inBaroimtioni^, and when it occuni the suppuration of
the denn does not take pluci* over large surfauen, but in foci more or less
Hcattcred. Each of the «mail dermic «Imcvhscs is «iinilar to that pro-
duced i» Uio »kin around a foreign body — around a xoton, for example.
In some intlammations, when Kuppuration occur» the cello are seen in
f laces to accumulate in the mvi^hea of the derm. The celU come either
rora a diapedesia of the white iilnod-cor|mscloa, or from a division of the
fixed cells; they become fatty degenerated, and are hut slightly colored
with carmine. These cells are dead, and constitute small foreign
bodies in the skin. Gencrallv they are collected into foci at varying
distances from the surface, wb^o the eurroun<ling fundamental substance
(eUietic Bbrea and conncctivc-tissue fibre») of the derm is absorbed.
Thus résulta a small cavity Sllcd witb pns, excavated in the derm. Sur-
rounding it there exists a con<r(;«tive inflainmntinn of the connective tissue.
The bloodvessels and csjwcially the arteries <if small calibre, are second-
arily infiamcil; endarteritis diminishes the ealihre of the vesucts, nnil in
conse<|ucn«e the amount of blood to the part is lessened. 'Die jmndent
fociis Ls enlarged at the expense of tlie surrounding slightly vascular tie.fue,
and when it reaches the surface ulceration occurs.
The method of forni-ttion of ;tr»nulBtion tissue at tlie cutaneoua surface,
and the process of cicalriitation have been considered (pagas tifl, 71).
According to the invcàligations of Keverdin. tlie ]jresetice of transplanted
epidermic cells upon a granulating wound of the sktn occasions an active
reproduction of the epithelium around the grafted cells. The epidenme
ceils appear to act, not bj multiplying through division, hut bv their
lircscncc, which causes, as it were, an epidermic evolntion of the sur.
' rounding embryonic cells, for the graft does not itself show anr signs of
activity, but is soon destroyed in the midst of the new epithelial tissue
which it bus caused to be developed.
A, Fihrlnvtiê Drrmntitit; Viffvtfâ PMtgnwn of the. Skin. — This
inflammation does not differ from that described under purulent inflam*
mation of the connective tissue at page 2-'>H. At the same time thore is
an abundant celhdar inliltnition between the connective tissue fasciculi
of the lierai, a delicate tihrinoiw reticulum is seen which incloses in its
meshes the ttimderiiig cells. Sometimes fibrin is exuded in abundance,
awl there is produced a very rapid necrosidi of the denn. This is very
marked in malignant pustule. Carhutkcle a only a milder degree of this
Tariely of gangrenous dermatitis. It occurs over large surfaces; is ac-
companied with a fibrinous exudation, which dislinguiiibes it from simple
■
728
rjtTBOLOOIGAL ANATOIIY OP TBS SKIK.
■Ciftdeaia; and it verv noon terminâtes in morliGcation. AVbeii tbe Inttor
llakflS [Jace, tlie entire derm is înfiUr»ted witli granular fibrin and grauD-
[lo-fatt^' embryonic cells. Id tlie suWulancous tissue, the fat o[ the
' tilipoHe vesicles breaks ap into small free f»t <lro|)6, scattered in tbe
interstices of the (issue; or there nutv be formed, during life, tbe ebankc-
U-ristic crystals of fattv acida, similar to those generally found in the
«dipoflc tis<iu(r of the cadaver.
c. P*«ud'-Mfmf>ran>AU» Ifrrmalili»; Ctitan#>ut Dipblii^ntie. — CuU-
ncous di]>hth<.TitiH bus nut been studied M a 8|>ccial lesion; wv Hill,
therefore, refer lor il« coneideriitioii to man 6a, where diphtliurilic exu-
dsiion» have bocn 8titdti.vl jienentlly. Wc navo been able to deBion«U4te
I that the brAiichiii)^ cell». Iiiiviii^uiulori^tiie tlie collotil tr»nsformnti»n which
1ia« been liuiicribed by Wu^iier, «re fouiul in the fnUe culaneoux nicui-
bmnea. The nalure of di|>litlioritii< coiiKi»U more in l*-!<ionf' of tlic C|nthe-
p liuni than in changes in tlie connective tiftiMii-it which iiii[i)>iirt tlieui ; and if
the mucous membrane of l\iti phni-yuic can bv com|i»red nitb tlie iikiii,
there is simply a diSiuied infliituintition under tlie diphtheritic exudation,
0. CliRONtc Diffused Inflammations «r tiii:Skin. — When repeated
ynflamtnations occur in the skin, or, what is tbe same, there is a prolonged
nibronic a'denia. the irritative process, maintained for n long time, occasions
in tlii« membrane chronic inflammations. Freipienily a local inflammation,
such M an ulcer, or an inflammation of a special nature, as eczema,
after a timo excites around it a zone of chronic inftammntion of the derm,
which progresses according to it6 spocl&l mode vf origiQ uid tbe moriMd
tenilencie<> of the jiaiient.
1. A'lAr-jux //y/ii'rfr'Y'fti'.' Drrmntilif.— hi this variety, which fre-
(jueutly follows prolonged irritnti<iii.<< of tlie .Tikin {eajieoially \-arteose
ulcers, chronic eczema of the legt*, etc.), tbe derm iit tliickeuen, aiwl the
fibrous fasciculi composing it are more numerous an<l deiuter. The
stellate lymph spaces form, in sections transverse to the direction of
the fasciculi, lar^e stellate spaces lined with endothelium. With tliis
hvpcrtrophy of the derm corresponds a relative atrophy of tlie p»]>ill%.
'Ac epidermic layers arc thin, and the nuclei of the cells are frefpiejitly
atrophied by the dilatiition of tbe nucleoli, whence there is an almost
coiilinnal di-nipiumatîon from the surface of the skin so inHamcd. Tbe
subcutaneous adipose tissue, blended with the derm, is hard, because
tlie adipose cells have pndifi.' rated in «neb a manner that each fat vesicle
is dimini>ihed in wse, and surrounded by u circle of embryonic cells,
Tliifl change W termed lanluccoiu, and is especially evident aruund old
lUcers.
2. PapiUary Varirtif; Diffwml Papilhma of the A'Hn.— Thi*
chronic inflammation of the skin is generally oliserved iu localities which
have been the seat of repeated œdemas. notiibly on tlie instep and around
the ankle in persona with chronic heart disease. Some writern, i>«rt>cii-
larly Virchow. have considered it a special variity of elii s
(JÎ, rvrnt""M). It bas been described by Hardy as by| ; . '■
lichen, in nbich the disease snmeâmes ascends as far as the jcitee, and is
freijuently acompiiiiicd l.y chronic varicose veins. The papillie are at
times cnormou», and i-acb is covered with a corneous layer, so that tbey
BLEPHAHTIASIS ASABCH. 729
reaemble the papiilse upon the tongue of a niminating animal. Usually
the akin is considerably thickened, wrinkled, and folded. In sections from
the skin, in vhich the lymphatics have been injected, and colored with
picro-carmine, the papillie are seen enormously enlarged, formed of em-
bryonic connective tissue (mucous tissue) analogous to that fomiing the
Whartonian jelly, in which run delicate vessels and lymphatics, without
special walls, as simple lacunœ lined with endothelium. In the derm
the meshes are filled with embryonic elements, and the small cells at
many points arc undergoing division ; generally an innumerable number
of newly.formed capillaries are seen. These embryonic vessels are
especially abundant in the deep parts of the skin around the sudorific
glands.
This abundant formation of new vessels is especially seen after chrome
oedem&s. In the interior of the derm, the lymphatic capillaries are also
much dilated, and gaping upon section.
The preceding form of diffiiaive dermatitis constitutes one of the varie-
ties of elephantiasis Arabum. Very different chronic inflammations, bow-
ever, have been classed under this name. The general law of develop-
ment of elephantiasis is not yet determined ; but it is known, that
when congestive inflammations are repeated, or prolonged, or frequently
return, as in erysipelas or œdema, the skin becomes hypertrophied, and
an elepbantiasic swelling is produced. In every case which we have
seen during seven years, the only constant lesion has been dilatation of
the lymphatic capillaries; the variety of chronic dermatitis has varied
considerably.
3. Elephantiati» Arahtm. — It is seen from the foregoing descrip-
tions, that chronic difl'use dermatitis, whatever may be its cause, has a
tendency to occasion hypertrophy of the skin.
a. If œdema has continued for a long time, there is produced, over a
large extent of surface, an indurated engorsiemcnt, due to stasis of the
lymph in the connective tissue spaces, in the dilated lymphatic capillaries,
and in the alTerent lymphatic trunks of the glands. The latter are trans-
formed into impermeable fibrous tissue, and they exert considerable in-
fluence in the production and in the continuation of elepbantiasic dematitis
(lymphangiectatic pachydermia of Rindfleisch ; lymphatic elepbantiasic
cedema). This variety is secondary to repeated œdemas, and is not
unfrei|uent in the lower extremities of persons with chronic heart disease.
Its most frequent seat is the skin of the scrotum, penis, and prepuce.
h. A second variety is characterized by a retuni to the embryonic
state of the entire hypertrophied derm, with the formation of large
lymphatic lacunce in the granulation tissue into which the skin baa been
transformed. This variety has been briefly described under lymphan-
giomata (see p. 141, fig. 105). The seat is also, like the preccdin;; va-
riety, usually upon the genitals (skin of the penis, clitoris, labia majora).
c. A third variety has been described, and consists in an enormous
increase in thickness of tlie derm, due to a multiplication of the con-
nective tissue fasciculi and elastic network; frequently the smooth mus-
cular fibres disseminated in small numbers through the derm, according to
some pathologists, eousiderahly increase in number and form in the deep
parts of the skin superimposed layers of fibres running in difierent direc-
730
PATflOLOOIOAL AMATOMY OF THE SK[!>.
tionn. As in the other rAtiolies of elephAotiAsis, tlie l^mpliatic <'a|>il>
lAries nro dilated, en^or^i) with lymph or Htuflod with ()c»|uaRmt«(|
endothelium, and «re widely (npin;;. Genpraltv in tlieae caws the *kin
\a reddened, wrinkled, and projects in riil;;fs. but presents no wiirt-liku
cxcroMences. Clinieatly ihis varietr of elephantiasis \s tvniwd «mir-(A
or rjlahrou» tlephantiit»!». Itul when the thickening of the «kin ifl *e-
compnnieil with papillnry hyportrophv and new ra^cular formattOM
(diRast'<l papillary or vai^cnlar dennntiti»), the clcphiintia«ri '\* finid to 1m
wnrty (A', pafnllari» ku wrrw^'fii). When the Mpillie formed of em-
bryonic tissue or of niueous tiwiie are enoroMninly developed, att in hjifrr-
trnpfiir tirhen, tlie elep1iimtia:tis i» named £, UiliirMa teu notlana. Tb«
nlcenitton ui>on ihe «iirfiiee nf the «kin occurring in tlie different vnrietiei
of hypertrophy w termed tth-frou* ft^fyhantiaiat. [K. anikum in W'lievivl
by ii'>mL* writer* to be cAUAcd by the presence, in the lyinphativs, of a
apecic» of tilnriit.J
Sci.KK(H)KBMA . — Sclerodeiroa has incorrectly been classed with elc-
phniitiasia. Il is an atrophic disease of llic skin, a tme cirrhosi». The
fuR'kmental mibatancc of the derm (conncctJve-lisstie fascieiili and elnstio
fibres) is jsreatly increased; the Hubcutanoona paoniculus a^lipiMua b
chronically int^amcd, and is finally transformed mto fibrous tisitue, and
becomes hurdened thron;;h the or^nization of the emhryonic tiwut
interposed between tiic adipose vesictc». and tlirouf^ the absoqition of
the latter. According to Ijajcranjcc and l>nret the vei«eU are eontraottrd
and compresucd liy \.\w. newly fomii-d fibrous tWue. The epidermis, lliili
and ira nu)» rent, is reduced to two or three layerti of celU, and at the
Gngor pulps, wiiere they nnlinarily atL-iln conwIeraMe sîxo, tite |>roject-
injc papill» are much HtuaUer or are completely eifaced. Thia lésion bfr
gins in the skin; bni the atrophy, ettending lo the bonca, which it eaosea
to diaapjiear. and lo the nerve trunks, which it allers in rarious ways
(peri- neuritis — inleratitial neuritis) is not without analo;:; with certain
lesions of the intcs""ieiit, terroed trophic. In paralysis, however, owr
of the varieties of eiepiiantineie netema supervenes secomlarv to thenorre
lesion, and not an atrophy, like that of scleroderma. The latter dtseaM
w often complicated with pemphi;;iiK-1ike bullic, and ulcerations npus
the altered surfaces, wtiich may be due to tlie leaiou* of the nervca, ud
inSammntory chaii;:c8 of the vessels. ^^fl
Seet. V.^Circomscribed Infiammations of the Skin.— Fatbolo^oal Anatoo;
i>f the Principal Elementary Lenons reeo^nked in Dermatology.
Inflammation, inflainniatory «edema, and the phenoroens of ulceratioa,
instead of occurrin;; over larj^e itiiHacea, may he circumscribed. In llua
case, local lesionH are produced, nliicli macrowopically asaume orilinarily
one of the types usually desorihed by dermatologists under the name of
tUntentOTji letioiit of Uu skin.
a. Co:»0K9TiVE Localised IsFLAUJiATtos of tiik Skis. Paim'Uî.—
When a congestive inflammation, instead of extending, is limited to a
SItLLJB AXD BLtSTKRS OF TUB ^KIV .
781
email siirracc, it forms a red ami circunwcrilwl jMinpIc t^rni«(l n papitlc,
of wlik'h tlip varioloid papule prccciliii;; piistnlation U a tjpo. A rcrti-
Ical ï«ctiuti of «nch a Ici-ioii shows the «kin to l>c altered u in any con-
gc«tiv« inflammation. The connective- li Mac spoci-H are Riled with yoiiii);
elements, and the vessel* are jitirroiinded with ombryonic cell». The
clcvatiun i» due to the local iiiflarunintory oidoma.
After Konie time the pnpide ii.'*u»lly *iiik«, the epiderrain npfiii its aur-
fac« tinder^e.i n i«li^ht ile^'iiiaiimtion, and. if examine'! liiiit<r>l»<;icnllY. the
dcnna il* found to he almo-it normal. Thit) complete disappearance of the
i<erfon occiira even in p^oriaai^, a pa»u1o-»{uamoufl form of a cutaneous
aRbctioD, in vhich the circum:4crihed iotinuimation caHsing the papule
1^ esiBls climnically, na it were, and from time lo time has wriod» of esa-
^H cerhation. In the papule of psoria^ix, the celttilar infillrniion and ecdema
~ ««peciiilly alfcct the piipillw, immediiitely benenth the retc tuuco:«itm: in
the lutkT lajrcr, cvoliilion then ^tcome* very active, and the dilatwlion of
tlie nucleoli rapidly oecnaion» atrophy nf the nuclei ; thcepîdenoic laniellie,
k which arc contîniinlly renewed, de*niinmati' in ;;rcat nnmliers in the form
of «ilvery 8cale«. When p«c)rifiiii» lotijr continue) in a [«rlio» of the in-
t<giinient, it occaHons n hypcrlrophy of the papilUe and a dilatation of
the ve^ael* (Neumann). There \^ seen in this lesion a tendency to
hypertrophy aa in chronic «lennatilia.
In Pruri;!" niul Uchm where the papule haa alao B very prolongea
esiateiice, the papilLne are elongated and considerably onlarfjud; the in-
flatnmatioii is not so superficial as in paoriaaia; the localixed chronic derm-
atitis Cfluse^ thickcnin*; of the denn, and. according to H . Derby , frc<[uenlly
^L also le«iouf of the hairs, incrr-Rsc in the nnrnlwr of >fini)(iih nmseular fibres
B of the derm, as well as the «evumulntton of lympli in the intcraiices of
^ the connective tissue. Hence, each jiripulo of prurigo or lichen présenta
the etnicture of a small nodule of clejihantiAai*.
I
b. LeHIOSB ok THK KpCDKKMIS IX ClRCl'MtiCRIBKl) IxPLAMMAT!0S9 OP
TllK Skix: 1)tiu.j; Axn lli.is-n:B8. — AVhen the inflammatory œdema at
any point Îb of aueh intensity that the lenHion of the fluid is so grejit as to
overcome the resistance of the cpidcmiis, tlie latter yields and is elevated
into the form of a bliat«r or bulla. These two elcmentarj' lesions differ
only in their size ; the process of tbcir formation is identical.
Tlic point of least resistance of the epidermic layers is the jrrniiHUr
layer, lyinj; between the vpdennic cells united by keratin and tiie spinous
ceils of the rete roucosum intimately united tnj;eHier. It is at the level
of this }rranular layer that the epidermic layers yield and are sepa.
rated. The fluid of inflammatory œdoma is now ooUectod into a bulla,
and conttiins white bloud «orpuitcles (wandering cellx), a very few r«d
disks, and a tibrinogcaic aubatanoe wliicti forms a fibrinous reticulum
inclosing the cellular elements. The deeper layers of the rete roucosum
are infiltrated with the migrating cells which subse'inently penetrate into
the bulla, and which are identical with those infiltrating the papillie.
In some varieties of herpes (_hemorrhaffip intter, efani/renoun Zftttr),
it is almost pur« blood which fills the vesiclos : in neuralgic xostcr ^ero
are always found one or more resiclei having a sanguineous color (Lnllier).
The evolution of a pemphigus bulla or of a blister is very simple. The
732
FATHOLOnlCAL ASATOUT OP TUB SKtS.
escitped Suid, containing living corpoâcles, is at firat clear and of a slï;;bt1jr
jrellow color. In a ntiorl tim« Uie while blood coqiuscles die, and llie
conicntâ of tlie blister bt-coino o]>ale«ccm like diliiled jms. Gi-ncnilly,
the extemnl jinrt of the blister formed bv the clcvatL'<I cpidunnic cell* is
solWned by imliibition of the Hubjuccnt Huid. Tiir fluid ct-i-ii)»'» tbrough a
fîssurc, and the cpidt-riii falls upon the surface of the rctc mucoflum ; ii«v
vpidormic layoni urc formed, and the lesion vntircljr di»ap|ii'ara. Tliii
mode of repair, howercr, does not a^rce with ihat pvcn bv Li>n<;4r)iaii>,
who considers tlio <;ranular eono as tlic formntive or<;aii of tbo Cjndomûii,
for in the blister tlii» j;ranulnr xone is elevitti-d aiid al^eru'unts dostro^rwt
without tJiere resultin;; iiny nbatenioiit in tlie formation of the ppidcmà».
Neithur doe« our dcscriptioii a>;ree with Ibal fpve» by Xeiimann, who
recogniuK» in the interior nf the blUter the exittteiice of a reticulnni fomwl
by stellate and aiuatomoaing cells-'» modificialion of epidemic cell».
ViairLKH. — The veaiclea of ecxenia — those which form «pnn the sur-
face of an eryaipelatona skin, or those piWuced artificially hy Croion
oil — arc formed by a process very different from ilie foregoing. The»
arc formed iu the substance of the rete mucosum. In the protoplaan of
the s]ûnouF cells aro developed highly refracting opalescent globules, not
colored by canoioc: as tlicy increase, tlicy piisli the nucleus to the peri-
pliery. The cells are transformed into enormous vceiclcs irhicb open
one into the other, forming a jmrlitioned anfractuous cuvity in the midille
Inyer of the rete mucosum. In this cavity are found ejiidermie cells with
several nuclei, besides wnnderiiig cells from the veitMN havîn;; the char-
acters of white blond coqiuscles. In time, tJic cellular elements uiwlcr^
fatty degeneration, and sometimes the Bnid of the vesicle, which at first
is clear, becomes yellow and opaijue. This transformation is very dis-
tinct in rheumatic miliary eniptiona. in sudamiua, and in the vesicles of
TariceHa, whieb are only diftcrt-nt varieties of vesicles.
In eczema, this transformation of the very small ami numerous vesicles
does not tate place before they break and discbarge a serous fluid. But
if the exuded Hnid is kept in eoniaet with the skin, by enveloping the
latter in an impermeable cloth, iu about twenty-four hours the fluid hat
all the characters of pus. The lesions prwluii-d in tlie dcnAa by cbrutik
ccKcniu do not dili'er from those following chronic dermatitis.
l*l'BTtil.B3. — The proccus of the formation of pustules has a very cl
analojcj,- with the preceding. The evolution of the pustules of varicda
may be tjiken as a type. (I*'ig. 352.)
A pnpulc of variola, examined on Ihc fourth day, presents Ute clinrfec-
ters of a congojrlive inilanuiiation of the denn». Soon, in the middle of
the epidermis, the .*piiioiL< cell* liecome distemled by miKOus manet
forming in their protoplasm, transfunuing tlie cells into vesioW which
open into each other, and forming «» anfmetuoa* cavity which eontains
white blood corpuscles and epidermie cells with soveml nnclei. If tlic
vessels of the derma are injectc«i with Prussian hlue, soluhle in water,
the coloring substance is dtfl'used to the neighburlKHxl «^f the vusîoo-pn»-
tnle. Tliis fornintion is associated with a softeninj; of the vesâvU, wuck
wry readily permit^ diapodesis. (Fig. 86^.)
iJ
CUTÀXIOtPS rUBTPLES.
733
When suppuration occurs, the swollen epitlielisl cella arc set free nnd
enter in great nuniliers into the CAvUy of the pustule ; the white corpuxL-leit
Plj[. SS2.
4. tfium «( Tkitiiloni ndrl*. n. Lnjtt of «{ililorinli. A. K*» ninrnxim drtpritnl ■! lb*
Pig. 3S3.
Tatlkil rill of thn r"tn ainroiDiii •! iha ■•rallou at tnAa\oat (>iitnla. iLi. r4itliu rkmnl Vf
lb* ttfalriilar *UL^«4f (bs «tLIb. And, at ihv umr tlm*'- IllitftI wUh pui dttpautM, ir, 4- RpUh'Jul
Mill. h. MulbdCDlli tsaUlDliii rai iiTpuxI». X^'^-
78*
PATnOLOOrCAL AKATOHT Of THE BEIS.
pOM out of tti« bli>odveMcli> aikI p«ii«trnte t)ie altored epidermis. The
roMiiliir loop» project from the floor of itie pustule is far as the extreme
Ittnil of the derm. The pApilUe are deprived of their ejiithelini covering,
nnd the li^iiue of the denn aldicked with dilTused îiiflaDiitmtion ischai^d
iuto euihrjroriic tissue. With the ptislitlc there is» oiore or less eoiD|)lete
dostruclion of the pa|HllK. which explains why in variola there is left a
permauent inaHc, while u llUler uud vi-sicio luarc no trace.
The ftofroetaoua cavity of the jHi^tulc is («rtîtioned hy aaastonnging
âUim-nt». the arrnii;;cmi;nt of which at tiret Hi^ht apjieuns similar to that
of thv delicate ooiimclive-tiKsuv fa«ciculi of reticulate^l tintnc. A num>
bcr of ihf Bliinu-Til)! arc arrau);ed in the form »f arches ; the;? an) tlic
ronutiiM uf the ruptiire<l cell» of the rctt- mucosum, nhich have becoow
voMOular and have ojiened one iiilo tlie other, llie traheculiv thuK fnnned
by the remains »f the cclU exisl only in the oavity of the ptutule ; l>ut
very titie filaments arc seen reaching from the derma to the e|)iderait!
layer, which forma the roof of tlie pustule. From the top of each denuded
papilla, projecting from the floor of the pustule, arise a number of these
oljuiiente. which at firat scorn to bo coniinnous with the fihrils of the p«>
Mllary connective tissue. This is, however, not tlic C4i«i, for it is known
(Ranriei') that tlio fundamental substance of the connective tissue ter-
minates bcncatli the rctc inueoeum l>y a series of Mrratious destined l«
receive the procesxea of the sfunous cells, and the <term does not send iuto
the (.'pidenuis any fibrillar prolongntiotu. The network which haa just
Iwen <lc«cribeil m always existing, possibly repre*ent« the cement sub-
Stance (Kittsiibslunn) heiwv«n the cdU uf the rote tnucojutn. It h«,
contrary to tbc opinion of some writers, no part in the umbiiicaliou of
the pustule. When this umbilication exists, it is caused by the centre of
the elevation being riddled by a partitioned cavity, while the postule
contimies to increase at the periphery (Fcorster). The cpidcmtic cells
at the periphery being swollen, there results a comiMtnitive prwjc«tiou ta
the form of a circular élévation.
The hain and glands take no part in the formation of pustule» m
variola (Charcot). Cicatrices exi*t only in the variety of piisUdes termed
diphtheritic, and in which there is produced a true necro«i» of tiie derm,
consecutive to the in&ttraUon of fibrin or of pu.t into the meshes of ibo
latter. I'his occurs iu confluent variola. The simple [lustule*, thom; gf
iinpcti>:o, for example, do not teafe any trace of Uieir existence, sînvc
the derm has not sphacelated beneath them.
Tl'DBHCULKS. — When a limited chronic inflammation extends iuto the
deep portions of the derm, the latter first returns to the embryonic state,
then elevates tlie superficial parts of the skin and forms a nodide, which
to the touch htis the feel of » driji nrcHmtcriied iTnlumtio». In dcr*
mstology thi.'t is termed a tubercule. Its stmctitre has been described
under the aflectîons in which it is developed — ri/fhiU», «crqfula, ffltmi-
er», etc. A tubercule, whatever may be its nature, nay ulcerate, may
ciiange into a fibrous nodule, or may become gangrenous, according to tbe
systemic conditions which influence its growth, and cause n tendeucy to
reparation, to new fortnalions, or to ganjfreae.
rRRI-OLANDrtAR tKPLAMMATIOKS — ACXK. 7&5
CtKCUMR^HIItED l'8RI-(ll.AN[liri.AR Ixn.AUMATIOKS. — OtrOIIRUcribcd
pcrt';:lniKlu)ur inHamiuittioii» rrei|iicii(l,v occur in dio itkiii, «.t Uiv requit
of nil nccunmlHtioii of U»> proilwow of »(-vr«ti»ii in Uie interior of tlie gliiwl
or in tu vxcnlory oaiml. Tliis i» seen in mJamimt, in tlie [)rinoi])ii)
varieties of inflamntttory acne, and in pitstules which form arouml the
baira in iitflainniatory Hjfcoai», or in the varietv termed arthritic Itr IJazio.
iSuitami»a.—\\'\icn ihe sweat is produced in «xcossire quantitj', ao
occurs in aouio articular iheumaûfliu, or in some fever», there appear
ufinn the surface of the skin email Mister-Iilie elcvalivns, ut first contain-
ing transparent content*. Tho reaction of the Bmd in tliusc small «Iuv5-
tions, is at the hc;{inning distinctly ncid (Lailler), wliîch distinguiiihes it
from all other morbid «ccrctiona. Ncnniaitn, on the contrary', wsèerld
thai iu reaction i« alkaline.
The content» of the nudainina cniuust of white corpuiicle«, identical
with thoHc of the blood, which are mi nnmeroiu that in a drop of the Buîd
taken from the «nail blijt«r tbey ap)iear to touch one another. But
in ahiiiit tut^nty-four or forty-eight hours those sodamtna which liave not
been emptied by H]iontnneoii# rupture, have become opaijue or yellow.
Their contents are alkaline, as all purulent âui<ts, and the suspended nh'tto
corpuscles have beci^me fatty granular: that is, they are transforowd
into pus cor]>uscles. \ section of a recent suilauiina tlirough the orifice
of the sudorific gland shows the epidermic cells accumulated in this
opening, and slightly elevating the corneous layers. A section of a
completely developed sudamina shows at the orifice of the glandular
canal, and in (he rote mucosuni a very smiill blii<ter, above wlilcli the
layers of the epidermis form a roof, and in which closely packed white
c0T|m»ctc8 are incloMd. It \a probable tbnl the fluid in « liich tlit'sc cor-
puscles Boat is sweat, :<ince it always lin^ an »cid reaction.
Af^nt Puttttlf : Phlriim'tnnuf lufiammatSr'n of l/ii^ •SiJiiirfnut Oliiud.
— This i« secondary to the distetisiion of the itebiteeouA gland, which be-
oomeK cyatic, and U filled witli epidermic cells united at the periphery
and softened at the centre. Around the cystic gland, tlic contents of
which constitute a foreign body in the skin, there is produced a slight
congestive dermatitis, and, finally, the iiiHamraatovy induration of an
acne |iustiilo. Kmbryonic cells accumulate about the gland. At the
same time around the obstructed glandular orifice, there are IcMons of
the rete mucosum similar to those which accompany the dcrclopment of
tho variolous pustule ; the epidermis finally ruptures, and the glandular
contents (comcdone), batJied in tho pus of a small peri-follioular abscess,
may be «(luceisrd out by pressure. T^-rmination by induration froijuently
occurs in this lesion ; there is now produced around the ^liind a chronic
inflMnmation, in every way identical with that which is mmn around se-
baceous cyst« or wens. When the glands are closo together, as upon
the nose, there is frequently developed a kmtfrtmphif tmte. Ktch
gland is surrounded at its periphery by a none of embryonic tissue, which
gradually isoi^nixcd into fibrout> tii!«ue, while a new layer of indiS'erent
cell» is Ibrnicd between ttie fibrous ti!>.<ue, mid llie sac of the follicle.
At the same time the vessels of the glnnd become varico«c, and ncw
onea aiv derelopcd in the recently formed tissue »eparating the glands.
These change» Result in exuberant productions, termed in dermatoloj^
T86
PATHOLOOtCAL ASATOIIT OF THg SKIW,
\m0llv»mm Mtiwrttm, nDd someliinet becoming verj diotinctly [wluii-
oulst«4.
Th« iiiflannnatiou occurring around the Imira in tntma or /iVyr>'aw«
pil/tri» iiccariionii the production of jiufltiilct (pikiltilca of ii^o(Mi«). 'Ilio
lHlt«r liavo for iheir nrifpn tim accumulation ot' the opiilemic c«lli' in tliv
shealb of the tiair, and liic process of tlieir formauon does not iliffiT
from tliat of the acne pnatnle.
Inflamaiation localised around (he eudoriGc glands has been eonaidere^l
as the cause of octLrma, furuncle, and antUrax, but this is diflictilt to
prove. Id the skin Bjmntaiicoiislv or artificiully inflamed the epilhetia
of the <;lBnil proliferate, and ini-Itisi- oumcmiu embryonic celU. In the
louse CMinective tiMuo »nrroundinj{ the gland, there is alM an infiltration
of cells. Finally, the adjacent jjortions of lh« body of the ^Inml open
into each other and forqi a cavity. The dtsappcarwioe of the eudoriBc
glanda is thus canned by a chronic iuflaniinatieu of tlie akin.
Seot VI.— Oeneral reuarl» apon the different tendeneiei and the varioiu
modes of Evolution of Cutaneout Inflammation*.
It has been seen that iiiH:imniiitlonN of the aWtn have a içrcat tcDdeocT,
in ninoy cases, to retum to the cun-fvtdvt tnmV/^, of which erysipelas is
the type. PifTuse suppuration of the skin almost never occurs. The
type or «uppttritive Jerotatitit is the pustuloo» inflammation of variola,
which occur» at more or leag dintanl points. On the other hand, hi/pfr-
pfa*tic inflammation A of ilie skin are fréquent, as are also the ilrifrnrr.i-
the injlamni'itionii, and they occur more fre.|Uently in the general dis-
eased, of which they arc the local raAnifcstations, and from which tliey
receive a peculiar impress.
1. HïPKWi-ASTic Imxammatioxs; Formativs Dbbmatitis. — It is
known that prolonged irritation of the derma ends in the pro>tuction of
a hyjiertrophic dermatitis, and iti new formations approximating lumon
(iliH'used papillomata of the skin). This tendency to the formation of
fibrous tissue is never more marked than in syphilitic ïuâjunmatious of
the skin, nud the latter may be Considered m the beat typc« of formative
dcriim litis.
a. Sj/iihililiiT J'tifiuli-. — At the bej^inning it cannot be dislincoiahed
from a simple intlummation. Itut very »oon the papillie of the skin ar«
hypertrophied, the derma is tliickened, and there is a new formation of
connective-tissue Bbres and elastic network beneath tlie papillary emi-
nence. The suhcutaneous adipose tissue becomes embryonie (Neumann),
and the sudorific ^Innds are inflamed. In very old syphilitic papales
vhieh are about disappearing, the congestive inGltration of the dertna
by white corpuscles no longer exist?, and the lesion consists only in an
enlargement of the papilliv and a greater thickness of fibrous tissue.
h. Stfphilitie Tubfretilr. — In this lesion, frequently eoiifoutkded »ilh
cutaneous gumma, the tendency of the syphilitic inflammation to prodoee
fibrous tissue is still more evident. The syphilitic Ë' '
; fibroD» fonns a nodule
SEOSNERATIVE TSFLAHUATIONS OF THE SKIM. 737
in the derma ; all around it there exist Buiall collections oF embryonic
cells between the separated connective-tissue fasciculi. In the middle
of the nodule the ncwlj formed tissue is very similar to that of tendona,
while at the periphery it resembles a sarcoma, except in oontaiuing
Qumeroue elastic fibres. The specific inflammation occasions, in the prox-
imity of the tubercule, a very marked endarteritis, which causes the calibre
of the vessels to be considerably narrowed. This narrowing probably has
some influence in the production of ulcers. The tubercule deprived
of vessels at its centre, and very poorly supplied at its periphery, rapidly
undergoes a slow molecular softening, and opens externally as an abscess.
The loss of substance is filled up with granulation tissue, and cicatriza-
tion takes place by the usual process.
e. False Keloid. — Sometimes localized pustular inflammations of the
skin occasion a secondary chronic formative inflammation. Consecutively
to variola, to the application of irritating ointments (Croton oil, tartar
emetic), or to the existence of pustular syphilides, true fibromata of the
skin, which have the homogeneous appearance of a tendon, may be de-
veloped. Surrounding the nodule formed of closely packed rascicnli,
between which are numerous clastic fibres or elastic plates analogous to
those developed so abundantly in fibrous carcinoma, there is a zone of
embryonic tissue. Tliis tissue is especially evident in the papillie, which
are enlarged, consist of embryonic tissue, and contain embryonic vessels.
In the interior of false keloid the veins are frequently dilated into large
irregular sinuses. The epidermic layers are thin, and des<iuamation is
active upon the surface of tlie fibrous nodule. True or spontaneous
keloids, which are true fibromata of the skin, do not essentially differ
anatomically from false keloids.
2. Deqexerative Inflammations ; Specific Ui/iers op the Skis,
— In inflammations of the skin due to tuberculosis, to glanders, to leprosy,
and to scrofula, the newly formed tissues die anil doi;cnerat« in several
ways ; usually they undergo easeous (tuberculosis, scrofula) degeneration,
or there is produced a true gangrene (glanders, etc.).
a. Tuherruhiis Ulcers of the iSkin are a very unfrequent manifesta-
tion of tuberculosis. When they do occur, tiiey are most frequently
accompanied with tuberculous granulations in the skin, in the subcuta-
neous tissue, and between the primarv fasciculi of the muscular layers
immediately subjacent to the integument. The evolution of these
granules is the Siime as tuberculous granulations in the tongue (see page
454), Around these granules the denna and subcutaneous tissue are in-
invaded by a diffuse inflammation. The muscles near the skin (it is
ordinarily upon the face or about the anus that these tumors are ob-
served) are the seat of a destructive inflammation ; tiie contractile sub-
stance disappears, while the nuclei divide, multiply, and fill the sarco-
lemma. In a short time the embryonic cells, which have accumulated
in the different tissues, undergo fatty degeneration, and form caseous
points. The vessels are obstructed by clots which become granular, and,
aa a consequence of the disintegration of the parts which they supply
with blood, an ulcer is produced.
This uleer does not granulate ; it rests upon a thickened, degenerated
47
7SB
PÀTUOLOGIOAL ANATOMY OF TUE SKtX.
tîttsu«, nod exunda br tfa« molecular destruction of its biiM ftnd fld]^.
The y;ramiUlioDS, aim tlio intiiimmiitorj zone surrounding them, hcin^ com-
pieteiy de gene rated. Ihc rMogiiitiim of the ^iranuW Wcoiuch iiiiirussiblv,
anil aimlomu-ally the ulcvr is sinipiv I'lscoiis. Tliv jirflcms U compam-
bio nith the evolution of tuborctdosi» of tbe lung or of Uif toucoiu
menibrano.
k. Perrnatilltof fflandrr»; Fan-fi OnumU». — In man th« cutaneous
Icsioiu «f gliindcra are profusely suppurative ; but in chronic farcy of the
tionv the farcy granule vonitljiuttr!* h d^^p^iunitire variety of dcnnatilis.
Tilvro U firât produced a locali/.od iiiflainmalion in tbo deep partâ of the
skiu, ami the fornut^on of a nodule, cnnsi-'itiii^ if embryonic cells. This
focus, round or stellate, varying in siio fivtm a pin-head lo a hem|>4eed,
is surrounded by a bcniorrhagic areola, in which the binud separatM tb«
faacicuU of the dvnna. This primary lesion \» surreundvd by a second-
ary zone of very intense; iliflïiïe iuHamniatton, so that in a short liroe tbe
fini I l:i mental (substance is absorbed, nud tliu skin at the di^easud point has
tliu iip[ieunince of rmnid-cclled sareoma. A noilulo of j^lamlera dilTers
fnnu a tiiheruiilon» ;iniiinlatioti in bvin^ formed of very aotive cells wliicli
arr nut united together, and in not proje^riin^ alwvo tbe cut surface,
iteiùdct, it is deeply eolurcd hyenrtnine in llio central jnrt. while tul>«^
des are not. 'ilic celU nliich compose it have prolit'entiii^ nuclei, and
jiresent none of the sij^ns of the dej^eneraliou which is so early charoc-
teriiitic of the cells of gunimata and ttiheiTles. The cutaneous lesion of
glanders may be considered na an inflammation of a special variety, and
not M El tumor. B<'»ide the hcniorrhasi* "wnc whieli surrounds ifae
farcy j^ranule, there are fonnud in the inflamed skin other blood foci da«
to the inptiire of embryonic vessels. Tlie arterioles of the t^nule are
aifcctod Willi endarteritis; their calibre i« considerably narrowed, and
nlceratiflu is probably caused by the 1«eal unwinta and the présence of
nutnoroiiH interstitial heinorrha;,;ie foci . 'I'he ulcer which result» is atonic,
and even gangrenous, on account of the iTiti-a-<lennic hemorriiagea. Sur-
rounding the lesion are seen numerous lymphatic cords, which are
somewhat characteristic of farcy granules.
e, Leprou* Dermatiti»; Cutamou* TtthemUe ^ Ltprogy. — By
cxaininiug » recent tubercule of leprosy after teasing, it is found that the
greater part is fonned of flat connective- tisane cells having several nuclei,
rei<«in)>ling {riant cells. Upon section, it is seen that the fuiidamenlal
subiftancc of the conneutivc tissue is destroyed, while the endothelial
oelU are multiplied. The appeanince of the lubereule of leprosy is tlwn
very little different from a fascicular sarcoma. In a word, in tliis sUge
Uiere is observed a formative irritation especially affecting tlie flat cells
of the connective liiuue.
vVl the same time, surrounding the tubereute of leprosy, tliem ftxiala •
diOiiae inflammation of the de nna, which extends in depth hy rows of
embryonic cells rtmuing towards tiie suhculaneoas adipise tissue. Tie
acenmidatiou of embryonic cells, as in every cbroiùe dermatitis, occurs at
fir^t an>uiid tlie vessels whew walU are thickened by endarteritis or
endnplilebitis. The vessels, however, ordinarily do not l>ccoine emhryoBie
as in the E-arcontata.
As a consequence of tbe inflamination of the internal coat of the
DYSTROPHIBB OF THE 8KIK. 7S9
vessels, there occurs in time an ischEemia of the leprous tubercule, the
capillary network of which no longer communicatcs with that of the
neighboring parts. The leprous neoplasm now undergoes granulo-
f&tty degeneration from the centre to the periphery, and may ulcerate
like an atheromatous abscess. The hair follicles in the neighborhood of
the lesion atrophy. The sebaceous glands, at first irritated by the chronic
inSammation, are gradually destroyed. The sudorific glands also disap-
pear, the destruction beginning in the excretory canals and e:ctending
downwards ; this accounts for the dryness of the integument in a person
affected with leprosy. Finally, the epidermis is very thin and smooth
around the tubercule; it freely desquamates, even from the heginniog,
for leprosy commences in the skin as a macula. Beneath this spot the
derma is inflamed and ita vessels are dilated, causing permanent hyper-
semi a.
The nerves are primarily attacked by interstitial inflammation (Steud-
ner}. The tactile corpuscles disappear, or at least they cannot be found
(Lamblin) in the finger pulpa, where they are very numerous in the
nonnal state. These changes connect leprosy with dystrophic aflectiona
of the skin which have their origin in nerve lesions, and account for
the anaesthesia constantly present in this disease.
Sect. Vtl.— Systropliies of the 6kin.
A. Tropuic Disturbances consécutive to Lesions of the Nervous
System. — It is known that the nervous system exercises a direct influence
over the nutrition of the anatomical elements. When the tissues are
removed from this influence, their elements actively increase, as if from
an individual impulse (see page 75, an experiment of 8chroeder van der
Kolk). There thus result aberrant formations, which generally have
the type of inflammatory neoplasms of slow growth.
Cutaneous oedema very often is seen in the skin of paralyzed limbs,
especially of the arms. The continuation of tlie œdema frequently ex-
cites a hypertrophic dermatitis, when the skin becomes warty. From
time to time, there are also often seen upon the uedematous integument
active congestions (erythema), which usually terminate by resolution,
but sometimes are tlie origin of gangrenous spots.
The influence of nervous lesions upon the [lutrition of the skin is well
shown by the patliological histology oî pin-f or tiling ulcer of the foot. In
this lesion it is found that the nerves of the skin in the proximity of the
ulcer are the seat of a degeneration analogous to that met with in the
inferior end of a divided nerve. The medullary substance breaks up
into small drops, the nuclei of the interannular segments divide and
cause a moniliform appearance of the nerve fibres. The axis cylinder
has been destroyed, etc. Associated with the nerve lesions there is
observed around the ulcer a zone of aniesthesia and of chronic inflamma-
tion. The cutaneous papillae of the derma have become gigantic in size,
resembling the subungual papillae. They are long and slender, and
contain vessels, and, if they are not entirely deprived of nerves, they at
least contain but very few. The tactile corpuscles have generally disap-
T40
fATIIOLOOtCAL ANATOMY OF TUB 6KIX.
penred. Die bottom of the utcer is formed of a disinugrating la^er
varying in depth, in which no detail of sinicture can he found. In the
neij^borhood of the iilvor the arteries Bhow a v-hroiiic inflammalion, ao<l
their calibre is contracted.
The changes in the c|)ii]crniie covering the cnlar;Kd pnptllsCi coneiat in o
thickouinfî, at times enormous, frcijiK-iitlT iviiL'htn<; Hcwra) millilnt■trl^s.
Tho corneous cells are i«upennipoKi-iI in thick layers, fonninf^ snccessire
Lcds iiilinmtoly united tojn'ther. Thu niiulei of the colls in the rvi« mit>
oosum, arv not ntrojihicd in the nci<;hborhood of the uloor ; conscquentl;
deiiquanintion doei) not occur.
Aa «xain[)W of cutaneous Irojihîc (ti<itiirbancoâ, in which the inllnom'e
of the ncrv«>» nvatom has been evidently ree<)gniiMtd, we cite the hiilhe of
zoitter and pemphigus, in the neighborhood of which there \a usually aeoo
an inflammation of the nerves or rather an inflammation of the nerre
sheath, or of the inter.fascicular connective tissue (Charcot, llSrengspung),
Finally in some cutaneons lesions of leprosy Stoudner has found lesious of
ihc nerve fibres, more or leas well determined.
0. Dr.STROPHIO ALTBRATlOXii OPTITR I->II>BnMie, AND ASAWOOUS £■■!•
UERUtc 1'roi>U(;ti«. — The type of tliene alterations is found in tlio cachectic
ichthroHix which occiin a\n»i t)ie i«iirfa«c of paralysed limbs, and in coo-
gciiitiil ichlliyosin which ii» a true ilcfonniiy of the «iin.
In fiilt/riaiii'- irhtlii/viiiii, characterised by Miti SK*\t», there are fmini)
only the sign.' of rapid evolution of the cells of the rote muco#um. l'île
nucleoli are onkr^cd, and the tiuotci of many of the cells are atrophied ;
the cells are no longer closely united toïcther, and they die before tiie
opidermis ac(|uires its normal finnue«s. From this process there résulta
a constant deiuiuamnlion.
Cùme-yu» i'hl/ti/"i'i» is clinracterixed by a superabundant formation of
Mk' cpidenni*, in «(wtM. It pre»ent» a variety, ifhthj/ofit riilari», incor-
rectly teniied )i!lyriaM* of the hair». In thw mricty «>f ichthyosis the
conieotiH epidermic layerii are continually produced hy (lie inii'mnl sbeuth
of the hair follicle, and accumulate around it^ shaft in an imbricated man-
ner. The hair follicle is soon stuffed with the corneous cone which Hnrmumls
tue shaft, and the hair breaks off at the point of emergence. When tlie
cpidermiâ continues to acciiniulate. the small peri-pilar corneous maas exca-
vates a cavity in the supcrfieial portion of the derma ; the skin now law
a granular apiirarance. .\(ler a time, the hair and the corneous roaas are
thrown off, but the loenlion of the intradermic cavity is marked upon the
skin by a small variola-like cicatrix.
r. Abnormal CouonATiosts ov Tim Skix. — Tin' alnwrmal colorations
of the skin arc numerou.'*. The coloring matter of bile nnifomly tiogas
ail the histological elements of the ti»>ue.4. In the skin it nets as an
irritant, and usually occasions small cnnge.ttive inflammatory points,
I and minute pruriginons papules. Frei)uetilly purpuric spots are also
seen; liiey arc due to the solvent action of the bile upon the corpnsclos
of the blood. Histologically, icteric pur]>ura does iK>t differ from any
other intersliliiil hemorrhafre of the skin.
The cau#c of tlie icteruid staining in cachexias (tuberculous, sstuniinc)
PARASITIC AFFBCTIOHB OP THE SKIM. 741
is not clearly understood. The coloration is sometimes bluish. The pig-
mentation of the rete mucosum is found to be more intense.
In Addison's disease the skin ia not only pigmented in the deep layers
of the rete mueosnm, but frequently also in the derma. A transverse
section of the skin in Addison's disease, shows not only the cylindrical
cells of the rete mucosum which cover the papillae loaded with pigment,
as in the negro, but often dark pigment ia also accumulated along the
vessels of the papillae, and in Ûie fixed cells of the connective Ussue.
This is also observed in certain pigmentations from external causes.
Pigmentation produced by sulphate of lead is due to a metallic de-
posit, not in the cells of the rete mucosum, which are never colored, but
in the fixed connective-tissue cells. The pigmentation is so abundant
in the bands of connective tissue which accompany the vascular tufts of
the papillae, that it has been believed that the sulphate of lead is contained
in the vessels. There is also found in the meshes of the derma a number
of wandering cells loaded with dark granules of sulphate of lead (Re-
naut), and which probably play an important part in the process of pig-
mentation by transporting the colored granules.
Sect. Vin.— Pansitio A&ctioni of the Skin.
Parasites of the skin in man are of two orders, animal and vegetable.
A. Animal Parasites op the Skin op Mas. — The true parasites of
the skin are those which are bom and developed, live and die upon the
surface or in the substance of the cutaneous membrane. The moat im-
portant arc arariia sfabiei and acarvB foUiculnrnm.
a. The acaru» icabiei (^sarcoptes hominig) occasions in the skin an
eruption, with the characteriiitic burrows in which the eggs are deposited.
The female acarus is most frequently found. It is visible to the unaided
eye, measuring about 0.33 mm. in its greatest diameter. Under the mi-
croscope its integument appears striated by numerous parallel lines; the
abdomen presents conical prominences, each terminating in long fine hairs.
At each side of the head or rostrum there are found two pairs of limbs
provided with suckers. At the posterior portion are seen two other
pairs without suckers and terminating in long hairs. The insertions
of the limbs arc upon the ventral surface. The head consista of two
cutting mandibles formed like scissors, behind which are two feelers
ending in bristles. Posterior to the head is found the digestive canal
whose terminal opening is in the posterior region of the animal. The
ovary is distinct and generally distended with eggs. The respiratory
apparatus appears to be rudimentary or absent. They live for a very
long time without air, either in the substance of the skin, or submerged
in petroleum (Iturchard). According to Bourguignon they respire only
by swallowing the air, the cesophagus carrying it into a number of
sinuses. The male acarus is smaller and is about one-tenth as numerous.
It is provided with an appendage (penis) situated between the two
posterior pairs of limbs.
Tiie female acarus impregnated and deposited upon the skin,
T42
PATHOLOdlCAL AHATOUY OF TUB SKIIT.
A<«rn**«M*> (t«»l*l,4arMl •«iffttc
Pif- :)M. pîcrc«ii with ÎUi naiuritilefl Ute •«•
pcrficial la^en of lli« epi'lentûa,
«net pASMA o1>rn|uol5 iiito tUc
dvnna cutting its furrow a.<i it
KWa. Al intenals it deposits nn
«;:;; in such a wajr that it cannot
rvtum ty th« snouj furrow, tbe
eg}; uMitcratiDf; tlto lUUMgn. It
lajrs forty to fifty tm mm) tlii'ii
die». A niinilwr oi tlMW) c^^«
arc dostmyrtl. i:<'m>n>]|ir iwlr K-n
to tîl'tvfii an' I'l'iin'i ill rach fur-
row, lîy tliir fniirt«pntliday nftur
ilic l»yin|£, having undcrgono tlic
tir«t piliiw* of t)ii-ir ilovelopmeni,
tlie younj^ br^ak the wnll »f th«
furrow formed hy the epiiii-rmia,
stk! api>ear upon lh« «iirfaceof th«
Hkiii. Tiicy have noir only six
limh<i,twa nnlerior and one |io6te>
rior pair ; and are asexual. The
itch docs not reach its pt'ricct development until after three sncMssiv?
moullin)^ which arc : tirst, the Imrrowini; of the itnprc^^natcd fcmiili-«
into the dubstance nf the cpiilermis ; bccoikI. lint prcHonet- oî the yi'iin^
Man upan the suHara of tho iikin: sihI (hiH. the nppoaraiice of iha
charact«rintic )H>lymorpliotu eruption of itch
from tlte scraichint;.
b. AiKuru» F'JIintf/tritm (demodex follicn-
lorum). — ^"I'hia parasite lives in nonual or
cystic sebaceous follicles. Its hody is Imtg,
measuring about 0.:{0 mm. Its bead is pro*
Tided on each side with a feeler formed hy
throe aruculations. an<t has a protuberance
or probofscifl provided with a pcidiar three»
forked or^ian, the points of which tei-niinale
by fine bristles. The head is bletided uicb
the thonix, which fonna with it one-fourth
the lvn;;th of the unimul. To the thoracic
jïUiTt arc attached fonr ;»irs of very short
liinbt* formed of three articulations, the last
terminating in three «nuill hook-sha[>ed
clawit. The posterior or aMominal jiart
of the body i« long, and. accoriling t» some
writers, cnntiiins an intvxlinal tubf nod a
hepatic gland (Bg, !J:"i.^). According to
Ntniniann. there exists anoUier variety nf
acaniH (demodex) folliculoruin provided
with only three pairs of limlEt.
The «carus of the follicle lives in the
comédon of aeneous j^landi. lis prcatMic*
Fig. 3».
.W
a. b'nflrn. ft. Uftlr^ e. 1<» tunt,
d rallld*. 1. UkiBd iMiwpnwn.
VEQSTABL8 PABASITEB OF THE SKIN OF MAN. 743
in the gland does oot cause &nj local cutaneous lesion. The animal ia
met with in the sebaceous glands of the face, external auditory meatus
and auricle which have become aeneous.
B. Vegetable Parasites of the Skin op Man. — Upon examination
of an uncolorcd aection of normal skin, previously treated with ether
and subsequently mounted in Canada balsam, there are seen in places
where the epidermis is thick a number of vegetable spores contained in
the corneous layers. These aporea vary in size and shape. They do
not correspond to any determined cutaneous affection; the probable
multiple vegetable species to which they belong have not yet been
accurately defined. When an inflammation occurs in the skin, and
especially when the latter has been covered by a poultice, the number
of microscopic plants is increased. If a vesicle or bulla is formed, the
fluid in it frequently contains spores. A number of pathological anato-
mists, especially Orth (of Berne), believe that these organisms play an
important part in the development of certain diseases of the skin, erysipe-
las, for example. But the true parasites of the skin, that is, those which
accompany or occasion cutaneous affections, never exist primarily in the
epidermis of the normal skin, and they cause in the diseased skin
characteristic elementary lesions.
a. Vegttahh Parasite of Tinea Favosa {Acliorlon SchoetileiHiC). —
Discovered in 1839 by Schœnlein in the scabs of favus, afterwards by
Gmby and Wedl, this parasite was 6r8t inoculated with success upon the
akin of the arm by Remak.
By removing a small piece of the yellow fungus of favus, and placing
it in a solution of ammonia, it soon breaks up, when the parasite may be
isolated. By the addition of a few drops of solution of iodine in water
containing ioflide of potassium, the fungus is colored red-brown, and ita
structure can be seen. It is composed of roundish spores, isolated or
united in the form of chains. These chains of spores usually terminate
the filaments of the mycelium (or tlmlus). At the free extremity of the
Utter they are at first spherical, afterwards becoming slightly elongated,
ao that the filament is formed by the union of short joints. The filaments
of the mycelium are composed of elongated, distinct, dotted, dichotom-
onsly ramifying, firmly united joints. The spores forming chains are
very frail, and arc considered aa a portion of the plant in the process of
germination. {Fig. â.W.)
Upon a vertical section of the skin through a sjiot covered by a favus
fungus, at the surface fonncd by the fungus, the epidermic layers are seen
filled with spores which are scattered between the corneous cells. With
the spores are always scon micrococci and bacteria, besides small drops
of fat. The accumulation of these foreign elements causes a prominence
and a peripheral swelling of the fungus. The deiireasod centre is usually
occupied by one or more diseased hairs ; here ia where the evolution of
the fungus takes place and where recovery begins. The affection heals
at the centre wliiie at the periphery it extends in a circular manner.
In favus fungi of considerable extent, the invasion of the parasite
is not limited to the epidermic layers. The mycelium penetrates per-
PlTBOLOaiOAL ANATOJIT OF THB SKtV.
[Npendicnlarlr into tlio dt-rina, urnl Oiktv ratniKe». This penetralion i«
'not due to'ii simplti juiHtiiiig luido ot llitr tliKuea, Wt Ui a truo invksivn
(MaIos^s): the tuW« of tlic myi-vlium arise from the lrf>ttotii of tlifi fno*
gus, and !«« in stiniglit lines into tlio connectire dsaue bciw«cn Uie
1^. as*.
Artiorlmi 8ch>nUlnl)iftwtrHlin*iil «Hb Ui'int iMuiv. a. Kfort*. t. Cbal« at tffttt MrM
n«nu lit ll>« ilml» oiui'uivd or cl«a,|iiie4 «ml bctlUuil (cilfaUUta*. X *"''
fiuciculi. The dcno slighllj nact* from this innuioo, and at tlic tiur.
f«cc of tlic funguA thorc i» a cnntiniLal exudation ur i-vcu suppuration.
In cverjrcaso tke oouneclive tissue tnvitded hy tlic tlinluH of thoacAortON
Â'cWn/eiRi't i» );raduaIlvabfior)>ed,and it i.s probitblt- that this abaorbdon
CAune.-t the oicamcea wliich are foumi beneath the fungi aft«r rccoverv.
The beard and the hair are invaded. The fuii^n.* ^rows principally
in the fihroiid ttliat'i of the hair between the loiijjittidinal opiilermic
UminK ; here the RIanienca are found to consiai mostly of atmrvs ; butj
the niycetiiin] 'n found in the tunics of tlio hair bulb in tli« tieighborho *
of tlie root.
b. Tn'ropfit/ton Tonturitna. — This parasite implanted «jton the hair of
the head causos tbo tine» tonenran» ; upon tlie face where the beard
grows the tinea »,^cosa; upon tho smooth rej^ions of the akin the tinm
circinata. Tho reactions of the integument from the same para«it« are
difiVrt-nt upon tliew several re;;ioii8 — a fact which is due simplr to tlto]
TuryinR structure which «ach jmrt offers. Tho tricophyton ini[)l:inte<
upon the smooth chin of an infant ocea«ion» the tinea ••irdtiata. If wiIIlI
tJie hiu'k of the hand one rnhn » patch of lrieo)>l]yton. tinea rirrinata is
produced u|>on the lutnd by transplantation of the parasite. The fun^c
does not occur vxchi'<ively upon tlic inl«gument of man, it uiay be irantu
plaoted to tlic cat, dog, or honte ; thus thcso aoimaU imy become
agent» of contagion.
Trifhophyton ti/Hiurttn» was discoTercil in ISIO by Malmsten. It
a growth formed of roundiah spores, meaAurin;{ about .0O.'> mm. Thes
spores art) isolated or in groups, between the lamollio of |hc cpidermi».
PITYRIASIS VEKSICOLOB.
745
A number are cylindric»! in shape, and placed end to end. Neumann,
m opposition to the assertion of Oh. Robin, has pointed out in this para-
site the presence of a ramifying mycelium.
The parasite is ordinarily found in the lamellse of the epidermis by
scraping the surface of a tinea cireioata and macerating it in a solutJon
of potassa or ammonia. The growth of the parasite in the hair differs
little from that of favus. The spores are usually abundant at the root
of the hair, growing from below upwards between the longitudinal fibres
of its cuticle. The epidermic lamtniB of the shaft of the hair are some-
what separated, in consequence of which the bair becomes brittle and
breaks. Around the hair in the inner epidermic sheath the parasite
accumulates and causes an abundant formation of epidermic laminie sepa-
rated from one another by rows of spores. There thus is formed a kind
of white collar around the hair, projecting above the point where it
emerges from the skin. This ensheathing of the hair is of great diag-
nosUc importance, but it is seen in other afi"BCtion8 besides parasitic.
Microscopic examination alone can fix the diagnosis in doubtful cases.
Fig. 357.
TrLchiiph^Ii>n ton^iifaiirt QbUluvd from ZiAfi>F4 rli-clnaLuB. n. ^^t>urFb. fi,d. y]tain«ntH of (he mjct-
Hum, cuDMiNLlug of Hliort nrLlL-iiLuMi-a». c. KlldUieuLflur the luj'Ci.-llum tuuKlHllJkg ofloag BDiL BhinlDg
■rtlcaJiliuii». I. Call of Iho epIdcrinU. X "0.
A number of dermatologists, and among them Ilebra, consider the
Tri'iophi/ton tonsuraim as a simple variety of the Anhorion Schœnhinii.
But Kobner, in cultivating the parasite, has reproduced it indefinitely,
with its specific characters. Ilallier considers it identical with the Peni-
'.'tUiur», and Neumann is lately of this opinion,
c. Ve</etaf>Je Paratite of Piti/rittsis Versicolor. — The JUierosporon
furfur grows ordinarily in the layers of the epidermis. Its mode of
implantation and the arrangement of its elements are characteristic. The
r46
PATHOlOeiOAL AMATOHT Of TDK SKIK.
Spores ftrc rouiulish, collcotoil into gmiipa in tlic laniiniu nf tlio oomomift
c]ùUit.-li»iii. Till- )nviu|i« iiru i\to rouiuli«li, and from tb«ir poripliory
proceed nimifyiii" lt!iuitt.-nU of the iii;rocliiitn. tlic jotntd of wliich nra
cxtrciiwljr Inu;-, Tlio Ui-vrlopnH'iil of llii» futigUA ia oxtri'iaely wlow. tml
it id rnniily cull: if «toil, ami may W grown in neutral glycerine (Neu-
RMnii)- Tlie .tjiorci» hare l>o<.'n «ccn lo <ii*i<le l>y segmentaiioii, and as
lliey elongate lieuomc llie origin of mycelium filamonu. Utlicvd bevnine
tbe source of new sjxireit l>y cndoj^ciious j;eneratinn. TIte tHternf/Mtro»
furfur was «IWovereil in 1H4t>, by Kiclmteilt, and inoculated snoCDdsfully
in l)i>i-i, by Kobner upon ttie skin of ouin (tî;;. !158).
likMapoNa fqtf ut. a. Principal snupar()Krrufi>[ialda xuiiadaJ ■■*•■ li Swit graiip» gf «yirw.
«, niaiDMM or nj^MllaiB (armed u( luai btUllau oal Mn«4 krUiuUUaoL X *a*>
J, Ve^etahle ParmiU •>/ tfiv Ahipt-^ia Oîrfumteripta (J/i/-mtp.Hnn
Aud^mui). — The vxistviico of tliln para:ti[e lia.H been much disputed.
Discovored in 1843. by Gnil.y. it was ai^rwanU iienii?Hi by many drr-
matologiste, aniong whom were Hebra. K. Wikon, nud îveuuuuin. Bamn
bdicved it to be ninay» preiîient iu tbia form of alopecia, but bin dvsurip-
tion illfTpr* frfJiii that given byOmby.
KeceiUly Mala^aez and aflcrwards Courrègea have give a good dcacrip>
PITYRIASIS CAPITIS SIMPLEX.
747
Uon of it. The seat of the parasite is in the corneous layer of the
epidennia, upon the surface of the epidermic cells, and in their inter-
stices. It does not penetrate into the hair follicle, and is only accidentally
met with upon the hairs (tig. 359).
It consists solely of spherical spores without any trace of mycelium.
The largest of the spores measure from .004 mm, to .005 mm. in diame-
ter, and present a double contour; others are only .002 mm. in diameter,
and have a single contour; and, finally, spores are seen loss than .002
mm. in diameter. The parasite would then seem to multiply by bud-
ding (fig. 360).
Fig. SSO.
Fi". 360.
<l— ,
é @o
ê-a â
G
A hklr rromft cfcKPDr*lo|>ccUi>f »iiLdd«v»1i>p-
iii«at : It Ib narrauuJod tiy «pLdermaL reUh fiJli>J
«Ith apom X ^^'-
Tiiolpiti<iL «pitrpH ûf Hlûpecla. l. S, ^, 4. Liri^e
iip->rFii "Aen Ht iltlToTonlf.ïClll point!. A. But] d Lu g;
Hpnr«i. *>, 7, 9. Lftrir** f mplj «porp». 9, 10, 11-
Ulnats nporii. 13. SiHirulai. X 1<X^'
Griiby affirmed that the mirrotporon Audouini is first developed upon
the surface of the hair, at a distance of one to two millimetres from the
surface of the 8kin, and that it sends ramifying filaments into the tissue
of the hair. Malasscz has not confirmed any of these assertions.
f. Vef/etafile Faraxite of Pitifriati» Capitis simplex. — This parasite
was discovered in 1ST4, by Malasse;f, in the ejiidermic pellicles of the
hair of tlic scalp.
Its seat is in the corneous layers of the epidermis, between the cells.
It penetrates into the hair follick's, but only near the point of emergence
and a little below it. It does not de.iccnd beyond the orifice of the seba-
ceous glands connected with the hair. It is freciuently very abundant,
although it has escapd! the investigation.'* of dermatologists until recently.
This parasite consists only of spores, gcneriiHy elongated and hud-
ding ; the largest have a length of .004 mm to .00.5 mm. and a width of
.00:i mm, to .002."> mm. The smallest are only .002 mm. long.
From the investigations of Malas^ez this paraeito appears to play an
imjiortant part in the production of the laraelliB of pityriasis. In this
cutaneous disease the alopecia is caused by two processes : first, the me-
PATKOLOOICAL AJfATOMT OP THB BKIS.
' ohnn'ml nclion of tU« ftinguH s«pAratln^ tho cpitliclUI lanvellm ; seoowl,
tlio [MiriLiito iictiii;^ aa n foreif^n bodj, irritating the c)>i<lermia and prodnc-
ing an incroatwil activity in the evolution of the cell» — the enlargement
of tlic nucleolus, and the cnn3e<|Uent atrophy of the nucleuK. There \a
oon.'U'ijuciitly a constant defi>|uamation unon the surface of the intejtii-
mcnt. Accnrillng to Mala^sez the alopecia of J'itf/riitU n'mpler is due
to the obstruction of that (<ortioii of the hair follicle above tlie orifice of
the sebaceous glands. This obstruction prevent* the regnlar j^rowUi of
die hair. It causes secondarily an irritation of tlie follicle, ei[>ecially
in the nei^hborliood of the bulb. Here the wall of tlie follicle under-
(•ocB an ascending hypertrophy causini; at first a diminution in tli« c:tli-
bre of till- hair; and, linnlly, an oblitération of the follicle which tx
transformed into a fibrous coml.
The nielhodn eini>loycd for the study of tlie vegetable parantes of tho
«Itin are very simple. The scales or hair* are ren»ved and carefully
washed ill ether. In a fevr dayi all the fat is diasolve<l, and the |>0Mi-
bility of ini.ttaking fat );ranulea for aporea is tlien avoided. Afterwards
the haint or ^icnles are dissociated upon a jfU^ slide, in a drop of a solu.
tion of potash, -10 in 100, or aaimoiiia. The tatter is less r«pid in ii«
nctirin, but ia preferable. The dissociation being accomplished in tbe
ammonia, the latter is allowed to ovaponttc. Tho parasite is then staiiivnl
witti iodine, and examined in glycerine, or is treated with oil of cloves
and Bubsetiuently mouuteil in dumotar.
APPENDIX.
PRESERVATION AND HARDENING OF TISSUES.
[For the benefit of those who are not practical microscopista, and who
conaequentiy are often obliged to refer !nterestin<r and valuable patho-
logical specimena to some physician in whose skill and knowledge they
have confidence, as well as in the interest of thoae who may be requested
to examine and report upon diseased tissue, this appendix is added.
Time and time again pathologists are called upon and expected to deci-
pher the evidences and nature of morbid processes in tissues half rotten
or so far decomposed that it is utterly impossible, even to the keenest
and moat practised eye, to recognize with certainty any but the grossest
elementary lesions. Methods of preserving tissues and organs in the
gross for naked eye inspection, with which the general practitioner of
medicine has been so long familiar, are, as a rule, worse than useless,
when employed in the preparation of tissues for examination under the
microscope. Much of the destruction of the minute traces of disease, in
specimens obtained from post-mortem examinations, is without remedy,
for fretjuently the autopsy cannot be made within twenty-four hours after
death, and after that lapse of time cadaverous decomposition has wrought
considerable change in many of the most delicate tissues, particularly in
the nervous system and the mucous membranes. It is obvious that no
method of preparation can repair the damage already done by decompo-
sition ; hence the necessity of performing the aut-opsy at the earliest
pmctjcable moment, and the demand for the preservation of the speci-
mens obtained without delay.
Those tiasuea which are secured during the life of the patient by the
interference of the surgeon or otherwise, fihould be at once submitted to
examination in the recent state or be immeiJiateJy placed in a proper pre-
servative agent for future study. The old custom of macerating or wash-
ing the tissue for the removal of blood, etc., should be avoided. In re-
moving the piece great care should be exercised lest pressure of any
kind he exerted. This caution is always important, but it should be
especially regarded when handling any part of the nervous system or
digestive appiiratus. In histologiciil examinations it is most important to
study the relations of the elements as well as their individual conditions.
For this, extremely thin sections must be made, and subsequently pre-
pared for the microscope. Hence it is necessary that the tissues to be cut
should be conveniently hard and cohesive. Soft parts must be hardened,
and bony or calcareous substances must be softened. There are various
methods of securing these essential conditions. It is not our purpose
APPSXDtX.
kere to (liâcuHH the many valuable methoda of préparation of tiasuM
emploTed ai the ]>rc3«nt lime by cxporioiiced liUtolojoeU. Our object ia
solely Ki indicate, in the briefest manner, a very few of the most valunblo
and most generally applicable nictliods of prcMnin;; ami hardening tî*-
eiiea for micnMcoptc oxuininatioii, for the ■;uidaiwo of ibe busy pmctt-
tioner who lias not tlic tiniv or the inclination t» xtii'ly itficciBl work* up»»
nicroxcoptcal technolo^yr, hut who often lia^ the o]HM.rtnnily of M-curin;i
for dcienee ino^t valuable pathological 8]>ccim«n», and of profiling by nn
inteli^iblo interprétation of llieir nature. The folloving Bugg«ations are
imjtorUint to oha«rve :—
■V/îK «/ thf Piei-t to he. Kr'tmined. — It ÎB es*enlial that ei-ery part flf
tlie tissue should be >|wiekly reachc<l and aclf^l upon by the a^cui;
this is tlic more essential the jn^^ater the delicacy of thv tissue. I'irccs
submitted to the action of the liarileDin<^ and preservin;* a^cnt, as n nilr,
should not much exceed half a cubic inch. Nervotu^ Miibstance ami other
delicate tiMtues «ho\ild have «nailer dimcnuions. When the whole or a
conàderahlo part of an orgnu ia to be examined, the relatiuna of tlte
difTcreiit pnrt^ titioiild not be entirely tiacriRced to the demand for small
i.iolated pieces, but the tissue should be inci.ied in varioiu direetionii in
such a manner as to allow the fluid to {jnickly reach every cubic inch of
it. The cuttin;;; iii;itru[Dcnt used for this purpose should hare a keen
edge, so that the slash can be made with a minimum of pre«8ure. Hie
spinal marm>w should be cut across at Intenals of half an inch.
Ilffative i'rcpnrtinn» of the Ti'mhc ami the Fluid. — Five or six ounces
of thi- fluid arc iMually roi|iii5itc for every cubic inch of tÎKSUC to W
pre]jiart'(). Kreahiieits of the fluid is alM> of great importance. A>> a
rule the fluid should be changed everv twenty-four hours during llie Brst
three or four davs. The liâsue alioufd be suspended in the midst of Uie
fluid by a threat! instead of being allowed to rest upn the bottom of tlie
vessel.
'riie choice of the fluids used for hardening and preserving should vanr
somewhat according to the nature and conditinn of the tissue and accont-
iDg to the methods to be folloned by the hislologist subsequent to the
making of sections. Those llnids most genenilly eflicieut arc Dame<l
below.
it/U//er*« Fluid.— Water, 100 parU; biohromatc of poUBw, 2 pnrts;
sulphate of soda, 1 jiftrt.
liithromatf of Aintimnia. — Thia agent may be used in the following
BtrengtJi: bichromate of ammonia, ^—'> parts; water, 100 parts.
Alcohol. — Alcohol, ilie oldest and one of llie most generally lueful
hardening agentt), should best be used in die following manner:^
The fimt solution should be 00 per cent, in strength.
The second solution should be to per cent, in strength.
The third should be the strongest alcohol.
The fir^t solution should be u^ed in the first 24 or 4â boars ; the
second for the next 4è hours, when llie strong alcohol may be snbstituicd.
Chromii- Afid. — This reagent needs t<i bo very carefully used. Thfl
«olution should be made by weight and nieasureoivnt, never by estimatia
from the depth of color, otherwine it becomes u very troublesome
often destructive fluid. The »trei)glh of ihis soUiiion «lioaM be 2 — 5
APPENDIX. T51
parts of chromic acid to 1000 parts of water, commencing vrith the weaker
and ending with a stronger proportion. This reagent makes the tissues
too brittle if they are left too long exposed to its action. It is particu-
larly valuable for the nervous syatcm and extremely delicate tissues.
I'hrie Add. — It should be used in saturated solutions. The crystals
are not very soluble. Hence solutions should be made with warm water,
or if made with cold water the sediment uliouhl be well stirred at intervals
during two or three days. With this fluid the tUaues are better placed
at the bottom of the vessel.
Timi- Ki'iimri'.d for Ifirdenin;/. — Most of the tissues are hardened lu
a few days when placed in alcohol or in picric acid. The latter fre-
qucTitly makes the tissue sufficiently firm for rough sections within twenty
hours.
Nerve tissue, especially that of the centres, the hrain, and spinal
marrow, rciinires much longer exposure to the action of the roa;;ent,
The brain or spinal cord must be immersed in chromic acid, MilUer's
fluid, or bichromate of ammonia five or six weeks before it is sufficiently
firm and tough.
Trfutiiii-nf of Tifnue» after Hardenimj. — When the specimen lias
become sufficiently firm, it should bo removed from the hardening agent
if chromic acid, picric acid, bichromate of ammonia, or Miiller's has been
used, should be thoroughly soaked in water until tbe tissue ceases to
tinge the water, and finally placed in alcohol of 8.5 per cent, for indefi-
nite keeping.
Deealn/i/inff Ajient». — Both saturated picric acid and chromic acid,
in the strength of '1 — -i parts to lUOO, possess the property of dissolving
the cakareoHs salts in hones or other tissues. Where the piece to be
acted upon is very small and the fiuid is in large amoinit, the acid should
be often renewed.
The portion of tissue to be softened should not exceed a (juarter of a
cubic inch, and the fluid should not be less than five or six fluid ounces.
These agents harden the elements at the same time that they dissolve the
lime Balte.]
BIBLIOGRAPHY.
Pathological histology of cells and tissues,— Rokitaxskv, Hmuib. <\vr path.
Anutomie, t. I. Vivmn:, IR^I-184il, 3° édition, 1855-1861. — Lkiikht, Plij-siologie
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un embryon noiiiifi6 ilana une grosatsiii' abdominale, in Vcrh. d. WUr^b. (ies., 1. 1, p.
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Ueb«r die VcrHiiderungeii der Oewebu durcli Brand, 1S57.
Kocoosand colloid degeneration.— Vmrnmy, Arch , t. L p. 105.— Wagner,
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Rl-d.shkj', VirthoWs ArcUiv, 1. XXIII, 186,").
Fatty degeneration.— lEi':i-N"n A HOT, Leber die lOnstehung lier Kornchcnzcllen.
in Yin'ioiv's Areliiv, 1S47, t. I. p. 31. — B.Mli'Ki.EitKN, .Jen. Annalen, 1851, t. II,
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Pigmentation. — Vnn'imw. Die patlioi. Piamente, in Areliiv. t. T, ji. 379. —
Tkauui-:, DeuiM'lie Klinik, 1860. — Kosciii.akokf, Virehow's An-hiv, t, XXXV,
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Calcareoci infiltration.- O. Wkheh, Virohow's Archiv, t. VI, p. 5GI.— Vm.
CHOW, Anhiv. I. VHi, p. 103; t. IX, p. 618.
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48
754
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SbtcoibA.— l'l^BVKT, I'livnolouk- |ulh«l<>f!W|ai-. l'nrû, ISti, I. II, p. Un.—
]'»>i:i, ]^irturc>* un «iiri'Kal (iiilh. I^milvn. 1X3-1, vol. 11, p. ISI, l£R, 313. —
ToiiH-tin à Divflofiliixca, iliiw. I'arv, I80<i, — Viiicliuw, PwtBniGiiMV vl ;:liOnii'>
(l'jlliulo}n<-(l<-*luniciin<>, IS* lfi;an. t. II ; StlrOiini, 19* kçaa. CoiXILMl'mft-
IM>r, l>i- In iiitlatiow, iii.4*. I'nrb', It4»8,
■yxoma.— )■ Mim-lkii, MQllfr*( AifliSr, IflSC — ViBCBOW, l'ktkolofEÎe do*
liitn>-iir>. }.'■< Iv^oii. t. I.
Fibrona.—VKHitKirii., QuHijik^ [wt^xvitiom wr Iiw fllirOmm oh ium«un Taimém
jMir ilu livtri rcDuUiir (Gbe. méit. >1r I'om, 1K£II, n° A, |>. ^11 ; n> >, p. V,^). — (.'«C-
Yi:iuiiii:ii. Tniiif «riiiiut. |i«lli. géuér.. t. Ill, ji. US, Ilv. — Vinviiow, Paibobpa
dvi liiiiicurB, l:>* Irijuti, I. I.
Lipoma.—l'Hi'VKiuiiKii, TmitA iranat. palli. ^fii.. I. Ill, p. St>i. — J. AIOluek.
Uf'Wi fcim-rcn Hbii. rlc, gi. ,'■(•. — Vkiim:)'!!., Hat. luii). t\<< rHrik. I^'i-I. n* If, f.
242. — E. GohAUii. Iti-t-Wn-bii tur U siibsliiutioii gmifKati: flu n-ln. I'M! ~
— Viut'uow, rmhuliigiv dm Kmcorv, L I, H* Ii-^mi.— Bruca, Traité «I«b
L II, |>. 3;3.
CBrcinoma.—CKCVF^ii.iiiFR. Anm. parli.. t. V.— Lf.bkut, Phn. mibnl.. t. II.
i_Viiii. II- iw, Virrlio»'» Awlii», I- I, ls*ï. — RnocA, M*iti. <iv l'À<-a<l, Ae ib^I., L
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Mdii. dc I'Auiul. dv niCd., t. XXVlC— KSiihikii, UniidUivli, t. I, V 6dit., loeo.
p. 3MH.
r>ri.i, IH.M,—
liHritl^, llntiii, lh«l\
1H9.— lyfiHAlK 0* ItimtV. I'm*. m*il. ■»« I'lwin. Idi.'i, «• tï.— VlllCltOW-,
luiiMtin.
Syphilil. — C)liiii|iio iooonmpl>i'|i>« ih^ riiC|ritiil dii v^ntrii'm.
ALui:\Hi-Kr.S(), ))cuiH'tH> Kllnik. l»M, kt K ; Annale» iW CkHrIt
ItA
I, IX, j>
S}'|>liil» ronilitiilioDiirllv; l*>lli«l. iti-t (iinw-iin. I. II. ïi)* li'i:on. — Va.s (hiiiur. Ihm
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^Altliiv Itir l(i'ilkiiii'lv), I. IV, ii. I, ICI, Si«, 430.— LaNccmgal'X, TrnitË bî>to-
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uiiiAriiit proiJuctiiMi uf tulx-n^lc (llritiili Jilrd. Joumnl, IHCg).
Qlauden. — ViiK-imw, I*Atb. dn tuim-un. Vf U^çnu.
Cho&ânmia. — J- Mi''m.kr. ttrdr mr Fvii-r dfr 4ï SiiAnn^aj;» di** K. mwt.
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OstfiOniB.— IIi:miv Mi-t-LKM. Ilcitriijiu ziir Krenliiuidcr Eiilini!ki.-I. d. Knacbm-
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Myoma. — Zkxhku, I'l^br* dir Vprnndtrningm Airr willk. ^laikelo in Tvphui,
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HesTOma.— OtiiKa. Munwl <!<.■ oiMi-riiw prntiqiic. GiTnirv, 1^3. p. 3;n.—
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tii-rtt, iii.>i. Tan», I8Î5, — Vale.'stin, Lclirbui-h di-r I'hjsiolop*^ I. I, p. TÎ1,—
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BIBLIOGRAPHT. 755
mflte Abliandl., p. S99; Tumt'nrj, t. 111. — Saxcam-i, ]>t-llu ipertrofia pjirzinlle
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t. XVIJI, p. 5J0. — AxMANS, Uuitriigi.' ^ur mikr. Aimt. di-r ganglion. Nurven-
systums. Bt-rlin, ISirA.
Angioma. — Pi-exck, DortrinH de morbùi culnnei*. 'Wien, 1 776. — Ditpuytkkn,
Clilii<)UiJ tliirurgicjilf, t. II. — -ALlBKltr, Nosiwnipliie njiliinOli". I'aria, 1M.1S. —
Bkksckkt, Hejifrtoire général tr»niit. "it phv.'. I'tiris, Im26, t. H. — Kayeh,
Malailif.'!! <lcs reius, t. Ill, 18-11. p. til2. — SciiL'ii, I'litliolngio nnil Thompic <ler
F!u.'Uilnplnpnii.-n. Wien, 1S,)4. — Li'kciika, Vircliow'n Arcliir, t. VI. — Ebmauch,
Viruhow'.i Airhiv, I. VI. — JtKDCA, Tumour», t, II, fluip. vii. — ViucHOiv, Tumtur*,
t. Ill, 2â'lL-.;oii.
Lymphangioma. — Ukmakqi-av. Mém. Soc rliinii^ie, I. III. p. isn.— Fet^.kh,
An'liivl. pli_\>ioi. HcllkuiKli', IMjg, t. VIII, p. liH. — JIicirKi- Cnz. niect. de Slraj-
bourg, lH5a. — Tn,K/KN. L'niistatt'9 .Inhrc:»b., IHSU, t. 111. p. ■17J. — Thélat. — Tii.
A.siiKK, Tile-".'. I'liris, ]8li7.^ViHCUoiv, Tumtiirs, t. Ill, ïù" li^(;oii.
Lymphadenoma,— HiN, Zcitsclirift. f. vfiss. Zool. Xi, p, (i.5; xil, p, 223;
Xlll, p, 4.15; XV, p. 127— !lo(iinii.N-, Sludif.-cliir. Trims., t. XVll, p. fi«, 1S.12.
— Viiifiiinv, Froritp'.< Notizi'n, IS-iri. — Hks.nktt, Kdiiib. mi'd. iiiid surg. .loiirnul,
18-i;i.— THDVssKAt-, (.'lini.pii' lU- I'llillcl-Uivu. I'liris, 18«2, t. II, 1™ édition
CoitML, Arcliivts di- médwiiic, lt(6â, t. 11. — WALDKVKir, Viri'Iiow'a Arcliiv. t.
XXXV, IHfij.— lîOTTCiiKH, Vircbow's An-hiv, t. XXXVII, p. 1G3, IHOII.— Bc)\--
yiL8, Soi-iété méd. d'ubs,, t. 1, p. 157, 1857-58.— Oi.LlviKPl ut Kanviek, Obs.
pour siTvir à l'iiistoin' <(f lu li-ucixïtliémii^ [Soc. du bioL, IStliî).
Epithelioma. — 3Iax S<'iiri.T7,K, Viri-how's Arc*biv, XXX. — His. Die Halite
uiul Ilijldc-[i ik'fl ini-ii-i{'lil. Kiirpers. Bus., 1800. — U<ihix, Soi', biul., 18.ïy, p. 210;
id. p. 28.3. (liiz. inéd., IMOK OiinoNKi!, Société île liioWie, ISOC. — Vkhn'euh,,
Ëtuilcs sur lf.< tiimi'ilrs de la ptuvi (.\n'liiv. de niétl., série \ . t. Ill, p. 5,î3 ; t. IV,
p. J'I7 cl COa).— TliiKEtscii. I>iis Kpitheliulkri-bs. U'ipzig. ISC.'i. — Cornu, et
Ea.nvikh, I )évflo|>]Himi'nt liî^t. {.roiiriml du I'mmt., vol. Il, p. îfiii et 470). — Bin-
iiKn, JIUUit's Ar>'li[v, lNj2.— GAUWiiiLorF, WUrtzb. lueil. Zeîluns, t. IV, 1803.
— I)i-:.Mi)\ciiv, É[iilliéliBm(! jiavinii-iiteux, thè.*e, l'aris, 18GU. — Mo.ntfl'mat,
l'olvjH's de ru(érii.-i, thèse. l'uris, 1870. — ItiN"i>FLKiscn, Lelirbiudi der piilli. Gewe-
belidin', 1807. — IIll.LliuTir, l'atliol. cbîrurg. génénde, trad. fnini;aise, lM09.
Adenoma. — CnfVKu.iuKn, Bulletin Aead. roy. de niéil., t. IX, p. 300, 1844. —
Vkm-kat. Diriioiimiire en 3U vol., t. XIX, p. ûD.^Lebkut, l'Iiys. piilli-, 1845,
BitorA, iirl. AliÉNÛMl': du lliel. em-velop-, t. I.
Cysts.— Kcmi.jtAL'scil, Kystes dennoîdes (Mnller's Areliîv, 1843), p. 3G5. —
Lehkut, Anat. iialli. — -UkmiU'lin, Sur ipielijiies proil net ions Iiélérotopiiiueii, etc.,
tliÈ.-e, 18011. — V ll.soN l'ox, Stir l'origine et la strueinre des kyste» de l'ovaire
(Journid île l'unat., 1865, p. Sa.l).
Ijesions of bone. — Tjuma, De novonim o?<iuni in inU'gris tint lliaxiniis, ob nior-
bos, de|HTdilioniliiis ri'gi'ni'viitione e.vpmineiita. Viin\ 1775, i"-r2. — UuilAMKI.,
ObsiTv allons sur la réunion des t'raetuivs îles os Oléui. de l'Aeail. de.i ne, 1742—
1743). — Tk.viix, Slénmire .-iiir l'e-xfoliation des os (Méin. de l'Atad. des se., 17j«).
— L'iMVKiT.iiiKi!, I',ss.ii .'iir l'aiiatomii' palliologii|ue, t. 11, p. 420. Paris, l8l(i. —
Gniiiiv, Ili'i-lienlus -ur la eaiie ((;a:!et(e lii-lidiiui;idaii-e, 1S54, t. 1, n'ïî); Mé-
moire hiir l'éla) nialériv! ou iiiiat(iniii|in' di-s os malades (Anliiies de médecine, lév-
rier I S;iO, 2'' ?f rie. t. X. p. 1 2'.') ; l>e lu périostite et di' la mfdnllite ( Archives péiié-
ndi-s de niéiiecine, anût lM5:i. .j" pérïe, t. 11, p. l;i(».— Oi.MKlt, Traité e.\ péri mental
et elioii|iii' rie la T^iîfnéralion des os, 3 vol. Taris, in-8. (ig., I8C7. V. Masson. —
II.AN VIKN, Considéra lions sur le 'Iével"]i[M'mi'1it du iissii osseux (^Thfeses de doctorat,
Paris, ls(i.>) ; l)eseri|ilion et dflinilioo de l'osléite, de In carie et liif tubeivnles dea
OS (Anliïves de pliy^iologie, t. I, janvier 1808) (.'liASSAHiN'Af, Iles alicfei ni;;u9
sou.«-|iérioslii]ues (Mém. de la Siw. de elnrnrp;., vol. IV, p. 2Sil) : Mémoire sur l'os-
téoniylile (liaz. méd.. lMj4. n* S:i). — VkiiNKIII-, Note sur les cellules du tissu
inédidiain' ries os et sur leur étiit lians rosléonivélite (<ijiz. niéil. de l'.iris, 18.>2, n*
211). — (ifissKM.v. Mémolri' snr les ostéites Épipliysaircs îles nilolmeenls (Aifliives de
niéil., 1808, 5' !iérle, t. XI, p. 513).— Giuai,i>rs, Gazette ileji hôpitaux, 1802.—
ïf)6
BISLIOORAPIIÏ.
liiorVKT, Do la pjrîmlîtc (lUWiiHioditc tliffiutc (T)i}i-><«'lr'liv(nTal. l'^ri", 18*7), —
Kfil.ATON. Itoi-bi-n-lM-J "itr VatfifUiMi tul>"Tnil.-iii«> Art m- (Tli*«-* ili- -Im-d)™!, l'iiHl,
IfiAtf). — IEak vtKi:, Allfrnligiw hiMuli^iiiw* 1I44 mililiipTi iliiii*ti:ii liimt-iir> I>Imik)h«
()v}clft6 anHtomûjUP. IH4S. p. rnt), — l'AtjirKr. ^^iii'li- nir lii tumiun bUni-kc*
ÎThbws lie l'iiri». 1f"S:) — K. Viii.KU.w.H. MnUilic <ln w. iUih k' llaivllii>-*li itrr
!liirurpi- (l« Pitkx l'I Itiltrolli : Sur rtiitrlolofiti- •l*' lu cut'ic vi •!•' l'osléilo ii> Lun-^-
brrk'B Awhiv, t. IV. — J. IJikiiik, Iti^lirn-liw sur Ir racliiiisiiw tlw* !■•" l'nranu
(dix. inM., I. Il, )>. fi. ifiSi l'I ltt.t!>, |h 4.1H). — llAVt.Aiil', Du rM'IiitUnir, <lv la
rnipli'' fie» m i-t "k l'(Hi#oiiulae)p (Tliitn "ii- l'Brit, IP.iï). — IImck'a. Sur (juM'iin*
point! <k-raiuil<iRiit-j>nI>i«lD|tii{iir <tu nrliitùtnc (KhII. à<- U Sw. nnikl., Ih.'.S. [i. Itl).
— Vtiiciiow. Dji!i iioniiilc Ki>(N-li>-iiirair1ii4huin miil i|h- Rir)iili>i-hi- S:<"' < '< ••
mIIh-d (An'liiv l'Ur pulli. Aiiul.. vol. V, p. 109>. — KtMiFiKt^rH, I.- r
]atllciln^iM-lii-n ( IrnrIii-li'Iirv, J>. «SC— Cw, RnulM, Sur l'rxili-iiil- ilr <lii\ ■ -i»' ■■*
lioiivi'llc* il'I^I^iiu'iilK nnnl'Mnuiucs •\m *■■ trmx'iil iliiria t>< rsiial rii^Iiillniri' d'*' u>
(Sa-. iJir liiul., Itkl.'O- — (■L'UJ^NV. \ki.atux, MtmiMiv »iii Im lumi-uni J> nittloplu^M
('l'hËK» <!•-• l'ari», 1 H«U).
LmIoiis rf ecrtiliigei and articulntion».— Dii-iv rur.x. Diniiiniiairr >lw «i-
«nri» ui+>lic-iil>'v 1, XNIl. [I. Hk. — |Ii \m.in. IiH-iimiunîn- <Ip mtiirt-iiir H (!<■ i-tiirar-
po pni[i<iurs ■- X, p. n'j. — VKM'fiAi', Ilii-rioïkiiitrv i-n Hu vol., lui. MnlaJiri lUi or-
liriKfiifioit.^ltiioDiK. On UÎM'iiM-ii «r ttip ■Idinl*. l^mtoii. IHIfi.^lluMV»;!, TniUi
ih-s niiilndici (k-9 nrtii-aliitioiii, l'urii. IN'lJï. — lt4)viLi.AVi>, 'l'niié il» Hi<-iiiBalÎMue
utile II Luiiv, l'arù. IKiit. — ItijirKiix. K<lii>l)«ir)tli Moiitlitv Jiiiifiial, UcIuImt. Infi,
Janlliu;, 11*^4. — VlMi'IloW. Anltiv fUr iwlli. AnKt.. I. iV, IHAÏ. — lti;<>i'A. Itult.ilo
la So.-, nimt,. l. XXIV, p. 4Si*<Bi>II..U-r,\«-l..l(. >iié-l.. IR.>r., 1. XXJ l».Wn.i:ii.
An-)iiv rUrpitUi. Annt., I. Xlll. p. 74.— Itinivr, M^iiioin' Mir !■■■> tuni-uni l4aB<'li«a
(Mroi. ilr l'Aoïd. An mM., IH^:!). — CitAKc'iiT. ttbi-iiiiiAliinic nrtii'uUifr cktiMiiniMi,
Par» (TU>c* dv iliN-Uiral, IM53h ti'Ç'it» fnitw jt la SalpHrItn-, l'-iérir: Artlira.
pathim ruii«6(^liim aux tiiiiIndW^ du cnii^u r\ di- ta inix-lli- (Arrliir. «le iilnuio).,
IHUK. p. 173 i-i HI1i).'-Oi.i.tVii:R KT ItvxvirR. É'ixti- liUloio^-iii*' wr V artlira-
Eiiliîc liM-iinutbiniiK- (Soc. dir Inol., IHS.'i).— Vkiki» t.v (Tlièt-rt ilr r«m). wr le
Inimalitnip lurlii-ulairc chronùiDi'. 1»CU. — CahiiI, Tlièiia du I'htm, ISiiA, — Vinjt-
MANX. -Vnliiv filr kliiii'W-lH- Climirj-ii-, I. M, p, -lIMii,
LeciOttt of «Unlar and wrou tlwuet.— !• Hcxtek, o» lidl^unnaaiion —
BliliAT, .Vnntointi' gtiifniW, I. I. l'arv>. 1813.— Hoi>r.KIN. lAT«*rM Ml tV' Hurtnil
Aiiiitomr of Si-r(Ki.'< nlid Mui-aiu ïlirritimnci. l.oiidnci. I8SC-IM0. CoiiMiEnl,
ËDlittmliin^ iiDil Eît<-n.ti>e(Aivliit' fUr pntii. Aiuit., 1. XI.. p. I. 1Mii;).>~U>;cHLi)'n-
UAI^nKN, Die Lvin(ilii:i-tï'M.' tiiid ihn- ItrzicItUllji tcuin Hiudi'jti'«i-tii-, IkUÏ, Berlin. —
L.VN(iKilllA\f^ i-t t. A. lloi'FMANN, Ubi-Tili-ii Vi-riilviil lin îii L'in-iilolÎMi eiuirllatir*
im '/.\niu.\H-r* ^An'hiv f&t uitli. Aont., tu). XLVIII, |>. ,S'>2). — A- Scuuii>T,
Arrhiii'* lie Itrii'lidl rt île du Itoi*- Itr vmoiid, If6l, p. !iAÙ <-t U7fi, l'I IM^3, 11. 4i8
et .li'A. — !.. IEanvikii, lli-i iH-innnb' •-■■!lul.iiiY« dv» tendiicif rt il» tiwii ivIlDUir*
(Areliîr» ik- phinio).). iKtln. ]i. 471: l.(<iont du tutu i-oujooc-tll' daiu l'œiltiBe
(Cunijid-^n'iitlitt lit- l'Acail. ik-n K-., juliivt l^■t). — K. \Va(i»:ii. l'oiitrîliiitiMu i
l'iinal(miH< luiiliol'ip'iiK.' A<- 1» plliin- ( Aivliïv dur Hvïlkiiiulu. 10I. XI, 1** IhrnuMm).
— K>rj>T>*li. |l^i'-'lii[>{Fi-iii.'itl. 'lu rarHliQiiM', IriC9; Surrinllaïaiiaatùiu roujwHHB W*
nrlii'uUiioiis (.Xn^Uiv l"ilr ]Mlii. Anat,, i. XI.VIll, p. ;ii).
Lenons of musclea.— Zkxkkk. iUl^tionn <l« mtivlM duu ta lîlim' trplxilde,
etc. l.K-iprig, IK)i4. îiil. — Wai.i.kvkk, Ari-lirv rtlr pilli. Aimr,. I. XXXlV, p. itZ,
~-V>vi:ni.X}<K (lin IlouhgiH-), Trait* di- l'tln-irÎNiiioii loejilî'*^, î" *-lit. ; l'iuslj'ti»
niinvuliiirc |»cii>l(>-1ivpr>lr<>piiîi|iie(An-liivrJ U^ii. do inéil,. jiiiivii-r IKfllS). — IIaTRM.
Ktiiil^ Hiir k'* mytvit'.'V si nilCmiiliiiiti-a ( .^n-liive* dr pliytîol.. IH<U. p. H), 369, 4Ï^
478, /iijfi). — (-'. O. WcHK.K, l>fTrlu[>pc'iiiL-nl du ran'iriftnn- ilaiw II-* ninirf'"» ( AitWt
fUr iialh. Aiint,, t. XXXtX).— WKtiiMAKK, in lli-nlt- nnd i'iViifur's ZriL^liKfi. voL
XII. p. i-'U, i-t vol. XV. p. 60. — VlRcmow, Sur l'iiilliimiiiHliufi |iEtn-tic h vaunnne
(Atvhiv Hir \<aût. Annt.. t. IV, p. -JOI).
LeeiftUOf blood, hoart, and veiaell.— 11nt<iLi,A(-n, Traita rliniqaii dM mala,
■iii-ï du .Mur (Arclilvi." cfn. di- niéd. Ui:i9).--l.K(i«iirs, Ilwlicralw» tnr 1»- oinici*-
lioi» niitciii»!^. I'nri^ 1NS7, i-t (lui. bi-bd.. l)Oi;.— IIf.kkrtt, t-^linlni^i Mi-il. and
Sorj, Jdiiinnl, U*i.".. lol. l.X V,— Viiiniovr, Sur la lim «inii- in llatidtiiirliiltTr>p«C.
PHtbale^ie luid Tlwmjtiir, I8&4, 1. I ; Uèiuoin» lui U i-oagutuùua ttu aiuift, wr la
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[jorls avee les vaisseaux { An'li. de pliysiol.. 1KIJ8. p. flit). — Luilvillk, Méningite
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d'ii;;ré^'ati(ui. isiil'. — ^('iiAUfiiT et Vi:li-Ias, Sur l'anat. patliol. de l'alaxïe locomo-
trice ((Jaz. liidid.. 1x02). — l'uKViJST et CoTAnii, Kluiles pbysiolojiiijues et patlio-
lo-^iipies sur li> ramollisse me ut eérébr.il {.\K'ni. de la Soe. de liiol., iMGO, p. 4fl). —
Rd^IA.v. Ueeli. sur le ranjollisseï lient dn eervean.v. Paris, 1M2U.— AM'IiAI,, Clî-
niipie ui^d,, 4' édit., 1. V, |). 373 ; Aiiat. piitliul,. t. II, p. 3ii1.',^IIaykm, Éludes
sur les ditrérentes t'ormes d'ern'é])lialile (Tlièses de l'aris, IHIi.''). — Vmcnow, C"n-
f.renitale enii'plialis ( .AivliivtVir path. Anal.. iKi;;, vol. XXXV III). — DfiiiKT, l'iiits
de selérti-e du eervelet (Soi', amitoiiiiipie. Inii3, p. 37), — VAniUiT, Élude sur k
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iréuiTesientes seeiuidairi'S de la moelle (Aead. des se,, de Vienne, IH.'jl. 1W.')3, IKj.'i).
— (;ilil,i-:ii, llii lamoiliyseiueut atriiplii<]ue envisaiif eoinme l^.sitin eonsfk'iitive à d'an-
tres alleeiious eneépluilicjiies ( Areluvesg^M. de niéd,. 18,")!l, t, II. p, 31). — Chaucot
el Jiifuiov. Cas de ]iuralysie infantile spinale (Andiives de pbysiol,, IMfii), p, 134), —
Vl■L^IA.^. Méuirifrile ,s|iinale avec selériw lortieale annulaire de la moelle (An'bîves
de jdiysiiil., lH(;;i, p, 27!i)- — Bkaimkt/., I>e la uivf'lite aiguë, tbè>e d'agrégation,
IM72, — IIajiam'iiiNi) el lioiiKH, Hii'beri'bes snr la paraly.sie spinale de l'enfanet;
(S.n-, lie liiol.. 1M72). — Laih)1i1>K, Paralysie csseutielie de l'enfanee. Paris, ]><6l.
— Loi'khai:tCi,ahkh, On tbeputliology of tetamiï(Medieo.eliirurgicalTrunBiictio»!i,
758
ILIOORAl
IRflJ, rdl.XI.VIlI); OnlliPBiorlnil.iiiiiloim ofi.rniiin(viiirM(l.ntr«t. Srp«. Iftfl*).
— J^iFFniir Vl I'AMKoT. I'n rj>' '!•■ lurnlw»' iiifiiiilili- ( An'liim -Ir (ilivainl., 1M19,
p. 310).— Jmii'iiov irt l>i;('iii:\K>:, Alroftliii- iIm n-lliitv* ruTï!-!)»-*, t-h*. MOmii
rrciiril, ImlS, |>. 4!i9. — lU'fHKSSK (di- Btmlfçoi-). I'linilisif Bimi'liiiiui' (rrawHiue
■la Vriilaiiri' (Aivliivi-* j^ii. lii- iiiM.. juitlci iMli)'- l'nrnh-<i<> miwciiljiin- [lu'iido-
kij~|H.-Tin>|il>ii|uv (Arcliivcv j^ii. itt- Rié-I.. JnnvHT IM^M) ; ]>l- l'iitiixii' )iN->n»-iinn<
( Arcli. id' iiiti!., rfri'i-rol>n- 1H5S. jiiiUK-r. ffvrirr, «vril Ifijifl. — ll"'f»!iKiN i-t l.i'**,
^lli'lcti rliliHiilct 111 liialr'!»-;!'!!»-* mr I'litaxjr l<voiit(i(r^i- ( Ariliirr* (;#ii. <)■■ niM..
noii-inhn' IHi:i ). — I'liiililMA.s, (.'ni>-r>ui'liiiii;[i-Ti Ulirr >1ii- nonii«l<> iui>l jHitliol. Alul'i-
■lir ilni HQi-ki-niiinHm. Jean. IkiS7. — I>k>im>:. IIi-îitIIki.- iiir fHthol. Ariut. 'Ii-r
TrlMiiui. Liiiwis, !n:.â.— l,.»St.i:m;A»'x, i\ha. S»-. tiiol., ImJI, |i. 223. --Mi-
OIIAl'l>, LbifM» <Iu >i-ttÈnii? ii<-rvi-u\ ilmiB Ic lélNB'i* ( Arr1i!*t-< dr |>l>ir9i«l,, 1HS3, p,
5»). — I'iFiiKtT, Not*' 'iir U *clMv^- lift «ifiloti* ii™i*"HrtiM | An-litvi-» ilv [ihyiiioi..
Wl, i>. 364).— Hit N J AN IX (Anrliiv lUr )ui(k. Annl.. I. XIV, )>. iii).
Recpinttorjr appnratos — Kami ftm».— StmiT»»^, Vntrrt. «twr iK-n lU»
iUt Nii.-i'ii-vMiimliiiiii, li<J2, — KoM.iKi.n. Hololoj.'ir, — liiKAi.i'lr', Mf loiiin-H ilr U
8<K-if'l6 ill- thiniiyic, l^.t. — Mrti(>.\, .^Iriivtuni t\r» fidjiivt nato-iitMrfnpfiu (liB>
ciélt <lc biiiltigri-. 1:^17(1, p. 923).
Larynx.— <'t>vNt:. Then- ilc •lociorui, I6T4,— Éhkrtii, It) RiNnn.KiM*». Tmlrt
(riiiili>l'ii;li' imtli'il'i^'iiitii;, Irait-liiU'il liv M. IJrii»*. Ihît, p. ;un, — F<Mt>Tt:ii. I<^,
cil. — l.iiciH. Kivlx-n-lHO aniiloini<itii-t. juitliotnijfiifim I'l (lifni)H-iili<[iic< «ur U (it I'm
Ivjiiuil'it-. Vnti*. IKO, S ïd. iri.H. — Mahkin. l»'-» iwi-i>l.'iii> liinii;'^* ■(.- U fi^vrv
li phol-li' (TUW, I'lirii. IKIl,i). — Klilnir.MiOl I'l I'c-TKK. iil'lii'ir l.nr^Ht 'lu IHt-
l!i»iiiiiimrlii'irlt>|ifctii|UCilmH-irt • iiié'liiuli-i. — C«tM|r, Y.UuXv* unr Ir* |Hi|y(ir* ihl
liin iix ohirji U« I'lifiiiib vt en partiviilii'C «iir Itv pQljpw fOtyitiiilitux. Xlièfv, fttrit.
Ids;.
Bronchi and lung.— I'Arwrc. TraliAd'atKrnltnttanmiiliaii'.— Av ' '
k|tif«ié>ll<*nli-. -I'f-ilit.. ■'( Triiiit il'uniit. |u(li. — tlAitrtr. Iti-rhrn'hr» -ur '
ticn l-itiKM'Iiv. l'.iii<. 18.^>!.'— (iOMUArM, blii'lc* Mir I'.iiinl'iiuii- |icilli(ilt-^'|...
itiUtaliiii lift ImxiL-liTn. l'arû. Ik.Ih— Kili.ikt rl IUutiilx. Tniilé il» tnslmlin
<lr« «■■■(iints. IKIS. — Fal'vkl, RiH'li«'iTW!<mr in Immrhiti.- i-ipilliiiir. Viuv, l^4(>. —
ItoN^-iiiMiL. l{i-<'lH-n'limHiiti.>i[>ii|tii->.<'ir..>i]rr<'iiiplit-èmi- |MitiiKiDair«r, ant- |iluiirlia.
Unixvik--. IM!t, — HoriMAVri, UWiniiiciin' 111 I.'." vrtl.. >ol. VII, p. 1 LM.— CH.
Ehkhaw, llUlnirf >!«■• polyru'^iiit [aryii\. Smulmiiiy. 184-1 el IHJit. — Ttiart^tAO
vt Itiït.i.iK'. Me In plilhi*ii- l.inn^^- (MAmoim il« l' Arailéiuip mvali> >li' n>t<L,
t. VI, IH.II). — Hiit:ii>9i\KAi.', \hr» iiitUmmiitioni *;>(>'iiili'* ilu ikjoi iiHii|uau.
TscAf, 1H*U.— SciiiiAtiKH. Di-iitM-W Klinili, n* in. IHH.— Lkiioï, t>r« roactf-
ticotx* broucliiiiufA, Thin- rli- iludiml. Pai», l^ilM. — I>I'iiiii:t. Ih' ra|-D|i)rxir fioU
monairT. Tli^- il'a^irfcKiioii, 1MT3.— Gaiki>neii. ilo'irlily Jixim. cil'ilMl St-., tuI.
Xlll. 18,^1, On (he |inili<ilii«. hiihI. fil' l*oin1iitia. K<linlttir;pli. ISAi>,~(.'onKi<:AS,
PuMiii Jniirii.it. IH^fi, !■• .IN. ft .\ivhiv>-< ^tnir. di- i»M.. IS.I^, I. II ; )8M, t. II.
Ihltilin iln>)iilnMinT<-l.. D°i4. IfiWi . — ('oKMt., l^colUiRtr t'aliiil. fall<nl>>L-. vt *«r W
rigni'"' toiiniii pur I'liim-uliiitioii dniw l« miiliidif* dii iioitnioii. in.«, )i*;4, G. Batl-
lièrr.^ — Ctii Vi:ii.iiii:ii. AtlHt il'minluiiiic imiliuliij^iijtti-. 'ni' livr. — ItAVMnxit, Tbti*
dp I'aris, 184'/. — CliOMr.L. NoM^:ra|>1iii' 'Ir In piuiinKqiic rlrroiiiipif, fond^ ntr knit
fnilfl. 184.1.— rMAHriit, Di; hi pti>-iiiii<.>iiir rlinxii-iiir. Tlikti- Ae onixfluni poor
l'ufcTi-ïtilioti, IHiiO.— TltAtiut, I>iiil*rW Kliiiik, 4», 49. 184:i..— Scilbiiti-r.ll VA»
riKR Kdi.K. OU. unnt. pnth., 1830.— f'AVAiiiirT, 11^ l'<'inpliy»iiiu> iwlm, Tliki»,
I'jiri*. 1843. — Vri.i-KMI»'. RFi-tii'rrh» 9ur la v^ficnk- {HitDioiiiiin< I'l rnnphr-èaii*
lArchivia jr^rifr. dp mW.. IMCU, t. II)-— Mawihci; llAvrtAi.'ii, Ufinoin- -iir I'ns-
f'oli'ucitu ;rfliériilû<i^<>(l(-H iHiiinimi* (SwiM^ in^dirnl*- <lr« liOpitaim. 13 innr^ )h;4). —
KiiKltriL el 'I'liAOV. SfN-iéi^ iiié^licnli' •\vi liApiNiux, IS'4. — Tkoimuk, ItivWrrliei
•ur ti-- lyiii;>li»ii^iir)> piilmonHin'*. Tlijl't' dc> diM'tonI, 1814,
Tnbercnlosii.— l^i'*^s'>Htvti^ rufilk'nledc'tiraiilioitity. tnj'ct ma;:. — Ymcnovr,
Wk-iiit uifd. Worlii-iw-lirirt, ISiC. riiiliiliij.'H' rvlliiliitrc— SIaiitri.. TIiè-* d«
l'an*, ISCr.. — ViM.Cills. Ilu tilliRrruIr (Ob/.-!!»' mrdl.-iil.- di.' Stnubourg, 1864.
ViLi-it>ii.\, KtDiIi'* «ir In hihrivuloM-, I'nri'. 18117. IV l.i iirvlciK«>-l di- la \^
i^ifiritS y\v lu loln-fi'idon- (Biillrli» dc I" AcjKWniic do mftiWiiw, I. XXX. n. 'i\.
Dtvi-^ioii fUr lu l>iWn'iil<vii- à l'Ar-arléinir 'li- m(>d. ( Italletiii d<' I' Aodémir. IKiTT
ot IBbS).— Kunt, Doliigrsiitilio, l'arii-, INC^.— lliiiiAiiD i'iCimixil, Di- U ptitkuii
BTBLIOaRAPHY. 759
pulmonttire, Pons, I86T. — Lkbert, Pliyaiologiu palholo<ri|iie 1S5G. De I'anatoinie
patlioloffiil»''' <-'t <lu la putliojiénii^ ili- lu piipuinuiite diK^éininéo et chroniijiK! et <lc3
tuberciiTi's (UazL'tte méii. lii- Paris, 18Cr, p. 3M)). — I.Eri.S'K. Vu In pneuniotiio l'asÉ-
eHBc (Thënu ct'Hgrégalioti, 1(173), — Tiiau.n, Ittflif ri'Iii-s eur I'xnatoiuic piitholo<;ii|uo
lie la tuberculose (1873). — Ukanciikh, l>e l'unité de la phthisie. Tlife-ie, 1873. —
XlBMEVKu, Leçons cliniiiiii's «ur la plitliiaie pu li non a in-. — ïiciirpi'F.i., Obwrviitions
HUT la tiibereiilosi; de^ panjjlions lymplmtiipu'S. Tilbiily;iii?, 1871. — SANBKnsft.v, Re-
E>rt on tlic iiiiK-iiIiibilitv unil di-ïi-lopuient of tiilicn'li:, also Tr.iiisat-t Path. Soeietv of
OMioii. vol. XXIV, pi. XII. Xlll. XIV i-t XV).— Caiii. Fiiikim.aesiieh, ïîe-
mcrituiipfn UbiT Ilicseiizellen unci ilir Vtrbaltnisii zurTuberfiiIo^L>(BiT!inerWoclicii-
sehrilï, 1H74, n° 37). — MisTEiiUv.vdA, Kfsai aiir la sfiuéjologie di-a crai'bats L'on-
BJilérffi surtout an point de vue niienwtopimie. TliÈ?<e, Paria, 1868. — Rasmussks,
Conlimieil observation on lisemoMvsis. hdinb"r|;h, 1870. — FkuhéOl, Ulcération
tlibercnleiist' <le bi liinpie (Xolt'8 lue.i à la Société médicale des hOpitaux. le 1 :> juilk't
et le 33 octolin' 1872) Ji'lliauii, Ile» ulcérations de tu bouche et du pbarvn.x duns
In pbtbijie pulmonaire. Thèse, l'arls, 1855 (Note *ur l'ulcèrt! tuberculeux de la
bouche, Lausanne, 1870). — (iossKi.iN-, Gazette des bfipitiiu-t, IHCS). — U. TnÉT.AT,
Note .«iir l'ulcfere tnlierculeux de la bouche tt en purticulier etc la lauffuc (Acud, do
méil., 27 nov. 1860), et Aifhives pén. de méd., I87i», t. I, p. 35. — La.sdkjklx,
Des pncumopulhics svjihilitiipica. TUèw, 1872, — E. Met/iickh, Pn>]ibvluxio île
la pbthiaie pidtnonuirc. Strnsl>our«, IKt>!l. — ^I'vtg(iNAT, Aluludie des tuilleurs de
crÎEituI de lîueenriit (Bulletin Acad. de méd., I>t5!i). — Fki.t/., Mulailie dcx tail-
leurs de pierre ((Jazette méd. de .Striisliouiç, 18C,'). n° 2 et 3). — GitAiMiKR Stew-
art, On dilutiitiou of tbe bronchi or bronchîecCasia. Edinburnh. 1807, — Wuod-
WARii, J. J,, Prt. 2d, Med. Vol. of Med. and Surg. Hint, of the \Yur of the He-
bullion.
Stomach.— lîl'.LAR», De lu mcmbmnc muijueuse jrastro- intestinale. 1 R2.'i.— Cru-
TEiLiiiKJt, lUuiotlinscnieut du I'estomne, mémoire lu à l'Institut en 1M21 ; Sléilecine
pnitique éi'liiiK'e pur l'unatomie et la plivsiolopie palbûlopicgues; Anut. pilli. gêné-
mlc, p. aO'i el suiv. — Liiris, Arebivcs (rénérules de médecine, vol. V. — Kaynal'd,
Sureneufide fîa,.=trite phle^moncuse (Société anal.. IKiW). — CliuvElLHlK», Anut.
path., livraison 'Jci, pi. V, \'I, !iv. 2o, pi. V, VI. Mémoire sur l'ukèrc simple do
l'estom.ic (.\eaiiémie dcB ?cienee#, 21 janvier IP.iG et .Vnliives générales de [nédti'iiie,
185li, t. I, p. IJy et 442). — KnHTKi'x, Andiiv. v. Virebow. t. XL.^Kii.Afss, Dus
perlbrin'nde Gcschwilr im Unoilenum. — CtutNii., Noie sur les Ivmphuu'iiles pulmo-
naires ï propos d'an eas de syphilis viscérale (Soc. méd des h&pitaux, 22 mui 1874).
InteitillG. — Vi'i.rlAS, Leçons sur l'apiwireil vaso-moteur, 13* et 14* leçon, t. I,
187.">. — Ills, in ZfilsehrlIIIUrwisB. Zoolcn/ie. XI, p. Cj; XII, p. 223; XIII, p. 455;
XV. p. 127. — Tkicii.manx. Dus Saupadersviiiuni, voii anat, Stiiudimnkt beobueh,
Lcipsig, 1NG1, — DKnuvK. Andiives de physiologie, lw70. — TiiiitY, Sur une nouvelle
niéthoile d'isoler t'intcsiiu pêlu (Comptes n'ndus cle l' Acaii. des sciences de Vienne,
I8I!4). — lî.ïi'ZiK.TK.ivsKv, Ziir pbysioliijii.-=clien Wirkung der AbfUrmillul. Rcichert'a
uud l)uboi.*.lieym'>nd's Arebiv, 1M7u, l_B7. — A. MnitEAV, Exitérienccs sur l'intes-
tin (Note cuniaïuniipLée à l'Acail. <le niédecine, 5 juillet I8ÎU).
Digestive apparatOB, — (iiANi:ï/,i. in .'^itzunfrslK'riclit der «acb.». Akndemie, nov,
ISOO. — DKniiVK. Du i>-orin>iis biiecid (Tlifeic de Paris, 1H74). — Davai.nk, Rechet^
ches sur les infut^oiiTs du .«aug dans la maladie connue sous le nom de sang de rato
(Coni|ilcj ri'udus de l'Académie dos .»eieuce«, 1, LVIl, p. 22», .151, 38li, I8U.'1, t.
LIX. !>. -VX.i. 420, 1K(14 et t. LX, ]i. 121(0, 18(îj, t. LXI. p. .l:i4B.— CiIARCiiT et
VfLi'lAN'. Sur les lésions lies nerfs diins la pandysic dipbthéritiipte du voile du palai.'i
(Gawtle bcbdomndaire, t. IX, 18i;2, p. 368). Doi.iiKAr et GfiANCiiKhi, Sur en
caii d'clcpbiiiiliEisis de la lèvre (Hulletin de thérapcutiipie, 1875). — Gt;ïox et Tlll-
KnUY. Note sur l'existeuce tem[Miruin' de kystes épidermiipies dans la cavité buceale
clicK le ficlus et le nouveau-né (Alvbives de pliysiologic, 18Cfl, ]i. .lOR et 5.'li|). —
QriNijiAii', Nouvelles reeliendics sur le muguet (An-bivc de physiolo"ie, t. I,
IMOR, p. ;iUH). — GlKNtAL' DEMt'risv, Traité de l'aiigiiic glanduleuse, Pans, IH57,
in-8.
Syphilis of tbe œsophagua.-— Wkst. Dublin QunrterL- Journal, Feb. I8G0, et
Areliiies iW méd., t. I, p. 714. Iwlilt. Itélréeisseuu^ut syphîlitnpiede l'icsophage (The
Lancet. !i Au-rust, 1872) — Kiii.i,ix,Tnvilé éléuientaireile putliol. externe, 1. 1, p. ii9G,
1«C1 — La.nceiikau-X, Traité historique et pmtii|ue de hi syphilis, 2* edit-, 1874.
760
BI8M06RAPiir.
Dywntery. — C'uaucit, Itn-ln-n-lm nnnlonK) inlliotcyl'iiM^ mr Ih <1vMinUrifl
(Tit"' ill- SuiliiT. V, SiTiiuii III, n' 3).— ('"itsii,, Stir I'miniuiiiK' pallioUif.'iiiiie iIm
lili-^rHlioiin iiilrtliiiiilc* ilaiiH U ilytriiti-rii' (Arrliivi-i ili' filiynut(i|;ii>, iKT.t. II t-.SIH)^
— K):i.i><'ii. Coiilriliulioii & I'Hnalumic [iilh. cli- hi ()vteDti*ri(- •.<linmii)Up ( Afrliiviv ila
LpIii-liiliiLîic, IM;,t, p, 4iKi ft fiTS).— CoiitrihiitJon A ('noMiMiik- [intli.ilr- In iIvM-nlrrM
ïliîjî"* ( Awliîïiii rlo (ilitvl.iln^o, IRTS. n. TIN).— WounlTAKI), J. .1-, IM. JJ, M<-<Ll
Vol. of U»l. mill Siiri;. IIiU. oT tUr: Wnr of iIm^ IlrMlton, \tiï9.
Cholera,— Il A V t. U r1 ttAVMAfri. Sm-tdt niMicillr lira ItOfiiUUlK, tfl'S, p. SC2 I't
Sn7. — l'Ai'i.ti, KiiTlnn>iiM-*|xi'<iili'-tiirli»lfnia<iiili[|iir, T'liin-i , Ikd.V. — DavainkJ
nrlifUt ISattirie du Uict. i-t»'i('l"|i^<li>|Lii- il'-i ir. iul>'lli.'iit<«<. — I'lit'cUKT, Inriisuirtd
Llnicro«<^|Mi|Oi'i< ilnm Icn <lrji'i*(iuiv< ■In' < liril'!-ri<|iii'?i (Ai'jmI. >kti .••'iriii'vs 1-1 avril l>i4yM
i— Kki.s<;ii ft J. Klnai T. I'ri^r^s mf-ilkat. {«"iX r1 ■lunnia) itct L'oaiinÎHMtwi-' mH
niciitc*, ISÏ.1, p. ÎÎ4. — 'Tnt,fir„ l>i-» iilU'i-ticiin iir^u]i>[iHfi il<i l'itiiroUn irni^« Vipn]
Itrljiliru-lirift. (. IV. I'l An-liivc* ^6ii. itf mf>t., iNi'.". t. I). — l.oi'ik, II it lion' b)** •od
''ïn fiiviv I V phril'tf, IPS!'. — (iiw.»>.i,iN, Do I'l'ii'uiij'trtnpTit ilni« Im bi-rii"' ''! '■■I'l
d'liirrfiHiilion. I'ari», l(i4J). — NtcAisc, Dr* l**ioiii ■)<• l'iii(i'»«iii iIkih !■ -. |
Tliit"', I Mill, — MauiaIi-XK:. iklf'iiivin.- sat \v* picinlx-elrniijilt'iiiviiti» i-l slir 1 uJ
ik-H lii-niici ( Alvliii'i-4 t!^ii. <ti.' Mif<l.. 1M4I, ct •Iiiiirii:<l ili-cliinittfii*. lMt.1. (. 1, ]>. ll?)jH
— (>i»'»>-|.IN el I.AIIIIÉ, I^-cini' 'ur I>-4 Itt'mii.'T' .i)i>lu>iiili:ilM, \M,j. — JiiiiKNT, MftUM
ilii**' An rntuil itiU-'liiiul, I. ll.^tliiiK'A. Ih- I'Mrnn^lctiivnt lUitx l<» kcriiM-» (Tli4>«u
il'nifrr-faiioi). IH^}. — l.AiiiiA. Exi'^Tiviioi-* mpporlfii (Uiii- In tKfco' ilu M. NicKiMtJ]
— roKXI, Etudia imr li» fisiulv«du)'iv|Hici:i>4-Jvi-rt«tnlnij<ËH<:iir (Tlitw ilii 'Inctont.
1873).
SfPhilia of the intettine.— Ct-u-cuiK* (UnEoti niHimK ih&4).— F<ïii«Tr«i.
Ilnuillmcli ilvr niKt'iclli'ii ikiIKuI. Aliiil'imir, p. I4X, — Mr-'CHfl'l: (Ali-hl*. V.
Virp|i..w. t, XXXVIl. p. iiSS),— Eiii.iiiii (Anliiv. t. Vinl.w». i. XI,, p, Mïil).~
Kt.ERM, Sypliilitic nLcvTiitioiu of the JiilMliur, in UuikIUicIi dor |iiil)ii!4i>>^i*i;lii'ii AiiNI-
omk-, j>. 3UI.
tyœpliadenoma.— 1 •>:"*!«« e, Etmli' «nr Ij» Irmplmdftii*, Mc. (Tlif=- '■ '-<■-.
toTJi. r.iri". l)i;i). — Piciiv I'l l!i:si>i-. I'nri». 1SÎH. — Ktwcii. Socîtién , I
Is;;!, — LamioIizv. SiM:i^téaiui|[iiuli|Uf. 1n;i,^Di:iiuv»:, Sa-îélôaiiitluiiit.,M-, .v.i. '
Limr. — Bt'noe. CvtuT iIlt Vi-rlnof dcr Gnlletinani^ tii SlUIlrr't iin'li., IRSfi. ]>■
GJS.^.^NHKiJKViÉ, ITi-bor ilrn fi-iiivrv" llnu <li-r I^Twr. in Wk'u, SiIhuiii'iUt.. t,
LIII. t>. srfl,— MAf-tîiiJ.AVRV. In Wi.'ii .<iiimi;«l«-r., t- I.II, ii. SHI. — Kniniii.
ill iiml. ConlnilliliiK, IM:"!. WS" h in Vinliow'- AnliiT. t. XXXIX, p. î<i.— Kiil-
UKr.R, Klfiii'-nl» ■rbirtoloyif liiimniiir. — Drritinit.KAi!, Truit* Ar* tnidudir* ili-'i
Eiirop(™i lUiH If» pa.yn ihuiKlt. I'nrii. isul. Arrhiii-» ffl>i>fnlui, IWjS,— Unit:*.,
iMiicii. Tmitf dfs iiiatiiilli-t iiifi-iiiMuci,^ — l-'i(»;Kici(«. l.^ii* Mi'UmiTiiiit' ( Zritsclirift tm
kliiiÎM'Iic Miilieiii. IlrvpUu, IN-liA), — Truite iiniiiijiii- dv« iniLiiIku ilii tnia-. 9*nli(il
Pant, 18€i;.— lIcRilirwiiS, TrmiiTiMiC'iiitiiiii"! rva-r^. UimUin, I8fl3. — GaiesdhiJ
Trallf «Ir In poiKw. — IIaspku Malnilii^ ik- I'Aly^ric, ïvol». IWiî l!«tv»:iutil£»n
Aimt. (iBtli.. lir. XVI. iit. S: liv. XL, ^il. Srt Sinktv, I)c I'^Mt itu foi.- i-lieï k-»
fciurlli'j i-n Incliilii»" <Tlifrw. Pnr». t»i7J(, — I)a«;k, Arpliirw k*b. di? in^looiiir, I.
XVni. IMfi. 1. \l\. iK^lt. — I^iciH, KwIh-ti'Ii. Hiinl.-pHth, lar <\),\vrv Diaki4i«d
(M6ui. '](■ 111 Sm-iflf iii^dk-«lr d'oliM-rv., I. III.^Hocib. Ki'I'IhtvIk- Mirlni fupiHM
ntioiia viiil^iiili|ii>.-* 'Ill isnv, ISÏ^Ii. — DiciiAT, llcrnk'r etmn 'uc I'muitimiio pallMlafl
ffi'iun, piblif- <l'iipib« iiii «11. pur P.-A. B*i.-liinl, iivw iiolr» p«r IIoiii*fsit. P«rid
iwm, )>. I^N-mo; ,I..It. lUiUièrr. — I.akk.vki-. .\u«-iduiioii (oMialr, I" éd.. oba,
3,'fc SO, HS. 36 : 2' éilit,, olw. Sfi ft noir nnin'xfp k «-iti» ol»<-naticni.— Itiii'LLAM',
I Hem, 1HI!(, lii- L» Société inMirnlc (réimilntioii. I. IX. p. ITO.— Cm vni.niEB,
lAnatottiiv [Ktlliol<);;i<|ii(.-, niln>. livraiioii lï, pi, 1; Traité iraiiatotiiH' iKiil>i<l-iHi>|iir
"gétif-nik-, I, III, p. ïlu et fiiiiuiiUfi. INiC. — Axihiai.. Pré<*i* (I'mintowiii |ihI)ioIii-
ei<|ui'. I, II, Ï* pariir, p. S83 et MiivnnlOf. Pari", )*43!>, — lk>i'iLi.Ai'i>, DirtioDnoHV
dp méilivim- i-t Av Hiirurjfio pnili(|Qc, nrl. Cirrho''- llKCttiKiiei., H.-'li-nln-i
«iialouiiv]iHtbc)t<i(iir]ui-ii iiir In riiTlia»r ilu l'ot<'. In Arrliivi-» pénéralc* <l.
arril ll4l>^~<ii.'l9Lï;H. Itiilktiil ili- In Société nliiitoiDiniir. juitk-t i-l aoAl
1^9. — Tliti'i' <rii;.'ré}!Hil<io nur In lliéorîc In |>Iii.< mtioniirllf ilv Im drr'< i,|
Cnxnlto médicnk il>- Pant. I8S« rt 18.M,— KlimSAS. Ptiik*<ipliK<l T- v]
IS33. — IIiiKiTA.tniir. LplirlmcU il'r l'util. Aiintmiiic. — Rrgi'iK, l'Rth> '~>-1
atlc, I. II, p. 'Î4, vt Supplémi-itl am Diclionaair* d«« diirlioiiiuiirM dc m/- : ..t.J
BIBLIOORAPHT. 761
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Ham) buc-h lier pnthol. Anatomii^. 1868-1873. — Coknil, Note pourBervlr à l'histoire
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Paris, 1870.
Pancreas. — Veiinkl'ii., Mémoire sur l'anatomie du pancréas (Guiette médicale,
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lojrie professé an Collénc de France, t. Il, 1840. — Sapi'KY, Traité d'iniatouiît'. —
Ebeiii.k, Physiologie dcrVcnliiung. Wurzburg, 1834. — Uovciiakdat et Samiha»,
Annuaire de thén(penli<|HP, 1843 et 1840. — L, CiiiiViSAiiT, Sur une (buctioii i)eu
conmie du pancréiLi, 1857. et Compti's rendus de l'Acnd. ded se, 1859. — Ki.ob,
Wiener, Zcit^clirilï, 1859. — Ahan, Arcliivea pénér. de médecine, 1846. — Williok,
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Virchow, t. XLI. — ViHCiiow, Patliologîe dca tumeurs, t. I.
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(luisitione.s de liene. Halis, 1861, A'îrchow's Archiv, XXIII et XXVII.— AxKL
KÉY, Vin'hnw's Archiv. XXI. — Mî'i.lkk. Uebor t'eineri'ii Khii derMilz I'bi.tikii,
Pathologie de la nite (Tlièsc de Paris, 1872). — I.f.os Ciil.iN, Rapports qiii existent
entre la pignienijition sp!éiiii|uc et celle des autres tissus dans la mélanéniii' (Société
med. des hôpitaux, 187.S).— Cahswki, (Illuslrat. fnseicul. R, pi. 3, fig. G). AbeÈ»
de la rate. — Hes.vikh, iirt. Rate du Itictioniiaire encyelcipédimie des sciences médi-
cales— Pi>Sf-[K, Etudes .-iur le typhus réi-urrent (Archiv von \ îrelioiv, mai 1874). —
Lecki'vue (Charles), Etudes sur h's infarctus viscéraux (Thèse de Paria, 1867). —
BiLi.iioTii, Areh. von Virclu™-, t. XVIII. — ViHCiiow, Patlioltçic des tumeurs. —
HÉK, Aiignientaliou de la rule dans la syphilis héréditaire in Roy. Med. and Chirur-
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1872. — Skk. Leçons de ]mthoioglc expérimentale. I8C6. — Anthai-, Kystes de la
Ole (.\Miit"inie jiiitli., t. Il, p. il,'!). — Leitikt, Clinii|iie niéd. de l'IIiiiel-llieu de
Rouen, 1874. — MAlilin.AlN in I'ÉaN', Ovariotoniîe et Sjilenotomie. Paris, 2'édit..
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— AiHJisii.v, On the coiistitntiouiil and loi'al eiriTts of Disease of the Supra- renal Ciip-
unle?". Liindou, IK.i,",, — It.EiiENsi'utNi;, Die hen'ditiire syphilis. Berlin, 1864. —
BÉiitKii, lA-':"ns ciinii|ues.— MaiiT[M--,al-, Thfeic de doctorat sur la maladie binjuzee
d' Addison. 1x64 — .Jaccch'I), art, .l/o/di/i'c 'i'.l'Wis'ui du nouveau IHi'tionnaire de
méd. el de cbiiiir^jie ]iratic(ues lÎAM,, iirf. Maliiitie hronzéi: du Dictionnaire eiiey-
elopédiijue des sclciicis uiédicidcs,— l,ANtK,LiKAV.\, Traité hi.-torltpio et iimticjue de
la syphilis. l'aris, 1874. 2'édit. et. art. lli-.in el Ciipsiilca giirréiiale$ (lu Diction-
nairc eiieyeUipédiijiic des sciences niédicah-s.
Kidney, — K'U.i.tKKii ('w. cit.). ïiv.si.v., Zut Analomie des Xiercn Giitlingen,
I8i;-,;,^l,i iJWKi, Stmciiin' du ri>in. In Strieker's llamlbuch der Lehn' von den
{Je""ci)cu, Ixîo.. — ClIAitCiiT. I.ei;(ms pnifessécs en 1874 à l'Ecole de médecine sur les
nialidics duiciu. In Progrès niédicai, 1867. — Kkl.sctl. Revue crilimie et rerhcndies
anatouio-j.atlii^logiiiiies sur la maladie de Bright. In .Vrchivi's de physiologie, n° de
septembre lM7 L — IU:isirAKi)T, Aniialeu cler Charité zii Heriin, 1851.— FnKHirHS,
Die lîrightsche Nierenkninkheit.— Viuuliow, l'eb<T parenchyiinitilse EntuUndung.
In Airh. lur ]inlli. Anatotnie, t. IV, ]). 2(iil; 1852 iliiIINsiiM (d.). JÎL-i(ish and
Foreign Mcdicn-Chirorgiciil lîeview, 18,"»-".; Med, Six-, of I^mdon in l.iiucct. .Tuly,
IH.-iH: .Mrdiiii-Clinntg. Transactions, t. XI-II, p. 1.14: t. M, p. 57, 1868; Medical
Times and liuzelle, -April, 1869; }t Ici lical Journal, Ajiril, 1870 (ii;Li. et St:TOX,
762 BIBLIOOKAPUr.
On the Patliol<^_v of the Morbid Stale commonly called Chronic Bright'» Disease
with conlnicltd Kidney (nrti-rio-fapillnrj-fibrosia). In ML-dico-Cbtnir^U'ul Tninaac-
tioi». t. LV. ]j. 213 ; 1HT2 GiijiiMit:i:-STEn'AKT,Brltl9h Mod. Journal, JuK. 18;2,
andBril. licv., Janiiury 1K(!7 Hiioii, Lancet, Aii^jimt, 1872. — Thai-he, Ge^ammtc
Ablianilhinpeii, I. JI.^Wii.Ks (Samnfl), t'nscaofBrieht's DUi'ase. In (Juv'a HtMp.
Reports. 2d Serii's, vol. VIII, ISSl — Handkiki.d JonK!*, Oh the CiimtiVc Treat-
nient of Clironic Morbii:' Briifhti. In Meitte. Times and (iaz., ISHib Totiii, Clini-
cal Lecturi's on ci'rtiiin Dixeasi-s of tbc Urinary Organs nnci on I>rui>sies. Loud., IS.iT.
— CiiAr!«i)T (^t CoKNii,, C'oiilribntion à l'6tiide ihw nWration» nnatomiiim»* du rein
cliez les goiitti'iix. In Sotifté df Liolowjc, liSCÎ Gai{hi>i>, TrailÉ de la (goutte, trad.
franc. ]iar M. A. Oilivier, note-" rie M. I'liareot, 186" Lkcokchk. Traitédc» mab-
dies den reins, iii-«. Jln^son, 187.'). — I'lutsii,, Dps <imfn'ntes es]ièpcs de néphrite*,
Thfese d'ajrrfjration, 18(!lt CmtMi,, Nott sur la dfjifnen-scfnee amylolde des or*
gant's (tndiéc an moyen île réactifs nonrcaux (Archives de physiologie, ltl75).
lîfDEX.
iBNORMAL coloralinns of skin, 740
Abscess, biltnry, &40
eni'iolic. 3.10
Intge, of liïer, 641
nietastattc, orkrituejs, G44
of liïfr, 530
of honp, ÏOS
of brain, 37(i
or conaeciiie (issue, "ÔÔ
of epiplijais. 'lia
of henrl, ■JOT
of kiJnej, 1543
of liver, large, 511
of lung. 4111
of pancrens, 5T!t
of pros tn le, tïTO
of spleen, b»^
of urctlirn, (154
retro-phnr;iigenl. 4iiS
Absorption of bone, I'.i?
Acarus rolliculorum, 74'2
BCnbiei, 742
Acephalooyst», l'.)3
Acetic acid, action on piii corpuscles, G7
Achorian -SchixDleinii, 743
Acinous adenoinii, I<jU
glsDJs, 3H
Acne pustule, 735
Acute phlegmon, ^û3
Adienin. 142
A ddii- II n'a disease, fitrl
Adenttiii, acute, syi
clirooic, 3'i3
Adeno-cliondronja. US
Adenoid (issue, \H
AdvnO'ljnipbocele, 141
Adi'noinn, ItlO
acinous, IT.O
dLignosis of, IC2
of inlestine, -!>14
of lar;pnx, 4U3
of mammary plnnd, 715
proRnosia of, lli4
tubular. dingnoiiïM of. ll>4
with cyliiidriunl eells. 1G2
AdeuD-mj'uma of prostate, (j71
A lenosarcoran, ^55
Adhi^aiie inflammation of seroiia mem-
bra ni-s, 2tl5
Adipo libromn, 05
Ailiponin, Oj
Adipose tisitne, 24
in iiiSammatioa, GO
in oedema, ^51
Albuminous interelitial nephritis, S31
nephrilia, tilO
Albumin urin, CI {I
from cold. 6:24
of alcolioliem. t)24
of nrlbrilis, U'JIi
ofcardiau diiicasei, 620
of gou(, 020
of phthisis, U24
Alcoholism, albuminuriit of, 024
liTcr in, 521', 614
Alopecia circumscripta, pnranile of, 740
Alterations of cells and tissues, 39
AWeolar carcinoma, 104
sarcoma, 84
Alveoli of carcinoma, 08
Aniœbuid nioTenieats, 10
Amjeliiiic neuroma, IRS
Am>loid degeneration of arteries, SS2
of capillaries, 387
of cartilage cells, 20
of hepatis cell!), 025
of kidney, 027
of liter, 557
of pancreas. 580
of epleen, 5M 1
of atiimach, 405
of Kupra-rena! cnpiule, 60O
infiltra lion, 4ii
Anmrnia, 287
of brain, 3G8
of kidne}-, f>l7
of lung, 408
of siomsch, 4'j4
Anatom; of miliarjf tubercle, tI5
Aneurisms, 314
arlerio-Trnoua, 316
clot in, 315
cjstogenic. 315
dissecting, 316
falae, 317
fusiform, 315
irritation from, 317
laminiB In. 3iii
miUarj. of brain, 371
of heart, 2!i5
sac of. 310
spontaneous, 315
^^^^tS^^^^^^^^^^^^^^irdbx^^^^^^^^^^^^^^^^^B
^H Aomnimi—
Ankriiji— ^^^^^^H
^H TnlfuUr. «f li«Hrl. 803
»h*ianiAtJe, 238 ^^^^^^^^|
^H Anpi«l(U«iin, lUâ
M»riiloua. 289 ^^H
^H AaRi«1lihle ■•r«0R>A, 84
•Implo. 220 ^M
^H Anilomn. ISD
UkU«w(l#. 229
^H n&slaailanl di'gnoti* «r, NO
Ar4t««l*T Tomgn boitip*. 38$
^^^^_ OAttrtiuun,
Ailloiilalloni. )n Rom ma (Ion of, 228
^^^H d»T*lDpiafnl of. 140
lipoma of. ',:lt
^^^H naiiltlTo •iKniloDi of, 140
normal liiiiologr "f- ^-^
^^^^H kiJn«y. 1^1
palboloiiicul mmCotiij W, 22?
^^^^M ii*«T,
tou»!» of. 244
^^^H muiiclB. -JH?
AtcIociiuU. 411
^^^^H pragnoti* of, 141
Aih«r«n* of tritrir*, 811
^^^H MU
Airopbieacirrhn!!. 10-1
^^^m
of mamnury glaail, 710
^^^^ a]iect«« of, 18ft
Alrophy, kput* 7*ll>i>, of tlf*r. &t2
rtvM «omprcoion, 42
^V trabtealaof. 189
^H AdbUkm, 189
from tiigufli«i»al nnlrltla^, 41
^H Anioiiil patfaitei at aktD. 741
of brurl. sn
^H Anton>-I*torAl icltrotU of »plaa,\ oord, ÏST
of liior frotn elnboita, M7
^H AnlhrKuciii. 4'J6
of lun;. 411
^H Aortk, Jpf-Eatrnlietii of, 9tS
of iDUBcle. 270
^H A[iD|i1oi]r. ca|>11liii;. nf bmln. 880
of p«ncr*iw, GSO
^H of luiiK. 40U
of akin. TilO
^H Appeiidit. 74»
of Bplceu. £84
^H 10 tuiiion. ISO
phT«iolo|tiol, 41
^H Argrrlu. 4E>I>
red, of liwr, 631
^m ArMTliii. 307
wilboul dcscnorntion, 43
^^^ Mul», 80;
Author*' pr«bo«. t
^^^^^ eliroiii«.
^^^^H <l*fapninni, HIS
RUnd. \'-e: :iJ
^^^^ I^rpliilllic, H-11
Axis cjlindcr t1 neno*, 88
^H Art«r]r. tun;rlo>J mctniDorphMU of, iSS
^^^^^ nlhfrainiL of, 8 1 1
^^^^M o'llcificniioii of, 813
pAlTEftlA. In hS»Hw, 0J>3
D in blood, 2S-)
^^^^B fttlf 'IcgmcrnliDD of, 810
^^^^H Iic«iii>ii nf. %Utr kCuprMMl*. S'i!S
ill r*vDK 4ftr>
^^^^B nfirr iiKMure. 318
in inonith, 4Glj
^^^H nritf tortlon, 82S
BnlblAul. int«*llK4li<(iu of, upoa o*p1«, 10
^^^H
tliI>il«K">P'iT- •"■^
^^^H or, sm
Uliary ■bM4*icf. G40
^^^^M otilUcTiitloii of bv enilarlarStif, 320
«*lMil«a, btiS
^^^H by ticnUN.'siS
pnMaRM in cirriieat* «f lltar, SûO
^^^H by thrombovlii. »i>t
»«m«U, cyal» of. B'W
InStmrnnllnu of. Û47
^^^^H nliAtru-ilinii uf by tiiihalinn, 9iS
^^^^H rrnnintiTuiis util 1 tara lion of. S2&
BlMiM^r, cnrrinQinn r>f, IIM
^^^^1 (j'pliiliric Itsioniof, SSI
«nUrrlinl hifliiaiinnli»n of, 6M
^^^^H Ihroinliut In, friiin liyiilur*, 819
Mioliuiidroiii» of. 6&&
^^^H luberolcs uf, SHi
liitlolof^r of, 062
^^^^r lumon of. i3'i
IiyponumU of, Cfi2
^V ArtlirktU, -i-lA
liypcrirepbj of, iv\8
^^^^ aeut*, IvHioDB of «nnihge in, 230
lubcrautoM* «f, 061
^^^K
tsmoti of, Kii
^^^^H •yiiuiiil ni«inbrtn« in, 3J9
voriooM *fiiu of, 6i'i
^^^^H nibuminuiiii of. 620
BUModrrm. IS, TIC
^^^H «bronk, iU
lllriiiitrli^ifln, (I.M
^^^^H by oonlSniiily, 383
Btiol«r of «kin, 781
^^^^B of i»r(itag« Ic, 238
Slood-elot, In beart. 804
^^^^H
otitaoitiiiMi of. In anrrtw. 819
^^^^B «ouliQiitlroM* in, 2U
Blood, oolori»)! mntvrial of, 386
^^^^B dFfarniitnB, ï34
bUlology of. 110. M; 2»!
^^H dry.
of clioJrni, MM)
^^^^H |t»uiy.
puriiailoin. 'JH9
^^^^H (ivrfoniliuj, 21S
V*t Winn loti blttoI«fy of, :ftt7
^^^^1
pigmeul in, StHf
INDEX.
r65
Blood-
red corpaacles o(, 284
whita cirpuacleH of. 28i}
BloodrsaseU in grnnuliilioii iïhsdc. 69
in sclerosis of spïmil copiI. iiSH
of kîiliipy, cLuLiges of, *il&
luniors i'ormect of. lîi'J
Boue, ikbsorpiLon of. 107
cnlliis, ■m'.l
cnrcinomn or, 214
cnries of, 207
cells ID cnrie*, 20»
cliondroiDit of. 218
congeatlon nnd bemorrbnge af, l'JG
corpuacUa, 26
cfsta in, 218
lietelopment of, 23, ISî
ebiiririiii.iii iif. :;iii;
encephnloid ijurconm of, 213
cpilbeliomn of, 216
ftisciculnr anrconin of, 213
frnclure of, [a cnrciaoïiis, 214
in rnchilis, 224
in sarcoma, 214
gomma of, 111,217
hemorrhnge of. 106
hislulog; af, 28~!0, 195
ioflnmiaatloa of, lOT
ItsioDS of. lOd
lipoma of, 214
tabulated epilbeliomit of, lôO
lymiili.iclenomii of, 218
IB.irlow of, 27
nwdnllnr; cuvit; of, 27
ai;r1oi-l âHreami of, 214
mjiomntoug lumorii of, 214
DecroBLS of, 204
osslfj'ing stircoma of, 214
oslpoma of, 2!8
round-celled anrcomft of, 2i3
BCleroals of, 2(J^
sequestrum of. 205
softening of, 219
Bpintlle-cetled anreoma of, 213
Btruoture of. 2G
tubereulosis of, 215
lumora of,212
BowmHn, sarcous etemenl; of, 31
Brain, nb^cessof. 37U
cnpillury npupleij of, S60
congp&lion of, ^fiH
cyst.- "f. :!«()
emhollc sofreniug of, 372
fibroma nf. S7K
hemurrlinge of, 300
hemorrbngic foci of, 370
bistglogy of, -11
infarctus of, 372
inflnmraation of, 37Ô
inflammatiiry softening of, 876
lipi^TTklL of, ;'r7^
uiehiikiemiu of, 360
niïlïiir^v aneurL'iin of, 371
rf'iiriitnfi of, ;i8o
ledemn of, 308
Brain —
pftpiltomti of, 378
red aoftening of, 370
sclerosis of. 877
softening of, S72
sjpbilis of, 378
thrombosis of, 374
tubercle of, 378
umors of. ^78
jrrllow softening of, 375
tirijiht'a disease of kidney. (i21
Bronchi, cnicilîoolion of, 407
coMge.ilion of, 404
dibilnlian of 405
heuiorrhnge ■<•{ 404
histolony of, 300
intinmiuation of, 404
li|ioliL I irf 407
oasilicntion of. 407
tubercle of, 407
tumors of, 407
uleeratiDD of. 407
Broncbieclnsis. 405
llroncliLtia. 404
chruDtc, 405
(lipbthevilic, 404
Bucod <:riviTy. tumors of, 453
mucous iiiu'rnbranT, bistiilogy of, iili
parnsites of, 4àû
patbùlogy of. 41S
p^orinr^iit of. 4â
tutnoFB of, 468
Uulla of skio, 731
Ilursfl, mucouB, 248
CALCAREOUS infiltrtiticu, 51
iraasforniatioD of pgs corpuscles. 68
Calcification of arteries, 312
of bronclii, 407
of capillaries, 337
of rftrtilagp, *2t\, 225
of tympb glnnd^, 354
of slomnch. 472
of veins, 342
Calcified caniUge. 2l\
Calculi of bladder. ^53
of kiilnp;, Hi5
of lirer. 568
of prostate, GTI
of Ttin.H, .'n"J ;i-i2
Calculous pyelitis, 645
CbIcuIu», btltarir, 5C8
of pancreas, 582
Callus, cnrtil glnnUF, 210
formation of, 200
pcripberal, 212
protisi'iii'il, 212
-CoricTuid, labtal, 454
Capilloriïs. amyloid depeneralion of, 337
«lili^fireuu." inlitlr;itlon of, 337
embolism of, 369
endolbelium of, 37
fnlly degeneration of, 33G
histology of, 384
W 76fi INTEX. ^^^H
H CoplllftHct—
CaKlInf 0. amjlojil ■!« tcDorallDii »f cell*. ^^^
^M infliintni.-iltoa 4f, 8S5
OKlciRdolion of. SÙ ^^^
^M nuliiiiie l^iloQii of, S3Q
dent np ment of, 35 ^^|
^M ChpWHty apifWir of ttfAtn.tOfl
«iiilirjrnviil. ^'t> ^^^^^|
^H CnpMil* ur tlNat^Ti ID cirrbosii, &1B
r*U]t ikfMivnliDIi of, 3ÎS ^^^^1
^H CaraptM» ol *cn>uit mtmbrauoi^ '16i
0 liront, ^^^^H
^M Cuaiiiamu, Wl
^^^M
^M nn 4 loin i a 111 ilikitno*ii or. IM
irrltalito l««l«ni> of. 3Ï6 ^^^^M
^^^^B oalMr«««ti iiiniiriid'xi ol, IW
ImIoiio ^^^H
^^^^1 CMoaD* in«lanior|)Lu)ii of, 103
iicui* orihiiliH, iSO ^^^^H
^^H wlla
in ibntoio iinbrllit, Ml ^^^^H
^^H eolloU, IM
la «bro&le tbvNintttlo ■Hhrtll»,
^^^1 clffinliion of. Wi
285 1
^^^^m diTctt)pm*iii of, W
In goiitr Biibrltli. Ii4l ^H
^^^H tnci*phiilai<t, 1U8
in «on'fulttuii n>lb>ii>«, 2SV ^^|
^^^H Uttf ilcgonernlioB «f, lOS
in «bilv DKfllipg. :.'3'J ^^^^M
^^H
^^^^^M
^^^H gea*r«l (Ivtori^lion of, 97
nuiriiine ie^ono f>r.':!2fi ^^^^^M
^^^^1 gonorali talion of, 101
oHifliinlioB of, 138 ^^^^^1
M ^^^^H
•iructoro of, ÎS ^^^^^|
^^^^1 liiHHUininltDO ot, IM
1^ ^^^^^1
^^H Juke or.
Carlilnginouf culln*. 'ilO ^^^^|
^^^H II pom* 10(11, lOfl
Cucuni DiclnmorphoHi i-t eutim«»». 1^^|
^^^H Ij'mv'i ie''""I"'"' I""-
pnfainonln, t'M ^^H
^^^H IjniphntiM uf. 1^, 1117
irnnifunniiiiac. in o*ri», SOfI ^^B
^^^^B iiii'iiiiitiir^, ins
of pu> eorpuxlH. vM ^^H
^^^^1 rorlnnolia. lUi
Omi*. toniiTil in urinifrroiM (itl»tr«. '"^^|
^^H
of ulf lOf, 6S6 ^^M
^^^H
OftUrili. RiaiHr. 4M ^^|
^^^1 of FuUopinn lubf. WH
uiFtifir. tVM ^^^M
^^^H of gnlI'Miiilikr, A09
Camrrbnl r^ptiriiiH, 1)20 ^^^H
^^^H nib
^^^^^B
^^H
pjtlunoebriil*. U« ^^^^1
Mlpinf(iil*. «SI ^^^H
^^^H of kr7Di, 403
^^H of
CnTfTunuii uigtolngt, IA4 ^^^^^H
^^H of loujc.
Cell*, umwboid muivnivDls of, ID ^^H
^^^^1 of Ijmpb jtlnnil*. S&O
nnti iUmoi. «lunliaM of. K9 ^^^^t
^^^^1 of niiiiii'iinri kImhI, 710
olotiilr ■•«'lling i>f, iX ^^^^^B
^^^H mutele.
drfinllion 21 ^^^^M
^^^^1 RiiB
«mbrjanle, IB ^^^^^H
^^^^B of oTiirjr, fi'S
^^^H
^^^H «r pNDOrcn*. A8I
ibrinoui dfc*a«T*>io« of, H ^^^^H
^^^H of iiorioardinm, '!9i
111 Hbriiinui rxudailon of Mien* m^^H
^^^H of periioooum, &TII
bnlMa, 261 ^H
^^^^1
truoiiK In fonmtlon «f, 6-1 ^^M
^^^H of prctliilt.
memhnm» of. 111, 'il ^^M
^^^H recluin.
maroui nnd oollUd ilogcBrratlon of. ff "■
^^^^B of tcfiiua mriutirnnt), SUT
iiialiiiiaeicaUJ, ÏI J
^^^H *pl««ii. b94
81 ^^m
^^^H of ttomncb.
nnckolu* at. 10 ^^H
^^^^B of nipra-r«ii]il cupDuIp, liOI
narliuf «t, ^^^^M
^^^H
onreinoma, BT ^^^^H
^^^H of tlijroid iilunil. ii'l
of (piiigrrac, 41 ^^^^^V
^^^^m of Irnflifin. i'H
of xirmlvinnin, Multiplionlion of. ST8* 1
^^^^1
of larciinu. TT g j
^^^H prognuil* of, ion
of iiitirrvia, 114 ^B
^^H
*rif(in of, 11^ ^^M
^^^H «I'Fftpi onJ vnrieUo* of, Iftt
pl|im«nuitl<in «f. 1ft ^^B
^^^^P itTonu >r.
■ finnlaiitoiu K«annlioB «r, 17 ^^|
•irociurv of, |7 ^^^^H
^^^■^ ulcrniiun of. 100
V Ttlious, tUi'. Tin
^^^H
B CKrdkc IWtr, r>:]u
Cpr«l>Tal nhMnii. SÎO ^^^^^H
H C■H*^ :'i)7
^^^^^H
^^^^ CBMou» trniufarmniicai In, 'UHt
cnpillair npoplttjr. SM ^^^^^|
INDEX.
767
Cerebral —
oangcatinn, 3G8
htmorrbnge. SliO
ID r» ret II H. 37'J
in flu m ma I ion, H7&
m«liiiiiBmiii, SUti
CDiltniB, 3liH
rheum ntiam. S 64
ïvlïro^ifl, 377
BOflcniog, an
typbiVif, S78
tlirutnboci.q. 874
tuliercle, HIS
tumura, S7H
Cercbro-apinal in en in gi (in, SG4
C1ia1k-Btoii?B, 24:1
Cbancrc, inihiration of, IDT
Cholern, 40!)
blood of. 600
Cboleslerin cryatnls, 41
ClionOromn {-n Knchonilromit)
{.'hondroDin of brine, '2tti
Cboroid pIPXU9. cj^f-tn of, HfiJ
CiMtriliilinn of ncriea, Kljl
ot woundi, 71
CirouInlioD in CL^^IlO^•i8 ot lirer, 649
Cirrliosii, cnpi'ule or GlieEon in, Û48
bepiiiic cclU io, bi'i
of liver. ,'i4)!
bilinry pn^nagcs in. 5&0
circulation in. <)4!l
tc-scIh in, C49
wilb atropliy, Ô4T
Willi grnnuliir nnrfacr. 547
«till snioolb aurfiice. àiô
Clnssilicaliriii of tuinora, 75. 17'i
Cliniciil fiirniB of infliimmiitioii, 7^1
Cloudj Birelliiig ipf tell», 43
of bepnlic cell>, â-4
of rnuHclir, L'71
Cobniieim'n tlicury uf iuBnmmBtion, GI
C'olilis. 4t<l>
CoLluid ciircinnm/i, 104
cj>t» iif ki'iiivy, 'i37
Iiililiriilion, 44
niiiltpr, 44
[incumonin. 4<'JG
Colnslruiii oiirpiiicles, 38, 705
Uciniedoiitri, lU-'i
Coriiti.'Lct usieftiiiji, I3'i
t'uuïi'iitriu ct'll-iiesl of epithrlîomn, 151
Concrfiiiiii» in oontriictïJ kiilii*y, fi>H
id prti>i]iri', <»7]
l-on<lpii~ii<i; iistcitls, ^02
Ciingriiiliil lijilroet'U-, 'iiii!
t'Dt>gl'^ti Ill) bïiiiiiti'hngi; of bone, 19lj
ciTi'liriil. :iiiS
iiiTbiiiiiii:itiiry, t\^
1)1' Kiiltopiiiii iiiliv, GSG
of iiile-tinp, 4^J
ofki'liiey, til 8
of liTiT, fr^X. 6:i-J
oflnnt:. 4(IH
cf lui'UiugfB, 3GI
' Congestion —
I of nerns, 300
! of oitnrj, 67fi
! of pleura, 433
of spiiinl cord, 380
I of spletn, &8&
I of Btomneb, 404
j of utcruB, I'M'J
■ (ïoDDtctÎTe tiseue, 23
■bHceiia of. ^&fi
and serous cniïtief, le&iona of,
I Ï47
[ obronic phlefiiaan of, '156
] congrBtiotia iind bemorrhkge of,
248
diffui'ed pbleginnn of, 2Ô5
i ftmigrene of. 2ûti
'■ hiatulogy of. 247
I bydmiJa of, tlûM
iiiduralion of, :!ô'î
infliiniDinlion of, J52
' tcdrni» of, 200
' of kidney, lesinns of. (114
I purulent inflummniion of, "û3
Rerou» cyals of, '2âl
! tumors nf. 26T
- type of tiiinois, t-O
Contenlii, Inbte of, i»
Coiilmcliiin of ccsopbngiis, 459
Ctirdéi, «54
Corneal fibroiun, '.'Z
I Conieou» ichtbyn!.ij, '
papillumn, 108
I Corna, 1 68
' Corpus tutenm, G7S
CorpQHcle, Pflcluinn, '
tnciile, 720
CorjiFi, fly 4
Croup, 3 '.17
Croupous eiudnllons, ti&
giistriii». 4)i8
nephrilia, G23
putunioniii, 41Q
Cryptucoucus ctreTi^iir, 40-i
Crysliils found in giitigreiie. 41
Cutnni'0119 dipblberitJB, 728
piirnsile», 741
Cylinilricnl-celled epithelloniii. 1 J4
Cylindroiiiii, 150
Cyslicercua cellulnsic, I'.'l
I'ysticeicua uf muscle. 282
Cyalic liyilrocele, 002
tiiyionin, (10
Cystilis, U-W
ulL-emling, 054
Cyalii-clioiidronin, 129
Cyatd, lr,4
colluirl of hidiiey, U37
dermoid, lOG
I dcTcloped from glnnd», IfiS
deTplopment of, I TO
hydiilid. 1!<1
niufiiu?', Ili8
mullil»euliir, IGO
of bone, 218
:w
720
V T68 ^ is»EX. ^^^^^^1
H CjrU—
Donaoiil «ytli. 1M ^^^^H
^^^ of bniin. seO
uvarj, «63 ^^^H
^^^K orcharolil pUlDl, fl6T
^^H
^^^H of itjrienti'rjr. 4Ud
Dwtraciiun of linn* in g«ntct«B«, 40 ^^U
^^^H of rallaplitii lul>e, G8Ï
DiTelopmvnc of Miflavia, )4U ^^U
^^^H kiiliipj, 030
of cuviDomo, 99 ^^1
^^^H
of «nritlage, 25 ^^
^^^H of iiiniiininry ir)«n4, TltV
of donMHlrk «fII-TiM(i-pllh*linmii. 162 1
^^^H of luoiitli.
»f ajtintlriotl-cellnl epiibilionit, "^^J
^^^^H ofiBiopliiiKut, 400
of e^tin, ITii ^^1
^^^H
of «nebon-lr-imi, Vi't ^^Ê
^^^H of |inJ3«re»*, Ml
of fibroin n. tH ^^|
^^^^H iplM-n. AVIj
of Abrouii iImim, 23 ^^M
^^^H of «lanini'A. 4ù'
of iciiiiiniii, 1 lu ^^1
^^^H
of lipoinu. ^^1
^^^H iirolirrTuiM, 169
of lahaliiir^l Tplllivltnina, 149 ^^H
^^H or omji. «90
of l}niF<li>i'l>'rii>inn, llfi ^^^|
^^^H Mtiae«oti>.
ttf (nuouoi papillvmu. IM ^^^^^Ê
^^^H MTOU*.
^^^^^H
^^^H 4,t ooDneciivc tiwnt, 3(7
ii«rir» Zi ^^^^^H
^^^^H >|iFriniilc,
nttTB ^^^^H
^^^^L uiiiluciiUr, of oT&Tj. &90
of «»-»iiit liimo, ^^^^H
^^^^^H
^^^^^^^^^^Ê
•niY-iiiiik, ^^^^^H
^^^^^flnATIl of tho tlomcnM. enaie of. 89
liibpTflo. 12! ^^^^1
^V 1/ ItiBcacmllan, siuftoy, of «niilll*rlMi
ot InbalBir-l rpilh«liom*, IflS ^^H
^^^
Dlagoo*!», aiintvinkal, of «ntlOMNil^^^^H
citTeriiMM, lOU ^^^^H
^^^^M
^^^^^^K of l^mph gknd*. SK
^^^^^M
^^^^^^B p«seT«ni, &80
oiyvniK. ISO ^^^^H
^^^^^^^ *plMD,
mftvauL, SI ^^^^H
^^^H Mlwooua, of lyiDjih ulnnil*. S-îl
at aouronu, ISS ^^^^^|
^^^H oMcoiu, of lymph glniuji. XSt
»f lab«n)I>. 126 ^^V^H
^^^^H of ■npra-reiinl <']i|i>iilii, Wi
diSktVDiUI, of MtiMnia knd «liNiii^^H
^^^^H of luberol*.
|ilit«(uiiB. 2'>7 ^^H
^^^H eolloUl. of Ijintih glnnjs, SU
of uoinEiiin nUroumii. 162 1
of cjilin-Jrioiil-Mllcil «plUitllOMk, H% j
^^H Inllr. 4»
of 1) iii)>li»-lHi<iln>i, 146 ^^H
^^^^E inflrnnmiitloa, '2
of pnpilloaii. 100 ^^H
^^^^^^H
of lubultr Hil«:ii>(Di, IM ^^H
^^^^^^H
OUnbora. if* ^H
^^^^^^^H carcinamn. I(U
DïffuMd aboccM of conncoiln titMl,^'
^^^^^^H riHilntr. V'JA
21U
^^^^^M of li«Ut, 'JSI8
conf^nilnt «norpkalitii, 375
^^^^^H of kl<liity.
mrainp» copliHlitU, ITU
^^^^^^^f
O^plirhii, (lïl
^^^^^^^ paocr«sK,
pblrgni^>ii of conMWtivo (lanM, 2U ^^A
^^^^H [>u* carpuiuir*, 68
DIgcsti'c jppAimiii. 4411 ^^H
^^^^H ribrinmia, of cïIIh. U3
UilMtiiljnii of bronchi, 4<K> ^^H
^^^H pigeDcniaT;. of bvnri, 201
Dipbtbtriiie broMbilï*, 401 ^^H
^^^^H
oxmliitiniiM, lift ^^^^^H
^^^^1 Hoouilnrj, of spiiial «onl. 3SI
Ul7i>Kiii>, ^^^^^M
^^^H ir*xj. vf l^mpiti Kliiudt, SM
pbnryngill), 457 ^^^^^|
^^^H
^^^^^P
^^^f Tilreou). of mniale, 3T<
DiphlliErilix. oiitnBtoQt, 728 ^^^^^|
^^^^ l>*nio<l«x f^lliculoruni. It:!
DtilOiDAot kUnry, Ml ^^^H
^M IMrinutiiio. iicii(«.7:!4
tHiriai-w of «pillrrllil IÎMU««. 89 J
^^^^H fibriooUB.
of n«rTta, lMi«ii> fvltowlBg, Itfl hJ
^^^^H ftbntui hjprrirtiphio, Tâ8
of iintmai liwuM, 22 ^^H
^^^^H formsiivp. lit
Dry antiriii», 3)14 ^^|
^^^^B Ifprou*. 738
gtogrtnc, 41 ^^H
^^^^H oC gtmidara, 73H
Unbrrng, 1. , ^^H
^^^^B pMuilo nivmbrnnoua, 728
DaJuHiB, ikfinition of oell*. IS ^H
^^^^L «nppurniiro,
UuuJcnlili, vm ^^^^1
INDEX.
769
Daodtnam, nicer of, 471
Dor» DialeT, faccmiilomn of, 867
inflsmmAtion of, Stif
Dyacnterj, 4S9
chronk, 4!<3
cyets of, 496
■tools of, 4'j2
DjameDorrlicEit, pseud o-neinbriTioiis, 686
DjsrrophieB of BkiB, 739
EBURNATED ostcom*, 1S2
EbumnliOD of booe, 20'2
EccliondroMs, 'Hi
incbronic rheumatic arthriUs, 235
Eccbymoma, IS'J
Eccbymosis of bearl, 204
of perknrJium. '2'M
of Btomacb. 4 til
Eebinococcus. 102
Eggs of Naboth, I6S, G84
Elastic tissue, 213
Elemenls, hjperlropbj of, 53
of milk. 705
ElepbnntifisiM Arabum, 141, 730
glabrous, "HO
tubernsB, 730
verrucosa, 728
Embolic abscess, 330
infarction of muacle, 277
Bofiening of bniiD, 372
EmbolUm, 320
of liver, 5^C
Embryonic cells, multiplication of, 21
Emigraiioa of while blood- corpuaclea, 02
Empbf seuiu of lung, 412
ËDCCphnlilia, ii75
chronic. 377
diffused congenital, 376
Eoceplialoiil cnrcinomn. 103
of manimHr; fnlnnJ, 713
of Btomnch, 47ti
putlDceous, 103
Burcomii. 7'<
EtiehoniIroiDa, 120
cieietopment of, 120
hjnline, \'J,S
moclificalioaa of, 120
of bInJiler, tiûQ
of lung, 42H
of lympU gUnil, 3'>7
of mnmninry gland, 714
of muscle, 2H1
of ovary, U7H
of testicle, lil)3
ossifying, 12H
ostcoi'l, 131
progDOBJs of, 131
Beat of, 1211
Tiirielits of, 128
with rnniifying cells, 129
Endocnrdilis, iicute, 3U0
cbrooic, li^'i
Endocnrdium. Iiistologf of, 208
Endothelinl coverings, 36
49
Endoiheliom of serous membrane, 88
of Tusculur syBlem, 37
of vessels in inflammation, 58
Enoatosei, 133
Epiphyseal eiostoiea, 132
osiellii, 203
Epipbjsis, abaoeia of, 216
Epiatftxia, 304
Epitbelia, inflammation of, 56
Epithelial cells, 34
nesta, 147
pearls, 147
pegs, 147
tissue. 34
divieion of, 36
Epithelioma, 140
concentric c«ll-Dest.develapmen( of, 1 52
cylindrical- celled, 151
development of, ISO
dingnosis uf, 156
lobnlnted, 14tj
development of, 140
generaliiation of, ISO
of muscle, 150
of sebaceous gland, 150
prognosis of, 161
of bone, 218
of gall-bladder, 570
of intestine. 516
of larynx, 402
of lip. 4Ô4
of li«er, 50*
of Ijmpb gland, 858
of mammary gland, 715
of moutb. 45)
of muscle, 281
of nasal fossae, 306
of nerves, SG3
of cesophngoB, 400 ' ''
of ovary, (;7H
of rectum, 510
of lerous membranes, 268
of Btomach, 476
of euprn-rennl capsule, 601
of thyroid gland, 606
of longue, 454
of uterus. COli
paie men t-celled, 146
labalnled, 162
development of. 158
prognosis of, 164
varieties of, 146
with concentric celt-nesis, 161
Epithelium, formation of, on ulcers, 72
glandular, 38
Epulis f-^, 214
Erectile liponia, 06
tumors, 130
Erysipelas, 724
Eryeipelatous laryngitis, 808
Exostoses, 132
epiphyaeni, 132
parencliymntous, 133
subungual, 8:). 214
Extension of sarcoma, 87
H IBDBX.^^^^^^^^^^^^H
1
^H EiuiUlion. «Toupoai^ BA
FibroiD^—
■
^K^^ diplillitrillc, C5
of lung. 42S
^^^^L llbfinPB*,
of m>inm«r7 cUnd, ÎIO
^^
^^^^H cf orroai m^mbruia*, SdO
of meningte. Utï
^^^^H kpiDMrbiigif, lis
of nioulb, 41>a
^^^^H IncloilnK nclliiUr cItcncDl*, 66
of auaeln, 301
^^^^B ialIntPlD.-ilary. (14
of pl««ra,446
^^^^H
«1 tMilelt. GU4
^^^^H of Mroiu mfiobrBnai In infliniinMion,
pr«gnnnls uf. Où
^^H
*eat of. 01
^^^^B pMoJo-mrnibraaouï, 06
•pf«ln *f, 02
^^^^B Hroai, 114
nbt*-in7*na of îhImUm, &tS
of o**r/, 1178
^Ê IJALLOPIAN TL'IIK, «««ln*iii« of. 088
nbroiw «ucinoua, lOS
bj(i«Tlrophlo dtrmalllli, T2B
^^^K c;il* af. <>KH
Hpomn, 90
^^^^H hvn)(>rrlin|[r cf. HM
IMtlypi *f M*al fon^B, SD«
^^^^^^_ lii^tolof;
iitmir. Ijrnipb r>p<i«F* of, 28
^^^^^^^1 Inlliiniiiiiiil-cD nf. U8ï
olmtiiir* uf, 'H
^ tiili«rvl« nt. Ilfi«
Flttol*. Tcftal. m:
^M iDiiior* cf. lies
FlBl-<wll<.t fitiToniB. t>2
^H Faroj Knulul*. TKH
FoeUI ciriilagf. W
^H rAHieuInl*<l f! lira m A, M
FODi. iirrrfmllriB ulocr of, 'it?
^B n«>ir<MiiK. 13*
Fonign lioiliet. arllouUr, ÏS8
^H •nmi-mii, fl)
Formititon of t«llua, 2D9
^^L Fa(t^ il«g«iivruiion. 48
of m|[*, lï
^^^^^ lu liifluDinMlloa. T2
«r MMout InbKvIn, 109
^^^^H <>( &l>ruinii. I>9
of t>ua, ihcorr of. <>î
^^^^H
Formalir* nribHii*, 281
^^^^1 272
dcTiBiiitU 736
^^^^r Infill rii'iuii, 4i
oalciii*. ^1)2
^^r oxli^Dporuhj*, 'J*0
FrKtui* uf haa«, ooMpauaJ, 2tO
^H Fntua riiiiguB. 711
ilWuion of. 2ll>
^H Free', Unclcrlu lii. I8'i
la MrdaoniB, 214
^H Fibrva ur fjliruiin Iihui!, iltiriopmtut 0^ 33
in oHwomsluiit, '.:2I>
■ of Itomïk. 33
in nchlii). 'îli
■ Fibrin, -^i:
{il>''iiiiniFn!t in, 21]
^H Conçolnlion nf. 04
Bimpls, 'ilO
^H plbrinE>gon]c tLit>!irLDt>f, 1*4, 'JRit
^M Fibrin')|<I>inl]i; -ul.-l.inn. Hi, 3S0
^M Pibrin«uii ■Iprmaiiiii, I:tT
p.lLACTOCELE. 707
U tiuU-iiluililiT. orcinom» of, Mï
^K^^ <iuJ4llui». U4
^^^^L or wrnuD itittintiniie, 'iiSO
V}]»ll)f UoniH uf. CrlU
^^^^Ê pl«ariiy.
iufliinBiatia*! of. Û67
^^^^^ lilit-uilinnlii, tIG
liiniuni ot. 6<>ll
^H Fibru-i:nrlitii)ii.>, "lii
QnnflinniD nvurouin, IS7
^H FlUro-oliandramn. 128
OnngUudi, Ul
^H FlbrnM |ii>)}'|>l ul lourni, 408
flingrpno, cflN In, 41
^H liiiiinr". Ul
crjdnU iti, 41
^M Flbromn. 01
<trj. 41
^K uimliiinlcxl ilinenDlia of, Si
Luiiiî'l nr ntolM, 40
^^^^L taloorvoiis iiiSIirikliaii «f, 9i
in inâimniBtlan, 7X
^^^^1 eoriioil.
of ti|ii>niR. W
^^^^H dïfliiitinn
of luug. 421
^^^^H ilriiari[>tioii
of niQolli, 153
^^^^H iltidiipmtTit 114
plif nwintua vf, 40
^^^^H
srnil<, 41
^^^^M fiitl; •]rg»ncriili«n of, OS
Qangronuui oranMtirc lUrac, 2M
^^^B
jtsmrliiB. 4i;'>
^^^^^B 93
0»ic> in porionrdian, 390
^^^^H muooid, W{
(ioitrio «gilarrb, 40&
^^^^1 or brain,
Osiftriiiii, 4t>û
^^^H 61S
obronifl. 4DS
^^^B «r lujrux.
cr««puu», 498
^^^H
INDEX.
771
Qaitritiï—
goDgrfnous, 4âfl
phlegm on nil s, 4GB
QaEtra-inlestinnl mucoug gUnds, b^pcr-
trophj of, 163
GelntiiiDUs cjbis of oinrj, C80
Q«DFnt dracripliaa oT cnrcJDOinn, 'J7
Oenernliiiitian or cftrcioomn, Idl
of lobulnled epilhïlioma, 1Û0
or sarconin. 87
OeatHtion, GlmngeH of Dlerus during, C8G
Giant cclla. 20
in Bnrcoma, 81
in lubcrctt, 118
Olikuilers, 12'!
dertnntilia of, '38
Inrjngiti» of, HOU
GtotidR, ucinou?, ilS
Cj-sis of, 16B
of Hkin, 720
of Htoinnch, Ualona of, 4(i5
taliuUr, A'è
mrieiU» of, 38
Qlnndulnr epithelium, 38
Gliumn, »:i
Glio-sareomn, 83
Glullia, (Eikma of, SOO
Goitre, S'.Ki
nnciiriamnl. C97
cnlcilii-d, 5117
cystio, 6!I7
fibrouFi^ ât^7
soft, fiST
Oonorrhccii, i>54
Gout, nlbuminurin of, fi'ld
Oout; nrtbritix, 'HI
urnle of Hodn in, 241
GraafiuD follicle, 074
dropiiy of, 1179
Qmnulnr kidney, ti2i>
liicr, 547
oa uteri, Gtll
pbHryngiti», 458
Granuliilion tissue, Wl
Gros-, S. Vf., 78, fi2. 84
Growtli oF enrcinoiiin, lot
Gummn, KIT
absorption of, 112
aaaloniiciii diiittno-iia of, 112
descrijilion of, lUll
development of, 1 10
metumorpboïir!! of. Ill
of bone. 111, 217
of intestine, '>I2
of kiduey, <>47
of liver, 111, SCO
of miii'clea, 2HI
of oinry, tJ78
of [i^increna. .'iSO
of epieen. 594
of !-upra-rennl cnpsule, GOl
of testicle, HtiT
prognosis of, 112
sent of, 112
Gum, lend line on. 450
silver line on, 450
H.EMATIN, 28G
iioamalooele, 6â3
of akin, 724
peri-uterine, 988
Illemnloidin, 50. 28G
Hn^mntomn of dura mnler, 3'j7
llicmin. 285
', llrGmoglohin, 285
I Iltemorrhoids. 613
I Hnril acirrhus, 103
; HnTersian canala, 27
i llenting nf nrteriea after ligature, -'^18
of wounds, 71
' Ilenrt, sbscessea of, 207
! aiieuriarna of. 205
! fttrophy of, 2B2
bloo<I-olola in, HOI
congestion of, 204
diaensea, nlhuminuria of, 026
ecclijmoaia in, 204
fnllj driienemlion of, 203
fiilty infiltration of, 2!)2
fibroid indurntion of. 207
hcmorrhnFiea of, 294
hypertrophy of, 2113
ln8;ininiatioa of, 2116
muscular fnEciculi of. 30
pigmentary degeneratioD of, 204
ruptures of, 295
luniora of, 308
*iLl*u1nr nneurisms of, 302
vegeUtiona on, 300, 308
Ilemorrhnge. nasal, 894
of bones, 100
of brnin, 803
of bronchi, 404
of connective tiasne, 248
of Fallopinn tube, <i8(j
of henrl, 294
of kidney, CI8
of muscle, 27 fi
of nenea, 300
of oTnry, 676
of pericardium, 200
of Bcrous membrane», 268
I of skin, 724
of apinnl cord. .'180
of supm-rennl cnpsule, GOO
of uterus. fi?0
Hemorrhagic exudation a, 45
infarction, 330
of lunft, 411)
I inflatnranlinn of serous me mbm ne a, 2^2
foci of brnin, 3Î0
myinmn. 00
pericarditis, 291
I peritonitis, 571
I pleurisy. 443
! Hepatic cells, amyloid degeneration of, S25
changes in, 622
clouiling swelling of, 524
fatly infillratiim of, 525
I in cirrhocis, 563
; Hepatitis, 51)2
' llepntili'i Klnbrn, 644
] interstitinl, 613
^^^^ïT2^^^^^^^^^^^^^I?DB?^^^^^^^^^^^^^^^^B
^H Hmi«i!(l<, InlcMiilîikl'—
Hrlro«I«— ^^^^^^^B
^ft^ •7pb)Illie. 1 1 1
«eanititol, sas ^^^^^1
^^^K mitlitr; Interallrlnl, iii
«yitie. Wi ^^^H
^^^^H |>nr(«ch]rni>lauK, [>3J
«f eord, «12 ^H
^^^^ liurulfMil, M6
«punollo. U6! ^
^V fltmi». Iriion* of inlMIio* ta, 608
^B BlrnugulDlcil. ôOn
HritToma. ItA
^H Itfrninl i>ii«, drep*7 of. W2
Q jpornmin- f-S
^H lIvrpM dircitulan, 741
of btiiJdtv. 6&2
^1 ntlcroplulft, M
of ianf. 408
^H^ llltiologf, nornuil, 17
«r ofttj, liTO
^^^^L of orUriM, X<HI
of iplotn, fi9-'>
^^^l «r articulation». 22T
«r Bupra-rcnol <«p*«l«, OOO
IIjp«rpU*U, Ktinplv, as
^^H of bloiJJtr. U3
^^H of blood, -at
H7P*rplM(i4 ioltoniBtiiMi of ooroui neni-
^^^^M padtaloglsal, 287
braa«!^ 'ÎU
^^^^1 liTonohi, ilEKI
tl^fpfriroph; ft «IfmenI». IWI
^^^^1 of baaoal mueoui mcmhranp. 446
ot KOtlro-iAlMllB»! «uuoaa gU»do,l>S
of Ikmi. ma
^^^^H of onpitlnry blaaJfOMol>. S94
^^^^H of oaonc«li>f tÎMiit. 'J.iî
of lip*. Uit
^^^^1 of «iKloeordinm, 296
«f Diiiintniirir (t'uid, T07
^^^H of Fnnoplon toboo, 68S
Of liluwlr, UTI
^^^H intntiot. 4T9
of uKtiouUr tÎMUO ol otoiKtob, 477
^^H «r kkliit7, UM
of proitolo, 071
^^^H la D'il I. nSB
of ili7rol'l tf*»4, 6IM
^^H t>r litor.
of longue, 4&S
^^^1 lunB. SW>
of o(*nu, liV7
^^^^1 «r IfmpliKlM ^onil*, 818
^^^^1 or Ifinpbaile re«*1*, S46
^^^^1 of iDOinmoTr Kliind, TOI
TCl!Ttir08l!4. c'lrntou». 740
1 loliiliyiipin piUri*. 710
^^^H inaKlet. 269
^^^H of Diual foMB, HSQ
Icbibjpiii pit^rioiis, T14
^^^^H ii*ri« tiBiM, S'ift
kl<ru>. &-1S
^^^^H of (e'ophniiu*, 46C
llnltiw, 41*7
^^^^1 ovoti».
lIluDrniiono, Ilot of, xi*
^^^^B pHnerM*, ••78
lad oral m». Abreid, of boarl, 2TPÏ
^^^^1 *r pboT^i. I&6
of Ijrmpltstie glMida. S58
^^^^H of pr««uiio. 6T(I
«r «bikn«r*. lOT
^^^^H of mpiratoij nppnnlaoi S59
of ennnocilto Umim, SM
^^^^B icrotu cflTtlitB, 2*1
of ptncreits, 579
^^^H of*klB, 7l'l
Infontion. 40
^^^H of «pkeo.
(riiibolk, «f nwwlo, £77
^^^^B of ttooinoh.
li«mf>rrbii;;ie, 330
^^^^1 of *apni-r«»>l eupoulr, A!ID
of brnin, 313
^^^^1 of Bjnoriol nembnne,
of kiJtiîj, .119
^^^^M of («ttinl».
of npUcn. li^
^^^^H of Ihj'foiil )ttiin<J, &!Hi
[nllIIrHlioD. nnifloid, K
^^^B of lnieta«B. aao
cnlcnrvou». Gl
^^^^1 of uraior.
of copillarici, S3T
^^^H of orolbra, fl&S
uf Riirdiiuion, 100
^^^H aitnio, S9S
of âbroms, !■!
^^^^r TOiD». Sitd
of llpaioa, \iti
^ HnbOïlt tinr, Û4I
nf myoïuo. ISS
^1 Horns, Ifiâ
vl pcrknrdiuin, SOI
^H H7«Ui» tHchondrama, 1 S8
of Toiii*. Ali
^M Ujûnnhntia, SS8
fiilly, 47
H lljdatid <r>i». 1»!
of bcart. 392
^1 of conDKil>o Umim, 'iô8
of brpulli: nlla, l>3&
^^^^ of liior, 5fiS
of l'uir, ôSS
^^^^L of mnmmnrj kIdBiI*. TI&
of ni^oiRO. ISA
^^^^H
of pnncr*»!, 670
^^^^H i>r iWntiiDfKin,
ntacau* nntl colloid, 41
^^^B tiimor. tnuliilocuUr, 139
oX u»iM, 6S
^■^ n^driDiulii. :;k7
wra«i otitl ■IbamlBoiu, 42
^1 If^drucvlf. uei
MTOM, of iibiii, î:tl
INDEX.
773
iDflammftlion, catnrrhiti, of bladiler, 003
of utprua, (iîiO
obronic 'lifîrrentinl, from Rarcoma, 2i>T
dlffustd, of skin, T^4
of canntctiTS tissue, 25Q
of liter, 6-IS
of lymph glands, 853
or niDscle, '2TJ
ot Bupru-Tennl capsule, G02
ci rcuiu fieri bed, of BkiD, 730
cliaical forms of. 7S
Cohnhcim's Ihenry of. 01
congcBlÎTe, of skin, 721
deRailion of. ^&
drgenerntive. of ekiii, 737
diffused, of skin. 7-4
exudntive, of skin, 727
hemorrhnpic, of nerous membranes, 2<~i2
hyperplastic, of serous membranes, 205
of skin. 73fi
in ooii-Tasculnr liSBoes, Go
new formniion of vessels in, G8
of «rieries, 807
of articulntions. 2'JR
of biliary vessels, 507
of hone, 197
of brnin. 37l>
of bronolii. 404
of capill]iric9, B3Ô
of cnrcinomn, 100
of colon, 4ttli
of canneciiTe tissue, 2Q3
of [looilenum, iHD
of rpidiclln, 0<>
of FiiUopinn tube. 687
of g III! -bin lid er, 007
of benrt. 2!i<i
of ileum, 487
of inlealine, 483
of kidney, lil'J
of tnr^ngeal citrlilnges, 401
of laryiii. 3!)ii
of lipoma. 90
of liwr. -'.3:i
of lung. 414
of IjmpU glnndn. a.j2
of lympliHlies gf lung, 420
of lyuipUiLtic vedseLf, H l.j
of mnmniarj' ginnd, 7U0
of mucous Tnembraue of moulb, 448
of muscle, 'SiS
of naatil mucous membrane, 394
of nerves, 300
of ocï'ipbapui. 459
of or^seous tissue, 00
of Oïnry, 077
of pancreas. i')7H
of pericnrdiuni. 2!*0
of peritfineuni, 571
of pU'irynï, 4G7
of pleur», 440
of proitftte, OTO
of rectum, 4a8
of Hebnceous );land9. 735
of seruua membranes, -59
Inflammation —
of spinal cord. 883
of spleen, 5ST
of stomach, 4G5
of subcutaneous tissue, tO
of BDpra-renal capsule, 001
of testicle, 059
of tonsil, 45'J
of Irncben, 403
of tunica Taginnlis, 001
of urethra. C.Î4
of THscular tissues, 69
of veins. 839
of vermiform appendix, 488
peri -glandular of skiu. 78ii
puerperal, of uterus. r>92
purulent, of conneolive tissue. 258
of serous membranes, 203
Borofulous, of lymph glands, 354
suppurative, of portal vein, ô37
ulceralite, of large intestines, 489
Inflammnlory congestion, 03
CindalLoril. 04
ne* furmntions, 06
softening of brain, 373
Innomn. 92
Intermittent fever, spleen in, 585
Interslitial hrpniilis, 543
myelitis, 884
nephritis, 031
pneumonia, 423
Intestinal cninrrh, 483
lesions of typhoid fever, r>01
ulcers of tul>ereuloniH, 510
Inlesline, adenoma of. tiH
carcinoma of, 515
congestion of, 483
epithelioma uf, Cillî
fibro-myoma of, 618
fibroma of, 513
gumma of, 512
histology of, 479
Inflammation of, 4fl3
Isrge, ulcerative iu^mmalion of, 4X9
lebions of in hernia, 600
lipoma of, 5l3
lympbadenoma of, 614
polypus of, 514
pnst-morlem changes of. 433
sypbililic tumors of, S12
syphilitic ulcers of, .^12
tuberculosis of, 508
ursemic utceralions of, 601
vuscular (umors of, 518
JAUNDICE. 535
JuicB of carcinoma, 97
KELOIDS, 737
Kidney, abscess of. 643
amyloid degeneration of, 0-7
aniomia of, lilT
aagionaot, 051
^m T74 ^ I.HDKX. ^^^^^^^^^H
H KiJMy—
LwioMt o*u>»d-~
^^^^ lliigtiCi Hf*tu» «r, 62t
bj tnauKoienl nalrilion, 41
^^^B tuti'iili «f. GI&
followlni •liTl>lt<n i>r narrpt, M'll
^^^^H MroÏBomn of. OôO
ill forHHlioB of orll*. 63
^^^^H clinng" !■ lilaolVHwI) tf, Ofl
irrllKlWe. of (iirlltirc '22!t
^^^^^ chnn(F« lu Fptihvlinl ««11» of, OOtf
auirili**. of <«pillnfi««. XSÛ
^^^B ooDoid «711U of.
of (anilngr. '."ïli
^^^^H «ao«r*lloai In iwiilrMlfil, N9
of muxlr. i'O
^^^^H conK*al>an sf, €ltt
•f iirtvrivf, JlIM
^^^^B c^rila of, G40
of booc. 111^
^^^^1 fnllT <l«|t«nfnitl«« of. Ii2f
of e»UtB|t*. 'i'H
^^^^H gr«iiiilnt.
«J «orrottve irriuata i* >taM«ah, llM
^^^^H gamma
•f MJttllli, 3U4
^^^^1 b«motTlM|t« of, flIS
«f nairition of «Umimu aaJ of iImino,
^^^H hUiolou of. 904
^^^H IkUrennQ of. AID
8»
Leoala ikxI ijmaln in uniigrcae. 41
^^^^1 iiiBnmainlioii of, f 19
lioaeaejrihorniin, 14:^ 'iV*
^^^^1 In pboipbormn potMninf, 639
*pl<ni«, !>vi
^^H Utk* «bll«.
LoDcucyloii». 3147
^^^^B kaiona of DOiiOMtiv* (iwiw pf. ON
I.FUfnphlPicmiliii, m
^^^^H lymiibadcnoom of. UtS
LeukiDmin. I'SB
^^^^1 met<u>Uii« nbMtM of, All
Iipukwiik luinoni of lifer, Ml
^^^^H fknuiite* of,
Lip, «i-lthiliomn of. 4M
^^^^1 MTeom« «f. M8
kjrpniropby of, 4ig
^^^^1 >Dppanillon uf. IH9
UpOiB», i]t«criplian vf, OS
^^^1 «nrgieoL M8
iloic'apmMit vf. W
^^^^H tahi>r«Dl9i>t* of. Ol'l
tT*«ille. I'll
^^^^H TtnelM ouiiOkcltil, Ktl
tnllj ii»|E«n«r>lioii of, M
^^^^^^ wiix;.
fibroua, »1
jCiiiiC'tn* nf. UA
^^^^^^^*
iiiBiimm«lion it. Oft
^H ij L>i'i*il<iii, fntr; InAttMtloa of Utcr.
myioiiin(oa<. Wl
of nrllcuUtloni, 311
^H durinn, 6&â
•f bonv.UU
^H L«tin*c'* thtor; of labercDlMb, IIS
of br*l*, 876
^1 Lanimil*!) «pitlirllnm, 8((
of brenfhl, 407
^H Urge «Mi* kulnt;. 4tl
of inleWiup, St 8
^H lAr^ngittl*. ctUi that. SOI
of moutb, '1&3
^H chraaii, 397
of matolo, »4I
^^^^ dlpbthrrhic. 3V7
of «Mfihnj-iia, 460
^^^^L tiTtlpoliilonti. 'AVS
of porlloncovi. 67'
^^^^1 «denuloun. !IV3
of Riumacb, 47'J
^^^H at (tUndm. 8t»
pTognosia of. 'M
^^^^f (jjihnlil ffiar, :K4
%e\i of, Kt
^^^^ ukerouf, 400
■P«<l«o nad ToriellM of,M
H" tkiicJoiw. SU8
Upoowloua «nnnaoaw, 101
^^^^ Iatjui, MtltflDina ttt. 408
njrxumn, CO
^^^^k oaralaoMa of.
snrtom*. 8*
^^^1 «fliMloma at, 402
Lilt of illuMmtioriK, izr
^^^^M fibroma 401
Uror, ahawmv*. \irg*, of. &tt
^^^1 bbtologjr of. af9
iDcinitmic. of. OW
^^^^H tiitkminnlloii i>f vnrf t1>g«a of, 4Dt
BOulo jotlow atrojihjr of. &^2
^^^^H Ijtnpbnileiin'n]! cf, 11)3
nnjrloiJ dtgencnlïoa of, fi6T
^^^^1 (ikpllloma
•Bgbniii nf. M9
^^^H paruiUM of, 40H
■irupby i>r. friim oiTrb<Ml». C47
^^H »;|>hili* 8U9
bjlinry pasHigpi io cinto*ii, CAO
^^^B Ubciclo of, W2
oirciaoma of. Iiltl
^^^H iwmon of.
cliToni* tnBammalion of, M3
^^^H Lelo-D>7ofna. I3I>
dKvlnilon of. la olrrboola, M>
^^^^P liopro*;. cuiitiieau) tsboicuto of, TSB
cirriiosh of. ûtH
^^^^ Lvprnu!» JwmBlili». T3tl
«Htrbotic. «lib ftranaUr mrlWoa, M7
^F l.apiollirix bueo«lb, 465
«lib MMOlb MirfMV, Mil
^K Lniana ctu»<l b; iloalk of ibc «Icmenli,
ooBfjOBtion of. GÏ3
■ 30
eytv of, 5tiQ
^1 b; «ICHK of natrilloa of e«11«, 03
dogonvralioa of, Uii
INDEX.
775
LÎTer —
embolism of, 636
epithelioma of, 6G1
fact; dcgeneratioii of, 657
fiktt; iD<rntioD of. SÔ3
during lactntion, &S5
general cirrhosis of, 541
grADuLftr, Û4T
gumma of. 111, GGO
hiatotogf of, 517
bobnail. 647
bjdaiiJ or, 565
in enrdiac diaense. fiSO
inflammolton of, 5^2
Id typhoid fcTcr, âSii
lesions of cellulo-fMonlnr syslem, 62G
lésions of vessels of, 627
lukiemio tumors of, 6lil
metasinlic abscesees of, 636
nutmeg, 53Q
purrial cirrhoaia of, 543
pnst-mort«m chnngea of, 627
pulsation of, 632
red atrophj of, 631
tbromboais of. 637
tubercle of, 650
tumors of, û59
TegetntioDs on, 648
TîHaela of, in cirrhosis, 54Q
Lobar pneumonia. 41C
Lobular poeunionia, 414
Lobulated epitheliomn. IjO
of bone, 160
myomn, 13->
Lung, nbsi^ess of. 419
anoimin of, 408
apoplexy of, 4118
atropliy of, 411
carcinoma of, 428
congeslioD of, 408
emphyaema of, 412
enchondromn of, 428
fibroma of, 428
gangrene of, 421
hemorrhngic infnretioD of, 410
liistology of, 39(1
hypersemia of, 403
iufliimmatinn of. 414
oflymplinlics of, 420
metastnlio nbscess of, 4-0
oedema of, 4U8
osteoma of, 4J8
pigmentation of, 421
sarcoma of, 427
tubereulosia of, 420
tumors of, 427
Ljmph glari'1.1, amyloid deEeneratiou of,
355
calcilicnlion of, ^ >4
carcinoma of. 3sii
caseous degeneration of, 354
colloid trAuaformation of, 365
enchondroma of, 367
ppilhelioma of, 35S
fibrous iaduralioQ of, 353
! Lymph glands —
in carcinoma, 102
InflnmmaCioD of, 862
I pigmentation of, 851
scrofulous, ioflammalion of, 854
' suppuration of, 368
I Byphilia of, 857
tuberculoaia nf, 356
tumors of, 355
naiy deiteneration of, S54
, Lymph lacuoa of Sbroua liaaue, 23
I plastic, 262
Lymph adenoma, 142
changes in, 146
I develop ment of, 145
diagnosis of. 146
' of bone, 218
1 of intestine. 614
I of kidney, t>48
I of larynx, 403
I of OTary. 67B
I of pancreaa, 580
I of stomach, 172
I of testicle, 667
prognaais of, 145
I seal of, 143
' Lymphnngiectusis, 346
Lympliangiectatic pachydermia, 723
Lymphangioma. 141
Lymphangitis, 34 ô
Lymphatic glands, histology of, 348
, «easels, dilatation of. 84(j
liislologj of, 345
I in carcinoma, 98, 347
' iiiBammalion of. 846
> luberoulosis of, 34li
Lymphatic! of tung. inflammation of, 120
of sitiu, dilatation of, 722
i in (edema, 723
MACRO-GLOSSU, 463
Malarial feter, spleen in, 685
Malpighiiin glomeruli, changea nf. CI6
Mammary gland, adenoma of, 715
atrophying scirrhus of, 710
axillary glands in carcinomk of,
712
carcinoma of, 710
cysts of, 716
encephaloid of, 713
encliondroma of, 714
epithelioma of, 715
fibroma of, 710
histology of, 701
hydatid of, 715
hypertrophy of, "07
înÛammatloD of, 70fi
melanotic tumors of, 190
! myxoma of, 709
sarcoma of, 8], 70S
1 Bcirrhus of, 710
' syphilis of, 710
I tumors of, 7lt7
; Tillous carcinoma of, 7t3
H ^^^^^^^ ISDKX.^^^^^^^^^^^^^^H
^H KUrrow of bon*. 27
Mnooiu pol^pJ — ^^^^^H
^H MiaMa. mtUniD. 189
ulMita, 091 ^^^^^1
^H Mflillili, TOG
timtt. 28 ^^^H
^H >l«ilulliirj eirolBoma. 103
llBltllemiUr C7«(a, 160 ^H
^H «atiiy *f boDV, ÏT
«f OTarj, eW ^
^H neuromn, ISî
hjiMM iiUBor. IIKI
^H MeUDwmi*. 2«9
itnltinwolMitd otil». 31
^H orbtnin. 3H0
U«Ml^ anglona of, 183
^H Malaalo mauv*. 160
airopb; of, 270
^H tURivr* nf luog, 437
Oarciiiama of, 2I^\
^H MaUDD-DarciDomii. ICiù
ebroDia întiAmmiilian »t, 3T9
^H Mrlnno laroomn, 8U
«load)' a*olUiie of. 271
^H Mclnnutio tuiDori of naBimitTj (laaJ, 100
«jvtiotnus of, ïH'i
^H Mtliccrouii wtiiB, l'iS
«abollo lafarotlon of, ST7
^H Manbrnn* of Sehirann, 82
«nebondroma of, '2iS\
^^^^ llfDiu;»», oolloiil dpjcPDVratioD of, SOT
•pilheliao» «r, ït^l
^^^^^ eoneetlion «f. Sftt
fait; degeneration et, 273
^^^^V ftbroma of, Xfiî
Bbrêa io froc, d««(t«cUa* pt, M
Cbr«mn of, Sèl
^^^^ Inmora of, Sil7
^H MtniDgltU, <«t«bTnl. aeulo, ZH
gumma of, 281
^^^^m MiBhr^-Kpiiul, S<A
btmorrbng* of, 276
^^^^1 obrooio.
biltolon «r, 249
br^atU of, i»i
^^^^r tubcroulDo), XC&
^V MiniD|i«-«no»p1in1ïii<, iJilTnwd, 8ÏS
^^1 Mïtamorphoan ol ^omiiiii. 111
^^Ê MeUatu 1 of laToomn, IW
h^pfrlroph; of, 271
ioHaiDDintloD of, ST8
lipoma of. S»l
^H Molaautio nliicata i>r iWar, 636
lobalaUd epitbHlnnia of, 160
^H or luii^, 4J0
m^ioma of, ^1
^H Me<Th>*, inlrrnal.'ilH)
nuiritite letiooa of, 270
^H MivmnpnrLjn Auilonini, 740
OBieonft of, 261
^^1 Microapoicn l'urfur^ 74')
pnrnallaa of, 282
^^^^ Mlli'iry iiiiruiimn of brntn, 871
plgmenEary dtKVncraltou «f, 271
^^^^H inlwri-lilinl biipatitin, ÔJ&
rupture of. 280
^^^V lubi>rclp, anntoin; at, 116
aurcoma of, 280
^ colla af, 114
au |>p lirai lull of, 2T0
^H Milb, «Ivaxnta or, "iOi
triihniic of. 2^3
^H Milk; paioh» of pcrkarJIau, 2BS
luinor* of. 28U
^^1 Mliïfr», jiEiHUinoniu (ifj 4^'>
Tiirfoim (ItfE*''ii^rntioii af. 274
^H MiiTil lumora, 17(1
«aiy 'IcfEdicmtioii at, 43. 274
^H MuJiri>'nt)oiii ot fnelionJrooia, 12A
Muac'ilnr fimclRnll at licarl, 3Ù
^H MiiiM lEUtie"'»*. 40
Ëbrcn. etii»li>i). SI
^H Molluicoid fibroma, S8
b^pnrirapby of alocDMb, 47T
^H MqIIiiiicuiii aobncaiim, 7A7
tlnaur, KO
^H Morbus coiiu Bunilïi, 281
tumon of, 1S4
^H Mortiflculion. 40
M)>«Ud. S2
^H Miiulli, rjtu or, 4(>3
Myvlinie niuroma, 13S
^^Ê cpilbi'lioina a(, Mt
Mytlitja. 8S3
^^^^_^ Gbrbm» of, 4C>^
liiitritilkl. '1)14
^^^^H KniT^imii* 4G3
Iriiciia ill. 81^
^^^^^
BiipputnlWo, :tSS
^^^^H pnrniiitni 4t'>&
Myalolit tnr<ii>inn, Si
^^^^f tubi-n:lo
Myocnrlilia, 31M
^^^^ tumara of, 4fi8
Myoenrdiuro, 292
^H Maain. 44
(iimiira uf, Î98
^H Mucoid ftbromn. 93
Myo-niiromo of alomaob. 418
^H^ Mueixu nixl r<:tloi<i tntlliraiiolia, 44
Mjumi, 1S4
^^^^ bum. :nd
aimtumieni fliiKUOsU of. IH
^^^^m cardtagf.
oulonrcDQi inâliralioD of, IXft
^^^H
doiclniniKiiil iif, ms
^^^^1 ntema, ef>8
(any iuQUrnlkoa of, ISO
^^^^H «ludntloi».
lubiilalcd. lU
^^^H »«Umorpbo*ia or 07001», 18B
DDSoua m«<aaiotyliO«ia 9t, 188
^^^^H pefiitloMS, KO
«fproalBI*, 671
^^^^B patch** »f mniiih. 4SI
of Btatvt, |)S9 j
^^^H fOljpi of Dual foBtiB, 396
pragDOtiB of, tM
INDEX.
77T
Mjoma —
seat of, 1S6
atrio-cellalare, 134
varieties or, 185
with smooth fibres, 135
M7ositie, 278
Myxoid epitbelioinn oToimj, SSO
of teaiicle, 665
Myioma, anAtomicat diagaoele of, Bl
cjstin. QO
deGailion of, 89
desoription of, 89
hem orrb agio, 90
lipomntous. 00
of mumniDTy gland, 700
of muscle, 'J81
papillary, 01
polypoid, 31
prognoBi» of, 01
scat of, 01
Myxomnious lipoma, 66
tumors of boiie, 211
Myzo-sarcoma, 86
ÏT^VUS, 130
Il Nasal fos'iB, epilheliomn of, 306
fibrouH polypi of, 3<J«
histology of, 380
papilloma of. 306
tumors of. 303
hemorrhage, H04
nucaus membrane, inSammation
894
mucous polypi, 305
Necrobioisie, 4<J
Secrosin of bone, 204
phoapLorus. of boae. 20G
sypbililic, of boor, 20(i
Nephtilia. nlbuuiinouB, 610
catarrhal, liil}
crnupoDS, 023
diffused. 621
interstitial, G31
albuminoid. G3I
non- albuminous, 641
para ei tic, 644
parenchymatous, C2t
portinl, iiiler«(ilinl, (S41
Bcnrlniinoue. I>23
superficial, 6^0
suppurative, G43
Nerre, hxîï cylinder of, 33
carcinoma of, 8U3
cells, 31
ia Bpioat sclerosis, 887
luii|;«iity nl. 30
COngealion gr. 860
cpilbplioma of, 363
fibres, development of, 33
Tnrieties of, 82
Leniorrhn(;e of, 360
inflammation of, 8tiO
lesions following diiision of, 301
tissue, 31
of,
Narre tissas —
histology of, 3l>g
tumors of, 137
tumors of, 302
NerTous system, ceatral, 864
Neurilemma. 32
Neuritis, 360
Neuroma, 137
amyelinie, 138
anatomical diagnosis of, 138
fasciculated, 137
gnogliouic, 137
medullary, 137
myelinic, 138
of brain, 8S0
painful. 137
plexiform cylindrical, 137
prognosis of, 138
seat of, 188
New formations, inSammatory, SO
Nodular rbenmatism, 23i
Noma. 458.
I Non-albuminous nephritis, 641.
I NoD-lflminnted epithelium, 80
Normal histology, 17
Normal tissues, 22
Norris, W. P., 63
Nucisolus of cells. 19
Nucleus orcelli, 10
Nutmrg liver, 630
Knlrilion, excess of, 53
lesions of, 39
Nutrili*e alterntionK of angioma. 140
modifications of tnbercle, 121
OBLITERATION of arteries by eodarto-
ritis. 826
spontaneous, 326
Odontoma. 184
(Eilemn, lymphatic, of skin, 723
of adipose tissue, 261
of brain, 868
of connectiTe tisane, 250
of glottis, 800
of lung, 408
of skin, 721
theory of, 251
Œdemntoua laryngitis, 300
(Esopbsgitis, 450
Œsopbiigus, cysts of, 460
epilbetiomn of. 460
Gbro-myoma of, 460
histology of, 456
lipoma of, 460
stricture of, 450
tumors of, 460
Oïdium albicans, 455
Urcbiiis, 650
chronic. G 60
syphilitic. 661
Organic muscle, elements of, 80
Organs and tissues, diseases of, 106
Oiaeous tissue. 26
derelopment of, 27
^m TW niDBx. ^H
^H 0«MOUS tiMU«—
nACCIIIONUX BODIES. WT ]
^^^^ Indkiiimtllas of, £0
^^^^h tuman
t*Bch;m«Bi*|tilin. UK' I
^^^^B tnbeeulo. roriDitllon of, 1D$
Paeinitn corpuack. 730 ^^J
^^^^L .
I'siafiil Muromi. 13! ^^H
^^^^■QMiSenl'ton fran «tttiUe», 38
Paocrt*', ahM*» of, A70 ^^U
^^^^F from dbrouii ii*NO. M
oMjIolil dci;eii*TS(l«d ol^ &80 ^^|
^^^^B ttam frtimuum, 'J9
■troptty of. C.M> ^H
^^^^m of broDcbi, 407
etloolua of, 682 ^^M
^^^1 «f «trtlUfr«. 183
MralBomn of, A6I ^^|
^^^V ONlfann liitac, 38
«j*iaor, ôHI ^^1
^V Otûtflug encboiMlroDia, 118
filly ilt(E«nFnillon of. &ÎD ^^|
^H nroanft, 08
faitf iiilltrallow of. 67ft ^^M
H Orftili*. I»T
guoiina of. 'fiNI ^^H
^H ooniUftiIns, 2»2
hlMcloKr of. 576 ^^M
^^^H t^^jatat. 'J08
iiiiltiMltnn of, &7I> ^^H
^^^H formallTc.
)oB«inii»t<Bn »r, {>T8 ^^H
^^^H rsrafjtna. 3UiJ
^^^H oiapl*. 300
Wmphonia. ti90 ^^H
lubrrcule»!* of, 580 ^^|
^^^^r mppitnilh*, dtffueil. ItUK
laiiioTi uf. &80 ^^H
^V OflMtd •nebondroma, 181
r>i[>iUn- ot ilffiD. 718 ^^H
^H l«mori, ISl
rnpillary iii/xvinft, 01 ^^|
^1 OtUoiiMi. IH:!
■nrcamft, 87 ^^H
^H oomimel, 182
rnpillatnn, IÂ7 ^^|
^^^^> devdopoieni of, 113
eornouiu. 169 ^^H
^^^H tburnkitil.
dhSnoala «r. IGO ^^U
^^^H «f bon», 318
d<ITt>M<l. of *kl». 7S8 ^H
^^^M oflaiiK. *■»
muaoui, 109 ^^|
^^^H ùT muwit, 3111
uf UxUcr, nm ^H
^^^H >Mt
of brain. 8>H ^^H
^^^^f upatigy, ISi
of Urrnx, «1)1 ^H
^^^ nriciiM or. I:13
nt niMl foMn, DM ^^M
^H Otteomitliteiii. 210
ot vlomitcb. 4Ù ^^H
^M fraciarei In, 220
proguMia *f, IGO ^^|
^1 *pi)iit<. :!»)
of, 100 ^^1
^^^_ (hlcamynlilU. £43
TtriBlieaof. IM ^^
^^^H Ihlfrtjihyte», -MI
rnpnli of alctn. TSO 1
^^^M OttrafoT^ai». Tally, 330
rnraaita of aloptcla clnaMxripu, 7U 1
^ HiiDe. 320
of ptjriuis oapttia limplcs, 747 1
^H OrnrlHii vytlH, CTÏ
vnvtoolor, 7 IS J
^H Ornritli. CÎ7
Fkruntrr. miiaial, of akio. 741 ^^M
^^^ ftrxTj, carclDomii of, 0*8
«uuntoui. Til ^^1
^^^^H cl«niioi4 cftl^ uf, KHi
(if hibfid, -^tl ^H
^^^^B riiohonilrainn of, C78
ef kj'invf, eat ^^H
^^^^H cplilii-Unma of, 1j>I'
Urynx, 401 ^^U
^^^^H flliro'inyiiiiin of. i)T8
lit moaih, 4U ^^^
^^^^B gelntinalii ejili ot^ liSO
of muaslc, 333 ^^1
^^^^H
of aptocn. 6M ^^1
^^^^H h«iri<>rrlin^« ot. Q7S
v«f^t«bl«, «luninnUoa of, 748 ^^M
^^^^H hiitolopy of, ■>?<
^^H
^^^^H li;i|-i'r»'iiil& of, tt'fl
Parnalrlï nffectlan* »f skill, 741 ^^|
^^^^H iuU Jim in at ion of. 0T7
iiïpbrili». <1I4 ^^1
^^^^H lynphadeaom* of. $T8
PkTCDObjnintasi rxoatoiîi, 138 ^^M
^^^^H mutliloCllIHT rjrllR «f, liHD
tiapitt'itlii, ^^H
^^^^H iiiiri0iJ-fpitbcli'ïinii of. 'V^
ll('p1Jrili^, IV.M ^^H
^^^^M ptolltetou* cjkU of. UâU
Pfttbolagicul pigincatalioQ, M ^^U
^^^^^ ■kreaniM
Paivinriil-coll»! rplUMllan*. 14S ^^M
^^^^P lubnrolc 078
Pturl; boJiea. 1*7 ^^M
^^^^^ lumiiri of. 078
PonipblBUB of «lOMMfe, iGS ^^1
^H niilloeuUr c;*U nf, 68Q
r^ppur. Wm,, 4G0 ^^U
^M Uittluou, lii*t«log; «f, (183
Vettoraliog uImt of fowt, 780 ^H
H (Mm«s. «th
P«rfornllaii of IracbM, 408 ^^M
H Omis Kmho4hi. 084
l'oriiirifriiii, Mtuto, 8M ^^H
^H Ovul*. l!Hlbiani's iaTPttigMloM lit, 1f>
chroB)«. HIS ^^M
^B MgraCDtBtlOD of, 18
l>gric«r<liiU. ïUO ^H
V Oimno, ii'Jl
bemorrtiasio, S91 ^^H
INDEX.
779
Peri cardi tig —
purulent. 291
tubercutous. 291
Pericardiam, 200
adheBÎDDi of, 201
calcnreoog inGlimllon of, 291
cnrcEDomn of, 292
dropaj of. 2!H)
eccliymosea of. 290
gnsen in, 2 OU
hemorrhagee of. 2^0
inSnmmnlion of, 290
milk; patches of. 292
pneumntosiH of, 2»0
PericliaLilrilis of larynx. Wl
Periotl«uni, itrncture of, 27
rrriostilia, pli legman 009, 203
Peripbeml caHus, 212
Perisplenitia, 588
Peritoneum, cnrcinomn of, 57S
byilatid of, 577
lipomn of, 577
tubercles of, 674
I'eritonicia, 571
cnrcinomaloui, 67S '
clirooio, 673
hemorrhngic, 574
tuherculoua. 574
Periljplilitis, 488
Pert'Utcrine hcEuiitlDcele, <^S8
Pejer's pnlches in typlioiil fcTor. 501
Plingeileiiic ulcer of uterus, G!)3
Pliarynpiis. 457
digilLtherilic, 457
granulnr, 458
of BCrtrlntinn. 457
of Ijphoiit fever. 4')"
Pbnrjnï, bisloloey of, 456
ey pbilis of, 4->8
luiiiora of, 4liO
PbUliitis. 339
riilebc.li(b9, 52. 342
PlilcgmnHin alba ilolens, 723
I'blegmon, acute, '-53
chronic, dingnnaia from anreomn, 257
of conncctiie tianue, 250
of sfciui 727
riilegnii>notia griatrilia. 408
pe<io;ti1ia, 203
Pli1liif^iï<, 4:13
nlliuminuriii of, 024
I'lioBphoruH uecrosis of Lone, 200
poisoning, kiilnoy in, 02ft
Ph;»Lologi«Hl pigmeiitntiaii, IJO
Pigment of l.looil, 2ti8
Pigmeiitnry degeneration of muscle, 274
iij6ltrnIiori of pua cofpuaclea, 08
Pigmciiintion of elements und tidsuea, 49
of ^urn, 450
of lung. 424
of lynipb gliLnda, 351
of serous membranes. 258
of spleen, 5fH
Pilaris iciltbyn^is, 740
I'ilyrinsis capiiia ainiplex, pnro^ite or, 747
I Pilyrinlis —
ichthyosis. 740
j versicolor, parasite of, 745
Pleura, cnrcinomn of. 445
' congestion nf, 438
fihromi» of, 445
[ inflmnnintion of, 440
I tumoni of. 445
i Pleurisy, chronic, 444
libriiiong, 440
; bernorrhngic. 443
idiopathic, 141
purulent. 443
Pleurilis. 440
Hleiiform cylindricnl neuroma. ]37
Pneumatosix of pericardium, 290
Pneumonia. 414
I caseous. 433
catnrrlinl. 414
I colloid. 430
croupous, 410
I fibrinous. 410
I interslitinl. 423
syphililic, lOS
I lobar, 410
I lobular, 414
I of miners, 420
syphilitic, 425
tube real oua, 433
catarrlial, 413
croupous. 437
interstitial, 437
Polypoid myxoma, 01
Polypus of inlenline, 614
of nasnl fosfie. 396
of slomacli, 468
Portal vein, suppurative inflammation of,
G37
Posterior spinnl scleronls, 3B5
Post-morlem chanftes of intestine, 483
of liver, 527
of stomnch, 4C5
Prefnce, authors', v
trnnslntnrs', jii
Proctitis. 488
Prognosis ol ndenom*. 104
of nnginoran, HI
of carcinoma. 100
of encbondrnma, 131
of libroma. O.'i
of gnmina, 1 12
of lipoma. fO
of lohulated epitheliomn, 151
of lymphadenomn, 146
of myomn, I3tl
of mjïonin, 91
of neuroma, 138
of papilloma. 100
of sarcoma. 88
of tubercle, 125
of tubulated epithelioma. 154
Proliferating rheumatism, 234
Proliferous cysts, 109
Prostate, abscess of, G70
adeDO-myoma of, 071
^^^ 780 ^^^^^^^^^PCDBX. ^^^^^^^^^^^^1
^M PrMiki»—
Uemailini, Mrehnl, SOI ^^H
^^^^ earciooBw or, 073
farawtlt«, 29i ^^M
^^^^L onorviiuni of, fl7l
aodulnr. Ï!I4 ^H
^^^^H liiniulopy of, UTO
prolir*miiD|!. 384 I^H
^^^^H hy|i>'r(ri>|i1iy ot. £71
RounJ orllcJ unreomn. 'It
^^^^H li'O
RuplHrti <i( licorl. ïtK>
^^^^^H myoma
of innxlo, ÏKI
^^^^H IllllAlcl»
of (pUtn, OBI
^^^^V luniutii oF, CTI
^V rrotoplium ot eclti. 18
^H Proiitiuiinl ciltot, SIU
O Sklitar^ (;Uadii, 417
^H l>«amnioma, 8&
^K P*eudo-ilicRibmnDUiidnrn)alitl»,îï8
Snlpliigidii. MiBrrlial, M'
^^^^B djtni*nOTthi»«. CtU>
Sardadr, 18
^^^^P •xadnlioiiB. UÛ
Svrcodlc n>o*ei»«ili^ 18
^^^^ pyclltl*. «4.1
l|lar«ti1rniaia, SI
^H^ r>iuriael«, hiicoiil. 'Ifil
mDliiplkaiioDor MUaftf.378
^^^^^ l'uluionary nnnniU, 408
Sarooron, *<)
^^^^ft apupli'iy, -40^
alnotur. «4
^^^^f gnniirMiv. 4ïl
nngiolllhia, 8&
^^^^ I'uUnlibii of llTcr, ^.12
caroinumDiaitct, 84
^H I'lillnorauR «ncvphnloM, 103
c^11s in, 77
^H Piirporn urlioai». 721
(■«TaloppMBt of, 67
^H rurukiil arllirllU, ::SI
ilntuotU, from ehrouk phlegmon, 2&7 |
^^^^_ lif I'liiilid, bsa
evoopbaloid, 7li
^^^^B Infljimninilon of conneoitip Umiw, S62
ef bono. SIS
^^^^H uf Krruat mvmbriinta, ÏM
»i(en>ioD of, f"
^^^^H p «rip» nil 111. 391
fiiiHouIalcil, 80
^^^^P plcurU;.
fanrlaular, of btiiP. 218
^^^^ |tjrttll(U. fftS
{•envral dfacrlpllon of, 77
^H Pua <«rptiMl«!>, ue
cone rati in lion of, 87
^^^^H OitoaTeout irnnfLfnrmiilian of, S8
lipooinlnilR. HU
^^^^B «Mtoaa imiHrnrmslian of, OS
n>«t.-ii><i(ic, Kli
^^^^V hiijr <leK«iientian of, 08
mclniUii* of, )<8
^^^^H plgOMiilBrj tnlttlrnliDii nf. Ii8
mjfldd. 81
^^^^V («roil» Mill (ranifomiiUiaa of, C9
of bona, 314
^ PuMut» of «kin, 7Sa
mjxamntou*. M
^H Putrcliiclinti. 41)
of kidnay I M8
^H Pjrelilin. oiiIculouK. (^l-ii
ol Inng. 4'i7
^H pBFuiln'mcinbrniiauai, IM
of lympb gland*. SU
^H piirulvril. lilO
of mammary (lasd, 81. 7 W
^H Pjelu-uepliritia. MS
nf nmtole. 380
^H Pylcpltlcblila, luppuraili*. C88
of oTary, WB
^H Pya'puKiimolbomx, 444
of Kapm-rtanl oapaule, GOl
uf Madek, <lâ4
canif}! BE. >^^
H nACiUTIS.3S0
H n bmuu. ice, 4&a
ol boat'. :i4
pii[«llpny, 87
^1 RarcQing ««toiti», ^0
progii""!™ of, SS
^1 B*oi>l lUtuU, iiOT
Toui^i <allrd. 71)
^1 UMtun, mrclnoma of, &IS
..r bniic. 213
^1 Idi^Mimatiaii of, 486
■pctÎFB bikI Tarif Uat of, 78
^m Red nirophy of liver. CSl
^H blood dlkk*. ÏM
apindk-Mllad. 80
Of bona, -IM
^H Bofi«iiin|c of brain, S'&
aynonjna of, 70
Sarcnptra nomlnti^ T4I
^H Rrmitli, Abrei of, 33
^1 origin of Dfllii, IS
ScBTlatina, na»britia of, BS8 1
pbaryngiua of. 4Û7
^H RcMoiliiii of neriva, onion of. 861
^H Ka*|>imior]r appuratun, bUlatiigy of, SHO
Sobmidt. thrnry ot (omaJtnii ol ftbrin, 380 1
^H Kcticulftr eiutlliiitt, Ï6
Scbnci'lvrina mvmbnlMi, 889
^m Uoiieulxo'l tiuaa. 34
Schwann, formation of oeK*, IT
^H RoUootam of bUod carfiniulr), SD, 28Q
mambnna of, 82
^^L Metro- phnryuRoal nhtairM, 408
Sclrrhu*, l>M
^^^K. Bbabdo-nyoiM, lU
atrophie. 1M
^^^H SJieuinaUa arthrUb, 228
of toaminarj glaail, TIO
INDEX.
781
Hclerodennn, 730
SelcToaÎB of bone, 202
of brain, 877
of lateral sp[Dnl columnB. 387
of poHterinr epinitl cnlumnB, 38S
of Bpinat «ord, 3S4
ner»e cells in, 387
Scorbutic atomutitis, j51
Serafuln nnd tuberculosis, 114, 125
ScrofuloaB nrtbritls. 2'18
Sebnceoaa cyala, 1G.>
glanil, inSnmmalioa of, 735
lobulateJ epitbeliomii of, ISO
SsKmentation of otule, IS
B«Tiile (('■"Kfcn^i 41
OS te om niacin. 220
SequehlTum of bone, 205
of en rie a, l^OS
Serous acid trnnsformntion of pnii. 08
und albuminous infiltriiliona, 42
carities, hislolog; of, 247
stomnla of, 248
ejsts, Hiï
exuibition, <!4
membrnnes, carnpaces of, 205
cnicipomn of, 267
endothelium of, 38
epitheliomn of. 2li6
exudation of, in inflammation, 2-)0
fibrinous eiudnlion of, 2ii0
bemorrhnge at. 258
hemorrbagic infliimmntion of, 2>'-2
bj'perplaslic infiammnlion of, 2UÛ
inSammation of, 25'J
pigmenlslion of, 258
purulent iaftiimmation of, 2G3
luberclea of, '166
(amors of. 205
Sliakespenre, origin of white cells In blood
of infinnimatioa. û8
repiimlory inflammation in arteries.
321
Shnrpej's fibres, 80
gideroaia, 42G
Simple angioma, 1^0
Sltin, abnormal colorations of. 740
nnimnl parn^iites of, 741
blister of. 731
bulla of, 731
cbrouic dilfuaed inflammation, 128
circumscribed inHnmnintion of, 7.J0
congestive inflammation of, 724
dcgeneratiie inflammation of, 737
diffused iuflnmmntinn of, 724
papilloma of. 728
[.blegmon of, 727
dilatation of Wmphntics, 7~2
dystrophies of, 7;t9
eiudiiiiTB inflammation of, 727
glanil a of, 720
biematocele of, 7'.i4
heicorrhnge of, 724
bialolupy of, 7l>j
hyperplastic inflammation of, 736
l^rmpbatic (cdeina of, 72S
Skin—
nerres of, T18
(edema of, T21
papilla of, 718
papule of, 730
paraaitio affections of, T41
peri -glandular inflammation of, 735
phlegmon of. 727
paftule of. 732
Mroua inSliration of, 721
specific ulcers of, 737
tubercule of, 734
tuberculous ulcers of, 737
tegetable pnrnsitea of, 743
I Tcaicle of, 732
, Softening of bone. 219
of apinal cord. 8B0
Spermatic hydrocele, 002
Spermatoioida, 058
Spinal cord, congestion of, 380
hemorrbage of. 380
in tetanoa. 388
inflammation of. 383
sclerosis of, 384
secondary degeneration of, 8 SI
softening of, 380
rumors of, 888
Spindle -eel led aarcomn, 80
: Spleen, abscess of, 689
amyloiil degeneration of, 601
B trophy of, 584
oarcinoma of, 594
cyals of, Ûiiâ
gumma of, r>94
histology of, fiS3
bypertemin of. 5S3
infnrction of, ii^'J
inflammation of, 587
of heart disease. 680
of infectious feïerp, 385
of intermittent feier, S8Ô
of typhoid fBTer, 58j
parasites of, 595
pigmentation of, 588
rupture of, 51)1
tubercle of, fiH4
lumora of, 593
I Splenic leucocytheemta, 503
; Splenitis, interstitial, 587
suppuratiTC, 581)
Spongy oateoma, 132
Stentoma, 91, 93
Stcatomatous Tens, 165
Stomacb, nniemia of, 464
calcifioBlion of, 472
carcinoma of, 475
catarrh of, 4U5
congestion of, 464
cysts of, 407
ecchymoses of, 404
encephaloid of, 470
epitbelioma of, 476
histology of, 4U1
bypertropbjr of muscular tissue of,
477
H 782 ^^^^^^^ isDBi. ^^^^^^^^^^^^B
^H S(«niMli—
g^rpliltia— ^^^1
^^^ ti>(liiininall««i ef miuoiu mvnbniM,
otin«niBt*r7 Klnnit. ïlO ^^H
^^^H
ftffibwjnx, 46S ^^1
^^^^H iMiiiiia »r «omaln Irriianii In, 4C1I
*raMMMb.4TS ^H
^^^" glniKU *l, 4<;j>
«itra*! tl9t ^^H
^^V n vrat*!* of, 4U
perioja of, lof ^^H
fljrpMllik ■■•padlU lalrrHitlal, 111 ^H
^H tipoNM »r, 4;j
^H l}MpltkiI«i>«ina of. 473
lottenii of aricrin. Ul 1
^^L^ iD]r*-fliwoin* «r. i'i
•( bvctal muMui nenbra«F, <H J
^^^^H ptipllluin* of, 'l'-H
nooroalii af bono, 300 ^^H
^^^^H |iirn>|>lii|[<»i «r. 4)18
or«hilit, UOI ^^^1
^^^^^^ f^ijpat of, -Itr^
papule o( *kl», T^ ^^B
^^V pMI-m')r(rni clianii* ot, 4(S
pMimonia. M>H. tV- ^H
^H MirrbiMo/, 4:t)
tubercule o( «kin. 780 ^^H
^H ajiphllla «f, 4T8
lumun nf lalrvilu*. ûlS ^^^H
^^^^ wbtNiM «r. 472
nloera tt IqUsIIdo, ùI2 ^^H
^^■K UlMT* of.
^^^M
^^^P aUw of. 4»«
^^^M
^^^^ SlonatK af »rni«« MTilie*, 346
'PAIILR of onnltau. rii ^^H
1 Tactile «iir|ruii<ï*, 720 ^^H
^H filMnnlKU. '118
^^^B •lirhllifrilic. 4(i-i
Toinia nliiiiDontoiu. VJ'i ^^H
^^^^H or lyplioid Tenir. 4t9
^^^1
^^^^^1 MMITllUllai
Tclaiigice latrie, 180 ^^H
^^^^B
Tfrntanin, ^^H
^^^P 8l04l> or chaUr*. 40n
Tcitlelc, ottcinomn «f, MB ^^^^^Ê
^ !"riii>K<ilnl<>'l heruiii. MXl
^^^^^H
^^M Sltiiittil Tnuioulur fibrts. ïl
ciiebn«droma of. Mt ^^^^^^|
^^P Siririurc «f mollira. C'il
flbr»iii* of, IWi ^^^^^1
^^B !4lri>rnK iif circinum^i. US
JtUMNM of, 647 ^^^^H
^H l^ltuclui« or cclla. 17
bistoUfj of, UT ^^H
^^M tiulxiiiuBrixii itKiu*. Inflnmniilioii «f, M
loflamuiallon of. CSO ^^H
^^^^^ SuliiinKiiiil rxa«ls>]ïit, 1M
l^mpbailunonia of, WIT ^^^|
^^^^B Bodimino.
mjt'1'4 rpithctiouia of, COS ^^^|
^^^^B Suppunillon.
«arcomik of, tjtil ^^^|
^^^^V or<onii«liT« llMDt, 3I>3
tjpbllUie iBn-i>nm*U«a of, QUI ^^M
^^^f kldncj',
lubvrclts of. iMi ^^H
^^^^^ of Ijuijih itUiidt, Sfit
lumoiior, liOJ ^^^1
^^1 of Iiiilaolc.
T*(n'iua, hpiiinl «ord in, 808 ^^H
^^M SoppurNtivc ilcrinittlU*, Ï3T
Tbeor* ol «Ib. IT ^^M
o faruialluii uf pa*, li* ^^^|
^H nj}«liiit, ^h;I
^H ti«i>hrili>. r-'CJ
Tbrombt-ttF, SïU ^^H
^H «i.ttiii». <llff>i>oJ, 20.1
of br«in. 814 ^H
^^K^^ Ijnprit rcunl <nprs1*, amjrloiil dfgtaeraliun
Vf llTtr, IV37 ^H
^^^^ COt)
t<r Kttpra' r«na] Mpsule, 800 ^^H
^^^^^H curai iKiin» <>f, 601
(cnou*, 310 ^^H
^^^^^H oiitroui JfROitrntJoil of. 003
Tliru'h, m ^^H
^^^^^1 cûnu<->tluii uf, MKI
Tbjrroid gland. MTviaoiM of, 68T ^^M
^^^^^1 uf, 6QI
•pllballoma of. WB ^^H
^^^^^^1 ^miiTTifi COI
hiiitology of, ilM ^^H
^^^^^1 hf nii>r>li4i|iB iif. fiOO
bfporirapbjr of. 6M ^^H
^^^^1
tiilifrcl* af, 697 ^^^M
^^^^^^1 iiiÛLiiniDaiion of, COI
Tint* tanrioalu, 744 ^^H
^^^^1
CaTon, 74S ^^H
^^^^^H •■rvomn «jOI
■TMMk. 744 ^^H
^^^^H IhromboMa ot. UOO
iDniumui. 741 ^^H
^^^^H lulirrculufir m'i
Ttwuf, nilipnor, :!4 ^^^|
^^^^^M luinan of.
oarlilaginoua, 'ii ^^^M
^^^H Svnnm kl<In«7, CI8
oontiroiiic, iS ^^H
^^^V Bjnovlu In ■eui« ■rlhrili». 2'i8
•iMtk, ^^U
^^V 8;uotSnl metobranc, hîitolofij of, 337
vpitliclial. 84 ^^H
^^L^^ in aamo artliriti», ^U
ntiroaii, alraelnTt Ol^ SS ^^^|
^^^H lubtrtUa of. 244
g;raniiLatioa, 09 ^^^1
^^^■SjphtlU oriiraiii. 878
niuoDUi, 38 ^^H
^^^m *f inr; m. SU»
iiiunïulnr, M ^^^B
^^^^B ofljaipli ilnod, >!t7
^^H
INDEX.
783
TtwUR —
normal, 22
OBsaoua, 26
ossiform, ^8
pigmeaCBlioD at, 46
reliculnled, 1!4
Tongue, epiibeliomn of. 454
hypertrophy of, 453
pnpillœ of, 417
Tonsillitia, 41)2
Tophus, 242
Traohen, cnrcinomft of, 403
bislolopj of, S!)0
perforstioD of, 403
ulcers of. 403
Traobeilis. 403
Tranalnlors' prefpiM, Mi
Traumatic arthritis. 228
oongestion of liier, 532
trichinn splrnlis in muscle. 2B2
Tricoplijton loQaunins, 741
Trophic cutaneous dislurbnncts. 739
Tubercle, fiiiiitoinicnl din^noï^is ef, 12S
caseous degeaeratioa of, 121
dsTElopment of, 122
elements of. 1 14
ime^iiniil ulcers of, 610
miliiirj, rtnnlotiiy of, llti
Dulriliie lunililioalian!! of, 121
of bla<lder, 054
of bone, 215
of bmln, 373
of bronchi, 407
of Fallapiao tube, 088
of intesline. 5US
of kiiloey, 540
of Isryni, 402
of liier, .J,*)!)
of lung, 4211
of lyiiipli gUocIs, 350
of Ijuiphalic Tessels, 34G
of nioulb, 454
of ovsry. 078
of pancreas, 580
at p«rLlont!um. 574
of proiliile. 072
of serous meiiibraoes, 200
of spleen, 5'.il
of stomach, 472
of Ëiiprn-reiial capsule, 002
of EjnoTial membrane, 244
of testicle, 'W;5
of lliyruid gland, 507
of ui'clhva, O'll
of olerm, ti'W
prognosis of, 125
senti.r, 124
Tiirii'iles of, 121
Tuberculi-, cutuneoua, of leprosy, 78S
of tkiii, 734
Bypliililic, of skin, 736
Tuberculosis, 112
Tuberculous catarrhal pneumonia, 433
crouprius pneumonia, 435
inlersliliiil jmeiimonia, 437
Tuberealoo» —
meningitis, 365
pericarditis, 201
peritonitis, 5T4
pneumonia, 433
. Tubular advndma with oylindrionl cell», 162
giniiils, '.if\
I Tnbulated epith liomn, 152
Tnmors, appendix to. 189
claasificntionnnddeBoriptioDaf, 75, 172
defliiition of, 74
dermoid, 01
fally, 95
fibrous 91
formeO of hlooiiTesaeb, ISO
of embryonal 1 issue, 70
of muscular tiasue, 134
of iieTTe tissue. 137
of oa^eous li^su^, 132
melanic, of long, 427
mixed. 170
of arteries, 832
of articulations, 244
of bone, 212
of bmin, 37S
of bronchi, 407
of buccal cavity, 453
ofcnrtiinitiuDUB-liasue type, 12G
of cunnecliie (issue, 25T
of connective-tissue type, 99
of c)iUlielii>lti9sue type, 145
of l''a11iipi:in lube, 088
of gall' bliuJder, 6(!V
of heart. 298
of larynx, 401
of liver, 659
of lung. 427
of lympb glands, 355
of lymphatic syslem type, 141
of maniniary gland, T07
of meninges, 307
of muscle, 280
of nasal fossie, 306
of nerves, 382
of œsophagus, 400
of ovary, 078
of pancreas, 680
of pharynx, 400
of pleura, 445
of pros) ale, 072
of serous membranes, 205
of spinal cord, 3S8
of spleen, 503
of stomach, 472
of supra-renal capsale, 601
of (esticte, 003
of ulerus, 093
of veins, 344
osseous, 212
osteoid, 131
Tunica vaginalis, JaSammnlioD of, 001
Typhlitis, 488
Typhoid fever, intestinal lesions of, ûOI
laryngitis of, 399
liier in, 630
784
INDEX.
Typhoid feTer —
pbnrjD^IU of, 457
spleen in, 5B5
Btomntiti» of, 44Q
ULCER of duodénum, 4T1
Ulcer of BlolcBch, 409
Uleer of trache», 403
pErfomting, of foot, 730
Bkinning of, 72
Bpecilia, of skia, 737
tubetcalouB, of sVia, 737
Uteerating cjBtitiB, Gâ4
CloerntioD of broDCbi, 407
or cnrcinoDia, lOG
of intestine, artemio, SOI
UloeratiiB atoatalitis, 452
Ulcerous InrjogitiB, 400
Umbilical cord, strnclure of, S3
Uramic ulcerfttions of intestine, SOI
Urate of soda in goatj RrlbriiiB, :i4I
Gralea, infillration of, 62
Dreler, bialologf of, H52
Uretbru. abecesB of, 064
hUtolagj of, 062
Birioture of, 054
luberculoeis of, 664
Urethritis, <>6I
Urine, oaatB in, 611
Urtloari», 721
Uterus, carcinoma of, CS4
ousts of, OH")
cnlarrhal inQammntion of, 000
changes iluiiiig neslaCioD, 080
congestion of, UK'J
epiibeliomn of, O'.'O
fibroid polypi of, 003
lieniorrhnge of, US9
histology of, OH-i
Lypertropby of, 0!)r
mucous cyais of. ti'JS
polypi of, 091
myonin. of, (iHS
plingedenic ulcer of. OnS
pnerjieml iotlanimnrïon of, 002
syphilis of, tilM
tubercle of, 0^i3
luiiiora of, 0'.p3
VARICOSE veins, 342
Varicoae veins of bladder, G&2
TarioloD» Uryogilii, 9iB
VaacDlar system, eadotbelium of, 37
tisaaea, inflammation of, 60
tumors of intestine, 513
Vegetable parasites, examination of, 748
of skin, 743
Vtgetationa on heart, SCO, 303
on liver, 64 S
i VeiDB, cnlcarpous infiltration of, 343
histology of, 338
inflammation of, 339
tumors of. 344
varicose, 342
VeoDUB tbrom bogie, 340
Vermiform appendii, inflammalioo of, 488
Vesical fungus, 0ô6
Vesicle of skin, 733
Vessels, new formation of, in inSammfttion,
OH
of contracted kidney, 638
of gtiinulation tissue, 09
of liver in cirrhosis, 649
lesioBB of, 627
of stomach, lesions of, 465
Villous carcinoma, IO(S
of mammary gland. 713
Vitreous degeneralion of rauBole, 45, 274
bnmor, structure of, 23
Voluntary mascutnr fibres, 3t
W'AGNER, filirons degeneration of cells,
40. Oâ
I Wnrts. 158
IViixy ile^enerntion of muscle, 43, 45
! kidney, 022
: Wens, 105
I White blood-corpuscles, t!), 281
i eniigrnliou of, >i2
I reliculum of, 2U, 285
I swelling, iW
■ IVoo'lwnrd, .1, J., theory of tuberculosis, 119
I WouDilii, cic»tniation of, 71
yENKEB, waxy degeneration of, 43
L
HEN"RY O. LEA'S
(LUI b>i > ■ t »<: a «H (■'■■}
OP
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Jnqratll' atfUUIilD anDa Ld Iba ^mcrUac^ KQd chrar- IrdrJil^warla Ffpijiafjatl ; Iha -tiUal BU oka vr ilia
fallT t«fnr4 Id M Iba Qf^t p'tf4k U'l U'lVf^ra ihalL vldi-vl ppfloJlptU Ig tba «»'Iit — a]4«F*at V^MVl fc>aa
va BBdneraabl' anil mora inûidal f lillr^iin. aod 'an nutulllad ntoti.—1/ntr i tUMorgu/JtrntrUH»
^vhn BOdb a i«fHn4t7 of abia «HflDal arrttlva. x*^ i,lf<r<AJam, IB7<.
Ia«««l. saw Itiai lira -Brill»!- «D.1 rsiaiiB «•aio— . .. ^ ^ ...... ..
ÂniraiiMI «ail-»" h.. I-imla.l»* M. «.«'. Die "' " Bni».r.tlly .(annwlad,.* loX Ua taaOac
AnnuaaJoaraal «.n.;. irllh»»! .nul -ioi.Jw. , *">«1"" ini"llcal JoaraU. >b4. la »ar aDIalaa. >a
îf"r7*F« a»J flo«^(r. Si»a, »*. U-, I »««« ia_^i«a» l»ti. I.ncmaat.- «a^.* JM ■«<
Tt» batl inaillral Journal tiu llia*unilBaol —*o#- "''* °" ' °"'
(•>« *.J nnJSHf* ■'..>."i-l, ipnin. 111». i ThUnlli.li.aJlc«l]oBro«loroarcoBaM7U»M(*
Tbapnaaaf sitnibarDf Iba Anarloan Jnnraal Man ilia Anarltan pbfilelan abrnad will psial vllb Iba
■ MlllitlrilJ C*b4 aaa^ aod «laat at«f7 ptt'lul** -it UTaaratl «af ^>faTM"d. ■• (^.-diMjUof Elia arata ar l»*4lfikl
faalBialaiai inawall a»raait ifpqlBllDB ^'filiaratkair eatinr* Is In* coaalrir F'^r aira^t maur yr*n a
Oar laatrabla auiilafii|->r«ia baj lïPF ba^t VMbt*. ba* ba*a IJ>a BivilkvBi Ebrouih viiltAaBr ablfM »til'
^^4 «-4 (B1I iin) j^'Kp'a-i iha liL»|>ii ilml VI may r^a- «r* btva laada liflk>*B tlitit illBiru^afliVBvjQbaarrt-
liBa* lUvnfli wllh »« inrich TLffol BDd 'ktallaao (or 'Hub* .—A'iflr'êii nf L, F Y/m'MI. Mf,0.,6^fntt trnXtt*
tht aaJKI nnt !r«vr> ai II Ii4a aablbUfit I g tba paat :H.i^l"niïJ JTr^. Conffvi*, bapl. IKît.
_JU.i.d..nl,«n~r. Soi JI. ISJT. I
And thAi ii wiLf uprciEciill; included in ibcuwardof a medal o( merit to ihe PnblUkcr
In the Vienna Exhibilloa in 1U73.
ThP>iil>K['Hptron prio«or ihe "Akbmioax Jovmai. ornm MsoieAL Seituns" baa
Dpvrr Wrn rai«i?f! during il« long career. Il it still Fivb I>OLi.AaB per ■nnoni : and
when patdforiniidTancF. thi^ anbiicriber receivM ia addition Ibe "Meuktai-Nicwb ami
A>BT8ACT," making in «II nc«r!j'2U00 targe o«luvo pugvs per auosn. fre* of postag*.
II.
THE MEDICAI, KKWS AND ABSTRACT.
Thirtj-BFTCQ yram ago the "Midicai. Nk»*" wsj oonoMoved m ■ monthl; Ui
conirj to the subscribers of the " AmtttOAK JopBttAt." ibeHinical fnilrvclioa and
• CvHiBUDlaailoi» aiak«TlW« liou it«i.VtB>*K laall puu «r IbtMuUr. tUbarsla aitlttv I aaaigj
»7 lb* Mltot »« paW loi bï VU* IToWVa^ai.
»
Hbhrt C, Lsa's PuBLicArioNs — (Am. JoHm. Mri. Soientf»), 3
current inroranlion which coald not be kcconaiDdBlcd la tbc Ijautedy. It toit-
■i»t*() or riiteVD )>nsi-a of inch instt^r. lORrtlMir with «ixUra marri kBonn as the
Lihrar; IfifpArlm-nt >di) JcTuUd to lb« publUliiiifC ol book*. WiUi th« iwttmuA
progr«M or *cieiic«, bowcvvr, Ifai* wa* ri>nDd iDinfliuMDl nod Kraa yean fioce no-
other p«riodic<tl. kQo«n M the "HoktbI.v AanBACt." >»• started, on d am* rut.
D'shtd nl H ino<l'>nil^ prifp to «ubniTihpt» W thu "AMRtin«ii Jiiuiir*i„" Th«ae
two luouiliUt» will br'eafier ba i-ooRolidkiltd. iiDd«r il>« title of '■Ton MKoirit,
Nkwh *ki> AusTKirr," and will be furnished /rra </ fAfii^; is oounccliofi with the
"ÂHItalCiN JOFRRIL."
Tbe"N«w8 AVD AMTkAtV «ill codmI of fil pagee monlblj. ta a oMt cover.
It will ouolaln a Ci.iHi'**!. PurintHanT to which «ill be coetisned the eeriea of
OmaiXAL Aasaici» Cuxif^^t. I.KorDRM, b; )teatl«in«u of the hi|rho«t n-piiuiloo
thro«f(bout the Uoiud i^tal**. iDRciber «i'li a choice mImIIdh of rorotjiii [.rciure*
aod Qospi'al Notes nod 0 linninit». Tlii-n will fullow Ihe Mo^tiiLv An*TR«<.f, bjb-
t«mailcally arraog cd ajid iluMilied. acd pr««onilog Ave or »ix bacdttsl antclea ^atly ;
and eauh number «ill eoaetade with a Nnia liaPAarKKKr. (['''"ï entrent profet-
■iucal lnl(illig««ce, doDieatie and for«lgn, tlie «huLe futl; indexed al tha dwe of
encli Tulume, rendering it of pomanent V4lae for refeienc^.
A* itated above, the «ubavrlptioa prke tu the "Nnw* avd Abitthact" will lie
Two Dollan and a Half per aanam, iuvurmbly in advunce, at whicli rate it will rank
on one of the cbeape«l medicul peri> ilkul* in ihe countrj. Bnl it «ill also be fnr-
niibed, free of all cliar^e. in comroulaiion with the " AHaaiVA» Jodrxal or Tita
Uksioal SetiKCH," to ut] «lio remit t'lra Uullakb in adrancu, hua ^iiiog to the
anbtcribur, for that vvvy uiodcrute Kuni. a cumplote ivcunl of medical praur«M
ihronghout the world, in tliu coropiua ofubuut two lbou»and larKn oct^rg pafM.
In ibia rlTort to turnUli ■<> lar^e an amuutit of practical informutioa at a price «o
nnprecedrnledl; low, und thus pluce it witliin the neach of everj* moaber of lUa
profcxaion, the pnblUber uonâd.'oily antii-ipalea the friendly aid of all «ho (eel an
iotcrett in the dimmiDaiiiia of auand medical Uterulure. He traata, Crpeclklljr, tliut
the stibAc-ribcrs (o the "Auuican Mkuicai. Jol'rnai." «ill call the attention uf their
a('[iiiiUnliitic<>R to thu udviL0lu({eH tbui utTcri-i). und that he will be smtaiDcd in Ihe
eudeuvor to perniiineiilly pstublJah medical periodical lilcralore on a footinc of
cheapneiss aever hsretoforo aUenpted.
PBEM1ÏÏK FOa OBTAININQ HEW SUBSCBIBERS TO THE "JOUBSAL."
Any gcnllcmau whi> will reuiit the uuiuunt for two »ub*cription9 for ISbtt, one of
«hitli ut least must \w tor a nnv luhirntier. wiil receiteas a PHaMiUM, free by mail, a
copy of any one of [fae fullowiog rectnl work«:
"BAatin'a MijirALor MrDwiraaT" (»ee p. 'it),
"TtLBUKv Foi'a ËPiToai or UisrAsat of tsr Sk-m," new edition, jnat n»dT
{te« p. 18) '•
" PoTHanniM.'* AaTAdoma» or Masictxn" (we p. 16),
" IIot,iiK)<'« La.idvahks, Hïmcal axi) ^itkoioal (mo p. 0).
■' tlaowMKOS Ttta ljtKurTuaOeHruALj(ogic<ii>K"(aoi>p. ÏV),
" Fi.ixr'aKasATi ok tJoKiaxrAtiTC MaDicua" (see p. 16j,
"Sriraon'* Ci.tHririi, MnDimaa" (aec p. Ul.
"BwATita'a OaaTaraio Ai-ttoiuiva." ne« edition (tee p. 31),
"Taiuikb'» CuKicAi. Ma*i'ai.'* (see p. 6),
"WuT OH Nxavotjs liisoRDKaa or Ouit-oaicH" [ace p. 30).
*-• Ijcntlemen deatriog lo arail thcmaeUe* ol the advantagea that oBvnid «ill do
«elf to fonrard their subacriptionjt al an early day, in order to in»ur« the receipt of
complete Mta for the year ItHJO,
tgr 'I'he aafett mode of remittaacfl ia by bank check or p<iir(nt mon^j order, dra«D
to Ui« order «f the andvraignod. \V hare these are iiul ucccwibk, r>:uiiu«aceii for the
" JooaxAL." nay be Made at the risk of the publisher, by fonmrdisg iu awiisTKKKÔ.
letters. Addirta.
UKNRY C. LKA, Nos. 706 «ad 708 Samsoh SJt., PniLAOKLMiu, Pa.
'UkNRT C. Lea's Pcblicatioss — (Dii-iionartea).
D
VNQUSOS (ROBLBF), M.D..
l^i/^lAwru/ ■- ■■- J- - " -- -- ■ J- -.^--.j.....^. p^«-|-^.^.
UI-)i)lCAL LKXICON; A Dic.TioxAar or Mbrioal Scibnoi: Oon-
ulatDi; k CDOelH stfUnulon of ihMvJaai SnbjMtf anil Tfrni of Auitonj. Pkyiiijan.
Palhiilo^. ii)^(i*R«, Tliriat»utifi, I*bwiiia4a1«(7. Phannïvit, S'atftty. Ob>t*irU*. HvdiMi
Jaritpndou». ud DMiHttry. KoIIhi of Cliiuau isd of Uiniir*! Walarj i ranii«lN hr
OOcinal.Knrlrlcal, MtdDUl«(l« Pr*p<uaiJ"Bi, «llh ih« Ac«aD(Btliaa»Bd tXjnthogj »t
lh« Tarau, %ni th« Ft*Bafa aoi) Mh«r Ë^non^inri . (o M le eoD(lllgt« • Fr*a«b aa ««II a*
Knjtliib Mtdlcat LcileOD. A IT*w B<lllinD. TboioDcbl; Railxil. «sd y*r) |:r**ll; Mtd-
Itrd and AuKinaatfd. Bj HirRAaa J, IlviiAtisoi. M.It. In not tatj larg* aad kaad-
«oni*f<>;a!aoU*iiTolunactoT*r HOD paix. Clotb, (A 10. I»aib<r, rab*d bandi, 91 H.
(Jitti InutJ-i
Tl» (ibjMt of tb* aniboT from lb* anUt) %>* Dotb*«B to loftk* lb* ir«ik > ■•r*Nlleoa or
ijitllona') ufuia», bRI laaSMd,an<I*itKh. • aaadMnd>i*«ot lUTailMinDfltaal rclMloat,
and tbui to tcpdcr Iha work an <pU»in< vt lb* *iitlln|t coadition of mrdif >l ifirDia. Startis|t
wllblhUTi««, tb«iiniiï«u*it«taand vlil^bbu iixlttad forth* «cirkhai ^nal-l*dbioi>in r*f*at*d
Nrltloni.tq «aKmoatilt eompl*t*naMaiidaiifutiifii.iinUt at lingtkll bu altalnad tk* pMHtun
of a rtODEBlMd «nd iwudanl aotlivrilj «bfrcctr Ih* UDjEnag* li i^ktn.
9p*«ial paint bar* b*»D lafcvD io ihr pr>|<it»lii:n nf ih> j'Ktrnl fdillos lo main lain tbt> aa
tiabUrtpalallen. Dnrlotlb* lin j*»(i«liii'h liar* «lipid ilac* lb> U*l rvTiiloD.ih* addillani
to IbcnomaBilalutvotib* mvdloalteUBMthaTebctnKrtalrrtban ptrbapal* aijalBllarporUd
of lb* fVi, and up(o lb* ilm* of blidralb <b« aalborlabAi^d uiidnauilj loixoriKiat* aKr;-
tblnn t*<iuiriDK lb< Hit*nlii'n of lb* Mad*Bl or praatlilonar, Klo» Ihan. (ha adllor ku baia
aqnall^iniluiCriuui.iulhat lhaaddilloMtolbavOMbniBfjarriiiorfnsDieti'P* tbas ta a>j f(«-
tIou* iaiiilun l!>i>MtaI atldillon haa b**n badoKad on IIi* aKcrnlualSon, sbleh «ill b* fog>4
markad on *v»r]r «ord T>>ii l]r|->|t(a)ihlral airiaganianl hai baan n*«k Inprovad. r>n4irl*c
rtfeTina* mnub DUra «•'J. Mid tttrj ear* ha* bacn lakan vjib lb* OMobiDlcal BXM«tt*ii Tb*
work ha* b**n prlbtad an ■>*■ iji», imall l>ul (iHtdinitl; rlikt. oilti ae aalarfad paga, aotbal
tb* ■ddlllon* bar* br*n inDi.>|iiir jl>d ailh an inorrtie mf tiui liillo riiar a bandtad p*B'*- '<■'
ika (idamaboit ooataln* Iba nstUr of al Itail (nur ordlnatj aclaro*.
A t«vk «IJ lBii«D tu oar t*a4ar>, anil ol abinb '
■ far I ArofTlmn 'nijihl tu b^tTowl- Wbtalli*1«amr<l
butbst uf lb* aork yaunl avajr, (mhabl; alt nf u>
faarvj WM l^ lutk «biruM itrii malctlaln i\* v'***
Id Um adfanrlBii cImii* abmrumi KJaHiiM. K*p
lgiiala1r»I*F'T^I''^U'4J [)uii|tll»ï1i.liatln| aiuiv^ad bis
■ml r.aitni bHii, Uncliri. InLu-t lallrrinilfcolaaDd
Imbu^l *tUi t^" ll^fll iit lB>* Enok* liftF brvu aMo u<
adli U, nut ITi «tf* fAl/itjwni'k nthnn«r *u dani If» lk«
U«*rt nf UmkIi ailktur>« «u rDt'Ul"t*a io ilir<1«Al*af InUJ-
lijEirtt hQakTwMtir>,T>Eir Lfiiniitl1a>i> wiTk ottht àliiiî
ibniltd t-4 fOtU-l — Xn PttrtjU Ob pLf niltky- *itl;i?01 Jar
or Inurruptloïi. «loi«kf i^^ (nv.nn of ihuuiihE It ha*
travolWI <lurlB| IW llfaUaia. Tu (hov Iht BBCn'>wl>
of ttiv th'X vlilrb tir. IlqnicU*aB hta Mauui'd and «at'
rltd thiDuckili I* oalf «ihmbi) In Hal* Uol Biur*
Ihav «in th^'UHBd naa tub>cvl< btvrbwB bld*>l In tb*
|ir~onlolit|i^n.— /^ila.jkbrf-riaiu. Iia.g. It; I
Alruut tbpfral book |inr«ba»*d by tb* unlioal rlu
dtBtlrlhaMnllaal DI«l«n*rT. T1i*l*>l«<n Mplaaa-
IO->of tMibnlmlI*iDiiit>iiiplT*<'»*jui>iiA. Ibi
a<itB«»ail*BilT(,and*IU>>ucb<«Ilaural(u Dt*m
«In». II S« u iDO-b a n—MMlj alioto Ik* |irutl>lB(
ptifili-lnB. To ni'il Ih* ■»<• nr MudtaM and uiwi
psjilrljri", th« iilcilon»rf iiiuil be (nDil*o"»fl ahlW
DompHbcnftlf Vh and prullnl mhii* p*r>(iirai-luij«. II
vaabanauM DaujEll-oir'v mrl ih**« I pOif-Ailnfij Lbal It
baMiit ainnMtliii [llL'Llunacj of i[i-ùp'»i in» ■^•r**•■
Bfdkli}^ a«f fltil'li'^t Irtllj^Kntflk^bloipfuaiFit lou^
tngrfit- ^jtiheLbii Aiilhi.»u>«ULllti'aaikb;i<rU*nJ]*rnii
b*>Bt>a*nKliI*il.Thneh»Il>riii>h»i<brrn>rI1ii blatk
Ittlt, vblla tl'p iL~rE*a1lT>v Totlna luprtiiifl »|it: ab
anaaf*DI*(]l ahlcb ttr^Hj Idi^lllLal** r^lfraqn. Wa
(0*7 «ahlji aiDbt» Ih* bnp) ««atatail t? tb* adIMr
" tbat iht aork.abbb poai ttut >** hi* a ULalaaaaH
a* an IndlTMaalfailaT**). all) bafouail *ima)i* •*•■
(lauaBra dI (ha pKlllaB lO lOBC MlWdjI W ■• ai a
•landHilaonnrtlf ■-(MHi•MH<^U■«I,l;■■.l•,l■I4-
ll bu Iba ra/>m*iliibaili autalair baaaarlni
iDltpf tn^t.^h !ftD(a*i* ri>f afraifccjaad aitaki tt
ra^raao** — L^nt^-^ Mtdi-'ni thittti»
liailibdird «artalt*fl|n)BM.ai*a*af lb*b««.
ir Dal 1)1 ••ri ti*-i, «.tdlfal dWIIuaarT la Iba tat-
Uih l4Ti[4jafa. Caci|flk4a'aw*bbMb«aBiraUILB*«a
t'yj ■l^iuL focir r*an, aad a**da aa «4>iIb «if paaM*
oQ DVf pan 1« ra<Hrm>4it4 It ta lb* aaMml^ra af Oo
in*4lvfti» and, 3lk*1*l■■^ af tb* fbafbafrvUral pTa-
Ifaat^a. Tfi9 Latlar ta^arlall^ ara \t aa*4 «f *a<a a
votk, «bl<b ai'*> tvadf aad t^iiabl* lafana^laa
an ihauamidi *J ■Dbit<u and Uria» vbl<b Iba/ ara
1 labia H aaaaBBUr la panalat ib*l> daUj aaaaa-
lluDi, bm Hitb «bleb lb*/ aBaaai b- aipHlad t* b*
IVmUlar, Tba work bafi-r* bb faHj tafpl&ta Ihit
«•at— JM. /uara. ^narai.. Fab. lïTi.
A iiluabl* dlntoparr •>' ita Utiu •aplarat t*
' madi'taa and Iba allifd «rlairtft, aad r^ Iba rv4a-
ili.aaor tb* nihjvfib 1i*ai*d ua4<f *AFh b*-4d h r^
I1<T%« artai Frt JH uo lia abj* ,ltaar1iaa aalbct, aad
irill daMrrai ilin amhorlir aad it^falantv ll baa
ohialntd — «rllliA Kid. v.ium.O». U, lift.
F*w wk'tha af Llilt «)h>4 aiblbll a afaadar la^aa-
lii*i]| vf Mllaql rvHarcb and of «naailA* lofa Tb*
• IliDl of Iha ul* nl laii lalliaa UMM<4tal U Ha-
ll r^ lo Ha aa*^Iaru.*ad Is Ibacnai •*r*lsa*aa-
(•irid bi Dt. B:>blar DVBitla4B oa tba piifaia'iia.
aad tadtat Da diban, bf lu lis**.— loB^aB lAaert.
Mar II, )*'!>
TJOBLYN {RiCBARD D.), M.D.
A PICTIONAKY OP THE TERMS D8BD IN MRDICIXE AND
TIIK COLLATBBAt. SCIKNCK5, Ilai-I»d, itilh oaiaoroi» adilUloni, by Tauc Bin,
U-Il., Kdltor of Iba " Amarifaa Joonial Of lb* Mtdleal Scianoa*.'' la obi larjfc rajal
Um* Toliin* «f o**r bOO dnubU-oolDmnad pag** : cIoUi, tl tO ; laatbar. f 1 O*
tl ta Ibi' h*>i ba'>b <>I daBali»ioi>t hn't, and nnibi alwafi tab* np^a <ha tladaBl'a la»la ITufkiia
jr«l. ■Hii Svff /unntof,
DOP WELl, (G. /■',). F.R.AJ;.. Iff^
A DICTIONARY OF SOIKNCE: Compri«!i»g Astronomy. CJiem-
litrj. I>jnninii'i. MMtrletly, RmI, Dydrod^mailO, H^ratallu. Llffit. Ha(n*lltB,
Marbaoi». Maiaaroioic;. PnanmaUn. 8nui<El, and Otalltr. Praocdod bj an Kiwaj oa iha
.. lllilo'j ol \ht Pb]r(w«l ScUdom. In una bandfon* oolaao >«lan« of ••« P^M, and
' Manj llluilTitUoi t «lutfa, t».
IIlMIIY C. L»A'B PfSLICATIOSS — (ifttMiah).
A CEyTUKl'OF AJiEmCA.V.VEnJrrsE.r.l6-\»7f: By noclor* B. B.
■*^ CUrkf. II J. Bif;*low, 3 D Qt—.T. a. TIWBW.MidJ. S. BIIHmc*- llt«>«TOT7 hii»|.
i-onr IJma >a)BM4 i>r>knat IMpagri i «lotb. %1 1i. iJutl KaaWy.)
Tbtt work a|}|ffir4il in (b* i-a^'a uf (he Amarkati JuUTikalqf tk« U^di^ftl t^oi«n««vdMf1ii; 1k«
;t([ 1^''! Ai ■•ItUiIei iftciiut of <hf diialnpuMnt vf nic-lleal >4lsnrg In An*rÏD«, h; g'" 'I**
mfn of lb* hlgtmi anibr^ril) in th*ir ropHliv* dtpu-lmfDU. Iba praJt«UD«lll b<i J*abl **1-
cuu» It in ■ r»>m «ilvpltil (*t iitm*' **■■>■■ *■>' nbitoc*.
J^HILL tJOBy). M.D., and OMfTH {FRANCIS O.). M.D..
AN ANALYTICAL COMPEXDICM OF THE VARIOUS
BBAKCUlit^ OF HKl'ICAL SClKHCKt tor IIm [Im »d KumlBitU» of 3iaJ*Di> A
D(i> t-litida. (••Im-1 kud ImproTad. lo oa* «arj lirfttand baoAioaitl; prlnt*d rnjil lluia,
raluna. nt 4bDDl at» iti«aia»d pagti. witk 114 ■tood-auU. «UU, M i 4i»D(ly b«aiid In
laslhar, urilb raij«d band*, %t 16.
TJARTSRORSR{fiF.NRr),MD..
A CONSl'ECTUS OF THE MEDICAL SCIEXCES; conUinin«:
Bandbooki on Analnmj, Pb7*lolaKr> Cl^"iii"'7. U*t<'>> M>d>i>i, Pm^tloal MMlii-iD«,J
Sarxvcy- *"<' QhHaitiM' fiarond Rdiiion, (hnrnuKblj rarli»! ■B'l imprOTed. Id ana Ur^a
rayai lime, ro^uwa »t «lora iban 1000 tlomXj priai*4 9»f»*. wUb «17 lIlDatraLioDa dd
wood, Clotb. %\ lAi laatbvr. ft 00, iLaitlf liturd.)
vantf, rFHstaait nail Da** a woipMlai.lbair
>I>1 W vrx la r>n>tara Ihal of Dr llinittiiiH —
Mn>l( Rt.i^Jfid an>( l>aiiri>,,aa« Ibr4
Wa a*a tay *>(li i)i> «ttaii^i <ni'i iliai ii )• iiia
baai vutkadbakled vlltvtvli w- af<««|i>atoit-t
\\ aatkiïjla* laaadadaa**! Fiirjo ai^ r*<*ii<4at'Lbq-
lloe» Ink pfAi^[lr«[ LurJidLiin^ tacL 1> iTiarafor^ iivaral
ifl «v#r7 Su>j ^rfct'lritib^r ibhi^niEh^ai aar cuaulty»
b*»]4'^* r>'>Off tilriiir^^Tr ^^'p'tu ■" 111* v*ttr«(4-
dial! -t mailltlhit. Tl» Il04k !■ auMnUj aail iliW
aiaeulxl — VA>irI»l>iii ilcl, Joutti . Ai-til, la.'l
Tlia v««k !■ laL'iiJad a* aq ak4 lath* marital
aiBNisi. au4 ai I mil appaara ta ad mtnblf hiOl lia
Tha*aik bâton ■>. kaVHtt. )iai laaa* rrOHB-
laa (auana aui viiiaMH4 br <iii»i>. nud f-ibt b»al
.,. J p, Hariih HI, — i-' -t;;! la
iit'—li.. «maj
■ ■ - wlnrai.,1. li.lVa"
fa „. , J 1,4 .jf kiiiiMll IV. L^ ,.■•' i.b. I'dpLfsF, I rbaaaaa '
■«Ma U'a aaan mailt atar* a* atiaulM iHtaoa.
a1ija«1 b; lt>pjE<*]l«pt Brrab|anaat,lba rallHoipl' TbauabikA! .dT jibjaiojair I'M alu i*»n IrqprwaA
lall^aif facli, tha p'rap^ffllfjr aodlaraahaa^ortia- and |1vt* ib' runal «i^rgprnliaarivf t1*v uriTiv tata I
cuift. %ni tba rUir aad ka4lra^ltrf IlltfilralUai ad van tet In Itta ■<!«&<< pu*»Jlilr Id iba tpacadtf.^ivii
la «kint pan* If iTin v.ifk — Àn^rio'in Javrn, d/\ I» iIj* tubjifi, Tbt mHtiaoiral tïfrqfitïb Qf iba
PaonniiTV. Pblladt :iii-la. JalJ. IM4.
Tba *'jlatB* a-ikl bt faabd aaafqt, aotaaly ta alo-
daatK. bdl lo Ei]aaroiU»f*«l>*tra4r ^aa^raiafafraak '
Ibair n^iiarlaa vltb ibaBOiulaatpaaalMtBi^Dtlt'
lataol iloa— 5 T Vi-<,'/i>a*aar.Sapl. INt.
Tbatiqdam vlllfladibl* tbaaiaalaaaTaoiaDi aud
uatfnl bona 1-r ih* hlqd oa whith ba «as tar 1*^
band— Pdsl/c Vet na-fSurir. /uiira . Ant Wt
TDl'l>1bebaBEb'hr<kiiflT*t]ud that va1lar*t>fr
• VamlnMil. II 14 an hf'Q'il, a<ciir«E«, avd cou4t!i«
aani^aa'l at nailleal uLi^af**. aa falrlf aapaulblo
rapraMallaa IfialrpHBtniaubiltEl'rB' Thaabaaft* aftiltaipalDlaaf «aeba'pajacliaad oT fpraaiattat Ifaara
aafl tba akliDiinD* baa* ba«r> na |a4l«1oah aad 1bE>- ' laa toDoaaaad T*t aaraattaaiia maaaai — f^diaaiw
roatb aitu nailar ll.ao fai ai II gnai.aDllnilr ifui- ; wrfft Nail. JKraatf. IML tVH.
b:iak lu«ta nniMof In »t 'Mad Kjt.—j-nfaiWar
/s'lntni.i/ jfirf(,-n<,eapi ]f;i.
AfKi niafullr li'i>kla( lhmii(b (|,|i (■•«•[•(tia,
w« ara rciD*lT*la^l I» aaf Ibal li la iha m<ï«( ctiHi'
pllla w.'lM. Hlvllillr io ll-Jlia-tia>ltiD>..<ril> klad
(bat vt laa«t >»□ — ila'-laBori A'ïaivf, bcpt l-i't.
Tha tiiLir nib wtvii ttia Oril «dlilna of ibia
OompvaltsiEi wai raf .rtd, vai aa «TliftfDaa vf lia
rar^pdi riMll4(if*a Tba pr'aaDI pflflli^g b*ar< aal-
daaeoirataiafilaDd ikaraailiiaiiiluu Or llaiti-
heria poaaaaaaa a bappy haajt; at ••iilef npua iba
T nDLOW{J.L.),M.D.
^A MANUAL OF EXAMIXATIOXS npon Anatomy, Phjsioloftj,
SntfTj, Ptuline of Madlclue. Obataliiai, UataiU Hadtca, Cbamialr)!, PhanoM j, and
Tharapaatla. To wk1;?h li&dilsd a Utdlcal Farmuiifj. Tklrdcllflaa. tber«B|kly raTlatd
and (raall; ailcadad and rnlargcd. Wilk JtO illualratl^ni. In aaa haodMin* rojil
lino. Tvlaa* ot SIA.laig* paga*. elalb, 13 11 ^ Ualbri, %X TA-
Tba artaBKaminlaf Ihiiialou* in Ih» farmatinaalloD andaniwrT raadan it Hpaelailjanll-
■bU for tba oSoa a lamination of itadtnla, and tor (boa* praparing fbr|iadmli«n.
q^ANNEH (THOMAS RAWKKS). if./>.,f<. , ■ , .,/, i
■* A MANUAL OF CLINICAL MEDIOINE AND PRTSIOAL niAO-
NOSIS. Third Ainaiiitnn frain Ibr Sacusd Lnndiin BdtlioD. Ravlii'l and Entargad I17
TiLlUKT Fux, M. D-, Phjililan tn Iba Skin Daparlowat is nniianltj Collajir Boipital,
é«. InananaatTolmuainjall lJnia..of aboatllS (nitaa. eloib. |1 M.
■a* Qa paga t. It ■III bo atca lli«^ IM* wark l< nforad aa a prtoilani tar progarin| B««
■abàtrlban to lb* "AiitbiCAa Joumxat, •* n« U«»icAt, SciKcct*.''
6
IlRNftv C. -Lea's PiJBLiOATio.-t8 — (Anatomy).
QUAY {RBSBY). F.R.8..
AXATOMV, DKBCKII'TIVE AND SURGICAL. The Drawlnpra by
B. V. C*«Ti«, M.D.,KiidIfr Whiuhaiuti. Tb» DUM«tlnniJDinlty hf Iha AitTauaftbl i
Ilr. CahTIIi. IVIih in Introduclloii bs Osnaial AnAtnm; nDiI UaTalbpinsiit hj T.
UoLMIt, U A,, Sar|t*oD to St. (Itvrff'p Hp-plOl. A mtr Aistrlcin, fro-n tta* «Ifbih
•1lUrg«t aiid lmjiri>f«d L«Tidan «ililloa , Tonbirli ii idrlr.l ■' l.^Mmmi. Munir o. iigi
StinaiCAI.." bjLiiTiiiN Qoldsji. F.K.C.S . luihur ar-'Huusn O-itolccf , " "A JlasiiiJ
0( DiiHciioni.'' «la. tn en* tDDgniflTrnl imprriil ocUio lotaoi* of MJ PNT**- *'th
Ml lirf* and alabar*!» *Dgr*vingii «n «aad. Clath, It) iMtbfr. r*lM4 b*B4(, t*.
Tb* auibor tuH •Ddakvoriii In Ibif KDik tn oortr ■mor*«it«iid«drknf*ofigbj«itilkta lt«a*-
lamirT '» *'<* "dlDU; Uit-bovki, b;r Ri''»* <">< ""Ij Ih* <l*tiiili oaptmrjrorthtttsdanl. bsl
■JiiMti* appll«all«n of Iho»d*talltliith*pnicllr<o1'oia<IUInBiBdiurg»FT. Ibairandarias )l botk |
n «uid* [or ilirltamM. and bd n^miniblt «ork at tnirifarr for Itaa acIlT* prBeUllMMT. TiM an-
gtmiinitf rum a i]>a«lal ftatui* tn lb* *ark, tsanj of lh>n bflnc tbt alt* *t Datara, ovar); all
nricinal. and bavkng the naniM of tba Tarloiu patt* pilnlad on tbr hodj of Ikavnt, in pla*« af
B|[ui«nifrafa'»no»,nlih4«prjplioni al lb» foot. Thajlbui furm a oumploia «nd fplmJid ••riti,
■ibtt<h will jxr«ïlly Milil lb' iluiltnttn obtaininji aoUar ld<a of Anali>iu;. and nill alio tarir la
tffrrtb Ihi mrmorj nf Ihon whu oiaj Cud in lb* •ilgaai'lri of praeticf Ihcnwftaltj of rocaJllBi
iha dclallinr th> diauollngraan ; «bUacumbinLng, aaildott. ««ouplal* Allaacf Aaatnoi}, will
a (boroagh (raatiiB on i7fIoniatl«. doKTlptivo.aDd applitd Aoaluaij, Iha wbrkaill b* foond of
aiasntlnl u» 10 all pb^viKlani itboiMrlTf iiudtrii in thoIrvOcM, rriUrlng bothfMMptOf and
imptl nf nucb lahcil In Urlnit Iht KroDHdwrk nf a IborftDgb (MdlMl MtatatlOB.
SIprb Itke aibp4[irnnca «fills IjL-i Aiutrk'nn Kiltitun, ih« work baar««alT*d11iraar«TWI'>»aal (b«
bandi of it* HrtiDiphthadfdiLor, Mr, llotinfi, who ha> tcdulooil^ laltoducad vbaiavar haa*oriD*4
(aqulilU 10 malnliiin it> ra|.uUli»n a* acnnplfta and autbotltr-it* standard Ifit-book B»d «ark
of rrftrtnor Ktill furthar to Incraa» Iti unfnlneH, tb*r* l.ut baan appandad lo It Iha r*«a«l
work bj lb* dliiinitaitliad anatointil, Mr. Lnthar Iloldan— " Laotlniarki. Madttaland Hurgkal'"
wbkb gl»* in ■ olanr. «ondanaad. and •rdamallo wa*. nil tb* Infnimatlaa b^ «liiiih lb* w— ■ '
tltlonarenn dalonulDf (rom lb< aiiamal larfaoa of tha bodytha nallton orintaml fsru, Tb«t
gidTpldr. Iba «qrk. it it bilimd. will fumiah all Iha uiiptanoa Ibatoan barMidarad bj IjpaanJ
illaitrallon in aiial'<inlcal iXniy. No palni ba<c bran ifiind iti tho tjpofrapblaal •■•cvlloa of.
lb* rolun», «blob will ba found in all mparit rnparior lo format lanca HatvUhflaadlac llMd'
ineraa» of ilia, aruuunlin; lo orar IDD t>a|tai and ïî illunlcalioaa. it will ba kap^ aabarMoftr*,
al a prloa tandartng It «naof tha shaapail worka »>r «llerad to Iha Amarieaa profilai (B.
Tha rai+ot work of Mr lloM^n. wliUli vaa uo-
llMd bJ OaOO P' &A->f ^h^* Tuluma. 1ih« Iimcd Kitdeit
41 aa appfodli. anibar. AiiutvTbur. ibi> ih ibv eddii
pra^Otal anil couiplal* aqmDinirri] iftAiu* avkllaljl^
Id Ain*r1»D tiadaala aad pbjritf^an*. TUt furiuai
audi la It iba DMfaaarf (aMi lu nuklni: di»>c-
iioaa: a vT auDprabnOBit* thwp^.t op mlnnia
anaiDiDF ; ""' abuoi all rfiai MTi Ii"Hi|itn Jjlm «t
faaafalanti tpK^al aaklLiEitt: wlilla Elia laELaF.lD
rt ii«»lm-oi u(t»(l. "fii'D fiom ■ .ntifiMl polni of
viaw ami Uv [>b" vaIuiMq «tlliUn of Kr HMlJao,
will Bnil nil i1'k\ will 1" •••eudal to him Ig hla
jrraailfa ~-.1"c Sfm.-dM. «"« l.iîli.
Tbii woih 1* a* aaar jiarrepil'^ii Aa nun foriht poa'
albtf i>F nka-ioal-lj «Kpit'l atijr liook iDLaudod at a
laat'boah of ■ a^aa'a' raf<ir«otp l»ool( an aaaiomf
to b* Tb* Amarir^ii pulill«h«f a*iu-Trfi* iba Ibiak*
Lif lh« }teu1r**[i't for apptbdkdir Iha ratpul Wkrrk of
Mr lliiMaa, ■•tiinJi'irii-W, .Vtillcul iinil Hutu""'."
whkli ba> atrAfdjr btoD 0i-IDmAnili>i1 aa a ippariMa
book- Tlip lallar wnrll-.-Irat.llrja ift rufiocrapli^Hl
■ eainfnr- hat lipi'Oio*4ii ««arpOal lo [lj» Uht^ry of
atari iolalllitiilil pra«llll-'li"r. Wn know nf ac
botfk llial '•!> ta'* It* v'a», WTltlan nil li Vj' t
»4BI dUllgaol«h#<J analomlil, ILWuald ba tlUkiiLj
a watia L«f WL.rd> 10 «A7 anjihUNfarlljar In p'alta
of Orajr'a io*ta™j, ILs imh-Sio* In almnil triij
nadUal »ll'cela iblaaqontrj. a oil Iba dallj rafor-
«taa book of avarj piaflililoatr wbo baa oeeialaa
vork la
•|D(>17 Udlipanubl*. npMiallT iKla p(*>*tl AbW
(. JfoolUr. Sapl. Itlf.
lo foaaiill III* booïB aa aoataBiT- Tbo
•Im^Lj ladlapankabl*. «
leaa adEI]oii.~r«t, M*<i
Tbe tdaiiloA of Ibo !*«■■ work of Mr. HoKm,
>• aa appaodli. raDdara Ibia Iba »«•! ptkMlial mmi '
«iinpl*» ttoilH arallabla I* Anattaaa atadaat^ I
wbo flad la II a aaiEilirahanalr^ cbaplar 0* Maaia-J
aaaiotar. about all i fait aa ba laafbt as (aaanlij
and ■[■•rial taalimj. wlillo lia Iraaliaaal of auk
[«cloa. fr^iu a Buitlral imIiI of ilav, )■ tht rala-
abla HiiloD bjMi Hill dia, lull ikaiwlll baauaa- '
liai lo ihan fs rraoiI«.-<Mlo Mtdttal M-Briiltr,
tl Is dlfflcall latpaab la »*4arala Mraa bI Ibia
aew «4tllos nf '■ Ocar." II sHiiia lo b* h aaarlp
psritci a* II la pvsalbia (o uaba a boak 4a«olo4 t« •
mat braaeb of aisdioal ■cjsnca Tba laboraaf th*-
■ n»IBr<BI insa wbo liar* lofrosalsttj rtrlaaj t%m
«Ifljl <^lliBaa Ihr^tif b wïiKb II lias psssad, voald
■«m lo loar* noLblBf fi>r fhUiirs «.liloralo do Tba
• ildltun i>f llriMrB't " l-aolULart." will makall aa
lO'iiir-ibHtils I» iijs piientioaat of ■*4iciBa aad
turtTTjiB ÏE ba» b**a baraUf fT* lo Iba aladaat Aa
"(•"I" ' nil pwi pass», aiM o[ rafbraaca^ «iiiiij
btw'iiT, aoil «lirapoits, ii (las ao ritaL Ho aca'
d<ol sboatd *D|rj a DiBdlc-si sibosN wtikaaA II : ao
ph}tlel>B riD aSofd id bars li absaal tiom Ua
llbrarj — «t tamU Otn. Mt*vr4. Bapt ItJ*.
m
H
A bio rVB aaLI SBPAIUTI—
LliKN iLUTHEIi). F.H.C.S..
ffur^n-n t'j %t. Bart/i"l"mtui't and M« fiftandttnff f/trpllmU'
LANDMAltKS. .MKPICAL ANDSUKGICAL. From the Sd Lnndou
Bd. laoaabandaoinaTOluitio.raral ISmo.,0r l2Spa|M;elOtb,8S««bU. (JVom Bimjy.i
BATa ICHRJSTOPnSIi]. F.R.C.S..
fVuHJ-J^o/ Optral*W Surjffr^itk UnitêrtUy CoUtff*^ I^n4trn.
PRACTICAL ANATOMV; A Mannal of DJMsoctiona. Prom tiie
aafond rsfltid and Improved Londou adill^m. K*!!!*!). with addltlsnr, h; W. W. Km*.
M.I'. Loctotar on Patbolo(!loal AnalnHij is ibr JsflViiot) Mi-illtal C-,II«ga, I'hilaiiclBbia.'
la oiichandiDiiiFroital llao.Tolniiii afïTS pagat, KlIhlllillaitralloDi. Cl«4b S3 til
lealbat, |i BO-
Heîjkt C. Lba'8 Pcbt-tcatiosb — (Anatomi/).
1
A LLES IHAPRtfOy). M.D.
ASV?TEMOFnCMAN ANATOMY: IXOLUDINO ITS MRDICAL
■nd Siireio»! R^Uliiin. PnJili» l'r» i.( Piurllliontr* ■n4 eiudmUnf Mf^kinr Wllb «H
Intt<Hluc<4r)rC)»|>t>ruii ttlilolocj, Bj K. O.SntKXraABi, U D .0|'hihslni*l(«Ull«lW
PblU. Ilotp. In niir Ur;ct ■D'I hindicma qD4ila rotum*i «lib «'«ni han^rM «rWlul
IlluftrïllaD* on lïtlif^gr^tphii^ pl4l«#. nnd nmotrou^ wond-rul' in lh« 14x1- lF'ff^t^tig-\
In thl> ■■■b6iiiu««rk. which baa I>hi> In»ll» prcparilinn forxTcrd ytu». tk* nnlbir hM
loughl («itiTe. Dcilonljr IbxUinlli ofilmripil» aDilanij ini4trariind««R'Itni(il rom.but atio
Ifar girurliol ■[^pUflutioni vf Ibmelenolo mt'lls!»* andiUfgEiy. Tbgwuikthoi h.-i> cluitna npon
iTi* n Util lion i>l tivffnrrBl fraoLl tinner, Ai*r«1J ■foftheilndvM^vnttt'EJnjE Lim nul (*ii}tIq ra-
(rdb bit r(Co1l<ielii;in uf [h* dlr'wilcm tccim, bul «laoto r*en||iiii» ■hxiKD'Hcmnc'Dr iiilvBrlti-
liant rtam ootidi) ovodltlon* Tb« uaïkcit aiilli; ut Ibs objtct ibua *0U|cbl bi ibi> anlhor ta
Mlta'ldrnl, tnd hU lonj[<xpfrïrnT( and SHidiiDiia d>*«ti(>n lo tl« Ibornagb dcrcIn^mtBl «r* ■
iii1Slc*i«n1 Eunrhnlt* fftbc tnannar iu vrbu^h bi»aEiD# bkvt bc*)l rATtUd itnt- Ko pkin*hiiT« b#m
■pnrpil niiE) ihtltlu^tFRiiona Thoft ornciniial KDalom; ftrr frou Qfi^initJ dirt«cli'i)i.4rn«ft «n
ft'»n« br Mr. JlTninnn Piibaf, *l1h Ibv nnin» Qf tt^rj ]imrt «Itarlj «nsTurtit upnn Iht Hgurn.
Bftfr Ibr uiann^i uf " Kntilan" ■D'I '' iitéj." >D<I in cnrr Ijpoiikpblcil d*t*!i il oii) b« (b*
•ffori of Ibe publithet ta rtodrr (b« rolame «ortb; orib* nrj dulin^aiibïd poiltluD abïcb M
kDiiclpaïad for il.
p/.tJS lOBORGE rtS'ER],
DEMONSTKATIONS OF AXaTOMV; Ik-injt a 0«Mc to tli« Know-
Udg* el tfaa lluniBn Bodf bj DiwMIinn, tiy Oaoflaa Vikiih Klldi, Eionillai I>roft««oT
ot AntMmj in UnliertUT ColUg*, Lundon. Frsn lbs Rlgbib and K*vit»l L»ad*>
EdilioD, Id oaf Tvrjr bandvan* oeta** tdIuib* of orir lUD paRM. nlib ÏÏS illuitraliou.
ClmU. •« ï& ; ]«*tb«, $» 3ï. (Jax Rurff )
Tblt woik haï long lictii knnao la RoRland ai iba iM^lrt aiilbirllj on pruotl»! anatomj,
arid Iha favbril* (uïd« in Ib* diktacilnf-rDom, ««U att'iUd \y Ihc niiiiitr^at tdtttuù» Ibrauj^b
■bl«b It bai piiiri. Id (h* lait raitilve. «hlnb liaj Jail appMrxl In Lundan, Ibt aoonai|Jiititd
•■Ibar b«a(>a|[ltl ta briaf II <•» a tvitl nitb Ifea moal r*K*nl adranoM nf MlvDoa b; aakinn lb«
nar*«farj ebangta in bl> accoant of iha inienxeoplo «ttoclnr* nf Iba diSnaal ntpn», m dai*)-
«pad b; Ib* lalact ttativrch» la triluin) aDaCamj.
Suit'* Damoatlrm(li>ai L« tbt faTorIra UiL-book tia Wadaribip o**r Iba ED^lttb manaala iipaa 4U-
ar ilia 10||liib iluijaai «f aatiuinj. la paulei
llirniifli tigbl rdUlabt It ba* bfva ko rariK*4 aid
• ilipiFrl la Iba oardi»' Iha •loa^ui bm It ireald
a#fm itif il bàd aluk^al r*ifbid parfidJoa Ib IbU
ti^'cmJ ll&Ar Tha daBcrl^lluEik ara rlc«r, aad Iha
lni«lh.H^U uf pnr'nlaf aiiftUmUaE 1&T«kïl^tLDbi ar*
|]»«u laUb tuib det*ll llihL Iba liook 1* baaailJi
anilllxl lo 1l> aaua — fif. LiaU ClInUul itacvrd.
JoB».l»!0.
Tha taaeatt af tfaU t>ld maDOal aaanii tobaaa vall
daaarv*4 Id ITih pratatii aa Id Iba pa-l ralamaa-
TMbauK Han» dattlaail m aalalaln jral foi jraara
mMUt.—flut<i. Mnl- rim—, Jlmj> m, |t:«L
it a dl>aa«lAt. 4f a «drk Xt kaia in ha*i aal
■Igdiat] wLila i>aa il aaiaj|*d la divaciLna. va t9
fard II a« Iba ttty b^a: vmrk airaal. wklak li car-
Ia]al7 ka^lai a i-^'j cF*a] it^\ a» a larl-bttab i«
b* tluJIad Lu IFia ilLitnia^'rvacii» Il La fiparlor la
W* mnti aarvHrvadir racnrnrnaad 11 14 «rarj
pniHiiaDar a{ eitdlaïaa wbt aai BMalbltnt it.—
' Fa. M<4. MaMAIj,. Jasa. I JM.
»r^
'ILaOff {ERASMUS), F.R.S.
A SYSTEM OF HUMAN ANATOMY. Ocneml and Special. Edited
bjr W. It. OuaiiEi'HT, M-D., PruttMorot arsaral ami liargicii Anatcm^tD Iba Hedloal Col.
lag* af Ohie. lllaatralad «ith Ibra* bua<lr*din<l ninvtjuTcn •ngraTlafian «o«d. In
Oaa larit* nod bandtame ottaio TolHtaa. of OT*Tt001ar|t* patra ,âoth. (d ; iaaUiar, $i.
(JJ//rfl { WK.VKF W,), ilt>: - «'«' IJORXKR ( W/LLfA M B.). M.D.,
Cfsi/. 0/Suri7irj((«lA< Til». :•/ Ftnna .tr. LiUt fr^.iy/ ^anll»itlllHtU4 VhH o/JVnsa.
AN ANATOMICAL ATI-AS : iUnHirative of the Structure of Ihe
HaoiaD Bodj. Ib on* taliiBi*,Ur|* iaiparial oatar», alMb,wl(b about ill baa4r«d and
Gflj baaaliful Hsuraa. t4 10.
S
CHAFER (ED WARD ALBERT). U.D.,
»9ittani f*rv/tia"r *}/ Phywi'i faff)/ m Vii1r*fUy OptUfft, t^n^At^.
A COURSK OF PRACTICAL HISTOLOGY: Being nn Tiitroduction to
tba tT»a of Iha Mlrrotaopa. Is una handaoma lofal I2nu. ruluoia of 3Ut pagaa. «ilb
Dumaruui llloxtatlana: «lolb, )1 04. iJuni luHf^.i
l|i»INtltH»PXCIAI. ASATnilT Aai> HKTOL-
OaV. Siiiblh •dillul. allaailtatf ti*lu4 and
■andlSad In 1 (Dit. »*o , al o*ai tOOU pagaa.
«lib Vfi «oiijautt : aloib.la Ofl
BlUMPEf «Nil QUjU.I'H llt'NAI* AKATOXT,
Katiatd, )ir ''■aarx LainT, H.Ii., Prat af Aaai.
Id I7:iIt. oI Paaa la <»v ualaTo lal* of abi>at
UOOpacaa.wlib tn IllaunllOBa. Clvlb.M OU,
BKLLAHrR «TVntST-G ODIDB TO SttliairAL
AX>ri>MÏ: A Tail-bouk r»t Bind-aii p(>[i<,r!D||
for I bal r l'as* Kmmid tiiua. VLtb aai(rA«iori on
wooil in OB* bandioiB* tujal lïcna. aulaaa
CMb.MU.
CLSLAXPIt DIKKCTOKT fOtt THB l>lS«£CriOX
or Tyt tll'MAH PODT. la vaa .mail lolana
rvTal 1ÏBU. ollbS p><*a^ tlaib II SI.
Hexrt C. Lka'» PrBtiCA»lOîM — {Phytiotog;/).
flARPENTER {WIU.IAM B.). M. V.. F.R.S..F.OS., F.L.S.,
PRINCIFLES OK m-.MAK PUYSI0L0GY;K«1iUtn.>- Hexr»Pow«r,
U B. LnnJ.. F R.C.R,. ïiaïuiotr in Nalurnl Srirn»», I'nlxnll} nl Ottott, A b'B
AuKriimii fivm lb* KUhth B«iU»<l and Kniiigfd EnalJih Edlllon, *hb Xolct tnt AéU-
llom, br Fii«i>cii 0 Saiii. H D.iPfcr«»i>r sr thtIn<li(nl«>or ï(tdicinaliitb«rkKtr-
■II7 of Pt^DfjItanii. i-l?. In OB* iirj ImrfOMi-) hnsJiiiuit 'jrt*io>«luint.o( IQM f«f>t,
«ilbl*opUU*>nJ 3';:i<n((»iEgr AD«<-bdi elotb.tS i» ; tiKlbvr. tf AI. (/■>( Zwairf )
Tb>|r«at work, tbt cru* nknji Inbot of tbt diillpcu'ihol sBlboi aB<l tbioHg^ablcb ■» nabj
(tnattlitniof iCsdcnli Iidx u^niifd Ihtii Imeolrdfaof Ph;fi(4ni:7.bM hum atoiaal tatlk
' orpboaad >n Ibr «nVirl Xf a^'apt U Ihorougfalj lo ibr rrt^ulrf JntnU ul mùdain AcltMt, Ëltt4a
ja tfpimi^Bf cf lh> Uat Atucikan tdltlgn. it baa had ■cTctal ravUiunral tbc (i^tl>nc>d
«nd ol Ur. Vi^nrt. nho baa modlHtd and (nUrcid il foaa to intjodatc all Ibal it kai|«irlaal
In Ibe tairiliRnlioDi an ddlnDDxHri of England, Franc*, and DatniaDj, r*iallii>(inaB«alarK*'
CB«nt «f nhcuiuna-foutlh in tb* taxi. Tb* itti») crillufltili'»!* bu undaf^tna a Ilk* laiiiias.
a laiga pttixxilcn «I Iba T'Tai*! un m baiing bon rtjictcd. and lb* lolal nviiiba* Inotaawd
to naafly four hni>ilr«d, Tbt tborou^h r«vi«inn wbifb Iba wirk h>a 10 roTfail^r^fi+Kad ÏD
^nxtund. bat (iiidiTidDDDtccHW; an; rla)i<iral< i.i1dili(ina liithUcuonlr;, but iba ADarÎMs
:dllor, Ptottitor ^mitb. hai iclroductd i««b nisttai» «■ bit loii|; «xprilisoe bit tkuwa bin t«
arr^^uiti(f<fcfrlb«*(pilfint- Kvar^para ba* b«an I'jbtiiwilb lb* lyi'ogtaYhi'u\tnt^9linm, and
Iha *uik I) prrfinitd.wUb Itj ihoHtand «•liwalj, but cisnilj priniiil («k». knaaii<ba(icalljtba
trsl'bookfoi tba •Ifliiinl nrei prgn<il<on*tof medlrlna— tbtontin Kbleh.aatKirlvtna. a>pa(>ial
oarf* Ndlrafflad to abuw (bt n^t''''^"^*^'*' '^^ I'bjrtinlf^lCj in Utavarioa» praotJ4*l bratiohaa of
mtdlcal aelanet. KoltiilbilondiDR Ki rrij (r<ai «Dlaigcmaut, Iba piica kaa i^el h*«v !■■
or<ar*d. r«nd>(lo| (hl> an* of tba chtaprit "6rkt nn<* haforr ihf ptolofiloa.
W« hav^btap aj(reFïMr4uriirt>Bd Ittflqd fh* *al Sarli fti'Tno'i* fli^\--v^ I'lTrrr^nllt W«D naAalB
■«■•■u fo«i>lalf timf4'<1 roLh^iiraciaT'ànii fiib^ nvr pli v ■l'sti»tT<^1 Vnfivlpdf*. tliit vliàt *kt yjrfwjy
tlaot of Iba asrrdot •fiiam la all lit nlaiiaai. ■[ aa« a fiu m laii ■i». Iml» bob » if II b^ laH a
tvbjnfiihai.ib uiaajitvjiflcih, Uobcaf lliQ TDoaiiiL4-i tYtfivAi 4i4ij «Bta^LUlif^ tvttitjf^r*^ in lbU*vT<
epit »f all. In lU'«b<iU raaf* ol plij-alnl^jij. lij^hc 1 ^log^ir^lLo «air It I* oarl>altnI. Ucro, aa It m ma M
wbUh (g piodarv a foH aad «alttlailflr; tf<alk<q i.<f uv,l-]bi?Krr4lrjlur .'Hiki li.iV: t«t UBaKlbavMlef
lt«0U»« 14 vfaliFk Ihtf rjaa l'alun aa li<-UHEii;t TIjf I a tlliOont lb II r< ' ' ' •' ttn aTfrtef may K***«
4
k( r« ft <uiiiM«T4iaa wtiam W^frnil ib^t *f th* Uu
IbaIkIi *4iilutia lu <'.iua]uk^>u. if « eu jrlf d vur cdi-
lUiil ivr'ii"ih*'D'lBLi->n L'l itie vcik ■• LL uriv >]>i-#ftn,
T^a rOiKiFt hi^v^, «rjr^ ih*lr iH^iliMcn' (n (hn nul^
ear mQ'* 4rib« w^rdn inht yn^datt^-^it -at h \-\ii\<^^i>-
pbaf ftt well»» ft ïihjïjLjlcjl-ï, brnktghr ^t up >4 full jr
■hicb U hUI ihin ^ SjtànA --'r' it ri Jbd
i
lli.lHd«.r..aljmi.alaljibatPl.«ill..aat— )"lir,....L;....., .«a l«..,l.t . ■■ ■.■ .,51^1.
hadlulbafato; »r ibrait<llat pf.>(-«nB^..«i-n. | ,„,,,„„,„,,„,,„,„„„, ^„ji„, f^toarf
V' .Vttoh. .1» J jr.n(..( Ou™', iprll. Itn, I „.„„ n ^j n, ,|i„i„K„|,h^ , ., ,j p,,„
*'i*<«il wliiD b*nl> nu l-Qili" ***■ ll<» pnrVsrb. ftbil I Tltc Aniurlcftu «llitir h^* lu^l' ii\- • iv«*« «u^bllfvv, 1ft
fturjM 4E»i1 fiiit1<ru1«0rT4tLilU4iii* " Mh'" tftrptniT. u |arH]BrfDii*tD^T>r thniiinr tïifti kuaUf««d •!■« tbi
tUnrj Vi>*ar»i*cdi litlltfif no t«DiDHid*40n bj u^\
fftOSTKH (MICHA EL). M.D.. F.lt.sl '
JT IT.'/, b/ FKytMngp in Oa^trMgt Vnlt., Xn^ranil.
TEXTBOOK OK PHYSIOLOGY. A new AmPricnn, from the thint
Bofiitb adrtlOD. Bditoit «llh ral*. and addilinnt bir Emiikd T. HxrcBIkv, M.D,.
DadiOniiralnr of Kiparimtnial Tbrinpaulici In tlnlr, orPanna. In «a* ita4»omm nn^
ISmo. rolumr. wllb over ÏAD illualrnluing (IVmrlt Rttdf.)
Tb* (italldsoc ot Mr. Fotlrr'i Hork aa un aipoiiiinn of rnanlionit ^ydtlon hu l«a|
h»n iTcoKiiiioli nbila for Ilia pucin.raK oS iht iludtnt li bu Ixcu xiinaiibal date (va I ai t*-
ir*a'a Iba drlalli *l iiiurlur* ma nfociiarf Id itiid'T ifiiflli){ibla Ibailrm aod IkcatfM *f ibt
tr!'ni:i. Then- il bs» ln>m Ihi «ITnfi nf Iba •drlnr In nJd In a> ruuci» n niannci aa poBibla.
and In aid of Ibli bt bw fiaatj lulTudurtr] illiiflfnllniTFi rrrn rtdngnttid aulborilîta. I> ihu
laiproitd rurm it I* tbnfCoT* bnpad ibat the vurk ua; proi* mora Iban «<•( aixaplab)* M lb
Madaataianlaarand compitbanaii* laiMiouk, praianling tbaae^M* In l(aUlafl«or«|afaaal.
Ill" ■■fn ma-la. ladtaa do B«liM« bi«rw (kaa (a
Sir* I^F. Fiai«r^- vi.rk *pma carafal r^idiaa Snt
limaJlu, Jati IIM
Aa »li1ivril« M'l'w (1 |.T**>a! la ml h^eIt**;
Il lauuT; saiMiicj' in .ij ibii li la |ka b»! h-^at
4fli*1iiim44jltin «i^in tar a--'*balkti>«i'<ai
•a tar. al ItatLaa au kHvladaa i
Jf-d, Timt; Jan. », 1;», "^ '
TIkt vork, ■la<p Iri Aral apptaraiKv. !■■■ d<ia-
tlanad to bfr .run of I hn m^al a»tul*(l.»rv Latt-bf>oka
OD (ha tntjtcl ILai v« liatt ID'I villi, and Ih la
uaDp rt'ptcu t>ai;aJfarly ajapi'd to Ibt nan nf
pracLiUuiiH:**. T1ji>** wlifltakùnvltilffaflfïl.* fnnf-
l.oD> oi fttffiau vaa fblaUr afqolrad a dt4adt afq»
■ Bil *t<i Iiata BUI lint* t>*ta dlilpal BladtBIi af
Iha audi*», tan liiila appncUla whal adraaMa
K
IHKKS ( WILLIAM SKXHOU^E), it.D.
A MANUAL OK PHYSIOLOGY". EdiUïd liy W. Mokkawt BiHKit,
M,D., F.S-CS. A ntw Amnrimn fri>iD tbt ti^falti and llBpt«T*d L*Bd«B adttivb. Wllb
abuui Iwobandrod and flfi; illioiitUanii. In on* lareaaadkaadfona imal Itaa. val.
noa. Cloth. tS H . laalhtr, |3 'ft. lUiiily /»■»).)
nARrStl<iRBX'li lUMiBOOKOP AHaTOXT «Mil aDdkrIilliiosi.b} J. CawiOJ Meaaa, KS. WUk
I'llY^IOLOOT. btiasd adiliAB, ia*lard. Is oaa lilDatiailoai un vutd. la oa* t^a» T^taaa if
rajal lloio, *«),, «Ilk tX vood taia ; tlotk, IM paxri. Clolb. (1 U.
•f ' LlllllAtiM-irnTCIOLoaiCtLCIIMraTSI C«ai-
LMimxHSS MltllVH. or CHKMICAL PIITSIOL- plaial>iv.l*>(.*ciBT«TalaMaor UM rtm*.
O0Ï. TnatUlad (iDU Iht UaiiBaa.vUb HdI** «lib IMIIJtuinUaaa; (t*tb.H.
Henry C. Lka's Toblications — (Physiology, Ohemisln/). 9
fkÂLTON {J. C.\. M.J>..
ATRBATISK ON HUMAN I'HVSIOLOftY. Designed for th« use
oFStiidfintixiiPriinilliAnsnnf Meili«!sc. tfltlh*Ji(l->B, lbii»aith>|rr*fUwlin>taaUrg*4,
M\\h xhrrt bunftri-d atiiI •li<«n Ulaitoilnni on wood. In id* Tar; bciatlfVI oaMva *«!•
um», nf ei-t f^lnpit»». Cloth. |Mn. r»«th»r. $4 M. iJku liimdi
MOi^t'iK fur tbafkior nf thvmvtlml iliiitrriL hiir
■wtMl, II •i1Iti>rouu<] tl>n(ijbr.!u(«isTkI.ii>all>r-<
litrr «flrfc of nb^onct tar Ih* pttPtWaawt^—C'KiMf
VrrX titlton hi< iHii-nant roBltMlnilhtorlM (iiil
n»M tnil ilpti In ll,r e^iV.it \.i,-\ Hui bli ilL-ci--*l'<r.>
■Ualllll-llcliinlilllillviaililltlDBnrdt-illlMlriwriWM.
''' 'I '.i^EIaT. fliLi^l^f in lll>t rtejiirliuanl* uf )}ftlk4»
I tf feO'^'^ hphT" thu^n rrnvUrj^, W][b •<> t^O'
pojriL r^FL-i<m \n'i «4i1t>|H^q'.lliBl lLwVlk*«Art lr*il
qtiinihaUq'v.ifjinmrtnuvl^palarMxiB«7 h*44i&fr
•Ivnllf (imll^rHI. nninuliiundinc lb* «oaiiMlUiiii M
■ ir «luuunlir. Tli<i>uliliibft'> «ark li oAmlr&Uf
lon*.'-.YI. r<4if jr-rf .IrKl.TH'y.J'Wni.ltw, HIT!
W> hiiutltr vflr^nr thl-. Ill* •lull •Dillon 9( Ibb
hlmlntlilettit N»*^ .lhÉnwhkbtb('f4raD'<fi»«rHfihl
■ «i«l In 1h- mlrtiltiii I nv1*^i4>«1ijT riP4> I th» Pr4A4wnTf>f Pb^rinlrp^ln lh'rnLvpr*tWi>f L*'Uitl-
babllltlsi, Ibtl DODp 'rf kil> rfvlvrv qaod bo l«d Into I ■!■*. H*bT fttlDa(BT>*lBntu*fb«nlfithaUHd1«d Stalw,
cnrr*rruftirhlI*injikfDEtb*at«*lvd7'— rjU Jlrdlfdl bikI vtwrvfatrbh* Kiullab l«acatc* !■ »»â, Iftta l««li
Jtmnl. rrh u, lilu, | l)»t h«<.i.i|>pf»>r»iM. Tn>pr"«it Htlilnn.BinidnSM
Fr>r cleiirn-~ »ni> r*n|ilrulI5', IHlmn'» Phjrinln»»
wmnwinlfa lu*inDll»>luitHil)Ht<a«».>nil •■••
pIPUkDl rsllul riom lhl> HTbo* pnxllTllnill •lllcli II
■ ar(*l^blwJ^ l'ïiTïliJiny b«4^bo«4f«r. ntJlD4n«A5 •■!-
VâlHtf «tqrt ILqii — 4iid Hbkl* Ihd tIjU bu 1w«P IfF*^
■vrad Inlul . t h> >ort In lb» piwnl «ilUlan bu tiwn
br«(titupfullr<ilirr»lurili*lliiii<. TIlCOavcIlHDWHl
QOlttl'rD «aO U<llDvn4ltfl4rv b*1* hi» bPvb IfllpvlQ'Vl
Intii Ih* pnontKllllno. ?(AI>1lb-ianc1iii ih> mulll-
Kr»'''?^!:"'*"'",'""'''^*''''""!'":"?'"""';" - --' y™-.-.™.,._
oni. qtd ilmr )H>i,ul(rlt7. Th* oi«l.»i.t«l •I'TUitun ■ m,, i,>,d K w. Iu-ll«»,mi tb* -h»l<^ lb* btti k«A le
"rL ■'",'L': •'.' ""*' "«■>';", btJ-'If^—P'"''"'''"' pl.1* III 111. b.ad. or lb. ■lutl'.iit.-Ua.dn JlBAal^
nlhAr. n"! 01LI7 in Ui4l U hrli>[- lb* ■ubjf^t up Uy lb*
(Inm, bul tbtl ■■ d'-** 4n mi>fr fkirlr BULL B&rblSic|ur11y
llliifiBnrirrih*l^biBPLli1Ji'(i T^krtlt tU'iC'iUirlIftni^Ûui
1onurbEl{^hI*D[*^t1lr«l>^1b«^m^'1I btpnk '>Dpbr>)i>l<i£r
LQ4I17 IfeOil nr UfllliLf*.-^TV.*'i'a(i?, Vat.O, IftïÂ.
A»*«bal*. «■ e»nlUtlr rwmvanrt Iha «Ark •■%
(•il'ltavpk fnr lb<i aind'nt- anrl At Onu tt Ib4 b^al,^
T%ii/a*nalV^'tnew<u< X'ltalPiimH.Jdi. me.
mm balil> Ita pattllBn m> ■ na-tfrplm dT 1u>M vrl t-
fjLASSF.S (AhEXANDKR).
ELKMKNTAUY QTIANTITATIVK AVAt.YSIS. Tiiin^Utei with
DoMt snil ail.litinu bj Enais F- Hiiim, l'b.t>-. AuULint PiM. it Cbsrautrr is tba
Tiiirni 8i!l<niinn !taili»iil, Univ. of Prnna. lu on* hiuiilium* rnjnl lima, volum*. nf 114
pugtf, wiih illiutrBtloni : olotb, (S 01). (JhA Knu/v.l
II li I'lubihli th« b»i iiLDcnl i>r r>a rliivtsitrj , ulianrlnf: In ih« aaiilrili "F Blmmili mil aiifb fift.
DaiEir* »TljiDl.iu«iiiiLiiGh«B ]Ev ■flc<t>iiidi)kn (ba Ijhe. -Iuru >« «rv m-i vilS la ippUtd fb«ial*<vr. It U
Il fAAiihht* \j ■XBinplw, «iinDitri<riA| vtib tlnnle 1*0 livjlapauvjilt b4ub Ibt alaJitBU la t^taA*try,-~
d>l4(uLiiilliiBv InWiwti bir H)i>r>llna>. •»< (kan »ii<DBA<m.a/ Oumi^wif,Ùat. IfTt.
(WALLOWA V {KOBE}tT\. F.C.S..
*-" /"r"/ «fAitihlti^ Olimiirtrv In '*' Jt^-yil ffofjf^ »/ IWmw/nr Irtlaiil.ite,
A MANUAL OF QUALITATIVE ANALYSIS. Prom tho Fifth Lon-
don E'Ikiiin, la one urM Tojral liinu. lolom*, wilh lilailrbtioDi i doth, $3 15, ^Lat^lf
_QO\VMAf/ (JOny K.),M.l>.
INTRODUCTION TO PRACTICAL CHEMISTRY. INCLUDING
AKALTIilS. Riiih Ainorinsn.frniB Iboiitb >nd nrÎMil Liimlmi f-lîtlon. With noser-
aaillliuirBtlonf. In od<d*Mtd)., rojkl ISna.oIolh. fS 11.
KKKSB (WIl.irAU HA. Ml)..
A MANUAL OF MKDICALCHKMiSTKY. Forlli<> tI*;rof Slndoiits.
JXjir^i niion SovmnD'p Jleilicnl Cbrmlatrj. Jq qu* loynl l2oi4* roiam* of About 400
|iii£*t. iwilk illaitrdioni iShtfi'y )
J^KMSK\{1KA). MB.. Ph.D..
PKINCIPLKSOPTHR0riKTICALCHKMISrRY.wUhspMaIrorerer.ce
M lb« CanplilDltnn ofCbemtf»! CompoiiBiU. In on» b kudu mat injal lîm». ïoI. gf ov»r
iSlfagtt: olntb,*! 10. iJnit Itiutd.i
"amriLKn Ayn fittio.~
" OUTLINES OF ORGANIC CHKMISTRY. Trauslatc»! with Ad-
dltlont frnm Ihr Bii-blh Otrmin Ed. By Ina RkUsi*. M.I> . Pb.l>-, Prof, af Chfoi-
»ad?lifi)ciln WlirUiDiCollig*, Mum. In ont vulatBa.tajial llmo.orïftOpp,, cloth, $S.
G
10
Hbkrt C. Lea's rusLiOATiONa — (Chemittry),
fVa'NES {OEOROB). Ph.D.
•* A MANUAL OF KLEMENTART OHEMKSTRY; Thcoretk-jil «nd
Pnctlcal, ]t*it»d ■»<! corrMIril bj llii:iiir ffjiiTS, PA., F h.8.. *alh«r«r"A l»«lloB-
sTj (if Cb^niïitfj»^^ slcv WUh b a<iUif«d i>]btB, atid «d* buBilr*<l BDdMT«nt7-i*v*iitlla«
t/Atloni. A ■><« Aiiiaiiduo. rioiu tb' iwrHtb »vl «nitrgid Lob4»d Mlltlon. IMit«l by
HuiKiT BmiiaBt, H.D Is ont \t,if.r roTil lino. t<ilam«. »f «in' lOOS p«ch,
alolb, t3 !i ; l«âlb>[, ti U. iJtin HtaJ^ )
Two eat*rul nvlalona h^ Ur. Watu. tin» the ■ppvaraoca or lli* l*»t AntriooB «iDliiiB «t
'' PuHD»." hate taenUntil ih* «nrh ihnt in Emtluiij i(hw bMBdlTlded Intol'it toIub» In
rt|jrii]ling it. bjr tb« ttiip "f » viurt^l mtkI «in^AtttnglTclrftr Xyp*. cut for lb« imrpd*. ÏL bi* b^ra
fuui4cl poaalbU (oeoiDiirita Iha whul», «ïlhout oaituioD, ii> one volttmou i>ot WthAnd; fvttM^ij %^
T*Ier*ncf Tli«*o>iii|[>n»alof Ibivoik h» indu ml th« Amiritito BdlMt !•*«■>■« hb MdHMkt
t» Iba nnrrownl oi-mjidM, and he hii> ncDbtitknitly lnH(ttdunl;r tnebdiaooTulw aibatrb*** ■••
nminiird linre ihe irtj lei^inl appenniTice if th> wmk in Bnitlaiid, and baa added Iha ilaaiUrdi
in fiupular ui* t» Ella l)scUiul nnil CaaL^grade >;>l<ui« auplnyad in Iba orifival
Amonff the nddtiLont to thU tdilion will be fcn»'^ a vary handsome «olond |<Jata, rapraaanlliif
a numbar of iptolra in lb* aparCraraop*. Sratr eanhu batn takan in lb* l)rpo|inpbl<al •!<««
tian lo (riidor Iha Toluiaa irorib; in anr; rei|>ect ol iu hlii'i repulallon and aiundad «a. and
tbcDKli it bni baa» enlatgad \>j mar* than on* busdiad and itKj pajtet. Éti nrj mwdarala prie*
will 'till laalolain it aa on* ottha ebaapaal (oIhib** aooeaaibl* la lb* (ih*n>i«al «lii4*»t.
i>a* a<}nTini*nt Ti^Jamf- Id il< uTJ^p«[ «JUlun* il
waa f"11ir up 14 tlie [al^l a'l vaur^rupaLi aaJ llia*-
riaauf llijit ODia, III lln iiraHuE Wiin, ll }>(«Miii*,
La araiDhrbtMr convpUni •ml *Ai\itf%ci\nj m«D-
a«r,lbrpr1a«lpEAMiii4l ItaJ^Q^f^firtof itirfliribl"lrj
lit it^-iinf CitqMTDibc ill* uiniiaBr la wtiffb ibe
nartau* Éq>»]*<u af* tf^tvii, luncb diu^rva* la b*
■àll.aDd iiibxtlj, rr»i>. la pr alia of lilt» bouk. A r*-
Tla» ^r mich ■ ivork a> />«tfH»w'« <^irmitr^ frUhtfl
Ilia tlmhlf "f A lii;^lr.ai>1iEti fur « in^Uf*! *rm\\j l4
aluplr<iv*urili0 qiiMiioa.— 'Clixtaitirl La^nl an4
Ollnle, D'C. 14, IB.*.
Whta ar# atala Ihaf. la ont apia\^ti,Hif pf«i«al
adtUev tutlaiaB la tatrr rvspvol Iha hl^l' rapalall^iu
vhlab lia prwlaca**oTb naaa «qiil'i»!! aitil aidji'j'vd,
«4 «kpi-fiMi Ihtraiallii oat It IE b«llar la 11* hnlrla-lc
ralu* B« a Icai'buuk *iitl w^rk al Fvlaraara.— Jhi.
Jiiutn.li/ fharm., Au|. UIl.
Tha cooafltbilT'at paia wl>irh hu baan liaaiovad
QpiiD Uh7 (Im AlDPflcatiaDii Enj^Llah aillfan raa^ara
ll f 11 11. pea bap*. Ill* l>*at book for IhaaludnnlApiiEh*
prajallliupBr vTiHj wodlj kaaji allTf, ilin br<Lnl*ukiu»
whal Airialdabla majriLiiiiie vlth 11a nbr« Ibaa a
Etmii-aail paft*. bulwlili la» it>a ini>D« 'iir tapra-
aaBlallaaarrktbUliya»!! eovliaauMjtlviit. Tka
17|ia>f aniati but *«ry«1*ar. aaatba ^filoaaara tary
luiidlf nmnfid lofHIIluia Htdj aad ralaaaaaa,—
Tha s ,11k !• iooHj.11 k nova In AnrTlraa ai aetata
Ituaa.i *iif -iianilpO o<-il<e : ladx ii i.i •>; il-i)
IlLaraTl'lnn fcjribt ËDtiL-li*dkl<ir banl^a^afAlrafalEf
don*, and <b>i Prufiunt Bndjaa k« a44*d una*
r<a>H led •aluabla niMlar. aafaalalljr la Ika la^r-
(■BEI (liaiDiHtr, Tba bank baa al*ara a»<i a k
vorlia la iblt rvnairr. aad la laa a*v akape blii
laitio riUiD ill Ha brial* sruilM.— 4aaMa Jtmr.
i>/<rk(.iHrv, ,iBi la'A
ti wilt bt'nLirar^BDDfjflaaar^rar uato Kakaaaf
lamariiarrlaMP) |M|br ^'•airat ckararlarut r>i«aaa'
UaBDal Y*fr afar ivtaKf jo^rt 11 baa b'Jd "U la*^
miiil plaM «1 I lail-bu.t. «nd iha al.bArtU aU
lbon>iij;b ratiatuan HliE£f> Lara kata «ada fruB like
lolluEalaaralilileebauia r«T aaj itlilB avaka ilaai t*
■ lap btfiiie 11.— Oaai'M-ia i>4ar«t- /aar,, Aa« IHt.
Aa a Baaiial sf ek>niiair*i< I* arlikaat a aapailar
of hia alBdaat daja. Il baa.lailiail, tiMbad a auna- 1 la ika laafaaft.— ITA Jtad. /««r., Aac. U7t
A TTFIKLD (JOBS). Ph.D..
■*A- Pr»/ni'-r <•/ Prattlml riimUtrrlolht Pharnutmllfata<ictity f/ (trial Brilaln.ér.
CHEMISTRY, GENBllAL. MKDICAL, AND PHARMACEUTICA I.;
ortb* Sclenc«, »ni) fhtir Af>p]l<^J1Uo1lto MMiciD< adiI Phitriauja Kifhili «ilfli^nrMtiu^
hj tbt «uthor. Id "hc hAncliomp rojal lïao. volsm* of TOO }i«g<«H «lib illaMnUoH.
t'aii*j siHE^* Tb* iTHABi ««IUqd oaaiatH tme\
otkAmLftJ priarlplvt. «ad Là* iftlHi *ltpllB*Urt> «f
cb*iBLi'.f7 In pïiraiHj, Il It «emc*!^ »f»^fy
for qa EA u}' IhM It «kBlbLu «b*MlMrf Ife ||* |»r*»
i#ni *Jrftfl««4 HM4.— (»it«4«n*ti JMIcaJ Stwt,
a/tw t'Hti<-it uf li, iLlLJr rtiikftLan fur Uk |u *tr. *i'
dKpL thftl *-* 'IfilMlt (bli «llbEh ■dlElaS Erh h* ta
Iudf*|i4iak»1ir« Eh.1 m à* itin »«f<mh 4r<r1 prvifinu*
«dillotiB ^KTa btau, WMla Ibu jftufral ^Un And
■iiiffl fJ]" former BjitjHkb TJio itr«ft«i]i JlUori fruiu
la tboui rph r"«*< <^f i^*«riii i»iir<<h A^dnfl lo iba
«pjiabJlv —Àfi J"^r. 'if t'h-irmttfji, MaJ, li7V.
TÏIA po|i4lkr11r vbieh tlil4 vorh bà* «vjir^td I*
oalj b4 ni*oLl4>D«>1 by u* litap. «iiIiikDl foribaF ' ArAtUjirltbaDl %rïdflDjr«r»>p*iélt4ia>lt4<«UA
«OBiDaDEa Tb* ifr*t#vl t^lrli^o v^^gu^fti auf-h ■! I to lb*i i*Ait*r, Ùt. ÀttÛrJà wt\t9t tut atmêt*l^ A»4
Urulvflt «Dd 44diEloDa » j*«iin«i1 n*e**ti.ij foi prlmirllf f^r nadit«3 •lu-r^aTB; h* «Ivs^ ha*«m
lb« d* man* In t It'll of (^* IaTA'I ii»TArnpin*DU ol iyvio l'as pbftrmfc»f«la «nd Iti ufliribBi pr«T>an>
*bt«)le*l pr^DFJpU*, Hfld 1b« JihE**E ■i>plkBllua> of Uont: «mt h* UranliiiiiHlLy pulUaf il<*- taiittr la
cfa#m1rirj' ta phhcainr Tb* aaTbnr hm b**ro«Pii Ehfi ii-x' «oibiil li r««p*d4j* lo ih* tta«*Ouu wlib
■rdnai* Utiof .ta Ib^ r*v1itiïQ^ aod tit* ti'anl of «rh1«h tkcb HrlliX 1> pr^tE^ad-. Tbat lb* »l*|4»|
tbAlarurtUitriuii Lb m lalfi^daptd in ty ^* *4ilmmd , l^troi vitaiiy. ft»d nm lîvtf* T*ftt«b «td tt*t bu
from lb* fki^E tbti tb« lq4»c ('«^DlkLaa Ibna baa
dt*4 b«Vf«f«HDH' rilAllDf |4P «diJlIl4B4l n»Bt«f'
l»L— />rndi0f«rt- Oirirttiar dutf Clftflniodl Oman*.
lUr. i£?ft
Ttlt Tftrj p4paUr ^«4 noHlorlov* «orb fati
BOV r«uTiAi1 111 fll|blb «dillva, wblcb f^rt tpttit
jn 144 bIffLatt Url»<lBO«ttm<t^Ak^\nn M Ut «icT
^«o<«. iibft«aowb*«OB«^^«V'\Bi^Vik\ ^«iv-Vui>\' ^ii^AHVa.
Wt DuUHd anlyfcboal iv.» T«ftrt*ad k bilf m^
l\* pdMlmlLna of ib< H*##-tlaf *i|]1lfib. *»4 r»
ii>«T%p^ npoi lb* *lr*prl««ftïlr valOftblacb«n«**
F>r Ihv work, Tb> vart povticlnd^i lb« vkitla «f
ihf Bb^inUtty itt tb* pb«riwU4tiTU «f lb* Tk^uiil
■^E«l*«, Orrvl Briula, ud Udl*.^jr»M ~
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ptOXASt IC.L.].
CHEMISTRY, INOROAMC AND ORGANIC. Pronj ihe Seconil Loo-
•loa KillUoa. In oii*vir7b*n'l>nin>«?ti>i'<>*i>1uinc. nf TOO p>|M, «lib kboot >00 illnii-
Inllan*. Ololb, t( OS; l*(thrr. M <'0. tlMily tttatd.)
Wi bmnla Ihla *urk ■ lumpIsIdDil ii><i>i*Hrl-1 [I «hdIiI Im iHOmtt lot a prullMl cbtralal and
iHrkM 10 AuJ aa; ni4<(ilal ftall «lib Ibli bi«i ad-
tnlialfl* trxll» Thraulhut liU(»M Mdnval ft
and Lia> di.111 •■' vtlti'iii p*Dntaf lb» lutttti [vn-
S(4l>toA tan cAiamvaly LDiliiiit ■■L' * tFt4( ph'l of till
1*1)1 lAlt'ttioh f«f Ibt cite of af Dni>lB,itDj c«ii hfftrl-
\\f r*4-3iiiinaBit Jl aaagch — Auafon JVftJ-uaif Slàrff.
/uur<i .U*r H. It>*.
TUiabortlalhtmEe^fAworV wltlnH w«fti mnal
IB.M*< ba-.m» 1m.lh..llp;.-«i..t,U.«»B,l J , ,;r„.l,l. pt..»«. aid .ll«...,f.
of lt>*l>«l«a(> at II SKW «lauila W* harr apolIiD ""■-—"
«nil* «ack •■ •'lniliiiMr»(ap'<-'< ><• >'"' *auia D(
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in*DU of t*rarïkllaa*n who «Ub la r#«|««lhvlt
rlB* ikQ «ay [tvlnl rtTaitur mil- 1q * «rord. It 1* «
b«4h Ifrhnr^tAd by All ifbn vUb to hanv «h»! 1*
lh«4b«iilttry 4f III* prai*Bl>J«7.— JmrH'viH ^iie
Ul^lttd Ti^riB <>; vi^trvuUolP v^ieb kT««tlrni;bB*r* I
*ipf«vtdiBT«i7>J4vrip4FAfrtpb4 ÛB« 1* tnivnt>d
yM. ^«r rMdlDf l«, h« 'h1> Ust ittllc. If ^ay mora
«b^iilil biT« bB«o«4ldr 4L(4p<bi«, kk«htI<J«aiyu4
AN ELEMKNTARY TRKATJSEON PRACTrCA L CHKMISTKV
AHE> Ql^ALlTATIVB INOROaNIC ANALY:^1Si Sp^Ulty bliptad Tot O» Ld tb»
LkHoratcjri'* of i^RhoMn in't rol|«if«'f ■n't by B^iïiciDtr'i Fmn <bt S«fiand axifl lUvti^d
Engllth B<lltîûn. wïfh nhfiut nrijr ilImtrjLtlbci» on «uud^ In on* i^tj bADdtom« roynl
ft I* *b«rl^«aa«1*«. «ad «mlataily pn^iitfal. W« «f* to «InpU- «od t«I aonf I«*. «* to b« lftl*r««iUc
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flULly to <hb>« «lin nf* iiliUftd L« itl*p<aA* vllb ■ tbanrtit»! 4*dat(li-n*, d'4-llB| vh-tlïy wMb llifl,
ÏmallH^ Diafi*'. «Ii1«b ll l« ttiOAiJaxf lUU t^tapf*-!
0a>U« EMt Iki'iH Id Impirl. Tin ««aftcy <}f Ilia|
(h-t ttiHiy Ethr4 kCL Ik^tD wi>rli*»1 ihwrk^ti by ib^i
aaihur and tlja nLOikbtr» 4f litt «Ikm. from 1h< i
prlnEad t*il- W" f*n iinatilly i^dniD m» n i1 ihvwnrk
(n tl)*>iqilAni •^i cli^ro^itry at brUf k f^JUMc ««d
BOiBprvbaailTa usa — i>rwtftf Ula' 44fv<Tf inr, 0<i.
la, itrtïa
■ y ilvl'
iDftMif r Of f our***
raM', but a f^ytA dair** tt tMh bici
ilnL kavvloilia t\u b^ «LLAlDpd vuii ilo oiii^r
QDilar coDtidtrHliuq.— âr Loui* Clin. Rt^frd.O^n.
I M J.
Tb« «arhli»irrlLt«BaDd MraPfad ihtllt aanba
■o<no»haDd*dbylb4 «Eqdvni vltb^ol * Uatbtr. and
Iba aaHrlpDabK Afld dlnclloa* forthii tarlauji ira/tt
K51FP'9 TlrBN0L0'}T;4r0baQi1-tr7App11ad to i r<ry buDdmmn Offl»Ta folOUH, V|lh WO tr04d
lb» Aria, K-nA if Mmrjfi^lDT*« Vuh Am<f^»al abcraotAft^fJoEL. tflOU,
4>ld]ilt<[i* \'y ^ruf. WA.vTik B- J(ihi>»«iii. Id two|
pARRlffH f/SPWARD).
I,nlt Frnfttrrr u/ViiIft-l» JfidlM ttlKi PhUadtlpliia CJItgi a/ Pltamuiag
A TREATISE ON PHARMACY. PeHigne.l as » Texl-Book f«r ihc
Sla4«nl. and u ■ Hold* Tor Iht Phfiltrlin kod PhknD>i>*all>t. Wtib muiy FarmOlK au <
Pmcriplluni. Pouitb KdilJon. lliAraa||hlj rttii>"d. hj Thoiii« 9. Witatyo. In en*
haD<UoBi*oeUto<OlDma(i(WI{»K<ii^*itbl80lliB>lr*tiuni;«lullt. titO; laatbat, tS 40.
il^tds luatd.i
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ruDialiialo lrt-4]d rLaT rha «dilur baaACfiamiilUbvd uhltlladu of fp*dic4l prBelilluaara vhp arr '>hUf«4
hia wmtII ao «til aaln nuilnlalii, Lu Ihla Foortb tH- I«ntnpnftb4 Ibair ovu mtdlrlBna- IritTll *T«r b i-td
tlDfl lb* blfli ttkBd^ril 4f «iffillviiet vlilFblltaJ an bnpcirad ptaca na uorovD bH>f.ic'baIi*a,-^l>wAfla
attalDtdlopmrloUNadlLluiiaL Dqd'rLbvadlIDralitptif JTiuf rrMfniiiT Cffrftitar. JLDf It.llCI^
pll.b.«»llll«lll ld«hlabi.f.aBi .ii..,.ddt1>»ll..ii<l "• "V'"—i -i>T"r'»l»B «f • fo™..«lUlM IB
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meilnriha ...rF.I fan. Jf lli" —rï. ai.d Ihr. aJdl- '■> ■l«"'"f'">n Ibal ovinlni. 1« '•«•'■"■- "-"h- P"-
llta of «.ne), saw laatlai. Wllh Ib. m»die<..10Ba a.nl.dH|..a. lhr|.Jal«f*ll"a«l wiarb b»af.Il(i,U.O
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prul»l*ii*r »l niadl4<i.td.air.>iia(.f lamllUtlili» P'a«'«-r*MVC *-* niHl«i.rff y™r»,JBO.. .(
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blnialf wllb tbaiili«rinii<«iD(lf^l pr«|iu»llvD a' lEi^
ftm«lM vblfili b* |br#*<r1bf» f«TbUp4tI*uta. — <'*lil'|
«a^o Mfi Jatim ,Ju1y, IKTl,
TbB «nrlil<«iAlii*nfly pr^rTiciiJ, and hi' ibvr^r*
iDBtlt »rb4iii||f**dk1<l'«oit lQ[*Tr4rlov. ivMlf Upr^-
Parbap" oa'. If aottha moti IrnpttrfaqE bni>b npua
phftriDB^y v-h1«b h4* BMiaarBd Ln lb* InAUnh Ibo^
lam^a bk* «inADB^fl tvtm \hp ir^iVB^tfi dllf pr4*L
"("«itiah • l*biLrinB«y"1" a wd^kaavd vark-ta ih Fa
•Id" Af ih* VB>r aiiPlib#f«r[abi'ir- fii rhul > really
t*r**t BBlrlcHy •cl'QiiBrïhBrseE'T Tb* «Etal* wE4b axTn] vittk nfr^r bi^t-tui** m^r^l^ 1'^i^> lu !(■ fBina^
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ll«b«r IlHtl1r-riiffy«^iu*ldBBt>ribBl4b«raTliy viilrh p"*ibar»iiD* H^il^u "f "P»ffl«h" H#i h**o •B'fî 10
biBb**h hftiFTWffd nfff-n irBpriidanïtn irh*t» v* maa- ib<i i-nMif wlrb alT tKb niBliir* tiparltiit* t^f lii bii-
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ULuBlrtti-fo*. Iii<«Belii*loD, «• baarllyracvnaitAd bLogd-— J^uvl^ J'\4m./oiirHaf>Ool^ IT, IIT4.
]2 Hexrt C. LxA'e PKBUOi,itO!sa~~iji(ah Mad. awl XVkrrapeuftM).
pAHqviiAnaos (RonuRT). M.n..
A «Ulim TorUERAI'HUTICS AND MATERIA MRDICA. .««•
alHcit «ad h^udy bout ia t*»» (Iihb Itr- jura m*v 4
iT*rtftl«l^ b« UVaii t> 40 tiinl fBO^tn of lit a>#rjl
I19M III fUA'^fll^tl 4Fr«tt<'Ui0Ul. tiki] Tta KfW-
ll<ii>, Abk], 41 tlf« »i±iUB llTnp f Kill f lprai]**i df Lfa* I
Ttt* **iHjr 4p[i*«r4dA« «F ft «tcnftj *JU|*b 9t Hr. ,
rftrilvbANni)'- Vdrli bHkPB «hOfi*ftt ttMLngsv (a
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plt4 |4 ■qE^ ftfe 111 til lot Iti* e^«r«ti*r ftb'l mUou qf
drug* lo ihn nvfk had m^iij vhlï» f1tf*rDf** Tftfn
4H9 v1|b irhMk li«iL fcdiLar ft«J a^J (4f b^vadoaa ^
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felt J ^h*t«V"^"<''J >clE4Jh af riiirjvill'4 fe* 4f* fffttoo '
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«tipltf» 04tfa kAirBlpH«lB<r«d**ad. «tobrt^rltf tbft
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U4 «BUâdftft* It lb* iBDia proAlii*ai p4<aiiBft, «a4
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liai «fed fht tuJuia*,— £>r«pp(i«M' Vtrt^lmr 0m4
>t t>fe pUa^ar* <A IbUt tbM 1^ t«pMllr ««lb
vMfih m M4fsd *i)Ul4B la d*Aftfed*4 mtty t« labaa
&■«« Uillf4l^tDl\iaLlbBafli»>ctf Apprt«la'l«« ufibo
Tkluauf rdltftbU In^unaAilLib rtcftHiuc lb* fl>* v/
rpm*4L«l' DQluQrirat; -ir^rwtir^iibW 1h ià4 fvlttv^
l^-a vriP4ibolnfi'4li(itJL?>^rhar«4)«ntilr4/tM ^fi^
a*Dt 4fey- tJirh W(^ fvilMalj' iMtfiltlba »fifaaal|
bM*4qalfiktjra<ai«tai,— >"«« JUK«dJH. July, 'tt.
TaEHArEUTICSAXDMATElUA MKDICA; ttSyeUmaticTreulîie
on itao Ac<lua frud Viot of Mt^i^inal Ajt^ntt. ÉDolu4tnc lh«lf Dtaohpli^^ii «ad Bl«l«n.
Pvutib edUli>n>rvTl«e4aD4 enlftfgpd. tn LvoTiffr* «ad hasdi«ai«9fO>T0U, of hbwtSM
piig«, CÎDth.tlO; JatlhrF.III. (Uutig /u*n^.)
It 1* nonrlt^flir*" ''i" ï'^^f'' W"*"* <(<An to Ail- of llkn iii«f^tiUJUhn,* wbolfCJcltMpJU vf lb*»-
ï<jufe<« ill" iip|>*>iBnir< -if tlio f^ïLiflTt PilTh.in 4]r l^l^ p^ulFot — <Ollr-r^i* Xv^tj^^if /«wrmtf/. I'ob IliTy
irf.11 Hii^nû -rtd 'l-^-ït^nt ir*>rli-^JIr(f r,«J J>,r, Tb«iapldaïli4a>»Ofeoflbi*tt4L|lo«*«id tbt baI-
ir*<e rftir /f-ic™,Ocl esta, Tar-mirat*-i»Uli«b..blba i»^»k fi"b-**r»«lt»l
Furatlvhai1*Éit»feC<>apJ«E« varkOBlb^raptollua' >15 Ll)« iJipd>f4l prj>fHvtoB. ar* tqAiUoi pr»f »11l*
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Lbn jrruf»>-]"ii uriklpT r^ni^wpht nbllthLlun-, 1'^ [b* tlilvral ftft4 «rtT
ovrcful ■■'■■ti-'i- tuiiiurrHi]iHi|dtI1mi>, Hb:] tjmiilf r* Hdn of Daitlbjlaii-, *'■
IftuLuK a vwk u^E «KitcEly mi^'pL^rnpnlM tj «op
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Ttif mv^1ifebl<4l «iwUiiii iijtukliiouifljr Jii»ii'at tli4
i-kbi^wd tklll irid |oi>d i*4TP nf iliv pob1l«b«r^—
4M. 6«aJ4 X^f aitiljrur^ /ofertuJ. U«c IkT4,
Ffoia Ebo ptiblLrailanof 1li* A'«L«JiUan *'SiLU^'a
Tk4tft]ii«uilet' ' bai Invtu 'JD^ of ilio I'Eiwaif*; i(* aL^
vb^ch P'AfiliJ hit 011^^1 t*f nc> >»4hfr ir^rk 1«i ibf t«d-
rltt of a» tL, loihlo'
pi>Ol4>. E4l44fDlBDID. ftpf »tb«r I«Bf4l««> *-^*>-
y^rupii o/Himrma^,fj^ I4?A.
Wt <«D )imnlJpa4miMbal li baa b rlv*i IB Ub
UlIlUïlBda of Itt «ii4U<»Bt iDil th* fB]b<*« f>f t1* H-
«44fcli 1a|jieltb1<4.| Maiotfiaa, a4iI ■*• mojiL ^a^i^iB K
B l>L4n la tb4pbr*10UB> ll^arj . b^jE. àBl'tJ.a*
fqtkf t«pl«**«llUBlbi pr*4^tl*iB]a »rhbi>v]*4^lB
pltJirra4»i1XDam:<*.bal4«bf fartkf nn*l «ooipiaBa
ir^t1<4 qiHoa iV f nn^nl ftbd pfitfitral «là* dJ ib*
ifdHf, Aodlla pr«asucv«4ppliai.lc>il>4lH<i f^ituuav. tinntti^b-^SoMon Maat «n^, nrg^VvvrBdli Jl4*.|ia
IHIFFITH iHOIiEHT R), M.D.
AUXIVERSAL FOKMITLAUY,0ontaimngthe M€thf>clfl of Prejttr-
Kagand AdmvniffUrioROfflclnBlBud oth^r UtUiclDe*. Tbo «halondBpUdto PbTBlciBrBBOd
PbArma^tEiIiaLi. Third BdUïon.lboroniïhlj- rtviied, vÉlh Qqiii«rottt4ddlll4«B,b) il>ll« îi.
M^Ei^n, Prof«uDrorUBl*riiM«<lirininLlLe FhJ]jid#JpbUOollvc*orPhBrDBr*. Ia««MlAm
BfidhBnJiomaocUTotuldniiBDf uliuuL ^DOpp,, rL, f 4 30; l*«tb*r. %h ïO. {L*t*tf /«no/)
Td ih* rtrUKilit a ipjod f.nnDUitry l> Blmpty IndU-
p«D»bl#< BUd iJBfbfep»"-' tiffnnuif Ilh* Wub iB-ira
«I-VUalfClir \ja-t4 IkàU iFkA «vJt-kUEiWii Vffk bflMTB
(UEb. T1>U U t'o» f4pp-vliil])r lit ihmt^atttij phytu
DlBQ. »Ad a «^rk «rLiLcli BbaU ««vb bint (ha uibboi
A TD«ra «4iBp1*U r^riaoUtJiBkii U t* Ib U> rr**~
■at (-nm lb* pliafBi«DL*t a«^lir*^ctaB ro«14 katdlj
d#tf<« To th* Vpt« A4«H BBib m*itk It Ia41»p*i<*'
l>]«,BDd II tabfcrJ^y laa4Ba#«B|]Bt |4 |ka pr*clhLj»«r
vbt> c-'jbp'-uiLilii hlBQiVB |n*4^«i.ta Mfefb^lvkAt
U toal&4u<^ii ill 1li4 Ulri>4B«ll*B -B^bl i* b* «+■•
bf <4hj4h EE'a'rEnlnLM;tT^>r ÇL.mtilao 1if« iHUi*<]i«i la j mkllfd I1 uiPriiur^ by otarf atadfil of b«lj<lBB.
til* uiii«[ «EllrBflunB Bud ptahABtLi mBbBBFt ttUl nl- Xtm h^lB Il> phx<l<^Unji U will b* fou fed luaalBLkti^
Wty» Jtold III pliiCB apoDÏt^Buboir A furmuUij '>f bb4 douMt*** «LJ| mab* lli «ap tftlu ab»ilw Ml
Jbl4 klQd U uf bBUtAl «l4U U iVa till bb|i|DLaii Id , tlt^mdj tuppllad vUb h ■UB4ar4 v«rb O'lA* bla4-
Jiir4BUpiiUile*.>-CU4]iik>4aL(':CUlc,VB'^i l\.\r4V.— tb4 4wrtfaBfyiBc<fltofur,t«aliTilKJjilp/1i.
Hx:(»T C. Lba'8 PUIIU04T10MS— (J/a'- ^««^ ond Ï7i«r«7wi(/ic«). IS
OTIU.K {ALFRKO). M.O.. LL.n..Mdl IfA/SCH (JOIIK U,). rh.H.. ^
THB NATIONAL IHSI'KNSATORV : Coiitnmirnr th<* Nntiir»! HUtory,
Chrniintrir. Pbirnkej. Ai<tloui lad Orcj of Mtdlcln», Incladinc lbai« r*o<>itnlui| In
the 1*bAroiBnoptfi&» of tb* Utii1<d £il>i1*t. Ortat ItrilAJn. and Qtttntnj, with ncintr-
(01 r*I<-r*ni<r> lo th*?r*>>vb Ci>d*i. frcond ■Jlllcn. lli'irua^tily trviit4, with nammot
nddliluni In da* T<ry hanlinnit aeUro TOlama or I<t9] pMM.oilb îtl lIlutliatioiiF.
iUlt* «Mb, I» TA I l«iiih»r, raiwd band», f M. (fTmc lUulf )
Pmirtra lo lai Giro^n Knnio?t.
Thr diniad whinh linii sihaDtttd to ■ f*v mniilbi nn nnnrunllt Img* «dlihn Cif <lit Xnlinn»!
Ptipfnvatorj 1i di>iihl5 ;;riitir^m|f to lb* nuihor*. a> »1}(tHinjr thai 1^*7 v«f« Oftrr^nl iti Ib^uhtog
Ihal lb* vinl nfnusb a work wu fill bi (b* iDadlciil nod ihnrniiictutlctt ptnfei>l'ini «n't thil
thttr rllaru to iniiply th«t vaut hnrt h*«n ««fplnbT*. Thia npptrnialinn (f Ihrit labor* bai
■limulitid thfin in th* r*tiM«ii lo («ndtr lb» volun» Bfirt Ktirlby of lb* iirf (aarksd faror
■illi «blab It b» lisrn rrcftrtd. Tb> llrrl «dllinn 't nwnili nT'Urb irtxiltod* aiu>l TiMcfacily
b<t ni^rf <ir Ir^t Lipp«rff0t : ■■nd Ihoufh l»ut titCo ibat rr nnir iind iiufiarrant bai b#rB brutj;(bt
tn I'lilit in Ills i>biiit inUrvsl )<n«E Ita piibtkvallrin. yet th* («nxtb or lima darins vbleh It w»
fiaiilnx lhr«uKb <br prm rvndrtfd th* t*rli«r par11<'n> nnr» in artwrt tbiui th» la ar- Tb*
Oppotlunl'j Tot a It I ■•■'>« hu >n*t>tBd lb» aulhora to aorulinb* iba «urk •■ • wbsU. noil lo
Intreduse altomlloiu and addlli»n( «hfi*Tc lb«r* hat (ermid to bt nvi'ail'in ter ImoiKvr-
mant or ^rtattr «Anip1fton«*ji Tht prinnipKl i-liLiiijt*" 'o 1>* nolad ^n Ibi int'odiiiiriitn '>f •Axe-
rai dtuKt uuUsi H|iiiraM biirilatti. and ul ■ laig* auu^x </t <1>U|>, cBtmlFiit. and phaiua-
niitfrnl prrftrntl'hTit c1ii<iii^*d at nlttrd drvj^ ami prrparallon' urdrr tJir h'adîni; r-f tnoro
Impoilnnl »r l>*tl>r known arikl»: [htoadJItiina enmi>tl» In p'lil nnrtjr rhe iiiilrr (Jtrman
Pharmnu-'i-viA iind namtrnut ail(«1ra from ih« Fnneb roilri ATI ntw lni*tii(»tj .on whith
onmt lo lb« qnlhorv' iii>lio# up lo tha tltn* of |mb]lc'tl-o(i bnfa ractivvil du« fl^f>li\ltff■tion'
TUa M-laaunilovtraltanr bui undergone ac'riotpgndlnfc rhuFtiugb revision. A nviubor havB
boan addad^ aod Bfill mot* bar « haan aohplilulod fnrtuDbutwtr* dpain*d Ivu aAlUfarUiT^.
Tb< nt9« maitar citil^rafrd Laihriait ^jKiaal to noarljoiia hindrvd paffti nribt Irai ail I Lion.
ConiiiIrruMc >• at* thaa* ithiini-'* aa a irhnta, t.hajr Sara haan atoomiBodaMd hj an Tnlarxaniaol
of tba l">f willictiM iiidTftn»!»^' uniloly tb« litc til iba *uliiiiia.
Whilo UQiimroai addUiona hava baen Dia>^a to Lba trctiona which Tblota to tba )jh}rlor'>|>lo4l
a^TlIfin of mrdtoiDa^ and tbair ua* In lb« traflimanl oT dlata**, jrr^al cnra haa haan luhm to
muha thain lU i-uni-iac ai wu ]ioarlt1* «llhoni naittiaf Ihoiu imumplMr ur obtour* The
dotal liatf haan alpr->p^#d in ih* tarma both uf Irtp/ wai^fht and of Iba DitlriflaJ jiTalean, f-ir lb«
liUipiiMD i>( Diak'iig ibuta whi auipln; tba I>lap«ni>tarr Umlllni w.tb Ihe laltat. aaJ |«ii<ig iba
wa; I'H it! Iiilrodaotion iatii ^xnacal uat.
Tba Tbarajiaulioul ludaji hai bran aMandad ij about 12S0 oaw r*fa(«nou. mi king iba toMI
QDmbar in the prrient edilLon 'kb'nt AOOD.
Tba jrllalaa thara ■nuin-raTad ■■ rainadlaa for [larlifuTar diaaavat ara not imlj choav wfilrh,
la tha avibori' opinion, art i^urallve» or aaan benaOtînl, bal tboaa airo lablcb hnva ui any t)(Qa
barn Binplr:)ract on th* (round nf juipnlar haliaf or profauiooal anlhmilj. It la oftan u! m
muoh uoniaquenc* lo b> *«a)n*lDttd vlth Iba worlblwaum i-f larrain madlcliira or wiih th*
nacrow IlinlM of ibair pbwer. u lo know Iba wall attattad ciituat uf olbtra *nd tin- ooriilitiina
nndar wiudh thaj afa ditplnjad- An additional Talna (t-^aa* aad hv auah Ha ljid«-i i*, ibiit it
i>Onlalna tha alamanta tf a natural claatiftoiiion of niadii'iDaa. f»>uiided upon an analjatt u£ tbo
rwuJti of aa^wrtanna, whinh ia tba onlj aafa jfuida in Iha IraJitmanI of divraaa- .
Tbla avM'Kïa at aqrcnaa, aajdarq paraUalad. i liriaud to L*l Eb* >rraaa |r«v oad*r Ibalr faat, birt la
abuwa aLfiAiiT hi>w wall iiit aqtb^n bavo ttaitba ktap tha w^rk ap lo Lba iiraa,— ^rv Jfaauaii'ta, Hot.
axtaEibf arfda "t ibd ptiariuatauueal abd uaJtral , lin.
<ri}fau;onpi. rJrdiirriuai u U laaat ba la l>iaHi, Ibay J _ . ^ , . . , .,
a.a amht.rad tba nniwriunii» oï.rad tut athor- Tbi- t«a«.« •"Tkhvi^nnf Iba »H-t .1 rltar» fra
eiuh Ta»M"» of tba w(i..la wnrt •imial U am- ' "latiKa m.-lin a ^jBarW Tl.r .i.il>..r< li.t„ tro-
bltMwublDli.llIDalolalil haa»bttBoBllliadlDld'"*"-'>""bl'h fci a«ur«y .»! r.m,vr-h~u.\...
th* f...m-r nLl1il„n. »od all Ibal H. c.-<r[j xvV""^ "'*'■ '""""Ta»-! >'<:tn} -ill. "o lb- .iil.J^I 1 h.ta
otMSalaal IHirtrUDXa durta* Iha .l,n.->Ml. «.L la noi™. In th* Knsll.h lai.»iii«. ah rh ™ot.ln..n
Ubor.ll.io. aod Iha.liull lalaia.l>l>|.wl .lor* th* ™""b "luabla Infriniit Ico f... iba -arloiia irUi-lfa of
pra«<-n. i>i.hll.^iu.u». *n.r ti.»lo» .«». «.i-lBllr iba malar!» loadl™ Tb. .ur« b.. «.i lUa aijihor.
■ IrroD.n H.a...lpin.» w- t.iii-i iJidIi I1..I .h.anlb-r. ""• ""«l»"!""- -inilï. I'O' ib-J hwa *-<«-lrf In
baa. l.l.o..d f.liliMlj. A,,.l will. .i.»pa«. Id ri,»la- ^'■''li'; n» • .ll.p.n.nmrv -blrb 1. nM nnl^ .-«.-^r
panAliim ma-Hix th. t.,iOir.m.o!. at Iha day. ». a'""'! "' Iba aulliivr. -liu t.r«dli«d .l».-iy.»*yrsk
ihiab ,,„„« .^My ,„to' I. 1,..., «f I». 1.'..' In- ""*'=' ^■»"-^- >"'■ laiW-
totmailuinun.-«ruli](a.arrlllloiir.iTiti)r..f natif» 1« 4 ,„ Miner, of Ibla (rati work, obIt ■ faw
onaoa.tK.1. Wllh fh.rioaar. ■«■"rl. M.tflf^ an* „„„-b, ,f,„, it, Bral. UHa. sa bf auri<n>a It la-
TbaniBilill»» ->■!>. /eur, «/ ''«'ir"....!,, Sua. IWi a„„„ ,h. hub «i.pr-euiKi.. i,f 11. .■!»• »g iba
111* «lib vraal plaaanfa Ibat va annOBOav 10 «dr pan itf phr* n aga and pharinar^tla. hf whffb a
raadara iba appiKraoaa af a aar«riiif adIlluD tt Iho lari^tillEli a hl« haaa aa «o-n aibaiialail. Tliu pra>
ifoilaaal Ulapaa-amr^. Tba lotal aihauniEoa ^fiba «•■( Ea odi utvraljr a r*(<^1aE bsE a FaiiHlL>a, wlib
llFal ««lllian la Iba «burl >para M «la luootb*. la a IrnpvaEanE ari^fUEika^ and jn^OEIIrarEiin*. t'intrlDa >><*
aullQUnl laallRi'iiir m iba aaLna |flaf*il nptu Iba pa^aa 'if ua*r EUaE -r. auij an iBilal Uar*a**if by
«ark li; Ibii pFi^fwalqb, ll appaara IbaE Ilia rapid ' l^l l#f*r*ii<i7a Tlia dr^aaa «ra «taEad lu Eidh Eïa
aaCa qMba (Irii MIUoi» m nil hntva ladiira>l bi-Eh tba i^rdLaarraad ina'rji tarioa, AM Eb>inH»r* EiikporiaaG
adlloft auJ Iba i-nbllahar tu inaka p<t(fhrai|"na f^r mataplal o^lha Eîtrmaa abd Traiirh ^barntdC-.p^alaa
a naiv «dUlnn IqiEEtPdIklaJf aflar Lha flrti ntit ba^a la amtpodlad il It tij fai mura liil-<t QaMnnaL vt aa1>
VanaA. f->r HP HillI a Earira am-aiEnI at nnw iiijiiipi r«r>.<l iliaq any oibtr h-'0)l ■>' lha kind Eq aor lab-
add p4 an J a ir-iLid daal uf Iba vravlotia l«vl tUtr-O Ruit^-- and |-|-<I4^ o.iuipraEianalia En naarj aaoaa.-'
and trnprurad, wtLlcb yrvm Lbal tbaaulbirradvnui i'aa^a Jfad- unJ Surff- JvVn , Ocl. I^TV.
e;
14
Henry C. Lba'b PtiBUCATiONfl — (Palholt>gtf, éû.).
nOKX!L(V.). Âffù TfÂSVIEH {L.\.
MANUAL OF I'ATHOLOOICAI. HISTOLOflY. Translaleil. witk
MslM BOil A'l<iltifln>. bjr K.O. 8n*iii*f>«iii, MD . P.illinlnçUI anil Optllmloik !'<*'|t*aa
lo PblUJi lloiplul, L»lDr*r ofl |{>rc*cliun noil Ojitmliv* Oplithnlnia Httgmij In III*.
of Prnn>.. and bjr IIdiki^ C. Sihks M I<.. neiuoDtldtu r «r PuholoRiekl lli*lul*CT I"
Ihf Univ. nf I'*. In nn« vrrjr liandinm» ootnin ("luint nt n't! TOO pa(*l. *'>b oitf
31<i illiwitatioDi Cloth. 41 i": lidlifr. |« M)_ |/uh SiaJ^.i
So mgcb bit( brrn rlnnr of latr jrar* in lb* •IncMntlon of piiliotni^ by niMni of Ik* aUra-
Mitp^, Aikfl tbiii lubjf^ci nownrrupiMHopr^ifiJDvnlft p'»iliun ap oDr i^rihfQif^tl important bt^Mba*
iif iBsilii'iil ivUnw. Ibal th* AioorlevD ■■(»rr><l(iB rniinii TaII lu i>*)rcjiur ■ttniiiUtiun aJIkl ft»-
HDl «'jrk, «tifoh, Ibrnngh it* own in*ri'« niil thifiaicb Ibi- wcli.liouwn ivputalion nf iU 4iMiB-
Suinbri] Huilitfri. <• r«garil>il In Buropa (• lh< lUmlniJ laxl-bnuk and ncirk of rf(*raa«* In lu
t|inrUoent Sueh lOTfitipttioat ami JifooTsrlt* ai have b«fn madrflD^a 11* appfrhfaii** aitl ba
InlrnilnMd bjr Ih* Icanatalnr, «ni lb* wnik in cnnliilanll} fxpint'd to *HUni« ia tliii «uanUJ Ik*
tarn» puiition «biah iiiia b»n m uplv*r»all| aceordtd to tiabiuad.
yTATSONlTflOMAS). M.D..^<.
LROTrRES ON THE PUINCIPLES AND PRACTICK OF
t'lirSir. DrllTtrcl ftt Kin)c'( Oollrg*. LodJvO A nao AiurilpaD, tiom Ihc Flflfc T<>
vLp^iI in^l^nlarifrl ï^ntflÏJih r4iliitn- KJII*'!^ with nirjitirtnn, «(ilI ivraral bundrvti illuplr*-
tir.ni.by UaiiRT lltnrtuunia. U.D., Ptutaaiui uf H}|{i*ii* in tb* Vninttlij vf Pata-
■Tl'kiiU. lalwotArR* kadhknd«i>iD«tT».r«Ia, Olotb.SV 0(i;laatbaT,|1104. (Laia^
Puilulinl.)
PKNWICfC (SAMUEL). M.D.,
THK STX:DENT*iS QrihE TO MKDICAl. PTAGNOSIS. From Lhe
Tbird Kariird un'i Knlarjixl Kntliih E^ltlloa Vfitb alKblr-fnnr lllailralUiM ok >aad.
In onviarr baniltoina laluma, rojal 13no.,«lolb. VI U> (-/iial /uiurf.)
/XRRKN [T. HKSRr\.M.D..
PATIIOLODY AXn MORBID ANATOMY. TliiH American.
tfa* Pnnrlh and Enlnritad and ItavlHd Rniliib F'lillnn. In nna «atf baadaaiii* «eU*0
Tnlnma ar XIS pB|;ai, «llh 131 llluilrniiDna: dgtb. fl It. (JnjI fUadg.)
i;:*
h*»* bn«iii>#cibwr#N.— ^ T. Vd /*»i»r, ^pd. lltp
pr*«>-4» itp ID ib«Min«'. a«r1 pi>]'iiUr ■« « ifir-book.
JJAVIStHATflAX S.).
p'^rtiat tdlTfoB. «arlt a*t niHirtf haa hvaa «44^ aa
ir«a n«<iai4«r7to«fftb'ata Ibti Ula* ra*aJla la rvlka-
T'Vlfal rnranta Ro daabi II «III cealiaia lo •■Jof
iht fa*<rr 1[ ba* r««t**J al ika li«tJ> vf ite f
•lue.— «ail mad A'ary, AipiTrir, FiV 1. )«;«-
Vor pitctkrai. of d^aa't d»ll j b*c- (bit I* aaiiaal^
>dW iha btal IrHtlH l&al i( nOwnl I* HVdatH «f
pALaalD^r aad a^rbld aaaiamy.^^YBrliahdft L*^
crt niul C((fi(<, Fab t, IK».
CLINICAL LECTITRKS ON VARIOUS IMPORTANT PI8EASRB;
balnK^^nil'iili"" "'' ih" Clintiial Lfciuraf daliiirid in lb* Molkal Ward* Dt Merc* Um-
pilal. ChlcaK" Bdltad bj Fam l(. OArii. M I>. KtdinrI rdllloa, «uJatgad. I» «Rt
haadiooie rojrai ISoio. voUmo, Clolb, SI 1i. (Laltlf luitrd.)
Clltt|sT1«(lS*» DlïrrSïlTilKT- Wllhïuploo.ad-
^litout, anil 31^ !■*;* wi^od tr>«ravkna> Hy K
■•I.iiriiio Oaifniii, U D, Obi lei. Sio., pp.
1«0«. elolk. (too,
OARPSKTSK'* PHIEI EMiT Of TRX ?81 OF
AU^OKOLIC Ll^POa* IV Hiai.TH A]r^p1r■A»■ )(««
•Aiiina.nlha Pnra» by 1> P.i^uiiiiii. M P ,tud
aitklïDBll^aaofaaiaBtLtairnrd-, ti^ «tnapaailSBo.
Tuiniiia. pp. IT*, «lolb, aUatnla.
«i.uursATi.tiDrPATanLoaiciLaitTni.onT
Traailaial. «Ilk S<-\— and J.4d1i><iii«. hj latmn
LbivT. m jj. In UD" «irluuiB, *arj iartf Impttlat
aaano, vilb HSO copptc^pULa I^at». plala aaJ
colored, •loth •4 6a
P*VÏ-« TIlllJlTlIt»: O.I TB» PÏISCTlUÎI OT Bl-
oej^noXr III l>1-.i"l>n aid ibair TiaatBaal.
Pfi'iu llta «acoutt [,jti.l'.a vilMIaD taxD* haad-
■oma T'tlama^ ■mall neuvo. «lalL. tS tO.
LI KOf^HSOM YELLOW riVXK «oaaidartdlaKa
IllilOflni. Palbnloilnl, Btlo)oi[l<al. aid Thara
quitta] IÛ1 alloua. lol»oUr|«aBd tiiadinma
•a(a*i>*«lan*aof a*»lTltn"ïP ,ttulb VI 1Q.
UULLAHII'S KKOI'TAL HOTEi A!ID BIPLIC-
rioa*. I tol ft»o . pp. ^00, alatb . %^ sn
SaXLOW'B MlKtliiL OP mi PXACTICI OF
■llniCi:!! Wtib JiddlUoaa b7 D r Oonni,
H D 1 T<il.a«D..pp WM.aloib a) M
T0[>ti'tCLti!tC11.l.R';TL'>UnaGUI-rAlIIUTm
ftiuaiw. It oga atai tala** lala»*, orno pp.,
•loi h *1 «ri
)rminw( iitTBf>i>rc-rios to th8 »Tm>y or
CI.IKICAlMSOlriM Balaya OaUaUlb* la-
•aatltalloB «r l>l«MaT. la *a> baadaana UtasL
IfUa,*, alolb, •■ II [toMp fuHad.l
sTitKBK- LtrrrttKi OS Fn-Bn Hii*t »;'•■■
WrM'ia •t-M*.VI v.. ti^iHaai Pb)r>*(l>a<aUa
Colli Ptrxi I'da.i' tloirliai. la »• acH taib
polowf. «l-"i, W" U~*t Itf^ I
THK CYCLOPSBU OF PBïCTIClL MSMMXIt:
f.ifipntlaflVaalia-' oaitaXamraaadTrvalaaal
of nlmva. Kadrla UodVa aad Tb-rt' ri.i,.. Ilia.
raaaa of Wnisae aid Cbll^ita. M- ' -••■
jaur*.*!^ K4 B/ llr*..UA>a, p..- 'i,
and roKoir.T. Tv It'll Una auf . ' ..la
voMvaa. flf 'ill d-abl* rolaiaaaj !■'*•.. .iriiala
a,ai baadaOBiilr lioaad <■ >faibu,(lt; HMb,Wl>
IIemht C. Lka's Publications — (Pradict of Mediciney.
15
tPLIST {A USTjy). M.D..
^ Pra/ttÉOr of Itkt PrliirlpUt a*4 Pntliet a/ UriUrttuIn attlfHHlftd.CtUigt.ir. T.
A TREATISE OX TUE PRIXCIPLES AND PllACTlOE OP
MEDICINE . d*ticn>d (or Ib* a» al Htudtnt* and Pruirliaotr* a( Hidlein*. Ftortk
•dilion. nvÎMil ■Di] >ntitrit*il. In an* l»rg>ond clowl; [itlBlnil uaUra *olutua of ahAut
lIDO pfi,^ eloib,|S00;orilragi8l7boaad InlaHbw, wltbrali*4 band*, IT tt. il^tttf
linu-t. I
Bjtammon eonMalof the Knit1i«li itii Amrrisim tocdiml prti.thii Kitk ha* l»*«KulsD*d
la ch« bi(EhMl |>o0itioD uh ir>iiiï>1''t«hi]J ruiuponiUnU) i«ir-!].jrjk un ilir u^it 4dv*oced cvmdl*
liunnf uadinal «sUne*. At (b« vi>r;r œoJiralT priée ■[ wbicb It U uStrcd le will b« found ont
of (ba ohtaprit rglnm** Hoir bcrois tbt prof»i))oii.
TBI! •ic<ll«ol liollx an uchIiciiii lut aiiiiutnl I nu a«a alliiftil atidlai tti Ik* lal«l eoslflba*
IbftI tii|(>]F«<J la KdicLauil bv (ttd «tjinliftltltfiaclftf** kn Eurt>pfl, Laf» r'4«Lifd <*rri^4; ftUf^DllOb bj ll»l
of SUTbamaa >VâUH>B yr* bKt* trt»rt*4 lo iu4ay
ar (lia oinal Ira routai rliir>IT'*i aort Quil I)i* toi
talbaUtft^fiiiaknivIVitaïuFib* (xr^ui il>7- Tli*
aoma ptrtlDb* bav* hraa anilrrlj rawiItUn, aad
•1ii>ol a«T4aif pif^t «F Bav luailar bav* b«*a ad*
4«d.— mina^ JT'd /awr, JuBa.lI?»
Ilaa navar bitaa aflrT«**-«d «• a r«ir-brtaW^Ar •id'
W0rtb..ai.,(aalr..«n.p,.l.4a.i»=.ll>.1111.laoot *al>"inj .book "fr«rfr '«'•"•« f-'i;"" •■
>al<.B>..aDtftA.f.fu>.wllta..lt.»...<arrlt/t»)l«lba "■ v?^''*';""',"'','''^';'";""!;" "'' ^"'.""'
•l'idcDi a.il,. i>„iii^ ïoiom.. -Mol. M.ai.l..Io.ir '"•*''•*;■ b»"l»fl >< »l»hoiil a rltal Is ilia laid
Ea(ll-iil.(t.b<iLik.arn>n<1l(ls«har*lrT«l<'p«'tlsl«. " '•—*«■ JTumr* Sapl. IS. I»T«,
—SrltttKani» rt>ril(ia *<rl -CMr. K«.. Jao IMJ II liiltan laTttgi^ir inaa lolitadla (lioUptol
ItLaortotiraadDn'avaaaf jrl^^>'lt«d*^*"'"^^"<!^^ ' '^■^■^^d VUdI. wljttaa iLDi|la vulaiB* 4B att41f1a««
Ibla aaw aiaadard ((aallx Tba r'f-«oi a4li>flii ih.^nali b«»aoi1 >b<ir*4af>eilT*, lia «aawt|>)ar*ol '
baabaab aqlafivd aad taiitft fabrlitii il up tu Ibe ! InrIpI c4^ii<?*nur^oa anil Af laaaral faapof aa «aur*
*4lbar'a praaaat leTeJ Af tiperlADH aa4 r*ai1kD|- 1 vuotljr «IJt iiibjaal ^loiad ^r^ifldtfvntr^pac.'Tt^
OLlMCAli MEDIOiXE; a Systomatic TrcatisA on tti« Dia^iiasis
Bnd Tt*a[ii»nl of Dluanxi. Uaiignad fur l-iu<!a»U aad Pra«(ilioR*r« ot Hadiolnf, In
on* larga nad liiudiuoc ocUto Totume of TVi pbgMj eloth, ft id | lakthal. |A tO.
Il U ban (bal ibi iklll aail Iw iil*(<tr lb< fnni
•IIllBibB tr< diapitirrd U* bM itira a> • >Tor«>
botiaaqf nadkca^ kitLtiriadf*, airEflliiitLE ri>r ib* «in-
daalimavaal'mrur Iba pr»4 iHiV^iar. Ib> TugJl af a
loaf Jim 4>rtlj<< nimf falLbfal cMol'aL w<iik, «allait*
ad hj aa wD9i^f at t-fgirnDT ami a^iftiukile aa da*
llrlaf, aad iraifbad bj a JUH^fiDtni ua !«■« riaar
tbaa bla obafliadga la tlua».— JraftlatJ pï JTaM'
(^Ch', tiaf. It;*
Tba aQlbr>r af Ib* ab4Ta wnt}t baa aal^clpalad a
waal taa% Ml hy (buta fur wTirtm it wa> «apttltll^
wfiii4<A — [hf tfilaiffai *'u.l*pE d arla^ bit ;iiipllai«.
and Ibff bdav pracclllio". Ut ba* ^taa la iba
tiitdical iTDraa^lua a varj uvrtaAtrj aDd DatfaL
wt>rt, o-rujiplclt la dbUtl. accnrait la u^>eraallta,
bTiar In »ial«iaaiil- — St, LoMlê CKUrltr <]/ Utd^,
Oct ItJ»
Tb*r« 1» arar/ raaaaa f4 ball^rt Ibal Ibla booh
■Ui bt v«LE r«<«]tfd. The tailTt lïTanlulaaar ta
rra^naetly ta aaod of >"ni* vuik ibal will «nabi*
hliB 10 obtain lafotmarlaa la tba d1a|;uoaiB aad
Iraaimtai of ra^a wiib comparai I «al T luda xabar
l>r. niai bu Iba faeulir uf aipraulai blBtalf
I «laarlf, and al Iba aao* Itm* » WDIItalr aa In
■DtW* Ibt Mi'ïli*r lu irtMtia (ha anllrr (loDiid
.tf hlaamrvts aad ai tbaaaua iIeb* oblala aU Eb'i
la aaaHlIil. Klibasl f>'>dilla( ibiasfbaii luluial-
DabU tpafa— ïr. r. It*t Jnttt.. Kbt. 1*7»
Tbaamlaaui faacbar wliv baa wrlttea ibaralaïaa
anit't enaal latallna b*< rMcofnlia^J iba q«ad* af
; tba iraerlaai pfofNalon, aod Ibt ratnll la tJJ Ibat
ivacunld with. Tb* a^^la la wnl^h It |t vniraa It
ppfnUarlf tbe aDtbiHf't ; *T li tlt^t aad farrlblt. and
marktO «7 Ibuta fbarkCJrrltMn whfeli bat* nv
dtrtd tilui uaa of tba b*>i wrliei* aad im^btFï ihla
I CdDDir j ba* «taj prodvivd Wa hav* aol >pM« far
M> fu]| aaB«*[d*ra1li>a of Ibia reiuarkabla «orh t*
** would daaira.— « tjauié Cllit- JUmré, Ott. la»
Il la «DniurlDf Unit in -a ;r Thaï ibrrtara Ctw niaa
ui well ailed a> Df Fhitl In knpt ri Lofi'tioittoa on
laete latl IPtD'Ivaed tuDJ >tlt, aad llie prr*tEi1 work
(■a 11m*lr un* aa ralhlta bprlL To IIIO aillbof '■ Ctt-
pacliy In aadeTiake 11 and Iba Daea fer 1r at au
aoiH>iapaaliaeBl lo Ibe lonllllarl* aoaf i*tutïl, 1D
whlgb llia •stotxl of trealnieni la but llUla nontld-
■lad— JVw /WnmU-m, »ai. If!».
KSSAV8 ON CONSERVATIVE MEI>ICINE AND KINI>KRD
TOPICS. I« oaa varj handanma rojal llm«. Tslona. Clolb, SI U. IJtm luttd.)
LJARTSHORNE [nBSRY). M.D..
ESSENTIALS OF THE PRINCIPLES AND PRACTICR OP MEDL
CINE, A bandjr-bouk turStndanta and Praniitinnert, Pnnilh adltlan, rctUaj and Itn-
proTed. With abnut nna bundred [llnitraiiona. In an* handaoDi* tajtil Ilmo. Tolume,
»f aboaliïO pnRH, elotb. $3ftll: half bound. $2 sa, iLoUly litutJ.)
Aaakaadbook, vblsbalearir aaiafotibihaaataa- ibook, It unset bainpmtad upon, — OMaatio JM.
TUi^ n'lli* taiitfiPLU aan rnaoTicanr arare-iaa. ttwtmtnrr. Xot. I&, ISTI.
irado»«l«ao»"f lu.,oal -r» JfM Jf^Aly. | w„i,„o,rtoBbtil,.b-I boakotlbeklad pobUtba*
At a brlaf. euDdaaatd, bolcoaiprtliiatlr* baud- i* ib* Cmiiali ltiiiaût0-~^Sl.Lviiutt'â.andaiira,
I /aiim.. 5vT. lȔi.
IG
HiiKiiT 0. Lea's I*('Bi.ioatioK8 — < Pm^tii-e of Sffiieirut),
DHI.<TO (VfUJOUX Smil). MP . FRCP..
JJ filfietiinti-l Jui^llmfrirvn Mt4irt»r.lU »■>■>«'• f)h>|Mr*r.
I A TItEATISE OX TIIK IMtACTlOB OF .MKDICINK. Swoiiil
Amtrican •diliun. mliEil bjr (be Aaibor, Kdltwl, «l)l> A'MilrnBi, tj jAUth II. ITiirB-
imiin. U It.. Ph;ilgb>n ■■> tlir Pinn* llwpitiit. In «a* liiiD'l>Din*Hta<» «itlam* (if
n«>Tl]r IIVO pi>iprt. With illuilraliani. Clulli, ti it) ; Irnlh». (ft »0 iJoa Kt/ilf )
In Mptlniing ihl> ««rk fr-ni lb* rrc«rl iliorftiiirbljr r«*l«»d orund Eacli'li »rfiiioo. Ik*
auih-ir til» mild* tut>b orrvciiuEi lU irtuitil ■d<l»klt', usil bur ulilvd ■ «bl|>l*r un iD'Kallj.
Tbt E-llior hoj Ilktnli* tcuri hif i«ld>ii«ni in i>i« tighi of tha l>Utt oprrlcDee, miil in*
wfrrk JA prrvfnlvd ■' r'fl'ctjnjt fu ev^y vn^ lb* mnti oi'hjrrri «'T^'c-t nf pitditii) f«i«i»riv. mM
■f futl.v fulirled li cininliin tIi* ifUlinj:iii«l*v<t p«pili«n «rc.rdfd U» ll f«n bcrfb *l4t# of tb«
AllAiitio Ik' «n Au^hwllJitlv* gbiilt '(■' lb* i1mJ*nl. atiJ a romplvl* thnn^h eAfc^i'* hAiik of
ftftranc* for th* prulillon'r. li'ilailtattu n'Unir II14 ■utbot'i larnrM rfArt M rnB|i»nluii,
tba «Uitloni ti»a nmounlfit In Abu I anr.Irnih "f ihr i^rrrlni» •illiiiiii . km k; th* un of an
toUrfn) f<wa IbM* ba» him srKiiuiin'nUiail nilli'iut >n.!rtuinj[ ih* •!» of tk« ?»)«■>•, wklU
■ ItducUoDln lb* friet iin<l*it ii nut ol Ibr chtaiinl vuckt •<;»iill>la lo lb» ffttMBian.
A ffic loliou i>r lb« Brit «lillbo ai* wkjulofd-
A D>v idllku vf (kli vrtlkDows w<ii1i «hkli
tiailit.1 tin ndiiDUoat «ntul lolilon tot uslf
by Uk iiqlbi.r l.QI tj'.i hr l>r MlilcbLftfr'B, *hM'i
wltuiu tit tin 'it tt" ■>«( lu Tlilif^niilry h*rt-r atltd
t«i |K> tfl — r*l.li. k.ct. TOn-: Ji» ). 1"*
DfuO liir <l«r iml inriilx "tj ID Hlll'll II !•
wfimn nuit lEi- tii»c.iiiie 'u -[•'■IS lUtty taamr
la lHnf(14f\ Mrl.fr ilito ■!>' .M«n-"ipn uE <|ii*4(lt>at
Wbti «• tail sr lb* Bni •Uitaa, w* «m. *lib
lBrmt*'«ii)ihBali.r*r*t't«*t*'>t*t*bl*: ■■K*wi
Coi'ittbir-noiKd'^ ibivliMxarv^f alk-aihr
ral ma U' 1(1 hM hHB ai-l. k» bH» »*ll uM.
• h' ir<t ntr 111* *ah'*tit fiHiltltiv^."— OAl-* Xtd!
knfrrJtj, /iB. r, l»v>
Till- la D'il Oblf n*taf 111* llIM aail ■•«>•< *■>>'
fr«(i*n«l*f< vijrk* w< vci Ih* |«a*ral «a^jvai «f
h-<>rr and Pnillr* <-! M*4l<ll*, km II It naiia**
I'nnablT Dm «I lit krM.— Sf
Jan liill
JVM. tVa^llN-
'' ni»^Ma(>.fWO<nf>flaffcip(Mf. M''«rfii(piU, 'on OUiT -iMOf l« JMt OTfair. /•/. OVv*
A HANDHOOK OF THK nilXCIPLES AND PRACTICK OP
Msillnlnc I for l)i< ai< of Slnilanl* anil i'rittlliviiart Itu*d apan Unibaa4'> lti»dlM»k
of fraclito. In una bvil Tolunif. royal llmg. (In Ptm.)
UABEKSffOS {Si ft.) Ml).
ON THK DISKASBSOFTHK ABDOMKN. COMPKISIN« THOSE
tub tdili^n, Vlih ITlaiilrHlioui. la oQq bandtvib» «Uvo KiIbu* ef oTvr 3#* V*ffM-
W* f«d dfl ».rT ""in TAHdii Id 1Ï1B ritu»T>1f r«' , of Inn^rnMl^tt, -rm^ftllMllr «rntcvd. » ftU «!•'
CftV4luD wh**h bti »l'**d^ 'tt-o jt>*"(i l"r<h* m*»l' »•■■«* vf1h« iTtiBMt^fj iHrLftvA tfc* i»*«lb ta iW
1-r*«?iil f<li|l<ib )■ ra]]«T ifiii fe4H*f *a**k« ''**ï
h»o «ililf ^, Viiiifint ih* «««li fvlly o^lr iWtiSHi
àuiJ EUkiiEif 11 ■TuIuBMirnatvrMl t4 iM fraclltlD»ar
lit tfrtj ft'M al KMLIdVfk kDil ■qrt**X l*»t^i>Bi
a«trttiaoUlBi»B*r'kfib va^iiiftrW ■nitaHfliimi
«4 l>ftT* to «uub«E, Bfld «« btfiJ ktt tba llftM IMl
ttg It* tihUIcwt la iiai;bj«^ to Utn^i me ptAur^
l>r lUbtrkli^m't V'lrk lt4»|liM «v#rT pnbtlUlAiar
*b»»]il r»d KQd «ludf «tr «Uv«l£,«^. T. Mtd^
VUfl'J (4
Wa'cODinpDd i« *N |*r4clUUD^r« • fmf#fal ]i«riiitB
runJ?iL In It" pinr»». p*"'" ttf «iirfm» ]urvr«i( thai'
cjiiifabd t<iikHi:-;o|||i<Ai[7 TLUntrtfaUccoMahHivr
IbAl i^nkitrV t" du t-i|np]lallLPii, bill J »j«rrkt *i|»h»«]-
M4ml ana nitfff. JovTH,. >ur, uja.
Ttili tnliiAbt* irrMlu «n d1i««Mt of iba «IfmiKb
kad i» Uitnfbr* a» »v ■v^n K«o*b la nia ^Kifta^iA^
ft* 1[ d*HlTI' ILP ba. El WiU id foDbd 4^croJiifijFi)lA
JpOTttEHGJLL {J. M/Lyh:H). MM. E*iin,, M.R.C.P- bond.,
J- Attt fhjir ltl\4 Witt Lati't H"tp : Am* PSpt. fitSf /^Vti •*/ L»***- ff**p Mf.
THK PRACTÏTIONEIVS HAXIHîOOK OF TKK ATMFNT; Or.lb*
rrinctjil'fl '>r Th*r4)hf<ulioi- la oa« t0tj Dtal oouro vuluma (>r»b6iil &50 njt*t ; d^tK
Ut b«*« ^« ntCM(l** *<i4 b*t*frl II wqbV U t*
•■«(■boiit-iftinl InUlJLffiitiuUtlliR^h t^tmftuBvf
Vtk; I« tho liftjn*««tlhK I'CvlU #rfitr[r|>wn ■■!!■-
mntfTiO AjFilK'Ujthliil^iLbllbri
Qar f rtf iii3a «111 A uJ iVk* *t<r]r r^t^nbl* bwliîMld
tbiitiltb«l»|>Kb' t>tKTi tïïtxy itirir* kl ioii''h*4,>«u^kQit
tb' £tra/i]tOan«r T^ Wl lnnrT4'*riiilTi nnikailkf^nt^alr U
Oui rtarlvra *i «ïni ir^nb^ c»f cafv^u) TJHrn^tl II llflln»
fh« «4T war '>T>*f ur^ kiiJ kllCTikult [»4**m k(i uii-IU^b)
■ th«niiVt*irliii4tiKa«iid inmrbfU** la b* (bdn4. It
I. a b«k a.*.T [i"«iti™« o„o.. ..« -pida b...,i/ «Tiiv;;:;::^:;,".'; "»";«îT
THK ANT\G0^1ft>\0¥1\\V.Y.KYV.Vi'ClC AOKNTS.AND WHAT
IT TEACUBP. B.ifiïVVia V<A>«it>W«t¥Aw^a»ll«\>.V*. \«tnA««tX *«!«»«, rajkt
lIiBu. ut lift pa5«, *l<'A.%\«'i. *,J"rt H«avA
FIlHBT C. Lba'b Pcblioatioms— (PrnWiM ûf Mfâieinf). 11
I
T>ErSOLl>S IJ. nrssEu.v M.D.. I
■"' Prf/, «/(*« FrintlftH and FnteUtt 1/ Kt4Mim* Omit. Cùlltt: Ititiln. 1
A 8YSTKM OF MRDIOINR witH Nom» *irn Aoi>i»io»« ht Hssst I1*»t«.
Bit Mil, M.D., t»t* Ptnfrum of Hyi[i»ini in Ih» r»ii'»niljrof Ptoiim. In Unw Uif* «ml
fasnâiam* aeUro itlumt. conUlnins (bout SVOD olottlj pTlnltd ilaubU-ialuan»! pt^n^J
«lib nniDtreai Itlnitrutlaoï. &oM oui; b; tabaoriptlDn. Ptke |>«r ol , lu «lotb, $t.<)a |I
la iMlbfr. SA.DD. ■
Votriia I- U—l rHifr) BDnUini 0(*»1I. tli!i>i4ii md IliiEiiii nr tie NuaTon* 6ti*I«.
VoLDaa II. <yujf ra*Vf) conulni niiitiiii or Hiimhitoht *nd CtHCrLuroir Stitib*.
Voti'Hi III. iprijiariBir far Hrlf fntilinuioK^ sill enninm DitKi*** nr ibk DiaiatiTa kud
llu«op OLAKDiain SviTCKi. or tui Taisinr Onoiit, or lai Fkii*l* lUrMM'ctira
SttTCu. ■nil or 1(11 CiiTAHKiiut Strtiiii.
RtjriDMi'i BiiTkv or Uxiticiai, riranily «"mplstsd. b» ■rqnlrxl.tln» tbe tint anwirKDi**
of lb* fltit loluin». Ibf ir»!l <l»»'"il r»|>iitnimn nf lp»in|[ Ih» wnrk in ntiirh mfij»rn Briti'h
IDtrfialii* !■ jiriHntfil \!> îti fullul «nJ iiiuit (iiiiclinil ruriii. Thii cuutd >cii« bt oih((*i>« la
Tlm of Ibt fini tbal It 11 Ibe [»alt rf lb( f qlliihitralluo et Iha Ivkftlrig miqdi «( tbr pofHtiun,
pAob tubjvct bp3ti|[ tr*«U<l h y >omf £xnll«mkn wboU TV|ctir'l*4 lu lU hïjrb**! ftBtbfittlT^-*! foVj
Iniinnc*. I>l»aua bl Ib* llkddrt b; Sir llaiinr TuOHPton, Mulp'otllonn nf lt>* Uiftna kj4
Ohailt IIiwitt. lw*ntt;i br Hkht Mi[ih«i.iiT. Oanitainptfnn br J. Hituhm Brvukt, DI*-''
•UM udh» Splnc b» CiiJRi.Hf l!mn KAncLim, PftiMTditti by I^bisch Kuioii. Alfobntlim
by Fmsti» É. AttiiK. B»niil Aff^oliom by Wiiutii Itair.aiB. Aithma by Iltn» F<>i,i*q,
Cvnbrml Afffclinna b^ U Ciiini.Yo* BiniA». liuut kiiil KliiruoiaibiD b* Atricn Itoiiin âiit-
■un. CnnilltnlIi'Dil l>i|>bili» hy Jayi,n±ii lli>T'-iiijrioN. l'ii'niri uf ihr Slomncli bjr WiLvix
Ftli, DlwttHi of lb# ffhln by Hai.hirii* FuutiiK, ASfclion* uf tb> Lnryix by Uoati.t. Mio-
(■■iiB, D1*H*M or Iha Romuoi by Bmiahr CuaLisn. Ulabau* by l.iUDia tlaviiruii. [ûtca.
litiql PÎHa'fi hy Jfiiili Stku RKiHTotta. CalaUpvy Jit>d ^amnikmbdli'm byTHViiAK Kivil Cu*ll-
lEHi. A|io[i1txy by J, lliJiiiii.ixai J*c«>u". AUft'o'^ Vtolvrit by Prafcajot Oaihdieo. KuipliVi^
r*iD> or Iba Ludbi by SJi Willi ah Jamiin. tie rl<<. Ail Iba ■•odlnf Mbnola In flroil BdialM
b^i-* cunlrlbulwl Ibaîr btal m>n in )[*iiari>ua riinlry. ta build up iblt mnnumrDt oruadiaEl *ttJM
•nrr. St. Barthoiomni'i, Uoy'i. ft Tlioiniit'i, L'nlircrilly Coll*;;». ^t Mtry'i In Lon-lon. vblla^
(bo Kdiobiiff^fa, Qlk^itfnw. and MdnrbHlvr lobooWur vqually w*r] r#iir«*f rtrd. Iha Army M«di«ftti^
Scbo<>1 ■( Nttloy. ib« ruilliory and DivoJ Mrrlooi^ tmi Ibo pabllo beallh bvarilt Thaï a m-rk
«onc*iv*U in tuch a 4|imt. «nd aarrîoJ oa< uitdor ooob an*|iio** ahr-piilrl |irii*i< an InHi'prntabla
trtsfury of fuU (ind <ji|istUim. auitod 10 Iba dally wiint» of ilia pruotliiuner, "w Irml'abli, anily
Iha tuoot» iiblAh i( Hm tnjnyod In Kncland, and Ib* rrimutlan nhiih il bai ■«qiiirrd ••■) MtM
iblvoflba AlLaiilic, brti*p*nl*d il will) Iba iipprobjtliDn of Ibflwapra.anÎDVDtly pra4lio«Jbnli4SI^
Itilsrceriu »nd hiKb yritt hAiine hepl 11 hcyinil tb* rtarh of mim; prMlillnn*ri la ihlf
«OIITiVrj vbo dvira lu |iu«j%u î'., a iumanil bn« nritcti far tu fldilÊon ni a pri^^v wbicb aball T*n-
dor ltaoc**aib1t lo ail To nint ilio dtmiknd tbc pr>-fn< •'liiinn hn< l><-fn nnilfrlnk'n Th*, ,
flT> Tdiamtt and liva tbi^uttad j^Lgrr it Ihi* nrifrinai rrili, ty 1ht u^fr 4if ï mnnll'r ivi'i* "ii.i Eliiubl^ifl
Ofitamni^ b« eomprotiod Int4 Ilir«v vulmnrji of ■L?iml thrc^ thuunaQd pagm, ol«arly aod band- i
•omdy printad, and nlfarwl ■[ k prioa nbloh will tandir il on* of Iha «ti*K|'ait worka otm pro-
>ant«d 11) ih« Aiurrl:?iin (irofaulon.
But nolunly oill tht Amrfioantditlon br mon eriniinlint and loircr priri*H than Ibr Enjrtl>b|
tl "111 alto be brtlor and mitra D'>mpl«U, Som* ytnrt bnvint; nljijutd ■incv Tbt apiittrHnt-H of a
portion uf Iii4 itorkt oddlliortt will bt< rrrfuiiad tu brlri^ up ibo ■tibjr'Mi lo thv tiliting cndlliuli
of tri^Mca. Bonit diatataa» alio, wbiiib ïrp oompatHtivtly iiDÎtDpitrEont in KnE^land, rti<iir« m«r«
vlaborato trtnlmtDi to adnpi ibo aitielvt dflvoitd tu tbtin tu tlm •* Hota of ibo Amorloan |ihTtS-
niant and thitr ar* piiinli on whinb ibe tfogliod pra^lirr in lhi> sDuntry différa from lh*4 j
•doplod abroad. Tba lupplyin^ of Ibsit dtDi-irni'ii't but born uodtrtaktn by IIeikt llaKKil
auAiE. M.D., lut* rrnfrator ef Hyxienr >n tb> l'nhtrilly nf l'cnniTlranla, itho «111 indaatora
to r«nd*r tbo K«rk fvily up lu Lbt day* mut a* UHfnl lo lli* Amorinan pbytii^inn at II b«< proT«^4
U) b<i t'> bia Eni^iÉib brolLron. Tho oumbcp tif mntlrnilon* iftll alto ba Tari^rly IncrMacd, uldfl
nn «ITiirt Vill ba ijuiitd t» ramlir Ihn lypcij-raphipnl tioDulibn unonrplinnthl» in »ï»ryr mptel, ^
Tba Sral knd MCOnd volumat kia now r«»dy, and Iba aoioplitluu of iha abula rua; ba oipaewd
iborlly,
Frum At-rttn KriLLi. M D . Prif of Tbaory and v> ni'O'i' tlaM tlm pnbllralluD uf l<> «ni >llll •»,£
PrarllFT <•! MtJiilu* and tl Cllsltal lUdirlat la i and [ dur* aliri.ii tpukia cMlu > v.itlli* toMtc-l
0BlvDrally vf PaatujrltapU- I ti.r t» FitrlMt^a i*^*brftiAl rTTiL>[i^ia and Tvt4*41t't ^
Ktyaoldi'i tlytUaor M'dlflaabu Iwa Iknilllar i Jjit-'ify. "^''^ w l^oo» malu^alood lk«r pi» la
lo ma tiarv Ita* poMkcaUoo of lu Hnt wtiutu^. Il |
iIlq a*i(Qca auJ *i!4flJ«oet ^I QrJlith a^d Amaricaa
■aittiinibt 1>M;»r> IB toitl:-K ■>- ih. mBJ«r. l'''T"i'aB«. Th. prtiaoïpMJonlonltao.LUiorat»
11t.'lDVrl»d,ai.^IlitiiirMMIt(n.laiBHliart nnr» ",'' "''"''•,"'V"° >.'•"**;
Ih«n iiortip ..m Llpr jir.'lul*<^ <if iLs flril.
tira UKlU It [haï trtty trlLelt 1> a niuQ.»j(ra(]tL prv
|mr^ by an taivrt, aad.r.kr ih«. nkoki ptrl, \f it*rj
■ U|M>l1nr piaDDtT I ha<p aiv*y« rvfnnimtD.Jad 11
toadvAu^il MOdeata Lu intlt^lut aad ioph*>Ur<au*;
■ltban|)i ihatott "I lai Kailiib idlli>ia Iim1i«d ibt
aamWr af tlt parfhawrt Mr tta ^TttttrptiWtnk*
f^r harinf r^ail-Jt*! mort arrti lib^o 1» anvricaa
roadiraa ouik uftuckouofMoaablaaitTti.
rroD J. M I>aCo<rt.X D. rtotof FracUc* uf
Htdklaala JtlT HbJ C.>Ut«t rblU.
I har* bwn ramllljtr Willi 1UyaolA«'t Sytlon of
Mt^lrlaa for ttveraT jfmn. aad kairv uf bo *ork lo
Iha EajlLkah laujiuaA* Eouro Ibomn^ta Bad «OBipttct^
rruoi li
llidiallac- "'"Blc. aod Ilparltat* •>< B lart* aumOtr »( Ib*
1 oialarad aud rnllii-ad mkuit.nf lofland. tr»- ■
laniL a4>d SfnlUad : Ir lu a «ir'rk <-r rar* ■i.^ll. 10
■ blfli «ftry arllota lafaUy Dr"ij«iii uj. Iv lae ■altl-
]B( xah at Iba a'tqQDB of vblfb t% Irvarv, aad o«ll-
fini ttx aaiiK Wiib fth aneait phytMiaaa iitat
Jl..]inpTa'4 Hiirffr J .Iota aunoc tarfauDA. TLa l«*ra*
ad AEETrlrabDrlIi.iE^Bad.rtilObtfqoirtbaiBinAL'rully
\t Ib* tBjD» iif (ba «<i'k — ao|b*«a at^nia u> Iibto
atra^**! >tU criucat ty* Tbr r«pii1>]lrriUjq of aaa^
B «u>k eaBavI fall to lia uf (rtai btatili lu oar prV'
fflttlua,
Prum auaaan BaaTioi.aiT. V D.. Prif of Mal«-
rii ■(•dioaanj Otoaral Tli*rBp*alloBlB JtS Kad.
Olltfr. Ptilla-lalphla
rua.» D Oao.. IID tt. D ,».•: t. 0«0., pMf lUyauld.'. a,.»™, rf AMM». a«K.a«u. •«»
urU>tllu(aaBadPi>c>latorBar|>ryUJ«t «•4.\„(«»i,»B.-\kiiA .*«»\\*«.V»>**'"'«^"-;**
«■yauIJ.'t ayiKm of ModMo* bat bMA ftaaMtal\ XbMbkbAt «1 lAV W»i«»«» V'>''P»«»**
18 Hekat C. Lka'h PuiLiOATtoxB — (Prttdice of ifeéicine, éc).
p/.\f.ArSOX [JAMES]. M.D..
CLINICAL DIAONOSIS; A HnmUiook for SlutleDU anil Pi-ao-
litlonvrr or U*dleîn«- In »n« bAbdiom» JîmO' volum*, of MA MfV. vUb 8A lll«ilr»>
Uoni. Cloth. 11 A3. {Jti*i EtaJy.i
Km, irrA<<j<&] It Lt rvfilDiH wHb (Sb r«ry httw
Vtt»ii> ■I'll ih9 \t\'«ni-}tf f'H III" ■■ra>sit ^ck'iuvDn.
vaiiU <if 'lLp"^^D^fl1l and iiidtr lU'Ur— J*Wa M^
Th^ ftliD of <}ia ■iiltttir U I** l«Mh a *lailii<it itAil
tnpEkUvbtrhw l4#iLBmi»» k o-" » 411 fa a-* "till
(' tnovfftfgt" to arrive n g «i 4 >Mnfnik-l« Alt Hi*
VB«t'ka»««iu|>Tvm*oni]fl*««*r»] •^^tvmiurr it^ufxij
lOir*lhar Id aitdl> tm^nbar »■ ii> luih' ilknlr nla'Lim*
lira dull 4lt4nii4t^ clA4r mii '««^ <if jip^irvbtDflab.
TbU*4'll bfe*bHB'IuLrv lit irkpu -t 1*f|e4ai[p*r1«m
■ad in»lB«4 gb»rfBiiuD, vLil< b-o i-««u ivug iteot-
iii«fitfttflit^«4il ED>irn>hHAl»i>'pt*f|tltfi ipd1a<iii*ki,
^1 rail? d~t»tB*»td. TIJ* >H0|( k4 Hll g.>*0 Wa r<»«'
>■■ worh ir-^ttbv vf « pUttlu IbtlriLbtmrm,— OMftf
Tbla U OD* ur t1]4 niiLlr artful l^a*^ Il U Mlr*^
flf^ttpUv on «Ttr* 'iai»UbU,h*t«i»*«lic«>«U]ta
hi'rant* IB LE* Arrtfif AlAtnl And tfrnqpl"!* IhpIpi. 41 U
ii4il*flAllj^ «^DTfïlriii for ^b>ik t*ft<rb»« !■ Mf
JJAStïLTOM [ALLAS MrLAyB). M.O..
NERVOUS I>iSK ASKS ;TUKmi>K8CKJ i'TJON AN» THEATMKNT-
In <pTt« b»ail*oma oolato volnint of Mf pup*', vlth M Ulu*-; eloth, $£ 50. (AVv JEm^^ \
«fftcrlofit. Ipoih ««lot* ««d ahr^tftlf. ^■itDi>tth*i*> ■*<
TliVt i> QDiciBfiLuiiiblj ih* bt*i 40^ mn<i mm
plfltfl |PKl'b>M»1i of ii*r<i.»il« ill*«*-*4 (liitL hal J«l 41»-
pp4r«>l. BBil Vf 'a iQi4tii>hiti]bihi JM^M|iJr lD4naii1>Dii
■ tfain al v\\. ft<7*tlMf. w<< niacin Ipa airgHd far A
f«4Uaj[ of fbkiflit tliai II iJkiuM b* uf JtmerlAD
fiirfaEAii', TriuiTPtk, Uowf*"f, hn-b**» pDrfDfn4d
h Hob Torh, 4ùi1 baa bHo *<■ w-lt parfAfmad lb4i
BO tt*'m !■ t*n for «fr^lhlof Itui romwrnlkElna^
Wllh^rMl «kill, Ur- HauLUun Jii» iif^xalfJ »o h>a
»4i|ort 1 aorvtpd «ad ta«M «□'**; nf *'il lUM U
ksKVa itT Iba iintUnlofF «jf LI>p Ti*<r*ou« N^tftia,
Tlfirod Ld til* tiiibt uF iho ninal rfCQiïl t«*r&ri;b4*d
Ffani iht prtlLmlnBry ilaarrliprl'in >■' ili* n^lb'rdf of
ox««iiOfci»ou «nd titiilj. «Dii ■>f ibf iDitfuniFiiiK uf
SrHtrWD rmplntril tn Ibo ifirMli|r«ll"D of qrrtoUi
t«a4Bf ■, up riLJ Itta Dual DoliPfiKiQ tif Ti^nulir, 1 t
book 1* «mlQeoLlj jTacllcal. — tfrdtn, Ltfailr<a, Oct
ISÎS.
Th* »nthnrti»Uaaa Id Ma prafhea Ibal 11 baa beau
bla')bj-rt III pf«Jn4« » aoBfilaa, prserlral buoli. aad
*« IbUL bt batbota aa«»HfqL. «oaalildrLait rhaai-
i«Dl 4^ Ih* aabjarl vblcb ba baa Ua'*«nak#a, ta ' atudturi hiid ï«a*ral prârrutia^r^ la p^rlwnUr at
fdffl. 11 U qi'-rt va[aikiiltf» llian lb* 1L|]« prttttrtf or 1 baip^ & fuLL 4«pn-J3U'B-iriil**a*a*«f ibai#rT4V«4rt*
aofiiini«'j \ni1lG*L4*, omhrArlng— 1'A<I4->- «hal ai* x^m . Eb^lr pjihHtb,^^ au4 iniatoanl, lo éala^ — A T^
B«qallr raiLarilad aa aarwda «IJataaaa— lulanAatorj | JftrJ, A4«>^< Aiji«. ;:^ Iftltt,
(tBARCOT [J. M.).
LECTURKS ON iHSRASKS OKTUK NKKVOrS SYSTEM. Tmn»-
InUtl fr»m Iha Second ïidll^oD by Otaftdi ^laaaion, M O . M Oh» Laolutof an VlotoOi
ct'? . Cûlb Untv. <if lT«Uiid. WhhilJBilrations. 1 vaL Svo. MlSJà pa^ca, Cl«4b. $1 U.
abltiii|t«'a. a|blBal aafit apd nftt**, vlib ibpoBVoBH
4ad «cobi»M«i4 of Otr 4Tt»rlafe, «Laa*»*, ■«<! '«««^
Tha fa^J«r mr ibrraf.ir* aipKl ka£«riDai|v4, b4«a
or L»* full auii Aatl-r»c[<pr)-, ou aliaoac **«'¥ p^itl
raaa*fTn>1 wirb <^« rr^FCiPUB »f«(c<w. Wf bar* h>
hMiLal^oii la «atluc ibiT fJiaufa na^ bt t^aa^ va
Df ttaiDUl^ii'aroiiteUiLL^iïPib prrf«r«kia" »' Maa^L
aai^jib*4 i*^, au bU •bomJnaaa af Jaâaaiaal:, ■*!
fr^Odin fr#(U f fiipLilolam.-'£diiat*ra4 Méé. ^aara.»
Om. IF79.
rriim a Tar^ «aftftiL nvtniaaUaa a' lb* vh*^a
work.vafl» JL-llf «arUiaUbtaalWf W4- aoL oalf
r1*4fl V had furt jp LF^aUJ ^f dUfv>«la aa4 iraMv^ai.
bill liai La* mi»! vnrh"»f IbtacUai^ H t- *rix CJ—
T>rflb4a>ira \n Ta««i*l (a alMlv^r, aaJ »sr*-a4* <ba
paiQulofr of u«f *vuBdlBtaH*lB («altf hi vf ibaTarf
iHia^L 'iv'rLinaaia «nd 4t*rjv*«1#4 Tba dr««t4fa
ara ■■[*l|*Dl and w*|| *c1<iolc>J Afl«' ihLi r«r*fHl
ravUk.ja, wt faa btarlMj T^vfumaiJ ibi* vjf1[ u
XGHVOCaill^OUl'EKPJ HvC.HiiijtriaLliJona.
U H . I'bralcidu 14 »l Uatf'a Heaplla), tc- aac
oad Amor^aanKilltl^a la 4a*bBm4aan« actava
*4lB na uf AU pafaa^a lalb. ftS U ^
BPITOMBOFSKIX IIISKASES. WITH FORMtTLJî. Fok Sic-
liBnTt a'h pKACTiTtuimii. Hwond «HIIna.lhiiraUElil/xtiMiland (rwltf •DUrt*4. Im
«n* 'try bindtoma llmo. «alum* of 314 pogri. Clclb, II tt. (/ho RWyl
Tha niiutfa uf lb* ftallli>f> «TO H'iitt iBAdUnL tn Tl,« prvHat arkllUA uf Ika BfUoBi* «4bal44nblT
«tpAmvuil ihii bubk, I>r. Ttilmr/ ¥vt bakaa «^1 axHfdt la «it*, ««J *trpua**it ■*«, tu prija^ti
Kaawu ■• iiHopilDK ■ pliM IB itit tTnsI nut tl >iir. Tb* «oik >• ttrtxiilr > TaliukI* ■44lll«a !•
AaiOAlolu^tBli «f/ibaj**.— Omodlati J«vrHal ^f i lb* *-bBft4TT>laA*"4*v«rlh4irlof Bvllvl Ul<
jr*<. «n, M.r. IbT*. I iim-n> «■(■ ii-iJMI-. Hit. UT».
WIWO»» «niDSJIT-* BOOK O» crTâSi!(HTi!iHll.LIK8Sl«*)ID»0(>K0»iKIII MUAnB.M
KSMCISK >ud PmuM ar tk. B»i» la aM | «nJas'aMil ' "•'"'""Î^_''S?Ï? *":."^ i'
«•If hiodauma nir*l Ubo. ■alum*. MOO. oaa ««•! llBo.MLwfaXff, WUhUi«li»«Ui«.
1 OIdiIi, É4 Sï^
jlfORRlS {MALCI10V\ M,D. , « < .^ ,
Hknky C. Lba'8 PcBLiCATrOîfB — (DiteoMê of the Chtrtt, rfc). 19
Sr^lnr awr0«M|4tA« O^r^l lifiu^ti 7%r***i( nii't ^nr li"Jtyttatyttt.t
THE THROAT AND ITS DtSKASES. Willi one hundred Typical
Klmltkli'ins in tiAnn. anil t^j «uud tn^riilnKf. itdlgn*!! «nil *i*<iul*d bT Ibe mulbor.
In oni r«rx hintliona Impatlil n«U>o Tolumc of 3il pts»; olotb, $A DO. (A'lt» /lad^f.)
Th* 4a'b^<'> nra (rlimiotlll b>t bwi aillinJ | trt ubuiusH; •ccuiu*. la »iiiln>l>ii. «■ »>«■-
It Ib4 rr^dEi«iloDor«D* Tinndftd twAullfa^ LllttXrh' uAr^d Ibla lM4uurQl mEiaD* '■ kb urvplaMr ^U'
Una* In fftloT*^ (h' Teiy W»( af lb« Klbtl w< htira I lÉda InlhA Uhfitrya/lhifi* c<Qj|U«i1 t» Jh«m*4totat
•r-(,aii4 wMcti biol-xg <l1>lrll>il*d ti Mo |>1*fH. ' r>( 4L»iimi at iba (brMI.~.V. Y. Jtnil Sannf, R»(.
Vit\y V'tod PDirnvJapk d«'ifii«d and ai*«BJ*d ^fj 9, IC^S-
Iba ■«l>«r, •ff^^,l la II» ba47 <iS tb* Kotk— (baM
ilF.ll.EK {CARL). M.IK
^^ Lfetvnr *tn IM^npi'tfipv 4' ^^ ff«f1. «/ /'mud , t?kUf 1/ "U T^rafl' JHtpfmr^ry at t%4
r-lr. Ir.ifiH.i;. AtJg , .if.
HANOHOOK Ol' lUAGNOSIfi AND TREATMENT OP DISKASKS OP
TUB THROAT AKD NASAL CAVITIES. In on* bandtgn* rajkl llm*. rclam».
or lia |ugt(. Blthll llliutintlant 1 clolh,$l. [JumI KuWy.)
ai^nuil ;uk]Kiu#DttEi pr«4ii». aifl ^'tr^jt ttiwiUiwr^^f àccu'iia in ii* iqvthoil. an A 4i1ni1ra1'1^ fuini]lH| Ma
*UT> III* ILtirmlarn vf lii» iBtrialiy 11 (oiNf tpl- pgc«i>-> of hllnilSf lb* isttjctl ut vulch II iraal»
lutalavi.— P«Uad» jr*>t.fbMM.J»l}ttlM«, Iwiliit tb* aampiabaB-tna al iba «aMial pn
' IIMar.— jr. 0. Jh«. ^««r., Jbb*, I*;*
pncU-
I
pLlST (AUSTIN). M.D.,
PHTHISIS: ITS MOBBIP ANATOMY. ETIOl.OriY. SYM I'TOM,
ATiC RVENTB AKB COMPLICATIONS. FATALITY AND PIW>OSO.«1,«. TBKAT*'
HB.VT. AND PHYIilCAL Dl AO.VOf-IS 1 Id k latiM of Clinical SloJIo Bj Aii«tiii '
Tunr, M.D. . Prof, sriba I'rln<-'ipl4> and Praollfeof Mr<jii<inr in Dfll*Tiif lliit^UI Itt4.
Cullrga, K*w York. In on* handinna i>vla(« Toluma : (3 it, {Laitlt JiiKfut.)
TtHt Uok «onEatnt an analj*li.ti> Ihaauibor'ftuoldJ vvnil tba l»«k lu Ib'iwruaalorall ibl*rvl«l ift tba
«Irlr, (irilir nni» whi'b br tiaa Diwlrln >«*ralhun-1 .lurlT af IM» )lli»«w.— JUm>w JM, aail Sarf /•wiwli
dn<l ov** In kv^iul anj piliaia cncU«. Wa hku' I fat. 10. IStS.
or r*r« M J MS juTBos.
A MANUAL OK PEllCOSSION AND AraCtirTATIO>* : of the
Ptajiiaal Dla^aiU of DiM«H> of tht LuoK* and Ilcarl. anil •( Thornols Aaaadim. Id
oD* baniiiomc tnjral llmo. toIddi*: bIoiIIi $1 tt. tJnM lumti.)
Dr TUB SAKB âOTHO»
A PRACTICAL TREATISE ON TH H DIAGNOSIS. PATHOLOGY,
AXD TK£ATMKXT Of 0ISKA8BB OF TUK HBAKT Hvond r^rltvd and anUrgad
■Jltioa. In nna oelaYe Toltina 4/ttH p*gM> <rltb ft plats, rluUi. 14.
Df.niniThotaa tfïa<apnnbjart taf blanMaffb^s , av4tl«ara«i ^ra'itftl iraailBaaalboa* anbja^ta.and
aad baa B)in»B [«iBaikatla pu vat* Vf obaanatioB , ibogld b*IB Ilia tmsda ^.(all prasiKlnuan and ilD-
BDd ralaalidn. aa«<lla>iiaallBda*liT. In blatraal- . laal* Il It atiadll t« laanua nadteal lllaralai*.
naaiiirit. lll(boollis»ita*«AB*ldaiadltiarDl1<*l ' -Amur.Jnm. «/ iht Mt4. SftHMoa, Iilf, IStO.
n r Tau Ȉ mw a vtuok.
A PRACTICAL TRKATISB ON THE PHYSICAL EXPLORA-
TION op TUB ClIKiiT ANb THK l>I.\tfNOBIS OP DISKASRS APPBCTIIJ» TH8
RBSPIRATORV OilOANS SMondand iaTl>ad*dlllDn. iDBnabasdmsiaDetai'ttTclunia
»f b9b p>K«> «lo'li. I* 40-
vii.i.rnita'!) reLxoiitiiy riLtrouPTio» ; i»
Katar*. Varlallaa. aad Traalmaai. w»th aa Ai'
alj*1* of Ooa Tboaaand i'4Ba* tn aitqipiify itM
«■rating, la as* e*al irtUlU Toigna ot ahnol
«11 pa4*a; a^Xt.VtHt.
SLADR OS OIPBTUUIU; Iw Hatar* nad TnaU
iBiBi. *tib an icinaar of Iba Biittaj of II* Vi*.
*alaD«la •arluaaOunalila* (Haalaad 'atlaat
adlllBB. laoaa aaaitoTal llBa.T«lBaia. glglb.
•I «
WALflaiOXTHIPIBS«l»0VTIIItrBJlRTA]ID
■>8IE*T Vlxtll.f, TI>Ii.t .«ntrltag EdlliDO. la
I tol. ^T»,. 490 PI' . alulb, U M.
LITTITRES OK TIIR UlftKAtSt ■>? TIIS BTOKACH.
Willi a a IniT'idBailon no lliABalunraad Pbrala-
la«r Bt Wii,i.ub Bararaa. M D . f K 8 finit
Ua aHiind (Bd •■Iu(a4 LaadoaadlUua . Wlibll-
IgalralltiA* "D Vk.«d [g aaa baadkosa oftavu
TulanaarBbBiiSMpaca*^ dolh. »l 11.
CMAxnti»'* ii»>rTj*L np wbt «so kujiiii»
IH HRiLTH IXIf «tCKXK^ It an*b*sd*>«(
•aUi» (slBioa. CIPIb, ta 14;
LA BOOMt OR PXIVJfOVIl. I T»I |T«.. «iHb,
1I «on M(*a Pilta. «.t 00.
UHroLN-S BLEfîTRU-THlaAPnmC»^ aCasal**
Kaogal ul U«dT<al n*rrrt<lijr, Jb flat tr'7 a*a<
•oral Itma, Tnlaina. alolb. WItb ll(D*liatla»,
(I M
VULURN''.* lll'-Ct^EMOI'THE L1<.<1>I!I .1.111 Alk-
l-tuiats Tb'lr r*Blb«Si>f,i,rt)r<l(a1 liliinvtli.
£<'inpr.>tii-. «Bil TraalBjaal Pr.-iii ]\* >.<r<.a<] agd
ravlaad Rnallab aditloa. Ig »b* baa-iaoiaa lïsalra
TalBtga Blabaui MMpai**: diib.klM.
HMITB OH COKSITMPriOV; ITCEAHLÏ AXD KI-
Hvmiat.iKTAnsa iioi.itn.pp »t tiw.
BAtiH(<('>5 RKt >L ntSNlSES: B niBlnl Oalta
lolliBlr ^LtKiï<f*la abil Trial Diapl WiEli tjln^ira-
l\i>sa In .>■!> I1ni>.. ml <.r ini p*a>-, al.")!, t1 iX'.
t-lirTItllRn "It Tllil»TIIIiï op FtvtK Hj 1,
III']»'». H.U , H R.I A,. PbpBlflks 10 III. Kaaik
ll^ïapHal ta *b* V'>l VTa., gl->lh, %1 ^Fi
k TRtATIIE OK FBVKR. Br Botiat D Lf»>i,
K DC. laaiaaviaTantaBaof MJpaHt.atMb
•tw.
Hexrï C. Lia's PuBLlOATlONS — ( Ventreut DUtnse*, éc).
DUJUSTKAD {FHBEMAy J.), M.D.J.hM,.
TIIK PATHOLOUY AND THEATMENT OF VENEREAL DIB-
BASBS- InilDilinK tll* rMulliof rM*Dl lat<Mi|[*>Ui>ia|iuo thriuhimi. Ffia rlk «ditla*,
rfiliad iiDil liirr>ly riWfllltn «llh Ibt ao-KprrMlcn uf K W, T*;li>r. M. D . cf Xi*
Viifk, Piof nf |i«iiniilMn|(7 in Ih« l'ni* •>( Vl (o on* lntgr an4 bsnilnaK nttwn
Telam* ef H.^ï pSK*'- "'<'> ■''* Klaiiraliuni. C[otb, $1 Tl : Iwlhtr, ti T9 (-'••r flMtéfi
TV* «ork, on lu fliil ■]j;>B*'*not. ImntiliaUlj took th* poiiiloo uf ■ (Uad&r4 auih-MlItta
lu )ubj*iit «htmar ih> lungoin* '■• *p»k«Ti. ■nj Ih* *ntcMt vf ■<> lUtLan Iranilattoii ■(ow
thtl il II itfwritâ *ïiti aquï) FnTOf bn ih> 0->iiiiii*nl of Kutn)»*. In npnltd i^iltMit tk* aathoi
Inbiirai) (plaloutlf to rrnlcr it uii'i* w<4lh; of )tt >r[>nU(Éqn. and In Iho |>rta>nt rxlilan »•
paidii ba*o b««n fftiir"! tu |i«rfrv( l( jm (m an fHiqrbU, fl^rrrul jrvi^ra hnHnic *laTi>t4 rlMa
(b« pnbllaalian of (ha Ib'rd tdltlan. BUrb malarial haï baao aacauiulrkUil ilnnB; Iba inlattd
bj tb* inJuiIry ••! >jpMlt>liLjl>t>. and n*w TÏafli ha** b*«n anunriattd. Ail Ibla lu lar u
«onlnnad bfubtiriaildn kdiI eipvrUnoa. lu* b«*n huM^raMd; inaay imniMM ■•l'Ib* inlaa*
barn raarilMn, thi- Mrio nf ilJuiiraLltn* ba* b*f* •a1nr|^•d and iin|>riivtd. and Iha iibAl* Ksf
ba rtgnrJod i*Ih>r ai • n*ir ««(k than ua n*w ("lîlian. Il if Onnlldiiillf prtnnud •< r»ll;ai
H )fi*I «k|h Ih* mill adTiiTiOfd «nmjiiion of >;(>blli-logj. and ai a w^rk to shlch Ih* pra*il-
tlou*r initjr irtti wlib Ibe a*»^]^; uf llndlug olaulj nnd (iwcId*!!)' t«l furik ■h«l*t(( lUIt
«Uhin lh« MO)]* o( iii«b ■ liaalli*'
noi**t»r ta4U4b]4 4L*r>r4Tii>i)i»Ti1l4u«bftv«bv«a.
Ibr riHBt 11. 1^ eut ItilBtlef, 4>'l>l"lif .-r m-t-
w-ffiii- An >M '>f *(iiBTil''[<«B*^— tr fiftTtof hftii nr-
lipf**t iDln Ui |*>i(«« fc.i Llif ^«'■1 If .n ' 11* V. il J »
*i^rUuf« ■II') tf«#tral] a^m 1L4 *ftbi«*L uf wbKb
U rr#«ra-1ju 1ia«n |.vfii li} lliA h<ï.ik, Wl1^l■al In
anr '■■7 dtariMiac tmiu ib* pfoiiurijr r'wrini
ttUt »l pnrllt* tdllluai. Xid* iIx 1>h tlielta!,
Ihp tratftta iiHiBt maEh tana tH>aiiir^p>lii«a, th^
p *••**! 4D Af nid rd^flnTl* will bf BH» firika* roih*
pFaf(*»<p1T* p1ijr»]?<tB Fi^r Hr>1 purfbHlac Ibl* tdt-
IIlnu, 4ud w* prr^'ai fûTl' » •*rF ■p»«"lj' **!■ W«
SUUtrBluUt* O' llQin4T*td nu Ul' Vl'ltt'D) Vlll^tl
Ivil lu iK* hp]f*<li>u uT I>r. TnylifF a> <tj|lHcu«, auJ
Uia i»ul'> or lh-A> labor.— rkModalpAM tl^U^al
T'mm, lim <i. I*M
!• Il BU* •laadi. ibli I* Ib* •■lTmn|4it* B>t>l'
arn vork d*TaUd «EtliitlTalf |a rh* 4>«r*4l«a tf
dIaUr valniuiv^ Vi •'! «bi daali* IV tavp abxaM
■ l.li iLa <lni>< la iV-lr itaawlMtcf ^'••••a';iaCI.
[| la ■ma ot itiii Irir mlir (v>d b»>ba a>Kl(4 bf
BT4rT pfavllll4LDr M nit-tlda* *t aarurt. vWW
«« Ih t Barrai pneuitautr m apacuHtl — Mr-»
t«an<, Doatmbcr. la;*
Dr, Va(Mi»4d'* omairal uVi.i •aml> t'n •>■
loraah pra-avlDanrl^ u t^t «qlliarK* -1
irjr p* raBnrr^t iriiA4<ah tim a<<i ' i«
ra^ mak* 14* prvvrai if«»ii** or luu ' tiu
Imum; ihd bïfaK |4 TalLf abiaaM ir 'A iittni
liifrainta oa ih> intjaaa <4 wMrk It ii**>-, >• i-
Iramnlr praf4lf*t la 4<*<nytl»a* vf Ua ■#**»•[
ir*B*iHl dlHAHiaad inM** sf i(*iin><ai. t«d hrtr*
thiiuld bt lu *»rf 4aK«r'* libnrv.— C*. JVM
No>»*fv. UtHmbar. I«t*.
flULLEttlF.R <^.). <«(* DUMSTEAD {FHEEMANJ.^.
y^i'ii't^iu iMd jHviMma. Jr. r
AN ATLA8 0F VBNRRFAL DISEASKS. Tr>ii«UU<tiin«i Krlîiwi by
Kb»iia» J- Bu Ht Ta AI'. In oni- larg* Ini|i«i1a1 4U,. toliina of 1)8 p*|l*i. d«uhli-e0lma*i.
wltb K plaïai. nuiiiaiiiiiiK about lift liKurat.haauilfallitanhpr*^. aanjr of tbaa Ika ititst
llTaiiUonitlj bound ia olulb. tll DO ; alio, la llT*,parU, «lanl wiappari, at tt ftt P*'^
Antlelpatintt ■ <«; large aala fai Ihla vork. It i> oITartd atthaTarrlow prie* «f TuaiiEWb'
LiMi • Part, thut pla«ifij- It «Ithin Ih* f*a«h o( alJ «ho ira Inuraattii 1> tht< dapArtmalit of
prnolïfl*, U*n11atnan dvBÎrtntf r arl v ïniprvuiiini of th* pl*T*t ««nid du wf-ll %/> ur^ar U laJlWll
dday. X (paolioan of th* plata* aud tait tant fraa b; mail, ua itMifi nf 15 ocuU.
LIB*)' MBTTHKK» OV SÏI'IIII.II' »!<tl BOMK
TonMs i-r Locii. wsBASb apubltino i-iuk-
ClfALLÏ THBbKOAKit UP<iK3IR)IATI0X. la
(■au h>udkata*oa14Tv tulBin*; Dlaih, VI V-
iiiLi. i>x «YpriUk amk uir«r. coarraaiucd
' Ulli^KlIXItt la *«a baadiMMoau» r4luwi
I cluU.Vlïl.
UZ-A-sr (CHARLES). X.D.. , , , ...
fhytlHa»tatK4llittT'<ttl/trKttltC*IUIrmtt. tu**m,4».
LECTURES ON THE DISEASES OP INFANCY AND CHILI-
BOOD. Fifth AmfrloanfrntntbrtiithrarlH-iandfnUritvd >tnitll*l> *>>llloa . !■ ovoiart*
and handtom* oolaToicIuoitnfAIH pacra. Clotbi t* AD ; i*alb*T. It tO. C l^lttg hnud )
J^T TUB SAMS AVTHl/X. i t^iMy ttn*S.)
ON SOME DISOUnEKS OP THE N'EKTOUS SYSTEM IN CHILD-
HOOD ; b*inK tbn Lom'eian Lofinrai drlitfta-l ti Ih* Bnjal Cu1l*s« of Pbjticiaai at
LuadoB, Id M»r<ih, 1871. In ena ioIbs* aniall lluio., «lutb. (1 00,
I'jpr TBKSAyK AUTHOR.
LECTURES OX THE DISEASES OP WOMEN. Third Am*ricM,
frnm Ih* Third London adldoa. lauDonaat octaTs Tolamoof akonl MO (UM.cJotb,
«3 -ii laathtr, )« li,
Ci'SniKR PRllTTIC»!. TiKATlim O» TUB 018. SMITH'S l-miOTK'AI. TRIUTISK OK Tilt WAM
laSKS i)F rtlt1.l>ltKN. Hub t4v»as. n<V>aiV ifitwiu^vvv.ol \'»ii.'i>t.1 kSOfiHtl.l>a'>l>li
aad aoronoliHl In one Uria noisin •'■\oiii« o\ *«-«»* k.wnij,v», li»» vV» *•«.%» w\>*k
••arlj so eluMlTprlai^ na^ aluik. tf> v.. .»\a.t^^ v^ViW, *v»-*, \..««h«».««
laalbfr ««il. ' •— ^ ,B,i,v'"j»»,*\'AV,>a»i.
HxxRT 0. Lea's Pvbucations — (Diteases of Chilâre«i d-c). SI
aMITH[J. LSWiS). M.J>.,
B A COMI'I-KTB I'RACTICAI, TURATI8E ON THB niSEASKS OF
^B CUILDREK. Ponrib HdUloB. Ht-lscd nnil tDUrgad, In no* bindnms oi-tttn i»ivia«
^H nr abniit TM) pA^**, with llloxinllaiia. Clolh, 94 ÏO : Uaibgr. ii 10. iNev Ki^Jrl
^B Tb* ••tjr in«ik*J faii'i iiilh «liich lb» itoik b» b>an t>o>it*d whtxitl l'..* bnftliih Un-
^Hfn&j|a U »pok«a. bai »timul«l*'l Ibe Aulhttr^ in Iho pit^^rkUon of ih* Fuvrlh EdUion, ti» F|4r«
^^90 p^inti in lb* andflnvor it r*ailir ii Wbfthy In mxuty r««pFOL nf » riiiniJiiiiAn«« of (irufctsi<<itAl
COBSUanc*. M*aj puilloii* u( th« noluio* b*v« bero itiriilicn. anil uucb n<> iDKtitT inlrs-
dnetd. hnl bj «d t^tatil tSoti st «ondoiiatioa. tha tiig of tbt «oik ha* net bMn ualstUlI/
iBorvutil.
m
•dlll^D at ihr «ifk, a^i aiffatl*" l>4«» ti*«n Ih* M-
r»uv«« l1)Bl «I'oii t1i«[*rprBr4'|UtPfJi4^br levtUif^,
~ittd h&tJlr ■ f^C crjqM vi^x «vLiliHjbl «^>ina itjiiEi r<*l
l1'>4iaJ«, *" r t>it1 ibr lii.rjk nmy 1>* «ostidtf^t h rB^lTi-
fal |i<jik(4i4u(* uf »u *i<*v'*-"''^-7 vUa tllbiE»!
ffll «luilj of (Eia rtftLii Ulanln» vf Hi* labJitL— '
ll U aearealr umoê^M^wj far a* |« «ty ib* ^ork ho-
fvrtPnU* aUDda'*! «<iii( vpan 4^*««tH ■>' tMlilfaa.
ud lliàF Qu Vi'rli If at ft Llitlicr ilftDiïlfl^ Ihab U ujujif
lbu*« iifftciJ.jn*- lo owmmtyiwutv vt Urn thnt-in^h n-
vLkliïD, Lh* «rv'k Lk4 hftti t*»*tlr ^^l mor* TuLud tii»9
•iVffa «uJ lu*;^ bt '««àrdad à» Tiillr abraaat i»l (b*
llBMi. Ur* «■jrUkBllj' ctrEuiKtaiJ it to vIaUbbLb tvd
pbftleltDA TberaLs qa biLUr i^wh !« (bit Jtiit»*t«
OB d !•»*«« of «bUdftu,— C4H«JnH»U Jlfeil. A<W,
thB«ii1b4irbB*4rld«DMjr>t«[«ribla«l IhmltAhAll
anil-»** K*i}gail iii tb* «mtfrn af ilm prnrA*4]->u for
Tfalv *TCflJl4iil V4rk It lA w*1l hbOWJ^ ihaE ta
*ï'**i]*d ai>ll»iil Iblt ITm» wotflJ bn atiji'fJluoB*-
Tb« luibk^r ba»lilaa aiLi4iiU|ii i>f lb* ilpmamt t9t
ftDoibvT D*v t-M vn la »*l*t Ib * vott fartfil
nthnii^ tbflonUrr booli ; tbi U" oiancruii* «otrv*-
pftpt lu >iH^ Tiilly «bfaa«l «lib tha rifil*! prufta^a
tbt It- bvtar m^^a lu lb* kAL.irle<l(a autl [iffeimaat
Af vblMnn't dltVM'^i Ujr lb* tdoptlaii oi » ivva-
wbfti fiu-vr ^jy*. *B \ar•1»**^^^t >llv<»f on'^ 'blitjr
j«4*« bta bnaa Dacta»lUl«<l bv lb* n*« *al>Jt#l
Iffej V, I IT*.
pjubabL^ no ûthnr wtt\ arnr pubUabdiI lu rbit
bvlfLlb ■■( ^i-\titii\y ft! b»i Ititi waU'bii4>v-a ir*«-
llkf. Ai 4 ttxL ftDd Mrarafic4-b«vb U ■■ rr«afl»L-
nrail; L^a ant h^^rtlT nptui dl>aftiaa of «btrdiva- Jt
■ LftUda •it*9trûà]y blfbar lu Eb« fHon'W* ft ib*
fTufdakLoQ ibftA apjr utbar vurb afitPD lbi*4iu4 aub-
nrf — «VdtfAMl^a VcMrn, o/ JVad, dh<f ^ir^-, Uaj,
Tha ftiifb^rof iMt w<\rt b«* aftjalfaJ la liiinfloa*
«ftcl of Ilia lain» baavLadj* <>n IbaE LinvMUbt «itmrlaiKo aa nb^a^elftB t» Ibrc» vf the lurjf rbar-
da^ftiitDvai i^r ibaillfioft. Ha bita fttcJidtnitlj la-
Varp«r4'#.il la ibe i>rta«pl *iJlu<in rbfn ni<<r«J ai>il
pwcllf^l rr<nL|f f iba lai?«1 «la^tir ab'! rjT]>cflan<v,
DBlb Aitb«rlf aa tbU fnfvijiJi. *«i»«t tftliy to-}» haarlaf
Oa Ibcra^t'qlJr' AUo^aiber iba bauli b4a b*40
f:T*ft(]<r Lpii>Ei>TdJ, «liUn II hai D"! bMo frpftilv
Dcraarfftj) la
Tira** kkjrTuni* alfiird iii]«rir|>tt»<i] up|i4^'tQeh1vi fof
al^A-ttluc till» rir^flu ihf 4hirpr4Eii pLauB .jf Lf*a<tnthi,
and til" ff.nTItat'mliidlniMhlTitaTLthint» ID4fba
■tctClvd "III! (aiU, aoil ilivnl'I ït l> >l>< |i"*m»i-'o
vf «tl ]>ratiilliib«r* tiutf, la i^pif d^rtLD4V!ir-<Bi>liluf
0. — Utio Itork Ml •ileal Joumm^ a#&tun wb'b ih* JuwmofetjLldtviiiLiaa^Biiiiifatja^
— -Vai JTM^MKif, April, m».
WAi'.WE {JO.SBPn GBIPFITHS). M.D..
OltSTKTRlC Al'UORlSMS FOB THK U.SK OP STUDRNTS COM-
MKNCIN'O MIUU'tFKRV PRAOTICR 6*«and Amfrlcnn, rram [ha Plflh and R>tii*d
London Killll«n with AdJItiont bjr B. tt. lli]Tvaia*. M.O. WItb tUuitraliou. In ona
ntnt llroo. voluuia. Clalh, tl ti, [LaUl^ luit'il.)
*t* Irt* \i. ( Df Ihia Catal'iguf for tbt Urma hd ■hl<rt] Ibli vork ii oBan4 Ua ptrmiun \a
• ubttribeit lu lb* '■ AhihkjlX Ju^nuutL or ih* Uiuiuit. 3i;i >«■'■■•"
Olt(iB'?HI1,[. AM TntPriRPtBALVKVIK AND
OTll(Kllt»K«»l»l>ECULIaKTOWOMlIt. Iinl.
StU. ,Jip l^ll. <tril1] t^ ûl>.
PBWBÏa'KTHSATIKIIOtlTIIllIIIXKkKKK OT tt-
XA1.X«, Willi ILIn.irallLiBa XUlaalll Idllluil
vlib lb*aitibnr'a[]Uiiiapra*aiiiHDUatiJ aorra^
lloaa. la nar L>ptaTk> tùIiiiaB of fJO i-a^rt», vUb
(.lllaa. rlulh. fl 00.
«mos OS TtfK s*Triiiï,im3tï. axd TStAT-
MEST or oniLDBfiD FKVIR. I >ol. •in . pv<
«liHWK1.1.> l'li.>lTli*Al.THItATI*SO»Tll» in».
EA^K« PECCUAR T'l WOXES. Tbliil ivailraB,
fiuintbB Third aaitrailud I^BdoaaillUaa. Ital-
ian., pp. dtS. tlvib. %iitl.
^ ON DISEASES PECULIAR TO WOMEN :iiH:IudingDi8pIa^'>'*'en'"
^^ of Iba rtaiua. Wilb uHKinnl illugfrntioni, 8fcnn<? adillan. mliad uod «ul.Igtd. In
^K ana baauilfutly prlnUd oKiavo luluDi* ofiSt p*)i>a, «tiitb. S< 90.
^H^ FrafaaauF Hoilaa'* vira l* tFnlj an orljiioa^ous fpaitrril}tiilu[iliati«-[OitT->f*o[a«D'ai11>aaB'a,w)Bff
^HproB ba^laalo^ («atiil. f^na^qnaDtl^ciAqD* aan p*- I JT*m% Talaa.aud ib abdadaallr afaj'lo aland oa Ita
^Bvvaa1l«paf4avU1ii>Ql laaratdiitaiaalbliijaaif. At a I «Va uailla-^^. 7- Mtdlcal ]ttr#rd.htyi- If', IMJ'
I
[(jHtrn
CHILL [FLEKTWOOD), M.D.. «.HI A.
ON THE THEORY AND PRACTICE OF MIDWIFERY. A new
Amvrivan f rom the foaitb ravlatd and*atai]i*d London cdllion. WUb oolatandadditiuit
\ty P. FKAKf'La Coxnim» M-D.» aiithorofa " lV*iiLiaal TraaLiaa an lb* Diiaaaaa uf Cbll-
dran." ta. Wilb (Fuatmiiilrad and ninaljr four llluitraiiuna In ona rtij haa4*«nia aOMfO
f fllana of naarJ; TDD larg* I'agH. Otolb. (4 0» ^ l**lbar, |1 0».
BofTO'iMUKT's exi-nsiTic)!! i>r till «i«»ic ituiiai'V «vitjiov >a\^'"\'»^'»x ■ww-v ■»■«.»
iXD HIUPTOM» i>P PREOKASCT Wlita tua ' afc« lL*4\\\oa»> VWi*"*.".".» '''***^ ^«*îl^_
•>4aMIWDoIdr<i)|:ta(**.inilDuin*r«aawood anla ' '«Wn». d»» aa\»«t» *'**^*»*'**^ ^™*"î^^
I» I ntl.ira.,otanrlyllm-fp.,ttt.xt,%»'li, \ KV>.
S3 JIexrt C. Lka's PuBi.tC'iTiONB — (Dixeatei of Womxn).
/THOMAS {T.OAILLARD),M.D..
APRACTICALTBEATISEONTHRPISEASKSOFWOMBN. Fourth
«lilioD.anUri[4>l iiiiil IhnrnaiibljrTfviHd. In one Uigr anil hkndiorn* a«tava Tolaai* tt
soil v»S*'~ «tib IÎI iJta>ltaiiana. Clath. ti OO; lHth*r, (A DO. (/ml fituiJ.)
Th» knthar h»» lak'nidviniag* nf ihixtppartunilynfrDidtil »j Ihtcall fr>raai>th*r>diti«a «f
Ihli woi\ 10 itDiIci II HiiilbT nfonllntKnfsof thcvei; rcDiarkiMp rirnrwilh «blob ll bw bstB
FBC*i*<d, Urn J porlUn hui b»n lUtiJcoUil tc ■ (ODioirniiiiBtTiTiiian. and ao UWr ha* b*Mi
Iparod to makti it a vompUl* Irralie* «n tb« mDatadTaDaadcuBdillaa o(iU InporUOl aab)**!.
A «MU olilch hu nnihrd a fiiurth •rtltlon, und l>tla«lB*lwllh<>i»l>ils(tiHaalle.falt>a iii>*tu(l<
thkl cnn. In il.< .ii.,fi.jiMT..f ntrvMri, In- .cblm^ i.f ■naloBI' »in1 pailnilo(7, wlllinal f<»4*nmt
a rvk(iiJi(lori «birl* filacM 11 fttoïMl t-mfjuil iha nnrfa traii4taii4>a4frp&(*«i.f ij«rmai ILf'falif*. 4**«r1^*«
«r crlLJruiD.«ia4 Ih- fhtar4hl#a|i1n1iini «kj^rh v«hiii« ijl4ll»«l>3r Eh« 4»[allfe4a4 J10r4lU***f «afk «p«ra-
duitv ihil «■ ali^ulil (Ici Ut[l« mnrfl than annauniv Iq «11 r**^*c[« h vi>rk vuriby vf C'-'ftd^l- ■'« iiÉtlkfr*
Ull' H** Utur- W* ntaniji Itfi^in ftom mtjtng Ih^U iDf thH b'fh rv^itarj Ln irtilEh lU i]i>Jti.4«li4*4 am-
a« « i^rfefTIr*! «»rtL^ (hh 1> «ix^'iiil ïon^Tip In ilkv Knt" [b"rl«rt«t4L]rili» ^r<*r«Bqi*>a.— ^^ Aifi^tbafat,
tfth. iitb IciHlnrvl, 111 ftiLy vllicr tairfutt*. Tltp Brrvtit*- OfiHrt. Jtnm-, Oet- MT4r
Diml i>f It» LvaE«ntj. th'' admlrAtiN «ilr^r inannpr In „ , -.. ,. » , ,^.« «1 it_ é «.4
«bUh th. .bUhI or ih- .iirt,».,»i,l dittf.,.. t I-r'.(--'Th..m..rii,IM''a> •■•■P"J«'l-»ortl^
•«ml or IbaUtHM» i- lMii.<l.-J, 1-.. uolhinit lo U "="•'1 ^'•"'"■T tlnriD wh.o M. I .«.t *>.! mM»lli
daHrrt b» Hi. |inBtUi..r.»f «ho -.ni. .«..«ht. •pw>'"i"«'-lj U iï*i Ii.r«.pil..ii w». .IbJ»
Sllaln.1 nrb. no» lo wM"li ftr r»i, r.>.r U .linir.itl •=il''*i>*il'. ■."l»iil..i.»JIB« aï»» >l.*f« crtll-
owHirdngHfHl .H«m..l.-ll(. Uir^.ulii(.of rtln- «■»■'"• f">m ■' .o.all.oM* hfotlit;., lb ^>i*
iBtfiifhtudia.i'u.'iinD. ui ■r!„m.-i..ni.i.»i<hi I -dm»" "•'•pidi»-"»-""»J. •»'!«•'» "•■•■lb..
«r»rl«r h.irt .nJ,|-i.l^ Tl..., »o1 Ih-rr wini lo "<""1'' ""' "• l-H"4.»ilfl In I»" TM»» alMr* •■•
h» oollilnf wlilcli hi. -luiurli ill-lltM ■•biiimilluna I ••• ■"""""'•'I •"■1 fiiibll.fctit.aod ■• tlt^nmfn-
Of 'Ilaoiivli riiid hllnJ ™uUt.. .iirl unr— .n»M- Ih-ni- ""•** '"■ '■">"''- Th» p*piilanir ..rU» ■■"* «•
BBuiiio. rh>»<i.ii>ni>howiii ihnmndiij.inay Dili o-Ji «rb"»"". •■") (i.<iir»»«w.. i..j«.ni-.u*n
tflV inilc^iluptinrlptohfTllalHloUirTailun.iiti lh»»iiB»l»rif.>t..m.i> m-iltr.] l.i..ai«». Kii )r»n
o..l.lr.lïiiiiib.(ulltjorih«faiilu^r-*ifi«i£««r,i, '• • ''"* V"""' '" •n-'ll*»! «'"lH* '— rtb. *al
Fab, ISl InTft, Tbi*™** • wiirV on "PI"*»"*' ofVinti
faoliïry Bullcanf kOHKOHUtiulB «ârk.anit InD^iDDln-
n"l>>IIIItb*
lM<lla( uaiiTi piuilDDiiuaDftli* DalMil HuIm. ti»
4riJ*r> ifif» iikai(«r, tb* atiwota nf ib4pr*tual lit* pa la
llTfhDtat, [Ii*f*lfan*«i>/«lal*ia*a1. aB4 I a* «!««*«••
hn,h,|.u< |,j,.aclldli^..P,,,,ThMn,..h.....l.lDlr ,1,, b„,^. |,il|«„ ,b,l PTOto-.,Tb.lB..4l/i.t
L.ih ,ï , ^^•^'*''"^ ,v*"^""'*i'"V*" i...f.-iiin.i.hi.i."— .-)i.eb.<oa«i«jita
Ttila Talavtnf I>(uC Tbuui<i« lo lt> lailMd foiBi MH« jri-l ^»ni<iJ. nipt. l»;4.
OARNES {ROBKHT). M.D.. F.R.C.P..
■*-' M>(i(Hii/-««iilrlnH(DSI Tftomcu'.Hui^Ofl/, *c
ACLINICAL liXPOSITlOXOF THE MEDICAL AND STTRQl-
CALDISKAIiBSOK WOMKN. Baonnil Araarion». rrcim IbcScfloa-l Balarscdanil RtTlctd
BnitliibRiIilinn. Innnc liaadaoiD* oeiaTo Tolaina. ariA4 mw. with Ifll iltoMratlaM.
Cloth, tt iD : t>ilh*r. •& aO. (Jhm Rtady.\
Th* enll TflT a na* •Hillnn nr Dr. Bsrnan'a «iirk on th* DIttaMt af PMoalM ha* *BMnrB|^
th* authnr to makv It cr«n mor* worthy of Iho far op of rha pr^ïfrvwïnn tbiia ba'ar*- Bj a r««r-
taB|t«iBaDt and cnnfal prBnine apann hu bmn founj for n ntw ehapltr «a tba â7iHteala|l«aI
lUlniinni of tb* Itla-lder ant Buail Uitorderi. wltbmit irnirvulne Ih^alt* of lb* book. »hil«
many u>n illflilralinm bait botn inifndurad «hatt *i|wri>noa haaibuim Iban io b> n**l*d. II
I1 Ibtr^for» hi^pad tbal tha vi»tiiina will ba CbudU tu rad«ot thoroughly and aoouiatol^ lb* prtaaal
oonilition of ^nioaolnjflcal ioicoa*.
I>r lUrori ilaait' al Iba tin! u[ li>> ptohHltn 1* th> work la a talaabla una. loJ ibHlit b> la>r>tT
Iha QlJ tonulry. and II raiinir** bni acnal t^tatiaj a-^a-nlioil ^7 Iba iirof^aaloa — i(h. S^j-t* i^tttCtitmi
or Ma hueili m ibiiW lh»I ll Ilia l>o"o "lailitiad li» a ^nura Ot. Brtlntfi and Irtlani.OtU IST»
o.a..f ll l.pUlo,[.r..-.ti...l.i>,n(ii.iu ..... .»owa | Ho olb,. „„«ol„,l(.l work bold. • llfUr >•»■
Btmlj t.lralatui) 10 In-pira •.lihn-li.im "-llhoolln- ,i|^u. ji _ ,. TI.H _~.k t.. li_. "- - ■-
«Kaiui. ra-hui..., pi.i„^„, ,,„ .'-■«". -o_i;o ;;::î;rb*,:;.i":;7r"...J.'';B:;'i^^" tr.%*p25i
tari-'O" UI^r.lloB" r-ïOBaclait »tLh ttl.i blivqtih of
oriil>IltiiarT.aii4lbaM<idH)*1ll taditsagpartH
IBHIrU.:-.B---.tl 1.1. ■BB.h lo .n>.,..b Ibo rn„.d u« .JI^MlrfH»:» ïj jS^
palb of tha ToBo, Mii«...lo,l.i aBd ra.lf... ib. oar- "«"'""«-"»■""»'"" ■"••• J"-». •»• "I»
Sla.lly i.f ll,. man .if «alun nu*. — (\iHiUnn TWaaaOBSd raTlwd.d'Moa.offWiM, d*M*w*an
Bun. itr jr«l ArKa». So*. ITT). 1 lb»«o««»*»d«'loa flwa U It* praJaMtar. wBb tba
addt(la*ali>B.il>*tiiapvnr*(*lHlad.aill wB*arty
all IbaaddUloaalsDar kBea(*4fa«JI<**BbJ*HlbM
W« pil» Iba doclof »bo. h»TlD( ny cnaaldtr^ I . . ._ .._ _, .^^
ablr pi «QIlM |q dJaa»".. <.r Viiinan, hta dl, ropy or , hair* tïtaBHtada ^o<4lb* lf|nr»ili If llii till idfl
■' Barav" Fur dattr iiiin«i]liA,^on aoil iQhiriicllou. ll Ilea Th. Aiuarlfaa r<'*r«acaa ara. tot aa fta|^lab
1b *I nnoa a bil»>k i,f cmal l.arulqjf. r-anrrS. and , v><rk, aaparlaLly fBit and apfcrrtalt**. aad V* 4*a
iBdlviilqal .IparlnDix, 4DiI aL Iba tAta» ilto* "ml. ; r-mlla^iy rfïninmaml Itia TatBW4 14 AnarWaa r^d-
B.iiilir P'aiilnl- TBii 11 haa bi^n >p[ir(*ia'.4 by va —joura. / "irr-tt irid Kiaf*l firiiiii'i. f^t
Iba piafaulOB. bolh III llrral Hrilalu ani) >u Ibii I It7&
eoBBlty. la ahuvu by ilia ..rodd -dUloB (»ll..wlii( ip^i „,n„a adlilo» of l»P KitBH'a naai wwk
I** ' rnAar* wbirh brtB« H ap id â««« !■ taa'y l**lPir*.
J»rr«ir lllutlr^tf^ from t*>*«in hUnwii «iivrlecrf rt^iiilie AuDnaf-lJ"*. ■<■ J «a t^ttfl it. ^j'o^^rj
bfll b^aviDfSB* roiiriued(»*acbKM «111 liB4*4tu*d ttoAilli«r vil fat lata^ t'*'* ^^ ■ -^li* p»
fraA tb# fftfC rta«t tie pii|l>i*% {t^>in ii" l«i« ibKt, ''1*% ilxUï m 4 »4nil4iit t#Ht-W«-t '*i|i fvr
Henet C. Lba*6 Pubucatio**»— < i>iwa«c» o/ Womrn)»
âS
PMMRT {THOMAS AO!)IS]. MI).
THE rKINrjPLKftANU PRACTICK OF flVN/f- OOLOGY, for th©
a*t of Sta^lfnU hnH ?ni>*lUiniifrt of M^diriita, In onft Inrj^ and iflry biridtom* i^nUvo
rttLriln^il «KEHriueiiltrirrD. «dJ ^■F lc*<lDf Iba
Vftlg* iiT lb* «ftfTlBkl ftbd ^auDac «fifrrklfiMi* flfal
proiif^'*' »ad pMfo'tDtid Itr til* 111 111 non* pTud'?-*'
«or* MforB rfMrrv^l tu. *«il Tir tl4«ltilDE o«w I'^+rt-
bfifiir*fea»ri*«L<J itr4l»<r1bail, whleb ao (it^D La t1i#
profM«i4a hMffr*f litf'-rs *#f"fetf. W* «Tin tMaV
aflar tuearafal p^rimar Itr^l b« h«>ii r*r«f9paelT^
for dUfrlnlaahof anal j>W. and i^iiAFalt j ftir pbl^
|a«ei>li1fal dvijg«ifaa aa4 ih* «tu«Uf Itopi^rTAQi
<)qa]tLr CÏ {"■I'Ol. bOD*a(,Ci»ai1aq'd HiTk tnt Ltlv
Wtifh &■ ■ who!'» *« hi*K iiuEf pr*]*^, !i JiHrr^t
i-irlata^l ■DCft'rik'ai, 1r* nnm^mai ^t4 imiftTtai
■ntlxilrfct iaVi]itt, kail. Id 4J>in4ilD>tftiii*#«, i(* aa*r-
1i«<rt'! ec^TirttuDa, wijl fviD|>«t kliaut^"*, ami will
rhirm rl^* ba<lr r» a v»*l d**^ qf «^qxc^Ufltftl
«tndr^nd )ltark1i3r4li> rlic Totara Ak( win» mtk*
QBi*. vUl f«*t iL4aiir*i1 IhftE I^r Kamtnl La» v«rl
*arcir4 >□>! wll rla^r^prl tb* rapaUEloa «blfb T4
W* Tiara «ramlaad IbWhoell TllbaOiV«l1lla|ttoV*«
aad *iU rarfif t)ia «rvfat 'tu-ly «if »lt «1i>idt*Lr« ihtq ordiaarjfara. aa4 aov lay 11 a>1da Ajip(lTai'<4
iL tiFtb'^41<M A Uric-ra'"4iiDi if aurafoU}' aaalyfad
patioBAÏ «it]i*rl4Df* to a iiDlijua A*id f"< u1i*-rVA.
Uan Ihita kp;* Tnrumt an litk*4«vi •*{ Wmn-ia whifh
h» jflr h»n piilillpi^pd, fu |rt-Ai lairt» coo»l*l> la
l^i« — 4vmlii4 •■ il rJuo fruu» a IËiorx>u|bl)r Uuaaal, I
br our ImprHtftOM of tl- Vrva ArM to Juti. Mfib
pa^ Jtrnwa to lalara*!. aod on* l* tlrucW »lLli iha
]>i*fiEUal Ittt of all Ibal I« uLd f( U la^*«il tb*
If D«>>l«i^<al *i>fV. fur Iha ;ir«4mi4»DAr, lE* >n°^t
U B0I f^«l pqh]l»h*d, Eiral L«a»l ««bu?! bqI »**nLL
Wft flitnni'i uti] ^hl* aor^fa f^rwrJ ■Lib"EiE rtA-t-j'
eoviicUEit nQ^l «falc ap^ctJiUAl. wbn liaftiD* ■ ap*- aUn^ TL^i. lu ifiF «inuii'ioB. Knir»ArB t'fl4c1]iUa
flt^Ual oalf sfrtr aa -loallfM imlBlDflkbd tiptrL and PufEtcwnf Qfbme*i\-tv !■ itDitr-ub4«<4 17 1b*b«a|
aavaat a cao^ral b<iapLia< pUr^kirlkb tai aurg^fiit- bi»h Tdr lEiMlnO^ai. a« ■'«II a* *>>" f*a*t*\ prartU
Tb« buok r> Dal an» tD b* JiuEU* j|F4tic«4 otfp. bat llnpitr wbtflb it m pr*«aat pqbLlabtd,— ^n Jffd.
«iJliaDaratbaPiLliraJ atuilr vl^jb*Qr»lii«lil«. ^l^1 ' Jifi>nM'y. Ut,j. UT9-
niWCAX (J. MATTUFAV^. }f P., LL.D.. F.n.S.K,. He.
CLINICAL LKCTUUKS OX THE DISRASKS OF WOMEN*.
pnfH, Utotb. )■ tO- [•/•'<' Ktaily.)
Ptot HallbaKi t>aninn'i orlKinAliijr (ml tiit|[f*ti*»i*a* ar* •nfllrittit (turkoUa that vbal-
trtf lit mnj m* III ta laj h*lnra thr prnr< ilnn I* *«ll anrth Mtanlinn ; «bil* th* imiMriane*
of il» lahJKilt iliicunad in tli* pru*Dlrnliiin> will (iia U tpfciul nliraçllTfno to lh< poolliing
fbjiifinn,
Lvnlura I. On Miiiad Aborlion. II. On Abnormjtl P>ItI>. III. On dironk Caunh olih*
Catvli Ul*rl. IV. On Orarltij. V, On Priimidiiii nn-l PnrnmctHii» VJ, Oa Kindi of
rri<m«(riii> VII, On Piirni of PnnmaUitlt Vltl On Punful )ïiil!nt. IX. On Arbinf
Kiilaair—Pj'untiibrntU— Eirleturs of Ctctbra. X. On Iin'ubla UMdni. XI On Vi|>nifinnii,
XII. On ânuiDndia DjimanonhoNL XUI. On Qcpalla Uliamc in <l7DaiDala0 in-I ObnUlrloa.
XIV. On ribraiu Tumor of Iba UlarM.
rmADWICR (JAMES R.). A.M.. JU.D.
A MANUAL OF THK DISBASKS PECULIAR TO WOMEN.
naat laiuiDa, rujpal IScno , ailb I II II >[ ration i. (Frtparing.J
Id on*
Jt
AMSBOTITAM [FRA.WCJS H.]. M.l).
THE PRINCIPLES AND PRACTICE OP OBSTETRIC MEDI
CrNH AND SUROKRT, in rrrirtnea to tbt Piocrii of Partnrilbn. A nitw andaalarcnl
«lltjiin, thnrnufhlr raviiod hj Ih* aulbor With addiiiuni bj W. V- KlAtiia. M.D.,
PriifciB^^r ol Obiutriui. Ac,. In lb* JtlTemon Mxliaui Culloii*. PbiludalpbU la one I -m
and bandjome ImpeFial octavo Toiunir ai 41U p>HÏ*'< «trongly bonnd in Itatbrr. «itb rfiivad
band' i «ith tilt;. four braatifDlptnlai.and naniaroa* wooit-tiitt In Iba tail, ooataloioif In
all naarljr JOO lac|* and baaotlfal flgnmi. IT SO.
IXriNCKEL (F.).
A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT-
MBNT OF CIlILDItKD. for Ëludinle and PraciUtionara. Tranilatad. «itb thr i">n>tnl
of thf aulbor, from thp 8*flnnd llarman Kdiiion. bj Jaau Kkad Ciunwica. H.l>. In
ont ootBTo TOlona. Clutb. $i OS. (LatrJr IiiifJ.i
qfANSEB {THOMAS B.). M.D.
ONTHBSIOSS AND DI8E.\SES0FPRE0XANCY. First Amerlosn
frooi Iha Sanund and BnlaiEad Hnjtlltb Bdillnn, Wiib fuur «olorad plain and llloalra-
tiOD» on vood. Id oa* bandivm* oolaiu roluioa ofabunt ftOO pogM, «lolh, t* !'■
34
Dembt 0. Lea's Pubiicatiosb— (J/trfici/ery),
»
PLA TFA!R ( TV. S). M.D.. FRCP..
Fr-\fttfir of tUtlilrte Mr*lti*,r (it Kt*t'f Ctllrf* ,ttr , Mr ,
ATllKATlSEONTHKSniKNOKANPl'R.vrrrnKOFMimTIFEKY.
Third Ani*rt(>nn viliiWm, r>ilM4 by ih* BUtbaf. K4li*d, «ilb addlUoat. bj Kidit P.
H4IIUI*, U I>. In arir hnriimm* nctiTD Tvlamr of kboat TOP p*8*'' *'"> UMkrlj K<
lllaittMiou. OI«ib. tt ; l*i>lh>r, >ï (/mi Ria^p »
■ iTHkCT rnoH mm idthu'i purici.
Thii ucond Am*rlc*D ■Jlltoc of my iinrk on Hlilolfrir bdng (ibkuiil'd Wot* Ui* MfT*.
tpoDdlnK Bucltib (dltidD, I vnnnnl l»Itir thow ikt ■^]%rr<'i*i>i'n of Ik* k>n<l tcMpUon ny bsok
h*( («i-flrM in lb* t'nUcd Hulta tlitn Xf leccling lo ibe |>iiï1t>bci'> tn)u«M llul I th*«ll
nfMiruniltrlik* tli< tamir nf i Ibfrd t^iil^n. A> liill* motr Ihko ■ }(■( bts •lapM') mum
ib# avOi-nd «dUl^n wn< Ï"«iioJh thr rr nra uniurillj Dfil iDUDf «hAD|[*a lj> DAk*. bul t b***,
ik«fvrlb«it*ji. ■ubjdAlti] tlid «DtW« «t>rk 1o ctrcffll r*vl«ttn. ^pd inlndii^d Iblo it ■ naUc« of
in<M( «r lb* mors Impodnni rtcint ndditinm li nbiultif Kim». T« Ih* ap(nal«« of (uln-
*lf IrMomy — fomtrlj dwrltad «Ion;; with Ih* CoMartlin irrtlon— I h«*a iiDif 4«*ated ■ nia-
!■(( «b*|-l<(. TIi« cilllui ol tb> Stcond Amarivin (dilion. t>r. flurrlt. laiklud it with uu;
Tftlimbl* note*, sr «blch. ■> 'HI b« nb»ii<d, I haia dotty atillail ajn\S.
A r>« uatlD« attha iTscIuat «^llluD ■(« luttloload.
Tlia ha4( «lïrlE^O IliflftQliJftfHf pnfcUtlifd Lb 1L« ' Ttipr* Ï4t b«rD h c^titritl HHBluK^ of fl^tha II
Kufllib l*i>(<itt* !>>• wniirB In irMtt, pl*Hnat
■tyl*. «llît'.tLl Ibal VK^l»<vNlE3P vhltA «btfadUrJMa
pDn* mo.1»rDigkl lilfhl^ prar^qiiAii'WdrlIh Thaaa-
Ili.i> It unit. II |i laliti ibi iinir.. |.>ih \n |>rarll(a asd
IbKOfj hiBlbt tHi t4iMi0]1( <v^Tia*affr*t4<1«eLJ.
•uj •gnioi'Diirfiiri «f ii>i>ii ■<. •nri'iT 'i' ^'^' v*i>it
of 1)1* praclUiriMflr. W« vtpill.I «(Imllf ■»• If lu Ih*
htuili or (II vbii praoilu nil<lwiliry. — Omntua
^nra. V MM. ••(,. II«t, 1«n.
It* prYif«BB]pQ *■ la it'b'th Fytf«(i«f v/ frr Pl»y»
Mf "> Vlf *. !l.i*ll t» * inK - ' ^' '■■» '^* .inrf-».< ml
nTltlva and kddli]i>»> i' j
witl nifi l.>"*f <V*t ltï..i , . . ^ -..- „ . - '-•
ailJIIIultl Bikda by i'l. Harrtt nrv vf viir* a 4%V.
±t\rT Mt TQ mutt at wl>t lli*^ vn ■(■>fa ia aab.
Ui aod iTHirr la axtwt — d«. /(■■■ni. «/ Vtd.
<«tmA*. Jan, im.
jy.MlXKS [FAXCOVliD. M.l)..
A WANUAl, OF MinWlFKKY FOR MIPWIVES AND MBDICAfi
HTirnKNT.^. VTitli ill lllaalrailoiii. Id Od« n*>l lujal 13iua. r^a» «f Ml) p4<Mi
«lolb, f I ÎS, i.Vvw RtaJy.)
n* baok la irilliao la p'*la. aad at hi u faê-
■Ibkla aBiMbalnl laotuif*. *ay 1oullli|i*l lald-
wtl* «f Dirdlfal Brutftmc '«n «»l1y A)iBfii<ab*itd Iha
dlnoliuui ll will aiiiliiiiblrdly DLI k *aal, •Bil
vlll b« |>nftnrar wuS no>a for tf b.iin 11 bat lin*o
|>rvlk«rt4 Tb* ««liii nltif; i4iifiB[|.>rit m Iba l^fM
■111 loifi.usd •■ly uuruL — (Varliin.ifl JTnf. AViw,
Aa| I»TV
Th* tlyla !• cl>ar, a*t lb* bMk >lll. dnatiMli
(ba ntlal tn ih* n-ran» 'ar vbiiai ti It laiaa4M.—
ttin*tit Mtd. TVhh aad Untt'l; A^. M. Ill*
Tb> hiHik la aiiiHo vuh •• Milt* lackabaal lia-
fi»4f a< [kofltlb^a AujrtiL]*lliribl«l4*tf««r taad.
ittX tTadfoE «aa tbUr OQ4*Faiha4 ilf* dJr*n1«i«
It "1L1 iiDduabi«dLy 1>t fttiad 9*ty ai*faL~04ii
I JTuI llrrar^T, M|>l. I*T1.
mitK OBSTETRICAL JOURSAU (^V« <./ poi*ayr/orl680.)
THE OBSTETRICAL JOrRNAt of Great Britain and Irdanil;
Ineludlnit HinwiriHT, and Ih* DttRAHKH ur Wohkx nim IsrintR. A monlhly nt
a fiplavki |>a^aji. Tiiry hiinliuiualy printed, Sabaiiripliimt Thrat DulJa'apvr aaaaa
SinK^v Kuttibart. 1!t crn1t*acb
With Ihn J.iDDBry nuiob*) viti I*rinlnalr Vol. Vrt. cf tht ObiUtrleal Jaamal. Tkt >n<
K*. of Vul. V'lII. Hill h* iBuad Bboul F*b. Itt : tb* ■■ AuEniCjiii Kcrri.a-MEXT" of It pa<M
p*r Ko. «ill bs dlnuntlou*d. and Ih* )i4rlodt<nl irill (ta*n«*forCh «osaiftnf fl )■•(** per Boailptt,
at tha aioftdin^lj Itaw prlf* nf Taiifit lldi.i.iBH \tr antiiiDi. ft*» af i>ntla|;*- For that ItiJUif
lam th« tublDtibir will tliui ublKln luor* IhiD TiU pnic'i V" nnnam. cunlaiBlac aa ■«(■Dl aBi
«aiialy r,t infarmatldD «liicli msy be taliiutiUd ttom tb* laal that Vol. VL *t 111* "OnTaiW'
Cki. JuuamL" genuint in
Ix MÔ!rriil.T SCHHAIT, OlKKCIC
" '■ pRDIATKtO
S«w»
-J '"
341
L
Oatoiiiti. UDHHiixiotTiaxi . . « Artt^tM
flau'i(;ti, PnitTica .... A "
OiHcfliii. Conimiii'OtiiXlicB . . t "
Rkvixws or BvoKi ♦ "
PnoCEtoifiiii or SoriittiM . . 101 '*
Is Mo»TBI.lSuK»»BÏ.O««T«tnlP 73 "
■nd tbit it ngmbfit am-in; lli cantdbutoM tb* dlitlnjtnithad oamat of Liiitia AtTaiti-, J. U.
Avii.iMi, RiiarKT BuKaa», J. linn m IlKiiitRT. KAtHjii Boibsii, Tnuati Cmihbkiu. Flbbt.
wo'iB CnuKFiiii.L. ITniBLiii l'L*T. Joiis Cliiï. J M»iinewi Hcacai, .4 mu ni l^inBK, Ru»»*f
tiKEiaiiai.iiH, W. M Oniitï IIkwiit. .r Bimr.n Hir «1. Wii.M«i( l.iii?>itiitii, Ancct H\1-
SDiiALn. Ai.rniii Miatidw*. Ai.Ki. Smnox. J. (1. Swat.ia. I.*i»DN T«iT. Ktxrtu» J. Til.r,
K. 11. Th(siii]|.ni!. T. Bi'irmn Watis. Aniava Wiooi.i>WDntn> and nany oiIm* dttUn.
ftniahad prutiilliDn*rn Ti^dar 4unh auiipictn 11 hu anifily fulfiliad Ita vbmt m prMMiUaf Io
Uw pbyalciaa all that li nao and Inlafciiloj; lu Ibe rapid darotapcuatl ai AiWirl«al aad gjaa-
oolof iaal >*i*nsa.
At a Tiiy lar^ inaiaw* In Iht lubicrlpiion Hit 1> aiilialpalad uiid*t (hit raduftlAo in prWc,
|[*nll*maii «bo |>rn|.<ia« lo aiibrrrib*. nnd labtcrlbsrt initadinK to rants ibtiF taHittiiftiami,
ar« raaommtndvd tu lo«t no tijnt in inahia^ thair r^iuillan^ai» at th* limJt*>d bqiabar priftt*d
may al any tin* bt tihauatfd.
ThiBlKAFitlnl; arury ttraJltbt l4htBal. (Lglt*i I W* *abbi>1 «llbbaU Ibt tif^tat^^^a nf tba bJbiI-
nt iba ba.i ubatdrltal lluralDTa tion Mi4U âi«\TV.V'.«vUiiA^>.u\«ia*V««u*a.— lrai<siii«aai«.
Henhi C. Lka'8 Pvni.KATWVa—i,iti4iei/erg, Svrger*/}.
as
TBISIiMAiV {WILLIAM). M.D..
A SYSTEM OF WlDWIFKltV, LXCLUDINfl THE DISEASES OF
PltE^HAKCr AKP TilK PrEKPKHAL SlATK. Tbiril Amvican tdUion. T*viF«<l hj
th« Aulltur« nhh a<JiU(f4aa b^ Jovn &. Pabkt, M,D,, (JbAUtrloiab loth* rbn«il*Jpblft
UutbtlAl. àe. la DTI4 lurge Bud T«r7 bAik<l»Pi« ortairo Tcjtum«« «f Ti3 pag». «tlh ovtr
ftm work* «D lJ)li 4ii><j+o( hAi4nift irLthA* trtti , W# tEli^tff v«]ri>iiH ib* ««««dLllnv if IhU «K'tl* i
tj tbt frtniiflBfj irj(lj which !!► itriLlii i'« t1-wi *i«
11r*ELiuT*. una «ouliL j<ii*i^ il>«( kJtm tra ftir phf'
ftltlAB* dqfjtifkf tnotti «llaDllun to ObiL4lrl««hu
■r« vUbt'Ui ll- TTifl iiqEhi>' I* dilildiill^ m tu A a at
I^^B «tltflkbt* *0J CH^D'4'TftIlTt <]«v*. taO In uo
ttFkDCh .if UBiliflifla in Tïkvh* rn^ra taIujiIiU Ibip In
Wt fef*cTiiJ 14 nM 'bt kliAQtl'Xi Vf «ar na^vn io i
JmiI i<hl btitk lit citlitvtr«rjr, Tb* fofmfit tJlikq*!
b*r* b«rg iDi?» flfuf»h.y f»(»lTFiï bj» 'h* f>Tt»]
■ u-n (III 1>'>rh a'dt^ "f itii H^flBnlfc Tn iba ]<rp|<ferMl
k 1*^11 vf iltv pF«*iCtr ti^ti^i» ThflaUtbhr dm niailt «■f'
AllalKlUiqa •■ ih* p"'*'**' ** -t-*Mt\Ctl ttUm^l
A*tm4 t-t r'tvlf*. &»'! «4 r^nqtt tnt 4.i1rn-ra Ihff.j
«hlJlt/ wllb wbicli rh« ink hbt bttu pqtf"fa<4, j
4litilD[ il^tlr iili«ïd->bix Ufriii IftcrvM, Huil b*TvJ
.,>^- «. -Tp. ,_, i-MhBinfJ-ifrrydf ïb* |>t#**J*i J»irliWof«>»I
rkl TifctoE liulh Id thla «vuniFv *«J ;d Aibrriot. la **^
DotJr;aK lIiL» ihi'd ctUlun* "4 in^à ob y dlracl ^r- Th« hnnk Ucr«ulrlnipn>Ttil^ laJ ^i *9tt, wl^lb*
IvbUob Ui Lh«iJL(r4rta<*< LiAiWMif 11 KQiI U« |if*>U' w*IicjUi«<J Vy lhu»«l)4 Artir^Lp^ lu kv^p i^tUii m
fiaatvfa. AlUtUDib ^Jr<1ti\ij r*T^ir>l lli^itHEl^oat, tli'* 'h^mI jidrftDt** vh'Ch 41* l>*ini miiio in ^b*
■Itb Dolsitfw nadltftfBt U TkrkiMii v^ituo». iliv u*i i »i^-ij •ti^ifftifttit.t.^lt*têt*n itvt undlt^rit Jnum.,
4AUrftttiiMi( ujinapUoDlr taftf*«pu««.- CMajcri>H flor^ II, ItfFtf.
pARRT {JOBS A). JtfO-,
EXTHA-UTKRINE PllEONASCY: ITS CLINICAL niSTOHY,
iJlAnxoSlB, i'HOGNO^l^. AM> TREAIMSKT, In not bafidtem* «oUto vvluoie.
Ol&lb. $2 ifO. {lAtuif It$v>9dA
THE PRINCIPLES AND PRACTICE OK OHSTKTRIOS. Illii»-^
Inlad wlrb iMFg* LLthoifTftphtc plit» coDlilnLrig od« biuiJf*^ Bn'S Aflj ni^f AjEtttf* froo.
oHjIdaI pboto^i-Bpbi, »nd vUh nnmtr^ui «uod-cnti' tn ont Jarj^' *ad baiutifuilj pripl«i J
4i3&rt4 ToJnmi of S&O doabl«-«ulamn*d pftgu. nr«fijtly bovad to «l4th. tl4^
a «Icnpt* ptM*ftlfc11ki(i o/ bin pfcj-ticinJftr vkw* la iht i —4m V'lf Tim", i*til '^. l<At
»««à<>piDdl. gfm.a-lfMj. Jl#ha.*^B»-<l t^.m ,^., 4b..-m=un. cjnh.A»-rk-.».*/k.-BtbV
«qr*1e knd rmrUJ pielurlal LlïflftLr«tloii>t » IKil no
a'a Spsoiminiot lb* [ilttat knd UlUi-prwl «Dl bvCnrwaidaiJ Io an; ftddrMI, frc«bj ukl^
OD nocipt «r rii e«DM In pattag* *tamp«.
STIMSON [LKWIS A-]. A.M.. U.V..
A MANUAL OF OPKHATIVE SURGEHT. In one Terv h«mI.om«
rnyxllIuiD.TglillDeof AbooCSCOpigfi. wllb JJl llliiitr>llonil4 «lolb, fl SO. |iYw Rtattf }
Thrw^rli baft» n> It > «OIL prlilcO, pr>>rsi>l)r frih!ai\iif IbntB. Th« iioik !• IiiD<1>oint1> Itliiu ,
pt^*^ Tlj« uvHTiH.bf 4 iwrii-ftl ut Ibn vnrk, vtd II l« t cUftr Ébd uiafDk TvlillH* . ttrij «rni3i«ftl1
^a *iti*™L ^^<* °' ^^* ■Mior4l 4j<jiuhtii i>f op*r4U*t «hupM p9H#ij [iDB Hia i-rnparnEinu '>f ihia Vkjrltl
turitrr. «JHI* Ih* pnul^rKi vntjIkLfll hJi* pra*«p[*4 du** afrty inih Ihn 0M4««U7 'ï' poDdirlai av*
10 hiHi willihQ h TAiir AiïD^^** «D'l lulnLllall'J* r-*rm i lArg*r v»Fk> -«n «uiKJf | Cvr dv^ctlv'^^l^* °f f^hTa
lb« iBlatI anil mi/al ftfipruT4<l ■qltcllona of 4^Ii«rtriT4 i ljun*,fe>ll j'H*«4ri In* am «b«lljDil tt£ialli »4aL«A
(tat lUSlUBl dl-JHIiiOt t» il..[ill..J aDIibl' 111» 11— W.(, JVlif ^/Httnill. Sttf.mt.
.at(i«lo<uiiiIiH«..liiim»o".»inBa«l"f pr»""*' Th. .alh^t'. osoL.n.u tod th* nnt.rfoco ot
lDft.m.ll~. >""'ï •l»»lU..O.(«fc-*. r, *^(«»l (,,. ,„,^ „,^ .,|„,BI. Ut,.l,«l..u. rt'iiu. II 1» b.
K(»anl, Ag(. 9, tJ.a. IjImt.J »ltli Ih* ttll l>oo»i fur tludioKot njnnrlr*
TbU vQlaEa* Ud*vott4 «ll1]t^lx I4 iv|i«riiil«*««r- jtupftr^. anJ «■ vu* ot tviutmat^ m ib* prifititoair,
fT. aa4 lilaouiliri ■■■ (ainllliili* ihrtliiAvnt Vilb — OlfirtnaiUI I-inrM >ia4 (,Vtiir«, Jalji ît, 1*7».
el-, ofanOpM» >*tibal>»ii< lonvsad-tnl* Kit
COOPER'S LlCTrK» OK TttErRISCIFI.UlX^
FaicTicaurSmua*!, lal •dLMo.d'h.TOur.tt. I
aiiit>nx'itixitTiT<tTE8iiti> rK*CTrctor»rK' ,
ciikT ajxiith aiUfa, impTiTfit aod 4Li«ff4 VfuJd
nmo, abui)il>>nnpp. .laiibar.ralHlktBiIi ts M
TRKfRIMCiPLES Aim l'HACTICÏOPïfHOEKr
l>r WiLLiJial'iaati. ru.!) K, Pi<if«'iof Kaintjr I
la Iba Dstnralir oIAbcid**». Ult*< br '•>■■ I
Vaii.L, K. D.,PTi)t«>aar«(SorHix lath* PanD*.
V4dlr«1Coll+|4.Saif~a(a(b« raaa>fl*Bbta Hot*
pital* Jbe. In DD* **rj hiatfianif 'Ht4TA vaL bf
■ "' !>■(*•, nitiAH il1a>Iratl<iii>.Ttr>ili.4s ia,
MlU.ltH'!il-kl.Mll-I.KSI>r Sl^fiKKV ^'Ollll^ Aoia-
ni-*i>, fivin IIh TMtiI (Utnborth Edtlfoa. la on*
\»iti- »•<'. ••>l.i>(;<IO tmtm, «llhMo IIIBitTalhiD*,
Ult,l,ltK'R rRACTICK orsOBDItlll. Vuunh .IBS-
Ttcaa^ 1n:u Lïi« tall l^ainl'urcb fAiUm- Uftitttlbr
Ikkf ■tUfTlutb «klluir In nne]arE4>'<v. *ut.Df naarlf
IM;a(w,VIUl3MUIlutnlluD*:cloU^|i;i.
99
Henry C. Lra's Publioations — {Surpery}.
flROSS [8AM0BL D.), M D.,
y^ rr<if for nf S^'Tfy !•,>*• Jifirtan M-tltmlOrlUptt/ nOadtlf^t».
SYSTEM OF SUKUEKY: Palliological. Diajfnoalic, TIiernt>«>iii(c,
>b4 Optntir*. [Ilnttratad b; ajrwkrdf of Poarittn Honid"] ^ngtniinf Ptflli «Jklni
«artfiallf r*vi»fl. >d4 tmproir«4r la («tiUr^a ind btituiïfbLlj prtDl*d lupariaf «A|at«T«^
iiu« sf kb««t 1100 pf ,ilr»P|tl7 bnuBil in [■alliir.willi rsLirilhinilt. lit. (Jtiit /tnurf.)
tb* rufillDS«>l faTor, «anwn bf (ba >ih>uili4fi o( luinutiT* litg*«lltl«Di Of thU (r*tl *«k,
fteTNtbat 11 hu lopBHarqlLj luppUtd » vant(*tt by Amtticut prMiiiiotirri and itudraU- la
thf prO'Dl itTiiliin DO pnini have b»ti ipand b; Iba aotb»! la ktlnK '< la (T*Tr T»|HCt fall}
ap l< tfat daj- To ttitt Ihit a lire* pati of lb* frark bat bâta rtwritUn, ubiI IW wbol* (a-
■rgod bj Boatlj oDOfouTib. Bot»liniil>Dilinx iililoh Ih* priri bar hitn kipl •! il* TuiUKr T>rf
si«4«ral* rai*. Bf tbo m* of aeluit. tbootth rarj ItglbU tjfa, an nauiaall; latf* aaoaalol
tBiltcr il loaAmiad in lu p>Kf«, Ibo Ivo Tolum» «nntalninic u much la ftior or ita ordiawr
ogtaibi Thii, vombÏDvd wtih Iht in«it r>t>(iil intrhaDliral ti*Tulii>n. aa4 iUrcTj darabltUal
lac roadortt yt Dnaoftb* ob«*p«al wiifki ucbuil>la to Ih* pr<'ffuiun, ËTar^aubJv^t ptirpttlj
baToB|tia( t« t bt Inmalii ot •i»it*i7 m treated la datail, ao Ibal (b* oadtal «ho poaaaaaMtbéi
work na; b* »M it bai* Id It a ■urgieal llbrarj.
W«ba«ao«« hmufht ..unui loummjutim, asi] i tiitlna utOn—'i "Sorinr,''*!!! *aa<T« bit ilUt M
bava lalAHa r**d a «i-rh »\'ii tivr |4«riir«J ««lue of
■o p«nn>f<l;t L>u* i-»ffrih^r lï^u H-f I'iibj iiF%r'lilf'orr.
vfïpn in<iiinci|]l>.nn •i'njï*fliiiIlU*iufijf*nifclion ba
r#qutr^. It^ vt^rt.t'Ti ih«n>urrmr>.ÉBM*aïi'lHï)ttaa.
th*>«irv<r:r uf (lia v«ilOI>irlovfu1I)r n^mntt^ In 11,
Tlie ai>il.1n l■l^I, \' •!• til-[i<rli>ll) uiifnJeiltrRl. anii
»t4mlii<titt!rpffc#tv#MMmL» ^Diutl aralpaenuttlt'
B«nl lu tftf llflt va ■•«Uf-r* Il Ih-i Fit 41»liii->J tttanitfj
aTitHtfiHitl plkr« «B ■ ir»r1l '•(rriitfUir. vbllaa »Jtt*m
atinrirfT lit* ih» tinwoi ntirm uf lunt^rr ii iha
ynr^lim tit tQTt^if Tli* iiilnUDgaDd Hnillnf «flhr
•T»rk II aa»<«pl)>»ble: Imlinl. It i>oi>I>ul>. In Ih*
Utur r«ipr^t. rrmitkaU^ viih Bnrli»b medlniand
•QrnÉ^alcWb-^tuiMl pd1il1f*tbiri', *hhb ir* i^'ntrailf
to wr't'-btaly iiachri u lu nwiil»» rt'blodinc Imlnr*
IliaT ua anr lima iB gia^lNib. Jiwrn. ^ JIM. Sri..
Uanb, 1R4.
DraroaVBartarT.aitNalwBTk.haa bacna* ittll
malar, Imin In •!•> ami cuirit. In lu nMiTrrvnl lomi.
Tba dÉIlHvn» la trta^laQvih^ cif pairv !■ n^i iH"t*
Ibw 100, bvl. ib* «lir *'T ibf T-*JI* l'aTLitR lv«n lii>
ttittml u>«hatv«n*ZI*Yvt<i««Ou^>al[r lamtM '^ala-
phMit.^tbtrr bu b*rn riwm'DCcun-lilatïblBuMIllDn*.
vhlrb, uinlbM 'llh ih* alUnlIDi», ai* Éoipn»-
Dienu—faiitf. tanM.Xoa.lS.lall.
Il tonMnw, aa pafAKUf M paailblt. tb*<|uallll« o(
alfit-loiill (Od «Brk afntrnnat. VTatblat tbitUal
PnwuiMl'r r\rtl" tl ii l'aritt^l. •vbofar'fVt*. I
tholtwl, iTlrl». anil ptl.iuitl». W> ■,>'->i- txi.l
anr llttBf ID»D^ ulit *Pli* Hi*<«plT4k '
tf fallu, nr n ni| riTiniil uniraaalU- Inii '
la lb*gl**n nitini-t.j- fi p*«ï**. Tb* Ft' r i_l . i-n'
bvva laiinrn*t, «itO il,p«jtfh ^t*4 rt^avitnvf |n«l
powan ul fuii»*!. mill (h> blfbHf in^r i<f InUlhtflval
4l^plih*Hndiii*i.hii4r«l JkB7calLHn,auilaraaffVtal
ofa4]ûiiJpf4 knfrai*d«>aadHBaaaAfaap«a1*Bi*^Jf*f-
JM. J*Hm.. V'b It»
Al airhala.aa rtftttt Iti» aart aalba r«|naiiatillra
''Syaltm (<r ?uit«r>" In Ib* lïncllab laojniga.^llt
£AaU Xnliial und Mary. Jftrn-, OM IbTt,
Tb>taaBia(alBr«bi«ala»*ibcllmu*allaida nvr
aamplala liaa «if ina «nr^kai M^alAla* nf tb« tef»
^aa* j«ara mfi> a* bad Ib* ^■aanra ol praaaattaf tM
ar>i cdliliiri «r iltctf '• 9u*e**7 Ia th* pnfc«*ba aa a
«rab of aartwJWI 'iHlIr*»: at»4 »>v trchavflbf
r^foIlBif yaarfO'aifafWvcw. iabqr.a»J •l"4y, aliian*
r1«i,*«4 u|inn ibacraalvofbbfA'^ n*. Aoif i4BliB4'ala
se |.i«wlHooaw dailf II» of ffcMnt ibair llaraty *lib
a Irc4iur« of ratal «rm, «a «aa tlA^f? aaaaaiapO Ua
pamhwa afllmc l*n intunsi of I ni xnir rMaarrh —
i n<dt^ltt*Ir>«a■■•>r•an*r)— H'-l > ■•!* lat-.tet*
flfnptirftitthn'.hut a«p|mlkCraisi,iinivrBar:glraIib'4rf
in^j prviiwin ail tu é*i«hfiaeou. — i^W. «ai^ nr.
Mnl. CAtr. itw, Jas. m t.
tir Tau mxK *CTiioit.
A PRACTICAL TRRATT8K ON THR PISRASES. INJCRIKS.
and Mtir.iruislloniof Ih* Itrinm} BUddar. Ih* Pruatito Oland. ladlba l'ralbr^ Tblrd
Bdillun. Ihoroajtblir Kariiait and Cundinrad. bj iitifliab W. Ohu«*, M.D.. Sarcaoa W
tba PbiUdrlphlii Haupilui. In «no baodaoDia aeMTO Tolamaaf AT4 pagaa, with lïV llla^
tratioaat qIolb,t4 (0. [Ji>i< /ii Horf.)
rarl*laT*nii**ail|P^unllnfiirmatbio.lhtpbr>lr'l>n'(aB((oribaBrlnatf atraiia — ÂSanla Jit4. Ji nm- 9t^
0r«ort*0B«aii0adnoaiirbiba4miai*ibalroc«e*akiiri| 16* A,
Bon ibaKSKbt» ibao tbl-, • r«i«d -dHioo o( an .;■ „ ,. ,„h plMar* a. b» a«Ua taka u» ilU ai<
».ll»BHt«"»-ani' ■"'™a4''a'"bT»'7 «hinH 1>»wHli- - " ^ .,....-
pal H- luplvl' allb bandauaia illn«1raii'tni ^n-\ it^hm)
iduai. Il b» Ib* uonioal ailTOiIM* "' Wlnn maill)
oniBptaliaiiilad.bTItaf nKiaii able and praitlaaloiinDM
In abiah tba larloiiB >«I|)im(i ««a ij.nnmli-J nnii
■mn»d Wahaartll)' r'mmBirnallioibt pniftMlrjn
>f ttaluaMtaiMItlmiUllialcopoRaDIllumBrioMli-
Hiiik In ailtïlilMl) lira Jlrai. InAtaiLIt Btul ba >*■
ï^nli^d a>a ut* bwb In Tvfy iBaoraf lih t«riA. tïa
i<H>l>tat> ^in "iiliK«> of lha IliaAlat.'' "Ptih^i
HoAt," i>n4 "Uiliouiai." ara afltndM ayat^ana tt
^i>M>rlJttiTit artElnic; wblla Iba «lupIrriH "fltrtplara'
l> ont uIlb*Bs>taaialiBBB«<i|aarlfea> aabatanar
t*(d,— A'fw r>rt IM. jaw.,Ka(.tllt«.
tir THK SAMK AVTKOK.
A PRACTICAL TRKATISE OS FOREION BODIES IN THE
AIK-PA88AUK8. la 1 roi, 8*0.. «itb iltaitraliDiir, pp. Ui, dolb, 42 Ti.
fïRUITT (ROBERT), M.R.C.S..^ ~
■^^TRE PRINCIPLES AXD PRACTICE OF MODERN StTROERT.
AnnwandrarlHd Amarioan.fcnmtba alfbthaalarcad andliBBrerad LoQ^on BiUtioa, tllM-
tTala4 with four bnDdrad and Ihirtj'two wood oDgratiop. (■ OM rarj haadaawe a«Mta
ralutoo. o( oaa-rlj IVO larga aait cigaolf priatod pafcat. riotk. t* 00 ; ItMhar, tS tt
llUKat lb* (aiflcal alDilaai or prafllIl>iBai<OBl<l
ilolia — DuMl» rti..i«wVv /iiar-n-il
[I !• a nuiIaOral'al'la buuh W* ilo lol ban
«)i*B "a b»« aiuoilBail o»e «11* »ota plauan.—
e-H«t *«(. oiid»Brp,/"a™n(.
piarTIf* iCiirirrjr ara iiaaiad.aaa a> atiBilf asd
par*piDiiunBJ7.aaI*aiDaJdaU«TB'7iDpprl«Biiop1*.
W.I nar>*iimlkad Ibobaab ■Hllbaraq^blT- aal
aaa ia|l ibat ibloBataaaliwatI BarUK^ lllibad
gaaraarai, pmiiimib» laaalliBabla idriaiMaaot
barlof Ib* iBblarU faiftMlf «allitraB^od aad
*\u^*4 hab'at V^<.«'aTl\L*B la a H*ia tl pBia
IiMr IKolll'l book. lboo(boo«la,Wlsl.<l»\TW»*\*\»»^**"*'^ >->.•■» anlManU a ht'
aaraabBOdrad paoa.bolb Ik* prttirtpV.. a.4\li.\*Wt »»*««^«v -*- i™r«.VM «.*
«at*MB>.
nK:«HT C. Lea '8 PuBUOATioxe — (Stirjrery).
2t
A SHHURST {JOHN. Jr.). MD..
TlIK FRIXCll'LKS AND I'RACTICE OF 8UK0KRY. S<c«n*l
•ilitloo. iolrii|[»4 iin<l i«tU*d. Id ■>■)■ xij 1kr|* and bkndtom* oeUv0 (olBBl«*t or*r
luuiip*^*, •ritliMJIIIuimlioot. Cloib.tt, l»lb«. ST. (JuM R*tJt.)
piHrhtd (FrnLi* «f cï>arftti4r li lib* iiMlivr <if lb>
•aaaat of Mh ni«nUi (mti is iii> pui. isi itm prc
gim* fruJ'if*. Tb* ^«DPral trraD^roiBDl of l^n *ul-
hiB tMn f A**f«Ilr rt*1>«d, AD't rimtb a4v naiitr
W* ba'a pr**l«ailT ifshaa if Dt. atbkitr'»
I 111 l*ru» elf pral» Wfwlib w taitorkUltiiH*
matitj if r"|ukf* kpKlaJ 4*iiitm*i}4fti1t>ii fr«n a*.
' Tltt«. iU ■«i<ll4 BdtEibb, ■nEalnJ t«d L^ol^Uf )i]]r
I f tll*«4, brUc* 11 BfA'ar t,»' Lklt* uf a lat>4*4 tmn*
bu'k l)i(« aa> (nrull) |iulilUb*il Imll.^ ThuUfh
annitraiiH ad4i'^<m> b%v* b««n ma^l*, Ebc >l» -tih*
Vitrk la gr»l ^«UrLallJ i4tff«aJi«i1 Tli« malt |pn{i|i|«
■ r f4it bihr<li« «r mi-itAri il»4a la ihai inpt ««^ lut
caBl^radUa^ Tb* >ltitl«ql D*«da « ti-'ilt «bifli trkll
fnrtlMb hlia Itia ta"Ml Iprorviativo lb Ibi «li^^fatl
Um* lb f-Tprj (r*|it<1 1LI* wptk *it \*lihitr*' i%
, - ,. . , ^ Ilia mudal 1(11 DtJoh fiilL.r«iiipnb4a>l<* auti c^a.
urn» h.F., .ail ll add Ihal >« mora aaiLfkcury „e,_jlf„MrtU./=iw- -/«W «M.Ti.ra.J.B.T»
tapraHaiaitoB of Uful*'* aafrarT '►•■ ja< (■llan ■ _. - .. , ,. . _
(ron. lb. K~.. iB t»liil o( juuitl.l rnF4«a. »t Tli« *»'»f»t"a r-criilni t! iba «nt .«liua |< ,
p>ir.r i-r D.'Bd4B>Ul.in. »( 4<CIin<I >ud ..,utl»a«. in.rBiit.a ,.f Iba li^Iiutariij of Ikl. .«lion, wKlcl, ts
ït «KprM^lu* and tbaraafkljr «•M ïu.ll-i., »'i..r. '"•'i tto» 'ti- "JH". tao/l. •HI, maty .al.,^.
*tbbBn<b..0<,.O|i.rl(.r.ui>D(ihawiIaalw>il>.i. ■n4B>.«B.1 oipfn..ai»i,ii Th» «oltiM «f llil- ...rti
' -- - .. 1> d>a4H«ll7 [■••pBlBf at an aJllot «Bd •fllM, Dud
LLa ci>ulribfi1ltfB* to Ih* lUaralm* nf aor^ar^ la»*
Rilbiil r>ir blm vld4 npalalloB, Tlia laiuiba tow
vVatad tii« prtifa-tioa win adj oa* Uarsia u- ibv«a
B^raadf *up b/ p'tftiiat «iBTribnllvaB. Wa aiB
□ DLf adJ LTial tb* vufb la «rfhll arrafifd. Sljad vl(b
iirjicrlral niall*'. anJ rniu'a^ua la brlai and ato^r
laa^aai^e all Ibal it Liacaaaarj U ba iHrDBd br llïa
• laJauL ciT ■ur^PTf wliltat \u AtlnBdabA* upofl Ttv
larta, otlh'iaaaial srasiinonat Ib bltditlr f«ulu
|>r*MIW.-iA. ««( /n.pmI, J,u, int. '
Tba IhI Ibil Ihla work baa raaaLtd a lacaad Hl-
llBB lo '•'J' ■"111 allai Ilia paMlMIIas of [ba Ant
vat. ipM^a mui* bltlilr "' 'ta inartla Iba» aiiT<blB(
wa Dllllil a*7 In Iba wtf of tvDUUaadBlleo. U
•aainato bat* loiiiiadlBlflf (ilaad lb* Itrtt vl alB-
daDUKBd pbJiIt.alK — (.'titmi. Jfid, Aua, Jia. la.
■nporif
tn Anarlea.— Jm, rrvtUiii
T. Jab. I>!D
Tb* aiuin|>i toambino* Id • *«)«»* at lon)pt(aa
Iba «bbla Dald of aùrfftrf, xaBOral aad apaftal.
WBoU baa bopal^a u>k unJaaa ibrua|Ei it* ibi«i
lUaltv IgdBKrr Is aalUUnf aad arraaglgi, ud
tba vivHL jitdcnanL lu ooiiiJau^iBj tud «■aiainuf.
Tbaaa fa.c01liaa bata baaiï abundaflijj ampjuj^ hj<
Iba ■BLb'>r, BBd ba hai Bivao a* a n\*^t «xrvllaill
lf«ail>a. bfvu«b( up by Iba raTlBlou r»r iha «a«oad
•dlEJOfl l'> Iba Ulaaidai*. ^f Fou(t4 114« b,"h L> atpi
dâaUn'd Tir apacUllBU, but aa a CitBrva nf cvearal
aBf^pal kB^i<lML» aad for fv^ial pF«cilLI«<li*ra.
aad aa ■ iai|. brink tor •iideau 1i i< uni mtf^tii
hj ur Ibal bi- *al appaand, vbalbar uf lioii-i «'
l9t«lia laibanhlp — V. Oaniltiui J(«il. .faiinMl.
Jaa. 1*7*.
DRVAST [THOMA^. F.R.C.S.,
TIIK PRACTICE OF SURGERY. Stcond American, fiom the Sco-
^_ bad and Reilrad BnglLib Kdilioa. Wllh Eii Iluodiad and liaoantj.iiro KD|tsTiDf[i on
^B Wood. Ib ooa lBr|« and *nj bandmm* Imparial muto T*laiD« of star lOdn Uirr aad
^B «loKlyprinUdpagN. ClDlb, t«; Icalbar, tl. (J<u> HfaJy)
^H TbUvoth bat *i>jn;*d th> advaoiaca of (wii Ibmougb fatlaiuui ul thabftndoriha aulhnr tiaea
^■Vb* njipaarBdra of Iba fifil Amadran adltlon. rHUlCinti in a itr; nolablo aiilarganant of aita and
liE[>ii)i*mrDt of nihtlar. It Kngland thit hat li'J I» ilia ditiiiim a! ih> nork [nio iwn Tolumaa,
wbÊf^b ara hvrr niiin|trw*<l in t>z*. Iba tUa balng IncramaH To n Inr^a lfii|irrml iirtart'^ (rinlfd od
a coDdtiiHd but dtnr Ijipa Tta* atrlH of illuatnlionr l>ai undarKooa a Ilk* leiUioa, and »iJ]
b« fAnnd oitmtpDodibjfljr impro^ad.
Tha markad luc^caii of iha work en bstb ddaa of (ba Atlaotio ahoira that Ib* author bat BOe-
latdad In tbi aSorl lu girt lo <lud*Dl and praclllioiiar a iou»d and IrutlHoriby vuid* |a (ha
praiilio* iif P«rgarTi «biU the aiioaUaoaiitiB appaaraiio* of tan ^irrpaiiL frlinun m Jp.'f,^t^^j ^^^^
In (bit oûDDtrj B^orda lo tha Amariciha ra«d«r ih« banafll uC lb* raoBt recent iLtirancai aad«
ahroaH in nur^i^Jai aciaaot-
Tbar* ar« » m*tiy FMbbocka of aurpT* "V many i
inlEIan by FililllfiJ ancl dl^tmiglnl)*.! band*, Chat U>nb
ula iba huanr of • Dilnl -tlilnii In Boclaad la an Ilihl
pralaa, ^Tr. EEryaiil niirll» Elil», by i^liaraaaa of fayLa.
had B<>n1 JuilifpiBnl ID B-ln'tiitu Eba DiHarauvba ba r^
<4iinm*nit'. In Ij14 naw *iiiLifiik4 1i* h^^w rarvtbllyoaar
tliMid Kf^»uiida. lEi ll^lil I'f lal'f ri«Prtr*b. Oa tbaaa
aail iDant alFltO lOlnta, Mr. brf aol Ir u enim and Hil-
jtaTli-aii i(aiirt«r. aii*! his tawk ilLrnunhout haa Iha
*»Mbarad!tloBoflhlt»aBOBlbaHof b«Ei«Ij„i
for,lha»iilhorbaaaB»ll.d blBi.alfiifu„.ij,,„rmBllT
la Eaaka do I.» alta'tlloaa In Iba anbalancsaB vaii
a. la il.t .irBUKi-tiiaiilotEh. "„rè.B»d.inib a tIbv
(oilaliapru>r]ii*u( b.araiaallbD Dialiitala aaj n.
llMd Iba Hhola Wa nofaaliaa aro of Eb. a,. 1,10a
Ibal Ibar* 1. a» bpllrf iforli no •<itmT aiiaoi _
(.l-rw».» Jf.J ,Vnr*, Harcb, l^îti
ir«i,r,™..rB.u,,u>ni„Ko^irn...i.niia,.jod,Bj^ tbr.'r:°;:;r:v7.i?i;',r,,';înbi'Lr.ri,'',ïï
' ' ■ iiiil"''""U*«.>UiiiBbif..rai(a«aiBdpi*utlD»"uio^
Tbawnrk balbfB u> t* Iha Aairilrtn rrprlnl <rf llip •••ry abajitti ,.< iba Ebutoafb nrlaloa ubiih it*
lailloBdiig idltlno, and Lai Iba adonUKi oaf Ibr wtiia >•• Dixlaipjaa, maajr parla baitai baaa «u
laltar ta baloji of R»ofa rouT^alaat BLaa, and lb bafnx out aad raplai'ro Ljr Biaiur aallralv ffaab — Y T
DDEBpraaaad f Bl« ana TBlnna- Tba autbar baa rawrli. Jfai. ji/i^m-, 4 phi, 1 6711.
tan tb* inalar pan of tkaarart. and bt> auaaaadfd.
In Iba antoiiBi «f Ba* mtiitaa addni. In uaktnf H niart<
a4ty dl-tlnctjta trniB praalaua Tdkloiia A 0r« eiUa
paru baiB Daan aililad. and al*B a fir* na* lltuatnUiiB*
iniri'hirwL Tb* puhllAm tiaaa ^laaaatad Itaavotk
tn ■ 'r-!tubi*,if|* Aa a «ndat and pnallcal auooal
at brllL*!» mmt; It la IKrIiapa altLoul an aqoal. and
viLl iiou1''.Jfaii.l4atB l4 a faT-rrilt t*i.l.bcvk «lib lit*
rlu'linl ana piaiiiUonar.— .V- >'. JM. Kmird, HiRli
Waltanaaaihaaavadlllaala. iBdaa nncb aatt
ta aullllad lo RpDBaiidatUa. rat Ita arpaaraan al
Ibta Usa la, IB a «t-a-, «,, n,Hli. o( r»r.i a.
II will b* lu •«DpalllluB wilb aootbai w^.b l„ii-
laaaad from iba aiiaa piHt. Bm, ,b, .uBcali Ea>£
ot (etiolBir a ludfmaai aa lo ih- lalailT. mfili, of
Kt/amaad A.bburaE w* win aol iii.niiit bai .r»
did Ibal, aiaaWarisK lb* l.ltii •i~il*a<* ,>r h'lb
oasy olbara will libol» ba Mnad i« bHiiaia Itaa
la BakUaahola* bflwaaa Ib.ia -«««.«ai. iaii
S8
De-vrt C. Lba'k Pobuoatioss — (Surgery).
£jRICHSF.ff [JOBS E.),
THE SOIEXOE ANP ART OF 8UKGKKY ; being a Treatise on Sur.
find IhjiiHm, DliFUff, lod Opération). Cinfullj rtTlt*4 b^ (li* sulbvr fron lb(
Sïn-jilh^Di! *Dl>t)[>il EtiKliih Kdillon. IllDfiriltit kj «Ighl bandrvd anil tin* l«*M.
graTlngi on «ooil. It lao l>rK* ■nd b*a«lira) «iMt* «otaUM «f UHrlj 3000 pimi
elolh. I«l<l ;I*klher.|IOÏ0 (Aw Rnr^v.)
la rrrkting thii slanilaH >i>Tk th* lalharhu ipand nD|MlBt(o rendtr It wanhf ifinDiitlM-
\ttf* of th» ï*'J mark"] f»v<ir nhtnfa it hn» m Innit rej9jr4, b* brltipl»g tt ihirou^tl/ ra ■
. Ittrl *iTb tb* iiIraDe* Id (be iclinee iDtl Br I of taiftiy mnda ainr* ih« app*ar>nH of tkt
llail tililion. Tn Moomplitb tbii h» ttqnictd th» uldlliinof itbniii Kmc h«adr*-l )>■<** «ftai^
■hilr iha lllutlrxlaot hav* uDdatp>Be H uiiirkt<l ini[>r»v*B«ni A bandradtnd tfty addttlMll
I W"od-i<iit* hmr* brm loitrtfil, *hilf ibnulAflj oihn div our' ha» bnn rinb«K*l*4 InrlgVW
I Kbif^b «*re liai dtnTiiDd Riidflfa^iofy- In fu »n1nr|^r<l mi^i im^oTt<l fora It Id t^^rafor^ arv
lotiilMl «lih thr oeaBdfnl anhcliuiilon llial It will uiilnlaln >U |>i>*iliun tn tb* (roal rail»'
f 1(11 'blink r t'a Iba »tud«iil. and I'l Hiirk< at tftfttovt tor <bt pfa<(lllogt'r, wbtla lU «Jic«adln|l)
UodaraU (irlea plaçât U wliblo Iba rcaab atull.
Th*t**«aib •^Itlga 1> liafv» Ilin vi^Illl Mllli l»i
rk>f 4 ■>' «dTg^c»! »(iaa» ru«r*ia«y L^ nonof ripb'
rinfb avfrii 11 idpitv fftrt4ib boiaii^ hni «» h itin-
kipH'tL* u^ua lorc^»! vriac1j<i'* aud pra<(lca 11 1«
I •oilxli'd. ll viU wall c»(id pr>ellil>>ii*n Id
^ ra<il u. f<" U It* baan a ii4«a]iar jt^bvin^ "t Kr
, HrlctiHQ t« ilPuouXral* lu* «b-yluu lDf<fJt]irD4j-
•i", «r mttinl tall •srilial iileun W> l>«4
aftrttlr adil» Id «abclDilna. Ihtx v-i baartllx 4oDi-
\ k>«D4L IIL4 wf'rk 1" »Ta4lcBEi ihaT tbtr ui*j ba
trijiiii4-J 1o a tuDsd Tatlb. and 1o tiraî^UWatra &■
aa iD'alDable ant^* al Iba b«d-l4a "-jln ^ra^fl-
ttonir. 1)011, IVV
II 11 BalllaaanplimiBl la Mr Iball1)t<1il1i«n»ii
rtdl'laa Kr. SrlebHa baaarar pruliind »f bU will-
''kaova btwb, llnldai labaililac lb* vLnivt* of kit
tndataiion, llpiiaataaamnUipifi noil* iltnvn.
larliu altltd Ibat Hi. gflcboa baa Incuii^uratiit
|J*I4 Ibl* fllllod *T9rj Mflaal ]nLpr«T*ni»qt la ibt
k telaoca tail an of tarflair.llifoiiL^ hn • mfpftruifa'
tloB EoiE'.** a J«<illtd V'ULrlaui Id tUurl, wa aa
oribatninr trattUaioD Aiircarjr «bl>A MbtabHa
iMr utM 1i»i<iit1y>nf Qfcf ^ItaaaFa loraa>-lb*f*ltatta
aUl/h In fcll (titloubta taibAvl «a ■* «*ll ti thr flanaii
Imll'p ol Ktkhwn, Itit ;inTI>la4.elts> •!/>•. hufw.
4a» milr pr-iliHlWa Boa bslMaa, lilaMMvr|ani«<»m
«rldi au'iji'i, and Tail («lDtt*l«^ittn».>)<ialll^bla
lilinlrabl^ iDsrIiaaEoMilltxi-beal:. WbtawavA
ai Ibalnat («tl ol Una, t* Ifaro Ikf taivlatautlil*
iU'(«T> "• 'iin. bf tfaftrntJB.to hiawtrk. It b t
|iTr«#or*t llirrvforr, io t*« thai lb* ayT**^***** **" *
irtiiatï1,Bnd bat 1<4 totbaaf^aaTaa'aaf aaf bar 14^
ihHi.— JM. and .TH'f «n^», Fib. a. 181*.
NatirllbtlaBdlutlbtlinrttaa la tli».»a ilBWrttbtl
mutli (ilil iDBltTt hat bain coBtUaL Iba cfclirt •««
iitiTiiii iiiiiiimitiij aiintiiiiii iBilaiinmnfj ■>»<
kI b; • r» f lira <-hB)i>''< A (MIlDttnOTtiBaal bit
l>T«u u*i»J*^filbt HlutlfBtlvti* Qoa bau4iad «Ad tfO
B*v on<« bai« batn tddad, and Bkanjr aC tb* «U tat
hart faeroi rHlraati Tha uUiorblghlj a^pnriataalbt
Citsr aiih ablihlila «nrk bat h**a rreativl tt iBrrv
itn aartfaout^ tii<l bat toi^*-f*mt be rawlar aka lBb«4
liHltaLiiiflr ■*•' ibaL «a Uuuw uF ti* olbar »1afl« adlibjq BCtf* ihau «T*r «ivib^ of lbtkraMCï«Bl Tbal
»<irb a holt IkaiiniUBl lail praKltloaat UB|>la ai Aa baa tumrlad BdniVa)J>. BlU», w* llilab. b> Da
uoiaautlaar aalotliblUblibt prfii(lp1atotiar(«ir, (inaral Ajilnioa. WthttNU; iWi»»*Dd Ua Wat tt
Bnd H (coii'lai* > lanvlKilH if Iha adtaid» ul bath dudtat aad rnnitlaw.— A'. V.Mtt. Avaal,
ta'4lHlrcatllea.-^ndra ianaat, Fab, ft. IMn . r*b, h:«,
■at Iba paallw*Dir jura Kiletiaaa'a «Brfatr baa Brl«h*ta bat alsad Ba proBlaaallj roi'arJ hi
aalBta1ti«41l.ap>lMnaBELtl*h4liif Mil-book, B<<l*Dtr jraara at a wrilei OB fiaifaiy» Ibal bla r*pata»*a It
laihlt f^immt]', bnMa UrraEUTnato. Tiiai kMt Bbla «T^iJd aid*, aod bl* aaina Ua* Ctmiliar ii>Tb*iB*4-
h.bObold IT* Rli<UL^4, If almttdAnllf I rdt*b hjr tb* Iba- ' Ital arndaalaA toifc* aerobpllabad aad *Tf4*I*ac*4
fFbafbDMa* viEb itblcli Iba f>rt*aDI «IMT'io ba* b*iD | *ar«*<>b r^# «,i<b la boi a racial of Ijraat *d^
ra*irf-l, aa^ bf lb* larin BEaaunE o/ falaakil* □LBt*'' IJjoa, bat baa la maay H ta** baa a aalifaljr lavfïi-
(baa brtD a,ii,]r<,i A«jdn rroiD ibLa.i D* tma- lau IWtitT Imprnvvmael* 1b ■harRMjr bita* a->l a*-
H[>td bl> aaiita. rarinat atir or-iaii 'at baa*b*M
EhriroaMMj BHlriad. aad tbair i^Hu Udr*a<at7
dLafU^aad '-'In* bBadnd BBd tUf BBV VB*d<alt
a44E.:ib><Blnao(lbu«Liili.— .V (i. JM.«ad4br«.
tUl Ell
dri«d and Brij* aaw JlLuaE'aiWua bare baau Ifittrt**!,
tD'^llillT^f ijiilEa * Dlimbaf it lUlar'Jtt'ijtttaJ apjitaiF-
aafva af l**l1l-ii '(lull ),rneaaa*t. Ilu intrltaHl la Ebkt
aliBB** ruriha baaWI, IbM th* vofb alDlr«al app*ti*
waBtallnlJatwoB* —M'd Kttifi. fab. li, IB.»
JJOlMKii [TIMOTHY). M.D.,
•A' 5<irf 'H f 0 AT O-tvtff'-M tf'iMjtttitt, tv»4oH.
SURGERY, ITS FRINCtPLES AND PRACTICE. In one lntn<l-
tome DOlaio aoluna of uaaclj 1000 p«CM. «ilh 411 lHaatiaUBD*. Clolba tA| l*«tk*t. tl<
iJmIt hiunl.}
Thitit avoib «bleb bitbatBluoliadtDTOBbDib rlutaicatBddlillscTBtaa.— JT, T. JM X«rar< Apitl
Bl.laaottbaAllaBlltarllbmaeblolxaai, Hi. Uolmai' It. It?*.
I |ta«ui«aoBoltanatadiail»fl.«|i.«aaM,ao4oo* , I, ail| babaail a n.^ai .it.llaBI ai.llaK*aI asp
b*r Iba batlkaoirn. and r.>b.|.. Eh. n.u.. Ii.iiu.bI i „,, j, ,h. _„„., p,.c„„„,., .h^ t.. aoi tb*
lyriMrapod .orii™i aobj-ara in Kb(1.di1 lu. a ,iD,,ofii(B»«.*iI.iuto m,..- la.aBa» at* ..indad
I knok f..f ilii**»I.-aBd t" «dEulfabla iMia-and (.ir I .„fi,,p(,„,b,_,i,„).m4„,. Jb (,„.■,»„■
,lh*bu.7(*n.ralprat»l_tl»B*r It irtl(,i..*.ind.Bt I „, ncioB.waeaa mcr* urJiUi^ ia.o»»,iid TM
kAtlITOHâJITBIDIEKASia. INJtmiE*. aid H At/- flAXOlfTOX l■llKDJla[^0 IKDOTnKH nriRA-
rOHHATlOX* ijr TIIR KKI^TUM INIi iNUSt
■rllb raiiiarht oa ntblloal CnBatlpatloD K*»nd
Xm*€Utm.tffin tb* fonitb a ad aulaicad LoadoB
Mditii^B. with illBtiiaiEoaa- la oa* ato lal-of
Stl pa«aMl4lb,«l».
Tioiiaoriii:i(>KHiiHu(KT x*w «iinoa. >iib
BB addltloaal thapiai «a Niliiaif aainn. Oaa
llno,T«I.aru>pat«B *llbUlir»*d-«ata.C»al^
tilt. ^
Benky g. Lea '8 ruBMCATiOKO— (O^A'Aafmofo^y).
«
I
flAMILTOS \FRASK H.). M.D..
A PRACTICAL TRKATISK ON FllACTURKR AND DISLOOA-
TI0K8. Fifib rdttinn, nilifdaiid tmpfotti In on* tirjcf >nil bktidiama «at>*OTolaaia
arnfiiilj fl00i>»j(*>,*IIli344irLuilrMliii». CIMb.tft T^: l*Blb*r.|IITl, [l^itlt hivtJ.)
Thl> acrk U «*ri linnHn, kbraiJ HIV*! I mi at hnii». ••thi higbtti milioiU^ oui» 1m)iurliD)
lobJrM — an Bnlhnril; trrofnyttA Ir t)ir «onrlt ai Vfll m In Ih* acbimli inpl in pridiFt—nnd
■gain to«nif"i«<l, nnt nolj hj ihr rinn«nd fpr ■ flflh ♦dilinn, but bj (r»n»rni>nit now in pro-
gnaf farih* ipred; »p|»iti>nii> nf ■ Iramimian in Oirmitn/. Th* ripcaUd lavltioni Hhkt Ih*
■nthor bMlhnibtd tbf oppvtiunitj of isnkliifEhFiTe tnabld him InjiTdht mattcanful e»niid>
«r>i&Dn tn «v*rj portion nf Ih* *'>runif, nor) h* hni pvilult'Uiiïir ■nil^jiiarvil in Ihf pr«p«hl Irtot,
I» pcifiet the Hulk by (ha ■!•! arbiinon n;lnr|;nd •ipariont*. nnJ lolncofpofsl» in il iih«l»»»r
Of TmJn* hita he^n added in Ibl* d«pkr1in«n( »lncf< tb« lHn« nf lb* fnnrtb vdiM-in. It vlU tbrr«<
for* bv fn'ind onnnid'rnbly Imfirofrd in miiUfr. whil* lb« qi<kil craraful «tttnlinn b«t hfpn paid
t« lb* tjpagriphiaiil «iKulinn, and lb> TcUuis i> protDlad lo Ih* piariialan in thr irunflttanl
bop* tbol It «IIJ mo» tbiiD m«inuln It* rar; diallnf^ulabad rtpolnllgn.
Th^niKD» Itpirvr vnrnnii ihvauttjar<1 lu flirtant»
IbBiiiiiaiuiDt. K.iniJUo, lE.bDuId iMin thtpuMH-
M<m *( rtttj ir«n.oil prviH1on»p «nd tDrcvoa— TH'
TIlB olugufi OMFk lilii IhU la lb* pTKtlHit |ibj>l-
' «l«aan»lrurç*nD Aiinhiinif;h«otBr'«aGlrnattd,ftbd th*
PMBUIIr •>( hailDi luib ■ book n<lH4 10 «b* Itlwl
dt4a^ n'Aatrrtijao «Mod nlvfthvpTtrlloallui iflftaiKB
i>r lu iKUhlnc. but 4l>n b^ Tttfif nf tb> DinHm-Trtnl
liMHnf*<irthr-r4tM<'f «MrhU tr*f(*.AUil«blfh Iat«
rsnvnlli^ TiflviL tIkiT »i>&J4ttETifu>erii1^>Apprf %jr t>r llftinU-
Inn ■nnnïbar*. I* ■uffici-niljiihTlPiiF ti ptiiy i>nf Th*
«r*i«ljt ffilnm* 'Mim* ïrp *ini»lj All all Ihr rr-juiilt*!^
Wr i?&n «ftfAljr r^p^'lUTUruil II h« Ih* \n*\ ul it.* Kind lA
th* KqEtl^U lani:uM''.*4^l nol-uvUb^Mn ■njnibat,
Jaum,»/ }ltnt<u»n4 Mnlal Diii*tu.ltit UTS.
UHOWNE [KliGMt A.),
^^ Surtf*on tA t\r Lir'rpfitt £ft fÊnH ttttr InJIrmarjf. timd lai%t Di*ptnâaiy /tir Skin lM*f^tê4.
HOW TO USK TIIK OI'HTUALUOSCOl'E. IteliiK Ricm.iitiiry In-
tiniatiunilnOpblhilaioaropj. artiinrtdfarlbdlM orSludnlt. Kith Ibirtj'ttidllNM*»*
lloai, In DDaima)! TOlam* rojBl limn, of IIOp«^: e)utb. fl. (TVw AtHfy.)
pARTER (R. BRVDESBLL). F.R.CS,
A PRACTICAL THKATISE ON HFSRASKS OF TIIK EYE. Edit-
ed, «ilb Itil'tjprf and Addiliunp, bf Joni du». M II. (of Gt. Lfub. Mo). In oaa
haudiona oouvo Tolatot of about MIU yaf,»; and I3( IliDitiBlloni, Clolb, (S It. çjuu
U'mt4.)
tllaolih (rHtplruDr>lb«t«a<<>o*niIanalb*aaI1l ^ ahapl*(ljd>«1If>) InadlwuHlnooribf UH«*BdM*(-
a* a vcrtL •alUAliUcrHDiribulJi-u to i>ntll**l opblb*^ llou oftpaolaplaa,and la adntrabljmiapKl. plains aad
tnnloo- ll'-Cartvr uaTvtil'iTlsiHfriTjnthaaridha baa navfuJ, aapadaltjr Iba panar*pb»«q Ui« trvAOiiFni of
In tl(V^ %hA pr»4vmf thr iiil^-^tEn arLaar anil Rtiufilw - prAthrnpIn and m^^pla- In mnciluilun^ iiar Ebiiika ara
maoiiar, «^a9^ i^f fiiuJL^fahbualuli, and b*Df> thf moT* , ilur tfia auEEji^f f^'f Diaiijr «ttvTuE b^uEsia Ebg k'Ff at rul-
raJiiabjB ^'q wcpuid itpm'hll)' t'umiut'ncj, ljotfo*«r. a» ,i«-l at uvt^^'iaJintc «uricfj aEiil Eh<c»pfuEI^*. a Arid
VoathjrqrhEghpmv. lEia Ennnnar III wlilrh Ilia thara- | wh«rf nllat* 7#arJi w* Etl#«xi bi^laffV f iklEla af «viE ud
pVEtfbvof «llataaaAf ih*TVb-ki«laT"inEa4, Arbrraiha I Bliaat frumamaaioffhafT'— «V«ia fWJI JltahottMHtr^t
aoVborl* liAFljrularlr «laarauil |<raclki«E.«faanalbvi | l)ct-X3. 1^3s
irilEaraarit uofHirtuEiafalr Itw un^n dpfit-laol. TbaAoal'
-OTBLLS [J. SOELBRHfïïT
A TREATISE ON DISEASES OF THE EYE. Third American,
ftnm tbf Fourth and fUrliad Londun XdJIioa. «lib additinoa i llInatritrilBlib nunitmaa
an(ta>Énjn"n wnnd, and 9ix«olored plaUa Togttbar vilb aalastiuu from the Tait-ljfai
at Jaagar and Knallan, In ona larg* and ttty bandaom* OotatO TbIniD*. (PrcfHriiif •)
TJETTI.ESHIP (KI) WAUD), F.U.CS-.
-*-" l/iM'-imifStirB unJ /-•«(. i>n <lj>«» Swrg at Ht Tfii-fat' Ootr^ilt. hfiloii,
MANUAL OF OPHTHALMIC MEDICINE. In oiw royal 13ido.
laliina of «>*r SSO pagar, with 9B IKoftrationi. Cloth. I). (/vM JlMify.)
auHHinr ur rniiTiiTa.
FART . ATmiu a/ Dia^-BAfu. Cbap. I. LanMinK K^nplnma. Cbap. It Bitcroal Xiai
Inatit'D c>r ibe K]<. Cbap III. EintLinaiiiD of iha t>t. PART II. CHuioil DirÙMà.
Cbap IV. Diranaaa of tbt Kjalidt- Cbap. %'. Uitaraiof tb. I.axbfjmal Apparaitm. Cbap.
TI. IkitaaaaaoC tbo Corjanauira. Cbap. Vtl. lllirAHa crib* C'lrnaa. Cbap. VIII. Dkffaw
Kaialllii Obap, IX Iritia Obap. X Pliaaafi nf the OillArj Hcglfiti. Chap. XI. liijuiiM.
Phap. XII. Oalaiacl. Cbap. Xlll Dlteaar* of sha Cbirmd. Cbap. XiV UigrajH of lb*
Katlna. Chap. XV Mtai'** of Ih* Viuinua. Cbap. XVI. OUneoma. Cbav XVII. Dta
•«aranf Iba Opiic Harir. Cbap. Will. TEiOuit nm! N'an ()r«<albi. Chap. XIX. >:fTati of'
KrfraslloEi and AoeoEnmodnlion Chop. XX, Ktrablamoi and faraljil*. Chao- XXI. Oprta-
llooa. FART Ht. lH-tami/ ih* £f '» Btlaiitm i, Gtiurai O.ttMt. Cbau. XXIl. A>
Haiianl Diaaan,. S. Local I>itaua al a Dlilanfs frdn lb* Kjw. C. Tba Bja Sfairing la ■
Local Diava** of th* NaigbboEiEig Part*. FEinaala, rl«. Ind*i.
ladmsick's KaMiTBiitiK Op i)i-iiTin!.»iir Li*»o7s iNJiratu to tub «tb. oBBrr.
■UkaKKr. fMibo a.a »t rruElii>n«t< "tnait aTP tVKMOfi ikrtr lanaAlaC* and Raaoi*
adUtVB. nrlaad and «siarinl Wrih lamatoaa Efliola Hlili abaal aaa baadnri lunatraltoaa. -
lElaauailuaa. lb va* lorx baadaoBt o4an T4l- 1 Ja eib* vac/ baad-oaa **ca'* taiiuaa. cloth.
ao*.<t.>ib, «1 ». 1 Win,
30
IlKNhV C. Lka'S PUBLICATIUKS— (Jftfi/lCOJ^/uriJiprKtfffK»).
J>CRSETT {CHARLES H.\. M.A . M.D..
Tin-: KAIl. ITS ANATOMY. PHYSIOLOOY. AND P1SKASB8.
A Pnsdeal ToaliM fur ih* Vtt of M*Jlr*l t^ludinli tni Prarlillcovri la «D* bald*
tame QDIiiTa Tolunt ofOU p^n, vllb >tfb(}-M>«ii Uiuittstieni : elolb. S* ftO i l<*lb«r,
K»riii )<ri>[iiF« Id tba larotlgstloa otiht itinctiir*! ef th« *bi. ■nd kdititna** mad* in lb*
CQoilri nf ln«l<D|; )(■ dioiief. <ioaldir*ni to rfnittr dtdiabU • ii«ii *oik i* •birbnll Ibtn-
«onrt*» oribiianitulvtDcrd feitno* ibonld b* pinrrd »■ tb* dlipofal of lb* |MBo<i(tun*r TbI)
it )iM brfii iba aim of Ur BarntCl to aeoampliib.aod Ibf adiaatafat «bicb h« baa aa^jaili
Iba apvelll (tud; «f tb* lultlaot ■'* asoaranltr thitlbi rtiult vfbU Ikbsitiitllprtti*«?MrriM
to (b« pr^faadoD at large, ai «ill ai lo Iba ipxiiliil in lbi> dti«iiiD>Bi.
ratrvuM anisg Ibr iiiiai>riiDi ttMsl egmtlbo iHitlial «nitrul. aa<I lu itadj olll «-(tl r>|«ii1M
rii'A» Iv larhi llMrtlarf w\U b« raokvil ibla witrt;
Ihu Titlumn <Tr -tTkr AM |Uf*« tft a iivc*>»arlL7 trlaf
u4^ii<« li ai'i^i kgittn It kiltl iltAt 11^41 hoot l« prfr-
Tub* If adit ■«urai*!/ ij]a4irait<44, iba ftJVraataa ar«
liua^ IltMIIEIuaaFIl} III* !»}•,> ft4 Ta fa* «ill 4«-r)r«'n«
IhD t^f**al»]* tnj\9 Id v^Lfb latar l^u^jvi** 4rj
anil iur>4ll;r nnkijLiVD aalijf^f* air- lfM44il T* l^«
«l>r<U1i>i lI'vvoflL 1a*>Ml« hljtfa««^ f «!•«. aaj kb
**ai* uf ffaTUtiila i* bf ltira«ii vllj va hrf*. W
LiUkCI*bllL.|k*ljr atkaoVivd^tHj wijLL* Ibt roadlt ha* Ijdkipvpri Li>aa la la lit» aaifaal vf Waall a* nta «MMI
>}«*a 11* Ehr<ji3ii(a a ir**IJi* wIlkIi VIII ]i<.Dc*rarLh riLjni ilta fafTfaJ «ludy of Iba Wall, aW a aavaUal
raak «111; 111 tlMaK vril>B(* ol Willi* aail VuB lalgfta» lu Il> \ntlwtn\j aaat»— S4M>B>M
TiAlKft —Tb tua-f. JViKf'fliniir. >Iar. llJl> , JTliI ^iiHr., «Uf IK*
Oa auMKOt u( Ihacnal id'aDO. wl,l*h tLa<al»tu . "" *""* '• 'l«l»a«l a-P-ilallJ ft» IBa oh aftli-
nada of la<* j.ai.lB ol«lM», and of Ik. latiau*.! '■'"■ •'•'' «""'al pr.«llloB.t. aod rlaeaa al l*«I
1»tri.HBi*ul!..l*dliill. ih-nH.tl.alpf.f.-lt.ii VIII JI'1—aH.BOl. "laafala iMiwla*. taah abMtai
nlcuiD* liiliu.w »oik. vliHh iiMMulxlaailv tai "" !■'— a'-'"». •• Ihlali. ha.lr>B(Uaa aH4ad.>l^
aod«>»lT 11. p«»oi ait-<» wiiiLi <i,ttlr Indi- •• "•"/ "■"<"i"i'i| "i« _a"ltior an Ut aacMa la
dlaa IHadVa'Uno la •hid, fnilh-r »*uF<[.f> »a ' "'"" "" •■■' """' •'"«'•1 *ad pru(l(>i-a*r «••
iai».IPMfllalp1r«a"la'i>'a. "• B t.ulu LI. «H^'ï 1"" ■■''' "HI' > (Cat daal „( k«Ul. ll «
» naluHd *>i»iUd». auri ..iiii„,t i,.n...if of ■ •■'■•'^■■■l» «ml hMniituHr llUMratai.- Jf. T. &f
IbaabHr.airm. and m.tnl.il*. nf oil-.I.. ba. »ro- | r*">' "^'U'. U«l 1-, 1*!'.
dvfad a vurk.viiiob a> a i'<i'l>",>k. ■Ut'd. /'*^if# i Dr liuiavEL i* labafoiaataadrdfitr k.tk»|i>rlitta
yrinctpt lu uur laviciiijrt. W. 1ib4 uia'ksd .avérai [ha IrttI bt>,ik uD lbaaii1;J*<E Id Iba KaflLb laaaatft.
Da.BUiaaa **IJ v^^nlix *f imiuiivti aad ifa* 4Libb- I an'l w^ut\^\\j t*f Ui* cart aad aU.ailaa £■ 4a»
clos at tli*|«a#i4l pfavilrE,ïa*r, l.al EbalraaiaWr «ad fU«a to ma •ci.&ilHf tUa af lia aitljacl.^jr, f*
Ibaapapa al oar «LiuiMifead fMllJ ^rbap» li labtt- JfnJ. ^aam,, l>af. ItiTT'
Itr, aa ifa* l<ai^k au^bi iv b« Id Iba baada af arary |
/PArLOR [ALFRED S.).M.D..
^ £rfrfi(r*r "K Jf'<' J^rirfi find /*&«vilffry In Odf'* JVorp(l4r
POISUXS IN KKLATION TO MEDICAL JURISPRDDENCB AND
UBDtClKE. TbirJ Aiuarloan, rrum iba Thiid and RaiiiaJ Hngliak KdilUn. Is OM
U>K* ontar* toIuui* ef S&O pagra ; elotb. )ï Ml ; laaibar, fO ÏU. iJm« /»i^0
btlDc dat«rlb*d *bIoli|1t« riaa ts Uiu UTnUaa-
iluaa ~na Clflale, H**. «, IK*.
I>|. Tarlar bat bf oB(b[ t* baal aa ika»B(llaII»a
i>f (Si. Tuluint, lUraa .f<Uaiakait.aip*naaai. aad
plaaElcaJa«<4qaiDlaflea«iltaaU4ubJ#ft, prvbablf Af
bajaad vha. aajr aibar ll<lafl«alh»ij|y va iailcai*
^ty tvuld ha*a anaaaad iir ail]ii*a 11* baa t%itj
■□«uliiBil bla rapaiaiiaa bjr lb* <aaaaiB«ai« abtil
au4 l*|al amcaaa Ii* la. <11<pla7*il la ibaamaia.
iDvut uf lnaa4t»3*<^'l">livT' "u^l iIl* F*paEi isa v^rh
ug piii.uga trlilab viLiliciadupaaaaVltitavfafjaia*
daal i^r pracuu^'aar ia lavaail ma^idaa ^TLtltyA-
UttJovn. tf Mti S«>., Ort.lSfl.
Tba pravaul I. band opoa Ilia ivh< prafl^a. «ijl-
EI,jD.;"iiulEl].e^)mpEA1*i0i'laloiiraDd.r*d b*cHBai;r
b/ tin. baa •■tuvartad It lorn a ofv vnrk " Thi*
a latent aa t frvn iba pralan aoulaia» all [LatltlaJa-
airvd 10 baaw lb r*lanaca Eo ihn u*v adliioa Th*
«arKa af thl- ailthni ar. altaadj la tM Elbrtrx af
«Tanr pbjraicUa wliu 1> llal'i* eii b« lalfad upvu for
jn<4ia'>'laa.l''^'Eli">Dr (atLilvlial"a*Li □iiEF)..ulbal
all tbal It rtuiilrail Ik I» Kaova ab'nu ibapraaaal
boab la Ibal IIj. aalbor bi. ktjil ll abraa.l Villi Iba
Ituaa- Wjial laak.. H buw. a* alvaj», avjjaelaljj
aalaabla lu i\it prhailtiaa^f u [iiLaoDEEa«aaa. aaa
prafiiuEeliarMiai.aal]! ibuaapvlauuaaaaabaiaoaM
ïjr Tiffi s.tJfK ÀvraQit.
MEDICAL JUKISPRTJDESCB. SovMith American Eilition. Edited
b; JvKa J. Kiaii. M.U.. Prcf of Uad. Jatlip ko tba UbI*. of Paoa, Id ana lais*
nnlaro rolEnna uf naarlj- VOU pagri. Clolb, t» 00 ; laaibar. SO Ml. {Laiiig httud.)
To Iba iriamlniaiif lb* Itfal luil mtillOal pmfaa- ba*[ aailinriljr OB lbl> ipaaiallf 1iaarlBa|ita(a. (i>
aiOBp LI L* uauHf .arj lu »*/ «UJEbEun (oTiiijiaada'
laff of TayL<i'»MAitLi:aLJiirli;]ra4*Di. W* fulfill
at vaUaadarr^ba Iw «Jinali of Eli* mAriE nf'tblEtr^*
Piwdint* — l')ict>p^ Ltfil -Vivt, Ufi. Is. 1813.
U EB bajoadiina.tlab lb* IklDaE allfa'Itt* aa wall
aa maal latlabla maaoalof uailltal jarlaprudanat
pflbllabad la iba KaaLEab Laafa^«r^^Bi,^uurita^
"/ ■VplWopraM». oal I'T.l.
II iialluiiailiai'npa'Iauaafaia.IanffarBDjrlbEsi
la lia liai fora vma <jd iiiaJlTa^Jurlti-rudaav* by a a
aalbor ia]L4l.*liniiai DBira'aHll^aattrDiad lobaifaa
ifalapolui, btfwarar, waarlHaaj IbBivaaif^aWaa^r.
r*rliiriv ba ibatataalBiadlts-livalaalhPrllTlstal-
lav. iBiaDaral.iaEib whiab vaaicaavaalaMjiaaat
lauituana.— Ca I7l(a. fttwrd, Haa laTi.
TblalaiiadliloBoribaHaiganaprataU/ibabaM
M fall. a. lE.ptatalaaiuuraiaatarUlaadL» narkadaa
lo tb* lalaal .livi .illb* altbni a I a r|ii liaal la Ibl
I ail 'dlIlUD L>l EbaPilaelplga. III. !!»••■. IBatdlli*
ul Eb. HaDuaE. ba. daa* aiariUlai losat* b>*
Vfirkaai'.fUtila ii bla niailEaal tDBBUiiaaa.— X. T.
Jfiif. RiirviJ, Jaa. lA, ll>;(.
or THK »*Mt àVTHoa.
TUE PRINCIPLES AXD PRACTICE Of MEDICAL JURISPRD-
DKNOE. SMond KiliiioD, Ravliail, nlU aaoiaroaa IlliulrBliou. In two lain* «itaTo
iToluiiiai.nlutb, f ID (lu ^ laathar, tl> DO
TbiiKtaai wurk itnuw ranfigaiiad in Rnjtland ai lh« fullMt and nailaatboritBlliatraallHaa
•TOj Urimrtuienlotlta Imgxiriaul aubjaal. In tajini; it, in ita impraTad (Mm. bafarelba Anti-
idAH profauioa, th« pablUhaiUutUvW V\iiU\aHAn%\^a»* yiaUJn^U t^it «««atry.
Hbnut C. Lka'8 PcsuoATiOMa — (afi»wï(aii«i«8>.
31
u
-DOBERTS (WILLIAM). M.D.,
A PRACTICAL TREATISE ON URINARY AND RENAL DIS-
KA888. lna1n4iaKUrin>r;D*po>llt. Illualtnlrdby nuiii«rniipeM>(»od cngraTlng), Third
Amrriun. rrnm lh« ThirdiUriMil «nJ BnUrgstl LunJon EiillloD. Id Db« litgt *a4
bicUsan* selaia valna* of oirr 600 jngo. Olalb, %i. {Jul Bitéf.)
rBOMPSON {SiH BENRT).
LECTURES OX DISEASES OFTHE URINARY ORGANS. With
illaiirdlona oa vond. Saftond Anarlnn from lb* Tblrd Biif;li9h Ediiton. Id ob* naat
OS U Tit TO la ma. Clolb. tl U. {Jiut lumtd.)
BY THB aiKK AVTIlnR.
ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF
THE VHEIURA ANU UHINAKY PIBTITLA. Wlib plilM ind «ood.<utj. From tta«
Ihlrd kod rcTi»* d Engliib «dldoD. In oti« f «r; taandium* ouMTa Tolaaa. «lolb, %% M.
{ Lairif PuiliiÀfd,}
q^CKB [DANIKL HACST). M.D..
ILLUSTRATIONS OF TII^; INFLUENCE OF THE MIND UPON
THE UObV IN IIRALTH AMI) DIKBA^K. DulsDrd to Itlnilril* tba Acilbn vt lb*
Icaai;! nation. Inon* bandxinia oetaroiolum* n(tin paK**' ilD'l>> |1 1'- il-ti't^ Uiufé-i
À
I
DLANOFORD (O. FIF.LDISG). MM.. F.R.C.P..
INSANITY AND ITS TREATMENT: Lectures on the Tn-.trocnt,
Hidleal asd L(|[at. of Inaana PaMrnU Witb a Sanniarj of lb* !<■«> lb fona Id lb*
Uiillad Slat*) on lh> Conlioamtvl of th* Ininnr. B; luac Hav, U. D. Jo OD* I*ry
bandnomr DOtniu idlgna •>! 471 pasani «lelb. 11 U.
t\ ■a(t*fl*fta*auiwiikb loD») b^^t b*«H taielf , aatuallj**** ia pr»«rlfeaad lb* appropriai* Imi-
Dial I'» ilisiii. HO BbiI la Dr. Blaaimd'* •orb ■
i\ 1&k4fH Ib« fufiu if » CA^antl t>rpt]nlf4[ d«.i4np(lon
of Iha r^nofK foftn* u[ LuaAiilljr, villi a [l««rTlrlk4H
af E h* lULiil* vlaaainlblDf )ifif»>«ii> aiitpteitd «f id*
■tally VI* emit i.triiCLilaf AL^bilUBK* fbl» rvaiai*
Ol Ik* biHiki ai (iTlugit a aaltUF ra)uc lo Ibr irut-
ral pTaciiiiuflfl* If w* j.iMfi'untiif-.intUfci&iiinrip-
tailaBa laiIeHrlptli>B>i>ribi>*ilill*ii>niiaaulija>
MfîtUtfftMfi A4T»ii<«atar prvTlofl» «rlilacaooiLa
• uLjigl Hli t>l'l>ir« uf lb* TarlOBi loiBIl oflDaBlal
4i**u« ■« ro clot niid (aadUiai to rtadxfas fall
io 1i« aitfuck «iiL iliqlF ■uparlonij lu lb(i>*flv*b la
iiillDiu; luioualBiB Iba Ro(lkti UB(nai(«Lir (««far
u niiT .>wn r«4i]]Da *al*ad»fia aaj inh^i.-^^I^nttom
frurlllluHir.rt)! U?l.
fEA {HENRV C).
8IJPKRSTIT10N AND PORfiK: ESSAYS ON THE WAOER OF
LAW. THK WAilBH OF BATTLE. TUKOBDKAL. AND TORTCRK. Third Koviitd
and BnUrcad Kditloo. Id od* liuidiome rojal ttuio. voUdi* of Hi P*C**- Olotb,
«I &a. {Ju4l Rtadyi
L*«l'4 "suJirrvlLlLoB anj Ki>r»" It 1 «.rq Ibat 4UF «Ir^Bjii/. b* «otc^til» in ■UalbLuK Impftntaillf.
iiiKti*»E]iFUuiar'liJv !■ nul wtlbuQI h^tniir la It* B4-'Wliatt<rJi}ak(id-]DakapftE4tiiDJa mLrru'.a «ark
tt'*ï4iiDi'/ Hr. I,*ji batiDfli ATprjr fft^b il^iDaad «act a* Ibu hn* a Uauag ralar,— <^1jFf.|itbifO
(or bu «iirl ollb a Daralal rouUa ot II. aiid Iba , Xiigatinr. I>t{ \W»
pr*-*Bl .om«ii 11 aoioBlr (ull-r .ail. If «....IBIa, , «,, i„-. tarmii. W.l«rl««l iBooo»raBh-,of irhKb
■MvaMBI.)* Ihan .IMt o(lb. pr«.a a», tm. I oo» 4f lb. no.. ImporUBl ta ti.r. ..p...Ja»d la .a
(roB iballiorooiihalHniF.iluo la uiuw lllic a liac | ,„|, ,j ,..„„_ ,,.„ ,,,,,, 1,,^ .^ uu,„o. p„,„i„B
BooloaawonroDj la» Ilka a Web ..I "Billa*.- , ,„„ok Kuai..l. aad Amtriaa» ub'il». Hil.dl..
rA« Adtfnn. Au( I, Ik. 4. I tiafoiihad (u( bta ntuwltl* ban tttLirul lt«ralB(.
HaBjr w\\\ ba laiapUd Io aar Ihat Ihl». h1l« Ibo bt» pviw«f of ■Ibaaalir* blalurlcai ariaijjiB. II t
■IMellBiabiirall.'taiiai uribaaueilllelnbl* boaii* \ braadlb aad afroiarjor bla inoiiirbi» >iu<ii>(ili*
tu laalaa'ttaaoDiarabLa.lta iLailUfMaa^.^mpltaDd . rarar avurcaa uf kDiiwl*iJf*.tUit irr.TUr kDd 4D|>*r.
laATiubla. aad lia chn^H^d<-/ritt of rafaroatt-
brlntlia^aad daat* *aaajili |4 mak* lb* baiaaal,
atou(4Bi. aad baal «gglppail aaaallBBI Ihlsk tvica
bafufa ailfaùfiBiç >4r ii Oft* anjtljkui| aoatro-
TaraUEio It la provoka a.a>ull, Tka am bar tt ao
aBoa at bia alatamaata. coui1i;a.<l vim Binfiiiar
taraeiLaevt offioBTioIJoa. aed lila «arm alcaabBtat
(4 lb* nu*a i>r JjiuaaB fraadum beiiI IniaJlaBLUAl prg.
fTou-— X /- Tril/nnt, ka$,t, laTi.
Jtr TBS SAMS AVTBOM ILattly rfilUht4.1
STUDIES IN CHURCH HISTORY— THE RISE OP THE TEM-
PORAL fUWER— UliNUVIT OF OLKRilY— KXCO.MMttNICATIOtt, Id od> larg*
rii;al ISioo. tdIdid* of >IA pp.; etoth, (t T&.
Tba aiarr vaa atiar laid noia calmlyai rllb baaapatallarlmportaBaafuf iiiaSBctla)ial(iil*il.aad
friatar I«ara1n|itr «laor1b.tQKbt. Wt il uQbt. 1 ad*td. I* aebaplar i»a ADCjanlL^vIUaljr l^bara^arilad bb
Tf aayolbar alody nf EbtaCaldcaa bacomparnt «lEh . Anal. Wac4b baidljr patafruia one maaEliyjL uf latb
IbiB for al«atb*aa. aflcaraaj, aad puvar. — CAloapo worki aa ibaa»— wllb irblvb (liai hd "il&faiiioiBl
KiunliHT. I>t* i^'i) I CallbUT" ttinaid ba lailalad— wiibnai aoitai-h*
Kr Lt»'« iBWai woib. -liiinlloBlBCbBMb HlBiory." l""atT phaBoiBanoii tbit Iba baadttoaa ai ibt arw
(Ollï.n-talu. lb. proiulw*f Eli»«rtl. lld.aU-Uli 'm-rHiao Ij.ium. I. .1.-. Iba iaHt.r i.f •■.m.of iMniuH
lbt« .oliJ«I.-ib. T.inpnral F.war. Baaali of »r!»U»lb«.k»-t^J^s.*(*n«igp..Ja*. I ISU.
Clarir, aad Sicomoiiinlcaiio*. Ibt rMotd of «bleb 1
32
tlxmT C. LbA'S PDBI.I0ATtON8.
INDEX TO OATAXOOUE.
âli4(><nrkil AlUa. l,x Saillti >ad llottM . - '
A'bloq ooLTia JCf4LncJt ■Mjlnfe* . .tS
luHdila I'lirm^ilf; tO
*»lilint-il'««iHf«(T t!
bij«iia umiiaTiimi . ■ 1»
UaiDMisa Itif Ki( a>
BaiBM* KlitvlCirr ...... II
BifttI ttmiif^l VvtftJ . . , . tl
blt*4''>riJ III! lUMullf . ..... i^t
Bt«b4lb <ID lt'B4l I>]a«*fi44 ..... LB
Bdmca oa lb* tiuiuffb Ift
tirluv < PiicUt* clUidlelB* , . . 1<
BOvmiB'* ilnhB K irfBHtrnlObtnlBirgr. . t
prliiiitt'i rricKc* II
||aru«c*44 on Vati«r*Bl 9)
Biin«iB*d BBil CiiI>tl<i'BillBBi)ITBO*ta*l . M
i:«rp«a(*r'B II amAB Pti^alvlt^^ ... 1
i;«(9fBl*r nalhrCte «Bd AltoHnIAtMbvl . U
C>iB>>i>Dd Rurt» )4
OBrl«r »Blli>lii< M
CI«lBn4'« Ii1»«Ior T
Ci«**«u'> Clividltirf > . ■ • , ft
ClaWM' <'h«Bit>iry II
CflOLur/Qf AmarldlB ^«dJctB* . . . . 0
CbA4>'itk ^u I*J>*4B<« Hif Wiiiu«n . . r 3fl
Cbiro^t OB [ÏJO l'îirtuBi fiju^m .... in
CbkUHri OB 1>Ib1 Ahft Kt^^tLft, . , * > 19
CQrl'LiioB'iid 41rt1Dlli'< ifMiif-it^tatj . . II
CbanblU'>niM>cB tf Mrd>i(air • ■ . n
ObaHblllOBr«*rp'<»l ft'tr . . . . R
Cittll* UB DlMu« or CIill4i>B .... in
Cs*p*I'< (U. KI Lailstrnaii Xart*rj . , jn
Cj|l>[l*r'> AIIbi of r<DtI*al lil-t»** . K
CfdVp'-O'd' r'><l><>' XnlltlDt ... 11
DaQ«Bb OB mt«ttM« 4f WvBiva . . . . ft)
&itlOB'i UombB Pb^ildlajir .... *
Vtnf'i Cllslnl taelura* It
DtvoHita DlMBHiat faindtt . ' . t)
OtBlII't MidttiSiKftrf ... Il)
DaafllHB't Hidlnl motoDiir . . . i
nil* • U>ni>i><im<'>i» Is AmiofBr . • . '
irlfliMB't 6)-«lolu «f ïriiMiy , . , , Jl
EiBrnal on Uluki" of WomoB . . . K>
P>r<iii<»»UB**rD«rap«a<ICB ■ ■ - , II
r<itut'> i'hyituluBX (
ttBVflf" 1>UtQ'>»U ...... IÏ
F1bI>t*<-b'*<'""">' "'■(■><"■* ..•.]>
riisi «B Roptidorj OffBBi . . I»
PilBi OB |i>* Hon 1»
rilBl't Piultta of VtdlelB*. . .la
rriBi'i »i"tr« m
PllBI'i ClIBlHl UmllciBB 19
niBloaCtiIblali I*
Fllal on f^KdtBli^B ...... Ifl
Volb*ti|iir> ><>i><11>">b arTmdiMBl . . 1«
pglb*n|iU'> ABii>(OBt<« of TBrniMiiUo A^bbIb . I«
P>vB>*'* B>«ni*B<arr CniuliKT • . 10
roioB (HiH«untIb*»IB .... IB
Falltt »a (ll^ LiiBj(>.ilg . , I*
aT«D'- 1-41 Ko loi T >b4 tfiirbiii AaaiBsr . ■ H
ai*ag*'> llldtlBl ChimMitj . . . . «
at^flf>n * Hiirj|«rt to
01ari'il'»bol'>«>»iniUelu«]F,br t>*Mr. ■ u
flfar'* AbbIibiX ■ ' .... *
obiik"]''* Ai'>ir>'* *
Orill'li'i iK K ) uultd»! FansnUir . 11
Orj**Vli UfiltLIf k>'pDA ..... 14
Orn» ifB VnrtliB Bi'JioiaUr-ruBBfta . . to
Ori^ta'Bef.ttia of Hurc'fy . . ' . . .30
Bttiuiibuu <>n ili« AhirmnB II
HBinlllOD OB OllluiallurjiBBil riBdllt» . . M
BaitibniBi'* KuastUli orWcdlTIn" , l;i
BarOBoTBi'tfloBtpKiU'ifilr .M'lilcilltUaMi t
HBfiihotBi'i ABiiorn; niid PUydolCjir . f
HbibIHoo in l'HTi-nn ni-»»BB« ,...}»
fiBtlli'B FraclKa] Àmtcmf ..,.*)
HoblfK'* HadlcBl MdloBBtr .... 4
1loil(< as Wdihib ....
HiJdg^'B ObÉl4ltfiet ....
lUILBBd'i Xt'llial JfanaaBd Ka4«tllaa*
âait&««>BijF4< ty - . . ,
Holilta'c LaB^niBrtl
HiTBBl'i ABBli'Uir asl nUtoUff .
I HudtfïB oq Favar .....
! Iliillai'i BiBilliuok «rskta Plitaiaa
loaia ((J H>D<))ltl<])i>B MiriDaa I>l>0T4«Ti
Kirt»' PtLTtlulOfT ....
Kuapp'i Cttiuli:ilT*(bt)»1ii(jr ,
' !<•«.'• Sspatiail '1 0 aad )'l'rc^
ts4'*nadlH 111 Cbunb BlttntJ
UB»t «Tptllll
t.iD(alD OB SlHirA'Th «rapts Hat
I LatitiiiiaB'allMwIla'r ...
La RatbaoB TtlTvv FavBT.
La Riif ba oa I'Bauni^aU. At.
I.aarsBH bbiI Nnu't Opblbal(nla8ari<>T
I Lb«>«b oalbt Kira ....
IiBlLmaaD'a Pbr*''>l''(''al CbfUltlif.l *»■■.
f.ahBBBB'aCbaiiilBBIPlyaLaL^ir
bqdUw'aKaBBII Bf ItavlaallDBB ■
tfuua as r«Tai
KadiF*! .*<••• ind Ahilratl
Uorita aa WIB Ulaaaaai
XaliBOB Puarparal FaTtT .
Nillar'BFtacllcaaC âatKarp
XUIar'aFtualpItt nf Ka><a'r ■
Uimtfunr OB PnitBBit
a*tllBablp'a OpUbalalc IbilKUB .
SCdllladllaillb'aComFasdlBMaf lUJ.atlBM*
Obtlaltleal Jaaiaal
I Pariy *B Ealn-riarlaa Pr<(aibC7 .
iFBVJ'ob OL||«*ltaB
, Panlab'a FratllMl FbirOHf .
Plnla'aSraUm at &ai(irr .
PUTtalr-a Kldviril^ ....
4uala toi Sliarji-r'> Aaalamr.br l>^*)r .
Riisalila' Siiltn tl VaJIflaa . ■
KgittUDB Urlaarx UlaauBB
ftamtbatbaiB oa PartgitUaA
Baraata'a PrlBDlplsaofCbaMloltf .
Klgb^'aXtilvl'iir ....
nikptvlTa IilcrLaaary of i£iaa4« .
âhinauB'a -'rpaf arlf* *-a'd*if .
I ^■'•JBa'ai'lbitalrJE l|illonaat .
. |l<]1fL* cpB iba Thfnat ....
Ibupair and Oaala'a Aaaltnr, bj l.aM7
«tara lljiotallra ^Jalfarjr .
Made i<a Iilgbilii-ila ....
ScbAfac'a Hialil-iiy ....
tsilb fi. L.J UB CblUraa .
Rmlib iR. H] abd Hsratr't AaaMMaal AilM
4inM1i )Ed*a[J) oa C'IbiobiHUb
Imlib ,>b «riillDtniaoaiatiaCLlUria
'llllt'iTbalal'Iull» ....
'irlllil ft Uilasli'a tllapasaaldtT .
!iiir(a«oBCllaiaaIHa4iita>
tiokai uB FavaF .....
TiBBaraManaalufCUBlui MaJleta*
TbbBMOB FlcaaaKT
Tailor'a )l*dl<a]Iirttuin4*Bt* .
Taflot-arrlBCJptaa Bsi PraM» BrM*4 Jarl^ M
TairornB I'lflaoBa ... "
Tata un ibt Infla*B(a*r fh* Xlté .
TbamaaoB Dtaaaaaa of FanaUa . .
ThOKpaoBOB Drlxarf*"!*" . •
Thanipaaa OB SificiiFf .
Tùii OB Acnt# thaaaavi
WaMlniTJ'a PrwaikT'
Waltbt DBtbiHtail ....
WattBo'a Fn«l«of Pbjil»
Walltoblbalra . , . ,
Wmi OB tritaait* of FaiBaUt
Whi ua DiKtw cf CkiMraa
W-ti ijB XarTiiBi DlasfdaiiafÇbtMm
WiiliiDiiaa iTat>BBp41<B .
wiiaoa'B Hflmaa Aiaïu&x -
VI Ills 'a iliBlbwb at CBiaBa^BBMallBl»*
Wohl.i'. I>tia»li danlttr»
WiMt*l*aCki>lbr4 ....
HBITBT C. LEA-Fhlladelpbia.
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