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AN  INTRODUCTION 


PATHOLOGY  AND  MORBID  ANATOMY. 


INTRODUCTION 


Pathology  and  Morbid  Anatomy. 


BY 


T.  HENRY  GREEN.  M.D.,  FRCP.. 

PHYMCUK  AND  SPECIAL  LEtmiRER  ON  CLINICAL  MEDICINE  AT  CHABINU  CBOiS  HOSPITAL, 

AND  PHYSiaAM  TO  THE  HOSPITAL  FOR  CONSt'MPTION  AND  DISEASES 

OP  THE  CHEST,  BHOMITON. 


SEVENTH  AMERICAN  FROM  THE  EIGHTH  ENGLISH  EDITION, 


BEVI8EU  AKD  ENLAIU)£I>  BY 


H.  MONTAGUE  MURRAY,  M.D.,  F.R.C.P., 

PHYSICIAN  TO  Ol'T-PATIENTS,  AND  LECTCRKR  ON  PATHOLOGY  AND  MORBID  ANATOMY 
AT  CUARIN<i  CROSS  HOSPITAL. 


ILLUSTRATED  BY 
TWO  HUNDRED  AND  TWENTY-FOUR  ENQRAVINQ8. 


PHIL.VDELPIIIA  : 

LEA  BROTHERS  &  CO. 

1895. 


/ 


Entered  according  to  Act  of  Coni;rvn  in  the  jttx  1895,  by 

LEA  BKOTHERS  *  CO., 

in  the  Office  of  the  Libntriitn  o(  CougreiM,  at  WaHhington.    All  righta  reaerred. 


■MTOOTT  4  TNOMWM. 
IktOTMOTV^tNS.    PMILAOA. 


PREFACE. 


The  last  edition  of  this  text-book  was  so  thoroughly  revised  by 
Mr.  Stanley  Boyd  that  my  task  in  editing  the  present  issue  has  been 
comparatively  light.  The  rapid  accumulation  of  facts,  and  the  con- 
sequent changes  in  opinion  which  have  distinguished  many  depart- 
ments of  Pathology,  have,  however,  rendered  it  necessary  that 
several  new  sections  should  be  added  and  several  old  ones  rewritten 
or  withdrawn.  In  making  such  changes  as  seemed  advisable— and 
they  occur  on  every  page — I  have  adopted  Dr.  Green's  concise  and 
lucid  sentences  as  my  model,  so  that  no  disadvantages  should  accrue 
from  the  admixture  of  different  styles  of  composition. 

In  view  of  the  existence  of  many  larger  and  more  elaborate 
treatises  on  pathology  it  has  seemed  unnecessary  to  burden  these 
pages  with  precise  references  to  original  papers.  I  have,  however, 
on  several  occasions  referred  the  reader  to  articles  likely  to  be 
within  his  immediate  reach. 

Sixty  new  illustrations  and  a  colored  frontispiece  have  been 
added.  To  these  the  increase  in  size  is  mainly  due.  Nearly  all  of 
"them  are  from  drawings  or  engravings  by  Mr.  Ceilings,  who  has 
taken  the  utmost  pains  to  ensure  clearness  and  accuracy.  Some  of 
these  replace  less  satisfactory  illustrations  in  the  last  edition.  In 
«very  case  where  specimens  have  been  lent  I  have  acknowledged 
their  source — in  the  case  of  those  which  have  appeared  in  previous 
editions  by  adding  the  name  of  the  donor,  and  in  that  of  specimens 
which  appear  for  the  first  time  in  this  edition  by  a  slightly  longer 
and  therefore  distinguishing  statement. 

I  gladly  avail  myself  of  this  opportunity  of  acknowledging  the 
help  I  have  received.  To  my  friends  and  colleagues.  Dr.  Mott,  Dr. 
Arkle,  and  Mr.  Stanley  Boyd,  I  am  indebted  both  for  suggestions 


9^r-74 


8  PREFACE. 

and  specimens.  Dr.  Mott  has,  in  addition,  contributed  the  chapter 
on  Diseases  of  the  Nervous  System.  I  much  regret  that  exigencies 
of  space  have  prevented  him  from  dealing  more  fully  with  the  sub- 
ject. In  like  manner,  Mr.  Boyd  has  written  the  section  on  Tuber- 
cular Diseases  of  Bones  and  Joints.  For  various  items  of  help — 
specimens,  drawings,  blocks,  or  criticism — I  am  also  indebted  to 
Dr.  Macfayden,  Dr.  Manson,  Dr.  Kolleston,  Dr.  RufFer,  Dr.  Sher- 
rington, Dr.  Woodhead,  and  the  J.  B.  Lippincott  Co.  The  Imlix 
has  been  prepared  by  my  friend  and  demonstrator,  Mr.  Harold, 
who  has  also  assisted  me  in  the  revision  of  the  proof-sheets. 

I  can  only  hope  that  neither  lack  of  knowledge  nor  defect  of 
judgment  on  my  part  will  in  any  way  mar  the  reputation  of  this 
text-book,  or  stultify  the  confidence  which  Dr.  Green,  my  predeces- 
sor in  the  lectureship  on  Pathology  at  Charing  Cross  Hospital,  ha« 
ventured  to  repose  in  me. 

H.  MONTAGUE  MURRAY. 
March,  189B. 


CONTENTS. 


INTRODUCTION. 

PAGES 

The   Normal    Oell— Characters— Physiology — Development.    Disease- 
Varieties — Etiology — Effects — Terminations 17-34 


NDTRITION    ARRESTED. 

CHAFfER  I. 
Necrosis — Gangrene — CoagJilation-necrosis — Senile  Gangrene  —Fat-necrosis. 
Post-mortem  Ohanges 3&-44 


ITOTRITION  IMPAIRBD. 

CHAPTER  II. 
Atrophy— of  Bone.    Pulmonai-y  Emphysema 44-55 

CHAPTER   III. 
Fatty  Infiltration — of  Muscle— of  Liver.    Patty  Degeneration — of 
Rlood-veesela — of  Muscle— of  Heart — of  Kidneys — Cerebral  Softening     .  56-79 

CHAPTER   IV. 
Cloudy  Swellingr— of  Special  Parts 79-81 

CHAPTER  V. 
Mucoid  Deereneration.    Colloid  Degeneration— Zenker's  Degenera- 
tion of  Muscle.    Hyaline  Degeneration 81-85 

CHAPTER  VI. 
Ijardaoeous   Degeneration  —  of  Liver— of   Kidneys  -of  Spleen  — of 
Lymphatic  Glands — of  Alimentary  Canal — Corpora  Amylacea 86-99 

CHAPTER  Vn. 

Oaloareoos  Defeneration- of  Arteries 99-103 

» 


10  cosTEyrs. 

CHAPTER  VIII. 

PAOB 

Pigmentary  Degeneration— of  Lungs 104-112 

NUTRITION  INORBASBD. 

CHAPTER  IX. 
Hyi)ertrophy— of  Heart 112-118 

CHAPTER  X. 
Regeneration — of  Vesselu — of  Connective  Tissue— of  Cartilage — of  Rone — 
of  Muscle— of  Nerves— of  Epithelium.    Healing  of  Wounds — Trans- 
plantation of  Tissues  1 16-131 

TUMORS. 

CHAPTER  XI. 
Tumors — Development— Growth — Ketn^reosive  Changes — Clinical  Conme— 
Causes  of  Malignancy — Etiology — Clawiticatiun 131-148 

CHAPTER  XII. 

Tumors  of   Higher   Tissues  — Mromuta  — Neuromata  — Angiomata— 
Lymphangiomata 149-163 

CHAPTER  XIII. 
Ttimors  of  Oonneotlve  Tissues— Fibromata — Myxomata — Liponiata— 
Chondmmuta — Osteomata — Lymphomata — Hotlgkin's  Disease 163-168 

CIIAITER  XIV. 
Tumors   of   Bmbryonio   Tissue— Sarcomata— Cieneral    Characters. 
Bound-oelled     Sarcomata — CiUomatii— Lymph  o-«arconiata — Alveolar 
.Sm-nniata.       Spindle-celled     Sarcomata  —  Melanotic     Sarcomata — 
Osteoid  Sarcomata — Myeloid  Sarcomata — C'ylindromata — Blood-cysts  .   .  169-182 

CHAFFER  XV. 
Eipitbelial    Tumors — Papillomata  —  Adenomata — Carcinomata,    General 
CharacterH — .Acinous  Cancer — Epitheliomata — Colloid  Cancer 182-207 

CHAPTER  XVL 
Teratomata— Oysts a07-21» 


DI8BA8BS  OF  THB  BLOOD  AND  OIRCULATION. 

CIIAI»TKR   XVII. 
AnsBmia  —  Chlorosis  —  Pemiciou!>      Ana-mia.    IjeuobSBmia  —  Lencocy- 
tosis 21S-2S4 


CONTENTS.  11 

CHAPTER  XVIII. 

PAGES 

liOoal  AntBtnla  —  Hyperssmia  —  Arterial  —  Mechanical  —  Post-mortem 
Evidences — Mechanical  Hypersemia  of  Liver — of  Langs.  Dropsy — 
Thrombosis— Characters  of  Clots  and  Thrombi — Later  Changes  in 
Thrombi.  Bmbolism— Infarction— Results  of  Embolism — CapilUry  Em- 
boli— ^Thrombosis  and  Embolism  of  Brain— Pulmonary  Apoplexy  .   .   .  225-270 


FEVER. 

CHAPTER  XIX. 
Temperature  in  Health — Symptoms  of  Fever — Post-mortem  Rise  of  Tempera- 
ture— Pathology  and  Varieties  of  Fever 270-27S 


INFLAMMATION. 

CHAPTER  XX. 

Histolocry — Changes  in  Blood-vessels,  Circulation,  and  Tissues — Explanation 
of  Changes.  Olinioal  Signs— Varieties — Serous — Fibrinous— Produc- 
tive —  Interstitial  —  Parenchymatous  —  Suppurative  —  Ulcerative  —  Hemor- 
rhagic, etc  Terminations — Btiologry— of  Suppuration.  Modes  of 
Spread— Modes  of  Arrest— Phagocytosis 279-31ft 

THE  VEQETABLB  PARASITES. 

CHAPTER  XXL 
Fermentation  and  Infective   Disease — Theories  of  Fermentation — 

Ferments. 
The  Sohizomyoetes — Morphology  and  Life-history- Conditions  of  Life 
and  Growth — Distribution  and  Habitat — Products — Fate  in  Living  Tissues 
— Methods  of  Investigation — Classification — Etiology  of  Infective  Diseases — 
Immunity.  Pathogenic  Baoteria-Sphaerobacteria— Fermentation 
of  Urine  —  Suppuration  —  Erysipelas  —  (lonorrhoea — Pneumonia — Sarcinse. 
Microbacteria.  Desmobaxjteria— Splenic  Fever— Typhoid  Fever- 
Bacillus  Coli  Communis — Diphtheria — Influenza — Plague— Septicsemia  of 
Mice — Tetanus — Malignant  (Edema.  Spirobaoteria — Relapsing  Fever — 
Cholera. 

Tlio  Blastomycetes— Oidium  Albicans. 

The    Hypbomycetes — Diseases    Due    to — Actinomyces    and    Madura 
Foot S16-403 


THE  INFECTIVE  QRANULOMATA. 

CHAFfER    XXIL 
Tuberculosis — Morbid  Anatomy  and  Histology — Etiology — Bacillus  Tuber- 
culosis— Entry  into  the   Body — Development   in  the  Tissues — Tubercular 
Meningitis — Tuberculous    Masses    in    Brain— Tuberculosis    of    Lymphatic 


12  coymxTs. 

FAura 
OIjiikIb— of  Mucoiis   Meniliranps — of  I^arrnx  and    Liiiiks— of    Bones  and 
Joints.    Lupus    Vulgaris— Scrofula— Leprosy— SyphiliB—Syplii- 
liiic    Disi-axe   of    Liver- Glanders   and    Farcy- Bhinoscleroma— 
Actinomyoosis 4(i3-l(>l 


SEPTIOiBMIA  AND  PT^SiMIA. 

CIIAPTEK  XX I! I. 
Septlceemia — Experimental    Kescarclu-x  —  ObavrrationR    on     Man.     Py- 
ffimia 461  -4«>8 

MALARIA. 

CH.VITEK  XXIV. 
Appvamnces  iieen  on  Kxaniination  of  Blo<xl— Etiology 4G8-47:{ 


DISEASES  OF  SPECIAL  TISSUES  AND  ORGANS. 

CHAITEK    XXV. 
Inflammation  of  Connective  Tissue— of  Cornea— of  Cartilaere— 
of    Bone-t'erioHtitiM— OBtitis— Necro6i.s.     Mollities    Ossium — Rick- 
ets   473-1S2 

CHAITEK  XXVI. 
Inflammation  of  Arteries  —  Acute  Arterhifi  —  chronic    Endarteritin — 
Efleett).    Inflammation  of  Veins— Varicose  Veins.    Inflammation 
of  Endocardium— Acute — ('hronic.     Inflammation  of  Myocar- 
dium—Kil)roid  Induration  of  Heart 4«2-49.5 

CIIAITER  XXVII. 
Inflammation    of  Lymphatic    Structures- Acute— CIin)nic.     Ty- 
phoid Fever 495-301 

CHAPTER  XXVIII. 
Inflammation    of  Mucous    Membranes— Catarrhal — Croupous    ami 
l>iplitlieritic.     Dysentery  —  Inflammation    of    Serous     Mem- 
branes   Wi-TAO 

CHAITKR   XXIX. 
Inflammation  of  Liver— Perihi'i);ititis—.\bs<'a« — Cirrhosis — Acute    Yel- 
low Atrophy 510-516 

CHAITEK  XXX. 
Inflammation  of  Kidney— Suppurative — Chronic  Constructive — Paren- 
chymatous— Interstitial 516-528 


CONTENTS.  13 

CHAPTER  XXXI. 

PAOO 

Infianunatioii  of  the  Luncrs — Acute  Pneumonia — Broncho-pneumonia — 
Hypostatic  Pneumonia — Interstitial  Pneumonia.  Pulmonary  Phthisis 
— Hi8tolog>— Pathology— Etiology 529-559 


PATHOLOGY  OP  THE  OBNTRAL  NERVOUS  SYSTEM. 

CHAPTER  XXXII. 

General  ConsidenitioDB.  Inflammation  of  the  Meningres— Pachymen- 
ingitis—Leptomeningitis.  Inflammation  of  the  Central  Nervous 
System  —  Encephalitis  —  Cerebral  Abscess  —  Myelitis  —  Poliomyelitis. 
Cerebral  Hemorrhage— Secondary  De^renerations — Primary 
Degenerations— of  Efferent  Tracts— Syringomyelia 559-587 


PRINCIPAL  WORKS  REFERRED  TO. 


Baumoarten:  Jahraibirieht. 

Lehriuch  der  pathologixhen  Mykoloffie. 

Billroth,  Theodor  :  Die  ailgemeine  chirwgitche  Patkologie  und  TlurapU,  10th  Ger- 
man edition. 

BiRCH-HiRSCHFKLD :  Lehrbueh  d.  paihol.  Analomie. 

BoYCB,  RtlBBRT:  Text-book  of  Moiiid  Hidotoffy. 

Buhl,  Lnowio,  Limgenenitundung,  TuberkuloK,  und  SchmndmehL 

Coats  :  Manual  of  Pathology. 

CoHNHElM :    VorUgungen  Sber  allgaminen  PatMogie,  1882. 

CoRXIL  ET  Ranvier  :  Manuel  dC  HiriologU  pa,tiu)logique. 

DucLACZ :  FermentJi  et  Maladies. 

Fluook:  Mienhorganima. 

Forster,  AuQi'ST :  Handbueh  der  jxUhologitehen  Anatamie. 

Hallopeau  :  Pathologie  gtntrale. 

HAinLTON,  D.  J. :  Tetl-book  of  Pathology. 

HoRSLEY :  "  Septic  Bacteria  and  their  PhTsiologicsI  Relations,"  (in  Rep.  <if  Med. 
Officer  0/  Local  Govt.  Board,  1881-82). 

HuTER,  C. :  Orundrim  der  Chirurgie. 

Journal  q/'  Pathology. 

Journal  (f  Phygiology. 

Klers:  Handbueh  der  paihologisehen  Anaiomie. 

Klein  :  The  Anatomy  of  the  Lymphatic  System. 

Koch,  Robert:  Untersuehungen  iiber  die  Aetiologie  der  Wundiiifeetiondkrankheiten, 
Leipzig,  1878 ;  Traumatte  Infective  Diaeates,  translation  by  W.  W.  Cheyne, 
New  8yd.  8oc. 

Kl'HNE,  W. :  Lehrbueh  der  physiologisehen  Chemte. 

Lister,  J. :  "  On  the  Early  Stages  of  Inflammation,"  Philoiophieal  Trans.,  1859. 

LucKE :  "  Die  Geschwiilste,"  Handbueh  der  allgm.  u.  spec.  Oiirurgie,  Von  Pitha  und 
Billroth. 

MicrnparasHes  in  Disease,  New  8yd.  See — selected  German  Essays,  edited  by  W. 
Watson  Cheyne. 

Metchnikoff,  Eli  as:  Lectures  on  the  Comparative  Pathology  of  Infiammation,  trans- 
lated by  F.  A.  Starling  and  E.  H.  Starling,  M.  D. 

Paget,  Sir  J. :  Lectm-e*  on  Surgical  Pathology,  edited  by  Prof.  Turner. 

Kecklinohausen:  "Handb.  d.  allg.  Path.  d.  Kreislaufs  u.  d.  Erniihrung,"  in  the 
Deutsche  Chirurgie. 

RINDFLEISCH,  E. :  Lehrbueh  der  paihologixchen  Oeuxbdehre. 

Btxeck  :  "  Zur  Kenntnisader  Stase  des  Bhitesin  den  Gefassen  entzundeter  Theile," 
Bollet's  Unlersueh.  aus  dem  Institute  fur  Phys.  u.  Histol.  in  Oraz. 

15 


16  PRINCIPAL    WORKS  REFERRED  TO. 

Sandersox,  J.  BuRi><)N :  Article  on  "  Inflammation"  in  Holmetf  SyOem  (jf  Sujyrry, 

vol.  i. 
S<.'||AFER :  Qnain's  Anntmnt/. 

Scini'PKi,  Oscar  :  "  rntersiichungen  liber  Lymphdrusen-Tuberkulose." 
StersbKRii  :  Jloflerioliyy. 
Stkk'KKR,  8.:  Various  Faiiers  by,  in  his  Sludien  aiig  dem  Ituliliile  Jiir  tiptrimentfUt 

I'uthoiogie  in  Witii,  1809. 
Manuai  nf  Human  ami  Oomparalke  Uintology,  vol.  L,  edited  by  Prof.  Strieker, 

translated  by  Mr.  Power. 
RfTTON,  J.  Ul,ASD:  -III  Intmdutiion  to  Ocneral  Pathology. 
SrTTON,  H.  (iAWES  :  Leeluret  on  Pathology. 
Traimtclian*  of  the  Pathological  Society  of  iMiitton. 
UllLE  USD  Wagner:  llandbueh  der  allgemeinen  Pathologie. 
ViRCHOw,  Rudolf  :  Pie  Cellular  Pathologic. 
Arehir, 

Die  hantha/ten  GexhmiUie. 

Oetammelte  Abhandlungen. 

Handbtieh  der  npftiellen  Pathologie  und  Therapie,  Band  i. 

Waoner,  E.  :  .Manmd  of  Oeneral  Pathology.    Translated  by  Drs.  John  Van  Dtiyn 

and  E.  ('.  Segiiin,  6th  ed. 
Weber,  O.  :  "  Die  (iewelwerkrankungen,"  HancUmeh  der  cdlgm.  u.  tpee,  Chirurgie,  Voo 

Pitha  und  Billroth. 
Weichselbai'M,  Astos  :  Handbueh  der  pathotogixhen  HiMologie,  1892. 
WlLKS  AND  MoXON  :  Leclwet  on  Pathologital  Anatomy,  3d  ed. 
WoODHEAD,  O.  Sims:  Pradieal  Pathology,  3d  ed. 
ZiEOLER :  Oeneral  Palhologieai  Analomy,  translated  by  Donald  MacAlistcr. 


EXPLANATION  OF  PLATE. 


Fio.  1.— Staphvixkxkxts  PviKiKSEs  AvREVs.  riilliiii  ill  iiiiiiinil  nmi  <f  ii.  It 
will  be  noted  that  the  orange  color  in  limited  to  the  mirface,  the  dee|Mr.fQr- 
tionx  of  the  growth  uecurring  along  the  line  of  pnncture  being  whita-  (ne 
p.  Sli").  'rV 

Vui.  2. — Bacilli's    Anthracis.      Culture  in   nutrient   agar-agar.     Th«  gtvf^ 
ntveni  the  Murface,   and  extends  alnng  the  line  of  puncture  in  tiw-.i 
of  a  thick  white  Hireak,  with  liner  streaks  spreading  at  right  angJeB ' 
it,  eKi>ccially  in  the  upper  part  (see  p.  377). 

Fi(i.  3. — TiiK  IlAciLLf.<<  OF   Malihsaxt  GCdema.      Culture  in  nutrient 

a^r.  The  growth  ixvurs  in  that  part  of  the  line  of  punctare  whidi  i« 
farthest  from  the  air.  ITere  it  liaH  a  somewhat  irregular  outline  and  jagged 
edge.  When  traced  n])ward,  it  soon  diminishes  to  a  just  peroeptibla  tnCL 
There  is  a  <-liaracteriHtic  development  of  air-bubbles  in  the  neighboriMod  ef 
the  growth  isee  p.  ."Wll). 

Vui.  4. — I'ai'ILI.is  DiPiiTHKKi.F.  Culture  on  I>efflcr's  blood-Minim.  This  dos- 
ing is  made  from  two  separate  cultures.  The  outlying  gray  spots,  widi  the 
i-entre  rather  more  opaque  than  the  |)eriphery  (p.  384),  is  the  form  genenHy 
s<-en  in  primary  cultures.  The  continuous  line  of  growth  represents  a  eoB- 
mon  form  itssumed  in  secondarh'  and  8ul)se(juent  cultures  (see  p.  383). 

Via.  ■'>. — TnK  SiMKiLLi'M  OF  CnoLKU.v.  Culture  in  nutrient  gelatin,  atcodaf 
M-cond  tiay.  l.i(|uefaction  has  cH-curre<l  at  the  up|ier  end  of  the  i"'"**""^ 
and  a  l>i.-ll-sha|ied  cavity  is  pnKluced.  The  principal  part  of  the  coltore  liei 
in  the  lower  part  of  this  depression  and  in  the  up|ier  part  of  its  ooifaow- 
like  termination  (see  p.  3',H)}. 

Fl(i.  (i. — HAfii.i.fs  TtBEKCTU)sis.  Culture  on  glyceriu-agar.  The  greater  psil 
of  the  growth  consists  of  opaiiue,  gniyish  or  yellowish,  heaped-up  miaWi 
lint  at  the  jK-riphery  thin  Hakes  or  scales,  which  are  very  characteristic^  oso 

Ih'  s<H'n  (see  p.  4 !•">). 


PATHOLOGY 


AND 


MORBID  ANATOMY. 


INTRODUCTION. 


Anatomy  and  histolooy  investigate  the  naked-eye  and  niicro- 
*«copic  structure  of  the  bealtby  body ;  physiology  examines  the 
Cunctionfi  of  the  parts  revealed  by  them,  and  ^»tlIdies  the  chemical 
jirooesses  which  constitute  healthy  life.  To  obt.iin  ii  knowledge  of 
«lisea«e  ]>arallel  courses  must  V)e  adopted.  At  [lost-mortem  exam- 
inations we  note  all  the  naked-eye  departures  from  normal  anatomy ; 
■vith  the  microscope  we  discover  the  finer  changes  to  which  these 
«lepartures  are  due;  and  by  e-\pcrimcntal  methods  and  bedside 
«:>lt8ervation8  we  investigate  the  causes  of  the  abnormal  structure 
*»nd  function,  their  mode  of  action,  and  the  nature  and  sequence 
of  the  disturbances  which  they  produce.  In  other  words,  just  as 
"^e  have  anatomy,  histology,  and  physiology,  so  also  we  have  mor- 
\)\A  unatomy,  morbid  histology,  and  pathology. 

Our  guiding  priiici[)le  in  modern  pathology  is  that  we  have  to  deal 
«iot  with  new  tissue-cells  and  functions,  but  simply  with  disturbances 
«3f  ordinary  elements  and  functions.  It  is  obvious,  therefore,  that 
Tor  the  purpose  of  studying  disease  our  aci|riiiintance  with  the  body 
in  health  cannot  be  too  intimate.  New  cells  (bacteria),  and  even 
entire  animals  (parasitic  worms),  are  frequently  introduced  into  the 
tissues,  but  as  niuiirD,  not  prmlurtti.  of  disease. 

The  complex  human  organism  can  be  reduced  to  very  simple  ele- 
ments— the  relh  ami  the  interi'iUuhir  Hub»trtiice»  to  which  they  give 
origin.  These  two  elements  make  up  every  tissue.  Sometimes  the 
cells  are  in  excess,  as  in  the  epi<lermis.  where  they  seem  to  be  in 
abt>oliiie  contact;  and  sometimes  the  intercellular  substance,  as  in 
i  17 


tn  ISTROUUCTIOS. 

thft  rjiuwKlwH  tiMUMi.  It  n  now  nnitersallT  believed  that  the  indi- 
vidual i^ell  \n  the  M<rat  of  nutrition  and  function.  Health  and  disease 
inuMt  b(;  coHMidcred  ait  terra.'t  referring,  not  to  the  bodv  as  a  whole, 
hut  u>  the  actual  cellti  of  which  it  consists. 

Ik-fore  treating  of  disease  allusion  must  be  made  to  the  constitu- 
tion of  cells  in  health,  as  well  as  to  their  functions  and  to  the  con- 
ditions under  which  these  are  normally  discharged. 

CONSTITUTION  OP  CELLS.— When  Schwann  established 
the  analogy  between  the  animal  and  vegetable  cell,  the  former  was 
held  to  be  constructed,  in  all  cases,  upon  the  same 
principle  as  the  latter,  and  to  consi.st.  therefore,  of  a 
cell-wall  enclosing  a  cavity  in  which  were  contained  a 
nucleus  and  fluid  contents  (Fig.  1).  But  the  fact 
that  no-cell-wall  could  be  demonstrate<l  in  embryonic 
cells,  blood-corpuscles,  and  the  cells  of  many  rapidly- 
growing  new  formations  led  Lcydig  and  Max  Schultze 
to  believe  that  a  little  mass  of  matter,  enclosing  a 
nucleus,  was  all  that  was  necessary  to  constitute  a  cell. 
Max  Schultze  established  the  identity  of  the  cell-sub- 
..  „    ^  stance  with  animal    sarcode — a  contractile  substance 

iniKvr  ■iinwiiiic  existing  in  the  lower  animals — and  showed  that  it  also 
I><'.I!i.*ni'.'  nil'  *'"••  capable  of  spontaneous  movement.  He  called  this 
«i«i,  ■iwi  mnio  substance,  of  which  all  cell-bodies,  animal  or  vegetable, 
■iivi.iinij  '"■•'<  »'  ""♦'  period  ot  their  existence,  composed,  pro- 

toplasm,   luid    pointed   out   that  a    distinct  cell-wall 
rwultod  fmm  ii  retrograde  process  occurring  in  its  outer  layers. 

Tlio  doftnilioii  of  a  cell  has  been  still  further  modified  by  the  dis- 
covery thai  a  nuel«>us  is  not  essential,  for  none  exists  in  the  crypto- 
gamia  and  in  s«>me  of  the  lowest  animal  forms.  In  these  excep- 
tioiinl  oa.'»es  the  cell  iH>n8ists  of  a  simple  mass  of  protopla.«m,  but  in 
th(<  higher  animals  the  nucleus  is  an  alnio.>it  invariable  constituent. 
The  oell-Mnll  is  much  K\os  inmstant.  and  must  be  regarded,  in  ]K>int 
of  vitality,  a.o  inferior  to  the  rest  of  the  cell. 

Protoplaani  is  a  tt>mplex  living  IhmIv  :  of  its  molecular  constitu- 
tion «o  !»rx>  ;«tiU  ignorant.  It  contains  a  large  <|uantity  of  water, 
and  u>  solid  rrv^idue  is  largidy  made  up  of  proteid  material :  but 
»«tli  this  thort'  an*  always  asmnMattnt.  ap)tarently  in  an  amalgam- 
like way.  some  earlndtydrate,  fat.  and  inorganic  ^^Its:  for  these 
are  luxisiblv.  and  vet  not  in  true  combination.     Some  authorities 


lyrRODVCTioN. 


19 


Bui 


■^Tcgiinl  the  protcid  element  as  alone  esaentiiil  Id  the  manifestation  of 
life.     Protoplasm,  as  seen  in  the  bodies  of  living  cells,  is  generally 
structureless,  soft  and  viseid,  but  varving  much  in  fluidity.      Gran- 
ules are  freijiiently  present  in  it.  often   in  one  jwirt   and  not  in  un- 
[>tber,  and  these  are  believed  to  differ  chemically  from   true   [ivnto- 
plasm.     Small   cavities,  full  of  iiuid,  iui)kin;j:  like  clciir  sjiaces,  are 
.often  seen:  one  large  one  may  occiij)y  a  considerable  portion  of  the 
■cell,  or  many  smaller  ones  may  be  distributeil  through  it.     These 
ciivities  are  called  vacuoles.    They  may  apjiear,  disappear,  or  change 
'their  position. 

In  highly  specialized  cells   protti|da8m   has  acrjuired  a  distinct 

Kstrnctiire — e.  </.  the  fibrillation  of  muscle  and  nerve-cells  and  the 

V«triatiou  of  nuiny  ciliated   cells   and   gliind-cells.      In   the  simpler 

H  cells,  after  hanleniug  in  chromic  acid,  a    fine   nctwurk   of  fibres  is 

■  seen  in  the  cell-substance — a  fact  which  has  led  to  the  belief  that  the 

protoplasm  of  all   cell-bodies    is   really  iiiT!iiij:cd  likv  a  spouj^e.  the 

interstices  being  occupied  by  fluid   containing  granules  which  are 

moved  about  by  contractions  of  the  protoplasm.    This  view  e.\[)lain8 

Ktnany   ])henomena  of  cell-life,   but  np  to   the  present  time  these 

^appearances  have  not  been  observed  in  living  cells. 

Schiifcr  has  recently  shown  that  protofdasiu  is  composed  of  two 

sul>stances :  (1)  sf>on</iophiiim,  which  forms  a  reticular  framework, 

^  (2)  hi/alopfnsm,  which  is  structureless,  seuiifluid.  ami  not  neces- 

y  confined  within  the  limits  of  the  rctictihir  framework.     The 

movements   of    the   cell    depend    ujion    those   of  the   hyaloplasm. 

But«chli  considers  the  structure  of  profoplasiu  ;is  analogous  to  that 

rof  foara — "minute  ilroptots  of  a  watery  iitjuid  take  the  place  of  air 

n  the  buhblen  of  foam."     He  agrees  with  Schafer  in  considering  it 

■fticular,  but  iliffers  in  his  interpretation  of  what  he  sees,  as  well 

,«-H  in  his  ob.scrvations  on   the  arrangement  and  disposition  of  the 

framework  ii.self.      He  thinks  he  can   trace  a  reticular  structure  in 

he  "processes,"  and  that  it  fades  gradually,  in  them  as  elsewhere, 

uto  thf  more  lii|uid  element.     Schiifcr  thinks  the  limit  is  sharply 

ofined  and  that  the  pseudopoilia  arc  houiogciicmis. 

Under    certain    circumstances    protoplasm    undergoes   metamor- 

'|)hti«e>i  into  various  other  substances — .'.  </.  iiiuciii,   globidiu,   kera- 

n.  pepsin  and  other  ferments,   glycogen,  colloid   matter,  and  fat. 

hese  may  form  large  portions  of  the  bodies  of  cells.     When  gly- 

n;;en  and  fat  arise  from  a  proteid  a  nitrogenous  molecule  must  also 

formed. 


Hsul>s 

K 


INTRODUCTION. 


This  protoplasm  is  the  essential  cou.stitueiit  of  the  body  of  every 
cell.  In  comparison  with  tlie  niicloiis  the  body  varies  much  in  aiae, 
being  wimetimes  lar^re  Jind  .S4)metimes  (Hiite  insignificaut. 

The  cell-wall,  v»lieu  presteuf,  is  of  much  firmer  consiistcncc  than 
the  rest  of  the  body,  and  seeiii.s  to  t>e  due  to  some  uietnmorphoaiB  of 
the  protoplasm  of  the  latter. 

The  nucleus  is  more  <-(int<tant  thiiii  the  body,  both  iu  sixe  and 
form.  It  is  usually  spherical  or  oval,  but  may  be  quite  rod-shaped; 
it  is  generally  placed  m.-ar  the  centre  of  the  cell,  and  may  \tv  .■•injile 
or  multiple.  It  resists  destructive  reagents  more  strongly  than  doc-s 
the  body,  and  in  disease  often  remains  after  this  has  been  destroy i*«i ; 
it  is  stained  more  deeply  by  carmine  and  logwood.  It.s  presence  may 
be  concealed  by  fat.  pigment,  or  other  substances  in  the  ceU-btHly. 
The  nucleus  of  epidermic  scales  may  finally  be  converte<J  int«> 
keratin  and  disap])ear. 

The  nucleus,  which  was  formerly  regarded  as  a  spherical  vesicle 
bounded  by  a  definite  memlmiue  which  separated  the  nuclitir  fluid 
from  the  cell-substance,  is  now  known  to  possess  with  greai  c-firi- 
stancy  the  following  much  more  intricate  structure:  (1|A  mem- 
brane bounding  it  externally ;  (-)  u  network  of  fibres,  itrobahly 
contractile,  and  certainly  capable  of  grout  changes  in  closeness  and 
general  form;  (3)  one  or  more  nucleoli,  s^iid  by  some  to  be  oiily 
Itodal  point.H  in  the  network  ;  (4)  a  clear,  more  or  less  fluid,  siili- 
stnnee  which  fills  the  membrane  and  lies  in  the  meshes  of  tlie  tiet- 
Vfork.  The  more  solid  portions — membrane,  network,  and  diicI(^>U 
— are  spoki-n  of  as  chromoplasm  or  nudfophism  ;  the  les.'t  fuilid,  as 
nuclear  matrix.  The  reuiarkalile  changes  which  occur  in  nurlci 
previous  to  the  division  of  cells  will  lie  described  subsetiuentljr 
(p.  -27). 

PHYSIOLOGY  OF  CELLS.— In  order  to  form  an  ade<|iiate 
conception  of  the  changes  which  occur  iti  liisease  it  is  essential  to 
remember  the  normal  functions  of  cells  and  the  conditions  under 
which   they  are  discharged. 

A  unicellular  organism,  like  the  anneba,  taki-s  in  f<H)d,  grows, 
excretes,  reproduces  its  like,  and  performs  certain  functions,  of 
which  motion  is  the  most  obvious.  The  whole  of  this  may  bu 
regarded  as  work  done,  and  implies  the  expenditure  of  force ;  and 
we  may  be  (piite  sure,  although  we  know  nothing  of  the  chemical 
processes  going  on  in  an  amiebu,  that  its  excreta  are  simpler  coin- 


TNTRODUCTION. 


21 


poiiuds  than  its  ingesta,  the  difference  in  heat-value  between  these 
tw«»  sets  of  coiu[ioiinils  representing  the  force  wliifli  is  iivailable  to 
tiic  organism.  The  ability  to  eflect  these  cheniiciil  and  iihy»ieal 
fifooesses,  in  which  the  "  life  "  of  the  animal — as  recognizable  by 
08 — consists,  is  inlieritetl,  ami  is  spoken  of  as  '■'■  i>itiil  aHiriti/ "  or 
"  vital  encri/if."  The  possession  of  this  is  naturally  the  first  essential 
to  living.  The  other  requirements  of  the  cell  are  a  sufficient  supply 
of  *iiittthlt-  food  and  an  iipi>roprliJte  physicnl  environment — such  as  a 
normal  tem|)erature  and  suitable  density  of  the  surrounding  fluid. 
To  these  must  be  added — in  the  case,  at  least,  of  nerves,  muscle, 
and  certain  gland-cells  in  man — connection  with  a  healthy  nervvut 
rentre. 

In  man,  a  multicellular  being,  the  cells  vary  much  in  form  and 
in  the  results  of  the  chemical  actions  wliivli  they  effect.  Although 
retaining  more  or  less  independence,  vurying  witii  the  kind  of  cell, 
they  arc  bound  together  for  the  coiaiuiiii  good,  and  each  has  some 
special  function  to  perform.  Thus  there  are  muscle-cells  to  pro- 
duce motion,  gland-cells  to  secrete  and  e.xcrete.  and  nerve-cells  to 
cv>ntrol  the  working  of  muscle,  glands,  anil  perhaps  other  tissues; 
certain  cells  are  set  apart  for  reprfiducfion ;  and.  Kiutliy,  there  arc 
the  connective  tissues  to  unite  and  support  the  other  structures,  and 
epithelium  to  protect  the  surfaces.  Thus  each  kiml  of  work  done 
by  the  one  cell  of  the  auneba  is  in  man  ])erfViriued  by  a  group  of 
cells  specializerl  for  the  purpose.  If  then  we  recognize  the  inter- 
dependencies  of  the  cells  in  the  hiimuii  organism  upon  each  other, 
and  the  differences  in  their  struetiirc  aud  purjio.se  in  the  economy, 
all  that  has  been  said  of  the  amrcba  will  apply  to  each  cell  of  the 
hotly  :  all  the  functions  of  the  amtrba  are  j)robably  present  in  each 
cell,  but  one — c.  <j.  contractility  of  a  muscle-cell — is  often  so  highly 
develojied  as  to  be  culled  thr  function  of  the  cell. 

Vital  Activities. — The  vital  i-neryy  of  each  cell  manifests  itself 
iu  three  channels:  hence  Virchow  speaks  of  the  Nittritii'i-.  Fmu;- 
tiiitial,  an<l  Jltpntiliirtirt'  ArfiriticH.  Between  the  two  former  there 
in  no  lint — the  existence  of  one  implies  that  of  the  other:  both  are 
clieiuical.  and  may  be  considered  together.  Fnml  is  taken  into  the 
body,  digested,  an<l  absorbeil  by  lacteals  and  blood-ves.scis  from  the 
intestines ;  the  various  excretory  organs  give  off  urea  and,  in  small 
<|UHntity.  other  nitrogenous  bodies,  carbon  dioxide,  and  water.  Sup- 
posing the  body  to  be  in  niitritivt:  ecjuililn-iuw — neither  gaining  nor 
losing  weight — the  amounts  excreted  will  account  for  the  nitrogen, 


22 


INTRODUCTION. 


ciirhori.  and  hydrogen  taken  in  as  fooil.  I'utting  aside  water,  c«>r- 
tuin  Kiilincs,  and  oxv^en.  whicli  are  ofHcntiul  to  life,  the  fbud->>tuff8 
are  proteids,  carbohydrates,  and  fati) — the  materials  of  which  the 
body  consists.  It  is  evident  that  a  large  amount  of  heat  tiiust  Im; 
set  free  in  tiie  breaking  down  of  these  bodies  into  the  simpler  sub- 
stances above  mentioned.  Tiiis  is  the  source  of  tlie  force  by  which 
every  act  is  performed.  The  blood  carries  the  prepared  food-stufls 
to  the  capillurio!*.  whence  they  pass  out  with  the  lym|ih  to  come  into 
actual  contact  with  the  cells — some  in  solution,  others  only  in  su»- 
|>ension.  Certain,  or  all.  of  these  bodies  are  now  taken  up  (appa- 
rently actively,  for  allmmin  will  not  ilift'use  from  a  watery  fluiil)  and 
become  part  of  the  nufi»tiince  of  a  cell,  replacing  some  older  material 
which  has  been  broken  down  to  supply  force  for  assimilation  and  all 
other  actions  of  the  cell.  This  breaking  down  of  cell-substnnco  con- 
sists in  the  union  of  it  with  oxygen  obtiiined  from  the  blood  and 
8tore*l  by  the  tissues  in  some  unknown  way.  All  such  oxidation 
processes  are  believed  to  take  place  ««  thr  celh,  not  in  the  blnoil : 
and  this  almost  necessitates  that  all  food  shall  become  {lart  of  a  cell 
before  it  is  oxidized;  it  is  not  oxidized  directly.  Although  the  tis- 
sues of  the  body  and  the  foo<l-stuifs  have  almost  the  same  chemical 
composition,  waste  tissue  is  not  repaired  by  a  process  of  simple  re- 
placement from  the  food,  if  we  except  fat :  when  a  fat  of  the  samt 
coni|K>sition  as  human  fat  is  contained  in  the  food,  it  may  Ih>  stored 
in  the  cells  without  undergoing  previous  change,  but  usually  some 
slight  addition  or  subtraction  of  hydrogen  is  necessary.  It  is  prob- 
able that  many  changes,  both  analytical  and  synthetical,  occur  in 
the  arrangement  of  the  elements  of  food-stuffs  before  they  form 
protoplasm,  the  real  liriiuj  ti.<sue.  an<l  force  is  thus  alternately  lib- 
erated and  rendered  p<itcntial ;  but  this  does  not  affect  the  uiaia 
fact  that  the  body  is  ultimately  enabled  to  utilize  the  force  equir- 
alent  to  the  <lifference  in  heat-value  between  the  ingesta  and 
excreta. 

We  have  enumerated  the  compounds  presented  to  cells  in  lymph, 
an<l  also  those  which  leave  the  body  as  the  ultimate  jiroducts  of  e<»U- 
ai-tion ;  hut  in  no  instance  do  we  know  the  connecting  links  betweeo 
the  end-|)roduct8.  Whilst  the  ingesta  of  cells  must  be  tolerably  uni- 
form in  character,  their  excreta  are  probably  a«  various  as  arc  the 
uses  of  the  cells  in  the  body — witness  the  different  compositions  of 
the  many  secretions  and  the  unei|uul  distribution  of  the  extractives, 
Ruch  as  kreatin  and  xanthin.     On  the  one  hand,  the  breaking  down 


INTRODVCTTOy. 


23 


» 


P 


of  tissue,  or  ufaste.  which  is  going  on  constantly,  and  on  the  other, 
the  building  up.  or  repair,  which  in  healtii  keeps  |»ace  with  it,  con- 
stitute the  nutritive  i-xchnni/f  of  tiie  cell  or  of  the  whok'  body.  This 
process  is  constantly  being  distiirbi'd  from  pathological  causes;  and, 
physiologically,  formation  exceeds  waste  during  the  period  of  growth, 
hut  the  opposite  obtains  in  old  age.  when  the  vital  efiergy  of  all  cells 
is  failing  and  their  functions  are  imperfectly  discharged. 

The  excreta  pass  in  two  directions :  into  lymph  and  back  into  the 
bloofl.  iir  out  to  a  mucous  or  cutaneous  surface.  ^vllcllCL'  ]iart  may  be 
reabsorbed — »•.  //.  saliva,  gastric  juice,  and  |iart  of  ilio  bile. 

Influence  of  the  Nervous  System  on  Nutrition. — Experimental 
physiology  teaches  us  that  the  nervous  system  has  an  important  in- 
floence  over  the  nutrition  and  function  of  nerves,  muscle,  and  such 
gl&nda  aa  act  normally  only  in  response  to  the  stimulation  of  .special 
nerves.  Thus  when  motor  nerve-fibres  are  cut  off  from  the  gan- 
glion-eclls  of  the  corresponding  (interior  eornu,  they  mpidly  degen- 
erate and  lose  their  power  of  transmitting  electrical  as  well  as 
voluntary  impulses.  The  muscles  they  supply  also  undergo  degen- 
eration (p.  78),  and  show  changes  in  their  electrical  reactions.  In 
the  same  way  section  of  the  chorda  tym(>ani  is  followed  by  wasting 
of  the  submaxillary  gland. 

It  is  at  present  uncertain  whether  the  nervous  system  has  any 
analogous  intluenco  over  other  tissues,  such  a.s  connective  tissues 
and  epidermis,  for,  while  lesions  of  these  structures  are  fre(|uently 
foand  associated  with  disease  of  the  nervous  system,  it  is  in  all 
ea.ses  diflicull  to  exclude  other  possible  causes.  Thus  these  lesions 
are  accompanied  by  more  or  less  aniesthesia,  disturbance  of  the  cir- 
culation, and  fall  in  temperature;  all  of  which  may  be  actively  con- 
cerned in  the  causation  of  the  subsequent  changes.  For  example, 
in  inflammation  of  the  peripheral  nerves,  such  as  occurs  in  chronic 
alcoholism,  not  only  do  the  nerves  and  mu.scles  undergo  the  changes 
just  mentioned,  but  the  skin  supplied  by  the  affected  nerves  fre- 
•jucntly  becomes  thin  and  shinv;  moreover,  bulhe  not  infre<(uently 
appear. 

Occasionally  in  cases  of  hemiplegia  and  of  sabre-wounds  of  the 
brain  extremely  acute  bed-sores  form  on  the  huttoek  opjmsitc  the 
lesion,  and  similar  lesions  may  appear  over  the  sacrum  in  para- 
plegia from  sudden  and  extensive  lesions  of  the  cord.  They  are 
distinguished  from  ordinary  bed-.sores  by  the  earliness  (second  or 
third  dav)  and  acuteness  of  their  onset,  and  by  the  usclessuess  of 


TofT 


precautionary  ineaAures.  It  may  be  replied  tbst  these  are  but  dif- 
fcrcni'i's  of  iK'grcf  :  that  the  bed-sores  occur  in  the  usual  positions; 
«nd  tiiiit  appareutly  siuiilar  lesions  show,  in  this  respect,  no  propor- 
tionate constancy  in  their  results.  In  this  class  of  cases,  t«M>.  cys- 
titie  iind  pyelitis  may  a|>pear  at  about  the  same  time  as  the  bed- 
sores, and  (.'lutreot  thought  that  these  inflammations  were  due  to 
irritation  of  tr<iphic  nerves:  but  as  exceedingly  foul  urine,  contain- 
ing organisms,  is  noted  before,  or  with,  the  onset  of  the  cystitis. 
others  believe  tliat  these  changes  are  due  to  the  organisms — either 
introduced  from  without  by  u  septic  catheter  or  from  witliin  through 
the  kidneys.  The  urine  is  thus  rendered  extremely  irritant  by  putre- 
faction. Similar  rcsidts  occasionally  follow  the  passage  of  a  catheter 
in  cascH  of  enlarged  prostate. 

Trifireminal  Keratitia. — Intra-crunial  section  of  the  fifth  nerve 
causes  cloudiness  of  the  cornea  in  twenty-four  hours,  and  often 
destructive  panophthalmitis  :  at  the  same  time  ulcers  apjtear  on 
intmsitivi'  parts  of  the  mucous  membranes  of  both  mouth  anil 
nose.  The  keratitis  can  be  prevented  by  carefully  cleansing  and 
accurately  closing  the  eyelids,  thus  protecting  the  parts  from  organ- 
isms an<l  injuries.  T\u'.  ulcers  in  the  mouth  are  probably  due  lo 
damage  inflicted  by  the  teeth,  and  the  ulcers  in  the  nose  to  the 
action  of  particles  of  dust  nn<l  organisms  on  the  dried  mucous  meio- 
brane.  In  both  cases  the  failure  of  the  insensitive  mucous  meiu- 
brane  to  initiate  any  of  the  vasomotor  and  other  protective  reflex 
mechanisms  renders  the  parts  a  suitable  culture-grouml  for  pass- 
ing  organisms,  which  arc  thus  enabled  to  thrive  on  the  insensitive 
surfni'cs.  Ulcers  on  the  foot,  often  progressive,  after  section  of  the 
eciatii^  are  similarly  accounted  for. 

Acute  fati;y  detr^neration  of  the  heart  may  follow  section  of 
the  vagi :  the  iiiiiiliin  n/n-niitili  is  unknown. 

Erythema,  Urticaria,  Pemphigus,  and  especially  Herpes,  msjr 
ap](ear  in  the  distribution  of  nt-rvcs  which  are  the  scats  of  somft 
irritant  lesion.  These  changes  have  been  obst-rveil  at'lir  fractured 
apine.  in  locomotor  ataxy,  in  ayringomyelia,  in  compression  i>f  iho 
cord  by  an  aneuryism  or  tumor,  and  in  inflamiuation  of  the  (Jas- 
serian  or  some  posterior  spinal  ganglion.  The  nerves  supjilving  the 
area  of  the  rash  have  been  found  in  a  state  of  neuritis. 

Qloesy  Skin  f  Paget). — In  some  cases  of  irritative  lesion  of  the 
sensory  nrrves  of  limbs  (»•.  //.  from  gunshot)  the  skin  becomea 
amooth,  »hinv,  hairless,  sometimes  hyperaimic,  sometime*  asdenu^ 


INTRODUCTIOS. 


25 


tocts.  and  often  superficially  intlameU  or  the  seat  of  sores  like  chil- 
hlains;  at  the  same  time  the  jiart  is  oiVen  the  seat  of  intense  neur- 
algia. All  these  chanj;os  in  the  nutrition  of  the  skin  arc  probahly 
•liie  to  vasomotor  changes  acting  in  conjunction  witii  externa!  inflii- 
encos  such  as  have  been  mentioned  above. 

Pigmentation. — More  or  less  symmetrical  patches  of  lencotlerma 
and  melatiiidermii  may  be  distributed  over  tlie  body,  with  more  <ir 
less  anscsthesia.  Pallor  with  ansesthesia  and  localized  grayness  of 
hair  mav  occur  in  neuralgia  of  brauc-lios  of  llie  fifth  nei-ve.  The 
c<dor  of  the  hair  may  to  some  extent  return  between  tiie  attacks. 
CaKes  have  been  rec()rde<l  in  which  the  hair  has,  within  a  short 
time  of  a  fright,   become  gray. 

Serous  Synovitis  and  Arthritis,  with  rapi<l.  painless,  and  exten- 
sive criision  of  the  articular  ends  of  the  bones,  may  occur  in  cases 
of  hemiplegia  and  locomotor  ataxy.  These  are  supposed  to  be  due 
Xn  involvement  of  the  cells  of  the  cnrrcsponiling  anterior  cornu  by 
progressive  atrophy.  The  causal  relationship  between  the  nervous 
disease  and  the  peripheral  lesion  cannot  yet  be  said  to  be  proven. 

Atrophy  of  Parts  cut  off  from  the  Nervous  System. — Mtis- 
bIp  and  certain  glands  have  alreaily  been  referred  to  (p.  2-'l).  In  tlio 
of  muscle  it  is  to  Ik-  noted  that  if  it  is  regularly  exercised  by 
t1»e  galvanic  current  atrophy  may  be  postponed.  In  a  paralyzed 
limb  all  ti.ssues  ultimately  waste:  so  al.to  do  those  of  the  face  when 
the  facial  nerve  remains  paraly/.ed.  This  is  due  to  impaired  blood- 
supply,  for  it  occurs  in  limbs  which  a.re  simply  kept  at  rest.  Atro- 
phy of  the  cock's  comb  and  the  turkey's  wattles  residts  from  sec- 
tion of  their  nerv<;s,  and  is  perhaps  to  be  similarly  ex])lained.  In 
citses  of  progressive  atrophy  of  half  the  face  there  may  be  nothing 
tn  guide  one  to  the  nervous  system  as  the  cause;  there  uuiy  be  no 
'*»ijbje«'tive  .symptoms,  anil  sensation  ami  motion  may  n-main  nor- 
mal. If  due  to  nervous  influence,  this  atrophy  wnuhl  seem  to  favor 
tlie  existence  of  trophic  nerves. 

Hypertrophy  of  bone  may  follow  section  of  the  sciatic  in  young 
[nnimnls,  anil  is  inflammatory:  for  it  never  occurs  unless  large  ulcers 
[fV)rni,  cxtemling  to  the  bone  and  even  causing  necrosis.  Hypcr- 
[tropiiy  of  the  rabbit's  ear  after  section  of  its  nerves  has  been  said 
Ito  occur,  but  many  observers  have  failed  to  produce  the  hypertrophy, 
>r  have,  at  most,  seen  some  thickening  of  epidermis  and  hair  upon 
jthe  surface  of  the  ear. 

Pathology,  then,  affords  nu  reliable  evidence  of  the  existence  of 


IS1 


special  trophic  nerves,  and  no  convincing  prool  ot  the  intorfe: 
of  the  ntTvous  Hystom  in  the  cheiuicul  processes  of  colls  whicl 
f«)riD  110  speiial  function.  That  these  inocesscs  may  go  on  umliv 
tiirbcd  iu  the  absence  of  nervous  influence  is  shown  by  »hc  perfect 
ilcvelopmont  of  other  parts  which  is  foun<l  in  ancnrephah»iis  autl 
umycious  embryos ;  by  the  growth  of  transphinteil  epithelium  ami 
connective  tissues;  and  by  the  nnion  of  completely  severed  fwrts. 
At  the  same  time,  us  we  cannot  offer  a  perfect  c.xplniiufioM  of 
many  of  the  above-mentioned  cases,  we  cannot  say  that  the  nervous 
system  has  no  direct  influence  upon  connective  tissues  ami  epider- 
mic cells  :  it  seems  most  probable  that  it  has.  It  is  impt^rtant  tltat 
the  facts  shouM  be  remembered.  The  explanation  of  some  of  them 
is  at  present  uncertain. 

The  Jiefiroil active  Activity  remains  for  our  consideration.  In 
early  life,  at  least,  all  cells  possess  the  |>owfr  of  reiiroducing  their 
like,  and  in  the  majority  this  |)ower  is  retained,  althougli  it  mar 
iiot  be  exercised  physiologically,  up  to  advanced  age.  CeHSHtion  of 
growth  does  not  imply  absence  of  ability  to  grow,  for  growth  some- 
times seems  to  cease  when  the  sup|)ly  of  nutritive  material  to  a  part 
is  only  just  sufficient  to  maintain  its  statng  ijuo.  This  is  seen  in  • 
hair,  which  will  not  grow  beyond  a  certain  length  :  cut  it  short  nnd 
growth  at  once  begins  again,  the  supply  of  food  being  greater  than 
the  now  shortened  hair  re(|uires  for  simple  nutrition.  ']'o  cause 
cells,  which  are  capable  of  multiplying,  to  do  so,  the  supply  of  food 
must  be  increa-sed.  Thus  exercise  of  a  muscle  causes  iuereaseil 
blood-sup|>ly  and  conse<|uent  growth ;  but  increased  blood-supply 
to  a  working  tissue,  without  exercise,  will  not  have  this  efleot.  It 
is  different  with  non-working  tissues.  The  hyperjemin  round  itn 
ulcer  of  the  skin  causes  thickening  of  the  epidermis  and  connective 
tissucM,  and  nothing  is  commoner  than  new  formation  of  bone  ronnd 
■  carious  focus.  To  produce  this  effect  the  increased  supply  must 
be  very  fretjuent  or  long  continued.     (See  •' Ostitis.") 

A  non-working  ti.-wue  apparently  tends  to  grow  also  when  the  re- 
siatauce  offered  to  its  growth  by  neighboring  tissues  is  diminished  : 
of  this  we  shall  find  many  examples  in  cirrhotic  processes  and  in  the 
etiology  of  malignancy  ((Johnheim). 

The  cells  of  the  body  inherit  very  different  amounts  of  vit^tl  energy. 
The  c«'ll»  of  the  thymus  are  soon  exhausted,  those  of  the  epiphyseal 
curtilages  later,  and  of  the  generative  organs  later  still.  Powers  of 
maintenance,  growth,  and  reproduction  are  by  no  means  proportion- 


INTRODUCTION. 


27 


I 


ate.  Tbc  power  of  reproduction  poasessed  by  cells  often  seems  in- 
versely pro|K>rtioiiate  to  tlie  speeiiilizatioii  of  their  functio!!  (p.  118). 
In  all  ciises,  probiibly,  tbe  rejirodtictivc  activity  is  tlie  first  of  the 
vital  tnHnife.<itations  to  suffer;  then  the  functional  atul  nutritive. 
Inability  to  perform  Hiich  elieiuical  changes  as  ure  necessary  to 
remove  cfl'ete  material  ami  to  repair  waste  is  normal  in  old  age; 
death,  which  may  be  termed  natural,  thou  results  from  ''  senile 
decay." 

GENESIS  OF  CELLS.  — Virchow's  dictum — Omnis  retlula  e 
reUula — is  now  admitted  by  all  but  a  few.  Probably  every  nucleus, 
also,  is  derived  fmm  a  jire-existitig  nucleu.s. 

Jilultiplication  of  cells  takes  place  by  simple  division.  The  cell 
divides  generally  into  two,  and  the  change  is  preceded  by  remark- 
able a]ipoarances  in  the  nucleus.  According  to  Flommitig,  the 
jirocess  of  "  karyokinesis  "  may  he  very  briefly  described  a^s  follows 
(Fig.  2):  First,  the  niielenr  iiicinbratu'  disappears;  then  the  regthuj 
nuclear  network  (a)  becomes  much  finer  ami  closer,  like  a  ravelled 
nkeiii :  then  again  more  open,  and,  if  not  already  so.  the  cell  be- 
comes round  {f>).  There  seems  to  be  now  only  one  long  fibre  form- 
ing the  nuclear  network,  which  next  assumes  the  form  of  a  rosette 

Fio.  2. 


,.\ '  "'i^-j 


>tMf 


FafDU  aiiKiiinv*!  by  a  itiuU-un  in  <livii]liiK:  u,  rti^liiiK  nunU'Uii ;  t>,  sICL-Ui-riirm,  opi'ti  xtagc; 
|^«  wr«ath  ftinii :  if,  lUttvr,  t>r  fliur-funn;  r,  vnuaiorinX  atuKt*  n(  diviiiiun;  /,  Ki-|)urufiiiu  more 
B<lraiicf<l :  ;;  uml  ».  HUir  iinrt  wrvmh  fnriu*  i)f  <liiui;htvr-niH'lvl.    (R«<luv«d  from  FIcmmlUK's 
I  tirawiiiirt  In  the  Afh.  J.  Mik.  .ln<i/,J. 

«r  wreath  (<•)  round  a  clear  central  space,  whilst  a  clear  zone  inter- 
venes externally  between  the  network  and  the  cell-substance  proper. 
[Jly  division  of  the  external   bends  of  the  fibre  and  approximation 
of  the  apices  of  the  V's  so  as  to  obliterate  the  central  space  a  star- 


tSTBOL-rKTlOS. 


f>?»_  *«(fv^ .  /^  i«  ;«r*iD<wi<L  TL*  fi!iip»  at  ili*  <Ui£it  <-fiea  l«««:«ine 
iutT  azri  vf.'T*  LTSKrc'^f  bj  V>!i£irs-iiikal  ■i:Ti».>a  ir'>3x:  tbeir  ft^ee 
«9ri«  '/'-aari  iLt-  <i»;ire.  Ist<«<»i  <*f  n>miit^g  &>c-sl  ike  oeeTre.  iher 
■»:■•»■  \'tc:yart  ins  i«rki3*l.  aa^i  tben  <»>nTrt-ceBt  v>var>i  rw<«  <-j-f«:t«iie 
c»>£Kti — iit-  :»>j*s— >f  til*  •-rLgiiMii  Bis^sru*.  *•:•  tiiii  tL*  fitne*  now 
fr'TK  r*":*  mc»  <-f  V'i  wiiii  t£i«-ir  utrle*  ***J  fi<i<m  tL*  «>i;|oator — 
«qpiasan*2  siaee  -■<  v  A  c-i'«ar  «*|«ai<>ral  hue  a;>j<ar&.  aiwl  widens 
«^*  »  a»  *<BFfr  *irt  '-'f  V-4brc*  rtxpt*:^  &>>9n  ti*  r^titT.  Frc'Ca  ir»«h  group 
til*-  iiioen*  <■{  *  -iaosiiicT-rt^S  i5  f:*Tiii*«i  hj  jmssins  tlir>>acL — in 
TtTtn^  "-r'ier— «Ii  u«-  <tau<e»  al«>Te  onHin^ked  4jr  and  «  l  until  the 
rsRsziX  •3ax<fr  a^  re»titfL  Meanwhile  the  f^^MOfulasB  <«t*  the  eell- 
li^'iT  <«>Z>en»  iy»zsri  c4ch  n«e]ea»^  ana  bj  the  tia»e  theee  have 
ajB^EOrtti  the  wRtt:h-(>ra  iu  4iTi«>->n  i«  (io«i|Jete.  The  'iaashter- 
<«&.  a:  xj¥t  «a!aiL  £iv.v.  azr-i  nar  thenk^eires  <^!>»n  divide:  thus 
Ki]t:}0>nz>c>n  iiEav  l«e-  vetj  ra;.>(L 

The  ii*eie«$  zav  divide  <evenl  t.mes  «ith<kat  anv  division  of  the 
«ej}-lK<HiT  itecvnins.   hvt  the  laner  iBcm^e^  <«>ntinvoas]v  in  size. 

This  is  said  to  be  <>ne  «av  in  which 
"giant"  or  -ayeJoid"  cells — lai^, 
irregular.  m«h:n«eleated  masses  of 
protoplaso;.  fi>«nd  in  the  marrow  of 
gro^in-^  U.'ije.  in  cLivnic  inflamma- 
ti<'>ns.  and  iii  <«>zi:,e  new  jjrv'wths — 
maT  W  |.r\«iSa<*d  ■  F^.  o  L 

PiDallr.  it  remaaks  to  W  {••inteii 
OTjj  that  ceii>  oririisat-ni:  frv^m  one 
t-nj^rv<•^l:^.■■  laver  never  give  rise  to 
ori]>  "fa  kind  l-'raji-i  &--rmalIy  fn>m 
ai»:Ler  layer.  KpibUst  forms  ner- 
v.;.-as  tjss-ae  and  the  epithelium  of 
<<•»*<-.« -rjaiis.  vf  ite  ventricles  of  the 
Vr»:ii  and  iiti;:r»!  cmidA  of  the  t»nU 
.>f  iLv  skin.  is.>-,ni..  and  lower  enti  of 


Fk.  :. 


^.r^ 
.-■=*—-■ 


J 


1.--;  •^-1   ?r  ai  "Qw  r^Tac 


Hypoblast  foriL: 


«  ;V 


e  e;  .i:;v; 


••''  she  urinary  bladder, 
i*!-;-:r«*--rT  itiki.  and  alitLeitary  \-anai  an  i  ••:"  a^l  glands  connect e«i 
with  h  Tie  Mesobl&st  frais  :Lr  e;  :;ht'.i.;2:  .>f  :i.v  kidney,  testi- 
cle, ai/^l  .-.Tarr  :  •,h-r  tr;i:Lv:: -k  of  vess*;*  and  s»-:vas  membranes :  all 
the  <»'i:t.e'c^-'»'e  liss^ses:  l"-»-i;  aad  musciiar  tissue. 


DISEASE. — Titr  fitcii-'iis  of  an  organ  are  rviallv  the  functions 


nfTRODUCTTON. 


29 


of  the  cells  of  wLicb  it  consists :  if  all  these  act  nornially.  we  say  that 
the  orgau  is  sound,  ainl  vvlu'ii  all  tlu*  fiinetidiis  of  every  organ  ami 
tissue  in  the  body  are  nonually  jierionned,  we  ilescribe  the  individ- 
ual as  being  in  perfect  health.  A  very  little  experience  shows  that 
physioloiiical  functions  vary  within  ctTtain,  j>er!i;i|i!<  rather  wide, 
limits,  the  perfect  well-being  of  the  individual  being  maintained. 
Con»ei|rieutly,  our  standard  of  health  is  no  rigid  one;  its  inaxiniiim 
and  minimum  are  widely  separated,  and  the  latter  shades  nil'  iuijier- 
ceptibly  into  disease. 

Disea.se  may  therefore  be  defined  as  the  abnormal  performance  of 
funetion  by  one  or  umrr  iiri/tam  <>r  tissues.  This  applies  to  "  dis- 
ease "  as  a  general  term;  but  when  we  speak  of  an  individual  dis- 
ease, .OS  rheumatism  or  .^yjihilis,  the  rtiu»r  of  suuh  disease — that 
to  which  the  peculiar  disturbances  of  functiuti  or  structui'e  whicli 
distinguish  the  disease  in  question  from  nil  others  iire  due — is 
often  implied  in  the  word.  The  same  or  indistinguishable  disturb- 
ances of  function  and  structure  may  sometimes  be  j)roduced  by  several 
pauses  ;  it  is  the  more  or  less  constant  groujiiug  or  seiiueuce  of  symp- 
toms or  of  lesions  which  in  such  cases  establishes  distinct  diseases. 

It  is  worthy  of  note  al.'so  that  the  inniit/einnirf-  »f  <i  physinlogical 
Moxivium  or  minimum  must  be  regarded  as  pathological.  For  ex- 
ample, a  man  out  of  training  will  eliminate  mufh  more  urea  than 
normal  on  the  first  duy  of  a  walking  tour,  but  the  average  daily 
elimination  for  the  whole  tour  will  not  vary  IV<in)  the  uorniid.  If, 
however,  the  man  were  to  go  on  excreting  the  niaxiuiuiu  iptantity 
of  flif-  first   il;iv,  his  state  would  be  one  of  disease. 


VAEIETIBS  OF  DISEASE.— The  complete  healthy  life  of  a 
cell  consists  in  the  perfect  performance  of  all  its  functions.  For 
this  three  things  are  necessary  :  1st.  that  which  it  inherits — its 
vital  energy — must  be  normal :  2d,  it  must  be  supjdied  with  suffi- 
cient suitable  food;  8d,  its  surrounding  physical  coiiditions  must  be 
uormal.  Failure  in  any  ont*  <tf  these  will  lead  to  disease,  and  two 
great  classes  of  diseased  conditions  are  at  once  evident :  inherited, 
«lue  to  abnormality  of  the  first :  acquired,  due  to  abnormality  of 
the  seconil  and  third. 

Inherited  Disease. — The  tendency  to  iuhurited  ilisease  either 
t'xists  in  the  ovum  at  the  ccnuuienceuiont  of  dcvflojunent  or  is 
aci|nired  by  the  ovum  in  fertilization;  tendencies  furmed  later  than 
this  are  obviously  acijuirud.     As   in   normal   development  certain 


1 


30  ISTEODUCTIOS. 

orgaiu  inauifetit  their  iuberit^Hl  t«ii<]enciej>  many  years  after  birth — 
i.g.  the  <levelo|inieiit  of  the  female  generative  ssystem  at  pubertv 
au<l  itK  atrophy  at  the  menoiiauire — hj  iuherited  tendencies  to  dis- 
«aH«  way  not  show  themM^lres  until  late  in  life.  a]>  xs  the  case  in 
cancer  of  the  brea«t  or  uterus.  It  ii^  fiosfsible  that  in  many  ca^es 
tlie  Kame  unrecognized  conditions  wliich  induced  in  a  parent  the 
morbid  tendency  handed  down  continue  to  act  on  the  offspring  until 
— with  or  without  some  obvious  exciting  cause — the  disease  becomes 
evident.  We  cannot  say  when  this  tendency  to  disea.se  begins :  it 
may  have  been  slowly  gaining  strength  for  generations.  The  fact 
that  no  progenitor  had  the  disease  in  question,  if  he  or  she  lived 
well  past  the  age  at  which  such  disease  usually  manifests  itself, 
shows  simply  that  the  causes  had  not  acted  long  enough  or  with 
sufficient  energy  to  produce  it.  It  is  important  to  recognize  that 
even  inherited  disease  has  its  starting-point  in  conditions  external 
U>  the  cells  of  the  body. 

With  regard  to  the  actual  mode  in  which  disease  is  inherited,  it 
is  in  some  cases  probable  that  the  {loison.  the  actual  cause  of  the 
disease,  is  present  in  the  ovum  or  spermatozoon,  as  has  been  shown 
to  be  the  case  in  the  silkworm  disease  (Pasteur).  But  how  disease 
and  tendencies  to  diseases  which  are  not  due  to  any  specific  })oi8on 
are  hande<l  down  we  know  no  more  than  we  do  how  it  is  that  chil- 
dren inherit  the  features  of  their  parents. 

Often  no  actual  tlisease  is  inherited,  but  the  power  of  resistance 
of  certain  tissues  against  the  causes  of  certain  disea.<»es  (e.  tf.  tubercle) 
is  more  or  less  ini[iaire<l.  or  the  tissues  degenerate  early,  esjtecially 
in  the  futty  or  ciilcareous  manner,  so  that  many  members  of  a  fam- 
ily may  tlie  at  alM>iit  the  same  age  from  fatty  heart  or  a|)oplexy. 

Acquired  Disease. — Starting  with  an  organism  or  part  possessed 
of  normal  vital  energy,  disease,  if  it  occur,  must  necessarily  be  the 
result  of  external  conditions :  the  supply  of  food  is  faulty  either  in 
((uantity  or  <{uality.  or  the  physical  conditions  to  which  the  part  is 
or  has  l)e«-n  exposed  are  unsuitable.  It  is  difficult  to  separate  the 
two.  If  the  bhtod-supply  to  a  part  is  abnormal  in  quantity,  the 
temperature  of  the  part  will  be  changed;  if  a  |>ortion  of  the  body 
is  mecliaiii<-ally  injured,  its  bluod-supply  becomes  abnormal;  if  a 
|M>i.xon  excites  fever,  the  cells  are  exposed  to  a  higher  temperature 
than  normal :  a  circuhiH  vitiosux  is  established.  Disease  may  be 
aci|iiired  even  during  intra-uterinc  lift — e.  ij.  one  of  the  acute  specific 
fevers  or  syphilis. 


INTRODUCTION. 


31 


General  and  Local  Disease. — Atiy  cliange  in  external  conditions 
acting  upon  a  unicellular  organisiu  would  jirobably  jiflcct  every  par- 
ticle of  its  substance  and  modify  all  its  functions ;  all  its  diseases 
would  therefore  be  general.  But  multiplication  nf  cellx  and  spe- 
cialization of  functions  enable  abnormal  condition.^  to  act  upon  cer- 
tain groups  of  cells  and  to  disturb  their  functions  without  affecting 
— primarily,  at  least — those  of  other  groups.  We  thus  get  local 
disease,  ami  the  great  majority  of  disea.'es  belong  to  thi.*  clu-s.s. 
Perhaps,  indeeil.  we  may  say  that  every  disousc  is  primarily  local- 
ized in  a  tissue  or  organ — the  blood  bciii^  counted  as  of  the  con- 
nei'tive-tissue  type  of  which  the  iutcvcclluhir  .substance  is  fluid. 

Structural,  Organic,  and  Functional  Disease. — A  disease  is 
localized  in  an  organ  or  tissue  during  life  by  its  symptoms  and  by 
its  physical  signs,  and  after  death  the  localixation  is  justified  by 
the  discovery  in  the  part  of  some  constant  structural  change.  This 
is  Btnictural  or  organic  disease.  Diseases  in  which  no  such  change 
has  been  found  or  is  believed  to  exist  are  classed  as  functional,  the 
belief  being  that  in  them  the  functions  of  certain  cells  arc  abnor- 
mally performo<l  without  any  structural  cliauge.  Modern  icsearch 
has  greatly  diminished  the  number  of  functional  diseases,  but  it 
is  almost  certain  that  a  very  largo  nundier  of  the  slighter  ailments 
are  due  to  transient  errors  in  the  metabolism  of  the  cells. 


ETIOLOGY  OP  DISEASE. — The  causes  of  disease  are  divided 
into  two  classes — Predisposing  and  Exciting. 

PuEDlspoi'lNfl  Causks. — Any  agency  which  tends  to  cause  depart- 
ure from  the  physiological  condition  of  a  function  must  be  regarded 
afl  predisposing  to  disease — c.  </.  privation  and  tVetjuent  irritation. 
Many  such  agencies,  when  acting  more  strongly,  become  excitants 
of  disease — i.  e.  cause  a  departure  beyond  the  physiological  limit. 
Thus  if  t4»  normally  acting  ciliated  cells,  detached  from  the  body, 
a  hot  iron  be  approached,  the  first  effect  will  be  to  increase  or  stim- 
ulate the  movement  of  the  cilia:  but  if  the  imn  be  kept  near  them 
long  or  be  brought  closer,  the  tnoveuictit  becomes  slower  and  soon 
ceases.  If  the  iron  be  then  removed,  the  cilia  will  after  a  period 
of  quiescence  begin  to  work  again — at  first  one  here  and  there, 
then  all — and  may  after  a  time  recover  completely.  This  experi- 
ment of  Lister's  illustrates  a  point  of  fundamental  iuijiortance  in 
pathology — the  infiereiit  power  of  every  cell  to  recover  after  injury. 
It  shows  for  the  elements  what  every  one  knows  of  the  whole — 


32  IXTRODVCTIOS. 

namely,  that,  ecrterii  parihus.  a  strong  man  will  recover  from  a 
disease  which  would  be  fatal  to  a  weakly  one.  It  is  certain,  too, 
that  the  ''  life  "  of  cells  resists  the  action  of  injurious  agencies,  and 
that  this  power  of  resistance  varies  l>oth  in  the  case  of  different 
tixguen — e.  g.  the  rabbit's  ear  resists  the  effects  of  ansemia  much 
longer  than  a  knuckle  of  its  intestine — as  well  as  in  different  indi- 
riJualf.  Thus  it  is  a  common  observation  that  certain  ]>eople  who 
have  not  suffered  from  the  acute  specifics  may  even  nurse  those  ill 
of  these  diseases  without  themselves  catching  them,  whilst  others, 
again,  fall  victims  to  them,  though  not  specially  exposed.  Such 
power  of  resisting  certain  causes  of  disease  does  not  imply  ability  to 
resist  others  of  a  different  nature,  nor  does  it  necessarily  go  with  mus- 
cular strength.     It  varies  at  different  times  in  the  same  individual. 

The  following  may  act  as  predisposing  causes : 

Aere. — Special  treatises  have  been  written  on  diseases  of  child- 
hood and  on  diseases  of  old  age.  showing  that  there  are  peculiarities 
with  regard  to  disea.Hes  at  these  periods  of  life.  The  special  liabil- 
ities of  childhood  are  to  some  extent  explained  by  sup]»osing  that 
the  power  of  resisting  injury,  which  all  cells  possess,  is  not  fully 
developed  until  adult  age ;  those  of  old  age.  by  the  fact  that  the 
vital  lowers  are  wearing  out  and  degeneration  occurring. 

Sex. — The  organs  special  to  the  sexes  render  each  liable  to 
special  di.seases.  Women  are  the  special  victims  of  hysteria  and 
chlorosis.  We  cannot  explain  the  special  liability  of  women  to 
endemic  and  exophthalmic  goitre  and  to  myxoedema,  nor  their 
comparntivc  immunity  from  Addisons  di.sease,  locomotor  ataxy. 
and  general  paralysis. 

Heredity. — It  has  already  been  stated  that  feeble  vital  power, 
without  actual  disease,  may  be  the  heritage  of  the  body  or  of  one 
of  its  parts.  It  may  further  be  noted  that,  like  physiological  and 
personal  peculiarities,  disease — e.  //.  gout — sometimes  skips  one  or 
more  generations  (iitiirii»ti).  In  other  cases,  as  in  haemophilia  and 
j»seu<h>-hypertrophic  muscular  paralysis,  the  disease  ap])ears  goner- 
ally  in  the  males  only,  although  the  females  may,  without  them- 
selves manifesting  it,  transmit  it  to  their  offspring. 

The  diseases  which  most  obviously  "  run  in  families  "  are — func- 
tional nervous  disorders,  such  as  hysteria,  neuralgia,  epilepsy,  insan- 
ity, and  these  are  more  or  less  interchangeable :  carcinoma,  especially 
of  the  breast  and  uterus:  some  simple  growths,  especially  if  multiple 
(lipomata.  osteomata.  papilloraata) ;  gout  and  tubercular  disease. 


INTRODUCTlOy. 


33 


Exrmxo  CAtrsES. — These  may  be  nrrangofl  under  the  heailings 
of  Abnormal  Bfooil-gupplt/  and  Abnormal  I'hysiral  Conilitionn  ;  it 
mav  be  necessary  to  add,  Atterai  Nerve-iujluvnci;  but  we  do  not  as 
yet  know  enough  about  it. 

Abnormal  Blood-supply. — Defects  in  the  b]of>(l-sii|i|ily  may  be 
due  to  errors  in  the  circidation  or  in  tlie  eotn|io.sition  of  the  ljh<od. 
It  may  result  from  Lypeneniiu  or  anteniia — from  all  abnormalitiea 
in  blood-constitution,  wliether  due  to  faults  in  its  fonuHtioii  or  jmrifi- 
cation  or  to  the  introduction  of  poi.sons  or  parasites  from  witliout. 

Abnormal  Physical  Conditions. — This  group  includes  injuries 
from  any  one  of  the  physical  forces,  applied  either  from  without  or, 
B«>  to  speak,  frc)m  within  ;  also  the  results  of  niecbauica)  obstacles 
to  discharge  of  function  or  of  contents — e.  g.  stricture  of  a  duct  or 
orifice,  strangulation  of  gut,  pressure,  and  the  mechanical  effects  of 
|)arH.<4ite8. 


I 


EFFECTS  OF  PREVIOUS  DISEASE. — Some  diseases,  when 
they  have  occurred  once,  teml  to  recur  again  and  again.  In  tlie 
case  of  others,  to  have  suffered  once  is  to  have  secured  practical 
immunity  against  a  second  attack.    (See  "  Immunity.") 

Certain  other  diseases,  again,  seem  to  modify  very  deeply  the 
functions  of  the  body.  Many  years  after  these  diseases  it  is  found 
that  illnesses,  which  seem  at  first  sight  to  have  nothing  to  do  with 
tiiem,  yield  only  to  the  treatment  proper  for  the  original  malady. 
Huch  are  malarial  fever,  syphilis,  and  gout.  The  poisons  of  the  first 
two  are  probably  still  latent  in  the  body  ;  as  to  gout,  we  know  too 
little  of  its  essential  nature  to  speak  definitely  of  the  way  in  which 
itj  influence  is  exercised. 

MODES  OF  EXTENSION  OF  DISEASE.— Primary  disease 
of  an  organ  or  ti.ssue  is  fre(iuently  followed  by  secondary  disease  of 
other  parts.     This  may  happen  in  several  ways : 

1.  By  direct  spread  of  a  morbid  process,  as  when  inflammation 
extends  from  .<kin  to  subcutaneous  tissue  or  when  cancer  of  the 
mamma  invades  the  superjacent  skin. 

2.  By  the  Carriage  of  the  Causes  of  Disease  from  a  Primary 
Focua  to  Parts  at  a  Distance. — Thus  organisms  may  be  carried  by 
ihc  li/mph(itici».  and  give  ri.se  to  inflamed  lymphatic  glands  ;  pieces  of 
clot  may  be  conveyed  by  the  blunil-i'ixHi'lK.  and  produce  embolism  ;  and 
a  renal  calculus  may  be  transferred  through  the  ureter  to  the  bladder. 

3 


34  ISTRODUCTION. 

3.  Mechanically,  by  so-called  "  baek-tflUng."  Thus,  stricture  of 
the  urethra  causes  hypertrophy  of  the  bladder  to  overcome  the 
obstacle  to  the  outflow  of  urine,  or  dilatation  of  the  bladder  if  its 
efforts  are  futile.  In  either  case  the  diflSculty  of  entry  of  urine 
into  the  bladder  is  increased,  and  the  ureters,  pelves,  and  kidneys 
dilate.  Interstitial  nephritis  results  from  the  pressure,  the  renal 
functions  are  imperfectly  performed,  and  this  is  detrimental  to  the 
organism  at  large.  The  succession  of  changes  which  result  from 
mitral  incompetence  is  another  familiar  example  of  this  mode  of 
extension  of  disease.    (See  "  Mechanical  Hypenemia.") 

4.  Failure  of  any  Part  to  do  its  Share  of  Work  in  the  Ecod- 
omy. — The  result  of  such  failure  will  depend  u|)on  the  readiness 
and  completeness  with  which  its  defection  can  be  compensated. 
If  the  work  can  be  readily  taken  over  by  other  parts,  as  can  that 
of  a  sweat  or  sebaceous  gland,  nothing  is  noticed ;  on  the  other 
hand,  extirpation  of  a  kidney  which  was  doing  work  is  followed 
by  a  time  of  danger  from  diminished  excretion  of  urinary  products, 
as  the  other  kidney  is  at  first  unequal  to  the  double  duty.  Absolute 
failure  of  the  canliac  or  of  the  respiratory  function  will  cause  death, 
there  being  no  power  of  compensation. 

TERMINATIONS  OF  DISEASE. — The  possible  terminatioiu 
of  disease  are  rcrortry,  or  return  of  the  part  to  the  discharge  of 
its  normal  functions ;  /mrtial  reorrry :  and  tleath,  or  complete 
cessation  of  function.  Certain  diseases  can  scarcely  be  said  to  have 
a  termination :  when  once  establisheil  they  remain  stationary. 

It  will  Ik*  useful  here  to  give  a  list  of  the  morbid  processes  to 
which  all  organs  are  more  or  less  liable: 

The  results  of  mechanical  or        Degeneration, 
physical  injury.  Necn»sis. 

Displacement.  Regeneration. 

Heniorrh.ige.  Hypertrophy. 


Developmental  errors. 


Tumor-formation. 

«       «       • 

Ltnlgement  of  parasites. 


Ansemia.  •       *       * 

Hvperwmia.  Stricture  and    its   consequence-'^ 

OMenia.  may   .nxnir  in   every   duct  orT" 

Inflammation.  canal :    and    calculi    may  de-^ 

.\tn»phv.  velop  in  any  of  them. 


NECROSIS.  35 


CHAPTER  I. 

NUTRITION  ARRESTED. 
Necrosis. 

The  complete  and  permanent  arrest  of  nutrition  in  a  part  con- 
stitutes necrosis,  gangrene,  or  local  death. 

ETIOLOGY. — Whatever  interferes  with  the  supply  of  nutritive 
material  to  a  part  or  destroys  the  vital  activity  of  its  cellular 
elements  may  cause  its  death. 

A.  Interference  with  the  Supply  of  Nutritive  Material. 
— Such  interference  may  be  the  result  of — 

1.  Obstruction  in  the  Arteries. — This  is  a  common  cause  of 
necrosis.  The  obstruction  may  be  caused  by  compression,  by  lig- 
ature, by  rupture,  by  thrombosis,  by  embolism,  or  by  disease  pro- 
ducing thickening  of  the  arterial  coats.  If  the  obstruction  be 
complete  and  a  collateral  circulation  cannot  be  established,  death 
of  the  part  quickly  ensues. 

2.  Obstruction  in  the  Capillaries. — Obstruction  is  often  the 
result  of  pressure  upon,  or  stretching  of,  these  vessels.  This  may 
take  place  from  the  accumulation  of  inflammatory  products  or  of 
extravasated  blood,  or  from  the  pressure  exercised  by  new  growths. 
The  resulting  obstruction  to  the  capillary  circulation  causes  the 
death  of  the  immediately  adjacent  tissues.  As  examples  of  necrosis 
from  this  cause  may  be  mentioned — necrosis  of  the  superficial  layers 
of  the  bone  resulting  from  periostitis,  and  due  to  the  compression 
of  the  capillaries  between  the  bone  and  the  periosteum  ;  the  slough- 
ing of  tendons  in  whitlows  before  the  latter  are  opened ;  and  the 
formation  of  ordinary  bed-sores.  When  inflammation  causes  gan- 
grene, it  is  by  the  production  of  stasis,  leading  to  death  of  the 
tissues  from  malnutrition  and  coagulation  of  blood  in  their  capil- 
laries. Whenever  necrosis  of  a  tissue  occurs  the  blood  coag- 
ulates in  its  capillaries,  and  thus  hemorrhage  from  gangrenous 
parts  is  prevented. 

3.  Obstruction  in  the  Veins. — Obstruction   to  the  return  of 


36 


TRITION  ARRESTE 


Mood  by  the  veins  must  be  so  complete  in  order  to  arreat  DutritMiQ 
tbttt  it  is  in  itself  rarely  a  cause  of  necrosis.  It  is  when  aMociMiii 
with  cardiac  weakness  or  obstruction  in  the  arteries  that  it  couyti* 
tntes  an  important  agent  in  producing  this  result,  for  then  the  fom 
necessary  to  drive  the  blood  on  through  the  much-narrow cd  venous 
channel  is  rjuite  inadequate.  Gangrene  due  to  tiiese  combinni 
causes  occurs  after  ligature  of  a  main  artery  and  its  vein,  wai 
may  follow  accidental  injury  of  the  vein  during  the  operation  nf 
a  ligature  of  a  large  artery,  especially  in  the  thigh.  It  tnty 
also  result  from  constriction  of  a  part  by  a  bandage  not  tight 
enough  to  occlude  the  arteries  as  well. 

4.  DiminiBhed  Cardiac  Power. — This  is  never  by  it-^elf  a  suf- 
ficient cause  of  necrosis.  In  ca.ses,  however,  of  excessive  genrrtl 
debility  or  of  disease  of  the  cardiac  substance,  the  wjnsefioent 
diminution  in  the  contractile  power  of  the  heart  materially  «Jii> 
the  foregoing  causes  in  proiiuciiig  a  fatal  blood-stasis.  The  nrrvM 
of  the  circulation  in  "senile  gangrene,"  and  in  that  form  which  •» 
often  occurs  in  the  tissues  of  the  back  in  adynamic  fever*  and  in 
chronic  exhausting  diseases,  is  in  part  the  result  of  diminishci 
cardiac  power.  This  arrest  in  the  last-named  conditions  is  osintlr 
dt'termined  by  some  injurious  irritation  of  the  tissue;  in  otJier 
words,   it   is  a   part  of  an   iutlammatory  process. 

5.  Inflammation. — As  a  cause  of  necrosis,  inilamroation  beloBf^ 
partly  to  the  group  we  are  now  discussing  and  partly  to  that  ou  thf 
next  page;  for  the  effect  of  the  inflammatory  process  is  to  impair 
or  arrest  the  circulation,  as  well  as  to  impair  the  vitality  of  tlic 
affeotcd  part.  The  intensity  of  the  process  may  be  so  great  atO 
cause  coagulation  in  the  capillaries  and  death  of  the  tissue.  Il  i* 
then  cailetl  nntyultilive  or  cntn/ufiitutn-nefroiiif  (p.  3(*).  When 
a  strangulated  or  invaginated  piece  of  gut  is  released  and  the  ci^ 
culntion  is  re-established,  severe  inflammation,  perhaps  leadinji  to 
gangrene,  fre(|uently  ensues.  Cohnheim's  experiment  of  tying  »ff 
a  rabbit's  ear  has,  in  effect,  been  repeated.  (See  "  Embolism.'^ 
It  is  of  practical  importance  to  note  that  inflammation  sets  in  onl? 
on  rf-entahlinhmenf  of  the  circulation — that  is.  when  the  gut  ** 
returned  to  the  peritoneal  cavity:  there  is  none  whilst  it  is  in  t 
R«c.  A  much-contu.sed  and  lacerateil  part  may  ultimately  be  kille-^ 
becau.se  the  pressure  of  the  effusion  from  its  injured  vessels  st 
further  impedes  tlie  flow  through  them.  Certain  inflaniniatin! 
have  a  special  tendency  to  terminate  in  necrosis,  such  as  diphtheri 


NECROSIS. 


S7 


I 


I 


cnrbiincle.  noma,  "  hospitul  gangrene,"  and  spreading  trauinntic 
gangrene.  In  these  conditions  the  intensity  of  the  injury  to  the 
tissues  ii«  jirobably  duo  to  the  action  of  minute  nrgnnisins.  In  all 
cases  the  more  impaired  the  nutrition  of  the  part  which  becomes 
the  seat  of  un  inflammatory  process  the  more  likely  is  the  influm- 
inatory  jirocess  to  cause  its  death. 

B.  DESTKiTrriox  of  the  vital  activity  of  the  cellular  elements 
mny  be  caused  by — 

Physical  and  Chemical  Agencies. — A  part  may  be  completely 
♦lisorganizcd  and  lose  its  vitality  as  the  result  of  external  violence, 
excessive  heat,  or  extreme  cold.  Many  corrosive  chemicals,  as  acids 
nnd  caustic  alkalies,  ilestroy  the  life  of  cells.  Putrid  urine  or  foul 
secretions  from  woumls  will  sometimes  destroy  the  cells  like  a  caus- 
tic. As  implied  in  the  last  paragraph,  other  organisms  as  well  as 
those  of  putrefaction  may  produce  a  similar  result.  These  physical 
and  chemical  agencies  frequently  cause  necrosis  by  exciting,  in  the 
first  place,  acute  inflammation. 

These  are  the  several  causes  of  necrosis,  but  it  must  be  borne  in 
mind  that  the  process  is  often  complex,  and  due  to  the  condiined 
intlucnce  of  two  or  more  of  them.  The  liability  to  necrosis  will 
greatly  depend  also  upon  the  potcer  of  the  thsueii  to  resist  iitjury. 
This  varies,  probably,  in  different  individuals,  and,  certainly,  in 
different  ti.ssues  in  the  same  individual — intestine,  for  example, 
being  much  less  resistant  to  injury  than  skin.  Conditions  which 
won]d  lead  to  the  death  of  a  part  in  which  the  circulation  was 
already  impeded  or  in  which  the  vitality  of  the  cellular  elements 
»as  inipaircil  would  produce  no  such  effect  where  such  local  weak- 
ness did  not  obtain.  This  is  well  exemplified  by  the  necrosis  of  the 
tiiWueH  of  the  back  from  pressure  wliicfi  so  of"ten  occurs  in  condi- 
tions of  debility;  by  ihe  foraiation  of  ulcers  near  varicose  veins  in 
the  legs;  by  the  gangrene  of  the  extremities  which  sometimes  re- 
sults from  the  long-continued  ingestion  of  ergot;  and  especially  by 
H.-iiil.'  ■,;angreiie. 


THE  CHARACTERS  OP  THE  DEAD  PART.— These  gene- 

lly   resemble   one   of  two   tyj)es,   known    as  dry  and  moist  gan- 

ene    respectively.      There   are    three    conditions    whi<'h    mainly 

etermine  into  which  of  these  two  varieties  a  given  instance  will 

These  are — (1)  the  amount  of  fluid  which  the  involved  tis- 

aaturally  contain  ;  (:i)  the  extent  to  which  the  vessels  of  the 


38 


yVTRITION  AJIRESTED. 


piirt  affected  are  engorged  with  blood,  uud  the  amount  nf  flnid 
which  is  therefore  present  at  the  time;  and  (3)  the  rapidity  of  thu 
evaporation   from  the  surfiiue. 

Dry  Qanerrene  will  therefore  occur  in  those  parts  in  which  the 
tissues  nutiirally  contiiin  but  little  Hiiid,  such  as  bone,  cartilage,  and 
tendon.  It  will  also  be  ft-enuently  associated  with  such  obfttructioiw 
of  the  arteries  as  may  occur  without  any  corresponding  interference 
with  the  circulation  in  the  veins  and  lymphatics.  Dry  gangrene, 
therefore,  may  result  from  enibolisni.  from  slowly  progressing  artif- 
rial  thrombosis,  and  from  the  prolonged  aduiini.'^tration  of  vtffyi. 
Again,  free  exposure  to  dry  air,  slow  progress,  and  the  dcj«tructwin 
of  the  epiflermis  will  all,  by  j>romoting  or  permitting  evaporation, 
aid  in  producing  dry  gangrene.  Tniler  these  circumstances  the 
part,  which  is  pale  from  the  first,  gradually  dries  up  and  b«c<inic« 
ctinverted  into  a  dark,  shrunken  mass,  undergoing  but  little  fur- 
ther change.  The  conditions  obtaining  in  dry  gangrene  are 
precisely  those  which  render  the  growth  of  organisni-s  alnxtst 
imjiossible. 

Moist  Oangrrene. — I'nder  opposite  circumstances  a  part  consist- 
ing largely  of  muscle  and  other  soft  structures  may  become  rapidly 
gangrenous,  either  from  an  acute  inflammation  or  from  renuas  ob- 
struction combine*]  with  a  weak  arterial  supply.  When  this  haj)- 
pen."*  the  tissues  are  accordingly  gorged  with  an  albuminous  fluid 
full  of  breaking-down  red  blood-corpuscles.  The  haemoglobin  of 
these  fonns  a  reil  solution  which  soaks  into  and  stains  all  the  tis- 
sues. The  limb  is  much  swollen,  of  purplish  color,  and  often 
studded  with  bullie  of  blood-stained  fluid.  If  such  a  part  is 
exposed  to  warm,  moist  air,  septic  bacteria  ipiickly  enter  through 
the  skin,  multiydy  rapidly  in  the  highly  putrescible  fluid,  and  gene- 
rate by  their  action  gases — chiefly  sulphuretted  hydrogen,  ammonia, 
nitrogen,  ami  carbon  dioxide — which  give  rise  to  the  emphjsema- 
tous  crackling  s^)  often  as.sociated  with  gangrene.  The  tissue*  soften 
and  liquefy,  the  whole  part  becomes  exceedingly  oflfensive.  auii  it* 
tissues  change  in  color  from  reddish  to  brownish  or  greenish  black. 
For  putrefaction  to  occur  it  is  absolutely  essential  that  septic  Imic- 
teria  be  admitted  to  the  part;  consequently,  such  cbnngfs  are  met 
with  chiefly  in  external  parts  or  in  those  intertuil  parts  to  which 
organisms  have  free  access. 

When  the  life  of  nn  internal  organ  or  part  is  destroyed  and  b«^ 
teria  are  now  admitted  to  it,  as  in  simple  infarction,  its  tMsuek 


NECnOSTS. 


39 


I 


umlergo  a  series  of  degenerative  fatty  changes  known  as  necro- 
biosis. 

Coagnilation-necroBiB  is  a  term  appliod  to  a  peculiar  form  of 
sudden  tissue-death.  The  cells  in  'lying  seem  to  give  rise  to  some 
substance  or  substances  which  unite  with  the  Ivniph  and  cause  an 
apparent  coagulation  of  the  dying  cells.  Microscopically,  the 
nucleus  disappears,  and  the  contents  of  the  cell  are  replaced  by  a 
etructureless  hyaline-looking  material.  Fatty  degeneration  subse- 
f|aently  sets  in.  The  process  may  be  the  result  of  bacterial  action. 
It  only  occurs  in  parts  freely  supplied  with  lymph,  and  is  never 
found  iu  the  brain. 


I 


COURSE. — Gangrene  may  be  circumscribed  or  spreading. 
The  courae  varies  chiefly  with  the  eauge,  but  the  remittance  of  the 
tissues,  which  depends  ujion  their  vital  energy  and  blood-supply, 
must  always  be  taken  into  account,  for  causes  which  have  little 
effect  on  healthy  tissues  may  lead  to  sloughing  in  the  aged,  in  the 
diabetic,  in  the  albuuiiniiric,  and  in  the  intemperate. 

With  regard  to  the  first  factor,  circumscribed  gangrene  im])lie8  a 
circumscribed  cause.  This  form  is  exemplified  by  the  death  of 
tissue  resulting  from  mechanical  violence,  the  actual  cautery,  or 
plete  stoppage  of  the  circulation.  On  the  other  hand,  spreading 
grene  necessitates  a  cause  which  spreads  before  it.  Thus  gan- 
grene from  arterial  thrombosis  often  spreads  but  slowly  and  with  a 
well-defined  margin.  But  the  typical  sfireading  gangrenes  are 
those  due  to  intlammation,  in  which,  probably,  the  actiiin  of  urgan- 
ijiins  on  the  fluids  of  the  part  constantly  provides  fresh  ijuantities 
of  the  irritant. 

When  the  process  becomes  circumscribed,  the  dead  tissue — 
»pharelug  or  »luiigh — acts  as  an  irritant  to  tlie  adjacent  living 
Mtructures,  causing  more  or  less  inflammation  of  them.  If  the 
slongh  is  aseptic,  the  inflnnimation  is  slight,  k-adirt;:  merely  to  the 
fortnation  of  a  layer  of  fibroid  tissue  round  die  dead  mass  by  which 
it  becomes  encapsuled.  This  occurs  especially  in  internal  parts, 
and  is  bt>8t  illustrated  by  the  fate  of  simple  infarcts.  When  thus 
encapsuled  the  dead  part  ceases  to  irritate ;  it  becomes  decolorized, 
fattjr.  infiltrated  with  small  round  cells  which  absorb  the  fatty 
•letritus,  and  is  ultimately  converted  into  a  small  fibrous  scar,  which 
mav  calcify. 

When  the  slough  is  superficial  it  generally  putrefies  and  becomes 


40  yLTRITIOy  ARRESTED. 

Etronglr  irritant;  but  mummificatioD  vill  minimiie  this.  The 
inflammation  of  living  tissue  round  the  now  limited  slough  is 
spoken  of  as  the  line  of  demazcation.  Exudation  and  migration 
occur  finely  into  a  narrow  sone  of  lirimp  tisttu  surrounding  the 
edges  and  base  of  the  slough :  fibres  and  all  firm  connections 
between  the  liring  and  dead  tissues  are  softened  and  eaten  through; 
and.  finallj.  when  this  process  is  complete,  the  sloogh  is  cast  off  bj 
suppuration  occurring  along  the  line  of  demarcation.  If  the  whole 
thickness  of  a  limb  die.  the  stump  left  by  casting  off  the  sphacelus 
will  be  conical,  for  the  soft  fiarts  retract  somewhat,  and  the  bone 
separates  lower  down.  The  less  vascular  a  tissue,  the  longer  will 
be  the  time  occupied  in  its  erosion — f.  </.  fiiscia.  tendon,  bone.  If 
the  dead  mass  be  deeplv  seated  and  suppuration  occur  aboat  it, 
fistulie  will  form,  leading  ftx>m  it  to  the  surface.  Through  one  or 
more  of  these  it  mar  nltiinatelv  be  cast  off.  as  is  seen  in  necrosis 
of  bone.     After  removal  of  the  slough  an  ulcerated  surfiice  is  left. 

Sknius  Oamobekb. 

This  is  a  form  of  necrosis  which  affects  especially  the  lower  ex- 
tremities of  old  people,  and  is  the  result  of  several  of  those  etiolog- 
ical conditions  which  have  already  been  enumerated. 

The  most  important  element  in  the  production  of  senile  gangrene 
is  the  presence  of  atheromat'iM*  or  mlearroH*  cAan^n  in  the  arierif$ 
of  the  limb,  which  greatly  diminish  their  elasticity  and  calibre  and 
profiortionatelv  impair  the  circulation  in  and  nutrition  of  the  part. 
This  is  shown  by  the  coldness  of  feet,  cramps,  and  other  abnonnil 
sen.«ations  so  often  experienced  by  the  patient  for  some  time  before 
the  gangrene  sets  in.     The  slowing  of  the  circulation  is  usually 
much  increased  by  defective  action  of  the  heart,  due  to  atrophy  o^ 
degeneration  of  its  muscular  substance.     Thus  the  contact  of  tia  ^ 
blood  with  an  abnormal  vessel-wall  is  prolonged,  and  this  is  some!= 

times  sufficient  to  cause  the  formation  of  a  thrombus  in  the  artert '• 

The  clot  thus  former!  slowly  spreads  until  it  may  extend  firom  th"  * 
foot  t"  the  groin.  Gangrene  then  supervenes.  It  begins  in  one  or:  ^ 
more  toes  simultaneously  and  extends  slowly.  It  is  often  surpris-^ 
inply  iimitetl.  and  even  where  the  thrombus  extends  into  the  pop—* 
liteal  artery  part  of  the  f<M»t  may  escape.  In  other  cases  emholi»m^  * 
with  superaddetl  tlin>mlx»sis,  may  be  the  starting-point,  a  chalkjr"^ 
jilate  *>r  a  parietal  thn>mbus  being  swept  from  a  large  into  a  smaller"^ 
artt-rv. 


NEcnosrs. 


41 


Finally,  the  gangrene  may  be  inflammatory,  due  to  some  trivial 
injury,  such  as  a  sliglit  abrasiim  of  the  fimt.  the  cutting  of  a  corn, 
or  some  excess  of  heat  or  cold  acting  upon  feebly-nourished  tissues 
supplied  by  disejised  vessels. 

Fat-necrosis. 

Under  the  name  oi  faUneerosit  a  peculiar  change  occurring  in 
fat  has  been  described.  It  consists  in  the  formation  of  opaque 
white  areas  half  an  inch  or  less  iu  diameter.  Tlie.se  are  of  firm 
consistence,  and  are  scattered  tiiroiigh  otherwise  normal  fat.  Tlicy 
stain  with  osmic  acid  and  melt  on  the  application  of  heat.  Under 
the  microscope  the  contents  of  the  affected  cells  are  either  crystal- 
line or  opa<jne  and  granular.  'J'he  transition  from  diseased  to 
'  healthy  cells  is  abrupt.     The  surrounding  parts  are  occasionally 

Fio.  4. 


TM-necnwif,    The  «lirupt  Irnii.-llinu  ft-om  Ilie  htnllliy  ctlbi  nii  the  left  to  the  nccroiied  celto 

»i>n  the  right  1>  well  markuil.    The  content*  of  the  affected  celb  an  finely  gnuiulju'. 
(From  ■  tiwrimen  hy  Dr.  Kollealuii.) 

infiltrated  with  small  ronnd  cells.  Fat-necrosis  is  most  frequently 
encountered  in  the  subperitoneal  fat,  but  is  occasionally  tuut  with 
.elsewhere. 

Pathology. — Four  distinct  e.xjtlanations  of  this  change  in  the  fat 
lavc  been  offered.    According  to  Balser  and  Zenker,  it  is  a  primary 
[necrosis  of  fat,  following  its  excessive  growth,  and  occurring  there- 
lore  in  fat  people.     Balser  also  noted   its  association  with  hcmor- 
Irhage  in  the  neighborhood  of  the  pancreas  and  surrounding  parts. 


IfVTRrTfOy  ARRESTED. 


Langerhans  attributes  it  to  the  destructive  action  of  steap&in  ab- 
Horbed  from  the  intestine.  Fitz,  recognizing  the  frequency  with 
wliich  it  is  associatoil  with  pancreatitis,  considers  that  it  is  due  to 
the  spread  of  inflammation  from  the  pancreas  itself.  Rollesiton' 
raises  objections  to  nil  these  views,  and  driiws  attention  to  the 
occurrence  of  the  change  in  conditions  due  to  severe  disturbance 
of  the  abdominal  sympathetic.  He  points  out  that  in  acute  lesions 
of  the  pancreas  the  solar  plexus  is  likely  to  be  involved,  and  sug- 
gests that '•  fat-necrosis  "  should  be  regiirdeil  as  a  disturbance  due 
to  some  affection  of  the  abdominal  synipatlietic.  In  this  way,  it» 
ordinary  Jigtriftutiong,  its  a-agociationg  with  inflammatory  conditions 
near  the  head  of  the  pancreas,  and  the  »i/mpf.<>ms.  resembling  those 
of  acute  intestinal  obstruction,  wliicb  freijuently  accompany  it,  are 
all,  to  a  certain  extent,  capable  of  explanation. 

Post-mortem  Changes. 

The  changes  which  always  occur  in  tissues  after  death  must  now 
be  confstdercd  more  particnlarly.  First,  with  regard  to  the  blood: 
this  fluid  undergoes  the  earliest  and  most  rapid  change.  The  hscmo- 
globin  escapes  from  the  red  corpuscles,  partly  by  oxidation  and 
partly  by  the  destruction  of  the  corpuscles  themselves,  and,  dis- 
solved in  the  liquor  sanguinis,  j)ermeates  the  surrounding  tiasu 
The  corpuscles  are  ultimately  completely  anniliilatetl,  nothing 
niaining  but  a  few  minute  granules.  The  staining  of  the  tissues 
with  hiemoglobin  is  conimonly  known  as  post-mortem  eteuninff, 
iiud  the  apfiearunces  it  presents  are  very  characteristic.  The  lining 
mend)rane  of  the  heart  and  blood-vessels,  being  in  immediate  con- 
tact with  the  blootl  after  death,  are  the  parts  princi])ally  affected. 
The  dissolved  hiemoglobin  also  soaks  through  the  walls  of  the  veins, 
thus  giving  rise,  on  the  surface  of  the  skin,  to  red  lines  which  mark 
the  position  of  the  vessels  lying  beneath.  The  staining  is  of  a 
uniform  pinkish-red  color,  thus  differing  from  the  punctiform 
and  stratiform  redness  of  byperjemia,  from  which  it  must  be  care- 
fully distinguished.  The  amount  of  staining  is  in  proportion  to  the 
rapidity  with  which  decomposition  lia.s  taken  place  and  to  the  amount 
of  blood  contained  in  the  part  at  the  time  of  death.  Marked  stain- 
ing of  the  endocardium  and  great  vessels  occurs  very  rapidly  after 
<lcath  from  septicaemia. 

Post-mortem  discoloration   must  be  distinguished  from   jxtst- 
■  Trant.  Path.  Soe.  of  lA>nd„  1893. 


NECROSIS.  43 

mortem  staining.  It  is  a  purplish  color  seen  in  dependent  parts 
which  are  not  pressed  upon,  and  is  due  to  the  gravitation  of  fluid 
blood  into  the  vessels  of  these  parts.  It  disappears  if  the  body  be 
turned  over. 

In  muscle  the  arrest  of  nutrition  is  accompanied  by  a  state  of 
rigidity  known  as  Bigror  Mortis.  This  is  a  peculiar  condition  of 
the  muscles  observed  in  almost  all  bodies  after  death,  in  which  they 
become  firm  and  somewhat  shortened,  a^  though  in  a  state  of  per- 
manent contraction.  It  comes  on  as  soon  as  the  muscles  have  lost 
their  irrit*bility — i.  e.  their  capability  of  responding  to  artificial 
stimulation  ;  in  other  words,  as  soon  as  the  nutritive  processes  have 
completely  ceased.  The  time  of  its  appearance  will  therefore  de- 
pend upon  the  state  of  nutrition  of  the  muscles  at  the  time  of 
death ;  the  more  healthy  and  vigorous  this  is,  the  longer  it  is  before 
the  nutritive  processes  completely  cease,  and  consequently  the  long- 
er it  is  before  the  rigor  mortis  supervenes.  The  length  of  its  dura- 
tion and  its  intensity  are  in  direct  proportion  to  the  lateness  of  its 
appearance.  In  people,  for  example,  who  are  in  perfect  health  and 
die  suddenly,  as  from  accident,  the  rigor  mortis  does  not  usually 
come  on  until  from  ten  to  twenty-four  hours  after  death ;  it  is  very 
marked,  and  often  lasts  two  or  three  days.  In  those,  on  the  other 
hand,  who  die  from  some  exhausting  disease,  as  from  chronic  phthi- 
sis or  the  adynamic  fevers,  in  which  the  nutrition  of  the  muscles 
becomes  much  impaired,  the  rigor  mortis  appears  very  soon,  some- 
times as  early  as  ten  minutes  after  death ;  it  is  very  slight,  and  may 
pass  off  in  less  than  an  hour.  It  has  been  said  that  in  cases  of 
death  from  lightning  and  from  some  of  the  severer  forms  of  the 
adynamic  fevers  the  rigor  mortis  is  entirely  absent.  It  is  doubtful, 
however,  if  this  is  the  case,  as  the  rigor  mortis  has  probably  escaped 
observation,  owing  to  its  early  supervention  and  rapid  disappear- 
ance. As  soon  as  the  rigor  mortis  has  passed  ofi*  decomposition  of 
the  muscular  tissue  commences. 

With  regard  to  the  nature  of  the  change,  Kiihne  and  others  have 
shown  that  it  is  really  owing  to  the  coagulation  of  the  albuminous 
substance  of  the  muscle — myosin.  The  myosin,  fluid  during  life, 
coagulates  when  nutrition  has  ceased,  the  coagulation  being  at- 
tended by  the  liberation  of  a  free  acid.  Thus  are  produced  the 
firmness,  hardness,  and  opacity  of  the  muscle  together  character- 
istic of  rigor  mortis.  These  disappear  as  soon  as  decomposition 
commences.     The  transverse  striation  of  the  fibres  then  becomes 


44 


KUTRmOV  mPAIRED. 


indistinct,  and  gives  place  to  irregulnr  rows  of  granules  and  fat- 
nioieciiles.  In  the  mean  time,  the  muscle  jioftcns,  its  sarcoleroma 
ili^appears,  and  ultimately  nothing  remains  but  a  aoft  Ktructur«l(«s 
debris.  This  change  is  not  confined  to  muscle:  in  the  cells  of 
other  tissues  a  similar  coagulation  of  the  protoplasm  takes  place  on 
the  cessation  of  the  nutritive  processes. 

Respecting  the  pn»t-mortcm  changes  in  other  tissues,  pn>toplasm 
geneniliy  not  only  coagulates,  but  tends  to  become  finely  grnnulM*, 
after  death.  Ft  sometimes  increases  in  bulk,  so  that  the  c«'lls  look 
swollen  ;  and  in  nucleateil  cells  tlie  nucleus  often  shrinks  or  eiitirelv 
disappears.  The  cells  ultimately  break  up  into  molecules  of  vnrions 
sizes.  In  adipose  tissue  the  cells  diminish  in  size,  owing  to  the 
escape  of  the  fluid  fat,  which  diffuses  itself  throughout  the  sur- 
rounding structures.  The  fibres  of  connective  tissue  swell  a|t, 
become  opa<(ue,  and  ultimately  li(|uefy.  In  nerve-fibres  the  white 
substance  of  Schwann  coagulates  and  collects  into  small  ilrons 
within  the  neurilemma.  Cartilage,  bone,  and  hair  resist  the  putre- 
factive process  longer  than  any  of  the  other  tissues,  and  arc  the 
least  altered  by   it. 


CHAPTER   II. 


NUTRITION   IMPAIRED. 


It  has  been  shown  in  the  preceding  chapter  that  the  complete  mnA 
permanent  arrest  of  nutrition  in  a  part  causes  death — that  is,  ce«- 
satiiin  of  function.  We  have  now  to  consider  those  morbid  pro- 
cesses in  which  nutrition  is  more  or  less  impairvd,  and  in  which, 
therefore,  proportionate  diminution  of  functional  activity  will  be 
the  characteristic  consc()Ufnce.  Nutrition  may  be  impaired  in  two 
ways:  in  f/umititif,  so  that  waste  comes  to  be  in  excess  of  Hssiniila- 
tiou,  or  in  qunlitt/,  either  the  food  or  the  metabolism  of  the  cell 
being  abnormal.  Excess  of  -waste  over  assimilation  leads  simply 
to  atrophy,  or  sim)dc  diminrition  in  the  sixe  of  a  part  r>r  of  the 
whole  body,  whence  results  impairment  of  its  functional  powers. 
On  the  other  hand,  alteration  in  the  chemistry  of  the  cell  or  in 
the  (jualitv  of  the  food  supplied  to  it  mnii  lead  to  degeneratioQ  of 
the  cell-contents:  some  abnormal  substance  appears  in  the  tissues. 


ATROPHY. 


45 


I 


iothim!  by  metamorpliosis  of  the  ceIl-f>rnt(>|ila.siD,  or  deposited  in 
the  cells  by  the  blood  and  uot  consiuned.  This,  nguiti^  causes  more 
or  less  impairment  of  the  functions  of  the  degenerate  tissue-elements. 
Both  atrophy  and  degeneration  must  therefore  be  regarded  us  stages 
toward  death  ;  and  in  both  cases  the  impairment  of  nutrition  not 
uncommonly  becomes  so  extreme  that  it  amounts  at  certain  spots 
tu  absolute  arrest.  Death  of  the  most  affected  cells  consei|uently 
ensues. 

Several  abnormal  substances  may  appear  in  the  tissues  as  results 
of  their  degeneration,  and,  according  as  these  substances  arc  believed 
to  be  derived  from  the  t-ell-protoplasin  itself  or  to  be  merely  deposits 
from  the  blood,  the  degenerative  processes  are  divided  into  two 
groups:  the  metamorphoses  or  degenerations  prof>er  sind  the 
infiltrations.  They  differ  essentially.  In  the  metamorphoses 
the  cell-protoplasm  is  gradually  transformed  into  a  new  material. 
This  process  is  often  continued  until  complete  destruction  of  the 
histological  elements  has  taken  place  and  all  trace  of  the  original 
structure  is  lost.  In  the  earlier  stages  of  tlie  process  function  is 
impaired:  in  the  latter  it  may  be  completely  arrested.  In  the 
Infiltrations  the  new  material  is  not  derived  from  the  cell-proto- 
plasm, but  is  deposited  from  the  blood :  there  is  an  infiltration  <if 
a  new  substance.  This  is  rarely  followed  by  destruction  of  any  of 
the  histological  elements ;  hence  the  structure  of  the  tissue  is  much 
less  altered  than  in  the  metamorphoses,  and  function  is  usually 
much  less  interfered  with. 

The  metamorphoses  are — fatty,  mucoid,  colloid,  and  probably 
albuminoid.  The  infiltrations  are — fatty,  calcareous,  and  i)ig- 
meutary. 

Atrophy. 

Atrophy  must  be  carefully  distinguished  from  arrested  develop- 
ment. It  is  a  decreuiti'  in  the  amount  of  a  tissue,  owing  to  diminu- 
tion either  in  tlzv  (simple  atrophy)  or  number  (numerical  atro- 
phy) of  the  histological  elements  of  which  it  is  coni[>osed.  It  is 
attended  by  loss  of  weight  and  iuipairnient  of  function.  The  two 
varieties,  simple  and  numerical,  are  often  associatLil,  the  latter 
being  an  advanced  stage  of  the  former. 

Atrophy  may  be  general,  affecting  to  a  greater  or  less  e.xtent  all 
the  organs  and  tissues  of  the  body,  or  it  may  be  local,  and  therefore 
limited  to  particular  parts.     In  general  wasting  the  stress  falls  at 


46 


NUTRITION  IMPAIRED. 


first  iifinn  the  aiibcuttineoiis  adijiose  tissue,  tlion  u[ion  fiit  in  other 
situations,  as  anmud  visciTa  und  in  the  oiucutiiin.  then  ujion  the 
mugclesand  glandular  organs,  and  lastly  mid  least  upon  the  osseous 
and  nervous  structures. 


AiIlpcMC  tlKBiie :   n,  ncinnal ;  b,  mnipliic,  (W>m  a  caxe  uf  |ilithiiU :  a,  ■  6lnslv  £>t-ceU,  wllh 
ceU'WaU,  nuvleuii,  and  drop  of  fat.    :<  ai»).    (Vlrthow.) 

Musfulur  tissue  also  may  atrophy  by  simple  diminution  in  the  sixe 
oT  its  jiriniitive  fascieuli :  and  here,  a,s  in  adipose  tissue,  atrophic 
prolifcratifin  of  the  muscle-nuclei  seems  to  be  common. 

I'nless  their  vital  nrtli'itj/  is  exhausted  the  shrunken  cells  arc 
capable  of  recovery ;  all  that  is  necessary  for  their  restitution  is 
diminution  of  waste  or  increase  of  assimilation,  according  as  one  or 
other  is  faulty. 


MICROSCOPIC  APPEARANCES.— Diminution  in  size  is  the 
most  common  condition  met  with  in  atrophy,  and  may  affect  all 
tissues,  as  is  well  shown  in  ordinary  emaciation.  Thus  adi{H)se 
tissue  is  merely  common  connective  tissue,  many  cells  of  which  are 
distended  with  fat.  When  a  person  emaciates  the  fat  is  gradually  j 
removeil  from  the  cells,  which  diminish  in  size,  and  the  fat  which 
once  filled  them  completely  may  be  reduccil  to  a  few  isolated  drops; 
it  is  usually  partially  replaced  by  serous  fluid.  The  cell-wall  ami 
nucleus  often  become  distinctly  visible  (Fi<r.  ■'>).  and  multiplication 
of  the  nucleus  is  not  infreijuently  observed  (atrop/iic  />roUt'f!rittion). 
This  example,  though  usually  given,  is  not  a  good  one,  inasmuch 
as  the  diminutiiin  in  size  of  the  cells  is  due  to  the  absorjition  of  s 
substance  with  which  they  have  been  hijjlirntvil.  and  which  is  not 
essential  to  their  well-being,  whilst  the  protoplasm,  at  first  at  nil 
events,  is  not  affected.  The  cells  of  all  glands  may  undergo  true 
atrophy;  they  become  smaller,  being  often  finely  granular  from  the 
presence  of  molecular  fat.     Shrinking  of  the  whole  organ  results. 

FiQ.  6. 


ATROPHY.  ^^^^^^ 

Numerical  atrophy  is  often  an  advanced  sta^e  of  »imple  atrophy. 
The  elonienis  not  onlv  tliiniuislt  in  si/.o,  but  some  actually  i»erisli, 
as  is  well  seen  in  advanocil  mrujiliies  of  niiiscle  ;  then  restitution  is 
possible  only  by  the  production  of  new  elements,  whereas  in  simple 
atrophy  repair  can  be  eflected  withont  new  Foniiiition.  In  certain 
tissues — as  the  spleen,  lymphatic  glands,  and  skin — in  whicli  growth 
occurs  by  addition  of  new  elements,  and  not  by  enlargement  of 
j)re-existing  cells,  atrophy  is  probably  always  due  mainly  to  nu- 
merical loss. 

Although  atrophy  in  its  strict  significution  consists  simply  in  a 
diminution  in  size  or  in  number  of  the  component  elements  of  a 
tissue,  it  is  rarely  ii  perfectly  simple  process,  but  is  iisually  asso- 
ciated with  more  or  less  fatty  degeneration.     This  itidicsites  fuiilt  in 
the  chemical  processes  of  the  cells.     Probably,  when  the  nutrition 
of  a  part  is  sn  much  interfered  with  as  to  cause  it  to  atro|)hy.  those 
portions  of  its  celts  which   sh(uild   be  combined  with  o.xygen  and 
rendereij    soluble   remain  :    fatty  degeneration  is  the  natural    fate 
of  protoplasm   under  such   conditions.     It  is  jiossible,  too,  that  an 
atrophying  tissue  would  not  store  sufficient  oxygen  for  its  use.     It 
will  be  seen  subsequently  that  fatty  degeneration  arises  from  causes 
similar  to  those  which  produce  atrophy  itself. 


PHYSICAL  CHARACTERS.— The  naked-eye  recognition  of 
at^Tophy  is  often  difficult.  Atrophied  organs  are  usually  diminished 
in   weight   and  size.     They  also  contain   less  blood,  iind  are  ilrier, 

pa-ler,  firmer,  and  more  fibrous-looking  than  in  health.     The  great 

B *^*'" tf "on  IS  diminution  in  weight  and  size  of  an  organ;  but  these 

^'•■•^■y  considerably  in  health,  especialh'  with  the  weight  and  size  of 

^_^"*^whule  body;  moreover,  they  may  be  small   from   incomplete  <le- 

^^^lopment.     Again,  accumulation  of  blood  and  other  fluids  in  an 

o»-|^Q  may  bring  its  weight  and  size  up  to  or  above  the  average, 

*it.Lnugh  its  essential  tissue  is  considerablv  diminished  in  amount. 

«c8anie  fallacy  mav  arise  from  overgrowth   of  the  fibrous  stroma 

*"    an  organ. 

-'^11  the  tissues  of  which   an   organ  consists  may  waste  simidta- 

'^^Kju.sly,   but  the  term    "  alro[ihy  "  implies,   primarily  an<l  chiefly, 

'^«»ting  of  its  characteristic  cells,  as  opposed  to  the  stroma.     The 

^^Kels  and   nerves  of  course  share   in   the  wasting  process.     The 

blirous  constituents  are  the  last  to  atrophy  ;   and  this  fact,  together 

*itb  the  diminished  blood-sup])ly,  accounts  for  the  pallor,  dryness. 


48  SUTHITIOy  IMPAIRED. 

toughness,  and  fibrous  appearance  above  mentioned  as  nsnal  in  atro- 
phied organs.  Not  uncommonly,  as  the  higher  cells  shrink  and 
disappear  the  connective  tissue  of  the  organ  incre<ue9 — as  in  the 
secondary  "  scleroses  "  of  the  spinal  cord — and  it  may  become  the 
seat  of  fat-infiltration,  as  in  pseudo-hypertrophic  muscular  paralysis. 
This  tendency  to  take  advantage  of  the  obvious  weakness  of  a  con- 
tiguous tissue  is  perhajvs  to  be  explained  by  Cohnheim's  theory  of 
the  "  physiological  resistance  "  offered  by  one  tissue  against  invasion 
of  its  territory  by  another.  (See  "  Tumors."')  More  probably,  how- 
ever, the  overgrowth  of  connective  tissue  in  such  cases  is  due  to  a 
general  attempt  at  repair  which  only  results  in  the  increased  growth 
of  the  least  specializeil  and  most  easily  regenerated  tissue. 

BTIOLOOT. — The  occurrence  of  atrophy  is  sure  evidence  that 
the  nutritive  exchange  in  the  atrophied  part  is  disturbed,  so  that 
tc<ui<  tjccfed*  attimilatioH.  This  is  the  imnuduite  caune  of  aB 
atrtiphie*.  A*gimiltttum  may  be  deficient  because  of  insuffieienl 
tuppljf  of  food,  or  because  of  inabiliti/  on  the  part  of  the  tissues 
to  u*f  the  food  supplied.  The  circumstances  which  excite  excessive 
waste  in  individual  cells  are  but  little  understood.  It  is  convenient 
to  speak  of  </«*h<t«j/  atrophy  as  distinct  from  locaL 

Qeneral  atrophy  may  be  causeil  by : 

1.  Deficient  Supply  of  Nutritive  Material. — Whatever  inter- 
feres with  the  supply  of  nutritive  material  to  the  tissues  will  be  fol" 
lowetl  by  their  atrophy.     Thus  the  following  conditions  may  all  l>® 
causes  of  general  atrophy  :  Deficient  supply  of  food:   obstructio**^ 
to  the  passage  of  food  into  the  stomach  or  intestines,  as  in  strictu  *"* 
of  the  ivs4>pbagus  or  pylorus ;  the  mala^imilation   which  resul  *^ 
from  the  various  conditions  giving  rise  to  dyspepsia ;  interference' 
«ith  the  abs*>rption  of  the  chyle  fn>m  obstruction  of  the  thorac^- 
duct  or  fn>m  disease  of  the  mesenteric  glands,  constituting  the  sC^ 
calKn)  "tabes  mosontorioa." 

•2.  Bxceasive  Waste. — .\ll  C(>nditions  attended  by  the  loss  o^ 
larc»»  «|uanti«ios  of  nutritive  uiatori.ii  may  also  be  causes  of  general 
atr»>phy.     Among  these  ar\» — ivntinuous  hemorrhages  :  profuse  and 
kntK-cootiaucHl  suppuration  fnnn  chronic  bi>ne  disease  or  empyema; 
^iMfkna;  and  the  excretion  of  large  quantities  of   albumin  in 
^|kl**  diMMiie  or  of  sugar  in  dialvtt^  mellitus.     The  waste  from 
Mtd  timue-changr^  acr>mi|Kinying  acute  febrile  disease  must  also 
MnA  under  this  hv«d. 


ATRoptrr. 


49 


to 

I 


^^.  Impaired  Vital  Activity. — This  constitutes  nn  important  ele- 
n]^r:it  in  tiio  piotliiction  iff  the  atrophy  of  old  age — eenile  atrophy, 
life  ailvnuces  the  ability  of  the  elements  to  perforin  those  cliem- 
processes  which  are  necessary  fur  the  preparation  and  aosiniiia- 
of  the  tissue-food  dimiuinhes   more  rapidly  than  the  ability  to 
iFortu  those  which  arc  uoticerned  with  the  prodnetiuii  of  the  waste 
«lucts.    Hence,  these  elements  gradually  atroidiy,  and  ultimately 
all       :xrDaoifestation3  of  their  vitality  may  cease. 

Although  general  atrophy  may  occasionally  be  referretl  to  one  of 
.he?  foregoing  causes,  it  is  usually  due  to  the  combined  influen<u'  of 
tw«:»  or  more  of  them.  The  atrophj*  associated  with  pulmonary 
ph'tVjisis,  for  example,  re^sults  partly  from  /o««  nf  nvtritiw  material 
in  j»r()fuse  expectoration  and  dian-luea,  jiartly  from  deficient  siippltf 
cor*  eic(jaent  upon  imperfect  oxidation  of  the  blood  and  upon  inter- 
fere?'nee  with  assimilation,  which  is  so  often  caused  by  structural 
ch(m.dges  in  the  stomach  and  intestines,  and  partly  from  the  inrrca»cd 
ti$tm^M^e-wngte  of  fever.  In  senile  atrophy,  again,  in  addition  to  the 
ge»»«jral  diminution  of  nutritive  activity,  there  is  freipiently  some 
oot»«3itiou  of  the  digestive  organs  which  interferes  with  a^^similation  : 
tbi^  materially  aids  in  producing  the  ultimate  result.  Increased 
tisEK^je-waste,  loss  of  appetite,  and  interference  with  assimilation  all 
''**1>  to  produce  the  atrophy  which  accompanies  fever. 


^t^OCAL  ATROPHY. — In  local  atrophy  it  is  often  very  difficult 
'**   *iiscover  which  factor  in  the  nutritive  exchange  is  at  fault. 

1  -  Deficient  Supply  of  Nutritive  Material. — The  effect  of  di- 

""^^ishing  the  blood-supply  to  a  part  will  vary,  according  to  the 

''*S*'ee  of  the  diminution,  from  slight  atrophy  to  absolute  necrosis. 

t^iminished  supply  of  arterial  blood  is  a  common  cause  of  atrophy 

i/**-»««Vf),  and  may  he  brought  about  in  various  ways :  (1)  By  oh- 

"^^tt-ction  of  the  itupplyinff  vesaeh  hefore  thetf  enter  a  part.     Thus 

P''<^«4sure  of  an  abdominal  aneurysm  on   the  8j)ermatic  artery  may 

^Uso  atrophy  of  the  testis,  and  fracture  of  a  long  bone  above  the 

P***»»t  where  its  nutrient  artery  enters  may  result  in  wasting  of  the 

Pl>«r  fragment.     (2)   Bif  uniform  and  eontinnoux  prexxure  which 

**'^»*  not   compress    the    veins    disproportionately.     Thus    atrophy, 

'  ^^»i  of  hones,  results  from  pressure  of  aneurysms  and  tumors; 

^^f  r  fissures  are  formed  in  solid  organs  fi-om  pressure  of  band-like 

** «-» ^jsions ;  atrophy  of  the  kidneys  will   follow  obstruction  in  the 

***ary  passages;  and,  rarely,  wasting  of  a  testis  may  be  due  to 


50 


M'TIirnoS   IMI'A  IHKU. 


pressure  of  oM  hivinntoeeles  nr  liyilroceles.  Pressure  msv  nl^o  arise 
within  the  enpsiile  oi'  an  orj^uu  by  the  appeuruuce  of  some  now 
growth  or  infl  a  minatory  eft'usion,  especially  that  leading  to  the 
forniiilion  of  young,  ftrongly-coutnictile  eientriciul  tissue.  Tlic 
eflcet  of  this  is  seen  in  cirrhosis  of  the  liver,  and,  according  to  some 
piithohjgists,  in  grannlar-contrnctcd  kidney.  In  all  "pressure 
iilrophies"  the  coustaiit  pressure  also  acts  directly  on  the  cells  of 
the  jiart  and  tlius  impiiirs  their  powers.  (3)  Mfchanical  ronffettinn 
in  the  same  way  sometiuies  leads  to  atrophy.  The  circulation  is 
iiu|teded,  and  the  blrMid  is  not  returned  normally  by  the  veins. 
Hence  there  is  deficient  iirterial  su]»]ily,  and  atrophy  results.  Thi.i 
is  seen,  for  example,  in  the  niechanieally  congested  liver  of  heart 
disea-se. 

2.  Diminiahed  Functional  Activity. — Atrophy  always  caiiw* 
diminished  funetionid  activity,  but  sometimes  dimitiished  fiiurlwwil 
aetiviti/  seems  to  be  itself  the  cause  of  atrophy.  In  these  cases  the 
immediate  cause  is  either  deficient  supply  uf  food  or  impairrd  rittil 
tiwn/if. 

Dimini.sbed  functional  activity  of  a  part  imjdies  that  the  chemical 
proces-ses  in  its  cells  are  less  active  than  irormal ;  such  celU  n-ipiirc 
less   fiHid.      How  tiie  needs  of  each   tis.siie  are  made  known   to  the 
bloiid-lorming  organs  is  not  utnlcrstood.  but  the  su])ply  is,  as  a  rule, 
speedily  adapted  to  any  variation  in  the  demand.     Couse((Ucntly, 
tissues  will,  .soon  after  they  have  ceased  to  perform  their  funcliorn*. 
receive  only  sufficient  material  for  tho.^e  chemicid   processes  wlii«3" 
still  go  on  in  them.     This  is  insufficient  to  maintain  the  mass  *>' 
proto]ilasra  retpiired  to  do  the  full  work  of  the  tissue,  so  some  of     '' 
!itro|ihies. 

After  birth,  those   parts  which   nre  no   longer  required   in   t»" 
altered  circulation  gradually  atrophy.     The   umbilical  arteries  »'• 
vein  become  thrombosed  up  to  (heir  first  branches,  and  shrink  to    * 
fibrous  cord  as  the  clots  organize — ^_just  like  any  other   vessel  Ci* 
across  or  tied.     Hut  this  does  not  explain  the  closure  of  the  ductii'^ 
venosus  or  iluctiis  arteriosus,  in  which  the  conditions  are  not  faviir-^ 
able  to  thrombosis.      lUililenitiori  of  these  vessels  caji  at  present  liff 
sjKiken  of  simply  as  a  developmental  fact,  comparable  to  closure 
of  the  foramen  ovale.     The  Wolffian  body  disappears  as  the  kitlnevg 
develop,  and  the  thymus  wa.stes  in  the  second   year.     These,  ]h'T- 
haps,  are  examples  of  atrojdiy  of  organs  following  the  development 
of  others  better  fitted  to  do  the  work — illustrating,  as  it  were,  the 


ATROPHY.  51 

converse  of  the  law  that  when  an  organ  atrophies  or  is  removed, 
correlated  organs  hypertrophy  and  take  on  its  function.  (See 
"  Hypertrophy.") 

Muscles  atrophy  when  they  are  rendered  inactive  by  chronic 

<lisease  of  joints,  by  splints,  or  by  paralyaia  from  disease  or  injury 

of  the  nervous  system  above  the  anterior  cornual  cells  with  which 

they  are  connected — i.  e.  by  an  "  upper-segment "  lesion.     When 

the  muscles  of  a  part  waste,  all  its  other  tissues — nerves,  vessels, 

bones,  etc. — suffer  ultimately  from  impaired  blood-supply.     Thus, 

in  part  at  least,  we  may  explain  wasting  of  the  bone  in  a  stump  or 

limb  long  kept  at  rest ;  the  absence  of  that  intermittent  pressure 

which  it  is  the  function  of  bones  to  bear  is  probably  a  secondary 

■cause :  at  all  events,  increased  strain  causes  hypertrophy  of  a  bone. 

After  removal  of  the  distal  part  of  a  limb  the  main  artery  and 

branches  supplying  it  become  smaller  and  thinner.     The  rectum 

dwindles  after  colotomy  to  a  scarcely  pervious  cord :  in  this  case 

the  passage  of  faeces  over  the  mucous  membrane  no  doubt  acts  as  a 

stimulant  to  its  vessels,  as  well  as  an  excitant  of  muscular  action, 

and,  as  after  colotomy  the  rectum  is  never  distended,  its  tissues 

adapt  themselves  to  the  empty  condition.     Atrophy  of  the  stump 

of  the  optic  nerve  follows  removal  of  the  corresponding  eyeball. 

The  female  generative  organs  atrophy  at  from  forty-five  to  fifty 

years  of  age,  the  male   somewhat   later;    the   spleen  and    whole 

lymphatic  system  waste  after  middle  life:  probably  in  these  cases 

the  vital  energy  of  the  cells  of  the  parts  concerned  is  exhausted 

*l>out  the  times  mentioned,  and  diminished  function  is  the  result, 

•»ot  the  cause.       Thus    these    are    really   examples    of    "senile 

<lecay." 

Ttephoneurosee. — When  a  muscle  is  cut  off  from  its  connection 

^*ththe  cells  in  the  anterior  comu,  or  when  these  cells  are  destroyed 

*■■  seriously  injured,  fatty  degeneration  of  the  muscle,  a  more  rapid 

V'ocegs  than  simple  atrophy,  sets  in.     In  the  case  of  atrophy  those 

^^a-nges  which  nervous  stimuli  alone  can  excite  (p.  23)  probably  go 

***>  but  in  the  former  they  are  completely  arrested.     Examples  of 

'Uis  atrophy  are  afforded  by  the  acute  bulbar  and  spinal  paralyses 

™  adults,  infantile  paralysis,  some  cases  of  progressive  muscular 

•ttophy,  neuritis  from  any  cause,  and  rupture,  contusion,  or  section 

^'  a  nerve.     Salivary  glands   waste   on  section   of  their   nerves. 

Serves  cut  off  from  their  ganglion-cells  (of  which  they  are  long 

Processes)  also  degenerate  rapidly  and  waste.    In  all  these  cases  the 


52 


yuTiiiTioy  mpAinKD. 


intorstitini  connective  tissue  increases,  and  often  becomes  loaded 
witli   fat  as  tbf  higlicr  tissue  lii^appears. 

'i.  Excessive  Functional  Activity. — This  mav.  (|uite  cxcojitioii- 
ally,  be  a  cause  of  atn»|iiiy — e.  g.  of  the  testis,  and  possibly  of  the 
kiilmy.  Tliis  will  be  further  discussed  in  the  section  on  "Chronic 
luttTstilial  ^'ejiLritis." 

Atbopht  of  Bone. 

As  in  other  tissues,  iitrojihy  of  bone  is  usually  accompanied  by 
more  or  less  fatty  degi'neratiou.  Old  aye,  dinunf.  and  coristant 
prenKure  art*  its  most  freijuent  causes. 

When  due  to  old  <r<if  tliere  is  ditiiiuHtinn  in  wcirrbt,  Imt  no  change 
in  size.  The  loss  of  weight  is  the  result  of  the  gnidinil  ennversion 
of  the  cdtiipact  tissue  into  one  closely  resembling  the  canctdlous. 
The  spaees  become  larger  ami  their  bony  walls  thinner;  the  con- 
sfijuent  britlleness  (if  the  bone  is  therefore  a  nnirked  feature.  This 
form,  known  as  eccentric  atrophy,  occurs  with  other  senile  changes, 
and  generally  affects  all  bones,  but  is  specially  marked  in  the  neck 
of  the  femur,  rendering  it  liable  to  frnrture  from  trivial   injuries. 

Atrophy  from  dinu^i'  or  from  rtiuHfaiit  /irrmurf  is  acconipanietl  bv 
diniinutiiin  in  size  as  well  ns  in  weight.  The  bone  beneath  the 
periosteum  is  gradually  absorbed,  and  the  medullary  eanal  shrinks 
pro|Mirtionately.  '['his  variety  is  known  as  concentric  atrophy, 
but  the  ehatiges  charact-eristic  of  the  eerentrir  form  are  often  pres- 
ent as  well.  It  is  a  local  alteration,  and  is  met  with,  especially  in 
the  Inng  bones,  in  cases  of  long-standing  ankylosis,  dislocAtion.  or 
paralysis.  The  effect  of  constant  pressure  in  the  production  of 
atrophy  is  well  shown  in  the  enlargement  of  clefts  ami  perforations 
of  the  hard  palate  which  often  residts  from  the  in.sertion  of  jdiigs. 
These  interfere  with  ihe  blood-supply,   and  thus  cause  atrophy. 

Atrofdiy  of  bone  must  not  be  confounded  with  arregted  dnrlop- 
mmt.  The  latter  is  eomtuiuily  met  with  in  the  later  stages  of 
infantile  paralysis.  A  very  similar  result  may  be  proiluce<l  by  any- 
thing which  causes  premature  ossification  of  an  epiphysis,  such  as 
rickets,  inflammation,  or  injury.  These  are  the  common  catises  of 
stunteil  lindis  ;  and  microcephaly  may  be  tine  to  premature  ossifica- 
tion of  the  cartilage  between  the  basi-sphenoid  and  the  basi-occipital. 

PtJLMONARY   VeSICTILAR    EmPHYSEMA. 

This  appears  to  be  a  proper  place  to  describe  the  changes  in  the 


iOPHY. 


53 


Inngs  in  emphyBema,  as  the  chief  of  them  is  atrophy  of  the  inter- 
alvcolar  8e])ta. 

Emphysema  consists  essentially  in  a  permanent  enlari^ement  of 
the  infunilibula  and  air-cells  due  Uy  atrophy  of  the  intervening 
septa;  it  should  l»e  distinfriiishtvl  from  the  acute  over-disteation 
often  seen,  especially  in  children,  uftur  death  from  bronchitis  or 
whooping  cougti.  The  condition  of  the  lungs  met  with  in  these 
diseases  is  sometimes  called  "acute  emphysema." 


VARIETIES. — Two  varieties  are  described  :  (1)  Ilypertrophous 
or  "  large-lunged  "'  emphysema — by  far  the  most  important,  and 
always  indicated  when  the  term  "emphysema"  alone  is  used;  (2) 
Atrophous,  small-liingeil  or  senile  emphysema. 

1.  In  Hypertrophous  Emphysema  the  lungs  are  enlarged,  some- 
times so  much  that  tliey  lu-tually  cro.ss  in  the  raid-line  in  front, 
obliterate  the  superficial  cardiac  dulness,  project  markedly  into  the 

Fifi.  « 


Rmphynema  nf  thr  long  I  from  a  case  of  clironlr  hriini'liUU):  A  pniiinn  of  th«  rounded 
anterior  edio!  of  the  lung  The  vnrli'd  size  of  ih<?  lavltles  furmtxi  hy  lUtteiitlon  oftbc  alveoU 
«n<l  atrophy  of  the  ]Mrtitiuns  in  wi-11  shown.    (From  n  «|H:c'lm«ii  liy  Dr.  Arkle.) 

neck,  and  push  down  the  diaphragm.     Owing  to  the  lo.ss  of  their 
elasticity  the  lungs  collapse  but  slightly  when  the  chest  is  opened. 


54  NVTRITJON  IMPAIRED. 

and  their  usually  sharp  edges  (in  front  and  round  the  base)  are  pale, 
thick,  round,  or  more  or  less  irregular  from  the  protrusion  of  soft, 
pale,  rounded  swellings :  similar  swellings  frequently  project  toward 
the  diaphragm ;  the  tongue-like  piece  of  the  left  lung  below  the 
notch  is  often  extremely  swollen,  and  the  lungs  may  bear  distinct 
grooves  corresponding  to  the  ribs.  Everywhere,  in  advanced  cases, 
the  air-cells  are  seen  through  the  visceral  pleura  with  abnormal  dis- 
tinctness, but  the  apices  and  sharp  edges  are  first  and  chiefly 
affected,  and  spaces  of  considerable  size  are  here  met  with.  Ab- 
normal pigmentation  is  usual.  The  lungs  feel  much  like  a  down 
pillow;  they  "pit"  easily,  and  crepitate  but  little.  On  section  the 
emphysematous  parts  are  pale,  dry,  and  bloodless ;  and  when  large 
spaces  are  present  in  the  part  cut,  the  collapse  of  the  affected  areas 
is  very  marked. 

Microscopic  investigation  shows  that  the  dilatation  commences  in 
the  infundibula,  and  extends  thence  into  the  alveoli  opening  into 
it ;  that  the  inter-alveolar  septa  atrophy  and  ultimately  become  per- 
forated, their  elastic  fibres  yielding  and  then  disappearing;  that 
the  stretched  capillaries  become  thrombosed,  and  then  likewise 
vanish.  The  apertures  in  the  inter-alveolar  septa  enlarge;  and 
later  others  form  between  the  infundibula,  and  thus  are  developed 
irregular  cavities  which  are  sometimes  as  large  as  a  filbert.  The 
largest  are  situate  in  the  pale,  rounded,  bleb-like  swellings.  Fattv 
degeneration  of  the  alveolar  epithelium  is  commonly  present,  and 
is  probably  secondary  to  vascular  disturbance. 

The  communications  between  the  pulmonary  and  bronchial 
vessels  become  dilated.  The  connective  tissue  round  the  smaller 
bronchi  may  be  increased  as  the  result  of  bronchitis. 

Hypertrophy  or  dilatation  of  the  right  ventricle  (p.  117)  fre- 
quently results  from  the  obstruction  to  the  pulmonary  circulation, 
any  marked  dilatation  being  accompanied  by  the  venous  congestion 
of  cardiac  failure.  The  thorax  becomes  barrel-shaped — almost 
fixed  in  a  position  of  full  inspiration. 

2.  Atrophous  Emphysema  occurs  usually  in  thin  old  people 
who  seem  to  be  undergoing  general  atrophy.  The  lungs  during 
life  may  leave  the  heart  unduly  exposed  ;  when  the  thorax  is  opened 
they  collapse  excessively,  falling  together  "like  an  inflated  bag  of 
wet  paper  "  (.Jenner).  They  are  excessively  pigmented,  and  their 
apices  and  borders,  even  after  collapse  has  occurred,  usually  show 
appearances  like  those  in  the  large-lunged  variety,  and  are  due  to 


ATROPHY.  55 

similar  naked-eye  and  microscopic  changes.  In  this  form,  appar- 
ently, the  elastic  tissue  is  not  so  generally  affected  as  in  the  largc- 
lunged  variety. 

liTIOLOQY. — All  conditions  which  increaae,  either  absolutely 
or  relatively,  the  pressure  on  the  inside  of  the  air-vesicles,  or  which 
w^eaken  their  walls,  may  act  as  causes  of  emphysema. 

(1)  Intra-alveolar  Pretture  Increased  Absolutely. — Increased 
pressure  in  the  air-cells  may  be  due  to  violent  expiratory  efforts 
with  closed  glottis,  as  in  coughing;  to  violent  muscular  efforts 
while  the  glottis  is  closed  and  the  thorax  distended ;  and  to  the 
blowing  of  wind  instruments.  Those  parts  of  the  lungs  which  are 
least  supported — the  apices  and  edges — will  be  most  affected.  This 
is  the  expiratory  theory  of  Jenner.  Emphysema  due  to  causes  such 
as  these  is  often  called  primary. 

(2)  Intra-alveolar  Pressure  Increased  Relatively. — When,  by 
reason  of  collapse,  compression,  or  consolidation,  the  entrance  of 
air  into,  and  the  consequent  expansion  of,  any  part  of  a  lung  are 
interfered  with,  inspiration  will  tend  to  produce  a  vacuum  in  the 
immediate  neighborhood  of  this  portion  with  greater  force  than  in 
other  parts,  and  the  air-cells  in  this  particular  neighborhood  will 
tljerefore  tend  to  become  more  distended  than  those  in  other  parts. 

Similarly,  when  from  the  same  cause  a  whole  lung  fails  to  expand, 

ita    fellow  stretches  over  toward  it,  and  even  the  mediastinal  con- 

tCEkXi  may  be  displaced  in  the  same  direction.     This  form  of  em- 

pii^sema  is  termed  vicarious,  compensatory,  or  secondary,  and  this 

®*r»lanation  of  its  causation  is  known  as  the  inspiratory  theory. 

(3)  Weakening  of  the  Alveolar  Walls. — This  weakening  may  be 

**'^*^    to  (a)  the  atrophy  and  loss  of  elasticity  which  accompany  old 

^S^,    the  most   important   element  in  the   causation  of  atrophous 

^***r>ly8ema;  (6)  atrophy  following  the  stretching,  narrowing,  and 

**  "I  *  deration  of  the  blood-vessels,  which  in  its  turn  is  a  result  of 

**^^*"-distention   of   the   air-cells   from    any   of  the   causes    before 

***^*itioned ;   and  (c)  inherited   weakness   (emphysema  may  run  in 

*^^**ilie8)  or  weakness  due  to  some  interference  with  their  nutrition 

Worn  the  mode  of  living  or  other  causes. 


M 


JVCTTR/r/OA'  HI  PAIRED. 


CHAPTER  ni. 


FATTY  DEGENERATION. 


The  term  Patty  Degreneration  is  here  used  to  include  all 
of  abnorninl  acciinitilatioii  of  fttt  in  tlie  tissues:  but  it  is  fre)|urnll 
cniploved    \i»    synonynious    with    "'fatty    metamorphosis"    nnd 
opposed  to  "fatty  infiltration." 

The  abuorraal  nccuuiulntion  of  fat  in  the  tissues  may  ri'siilt  fi 
either  iitfiltratiou  or  metamorphosis  (p.  4.3) — two  essentially  iliffer 
ent  processes  as  regards  causes,  nature,  and  effects.     E.xample*  ol 
both  occur  in  health  (pp.  t)l,  (34). 

According  to  Cohnheim,  all  fat  found  in  the  body  has  the  win 
chemical  composition,  being  a  mixture  of  tripalmitiu,  triolein,  ah  ^M. 
tristearin.  It  has  since  been  shown  '  that  if  dogs  are  fed  on  colics 
oil.  linseed  oil.  or  mutton  fat,  tiie  melting-point  of  the  deposite<l  fm.« 
will  vary  with  that  of  the  form  in  which  it  was  given,  and  thmin 
the  case  of  the  colza-oil  diet  the  tissues  will  contain  eracic  »cici« 
which  under  ordinary  conditions  is  absent. 


PATTT   INFILTRATION. 
In   fatty  infiltration   fat   bron;rlit  by  the  blood  is  taken  up 
deposited  in  the  substance  of  ci-rtain  cells — viz.  those  of  the  c-onM*"*' 
tivg  tinntf  of  certain  parts  (especially  subcutaneous  and  subserous) 
those  of  the  mnhilln  of  limb-bones;  and  to  a  less  extent  those    ** 
the  lirtT,  which  thus  serve,  physiologically,  as  reservoirs  of  fal.         ' 
is  impossible  to  draw  any  line  between  normal  and  pathulogi^^' 
fatty  infiltration  so  long  as  the  process  is  confined  to  those  e 
grou|>8  which  are  j)hy8iologically  liable  to  this  infiltration.     TL»- 
the  subcutaneous  fat  and  the  fat  normally  present  along  the  coi 
nary  vessels  in  mi<ldle-aged  a<Iults  varies  much  in  amount  consL 
ently  with  pt-rfect  health.     But   when  the  fat  spreads  wiiU-ly  ov- 
the  surfa^-c  of  the  heart,  it  is  clearly  abnormal,  and  the  evident 
of  disease  is  still  stronger  when  the  fat  appears  between  the  m 
cular  fibres  in  cells  which  noriually  contain   none.     The  tondcn 
to  morbid  fatty  infiltration  may  be  general  {o/n-iiifi/)  or  local. 

CAUSES. — It  may  be  stated  generally  that,  whenever  oxidizalil 
material  is  present  in  the  blood  in  excess  of  the  amount  rciiuire^ ' 
'  Lebeiletl  and  Muiik,  i|Uoted  by  Uungo. 


FATTY  DEGENERATION. 


57 


r  tho  supply  of  force  ami  maiutenance  of  heat  of  the  body,  there 

a  tendency  to  the  deposit  (storuge)  of  fat,  first  in  regions  in 
hich  it  \a  normally  firescnt.  and  later  in  parts  which  usually  con- 
lin  none.  For  this,  fat  itself  need  not  be  jiresent  in  excess  in  the 
)od;  the  presence  of  carbohydrates  in  quantity  sufficient  to  satisfy 
ihe  Wants  of  the  organism  will  protect  fat  from  oxidation.      But  it 

ould  seem  that  there  are  factors  in  the  process  of  fattening  other 
ian  the  relation  of  food-supply  to  oxidation,  for  nothing  is  more 
»rtfflin  than  that  a  tendency  to  obesity  or  to  leanness  runs  in 
tmilies,  and  it  is  notorious  that  some  very  stout  people  are  small 
Iters  and  active,  whilst  many  thin  subjects  are  just  the  reverse, 
'ohnheira  has,  it  is  true,  advanced  the  hypothesis  that  in  the 
Wmer  oxidation  is  naturally  slow  and  imperfect,  but  we  know  of 
experimental  facts  in  support  of  the  view. 

With  regard  to  the  sources  of  fat  deposited  in  the  body — the 
•l-stufTs  whence  it  is  derived — many   views  are  still   lield. 

(1)  It  appears  possible,  from  the  facts  stated  on  the  preceding 
ige,  that  Bome  fat  may  be  absorbed  and  deposited  without  change 

the  tissues,  even  when  the  food  contains  fat  dissimilar  in  com- 
ition  to  that  generally  met  with  in  the  human  body.  On  other 
•casions  if  any  fat  of  the  food  is  store*!  in  the  body  it  must  some- 

*•!"«    undergo   the    change    (usually  the  loss  of  some  hydrogen) 

•ossary  to  assimilate  it  to  human  fat.     it  is  generally  held  that 


Fig.  7, 


68 


NVTRITION  IMPAIRED. 


which  implies  passiveness  on  the  part  of  the  cell,  is  therefore  prob- 
ably incorrect  in  these  instances. 

(2)  It  is  t;eueniny  believed  that  ftit  is  not  formed  directly  frmn 
carbohydrates,  but  that  these  take  the  place  of  the  material  from 
which  fat  can  be  formed ;  there  are,  however,  many  facta  in  favor 
of  the  opposite  view.  Thus  bees  while  livin;;;  on  carbohydrates 
continue  to  produce  wa.x.  In  the  case  of  pigs  it  has  al.»o  Wn 
shown  '  that  under  certain  conditions  the  deposit  of  fat  is  Aw  to 
the  carbohydrates  in  the  food.  Nothing  is  known  concerning  the 
nature  of  the  change. 

(3)  It  is  thought  that  the  chief  source  of  fat  deposited  in  the 
tissues  is  the  proteids  of  the  food.  These  are  said  to  be  absorbe^i 
and  sydit  into  a  nitrogenous  and  a  non-nitrogenous  molecule,  from 
the  latter  of  which  fat  is  formed,  and  stored  if  not  re<|uired. 

It  would  appear,  therefore,  that  excess  of  the  diet  over  th^ 
wants  of  the  body,  particuhiriy  if  the  excess  be  in  hydrocarbons  •»"■ 
carbohydrates,  is  one  great  cau.se  of  fattening. 

With  regard  to  the  second  great  canse — diminished  oxidatioo— — 
this  may  result  from  sedentary  and  luxurious  habits,  ease  of  miO" 
and  body,  high   external   temperature,  destruction  of  much  lu»|Z- 
tissuc    by  chronic   disease,  or    reduction   of  the   oxygen-carryio  ^ 
power  of  the  l)lood  owing  to  diiuiiiiition   of  red   corpuscles  or  c» 
their  hienioglobin.     The  fat  contuiued  in  a  normal  diet  may,  umi*^*" 
such  circumstances,  be  incompletely  oxidized.     Locally,  oxidatio** 
may   be  tliniinished  by  slow   circulation  or   by   the  circulation  o* 
deoxidized  blood  through  a  part — conditions  which  normally  obtai  ^ 
in  the  liver  and  in  parts  thrown  out  of  work,  as  in  a  muscle  kept  »•* 
rest.     Excesses  of  fat  may  sometimes  be  present  in  the  fluids  around 
certain  cells — «•.  g.  the  liver-cells  after  a  meal  containing  much  fat» 
and  the  connective-tissue  cells  and  wandering  cells  near  a   focus  of* 
fatty  degeneration. 

Thus  to  prevent  fatty  infiltiMtion  the  diet  should  be  moderate, 
carboliydrates  and  alcohol  being  as  far  as  possible  excluded. 
Appropriate  exercise  and  the  drinking  of  large  quantities  of  water 
will    favor   oxidation   and   ensure   the   prompt  removal   of   waste 


-1.  Microscopic. — Cells  undergoing  fatty 
c«»titjiln  dropKts  of  oil — very  small  at  first, 
insk;  aud  nthere,  qiioird  \\j  Buogv. 


FATir  DEGENERATION. 


59 


II  distinct  droplets.  These  run  together,  jtush  the  cell- 
Ptts  asiilr,  and  distend  the  cell  until  its  original  contents  seem 
bave  become  u  mere  capsule  to  the  fat  (Fig.  H).  As  the  fat  is 
ie«l  to  the  previous  cell-contents,  the  cell  is  enlarged  in  propor- 
>&  to  the  amount  of  fat  it  contains. 


Fio.8. 


UviT-ci'llc  In  vnriniui 
KtOKOi  of  Catty  liilUlm- 
tliin.  X  aoo.  (Riiid- 
flclwh.) 


'2.  Naked  Bye. — A  fnttily  infiltrated  organ  is  consetiuently 
|wr«  or  Ie«8  swollen.  Any  sharp  edges  it  may 
K^ssfes)!  teml  to  become  thick  and  rounded.  It 
tnoro  or  less  pale  and  yellovvi.>*h  on  account 
f  anicmia  (from  increased  intra-capsulur  pres- 
re)  and  the  presence  of  fat ;  it  is  doughy  and 
•t'lastic,  and  both  receives  and  retains  an  iui- 
fP-'wion  from  the  pressure  of  a  finger;  and  it  is 
'ftt*r  than  natural.  But,  except  mechanically, 
fat  does  not  hinder  the  protoplasm  of  the 
11  from  discharging  its  functions.  I'lti- 
oly,  however,  pressure  npon  the  cells  proper 
J"  become  so  severe  that  they  iiiuy  fjiil  to  get 
cieut  nourishment ;  they  will  tlieu  undergo  fatty  metnmorphnsig 
atrophy.  The  knife  used  to  cut  a  fatty  organ  becomes  greasy, 
»Btty  show  distinct  oil-drops  on  the  blade. 

lEJATS. — The  cells  mo.st  commonly  affected  to  a  morbid  e.xtent 
tliose  physiologically  liable  to  the  process — viz.  connective-tissue 
and  liver-cells:  with  regard  to  the  former,  it  is  to  he  noted 
normally  the  cells  of  the  interstitial  connective  tissue  of  woik- 
organs  (muscles,  nerves,   and  glands)  are  not  infiltrated,  but 
Itecome  so.  especially  if  the  activity  of  the  organ  and  the  con- 
lUent  afflux  of  arterial  blood  are  in  any  way  arresti-d.     In  obesity 
le  commonest  result  of  morbid  fatty  infiltration — the  subcuta- 
*»>s  and  subperitoneal  connective  tissue  suffers  earliest  and  most, 
iiiBltration  spreading  later  to  the  interstitial  connective  tissue 
l-org»n»  in  which  oxidation  is  still  active.     The  process  in  con- 
st! vi-  tissue  needs  no  description  beyond  that  just  given  and  illus- 
te*!  by  Figs.  7  an.l  0. 

Fatty  Infiltbation  op  Muscle. 

niuscle  fatty  infiltration  is  common  as  a  morbid  process.     The 
»i   tA/!  connective  titumt  which  surrounds  the  fasciculi  of  the 


eo 


KUTRTTTOIf  mPAIRED. 


{ 


muscle  becomi-  filknl  with  fat,  and  tbis  development  of  fat  fHrtwfiHt 
muscular  fasciculi  (Fi<;.  !•)  must  not  be  confounded  with  degcnei* 
tion  of  the  fibres  tliemselvcs.     Tlie  interstitial  fat  varies  iu  amount 
In  some  rases  single  rows  of  fat-cells  alternate  with  rows  uf  niw- 
cular  fasciculi ;  at  other  times  the  accumulation  is  less  refiular.  morr 
existing  between  some  fibres  than  between  others:  in  all  bnt  tht 
most  advanced  cases,  however,  the  mnscular  elements  luay.  under 
the  microscope,  be  discovered  lying  amongst  the  fat,  even  thongfa  to 
the  naked  eye  the  muscle  appears  to  be  entirely  converted  into  fat 
Ultimately  the  muscular  fibres  may  undergo  true  fatty  nict«mor|iho- 
eis  an<l  atrophy  until  they  completely  disappear. 

This  condition  is  fi-eijuent  in  animals  which  have  been  fattenctl, 
the  fat  not  only  increu-^iing  in  the  usual  situations,  but  also  accumu- 
lating between  the  fasciculi  of  the  muscles.  It  mav  also  occur  in 
muscles  which  from  any  cause  have  been  incapacitated  for  lutmt 
time,  and  in  which,  conseiitiently,  circulation  and  oxidation  arc 
reduce<l  to  a  minimum.  Thus  it  is  found  in  Ioug-st4tnding  paralyse 
from  lesions  of  the  brain  or  cord.  an<l  in  muscles  which  have  been 
rendered  u.^eless  by  ankylosis  of  a  joint.  In  progressive  muscular 
atrophy  anil  in  chronic  lead-[)oisoning  the  affected  muscles  exhibit 
this  change,  together  with  true  metamorphosis. 

Fatty  Inflltration  of  the  Heart. — This  is  not  infre(|Uftii  in  gen- 
eral obesity  an<l  after  pericanlitis  followed  by  adhesion  of  the  two 
contiguous  surfaces.  It  must  be  carefully  distinguished  from  th« 
much  graver  condition  of  fatty  degeneration.  In  health  thero  w  a 
varying  amount  of  fat  beneath  the  visceral  pericardium.  alMavs 
most  abundant  around  the  vessels  in  the  grooves  between  the  auri' 
cli'8  and  ventricles.  This  may  increa.se  so  as  to  cover  the  right 
ventricle,  but  the  left  is  rarely,  if  ever,  completely  en velopcnl;  at 
the  same  time,  the  fat  may  push  in  along  the  vessels  between  the 
muscular  fibres,  so  that  on  the  rigiit  side,  to  the  naked  eye.  all 
appearance  of  muscular  structure  may  be  lost,  the  walla  looking  liktf 
a  layer  of  fat.  |>erhaps  half  an  inch  thick.  In  hearts  leas  aflected 
■triffi  of  fat  will  be  seen  lying  amongst  the  muscle  (Fig.  9).  Tho 
lilt  is  always  most  abundant  near  the  surface,  the  muscular  struc* 
tun- b«'couung  more  evident  toward  the  endocardium:  at  the  base 
of  the  ventricles  thick  villous  processes  may  form. 

The  interstitial  fat  displaces  and  compresses  the  muscular  tibrea 
between  which  it  lies,  and  diminishes  the  blood-supply  and  conirac- 
tile  |)Ower  of  the  muscle    [lerhaps   ultimately   causing   tnii;   laRj 


FATTY  DEGENERATION. 


61 


metamorphosis  of  the  muscle  ([>.  73).  These  two  processes  not 
uncuinmnnly  go  hand  in  hand,  hut  it  is  difficult  to  s[)e!ik  dogmati- 
cally  as  to  which  in  vnxy  given  case  is  primary:  fatty  intiltration  is 


K:r;.  'I 


f—'^ 


.-o 


F»tty  InflUrnticin  of  heurt :  n  nwtlon  from  the  outer  part  of  the  left  ventricle,  ahnwlng 
ICTowth  of  fkt  I/)  drfiMrn  the  muscular  fibres.  In  some  pliiei's  (Utty  metnniorphimis  Is  eora- 
meDelng(d).     x  'J»a. 

probably  possible  only  as  the  functional  activity  of  the  heart  (or 
any  other)  muKcle  sinks,  and  the  continued  action  of  the  causos 
leading  to  this  depression  woidd  idtiniately  cause  degeneratiim  of 
the  fibres;  the  presence  of  interstitial  fat  must,  however,  tend  in 
the  same  direction.  Fatty  dcfrfneriition  and  atrophy  of  muscular 
fibres  on  the  other  hand,  is  very  likely  to  be  fidlowed  by  inter- 
stitial infiltration. 

Fatty  Infiltration  of  the  Liveh. 
CAUSES. — In  the  liver  fatty  infiltration  is  exceedingly  frequent, 
constituting  what  is  commnidy  known  as  the  "  fatty  liver."  This 
is  owing — first,  to  the  excess  of  non-nitro;;ennii3  oxidizalde  matter 
in  the  portal  blood :  secondly,  to  the  deoxidized  condition  of  the 
jMirtal  blood;  and  thirdly,  t"  the  low  pressure  and  slowness  of  cir- 
culation in  the  portal  vessels — conditions  least  favorable  to  oxida- 
tion and  most  favorable  to  deposition  of  particles.     An  accumula- 


62 


KUTRITIOX  IMPAIRED. 


tion  of  fat  in  the  liver  thus  occurs  uixler  two  opposite  con«Iitions — 
one  in  which  there  is  general  obcgiti/.  and  the  fat  nccmiiuhtt*.-;)  in  t 
liver  in  coiuiuon  with  other  futrts;  the  other,  in  wliich  there 
r/ffit'nil  emnrintion,  an<l  a  consequent  iiupninncnt  of  the  nxyjr" 
Hating  power  of  the  blood.  The  liver  in  ])hthisis  is  an  example 
the  Bccond  of  these  conditions,  though  in  this  cnse  the  dcfcrt  in  tb 
O.X  vpenating  power  of  the  blood  is  increased  bv  the  dcstnietion 
the  lung  tissue. 

Pbyaiolosrical  Infiltration. — The  liver-cells  always  contain 
small  i|uuntity  of  fat,  which  is  tcinfMtrarilj  increased  a(\er  tla 
ingestion  of  fatty  sub.stances.  Ingot<tion  of  food  rich  in  fat 
followed  by  a  temporary  excess  of  fat  in  the  portal  blood,  and  ha 
the  conse<|iu'nt  deposition  and  temporary  accumulation  of  part( 
this  in  the  livcr-cell.x.  Thi.s  fat  is  first  de|K>sited  in  the  rin-umfi 
ential  r.tlh  of  the  lobules :  that  is,  in  those  which  are  in  immediifl 
contact  with  the  capillaries  nf  the  portal  vein,  From  these  it  p 
ually  passes  to  the  central  cells,  whence  it  is  ultimately  conveyi 
again  into  the  circulation.  This  process  goes  on  until  the  exoeai 
of  fat  is  removed  from  the  blood  and  the  cells  regain  their  form* 
character.  There  is  thus  a  transitory  accuiuulatiou  of  fat  with* 
the  liver-cells,  but  the  vitality  of  the  cells  is  not  iui]iaired  therebV 


APPEARANCES.—!.  Microscopic— The  morbidly  fatty  Ii%'' 
isonewliicli  constantly  contains  an  abnoruial  ({uuntit}-  of  fat,  s* 
here  also,  as  the  fat  is  usually  dejwsited  from  the  blood  in  the  por^ 
capillaries,  the  increa.se  is  first  observable  in  the  external  /one  * 
the  hepatic  loliules  (F'ig.  10).  It  accumulates  here  within  the  ec  J 
ns  minute  globules  which  increase,  coalesce,  and  form  large  dro] 
of  fat-  The.Hc  ultimately  distend  the  cells,  which  become  larger  ari 
more  globular  (Fig.  >^).  As  the  process  advances  the  iufiltrati<ii 
spreads  from  the  periphery  toward  the  centre  of  the  lobule,  unf- 
its whole  mass  may  be  involrol  and  all  its  cells  di.stended  with  fal 
The  vitality  of  the  cells  is  not  materially  impaired  by  the  infiltra 
lion,  as  is  shown  by  the  presence  of  bile  in  the  stools  and  in  th 
gall-bladfler.  lu  some  exceptional  cases  the  accumulation  of  fal  i 
most  nuirkfil  iiroiirnl  the  intni-lobular  veins.  In  these  Virchm 
suggests  that  the  fat  is  becoming  excreted,  anil  that  onh'  the  Im 
cells  retain  a  little  of  it.  In  extreme  cases,  such  as  sometiiac 
occur  in  persons  dying  uf  cancer  or  phthisis,  a  section  of  the  liv« 


4 


FATTY  DEaENERATTON. 


63 


may  look  exactly  like  ordinary  adipose  tissue,  being  distinguishafde 
from  it  only  by  a  faiut  afipearance  ut'  a  radiating  structure  here  and 


Fio.  10. 


,^--*  1^.>_'^^'X"-,9 


'***7  Uvor. showing ■ccumulalion  of  f»l,  miiri-  usiii'ilally  In  thr  cells  of  the  cxJcmal  «one 
!*"***«  lobule.    TliC'iv  is  al»u  some  Incrcasu  lu  the  iuter-lobulur  uonnectlve  Itnue  (cirrbimti)): 
•  "CfMiUc  vein;  *,  Intcr-lobuUr  connective  tliwue.    x  50. 

*^»*«  or  an  occasional  section  through  the  portal  canal  and  its  con- 
[taitted  vessels. 

2.  Naked  Eye. — The  fatty  liver  is  increased  in  size,  in  advanced 
stages  to  perhaps  twice  the  uormal.     The  surface  is  smooth,  the 
*''6es  are    thickened    and    ruuiulfd,    nnd    tlie    si)ecific    gravity    is 
***Ujinigliyj^  80  tliat  detiiclied  portions  may  float  in  water,  aitiiough 
^"*  absolute  weight  uf  the  whole  organ  may  be  increased.     If  the 
•ufiltrntion    be    slight,    involving    merely   the    portal    zone    of    the 
'""ules,   the   cut   surface    will    present   a   mottled    appearance,    the 
txtepnal  fatty  zone  being  opa(jiie  yellowi.sh-whitc,   whilst  the  cen- 
tre ig  unaltered  or  is  hyperiemic  and  appears  as  a  red  spot  {fattif 
mitjiug  liver).     The  more  extensive  the  infihrution,   the  larger  is 
tbt  pall-  zone,  and   ultimately,  when   the  whole  lolmie  is  involved, 
tbfre  is  left  in  the  centre  only  a  reddish-brown  point  marking  the 
posiliou  of  the  intra-Iobuhir  vein  ;   in  many  cases  even  this   point  is 
loul     Then  the  organ   is  of  an  almost   unifurra  opaijiie   yellowish- 
tiliite  color,  and  the  boundary  between  the  individual  lobules  may 


64 


NUTRITION  IMPAIRED. 


be  coiDfiletely  obscured.  In  excciitiMiuil  cases  the  »ccumiilnti<in  of 
fat  is  uiucb  more  fibimdaut  in  some  ji'irtions  of  the  liver  than  in 
others,  so  that  on  section  yellowish  points  and  streaks  are  seen  scat- 
tered over  its  siirfiice.  The  cousistence  of  the  organ  is  luiicb  dimin- 
ished, it  feels  doughy,  and  pits  on  pressure  with  the  finger,  and  the 
knife  used  to  cut  it  becomes  coated  with  oil.  The  pressure  exercised 
by  the  infiltrated  fat  j>roducos  eonsidenible  anaemia  of  the  organ,  but 
the  interference  with  the  circulation  is  mi'tr  miffirient  to  cause  atcitfi, 
hemorrhage,  ur  other  evidenreH  of  jjurtnl  coniffstion. 

FATTY  METAMORPHOSIS. 

This  differs  from  fatty  infiltration,  inasmuch  as  the  fat  is  formed 
not  from  the  fatty,  saccharine,  or  nitrogenous  principles  of  the  food, 
but  by  metamorphosis  of  the   protoplasm   of  the   cells  tliemselvcii. 
There  is  reason  to  believe  that  cell-pmtojihisiu.  as  it  becomes  efFetc. 
takes  up  oxygen  and  sjilits  into  a  nitrogenous  roolecnie,  which  is 
tlie   first   stage   in    the    foritiatiuii    of  urea    and  a  n<>n-nitrogeniiu« 
nudecide  which  forms  fat.      To  repair  its  loss,  the  living  protoplnsiu 
at  the  same  time  assimilates  material  if  lias  ])repared  from  the  pro- 
teiils  of  the  fund.      In  the  process  of  hcaltliy  nutrition  ilestructioo 
of  small  ijuantities  of  protoplasm  and  corresponding  reptur  are  cod- 
stautly  going  on,  and  the  products  of  the  decompositinn  of  effete 
albumin  are  still   furtlicr  oxidized,  rendered  soluble,   and   then  At 
once  removed.      Cijnse(|uentlY,  we  do  not  find  in   healthy  cells  fat- 
granules  bearing  witness  to  the  occurrence  of  the  above-described 
decomposition.     When,  however,  a  whole  cell  or  many  cells  die  and 
are  protected  from   ferments,   evidence  of  fatty  luetamorphosia  of 
protoplasm  is  soon   forthcoming.      This   we  can    watch    in    various 
])hysio!ogical  processes — e.  g.  the  formation   of  colostrum,  sebum. 
and  cerumen.      In  all  of  these  the  fatty  degeneration,  death,  cast- 
ing off,  and  disintegration  of  superficial  cells,  and  the  constant  pro- 
duction of  new  ones  in  the  deeper  layers,  play  a  chief  part.     Evi- 
dence of  the  same  process  is  seen  in  the  fatty  degeneration  nf  the 
musctdar  fibres  of  the  uterus  undergoing  involution.      It  was  for- 
merly suppose<l  that  the  transformation  of  entire  bodies  which  have 
lain  for  many  weeks  or  months  in  water  or  ilamp  soil  into  adipoctrt 
(an  ammonia  or  a  lime  soap)  wa.s  an  illustration  of  the  same  proccco, 
but  the  change  is  now  known  to  be  due  to  organisms. 

It  is  now  universally  recognized  that  the  fat  seen  in  the  musciilM* 
fibres  in  fatty  metamor]iho8i3  is  the  result  of  a  change  in  the  fibres 


FATTY  METAMORPHOSIS. 

lemselves,  and  ia  not  derived  from  without.     The  experiments  of 
Bauer  prove  this,     Those  experiments  were  made  to  de- 
lermiiK'  the  source  of  the  fjil  in  the  aeute  fiitty  degeneration  pro- 
duced by  poisoning  with  phosphorus.    Dogs  were  starved  for  twelve 
days,  so  that  all  availahle  fat,  whetlier  in  the  tissues  or  in  the  food, 
"li^lit  be  exhausted.     At  this  period  the  daily  excretion  of  nitrogen 
(uron)  »veraged  eight  grammes.     Small  doses  of  phosphorus  were 
thetx  given.     The  average  daily  excretion  of  nitrogen  at  once  rose 
to  t'wenty-four  grammes,  while  the  amount  of  oxygen  taken  up  ami 
"f  carbon  dioxide  given  off  was  greatly  diminished.     The  animals 
were  then  killed,  and  large  quantities  of  fat  were  found  throughout 
tlie    l(ody.     The  increase  in  the  excretion  of  urea  showed  that  the 
|de!*t  mction  of  proteids  was  also  increa.sed  ;  and  the  presence  of  the 
|1'U'J5«  i}uantities  of  fat  found  itftiT  dvnth  made  it  highly  probable 
rtbai^   it  had  been  formed  as  part  of  the  general  pmteid  destruction. 
In     other  words,  the  phosphorus  produced  very  extensive  ami  gen- 
era. 1    fatty  degeneration,  and  the  fat  must,  have  arisen  from  the  pro- 
tf{*f<j»tn  of  th<'  cell*.    Voit  concluded  from  these  investigations — 1st. 
Tha*.t  the  transformation    of    cell-albumin    is    independent    of   the 
*up»j3ly  of  oxygen,   but   that  if  oxygen   be  deficient  the  fet  and 
otl»cir  products  of  the  transformation,  being  incompletely  oxidize<l. 
*ct5»-»mulate  in  the  cell.     2d.   That  the  presence  of  fat  in  the  cells 
™*^^^  thus  be  due  to  increased  tran.sformation  of  the  albumin  or  to 
<lii«a  inished  oxidation  of  the  products  of  its  decomposition.      3d. 
T»»«.t  the   fatty  degeneration    in    poi.sivning  by   phosphorus   is   due 
''"*l»  to   an   increased  transformation   of   the  albumin   of  the  cells 
"•^i   to  diminished  oxidation  of  the  fat  and  other  products  of  the 
''^•lasformation. 
L     Stolnikow  and  Gaide  have  recently  published  experiments  which 
to  show,  as  Cohnheim  suggested,  that  fat  can  be  produced  by 
"^     ilecomposition  of  lecithin,  the  phosphuretted  fat  of  the  nervous 
'.^**tvm  and   a  constituent   of  many  other  ti.ssues.     According  to 
">ose  observers,  glycero-phospLoric  acid,  stearic  acid,  and   cholin 
"•s    formed  in  the  process. 


OaUSES. — A  study  of  various  examples  of  fatty  metamorphosis 

i'«*»iOer8  it  clear  that  the  occurrence  of  this  change  indicates  the 

|^*^*^-ay  of  the  protoplasm  concerned ;  that  the  larger  the  proportion 

^    the  cell-albumin  replaced  by  fat  the  nearer  is  the  whole  cell  to 

^^^h ;  and  that  the  nearer  the  cell  is  to  death  the  more  impaired 


66 


JfUTRlTlOy  IJII'AIRI 


- 


will  be  its  power  of  taking  up  oxygen  and  coubiniDg  it  witli  cBfi 
materials.     Con8ei|iiontl_v,  we   may  give  tbe  riinse  of  fattv  mctai 
tuorphosis  as  grave  depresiiioii  nf  thr  rilal  actiritif  of  a  cell — loadin 
to  (1)  too  rapid  destruction  of  protoplasm,  (2)  lesaeninl  sbilitv  ra 
repair  louses,  and  (3)  im[>aired    oxidizing  p«.)wcr.     Tbi.>«  depre«M>4 
vitality  is  always  the  prorimati'  rainif,  an<l  is  iisiinllv  indacetl  b 
(a)  alteration  in  the  iiuantity  and  (|uiiiity  of  tbe  food  brought  t 
tbe  cell:  or  (/»)  by  change  in  tbe  physical  contlition  of  tbe  cell 
((•)  by  the  gradual   but   natural    death  of  tbe  cell,   for  there  u 
natural  limit  to  the  life  of  a  single  cell,  as  there  is  to  tbe  life 
the  whole  organism. 

a.  The   effect    of  diminisbing    the    blood-supply  (•'.  e.   food  la 
oxygen)  to  a  part  is  seen  in  the  fatty  degeneration  of  the  hearCQ 
walls  whicb  follows  atheromatous  changes  in  the  coronarr  arterice 
t»  well  as  in  organs  in  which  the  lumen  of  tbe  vessels  is  diminishc« 
by  lardaceous  or  sy]>bilitic  changes.     Working  organs  and  titisoa 
which  have  been    long  disused,  and   to  whicb,  consequently,  tk' 
blnoil-supply   is    diminished,    undergo    fatty  changes    anil    atniphj 
until   they  become  so  small   that   the  blood-supply   is  sufficieut  t- 
maintain  the  nutritive  ei]uilibrium.     Impaired  circulation  in  a  pir~l 
— e.  g,  mechanical  congestion — has  a  similar  effect.      Fatty  dcjci»H 
eration  of  the  cells  of  cancers  and  other  rapidly-growing  tu; 
and  of  inflammatory  exudations  is  oft<>n  due  to  insufficient  b1 
aapply :  but  the  cells  may  be  naturally  sbort-liveil,  and  in  inflm 
mation  the  cause  of  the  process  must  have  an  injurious  action 
the  leucocytes  as  well  as  upon  the  fixed  cells.     These  variatioi 
the  (fuantity  of  the  blood-supply  act  locally  (p.  77).     Alteratioi 
the  ijuiillty  of  the  blood-supply  act  gciirrally,  and  all  colls  are 
liable    to    be    affected.     Thus,    fatty    metamorphosis    of    the   iu<»*' 
important  organs  may  result  from  various  forms  of  anaemia,  fro* 
scurvy,  and  from  the  addition  to  the  blo<id  of  a  protoplasmic  p**' 
son,  like  phosphorus,  arsenic,  or  antimony.     Poisoning  by  cu{r*^ 
monoxide  has  a  similar  effect,  due  to  the  power  this  g«ii  poiuMja^' 
of  combining  with  oxygen  and  thus  preventing  the  oxygen  firt^ 
nijcbing  tbe  ti.ssues.     It  is  sometimes  maintained  that  the  presett  ^ 
nf  an  excess  of  carbon  dioxide  is  a  more  important  fact4)r  in  t^^ 
prudnction  of  fatty  changes  than  any  deficiency  in  the  supply  (^ 
oxygen. 

h.  The  action  of  fever  as  a  cause  of  fatty  metamorphosis  depeotd 
pftrtly  on  the  action  of  a  high  temperature  on  protoplasm;  but  tltf 


FATTY  METAMORPHOSIS. 


«7 


iuses  of  the  specific  fevers  and  other  circumstances  probably  give 

rise    t<i  blouil-i-han^es   which   act    in   the  same   direction.     A   high 

External  temperature  tends  to  diminish  oxidation.     (See  "Fever.") 

e.  When  the  limit  of  life  of  a  cell  is  approached,  it  undergoes 

ttty  degeneration;  thus  wo  account  for  xemfe  fatty  nietamorpbosis 
)f  tht*  cells  of  cartilage,  cornea,  bone,  and  other  parts.  Under  this 
[leading  may  be  included  the  fatty  degeneration  of  nerves  which 
Kdlows  interruption  of  their  connection  with  their  corresponding 

fWs.  Such  degeneration  seeni.s  to  be  the  direct  result  of  the  loss 
l>f  the  normal  physiological  stimulus  (Fig.  41,  p.  12.")). 


A  PPEARANCES. — 1.  Microscopic. — The   process   consists   in 

the    tran^ifiirmation   of  the  proto|)la.sni  of  ceils  into   molt'cubir  fat, 

rbich   appears  as  minute  granules,  first  of  all  in  the  protoplasm, 

»nd  later  on  in  the  nucleus.     The  granules — characterized  by  their 

tmall  size,  sharp  contour,  strong  refractive  power,  staining  reaction 

(black  with  osmic  acid),  insolubility  in  acetic  acid,  and  solubility  in 

etlicT — gradually   increase  in   number  till    the  whole  of  the  proto- 

iplaiSTn  may   be  transformed;  some  of  theiu  may  coalesce  and  form 

•'"'■tinct   drops  of  fat.      As  the  process  advances  the  cells  umlergo 

*"    increase  in  size  and  become  more  globular  in  shape,  the  nucleus 

''•'*^«^»Dn«  involved,  the  cell-wall,  when  this  exists,  is  destroyed,  and 

''*^    cell  may  thus  be  converted  into  a  mass  of  fat-granules,  known 

"     «»  granule-cell  (Fig.  11). 

^^ranule-cellB  may  be  of  two  kinds:  (1)  dend  or  dying  cells  con- 

^]|^''*"t.i'il  into  ma.xst's  of  c<dieriiig  fat-granules,  or  (2)  living  leucocytes 

f*~f*nule-rinrif!rg)  which  have  taken  up  fat-granules  from  a  focus  of 

'J^t'tierafion,  probably    to    convey 

-141  into  the  lymphatics  and  thus 

'"Bet  ab.sorption.      Connective-tis- 

*«<i     and   neuroglia-cells   near    foci 

*'      degeneration    similarly   become 

Nutirjrwl  with   fat-granules,      (iran- 

]lle-<!tl|8  are  often  called  "  influni- 

a»aiory"  eorpiisi-le.'H  or  "  corpuscles 

[**•    Ciluge."     .\mong  typical  gran- 

I         I  ^  I"  %,     t  Cr  t'lllIlK-        I'll-'     llllltTMlI}' 

I'ule-celU.  formed  by  metamorphosis     nU'-ccUs,"  «mi  »t«ii  iii.>  mannur  in  which 
"   ®liilhelial  cells  or  leucocytes,  are 
"^   "c<ilosirum"-cor|)uscle8  of  the  first  milk  secreted,  but  later  on 


i^ 


Fio.  M. 


# 


FMtty  im'l»mon>hoiil«  of  i'i>ll»:  o,  from  ■ 
caiiirr :  b.  fniiii  the  liraiii  hi  rhroiilc  ioft- 
eniiii;     The  liitUTKhow  the  larcc  "Bmii- 


Ch 


•*  process  becomes  one  of  true  secretion,  and  the  resemblance  ceases. 


68 


NUTRITION  n 


I'ltiiniitcly  fatty  degeneration  may  affect  connective-tissue  fibres. 

In  old  foci  of  fatty  degeneration  slieaf-like  bundles  of  acicular 
crystals  of  margaric  acid  and  rbuuibic  crystals  of  choiestcrin  are 
found. 

It  is  said  tliat  in  fatty  metainorjiliosis  tbc  percentage  of  fat  in  tlic 
tissue  is  but  little  incfcased,  tliuugh  this  is  disputed  by  Krehl:' 
apparently  many  of  tbc  granules  are  formed  by  the  invisible  f«t 
wliicli  is  noiunilly  bniiiid  up  with  protoplasm,  as  it  were  in  «n 
"aniiilgam"  (p.  1.^)  (Birch-Hirscbfeld). 

2.  Naked  Bye. — In  advanced  stages  fatty  metamorphosis  pnv 
duces  defiuitu  naked-eye  ajipenrances.  Those  are — (1)  slight  or 
modcriite  swelling,  which,  however,  is  often  replace<l  liy  mort'  or 
less  shrinking  of  the  organ  when  absorption  of  the  fat  is  going 
on,  as  in  advanced  acute  atrophy  of  the  liver;  (2)  admixture  of  »d 
opatiue  yellow  color  with  the  normal  tint  of  the  ti.ssue,  often  in  the 
form  of  patches,  spots,  or  streaks,  as  extreme  degrees  of  the  change 
are  usually  reached  only  in  limited  area.'^ :  and  (3)  loss  of  elasticitr 
with  diminisheil  consistence,  the  organ  being  flabby  and  friable  ami 
its  capsule  wrinkling  easily.  Fat  may  be  foinid  upon  the  kiiifis 
and  the  nortnal  ilistinctness  of  structure  (upon  section)  is  obscurM. 

The  mieroscojie  is  necessary  in  the  diagnosiB  of  the  earlier  st.n2«** 
of  this   metamorphosis.     It    reveals    the   gninular   and   somewhat- 
swollen  state  of  the  cells.     The  larger  size,  higher  refractive  powf. 
insolubility   in  acetic  acid,  solubility  in  ether,  and  blackening  ^X 
osniic  acid  distinguish  the  fatty  gniniiles  from  the  albuminous  gr»** 
ules  of  "cloudy  swelling"  soon  to  be  described.     When   possil*!^* 
the  distinction  from  fatty  infiltration  must  also  be  made.     Difficalty 
in  this  arises  with  regard  to  coimeetive-tissue  cells,  liver-cells,  bTi*' 
intestinal  ejiitlielium,  in  whicli   both   intiltratiou  and  me(aiiiorpb«»*** 
may  occur;  perhaps  also  the  usual  epithelium  may  contain  infil- 
triited   fat   when   this   is  being  eliuiinated   after  severe  contusions. 
The  cliief  point  of  difference  between  the  two  processes  is  the  siie 
of  the  droplets,  which  are  small   in  the  metamorphosis,  but   tub 
readily  together  in  the  infiltnition.     This  holds  good  as  a  rule,  hit 
infiltrated  fat  e.vists  in  small   droplets  at  first,  and  becomes  fint'/y 
divided  before  absorption,  should  this  occur;  on  the  other  haini. 
<brm  in  fatty  metamorphosis.  an<l  are  characforisdi- 
rule  atrophv   ancl    ])hosphoriis-poi.«ioning,  anil  in 
len  the  metamorphosis  is  at  all  advauced.    I'i»g- 
whl,  DniUth.  Areklv  /.  Uin.  Med.,  Bd.  It 


FATTT  METAMORPffOSrS. 


69 


lis  may.  therefore,  occasionally  be  impossible.     Evidence  of  de- 
ruction  of  cells  is  conclusive  in  favor  of  metamorphosis. 


IITERMINATIONS. — 1.  Absorption. — The  fatty  particles  into 
licb  the  cells  have  been  transfoniu'<l  arc,  under  favorable  circum- 
inccs.  readily  absorbed.  The  ik'generative  process  may  cea.se 
itl  the  fat  be  removed  before  the  part  has  been  dangerously 
Irolved.  Such  recovery  probably  often  occurs,  for  example,  in 
e  kidneys  and  heart.  Also  when  elements  are  completely  degen- 
kted  the  fatty  dt'bris  is  usually  removed  by  absorptitni.  This  is 
»n  in  the  fatty  degeneration  and  absorption  of  inflammatory  prod- 
Is,  such  as  occur  in  t;rou|H)us  pneunioniii:  iu  the  degeneration 
d  absorption  of  the  cells  of  new  growths,  leading  to  central 
Juppiug""  or  •'  unibiliciition"  of  nodules  or  to  shrinking  of  the 
lole  nmsi*  (atro[)hic  scirrhiis);   mid   in   tlie  degeneration  of  small 

Rsuch  as  results  from  embolism,  thrombosis,  or  hemorrhage 
brain  or  other  organ.  As  the  restilt  of  such  absorption  we 
..  jave  loft  a  mesh  work  of  vessels  and  connective  tissue  whence 
'  os^ential  cells  have  disappeared,  as  in  the  later  (red)  stage  of 
*t«  yellow  atrophy,  or  we  may  have  an  ordinary  scar  from  the 
^'•loproent  of  fibrous  tissue ;  or,  lastly,  a  cyst  of  dear  fluid  may 
^ain.  For  absorption  to  occur  the  tissues  roiinil  the  degenerated 
■  «  mu.«t  be  freely  su|)plied  with  blood. 

8,  Caseation. — In  this  mode  of  termination  the  fatty  products 
not  absorbed,  but  are  gradually  converted  into  a  yellowish 
ble  material  which  has  been  compared  to  soft  cheese.  It  is 
k.erally  said  to  result  from  disproportion  between  the  degenerated 
38  ami  the  vessels  by  which  absorption  might  be  effected — a  <lis- 
portion  which  is,  in  the  first  instance,  the  principal  cause  of  the 
;eueratton.  It  is  most  fre(|uent,  therefore,  in  parts  which  con- 
3  but  few  vessels  or  in  which  the  vessels  become  obliterated  by 
^««iire  from  without  or  by  thickening  of  their  walls  by  endar- 
tis.  Caseation  is.  conse(|uently.  most  often  met  with  in  tuber- 
ir  and  gummatous  masses  and  in  rapidly-growing  cancers  and 
-'omata. 

t-'lieesy  niassea  are  constantly  met  with  in  the  lymphatic  glands, 
k  brain,  the  bones,  and  especially  in  the  lungs.  Considerable  con- 
>5on  has  arisen  as  to  their  nature  and  origin.  Formerly  all  cheesy 
*»e9  were  regarded  as  essentially  tubercular,  and  it  is  true  that 
>ercular  lesions  have  a  greater  tendency  than  any  others  to  case- 


SUTRITION  IMPAIRED. 


ate  fully  nn<l  to  form  tyjncal  cheesy  collections.    (See  "  Tubcrculi> 
sis.")     Bat,  ns  just  stated,  other  formations  may  under^jo  a  change 
which  is  practically  imlistin^uishable:  so  caseation  cannot  be  re- 
garded as  proving  more  than  the  occurrence  of  fatty  degeneration- 
A  caseous  mass  is  tubercular  only  when  it  is  due  to  the  presence  of 
the  bacillus  tuberculosis.     Still,  it  is  doubtful  if  fatty  defeneration 
of  a  gumma  or  of  a  rapidly-growing  tumor  ever  give*  rise  to  ^ 
typical  "  caseous  "  mass,  such  as  we  often  fin<l  a.1  the  result  of  tuber — 
cular  inflammation,  and  it  has  yet  to  be  shown  that  caseation  caim 
occur  apart  from  the  action  of  some  niicro-orgnnism. 

The  process  consists  in  a  grailual  drying  up  of  the  degrncmtecS^ 
I  elements  ;  the  fluids  are  absorbed,  the  cells — which  are  many  oP 
'them  incompletely  degetieriited — shrivel  and  atropliy.  the  fiit  utidiT — 
goes  partial  saftouification,  cholesterin  forms,  and  the  tissue  ihu^ 
becomes  converted  into  a  soft,  yellowish-white  cheesy  suhstaure.. 
compose<l  of  atrophied  cells,  fntty  d«?bris,  and  cholesterin  cryst«l*- 
The  cheeey  material  may  gradually  dry  up  more  and  more.  txoM. 
ultimately  become  encapsuled  by  a  layer  of  fibrous  tissue,  ntufl 
even  calcified.  In  other  cases  it  may  undergo  a  process  of  sof^eniu^ 
and  lii|uefaction. 

8.  Calcification. — This  is  an  advanced  stage  of  the  preceding 
process.  It  most  frei|uently  occurs  when  the  caseous  mass  is  com- 
pletely shut  off  from  the  external  air.  as  in  lym|>hatic  glands  tnd 
bone,  or  when  encapsuled  in  the  lungs.  The  mass  becomes  infil^ 
trateil  with  ealcnreotis  particles,  and  is  thus  converted  into  a  calct- 
reotis  concretion.  Single  cells  in  a  fatty  focus  may  undergo  tlii* 
infiltration — p.  g.  ganglion-cells  in  an  area  of  cerebral  .Hufteninfr. 

4.  Softening. — An  inHammiitory  cell-exudatioti.  usually  nf  tuber- 
cular origin,  may  undergo  fatty  metamorphosis,  and,  as  it*  ci-lU 
break  up  into  granules,  sufficient  food  is  often  effused  to  form  a 
thin  purifonn  liquid,  usually  containing  curd-like  cheesy  mB*se«; 
this  looks  like  pus.  but  really  consists  of  granules.  fat-<ir(>ps,  and 
perhaps  cholesterin  crystals  suspended  in  fluiil  ("  pathological  milk  "\. 
This  is  the  pathology  of  chronic  abscess  of  tubercular  origin.  If 
nut  diicbnrge<l.  the  fluid  may  be  absorbed,  leaving  a  caseous  mu^ 
which  may  calcify. 

Sometimes,  after  long  (juiescence,  caseous  and  even  calcified 
masses  iifi|><-itr  to  excite  sufficient  nutrition  to  result  in  the  forraa- 
tion  of  an  abscess  and  in  the  discharge  of  the  ui!i.s.s.  Tin-  nat 
of  the  fresh  irritant  is  unknown. 


PATTY  DEOEyERATTOJT  OP  BLOOD-VESSELS. 


71 


I 


I 


The  effect  of  fatty  mctainor|ihosis  is  to  iinjiair  or  arrest  function. 
Recovery  is  only  possible  in  the  earlier  stages. 

Pattt  Degeneration  of  Blood-vessels. 

f  rimary  fatty  degeneration  of  blood-vessels  is  in  most  cases  a 
serxilc  change;  it  is  an  expression  of  that  general  iin|iairuient  of 
vits«.lity  which  exists  in  advanceil  life,  and  is  usually  asssociated 
witFi  similar  changes  in  other  parts.  There  is,  however,  a  variety 
liin  i  ted  to  the  lining  meinbraue  of  the  largest  arteries  :  this  is  often 
me-'t  with  in  early  life  and  in  persons  who  are  otherwise  perfectly 
hi's«.  1  thy. 

Jt'-fttty  Degreneration  of  Arteries. — This  may  hv  primary,  or 
8e<2<Dndary  to  atlieronia  or  r)tlier  intlauiuiatory  condition  of  the  ves- 
wle*^  the  fatty  change  being  preceded  by  cell-infiltration  of  the  sub- 
end  othelial  connective  tissue.    (See  "  Athcnmia.") 

-fc- *rimary  fatty  degeneration  is  not  preceded  by  any  disease  of  the 
par-**  affected  by  it.  It  may  affect  any  or  all  of  the  coats  of  the 
•n^sry,  but  is  most  commonly  met  with  in  the  intima.  The  change 
"'ViaJilly  commences  in  the  endothelium  and  the  subendothelial  eon- 
"ccr-tive-tissue  cells,  small  groups  of  cells  becoming  affected  in  va- 
"OVJ8  parts  of  the  vessel:  and  it  may  gradually  extend  from  within 
OD'txrard,  the  intercellular  substance  softening,  until,  in  exceptional 
<^»«3s,  the  whole  thickness  of  the  intima  is  destroyed  (Fig.  12). 

L  n  the  earlier  stages  this  condition  is  recognized  by  the  existence 
of  ^mall.  irregidar.  opaipie.  yellow  i.sh-w bite  patches  projecting  very 
sli^litly  above  the  surface  of  the  iutima.  These,  which  are  so  con- 
*'««'»»tly  met  with  on  the  lining 
'»«-*  1  nhraue  of  the  aorta,  may  at 
first  be  mistaken  for  atheroma. 
Ttx^yare  in  most  cases,  however, 
Tf««.*lily  distinguishable  by  their 
«««T*^crficiality,  ami  by  the  facility 
*'»tli  which  they  can  be  stripped  <s 
on      from    the   subjacent    lavers, 

»  .   ,  '  ■  Fattv  (Icgi'neriit ion  "f  llu'  iiilirniil  inni  nf 

■*o>cti  present  a  natural  aj)fiear-  the  aoru:   Kmiiu  yi'iiowish-whUo  p.it(iu-« 

»ttCC.     In  atheroma,  on  tiie  other    v^-»catlvrvd  ..vir  Ilu-  UninK  mornhmni- ..r 

thp  vennel.    A  »'ery  Ihiti  Inycr  wiw  iweleil  nIT. 

bWil — which   affects  the  deeper  Tho (m>iii»i or ratmniiTiiiM »ti<i tin- iiinirihu- 
^tractiirt"*— if     the      superficial   «'">'•' i"!  m  the  i.uinm  «r..  ,ho«n.  x  m 

hyer  be   removed,   the  opacity  anil   thickening  are  seen  to  exist 
tienfiith  it.     In  many  cases  the  change  is  limited  entirely  to  the 


Fio.  12. 


72 


NUTRITION  IMPAl 


innermost  layers  of  the  vessel.  Tlie  more  the  subjacent  tissues  i»r« 
involved,  the  greater  is  t-lie  irreijithiritv  in  the  shape  of  the  putchct, 
anil  the  less  readily  can  they  be  separated  ■with  the  forceps. 

The  opai|ne  patches  occasionally  break  down.  For  this  to  happen, 
the  cells  must  beconie  destroyed  by  the  fatty  change,  and  the  inter- 
cellular substance  softened.  The  f2;ranidar  dc'bris  thus  formed  in 
carried  away  by  the  circulation,  leaving  small,  irregular.  8uperfici«l 
erosions  upon  the  lining  nienibrane  of  the  vessel.  These  erosions 
are  not  iilri-r»  in  the  true  sense  of  that  term,  not  being  the  result 
of  an  inflammatory  process.  They  resemble  the  superficial  ero- 
sions so  common  upon  the  mucous  membrane  of  the  stomach. 

Simple  fatty  degeneration  may  occur  in  any  artery,  but  in  the 
smaller  ones  it  is  especially  liable  to  affect  the  e.Kternal  coat  (Fig. 
18),  and  in  this  situation  its  injurious  inHuence  is  most  marked. 
Here,  by  diminishing  the  elasticity  and  contractility  of  the  vessels, 
it  causes  degi'tuTative  changes  in  tlie  parts  whicii  they  supply,  and 
often  leads  ti>  rupture.  This  is  exemplified  by  many  cases  of 
chronic  cerebral  softening  and  cerebral  hciuorrhage.  although  in 
such  instances  atliei'oniatous  are  generally  associateil  with  the 
simple  fatty  changes.     In  the  larger  arteries,  as  the  aorta — where 

it  is  exceedingly  common — it  is  of 
less  importance;  the  more  e.xtCD- 
sive  jirocess,  atheroma,  has  a  far 
more  ileleterious  effect. 

Fatty  Degeneration  of  Capil- 
larieB. — Fiitty  changes  arc  also 
fouml  in  the  capillaries,  especially 
in  tlie  nervous  centres  and  the 
kidneys,  in  Bright's  disease  (Fig. 
13,  b).      The    process    commences 

F«tty  defioncmtlon  of  •mull  vi-wrln  uf      .  i      i     i-    i         ii  i 

pin m«ier  (from  a r«i* ..r chronir  nriKhtfi    ""  the  endotliehal   cells,   and   may 
.ii»(»«-) :  «,  iininii  .rtfo'.  "'f  onMia  ..f    involve   considerable   areas  of  the 

which    ore    nonu'Whnl    Ihlrlieiicil;    h,   h 

implUnry.  In  whleh  an  siin  h  fiw  r>d     Capillary    Wall,    80    that    ruptUre   IS 

WoodHarpuwie..   y  «oo.  ^^f^^j^  ^^^  ultimate  result.     Thi.*  is 

common  in  the  smallest   cerebral  blood-vessels,  where  it  is  8ome> 
times  a  cause  of  cerebral  (ca[)ilhiry)  hemnrrhage. 

Fatty  Deobnbbation  of  Muscuj. 

Both  striated  and  non-striated  muscle  may  be  the  sent  of  fntty 
degeneration.      In  both  the  iiiusculur  fibre-cells  are  the  seat  of  the 


Fio.  13. 


FATTY  DEOENEBATrON  OF  THE  HEART.  73 

change;  they  become  filled  with  fat-granules,  and  are  ultimately 
destroyed :  the  process  thus  differs  essentially  from  fatty  mflltra- 
tion  (p.  59). 

Non-striated  Muscle. — Fatty  metamorphosis  is  frequently  met 
with  in  the  middle  coat  of  arteries  undergoing  fatty  degeneration 
and  in  the  muscular  fibres  of  a  uterus  in  process  of  involution. 

Striated  Muscle. — Both  the  voluntary  muscles  and  the  walls  of 
the  heart  show  identical  changes.  The  earliest  stage  of  the  affec- 
tion is  characterized  by  an  indistinctness  in  the  transverse  mark- 
ings of  the  fibres,  which  in  many  parts  become  studded  with  minute 
particles  of  fat  (Fig.  14).  These  gradually  increase  in  number  and 
size,  but  almost  always  remain  small,  and  are  usually  distributed 
somewhat  irregularly  within  the  sarcolemma.  In  some  parts  single 
or  parallel  rows  of  granules  are  found  running  along  the  length  of 
the  fibre ;  in  others  they  are  grouped  around  the  nuclei,  which  they 
seem  to  lengthen,  or  arranged  in  transverse  lines 
corresponding  with  the  strise  of  the  muscle.  The 
fibres  become  extremely  friable,  and  are  readily 
broken  up  into  short  fragments.  As  the  process 
advances  the  transverse  markings  entirely  dis- 
appear, and  nothing  but  molecular  fat  and  oil-  "' 
globules  are  seen  within  the  sarcolemma.  It  has  tinn  of  muscular 
recently  been  affirmed  that  in  some  cases  the  stria-  carter"' sto^  1', 
tion  is  merely  obscured  by  the  fat-droplefes,  and  more  advanced,  x 
that  these  are  in  the  early  stages  confined  to  the 
interfibrillary  sarcoplasm.  The  sarcolemma  itself  may  ultimately 
be  destroyed,  and  nothing  remain  of  the  original  fibre  but  the  fatty 
debris  into  which  its  albuminous  constituents  have  been  converted. 
This  is  true  "  fatty  degeneration  "  of  muscle. 

Fatty  Dbgbnbbation  op  the  Heart. 

It  is  in  the  heart  that  fatty  degeneration  of  muscle  is  most  fre- 
quently met  with,  and  here  it  assumes  a  most  important  aspect  from 
the  deleterious  influence  which  it  exercises  upon  the  motor  power 
of  the  organ.  The  degeneration  may  be  diffuse  or  eimimgcribed, 
acute  or  chronic.  The  wider  the  extent  of  tissue  that  is  affected, 
the  less  advanced,  as  a  rule  is  the  degree  of  the  degeneration.  It  is 
in  those  cases  in  which  small  tracts  of  tissue  only  are  involved  that 
the  process  is  met  with  in  its  most  advanced  stage. 

When  the  change  is  slight,  as  in  the  difhise  form,  the  muscle  is 


NUTRITION  I M Pi} RED. 


somewhat  softer  and  more  flabby  than  naturnl ;  it  in  more  friable, 
and  i»fti'ti  breaks  witli  a  *ift  griimilar  frsictiiro  ;  and  its  color  is  rather 
[mler  and  more  (i])ai|iK'  tbaii  that  oi"  healthy  eardiac  tissue.  The 
microscope  shows  the  muscular  fibres  to  have  lost  to  some  extent 
their  striation  and  to  coiiKiin  {jranules  of  fat  (Fig.  15,  /»). 

Tlie  diffuse  form  of  degeneration  is  caused  by  defects  in  the  "/W- 
ity  or  in  the  amount  of  the  blood  which  is  supplied  to  the  heart- 
walls.  Thus  it  may  be  due  to — 1.  Diseases  in  which  the  oriJatinn 
prorenKes  are  reduced  to  a  miuimuui.  This  will  be  the  case  in  dis- 
eases which  are  attended  by  nnirked  anivmia,  whether  gradually  or 
rapidly  induced:  such  are  uniemiafrnni  repeate<l  or  excessive  bleed- 
ing, pernicious  anaemia,  advanced  leuchieniia,  malignant  and  other 
caclu'xi:e.  The  aeenuipanying  drawing  (Fig.  10)  was  taken  frona 
the  case  of  a  weakly  young  girl  who  was  under  my  care  suffering- 
from  slight  valvular  disea-so.     She  cjuickly  succumbed  with  acat® 

Fig.  16. 


Acute  fatty  difivncrntloD  of  hcnrt  iind  of  other  muacles:  <i.  heurt:  fc,  rertii*  *Moml^=^ 
Tlu'  wlinli-  <if  till"  lu■urt•ll^sul•  «u*  uflectuil,  uiiO  Bind  tlif  miiDdeti  In  other  pnrt»  of  the 


fatty  degeneration  of  the  heart  and  other  muscles,  induced  by  pi 
fuse  loss  <d'  blood  thiring  a  menstrual  period  and  by  inability  tc 
retain  food,'  (See  '•  Pernicious  Anicmia.")  2.  Certain  poiton*^ 
especially  phosphorus  and  arsenic,  have  a  similar  effect.  In  ihifi^ 
'  Tfati*.  Clin.  Soe.  Land.,  vol.  riii.,  1875. 


FATTY  DEGENERATION  OF  THE  HEART.  75 

group  must  be  included  poisons  developed  in  the  body  in  the  course 
of  acute  infective  diseases,  especially  diphtheria,  in  which  a  some- 
what high  degree  of  degeneration  may  be  attained  and  be  the  cause 
of  sudden  death.  3.  Interference  toith  the  circulation  in  the  coro- 
nary arteries  is  also  a  frequent  cause  of  a  more  or  less  general 
degeneration  of  the  muscular  tissue.  This  occurs  especially  in 
connection  with  aortic  incompetence,  and  explains  the  early  failure 
of  cardiac  power  in  this  form  of  valvular  disease.  Atheromatous 
changes  at  the  orifices  of  these  arteries  lead  in  the  same  way  to 
diffuse  fatty  degeneration.  Adhesive  pericarditis  and  myocarditis 
act  similarly ;  they  hamper  the  heart  mechanically,  and  the  cause 
of  the  inflammation  acts  injuriously  on  the  muscle-cells. 

There  is  no  clear  line  dividing  the  circumscribed  from  the  dif- 
fuse   form.     Sometimes  the  degeneration,  although   perhaps  more 
or  less  general,  is  much  more  advanced  in  some  parts  than  in  others. 
In  such  cases  the  heart  presents  a  mottled  appearance ;  opaque,  pale 
yellowish,  or  brownish   patches   are   seen   irregularly   distributed 
throughout  its  substance.     These  patches,  which  vary  considerably 
in  size  and  form,  are  met  with  especially  in  the  papillary  muscles, 
the  columnse  carnese,  and  in  the  layers  of  fibres  immeiliately  beneath 
the  endocardium.     They  may  also  occur  beneath  the  pericardium 
*nd   in  the  deeper  portions  of  the  organ.     They  correspond  with 
the  most  degenerated  portions  of  the  tissue.     They  are  soft  and 
flabby,  and  have  a  rotten  consistence,  tearing  readily  under  the 
"^ger.      Under  the  microscope  the   fibres  are  seen  to  be  in  an 
advanced  stage  of  fatty  degeneration,  the  sarcolemmata  containing 
"***lecules  of  fat  and  oil-globules,  which  in  many  parts  have  escaped 
.^*i  lie  free  amongst  the  surrounding  but  less  degenerated  tissues 
'      *g.  14,  b).     These  more  localized  degenerations  are  most  common 
*^ld  people,  and  usually  result  from  considerable  disease  of  many 
t:he  small  branches  of  the  coronary  blood-vessels,  and  not  from 
'.    **<litionsof  general  anaemia.     The  peripheral  layers  of  muscular 
^^We  also  frequently  undergo  extensive  fatty  degeneration  as  the 
J  ^^alt  of  pericarditis.      The   connection   between    these   localized 
^fenerations  and  the  occurrence  of  rupture  or  of  aneurysm  of  the 
^^Tt  is  well  known. 

^rown  Atrophy  of  the  Heart. — Somewhat  allied  to,  and  occa- 

*^*»ally  associated  with,  fatty  degeneration  of  the  heart  is  the  con- 

^^ion  known  as  brown  atrophy.     This  consists  in  a  gradual  atrophy 

''^  the  muscular  fibres,  together  with  the  formation  of  granules  of 


76 


NVTRfTION  IMPAIRED. 


brownish-yellow  or  hlurkish  pigment.  These  granules  of  pigment, 
which  arc  pruhahlv  the  L-ohiring  matter  of  the  muscle,  are  either 
groujied  in  eliisters  arouiul  the  nuclei  or  more  generally  ilistributcJ 
witLii)  the  fihie.  The  fibres  are  Jre([uently,  at  the  same  time,  the 
Beat  of  more  or  less  fatty  degeneration  (Fig.  ItJ).  This  change 
usually  occurs  as  a  senile  one  or  as  a  part  of  general 
marasmus  from  other  causes.  It  is  also  met  M'ith  io 
Some  eases  of  canliae  hy|iertro]ihy.  Its  recognition 
is  in  most  cases  impossible  without  the  aid  of  the 
microscope. 


Fio.  16. 


Fatty  Degeneration  of  the  Kidneys. 

Fatty  degeneration  of  the  kidneys  fretjuentlj 
occurs  as  a  result  of  inflummation  of  these  organs. 
This  secondary  degeneration  will  he  alluded  to 
when  treating  of  rcitul  inihimitiations.  Primary 
fatty  degeneration  is  much  less  freijuent.  It  murt 
iiiiv.'    In    wmie     1,^.  borne  ill  mind  that  the  renal  epithelium  verv  com- 

piirln  uiiili'ntniiv 
flight     r«  1 1  y 


Brown  Mrophy 
of  the  hcjirl, 
showliiK  t  h  V 
gTNIillli.'S  or  (iIk- 
tniMit  and  thv 
ainipb)-  nr  the 
tlhrt's.  Thi'  lallvr 


monly  coutuin.'*  more  or  less  fat.  hut   it  is  onlv  when 


mctamorphosiii.  jjjjg  jj,  excessive  that  it  can  he  rejiarded  as  a  diseMcJ 
condition.  This  e.xeessive  formation  of  fat  in  the 
kidney  is  less  common  than  is  generally  supposed.  It  is,  however, 
occasionally  met  with  in  chronic  diseases,  especially  in  pulmonury 
phthisis.      It  is  also  a  result  of  ]n>is(Uiing  by  phosphorus. 

In  sinifde  fatty   degeneration   the  cliangc  is   usually  confined  t" 
the  epithelium  of  the  cortex.     The  cortex  presents  on  section  » 
somewhat  yellowish-white  surface,  often  slightly  mottled,  and  th»*i 
in  most  cases,  is   nio.st    marked   near   the   bases  of  the   pyrauii'*** 
There  is  no  adhesion  of  the  ea|isiile  or  granulation  of  the  siirfa*?* 
Microscopically,  only  the  nuclei  of  the  vessels  and  of  the  connect*  ^ 
ti.sauc  stain  «vell.     This  ehniige  apjjears  t<v  interfere  but  little,  if 
bU,  with  the  ftinctinns  of  the  organs,  and  in  this  respect  it  rese; 
bles  the  analogous  chatige  in  the  liver.     It  is  not  usually  accoc 
paniod  by  albuminuria. 

Cerebral  Soptenino. 

This   is,  perhaps,  the   most   suitable    place   to   speak   of  cerehra 
eofteuing.  iiia.-^much  as  fatty  ilegeneration  of  the  brain-tissue  usuallj 
constitutes  a  prominent  feature  in  tlie  histological  changes.     Soften' 
Jng  of  the  cerebral  substance  is  essentially  a  necrotic  process,  ant 


CEREBRAL  SOFTENim 


11 


ly  result  from  any  cnndition  interfering  with  blond-supply — viz. 

lammation,  embolism,  thrombosis  of  arteries  or.  mueb  more  rarely, 

of  veins.      Portions  of  tlie  brain  wliieli  are  the  seat  of  this  change 

Kmay  be  merely  rather  softer  than  the  surrounding  healthy  tissue, 

^HHaking   down   more   rcailiiy   under    a   stream   of  water   which   is 

^Hnbwed  to  fall   upon  tliem,  or  they  may  be  comjdctely   diffluent. 

They  arc  never  distinctly   circumscribed,  but  pass  by   insensible 

gradations  into  the  neighhoriti;;  tissue. 

Il'nder  the  microscope  the  chaiij^e  is  seen  to  consist  in  a  disinte- 
gration of  the  nerve-tissue.  The  fibres  suffer  earliest;  their  white 
substance  first  coagulates,  and  then  breaks  up  into  masses  of  various 
sizes,  giving  the  reactions  of  fat:  these  give  place  to  masses  of  fine 
fat-granules.  These  granules  are  for  the  most  jiart  the  proilucts  of 
the  degeneration  of  the  myelin,  and  are  due  to  the  decomposition 
of  lecithin,   which  is  its  |n'iticipal   constitiieiit. 

Next,  when  the  gray  matter  is  implicatLMl,  the  large  nerve-cells 

H  are  involved  in  the  necrotic  stage,  but.  though  full  of  granules, 

their  outline  may  lon^  remain  visible.      Tiastly,  the   neurogliii-cells 

I  and  those  of  the  small  blood-vessels  degenerate  similarly,  and  the 
tissue  is  thus  converted  into  broken-down  fibres,  granular  matter, 
and  molecular  fat.  among.«t  which  are  many  granule-cells  (p.  67). 
These  corpuscles  are  more  common  in  cerebral  softening  (Fig.  17) 
than  in  any  other  condition,  and  form  very  characteristic  objects: 
■  they  vary  from  j-J^f  to  j^'f^r  inch  in  diameter,  and  the  granules  they 
contain  are  possibly  myelin,  but  usually  fat.  Many  are  formed  by 
degeneration  of  gangiion-eclls  and  neiiroglia-cells,  but  many,  per- 
iaps  most,  are  leucocytes  which  have  taken  up  granules.  Ulti- 
roately  all   trace  of  structure  is  lost. 

The  color  of  the  softened  portion  varies  considerably,  chieHy 
with  the  amount  of  blood  in  the  vessels  or  extravasated  into  the 
tissues.  It  may  resemble  that  of  the  surrounding  healthy  tissue  or 
o^  of  a  yellowish  or  red<lish  tint.  Aecoriling  to  these  variations  in 
*^*>l<)r  cerebral  softenings  have  been  classified  into  white,  yellow, 
*1«5  red.  As,  however,  a  yellow  softening  m!\y  be  but  a  later 
®*-^ce  of  red.  and  as  white  may  be  succeeded  by  red  due  to  hemor- 
*''*«ge  into  the  area,  and  again,  as  softenings  of  iuflamtiiatory  and 
**•  simple  degenerative  origin  may  be  to  the  naked  eye  indistinguish- 
f*>l«».  this  classification  ha.s  little  practical  or  scientific  value. 

"White  Softening  is  sometimes  acute,  iiml  is  then  diu-  to  embo- 
WsjD  of  one  of  the  larger  arteries,  and  which   usually  soon  causes 


78 


SVTRITIOy  IMPAIRED. 


riironlr  whltPBnftcnliiiir 
of  the    brain :    ncriiniilur 


death.  Far  more  commonly  it  is  chronic,  occurring  especially  in 
tin'  agcil.  It  is  then  fltic  to  gradual  narrowing  of  the  artcrif*  liy 
chronic  endarteritis  (atheroma),  often  couibincd  with  senile  impair- 
ment of  the  heart  force  as  a  subsidiary  cause  of  the  imperfect 
blood-siipiilv.  Narrowing  of  the  arteries  from 
syjihilitic  vtnlarteritis  will  act  siuiilarly  iu  ear- 
lier life.  The  process  is  really  one  of  ttiniplf 
necrosis,  sudden  or  gradual :  when  it  is  grsiinal 
there  is  no  reason  for  hemorrhage,  and  even 
when  it  is  sudden  hemorrhage  is  often  absent, 
for  infarction  is  rare  after  embolism  of  tlie 
brain.  When  the  blood-supply  is  suddenly 
cut  off.  it  might  be  expected  that  coagulative 
necrosis  (p.  39)  would  occur,  but  it  never  doesi- 
oirpimuUi",  brnketnii.wn    The  urea  is  softeiH'cl   nitd  untinged  hv  hlo<»«l. 

iKTVc'-Hhnii. iiuii  fiit-itraii-      ■  i        i  •  •   ■  i-     *        i-.. 

uiw. of  whuii  the »oftoii-     involved,   and    presents    either    a    dirty  *hit^ 
«ui*tanciii. composed,    ^olor  or  looks  exactiv  like  the  brain  sronnd 

ii>  one  orlwo  nucleatert      .  ,ni  •        n-  i  '  _a 

coll*  are  prob»biy  ncne-  It.  i  hts  affected  area  may  be  merely  soltenecf 
cciu,   x2.io.  or  quite  dilHuent ;  it  may  result  in  a  cyst  "f 

clear  flui<l  irithout  any  hlooti-pifimmt  in  it»  wall,  or  in  a  scar — tli« 
latter  appearing  at  first  as  a  meshwork  the  spaces  of  which  ar« 
full  of  milky  fluid.  Before  the  circulation  ha.s  ceased  and  tUe 
death  of  all  the  element.s  in  an  area  of  white  softening  i»  coi**" 
plcte  a  fatty  degenerated  vessel  may  burst  into  the  area  aud 
transform  it  into  one  of  red  softening. 

Red  Softeniner  is  commonly  depenilent  upon  vascular  obstruction*' 
either  from  embolism  or  thrombosis.    There  is  collateral  hyperjem***^ 
rupture  of  capillaries,  and  extravasation  of  blood  :   the  softened  •^''^i 
sue  usually  exhibits  reel  jioints  and  patches  mingled  with  white  a'* 
yellow;   the  patch   is  swollen   in   proportion  to  the  hemorrhage  a** 
ledenia,  and   is  rarely  <liffliietit.      Red  softening  is  most  common    • 
the  viusenlar  gray  matter  of  the  cortex  and  of  the  basal   gaiigli 
Red  softening  is  also  sometimes  associated  with  the  chronic  whi^ 
variety.      It  may  be  inflammatory. 

Yellow  Softeningr  is   a  later  stage  of  red   softening,  and.   lilt 
it,   is  usually  situat«  in  the  gray  matter — chiefly  of  the  con  vol  i^ ' 
titms.     The  color  is  due  to  the  presence  of  altered  blood-pigment 
the  result  ftf  the  previous  extra va.sat ion.     The  pigment  mav  be  seel 

lules  and  hivmatoidin  crystals  scattered  through  th<^' 
roglia  and  the  nerve-cells  of  the  gray  matter :  i^ 


CLOUDY  SWELLING.  79 

first  sight  the  granules  look  like  fatty  particles,  but  are  distin- 
guished by  their  deep  black  color.  White  and  yellow  softening 
may  remain  unchanged  for  long  periods. 


CHAPTER  IV. 


CLOUDY  SWELLING  (PAEBNOHYMATOUS  OR  GRAN- 
TTLAB  DEGBNERATION,  ALBUMINOUS  INFILTRA- 
TION). 

Cloudy  swelling  is  a  frequent  change,  being  found  in  all  dis- 
eai3«8  attended    by   considerable   pyrexia.      Wickham    Legg   and 
li  ^  hermeister,  having  produced  it  by  subjecting  animals  to  a  high 
ext;«rnal  temperature,  regarded  the   change  as  due  simply  to  the 
fev-^r,  which,  in   their   opinion,   caused   increased   destruction   of 
alt>  mjmin.     Increased  destruction  of  tissue  may,  however,  itself  pro- 
da  «:s«  the  elevation  of  temperature;    moreover,  the  change  is  not 
roc^sn  marked  in  long-continued   secondary  fevers,  but  in  the  rel- 
ati  -v-  «ly  short  primary  fevers  of  the  acute  specific  diseases.     Further, 
th^     degeneration  is  specially  pronounced  in  bad  cases  of  diphtheria, 
ii*    '^rhich  disease  the  temperature  is  often  low.     All  this  leads  to 
th^    belief  that  mere  fever  is  an  insufiicient  cause.     A  more  prob- 
"■"l^  explanation  is  that  the  infective  material  in  the  blood — the 
<!avise  of  the  fever — has  a  more  or  less  deleterious  action  on  the 
tissues.     This  is  supported  by  the  observation  that  cloudy  swelling 
"*   tie  first  change  noticeable  in  poisoning  by  phosphorus,  arsenic, 
**»<!  the  mineral  acids,  all  of  which  lead  ultimately  to  fatty  degen- 
®'"*^tion  of  protoplasm.     Again,  cloudy  swelling  is  found  in  inflamed 
P&rts,  and  we  shall  see,  when  considering  inflammation,  that  it  is 
*Iwny8  due  to  the  action  of  an  irritant,  which,  if  it  were  of  suf- 
"*^»ent  intensity,   would   produce   death  of  the  tissue.     It  would 
*Ppear,  therefore,  that  cloudy  swelling  is  due  to  the  action  upon 
^«  tissues  of  some  poison  which  tends  to  cause  their  death ;  eleva- 
*»on  of  tijg  temperature  of  protoplasm    above  the   normal  would 
'^^doubtedly  assist  its  action. 

Iq  considering  the  histology  of  this  change  we  shall   find  that 
*'**anced   cloudy   swelling   passes   insensibly  into   fatty  metamor- 
phosis: it  is  therefore  to  be  regarded  as  the  fir »t  step  toward  fatty 
""^^Uiraorphotia. 


I 


80 


yVTRITION  IMPAIRED. 


SEATS. — Tlte  lurjro  mjissies  of  jtrotoplasni  sliow  the  change  most 
plainly — the  liver,  kidneys,  heart,  anil  voluntary  muscles:  but 
probably  all  protoplasm  suffers.  The  change  may  be  much  more 
advanced  in  some  organs  than  in  others,  owing  perha](S  to  differ- 
ences iu  the  local  circulation. 


APPEARANCES. —  1.  Microscopic. — The  cells  are  swollen  and 
their  protoplasm  is  finely  granular,  the  nucleus  and  any  cell-stmc- 
ture  being  obscure  or  even  intlistingiiisbable ;   the  granules  refruri 
light  but  feebly;  they  are  unstained  by  osmic  acid;  they  dissolve 
in  dilute  acetic  acid,  but  not  in  other,  and  are  therefore  albuininnu?. 
In  advanceil   cases  larger,  strongly-refracting  granules,  blnckeiiiug 
with  osmic  acid  and  soluble  in  ether,  but  not  in  acetic  acid — there- 
fore   fatty — are    found    associated    with    tlie    albuminous    pranale« 
which   first  appear  like  a  precipitate  in   the  cells. 

2.  Naked  Eye. — When  the  change  is  well  marked  the  affecl£s-'<l 
organs  are  somewhat  swollen,  and  may  be  either  an:cmic  or  sligbt^^y 
hyperremic ;  the  surface  of  a  .«eetion  bulges  up  a  little ;  the  ti!«i 
is  soft-er  and  more  opaque  than  natural. 


EFFECTS. — This    change    must    impair,    in    proportion    to 
degree,   the  vital    activity    of   the    cell ;    on    the    other    hand,    *- 


Fio.  18. 


Fio.  19. 


I.lvcT  from  ■  case  of  acute  rheumBtinn 
with  hlijh  tcmpiTaturt?:  tlit  UvLTcells 
•wiiUeii  anil  irronulNr.  the  nuflc-tia  In  many 
twluK  iiIino8t  iDdlttlDguldhatilc.    X  2D0. 


Mii.fciitar  tlMutr  of  tliu  hcnri  i 
ft  faee  of  aevore  typhoid  fever t : 
fibres  arc  granular.  Ihr  ourlrl 
scared,  and  the  strlatlon  lust,  x 


affected  parts  completely  recover  in  those  cases  in  which  the  primal 
disease  does  not  prove  fatal.     (.If  course  its  most  serious  action 
upon   the  heart. 


MUCOID  AND  COLLOID  DEOENERATION.  81 

The  Liver. — Here  the  change  is  usually  most  marked,  and  is 
absolutely  characteristic  (Fig.  18). 

The  Kidneys. — The  cortex  is  principally  affected.  The  Mal- 
pighian  bodies  and  the  pyramids  are  usually  hypersemic,  and  con- 
trast with  the  general  pallor  of  the  cortex.  The  tubal  epithelium 
presents  the  appearances  above  described;  they  are  veil  seen  in 
tiie  early  stages  of  scarlatinal  nephritis. 

The  Heart  and  Muscles. — The  heart  becomes  slightly  opaque, 
pale,  and  soft.  The  muscular  fibres  are  finely  granular,  and  have 
lost  their  distinct  striation  (Fig.  19).  Such  a  condition  must 
materially  interfere  with  the  contractile  power  of  the  organ.  A 
similar  change  is  met  with  less  frequently  in  other  muscles. 

The  Lungs. — The  change  cannot  be  recognized  by  the  naked 
cje.  The  epithelial  cells,  according  to  Buhl,  are  swollen  and 
granular  from  the  presence  of  albuminous  and  fatty  particles,  and 
M'e  easily  detached  from  the  alveolar  walls. 


CHAPTER  V. 

MUCOID  AND   COLLOID  DEGENERATION. 

Mucoid  Dbobnebation. 

MtJcoiD   DE6BNEBATI0N  consists  in  the  transformation  of  the 
proteid  constituents  of  the  tissues  into  mucin. 

C^bemically,  mucin  is  closely  allied  to  albumin,  more  so  than  to 
*ither  gelatin  or  chondrin.     Like  albumin,  it  is  met  with  only  in 

_**line  fluids,  being  held  in  solution  by  the  free  alkali ;  it  is  pre- 
f  P*tated  by  dilute  acetic  acid  and  alcohol.     It  differs  from  albumin 

"  Dot  containing  sulphur,  it  being  insoluble  in  an  excess  of  the 
*'^*'l,  and  also  in  not  being  precipitated  by  boiling,  by  tannin,  or 

y  perchloride  of  mercury.     These  two  reagents  will  distinguish  it 
*'8o  from  gelatin  and  chondrin,  which  are  both  precipitated  by  them. 

CAUSE. — This  is  unknown.     It  appears  to  be  a  reversion  to  an 
*»rlier  state,  for  in  the  foetus  the  connective  tissues  consist  almost 


KUTRITION  IMPAIRED. 

entirely  of  soft  mucin-yieUling  substauce:  the  umbilical  cord  ami 
vitreous  humor  rt-tdiii  this  pwnliarity.  Throii^ihout  life  a  mucoid 
cluinge  occurs  libysiolugicaily  in  the  secrctiou  of  mucus ;  a  clear 
drop  of  mucus  apiiears  in  the  protoplasm  and  increases  till  the  cell 
bursts  and  the  mucus  is  evacuated,  the  cell,  ns  a  rule,  not  being 
destroyed. 

Myxoedema,  a  disease  due  to  atrophy  of  the  thyroid  body,  was 
80  named  because  it  was  supposed  that  the  swollen  connective  fis«iie 
contained  a  large  quantity  of  mucin.  Recent  observations,  how- 
ever, have  shown  thtit  ut  ihe  time  of  death  the  proportion  of  roiirin 
in  the  skin  is  only  slightly,  if  at  all.  in  excess  of  the  normal  amount. 

SEATS. — Pnthohgicnlhf,  mucoid  degeneration  may  affect  both 
cells  and  intercellular  substance.  It  is  met  with  in  catarrh  of 
mucous  menibrsines.  the  transformation  occurring  niueh  more  rap- 
idly than  under  normal  conditions,  and  the  cells  iieiiig  often  MSt 
off;  also  in  connective  tissue,  in  cartilage  (especially  the  inter- 
vertebral and  costal  cartilages  of  old  people),  in  bone,  and  in 
many  new  growths,  not  only  in  those  of  the  connective-tiMU« 
type,  but  in  both  cells  and  matrix  of  cancers. 

APPEAEANCES. —  I'luler  the  mu-rnKcopr   these  are  the  8aJ»* 
as  in  the  [diysiological   process,  but  the   cells  are  much  more  fr*^ 
quently  destrojed.     T<t  the  naked  eye  the  affected  parts  are  tr****^ 
formed  into  a  homogeneous,  colorless  material  of  a  soft,  mucil»^'' 
nous,  jelly-like  consistence.     When  the  change  is  limited  to  i**^^ 
lated  portions  of  the  tissue  the  softened  parts,  surrounded  by  th«^^ 
which  are  unaltered,  often  present  the  appearance  of  cysts.     Th*""' 
cyst-like  formations  containing   mucoid  substance  are  not  unct>* 
monly  met  with  in  the  costal  cartilages  and  in  new  growths. 

EFFECTS. — Complete    mucoid    degeneration    implies    aboliti  ^^ 
of  function. 

OoLLom  Deoenehation. 

Colloid  degeneration  consists  in  the  metamorphosis  of  cell-prot^^ 
plasm  into  a  substance  known  as  "  colloid." 

Chemically,  colloid  differs  from  mucin  in  containing  sulphur  an*' 
in  not  being  precipitated  by  acetic  acid  or  alcohol.  It  swells  whet* 
treated  with  acetic  acid. 


MUCOID  AND  COLLOID  DEOENERATIOS. 

ilu  the  adult  many   vesicles   of   the    thyroid    Dormally  contain 
Uoiil;  it  is  only  when  the  formation  of  this  mate- 
becomes  general  and  excessive,  producing  one  Fw.  20. 
of  goitre,  that  the  process  is  to  be  regarded  as 
lologicul. 

JAUSE. — This  is  quite  unknown. 

IBATS. — Colloid  degeneration  occurs  most  often 

tlic  thyroid;  then  in  certain  new  growths,  both 

Kxnata  and  cancers :   the  secondary  growths  in 

a*\*  and  elsewhere  unilergo  the  same  change.     It 

It  bo  remembered  that  the  term  "  colloid  tumor  " 

ilic!<  nothing  as  regarcls  the  nature  of  the  growth. 

triau  tumors  often  contain  "colloid,"  but  sometimes  the  contents 

'<?  nearly  correspond  to  mucin.     Other  seats  are  rare. 

lI'PEABANCBS.— 1.  Microscopic  (Figs.  20  and  21).— One 
r%%-o(.niall  masses  of  colloid  appear  in  the  cell,  increase,  and  )iush 
^  the  nucleus  until  they  have  replaced  all  protoplasm  and  the 
is  considerably  swollen.     The  nucleus  usiiuUy  atrophies  and 


CoUold  tx\\»  (ftvm 
K  t'oUiiliI  ntucur). 
IKIuddetacli.) 


'^.'f,.,- 


'""^(wccr,  tbuwing  the  Urtcv  alvcoU  wlthlu  which  1*  coutalned  tbti  gulitUnuiu  coUuld 
iniitrrliil.    X  «M.    (RlndfleUch.) 

li«ijjpe»n».  but  may  become  colloid.  Neighboring  cells  coalesce 
ini'i  small  masses,  and  these  again  into  larger,  which  not  uncom- 
iiiaiilv,  under  the  microscope,  look  as  if  they  were  concentrically 


mm 


84 


NUTRITION  IMPAIRED. 


laminated   (Fig.  21),     Thus    cavities    full    of  colloii]    are   formed. 
TLo    intercolluiar    substance    atro|iliies    rather    than    <lept'i' 
whilst  iu  mucoid  degeneration  it  is  frei|ueully  aflected  by  the  i...:; 
process. 

2.  Naked  Eye. — Colloid  is  colorless  or  pale  yellow,  glistenili|;<- 
and   has   tlie   consistence   i>f  rather  soft   gelatin,  which,  indeed.  Ttj 
much  resembles.     Quite  small  points  of  colloid  catch  the  eye:  ibejf 
do  not  stain   characteristically   with    iodine   or   the  aniline  dt 
The  physical  characters  of  colloid  tissues  are  thus  very  diffefel 
from  those  of  mucoid  tissues.      In  advanced  stages,  however,  wlloi 
may  soften,  and  masses  of  softened  colloid  separated  by  scpu 
comparatively  undegenerated  tissue  give  the  appearance  of  eyrt* 
a  tumor. 

EFFECTS. — Abolition  of  function  is  proportionate  to  the  ei 
of  the  metamorphu.'iis. 


but  its  nature  is  doubtful. 
Fio.  22. 


Zenkbr-8  Deoenebation  of  Muscle. 

This  change  has  been  regarded  as  allied  to  colloid  dcgenerml 

It  was  first  described  by  Zenker 
occurrinp  in  the  muscles  in  typlw 
an<l  chietiy  in  the  recti  abdominis, 
ductors  of  the  thigh,  the  riiaph 
and  tongue-muscles.  It  is  now  k 
to  occur,  though  less  often,  in  oti 
infective  febrile  diseases,  such  as  small- 
pox and  cerebro-spinal  uiciiingitis:  in 
trichinosis;  also  in  the  neighborhood 
of  burns,  bruises — either  before  »r  aft«T 
systemic  death — abscesses  and  tumon 
of  muscle.  Probably,  as  Cohnheim 
suggeste<l,  the  unusual  appeannee  «f 
muscle  thus  affected  is  due  to  a  disturfc- 

A    portion    of   the  miIimu    iiium'U*  .      .■  <■ 

,fr..m........rty,.i...MfLvon    fr.|v   "n<'t'  '"  "'i'  ordinary  post-m.)rtem  e«j«s- 

■mtion  xvuMv^  »ft.r  tniitm.nl  with   ulation    of    mvosin :     in    other    »nril», 

Uailrr't  fluid.    X  '»>,  i*«Jutf.l  J.  r.      1       .      1     ■  ....  , 

"  /ienker  s  degeiienition  is  an  example 
of  coagulative  necrosis.  The  appearances  may  certainly  b*  pi»- 
duced  after  systemic  death,  and  may  almost  certainly  occur  doriag 
life  iu  individual  fibres  dying  from  any  cause. 


MUCOID  AND  COLLOID  DEGENERATION.  85 

APPEARANCES. — The  altered  fibres  are  much  swollen  and 
the  transverse  striation  is  lost.     The  sarcolemmata  are  occupied  by 
*  homogeneous,  structureless  material,  which  is  exceedingly  brittle, 
SQd  usually  presents  a  wrinkled  appearance  or  is  broken  up  trans- 
versely into  several  irregular  fragments  (Fig.  22). 

The  portions  of  muscle  aifected  are,  to  the  naked  eye,  semi- 
opaque,  pale,  slightly  lustrous,  of  a  reddish-gray  or  brownish-yellow 
color,  and  abnormally  friable.     They  appear  somewhat  like  the 
Qiuscles  of  frogs  or  of  fish.     The  fibres  are  never  universally  af- 
fectiei ;  many  normal  are  found  associated  with  the  altered  elements. 


3FPBCTS. — This  change  necessarily  impairs  the  contractile 
po  ^?«-er  of  the  muscle,  and  it  is  believed  often  to  lead  to  rupture  of 
wnc*.  e  of  the  fasciculi  and  to  hemorrhage.  The  dead  fibres  appear 
0      "be  readily  absorbed  and  quickly  regenerated. 

Hyaline  Dbqensbation. 

'-■-''his  name  was  given  by  Recklinghausen  to  a  morbid  change 

:haa.:»acterized   by  the   presence  in  cells   of  drops   of  a  substance 

n^'^^'ing  an  appearance  like  that  seen  in  albuminoid  degeneration, 

^"^"•i    not  giving  the  color-reactions  of  the  latter.     It  is  stained  pale 

yellow  by  iodine,  and  in  other  respects  seems  allied  to  "colloid." 

"is  said  by  v.  Recklinghausen  to  be  a  normal  constituent  of  cell- 

pi'^^toplasm,  and  to  be  set  free  when  the  cell  dies.     Very  little  is 

kaown  about  the  substance,  however,  and  there  is  a  tendency  on 

^"^    part  of  some  writers  to  include  under  this  heading  all  morbid 

^ii^-Bges  resulting  in  a  hyaline  appearance,  and  especially  those  due 

*«  coagulative  necrosis. 

The  chief  seats  of  this  change  appear  to  be  the  arteries  of  the 
'"■*in  and  of  lymphatic  glands ;  in  arterioles  the  adventitia  is  con- 
v^i^ed  into  a  shining  thickened  layer.  In  larger  arteries  becoming 
•ttenrysmal  Meyer  has  described  the  yielding  as  being  due  to 
V  aline  degeneration  starting  Internally  and  passing  outward.  The 
*"x»e  degeneration  is  said  to  be  frequent  in  inflamed  parts,  the  con- 
nective tissue  being  affected.  Gull  and  Sutton  have  described  a 
"yalin-fibroid  change  in  the   arteries  in  chronic  Bright's  disease. 


86 


XVTRITION  IMPAIRED. 


CIIAPTER    VI. 


LAEDACEODS    DEQENERATION. 
(Syn.  Waxy,  Albuminoid,  ob  Amyloid  Degeneration.) 

This,  which  \s  one  of  the  most  imiwrtant  degenerative  procesMi 
is  characteriKofl  by  tlie  ajtpciirancc  in  the  tissues  of  a  colorl 
translucent,  firm,  Innhiceous  Bnhstunce,  giving  them  somewhat  thi 
appearance  of  boiled  bacon  or  of  white  wax.  This  substance  offiT 
an  exceedingly  imdonged  re.sistiince  to  gastric  digestion,  am 
exhibits  some  remarkiibly  cbnractcristie  staining  reactions.  Th« 
reaction  with  iodine  led  Virchow,  its  discoverer,  to  regard  the  sub 
stance  as  allied  to  starch  and  to  jiropoae  for  it  the  name  *'amyloi« 
substance." 

Chemical    Nature    of    the    New    Material. — By    submittiuj 
affected  organs  to  gastric  digestion  the  substance  may  be  obtained 
practically  pure,  ami,  thus  ol>tained,  it  has  been  shown  by  Kiiba 
to  be  nitrogenous,  closely  allied  to  albumin,  and  not  starchy.     It  ■ 
distinguished  from  albumin  chiefly  by  its  resistance  to  the  action* 
(1)  dilute  acids  and  iilkiilies,  (-)  the  gastric  juice  at  the  body-teia  — 
perature,    and    (;^)    jiiilrefacfion ;    also    by    certain    eolor-reacti"n»- 
Marcet  has  shown  that  the  organs  containing  it  are  notably  defi- 
cient in  potnssium  and  phosphoric  acid,  but  they  contsin  excess  of 
Bodium  and  chlorine. 

With  regard  to  its  color-reactiona,  the  best  and  longest  kno*l> 
is  that  with  iodine.  To  obtiiiii  this,  wash  a  thin  slice  of  an  affected 
organ  thorouglily  to  free  it  from  blooil,  and  then  pour  over  it  » 
watery  solution  of  iodine,  made  by  diluting  one  drachm  of  li(|Uor 
iodi  with  seven  of  water.  In  this  way  the  lardaceous  portions  are 
(juickly  stained  dark  mahogany  brown,  the  healthy  tissues  assum- 
ing a   bright  yellow  color. 

If  this  stained  surface  be  treated  with  a  10  per  cent,  solution  "f 
sulphuric  acid,   de^'ciicriited   (iiirts  assume,   cither  at  onee  or  after 
some  time,  a  dark   greenish,  blui.^li,  or  blackish   hue,  whilst  healthv 
parts  become  grayish.     Unfortunately,  this  second  reaction  is  very 
variable  and  of  little  value. 

For  microsctjjiic  purposes  the  iodine  and  sulphuric-acid  reaction 
may  be  obtained  by  staining  the  sections  with  iodine,  mounting 
them  in  glycerin,  and  placing  at  the  edge  of  the  cover-glass  a  Tcry 


LAEDACEOUS  DEGEXEBATTOX 


87 


sail  (juantity  of  strong  sulphuric  acid ;  in  about  twenty -four  hours 
"the  ianlaceous  tissue  will  be  found  staint-d  blue.  But  a  more 
valuable  though  still  somewhat  variable  process  is  that  of  staining 
tbe  sections  with  methyl  aniline  or  gentian  violet  (1  per  cent. 
«atery  solutionj ;  after  some  hours  the  degenerated  parts  are 
I'taine^l  bright  magenta,  but  the  healthy,  blue.  This  staining  is 
more  penuanent  than  that  by  iodine,  and  is  valuable  as  a  c-onfirnia- 
torj  test;  for  the  iodine  reaction  may  be  obtained  with  glycogen 
»nil  some  forms  of  altered  albumin,  and  cannot  therefore  be  re- 
garded as  absolutely   characteristic   of  lardaceous  degeneration. 


ETIOLOGY. — Lardaceous    degeneration    is    said   to   be   much 

<-"<>inmi>ncr    in  males    than   in  females,   and  the  ages  of  tbe  great 

"•ttjority  of  patients  fall  between  ten  and  thirty,  especially  between 

''^"oiity  and  thirty.     It  is  almost  always  fteeondary  to  prolonged  and 

pre^fuge   suppuration,  due   usually  to    tubercular   disease  of  lung, 

•*c»uc,  joint,  or  kidney,  but   sometimes  to   traumatic  (septic  com- 

Jound  fractures)  or  other  causes  (dysentery,  actinomycosis).     Much 

'•^ss  commonly  it   is   found    in  the  cachexia  of  tertiary  syphilis, 

*"*t>«cially  when  there  is  chronic  bone  disease.     Rarely  it  appears 

**    the  cachexice  of  severe  malaria,  of  leuchtemia,  and  of  cancer,  and 

■■y  rarely,  especially  in  children,  the  degeneration  may  seem  to  be 

~«Hwry.    Most  of  these  diseases  belong  to  the  class  of  infective  dis- 

,  and  Birch-Hirschfeld  suggests  that  the  degeneration  may  bo 

^  to  an  infective  cause,  but  he  adduces  no  evidence  in  favor  of  this. 

The  degeneration  may  be  very  rapid  (two  to  three  months,  Cohn- 

i  m)  in  ap[iearing,  or,  under  apparently  similar  circumstances,  its 

'^'^Siet  may  be  long  delayed;   this  is  more  likely  to  be  the  ease  in 

Ck»-»ng  children  than  in  adults.     Like  hectic  fever,  thi.s  degeneration 

c^u^s  much  more  readily  from  suppuration  of  foul,  ill-drained  cav- 

»«^  than  from  a  much  more  free  discharge  from  a  cutaneous  ulcer, 

l>*jn  which  the  pus  cannot  accumulate  under  [iressure. 


»- 


©EATS. — The  change  is  almost  always  widely  distributed :  only 
^*"cly  is  it  limited  to  a  single  part.  It  may  be  found  in  almost  any 
'''•'gan ;  those  most  fre(juently  affected  are  the  spleen,  liver,  kid- 
**ey8.  intestines,  and  lymphatic  glands.  Less  fref{uently,  anil 
specially  when  the  change  in  the  organs  just  mentioned  is  ad- 
*iiQced,  minor  degrees  of  it  may  be  found  in  the  stomach,  supra- 
renal capsules,  pharynx,  oesophagus,  bladder,  prostate,  generative 


88 


NUTRITION  IMPAIRED. 


organs,  serous  membranes,  tlie  nieiiilinmes  of  the  brain  and  cori 
anil  muscle.  There  is  uo  rule  as  tu  tlie  order  in  which  the  organj 
are  uffected,  nor  as  to  which  will  be  uffected  in  any  given  case.  Aj 
a  local  change,  ajijiarently  t|uite  distinct  from  the  condition  imli- 
cated  by  "  lardiU'eous  defeneration,"  it  occasionally  affect.s  jinthn- 
loi/iral  pro<liict¥.  us  old  thrombi,  iiiflumed  glands,  scars  (esj>eciallj' 
syphilitic),   and  tumors. 

APPEARANCES. — 1.    Microscopic. — The    morbid    subsfnnce 
usually  appears  first  in  the  subendotliefial  connective  tissue  of  tbe 
arterioles  and  capillaries,   and   in   the  media  of  the   former:  the 
endothelium  is  unuffeeted  and  the  adventitia  usually  escapes.     Tbe 
change  greatly  diminishes  the  lumen  of  the  vessel;    it  does  no* 
affect   the   latter   uniformly,    but  freijuently   causes  spindle-shapt'tri 
cnhirgements ;  and  not  only  do  the  vessels  of  many   jiarts  escap 
eutirely.  but   the  distribution  of  the  change  in  an  affected  orgai 
may  be  quite  irregular. 

With  regard  tn  the  further  spread  of  the  change,  all  authoriti* 
of  recent  date  apjioar  agreed  tlisit  the  couuectifr  ti$tuv  in  ever 
affected  organ  Buff"ers  most,  and  swells  into  homogeneous,  w»x, 
looking  masses,  fre((uciitly  CKulescing,  between  which  the  essenti 
cells  of  tlie  organ  atrophy  even  to  disappearance.  With  osmic  ad 
and  ordinary  staining  reagents  Ziegler  says  that  there  is  no  difficult; 
in  {Icuionstnitiug  the  fatty  liver-cells  between  the  homogeneou 
block.i  into  wliicli  the  connective  tissue  has  swollen  (Fig.  23,  fmi 
Rindfieiscli,  and  saiil  by  hiui  to  represent  degenerate  liver-ccIL*^  — 
Many  writers,  in  opposition  to  the  old  view,  now  deny  that  epitbcs— ■ 
lia!  cells  can  undergo  this  <'liange,  though  others,  like  Ziegler.  cor» — 
tent  theuiselves  with  saying  that  they  may  be  (]uite  nnafiected  »'* 
advanced  stages  of  the  disease.  Opinions  differ  as  to  wheih«?r 
muscle-cells  and  tlmse  of  lymphatic  glands  become  lardaceons. 

'1.  Naked  Eye. — (•rgaiis  in  which  this  cliniige  is  at  all  a^lvaiiccii 
present  features  so  characteristic  that  its  nature  can  be  reailily  r«c- 
ogni/ed  by  the  jmktMl  eye.     They  are  considerably  increased  in  sw, 
but  their  geneml  form  is  preserved,  any  edges  becoming  more  or  less 
rounded.     Their  absolute  weight  is  increased,  and  also  their  specific 
gravity ;  their  surface  is  smooth  and  the  capsule  tense  and  strctcl/ctil 
their  consistence  is   firm  and  somewhat  elastic.     On  section  tiiov 
[exhibit  a  peculi-i"  '•"  'is,  glistening,  translucent  appearand"' 

t»omew  •  wax.     Owing  to  the  vVv^Ww^*^ 


m 


WACEOUS  DEom 


\TION. 


89 


Fio.  23. 


calibre  of  their  bloo<l-vc8scls  and  to  the  pressure  exercised  by  the 
ae»v  material,  they  contain  btit  little  blood,  and  hence  are  always 
|)alt'  in  color.       In  slighter  degrees 

of  tLe  change  spots  and  patches  of 

the  morbid  material  may  be  scat- 
tered,   like    grains    of    boiled    sago, 

through   the   tissue.     Although   the 

above    chiirnctcrs    are    sufficient    in 

advanced  stages,  the  color-reactions 

alrea<ly  mentioned  should  always  be      i-ardnccoiis  iivcr-ccii*  (accordinjt  lo 

u?e<l.  for  they  will  reveal  altered  whi.  i.  imv.Moftio.c.i.  •  :«>.  iTobHhiy 
patches — r.  q.  in  intestine — not  ob-  th<.'ttiK)vfmiii>»c»ari' fhl(fmt■(lUofcu^^l- 
_-  •  1  '  1  T->  1  laric»  or  of  conncrtlve  ttwue. 
»»<»us  Without  them,  rnr  the  recog- 
nition of  the  degeneration  in  its  earliest  stage  the  microscope  is 
necessary.  The  pregencc  of  hirdm-foug  degeneration  it  often  marked 
hf   *i>mif  iithf.r  ehnnije,  egpenally  fnttij. 

"Tile  primary  change  may  occur  in  the  connective  tissue  of  an 
'  '""■5*">  *nd  not  in  the  vessels. 


Effects. — The  result  of  diminishing  the  blood-supply  to  the 
^^•^fntial  elements  of  a  part  by  narrowing  the  nrtcrioles  and  by 
*  ■"t'c.t  pressure  on  the  elements  is  naturally  to  cause  atrophy,  fre- 
H'*-*«ntly  accompanied  by  fatty  degeneration  (p.  4'J).  and  propovtion- 
'^-*-s  diminution  of  function  follows.  The  change  in  the  veB.sel-wall3 
*-»1<'r!«  the  <|nantity  and  ((Uiility  of  the  transudation,  as  is  shown  by 
*"*«j  changes  in  the  urine  when  tiie  kidmys  iiie  iiilected. 

It  acems  probable  that  removal  of  ihe  cause — c.  </.  chronic  sup- 
Plration — of  lanlaceous  degeiuTiitioii  may  lead  to  arrest  of  the 
'*p(Kisit  and  to  its  removal  from  the  di.Heased  organs,  even  in  marked 
cases;  but  in  the  great  majority  of  instances  the  change  is  steadily 
priigressive,  and  proves  fatal  by  exhaustion,  fireceded  by  anreraia, 
lirdrwmia.  albuminuria,  and  diarrbcpa, — all  of  which  are  easily 
accounted  for  by  the  morbid  anatomy.  But  the  other  effects  of  the 
immary  disease  must  also  be  remembered. 


NATURE  OP  THE  DEGENERATION.— Is  the  process  an 
infiltration  or  a  metamorphosis?  It  is  generally  regarded  as  an 
infiltration :  and  it  is  believed  that  a  soluble  lardaceous  substance 
i»  iloposited  friiiu  the  blood  in  tissues  predisposed  by  some  morbid 
change  to  receive  it,  and  to  combine  with  it  to  form  the  very  insol- 


90 


NUTRITION  IMPAIRED. 


uble  "  lardacein  "  or  "  Iardace<:)U8  substance  "  found  in  the  organs. 
The  latter  change  accounts  for  the  irregular  distribution  of  the 
degeneration.  A  parallel  was  di'awn  by  Virchow  between  this 
degeneration  and  calcareous  inliltnitiun.  in  which  the  deposit  of 
salts  occurs  only  in  dead  tissues.  The  nature  of  the  process  is, 
however,  by  no  means  certain,  some  facts  supjiorting  the  view  that 
it  is  a  metamorphosis — e.  if.  the  occurrence  of  the  lardaceous  sub- 
stance in  thrombi,  and  perhaps  in  casts  (page  93).  Dickinson 
maintains  that  the  substance  deposited  from  the  blood  is  dealkalized 
fibrin,  rendered  insoluble  by  loss  of  alkali  carried  away  in  the  pus. 
But  this  explanation  fails  to  cover  many  cases,  and  Budd  considers 
that  such  a  substance  should  digest  easily. 

Seegen  thought  he  found  in  normal  blood  a  substance  named 
"dystropodextrin,"  which  has  the  peculiarities  of  the  lardacein: 
he  believes  that  this  substance  loses  its  solubility  and  is  then 
deposited. 

According  to  Kekule  and  others,  lardacein  is  a  possible  inter- 
meiliate  product  between  albumin  on  the  one  side  and  fat  and 
cholesteriii  on  the  other. 


Lardaceous  Degeneration  op  the  Liver. 

APPBAEANCES. — 1.  Microscopic. — The  change  usually  be- 
gins in  the  walls  of  the  capillaries  and  arterioles  of  the  hepatic 
artery;  rarely,  it  is  said,  in  the  capillaries  of  the  portal  vein. 
Thence  the  deposit  spreads  to  the  intra-aciuous  connective  tissue 
nmnd  the  affected  vessels,  ultimately  reaching  and  affecting  the 
tissue  between  the  lobules  and  leailing  to  confusion  of  their  out- 
lines. The  connective  tissue  swells  into  homogeneous  columns 
wliich  split  readily  into  flakes,  like  hepatic  cells,  and  which,  in 
section,  look  like  masses  of  degenerated  cells  or  even  whole  lobules. 
<^nreful  examination  (p.  8fi)  will,  however,  reveal  between  the  Inr- 
<iaceous  masses  the  liver-cells  more  or  less  atrophied  and  pigmented, 
the  peripheral  cells,  especially,  being  infiltrated  with  fat.  These 
changes  are  beautifully  shown  if  a  very  thin  section  be  dehydrated 
in  alisolutc  alcohol,  stained  in  an  alcoholic  solution  of  alkanet, 
ilecolorized  in  alcohol  acidulateil  with  hydrochloric  acid,  washed  in 
water  tinted  with  acid  hsematoxylin,  again  washed  in  water  colorwl 
with  solution  of  iodine  and  iodide  of  potassium,  once  more  rinsed 
in  water,  and  then  mounted  in  glycerin:  the  fat  is  bright  red,  the 
lardaceous  substance  brownish-red,  the  liver-cells  yellow,  and  the 


LARDACEOUS  DEGENERATTOX 


n 


nuclei  dark  grayish-blue.     The  fatty  liver-cells  show  up  clearly  be- 
tween the  lar<laccous  lusisses,  esjieciaHy  if  a  condenser  is  used  (<  )rth). 
2.  Naked  Eye. — The  lardaceous*  liver  i.s  increased  in  size,  and 
may  be  so  large  as  almost  to  fill  the  abdominal  cavity.     Its  weight 

Fig.  24. 


.JiJIth^^. 


Fio.  26. 


sEiSwMmu  liver,  iwrt  of  II  luliiiU',  showliiK  mnsscs  of  Inrclm'Cims  Fuhftanoi".  ri'M-mlillnK 
In  ncflliin  <1eecncriiU'  ami  ftisol  hi-ijntlc  i.'clls.  nivl  vTi'iiliT  liii|illi-nlliin  of  the  iiitermecIltiK' 
>une.     Ex1«rnAlly  «iv  »>xt\  scvornl  fntty  cvlU,  ii  i-crtaiii  aim^iiiit  of  (Btly  iDHltratiua  bving 
ciutcd  with  the  Inrdaceous  change,    v,  hc-pmle  vein.    ,-.  Iim. 

is  increased,  and  also  its  specific  tjr*^'i'^y-  Tlie  enlargement  being 
uniform,  the  natural  xbape  of  the  organ  is  Imt  little  altered  ;  the 
free  edge  is  rounded,  the  surface  smooth,  and  the  capsule  tense  and 
stretched.  The  consistence  is  firm  and  elastic.  The  cut  surface  is 
dry,  bloodless,  smooth,  translucent, 
and  waxy-looking,  and  of  a  pale 
reddish-gray  or  dirty-yellow  color. 
If    the    change    is    very     far    ad- 

•  vanced,  the  tissue  may  be  perfectly 
homogeneous,  all  distinction  lie- 
tween  the  individual  lobules  being 
^.  lost.  In  other  ca.ses  the  lobules  are 
^  distinctly  mapped  out;  they  are 
enlarged,  and  the  external  zone 
niay    be   of   an   opaijue   yellowish- 

wLrte   color,  owing   to  the   presence         Ijmlaceoun  Uver,  stained  with  IwUne. 
mi-'  •      •  p     \      p  Thedorkpat  portlnnn  rrprenonttlicoffcet- 

Of  fat.      IhiB  aasociationof  the  fatty      ert  intonncllut.!  »mw.    Natuml  slzu. 

and   lardaceous   changes  ia  exceed- 
ingly  common.     Lardaceous   degeneration    does    not    obstruct    tlie 
portal  circulation,  and  hence  does  not  cause  ascites.     (See  "  Cirrho- 


1 


92 


NUTRITION  IMPAlIiED. 


sis  of  Liver.")  It  causes  fatty  degeneration  and  atrophy  of  the 
hepatic  coll.s,  antl  thus  interferes  with  the  functions  of  the  organ. 
If  thin  washed  sections  of  a  liver  in  an  early  stage  of  the  affec- 
tion be  staineil  with  iodine,  the  mahogany  color  will  be  found  limited 
to  the  so-called  '"  intermeiliate  Kone"  of  the  lobules,  the  area  of  dis- 
tribution of  tlie  hepatic  artery.  The  apjtourauce  thus  produced  is 
that  of  a  number  of  partially  compressed  rings  with  pale  centres  and 
still  paler  iuterveiiiug  sjiaces  (Fig,  2.')).  The  earliest  seat  of  larda- 
ceous  degeneratiiin  thus  differ.s  from  that  <vf  fatty  infiltration,  in 
which  the  fat  first  accumulates  in  the  cells  of  the  outer  or  portal 
zone  (Fig.  '24),  and  al.so  from  that  of  pigmentation  of  the  hepatic  cells 
from  mechanical  congestion,  which  begins  in  the  central  zone  around 
the  hepatic  vein.  All  these  changes  not  uncommonly  occur  together. 
As  tlie  lurdaceoMS  change  advances  the  whole  lobule  and  the  inter- 
lobular connective  tissue  may  become  involvetl. 

Lardaobous  Deqenehation  of  the  Kidneys. 

The  ki<lney8  suffer  frecjuently  fnutt  tlris  ehiiiige,  though  the  .spleen 
and  liver  are.  as  a  rule,  mure  uiarkedly  all'ected.      Sometimes  the 

degeneration  apjiears  to  commence  in  the 
kidneys.  Albuminuria  being  one  of  the 
most  constant  sign.s  of  this  cliange,  it  is 
often  classed  as  one  of  the  varieties  of 
"  Bright 's  disease." 

The  combination  of  lanhiceous  aud  fatty 
changes  is  exceedingly  common  in  the  kid- 
ney, the  latter  being  to  some  exteut  sec- 
ondary to  the  former,  but  the  two  bear  no 
constant  or  proportionate  relation.  Lurda- 
ceouschangeisalsofrcijiiently  combined  with 
the  signs  of  intlamniation,  both  interstitial 
and  pareuehyuiatous :  the  nature  of  the 
relation  is  sometimes  obscure.  It  has  been 
hebl  that  the  nephritis  causes  the  Iard»- 
UrdiccoiH    kidney,  stoinert    ceous  change,  that  the  lardaceous  cdianj^ 

with    iiuliiif.     Tlie    lUrk    piirta  ,  ,     .   .  ,       ,  ,       , 

rcpr, «-„i  tiu' M«iMKi.i..n  i-kUi-k    causes  the   nephritis,    anil    that    both   arc 
iin.i  Hrtiriei!  wi.itii  ii«v..'  unrt.-r-    coDcomitant  results  of  the  same  cause. 

IfoiK*    the     lanUoetiUft    change. 
(From  a  rhlld.l    Niitunil  size. 

APPEARANCES. — 1.  Microscopic. — 
The  degeneration  usually  begins  in  the  Malpighian  bodies.     At  first 


Fio.  20. 


/ 


i'Vwi  •' 


m 


Vj 


J5>i:#>. 


LARDACEOUS  DEOESERATIOS. 


93 


only  a  few  of  the  capillary  loops  in  each  tuft  are  affected,  but  all  the 
loops  griidiijilly  become  involved.  The  whole  coil  tlu-u  presents  iin 
ill-defined  outline  and  glistening  surface.  The  change  in  the  mean 
time  extends  to  the  afferent  arteries,  to  the  capillary  network  around 
the  tubules,  to  the  arteriolie  rectic  of  ttie  medulla,  and  in  advanced 
cases  to  the  intertubular  tissue,  and  even  to  the  tunica  propria  of 
the  tubules.  It  is  doubtfid  if  the  epithelium  vvvr  undergoes  larda- 
ceous  change.  The  distribution  of  the  change  may  for  long  be  very 
irregular. 

The  minute  changes  are  first  observed  in  the  subendothelial  con- 
nective tissue,  the  endothelium  remaining  sound:  the  uiedia  of  the 
arterioles  is  next  involved,  the  luuscular  fibres  either  ;itni|ihying  or 
degenerating;  in  this  way  a  homogeneous  glistening  iuyer  of  vary- 
ing thickness  (Fig.  27)  is  formed.  The  lumen  of  the  vessels  is 
finally  obliterated,  and  the  enlargi'd  Miil[iiirhiiiii  ttift  becomes  a  solid 
ball,  bearing  on  its  surface  the  unaffected  epithelial  cells  of  its  caj)- 
Bule:  these  can  be  demonstrated  by  ordinary  staining  reagents. 
From  the  Malpighian  tufts  and  afferent  vessels  the  degeneration 
spreads  as  above  described,  giving  rise  to  the  dots,  streaks,  and 
finnllT  coalescent  patches  presently  to  be  described. 

At  first  the  tubes  and  their  epithelium  appear  normal.     Many 

Fio.  27. 


UinUccou*  de«rneratl<in  of*  MRlplKhlnn  tuft  «n<l  imall  artvr;  of  the  kidney.  «how  I  ng 
t»ie  tbU-ki-uttiK  i>f  Um  wnUs  <if  the  veiwi'l.  the  vnlonremciU  nf  the  Cflls  of  thf  circular  nnii^ 
cular  rout,  mid  the  homiiKciieuui  Inyer  funned  liy  the  intima  iind  liniKitiidinal  inutiiilnr 
m.r.^      .  aw.  rednced  \. 


c«Mitain  the  pale  hyaline  casts  wliicli  appear  in  the  urine.  These 
■re  probably  simple  exudaticin-prodiicts.  but  tlit-v  orcjisionallv  stain 
de«p  brown  with  iodine,  and  thus  have  been  supposed  to  consist  of 


NUTRITION  IMPAIRED. 


lanlnccoiis  substance   formed   by   metamorphosis  of  the  exndati'>w 
iiiaterini ;  ueeonlinii  to  Ziegler,  however,  these  casts  Jo  uot  exLdul 
the  otiier  reactions  of  h»nlaceous  substance.    As  the  change  advaucc* 
and  the  new  material  increases  in  amount,  the  blood-siipidy  become* 
less  and  less,  while  the  tubes  themselves  are  subjected  to  actual  on 
jiression,  which,  if  it  is  uniform,  lends  to  their  atrophy,  and  perha 
even  to  their  disajipea ranee,  anil,  if  it  is  irregular,  to  their  dilatation 
into   small   cysts,       The   epithelium  undergoes   atrophy   ami   fattjr 
metamorphosis,  producing  the  opaque  yellowish  streaks  and  pati:li€?» 
above  mentioned,  but  this  change  varies  much  in  it.s  amount  and 
distribution.     Not  uncommonly  a  parenchymatous  nepliritis  L<  pre^ 
ent,  the   tubes  being  distended  with   cloudy  or  fatty  cells  and  ti«^ 
intertubular  tissue  being  more  or  less  infiltrated  with    leucocyte^ 
{large  white  tardaccouB  kuinri/).      In  the  later  stages  of  the  proni»*i 
there  is  almost  always  increase  of  the  intertubular  tissue,  whifh^  • 
together  with   the  disappearance  of  tubes,  leads  to  shrinking  nn^fi 
toughening  of  tlie  organ,  to  adhesion  of  the  capsule,  and  tu  irrcgtv^    ' 
larity  of  the  surface. 

2,  Naked  Eye. — These  will  vary  with  the  extent  of  the  degr-n 
eration.  and  may  be  modified  by  the  presence  of  associated  ehangi 
such  as  fatty  degeneration  of  renal  epithelium,  and  of  those  due 
intluniuiatory  processes. 

At  first  the  changes  are  microscopic  only :  at  this  stage  the  stain- 
ing of  thin  sections  with   iodine  will  show  here  and   there  a   Mal- 
pighinn  body  as  a  brown  dot,  and  the  straight  arteries  of  the  pyr- 
aniid.x  as  brown  lines.     The  unstained  kidney  is  either  still  normal 
to  the  naked  eye  or  perhaps  pale,  yellowish,  and  slightly  softened. 
As  the  disease  advances  the  organ  enlarges,  especially  the  cortex. 
The  surface  is  to  the  naked  eye  smooth,  and  the  capsule  separates 
reailily.     The  enlarged  cortex  is  remarkably  pale  and  aniemic,  and 
ha*    a    jM'culiar    translucent,    homogeneous,    wax-like    appearance, 
lis   <'orisisicnce  is  hanl  and  finn.       A    few    scattered   vessels  may 
be  !si-en  on  the  surface,  and  the  bases  of  the  pyramids  sometimes 
exhiltit   iniTcn.xed  vascularity.      If  iodine  be  ajiplied  to  the  cut  sur- 
face (p.  H<!),  the  Malpighian  bodies  and  the  arteries  of  the  cortex 
become  mapped  out  as  clearly  as  in  an  artificial   injection  (Fig.  26). 
The  enlarged  Malpighian  bodies  may  indeed  be  seen  as  glistening 
pointK  before  the  iodine  is  afiplied.      Frequently  the  homogenc«tt« 
aj)peMrance  of  the  cortex  is  interrupted  by  minute,  opaque,  yellow- 
ish-white lines  and  markings :    these  are   produced  by  the   fatty 


LARDACEOUS  DEGEKERATfOS. 


95 


,a»nges  in  the  eitithelium  of  the  tubes,  already  descrihed.  I'lti- 
frtely,  thir  caj)siile  becomes  more  or  less  adherent,  and  slight  irreg- 
IgL  depressions  make  their  appearance  upon  the  surfaee  of  the 
Hpk;  the  latter  are  due  to  atrophic  changes  in  some  of  the  tubes. 
'as  is  usually  the  case,  the  process  is  associated  ■with  an  increase 
^«lie  iutertubular  connective  tissue,  the  atrophy  may  render  the 
^4iD  even  smaller  than  normal. 

Sometimes  the  enlargement  of  the  organs  is  very  great.  In 
the  increase  in  size  is  mainly  due  to  inflamiuatory 
inch  as  have  been  referred  to.  The  freiiuency  with 
iich  Buch  combinations  occur  render  it  advisable  to  examine  all 

SLpalc  kidneys  for  lardaceous  changes, 
PFECTS. — The  first  effect  of  this  change  is  to  obstruct  the 
Fculation  in  the  cortex  ;  hence  the  incresi.Hing  pallor  of  this  part. 
|e  arterial  walls  are  so  altered  that  iiuida  and  albumin  readily 
•*ineate  them,  and  thus  is  produced  the  large  quantity  of  urine, 
fctled  with  albumin,  which  characterizes  the  earlier  stages  of  this 
!«-"clion :  the  polyuria  i.«,  however,  not  so  great  as  in  the  granular 
htraeted  kidney,  in  which  the  arterial  tension  is  much  higher. 
is  unusual  to  find  the  heart  hyjiertrophied  in  cases  of  lardaceous 
kiase.  As  the  arteries  and  the  tubes  become  more  obstructed  the 
»Bc  diminishes  in  quantity.  The  excretion  of  urea  is  less  inter- 
ted  with  than  in  other  forms  of  Bright's  disease,  and  hence  symj)- 
hx  due  to  its  retention  seldom  occur.  Tube-casts  are  rarely 
fcuerous;  they  are  for  the  most  part  hyaline  or  finely  granular, 
►  «gh  sometimes  they  are  covered  with  fatty  epithelium. 
In  advanced  cases  there  is  marked  dropsy. 

^B  Lardackous  Degeneration  of  the  Spleen. 

VARIETIES. — The  spleen  is  very  liable  to  this  change,  and  is 
Jiidlv  one  of  the  first  orjjans  to  be  affected  bv  it.  Two  forms  are 
bcrally  described:  (1)  the  sag^o  spleen,  in  which  the  disease  is 
fcited  to  the  Malpighian  corpuscles;  and  (2)  the  diffuse  form,  in 
[ich  the  whole  splenic  pulp  is  implicated,  but  in  which  the  Mal- 
duan  corpuscles  generally  csca[)e.  Kyber  speaks  of  the  latter 
renchymatous  degeneration."  and  makes  a  thiril  form,  indis- 
ISBwhabb*  from  it  by  the  naked  eye,  in  v.hich  the  disease  begins 
fhultaneously  in  the  Malpighian  corpuscles  and  the  pulfi.  He 
strongly  that  these  forms  do  not  pass  into  each  other,  and 


Larclacpniis  dviieiK'rntliin  of  thv  spk<«n  i"siik<>  «plci;u'  > ;  part  "fiin  nltcrvd  Mal(>iKhi«n ' 
piuolv,  <i,  witli  the  aiUacent  noruml  aplviilc  Uasue.t).    Tbe  Muali  in  u  «re  ileKi.'nvratr<l  t< 
svIb.     ■    2(1(1. 

[lurticiilarly  that  tbe  parench}'niatou»  form  is  not  uu  advauceil  sU^^* 
of  the  sago  spleen. 

APPEAEANCES. — 1.  Microscopic. — In   tlie  sago  spleen  ifc»« 
change  commences  in  the  capillaries  und  urteriolcs  of  the  Malpighi*-** 

corpuscles,  next  involves  the  filiri  1» 
of  the  network  of  which  the  corpus*" 
cle  liirjjely  consists,  and  then  extcDi-4* 
to  the  small  vessels  in  the  neighl)»«"~ 
hood.     At    first    the   central   artct"^ 
of    the    corpuscle    usually    escap*^^- 
When  it  becomes  affected  the  changT* 
is  first  observed  in  its  middle  co**'- 
In  tbe  difPuse  or  parenchymatoix^ 
form  the  degeneration  begins  in  tU^ 
neighborhood  of  the  capillary  vciii^ 
of  tbe  pulp,  and  spreads  thence  t«^ 
tbe  trabcculiTS,  arterial  capillaries,  and  pos.siblv — though  this  is  very 
doubtful — to  the  cells.     The  Malpighiun  bodies  often  escape,  bui^ 
tiieir    central    iirterics    are    generally    involved.      Kyber's    general 
lardaceouB  degeneration  shows  the  lesions  of  both  the  other  furiu* 
progressing  simultaneously. 

2.  Naked  Eye. — Tbe  sago  spleen  is  more  or  less  enlarged ;  its 
weight  and  density  are  al.-^o  increased.  The  cut  surface  is  smo(ith, 
dry,  and  studded  all  over  with  small  glistening  sago-like  bodic*. 
varying  in  size  from  a  millet  to  a  hemp-seed.  These  are  stained 
reddish-brown  by  the  iodine  solution,  but,  as  the  central  artt-rv 
generally  escapes,  the  mahogany-colored  nodules  have  pale  centres. 
These  nodules  may  enlarge  until  they  occupy  a  considerable  portion 


TjirdAopniu  sagn  iip)o<>ti,  ititlnpil  with 
ln<lliu'.  Mal|>i|{hiaii  hi»lk-s  Hre  darkly 
staliic-il.  nnil  u  ■  niK-  haw  untiliilni'd 
cvntni.   (From  a  child.)    Natural  hIju.'. 


LARDACEOVS  DEGENERATION.  97 

of  tlie  organ,  although  in  earlier  stages  of  the  affectiou  they  are  so 
minute  that  they  can  be  seen  only  in  thin  sections  of  the  tissue. 
In  tixe  later  stages,  therefore,  there  is  a  considerable  resemblance 
bet^-een  iodine-stained  sections  of  liver  and  spleen  respectively,  aa 
maj-  be  seen  by  comparing  Figs.  25  and  29. 

In  the  parenchymatous  and  general  forms  the  organ  often 
attains  a  much  larger  size  than  is  met  with  in  the  sago  spleen.  It 
is  remarkably  hard  and  firm,  and  the  capsule  is  tense  and  trans- 
Parent.  On  section  it  presents  a  dry,  homogeneous,  translucent, 
bloodless  surface  of  a  uniform  dark  reddish-brown  color.  Thin 
sections  can  be  readily  made  with  a  knife,  the  organ  cutting  like 
soft  ^ax.  The  corpuscles,  if  affected,  are  not  visible,  as  in  the 
K>*"Hier  variety,  being  probably  obscured  by  the  surrounding  pulp. 

_  ^iPPEOTS. — Anaemia  and   emaciation   follow  the  interference 
***li  the  blood-forming  function  of  the  spleen. 

Labdacbous  Dboensbation  of  Lymphatic  Glands. 

-iTn  the  lymphatic  glands  the  process  much  resembles  that  in  the 
'Pl^n.  The  small  arteries  in  connection  with  the  follicles  of  the 
S'^k-%d  are  the  earliest  seats  of  the  change,  and  from  these  it  extends 
'**  "khe  trabeculae  and  possibly  to  the  lymphoid  cells.  The  follicle 
'■'^^^a  becomes  ultimately  converted  into  a  small  homogeneous  mass. 

"^he  glands  themselves  are  enlarged,  and  on  section  the  minute 
'^>t-like  bodies  can  often  be  seen  scattered  through  the  cortex. 
•'^^^  cut  surface  is  smooth,  pale,  and  translucent. 

Ihe  effects  are  the  same  as  in  implication  of  the  spleen. 

X_iABDACBOUS  DbOBNBBATION  OF  THE  AlIMENTABY  CaNAL. 

T?he  whole  alimentary  tract  may  be  affected,  but  probably  never 

P'^ixnarily  or  alone.      The  change  frequently  coexists  with  tuber- 

**l«r  ulceration.     The  disease  in  this  situation  is  very  apt  to  escape 

observation,  as  it  usually  produces  but  little  alteration  in  the  ap- 

P^a.Tance  of  the  parts.     The  mucous  membrane  may  look  somewhat 

P^l«,  smooth,  translucent,  and  oedematous ;  in  very  advanced  cases 

there  may  be  some  rigidity  and  thickening  of  the  bowel-wall,  and 

even  nlcers,  due,  it  is  supposed,  to  the  tearing  off,  by  the  passing 

ox  food,  of  rigid  villi.     But  the  effect  of  the  application  of  iodine 

to  the  washed  mucous  surface  is  very  characteristic.     In  the  small 

intestine— perhaps  the  part  most  commonly  affected — a  number  of 

T 


NUTBlTlOtf  IMPAIRED. 


Bmall  n-fltlish-brown  points  u[)|)eiir  over  the  whole  surface  of  the 
lueinbraiie  ;  tlit'sc  rorresponi]  to  the  intestinal  villi,  the  arteries,  nml 
Ciijiilliiries  of  wliieli  have  undergone  the  liirdaeeous  chiingt?.  In  the 
stomach  and  (esophagus  the  vessels  are  similarly  uia|)peil  out  br 
iodine  (j).  S(>j. 

The  change  in  the  intestine  gives  rise  to  serous  diarrhoea.  prol>- 
ably  due  to  increased  perueability  of  the  degenerated  vessel-walls. 
Both  !ilisor|ition  and  secretion  are  much  impaired,  so  that  im|ili(-a- 
tioit  of  the  alimentary  tract   has  a  grave  general  effect. 

The  Corpora  Amylacea. 

Corpora  ainylaeea,  or  "iitnyloid  hodies."  were  formerly  looked 
upon  as  consisting  of  lardaceons  substance :  there  appears,  how- 
ever, with  the  exception  of  a  certain  similarity  in  their  behavior 
with  iodine  and  sid])hiiric  acid,  to  he  no  connection  between  them. 
They  are  round  <ir  nval  boilies  formed  of  a  succession  «»f  concen- 
tric layers,  anil  arc  often  changed  to  a  deeji-blue  color  by  iodine, 
thus  bearing,  both  in  structure  and  elieuiical  jiroperties.  a  strong 
resemhlaiiec  to  granules  of  vegetable  starch  (Fig.  •■5"):  but  some- 
times the  blue  is  exhibited  only  after  the  subse(|uent  addition  of 
sulphuric  acid,  and  thus  a  rescuibbince  is  shown  to  the  lardace«>UB 
substance.  Many  of  these  bodies,  however,  are  colored  green.  « 
even  brown,  by  these  reagents.  The  green  is  due  to  their  admix- 
ture with  nitrogenous  matters,  which  give  a  yellow  color  with 
iodine,  and  lienee  the  nnuiliination  yields  a  green.  The  greater  the 
amount  of  tiitrogeiuuis  iiiatter  the  more  lirown  does  tlie  color 
become.  They  vary  in  size  from  microscopic  granules  to  bodies 
which  are  distinctly  visible  to  (he  naked  eye,  sometimes  being  as 
much   as  one  or  two   lines   in   diameter.       The  larger  are    usually 

fiu'uied  hy  tlie  conglomeration  of  smaller 
granules,  which  are  often  enclosed  by  a 
common  envelope. 

They  especially  occur  in  conditions  of 
atrophy  or  softening  of  the  nervous  sys- 
tem. The  ependyma  of  the  ventricles,  the 
white  substance  of  the  brain,  the  choroid 
plexus,  the  optic  nerve  and  retina,  and  tlie 
linal  cord  ar-  •'•••^•r  favorite  seat.s.  The  larger  fonns  are  met  witli 
ost  f«"'  e  prostate.     The  prostate  of  nearly  every  ailult 

.♦e  bodies,   and   thev  mav  accumulate  in  th«t 


Fio.  30. 


Corporn   iin>yl««««    ttova   W\v 
]>rn«titt«.    iV' 


CALCAREOVS  DEOEHERATION.  99 

organ  to  such  an  extent  as  to  form  large  concretions.  They  are 
ocea!<ionally  met  with  in  the  lungs  and  in  mucous  and  serous  mem- 
branes. 

From  their  laminated  structure  these  bodies  would  appear  to  be 
formed  by  the  precipitation,  layer  by  layer,  of  some  material  upon 
the  surface  of  pre-existing  particles.  The  material,  however,  does 
not  appear  to  be  that  met  with  in  lardaceous  degeneration.  The 
two  processes  are  so  different,  both  in  the  circumstances  under 
which  they  occur  and  in  the  characters  and  seat  of  the  morbid 
products,  that  tliey  cannot  be  looked  upon  as  analogous.  Larda- 
ceous degeneration  is  a  general  change,  whereas  the  formation  of 
the  corpora  amylacea  is  evidently  of  a  local  nature.  The  latter  is 
often  preceded  by  those  local  atrophic  changes  associated  with 
advancer!  life,  and  appears  to  consist  in  the  deposition  of  some 
material,  probably  liberated  in  the  tissues  themselves,  upon  any 
free  body  which  may  exist  in  its  vicinity. 

The  corpora  amylacea,  especially  those  occurring  in  the  choroid 
plexus  and  in  the  lateral  ventricles,  are  very  liable  to  become  calci- 
fip'l,  and  they  then  constitute  one  form  of  "  brain-sand,"  which  is 
**   often  met  with  in  these  situations. 


CHAPTER  VII. 

CALCABBOUS  DEGENERATION. 

^^EPINITION. — Calcareous  Degeneration  or  Calcification  consists 

the  infiltration  of  tissues  with  calcareous  particles.     It  is  a  purely 

^**-e«V<'  process,  the  cells  taking  no  part  in  it ;  the  tissue  is  grad- 

"^*ly  petrified  by  the  deposit  of  earthy  salts  from  the  blood,  for 

*^ir  quantity  greatly  exceeds  that  present  in  healthy  tissues.     It 

'*    *lifficult  to  find  a  physiological  type,  but  perhaps  the  deposit  of 

^'*^*"thy  salts  in  the  walls  of  the  primary  areolse  (see  "  Rickets")  in 

*  Sirowing  long  bone  may  be  regarded  as  such.     Onitification  is  (juite 

*>»tinct  from  calcification,  for  in  it  everytliing   points  to  life  and 

P')wth ;  the  cells  are  undergoing  active  changes,  and  are  obviously 

•^•^ncemed  in  receiving  the  salts  from  the  lymph  and  in  combining 

them  most  intimately  with  the  organic  matrix. 


100 


NVTRITIOy  IMPAIRED. 


ETIOLOGY. — Earthy  salts  in  solution,  chiefly  the  pfitigphatu* 
ami  furhMiiitfH  nf  ntlriuvi  and  nuif/ni'xiiim.  are  brought  to  the  part 
by  bliuiit  and  lymph,  cjirbon  dioxido  being  probably  the  !*olvent. 
We  have  to  determine  why  these  salts  should  be  peruiauenlly 
deposited  in  certain  tissues,  and  we  are  at  once  struck  by  the  fact 
that  in  the  imnieit.'<e  majority  of"  eases  the  tissues  aft'ected  are  de»il 
or  dying.  It  is  probable,  therefore,  that  feeble  nutritive  activity 
and  a  retiird('<i  hlood-stream  are  together  respon.^ible  for  its  occur- 
rence. Rindlleisi-h  taught  tijat  carbon  dioxide  escapeil  from  the 
stagnating  lymph-stream,  and  that  the  earthy  salts  were  conse- 
((uently  jirecipitated ;  more  recently  others  have  held  that  calcifica- 
tion is  due  to  a  combination  of  these  salts  with  certain  albuminoid 
bodies  and   with   fatty   acids. 

Much  more  rarely  calcareous  infiltration  appears  to  be  due  to  u 
absolute  increase  of  calcareous  salts  in  the  blood,  such  as  may  be 
supposed  to  occur  in  extensive  caries  and  in  osteomalacia.  A  |K>r- 
tion  of  the  c-^cceas  is  then  deposited  more  or  less  widely  in  the 
tissues — first  in  the  lymphatic  glands  and  kidneys,  more  rarely  in 
the  lungs,  stonmch,  intestines,  dura  mater,  and  liver.  The  deposit 
takes  place  chiefly  in  the  connective  and  least  active  tissue  of  the 
organ,  which,  moreover,  ininuMliately  surrounds  the  vessels — e.  g, 
in  the  interlobular  tissue  of  the  lungs  and  in  the  stroma  betwccii 
the  glands  of  the  stomach  ;  but  in  the  kidney  the  epiiheliuin  is 
infiltrated  as  well  as  the  intertubular  tissue.  Analogous  to  this 
form  of  calcification  is  the  deposition  of  the  excess  of  bi-nratc  of 
sodium  which  takes  place  in  gout.  It  is  probable  that  in  this  ease 
also  the  deposit  occurs  first  in  ti.ssues  in  which  the  nutritive  activity 
is  most  feeble.  A  certain  -iniount  of  chalky — like  fatty — infiltra- 
tion may  perha])s  occur  without  marked  impairment  of  function; 
but,  as  completely  calcified  parts  are  certainly  dead,  either  the 
infiltration  has  the  power  to  kill  or  it  affects  dying  parts. 

SEATS. — Diminution  or  extinction  of  vital  activity  being  MB 
important  element  in  its  causation,  we  are  not  surprised  to  find 
that  calcification  is  very  common  as  a  senile  change,  affecting  mast 
frci|iu'iitly  the  arteries  an<l  hyaline  cartilages,  excepting  articular 
cartilages.  It  occurs  similarly  in  pathological  tissues  of  which  the 
life  is  feeble — e.  (/.  in  uterine  myomatu  after  the  climacteric  and 
in  old  scars.  Lastly,  dead  ti.ssues  locked  n|i  in  the  body  are  very 
likely  to  become   calcified  —  e.  </.   thrombi    (jMfholithf),  parasites 


Fio.  31. 


CA  LCA  REO  US  DEOENERA  TTOH. 

(Fig.  31).  atheromatous  patches  in  arteries,  and  caseous  masses — 
(lie  results  of  arrested  tubercular  inflammation  so  common  in  lungs 
and  Irmpbatic  glands.  The  best  ex- 
ample is  the  complete  calcification  of 
a  dead  fcetus.  which  sometimes  occurs 
when  this  is  retained  in  the  abdomen 
in  the  case  of  an  extra-uterine  fcetar- 
tion  {jUthnptrdion). 


AJ>PEARANCES.  — 1.  Micro- 
scopic.— The  calcareous  particles 
make  their  appearance  both  within 
the  ct'lis  and  in  the  intercellular  siib- 


('Alclfted  trichina'  In  mnsde.    In  two 

of  till'  (uiriulti'ii  thi'  raiwiili;  anil  con- 

tcntK  arc  so  fur   cttU'iflcil   llial  hiinlly 

BtaUCc;    they    are    much     more     fre-      any  imei- or  tbi- rolU-d  pmbryu  remttlUB. 

,  -11  In  the  other  the  Irfrhlna  Is  dead,  ehrtv- 

•jueut,  liowever.   in  the  latter  situa-    i.ii,,,i.a„,nw«:oiuinginniit«i«d. 


ao. 


tion .      They  are  seen  at  first  as  very 

fine  dust  scattered  irregularly  through  the  intercellular  substance 

(fiff,   :J2),      They  are  characterized,   when   viewed  bv   transmitted 

light,  by  their  opacity,  black  color,  irregular  outline,  and  solubility 

1  «lilute  mineral  acids,  usually  with  evolution  of  bubbles  of  carbon 

•wxide.     They  gradually  increase  in  number  until  ultimately  large 

jtracts  of  tissue  may  be  convertetl  into  an  opaijue  calcareous  ma.ss,  in 

^*J>icL  the  cells  are  enclosed  and  can  no  longer  be  recognized.     These 

c  masses  have  a  sharp  black,    irregular  outline,   and  as   the 

cification    becomes    complete    acquire   a    homogeneous,    glisten- 

'"g,  serai-transparent  appearance.     The  cells  themselves  are  much 

Fio.  32. 


A  nlrlflnl  sarccima.    Minut<- ralcarvoiu  [lartiL'U-^  are  Hcativred  tJirough  the  intercelluUr 
lObftanrv.  on  the  left  ko  thickly  an  U*  aUnoHt  voneeal  the  eelUt.     ■.  'JUU. 


Javi  fre<jnently  infiltrated,  being  merely  enclosed  and  obscured  by 
tie  calcified  intercellular  substance.  Calcareous  particles  may, 
however,  make  their  ajipetirnmc  in  the  protoj)lasm,  and,  gradually 


102 


increasing,  convert  the  cell  into  a  homogeneous  calcareous  botlv- 
C'ak-ificntion  of  gnnglion-cells  nlone  is  tmt   niicoiiinion  in  degenera- 
tive jirocessei*  in  the  Itrain. 

If  the  Baliue  mutters  itre  dissolved  out  with  a  little  dilute  miueRil 
acid,  the  structure  of  the  part  may  be  again  recognized,  unless^ 
iiitlet'd,  as  is  tn}  often  the  cafe,  it  has  been  destroved  by  soiiio- 
antecedent  change. 

2.  Naked  Eye. — Ajiart  from  the  microscope,  calcification  can  li^ 
recognizetl  more  readily  by  touch  than  by  sight.  If  the  calcareous 
particles  cohere  in  minute  groups,  such  as  is  common  when  tli^s- 
proce.ss  •succeed.'*  that  of  ca.seation.  a  white  niortar-like  sub.«tanc^»- 
i,s  produced.  When  the  cohesion  is  more  marked  the  de|)osit  leK' 
coinimrable  to  fine  sand,  and  all  stages  between  this  and  nolici. 
stony  masses  may  not  iufrcipiently  be  met  with.  The  latter  bre«hc: 
with  an  irregular  surface  and  j)resent  a  yellowish  or  grayish  aspe<'t:_ 


EFFECTS. — .\  calcified  part  is  dead  ami  inert :  it  therefo 
uiidcrgncs  no  ftirther  dumge.  In  this  respect  calcareous  diffen 
from  fatty  degeneration,  in  which  subsctpicnt  changes  invariahlj 
tiike  place — either  softening,  caseation,  or  calcification.  It  diffc 
also  in  its  effect  upoti  the  tis.suf,  for.  unlike  fatty  metamorphosis'. 
it  does  not  cau.se  annihilation  of  the  tissue-element.s.  The  tissiie- 
is  simply  impregnated  with  calcareous  matters,  which  have  no  oth*?*" 
effect  u[ion  it  than  to  render  it  inert;  its  vitality  is  destroyed,  b«** 
its  structure,  in  so  far  as  the  calcification  is  concerned,  renini"® 
unaltered. 

Calcification  must  thus  be  looked  upon  in  many  cases  as  a  s»l**" 
tiiry  lesion,   the   impregnation    witli   calcareous  matters  preventi**^ 
suh.seijuent  changes  in  the  part.      This  is  especially  the  case  whci*    * 
occurs  in  caseous  tithernilur  t'uri,  as  it  imprisons  the  cause  of  *•* 
disease.     It  is  doubtful  whether  calcification   of  a  fiinmr  is  of  a  f^- 
benefit  to  the  patient,  for  the  infiltration  is  probably  limited  to  t  **   ' 
•lead  or  dying  parts  of  the  growth  and  does  not  hinder  its  spreJ»* 
<  )n  the  other  hand,  when  it  affects  the  arterial  system  calcificati*  * 
may  be  attentled  with  the  most  deleterious  consci|uence8.  as  will  K^^ 
seen  in  the  foUowins  seetimi. 


Calcification  of  Arteries. 

Calcification  of  arteries,  like  fatty  degeneration,  may  be  primary 
or  sifcondan/.     As  a  secondary  change  it  occurs  in  atheroma  an*' 


CALCIFICATION  OF  ARTERIES.  103 

forms  one  of  its  final  changes.     In  this  form  it  is  constantly  met 
w-it:h  in  the  aorta  and  its  branches  and  in  many  other  situations. 
JPrimary  caloifloatioii  is  essentially  a  senile  change,  a  result  of 
tb^t  impairment  of  nutrition  which  appears  and  increases  as  life 
advances,  but  which  appears  earlier  and  increases  more  rapidly  in 
some  than  in  others.     The  change  is  more  or  less  general.     It  is 
associated  with  atrophy  of  the  arterial  tissues,  and  in  some  cases 
witL  fatty  degeneration.      It  usually  occurs  in  vessels  of  medium 
size,  the  arteries  of  the  upper  and  lower  extremities  and  of  the 
brain  being  those  most  commonly  affected.     Its  most  common  seat 
is  the  middle  coat,  where  it  commences  in  the  muscular  fibre-cells. 
The  calcareous  particles,  deposited  from  the  vasa  vasorum,  make 
their  appearance  at  first  around  and  within  the  nucleus,  and  grad- 
ually increase  until  they  fill  the  cell,  which  becomes  converted  into 
a  small  calcareous  flake.     The  process  may  go  on  until  the  muscu- 
lar coat  is  completely  calcified,  or  it  may  be  limited  to  isolated  por- 
tions of  the  coat,  giving  rise  to  numerous  irregularly-distributed 
<»Ic«reous  rings  and  plates.     These  are  best  seen  in  vessels  clarified 
•n  spirit  and  turpentine.     From  the  muscular  it  may  extend  to  the 
external  and  internal  coats,   until  ultimately  the  vessel  becomes 
<»lcified  throughout. 

The  vessel  thus  calcified  loses  its  elasticity  and  contractility ;  its 
lumen  is  diminished,  and  it  is  transformed  into  a  hard,  rigid,  brittle 
tube,  or  "  pipe-stem  artery."  Such  an  artery  is  strengthened 
*S*in8t  dilatation,  but  is  predisposed  to  rupture:  in  amputations 
great  diflSculty  may  be  found  in  securing  such  vessels,  as  ligatures 
cut  throngh  them  at  once.  The  nutrition  of  parts  supplied  by 
"»ena  ig  more  or  less  impaired,  and  tubular  calcification  of  the 
'^teries  of  the  lower  limb  therefore  predisposes  to  "senile  gan- 
6*"ene "  (p.  40),  inasmuch  as  it  renders  the  vessels  less  able  to 
*<iapt  themselvea  to  the  varying  requirements  of  the  circulation. 


104  NUTRITION  IMPAIRED. 

CHAPTER    VIII. 

PIGMENTARY   DEGENERATION. 

PiOMENTARY   Deoenkration,  Or   Pigmentation,  consists  in  ^b-^** 
abnormal  formation  of  pigment  in  the  tissues. 

Normally,  many  pigments  occur  in  the  body,  and  probably  ^  ^  ' 
are  the  results  of  cell-action  upon  hiemoglobin.  Some  of  them  pa  «===-* 
out  in  the  fieces  and  urine ;  others  are  deposited  as  normal  co^c^  - 
stituents  in  cells,  the  best  examples  being  the  cells  of  the  rete  M».  ^  - 
pighii  (especially  in  the  negro)  and  those  of  the  pigment-layer  cm^  "^ 
the  retina.  But  pigment  is  not  limited  to  epithelial  cells ;  it  exi»  "^c  a 
in  the  cells  of  the  choroid  and  iris,  of  the  sclerotic  (lamina  fusca  ^  i 
and  of  the  pia  mater.  Muscle  also  is  pigmented,  and  yellow  i  j^  '* 
brown  granules  may  sometimes  be  seen  in  the  heart.  - 

Pathological  pigmentations  may  be  arranged  under  four  heacr~*.- 
ings,  according  as  the  pigment  is  derived  (1)  directly  from  hcemm'—^- 
globin ;  (2)  from  the  blood  by  ceU-action ;  (3)  from  bile ;  (4)  fn>^"«ci 
extraneous  subgtanres  introduced  into  the  body. 

1.  Heematio  Piennents,  or  those  derived  directly  from  haemogltzz*— 
bin.    are   the   commonest.      Red    corpuscles   break    up   and  the^i  x- 
hsemoglobin  becomes  dissolved.     This  may  occur  either  within  tb».  ^ 
vessels  (malaria,  septiciemia),  which  is  uncommon,  or  after  esca|~»«? 
of  the  corpuscles   into    the   tissues.     The  latter  is   due  either  *:  o 
wounds  or  rupture  of  the  vessels,  or  to  congestion  or  inflammation* 
without  any  breach  in  the  vessel-wall.     Such  causes  of  pigmentation 
are  common ;  witness  the  frequency  of  bruises  and  apoplexies.  <'• 
congestion    from    varicose   veins,    portal    obstruction,   and   cardi**" 
incompetence,  and  of  stains  after  various  inflammatory  lesions- 
All  are  familiar  with  the  changes  in  color  which  occur  after  * 
bruise — first  purple,  then  green,  and  finally  yellow.     The.se  col<'^" 
changes  are  due  to  corresponding  tissue-changes  which  follow  t»* 
infiltration  of  the  skin  by  the  extravasated  blood.     Briefly,  *b*^ 
ehanjres  are  as  follows:  1.  Some  of  the  fluid  and  cells  are  absorb*^ 
at  once  by  the  lynipliiitios.     2.  The  hivmoglobin  is  dissolved  out  " 
many  red  cells,  and  tlie  stromata  disappear — no  doubt  after  faf*^ 
degeneration.     \    red    fluid    is    thus  formed  which    infiltrates  tl'^ 
tissues  and  stains  them  yellow  or  Itrownish  red:  the  cells  are  cO*' 
ore<l  more  tlecply  than  the  iiitereellular  sub.stanee  or  than  the  meflO' 


PmnrENTARY  DEOEyERATIOX 


105 


W  branotia  or  fibrous  structures.  The  color-changes  on  the  surface 
I  »rv  owing  to  changes  in  this  ilisw)lvt'cl  ha-niniilohin.  which  is  srjon 
I  ilrcoiujiosed  into  hieuiatin  unil  an  iilbiiiuinciid  boil y :  [tart  of  the 
I  lia'Diatin  is  reabsorbed,  and  appears  in  the  urine  as  nrobili]i  :  the 
I  rest  II niierjroe!«  a  change,  and  is  deposited  as  granular  or  crvftiiliiue 
I  iiioitiutiiidin.  3.  Many  corjmscles  simply  shrivel  into  brownish 
I  grstiiikr  nuisses  of  pigment,  said  to  occur  chiefly  in  "  h:eiuatomata," 
I  or  ttimor-like  collections  of  blood.     4,  Many — according  to  some, 

f  nifMt red  corpusclea,  or  the  ])igiueiit-ra:isses  rcsiihiiig  from  them, 

,  •I'l'  tnken  up  by  leucocytes,  which  wamlcr  in  large  numbers  into 
I  •^•e  extrava8,ation  and  are  converteil  in  them  into  hjematoidin. 
"ue  f  liguient  thus  formed  mfiy  be  deposited  on  the  death  of  the 
^clll  <ir  it  may  be  carried  by  the  cell  into  the  lymphatics,  when  it 
'''"  probably  be  arrested  in  the  nearest  lymphatic  glatuls.  the 
yniF*li-piiths  of  which  will  be  found  beautifidly  iiuirki'd  out  by  [lig- 
nent  -  or  it  may  pass  through  into  the  circulation  and  give  rise  to 
pign^nt-emboli  of  various  organs. 

"^^^nntftuUn  appears  to  be  closely  allied  t(» — according  to  some, 

^luvnt^ical  with — the  coloring  nuitter  of  the   bile,  bilirubin,  which  is 

*'*•'     a  derivative   of  h.Tinoglobin.     It   exhibits   similar   reactions 

«n«H  treated  with  concentrated  mineral  acids,  displaying  the  same 

varvjitjons  of  green,  blue,  rose,  and  yellow  colors.     It  is  insoluble  in 

**'«?r,  alcohol,  ether,  acetic  acid,  and  in  dilute  mincriil  aciils  and 

•'Kllies ;    it    Is   soluble    in  concentrated    acids  iiiul    in    the  caustic 

■'kiilies,   giving  in   the  latter  case  a  red  color.      It   docs  not  con- 

*"»    iron.      Mixed   with   hsematoidin.  and   very  closely  resembling 

I   '  '8  a  pigment  containing  iron.     This  has  been  named  "  hjemo- 

••♦y-rin." 

*hese  final   stages  of  extravasated  blood  occur  in  two   forms — 
j'^nular  and  crystalline.     IJoth  are  of  a  very  permanent  nature, 
may  remain  uiniltered  for  years. 

ie  granules  of  ha^matoidin  vary  in  size  from  the  snuillest  par- 

'^'es  to  masses  as  large  as  a  red  blood-corpuscle.     The  larger  are 

^'^••iijonly  irregtilar  in  shape,  sharply  defined,  and  nmrc  or  less  glis- 

"'>»g.     Their  color  varies  from  yellowish   red  to  brown  or  black  ; 

'nt'  older  they  are  the  darker  they  become.      The  smaller  granules 

***  usually  dull  and  opa(|ue. 

I      Tlie  crystals  of  Inematoidin  are  opa(|iie  rhombic  prisms,  usiuiUy 

L  ''f  a   beautiful  yellowish-red  or  ruby-red  color,  sometimes  approach- 

I  ^  to  brown  or  black.     They  may  also  occur  as  little  plates  and 


106 


yVTRITIOy  IMPAIRED. 


Pio.  33. 


'^ 


Uu'ioatuldin  cryiUU. 
lVlr«haw.) 


fine  needles,  bat  these  are  les8  coninion  forms  (Fig.  33).  Theruc 
in  most  cases  so  small  that  considerable  care  is  reijiiired  to  recogniu 
their  crvstalliMc  nature  under  the  microscope,  and  they  may  ewilv 
be  overlooked  as  merely  irregular  granular  masses.  In  some  cm««, 
however,  they  attain  a  larger  sixc.  Ther  ut 
more  or  less  transparent,  and  present  a  shiih 
ing,  strongly  refractive  surface. 

Intensely  black  pigment,  granular  or  en* 

#VV  tallinc,  has  been   called  viflonhi.     This  term, 

as  at  present  cniployod.  includes  several  dif- 
ferent pigments,  some  containiDg  iron  ud 
some  free  from  it. 

Whether  hiemoglobin  is  conxerted  into 
granular  or  crystalline  hacmatoidin  appears  partly  to  defiend  n|Mti 
the  tissue  in  which  it  is  situated,  crystals  being  exceedingly  com 
mon  in  some  situations — c.  (f.  the  brain  and  ovaries — vt  hcresj*  ii 
others,  f..  g.  mucous  membranes— only  granules  are  met   with. 

Acconling  to  Kunkel,  some  of  the  pigment  left  by  hnMnoglobin  i 
pure  hydrated  peroxide  of  iron.  ^^ 

As  to  the  idtiniate  fate  of  extravasations —  ^B 

1.  Absorption  may  be,  and  in  vascular  parts  often  is.  to  the  nakc 
eye,  complete,  but  crystals  or  granules  of  htematnidiii  may  n* 
infrequently  be  found  by  the  microscope.  '1.  A  yellowish,  browl 
ish,  or  blackish  scar,  from  gramdar  or  crystalline  pigment,  m* 
mark  the  site  of  the  destruction  of  ti.ssue  by  hemorrhage.  8.  ■• 
collection  of  prune-juice  or  chocolate-colored  fluid  may  long  rrmM 
surrounded  by  a  capsule  of  inflammatory  tissue,  often  lined  b 
layers  of  clot,  more  or  less  decolorized  and  organized  (hjematonia"! 
the  fluid  contains  pigment  and  fat-granules  anil  cholesterin-cryst»Ii 
4,  The  fliiiil  may  be  absorbed  and  the  clot  become  completely  dei-o 
orijse*!  and  organized — a  good  example  of  «hich  is  seen  in  tb 
so-called  "•membranous  pachymeningitis."  The  process  can  fr« 
•  (uently  be  watched  in  aseptic  wounds.  ;"i.  A  cyst,  with  more  o 
les«  pigmented  walls,  containing  clear  fluid,  may  be  left,  especially 
in  the  brain. 

Pigmentation  is  a  very  common  form  of  degeneration,  but,  f«M 
nately,  one  of  little  importance.  The  presence  of  pigment  i^m 
between  the  cells  of  a  tissue  can  have  little  effect  on  the  clemenf><» 
their  functions;  any  di.'sturbance  of  these  must  be  attributtMl  rathe 
to  the  conditions  upon  which  the  formation  of  the  |iigment  depenib 


PIGMENTARY  DEGENERATTOX 


107 


Fio.  34. 


As  evidence  of  antecedent  conditions  (hemorrhage,  congestion,  or 
iiiliainmation)  the  presence  of  hicraiitoiilin  iimy  sometimes  stand 
ilone;  c, ,'/.  after  cerebral  hemorrhage  from  capillaries  ery.stals  of 
bffinatoiilin  may  alone  remain ;  agiiin.  slate-gray  discoloration  of 
the  intentinal  mucosa  points  either  to  chronic  catarrh  or  portal  con- 
RWtion,  and  that  nf  the  vesical  mucosa  to  chronic  catarrh.  Slate- 
gray  discoloration,  seen  po8t-mortetu  on  solid  abdoiuiiiiil  viscera, 
«nd  de|ieDding  on  the  action  of  sulphuretted  hydrogen  (from  decoiu- 
|"wition)  upon  the  iron  in  hiemoghthiii.  must  not  he  mistaken  for 
true  pignientatiiiti. 

2.  Pigment  derived  trova  the  Blood  by  Cell-action. — The 
chief  examples  of  this  change  are  mehuiotic  warts,  nsevi,  sarcomata, 
«nd  careinomata.  The  pigment  lies  in  the 
ceil«  more  often  than  between  them,  is  gran- 
ular, and  varies  from  yellow  to  black  in  color ; 
''  probalily  contains  iron.  It  differs  s])ectro- 
"Wliicajiy  from  all  known  blood-pigments,  and 
•*  often  inc]iide<l  among  the  melauins. 

The  bronzing  of  the  skin  in  Addison's  dis- 
i.s  not  sati.sfactorily  explained.      Irritation 

"'"  the  abdominal   sympathetic   is   believed    to     """^"■'«  "'  "•«   liver). 

f>«        •  1     .    ■  •  •  *^- 

"■Use  mcreascd  pigmentation. 

Variations  in  the  normal  pigmentalion  of  the  skin  occur  rluring 

I'fegnancy  and  with  various  uterine   troubles,  in  leucoderina   iiml 

•"Pliiniiderma ;  but  no  certain  explanation  of  these,  or  of  blanching 

"    the  hair  from  neuralgia  or  fright,  can  be  offered. 

8.  Pigmentation   from   Bile. — The  only   well-established   cause 

"    this  variety  is  obstruction  of  the  hepatic  or  of  the  common  bile- 

''»ct.     This  is  most   fretjuently  due  to  swelling  of  the  walls  from 

ti^tarrhal  intlamiiiation,  to  Idockinj'  of  the  luuien  by  j;ull-stones,  or 

^   the  pressure  of  a  growth  outside  the  duct.     The  bile  secreted 

wbiiid  the  obstruction  is  ubsnrbcd   by  tlie  veins  and   lyniphiitics, 

w»d  distributed  throughout  the  budy.      It  a])peurs  first  in  tlic  urine, 

KMTi  afVer  in  the  conjunctivrc  and  .skin,  and  may  ultimately  .stnin 

»11  the  tissues  yellow  or  greenish  yellow.     The  stniniiig  of  the  skin 

is  kiKiwti  as  jnundiiH'  or   icUtrun,  and   persists  some  time  after  the 

oil*  hw  ceased  to  circulate  in  the  blood.     When  the  seat  of  obstruc- 

"*u  is  in  the  small  bile-iluct.s,  as  in  cirrhosis,  the  change  may  be 

hraitcd  to  small  areas  of  the  liver. 

The  pigmentation  is  due  to  diffuse  staining,  but  granules  and  even 


r«ll«    rontainiiiK    I'iff- 
mi'iil  (fnuii  a  iiK-liiiinUc 


108 


NUTRrrrox  rat  paired. 


crvstttls  of  bilirubin  are  occasionally  found,  especiallv  in  ickmi 
neonatorum. 

With  regard  to  the  slight  jaundice  that  occurs  in  septicaemia.  tlM 
malignant  forms  of  acute  infective  fevers,  and  some  other  disetioi 
no  inarkod  obstruction  can  be  demoni*tratt'il  in  tlii-  ductit.  anil  tko 
exact  cau8c  ii!>  doubtful.  It  is  probable  that  both  iurreased  coniuC 
ence  of  the  bile  and  diminished  pressure  in  the  bbwd- vessel*  m^ 
each  cause  the  teiis'iiin  in  the  ducts  to  exceed  that  in  the  blo^fd-iM 
aels,  or,  at  any  rate,  in  the  lymphuti(■^<.  and  thus  induce  a  slight  »b 
sorption  of  bile  into  the  vessels,  sinil  a  conseiiuent  niiM  ilegreeW 
jaundice.  This  is  the  most  probable  ex|)lanation  of  many  of  tb 
<loubtful  cases. 

4.  Pigmentation  by  Extraneous  SubBtances. — Exaniplw  < 
this  form  of  pigmentation  occur  in  the  lungs,  the  skin,  the  \xt 
phatic  glands,  and  the  mucous  membranes.  The  substances  accri 
ited  with  its  production  are  carbon,  silver,  lead,  arsenic,  and  hi 
pigments  as  may  be  used  artificially :  to  these  may  be  added,  in  r* 
instances,  mercury  and  picric  acid.  ^| 

The  inhalation  of  fine  particles  of  carbon  and  other  substiBi 
produces  pigmentation  of  the  lungs  and  bronchial  glands.  This* 
of  considerable  im|>ortance,  and  will  be  described  in  the  next  secti«3 

The  prolonged  administration  of  salts  of  silver  leads  to  the  der 
opuient  in  the  skin  and  adjacent  mucous  membranes  of  a  |>eculi 
brownish-gray  color.  That  portion  of  the  metal  which  finds  itavi 
to  these  parts  is,  owing  most  probably  to  the  action  of  the  ligl 
de|)OHited  as  an  oxide.  This  comlition  is  known  as  urtfy riit$i*. 
is  permanent. 

The  presence  of  lead  in  the  tissues  is  often  demon?trate<l  f»y  tJ 
occurrence  of  a  narrow,  well-defined  black  line  in  the  gums  whei 
they  are  in  contact  with  the  teeth.  It  is  due  to  the  action  of  ll 
•ulphuretted  hydrogen  given  off  by  the  decom|»osing  matter  whic 
collects  between  the  mucous  membrane  and  the  teeth  ujxm  the  lei 
in  the  adjacent  tissue.  The  ••  lead-line  "  is,  therefore,  usually  brukei 
and  in  those  whose  teeth  are  kept  thoroughly  clean  often  absea 
even  though  other  symptoms  of  lead-poisoning  may  be  prii««>ii 
I'igmeiitutinn  <jf  the  mucous  membrane  of  the  large  intestine  hi 
been  found  associated  with  the  presence  of  considerable  i|uaDtiti> 
of  lead  and  of  mercury  reA]>ectively  in  that  |iart  of  tbe  alimentat 
tract. 

In  tattooing  artificial  pigments  are  placed  in  the  dee[>er  I«y«n  I 


PIGMEXTA  r/OiV  DEOENERA  TION. 


109 


the  stkiti.    Most  of  the  pigment  remains  in  its  original  position.    Of 
tbv  reiuainder,  some  is  devoured  by  wandering  leucocytes,  and  some 
w  »ra.shed  on  into  the  lymphatic  and  filtered  out  by  the  glands,  where 
it  h   x~«Uined. 

I>^^Mi  tistui's  in  process  of  separation  are  frequently  discolored — 
bfnvk  ,  greenish  black,  or  slute  gray — by  the  action  ivf  !<u)|ihuretted 
hydirogi-n.  and  atrophied  nr(fan«.  in  which  the  pigment  is,  as  it  were, 
concentrated,  often  appear  darker  than  normal.  Neither  of  these, 
how^  %rer,  is  an  instance  of  true  pigmentation. 

Pigmentation  of  the  Lungs. 

I  lr»  no  organs  is  pigment  met  with  so  frequently  and  in  such  large 
I  (fuaritity  as  in  the  lungs,  and  mucli  discussion  has  arisen  as  in  its 
I    nati»T»>  mid  origin.      Its  iiuioiint  gnidually  increases  witli  ;nlvanciiig 

I    »gc the  lungs  of  infants  being  free  from  it,  whereas  those  of  adidts 

I     invuriiiMy  contain  considerable  quantities. 

I  'it\»  pigmentation  of  the  lung.'*  is  due  principally  to  the  presence 
I  ui  Carbon,  an<l  not  of  hiematoidin.  The  carbon — derived  from 
I  "H'ltupiete  combustion  of  wood,  coal,  and  other  substances,  and 
I  ''^ajTS  present  in  varying  quantities  in  the  atuiosjihere — is  inhaled, 
I  ""d  the  minute  particles  pass  into  the  finest  hroticbi.  Many  are 
I  •*««!»  np  by  mucus-corpuscles,  juui  may  be  seen  as  small  black 
I  ^fannies  in  the  cells  of  the  grayish-black  sputum  fre((ucntly  e.xpec- 
[  ''^>"atcd  in  the  early  morning.  Much  of  the  ciirbon  is  thus  elimi- 
■***ecl  by  expectoration,  but  many  particles  pass  into  the  air-vesicles, 
F  ■li«l  here,  their  removal  by  this  menus  being  less  reaiiily  effeeted. 
I  *"«y  gradually  penetrate  into  the  alvenlur  walls  atnl  interlnbuhir 
I  ''ss«n?.  Most  of  the  pulmonary  pigment  is  found  in  these  situations, 
I  *'thfr  within   the  connective-tissue  cells  or  free  among  the  fibres 

(Pig.  .35). 
I  According  to  Tyndall,  exhaled  complemental  air  is  free  from 
I  V*rticles.  The  carbon  particles  can  be  carried  by  the  air  only  .so 
I  w  as  it  is  tidal  or  complemental.  Any  cilia  would  work  against  the 
I  "<i.Hcent  of  the  particle  and  its  carrier  cell.  The  difficulty  with  whieh 
I  »«ptic  organisms  gain  access  to  the  minute  ramifications  of  the  air- 
I  V*»8nges  is  shown  by  the  rarity  with  which  empyemata  from  per- 
I  fi'Tntion  of  the  lung  putrefy,  and  by  the  reatly  ilisappearauce  of 
I  putrefaction  in  offensive  sputum  when  intra-laryngeal  injections  arc 
I  employed. 
^^      The  means  by  which  the  particles  of  carbon  can  penetrate  the 


IIU 


yUTRITlOy  IMFAlllKD. 


walls  of  tlic  air-vesicles  and  make  their  way  into  the  inter-alvcdlir 
tissue  has  been  explainod  by  Klein.     The  branched  couuectiu'-ii- 

Fia.  35. 


J3 


Pltnneiitntloii  nf  the  lung  ift-om  »  woman,  wt.  dxty-flve,  wllh  hUkIiI  rniphywinnl.  «how 
till-  fItiiiiUon  iif  the  plipiit'nl  in  thi-  thirki-ni'cl  alveolar  w«ll»  nml  uroiinrt  the  blno<l»»«r  S 
The  wullii  of  the  Utter  nre  aUn  thickened  and  its  tnmcn  diminished,    y  78. 

sue  cells  of  the  iilvrohir  walls  send  a  process  or  a  greater  or  I<? 
iiortioii  of  their  bddv  between   the  eiiitttelial   cells   of  the  alveo!  ^*    i 
into  the  itlveolar  cavity.     As  tliese  coiini'etive-ti.'»8iie  cells  lie  in  tt  • 
seroHS  canals  which  constitute  the  coninieueement  of  the  |>eriv»-^^ 
cular  lymphatics,  it  is  easy  to  understand  how  tliese  openings  in  tl^ 
alveolar  walls  (pseiido-stomata)  may  become  .sufficiently  di.stenJcJ  t: 
allow  cells  and  ottier  substances  to   pass  through   from  the  alveola- 
cavity  into   the   inter-alveolar  tissue.     When  once  the  carbi>n  b» 
made  it,<  way  into  the   interhditdar  tissue,  some  of  it   is  taken  a 
by  tlie  fixed  cells  in   this   situation,  whilst   that  which   is  not  thii 
fletained  [msses  on  to  the  lymphatics,  ami  is  deposited  in  the  bron- 
chial  lyiiiphatie  glands,  where  the  black    |mrticles   are  also  visible. 
The  wandering  leucocytes  ])robably  convey  particles  from  the  luiiicn 
int«  the  mucous  membrane  of  the  bronchi. 

Closely  allied  to  the  physiological  pigmentation  of  the  lung  fn>!n 
the  inhalation  of  carbon  are  those  morbid  con<litions  which  restdl 
from  the  inhalation  of  particles  of  coal,  stone,  iron,  and  other  sub- 
st4inces,  of  which  the  lungs  of  miners,  stone-masons,  and  grinders 
afford  fre()uent  examples.  Here  also  minute  particles  enter  the 
bronchi,  penetrate  the  walls  of  the  alveoli,  and  are  de]iosited  prin- 
cipally in  the  interstitial  tissue.  In  the  case  of  miners — in  which 
this  is  most  ecuumon — the  parlicles  of  coal  enter  the  lungs  in  sncll 


FIOMEyTATlON  DEGEXERATrON. 


nt 


Fio.36. 


» 
^ 


Urge  quantities  as  to  give  to  tlicni  an  nltncst  uniform  deep  black  color 
(tttillinwimirL).  In  stiiin'iiiiisoiis,  j^i'inik'fs,  ami  others  the  lungs  al«o 
bcoioie  deeply  pigmented  (iniUcijsig),  although  to  a  less  extent  than 
those  of  miners. 

The  Itliiek  eolor  of  the  lungs  in  these  cases,  however,  is  not 
entirely  due  to  the  (iresence  of  the  inhaled  substances,  but  partly 
to  that  of  hivuiatoidiu.  The  inhaled  and  irritating  particles  set  up 
intlauimatory  changes  in  the  bronchi  and  pulmonary  tissue,  causing 
chronic  bronchitis,  chronic  catarrhal  jinenmonin,  and  a  large  increase 
in  the  fibrous  tissue  of  the  lungs,  which  thus  become  consolidated, 
tough,  and  fibrous,  in  the  most  severe  forms  ulceration,  starting 
from  the  bronchi.  pro<lnces  cavities  {'•  rolliers' "  and  ''knife- 
grinders"  phthisis").  Owing  to  these  structural  changes,  there 
is  a  considerable  e.scapc  of  red  corpuscles  fnuii  rupture  of  capil- 
laries or  inHaiuinatory  exudation,  and  hence  a  large  formation  of 
l>igment.  to  which  much  of  tlie  dark  color  of  these  lungs  must 
undoubtedly  be  a.scribed.  The  lungs  of  stonenia,sons  and  grinders 
"re,  like  those  of  miners,  deeply  pigmented,  though  to  a  less  degree; 
l>«t  the  black  color  in  the  former  eases 
r»nnot  be  entirely  accounted  for  on  tiie 
""Pposition  that  it  is  due  to  the  presence 
"'"  iiihaled  particles.  Carbon  particles 
•"*  V>lack,  angular,  and  very  variable  in 
"*e  and  shape.  They  are  unaffected  by 
*troDg  acids  and  alkalies.  I'igiiieiit  ile- 
•"iVfJ  from  tlie  blorid  is  generally  brown- 
ii»L    and   ffrnnular  relU  from  the  nputum  ..r  nciitc 

«no  granular.  hromliltl*.  «h»winij  ilir  mUmte 

•*igmentation  of  the  lungs  from  the  (tranuiM  or  [.iimuni  within  the 
I'res^nce  of  hjvmatoidin  occurs  as  the  tain,,  f.w  f.uty  m.i.mu-s.  xwo. 
"^ult  of  many  other  morbiil  conditions. 

"laiiy  diseases  of  these  organs  being  attended  by  the  formation  of 
l**gim»nt,  In  chronic  phthisis  pigmentation  occurs,  partly  as  the 
f^ult  of  ijje  inflammatory  process  and  partly  fnou  the  obstruction 
***  the  vessels  caused  by  the  new  ti-^sue;  lines  of  pigmetit  are  con- 
**tjtly  seen  surrounding  the  nodules  of  consolidation.  In  acute 
*^OU|>ous  pneumonia  the  blood  which  is  extrava.sated  into  the  air- 
dcd,  and  which  in  the  early  stages  gives  to  the  expectoration  a 
y  or  jinine-juice  color,  «ubsei|Uently  becomes  converted  into 
pigment,  and  the  sputum  becomes  of  a  grayish-black,  the  pigment- 
P»ii«lc»  being  visible  in  the  newly-formed  cells.     The  cells  met 


112 


NUTRITION  IMPAIRED. 


with  in  tlie  sputum  of  ln'niichitis  also  contain  griinules  of  pijrtiicut 
(Fijj;.  -itJ),  and  pigmentation  ])lays  an  important  part  in  tlii'  comliiinn 
of  tlie  lungs  known  as  brown  induration. 

I'l^rniunt  in  the  lung  usually  occurs  as  black  irregular  grauuh-r; 
it  is  rarely  met  with  in  a  crystalline  form.  In  all  cases  in  which  it 
is  fiMUHl  in  any  ipiantity  in  the  lung  it  in  found  in  the  bronchiiil 
ghiuils  also.  It  i«  taken  up  by  the  lymphatics,  and.  like  tbe 
iuhaletl  carbon,  becomes  arrested  in  its  passage  through  these 
glands,   where  it  remains  perniauentlj. 


CJIAPTEH   IX. 


NUTRITION  INCREASED. 


HYPERTROPHY. 


L 


The    morbid   processes    ih\\»  far  described  have  been  attentB-   * 
either  by  arrest  or  by  impairment  of  nutrition :   there  remain 
be    ciiusidered    those    in    which    the    nutrition  is    so  changed  tl^^ 
ftirniation  exceeds  waste,  and  growth  resull.s.     They  include  hypt*-^ 
trophy,  regeneration,  and  tumor-formation. 

Normal  growth  depends  u])on — (1)  the  itiheriled  tendency  of  t^K^ 
cells  to  grow  ;  ('2)  the  siipjd_v  "f  food;  and  {'i)  the  amount  of  wast    -^ 
In  all  abnormal  overgrowth   one  or  more  of  these  factors  arc  ^^ 
fault.       There   is,    however,   a   marked   ilistinction   between  hype^^ 
trophy  and  regeneration  on  the  one  hand  and  tumor-formation  <>    -^ 
the  other.      In  the  fonner  the  new  tissue  is  an  exact  reproductiu:^* 
of  the  original,  and  has  the  same  function  ;  in  the  latter  the  8tru(^^  . 
ture  of  the  new  tissue  is  not  an  vrai-t  reproduction  of  the  old.  aiii- 
the  arrangement  of  its  elements  is  still   more  distinctive,  while  DC 
tumor  possesses  any  known  function. 

Hypertrophy. 

Hypertrophy  may  be  defined  as  an  "  increase  in  the  siy.e,  weight, 
and  functional  activity  of  a  part  beyond  the  limit  of  health,  due  lo 
an  orderly  enlargement  or  midtiplication  of  all  its  normal  constitu- 
ents." From  this  definition  it  will  be  seen  that  the  wrt^wrr  of  the 
process  is  strictly  physiological ;  in  extent  only  it  is  pathological- 


BTPERTRnpnr. 


113 


^H^  ETternnl  form  and  luiuiite  structure  alike  exhibit  a  single  change — 
^H  tJiHt  of  size.  The  weight  of  an  liyiiertropliifil  organ,  however, 
^H  gives  the  most  reliable  indication  of  the  extent  of  the  change. 
^H  Strictlv  proportional  to  the  increase  in  size  and  weight  is  that  in 
^H     functional  activity. 

^H  The  termH  "•  false  hypertroj)h_y  "  and  "  pscu<Io-hyper{rophy  "  are 
^H  owd  to  indicate  tiiat  the  increase  in  size,  wliile  presenting  a  siiper- 
^H  fii'iiil  resemblance  to  hypertrophy,  is  <liie  eitlier  to  the  unequal 
^H  overgrow  til  of  the  tissue-elements  or  to  liiv  giontli  of  only  one  of 
^H  tlicm,  often  at  the  expense  of  the  rest,  ami  that  lliere  is  no  increase 
^B  iu  functional  activity.  Thus  pseudohypertrophic  nuiscular  paraU 
^H  5*'8  is  characterized  by  a  marked  enlargement  of  certain  muscles. 
^H  <liie  to  an  increase  in  their  connective-tissue  eleiiienls,  and  accoin- 
^H  panied  by  atrophy  of  the  muscular  tissue  and  diminished  functional 
H    activity. 

^H  Hypertrophy  is  said  to  be  '"simple"  when  it  is  due  to  an  in- 
^H  freast.'  in  the  size  of  the  elements  of  the  affected  part;  "numeri- 
^H  *l."'  when  to  increase  in  their  number.  The  latter  is  also  called 
^B  •'yporplasia.  These  terms  are  of  little  practical  value,  for  hyper- 
^1  trophy  is  in  nearly  all  cases  bclicvcil  to  be  numcricitl,  and  in  most 
^H  <**e8  it  is  simple  as  well.  In  the  great  example  of  physiological 
^m  "yiHTtrophy — tiie  gravid  uterus — some  of  the  muscular  fibres  may 
H  "'-   tea  times  their  normal  size. 

^  Etiology. — in  many  cases  we  cannot  say  how  far  a  given 
'Ostaiicc  of  hypertrophy  is  due  to  excessive  vital  energy  of  the  cells 
**f  the  part,  to  the  setting  aside  for  its  embryonic  rudiment  of  too 

|'*''}fe  a  number  of  cells,  to  iliniiuutioii  of  the  resistance  to  growth, 
'**   «n  ampler  food-supply,  or  to  diminished  waste. 
Iti   a  large  number  of  cases  hypertro])liy  seemi  to  occur  as  a 
ttpponse  to  a  tlemand  which  has  arisen  for  increased   work.     Thus 
P^ifficulty  arises  in  the  circulation.      It  may  be  due  to  a  narrowing 
'"   the  arterioles,  or  to  obstruction  at  one  of  the  orifices  of  the 
"Wirt,  or  to  some  interference  with   die  movements  of  the  heart- 
1^  *all»  themselves,  such  as  may  be  caiised  by  the  jiermiiucnt  aclliesioii 
^f  **'   thf  visceral  and   parietal  surfaces  of  the  pericurdium.       Under 
"I'  altered  conditions  the  normal  blood-flow  can  only  be  maintained 
"y  'nrreased  functional   activity  on  the  part  of  tlie  heart.      Now,  it 
PQemliy   happens   that    in   jiroportion   as  the   dilFiculty   gradually 
""kWe*  itself  felt,  so  the  part  or  parts  of  the  heart  upon  which  the 


114 


NVTRITIOS  INCREASED. 


extra    work    re(iuirc<l    fulls    gruduuUy   hypfrtrophy :    thus    tbe  t 
creased  (leniuncl  is   pertiuuiently  provideil  for.     At  the  snmc  tii 
the  supply  of  blooil  tiirnrif;li   the  coronaries  is  a!s(»  increased 
would  seem,  indeed,  that  this  is  the  conuectiug  link  hctween  \MitM 
increased    functional    iictivity  and    the    production    of  the    hypei 
trophy;  for  if,  through  disease  of  tlic  coronurics  or  other  cause,  m: 
increase  in   the   hlood-su])jily    to   the  heart  niuuot  be  effected,  tH 
rciptisite  liy|icrtro|>hy  din's  not  occur.     Whi'n  hypertropliy  arises  i 
tlii.s  way  it  is  termed  "  ciunpcnsatory." 

'I"he  power  of  an  organ  thus  to  hypertrophy  is  by  no  inoaKkS 
iinliniitcd.  One  Sfuirce  id'  liinitntion  is  very  clear:  this  is  in  tl»e» 
l>loo(i-sui>ply.  If  in  any  way  the  i|nality  of  the  blood  dcterionite* 
or  the  coronary  vessels  become  rigid  or  partly  obstructed,  not  onl^ 
is  increased  growth  an  impossibility,  but,  as  has  already  been  said. 
fatty  degeneration  will  inevitably  ensue  (p.  HO).  The  other  chic*f 
source  of  limitation  lies  in  the  "growing  capacity"  of  the  ceil»- 
When  the  original  disease  is  of  a  progressive  character  or  when 
its  ravages  are  increased  by  the  help  of  allied  discuses,  it  is  cle»»r 
that  there  must  ctinic  a  time  when,  even  though  the  coronary  circu- 
lation be  apparently  adetfuaie.  tlic  inherited  capabilities  of  the  coll* 
will  fail  and  gimvtli  ('i)iisei|Ueiitly  cease.  We  know  very  little  con- 
cerning this  inherited  gruning  capacity,  but  it  is  a  very  iiuportnli* 
item.  Trobably  no  increase  of  the  blood-supply  could  save  • 
thymus  gland  from  atrophy  or  increase  the  number  of  ndal* 
ganglion-cells. 

When  muscle  contracts  freipiently  against  an  increased  load,  i* 
hypertrophies — as  is  seen  in  tj-aining — unless  the  load  is  too  heavy- 
when  atrophy  may  result.  Frequent  contraction  alone  is  insufficient .» 
for  the  uin.>*cles  of  hands  used  actively  but  not  forcibly  do  no* 
enlarge,  imr  is  rrequent  micturition  in  pyelitis  followed  by  thick' 
ening  of  the  niusctihir  walls  of  the  bbnblor.  But  insert  an  obstrac- 
tion  in  the  urinary  jmssages  which  the  iiladder  can,  by  more  power 
I'ul  contraction,  overcome,  and  hypertrophy  begins.  Other  e.xam- 
|>lcs  of  these  rnni/ifiiniitiin/  hypertrophies  may  be  seen  in  the  wall* 
of  (he  intestine  ju.<t  above  a  peruianent  stricture  or  in  those  of 
a  vein  in  aneurysmal  vari.x,  or  of  any  vessel  through  which  an 
abnormal  ijuantity  of  blood   is  forced. 

\\  lieu  an  organ  is  removed  or  prevented  from  fulfilling  its  ordi 
nary  function,  other  organs  which  take  on  its  work  hypertrophy, 
receiving  the  blood  which  should  have  sup]died  the  diseased  organ 


HYPERTItOPm: 


uh 


itir  own.  Tliis  ia  best  »wn  in  the  kidney,  raivly  in 
twti^  anil  lung.  Removal  of  one  snbniaxillsiry  gland  '\n  not 
eceMarily  followed  by  hypertrojihy  ni"  ntlier  salivary  glands;  this 
ould  occur  only  from  more  frequent  stimulation  of  their  seeretory 
trvcs,  which  probably  producer  the  large  submaxillary  glands 
len  in  epithelinma  of  the  tongue.  But  the  kidneys  are  under 
irve-coutrol  in  a  diflerent  way :  they  seem  to  be  exvited  to  secrete 
]  the  presence  in  the  blood  of  material  suitable  for  their  secretion, 
lilhyiiprtrophy  naturally  results  from  continued  greatly  increased 
ipply  of  Idood  containing  excess  of  urea  and  other  products  of 
teue-inctabolism.  Enlargement  of  lymphatic  glands  ha.s  been 
He<l  lifter  removal  of  the  .ij)leen.  Increased  weight  thrown  on 
Iwne  causes  thickening  of  it — e.  </.  of  the  fibula  in  ununited 
Itcture  of  the  tibia. 

Repeated  hyperaetnia  from  hard  use  and  slight  injuries  is  fol- 
ded by  thiekeuiiig  of  the  epithelium,  as  in  a  laborer's  hand. 
B'ler  (limilar  comlitions  a  corn  may  arise.  Increa.seil  blood- 
f»ply  fo  a  limb  may  cause  lengthening  of  a  bone  if  the  epiphysis 
iiDunited.  as  has  been  seen  in  large  ulcers,  caries,  necrosis,  and 
Ict  conditions.  The  soft  parts  iiK-rease  secondarily. 
IV  hypertrophied  spleen  of  intermittent  fever  and  the  thyroid 
enilemic  goitre  (Klcbs)  are  due  to  active  hy|«eneniia,  perhaps 
btod  by  the  presence  of  organisms.  Exophthalmic  goitre  ha.s 
^Btributed  to  vasomotor  paralysiR  from  disease  of  the  sympa- 
Bc  ganglia,  but  it  is  very  doubtful  if  it  could  result  from  such 
i^ion. 

Diminished  waste  is,  apparently,  not  a  couiumn  cause  of  hyper- 
|)hy.  An  example  often  ijuoted  is  the  subinvohited  uteruH,  the 
!lt  of  which  is  made  up  of  hyjiertrophied  muscle  and  connective 
►lie  with  thick-walled  vessels,  but  it  is  doubtful  whether  chronic 
lammation  is  not  largely  res|ionsible  in  these  cases.  Uncut  hair 
I  nails  anil,  in  the  ca.se  of  many  animals,  unojipo.svd  teeth  grow 
^Wir  ves.sels  su)iply  only  nutriment  ciiough  to  uuiintain  tlu-ni  in 
^Hially-attained  condition.  Tlie  sclerosis  of  bone  produced 
^mall  doses  of  phosphorus,  the  increase  in  size  and  strength 
[tals  treated  with  small  doses  of  arsenic,  and  the  invigorating 
this  drug  upon  Styrian  mountaineers  may  perhaps  be 
iined  by  "liminished  waste. 
removal  of  resistance  to  grrowth  is  difficult  to  ascertain. 
'  a  factor  in  the  production  of  such  deformities  as 


NUTRITION  INCREASED. 


"knoek-knee"  {genu  valyum):  here  excessive  pressure  is  thrown 

ou  till-  outtT  articular  siirfacos  of  the  femur  ami  tibia,  whilst  the 
weight  Ijorin'  liy  tlu'  imii-r  surfaces  is  less  than  iKiriual.  anJ  thev 
conseiiuentiy  grow  excessively.  Many  ideroses  or  hypertmphie* 
of  connective  tissue  fitllow  ujion  ittrojiliv  of  the  essential  elements 
of  the  organ :  the  natural  resistance  between  the  two  tissues  hn* 
been  removed  (see  p.  140). 

There  reniiiiii  certain  cases  in  which  the  etiology  is  even  more 
doubtful  than  in  the  above.  First,  cases  of  true  " ifiaiit-tfrotrth" — 
increase  in  length,  rather  than  in  breadth,  being  implied;  hyper- 
trophy of  the  whole  body  (giants) :  of  half  the  body;  of  whole  limbs 
or  of  parts  of  them,  as  fingers  and  toes.  Such  yiarts  are.  on  dissec- 
tion, normal  except  in  size.  Secondly,  cases  of  /'h/mc  (/iV/H^w/row/A, 
in  which  tlie  connective  tissue  alone  is  increased,  the  part  being; 
often  iiiisshapen ;  lyiupliatics  are  often  ililiited  mid  the  Idood-vessels 
may  he  usevoid.  Examples  are  met  ujih  especially  in  the  lip  (mnkro- 
cheilia),  tongue  (makrojfhiisia),  and  lower  extremity.  Hypertrophy 
of  connective  tissues  ami  surface  epithelium  uuiy  result  from  an 
exces.sive  though  slow  and  impure  supply  of  blood.  In  some  of  the 
above,  which  are  congenital  or  appear  soon  after  birth,  there  may 
be  excessive  vital  energy  or  too  large  a  number  of  the  cells 
forming  the  rudiment  of  the  part  or  tissue. 

Nothing  is  known  of  the  causation  of  senile  hyj>ertropby  of  the 
prostate,  uor  of  the  enormous  but  rare  enlargement  of  the  female 
breast  which  may  occur  at  puberty. 

Hypertrophy  of  the  Heart. 

Hypertrophy  of  the  heart  has  been  already  referred  to,  bat  is  of 
sufficient  importiince  tn  merit  a  more  detailed  account. 

The  whide  heart  may  be  uniformly  affected,  or  the  enlargement 
may  he  mainly  contiired  tt)  one  of  the  two  ventricles. 

Uniform  hypertrophy  of  the  whole  organ  is  a  common  result  of 
adherent  pericardium.  By  this  change  the  sliding  action  of  the 
heart  is  interf<"rci!  with,  and  the  work  thrown  u|Kin  its  muscular 
walls  proportionately  increased.  A  heart  thus  enlarged  may  weigh 
from  twelve  to  thirty  ounces,  even  after  the  parietal  layer  of  the 
pericardium  has  been  dissected  off".  The  normal  shape  of  the  heart 
is  preserved,  hut  its  general  dimensions — both  external  and  internal 
— and  the  thickness  of  its  walls  are  alike  incrciised. 

Hypertrophy  of  the  left  ventricle  follows  any  changes  that  give 


HYPERTROPHY. 


117 


rise  to  obstruction  at  the  aortic  orifice  or  permit  regurgitation  from 
tie  aorta.     It  also  follows  obstruction  in  the  arterioles,  such  as 
occurs  in  some  forms  of  chronic  Bright's  disease.     The  weight  of 
tie  organ  frequently  exceeds  twenty  ounces.     In  shape  it  is  elongat- 
ed; the  septum — and  therefore  the  left  coronary  artery — is  displaced 
to  the  right  of  its  usual  position  on  the  anterior  surface.     On  ex- 
ininiiig  a  vertical  section  the  apex  is  seen  to  be  formed  entirely  out 


—I.V 


Hyi>^itrophy  of  left  ventricle  (flront  view).  Heart  Is  elongated.  Septum  occupies  middle 
of  ■n«4e  Yita  aurfitce.  (From  a  case  of  granular  kidney  from  a  specimen  In  Charing  Cross  Hos- 
t*«^  ^Mtxueum.) 

of  tlx«  wall  of  the  left  ventricle,  and  the  walls  of  this  cavity  are 
theaaselves  thickened  (Fig.  39). 

Fio.  38. 


-LV 


Hjrpertropby  of  right  ventricle  (ftx>nt  view).  Heart  is  quadrilateral  and  septum  is  displaced 
tolbeleft.  Right  auricle  is  dilated.  (From  a  case  of  chronic  bronchitis  and  emphysema 
tarn  a  specimen  in  Charing  Cross  Hospital  Museum.) 

Hypertrophy  of   the    rigrht  ventricle    follows    corresponding 
changes  in  the  mitral  orifice  and  regurgitation  from  the  left  ven- 


JfrrRlTlOS  ISCRKASE1). 

tricle.  It  may  also  be  due  to  obstruction  to  the  flo' 
through  the  lungs,  as  in  eiuphysnnn  (p.  ."►4).  In  this  chh 
is  (juadrilattTiii.  ami  its  anterior  surfarp  consists,  almost  « 
the  wall  of  the  right  ventricle.  On  section  both  ventricle 
to  take  about  an  equal  share  in  the  formation  of  the  s 

Fiu.  3».  Fi«.  -10 


LA 


yi 


RA 


-nv 


LV' 


AnUTliir  half  »t  hrait  iFIg  3D,  «e«n 
ftwm  bchlnil  U-ft  vciiirlcU-  rormn  the 
whole  of  itixx.  Wall  of  /.)':  wall  of 
MV::  10:  'J  i niirinitl  |ini|Nirt Ion  .^ :  2). 


Antpiior  ImUiif  liran  (Ply. 

brhlnil      Klutil   v.  i '     ' 

)m*M(r<riili«r\<  In  ftwi 
vonirlilf  lUic*.    Ml. 
i*iu*il,  hut  ni»l  DO  thick  iw  tlia 
i-iiji|»Ul  iirltli'c  «nil  RA  Arv  til 


organ,  while  the  usual  difference  between  the  thicknei**  ol 
i»  much  diminished.  Except  in  cases  of  congenital  d 
thickness  of  the  ri<rht  ventricle  never  reaches  that  of  the  h 
distinctions  are  well  shown  iu  the  accoiu{>an\'iug  illnstmti 


CHAPTER  X. 

REGENERATIVE    PROCESSES. 

DB»TRrCTION  of  tissue-elements  has  freqnently  been 
in  earlier  chapters  as  the  result  of  injurit^  and  various 
tive  and  inflammatory  processes,  We  must  now  briefly 
such  losses  are  repaireil.  It  has  already  been  saitl  (p.  2) 
oells  of  one  embryonic  layer  always  produce  tissues  orij 


k 


REGESBBATIVE  PROCESSES  IN  TISSUES. 


119 


h 


reloped  from  the  same  layer;  and  it  is  upparcntly  true  also  that 
true  regenerntion  of  u  tissue  occurs  only  (Voin  cells  of  that  tissue — 
muscle  from  muscle,  epithelium  from  epithelium.  Any  form  of  con- 
nective tissue  may,  however,  give  rise  to  any  other  form — areolar 
tissue,  bone,  cartilage,  etc.  With  regurti  to  the  origin  of  these 
liMue*  from  leucocytes — if  this  ever  happen — the  latter  must,  when 
wc  consider  their  sources,  be  considered  as  connective-tissue  cor- 
ptwfles. 

The  regenerative  processes  which  may  go  on  in  inlult  niesohlastic 
ligsu«s«  are  still  imperfectly  known.      Their  reproductive  energy  hiis 
I  been   supposed  to  be  limited  to  molecular  repair.     Nevertheless,  it 
is  certain  that  the  cells  of  most   iidiilt   tissues  retain  the  power  nf 
multiplication,     'i'hiit  this  is  not  tniuiifest   under  normal  conilitions 
is  possibly  becau.se  the  blood-supply  the  ti.ssues  receive  is  sufficient 
^Vly    to  maintain    the   status  i/ii.'>.    while   the   re.sistanres  opposing 
roh"'^tli.  such   as   pressure  within  the  tissue,  arc  erjual  to  the  force 
•"th  which  they  tend  to  multiply.     But  if  the  intercellular  pres- 
sor© be  loosened   by  wound  or  by  destruction,   absorption  of  the 
uuuage«i   elements   and    multiplication    of  cells  round  about  will 
wgin.      Such  injuries  usually  increase  the  blood-supply. 

'-*'  fi»r  as  investigation  ha.s  yet  gone,  the  nuclear  figures  described 
it  p.  27  hove  been  found  in  each  tissue  to  form  the  first  stage  of 
division  of  cells. 

•^    no  extensive  regeneration  occurs  without  the  formation  of 
"P*    vt'ssels.   we  shall   first  state  what  is  known  concerning  their 
[.rod  motion. 
1  Vessels. 

'Qe  formation  of  new  vessels  has  been  studied  chiefly  in  the  tad- 

W^  *  tail,  in  sections  of  healing  wouiids,  and  in  teased  ))reparation.s 

"' Krj»m,|„tion  tissue.    At  the  eml  of  the  second  day  after  the  inflic- 

liou  of  fi  wound,  anil  later,  solid  jiointeil  processes  are  seen  project- 

'"g  from  cells   forming  the  walls  of  capillaries ;  they   increase  in 

^''Rth   iitid  join  similar  processes  from  other  eapiUaries,  or,  occa- 

'■lottally,   processes  of  brajichcd  conneitive-tissue  corpuscles.       At 

hM   Very  fine,  the  proce.sses  gradiiully  widen  and   become  hollow. 

*"'»  thus  an  unnstomosing  set  of  vessels  (/«</7/-cellular  rliaimels)  is 

F'Mluced.     At  this  time  a  few  nuclei  are  seen  in  their  walls,  the 

"suit  of  division  of  the  original   cell-nuclei,   but   nitrate  of  silver 

'"*'**  Hot  show   the   lines  of  union  of  individual   endothelial  cells. 

""•"••  develop  subsequently.     The  process  eorrespomls  with  that 


120 


SVTRITTON  INCREASED. 


observed  in  the  embryo  (with  the  exception  that  no  red  oorpuscl« 
form  in  the  cells),  and  is  the  same  in  the  healing  of  wounds,  in  nrw 
growths,  and  in  reproduction  of  lost  parts. 

Two  much  le.sg  certain  modes  of  origin  of  vessels  are  dejtcribtil; 
(1)  In  frraimlatinn  ti.'ssire  Thiersch  states  that  lymph-streams  is-tiiing 
from  the  vefsel*^  Form  ehiiiiuels  between  the  looselv-eonnected  cell*, 
which  uhiuiatelv  eoiiinituiicate  with  vessels  and  fill  with  corpufdi-*- 
Observations  of  Bireh-Ilirschfeld  siipfwrt  this  view.     (2)  Spindle- 
cells  in  granulation  tissue  are  saiil  so  to  arrange  themselves  n*  t"* 
form  canals  which  eomimniicate   with   vessels.      It   is   probable  tb***- 
they  are  really  collected  round  a  hud  from  a  vessel  (Zieglcr). 

.'\s  ill  the  embryo,  the  new  ves.xels  may  increase  in  size  withti*" 
demands  made  upon  them,  muscular  and  iihrous  coats  being  form  «^~^  j 
by  cells  which  apply  themselves  around  the  original  tube. 

Adult  vessels  may  increase  greatly  in  si/.e  and  thickness,  as  is  sC'^ee^"^ 
in  the  gravid  uterus  and  collateral  vessels  of  a  limb  in  which  t 
main  trunk  has  been  tied ;  such  vessels  generally  become  tortuous 
well  as  wider.  Increased  How  through  the  vasa  vasorum  is  alw«_  ^^ 
present. 

Common  Connective  Tissue. 
This  is  the  most  freipient  seat  of  new  fornuition  of  all  kinds 
hypcrtr<i|i|iy,  tumor-formation,   and  regeiierntiou.     With  regard 
the  latter,  it  seems  most  probable  that  loj^s  of  substance  is  made  u 
by  iiiultiplicatiou   of  the   surviving  eounective-ti.ssue  cells.     For 
time  it   was   thought   that  adult  connective-tissue  corpuscles  wer 
incapable  of  growth,   and  that  almost   all   new   fibrous  tissue  i»« 
formed   from    wandering  leucocytes.     The  difficulty   in    estimating 
the  [lart  jdayed  by  each  of  these  elements  is  extreme.     Senftlehcn' 
experinu^nts   on   the  cornea   prove  the  regenerative  power  of  con 
nective-tissue  cells.     Sherrington  and  Ballance  deny  leucocytes  aiiy 
fibrnus  tissue-forming   power.      Metchiiikoff"  believes  that  only  tlif 
large   moiionuclear    leucocytes    are    capable    ftf   such   development. 
The  subject  is  discussed  more  fully  in  the  chapter  on  "  Inflamma- 
tion."' 


Adipose  Tissue. 

This  is  merely  connective  tissue,  of  wliich  the  cells  are  infiltrated 
with  fat.  Newly-forme<l  eonneetivc-tissne  cells  may  certainly  thus 
become    infiltrated  —  e.  y.  in    pseudo-hyfiertrophic    and,    to    u    loss 


REGENERATIVE  PROCESSES  IN  TISSUES 


121 


extent,  iu  infuntile  paralysis — but   inflnimnatory  tissue  as  a  rule 
reiuaiiis  free  from  fat. 

Cartilage. 
I  A  ■Mound  t>r  lireach  in  curtihigu  is  iroutTiilly  r(.']iuire(i  in  tbt'  fir.^t 
I  instance  by  .si/ur-tissue.  Tliis  may  l>e  rejibiuetl  hitcr  hy  byaiine 
I  cartilngt'  funned  from  the  pericbondriuni  and  by  prolifcratiou  of 
I  neigh bririufr  curtibige-i'ell.s.  Tlie  uiutri.x  i.s  formed,  iiccordinii;  to 
I  StnuwiT.  from  tbe  protoplasm  of  the  ct'lls.  Often  tliis  replacement 
I  by  cartilage  docs  not  occur,  in  cases  of  fractured  rib-ciirtilage  the 
I  fibmiis  tissue  may  os.sify  into  a  clasp  of  bone  round  tiie  )>roken 
I  eiuU. 
I  BOKE. 

I       The  regenerative   power  of  bone  is    couj^idernble.     It    depends 

I    chiefly  UfKjn  tbe  periosteum,  find  to  a  less*  extent  iifiori  tlie  niiirrow. 

I    Tb*;  prooeM.x  '\n  be?t  illii.-strateii  by  tbe  rejiair  of  a  simple  fracture. 
Repair  of  a  Simple  Fracture. —  During  the    first    twenty-four 
'"•urs  an  examinatiiin  shows  tbe  broken  ends  of  tbe  bone  lying  in  a 
collection  of  blood  coagulated  where  it  is  in  contact  witli  tbe  tissues, 

I  "Ot  fluid  round  tbe  fracture.  The  ends  of  the  bone  are  sliarp  and 
j*|rge<l,  tlie  periosteum  is  more  or  less  torn  and  stripped  off.  and  the 
•"eJiilla  deeply  eccbymosed.  The  injury  to  the  ves,sels  of  the  part 
excites  exudation  of  fluid  and  of  colls:  the  torn  ti.xsues  are  infil- 
'•"ate<l  bv  these  cells,  .so  that  in  ttiree  or  four  days  they  are  found  to 
navo  lost  their  earlier  appearance,  and  to  have  beeonie  soft,  jiink, 
autj    gelatinous,  as  is  best   seen   in   tbe   medulla.      In  fact,  they  arc 

I  ■  grnnulating,"  and    the   granulation    tissue    increa.ses    in  amount 

|*'Htil  the  blood  arounrl  the  frnetiire  lias  altogether  disap])eared.  and 

|ttie  emh  of  the  bones  are  imbedded  in  a  mass  of  soft  tissue.  This 
**sue  i*  formed  from   tbe  periosteum,  medulla,  and  any  other  soft 

l^l'^i-ts  that  are  injured.  From  the  thini  or  fourth  day  certain  largo 
'*•}? iilar  cells  are  seen  close  to  tbe  bone :  these  play  the  part  of 
Osteoblasts.      Here,   as    elsewhere,    the    source    of  the  cells  of  the 

lK*^nnlation  tissue,  after   tbe  effect  of  the  primary  injury  has  sub- 

'••l«ttl.  is  disputed,  some  referring  their  origin  to  leucocytes,  but  the 

'•yority  to  the  cells  of  the  medulla  ami  periosteum.     Possibly  both 

**»tTibHle:  the  effect  of  irritation  (nmbility  of  fragments)  in  caus- 

•  tijj    fjgj.   f„,.njj,tion  of  new   tissue   is   urged   in    favor   of  a  largely 

I  •'••oocylic  origin.  This  soft  tissue  is  found  in  plenty  about  the 
'^•*tli  day,  when  it  is  difficult  to  recognize  tbe  periosteum,  which  is 


I 


122 


yUTRfTIOy  ISCR RASED. 


nHollen  and  in6]trate4i  with  cells  like  other  parts.  Next,  tl»*i 
^riiiiitliitioii  tissue  bc><.'orac8  firmiT,  and  at  nbtmt  thr  foiirtcfntli  tl«y 
tlic  i><.Tio8feiim  can  again  be  seen  covering  a  spirnUc-^'hBpcil  »wclliB|B< 
wlrich  extends  beneath  it  for  sotne  distance  up  and  down  the  bone- 
A»  Billroth  says,  the  ends  nf  the  bone  are  stuck  into  this  jpimilr- 
sliaped  mass  a«  if  it  were  soft  sealing-wax ;  there  is  »  ring  out»itl« 
and  a  plug  in  the  medulla.  This  uniting  tissue  is  called  the  prt^- 
visional  callus.  In  animals  it  is  generally  convcrto«l  into  orti- 
lage,  but  in  uinn  direct  ossification  usually  begins  in  the  tbtrrf 
week.  In  man.  however,  when  tolerable  rest  cannot  be  nmintaintxL. 
M  in  fractured  ribs  and  many  fractures  in  children,  cartilage  iwy 
be  develojied.  It  is  always  in  greater  ipiantity  where  the  bunr  i«i 
thickly  covered  by  soft  parts,  and  rarely  forms  a  complete  rlDjf  in 
man.  It  is  strongly  developed  in  any  angle  or  gap.  Where  lk« 
most  perfect  rest  is  obtnincd,  us  in  fissures  of  the  skull,  little  dtB 
liroviwional  (or  permanent)  callus  is  formed.  " 

Ossification  of  the  provisional  callus  begins  in  the  angle  bctwwo 
the  periosteum  and  the  bone.  an<l  extends  thence  beneath  the  fieri' 
ostouui  and  along  the  surface  of  the  bone.  The  plug  in  the  niedulVf 
ossifies  a  little  later.  At  first  the  bone  is  soft  and  open  in  str«»< 
ture,  and  easily  picked  ofl'  the  shaft.  Its  canals  are  more  or  le* 
vertical  to  the  surface  of  the  shaft,  and  continuous  with  abnonn»^' 
witle  Haversian  spaces  in  the  latter.  Ossification  begins  round  t> 
vessels  passing  from  the  callus  to  the  bone:  the  cells  farthevt  fr^ 
the  veswels  assume  the  shape  of  osteoblasts,  and  become  surroun<i' 
by  or  converteil  into  bone.  Osteoblasts  inside  each  ring  next  l^ 
down  laminnr  of  bone  until  Haversian  systems  are  forme<i.  T* 
callus  is  now  intimately  unito<l  with  the  original  bone  and  hold*  t  J 
ends  firmly  together,  The  medullary  canal  is  blocked  by  bone  all 
osseous  buttresses  fill  up  any  angle.  This  complete  oseificatioD.tfl 
the  provisional  r-allus  is  finished  in  man  between  the  four 
eighth   weeks,  according  to  the  size  of  the  bone. 

So  far.  the  bony  tissue  has  not  been  mentione<l.  The  nexf4 
is  to  unite  the  two  ends  directly  by  what  is  termnl  permanent  C 
definitive  callus.  This  begins  to  form  when  tin-  provisional  callu 
has  fixed  the  ends  of  the  bones,  but  preparation  for  this  iinioi 
begins  much  earlier.  The  enils  of  the  bones  are  to  be  softened  iirt 
a  tissue  which  can  bridge  over  the  gup,  blend  the  two  fi  .  '' 
into  one.  and  finally  ossify.  A  rarefying  ostitis  begins  in 
ability  immediately  after  the  iiyury,  and  results  in  a  rounil-wllc 


attoaw 
iirtM| 


REGENERATIVE  PROCESSES  IN  TISSUES  123 

gron-th,  which  slowly  eats  away  the  walls  of  the  Haversian  canals, 
viiicli  thns  become  enlarged.  Naturally,  this  is  a  much  slower 
process  than  similar  infiltration  of  the  soft  parts.  So  long  as  the 
bones  are  moving  on  each  other  the  granulations  would  have  little 
chance  of  blending  across  the  gap,  but  so  soon  as  the  fragments  are 
fixed  this  union  occurs,  and  ossification,  running  on  to  sclerosis, 
foIlo-^8.     It  is  probably  not  complete  before  the  fourth  month. 

Tlie  final  process  in  the  union  of  a  simple  fracture  is  the  rounding 
off  of  all  prominences  and  the  absorption  of  all  unnecessary  provis- 
ional callus.  The  completion  of  this  may  occupy  years ;  but,  ulti- 
mately, in  an  accurately  set  fracture,  the  medullary  canal  may  be 
I  opened  up  and  most  of  the  thickening  around  the  shaft  removed. 
Generally  the  seat  of  fracture  remains  evident,  but  Billrotli  says 
that  in  some  cases  it  cannot  be  recognized.  The  analogy  between 
the  repair  of  bone  and  the  repair  of  ordinary  connective  tissue,  as 
ilescribed  under  Healing  of  Wounds,  scarcely  needs  pointing  out ; 
ossification  of  the  scar-tissue  is  the  main  difference. 

Repair  of  compound  ft-actures  is  effected  by  the  ossification  of 
gnnulation  tissue,  either  directly  or  after  its  conversion  into  fibrous 
tissue.  But  suppuration,  implying  more  or  less  destruction  of  the 
"**"  tissue,  and  oflen  necrosis  of  soft  and  hard  tissues,  greatly 
(lelayg  the  process.  (See  "Necrosis  of  Bone.")  Even  where  com- 
pound fractures  become  simple  from  the  first  by  union  of  the  wound 
"•^y  are  often  much  longer  in  healing :  the  reason  is  not  evident. 

MtrscLE. 

■A.  wound  in  muscle,  as  a  rule,  gapes  widely  and  heals  by  granu- 

***on.    In  some  parts,  as  the  tongue,  retraction  is  prevented,  and 

***on  by  first  intention  occurs  readily.     The  protoplasm  escapes 

^''Ougli  the  opened  sarcolemma,  and  leucocytes  penetrate  for  some 

'stance  between  the  fibres.      Ordinary  scar-tissue  develops  from 

**    granulation  tissue  and  unites  the  ends  of  the  muscle.     Now 

®*Is  are  now  produced  by  the  muscle-cells  on  each  side  of  the  scar, 

^**  they  invade,  and  may  eventually  replace,  the  cicatricial  tissue. 

^^■^flke  says  that  new  muscle-cells  are  produced  only  by  multi- 

P'lcation  of  the  nuclei  of  the  old.     Each  nucleus   becomes  sur- 

^ttuded  by  a  spindle-shaped  mass  of  protoplasm  and  divides  to 

'**'0»  muscle-fibres.     In  some  cases  no  regeneration  is  evident. 

Hegeneration  occurs  more  frequently  to  repair  losses  from  degen- 
*^tion,  snch  as  that  which  occurs  in  acute  febrile  diseases,  espe- 


ITION  INC 


cially  typboitl.     Tte  new  cells  are  believeil  to  spring  from 
elements  Ij'ing  between  the  original  muscle-fibres  or  by  «plittia 
the  oM  eells  from  end  to  end. 

Involuntary  innscle-cclU    multiply  also    by  division.     Tluir 
Aome  doubt  us  to  whether  those  may  not  arise  from  euuucctivc-i 
terpiisdes. 


] 


Nebvb-oells  and  Nerves. 

Nothing  is  known  of  a  regenerative  process  among  ganglion-* 
and  many  think  that  none  oecurs  in  adult  life.     An  ordinary  «cv  ii 
all  that  is  known  to  replace  destroyed  ganglionic  tissue.  J 

When  a  nerve  is  cut  across,  union  takes  place  readily  by  mR 
tissue  if  the  ends  are  brought  together:  and.  as  a  rule,  function  il 
restored  in  the  course  of  time,  even  when  a  considerable  piece  (i* 
some  cases  nearly  two  inches)  has  been  excised. 

Afti-r  division,  myelin  escapes  up  to  the  nearest  nodes  of  Ranrier 
and  blood  is  extravasated  between  the  fibres  and  in  the  sfactiK 
Then  leucocytes  infiltrate  the  en<is  for  a  short  distance,  rcndcrinj 
them  bulbous;  the  soft  parts  are  similarly  infiltrated,  and  a  uiaA> '>( 
granulation  tissue  soon  unites  the  ends.  Later  this  develops  inii 
ordinary  scar-tissue. 

Boyontl  the  degeneration  of  a  lew  fibrils  no  immediate  chsOi 
occurs  in  the  central  eml.  In  the  peripheral  end,  however,  chaog* 
occur  rapiilly,  antl  lead  to  destruction  of  the  nerve.  In  ¥farni-bloo3< 
animals,  according  to  Runiver.  after  twenty-four  hours  the  nud 
in  the  primitive  sheaths  are  found  enlarged  mid  the  sheath  is  eve*" 
where  visible;  then  protopla.sm  accumulates  round  the  nuclei, at*-' 
nodes  and  other  points,  replacing  the  medullary  substance.  On*-' 
third  or  fourth  day  these  protopliismic  m;i!<sf.H  are  so  large  as 
completely  break  up  the  slieatli  of  Schwann  at  many  points.  -> 
the  same  time  the  nuclei  are  seen  to  have  multiplied  once  or  t»ic! 
\  little  later  almost  all  the  degenerated  myelin  has  disappeartr 
and  the  axis-cylinders  are  broken  into  short  segmentit  which  mx) 
finally  sufTer  the  same  fate,  nothing  remaining  of  the  peripheral  cri 
of  the  nerve  but  the  primitive  sheaths,  distended  :it  intervals  b 
nuclei  which  are  abnormally  freijuent.  Sometimes  dro[>8  of  fat  pel 
aist.  A  few  fibres  do  not  umlergo  degeneration.  They  are  thoDgl! 
to  have  sprung  from  other  undivided  nerves  lower  down,  and  to  b 
taking  a  recurrent  course  in  the  divided  trunk.  These  fibres  deger 
rrate  in  the  central  end.     These  changes  are  said  to  begin  in  tla 


REGENERATIVE  PROCESSES  IN  TISSUES. 


125 


Kio.  41. 


miiscle-platps  in  motor  nerves,  but  they  occur  practic;illy  at  the  name 
time  throughout  the  iicrifiheral  ends.  They  are  generally  complete 
in  fourteen  ilays.  The  nerve  i.s  now  gray  ami  shrunken:  its  fibrouc 
tissue  overgrows,  and  further  wasting  and  induration  follow. 

No     regenerative   changes  occur   for 

four  or  five  weeks.      Then  it  is  found 

H  thrtt    the  axis-cylinders  uf  the  central 

eufl       are    dividing    into    two    Imndles 

»(whi«j-lj  again  divide  several  times)  or 
into  several,  and  that  these  small  new 
axi»-c\linders  are  finding  their  way 
through  the  sc^ar-tissue  into  and  be- 
^ptweon  the  old  primitive  sheaths. 
(iro\vth  of  the    axis-cylinders   always 

Ihegi  r»3  from  a  node  next  above  or 
close  to  the  section,  where  tlie  sheath 
<>'  Schwann  is  bulbous.  A  cross-section 
"f  tijc  perijihoral  end  at  about  the 
figlitli  week  shows  small  riiedtillated 
»'>'•  non-medullatcd  nerves,  among  the 
"111  primitive  sheaths,  full  of  proto- 
pljksm_  The  course  of  these  new  fibres 
H  '*  "^©'y  irregular,  especially  through 
the     scar,    where   they   may   even    loop 

■   hac-lt       At    first   non-niedullated,   they 
'";*^\»jire.    later,    sheatlis    of    Schwann, 
'*-*3  nodes  of  Ranvier,  which  are  at 
'^*'t  placed  at  short    intervals,    as    in 
'.    '-^ng  nerves.      In  the  sear  even  primi- 
^  gheaths  are  at  first  wanting,  but 
'^  ultimately    form    from    the    sur- 
^*  Jiding  connective  tissue. 


Fibres  fnmi  llif  iHTljiliiTal  cnrt  "f 

H  nervo  ten  tluysuaerftecllou,  ittained 

~j^,        "-'  with  rjsmic  acid.    One  rlhre  HliKWBthe 

-*^Iany  months,  or  even  a  vear,  may  mHsse*  <.r  <iei{ener«tiri  mjeiin ;  the 
t«  before    function    is    restore.l,    a  ^'.^Tr '  m^h  r*;  siT'"' "  "^''■'"''" 
Tier  time  being  required  in  sensory 

•n  in  motor  nerves,  and  it  is  supjiosed  that  during  this  time  the 

*»-cylinders  are  slowly  finding  their  way  nlong  the   nerve.      The 

^^le  varies  with   the  length  of  nerve  beyond  the  division  und  with 

'    ^  distance  between  the  ends.      The  number  of  axis-cylinders  pro- 

Atj^jej  in  this    process    is  much   greater   than   that   of  the   nerves 


120 


SVTRlTtOy  IXCREASKD. 


deNtro_ve»l.  It  pccms  |tnibnhle.  tluTofore.  that  manv  atro|ihv;bat 
their  further  history  is  not  known. 

CaseH  occur  iu  which  restoration  of  Heusation  takes  place  witlim 
a  few  (lavs  of  the  division  of  a  nerve.  The  probable  explanition 
is  that  coniniiinicutiug  nerves  take  on  the  function  of  ihr  iliriilc<l 
line;  but  Hoss  and  others  think  that,  if  the  ends  are  kept  in  md- 
tact  "  iunnciiiate  "   union  of  the  axis-cylinders  may  occur. 

When  union  does  not  occur,  and  after  removal  of  the  pcri]ilifrsl 
part,  the  jiro-vima!  end  becomes  bulbous  (p.  160). 

EPITHELrCTM. 

Epithelium  is  always  derived  from  pre-e.xi8ting  epitheliuni  bj 
simple  division  of  the  cells.  This  is  shown  by  the  f»ct  that  i> 
always  spreads  in  from  the  edge  of  an  ulcer,  unless  islets  of  thr 
retc  have  been  left  undestroyed  iu  the  midst  of  the  graniilatiofl 
tissue. 

The  epithelium  of  the  skin  and  mucous  membranes  and  of  luno^ 
{;lan<ls  is  beinj;  destroycil  and   replaced   throughout  lift" — si>metin»** 
very  rapidly,  as  in  catarrhs  of  mucous  membranes  ami  of  the  kidu^? 
(acute  nephritis). 

Rut  if  all  ihe  cells  of  an  u<'inus  or  tubule  of  a  gland  be  destroy*^ 
llii-re   is   prol)ably  no   repniductioii   of  epithelium.      A    woiintl  of      ' 
gland,    with    or    without    loss    of   substance,    heals    by  scar-tiMK-**' 
which   is   permanent.      According  to  von   Meister.  regeneratiiui   ^*" 
liver-cells  can  take  jdace  in  the  dog,  cat,  and  rabbit.     The  mnlt 
however,  needs  further  investigation.     The  more  highly  specialii 
tiie  function,  the  less  likely  is  the  tissue  performing  it  to  be  cspal 
of  regeneration. 

llegeneratioQ  of  nails  and  hair  is  frequent. 


Heaunq  of  Wounds. 

The  union  of  most  wounds  and  the  repair  of  losses  of  substalu^* 
are  effected  primarily  by  the  formation  of  more  or  lews  scar-tissni- — - 
/.  f.  by  the  development  of  new  vessels  and  new  connective  tissue. 
Subsei|uently  more  or  less  regeneration  of  the  injureil  tissui-s  may 
take  place  in  the  modes  above  described.  Several  modes  of  healini; 
are  desi-ribeil,  but  they  are  fundamentally  the  same.  They  ar^^ 
(I)  Immediate  union:  (-)  I'nion  by  first  intention;  (8)  Healing  by 
second  intention  or  by  granulation;  (4)  Healing  under  a  scab;  (5) 
I'nion  of  two  granulating  surfaces. 


REGENERATIVE  PROCESSES  IN  TISSUES. 


127 


Fio.  42. 


late  Union. — Described  b_v  Macartney  in  1H8H,  the  occiir- 
llio  process  has  been  confirmed  by  Paget  and  Thiersch, 
states  that  it  occurred  in  wounds  inflictetl  on  the  t<jngiie8 
The  union  is  said  to  be  effected  by  a  blending  of  the 
unchanged  surfaces  of  the  wound,  no  lymph  intervening 
It  is  com|)b,'te  in  twenty-four  Imtir*.  and  no  scar  results. 
lologists  deny  that  such  a  process  ever  occurs.  Tliey 
at  lynijih,  jiossibly  only  in  niicroscopic  i|Uiintity,  invnria- 
the  first  bond  of  union.  Willi  tiieui  uninn  by  jirM  iiiten- 
speedJe.xt  mode  of  healing  possible. 
iy  First  Intention. — This  generally  occurs  in  well-treateil 
uiids.  It  is  prevented  if  the  surfaces  are  not  accurately 
tgether,  but  left  gaping  sii- 
or  separated  in  their  deeper 
reign  bodies,  blood,  or  fluid 
in  any  tjuantity.  It  is  also 
by  movement  of  the  surfaces 
ither.  by  sloughing  of  the 
r  by  irritation  of  any  kind 
ites  inflammation  going  be- 
brinous  stage.  When  these 
»re  avoiiled  by  carefid  arrest 
^age,  cleansing,  drainage, 
provision  for  rest,  and  pre- 
septie  and  infective  inflam- 
he  following  changes  take 
capillaries  become  tlirom- 
to  the  neare.«t  collnferal 
any  arteries  or  veins  have 
or  torsioned,  the  changes 
in  Chapter  XVIII.  set  in. 
inflicted  by  a  knife  is  se- 
\j  localized,  and  of  short 
It  excites  free  exudation 
id  corpuscles.     At  first  there 

ed  corpuscles  in  the  e.xudation,  hut  they  rapidly  dimin- 

!  fluid  becomes  clear  and  deep  yellow.     If  this  exudation 

rpjantity.  it  can  escaj>e  between  the  edges  of  the  wound, 

'.  channels  should  be  purjiosely  jirovideil.     The  fibrin  <'ipii- 

tbe  exudation  coagulates  on  the  op]iosed  surfaces,  bind- 


i-A 


V20 
Union  by  flrat  tntcuiion.  (Sec  text.) 


128 


yummoy  ixcheased. 


Fio.  43. 


in;^  them  togetliiT;  it  foiitaiii.s  ii  viiriaUle  jiroportion  of  leucocvlwL 
It  is  tliis  "lyiiipli"  wliii'li  Ibrmsi  the  "jiiti/.o"  on  wounds  left  oprn. 
The  exudation  <liuiini»lie8  greatly  as  the  cfTeet  of  the  injury  |«i»« 
off.  Mit-ntsfoftii-  exinuiiintii(n  iiftrr  fwi-nty-foiir  to  thirty-six  b'iHr« 
MJiows  the  i'(jj;i's  of  the  woimd  aefiuraled  by  ti  narrow  band  of  siiial! 
roiind-cetlEi :  the  tissues  close  to  the  incision  are  swollen  and  h»iT. 
and  more  or  Iosh  infiltrated  with  leucocytes.  New  vessels  develop 
after  the  second  day  and  shoot  acros.s  from  side  to  side,  converting 
the  lymjdi  into  jiranidatiim  tissue.  This  then  goes  on  to  the  ilrvcl- 
optiient  of  scar-tissue.     The  mnnber  of  leucocytes  about  the  wound 

varies  with  the  amount  and  diimtinn 
of  tlie   irritation;    in  some  casts  it 
is  ijuite  diflieuit  to  make  out  what 
tiolds  the  edges  to;.;ether.     Thii.i  in 
a   herniotomy   wound   examine*!  on 
the  fourth  day  (Fig.  42)  the  line  of 
incision  was  recognized  iilmost  soiclr 
hy  the  fact  that  the  fat  on  one  si«it 
was  adherent  t«  tlie  deeper  Ujff 
of  the  cutis  on  the  other ;  the  t«o 
seemeil  to  he  in  actunl  contact, «»" 
there  was   hardly   any   round-ci'lh''* 
infiltration.     The  j.art  taken  bj  t*** 
tissue-elements  in  sear-formatioD  '•H 
discussed    in    Chapter   X\.     T**' 
older   a   scar   is,  the   more   cloS**- 
does  it  resemble  the  normal  tisi***' 
Union  by  Granulation. — Wb** 
a    wound    cannot    be    brought     ** 
getlier.  or  wlien  union  by  first   •* 
tentioa  is  [irevented,  this  form  * 
..  .  ,  occur.     I'ntil  union   takes  place 

I'nlon    of    iwii    KniiiuIMlnK    niirmiT!!  .  .  .  ^ 

Trom  a  breant  wcumi.     Tti.-  iiiiiiiiiK     raw  surface  18  necessarily  exjiop*' 
nmteri..!  I.  m  mm-1.  «n.»ur  amount     to  some  irritation.    This,  s-me  thin  I 

Ihmi  III  Fig.  42.    X  V>. 

keeps   u|»  a  constant   e.Kudation  <' 
fluid  and  leucocytes  from  the  new  vessels,  just  aa  the  original  injnf 
excited  such  exudation   from  the  vessels  of  the  normal   tissue.  ar» 
fill-  liMicoeytes  imbedded  in  a   little  intercellular  substance  becoD>' 
^  into  granulation  tissue.     The  majority  of  patholog 
ilieve  that  after  the  primary  severe  irritation  has 


X 


BEGEXERATIVE  PROCESSES  IS  TISSUES. 


129 


yjflefl  gniniilation  tissue  is  protluced  by  nuiltiplicnfinn  of  the  npijt;li- 
biring  comiectlve-t issue  corjiuscles.  However  fornieJ,  the  tissue 
incroaMS  in  amount  until  the  wound  is  filled  up  to  the  level  of  the 
sniTac-e,  when  the  granulations  skin  over,  as  described  in  Ohajiter 
XX.  A  granulating  wound  under  the  old-fashioned  dressings  sup- 
pumted  more  or  less  freely;  but  one  treated  antiseptically,  and 
therefore  protected  from  irritation  by  the  iuitisejitic  euqdoyed,  dis- 
cliitrpcs  a  serous  fluid.  A  seetinu  through  graiiiilatioii  tissue  shows 
on  tLe  surface  a  layer  of  small  rmind-eeils  with  bi-  or  tri-partite 
i  hnclei,  imbe<lded  in  a  substance  which  is  actually  fluid  superRcially  : 
this     biyi-r  is   breaking   down    into    pus.      Deeper   down    are   found 

IfibroMasts,  and  ilecper  still  scar-tissue  in  all  stages  of  formation. 
The  thickness  of  the  surface  layer  and  the  amount  of  jms  formed 
Vary  with  the  irritation  to  which  the  tissue  is  subjected.  In  some 
tases  destruction  ei|uals  or  exceeds  growth  of  granulations.  Here, 
•g*in,  therefore,  treatment  should  be  directed  to  the  avoidance  of 
»II  unnecessary  irritation, 
^ealinff  under  a  Scab. — In  this  form  the  exudation  is  small  in 

k amount  and  ilries  into  a  scab.     It  is  not  common   in  man  except  in 
•'i[>^Tficial   abrasions.      Formation   of  gi-anulation-    and    scar-tissue 
"^-'CtiTs  beneath   it,  as  also  does  the   inward   growth  of  epithelium. 
Wti^ii  "skinning  over"   is  complete  the  scab  drops  ofl'.     The  dry 
•<*V>    is   but   slightly    irritant   in   itself,  and  it  does  not  putrefy. 
"Qen   ulceration  spreads  beneath  a  scab  some  infective  agency  is 
.      |ir(>"lj,jl,]y   (jjg  cause.     The  process  of  scab-formation   is  sometimes 
H  imitated  by  closing  wounds,  often  leading  to  cavities,  with  coUo- 
H  4i<>u,  „r  by  allowing  blood  or  tincture  of  benzoin  on  lint  to  dry 
H  »n«J   occlude  the  opening.     Such  treatment  is,  however,  dangerous, 
H  lor   if  septic  or  infective  organisms  have  entered  and  excite  inflam- 
r      mation,  the  absence  of  drainage  will  be  most  prejudicial. 

XJnion  of  Two  Granulating  Surfaces. — When  two  surfaces 
h&Vc  granulated  as  above  described,  they  may  be  brought  together; 
iin»\  frequently  the  two  surfaces  Avill  blend,  thus  saving  the  time 
*bich  would  be  required  for  filling  up  from  below.  Free  suppu- 
r»tion  and  im]»erfect  drainage  will  prevent  such  union.  This  is 
tlie  way  in  which  abscesses  should  heal  when  their  walls  are  allowed 
(0  full  together  by  evacuation  of  the  pus  (Fig.  43). 


180 


yvTiiiTioy  rycREASED. 


Transplantation  of  Tissues. 

Even  before  Joliri  Hunter's  success  in  tran8]>lanting  a  cock's  i 
into  it»  comb  it  waa  believed  that  pieces  of  the  body,  like  tbc 
of  the  nose  or  finger,  might  remiito  if  fixe<l  in  position  soon  afl 
complete  separation  from   the   bodv.      But  accurate  knowledge 
this  subject  has  been  nciiuired  only  since  Reverdin's  di«coverr) 
"skin-grafting." 

The  tissues,  as  is  well  known,  may  survive  systemic  de«»b  (i»r 
a  short  time.  Portions  of  almost  all  tissues  may  be  removed  froia 
one  part  or  animal  and  successfully  transplanted  to  another  (« 
or  nniinal  if  the  conditions  are  suitable.  These  are:  Transferrn 
v»f  the  portion  of  tissue  with  suflicient  gentleness  and  t|uit-kiie-<»( 
ensure  that  it  is  alive  when  transferred:  close  contact  with  the  raw 
surface  [trepared  for  if:  maintenance  of  its  temj)erature :  nml 
avoidance  of  all  irritation.  e.><peciully  septic.  The  piece  of  tiw 
will,  under  these  circumstances,  become  united  by  first  inlcnti 
to  its  bed.  and  will  be  nourished  by  lymph  transuding  fn>m 
surface  until  vessels  shoot  across  into  it.  Naturally,  thmc  liiwd 
which  are  least  highly  organi/.e<l  and  which  re<{uire  the  Ifi 
ntifrim<'nt  bear  transphintatinn   best. 

Epithelium  is  the  tissue  which  bettt-r  than  any  other  benr»  tni 
planting.     Use  is  made  of   this  in  the  operation  of  grnt\iiig. 
which  small  bits  of  the  tujtfrfiriul  jinrt  of  the  rete  are  placed  np 
a  healthily-granulating  surface.      At  first,  nourished  by  the  cxiiJ 
tion,  these  fragments  grow,  adhere,  and  form  centres  wht-nce 
thelium  spreads  over  the  surface.     The  cells  of  the  root-itheath  I 
plucked-oiit    hairs    answer  the    purpose    well,     (jrranulatioii  li.« 
mav    be   skinned    over    in    this    way,   but    unless   scar-conlracti( 
accompanies    the   skinning   over,  the    cicatrix    is    liable    to  br 
ilown. 

\  piece  of  akin  an  inch  sfpiarc.  freed  from   all  fat.  may  be  tri 
planted,  and  thus  fi'tro/non  ami  similar  deformities  may  be  reme 

Similarly,  a  bit  of  murouu  mrmhraiD-,  usually  obtained  frooi  < 
rabbit's  conjunctiva,   is  transplanted   in  ca.xes  of  rtitropi'im. 

t'ltrtiltu/f  and  /irriimtfuw,  especially  when  young,  bear  transpl) 
tation  well.     (Sec  also  pp.  157  an<l  143.)     So  also  ilo  bits  of 
Macewcn  of  Gbisgow   built   uji   part  of  an   ulna  with  bits  rero<i 
from  ilcformcd  tibiae,  ami  introduced  the  practice  of  ri-plncini 
of  the  bone  removed  in  the  opening  made  by  a  trephine. 


TUMORS.  131 

Pieces  of  muBcU  have  been  successfully  transplanted,  and  part 
of  the  sciatic  nerve  of  a  bird  has  been  substituted  for  a  correspond- 
ing piece  excised  from  another  bird :  the  transplantation  of  nerve 
lias  been  successful  in  man,  so  far  as  the  mere  healing-in  of  a  por- 
ion  of  rabbit's  nerve  placed  between  the  ends  of  a  divided  median, 
'ut  time  had  not  been  allowed  for  restoration  of  function  when 
lie  notice  was  published. 


CHAPTER   XL 
TUMORS. 


Th  E  first  notion  which  the  name  "  tumor "  conveys  is  that  of 
?lling;  but  swelling  may  result  from  very  different  pathological 
•cesses,  while  the  term  "  tumor  "  has  a  much  narrower  connota- 
"•  It  is  impossible  to  give  an  accurate  definition  of  its  meaning, 
»Use  its  real  nature  is  not  understood.  It  is  generally  described 
*  formation  of  new  tissue  which  is  abnormal  to  the  part ;  which 
itarbs  its  form,  and  differs  from  it  more  or  less  markedly  in  gross 
'I  in  minute  structure;  which  performs  no  physiological  function; 
lich  tends  to  continuous  growth,  and  is  more  or  less  independent 

the  general  nutrition  of  the  body ;  and  which  has  not  arisen 
oitt    the  causes  or  in  the  course  of  inflammation. 

Ihat  tumors  are  formations  of  new  tissue  necessitates  the  rejec- 
wn  of  all  swellings  due  solely  to  retention  of  secretions  (retention- 
iysts)  or  to  extravasation  of  blood  (hsematomata).  True  hypertro- 
phies must  be  rejected  because — though  they  involve  an  increase  in 
i«e— the  shape,  structure,  and  function  are  preserved.  Finally,  all 
wflammatory  swellings,  tumor-like  products  of  infective  inflamma- 
*'0D»— such  as  gnmmata,  tubercles,  farcy-buds,  and  condylomata — 
•Ddall  localized  oedemas  and  effusions — such  as  hydrocele — must 
^  eliminated. 

The  definition  of  a  tumor  as  an  atypical  new-formation  would 
leparate  the  class  from  retention-  and  extravasation-cysts  and  from 
roe  hypertrophies;  but  many  an  inflammatory  new-formation, 
rch  as  callus  or  a  condyloma,  is  atypical  enough  both  in  form  and 
•uctnre.  Moreover,  there  is  a  whole  group  of  tumors  (sarcomata) 
licb  it  is  impossible  to  distinguish  anatomically  from  the  results 


132 


yVTRmON  IXCREASED. 


of  inflammation.  It  is  therefore  neccBsary  to  include  in  a  definition 
of  tumors  soinetbing  wliitL  sball  draw  the  lino  between  thcra  ami 
inflammatory  products :  such  a  ilistinetion  may  be  found  in  their 
causes,  modes  of  origin,  and  progress.  We  may  say,  then,  tbit 
{I  tumor  in  tui  aU/pifol  new-format  ion  not  the  remilt  of  an  infinnmn- 
tion.  False  hypertrophies,  especially  such  as  affect  limited  »nxi 
{e.ff.  accumulation  of  fat  on  the  buttocks  of  Hottentots),  are  chisflf 
allied  to  simple  tumors  and  especially  difficult  to  separate  fn>m 
them. 

DEVELOPMENT.— The  nutrition  of  tumors  is  not  rcgulmed 
like  that  of  iioruiai  tissues.  When  the  body  gets  thin  and  tlie'^^^ 
••utanvfius  fat  disiippears,  &  fatty  tumor  wastes  but  little  or  not  »t  sll 
and  malignant  growths  often  grow  luxuriantly  while  their  victim 
are  rapidly  emaciating.  With  this  fact  it  may  be  noted  tli.it  tumor* 
have  no  uerve.s,  though  the  relation  of  nerves  to  nutrition  is  wrrt 
little  understood. 

A  tumor  consists  of  cells,  formed  by  multiplication  of  pren'xistiug 
cells,  nnd  here,  as  elsewhere  in  nature,  the  characters  of  the  psrrnl 
arc  handed  down  to  the  off'spring.  In  other  words,  a  tumor  nnilth« 
cells  from  which  it  springs  always  belong  histologically  to  the  -tuo* 
class  of  tissues  (see  p.  28). 

In  development   and  structure  the  tumors  resemble  the  norH**^ 
tissues — every  pathological  growth  bus  its  physiological  prototyP^" 
The  resemblance,  Jmwever,  is  by  no   means  coraj)lete,  for.  as  \o" 
cated  in  the   detinitiun,  they  are   always  more  or  less  atypical  • 
their  structure.     As  a  rule,  the  diff'erence  between  the  normal  »** 
abnormal  tissue  is  such  that  with  the  nakeil  eye  one  can  tell  roug»**. 
where  the  one  begins  and  the  other  ends. 

The  histological  processes  which  give  rise  to  the  formation  »• 
tumor  are  doubtful  in  the   extreme.     It    is   uncertain    whether 
tumor  grows  from  a  portion  of  the  mature  tissues  or  from  a  ki'* 
of  "resting  spore  "  of  embryonic  tissue,  as  suggested  by  Cohnbr** 
(p.  143).     Evidence  of  the  multiplication  of  normal  tissue-elemef 
round  about  a  growing  tumor  is  often  ulitainiible.  hut  it  is  very  J* 
ficult  ti)   tell  what    becomes   tif  them,  and   Ziegler   was   incline<l     * 
think  that  most  disappeared.     A  cancer-embolus  in  a  gland  almt"*^ 
certainly  grows  without  any  additions  from   the  surrounding  eel  ■■ 
and  there  does  not  seem  to  be  any  a  priori  reason  why  a  fibroma 
a  sarcoma  should  receive  any  either. 


TUMORS. 


The  elements  from  wliieli  tniuors  most  freipiently  originate  are 
those  belonjiin;:  to  tlie  common  connective  tissue  and  U<  the 
blood-vessels  iirnl  IvmpLiitic  system  with  whicii  it  in  so  iiitiiiiatelv 
liated.  By  eoinmon  connective  tissue  is  meant  that  tissue 
wTiich  ui  all  piirts  surroumls  the  l)lootl-vesseis  uiul  is  so  iiniversaliv 
•listributed  throiigbout  the  entire  orguuism.  This  must  be  ciirefully 
tiirtingiiished  from  the  special  varieties  of  connective  tissue — tendon, 
artilage.  bone,  etc.  In  this  eouimon  eotinective  tissue  we  distiii- 
guish  two  kinds  of  cells — the  stable  or  connective-tissue  corpuscles, 
•111  tlic  mobile  or  "wander-cells."  Both  are  in  intimute  relation 
*itli  till'  endothelium  of  the  lymphatics,  which  commence  as  spaces 
distrilmtod  throughout  the  tissue.  Further,  the  etidothelinm  of  both 
lymplintics  and  blood-vessels  closely  resemldes  in  its  pliysiological 
functions  the  fixed  cells  of  the  connective  tissue. 

Coniiei'tive  tissue  is  .said  to  give  rise  to  tumors  by  multiplication 
wits  cells,  the  part  played  by  the  two  kinds  being  donbtfiil,  Em- 
■"Tonic  tissne  consists  of  small  round-cells  with  no  limiting  mem- 
'"'«»n>  and  a  large  nucleus,  lying  in  a  .scanty,  semi-tlnid,  and  faintly 
['■»n«ilar  intercellular  material.  This  tissue  is  ofteti  called  "  indif- 
f'Pnt."  aa  it  is  impossible  to  determine  in  this  early  stage  of  the 
'''»**'th  what  it  will  ultiinati'ly  bfconie — whether  u  libronia,  a  ,sar- 
<"•»».,  or  an  enchondroma,  etc. 

»  his  "  indift'ereiit  "  tissue  now  develops  into  that  of  the  perma- 

"»t  growth,  much  in  the  same  way  as  the  immature  connective  tis- 

•^  of  the  embryo  develops  into  variou.s  conTrective-tissue  substances 

iicous  tissue,  fibrous  tis.sue.  cartilage,  nr  bune.     The  embryonic 

iwue  may  undergo  no   higher  development,   the  cells   remaining 

"Uiid  or  oval  an<l  the  ground-substance  homogeneous;  or  the  nuclei 

''  several  cells  may  multiply  without  any  corresponding  division  of 

we  cells  themselves,  thus  forming  giant-cells ;  or  most  of  the  cells 

"•ay  lengthen  out  into  spindles.  an<l  perliajis  here  and  there  fibrilla- 

li"U,  with  disappearance  of  some  Cflls.  may  occur.     We  thus  get  the 

wund.  oval,   myeloid,   or  spindle-celled   sarcoma;   also    the    fibro- 

Mrwjma.     General  fibrillation  with   di.<appearance  of  most  of  the 

cfUi,  and  raucous   degeneration,    choiidrification,  or  ossification  of 

fie  ttroma.  may  occur,  thus  forming  fibrnma,  my.\oma.  clmiidroma, 

r  osteoma ;  or  fat  may  form  in  the  cells — lipoma.     A  combination 

f  two   or  more   kinds  of  structure   may  be   met  with   in  the  same 

mor — as  a   combination  of  sarcoma   ami  lipoma,  of  enchondroma 

it   myxoma,  and  so  on.     We  are  i|uite  ignorant  of  the  causes. 


134 


NUTRITIOS  lyCRRASED. 


upart  from  heredity,  which  determine  the  ultimate  character  of  tht    M 
tissue.  m 

Next  to  connective  tissue,  epithelium — surface  and  glandular — i«  M 
the  tissue  fmm  which  tumors  most  frequently  originate;  ami  m  H 
from  connective  tissue  are  produceil  growths  of  the  cnnnectivr-tii«uc  H 
type,  so  growths  originating  from  the  ej)ithelia  preserve  the  ejiitJn'-  I 
lial  type.  A  priori,  it  would  be  entirely  contrary  to  evolution  fnr  W 
them  to  do  otherwise;  ami  the  great  majority  of  observers  ststru  ■ 
the  result  of  their  investigations  that  epithelium  never  arise*  but  I 
from  epithelium.  It  is  nevertheless  believed  by  some  that  an  rpi-  I 
thelial  eel!  may  by  mere  contact  so  influence  a  eonnective-tis'i**  1 
cell  that  it  becomes  epithelial,  or  viff  vfrnii.  This  influence  of  une  I 
cell  up3n  another  is  called  *'  spermatic  "  (Creighton).  The  point  I 
lias  Iku'Ii  carefully  investigated  by  Zieglcr  with  a  negative  resnlt.  I 

Fnuu  the  remaining  tissues.  muBcle  and  nerve,  the  devel<>|»-  I 
ment  of  tumors  is  comparatively  rare,  and  from  the  highest  aiinlt  I 
nerve-tissue  it  is  doubtful  if  tumors  ever  arise.  I 

According  to  the  similnrity  or  diflference  which  subsists  lift«c^'*»       I 
the   new  growth   and  the   tissue  from  which    it   grows,   luiuors  »**      I 
divisible  into  two  classe.x — bomologrous  and  heterolog'ous.     Wb*-""     | 
the   tumor  resembles   in   its  structure  and  development    I  In-  tifs**'^     | 
from  which  it  originatt'*.  it  is  sai<l  to  be  hoimdogous;   *lieii  it  diflT*^*^     i 
from  it.   the  tumor  is  said    to    be  heterologous.     A  eartilagin*****  I 
tumor,   for  example,   growing  from   cartilage,    is    homologous,   t**^ 
growing  from   any   other   tissue,   as  from   the  parotiil   gland,  it       ^ 
heterologous.     This  distinction  is  probably  artificial,  not  real.     I» 
be  correct   that  tissue-typt^s  "breed  true,"  the  only  even  opparr""**j 
heterology  which  we  know  to  occur  is  the  development  of  the  diflT**^ 
ent   connective   tissues  from    the   same   embryonic  tissue.      In   C-**  , 
example  given  cartilage  does  not  arise  from  the  essential  epithel » 
cells  of  the  |iaroti<l.  but   from   the  8upjs>rting  i-onnectivc  tissue     ^^^ 
from   an   aberrant    bit   of  cartilage  from   the   rudiment  of  the  ja  "^^ 
Heterology,  however,  is  not  limited  to  the  production  of  a  ti«s^* 
which  is  dissimilar  from  that   fmiii   which   it  originates:  a  tumor 
also  said  to  be  heterologous  (or  beteorotopic)  when  it  difiers  fn*'  ^^ 
the  tissue  in  which  it  is  ritwited :  and  this  may  occur  without  9  "^^ 
being  the  direct   product  of  the   latti-r.     It   is  heterology  in  tl»    * 
sense  that   is  so  characteristic  of  malignant  growths.      Cahceri.  f5»— -^ 
example,  become  heterologous,  owing  to  the  gr<>wth  and  extensi*^ 
of  the  efiithelium  beyond  its  normal  limite  (see  "  Epithelioma  "  ~^  * 


TVMOnS. 


135 


M)d  tLe  same  form  of  heterology  obtains  in  the  case  of  all  growths 
'>ngiiinfing   frmu    ok'Uients    which    have   iiiii;viito(l  or  boen   carried 

ffom  their  original   habitat,  ami  have  t.leveh'[it'<i  into  a  tissue  difter- 

ing  from  that  in  which  they  are  found. 


RELATION    OF  THE    TUMOR  TO  THE    SURROUNDINQ 

TISSUES. — The  relation  of  the  tumor  to  the  surrounding  striic- 
liires  varies.  In  one  case  the  tumor  is  circumnrrifu'ii,  m<'rely  dis- 
placing the  surrounding  parts  and  stretching  and  irritating  their 
conne<-tive  tissue,  .'<i>  tliut  this  coines  to  form  a  fibrous  capsule 
•roHiid  the  tumor,  by  which  it  is  completely  isolated.  The  lipo- 
iiiata,  fibromata,  and  encbondromata  arc  usually  thus  ciicapsuled. 
fn  other  ca.ncs  tlie  growtii  inviuiri)  the  a<tjaccnt  structures.  There 
i«th«'n  no  line  of  demarcation  between  the  tumor  und  the  surround- 
ing part*,  and,  although  to  the  nakoil  eye  there  may  seem  to  be 
lino,  tlic  microscope  will  siiow  that  tlie  apparently  healthy  tissues 
»"*  infiltrated  with  a  small  round-celled  growth  (Fig.  44),  into 
*l»icli  the  specific  tumor-cells  are  advancing.  The  former  is  proba- 
*■'>'  tlio  result  of  tissue-irritation  set  up  by  the  latter. 

Retrogressive    changes. — a  tumor  very  rarely  disap- 
I'cai-D.  and   it   thus  diflcrs   from   iiu    intlammatory  growth — <».  </.  a 

Fi...  44. 


.^       'frhtu  »f  the  niBnuna.    SpreadiiiK  mnrtrln:  •mull  oellrd  Innitrntlon  nf  the  raiMcuUr 
I     ^*'*^  Mill  KilijMi»«  tliisui:  ill  ihe  iieij(lil)4»rluHMl  of  IJie  kIhikI.      •    'jno. 

^**ii!nft.     It    may   either    remain    stationary,    or   grow — slowly   or 

*iUly.     Sooner  or  later    it    usually   becomes  the  seat  of  retro- 

sive  changes.     The  time  at  wliicli  these  conimence  varies.     As 

I      ''•lie.  the  permanence  ami  durability  of  a  tumor  bear  an  inverse 

I  ^'•'ttion  to  the  rapidity  of  its  growth  and  to  the  inferiority  of  its 

'^'Kanizafion.     The    more    rapid    the    growth   and   the   more  lowly 

•"ganiieil  the  ti.ssue  formed,  the  less  its  durability  and  the  sooner 

retrogressive  changes  occur.     The  carcinomata  and  sarcomata 


136 


yurntTwy  iscreased. 


develoi)  nt|ii<Ily  and  degenerate  ([uickly.  They  consist  for  llii' 
most  part  of  (.-ells ;  their  eit-nu'iits  art-  unstahle  and  soon  jtcrisii. 
Omscous  tumors,  on  the  other  hand,  develop  more  tslowly,  and  are 
but  little  liable  to  retrogressive  metamorphosis.  They  consist  of « 
u  more  hijfhJv  orjiunized  tissue  and  have  niiicli  trreater  stabilitv, 

'I'lie  retrogressive  changes  are  similar  to  those  mot  with  in  theimr- 
mal  tissues.  Deficient  aujiply  of  blood  is  followed  hy  fattj/  daienrrn- 
tion  and  its  various  terminations — softening  and  caseation.  /'';/- 
mvntary.  calcareoux.  i-dlloiil,  and  mucoid  dejjrneriitiftn  may  «1» 
occur.  Tumors  may  become  the  seats  also  of  inflaiiniuitioH,  u/crii- 
tioit,  7U'cro»i»,  and  hemnrrlitHfv. 


OLINICALi  COURSE. — Tumors  are  divided  clinically  into  two 
great  groups,  the  simple  and  maligrnant.     A  simple  tumor  is  one 
which,  as  a  rule,   grows  slowly  and  steadily,  or.  having  attaim'<i  * 
certain  size,  remains  stationary.    It  consists  of  tissue  apjiroximatii'B 
closely  in  structure  to  srnue  normal   adult  tissue,  and  is  general*}" 
surrounded  by  a  distinct  capsule,  ont  of  which  it  can  be  complete*? 
shelled,   for   there  is  no   infiltration   of  stirrounding    parts.     Aft*^ 
such   removal  it  does  not  recur  locally,  and  secondary  growths    ** 
glands  or  more  distant  parts  ilo  not  result  from  it.     Its  interferef*-'^ 
with  health  is  only  mechanical,  unless  sumo  accident — as  inflamU*^ 
tion — occur  in  it.     Tumors  of  the  fully-developed  conueetive-tise"*-* 
type  generally  pursue  this  course  and  may  grow  to  a  huge  size. 

A  maligrnant  growth,  on  the  other  haBitl.  generally  grows  rapiil  *_^| 
and  tends  to  enlarge  continuously.      It   consists  of  tissne  which      * 
markedly  "atypical,"  and  is,  as  a  rule,  surrounded  by  no  capsuJ' 
but  progressively  infiltrates  the  surrounding  tissues.     Af^er  app 
rentiy  complete  removal  it  recurs  locally,  and,  whether  removed  ^^ 
not,  tends  to  give  rise  to  secondary  growths   in  the  nearest  \jX0^ 
phatic  glands  or  in  distant  parts,  or  in  both.     Though  the  palicT^ 
is  itfteu  in  excellent   health  when  (he  tunuir  first  appears,  he  soont^ 
or  later  wastes,  loses  strengtli  rapidly,  and   becomes  very  anieinic 
cachexia  is  produced.     This  is  due  t(i  many  causev« — e.  g.  to  removal'-' 
from  nornml  tissues  of  imtriuient  reijuived  for  the  active  growth  or 
the  tumor-cells:   perhaps  to  the  metabolism   of  the  latter,  ponrin^^ 
abnormal   excreta  into  the  blood;  to   pain  ami  an.xiety;  often  ti^ 
jirofuse   discharge   ami    .septic  absorption   conseijuent  upon   nlccra- 
tion:  and  occasionally  to  actiml  interference  with  the  ingestion  and 
absorption  of  food.       The  more  rapidly  and  the  more  completely 


TUWORS. 

8  tumor  produces  thene  results,  tlie  greater  is  its  malignancy. 
E^erl  frrowths  of  the  same  class  vary  iinich  in  these  respects,  and 
ililfert'Ut  classes  vary  still  more.  Though  in  a  high  degree  charac- 
It-rintic  of  cancers,  the  purely  clinical  term  "  malignnnt  "  must  he 
diiitinguished  from  the  pathological  term  ^' f<mcerim«."  which  im- 
plies a  specific  structure  in  tiie  growth  to  which  it  refers.  Sarco- 
mata lire  often  rjiiite  as  malignant  as  cancers. 


b 


RECURRENCE  AND  GENERALIZATION.— A  tumor  may  re- 
cur/i«v7//y  after  removal,  and  either  after  nr  liefore  removal  growths 
wmilar  to  the  primary  tumor  may  form  in  the  nearest  lymphatic 
gkndxw  in  more  ili»tnnt  timt-wn  <>r  ort/ini».      In  the  highest  degrees 
of  luiilitinancy  all  the.ie  occur.     Each  must  he  considered  sejiarately. 
Reproduction   of  the  Tumor  in  Adjacent  Structures. — This 
riTurri-nce   in    furo   after   removal    is   usually  the   earliest   and   the 
'•'ast  imfiortant  evidence  of  malignancy.      It  is  due  to  some  of  the 
tnmor-colls  having  been  left  behind,  and   is,  therefore,  much  more 
''*ely  to  occur  in  those  growths  which  infiltrate  tlie  surrounding 
tissnea,  and    ri'aHit  extend  beyond   their   iip/iitreiif  limits,   than   in 
'Oose  which   are   enc*psuled.      The   cells    left    behind   contiiuie    to 
If^yr  and  recurrence  occurs.     Cells  may  be  carried  to  some  little 
•''"tjince  from  the  primary  growth  by  Ivnifih-  or  blnod-ciirrents,  and 
•'o  becoming  impacted  form  the  nucleus  of  secondary  nodules  vdiich 
•••y  spring  up  around  the  original  tumor.     In  some  tumors  local 
'^urrence  occurs  many  times,  and  often   kills  the  [latieiit  without 
*'«.v   infection  of  glands  or  distant  tissues. 

Reproduction    of   the   Tumor    in   the    Nearest    Lymphatic 

^^■lands, — This  is  owing  to  the  entry  into,  and   transmission  by, 

^''e    lymph-stream    of    cells    from    the    maligiwiit    growth,    which 

••ocome  arrested  in  the  nearest  lymphatic  j^lands  an<l  there  develop 

•li«to  secondary  tumors.     These  are  in  all  cases  of  the  same  nature 

■'**  the  primary  tumor.    Wheti  the  lymphatic  glands  have  theuiselves 

•Jev«-lopefl  into  secondary  growths,  they  in  their  turn  constitute  new 

**tttre5  of  infection,  and  may  thus  infect  the  more  distant  glands 

tlie  immediately  adjacent  tissues.      When  the  lymph-sinuses  of  a 

iftd  are  so  blocked   by  new   growth  that    lymph   cannot  pa.«s,  a 

•^^Riirgitant  flow   is  the   natural    result,  and    the   lymph,   bearing 

tutuor-cells,  has  to  pass  through  abnormal  vessels  and  glands.     In 

'hi&  way  we  can  account  for  infection,  say.  of  the  abdouiinnl  glands 

"T  a  tumor  of  the  lunj;;-  and  for  the  numerous  nodules  in  the  skin 


m 


KUTRlTlOy  INCREASED. 


1 


which  sometimes  occur  widely  all  roiiud  an  ntrophied  scirrhtu  ftf 
the  mauiiun.  A  ilisturit  l_vnij)liatie  glainl  iiiiiv  bo  infected  by  cmlio- 
lism  of  its  urtt'i y.  The  tendency  of  uialigunnt  growths  to  bccoOMl 
reproduced  iu  the  lymphatic  glands  varies  very  mach.  It  is  Tcrjl 
mnrked  in  the  carcinonutta.  while  in  the  sarcomata  it  \h  compm< 
tively  slight.  The  reason  fur  these  dilferences  will  be  seen  io  i 
({Uent  chapters. 

Reproduction  of  the  Tumor  in  Distant  Tissuee. — Thi»  i) 
usually  the  final  stage  in  the  history  of  malignant  growtiis,  and  H 
known  as  their  "gencraliv.atiou."  The  reprotliu'tion  <>f  the  niilig 
nant  growth  in  distant  tissues  is.  in  the  grest  majority  of  n*M 
owing  to  the  entry  i)f  some  of  its  elements  into  the  blnod-xtrram 
The  secondary  tumors  are  therefore  the  result  of  etnbidism 'iftiiimir 
cells,  and  the  {mints  at  which  the  cell-masses  may  be  »rrr«te<l  in 
stated  in  the  chapter  on  Embolism.  As  in  the  lynifdmtic  glsiul* 
they  are  in  all  cases  of  the  same  nature  as  the  primary  one,  altlntu^l 
they  may  be  larger,  and  are  often  softer,  more  vascular,  and  in»n 
active  in  growth.  They  may  themselves  become  secondary  ccntret 
of  infection,  and  in  the  same  way  cause  tertiary  growths  in  pirtl 
beyond. 

Although  the  general  dissemination  of  a  malignant  growth  is  ibiH 
iu  most  ca.ses  due  to  the  transmission  of  its  element,-'  by  the  hicio«l' 
stream,  this  is  not  the  only  way  in  which  it  may  be  brought  alioat 
Exceptional  cases  have  been  described  in  which  the  elements  <^  < 
tumor  have  been  distributed,  and  have  caused  secondary  growih  ^ 
other  ways,  as  by  passing  ilown  the  trachea,  between  the  layer*  ^ 
the  |K>ritoneum.  or  from  the  kidneys  down  the  ureters  to  the  bl«d«l* 

Lastly,  it  must  be  borne  in  mind  that  growths  may  be  s<Tonfl*' 
to  each  other  oidy  iu  tinii' ;  that  is.  they  may  be  entirely  inilcufl 
ent  of  each  other,  originating  from  different  primary  foci.         ^| 

We  have  sjKiken  of  generalisation  and  lymphatic  infection 
being  due  to  the  transference  of  tumor-cells  from  the  primary  gr 
That  the  primary  growth  i«  the  real  source  of  the  secondary 
is  shown  by  their  similarity  in  structure,  by  their  time-relationsb^ 
by  their  deiiioiistrable  i-onnection  by  means  of  blood-  or  lymph-ch* 
nels,  and  by  the  fact  thai  tin-  set-ondary  growths  often  occur  i^j 
Mues  iu  which  primary  tumors  of  the  structure  in  question  i^m 
S?ome  Buthorilies  tliiiik  that  it  is  the  juice,  anil  t»oi  thei^H 


ionsbi 


occur. 

of  the   primary  tumor  wliieii   is 

8c>conilary  no<liilc8.     But  against  this  view  may  be  urged  the  loc^ 


conveyed   to  the  future  site  nf  tJ 


TUMORS.  139 

ized  action  ;  the  distribution  of  secondary  growths  in  the  next  capil- 
lary area,  and  the  possibility  of  explaining  exceptions  to  this  rule ; 
(ie  occasional  discovery  of  tumor-cells  in  the  blood,  most  often  im- 
pacted in  the  vessels  as  emboli ;  the  frequent  existence  of  tumors 
growing  into  veins  and  lymphatics,  so  that  cells  may  easily  be  swept 
off  bj,  or  migrate  into,  the  stream  ;  and,  lastly,  the  fact  that  second- 
ary growths  have  never  been  found  in  cartilage  or  cornea,  which  are 
both  permeable  to  fluids. 

Two  views  are  held  concerning  the  way  in  which  migrated  cells 
produce  secondary  growths : 

1.   It  is  said  that  the  cells  impacted  at  a  certain  spot  so  influence 
the  vessel-wall  and  surrounding  tissues  that  their  cells  multiply  and 
produce  a  structure  like  that  of  the  infecting  particle.     The  objec- 
tion has  already  been  stated  to  this  theory  of  "  spermatic  influence," 
which  would  require  us  to  believe  that  liver-cells,  for  example,  may 
by  their  multiplication  produce  not  only  epithelial  cells  like  those  of 
scirrhusor  epithelioma,  but  even  connective-tissue  cells  of  all  kinds. 
2.  The  cells  of  the  secondary  nodule  are  believed  to  be  the  prod- 
nets  of  multiplication  of  the   cells  of  the   tumor-embolus.      The 
'inestion  thus  arises.  Can  a  bit  of  tumor  thus  cut  off  from  its  base 
grow  ?    Artificial  embolism  has  been  produced  with  pieces  of  fresh 
P«no8teum,  with  the  result  that  they  grew,  and  produced  first  carti- 
"ge  and  then  bone,  but  after  the  fifth  week  all  trace  of  them  had 
•iisappeared.     In  effect,  they  went  through  the  same  course  as  do 
pieces  of  normal  tissue  or  of  tumor  which  are  placed  in  the  subcu- 
'»»eoa8  tissue.     We  see,  therefore,  that  they  can  grow,  but  some- 
thing in  the  healthy  tissues  prevents  their  attaining  any  size.     On 
we  other  hand,  a  piece  of  bone  or  other  tissue  placed  where  similar 
''*ue  usually  exists  does   not   thus  disappear,  as  transplantation 
operations  show. 

THE  CAUSES  OP  MALIGNANCY.— Why  do  some  tumors 
'"Tade  adjacent  tissues  and  distant  organs,  whilst  others  do  not,  even 
'wugh  the  latter  grow  as  rapidly  as  the  former  ?  Hitherto  differ- 
*"<!«  in  structure  has  been  held  to  explain  the  matter.  The  more 
pOTely  cellulur  the  tumor,  the  more  numerous  its  blood-vessels,  and 
™e  less  developed  their  coats,  the  more  rapid  is  its  spread  and  the 
••rlierand  more  certain  is  its  generalization. 

Bat  occasionally  we  find  that  a  tumor  which  has  run  a  simple 
worse,  and  which  does  not  recur  after  removal,  has  a  structure 


SVTRITWN  UfCREASED. 


uccct«8itating  its  being  placed  among  the  sarcomata.     Epulides.  ceo-    1 
tral    sarconiiita  of  bones,   and   some   sarcomata  of  tlie  ovarie.i  mid     I 
fascisv   may  grow  to  a  large  size  witiiout    itiva<ling  other  ti»sul•^<lr     I 
generalizing.     On   the  other  hand,  examples  of  the  gcneraliulion     1 
of  many  simple  tumors  have  been  frei|(iently  reeorde<l — «'.  g.  I'lion-      1 
ilroniata,  myxolipomata,  and  even  tibromutu  ;  also  adenomata  uf  tlic 
ovary  and  thyroid.     It  is  true  that  eonuective-tissne  growths  ilo 
generally  contain  a  prejionderance  of  round-cells  liefore  they  general—   | 
ize:  but  in  .some  cases  the  structure  of  the  secondary  growth  is  tfanK. 
of  the  primary,  and  is  such  as  is  usually  seen   in  specimens  wbicfc*. 
show     no     mnlignaney.      Cohnheim     thought,    therefore,    that   th^^ 
essentia!   faetor   in    "  malignancy  "  was  not  a  certain   sfriictiire  nwr^ 
the  part   of  the  tumor,  but  rather  some  change  in  the  siirroiiuilin^^ 
ti.ssues  which  rendered  tlieui   iniafde  to  resist  invasion.     For.  froi^cB 
the  way  in  which  physiological  tissues  lie  side  by  side,  never  iuvsii— 
ing  each    other's   precincts,   though   one   or  both    jnay  he  growiu.^^ 
actively,  it    is    evident   that  each   tissue   possesses  a  {wwer  wbic^ 
opjioscs    infiltration    iiy    any    other    tissue;    this    jwwer    Cohnbri^s 
called  "  physiologrical  resistance."     Its  existence  is  further  shn«  m» 
by  the  results  following  the  artificial   production  of  embolism  »itb 
pieces  of  periosteum  (p.  139):  these  results  prove  that  bits  of  ti««<'     i 
transplanted   into  the  tissues  of  a  normal  animal  may  become  vii»-      I 
cularized  and  grow  ;  linf  also  that  they  will  sliortly  after  disa[>|K'»r,      I 
the  healthy  tissues  seeming  to  regain  the  upper  li.iiid.     To  pcrniil      J 
the  infiltriition   of  one  tissue  by  the  eleiiients  of  another  the  pliV'""      I 
ologieal   resistiiiiee   -^f  tlie  former  must   be  rediiceil.      This  ma>  I"      I 
effected  by  {!)  Irgury,  and  therefore  in  iiijlammation,  as  in  chronic      I 
inflammation    of    epithelium-covered    membranes    (lupus,    chnm"'      1 
glossitis,    eirrh()si.s    of    liver,    interstitial     |>ncnmonia,   etc.),  wbtrc      I 
raa.sses  of  epithelium  are  found  in  the  infiltrated  connective  tisno*'      I 
(2)  Age:  connective  tissues  grow  most  vigorously  in  early  life. an''      I 
.sarcomata,  which  are  of  the  connective-tissue  type,  are  comiuom*'      I 
during   this   period.     But  the   [preponderating  activity  of  one  form      I 
of  tissue  at   one  special   time  is  best    illustrated  by  Thiersch,  wb"      | 
showed   that   after  midlife  connective  tissues  atrophy  from  dimin-      i 
ished  vital   activity:   diminished    physiological  resistance  probable 
accompanies  this,  aod  thus  the  more  active  surface  epithelium  it 
enabled  to  invade  tha  sub-lying  cutis.     This  he  regarded  as  esseif 
tial   to  the  growth   of  an  epithelioina.      It  is  certain  that  normally      I 
epithelial  tisfluea  grow  most  actively  in  later  life,  and  that  the  least 


fc 


Ttmons. 


141 


(Specialized  forms  show  the  tendency  Inst — a  fact  which  may  explain 

»liv  cancer  of  some  organs   occurs  at  an  oarlifr  ajr<'  titan  that  of 

otJjcr  organs.'     (3)  Heredity:  hereditary  weakness  on  the  part  of 

tic  ttaaue  surrounding  a  "'  tumor-germ  "  mnst  he  assumed  in  young 

/"♦^tple.  in  whom  neithiT  injury  nor  ago  can  be  regarded  a.s  a  cause 

of  diminished  physiological  resistance.     But  even  if  the  power  of  a 

liitnor  to  infiltrate  is  dependent  on  the  presence  of  this  diminished 

physiological   resistance  in  tin.'  adjacent  tissue,  the  structure  of  the 

gro««'th  probably  has  also  a  marked   influence  upon   its  malignancy. 

fmnors   which   have  great   power  of  growth,  whose  cells  are  lield 

loosely  together,  perhaps  actually  lying  in  lymph-spaces,  and  which 

possess  numerous   and    thin-wjilletl   blood-vessels,   must    generiili/.e 

inor«'  readily,  when  this  is  possible,  than  tumors  in  which  the  oiijto- 

«t«   conditions  obtain. 


ETIOLOGY. — Little  is  really  known  on   this  point.      We  have 

'o     account  for  the  presence,  in   the  affected  tissue,  of  cells  which 

biive  capabilities   of  growth    greater   tlian  those    po.ssessed  by  the 

"'H'tnal  cells  of  the  tissue.      lncreu,»ed  /(iini-ituii/ift/  will  of  course  he 

t'«ltjired,  but  this  is  of  secondary  importance;  so  also  are  the  sur- 

I  founding  physical  conditions,  which  may  be  favorable  or  unfavorable. 

-/Vt  first,  all   tumors  appear  to  be  local,  and  local  causes  have 

itoxiseipiently  been  sought.     A  causal  relation  seems  in  .some  cases 

I  to    «5xist  between  iixjury  or  irritation  and  the  formation  of  a  tumor. 

B»»t  we  know  that  the  effects  of  these   iiifliifnces  on  normal   tissues 

i«rtf    inflammation    and    hy])erplasia,   and    thai   they    produce  these 

■  eir<&«t8  even  in  those  who  are  the  subjects  of  tumors.     Further,  no 

u'story  of  injury  can  be  obtained  in  1.')  jier  cent,  of  the  cases,  and 

*■*«?    injuries  followed  by  tumors  must  constitute  a  very  small   )>rii- 

l**i~tion  of  the  total  number  of  injuries.     Still,  it  is  probable  that 

"*Jtiry,   by    producing    hyjierivmia    and    inflammation,    may    bring 

*tt.ra  food   to   cells   ready  to  grow,  and  may  diminish  the  j)hysio- 

''*t5ical  resistance  of  the  tissues  round  them.     Irritation  certainly 

''**e«  seem  to  have  a  powerful  effect  in  the  production  nf  certain 

*t*itbeliomata :  of  these,  rcHletit   ulcers  and  epitheliumata  occurring 

'^*-   «ild  scars  or  in  the  scrotum  of  s\vcep.s  are  good   examples.      For 

**>o  vast  majority  of  cases  no  local  cause  can  be  found. 

The   cachexia    produced    by    malignant    growths,   together    with 
*«*eir  very  fre<|ucnt  recurrence,  their  multiplicity,  and  their  heredi- 
■  Woodbead  :  Morton  Lecture,  Brit.  Med.  Journ.,  vol.  i.,  1892. 


142 


NUTRTTTOy  INCREASKl). 


tariness — all  pointing,  it  was  >iiiiil.  to  a  deep  affection  of  thi*  wbftle 
iii'gnni.xiu — gftvi.'  rise  to  the  belief'  tluit   niiiliguunt   growtU8«en4 
constitutional  origin.     This  is  a  bail  term,  for  it  may  mean  "yrt- 
eral"   nnil   refer  to  the  constitution  of  the  whole  organism,  iir it 
may  refer  to  the  constitution  of  certain  cells  and   have  »  Itn-al  m^- 
nificance.      We  shall  therefore  use  the  word  tjenenil.     Now.  we  L»ff 
already  explained  that  cachexia,  local  recurrence,  and  multiplicitT 
may  be  the  results  of  the  growth  of  a  tumor  which   wn.*  pniilurfil 
by  multiplication  of  a  few  ubnornial  cells — /.  r.  that   may  be  duel" 
a  Itxral  abnormality.     There  is  therefore  no  need  on  these  gmuniis 
to  consiiler  that  the  physiologii-al   processes  of  all  the  cells  of  thf 
organism  are  abnormal  and  tend  tu  produce  cancer :  or  that  renioa^ 
of  the  primary  growth  would  be  useless,  because  continuance  of  ^t^M 
general  abnormality  would  reproduce  the  disease  elsewhere.     Sw 
does    heredity   lead    to   this    conclusion,   for   the   whole   of  normil 
development  is  nothing  but  the  transmission  of  local   peculiaritiw: 
and,  moreover,  heredity  is  at   least  a«  marked  in  multiple  oimple 
gro«th.« — fibromata,  warts,  lipomata.  osteomata — as  it  is  in  cano 
It   is   pi-olialtle  tliiit  III!  tumors  are  at  first  Inail,  and   that  ccri 
of  them    become  malignant,   as    above  explained;    als4>  that 
inherited    peculiarity  which  results  in  ubnoriual  growth  at  a  cert»i 
time  affects  only  a  few  cells,  or  it  may  be  many  foci  of  cells,  in  "M 
tissue,  and   not  the  organism    at   large.     It  is  obvious,  howcTCTf 
that  neither  the  constitutional   nor  the  local  view  luakes  any 
tence  at  explaining  how  the  abnormal  ability  to  grow  is  acqui 
by  the  cells   that    give  origin  tu  the  tumor.      Cohuheim  adNaoi 
an  hy|K)thesis  which,  if  true,   would  offer  a  partial  solution  of 
difficulty. 

Theory  of  Embryonic  Remains. — (»n  thinking  over  the  bypw 
trophies,  the  excessive  formations  (supernumerary  digits  Knd  umrt 
marked  examples  of  "monster  by  excess"),  the  teratomata. 
other  congenital  tumors,  all  of  which  are  admitted  to  be  due  tn 
embryonic  cause,  many  of  which  are  hereditary,  and  some  of  *hicli 
do  not  appear  until  years  after  birth,  it  occurred  to  Cobnheim  lli»t 
all  tumors  might  be  iluc  to  developmental  faults,  lie  supgenteJ 
that  more  colls  than  are  needed  for  a  part  are  produces!,  and  ihii 
the  sur))lus  remain  in  nn  embryonic  state,  either  in  one  spot  or 
acattered  over  a  whtde  tissue.  The  cau.ses  of  this  error,  and  tb* 
reason  why  the  cells  do  not  develop  like  their  rotifrrrfM  and  simply 
enlarge  the  |wrt,  arc  unknown.     We  know  little  of  suck  collections 


TUMORS.  143 

"resting"  embryonic  cells,  perhaps  because  of  their  small  size 
I  resemblance  to  leucocytes.  Small  nsevoid  spots  may  enlarge 
«tly  after  birth ;  congenital  moles  which  have  the  structure  of 
eoiar  sarcomata  may  later  on  become  malignant ;  and  islets  of 
■tilage  from  which  tumors  may  start  have  been  shown  by  Virchow 
occur  in  the  shafts  of  long  bones.  Perhaps  all  these  may  be 
;arded  as  embryonic  remains. 

Affiuming  that  such  embryonic  foci  may  remain  among  adult 
jues,  Cohnheim  found  that  his  view  accorded  with  observed  facts, 
ere  would  be  no  difficulty  about  the  reversion  of  adult  cells  to 
!  embryonic  type ;  the  cells  in  question  would  start  with  their 
1  developmental  force.  The  rea-sons  for  believing  in  the  unde- 
loped  nature  of  the  rudiment  are — (1)  that  ])Ower  of  growth  is  at 
greatest  in  the  cells  of  the  embryo,  as  is  shown  by  the  fact  that 
ibrjonic  cartilage  transplanted  to  the  anterior  chamber  of  the 
e  grows  into  a  regular  chondroma,  whilst  adult  cartilage  is 
sorbed;  (2)  that  many  tumors  are  obviously  distinct  from  the 
rt  in  which  they  lie — e.  g.  adenoma  of  the  mamma  is  encapsuled, 
d  ite  ducts  do  not  open  into  those  of  the  normal  gland  ;  and  (3) 
it  tumors  are  not  subject  to  that  regulating  mechanism  which 
iders  the  metabolism  of  each  tissue  subservient  to  the  good  of 
!  tissues  generally. 

Moreover,  many  tumors  occur  at  points  where  the  developmental 
Jcesses  are  complicated,  and  where,  therefore,  errors  are  most 
ely  to  occur.  This  is  shown  by  the  frequency  with  which  car- 
loma  affects  (1)  the  openings  on  the  surface  of  the  body ;  (2)  the 
ophagus,  where  it  is  crossed  by  the  left  bronchus  (the  food-  and 
-passages  were  originally  one  here) ;  (3)  the  cardia,  pylorus,  and 
nmencement  of  the  pyloric  portion  of  the  stomach,  where  the 
»nge  of  epithelium  occurs ;  (4)  the  rectum,  at  the  line  of  union 
»een  the  invaginated  epiblast  and  the  hind-gut;  and  (5)  the 
ernal  os  uteri,  where  MuUer's  ducts  opened  into  the  uro-genital 
us.  Adeno-myomata  of  the  prostate  occur  at  the  same  spot  in 
male.  Smooth  myomata  occur  almost  exclusively  in  the  uterus. 
!  whole  uterus  is  made  up  of  foci  of  cells  awaiting  the  stimulus 
mpregnation  to  great  development.  Atypical  development  of 
focus  may  occur  without  the  usual  stimulus,  and  perhaps  we 
lid  rather  expect  this  when  pregnancy  has  been  absent  or  infre- 
it ;  so  we  find  that  myomata  are  commonest  in  elderly  sterile 
len.     Adenomata  of  the  mammae  may  be  similarly  explained. 


144 


UrUTRITIOy  ly CREASED. 


Heterologous  tumors  are  always  so  placed  that  it  is  posstblr 
see  how,  by  dovelopineiital  error,  some  cells  which  would  nator»Ilj 
give  rise  to  tiic  heterologous  tissue  might  have  been  included  m  tb4 
tumor-germ.  Thus,  dermoids  occur  in  the  neighborhood  of  norm 
invaginations  of  the  epiblast.  Muscle  may  easily  get  luto  tl 
Wolffian  bodies  from  neighboring  muscle-plates,  and  cartilagv  GrxMl 
the  rudiments  of  vertebrte. 

Finally,  from  so  atypical  a  rudiment  an  atypical  result  mi^U 
reasonably  be  exj)ected. 

.Vguinst  Cohnheim's  view   it  may  be  said  that  nothing  i*  reallj 
known  of  such   embryonic  remains;   that  many  of  the  [loiiiO 
com[dicated  development  which   he  mentions  are  aUo  jMiint.*  iif 
tatiou — c.  //.  the  narrowing*  of  the  alimentary  conal :  and  that  mas; 
tumors  of  the  gullet  and  rectum,  for  example,  though   nrar  tb 
[wints  mentioned,  are  not  at  them.      Cohnheim  himself  was  olili, 
to  exclude  from  this  class  of  tumors  such  cases  ius  epitiieliiuua  m 
Bears,  of  the  scrotum  in  sweeps,  and  of  the  arm  in  paraffin- w(.irker«i 
in  all  iif  which  irritation  plays  s«»  obvious  a  part. 

The  concurrence  of  increased  blood-supply  is  evident  in  man; 
cases — f.  (/.  enlargement  <if  ovarian  dermoids  at  puberty,  of  tiiB' 
of  the  breast,  ovaries,  and  uterus  in  pregttancy.     Ttiis  may  oi 
the  multiplication  of  cells  capable  of  growth,  and  may  explain 
apparent  causation  of  tumors  by  injuries. 

Parasitic  Theory. — Malignant  growths — carcinoma  and 
— in  their  obscure  origin,  their  tendency  to  spread  lucallr, 
their  ilissemination  by  lymph-  and  blond-paths,  present  so  obv 
resemblance  to  certain  infective  disea.«e8.  such  as  tuberculosis,  th^^ 
the  parasitic  nature  of  these  infective  diseases  having  been  ili 
strated,  the  malignant  growths  are  naturally  suspected  of  hiv 
the  same  etiology.  Some  pathologists  lean  strongly  to  the  ««? 
that  these  growths  begin  by  the  inoculation  at  some  »p<it  of  n'l 
parasite  which  excites  the  cells  to  rapid  multiplication,  and  lieli*** 
that  infection  takes  place  from  this  focus  by  the  c<)ii\eyance  of  tB*" 
parasite  along  the  lymph-  and  bl(X)d-path8.  In  the  somewhat  uO' 
usual  cases  of  a  general  outbreak  of  malignant  growths  it  is  a«»tiiB«« 
that  the  primary  focus,  in  which  the  poison  wa^  re<'eived  •»<' 
multiplied,  was  not  recognized  :  a  parallel  can  be  established  be- 
tween them  and  cases  of  general  tuberculosis  in  which  no  |Miu>an 
focus  is  found. 

The  "constitutional  theory"  is  also  resuscitated,  but  it  is  D0« 


TUMORS. 


145 


ic  to  correspond  to  the  "  tubercular  diathesis,"  or  iiredisposition 
of  cert II in  tissues  to  |ieriiiit  the  jjrowth  uf  the  bacilhis  tubercuh)sis. 
It  IS  nu  lunger  supposed  that  all  the  tissues  of  a  cancerous  patient 
ire  tending  to  grow  cancerously  or  throwing  something  into  the 
blood  which  "will  out"  soujcwhere.  but  merely  that  certain  tissues 
will  permit  the  growth  of  the  hypothetical  parasite,  should  it  ever 
reach  them.  This  '•  malignant  predisjiosition  "  may  be  inherited  or 
leqnired;  it  may  be  so  strong  that  nothing  is  reijuire<l  for  the  pro- 
duction of  a  malignant  growth  but  the  arrival  of  the  genu  at  u  pre- 
ili«|K»ed  sf»ot.  In  other  cases  the  f)hysiological  resistance  of  the 
timues  may  reijuire  still  furtiier  dejn-ession  by  injury  or  ))rivation 
before  thev  will  jiermit  the  niiilti[)lic:ition  of  the  gerui  in  their 
midfli,  the  effect  of  irritation  and  injury  in  cases  of  tuhi^'cular 
diaeane  following  bronchitis  or  strain  of  a  joint,  and  those  of  cancer 
MIowmg  irritation  by  soot,  t-ar.  or  a  blow.  Irritation  is  upon  this 
>iew,  in  the  case  of  cancer,  held  to  depress  the  vitality  of  the 
epithelium,  and  to  cause  it  to  admit  to  its  own  sub.stance  a  germ 
previously  resisted ;  and  the  frequent  origin  of  cancer  of  the  breast 
»t  the  menopause,  when  the  breast-epithelium  is  degenerating,  is 
'|«ote<l  in  support  of  it.  The  analogy  betwwii  cancer  and  tubercle 
may  he  traced  into  even  finer  details :  thus  both,  when  they  affect 
the  face  (rodent  ulcer  und  lupus),  take  an  unusual  course — slow 
olcerHtion  without  any  affection  of  glands  or  of  di.stunt  parts  and 
*itliont  any  accompanying  "  cachexia." 

It  is  further  suggested  in  favor  of  the  parasite  theory  tliat  the 
»bi<.>rption  of  the  products  of  bacterial  decomposition  would  help  to 
MpI«iD  the  cachexia,  and  might  account  for  the  fever  which  accom- 
C'liies  the  growth  of  some  tumors,  especially  lyiiiphomata;  and  that 
wih  the  alleged  incompatibility,  so  to  speak,  of  active  tubercular 
*"«  eaucerous  disease  in  the  same  subject,  and  the  rare  disapjiear- 
^uce  of  a  malignant  growth  after  a  fever,  especially  erysipelas,  may 
wdue  to  the  triumph  of  one  organism  over  the  other  in  the  strug- 
gle for  existence. 
The  presence  of  sjiecific  parasites  in  emboli  derived  from  tumors 

Hoiild,  it  is  said,  explain  the  growth  of  secouilarv  tumors  without 

the  aid  of  any  special  diminution  of  the  physiological  resistance  of 

the  tissues  in  which  the  embolus  lodges. 
Ltstly.  there  is  a  small  number  of  cases  recorded  in  which  can- 
of  one  labium  has  caused  cancer  of  the  ofiposing  surface,  and 

;ripps  mentions  a  case  of  cancer  of  the  arm  resulting  from  contact 
IC 


14« 


KVTRITIOy  INCREASED. 


with  an  ulcerating  scirrhiis :   tbe-se  are  regnnled  as  provnog  inon- 
lability. 

This  concliideAi  the  a-priori  case  which  has  hccu  made  out  for  tli» 
parai«itic  origin  of  tumors.  There  is  but  little  positive  evidence  la 
its  favor.  Gussenbancr  alleged  that  he  had  discovered  the  caiuera 
certain  minute  highlv  refracting  particles  in  and  between  the  an- 
cer-cells.  Observers  have  uniformly  failed  to  fiml  any  [Mmwilebt 
means  of  the  ordinarif  staining  methods  or  by  me«iui  of  cultiTV 
tionH.  Shattock  an<l  Balhiiice  publisheil  the  results  of  eultivati»B> 
from  a  large  number  of  tMni<.)rs,  malignant  and  simple,  in  whirl) 
no  antiseptic  (that  might  kill  any  germ)  was  used;  but  their evitt- 
vations  reuiained  sterile.  They  concluded  that  if  the  parasite  i»» 
pnitophyte,  it  must  be  of  a  very  special  kind,  aud  inclined  t"  lt<» 
view  that  it  is  probably  a  protoitoon,  which  either  exerci»e»  • 
"spermatic  influence,"  or  lives  as  a  true  parasite  in  the  epitbflial 
cell,  or,  by  conjugating  with  an  eiiithelial  cell,  t'onfers  u|Min  it  fiwh 
life  and  power  of  multiplication. 

During  the  last  few  years  many  observers  have  found  in  the 
epithelial  cells  of  cancers  what  they  believe  to  be  parasitic  jtfw- 
tozoa.  These  "cancer-bodies  "  will  be  describol  and  figured  in  tb* 
chapter  on  Carcinoma.  Their  features  have  many  points  in  ocw 
mon  with  the  coccidia  known  to  produce  marked  epithelial  prnlif*- 
ration  in  the  rabbits  liver:  the  absence  of  8|)ore8,  however,  conrti- 
tutes  a  notable  difference.  TneiTectual  efforts  hare  been  laaii*  t* 
supplement  the  purely  anatomical  evidence.  The  capsule  of ««»" 
cystf'd  protoioa  is  believed  to  consist  of  chitin  or  of  celluloM.  W* 
careful  analysi.s  of  cancerous  growths  fails  to  establish  the  preMoe* 
of  either  of  these.  No  one  has  yet  succeeded  iu  se(iaratiD(;  c'' 
cultivating  these  supjMJsed  parasites. 

Inoculations  of  cancer-juice  u)>on  luan  aud  animals  fail  not  ddIv 
to  produce  the  disease,  but  even  any  inflammatory  reactioiu  though. 
i»n  the  other  hand,  it  is  argued,  with  fairness,  that  to  produce  t''*" 
ili.^ease  predisposition   may  be  recjuired. 

In  spite  of  the  resemblance  between  the  modes  of  spreaditig  W' 
the  conse<|Ucnt  morbid  anatomy  of  the  itiulignant  growthii  iO<' 
tubercle — which  really  goes  for  very  littU- — and  of  the  plauKiH' 
nature  of  the  other  arguments  adduced  in  favor  of  the  parvit"' 
origin  of  malignant  growths,  the  probability  seems  to  us  to  be  ■* 
much  agaiii^^t  as  in  favor  of  it,  at  least  as  regards  the  true  cano*'*' 
In  the  infective  grauulomala  bacilli  carried  by  the  lymph-  or  bloo''' 


TUMORS.  147 

earn  lodge  and  excite  an  inflammation  similar  to  that  which  they 
ised  at  the  primary  focus :  the  cells  of  the  granuloma  are  chiefly 
icocytes — not  the  progeny  of  cells  from  the  primary  focus — and 
;  tendency  of  the  cells  of  granulomata,  even  when  supplied  with 
lod,  is  never  to  multiply  indefinitely.  It  has  hitherto  been 
ieved  that  secondary  sarcomatous  growths  were  truly  the  prog- 
f  of  the  primary  growth,  formed  by  multiplication  of  cells  car- 
d  from  the  primary  focus ;  and  the  melanotic  nature  of  the 
«ndary  growths  in  melano-sarcoma  has  generally  been  regarded 
proof  of  it,  there  being  no  positive  evidence  of  "spermatic 
luence"  (p.  134).  But,  as  sarcoma  tissue  is  indistinguishable 
m  inflammatory  tissue,  and  as  our  beliefs  as  to  the  origin  of  sar- 
n»-cells  are  based  on  inferences,  and  not  upon  direct  observation, 
3  possible  that  we  are  mistaken  as  to  the  nature  of  some  morbid 
coma-like  processes,  and  that  we  shall  find  them  to  be  inflamma- 
T  and  to  depend  upon  an  infective  cause,  like  rhinoscleroma. 
ith  regard  to  the  epithelial  multiplication  which  characterizes  true 
icer,  however,  there  can  be  no  such  mistake :  the  immediate  cause 
cancer  must  induce  this.  The  question  then  arises.  Is  it  conceiv- 
e,  in  the  face  of  the  necessarily  deleterious  action  upon  their  host 
all  parasites,  that  this  cause  can  be  a  parasite  ? 
Reviewing  the  whole  question,  it  is  obvious  that  we  have  only 
re  or  less  probable  surmises  before  us.  With  regard  to  simple 
Hon  Cohnheim's  theory  of  "embryonic  remains,"  which  brings 
m  into  relation  with  "  monsters  by  excess."  seems  to  be  the  most 
ely.  As  to  true  cancers,  the  view  that  the  physiological  resist- 
ueof  the  connective  tissue  is  reduced  until  epithelium,  having, 
fhapg,  only  its  normal  tendency  to  grow,  can  invade  it,  appears 
accord  best  with  known  facts:  unusually  rapid  multiplication 
epithelium  would  then  naturally  result  from  increased  food- 
?ply.  As  to  the  etiology  of  the  sarcomata,  there  is  even  less 
>Qnd  for  surmise. 

CIjASSIPIOATION. — Tumors  having  the  most  obviously  simi- 
'  structure  vary  much  in  their  clinical  history,  whilst  others  of 
lically  different  structure  have  very  similar  physical  signs  and 
"rses.  In  our  present  state  of  ignorance  no  satisfactory  classi- 
Mion  of  tumors  is  possible.  The  one  we  shall  adopt  is  based  upon 
sir  histological  characters.  Tumors  arising  from  mesoblastic  tis- 
*8  will  be  arranged  in  three  groups;  the/r8<  resembling  the  most 


148  NVTRITIOfH  JNCREASED. 

highly  differentiated  tissues;  the  second,  the  ordinary  connec 
tissues;  and  the  third,  the  embryonic  tissue.  In  dealing  v 
tumors  from  epiblastic  and  hypohlattic  tissues  the  same  order  \ 
be  followed. 

For  convenience'  sake  all  cysts  will  be  grouped  together,  a 
remarks  on  them  made  at  the  end  of  Tumors,  though  the  gn 
majority  of  cysts  are  not  tumors. 

Classification  of  Tumors. 

I. — Type  of  Higher  Ti»itue». 

Type  of  moBcIe Myoma. 

"        nerve Keuroma  (aee  note  on  p.  150 

"        blood- vessels Angioma. 

"       lymphatic  vessels  ....  Lymphangioma. 


I 

a 

I 


II. — I^pe  of  Fully-developed  Connective  Ti»»ut$. 

Type  of  fibrous  tissue Fibronu. 

"       mucous Myxoma. 

"        adi|KMe Lipoma. 

"        cartilage Chondroma. 

"        bone Osteoma. 

"       lymphoid  tissue Lymphoma. 

III. — Type  of  Embryonic  Connective  Tittue. 
The  varieties  of  Sarcoma. 

IV.—Type  of  Epithelial  Titnut. 
Epiblast    f  Papills  of  skin  of  mucous  membrane PapiUoma* 


and 


f 


hypoblast  ((Jlands f  Adenoma, 

V. — Teratomata,  or  Congenital  Mixed  Tumor$. 


THE  MYOMATA. 


14f» 


CHAPTER    XII. 

THE   MYOMATA,  NEUROMATA,  AND  ANGIOMATA. 

THE  MYOMATA. 

TuE  Myomata  are  tumors  consisting  of  muscular  tissue.  There 
rp  two  varietirs — tlie  .stritatetl  and  non-striateil. 
,  I.  The  Striated  Myomata  con.sist  of  striated  muscle.  They  are 
Iceedingly  rare,  only  two  or  tiivee  examples  having  been  recorded, 
«1  these  were  congenital.  Striated  muscle-cells,  generally  mixed 
til  a  few  mm-striated.  occur  in  the  sarootiiata  of  the  kidney  and 
tis  found  in  young  chiltlren.  Striated  muscle-cells,  in  congenital 
>wth8  of  organs  developed  from  the  Wolffian  body,  are  probably 
fc    to  inclusion  in   this   body  of  cells  from  the  ai^aceut  muscle- 

p.  The  Non-striated  Myomata  are  most  frei|uent  in  the  uterus; 
y  occur  al.**o  in  the  prostate,  the  oesophagus,  the  stonuu-h.  and  the 
featines.  They  frequently  become  pedunculated  and  ftunu  [lolypi. 
py  are  much  commoner  tiian  the  striated  growth.^,  and  pmbaldy 
Fays  originate  from  muscle.  They  may  form  distinctly  circum- 
ited  tumors  surrounded  by  a  fibrous  capsule,  or  ill-defined 
Ocular  ma!<8e»  in  tlie  mid.>Jt  of  the  muscular  tissue   in  which  thev 

I^hey  consist,  like  the  )>hysiological  tissue,  of  elongated  spindlc- 
wjth  rod-shaped  nuclei,  more  or  less  isolated  or  grouped  into 
li  of  various  sizes,  with  a  varying  quantity  of  connective  tis- 
P  The  muscular  elements  either  present  a  more  or  le.ss  regidar 
ement  or  pass  in  all  directions  through  the  tumor.  The 
reaoels,  which  usually  are  not  numerous,  are  distributed  in 
connective  tissue. 
■Tie   mnsi   frequent  secondary  change  which  myomata  undergo 

Bciflcation.  Hemorrhage,  mucoid  softeniner,  and  the  foruia- 
^  cysts  are  occasionally  met  with  :  also  inflammation,  ulcera- 
and  necrosis. 

Kically,  the  myomata  are  perfectly  innocent. 
.  >ma  of  Uterus. — The  uterus  is  by  far  the  most  frequent  seat 


rom 


uta,    and    here    thev    constitute    the    so-called 


uterine 


In  most  of  these  muscular  tumors  of  the  uterus  there  is  a 


150  NUTRITION  INCREASED. 

large  proportion  of  connective  tissue ;  hence  the  terms  "  fibroid " 
and  "fibromyoma."     This  is  the  case  especially  in  older  growths. 
Those  newly  developed,  however,  consist  almost  entirely  of  true 
muscular  tissue.     They  either  form  firm,  hard  masses  imbedded 
in  the  uterine  walls,  or  project  into  the  uterine  or  abdominal  cavi- 
ties.    When  projecting  into  the  uterus  they  constitute  a  comnioD 
form  of  uterine  polypus.     They  do  not  form  till  after  puberty,  and 
are  commonest  in  elderly  sterile  females.     Their  growth  is  usuallv 
slow.     Pregnancy  causes  them  to  enlarge  rapidly,  and  they  undergo 
some   involution  after  delivery.     They  generally  atrophy  at  the 
menopause.     These  tumors  are  often  multiple.     The  older  ones  are 
liable  to  become  calcified.     They  also  sometimes  undergo  mucoid 
softening,    which   gives   rise   to   the   formation   of  cysts   in  their 
interior. 

THE    NEUBOMATA.'  , 

The  Neuromata  are  tumors  consisting  almost  entirely  of  nerve- 
tissue,  and  are  among  the  rarest  of  new  growths. 

The  term  "  false  neuroma  "  has  been  applied  to  many  growths 
found    in    connection    with   nerves.     Fibrous,    myxomatous,  and 
gummy  tumors  growing  within  the  nerve-sheath  have  been  includ<?" 
under  this  head.     Small  multiple  fibromata  of  superficial  nerves  a^e 
sometimes  hereditary.    The  bulbous  ends  of  nerves  in  stumps  are  t»y 
some  called  amputation-neuromata.     They  often  consist  only  ^* 
fibrous  tissue,  but  may  contain  rolled-up  nerve-fibres — attempts'  ** 
regeneration   rather  than  a  tumor.     They  are  usually  intimate'* 
connected  with  the  cicatricial  tissue  of  the  stump. 

The  structure  of  true  neuromata  is  most  commonly  that  of  a  m*^ 
of  ordinary  mcdullated  nerve-fibres;  they  therefore  resemble  * 
structure  the  cercbro-spinal  nerves,  from  which  they  most  frequent'^ 
grow.  The  nerve-fibres  are  associated  with  more  or  less  connecti"* 
tissue.  A'irchow  has  also  described  as  exceedingly  rare  formatio** 
tumors  composed  of  non-medulhited  fibres  and  of  ganglionic  ner*'*^ 
tissue. 

Neuromata  rarely  attain  a  large  size,  but  usually  exist  as  sraa^  *' 
hard,  sin;;lc  nodules. 

True  neuromata  always  originate  from  pre-existing  nerve-ti9.«* 
— eitluT  from  the  cranial  or  from  the  spinal  nerves.  This  fa<^ 
deti-rniinos  tlieir  site. 

'  If,  :is  seems  prob-ilile,  nerves  an-  oiitgrowtlis  from  the  cerebro-spinal  centre,  tr«* 
neuromata  should  be  <-lassed  as  epibla»tic  growths. 


THE  ANOIOMATA. 


151 


Clinically,  the  neuromata  arc  perfectly  innocent  tumors.     They 
often  cause  considerable  pain.     Their  growth  is  slow. 

THE   ANGIOMATA. 

The  Angiomata,  or  vasciiliir  tumors,  consist  of  blooil-vesseis 
licid  together  by  a  smuli  amount  of  connective  tissue. 

This  group  includes  the  various  fiirtns  of  ntevi  and  aneurysm  by 
anastomosis.     They  may  be  divided  into  two  rarieties — the  simple 


Fid.  45. 


cap 


k^ 


m^. 


^^pllUry  narviis  tmm  aiiljciiutiiM'iiui  (Imiic  of  h  child:  tap,  vemels  of  new  growth ;  a,  nor- 
I"*!  "iltry ;  /,  fal-velln :  c,  rupaulv.     ..  aou,  reduced  I.    (Boyd.) 

oi"  oapillary  angiomatii,  in  which  the  new  vessels  resemble  chiefly 
oornial  capilhirics ;  and  the  cavernous  or  venous  an<;iomat!i,  in 
*hich  the  blood  circulates  in  a  cavernous  structure  similar  to  that 
'"  tilt,  corpus  cavernosuui  of  the  penis.  The  characters  of  both 
*'"*'  Well  shown   in  tiie  accompanying  Figs,   4.')  and  4*3. 

1.  Simple  Angiomata. — These  consist  of  tortuous  and  dilated 
'■»pillary  vessels  held  togetlier  by  a  small  ipiantity  of  connective 
"'"'  adipose  tissue  (Fig.  45).  It  is  doubtful  wiiat  ]iroportion  of 
*"*  Vwisels  is  due  to  tiilatation  of  the  original  capillaries:  Ziegler 
thinks  that  many  are  formed  this  way.  Some  are  of  new  forma- 
''on.  V'ery  irregular  dilatations  are  common.  The  capillary  walls 
"••y  be  thin  or  thick,  consisting  of  a  double  tier  of  cells.  One  or 
**o  supplying  arteries  can  be  seen  in  most  sections.  These  growths 
^^fterally  occupy  the  superficial  layers  of  the  cutis,  and  form  the 
P'^rt-wine  stains  and  niotber's  marks:  they  are  sliuhtlv  or  not  at 
*"  elevated.     Others  lie  in  the  subcutaneous  or  submucous  tissue. 


r^vi'miiiu  nitvus-  uf  liver  (fnim  a  Huniuii  utti'rl  ;i!)(:  «,  Intxc  •p«o«»  Imuuilcd  by  ""*"!' 
w»llfi,  aome  coiitalnliiK  lil(>o<l-<l<>brts :  c,  livi'rrvlU  IUhi  Ihixv),  tnwanl  wliiij)  tb«  Kto^** 
lioundi'd  liy  thick  lllirmiit  walls.    X  *'.  rwlin'od  I.    (B<iyil.) 

genital,   thoiigli   they  nuiy   not    be  noticed   for  a   few   weeks  »t^'''^ 
birth. 

Simple  angioma  is  often  combined  witli  lipoma,  glioma,  or  s*""' 
coma.     Somotinu's  cyst?  contniiring  ihirk  fluid  form   in  them. 

2.  Cavernous  Aneriomata. — Tliese  are  the  venous  tumors, 
growth  is  made  up  of  irregular  fibrous  alveoli,  which  conimunic»** 
freely  with  one  another  ami  are  lined  with  an  endothelium  simil*' 
tu  that  of  the  veins  (Fig.  4ii).  These  spaces  are  distende<l  wit"* 
blood,  which  is  supjdied  to  them  hy  numerous  tortuous  vcsaela  ai*" 
circiihitcs  wit!)  varying  (h'grees  of  rapidity.  The  arteries  opt*** 
directly  into  the  spaces.  Tliese  growths  are  commonly  of  a  blui?'* 
color.  They  may  be  diffuse  or  form  distinctly  circumscribed  tumors 
They  sometimes  exhibit  distinct  pulsation.  Their  favorite  seat  i* 
the  skin  anil  subcutaneous  tissue.  They  may  occur  also  in  the  orbit* 
muscle,  liver,  spleen,  and  kidneys.  They  may  develop  by  dilatation 
of  the  vessels  of  a  .simple  angioma.     They  may  be  eougenital,  bnt 


i 


THE  FIBROMATA.  153 

^*  the  liver  Ziegler  thinks  they  may  develop  after  middle  age,  when 
*^e  cells  begin  to  atrophy. 

Aneurysm  by  Anastomosis. — The  arteries  of  an  area,  especially 
"o  the  head,  become  dilated,  greatly  elongated,  and  tortuous ;  per- 
''*p8  new  vessels  form.     Some  are  congenital,  others  follow  injuries. 

Ziymphangiomata. — See  p.  168. 


CHAPTER  XIII. 

CONNBCTIVB-TISSUB  TUMORS. 

THE  FIBROMATA. 

The  Fibromata  consist  of  some  form  of  fibrous  tissue. 
Tue  fibres,  which  constitute  the  chief  part  of  the  growth,  are 
'^"«r  loosely  or  densely  packed  according  to  the  variety,  and  are 
rrangej  either  without  definite  plan,  or  in  intercrossing  bundles  of 
*"^>ous  sizes,  or  in  whorls  around  the  blood-vessels  (Fig.  47).  Yel- 
'"■  elastic  fibres  are  very  rarely  met  with.  The  cells,  like  those  of 
•"Qiai  fibrous  tissue,  are  generally  few  in  number,  and  are  usually 
^*t  abundant  around  the  vessels.  They  are  minute,  spindle-shaped, 
^•form,  or  stellate  bodies,  the  latter  having  processes  of  varying 
^gth.  which  communicate  with  similar  processes  from  neighboring 
'**».  In  the  fresh  specimen  the  cells  are  often  so  small  and  indis- 
'<^  as  to  become  visible  only  after  the  addition  of  dilute  acetic 
<1.  These  cells  var}'  in  size  and  number  with  the  rapidity  and 
^  of  growth — the  slower  and  older  the  growth,  the  denser  the 
*Ue  and  the  flatter  and  less  numerous  the  cells. 
rhe  fibromata  usually  contain  but  few  blood-vessels.  In  the 
*er  growths,  however,  these  are  often  more  numerous.  Dilated 
*»8  sometimes  form  a  cavernous  network,  the  walls  of  which  are 
*»ly  united  to  the  tissue  of  the  tumor,  so  that  if  divided  or  rup- 
■e<i  they  are  unable  to  retract  or  collapse,  and  profuse  hemorrhage 
•y  thus  ensue. 

Partial  mucoid  softeningr  and  calcification  are  the  most  common 
^ondary  chancres ;  ossification  occurs  in  fibromata  springing  from 
**e.  Ulceration  also  sometimes  occurs  in  those  growths  which  are 
'^ated  in  the  skin  and  submucous  tissues. 


NUTRITTON  lyCREASED. 


Fibrous  tuuiors  present  two  varieties,  the  soft  and  be 
Bponding  to,   and    usually  originuting    from,   the   loose 
varieties  oi'  ordinary  connective  tissue  respectively. 


Kio.  47. 


t:^. 


,M 


^m 


Klhniiia  tiimnn  tram  the  lUn.    N'i<ar  the  cut  bloml-veiMU,  V,  mre  M«n 
niirra  I'lil  Iritnarpreelx-     ■   WO,  »u<l  reduced  i. 

1.  Soft  Fibromata. — These  consist  of  the  looser  and  1 
form  of  fibrous  tissue.  They  are  met  with  an  diffused  gr< 
the  sabcutanoous  and  submucous  tissues.  In  the  former 
they  often  form  large  pe<luneulato<l  and  non-encapsule<l 
which  are  commonly  known  as  wens.  These  arc  sometimes 
A  similar  growth  of  subcutaneous  tissue  is  met  with  in  tnc 
flbrosum.  In  this  disease  the  large  masses  which  hang  do 
tiu-  tlii;;Ls,  butineks.  and  other  situations  consist  entirely 
fibrous  tissue.  They  often  contain  many  large  blood-vessela 
their  removal  may  lead  to  severe  hemorrhage. 

In  addition  to  these  difruse<l  growths,  more  circumscrJ 
encapeuled  fibrous  tumors  of  the  soft  variety  are  occasioi 
with  growing  from  the  scalp,  scrotum,  labium,  intermu!«cull 
or  other  situations. 

2.  Hard  Fibromata. — These  are  composeil  of  dense  fill 
sue,  like  that  in  tendons.  They  are  firm,  hard,  encapsuled 
presenting  on  section  a  grayish-white,  gli.stening.  fibrous 
anee.  These  tumors  often  occur  in  connection  with  bone — et 
the  upper  and  lower  jaws — originating  either  in  the  eentfi 
bone  or  in  the  periosteum.  (Growing  from  the  perio.*ti-i; 
alveolus  they  constitute  .simple  fibrous  epulis.  They  are 
with  in  the  nose,  where  they  form  one  variety  of  naaal  P0I7 
in  the  nasopharyn.x.  springing  fmui  the  fnuit  of  the  »pin» 
the  base  of  the  skull.  In  these  liriii  fibrou.s  jrrowth.-^  thr  v 
form  cavernous  spaces. 


THE  MYXOMATA.  15& 

Another  variety  of  hard  fibrous  tumor  grows  in  connection  with 
i^trves,  and  is  often  described  as  a  neuroma.     True  neuromata, 
Wever,  are,  as  has  been  said,  among  the  rarest  (p.  150)  of  new 
growths.     These  false  neuromata  most  frequently  occur  in  connec- 
tion with  the  superficial  nerves.     They  grow  from  the  neurilemma, 
sodas  they  increase  in  size  the  nerve-fibres  become  expanded  over 
'icm.    They  are  very  firm  rounded  tumors,  and  are  frequently  mul- 
tfpie  and  hereditary. 
Some  old  tumors  of  the  uterus  are  almost  or  quite  pure  fibromata ; 
lot    the  so-called  uterine  "  fibroids  "  are  in  most  cases  local  over- 

povrths  of  the  involuntary  muscular  tissue  of  the  organ  (p.  150). 
The  fibromata  orififinate  from  connective  tissue  ;  from  the  cutis 

or  anlcutaneous  tissue,  from  submucous  or  subserous  tissue,  from 

fascia,  firom  periosteum,  from  neurilemma,  or  from  the  connective 

tissue  of  organs. 
Clinically,  the  fibromata  are  perfectly  innocent ;  they  grow  slowly, 

«nd  <Jo  not  recur  after  removal. 


PSAMMOMA. 

file  most  characteristic  feature  of  this  rare  growth  is  that  it  con- 
sists largely  of  calcareous  particles.  These  are  contained  in  the 
coftcentric  bodies  already  described  as  the  corpora  amylacea,  where 
^^y  give  rise  to  the  so-called  "brain-sand  " — hence  the  name  of 
the  growth.  The  calcified  corpora  amylacea  are  held  together  by  a 
''wying  quantity  of  loose  fibrous,  highly  cellular,  or  mucous  tissue 
fotttaining  vessels. 

I*8ammomata  grow  from  the  pineal  gland,  the  membranes  of  the 
■•rain,  or  the  choroid  plexus.  In  the  latter  situation  a  psammoma 
often  contains  numerous  cysts.  It  is  of  no  pathological  importance, 
eicept  when  of  sufficiently  large  size  to  produce  symptoms  from 
pressure. 

THE  MYXOMATA. 

The  Myxotnata  consist  of  mucous  tissue — i.  e.  a  fragile  connec- 
*"e  tissue  of  which  the  intercellular  substance  is  translucent,  homo- 
l?*Oe<»08,  and  jelly-like,  containing  much  fluid  and  yielding  mucin, 
"hysiologically,  this  tissue  is  met  with  in  the  ritreotis  hodtf  of  the 
^yC"  in  which  the  cells  are  roundish  and  isolated  ;  and  in  the  */;«- 
tiitcai  cOT"d,  in  which  the  cells  are  fusiform   or  stellate  and  give  off 


2 


Flo.  48. 


MyxnniK  (fhnii  thmrinl.ihowlnKthe 
fharertiTlntU  l>ruiirhp<l  knutoniiinliiK 
i-rlU.  a  f<-w  li<u<'<x'yl>-«,  mid  one  <ir  two 
•(•lixllrcrlU.    X  JW. 


TRITIOX  ISCREASKD. 


fine  ansstoinosing  prolongations.     All  enibrrnnic  counrctive  i 
(p.  82)  pow^e.sses  nn  intercellular  Biibstaneo  oontuining  much  uiuda. 

eMpt;cially    that    mIucIi    snh)M<<|iifiitlr 
bfcouiei*    adi|K>s«.     New    formatioiii 
may    iinilfr;;<i   miicoitl    ilfgi'nrratinn. 
and   thii-H  fhiscly    rOiH-inhU'   in    tJirir 
phyeic-al  and  cht'tniral  charkctvn  ti* 
niyxoniuta:  but  n  myxoma  cnn>iit> 
of  miii.'oui'i  tiiufuc  from  the  first.    Tiif 
niyxouiata  arc  thus  very  clo«cljil- 
lied  to  the  sarcomata,  auii  by  miat 
arc  included  in  the  .«anie  clawnf  Df« 
formatiiinH.      An  (t-deuiatou»  fibrmuA 
or  lipoma  closely  resemble*  a  ditk* 
oma  or    niyxo-li|Kima:      Ki>»t«t  br- 
lieves   that    they  are    iiieutical. 
Structure. — The  majoritr  of  tS»« 
cell.'*  are  angular   and    stollntc.  with    long  anastomoHiiig   prolon^ff*" 
tioni*:  others  are  isolated,  and  fusiform,  oval,  or  spherical  in  >btf»* 
(Fig.  48).     Their  contour  is  rery  indistinct,  owing  to  the  refnic^ 
ing    nature   of  the    intercellular    substance.     The   latter    i«  wry 
abundant,    jierfectly    h<imogene<iu.s,    soft,   gelatiniforni,  viscifl,  »!»•• 
yiehls  large  ([uantities  id"  mucin;  in  it  are  a   varying  number c»" 
anneboid  cells.      Blood-vessels  are  not    uumerons,  ami  are  reaihl  ^ 
visible  and  easily  i.solatetl.      A  few  elastic  fibres  are  soni<'timc*  w"  ■• 
between  tin-  cells. 

Among  the  secondary  chancree  the  most  common  is  rupture'** 
the  capillaries,  bemorrhaGTe,  and  the  forinatinn  of  blood-cystic 
this,  however,  is  It-ss  frc(|iieiit  than  in  the  sarcoinata.  The  cti  • 
theraa«dves  may  umlergn  mucoid  or  fatty  defeneration,  anil  th««* 
l>e  destroyed  :  this  is  usually  ac('om|)lished  by  liipiefaction  of  the  inle^" 
cellular  siibsiaiice.  The  growth  may  inflame,  ulcerate,  and  necn*^- 
The  varieties  of  myxoma  depend  principally  upon  its  combu*^^ 
tion  with  other  growths;  a  pure  myxoma  is  very  iiniisuKl.  I*  '' 
moxt  common  combination  is  a  myxo-lipoma.  Combinations*'^  ' 
sarcoma,  fibronia.  cboiirlronia.  and  a'lenouui  are  also  met   with. 

To  the  naked  eye  the  my.xomata  are  of  a  [K>culiar  aofl  griat   ' 
ifonn    consistence  and   of  a    pale   grayish   or    reddish-white  c««l"' 
Their  cut  surface  vieldi  a  tenacious  mucila;'inouh  liiiuiil.  in  wb»*" 
may  be  seen  the  cellular  elements  of  the  growth      They  arc  xan»'  ' 


THE  UrOMATA. 


187 


separated  from  the  surrouiKliiig  structures  by  a  very  thin  fibrous 

capsule.      Fine   prolotij^ations   extend    from   this    into   the    growth, 

ilividing  it  into  h)bules  of  various  sizes.     In  exceptional  cases  a 

myxoma  may  increase  by  the  continuous  invasion  of  the  surround- 

it\^  tisxuen. 

Myxoniiita  grow  trova  connective  tissue,  und  arc  most  common 
in  subcutaneous  and  sul)serous  fut  and  in  submucous  und  inter- 
BiHscnlar  tissue.  They  also  grow  from  tiie  periosteum  and  medulla 
nfboric.  from  the  connective  tissue  of  organs  (esjK'cially  the  breast), 
»Dil  from  the  piTineuriitiii  of  nerves,  forminfi  one  variety  of  "'false 
neuroma."  They  may  grow  from  the  jplarcnta,  constituting  the 
»i>-CBllcd   "uterine  hydati<ls." 

When  situate  in  superficial  parts  thoy  may  become  i)cdiiiic(ilatod: 
ia  the  submucous  ti.ssue  of  the  no.se  they  constitute  one  form  of 
na^al  polypus.     In  the  skin  they  are  often  papillary. 

Clinically,  myxouiata  occur  chiefly  after  mid-life,  and  are,  for 
•he  most  part,  benign.  Their  growth  is  usually  slow,  but  they 
may  attain  an  enormou.s  size.  If  completely  removed  they  rarely 
fpcur.  Sometimes,  however,  they  recur  locally  after  removal,  but 
oy  probably  never  reproduce  themselves  in  internal  organs.  In 
•peaking  of  their  malignancy  their  occasional  association  with  sar- 
coma must  be  borne  in  mind. 


^Uk 


Fiu.  40. 


h' 


THE   LIPOMATA. 
.A    Lipoma,  or    fatty    tumor,  is    a    localized   and    circumscribed 
formation  of  fat. 

The  li]K)mata  resemble  in  their  Btructure  adipose  tissue  (Pig. 
^).  They  consist  of  cells  containing  fat 
*1  a  variable  i|uantity  of  comiuon  con- 
"ftctive  tisAue.  The  cells  are  like  those 
"'"  adipose  tissue,  though  usually  some- 
what larger.  The  nucleus  and  proto- 
[ilasui  are  so  compressed  against  the 
•^ll-WttU  by  the  fluid  contents  that  they 
■""^  readily  visible  only  when  the  cell  is 
*tpopbied  and  contains  less  fat  (Fig.  ;>, 
48).  Connective  tissue  varies  much 
atnrtiinf,  unites  the  cells  in  nuisses  or 
lo^Jiiles  which  are  larger  than  normal,  and 
'omg  in  niost  cases  around  the  tumor  a  thin  capsule  more  firmly 


Upomk.    Somi-  of  tin-  celU  con- 
tiiln  cryetslUiseil  fiilly  nrlilii.    x 


168 


KUTRlTIOy  INCREASED. 


ailhercnt  to  surroiiinlin;;  parts  than  to  the  tiiinor ;  so  the  latter,  in 
most  cases,  "shells  out"  easily.  Bh)od-vessoIs  are  ilistrihiiiisj  m 
the  fibrous  septa.  Mucous  tissue  is  often  associittod  with  the  fattj 
(myxo-lipoma). 

Secondary  changres   in    tlie    lipomata  aro  not   cnnitnon; 
fibrous   septa    may.  however,   become    calcified,  or    oven 
Softening  may  occur  also  from  a  mucoid  change.     InflainmAti( 
is  rare,  but  when  large  and  situated   in   the  8ubcutani-<)ua  tiwuetli* 
skin  over  them  may  become  adherent,  and  ulceration  and  necrow 
of  the  tumor  occur. 

The  chief  varieties  are  the  flbro-Iipoma,  in  whieli  the  filrM'- 
tissue  is  excessive,  and  tiie  myxo-lipoma,  or  combination  of  lum i  i- 
with  fatty  tissue.     (For  lipo-sarcoma,  see  p,  171). 

To  the  naked  eye  the  li[Kiniuta  are  more  or  less  lobulateil.  «ini 
usually  snrroundeil  by  a  fibrous  capsule.     When  subcutaneous  th'J 
move  freely  over  the  <leep  fa.scia,  but  often  the  attempt  to  rniw  th« 
skin  from  them  causes  it  to  dimple.     On  section  they  present  \kt 
ordinary   a[)|iearnnce  of  adipose   ti.ssuo.   with    more  or    less  d«W« 
fibrous   sejifa    between   the    lobules.     Their    consistence  and  theit 
adhesion   to   the  capsule   vary    with   the  amount  of  fibrous  tinu* 
which   they   contain.     In   their  growth   they   occasionally   beMB>* 
pedunculated. 

Lif)omata  firrow  firom  connective  tissue,  and  their  iiossible  iii^>' 
tribiition  is  almost  coextensive  with  that  of  ailipose  and  connecii*"* 
tissue.  They  (x'cur  most  fr<M|uently  in  the  subcutaneous  tissueo** 
the  trunk,  especially  of  the  l)ack  ami  abdominal  wall;  .somflimw  i^ 
intermuscidar  8e|ita,  subsynovial  and  subserous  tissui«,  and  ooe^*' 
sionally  also  in  the  submucous  tissue  of  the  stomach  and  inte*line^*> 
and  even  in  internal  organs  where  there  is  normally  no  fat. 

Olinically,  i!ie  lipomata  are  ijuite  innocent :  they  grow  slowly,  bt»* 
may  attain  a  huge  size;  thev  are  usually  single,  but  are  not  iiifr^^ 
ijuently  midtiple  and  hereditary.  Sometimes  they  change  tli<?»'' 
]H>»ition  considerably,  presumably  from  the  influence  of  grmritV* 

THE  OHONDROMATA. 

A  Chondroma  is  a  tuinor  composed  of  cartilage. 

In   minute  structure  these  tumors  consist  of  cells   and  of 
intercellular    substance,   Itoth   of   which   present   all   the   vari«ti«»' 
observed  in  normal  cartilage.     The  intercellular  substance  in< 
be  hyaline,  fibrous,  or  mucoid.     When  fibrous  the  fibres  m*y 


THE  CHONDROMATA. 


159 


Fio.  50. 


.0_^Jj^^ 


Fibruiis  chondroma. 
X  200. 


Qged  like  thofie  of  fibro-cartilage.  or  more  or  le.sp  conceiitrii-ally 
ntl  the  cells.  aj»  in  the  reticular  cartiliiges  of  the  ear  ami  laryii.x 
:■  50).  The  fibres  may  be  distinct  or  hardly  peree[)tible. 
m  hyaline  or  mucoid  it  i»  sotnetinies  quite  soft  in  consistence. 

cells  may  be  numerous  or  few  in  |)ro|Mirtion  to  the  matri.v. 
he  fibrous  foruis  they  are  oiYen  suiiiii.  and 
I  oomewhat  spindle-shaped,  more  resem- 
g  those  of  connoctivc  tissue;  in  the  iiyiiline 
Mthey  are  usually  large,  and  eitiier  round  or 
[(Fig.  SI);  and  in  the  rarer  mucoid  forms 
rare  more  commonly  ."tellate  and  brani'lied, 

the  transitional  cell.s  at  the  edge  of  artic- 

cariilages  where  the  synovial  membrane 
i.    They  are   either  single   or   arranged    in    groups,   and  are 
Jly  surrounded  by  a  capsule,  as   in   normal   ciirtiluge.  although 

is  often  very  indistinct.     Tliey  enclose  one  or  tiiorc  nuclei  and 
btly  granular  contents ;    sometimes  a  cell-wall  cannot  be  dis- 
uifthed. 
alciflcation  is  the  most  common  secondary  Chang's.     It  affect.s 

peculiar  frequency  the  largest  group  of  chondrnmata.  those  of 
metacarpals  and  phalanges  of  the  hands.  It  spreads  from 
V  centres,  commencing  in  tite  capsules  and  then  involving  the 
cellular  substance.  Ossification  is  especially  frequent  in  the 
dronuita  which  grow  near  the  junctions  of  the  e])iphyses  and 
H  of  long  bones.  These  ossify  as  they  grow,  and  form  the 
nculatcd  e.xostoses.  So  also  does  the  couimnn  subungual 
.0818  of  the  great  toe,  which  is  generally  an  ossifying  fibroma, 
ilroma.  or  fibro-chi>ndr(imii.  Fatty  degeneration  and  mucoid 
ning  are  common  changes,  and  may 
to  the  formation  of  large  softened 

•which  present  the  appearance  of 
In  rare  cases  the  skin  covering 
imor  ulcerates  and  a  fungatiug  mass 
udes. 

le  varieties  of  chondroma   ilepend 
the  nature  of  the  intercelluliu'  sidt- 

e,  and  are  therefore  fibrous,  hyaline, 

.  ,       ,  ,,  1  •       .  ■  HyuUne  rhondromA.    X  ann. 

nucoid  ;  these  areottcii  combined  in 

»me  tumor.     As  a  rule,  those  originating  from  the  medulla  of 

f  the  hyaline  and  min'oid  class,  whilst  those  originating 


Ki.,.  .51. 


I  GO 


NUTRITION  INCREAHEt). 


>im| 


from  connective  tissue  in  otlier  situations  are  moro 
fibrous.  The  ra|iidI_v-growing  fibrous  ibrnis  a|i|iroacL  verjJ 
to  the  sarcomata  (chondro-sarcoma),  the  mucoid  forms  to  \hm 
mata(myxo-chondroma);  and  these  two  kinds  of  growth  iin 
a.ssociated  in  the  same  tumor.  Chondromata  are  rarolv  boo 
in  the  strict  sense  (p.  134). 

A  variety  of  chondroma  has  been  described  under  the  itai 
OBteo-chondroma,  which  in  structure  more  closely  rescmbiM 
than  cartilui'e.  It  consists  of  a  tissue  similar  to  thai  miH 
between  the  periosteum  and  bone  in  ricketa,  which,  from  it.*  r 
blance  to  osseous,  has  been  called  osteoid  tissue.  This 
re(|uircs  calcifying  to  become  true  bone.  Like  bone,  it  is  ma 
of  trabecultp  and  mcdulliiry  spaces;  but  the  trabeculn!,  inste 
being  formed  nf  boric-corpuscies  and  lamcllie.  consist  of 
angular  cells  without  a  capsule  situated  in  an  obscurely  fibri 
matrix,  which  in  part  is  calcified.  The  medullary  s|)ace«  oc 
a  fibrous  stroma  and  many  blooiUvessels.  The  osteo-chondro 
although  consisting  mainly  of  this  osteoid  tissue.  Cf>ntain 
a  small  projiortion  of  cartilage.  They  originate  beneath  the 
osteum,  their  common  seat  being  the  ends  of  tiie  long  boneei.H 
grtiwth  is  very  rapid,  and  they  often  attain  an  enormow 
They  are  much  more  freely  supplied  with  blood-veS!»els  thai 
ordinary  chondromata,  and  hence  they  are  much  less  frequentl 
■eats  of  retrogressive  clmnges.  They  arc  especially  proi 
become  ossifieil.  and  to  be  thus  converted  into  true  bone. 

To  the  naked  eye  the  morr  tloH'h/-</rowing  chondrouat 
hard  or  slightly  elastic  tumors,  smooth  or  lobiilated.  and  a| 
exceeding  the  size  of  an  orange.  They  are  enca|isuled,  and  « 
either  of  a  single  tumor  or  of  several  smaller  masses  held  tog 
by  fibrous  tissue,  in  which  the  few  blood-vessels  run.  On  « 
they  present  the  appearance  and  consistence  of  hyaline  or 
cartilage,  frequently  inotlified  by  one  or  other  of  the  »eoal 
changes  above  mentioned.  The  appearances  may  be  tha 
fibroma,  the  cartilage-cells  being  unrecognizable  without 
of  the  microscope. 

The  more  rapuili/-<jrotcin(/  forms,  such  as  often  start  from  tha| 
bonefl  or  ribs — myxo-chondromata,  osteo-chondromata.  and  cbo 
sarcomata — arc  much  larger,  .softer,  and  luore  vascular, 
prenent  the  appearance  of  pure  cartilage ;  only  a  few  islets. 


»eoal 

1 


THE  OSTEOMATA.  161 

will  be  distinct  in  the  soft  grayish  tissue,  which  is  not  separated  by 
any  capsule  from  the  adjacent  tissues. 

Cbondromata  most  frequently  grow  from  oonimon  connective 
tissue  and  bone,  very  rarely  from  cartilage.  About  three-fourths 
of  them  start  in  connection  with  bones,  growing  either  centrally  or 
tubperioateally.  Their  favorite  seats  are  the  bones  of  the  fingers  and 
toes,  the  lower  end  of  the  femur,  and  the  upper  ends  of  the  humerus 
and  tibia.  Much  less  often  the  ribs  and  the  hip-bone  are  attacked. 
Vi*-«hDw  has  shown  that  islands  of  cartilage  not  uncommonly  remain 
in  t;lie  shafts  of  bones ;  and  it  is  probable  that  many  cbondromata 
spring  from  such  islands  (p.  143).  The  tumors  generally  begin 
be£V>re  the  ossification  of  the  epiphyses,  whilst  the  bone  is  actively 
gro-wing  and  vascular. 

^dost  of  the  remaining  fourth  occur,  in  combination  with  other  tis- 
sues, as  "mixed  tumors"  in  the  parotid  and  testicle.  Cohnheim 
suggests,  as  the  source  of  cartilage  in  the  parotid,  an  aberrant  bit 
of  tlie  rudiment  of  the  jaw ;  Virchow,  a  piece  of  the  pinna.  In  the 
tes-tis  a  portion  of  the  rudiment  of  a  vertebra  may  have  been  in- 
clu<Jed.  The  intermuscular  septa,  the  subcutaneous  tissue  of  the 
hreast,  and  the  lungs  are  occasional  seats. 

Xiastly,  cartilaginous  growths  may  originate  from  cartilage  itself 
(**5<shondro8e8).  These  are  sometimes  seen  on  the  surface  of  the 
artiicular  cartilages,  in  the  larynx  and  trachea,  and  on  the  costal  and 
intervertebral  cartilages.  They  are  simply  local  overgrowths  of 
''y^a.line  cartilage. 

Olinically,  the  cbondromata  are  for  the  most  part  innocent 
P^"Wth8.  They  are  usually  single,  except  when  occurring  on  the 
^''gers  and  toes,  in  which  situation  they  are  more  frequently  multi- 
ple. The  central  growths  of  the  phalanges  and  metacarpals  occur 
"1  children  or  before  ossification  is  complete :  the  graver,  subperios- 
*<**/,  forms  are  commoner  later  on. 

The  softer  forms,  especially  those  starting  from  bone  and  glands, 
occasionally  exhibit  more  or  less  malignancy,  tending  to  recur  locally, 
M»d,  rarely,  to  infect  the  lungs  and  even  other  parts. 

THE  OSTEOMATA. 

The  Osteomata  are  tumors  consisting  of  bone,  either  compact  or 
wncellous. 

The  osteomata  are  the  result  of  the  ossification  of  newly-formed 
connective  tissue  other  than  of  inflammatory  origin.  They  must  be 
u 


NUTRITIOS'  INCREASED. 


clearly  distingnisljed  (1)  from  the  simple  f>9»ili ration  of  normal 
iitfini}  tiMuiH — (•.(/.  coHtiil,  luryugeal,  or  bronchial  cartilages,  it 
tions  of  muscles  (rider's  bone  in  abductor  longus  and  the  like),  l 
membranes  of  the  brain  :  and  (2)  from  similar  imtififatiou  of  inflm- 
niiiton/  tiii»Ui\  Hueh  as  nodes  or  general  thickenin<j»  of  lM)nt<8.  thr 
sharp  stalactitie  processes  which  may  j^row  uroiind  a  oarioiis  joini 
or  on  the  surface  of  bone,  and  the  smooth  round  prominences  whid 
almost  encircle  a  joint  in  rheuniatoi<l  arthritis.  Thev  must  bcdi.*- 
tinguished.  also,  from  ralcurruuii  dr/xin'ty,  in  which  tlnri'  i«  iin  t«'ni 
formed  (p.  100). 

nstcomatn  are  generally  divided  into  two  niniti  varietiM.I 
Homologous  OBteomata,  subiiivided  into  exostoses  .unl  MioetocM 
according  an  they  project  from  the  surface  or  info  tlic  mciliiil«n 
canal  of  a  bone.     2.  Heterologous  osteomata. 

1.  Homologous  osteomata  :  '/.  Exostoses  are  dividt-d.  noHirini; 
to  the  density  of  the  bone  of  which  they  consi.<t,  into  two  kind*— («l 
the  compart,  ivory,  or  ehurnated ;  ami  (^)  the  canrrUout  or  'panjy- 

(a)  The  ivory  exostosis  grows  from  y)eriost.cum.  It  occur*  nin»t 
fre<iuently  on  the  external  and  internal  surfaces  of  the  skull:  tlif 
orbit  is  an  especially  favorite  seat.  It  is  met  with  abw  »n  tlif 
scapula,  pelvis,  anri  on  the  u|)per  and  lower  jaws.  In  the  la*1twmf<i 
situation  it  may  grow  from  the  dental  periosteum. 

Such  growths  are  smooth,  low,  rouixled,  widc-ba«ed,  covemi  lij 
the  periosteum,  and  continuous  with  that  of  the  idd  bone  from  »l 
they  grow.     On  section   they  are  throughout  of  ivory-like  deni 
and  they  are  usually  well  ilefined  from  the  adjacent   ti.<isue.     )Ii( 
dcopically,  the  lamelln?  are  arranged  concentrically  and  arc 
to  the  surface  of  the  tumor;  cancellous  tissue  is  absent  and  Hi 
sian  canals   are  few  ami   narrow.     Some  sftecimctis  are  less  ile 
the  Haversian  canals  being  as  numerous  as  in  ordinary  com|>act  1 
but  less  regularly  arrangeil. 

{^)  The  spongy  or  cauliflower  exostosis  is  really  an  oesH 
chondroma.     It  grows  from  cartilage,  usually  near  the  junctio^ 
an  cpi|divsis  of  a  long  bone  with  the  shaft.     It  is  especially  con 
at  the  lower  end  of  the  femur  and  at  the  upper  ends  of  the  tit 
humerus.     Its  outline  is  less  regular  than  that  of  the  ivory  gro* 
but  it  is  prominent,  more  or  less  |>edunculate«l,  and,  so  long 
growing,   covered   by  a   cap  of  cartilage.      When    this   cap 
growth  ceases.     A  section  shows  that   the  nta-Hs  consists  of  •{ 
bone,  directly  continuous  with  the  cancellous  tissue  of  tht 


ibial 


•A] 


THE  LYMPHOMATA.  163 

[i«ace  it  springs,  and  surrounded  by  a  thin  layer  of  compact  bony 
S8ue.  The  medullary  spaces  may  contain  embryonic,  fibrous,  or 
itty  tissue. 

(h)  The  enostosis  is  a  dense  bony  growth  projecting  into  the 
Bodulla,  and  is  very  rare. 

2.  Heteroloerous  osteomata  are  very  rare  as  primary  growths. 
They  have  been  described  as  occurring  in  the  subcutaneous  tissue ; 
but  Malherbe  has  shown  reason  for  believing  that  such  growths  are 
really  sebaceous  adenomata  with  ossified  stroma  (p.  188).  Bony 
tumors  have  very  rarely  been  found  in  the  brain  and  cerebellum. 
Parts  of  fibromata,  lipomata,  and  chondromata  may  ossify.  The 
secondary  growths  of  ossifying  sarcomata  connected  with  bone 
often  ossify. 

The  commonest  secondary  changre  is  inflamination.  Osteo- 
mata may  also  become  carious  or  necrose.  The  last  change  is  most 
likely  to  occur  in  ivory  exostoses,  effecting  their  separation  and  cure. 

Osteomata  generally  grrow  in  conneclaon  with  bone  (homolo- 
^us),  commencing  in  the  periosteum,  medulla,  or  persistent  islands 
>f  cartilage ;  but  connective-tisBue  tumors,  apart  from  bone 
heterologous),  may  ossify. 

Clinically,  the  osteomata  are  perfectly  innocent  tiimors.  Their 
?rowth  is  very  slow.  They  rarely  attain  a  large  size.  They  are 
often  hereditary  and  multiple,  in  which  case  they  usually  occur  in 
«rly  life.  Osseous  growths  which  exhibit  malignant  characters 
are  either  sarcomata  or  chondro-sarcomata,  which  have  undergone 
partial  ossification.  From  these  true  osteomata  must  be  carefully 
^inguished  (p.  178). 

THE  LYMPHOMATA. 

The  Lymphomata  are  new  formations  consisting  of  lymphoid  or, 
*■  It  is  sometimes  called,  adenoid  tissue. 

lymphoid  tissue  is  now  known  to  have  a  much  more  general  dis- 
•"oution  than  was  formerly  supposed.  It  not  only  constitutes  the 
'o'licles  of  the  lymphatic  glands  and  the  Malpighian  corpuscles  of 
~*  spleen,  but  also  Payer's  glands  and  the  solitary  glands  of  the 
""estines.  the  follicles  of  the  pharynx  and  tonsils,  the  thymus 
llsnd,  and  the  trachoma  glands  of  the  conjunctiva.  More  re- 
'^'"ly,  lymphoid  tissue  has  been  found  in  other  situations,  as 
*rottnd  the  blood-vessels  of  the  pia  mater  and  of  other  parts,  in 
»e  neighborhood  of   the  smallest  bronchi,   in  the  pleura  imnie- 


SUTRmOS  ryCREASED. 


Fio.  62. 


^0 


(liately  beneath  its  endothelium,  in  the  peritoneum,  in   t 
membrane  of  the  alimentary  canal,  iiml  in  the  niedtilla 

Wherever  it  exists  the  same  general  structure,  that 
licle  of  a  lymphatic  gland,  may  bo  taken  as  the  type  n 
physiological  lymphoid  tissue,  but  alw  of  that  of  | 
growths.  This  tissue  consists  of  a  delicate  reticulum 
meshes  of  which  are  numerous  lymi)h-corpu8cle«.  The 
is  a  close  network  of  very  fine  fibrils.  Its  meshes  are 
enough  to  enclose  one  or  at  most  very  few  corpuscles  in 
fibrils  usually  present  a  more  or  less  homogeneous  ap|>eM 
nuclei  are  sometimes  to  be  distinguished  at  the  angles 
work.  The  lifmph-eorpuiti'li's,  which  constitute  the  groa 
the  tissue,  can  in  most  cases  be  readily  removed  from  t 
of  the  reticulum  by  the  agitation  of  thin  sections  in  wb< 
are  identical  in  tlicir  chaniclers  wi 
cooytes  of  the  blood.  As  usually 
death,  they  are  spheroidal,  pole. 
parent  bo<Iies.  varying  considerably  i: 
presenting  slight  differences  in  struct 
arc  granular,  an<l  appear  to  |>os.ses« 
in  others  a  distinct  simple  or  com 
cleus  is  visible,  which  is  usually  also 
others,  again,  are  much  larger,  and 
or  even  three  nuclei  (Fig.  52). 

The  histological  an<l  physical  chai 
the  lymphomata   vary  according  to  the  rapidity  of  their 
ment.     In  the  rapidly-grotvina  forma  the  pro|>ortion  of  oa 
great.    Many  of  the  cells  are  larger  than  those  normally  ra 
lymphatic  glands,  and  contain  two  or  even  more  nuclei.    T) 
are  of  a  grayish-white  color  and  soft,  brain-like  consiste 
like  encephaloid  cancer — yielding  abun<lance  of  milky  jo: 
may  reach  a  great  size.     The  more  »loicly-iirowiny  tuiiti 
other   hand,   are   less   richly   cellular.       The   larger  cell 
almost  entirely  wanting.     The  reticulum  constitutes  a 
inent   part  of  the  growth  (Fig.  o3),  and,  instead  of  bei 
ingly   delicate,    is   much   coarser,    and    forms   a   network 
homogcneoufl  or  slightly  fibrillated   bands.     As  the  rvtii 
creases  the  lymph-corpu.scles  gradually  diminish  in  nnrolK 
come  arranged  in  smaller  groups  within  its  meshes  (Fig.  5 
growths  are  much  harder  than  the  more  rapidly-growing 


CcUii  (hiiii  *  IjrmphiiUc 
PTiwtli  III  llip  liver. 
Thoac  to  thr  liR  an^  tliu 
orillrtnry  lyiii|ili  for^tiiH- 
rlrt,  which  oonttltutol 
(he  KTciitor  i»n  of  ilic 
(niwtli.  To  lliv  riKlii 
•re  Dome  of  the  Urgrr 
clemcnta.     :■:  830. 


THE  LYMPIWMATA. 


165 


Fio.  •">.'$. 


Lymphimm  ^.-iiiiMi  iif  ii  firm  lytn- 
phomH  nf  the  niinlluytliiiiin,  shiiwlnfc  n 
very  thickencfl  rftk'iilimi,  withfn  the 


*rc  sometiiuos  exceedingly  dense,  and  are  rarely  very  large.  These 
Variations  in  tlio  itroymrtifin  of  cells  and  stroma  are  precisely  anal- 
mEotw  to  those  met  with  in  ly)nphatic  glands  us  the  result  of  acute 
uii  chronic  inflammation  respective- 
It;  but  in  many  cases  the  relation 
Ix-tireen  cells  and  stroma  remains 
oormal.  as  in  hyperplasia. 

The  lymphomata  do  not  undergo 
marked  secondary  changes.  There 
ulittli-tfiiilriiri/  to  fatty  degeneration, 
caseation,  or  softening,  such  as  occurs 
ia  Bcrufuloiis  glantls. 

The  lymphomata   originate    from 
lymphoid  tissue,    being   apparently   °'™"«/'r»hi..h  thel.vnlphoicloeu.«n.• 
uniform  overgrowths  of   pre-existing 

lymphatic  .structures,  mainly  of  the  lymphatic  glands.  They  are, 
therefore,  usually  homologous.  They  may,  however,  he  heterologous, 
either  owing  to  the  new  tissue  e.xteniliug  considerahly  beyond  the 
wufincs  of  its  origin,  or  to  its  occurrence  in  situations  where  lym- 
phoid tissue  is  not  present  normally.  This  hitter  ciuidition  obtains 
ill  Ilojgkiu's  disease  and  in  certain  form.*!  of  lymphona  which  are 
n>»li|:iiant. 

Ill  smne  cases  of  round-celled  sarcoma,  which  may  originate  in 
•nv  connective  tissue,  the  matrix  undergoes  development  into  a  net- 
work; till' growths  spread  and  generalize  like  onliiiury  sarcomata, 
«i)il  »re  called  lympho-sarcomata.  They  may  originate  in  lym- 
phatic glands 

In  Considering  the  development  of  these  growths  it  must  be 
WTDe  in  mint!  that  enlargements  of  lymphatic  structures  are  most 
frwjuently  of  an  inflammatory  nature,  being  due  to  some  injury, 
•""I  that,  histologically,  as  already  indicated,  there  is  but  little 
'""crunee  between  these  inflanimntory  growths  and  true  lymjdio- 
"'*'>•  The  inflammatory  growths,  however,  tend  to  subside,  the 
*iinior»  continuously  to  increase.  Further,  the  development  of  the 
iTOtor*  ;*eems.  like  that  of  the  inflammatory  growths,  to  be  occa- 
'"'iiaily  deteruiine<l  by  some  injury.  Thus,  an  ii»jury  may  give 
"**  to  inflammation  and  enlargement  of  the  gland;  but  this  en- 
lurijf'meiit.  instead  of  subsiding  with  the  inflammation,  continues  to 
""■ffa.tc.     (See  -^Etiology  of  Tumors.") 

Clinically,  the   lymphomata   are,  for  the    most   part,   perfectly 


I«6 


JWTRITlOy  I  yen  EASED. 


''11 


innocent  tumors.  They  originate  niont  frecjnontly  in 
glands.  wliii'Ji  tIiereii|ion  iin<loijr"  u  continuous  int 
Sometimes,  a.-*  alrendy  atat«!il.  the  enlargement  of  tli 
|iearH  to  be  the  result  of  injury.  In  mo8t  cascH.  hov 
Houree  of  irritation  is  discoverable.  The  giamli  whicB 
eially  prone  to  this  diseasse  are  the  cervical,  the  suhtj 
a.xillary,  the  inguinal,  the  bronchial  and  mediastil 
abdominal  glands.  Usually  only  a  single  ghind  or  a 
of  glands  is  affected;  Honietimes.  howev<'r.  the  growth 
general.  As  the  glands  enlarge,  they  gradually  unite, 
ultimately  they  may  form  very  large  lobulated  tiimoni. 
occurring  in  the  media.'^tinum  they  may  invade  nne  or^ 
they  constitute  one  common  form  of  mediastinal  tumo| 
phatie  structures  in  the  intestine  may  in  the  same  wi 
larged,  ami   project  so  as  to  form  poly|)i. 

The  lymphomata  occasionally  exhibit  malignant  proj! 
is  especially  the  case  in  those  richly  cellular,  soft,  rapidlj 
forms  which  are  sometimes  met  with.  Such  growths  ma 
infiltrate  the  surrounding  structures,  involve  the  neighbol 
phatie  glands,  and  even  infect  distant  parts.  To  these  i 
forms  the  term  lympbadenoma  is  sometimes  apidinl. 

In  the  (Condition  known  as  '•  llodgkin's  disease"  and  il 
mia  lym|ihomatous  growths  are  met  with  in  various  ^wr 
body. 

HoDOKiN-8  Disease. 

This  disease  is  characterizol  by  the  enlargement  of  I 
glands  in  various  parts  of  the  body,  together  with  llipJf 
of  lymphatic  growths  in  internal  organs,  esjiecially  in  th 
and  by  a  progressive  diminution  in  the  number  of  the 
puseles  in  the  bltH)i|.  The  new  growths  are  precisely  sin 
tologically,  to  lymphoma.  The  disease  wias  first  dr>*C 
llodgkin.  an<l  is  called,  after  him,  "llodgkin's  disi-asc:" 
known  as  "amemia  lymphatica."  It  is  allied  to  li-uchi« 
differs  fSHciifially  froui  it  in  this  respect,  that  the  nc«  fijrn 
lymphatic  tissue  is  not  a.ssocialcd  with  any  notable  inc 
number  of  the  white  corpuscles  in  the  blood.  (Sc<e  " 

The   lymphatic  glands  are  usually  the  earliest  seafil 
growth.     .\t  first  only  a  single  group  of  glands  raaj 
subsequently,  however,  the  proe«'«s  be<"iu«e«  more 


HODGKfN'S  DISEASE.  167 

gUuds  throughout  the  whole  body  may  be  more  or  less  involved. 
The  groups  of  glands  most  often  aflFected  are,  in  the  order  of  their 
frequency,  the  cervical,  the  axillary,  the  inguinal,  the  retro- 
Iteritoneal,  the  bronchial,  the  mediastinal,  and  the  mesenteric. 
The  new  growth,  which  in  the  earlier  stages  is  limited  to  the 
glands,  gradually  breaks  through  the  capsules,  so  that  the  enlarged 
glands  become  confluent  and  form  large  lobulated  masses.  The 
growth  may  also  extend  still  farther,  beyond  the  confines  of  the 
gland,  and  invade  and  infiltrate  the  adjacent  structures. 

This  new  growth  of  lymphatic  tissue,  which  commences  in  and 
often  extends  beyond  the  confines  of  the  lymphatic  glands,  is  ulti- 
mately followed  by  the  formation  of  lymphatic  growths  in  various 
internal  organs,  but  more  especially  in  the  spleen.  The  spleen  is 
affected  in  a  large  proportion  of  cases.  Here  the  new  growth 
originates  in  the  Malpighian  bodies,  and  so  gives  rise  to  dissemi- 
nated nodules.  These  vary  in  size  from  minute  points  to  masses 
M  large  a,s  a  hazelnut  or  walnut.  They  are  usually  more  or  less 
irregular  in  shape,  of  a  grayish-  or  yellowish-white  color,  firmer  in 
insistence  than  the  splenic  tissue,  and  not  encapsuled.  In  addi- 
tion to  these,  wedge-shaped  infarctions  surrounded  by  a  zone  of 
'■yperaemia  are  sometimes  met  with,  similar  to  those  which  are 
often  seen  in  leuchsemia.  The  spleen  itself  is  generally  some- 
what increased  in  size,  and  its  capsule  is  usually  thickened,  and 
often  adherent  to  adjacent  organs.  In  quite  exceptional  cases  the 
>|>leen  is  not  the  seat  of  these  disseminated  growths,  but  is  simply 
"mformly  enlarged,  like  the  leuchaemic  spleen. 

The  liver,  kidneys,  alimentary  canal,  medulla  of  bone,  lungs,  and 
"ibcutaneous  tissue  may  all  become  involved,  the  new  growths 
•scarring  either  as  nodules  of  various  sizes  scattered  through  the 
"'g*n8  or  in  a  more  infiltrated  form,  like  many  of  those  met  with 
"1  leuchsemia. 

Histologically,  the  new  growths  are  precisely  similar  to  the 
'y^Bphomata,  and,  like  these,  present  differences  in  the  relative 
P'^portions  of  cells  and  stroma.  The  richly  cellular  forms  are 
*"  and  pulpy,  whilst  those  in  which  the  stroma  is  more  abundant 
*'*  firmer  and  more  fibrous  in  consistence.  Retrogressive  changes 
'^fely  occur. 

"  ith  regard  to  the  pathology  of  the  disease,  it  is  undoubtedly 
otiscufe.  The  development  of  the  new  growths  cannot  in  most 
**8e8  be  regarded  as  the  result  of  infection  from  a  j)rimary  centre. 


168  NUTRITION  INCREASED. 

as   the    process  is,   for  the  most  part,  confined  to  the  IrmpLatic 
structures,  and   many  and  widely  distant  groups  are  often  siuiui- 
tancously  involved.     The  disease  thus  appears  to  occupy  a  (lifferrot 
pathological   position  from  that  of  the  malignant   tumors.     It  i< 
probable  that    there   is  some  special  weakness   of  the   lympbitir 
structures   generally  which  renders  them  prone  to  undergo  the* 
active   developmental   changes,  the   process  being   determineii  bj 
some   unknown   factor.     The    progressive    anaemia   which  acvom- 
panics,  but  does  not  precede,  the  gland  affection  is  possibly  doe  to 
the  progressive  implication  of  the  lymphatic  structures  and  to  tk« 
consequent  interference  with  the  formation  of  the  blood-corpu.4clec- 
(See  "  Leuchivmia.") 

The  Lymphangiomata. 

The  Lymphanfiriomata  are   tumors   consisting  of   abnormtE  '! 
large  lymphatic  vessels.     It  is  doubtful  how  much  of  the  growth       * 
due  to  simple  dilatation  and  how  much  to  new  formation  of  lyr"^*" 
phatic  vessels.     The  divisions  are  the  same  as  those  of  angiow-^^^ 
— simple  an<l  cavernous.     A  section  of  the  latter  would  scarce^^J 
be  <listinguishable  from  one  of  cavernous  nwvus  (Fig.  46),  exce^0^ 
by  the  contents  of  the  spaces.     There  is  generally  fat  in  the  stroui    ■"■  • 

Each  kind  may  be  congenital  or  ae(juired.  Congenital  dilat^s^  »' 
tions  are  found  in  the  tongue  (macroglossia),  lip  (macrocheilia).  •n^t^d 
labium,  causing  hy|)ertrophy  of  the  jtarts.  They  are  also  found  ^^ '« 
other  jiarts  of  the  skin. 

Acquired  dilutntion  of  lymphatics  is  found  in  the  skin,  e8i)eciilK'    h' 
that  of  the  thigh  and  thora.x.     Tumors  sometimes  as  large  as  ^aanu 
orange  may  be  thus  formed  in  the  subcutaneous  tissue.     Dangen)«~     u* 
loss   of  lyni]>h    nuiy   occur  from    rupture   of  one   of  the   vessel      k 
Fibroid  thickening  may  occur  in  the  parts  from  which  the  Iv^^bd- 
|>hatics  ]>ass  to  the  tumor. 


THE  SARCOMATA.  169 

CHAPTER    XIV. 

THE   SARCOMATA. 

The  Sarcomata  are  tumors  consisting  of  connective  tissue  of  a 
Dore  or  less  embryonic  type,  in  so  far,  at  least,  that  cells  predomi- 
late  over  intercellular  substance.  But  in  central  parts  the  process 
f  development  seems  sometimes  to  proceed  to  a  further  stage,  and 
illy-developed  connective  tissues,  such  as  fibrous  tissue,  cartilage, 
'  bone,  are  formed.     In  this  way  a  mixed  tumor  may  result. 

STRUCTtJEB. — All  sarcomata  consist  of  cells  imbedded  in  more 
less  intercellular  substance,  which   varies  in  amount  and  cha- 
rter and  supports  the  blood-vessels. 

The  cells,  which  usually  constitute  almost  the  whole  of  the 
owth,  consist  for  the  most  part  of  masses  of  nucleated  protoplasm, 
rely  possessing  a  limiting  membrane.  They  vary  much  both  in 
ie  and  form ;  and  though,  in  any  given  tumor,  one  form  usually 
edominates,  all  may  generally  be  found  by  searching  teased 
eparations,  which  should  always  be  employed  for  the  purpose. 
Tten  the  different  forms  are  pretty  equally  mixed  in  the  same 
ovrth.  There  are  three  principal  varieties — round,  spindle,  and 
7'eloid  cells.  The  round  and  spindle  forms  may  be  either  small 
large.  The  irregular,  multinucleated,  myeloid  cells  vary  in  size 
d  in  the  number  and  size  of  the  contained  nuclei.  One  cell  may 
v«  as  many  as  thirty  nuclei. 

Xhe  intercellular  substance  usually  exists  in  but  small  quantity. 
intervenes  between  all  cells,  and  is  as  closely  connected  with  them 
in  ordinary  connective  tissue.  These  points  are  often  relied 
on  to  distinguish  certain  sarcomata  from  cancers,  but  they  prob- 
ly  do  not  always  hold  good. 

The  stroma  may  be  fluid  and  homogeneous,  or  firmer  and  gran- 
^f,  or  more  or  less  fibrous,  or  even  chondrified  and  ossified.     On 

amount  and  nature  the  consistence  of  the  growth  depends. 
The  blood-vessels  are  usually  very  numerous,  and  are  either  in 
*«ct  contact  with  the  cells  or  separated  from  them  by  a  little 
*"illated  tissue.  Their  distribution  is  very  irregular,  and  their 
^lls  are  often  formed  by  nothing  but  the  cells  of  the  tumor. 
&»ce,  on  the  one  hand,  the  ease  with  which  portions  of  the  tumor 


170  SVTRITIOS  IXCREASED. 

are  carried  away  in  the  blood-strcain  aud  the  tumor  gener>)iied. 
and,  on  the  other,  the  frequency  with  which  the  vessels  mptBit 
and  permit  extravasation  of  blood  into  the  substance  of  the  growtb. 
Lymphatics  are  unknown. 

An  examination  of  the  growing  border  usually  shows  b  gnat 
excess  of  small  roun<l-cells  over  all  other  forms.     These  cells  exttni 
along  the  connective  tissue  in  all  directions,  and  force  thcmMWw 
between  the  essential  elements  of  muscles,  glands,  and  any  adjicent    ] 
organs,  while  these  elements  themselves  become  pale,  undergo  atro- 
phy, and  finally  disapi>ear.     In  the  invaded  connective  tissue  many 
cell-forms  are  seen,  which  may  possibly  indicate  multiplication  wf 
the  fixed  cells ;  but  it  is  almost  impossible  to  obtain  any  pn>of  tb* 
they  help  to  form  the  tumor.     (See  "  Modes  of  Sprrad  of  InflaO*- 
mation.') 

In  an  ordinary  examination  of  a  sarcoma  the  growing  edge  shuiaM 
be  avoided,  on  account  of  the  predominance  in  that  part  of  »m»" 
round-cells  over  those  most  characteristic  of  the  tumor. 

SECONDAKY  CHANGES.— The  most  important  of  these  » 
fatty  degeneration.  This  always  occurs  to  a  greater  or  less  ext*»»>t 
in  the  older  portions  of  the  growth,  causing  either  softening  or  tl»' 
production  of  cyst-like  cavities.  It  is  frecjuently  associatetl  wi*'' 
rupture  of  the  blootl-vessels  and  hemorrhaere ;  the  latter  may  gi  '*"* 
rise  to  the  formation  of  sanguineous  cysts  (p.  181).  Calciflcatioin 
(Fig.  ♦iO).  oaeiflcation  (Fig.  HI),  and  mucoid  desreneration  a«^ 
less  common.  The  occurrence  of  calcification,  ossification.  ar»<» 
pigmentation  is  influenced  by  the  predisposition  of  the  matrix  fn»«» 
which  the  growth  is  produced  ;  thus,  calcification  and  ossificati*  •» 
are  more  prone  to  occur  in  tumors  originating  in  connection  »i*" 
bone,  pigmentation  in  those  originating  from  the  cutis  or  eyeba  1  •• 

VARIETIES. — Though  all  sarcomata  possess  the  same  gener-^ 
characters,  they  present  histological  and  clinical  differences  wbic"' 
serve  as  bases   for  their  classificatifin. 

The  principal  features  which  are  thus  utilized  are — (1)  the  l'"^* 
doiiiin.int  lonn  of  cell:  {i)  the  nature  of  the  stroma;  and  (3)  thr" 
.>'«Tiiii<l;irv  cliiingcs  to  which  the  growths  are  liable. 

( 1 )  The  predominant  form  of  <•<//  enables  us  to  distinguish  fon^ 
ps — tlic  round-celled,  the  spindle-celled,  the  mixed-celtod,^ 
uliich   no  special    form   pre<louiinates.  and  the  myatoid-oeUtd. 


irroii 
in 


THE  SARCOMATA.  171 

Strictly  Hpeaking,  this  last  group  is  a  mixed-celled  sarcoma,  but 
though  the  myeloid  cells  can  never  be  said  to  predominate,  rhey  arc 
frequently  so  numerous  as  to  be  the  most  striking  objects  in  the 
field  when  examined  microscopically. 

(2)  The  Htroma  may  be  mucous,  fibrous,  cartilaginous,  or  bony ; 
hence  we  may  have  a .  myzo-sarooma,  flbro-sarcoma,  chondro- 
earcoma,  and  osteo-sarcoma. 

(3)  Sarcomata  may  undergo  tecondary  chdnf/es,  which  are  justi- 
fiably described  as  distinct  varieties,  insomuch  as  the  peculiarities 
ire  reproduced  in  the  secondary  growths.  The  chief  of  these  are : 
melano-sarcoma,  characterized  by  the  development  of  black  pig- 
ment, and  chloroma,  a  very  rare  form,  with  green  pigment ;  lipo- 
aarcoma,  in  which  the  cells  undergo  fatty  infiltration ;  and  calcify- 
in?  sarcoma,  in  which  calcareous  infiltration  is  marked. 

PHYSICAL  CHARA.CTERS. — Portions  of  sarcomata  which 
have  undergone  no  secondary  changes  are  soft,  semi-translucent,  and 
grayish  or  pinkish  gray.  These  appearances  are  best  seen  near  the 
Urotemg  edge,  which  may  be  very  narrow.  The  diagnosis — even 
»ith  the  microscope — between  a  sarcoma,  especially  a  fibro-sarcoma, 
•nd  the  different  forms  of  simple  connective-tissue  tumors  may  be 
Mcee«lingly  difficult.  This  is  due  to  the  higher  development  of  the 
wntral  parts  of  the  sarcoma  toward  one  or  other  variety  of  fully- 
fonned  connective  tissue.  Degenerative  i)rocesses,  such  as  fatty 
mftamorphosis,  and  especially  hemorrhage,  may  greatly  interfere 
*ith  the  usual  appearances :  the  occurrence  of  hemorrhage  may  con- 
'^frt  a  solid  tumor  into  a  blood-cyst  with  a  scarcely  recognizable  wall. 

As  a  rule,  the  growing  edge  is  ill  defined,  there  being  no  sharp 
line  of  demarcation  between  the  tumor  and  the  adjacent  parts ;  but 
l^metimea  a  slowly-growing  tumor  may  acquire  a  capsule  by  stretcii- 
'"?  around  itself  the  connective  tissue  of  the  organ  in  which  it 
""ginates. 

Mode  op  growth  and  seats.— The  sarcomata  always 
pnng  ffom  connective  tissue,  and  may  occur  wherever  connective 
"8Ue  ig  present.  It  is  doubtful  whether  they  start  from  adult  tissue 
"''  from  gome  embryonic  remnant.  Congenital  warts  and  pigment- 
'l*t»  often  serve  in  later  life  as  their  starting-points  (j).  142).  The 
^■'■n  and  subcataneous  tissue,  fasciae,  periosteum,  medulla,  uml  lym- 
I'hatic  glands  are  the  commonest  seats  of  .sarcomata. 


yVTRJTIOS  TSCREASRD. 


CLINICAL  CHARACTERS. — The  wrcomaU  occur  mort  fr^ 
<|iiently  in  earlv  iitul  iriidiile  li(V,  timl  lire  auionj;  the  nioHt  ui:h 
of  new  foriiiutitiiis.     Thev  are  cspt'oiHllv  cliiiructoriwMl  l»_v  thru 
tendency  to  extend  locally  and  to  infiltrate  the  surrounding  ntnic- 
tiircs.  so  thnt  tlipy  nre  exceedingly  prone  to  recur  »'«  lorn  after  renunaL 
Butliri  has  shown  that  sarcomata  of  certain  jiarta  altuo»t  always  affrc^ 
lymphatic   glands  at  an  early  stage — vik.  sarcomata  of  the  testi*. 
ton)«iK  lymphatic  glands,  and  some  faseire.     Those  of  certain  otbw 
jiartR  show  no  tendency  toailect  lymphatic  glands  at  all :  so  that,  oa 
the  whole,  sarcomata  present  a  contrast  to  cancers  in  this  re»f»ct. 
Like   cancers,  they  are   very   liable   to  become   generalixtni    Tb« 
secondary  growths  occur  most  freijuently  in  the  lungs.     Thr  Jinrr—i" 
nation  IK  I'lf'ertfd  hy  iiu-an»  of  the  blood,  and   is  a   natural   r(*«ult   o» 
the  thinness  of  their  vessel-walls  and  the  immediate  contuct  of  th 
with   the  cells  of  the  growth — conditions  most  favoraMe  to  the 
trance  of  the  cellular  elements  into  the  circulation.     The  di 
nation  of  the  sarcomata  is,  on  this  account,  sometimes  more  T%f> 
than  that  of  the  carcinoniata.      In  thr  cdrrtnouiata  rrtrntiion  in  f 
fiirhf  utiufi-  litki'H  plftcf  hy  tfii-  b/mphatirg,  an(l  dissemination  hy  i 
blood  occurs  later  in  the  disease.      The  si'condary  .«iareoinata  ii!<tial 
resemble  the  pritiuiry  growth,  but  in  exceptional  cases  the  aer 
varieties  may  replace  one  niujther. 

It    has   already  been   pointed  out  that  the  different   varietie* 
sarcoma  |M)s8e88  very  different  degrees  of  malignancy.     As  a  rul 
the  sotller  Jiiul  more  vascular  the  tiinior,  and  the  less  its  tendency 
form  fully-devciopetl  coivnective  tissue,  the  greater  is  its  mnlignitnc- 
The  soft    fotind-rAlfd  and  Inrye  tpindh-celled  varieties   are  th 
usually  much  more  malignant  than  the  finner  »m<iU  gpindlrirli 
growths.     .Many   small   spindle-celled    tumors  after   removal  ue* 
rocur.  whilst  others  recur  locally  several  times,  and  ultimately 
duee  themselves  in  ilistant  parts.     Asa  rule,  largeness  of  the  spiai 
elements  and  the  existence  in  many  of  them  of  more  than  one  nude' 
are  together  evidence  of  N|>ecial  malignancy.     Central  Barcumala 
bone  are  much  less  malignant  than  the  subperiosteal  varictir*. 
latter,  with  sarcomata  of  the  tonsil  and  testis  and  melanotic  aa 
of  skin,  being  among  the  most  malignant  of  tumors.      The  p: 
of  a  capule  limiting  the  growth  must  also  be  taken  into  accunat 
judging  of   the  degree  of  its   malignancy.      If    must,  howevi-r. 
l>orne  in  minil  that  even  in  a  growth  distinctly  eucapsuknl  the  mm 
matous  elements  may  invade  the  adjacent  structure*.     The  mvrloi 


THE  SARCOMATA. 


173 


Fig.  54. 


IJimifl  •■.Itc.I  sfiri'iinio.     \ 
Cbiu     soi-ti(-iu     ot'    u    HinuU 


growths  are  the  least  malignant ;  they  may  in  exceptional  cases  give 
rise  10  secondary  growtLs*  in  internal  organs,  but  "  complete  "  re- 
moval gives  a  very  good  chance  of  non-recurrence.  This  .sometimes 
occurs  with  growths  having  every  appearance  of  malignancy. 

According  to  Cohnbeim,  the  very  varying  maligii;iiicy  of  sarco- 
uialoua  tumors  goes  far  in  proving  the  necessity  for  that  diminished 
physiological  resistance  already  alluded  to  (p.  140). 

Roitnd-ceijLBd  Sarcoma. 
This  is  of  soifter  consistence  than  the  spindle-celled  growths,  and 
from  its  frequent  resemhiance  in  physical  charactei-s  to  encephaloid 

I  it  is  sometimes  known  as  "medullary," 
'*  encephaloid,"  or  "soft"  sarcoma.  Histo- 
logically, it  is  elementary  embryonic  tissue, 
consisting  mainly  of  vound-cclls  imhodded 
>n  a.  scanty  and  usually  soft,  homogeneous, 
•>"■  finely  granular  intercellular  substance 
(*'>g.  54),      The  cells  usually  resemMe  tho.se 

»^^t   vith  in  the  most  elementary  embryonic 
tissue;  less  frequently  they  are  bigger,  and     round-ceUod  Mrromii  of  the 
•^'•ntain    large    round    or   oval     nuclei    witfi 

origljt  nucle<}li.     There  is  an  almost  complete   absence  of  fusiform 
^cells    and  of  the  partial   fibrillation  which  is   so  frequent  in  the 
•nore  highly-developed  spindle-celled  variety. 

■        The  round-celled  sarcomata  are  of  a  uniformly  soft,  brain-like 
****i8istence,  somewhat  translucent  or  opa(|ue,  and  of  a  grayish  or 
reudjsh-white  color.     On  scraping  the  cut  snrface  they  yield  a  juice 
_  which  is  rich  in  cells.     They  are  exceedingly  vascular,  the  vessels 

■  ofteti  being  dilated  and  varicose,  and  from  their  lialiiiity  t<»  rupture 
Vthey  frequently  give  rise  to  ecchymoses  and  to  the  formation  of 

■  sanguineous    cysts.      (See  "Blood-cysts.")     They  grow    from   the 
V  *^'^tis,  the  subcutaneous  cellular  ti.ssue,  the  periosteum,  the  fasciit!, 

■Dt»    the   connective   tissue   of  organs.     They   extend    rapidly  by 

V'^r^'pheral  growth,  infiltrate  the  surrounding  structures,  repnuiiice 

^''(^noselves   in    internal   organs,   and   often    involve    the   lymphatic 

P'ftnds.     From  their  clinical  and  physical  characters  these  tnniors 

We  verv  liable  to  be  confounded  with  encephaloid  cancer :  they  are 

•Jistinguished  by   the    absence  of  an   alveolar   stroma    and  by  the 

|*netration  of  the  intercellular  substance  between  the  individual 

cells. 


174 


SVTRITIOS  INCREASED. 


GLIOMA. — This  is  a  viirietv  of  rouiid-fflled  sarcoma  giDwiiij 
from  tlif  iieurojjlia  or  connective  tissut-  of  nerve.  It  cousisi"  "i 
very  small  round  cells  imbcddctl  in  an  e.vceedingly  scantv,  honnv 
gencoiis.  granular,  or  sliglitly  fibrillatt-d  intercellular  aubstanci' 
(Fig.  'm).  Some  of  tbe  ceils  uiav  possess  fine  prolongations  wLicb. 
by  communicating  with  one  another,  form  a  somewhat  reticulstd 
.'Structure.  These  tumors  jiri'  of  soft  consistence  and  of  pinkisb- 
gray  color. 

Gliomata  occur  in  the  gray  and  white  substance  of  the  brain,  in 
the  cranial  nerves,  and  in  the  retina.     In  the  retina  a  glioma  uaaalljr 

Fio.  65. 


Snn-rimatou»  tuniore  (Vnm  thu  bnlii :  a,  a  KlIonM  uf  the  cvrehtiUnin.  abuwlng  lbi>  «| 

miifi'  onUniirlly  prfstnleil  liy  tticsp  prfiwllis;  It.  n  niniptinitlvi'ly  mri'  is>nii  of  Hiroinm. 
flSthiK  ttf  liifKc  riurh'iiti*"!  rcUj*  iTiolose*!  within  lln*  mi-^hf*  t'f  u  vnx-iiUr  iielwnrt  t"*** 
4lcvi'li)imn!Ut  of  llils  tuniur  took  idari'  in  lliu  liralii  KulMc'qiU'ntly  lo  llmt  of  epInillC'Ccll*™ 
HTuwthn— jirimiirily  in  thf  thigh  and  seconiiarlly  In  llic  \nwf.    X  200. 

commences  as  a  minute  nodule,  which  may  gradually  increase  nDti' 
it  jirojects  as  a  large  fiinguting  tumor  from  the  orbit.  Altltoiigk 
gliomata  grow  slowly,  they  are  not  encapsuled,  and.  although  tlie5 
may  occasionally  infiltrate  the  tissues  in  which  they  lie  anil  c»ni?* 
seconrlary  growths  in  their  imiiu'ditite  vicinity,  they  very  nn\y 
reproduce  themselves  in  neighboring  lymphatic  glands  or  in  distan* 
organs.  They  are  liable  to  small  hemorrhages  into  their  structure*- 
anil  sometimes  become  more  or  less  caseous.  So  often  are  thes^ 
growths  clinically  "  innocent  "  that  by  some  they  are  dasstnl  ** 
a  variety  of  connective-tissue  tumor  of  a  "neuroglia"  type,  whicl* 
may  occasionally  become  sarcomatous. 


LYMPHO-SARCOMA.— This  is  a  round-celled  sarcoma,  in 
which  the  matrix  has  developed  into  a  more  or  less  perfect  reticulum, 
like  that  of  lymjihoiil  tissue.  It  may  begin  in  lymphatic  glands  »i 
in  connective  tissue  anywhere.  It  is  distinguished  from  lymphoma 
by  its  more  rapid  course  and  by  tbe  formation  of  secondary  growtbi 
by  embolism  (p.  169). 


THE  SARCO^TATA. 


175 


Fio.  66. 


AJjVEOLAR  SABCOMA. — This  is  a  rare  form  of  round-eelleJ 

ffc*rcotuii  wliieb  was  first  (lescribed  by  Billroth.      'I'lit'  cells,  wliicb  :ire 

Iwgc.  sharply  defiued,  round  or  oval  in  shapie,  uuil  contain  round, 

prominent  nuclei,  are  separated  from  each  other  by  a  more  or  les.s 

marked   fibrous  stroma.     In  some   parts  this  stroma  forms  small 

»lvt!«)li  \^ithiu  which  the  cells  are  grouped,  but  careful  examinatiou 

will  always  show  that  in  most  parts  of  the  section  the  stroma  really 

l/ieuetnites  between  the  individual  cells.     This  last-named  character, 

Mogrthcr  with  the  nature  of  the  ti.ssue  from  which  they  arise,  serves 

'At  ilistiiigui."!!  these  tumors  from  the  can- 

crs,  with  which,  in  many  ctkses,  they  may 
RiKily  be  confounded.  The  accompanying 
Irawing  shows   their  microscopic  charac- 

ltj*  (Fig.  06).     The  stroma  is  often  much 

more  delicate,    and    the   cell-masses    are 

.occswionally    much    larger,   than    in    the 

-drawing.     The  cells  are  generally  in  close 

[wnnection  with  the  stroma,  though   ves- 

mIs  never  pass   in  among  them.     In  this 

latter   respect    they     resemble    epithelial 

growths,     Ziegler  says  the  alveolar  struc- 

''ire  may  be  due  to  the   transforni.Ttion  of  nonniil    intcrva-scuhir  tis- 

*if  into  sarcoma-cells,  whilst  the  ve.-^.icls  with  the  neighlwriug  cou- 

"•'^V'e  tissue  remain  aa  septa. 

A/velor  .sarcomata  are  met  with  principally  in  the  skin,  bones, 
""'tnuscies.      In  the  skin,  where  they  are  often  multiple,  they  leail 
I  "  ulceration.     They  tend  to  recur  locally,  and  also  to  produce  them- 
in  internal  organs. 


''^-> 


C/ 


Alvenlnr  iiarrnma  ((hiro  a  tu- 
mor »r  the  skiM).  X  200.  Ktml- 
\w.  1 


Spindle-cblled  Sarcomata. 

'^*e  tumors,  which  include  the  growths  described  by  Paget  in 

lAb>>la.f„{  ^  "  fibro-plastic  "  and  "recurrent  fibroid,"  are  the  most 

"iiniii**!!    of   all    the    sarcomata.      They    consist  of    cells,    mainly 

'P"'**lf8hapod  and  fusiform,  separated    by  only  a    little  homoge- 

llimiis  411-  slightly  fibrillated  intercellular  substance,  and  nftcn  form- 

['"R  whorls  round  the  vessels.     The  cells  contain  well-marked  oval 

nticlei  ^jij,  QQp  or  more  nucleoli.     They  are  arranged  in  bundles 

'™«>  pass  in   all  directions  through  the  growth,  anil  often  give  it 

r^  appearance  of  a  fibroma  or  myoma.     In  those  portions  of  the 

Aon  in  which  the  bundles  of  spindle  elements  have  beea  cut 


176 


yUTRITIOy  INCREASED. 


transversely  or  obliijuelv  they  prexent  the  appearaure  of  maod'V 
oval  cells.  The  cells  vary  cnnsulcrubly  in  size  in  liiffereut  tumon. 
Lence  the  division  into  small  and  lar^e  spindle-celled  growths. 


Fio.  67. 


SMALL  SPINDLE-CELLED  SABCOMA— In  thi»  the  «ll» 
are  small,  often  not  more  than  ps'ojy  inch  in  length,  and  the  inl«T* 
cellular    substance    is   occasionlly    im|*ffNi*y 
fibrilhited  (Fig.  57).     These  growrtli""  oppn»A 
therefore   the   confines  of   the  fibniiuata.  an* ' 
histologically  they  must  bo  regarded  u  (icr«ii-i 
pying    an    intermediate    place    between 
bryonic    and    fully-doveloped    couneetive 
sue.     They  grow  from  periosteum,  fabric. 
connective   tissue   in    other  parts.     They 
usually  Krm  and  whitish  or  pinkish  white, 
present   on   section   a    translucent    .•■omew] 
fibrillated  appearance.     They  are  much  more  freipiently  rncajM 
than  any  other  variety  of  sarcoma,  but  they  are  \  ery  liable  to  it 
trate  the  surrounding  structures  and  to  recur  locally  after  renins 

LABGE  SPINDLB-CELLBD  SARCOMATA— The  cellular* 
menta  in  these  tumors  are  much    larger    than    in    the  precedi 


SuisU  >|>lliiUr-ctflIC(l 
Mirt'MtiiH  (fViiiu  M  tiitiKir 
••f  the  leg).     •:  a». 


/^ 


Fio.  68. 


/ 


1< 


tiinp'«|iliuUr  cclU-<l  »«r>'ciin>.    T>>  ihr  left  ilir  <'<-Uh  tiavi-  brcn  cv|<«riiU'<)  hjrl 
tlm(  tlit'lr  ItuUvlilunl  (umM  arv  apiatn'iit :  to  tli«  riKl>>.  ilify  itv  In  tlii-tr  lutunl  ill 
puslUoti,  rarh  u  wmilil  tw  wen  In  ii  tliln  aertlon  of  thr  tumor.  ( Vlrrhow.) 

The  cells  are  plumper,  and  both  nuclei  and  nucleoli  are  i 
prominent    and  frequently  multiple  (Fig.  58).     The    interwlh 
substance  is  more  scanty,  and  there  is  a  complete  absence  of  i 
fibrillation.     These  growths  are  much  softer  in  consistence  tbaal 
small-celled  rariety.     They  are  of  a  pinkish-white  color,  and 


THE  SARCOMATA. 


177 


often  stained  b}-  extravaf^ation  of  blood,  and  in  purt^  are  sometimes 
almost  diffluent  from  extensive  futty  degeneration.  They  grow 
rapidlv  and  are  usually  exceedingly   malignant. 

MELANOTIC  SARCOMA.— This    is  ii  variety   of  siircnma  in 
which  many  of  tLe  cells  contain  gramiles  of  dark-colored  pigment, 

Fiu.  69. 


*  li)«luiii||i:  •nniiiun  'if  tin-  penis.  .1,  nei'tlim  uliowlng  tho  (jcncral  arrangement  of  tin- 
**'*'"il»,  ■■.  a*i.  B,  avi'Iliin  from  the  iM-riplii'nil  piirt  nf  Ihe  (trowth,  xliuwing  the  "ludlfler- 
'^^  <^IU."  iiiiiunic«t  wlilrb  tire  xmutl  iKolnteil  pignHMiteii  elements.    At  a  a  blood-veMel  U 


^*».    >  jn     ('.  some  of  tticcIemenlH  si'iHirnted  by  te<l^ing.    In  these  the  plgment-gianuleo 
**•  Wfltieen       .  Jim 


*». 


luito  distinct  from  tin-  ]iiginent  of  extravasateil  Mood.     By  far  the 

igToater  number  of  melanotic  tumors  are  sarcomata,  and  most  of  the 

IStmlis,  which  were  formerly  described  as  "  melanotic   cancers," 

j'>tlcjng  in  reality  to  thi.«  class  of  new  formations. 

I      The  luelanotic  sarcomata  originate  |)rincipally  in  two  .-iitiiatious — 

I***  the  choroid  coat  of  the  eye  and  in  the  su(ierficiiil   integuments. 

'U  both  of  these  situations  jiigment  is  a  normal  constituent  of  the 

''sHries.  and    this  tendency  of   pigmented   structures   to   originate 

"it'laiiDlic    growths    is    exceedingly    eluiracteristic.     These    tumors 

ttauBlly  consist  of  8pindle-9ha|)ed  cells  (Fig.  51»),  and  hence  they  are 

'U«&«:rihed  in  the  present  section;  but  in  fiome  ca.st-s  the  prevailing 

'yi>*iif  cell   is  rrumd  or  oval.     The  pigment   which  gives  to  them 

»*eir  distinctive  characters  consists  of  grunides  of  a  brownish  or 

'lark  aepia  color.     The.se  are  mainly   distributed   within   the  cells 

(•^ijf.  59,  V),  but    are    also   found    in   the    intereellular  sub.stance. 

'rwjoently,  only  a   very   small    proportion  id'  the  cells  are  pig- 

u 


178 


NvrRirioa  increased. 


moiitcil.  whilst  in  other  instances  the  pigmentation  is  much  niorr 
universni.  In  all  ca^es  a  large  number  of  the  elements  will  lie 
foiiuil  to  be  ((iiite  free  from  pigment. 

These  melanotic  tumors  are  !im<tngst  the  most  malignant  of  the 
sarcomatous    growths.      Although    thev  show    comparatively    litllr 
tunilciicv  til  exteuil  h'l-iillv,  thev  are  rapiilly  disseminateil  by  mean* 
<if  I  he  blood-vessels,  iiml  occasionally  also  by  the  lymphatics:  thev 
tints   reprndiice  themsches,   often   very  rapidly,  in   distant   tissue. 
Although  the  secondary  growths  almost   inviiriiibly  maintain  tbcir 
melanotic  character,  the  degree  of  their  pigmentation  varies  con- 
sidenibly.     Whilst  many  of  them   may  be  perfectly  black  in  ruinr. 
others  may  be  much   paler — perhaps  only  streaked   with   jtigiuciit. 
The  seconthiry  growths  are   soft,  usually  distinctly  circumscribHt 
and  often   encapsuled.     They  may  occrir  in  almost  every  orgiiu  "f 
the  body  :  the  liver,  the  spleen,  the  kidneys,  the  lungs,  the  heart, 
the  brain  and  spinal   coni,  and  al.no  the  lymjihatic  glamls  and  taV 
cutaneous    tissue,  nuiy    all    be    simultaneously    involved.     Whrn 
occurring  in  internal  organs  the  |>ignientatioir  is  not  always  liiuiifi 
to  tlu'  secr)udary  iKwiules,  but  many  of  the  cells  proper  to  the  organ 
itself  are  filled  with  granules  of  similar  pigment,   which  in  niort 
iibunditnt    in   the  cells    iuiniediately  adjacent    to  the    new    growtli. 
This  pigmentation  of  the  ceils  of  the  organ  often  extends  for  .'i<iiiio 
distance  beyond  the  confines  of  the  tumor. 

OSTEOID    SARCOMA. — This   is  a   variety  of  sarcoma  whif^" 
was  foriuorly   known   as '-osteoid    cancer."     The  growth  (uRUttll> 
spindle-celled)  is  either  more  or  less  calcified  or  partially  convert*'" 
into  true  hone.     \n  a  primary  growth  it  is  met  with  almost  cxd**' 
sively  in  connection  with  bone,  growing  either  from  the  periostoutf 
or  the  medulla;   but  the  osteoid   characters  are  usually  reproduce^* 
in  secondary  tumors  occurring  in  the  lungs  and  other  parts. 

■  Valfiticaliuii  is  much  more  common  than  true  oHsifiratloti.     Enct* 
of  these  processes  may  occur  separately,  but  they  are  often  com" 
biued.     Bands  and  patches  of  granubir  iippcarance,  in  which  tlit* 
outlines  of  cells  may   still   be  visible  or  in  which  all   structure  bn.« 
disappeareil,   and   which   stain   but   slightly,   show   where   calcifica- 
tion ha.s  occurred  (Fig.   (!0).      In   other  parte,  especially   near  tin- 
bone,  spicules  having  the  structure  of  more  or  less  perfect  bone — 
Haversian  canals,  lacunji?,  anil  imjierfect  eanaliculi — will  be  seen 
penetrating   the   growth    (Fig.    t>l).     The   spicules   are   generally 


vertical  to  the  surface  of  the  bout.      In  some  cases  a  skeleton  of 
ibowy  spines  radiates  from  the  bunt-  through  the  growth. 


.,„„„  I  rrnni  R  KiH'onctary  tumor  iif  the  Iiuig).  ohowlnir  tin-  ralclflcatlnn  of  « 
"lUili  unrl  till'  r'>riiiiitii>ii  nf  Imuiil  luiuits  iircnlcilU'il  hitcn'oUulur  material 
..    ,..1  r.  which  contain  rouml  ami  oval  i-clU.     ■:  JU. 

Both  calcification  and  ossification  may  be  very  complete,  but  n 
thill  mnryin  of  atirauna-tUme  is  always  present.     A  sini)ile  osteoma 

Ki<(  61 


— 1» 


^  **  ■  Mfcoma  uf  lowt'r  Jnw  ■  *,  8iin'omA-llsRiii* ;  /»,  Ixtfu'.  i^rowiiiK  from  J»w,  of  whirb  the 

Hull    in^    '"  '''''''^  l)TiI''al .  p.  \«i\M  of  oommelirini!    owlrtciitloii.    Only  ntu'lrl  of  I'cIIi  art" 
^^^  :  eli«e  til  the  boii«  the  itrornu  is  vurj-  Abroiin.     •  ^O.    (Boyd). 

'"  *l    Iiavc  cartilasio  or  perio.steiim  on  its  siirfVicf  and  would  he  of 

"^"  **ln\*er  growth.      It  is  most  imjiortant  to  recofruize  this  differ- 
ence. 


Thi: 
«Ui«.\ 

huto\ 


Myeloid  Sarcoma. 

*.  which  is  the  well-know  n   "  myeloid  tumor,"  is  somewhat 

V»i  the  !<pindli'-felli'<l  jrrow  tliM.      If  jjossc-tses,  however,  ccrtiiiii 

'^giciil    |ieciiliiiritit'.>'    HJiiidi    probnblv    dcpoiid    upon    tlic    rliii- 


180 


NUTRITION  INCREASED. 


racten  of  the  tissue  from  which  it  grows.  Myeloid  tumors  nmrlf 
always  wear  in  connectiou  with  b<jnc.  and  niuHt  frei(uentlr  orixi- 
nato  in  thi-  uieduliiiry  cavity.  They  contain  many  of  the  laryr.  i 
multinucleated  cells   already  described  as  "myeloid  cells,"  wiiiiii 


Kio.  «2. 


Myeloid  urfinia.    iVItvhuw.) 

resemble  the  cells  of  the  medulla  in  a  state  of  excessive  nnt 
activity,  together  with  numerous  fusiform  cells  like  those  mc 
in  the  spindle-celled   varieties.      There  are  also  some  smaller 
and  oval  elements.     The  large  myeloid  cells  which  gi\e  to 
tumors  their  distinctive  characters  are  usually  much  more  nan 
in  those  growths  which  originate  in  the  medullary  ca\tty  fbi 
those  which  sjirinp  from  the  periosteum.     These  various  for 
celU  arc  nlini».*t    in  contact,  there  being  very  little  interc-ellular  i 
stance  (Fig.  62).     The  growths  are  sometimes  so  vascular  u 
give  ri.'^e  to  distinct   pulsation.     They  oftrn  contain  cyst*. 

Myeloid  tunmrs  almost  always  grow  in  connection  with  boBf.  I 
ends  of  the  long  bones  being  their  favorite  seat.     They  are 
frei)uently   met   with   springing   from   the   fR-riosteum  of  the 
and   lower  alveolar   processes,  where  they  constitute  one 
epulis.     When  originating  within  the  meiluUary  cavity  the  i 
tissue  of  the  bone  becomes   "expanded  "  over  them,  and  thov ' 
often  communicate  to  the  fingers,  during  examination,  the  ftruM 
sensation  known  to  surgeons  as  "  eggsht-ll  crackling."     TrueM|! 


THE  SARCOMATA.  181 

*ion  of  bone  is,  of  course,  impossible;  really,  the  old  bone  is  ab- 
sorbed from  within  by  the  tumor,  and  the  periosteum  lays  down 
ii«w  bone  on  the  surface ;  absorption  is  more  rapid  than  new  forma- 
tion, and  the  thin  surface  layer  of  bone  yields  and  crackles  under 
pressure  or  is  actually  wanting  at  spots  where  pulsation  is  marked. 
These  tumors  are  for  the  most  part  of  firmer  consistence  than  the 
other  varieties  of  sarcoma.  Many  of  them  are  firm  and  fleshy ; 
others  are  softer,  more  resembling  gelatin  size.  They  are  not  pulpy 
and  grumous  like  the  soft  sarcomata,  neither  do  they  present  the 
fasciculated  appearance  of  the  spindle-celled  varieties.  Their  cut 
surface  has  a  uniform  succulent  appearance,  often  mottled  with 
patches  of  red.  This  red-brown  or  maroon  color  varies  with  the 
number  of  giant-cells  present,  and  is  very  characteristic.  The 
tumors  are  often  encapsuled  by  the  periosteal  covering  of  the  bone 
from  which  they  grow.  They  are  rare  after  middle  life,  and  are 
the  least  malignant  of  all  the  sarcomata. 

Oylindboma. 

The  name  Cylindroma  is  applied  to  a  group  of  tumors  in  which 
the  cells  are  arranged  in  hollow  columns  or  globes.     The  interior 
of  these  structures  is  frequently,  but  by  no  means  always,  occu- 
pied by  a  blood-vessel  surrounded  by  hyaline  material.     Accord- 
itig  to  some  authorities,  these  tumors  are  really  myxo-sarcomata 
"^m    the  first.     In  the  opinion  of  others  they  are  sarcomata  in 
*liich  the  adventitia  of  the  vessels  has  undergone  mucoid  degener- 
ation, while  the  vessels  themselves  have  developed  varicose  dilata- 
tions.    Ziegler,  to  emphasize  the  large  size  and  number  of  the 
^esselg  and  the  general  character  of  the  tissue  around  them,  has 
'"ggested  the  name  anerio-sarcoma  myxomatodes.     In  all  prob- 
ability several  forms  of  new  growth  have  been  included  under  the 
"awe  cylindroma. 

Blood-cysts. 

^*»inor8  are  occasionally  met  with  into  which  so  much  hemorrhage 
»«8  taken  place  that  their  real  nature  is  masked,  and  their  appear- 
ance  U  that  of  blood-cysts.  The  nature  of  these  blood-cysts  has 
oi»iy  recently  been  understood.  They  are  now  known  to  be  in  the 
majority  of  cases  soft  round  or  spindle-celled  sarcomata.  They 
**>'*8iiit  of  broken-down  blood-coagula  surrounded  by  an  ill-defined 
^y*T  of  soft  sarcoma-tissue,  which  is,  as  a  rule,  clearly  revealed  by 


182  NUTRITION  INCREASED. 

the  microscope.     These  growths  are  exceedingly  malignant.  wA 
hence  the  recognition  of  their  sarcomatous  origin  is  all-importut. 


CHAPTER  XV. 

EPITHELIAL  TUMORS. 

THE  PAPIIiLOMATA. 

The  Papillomata  arc  new  formations  resembling  in  structa."^ 
ordinary  papilhc. 

Tliey  consist  of  a  basis  of  connective  tissue,  which  sends  tovx*  ■"*' 
the  surface  numerous  papillary  processes,  each  supfwrting  bliw  »•*" 
vessels  wliit-h  end  in  a  capillary  network  or  single  loop,  the  wh«  »'* 
being  enveloped  in  a  covering  of  epithelium.     The  {mpillie  may      •»* 
short  and  siuiplo.  as  in  an  ordinary   wart,  or  thev  may  be  lor*  !£• 
delicate,  branching — g'^'ng  "ff  secondary  and  tertiary  offsets — *»»•' 
very  numerous,  as  in  rilhiux  tuinorn.     The  covering  epithelium      '" 
skin-growths  is  thick,  hard,  and  stratified,  and  may  actually  bi»»« 
the  papilhe  into  a  solid  mass;  but  on  mucous  membranes  the slend ^r 
vascular  processes  are  covered  by  a  small  amount  of  delicate  ey»' 
thelium,  and  in  consecjuence  they  are  easily  lacerable.     Warts  <■»•» 
serous  mend)ranes  are  often  covered  by  a  ninffle  layer  of  endotheli*' 
cells. 

llcuiorrha^e  and  ulceration  resulting  from  injury  can  hardly  b* 
classed  as  secondary  chaneres.  The  only  important  change  is  tb^ 
possible  conversion  of  a  papilloma  into  an  epithelioma.  Inawa'' 
all  the  epithelium  is  on  thi-  mrfaci\  no  matter  how  irregular  tb  at 
surface  may  be.  As  soon  as  the  epithelium  begins  to  invade  tf»e 
tixsiD-H  hfiiiiith  it  the  wart  has  become  a  cancer.  I*iginente<l  wirts 
not  uncommoidy  forui  on  tlie  face  in  old  age.  and  it  is  well  to  witc*h 
but  not  to  irritate  tlicui. 

Four  varieties  can  be  readily  <Iistinguishcd : 

1.  The  ordinary  skin-wart  with  its  covering  of  hard  s«|U8IB<>*'* 
epid«'rmis.  Condylomata  and  veneri'al  warts,  due  to  the  irrit»ti*>'' 
of  the  secretions  of  soft  .xores  or  jronorrhcca,  deserve  special  m^*' 
tion.  These,  tiioujrh  coveretl  by  s<|uamous  epithelium,  are  iiii>*-_ 
softer,  more  vascular,  and  more  luxuriant  in  growth  than  the  of** 
nary  skin-wart.     Tliey  affect  warm,  moist  parts. 


TBE  PAPILLOMATA. 


183 


2.  The  Boft  warts  and  villous  tumors  of  all  mucous  surfaces. 
Tliesc  nre  usually  fbarticU'ri/.fd  I)y  \<n\^.  delicate  compound  papillse. 
iht  tongue,  cheek,  laryux,  and  bladder  are  the  parts  most  often 


Fig.  63. 


#.:«.»JTr;:'^ 


Bon  iif  w»rt  <iti  skin  of  nlKlimuMi :  r,  I'pltholliim  :  <•./.  connective  tiitsue  coiitlniioiM  with 
aif  (Utl  <'Uli»  .  <.  •c'cnmul«tii>iuir>r  horny  t'|>lilcrml»<li-cp  down  livtwecn  the  iHtpUIa', 
^tiK  in  (w-Uon  Ukv  Urxv  nvstii.     v  10.  (Boyd.) 

•ffecteil.     The  papillary  enlargements  of  the  synovial   villi  uliich 
}«re  common  in  chronic  arthritis  may  be  inclmled  in   this  group. 
3.  Corns. — These  i-ommcm;'  as  papillnuiata.  but.  as  tlic  ejiidcrmis 
I  thickons  and  is  pres.>»ed  by  the  boot  into  the  .soft  parts,  the  paj)ilUe 
"'Umatcly  atrophy. 

■t.  BoniB  some  inches  long  occasinnally  springing  from  the  skin, 
ihes*  consist  of  epithelium  and  sebaceous  .secretion,  and  originate 
iroiu  sebaceous  follicles  or  from  a  sebaceona  cyst.  It  is  said  that 
'"";?  papilln>  project  into  their  bases,  .so  they  seem  to  be  allied  to 
*«rts.  The  base  must  be  removed  with  the  horn  or  the  latter  will 
recur. 

'o  the  naked  eye  the  ordinary  wart  is  a  hard,  abruptly-elevated 
''Mle  inatts.  a|>|iareiitly  formed  of  epithelium.  It  presents  an  irreg- 
"'•'  ("wartj'")  surface,  often  divided  by  dee[>  fissures.  If  the 
'Ovcsting  epithelium  be  abundant  or  the  papilhe  be  very  short,  a 
""iiided  luass  having  a  merely  furrowed  surface  resiiltf<;  but  as  the 
l*'pilla>  lengthen  and  the  ejiithcliiiin  tiiiiis  the  growth  presents  first 
*  <^i«liflower.  then  a  branched,  and  finally  a  villous,  a]>peurance. 
">"■  liiitiT  ajijjearance  is  best  seen  on  jducing  a  "  villous  tumor"  of 
"""  bladder  in  water,  when  the  long  delicate  papillie  float  up.  They 
•**  txcM'dingly  vascular.     On  section  of  a  papilloma  the  relation 


J/r/OA-  rKCREASED. 

bftttccn  stroma  and  epitlieliuin,  above  described,  can  be  seen  orcn 
with  the  naked  eye  (Fig.  *!:!). 

Pnpilhmiiitii  alwiiys  originate  from  skin  or  from  mucous.  stTim*, 
or  synovial  membranes.  They  most  frequently  grow  from  pre-e.tisl- 
iiiji;  pajiillic;  sometimes,  however,  they  occur  where  no  papill*- 
exist,  springing  directly  from  the  subepithelial  connective  ti.*«ur: 
this  is  the  case  in  the  stomiicb  ami  larynx.  As  all  new  growths  no 
free  surfaces  tend  to  become  "  papillary,"  this  form  of  tumor  is 
probably  the  result  of  pby.sical  conditions.  According  to  this 
view,  a  wart  is  simply  a  fibroma  become  pupillary  i)y  an  nccidcDt 
of  position,  and  piapillonuita  as  a  class  should  therefore  disappwf. 

Clinically,  warts,  .so  long  as  they  remain  warts,  are  i|uifc  innc- 
cent.  They  are  common  in  childhood  and  early  adult  age,  e*!*- 
cially  upiin  the  liands  anil  face.  They  may  be  single,  but  n\M 
tbf  liands  they  arc  coinuionly  multiple.  They  generally  dis»pj»'»'' 
after  a  time,  tlnoigii  ihey  may  persist  for  years.  Wart.s  on  luiif""' 
surfaces  give  trouble,  and  may  cause  death  by  bleeding:  in  tbf 
bladder  difficiilly  may  arise  from  id»struction  to  the  inflow  or  not- 
(low  of  urine,  the  entrance  of  the  ureter  being  a  favorite  »ci»l- 
Lastly,  the  tendency  of  warts  anil  warty  surfaces  {irht/it/o*U  limjit'^^ 
to  become  epitheliomatous  in  advanced  life  must  be  remembere<l. 

THE  ADENOMATA. 

The  Adenomata — or,  as  they  are  more  commonly  called,  grlaa^^ 
ular  tumors — are   new    fornuitions   of   gland-ti.ssue,    more  or  It?** 
atypical    in   structure,  having  an   abnormal    relation   to   the  tiss*** 
around,  and  incapable  of  jierforming  the  function  of  the  gland  tL^* 
imitalc.     Their  ducts  do  not  enter  those  of  the  glan<l  whence  tb*^^ 
spring- 
In   structure   the   adenomata   resemble    either   the  racemo.w  *^' 
tubular  glands,  and   are  <livided  into  two  corresponding  varietiff^^ 
1.   The  racemose  adenomata  consist  of  numerous  saccule*  «^* 
acini  lined  with  small  epithelial  cells.     The«e  usually  form  a  siujc**^ 
layer,  though   tbey  may  be  two  or  three  deep.      A  section  cut  \ft^^ 
oblii|uely   through   the  wall   of  one  of  these  acini  will,  by  cuttii*.^ 
across  adjacent   cells   at   different    levels,  give  the  appearance  »' 
superimposed  layers.     The  acini  communicate  with  each  other  »ti  *^  ' 
are  grouped  together,  being  separated  merely  by  connective  tissut^' 
in  which  are  contained  the  blood-vessels.      The  connective  tissue- 
varies  in  amount;  when  iimcii  in  excess  of  the  normal  the  growtf^^  | 


THE  AlfENOMATA. 


18S 


calloil  an  adeno-flbroma.    Sometimes,  in  the  most  rapidly  grow- 
hivg  forms,  tlif  stromn  is  riclilv  cellular,  consisting  of  roiui<l  and 
swindle  elements  :  the  histological  distinction  between  such  growths 
»u»l  sarcomata  is  impossible  (Fig.  64). 

\11  growth.^  originating   in   glandiiliir  organs  may  be  associated 
«ilh  more   or  jess  gl.-iDdiilar   structure.      In    tjie   niiininia,    for   cx- 

Fui.  fW 


y^ 


Adenums  of  mninms.    >:  300,  reduced  J.    iCautlle  ) 

•Tie,  parcoma,  myxoma,  and  other  forms  of  tumor  are  often  so 

'Diormingled  with  the  gland-ti.nsue  of  the  organ  that  it  becomes 

•iifficolt  to  say  which  is  the  predominant  structure.     In  many  cases 

It  Is  evident  that  the  development  of  such  tumors  is  accompanied 

V  an   increase   of  the   gland-tissue   amongst    which    they    grow. 

•''iJtecl  forms  are  thus  produced — adeno-sarcoma,  adeno-myxoma, 

*''^-      Adenoma  is,  bv  itself,  an  insufficient  nauir  for  these  tumors, 

''*<*Uso  their  stroma  is  different  from,  or  in  excess  of,  that  found  in 

""ftOnl  gland-tissue. 

—   The  tubular  adenomata  grow  from  mucous  membranes,  and 

f    "'♦•tst  of  groujis  of  tubules  lineil  with  epithelium.      Tlicy  will  lie 

[•""^i^.J  ti.  hereafter. 

'^■*e  adenomata  almost  always  originate  ftom  pre-existing 
SlWiciB.  They  generally  grow  slowly,  and  possibly  from  some 
liitttfTto  quiescent  congenitally  misplaced  rudiment ;  otherwise  it  is 
^iiracult  to  explain  the  complete  encapsidutiou  and  separation  from 


186 


yuTitmoy  lycREASED. 


the  normal  gland  which  distiiiguish  an  adenoma  from  a  localanf 
enlargement.  The  latter  swelling  remains  in  intimate  relattoB  witi 
the  gland,  and  is  probably  often  of  intlannnatory  origin. 

The  mo."ft  frei|uent  secondary  change  found  in  these  tmuiTui 
fatty  degreneration  of  the  epithelium,  which  may  give  rii« 

I'lo.  t'.6. 


Aileno-fllironM  of  ni" 
iHU*.   X  too,  iwiucvd  |. 


_    -I 


formation  of  Mmaii  caseous  ma.s.«es  in  the  growth.     Dilntxtion  of 

.faccnle.'*  and   tiibule.s  into   cyats  and  mucoid  eofteninflr  ar*  ^  ■ 

crMiimon.     The  origin  of  eaneer  has  several  times  been  traced  l»i       ■ 

adenoma.  J 

The  word  ndenoina  has  been  used  loosely,  as  already  pointed  •»  ^^ 

to  include  all  new  formiitinns  of  gland-tissue.  ] 

Adenomata  occur  in  the  following  organs :  | 

Mamma. — This  is  much  the  most  common  seat  of  adenoma. 

rather  of  adeno-fibnuiia  :   for  a  glandular  tumor  which  is  structural-^ 

indistingiii.-<hable  from   normal  brea.tt   is  very  rare  (Fig.  ••4). 

arrangement  of  the  epithelium,  the  number  and  •ise  of  tlie  ^ 

the  proportion  of  stroma,  and  the  number  of  cells  it   cmtain*  »• 

more  or  les.s  abnormal  (Fig.  tJo),  hence  the  name  adeno-fibroma 

generally  moat  applicable.     These  tumors  arc  also  called  "  chrobi 


THE  ADENOMATA. 


187 


Inittuiuiary     and  "  adenoid."     They  are  cncapsuled.  are  round,  oval, 

[or  lobiilated,  and  lie  in  or  on  tlie  breajst.     Tliey  are  of  liard  ela«itic 

Iconsihtence.     Their  section   is  convex   rather  than  cuj»]ieil.     It  is 

[cither  lobiilated  and  fibrous-looking,  or  shows  distinct  slits  and  a 

iTacfmose  structure  even  to  the  naked  eye.     The(<e  tiituors  are  most 

[common  in  early  life.     They  may  be  multiple.     Many  adeno-fibro- 

Imata  contain  cysts,  which  may  be  very  numerous,  and  vary  in  size 

I froni  slight  dilatations  of  ducts  and  acini  to  cavities  holding  some 

jounces.     The.se  cysts  contain    yellow,  mucoid    fluid,  which   may  l)e 

reildish  or  brownish  from  e.vtravasated  blood.     Many  are  lined  with 

cylindrical   epithelium    like  that  of  the   gland-spaces,  but   others 

appear  to  be  formed  by  localized  soften  in;;.'*  i)f  the  stroma.      .\t  first 

they  appear  on  section   tike  irregular  au<l   braiieht'd   lissures,  then 

like  spaces  full  of  fluid:   in  other  ca«es  they  are  almost  completely 

filled  by  papillary  fibrous  growths  projecting  inward  from  the  wall 

Fio.  (16. 


■o 


WU«iy  (tnnrth  IilsIiIc  iin  tivnriiiii  i  \-i.  |.r.iji  i  link-  from  its  waU  (wl.     U  I'nii.slKis  iif  loose 
"■  '•"•tlvp  ijiotiu'  iri,  viiiitnlnlnic  iniiny  bnincluil  cv\U  ifrivt'n"<l  by  ii  layer  of  coluniDur  celU 
^""'"Inry  proci'iuwM  iirc  iiunit-rnus  (jn.     ■    4<i.  ri'iliiced  i.    (Boyil.) 

•*"•  Covered  by  cubical  epithelium.  These  cystic  growths  are  called 
''^^c  adenomata,  or,  if  the  stroma  is  richly  ccdlular,  cystic 
**^no-Barcomata. 

''"'  non-cystic  growths   must    be  distinguished  from   local   and 
general  hypertrophies  of  the  gland. 


KUTBiriOy  IXCREASKD. 


Ovary.— Many  compound  ovarian  cysta  are  reAlly  cystic  tubular' 
adi'iioiniita.  und  often  contain  pajiiliary  jjrowthf  (Fig.  ♦»•>). 

Testis. — Xo  pure  inlcnoMiuta  occur,  but  only  mixed  tuuiutx  liia 
those  in  the  parotid  gland. 

Prostate. — In  advanced  iigi-  sonic  of  the  tuiuor!(  Mbich  form  iB 
thi.s  body  contain  gland.*  a.«  well  siS  muscle  and  eoiirifctive  iiwiie 
(adeno-myoma). 

Thyroid. — .-Vpart  from  the  hypertrojdiy  of  en<ieniir  piitrr  tni 
Graves  s  disca.se.  distinct  encapsuled  tuiuori*  having  the  structure  <•/ 
the  normal  thyroid  may  occur  in  the  substance  of  that  gland. 

Parotid. — Purr  glan<lular  tumors  are  infre<|Uent,  a«fi  the  glsorf- 
opitlieliuui  of  such  tumors  as  do  occur  is  genemlly  very  atypinL 
Fibro-adenomata  are  commoner.  The  oniiiKiri/  "parotid  tumor  '  i* 
*'  mixed."  containing  cartilage,  mucous  and  other  ti»8ue«i.  Thciitbw 
salivary  glands  are  still  less  frpijuently  nflVrted. 

Liver. — Small  encap-sulcd  tumors  having  the  structure  of  the  li** 
have  been  described. 

Glands  of  Mucotis   Membranes. — ninnd-tissue  enters  U: 
into  the   struct\ire  of  some  of   the  '•mucous"  polypi,  which 
spring  from  any  mucouB  membrane,  especially  in  cAtarrhal  sts< 
In  some  case."*  it  is  probable  that  the  glands  primarily  enlarge.  tl»' 
project,  and  finally  become  polypoid.     In  other  cases  it  in  sup|: 
that  locali/e<l  increase  of  connective  tissue  from  iuflauimuiion 
lead  to  increase  of   the  e|iithelial   structures   in   relation   with 
Polypi  of   the  nose,   stomach,   intestines,   rectum,  and   utervA 
examples.     The  connective  tissue  is  soft  and  <i-<lcmatiiu.i ;  the 
face  is  covered  by  the  epithelium  of  the  part. 

Sebaceous  and  Sweat-glands. — So-calle<l  adenomata  of 
glariils  are  iiniforui  enlargements  rather  than  tumors.     Fig.  67  »i 
a  small  portion  of  a  sebaceous  "adenoma"  from  the  chin  of  a  cli* 

.Amimj:  secondary  changes  are  calcifloation  which  may  af* 
the  epithelial    masses,   and   ossification,   which  may  take  place 
the  fibrous  stroma.     Tumors  undergoing  the  latter  change  are 
and  have  been  called  "osteomata  "  of  the  skin  (p.  103)- 

Adenomata  nffonl  further  support  to  (^ohnheim's  view  roocrrni 
the  nature  of  maligtiancy  (ji.  140).      Adenomata   and  adeno-fib*^ 
mata  are  alinoMt    invariably    innocent.      ( )cca.sinnally  cbmi 
which  clinically  and  microstopically  appear  to  be  ordioarr 
mata,  but  which   re<-iir  locally  after  removal.      It  is  no  explai 
to  call  these  .sarcomata.     Again,  there  are  several  0M«8  on 


THE  CARCtyUMATA. 


189 


of  the  generalization  of  ovarian  udenoiiiata  as   well  as  of  tumors 
having  the  structure  of  the  normal  thyroid  glaml. 

The  lumina  of  racemose  adeiionuttii  are  sometimes  filleii  up  with 
epithelial  cells;  it  is  then  impossiFjie  to  distinguish  them  micro- 
scopically from  scirrhus  in  its  earliest  stage — that  of  multiplication 

Fio.  67. 


r.t^ 


J'-ti- 


'  -i^ '  V  :  •'    i 


MA 


♦-JO.? 


l^'bulp gf  a  scUarpoUB  Hdonumii ;  r.r  ciintiepUvc  liSKiie  cnntniniiiK  iniiiiy  ii'Ms  fiihI  rnnnini; 
"lUe  >uil  iM-'ptn  :  r.  B«i-iMiIc  ftiU  uf  t-iittliL'Unl  pelln,  few  (if  which  «h<i\v  sliftid  <if  futty  ili'^i'ii- 
(Unri— «  i-leHr  xjiact-,  )iiuliliig  niirliMiii  nsldc.     In   larger  Mfi'ules  di^i'iiiTiitioii   is  more 
l»Oer«l  and  extreme  (/. '.)     ■  aoo.    iBoyd.) 

epithelium.     Indeed,  the  origin  of  cancer  from  adenomata  has 

<'n  proved  several  tiaif.'»,   both   microseojiicallv  ami   clinically. 

Aa  sarcoma-tissue   passes   insensilily  into  fihrous.  it   is  often   im- 

I'Wsible  to  say  with  certainty  which  name — adeno-fibroma  or  adeno- 

*»rcoina — should  be  applied  to  a  given  tumor  containing  gland-tissue. 

^K  THE  CARCINOMATA. 

^VThe  Carcinomata,  or   Oanccrs.   are,   of  all    new  formations,  the 
^feust  atypical.     They  are  made  up  of  cells  of  the   epithelial  type 
^^""ped  irregularly  in  the  alveoli  of  a   more   or   les.s  dense  fibroid 
r«troma.      The   "epithelial   type"   implies  origin    from   epibla**   or 
'•ypobliist  anil  the   absence  of  intcrcellulur   substance;  it  doc«  ui»t 
""I'l.v  any  specific  form  of  cell. 
Tilt-  alveolar  structure,  as  seen   in  sections,  has  CMUcd  it  to  be 
•111  that  cancer  is  an   atypical    gland-structnrc.      Etctt  taaor  i» 
">'pical  mor|ihologically  and  pbysiolDgically  ;  almost  all  arpMVtroe- 
"i^lly.     In   cancer  we  have  epithelial   cells,   often  «f  the 


190 


NUTRITION  INCREASED. 


abiinriiiiil   form,    filling    up  the   liiiniiin   of  g1;in<l-tiilH*!»   (tfit 
from  u  ;;liiiiil).  )>iir!<tiiig  through  their  bii.si.'mi-nt   or  liiuiliD^ 
brane  and  ramifying  in  the  s|iace  of  connective  tiraue.     Th 
type  for  such  a  process  as  this  is  the  development  of  a  glsnj 
the  liver)  by  the  growth  of  s<did  hypoblast ie  rods  into  a  mcmt 
htromii. 


(ktli  tram  n  •rirrhoi  of 


STRUCTURE.— In  rli-iding  with  the  microscopic  Btnic 
have  to  describe,  first,  the  e|iittielinl  cells;  ami.  secondly,  tbc 
which  form»  the  spaces  in  which  they  lie. 

The  cells  arc  characterized  by  their   large  sijse.  bv  ihr  "31 

of  their   forms,   and  by    the  magnitude  and   ]>roniiueuce  of 

nuclei    and    nucleoli    (Pig.    08).       TIm 

''"'■"''•  round,  oval,  fusiform,   caudate,  or  jwl; 

^jA'^^^  — exhibiting,  in  short,  every  iliven«ity 

^I^L    ^9   BBl         line.    These  variations  in  form  arc  priui 

owing  to  the  mutual  pressure  tu  which,  ii 

growth,   they  are  subjected.     The  nm 

large  and  prominent,  round  or  oval  in 

and  contain  one  or  more  bright  uiicitfnli 

nuclei  are  perhaps  most  frei|uenily  i^ing 

two  are  often  met  with,  and  in  the  s«jft 

more  rapidly-growing  cancers  there  may  be  more.     The  « 

loosely  in  the  alveoli,  and   no  stroma  passes  between  thrni. 

rapiilly  undergo  retrogres.sive  changes;  hence  they  usually 

molecular  fat.      Sometimes  so  many  have  been  destroyed  th 

free  nuclei  are  visible  than  cells.     Cells  precisely  similar  to 

are  mot  with  in  other  morbid  growths  and  al.«o  in  the  nnrtnal 

There  is  thus  no  »pfcttic  ■"cancer-cell." 

During  the  last  few  years  the  minute  structur©  of  c»nc 
be<'n  subjected  to  a  very  rigiil  examination  in  scarcb  for  anv 
site  that  may  be  present.  Nearly  all  observers  are  agree< 
when  suitable  {strtions  of  cancerous  tissues  arc  harden 
stained  by  special  tuethods  pecidiar  a|tpearances,  the  signi 
of  which  is  still  in  di.spute.  an;  to  be  seen.  These  are  kn 
"cancer-bodies"  or  "cell-enclosures."  They  vary  greatlj 
Iteing  on  an  average  sontewhat  smaller  than  red  corpuscles, 
arc  encapsulated,  anil  for  the  most  part  spheroiilal :  they 
sharplv-dcfincd  outline.  They  possess  staining  affintLic!*  ho 
different  to  those  of  the  ordinary  cells  of  the  growth.     Thoir 


192 


yUTRITIOy  INCREASED. 


i»  geuerallv  roiiinl  (ir  oval.     There  is  usually  but  one,  ami  this  may 
be  ciiurn'Cieil  utlh  the  t«.'ri])her_v  bv  faint  rays  (.Figs.  69/',  auiiIiJ<'^ 
The   I'uiHHT-bodies    eoinmouly    multiply   by   binary    division:  the 
occurreiiee  of  sporulntioii.  Jiltiiou^ili  .'iffirtnetl  by  some,  is  dcninibv 
most.     TLey  are  usually  Ibuiui  enclosed  in  the  ordinary  cells  of  ibe 
growth,  but  they  have  been  described  in  the  alveolar  spacee  outside 
the  cells,  and  even  m  the  lymphatics  of  the  alveolar  walls.    Tlirir 
position  has  no  ascertainiihle   influence  on  their  general  char«cti'r»- 
As  a  rule,  no  cancer-cell   contains  more  than  one  of  them.    Tlic 
cancer-body  may  occupy  only  an  insignificant  part,  or  it  niay  fill 
nearly  the  whole  of  the  cell  and  displace  the  nucleus  to  the  [pe- 
riphery.    Still  umre  rarely  these  bodies  may  be  found,  singly  "f  in 
numbers,  in    the    nucleus    itself:    in    this  case  they  are  gcncnillj 
smaller  than   when  found  elsewhere. 

The  cancer-boilies  are  most  comnion  in  growing  edges  uiiil  in 
secondary  deposits,  and  are  rarely,  if  ever,  found  in  degcinTsicJ 
parts.     On  the  other  hand,  there  is  no  evidence  that  thoy  oxciw 


Kio.  71. 


/■      P 


.--•A.. 


Canc'irlxvUi's  xhowltit;  jinilmWc  mi-thoda  of  repnxliictliin :    (r)   yurloiis  of  |*r»»l* 
dlvldlUK,  and  Ihu  coriuwtlTiK  tliri-adn  are  shown.     ■-;  ti«10.— <«)  DlvUilon  of  nuclrtiit  aJi'l 
w»U  Ik  cumpli'tv.     v.  film.— (hi  1'iirui.lii'  Kli<>wini;K''i>nuUii>  at  the  ptTiphory  of  the  ci-ll. 
—(f)  Coninicnrine  tn'urmi'iitnltoii  <•(  |>imu>lti-.  Bhowlnit  a  acaUopfil  luanrln.  each 
which  contains  a  iKirlion  of  Ihi-  frntintMited  niieUnu.    X  HKKI.— irt)  Cell  niiitalnlni  a  ell 
of  Hmall  iwrHBllcrt,  prcHiinmlily  n  laicr  Mn^v  of  the  proovKS  soi'U  In  (rK     V  Iijii— OiIDl 
thcuc  with  drawing  of  malarial  [laraiiltcii.    (Spvclnif  n  and  drawing  by  Dr.  Kulhr.l 

any  unusual  activity  of  growth  in  the  cells  containinir  them,     '* 
they  degenerate   they  lose  their    sharp    contour :    and    Ruffer  !»** 
drawn  attention    to  the    fact  that   this    not  iinfrei|uently  bsppe"^ 
when  a  leucocyte  invades  a  cancer-cell  already  occupied  by  one  o* 


THE  CAnCINOMATA. 


103 


Fifi. 


[these  "cancer-bodies."'     The   imture  of  these  boilies  is  discussed 
[on  p.  11I5. 

The  Btroma  varies   considerably   in    iiitiounf.   being   much  more 
I  abiindaiit  in  some  specimens  than  in  others.     It  consists  of  a  more 
lor  less  distinctly  fibrillated  tissue  arranged  so  as  to  form  alvenli  of 
I  various  shapes  and  sizes,  within  which  tiie  cells  are  groujied  (Figs. 
1 7'2  and  74).     It  is  not  closely  connected  with  the  cells,  and  none 
l)enetrate    between   them.     These   alveoli    communicate    with   one 
■nother,  so  as  to  form  a  continuous  cavernous  system.     The  cha- 
!  racters  of  the  stroma  vary  with  its  rate  of  growth :   if  this  is  rapid, 
[•'  ■will  contain  some  round-  and  spindle-shaped  cells  (see  Figs.  76 
i»ndSl);  if,  on  the  other  hand,  it  is  slow  or  has  altogether  ceased, 
"»e  tissue  will   contain   few   or   no  cells. 
"lij  will  be  denser  and  more  fibrous  in 

Eiararter  (Fig.  74).  The  latter  is  the 
ndition  in  which  it  is  most  commonly 
et  with. 
In  the  stroma  are  the  blood-vessels. 
aese  are  often  very  uumentus,  ami 
foi-ni  a  close  network  round  the  alveoli, 
rin-yare  limited  to  the  stroma,  and  never 
■i)ti3s  into  the  epithcHal  mas.ses.  This 
Histriljution  of  the  blood-vessels  is  im- 
Bportant,  as  it  serves  to  distinguish  the 
^  can-inottiata  from  the  san'omatu  (p.  1  (»!)). 
To  alveolar  .sarcomata  and  tiiiiiors  s[irtng- 
ing  from  endothelium  this  ride,  however,  does  not  apply. 

Lymphatics  citmmiinieate  freely  with  the  alveoli.  This  explains 
the  great  tendency  of  cancer  »o  infect  the  lymphatic  glands.  In 
"•'t.  the  alveoli  may  be  regarded  a.s  dilated  lymphatics,  fur  the 
•"Iiithelial  columns  grow  along  lymphatic  spaces — the  lines  of  least 
"^•stiuice. 


) 


Ttie  alvt'olar  stn^ma  from  a 
acirrhus  of  tin-  niumrnu.  The 
I'lMls  liMvu  boon  ri'iuiivi'il  !)>•  pcn- 

cuiing.  X  aoo. 


ORIGIN. — The  question  of  the  genesis  of  carcinoma  involves 
tlim  nf  the  genesis  of  epithelium  generally.  It  is  iii;iintiiiued  by 
"•""l  liistologists  that  epitheliuiu  can  originate  only  fnuti  epitltelium, 
*iu  that  the  epiblast  and  hypoblast  are  the  sources  from  which  all 
'puhelium  is  .subsequently  derived.  Others  state  that  epithelium 
"iiT  originate  also  from  connective  tissue.  A  like  dift'erence  of 
cpinion  exists  as  to  the  source  of  the  epithelioid  cells  of  cancer. 

13 


194 


miTRITIOS  IXCREASED. 


By  iniiny  tliev  are  rririinli-d  as  (iri^inntiiig  only  from  |»r^-ipv 
e|iitlii'liuin.  Otla-rs  muitituiii  tliat  tlioy  luay  b«'  diTivcil  •!«> 
cells  belonging  to  the  connective  tissue.  It  is  aUo  bclicTcd  bt 
some  tliiit  niiiny  ciiru;ers  originiito  from  tlie  endotlifliiim  of  tli» 
lympbutics — /.  c  8])cuiuliy.etl  connective-tissue  corpuscle*. 

Nearly  all  nioilem    observations  tend  to   support  the  epillifliil 
origin.     This  renders  it  impossible  for  true  cancer  to  arise  in  «o« 
mesoblastic  structure.      Cases  have  been  re|iortetl  of  primsr)'  vncrt 
in  jynijibatie  glands,  in  bone,  in  the  nienibranei>  of  tbt>  brain.  io<l 
in  other  places.     Of  these  cases  there  are  three  possible  expliw 
tions:  (1)  some  snnill  primary  jjrrowfh,  which  g.ivi-  rise  lo  n 
tom.*.  may   have  bei-ii  ovf-rlooked ;  (2)  some  ubn<irriiality  in 
existed,  such  as  a  detaclied  piece  of  mamma  lying  near  the  axill«7 
giniids  or  the   ftetnl   iru'liision  of   an   epitlu-liiil   rtidimcnt ;     ' 
growth  may  have  been  one  of  those  sarcomata  which  can  I" 
guishe<l  from  true  cancer  only  by  the  closest  examination  ami  k" 
i-areful  inquiry  into  their  development  (alveolar  sarcomata,  cjlin- 
dromata). 

Epithelial  cells  are  said  to  occur  round  a  cancer  quite  iwUl**' 
from  it.  They  lie  in  the  connective-tissue  spaces.  The  isoltttiun '» 
very  ililTicult  to  prove,  and  <loes  not  necessitate  the  origin  of  tB"" 
ci'll.H  front  connective-tissue  elements,  for  the  cells  may  havt*  b»«« 
carrietl  by  the  lymph-stream,  aifled  by  the  spontaneous  mo't' 
ments  ntited  in  cancer-cells  by  (.'iirnuilt.  (Iften  delii-ate  cluittf™ 
cells  oui-  or  lwi>  inches  long  havt-  bet-n  traced  bftween  a  w*'" 
growth  and  an  apparently  isolated  nodule:  such  a  chaio  tui^* 
easily  be  interrupted.  It  is  worthy  of  note  that  very  few  ctM*  '" 
so-called  primary  mesoblastic  cancer  are  nitir  reported. 

It  is  most  probable,  therefore,  that  a  cancer  originatos  eithi 
the  growth  of  a  resting  embryonic  epithelial   rudiment  (fob 
or  in  the  multiplication  of  some    epithelial  cells.      (Mher  eondi' 
being    favorable  (p.    14rt),    the    cells  grow    through    any  basemC*^ 
membrane  that  may  exist,  and  s|iread  in  the  connective  tissue 
lymph-spaces    and    channels.     At    this   stage    the    epithelial 
actually    lit-    in    the    lymph-current,    where    they    wouUI    nat 
multiply  very  rapidly,  being  bathed  in  nutrient  flnid.     In  thi» 
glan*lular  infection   is  easy  to  explain.      Where  resistance  is 
the  growing  fcll-coiinuns  nn-  narrow  :   where  it  is  sliirlit  tbrv 
out. 

The  connective-tissue  bundles  of  the  part  .••re  at  first  the 


THE  CARCIS03IATA. 


195 


of  tbe  stroma,  but  round-celled  infiltration,  probably 
nf  more  or  less  intense  intlauiniatiun  excited  by  tbe 
Invasion,  soon  appears,  and  is  followed  by  fibroid  tissue 
Tacts.  At  fir.st  other  elements  of  the  part  nuiy  also  pcr- 
etrowa — ('.  (/.  fat-cells  iti  the  breast  and  tiHisele-fibre.«  in 

mode  of  growth  tbe  Cttrcinomata  never  beeome  enciip- 
jraduiilly  infiltrate  Hiirroiiudinu  striietiires.  This  j)roe.e8S 
ion  i.<  very  eliaracteristie.  and  is  more  markeil  iu  cancer 
iT  of  the   malignant    growths,     A  zone  of  small-celled 

is  wen  for  .some  di.stance  around  the  confines  of  the 
liat  there  is  no  line  of  demarcation  between  it  and  the 
ucture.s  (Fig.  73). 

at  jiresent  no  general  agroeiiienf  concerning  the  nature 
,ncer-bodies  "  before  describi-d.  or  tbe  jiart  tliey  take  in 
and  growth  of  cancer,  lltiffer  coni[)are.s  llieni  to  the  pro- 
ilnria  (see  "  Malaria  "),  and  by  many  observers  they  are 
he  parasitic.  Tbe  evidence  in  favor  of  this  view  may  be 
iri/ed :  (1)  their  occurrence  within  the  cell  a.s  a  distinctly 
fetaoce;  (2)  their  appearance,  so  strongly  suggestive  of 
leil  structure:  ('^)  tbeir  staining  reaction.s.  .so  distinct 
I   presented  by  the  normal  contents    of   cells;    and   (4) 

analogy  to  well-known  species  of  sjMjrozoa  recogni/ed 
P.S  of  epithelial  proliferation  in  the  intestine,  bile-ducts, 
>f  certain  animals, — all  point  forcibly  to  the  conclusion 
liodies,  though  not  necessarily  eoecidia,  arc  nevertliel<'ss 
Dd  are  parasitic  in  cancerous  epitlieliuui.'  But  tlieso 
\  no  means  jiass  uncballcnged.  It  is  niaititained  that 
*.«ie  so-called  parasites  arc  nothing  mitre  than  the  appear- 
nced  by  the  invagination  of  a  part  of  one  cell  by  the 
ft  substance  of  another,  as  might  be  seen  in  a  section 
Igh  the  invnginating  cell   [larallel  to.  and  just  below,  the 

ugh  which  the  indieddod  cell  enters  (Fig  70,  <•).  It  is 
y  others  that  enclosed  leucocytes  and  ilegenerative 
ve  in  like  manner  been  misinterpreted.  A  still  more 
Ipported  suggestion  is  tiiat  these  bodies  are  really  due 
I0U8  formations  in  tbe  originul  cancer-celU.  This  may 
\r  from  an  arrest  of  the  process  of  direct  division  (ami- 
Vm  some  irregularity  in  that  of  indirect  division  (mitotic, 
kalluwny  •.  Morton  IjW-tiire,  Bvil.  Hftfl.  Jnurn.,  vol.  i,,  1S93, 


15)6 


NUTRITION  INCREASED. 


karyrikinetic).  Round  ji  detacheil  portion  of  chromatin  »  cell 
forms  ami  grows  rapidlv,  but  remains  a  daugbter-Cfll  within  iLf 
substance  of  its  parent.  If  this  be  so,  it  is  difficiih  to  see  «bT 
(laugUttT  and  parent  .should  present  any  marked  difterence.s  from 
one  another  in  their  staining  reactions. 

These    various   objection.s    may   doubtless    e.\{>lain   many  of  tiir 
appearances  described  by  over-zealous    advocates  of  the  pnmsilic 
the<:>rv.  but  there  remains  a  considerable  residuum  not  so  ea.sil_v  Jis- 
po.se(l  of.      In  the  nicjin  time  mucli  of  the  argument  depends  on  it* 
experience  and  authority  of  the  difl'erent  observers:  and  until  thf 
existence  of  c!)!(r!ictf'ristic   spores  has  been  definitely  made  (iiil.  "f 
until   there  is  forthcoming  stich  cotifiriuiitory  evidence  a.s  cheniisirv 
!iiid   iuoculiitioii  and  cultivation  ex]>eriu]ent8  can  alone  supiiWfp- 
145).  the  iiiter[)retation  of  the  ii)>pearances  described  seems  likfh 
to  remain   more  or  less  in  dis|uite. 

SECONDABY  CHANQES.— The  most  im(K)rtant  is  fctW 
degreneration.  This  occurs  in  all  the  varieties  of  carcinoiiin.  The 
more  rapid  the  groxvth.  the  earlier  does  this  retrogressive  cb»iig* 
take  place  and  the  greater  is  its  extent;  hence  it  is  usunlly  m"*' 
marked  in  the  riirr/ilmlni'il  form.  It  produces  .softening  of  '■"' 
growth,  uliich  is  often  reduced  to  u  l>ulpy  cream-like  cnusislcnC'J- 
Hemorrhage,  pig-mentation,  mucoid  and  colloid  degenerate*''' 
may  also  occur,  with  cyst-formiitioa.  Cysts  may  be  due  al^' 
blocking  of  ducts — c.  </.  in  the  manume.  Calcification  atul  t*^* 
ossification  are  very  rarely  met  with.  Formation  of  an  abaoefl*  ' 
rare,  but  important. 

VABIETIES. — The  varieties  of  carcinoma  are  arranged  on    •^ 
anatomical  basis.     The  cells  vary  markedly  in  character  accor  J  •'^' 
as    they  spring    from    stratified    epithelium,   columnar   epitheli  «• 
or  the  epithelium  of  acinous  glands.     They  inherit,  to  a  gre*** 
or  less  extent,  the  form  and  temlencies  of  the  variety  of  epithel*** 
from  which    they  ofigiuate.     Thus,  colls   of  cancers  springing  ft'*' 
stratifieil  epithelium  tend  also  to  undergo  the  .same  epithelial  evf»" 
tion.  ending  in  cornification  ;  anil  in  many  eases  they  show  priclc  ' 
cells.     Columnar  epithelium  id'teu  retiiins  its  typical  form  and  «-• 
tinues  to  surround   open  s]jaees;  but  in  other  cases  the  cells  mill 
ply  so  Hs  to  fill  the  spaces,  the  outermost  cells  generally  retaining 
cylindrical  shape.     Cells  of  acinous  glands  undergo  no  evoliitioC* 


THE  CA  RCtSOMA  TA . 


197 


Y  muUipIicatiou  thev  produce  cells  of  their  owu  kind,  which  may 
much  iiltfrt'tl  ill  nhape  by  raiituai  pressure.  Upon  this  reti-ntion 
>>y  the  celln  of  ancestral  unatouiical  ciiaracter.s  the  (•iiief  varieties  of 
cancer  are  based.  Thus  we  have  tlie  squamous  epithelioma,  the 
columnar  epithelioma,  and  the  acinous  cancer.  But  ancestral 
peculiarities  are  not  always  retained.  Certain  cancers  sprinjijing 
frnui  Kirntified  epithelium — perhaps  from  the  .hiiiiiII  glaruls  in  rela- 
tion with  it — undergo  no  evolution  and  are  imlistinguisliable  from 
wirrlnis,  while  tumors  springing  fmni  (•iilnnrtiav  epithelium  are  in 
raanv  |mrts  exactly  similar  to  acinous  cancer. 

In  all  varieties  of  carcinoma  the  secondary  growths  tend  to  repeat 
tlie  pcctiliarifies  of  the  primary,  especially  in  epithelioma.  In  scir- 
rhiw  the  secondary  growths  in  internal  organs,  though  sometimes 
rwcmbling  the  primary  tumor,  are  often  more  rapidly  developed. 
Further,  they  are  softer  and  more  vascular,  so  that,  in  accordance 
*ith  till'  artificial  distinction  between  scirrhus  and  encephalnid  (p. 
201),  fhev  must  be  regarded  as  belonging  to  the  latter  variety  of 
ciineer, 

The  name  epithelioma  was  given  to  cancers  springing  from  the 
*I"tlu'lia  in  opposition,  a.s  it  was  thought,  to  the  cancers  of  connec- 
ti'Miwue  origin.  The  distinction  of  the  forms  is  of  iniicli  less 
iitifiortance  now  that  the  epithelial  origin  of  all  is  couiing  to  be 
more  and  more  recognized.  Still,  the  histological  differences 
■"^'wei-n  well-marked  cases  are  sufficient  to  justify  a  separate 
'Iwcription  of  the  above  varieties. 

'arciuomata  are  accordingly  divided  into  two  groups — acinous 

cancer,  with  m-irrhuuii  or  rhronic  cinicrr  and  ctirrfiliuhiiil  or  nmti' 

fitnfer  as  subdivisions;  and  epithelial  cancer,  including  Ki/tiiinKnix 

*^'i  cnluinniir  i'f>it/ieliointt.     Of  these,  coluiunar-celled  epithelioma  is 

""*'  allied   in  structure  to  inlcnoma.      <  o/lniil  or  jii'lutlni/unn  i-an- 

'''■•  due  to  colloid  degeneration   of  the  ciini  cr-eells,  was  formerly 

'•'^ardcd  as  a   sid)division   of  aciuoiis  csiticcr  or  even  as  a  separate 

'■"■ifrty.  but  all  the  above  varieties  may  undergo  tliis  form  of  degen- 

•nitio,,. 

^^tJNICALi  CHARACTERS. — Cancers  occur  with  increa.sing 
'J'lcDcy  after  the  age  of  thirty-five;  below  that  of  thirty  they  are 
**  tumors.  The  primary  growths  are  almost  always  single.  They 
'  *nioDg  the  most  malignant  tumors,  there  being  little  ground  for 
'Ce  between   them  and  the  .sarcomata  as  regards  their  mortalitv. 


198 


SUTRmON  INCREASED. 


As  a  }»ro(ip  the  cancers  grow  rapidly,  widely  infiltrate  aurroumlinj; 
jiiirts.  curly  iiiffct  lyni[ihiiti(;  ^I.'iiuls  (().  193),  and  idtimately  hfcoiiio 
difsouiiuatiMl  gfiienilly  tlirouglmiit  the  system,  liiless  ejcciseil  very 
early  and  very  freely  thov  recur  in  loco.     They  freouentlv  lirctk 

•  •  *  •  (la 

down  and  give  rise  to  very  offensive    sores  which    bleed  rt'inlily. 

It  will  he  reuR'uihered  that  while  the  sarconmtii  us  a  «;roii|Ml"iint 
infect  lymphatic  ginnds  (p.  172).  they  are  siip|)08ed  to  genrmliir 
more  early  and  more  readily  than  the  carciuoiuata.  The  rensnu  It 
this  is  that  the  surcoina-cells  fvcijitently  form  tlie  very  walln  of  ti» 
blood-vessel,  whilst  the  cells  of'euucer.s  do  not  even  come  int»  eim- 
tact  with  tin-  walls  uf  the  vessels. 

Just  as  the  sarcunialii  vary  in  malignancy,  so  also  do  the  carciii"- 
mata.     On  the  wliole.  cnceplialoid   is   more  speedily  fatal  than  wir- 
rhus,  owing  to  its  more  rapid  growth,  greater  vascularity.  andnnTf 
active  epithelial  elements.      Colloid   degeneration  seems  to  diniini^li 
malignancy.     Every  now   and   again   an   encapsuled   tumor  i.*  nici 
with,  especially  in  the  soft  palate,  showing  no  sign  of  inaligiwnfy. 
yet  having  the  structure  of  acinous  cancer.     In  the  variety  kiio»r 
as  atro])hic  scirrhus  the  duration  of  the  disease  is  not  uncommonly 
from  ten  to  twenty  years  and  the  e.xtension  only  local  and  glandnl**"' 

Epithelioma  is,  jmthologically,  mncli   the  least  malignant  oft"* 
cancers.      It  extends  locally,  breaks  down  early,  and  often  inf**^** 
the  neiirhborinjt  Ivnipliatics,  hut  it  comicirativelv  rarelv  reprodu*^*- 
itself  in  internal  organs.     Thi.s  is  jirohably  owing  to  the  sixe  ***    1 
clianicter  of  its  epithelial  elements,  which    render   them  much    ■*  '  ( 
liable  to   tnmstiiissioii   by   the   blood- and  1\  mph-streauis   than    *"_     ' 
cells    of  the    other    varieties    of    cancer.       Its    malignancy    v**** 
curiously  with   its   seat:   thus,  on  the  skin  of  the  face  epitheli*^' 
ha.s  genendly  a  very  chronic  course,  and  rarely  affects  even 
glands:  on  the  lip  early  excision  gives  a  fair  chance  of  cure: 
the  tongue  its  cour.se  is  often  so  rapid,  aflection   of  the  gland* 
enrly,  and  citchexin  and  death  so  .speedy  that  it  must  be  rankc«» 
one  of  the  most  nuiligiiant  timiors. 


ACINOUS   CANCER. 
1.  CHRONIC    CANCER   or    SCIRRHUS    is  charactcrixed     ]'- 
be  anioutit  iind  density  of  its  .stroma  and  by  the  slowness  of    ■ 
growth   MS  ccimp:ircil   wiih   that  of  ence]ihiiloid.     The   latter  fH**** 
arohnbiy  accounts  in  great  measure  for  the  peculiarities  in  its  stri**^ 
tiirc  and  physical  characters. 


ACINOUS  CAXCER. 


199 


Tlie    epithelial  growth,  although   Jit   first   it  may  be  luxuriant, 
"Quickly   subsides.     The  elements  soon  atrophy  and  undergo  fatty 

Fig.  73. 


'*»-lrThu«  nfthe  miimma :  « ii««tlon  tbinuBh  the  vCgv  of  ttii'  tumor,  nhowlnK  the  DmaU-oeUed 
^aaitntliiii  iif  thv  niuwulnr  ntinA  unrladlpuau   tiwuv  in  thu  iii-lg)ib<irhoo<1  i>r  thi;  kIauJ. 

"i-V  aw>. 

metnmorphoHis.  They  are  most  abiiiidiuit  in  die  external  portions 
^^  t\n'  tuninr  where  growth  is  tali  lug  phiw  ;  in  thu  funtral  jxvrtion.s 
'bey  may  be  almost  entirely  wanting.  Figs.  73  an*!  74  show  the 
»p|H>nrance8  presented  by  scirrhus  of  the  mamma  in  the  earlier 
•ittjL'fx  of  its  development. 

Tbe  defeneration  of  the  e])jtlieliiil  elements  i.s  prohiihly  tine  to 

"Miteration  iif  the  vessels  by  tlie  seiir-like  contraction  of  the  stroma, 

*'i)cli  ijuiekiy  becomes  hard  and  indurated.      In  this  way  growth 

"'  thut  part  of  the  cancer  is  arrested.     The  whole  of  the  central 

/"^rtions  may  thus  ultimately  consist  of  dense  fibroid  tissue,  amongst 


"•Tr»i„„  ,,f  II,,,  i„»iiiiiiii    H  pi>ni>iii  of  iIh'  junior  Koincwhat  internal  to  that  represented  In 
*    •'■'.  (hoMlng  thp  C'banirtorlatic  alveolar  strucluru  of  tlie  i-aucer.     -   auo. 

"'cli  are  scattered  groups  nf  atrophied  ejtithelial  cells  and  fatty 
I  ,.    *•■>»  (Fig.  75);  but  even   in  these  ca'ses  tlie  epithelial  structure  is 
^     ***'tictly   visible  at  the  periphery.     The  amount  of  atrophy  and 
I        **-t*artion  varies  considerably  in  ilifTerent  cases. 
,   I     *  «»e  physical  characters  of  scirrhus  are  in  the  same  way  due  to 

^  *«.bHudance  of  its  stroma.     The  growth  is  firm  and  hard,  and  is 
*«*lly  depressed   in   the  centre,  owing  to  contraction  of  the  fibroid 

^Uv  and   atrophy   of  the   cells.      Thi.s   is    very   characteristic   of 


200 


KUTRrriON  mCREASED. 


scirrhiis  of  tlic  breast,  wht-rc  it  causes  retraction  of  the  nipple  irnl 
puckering  of  tin-  skin.  Tliu  growth  is  verv  biinl  and  i'r<'aks  as  il 
is  cut.  TLe  surfucc  of  the  section  i.s  generaliv  "  cupped."  nnil'if 
grayish-white,  semi-translucent  appearance  ("  like  an  unripe  }H'ar  / 


Fio.  76. 


• 


SoliThiiBnr  ihr  mitniuiii:  a  m-cUon  frimi  the  more  centrni  inirtlonsof  tho  turoor.tho»"< 
the  utrt'iihy  of  tin- epHlicltul  I'flls.thertliuiuutloii  liuliv  iti/i' of  tlu- alveoli,  Ihe  BliwM  0»»»'. 
luul  iIr' rutty  ilObrin.  u,  rurliur  stage;  b,  luon.' lulvimi'ist.    v  'JUU. 

It  is  more  or  le.ss  mottled  with  dots  and  streaks  of  opaque  vrll''*' 
due  to  fatty  epitbeliuu)  in  alveoli  or  milk-ducts.  The  latter  W*J 
be  cystic.  The  central  part.s  are  pale  and  fihroid  :  the  more  extern** 
are  pinker,  because  contraction  lias  not  obliterated  the  vessels,  ***' 
less  finn  than  the  central  portions  of  the  growth.  They  yicM.  '* 
scraping,  a  juice  which  is  rich  in  nitcle!ite<l  cells,  free  nuclei,  *** 
granules.     The  outlying   parts  of  the  tmnur  can   he  brought   •' 


it" 


t^ 


u| 


view  by  the  local  application  nf  a  /">  jier  {'cnt.  solution  of  nitric  fc^ 
Opa<(ue  white  lines  murk  the  affected  areas. 

By  far  the  commonest  seat  of  scirrhus  is  the  female  breast,     t  * 
also  found  in   the  mule  breast,  the  stomach,  the  liver,  the  pancr 
the  prostiite,  the  skin,  and  the  mucous  meinbriiues.  where  it  «i 
from  racemose  mucous  glands.     The  .secondary  growths  to  wbict*^ 
gives  rise  are  often  encephal(ii<l. 


•2.  ENCEPHAIiOID    or   ACUTE    CANCER   differs    from 
preceding  in  the  greater  rapidity  of  its  growth,  and  in  the  oon^-^- 
<]Uently  smaller  amount  of  its  stroma  and  greater  softness  of  its 
sistence.     Eiice|tliiiloi(l  and  scirrlius  uiinttot   be  regardeil  as  in  a - 
way  constituting  distinct  varieties  of  carcinoma.     There  are  mas 
interuieiliate  st;iges  between  them  (scirrho-cncephaloid),  and  all  the 
structural  and  clinical  difl'crenccs  arc  accounted  for  by  differcuccii 
rapidity  of  growth,  which  probably  depends  upon  the  vascularity  c^^ 
the  part  in  which  they  arc  situated. 

The  cfiitliclial  growth  in  encephaloid  is  rapid  and  abundant;  ll^ 
cells,  which  may  be  either  larger  or  smaller  than  those  in  acirrhu^* 


KPfTHELTOWA. 


201 


Kiii.  7(>. 


>xJ 


quickly  undergo  fatty  tlegeneratiou,  so  that  often  there  are  more  free 
nuclei  visible  tlian  cells. 

The  j)rop(irtioii  of  stroma  is  very  bidjiII,  lunl.  owinfr  fi>  tlie  nijiidity 
of  its  growth,  it  i.«  much  less  fibrous  than  that  of  seirrhuB  and  does 
not  undergo  a  similar  cicatricial  omtnictioii  (Kig.  T'i).  The  blood- 
vessels are  often  very  abundant  and  the  tissue  supporting  them  is 
»oft  and  non-resistant.  Hemorrhage 
into  these  growths  is  therefore  fre- 
quent. 

Encephaloid    cancer  is  of  a  soft. 

brain-like    consistence,    the    central 

portions,    where    fatty    degeneration 

IS   most  advaneed.   often   beinj;  com- 

pletely  diffluent.     The  tuniDC  is  sonie- 

titnes   more   or   less    lohulated.     On 

w?otion  the  uudegencrated   (larts  are 

S^^y,  pinkish,  soft,  and  translucent, 

''hilst  the  degenerated  form  a  white      Emcph«i..ici  ...nrer  ifr,m.«i*eeondury 

l"'lpv  mass  much  resembling  brain-  '''nnr  „r  thu  Uvir.  shcwinif  the  iur»e 

.      -  1  •    1     ■        r  11       "''"^  "^  ""•■  "l*'*^""  ""'1  'he  thinmsas  of 

»'« "Stance,  which  18  often   irregularly   ihi-irwaUx.  in  the  iihut small. wu are 
«aiued  with  extravasated  blood.       "    '■'»"''^-'-  J^''  ''"i:"^'!''"'''""!  "'i''  »«> 

-C'nccphaloid  is  much   less  eotnmon    phmis.    •:  ax). 
*uau    scirrhous   cancer.       It    is   most 

n"e«^uently  met  with  in  internal  organs  as  a  He<-ondary  growth.  It 
'^  Sometimes  jirinian/  in  the  testis  and  mamma.  It  may  fungiite  and 
oleecj  (fungus  hicmatodes).  Many  growths  formerly  described  as 
cocephaloid  cancers  were  really  soft  sarcomata  (see  p.  173).' 

P  EPITHELIOMA. 

1-    SQUAMOUS    EPITHELIOMA  cnnstitntes   a    tolerably  dis- 

j?***^t   variety  of  carcinoma,  but   tiansitioital    forms   between   it   and 

^'*~*'liu8  arc  occasionally  met  with.      It  always  grows  from  a  surface 

overed  by  squamous  epithelium,  either  cutaneous  or  mucons  (the 

J^'Hction  of  the  two  being  a  cuninion  seat).     Its  epithelial  elements 

ciosoly  resemble  those  of  s(|uamoiis  epithelium. 

•he  cells  (Fig.  77)  are  often  coiisiilerably  flattened  and  distorted 

?*'  "bape,  owing  to  the  pressure  to  which,  in  their  growth,  they  are 

l*uhjpeted.      The  cells  grow  dnwn  from  the  surface  epithelium  into 

"^  lymph-spaces  of  the  conneetive  tissue,  and.  [lUshing  their  way 

*lotig  these,  are  formed  into  solid  cylinders,  which  twist  about,  branch. 


202 


SVTRITIOlf  INCREASED. 


Via.  77. 


ami  intercommunicate — ^swellingoiitatsome  ))ointsnnd  liccotniug con- 
stricted or  even  iiiternipti'd  at  otliers.  Single  epithelial  cells  nwj 
be  recognized  here  and  tiiere,  evidently  swept  ou  by  lymph.  Tlit 
rods  cut  acro.ns  a|ipear  as  round  or  oval  nntt^seH  of  cells,  of  whieli  tiit 

oiiterniuHt  are   usually  large,  irhilxt  tb» 
eentral  are  more  or  less  (<i]namous  ami  fnrtii 
a  yellowish  oiiiou-like  ma.«s.     Sonii'iimw 
the  central  cells  a|)pear  large  and  vesic- 
ular, whtl.st   the  outermost  are  scaly  ind 
llattened.      The.><e  concentric  mnsm-s  of 
cells   are    culled   '■'■  coticmtric  i/l<^»"  of 
'■^  4'fiitheh'(i/  tirstit."  ani\.   though   not  Ji*- 
tinctive  or  essential,  they  are  cxcccding^J 
characteristic  of  epithelioma.     The  «*W 

rcll.fr»m«nc.pUht.ll»m.oftl,e     fo,.„ii„g   il,„„  ^^g  „„,„11^.  ,„„^    „„,]   ^»V 

lip.      .<    JIM.  ^  •  •  _ 

be  so  closely  packed  as  ultimately  tu  »■»*' 
come  hard  and  dry  like  tho.so  of  the  nails  and  hair:   the  globe**   ■ 
then  of  a  brownish-yellow  color  and  of  a  firm  consistence.    T^* 


I 


Fio.  78. 


W 


E]iillK-Uuinu  III  lla-  Up,  sliiiwliit:  llii.'  iiiiiuunlrk'  k'u'i^'i  »'  epilliL'Uul  rvlU 


i 


globes  are  often  lar;ie  enough  to  be  readily  visible  to  tlie  naked  vy 
and.  owing  to  the  onion-like  arrangement  of  the  cpidennii-  *'•*!( 
they  usually  present  a  fibrous  appearance. 


The  stroma  presents  every  vtiriiition  between  nipidly-prowin-j: 
embryonic  and  an  inci)nii)letely-fit>rill:ite<l  tissue.  It  may  be  tolera- 
bly abundant  or  almost  entirely  wanting.  It  rarely  forms  siicli  a 
mni'ked  alveolar  stnictiire  as  that  wliicli  cliaracteri/.es  tlie  ntlier 
vuiclies  of  carcinoma,  and  consists  siin|dy  of  tlie  fibi-ous  tissue  of 
the  part  more  or  less  intiltraled  with  small  round-cells,  which  may 
Itf  nltimately  replaced  by  eormeetive  tissue  (Fig.  7!l). 

The  development  of  epithelioma  is  due  to  the  down-growth  of 
tlie  surface  epithelium  of  skin  or  of  certain  mucous  membranes  into 
the  connective  tissue  and  deeper   parts,  as  is  described  on  p.  184 

I'Ki.  73. 


'^«tk«||oni»  nt  ihe  toti^if :  ■  vertical  UTtlon,  nhnwinR  exceailve  e|iltlielfal  growth  u|ion 
*r  ***»"li»oc  .if  the  i>iiiUn»'  unci  fXtru.Hli.ii  uf  the  celln  Into  the  aulijiioi-iit  oumieetlve  tluiir. 
«*"'*'''""•■""'  tlwiK' U  liiHllrul«-i\  wilh  siiiull  cfUa,  uiiiiiiin:  wliirh  are  single  epithelial 
'*"»'«tnl"ooneenti1i'(tlo)jc»."     •;  100. 

*^'R.  70).  The  tendency  of  epithelinma  is  to  bnak  ilown  at  an 
'"7  stage:  this  is  due  to  fatty  degeneration  <A'  (he  cells,  and  not 
'"  'f  flammation. 


204 


NVTRITIOy  INCREASED. 


Epitbelionia  usually  presents  itself  as  a  small  hard  ulcer,  or  ii 
an  iii(liirii1i.'<l  fissure,  or  as  a  subcutaneous  nodule  wliieli  siibw- 
((ueiitly  breiiks  down.  The  surface  of  the  ulcer  is  irregular,  and 
may  be  sloughy.  It  is  often  clean,  and  covered  by  large,  firm, 
hhiish-red  {iranulations,  consistiuj;  largely  of  epithelium ;  more 
rarely  the  surface  is  mnrkcdly  warty.  The  tumor  itself  is  firm  in 
consistence,  often  more  or  less  friable,  and  on  section  present*  ■ 
grayish-white  gruiitilar  surface,  sometimes  intersected  with  linefl  of 
fibrous  tissue.  The  cut  surface  yields  on  jire.ssure  a  small  ijuantity 
of  turbid  !i((iiid.  In  many  cases  a  peculiar,  thick,  crumbling,  curdy 
material  can  also  be  expressed,  which  ofYen  comes  out  in  a  worm- 
like shape,  suggestive  of  sebaceous  matter  from  the  glands  of  the 
skin.  This  niutcrial  is  very  characteristic.  It  is  composed  of  fatty 
epithelial  scales,  and  on  being  mixed  with  water  it  does  not  difTnse 
like  the  juice  of  other  cancers,  but  sepurates  into  minute  visible 
particles.  If  it  is  very  abui)(biiit.  the  cancer  is  soft  and  friable. 
and  the  material  can  be  seen  on  the  cut  surface  as  small  scattered 
opa(|ue  dots. 

Irritation  has  more  to  do  w  ith  the  cau.sation  of  epitlieliomn  thau 
of  other  kinils  of  cancer.  Some,  such  as  cancer  of  the  scrotum  from 
soot  and  e{)ithelioma  of  the  arm  in  workers  with  tar  or  paraffin, 
appear  to  be  due  simply  to  irritation  in  people  the  phy.«!iologic«l 
resistance  of  whose  connective  tissue  is  diminished  until  invasion 
by  epithelium  is  rendered  easy.  Other  epitheliomata  occur  at 
points  where,  the  process  of  develo])mcnt  being  complicated,  errors 
;ire  likely  to  have  <u-cuvred.  These  places  liave  been  alreadv  enu- 
merated (p.  142).  Miiny  of  these  are  points  exposed  to  irritation. 
S<|iiauious  epitlieliouia  usually  infects  the  lymphatic  glands,  bat 
rarely  occurs  in  internal  organs. 


Rodent  Ulcer. 

Rodent  Ulcer  deserves  a  short  notice.  It  is  a  form  of  epithe- 
lioma beginning  as  a  pim|de  ujion  the  nose  or  check,  and  liable  to 
freipient  irritation  from  rubbing  or  picking.  After  a  time  it  breaks 
down,  and  (he  ulcer  thus  formed  slowly  .spreads,  destroying  crcry- 
thing  that  it  meets,  including  bmies,  and  jjroducing  the  most  hid- 
eous deformity.  This  may  go  on  for  many  years,  the  health  re- 
maining good  and  no  gland  being  affected.  It  differs  from  ordinary 
eijiiiimous  epithelioma  cbielly  in  the  small  size  of  the  cells,  iu  the 
absence  of  prickle-cells,  in  the  slight  tendency  the  cells  show  to 


RODENT  ULCER. 


205 


lome   scaly  ami  to  form  iiostts,  and  in  the  case  with  which  the 
[epithelial    coluuius  can    be   traced   (Fig.  HO).     Some   believe  that 


^^    KcMlonl  ulcer  of  n>wv,    Tbc  patlunt  hnd  ■iiinll  rodent  ulcvra  of  the  nose  and  cheek  and  in 
rl>   v|«llli«Iioum  iir  the  Up.     ^  50.     iBoyd.) 


k 


rodent  nicer  lu-gins  in  the  root-sheatliN  of  the  hairs  or  in  the  gland- 
©pitlieliuin  of  the  skin.  In  some  case.s  liuving  the  elianicferistic 
history  of  rodent  ulcer  the  struct utc  is  that  of  tyjiicnl  eijithelioma. 

2.  COLUMNAR-CELLED  EPITHELIOMA  or  ADENOID 
CA_NCEB. — These  terms  are  applied  to  those  forms  of  epithelial 
c&ncer  which  grow  from  mucous  membranes  with  columnar  (cylin- 

Fio.  81. 


rjrllndrlcol  epltheUoma  (firoia  the  colon),    x  2D0,  reduced  (. 

tiricul)   epithelium — ^.  </.  the  stomach  and  intestines,  and  especially 
the  rectum  and  uterus.     In  these  tumors  the  epithelial  elements  are 


2l)() 


yUTRITIOy  JSCREASF.D. 


vsimilar  to  those  of  the  mucous  menibniiie  from  whieh  tV 
They  are  cylindrical  iu  Mliape.  ami  are  arrangeil  perjivnii;- 
the  walls  of  the  alveoli  in  a  manner  precisely  aualogotie  to  tliat  of 
the  columnar  epithelium  on  the  mucous  surface  (Kip.  81).  Tli« 
slower  the  growth  the  more  typical  the  glaiul-formatiun.  In  rmpid 
growths  and  reeiirreuces  the  cells  are  small  and  the  lumiua  iinper- 
feet.  The  latter  may  be  filled  up.  and  the  growth  !)»•  indii<tingui«ii- 
able  from  acinous  cancer,  except  by  its  edge,  where  u  low  culumnar 
or  cubical  form  usually  iiersists;  hut  this  too  mny  W  lcM>t.  Tbr 
growths  are  of  a  soft  and  ofken  gelatinous  consistence;  thov  show  • 
marketl  tendency  to  undergo  colloid  degeneration.  Tbi?MJ  tiuuon 
cause  secondary  growths  in  the  lymphatic  glands,  and  somctiaci 
in  the  liver,  luugs.  and  boucs:  the  secondary  tumors  powacat  the 
same  characters  as  the  primary  cancer.  The  distinetioii  Wtwccft 
adenoid  cancers  ami  simple  adenomata  de|)eud8  u|K>n  the  inri 
of  the  neighboring  tissues  by  the  former. 


OoLLotD  Cancer. 

Colloid  or  Qelatiniform  cancer  is  simply  one  of  the  pnwedilig 
forms  which  has  undergone  u  mucoid  or  colloid  change.       S«m>- 


Kio. «. 


r'nU')t<l  ranrvr.  ihnwlnic  ihv  Iktiiv  iilvcuU  within  whipli  te  ounMaed  Uw  | 
tnaliTlnl      <  :nO.    (Klm1l1ct»cti.| 


matou*  anil  other  non-cancerous  growths  may  undergo  the 
change. 

The  alveolar  structure  in  colloid  cancers  is  very  marked.      T 
alve«>li  have  verv  thin  walls;  tbcy  are  large,  distinct  and  more 


THE  TERATOMATA.  207 

less  spherical  in  shape.  The  large  size  and  distinctness  of  the 
alveoli  are  owing  to  their  distention  by  products  of  degeneration. 
These  products  form  a  gelatinous  colloid  material  which  is  glisten- 
ing, translucent,  colorless,  or  yellowish,  and  of  the  consistence  of 
thin  mucilage  or  size.  In  the  main  it  is  perfectly  structureless; 
within  it,  however,  are  imbedded  a  varying  number  of  epithelial 
cells  (Fig.  82).  These  cells  present  a  peculiar  appearance:  they 
are  large  and  spherical  in  shape,  and  arc  distended  with  drops  of 
the  same  gelatinous  material  as  that  in  which  they  are  imbedded 
(Fig.  82).  Many  of  them  display  a  lamellar  surface,  their  bound- 
ary being  marked  by  concentric  lines.  It  wouhl  appear  that  the 
colloid  change  commences  in  the  cells,  which  become  gradually 
destroyetl  in  the  process. 

In  other  cases,  similar  to  the  naked  eye,  the  cells,  with  the  ex- 
ception of  slight  fatty  metamorphosis,  arc  but  little  affected,  and 
the  substance  distending  the  alveoli  is  more  viscid  and  mucoid  in 
character.  This  is  due  to  a  mucoid  degreneration  (p.  82)  of  the 
intercellular  substance  rather  than  to  a  colloid  change  commencing 
in  the  cells. 

Colloid  cancer  is  most  frequently  met  with  in  the  stomach,  intes- 
tine, ovary,  and  peritoneum.  In  the  latter  case  it  is  either  second- 
ary or  the  growth  is  a  sarcoma.  The  tendency  of  abdominal 
tumors  to  undergo  colloid  degeneration  is  at  present  unexplained. 


CHAPTER  XVI. 

THE  TERATOMATA.— CYSTS. 

THE  TERATOMATA. 

These  tumors  are  congenital.  They  occur  chiefly  in  the  sacral 
region  (coccygeal  tumors)  and  about  the  head  and  neck — points  at 
which  double  monsters  are  united — but  they  may  be  internal.  Some 
of  them  are  due  to  the  inclusion  and  imperfect  development  of  one 
foetus  within  another ;  others  to  the  abnormal  development  of  the 
tissues  of  a  single  foetus.  They  are  mo.xt  complex,  and  may  con- 
tain all  the  tissues  of  the  body  up  to  ganglion-cells  more  or  less 
«'onfuse«lly  mixed.  They  may  be  very  large  at  birth  or  may  not 
attract  notice  till  later.     Dermoid  cysts  belong  to  this  group. 


2U8 


yHTRITJON  jyCREASED. 


Cysts. 

In  addition  to  the  new  growths  already  described  there  is  n  I«rgt 
clashi  lit'  foniiations.  raany  of  which  canuot  be  regarded  as  "  tmunr'" 
in  the  .strict  iijtiilication  of  tliis  term.  These  are  the  cysts  "f 
"cystic  tumors." 

A  cyst  is  a  cavitv  cnntiiining  lifjiiid  nr  jiiiltaceoiis  nmifrm). 
which  i.s  sejianUed  from  the  surrounding  structures  bv  a  mnrc  nr 
less  distinct  cafisule.  It  may  be  (1)  a  new  formation,  or  (2)Bp»- 
exiating  structure  which  ha.s  become  di.«tended  either  by  it.*  "»" 
.secretion  or  by  the  extravasation  of  some  other  fluid  into  it.  ••nlj 
the  former  comes  within  the  category  of  new  growths;  but  forth* 
sake  of  convenience  it  will  be  advisable  to  consider  them  both  i" 
the  present  chapter. 

There  are  thus  two  principal  modes  by  which  cysts  origiDit*- 
The  first  and  most  frequent  is  by  the  gradual  accumulation  of  job- 
stances  within  the  cavities  of  pre-existing  structures.  These  *a\>- 
stances  arc,  fur  the  most  part,  jiroducta  of  the  parts  in  which  thej 
are  fnund.  being  it)  some  caaes  a  secretion  and  in  others  a  oeU* 
growtii.  The  second  and  less  fre(|uent  mode  of  origin  is  bytb* 
independent  formation  of  a  cyst  in  the  tissues. 

The  accumulations  of  secretions  and  of  other  products 
within  pre-existing  cavities  may  be  effected  in  the  three  following 
ways : 

Ist.  By  the  retention  of  the  normal  secretion,  owing  to  the  rlosaK 
of  the  excretory  ducts,  as  so  often  occurs  in  sebaceous  glands. 

2d.  By  excessive  secretion,  the  cavity  being  unprovided  with  »" 
excretory  duct,  as  in  the  distention  of  biirsie. 

3d.  By  the  extravasation  of  blood  into  the  cavity,  as  iu  hieBi*' 
tocele. 

The  independent  formation  of  a  cyst  may  take  place — 

Ist.  By  the  softening  and  liquefaction  of  the  tissues  in  eoD** 
particular  yiurt,  owing  to  mucoid  or  fatty  changes.  The  ti»u*'* 
arouml  the  softened  mutters  become  condensed,  and  ultiiuate'5 
form  a  kind  of  cyst-wnll, 

2d.  By  the  collection  (tf  fluid  in  certain  connective-tissue  sp«cc*' 
and  the  subse(|uent  enlargement  and  fusion  of  these  spaces.  Tp* 
surrounding  ti.'*sue  becomes  ct>ntle!i.><ed  and  forms  a  cyst-wall :  »'>** 
this  may  in  some  cases  become  lined  with  flattened  connective-tis*"^ 
bUb  (endothelium). 


I 


CYSTS.  209 

3d.  By  the  formation  of  a  cyst-wall  round  foreign  bodies,  para- 
ntes,  or  extravaaated  blood :  the  wall  consists  of  fibrous  tissue  and 
is  the  result  of  a  chronic  inflammation.  Smooth,  heavy,  sharp- 
edged  foreign  bodies  are  particularly  liable,  during  the  process  of 
"healing  in,"  to  produce  cysts  of  this  character,  especially  when 
the  parts  are  not  kept  at  rest.  Salzer  has  suggested  the  artificial 
introduction  of  such  substances  when  adhesions  are  feared  or  a 
hlae  joint  desired. 

Straoture. — The  wall  of  the  cyst  will  vary  in  its  nature  accord- 
ing as  it  is  that  of  a  pre-existing  or  a  newly-formed  cavity.     In  the 
/brmer  case  it  will  possess  an  epithelial  lining  which  will  present  the 
same  characters  as  that  of  the  gland,  serous  membrane,  or  other 
structure  from  which  the  cyst  originated.     If  the  cyst  is  of  inde- 
pendent formation,  there  is  at  first  no  endothelial  lining  to  the 
fibrous  capsule,  but  one  may  develop  later,  as  in  false  bursaj.     The 
cyst-wall  is  sometimes  firmly  connected  with  the  adjacent  parts,  so 
tliat  it  can  only  with  difficulty  be  separated ;  in  other  cases  the 
anion  is  much  less  intimate.     Instead  of  being  a  distinct  structure, 
it  my  simply  consist  of  the  surrounding  tissue,  which  has  become 
tleoiie  and  fibrous  in  character. 

The  contenta  of  cysts  are  very  varied,  and  may  serve  as  a  basis 

for  their  classification.     In  the  retention-cysts  they  will  vary  with 

tlie  nature  of  the  normal  secretion.      Serum,  sebaceous   matter, 

saliva,  milk,  seminal  fluid,  and  other  substances  are  found  in  these 

cysts;  they  are  more  or  less  altered  in  character  from  having  been 

retained  in  a  closed  cavity.      In  the  exudation-cyst-s  serum  is  the 

roost  frequent  constituent;  and  in  extravasation-cysts,  blood.     In 

those  cysts  which  originate  from  the  softening  and  breaking  down 

of  tissue  the  contents  are  formed  from  the  products  of  retrogressive 

tissue-metamorphosis,  such  as  mucin,  fatty  matters,  and  serum. 

Cysts  may  be  simple  or  compound.  A  simple  cyst  consists  of  a 
"Ogle  loculua.  A  compound  or  multilocular  cyst  is  one  consisting 
01  numerous  loculi,  which  either  communicate  with  one  another  or 
'^'nain  isolated.  Another  variety  of  compound  cyst  is  one  with 
nidogenous  growths,  or,  in  other  words,  a  large  cyst  with  others 
powing  in  its  walls.  A  compound  cyst  may  become  a  simple  one 
■y  the  destruction  of  its  walls. 

Cysts  are  frequently  associated  with  other  growths,  hence  the 
'*nn»  "cystic  sarcoma,"  "cystic  cancer,"  etc.     It  is  especially  in 
''"Xe  growths  which  originate  in  glandular  structures,  as  in  the 
14 


mVTRITION  INCREASED. 


innuiina,  testicle,  and  uvarv,  that  this  combination  is  met  with. 
The  cystic  devt'lojiuu'nt  nmy  iiluiost  entirely  obliterate  the  .'triic- 
ture  of  the  tuiunr  in  wliicli  it  takes  place,  so  that  ultiuiatelv  th>- 
latter  may  btcome  couverteil  iiitci  a  mere  congeries  of  cyst*.  In 
other  cases  large  jiu[iilliirv  masse.H  of  the  tumor  grow  into  tin-  n»iii" 
cavities  ("  coin]ioiiii<i  ]iruliferou8  cysts").  Considerable  difficNiiv 
in  determining  the  nutiire  uf  the  original  growth  is  thus  not  iofir- 
((uently  ex|)i.'rifiic(.'d. 

Secondary  Changes. — These  may  take  place  in  the  wall  of  the 
cyst  or  in  its  contents.     The  cyst-wall  itself  may  become  the  wat 
of  new  growths,  and  produce  secondary  cysts,  villous,  glandnlnr. 
and  other  structures;  this  process  occurs  in  many  conipouml 'i>»- 
riun   cysts.     It  may  also  be  the  .seat  of  an   inflaniuiatory  procrs* 
which  terminates  in  supjiuration  and  granulation:  by  this  towns 
the  cyst  frc(|iiently  bewmi's   nlilitcniteil.   its  contents  being  filher 
absorbed  or  dis<-liiirj;fd  f.\tenii«liy  and  the  cavity  closing  by  gran- 
ulation.    Calcification  and  ossification  of  the  wall  may  also  txxor. 
The   contents  of   cysts    undergo    varinus   changes,   owing  to  tiieir 
rt'teiitiou    in   a   closed   cavity.     The   secretions   become   altiTtnl    »" 
character,    thickenetl,    and    viscid.       Epithelial    elements  aDiii'n?" 
fittty  changes,  and  so  give  ri.se  to  cholesterin  crystals.     Calcifi*^' 
tion  of  the  contents  is  also  eoninion. 

CLASSIFICATION. — Cysts  may  be  most  conveniently  class'**^ 
accordin'T  t<)  their  mode  of  nrijiiu,  thus: 
1.    <.'yi>t»  foriHid  III/  till'  <tc<-utintliition  of  Hiifwtiifuti'S  irithhi  the  caC*' 

of  prf-exufiiiy  gtriu'ttiren.  . 

A.  Retention-cysts. — Cy.sts    resulting    from    the    retention 
normal  secretions.     These  include — 

git* 

a.  Sebaceous  Vu»ts. — These  are  formed  bv  the  retention  of 

cretions  in  the  sebaceous  glands.     They  posses.s  a  v"  ^  " 
thin  connective-tissue  wall  lined  by  stratified  epitheli  •*  . 
(Fig.  83).    They  contain  a  mass  of  fatty  epithelium  *•" 
its  products,  cholesterin  and  nuinrphous  debris. 

/3.  Mufous  Ci/ntn. — These  are  formed  by  the  retentinn  of  setT*" 
tious  in  the  glands  of  mucous  membranes. 

y.  Oi/»t»  from  the  retention  of  nerretiottg  in  other  parts,  includi**^ 
— ranuhi,  from  occlusion  of  the  .-salivary  ducts;  encifff*" 
hi/tirnrele,  frout  occlusion  of  the  tubidi  testis;  nuimiHttrr 
ei/gtt,  from  obstruction  of  the  lacteal  duct«:  nimple  it0*" 


] 


tation 
the  (jrnafiiin  follicles;  and  simple  ci/stn  of  the  liver  ami 
kiiliwyr.   tVom   lociil  obstruction. 
B.  Exudation-cysts. — Cvsts  resiijtiuji    from  excessive  secretion 
in    cavitii'S    iinprovidoil    with    an    excretory    iliict.      These 
iuclmle  hurna;,  ifiini/lia.  Iii/ilnicrli;  mi-niuffoeeles,  cystic  lironcho- 
rcUf,  and  many  i\>f»t»  in  thf  hrund  /iffumoit. 
C.  Extravasation-cysts. — Cyst*    nvsitlting    from    extravasation 
into   closed   cavities.     These  iixhide  hirmnlovele  and  some 
other  forms  of  sanguineous  cysts. 


II.  ('\i»t)i  iif  itnlvfu'tiilriil  (irifpn. 
■K.  Cysts   from    Softening   of  Tissues.- 


-'riipsc   arc   especially 


Fio.  X3. 


,     I*"""!*  rjfii:  r /.  Ihc  llilii  fiiimeHivi-ti.sBii.  11.  IIiiimI  liy  i»  thick 

■''■■Hum.     Tho  t»«UT  I'ftllfl  of  thUi  an-  .luim-whul  t-uljifiil .  tlit-ii.  |His.<»lne  (nwiinl, 

iliiLtt'fiiMl ;  nnd  flnully  tlH*y  cnUrjifi'  r^iiiHldtTHbly,  U't-nini'   fMtty,  and   rHther 

-■>  niLr  III  iitiiln.    They  art-  fuccwdoij  liy  futty  di^brls  {/>»'<  •'<ini|irv'w<-d  at  to  have 

^•^•"I.Tt.    lUofd.) 

common  in  new  formations,  a.«  in  chondroma,  lipoma,  sar- 
coma, etc. 

•  Cysts   from   Extravasation  into   Solid  Tissues ;  <:  //.   into 

hrain  or  soft  new-irrowtli.*. 
P 

•  Cysts  from  Expansion  and  Fusion  of  Spaces  in  Connec- 

tive Tissue. — Thf.se  incliitU' — 


CHLOROSIS.  213 

CHAPTER  XVII. 
DISEASES  OF  THE  BLOOD. 

ANiBMIA. 

The  term  anoemia  has  no  very  definite  connotation.    As  generally 
employed  it  includes  all  diseases  of  the  blood  which  are  character* 
ized  by  a  deficiency  in  the  number  of  the  corpuscles  or  a  diminu- 
tion  in   the  total  percentage  of  haemoglobin.     Other  expressions 
with    a    more   precise  significance  are   sometimes   used.     Thus  a 
diminution  in  the  number  of  red  corpuscles   is   known   as  oligo- 
eythatmia  or  aglobulitm,  and  a  deficiency   in   the  haemoglobin  as 
aehromatotit.     These  results  may  be  produced  by  temporary  con- 
ditions.    Thus,   anaemia   is    common    during  convalescence  from 
acute  fevers  and  after  severe  hemorrhages.     It  may  also  owe  its 
origin  to  deficiencies  in  the  ingesta  or  to  that  which  produces  the 
same  practical  result — stricture  of  the  oesophagus  or  of  the  pylorus. 
In  cases  due  to  these  causes  the  number  of  red  corpuscles  is  always 
reduced,  while  the  leucocytes  may  be  either  slightly  diminished  or 
slightly  increased.     Not  only  is  the  total  percentage  of  haemoglobin 
below  the  average,  but  the  amount  contained  in  each  corpuscle  is 
Ivss  than  normal.     Anaemia  following  acute  fevers  or  hemorrhage 
rapidly  disappears,  the  exact  rate  of  disappearance  varying  with 
the  nature  and  severity  of  the  disease,  the  recuperative  power  of 
the  patient,  and  the  general  conditions  of  convalescence. 

To  two   varieties  of  anaemia  special   reference  must  be  made. 
These  are  (1)  Chlorosis,  and  (2)  Pernicious  Anaemia. 

I.  Chlobosis. 

Chlorosis  is  mainly  a  disease  of  girls  and  young  women.     It 

^Ises  its  name  from  the  effects  of  its  most  marked  feature,  which 

'*  the  deficiency  of  luamofirlobin.    This  is  so  great  that  the  skin 

'"d  mucous  membranes  of  the  patient  assume  a  very  pale  and 

"'gutly  green  tinge.     In  extreme  cases  the  haemoglobin  may  fall  to 

Oe-eighth  of  its  full  amount,  and  in  most  it  is  less  than  a  third. 

'^  fill!  in  red  coipuscles  is  by  no   means   parallel.     In  mild 

»k^*  they  may  average   3,500,000   to  the  cubic  millimetre,  and 

Y>"  seldom   fall   below   2,000,000.     The    corpuscles   are,  on  the 


^le,   distinctly  smaller  than   usual.     Some  of   them 


are   verv 


214 


DISEASES  OF  THE  BLOOD. 


Binall,  Hinging  down  to  A/i  in  tliiirauter  (niicrocytes);  a  few  »re 
large,  with  a  iliiiUK'tcr  up  to  \'2n  (matTocytes);  wliile  otheri*  vritb 
an  irrt'griliir  outtinc  are  occasionally  f'oimii  (|ioikilocyte»).  TUc 
Bpeciflc  gravity  of  tiit-  blood  may  fall  ten  to  twenty  degrees,  thii* 
furnishing  rcliahlc  evidence  of  its  "watery"  condition.  In  some 
few  cases  where  death  had  occurred  the  heart  mid  liirge  arteries 
were  unHSually  small.  Other  morbid  conditions  secondary  to  the 
changes  in  the  blood  rnay  coexist.  .Viuong  these  are  dyspmca  tnd 
the  occasional  dejiosit  of  fat.  both  resulting  from  the  deficient  oxygen- 
carrying  power  of  the  blood;  slight  oedema,  probably  from  defectire 
nutrition  of  the  ve.ssel-walls:  and  varir)us  auscultatory  signs,  due  to 
the  lowered  .specific  gravity  of  the  hlooil  and  defective  action  of  tlie 
inadeijiiately  nourished  heart. 

PATHOLOGY. — No     generally-acccj.ted     e.\pIanation    of    the 
changes  in  the  blood  has  yet  l>een  found.     Virchow  first  drew  Htten- 
tion  to  the  small  size  of  the  heart  and  large  arteries.  »n<l  attributcJ 
it  to  defective  ilevelopnient.      He  regarded  the  disease  as  the  ex- 
pression of  III!   iuabiiity  of  (he   l)bK)d-forn]ing  organs   to  meet  ih* 
demands  made  upon  them  during  a  period  of  rapid  development — • 
disea.se  especially  liable,  therefore,  to  occur  in  tho.se  iu  whom  tb«w 
parti^    arc   congenitally  defective.      In    many  cases    the   generative 
organs  are  also  backward  in  their  dcielopment :  and  this  fact  un- 
doubtedly  affords    some    sufiport  to   Yirchow's    theory.     Still.  A* 
enormous   freijuency  of  tlie  disease,  its    practical    limitation  tnnne 
Bex.  its  ready  curability,  and  the  want  of  jiarallel  between  the  jjre** 
fall  in  h.T?raoglobin  and  the  slight  fall  in  corpuscles,  point  to  a  mof* 
transient  and  less  organic  causation.      It  is  unquestionable  that  g^^" 
tralgia.  gastric  catarrh,  gastrii;  ulcer,  rniDstifiatwn,  defective  hygitn'* 
surroundings,  and  irregular  habits  are  frc((uently  associated  with  tb* 
condition,  aud  that  in  niaiiy  extimplcs  of  the  disease  the  admini't'** 
tton  rif  iron   fails  to  effect  a  cure  until   these  be  relieved.     Ihi  «•* 
other  hand,  it  is  no  less  certain  that   the  relief  of  these  condiiioW* 
without   the  adTuinistration  of  the  iivm  is  ineffectual  as  a  cure  in*' 
hilt  the  mildest  forms.     Now,  it  is  notorious  that  hiemoglobin,  wliic"** 
contains  a  very  apjireciable  amount  of  iron,  is  the  progenitor  off'?' 
ments  which   contain    little  or  none.     The  amount  of  this  Bic<* 
excreted  in  the  f;vces  and  the  urine  is  excessively  small,  and  i«  "'* 
appreciably  increased   in   aujetiiia.      It  seems  reasonable  to  supix*^ 
that  the  iron  thus  left  behind  is  utilized  by  the  newly-forming  haMBO^ 


CBLonosrs. 


215 


globin;  aud  iF,  therefore,  the  hemoglobin  in  the  blood  is  deficient, 
it  Would  .toem  luore  rutioiial  to  look  tor  a  ctmsi'  tlmt  interfores  with 
tlif  syiitht'sis  of  hjetiKtjrlobiii  t'rom  the  aocniiiiilutiiig  stock  of  iron, 
nttlier  than  for  one  which  leads  to  anv  loss  iu  the  total  amount  of 
iron  coiitnini.'il  in  the  body.  Any  supply  of  iron,  in  addition  to  that 
already  storetl  in  the  liver,  needed  to  meet  the  demands  of  growth 
and  waste,  must  clearly  come  from  the  footl.  Much  evidence  is 
'■vailnlile  to  show  that  most,  if  not  all.  the  iron  iilKS<>rbc<l  or  excreted 
is  absorbetl  or  excrete<l  in  nrgnnir  forms  only,  though  it  is  impossible 
lo  deny  that  it  may  exist  in  an  inorganic  form  in  the  portal  vessels 
nd  bo  retained  and  recombined  iu  the  liver. 
According  to  Bunge.  the  iii)tiie<tiatc  precursor  of  hivnioglobin  is 
ttiatogen.  a  nnclein  containing  iron,  phosphorus,  and  proteid 
•tt^r.  He  suggests  that  the  sulphuretted  hydrogen  develojied  in 
•<?  alimi'Ufary  tract  of  dyspeptic  and  constipated  persons  seizes  on 
It'  organic  iron  (hsematogen)  in  the  food  and  cmiverts  it  into  sul- 
fide, which  is  in4!apable  of  absorption.  Thus  the  body  is  starved 
iron,  and  cidorosis  residts.  The  success  following  the  adminis- 
tion  of  large  do.ses  of  iron  he  explains  by  siipjiosing  that  the 
^traction  of  the  sulphurette<l  hydrogen  for  the  iimrifauif  salts  is  so 
e»t  that  the  organic  compounds  are  undisturbed  and  allowed  to 
on  into  the  body.  Sulphuretted  hydrogen  is  very  diffusible 
l«d  is  very  readily  absorbed.  Its  destructive  action  on  organic  iron 
'impounds  is  therefore  not  necessarily  limited  to  the  intestine,  but 
night  easily  be  exercised  in  the  blood  itself  Stockman  has  pub- 
«»h«r«l  some  eases  in  which  sid|jhide  of  iron  enclosed  in  capsules  to 
protect  it  from  the  action  of  the  gastric  juice  was  followed  by  dis- 
tmct  benefit.  The  sulphide  could  not  have  attracted  any  of  the  sul- 
pburettcd  hydrogen  away  from  the  organic  iron.  The  failure  of  both 
uinnuth  and  manganese  to  act  in  the  .same  way  as  curative  agents 
*i*o  iiwts  adilitional  doubt  on  the  sufliciency  of  Bunge's  theory,  as 
uiio  does  the  success  which  has  attendcil  the  subcutiineous  injection 
of  very  small  doses  of  iron. 

Among  other  theories  may  be  mentioned  Landwehr's.  This  ob- 
•ener  is  of  opinion  that  at  the  age  when  aujeuiia  is  common  there 
•*  «  tfndcnry  to  the  exce.«sive  formation  of  animal  gum  (I he  carbo- 
''.'farate  constituent  of  mucin),  which  is  needed  for  the  euibryo. 
"ii*.  wlu-n  present  in  excess,  may  interfere  with  the  foruuUion  of 
'i*ni.,„l„i,i„. 

*aniler  attaches  much  importance  to  a  supposed  deficiency  in  the 


DISEASES  OF  THE  BLOOD. 

hydrochloric  acid  contained  in  gastric  juice.  But  this  deficiencT  is 
not  uniform.  The  gnstric  juice  of  some  case.s  of  ciilorosi.>i  contain* 
a  large  excess  of  bvilrocljioric  acid,  which  is  perhaps  partlj  ru- 
sponsible  for  the  occasional  development  of  acute  gastric  ulcers. 
Further,  the  luluiitiistnition  of  this  acid  Uiin  no  curative  value  in 
aiuemia.  This  disease  is  therefore  unlikely  to  be  due  to  »  «!iiii 
of  it. 

II.  Pernicious  An.£mia. 

Pernicious  ansemia  differs  from  chlorosis  in  many  particular*.  It 
does  not  show  the  same  preferences  as  regards  age  and  sex,  beiag 
commoner  in  older  jjcr.'ions  atid  in  males.  It  is.  moreover,  generally 
fatal. 

Pernicious  anwmia  may  be  the  apparent  result  of  hapmorrhage 
after  cliildhirtli  or  of  any  of  the  ordinary  antecedents  of  anwnii* 
alreadv  iiientioncd.      More  often  it  has  no  obvious  cause. 


+' 


^ 


APPEAKANCES. — The  blood   in   pernicious  ansemia  is  very 

different  from  that  in  chlorosis.     I* 

^"i-^^-  differs  from  it  in   three  especially 

*  M    ^^  ^  important  particulars :  (1)  In  chlo- 

^        •     ^.  rosis  the  most   marked  feature  i«  » 

^  ^    ^^      \     0  ^        drop   in    the  pciccntaife  of  hxuto- 

globiu,  whereas  in  pernicious  »nw 
miu  the  most  markeil  feature  i." 'b' 
diminution  in   the  number  of  r©" 
corpuscles.      Thus,    although  *'"■' 
total  amount  of  hipmoglohin  is*  '"' 
variiibly  diminished,  yet  the  aiiioiH'' 
contained   in  each    corpuscle  v>»}' 
even   be  in  excess  of  the  iuirm«' 
The  fall  in   the  percentage  "f  "'"^ 
corjiuscles  is  enormous.    Blood  with  only  :}(M|.0(l()  red  corpuscle* '" 
the  cubic  millimetre  has  been  described.     (2)  The  next  most  fban"" 
teristic  difference  is  the  ri'oi|iien<'y  of  changes  in  the  form  sud  stf* 
of  the  corpuscles.     Sometimes  there  are  found,  a.s  well  as  iion""' 
blasts,   enormous  nucleated   red    corpuscles   (20/i  dia.),  known  *■ 
giganto-blasta  (Fig.  86).     According  to  Eichhorst.  the  micp'cy'*'' 

'  I'erchloride  of  mercury,  0..5  grm. ;  chloride  of  siMliiim,  1.0  prm. ;  niilpbMf  "' 
iKxliiim,  a.O  grni. ;  distilled  water,  200.0  c.  c. 


Pernirioiu  anmnlii:  blood.onrpiu>rlc!i 
sliowInK  polknocyu-s  Ifi),  mlcrocytes  (i«). 
and  iiticleated  porpti8<!lL.fl  (nit*giilu<*ytoK) 
in).  !*rrM«'rvu(I  in  Huyem's  fluid.'  (Sjicri- 
men  mid  ilmwInB  by  Dr.  Molt.) 


PEBA'ICrOUS  ANjEMTA.  217 

e  not  only  much  more  numerous  than  in  chlorosis,  but  have  a 
jry  characteristic  appearance.  They  are  spherical,  granular,  and 
ighly  pigmented.  The  number  of  leucocytes  and  of  blood-platelets 
i  somewhat  diminished,  the  tendency  to  the  formation  of  rouleaux 
8  less  marked,  and  the  coagulating  power  of  the  blood  is  feebler. 
3)  The  total  quantity  of  blood  is  most  markedly  diminished.  At 
ft  post-mortem  examination  the  vessels  are  almost  empty.  If  this 
fact  be  considered  in  connection  with  the  percentage-fall  in. red  cor- 
puscles and  the  diminished  specific  gravity  of  the  blood  (1028), 
some  idea  can  be  formed  of  the  enormous  extent  of  the  change  so 
far  as  the  blood  is  concerned. 
The  marrow  of  the  long  bones  is  generally  red,  and  contains  less 

Fig.  86 


o.m.c. 

Y'oIcIoiu  ansemla :  fresh  marrow  from  humerus.  Appearauce  of  yeUow  marrow  is  not 
™"lke  that  of  raspberry  Jam.  Ordinary  marrow-cells  arc  shown  ifl.m.c).  The  shaded  cells 
^I'lgoented  marrow-cells  forming  blood-corpuscles :  the  larger  are  megaloblasts  and  the 
"**"*'  normoblasts.    The  cells  marked  (/)  show  multiplication  by  flssion.  those  marked  (p) 

°'"plIaition  by  gemmation.  Marrow  treated  with  Hayem's  fluid  and  teased.  (Specimen 
*M<lrtwingbyI)r.  Mott.) 

"'  than  normal.  Large  numbers  of  giganto-blasts  are  found,  and 
^"Wc  is  also  an  increase  of  normoblasts,  and  often  in  great  numbers 
*'  microcytes.  The  red  marrow  contains  pigment,  giving  the  iron 
Action  (see  below).  The  finer  bony  trabeculse  occasionally  become 
•Wrbed. 
The  changes  in  the  liver  are  of  considerable  importance.     In 


L/SKASES  01 

flie  centre  of  the  lobule  there  may  be  an  excess  of  pigment,  ami  in 

the  j)ori|>lieral  zone  inm  so  loosely  combined  with  orgimii"  uiaiicr 
that  Ji  liiiitinct  hliie  cnlorution  can  ho  obtainoil  on  treutiuj:  .st'Ciiow 
of  ihe  organ  with  ferrocviuiiik'  of  potns.sinm  and  dilute  hydro- 
ehluric  acid.  The  cells  in  tin.'  immediate  neighborhood  of  the  iotn- 
hibiihir  veins  arc  occiisionaily  fatty. 

The  heart  tinil  siiiallcr  blood-vessels,  and  occasionally  the  iiitinii 
of  the  large  ai'tfi-it-s,  slicyw  extensive  fatty  changes,  fmm  which  tlif 
.skeletal  muscles  ai'e  practically  free.  The  changes  in  the  heart  »rf 
particularly  well  marked.  In  the  left  ventricle  the  fatty  intftn 
80  distinct  that  the  terms '"  thrush-breast"  and  '*  tabby-cat"  bsve 

Fio.  ST. 


-^: 


:\  o 


Pcrntclons  iinirmia  •  tmme  miiiTow  ««  in  Fig.  Sfi,  but  Imrili-iied  In  Mullrr't  fluid  •"  ' 
n-Uoldln.    Somf  hnlftlo/x-n   fat-vi-sloK-«  arc  seen,  with  tlie   InteneniQi;  cji|)illi>c! 
ililnted.    These  roulaln  iKinniililnsIs  wllli  nwetteil  inielel.    The  smallest  eells  »miiiir-N  ■ 
those  i>f  Inteniieillste  slue  «re  ^niiiilnrliKikiMK  reil  eiirpusele*.     i  Fnim  u  spcolmt'ii  bj  l" 
MotU) 

been  used  to  denote  them.     The  subcutaneotis  fat  is  very  genemlW 
increased.     The  skin  acquires  a  faint  yellowish  or  "  old-wax"  color, 
suggestive  of  slight  jaundice.     Small  hemorrhagres  are  common  in 
manv  ports.      Flamc-slia[icd  hemorrhages  clustered  round  the  di«k 
are  particularly  frci]uent  in  the  retina,  and  are  an  important  aid  to 
diagimsis.     E.xacerbations  are  accompanied  by  fever.     The  urine  is 

Mv  dark.      *i  n    -'ssive  amount  of  urobilin  is  e.Kcreted.    This 

II  liv  ibo  ii-band  at  F  when  the  urine  i^  examined 


LEUCILEm.i. 


2I» 


PATHOLOGY. — Besides  the  flifferences  above  tncntioneil,  which 
mar  Ih;  lieliJ  to  tniirk  off  chlorosJ!*  from  pernicioii!'  iinii'iiiiu,  there  is 
»hc  ailditionul  evidt-uce  which  is  gained  by  the  aduiiiiistration  of 
iron.  This  drug,  which  effects  a  cure  in  clilorosis,  is  utterly  useless 
m  pcrniciiius  nnieinia. 

Tlie  increase  of  iron  in  tlic  liver  and  marrow  ami  nf  urobilin  in 
tie  urine  affonls  evidence  that  the  disease  is  due  to  the  excessive 
liwtruction  of   red   blood-cells — hiemolysis.      The   changes   in   the 
marrow  of  the  lonfj  bones  an<l  the  existence  of  nucleated  corpus- 
vieu  in  the  blood  is   uo  argument   against  this  view,  as  they  might 
fie  due  to  increased  phj'siologicul,  not  to  pathological,  hoeuiogenesis. 
This  explanation    is  the  more   probable   as  repeated   bleedings  of 
aniiDKls  produce   similar   effects.       A   somewhat    .<iuiiljir   condition 
J  Jima  been  produced  in  the  liver  by  the  aduiinistration  of  ri.lnydeue- 
Mliamine.     This  discovery  has  led  to  the  suggestion  that  the  iliscase 
ris  tine  to  the  absorption  of  to.xic  products  from  the  intestine.     If 
this    be  correct,  the  "poison"  must  be  some  definite  substance  or 
H|nrjsanistn  which  very  rarely  finds  its  way  into  the  blood;  for.  while 
^■ulceration  of  the  intestine  and  all  manner  of  decomposition  of  it-s 
^Prnateiits  are  common  enough,  pernicious  auicniia  it.^elf  is  compara- 
tively nre.     The  gradual  progre.is  and  persistence  of  the  condition 
»«  also  much  against  a  purely  cliemical   cause,  unless  it  be  the  prod- 
i«ct  of  some  organism  which  takes  up  its  abode  in  the  intestine  with- 
[***•*   prodacing  any  local  irritation.     Two  observers  have  described 
^'gnuisins,  but  their  results  have  not  yet  been  confirmed. 

It  ii  worthy  of  note  that  while  in  phosphorus-poisoning  the  fatty 
''^generation  is  almost  universal,  in  pernicious  aniemia  it  is  far  more 
'narkeil  in  the  heart  than  elsewhere.  Mott  has  suggested  that  while 
'hf  fwling  of  languor  so  characteristic  of  the  disease  iuip<vsos  rest 
'•Pon  the  skeletal  muscles,  tiie  <leficient  quantity  and  diminished 
""ygenating  capacity  of  the  blood  necessitates  '  increased  work  on 
'■'<'  port  of  the  heart.  The  balance  of  work  and  repair  in  the 
^'gaii  cannot,  therefore,  be  maintained,  and  ilegeueratiou  ensues 
*  a  much  greater  extent  than  elsewhere. 


LEUOH^MIA. 

Leuchsemia,  or  Leucocythremia,  is  a  disease  characterized  by  a 
**">si(l,.rable  and  permanent  increase  in  the  number  of  white  cor- 
PUsfl,.^  ijf  j|,p  hlood,  bv  a  climinution  in  the  number  of  the  red  eor- 
'"**cleji,  and  by  enlargement  of  some  of  the  lymjihatic  organs.    The 


DISEASES  OF  THE  BLOOD. 


Ivtnphatic  organ  mui^t  freqiientlj  involved  >8  the  splevn.     Tlii«  \i 
enlarged  in  the  great  majority  of  cases  (splenic  lencluvmiai.    T\y 
eulurgement  of  tlie  spleen  is  sonietinies  iiesociatetl  with  eulargcmc 
of  the  lyuiphutic  glands,  and  sometimes,  although  mnch  lra> 
ipiently.  uifii  changes  in  the  medulla  of  bones.     In  very  rmnji 
the  lymphatic  glands  only  are  involved  (lymphatic  IcuchiPmia),  ii»«i 
cases  have  been  described  in  which  the  tisscous  medulla  i»  |irii 
pally  affected  (myelogenic  leuchicmia).     The  lymphoid  tissav  of  tl 
intestine  may  he  hypertrophied.      In  most  cases  of  louch«nii« 
overgrowth  of  lymphatic  tissue  in  other  organs  occurs  in  the  o»a 
of  the  disease. 

Leucocytosis. — Before  proceeding  to  the  consideration  <tf 
chieuiin  it  will  be  well   to  allude  to  that  slight  and  temporary  n 
erease  in  the   number  of  white  blood-corpuscles  which  bu 
termed    "leucocytosis.""       This    differs    from    leiichii'miu     in   thr 
respects:   that  the  increase  in  the  number  of  white  eorp«»<"lr» 
only  tetnporart/,  is  not  necessarily  as.sociateil  with  any  diniiiiutio 
in  the  number  of  the  red,  and  is  never  so  market!  as  in  Ivurhi 
in  which  there  are  always  more  than  one  white  to  every  twenty; 
corpuscles.     Moreover,  in  leucocytosis  the  increase  is  nlmnst  limiti 
to  the  mvUinuch'ated  leucocytes.     A  slight  and  temporary  iac 
in  the  number  of  white  blood-corpuscles  occurs  in  many  coDiiiti 
Physiologically,  it  occurs  after  a  meal  nntl  in  the  later  nioutlMi 
pregnancy.    In  pyiemia  and  in  many  of  the  acute  pyrexiol 
es|>ecially  those  in  which  there  is  acute  swelling  of  lymphatic  «trTM 
tures,  such  as  typhoid  and  scarlet  fever,  there  is  often  u  m«rke-« 
excess  of  white  corpuscles.     The  same  change  ha»  been  dewrrib 
in  tubercidar  diseases  and  in  conditions  accompanied  iiy  suppur 
tion.      After  large  losses  of  l)lood,  also,  there  is  an  increase.  o»it 
to  the  pouring  of  lymph  into  the  blood  to  make  ap  its  moM. 
cocyttisis  does  not  seem  to  interfere  either  with  the  circulation 
with  fh<'  general  health. 


PATHOLOGY.— The   pntliology  of  leuehn»niia   iit  still  exe 
inglv 'discure.  and   will   probably  remain  so  until  our  know ledp'*  •"_] 
the  physiology  of  the  blood  and  the  origin  an<l   fate  of  the  M" 
corpuscli-s  is  more  complete.     Physiologically,  we  know  that  \r»* 
white  corpuscles   originate    in  the  lymphatic   organs,  fn>i"   •'"'^ 
they  pass  into  the  blood,  either  ilircetly  or  through  the  lym|>l»»'* 
vessels.     Owing  to  the  enlargement  of  one  or  more  of  the  Iv' 


LEUCH^MIA.  221 

pba.i\c  organs  which  always  exists  in  leuchsemia,  it  has  been  sup- 
posed that  the   increase   in  the  number  of  the  white  corpuscles 
irliich  characterizes  the  disease  is  due  to  their  excessive  production 
by      the  enlarged  organs,   such  as  occurs  in  some  cases  of  leuco- 
cjt:osi8.     Inasmuch,  however,  as  there  is  not  only  an  increase  in 
th^     number  of  white,  but  a  diminution  in  the  number  of  red,  this 
hypothesis  is  insufiScient  to  account  for  the  change.     Further,  lym- 
ph xk.  "tic  organs  may  become  enormously  enlarged  without  the  pro- 
dncs'tion  of  any  leuchsemia.     This  occurs,  for  example,  in  the  spleen 
in   ISplenic  Anaemia,  which  disease,  but  for  the  fact  that  there  is  no 
incirease  in  white  blood-corpuscles,  is  similar  to  leuchsemia.     It  also 
occsiirs  in  the  lymphatic  glands  in  Hodgkin's  disease.     The  other 
vie^w,  promulgated  by  Virchow,  is  that  the  transformation  of  white 
corpuscles  into  red  is  diminished.     Hence  the  former  tend  to  accu- 
mulate and  the  latter  to  disappear.     Against  this  view  it  may  be 
urged  that  there  is  no  constant  proportion  between  the  increase  of 
the    white  and  the  diminution  of  the  red.  and  that  many  of  the 
leixcocytes  show  evidence  of  active  growth,  not  of  diminished  vital- 
ity.    It  must  also  be  remembered  that  the  origin  of  red  corpuscles 
from  leucocytes  is  by  no  means  certain,  while  it  is  quite  certain 
that  they  are  the  offspring  of  the  nucleated  red  corpuscles  found  in 
the   red  marrow  of  bone.     It  is  quite  possible  that  the  different 
varities  of  leuchsemia  have  each  a  different  pathology. 

APPEARANCES. — ^Blood. — The  increase  in  the  number  of 
white  corpuscles  varies  very  considerably  in  different  cases.  A 
proportion  of  one  white  to  ten  red  is  quite  common,  and  often  there 

Fig.  88.  Fia.  89. 


'^^■^ 

j^chamlc  blood  (from  a  young  man  Blood  from  a  case  of  splunlc  ana-miu  (from  a 

"  enonnoua    enlargement  of  the         middle-aged  man  with  great  enlargement  of 
•PMien).  X20O.  the  spleen).    X^MO- 

we  as  many  as  one  to  three  (Fig.  88).     This  increase  gives  to  the 
blood  a  paler  and  more  opaque  appearance  than  is  natural.     In  the 


222 


DISEASES  OF  Till-:  ULOOD. 


rb^ 


earlier  stages  of  the  disease  the  i)ro|)ortion  may  not  be  inowtl 
one  to  twent}'. 

In  sph'iiir  leucocythannia  it  is  the  large  uionouiicleHted  corpi 
which  arc  particularly  aljuutluiit,  and  in  Ij/itiphatic  leiieoci/lhinnin 
the  smaller  lyiiijihocytes.  In  the  >tit/<lofffnic  fonn  the  ntttiirc  "f ilie 
new  cells  is  less  certain.  Among  the  new  element**  found  in  iIk 
Mood  in  this  variety  are — (1)  large  mononucleated  neutrophils  cell* 
closely  resembling  "■'marrow-cells;"  (2)  nucleated  red  corpujclw 
suggestive  of  iicirmolilasts :  unti  (3)  eosinophile  cells  and  celi>  «ii^^ 
'^mast-cell"  granules.  ^H 

It  ii!is  (iften  Iiecn  iiffirmcd  that  the  new  corpuscles,  when  eiduniw^ 
on  the  wiinii  stage,  show  no  iiwueboid  movements.  This  ohservatinn, 
together  with  the  liict  thnt  I'iitty  degeneration  has  been  occnsiunalh 
observed,  has  led  to  the  belief  that  the  majority  of  the  leiicticvto 
are  dead.  Muir  has  lately  pointed  out  that  the  absence  of  l(lov^ 
ment  is  confined  to  the  large  mononucleated  variety,  and  tli»l  MJ 
multinucleated  leucocytes  present  exhibit  their  normal  motility. 

The  red  cnr|uiscles,  like  the  white,  vary  in  their  numbers.    Tl 
may   be   reduced   to   a    half  <ir   a    ipiarter  the   normal.     They  »" 
usually  natural   in  jippearance,  but  sometimes  they  are  distinctly 
paler  tliiin   in   lieahli.      Occasionally   they  «()pear  to   be  uniisiulh 
soft,  and  exhibit  a  tendency  to  .stick  together,  instead  of  forming 
the  natural  rouleaux.     In  the  case  of  uphnic  anamia  rcferrnl  lo»o 
]).  224    these   characters   were   especially    marked   (Kig.  K!)).    The 
diminution  in  the  number  and  the  impairment  of  the  i|uality  of  tlif 
red  corpuscles,  which  e.xist  not  only  in  leuchiemia,  but  in  mo* 
cases  of  great  splenic  enlargement,  account  for  the  anxmin  wdii'ii 
exists  in  these  conditions.      In  addition  to  tiie  re<l  and  vhite  W" 
pusclcs,  nucleated   red  corpuscles    have   been    found    in   leucha'niic     ' 
blood,  and  minute,  colorless,  long,  slender  octohedral  crystals  of  ||^B 
nlbuuiinou.s  dianicter  have  been  diseovereil  in  the  blood,  liver. '"^n 
spleen.      The  coagulating  power  of  the  blood  in  leucluemia  is  ni"*"'' 
diminished,  juul  when  this  liquid  is  alloweil  to  stand  the  white  <-'*"■ 
])uscles  fortii  a  cri'iiiuy  layer  n|Kin  its  surface. 

Spleen. — In  this,  which  is  mucli  the  most  important  organ  i» 
jiroduction  of  leuchtcmia.  the  change  is  characterized  mainly 
increa.sed  growth.  The  organ  l>ecomes  enlarged,  often  enormoi 
so.  The  enlargement  is  uniform,  so  that  the  shape  of  the  or; 
but  little  altered.  The  capsule  is  often  thickened,  and  therr 
usually  adhesions  with  the  adjacent  viscera.     The  consistence 


LEUCH^MIA.  223 

the  spleen  in  the  later  stages  is  firmer  than  natural.  The  cut  sur- 
face is  smooth  and  of  a  grayish  or  brownish-red  color,  while  thick- 
ened trabeculae  can  often  be  seen  marking  it  as  whitish  lines.  The 
Malpighian  corpuscles,  although  they  may  be  slightly  enlarged  in 
the  earlier  stages  of  the  disease,  are  seldom  prominent,  and  they 
are  often  invisible  when  the  splenic  enlargement  is  advanced.  In 
exceptional  cases,  however,  and  especially  when  the  lymphatic 
glands  are  involved,  they  may  form  prominent  growths.  Some- 
times wedge-shaped  masses,  of  a  dark-red  or  reddish-yellow  color, 
are  seen  near  the  surface  of  the  organ.  These  are  probably  infarc- 
tions of  embolic  origin. 

When  the  spleen  is  examined  microscopically  its  structure  is 
found  to  be  but  little  altered,  the  enlargement  being  due  mainly  to 
»n  increase  of  the  splenic  pulp.  The  trabecular  tissue  is  also  in- 
CTeased  and  thickened,  and  this  change  advances  with  the  continued 
fnlargement  of  the  spleen.  The  Malpighian  corjiuscles  are  but 
little  increased  in  size:  sometimes  they  are  atrophied. 

Lymphatic  Qlands. — The  enlargement  of  the  lymphatic  glands 
IS  much  less  in  splenic  leuchtemia  than  in  tho.'ie  ca.ses  in  which  the 
glands  are  primarily  and  principally  affected.  In  splenic  leuchaemia 
one  or  more  groups  of  glands  are  slightly  enlarged  in  about  one- 
third  of  the  cases.  The  glands  are  rarely  increased  in  consistence, 
»nd  are  usually  frecl}'  movable.  On  section  they  are  of  a  grayish- 
^  color,  and  are  often  mottled  with  hemorrhages.  Microscop- 
iwlly,  the  enlarged  glands  show  increase  of  the  pulp  and  blocking 
»f  the  lymph-channels. 

The  red  marrow  found  normally  in  the  bones  of  the  head  and 
'fonk  of  adults  and  throughout  the  limbs  in  the  foetus  is  a  blood- 
forniing  organ.  In  leuchwrnia  it  may  become  more  highly  cellular, 
•id  consequently  softer  and  grayer  or  yellower  in  color.  Further, 
Hereas  in  normal  growth  the  red  marrow  is  replaced  by  yellow 
Progressively  from  the  toes  and  fingers  up  to  the  heads  of  the 
'SOora  and  humeri,  in  this  disease  the  opposite  change  occurs,  and 
""^  yellow  marrow  is  progressively  transformed  into  red  from  the 
'""'ik  toward  the  extremities  of  the  limbs. 

^he  follicles  of  the  intestine  may  become  so  much  enlarged  as 

^  form  distinct  projections  from  the  mucous  membrane,  although 

'*  is  less  common  than  in  Hodgkin's  disease. 

^^ther  Orgrans. — In  the  course  of  the  disease  masses  of  lymphatic 

^'>e  or  of  lymphoid  cells  usually  appear  in  places  otherwise  free 


224 


DISEASES  OF  TUB  BLOOD. 


from  tlu'in.  These  masses  are  principally  found  in  the  liver  tm 
kidneys,  less  frequently  in  the  lungs  antl  muscles.  The  new  growth 
in  these  organs  sometimes  forms  distinct  tumors,  but  much  mure 
commonly  exists  as  an  iufiltrtiticm.  How  far  these  lymphoid  growtlu 
lire  the  products  of  a  hyperplasia  of  the  cells  in  the  iuterstiiiaJ 
tissue  of  the  organ  in  wliirli  tliey  are  situated,  and  bow  far  thev 
are  the  result  of  cmigrHtiori  of  the  leucocytes  which  exist  in  unci 
large  numbers  in  the  blood,  is  unknown.  The  former,  howerer.  a 
probuhly  the  riio.<t  iniportiiut  factor  in  the  process. 

The  org;iii  which  is  most  frequently  affected  is  the  liver.  Hiw. 
in  IfiichuMuia.  ihe  vessels  gencrtiliy  are  enlarged  and  <listeniif<i 
with  white  blood-corpuscles.  Accumulations  of  cor|iuscles  »nil 
lymf>hoid  tissue  are  seen  between  the  acini  and  extending  »l«ii| 
the  intercellular  network  into  the  acini  themselves,  so  thai  iIk 
lobules  are  sometimes  seen  to  be  clearly  map[icd  out  by  n  gravisb- 
white  interlobular  infiltration.  As  this  increa.ses  the  liver-telli 
become  compressed  and  atrophy,  until  ultimately  the  lohulw  vm\ 
be  entirely  replaced  by  it.     This  is  well  shown   in  the  liver  from 

Vu..  iK». 


Livpr  fW>in  a  r^e  of  itpleiin'  uiiiL-tnin,  !«tiiiM  iiiK  inv  cxinialvc  i-i-lluinr  Inrtltretlct; : 
the  tntiTt'oniilur  iK'twiirk.  The  nriiau  wHx  greutly  calariiTd,  niiil  lliv  urn  lUtur  u 
to  the  nuked  oyo  between  the  Hclni.   X^IX). 

the  case  of  s))lenic  anafmia  (Fig.   90),   the  blood  from  whioh  * 
re|)rt'9entcd  in   Fig.  89.      Associated  with  this  infiltration  tlit'r^  '* 
often  a  formation  of  small,  round,  whiti-^h   lymphoid   no<lules  ?oiP 
what  resembling  gray  tubercles.     These  al.so  are  8ituate<l  in  ^^ 
inlerlolmlnr  tissue.      Owing  to  these  changes  the  liver  becouiw  »P*^ 
considerably  increased  in  si/,e. 

In  the  kidneys,  which  are  also  frei|uently  affected,  thf  cli»n^ 
is  similar  to  that   in  the  liver.      Here  al.so  it  consists  for  the  tn*- 
part  in  an  infiltration  with  which  may  be  associated  the  furniatio*^ 
of  roundish  nodules  and  masses. 


DISEASES  OF  THE  CIRCULATION.  225 

CHAPTER  XVIII. 

DISEASES  OP  THE  CIRCULATION. 

The  efficiency  of  the  circulation  depends  on  the  maintenance  of 
&  correct  relationship  between  the  action  of  the  heart,  the  size  and 
elasticity  of  the  blood-vessels,  and  the  quantity  and  composition  of 
the  blood,  as  well  as  on  the  maintenance  of  a  healthy  lining  mem- 
brane throughout  the  whole  of  the  vascular  tract.  It  is  altogether 
out  of  the  scope  of  this  work  to  deal  fully  with  the  many  ways  in 
vhich  these  various  factors  may  deviate  from  the  standard  of 
health.  Practically,  in  disease  they  are  nearly  always  combined. 
Structural  diseases  of  the  heart,  arteries,  and  veins,  together  with 
their  results  on  the  general  circulation,  will  be  dealt  with  sub- 
sequently. We  shall  here  limit  ourselves  to  a  brief  review  of  the 
causes  and  effects  of  both  dimunution  and  increase  in  the  blood- 
supply  of  a  part,  and  then  deal  at  greater  length  with  the  phenom- 
eua  of  mechanical  congrestion,  dropsy,  thrombosis,  and  em- 
bolism. 

liCtOAI.  ANiBMIA. 

By  local  anaemia  is  meant  diminution  in  the  amount  of  blood 
in  a  part  owing  to  deficiency  of  the  supply.  It  may  be  partial  or 
complete. 

CAUSES. — The  causes  of  diminished  arterial  supply  comprise 
*"  those  conditions  which  either  narrow  or  completely  close  the 
'omen  of  the  supplying  artery.     The  lumen  of  an  artery  may  be 
•I'lninished  by  disease  of  its  walls — atheroma,  calcification,  or  syph- 
'htic  thickening ;  or  by  pressure  exercised  upon  it  from  without,  as 
•>J  new  growths,  constricting  scars,  inflammatory  exudations,  and 
Biechanical  effusions,  especially  in  unyielding  tissues,  as  bones  or 
tendon-sheaths.     Complete  closure  of  the  vessel  may  result  from 
«>nie  of  the  foregoing  conditions,  or,  more  commonly,  from  throm- 
bosis, embolism,  or  ligature.     In  some  cases  the  supply  of  blood 
18  diminished  by  an  increase  in  the  natural  resistance  from  irrita- 
tion of  the  vaso-motor  nerve.     This  occurs  in  some  neuralgic  and 
other  nervous  affections,  or  from  the  action  of  certain  substances, 
«uch  as  ergot  of  rye  and  opium,  or,  again,  merely  as  the  result  of 
a  Jow  temperature.     It  is  sometimes  attributed  to  the  presence  in 
15 


DISEASES  OF  THE  BLl 


the  vessels  of  j>rodiict!'  of  metabolism,  either  in  excessive  amount  or 
of  abnormal  cluirauter.  Anivmia  of  one  part  may  be  secondarr  to 
hypenvmisi.  of  other  parts,  such  as  an;i'mia  of  the  brain  and  skin 
in  congestion  of  the  abdominal  viscera,  or  it  may  be  due  to  a  general 
dimimition  of  the  total  ijuantity  of  blood,  as  after  hemorrhage,  in 
which   case  the  distal  parts  suffer  most. 

RESULTS. — A  part  with  a  diminished  arterial  supply  is  ususllr 
[lalcr.  lest*  tense,  and  of  a  lower  temperature  than  natural.  lu 
nutrition  and  function  also  are  impaired,  so  that  it  mar  underjM 
fatty  degeneration,  atrophy,  or  death.  These  results  have  hwti 
exemjdificd  in  the  chapters  on  Fatty  Degeneration,  Atrophy.  Bfni 
Necrosis. 

Obstruction  of  a  large  artery  causes  rise  of  pressure  (triincieni 
under  healthy  conditions)  everywhere  except  in   its  own  area;  awl 
this  increased  ))ressure  endangers  the  .safety  of  delicate  or  di.scswil 
vessels  until  the  extra  blood  thrown  into  the  suddenly  curtailed ra*- 
cular  system  is  accominodtited  in  some  way.     The  heightened  lire.*- 
sure  affects  the  vaso-inotor  centre,  and  this  speedily  producer  ilil»- 
tation  of  vessels  sufficient  to  restore  the  normal  pressure.     But  tl* 
vessels  which  dihitc  most  miirkeillv  and  persistently  are  those  going 
to  the  auiemic  part  and  anustomosing  with   liranches  from  the  tnins 
beyond  the  obstruction ;  this  is  probably  owing  to  some  ol)!Wttre 
vaso-motor  mechanism,  excited,  it  may  be,  by  the  aiuemia.     Tliea* 
"collateral"   vessels  become  Inrger,   longer  (tortuous),  and  thicker 
until   the   circulation   in   the  part   has  again  become  normal — «'■«"- 
collateral  circulation   is  established.      At  first,  all  vessels  hatiog 
anastomoses  with  the  obstructed  one  probably  dilate,  but  those  wliicl' 
enlarge  jtermarieutly  are  almost   invariul)ly  branches  on  the  mm*' 
side  as  the  obstruction — e.  tj.  the  ritiht  inferior  thyroid  and  vertebr** 
arteries  dilate  after  ligature  of    the  rti/hl   carotid.     The   prira»ry 
anaMiiia,  the  blush   and  heightened  tem|(er:iture  of  vascular  iliUt*' 
tion,  and  the  final  return  to  the  normal  can  be  seen  in  limbs  afte^ 
ligature  of  main  vessels  (p.  257). 

HYPERJEMIA. 

Hyperemia,  or  Congrestion,  is  excess  of  blood  in  the  raorf  or 
less  dilated  vessels  of  a  part.  It  may  be  (1)  active  (arterial),  or 
(2)  mechanical  (venous).  These  two  varieties  must  be  considered 
separately. 


HYPEREMIA. 


227 


Active  or  Arterial  Hyperemia 

Active  livperii'iuin  luouiis  excess  of  arterial  hlood  in  :i  part,  with, 
in  most  cases,  acceleration  of  How. 

CAUSES. — 'I'lie  iiiiuKxliute  cause  of  active  hypernemia  is  in  all 

diminished  arterial  resistance. 
Diniinisbe<l  arterial  resistance  may  be  produced  pathologically — 
Ist.  By  certain  agrencies  which  have  a  weakening'  or  para- 
lyzing effect  upon  the  involuntary  muscles  of  vessel-walls. 
Fntiifuf  from  previous  prolonged  contraction  has  this  efl'ect.  as  seen 
in  thfi  liypera'TTiiaof  the  hands  which  follow  suowhallin>;.      Warmth, 

I  to",  in  generally  placed  under  thus  heading.  Injuriv*  of  all  kinds, 
then  iiol  acting  su<ldeuly  and  with  extreme  severity,  produce  a 
rpflex  hyperivniia  by  their  influence  on  sensory  nerves.  This  occurs 
In-fore  the /rue  inflammatory  dil.itation  sets  in.  and  must  be  included 
m  llie  next  group  of  cases.      The  dilatation  f/tarncterigtir  of  iiijl/im- 

j  mafwi  is  ilue  to  direct  ilamage  of  the  vessel-wall,  an<l  therefore  falls 
stiller  this  beading,  and.  so  long  as  it  is  more  than  sufficient  to 
ft'nnli'rbnlancc  the  increa.scd  resistance  which  always  aceomjmnies 
it  (we"  Inflammation"),  the  quantity  of  blooil  passing  through  the 
part  is  greater  than  normal — /.  c  the  part  is  hypenemir.  The 
»ut\dai  remoriil  of  jtrrgxiirf  is  another  cau.se  of  hypera'niia.  Thus, 
wogMtion  of  the  abdominal  ves.sels  follows  the  removal  of  much 
«»<:itic  fluid  or  of  a  large  ovarian  tumor:  bleeding  from  the  pleura 
"ccnr*  when  the  cavity  is  ra|>idly  emptied  by  aspiration  or  strong 
•Jlihon-action :  bleeding  may  also  toUow  the  complete  emptying  of 
» cliroiiically  distended  bladder.  The  muscle  of  the  vessels,  accus- 
'^nied  to  much  su|>]Mjrt,  ha.s  |i>st  power ;  so.  when  the  supjiort  is  sud- 
'iciiiyrfinoved,  the  ve.'«sels  dilate  fully,  and  small  one.s  perhafis  rupture. 
2<l.  By  the  removal,  either  directly,  or  reflexly — /.  *•.  by  in- 
Wbitjon — of  the  vaso-tonic  action  of  the  sympathetic. — Thus, 
"''tiVf  congestion  follows  pressure  uj)on  the  sym]>athetic — as  in  the 
"wk—by  an  aueurysm.  Certain  drugs,  taken  internally,  are  be- 
''«*«!  to  directly  jiaralyze  the  vaso-tonic  nerves — e.  if.  nitrite  of 
""vl,  alcohol,  tobacco. 

Tlic  fffUx   process   is  generally  due  to  stimulation  of  sensory 
flwu's,  the  diminution  in  tonus  thus  produced  being  more  or  less 

«cnirately  confined  to  the  region  supplied  by  the  nerve.      Friction 

iDrl  slight  irritants  in  the  early  stages  of  their  action   i)roduce  by- 


228 


DISEASES  OF  THE  BLOOD. 


penpinia  in  tliiti  way  (se«  nbove).  It  seems  that  vascular  dilai 
of  deep  organs  may  be  produced  reftexly  by  tin?  applicmttu 
stupes  to  the  skin  over  them. 

Anamia  of  any  Inrpe  part,  a«  of  a  limb  compressed  by  Esmarcb' 
bandage,  or  of  the  skin  fruiii  cold,  necessarily  cause*  htfftfnrmm 
otlier  parts — compensatory  hypereemia.  But  all  parts  do 
suffer  enuully.  as  tliey  would  do  were  the  bypera'nua  the  rc»ai 
simply  of  increased  arterial  pressure :  certain  vesaeU,  as  the  gnr< 
abdominal  veins,  dilate,  showing  that  the  vaso-motor  system  ami 
for  the  accommodation  of  the  surplus  blood  by  producing 
diminutions  of  vascular  resistance.  After  extirpation  of  one 
its  share  of  blood  passes  mainly  to  the  other. 

3d.  By  excitation  of  vaso-dilator  nerves,  such  as  the  cl 
tympani. — Nothing  is  certainly  kiu)wn  of  this  as  a  cause  of  I 
Kmia,  but  the  hyperiemia  u.'«sociate<l  with  facial  neuralgia  and| 
of  the  thyroid  in  exophthalmic  goitre  have  been  refernnl  to 
dilator  neuroses  and  also  to  iidiibition  of  vaso-fonir  nerve*. 


RESULTS. — Tlie  results   of   active  hypera'mia   nn-   prinfi|l 
Buch  as  might  be  expected  from  increase  in  the  amount  of  ar 
blood,  and  in  the  rapidity  of  its  flow,  in  any  particular  oi 
tissue.     The  symptoms  in  a  superficial   pnrf  are — increased 
and   pulsation,  a  subjective  sensation  of  throbbing,  some  in* 
in  bulk,  and  nuirked  elevation  of  surface  temperatare  nntil 
approaches  that  of  internal  organs.     If  the  hypenrmia  be  of 
duration   or   frei|uently    repeated,    the   small   arteries    remain 
nuuit-ntiy  enlarged,  their  walls  gradually  thicken,  ami  the  pjiitk* 
Hum   and  connective  tissues  of  the   part   increase.     This  mi 
Boen  in  the  papillary  thickening  round  a  callous  ulcer  of  thfl 
and   the  occasional   spread   of  ossificntioii  from   the  tibia  inb 
granulation  tisane.     The  ability  to  work  is  increased,  and  M 
trophy  will  follow  if  the  increa.se<l  work  is  maiittainc<i  (p.  IISV 
bypenemia  of  the   nervous  centres  we  see  great   exeitabilityj 
trathesiK  of  sight  and   hearing,  and  even  convuUion*.     In 
glanib,  such  as  the  kidneys,  secretion  is  increased,  the  nrine 
water V  and  sometimes  albuminous. 


Mechanical  or  VeNons  Hyperjbmia. 
In   venous   hypenvmia  the  excess  of  blood   is  in   the  Tei« 
capillaries,  and  the  flow,  iuAtcad  of  being  accelerated,  is 


229 

This  is  so  frequently  pnxluced  b_v  some  obvious  mechanical  obstacle 
fo  the  return  of  hlood  through  the  veins  that  it  is  often  ealled 
oechanicekl  hypersemia.  The  eongestiou  of  a  finger  jiroduced  by 
8  moderately  tight  band  tied  round  it  may  be  taken  as  tiie  type  of 
«uch  cases. 


CAUSES, — Anything  which  weakens  the  forces  carrying  on  the 
venous  circulation  or  which  opposes  iinusuai  resistance  to  this  cir- 
culation must  tend  to  produce  venous  hypers«uiin.  Such  causes 
nii»y  exist  in  any  part  of  the  vascular  system — heart,  arteries, 
I'spillaries.  or  veins — some  having  a  local,  others  a  general,  effect. 
They  may  be  arranged  under  two  headings:  (1)  tliose  which  liimin- 
i»h  the  vis  a  tergo,  or  propelling  force ;  and  (2)  those  which  intro- 
•iturr  a  vis  a  fronte.  thus  placing  a  direct  impediment  to  the  return 
"f  blood  by  the  veins. 

1.  Chief  in  the  first  group  is  diminished  cardiac  power.     The 

heart  may  act  so  feebly  or  be  so  damaged  structurally  (see  "  Endo- 

<^Ti|iti«'")  that  too  little  h]oo<l  enters  the  arteries  at  each   stroke, 

»inl  generally  at   a   pressure  less  than  normal.      As   a   result   the 

'  •'Serial  supply  of  all  parts  is  diminished,  blood  lags  in  the  veins, 

"»<1  a  less  i|uantity  than   normal   returns  to  the   luMrt  during  each 

"lastule.     This  is  very  evident   in  prolonged  febrile  diseases,  such 

**   typhoiil,  and  in  those  degenerations  of  the  walls  of  the  heart 

*hich  lead  to  dilatation   of  its   cavities..    In   whichever  of  these 

I  ^wjt's  the  via  <t  ti'rgu  is  diminished,  that  diminished  fulness  of  the 

lartcries  and  overfulness    of  the    veins  wliicli  are  so  familiar  clin- 

lically  ns  the  result  of  cardiac  failure  will  be  prodiued.     If  this 

|«>nditiou  be    of  long    duration,    there   is   necessarily   so  much    in- 

P'*»"fer('nce  with  the  oxygenation   of  the   blood,   with   the  functions 

|of  the  blood-forming  organs,   and  with  the  processes  of  digestion 

[ulifl  assimilation  that    the  blood   itself    l)eeomes  deterioratetl.  and 

|t'»ii»  Iiy  its  lagging  in  every  tissue  the  nutrition  of  all  suffers. 

In  the  arteries  the  driving  force  may  be  weakened  (1)  by  total  or 

V*rti»l  oli^truftion  of  an  arterial   trunk  ;  (2)  by  dilatation,  arising 

"■"m  simple  atony  or  from  those  general  fatty,  atheromatous,  or 

"liroiil  changes  of  the  arterial  wall  so  conimon  in  advanced  life ; 

or  (8)  by  ritjidity.  in  which  case,  owing  to  loss  of  arterial  elasticity, 

the  heart's  force  is  wasted  against  the  walls  of  rigid  arteries. 

Obstruction  tn  the  circiilattim  in  capillaries  arises  mainly  from 
/injure  of  inflammatory  and  serous  effusions  on  capillary  areas. 


230 


DISEASES  OF  THE  BLOOD. 


AVith  regard  to  veins  tlic  circulation  will  l»e  slowed  b_v  (1)  nbsenrr 
of  muscular  contractions,  especially  in  the  lower  extremity  ;  (2)sucb, 
ililiitiition  iis  [irodiices  incoin|)etenee  of  valves,  thus  reudering  mo 
cuhir  action  useless  as  an  aid  to  circutiition ;  and  (3)  by  »nvlliin;r 
vvliicL.  diuiinisliinn;  the  elastic  force  with  wliicli  the  lung  tendsi  to 
drjivv  away  from  the  pleural  wall,  lessens  thoriicic  as|iiratioD.  For- 
cible expiration  will  replace  the  normal  wjtWM^-pressure  within  the 
thorax  by  a  /i/«x-iiressure ;  thris,  playing  wind  instruments  im|ii?<icj 
entry  of  hlood  friMu  veins  into  the  heart.  Emphysema,  effiisiKU  of 
air  or  fluid  into  the  jdeural  cavities,  and  large  new  growths  of  tli» 
lung  act  similarly.  These  causes  might  fairly  rank  tinder  the 
second  heading. 

When,  by  various  combinations  of  the  above  conditions.  Ihecirca- 
lation  is  much  retarded,  hypostatic  congestion  occurs.  The  com- 
monest seats  of  this  are  the  [losterior  edges  and  bases  of  the  limp, 
the  skin  over  the  sacrum,  and  any  jiarts  kept  constantly  dependonl. 
Slowing  of  the  circulation  causes  distention  of  the  veins  and  in- 
crease of  the  intnnenous  [tressure.  In  iiny  such  jiart  which  is»l.«o 
dependent  the  intravenous,  and  therefore  capillary,  pressure  is 
further  increased  by  ijravitif.  Tlic  force  of  gravity  is  in  projiortion 
to  the  vertical  distance  between  ttie  highest  point  of  the  bod\-  Pi 
the  time  being  and  the  part  in  t|iiestion.  If  the  patient  is  so  we 
as  to  be  unable  to  change  his  position,  this  ])ressure  constantly  v^ 
upon  the  same  veins  and  ca)iillaries,  diluting  them,  and  <i\'-  ' 
increasing  the  tendency  to  leakage  through  their  badly-noui:-!  • 
walls.  Thus  the  part  is  redder  and  softer  than  normal,  and  * 
a'domiitoiis  {p.  238).  In  bedridden  patients  breathing  is  often  ve'TT' 
shallow,  and  the  effect  of  expiration  in  ilriving  blood  on  to  thel«?" 
auricle  is  therefore  (liminished.  (Sec  "Hypostatic  Pneumonia.')  ■•'' 
people  who  are  walking  about  dropsy  from  heart  disease  gcncrft'*!' 
begins  in  the  logs.     This  is  due  largely  to  the  action  of  gravity- 

2.  Examples  of  direct  impediments  to  the  return  of  blood  by  '""^ 
veins  are  numerous.  Tlius,  congestion  of  the  chylopoietic  vit**^ 
from  coni]iression  of  the  portal  capilliirii's  occurs  in  cirrhosis  of  '^ 
liver;  congestion  of  the  lung  follows  mitral  constriction  or  regti*"^ 
tation ;  congestion  of  the  systemic  circulation  results  from  jne»" 
cicncy  of  the  tricusfiid  valve;  and  in  the  lower  extremities  theii**'^ 
result  maybe  due  to  jiressure  of  the  gravid  uterus  on  the  iliac  xe***— 


1^ 


RESULTS. — Whether  there  be  a  direct  impediment  to  the  retm 


BYPERJEWIA. 


Mood  by  the  veins  or  n  failure  in  tlio  forces  of  circulation,  the 
ins  ami  capillaries  dilute,  and  the  hlood.  iiiovini:  with  diiiiinislRul 
ocitv.  tiocuuiuliites  in  them.  Tlie  .lubseciuent  cliauges  will  depend 
^bc  degree  of  obstruction  tn  the  venous  return  and  upon  the 
wis!  presiiure — in  other  wurdss.  iijmn  the  injury  sustaincil  by  the 
Bewails  from  impaired  nutrition  uud  upon  the  increa.se  of  pres- 
^H  the  veins  and  eH|)illaries.  In  addition  to  the  immediate 
cts,  such  as  the  <limini>ihed  .secretion  of  urine,  the  most  imjiort- 

of  the  more  gradually  induced  changes  are  the  exudation  of 
iin.  the  escape  of  red  blood-corpuscles,  hemorrhage,  fibroid  indu- 
on,  thrond)osi8.  und  necrosis. 

.  Exudation  of  Serum  is  one  of  the  most  important  results  of 
:iianical  iiyper:eniiii.  It  i.«  disiciissed  un  p.  23t). 
-  Escape  of  Red  Blood-corpuscles  occurs  when  obstruction 
the  venous  return  is  very  great:  they  transude  with  the  fluid 
n  the  veins  and  capillaries.  The  blood-stream  in  these  ve.ssels 
ipletely  stagnates,  and  the  red  corpuscles  become  packed  into  a 
Went  ma.ss  which  iiscillafcs  to  and  fro  with  the  arterial  pulsation. 
•n.  suildenly.  .some  of  the  red  corpuscles  peneti'ate  the  walls  of 

small  veins  and  capillaries  and  escape  into  the  surroumling 
ues.     This  seems  to  occur  without  rupture  of  the  vessel,  for  if 

ligature  be  removed  the  blood  again  circulates  in  a  perfectly 
mal  manner.  The  corpuscles  rarely  escape  in  great  numbers. 
bag  been  suggested  that  they  pass  through  the  stomata  which 
;klingbausen  ha.s  shown  to  e.xist  between  the  endothi-lial  elements : 

<it>  plasma  coidd  easily  |iass  through  openings  large  enough  for 
^krpiLscle,  and  as  the  transudation-fluid  differs  markedly  from 
•ma.  Oohnheim  considereil  that  the  existence  of  these  stomata  ia 
iccessary  to  account  for  the  escape  of  corpuscles. 
s  Hemorrhage  is  another  residt  of  mechanical  hyperiemia,  and 
ally  occurs  only  when  the  obstruction  to  the  venous  current  is 
y  great,  and  when  the  nutrition  of  vessels  and  tissues  has  suffered 
n  long  congestion.  Healthy  vessels  can  bear  very  heavy  strains 
bout  giving  way.     Those  vessels  which  are  the  least  sujjported 

the  first  to  give  way.     Hemorrhage  into  the  stomach  in  cirrhosis 
he  liver  and  into  the  lung  in  mitral  stenosis  is  a  familiar  example 
tbi*  result. 
.  Fibroid  Induration  is  due  to  a  gradmil  increase  in  the  connec- 

tisHue  round  the  blood-vessels,  and  is  one  of  the  most  important 
ilt8  of  long-continued  mechanical   hyperteraia.     The  interstitial 


282 


DISEASES  OF  THE  BLOOD. 


growth  was  forraerlv  siijiposcd  to  lead  to  atrophy  of  the  higher 
structures,  and  thus  to  imjiainiipnt  of  the  functions  of  the  org»D, 
In  the  stomach  it  was  said  to  [>roduce  atrophy  of  the  glamlnltr 
structures;  in  the  kidney,  compression  of  the  urine-tubes;  aud  in 
the  heart,  diminution  in  motor  power.  It  is  probable,  however,  thi\i 
the  atrophy  iu  tliese  cases  is  primary,  following  the  deficient  siiji|ih 
of  oxygenated  blood,  and  that  the  increase  in  the  stroma  is  dai?  to 
the  fact  that  it  is  the  only  tissue  [iresiMit  that  can  thrive  mi  ihf 
material  supplied.  The  alterations  which  this  change  ppxhuw  in 
the  physical  characters  of  the  organs — viz.  induration  associatrJ 
with  alinoniiul  redness,  due  to  the  excess  of  blood  or  pigmentatinn 
from  hicmatoidin — are  exceedingly  characteristic. 

5.  Thrombosis  (see  ]i.  240). 

6.  Necrosis  occurs  from  mechanical  hypericmia  only  when  the 
obstruction  is  very  general  and  complete  (fip.  35,  3H  and  44). 

To  sum  up.  long-eontiuued  mechanical  hyperemia  leaiis  to 
impairment  of  vitality  and  function.  The  tissues  gradoillr 
undergii  retrogressive  changes  and  atrophy,  although  from  tli'' 
amount  of  exudation  aiul  blood  they  contain  their  size  and  nl^ii- 
hite  weight  may  be  increased.  This  form  i>f  hypertvmia  hw  no 
temlency  to  cause  multiplication  of  tissues  other  than  of  the  con- 
ni'ctiiu-.  an<l,  in  the  case  of  catarrhs  of  mucous  membranes,  of  the 
fpitlu-liiil. 


POST-MORTEM    EVIDENCES    OF    HYPEILffiMIA.-P»rt» 
which    were    actively    liy[ier;einic   during  life   frenuently  show  i*** 
fligns  of  it  after  death  ;  for,  if  coagulation  does  not  occur  immftl  >• 
iitely,  contraction  of  (he  arteries  or  of  the  elastic  capsules  oforg»«** 
forces  the  blood  on   into  the  veins,  finis  rendering  the  recogniti*"*** 
of  arterial    or    capillary    hypen^inia    impossible.     Further,  uiil^ 
the  influetiee  of  gravity   abiue  tliiiil  will    tend   to  run  to  the  itio  ^"* 
dependent   parts,  and  thus  a  liyperremic  organ — whether  actively  ^^ 
passively  so — may  be  emptied  of  blood,  and  may  thus  appear  p»lc^  " 

IJiit  dependent  parts,  on  the  other  hand — the  posterior  jiorlioi 
of  the  lungs,  the  lowest  coils  of  intestine,  the  skin  on  the  jio.'rtorit 
surface  in  dorsal  decubitus — which  may  have  been  healthy  durii*-^ 
life,  now  become  full  of  dark  blood.     It  is  oflen  diflFicult  to  say  li""^ 
much  of  the  congestion  of  the  base  of  a  lung  is  ante-mortem  an*^- 
how  much   fiost-mnrteui. 

.\  further  source  of  error  exists  in  the  post-mortem  staining  oi 


IITPER.ICMTA   OF  THE  LIVER. 


233 


psrti,  especially  of  the  fiKlocariliuni,  tbo  linings  of  great  vessels, 
and  the  tissues  round  veins,  siieli  as  is  met  with  particuliirlv  in 
wpticivraia.  The  redness  in  these  cases  is  aiufonn,  and  no  uiag- 
nifiation  will  show  that  it  depends  upon  distended  vessels,  while  a 
cimpit.'  lens  will  generally  show  the  capilliirj  nature  even  of  an 
«[ip»rcufly  uniform  /ti/pera'inic  redness. 

When  large  veins  arc  hyperremic  the  injectiou  is  said  to  he 
"runiibrm,"  from  their  branching  form  and  dark-blue  color.  In 
the  intestine,  skin,  and  kidney  hyjierjcmia  may  appear  [lunctiforui 
frnm  the  arrangement  of  the  vessels  in  villi,  papillie,  i>r  Mulpighian 
("rjmsck's.  as  the  case  may  be.  Minute  punctiform  hemorrhages 
must  uijt  he  mistaken  for  such  ciises. 

I'igmeutation  (slate-gray,  black,  or  brown)  from  tlie  altered 
hwmrjglobin  of  disintegrated  corpuscles  generally  remains  after 
fliriitiic  hypenemia,  as  is  nften  seen  in  the  stomach  nnd  intestines 
ifter  portal  congestion,  and  iu  the  bladiier  and  the  lungs  after 
flironic  catarrh  (p.  235). 

Mechanical  Hypeb.«!mia  of  the  Liver. 
Long-continned  mechanicii!    hypersemiii  of  the  liver   invariably 
g'ves  rise  to  the  condition    known  us  Nutmeg:   Liver,  which  so 

Fio.  91. 


»»r     OestTiirllnii  of  llu'  HviTi-rlls  uikI  |iii^iiL-iitiitioii  nf  llip  ii'iitrnl  |Mirtloni'  of 

I  •rinni;  nrw  ),'ruwtli  of  luiirn'ctivi'  ti»Hiii'  at   tlic  jifrliiluTy.     l,  luiMitli' vein  ;  /'.  (nirtnl 

<S"    Wlivti  more  highly  mttgtillifd  nuiinniiis  mirlcl  «rir  ncen   In  the  |>«rl|ilii'n>l 

uttlro  Utniio.    In  ilil*  ttpvcimvn  thvre  In  more  now  tluuo  >t  the  periphery  lb«n  la 


234 


DISEASES  OF  THE  BLOOD. 


;v<?i 


J  V       4 


I 


fre<|iiently  results  from  oiinliao  inconi]>etonce.  The  chu 
chanicteri/.i'fl  by  a  large  ao'iiuiiilatiixi  dI"  MkchI  in  ilu-  siiblii 
ami  iiitraloliiilur  voinx,  whicli  ililati'  and  thirkrn ;  bv  stropkf 
the  hepatic  cL'li»  in  the  central  ])()rtion8  of  the  lobules :  tinil  nuclj 
by  increase  of  the  interlohiilar  foiiriectiv*-  tissue.  The  impfili- 
nient  to  the  return  of  blooii  by  tiie  hepatic  vein8  lemla  to  atmiili; 
of  the  cells  in  the  central  portions  of  the  acini  iind  to  the  ivfmi 
of  piprnetit,  so  tlial,  when  examined  microscopically,  thc-e  pin 
of  the  acini  are  seen  to  consist  of  broken-down  cells  and  gri 
P„,   92  of  pigment  {Fig.  yi).     The 

",^'  lobular    veins   nud    their   radicle*' 

are  much  dilated,  and  filled 
red  blood  -  corpuscle*  (  Fiji. 
Their  walls  arc  thickened.^ 
there  often  appears  to  be  < 
mure  or  leB«  thickening  ofr 
intercellular  network  which  tsi 
mediately  surrounds  the  centra 
vein.  Owing  to  thiw  thickes 
of  the  central  \fin  ami  nf  tfc 
Nutni.Ti  iiv.r    T'..rti.m  ..f  kik.  !»i.  m-0r   jaeenl    intercellular  network 

n'litnil  tii'iMtlr  vi-Ui  i  IT.  ninn'  lilKhly  miiK- 

iiinoi.ithuwinKthi'itiirki'niiiKor  the  vrini    to    the    destruction    of    the 

.mllh.«.-.u.nul«ll......f  r,-.n,l.>.Kl,...rim.-         .,|       j,,^.  ,„„,,  ,.^  ,        ,  j^ 

rim  wUlilii  tlioiu.     .-  MU.  ' 

the  acini    in   advanced  sta 
the  disease  may  present  a  fibrous  apjiearance.     This    i-    • 
much  less  marked   in   injected  specimens,  and  is  tht  r. : 
due  to  atrophy  of  the  cells  and  distention  of  (he  vesacU. 
peripheral   parts  of  the  ai-ini   new   interlobular  growth  is  o« 
ally  seen  insinuating  itself  between  the  almost  unaltered  liverH 
This  new  interlobular  growth  is  less  nucleated  than   that  inet^ 
in  cirrhosis  of  the  liver. 

In    the   earlier   stages  of  this  affection   the  liver  is  smootl) 
often  considerably  increased  in  size  from  the  large  amount  of 
which  it  contains.     On  section  it  presents  a  peculiar  mottJet]  ap 
ance.  the  centre  of  the  lobules  being  of  a  dark-red  cfdor.  »hi 
peripheral   [K>rtions  are  of  a  yellowish-white.      This   latter  a{ 
ance  is  occjisionally  inereaseil  by  fatty  infiltration  of  the  peri| 
liver-cells.      The  appearance  of  such  a  section  is  not  unlike  thaTi 
a  nutmeg.      I'ltimately.  the  organ   may   undergo   a  gradual 
nutiou   in  size,  becoming  more  or  less   irregular  on   the   av 


nrPERXMIA   OF  THE  LVXGS. 


235 


'  This  is  due  to  atroy)hy  of  the  central  cells  of  tlie  lobules,  mainly 
from  inaluntritiou  (p.  231).  but  |iiirtiy  from  prt'ssiirc  uf  the  dilated 
cciitnil  veins  and  the  coutructin;;  interlobular  ;'rowth. 

Mechanical  Hyper^emia  of  the  Lungs. 

In  tlip  lungs  long-continued  mechanical  hypcnemia  produces  that 
pMiilinr  induration  and  pigmentation  which  is  known  as  Brown 
Induration.  Thii?  must  frequently  results  from  stenosis  and  in- 
sullicicnoy  of  the  mitral  orifice,  'i'he  alterations  pnnluced  in  the 
puhiiiinary  texture  consist  in  the  Hrst  place  of  elongation  ami  dila- 
tation of  the  pulmonary  capillaries,  so  that  even  in  nninjectcd  prep- 
trations  the  alveolar  walls  appear  abnormally  tortuous.     The  epi- 

Fin.  m. 


sTl 


^^'e 


^liwnlndunitlon  iif  IIk!  hint;,  filinuiiii,'  llir  ■ilinnruiiil  miuilx'r  of  .snolti'ii  i>lKHifnU<l  I'pl- 
"*"«1  cells wiviTinj!  tlU'  nlvi^ilnr  wnUx.  Iht  ilii-n'iue  iif  ironniTllve  tUsiiu  arDUiul  Ihe  blixxl- 
'■"''•.n.  will  the  large  niiaiiOty  uf  piiciiK-iil ;  (»,  (lie  alvoolor  ciivily.      ■    Jii 

Uieliiil  cells  lining  the  alveoli  become  snolJcTi,  probal>ly  multiply, 
siiil  iii^.  jjpeu  ill  large  numbers,  filled  with  dark-brown  pigment, 
"JVuriiijj  the  alveolar  walls  (Fig.  03).  They  freipieiitly  accumtihite 
*'lliin  the  alveolar  cavities.  These  changes  are  followed  bv  an 
'UtTeiwe  in  the  interlobular  ci>Tinective  tissue,  by  the  formation  of 
'"?P  i|imntitie8  of  browni.sh-black  pigment,  and  often  by  a  thicken- 
'"gof  the  alveolar  walls.  The  bronchial  mucous  membrane  is  dark 
*l"i  the  small  peribronchial  vessels  are  dilated,  Sttmctiuies  these 
*M«el8  rupture  and  blood  is  extrava.sated  into  the  tissue  of  the  lung. 
(See  '•  Piiliuonary  .\poj)le.\y.") 

hiings  in  which  these  changes  are  at  all  ailvanccd  present  a  more 
'"  'ess  uniform  brownish-red  tint,  mottled  with  brown  or  blackish- 


DISEASES  OF  THE  BLOOD. 


colored  s|)ecks  atnl  streaks.  Tker  are  heavier  and  tougb 
natural,  less  crepitant,  and  iiptjn  squoezinj;  tlioin  tin*  pitlmoa 
sue  IS  foiiiiil  to  be  denser  and  thicker  tliuii  tiiat  nf  u   liei 

DROPSY. 

The  normal  tissues  are  continuously  bathed  in.  and  noarii 
the  lymph,  which  derires  it»  nutritive  properties  from  the  I 
and  passes  on   info  that  fluid  the  prnduct*  if  receives  in  exd 
from    the  tissues.     These   j>roducfs   find   their   way,   either 
veins  or  by  the  lymphatics,  back  to  the  heart,  and  thenrt 
lungs,  skin,  iimi  kidneys.     In  all   probability  the  vein.'i 
as  much  tiie  soil-pipes  of  the  tissues  a.s  the  lymphatics.      To 
in  all  parts  of  the  Ijody  a  constant  circulation  of  lymph  t 
from  the  capillaries  and  returning  by  the  lymphatics  is  ma 
is  justified  by  our  present  knowledge.     In  the  dop,  at  any 
know  that  during  rest  there  is  no  flow  at  all   fr<im  flu-  lyi 
of  the  limbs.     The  lymphatics  seem  to  perform  most  of  th 
during  active  exercise  or  in  other  local  c-uicrgencies. 

Lymph   varies    both   in    amount   and    in   comiMtsitinn.     ' 
factors  which  arc  mainly  operative  in  dctennining  thntc  i 
the  excess  of  the  pressure  within  the  capillaries  over  that 
tissues  immediately  around  them :  and  (2)  the  special  propa 
the  c*lls  of  the  capillary  walls. 

1.  The  capillary  pressure  is,  in  general  terms,  a  sort  of 
between  the  arterial  and  venous  pressure.  It  usually  folloi 
closely  that  in  the  veins.  If  either  the  arterial  or  the 
pressure  rise  or  fall  while  the  corres|>onding  reaoua  or 
pressure  remains  cini»tant,  the  capillary  pressure  will  rise 
too.  as  the  case  may  be.  If,  however,  one  of  them,  ei 
arterial  or  the  venous  pressure,  rise  or  fall  while  the  otlif 
in  a  rovtniri/  direefion.  the  residfing  capillary  pri'ssure  nd 
remain  constant,  or  fall.  I'uder  such  circumstances  the  " 
pressure  is  diflicuh  to  estimate,  for  there  is  no  method 
measurement.  Most  often,  as  has  been  said,  it  ftdlows  tha 
veins.  A  statement  regarding  flic  arterial  pressure  alone  i 
a  safe  guide  to  that  in  the  capillurics,  partly  for  the  mH 
stated,  and  jiartly  because  the  arterioles  may  inter|>o»e  an  a< 
in<lcfcrmin.'ible  factor. 

2.  The  influence  exercised  by  the  capillary  walla  upon 
duction  id'  lymph  has  been  supposed  by  Heidenhain  and  « 


DROPSY. 


237 


be  of  the  nature  of  an  active  secretory  process,  but  by  many  it  ia 
Rtill  regarded  as  a  passive  tiictor,  the  efficacy  of  which  depends  only 
on  the  efficient  nutrition  of  the  vessel-walls.  According  tn  this 
Kcoad  view,  a  vessel-wall  is  said  to  be  more  or  less  "  permeable  " 
in  pro|)ortion  to  (1)  the  readiness  with  which  it  iil!>)«s  fluid  to  trana- 
nde (sensitiveness  to  pressure),  and  {'1)  the  resembliince  which  the 
tnnsuded  Uuid  bears  to  the  ]dn.>:Uia  of  the  blood.  Thus,  so  long  as 
thf  pressure  remains  constant  the  jn'rim-nhiUty  of  the  i:ai)illarivg  is 
the  measure  of  both  the  amount  and  the  composition  of  the  lymph. 
For  example,  the  capillaries  of  the  liver  are  said  to  be  more  per- 
nivsblr  than  those  of  the  intestine,  and  those  of  the  intestine  than 
tbo,«o  of  the  limbs.  By  this  is  meant  that  a  similar  increase  of 
pressure  imluccd  in  such  case  will  not  be  fidlowcd  by  a  similar 
result,  but  that  there  will  be  a  marked  increase  <>f  the  lymph-flow 
friiin  flie  liver,  a  let's  increase  from  the  intestines,  and  the  smallest 
iiierease  of  all  from  the  limbs,  and  that  in  any  case  the  lymph  from 
the  liver  will  contain  more  proteid  matter  than  that  from  the  intes- 
tines, and  that  from  the  intestines  more  than  that  from  the  limbs. 

The  saline  constituents  are  the  same  in  all  cases,  aiid  correspoird 
in  amount  to  that  found  in  the  blood-piasimi.  It  is  well  known  tlint 
tscitic  fluid  contains  more  albumin  than  cedematous  fluid  fnim 
the  Ifgs.  ancl  that  this  is  so  under  all  conditions,  and  docs  not 
depvnd  nn  the  disease  producing  the  dropsy,  Dumaifv — such  aa 
dipping  a  limb  into  very  hot  water — increases  the  permeability  of 
the  capillaries,  and  therefore  both  the  nmoiint  of  fluid  transuded 
anil  the  resemblance  which  it  bears  to  blood-plasma.  It  is  jjrobable 
•J^t  a  somewhat  similar  but  less  pronounced  change  may  be  caused 
h.v  gradual  alterations  in  nutrition,  due  to  the  circulation  of  defec- 
tive or  vitiated  blood,  and  that  increased  friction  and  greater  perme- 
•kility  may  result, 

lleidenhain  found  that  by  introducing  certain  sub.stances  into  the 
blond  he  could  produce  an  increase  in  the  flow  of  lymph.  These 
""Wtaiices  he  called  •*lymphagogues,"  believing  that  tliey  in  some 
*•;  stimulated  the  supposed  secretory  power  of  the  capillary  walls, 
'ttrling'  has,  however,  by  very  ingeniously  contrived  e.\))orinient8 
"hown  that  in  the  case  of  dextrose  the  first  eft'ect  of  its  introduction 
Mtoeauijc  ft  reabsorption  of  fluid  into  the  vessels,  and  a  consetjuent 
"lerensc  in  the  total  qimntity  of  fluid  they  contain.  This,  in  its 
'"rn.  pruduces  a  rise  in  the  venous,  and  therefore  in  the  capillary, 
'  Juumai  of  Phyaioloyij,  1S94. 


238 


DISEASES  OF  THE  BLOOD. 


pressure ;  and  to  this  increased  pressure,  ruther  than  to  any  »ii«ijI 
secretory  process,  he  uttribiites  the  additionul  lymph-flow.  Stwiiaj 
further  shows  that  if  uu  amount  of  blood  c(|unl  to  the  cxptrtMl 
ab8or|ttion — caused  by  the  introduction  of  the  dextrose — be  pn- 
viously  withdrawn,  no  increase  in  the  total  amount  of  blood,  niirM 
of  the  venous  pressure,  and  no  addition  to  the  onlinary  lymph-io* 
will  occur.  It  seems,  therefore,  that  perinenbility  should  rtill  W 
regarded  as  the  pos.session  of  a  special  power  of  retention  rttW 
than  as  an  active  secretory   process. 

By  dropey  is  meant  the  retention  of  lymph,  either  in  co»n^fm^ 
tissue  spaces  or  in  serous  cavities,  though  by  some  it  is  ucwl  odIt 
with  reference  to  the  serous  cavities.  The  term  csdema  u  liimte' 
to  dropsy  of  the  connective-tissue  spaces,  while  nnnnnmi  MW 
«ilema  of  the  subcutaneous  tissue.  Thus  we  speak  of  "pMtA 
dropsy,"  "a-dcnia  of  the  Inngs."  "anasarca  of  the  legs." 

It  is  tolerably  certain  that  the  causes  of  increased  lympb-ll(>»M» 
also  the  causes  of  dropsy.  It  is  quite  certain  that  the  most  mark^i 
examples  of  tlrnpsy  are.  in  practice,  associated  with  enonnou«m- 
crease  in  venous  pressure  acting  over  a  long  period.  .\m"n£ 
these  local  obttniction  to  the  return  of  venous  blood  plays  the  chiff 
part.  This  may  be  caused  by  the  pressure  of  cicatricial  tissue  fir » 
tumor,  or  by  thrombosis.  Itufficient  action  of  the  heart,  such  •» 
tliat  occurring  in  late  stages  of  valvular  disease,  causes  a  &ilit 
arterial,  but  a  rise  in  venous,  pressure,  with  a  conseijuent  slowinj; 
of  the  circulation.  As  the  veins  become  distended  their  v»lit* 
become  incompetent,  an<l  the  action  of  gravity  on  the  eniarjpJ 
blood-column  adds  enormously  to  the  pressure  in  the  capillarirt  of 
the  legs,  and  thus  produces  anasarca.  A  slighter  form  <<f  fledtta* 
of  the  legs,  in  women  whose  occupation  involves  much  standing,!* 
duo  to  the  combined  inHuence  of  constipation,  garters,  and  grv 
In  all  these  cases  the  mechanical  congestion  may  mtl  impn«bi 
increase  the  pennrability  of  the  capillary  walls.  The  certainty 
the  increased  venous  pressure  is  the  cause  of  the  dropsy  rwta 
on  the  constancy  with  which  the  dropsy  ilisappcars  when  the  inci 
in  pressure  is  removed,  liwrfunfd  arterial  preitturr  is  )M>mel 
credited  with  the  production  of  dropsy,  but  it  is  uncertain  wbi 
in  the  absence  of  increased  venous  pressure,  it  is  a  sufficient 
In  that  form  of  chronic  Bright's  disease  known  as  granular  kr 
there  is  a  marked  increase  in  the  arterial  pressure,  but  no  opi 
until  the  heart's  action  begins  to  fail  and  the  venous  preMuro 


DROPSY.  239 

y  rises.  Possibly  in  such  conditions  the  contracted  arterioles 
artially  neutralize  the  effect  and  act  as  a  guard  to  the  capil- 
An  experiment  of  Heidenhain's  shows  how  fallacious  it  is 
it  to  arterial  pressure  as  a  guide  to  that  in  the  capillaries, 
struct!  ng  the  thoracic  aorta  this  observer  enormously  reduced 
terial  pressure.  Notwithstanding  this  reduction,  he  found  that 
)mbined  lymph-flow  from  the  intestines  and  liver  together 
d  no  proportional  fall,  though  the  lymph  obtained  included 
preciably  larger  amount  of  proteids.  Heidenhain's  inference 
lat  no  process  of  mere  tissue-filtration  could  possibly  explain 
suit.  Starling  repeated  this  experiment,  but  took  the  pre- 
n  of  measuring  the  pressures  in  the  portal  vein  and  in  the 
)r  vena  cava  as  well  as  in  the  femoral  arterv.  He  found  that 
lormous  fall  in  the  arterial  pressure  was  accompanied  by  a 
lerable  drop  in  that  in  the  portal  vein,  but  by  a  distinct  me 
it  in  the  inferior  vena  cava,  so  that,  though  the  pressure  in 
testinal  capillaries  was  almost  niU  the  pressure  in  those  of  the 
ffas  probably  increased.  He  further  showed  that  the  flow  of 
1  from  the  intestines  ceased,  while  that  from  the  liver  (nor- 
the  more  concentrated)  continued,  as  might  have  been  inferred 
the  pressure  conditions.  In  this  way  the  changes  in  capillary 
ire  were  found  to  explain  the  alterations  in  both  the  quantity 
iaracter  of  the  lymph. 

;  second  great  class  of  dropsies  are  those  associated  with 
unation  of  the  kidneys  and  deficient  urinary  secretion. 
»e  cases  there  is  no  ascertained  increase  of  venous  pressure, 
true  that  the  pressure  in  the  arteries  is  often  raised,  but  the 
ears  no  uniform  relation  to  the  oedema.  It  has  been  suggested 
n  these  cases  there  are  substances  circulating  in  the  blood 
;  like  the  experimentally  injected  dextrose,  and  that  these 
mces  produce  a  condition  of  plethoric  hydrnemia  and  a  con- 
nt  general  rise  of  blood-pressure,  followed  by  oedema.  Against 
iew  it  may  be  urged  that  in  the  experiment  referred  to  the  in- 
jd  flow  affects  only  the  abdominal  viscera,  whereas  the  oedema 
ight's  disease  is  distributed  over  all  the  loose  tissues  on  the 
»  of  the  body.  We  know,  however,  practically,  that  improve- 
in  the  quality  of  the  blood  is  followed  by  diminution  in  the 
Bt  of  oedema. 

cardiac  failure  there  must  be  some  hindrance  to  the  exit  of 
1  from  the  thoracic  duct,  and  this  may  be  an  adjunct  in  dropsy 


240 


DISEASES  OF  THE  BLOOD. 


due  tu  cardiac  causes.  Lucul  [tiessure  un  the  Ivmphatics  Jov*  o4 
usually  produce  icdeuia,  though  the  occasional  jtresencc  of  chrlf  a 
the  urine  or  in  the  pleural  or  peritoneal  cavities  is  gcncmlly  attnU 
uted  to  hlockiug  of  the  respective  lymphatics  by  growths  or  puv 
sites  or  to  rupture  of  the  thoracic  duct  or  rcccptaculum  chyli. 

In  anicniia,  neuralgia,  cxoplitlialuiic  goitre,  tumors  of  thr  ipinal 
cord,  and  other  diseases  slight  degrees  of  a-deoia  are  occwinDilij 
met  with.  Section  of  the  spinal  cord  produces  ra«o-courtn<l«r 
paralysis,  and  tumors  probably  act  iu  a  similar  manner.  In  t^ 
other  ca»ea  vaso-motor  derangements  are  common,  and.  iLmii^ 
their  cause  is  less  definitely  ascertained,  paralysis  of  ■ 
strictor  or  direct  action  of  vaso-dilator  nerves  is  probaLi..  -■- 
would  furnish  a  sufficient  cause.  Experimental  aiiiemia  gives  w 
to  nn  increased  lymph-How.  but  it  does  not  foiluw  that  ili-fccti'c 
blood  acting  over  a  long  period  might  not  increase  the  permcsbilin 
of  the  capillaries.  Experiments  on  the  spinal  cord  and  un  ti* 
splanchnic  and  vagus  nerves  have  hitherto  faiUsl  to  afford  atti*- 
factory  evidence  of  the  existence  of  any  nervous  cftUM  of  ftkBt 
apart  from  vaso-motor  changes. 

THROMBOSIS. 
ThrombosiB  is  the  coagulation  of  the  blood  within  the  v«*A 
during  life.  The  proiluct  is  called  a  thrombus,  in  oppoaitioo  «"• 
coa^ulum  or  clot,  the  result  id'  |)ost-morten»  coagulation.  Tlifu»" 
bosis  may  occur  in  the  heart,  arteries  capillaries,  or  vriun.  1*  ** 
in  the  reins  that  it  most  frei|uently  occurs. 


CAUSATION. — Thrombosis   is  generally  said  to  be  ilnr  t-  ■'=*'-' 
or  more  of  three  causes  :  damage  or  absence  of  the  lining  of  t"** 
vessel-walls,  retardation  of  the   blood-stream,   and  cbaog««  w  v>^ 
blood    itself  increasing    \tA    coagulability.     These  cuiuoi  we  >b**^ 
now  |)rocefd  to  discuss. 

I.     Damage    or   Absence    of    the   Lining    of    the    V( 
wall. — The  most  striking  points  arc — first,  that  blooil  rirrwlsti 
in  living  vessels  remains  Huid,  while  blood  drawn  from  the  Ui**. 
coagulates;    and.   secondly    that    when  coagulation    of  ctmilati 
blood  occurs  it  is  usually  upon  some  obviously  disossed  suKaee  t^ 
in    some    place   where   the   blood-strc-am   has  been   mach  r«(anl«^ 
Krom  tlu'.'.e  fact.i  it  has  been   inferred  that  the  hcaltbT  rc(»«U' 
exercises  an  inhibitory  intluence  upon  the  coagulation  of  Uw 


THROMBOSIS.  241 

preventing  the  changes  (whatever  they  may  be)  which  lead  to  the 
formation  of  fibrin.  It  is  probably  more  correct  to  say,  with 
Lister,  that  blood  within  normal  vessels  does  not  tend  to  coagulate, 
the  vessel-wall  being,  so  to  speak,  neutral  or  passive  so  long  as  it  is 
living  and  healthy.  In  this  light  the  normal  vessel-wall  may  be 
compared  to  greasy  and  viscous  substances,  like  vaseline,  paraffin, 
and  castor  oil,  in  which  blood  may  long  be  kept  fluid,  and  yet  be 
ready  to  coagulate  normally  as  soon  as  it  is  brought  into  contact 
with  solid  matter.  Contact  with  ordinary  solid  matter,  on  the 
other  hand,  induces  coagulation  more  quickly.  When  drawn  into 
t  basin,  blood  usually  clots  in  from  three  to  eight  minutes,  but 
Lister  saw  blood  remain  fluid  for  a  long  time  in  the  angle  between 
an  amputated  sheep's  foot  and  the  skin  raised  in  a  flap  from  it. 
Moreover,  extravasations  about  simple  fractures  and  into  the  cav- 
ities of  the  body  are  often  long  in  coagulating,  though  they  vary 
much  in  this  respect.  Coagulation  occurs  more  rapidly  on  a  rough 
surface  than  on  a  smooth  surface. 

Although  the  integrity  of  the  vesgel-wall  has  been  spoken  of,  the 
integrity  of  the  endothelium  is  alone  necessary.  Fatty  and  cal- 
careotis  changes  of  the  deeper  structures  do  not  cause  thrombosis, 
whilst  atheromatous  ulcers,  foreign  bodies,  and  nodules  of  new- 
growths — all  bare  of  endothelium — may;  moreover,  severe  injury 
of  capillaries,  which  possess  only  endothelium,  causes  thrombosis  in 
them.  It  may  therefore  be  concluded  that  damage  or  ahgence  of 
the  vascular  endothelium  is  an  essential  condition  in  the  production 
of  thrombosis.  This  damage  or  absence,  as  already  stated,  may  be 
due  to  many  causes. 

1.  Iqjuries  may  destroy  or  injure  the  endotheUiivi.  Among  the 
most  important  of  these  are  section,  rupture,  ligature,  and  torsion 
of  vessels.  In  section  and  rupture  thrombosis  starts  from  the  dam- 
aged intima,  and  constitutes  the  means  by  which  hemorrhage  is 
naturally  and  temporarily  arrested.  By  ligature,  torsion,  and 
other  operative  proceedings  surgeons  can  also  temporarily  arrest 
hemorrhage  which  the  natural  processes  are  insufficient  to  stop. 
Cauteries  and  caustics  furnish  other  examples  of  the  effect  of 
'Bjurr  in  producing  thrombosis. 

2.  Diseases  of  the  i'es»e.l-walls  may  affect  the  endothelium. 
'^^,  thrombosis  may  occur  on  atheromatous  ulcers,  bare  cal- 
careous plates,  or  an  intima  damaged  by  syphilitic  inflammation 
01"  by  the  extension  of  spreading  inflammation  from  other  parts. 

16 


242 


DISEASES  OF  THE  BLOOD. 


IiiHaniination  \vii!»  formerly  regardeil  lu*  tlu<  innin.  if  not  the  miIt, 
cuuKi-  of  thrumbosis ;  bouue  throiiibosis  iti  veiiw*  i»  frttinriidt 
tcrmud  "  plilebitis  "  eveu  at  the  jircsfnl  dny.  InllMtnniatiiio  uf 
vciu»  i»  rurc  lus  n  prinimy  condition,  but  it  may  be  due  to  extrntuia 
of  inflatuiutition  from  neighboring  tissues,  and  not  infre<juentlj 
re»ult*  t'niiH  tlie  formation  of  a  thrombus. 

The  thrombosis  wliicb  occurs  as  an  occasional  complimtioti  of 
acute    specific  fevers   is  explained    by   the   obwrvution  nf  I'  • '  ' 
that  in  thef<e  dit«ea!«e8  desi|iiumiitiiiii  of  endothelium   miiy  iMim 
large  areas  of  vessel!^. 

fti  tfir  hi'iirt  inflammatioii  of  the  endocardium  enti.«e:«  drsirnftinn 
of  its  endothelium,  followed  by  the  growth  of  granulation  tueuf  m 
the  op{>osed  surfaces  of  the  valves:  thrombosis  fre<|uently  cam* 
upon  these  vegetations.     (See  "  Endocarditis.*') 

Fio.  94. 


'  fcetlno  or  •  IhromboMMl  pnpllli'iil  nrh'ry  •  fnrtiilKhl  »Arr  U(Mur»,  ■tio«ia(  , 

■Iniait  Ihp  wtaiilv  i>r  tbv  Inlltnii.    The  thrumbun  liaii  bcvn  torn  ih>in  Ih*  veawl-valL  IlkM- 

8.  Imperfect  blood-supply  nf  a  part  raimwif  liim-atr  nf  ikf  n*'**' 
vtilh  fill  iiii/ifi-ffct  nutrition.  Here  slowingnf  the  circulation  ia  •■* 
iudireet,  and  deficient  va.seulnr  8U[)ply  the  iram<Hlijne,  cause.  It* 
probtihly  not  a  very  important  group,  as  there  are  rossons  foraf 
picking  the  nutrition  of  the  vessel-wall  depends  on  the  circnUlJoa 
in  the  vn.-ia  vasorum.  and  not  on  that  in  the  afTcctetl  v«wel  (Fig-  W; 
see  "  Inflammation  of  Arteries"),  and  there  is  uo  Decosaarr  rtla- 


THROMBOSIS.  243 

hip  between  these  two  portions  of  the  circulation.  This  cause 
iefly  operative  in  the  case  of  the  smallest  vessels.  The  con- 
is  affecting  the  blood-supply  will  be  considered  in  a  subse- 
t  section. 

The  presence  in  the  vascular  »ystem  of  substances  not  covered 
dothelium.  These  comprise  such  things  as  needles,  horse-hair, 
re  introduced  into  the  sac  of  an  aneurysm ;  pre-e.xisting  clots 
mbi  or  emboli) ;  parasites  which  have  penetrated  the  vessels ; 
lew  growths  which  project  into  the  interior  of  veins.  In  all 
instances  the  clotting  first  takes  place  upon  the  foreign  sub- 
e  itself. 

Retardation  of  the  Blood-stream. — Sometimes  abnormality 
rface  is  insufficient  to  cause  extensive  clotting  until  retardation 
c  blood-stream  is  added.  For  example,  in  the  aorta  we  some- 
i  find  calcareous  plates  uncovered  by  endothelium,  but  with 
or  no  adherent  fibrin.  In  aneurysm,  too.  the  wall  is  always 
rmal  and  the  circulation  somewhat  retarded;  but  sufficient 
ng  to  effect  a  cure  may  not  occur  until  by  treatment  we  still 
er  reduce  the  current,  and  thus  prolong  the  contact  of  the 
1  with  the  abnormal  surface. 

I  the  other  hand,  retardation,  or  even  arrest,  seems  quite  unable 
tsclf  to  produce  thrombosis.  So  long  as  the  endothelium  is 
fairly  nourished  within  the  vessel  the  stagnant  blood  will  not 
iiiate.  Blood  within  a  tied-off  turtle's  heart  does  not  coagulate 
the  heart  dies.  The  time  preceding  the  occurrence  of  coagu- 
a  in  the  jugular  vein  of  a  mammal  is  longer  in  proportion  to 
are  exercised  in  laying  it  bare  and  applying  the  ligatures ;  and 
is  operation  be  done  antiseptically,  coagulation  may  not  occur 
I. 

IV  are  these  very  different  results  to  be  explained  ?  Impaired 
lation  in  a  part  means  damage  to  all  the  tissues  supplied — to 
ascular  endothelium  among  others.  It  is  of  course  possible 
diminishing  the  rapidity  of  the  blood-atream  may  have  no  other 
;nce  than  that  which  it  exerts  in  this  direction.  There  are, 
ver,  rea.sons  for  assigning  to  it  a  more  direct  action.  All  parts 
stream  flowing  through  a  tube  do  not  proceed  at  the  same  rate, 
lentral  or  axial  part  of  the  stream  invariably  travels  faster  than 
peripheral  or  periaxial,  for  it  is  exposed  to  less  friction.  If 
particles  be  suspended  in  such  a  fluid,  those  with  a  specific 
ty  most  closely  approaching  that  of  the  fluid  will  move  most 


LEASES  OF 


BLOOD. 


luiiidly  and  inuintuin  their  position  in  the  axial  !<tre«ni  tiu'rt  cuily. 
If  the  rate  of  flow  bo  climininhoil.   tlic  leii<lency  of  the  m;--  -'  ' 
particles  to  remain  in   the  axial   stream  will  also  diniiniijii. 
will  be  in   pro|H)rtion    to  the  difference    between   their    n-sjiwtnf 
specifie  gravities  and  that  of  the  fluid  in  which  thev  »■ 

In  most  arteries  und  in  many  veins  the  periaxial   str. 
only  plasma  and  a  few  leucocytes.     But  directly  the  stream  *l*ckra» 
the  leueoeytes  fall  out  more  rapidly  than  ever,  anil  Ian  lieliiml  fW 
to  the  walls,  while  even  the  red  corpuscles  maintain   lew  piTt'cfl]' 
their  axial   position.      The    hlood-plateleto   (blood-plale<<.  binnK^ 
blasts)  j»enerally  occupy  the  axial  stream,  but  fall  out  wion  ^f^n■ 
and   from   the  same  cause    as  the  leucocytes.      Now.   whit'i'f  ■' 
attribute  to  the  leucocytes  or  to  the  platelets  the  chief  fiiiH: 
the  production  of  the  thrombus  (p.  24G).  it  is  cjiiite  evident  iwt 
thoujrh   the  lining  membrane  of  the  ve.isel  be  diseased,  yet  tbf  i»- 
creased  IViction  thereby  j)roduced  may  be  insuflicient   to  caum-  »ii' 
practical  slowing  of  the  blood-stream  at  that  point,  bikI  iiwuffioifoi. 
therefore,  to  bring  either  platelets  or  leucocytes  into  rotj' ' 
the  damiiged  part  of  (lie  wall.      In  this  way  we  mn_\  have  .n. 
mal  endothelial  lining  without  any  resulting  thn>mbn»is. 

On  the  other  hand,  when  the  current  is  slow,  a.*  in  the  vi-iiu.  ili* 
leucocytes  and  platelets  will  readily  come  into  cuntnet  with  tbf  mi1« 
of  the  vessel,  and  may  proiluce  clotting  even  though  the  •l»iu»i.i'  '* 
vessel-wall  be  comparatively  slight.  In  this  way  wo  find  that  neilk** 
damage  to  the  endothelium  nor  slowing  of  the  circulation  ncf<l  I* 
followed  by  thrombosis,  and  that  the  furmer  is  the  more  i»i|i'irt*i>l 
cause  of  the  two.  because  there  are  many  plBci>s  where  the  bl'W^ 
stream  is  naturally  slow. 

A  tendency  to  stagnation  of  blood  may  be  due  to  many  cam* 
of  which  the  most  importattt  are  cardiac  weakness,  general  ilimin*" 
tjon  of  vascular  tonus,  and  ililatation  (varix)  of  veins.  .\ll  tl"^ 
may  well  !»«•  combined  in  a  single  case  to  retard  the  circiilatiou.  »"'' 
thus  to  produce  an  abnormal  vessel-wall  and  prolonge<l  contact "« 
the  same  blooil  with  it.  They  are  conditions  which  give  rv» 
"  marasmic  clots  "  of  Virchow.  These  form  in  the  mi-»t  <irf 
Print — f.  </.  those  of  the  lower  limb,  pelvis,  or  back  ;  in  fh< 
rein*  ami  »inu»i!M,  where  the  venoua  circulatioD  ia  ordiitarily 
slow  and  difficult;  ami  in  those  part*  of  the  heart  in  which 
tends  to  remain  when  the  organ  first  fails  to  contract  eflicirn 
r.  g.  the  auricular  appendices,  the  apices  of  the  ventricles,  and 


THROMBOSIS.  245 

spaces  between  the  trabeculee.  In  veins  these  clots  begin  just  behind 
the  flaps  of  valves.  The  force  of  the  venous  current  is  so  slight  or 
the  resistance  to  it  so  great  that  it  no  longer  opens  the  valves  com- 
pletely; the  blood  consequently  stagnates,  and  after  a  time  coagu- 
lates behind  the  cusps,  Such  clots  occur  in  the  course  of  many 
exhausting  diseases — as  phthisis  and  cancer — in  which  thrombosis 
is  materially  facilitated  by  the  (juiescent  state  of  the  patient.  Care- 
ful examination  of  the  sites  of  recent  thrombi  is  said  to  have  dem- 
onstrated absence  of  endothelium,  but  this  is  hardly  proof  that 
alteration  of  the  endothelium  was  the  cause  of  the  thrombosis,  for 
the  cells  may  have  disappeared  secondarily. 

In  varicose  veins,  which  are  frequently  the  seats  of  thrombosis, 
the  circulation  is  extremely  slow,  and  the  endothelium,  owing  to  im- 
perfect nutrition,  can  scarcely  ever  be  healthy,  though  it  is  not 
always  so  damaged  as  to  excite  coagulation. 

III.  Certain  Conditions  of  the  Blood  favor  coagulation  and 
promote  the  occurrence  of  thrombosis.     It  is  said  that  the  tendency 
to  coagulation  is  increased  during  the  later  months  of  pregnancy, 
after  profuse  hemorrhage,  and  in  certain  acute  inflammatory  diseases, 
such  as  acute  rheumatism,  erysipelas,  pneumonia,  and  pleurisy.    To 
whatever  cause  it  may  be  due,  an  increased  tendency  of  the  blood 
to  coagulate  is  probably  never  more  than  a  predisposing  cause  of 
thrombosis.     In  septic  fevers  thrombosis  is  not  uncommon  in  places 
taving  no  direct  relation  to  a  wound.     This  has  been  attributed  to 
the  breaking  up  of  leucocytes  in  large  numbers,  for  it  has  been 
shown  that  injection  of  leucocytes  into  the  circulation  of  animals  is 
followed  by  their  rapid  disintegration  and  local  or  even  general 
thrombosis.     In  all  these  diseases  a  failing  heart  and  flagging  circu- 
lation— the  causes  of  ordinary  marasmic    clotting — are    present, 
whaps  desquamation  of  endothelium  (p.  241)  occurs,  and  it  is 
possible  that  organisms  may  play  a  part  in  the  proce.xs.     The  pres- 
ence of  organisms  seems  particularly  likely  in  those  frefpient  cases 
'f  Tenons  thrombosis,  often  going  on   to  puriform  softening  and 
"ewndary  phlebitis,  which  occur  side  by  side  with  erysipelas  and 
Pyemia,  and  which  have  gained  for  "  phlebitis  "  a  place  amongst 
"hospital  "  diseases. 

« is  well  known  that  the  presence  of  calcium  salts  is  essential  to 
™*  coagulation  of  the  blood,  while  the  addition  of  oxalates  will 
neutralize  the  effect  of  their  presence  and  prevent  coagulation.  So 
*''o  among  the  products  of  cell-action  substances  allied  to  nuclein 


246 


f^ool 


ai<l  coa{rulntion.  whilo  albumoson  hinder  it.     We  do  not  tei 
the  bearing  i)f  these  f'nets  tijwn  the  phenomena  of  tbroinbosi 

CHARACTERS  OP  CLOTS  AND  THROMBI— Poet-mi 
ooagula  in  the  heart  are  generally  fxtffi/.  The  thirknei 
pule  layer  varies  ilireetly  with  the  time  whieh  elapses  h«l 
changps  in  the  hoart-substanee  allow  coagtilation  to  begin,  w 
position  inilieates  the  part  that  was  iipi)crmost  after  lienib. 
mortem  clots  are  red.  soft,  watery,  and  never  adherent.  1 
not  JiH  the  vessels,  and  can  be  easily  drawn  out  of  thetii  i 
strings. 

Clots  formed  in  the  heart  Just  before  death  difl'er  imi 
from  the  preceding.  They  are  partly  due  lo  the  •■  nhippi 
the  blood  by  the  chordie  tendineue  and  other  structnrcB. 
oceiir  in  ca.^es  of  slow  death,  when  the  heart  is  too  weak  l«i 
its  cavities  an<l  the  hlooil  tends  to  stagnate.  As  wmilil  be  ex 
they  are  more  or  le.ss  nniformly  dccolori/.ed.  and.  thongh  n^ 
rent,  are  often  so  much  entangle<l  among  the  ehordar  and  tm 
that  they  cannot  reailily  be  removed.  From  their  longer  di 
anil  more  complete  contraction  they  arc  firmer  and  totigh< 
true  jKist-mortem  clots. 

Thrombi  or  ante-mortem  clots  are  of  two  kin«l« — r 
white — according  as  they  originate  from  tfuietcirtit  or  rire 
blood.  In  the  former  case,  as  seen  in  an  artery  or  veil 
ligature,  more  or  les.s  of  the  (stagnant  blood  on  either  sidt* 
knot  coagulates  into  an  onlinary  red  clot — soft,  unifonn  on  i 
and  adherent  to  the  ve.ssel-wall  where  this  is  injured.  The 
bus.  still  atlhering  to  the  wall,  then  contracts,  becomes  d 
less  elastic,  but  still  remains  red.  This  is  the  state  in  wi 
thrombus  is  generally  found. 

Kut  y>  hen  coagulation  occurs  in  blood  whirh  i»  ttill  rireiii 
in  the  sac  of  an  aneurysm  or  on  a  cardiac  vegetation,  a  w 
mixed  thrombus  results.  Zahn  studied  the  formation  of  su( 
in  small  veins  irritated  by  a  small  crystal  of  salt  in  their  ne 
hood.  .According  to  this  observer,  the  abnormal  surface 
eai'b  successive  ipiantity  of  bhutd  which  passes  to  |i>ave  up 
little  fd>rin  and  some  leucocyte!*,  whilst,  if  the  blood-»t| 
languid,  soiue  red  cor[)uacles  remain  in  the  ihrombuii.  r«>nd 
mixi'd.  Hut  later  observers  have  sliown  thai  innumerablu 
plateleta,  and  tiot  leucocytes,  are  deposited  upon  a  thread 


rirw 


^^^^^^         THROMBOSIS. 

ngb  H  vessel,  and  alsn.  in  the  case  of  a  severed  urtery,  upon  the 
lilvenlitiii  within  wliieh  the  cut  vessel  bus  retracted.  Moreover,  an 
txaiuiuiition  of  old  clots  in  aneurysuis  lias  convinced  <.)8lcr  that 
they,  too,  consist  of  )dutelets,  and  he,  consequently,  regards  leuco- 
tyti's  lis  of  little  inijtortanre  in  the  formation  of  thrombi  (p.  'lAA). 
These  throiubi  are  grni/ig/i-whitc  or  reddimli,  Jirinli/  aiUii-rvul  to  (he 
wall,  and  it  U  pveuliar  to  them  t/iat  they  are  often  atratified.  This 
is  probably  due  to  variations  in  the  rate  of  do|iosition  of  the  fibrin, 
in  the  bloiid-pressure  to  which  it  is  subjected,  and  in  other  physical 

E'  tins.  Fretjuently  white  and  reddish  layers  alternate. 
rombuB  may  be  "parietal  "  or  "obstructive."  causing  ]<artial 
plete  occlusion  of  the  vessel.  Once  formed,  it  extends  by 
liepofiition  of  umre  fibrin  on  its  surface.  As  a  rule,  this  extension 
i»checke<l  by  the  rapidity  of  the  blood-current  at  the  junction  of 
the  first  large  collateral  branch  in  each  direction  ;  but  sometimes, 
jgMcially  in  veins,  thrombosis  becomes  "  c(;ntiniied."  and  a  clot 
^^bztentl  from  the  foot  to  the  vena  cava.  Both  in  arteries  an<l 
'VW!i»  extension  is  most  likely  to  take  place  toward  the  heart, 
ih  it   may   occur    in   an  oppo.site    direction.     These   thrombi 


'"'^Sfe^; 


-^^^^m^r?^- 


1  III  lui  arterUI  tliroinbiM  thtrty-«evc-u  dnys  old :  a,  new  blood-rcssels :  6,  leuc-ocytoK 
ItUiiiioaliiii  ccllii.    iKIiidHoltrh.) 


»Ily  adhere  to  the  wall  throughout  their  whole  length,  but 
Smea  they  <lo  so  only  at  their  jiointa  of  origin. 

hhe  capillaries  coagulation  occurs  ordy  as  a  result  of  necrosis 
>ve  injury  of  the  capillary  walls,  for  they  are  »n  small  that,  so 
,'""6  M  they  are  living,  their  intliienee  in  preventing  clotting  will 

Ipon  the   whole  of  the  contained    fdoud   (Lister),  and  conse- 


248 


DISEASES  OF  THE  BLUOO. 


f|iiently  tliromhosis  docs  not  extentl  into  tlicui  »o  lonjj  a#  tLcrcu 
sufficient  blood-siipiily  to  kevp  tbein  alive. 

LATER  CHANGES  IN  THROMBI.— These  arc— dccoloni*. 
tion  (when  reii).  rcHoliitioti.  or;^anr/.iitii>n.  calcifiestiuii.  soAniiBg 
(ninijile  mill  infeetive),  and   piitrefacfinn. 

Decolorization. — Tlic  first  ehange  in  a  rod  throinliiut  is  %  brak- 
ing down  iif  the  red  i'"r|iiisele8.  Their  stroniata  beconio  unrwof- 
iii/uhle.  and  the  h:enio;:li>bin  in  set  free  and  in  great  part  ahwrbtJ. 
though  some  may  remain  at*  granular  hnematoidin.  A*  a  mult  thf 
throniliu.t  limes  its  deep-red  eolor  and  accpiires  a  finely  mouM 
reddich-gray  tint.  The  procos!<  begins  in  the  centre,  and  tdM 
weeks  or  inonthH  before  it  is  coinpieteii, 

Resolution. — That  many  thrombi  dinappear  is  certain.  f<»r  »lmi 
it  wa!<  the  ciihtoni  for  venesection  to  be  yierfornied  at  regular  luif- 
vaU  the  repeated  bleedings  were  lVe(|uently  effected  from  the  muk 
vein.  Ill  UKiderii  times.  aJHo,  re-establishment  of  the  eirt-uiatmii 
is  known  to  have  occurred  through  spermatic  veins  and  il 
the  supi-rficial  veins  in  tin-  leg  in  eases  where  thronibrMiis  i  ■ 
doobtedly  taken  place.  The  steps  of  the  proceiw  are  nol  knn"*- 
In  some  eases  of  death  from  septic  poisoning  appearanc*vs  founil  IB 
vessels  which  have  been  tied  indicate  that  thrombi,  (••rni.-il  )»(i\n 
the  on.oet  of  the  fatal  disease,  have  brokeit  down. 

Organization  has  been  mainly  stuiiied  in  thrombi  forroiii);  in 
ligatured  ve.ssr-l.s.  The  effect  of  the  application  of  u  ligBliiff  •» 
usually  to  cut  through  the  miildle  and  internal  coats  of  the  «(W>> 
the  ends  of  the  divided  coata  c^tntract  and  retract  aomewhat.  tarniDf 
up  and  down  into  the  lumen  of  the  vessel ;  anil  the  coii-'  '  " 
external  coat  is  all  that  is  left  in  the  grasp  of  the  noose.  Ii 
hours  a  red  thrombus  forms,  conical  in  shape,  and  adherent  by  it* 
bajte  10  the  iineried  inner  and  middle  coats.  For  two  or  tbr 
<luys  it  extends,  until  it  finally  reaches  the  junction  of  the  I 
collateral  branch^-often,  for  some  unknown  reaM)n.  stopping  al 
of  this  lUi  the  distal  siile.  .Meanwhile,  it  has  become  firmer.  ilri<*i 
and  more  widely  ailherent  about  its  ba.se  to  the  artery.  Tht 
of  adhesion  progri-s-ses.  as  the  thrombosed  piece  of  veMel  coni 
upon  the  clot,  until  it  becomes  universal.  By  the  seomd  lUy  * 
luiffy  nodule  tnay  be  seen  in  the  base  of  the  ilee|»-r€<«l  throml 
anil  this  rapidiv  increa.«es,  so  that  in  a  week  or  two  the  color  of 
clot  has  disappeared.     .Vfter  some  weeks  or  months  this  ilecohu 


THROAfBOSIS. 


249 


Fui.  9f.. 


i>und  to  have  been  replnccd  by  connective  tissue  intimately 
Uritii  the  artery,  wliieli  Ims  tin-  appearance  of  a  firm  fibrous 
The  microscope  gives  the  t'oliowing  explanation  of  the  ]iro- 
Thc  red  thrombus  couisists  of  red  corjotsscles.  witli  a  few  wliile, 
» meshes  of  a  fibrin-con^rulnm.  The  biifly  nodule  which  grows 
the  base  of  the  clot  is  formed  of  ^uiuil  r«>ui)(l-cell.x.  wliieh  at 
»re  undoubteilly  leucocytes  migrated  fnou  the  vusa  vasorum 
wi  by  the  ligature.  But  there  is  a  diflVnuie  nf  opininn  as  to 
rigin  of  those  formed  atVer  (say)  the  tliird  dtiy.  By  this  time 
ells  of  the  part  iiave  recoveretl  from  tiie  injury  <\u)\v  thi'in  by 
'Qund  and  ligature.  It  has  been  niainttiincd  i)t:it  tin'  new  tills 
Jl  It-iiroriftrii  '</•  t/irir  protjnii/.  Si-liftU-beu  Sfciin'd  hctuvrii 
le  ligatures  pieces  of  vessels  and  put  them  into  the  abdomens 
bbits — an  experiment  which  is 
ically  repeated  in  the  bits  of 
1.1  wiiieli  lie  hei/oiid  the  liga- 
in  all  aseptic  stumps.  He 
1  tliat  they  became  filled  with 
fctive   tissue   containing   well- 

f  I  Spindle-cells.     It  is,  how- 
no   means    certain    that 
'  spindle-cells     were     derive<l 

E)cytes  (p.  120);  and  even 
ere.  the  ability  of  white  'aJ 
1  to  form  the  new  ti.isue 
|^>ot  exclude  endothelium 
Hp  doing  8o  as  a  regenera- 
^■peas*  A  more  probable 
Bnon  is  that  the  organizing 

{' les  from  tiie  endothelium 
the  deei>er  layers  of  the 
The  iiitima  is  often  found 
,  and  the  internal  elastic 


lA 


>. 


LiMiiritiKliniil  Kvctliin  of  the-  Uifntiirpil 
eml  (If  llu-  I'rurni  iirtcry  of  a  ling  tlRy 
ilnyn  nftcT  thr  nppUcaliDii  nf  lUc  UKUtiirr. 
^hor•rillK  till'  iiHwly-fitriiifd  vi*!«ho1s  in  tla* 
thrombus  ami  tlu'lr  I'omniunti'Ution  with 
imultaneOUSly  obscured  or  thv  vun  vasorum;  n.  Ihrmnliii!!:  jtf. 
_  n  1.1       iniiM'iilHr  riiul :  Z,  pxtt'ninl  null  iiikI  VRim 

IB  op.     Processes  can  he  triice<l 
y^  lining  membrane  ilis|)la(-- 

^■riginal  clot.  However  formed,  the  cell-mass  is  penetrated 
lood-vessels,  which  form  us  in  granuhition  tissue  (p.  128). 
become  spiuille-shaped  or  briiiit'lu-d  4 Fig.  DU);  fibrillation 
litbcr  in  them  or  in  the  ground-substance  between  them; 


vusoriim.     ■    20.    (O.  Weber.) 


250 


DfSEASES  OF  TBK  BLOOD. 


many  cells  (lisHp|iear  aii  the  fibres  increase ;  the  latter  contnrt  i»l 
iMiiiiy  vessels  are  oblit'Tatcd.  the  result  beinp  the  fil>r<>u»  c<»nl  ilnnt 
mentioned.  This  is  called  organization  ol'  a  throntbos.  but  ii  » 
evident  that  the  original  thrombus  disappears  entirelr.  and  Iw 
nothinj:  to  do  with  the  proeoss  which  goes  on  in  the  n>nt 
muss  the  origiii  of  which  we  have  discussed.  The  ve!*fl  .;_..  .. 
ex>nverted  into  fibrous  tissue  and  blends  with  that  of  the  riot. 

In  certain  cases  channels  are  formed  in  the  new  tissue:  tb»» 
communicate  both  above  and  below  with  the  lumen  of  the  vtwfl 
and  thus  tlie  circulation  is  more  or  less  completely  re-esti»l)li»kf(i- 
They  are  probably  due  to  dilatation  of  the  vessels  of  the  thromKw 
(though  «hy  this  niiould  occur  in  some  cases  and  not  in  ■•'' 
unknown),  mid  give  rise  to  the  »iiiii»-likr  (hijrniTiitiim  of  Hoki! 
It  is  espceialiy  fret|uent  at  the  junction  of  the  common  iliac  \rM 
ill  cases  of  •'  white  leg."  and  leads  to  more  or  Ie«8  perfect  recortri- 
It  is  rare  in  .irteries. 

Organixiition  is  most  frequent  in  uniform,  unstratifim)  ihrmn'"' 
and  especially  in  those  occurring  iti  arteries.      But  longchtt- 
kind,  such  as  occur  after  ligature  of  the  lower  i>arl  of  the  ....  ■ 
as  well  as  large  laminated  thrombi,  like  those  in  aneurysm.'.  o»»J 
remain  as  more  or  less  granular  masses  of  non-irritant  fibrin,  witbo*' 
any  sign  of  organization. 

Calcification. — This  occurs  in  some  clots,  giving  rise  to  phl«***^ 
liths.     These  are  especially  common  in  the  prostatic  plexm- 

Softeniiier. — 1.  Simple. — A  fhronilms  which  undergoes  none 
the  prev  ioiisly  described  changes  often  softens.  This,  in  the  tu«jnr»*? 
of  eases,  is  due  to  the  chemical  changes  which  the  constitueut«  *^ 
an  a.septic  tliromliiis  undergfi  when  no  organization  or-curs.  Tl»*^ 
result  in  the  forinntion  of  u  more  or  le.>ts  Hiiid,  pappy  substaii< 
which  has  a  red<lish-gray  color,  varying  with  that  of  the  ihromb 
which  is  undergoing  ihe  change.  To  the  naked  eye  ihr  fluid  oft^ 
looks  liki-  pus,  and  the  process  is  still  spoken  of  as  the  jtHiifnf' 
»oftfiii)ii/  of  a  clot.  Itiit  N'irchow  pointed  mit  that  the  fluid  f<>l 
sisted  of  the  d(^ris  of  corpuscles  and  fibrin — albuminous,  fatty,  atf 
pigmentary  granules.  Thi-re  may  be  a  few  reeognixable  white  e» 
pii,-«'b's  in  it  »lii<'li  have  prolialdy  niigraieil  from  without.  In 
of  constriction  of  the  mitral  orifice  of  the  heart,  with  con!»e«|a« 
dilatation  of  the  left  auricle  and  slowing  of  the  circulation.  I«r; 
cloi.s  undergoing  this  change  may  be  found  in  the  auricle*.  Tbtr 
consist  of  little  more  than  bags  of  thick,  grumous  fluid.     The  oatn 


THROMBOSIS.  251 

lamioic  generally  form  a  firm  case  for  the  softened  central  part,  and 
if  the  softening  approach  the  surface,  this  case  is  often  thickened 
at  that  point  by  the  formation  of  fresh  protective  clot.     Not  infre- 
quently, however,  the  encasing  clot  may  be  perforated  and  the  con- 
tents discharged  into  the  circulation.     The  larger  particles  may 
form  emboli  (p.   255)  probably  too   minute   to   cause  syuii)tonis. 
When  occurring  in   an  artery  or  vein  circulation  may  be  thus  re- 
established through  the  thrombus.     This  process  constitutes  canali- 
Kklaon  of  a  thrombus. 

2.  Infective. — But  certain  cases  of  puriform  softening  similar, 
so   far  as  the  naked  eye  can  detect,  to  the  above  are  accompanied  by 
all  the  symptoms  of  septic  poisoning.     Acute  suppurative  inflamma- 
tion of  the  vein-wall  is  shown  by  the  microscope,  and  any  portions 
of   the  clot  which  enter  the  circulation  are  so  intensely  irritating  as 
to    cause  suppuration  wherever  they  lodge.     (See  "  Pyaemia  and 
Septiciemia.")     The  difference  between  the  two  cases  is,  that  in  the 
latter  form  of  softening  micrococci  are  constantly  present,  and  it 
is  to  them  that  the  infective  properties  of  the  broken-down  clot  are 
due.    In  the  great  majority  of  these  cases  the  veins  affected  lead 
directly  from  a  wound,  and  then  the  mode  of  entry  of  the  specific 
micrococci  is  evident.     In  a  small  number  of  patients  also  with 
wounds  the  thrombosis  and  softening  occur  in  veins  having  no  kind 
of  direct  connection  with  the  wound :  here,  too,  the  organisms  have 
entered  by  the  wound,  and  in  some  cases  at  least  the  thrombosis  is 
•^condary  to  a  general  septic  infection.     Finally,  there  remain  a 
'*f  instances  in  which  no  pathological  breach  of  surface  can  be 
Wind  for  the  admission  of  the  germs ;  it  is  thought  that  in  these 
"■^y  must  have  passed  into  the  blood  through  the  alimentary  or 
''^piratory  mucous  membranes. 

^trefiiction. — This  rare  change  is  due  to  the  entry  into  the  clot 
f  the  putrefactive  bacteria  from  some  very  foul,  and  often  gan- 
S'^Qous,  surface :  the  growth  of  these  organisms  converts  the  throni- 
"*  into  a  stinking  yellow-red  fluid  which  is  highly  irritating. 

.  *^8ULTS. — The  results  of  thrombosis  comprise  certain  changes 
*he  walls  of  the  vessels,  more  or  less  obstruction  to  the  circula- 
"">   and  embolism.     These  must  be  considered  separately : 
1-     Ohansres  in  the  Vessels. — More  or  less  alteration  in  the  wall 

01  th^  Tessel  is  an  invariable  con8e(jucnce  of  the  formation  of  a 
"^^bns.    When  the  thrombus  undergoes  a  process  of  organization 


DISEASES  OF  THE  BLOOD. 


it  becoinca,  as  alreatly  <l<'9criin'(l,  ititiiiintcly  iinite<l  with  the' 
wall.  The  Intter,  in  tlic  first  jilin-c,  l>c»«iiie!*  infiltrntr<l  *>id 
and  fonsiilcrahly  tliiciifiHMl,  hm  iiiiiiniiti.-lr,  ti);;f»lifr 
thruinbns,  gradually  iitrupbit'S.  It  is  wlieu  tin-  thronibun  U9 
a  process  of  inffrtive  /iiirij'urtii  Koftrtiitii/  tliut  llir  niii)«t  in 
vhiiiigcs  of  an  acute  iuflnmuiatory  nature  tiiki-  )ilace  in  tht 
They  are  due  to  the  irritation  of  the  deeoiuiMJiiin^  ihromt 
are  most   frequently  observed  in  the  veins, 


where   i«fe<-tivr  I 
h  11  vein  are  eonoi^ 


thickened,  so  that  to  the  nuked  f.ye  it  resembles  an  artrrjl 
inner  surface  has  lost  its  tranflliiccncy,  and  is  of  a  dead] 
color.  The  ndventitia  and  middle  (roals  are  iuje<Tted  audi 
numerous  heUKirrliiigic  points,  which  are  often  visible  ihrol 
intiiua.  The  swelling  of  the  wall  ia,  under  the  niicro»cope,l 
be  due  to  dense  infiltruticin  with  leucocytes,  which  cDnceaUJ 
mal  structure  (Fig.  I'T),  while  the  innermost  cells  die  aud  ai 
into  the  lumen  of  the  vessel.     Small  collections  of  pu»  mav 

Fio.  97. 


'f^ 


\ 


\ 


>^ 


ikptloii  iirna*  •  |>irtul  I'luwl  In  a , .  •  ^         ,  >  IrphlfliUI*  arlalus  la  { 

Mitli  "  iiinliillral  pyarmU."    The  vcln-wiU  ( K)  I*  converted  Into  (Tmnulatlnn  « 
<if  vi'lii  1»  IK-Iiin  on  III)'  li'ft.    iHoyil ) 

in  the  externiil  un<l  middle  eoal.-«.     The  neighboring  tiMue  | 
become  involved.     The.sc  acute  inflammatory  changes  in  n 


THROMBOSIS.  253 

stitute  what  is  known  as  suppurative  phlebitis.     Although  most 
freq^uently  due  to  thrombosis,  they  may  also  occur  as  the  result  of 
extension  from  adjacent  suppurating   tissues,    in  which    case  the 
tbroxubus,  which  also  undergoes  puriform  softening,  is  gcnondary  to 
the   phlebitis.     Similar  changes  are  observed  in  the  arteries.    Septic 
arteritis,  attacking  a  ligatured  artery  in  a  putrid  wound,  was  for- 
merly a  most  disastrous  sequela  to  operations,  being  the  commonest 
cause  of  secondary  hemorrhage,  now  so  rarely  seen. 

2.    Obstruction  to  the  Circulation. — The  consequences  of  the 
obBt;T*uction  to  the  circulation  resulting  from  the  formation  of  the 
thrombus  will  depend  upon  the  rapidity  and  manner  of  its  forma- 
tion, the  nature  and  size  of  the  vessel  obstructed,  the  situation  and 
nnmber  of  the  collateral  branches,  and  the  force  of  the  circulating 
•     current.     The  rapidity  with  which  the  obstruction  is  effected  is  of 
considerable  importance,  inasmuch  as  the  more  gradual  the  process, 
the  longer  is  the  time  allowed  for  the  establishment  of  a  collateral 
circulation.     For  this  reason  the  interference  with  the  circulation 
<*ttsed  by  thrombosis  is,  for  the  most  part,  less  marked  than  that 
'thich  results  from  the  more  sudden  obstruction  caused  by  embolism. 
In  the  veins,  when  thrombosis  occurs  in  a  vessel  of  small  size  and 
^oen  collateral  branches  are  numerous,  as  in  the  prostatic  or  uterine 
P'^xuses,  the  circulation  is  but  little  interfered  with,  and  no  symp- 
™ttjs  of  obstruction  result.     If,  however,  the  main  trunk  of  a  large 
*'**•*»,  as  the  ilio-femoral,  becomes  obliterated,  the  obstruction    is 
***«Owed  by  mechanical  hyperaemia,  the  extent  and  duration  of 
"^'lich  will  depend  upon  the  facility  with  which  the  circulation  can 
^  i"e8tored  by  the  collateral  vessels.     It  must  be  remembered,  how- 
®^^i",  that  the  valves  in  veins,  when  they  exist,  may,  by  preventing 
"*cIc-flow,  offer  a  great  impediment  to  collateral  circulation.     Throm- 
|*08ia  in  the  ilio-femoral  vein  frequently  occurs,  as  already  stated, 
I**  the  later  stages  of  many  chronic  debilitating  diseases,  especially 
'**    phthisis;  also  in  the  puerperal  state,  where  it  gives  rise  to  the 
'^ontjjjjQj,  known  as  phlegrniasia  dolens.     As  the  femoral  is  almost 
****    only  vein  which  carries  blood  back  from  the  lower  limb,  the 
*«ect  of  suddenly  blocking  it  is  marked.     At  first  cyanotic,  the 
'**>i6  becomes  swollen,  pallid,  white,  painful,  and  too  tense  to  pit, 
*^<l   there  is  more  or  less  tenderness  along  the  rf/n,  which  feels 
enlarged,  hard,   and   knotty.      These   symptoms  vary  greatly  in 
*''aonnt,  and  to  them  are  sometimes  added  those  of  lymphangitis 
*^d  cellulitis.     The  extent  of  the  thrombus,  the  number  of  col- 


254 


DISEASES  OF  THE  ULUOD. 


lateral  bniiulics  which  it  blofks,  ami  the  streiifrlli  of  the  iirculniM 
will  do  niiK-li  to  uceoiiiit  for  the  uuiount  of  ilmIciuu:  ami  it  i»  protw- 
blc  that  the  more  acute  iutlauuiHtory  symptutnti  arc  of  septic  ongn. 
The  eirciilutioii  is.  in  nioHt  cases,  ultiiiiutely  restored;  but  iflbe 
iuipeiliuH'iit  huH  been  of  a  lung  iluratiMU.  (he  tiaiiues  become  thickdtnl 
anil  the  limb  remains  hard,  indurated,  and  somewhat  enIarg«<L 

The  re.sultti  of  obstruction  in  arteries  will  be  considered  •!  tti« 
end  of  this  cha|)ter.  It  is  in  tissues  with  "terminal  "  arttriwtlul 
the  interference  is  most  marked,  and  here  heuiiirrh!i)ri<-  infanliiiu. 
tvhich  so  often  results  from  embolism,  may  occur,  nlth<Mij;b.  oiitf 
t«i  the  more  gradual  obstruction  of  the  <Mrciil!ition.  it  i.s  Ie-*s  likfh 
to  do  .Ml  (.•'ee  iielinv). 

8.  Embolism. — Tortious  of  the  thrombus  may  be  corrii'd  »to 
by  the  circiilatinn.  thus  coiistitutinf;  enilxdism.  This,  which  i«  Ik* 
most  important  result  of  throndnisis.  will  be  considered  ui  tl>f 
following  section. 

EMBOLISM. 
Embolism  is  the  impaction  of  solid  substances  circulating  iu  tk* 
blood   in  vessels  which    are  too  stnall  to  allow  tiiem   t<i   pa».    Tbf 
Flo.  68.  soliil  substance-s  are  termed  emboli,  and  art- of 

very  voried  nature. 

By  far  the  most  frequent  Bources  «>f  erol-'l' 
are  thrombi,  jiortions  of  which  ore  carried  ffw 
the  seat  of  their  formation  by  the  circulali<ii»- 
Many  other  subettknces,  however,  may  ut 
emboli,  .\montr  these  are — (1^  vefretatioii' 
ciilcareous  or  atheromatous  ma«^»eii  sepanttiii  fi 
the  valves  of  the  heart  or  from  the  innrr 
face  of  arteries:  ('!)  portions  of  new  pr^i 
as  .sarcomata — which,  having  perforate*!  i 
...  .,  ,  ..  sels,  have  been  carried  awav  bv  the  ciimeirt :  ("l 
••i>h<-iii>u>  vrin. iihow.  parai<ites  which  have  made  their  war  into 
rru.l;rr:;:.^l  int-Hor  of  vesseU:  (4)  liui.l  n.t  wh^ch  h» 
iiinimiiiiK  Into  (III- mil     caped  from  the  fat-cells  and  entered  open  \\ 

•  ■ml   vi-««'l     .«.  uphv-        ,       ,  .         , 

pbatics — an  occasional    occurrence    tu 
and  contusions:  antl  {'A  f>ipnient-jrri»nnle4. 
.\  thrombus  may  produce  embidi   iu   va 
ways :  (1)  It  may  soften  and  break   dowii. 
its   fragments  be  distributed  by   the  bl 


nttu*  v<-ln .  T.  throm- 
hiu  ''.  I'onlriil  <''■•! 
prajortlnff  Into  f«-iii<>r.«) 
%*'ln.  At  r,  f,  iip|M.»i!*- 
Ihip  valvt«,  thn  Uinini- 
Im*  l»  •(>(Um<Hl.  (Vlr- 


EMBOLISM. 


255 


Fig.  99. 


rtions  of  a  parietal  thrombus,  not  filling  the  vessel,  may 
by  the  passing  stream.  But,  on  the  whole,  the  most  fre- 
;  (3)  that  illustrated  by  the  accompanying  diagram.  A 
tally  ceases  at  the  junction  of  the  vessel  containing  it  with 
e  collateral  branch.  The  cardiac  end  of  the  clot,  how- 
.xtends  as  a  firm  conical  projection  into  the  lumen  of 
i"ig.  98,  C),  and  the  strength  of  the  blood-current,  which 
factor  in  preventing  the  further  extension  of  the  clot 
heart,  may  break  off  this  projecting  end  and  sweep  it 
eral  circulation.  Some  sudden  movement  or  exertion 
lines  in  these  cases  the  separation  of  the  fragment 
brm  the  embolus.  The  veins  are  the  commonest  seat 
s,  and  venous  thrombi  are  common  sources  of  embo- 
ins  of  the  low^er  extremities  and  the 
s  being  the  most  frequent  sites.  Em- 
cardiac  thrombi,  whether  attached  to 

projecting  from  the  valves,  is  also 
common,  and  is  produced  in  a  similar 
3  frequently  arterial  thrombi  give  rise 
•esult. 

come  arrested  in  the  first  vessels  they 
are  too  small  to  allow  them  to  pass, 
refore,  the  seat  of  impaction  will  be 
lation  of  the  vessel  or  at  some  point 
the  giving  off  of  large  branches,  the 
lishes  suddenly  (Fig.  99).  The  par- 
!  so  small  as  to  pass  through  even  the 
ries,  and  not  give  rise  to  any  symp- 
Y  may  pass  through  large  cajjillaries, 
i  in  a  finer  set  beyond ;  but,  as  a  rule, 
lacted  either  in  the  first  set  of  capil- 
;h  they  come  or  in  some  larger  ves-sel 
set  and  their  seat  of  origin.  Thus,  emboli  originating 
lie  veins  or  in  the  right  cardiac  cavities  will  most  com- 
e  arrested  in  the  ves.sels  of  the  lungs.  Emboli  origi- 
e  pulmonary  veins,   the  left  cardiac  cavities,  or  the 

be  similarly  impacted  in  the  systemic  arteries  and 
•specially  in  those  of  the  spleen,  kidneys,  and  brain, 
oli  originating  in  the  portal  venous  system  will  block 
he  portal  vein  in  tlie  liver.     With  the  exception,  there- 


/ 

Embolus  Impac-ted 
at  the  bifurcation  of 
a  branch  of  the  pul- 
monary artery,  sbow- 
inK  the  formation  of 
thrnmbl  behind  and 
in  front  of  it,  and  the 
extension  of  these  as 
far  as  the  entrance 
of  the  next  collateral 
vessels :  E,  embolus ; 
tX.  secondary  throm- 
bi.   (Virchow.) 


25ii 


DlSfAHES  OF  rUE  BLOOD. 


fore,  of  emboli  oripiiiiitiiig  in  the  portal  .syHteai  tbe  »e«t  of  arrK  u 
the  artc^ie^<  or  cii|iillarieK. 

Eiuholi  are  carried  usually  in  the  direction  of  tbe  main  curmi; 
hence  tlidse  <-nrrie(l  hy  the  iiortic  xtreani  pas(«  int'>  the  thoracinotu 
more  commonly  than  into  the  carotid  or  subclavian  v(«iM>b,  uil 
into  the  left  carotid  or  left  renal  artery  more  often  than  into  lb* 
corresponding  artery  of  the  op|K>»ite  »ide.  (iravitation  bU»  inRii- 
ences  the  direction  in  which  they  are  carried,  cspecinlly  \\wym  «f 
large  e\7.c.  which  move  somevNhat  luore  slowly  than  the  blu«4- 
8tream ;  hence  they  are  more  common  in  the  lower  VAtr*  auJ  po^ 
terior  parts  of  the  lungs  than  in  the  superior  and  anterior  iMirtiow 
of  these  organs  (p.  268). 

It  is  not  uncommon  to  find  that  the  small  vcsselo  nf  an  area  <^ 
which  the  supplying  artery  is  plugged  also  contnin  enihuli.  Tli" 
may  be  accounted  for  in  two  ways:  Firttl,  if,  a*  i.«  fro^nrtdh  i^ 
case,  the  mrrcst  takes  place  at  a  point  of  bifurcation,  the  ruMt 
may  partially  fill  both  bninches.  allowing  ii  small  stream  "I  ' 
pass;  this  imiy  iireak  oft'  portions  of  it,  and  so  produce  m  :.. 
emboli,  which  become  impacted  in  tbe  smaller  divisions  of  tlf'W* 
main  trunks.  The  »eeond  mode  is  by  the  detachment  of  wTffw 
small  emboli  from  some  distant  source,  which  subscifucntir  yifltb* 
mash  large  i>nougli  to  stick  in  the  main  trunk.  It  r-.  founil  ijpt**" 
mentally  that  small  bodies  injected  at  intervals  into  the  jnj;uItr<M> 
are  sometimes  swept  into  the  same  division  of  the  pulmonai 

The  amount  of  obstrtiction  which  immediately  follows  k  • 
will  de|ieiiil  u|>on  the  naturf  of  the  embolus  as  well  a«  upnn  itttf* 
and  shape.  If  the  embolus  be  from  a  soft,  recently-formed  ill'*' 
bus.  it  will  be  at  once  moulded  to  the  cavity  of  tbe  veMrl,  »k** 
will  thus  be  immediately  and  com|>letely  plugged.  If,  on  thr  i>^*^ 
band,  it  is  irregular  in  shape  and  firm  in  consistence,  as  whelfH 
rivetl  from  a  calcified  cardiac  vegetation,  it  may  not  complelel^^ 
the  vessel,  hut  allow-  a  snuill  current  <if  blood  to  pass  it. 

The  arrest  4)f  the  embolus,  and  tbe  conseiiuent  obstruction  tot^ 
circulation,  are  followed  by  the  formation  of  secondary  throiri* 
behind  and  in  fmnt  of  it,  which  extend  ».><  far  :is  ihc  juncimn  ofiW 
first  large  collateral  vessels  (Fig.  98).  If  the  emhtdus  dcie«  not  ttnr 
plelcly  (ill  the  vessel,  thrombosis  leads  to  the  dc|M>sit  of  Kucvcanvt 
layers  u|sjn  its  surface  until  the  occlusion  of  the  veftsrl  is  o«>iap]ct(« 
and  then  the  secondary  tbrombos  vxtends,  as  in  the  ffirmrr  a 
until  it  meets  with  a  current  of  blood  strong  enough  to  anreat  il 


EMBOLISM.  257 

progress.  If  the  embolas  is  a  portion  of  a  soft  thrombus,  it  will  in 
most  cases  be  impossible  to  distinguish  it  from  the  secondary  throm- 
>a£  which  surrounds  it.  If,  however,  it  is  a  calcareous  mass  or  a 
>OTtion  of  an  old  thrombus,  it  may  usually  be  distinguished  from  the 
aore  recent  secondary  coagulum. 

Emboli  may,  in  rare  cases,  become  absorbed.  They  may  also, 
rhen  derived  from  thrombi,  soften  or  become  organized.  The 
hsnges  in  the  secondary  thrombi  are  similar  to  those  already  de- 
cribed  as  occurring  in  the  primary  (p.  247). 

XESULTS. — The  results  of  embolism  are — (1)  those  depending 
ipon  obstruction  to  the  circulation,  and  (2)  those  produced  by  the 
irritation  of  the  emboli. 

Trom  the  facts  disclosed  in  the  preceding  paragraphs  it  may  now 

be  inferred  that  embolism  of  either  the  pulmonary  or  the  systemic 

veins  is  practically  a  mechanical  impossibility ;  but  that  in  any  of 

the  remaining  vessels — arteries,  capillaries,  and   portal   vein — we 

may  expect  its  occurrence.     As  embolism  of  the  arteries  is  followed 

by  very  different  results  to  that  of  the  capillaries,  the  two  conditions 

must  be  considered  separately.     For  our  present  purpose  the  portal 

Tein  will  be  grouped  with  the  arteries,  from  which  it  differs  mainly 

in  its  lower  blood-pressure. 

Abtbbial  Embousm. 

1.  OBSTRUCTION  TO  THE  CIRCULATION.— The  results  to 
tile  circulation  depend  chiefly  on  the  extent  of  the  arterial  anasto- 
moses in  the  affected  part. 

Sudden  and  complete  obstruction  of  some  arteries,  such  as  the 
™ial  or  a  second  or  third  branch  of  the  mesenteric,  is  practically 
without  effect  upon  the  circulation,  which  is  carried  on  through  the 
■"ge  vessels  which  anastomose  with  those  branches  of  the  obstructed 
"'siy  which  are  given  off  below  the  seat  of  the  obstruction.  Yet 
''pture  of  the  common  carotid  is  occasionally  followed  by  cerebral 
•onening,  easy  though  it  would  seem,  when  only  one  of  the  arteries 
'applying  the  circle  of  Willis  is  blocked,  for  the  cerebral  circulation 
^  '^  efficiently  maintained. 

">  other  cases  there  is  some,  perhaps  even  very  great,  difliculty  in 

•fleeting  the  re-establishment  of  the  circulation.     This  is  owing 

*'tiier  to  the  small  number  and  size  of  the  vessels  anastomosing  with 

"'e  bruiches  of  the  obstructed  vessel,  or  to  some  disease  of  these 

17 


258 


DISEASES  OF  THE  BLOOD. 


vessels  interfering  witii  their  normal  power  of  ililntation.  Ihilip' 
ture  of  the  fenionil  artery  the  limb  becomes  pale  ttn<l  it*  «orf»f»- 
temperature  falls  many  ilegree.s.  In  this  condition  it  remain'  w^rnl 
faoDrK;  then,  if  all  goes  well,  the  superficial  vctioelM  dilnto.  thccirr*- 
lation  through  them  proceeds  with  undue  rft|iidit_v.  and  thi'  «.iirfK<i«- 
t«'niperature  rise.s  some  ilegrees  higher  than  that  of  its  fell'>«.  Thii 
reaction  gra<lually  disappears,  and  ultimately  the  part  may  rrnnii 
abnormally  cool. 

On  the  other  hand,  the  part  deprived  of  its  blood-supply  nuTJit 
en  vuttmif.  Between  the  two  extremes  of  recovery  and  death  tliew 
are  many  possibilities — from  death  of  a  single  too  upward.  Tbf 
part  which  ultimately  dies  may  remain  pnic  and  bloodlcsv,  U'l 
gradually  mummify,  but  usually  it  becomes  more  or  htm  »mtlleii 
with  blood  driven  into  it  by  a  pressure  insufficient  to  send  the  lilwJ 
right  on  through  the  veins:  fluid  ami  cells  jiass  into  the  ti»i«». 
organisms  thrive  and  invade  the  part,  and  moist  gangrene  result*- 
Similarly,  embolism  of  an  ultimate  branch  of  the  roesenteric,  vitk 
secondary  thrombosis  obstructing  the  vessels  on  either  wdc,  «iU 
lead  to  a  partial  necrosis  of  a  small  segment  of  bowel  and  be^lo^ 
rhage  into  its  lumen  (vide  infra\  probably  ending  in  recovrry: 
but  embolism  of  the  main  trunk  of  the  vessel  caufleit  gaiigrenr  o< 
the  whole  intestine. 

Infarction. — This  seems  the  best  place  to  discuss  infaretinH, » 
process  often  produced  by  embolism,  but  not  infreijuenlly  dae  "' 
other  causes.  In  some  organs,  such  as  the  spleen  and  kiduey,  tk' 
arteries  have  capillary,  but  no  arterial,  anastomoses  with  the  nfij^ 
boring  vessels.  Such  arteries  are  called  end  or  terminal  art*ri<* 
Each  of  these  arteries  supplies  a  conical  compartment  of  ih'  ■""'' 
in  ijuestion.  The  base  of  the  cone  is  r)u  the  surface  of  ih.  .  _ 
while  its  apex  points  toward  the  centre,  and  corrcsjionds  to ' 
jioint  of  entrance  and  exit  of  the  artery  and  vein  rfsjKH-li» 
The  possible  lueans  of  access  which  the  blood  has  to  such  a  por 
of  tissue  are — (1)  the  main  artery  and  vein  just  mentioned,  (2) 
small  vessels  ])assing  from  the  capsule  into  the  cortical  part  uf 
organ,  anti  (8)  the  capillary  anastomoses  with  the  neighboring^ 
sels  on  each  side. 

If  by  means  of  embolism  or  thrombosis  the  main  artery  suppl] 
«>ne  of  these  conical  segments  of  tissue  becomes  blockitl.  nc 
and  other  degenerative  changes  will  occur  in  it.  for  the  cmp 
vemeU  and  the  lateral  anastomoses  together  are  nnable  to  ma 


EMBOLISM.  259 

nutrition  of  the  part.  As  seen  post-mortem  these  cones— or, 
hey  are  then  called,  infarcts — when  cut  from  base  to  apex  have 
ery  typical  triangular  section  (Fig.  101).  Two  varieties  are 
cribed :  (1)  the  white  or  ansBinic  infarct,  and  (2)  the  red  or 
norrhaeric  infarct.  A  white  infarct  is  pale  yellow,  and  has  its 
e  level  with  or  depressed  a  little  beneath  the  rest  of  the  surface 
the  organ.  A  red  infarct  is  blackish  red,  and  has  a  slightly 
»ed  base.  Recent  infarcts  of  both  kinds  are  surrounded  by  a 
peraemic  zone.  Red  infarcts  are  common  in  the  lungs,  spleen, 
i  kidney,  and  are  occasionally  found  in  the  intestine.  White 
arcts,  when  primary,  are  found  in  the  brain,  retina,  and  the  mus- 
ar  walls  of  the  heart. 

Microscopic  examination  of  a  tohite  infarct  will  reveal  coagula- 
n-necrosis  and  fatty  degeneration  of  its  tissue-elements.  Some- 
les  transudation  from  surrounding  parts  supplies  sufficient  nour- 
ment  to  keep  alive  the  connective-tissue  stroma;  the  nuclei  then 
in  with  logwood  (Fig.  101). 

In  the  red  infarct  the  tissue  is  so  crammed  with  blood-corpuscles 
It  the  degenerative  changes  are  often  obscured. 
Some  white  infarcts  contain  granules  and  crystals  of  altered  blood- 
ment.  These  are  considered  to  be  a  later  stage  of  red  infarction 
which  the  rest  of  the  hemorrhagic  extravasation  has  disappeared. 
It  is  very  important  to  remember  that  all  tissues  do  not  equally 
ist  the  effects  of  anaemia :  those  of  the  skin  and  muscle  are  most 
'stant ;  those  of  the  brain  and  intestine  least.  A  piece  of  strangu- 
ed  gut  dies  more  rapidly  than  a  tied-off  ear.  This  power  of 
■stance  is  not  the  same  in  all  individuals, 
i/essation  of  function  soon  follows  cessation  of  nutrition.  The 
«tg  of  this  may  be  extremely  serious :  thus,  plugging  of  one  of 

larger  cerebral  arteries  is  generally  followed  by  sudden  loss  of 
isciousness  and  paralysis ;  plugging  of  the  pulmonary  artery,  by 
den  asphyxia ;  and  plugging  of  one  of  the  coronary  arteries,  by 
den  paralysis  of  the  heart. 

"athology  of  Infkrction. — Very  different  explanations  have  been 
red  of  the  exact  manner  in  which  infarcts  are  produced. 
Arguing  from  the  above  data,  Cohnheim  offered  the  following 
lanation.  In  his  opinion,  the  first  effect  of  the  plugging  of  a 
ninal  artery  is  the  stoppage  of  the  blood  passing  through  it ;  the 
rides  contract  and  empty  them.selves,  but,  being  deprived  of 
r  blood-supply,  they  subsequently  dilate,  and  the  pressure  in 


860 


DISEASES  OF  THE  BLOOD. 


Fio.  100. 


thctn  is  fluis  reduced  to  nil.     Venous  pressure,  though  low.  if'n 
exco.ss  of  this,  and  so  Idood  regurjiitatt's  froni  tlie  veins  to  fill  0 
cajiiliaries  ami  lU'tfriole.s  on  tlu'  jieri])lii'rul  side  of  the  plug,  «sid 
be  seen  with  the  microscope  in  the  tongue  of  a  frog  one  of  whi 
linj^iud  iii'ti'rifs  has  heen  tied.      The  arteries   rouiiil  about  the  »r' 
dilate  and  their  capillaries  become  full  of  blooil :  but  even  «iililk** 
assistance  the  blood-pressure  in  these  circumferential  capilluriH 
still   insufficient   to  force  the  blood  through   more  than  a  few  of  t 
outlying  capillaries  of  the  ob.structed  area.     Consequently  such 
area  will  be  dark  from  the  presence  of  stagnant  venous  blowl.  \^  w 
surrounded  by  a  ring  of  arterial  redness.     Later  on.  the  csca|>t 
red  corpuscles  itito  the  tissues  will  darken  the  mass  still  furthi 
This   occurs   without   any    rujtture   of  vessels,  just   as   happcn-t 
venous  congestion  (p.  231).     Finally,  secondary  thrombosis  of  t 
vein  and  other  vessels  is  said  to  occur  in  the  area  (F'ig.  I'M'). 

The  changes  which    usually  result   from    deprivatinn  of  an*f 
blood  were  studied  experimentally  by  Cohnheim.     If  the  e«r  o 

rabbit  be  cmj)tied  of  blood,  ligatiireilut 
root  for  eight  to  ten  hours,  and  the  W' 
be  then  allowed  to  circulate,  the  org»ii 
comes  exceedingly  red,  swollen,  ami  n'J*^ 
niatous.     When  examined  microsropiral'J 
the  ves.sels   are   found   to    be  dilati^l,  »«" 
numerous  white  blood-corpuscles  arc 
to  have  escaped  from    them   into  the  J" 
rounding  tissue.     The  longer  the  pf 
deprived  of   blood,  the  more  abnn<l»nt 
the  subsei|uciit  infiltration  with  leucocyt 
and  when  the  obstruction  has  lasted  I**"', 
four    hours    small    extravasations  of 
cor[)usclcs  also  occur.      If  the  ligatiiri" 
«!nii.iiiii»  1.);  r.  vi-in  Hiif.i  with    main  cin  for  forty-eight  hours,  the  earJi' 
m.tn.  ..f  lufnrr.  «i,i,..,  (,  la-    t  <dnilieim  Concluded  that  when  blood-T^ 
.•umiiiK  rtisiiii.-vniii'') ;   -'.  •rca    gpja  with  their  vasa  va.soruni  are  depf 
tatc-rai  byix-mmu.   «*.  wobtT.)    of  errculatmg  blood  for  a  sufficient 

of  time  they  lose  their  power  of  retaJ"' 
the  blood,  and  allow  first  the  liipior  sanguinis  ami  leucoeytc* 
subseipientlv  red  corpuscles,  to  csca[ie  from  them,  the  esea[ie  t."»k' 
place  only  through  the  capillaries  and  venules.      The  whide  pp"^" 
can  be  watched  in  the  tongue  of  a  frog  to  the  base  of  which  a  I' 


k: 


ton-l :  »i.  urtery  oMiliTiiU'il  hy  itn 


EMBOLISM. 


261 


ture  hsti  been  applied.  For  the  walls  of  bloo«l-ves8cl«  to  be  thus 
altorcil.  interference  with  the  eirciilation  must  be  verv  eoiiiplete,  :i 
very  little  VHScnbir  supply  serving  to  prevent  the  above  phenuineua. 
Still,  it  is  a  wide-reaching  fact,  wliicb  must  always  be  borne  iu 
minii  that  imperfect  nutrition,  however  slight,  is  a  step  toward 
<l«ith,  and  must  render  tissues  less  resistant  to  injury.  These 
obMrvatiims  explain  all  the  changes,  from  wdema  to  moist  gan- 
grene, given  above,  which  may  follow  ligature  of  the  main  artery 
of  a  limit. 

dilinheim  thought  that  when  iiiilioli  binekcd  terminal  arteries  the 
Kttilt  was  almost  always  hemorrhagic  infarction.  In  his  opinion, 
eicejitiiins  to  this  rule  were  due  either  tti  the  veins  of  the  part 
b«iii(j  vulved  or  thrombosed,  so  that  regurgitation  was  prevented,  or 
to  tlie  part  being  so  placed  that  gravity  strongly  favored  the  return 
of  blood  by  the  veins.  In  the»e  cases  the  area  remained  [)ale  and 
bWless.  He  considered  that  stmio  fipparcnt  exceptions  were  owing 
to  tbu  existence  of  fine  arterial  anastomoses  with  certain  arteries,  of 
»liich  the  greivt  majority  were  ri'tiflt/  terminal.  Tlina  anastomoses 
of  tile  bronchial  artery  with  the  pulmonary  might  sometimes  ward 
off  infiirction  in  the  lung,  and  the  presence  of  branches  of  the 
hepatic  artery  might  similarly  prevent  infarction  of  the  liver  re- 
«altiii;i  from  embolism  of  a  branch  of  the  portal  vein.  One  reason, 
Kconling  to  (.'ulinlieim,  why  infarcts  are  so  much  commoner  on  the 
Mrfac«  than  in  the  substance  of  an  organ  is.  that  in  the  former 
situation  the  whole  base  is  almost  absolutely  cut  off  from  collateral 
«"pply. 

bitten  disputes  the  truth  of  Oohnheim's  explanation  of  the  whole 
prooesjt  of  infarction.  He  shows  that  the  infarction  of  the  kidney 
*liich  fiillous  ligature  of  the  renal  artery  cannot  be  due  to  regurgi- 
•»titm  from  the  renal  vein,  as  it  is  most  intense  when  the  renal  vein 
"  iticlf  simultaneously  ligatured.  Under  these  conditions  the 
kidney  s\v<dls,  becoming  first  congested  and  then  infarcteil.  The 
wnj^tion  begins  in  the  subcapsular  /.one  of  the  cortex  and  at  the 
''Mwof  the  pyramids  nearest  the  attachment  of  the  pelvis.  This 
<»tig(>sti(>n  is  due  tn  the  continued  supply  of  the  organ  by  small 
Woriesinow  much  ililated)  which  spring  from  the  liunbar,  supra- 
■*"«!,  and  phrenic,  and  pierce  the  capsule,  as  well  as  by  others 
'luch  spring  from  the  spermatic  and  run  up  along  the  ureter.  If 
"•* renal  vein  is  left  open,  the  kidney  swells  more  slowly,  because 
*tii6  t)f  the  blood  entering  from  these  arteries  can  then  escape  by 


262 


bISKASkS  OF  THE  BLOOD. 


the  vein;  the  venous  stream  is  therefore  away  from,  not  tonard,' 
kidney.     But  the  coni[>lrti«m  of  tlie  proof  that  ih»'  infarctiou  isi 
to  HU|i|tly  throii^rli  tliest;  nrtfriox.  uiitl  not  lo  vt'iioiis  rt'tliix,  is  i 
hy  an  experiment  which  shows  that  when  theMc  are  detached  iuG 
tion  ihies  not  oeciir.      Oin-  kidney  is  fhelli-d  out  of  its  hi-ti  of  6? 
and  its  artery  is  tints  rendered  pfally  termimil.     The  rrtiwl  urtpnw 
CD  both  sides  are  then  tied,  while  the  veins  on  (>otb  sidcsi  arr  Irft 
patent.      The  "shelled"   Icidncy  now   hcconit-s  slightly  rong 
but,  as  a  rule,  no  vi-nmis  refriirj;itatioii  occurs;  the  organ  remt 
lighter  and  sninlier  tlian  its  fellow,  and  docs  not  beeoiae  engui] 
with  extravasated  corpuscles.      In  the  opp<}»ite  kidney  typical  i 
farction  occurs.      It  would  seem,  therefore,  that  in  many  ca.-*!-*.  «i 
the  H)uin  artery  and   its  small   collutenils  are  tied,  the  prc«tar«J 
the  renal  vein   is  not  snfficient  to  overcome  the  resistauw  in 
capillaries  and  to  distend  them  with  venous  bloo<l :  much  Icj*!'  wo 
it  be  able  to  do  so  when   the  capsular  arteries  ore  piiaipiuj 
into  the  cortex,  and    thus  increasing    the   intracapsular 
If  by  coughing  or  vomiting  the  pressure  in  the  renal  vein  i»' 
infarction  is  more  likely  to  occur,  and  it  is  iiroibiced  in  ii«  i 


Fio.  101. 


■*•»**" 


iv^lJfV^Ji^^ 


'V 


;'/-A      »     ,^- 


■MM 

AInvr,  •«!  Ihi-  lefl,  H  •  rvprtwnlnilmi  ituliiml  •Iwi  nf  n  M-rtlnn  tlirouch  •  .. 
of  the  kliliH'y  Um  rtrrlr  innrka  fiiiKhly  tlif  i«n  miiiriiltli'd  iiml  ilnn  ii  (m  Ih*  «u 
IK>lnU  to  bmllhy  kMiirjr ;  nm,  u(a  miniiul  Mnll'ln'ilnn  tnfl :  r.  to  Hii  »t<  ■  it 

Arv  rininiiirit  viUh  r»*<l  n*»n»»t"*'l''*  ""**  th**  Omih-*  on*  uuiri-  ur  lr»%  •'■  ■  •m 

kl<lD*T  •iitnUiii*  «iiU  ■  MnlplKhUii  lurt  whiob  urv  Um  <lcKiiiii<nlx  |«  >kiiii>     .  »vil.> 

form  by  clamping  the  vena  cava  inferior  above  the  entry  of  thr  i 
vein.     These  observations  were  extended  with  similar  results  I9| 
spleen  and  lung.     Since  then  amemic  infarcts  in  tb«*  sple<»o 


EMBOLISM. 


263 


Imu  foimd  associated  with  thrombosis  of  the  splenic  veins  without 
miv  iibstnictioii  in  the  artery. 

lu  the  great  majority  of  cases,  wlieii  a  truly  "terminal  "  artery 
isblocke*!.  mj  infnrction  occurs.  The  area  formerly  supplied  by  it 
remains  pale  and  miieniic,  ami  microscopic  examination  reveals  no 
trace  of  red  corpuscles.  This*  is  seen  in  cases  of  euiboliism  of  the 
cerebral  arteries  (while  softening)  and  of  the  central  artery  of  the 
retina. 

When  iin  artery  of  some  part  (c  ij.  limb)  in  which  the  veins  are 
vabwl  liecomes  blocked,  no  reflux  can  occur,  but  infarction  may. 
Such  infarction  is  rare,  because  these  parts  generally  have  a  rich 
»rt*ri»]  supply  sufficient  to  carry  (ui  the  circulation  ;  it  is  most 
likely  to  follow   blocking  of  the  iiiniii  artery  (p.  i.'iS). 

Litton  agrees  with  Cohnheim  that  the  red  corpuscles  escape  by 
iliapedesis,  but  considers  that  this  i.><  due  to  the  distention  of  the 
cspillaries  and  small  veins  by  the  mechanical  congestion.  It  almost 
immediately  follows  the  application  of  the  ligature,  before  ansemia 
lin-H  hail  titne  to  effect  any  niarkeil  change  in  the  vessel-walls :  and 
"idecd,  if  a  ligature  be  placed  on  the  artery  of  a  "shelled"  kidney 

Fio.  102. 


Il<i  ktdnt'S'  ifrnni  *  cue  of  ancnryim  of  the  ftbdomiiml  uurtji:  muiiy  sunall  ypllow- 
rwchra  wen*  •••■ItertKl  tlirouBh  ttio  I'nrtlci'n  of  the  orKitu*).    B'si-ntlul  roll*  thttlly 
^^"oriAmcd.  conncctivo-Usauc  cell*  «tin  c-iiiMitili'  nf  BtnliiiiiK.    x  3X1. 

*<"*  retnove<J  after  four  hoiirn,  no  fresh  blood  enters  and  no  escape 

«  <:'>rpus<des  occurs. 

"  »ould  seem  that  the  true  reason  why  red  infarcts  are  found  so 
'f(i<|uently  on  the  surfaces  of  the  organs  in  which  they  occur  is  not 
wit  the  base  is  almost  entirely  cut  off  from  its  blood-supply,  but 


DfSEASES  OF  THE  BLOOD. 

that  there  the  sroall  capsular  arteries  enter,  nnd  that  throuf^fa  thm 
blood  is  still  driven   into  the  area. 

Litten's  experiments  are  conelimive  .•»o  far  as  the  kidiicv  u  a* 
cerned.  Cohnheim's  ret/unfitalion  theory  probably  holds  {;ikh|  bt 
a  few  cases,  and  in  its  favor  it  must  be  reiiienilien*d  that  in  (lit 
majority  of  cases  in  which  simple  embolisms  from  rnrdinr  riltn 
occur  there  is  "  back-telling"  (p.  84)  upon  the  lun>rs  and  rrno«i 
pressure  is   abnormally  high.     Nor  should  it  be   forjfotten   '' 

resistance  oftcred  to  regurgitation  from  the  veins  by  the  cu) 

of  the  tongue  or  ear  is   probably  much   less  than    that   offereti  b_T 
those  of  the  firm  kidney  within  its  elastic  capsule. 

IRRITANT  EFFECTS  OF  AN  EMBOLUS.— .\  simpla  anbo- 
has,  such  as  a  bit  of  non-infected  fibrin  or  a  fragment  of  •  csin- 
reous  plate,  causes  slight  irritation  of  the  vessel  where  if  ' 
Such  an  embolus,  with  its  secondary  thrombi,  will  iisn ' 
absorbed  or  become  organized.  This  irritation  may  oecawioiuJI.* 
cause  so  much  inflammatory  softening  of  the  vessel-wall  tb>i  '* 
yields  before  the  blood-pressure,  and  an  aneurj-sm  results.  (S«« 
"Arteries.")  This  is  now  held  to  be  the  pathology  of  nm* 
aneurysms  occurring  in  people  too  young  to  be  suffering  fro* 
atheroma  or  acquired  syphilis;  and,  as  the  emboli  are  nsually  ♦!!»»*' 
or  of  moderate  size,  dilatations  from  embolism  affect  <'H|K><"iall*  ••*• 
cerebral  arteries  and  the  smaller  arteries  of  the  limbs,  from  the  M** 
of  tlic  briichial  downward. 

An  infective  embolus  is  one  which  has  brought  with  it  from  ■' 
source  organisms  capable  of  growing  within  the  body — at  all  evn» 
in  the  dead  or  gn-iitly  depressed  tissues  of  an  infarct — and  wh» 
thus  gives  rise  to  bacterial  changes  at  the  point  where  it  is  a: 
The  result  depends  upon  the  intensity  of  the  irritation  whick  ft 
particular  bacteria  can  excite:  in  cases  of  rheumatism  they  o(k 
seem  to  render  the  embolus  but  little  more  irritant  than  ainf 
fibrin:  but  in  pyicmia  the  micrococci  cause  secondary  suppontk^ 
(See  ••  PysBmia.") 

LATER  CHANGES  IN  EMBOLISM.— These  depend  npon 
two  considerations  Just  discussed:  (1)  the  extent  to  wliidi  tlte 
culatiou  is  intcrfere<l  with,  and  (2)  the  amount  of  irritation 
by   the  euibdlus. 

1.  Small  Infarcts.  —  In  the   case  of  tinall  red  infarctt,  if 


EMBOLISM.  265 

embolus  is  free  from  organisms  the  coagulated  blood  gradually  loses 
color,  becoming  brown  or  yellow,  and  absorption  proceeds  slowly. 
lo  the  case  of  amaU  anaemic  infarctg  the  tissue-changes  are  more 
clearly  seen  than  in  the  red  infarcts,  where  they  are  obscured  by 
the  extravasated  blood.  In  these  white  infarcts  lymph  reaches  the 
part  by  transudation  from  parts  around,  the  cells  swell,  lose  their 
nnclei.  and  blend — in  fact,  undergo  coagulation-necrosis  (p.  39), 
and  thus  form  the  well-known  white  wedges.  The  more  external 
portions  of  this  mass  of  coagulated  blood  and  necrosed  tissue 
become  infiltrated  with  leucocytes.  In  this  area  fibrous  tissue  sub- 
sequently develops ;  this  contracts,  and  ultimately  a  depressed  scar 
may  be  all  that  remains  to  indicate  the  change.  For  some  time, 
whilst  these  secondary  changes  are  taking  place  in  the  infarct,  its 
most  external  portions  are  surrounded  by  a  red  zone  of  hyperaemic 
tissue.    This  is  exceedingly  characteristic. 

2.  Large  Infarcts. — In  the  case  of  a  large  infarct  the  central 
portions  may  disintegrate  and  soften.  This  may  subsequently  dry 
up  and  leave  a  depressed  scar. 

3.  Infective  Softeninsr. — If  an  embolus  is  derived  from  a  part 
where  an  infective  inflammation  is  going  on,  it  sets  up  a  similar 
inflammatory  process,  both  in  the  vessel  within  which  it  becomes 
impacted  and  also  in  the  surrounding  tissues.     These  septic  inflam- 
matory changes  lead   to   the   formation   of  abscesses,  which   are 
known  as  embolic  or  metastatic  abscesses.     Microscopic  organ- 
wms  are  almost  invariably  found  in  these  abscesses,  and  it  is  to 
them  that  the  infective  properties  of  the  embolus  are  probably  due. 
No  more  suitable  nidus  for  their  development  can  well  be  imagined 
""in  a  tissue  in  which  infarction  and  necrosis  have  occurred,  and 
'hich  is  kept  moist  at  the  temperature  of  the  body.     Infarction  is 
lot  an  essential  antecedent  of  a  metastatic  abscess.     If  the  metab- 
olism of  the  tissue  in  which  the  embolus  lodges  does  not  destroy 
»e  organisms,  but  affords  them  suitable  pabulum,  inflammation  will 
«Mae.    This  subject  will  be  considered  further  in  the  chapter  on 
"Septicsemia  and  Pyaemia." 

4.  The  other  possible  results  of  embolism  have  been  referred  to 
«"  p.  258. 

Capillary  Emboli. 

yi'Me  generally  consist  of  fat,  masses  of  organisms,  clumps  of 
"••te  blood-corpuBcIes,   pigment-granules,   or  air.      In   fractures. 


2fi6 


DTSRASES  OF  THE  BLOOD. 


contusions  of  subcutaneous  tissue,  ruptures  of  fatt^  liter.  ««» 
osteomyelitis,  anil  otber  morbid  conditions  in  wbirb  fi»t-rell«  ir» 
broken  up  luid  the  fat  set  free  the  droplets  lire  nljsorbnl  bj  '►<» 
lymphatics  and  veins,  especially  when  pri'ssnre  in  the  |i«ri  » 
increased  by  inHanntiiitory  effusion  or  beinorrbiiffe.  t>n  ^ 
the  right  side  of  the  heart  they  are  carried  into  the  puii..  ..-. 
arterioles  and  capillaries,  where  their  presence  may  n»i\j  W 
demonstrated  by  staining  with  osuiic  acid  (Fig.  103).     t  ►ne  h«  oM 

Flo.  103. 


WtlM 


y»\  cmbotlani  nf  Iiiiik  ilViiiii  iMii  r<mi|iniiiiil  fmi'Hirc  ofli-n  atul  mitvM'  •ulx'iitiinf  "'  ■  '" 
tkml.  Till'  tilnck  iiiU!i!><-s  uri'  ilrKi"*  "f  •*".  "tiiliiol  wlili  mmlr  mltl,  lylnir  In  rufllliin"  *='' 
•tUTtiiln  i>r  nlvi'oliir  HnlU       ■  4"!.     iBi>y>I.) 

these  soft  and  easiiy-nioiilded   plii^rs  are  swept  on   to  tiie  left  m'"* 
of  the  heart,  and  di.stribiited  by  the  systemic  circulation  t"  nl'*'* 
off^ans,  in  which  also  they  may  be  very  numerous.     For  t  ti»* 
fresh  emboli  are  constantly  reachin)j  the  lun;:s.  but  when  thia  ««••* 
the  fat-masses  are  passed  on  to  other  orj»ans  and  elimiuate<L  tB  ^^ 
at  least,  through   the  kidneys.     This  fat-embolism  is  beiievfJ  'f 
some  to  be  the  cause  of  death  after  simple  fractures — a  renr  r^ 
event.     But.  as  large  i|uantities  of  fat  may  exist  in  the  lunps  »*•' 
other  organs  of  animals  without  causing  any  symptoms  what**'** 
some  skepticism  is  justifiable.     If  a  sufficiently  large  niimbentf  *" 
capillaries  of  the  lung  or  any  other  organ  be  blocked  by  &(. 
functiiin  will  of  coiii-se  be  interfered   with,  and  in  the  case  of  st 
organs  this   would   mean  speedy  death.     It   is  probable  that   *' 
lungs  always  coiitMiii,  proportionately,  many  more  emboli  thai 
organ  supplied  by  the  systemic  circulation.     It  has  been 
that  half  the  puhuonary  blood-path  may  be  obstructed  withootj 
turbiiig  the  circulation  at    large  (Cobnlieim).     We  most  th 
suppose  that,  as  a  rule,  the  passage  of  fat  on  to  the  systemic 
lation  keejts  the  number  of  plugged  capillaries  below  the  poi 


THROMBOSIS  AND  EMBOLISM  OF  THE  BRAIN.  267 

mger.  In  acute  osteomyelitis  it  is  probable  that  the  fat-drops 
ay  serve  as  carriers  of  pyogenic  cocci  from  the  seat  of  inflamma- 
Dn,  and  cause  their  impaction  in  vessels  which  they  would  other- 
ise  pass  through  freely. 

Clumps  of  leucocytes  form  emboli,  and  therefore  petechise,  in 
iptic  fevers  (Huter).  Air  entering  the  veins  may  give  rise  to 
nbolism.  Here,  as  in  fat-embolism,  the  air-plugs  have  little 
Feet:  to  cause  death,  air  must  be  injected  so  quickly  and  in  such 
laDtity  that  the  blood  in  the  right  heart  is  churned  into  foam, 
pon  which  the  viscus  fruitlessly  contracts.  Pigment-granules, 
robably  parasitic  in  origin,  have  caused  capillary  embolism  in 
alaria.    (See  "  Malaria.") 

Thrombosis  and  Embousm  of  the  Brain. 
Thrombosis    and    embolism    are   the   most   common    causes   of 
irebral  softeninfirs. 

Softening  frova  Thrombosis. — This  is  commonly  the  result  of 
heromatous,  calcareous,  or  syphilitic  changes  in  the  cerebral 
■teriee.  Such  changes  favor  the  occurrence  of  thrombosis,  caus- 
g  diminution  in  the  lumen  of  the  vessels,  roughening  of  their 
ternal  surface,  and  impairment  of  their  elasticity  and  contractil- 
'•  As  a  result  of  the  interference  with  the  supply  of  blood  the 
wbral  substance  undergoes  a  more  or  less  rapid  process  of 
wosis  (p.  76). 

Thrombosis  may  also  occur  in  the  cerebral  sinuseB  and  veiiis. 
irombosis  of  a  sinus  may  be  primary,  and  fall  under  the  heading 
narasmic  (p.  244),  or  it  may  be  secondary  either  to  (1)  disease 
some  adjacent  part,  such  as  of  the  bone  in  inflammation  of  the 
iddle  ear.  or  (2)  to  extension  of  a  thrombus  along  a  vein — as  in 
e  case  of  the  orbit — from  an  inflamed  part  to  the  sinus  into 
liich  it  opens.  The  result  is  great  distention  of  all  veins  opening 
•o  the  sinus,  oedema  of  the  area  whence  they  draw  their  blood, 
'Bote  hemorrhages,  especially  in  the  vascular  corte.x.  and  .soften- 
g  from  impaired  nutrition. 

Softening  from  Embolism. — The  .softening  resulting  from 
loolism  is,  for  the  most  part,  entirely  dependent  upon  the 
"triiction  to  the  circulation  caused  by  the  embolus  and  by  the 
'"Iting  thrombosis.  It  is  rapidly  induced,  and  is  often  attended 
!■  Ae  extrava.sation  of  blood  in  its  neighborhood,  when  it  consti- 
'tes  one  form  of  acute  red  softening  (p.  78).     If  the  interference 


268 


DISEASES  OF  THE  BLOODT 


with   the  circulation  be  slight  and  there  be  no  extravasa^ 
blood,  the  softened   portions  are  white  in  color  (p.  7rt).     Thfl 
most  IVeiiiiently  blocked   is  the  middle  cerebral  arterv,  and 
majority  of  cases  it  is  that  of  the  left  side.     In  altuoHt  all 
which  softening  of  the  cerebrnl  substance  re.«iilt.H  frnui  einl 
is  duo   to   arrest  of  the   embolus  in  one  of  the  ve»sel9 
circle  of  Willis,  because  here  the  circalation  cannot    b« 
rc!Stored   b_v   the   collatenil    vessels.      Softening,   however,  do 
necessarily  follow  the  blocking  of  a  cortical  artery,  for  coiim 
tion  between  these  branches  is  freer  than  is  often  supposed. 
Engorgement  of  the  area  beyond  an  obstruction    in  a  c 
artery  is  an  exceptional  occurrence,  but  it  is  sometime*  s" 
as  to  cause  rupture  of  a  large  artery  beyond  the  obstruction  aii4 
hemorrhage  some  days  after  the  embolism.     For  rrasons  just] 
this  is  ii  fjir  more  likely  occurrence  in  obstruction  cif  corticaU 
of  larger  or  basic  \essels.      When   interference  with   the  circu 
is  attended  by  vascular  engorgement  and  extravasation  of  bl< 
softened  portion,  in  tlie  early  stage,  is  either  of  a  uniform  d« 
color  or  presents  numerous  hemorrhagic  jsjints.     The  softefl 
most  marked  in  the  centre,  whilst  the  hy|>erR>mia  and  rcdh< 
extend  for  some  distance  around  it  (p.  7H).     The  surmundir 
laries  are  dilateil  and  filled  with  coagula.  and  granular  cor 
envelop  their  walls.      In  a  more  advanced  stage  all  trace  uf 
structure  is  lost:  the  softened  mass  becomes  decolorised,  aad| 
from  a  dark-red  color  to  a  chocolate,  brown,  yellow,  or  cv«i ' 
It  muv  iiiiuefv,  and  form   a  cyst  with  clear  contentj«  and  a 
wall.     More  commonly,   however,   it  is  gradually  absorbni,^ 
replaced  by  fibrous  tissue,  which  contracts;  and  ultimately  ai 
with  hienuitoidin  crystals,  may  be  all  that  remains. 


Inpakction  op  the  Luko.— Pulmonaby  Apof 
This  condition  is  sufficiently  distinctive  to  merit  sefuir 
sideration.  The  so-called  infarcts  of  the  lung  are  most  con 
met  with  in  cases  of  mitral  stenosis,  and  to  a  less  extent  in  til 
tnitral  regurgitation.  They  are  found  in  the  lower  lobes  anj] 
lower  iin<l  outer  parts  of  the  U|)per  lobes.  In  most  owe* 
irregidarly  conical,  but  occasionally  nearly  globular.  In  ili 
they  vary  from  a  fraction  of  an  inch  to  that  of  an  entir 
Illackish-red.  firm,  with  well-defined  margin,  often  iuulti|i 
occasionally  continent,   they    present    sujicrficial    rraembla 


INFARCriOy  OF 


•2(59 


Inoinrs  on  the  one  hand  and  to  lobular  iint-iniionia  on  the  other. 
Fnitji  the  former  they  are  distiri;j:iiisbed  by  tlit'ir  c()I<)r,  shape,  posi- 
tion, and  the  conditions  under  whicli  tliey  occur  ;  from  the  latter,  by 
their  nnmber,  .shape,  darker  color,  and  better-defined  limits.  They 
m' not  iufrei|iiently  the  .starting-points  of  a  hypostatic  pneumonia, 
•oil  iirr  then  ies.s  easily  reeogni/.e<l.  In  such  cases  the  mljucent 
portion  of  the  visceral  pleura  is  roughened  by  the  iuHummatory 
Mmlation  on  its  surface,  while  by  the  same  factor  in  the  suhstunce 
(if  the  organ  the  maasea  are  welded,  the  color  mottled,  and  the  edges 
»b«ciircd. 

Mode  of  Formation. — There  can  he  no  doubt  but  that  these 
BiMso.s  consist  mainly  of  c.xtravasated  blood,  but  there  is  consider- 
»ble  difference  of  opinion  concerning  the  reason  of  its  upiiearanco 
in  the  tissues.  They  are  regarded  as  the  several  products  of  embo- 
liam,  thrombosis,  or  rupture  of  the  pulmonary  vessels. 

Infavr  of  embolism  id'  one  or  more  branches  of  the  pulmonary 
irtcrv  may  be  urged — (1)  the  frequent  existence  of  a  thrombus  in 
the  right  auricle;  (2)  the  di.soovery  of  iin  emlxdus  in  tfie  largest 
•riery  entering  tlie  infarct ;  and  (3)  the  general  resemblance  wliich 
thtw  nia.s!<es  bear  to  infarcts  of  tlie  spleen  and  kidney.  Agaiimt 
embolism  us  the  sole  cause  are — (1)  the  not  infre([uent  absence,  in 
the*  casses,  of  thrombosis  and  all  other  known  causes  of  embolism 
«ilhcr  in  the  systemic  veins  or  in  the  right  auricle:  (*2)  the  still 
Bwrr  frec)uent  failure  to  find  an  endwliis  in  any  branch  of  the  pul- 
luiinary  artery  itself;  and  (;i)  the  eotnplcnicntary  facts  that  embolism 
lB«y  be  found  without  infarcts  and  that  artificial  embolism  in  animals 
Ms  to  produce  infarction. 

Tlmt  thrombosis  is,  at  least,  nn  oernsiomil  cause  of  "  pulmonary 

iluxy  "  is  inferred  from — (1)  tfie  existence,  in  a  few  of  the  I'ases. 

eroma  in  the  pulmonary  artery  ;  (2)  the  presence  of  a  throm- 

without  any  sign  of  embolism)  in    the   nuiin   artery  supjdying 

W^nfarct:  and  (3)  the  extreme  retardation  of  the  blood-current  at 

ime  the  "infarct"  is   formed.     On  the  other  hand,  all   these 

nnu-na   may  exist  without  any  infarction. 

I  ii(|iicstionably,  the  most  constant  condition  present  in  these  cases 
'» Ik  ionjr-continiied  anil  t7iarke<l  increase  in  the  pressure  in  the  |>ul- 
Bwiiary  veins  and  capillaries.  The  numerous  anastomoses  of  the 
•""iichial  vessels  with  the  pulmonary  veins,  and  the  weak  action  of 
Wi'  hourt  which  usually  co-exists.  ci>-operate  with  the  increa.sed 
pfwmirc  in  distending  the  vessels  and  in  lowering  the  nutrition  of 


270  FEVER. 

the  vessel-walls,  and  thereby  increasing  their  liability  to  rapton; 
while  the  enormous  strain  thrown  upon  the  parts  in  coughing  tap- 
plies  an  exciting  cause.  The  chief  objection  to  this  explanation  Hm 
in  the  fact  that  all  these  conditions  so  frequently  obtain  withont  m 
infarction  occurring  (p.  55). 

Grawitz  has  formed  the  ojtinion  that  all  these  "  infarcts  "  are  doe 
to  the  rupture  of  newly-formed  vessels.  A  careful  e.xaminatioii  of 
some  fifty  ca.scs  showed  that  the  structure  of  the  aficctetl  parts  it  it 
all  cases  similar.  In  the  parts  supplied  by  the  bronchial  Tcswlt— 
i.  t:  the  subplcural,  peribronchial,  and  interlobular  tissue — Gnwib 
found  numerous  large,  tortuous,  and,  in  his  opinion,  newly-fomfd 
arteries.  In  the  neighborhood  of  these  he  thought  he  could  true 
commencing  hemorrhages.  But  the  most  important  of  his  rwallt 
seem  to  have  been  his  success  in  protlurhig  infarctions.  Thi»  ii« 
accomplished  by  simultaneously  compressing  the  bronchus  an<i  the 
pulmonary  artery.  The  infarctions  took  some  weeks  to  develop. 
He  explains  those  ca-ses  in  which  emboli  and  infarctions  havebeea 
found  a.Hsociated  by  the  suggestion  that  small  peribronchial  htemito- 
mata  may  so  invade  and  damage  the  walls  of  the  adjacent  arteriet 
as  to  give  rise  to  the  gradual  formation  of  a  thrombus,  which  be 
thinks  has  often  been  mistaken  for  an  embolus. 


CHAPTER   XIX. 

FEVER. 

Bv  the  term  ••  fever  "  is  meant  an  abnormal  rise  in  the  tempff- 
ature  of  the  body,  together  with  other  changes  due  to  incre«<* 
c<mibustion  of  the  ti.s8ues. 

TEMPERATURE  IN  HEALTH. — It  is  usually  stated  that  the 
normal  temperature  of  the  body  is  WA°  F.  It  must,  however,  h* 
remembered  that  the  temperature  not  only  varies  in  different  p«^ 
of  the  body,  but  also  varies  slightly  with  the  time  of  day,  the  »P 
(if  tlic  patient,  and  the  surrounding  temperature.  The  norm" 
tfuipfrature  of  the  nurfarc  of  the  body  is  always  lower  than  th»' 
of  the  intirniil  partx.     Moreover,  it  is  lower  in    pro|M»rtion  u  *' 


FEVER.  271 

the  trunk  toward  the  periphery,  as  well  as  more  liable  to 
from  change  in  external  conditions.  To  ascertain  the 
re  of  the  body  for  clinical  purposes  a  thermometer  is 
ween  folds  of  skin  in  the  axilla  (or,  in  the  case  of  children, 
,  under  the  tongue,  or  in  the  rectum.  If  results  are  to 
'ed,  it  is  essential  that  all  observations  be  made  in  the 
e,  for  the  temperature  in  the  axilla  is  generally  half  a 
rer  than  that  in  the  mouth,  and  that  in  the  mouth  half 
ower  than  that  in  the  rectum.  Again,  the  time  of  the 
tt  must  be  stated,  for  the  temperature  rises  during  the 
les  its  maximum  between  five  and  eight  p.  m.,  and  falls 
night  to  its  minimum  between  two  and  six  A.  M.  Further, 
e  temperature  of  an  infant  or  young  child  is  slightly  higher 
of  an  adult,  and  in  the  aged  it  may  be  slightly  behw  the 
the  adult.  The  full  range  between  all  these  extremes  is 
ne  and  two  degrees. 

;ulating  (thermotaxic)  mechanism  is  less  easily  disturbed 
Ivances.  The  temperature  of  young  children  is  easily 
lepressed :  an  attack  of  crying  may  cause  a  distinct  rise. 
,  on  the  other  hand,  when  oxidative  processes  are  feeble, 
rature  is  more  easily  depressed  than  raised.  For  this 
;ht  rises  of  temperature  in  the  aged  are  of  much  graver 
:e  than  in  the  average  adult,  and  in  the  former  even 
OS  of  inflammation  may  be  present  without  any  accom- 
rise  of  temperature.  The  effect  of  food  is  to  excite 
n  in  the  large  mass  of  gland-tissue  connected  with  the 
!  tract,  and  to  cause  a  slight  rise  of  temperature:  the 
food  may  therefore  quicken  a  rise  or  retard  a  fall.  The 
>rdinary  exercise  is  slight,  but  tends  to  produce  a  rise: 
Tcise,  such  as  prolonged  running,  may  cause  a  rise  of  one 
;rees,  or  even  more.  Mental  exertion  tends  in  a  similar 
and  it  is  evident  that  the  activity  of  all  protoplasm  must 
be  greater  activity  of  the  tissues  and  the  combustion  of 
a  are  the  most  obvious  reasons  for  the  higher  temperature 
e  day.  The  diurnal  variation  is,  however,  said  to  occur 
confined  to  bed  and  deprived  of  food,  so  that  the  expla- 
y  lie  in  the  diminution  of  tissue-activities  during  sleep, 
that  in  those  people  who  are  in  active  work  during  the 
are  asleep  during  the  day  the  normal  course  of  the  tem- 
s  reversed. 


272 


FEVER, 


SYMPTOMS  OF  FEVER.— Since  the  introduction  ul'  at 
cliiiii'ii!  tLt'iTiKiiin.'ter  the  term  "fever"  has  come  to  he  almuS 
gvnonyinoiis  with  that  of  rise  of  temperature.  This  latter  coiiili- 
tion  is  certainly  the  most  easily  ascertained,  the  most  rwiiilt 
recorded,  and.  i>n  the  whole,  the  most  reliable  symptom  of  imt- 
The  course  (»f  the  temiieratiire  in  all  febrile  attaekft  is  tlivi>itJ« 
into  three  stages:  (1)  the  (mmt.  or  period  of  rise;  (2)  the  «iw. 
fastigiiiin,  or  stationary  period,  during  which  the  temperjturf  is 
more  or  less  at  its  height ;  and  {'6)  the  fall,  decline,  or  iirtici  "f 
defervescence. 

The  onset  may  be  middcti,  the  temperature  rising  three  t 
degrees  before  the  end  of  the  second  day ;  or  it  may  be  ;/ 
rising  every  evening,  and  falling  slightly  every  morning,  until  ^ 
full  height  is  reached,  as  is  seen  in  typhoid  fever.  The  smW™ 
onset  is  frequently  accompanied  by  an  intense  sensatiiiu  of  mi 
and  a  violent  attack  of  .shivering,  known  as  a  rigor.  The  ieiii|*t- 
ature  is  at  the  time  high,  the  ves.sels  of  the  skin  are  contracted,  w' 
excessive  lo.^s  of  heat  is  thus  prevented.  In  children,  in  xtbomtbf 
controlling  power  of  the  nervous  system  is  less  dcvelopdl  thiw"' 
later  life,  a  I'oni'uhion  often  replaces  the  rigor.  The  gradual  on*** 
may  be  marked  by  .flight  chiliness,  but  very  rarely  by  rigivr*. 

The  fastigium,  or  second  stage,  may  be  over  in  a  few  hours  "t 
may  last  for  weeks.  The  temperature  may  remain  at  a  fairly  cot*" 
stant  level  nr  it  may  oscillate  several  degrees  each  day. 

The  final  stage  of  fever,  like  the  onset,  may  be  sudden  or  gr**" 
nal.      When  sudden  it  is  said  to  end  by  criaiB.     The  drop  i*  oft«f' 
acpomjianied  by  '"  critical  "  swciiting  or  diarrhcea.     Sometinip'  '''*" 
fall  ia  so  r.xpid  and  so  marked  that  the  patient  may  be  in  dnngft  w' 
dying,  and  may  even   die,   of  collapse.      When  the  fall  i.-*  gmuo** 
it  is  said  to  end  by  lysis.     This  is  analogous  to  the  corresponJii*^ 
form  of  onset,  as  the  tenipernture  falls  by  a  series  of  morning  drof*» 
broken  by  slight  rises  in  the  evening.     The  special   types  uf  ffv** 
characteristic  of  some  diseases  are  in  all  probability  dependent  t**" 
peculiarities   connected  with  the  growth   of  sj>ecial    parasite*.  (^^** 
"Malaria.")     When  fever  ends  in  death  the  temperature  genenl'.*' 
rises  just  before  this  occurs,  and  may  occasionally  go  on  rising  f***" 
a  short  time  afterward. 

Febrile  temjieratures  almost  alway.s  exhibit  a  tendency  to  rhytb- 
mic  daily  variation  like  the  normal  temperature,  being  higher  lO 
the  evening  than  in  the  morning.     Sometimes  the  opposite  « ^ 


FEVER.  273 

ttise,  and  the  tempersture  is  then  said  to  be  of  the  inverted  type. 
When  the  daily  variation  does  not  amount  to  much  more  than  two 
degrees  the  fever  is  termed  continued.  When  the  variation  is  greater 
than  this  the  fever  is  remittent ;  of  this  type  hectic  fever,  which  ac- 
companies chronic  suppuration,  is  a  good  example.  When  the  drop 
between  two  maximum  points  reaches  or  falls  below  normal,  so  that 
there  is  a  fever-free  period,  the  fever  is  said  to  be  intermittent ;  of 
this  variety  malaria  is  the  type. 

The  extent  of  the  rise  of  temperature  varies  greatly.  Certain 
terms  are  sometimes  employed  to  express  the  average  height  of  the 
temperature.  It  is  however,  quite  easy,  and  always  better,  to  give 
the  figures  themselves.  Above  107°  F.  the  fever  is  called  hyper- 
jyrtxia,  and  a  temperature  at  or  above  this  point  enduring  for  any 
length  of  time  is  usually  fraught  with  the  greatest  danger  to  life. 
When  the  temperature  of  the  body  as  a  whole  reaches  109°  to  110° 
F..  prompt  measures  are  necessary  to  prevent  death.  As  in  sun- 
stroke, this  termination  is  possibly  due  to  some  decomposition  of 
the  tissues.  So  called  paradoxical  temperatures,  even  up  to  128° 
F.,  have  been  recorded  as  occurring  in  hysterical  individuals,  and 
in  a  few  of  them  the  most  careful  watching  has  failed  to  detect  de- 
ceit. In  some  cases  very  high  temperatures  have  occurred  again 
Mil  again.  They  are  often  quite  local,  the  temperature  on  the 
opposite  side  being,  for  example,  practically  normal.  They  are 
»«ompanied  by  few  or  no  symptoms.  Wasting  especially  is  ab- 
*nt.  Hale  White  regards  these  cases  as  of  central  origin,  due  to 
perverted  action  of  supposed  calorific  centres,  comparable  to  the 
derangement  of  the  motor  centres  in  hysterical  hemiplegia.  Hys- 
terical persons  are  very  liable  to  disturbances  of  body-temperature. 

High  temperatures  are  generally  accompanied  by  cloudy  swelling 
"f  the  tissues,  and,  if  prolonged,  by  fatty  degeneration :  poisons 
tirculating  in  the  blood  have  very  likely  a  share  in  producing  this 
"suit  (p.  79). 

Apart  from  rigors  and  chilliness,  which  are  usually  associated  with 
">e  onset,  the  earliest  symptoms,  as  regards  the  nervous  system, 
>fe  headache,  incapacity  for  self-application,  general  sluggishness 
*'  mind,  loss  of  self-control,  and  byperaesthesia  of  the  special 
""ses.  Then  comes  delirium — at  first  at  night,  and  for  short 
periods  only,  but  later  on  often  becoming  more  marked  and  even 
Wiwtant.  Vague  muscular  pains  are  common  in  early  stages : 
e^en  in  their  absence  unwillingness  for  exertion  is  marked.     The 

18 


274 


FKVKR. 


muscles  waste  rapidlv  and  their  movenu'rit!*  hecomr  ««k  iixl 
tretnuluus.  The  nervous  svHteui  ha.«  a  large  8harc  in  pnxlanaf 
tremor  and  proHtration.  and  is  resjionaiblc  far  such  «  evmptoa  as 
constant  picking  at  the  beti-clothcs  (carpholniry).  In  fever  thcfrf- 
ijuency  of  tlie  heart-beate  is  increased.  This  result  run  he  obtainni 
experimeutully  by  flie  ajiplieution  of  heat.  Yet  tiie  rapidity  of  tbf 
pulse  bears  no  reliable  proportion  to  the  height  of  the  tenipenitnrf. 
It  is  uiueh  jtreater  in  some  diseases  than  in  other* — fur  •  ' 

scarlatina  than  in  typhoid.     The  heart,  ainon^  other  ii< 
progressively  in  quality  and  power,  and  n»  it  docs  so  it«  beat  I 
more  frequent  and  less  effective.      Here,  again,  the  nen'<ni> 
may  be  partly  at  fault,  the  inhibitory  influence  of  the  vagu- 
impairod.       Similarly,   arterial    tone   is  progreiwiTely  Wt.      Th» 
result  iif  the  progressive  failure  of  the  heart-force  and  arterial  to« 
is  that  the  pulse,  which  in  a   healthy  inilividual   at   the  comnK-ot'r- 
nient  of  a  long  fever  is  quick,  full,  strong,  and  often   jnclin»<i  to 
hardnens  from  high   itrtcrial   tension,  becomes,  ns  the  discaj«c  |ir»- 
gresses.  quicker,  softer,  and  fuller,  though   no  further  rise  of  ten- 
porature  has  occurreil.      The  softness  and  fulnes*  of  the  pulwirr 
due  to  loss  of  arterial  tone  while  the  heurt-bent  is  still  strong:  lk» 
softness  increa«ca  ».s  the  arterial   tone  yields.      liitter    on  il 
diminishes  as  the  still   more  rnpiilly-bentitig  heart  fails  to  i 
veMels.     Ultimately,  the  pulse  is  very  small,  soft,  nnd  frequent,  «r, 
as  it   is  termed,   threaihi.      Increasing  frequency   of   puW  with  • 
steady  or  falling  temperature   is  often   regardcfl  as  thr  sigjj  of  • 
failing  heart,  though  the  ''quality  "  of  the  first  sound  really  alToni* 
an  earlier  indication  of  its  approach. 

Respiration  is  quickened.  This  change,  like  th«-  iuereaMHl  fr»- 
quency  i)f  the  pulse,  is  possibly  in  some  meitsurc  due  !<•  the  efrrt 
of  the  rapidly-heated  blood — in  this  ease,  on  the  respiratory  cwitr*, 
as  it  can  be  induced  experimentally  by  similar  means.  The  "Xyj!*" 
absorbed  and  the  carbon  dioxide  exhaled  arc  both  increase*!.  •"B^ 
times  in  exact  proportion  to  the  rise  in  teni|)erature. 

Digestion  is  impaire<l.  for  secretions  from  the  glund.>>  difccbnr;ii"i 
into  the  alimentary  tract  are  diminished.  Appetite  is  lo*t  (»'•'*• 
rezia).  and  its  place  is  taken  by  thirst  The  tongue  is  liry  •!>" 
often  furred.  There  is  usually  constipation,  due  probably  lo  si"?" 
giikhnes.^  of  the  intestinal  muscle,  to  lack  of  secretion,  and  }>erL«!* 
to  absence  of  some  of  the  normal  stimuli  to  contraction.  Exct** 
tiOD,  as  tested  by  the  rapidity  with  which  eertnin  ingesta  'I'C*^ 


FEVER.  275 

the  urine,  is  said  to  be  slow  in  fever.  Although  the  amount  of 
id  taken  is  larger  than  in  health,  the  urine  is  small  in  <}uantity, 
1  a  high  specific  gravity,  yields  a  copious  precipitate  of  urates, 
i  contains  an  excess  of  urea,  uric  acid,  potassium  salts,  and  pig- 
Bt  (pathological  urobilin).  The  chlorides  arc  diminished.  With 
excess  of  coloring  matter  in  the  urine  may  be  taken  the  fact 
t  in  fever  there  is  a  progressive  decrease  of  red  corpuscles,  and, 
Qfding  to  some,  corresponding  increase  in  the  amount  of  iron 
linated  in  the  urine.  According  to  Hayem,  both  hfematoblastH 
red  eorpuHchs  are  less  numerous  during  the  stationary  period 
Fever.  Directly  the  fall  in  temperature  begins  the  number  of 
natoblasts  increases,  reaching  its  maximum  a  day  or  two  after 
disappearance  of  the  fever.  During  the  following  week  it  grad- 
ly  sinks  to  normal.  An  increase  in  the  number  of  red  corpus- 
I  and  a  .simultaneous  diminution  in  the  proportion  of  hcpmoghbin 
V  contain  closely  follow  the  increa.se  in  the  hsematoblasts.  The 
'  in  the  percentage  of  haemoglobin  completes  the  return  of  the 
A  to  its  normal  state. 

fhe  excess  of  urea  is  one  of  the  earliest  changes,  and  may  even 
cede  the  rise  of  temperature.  The  excess  is  generally  absolute, 
netimes  it  is  only  relative ;  that  is,  more  is  passed  than  would  be 
reted  by  a  healthy  man  confined  to  bed  on  a  similar  diet.  There 
soally  a  marked  increase  at  the  commencement  of  defervescence : 
I  is  most  likely  due  to  an  accumulation  of  its  precursors  in  the 
«1  or  tissues. 

■OST-MORTEM  RISE  OP  TEMPERATURE.— A  slight  rise 
:emperature  often  occurs  after  death,  especially  in  those  dying 
denly  or  of  acute  diseases.     It  is  most  marked  in  cases  of  fever 

to  the  presence  of  a  ferment  in  the  blood,  or  in  cases  where 
th  occurs  with  a  high  and  rising  temperature.  Tetanus  is  prob- 
1  the  best  example.  The  explanation  is,  that  cessation  of  the 
on  of  the  heart  is  not  accompanied  by  immediate  extinction  of 
oe-change.  Thermogenic  processes  continue  for  a  longer  or 
fter  time ;  and  thus,  while  the  production  of  heat  ceases  grad- 
'y,  the  loss  of  heat,  being  largely  dependent  on  the  respiration 

circulation,  is  cut  down  so  suddenly  that  the  rectal  temperature 
8  for  a  brief  interval,  and  then  falls  as  usual. 

'ATHOLOOY  OP  PBVBR. — The  foregoing  account  has  shown 


«r« 


FEl^ER 


that  the  css«>ntial  condition  in  fever  is  increued  thfrnio|rrii<!>i* 
to  incrca.scd   brcakiiip  down   of  the  tis<f«ii(>!«,  niid   I'-iitfcinlU  «f  il»* 
niiisclfs ;  for  the  functions  of  the  glands,  the  second  gn-nt  hf-at-pro- 
ducing  organs,  are  almost  in  sbevance.     Ah  rtr  have  nlreadr  indi- 
cated, by   increased   thermogenesis  we  mean  ihnt   ii   fehrile  |MiU(Ot 
will  produce  more  heal  in  a  given  time  than  a  healthv  periuib  npaa 
the   same  diet   and   under  Kimilar    circum!<tnnce!< — mil   neccMuilT 
more  than  a  healthy  person  on  onlinary  diet,  though  rren  lhi»  m»T 
be  the  case.     While  the  febrile  patient  takes  le**  food,  he  »\tti>ih» 
more  o.xygen,  and  the  increa-te  in   iieat  he  product-*  i.*  due  ti>  tke 
excessive  combustion  of  his  tissues.     Traube  held  that  diminiibed 
loss  of  heal  tiHik  the  greater  share  in  the  niaintrnnni'c  of  tli< 
temperature   in    the   body   of  a   febrile   pntieut.  and   tlint  tir 
brought  about  by  an  energetic  contraction  of  the  viwsels  of  xhr  dtia. 
But  wuch  a  contraction  of  vessels  is  by  no  means  constant,  .ih  : 

it  occurs  is  nut  (d'  long  persistence.      Moreover,  a  high  tcin|u: 

»ud  a  freely-sweating  .skin  often  occur  together,  and  calnriioffnc 
observations  have  actually  demonstrated  the  increaseii  ihenatigeii- 
esis.  If  stipport  is  required  for  the  view  that  fever  is  depeiHlent 
on  increased  destruction  of  tissue,  it  is  found  in  the  projM'rtiotiitrlT 
increa.sed  discharge  of  urea  and  carbon  dio.xide. 

Some  physiologists  believe  that  thermoereneeiB  ik  iinil<r  im- 1"»- 
trol  of   a  cerebral   centre  or  centres  which   control   other  tbrtiB*' 
centres  in  the  cord;  but  in  the  present  state  of  kno>»leilg«  it   ^ 
impossible  to  speak   certainly  of  the    position  of  these  centrw.  <»* 
their  function  (excitor  or  inhibitory),  or  of  the  paths  of  their  tSntr* 
and  eff«-reni  fibres.     The  effect  of  curarizing  an  animal '  would  wn^ 
to  demonstrate  that,  normally,  heat-production  in  muscle — likeo**^ 
traction — takes  place  nuly  in  rcspon.se  to  a  .stimulus  along  a  thenui 


'  Mnc.'MliMer  khowol  thai  the  wnrk-perforniini;  «n<1  hntl-produring 
miUM'le  are  to  »  certain  exitriU  ilixtiticL     Siiiiiiilulioii  nf  a  niiwular 
ililntalioii  «f  it*  veMnels,  Utmpnrnry  rtiiitrai'lion  of  tlii<  muM-lr,  untl 
diu'tiuD 'if  tirnl.     FaliKiK-  nriil  ifilil   t>i>lli   iiiUTri-ntl  willi   tlii>  llifrni(^i(«<nir  I 
I<in|{  ln'firin'  llioy  jiii|>iiitv<l  tlii'  (Kiwcr  i>f  c-oiitrnction.     •  tn  the  ntlior  Uaod.  | 
!>v  niranr — which  .•"•l»  nu  ihi-   iHTv<--<'niiiii|p.  in  miwvlr— (laralrwd  |J|» 
lh<'rnii>|^-iiir  fiinclionN  i<(  the  tiiui(.-l«  Binniltaneoiuil^.      If  an  antinal 
mainlaininKa  fairly  uniform  U-ni[H-reture  i  lumioiotkn-mie  \  be  |K>iwnicd  with  < 
ttcoomc*   ineapalile  of  niaint.iininK   it«  t«ni{)«ni(un!,  whii-li  mimitlipi^W  rBriai  < 
thni  of  ihv  nunuunJing  uiwliiini  i  poikilolhermie),  al(houf;h   the  rirculatkm  t4  lW| 
blood  ia  unim|mirr<i  nnil  ihe  normal  rate  of  rexpiration  it  kept  up. ^laxiri;  r^Li 

itn. 


FEVER. 


277 


(caUibolic)  nerve;  but  it  does  not  prove  the  iinijossibility  of  directly 
ttiiDiilatiiig  the  tnuscle  to  proiliiuo  heat,  es|ieciiiily  iis  we  know  it 
can  wiitmcf  alter  its  motor  nerve  is  deiid.  It  is  evident,  therefore, 
thtS  tliv  causes  of  fever  may  induce  the  increased  tliermogcnesis, 
cither  by  acting  lUrectly  upon  the  tissues  or  by  acting  on  them  /«- 
(ilin-tiylkrnu(/fi  l/ie  nervous  Kifgtem.  In  certain  cases — <•.(/.  nervous 
or  hygtcrical  fever,  it  seems  impossible  that  the  cause  ciin  act  ujion 
till'  tiwiies  otherwise  than  through  the  nervous  system  :  but,  in  the 
majority  of  cases,  it  may  act  either  way,  and  until  recently  it  has 
pwruliy  been  assumed  that  the  action  has  been  ilirect  from  tlie 
blood  upon  the  tissues. 

Still,  as  we  have  already  shown,  thermogenesis  may  be  increased 
euormoiisly  in  health  without  any  rise  of  temperature,  ami  we  must 
therefore  consider  that  fever  aLso  involves  a  disturbance  of  the  heat- 
rcgiiiating  lueciiaiiisni.  or  thennot»xi8,  whereby  it  fails  f<>  maintnln 
the  balance  between  heat-production  ami  heat-loss.  If  tliis  balance 
»cre  maintained  as  in  health,  we  should  have  a  stable  temperature 
«t  »  higher  level  than  the  normal.  Hut  the  chief  characteristic 
of  the  temperature  in  fever  is  it.s  variiibiliiy.  fold,  food,  excite- 
ffli'iit,  effort  antipyretic  drugs,  all  afi'ect  the  temperature  in  fever 
much  more  markeilly  than  the  temperature  in  health.  As  Mac- 
Alister  says,  the  ttderably  regular  daily  tluctitatiou  of  the  tenipera- 
t'lre  ill  fever  shows  merely  that  nil  the  thermiil  processes  are  not 
atterly  disturbed,  some  which  are  rhythmic  in  health  remaining  so 
in  diwane. 

hike  intlaininations,  fevers  may  be  divided  into  the  infective  and 

non-infective.     The  infective  fevers  are  those  due  to  the  multi- 

(ilicstidii  in  the  body  of  a  micro-parasite.     This  explanation  serves 

for  the  group  of  "acute  sjjecific  fevers,"  malaria,  and   febrile  dis- 

flVnin  which  there  is  no  inflammation  present,  at  least  in  the  early 

(»r»  of  their  course.     These  cimstitiited  the  old  groups  of  primary 

or  essential  fevers.      In  some  (typhus,  niahiria)  there  is  no  intlain- 

niation ;  but  in  many  an  intlamniatioii   tippi-ars  (of  throat,  nose  and 

eyc»,  skin,  intestine) — too  late  anil  often  too  slight  to  account  for 

the  fever  present.     There  are  also  the  cases  of  fever  secondary  to 

Koiind  through  which  organisms  liiivi>  gained  access  to  tlie  body 

f.if.  Septic  infection,  pysemia,  erysipelas,  and  lymphangitis — and 

lie  large  grouji  of  fevers  .secondary  to  infliiiiimations  (inflammatoir 

ircrs),  practically  all   of   which   are  infective.      In    most   of    these 

secondary"  fevers  the  pyrogenous  materials  are  manufactured  b\ 


278 


FEVER. 


nrgnnisins  in  some  definite  part  oi  the  fxuly.  nml  nre  tbHI^B^int* 
fli»'  lilood. 

In  the  non-infective  group  wo  liml.  Hr»t  of  nil.  two  w ouutl  iii«»— 
e»ses :  (l)sini|)le   trmitniitic  fever,  nnd  (2)  it«  tiiorc  inienm"  fnm. 
iiciite  septic  poisoning  or  sRpneniia.    (See  "  Septicjeuiin.")    Simple 
traumatic  fever  ensues  upon   "simple"   injuries  (eontiisionj' (n«i 
fractures).      It   is  penenilly  slight,  and  is  most  probably  due  ti>  tb*- 
absorption   of   fibrin-ferment  (and    very    likely    other    pyrogenun* 
bodies)  from   the  sent  of  injury:  ptissibly,  irritation  of  nerve- '-^ 
llie  original    injury  or  by  fragments  of  b<<tie  or  tissue — may  L.i>  ■- 
some  effect  in  causing  the  fever,  though  gtrong  irritation  of  ti 
sory  nerve  causes  de|>ression  nf  tem|)ernfiire.     Aseptic  inn 
fever,  wliicli  occurs  in  aseptic  wounds,  is  |)robnbly  due  to  thci 
c»uses  as  the  simple  traumatic.    Nervous  (hysterical)  fever  inoap- 
|iosed    to   be   due    to   the   influence  of  higher  over   lower  thfrmal| 
centres.     The  rises  of  temperature  which   occur  in  ehihlrcn,  parr- 
peral  women,  and  other  weakly  adults,  from  varioun  emotion*  tnd 
oilier  slight  causes — e.  jf,  the  rise  which  is  so  commonly  fonml  »fier 
an   entertainment   has   been   held  in  a  hospital  ward — »wm  l"  *»* 
examples  of  nervous  fever. 

Further,  eases  of  nervous  injury  or  diseaso   not   unei»niroonlT 
occur    in    which  one   cannot   help  susfiecfing    either    that   tlierm***' 
inhibitory  centres  or  fibres  are  destroyed  i>r  that  therniognii"'  f** 
tre«  or  fibres  are  irritated.     Hale  White  has  broup;bt  a  nninbrf  •" 
such  ca-ses  together.      In  a  most  interesting  case  of  bullet  wMjiid  •" 
the   bead   accompanied   by  fever,   not  otherwise   explained,  it  ••* 
found  that  the  motor  area  of  the  cortex,  corresponding  to  EulcBb**" 
and    Laniloiss  heat-centre  in   the  dog.  had   been   ilestniye<l.     T*** 
inbibitorv   influence  of   this  centre  may  apparently  be  cut  oS    * 
destri>ved  by  sudden  and  extensive  intracranial   hemorrhaije,  oT   *'• 
hemorrhages,  scleroses,  and   tumors  of  the  brain  so  plsce«l  u0 
dextroy  inhibitory  fibres  or  to   irritate  thermogenic  tract*.     It    ""^  i 
long  bt'cn   kiniwn   that   injuries  and   tumors  of  the  cervical  w**"^' 


along  which  most  thermal  fibres  must  pass,  are  apt  to  eaiise  __^        , 
fever.      In  a  girl  with  a  fnictiirrof  tin-  cervical  spine  Teale  nt!or«»*'^i 


a  tempenitureof  I'iU'^  K.,  recovery  iiltimutely  occurring  :  Mime  rrjr**^ 
this  as  an  iustauee  of  hysterical  fever. 

Lastly,  there  are  many  fevers  of  whose  pathology  we  are  >t''' 
ignorant — (•.</.  the  fever  met  with  in  various  anivmic  state*,  i** 
lyniphadeuoma,  and  occasional  cases  of  malignant  dUease. 


lyFLAMMATlON.  279 

CHAPTER  XX. 

INFLAMMATION. 

Inflammation  may  be  defined  as  "the  succession  of  changes 
which  takes  place  in  a  living  tissue  as  the  result  of  some  kind  of 
injury,  provided  that  this  injury  be  insufficient  immediately  to 
destroy  its  vitality  "  (Sanderson). 

HISTOLOGY. — The  exact  nature  of  these  changes  was,  for  the 
most  part,  ascertained  by  the  experimental  researches  of  Cohnheim. 
The  method  of  investigation  consisted  in  the  artificial  production  of 
inflammation  in  transparent  parts  of  the  lower  animals,  and  in  the 
observation  of  the  process  thus  induced.  The  parts  employed  have 
been  the  foot,  tongue,  and  mesentery  of  the  frog,  the  tongue  of  the 
toad  (the  best  for  many  purposes),  the  mesentery  of  the  rabbit,  and 
the  wing  of  the  bat.  The  similarity  of  the  different  observations 
i)as  shown  that  the  process  is  essentially  the  same  in  warm  and 
cold-blooded  animals,  and  by  microscopic  examination  of  the  lip 
^J  reflected  light  Hiiter  proved  that  it  is  the  same  in  man.  The 
Procees  of  Inflammation  is  generally  described  under  three 
keadings : 
J-  Changes  in  the  blood-vessels  and  circulation. 
2.  Exudation  of  fluid  and  of  blood-corpuscles  from  the  vessels. 
''•  Changes  in  the  inflamed  tissues. 

Though  separated  for  purposes  of  description,  it  must  not  be  sup- 

P<*8e(l  that  these  changes  occur  successively  in  the  order  in  which 

"*.V  are  placed ;  on  the  contrary,  they  all  go  on  together. 

1.  Chanfirea  in  the  Blood-vessels  and  Circulation. — Changes  in 

^th  blood-vessels  and  circulation  are  absolutely  essential  to  the 

*'stence  of  inflammation.     This  is  true  of  non-vascular  as  well 

of  vascular  tissues.     In  the  former,  which  comprise  the  cornea 

**«  cartilage,  the  changes  occur  in  the  adjacent  vessels  from  which 

**8e  tissues  derive  their  nutritive  supply.      The  nature  of  the 

"bilges   may  be   studied   in  the   mesentery  of  a   curarized   frog. 

*'iefly,  they  are  as  follows : 

The  first  effect  of  injury  of  the  mesentery — mere  exposure  to  the 
'**■  being  sufficient  for  the  purpose — is  to  cause  dilatation '  of  the 

With  certain  irritants,  as  ammonia,  a  short  contraction  of  the  arterioles  may  be 
tW  first  result 


2S() 


INPLAMMATIoy. 


arteries,  which  gradually  extends  to  the  veins  and  eapillarir*.  Ti* 
dilatation  of  the  arteries  coinniencea  at  ouec.  and  ix  not  pni .  ^ 
anv  contraction.  It  increai<e8.  steadily  and  slowly,  for  nlioii!  • 
hours,  and  is  accompanied  by  an  increase  in  the  len/fth  »(  ihir  f»- 
aels,  so  that  they  become  more  or  less  tortuous.  It  affrcf*  tb' 
arteries  cliieHy,  then  the  veins,  and  slightly  the  cupillane?.  Tim 
enlargement  of  the  blood-vessels  is  HKsociateil  at  the  roninicn<Tnii>ni 
of  the  process  with  an  acceleration  in  the  flow  uf  blood,  whirb, 
however,  rarely  last.-*  more  than  an  hour,  except  in  the  ontlvm^ 
partH.  anil  i»  followed  by  a  considerable  retardation  in  tlir  rir- 
culation.  the  vessels  still  remaining  dilate<i. 

Pulsation  is  now  evident  iu  the  smallest  arteries,  niul  thr  »irj'-. 
is  slow  enough  to  allow  the  ubserver  to  di.^tinguish  indiviJuuI  '"r- 
puscles  in  the  capillaries  ami  smaller  vein.s — p<-rha|M4  even  in  li>e 
artericdes. 

It  ha.«,  however,  long  been  known  that  the  ttccelemtion  of  ik« 
blood-flow  in  an  injured  part — the  so-colled  determination  ofhlauJ — 
is  not  constant,  and  often  subsides  withioit  the  occurrence  of  »n)'  •»( 
the  characteristic  phenomena  of  inflammation.  Cohuheim  c«ii?i«i- 
ered  that  dilatation  of  vesxels  with  increased  veloeit;/  of  the  blooi 
current  en.^uing  immediately  after  the  infliction  of  an  injury  i»  »*^''" 
dental.  In  some  cases  it  is  followed  by  contraction,  after  »bi*» 
dlltitiitiiiii  it'ith  dimiuin/ied  eelnrit;/  commences.  This,  on  the  otb«T 
hand,  comes  on  slowly,  is  constant,  and  persists  as  long  as  the  rao"- 
f>ihtliilii>ii  irit/i  diiniuixheJ  lufixiti/  must  be  regarded  as  the  bmbd*** 
vascular  change  of  the  inflaniinalion. 

Returning  to  the  observation  of  the  frog's  mesentery,  the  reU»"* 
atiori  of  the  circtdatinri  in  the  dilated   vessels  is  sometimes  aeeO  " 
lake  place  somewhat  suddenly,  and  is  u.iually  first  observable  ia  A' 
veins.     As  the  stream  gets  slower  increasing  numbera  of  whiteoir' 
puscles  are  seen  in  the  periaxial  stream  of  the  »mrt//rr  rrtwa-^-riiUinjf 
slowly  along,  stopping  here  and  there,  anti  finally  coming  to  a  .-itand- 
still.       Thus  the  smaller  veins  become    lined    with    leucMcyloi  u 
with  a  spheroidal  epithelium,  often   more  than  one  cell  in  ihickntM. 
Some  stick  iu  the  capillaries.      The  time  ut  which  the  ehaogv  oceun 
varies,      The  severer  the  injury,  the  earlier  this  layer  of  Ivuracytia 
is  formed.     The  narrowing  «if  the  vein*  by  layent  of  leucncytct, 
among   which  there  an-  no  red  corpu.scle.s,  seems  to  inrrcaae  tlie 
obstruction   to  the  circulation,   which    becomes  slower  nnd  slower, 
poasibly  both  on  this  account  ami  because  the  damage  \*  Itccaming 


INFLAMMATION.  281 

^ter.  The  red  corpuscles,  with  some  white,  accumulate  in  the 
capillaries,  which  appear  as  if  distended  by  a  red  injection-mass. 
Actual  measurement  shows  that  they  may  be  one-fourth  larger  than 
Datnral.  After  a  time  all  onward  movement  ceases  in  the  capillaries 
tod  their  contents  sway  to  and  fro  with  the  pulse.  This  is  the  stage 
of  oscillation,  and  it  is  succeeded  by  that  of  stasis,  in  which  no 
moTement  of  any  kind  occurs ;  but  the  blood,  though  stationary, 
may  remain  fluid — for  as  long  as  three  days  in  the  bat's  wing. 
Finally,  thrombosis  or  coagulation  may  take  place,  but  not  until 
the  capillary  walls  are  dead.  Thrombosis  puts  an  end  to  that  escape 
of  corpuscles  from  the  vessels  which  will  be  treated  of  in  the  ne.\t 
paragraph. 
These  changes  in  the  circulation  may  be  thus  summarized : 

1.  Dilatation  of  small  arteries,  then  veins,  and  lastly  capil- 

laries. 

2.  Acceleration  of  blood-current,  quickly  followed  by  gradu- 

ally increasing 

3.  Retardation  of  blood-current — first  observed  in  veins — and 

simultaneously  with  this 

4.  Leucocytes  in  large  numbers  fall  into  periaxial  stream, 

and  lag  behind. 

5.  Pulsation  in  smallest  arteries,  oscillation  of  blood-stream, 

and  perhaps  stasis. 

2'  Escape  of  Fluid  and  Blood-corpuscles  ft-om  the  Vessels. 
-The  circulatory  and  vascular  changes  have  been  described  as  if 
My  were  the  only  phenomena  of  inflammation.  But  this  is  far 
rom  being  the  case.  Soon  after  the  veins  become  lined  by  white 
^rpuscles  the  field  becomes  more  and  more  obscured  by  the  presence 
"f  small  round  cells  in  the  substance  of  the  mesentery.  At  even  an 
wlier  period,  though  the  miscroscope  does  not  show  it,  the  fluid 
»hicb  naturally  escapes  from  the  vessels  increases  greatly  in  quantity 
"d  changes  in  quality.  As  soon  as  the  lymphatics  become  unable 
to  carry  it  off,  it  accumulates  in  the  connective-tissue  spaces  and 
eanseg  swelling.  These  finally  become  insuflicient  to  hold  it,  and  it 
therefore  escapes  on  the  surface,  together  with  a  number  of  the  small 
round-cells.  Here  a  coagulum  forms,  consisting  of  fibrin,  small 
vand-cells,  and  some  red  blood-corpuscles.  This  false  membrane 
an  be  removed  and  the  fieM  cleared  for  observation  until  another 
lembrane  forms. 

a.  Source  of  the  New  Cells. — If  a  small  vein  lined  by  leuco- 


ryFLAMMATIOir. 


cytc8  be  carefully  watched,  the  following  cbangee  will  ht  fteeo- 

baps  at  once,  perhapi*  not  for  norae  tinif :   Sonic  of  thr   l« 
innncdiatcly  adjacent   to  the  wall   gradiiHlIy  sink    into  jL,  Mi«l  pa>  I 
tiirough  into  the  Riirrounding  tissues.     Various  stHgv9<  of  tliotrfa» 


Flo.  104. 


X 


^^ 


•t- 


\ 


Snbriitttnooiif  tl<«ut'  ••>tii<r  •lUliinr-f  nN>vr  HchiX   imhI   111  •  CM<  of  •(■rntillrtf  i 

Three  Vulm  inrkl'il  Witll  Inumylrs  I'l.Ulllrh  arv  >«i'u|ihl|i  fr%Ml>.     I:>>llll<l  111!  iflrrj'' 

thtn  nrr  uoiir.    Uuulili-  (he  vtvu-U  iimii)  UrKvr  cells  ari'  ff<-ii.    X  J*'- 

awe    nmy   be   olK^erved.      .\t    first    y>innli     iMiitnn-xbnprd    il. 
appear  on   the  outer   wall  of  the  ves!»el.      'rhi-fc   j;riidMall_\    ' 
until  they  assume  the  fonn  of  pear-^(haped  bodie.s  adherent  brtlwi' 
Hnutll  en«lM  to  the  vessel-wiill,  often  sending  out   proceswe*  "' 
attached,      t'ornii  and  Kunvier  say  that  if  an  aillierent  Iciu -  . 
torn  from  the  wall  and  swept  on,  tiie  adherent   part  is  •*finjrf'<*'- 
and  von  Recklin-jhausen  lias  dt-.^eribed  the  part  irithin  the  i*-**!!* 
n  tailpole's  tail)  as  sending  out   processes,      litiniateiy.  the 'O 

[K-dide  of  protoplnsiu   gives  way,  antl  the  passage  is  complolc  

corpuscles  remaining  free  outside  the  vessel.     A  similar  wctpet**** 
place,  but  to  a  less  extent,  from  the  ca[iillaries. 

As  a  rule  in  iidlainmation  the  escape  of  white  corpuscUf  pwW? 
excee<U  that  of  the  re<l;  but  in  the  roost  severe  cases,  iu  whielil 
nation  is  in<luced  in  a  large  number  of  capillaries,  the  usual 
id' affairs  nmy  be  reversed  (Fig.  11-,  p.  liOfi).      From  such  n{Ml1 
th«  re<l  corpuscles  pass  out  in  great  numbera,  occupy  the  inMnM* 


INFLAMMATION.  283 

he  tissues,  and  give  the  exudatioD  a  hemorrhagic  character, 
the  other  hand,  when  "  retardation  "  has  not  culminated  in 
uis,"  most  red  corpuscles  remain  within  the  vessels  and  pass 
ig  through  the  inflamed  area,  whilst  the  white  adhere  to  the 
k  The  intensity  of  the  injury  and  profusion  of  capillaries 
ermine  the  proportion  of  red  corpuscles  in  an  exudation.  These 
ffl  out  chiefly  from  the  capillaries,  and  several  may  escape  in 
ick  succession  from  one  place,  giving  rise  to  a  red  spot  visible  to 
e  naked  eye  as  a  punctiform  hemorrhage.  No  rupture  of  vessel 
curs,  as  may  be  shown  by  injection. 

Both  red  and  white  corpuscles  at  first  remain  near  the  vessels 
lence  they  have  escaped,  but  they  are  soon  pushed  away  by  other 
rpuscies  or  washed  on  by  the  escaping  fluid.  The  white  cor- 
acles have,  in  addition,  their  own  peculiar  power  of  locomotion. 
108  they  may  ultimately  be  found  far  from  their  place  of  egress. 
But  are  white  blood-corpuscles  the  only  source  of  the  numberless 
nnd-cells  which  crowd  the  tissues  in  every  inflammation  but  the 
Mt  trivial  ?  Virchow  advanced  the  view  that  they  all  arose  by 
»ltiplication  of  connective-tissue  corpuscles.  Addison  in  1842 
ferred  from  his  observations  that  leucocytes  passed  through  the 
88el-walls  and  became  pus-cells,  and  in  1846,  Waller  actually  saw 
em  escaping.  These  observations  were  unheeded  until  Cohnheim 
1867  asserted  that  all  new  cells  formed  in  the  tissues  as  a  direct 
'lit  of  injury  were  escaped  white  corpuscles  which  had  migrated 
the  8j)ot  where  they  were  found.  And,  in  spite  of  opposition, 
» view  has  held  its  ground,  and  all  arguments  and  experiments 
vaoced  to  show  that  the  small  round-cells  of  aeute  inflammation 
i  due  to  the  multi])lication  of  fixed  tissue-cells  have  proved  incon- 
sive.  Experiments  have  amply  shown  that  migration  of  leuco- 
<8  will  give  rise  to  all  the  appearance  noticed,  but  it  is  diflicult 
Wclnde  the  possibility  of  the  multiplication  of  the  fixed  cell.'', 
-^bnheim,  however,  believed  that  the  subsequent  regeneration 
tissues  was  also  due  to  the  development  of  leucocytes ;  but  this 
t  of  his  conclusions  is  now  generally  disputed. 
I'hc  following  method  has  been  adopted  to  .show  that  leucocytes 
■  produce  an  infiltration  of  tissue  with  small  round-cells  without 
aid  of  the  fixed  elements.  A  cornea  or  other  piece  of  tissue, 
cells  of  which  were  suspected  of  multiplying,  is  excised,  kept 
some  days,  rendered  aseptic,  and  then  placed  in  the  peritoneum 
subcutaneous  tissue  of  a  living  animal.     On  subsequent  examina- 


*«84 


ISFLAMMATIoy. 


tion    clumps  of   small   round-cells  arc  always   found   In    {lositiim* 
normally  occiipicil    by  tissue-corituscles.   but  multij'V  *"    ' 

latter,  wliicb  were  prcHumablv  (load,  was  clt-arly   im; 
fixed  counoctive-tissue  cells  lie  in  spaces  and  clefts,  and  the  i*i 
cells,  taking  the  easiest  i'oiir><e  open  tn  tliem.  invade  and  accm 
in  these  spaces  and  arouml  the  fixed  cells. 

The  non-vascular  tissues,  and  especially  the  cornea,  were  tl 
strongholds  of  those  who  maintained  that  these  cells  nri|rinatf<l  tr-m     i 
multiplying    connective-tissue    corpuscles.      Biittcher    showeil  tiu^J 
after  slight  central   injuries  of  the  cornea  with   nitrate  of  aiU«f|^| 
which  caused  no  affection  of  the  surrounding  vesaela.  the  site*  nf    1 
the  corneal  corpuscles  in  the  neighborhood  were  occupied  by  rlump^J 
of  euibryitnic  cells,  which  lie   believed  could  have  been  fornini  <>dI]H 
by  multiplication  of  the  fixed  cells.     Cohnheim  pointed  out  tkittbe 
new   cells  might   be   leucocytes   wbidi   had  tiiignited    from  tlif  i-no- 
junctival  sac.  and   ^enftleben   jiroveil   that   this   «as   their  *av,K*^ 
This  observer  succeeded  in  applying  t4>  a  minute  8|M>t  in  thr  cnti*   | 
«f  the  anterior  surface  of  the  cornea  a  sciliitioM  of  chloride  <•! 
which  soakeil  through  the  dense  anterior  corneal   lamina  «::■ 
destroying  it.     By  this  method  he  found  it  was  fiossible  to  kill  il»« 
corpuscles  in  a  small  central  area  of  the  cornea  without  uffr^tinf 
the  marginal  vessels.     The  spot   remained  clear,  and  no  cliit!'    ■■*^ 
embrvmiic  cells  were  found.      But  if  the  spot  irritated  via*  in- 
margin  of  the  cornea,  the  neighboring  vessels  dilated  and  the  «lM«»' 
ageil  area  became  cloudy  from   infiltration  with   Ich'  If  •* 

the  slight  central   injury  first   described  a  cut  or  stu  i/hl^* 

anterior  lamina  was  added,  opacity  of  the  cornea  and  infiltnUJi*^ 
of  eorpiiscles  from   the  conjunctival   sac  oc<'urre<l  simultaneoittl*'"^ 
It  seems,  therefore,  that  Cohnheim  was  right  in  supposing  that 
small  round  cells  found  in  inflamed  tissues  as  a  direct  result  of  iIm^ 
injury  which  caused  the  process  were  escaped  leucocytes.     A  km 
of  the  cells  may  be  due  to  lU'ip'twrativi-  changes  (p.  47). 

Moreover,  in  the  less  acute  forms  we  find  cells  which  are  fonnrd 
by  rfgenfratirt  processes  going  on  in  the  cells  of  the  lissur*.  bal 
these  can  ntnl  must  be  sharply  distinguished  frotu  those  wc  kaie 
been  discii^^iiig  (p.  28*!). 

^.  Exudation   of  Fluid. — As  before  stated,  one  of  the  c«riini 

,  ♦fTivfs  of  the  vascular  changes  in  inflajiimation  is  iiH    .         '  .l». 

tion  of  fluid.     This  was  noted  in  the  microscopic  •  •.     i^  of 

the  inflamed  mesentery,  but  other  experiments  show  th«  proceas 


INFLAMMATION.  285 

mucb  better.     Lassar  tied  a  cannula  into  a  large  lymphatic  of  each 
Wnd  leg  of  a  dog.     He  then  stopped  the  circulation  in  one  leg, 
»nd  dipped  this  into  water  at  130°  F.,  thereby  exciting  acute 
inflammation.     On  removing  the  fillet  the  lymph-stream  from  the 
c&nnula  at   once   exceeded   the   normal,  and   soon   reached  eight 
ima  that  on  the  sound  side.     At  first  the  fluid  was  clear,  but  after 
a  time  increasing  numbers  of  white  corpuscles  made  it  cloudy,  and 
red  corpuscles  were  also  found  in  small  numbers.     Swelling  of  the 
foot  began  while  the  flow  of  lymph  was  free,  evidently  because  the 
exudation  was  too  rapid  to  be  conveyed  away  by  the  lymph-chan- 
nels, even  when  fully  dilated.     Later  in   the  experiment  the  flow 
diminished,  partly  because  exudation  diminished  as  pressure  on  the 
vessels  (from    effusion   beneath    the   skin)  rose,  and   partly  from 
coagulation   in,  and   consequent    blocking    of,    lymphatics.     The 
lymph  collected  difiered  from  the   exudation-fluid  in  mechanical 
liTpenemia  in  containing  a  much  larger  proportion  of  albumin  and 
in  having  a  much  greater  tendency   to   coagulation.     This  latter 
property  varies  with  the  number  of  white  corpuscles  which  it  con- 
tains.   The  lymph  differed  from  liquor  sanguinis  in  containing  less 
•Ibamin  and  having  a  slighter  tendency  to  coagulate.     The  compo- 
wtion  of  inflammatory  effusion,  however,  is  not  constant.     In  the 
■"ost  acute  inflammations  it  contains  a  large  number  of  red  cor- 
puscles; in  less  severe  forms  white  corpuscles  are  greatly  in  excess 
of  red.     In   the   more  severe  inflammations  the  fluid  approaches 
plasma  in  its  composition  and  tendencies,  wliil.xt  in  the  less  severe 
't  becomes  very  like  the  fluid  in  mechanical  hypenvmia.     It  also 
varies  according  to  the  part  from  which  it  comes.     A  mild  degree 
of  peritoneal    inflammation   will    produce    an    effusion    containing 
more  proteid  matter  than  a  far  severer  inflammation  limited  to  the 
leg  (p.  237). 

3.  Chaneres  in  the  Inflamed  Tissues. — Inflamed  parts  are  soft, 
and  the  component  tissues  are  blurred  or  altogether  indistinguish- 
•We.  Microscopically,  the  tissue-elements  are  at  first  separated  by 
flnid  and  obscured  by  leucocytes  and  fibrin-filaments.  The  tissue- 
cells,  when  not  obscured  by  leucocytes,  are  either  structureless 
masses  from  coagulative  necrosis  or  are  undergoing  fatty  degenera- 
tion. The  tissue-fibres  are  swollen  and  indistinct :  they  ultimately 
degenerate.  Red  corpuscles  are  found  in  even  moderately  severe 
inflammations.  The  changes  in  the  escaped  leucocytes  and  the 
actual  destruction  of  tissue  will  be  described  subse(iuently. 


*286 


lyPLAMMATIOX. 


We  must,  however,  liere  point  out  that  regrenerative 
arc  8onictiuic8  disco vorublc  in  the  cells  oi  an  iullunied  am.  mtAt 
I'oUowing  experiment  shows. 

When  Senftleben  (2><4)  with  chloride  of  zinc  destroyed  all  etlh 
in  the  centre  of  a  cornea  without  ndiuittin;;  any   white  corf-'- 
to  the  area,  the   part   remained  quite  clear  an<l  showtnl  no  i 
eye    change.     But   on    the    third    day    niicroscapic    exauitusluia 
^^howed  that  the  corneal  corpuscles  around  the  damaged  arc.i  " 
.«liooting  proce!*se(<  inio  it.      Nuclei  appeared  on  the  proce-ti;  ji  -' 
plastu  collected  around   thetu  :   and  brunehiHl   cell.«  fomuMi.  obidi 
apiin   threw    out    rejienerative    proi'es'se.f.    and   so  the    riiriirni  ■  ■ 
puscles  were  completely  restored.      Had    leucocytes   bet'ti  aiiiii  i;  i 
to  the  corneal  tissue,  controversy  would  have  ariocn  as  to  wbt-ibcr 
tlii'v  also  did   not   sprinp   from    the  cells    by   multiplication:  but, 
inllamnuitory  |)li<-nomena  being  prevented,  the  regenerative  prnciiMi 
coiilil  be  studied  alone.      In  other  ti.ssues  alsti  regenerative  prwrtM*' 
occur,  the  more  resistant  elements  endeavoring  to  make  pxxi  tlif 
lo.«s  sustaine<l  by  the  tissue ;  but  such  attempts  are  found  nininiv  id 
clironic  and   subsiding   intlamuiations.      In   these  we  must   lu'  pr^ 
pared  to  find  evidence  of  cell-multiplication,  which  will  I*  nor* 
marked    and    commence    sooner    when   the    injury   is   slight.    Tit 
greater    the    injury,    the    Mure    marked    will     be    the   Jft^mrrttk* 
changes  and  the  lea$  marked  the  regenerative. 

THE  ESSENTIAL  LESION   OF   INFLAMMATION. -H»f 
ing  thus  briefly  described  the  succession  of  changes  which  nwur  •» 
the  process  of  inflammation,  we  may  next  consider  how  an  >' 
produces  them.     An  injury  has  been  held  to  cause  abnomol  • 
ditious  of  the  blood,  of  the  tissues,  of  the  nerves,  and  4)f  the  liK"**" 
vcflsela.     Ou  one  or  more  of  these  it  must  neci^sarily  act. 

There   is  no  re.ison  for  supposing  that  the  blood   is  nec«K«rt»J 
damaged.     We  can  see  that  while  the  circulation   round  a  mi*^***" 
seopie  inflammation  proceeds  in  a  normal  manner,  any  corpo#^**^ 
entering  this  region   rend  to  stick  i<i  each  other  and  to  the  ti 
walls  (p.  2H(I) ;  but  when  they  get  through  the  part  again  tbeV" 
on  toward   the   heart  (piite   normally,  aa    before.     Further.  bl<**^ 
drawn  from  an  inflamed  area  behaves  exactly  like  that   frtiin  oti*^ 
parts. 

The  tiflsue-elementa  are  certainly  affecteil  in  ca«efl  dn«  to  obvio** 
external  injury,  and  probably  in  all  others,  but 


11 


lyFLAMMATIOy. 


287 


to  show  that  hijurif  to  vesseU  alone  would  give  rise  to  inflara- 
ItioD.  He  injured  the  vessels  of  a  part  by  witlHirawinj;  the  blood 
Dm  them  and  then  injecting  them  with  iiTitatiiig  i^idutions*.  On 
Bowing  blood  to  flow  through  the  part  again  he  found  that  all  the 
ttt'iiDuiena  of  inflammation  ensued.     It  is  therefore  possible  to  j)ro- 

Ecc  inllnmmaiion  Itv'  injury  of  the  vessels  alone  if  we  can  be  sure 
It  in  this  experiment  the  irritant  did  not  pass  througli  to  rlic 
i*nvf  H!id  ilaniage  t/icm  as  well.  Conversely,  injury  of  a  uou- 
luciikr  tissue  which  does  not  at  the  same  time  affect  vessels  is  not 
lllowed  by  the  phenomena  of  inHammation  (p.  287). 

Sensory  and  vaso-motor  nerves  must  ofttrn  be  affected  by  irri- 
ints.  nnd  no  doubt  take  their  part  in  producing  those  variations 
t  calilire  and  flow  which  oflen  precede  the  essential   phenomena  of 

liunination.      But  as  all  these  latter  occur  with   perfect  regularity 
a  part  of  which  everything  except  the  main  artery  and  vein  are 

vi4'il,  nerve."*  cannot  be  regarded  as  essential  t<»  tiie  process. 

There  remains,  then,  only  the  vessel-wall.     That  this  is  affected 

shown  by  the  facts  that   the  earliest  plu'nouieua  nf  inflammation 

e  VMcular ;  that  injury  of  vessels  causes  these  phennmena  ;  that 
kjurjr  confined   to   non-rascnlar    ti.ssues    does    not    cause    them. 

'irtlier.  Ryneck  has  shown  tiiat  stasis  may  be  prodm-ed  in  the 
fog*  neb  in  which  milk  or  detibrimited  blood  is  circulating  in 
••oeof  normal  blood,  and  also  that  in  vessels  the  vitality  of  which 
*»  been  completely  destroyed  by  the  injection  of  metallic  poisons 
^  fiich  stasis  can  be  produced.  In  all  spontaneous  inflammntions 
*  CftUHe  is  probably  carried  to  the  part  bv  the  blooil,  acting  pri- 
fcrily  upon  the  vessels  and  secondarily  upon  tlic  tissues. 
There  is  no  iletectable  structural  altcrnlinn  of  the  vessel,  how- 
*r:  so  Cohnheim  sjjoke  of  the  clniuge  as  "  molecular,"  and 
f*f<led  it  a«  fiossibly  chemical  in  nature.  To  cover  all  that  we 
f*  know  of  the  escape  of  fluid  ami  corpuscles,  it  is  neces.sary  to 
I^E  that  the  molecular  change  not  only  increases  the  friction 
^^■t  the  blood  and  the  ve.ssel-wall,  but  also  that  it  renders  the 
^^Bore  "  permeable  "  (p.  237). 

Explanation  of  the  microscopic  phenomena. 

p''  hen  contraction  of  arterioles  is  the  first  effect  of  an  irritant, 
'5  probably  due  to  its  action  as  a  direct  stimulant  of  the  vessel- 
p'l ;  but  nothing  is  really  known  on   this  point. 
i^Uatation  with  acceleration  of  flow   may   ju-obably  occur  in 


288 


T^^FLA^f^fAT^ny. 


two  ways:  (1)  Irritation  of  a  sensory  nerve  is  >*rll   known  tel 


•iila 


ib 


latatiuD  ot   till'  urtcnoU'H  in   it»  own  area  of  ili»tn 
action  of  an  irritant  not  siifliciently  intense  to  pnrni\-)io  tbr  \tmti$ 
at  once  will  stiuiiilate  the  s«'nttory  nerves  ami  eAime  this  rrfirx  IdkJ 
ililatittion.     Tlic    arterioles    dilate,   anil,   the    l.i|ooi|-|tre*!«nrr   bciftj 
uiaintained.  a   larger  i{tiaiitity  of  blood  is  adniilte<i  to  their  rajiiJ- 
laries,  which  cannot  diiat^i  proportionally.     The  bIood-pre««nrr  n 
the  eapillarv  ureas  is,  firtrrif  /inrihim,  rnii«e<l   in   propi>rtiou  to  ilr 
increase    in   the  cross-seetion   of  the  supplying   arterinU';*.     I'mkr 
these  circumstances  acceleration  of  the  streaiu  will  acooni|MiDT  ifali- 
tation   of  vessels.     The  wiill.s  of  the  latter,  being   uuinjur*<l,  miy 
contract  after  such  dilatation.     (2)  Hut  Cohnheini   found  that  tl« 
same  phenotuena  occurred   in   the  frog's  tongue  after  i^ectipD  nf 
everything  exce|)t  the  lingual  arteries  and  veins.     Ther  arc  tka 
due,  perhajis.  to  Jirt'ct  artiim  of  tin-  irritant  upon  t/ir  lot-nl  rturtlt 
nervous  fi/»teni,  which  maintains  a  certain  "  tone  "  in  the  vtiwW 
even  after  section  of  the  sympathetic.     Dilatation  of  arterie*  ilimio- 
ishes  the   resistance  to  the  flow  of  blood;  injury  of  eoil't'  '  " 
increases   it.      If  (he   former   is  in  e.xce8H  of  the   latter,  tii<    - 
phenomena  will  occur.     They  are  not  seen  in  severe  injurioBM' 
from  the  slow  action  of  croton  oil  on  a  part.     Tlie  aecdvratidB  i* 
most  marked  in  the  outlying  parts  of  the  intlnmed  area. 

Dilatation  with  Retardation  of  Flow. — Keturdation  noon  fol- 
lows uj>on  acceleration,  though  the  driving  fore*- ••onlinuc* 'f 
and  no  contraction  of  vessels  has  occurred.  Alnmst  the 'n. 
ceivable  eaiu$o  of  slowing  is,  therefore,  increased  local  re»i«t«Bi». 
<lue  to  alteration  in  the  ves.sel-wall.  It  is  one  of  the  result*  "f '!>♦ 
molecular  changre.  Resistance,  and  therefore  retardation,  imrr*-*" 
with  the  alteration  of  vessel-wall  until  stasis  and  evt-n  thromboii* 
are  reached,  the  latter,  in  the  case  of  capillaries,  probably  mf^yf 
death  of  the  part. 

Escape  of  Contents  of  Veeeela. — Nonually.  the  veMelt  1*^ 
tnit  the  escape  of  fluid,   for   healthy   lymph,  cerebro-spinal  8ii«»' 
and   the  fluid  which  tuoistfiis  the   pleum   are  all   ilerived  fr 
blood.     These   fluiil.*  differ  from   each   other  in   many  par? 
These  differences  depend  on  that  s{H.>eiaI  quality   which  mt  I*" 
apoken   of  as    ••  |>ermenbility  "    (p.   237).    and    which    ll<i 
regards  as  an   active  secretory   process.      Directly  an  inflam-^ 
set«  in.  the  normal  fluid  of  the  part  is  changed  in  pro|inrtion  tntK 
intensity  of  the  process  (p.  285);  the  ifuantity  of  albumin  riMa.tb' 


INFLAMMATION.  289 

f  to  coagulate  increases,  and  corpuscles  appear,  as  already 
d  (p.  283).  All  this  is  attributed  to  a  molecular  change, 
^nders  easier  the  escape  of  proteids,  as  has  been  shown  by 
5  solutions  of  such  bodies,  though  the  vessels  bore  the  nor- 
od-pres8ure  without  bursting  even  after  red  corpuscles  had 

generally  stated  that  heavy  particles  are  drawn  into  and 
along  by  the  swift  axial  stream,  and  that,  when  the  parti- 
such  a  stream  are  of  different  weights,  there  is  a  tendency 
lighter  to  be  thrown  toward  the  circumference.  Thus  the 
;e8,  being  lighter  than  the  red  corpuscles,  consequently  pass 
)  periaxial  stream  whenever  the  current  is  slowed  beyond  a 
point.  They  lag  behind  because  they  are  in  the  more 
loving  stream.  These  phenomena  will  therefore  most 
occur  in  the  slower  parts  of  the  blood-current  (veins).  But 
ilanation  is  insufficient,  as  leucocytes  weighted  with  particles 
ilion  act  in  a  precisely  similar  manner.  Many  observers 
n  that  the  difference  between  the  specific  gravity  of  the  sus- 
particles  and  of  the  whole  fluid  represents  the  tendency  the 
i  have  to  fall  out  of  the  stream  (p.  243). 
regard  to  the  migration  or  diapedesis  of  corpuscles,  the 
re  ill  chosen  as  regards  the  red  corpuscles,  which  can  take 
?  part  in  their  escape.  Moreover,  it  is  plain  that  the  force 
rives  out  the  red  corpuscle  when  lying  against  the  vessel- 
II  act  also  upon  the  similarly  situated  leucocyte.  It  was 
r  thought  that  these  manifested  no  signs  of  activity  whilst 
re  within  the  vessels,  but  many  observers  have  shown  that 
Further,  von  Recklinghausen  has  seen  a  pigment-cell  in 
;  frog  work  its  way  into  a  capillary  and  while  there  send  out 
8.  He  argues  from  this  that  a  leucocyte  can  work  its  way 
any  rate,  we  must  admit  that  leucocytes  probably  are  able 
mething  toward  their  escape. 

nfluence  of  intravascular  pressure  upon  diapedesis  is  uncer- 
)ompression  of  the  supplying  artery  will  generally  stop  the 
ive  migration.  On  the  other  hand,  the  arrest  of  the  heart's 
n  the  tadpole  has  no  such  effect.  The  results  of  experi- 
jvised  to  show  the  effect  of  vaao-motor  paralysis  are  also 
ctory.  While  in  the  majority  of  cases  vascular  dilatation 
iapedesis,  there  are  many  exceptions  to  the  rule.  Metch- 
>mpares  the  results  of  inoculating  two  guinea-pigs  under  the 
R 


290 


ISFLAMMATIOS. 


skin  of  t)ic  car,  one  with  tubcrfle  bacilli,  tlu-  other  with  the 
Mi'tchnikowii :  in  the  Hrst  aniniul  the  dilatation  will  hv  flight 
the  (linpeilesi^  considerable ;  in  the  second  the  dilAtation  will  be, 
marked,  while  there  will  be  scarcely  any  diapcde*i»  «t  ■]]. 
frog's  mesentery  be  moistened  with  a  s<^liitinu  '»f  <)tiiniiir. 
tliapedesis  will  occur,  though  from  their  siibseijuenl  behnridr  ft 
can  be  shown  that  the  leucocytes  are  not  |iiirnly9ced.  Hax  tlr 
<|iiinine  a  repellent  action  on  the  leucocytes',  or  iloes  it  priMiuo 
some  inex|ilicable  resistance  in  the  vessel-wall?  The  Utter  vift 
IB  opposed  to  all  we  know  of  the  phenomena  in  i|rje)<tion ;  ud 
MetchnikofT  ac<"ordirigly  ikmcjiIs  the  former  exfdiinntion.  nii'l  O'n- 
siders  that  diai)eilesi.s  nininly  depends  on  some  variable  nualitv  p* 
Bcssed  by  the  leucocyte  which  causes  it  to  seek  or  to  avoid  tl» 
vessel-wall.  Others  are  inclined  to  attribute  ilifTerenccs  in  lb* 
behavior  of  the  leucocytes  to  differences  in  tJio  chemical  eonilitioM 
in  the  environment. 

DestructioD  of  tissue  is  due  to  the  damage  done  by  thr  injifj 
to  the  element.s  of  the  part,  to  abnormal  physical  and  chemical  wo- 
ditions   produced   by   the  exudation,  to   the  pejitoni/.ing  aition  wf 
organisms,   and  to  imperfect    blood-supply  in  the  more  advanM^i 
stages.      It  is  doubtful  whether  the  leucocytes  actuallv 
sue,  or  whether  their  only  function   is  the  removal  i>t    _ 
ar4>  dead,  and  of  such  substances   aa  they  may  be  unac< 
to  encounter. 


CLINICAL    SIGNS    OP    INFLAMMATION.— TbeM 
rediirKt,  heni,  »wfllin<f,  pain,  nmi  imfxiimd  function. 

Redness  and  Heat  may  lie  taken  together,  as  they  botli  ikp'O'i 
upon  the  ipuintity  of  blood  passing  through  the  |iart  in  a  unit  ki 
time.  Ab  a  rule,  this  quantity  of  blood  18  incre««e<l,  the  »x«» 
being  most  marked  in  the  early  stage  of  the  pro<'ess.  when  tbf  l*** 
is  bright-red  and  hot.  Its  ves.sels  are  then  fully  dilatctl  ainl  ^' 
resistance  but  little  increased.  As  the  resistance  grows,  from  n^"* 
marked   molecular  change  and  from    pressure  of  incrt-.i    ■  i" 

tiou  the  i{uantity  of  blood  passing  through  the  part  i>   ..:!       '"j 
Cohnheim  excited  inflammation  in  one  foot  of  a  dog.  aoii  meail 
the  blood  returning  through  Itoth  femoral  veins  afterward.     All 
the  delivery   on   the  injured  side  was  excessive,   sometime* 
than  twice  the  normal :  but  when  diffu.se  suppuration  or  sluoj 
was  induced  the  deliverr  became  markedly  less  than  normal. 


INFLA  MM  A  TION.  291 

must  accompany  such  a  condition,  and  such  a  part  will  be 
I  if  its  vessels  are  dilated  and  full,  but  mottled  or  pale  if  they 
impressed  by  exudation.  In  most  inflammations  the  internal 
external  resistances  to  the  circulation  are  not  sufficient  to 
terbalance  the  efi'ect  of  dilatation,  and  the  blood-pressure  is 
up;  consequently,  the  delivery  from  the  veins  remains 
»ire  throughout,  and  the  part  is  red  and  hot.  Both  redness 
heat  may  be  concealed  if  normal  tissues  cover  the  inflamed 
An  inflamed  foot  may  appear  to  be  several  degrees  hotter 
its  fellow,  but  its  surface-temperature  will  never  equal  that  in 
■ectum.  An  inflamed  pleura  is  never  any  hotter  than  its  fellow, 
may  be  colder.  The  local  rise  of  surface-temperature  is  due 
ly  to  more  rapid  circulation  of  arterial  blood  :  excess  of  heat 
t  produced  in  the  part. 

relling',  beyond  the  most  trivial,  which  may  be  due  to  dilated 
jIs,  is  the  result  of  oxidation  of  fluid  and  corpuscles.  It  may 
ntirely  owing  to  fluid,  as  in  hydrocele,  or  entirely  owing  to 
1  round-cells,  the  fluid  having  been  absorbed,  as  in  orchitis.  It 
s  in  amount  with  the  distensibility  of  the  j)art,  being  most 
:ed  in  such  tissues  as  the  scrotum  and  eyelids,  and  least  marked 
me.  When  due  to  fluid  (oedema)  the  affected  part  "  pits,"  un- 
it is  very  tensely  stretched.  Swelling  from  cell-infiltration  is 
does  not  pit,  and  is  sometimes  called  "solid  oedema."  Swell- 
may  escape  detection  in  cases  of  slight  inflammation,  in  which 
Tmphatics  suffice  to  carry  awav  the  increased  exudation  (see 

in  is  due  to  pressure  of  the  exudation  on  nerve-endings;  per- 
also  to  chemical  irritation  of  them.  It  varies  directly  with 
«nsitiveness  and  the  tension  of  the  part,  as  well  as  with  the 
ity  of  the  effusion  into  it,  as  is  seen  in  acute  suppuration  in  a 
il  tendon-sheath.  It  is  often  throbbing  from  the  increase  of 
»n  produced  by  each  heart-stroke.  The  eflfect  of  increase  of 
are  in  producing  pain  is  well  shown  by  allowing  an  inflamed 
to  hang  down. 

pcured  ftinction  is  due  to  the  fact  that  every  inflamed  tissue  is 
id.  It  is  proportional  to  the  damage  of  the  essential  cells  of 
ITected  part. 

lBIBTIBS*  of  inflammation.— The  j9roce««  of  inflam- 
'  Perhaps  "  Degrees  "  would  be  n  better  term. 


292 


rSFLAMMATlOH. 


mution  is  liable  to  no  important  vurintioo,  but  the  rmc 
duced  by  injuries  of  different   intensity  aeting  f"r  difffrvnf 
of  time  tipon  different  tissues  vary  sufficiently  to  penuit  of  a  i 
cloiisification  being  made  upon  this  basis.     It  will  be  renirfl 
that  the  first  effect  of  injury   upon  tlie  normal  exudntioo 
increase  the  (|iuintity  of  fluid  which  escaped  from   the  va 
to  render  it  more  albuminous.     Next,  whiUt  the  rise  ii 
of   albuminous   constituents  continued,  leucocytes  sppearml 
creasing  numbers,  and  the  fluid  became  more  and  more 
Furthermore,  with   the  leucocytes  came  a  few  red  corpu 
these,  in  the  most  intense  inflammations,  were  vastly  in  exe 
the    white.     These   differences   in   the  exudation  may  be  foti 
passing  from  the  spreading  odge  toward  the  centre  ■>f  an  infl 
tioD  such  as  that  which  constitutes  spreading  traumatic 
There  is  no  break  in  the  continuity  of  its  producfinn  ;  the 
from  .serous  to  hemorrliagic  intlauimation  occurs  gradually  an 
{lanKii  with  the  increasing  intensity  of  the  injury.     Oonseqi 
the  following  *'  varieties  "  are  to  be  regarded  simply  a«  stepal 
process  of  intianiiuation  due  to  variations  in  (1)  the  n*«i«tingj 
of  the  tissues  (:!),  the  intensity  of  the  cause,  and  (8)  the  dc 
its  action. 

1.  SerouB  Inflammation. —  Injuni  SHi/hl. — .\s  a  ro*ul 
injury    the   noruial    tninsudntiou    from   the   vckM'U   is   iiic 
ijuuntity,  and  contains  excess  of  albumin,  but  very  ffw  l«Mtc 
Conse(|uently,  it  contains  very  little  more  itll)iimiu  than  .••erumj 

the   name),  and  does  not  euugulaie 
^"^■i^-  most  a    few   flakes  form.     The 

amjdes   are  chronic   effusion*  into 
cavities — the     pleura,    jointD.    or 
vaginalis  (hydroctde).     In  each 
lining  of  endothelium   \»  not 
.\n  effusion  of  the  same  kind  occ 
in  the  substance   of  a    part,    r«»n»ti 
inrtHLinwinry  .iMiemn  ..f  .kiu.    ..  inflamuiBtorv  oBdcma  "  (Fie.  105).| 

The    UriB-    «i«p«    ■how  II    wi-rv  •  ...  ' 

flu<ii  •nil  ihf   cxu.ic<i  fliiKi     a  j)art  is  swollen,  "  pit*     ou  pr 

<Km....  Mi-cluw"  l-y  Mr  Boyd.,     ,^^^    y,.^^  ,^,j^^.j    ^^j    ^^  fp„„,|  j,, 

t rated    with    excess   of    Bnid. 
occurs  on  a  mucous  surface  such  an  intluiumatinn  is  calleil 
rhal."     In  this  ca.«e  the  exudation   contains  mucin.      In  i| 
ished  states  of  the  blood,  especially  w  hen  the  albumin  is  dinii 


INFLA  MM  Alloy. 


293 


flammatory  cxudiitions  are  liable  to  be  serous,  even  when  the 
•riicess  is  i»f  considerable  intensity.  In  the  earlier  stages  of  more 
ihlenso  intlaiiiiuutions.  where  the  emijjration  of  blooii-turpuscles  is 
ftot  fully  established,  as  well  as  in  cases  where  the  injury  t<»  the 
■vessoLn,  although  severe,  is  rapid  antl  transient  in  its  action  (as 
tbiit  caused  by  heat  and  blistering  agents),  the  effusion  is  often  a 
clear  aud  only  slightly  eoagiilable  lii|iiid.  With  more  severe  dam- 
ajp  the  coagulating  jiower  of  the  exudation  increases.  Networks 
iif  fibriu  are  freijuent  in  the  meshes  of  inllamod  connective  tissue, 
and  inrge  flakes  of  it  may  come  away  in  otherwise  serous  efl'usions. 
i'lrcst'  inflammations  are  called  sero-flbrinoue,  and  lead  on  to  the 
next  class. 

Fibrinous  Inflammation. — Itijimf  more  Intcimr. — In  this  form 
tlie  exudation  is  still  more  riclily  nlbuininous  and  contains  more 
leuciit'vtes :  it  consei|Uently  has  a  much  greater  tendency  to  coagu- 
lite.und  "  lymph  "  forms  on  the  inflamed  surface  or  in  the  substance 
of  the  inflamed  tissue.  The  most  ty])ical  examples  are  found  cm 
serous  membranes.  On  the  surface  of  the  visceral  ])loura.  for 
esamplc.au  irritant  jtrnduces  redness  from  dilntntion  of  vessels: 
llicu  fiillows  exudation  of  fluid  and  leucocytes,  with  <lamage  of  the 
emliiilielial  lining,  and  fibrin,  funning  upon  the  siirfiice.  entangles  the 
li'Hccintes  in  its  meshes.  Fi/n-in  riintdiniiKj  lfu<-iiri/te»  conKtitiiten 
" injliiwmatori/  li/)iip/t."  The  white  corpuscles  may  be  very  numer- 
"lu.  iir  only  a  few  may  be  distingiiisliiible  in  a  granular  or  obscurely 
filirilluted  matrix.  "  Lymph"  may  now  form  upon  the  opposed  stir- 
lucciif  the  parietal  pleura,  which  becomes  infected  from  the  original 
f'fus,  and  the  two  ])atches  blend.  This  is  the  first  stage  in  the  for- 
inMiori  of  an  "adhesion  " — /.  c  a  band  of  connective  tissue  between 
"I*  t«o  surfaces.  "*  Ijviuph,"  formed  in  exactly  the  same  way,  is 
'1'*  temporary  uniting  luediuiu  in  healing  by  the  first  intention,  and 
'''■'<  siiiiilar  ■■  lymph  "  wliieh  "glazes"  the  surface  of  an  open  wouiul 
*  li'i  hours  after  its  inllictioii.  In  these  cases  the  fluid  escapes 
iroa  file  f|.f.p  surface.  When  it  ocnns  on  a  niur'nus  surface  such 
■nfiiinunation  is  calletl  '■  cnutpous  "  or  "mendtranous."  A  similar 
eolation  occurs  into  connective  tissue  as  a  result  of  chronic  slight 
'nitation ;  the  fluid  is  apparently  absorbed  as  fast  as  it  escapes ; 
"'iriii  prolialdy  forms,  but  it  soon  disappears,  and  with  it  those  leu- 
<iic_vte8  which  crowd  the  tissue:  while  those  parts  of  it  which  have 
"•fMi  destroyed  by  the  prinniry  injury  and  tiic  jirocess  excited  by  it 
»re  ^mtlually  replaceil  by  prolifcnition  of  neighboring  connective- 


294 


INFLAMMATION. 


L 


tissue  cells.  Such  itn  iiilltiuniiiitinn  nmy  end  in  ivbsyrption — now 
leucocytes  wandering  into  lyuipliiiiies  and  re-eutering  the  circulj- 
tion ;  others,  together  with  the  filnin.  laulergoing  fatty  changwiuiJ 
fiirniing  an  emulsion  uliifli  is*  simiitirly  alisorbed. 

Productive  Inflammation. —  Injury  Sliyht,  hut  Lotuj  Cotitmuni. 
—  In  many  cases  tlio  intianimatDry  process  ends  in  the  formatirm  "( 
new  tissue — infiauiiiiatory  fibrou.s  tissue ;  and  the  inflamtnatioD  i» 
then  said  to  be  productive.     In  this  case  the  fibrin  j)resent  ilr  ■ 

IH'ars.  and  the  exiulation  seems  at  this  stage  to  consist  of  cl 

packed  leucocytes   in  a  scanty  homogeneous  luatrix.     The  vitalitv 
of  these   is   maintained   by  vascular   loops  which    spring   from  il»^ 
capiltiiries  of  the  inflamed  tissue  and  penetrate  among  the  celi^  >n 
all  ilirections:   tliis  is  granulation  tissue.      It  differs  from  infliun- 
iiiittitn/  hfiiijih  ill   possessing   vessels  and  in  having  a  honiogeoe<»u* 
instead  of  a  fibrinous  matri.x.     It  derives  its  name  from  the  f*<?t 
that  on  the  floor  of  a  healing  ulcer,  which  consists  of  this  tissue, 
the  young  cells  mass  tliemselves  round  the  apices  of  capillary  liiiif»*. 
all  of  which   project   toward  the  surface,  and  wo  thus  get  the  fli****" 
macle    up  of  ruundeil    projections,  about   the  size   of  a  pin's  he*«* 
which  are  called  '"granulations  "  (Fig.  111.  p.  303).      The  pltntit'**^ 
formation  of  rrgnt'ls  in  I'ttxtntidl to  the  r/ianffei)  which  thl»  ti»»Hr  umir-^- 
(joi't:  in  the  prodiirtion  if  riiiini'rtire  tinxur.     In  healing  wounilsn^^ 
vessels  have  been  found  protruding  from  adjacent  capillaries  by  it'*' 
end  of  the  secntid  day  (Wywoil/nff'). 

To   ascertain    (lie   exact   development  of  granulation  tissue  in*** 
fibrous  tissue,   Ziegler    placed    chambers,    formed   of  two   slightly 
separated    cover-gla,sse8,   in   the  subcutaneous   tissue   of  dogs.  »o<l 
removed   them  at  varying  periods.      U|i  to  the  fifth  day  they  «>»»" 
tained  round-eelLs — some  with  one,  others  with  a  hi-  or  tri-p«r1it* 
nucleus  ;  then  there  appeared  cells  twice  the  size  of  leucocyte*,  con- 
taining ft  large  vesicular  nucleus,  slightly  contractile  and  capal'l*' 
of  taking  pai-ticlcs  into  their  substance.     These  are  called  epithe- 
lioid cells,  on  accintrit  of  their  appearance,  and  formative  celte,  !>•■ 
fibroblasts,  be<-;itt SI'  from   them   all   new  eonneetive  tis.sue  devr!  !■  "^ 
As  they  increased  in  nniidier  those  witji  divided  nuclei  ilisapji'i  - 
so  it  is  jirobablf  that  (lie  fibroblasts  feil  upon  degenerating  leuco- 
cytes.    After   the   twelfth    ihiy   giant-cells    in    increasing  nnnil'i''^ 
were  foiiml,   formed   afiparently  at   the  expense  of  cells  in  tli'"''" 
neighborhood,   either   by   their    coalescence   or  by   their  aborli'' 
attempts  at  multiplication.     Many  giant-cells  degenerate,  but  .<oiu* 


may  develop  into  connective  tissue.  This  tissue  is  formed  thus :  the 
fibrobliints  assume  various  shapes — pyriform,  spindle,  ainl  bniiR-hed 
—ami  are  closelv  packed  in  a  homogeneous  intercellular  sub.^tance. 
The  protoplasm  of  the  Hbrohlasts  eitlier  secretes  or  is  itself  con- 
♦erteil  into  a  substance  which  fihrillates.  By  the  union  of  bunrlles 
ffiitn  different  cells  and  by  spread  of  the  process  to  the  intereelhihir 
nuiwtance  there  are  formeil  intercrossing  fasciculi  of  fibres,  to  which 
adhi'W  some  of  the  nuclei  of  the  original  cells  with  :i  little  proto- 
plwmfFig.  10(i). 

Shwiiigtiin  and  Hallance  repeated  tliose  ex|ierinients.  with  this 
additional  precaution,  liint  they  only  left  one  .small  aperture  bv 
«rhicli  cells  coidd  enter  the  s|)ace  between  the  two  cover-gla.sses. 
Tbey  ngrectl  with  Ziegler  that  leucocytes  were  the  first  cells  to 
enter  this  spnce.  and  that  these  were  succeeded  by  fibrobhists. 
They  differed  from  him  concerning  the  origin  of  these  fibroblasts. 

Flo.  106. 


^"""m  of  new  growth  reiiultlnii  from  chnmlc  iullauinialliin  of  conncpttve  ttuue :  A,m 

"'•""I'l,  a,  •  (ll.roSd,  structure.    .<  •-'uO. 

'"  «»me  cn.ses  in  less  than  twenty  four  hours  after  the  cover-glasses 
*tff  placed  in  position  leucocytes  had  entered  in  considerable  num- 
Wru  iind  had  distributed  themselves  all  over  the  enclosure.  Hut 
"Mr  the  |x>int  of  entry  were  other  cells — plasma-cells  or  fibroblasts. 
Thcsp  Cells  differed  from  the  "  ]iioneer  "  leucocytes  in  that  they 
wn  larger,  more  coarsely  granular,  and  possessed  a  single  dear 
on\  nucleus.  In  im  case  were  transitional  forms  seen.  The 
oripiial  leucocytes  were  never  ob.served  to  undergo  any  but  de- 
generative changes.  The  fibrobhists,  on  the  other  haml,  showed 
greater  power  of  amtrboid  movement  and  of  enclosing  corpuscles 
tliHU  the  original  leucocytes.  It  .seems  clear  that  the  fibroblasts  are 
he  i>w't'fi)»<ir».  hat  not  tin'  prot/i'n//,  of  the  small  round-cells  founil  in 
lie  t«rlieat   stages  of  infianmiation.       Sherrington  und    Hullance 


TNFLAMM.iTTON. 

consider  tbat  the  fibroblasts  are  one  of  the  normal  conatitucDtt  of 
onnnoctivo    tissue.      Motcbnikoff  maintains    that    fixcil   c■onDl■cti^^ 
tissiu'  cflls.  c'liilotlipliiil  I't'lls.  ami  tlii'  l!ir;j;e  nioiioiiticlenr  variety  of 
leucocytes    havt-    all   the    powi'r    of  (ievcli)iiing  intc  fibrous  tismf. 
The  exac-t  origin  of  the  fibroblasts  must  still  l)e  rt-ganled  a><  ilmilii- 
ful.     In   thf  mean  time  it   may  be  observeil  that  the  rcscmbLiiitr 
between  MetchnikofTs  large  mononuclear  leucocytes  and  Shcrrinz- 
tnn   and  Rallunce's  plasma-cells   is  very  close,  both  in  appearand 
ami  beliavirir.       It  is  worthy  of  special  note  that   in  the  eifxTV 
incnt8  of  these  last  observers   blood-vessels  had  not  clevelofH-il  be- 
tween the  cover-glasses  even  by  the  eighteenth  day. 

Tlic  new  connective  tissue  is  calleil  inflammatory  or  scar-tiseue' 
At  first   it  is  highly  vascular,  a  recent  scar  being  redder  than  tb^ 
surrounding  parts;  but  tlie  ttiulency  to  contract  is  characteristic  of 
this  new  fibrous  tissue,  and  as  this  proceeds  vessels  disappear,  »nd 
the  sear,  in  the  course  of  some  weeks  or  months,  becomes  white  «u» 
compared  with  surroun<Iing  parts.     This  contraction  of  scar-ti»*ue 
tnay    produce    serious    results,    such    as   the  gravest   deformities    of 
atrophy  of  the    essential  epithelial  elements  of  glands.     (See  "(Tir- 
rhosis  of  the  Liver.")     The  contraction  is  most  marked  where  tl>9 
tissues  are  loose,  as  uliotit   the  scrotum.      It  appears  to  be  essentia" 
to  the  process  of  healing;  for  this  will  cea,se  in  a  callous  ulcer  of 
the  leg  if  infiltration  of  surrounding  tissues  and  adhesion  to  dee|r>*' 
parts  arrests  contraction.     A  scar  is  always  a  weak  point  in  cfc* 
system,  and  a  tight  scar  is  always  irritable  and  very  liable  to  lin?*»' 
down.     The  tendency  of  scars  is  to  become  fainter. 

But  granulation  tissue  does  not  always  develop  into  sear-tissi**- 
If  the  continued  irritation  become  excessive  or  the  vascular  sii|i[»'.^ 
be    deficient,   the  [irocess    may  be    arrested  at  any  stage,  und  J*" 
generation    will    follow.      Deficient   blood-.«upply   may  be  due    *** 
insufficietit  lievelojimeiit  of  vessels,  diminution  of  their  liiininu  {«•* 
occur  in  giinimata),  or  to   pressure  from  too  dense  ])acking  of  tl»'' 
cells.     It  has  been   found   thnt    imperfect   blood-supply  is  accow*' 
panied  by   tlic  development   of  giant-cells ;   they   arc  found  in  »'' 
really   chronic   inflammations.      Thus,   the   typical   structure  of    * 
tubercle   is — a  giant-cell    in    the  centre,  surrounded  by  fiiraiati*'" 
(epithelioiti)  cells,  whilst  outside  these  and  intermingled  with  the"! 
is  usually  found  a  /one  id' ordinary  leucocytes  (Fig.  lit").     In  giiP'' 
raata  and  lupus-nodules  sitiiilar  structures  are  frequent.     A  Jec''"" 
through  the  thickened  synovial  membrane  in  a  case  of  cbr«.>nii*  *rt''' 


lyPLAMMATION. 


riti*  often  sIiomts  the  following  appearances:  Externally  we  find 
(iTdinary  jjrnii Illation  fi».>«uc.  with  j>oini'  <levelo|»ing  scar-tii^iie  :  pass- 
ins;  townnl  tlic  joint-cavity,  we  fin<l  next  «  layer  of  tVjnnative  cells 
iawhicb  giant-cells  become  increasingly  numerous,  ami  even  typical 
"  tiiln'relest  "  may  occur :  yellow  spots  and  patches  of  fatty  degen- 
fration  next  become  frequent,  and  the  surface  may  be  composed  of 
pwmiiir  debris  in  whicli  cell-forms  are  no  longer  distinguishable. 
A  liiiid  looking  like  thinnish  pus  may  occupy  the  cavity;  it  con- 
iiiiis  however,  very  few  pus-cells,  but  consists  mainly  of  fatty 
jfniniilci' — formed  by  degeneration  of  the  superficial  cells — sus- 
[wmled  in  fluid.  This  is  the  change  known  as  ••chronic  suppu- 
ntion"  of  the  knee.  "Chronic  abscesses "  of  similar  nature 
inur  form  dsewliere.  especially  in  cotinection  with  bone  (caries  of 
'frtpbr*).     When  starting  from  bone  the  purifonn  fluid,  formed  by 

Fio.  107. 


\- 


>  AVrrln  frum  a  raw  nf  lii'irrculniil.i  of  »»•  Uvpr.  A  miUtlnucU-alcd  «l«iil-ceU  ikrcuple* 
Itentittr  kroiitiil  l»  nil  ari'ii  iirmmiiu-iwiim  <°iuiriiliiin,  uiiil.  oiiUlilr  this,  n  ujiie  ('uiuUnUlIK 
v™«lt«ll>  or  nr.rv.tilii.t».  an.!,  t<)  «  \vm  cxtpiit.  nf  lfu<'«>cjl«i.  Tlie  IcueocyUw  are  mo»t 
nuuniiu  ,in  tin-  «iile  wluTf  Ihe  <mif«l|iiii  l>  ini»l  «<lvanc-o<l.     '  'JS*y 

liegeiicration  of  the  granulation  tissue,  simply  distends  the  tissues 

muDil  »bout  and  converts  them  into  a  bag,  the  wall  nf  which  yiehls 

I  little  pus.      <tn   the  other   liiiiid,  increased  irritation  will  destroy 

ffimcof  the  cells  of  the  granulation  tissue  and  will  pnnitnH-  inflam- 

vatidu  of  it,  with  free  escape  of  corpuscles  from  its  ves-sels — in  other 

wonls.  will  cause  it  to  "break  down   into   pus."     This  is  best   seen 

when  a  healing  aseptic  ulcer  with  a  serous  discharge  becomes  septic; 

the  Jischarge  then  becomes  purulent. 


2»8 


INFLAMMATION. 


Interstitial  is  the  tenri  applioil  to  intintiiniatinn  of  politf  orgiw 
when  the  uinuifestiktions  of  the  process  ure  pritnorily  liuiilr<i  to  cJw 
connective  tissue  between  the  casentinl  element*  of  theorgBM.    In- 
terstitial intliunniiition  may  he  ncute.  ninnin;:  on  even  to  fiiippunliniL 
but  as  a  rule  it   is  an  ordinary  proiliictive  inflammation  in  wliifli 
there  is   but   little  exu<lutioit    and   a  eonsiUernhle  amouut  "f  wll- 
niultiplication.      It    is  iieeompanied   by  secoiulary   chnngw  in  tfc* 
essential  eells,  iluc  to  inferfercnee  with   their  nutrition.      In  pano- 
chymatouB  iufiiiintnutions  the  epithelial  elements  of  the  "rfcan  ««■ 
to  be  primarily  affected,  becoming  swollen,  finely  grnnuUr.  or  r»ni 
structureless  and  incapable  of  staining.     These  are  probaW 
degenerative  and  tieerotic  nature,  mixed  up  with   regeneratiu  ; 
cesses  (pp.  38.  79).     The  essential  lesion  of  the  inflammation  mn*. 
of  course,  be  of  the  vessels  in  the  connective  tissue;  but  the  wsentiJ 
cells  of  an  organ  are  much  more  delicate  than  those  of  it*  oono**- 
tjve  tissue,  and  show  more  (juickly  the  efl'ects  of  a  strong  irrit»»^ 
which  causes  engorgement  of  the  vessels  of  the  conneetire  ti*^* 
and  free  escape  of  ceils  and  fluid  into  intercellular  au<I  intrafr**' 
ular  spaces.      I'nder  the  action  "f  very  slight  chronic  irritants  f***** 
liferntion   of  connective-ti.s8ue  celU  occurs,  with  but   little  or 
acetitiiulatiiin   of   leucocytes.      Scar-tissue   is   thus   fornn**!.   «n<l 
nutrition  of   tlie  essential  cells   is  more  slowly,  but    none  the  B 
snrely,  interfered  with. 

Suppurative  or  Purulent   Inflammation, —  Injun/  lutrnrt 
J'rolont/i^tl. — This  is  a  \ery  common  form.      In   it   the  exu^ 
contains  the  same  elements  as  in  the  fibrinous  form  :  the  pecoliar*^ 
of  the  process   is  that  no  coagulation  occurs,  no  "  lymph  '"  fo 
and  no  new  vessels  appear  ;  and  even  such  "  lymph  "  as  may  li» 
been   formed  at   an  earlier  stage  of  the  inflammation  is  de»itmy ' 
when  suppuration  sets  in.     The  irritant  is  more  intense  than  tb 
usually  re<|uire<l  to  produce  fibrinous  inflammation*,  and  it  is 
tial  that  its  action  l)e  ]U'olonged,      Serous  ainl  fibrinous  stage*  o{brf> 
precede  the  suppurative,  showing  that  they  arc  minor  grades  of  ibtf 
same  process. 

.Suppuration  may  be  either  acute  or  chronic;  with  the  latter  wt 
have  already  dealt.  Either  of  these  may  appear  in  s  nrrum»erAed 
(ithtivmi)  (Fig.  lOH)  nr  in  a  iliffiim-  form,  either  in  the  mf'stitncf  uf  a 
part  or  on  tifrff  mtrfarf — mucous  membrane  or  skin.  lu  tlir  latter 
case,  when  the  epithelium  is  destroyed  with  more  or  Ie«s  ofilir  miI»> 
jacent  tissues,  the  process    is  called  \ilceration,  but   wbere  tbe 


iidat^l 


J 


ryFLAM.VATTOX 


299 


deeper  layers  of  the  epithelium  remain   it  is  termed  a  punilent 
CAtarrh. 

Formation  of  an  Acute  Abscess  — When  we  cotno  to  consider 
the  etiology  of  acute  Ruppiiration  we  shall  find  that,  in  all  proba- 
kility,  it  is  always  due  to  the  action  upon  the  tissues  of  organising 
—most  commonly  the  staph iilncurrug  pi/oi/mu's  tiitrciig.  Some  of 
thfoc  organisms  become  arrested  in  the  capillaries  of  a  part,  and, 
ifthteondtdoiiD  are  nultahle  for  their  t/rowtfi,  they  proceed  to  ninl- 
tiplvand  to  give  off  the  products  of  their  mctabolistn.  All  around 
tliem  appears  a  clear  hyaline  ring  of  tissue,  «hicli  docs  not  stain 
«nd  in  which  all  structure  is  lost.  Obviouflly,  some  irritant,  .soaking 
fwni  tile  cocci  into  the  tissues,  has  destroyed  the  latter  and  they 
h«ve  UQilergone  coagulation-necrosis.  In  the  course  of  a  few  hours 
a  ring  of  leucocytes  appears  rnund  this  area  and  becomes  increas- 
ingly ilwime :  they  infiltrate  the  necrosed  urea  irnd  press  in  towiird 
lln'  ceutre.  whilst   the  cocci,  on  the  other  liimd.  uniltiply  and  pass 

Kin.   lOH. 


Ktf0  <u  the  tklii.  The  huniy  lnyiT  hu»  lurxvly  lUsaiiiiearecl,  snd  the  MalpiKlilan 
T^'llVl  upward  l>y  the  subjnitnl  utmci-ss  (a).  The  raaes  of  piiSK-orpiisolos  is  Just 
'••k'lUrilnmi  to  f.)nn  a  ravlty.  the-  wh11»  of  which  are  thickly  liillltrAtfil  with  siinilnr  cclU. 
itomintj  KIk.  lifj.)    iFiMin  ■  ^iieclmi-n  by  Mr.  lioyil.l 

'"'^-  The  cocci  penetrate  the  tissue  in  all  directions,  lying  e8f)e- 
*'*lly  in  lymph-spaces,  and  everywhere  a  layer  of  leucocytes  is 
'i'nnod  to  oppose  them — at  first  in  vain  {p.  315).  However,  after 
nuinv  leucocytes  have  been  either  killed  by  the  chemical  products 
of  llie  organisms  in  the  tissue  or  starved  by  the  inaccessibility  of 
lie  necessary  nutriment,  the  resistance  to  invasion  becomes  suc- 
H>sMfid,  and  by  degrees  the  cocci  are  completely  walled  in  by  gran- 
iJafion  tissue  which  everywhere  intervenes  between  thein  and  the 
fslthj  tissues.     In  rabbits,  after  injection  of  cocci  subcutaneoiisly. 


the  limitation  be>:inH  on  the  third  or  fourth  <Iav.  but  is  not  oon 
ou  tlic  average  till  the  ninth  :  in  man  it  iiKtiallv  occurs  more  sp 
At  firnt  a  central  yello\vii!>h  mu88  uf  uocrooed  tissue  infiltrated  vitli 
cocci  and  leucocytes  is  found,  surrounded  by  the  layer  in  «liiek 
cocci  and  leucocvtcs  are  striiirtrlinc  for  the  niiisterv.  '■ 
central  niahs  Hnftenj*,  and  it  ist  noticed  that  the  tissue-t 
Up  and  become  indistinct  as  the  cocci  spread  among  them;  I 
no  fihrin  forni:*  in  the  fluid  exuilation.  All  this  in  attrihntr 
peptoni/.ing  action  of  the  cocci  which  in  acknowledged  to  txil 
energetic.  80  long  as  the  process  is  actively  spreading  tu>] 
ves!«els  form,  but  as  soon  as  the  leucocytes  have  got  the  tipiNrl 
vessels  iijipeur  and  "granulation  ti.'-isiie  "  is  formed.  Thus 
veloped  ii  cavity  horderetl  by  li.'tsue  infillrnted  Mrith  living 
This  rnvity  contains  dead  leucocytes,  destroye*!  and  Ii(|nefie<r 
an<l  exudation,  as  well  as  a   few  living  cells  which   have^ 

Kio.  109. 


84**'ttt>li  Oiroiik'li  II  ^nniii  pov  iHitiu..'       liM'  ii<>Mi>  i.i>t-r  i)\i-r  iiii' {riilrr' i>t  Ui« 
dUii|'[K'«rtsl,  Mini  tliK  frt'f  i'(Ik\>  nn-  ktiuwii.     A  niiiM  it(  rclU  U  Mrfti  lit  Ih^  lwmii4ii| 
UietMdlU'ii  Mi>l|ili;l>luii  U>ur  ami  th«r  Iruv  •lOii,  miikliie  iu  wit)r  li>  llie  Hirlker. 
■rtiml  Inlmi  U  i>lliiiil<'  wltnUy  In  ilw  fpliliTiiiln,  while  ilir  llnid  »n<l  r«ll«  liair 
IVniii  the  derma,  the  tnirk   bring  uliuwii-    (Oiinpain  Kik  UJS.)     (Krom  •  Hi 
Buyd.) 


ealle^H 

iMNitira^ 


migrated   from   the  surrounding   tissues:  ttiis  fluid   is  ealle 
Once  formed,  such  a  cavity  either  enlarges  or  .<!hiftH  it.*  |)Oiiiti<i 
both.     The   extension  occurs    in    the  direction  of  b-a.il   rr«Utaa'4 
Its  appn>ach  is  marked  by  thrombosis  of  the  minute  veMdft  *J 
mnleciilnr  disintegnifion  of  the  cells  they  supply,  by  mizntlii 
corpuscles,  and  by  exudation  of  fluid  into  the  newly-fonued 
Its  progress  is  not  arrested  until  it  reaches  some  free  nor 
open  cavity,  upon  or  into  which   it  bursts.     We  find  on  MXti 
the  Willi  of  n  sprendiiig  ab.scess  all  the  stages  of  inflammatt 
proof  of  the  prolonged  action  of  the  cause.     In  the  centre.  1 


INFLAMMATION. 


301 


ud  in  sncce^sion  as  we  pass  outward  from  this,  thrombosis,  stasis, 
rrtaiilatixn  of  (low,  (litninisliing.  and  jierbiips  giving  plni-e  to  acctd- 
twliod.  bidorc  the  normal  circulation  is  reached.  With  hypcrtcmia 
exudation  increases ;  much  of  the  fluid  is  taken  oflf  by  lymphatics, 
hilt  tli('  c<irpusclos  acounudate  in  increasing  luinibors.  and  red  join 
tbt'  wliitu  outside  the  vessels  as  the  centre  is  approached.  This 
iccuiint  explains  how  it  is  that  we  are  led  to  the  belief  that  sup- 
piiratioti  has  occurred  when  we  find  redness,  heat,  and  inli'irui 
developing  over  a  deep-seated  swelling. 

•Vii  ncute   abscess   almost    always   extends   until    it   bursts  or   is 

ofn'in'ij;  by  either  of  these  means  tension,  a  great  cause  of  the  con- 

liniijiiiwof  the  inflammation,  is  relieved,  while  the  pus  and  its  orig- 

in.ll  cause  escape  together.      If  the  cavity  is  couiplctely  dniiuetl  aud 

kept  ftt  rest  and  putrefaction  of  the  discharges  is  prevented,  all  pus- 

formarKiii  cea-ses.     Vessels  i|ui(jkly  develop  in  that  fiart  of  tlieround- 

<*llt!i|  inKltration  of  the  walls  iu  whicli  this  hu.s  not  niready  nccurreil: 

Ions  tbcy  become  lined  by  granidation    tissue.     This  grows  and 

Wends  across  the  cavity,  which  is  often  tliniiTiishiMl  by  sonic  falling 

"•  of  the  wall.>».     Scar-tissue  then  develops,  and  thus  the  abscess  is 

'•eale.i  (pp.  128,  129). 

Diffuse  suppuration  is  exactly  the  same  proce.ss  going  on  over 

*  *idc  area.     It  is  often  more  intense  than  when  circumscribed,  and 

•t  18  by  no  means  uncommon  to  find  shreddy  slouglis  in  tlie  pus,  for 

effect  of  the  injury  on  some  portions  of  tissue  is  so  great  as  to 

»8t>   miliar  death.     Diffuse   suppuratiiin    is   generally  due  to  the 

\*^r«ptoeoccns  p-yo(iene» — an  organism  id"  whicii  die  peptonizing  jiower 

P*  more  intense  than  that  rd'  tlie  staphylococcus,  which  possibly 

[»ceom,t8  for  the  difference  in  tlieir  airtion.      (See  "Micrococci.") 

I*U8  from  a  simple  abscess  occurring  in  an  otiierwise   healthy 

P*f8©n  {liiuiliifile  pus)  is  a  thick,  creamy,  opaque,  yellowish-white, 

*''glitly  viscid  fluid,  having  a  faint  odor,  an  alkaline  reaction,  and  a 

[•pe«ific  gravity  of  1030  to  10:^;^.      It  contains  10  to  l.'i  per  cent,  of 

|*oli,|  matter,  of  which    two-tliirds   an-  albiiuiin   and  the  rest   fatty 

latter  and  salts,  such  as  are  found  in  blood.     On  standing  it  scpa- 

*'es  into  a  dense  yellow  layer,  /iit>f-ci>rfiiiiii'(<'i<.  and  a  dear  siipcr- 

**tant  fluid,  llijuor  pur  in. 

I*U8-corpu8clea  are  spheroidal  bodies  about  t^Vj  '"^^h  in  diameter. 

!■*  «»oy  are  semi-transparent,  more  or  less  granular,  aud  motionless: 

•**v  usually  contain  a  hi-  or  tri-partiie   nucleus,  the   .segments  of 

'•*ich  together  are  no  larger  than   the  original   nucleus.      Such 


302 


IXFLAMMATlOy. 


Fin.  110. 


I'n*  rorptiHrlc*)  wt  •*'♦•»  nftor 

di-Htli .    •!.  iR'forv.  >>,  •flvr  the 

dilllliiii  iif  diliiU!  M«tle  *cl(1 


division    is   therefore   regarded  as  evidence  of  degeneration  raflirr 
than  of  iiinltiplieiition  and  of  growth. 

A  small  minority  of  the  cells  have  exactly  the  appearanc*  M 
Icucoeytes  and   j>erf(>nn  iiintrboid.  moveinentit.     These  are  tin 
recently-escaped  cell».     Acetic  acid  clears  up  the  cells  and  ru....- 
obvious  the  often-obscnre  nucleus  (Fig.  110). 

It  is  noteworthy  that  pus  hits  no  jKjwer  of  absorbing  sloughs'* 
sequestra  ;  //«•««</  cells  arc  rei|uired  for  this.  A  bit  of  bone,  evfi  ^v. 
ivory  |K>g.  surrounded  by  granulation  tissue  will  be  slowly  tT'ili  i 

but  it  may  he  in   piu  for  months  witlmctt 
losing  weight,  and  suppuration  is  not  likcW 
to   cease    until    it    is   reinovtHl.      The  pr** 
vention  of  suppuration  is   therefore  to  ^ 
aimed   at    in   all   cases  of  necrosis  and  •• 
foreign  bodies  (especially  aliHurbiiM.    li 
tures)  retaineil  in  wounds. 

Sometimes,  though  rarely  in  ihf  ciLxf 
iin  acute  abscess,  after  a  collection  of  pus  has  furmeil  the  irritat 
diminishes  so  much  that  granulation  tissue  forms  mund  the  fluid 
develops  into  fibrous  tissue.     Such  pu."  may  long  remain  eucapsiil 
its  corpuscles  breaking  down    into  fatty  d(^bri« ;  but  as  a  rule  i 
fluid  part  is  iiltsorbed.  and  a  more  or  less  dry,  chccsj-looking  ui 
et)nsisting  of  cell-d<^bris  and  cholesterin  cryst^ils,  is  Irft  in  the  t^^^m 
sule.     The  mass  nuiy  calcify.      Such  collections  may  lie  harnil 
in   the  tissues   for  years,   and   finally  become  the  centre*  of  ft.  . 

suppuration.     These  changes  are  much   more  commuu   in  chroi^^*^ 
abscesses. 

Ulcerative  Inflammation. —  Wv  have  seen  that  suppuretion 
the  substance  of  tissues  jiroduces  nndeenlar  disintegration  of  ih 
as  a  rule  no  distinct  slough  is  found  in  pus.  The  same  tnoleci 
destruction  eating  away  the  tissues  on  a  free  surface  consti 
ulceration.  I'uder  the  action  of  an  irritant  the  su|KTficial  layer  oT" 
the  fekin  becomes  soaked  with  fluid,  and  leucocytes  esca|te  in  non- 
liers  from  the  vessels  and  wander  even  into  the  epithelial  cell*,  whi 
they  .seem  to  have  arisen  by  endogenous  niidtiplicatiuii.  L" 
these  circumstances  the  superficial  cells  do  not  become  hornjr.  •ad 
art-  I'ttsilv  brushed  ofl".  or  the  original  irritant  may  ha<e  destroyei 
their  \itality  and  cohesion,  and  they  are  washed  away  by  escaping 
fluid.  The  rete  is  now  exposed,  and  the  deeper  tissues  are  liabks  to 
irritation   from   slight  friction,  contact  with  chemical    irritant*,  or 


IXFLA  MM  A  TION 


:M)3 


putriil  liistchnrges.  The  inflainniutorv  pntcfui*  l>ccotm'»<  inori'  intense, 
the  t'>ca|)e  of  IJiiitl  and  leiiencytes  (Veer,  ami  stanis  and  tlirombiKsis 
occur  here  and  tbcre.  Portions  of  the  pupillary  layer  and  of  the 
wvcriug  epithelium  die,  disinte;irate  rapidly,  and  come  away  in  the 
(liMlarge.  The  process  spreads  by  tlu^  j)rodiiction  of  limited  stasis 
mil  death  of  tissue ;  if  the  stasis  is  at  all  widespread,  a  visible 
slough  will  result.  It  is  common,  indeed,  to  see  tags  of  dead  tissue 
»ilhereiii  to  the  floor  of  a  spreading  ulcer.  If  the  irritation  becomes 
oure  intense,  these  shrcfls  will  increase  in  size  and  fomu  "•sloughs." 


Fio.  111. 


_®o  o^^o, 


p«-'aa 


'toi 


/^^ 


y^iH 


lilnf  •iirfkrv :  n,  layer  of  pas ,  fc,  Kniiiulaiiun  ii».siii- with  IiH<r«  of  blcxid-veaiole : 
<  "■miiii;ririii|{  ili!V(-l4i|.ini'iii  of  thi-  itrBnuliiiiiin  tlnKUf  liiln  ii  niirilliilfd  ktructuri-.  x  3X1 
(KUKWcUib.)    Di«|{ri.mui»tic. 

ilcentioii  passes  insensibly  into  giini;reiic  in  proportion  as  death 
bcfoiuw  tiw  rapid  to  porniit.  by  lui-aiis  of  deirencrntion  and  the 
jctirtn  of  leucocytes,  the  molecular  disintegration  nf  the  parts  as 
lliev  file.  The  discharge  in  the  spreading  stage  consists  of  a  few 
ieucocTtcs  and  the  debris  of  broken-down  tissue  suspended  in  fluid. 
JjiVe  the  edge  of  advancing  suppuration,  the  margin  of  a  spreading 
loer  e.xhibits  all  the  stages  of  in flaiuniation,  from  the  mildest  to  the 


J}rFtAMStATTOK 


prodiirtion  of  molecular  death.  An  alwceiis  is  often  li 
closed  iilrer  When  tlie  chiisou  of  the  iiitiiiuiniutiuii  are 
riMind-celliMl  infiltration  of  the  floor  increases  ami  becomes  Mur*r 
Inrizcd  into  grnnulation  tisfnio  (Fig.  111).  Sloughs  arc  det»rfa(>(f  by 
the  action  of  leucocytes  which  eat  through  their  couuectutns  titk 
living  parts,  and  the  base  soon  becomes  covered  with  "granidation*." 
When  healthy,  these  are  bright-red.  slightly-raised.  roiin<leii  rlr> 
vations,  about  the  size  of  a  smull  pin's  head,  and  consist  of  nil* 
grouped  round  a  capillary  loop.  They  contain  no  lymphatin  mA 
no  nerves,  are  not  tender,  and  do  not  bleed  readily.  ho|>artrire 
from  this  type  indicates  disease  of  the  granulations. 

The  granulation  tissue  grows    by  multiplication   of   thr 
cells,  and  such  loss  of  tissue  as  has  occurred  is  thus  replaci 
the  same  time  the  cells  infiltrating  the  edges  disappear,  ami  i 
sink  gradually  t"  the  level  of  the  base.      Epithelium   now  shooU 
from  the  cpitheliul  cells  at  the  margin,  and  three  zones  cannl 
be  distinguished  at  this  stage — an  inner,  dry,  red  zone,  wherr  tk* 
cells  arc  one  or  two  thick  ;  then  a  wider  blue  zone,  where  th« 
thicker,  but  where  no  horny  cells  exist:  and  lastly,  an  opaipie  «■ 
ring  of  sodden  horny  epithelium      The  deeper  layers  of  thcjff''** 
ulation  tissue  are  meanwhile  becoming  scar-tissue.  contractin)( »■>*' 
drawing  together  the  edges  of  the  sore,  so  that  the  epitbeliuv 
less  and  less  to  cover;  and   tinallv  the  whole  surface  i*  skim 
over  and   all  granulation  tissue  is  converted    into  fibrous  Hf^ 
Contraction  goes  on  even  after  this,  and  the  re^tiilting  acar  it  **? 
much  ^<ul!llk■r  than  the  original   ideer  (pp.  l:iH.  \2\i). 

Hemorrhaeric  Inflammation. — This  form  of  inflamuiatioP  " 
characterized  by  an  exudation  in  which  red  corpuscles  are  in  ^r*' 
excess.  So  far  as  can  be  observetl.  red  corpuscles  are  the  latest  <*' 
all  the  contents  of  vessels  to  escape.  In  a  case  of  .spreading  ti*"" 
matic  gangrene  the  ti.ssiies  a  »hitrt  dintance  alxivi'  the  wtiially  g*''' 
grenous  part  were  crammed  with  red  corpuscles,  showing  that  tat 
vessels  couhl  hold  none  tif  their  contents  (Fig.  11-);  hitfher  uf 
there  was  a  free  escape  of  leucocytes  and  of  sero-fibrinoiu)  •fffiwi"* 
(Fig.  1<H);  and  hit/fur  utiff  there  was  effusion  of  simple  wwww 
lluid  only.  <lf  course  the  injury  may  be  .so  inten.on  as  to  moM  la 
immediate  and  free  escape  of  red  corpuscle*  from  the  capilUrin 
The  fluid  which  i»oaks  the  part  in  these  cases  is  usually  thin 
more  or  less  deeply  blood-stained.  The  grtwter  the  nam 
capillaries  present  in  a  tissue  the  more  likely  U  an  t* xiiiUtiaa  to 


lyFLAMSfATTOt 

be  hemorrhagic ;  severity  of  injury  is  the  other  factor.  There  are 
gciu'rally  many  red  corpuscles  present  in  the  exudation  of  acute 
[ineiimonia.  The  free  escape  of  red  corpuseleM  shows  that  the 
cajiillary  stream  in  the  part  is  reduced  to  a  niiniinuiu,   that  the 

Fig.  112. 


en 


•^#»® 


BwfiT  iKjrur  of  ••litis  i«n<l  *ul)<'iilnn«Hiim  fiit  n  sliort  dlntanoe  nbove  llie  dead  part  In  a  <•««> 
oripniniiiiix  i(iiiiim-nv.  Tin-  liiUTstlres  of  the  tlMtiex  art  crnmnicd  wUli  rfd  coit'ispIc's  mid 
«fr«  Kblht;  r,  (,  rtmnectivu  liiviue;  y,  fHt-oullii;  r.  c,  red  cun>Ufit>l(.'S,     •.   lAX).    vBuyd.) 


injury  done  to  the  tissue  is  a  very  grave  one.  and  that  stasis,  death, 
•ml  thrombosis  arc  impending,  Too  often  gangrene  is  the  terniina- 
tiw  uf  such  iutlaiuiuatiou. 


TERMINATIONS  OF  INFLAMMATION.— These  are  retolu- 
'i«B,  ii,(Ti"tM,   and  new  i/rowth. 

!•  Resolution. — This,    the    most    freijuent    and    most    favorable 

•♦nnination  of  inHammation,  consists  in  the  cessation  of  the  pro- 

"**«»nil  the  restoration  of  the  part  to  health.     For  this  to  occur 

"  i»  necessary,  lirst,  that  tjjc  t-xcitiiig  ciiusu  b<?  removeii ;  secondly, 

'Mttli«  walls  of  the  hiood-vessels  he  restored  to  their  normal  con- 

'litinii.   in    order    that    abnormal    tran.Hudation    may    be    arrested; 

'""filly,  that   all  exudation    be  disposed  of;    and   lastly,   that  any 

onMl  or  damaged  tissue-elenienta  be  regenerated.     Obviously,  this 

fMtorntion   will   be  more  easily  eftVcted  in  the  earlier  than  in   the 

more  advanced  stages  of  tiie  inflammatory  jjrocess.     But  resolution 

Isvcnof  ''stasis"  sometimes  occurs,  and  may  be  watehed  under  the 

sicroitcope.     The  corpuscles  of  the  stagnant  blood  move  off,  one 

IT  another,   till    a    slow    stream    is    re-establis!ied    through    the 

iflajuod    area.      This   stream    ipiickens    as    resistanre    diminishes, 

ctiDtraction   of  the    vessels    follows  the   gradual    recovery  of 

30 


SOS 


ryriAXirATTOJf. 


their  muscular  coat«.     ExndatioD.  first  of  corpiuicle».  tlien  of  llaidL 
ct'asc».  and  tin*  ciroiilntion  ac;ain    becomes  normal       Sentm.  i»r»- 
fibrinous,  and   productive   infianimatiood  in  their  early  ht^fu  trv 
those  which  end  in  retolution :  but  if  normal  tissue  has  be«o  one* 
replaced  \t\  firiiniilntion  tissue  or  scar-tissue,  or  has  been  tl» - 
by  suppuration,   ulceration,  or   gangrene,  remlution   is  imiH.-- 
A  normal  con<lition  of  the  walls  of  the  blood-vessels  is  deiniil'T 
upon  the  proper  circulation  of  the  blood  through  them  and  ibftr 
va,sa  vusortim.      Whatever,  therefore,  favors  the  re-establishment  wf 
normal  circulation  in  the  inflamed  area  will  favor  resolution. 

The  last  element  in  resolution  is  the  removal  of  the  int1atumtt'>rT 
products — fluid  iind  corpuscles,  These  are  removed  un 
lymphatics,  but  after  restoration  of  the  circulation  al  ,  • 
carried  on  to  some  extent  by  the  veins  also.  In  the  later  »Ujt« 
of  the  process  any  unabsorbed  blood-corpuscles  or  fibrin  iindftyi 
fatty  degeneration,  and  thus  the  complete  removal  of  the  infl»»- 
matory  producta  is  much  facilitated.  (See  "Gray  Iiepatiaati<iD-~i 
The  process  of  regeneration  in  the  various  tissues  has  already  bc« 
describe<l  (j).  11!>). 

All  conilitions  interfering  with  the  lymphatic  or  vaacular  circa^' 
tion.  such  as  the  pre-ssure  exerci8e<i  by  a  large  effusion  in  a  mto* 
cavity  or  by  a  richly  celluliir  exudation  in  a  lymphatic  gland,  m** 
retard  resolution.      It  is  generally  believed   that   interference  *'" 
the  li/iii/)hatu'  circulation   tends    especially  to  prevent  absoqitK*- 
and  interference    with  the    circulation   in  the    hhunl-rriinfU  < 
vent  that  restoration  of  those  vessels  to  a  normal  condition  v: 
necessary  to  arrest  the  continued  transudation.     Recent  nhnmritt* 
have,   however,  shown '   that    fluid   artificially  introduce*!    into  ti« 
pleural  cavity  is  mainly  absorbed  by   the  blood-ve.ssels :  and  it  • 
possible  that  the    absorptive    power   of  the    lymphatics    ha>   b«« 
overrated. 

II.  Necrosis. — Inflammation  may  terminate  in  death  of 
inflamed  tis.-iue.  Wcigcrt  has  shown  that  in  all  but  the  sligl 
forms  of  inflammation  the  inability  to  stain  will  reveal  cells  m^\A 
have  undergone  coagulative  necrosis  (p.  80).  In  nin«t  inflaauna- 
tions  the  destruction  of  the  tissue-elements  is  .siill  more  niarkeiL 
Clinically,  we  do  not  speak  of  necrosis  unlfss  nbviou*  molar  destk 
of  tissue  has  occurred,  a»  lilstingiii.Hiii-d  fpiiii  the  iitolrcular  dgatfe- 
lion  characteristic  of  sii|)ptinilion  and  ulceration. 

'  Htarling  ami  Tubby,  Juurnal  i^f  Pkyoiolugy,  I8M. 


WFLAMMATTOy. 


307 


Tbe  severer  the  injury,  the  longer  its  period  «f  action,  and  the 
cbler  ihe  rosistance  of  the  tiswiies,  the  more  likely  is  necrosis  to 
B«U.     It  may  be  produced  in  the  tbllowing  ways: 

1.  By  direct  injury  to  a  part,  producing,  by  its  continued  action, 
itl«Tninati>ry  disturbance  of  the  circulation,  ending;  in  tiironibosis. 

tissues  are   affected   by   the    injury   siniuItaneouHiy    with    the 
i,  and  suffer  also  from  the  interference  with  the  circulation. 

2,  By  an  irritant  conveyed  to  a  part  by  its  vessels,  affecting  them 
•rimsrily  ami  inducing  in  them  changes  similar  to  tiie  foregoing. 
Ibe  tissues  are  affected  secomliirily  both  by  the  irritant  and  by  the 
circulatory  disturbunec. 

•1.  By  pressure  of  a  neighboring  inflammatory  exudation.  This 
ttraiigHJatcs  the  supjdying  vessels,  as  in  sl<Higliing  of  skin  from 
WiWflcdeina.  in  necrosis  of  tendons  in  a  whitlow,  and  in  death  and 
pgi'iitration  of  cells  in  chronic  tiithimnmtinns.  Death  is  lunrc 
kely  fo  be  produced  in  this  way  when  the  cxudsitiou  occurs  in 
tyiitlding  parts,  e.specially  in  bone;  here  sudden  dcatli  of  an  c.xten- 
Vc  exudation  means  death  of  the  affectc<l  part  of  the  bone  and  its 
Jbcequent  separation  iit  the  foi-m  of  a  sei(Uestrum.  (8ee  "  Necrosis 
'  Bone") 

lu  all  infective  inflammations  the  irritant  exercises  its  deleterious 
tfct  upon  the  cells  of  the  inflammatory  exudation  and  tends  to 
Wroy  them. 

•  Some  causes  of  inflammation  always  lead  to  gangrene — e.g.  those 
'  carbuncle,  nnilignant  pustule,  and  hos[iital  gangrene.     Such  in- 

mmations  are  sometimes  called  gangrenous  or  necrotic. 

The  ulcerative  process  by  which  a  slough  or  8e<|uestrum  is  de- 
fliwl  lias  ah'eady  been  described  (p.  40). 

III.  New  Growth. — Inflammations  ending  in  new  growth  are  the 
N»lled  "productive"'  intiunimations  (p.  '2!*4).  For  this  to  occur 
le  inflammation  must  reach  tlie  fibrinous  stage,  must  endure  for 
Bie  time,  and  must  not  pass  on  to  suppuration.  Moreover,  the 
0(>d-supplv   must  be  plentiful. 

ETIOLOGY  OF  INFLAMMATION.— riinicnl  observation  has 
[>wn  that  certain  intbimiriiitions  appear  to  have  obvious  causes. 
5h  as  blows  and  strains :  these  are  called  simple,  traumatic,  or 
Bnerogenetic.  We  shall  presently  see  how  few  inflammations 
I  entirely  under  this  heading.  In  the  vast  majority  of  instances 
cftiise  is  obvious:  these  ma v  be  calle<l  cryptogenetic,  uUhough 


ha 


308 


ISFLAMMATIOy. 


of  lat€  years  the  causes  of  many  sucb    influiniiiations  have  b**" 
clearly  demonstrated. 

It  iiKist  iihvuys  1)0  remembered,  in  considering  the  mode  of  pn*" 
ductimi  of  an  iiiiluinuiutioii,  that  there  are  two  /aciom  in  the  pntf^ 
— the  cause  iiud  the  tissues  njion  which  it  acts.     A*  in  (Lt'o*^* 
of  other  utorliiil  foiidition.-j,  tlif  ciiiiscs  of  iufluiumation  are  ezcitiofi 
and  predisposing.     Sometimes  no  predisposition  is  necessarj.  bi** 
often  the  exciting  cause  of  sin   inflammation  cannot  act  iinlc*  ll»« 
resisting  jiowcr  of  the  tissues  to  the  irritant  in  question  ha.'  Ih^«» 
lowered.     This  impairment  of  resisting  power  is  the  work  of  llt« 
prcili'xponiiii/  causes,  and  it  may  be  cither   inherited  or  8c<|iiirir<l 
(p.  2ti).     It  is  obvious  that  in  cases  where  preilisposition  is  ncci-s-'sry 
the  condition  of  the  tissues  is  as  essential  to  the  production  nf  •.«» 
inflamiuation  as  is  the  presence  of  the  exciting  cause:  the  M'fti«i»«J 
the  yiiitiifi/f  soil  must  come  together  to  produce  the  jdaiit. 

Willi  rcgiird  to  the  nature  of  the  exciting  cause,  it  is  alway.".*!!!** 
mechanical,  chemical,  or  physical  agency.  The  simple  dcpriv«ii(»t> 
of  liloiiil-siipply.  which  lends  to  injury  of  the  vessel-walln  nml  the 
surmuruliug  tissues,  is  enough.  If  these  agents  he  of  sufficiciit 
strength  and  be  continued  for  a  sufficient  time,  they  cause  Jwlhof 
the  part;  short  of  this,  they  ]iro<luce  distinct  changes  toward  dtito 
(p.  315),  and  in  their  sligiitest  intensity  they  act  as  simple  "licprt**- 
ants  " — /.  e.  as  predisjmsing  causes  of  disease.  Every  condition  "P* 
posed  to  the  health  of  the  whole  or  of  part  of  the  body  will  lie»^ 
finil  its  jilace. 

DifFtcult  us  it  is  to  discover  the  cause  of  many  inflamniatiow^  *** 
should  bear  in  mind  the  very  obvious  fact  that  «<»  infiaiumatiun  c** 
arisi'H  trithoni  a  oniJir,  giinjile  or  complex.  If  an  inJhimiiKtliff* 
ttprfaJn,  its  r<ni»e  hati  Hjiread  he/ore  it  ;  and  pemititfuce  nf  itn  iKJlitf**' 
mation  [chronieity)  implies  continued  action  of  its  cause. 

I.  Simple,  Traumatic    or    Phanerogenetic    Inflammations-—^ 
These  lire  due  to  the  action  of  some  very  evident   injurious  i>{;tii<^.>- 
such  as  median iciil  violence,  caustic  and  irritating  chemicals,  «?<?*" 
sive  heat  or  cold,  electrii-ity  strong  enough   to   produce  electrrtly**^ 
of  the  fluids  of  the  ]*!irt,  or  prolonged  local  ann>nii»  and  con»f<|"it*'* 
privation  of  blood.      It  is  characteristic  of  inflaniniation  from  tb*** 
causes  alone  that  it  iias  no  tendency  to  spread  beyond  the  ftart  or*!' 
ivally  injured  nor  to  pass  on  to  more  adrnnred  statjes  after  thr  en^*^ 
hail  ceased  to  act.     Every  one  knows  how  slight  are  the  inflauunn'"''* 
changes  induced  by  very  severe  siibrutaneous  injuries,  even  ih"'^ 


mFLAMMATION. 


bo  broken  and  tbc  capsules  of  joints  torn ;  and  it  is  to  be 

tiiat  all   will  xooti   bo  cinially  familiar  with  the  absence  of 

ilflamuiation  when  siiniliir  injuries,  i-cmmnnicatintj  icith  the  atmo' 

tfktre.  are  treated  in  such  a  way  (antiseptically)  as  to  exclude  all 

ondary  causes.     In  animals  thi'  eft'ects  of  each  of  these  irritants 

'wn  be  accurately  »tudie<l.     tliiter  injected  a  .">  per  cent,  solution 

of  nitrate  of  silver  or  a  similar  solution  of  chloride  of  zinc  into  the 

mnscles  and  other  tissues  of  animals,  and  thus  killed  the  part  acted 

on.    In  a  large  number  of  the  cases  no  sign  of  inflammation  was 

(blind  in  the  surrounding  tissues.     Other  experiments  were  made 

br  |ilitnging  a  cautery  into  a  muscle  (llailhauer)  and  bringing  the 

prfvioiisly  diviiled  .skin  together  over  the   injured  part,  antiseptics 

Ijt'ing  used.      Only  such  changes  occurred  round  the  eschar  as  take 

pl»ce  in  the  absorption  of  a  simple  infarct  and  its  replacement  by 

Hliroiis  tissue.      Here,  then,  we  have  examples  nf  the  most  severe 

luirbanical.   chemical,  and    jdiysical    injuries    killing    c<tiisiderable 

nia«ses  of  tissue,  but  only  giving  rise  to  the  slightest  forms  of  in- 

'I'tmtnation.      In  each  case  the  action  of  the  irritant,  though  intense. 

'»  localized  and  of  short  duration.     Certain   parts  are  killed  abso- 

I'ltely.  and  the  surrounding   damaged  area  is  a  very  narrow  one. 

^  .'«oon  as  the  mo.xa  has  ceased  acting  the  tissues  tend  of  them- 

*«'vf»  to  recover;  hence  inHammation  excited  by  such  cati.ses  as  the 

above  reaches   its  height   very  soon  after  the   introiluction  of  the 

"Tilant,  and  soon  subsides  unless  .some  fresh  irritant  is  superadded. 

I    'his  is  frei|uently  seen  after  the  infliction  and  projier  treatment  of 
*  clean-cut  wound  by  a  shar|)  knife  (|i.  1"27).     A  chemicnl   irritant 
"lay  enter  the  body  at  a  distance  from  the  fiart  at  wliich  its  chief 
"•^tion  takes  place;  thus  alcohol  taken  by  the  mouth  causes  cirrhosis 
'^f  the   liver,  and   turpentine   or   cantharides,   inflammation   of  the 
''•diieys. 
Tender  this  heading  come  inflammations  which  arc  referred  to  cold 
'•'*ti  wet — •'rheumatic  "  and  "reflex  "  inflammations.    WlicJi  a  man 
K«ta  conjunctivitis  from  the  action  upon  his  eye  of  a  draught  through 
*  keyhole,  the  relation  between  cause  and  effect  is  easily  comprehen- 
*''>le;  but,  except  on  the  hypothesis  of  greater  delicacy  of  nerve- 
"**»iie.  it  is  not  iiuite  so   easy  to   understand  why  inflammation  of 
'•«"  facial  nerve  shoidd  ensue  from  exposure  to  cold,  whilst  a  great 
_titit_>kness  of  superficial  tissue  seems  uninjured.     But  this  difficulty 
^P*^<^<)lnes  much  greater  when  internal  organs  (lungs,  kidneys)  become 
'^''ameil,  apparently  in  <'on8equence  of  cold  acting  upon  the  surface 


310 


INFLAMMATION. 


or  of  wet  feet.     Pneumonia,  which  ay)peare<l  to  be  an  example  of 
this,  is  now  alinii^t  j)rove(l  to   be  an   infective  ili;$ease.     In  thisMs* 
any  effect  ]irodiice(l  by  cold  can  be  regarded  only  as  predi«poeiD|!' 
We  know  thiU  surface  cold  drives  the  blood  to  internal  orgmMud 
raises  the  hlo()il-j)ressiire.     Ciiii  this  produce  inflatntnution  ?     La»H 
plunged  rabbits,  shorn  of  fur.  into  iced  water  and  tliorouvblv  cliille 
them  ;  he  found  changes  in  all  the  organs,  especially  the  lungs  inJ 
liver.      In  these  the  vessels  were  often  greatly  dilated,  the  arlmi'S 
thrombosed,  and  the  veins  surrounded   by    patches  of  rouud-ci'll*- 
When  the  animals  were  pregnant  the  same  changes  were  noted  io 
fiietal  oi-gans.      He  believed  the  changes  to  be  due  to  the  irritant 
action  of  cooled  blood  iijion  the  vessels  of  internal  parts.     I'erli»|« 
something  of  the  same  kind  may  occur  in  man.  and  a  lui-u»  mmri* 
irHi'stentitr  must  be  assumed  to  explain  why  the  kidney  in  one  ow. 
the  lung  in  another,  is  affected.      Freijuent  exposure  to  cold  iniglit 
then  be  regarded  as  a  cause  of  chronic  nephritis,  for  the  tempor«ry 
albuminuria  induce<l  in  some  people  by  a  cobl  bath  shows  thatiu 
them   the  kidneys  may  be  easily  damaged. 

It  is  held  by  srnue  thai  em'Kitii'e  J'unrtioniil  nctU'tltf  is  a  din 
cause  id'  inflammation,  eoujunctivitis  from  overwork  being  the  usu 
example. 

Nerrotis  hifluencr,  too.  called  into  action  by  irritative  lesions' 
nerve-trnnks.  is  regarded  as  a  direct  cause,  herpes  zoster  being  tl>«-* 
favorite  instance  out  of  many  which  might  now  be  quoted  ».<  lu*'*"* 
or  less  probable  examples.  The  data  are  not  yet  sufficient  in  •liM-i"*' 
the  ipiestion  (p.  24). 

II.   Cryptogrenetic  Inflammations. — In  a  very  large  numbt-r  ••  ' 
the  intlainniations  met  with   in   iiractice  there  has  been   no  obvity*** 
iiiccbanical.  chemical,  or  physical  injury.    Until  recently  the  c»u** 
of  such  were  obscure,  and  they  have  hence  been  called  cryptogentt  ** 
a  better  name  than  "  idiopathic." 

In  the  ne.\l  chiqiter  evidence  will  be  given  which  proves  that  m)*-* 
of  the,se  inflammations  are  due  to  the  action  of  fungi.  Thtwe  m  -^" 
act  either  as  mechanical  or  as  chemical  irritants;  essentially,  the^*^ 
fore,  they  produce  iiillatiimalicin  in  tlii'  same  way  as  do  liie  gn  "^ 
lesions  which  have  been  nictitidnetl  as  eau.ses  of  simple  inflnmn^^* 
tion.  But  fuiijri  vshich  arc  callable  of  jrrowth  in  the  body  keeii  -^^ 
a  continuouH  sup[dy  of  the  products  of  their  life-action  as  long  * 
the  conditions  are  suitable  for  their  development.  The  products  ^^^ 
different  fungi  vary  enormously  in  their  power  of  injuring  the  I  •*• 


INFLAMMATION.  311 

—some  producing  actual  gangrene,  others  varied  degrees  of 
mmation.  It  is  for  the  production  of  those  forms  of  infiamma- 
which  require  the  prolonged  action  of  an  irritant  that  the  fungi 
so  peculiarly  suited,  for  so  long  as  they  can  grow  a  continued 
)ly  of  irritant  is  kept  up.  If  the  irritant  is  tolerably  intense, 
'variety  of  fibrinous  inflammation  is  induced,  just  as  by  croton 
p.  311);  when  a  strong  irritant  can  also  peptonize  dead  tissue 
fibrin,  suppuration  results.  If  the  irritant  is  less  intense,  the 
I  stages  of  productive  inflammation  (p.  294)  result,  as  in  tuber- 
ind  leprosy.  The  characteristic  lesion  of  those  and  some  other 
ises  is  a  tumor-like  inflammatory  nodule  developed  round  a  spot 
hich  parasites  have  lodged,  and  whence  they  may  spread  and 
:t  neighboring  and  distant  parts.  Diseases  characterized  by 
;  lesions  are  therefore  spoken  of  collectively  as  the  Infective 
milomata — a  name  signifying  infective,  tumor-like  formations 
rannlation  tissue. 

It  it  wonld  be  a  very  great  error  to  suppose  that  the  presence 
rgranisms  capable  of  producing  irritant  products  is  sufficient  to 
;  inflammation.  We  have  already  pointed  out  that  the  resist- 
of  the  tissues  must  always  be  taken  into  account;  and, 
ugh  we  are  still  probably  far  from  knowing  all  the  conditions 
1  influence  these  two  factors — the  germ  and  the  soil — experi- 
al  pathology  has  discovered  some  of  them,  often  of  a  most 
ishing  nature. 

e  role  of  organisms  in  the  production  of  inflammation  will  be 
snced  by  their  detention  in  the  tissues,  by  any  local  or  general 
sposition  in  the  tissues,  by  the  anatomical  characters  of  the 
and  other  considerations.  These  subjects  are  discussed  in  the 
ring  chapter. 

ioloery  of  Supptiration. — No  one  now  doubts  that  suppura- 
s  commonly  the  result  of  organisms  (p.  298),  but  the  question 
lether  it  is  always  so.  There  is  considerable  doubt  as  to 
ler  certain  simple  irritants  cannot  be  so  employed  experi- 
illy  as  to  produce  suppuration.  Nitrate  of  silver  and  similar 
when  injected  form  albuminates,  and  probably  soon  cease  to 
te ;  but  if  glass  capsules  of  croton  oil  or  turpentine,  which  are 
bus  neutralized,  are  placed  aseptically  in  the  subcutaneous  tis- 
nd  the  capsules  broken  when  the  wound  is  soundly  healed,  sup- 
;ion  results,  and  no  organisms  are  found  in  the  pus  (Cheyne, 
icilman). 


312 


INFLAMU 


Strauss,  Klempcrcr,  and  mnny  other  recent  observer*,  on  lli' 
other   hand,   using    extreme   prceautions  to  prevent   the  vntrj  of 
organisms  (ilnnjr  with  the  nceillo,  tmve  coiue  to  the  opposite  eoncln- 
sion — viz.  thnt  under  no  conditions  do  simple  chemical  irritant* 
give  rise  tn  tlie  fnriuiitioti  of  pus.      Cheyne,  in  summing  up  the  evi- 
dence iifion  the  ((uestion.  coiK'liidos  that  tiio  difference  of  opinion  i' 
duo  to  the  fact   tluit  tiie  putty-like  \nma  of  8lowly-«H»solving  <\fd 
cells    and    fibrin,    which    some    oh.servers    have    called    ]>m.  is  ni>t 
regarded  in  this  light  by  otbur.s ;  and  he  agrees  that  true,  crfamv 
pus  is  never  seen  in  man  apart  from  organisms.     He  mentinam 
however,  tiiat  (5 rawitz  and  Scheuerlen  have  produced  acntr  aipptii" 
(free  from  organisms)  suppuration  by  the  injection  of  cadaviTini' 
and   i>utrescine,  alkaloids  sp|>arated   by  Brieger    from   putrid  flr*li. 
which  are  not  only  irritants,  but  are  algo  the  possessors  of  pepmnit- 
ing  powers. 

The  cnntliision  is,  that  in  practical  medicine  and  surgery  wfti* 
not  meet  with  the  formation  of  true  pus  as  a  result  of  the  action »( 
"  simple  "  cau.se.s. 

MODES    OF    SPREAD    OP  INFLAMMATION.— SprwMJ  of 
an  indnmuuition   implies  the  previous  spread  uf  it.*  cause.     No*,  it 
is  difficult  to   understand  bow  any  of  the  nrdinary  mechanical  or 
physical   irritants  can  advance  from  the  spot  at  which  they  fining 
upon  the  body;  and.  although  it  is  conceivable  that  some  cbcnii»' 
irritant,  dtie  to  a  faulty  luetabolism  on  the  part  of  a  group  of  reil< 
might  soak  from  the  morbid  area  into  the  surrounding  ti.ssiic*.  a"'' 
thus  excite  a  more  or    less    progressive  inflammation,  nothing  '* 
known  of  .such  a  process  ajiart  from  organisms.     An  infl»uiniatit>" 
which  is  characterized  by  a  tendency  to  spread  will  always  be  foun'' 
to  be  of  parasitic  origin.     Clinically,  inflammations  spread  by  con- 
tinuity of  tissue,  by  the    lymphatics,    or  by   the  blood-path.    Tb^J 
third  mode  of  ailvance,  if  not  also  the  second,  necessitates  nn  irt^B 
tant  in  a  particular  state,  for  ueitlicr  a  gas  nor  a  fluid  in  the  bl**** 
cttuhl  cause  a  patch  of  inH:unau\tion  at  a  distance  from  the  priiu*'^ 
focus,  but  would  irritate  the  tissues  generally.     Micro-orijanUm*'.  "" 
the  other  hand,  having  settled  at  a  spot,  can  spread  thence  »'^^* 
much  as  in  the  case  of  malignant  growths.     (1)  They  may  p*** 
their  way  along  the  paths  of  least   resistance  as  they  grow,  or  '" 
carried  for  short  distances  by  lymph-streams  or  by  leucocytes  wb'*"' 
have  taken  them  up,  sjiread  of  the  inflammation  by  '•  continnity  •'' 


INFLAMMATION. 


313 


ihing  in  each  case  (Fig.  113).  (2)  They  may  be  car- 
ly  the  lyiii])li-streiun  long  di.stiiTii'es  from  the  primary  focus. 
pyc<]  in  this  way.  they  are  usually  arro.sted  in  the  first  lym- 
L'  gland  they  reach.  Here  they  often  excite  a  secondary 
imation  without  having  caused  any  trace  of  intiamniation 
m  the  ])rimary   focus  and  the   glanil.  the  organisms   jia.ssing 

EDUgh  the  lymi»hatic  vessel.-*,  but  becnniing  ant-sted  in  the 
hannels  of  the  gland,  precisely  like  the  particles  of  pig- 
L'h  may  be  found  upon  microscopie  examination  of  a  <rlnnd 
k"  central"  side  of  any  extravasatinn  of  Ijlood.  (3)  The 
|b  may  enter  the  blood-vessels  and  be  carried  about  by  the 
-Strejun  until  arrested,  when,  under  favorable  conditions,  they 
udtiply  and  give  rise  to  a  secondary  (meta.static)  inflammation, 
H  we  get  in  pysemia  in  almost  all  organs  or  parts.  an<l  in 
|)s  when  the  testis  or  ru-ary  becomes  inflamed. 


DDE  OP  ARREST  OP  AN  INFLAMMATION.— The  dying 
f  un  inflammation  e-xciteil  by  one  of  the  »imph  cau.ses  is  easily 


Fio.  113. 


r*  niiui'U-  Drar  nhiiukU'r  ifruiu  n  ciuv  of  Mtrcouia  uS  the  ki'ml  nf  the 
Ul,  ahiKrln)!  jiaiwitKe  n(  shiihU  roiiiiiI-oi'lU  ipnihably  iukrroinAlou« I  nloni;  the  "  Uiifo  »f 
•Ulanoi-."  »t  In  cliiTim-  Innninniation.  Wlieru  tin-  iwlbi  are  thickest  tht-  muw-k'tilirw 
nucil  >ir  Imve  (lU«t>|iearf<l.    i  From  >  <p«i'tiiivn  by  Mr.  Buyd.) 

HtxI.  As  BOOH  as  the  causes  are  removed,  the  cells  of  the 
(fed  tissues  begin  to  exert  their  inherent  tendency  to  recover 
injury  (p.  3*2).  Dead  and  dying  cells  are  removed  by  leuco- 
anil  their  places  are  taken  by  new  cells  springing  from  the 


314 


INFLAMMATION. 


normal  tissue-elements.  But  when  once  a  brood  of  bacteria  h» 
pained  a  fontlmid  in  the  tissues  and  has  begun  to  n)Mhi|ily  mil 
spread,  the  iiillaiumatory  jirocess  also  spreading  pari  /uintu.'n  \t 
difficult  to  see  how  the  advance  is  checked.  Clinically,  inflamun- 
tious  spread  rajiidly  and  widely,  and  yet,  perhaps  after  cutuinjE 
gangrene  of  a  large  part  of  the  body,  become  ultimately  arrrKleA 
The  fact  is.  that  nil  the  time  there  is  a  .struggle  for  existence  ]P)ing 
on  between  the  eells  of  the  body  and  the  invading  parasiti's.  tnd 
the  victory  may  lie  with  either,  and  may  be  won  perhufis  ciuily, 
perhaps  only  after  a  struggle  of  wliich  the  issue  is  for  long  iluubl- 
fill.  It  will  be  remembered  that  the  first  effect  of  an  injury  into 
cause  dihifation  of  the  ve.s.sels  of  a  part,  and  Landerer  »nrmi»» 
that  this  Hu.shtng  of  the  j»art  is  often  successful  in  sweeping  am.v 
for  destruction  or  elimination  from  the  system  bacteria  which  hvt 
.nettled  and  begun  to  exercise  their  nn.xiotis  influence.  If  thisilo* 
not  hapj)en,  the  germ.'*  will  probably  liiid  their  way  into  the  tiwac* 
and  the  inflanim:ition  will  sjiread  more  or  less.  In  the  case  «f 
pyogenic  cocci  giving  rise  to  an  abscess  we  have  seen  (p.  29>''|  tbii 
at  first  a  zone  of  coagiihitive  necrosis  forms  rotmd  the  microlx*: 
that  this  is  infiltrated  by  leucocytes  from  out.side  and  by  cocci  from 
within;  that  it  next  softens  and  disappears,  leaving  the  Icucocyti* 
and  cocci  more  or  less  mixed  up;  but  that  by  the  eighth  or  nin''' 
day  sections  of  the  abscess-wnll  no  longer  show  this  mim/Z/ni/ of  tl"' 
opposing  forces,  the  leucocytes  now  forming  a  compact  wall  n>upJ 
the  central  flui<l  (pus),  which  contains  both  <lead  leucocytes  .■Jini 'lif 
cocci.  Similarly,  beyond  the  edge  of  an  advancing  erysipclaH'ii^ 
or  other  spreading  iuflummalion  there  appears  n  cloud  of  thesv  I""" 
cocytes,  no  doiibi  exercising  a  corresponding  function.  .\s  to  thf 
weapons  with  which  the  war  is  waged,  nothing  very  exact  is  kn"*''- 
It  may  be  that  the  products  of  the  two  classes  of  cells  flotiliiij: '" 
the  same  nutrient  fluid  are  mutually  injurious,  and  that  tho»f '•' 
the  body-cells  tend  to  render  this  fluid  unfit  for  the  growth  oft'" 
bacteria.  .Vgain,  it  may  be  that  the  bacteria,  as  is  usual  with  ro'i"!^ 
things,  secrete  or  excrete  jiroducta  hostile  to  their  own  exislfDCf. 
and  that  these  at  last  accumulate  in  such  i|uantifie.«  a.s  to  chcrk  t"' 
growth  of  the  organism.  But  there  is  another  way  in  which  micnil"'* 
:i])pi'ar  to  be  destroyed,  about  vhich  more  facts  have  been  accum"' 
lated.  It  iias  long  been  known  that  micro-organisms.,  like  "tin'' 
particles,  are  taken  up  by  leucocytes;  attention  was  finst  drawn''' 
it  by  Koch  in  his  account  of  mouse-septica>roia.     In  his  p«()er  <'0 


INFLAMMATION.  315 

e  Etiology  of  Tuberculosis,  Koch  has  advanced  the  view  that,  as 
e  tubercle  bacilli  are  incapable  of  locomotion,  the  commencement 
a  tubercle  is  due  to  the  escape  from  a  vessel  of  a  leucocyte  which 
IS  taken  up  from  the  blood  one  or  more  tubercle  bacilli.  He 
presses  his  belief,  founded  upon  numerous  observations  of  micro- 
)pie  specimens^  that  this  leucocyte  soon  sickens  and  swells  up, 
8t  into  an  "  epithelioid  "  cell,  then  into  a  giant-cell,  and  that  the 
cilli  are  short-lived,  not  uncommonly  dying  and  disappearing 
tm  a  cell,  but  often  maintaining  their  position  by  the  production 
fresh  bacilli.  Metchnikoff  has  confirmed  Koch's  observation  by 
rery  direct  method.  He  found  that  a  little  crustacean,  the  water 
a  (Daphnia  pulex),  suitable  for  microscopic  observation,  was  sub- 
ct  to  invasion  by  a  fungus,  the  pointed  spores  of  which  penetrate 
intestine  and  enter  its  tissues,  where  they  are  at  once  surrounded 
amoeboid  corpuscles  like  leucocytes.  The  spore  swells  and  ulti- 
ttelj  breaks  into  fragments,  whilst  the  victorious  leucocytes  blend 
form  a  giant-cell.  All  this  goes  a  long  way  toward  proving  that 
der  favorable  circumstances  leucocytes  may  take  into  their  sub- 
nee  and  destroy  these  vegetable  parasites ;  and  it  seems  likely 
tt  the  beneficial  effect  of  moist  warmth  in  inflammation  is  due 
gely  to  the  fact  that  it  aids  migration,  and  thus  increases  the 
ny  of  leucocytes  upon  which  so  much  depends. 
Phasrocytosis. — Mention  must  here  be  made  of  Metchnikoff's 
planation  of  inflammatory  phenomena  in  general.  In  his  opinion, 
!  whole  process  is  the  result  of  an  effort  made  by  the  invaded 
;»ni8m  to  destroy  any  virus  that  has  gained  access  to  it.  Thus, 
!  dilatation  of  the  vessels,  the  increased  diapedesis,  and  the  appa- 
it  conflict  between  leucocytes  and  organisms  are  all  automatic 
•rts  on  the  part  of  the  individual  invaded,  and  not,  as  has 
herto  been  suggested,  the  purely  passive  results  of  ordinary 
cesses  on  damaged  tissues. 

tietcbnikoff  divides  leucocytes  into  four  varieties : 
.    Small  leucocytes  with  a  single  large  nucleus.      These  are 
nd  in  lymphatic  glands  in  large  numbers,  and  are  hence  called 
phocytes. 

.  Large  viononucleated  leucocytes.     These  are  full-grown  lym- 
cytes. 

.  Large,  coarsely  granular  leucocytes  with  lobed  nucleus,  stain- 
with  acid  aniline  dyes  {eosinophile  cells). 
Large,  polynucleated  leucocytes,  difficult  to  stain  (except  nu- 


816 


TffK  rFOBTABLE  PAKAStTKSi 


cleus),  and  therefore  called  ncutrophile  cells.     These  ire 
numerono  of  nil. 

The  meniber«  of  the  second  and  fourth  groups  are  phagttftn — 
i.  e.  ther  attack  and  attempt  to  engulf  any  organism  nr  iitbpr  {m^ 
eign  substance  to  the  presence  of  which  thoT  are  niuMcnitWMd. 
The  endothelial  cells  are  also  phagocvtes. 

According  to  MetchnikoflT,  the  phenomena  of  inflammation  ir* 
directed  to  bringing  the  phagocytes  into  contact  with  the  im^iiiau 
organisms  in  order  that   thoy  may  be  able  to  enclose  and  destroy 
the  invaders      luflanniiation  tiiay  thus  be  either  rrtntrttaruhir  <a  m- 
travastrular.    The  former  has  already  been  descrilxMl  at  length.  Bj 
the  latter  is  meant  the  action  of  the  phMgocytes  on  any  foreiim  pi^ 
tides  ///  t/n'  circulation.      Wiien  an   inlluiuiiiatinii  li-ruiinates  br«r- 
ably.   the  phagocytes  survive   and  the  organisms  disappear.     U, 
however,  the  organisms  are  too   j>owerful   for  the  phagocyt«.  th« 
latter  will  die  and  fall  to  pieces  and  the  organisms  will  be  set  fr»»: 
this  frequently  happens  in  tubercle.     Chemiotaxia  (cherootazi»>  1»  • 
term  used  to  express  the  attractive  or  repellent   influence  wi 
environment  exercises  over   the    phagocytes   that    come  un . 
influence.     According  as  it  attracts  or  is  neutral  or  is  rejiellrni  it 
is  caile<l  |)ositive.  neutral,  or  negative.     In  conditions  of  i 
chemotaxis  the  organisms  are   unmolested,  and  conse<|' — 
agate  rapidly,   but   the  phagocytes  may  become  proof    . 
condition  and   cease  to  be  repelled.      In  this  caHe  the  tinal  uw* 
may  be  reversed.' 


CHAI'TKK    .\XI. 
THE   VEGETABLE   PARASITES. 


Fermentation  and  Infectivb  Diseasb. 

It  has  long  been  thought  that  the  group  of  acute  speciSc 
must  have  a  very  special  cause.     The  characteristics  of  this  jrroap 
are — (1)  that  they  occur  in  epidemica;  (2)  that  they  are  obvioiutT 

'  For  further  inforniatUm  on  thevc  |M>inl8  the  uludenl  in  refemd  to  tli«  aitirW  <«j 
"  PhnjforyliMiid  "  by  Sidney  Mnrliti,  in  ({iiiiin's   Oietionory  <^  Utiieimt,  1894,  i 
Mrli:>inikoir«  lixlurvit  on  ibe  Vamjiamlitr  Palhole^  (^  li^/kmmitliiiu,  twariaiwi  hj' 

t^tarling,  iH'JS. 


THE  VEGETABLE  PARASITES.  317 

coDtsgious  and  infectious;  (3)  that  each  member  is  absolutely  dis- 
tinct from  its  fellows  and  runs  a  typical  course ;  and  (4) — the  most 
important  distinction  of  all — that  the  poison  which  gives  rise  to  each 
of  them  multiplies  in  a  marvellous  manner.     Thus  the  introduction 
into  a  community  of  a  single  case  of  one  of  these  diseases  may  be 
followed  by  the  death  of  thousands  from  the  same  disease.     For  a 
long  time  nothing  could  be  discovered  to  account  for  the  appearance 
of  these  diseases,  though  they  were  obviously  produced  by  some- 
diing  which  multiplied  in  the  patient,  which  clung  about  his  cloth- 
ing, and  which  could  be  carried  through  the  air  for  considerable 
liigtances.     This  "  something  "  was,  and  still  is,  called  the  "  eon- 
\     tagion  "  of  the  disease,  and  for  many  years  science  has  been  en- 
l     deavoring  to  discover  its  nature.     It  was  soon  recognized  that  no 
[     gas  would  meet  the  requirements  of  the  case,  for  diffusion  would 
I     won  put  an  end  to  its  power  for  mischief.     A  fluid  was  still  more 
I     out  of  the  question.     Contagion  was  therefore  necessarily  regarded 
w  a  solid  in  a  state  of  very  fine  division^— particulate.     This  con- 
tiigm  is  known  to  be  insoluble,  because  it  can  be  removed  from 
Saids  both  by  subsidence  (vaccine,  Chauveau)  and  by  filtration,  the 
poison  not  passing  through  the  filter.     These  facts,  taken  with  its 
power  of  multiplication,  seemed  to  show  that  the  contagion  was  some 
living  organism,  hence  the  origin  of  the  contagium  vivum  or  germ- 
theory  of  disease.     In  1840,  Henle  clearly  formulated  the  doctrine 
that  living  organisms,   probably  of  a  vegetable  nature,   were  the 
causes  of  the  acute  specifics,  and  supported  the  view  by  arguments 
which  have  withstood  all  endeavors  to  refute  them.    Since  that  time 
an  enormous  number  of  researches  have  been  carried  on,  to  some  of 
which  allusion  will  subsequently  be  made. 

Long  before  1840,  however,  it  had  been  noticed  that  a  close  par- 
allel might  be  drawn  between  an  infective  disease  and  a  fermenta- 
tion.    It  may  be  presented  thus : 

Infection Addition  of  ferment. 

Incubation /  VenoA  during  which  nothing  is 

I      noticed. 
Fever,  outbreak,  and  course  of    (  Rise  of  temperature  and  active 

disease "l      fermentation. 

Decline  of  disease Gmduat  oes.-<ation. 

Period  of  protection  from  same  (  Addition  of  more  ferment  has  no 

disease        \      effect. 

It  may  be  further  noted  that,  except  in  cases  in  which  yeast  was 


918  THE  VKOETASLE  PARASITES.  ^^^^^M 

added  to  tbe  saccharine  li<|uid,  the  source  of  the  ferment  iaoaaa 

of  alcoholir  foniifiitutioi)  wsk*  us  in_vsl<Ti<>iis  ns  wa-i  the  #onrw  of 
the  jK)if*i>ii  which  gave  rise  to  iiii  epiilcinic  of  whooping  cng^. 

ETIOLOGY  OF  FERMENTATION.— The  nhove  fiamllel  wm 
gfiici'iiliy  i'ci:oguizf(l,  uiiii  the  cause  of  ferincntAtion.  beinf^  nook  i 
more  open  to  expcriineut  than  the  cause  of  infections  (liMMe.  w  I 
iiivesti'tated  first.  Many  kinds  of  fermentation  were  specdilr  rto)^  I 
nized — hictic,  hutyric,  viscous,  etc. — and  tlie  close  relation»btp  iCJ 
putrefaction  to  these  ]>rocesse.<  wa«  soon  acknowledged.  In  «aokl^| 
these  organisms  were  found,  and  their  relationship  to  the  pncmm  J 
has  been  the  moot  point  between  the  uj)holiler!>  of  the  nhil  ur  fom^^ 
thforif  of  fermentation  and  the  Hup|)orters  of  the  j>hif»ical  (Am|I^| 
Alcoholic  fermentation  has  been  used  as  the  tyyie  of  all.  ^| 

The  Germ-theory  is  adopted  i)y  the  jfr«'at   majority  of  »ricBt>l^| 
men  at  the  jiresent  day.      According  to  this  view,  tht-  sacehnnimrf^^ 
cerevisiiE  (yeast-plant)  is  the  rauKf  of  the  alcoholic  femienutioB.     I 
Its  food  is  sugar,  together  with  nitrogen  and  .«ome  in<irgnui(' tDat^      | 
rials,  which  must  also  be  provided;     the  immediate  pnKluct)>  of  it>     J 
liftvaction   are  alcohol,  carbon   dioxide,  glycerin,  and  !«ucrrnir  *ri<i      I 
It  is  supposed  that  the  sugar  (Msses  into  the  cells,  which  takr  «hit 
they  r<'(|iiire  for  tlu-ir  own  growth  and  repair,  anil   throw  back  ml" 
the  surrounding  tiuid  the  products  of  tiirir  activity.     Thus  a  y«v»'      I 
cell  forms  the  above-mentioned  sid)stnnces  just  aa  a  hepatir  nil 
forms  the  constituent.-*  of  bile.      Organisms  which  act   in  lhi»  din** 
way  are  known  as  otyaiiuftl  feniifnU.      But  there  is  another  w»T  « 
vrhich  very  similar  results  are  produced.     Instead  of  acting  dirwdj.     ' 
the  living  cell  may  act  only  through  a  "middleman."  which  alwajt 
forms  the  connecting  medium  between  the  organism  and  its  char*f- 
teristic  chemical   products,  but  which  does  not  itself  nnderitu  ta} 
change  (p.   321).     These  "  mi<ldlemen  "  are  known   a«    ttm/ormti 
ffrniriitii.      Thus,    the   diphtheria   bacillus,    resident    in    the    fidsr 
mcmbranr,  gives  rise  to  a  ferment  which,  circulating  in  the  blooA. 
produces — mainly  in  the  spleen — the  toxic  albumoses  to  which  maaj 
of  the  symptoms  of  dipbtberiii  arc  due. 

The  Physical  Theory  aflTirms  tiiai  fermentation  is  a  "  molemlar 
motion"  transmitted  to  unstable  organic  compounds  (fermcniablr 
substance)  by  albuminoid  parti<'les  (ferment)  which  are  tbtsnadreB 
the  seat  of  "motor  decay"  (»'.<■.  arc  undergoing  decompomtiofiV 
The  molecular  motion  of  these  particles  may  initiate,   in  a   largf 


THE  VEGETABLE  PARASITES. 


■  amount  of  a  more  stable  substance,  chuuges  similar  to  those  of 
I  »hicli  tLev  are  flii-msclvos  the  sent.  Any  portion  of  the  sulistance 
I  tu  which  thi*  molecular  motion  ha.-*  been  eoiniutmieiitetl  is  eajmble 
I  of  traoMiuitting  it  to  other  suitable  material,  and  thuH  the  ferment 
I  (-lo/M  lo  multiply.  The  ferment  communicates  its  vibrations  to  the 
I  |iiirtidt>8  with  which  it  comes  into  contact,  and  tlic^e  again  to  neigh- 
I  Uriug  particle.s,  much  as  a  spark  causes  the  decomposition  of  a 
I  train  of  gunpowder.  Rastian  says  that  there  is  no  proof  of  muiti- 
I  |ilir«tion  other  than  that  which  occurs  in  a  sufficiently  strong  solu- 
I  lion  iif  sulphate  of  sodiuuj  when  a  crystal  of  the  same  salt  is 
I  ihroirn  in. 

I  It  is  very  difficult  absolutely  to  disprove  the  physical  theory.  Its 
I  »iip|i<irters  atlmit  the  frei|uent  presence  of  organisms  in  fermenting 
I  Suiils,  but  regard  them  as  accident.s  or  a.s  spontaneously  generated, 
I  betMiiiiie  the  same  decorapositinns  cun,  m  some  instances,  be  effected 
I  in  tlieir  absence.  Thus  dilute  alcuhoi  run  over  wood  shavings  or 
I  charcoal  so  a«  to  expose  a  large  surface  to  air  is  converted  into 
I  'iut-gBf.  But  this  is  no  evidence  against  the  ability  of  the  myco- 
I  'Iwma  aceti  ixlso  to  effect  the  oxidation  as  a  vital  act :  and.  indeed. 
I  'listinct  differences  exist  between  the  two  processes. 
I  On  the  physical  theory  much  was  made  of  the  fact  that  spon- 
I  Uneous  fermentations  are  always  more  or  less  impure — that  is.  there 
I  We  fountl  III  the  fermenting  fluid  many  germs  <juitc  different  from 
I  tkoM  essential  to  the  particular  fermentation.  Again,  organisms 
I  pxnctly  corresponding  in  form  were  foimil  iu  fluids  undergoing  very 
I  'lifferent  decompositions.  From  such  facts  it  was  argued  that  there 
I  »M  no  constant  relationship  between  any  one  germ  and  any  partic- 
I  "Itr  kind  of  decomposition.  The  jin'iloiiunaurv  of  one  character- 
I  Litic  form  was  accounted  for  bysup]iosing  that  the  comlitions  peculiar 
I  l«cai-h  kind  of  fermentation  either  favored  the  growth  of  a  certain 
I  organi.Hui  or  originated  it  «i«'  novo.  But  it  has  now  been  shown  in 
I  »CTy  niiinerons  instances  that  it  is  possible  t<>  obtain  a  cultivation  of 
I  raeh  of  the  various  organisms  fotiml  in  a  ferment iusi  fluid,  ami  to 
I  demungtrate  that  a  special  decomposition  does  not  occur  unless  one 
I  particidar  form  of  germ  is  present,  all  other  forms  being  variable 
'  anil  uocideutal  im|)urities.  Ami  it  has  also  been  shown  that  urgan- 
isms  indistinguishable  from  vnv\\  ntlier  under  the  inicrHscope  may 
gire  rise  to  very  different  eliemical  jimducts  wlnn  gnnvn  upon  the 
ue  culture-medium,  and  may  produce  absolutely  different  results 
rben  inoculated   u|ion  animals  of  the  same  species.     It   is  clear. 


■ 


32<) 


TllK   VECiETABLE  PARASITES. 


tborcf'uro,   that  similarity  of  exteraal   form   does  uut    imply 
tity. 

A  pure  cultivation  of  uii  organism  is  obtained  dy  truti.<rcrriii^ 
minute  (|uantity  of  tlic  substiiuce  containing  it  to  Miaie  tuaicria/  la 
or  on  which    it  will  grow  rt-iiJily.     The   tran.ofi-rfUte   it*   ■■:■■,■'■'• 
effected  by  means  of  a  .Hterilizeil  needle.     Sometimes  nolid  a:. 
times  Hnid  culture-grounds  are  employed  (p.  SoO).     For  the  prcfcu 
purpose  a  solid,  transparent  material  is  the  best.     (Uu-e  pinctil  iiB<Jrf 
favorable  conditions,  the  organi.>'ui  grows  rapidly.      From  thenm'yM 
of  the  patch  formed  by  it  a  fresh  culture-ground  is  inoculated  «itk 
a  necflle  in  the  same  way  as  before.      This  procejw  may  be  rcp«t<4 
any  number  of   times,      (ierm-theorists  believe  that   they  can  tkat 
eliminate  everything  taken  from  the  original  fermentation  eicrfi 
the  organism  which  is  capableof  growth  :  and  they  have  ei. 

to  make  this  still  more  certain  by  the  addition  of  further  pn*.- 

0uch  as  (1)  by  washing  the  organism  with  sterilized  water  au>l  niWr 
fluids  incapable  of  destroying  it;  (2)  by  infiltration;  and  (3)  kr 
drying.  They  show  that  even  after  the.se  procedures  inoculation «f 
a  suitable  substance  »itii  tlic  surviving  and  purified  orgaiti»ii)  *tiU 
ivadfl  to  the  characleristic  fermentiition.  But  it  is  pottiUe  ^ 
"particles  in  a  state  of  motor  decay"  may  have  been  in  •'  ' 
and  each  succeeding  instance  inoculate<l  upon  the  cultur.  ^ 
with  the  organisms,  and  that  they,  too,  may  have  be«tt  praciioll.* 
multiplied  by  the  conimunicatioii  of  their  molecular  wotidd  tn  ik* 
molecules  of  tiie  culture-grounil.' 

Nevertheles.'N.  germ-theorists  have  rendered  it  certain  that  ill''* 
"  particles  in  a  state  of  motor  decay  "  adhere  so  closely  lu  ll 
ism  which  is  constantly  present  that  they  are  only  able  to  inijui'  - 
molecular  motion  to  substances  in  which  this  organi<in  will  f^*' 
for  if  the  organism  dies  no  fermentation  occurs. 

Moreover,  the  "particles  in  a  state  of  niotor  decay     iii 
been  shown  to  jws.seHH  existence  apart  from  organisms.     ■"" 
"antiseptics,"   which   are  selected  on    account  of  their  abililj '* 
destroy  the  biwer  organisms,  invariably  check  the  molevalar  isaiJoB* 

'  Innnli-  power  of  inrmutini;  or  ifmwinif  U  m>l  oini-liisiTe  nf  lift).  IJ«tiic  H**^ 
oil!  Ilisl  n  amall  i|iiniility  of  ox:ilic  arid  will  not  u|ioii  >  very  Urgv  quuMit^  ^  ^^ 
Diidr.  aplitling  ilir  IiiIUt  tiilo  oTitlir  ni-iil  niiil  aiiiiiiutiiii :  one  uii|;til  t»x  Itiai,  •"H'* 
with  tuitaMr  |inliiiliini,  the  nxalli'  oc-ul  itirrv.-i^-M  jtHU'liiiitely.  BaunupuMi  <an  1^ 
diffiweni.'*'  N'lHt-en  lliv  clipniii-Hl  chango  cli'rotttl  br  oxniir  acid  and  \tj  llriiif  «IV^ 
ians  b  thai  the  forincr  ai'ts  liv  juiitiimnilinn,  ihu  latb*r  hy  inhimitMtrtalum  .-  Um  Mt  Mf 
mean  only  juita|iOHition  with  Intentol  tlMuei. 


THE   VEGETABLE  PARASITES.  321 

be  physical  ferments;  so  also  does  heat  sufficient  to  destroy 
luisins.  In  general  terms,  the  properties  of  the  physical  fer- 
its  are  those  of  the  organisms. 

'inally,  it  has  been  shown  of  several  fermentations  that  the  thin- 
c  membrane  or  the  shortest  column  of  fluid  is  sufficient  to  pre- 
t  the  transmission  of  these  supposed  vibrations ;  that  direct  con- 
t  with  the  ferment  is  necessary ;  and  that  sonorous  vibrations 
e  no  influence  upon  fermentable  substances.  If  a  solution  of 
;8r  in  a  test-tube  is  divided  into  two  parts  by  a  plug  of  cotton- 
ol,  and  yeast  is  introduced  into  the  upper,  this  part  alone  fer- 
nts,  though  fiuid  continuity  is  uninterrupted. 
Although  the  physical  theory  may  be  theoretically  possible,  the 
igress  of  discovery  has  shown  that  its  rival — the  vital  theory — is 
•■  truer  one.  To  accept  the  physical  theory  one  must  set  aside  a 
fectly  satisfactory  and  evident  cause  (the  organisms)  and  j)roceed 
rapport  one  hypothesis  by  another.  We  therefore  conclude  that 
th  processes  comprised  in  the  terms  fermentation  and  putrefaction 
due  to  the  action  of  vegetable  organisms. 
Jew  do  these  oreraoisms  act  ?  The  principal  views  are — 
I.  Organisms,  like  all  living  cells,  require  certain  materials  for 
»th  and  repair.  They  take  into  their  substance  the  organic  and 
rganic  compounds  which  are  necessarily  present  in  any  liquid  in 
ch  they  can  grow,  and  they  give  back  to  the  fluid  the  products 
their  action.  These  are  known  as  "  organized  ferments." 
i.  Certain  organisms  produce  "  unformed  ferments "  (p.  318). 
?  chief  characteristics  of  these  unformed  ferments  are — (1)  that 
f  seem  to  act  by  mere  contact  ("  catalytically  "),  taking  no  part 
he  decompositions  to  which  they  give  rise;  (2)  that  they  act  in 
remely  small  quantity ;  (3)  that  they  do  not  multiply,  but,  never- 
ess,  can  transform  many  times  their  weight  of  the  fermentable 
Jtance,  though  ultimately  they  become  exhausted ;  (4)  that  they 
soluble  and  are  always  derived  from  living  cells ;  (5)  that  they 
require  water  or  moisture  to  enable  them  to  act,  some  preferring 
acid,  others  an  alkaline  reaction ;  (G)  that,  like  the  organisms, 
r  act  best  at  a  certain  temperature;  and  (7)  that  while  any 
ke<l  deviation  of  temperature  arrests  their  action,  and  any  con- 
rable  degree  of  moist  heat  destroys  their  properties,  they  are, 
a  dried,  as  resistant  to  all  physical  and  chemical  agencies  as 
es  themselves.  They  arc  complex  albuminoiil  bodies,  and  can 
xtracted  by  glycerin.  Ptyalin,  pepsin,  trypsin  are  well-known 
21 


:V2'2 


TUli    VEGKTABI.K  I'An.iSITHS. 


exaiiinles  fnnii  tlu-  liimiiiii  boily  ;  t'Tiiiiii^iti  (liititT  iiliiiniiil)  iitnl  liui- 
tase  (l)arU'y),  from  the  vegotaljk-  kingiloiu.  Il  is  cfi-laiti  iLnl  wnir 
hacteria  {v.  g.  putrefactive  uu<l  pyogenic  cocci)  form  ilia»t»tic  mil 
pej)tii'  ferments,  wliifli  ciin  tie  se})ariite<l  from,  ainl  act  in  thealwntf 
of,  tbe  or^auisms.  Miisctiliis  lias  Mepurated  from  the  raiiTrnvKois 
urpw  a  body  cajvable  of  changing  urea  into  ammonium  ettrbiiiiate. 
The  organisms  of  cholera  and  diphtheria  furnish  excellent  c^a^lplrt 
of  the  power  of  a  strictly  lociilized  orgiinism  to  give  rise  to  pcncril 
cbaiige.s  through  the  mediiitidii  of  "  iinfornied  ferments." 

3.  Niigeli  lias  adopted  the  view  to  which  Liebig  seemed  tcn<lin|j— 
that  the  life  and  growth  of  cells  is  necessary  to  fermenlatinn,  iW 
chemical  changes  being  always  due  t.n  the  transmisjiiun  of  lln' 
molecular  motions  of  Uviiig  ]>roto)dasm  to  the  uuHtable  comp'*iiDii> 
around  it. 

Products  of  Fermentation. —  In  all  jirivcesses  bodies  are  fiimn^ 
which  hinder  the  development  of.  iiiid  ultimately  dcstror,  ^^| 
organisn)s  which  produce  them.  Thus,  the  alcoholic  fermenlation 
is  checked  iiml  ultimately  arrested  by  the  accumulatiun  of  .ilwbol, 
while  putrefaction  is  himlered  by  the  development  of  bodies  iil« 
carbolic  acid  and  crcssol.  It  will  be  remembered  that  animals  p"" 
duee  substances  having  a  corresponding  efl'ect — c.  //.  carbon  liinxi'l''' 

If  the  analogy,  pninttil  out  uri  p,  'ill .  between   infective  di*i"»»'* 
and  fermentation    were  strictly    true,  we  might  at  once  infer  tim 
these  iliseases  were  caused  by  the  growth  and  life-action  of  vc^'i'lsl'l' 
organ isius  in  the  tissues  of  the  Ijody.  especially  a.s  uniny  low  I'"''''' 
of  vegetable  life  have  been   found  associated  with  Ruch  dl 
But  no  one  could  nccept  the  eonclusion  on  the  evidence  of  mi  <iip"^ 
ficial  a  resemblance.     The  same  stringent  proofs  mu.'it  be  nffuriiw 
in  the  case  of  each  disease  as  were  deuuintled  in  the  case  of 
fermentation.      How  far  these  proofs  are  forthi-(»ming  will  he  ••'I 
in  the  concluding  part  of  the  present  chapter.     We  shall  now  f' 
shortly  what  is  known  of  the  botanical  position  and  life-hi.storv  •> 
the  vegetable  parasites  of  man. 

The  Bacteria  or  Schizomycetes. 
MORPHOLOGY  AND  LIFE-HISTORY.— The  vegeUbU  of- 
ganisms  which  have  been  found  couueeti'd  with  the  diseases  i" 
man  are  all  T/tnllnjifii/teg,  or  plants  in  wbieii  no  distinction  bctwi*" 
stem  and  leaf  exists ;  and,  as  they  are  all  destitute  of  chlorophvu- 
they  belong  to  the  class  of  Fungi,  not  Algae.     The  parasitic  fnnp 


THE  VEGETABLE  PARASITES.  323 

tie  of  three  kinds — ^Bacteria,  or  Sehizomyeetes,  Yeasts,  or  Blasto- 
ay:ete»,  and  Moulds,  or  Hyphomycetes.  The  bacteria,  besides 
causing  putrefaction  and  several  of  the  "fermentations,"  include 
almost  all  the  organisms  which  are  believed  to  produce  the  infective 
diseases.     They  are,  therefore,  by  far  the  most  important  group. 

The  Sehizomyeetes  or  Fission-ftingri  are,  with  very  few  e.vcep- 
tions,  achlorophyllous,  non-nucleated,  unicellular  organisms.  Many 
of  them  approach  the  limits  of  microscopic  visibility,  whilst  all  are 
wry  minute. 

Form. — In  form  they  may  be  said  to  follow,  more  or  less  closely, 
one  of  three  types — the  »phere,  the  rod,  and  the  comma.  The 
tpherical  bacteria  comprise  those  of  any  shape  between  a  sphere 
and  a  cube.  The  rod-shaped  bacteria  may  be  short  and  thick  with 
rounded  ends,  so  as  closely  to  approach  an  oval,  or  they  may  be 
long  and  thin  with  scjuare  ends,  or  they  may  exhibit  any  possible 
combination  of  these  features.  The  commas  in  some  cases  are  long 
«ndthin,  in  others  short  and  thick;  they  differ  also  in  their  degree 
of  curvature.     Spiral  and  dumb-bell  forms  are  less  common. 

Structure. — Bacteria  consist  of  a  peculiar  form  of  protoplasm, 
n^oyrotein  (v.  Nencki),  and  appear  structureless ;  but  it  is  very 
probable,  from  their  great  resistance  to  alkalies  and  dilute  acid.s, 
'hat  they  possess  a  cell-membrane  of  some  carbohydrate  allied  to 
«ellul(we.  During  the  formation  of  spores  and  after  the  action  of 
tincture  of  iodine,  which  stains  and  causes  shrinking  of  the  proto- 
pl«8ni,  a  fine  membrane  may  be  actimlly  seen.  It  is  very  elastic, 
ttd  seems  to  form  the  inner  layer  of  a  gelatinous  envelope,  by 
■Dore  or  less  of  which  all  bacteria  are  surrounded. 

Color. — Bacteria  refract  light  strongly,  and  cause  turbidity  of 
Mj  culture-fluid   in    which    considerable    numbers    are    present. 
Apart  from   artificial   staining,    a   ma.ss   of  organisms   is    usually 
colorless — /.  c.  white  or  grayish.     Some  organisms  are  green  from 
chlorophyll :  others  are  brightly  colored,  red,  blue,  yellow,  etc.,  the 
tint  being  mainly  in  the  envelope.     Bacteria  are  stained  with  more 
or  less  difficulty  by  several  aniline  dyes,  and  many  of  them  may  be 
identified  by  their  special  staining  reactions.     The  color  proiluced 
is  not  always  uniform.     This   irregularity  generally  depends   on 
spore-formatioD    or    on    degenerative    changes.      By    some    it    is 
regarded  as  a  possible   indication    of    definite    structure.      Some 
forms  are  stained  brown  by  iron  salts  in  water.     The  starch  reac- 
tion with  iodine  is  not  rare. 


324 


THK  VEGETABLE  PARASITES. 


Movement. — Single  round-cells   have  no  movement  other  thu 

Brownian ;  but  chains  and  colonies  of  them  are  said  by  Ogston  to  be 

capable  of  locomotion,  thouehthii 
Kui.  in.  \    .         .  ^  n  .^ 

opinion  IS  not  generally  acceptw. 

The  rod-forms  have  often  a  mobile 
and  a  motionless  stage,  but  some 
never  move — e.  //.  B.  autliracis,  B. 
tuberculosis.  In  a  few  eases.  *beii 
specially  stained,  one  or  more  cili»- 
like  filaments  or  flagella  have  been 
found.  These  seem  to  be  con- 
nected with  tlie  cell  -  membwiie 
rather  than  the  protoplasm,  thus 
differing  from  true  cilia.  In  some 
organisms  one  or  more  flagelU  «re 
found  at  one  end  only;  in  others. 
as  in  the  cholera  spirillum,  thej 
may  grow  from  both  ends ;  and  in  a  few,  among  them  the  typhfli<l 
bacillus,  they  are  very  fine  and  are  attached  all  round.  By  metn* 
of  these  flagella  movement  is  probably  effected.  No  motionle» 
bacterium  is  provided  with  flagella,  though  on  many  mobile  form* 


"BlHc-mllk"  bacilli,  stained  by  \as(- 
fler's  method  to  show  flngcUa.  (From  a 
specimen  by  Dr.  Arlile.) 


Fig.  11.5. 


I>ia);runi  to  sliow  )iietho<i»  of  re|irodii(ll(in  by  llsslon:  n,  t1st<iim  iu  one dirccti""' '     \^ 
iiients  U'liiitlieniMK  iis  they  divide;  fc,  fission  in  two  dirt'ctions— «aoh  seftment  fu**"'.  ^j,j 
ilividi's  in  tlie  siime  rlinction  us  in  «  ;  c,  Hssion  in  three  directi<m«— in  one  direrti"" 
tali  OS  place  in  two  paraliei  |ilaiii's :  (/.  fission  in  three  directions. 

none  have  yet  been  found:  in  these  the  mode  in  which  motK""  ' 
produced  is  nncxplaiiied.     Certain  algae,  larger  and  higher '" 


THE  VEGETABLE  PARASITES.  325 

Kale  than  bacteria,  move  in  a  similar  manner,  but  have  no  cilia. 
Often  no  reason  can  be  assigned  fur  a  change  from  motion  to  rest, 
or  wee  ver»d.  A  good  supply  of  oxygen  seems  to  be  connected 
with  the  active  motion  of  some  forms. 

Reproduction.  —  1.  By  Fission.  —  All  bacteria  multiply  by 
transverse  division.  In  the  rod  forms  this  occurs  in  a  direction  at 
right  angles  to  the  long  a.xis.  In  the  spherical  forms  it  may  take 
place  in  two  or  in  three  directions  at  right  angles  to  each  other. 
Thus,  one  cell  may  divide  by  a  single  act  of  reproduction  into  two, 
four,  or  eight  equal  segments.  If  two  or  more  parallel  dividing- 
planes  occur  before  the  separation  of  the  segments  takes  place,  the 
number  of  these  will  be  largely  and  proportionately  increased  (Fig. 
115.  c).  A  cell  which  divides  in  a  single  plane  elongates  as  it 
<livides,  so  that  the  progeny  retain  the  proportions  of  the  original 
l«rent-cell. 

The  first  sign  of  division  is  the  appearance  of  a  fine  transverse 
line  crossing  the  cell,  continuous  at  its  ends  with  the  cell-membrane, 
>nd  often  at  first  imperceptible  until  stained  with  iodine — a  point 
to  be  remembered  in  estimating  the  length  of  apparently  single 
wlls. 

The  new  cells  formed  by  fission  may  at  once  separate  from  the 

P»rent,  or  they  may  for  a  time  remain  united  to  each  other,  end 

'oend.     In  this  way  pairs  or  chains  of  cocci  and  long  filaments  of 

■^'Is  are  formed.     A  mass  of  organisms  lying  side  by  side  in  more 

*"■  'ess  spherical  colonies,  and  bound  together  by  a  viscid  substance 

'ormed  of  swollen  cell-membrane  or  of  mycoprotein,  is  known  as 

*  ~foghea.^     Zoogloea;  often  combine  to  form  constant  characteristic 

Ca-ci  and  micrococci  .  Spherical  or  nearly  spherical. 

t)iplococci Cocci  in  pairs. 

^Streptococci    ....  Cocci  in  chains. 

Staphylococci ....  Cocci  in  groups  like  bunches  of  grapes*. 

tetrads Group  of  four  cocci  produceil  by  imperfect  cleavage. 

*SarciiMe Group  of  eight  or  more  cocci,  similarly  produced. 

^licrobacterium  .   .    .  I.iength  not  more  than  twice  breadth. 
t)e8mohacterinm    .    .  Length  more  than  twice  breadth. 

Bacillus Straight  desmobacterium. 

^Spirillum  and  vibrio  .  Curved  desmobncteria. 
SSpiroclwta  .       .    .      Flexible,  corksi'rew  desmobacterium. 

Jjeptothrix Long  unjoined  thread. 

2^oog]oea  .....  Group  of  agglutinated  bacteria  of  any  form. 
Clostridium     ....  Bacillus  with  transverse  projection, 
fipirobacterium  .   .    .  Curved  bacterium. 


326 


THE  VEGETABLE  PARASITE. 


appearances  by  which  the  organisms  may  be  recogni/.ed.  even  W 
the  naked  eye  (Fig.  110).  Lnrgu  aggregations  of  hacteri*  wt 
always  slimy,  owing  to  tlie  zooglteju.  The  ••  IVog-spawn  "  eoccu* 
(^Liuconostoc)  may  fill  wliole  vaf,s  in  sugar-factories:  tVrtii4rij 
Kuhniana  and  Claduthrix   ilifhutuma    may  block   wate^-pipo^  aiid 

F>o.  116. 


(V>1oiiii'»  of  iHtclvriH.    In  thi^  (if^iri*  tlit*  eiiDriuotih  ilillVn-iiri-  lltul  inu>  t'Xii>l  IvtftcfflU 
KTVupiiiK  of  OIR*  nutaft  of  firKHnUniM  uinl  Itml  i*r  utltore  is  t^howii.     i  An^r  StvrnU'rf  I 

cover  reservoirs  to  a  ileptfi  of  several  feet ;  and  a  species  of  • 
giatna  covers  a  large  area  at  tlie  buttoin  of  the  Bay  of  Kiel.  (.nlW 
the  "dead"  ground,  because    fisii    avoid    it:    these    few  exumpl^ 
show  how  extensive  may  be  the  development  of  zoogltrw. 

The  time  occupied  in  division  hn-s  been  variously  given  ni  from 
ten  to  tliirty  minutes;    and,   as   the  iifTspring  proceed  at  oricf 
divide    like  their  parents,  a  single  biicterinm   may  in  tweiitv-l 
hours    give   rise    to    a   progeny    which    Cnbn    estimates   at 
KIOOO.OOO. 

2.  By  Spores. — Another  method  of  multiplication  is  met  »'"• 
among  the  fission-fungi — namely,  the  formation  of  sporefl.  Spo«- 
bearing  organisms  have  been  divided  into  two  groups — endotji»r«<i* 
and  arthrogpi/ruun. 

The  i-nJogpurous  (/roup  consists  at  present  of  certain  long  f"" 
forms  (fiirrilli)  and  some  spiral  forms,  liut  it  is  more  than  likely  tli»' 
spores  will  be  futmd  in  species  in  which  they  arc  not  now  kBii»f 
to  occur.  The  spore  forms  as  a  minute  point  in  the  cell,  enlarv'ii'P 
rapidly,  and  often  attaining  maturity  in  a  few  hours.  It  i.«  'l"^" 
a  clear,  round  or  oval,  iiigldy  refnvctiug  bo<ly,  which  has  eviilfD''/ 
grown  at  the  expense  of  the  «-ell-ei)iitents :  the  latter  gradii'"/ 
disappear.  A  sjiore  ennsists  of  [trotophism  and  fat  enclowo  '" 
a  firm  capsule.  It  is  (|uite  excejitional  to  find  more  than  "i"" '" 
a  single  segment.  S]>ores  have  often  a  very  close  resemblancf  '" 
vacuoles. 


THE   VEO STABLE  PARASITES. 


It  was  formerly  supposeil  tlmt  s|iori'-tortiKitii)u  was  a  result  of 
*xl>iiu»tion  of  the  aiibstratiiiii,  iiiid  ovidt'iiut',  tlu'retorc.  of  lowered 
viUility.  But  it  i»  now  known  to  take  [iliu'e  most  readily  when 
llie  conditions  of  growth  arc  most  favorable.  Spore-forniation  in 
»tithnix  bacilli  can  be  arrested  by  reducing  the  temperature  of  the 
orpjnisms  below  '20°  C.  or  by  introdm-inu  (•ertnin  nmdifications 
intn  tin-  culture-j^round.  Fission  ami  spon'-iiiniuition  may  go  on 
liigcther. 

Th»(  spore!'  are  extremely  resistant  to  iinfavoniliU'  surroundings. 
imttfi.  nppareutly.  to  the  ([tialities  of  tlu-ir  tine  liuiititi;;  meinlirane. 
If  after  long  periods  of  (|uiesceiice  they  are  piarcd  in  favorable 
fiiiditiiins.  germination  takes  ])!aee;  their  membrane  swells,  they 
lose  their  fine  dark  outline,  and  tlie  new  vegetative  cell  grows  out 
in  tin;  direction  of  the  long  axis  of  the  spore. 

In  the  iirtfiroHporiiiDt  ffroiip  no  spores  are  found  within  the  cells, 
Imt  certain  cells  during  the  process  of  division  by  fission  exhibit 
'iniistia!  reju'oduetive  powers,  and  are  therefore  regarded  as  spores, 
'^onictiines  these  arthrospores  are  larger  than  the  rest  of  the  cells: 
'"  iifher  instances  no  diff"eren<"e  in  apjiearatice  can  be  made  out. 

As  an  example  of  the  first  variety  the  fmg-spawn  coccus  may  be 
'■hosen.  It  consists  of  chains  of  cells  agglutinated  into  zoogbeie, 
*t>'i  the  zoogbea-forms  are  blended  together  into  irregular  masses 
*"  large  as,  or  larger  than,  a  hazelnut.  Here  ami  there  a  cell  in 
'nechiiins  becomes  larger  than  its  fellows,  all  of  which  die.  The 
wge  cell,   if  transplanted,   germituites. 

All  micrococci  and  niicrobacteria  are  believed  by  some  to  furnish 
tsiniples  of  the  secon<l  variety.  No  distinction  can,  however,  be 
'Ifswu  between  the  early  and  late  stages  of  cocci,  and  it  is  better, 
iherefiire.  not  to  include  spherical  forms  among  spore-bearing 
|>rg»nisins. 

llatiy  bacteria  are  monomorphic — /.  *'.  between  their  spore  and 
tlieir  fidl  development  they  exhibit  otdy  one  form,  that  of  their 
«|<ore.  Slight  variation  in  the  si/e  and  form  of  the  cidl  is  the  only 
Tariation  that  such  organisms  present.  ( Ithers  arc  inore  or  less  polt/- 
t>i"rjifiic — /. »'.  in  their  life-history,  rods,  spores,  fibitnents.  and  zoog- 
(Hx  can  be  traced,  succeeding  each  other  or  mixed  up  together. 

CONDITIONS  OP  LIFE  AND  GROWTH.— Environment.— 
lere  is  often  a  marked  contrast  between  the  contiitious  essential 
the  more  existence  of  an  organism  and  those  which  are  necessary 


32« 


THF   VEGETABLE  PARASITES. 


if  it  is  to  grow  freely.     In  this  section  will  be  tK)nsiflerc<l  tlir  iiiilii- 
euce  which  a  few  niodifirntioris  in  the  environment  htive  mi  ll"  'if^ 
and  growth  of  orjiiiniMiis  taken   together.      Kach  variety  of  fmi^n' 
seems  to  diflFer  from  all  others  in  its  ff>od-re<juirements.  tliouph  «H 
must  be  sujijilieil  witli  ilie  iiinterisils  whence  they  can  obtnin  tiirelf- 
ments  of  whicti  they  consi.st.    Tiiese  are  curbon,  hydrogen,  tiiir«2<'"- 
[ihosphonis.  sulphur,  calcium,  mngnesium.  and  potassium,   Tbi-ln*' 
four  are  generally  provided  by  carbnhydriites  an<l  albuminoiili*:  the 
rest  by  inorganic  .salts  present  in  aniuuil  and  vegetable  tissue*.  tV' 
tain  bacteria,  however,  can  asr'imilate  nitrogen  and  carbon  froraniod' 
less  comple.x  sub.'^tances  than  albumin  and  carbohydrates  when  tin* 
are  not  avaibible.     This  i.f  shown   by  the  growth  of  putrefactive'* 
ganisnis  in   Cohn's  fluid  (phosi)hate  of  pota.«.siuni,   .ii ;  sulphni<-  >■•' 
magnesium,  1:  phosphate -of  calcium,  .05;  tartrate  of  ammoniuiD. 
1  ;   wafer.  10(1).      For  the  growth  of  others  the  more  compleT  IkmII** 
are  essential.    Thus,  beer-yeast  will  not  grow  unless  glucose  or  siO«* 
body  convertible  into  it  is  present.     It  is  possible  that  such  »  fta><* 
and  such  conditions  could  be  discovered  for  each  fungus  that  it  «l"n* 
would  grow  in  them,     Kaulin  worked  out  the  com|>osilion  of  MC** 
u  fluid  for  a  mould  (Asjiergillus  niger).  and  proved  the  vain*  o» 
each  constituent  by  estimating  the  iliniinution  in  weight  of  a  speci- 
men of  the  dried  plant  yielded  by  a  certain  i|uantity  of  the  flni«» 
from  which  the  constituent  uniler  investigation  had  been  witlulra*!*- 
Very  slight  differences  in  the  t(>ni[>ositicin  of  the  food-material  ni»y 
favor  the  growth   of  one  orgjinistn   ninre  than  nf  another.     XSi»i*l* 
says  that  in  n  neutral  fluid  eontniniug  .sugar,  in  which  were  uioulil** 
yeastJ!,  and  bacteria,  only  the  latter  flourished,  causing  lactic-«ct*l 
fernu'iitation  ;    but    the    addition    of    \    per   rrtit.  of    tnrtarii'  ici" 
brought  the  yeasts  to  the  fore,  with  the  formation  of  alcohul,  Khil*" 
the  addition  of  -f  to  ,5  prr  ernt.  of  the  sanu"  acid  caused  the  inoal«» 
to  develof).     The  reactions  of  the  fluid  has  a  marked  iutliience  in 
this  respect.     As  a  rule,  acidity  is  unfavorable  to  the  developmeU* 
of  bacteria,  alkalinity  favorable — the   reverse    usuallv  holiiiii^  I***" 
yeasts  and  moulds.     Very  slight  differences  may  suffice  to  prnpot 
the  growth  of  a  bacterium;   for  example,  Koch  was   nnnhle  to  pro- 
duce any  disease  in  (ir/it-mire  with  an  organism  which  always  P* 
duced   fatal  septicnemiu   in    hon»e-micv.      Some   similar  diffcwn*^ 
would  .seem  to  e.xist  between   two  men   exposed  to  the  poison  "f  •** 
acute  specific,  one  of  whom    catches  it.  whilst   the  other  does  D«'*- 
A  very  slight,  practically  imperceptible,  change  iu  the  metalx'l*® 


THE  VEGFA'ABLE  PARASITES.  329 

of  the  body  or  of  a  part  may  enable  organisms  to  flourish  there, 
even  though  they  were  quite  unable  to  do  so  a  short  time  before. 
Many  chemical  substances  are  inimical  not  only  to  the  growth, 
but  also  to  the  very  existence,  of  organisms.  It  has  been  suggested 
tiiatthe  term  "antiseptic  "  should  be  reserved  for  those  substances 
wliich  prevent  their  growth,  but  which  do  not  cause  their  destruc- 
tion, while  those  which  actually  kill  the  germs  should  be  called 
'•germicides."  But  the  distinction  is  not  an  absolute  one.  The 
difference  in  many  cases  depends  on  the  degree  of  concentration. 
Thus,  most  germicides  can  be  so  diluted  that  tliev  act  only  a« 
"antiseptics,"  though  the  converse  is  not  equally  true. 

ilermrii'  chloride  is.  on  the  whole,  the  mo.st  powerful  chemical 
germicide  known.  A  solution  of  1:1000  will  kill  any  spores  in 
kalf  an  hour.  Its  power  is  increased  by  the  addition  of  salt  or  of 
hydrocbloric  acid  (five  times  as  much),  while  it  is  seriously  dimin- 
ished by  the  presence  of  an  albuminous  fluid,  and  absolutely 
destroyeil  by  the  addition  of  alkalies,  and  therefore  of  .*!oap. 

A  1 :  20  watery  solution  of  carbolic  acid  rapidly  destroys  fully- 
developed  bacteria,  but  takes  a  few  days  to  kill  the  more  resistant 
spores.  The  addition  of  hydrochloric  acid  (half  as  much)  increases 
'to  germicidal  value.  On  the  other  hand,  anthrax  spores  have  sur- 
vived for  three  months  a  1 :  20  solution  of  carbolic  acid  in  oil. 
Typhoid  bacilli  have  an  unexplained  tolerance  for  carbolic  acid. 
Saiicyhc  acid,  boric  acid,  sulphur  dioxide,  chlorine,  bromine, 
'O'line,  an<l  a  multitude  of  other  substances  have  a  weaker  but 
•naiogous  action.  It  is  especially  worthy  of  note  that  while 
^ood-elot  in  wounds  is  a  substance  on  Avhich  most  bacteria  thrive, 
ilitod-gerum  in  artificial  cultures  is  distinctly  inimical  to  the  growth 
of  many  of  them. 

It  will  be  readily  understood  that  the  germicidal  power  of  any 
*ibstance  must  to  some  extent  depend — (1)  on  the  nature  of  the 
"fganism  ;  (2)  on  the  degree  of  virulence  of  the  particular  specimen 
'"  <}uestion ;  (3)  on  any  physical  conditions  that  may  interfere  with 
"nniediate  contact ;  and  (4)  on  the  presence  of  any  neutralizing  or 
'"Compatible  substances.  It  must  be  remembered,  too,  that  the 
"^pidity  and  extent  of  the  efl^ect  produced  on  organisms  separated 
^^"  cultivation  from  all  the  constituents  of  the  exudations  and  .secre- 
"^na  in  which  they  are  commonly  found,  as  well  as  from  other 
'•"danisms  that  may  usually  coexist,  is  no  exact  measure  of  the 
"Vets  that  will  be  produced  when  wounds,  cavities,  or  surfaces  of 


330 


THE  VEGETABLE  PARASITES. 


the  body  are  concerned.  Neither  must  it  be  forgotten  that  thi" 
very  substances  which  are  most  efficacious  in  dcstroyinj:  organiw" 
are  generally  those  which  interfere  most  readily  with  the  nutritioj 
of  the  tisHue-cella. 

Water. — Nothing  that  is  really  dry  fcrmi'tit.s,  The  presence  or 
«"»«>•  water  is  e.s.siontiiil  to  the  dcvolopment  uf  nil  fungi,  for  it  iictjM 
the  medium  foi'  conveying  oxygen  ;inil  food-suljatance."*  into  tin- i-ell. 
It  is  easy  to  add  too  much  or  too  lit  lie  for  a  given  speeiee. 
moulds  reiiuiro  less  tluin  the  ye:ists.  and  these,  iipain.  les»  th 
hiscliTia.  I'jion  jam,  driotl  by  aihlition  of  sugar  moulds  nfien grotj 
if  less  sugar  he  iuhlcd  or  more  water  left  in  the  fruit.  Hicnholic 
fermentation  is  comuinti,  svhilat  if  the  proportion  of  water  be  still 
greater,  putrefaction  may  occur. 

Desiccation  destroys  many  vegetative  cells  within  n  few  liavsur 
hours,  but  many  resist  drying  for  niontlis,  and  spores  of  the  t'nil'>- 
sporous  group  do  so  for  years — it  is  impossible  to  say  how  lonfi- 
Thus,  dried  cholera  spirilla  die  in  three  hours,  whilst  dried  tvphoiil 
bacilli  survive  nearly  as  many  months,  and  dijihtheria  bacilli  lonjef 
still. 

Oxygren. — I'asteur  has  divided  fungi  into  two  varieties — aerobic 
and  anaerobic.  The  presence  of  oxygen  is  essential  to  the  tnembfn 
of  the  first  group,  while  it  is  fatal  to  (hose  of  the  second.  .Xiiiicr- 
gillus  niger,  U.  subtilis,  and  Mycoderma  aceti  are  examples  of  lU 
fir.st  group ;  the  bacilli  of  tetanus  and  of  malignant  oedema  Wfl 
to  the  second.  By  far  the  larger  number  of  pathogenic  orgnuis 
are  able  to  live  either  with  or  without  o.xygen,  at  least  for  a 
siderable  time.  An  organism  which  thrives  bi'»t  in  the  presence^ 
oxygen,  but  which  run  grow  in  its  absence,  is  said  to  be  "acn 
and  capably  (facultative)  anaerobic,"  and  vice  vrmd.  The  first( 
these  two  groups  is  the  most  important,  and  includes  the  hiicill 
anthrax    trd)ercle,  typhoid,  and  diphtheria. 

Oxygen   under   pressure  may   prevent   the  growth  of.  and  »" 
months  kill,  even  (f('V<'/i/<' organisms.     Their  spores  also,  according 
to   Diielaux.   retain    their   power  of   germinating  much  longer 
oxygen   is  excluded  :   if   true,  this  may  partly  explain  the  act* 
of  air  as  a  disinfectant. 

Temperature. — Each  organism    flourishes  best  at  a  partiruU' 
temperature.      All   will    grow,    but    less   actively,   at    tempeml'i' 
somewhat  above  or  below  this  jwint.     Now,  no  organism  can 
come  parasitic  unless  the  temperature  at  which  it  grows  corresp*" 


Tim  VEOSTABLE  PARASITES. 


331 


to  that  uf  some  pari  of  the  body  to  which  it  finds  ttcces*.     Hence 
it  ha[)[ieii8  that  all   pathoirenic  bacteria  grow  rcudily  at   about   the 
li'm(iiT!i(iire  of  the  hiiiiiau   body.      In   some  casfs  tho  ratigi'  within 
wliicli  iJirowth  is  possible  is  very  limited,  as  in  the  tubercle  bacillus, 
"hifli.  while  it  thrives  at  f>!1°  F.  (-'iT"  C),  can  grow  with  more  or 
\m  difficidty  at  any  temperature  ranging  fi-om  S2°  F.  to  l')8°  F. 
Fmm  this  it  may  be  inferred  that  this  bacillus  is  less  likely  to  exist 
«5  »n  external  than  as  an   internal   parasite,  and  that  when  it  does 
•fleet  tile  surface  its  growth   is  likely  to  be  slower  and  its  progress 
iiiore  easily  arrested.     Other  organisms,  such  as  those  of  cholera 
smi  typhoid,  can  in  suitable  media  grow  at  a  temperature  of  00°  F. 
and  upward.     These  can,  therefore,  easily  multiply  apart  from  the 
l>i)dy    The  general  statement  iuay  be  made  witli  reganl  to  bacteria 
that  reproduction  ceases  when  the  temperature  is  reduced  to  40°  F., 
•ud  in  the  ea.se  of  luany  org.Tnisms  at  a  much   higher  point;  but 
they  do  not  neccs.sarily  die.     Though  rendered  rigid  and  motion- 
les!,  some  can  survive  extreme  cold.     The   spore-bearing  B.  an- 
tliracis  h.as  been  frozen  in  a  Huiil  at  — 11<l"  C.  without  itijury.  and 
the  typhoid  bacillus  has  survived  tliree  hours'  freezing      The  nia.\- 
imiiin  temperature  at  which   bacteria  can  grow  is  in   most  cases 
Wtweeti   100°   F.  ami   120°   F.     By  further  rise  of   temj)eniture 
fijtidily  and  denth  are  induced — more  easily  in  moist  than  in   dry 
Conditions,  and  mucii    more  easily  in  the  adult   thun   in   the  spore- 
form.    The  reaction  and  nature  of  the  medium  in  which  the  germs 
We  heated  have  a  deci<led  infhience.      Boiling,  and  indeed  a  much 
liter  temperature   (140°    F. )    than    212°    F..    will    kill   the   great 
Bajority  of  fungi,  but  solutions  containing  spores  may  need  ex- 
["wiiire  to  a  temperature  of  212"^  F.  f'ltr  many  hours  before  they  are 
fninplctely  sterilized.       Thus,    Tyndall   failed   to    sterilize    a   hay- 
ittfttiiion  by  eight  hours'  boiling.      This  jirolonged  resistance  of 
•(wre-containing  tliiiils   to  boiling  is  explaiued  by  sufiposing  that 
frwh  jrcneralions  of  adult  orgiinisms  are  developed  after  the  boiling 
ttoter  from  spores  able  to  resist  that  temj>erature  for  a  long  time — 
•  view  supfKtrted  by  the  fact  that  such  fluids  may  be  readily  steril- 
iwd  if  boiled    for   a   few  minutes  only   on  four  or  five  successive 
occi«io»8  at  intervals  of  several   hours. 

Id  like  manner,  alternate  freezing  ami  thawing  destroys  organ- 
i''tt)s  more  rapidly  than  continuous   freezing.     Tyjihoid  bacilli  suc- 
cumh  to   this  treatment    in  a  month,  while   they  resist  continuous 
[freezing  more  than  three  times  as  long. 


THE  VEQETABLE  PARASITES. 

•Some  vegetiitive  forms  hare  been  fouod  which  withstnnd  tviupen- 
turc3  higher  tlian  tliosc  nnmoil.  Ditclaux  found  sonic  haeilii  I';/'* 
////•/.(■  in  choffiiv)  whicli.  wlifU  siispcndt'd  in  (tlightly  alkaliiu'  liuid. 
were  not  destroyed  by  100°  C,  but  in  acid  medium  were  kilNia* 
minute:  the  sport's  were  not  destroyoil  l)y  11.")°  ('.  (hlicr 'in^ii" 
of  sporo  iiiivc  bt'cn  na-t  with  vvhidi  have  withstor)d  a  moist  init  •' 
even  130°  C. 

Strciiining  steam  has  n.  more  powerful  jrermicidal  nrtimi  iliaii 
superheated  steam.  This  is  probably  due  to  its  grc.iter  ilcsn'' '" 
moisture  and  its  eonserpiently  greater  penetrating  power. 

The  (//•//  spores  of  tfie  R.  antliraeis  and  of  tlie  U.  subtilis  arr  n"' 
destroyed  by  less  than  three  hours'  exposure  to  140°  C. 

Best. — Fungi  flourish  better  in  a  still  medium  than  in  one  who** 
particles  are  constantly  moving :  wliilst  the  B.  unthracis  ilividt* 
actively  in  the  blood-strcjini,  luanv  lither  kijidsfmicrococcuaseptico** 
seem  always  to  settk'  befcu'c  n)ulti]>lyiiig. 

Light.  —  Light,  e-specially  bright  sunlight,  has  n  destriicti*''' 
influence  cm  orgjiiiisuis.  Tli«'  rays  from  th<'  viidcf  end  are  siii"!  *'• 
be  the  most  powerful,  those  from  the  red  end  the  least.  All  <irpin- 
isms  do  not  sutler  e(|ually.  A  few  even  multiply  under  the  action 
of  light  llecorded  exjieriinents  on  this  subject  are  contnuliotor** 
The  contradiction  may  lie  due  to  the  difficulty  in  exciutliiig  tb* 
influence  of  desiccation,  oxi<lation.  and  changes  in  the  mo<lii  »" 
which  the  organisms  are  phiced.  Vomhhied  with  these,  light  iiininC*" 
tioiiably  forms  a  valuable  means  of  disinfection. 

Soil. — Ajiart  from  their  degree  of  moisture  and  from  the  prescnc* 
of  other  orgunisms,  the  intliience  of  most  soils  on  the  growth  *>• 
jiatliogeiiic  bacteria  does  not  seem  to  be  marked.  l\'at,  howev«?*'> 
h;is  a  distinctly  destructive  influence  over  the  organisms  of  cboirr* 
and  typhoid  fever  (Dempster). 

These  arc  the  essentials  by  wliich  the  growth  of  orgnuisiim  r*** 
lie  modified.  Absence  of  growth  does  not  necessarily  mean  ilea*' 
<if  the  organism.  If  the  conditions  are  unfavorable,  the  cells  »»• 
not  develop,  but  they  may  not  die.  By  making  a  compnnitivr"  * 
small  change  in  scune  of  the  above  conditions  the  developmriii,  a** 
couse()uently  the  nctiun,  of  any  given  organism  may  be  prevent 
This  may  often  he  possible  when  it  is  ijuite  out  of  the  i|ii«ti'in  *" 
employ  measures  powerful  enoiigli  at  once  to  dettroy  the  iirgani'*"' 
themselves. 


THE  VEGETABLE  PARASITES.  333 

DISTRIBUTION  OP  BACTERIA  IN  NATURE.— Where  are 
these  microscopic  vegetable  organisms  to  be  found  ?  A  putrid 
wound  swarms  with  them.  Whence  do  they  come?  There  are 
three  possible  answers :  1.  They  may  find  access  to  the  body  from 
some  outside  source;  2.  They  may  exist  in  the  healthy  body, 
developing  only  under  special  circumstances ;  3.  They  may  be 
spontaneously  generated  from  the  tissues. 

1.  Earth,  Air,  or  Water  may  be  the  Habitat  of  Germs. — ((/) 
Barth. — The  soil  is  the  principal  .storehouse  of  organisms.  Portions 
of  mould  taken  from  the  surface  and  dropped  into  a  sterilized  cul- 
ture-fluid invariably  infect  it.  Pyogenic  cocci  and  the  bacilli  of 
tetanus  and  malignant  oedema  are  among  the  forms  usually  found. 
In  winter  Koch  failed  to  find  any  organisms,  iit  a  depth  of  one 
metre  in  soil  which  had  not  been  recently  disturbed,  which  was  not 
formed  largely  of  decomposing  material,  and  into  which  no  unusual 
soakage  of  water  had  occurred. 

All  .solids  in  contact  with  air,  including  the  surfaces  of  animals, 
bavc  organisms  upon  them. 

(/))  Air. — That  dust  contains  much  organic  matter  is  easily  shown 
by  combustion,  and  by  artificial  cultures  it  can  be  proved  that  some 
of  this  is  living.  It  has  thus  been  found  that  spores  of  moulds  are 
the  commonest  forms,  then  bacilli  and  their  spores,  whilst  putrefac- 
five  organisms  are  comparatively  rare.  Organisms  of  some  kind 
«xist  in  the  air  everywhere  except  away  from  all  lift — in  mountains 
*bove  the  line  of  perpetual  snow  or  on  the  ocean  far  removed  from 
land  and  ships.  In  such  places  a  sterilized  fluid  would  not  ferment, 
even  if  left  exposed  till  it  dried.  But  wherever  life  is  found  germs 
*fe  found.  They  increase  in  number  as  the  population  grows  and 
*s  putrescible  material  becomes  more  plentiful.  Ilesse  found  that 
*ne  air  in  a  hospital  ward  in  Berlin  contained  thirty  times  as  many 
■bacteria  as  the  air  out  of  doors.  In  some  parts  of  London  it  is 
possible  to  pour  sterilized  fluids  from  one  flask  into  others  with  the 
'^sult  that  but  a  small  percentage  will  become  turbid  from  the  growth 
'^^  germs ;  in  other  parts  every  flask  will  be  infected.  I'recautions 
*g*inst  infection  become  more  necessary  as  density  of  population, 
***<!  imperfect  ventilation  increase ;  and  it  is  obvious  that  in  the 
"Ospitals  of  large  towns  such  measures  to  be  successful  must  be  most 
*t*'ingent,  for  here  putrefactive  organisms  will  be  comparatively 
'^timerous. 

The  air  is  kept  supplied  with  organisms  from  the  surfaces  of 


334 


THE   VEGETARIJ-:  PARASITES. 


objects  over  wliicli  it  jiassos.  The  dust  left  as  tiic  final  n-xiilti 
putrefactive  proeesfes  is  a  fertile  Hoiireu  of  eoiitaiiiitiatiou.  I'crfw 
»till  air  becomes  pure  by  Bubsidence  of  its  germs. 

(r)  Water. — All  water,  except  such  as  comes  from  a  p 
(artesian  wells),  cinitains  orj:aiiisms.  Kaiu-water  sweeps  tiic iiir. ami 
infects  the  soil  with  the  germs  which  it  carries  iIowd.  All  snrfw*- 
wftter  is  infected  frnm  the  ground  tliruiigh  which  it  soaks.  Ri>rt- 
water  is  exposed  to  all  (lossible  sources  i«f  pidiutiun.  It  is  ^nmU 
necessary  to  add  that  iiidcss  the  water  contains  suftieieiit  orpiiic 
matter  to  serve  as  fund  fur  the  fiiugi.  no  multiplication  will  lake 
place,  and  that,  sooner  m-  Inter,  tiie  germs  will  die.  though  [xTlup 
not  fur  many  weeks.  The  existence  of  many  organisms  in  a  Mtiijilf 
of  water  render  much  organic  impurity  probable. 

2.  Do  Organisms  Exist  in  the  Living  Body? — They  exist  iff 
large  uundters  on  its  extcnml  (.ikiii)  and  iniernul  (bronchial  anil 
alimentary)  surfaces  which  are  in  contact  with  the  air.  On  the  skin 
they  are  most  numerous  on  the  /lamh — beneath  the  nails  ami  in  ll"' 
folds  of  skin  about  the  nails;  and  on  finrtK  jirovidol  with  Imiraii'l 
large  iflanih — r.  g.  the  scalp,  axilla,  and  perineum.  Special  earei* 
therefore  reipiired  to  disinfect  these  parts.  Inhaled  witli  the  hreuth- 
organisms  are  found  in  the  larger  bronchi,  but  the  smaller  futi« 
and  alveoli  are  jtrobahly  free,  for  Tyndall  has  shown  that  lliewinr 
plemental  air  is  pure,  a,s  it  causes  a  nondundnous  gap  in  an  elcftnc 
beam  thrown  across  a  dark  room.  Fiii'lher  proof  lies  in  llu-firt 
that  *•  medical  "  einpyeniata.  communicating  with  the  air  tlinnijel" 
the  linig.  generally  reuiain  free  from  putrefaction,  whilst  surgiol 
empyemata,  I'ollovvirig  an  external  wound  of  the  pleura.  aN 
putrefy. 

With  food  and  drink  manv  living  germs  are  carried  into  the »!>• 
mentary  canal.  .\ll  kinds  of  fungi  swarm  in  the  mouth.  Tbej 
grow  fewer  as  the  stomach  is  reached,  for  the  acid  gastric  juicej 
unfavorable  to  the  dtivelopment  of  most  of  them.  Orpnni.sms 
plentiful  in  the  duodenum  before  the  food  has  become  alkaline, 
the  pancreatic  juice  swanus  with  organisms  after  impure  fee'lil 
Indeed,  the  products  (vf  normal  ])ancreatic  digestion  and  th<»i'«< 
the  ordinary  putrefaction  of  albuminoids  are  practically  the  sa 
Throughout  the  whcde  intestine,  but  varying  with  the  product* i 
stages  of  digestion,  euoriuous  numbers  of  organisms  occur, 
abnormal  states  of  the  mucous  membrane  or  in  too  prolonged  ret< 
tiou  of  intestinal  contents  the  fungi  may  multiply  and  excite 


THK    VEGETAnLE  PARAfilThlS. 


335 


ana  even  jioisoning,  by  the  proiliii't!-  of  their  iu-tioii.  Expe- 
siliows  that  allLT  death  piitrt-'f'actiou  begins  in  tlie  altilomen, 
ling  from  the  alimentnrr  cuiin). 

obtaining  pure  urine  ilirectly  fVoni  tbi-  iirethni  Linter  showed 
healtliy  urinary  tract  is  tree  from  organisms. 
!teri)i  iin  the  skin  and  mucous  surfaces  mav  fairlv  be  reganled 
muil  to  the  body  proper — /.  e.  to  the  tissues.  Organisms  are 
ill  the  ti-ssues  in  many  dhrani-f :  wc  have  now  to  in(|uire 
w  tlicy  exist  in  the  /leult/ii/  tissues.  Tliere  are  two  routes  iiy 
organisms  may  reanh  the  tinsui'S.  One  is  tiirough  the  nkin  ; 
lier  tiirough  the  murniis  tnembnateg,  esjiecially  the  respiratory 
le  alimentary. 

The  Skin. — As  a  generiil  rule  iniinjiiri'd  ejiiilcrnris  is  imper- 
ii) organisms,  and  in  priictirc  ncin-ly  ;i!l  mganisius  that  gain 
hy  tiiis  means  enter  tiirough  wounds  or  slight  abrasions, 
k's  liavc.  however,  been  produced  by  rubbing  into  the  skin  a 
culture  of  the  stophylococeiis  pyogenes  jiiireiis.  Inoculation 
Se  ca.ses  .seems  to  have  occurred  through  the  walls  of  the  liair- 
BB  or  the  8wcat-duct«.  as  it  does  in  the  case  of  acne  pustules. 
The  Mucous  Meml>rane». — If  organisms  enter  by  the  skin,  it 
'ortinri.  likely  that  they  will  also  enter  by  the  niiicoiis  nieiu- 
I.  To  decide  this  (jiiestiod.  s<»  f;ir  ii.s  the  respiratory  tract  is 
ned,  animals  were  placed  in  an  atmosphere  impregnated  with 
,X  spores.  Aiithra.x  is  a  pMrtinilarly  siiitalile  organism  to  use 
Ht,  from  the  readiness  v»iih  wliich  it  thrives  in  the  tiornial 
I  In  an  experiment  of  Buchner's  out  of  sixty  animals  thus 
Ffifty  died  from  antlirax.  It  is  unlikely  that  the  organisms 
iwallowed  and  alisorbed  through  the  wall  of  the  alimentary 
-first,  because,  while  large  numbers  were  found  in  the  lungs, 
none  were  present  in  the  spleen  ;  and  secomily.  because  out 
ty-three  animals  fed  on  double  the  proportion  of  unthnix 
only  four  succumbed.  These  experiments  not  only  showed 
the  ease  of  anthrax  the  organisms  can  gain  an  entry  through 
bcse  miK'Oiis  nieiiibrmie,  but  also  that  the  entrance  through 
■piratory  mucous  lueiiibrane  is  the  more  readily  eflected.  In 
Ig  they  are  probably  taken  iiji  like  ("trhon  particles,  carried 
phatie  glands,  and  thence  perha|ts  to  the  blooil.  It  is  diffi- 
^cny  that  in  many  cases  there  may  have  been  some  slight 
Wt  the  point  of  entry. 
m  animals  are  fed  on  putrid  material  living  organisms  may  be 


san 


THH  vh:ai:TAtiLK  parasivkk 


foiinil   ill  tlio  iiritif.     This  is  iil.io  tlit-  case  wlioii  it  liiry 


(|UMT 


\ml.sIm'i1  iiiitrfiix-live  orgiiiiistiis  i;-  inji'cto<l  into  the  rirculj 
Ortlinarily,  as  above  said,  frei>)i  liiiiniin  iirinc  is  stcrilr. 
goriiis.  of  coiirsf,  are  (•.•iiTitMl  to  otlirr  or;:iiii)»  than  the  kiditft 
arc  foiin<l  us  vfllowish  iiiii!<i«fs  in  tin*  cu|jilluric»:  tlicv  are  uuak 
thrive  in  the  hcaltbv  system,  and  die  and  dixappear  in  twoortbm 
vrt'ks — often  much  more  nipidlv.  Kmni  the  above  data  it  i»  piw^- 
able  thiit  iindt^r  onliiiurv  eirciimstanees  or<!nniMn!«  can  pas*  thrnnjk 
the  miicoiis  inenibrHne^  of  man  in  i^mull  tjimntitieH  only,  ninl  tt>il 
any  which  do  enter  soon  die  nntl  t|o  not  reaeh  tlic  tirine  aliTc^l 

Kx|>eriments  have  been  nnub-  to  determine  \« hether  or|;auifa(W 
liabitiuilly  present  in  heullliy  tissues,  I'ortions  of  liealthy  nrpu 
have  been  removed  with  precaiitiontt  and  placed  under  conditi««» 
best  calculated  to  enconrn^re  tlie  growth  of  any  or;:ani*rai'  tint 
mi;j;lit  l>e  ])rescnt,  as  well  nr.  to  prevent  their  contaminalinn  fn« 
any  extraneous  source.     The  results  have  been  contradictorj.' 

The  balance  of  evidence  seems  to  be  distinctly  in  favor  of  tl* 
view  that.  </»  a  ruli\  no  living  germs  nre  to  be  found  in  linllk* 
tissues.  But  that  the  blood  may  contain  liviiig  pyogenic  opcci  il 
|irol»ible  from  the  freipiency  with  which  inflnmmution  and  »!•«• 
ri'sult  from  bruises  occurring  in  depresse<l  states  of  the  t\*um 
(|).  M48),  but  without  any  break  in  the  continuity  of  the  e|ii*lrrD<» 
(p.  <'137).  If  cocci  could  onliimrily  obtain  accesa  to  the  tiMow  by 
means  of  the  vessels,  il  woiihl  be  impossible  by  autisejitic  trMlJM** 
(adapted  to  prevent  the  entry  of  living  cocci  t'rom  without)  to  ^ 
vent  suppuration  of  wounds  from  causes  reaching  theiu  from  inih»- 

Agdin.  the  rarity  with  which  any  collection  of  pulre*ii' '  """ 
in  the  body  undergoes  putrescence  (notwithstanding  the  -^ 
of  the  temperature),  and  the  certainty  with  which  by  care 
keep  wounds  -'sweet,"  seem  to  be  strongly  against  the  e\i 
of  putnfitctiv  fungi  in  healthy  tissues.  It  is  certain,  hut 
that  if  these  do  gain  access,  tliey  may  survive  for  some  Lot 
that  the  jiutrefuetion  of  removed  portions  of  tisane,  osnally  attril 
uted  to  want  of  cnre,  may  .sometimes  have  been  due  to  the  {rcMftC 
of  living  genus  in  those  pi>rtions  at  the  time  of  their  reuitMal  6w 
the  body.  Again,  if  a  suitable  ni<ius  be  provided  for  tiie  do^B 
nient  of  organisms,  they  luuitiply  and  .set  up  their  rhamrtiM 
ilccomposition.     Thus,  Ohauveau  performed  fii»tourtK2yf  ttf  »  siterj 

'  W>twiri  ('h«Tne,  7Vaii<.  PalM.  Society  of  JjoiMlon,  IH79 ;  Mott  aad  Honigy.Jmt 
of  Pk!f$Uilogti,  ToL  iii. 


THE   VEGETABLE  PARASITES.  337 

testis— I.  e.  subcutaneous  torsion  of  the  organ  and  its  main  vessels 
—in  one  case  before,  and  in  another  after,  the  injection  of  septic 
bacteria  into  the  blood.  In  the  latter  case,  in  which  the  testis  pre- 
inmablj  contained  imprisoned  organisms,  it  broke  down  into  a 
potrid  fluid  and  excited  much  inflammation  around.  In  the  former, 
in  which  the  injected  bacteria  were  shut  oflF  from  the  damaged  testis, 
the  organ  underwent  the  fatty  changes  known  as  necrobiosis.  This 
is  the  invariable  course  when  under  normal  conditions  the  operation 
is  performed  as  a  method  of  castration  :  it  seems  to  show  that,  nor- 
maiiv,  organisms  are  not  present  in  the  sheep's  testes. 

Some  organisms,  however,  seem  capable  of  flourishing  in  tissues 
which  are  perfectly  healthy — e.  g.  the  poisons  of  the  acute  specifics 
and  the  B.  anthracis.  Even  here  there  is  some  very  obscure  differ- 
ence between  individuals  of  the  same  species  or  of  closely-allied 
species  which  renders  some  of  them  suitable  media  for  the  develop- 
ment of  certain  organisms,  whilst  others  are  unsuitable — i.  e.  more 
or  less  predisposition  is  required  even  when  a  species  of  animal  /« 
UaUe  to  a  disease.  Thus,  some  people  do  not  appear  capable  of 
contracting  the  acute  specific  fevers ;  children  are  more  subject  to 
Mute  specifics  than  adults;  Algerian  sheep  are  immune  to  anthrax  ; 
joung  dogs  are  easily  inoculated  with  the  6.  anthracis,  but  old 
ones  are  not.  One  great  diflBculty  in  the  experimental  study  of  the 
infective  diseases  of  man  is  to  find  animals  which  are  subject  to 
them.  Many  organisms  will  thrive  only  in  some  particular  tissue 
or  fluid  of  the  body ;  thus,  some  multiply  in  the  blood,  others  in 
lymph,  some  in  bone  (osteomyelitis),  others  in  the  cerebro-spinal 
meninges  (epidemic  cerebro-spinal  meningitis).  (See  "  Micro- 
cocci.") 

To  sum  up :  Organisms  in  great  variety,  but  in  very  varying 
Bumber,  exist  in  air,  water,  earth,  and  on  all  objects  exposed  to  air, 
on  the  skin,  and  on  those  mucous  surfaces  which  are  in  contact  with 
*ir.  Organisms  can  probably  pass  through  the  pulmonary  and  intes- 
tinal mucous  membranes,  but  in  small  number ;  and  such  as  ordi- 
•"irily  thus  enter  the  tissues  are  unable  to  develop  so  long  as  the 
latter  are  healthy.  The  life  of  such  fungi  among  the  tissues  is 
^oort.  It  seems  to  be  a  very  rare  thing  for  them  to  reach  the  urine 
«ive.  Occasionally  an  organism  which  can  develop  in  living  tissue 
titers.  The  recipient  of  such  organisms  is  in  more  or  less  danger 
of  disease.  Some  fungi  seem  to  find  a  suitable  nidus  for  their 
development  in  the  great  majority  of  mankind ;  thus,  few  are  im- 

22 


THE   VEGETABLE  PARASITES. 


niiine  to  tlip  vaccine  vims.      All  m-jriinisnis  flourish   Ijest  in  ti«»M 
the  vitality  of  which   is  im|iairetl :  soiiif   probably  cimnol  di'vtlop 
niilesH  this  is  the  case;  and  8till  another  group  cannot  multi]ilT  it, 
livini;  tissues  at  all.     Two  preat   ilivisions  (clinical)  of  axpum 
are  thus  obtaineil:   1.  The  Patboerenic,  or  those  «hich  can  invn 
and  multiply  in  livin<»  tissues,  almost  invariably  j;ivinj»  rise  to  di 
ease.     2.  The  Non-Pathogenic,  or  Simple,  which  can  develop  onl 
in  (load  tissue,  and  arc  tlierefnre  found  chiefly  on  the  surface  of  tl 
body,  where  slouglis  and  discharges  are  common.      It  i.s  u  verv  raW 
occurrence  for  putrefactive  fungi  to  find  their  way  tiUre  to  an  intM- 
nnl  slough  or  piitrescible  effusion,  as  they  did  in  Chaiiveau'noxpvri- 
nient  ([>.  8o<)). 

3.  Spontaneous  Generation.  —  The  pos.sibility  of  organiitu 
originating  </»•  novo  from  the  molecules  of  decoiuposiiip  ' 
must  be  mentioned,  but  cannot  be  discussed.  The  great  lua;  . 
of  observers  are  agreed  that  there  is  no  evidence  that  it  ocean 
They  hold  that  if  a  fluid  or  moist  solid  be  thoroughly  sttriliifl 
and  placed  under  such  conditions  that  no  organisms  can  enter  from 
without,  no  organisms  will  ever  develoji. 

We  conclu<le,  therefore,  that  organisms  found  in  a  putrid  woiiml 
have  entered  it  fnim  iri'thout,  and  that  the  same  is  true  of  fiiii|.i 
found  in  patliologica!  lesions  within  the  tissues,  the  organ i.-suis  hid- 
ing entered  by  a  wound  or  through  a  mucous  surface.  For  tb' 
present,  at  least,  we  uiii.'<t  adhere  to  the  belief  that  neither  livin? 
organisms  nor  their  spores  exist  nornuilly  in  the  tissues,  ami  tlia' 
they  are  never  eliminated  alive  by  an  excretory  organ  or  bj  • 
wound.  ' 

This    is  of   fundaUH'iitid    importance   in    surgery.      If  orgaiii*m» 
couM  enter  n  wound  from  the  side  of  the  tissues,  aseptic  treatrac»' 
would  be  impossible.     As  it  is,  we  are  sure  that  if  we  allow  no  liwf*"  i 
hole  for  the  entry  of  germs  from  without,  our  wounds  will  rem***  j 
free  from  feruient-proce.sses.      Patietits  are  thus  saved  from  the  ila»'" 
ger  of  septic   intoxication,  of  septic  infection  or  pysemia.  and  **• 
other  infective  diseases.     (See  "  Pyiemin  and  Septicemia.")    Ob<^* 
organisms  have  gained  access  to  the  tissues,  it  is  extremely  diffict*'* 
to  destroy  them  without  also  destroying  the  tissues.     Improvemr*'* 
of  the  general    health  often    enables    the  tissue-clement*  to 
invasion  succe.ssfttlly.     (See  "  luiniunitv.") 

Products   of    Bacteria. — The  chemical    products    which  »"•»" 
from  the  growth  of  bacteria  are  both  numerous  and  varic<l.     *" 


THE  VEGETABLE  PARASITES. 


339 


ses  they  comprise  a  series  of  complex  changes  which  are  as 
imperfectly  made  out.  To  a  considerable  extent  they 
upon  the  nature  and  amount  of  the  material  from  which  the 
a  in  question  derives  its  nourishment,  as  well  as  upon  the 
1  conditions  by  which  it  is  surrounded.  Thus,  the  cholera 
when  grown  in  weak  meat-juice  produces  a  peptonizing  fer- 
ut  when  supplied  with  a  much  stronger  solution  forms  a 
;  ferment  instead. 

products  of  bacterial  action  have  no  pathogenic  import- 
hese  we  shall  not  discuss.  They  include  many  pigments, 
ve  of  aniline  dyes  and  certain  fluorescent  and  phosphores- 
(cts  ;  many  on/atnc  acids,  such  as  lactic,  acetic,  and  butyric, 
er  allied  substances;  a  few  gases,  including  carbon  dioxide, 
as,  hydrogen,  and  sulphuretted  hydrogen. 
;hief  products  of  pathogenic  importance  are — (1)  unformed 
s.  (2)  albumoses,  (3)  alkaloids  or  torincs,  and  (4)  caustic  siib- 


coMPARiNQ  Action  of  Anthrax  and  Diphtheria  Fer- 

nS   WITH    THOSE    OF    PePSIN    AND    TRYPSIN    (MaRTIN).' 


\gent,    Ferment  or  Secondary 


iry  In- 
igent. 


CeU. 


Cell. 


Ins 
erise. 


Infective  Agent. 


Pepsin. 


Trypsin. 


Anthrax  ferment. 


Diphtheria  ferment 
in  membrane. 


Digestive  Products. 


Syntonin. 

f  Hetero-albumose. 
Albnmose  -j  Proto-albumose. 

I  Deutero-albumose. 
Peptone. 


Qlobulin-like  body. 
Tryptone  (peptone). 
I.«ucin  and  tyrosin. 
A  bitter  body. 


{Hetero-albumose. 
Proto-albumose. 
Deutero-nlbumose. 
Peptone. 

I>eiicin  and  tyrosin. 
Alkaloid  (base). 


(  Hetero- 
Albiimose  <  Proto-      ] 

(  Deutcro- 
Organic  Acid.  J 


•  in  the  membrane, 
in  the  bodv. 


relation  of  these  different  groups  to  one  another  can  be 
understood  by  a   reference  to  the    preceding  table.     The 
'  Goulstonian  I,ecturcs,  liril.  Med.Joum.,  vol.  i.,  1892. 


340  THE  VEGETABLE  PARASTTES. 

most  striking  feature  it  presents  is  the  general  similarit 
the  products  oi  proteid  digestion  and  those  o(  bacterial  act 
processes  are  not  so  similar  as  they  appear  at  first  sight 
first  place,  the  ultimate  products  are  difiercnt.  In  choler 
loid  is  the  final  product :  in  diphtheria,  an  organic  acid, 
more,  the  experimental  inoculation,  of  animals  with  the  ; 
produced  by  different  organisms  clearly  shows  that  thc« 
albumoses  are  by  no  means  identical,  and  that  their  clien 
tions,  so  far  as  at  present  known,  give  no  indication  of  thi 
genie  effects.  Thus,  in  diphtheria  the  albumoses  can 
degeneration,  while  the  organic  acid  seems  almost  ham 
cholera,  on  the  other  hand,  the  alkaloid  or  final  product  se 
the  real  cholera  poison.  So  far  as  is  at  present  known,  t 
tion  of  an  alkaloid  by  an  organism  is  not  necessarily  pr< 
that  of  a  ferment. 

In  connection  with  about  one-fifth  of  all  known  pathogei 
isma  ferments  have  been  discovered.  The  nature  of  those 
already  described  (p.  322) 

Albumoses  are  common  intermediate  products  in  the  se* 
bacterial  reactions.  In  some  cases  they  arc  the  mo.-it  vi 
all  the  resulting  c<mi]iounds.  This  is  so  in  diphtheria  and 
|H)ison.  In  anthra.x  and  cholera,  on  the  other  hand,  they 
parativcly  of  slight  importance. 

Among  the  varied  products  of  bacterial  growth  are  a  h 
her  of  alkaloid  suhstanees.  Some  of  these  are  harmless, 
are  poisonous.  The  latter  are  known  as  torines.  E.xampl 
these  varieties  may  be  found  in  putrefying  meat,  fish,  an 
They  can  be  easily  separated  and  their  nature  investigaJ 
virulence  of  both  anthrax  and  cholera  is  due  to  the  fori; 
toxines. 

Fate  of  Org'anisms  in  Livingr  Tiesuea. — It  by  no  meai 
that  germs  which   have  actually  entere<l    the  tissues  will 
and  give  rise  to  disease.     Ju.xt  as  in  the  case  of  infective 
tions,  so  in  all  other  infective  diseases,  there  are  tirn  fad 
produetion  of  disease — the  attack  of  the  germs  on  the  one 
the  resistance  of  the  ti.ssues  uj>on  the  other  (p.  307). 

Supposing  the  conditions  to  be  favorable  to  their  grow 
genie  fungi  differ  nineh  in  the  course  which  they  pursu 
remain  about  the  spot  at  which  they  first  settled.  Others, 
ferent  degrees  of  rapidity,  spread  by  continuity  of  tissue. 


THE   VEGETABLE  PARASITES. 


341 


a^in,  are  carried  along  in  tlie  lyinpliatios,  settling  in  tliem  here  and 
tlii-re,  or  passing  on  until  the  nearest  ghinils  are  reached.  Another 
gnmp  enter  the  circulation  at  once  nn<i  are  carried  in  the  blood  nil 
over  the  body.  Some  species  remain  and  multijih'  in  the  blood, 
mil  in  tritnslucent  i)arts  may  be  seen  in  the  plusrautie  zones  of  the 
terns;  others,  again,  re(|uire  to  be  deposited  I'roin  the  blood  at  some 
spot  preilisposed  to  receive  them.  Escape  from  disease  after  expo- 
»iirc  to  infeetion  is  doubtless  often  due  to  the  deiiosit  of  germs  »t 
jpots  other  than  "  weak  "  ones. 

The  spread  of  organisms  in  the  tissues,  like  that  of  an  absce.s.s, 
»lw«T8  occurs  along  the  lines  of  least  resistance.  Fiirtherniore,  it 
is  not  necessary  that  the  organisms  should  inter  the  tis-siies  at  all  in 
iinler  to  produce  disease.  In  diphtheria  the  bacillus  is  confined  to 
tbefiiise  membrane:  this  becomes  simply  a  manufactory  of  the  fer- 
ment, which  is  rapidly  distribiiteil  throughout  the  body,  giving  rise 
in  the  tissues  to  the  albunioscs  alreinly  referred  to.  In  cholera,  too. 
tile  bscillus  is  only  found  in  the  intestine,  while  its  products  are 
rapidly  absorbed  and  lead  to  the  well-known  8yin|itoHis.  It  is 
therefore  clear  that  the  effects  of  the  action  of  organisms   in   the 

Fi(i.  117. 


ib^ 


^^:^m 


B/ 


u  ■■- ,  ■ 

"■JOw't  lan«— vcHsU  p1iik8»<I  with  baclUt  antlirnctii :  n,  alvenlus:  v,  rein  tul\  of  iMClllI : 
'•'^PtlUrj',  iil*<i  ftill ;  fcr,  lirDiu'hiui.    X  .VX», slUfhlly  reduced.    (Bonley.) 


iioiiy  a|.^  ypry  varied.  Sometimes  they  are  str'retly  locaf,  A  small 
•"i"**  of  organisms  by  means  of  its  chemical  jiroducts  excites  an  in- 
"ininiatory  focus  anti  exerts  n  po])torii/,ing,  caustic,  or  other  action 
on  the  tissues  in  which    it   lies  (Figs.   107.   108).     The  action   is 


342 


THE  VEGETABLE  PARASITES. 


litiiited  to  invasion  of  the  tissues  ueiir  the  }>oint  of  entrT. 
times  the  action  is  less  strictly  locul.     Such  inflauimntiun  w 
diffuse.     Occasionally  the  mere  mechanical  plugging  of  tht*  rrm*it 
may  be  of  importance.     The  accom|ianying  figure  (Fig.  11"). »li 
iug  the  bacillus  of  splenic  fever  in  the  vessels  of  a  mou»c's  lui 
gives  an  iilca  of  the  extent  to  which  this  process  may  be  rsmnl 

Sometimes,  when  the  orgunisms  uniltiply  in  thv  blcMtU  or  Ji»ch«r)^ 
into  it  the  products  of  their  action,  the  most  marke<l  fffects  arc//f«- 
eral.  These  consist  mainly  of  fever,  wasting,  and  coma  frum  tU 
action  of  substances  circulating  in  the  blood,  the  coaguUbihij  iif 
which  is  sometimes  le.xsencd.  lu  others,  again,  in  achlition  In  iht 
strictly  local  and  general  effects,  the  circulating  producLt  an«rk 
special  parts;  as  in  diphtheria,  in  which  the  albumosc*  nnf 
marked  dcgcnenitinn  of  certain  nerves  and  eon.«r(|Ui'nt  local  |>i 
ysis.  I'ossibly  p»ru:<itic  fungi  also  produce  >i)imi'  ■■fTi-ct  li\ 
abstraction  of  nourishment  from  their  host. 

Reference  must  here  be  made  t<»  the  conditions  whidi   iiiHurt 
these  two  factors,  increasing  or  diminishing  the  power  of  thei 
isms  or  the  resisting  capability  of  the  tissues. 

(1)  Arreet  of  an  orgranism  is  absolutely  necessary  before  it  ( 
by  its  metabolism  produce /wvi/  irritation  and  intlammatiou,  forifl 
products   are   poured   into  the  circulating   blood,  they  become 
dilute  to  effect  any  local  injury.     Tbun,  pyogenic  oocci  have 
Uncntly  been   found   in    the   bloorl  of   persons   having  no  >b 
Again,   lym]ihadenitts  is   much   commoner  than   lymjiluiiigiut. 
because  the  glands  are  more  accessible  toorgani«mJi  than  there 
but   because  the  organisms   are  more  likely  to  be  arrested  in 
narrower  and  more  sinuous  channels  of  the  former.     Kut  *uch  i 
is  not  neces.«ary  for  organisms  which,  like  those  of  septic  infn 
of  mice,  act  by  pouring  into  the  blood  fsiisons  which  cau.se  fercfi 
other  symptoms,     infill,  though  n-nt  is  only  mxt'ittial  to  the  innltif 
cation  of  tome  organisms,  it  is  itdvantittjeon*  to  the  growth  of  '"t| 

Organism*  circulating  in  the  blood  may  be  arresttfii  iu  one  | 
many   ways.     Of  these  the   conunonest    are   rmtii>(i*m,   f/ma 
estrai'titiitioii  of  blood   from   injury,  anti   the  miifratiou  and  »o 
i|uent  death  of  a  leucocyte  bearing  in  its  interior  onr  nr  more  li» 
germs;  which  will  occur  most  easily  in  part-s  in  which  the  vt 
are  distended  and  the  circulation  slow  (venous  congestion).     1*1 
conceivable  that  a  germ  might  escape  uuaide<l  from  a  vessel  uo 
tbeae   oircumstaucen,  just    as   a    red    corpuscle    ilocs.      Xt 


THE   VEGETABLE  PARASITES. 


S43 


itthods  httve  been  devised  to  cause  tiie  detention  of  organisms  iu 
ipillnries  (hruiigh  which  they  could  ordinarily  pass,  such  ivs  mixing 
\m  with  sterilized  cinnabar  or  potato-starch.  The  result  was  the 
jpaction  of  the  cocci  and  the  development  of  intlammatinn,  thus 
imon-strating  the  effect  of  simple  arrest  of  the  germs. 
(2)  Predisposition. — Unless  there  is  pn'disposition  to  suffer  from 
8  products  of  the  organisms  thus  arretted,  their  impactinii  in  ves- 
li  may  not  be  sufficient  to  enable  them  to  excite  inHammation. 
lus,  in  rabbits  Rildiert  fouud  numerous  masses  of  pyogenic  cocci 
the  capillaries  of  the  lung  and  other  organs  twenty-four  hours 
er  their  injection,  but  all  disajipeared  in  forty-eight  to  seventy- 
it  boiirs.  except  in  the  kidney.s,  where  alone  abscesses  formed, 
ibits  are  less  prone  than  man  to  suffer  from  these  organisms,  and 
them,  at  all  events — and  very  likely  in  man  also — tlte  predhposi- 
i  of  the  ti$tiut'»  mti»t  br  imreaged  before  these  particular  organ- 
w  (pyogenic  cocci)  can  excite  inflammation.  The  predisposition 
mlTcr  from  the  attack  of  organisms  is  increased  by  general  de- 
Msion  of  vitality.  This  may  arise  from  privation  and  faulty 
gicnic  surroundings.  Dcfircssed  vitality  is  also  seen  after  severe 
Itc  fevers,  and  in  alcoholic,  albuminuric,  and  diabetic  patients, 
long  these  trival  wounds  often  prove  serious,  and  operations 
fuld.  if  po.ssible,  be  avoided.  Pyogenic  cocci  easily  gain  access, 
Icellulitis,  boils,  and  carbuncles  result.  Among  savage  races  and 
mals  serious  wounds  frecpiently  heal  by  first  intention.  Local 
TTeseion  of  vitality  may  be  brought  about  by  any  kind  of  injury, 
]  it  is  here  that  the  ■■•  simple  "  causes  of  inflammation  chiefly  come 
M  pretlisponents.  rendering  the  tissues  more  open  to  the  attack 
micro-organisms.  It  ha^  been  experimentally  demonstrated  that 
tmia  or  mechanical  hypenemia  of  a  part  for  some  hours  enables 
tic  cocci  to  .settle  and  excite  a  progressive  iiitbimmation.  Thus, 
terbouse  injected  staphylocoeci  subcutaticously  into  his  own 
Unni  with  a  negative  residt.  He  then  constricted  a  portion  of  it 
11  it  was  purple  and  swollen,  and  made  a  similar  injection.  An 
iena  resulted.  The  effect  of  ordinary  mechanical  injury  {iisunlh/ 
\i)  in  leading  to  simple  abscess,  osteomyelitis,  and  tubercular 
*wc  of  joints  has  been  known,  and  it  has  been  proved  that  such 
>nfl  act  cither  by  simply  depressing  the  tissues  or  by  causing  ex- 
'watiou  of  blood,  and  thus  allowing  germs  which  cannot  grow  in 
circulating  blotxl  to  pass  out  into  the  connective  tissue,  there  to 
and    excite    inflammation.      Drdinurv  chemical    irritants 


344 


THE  VRGETABLE  PARASrTES. 


i k 


3 


$<itnilarly  (lo|)re8K  the  ti^i«lU'8  and  excite  RiiDpie  itiflaininstioa 
Clicync  point.'*  out  that  Ktronj:  injoctinns  into  noptic  cavitiee  pM 
!il)ly  fac'ilitatf  tlio  untn  into  tlie  general  circulation  of  auyorj 
which  the  injections  fail  to  lU'stroy.  The  injurious  effect  ny 
tissues  of  strong  coM  or  lieut  applied  directly  to  a  part  nc 
comnient.  arnl  liadsar's  exj)erinieT)ts  (p.  309)  dhow  tin-  effect 
inteniul  organs  of  cold  applied  to  the  surface :  ami.  tliough  it  itw* 
yet  known  how  the  cold  acts,  we  may  conclude  that  it  would  &oili 
tnte  the  passiige  of  organisms  into  the  tissues  of  the  |«rt» 
become  intcrstitially  inflanu'd.  These  agencies,  if  they  cbu)«' 
nizable  changes  at  all.  excite  simple  inflammation,  and  the  vie 
an  infective  inflammation  may.  so  to  speak,  be  grafted  <tn  t<>  n  i 
inflammation  has  met  with  wide  acceptance.  It  would  siTni.J 
ever,  that  pyogenic  cocci  and  other  organisms  circulating 
Mood  do  not  enter  the  inflanied  area  and  {lass  out  into  the  ill 
tissues  iluritxj  nil  ulnr/rii  of  the  inflammatory  process:  they 
freely  until  the  stage  in  which  leucocytes  escape  in  numli 
reached,  when,  according  to  Rinne's  experiments,  they  are  no] 
to  be  found  in  the  vessels  of  the  inflamed  area.  Tocci  in 
•luring  the  formation  of  scar-ti.osue  are  said  to  enter  the  vcf 
the  damaged  part  in  excessive  numbers.  Thence  they  may  | 
into  the  tissues,  but  when  the  scar  is  fully  formed  no  such  dil 
is  noticeable.  The  explanation  given  of  these  observations 
in  the  early  stage  of  inflammation  the  tissuen  are  weakeuiMi  1 
injury  and  unable  to  co|>e  with  invading  organisms,  which 
ijuently  multiply  in  them:  but  in  a  more  advanced  stage,  nhc 
escape  of  leucocytes  is  occurring,  the  damaged  ti.ssues  are  inii 
and  fK>rhaps  replaced  by  a  swarm  of  healthy  active  cells,  and] 
Idy  by  an  antagonistic  fluid,  both  capable  of  dealing  with  py4 
eiKici.  Sear-ti.ssue,  again,  in  its  early  vascular  stage  seem*  t#ij 
feeble  resisting  power.  It  sounds  some  what  strange  that  l)i< 
stage  of  inflaiuMiatinti  should  give  ri.ne  to  u  liicu»  minnriM  rr 
— as  regards  puigenic  cocci — whilst  a  later  stage  i|oe»  not  4*l| 
but  Cheyne  thinks  that  it  fits  in  well  with  the  fact  that  acQiaj 
iiivclitis  and  tubercular  disease  are  often  indnc<'d  by  slight  il 
— rarely  by  severe,  whieli  ."eeiu  to  excite  tno  miieh  renctioti. 

(8)  The  seat  of  inoculation  and  the  anatomical  ar 
of  a  part  are  of  importance  in  enalding  organisms  to  obtain  i 
hold  in   the  body  in  two  ways:   1.  I'frtnin  wiVtuAc*  can  only. i 
in  crrtain  ti»»uc»  ;  thev  are  harmless  unless  thev  reach  and 


THE  VEGETABLE  PARASITES.  345 

these  tissues.     2.  The  physical  characters  of  a  part  have  much  to 
do  in  determining  whether  an  organism  will  live  in  it,  and  what 
form  of  inflammation  will  result  from  its  growth.     The  bacillus  of 
malignant  cedema  illustrates  both  these  points.     It  can  grow  only 
in  connective  tissue :  when  introduced  into  the  blood  it  sooner  or 
liter  dies,  leaving  the  animal  protected  against  the  disease ;  but  if, 
vhilst  it  is  circulating,  a  bruise  is  produced,  the  bacilli  pass  out 
with  the  extravasated  blood  into  the  tissues,  commence  to  grow,  and 
thus  cause  the  lesions  of  the  malady.     Again,  inoculation  with  this 
organism  at  the  tip  of  the  tail  in  cattle  has  little  effect,  on  account 
of  the  density  and  coldness  of  the  part:  the  intensity  of  the  inflam- 
mation increases  as  the  point  of  inoculation  approaches  the  body, 
and  the  reaction  may  also  be  increased  by  raising  the  temperature 
of  the  more  distal  parts.     Sheep,  which  have  loose  tissue  in  their 
tails,  react  strongly  when  inoculated  even  at  the  very  tip  of  this 
»ppendage :  the  reaction  is  diminished  by  cooling  the  part.     Cheyne 
showed  that  the  injection  of  a  certain  quantity  of  a  cultivation  of 
the  Proteus  vulgaris  into  the  subcutaneous  tissue  of  the  back  of  a 
rabbit  caused  an  abscess,  but  the  same  quantity  in  the  muscles  of 
the  back  produced  death  ;  and,  further,  an  amount  of  the  cultivation 
too  small  to  have  any  appreciable  effect  in  the  subcutaneous  tissue 
cansed  an  abscess  when  placed  among  the  muscles.     No  explanation 
is  as  yet  forthcoming.     The  limitation  of  acute  infective  osteo- 
mjelitis  to  growing  bones  is  another  example  of  the  influence  of 
structure  upon  disease.     A  last  illustration  of  this  point  may  be 
fonnd  in  the  difference  between  the  behavior  of  the  peritoneum  and 
the  cellular  tissue  to  pyogenic  cocci.     The  success  of  a  surgeon  who, 
*fler  an  operation,  washed  out  the  peritoneum  with  ordinary  un- 
imrified  tap-water  has  been  greater  than  that  of  any  one  practising 
the  most  rigid  antiseptics ;  but  the  result  of  washing  out  wounds  of 
sofl  parts  or  of  bones  has  been,  on  the  other   hand,  extremely 
unfavorable,  acute  inflammation  often  supervening.     The  explana- 
tion given  is  that  the  peritoneum  has  great  powers  of  rapid  absorp- 
tion, so  that  considerable  quantities  of  putrescible  fluids  may  be 
•njected,  together  with  septic  organisms,  into  its  cavity,  and  they 
*ill  be  completely  absorbed  before  putrefaction  has  time  to  advance 
*'^'  » jwisonous  extent ;  but,  if  injected  in  still  larger  quantity  putre- 
•ftction  occurs  with  great  rapidity  in  the  unabsorbed  fluid,  and  death 
•tim  septic  intoxication  results.     Waterhou.se  showed  that  if  a  given 
'*ose  of  pyogenic  cocci  were  suspended  in  normal  saline  solution 


346 

and  then  injected  into  the  peritoneum,  uo  |H*ritonitis  followed:  W 
that  if  a  tvnth  part  of  the  dose  were  injected  n'ilh  hh»MM>it    ■•■ 
peritonitis  resulted.      It   is  easy  to  understand  that  the  gr  • 
such  organisms  may  fre(|uently  depend  upon  the  irauicdiate  .<  <" 
ihility  of  suiliihle  noiirishnient  (p.  ii.'UJ).      It  is  notoriou.'i,  ni" 
that  a  chronically  inHanied   peritoneum  with  a  j5iK>d  ninny  ><  i 
ndhesiouH  staniLt  itgury  bettor  thau  a  normal  membrane,  iiKi  w 
jiroof  exists  that  the  lymph-flow   frrmi  the  former  is  more  fr 
from  the  latter.     Possibly  there  are  more  availabh-  i.lii.'i' 
this  case. 

(4)  The  niunber  of  orsanisms  which  gain  entry  to  the  Uxi*  «i 
any  one  time  is  a  matter  of  j-reat  importance.  At  first  si?)"  "■■ 
might  think  that  tiie  only  difference  in  the  results  after  tli 
tion  of  1  and  of  1.000.000  pathogenic  microbes  would  br  thr  »oni*- 
what  slower  development  of  the  disease  in  tiie  former  ease.  It  «u, 
however,  stwn  found  e.xpennientally  that  this  was  not  so.  except* 
cases  of  animals  strongly  predisfKised  to  suflcr  from  the  orpaniim 
in  ({uestion :  and  it  was  then  understood  that  small  niiml)<T>  •>( 
organisms  would  be  destroyed  by  the  tissues  before  they  omM 
produce  their  products  in  any  iiuantity,  whilst  a  rery  large  number 
could  not  he  got  riil  of  with  sufficient  speed  to  prevent  thcni  fn'iu 
producing  more  or  less  poison,  and  thus  gaining  a  greater  »x\v» 
ailvnntage  over  the  tissues,  ('[(on  this  jioint  Cheync's  own  re- 
searches enable  him  to  enunciate  the  ftdlowing  laws:  1.  Tin*  ji»t!i"- 
genie  dose  of  a  virus  varies  inversely  with  llie  |ire<lts|>o»itiou  of  il"' 
animal  to  the  disease  in  ijue^tion.  '2.  In  animals  nut  very  lutc'f' 
tible  to  a  germ-disease  the  severity  of  the  disease  varies  dirwtlj, 
within  certain  limits,  with  the  dose:  a  small  dose  produce*  d" 
effect,  the  germs  being  rapidly  destroyed ;  a  larger  cue  c»u»»  » 
local  inflammation,  the  organisms  being  hemmed  in  and  drstro^ 
more  or  less  speedily  by  leucocytes;  whilst  a  very  large  dow  "' 
comes  all  local  limitations,  the  organisms  [lenetrating  into  the ' 
culation,  producing  poisons  freely,  and  causing  death  from  wp 
(loisouiug.  We  cannot  with  certainty  predict  the  <lo»e  nec«ri«>aryj 
pro<lucc  any  om*  nf  the  above  results,  because  predisposition  ''I 
greatly  even  amniig  animals  of  the  same  species. 

(6)   The   viruleDce   of    orsranisms    may    usually    be   it 
(**exaltetl ")   or   diminished    ("attenuated")    by   suitable   cxtr 
conditions;   thus,  attfiiinition  may  result  from  cultivating  an 'irij 
ism  and  allowiug  long  intervals  to  elapse  between  the  mect^' 


THE  VEGETABLE  PARASITES.  347 

loculations,  or  from  cultivating  it  at  a  temperature  at  which 
rowth  is  very  slow,  or  upon  media  containing  antiseptics  in 
uantity  not  sufficient  to  inhibit  growth.  Exaltation  of  virulence 
I  less  readily  produced.  In  the  case  of  the  spirilla  of  cholera  it 
an  be  effected  by  procedures  described  on  p.  363.  As  these  proce- 
urc8  can  effect  such  important  modifications  in  these  organisms,  it 
I  evident  that  the  body  may  have  to  deal  with  them  in  states  of 
arying  virulence;  the  weaker  the  virus,  the  more  of  it  will  be 
equired  to  produce  a  given  effect,  and  vice  versd.  The  absence  of 
ttflammation  from  a  wound  treated  carelessly  or  left  to  nature  may 
ometimes  be  due  to  the  attenuation  of  any  organisms  which  may 
are  fallen  upon  it. 

(6)  Concurrent  errowth  with  other  bacteria  may  either  increase 
r  diminish  pathogenic  action,  and  many  facts  make  it  probable 
bit  the  presence  of  putrefactive  with  pyogenic  cocci  in  a  wound 
onsiderably  increases  the  danger  to  the  patient ;  for  the  putrefac- 
ive  organisms  by  their  irritant  products  destroy  the  granulation 
ssae  and  open  up  a  way  of  entry  for  the  pyogenic  germs.  A 
irresponding  fact,  vouched  for  by  Cheyne,  is  that  general  tuber- 
ilosis  is  much  commoner  in  cases  of  joint  disease  complicated  with 
ptic  sinuses  than  in  cases  which  are  kept  aseptic.     The  presence 

pyogenic  cocci  does  not  seem  to  increase  the  spread  of  tuber- 
ilar  cavities  in  the  lung,  but  the  cocci  certainly  intensify  the 
ects  of  the  B.  diphtherise  (p.  386).  Again,  it  is  said  that  an 
teomyelitis  due  to  a  mi.xed  infection  of  the  staphylococcus  aureus 
d  albus  is  of  greater  severity  and  of  worse  prognosis  than  a  case 
which  only  one  of  these  species  is  present.  On  the  other  hand, 
«nt  experiments  have  shown  that  two  microbes  growing  in  the 
ly  may  successfully  oppose  each  other.  Thus,  if  erysipelas  cocci 
injected  both  under  the  skin  and  into  the  blood,  and  if  a  large 
le  of  anthrax  bacilli  be  introduced  twenty-four  hours  afterward, 
that  a  large  numbr  of  cocci  are  present  at  the  time  of  the  infec- 
a,  the  anthrax  bacilli  will  all  die  out  in  seventeen  to  twenty-four 
irs  without  causing  even  local  oedema.  Now,  these  two  organ- 
la  will  grow  together  readily  outside  the  body,  so  it  is  not  clear 
*■  their  opposition  in  the  body  is  brought  about. 
,7)  Lastly,  it  is  probable  that  local  and  seasonal  conditions  may 

upon  pathogenic  organisms,  and  thus  account  for  such  peculiari- 
*  of  disease  as  endemicity,  or  greater  prevalence  at  certain  times 
i  under  certain  atmospheric  conditions. 


JETABLE 


METHODS  OF  INVESTIGATION— I.  Presence  of  MicTO- 
organisms  in  Fluids. — .Sim/>Ir  mirrnornpic  rrainiiuttiim  may  he  «uf- 
fieii'iit  to  rt'vcal  oririiiiisin.s  of  ilistiiictive  form  or  possessing  markwl 
])owc'rs  of  locomotion.  No  preparation  will  be  necessary  bvyotii 
niountiiijr  u  thin  lnyer  of  blood  nr  titlitT  fliiifl. 

Stiiiiiiii;/  is  In-  far  tla-  nio.^^t  iiiiportiuit  mctliod,  ami  it  is  to  Wi-ijtrrt 
that  we  owe  tltc  introfliiction  of  the  most  Hiiitable  rejigenl-*— 4lii' 
aiiiliiH"  dye.''.      Logwuoil  stiu'iix  iiiiiny  fiui<ri  well.  Imt  it  has  no  prcfrr- 
eiHX'  for  them  over  imiDiiii  tissues,  uinl  tloes  not  therefore  make  tiio^ 
siifliciently  prominent.     The  aniline  dye?  most  often  used  are  fl^H 
sine,  methyl  violet,  methylene  hliie.  iind,  for  photo;»raph»  espeoi-illf. 
Bisraarek   brown  :   watery  solutions  are  employed,  from  J  to  5  f<r 
cent.     ( 'over-glas.ses  anil  slides  should  be  eleaned  in  dilute  niinc 
aeid  and  kept  in  aleohol ;  before  use  they  should  be  heated  in  a  »pirit 
flame  whilst  held  in   forceps.     The  followiiii;  is  the  niefho<l  of  |iw- 
cedure:  Take  two  enver-glasses  whiuh  ha\e  just  cooled  :  place  i» '""i" 
drop  of  the  fluid  on  one,  put  the  other  glass  on  the  top  of  it.  wjuiti* 
the  glasses  getitlv  together,  ami  then  glide  one  off  the  other.  «'** 
to   leave  a   reri/  thin   layer  of  the  fluid   on   i^aeh.      Ne.xt  set  alio* 
both  cover-glasses  to  dry  in  "air."  and  then   pass  them  three  tinw* 
through  a  spirit  flame.      A  ti-mperature  of  li!()°  C.  should  be  re.ti 'hiHi 
for  a  few  seconds  to  precipitate  and  fix  any  albuminous  matenilw 
the  glass.      If  a  weak   staining  solution  is  used,  the  cover-gl«-«** 
must  he  flouted  on  it,  prepared  side  downward,  for  some  minntf*"*' 
hours.     A  strong  solution  ('2  to  5  per  cent.)  is  sometiini's  as  px)**- 
and  stains  deeply  in   less  than   a   minute.     Pour  a  little  on  to  ih* 
dried  cover-glass,  leave  it  for  a  few  seconds,  wash  with  distille<l  w»'^ 
frr)ni  a  wash-bottle,  and  dry  over  a  flame.     Next  warm  a  slide,  »***! 
just    melt   III!    it   a   little   solid   Canatla  balsam:   drop  the  slight'* 
warmed  cover-glass  mi  to  this  and  press  it  down  very  carefully,        ] 

Certain   organisms  arc  distinguished   by  retaining  basic  niiili*^ 
dyes,  such  as  I'uehsine,  gentian  violet,  and  methyl  violet.  rrvM  »U 
they  are  acted  on  by  a  solution  of  nitric  acid  (1  :  3),  which  ilecol 
izes  everything  else,  including  other  kinds  of  bacteria.     After  t 
acid  has  been  washed  oft'  the  clec«doi 
some  contrast  color — c. //.  fuehsine  ( 
fungi  known  to  stain  in  this  way  are 

leprosy.     H.  tuhereulosis  is  now  constantly  sought  for  in  pu^ 
sputum,  and  in   urine,  either  for  pur|K)ses  of  diagnosis  or  to  I 
the  result  of  treatment. 


■r  kinds  of  bacteria.  After  t  ^ 
irized  parts  may  be  stained  *•  ] 
or  methylene  blue.  The  ehi4 
ire  the  bacilli  of  tubercle  «iiil     ] 

d 


THE  VEGETABLE  PARASITES.  349 

For  the  examination  of  fluids  for  B.  tuberculosis,  Gibbess  double 
stain  is  the  quickest.  It  consists  of  two  parts  of  fucbsine  to  one 
part  of  methylene  blue  dissolved  in  an  alcoholic  solution  of  aniline 
oil. 

A  method  of  very  general  use  in  the  search  for  bacteria,  both  in 
cover-glass  specimens  and  in  sections,  has  been  introduced  by  Gram 
of  Copenhagen.  Prepared  cover-glasses  are  soaked  for  some  min- 
utes, and  sections  for  some  hours,  in  Ehrlich's  solution  of  gentian 
violet,'  until  they  are  deeply  stained.  They  are  then  placed  on  or 
in  a  solution  of  iodine*  until  they  turn  brown  (i.  e.  two  or  three 
minutes).  The  specimens  are  next  washed  in  alcohol,  dried,  and 
finally  mounted  in  Canada  balsam.  Some  organisms  remain  deeply 
stained,  but  some — such  as  the  gonococcus  and  Friedlander's  pneu- 
mococcus — are  decolorized.  Eosine  or  Bismarck  brown  may  be 
ased  as  a  contrast  stain.  This  method  of  staining  often  helps  to 
distinguish  allied  forms  of  bacteria. 

n.  Presence  of  Mioro-orsranisms  in  Tissues. — Thin  slices  of 
the  tissues  to  be  examined  should  be  placed  as  soon  as  possible  after 
death  in  strong  methylated  spirit  or  in  absolute  alcohol.     When 
thoroughly  hardened,  sections  may  be  cut :  these  must  be  very  thin. 
If  a  freezing-machine  is  used,  a  thinnish  slice  of  the  tissue  must  be 
soaked  in  plenty  of  water  for  two  or  three  hours  to  remove  all  trace 
of  alcohol,  and  then  put  into  mucilage  for  a  similar  time.     The  sec- 
tions are  washed,  and  then  placed  for  twelve  hours  or  longer  in  a  1 
per  cent,  watery  solution  of  the  dye  selected,  which  must  always  be 
filtered  before    use:    warmth   facilitates   staining.     Some  workers 
transfer  the  stained  section  to  a  1  per  cent,  solution  of  glacial  acetic 
•O'd,  then  to  absolute  alcohol,  and  finally  to  whatever  clarifying 
'gent  is  employed  (cedar  oil,  xylol,  coal-tar  naphtha) :  others  omit 
"■0  acetic  acid.     Each  of  these  fluids  dissolves  the  dye  out  of  the 
tissiie  and  the  difficulty  is  to  carry  the  sections  through  them  rapidly 
enough.     It  is  best,  therefore,  at  first  to  take  only  one  section  at  a 
'■iDe   out  of  the  staining  fluid.     One  or  two  trials  will  show  how 
""S  the  section  must  be  left  in  each  fluid  in  order  that  it  may  still 
'*'*iii  a  rather  pale  color  when  it  is  spread  out  on  the  slide.     Excess 
^'  tte  clarifying  reagent  is  removed  with  a  piece  of  clean  filter- 
P*F>«T  pressed  firmly  on  it.     A  drop  of  Canada  balsam  dissolved  in 
^^ol  is  put  on  the  cover-glass,  and  this  is  applied :  chloroform  and 

Stunted  alcoholic  (olution  of  gentian  violet,  5  c.  c. ;  aniline- water,  100  c.  o. 
Iodine,  1  grm. ;  potassium  iodide,  2  grm. ;  water,  300  c.  c 


350 


THE    VEGETABLE  PARASITES. 


benzol    li.'ilsiiin  slowly  dissolve  out   the  stain,  and  pure  bulsani  ii 
nitbur  (litliuult  to  work  with. 

If  a  blue  or  violet  8tain  has  been  used,  the  sections,  after  wMbiniJ 
in  nlcohivl,  niav  be  dipped  in  water  for  ii  moment,  and  then  pl»c<J 
in  eosine  or  carmine  solution  for  an  hour;  the  tissue-eirati 
acijuire  a  red  tint,  whilst  tliu  orjjanisins  remain  blue  or  viol 
The  sections  must  now  be  placed  in  alcohol.  The  gabsctint-nt 
stages  are  the  same  as  before. 

To  examine  lisHiies  for  B.  tuberculosis  or  B.  leprte.  Ziehl's  sttio- 
inj5  fluid '  J8  the  best.  A  satnrated  alcoholic  solution  of  tnethylfiif 
blue  will  also  be  rei|uired,  as  well  as  a  mixture  of  nitric  aeid  (B.  I'-) 
with  two  or  three  ]iarts  of  water.  I'lace  the  sections  in  the  fuchsi 
solution,  and  leave  them  in  a  warm  place  for  at  least  two  hoi 
then  transfer  them  to  the  nitric-acid  solution,  iind  leave  them  nntl 
the  color  is  almost  gone;  then  rin.se  them  in  water,  and  put  them 
into  methylene  blue  for  an  hour.  Now  i)ass  them  through  aWulf 
alcohol  and  whatever  clearing  reagent  is  used,  and  then  mount « 
before.  B.  tuberculosis  and  B.  Icprre  will  appear  iw  rod  ro<lii  »n 
a  blue  ground  ;  all  other  organisms  present  will  be  blue. 

With  large  and  delicate  sections  it  is  a  good  plan  to  use  the 
slide  as  a  section -lifter,  ))ushing  it  obIii|uely  into  the  xylol  <irc« 
the  alcohol,  and  there  spreading  the  section  out  upon  it. 
vessels  ami  plenty  of  the  fluid  must  be  used  for  this  purpos<k< 

With    large    organisms    or    with    sucrcssfiil    contrast-stainiii| 
power  of  500  diameters  and  ordinary  illumination  will  be  suffici 
for  most  purposes;  but  for  the  smaller  fungi  an  oil-immersion 
and   a   sub-stage   condenser   of   very   wide   angular   aperture 
necessary. 

Cultivation  of  Micro-orgranisms. — Having  determined  the  pr<* 
ence  of  organisms  in  :i  lliiid  or  tissue,  it  may  be  necessary  toci 
vate  them,  in  order  cither  to  study  their  life-conilitions  or  to  n 
rate  tlu-m   IVmu   all   otiicr  species  mid   other  matter.      Cuitimtii 
may  be  uiade  in  fluids  or  in  scdids, 

In  Fluids. —  Klebs  iutnuluccd  a  method  which  consisted  inadililf 
to  a  sterile  Huid  a  small  ([Uantity  of  the  substance  containing  <'"* 
fungus.     Under  suitable  conditions  the  latter  will  grow.     A 
quantity  of  the  culture-fluid  may  then   be  added  to  another  Hi 
and  so  on   until  all    vestiges  of  anything  introduced  into  tie 

DiHsnlTe  one  )j:rainnic  of  fiiclmiiie  in  10  c.  c.  of  alcohol,  and  add  100  (■(• 
■mtiKTj  «olution  of  carbolic  acid  \  1  :  *20). 


1 

anttM 


THE  VEGETABLE  PARASITES. 


351 


h  the  original  organisms  must  have  practically  disappeared, 
than  one  kind  of  fungus  is  inoculated,  or  if  in  the  inocula- 
successive  flasks  contamination  from  the  air  or  apparatus 
it  ma}'  be  impossible  to  obtain  a  pure  cultivation  of  one 
a. 

lids. — Koch  therefore  introduced  solid,  transparent  culture- 
.  Clear  meat-broths  and  other  fluids  are  peptonized,  and 
lened  by  the  addition  of  sufficient  gelatin  (5  to  10  per  cent.) 
;r  them  solid  at  65°  to  80°  F.,  at  which  temperature  most 
ill  grow  fairly.  Agar-agar,  obtained  from  dried  seavreed, 
ased  (1  to  2  per  cent.)  to  stiffen  fluids  required  to  remain 
temperatures  above  that  of  the  melting-point  of  gelatin,  in 
at  the  life-conditions  of  organisms  at  any  temperature  pos- 
the  body  may  be  determined.  Solidified  blood-serum  and 
edia  are  also   employed.     In  all  cases  the  culture-ground 

sterilized  by  heating  to  60°  C.  (140°  F.)  for  short  periods 
ecutive  days.  Transparent  culture-grounds  are  generally 
d  in  one  of  two  ways. 

be-cultures. — Fill  the  lower  third  of  a  test-tube  with  the 
culture-ground ;  insert  a  plug  of  cotton-wool  into  the  orifice 
tube ;   sterilize  according  p^    ,  ,„ 

lethod  just  described,  and 
t  the  tube  aside  to  cool, 
a  a  vertical  or  an  oblique 

according  to  whether 
or  surface  is  required, 
id  the  following  details 
wn  in  Fig.  118.  To 
cultivation  on  the  ground 
jpared,  invert  one  of  the 
>move  its  plug,  then  with 
ized  platinum  wire  take 
the  suspected  liquid  and 

it  to  the  culture-ground, 
ing  this  with  the  wire  as 
in  the  figure.  Re-insert 
;,  and  put  the  tube — the 
ly  up — in  an  incubating  cliamber  under  such  conditions  of 
ture  as  may  be  desired, 
ies  of  organisms  will  gradually  appear  (1)  on  the  surface 


Culture -tubt's:  n,  tube  prepared  for 
"  stick  "  •  culture ;  6,  tube  preiiarcd  for 
"streak  "-or  "  rub  "-culture ;  f,  method  of 
making  "  stick  "-culture. 


352 


THE  VEGETABLE  PARASITES. 


only  if  oxygen  is  essential  (aerobic);  (2)  in  the  lower  part  of  thrtnd 


Fio.  119. 


<;==^ 


n 


%f 


fO^ 


'"      — '  6  c  fl  r 

DiaKrammattc  ruprcucntatinn  of  vartnun  fornw  of  iitlrk-<'nltare :  a,  an  aftoMr  ot«Mil«- 
RrowH  lliureforc  only  on  stirfaco:  It,  an  HnaiTiilito  orKaiiUm— Krowa  tht-rffon>  oiil;  brMtt 
the  KurfHce;  r,  an  omnlam  IndifTerent  to  the  preaencfl  of  air— tcmwa  thcnfure  (•  ■■' 
lnMU-ath  Hurfacc :  ><,  an  ai'mlilc  ormntnni  whirh  Ilc|urfiv«  Ki'laOn :  r,  an  af-rnbic.  bal  <t^'^ 
anacroblir  orKanlxm,  « liloh  also  lli|uvflc8  Kclatin,  but  In  a  diflcrvnt  manuvr  to  d. 

only  if  oxygen  is  fatal  (anaerobic);  or  (3)  on  the  surface  an>l  along tbr 
track  if  the  j)re8ence  of  oxygen  is  a  matter  of  comparative  indilTrt- 

ence.     In  some  cases  the  form  <>f 
■■""'    '-"•  the  growth  is  chara<'teri>tif  {T\p    \ 

120);  in  others  the  metlii  )« 
li(|ncfied  in  some  peculiar  ax> 
therefore  diagnostic  manner  (Fig- 
119). 

II.    Plate  •  culturee.—Inori' 
late  a  tube  as  before,  warm  tl* 
medium    until    it    is  jnst  fla>^ 
jiently   agitate  the  contcDt*.  •»■ 
ociilate  a  second  tube  from  tl" 
first,  and  then  a  third  fmm  tl" 
second.     Pour   the  contentii  •« 
each  on  to  separate  glass  plat^ 
and   keep  these  in  glass-cove*^ 
chambers  under  the  <lesirtil  c«^' 
ditions.     Isolated  colonies  will  gradually  develop  in  different  p*' 
|><irti<nis  on  each  plate,  and,  if  very  numerous,  may  run  togctb*^ 
DiflVreiit  orfianisnis  will  produce  colonies  differing  in  api)ear»B*^ 
Tiil)es  can    he  siihsoijuently  inoculated   from    whichever  of  th*^ 
colonies  a  cultivation  is  desired.     Thu.s,  for  each  organism  ne  c^ 


1.1 


a  ft 

TuU-iiilturri-.  "huwlnc  |p<'<ullnritloi.  nf 
Kriiwtli  ulonK  thv  limii  of  punctiiri-.  (.\fti'r 
StvniUTR.) 


THE  VEGETABLE  PARASITES. 


353 


[•sccrtain  tbe  influence  of  different  temperatures,  media,  and  gases, 
well  ns  separate  one  organism  fi-om  any  others  that  may  have 

simultaneously  introduced. 
To  examine  air.  a  glass  plate  covered  with  gelatin-peptone  may 
[be  exposed  for  a  given  time,  and  then   kept  undor  a  uioist  bell-jar: 
[colonies  will  grow  wherever  germ.s  have  fallen,  and  any  of  theui  cau 
[be  »ubse(|uently  cultivated  in  tubes.     Again,  a  jiortion  of  earth  or 
'  ti.<<siie  may  be  broken  up  in  sterilized  water,  and  a  little  of  this  may 
be  slutken  with  sterilized  gelatiu-[)eptone  ;  the  latter  is  then  poured 
on  a  plate  and  allowed   to  set.      Host  fref|uent]y  sni'li   ruUivations 
»re  carried  on  in  test-tubes  inoculated  with  a  platinum  wire  heated 
to  reiliu'ss  just  before  it  is  dip))od  in  the  substunee  to  lie  exiimiiii'il. 
A  puncture  with    it  is  then  made  into  the  gelatin.     A  very  liandy 
methwl  of  cultivation  is  the  inoculation  of  slices  of  recently-boiled 
]i*itiitn,  made  with  a  pure  knife  and  kept  under  a  bell-jar  in  moist  air. 
Ill  all  experiments  the  Hp])aratiis  must  be  carefully  sterilized,  and 
wch  procedure  carried  on  in  as  still  and  pure  an  atmosphere  as  pos- 
sible. 


CLASSIFICATION  OP  BACTERIA.— It  has  already  been 
pointed  out  that  all  organisms  are  by  no  means  of  the  same  shape. 
Are  tLere  sufficient  grounds  for  assuming  that  because  organisms 
differ  in  shape  they  also  difl'er  in  species,  and  that  each  shape  means 
tdifferent  species  ?  or  do  tbe  nuiny  different  shapes  merely  represent 
different  stages  in  the  life-history  of  a  companitively  few  species? 
Ni)  classification  is  possible  until  this  matter  is  set  at  rest.  The 
Uuwer  is.  that /orm  alone  is  not  sufficient  to  establish  or  to  disprove 
iilontity  of  species.  To  obtain  satisfactory  evidence  on  this  point  it 
U  kbsolutely  necessary  to  Match  a  given  organism  pass  through  its 
vh)l« dn'elopinenial  cycle  irwn  beginning  to  end:  to  note  carefully 
Reform,  size,  structure,  staining  affinities,  ami  method  of  reproduc- 
lioii  of  the  individual  ceils  in  each  stage ;  and  to  observ  f  their  group- 
'fg  and  effects — macroscojiic  and  microscoj)ic — both  in  the  tissues 
Mill  on  various  culture-grounds.  It  is  necessary  also  to  discover  and 
^panjte  their  chemical  proiiucts,  and  to  ascertain  the  effects  of  inncii- 
'»li'in.  All  these  observations  must  be  carried  out  nut  only  under 
•^nditions  us  natural  as  can  be  devised,  but  also  under  such  as  are 
'"'St  calculated  to  induce  variations.  In  this  way.  and  in  this  way 
"loiip,  can  the  specific  individmility  of  any  organisms  be  made  out 
*iiil  a  useful  classification  of  the  different  sjiecies  be  devised. 

2S 


S54 


?TABLK  PARAStTBS. 


WluTCvtT  this  laborious  investigation  Ims  bf^fn  carried  oot 
reason  hu*  been  found  to  ilonbt  the  exislenrc  of  ili^itinct  »]«  ' 
bucteriii.  And.  just  a»  anioii^  hij;her  fornis  9|>e<;ie»  nnd  evi-ii 
Lavo  been  confounded  with  one  another  until  the  difTcrcntuitmi; 
point*  were  discovered,  so  iloiibtless  \^  it  with  bncteria.  sml  ti» 
number  of  recognixcd  speeies  uiuy  therefore  be  cx{>ected  to  incrpwr 
continuously.  Two  coceus-fornis  may  apfiear  to  be  exactly  the  wbt 
until  inoculated  upon  some  particular  anininl.  when  marked  diff(T- 
ences  between  them  will  become  apparent.  Cohu  points  nut  si 
analogy  to  this  in  the  close  naked-eye  and  microscopic  resemblinrr 
between  the  sweet  and  bitter  almond,  the  chemical  constituent* aixi 
conseipient  physiological  actions  of  which  are  so  very  difTeront:  wl 
Virchow  allu<les  to  the  impossibility  of  distinguishing  l»etw«?en  tb» 
cells  of  the  early  embryo,  thongh  their  potentialiti4'»  are  wi  ranai. 
In  ftome  of  the  cases  in  which  bacteria  resemble  one  another  ii 
microscopic  appearances,  in  staining  affinities,  an<l  in  culture-effrciv 
differing  only  in  pathogenic  results,  it  is  i|uite  possible  that  tlir  ii>* 
nocuous  organism  is  not  a  distinct  species,  but  only  an  atteaiufJ 
variety  (p.  84G). 

Difficulty  naturally  arose  in  early  times  from  imperfertion  ia  ti» 
culture-methods,  from  inappreciation  of  the  absolute  uccewitY  (^ 
seeing  the  development  of  any  given  form    throughout  it«  ■b"l« 
cycle,  and  lastly  from  the  polymorphism  of  certain  forms  »Lichb»» 
before  been  alluded  to.     The  introduction  by  Koch  of  solid  cultiirr 
grounds  enabled  observers  to  fix  the  organisms  under  examinatio>i 
and  added  enormously  to  the  ease  an<l  certainty  with  which  p*" 
cultures  were  obtaine*! ;  and  when    it  was  found  tliat  the  vtmio* 
developmental  stages  of  polymorphous  bacteria  were  constant  h"*" 
in  appearance  and  in  order  of  sticeession,  it  became  clear  that  tb*'' 
wore   no   more  disipialified    by  their  polymorphiMn    from   •pwi* 
classification  than  was  the  frog  on  account  of  its  tad|Mde  ktage- 

In  sup]M>rt  of  the  view  advanced  by  IJillroth  and  Niigeli,  that  ^ 
organisms  are  variation.s  of  one  or,  at  most,  of  a  very  few  «li«lii^ 
species,  the  following  are  the  chief  arguments: 

1.  That  in  auccessh'v  culfhuitionii,  et/teritilly  in  dijfrreut  mm<Jm, 
fonnn  developed  vary  i/ri-atli/  from  the  orlijiiuil :  that  ihrte  itMMM 
tucceution  the  thapea  e/iaracten'itir  of  Cohn't  orden  ; '  and  thtit, 
the  tiiiiiir  time,  their  phi/»i"lot/irit!  artiriti/  ehtingea  e^fHaJlg.  Tbi» 
of  course,  a  direct  contradiction  of  Koch's  experience  mnd  may 
'1.  Coed;  2.  Microbacteria;  S.  Denaobacteria;  4.  SpirotecMria. 


rms  VEGETABLE  PABASITES. 


355 


uae;  but  it  must  be  renK^mberod  that  these  results  were  obtained 
Willi  fluiil  ciilturf-niedia  ;  that  thi-  difficulty  of  obtaiuiiij,'  pure  ciilti- 
mions  Id  fluid  media  is  gi't;iit ;  and  that  the  iiiethoil  i')i)plo_ved(MUC- 
ccMive  cultivation)  ia  one  in  which  the  accidental  iiitroduotiun  of 
either  organisms  renders  error  easy.  In  fact,  it  is  far  easier  to  fail 
than  to  succeed  ;  so  the  suspicion  arises  that  the  cultivations  were 
never  pure  or  that  they  became  contaminated  by  other  organisms. 

2.  That  di(f'rri'nt  f'irrmg  of  hnetitia  art-  found  taking  ptirt  in  the 
tamt  ihe<imi>oni(ioii  (»•.  7.  putrefaction).  This  shows  simply  that 
!H;ver»l  difTerent  organisms  are  capable  of  living  in  the  same  fluid. 
The  process  is  a  complex  one,  and  the  products  arc  the  result  of  the 
lifc-aetions  of  different  forms  :  it  does  not  show  that  different  forms 
<li;velop  from  one  species. 

S.  That  the.  name  form  may  he  fnund  associated  with  the  very 
Jifffrrnt  rhi'niifdl  fhtintjcK.  Thus  microencci  in<Ustinguishal>le  from 
each  other  by  form  or  size  occur  in  relation  with  pneumonia,  ery- 
iipelas.  small-jM)x,  pyamia,  infective  osteomyelitis,  and  many  other 
<li»ea8es.  This  argument  can  oidy  be  met  by  tracing  the  life-histnry 
»a(l  e.vamining  the  products  of  each  organism  as  described  on  p. 

4.  That  the  virtilence  of  orffanismg  can  he  modified  in  either  direc- 
^.  Davaine  produced  an  artificial  septicsemia  hy  injecting  putrid 
fluids,  contaitiitig  many  forms  of  bacteria,  into  rabbits,  and  found 
•hat  the  virulence  of  the  poi.son  increa.<e(l  as  the  disease  was  trans- 
tuitttrd  from  animal  to  animnl,  but  that  no  increase  of  virulence 
wiirred  after  the  second  or  third  generation :  and  Koch  sliowed 
'h»t  this  increase  was  due  to  the  preponderating  growth  of  one  of 
the  organisms  inoculated  and  the  simultiineous  disap|)earance  of  all 
oihrr  forms,  so  that  the  a])parent  in(rrease  of  virulence  was  really 
«ae  to  the  injection  of  a  larger  ((uantity  of  the  specific  organisms, 
"itiiilar  increase  in  physiological  activity  produced  by  cultivation 
oaa  been  alleged  to  occur  in  other  organisms,  and  have  been  simi- 
'■'"ly  explained. 

Moreover,  it  has  already  been  shown  that  the  virulence  of  some 
*l5"'''*n>8  '■'"'  '"-^  modified  by  cultivation  and  inoculation. 

The  whole  argument,  however,  is  beside  the  mark  :   for  variation 

I  '*>  intcuAity  of  virulence,  in  whichever  direction,  accompanied  by 

^  morphological  or  other  change,  is  no  evidence  against  the  indi- 

^'lunliti/  of  organisms.      A.*    Baumgarten    ))uts  it,   mitigation  of 

Virulence  is  no   better  ground  for  depriving  a  bacterium  of  its 


366 


TBE  VEGETABLE  PARASITES. 


specific  character  than  would  the  extrttcliori  of  the  t«th  of  i 
[H>i8<>tiou8  snaicc  be  a  reosou  for  rcgariiibg  it  n!<  a  noD-puijOttMW 
species. 

5.  That  une  onfanitm  can  be  erpcrinu-ntalh/  cimvrried  itUv  imMkir. 
Buclirier  !»t:ite«l  that  by  ctiliivittin^  the  iioii-iiatli<ij;oiii('  h«v  ' 
in  uioHt-iufusioD8  and  in  utiiiterilizeil  hluod  he  nitnlv  it  "  wi!  : 
converted  it  into  B.  anthracis,  and  that  by  »  convorse  pp"  >  ■ 
converted  B.  itnthraciH  into  B.  Hubtilis.  The  oxperinicnt*  h«<f 
been  repeated  by  Koch  and  others  with  a  negative  result.  Ihert 
ure  distinct  morphological  diflerencen  between  the  two  bacilli  »! 
which  Buchuer  does  not  seem  to  have  been  aware,  and  ioabilit;  to 
distinguish  between  the  two  clearly  invalidates  the  rmult  uf  tb« 
investigation. 

This  is  the  experimental  evidence  as  to  the  mutability  of  btiO- 
teria.     At   present   the  liahince   is   most    decidedly   agauiiit  it,  M 
Koch    himself  recognizes   that    his   experiments   do   not    |>rovf  i« 
impotigiliilitff.     Like  all  other  organisniB.  these  unicellular  Wwf* 
must   have  more  or  less  power  of  adapting  themselves  to  «ltiT«"l 
surroundings,  and  be  liable  to  modification   by  their  envir^muicnl* 
They  may  grow  more  or  less  rapidly,  may  be  larger  or  smaller,  ami 
may  separate  early  or  remain  united  in  strings,  tbread.<i.  or  hft^ 
On  poor  substrata  the  developmental  cycle  of  a  jKilyinorphon*  forw 
may   be  incomplete,  or  the  cell.-*  of  a  monomorphous  form  mar  I* 
stunted  and  irregular,  or  abnormal  ("involution"  Niigeli)  fotv* 
may  appear:  an<l  tliey  may  be  rendered  more  or  less  viruleal.     B"* 
Koch's  observations  of  various  bacteria,  often  extending  fiver  ye***- 
suffice  to  show  that  all  he  dealt  with  preserved  unaltere«l,  throvgk  * 
long  series  of  cultivations,  their  inherileil  charucterii«tic«.     Wli*** 
ever  the  life-history  of  a  species  (muiiuimirphous  or  jMilyniorpfco^' 
has  been  made  out,  no  important  departure  from  its  various  »ia^^. 
has  ever  been  recorded :  the  coccus  of  erysipelas  has  never  heat 
to  grow  into  a  bacillus  or  a  spirillum. 

Looked  at  from  the  clinical  point  of  view,  every  one  feels 
the  best-marked  group  of  infective  diseases — the  specific  h' 
must  have  an  unvarying,  speciBc  cause.  Most  observer*  beli^'^ 
that  tbcMe  diseases  never  arise  except  by  infection  from  a  previ^j 
case.  Assuming  the  virus  to  be  a  fungus,  tbey  admit  that  it  bc^I 
at  souie  time  have  accjuired  the  physiological  action  which  enab^^ 
it  to  produce  a  certain  disease;  but  they  hold  that  there  i*  no  '"^^ 
dcnce  that  harmless  fungi  do  at  the  present  time  ever  aci{uire  sv^^ 


THE  VEGETABLE  PARASITES. 


poirere.  Isolated  communities  remain  free  from  such  diseases  for 
centuries  until  a  case  is  introduced  among  tlieiu ;  then  it  spreads 
»ith  the  utmost  rapidity.  In  li>2(>  a  negro  covered  with  stnall-pox 
|iuatule8  was  landed  on  the  Mexican  coast,  where  the  disease  was 
D<il  then  known:  three  and  a  half  millions  are  said  to  have  died  of 
it.  In  184»»  measles  was  introduced  from  Copenhagen  into  the 
Faroe  Islands,  and  almost  every  one  suffered.  Similar  facts  con- 
cerning other  acute  specifics  are  given  by  Sir  T.  Watson  in  the 
first  volume  of  the  Xineteenth  Cfluturi/.  Murchison  and  others 
believed  that  typhus  and  typhoid  might  originate  </»'  novo,  being 
filth-begotten ;  but  the  conditions  of  life  in  slave-ships  and  Arctic 
winter-houses  arc  as  insiinitary  as  ever  they  were  in  our  jails  when 
tyjihiis  was  endemic  in  them,  yet  no  typhus  occurs.  As  to  the 
origin  of  typhoid  fever  from  sewer-gjis,  many  towns  and  hotels  show 
th»t  I'xliiilations  of  it  may  be  intense  and  prolonged  without  ever 
gvneniting  typhoid  fever. 

The  poison  of  the  most  infectious  diseases  sj)read8  so  easily  by 
»ir.  fund,  and  clothing  that  it  is  exceedingly  difficult  to  find  a  case 
io  which  the  possibility  of  infection  from  a  previous  case  cannot  be 
shown.  The  less  infectious  kinds  have,  therefore,  been  turned  to 
br  the  advocates  of  the  dc  novo  origin.  Many  cases  of  diphtheria 
believed  to  have  arisen  spontaneously  have  heen  recorded,  ami  an 
urethral  di.scharge  like  gouon-liu'a  in  symptoius  ami  roniiininicability 
luay,  it  is  said,  be  contracted  from  a  woman  suffering  from  any  foul 
discharge  not  gouorrhital.  It  is  of  course  ijuite  possible  that  ure- 
thral discharges  may  be  excited  by  infective  irritants  other  tlmn  the 
irrhueal  poison.  With  regard  to  the  so-called  "  liosjiital  clis- 
•wes" — pysemia,  sejjticaMuia,  and  hospital  gangrene — there  is  per- 
hapa  evidence  of  some  change  from  non-pathogenic  to  pathogenic 
organisms.  How  otherwise  is  it  to  be  explained  that  when  a  new 
building,  which  has  never  before  contained  wounded,  is  used  in  time 
of  war  as  a  hospital,  these  diseases  bresik  out  as  soon  as  the  crowding 
"f  the  wounded  reaches  a  certain  point,  whilst  they  do  not  attack 
P»tieut8  in  tents  close  by  ?  Is  it  likely  that  the  specific  causes 
•ere  present  in  the  building?  Do  not  the  facts  tem|it  to  the  belief 
that  ordinary  bacteria  acijuire  patliogenic  ])ro]»erties.  or  at  any  rate 
•oeh  a  degree  of  virulence  as  enables  them  to  become  pathogenic, 
"J  cultivation  under  the  cuiiditions  brought  about  by  overcrowding 
of  the  wounded  ?  The  state  of  atmosphere  produced  in  tiie  building 
•ould  seem  to  be  analogous  to  the   "  epidemic  iniluence  " — that 


358 


THE   VEGETAIiLF.   PARASITES. 


influence  wliicli  cunscs  infective  diseases  everv  now  and  «gsinw 
became  widclv  epidemic.  From  the  clinical  standpoint,  therefore, 
it  would  seem  that  but  little  evidence  is  forthcoming  in  favor  of  tLf 
uiutubility  of  bacteria,  but  the  ([uestion  must  be  regarded  as  »till 
suit  juiiice. 

It  will  be  seen  that  by  origin  de  novo  is  meant,  uot  the  sponlwiMiii 
development  nf  uii  organism,  but  the  acquisition  in  an  organinmof 
siicli  ]iiitliogeiiir  iuid  ntlier  properties  as  may  fairly  entitle  it  to  be 
regarded  as  a  diHliiK-t  >(jiecio.s. 


VARIETIES  AND  ETIOLOGY  OP  THE  INFECTIVE 
DISEASES. — The  acute  s]ieeifie  diseases,  to  which  allusion  lias  •" 
often  been  made,  are  now  regarded  as  forming  only  a  class  in  ibe 
much  larger  group  of  Infective  Diseases.  An  infective  ilis*** 
iiuiy  be  defined  as  a  disea.se  iliie  to  the  action  of  a  poison  or  vini» 
wiiieh  has  the  power  of  invading  and  multiplying  in  or  on  liviiijt 
tissues.  Infective  diseases  may  be  locfd  or  erenersl,  just  m  tin* 
effect.s  of  organi.sms  may  be  local  or  general  (p.  841). 

There  i.s  at   present  no  satisfactory  da.ssification  of  infectivt  dis- 
eases.    They  are  generally  grouped  according  to  the  acutonesj"' 
their  course,  the  n.'iture  and  distribution  of  their  lesions,  and  ?ucb 
prdiiriuoit  cliiiiciii  <'liaracter.s  a.s  they  may  possess.     The  seat  of  ll>'^ 
micro-organisms  has  been  suggested  as  a  basis  for  clsssificatiou- 
Three  groups  might  in  this  way  be  made — (T)  those  due  to  organisu'^ 
which  do  not   penetrate   beneath   the  surfaces,  but  discharge  tlie'*' 
products  into" the  blood;  (2)  organisms  which  thrive  in  the  tissn«T* 
anil  produce  local  effects:  (3)  organisms  which  enter  the  circulttio** 
and  thrive  iu  the  blood.    (See  "  Pyicmia  anil  Septicemia.")    In  tl>* 
majority  of  cases,  however,  it  is  still   impossible  to  say  into  whicri* 
of  these  groups  a  given  instance  should  be  placed. 

Tlicre  is,  on  the  strength  of  the  analogy  which  exists  between  ff  «*' 
mentation  and  infective  diseases  (p.  ;]1T),  a  prinid  fiicie  case  in  fav*^** 
of  the  germ-theory  jis  applie<l  to  the  infective  diseases.  And  it  «i  ■' 
be  found.  u{)on  exauiiuatiou  of  the  evidence  yielded  by  actual  ubst^*'' 
vation  of  these  diseases  and  by  exjieririieiits  upon  aniiuals,  lliut  tt»^ 
deiuonstration  of  the  casual  relationship  of  organisms  to  tlicm  i»  ••• 
some  cases  as  cotiiplete  as  it  is  iu  the  case  of  fermentation,  altlmn^'" 
in  the  great  majority  the  proof  is  still  more  or  less  doubtful. 

To  prove  that  a  micro-organwm  i»  thv  catise  of  a  diteate  it  is  m 
sary — 


THE   VEGETABLE  PARASITES. 


359 


1.  That  the  organism  in  question,  as  recognized  by  its  form,  mode 
of  v'mwtli,  or  products,  be  found  constantly  associated  with  the 
ilisciisi',  at  least  in  its  earlier  stages,  and  in  sufficient  numbers  to 
KcDnnt  for  the  symptoms. 

2.  That  "pure"  cultivations  of  this  orjianisrii  tlirough  several 
lenerutions  he  made,  until  it  may  reasonably  be  su))[)osed  that  every- 
iin^  which  could  possibly  have  been  taken  from  the  animul  that 
ieliicd  the  virus  has  disappeared. 

3.  That  other  susceptible  animals  be  innculated  with  the  culti- 
llcd  organism,  and  that  the  di.^ease  be  thus  reproiluccd. 

4.  That  the  same  organism  be  fitimd  in  the  tissues  of  the  success- 
lly  inoculated  aninuils,  in  such  nuiul)crs  and  with  such  a  distri- 
Ition  as  to  account  for  the  disease. 

The  demonstration  of  a  well-fharacterized  organism  in  ronstant 
Sociation  with  a  disease  is  now  by  many  taken  as  almost  eijuivalent 
proof  that  it  is  the  cause  of  the  morbid  process.  For  it  is.  in 
tat  cases,  impossible  to  experiment  on  man,  and  frei|uently  no 
Jmal  can  be  found  which  siifTors  from  the  ilisease  under  investi- 
tion.  Consequently,  the  proof  cannot  be  carried  beyond  the  first 
Ige.  This,  however,  is  no  proof  at  ail  to  those  who  believe  that 
ider  certain  circumstances  a  certain  form  of  organism  will  develop 
Dntaneously,  nor  is  it  satisfactory  to  others  who  think  that,  when 
uidus  favorable  to  a  certain  organism  exists,  that  organism  is  sure 
drop  into  it.  Sidney  Martin  has  suggested  that  an  attempt  should 
made  to  discover  and  separate  the  cbeiiiical  prmlucts  (»f  the  organ- 
D.  both  in  the  tissues  of  the  animal  or  person  dead  of  the  ilisease 
d  in  the  subsequent  culture-ground.  If  suitable  media  are  selected, 
ese  protlucts  shoulil  clearly  be  identical. 

The  amount  of  patience  and  skill  necessary  to  carry  on  an  in- 
■tigation  of  the  above  kind  can  be  appreciated  only  by  those  who 
|ve  worked  at  the  subject.  T/iej/  are  not  surprisetl  that  so  few 
leases  have  been  thoroughly  investigated.  In  the  case  of  man  tho 
fficulty  of  obtaining  material  in  the  early  stages  of  diseases  au<l 
toediately  after  death  must  also  be  taken  into  account.  Until 
'te  recently,  too,  the  methods  employed  were  wholly  iuadoijmite 
'he  discovery  of  many  kinds  <if  fungi.  At  first  tliere  was  uiiaidi-d 
Ctoscopic  examination  otdy,  and  with  inferior  objectives.  The 
Section  of  all  fungi  under  these  circumstances  was  very  difficult, 
d  often  impossible.  A  considerable  step  was  made  when  von 
tcklinghaitsen  iri  1871  pointed  out  that  the  uniform  sixe  of  micro- 


360 


THE   VEGETABLE  PARASITES. 


cocci  and  their  resisting  power  n^ainst  dilute  acids  and  alkt 
glycerin  iiiiglit  be  employed  as  a  meuns  of  diagnosis  between' 
and  fatty  atid  albiimiiioid  ]»artit'les.  But  progress  lias  been  macli 
more  rapid  since  the  introduction  by  Abbe  of  a  powerful  8ub-'Ugc 
condenser,  by  Weigert  of  the  aniline  dyes  as  stains  for  orgauiso)', 
and  by  Koch  of  many  improvements  in  the  mode  of  ex&miiiJiij 
specimens  and  of  car'-ying  on  pure  cultivations. 

IMMUNITY  FROM  INFECTIVE  DISEASES.— Some  di«- 
eases  tend  to  recur  again  and  again  in  the  same  individual.  Of 
these  bronchitis  ainl  facial  erysipelas  are  prominent  examplw. 
Other  diseases  show  a  preci.scly  opposite  tendency.  To  have  dif- 
fered once  from  one  of  them  is  to  have  secured  almost  certain  frw- 
dom  from  a  second  invasion.  Freedom  thus  ensured  is  knowni 
(ict^uiri-il  hnntuvlt}/.  Persons,  for  example,  who  have  had  small-] 
arc  said  to  be  iinmiine  against  a  second  attack.  The  same  is  pn 
tically  tnic  of  typhoid  fever,  measles,  and  other  speciBc  diseases, 
is  by  no  moiitis  ccrtjitn  how  long  such  iiiimnnity  lasts,  and  in 
there  arc  no  tiifatis  of  definitely  usccrlaitiing  its  duration.  Ag 
certain  diseases  which  arc  coinmon  in  some  species  of  auiniabi 
]iractio;illy  unknown  in  others  very  closely  allied  to  them.  Thus. 
tubercle  is  common  in  pigs  and  cows,  but  excessively  rare  in  slici'p. 
goats,  horses,  nn<l  asses.  Mice  fall  a  ready  prey  to  anthrax,  while 
rats  escape  unharined.  Acconlingly,  |)igs  and  cows  are  said  tn  Iw 
gugrrpfililt'  to  tubercle,  while  sheep,  goats,  horses,  and  asses  arci" 
like  manner  said  to  be  liiimiiiir  against  it.  The  exact  condition* 'in 
which  this  susceptibility  or  immunity  depend  are  unknown.  Toiiis- 
tinguisli  it  fnnu  the  stcipiired  form  it  is  known  as  tKifiinil or  inhfriteJ 
iiiuintiiiti/.  When  iiti  animal  is  only  slightly  susceptible,  an<l.vi'tiw' 
absolutely  immune,  it  is  often  termed  refractory. 

In  Ininntu  patliolngy  there  are  also  many  examples  of  th'"'*' 
peculiarities.  Negroes  are  immune  against  yellow  fever;  w'''"" 
races  are  susceptible.  A  nurse  in  a  fever  hospital  may  never  b*"* 
had  scarlet  fever,  and  yet  may  continue  to  resist  all  exiiosurp  to  tli* 
infection.  It  may  be  that  inheritdl  immunity  is  due  to  flu'  Iw"'' 
ing  down  to  offspring  of  that  aci|uircd  by  ancestors.  Thus,  r»«* 
among  which  certain  acute  fevers  (like  measles)  are  common  c""'''' 
much  less  severely  than  those  among  whom  the  disease  appears  ni'l' 
at  very  long  intervals.  Tlio  ronipletc  immunity  of  the  nt'pni  t" 
yellow  fever  is  generally  accounted  for  by  supposing  that  thow*'"' 


THE  VEO STABLE  PARASrTES. 


981 


W    could  resist  the  disease  best  would,  by  living  longest  luid  Laving 

■  mint  children,  be  most  likely  to  hand  on  their  peculiarities  to  the 
I  succeeding  generation  ;  and,  furtiier,  that  the  degree  of  iminiinity 
I     thuii  gained  would  be  strengthened  by  the  intermarriage  of  those 

■  alreaiiy  partly  immune.  But  this  ex[ilanatioii  ofterj*  no  ad('(|i!ate 
H  reason  for  the  peculiar  sporadic  immunity  enjoyed  by  some  iudi- 
I  viJuals,  as  in  the  case  of  a  fever-nurse  just  cited.  Occasionally  this 
I  sort  of  immunity  is  more  apparent  than  real.  Two  medical  students 
I     pail!  almost  daily  visits  to  scarlet-fever  wards  for  several  months, 

■  Mil  failed  to  contract  the  disease,  but  late  one  afternoon,  on  entcr- 

■  ing  ihti  wards  much  exhausted  by  severe  e.xercise  and  a  fast  of  five 
^     hours,  h()tli  took  the  disease  in  a  severe  form,  and  one  ilied. 

M  Artiflcially-acquired  Immunity. — Three  forms  of  preventive 
H  inoculation  have  been  employed  to  secure  immunity  from  disease  or 
H  t)i  arrest  the  development  of  contagia  that  have  already  reached  the 
I    ti.itiues : 

■  1.  Inoculation  with  the  attenuated  virus  of  the  original  disease. 

■  -.  Inoculation  with  the  chemical  products  of  the  organisms  of  the 

■  '•figinnl  disease. 

I  -i.  Inoculation  with  serum  obtained  from  an  animal  that  has  been 
I     '•'I'ated  by  one  of  the  two  preceding  methods. 

I  I.  If  has  been  well  known  siiice  the  sixth  century  that  the  arti- 
I  ^fial  inoeulation  of  small-pox  ])roduce8,  on  the  one  hand,  a  mild 
I  y*ttB  of  the  disease,  and,  on  the  other,  confers  upon  its  subject 
"Dftiunity  against  a  second  attack.  In  one  ci>nutry  after  another 
"  has  for  a  time  been  the  custom  to  practise  inoculation  to  ensure 
I  **>i«  resnlt.     It  has  also  long  been  recognized  that  epidemics  vary  in 

■  ■eTCTity.  and  that  mild  attacks  and  severe  attacks  are  eijually  effica- 
t  *^ioii»  in  securing  immunity. 

I  Pasteur  was  the  first  to  place  preventive  inoculation  on  a  scientific 
*HmU.  He  demonstrated  that  the  virulence  of  some  contagia  can  be 
l**Hed  by  experimental  procedures.  In  the  case  of  chicken  cholera 
P**  showed  that  by  exposing  ciiltiires  of  the  virus  for  long  jjeriods 
P***  virulence  became  so  reduceil  that  inoculation  of  the  weakened  or 
¥**f*rftuatril  organisms  gave  rise  to  a  coinjuirutively  mild  disorder, 
[^'*ich,  however,  sufficed  to  secure  innnunity  against  subseijtient 
l^ltacks,  Other  observers  have  since  shown  that  the  virulence  of 
|'*^>»liy  other  organisms  can  also  be  modified,  and  that  the  organisms 
I  *^*H  be  kept  in  their  attenuate<l  condition  through  .several  cultiva- 
*'<Jii»,  though   there  seems  to  be  a  general  tendency  for  them  to 


362  THE  VEGETABLE  PABASITES. 

return  to  their  previous  degree  of  virulence.     The  atteniutioD  ii 
generally  eflfected  by  one  of  two  methods : 

(1)  A  series  of  animals  is  experimentally  selected,  genenllr  od 
account  of  their  slight  susceptibility  to  the  disease  in  question.  Sk* 
cessire  inoculations  are  then  made  from  one  to  another,  until  it  ii 
found  that  the  desired  degree  of  attenuation  has  been  reacheil.  {i) 
Cultures  of  ordinary  virulence  are  exposed  to  the  air.  or  to  u  in- 
creased temperature  only  slightly  below  the  fatal  limit,  or  to  tlw 
action  of  small  doses  of  various  antiseptics.  Pasteur's  treaimeu 
of  persons  bitten  by  rabid  animals  is  the  best-known  illustration «( 
this  method,  though  no  hydrophobia-organism  has  yet  been  di«cov- 
ered.  By  a  series  of  successive  inoculations  a  special  virus  is  pre- 
pared which  is  known  to  have,  when  injected  into  rabbits,  a  coD^tut 
incubation-period  of  six  days.  Rabbits  are  inoculate<i  with  tbit 
virus,  and  their  spinal  cords  are  subsequently  drie<l  very  giwl- 
ually  in  tlie  presence  of  caustic  potash.  The  longer  the  drying  ii 
continued,  the  weaker  the  virus  becomes.  If  an  emulsion  of  a  cord 
that  has  been  dried  for  six  days  be  made  an<l  inoculated  uponnb- 
bits,  it  entirely  fails  to  produce  the  disease.  Pasteur's  method  i» 
to  give  ten  injections,  extending  over  four  days,  according  to  the 
following  table: 

FirHt  injection,  first  (lay,  KmuUion  of  cord  dried  ten  davs. 
ScH-ond      "  "'  "  "        "  nine  •*' 

Thirtl        "  "  "  "        "  eight" 

"  «        «  aeven" 

"  «        «  five    " 

"        "         four  " 

thrw!" 
a        u  „„    .. 

Tenth       "   fourth   "  "  "        "  one  d«T. 

After  three  <lays  a  few  more  injections  are  given  daily,  and  tbe 
process  is  complete.  Statistics  are  strongly  in  favor  of  the  effit*'.^ 
of  the  method.  There  is  generally  plenty  of  time  to  carry  it  ">iA 
as  the  iiictibation-period  in  man  is  never  less  than  twelve  day**"" 
is  usually  about  six  weeks. 

This  nietlio<l  of  securing  immunity  is  not  applicable  to  the  »»" 
majority  of  specific  disea.ses.     On  the  one  hand,  certain  orgaoi*"''" 


Fourth 

"   second   " 

Fifth 

((                ((              11 

Sixth 

i(                 (1              (• 

Seventh 

•'    thin!    " 

KiKhth 

tt                11              *l 

Ninth 

I.            tt          ii 

THE   VEGETABLE  PARASITES.  363 

inch  as  the  tubercle  bacillus,  have  hitherto  defied  all  efforts  made 
to  attenuate  them,  and,  on  the  other,  there  is  some  risk,  even  after 
attenastion,  that  the  disease  may  be  produced  in  a  virulent  form. 

2.  To  avoid  this  latter  danger  the  chemical  products  have  been 
freed  from  the  living  organisms  and  injected  alone.  The  organisms 
CM  be  removed  by  filtering  fluid  cultures  through  porcelain,  or 
they  may  be  killed  by  the  action  of  heat  or  of  some  volatile  anti- 
septic, such  as  oil  of  mustard,  which  can  be  subsequently  removed. 
Sometimes  the  full  degree  of  immunity  attainable  is  reached  after 
two  or  three  injections,  but  in  other  diseases  and  other  animals  the 
injections  have  to  be  repeated  every  two  or  three  days  for  several 
weeks  or  even  months.  Immunity  thus  conferred  is  not  always 
very  certain  nor  of  long  duration,  and  the  method  is  not  attended 
with  favorable  results  in  those  cases  in  which  exposure  to  infection 
precedes  its  application. 

Haffkine's  vaccination  against  cholera  illustrates  both  this  and 
the  precetling  method.  He  employs  two  vaccines.  One  is  made 
from  an  attenuated  virus,  the  other  from  an  exalted  virus.  The 
attenuated  virus  is  prepared  by  cultivating  the  cholera  spirilla  in 
aerated  media  at  a  temperature  of  39°  C.  (102.2°  F.).  The  exalted 
virus  is  prepared  in  the  following  manner :  A  pure  culture  of  the 
organism  is  introduced  into  the  peritoneal  cavity  of  a  guinea-pig. 
Death  follows  in  twenty-four  hours.  The  peritoneal  fluid  is  im- 
mediately removed,  and  another  guinea-pig  similarly  inoculated. 
This  process  is  continued  through  a  series  of  animals  until  the 
interval  between  inoculation  and  death  falls  to  its  lowest  limit. 
Persons  to  be  protected  are  vaccinated  twice.  On  the  first  occasion 
the  attenuated  virus  is  used;  on  the  second,  three  to  five  days 
afterward,  the  exalted  virus.  The  vaccination  is  supposed  to  pro- 
'hce  a  sufficient  tolerance  to  the  cholera-poison  to  enable  the  body 
*«" react"  more  vigorously  when  attacked  in  the  ordinary  way. 
Sometimes  the  living  cultures  are  used,  but  more  often  the  vaccine 
"  fterilized  by  the  addition  of  carbolic  acid.  Prepared  thus,  the 
"lid  can  be  more  easily  preserved  and  can  be  introduced  with  less 
"m.  but,  as  in  other  cases,  the  results  are  neither  so  certain  nor  so 
prolonged.  The  sterilized  products  of  bacteria,  irrespective  of 
Weir  exact  nature,  are  often  termed  toxines. 

3-  These  results  led  Behring  in  1890  to  examine  the  serum  of 
'Dirnals  thus  immunized,  and  since  that  time  many  observers  have 
ioOowed  in  his  footsteps.     In  the  case  of  tetanus  the  serum  of 


THE  VEOETABLE  PARASFTF^ 


immunized  rabbitM  vi&s  used,  and   three   rerj  remarkable 
were  established.     It  was  found  that — 

(1)  Ke|)eated  injections  of  this  serum  will  render  mice,  which  ut 
particularly  susceptible  to  the  disease,  absolutely  immune. 

(i2)  The  addition  of  the  serum  to  living  or  t«  steriliz<<<l  niiturs 
of  the  bacillus  will  completely  destroy  the  pathog<''nic  jmiwit  4 
«aoh. 

(3)  The  injection  of  the  serum  into  animnls  nlrrady  unSmtit 
from  tetanus  will  not  iufreiiuently   lead  to  nbs<jlutv  reco\i-n. 

Furthermore  it  was  found  that  while  the  ordinary  scnimnfi 
naturally  immune  animal  possessc<l  none  of  these  propertiet,  litn 
could  be  developed  by  a  series  of  similar  inoculations. 

This  method,  when  aj)plic<l  to  the  treatment  of  disease  *\n»it 
contracte<l,  is  known  as  »erum'therapeulir$,  or  treatment  by  «•*>• 
toxin.  It  has  been  employed  in  tetanus  with  not  very  satisfid^T 
results,  but  is  more  extensively  used  '  in  diphtheria.  The  nrio* 
stages,  comprising  the  whole  process  as  given  by  Roax  it  ik 
Budapest  Congress  in  1894,  will  serve  as  an  admirable  illnstnMfc 
They  are  as  follows : 

(1)  A  pure  culture  of  the  bacillus  diphtherii«  (Locffler)  i»  aiit- 
This  takes  about  three  weeks. 

(2)  The  organisms  are  removetl  by  filtration  through  porCfl»i« 

(3)  The  toxine  thus  obtained  is  injected  into  the  liorw  in  n"*" 
quantities  two  or  three  times  a  week,  until  no  reaction  foUn"' 
This  periiiil  extends  over  from  one  to  three  months. 

(4)  Some  of  the  blood   is  then  withdrawn,  and  the  seram 
arated,  sterilized,  and  stored  for  subsequent  use. 

(o)  When   rec|uired   for   the  treatment  of  diphtheria  a 
about  20  c.  c.  is  injected  under  the  skin.     A  second  do8«  if 
sionally  required.     Improvement  follows  in  the  coarse  of  tantt* 
four  hours. 

The  active  principle  contained  in  the  serum  is  unknown.  ^ 
this  Cfiuntry  it  is  generally  referred  to  as  ••  anti-toxin." 

Attempts  have  been  made  to  ileal  with  tuberculous  disease  is  V* 
same  manner.  The  tubercle  bacillus  has,  however,  sucoeMWv 
resisted  all  attempts  made  to  attenuate  it,  and  to  inje<'t  the  orgssil* 
in  its  ordinary  degree  of  virulence  is  simply  to  inoculate  tke  iiio* 
from  which  immunity  or  relief  is  sought.  The  next 
by  Koch,  who  prejjared  a  sterilized  extract  of  itji  pi 

'  Novumbor,  1894. 


low** 

I 


JBE'  VEOETABLK  PARASITES. 


365 


WM  known  as  "tuberculin."  This,  wbeii  injected,  produces  an 
iDflammBfory  reaction  at  tlie  sites  of  tuberculous  infection.  At  the 
present  time  experiments  are  being  made  to  discover  an  anti-toxin 
analogous  to  that  just  described  in  connection  with  diphtheria. 

It  may  hero  be  mentioned  that  ordinary  healthy  blood-serum  is 
foiinJ  experimentally  to  be  in  many  cases  a  distinct  germicide.  If 
anthrax  organisms  be  suspended  in  it,  most  of  them  will  die.  Evi- 
dence has  been  adduce<l  to  show  that  this  germicidal  action  is  due, 
It  anv  rate  in  part,  to  the  action  of  nuclcin.  It  was  found  that 
digestion  of  the  serum  did  not  remove  this  influence,  but  that  a 
temperature  of  55°  C.  (131°  F.)  did.  It  was  accordingly  assumed 
that  while  the  action  was  clearly  not  due  t<>  albutuin.  it  was  still 
mont  likely  due  to  some  form  of  protcid.  The  proteiiis  were  there- 
fore precipitated  with  alcohol  and  ether,  and  the  precipitate  digested 
with  iiopsin  and  hydrochloric  acid.  The  undigested  residue  was 
then  washed  and  sterilized.  The  compound  thus  (drtained  gave  the 
n-actious  of  nuclein,  and  was  fonnd  to  possess  a  germicidal  |)ower 
over  cholera  spirilla,  staphylococcus  j)yogenes  aureus,  and  a-sporo- 
genc  anthrax. 

Theories  of  Immunity. — Much  controversy  has  taken  place 
during  the  last  few  years  concerning  the  real  nature  of  the  immunity 
*liich  has  been  discussed  in  the  proceiling  pages. 

It  is  well  known  that  immunity  against  some  chemical  substances 
tan  be  obtained  by  certain  persons.  Opium-eating  an<l  arsenic- 
fating  are  illustrations  of  this.  Furthermore,  it  has  liitoly  been 
»h«»n  that  if  minute  but  gradually  increasing  doses  of  ricin,  the 
•ctive  principle  of  the  castor-oil  bean,  he  given  by  the  mouth  to 
guinea-pigs,  they  can  be  renilered  so  far  immune  against  the  action 
"fthe  poison  when  injected  subciitaneously.  that  they  will  survive 
•dose  four  hundred  times  that  ordinarily  sufficient  to  produce  death. 
In  other  words,  the  tissues  of  the  higher  organism  possess  a  certain 
power  of  ailapting  themselves  to  a  new  environment  if  only  a  suffi- 
"ifnt  time  be  allowed.  But  as  soon  as  we  attempt  a  detailed  ex- 
planation of  these  results,  as  well  as  of  those  previously  mentioned, 
•c  find  that  they  appear  in  many  cases  to  be  absolutely  contra- 
dictory. The  serum  of  some  iuuiiune  animals  is  fatal  to  cultures 
of  the  virus  in  question ;  in  other  cases  it  is  not.  Again,  while 
'«0  Serum  may  be  fatal  to  cultures,  the  blood  itself  may  have  little 
"r  no  resisting  power  against  the  organisms  when  introduced  into 
tlie  body.     Possibly  the  term  "  immunity  "  covers  several  dissimilar 


366  THE  VEGETABLE  PARASITES. 

and  complex  processes.  It  is  suflicient  to  mention  that  then  art 
two  views  current.  According  to  one,  immunity  is  simply  a  t\m' 
tion  of  chemical  reactions ;  according  to  the  other,  it  is  due  to  vital 
forces  which  arc  called  forth  by  the  action  of  the  virus.  Mrttk- 
nikoflf  in  his  "  phagocytosis  "  theory  considers  that  it  depends  nuiiniT 
upon  the  specific  action  of  certain  of  the  leucocytes  (p.  315). 

Pathoobnic  Bactbhia. 
A  more  detailed  reference  must  now  be  made  to  certain  mirni- 
organisms  which,  on  more  or  less  satisfactory  evidence,  are  belieT»J 
to  be  the  exciting  causes  of  certain  infective  diseases.     For  vaal 
of  a  better  classification  we  shall  follow  Cohn's  (p.  3{>4). 

I.  SPTT  /TIROB ACTEMA  or  MICROCOCCI.— These  are  nnti 
or  oval  cells,  generally  .5  fi  to  2  ft  in  diameter      They  are  arranjwJ 

Fio.  121. 


^ 


^^-r^ZW^J 


I.  mlrnKMMTl  from  «ii  iwiilr  iiliw'fw— Mrt'iitiK'iH-H  trvv,  hta|>li>'I<>nK-rt  in*  |i«i»<*l''  - 
Mrt'iiUx'iHil  friim  wcoiiilnry  su|i|>iirHlli>ii  In  the  cHhiw,  tKiMirrlnn  In  iMH-riwrnl  Mi* '"''*■ 
l<'j  I :  :t,  nilir'M'iw'i'l  In  iv\\»  ftnni  K<>niirrli<i'al  jmH :  4,  Hnrt-ina'  vi-nlricull :  .'•.  wM-mlW  tarW" 
t<'rni<i:  A.  luiiilli  anilirni'is  fniin  IiIihhI  of  iniiusf  iHorKlcyi:  7,  i-hainn  fhim  i'nltir*tl>«  "<  ^ 
Hnllirni'U.  xomi'  N'Mrini:  siHin-H  innt-r  IMiclanx):  K,  ImHIII  iirtyphotil  frvcr,  ftom  •  mrKUl'''' 
(.'Iniiil  (i;HitK-i;  1".  i.pl'-lUn  of  n-la|MinK  fi'ViT.  and  iv<l  tHirpuM-lc*  (afWr  Vaniljkr  rut"- 

singly ;  in  |)airs  (iliplororci) ;  in  chains  (gfreptococci)  of  fonr  «'*' 
to  three  hundred,  which  may  be  straight  or  wavy ;  in  grouf*  1'** 
bunches  of  grapes  {ntdphifloi'orci);  or  in  colonies  and  loogl"'*' 
Miiis.««'s.  The  organisms  belonging  to  this  order  differ  among  tb**" 
.srlves  in  form,  size,  mo<le  of  grouping,  and  physiological  action. 

The  absence  of  <listinctive  form  makes  it  very  difficult  to  v^' 
tiiiii  ulu'tluT  a  culture  is  '•  pure,"  and  whether  a  coccus  under  ob«f* 
\atii>n  is  the  caii.««e  of  a  di.«»ease  in  <|uestion.  Of  all  forms  of  fung"*- 
cocci  are  the  mo.st  frequently  associated  with  disease. 


THE  VEGETABLE  PARASITES.  367 

1.  Farmentation  of  Urine. — The  Micrococcus  urece  is  one  of 
causes  of  the  ammoniacal  fermentation  of  urine,  which  it  enters 
n  the  air.  Urine  obtained  pure  and  exposed  only  to  pure  air 
I  keep  acid  for  years.  The  transformation  of  urea  into  ammo- 
m  carbonate  is  said  to  be  usually  due  to  the  action  of  an  "  un- 
ned  "  ferment  secreted  by  this  micrococcus.  The  ferment,  how- 
r,  must  be  indiifusible,  for  the  urine  in  an  excised  bladder  does 
putrefy  even  if  placed  in  putrid  urine.  The  change  often 
irs  in  urine  contained  in  the  living  bladder,  and  may  extend 
» the  pelvis  of  the  kidneys  with  the  most  fatal  results.     (See 

Fio.  122.  Fio.  123. 


■pbylococcua  pyogenes  aureus  (from  a         Streptococcus  pyogenes  (from  pus  found 
culture).  in  a  pysemic  abscess). 

appurative  Nephritis.")     The  M.  ureae  is  rather  large  (2  /<),  and 
in  singly  or  in  chains. 

enbe  has  demonstrated  the  existence  of  four  other  distinct 
«ria  producing  the  same  effect  on  urea.  These  and  the  M. 
e  are  capably  anaerobic,  and  may  therefore  be  the  causes  of 
efaction  of  urine  in  the  bladder.  Miquel  has  discovered 
ilicate  bacillus  which  has  a  similar  action,  and  is  anaerobic. 
Sappuration,  or  Pyosia,  whether  in  the  form  of  acute  abscess, 
DOyelitis,  or  metastatic  pyaemia,  is  usually  associated  with  the 
ence  of  cocci.  Many  varieties  of  cocci  are  described  as  occa- 
illy  present.  By  far  the  most  common  of  these  are  the  Staphy. 
■cut  pyogenes  aureus,  the  Staphylococcus  pyogenes  albus,  and 
^reptococcus  pyogenes.  They  all  grow  readily  at  the  body- 
lerature.  The  Staphylococcus  pyogenes  aureus  and  the  Staphy- 
cut  pyogenes  albus  differ  from  one  another  in  only  one  import- 


368 


THE   VEGETABLE  PARASITES. 


ant  particular — namelv.  that  the  former,  when  cultivated  on  p-litit.' 
agar-agar,  or  potato  iu  the  presence  of  oxygen,  produces  »  i4^ 
orange  pigment,  while  the  latter  does  not.  (Sue  Frontwpif««.| 
They  resemble  one  another  in  forming  clusters,  in  liquefying  gtlatiit, 
and  in  being  able  to  exist  for  weeks  in  the  dry  state.  M 
when  ititroduced  into  the  tissues  under  favorable  eircumsi^i 
both  form  a  peptonizing  ferment;  albumoses  and  peptones  cinilnn 
be  obtained  from  pus.  The  Streptococcu*  pi/oiffnes  ronsixta  «>f  oxri 
rather  larger  than  the  preceding,  and  grows  in  chains.  Ii  liM 
not  Ii<|uefy  gelatin,  and  does  not  form  pigment.  When  introdiwrJ 
into  the  tissues  it  peptonizes  even  more  vigorously  than  the  sUiJij- 
lococeus.  The  staphylococcus  is  principally  found  in  circum.vrM 
abscesses,  while  the  streptococcus  is  especially  ««»<ici»trtl  »i]4 
spreading  and  diffuse  suppuration.  H 

All  these  organisms  exist  in  considerable  numbers  on  inr  mt 
especially  where  they  can  "obtain  cover."  'i'hey  reach  w(>uDd«bj 
growing  under  the  dressings,  and  not,  ns  a  rule,  by  failing  fma  Al 
air.  Minute  i|uantitios  of  boric  acid  (1:  300.  applied  tu  cultara) 
and  other  antiseptics  suffice  to  flop  th'ir  tfrutcth.  Obsorvew  »rr  W 
no  means  agreed  as  to  the  length  of  time  which  a  1 :  1000  tolnDsa 
of  mercuric  chloride  takes  to  hill  them,  tin-  times  given  varyin|{6«* 
eight  seconds  to  thirty  minutes.  Possibly  some  of  thi*  diffntsrt 
ilcpends  on  the  different  virulences  of  the  8(>eciuieu»  loueA,  •» 
may  be  said  to  be  consistent  with  the  results  obtained  by 
tion. 

In  the  case  of  these  organisms  the  chain  of  prwif 
(p.  3.*)H)  is  complete.  Ogston  inoculated  eggs  with  cocci  fnxn  ' 
acute  abscess.  By  a  series  of  cultivations  he  obtained  the  «<« 
"  pure,"  and  with  these  he  successfully  inoculated  ftnim*!* 
Although  abscesses  were  the  usual  results,  well-marked  septi**** 
occurred  in  some  ca.<»es.  Cocci  were  then  found  in  tht  Uw* 
though  never  in  very  large  numbers. 

Further  proof  that  these  organisms  can  cause  suppuration  W 
been  given.  Similar  operations  were  performed  with  •ntii'f*'' 
precautions  on  both  eyes  of  each  of  a  series  of  rabbitji,  and 
in  each  animal  was  inoculated  with  [lyogenic  cocci,  chi* 
staphylococcus  pyog«!nes  aureus :  all  the  aseptic  eye*  healMi 
out  suppuration,  while  all  those  infected  suppurated  and 
destrovc<l,  except  some  in  which  the  operation  was  ijuite  supeffr'* 
(Knapp),     Upon    man    numerous    experiments   bave   bMii  v**' 


byiat^ 
deiiii| 


THE   VEGETABLE  PARASITES. 


369 


cultivations  of  staphylococci  have  been  inoculated  upon  the  cutis 
ind  have  leil  to  the  foriiifition  of  small  iiliscesses.  Similar  cultiva- 
tions have  beob  rubbt-iJ  into  the  normal  skin  of  the  arm,  and  have 
indncxMl  the  formation  of  numerous  impetiginous  pustules.  Boils — 
ud  in  one  case  a  large  carbuncle — have  been  pnjdiiced  in  a  similar 
manner.  Lastly,  the  subcutaneous  injection  of  these  organisms 
has  resulted  in  the  formation  of  abscesses  (p.  343). 

Under  ordinary  circumstances  pyogenic  cocci  can  enter  the 
skin  by  the  orifices  of  ducts  or  tlirotirrh  small  abrasions.  Impetigo 
results  if  they  gain  entrance  to  the  ducts  and  mnltiply  there  with- 
"iit  penetrating  the  true  skin.  If  the  cocci  reach  the  de[)ths  of  a 
li«ir-fi>llicle  or  sweat-gland,  their  action  is  more  vi<dcnt.  mid  tliey 
prixlnce  a  slough — a  boil  results.  When  the  cocci  actually  pene- 
trate the  cutis  vera  they  cause  an  abscess  of  the  skin. 

Ill  metastatic  pysemia  the  proof  is  not  ijuite  so  complete. 
Large  numbers  of  micrococci  are  found  in  the  secondary  foci.  It 
ha*,  moreover,  been  shown  that  the  unhealthiness  of  the  wound  is 
in  proportion  to  the  number  of  zooglnea-masses  on  its  surface,  and 
tbe  severity  of  the  disease  to  the  number  of  cocci  in  the  blood; 
"bilst  the  cocci  have  been  traced  from  the  wound  into  conuective- 
tiaue  interspaces,  and  even  into  a  vein.  They  are  present  in  all 
clotii  undergoing  infective  softening.  On  the  other  hand,  large 
tiumbers  of  cocci  have  been  forind  in  the  blood  of  healthy  persons. 

Concerning  the  special  organism  present,  it  may  be  noted  that 
iMtnbach  examined  six  cases  of  metastatic  jiyfemia  and  found  the 
mtftococcux  pyogenes  in  five,  in  two  of  which  it  was  accompanied 
by  aainaller  number  of  the  ntaphylococcug  pyogenet  aureus.     In  one 

K— the  only  one  which  recovered — the  latter  coccus  occurred 
t. 
In  acute  osteomyelitis  Kosciibach  demonstrated  that  the  »ta- 
piyfocoetru*  pyogenes  aureus  was  present  in  the  great  majority  of 
■ssw;  and  he  was  further  able  to  support  Lccffler  in  his  statement 
'liat  the  same  organism,  when  injected  into  the  veins  of  aniiuals 
*no8e  bones  had  been  bruised  or  fractured,  caused  acute  osteo- 
li.vclitis;  and  this  whether  the  source  of  the  organism  employed 
*w  a  case  of  osteomyelitis  or  a  boil. 

Spreadingr  traumatic  eran&rene  often  seems  to  be  due  to  the 

'^^fptoeorcu*  pyoge-nes.     Ogston  found  that    injections  of  »tuphyln- 

fix-d  might  cause  similar  gangrene  of  tbe  skin  in  animals.      Koch 

mdaced  a  spreading  gangrene  in   rabbits  by  injections  of  a  little 

u 


870 


THE  VEGETABLE  PARASITES. 


putrid  blood,  and  in  bis  cases  only  ttreptoeoeei  developed.    In  I 
cases   of    stircadinjx    traumatic    eanei'cne    in    wbich    aubcutaneoi 


ompbyscma  was  u  iiiiirkeil  featiiif  Rosenbacii  found  a  b<ii-illu$.  vprr 
few  cocci  being  present. 

Lastly,  the  above  cocci  may  give  rise  to  inflammation  ttopyiM 
thort  of  suppuration,  the  streptococcus  being  associated  with  ihe 
more  dtffute  varieties.  Cocci  are  frequently  associated  with  inliani- 
niations  about  tlie  fauces,  even  without  the  presence  of  pus.  The 
evidence  we  have  of  tlie  infective  nature  of  papillary  and  ulcerstiie 
endocarditis  is  given  in  Chapter  XXVI. 

Ill  the  large  majority  of  cases  in  which  pyogenic  cocci  are  inlro- 
duced  into  the  tissues  only  local  results  follow.  In  the  presence* 
conditions  favorable  to  the  growth  of  the  organisms  they  tend  | 
spread.  With  especial  ease  they  are  carried  to  the  lymphatic  gl» 
There  they  becouie  arrested  luiil  give  rise  to  glanilulnr  iihscea 
Thence,  once  tii<tre.  their  progeny  and  their  products  are  distrilmM 
to  more  distant  parts — it  may  be  throughout  the  body.  SL«lt< 
has  drawn  a  jiaciillcl  between  this  process  and  that  wliiidi 
"tubercular"  infection.  As  the  latter  is  called  '■  tubercidmsis,"! 
suggests  that  the  process  we  are  now  considering  should  be  n«nitHl 
"  pyosis." 

Tfie  circumstances  under  which  these  very  different  results  fiill 
are  unknown.     The  probable  factors  have  been  already  discuwi^ 
(p.  340). 

Bryeipelas. — Micrococci  have  often  been  described  in  eryjip 
tous  skin.  es|it'cially  at  the  spreading  cdgi-.  They  occupy  the  Ij 
phatic  channels  and  spread  along  thetn.  hence  the  name — inf«t4 
cujiilliiry  lynij)!iiiiigitis.  Ortli  pmdiict'd  ty))ical  erysij>elas  in  » I 
lilt  by  subcutaut'utis  iiijection  of  the  tliiiti  ivum  an  erysi|K.'l«* 
bulla:  with  ccdema-fliiid  from  this  aniuiul  li«'  successfully  inociil*'" 
a  secontl:  the  fluid  and  affci-tcd  skin  cnntained  cocci  in  large  oo 
bers.  He  next  cultivated  the  fungus,  and  proiluceil  erysipelas  1 
injecting  it.  In  ISSl,  Fehleisen  fouml  chains  of  cocci  con.'tJ'i" ''.''' 
j)resent  in  pieces  of  skin  excised  from  the  /</>rcrt<//w</ <•</</(•  of «" 
erysipelas  rash.  The  cocci  filled  the  h/m/ifiatirfi  of  the  ftiprrifi^' 
part  of  the  corium,  like  an  injection-mass,  and  occasionally  extondi'^ 
to  the  subcutaneous  fatty  tissue,  but  were  tifver  found  in  tbr  hi""* 
vessels.  R(Mind-celleil  infiltration  and  dilated  blood-vessel."*  niar 
their  presence,  and  in  jiarls  where  the  inflammatory  zone  liad  '>'''■ 
ajipeared  the  cocci  had  vanished  also.     The  organisms  wrr*  c'' 


THE  VEGETABLE  PARASITES.  371 

sted  upon  gelatin  through  fourteen  generations  in  two  months :  eight 
ut  of  nine  rabbits,  subsequently  inoculated,  suflFered  from  the  dis- 
ise,  and  six  out  of  seven  inoculations  upon  man  were  equally  suc- 
essful.  The  incubation  was  fifteen  to  sixty  hours ;  then  followed 
igors,  fever,  and  typical  rash.  The  evidence  assigning  a  causal 
sintionship  to  the  streptococcus  is  therefore  complete.  Immunity, 
'  conferred  at  all,  did  not  last  two  months.  Three  per  cent,  solu- 
OD  of  carbolic  acid  or  one  per  thousand  of  mercuric  chloride  suf- 
ced  to  destroy  the  vitality  of  the  fungus. 

Fchleisen  stated  that  the  gtreptofovauis  ciyHipelath  presented  dis- 
ncf,  though  slight,  difiFerences  from  the  streptococcus  pyogenes, 
Q(l  that  it  never  caused  suppuration ;  if  ab.scess  occurred  with 
rysipelas,  it  was  due  to  a  mixed  infection.  The  majority  of  recent 
riters  upon  the  (juestion  have  failed  to  detect  either  morphological 
r  phygiological  differences,  and  many  are  therefore  inclined  to  think 
lat  the  two  organisms  are  identical,  and  that  the  point  of  inocula- 
on,  attenuation  of  the  virus,  and  similar  conditions  must  determine 
hether  erysipelas  or  diffuse  subcutaneous  suppuration  shall  occur 
I  any  given  case.  The  clinical  differences  between  the  two  diseases 
nuld  seem  to  warrant  hesitation  in  accepting  this  view  until  it  has 
■en  proved  that  the  streptococcus  erysipelatis,  taken  from  a  case  of 
I'loubted  erysipelas,  can  cause  diffuse  suppuration,  and,  on  the  other 
md,  that  the  streptococcus  pyogenes  from  an  acute  abscess  can 
verise  to  erysipelas.  No  case  of  erysipelas  from  inoculation  of  a 
'und  with  pus  containing  streptococci  seems  to  have  been  recorded. 
Oonorrhoea. — Neisser  in  1878  discovered  in  the  urethral  pus  a 
ge  micrococcus  (gonocoecug.  Fig.  124)  peculiar  to  this  disease. 
-  recognized  it  by  "  facets  "  or  flattenings  on  the  surface  in  con- 
■t,  such  a-s  are  now  known  to  occur  in  other  rapidly-multiplying 
-ci.  It  is  distinguished  from  ordinary  cocci  by  its  size;  by  the 
istant  interval,  about  equal  to  the  diameter  of  the  coccus,  between 
'individuals  in  the  groups;  and  by  the  frequency  of  its  occurrence 
n  and  in  the  pus-cells.  Neisser  considered  its  presence  a  means 
diagnosing  gonorrhoeal  from  other  discharges.  It  was  subse- 
mtly  shown  that  the  separation  of  the  cocci  is  due  to  swelling 
their  capsules.  It  multiplies  by  fission  in  two  planes  alternately, 
the  first  stage  it  is  a  diplococcus,  each  coccus  having  a  bean-shaped 
line.  In  the  next  stage  each  "  bean  "  subdivides  and  a  tetra- 
CU8  is  formed.  The  number  of  cells  affected  is  always  relatively 
dl,  and  varies  in  different  cases.     The  coccus  is  cultivated  with 


372 


THE  VEOETAHLE  PARASITES. 


luiK'li  difficulty.  Cultures  were  first  carried  out  succeMfuIW  bv 
Bockiiunlt.  Tliix  iiivt'stif^iitor  injcotfil  u  "•' fourth  "  cultivatiou  iuto 
the  urt'tlini  <ii'  a  <;fiifral  [)itrnl_vlic  and  produced  ii  purulent  di:^ 
charge.  The  uiuu  died  of  piieunioiiiu  teii  days  later,  and  an  exuni- 
natioii  of  the  iirctiira  led  Bockliiirdt  in  believe  that  the  cocci  |irob»- 
bly  pass  throiigh  the  epithelium  into  the  lymphaticii  of  the  fossa 
navicularis.  wlierc  they  excite  acute  inflammation.  They  enter  into 
white  corjjuscles,  and  either  pass  with  them  into  hlood-vessel.H.  where 
they  die,  or  they  come  iiway  in  the  pus. 

Since  then  Bumiii  has  succeeded  in  cultivating  the  gonococcu* 
upon  solidified  blood-serum :  he  inoculated  a  second  and  a  twcutietb 
culture  upon  the  fcnuile  urethra,  ciiusing  tyj)ical  gonnrrhira  in  each 
of  the  two  cases.  The  proof  of  causation,  thus  placed  beyond  dftiiljt, 
was  diflicult  to  obtain,  as  no  animal  is  snsceptible  to  the  diBea'f. 

With  regard  to  complications:  the  occurrence  of  suppuniti'* 
lymphadenitis  (bubo),  which  is  unusual  in  gonorrhcca.  is  s«i<l  i"  '•<? 
due  to  infection  of  the  gland  by  ordinary  pyogenic  orgnnisim,  the 
urethra  in  these  caaes  being  the  seat  of  a  mixed  infection.    Th( 

Flo.  124. 


GonococcI  from  urolhinl  jnia :  the  I'm-cl  arr  111  the  pii»-ofll».    There  »rs  Iw"  ' 
two  (Ingle  uoccl;  the  rent  are  UipUiroori.    The  three  ceUii  ahown  are  kll  of  Ui*  I 
cleated  variety. 

gonococcus,  injected  into  subcutaneous  tissue,  does  not  c»nae  0**"" 
ration,  but  disa|)[pears  in  twenty-four  to  thirty-si.K  hours. 

The  evidence  as  to  the  presence  of  the  gonococcus  in  joints 
are  the  seats  of  gonorrhoea!  arthritis  is  contradictory :  perbaj'-"' 


THE  VEGETABLE  PARASITES. 


373 


r    tbritis  also  is  the  result  of  a  mixed  infection,  but  we  may  note  that 

I      it  is  quite  unusual  for  goiinrrlia'iil  joiut.s  to  suppurate. 

1        The  gonococcus  is  infapiiljlf  of  multiplying  external  to  the  body, 

I     except  under  the  very  special  conditions  of  a  culture.     Its  resisting 

I     |iu«er  is  feeble,  and  it  soon  perishes.     If  thi.s  wore  not  so,  consider- 

L^  ijigtbe  great  frequency  of  the  disease,  infection  otherwise  than  by 

HI  tontaot  would  almost  certainly  occur. 

W      Pneumonia   (see   Chapter  XXXI.). — The   production   of  acute 

m     pneumonia  has  been  attributed  to  two  distinct  organisms.     (1)  The 

I     first — known  as  Friedliiuder's  pneumococcus,  though,  strictly  speak- 

■  ing.  it  is  a  microbacteriuin — was  discovered  by  that  observer  in 
^■l168'2.  lie  found  groat  numbers  of  these  organisms  in  the  early 
^BStage<i  of  pneumonia,  not  only  in  the  e.xudation.  but  also  in  the 
V  lymphatics  of  the  lung  and  in  the  tluid  of  any  pleurisy  or  pericar- 
^Lditis  tthich  was  present.  These  cocci  are  oval  or  rod-shaped;  they 
^■irc  contained  in  oval  or  elliptical  capsules  with  rouniled  enils. 
I  Two,  four,  or  even  more  cocci  may  be  found  in  these  capsules.  The 
I  capsiilt'  is  ili.s.solved  by  alkalies  and  by  water  ;  is  contracted  by  acetic 
I  aciij  (liku  mucin);  is  present  only  in  the  lung;  is  scarcely  or  not  at 
I  "11  (levelope<l  in  cultures;  and  is  best  stained  in  cover-gla.ss  prep- 
I  stations  by  immersion  for  two  to  three  minutes  in  a  solution  of 
I  ?<"itian  violet  in  aniline-water,  followed  by  treatment  with  alcohol 
I    "'f  lialf  a  minute. 

I        Friedlander  subsequently  stated  that  he  had  cultivated  the  coccus 

I    '^  blood-serum  and  gehitinized  meat-iiifusinn  and  on  potato.      Intro- 

'  **"eed  by  needle-puncture  into  tiie  two  foraier  siib.strata,  the  growth 

'*»kes  the  very  characteristic  form  of  a  round-headed  nail ;  on  the 

L  «att«.r  ground   it  forms  grayish   drops.      Diffused  in  distilled  water 

'    '"1  injected  into  the  lung  and  pleura  of  rabbits,  the  organisms  pro- 

^'^cod  no  eftects,  but  of  thirty-two  mice  inocidated  all  died  in  less 

"*ii  twenty-four  hours.     The  lungs  were  very  red  and  almost  uni- 

'**^allv  stdid,  and  the  spleen  was  en  larked;  both  orgiitis  contained 

■  '*■  characteristic  cocci,  whicii  were  also  present  in  cnnsiderable 
'•ttibers  in  the  blood  and  in  enormous  numbers  in  some  Huid  which 
*^*-»ipied  the  pleura.  Guinea-pigs  were  more  ri'fraetory  to  the  poi- 
"**».  ami  out  of  five  dogs  only  one  suffered. 

^ianmgarten   is   strongly  of  opinion   that   tliis   parasite  lins  no 

VTitMiiiionia-exciting  action  in  num.  but  tliat  it  enters  the  pneumonic 

V^tcli  from   the  upper  air-tubes  or  pharynx   and  multiplies   in  the 

^t^flamed  tissue.     For  it  seems  that  apparently  identical  "  capsule- 


374 


THE   VEGETABLE  PARASITES. 


Flfi.  125. 


cocci  "  are  not  uncommonly  to  be  uict  with  in  pus,  in  the  epitLelmm 
of  the  mouth,  in  sputum,  or  in  the  secretion  of"  uasal  catnrrh  m 
Otherwise  healthy  men.  A  still  more  serious  objection  lies  in  tbr 
fact  that  other  ob-scrvers  have  not  been  able  to  demonstriitc  tlii- 
organism  with  the  constancy  of  which  Friedliinder  spoke  The 
stroniffgt  objection,  however,  seems  to  be  that  the  cocci  found  »iiil 
the  cncci  cultivated  are  not  identical;  for  Friedliinder  considfird 
that  his  coccus  retained  the  aniline  stain  when  treated  with  Oruin'* 
iodine  solution,  whereas  the  coccus  which  he  cidtivated  is  ilecoliir- 
ized  by  this  treatment.  The  cocci  which  remained  staine<l  in  *k- 
tions  of  pneinnnnie  lung  prepared  aecordinj;  to  Gram's  methoii  wi'W 
therefore  not  the  cocci  Friuilliiiider  cultivated,  but  were  prolmlilt 
those  subsei]uentl3'  demonstrated  by  A.  Frnnkel  and  Weichseibttniiu 
to  the  description  of  which  we  now  pass. 

(2)  Friinkel  and  Weichselbauni  independently  demonstrateii  ihf 
presence  in  pneumonic  lungs  of  another  organism — the  pneumo- 

COCCU8  (or  diplococcusj  pneamo- 
nisB.     This  consists  in  cultiirf.'>  I'f 
round  or  oval  cells,  usually  in  p»i'*< 
but  often  in  chains  of  four  to  ten. 
or  even  twenty  to    thirty.    Thw*^ 
longer  chains  are  much  straiplitf' 
than  those  of  ordinary  streptococci 
(Weichselbauni).       In    the    tissu<?* 
the  microbes  often   become  lanf*' 
shaped,  and  their  pointed  ends  a»*3 
be  tfiw  ard  or  away  from  each  oth*'' 
usually    the    latter.       These  cO*** 
have     capsules    just     like    Fri^*^' 
liinder's,   and    they   may    be  si*** 
larly    stained.        They    retain     ^^ 
avilhie      »tam     when     treated       ^^ 
Grnmn  method.     Kruse  and  I*^^*^ 
sini    insist    on    the    variability      •^ 
form.     They  describe  no  less  than  thirty  varieties.     Wherciw  Fri*'^ 
lander's  coccus  can  be  reaflily  cultivated  on   gelatin    at  70"    *''^ 
Frankcl's  is  best  grown  on  agar  at  a  temperature  of  95°  F.  to  9^-** 
F..  and  tin-  .Mnutb  is  scanty  and  not  nail-shaped,  but  of  charac*^'* 
istic  *'de>  form.     "When  the  organism  is  grown  on  gel»**** 

tiii.s  medii""  c6eil.     In  many  of  its  character*  it  tb"** 


niplnooopl  r>Mciiiui>iilii'.  (■ntnuKli-il  In 
the*  iiieRhfH  of  Ihf  hliriiiouH  exudation 
ffW>ni  a  wrtinn  of  liinji  in  tlu*  red  hofi«- 
tlKHtion  BtsKi'  of  iiriito  iint'iimonln).  In 
the  iipptT  pMii  iif  the  (ieid  1r  a  cell  er>n- 
lalnlng  several  cocci — pueHllily  a  [itiagu- 
cyte.    X  icon. 


THE  VEGETABLE  PARASITES.  375 

obles  the  streptococcus   pyogenes.     The  substratum  must  be 

slightly  alkaline  or  growth  ceases.  Even  when  transferred 
•  from  tube  to  tube,  the  diplococcus  rapidly  loses  its  virulence 
assumes  the  streptococcus  form :  to  preserve  or  to  restore  its 
jgenic  power  an  occasional  inoculation  upon  a ,  susceptible 
al  must  be  resorted  to.     Cultivation  for  one  to  two  days  at 

F.  destroys  the  virulence ;  it  is  weakened  by  longer  culture 
ightly  lower  temperatures. 

ibcufaneous  injections  of  virus  of  full  intensity  into  rabbits, 
,  and  guinea-pigs  cause  an  acute,  generally  fatal,  illness,  like 
csemia,  with  characteristic  post-mortem  appearances ;  but  there 

sign  of  pneumonia.  An  attenuated  culture  introduced  beneath 
ikin  does  sometimes  give  rise  to  pleurisy  or  pneumonia,  or  both, 
these  results  are  usually  after  injection  of  such  a  culture  into 
lungs.  Then  the  appearances  usually  very  closely  resemble 
J  in  pneumonia  and  pleurisy  in  man,  and  the  exudation  con- 
i  large  numbers  of  encapsuled  cocci.  Pericarditis  also  may 
e. 

le  inoculation  either  of  filtered  cultures  of  the  organism  or  of 
lerum  of  animals  vaccinated  with  them  is  in  each  case  said  to 
;r  a  temporary  immunity.  Issaeff  asserts  that  the  cocci  thrive 
Itures  treated  with  the  "immunized  serum  " — a  result  altogether 
rary  to  that  obtained  under  similar  conditions  in  tetanus  (p. 
Sputum  before  the  "crisis"  is  virulent,  but  sputum  after 
'  crisis "  is  said  to  confer  immunity. 

lumgarten  believes  that  this  coccus  may  be  regarded  as  con- 
ly  present,  for,  though  Weichselbaum  found  it  in  only  92  per 

of  a  large  number  of  cases,  his  method  of  examination  ren- 
l  it  possible  to  miss  the  coccus ;  and  if  it  really  waa  absent  in 
cases,  it  might  have  been  dead  at  the  time  the  cases  were 
lined,  for,  as  in  cultures,  so  probably  in  the  body,  the  diplo- 
18  pneumoniae  has  but  a  short  life.  These  cocci  occur  in  suf- 
it  numbers  to  account  for  the  symptoms, 
sides  being  present  in  pneumonic  lung,  it  is  occasionally  foond 
le  blood  (sparingly)  and  spleen  and  in  inflammations  arising 
pendently  or  during  the  course  of  pneumonia — plenrisy, 
ircma,  meningitis,   endocarditis,   peritonitis,   and  otitiB  media. 

it  appears  to  be  an  oeeasional  denizen  of  the  month,  also 
rring  in  the  saliva  and  in  the  middle  ear  of  bealthy  people, 
t  suggests  that  it  is  only  an  accidental  parasite  in  pnenmonia. 


376 


THE   VEGETABLE  PARASITES. 


Against  this  view  the  following  points  seem  to  tell :  Ita  incon 
in  the  mouth ;  its  constant  occurrence  in  fineumonic  lung,  som? 
times  as  the  ro/c  lifnioiintni/iff  iirijnnisiH  ;  its  distributiou  not 
uniform  in  the  inflamed  area,  but  chiefly  at  the  Hpreadiug  «lge 
and  in  tlio  »iirrouii<ling  (eilenui.  rneomonia  does  not  follow  inwy 
ulation  unless  the  parasite  is  loejilizeil  in  the  lung.  Salvioli  !*» 
that  he  succeeded  in  inducing  lobar  ])neumonia  in  guinea-j)ip  br 
intratracheal  injection  of  pneumonic  exudation  containing  tliwe 
cocci ;  but  Fatichi  I'ailed  with  rabbits.  Further  e.xpfrimontJ  of 
this  kind  arc  required,  for  there  is  every  reason  to  believe  tbil  n 
man  infection  occurs  through  the  long,  though  in  some  ciwi-s  ihc 
disease  in  thi.s  organ  may  be  .secondary,  or.  at  any  rate.  merclv»n« 
of  several  morbid  changes. 

When  pneumonia  runs  on  to  suppuration  and  gangrene,  lb«f 
complications  are  possibly  due  to  a  secondary  infection  by  the 
staphylncDcctis  pyogenes  aureus  or  streptococcus  jtyogenes.  fLougt 
pyogenic  effects  have  been  attributed  to  the  unaiiled  pneuniococcuj- 


Micrococci  have  been  described  in  meatleg,  vaccinia,  rariola^^li^- 
demic  cerehro-apinal  mcniiujitiit,  typhun  fever,  acutr  yellow  atrofhji 
of  the  /(Vcr  (early  stage),  whoopini/  cnnqlt,  di/xniteni,  fat-vn'rntiit.iw 
many  other  diseases,  but  the  evidence  in  favor  of  their  wi 
relationship  to  the  respective  diseases  is  not  sufficient  to  jiisti^ 
description  of  them  here. 

A  micrococcus  which  divides  in  tijree  diameters  at  right  snglw' 
each  other — Sarcina — is  often  fijiind  in  vomit  from  stomachs  ililatf"! 
from  pyloric  obstruction  and  in  cases  of  dyspepsia  from  chr 
catarrh  {Surclna  reiitricitH) ;   in  the  bronchi  and  deeper  parts  oft 
lungs  in   phthisis  (Sarrina  pii/iHi)niiiii);  and  in  the  urine  (>'<»''" 
urina) :   it  has  been  seen  also  in  abscesses  and  in  blood.    Sin 
cocci  may  be  seen,  but   the  majority  form  cubical  groups  of  four ( 
some  multiple  of  fViur  (Fig.  121).     S.  ventriculi  (2.5  /i)  i.«  Urj 
than  S.  urinw,  or  than  the  fungus  of  this  shape  occurring  in 
lungs  (1  ft  to  1..')  fi).     iSarcinse  may  occur  in  the  stomach  wid" 
appearing  in  the  urine  or  elsewhere.     It  is  extremely  difficult  to  j 
rid  of  the  fungus  when  it  is  once  establisheil.     The  nature  of  I 
decomposition  to  which  it  gives  rise  is  unknowo. 

MICROBACTERIA. — This  group  contains  no  organism  pa<* 
genie  in  man, 


THE  VEGETABLE  PARASITES. 


377 


DESMOBACTERIA. — The  members  of  this  group  are  sleudcr 
frxb,  of  which  the  leugth  is  generally  much  uinri:'  tli:>n  tAvice  tlio 
ireadtb.  Thi-y  multiply  by  tninsverse  division,  anil  oftcQ  grow  into 
^ng,  jointed,  but  nnbrttnehe<i  filameuts,  without  constrictions  at  tho 
lointii.  Formation  of  spores  bus  been  detected  in  some  species. 
Ill  the  pathogenic  organisms  in  this  group)  arc  straiglvt:  they  are 
Down  as  bacilli. 

The  Bacilli  of  Tubercle,  Leprosy,  Syphilis,  Glanders,  and 
liinoecleroina  are  described  iu  the  chapter  on  the  "  Infective 
iTiDulomata," 

Splenic  Fever. — The  B,  anthraci»,  found  in  tins  tiisease.  is  the 
let  known  of  all  parasitic  fungi.      Its  life-history  was  worked  out 

Kli.  In  blood  from  the  s|ileen  of  nniniiils.  deail  of  splenic 
e  found  enormous  numbers  of  rods  ;V-2il  //  long  by  aljouf  1 
.  They  have  slightly  concave  ends,  are  straight  and  niotton- 
Bs  (Fig.  121).  In  a  suitable  culture-material,  such  as  the  blood 
I  the  ilcad  animal,  with  a  plentiful  supply  of  oxygen  and  a  temper- 
iure  between  60°  and  10"'^  F.  (77°  to  S7°  F.  being  most  favorable), 
I*  rods  grow  into  very  long  interlacing  filaments  often  groujied  into 
WiTolutcd  bundles.  (See  Frontispiece.)  In  these  filaments  round, 
Ighly  refracting  spores  form  at  short  and  regular  distances;  the 
icilli  now  break  up  and  the  spores  are  set  free.  Under  favorable 
fcumstances  these  grow  into  bacilli.  In  living  animals  long  iila- 
^Vand  spores  are  never  found,  the  rods  multiplying  solely  by 
Pmon.  The  rods  exist  in  enormous  numbers  in  the  cn))illarics, 
>p«cially  those  of  the  spleen,  lungs,  liver,  kidneys,  and  mucous 
*nibraue  of  the  intestine  (Fig.  117).  Numbers  leave  the  body  in 
w  urine,  fjecos,  and  blood  flowing  from  the  nose  anti  mouth  of  the 
Mnjal  before  it  dies ;  thus  the  ground  in  its  neighborfiood  is 
■Vered  with  the  fungi.  In  bodies  buried  at  the  depth  of  one  metre, 
l*re  there  is  neither  oxygen  nor  a  suitable  temperature,  no  de- 
lopment  of  spores  occurs  and  the  bacilli  soon  die.  As  to  the  mode 
'octioii  :  I'asteur  says  that  the  mouths  of  unimals  :ire  wounded 
sous  grasses,  and  believes  that  the  cuts  thus  made  ore  inoeu- 
with  bacilli  or  spores.     This  view  is  supported  by  the  fre(|uent 

Rof  the  cervical  glamls  in  sheep,  Init  both  these  animals  and 
frcf^uently  infected  by  insects  which  bite  men  on  the  face, 
inks  the  intestine  is  the  commonest  seat  of  infection.    Klein. 
i*cver,  records   a  case  in  which  one   mouse  ate,  without   any  ill 
t8,  most  of  another  that  had  died  of  splenic  fever.     Iu  warm, 


THE  VHOETABLK  PAKAStTES. 


iiiarsh V  districts  the  bacilli  form  sjiorett  plentifully ;  thcw;  are  ( 
by   floods    to   meadows    where    iiiithrax    Duiy   not    bttve    prcT 

OCCIUTimI. 

[n  uiuii  uHlignant  pustule  is  due  to  inoculation  with  (kt  & 
authnicis;  and  peiienilly.  in  England,  from  wwjI  or  liiilee  linmrit 
from  countries  where  the  discnise  Ik  endemic.  Some  time  after  ihf 
a|)pearance  of  the  pustule  generol  symptnnis  a[i()«nr,  bronehitimr 
diarrhoea  being  common.  Duvies-Colley  found  numcrou*  bacilli  lo 
serum  pressed  from  sm  excised  pustule  and  in  the  spntuni.  aniir. 
f«ccs.  and  sweat.  Tlie  patient  recovered,  but.  though  free  frm 
symptoms,  he  was  still  eliminating  in  his  urine  a  few  bacilli  a  noDtk 
after  excision  of  the  pustule.  In  some  cases  there  is  no  <>u|>fHii'i>l 
lesion,  and  the  symptoms  may  be  those  of  acute  septic  iKUsouin^ nr 
be  chiefly  |>ulmonary  or  intestinal  (woolsorter'a  disease).  I'rrfaif* 
the  predominant  symptoms  indicate  the  mucous  membrane  tbroof^ 
which  infection  has  taken  place  (p.  ;{.'{;)).  'f  he  pn>ducts  of  tie 
anthrax  bacillus  are  shown  in  the  table  on  p.  889.  Other  £wi* 
regarding  the  R.  anthracis  are  given  in  the  early  part  of  the  pmrtt 
chapter. 

B.  anthracis  is  constantly  present  in  splenic  fever,  and  nltim«i'l; 
in  enormous  numbers.  The  blood  of  a  ftetus  in  an  animal  "ii^ 
splenic  fever  contains  no  organisms,  and  iloes  not  produce  ib« 'U*- 
ease,  whilst  blood  containing  spores  or  bacilli  capable  of  d«?»rl'i|>' 
ment  always  does  so  in  suitable  animals.  The  bacilli  may  beM{*- 
rated  by  filtration,  washed  with  distilled  wiiter,  alcohol,  iil^ 
then  ilried,  but,  notwithstanding  all  this,  they  can  still  caii"  ■; 
fever.  Pure  cultivations  may  be  niaile  through  fifty  geiieratwi* 
with  the  same  result.  They  never  give  rise  to  any  other  dl"***'- 
If  this  is  not  proof  that  B.  anthracis  is  the  ritutt  of  splenic  ferttj 
the  belief  that  itch  is  due  to  the  acarns  scabiei  or  that  trichii 
line  to  frichiuie  must  also  be  regarded  as  ill-founded. 

By  cultivating  B.  anthracis  for  twenty  days  ut  107°  to  V 
and  using  the  vaccine  for   rcpeatcil  inoculations   upon  sbwp' 
cattle.  I'asteur  rentlere<l  these  immune  to  the  spontane«>it> 
and  to  the  action  of  the  virulent   virus,     .\fter  much  contni' 
the  possibility  of  this  "  attenuation  "  has  been   fully  e»tabl 
there  is,  however,  still  some  doubt  as  to  the  valne  of  vorcti 
against   splenic  fever;    Koch,  for  instance,  maintaining  that 
of  any  use  the  vaccine  must  be  so  strong  that  «»me  anim; 
perlitt|ta  very  many,  will  die  of  the  disea.se  induced.     The  all 


THE  VEGETABLE  PARASITES.  379 

tion  of  anthrax  bacilli  has  been  brought  about  in  other  ways — by 
cultivation  in  air  under  a  pressure  of  eight  atmospheres,  by  the 
iddition  of  small  quantities  of  antiseptics  to  the  substratum,  or  by 
the  passage  of  the  organisms  through  the  bodies  of  certain  animals. 
Klein  failed  with  Pasteur's  vaccine  to  protect  rodents ;  they  seemed  to 
hare  no  immunity :  if  the  vaccine  acted  at  all,  it  caused  splenic  fever. 

The  attenuation  is  not  accompanied  by  any  morphological  change ;. 
the  virus  "breeds  true,"  and  its  virulence  may  be  restored  at  any 
time. 

Typhoid  Fever. — Klebs,  Eberth,  Koch,  and  Meyer  were  the  first 
to  describe  organisms  in  this  disease.  These  organisms  were  figured 
u  small  bacilli  with  rounded  ends.  They  were  found  in  the  intes- 
tinal lesions,  mesenteric  glands,  and  spleen.  They  were  most 
Damerous,  and  therefore  easiest  to  find,  during  the  first  and  second 
»eek8  of  the  disease.  They  stained  badly  with  aniline  dyes,  and 
for  a  time  these  observers  worked  with  unstained  specimens  clarified 
by  an  alkali.  Eberth  was  thus  able  to  discover  the  bacilli  in  eigh- 
teen out  of  forty  cases.  Koch  succeeded  in  staining  the  organisms 
with  Bismarck  brown,  and  demonstrated  their  presence  in  half  the 
CMes  examined  by  him. 

All  these  observers  made  control-observations  on  other  cases,  such 
u  tubercular  ulceration  of  the  intestine,  but  they  never  found  the 
typhoid  bacillus  in  diseases  other  than  typhoid  fever.  They  some- 
times found  cocci  in  the  intestines  and  glands,  but  regarded  these  as 
secondary. 

A  very  important  paper  by  Gaffky  appeared  in  1884.  He  started 
»ith  the  observation  that  the  bacilli  had  been  found  in  only  half  the 
'Mes  examined.  They  must  therefore  have  either  disappeared  be- 
fore the  disease  which  they  caused  had  run  its  course,  or  else  they 
'«e  present,  but  not  found.  The  latter  alternative  seemed  prob- 
*We,  as  they  had  been  demonstrated  in  late  stages  in  some  cases 
•"d  missed  at  early  stages  in  others.  He  pointed  out  that  in 
typhoid  fever  the  bacilli  are  not  scattered  everywhere,  but  are 
'Iwayg  in  foci,  and  therefore  more  difiicult  to  find. 

Gaffky  himself  investigated  twenty-eight  cases,  and  in  twenty-six 
'eoionstrated  the  presence  of  bacilli  in  parts  other  than  the  intes- 
''De,  such  as  the  mesenteric  glands,  spleen,  liver,  or  kidney.  In  one 
'f  the  other  two  cases  the  bacilli  were  found  in  a  recently  swollen, 
"^'itary  follicle,  and  in  the  second  the  intestines  showed  only  healing 
■'cers. 


THE  VEGETABLE  PARASITES. 


Ill  one  cs8e,  which  Gaffkj  doeH  not  inclinU'  in  his  Htit.  althuu^iit 
had   bcoQ  diagnosed  -ah  typhoid  fever  buth  during  life  and  at  tti« 
post-mortem  examination,   immense  niimhers  of   cocei   «rcr«  fbikl 
in   the  organs,   and  it    wan   impottAiblc  t«i  disitingiiiith  the  tTj 
bacilli.     Gaffky  tiirows  mit    the   suggestion   that    thrn-  m»\ 
disease  clinically  like  typhoid   fever  due  tn  in\nsii>ii   of  tlir 
tine  by  cocci. 

The  earlier  the  ease  the  more  numerous  are  the  haeilli.     If 
aw  found  in  old  eases,  it  is  j>ndjalde  that  a  relap.^e  ha«  occum* 

Since  that  time  many  other  observations  have  been  pabli 
The  following  is  a  summary  of  the  results  arrived  at :  The  li 
can,  with  some  diffieulty,  be  found  during  life  in  the  fjpccd. »] 
(obtained  by  {>uneture),  and  urine.  After  death,  if  the  part* 
removed  without  any  delay,  the  organisms  can  bo  cAsily  diiw 
in  the  intestines,  spleen,  liver,  mesenteric  glands,  and  kiili 
They  occur  in  groups,  but  do  not  give  rise  to  "tubercles."  Tbai 
presence  can  be  more  readily  ascertained  by  inornlating  a  ci 
ground  with  a  piece  of  the  suspected  organ  than  by  cxaminliw 
atained  sections  under  the  microscope.  They  stain  slowU  w^ 
part  with  the  color  easily.  The  best  stains  are  probably  Ii<ill0' 
methyhme  blue  (p.  384)  and  Ziehl's  fachsine  stain  (p.  3.10).  Tk* 
bacilli  will  not  retain  the  color  when  treated  by  (iraw'.'i  mrlfc*' 
(p.  .-UO). 

In  ap|>earanee  typhoid  bacilli  are  not  unlike  tubercle  bacilli.   Tbrif 
breadth  is  abnut  a  third  of  their  length,  which  varii-s  betwefii  i  " 
and  3  ft.      Thns  they  are  a  trifle  thicker  than  tubercle  bacilli.  »l"i«' 
tlieir  ends  are  distinctly   rounded.      Clear  spacea  often  <»ccnjij  ih* 
centre  of  the  rods.      There  is  some  doubt   as  to  the  exii«ten( 
spores.     Those  who   believe    in    their    existence    describe  lb 
rounded  bodies,  reaching  right  across  the  breadth  of  the  ro<l» 
lying  at  their  ends.     The   chief  microscopic    feature!*    nhirh 
tinguish   tyj>hoi<l  from  tubercle  bacilli  are  the  possession  «»f  flap'l'*' 
the  power  of  active  movement,  and  some  of  the  staining  reartio"*- 
A  typhoid    bacillns    when    stained    by    Locfller's    method    afp*'* 
enveloped  by  a  thick   capsule.     In   intimate  connection  wiili  •*•** 
capsule,    ap|>arently    composed    of    the    same    substance,   and  '»'*'' 
triboted  over  its  whole  surface,  arc  the  llagella,  eight  to  t*eb«  '* 
number,  varying  mu<'li  in  li-ngfli  and  thickness.     Sometime*  ^f 
are   considerably   longer    than    the    parasite    itself.      Some  ci  '■' 
bacilli  are  said  to  have  only  a  single  flagellum  at  one  rktl 


THE  VEGETABLE  PARASITES.  381 

Caltares  can  be  readily  obtained.  The  organism  thrives  in  milk, 
and  can  even  multiply  for  a  time  in  sterilized  drinking-water — 
points  of  practical  importance.  It  does  not  liquefy  peptonized 
gelatin,  but  produces  in  it  roundish,  slightly  granular,  yellow-brown 
colonies.  It  is  mainly  aerobic.  Potato-cultures  of  this  bacillus  are 
almost  invisible :  this  fact  is  utilized  in  the  recognition  of  this 
organism.  Thus,  if  a  fresh  potato-culture  be  incubated  for  forty- 
eight  hours,  no  visible  change  occurs,  but  if  surface-scrapings  be 
then  taken,  stained,  and  examined,  threads  of  the  bacilli  will  be 
easily  found.  Other  methods,  none  of  which  are  absolutely  cha- 
racteristic, have  been  devised  to  meet  the  same  diflficulty.  Singly, 
each  is  of  little  value ;  taken  together,  they  are  practically  sufficient 
for  the  purpose  of  identification.  Thus,  acid  products,  but  no 
indol,  are  formed  in  bouillon-cultures,  while  most  bacilli,  occurring 
nnder  the  same  conditions,  form  indol.  Another  suggested  test 
depends  on  the  tendency  which  this  organism  possesses  of  absorbing 
the  color  when  cultivated  on  a  gelatin  medium  stained  with  gentian 
violet,  thus  leaving  the  gelatin  colorless.  Still  another  is  founded 
on  a  slight  indifference  which  some  organisms  show  to  the  action  of 
carbolic  acid.  Thus,  if  a  minute  quantity  of  carbolic  acid  (2.5  per 
1000)  be  added  to  a  culture  of  mixed  organisms,  the  growth  of 
most  Till  be  arrested,  but  that  of  typhoid  and  a  few  others  will  con- 
tinue. 

According  to  Sternberg,  ten  minutes'  exposure  to  moist  heat  at 
140°  F.  destroys  typhoid  bacilli :  others  give  the  boiling-point  as 
the  fetal  limit,  and  state  that  "  spores  "  will  survive  a  temperature 
of  194°  F.  Brieger  has  separated  from  cultures  some  fatty  acids 
»nd  a  poisonous  basic  substance  which  he  names  "  typhotoxin." 

Inoculation  has  hitherto  been  only  partially  successful.  It  is 
<loubtfnl  if  any  animal  is  susceptible  to  typhoid  fever  as  we  know 
It  in  man.  Rabbits,  dogs,  and  mice  have  been  inoculated,  and  have 
died  in  thirty-six  hours  with  symptoms  of  general  septicaemia ;  but, 
•hoogh  enlarged  spleens  and  swollen  Peyer's  patches  have  been  very 
gonerally  found,  the  disease  never  runs  a  longer  course,  nor  is  there 
ever  any  characteristic  ulceration.  Furthermore,  almost  precisely 
"ailar  results  have  been  obtained  by  injecting  either  the  filtered 
products  of  the  organism  or  the  typhotoxin  itself  In  spite  of  this 
8*P  in  the  chain  of  evidence,  all  the  observers  quoted  believe  that 
this  bacillus  is  the  cause  of  typhoid,  and  we  may,  at  any  rate,  affirm 
that  it  is  constantly  present  in  typhoid,  is  recognizable  from  all 


382 


rilK   VEGETABLE  PARASn'K& 


known  bacilli  by  tbo  various   cLarnctcristics   given   above,  ana 
not    found  in  any   otliiT    tiisease.     Uaffky  believes  that    infw 
always  occurs  through  the  mucous  lueuibranc  of  the  intestine : 
when  the  poison  seems  to  have  been  inhaled  as  dost,  be  thiuk»ittf 
caUjLrlit  on  the  mucous  membrane  of  the  pharynx,  swallow.  ' 
rie<l  through  the  stomach,  anil  thus  brought   into  contact  "m' 
bowel. 

Bacillus  Coli  Communis  (Hnctcriuni  c<ili  comn 
bacillus  is  a  coiiinion  lU-nizeti  nfilic  uiiinciitiirv  tract,  aii 
of  the  neighborhood  of  the  ciecuin.  It  is  nltw  found  in  the  DiootlL 
and  occa:<ionally  in  other  parts.  It  very  rarely  occurn  alone.  Insw. 
in  shape,  in  the  po».se»sion  of  flagella,  and  in  staining  reacti-'f^*  ''  • 
organism  very  closely'  resembles  flint  of  typhoid  fever.  Ai 
to  some  observers,  the  B.  coli  communis  has  fewer  flagella,  hut  iJi» 
supposed  peculiarity  is  certainly  not  constant.  There  is  a  lemlrDn 
for  the  bacilli  to  occur  in  pairs,  and.  when  cultivated,  in  tlwrt 
threads.  This  organism  probably  doea  not  form  Hporen.  It  i* 
mainly  aerobic,  and  seems  to  have  a  slight  power  of  activr  mort- 
nieiit.  Like  the  tyjihoid  bacillus  it  grows  best  in  acid  media.  It 
is  easily  cultivated,  but  the  results  are  not  sufficiently  distinctir 
be  of  much  diagnostic  value.  In  gelatin  tube-cullun-s  it 
the  form  of  an  irregularly  encrusted  stick,  with  small  oatgrov 
here  and  there,  but  without  tapering  in  either  direction. 

There  can  be  no  doubt,  on  the  niu-  hand,  that  this  organi^n  I'l 
in  perfectly  healthy   intestine,  nor  any  iloubt,  on  the  other,  tbrtj 
many  disca«!r<l  conditions  it   is  by   far  the  most   prevalent  of  I 
organisms  present,  and  occasionally,  perhaps,  the  only  one  that  i 
be  fouml.      Hence  it  seems  probable  either  that  other  barilli  i 
present  confounded  with   this  one,  or  that   this  is  subject  »•> 
great  variations  in  virnlvnce.     There  is  a  very  general  Wlwf  i 
at  any  rate,  the  latter  alternative  is  true,  though  the  cau»e  »f  I 
variation  is  i|uitc  unknown.      In   .some  states  the  orgBDi^m 
able  to  produce  a  condition  similar  to  scptiiwmta :  in  otb(t«.  i 
to  give  rise  to  local   irritatictn  and  sup[)unition.      Maraignr  is| 
opinion  that  this  organism  is  the  chief  causative  agent  in  the 
lowing  comprehensive  group  of  con<litions.     The  cviiiencc  on  ' 
be  ba.Hcs  this  opinion  will   be  found   in   his  very  interesting 
graph.'      In  no  case  does  the  evidence  amount  to  absolute  prouf* 

Qmerai    J}i»f(iiifg. — Clmlcra   nostras,  cludera    infantum, 
'  "  Ixi  Raclcrium  Coli  IV.minuiie,"  I'aria,  1892. 


THE  VEGETABLE  PARASITES.  383 

obscare  infective  febrile  disorders,  and  chronic  enteritis  with  marked 
wastiog. 

Local  Di»ease». — Dysentery,  ulceration  of  the  vermiform  appen- 
dix, pylephlebitis,  abscess  in  the  liver  or  gall-bladder,  and  peri- 
lonitis. 

It  has  been  suggested  that  the  bacillus  coli  communis  and  the 
rphoid  bacillus  are  identical.  Besides  the  points  of  similarity 
Iready  mentioned,  it  is  found  that  when  injected  into  the  veins  of 
ibbits  and  guinea-pigs  it  produces  a  fatal  disease  identical  with 
at  already  described  as  occurring  when  cultures  of  the  typhoid 
cillus  are  similarly  introduced. 

Diphtheria. — In  1888,  Klebs  drew  attention  to  a  bacillus  which 
had  found  constantly  present  in  diphtheritic  membrane.  In  the 
lowing  year  Loeffler  published  a  full  account  of  its  morphology 
d  cultivation,  together  with  results  obtained  by  inoculation, 
nee  that  time  many  workers  have  traversed  the  same  ground, 
d  the  main  facts  concerning  the  organism  have  thus  been  fully 
oved. 

The  bacillus  is  to  be  found  in  all  cases  both  of  diphtheria  and  of 
;mbranous  croup.  It  is  limited  to  the  false  membrane  and  its 
ighborhood,  and  grows  most  abundantly  in  the  more  superficial 
rts  of  the  membrane.  It  is  never  found  in  any  internal  organ, 
ough  its  presence  in  the  membrane  can  be  made  out  during  all 
Jges  of  the  disease,  while  the  examination  of  scrapings  from  the 
ucoas  surface  of  the  mouth  shows  that  it  may  continue  to  live  a 
ecarions  existence  for  three  weeks  after  the  fever  has  disappeared. 
is  not  found  in  any  other  disease ;  at  least  such  is  the  conclusion 
the  vast  majority  of  competent  observers.  Bacilli  having  a  close 
Mphological  resemblance  to  it  seem  to  be  occasionally  present  in 
e  mouths  of  healthy  individuals,  as  well  as  organisms  giving  even 
esame  culture-results  as  the  diphtheria  bacillus,  but  not  possess- 
g  any  pathogenic  power.  These  may  be  attenuated  forms  of  the 
Jginal  bacillus.  Bacilli  taken  from  diphtheritic  membrane  can  be 
'hivated  through  many  generations,  and  after  an  interval  of  some 
onths  are  still  capable,  when  inoculated,  of  giving  rise  to  the 
•ginal  disease — not  merely  the  local  inflammation  and  membrane, 
'•  also  the  subsequent  paralysis. 

The  diphtheria  bacillus  is  generally  rather  shorter  and  thicker 
»n  the  tubercle  bacillus.  It  is  usually  from  1.6  fi  to  2.5  [x  long, 
id  about  a  third  as  broad.      Some  observers  have  accredited  it 


384 


THE   VEOKTARLE  P^iRASITES. 


Via.  126. 


Bacilluii  of  diphtheria 
(Ijt-IIUt.)  (From  a  iipcd- 
mcn  by  Dr.  Arklt.) 


witli  .1  U'li^rtli  iif  <!  //  to  S  ji,  hut  tliev  Liive  probalily  inclnJeil  nwre 
thun  one  iiidiviilual  in  tlieir  measurement.  Its  shape  is  not  bUih 
regular :  sometimes  tlie  ends  are  thicker  than  the  centre,  ami  M)nl^ 
times  the  cen^e  than  the  end-*.  The  l«iw 
are  roiiniled.  The  bacilli  not  infrecjiiciitlf 
contain  a  row  of  two  or  three  highly  refraiiioj! 
areas,  the  nature  of  which  is  unknown.  In 
all  ))rol)ability  they  are  not  spores.  The  w- 
ganisni  i.s  believed  to  multiply  bv  fission  oiik. 
It  never  forms  long  threads :  it  is  motionW 
LicHler's  iilkiiliiie  mefliylene-blue  soiutinn' 
gives  the  best  .staining  resiilt.s.  but  (inmit^ 
method  cau  also  be  employed.  ^| 

The    orgaui.sm    can    be   cultivated  in  msiif 
media.     It  <Ioes  not  liquefy  gelatin.     It  grows  well  in  milk,  bm  lit 
mo!»t  fre<(uently  employed  culture-ground  is  Ltcffler's  sernm.*  A 
minute  i)ortinn  of  membrane,  transferred  to  this,  will  develop  in  tli» 
four.sc  of  twenty-four  hours  small  gray  elevated  disks  with  paiecif- 
eumferences.     In  secondary  cultures  these  show  a  tendency  tolHtoiM 
arranged  in  lines.     (See  Frontispiece.)     Growth  can  take  pli 
any  temperature  between  70°  F.  and  108°  F.,  but  is  most  Inxii 
when  it  remains  between  !)2°  and  99°   F.     Moist  heat  of  140*, 
is  fatal  to  its  life.     A  free  supply  of  oxygen  encourages,  btit  it 
essential  to,  its  growth.      There   is  no  difficulty  in  maintaining t' 
virulence  of  the  organi-sm   during  cultivation :  but  if  a  culimvlii' 
left  undisturbed  for  some  months,  its  virulence  diminishes,  nnJ  'I"* 
result  follows  much  more  rapidly  if  it  be   allowed   to  bccoiui;  wi"!- 
In    either   ease  replantation    into   a    fresh   culture-ground  rapi 
restores  the  virulence.     The  organism   resists  drying  lo  a 
greater  extent   than    is  usual   in  non-spore-bearing  bacilli, 
specimen  be  dried  and  kept  dry  for  six  months,  it  will  grow  «s 
as  it  is  placed  under  favorable  conditions.     This  pt)iut  is  of 
practical   importance,  and  em|diasizes  the  necessity   for  thoi 
disinfection. 

In  189(1,  by  means  of  filtration  through  porcelain  and  sub«e<[ 
precipitation  with  absolute  alcohol,  Houx  and  Yersin  succowW 

'  Saturated  alcoholic  solution  of  methylene  hi  ue.  30  c.  c. :  solution  of  aiaill>'  f*** 
of  1  :  10,0(10,  100  c.c.     Ivctffler's  rnfthwj  of  slaining  fliigcHa  is  altogwW  diftw*' 

'  I'eplonc,  1.(1;  ^rape-«UK:>r,  1.0;  chloridv  uf  suUiuni,  .5;  DeutnU  geUUniOu^ 
broth,  100.0 ;  blood-serum,  300.0. 


THE  VRO STABLE  PARASITES. 

isolating,  from  cultiircs  of  tlic  organism,  a  poison  which  if  injected 
iiiiii  auimals  in  large  (loses  ciiiiscd  prostration  and  death,  L tit  if  in 
yiunli  (luses  only  paralysis  and  alljiiiniiiiiria  (iu  rahbits  on  the  tifth 
tisy).    In  no  case  v/as  any  moubranu  formed.     It  was  also  noted 

Fio.  127. 


* 


Birdluj  of  (llphtherl*.    Colony  on  iMjar  twcnty-Ciur   houni  «Rer  Inocalation.    x  100. 

I««  Fninktil.l 

•li«t  the  addition  of  acid  to  the  poison  rendered  it  harmless.  They 
Wi«ved  this  poison  to  be  an  ■'  unformed  ferment." 

Two  years  later,  by  very  similar  procedures,  Sidney  Martin  sepu- 
"itftl  identical  series  of  substances  (1)  from  the  tissues  of  persons 
lieadof  diphtheria,  and  (2)  from  cidtures  of  the  organism  on  media 
tlosely  resembling  those  of  the  tissues  (p.  359).  This  series  cou- 
"iflwlof  hetero-albumose,  j)roto-albumo.se,  deutero-albiimoso,  and  an 
Ofpmic  acid.  Of  these,  the  first  was  only  to  be  obtained  from  the 
ttifuilirane  and  the  last  from  the  tissues ;  the  proto-  and  deiitero- 
>ll)muoses  were  present  in  both  membrane  and  tissues.  Martin 
woweJ  that  the  factory  of  the  albumoscs  was  the  tissues,  anil  espe- 
ei»liy  the  spleen,  and  that  but  little  was  formed  at  the  site  of  the 
"■finbrune.  He  regartled  all  tlie  products  as  the  result  of  a  ferment 
produced  at  the  seat  of  llie  local  disease,  and  thence  entering  the 
"STcqlation.  He  showed  that  the  paralytic  effecte  were  due  to  the 
*«tii)ri  of  the  ulbumoses  on  the  periphcvnl  nerves,  which  caused 
breiilting  up  of  the  myelin  sheath,  and  move  or  less  thinning  anrl 
•**n  ilisappearance  of  the  a.xis-cylinder:  fatty  degeneration  of  the 
'''^rt  nnd  voluntary  muscles  were  also  found  (p.  340). 

Prom  the  foregoing  account  it  will  be  seen  that  the  requirements 
*'  the  organism  aa  regards  air,  temperature,  and  moisture  are  ad- 


386 


THE   VEGETABLE 


lin 


mirably  provided  for  iu  the  mouth  and  upper  air-pasMges.  Mor^ 
over,  they  arc  .sup|ileincnteil  by  the  co-operation  of  varion«  own. 
especially  the  j)yogenic  varieties,  whicli  are  always  ready  to  haml. 
The  spread  of  the  membrane  inward  is  probably  due  partly  to  lie 
mure  suitable  temperature  and  partly  to  the  force  of  inspirati.  i. 

Auutlier  step  in  advance  was  iiuide  in  the  same  yearll^'. 
Behring,  who  drew  attention  to  the  acijuired  immunity  wbicb  coald 
be  obtained  iijiainst  these  diplillieria  liiicilli.  He  ilesii-ribed  four 
ways  b_^  which  animals  co(dd  be  rendered  immune.  He  injected  (1| 
cultures  of  the  bacillus  attenuateil  by  heat;  (2)  cultures  attcuuat«<l 
by  the  addition  nf  trichloride  of  iodine ;  (3)  the  pleural  exuiiation 
of  animals  dea<l  of  experimental  diphtheria:  or  (4)  a  dose  of  viru- 
lent diphtheria  bacilli,  folbivved  by  one  of  trichloride  of  iodine  Hf 
next  showed  that  the  addition  of  some  serum  from  an  auimnl  tbii' 
iuimunized  to  an  ordinary  culture  of  the  organism  not  only  kilW 
the  bacilli,  but  neutrali/ed  the  jioisun  as  well,  so  that  when  injrcifi 
it  was  found  to  be  innocuous.  The  iinal  stage  was  reached  when  hf 
showed  that  if  a  fatal  dose  of  diphtheria  poison  hail  been 
it  could  be  neutralized  by  a  subsequent  injection  of  this  "  imi 
serum."  A  good  deal  was  found  to  depend  upon  the  method  fin- 
ployed  for  rendering;  immiine  the  animal  from  which  the  scrum  »*• 
taken.  Within  certain  limits  the  injection  of  small  amount*.  s|iri*l 
over  a  long  period,  was  found  to  give  the  best  results.  The  princi- 
ples determining  the  dose  of  •' imnuini/.cd  serum"  or  ••  antitoxin 
are  not  yet  understood.  Does  the  "  antitoxin  "  simply  neutrali« 
the  chemical  poison,  or  does  it  induce  action  on  the  jmrt  of  tlif  tis- 
sues ?  In  eases  iu  which  only  the  filtered  culture,  and  not  ti* 
actual  bacilli,  is  employed  the  dose  of  serum  reijuired  is  fopml  l*" 
vary  not  only  with  that  of  the  (Toison,  but  also  with  the  body-weig"' 
and  possibly  with  the  species  of  animal  employed.  Again,  thclw* 
rc(|uisitc  depernl  upon  the  interval  between  the  two  injections.  •' 
was  smallest  when  that  of  the  serum  immediately  followed  the  pobon- 
These  results  have  led  to  the  extensive  use  of  the  jmmuni«e<l  s«i»* 
for  therapeutic  purjwses :  these  have  been  more  fully  referred  U>  •■ 
the  section  on  Immunity  (p.  3()8). 

Influenza. — In  1S!*2.  Pfeiffer,  Kitasato,  and  Canon  aucct'eded  id 
finding  a  minute  bacillus  which  they  believe  to  be  the  cauM.-  of  ih" 
disease.  If  is  extremely  minute,  measuring  .0  fx  by  .2  ft ;  that  \i,  it  " 
about  half  the  size  of  the  bacillus  of  "  mouse-septicarmia."  It  st«iD* 
with  Ziehl's  and  Loefller's  fluids :  the  ends  take  the  stain  best,  aoil 


THE  VEGETABLE  PARASITES.  387 

tius  the  organism  often  looks  like  a  diplococcus.  It  occurs  singly, 
in  pairs,  and  in  short  chains.  Large  numbers  have  been  found  in 
the  bronchial  secretion :  they  disappear  with  the  catarrh.  The 
orgaoism  has  also  been  demonstrated  in  the  blood.  In  that  fluid 
it  is  either  less  frequently  present  or  more  difficult  to  stain.  It 
ius  been  found  in  the  peribronchial  tissue. 

Pare  cultures  are  not  easily  obtained.  On  sugar-agar  these 
tppear  as  small,  discrete,  transparent  globules  visible  only  with  a 
lens.  The  bacillus  is  aerobic,  grows  best  at  the  body-temperature, 
and  is  easily  destroyed  by  drying. 

Local  inunction  of  pure  cultures  into  the  respiratory  mucous  mem- 
brane of  monkeys  and  rabbits  is  followed  by  the  disease. 

The  Plaerue  (Bubonic  Fever). — In  a  preliminary  communication  ' 
Kitasato  has  described  bis  researches  during  a  recent  epidemic  at 
Hong  Kong. 

(1)  He  succeeded  in  finding  bacilli  in  the  blood,  buboes,  and 
internal  organs  of  the  plague-stricken  patients.  The  organisms 
stained  readily  with  the  usual  reagents;  they  had  rounded  ends, 
vhich  appeared  darker  than  the  central  parts ;  they  possessed 
•light  power  of  movement.  No  spores  were  discovered.  The 
organisms  were  easily  destroyed  by  sunlight,  heat,  carbolic  acid, 
»nd  quick-lime.  Similar  organisms  were  never  found  in  healthy 
persons  or  in  those  suffering  from  any  other  disease. 

(2)  Cultures  were  obtained  on  blood-serum,  glycerin-agar,  and 
other  media.  The  colonies  were  whitish-gray,  rounded  patches 
»ith  uneven  edges.  In  the  cultures  the  bacilli  often  formed  long 
threads. 

(3)  Mice,  rats,  guinea-pigs,  and  rabbits,  if  inoculated  with  pure 
cultures  or  with  blood  from  patients,  succumbed  with  a  constant 
*iaenee  of  symptoms.  Roughly  speaking,  these  appear  to  have 
^"Tesponded  to  those  in  man,  though  the  enlargement  of  the  glands 
••oes  not  seem  to  have  been  so  marked.  The  bacilli  were  found  in 
">«  blood,  glands,  and  organs  of  these  animals.  Pigeons  are  im- 
""De.  Animals  fed  with  the  organism  or  blood  died  in  the  same 
•*J  as  those  inoculated. 

Septicseznia  of  Mice. — Koch  injected  putrid  fluids  beneath  the 

'•in  of  mice  in  quantities  too  small  tocau.se  septic  intoxication.     A 

Peculiar  disease,  without  abscess-formation,  occurred  in  some  cases, 

*nd  was  transmissible  with  certainty  to  others  by  inoculation  of  a 

•  The  Praetitiotwr,  October,  1894. 


riTB  VEGETABLE  PARASITES. 


Fio.  i2tl. 


very  small  tjiiaDtity  of  blood.     Extroindy  »niall  bacilli,  cliiefly 
leucocytes,  were  mIiumii  to  hv  tlio  cansi-  of  the  (lijiiease,     <*no  atUi 
confer«  iiiitutiiiity.     It   is   not   iiioctilulili*  ujK)n   ticlil-iuice,  gi 
pigs,  or  chickeus.    (Sec  "Scpticnjmia,") 

Tetanus. —  Iti   1SR4  it  was  shown  tlnit   trtanus  W8;<  an  in< 
disease.      In  the  same  year  a  special  bacillus  was  described 

was  not  isolated  and  cultivai 
til  IS^n.  KitaiMito  ac<Htni|ilisfc< 
these  results  by  koatiug  the  inipo 
cultures  of  pus.  obtained  from  d 
original  wound,  to  a  tempenlv 
of  80°  C.  (ITfi"  F.).  and  then  r 
cubating  the  residue  in  an  mm 
sphere  of  hydrogen.  ■ 

The  bacillus  thus  obtnineil  in  ♦»! 
small.     It  is  generally  armng<[^ 


lUeUliu  of  tcun....    ,r«r  U«criptloD,    p„|,^.   ^^^^    ^^j    „,-  ,,,p    {,„,.in„^ 


■WtrzU) 


longer   rods   (8  //  to  5  /t  X 
Spores  are  often    found.     TIipt~ 

being  two  to  four  times  the  tiial^ 
of  the  organism,  give  it  the  appearance  of  a  miniature  dmiiiltii 
(Fig.  128).  One  or  two  flagella  at  the  oj)posite  end  arif  draeribi 
by  some  observers.  The  bacillus  can  be  staineii  by  the  ttfa 
methods.  Its  habitat  seems  to  be  the  superficial  s«iil,  frun 
it  can  often  be  obtained. 

It   can   be  readily  cultivated   if  great  care  be  ukcD  to 
oxygen :  this  bacillus  and  that  of  malignant  a*demB  arc 
most    prominent   examples   of  anaerobic    organisms.     The  tt4/St 
bacillus  lii|uefies  gelatin  slowly  and  grows  only  beneath  the  si 
The  most  suitable  temperature  is  l»7°  F.  to  100°  F.     The  ci 
have   a  characteristic    odor.     The  spores  are  noted   for  the  p«> 
resisting  power  they  show  to  the  ordinary  methods  of  dcst 
Thus,  they  have  been  known  to  resist  successfully  /»«»i7i»«y 
minutes.   Jn/in;/  for  five  months,  and  immersion   in  rnrh«\H 
(1  :  20)  for  ten  hours  and  in  mfrmric  vhloride  (1  :  10«MH  for 
hours.      Fifteen  minutes'   boiling  is  invariably   fatal.      For  a  1^ 
time  all  attempts  at  attenuation  failed,  but  it  has  lately  b««n 
by  Tix/.oni  and  Oattani  that  attenuation  results  froin     < 
sure  to   the  air  of  s[>orp»  on  threads,  and  (2)  the  pi' 
cultures  in  various  gases  for  long  periods — generally  or*r  a  y* 


389 


The  constant  presence  of  the  bacillus  in  cases  of  tetanus,  and  the 
possibility  of  purifying  it  by  cultivation,  having  been  established, 
it  renuiiiieil  for   Kitasato  to  couijilcte  the  proof  by  successfully  in- 
ociiluting  these  cultures  on  animals.     lie  showed  not  only  that  iu- 
ui'nlation  of  the  bacillus  proiluces  the  disease,  hut  nlso  tlmt  in  such 
ciwoi  the  organism  remains  confined   to  the  wound,  mid   thstt   the 
imptonis  arc  due  to  the  absorption  and  (.irculation  of  their  prod- 
ncld.     Thus,   he  found  (1)  that  irmcultition  of  a  utrrilizftl  culture 
produced  a  fatal  form  of  the  diseuse,  but  that  no  bacillus  could  be 
found  in.  and  uo  cultures  obtained  from,  the  organs  of  an  animal 
iillcd  in  this  way;  (2)  that  inociil.itioii  of  an  unMfrlUzi'd  culture 
/iroducetl   a   similar  disease,   and.   similarly   again,  that  no  bacilli 
wtild    be    found    in.   and   no    cultures   obtained    from,    the   dixtuiit 
•Tgans;  and  (3)  that  in  the  latter  ca,«e  the  symptoms  were  first 
wliserved   in    the   locality   of  the   itioenhited   part.     He  concludeil, 
'herefore.   that  the  bacilli    in   tlie  wound  ])rodiiced  their  effect  by 
taanufacturing  poi-sons  which  are  gradually  disseminated. 

The  first  of  the  products  se))iiratcd  was  a  crystallizable  substance 
»Oown  as  tcfariiiii',  while  the  second  was  called  ti'tnnotorinc.  The 
third,  in  order  of  discovery,  though  the  moat  poisonous  of  the  three, 
«L««  been  named  ti-tnrius  tuj-nlbinnnae. 

tlvitiksato  conferred  a  two-months'  imuiutiity  on  riibbits  by  inject- 
">  tj  II  small  portion  of  a  sterilized  (filtcruJ)  culture,  followed  by  five 
da».ily   injections  of  trichloride  of   iodine  (3   c.   c.   of   1    ))er  cent. 
**>lution).       Subsequent   observers  have  obtained   results    precisely 
*-Ta»lr)gous    to    those   already    described    in    di]ihtheria.       Small    but 
■f^^ularly  increasing  (3  c.  c.  to  120  c.  c.)  and  repeated  doses  of  the 
I     ■It'orcd  cultures  gradually  confer  imnuinity.  and  the  serum  obtaiiieil 
™~«Jiii  animals  thus  protected  is  found  to  prevent  llie  develojinieiit  of 
^.y mptoms  if  injected  bt'foir,  or  with,  a  fntal  dose  of  the  toxines. 
■V  some  observers   the  same   result  is  claimed  when  the  injection 
L'*'-»//o«'»    the    development   of  the    8ym]>toms   of  the   disease.     The 
^*^^cacy  of  the  "  antitoxin  "  serum,  when  kept  in  tubes,  lasts  little 
**»«tre  than  a    week. 

Maliernant  CBdema. — A  spreading  tedema.  ending  fatally,  may 

'*<?  [iroduccd  by    inoculation  of  mic<'.   guiiifa-|jigs,  or  rabbits  with 

^rden  mould.     One  form  of  bacillus  develo|is.  and  the  tedema-tluid 

**>ntainiug  it  is  easily  inocMilahlc  (ji.  34.">t.     The  bacillus  is  3  ft  to 

3.0 ;/  in  length,  but  gro«s  iiiln  longer  threads  which  much  reseudjle 

Mtkrax  bacilli.     They  diflcr  in  showing  no  segmentation,  in  having 


390 


THE    VKGETAIiLE  PARASITES. 


roiinilod    cmis,   amJ    in    being   iibsoliitoly    anaertibic.     In   culmre*J 
cLnractcristic    air-bubbles    occur    at    the    fhlan  nf   the   tube.    (Sc« , 
Frontiapiocc.) 


8PIROBACTERIA. — Two  ilisoases,  Ki'la|i8iug  Fevt-r  nntl  f'hol. 
era,  arc  assuciatfil  with  curved  organisms  behmging  tu  thix  ordi*r. 

Relapsixifir  Fever. — The  Spirocha-la  Ohermeirri  (Fig.  121).  nftcn 
called  spirillum,  i^  fouml  in  the  blood  in  this  dixeuxc.      It  «v  lii*- 
covcrcd   by  Uberiueier   in    1873.      It    is  ii  /.ignag,  !«har|dv  cnr»«L 
uniform  thread,  16  to  40  ft  long,  with  quick  nnduUting  roorcmi'iiU. 
No  8]M)rc.»i  arc   known.     The    organism    takes   the  ordinary  »uui» 
feebly,    and    does    not    retain   the  stain    when    treated   hv  <tnJn« 
method.     The  organisms  appear  in  the  blood  soon  nfWr  the  mn* 
mencement  of  an  attack,  and  disappear  with  remarknhle  »pi>rd  »ft«r 
the   crisis.      Metchnikoff   states   that    during    the   afebrile   intrrv*^ 
they  accumulate  in  the  spleen,  and  Soudakewitch  has  shown  lt»*^ 
the  previous  removal  <if  this  organ  enormously  incrcamw  the 
tality.      Nothing  is  seen  of  thorn  till  the  relapse,  when  they  n-tuTt*^ 
All  attenijits  to  cultivate  them  have  hitherto  failed.      The  di»t**** 
hiM   hern    inoculatc<l   from   man    on    man  and  from  man  on  Ap*^ 
(Carter.  Koch),      It  is  said  that  blood  taken  io  the  fever-free  prt^***^ 
is  not  infective. 

Cholera. — The  infective  nature  of  cholera  has  long  been  m^**' 
tained  by  many  observers,  but  nothing  ilelinite  was  known  in  If***-** 
when  Koch  began  his  work  in  Egyjit  an<l  India.     He  was  at  <»«**^ 
struck  by  the  discrepancy  between  the  accounts  of  the  poM-\ 
appearanri-t  as  given    in   text-hooka  and   the  con<litions  which 
actually  found.      He   observed    that    it  was  (|uite  rare  to  find 
intestinal  mucosa  simply  opaipie  with  slightly  swollen  folIicl<« 
the    intestinal   contents    like    gruel,   as    had    been   described, 
found  that  this  happened  only  in  the  most  acute  cases,  and  that 
gruel-like  content.-*  then  consisted  of  un  almost   pure  cultivation 
the  jmrasite  presently  to  be  described.      Koch  only  vcnr  cxcepltt^^ 
allv  found   in  the  intestines  any  fluid  so  thin  as  to  be  <-om|uiraE^ 
with  rice-water.     In  cases  of  somewhat  longer  duration  he  foo^* 
the  follicles  and  Peyer's  patches  surrounded  by  «ones  of  by 
mia.  running  together  into  red  areas;  and  idtimately,  in  the  I-'Tiu' 
est  cases,  the  small  intestine  became  int«'n»ely  cougeste*!,  the  cun- 
ge«tion  being  most  marke<l  above  the  ileo-cwcnl   valve  and  djinf! 
away  in  the  upward  direction.     With  these  chungcs  the  totMtioal 


m 


THE  VEOETABLE  PARASITES. 


391 


Dlents  became  increasingly  bloody,   and   finally   exhaled  a  dis- 
JCtly  putrefactive  odor,  whilst  the  parasite  above  referred  to  was 
»re  or  less  replaced  by  other  bacterial  forms. 
Li  the  stage  of  patchy  redness  .sections  of  the  mucosa  parallel  to 

surface  showed  that  in  the  most  acute  cases  the  redness  corre- 
Joded  to  an  invai<ion  of  the  e[iitheli(iiii  of  the  tubular  glands  by 
^parasite  found  in  the  intestine  :  the  organisms  were  found  lying 
*ecn  the  epithelium  and  the  basement-membrane.  This  bacte- 
m,  therefore,  soon  attracted  attention  by  its  definite  form  and  by 
apparent  constancy. 
Koch'it  i'holtrn  Spirilfum  or  Vibrio  is  about  one-half  to  two-thirds 

length  of  a  tubercle  bacillus,  but  thicker  {aliout  .;')  //).  It  is 
md.  usnally  to  a  degree  ei|uul  to  that  of  a  comma  (hence  the  first 
^p>comma-baci)liis).  bnt  sometimes  to  that  of  a  semicircle.  It 
lipfies  by  transverse  division,  and  wlien  the  organism  is  grown 
^I'lutinnus  media  or  the  intestinal  mucosa  tiie  segments  sepa- 
^om  each  other  at  once:  if  two  remain  united,  they  form  an 
^g.  12f'),  their  curves  being  in  opposite  directions.  When  cui- 
ted  for  any  length  of  time  in  nutritive  fluids,  the  spirilla  may 
ttiu  united  until  they  form  <k'liciitc  sjurals  of  seuiie  lengtli,  very 

tB  spirillum  of  relapsing  fever:  these  are  probably  degenera- 
rms.  A  single  flagelluui  is  usually  attuciied  to  one  end  of 
I  organii^m.  Occasiiuially  two  or  more  tiagella  may  be  sinn'larly 
ched.  More  rarely  still,  flngella  may  be  connected  with  both 
I.  Botli  single  cells  and  sjiirals  are  actively  mobile.  When 
*nt  in  the  intestines  in  large  numbers,  thcv  form,  according  to 
h.  little  heaps  in  wliich  the  single  cells  have  all  tlie  same  <lirec- 

tthat  it  looks  as  if  a  little  swarm  of  them  were  making  their 
e  behind  the  other,  like  fish  in  shnvly-moving  water  (Fig. 
I.  The  organisms  stain  with  tlie  ordinary  solutions  before  men- 
ed.  but  do  not  retain  the  color  when  treated  by  Gram's  method. 
he  vibrio  grows  well  upon  nil  the  onliiiary  media  ami  its  rapid 
tiplication  can  be  watched  in  a  droji  of  meat-infusinn  u(ion  the 
IT  surface  of  a  cover-glass.  If  linen  stained  with  cholera  dejecta 
;ept  moist  and  e.xjxiscd  to  rlie  air,  growth  is  also  very  free  for 
jg  three  days.  The  colonies  upon  nutrient  gelatin  or  agar 
^k  very  pale  tiny  spots,  which,  as  they  get  larger,  present  a 
nljr  irregular  outline  ami  a  finely  granular  surface:  Koch  com- 
M  them  to  heaps  of  fine  bits  of  glass,  On  the  second  day  the 
ilia  liquefies  in  the  immediate  neighborhood  of  each  point,  an<l 


392  THE  VEGETABLE  PARASITES. 

the  colony  sinks  into  a  bell-shaped  depression  with  a  white  apical 
point.  The  appearance  of  a  long  narrow  funnel  is  very  typicai 
when  a  tube  is  inoculated  by  puncture.  (See  Frontispiece.)  In  the 
case  of  allied  organisms  liquefaction  generally  takes  place  Bort 
rapidly.      For  diagnosis   Koch   relies  on   the  combined  eridenc* 

Fig.  129. 


Cholera  uptrilla.  Klagella  not  nhown.  (From  it  upvcimeD  by  I)r.  ArUe,  prepMcd  in  Korh'k 
laborelor)') 

afforded  by  (1)  the  microscopic  appearances :  (2)  the  result?  of  culti- 
vation on  gelatin  and  on  agar ;  (8)  the  indol  reaction  with  peptone- 
cultures:  and  (4)  the  effect.s  of  inoculation  on  animals. 

The  growth  of  this  spirillum  is  unusually  rapid ;  it  roacbeff  its 
limit  in  u  few  days,  remains  a  short  time  stationary,  and  then  dimin- 
ishes, the  bacilli  either  shrivelling  or  swelling,  and  staining  more 
or  le.«s  imperfectly.  Many  strange  "  involution-forms  "  appear :  these 
have  been  thought  to  belong  to  different  species.  Clear  spots  failing 
to  stain  have  often  been  taken  for  spores,  but  Koch  showed  that 
spirilla  containing  these  spots  were  obviously  dying,  for  they  failed 
to  grow  and  did  not  po.isess  the  resisting  jmwer  of  spore-bearing 
organisms.  He  does  not  believe  that  s|)ores  are  formed,  but  Hiippe 
and  others  have  described  the  splitting  up  of  vegetative  cells  into 
small  fragments,  which  become  rounded,  like  spores:  these  when 
transplante<l  grow  into  spirilla  (iirthrosporet). 

Growth  is  most  rapid  at  8t>°  F.  to  104°  F.  (30°  to  40°  C),  anJ  ^ 
stops  below  (10.8°  F.  (H»°  ('.).  Death  results  from  exposure  ti>^m. 
a  moist  temjjeratiire  of  l^il"  F.  (.").'>°  C.).     Oxygen  is  essential  tci».^ 


THE  VEGETABLE  PARASITES.  393 

grotith,  but  neither  its  absence  nor  an  atmosphere  of  carbon  dioxide 
causes  death.     An  alkaline  reaction  is  most  favorable  to  growth, 
while  distinct  acidity  often  arrests  it ;  but  all  acids  have  not  this 
effect,  for,  though  the  surface  of  a  potato  is  acid,  yet  growth  occurs 
freely  upon  it.     Koch  added  many  antiseptics  to  cultivations  to  dis- 
cover those  which  most  powerfully  hindered  development.     Quinine 
(1 :  5000)  and  mercuric  chloride  (1  :  100,000)  head  the  list,  but  it 
is  obvious  that  the  constitution  of  the  material  to  which  they  are 
luhlei  will  greatly  affect  the  result.     Koch's  most  important  obser- 
'ation  on  this  point  was  that  complete  desiccation  killed  the  vege- 
tating cells  of  these  bacteria  in  three  hours.     It  must  be  remem- 
bfred  that  in  pappy  substances  many  hours  may  be  recpiired  to 
<^oniplete  de.«iccation,  but  even  in  such  twenty-four  hours  suffice  to 
Jcstroy  cholera-germs.     On  the  other  baud,  Hlij)i»e  obtained  fresh 
^''Jltures  from  arthrosporous  spirilla  after  four  weeks'  desiccation, 
and  vigorous  growths  have  been  obtained  from  desiccated  cultures 
•fter  ten  months.     It  is  not  yet  certain,  but  Hiippe  believes  that 
**"throspores  were  contained  in  the  latter,  and  that  new  growths 
*fter  long  intervals  always  arise  from  these  structures.     Lastly,  it 
is    very  probable,  if  not  certain,  that  this  spirillum  soon  dies  in 
pKtrid  fluid,  cesspools,  and  the  like,  and  that,  consequently,  the 
**J<lition  of  antiseptics  to  such  collections  of  matter  may  possibly 
P^'eserve  rather  than  destroy  the  cholera-germ. 

Koch  was  strongly  of  opinion  when  he  wrote  his  early  papers  on 
*»*>8  subject  that  the  form  of  the  "comma-bacillus"  was  quite  cha- 
racteristic, but  Finkler  and  Prior  discovered  a  spirillum  very  like 
**  in  "English  cholera;"  Denecke  found  another  in  cheese; 
*«8clierich  obtained  one  from  the  alfine  discharges  of  infants  with 
**'»namer  diarrhoea;  and  Metchnikoif,  one  from  fowls  suffering  from 
*•  special  form  of  enteritis.  Koch  found  a  bacterium  like  it,  but 
thicker,  in  the  water  of  the  Hooghly.  Careful  study  of  the  plate- 
*'*«l  tube-cultivations  of  these  very  similar  organisms  and  of  their 
T**thogenic  effects  has  shown  that  they  can  be  readily  dii^tinguished 
**.y  thoroaghly  competent  observers. 

It  would  seem  from  the  above  morphological  and  physiological 
"stalls  that  Koch's  cholera  germ  is  a  perfectly  distinct  organism, 
*^d  that  it  is  invariably  present  in  the  early  stages  of  the  disease. 
*  ®t  all  of  Koch's  statements  are  not  fully  accepted.  Some  observ- 
^''s  affirm  that  the  spirilla  do  not  necessarily  invade  the  intestinal 
Epithelium.     Gruber  maintains  that  variations  in  the  size,  curve. 


:t94 


THE  VEGETABLE  PARASITES. 


Hharpncss  of  ends,  and  number  of  flugdiii  ar<>  (!(>iiini«ti,  nt 
on  the  special  epidemic  in  i|iiegti<>n,  on  the  eonditioni*  n 
and  on  the  stage  of  cultivation. 

Koch's  theory  as  to  its  action  is  that,  being  eonfineti  tci  th<-  inti*- 
tine,  it  produces  a  virulent  general   puiiwn,  which   is  alxwirW  Mii 
at  the  same  time  nets  as  :in  intense  irritant  to  the  niiicoiis  men  '  ^• 
Early  death  in  coilapwe.  perhaps  liefore  the  passajre  'd' «i«in;:l- 
may  result  from  general  {tui.soning,  and  it  is  in  thitie  raoitfi  that  tb» 
intestine  is  found  pule — simple  hypertemia  having  <lied  a»  ■ 
longer  cases  the  loeiil  eflects  iteeome  more  markc<I.  and  ini : 
extravasation  of  re<l  eorpuseles  remains  to  indicate  the  existenwf 
the  liyper:rmia.      Then  tlie  eholeru  germ  having  rearhe<l  itJ"  ■      ' 
development,  hindered  perhaps  from  further  growth  by  the  | : 
of  its  own  action,  is  more  and  more  replaced  by  putrefaetiT«'  j^^i' 
the  proflucts  of  which  are  both  extremely  irritant  and  pt>i»oiK'i»- 
Various   toxic    bodies    have    been    obtained    from    culturei   of  tk» 
cholera  spirillum.     These  when  injected  give  rise  to  cram|i«).  otrdiv 
failure,  and  lowered  temperature,  respectively.     The  exact  n»turr 
of  these  is  at   present   unknown. 

Koch  examined  the  intestinal  contents  and  stoids  of  a  \*t^ 
number  of  ca.ses — dysentery,  intestinal  catarrh,  nlceration.  t\pb«i'l 
iiikI  tvphns.  diurrhieu  nf  iidtilts  and  children  :  the  stools  of  aoiiDil*- 
normal  and  after  arsenical  {>oisoning:  the  contents  of  the  ('il<"ii"» 
drains;  and  water  from  the  most  varied  sources.  iUxcv  odIt.  in* 
tank  in  a  cludera  district,  was  the  spirillum  found  externn' 
body,  and  here  it  .seemed  to  have  a  dear  relation  to  the  tj..u- 
around  it.  Koch  therefore  cotieludes  that  thi»  HyiriUiim  ocrun**rl 
tn  catfii  itf  cbolfra.  It«  di.icovery.  therefore,  in  tlie  stools  of  dis'- 
rhira  would  be  most   imjwirtant. 

Metehnikoff  has  |M)iiited  out  that  during  a  neighboring  epiJ"** 
of  cholera  the  drinking-water  of  Versailles  containe^i  the  cb'ilf* 
vibrios,  yet  that  those  who  drank  the  water  remained  unaff'*''''- 
He  has  further  shown  that  the  organism  persistiil  in  the  »»"■' 
for  months  after  the  epidemic  had  ceased,  and  therefore  ih«l  "* 
appearance  of  the  microbe  in  water  did  not  neecs.sarily  invoh 
appearance  of  an  epidemic.  He  believes  that  cholera  or/j 
may  exist  for  some  time  in  the  intestines  of  animals  without 
ducing  cholera.  This  result  he  attribute*!  to  the  action  of  < 
tiguous  and  contemporary  organisms.  Some  of  these  aid. 
otht^rs  hinder,  the  action  of  the  cholera  vibrios. 


THE  VEGETABLE  PARASITES.  395 

In  the  proof  of  causation  we  have  now  shown — 

(1)  That  Koch's  cholera  spirillum  is  a  specific  organism  to  be 
and  in  all  cases  of  cholera,  and  rarely,  if  ever,  in  persons  not 
iSering  from  the  disease. 

(2)  That  pure  cultures  of  the  spirilla  can  be  obtained,  but  that 
ccessive  cultivations  tend  to  cause  their  degeneration. 

The  possibility  of  inoculating  the  disease  must  now  be  considered. 
'  an  accident  cholera  dejecta  became  mixed  with  water :  this  was 
mk  by  seventeen  persons  ;  of  these,  five  had  cholera  (Macnamara). 
;ain,  at  Berlin,  during  a  course  of  demonstrations  upon  the  bac- 
ia  of  cholera,  one  of  the  members  of  the  class  was  attacked  by  a 
tinct  though  mild  form  of  the  disease,  his  stools  containing  num- 
ra  of  spirilla.  No  other  source  of  infection  seemed  possible. 
Meanwhile,  Nicati  and  Rietsch  at  Marseilles  succeeded  in  infect- 
;  dogs  and  guinea-pigs  with  a  disease  like  cholera  by  injecting 
Itivations  of  the  spirilla  into  the  duodenum,  and  their  results 
!re  repeated  and  confirmed  by  Koch  and  others.  This  method 
i«  adopted  to  avoid  the  stomach,  in  the  acid  secretion  of  which 
e  cholera  germs  ordinarily  perished.  Of  eighteen  guinea-pigs 
08  treated,  thirteen  died  of  "  cholera,"  whilst  of  "  control  "  ani- 
ils  injected  with  other  bacteria,  none  died. 
Koch  next  neutralized  the  gastric  juice  for  about  three  hours  by  a 
itable  injection  of  carbonate  of  sodium,  and  later  injected  spirilla 

meat-infusion,  but  with  a  negative  result.     He  next  delayed 
iristalsis  by  means  of  opium,  with  the  result  that  of  thirty-five 
'inea-pigs     infected     through     the     stomach,     thirty     died     of 
cholera." 
Infection  through  the  stomach  would  apparently  be  much  easier 

man  than  in  guinea-pigs.  Ewald  finds  that  water  introduced 
to  an  empty  stomach  remains  neutral,  or  even  becomes  slightly 
Wine :  its  quantity  decreases  slowly  for  an  hour  or  more ;  then 
'^Teases  suddenly — evidently  from  opening  of  the  pylorus — before 
'  reaction  has  become  acid.  Cholera  spirilla  introduced  shortly 
'fore  this  juncture  might  reach  the  duodenum  alive.  If  arthro- 
Ofes  exist,  this  is  even  more  likely.  It  would  therefore  seem 
•ssible  that  the  cholera  spirillum  might  occasionally  pass  through 
*  stomach  of  man  without  predisposition.  As  with  other  acute 
*cific  diseases,  of  those  exposed  few  take  the  disease ;  and,  accord- 
gto  Koch,  almost  all  these  had  digestive  troubles,  gastro-intestinal 
tarrh,  or  an  overloaded  stomach,  the  latter  condition  diminishing 


TBE  VEGETABLE  PARASTTMS. 


the  general  aciclity  of  the  stomach  and  enabling  the  »pi 
\niss  with   undigosfed  ntn-sses. 

The  I'imtiiijion  of  cholera  frUt$  in  the  rtrjecta  and  finite  < 
ally  in  vomit  (when  this  has  regurgitated  from  thu  int«Httn( 
uprfdd  to  oeciir.  tiioistnre  n*  essentini,  lu*  de!<icration  »)•  a 
above)  means  death  ;  cholera,  therelure.  does  Dot,  like 
spread  by  the  shaking  of  dust  from  linen;  it  is  not  e^rrioi 
nor  by  inerchnn<li.se,  but  by  man.  As  a  rule,  it  is  sprau 
infection  of  water ;  this  occurs  very  easily  in  India,  vrhor 
tank  i.<  employed  to  collect  water  for  nmny  [icople.  and  the 
is  used  indifferently  as  a  public  bath,  a  w.ish-tub,  a  cosap< 
reservoir  of  drinking-water.  Koch  (|Uote.s  convincing  i-j 
show  thill  the  su|iplY  of  pure  water  will  preveni  thr  nn-w 
the  ilisease  where  previously  it  has  been  rife.  Most  prov 
be  infect^-d  by  contaniiniitoi  han<|?i  or  perhaps  by  Hies. 

It  has  already  been  shown  liiat  ifiin  para»itr  ran  tuMit 
from  the  body — e.  g.  on  moist  linen,  on  }>otato.  or  in  nettl 
As  it  requires  rather  concentrated  nourishment,  it  prnli 
not  multiply  in  ordinary  running  water :  but  many  of  t 
of  India  are  extremely  foul,  and  organic  matter  incrcasi 
where  the  waters  stagnate,  drains  and  gutters  enter,  and 
and  animal  refuse  collects:  round  about  such  ma.sses  wati 
muddy  froui  germs.  Stnguant  surface-water.  ibiMvfore.  *^ 
the  great  culture-ground  for  cholera  germs  external  to  tlie 

.Ml  cviilence  g(»es  to  show  that  thf  hurin'  of  thr  rholrrA 
the  delta  of  the  Ganges — a  region  so  peculiarly  a'Upt 
growth  of  micro-organisms,  by  the  <|uantity  of  dend  aa 
vegetable  matter  and  by  the  heat  and  the  moisture,  that 
expect  to  meet  with  i|uite  special  forms  of  bacteria.  To  ij 
careful  incjuiry  has  always  been  able  to  trace  epidemic*  of 

For  an   account  of  fireventivc   vaccination  against   rb 
p.  363. 

The  Buastomycbtes,  ob  Yeasts 
These  are  small   round  or  oval  cells  which  multipl 
(gemmation).      Sometimes    the    cells    cohere    au<l    f« 
chains.     When    food    is    not    abundant,  oa  in  the 
cultivation.*,  one   to  four  sjiores  may  form   in   the  intei 
yeast-i-ell.>» ;     these    develop    when     placed     in    fermeuial 
Under  these  same  conditions  unjointed  mycelium  may  W 


THE  VEOETABLE  PARASITES. 


397 


Fio.  130. 


Furthenaore,  when  it  is  remembered  that  the  growth  of  some  higher 
fungi  (e.  g.  Mucor  Mucedo)  under  exceptional  circumstances  is  the 
«»me  as  that  of  yeasts  under  ordinary  circumstances — i.  e.  by  gem- 
nation — it  seems  possible  that  yeasts  may  really  be  vegetative 
forms  of  higher  fungi. 
Yeasts  are  of  importance  only  as  causes  of  fermentation.     They 

nerer  invade  living  tissues.      They  are  common  in  the  stomach, 

either  alone  or  in  company  with 

MTcinse.       They    are    frequently 

foand  in  diabetic  urine,  but  not  at 

the  time  it  is  passed. 

Thrash.  —  In  this  disease  toler- 
ably adherent  gray  or  milky  patches 

form  in  the  mouth,  pharynx,  and 

gullet,   either   of   children   at   the 

breast  or  of  adults  exhausted  by 

wasting  diseases  (typhoid,  phthisis). 

These  patches  are  due  to  the  growth 

of  the  oidium  albicans,  a  parasite 

which  was   regarded  as  a  mould; 

bnt  Grawitz  states  that  when  cnlti- 

nted  this  fungus  shows  itself  to  be 

»  yeast,  and   probably  the  Myco- 

flerma  vini,  which  he  has  proved  capable  of  growing  on  mucous 

■netnbranes.     The  patches  consist  of  tortuous,  often-branched  fila- 

"•ents,  formed  of  long  cells  united  end  to  end  and  distinctly  con- 

"ricted  where  they  join.     The  filaments  end  in  roundish  cells  which 

P>x>dnce  one  or  more  spores :  these  form  heaps  in  the  epithelium 

(^ig.  180). 

Thb  Htphomycbtbs,  OB  Moulds. 

These  consist  of  filaments  {Myphce)  formed  by  a  single  row  of 

''^lls  placed  end  to  end,  growing  by  means  of  an  apical  cell  which 

'•ongates  and  divides  transversely.     Lateral  offshoots  are  common, 

"**t  dichotomous' branching  is  rare.     The  thallus  may  consist  of  a 

*'Ogle  hypha,  but  usually  the  hyphae  are  numerous  and  intercross 

'^sely  or  closely.     All  spring  from  an  axis  or  germinal  tube  which 

pt)wg  directly  from  a  germinating  spore.     Compared  with  that  of 

oacteria  (p.  326),  their  growth  is  extremely  slow. 

In  the  adult  plant  the  hyphse  are  of  two  kinds :  (1)  the  nutritive, 


Oldlam  albicans.  Cells  and  spores 
seen  on  the  surface  of  epithelium, 
scraped  from  an  "aphthous"  patch  on 
an  Iniiint's  tongue. 


398 


THE   VEGETABLE  PARASITES. 


which  grow  intn  iiml  extriict  iiourifihim'nt  from  the  ciilttir?«i 
roniiiiig  ill  it.  Iiv  their  iiiti-rlacfuicnt,  tlie  mt/ri-lium  ;  aud  (2)  (be 
reproductive,  which  s|>riiig  from  tlic  mycelium  ami  stand  up  frnni 
the  substance  in  which  the  mycelium  lies:  these  are  called  friiil- 
hyphtc.  They  are  simple  or  branched,  and  bear  at  their  ends 
spores  or  sexual  organs.  Reproduction  is  either  asexual  or  oexual: 
the  two  methods  may  occur  together  on  the  same  plant  or  nn; 
alternate  regularly  nr  irregularly.  Spores  are  fornietl  by  {-ach— 
round,  oval,  or  cylindricul,  f»uiootL  or  irregular,  colored  or  color- 
less; most  are  motiouless,  but  some  '"swarm."  Each  consiM  of « 
little  mus.s  of  protojibism.  surrouinlpd  by  an  envelope,  which  is  m»il( 
U|i  of  an  outer  {ijuxjinfiuii))  and  an  inner  {I'UihitjMjrtuin)  lavir:  iL* 
exo8])orium  is  often  pigmenteil.  All  spores  have  great  power  of 
resisting  the  action  of  physical  ami  chemical  agencies,  and  roiiin 
life  for  long  periods;  those  lnrmed  asexinilly  are  ready  at  nm-etd 
germinate,  but  those  due  in  a  sexual  process  almost  always  ret|iuit 
a  rest.  The  latter  are  the  true  refitinij-i>porrit ;  but  this  name  is 
often  apjdicd  to  all  spores  capable  of  retaining  life  for  long  periodi 
in  spite  of  adverse  conditions. 

To  unilerstand  the  above  and  what  follows  the  student  sliouU 
examine  a  few  moulds  from  the  surface  of  thin  jam.  paste,  dceaviB^ 
fruit,  or  the  surface  of  a  slice  of  potato  which  has  been  exjiosed  f"r 
an  hour  nr  two  in  a  dwelling-nmiu.  In  all  the  aerial  jwrtion  tf 
easily  studied,  and  tlie  mycelium  is  readily  shown  by  crushing  »  kit 
of  the  cultiire-grnuiid  under  a  cover-glass. 

Asexual  spore-formation  occurs  in  three  ways: 

(1)  Ilyidiie  spring  frnin  the  mycelium,  and  perhaps  bninoh.  Thi 
terminal  cells  divide  transversely  into  .spores  (^coiiiih'n).  whirii  ciibcr 
fall  away  singly  or  form  chains. 

(2)  A  hyjdia  (Mfiiiniiii/iitp/inrc)  stands  up  from  the  mycelium,  ai"! 
its  end  swells  into  a  ball  full  of  jinUoplasiu,  which  .segment*  »i" 
forms  ronidia  {uporauffiuii)). 

( -i)  Fr()ni  the  surface  of  a  knob  on  the  eml  of  a  hypha  {ronidiifhpr'] 
peg-like  jirocesses  (Wcrf(/w(»^7)  sprout,  each  sterigma,  by  growth  •"fti 
tninsverse  ilivisinn,  forming  a  chain  of  s|iore8. 

Sexual  reproduction  occurs  in  three  ways : 

(1)  Coiyugration. — The  a|dcal   cells  of  two  hyphae  meet  cinl 
end  and  blend   into  one  cell  {zi/fpmpori').     From  this,  after  a  Ion 
or  shorter  rest,  a  sporangiophore  8j)rout8,  and  from  its  sjiorcs 
plants  grow,  as  in  Mucor. 


TBE  VEGETABLE  PARASITES. 


399 


I 


(2)  Fertilization. — («)  The  end  of  a  hvpha  becomes  twisted  like 
» ciprliKcrrw.  niore  iind  more  closely,  until  the  turns  form  a  contiii- 
miuii  tulie — the  'tuiw/oiiitim.       From    the  lower  turns  spring   fine 
linmciies.  one  of  which  (antheridium)  conjugates  by  its  apex  with 
llic  ancogoninm ;  and   others   siinjily  cover  the  ascogoniinn   oontin- 
imusly,  and  are  converted   by  division   into   polygonal  cells  which 
(«m  a  capsule  {peritJiecium)  around  it.      Many  transverse  septa 
fonu  iij  the  tube  of  the  aiicogonium,  and  from  tlie  cells  thus  pro- 
duced fla.-'ked-shaped  lateral   jirojot-tions  (*»»(•/)  develop ;  in  each  of 
these  eight  spores  generally  appear.      The   perithecium  thins  as  the 
Mci  enlarge,  the  walls  of  the  asci  disajipear,  and  an  easily-ruptured 
sphere  of  spores  remains.       When   these  germinate   the  ciidospore 
swells,  splits    the    exosjtore,    and    throws    out    the    germinal    tube, 
whence  springs  the  mycelium.      This   again   gives  origin   first   to 
conidiophores,   then   to   perithecia.       Eurotinm    repens  and   Asper- 
gillus glauciis,    found   especially  on    preserved   fruit,   show    these 
ch»ngcs  (Sachs). 

(A)  In  some  species  certain  cells  form  an  organ  (oo;jonium)  in 
*hich  one  or  more  female  reproductive  bodies  (ooHphi-rm)  are 
formed,  whilst  other  cells  form  a  male  organ  [iin/ln'ridiinn)  in 
*hich  *permatozouln  are  produced.  The  oosphere,  which  is  hun- 
dreds of  times  larger  than  the  spermatozoids.  remains  in  the 
*'g>iniiim,  and  is  there  fertilized  by  the  mobile  spermatozoids.  It 
•»  now  called  an  oospore,  and  may,  after  a  rest,  directly  develop 
into  a  new  plant  or  form  cells,  each  of  which  develii])s  in  like 
manner. 

Conditions  of  Life. — Food. — Possessed  of  no  chlorophyll,  moulds 

"*    niiitble  to  build  up  carbon-compounds.     They  a,ssimilate  those 

'"'•It  up  by  other  plants  or  animals.      They  are  therefore   always 

titlier  saprophytes  or  parasites;  in  the  latter  ciise  they  may  kill 

['"fir  Lost.     They  reijuire  a  free  supply  of  oxygen,  but  some  can 

ifotain  it,   at   least   for  a   time,  by  decom]iosition  of  organic  com- 

iTwund.s  like  sugar.     Thus.  Mucor  racemosus,  cultivated  on  the  sur- 

»<•&  of  a  saccharine   liipiirl.   absorbs  oxygen,   oxidizes  completely 

"*>neof  the  sugar,  exhales  carbon  dioxide,  and  grows  rapidly.     If 

''^'lirivrd  of  oxygen,  as  by  immersion,   ojdy  the  mycelium  grows, 

••xl  this  becomes  broken   u])  into  shoi^  cells,  which  multiply  by 

("idding  and  much   resemble  yeast-cells.      Their  growth    is   much 

''"wer,  carbon  dioxide  escapes  in  bubbles,  and  alc(d)ol  appears  in 

tile  li({uid.     But  all  these  changes  soon  cease,  and  the  process  can 


4UiJ 


THE   VEGETABLE  PARASITES. 


bo  started  again  only  bv  a  frcsli  supply  of  oxygt-n  ( l)uclaus 
luuulds.  as  Pfni'.Mlliiini  gluucntn,  Aspergillus  uiger,  iinvc  no 
of  thus  obtaining  oxygen,  and  die  if  cat  off  from  the  (re*l 
The  change  in   the  cliaracter  of  growth   above  nieutione»L  ttrtm-* 
panying  changes  in  conditions  of  life,  is  often  pointed  to  «»  e»ji 
in  favor  of  the  mutability  of  bacteria. 

Light. — Many  moulds  can  develop  completely  without  light; 
reijiiiru  it  for  the  discharge  of  spores  and  other  proce!«m». 

Temperature. — Ziegler  states  that  moulds  flourish  Initt  it  Ira- 
poratures  hfihw  that  of  the  body,  and  that  s«»we  will  not  gr««tiiD 
at  so  high  a  temperature.  .\  few  species*  of  Aspfrgillu.'*  and  Miiror 
grow  well  between  9.0°  and  10;"»°  F.  The  8[>ores  are  a*  rrsiMai^* 
external  agencies  as  are  those  of  bacteria. 

Water  is  essential,  but  mere  dampness  is  sufficient. 

Action, — Moulds  are  associated  with  processes  of  rottiHjf 
The  peculiar  smell  and  taste  which  they  impart  is  known  to  alL  Tb* 
products  of  their  life-action  have  not  been  closely  invontipitcil.  V«l 
they  are  neither  very  |M)isonou8  nor  very  irritating,  so  far  a*  hum** 
tissues  are  eimcerned. 

DiBtribution. — The  spores  of  moulds  are  much  more  numeroa*" 
the  air  than   are  other  organisms.      They  therefore  conxt 
upon   tlie  skin   and  enter  the  air-passages   with   air  ami  li 
passages  with  food.     As  a  rule,  they  find  no  nidus  suitable  fur 
development :   the  supply  of  free  oxygen  is  <»fkcn  in.^uffieienl 
temperature  too  high.    Certain  of  them,  however,  when  bnn 
contact  with  accumulated  inflammatory  discharges  or  with 
take  root  and   fructify.     This  i.i  most  likely  to  occur  in  the 
mouth,  and  pharynx.     They  are  here  saprophytes,  but  tbr 
to  which  they  give  rise  may  irritate  the  living  tissues  lying  l 
the  soil  in  which  they  grow.     Species  of  Mucor  and  Asper^gilli 
those  commonlv  fouml. 

Patboerenic  Moulds. — Owing  to  the  ]»eculiarities  mentioiKvl 
their  life-history,  these  fungi  have  but  little  |>ower  of  inradio ^  liri 
tissues.      Certain  skin  diseases  are.  however,  due  to  the  gro 
speciej*  of  this  cla.ns  in  epiilermic  structures:   they  are  (!)/< 
(2)  tint^a  tonturaut,  t.  kfrion,  t.  ttirrinata,  t.  ai/cona,  and  I.  un^ 
and  ('i)  tlnfii  rrrtifolor.     Two  disen-ses.  ai-tinumtie«»i»  an' 
J'ltot  of  India,  have  been  aliribuled  to  penetration  of  i;. 
sacs  by  byphomycetoug  fungi,  and  true  mycoses  may  a]M>  c 
ally  be  due  to  growtbs  of  the  AtperyllUui  fumigatut  or  A. 


..I..  f.;i 


THE  VEGETABLE  PARASITES.  401 

Favus. — The  Achorion  SchSnleinii  forms  almost  the  whole  of  the 
light,  yellow,  mouldy-smelling  crusts  characteristic  of  Favus. 
When  in  hairy  parts,  which  are  the  usual  seats,  the  hairs  are  always 
invaded,  especially  the  roots.  Here  the  parasite  grows  luxuriantly, 
but  it  does  not  extend  far  up  the  shaft :  its  primary  seat  is  the  epi- 
thelium of  the  hair-follicle.  On  non-hairy  parts  the  mycelium 
invades  the  deeper  layers  of  the  epidermis,  and  may  ev«n  penetrate 
to  the  corium :  in  this  case  the  local  irritation  will  be  more  marked. 
The  mycelium  consists  of  unjointed,  branching,  confusedly  inter- 
crossing tubes ;  in  certain  of  them,  which  become  divided  into  joints, 
oval  spores  form. 

The  nails  are  very  rarely  invaded,  and  then  only  by  mycelium. 

Tinea  Tonsurans. — The  Trichophyton  tonsurans  is  generally 
assumed  to  be  the  one  parasite  common  to  tinea  tonsurans,  tinea 
kerion,  tinea  circinata,  tinea  sycosis,  and  tinea  unguium.  Different 
varieties  have  lately  been  described.  These  are  distinguished  by 
die  size  of  the  spores  (t.  megalosporon,  t.  microsporon),  their  pyo- 
genic effects  {t.  megalosporon),  and  their  culture-results  (Sabouraud). 
These  forms  are  not  found  growing  together. 

Wben  the  hair  is  affected  the  root  and  the  lower  part  of  the  shaft 
we  crammed  with  spores  lying  in  rows  between  the  fibrils  of  the 
degenerate  hairs,  which  are  opaque  and  brittle.  It  is  doubtful  how 
fiff  the  fungus  makes  its  way  down  between  the  shaft  and  the  wall 
of  the  follicle  before  it  penetrates  the  former.  The  hair  breaks  just 
beyond  the  scalp,  leaving  a  stubbly  line  of  split  or  twisted  ends. 
Epidermic  scales  from  the  surface  of  the  scalp  may  contain  the  fun- 
gns,  but  the  deeper  living  cells  of  the  root-sheaths  are  always  free 
from  it  (Thin  and  Taylor).  Spores  are  abundant  and  oval  in  shape ; 
■"jcelial  threads  are  rare.  Points  worth  remembering  in  connection 
"•A  the  undoubted  fungoid  origin  of  the  disease  are — (1)  its  usual 
'imitation  to  children ;  (2)  its  tendency  to  fasten  upon  the  weakly ; 
(3)  its  great  contagiousness  when  acute,  diminishing  as  it  becomes 
*hronic;  and  (4)  its  greater  severity  when  contracted  from  animals, 
**  tbe  horse  (Tinea  megalosporon).  It  may  excite  severe  irritation, 
*id  even  suppuration — T.  kerion. 

Tinea  Circinata. — Here  the  parasite  infests  epidermic  cells, 
'^vayg  causing  desquamation,  sometimes  vesiculation,  or  even  more 
SSTere  inflammation.  It  spreads  uniformly  from  the  point  at  which 
•t  first  takes  root,  and  consequently  assumes  the  form  of  a  gradually 

2t 


402 


THE  VEGETABLE  PARASITES. 


enlarging  circle.     The  central  partM  of  the  funguit  die.  ami  tlir  I 
cuinlVrential  give  rise  to   hyjicrseniiii  in  tlifir  ni-ighlMirhood. 
celiiim   is   present  chiefly    in   the    fonu   of  very   long  jointni 
branched  threads;  the  sjwres  are  scanty,  single,  or  in  »h«rt  cht 
The  fungus  altogether  is  often  sciinty,  and  is  especially  tlifficnlt  u 
detect  if  it  haw  excited  intlaiumation. 

Tinea  Sycosis  ( ?'/«<■(»  invtfahiitfioroti). — When  attacking  the  \mv>\ 
the  fungus  is  found  chiefly  in  the  hair,  but  also  in  the  follicle ;  Imtii 
mycelium  and  spores  are  seen,  the  latter  in  exccM.  bat  not  » 
markedly  a»*  in  T.  tonsurans.  The  mycelium  generally  lie*  roirod 
the  root  of  the  hair,  and  is  pulled  out  of  the  sheath  with  it.  Sevat 
inflammation  is  generally  excito<l. 

Tinea  Unfiruium. — Mycelial  threads  of  trichophyton  may  oca- 
sionnlly  invade  a  finger-nail,  rendering  it  opaque,  thick,  ami  brittlr. 
I'nlike  a  general  condition,  the  fungus  produces  these  chanjjw  in 
two  or  three  nails  only,  and  the  toe-nails  are  scarcely  ever  affwtrJ- 
In  this  situation  it  is  extremely  diflicult  to  destroy. 

Chloasma,  Pityriasis  Versicolor. — Micronporon  furfur  inr»il« 
the  horny  layer  of  flic  epidermis  of  covered  parts  of  the  trunk, 
growing  more  superficially  than  any  of  the  above,  rarely  ctuio; 
irritation  and  not  attacking  nails  or  hair.  It  consists  of  ymxti 
mycelial  threads,  which  are  always  almndaiit.  and  spores,  »liifk 
vary  in  form,  lie  in  groups,  and  grow  at  the  ends  of  ihc  nivc«li»l 
threads.     It  can  be  easily  cultivated. 

Actinomycosis. — The  ray  fungus  (actinomjfcet)  is  believe<i  tol 
the  cause  of  this  disease.      Its  de.scription  will  be  found  in  the 
ter  on  "  Infective  tirnniilomata."     Its  botanical  pt>sition  is  douUfl 


Madura  Foot. — Mtjiilninn. — In  certain  parta  of  India  thr 
of  the  natives  lire  linlile  to  ii  [leculinr  swelling :  "tubercles" 
beneath  the  skin,  burst,  and  leave  Minus«»s  froJU  which  IsHlirt 
those  constituting  the  roe  <»f  a  fish  are  dischargeil,  or,  more  rmrrly. 
bodies  like  grains  of  gunpowder.  In  the  latter  fungous  eleincB'* 
have  been  recogniied,  and  called  i'liioni/fthf  i'urirri.  The»»  »'* 
believed  by  some  to  be  the  cau«e  of  both  classes  of  the  dise««e.  '*' 
section  masses  of  the  above  bodie.n  are  seen,  especially  in  the  fr**,^ 
layer;  the  masses  may  have  no  obvitms  communication  with  <*^ 
other  or  with  the  surface.     The  botanical   position  of  the  f"^ 


THE  INFECTIVE  ORANVLOMATA.  403 

I  doubtful.     Kanthack  considers  the  disease  a  form  of  actino- 
Boyce  and  Surveyor  acknowledge  the  similarity,  but  not 
itity,  of  the  two. 


CHAPTER  XXIL 

THE  INFBOTIVB  QRANULOMATA. 

term  infective  granulomata  is  applied  to  a  group  of  diseases 
g  tubercle,  lupus,  syphilis,  glanders  and  farcy,  leprosy, 
yeosis,  and  rhinoscleroma.     It  was  originally  used  by  Vir- 

emphasize  the  points  of  resemblance  which  the  lesions  of 
ve  diseases  show  to  some  forms  of  tumor.  These  lesions 
3f  cells  varying  between  lymphoid  and  giant-cells  in  size, 
ig  in  a  scanty  matrix,  while  the  mass  thus  formed  presents 
aked  eye  a  more  or  less  defined  outline.  The  lesions  there- 
;mble  sarcomata  in  structure.     Many  of  them  develop  with- 

obvious  cause,  and  are  not  accompanied  by  any  distinct 
inflammation ;  they  often  pertist  for  long  periods,  and, 
e  exception  of  gummata,  rarely  undergo  absorption  ;  they 
^generate  early,  and  show  little  tendency  to  develop  into  a 
!nt  tissue ;  and  lastly,  most  of  the  lesions  have  an  infective 
•eproducing  themselves  in  neighboring  or  distinct  parts  by 
od-  and  lymphatic  vessels.  In  all  these  respects  the  above- 
ed  new  formations  resemble  malignant  tumors,  but  they 
om  them  etiologically.  In  the  case  of  some  it  is  certain, 
he  cSse  of  all  it  is  probable,  that  the  tumor-like  nodules  are 
i  of  chronic  inflammation,  excited  by  the  growth  of  organ- 
certain  points  in  the  tissues.     Irritation  is  maintained  as 

the  fungi  grow,  and,  as  their  growth  is  often  slow,  the 
s  are  often  chronic.  The  development  of  vessels  is  im- 
and  so  degeneration  is  the  rule.  Secondary  growths  in 
rts  are  due  to  infection  from  the  primary  focus,  but  organ- 
d  not  tissue-cells,  are  the  active  agents, 
bove  diseases  are  as  specific  as  the  "acute  specifics."  Their 

lesions  have  a  general  resemblance,  but  the  primary  seats, 
if  generalization,  varieties,  and  times  of  degeneration,  as 

the  clinical  symptoms,  establish  them  as  distinct  diseases, 
ismissibility  from  person  to  person  of  syphilis  and  glanders 


404 


THE  INFECTIVE  ORANULOMATA. 


is  well  knnwn:  tubercle  can  be  transmitted  experimentally,  and  the 
clinical  evidence  of  its  ordinary  communicability  from  man  to  uua 
is  Vi'Ty  strong.  Leprosy  lias  been  ac<iiiired  through  a  po9t-raorl«ii 
wound,  and  exjifriiiu'iital  inoculation  has  been  successfully  per- 
foi!))i'd  upon  a  criminal.  Actinomycosis  baa  been  transmittoil  fniis 
man  to  animals.  The  term  infective  granulomata.  though  .iilnpifil 
at  a  time  wlieu  their  real  nature  was  little  understood,  seems  ticltcr 
fitted  than  any  other  to  express  the  nature  of  the  lesionfl — tnnior- 
like  bodies  consisting  of  granulation  tissue  and  locally  or  genenllj 
infective. 

TUBERCLE   AND   TUBERCULOSIS. 

Tuberculosis  is  an  infective  disease  which  is  cbaracteriiwl  «»»- 
tomicully  by  the  formation  of  those  small  nodular  lesions  known  >► 
tubercles.  The  distribution  of  these  lesions  may  be  more  or  l« 
general — acute  general  tuberculosis ;  or  they  may  be  liinitc*!  to 
small  areas — c.  7.  a  pleura  or  the  synovial  membrane  of  a  jnint— 
local  tuberculosis.  The  latter,  as  a  rule,  runs  a  much  more  cIiphib 
course  than  the  former,  and  perhaps  its  chief  danger  is  that  it  wtf 
serve  as  a  focus  for  general  infection. 

The  virus  of  tubercle  does  not  always  produce  nodules.     Lairniw* 
divided  tiilicMTuhir  lesions  into  the  nodular  and  the  infiltrating,   l** 
tlie  hitter  case  a  diffuse  inflammatiuu  is  found,  and  micr<i.>>i'Opic  f*' 
auiiuation  shows  the  presence  of  numerous  non-vascular  collection* 
of  cells,  not  aggregutcd  into   visible  nodules,  but  separated  by  »* 
ordinary  nmnd-cellcd   infiltration.     The  presence  of  the  orJini»'fi 
tubercles  in  a  tissue  is  always  accompanied  by  more  or  less  i: 
mation,  as  is  best  seen  in  serous  membranes. 


I 


NAKED-EYE  APPEARANCES. — Tubercles  are  divided  i«»' 
two  varieties,  gray  and  yellow,  the  latter  being  later  stages  of  ** 
former.  Gray  nr  miliary  tubereles  (gray  grrunulataonsi an 
semi-translucent,  rounded  bodies,  varying  froui  just  visibi'  , 
to  nodules  the  si/,e  of  a  ]iin's  head  or  larger.  They  art  firm 
shot-like,  distinctly  circumscriiicd  and  prominent  above  the  snrfi 
of  the  section.  Yellow  tubercles  are  generally  larger,  less  regu' 
less  closely  defined,  and  softer  than  the  gray.  They  may  even  (at^ 
masses  the  size  of  a  cherry  or  small  walnut.  In  some  caim*  id9^ 
of  the  tubercles  present  are  gray,  whilst  in  others  all  arcycll(»^i 
but  it  is  fre(jueutly  po.ssible  in  the  same  case  to  trace  every  htagt  H 


ul»^ 


TUBERCLE  AM)  TUBERCULOSIS. 


405 


tlie  formation  of  a  yellow  from  a  gray  notliile.  Fatty  (lo<:^encration. 
connivncing  centrally,  is  the  main  cim.ic  of  tlio  clifl'erence  between 
them.  A  large  mass  of  yellow  tubercle  is  formed,  not  by  the  growth 
of  uny  single  tiibercle.  but  by  the  blemiing  of  several  arising  close 
liigethcr.  It  is  often  jKissible  lo  recognize,  round  a  yellow  cheesy 
Dmss,  a  narrow  gelatinous  zone  consisting  of  gray  tubercles.  Gray 
tuljorcles  may  be  also  seen  radiating  frnni  the  eheesy  focus  into  the 
ailing  tismics,  thus  indicating  that  infection  from  the  central 
to  the  formation  of  fresh  tubercles  in  itx  immediate 
neighborhood,  and  these,  as  they  enlarge  and  degenerate,  become 
part  of  the  central  mass.  A  yellow  uniss  thus  formed  is  called  con- 
glomerate tubercle. 

SEATS. — The  skin  and  subcutaneous  tissue,  the  inucons  mem- 
branes— res|iiratory,  aliuientiiry,  and  geiiito-urinary — ami  the  serous 
Mil  synovial  membranes  are  very  commonly  affected ;  so  also  is  the 
pia  mater.  The  dura  mater,  the  e|(eiiilyrn!i,  and  the  endoeardium 
rarely  suffer.  Tubercles  are  frenuent  in  the  lyiu|iiiHtic  glands,  lungs, 
liver,  spleen,  kidneys,  and  testes;  less  common  in  the  brain  and 
spinal  cord,  adrenals,  and  ju-ostate ;  rare  in  the  heart,  salivary 
gland-s,  and  pancresis  ;  and  very  rare  in  the  mamra.T,  ovaries,  thyroid, 
»n(l  Voluntary  muscles.  They  are  common  in  bone,  es|)ecially  in  the 
cancellous  part.  They  are  particularly  comuuiu  in  childhood  and 
wiflv  adult  life,  but  no  age  is  cxenijit. 

HISTOLOGY. — On  examining  microscopically  even  the  funnlh-Ht 
tiiheri-h-  fim'fi/r  tn  tlif  nnki'il  i'i/i\  it  is  found  to  be  made  up  of  a  col- 
lection of  still  smaller  tubercles,  eiicli  of  ir/iif/i.  as  a  rule,  contains 
'iiK  following  elements:  (1)  centrally,  either  one  or  more  multi- 
"iideatcd  eriant-cells  (Figs,  l^^l  and  1:^2)  or  some  granular  iltM)ris 
"urroimJeil  by  giant-cells  ;  (2)  outside  the  giant-cells  usually,  but  by 
""means  invariably,  large  cells  with  big  nuclei  and  granular  proto- 
l''»sm,  often  called  epithelioid  cells;  and  {•1}  imtside  these,  again,  a 
*ine  of  lymphoid  eleiueiits  which  has  no  definite  external  or  inter- 
"*'  limit.  The  giant-cell  or  cells  in  many  cases  .send  off  processes 
»luch  ana-stomose  and  form  an  open  network  (Fig.  133),  in  which 
"ic  other  cells,  especially  the  epithelioid,  lie.  The  lymphoid  cells 
•fp  commonly  containe<l  in  the  meshes  of  a  homogeneous  or  more  or 
leii«  fihrillated  reticulum,  which  in  some  eases,  especially  in  slowly- 
Jfvclopcd  lesions,  is  well   marked  |Fig.  1;^4).      In  others  it   is  less 


AND  TUBERCULOSIS. 


407 


Kui.  i;J4. 


■^^f^, 


A  portion  of  «  tiTRV  mili- 
ar}' tulRTi'lc  of  ttic  luni;, 
tilir>\vlii|<  the  rctiiulBtud 
Ktnu'tiiro  ofti'ii  mi't  with  in 
tbeae  iiodulen.      :<  20U. 


I'ng  fine  hairs  into  it.     Laulauit'-  states  that  in  t)ie  lung  disease 

>d  in  dogs  by  the  gtnmr/i/lug  vnaoriim  the  ova  ami  cnihryof*  may 

)en  in  giant-cells,  suri-ounded  by  zones  of  ejiithelioiil  and  lym- 

I  cells.     In  actinomycosis  in  animals  uu 

:lv  similar  arrangement  of  cells  is  found 

^^Ktnt  the  central  iwHnoinyvcs  or  fungus 

^Bsease. 

T  can  the  .ibovc  structure  be  said  to  be 

ant.     For,  especiall}'  in  acute  cases  end- 

'atally.   some  of  the  tubercles  seem   to 

St  entirely  of  small  round-cells,  no  epi- 

»id  or  giant-cells  being  visible.     In  the 

the  alveolar  epithelium  often  enters 
■unto  the  constitution  of  the  lesions. 
Ries  visible  to  the  nakeil  eye  will,  however,  generally  consist 
;gregations  of  nodules  of  tlie  above  structure  (Fig.  102). 
urce  of  the  Cells  in  Tubercle. — Baumgarten's  explanation  is 
>ne  mo.st  generally  aefe]tteil.  According  to  liiui.  the  cells  are 
ed  from  the  local  tissue-cells,  including  both  epithelial  and 
Bctive  tissue  (fixed  and  endothelial).  This  observer,  experi- 
ing  with  albino  rabbits,  introduced  pure  cultures  of  tubercle 
h  into  the  anterior  chiuuber  of  the  eye.  In  a  few  days  there 
»red  i»uclear  changes  in  the  connective  tissue  and  endothelial 
of  the  iris,  such  as  are  characteristic  of  cell-division  (p.  27). 
e  changes  were  limited  to  the  cells  in  which  bacilli  were  pres- 

They  were  followed  by  pndifenition  of  the  cells  themselves, 
h  then  gradually  assuiucd  au  e])ithelioid  type.  No  nuclear 
ges  iiulicative  of  ])rolift'ration  of  any  fiu'ui  of  leucocytes  were 
"ved,  but  the  jiroliferating  [mtuli  was  gnidiiiilly  invaded  by  leu- 
■nutil  they  ijuite  obscured  the  epithelioid  cells.  Giftnt-cells 
oocasionally  present,  but  only  in  the  Inter  stages;  when  pres- 
hey  showed  no  sign  of  division,  but  only  of  degeneration. 
^tchuikofT  maintains  that  the  cells  believed  by  Baumgarten  to 
H|)rogcny  of  connective  ti.ssue  are  niononticlenr  leucocytes. 
[Rase  of  the  lung  he  admits  the  endothelial  cells  of  the  blood- 
Is  to  a  share  in  the  jirocess,  and  also  attributes  to  them  a 
ocytic  function.  In  his  opinion,  the  tubercle  is  formed  by  the 
mulntion,  not  by  the  prolitVrtitimi,  of  phagocytes.  Giant-cells, 
rdiog  to  him,  are  phagocytes  that  have  eoud)ine<l  for  the  common 
)  to  Baumgarten  and  Koch  they  are  solitary  individuals 


408 


THK  INFECTIVE  OBANULOMATA. 


tlisit  have  tried  to  niultiply.  but,  tlioiiph  their  nuclei  bave  diri<l«4 
utitl  iLfir  size  has  increased,  have  failed  at  the  final  stage  nf  e^U- 
division.  In  parts  in  which  epithelium  is  present,  *s  in  the  loEmi:. 
liver  (Fig.  IS.")),  kidney,  or  testicle,  there  can  be  no  qnestioo  hmvt 
that  the  ei)ithclial  cells  multiply  freely.     In  a  lun;:  affected  by  acv^tt 

Fro.  l:«. 


\ 


A  »liii;le  tubercle,  Invlalble  to  the  iwk«d  cj*.  tnm  the  IlTer  nf  k  rhilil,  a«n|  flv*.  vke^ 
from  ncutc  tiilirrculcpilf.    .iiiUiit.rcll  with  (wo  i,T<iii|*  uf  iiu>  \mrtOihi 

tii-iir  DuM'L'filn*.    Surrtitifidiiijc  it  Ih  All  iire4»  <if  L'oinnieiictnK  '  i.llieeKUa 

InwoiuIiik  IniliKllncl.     KiivoIujiIhk  thU  U  n  «>iic  of  crlU  con-  •(•  i 

cjrtM,    The  leueiioytc*  lire  1111141  niiini'rvii<<  mi  llir  >liU- Mlurt  <<all 

Tba  wbok' lUttM  !•  liiilwiliU'il  itmiiiiu  KnifiiiUr  IIvitivIIk  III  III  irra.    Xt 

miliary  tubercuhisis  we  find  that  many,  even  the  majority,  of  i 
nodules  do  not  {losse.ss  the  lymphoid  structure  above  de«rrititfd.  1 
are  collections  of  epithelial  cells  in  the  alveoli,  (iiant  and  t>|»itb« 
oid  cells  may  be  present,  formeil  apparently  from  alveolar  epithdii 
as  Klein  and  Cheyne  a.><sert.  Koch  al.so  regard.s  certain  pi^ 
containing  giant-colls  as  originating  in  alveolar  epithelium, 
ijuotes  Cheync's  observation  of  giantH'ells  in  the  alveoli  in  Mf 
of  his  view. 


SECONDARY    CHANGES.— Tubercle    invariably     nnrl 
more  or  less  fiilty  metiimorpliosis  and  caeeation  with  its  iiltii 
changes  (p.  B9).     In  some  cases  the  nodules  may  become  devdi^ 
into  an  imperfect  fibroid  structure. 

Caseation. — The    occiirreiice    of    fatty    changm   and 
before  the  vessels  have  developed  is  probably  due  to  the  actkMii 
the  surrounding  tissues  of  some  substance  secreted  by  the  barilli. 


TUBERCLE  A^^D  TUBERCULOSIS. 


409 


Fii,.  \m;. 


— -  -i^^io  --■ 

One  of  the  irrey  ntxl- 
uli'S  from  tb(?  tuni;  In  a 
I'm!!'  tif  acute  tutjcn'iilo- 
si*.  wliirh  ly  booominn 
i>|)U(liiir  niid  Hon  ill  thv 
"i.'iilri-.    (lUnKrammatlc.) 


Thifl  uittj  also  account  for  the  obliteration  of  pre-existing  blood- 
vessels which  accompanies  the  sprcu.d  of  the  lesintyy.     The  change 
commences    in  the  centre  of  the  nodule,  this  being  the  part  first 
«lcveloped.  and   consequently  that  which  is  the 
[farthest  removed  from  vascular  sup|)ly  :  it  is  also 
the  jinrt  nt  which   the  bacilli   are  at  first  most 
niinierous.  arnl  it  is  therefore  most  expose<l  to 
■their   deadly    influence.       The    noddle    breaks 
■down  into  a  granular  fatty  d^-bris,  so  that   its 
Kcentral  portions  soon  become  opuijui'  and  yel- 
lowish (Fig.  130).      In  some  cases  the  process 
of  di?inte;:ration  is  rapid,  whilst  ig  others  it  is 
more  gradual.      It  is  usually  most  marked  in 
the  larger  and  more  diffused  lesions,  and  hence 
is  these   lesions  which  are  most  commonly 
>f  a   yellow  color  and  soft   consistence  ("yellow  tubercle"). 

Fibroid  Chang's. — In  other  ca.ses  the  retrograde  change  is  less 
larked.  The  central  portion  undergoes  fatty  degeneration  and  is 
n>re  or  less  completely  absorbed,  whilst  the  ring  of  leucocytes 
ibicb  intervenes  between  the  baccilli  and  the  liealtby  tissues  is 
dually  replaced  by  a  dense,  contracting,  fibrous  capsule.  Ulti- 
mately, a  mere  sear  may  remain,  but  points  of  fatty  degeneration 
lire  fretpient  and  may  undergo  further  changes. 

It  will  be  noted  that  this  "  fibroid  change"  is  simply  the  eneap- 
sulntmn  of  a  slightly  irritant  foreign  body,  iiTid  might  take  place  in 
e.xiictly  the  same  wiiy  if  a  bullet  or  piece  of  wire  lay  in  the  ti.s.sues 
instead  of  tubercular  organisms  in  fatty  detritus.  This  replace- 
Bient  of  the  tubercular  tissue  by  scar-tissue  occurs  in  the  smaller 
lesiiins  and  in  many  of  Inrger  size  which  o|ien  upon  the  inner  or 
'>ut*r  surface  of  the  body,  and  from  which  the  infective  material 
tan  be  thus  discharged.  The  change  obviously  tends  to  protect  the 
•"■gsni.sm  against  generalization  from  the  focus  in  which  it  occurs. 
""'l  indicates  that  the  tissues  have  gained  the  upper  band — they 
''*^»'  imprisoned  the  bacilli.  There  is  the  same  antagonism  between 
tuc  organisms  and  the  tissues  in  tubercle  as  in  other  diseases,  and 
""■'  rwisting  power  of  the  ti.ssues  may  also  be  sutlicient  to  enable 
'■'fni  in  the  long  run  to  overcome  the  invaders — a  fact  for  some 
tinie  overlooked.  But  fretpiently  the  predisposition  of  the  tissues 
•o suffer  from  tubercle  is  so  great,  or  the  <lose  of  the  organisms  is 
W  large — as  when  most  of  the  contents  of  a  small  cavity  which  had 


410 


THE  INFECTIVE  GRANULOMATA. 


just  burst  into  a  broncbus  i.s  sucketl  hy  inspiration  into  othwl 
tubes — that  a  wiilespreiid,  diffuse  intiaiumiilion  results;  and  llici 
extended  the  lesion,  the  more  rapidly  and  freely  the  inflauimsU 
products   caseate. 

Sometimes,  es]>ecia!ly  in  cases  which  have  run  u  chronic  cni 
and  in  which  the  diagnosis  may  have  been  "chronic  brontliitis, 
hard,  glassy  bodies,  often  specked  with  black  pigment,  are  foun 
the  lun^-tissue.  There  is  no  caseation,  and  tlie  microscope  sll 
tlie  masses  to  consist  of  almost  hyaline  fibrous  tissue.  Tbi«i 
plete  fibroid  transformation  is  said  by  Birch-Hirschfeld  to 
occasionally  in  lyui))liiitic  glands,  and  is  often  thought  to  iti'li 
that  the  bacilli  are  dead.  On  the  other  hand,  while  the  oa« 
material  persists  the  focus  remains  infective,  and  the  organian 
tlu'ir  spores,    tiiough   ([iiiescent,  are  alive. 

Calcification  fro(juently  ensues  upon  caseation,  when  the  ch« 
])roiiuuts  bec<mic  encajisuled  and  ahuost  all  fluid  is  ubsorM: 
deposit  of  earthy  salts  in  this  truly  cheese-like  material  eoiivf 
either  into  a  gritty  mass   or   into  a  more  or  leas  irregular  *l 
body.     Caseous    mesenteric   glands    are   especially    prone  tu 
infiltration. 

Sections  of  these  calcareous  nodules  when  decalcified  ntid 
amiued  under  the  microscope  are  seen  to  consist  chiefly  of  n  ( 
of  concentric  layers.  These  layers  are  composed  of  a  substi 
which,  according  to  Metciiiiikoff,  gives  the  same  reactions  iw  t^ 
forming  the  envelopes  of  the  tubercle  bacilli.  Arguing  from  ^» 
experiments  on  Algerian  rats,  he  maintains  that  these  laycn^^ 
formed  by  successive  secretions  of  the  bacilli,  and  that  they  sow*' 
•  piently  become  infiltrated  with  phosphate'  of  calcium.  Accord^j 
to  his  view,  the  concentric  layers  would  seem  to  be  the  hned^l 
defence  which  the  bacilli  tlirow  up  against  the  advancing  pL«^*^ 
cytes,  while  the  calcification  is  the  investing  earthwork  by 
the  attacking  phagocytes  seek  to  enclose  and  to  reduce  by  »t) 
tion  the  organisms  they  cannot  reach,  or,  reaching,  cannot  destl 

Softening    and    Chronic    Abscess. — Caseous    ma.ss«'s    do 
always  dry  u|)  and  become  encapsuled.  but  often  soften  and  bl] 
down  into  the  pus  of  a  chronic  abscess;  and  even  when  they  1 
become  encapsuled  and  calcified,  softening   may  occur  mund 
them :  a  chronic  abscess  is  then   furmed  and  the  dead  muteril 
discharged.     It  is  the  smaller  encapsuled  foci,  and  especially  ' 
which  lie  deep  in  the  substance  of  organs,  that  become  dry  • 


TUBERCLE  AND  TUBERCULOSIS.  411 

alcified ;  whilst  the  extensive,  diffuse  lesions  and  those  lying  near 
I  skin  or  macous  surface  tend  to  soften.  In  other  words,  the  less 
he  resistance  of  the  tissues  to  the  infective  process,  or  the  greater 
:heir  proneness  to  be  irritated  by  the  tubercular  organism,  the 
^eater  is  the  tendency  to  softening.  It  seems  likely  that  this  irri- 
tation of  the  tissues  is  the  cause  of  the  exudation  of  fluid  into  the 
ciieesy  mass,  and  that  this  exudation  changes  the  latter  into  a 
:hronic  abscess;  for  an  examination  of  the  "pus"  of  a  chronic 
ibsces-s  shows  that  it  consists  chiefly  of  fatty  granules  suspended  in 
finid,  with  here  and  there  a  fattily-degenerated,  granular  leucocyte. 
The  fluid,  therefore,  is  quite  different  microscopically  from  that  of  an 
icute  abscess  (p.  -301).  It  differs  also  to  the  naked  eye,  being  gen- 
erally whiter  and  thinner  than  true  pus,  while  it  often  contains 
curdy  masses,  which  may  be  either  gritty  or  stony  from  calcification. 
The  "  pus  "  of  chronic  abscess,  being  thus  formed  by  the  suspen- 
sion in  albuminous  fluid  of  fatty  particles  derived  from  the  fatty 
degeneration  of  cells,  has  received  the  name  of  "  pathological  milk." 
The  enormous  majority  of  chronic  abscesses  are  of  tubercular 
origin:  a  tubercle  forms,  spreads,  and  softens  as  above  described, 
the  originally  firm  swelling  becoming  more  and  more  fluctuating  as 
the  softening  proceeds.  So  chronic  is  the  process  that  there  is 
often  no  sign  of  inflammation  until  just  before  the  "  abscess " 
bursts,  when  the  tense  skin  where  it  is  pointing  becomes  red,  shiny, 
>nd  progressively  thinner.  Ultimately,  the  epidermis  bursts  and 
the  cavity  discharges  its  contents.  The  wall  of  such  a  cavity  is 
lined  by  a  thick  layer  of  pale  purplish  granulation  tissue  in  which 
••■e  yellow  foci.  This  lining  is  so  loosely  adherent  to  the  surround- 
">g  tissues  that  scraping  with  a  sharp  spoon  easily  detaches  it,  and 
brings  it  away  either  entire  or  in  large  pieces.  The  tissues  beyond 
"  are  not  infiltnited.  It  is  very  important  that  the  wall  should  be 
■^njoved  from  such  abscesses,  as  well  as  the  base  from  any  ulcers 
f^sulting  from  their  bursting ;  for  the  granulation  tissue  is  infected 
V  the  tubercle  bacilli,  and  will  continue  to  caseate  and  soften  in 
'P<its,  and  perhaps  slowly  to  invade  surrounding  parts.  Healing 
*  'mpossible  until  the  diseased  layer  has  been  cast  off  and  replaced 
'y  healthy  granulation  tissue. 

This  account  of  the  formation  of  a  chronic  abscess  holds  good 
*herever  it  may  appear :  in  the  subcutaneous  tissue  {subcutaneous 
^f^mout  nodule,  so  common  in  children) ;  in  a  lymphatic  gland  (the 
^'^moua abtceas, par  excellence);  in  the  lung,  where  sooner  or  later 


412 


TllK  ISFECTTVE  GRANVLOMATA. 


it  bursts  into  n  bronchus,  dischurgfs  its  contents,  nnd  forms  «< 
or  vomirn  ;  in  the  tLickcued  synovial  meuibrnuo  of  a  scrofulous] 
{white  atpeUing) ;  or  iu  a  bone,  as  is  seen  in  cnries  of  the 
The  chronic  abscesses  which  arise  in  connection  with  deep 
especially  those  of  the  spine,  are  freipiently  eallefl  gra 
af>»ff»ni'K,  because  the  pus  often  runs  long  distances  among  i 
partM  before  it  reaches  the  surface,  and  usually  in  a  di< 
toward  the  feet.  But  extension  by  no  means  always  occurs  ial 
direction,  and  when  it  tioes  occur  is  not  iirrestc<l  by  placing 
|)aticnt  in  the  horizontal  |)08ition.  We  may  thecefore  cno 
that  in  these,  as  in  all  other  cases,  tlie  pus  spreads  in  the  ilirfl 
of  least  resistance,  and  that  gravity  has  couiparatively  little  I 
with  it.  Instances  have  been  recorded  of  alwcess  starting  from  d 
low«'r  dorsal  or  luiiiliiir  spine,  entering  the  sheath  of  the  pooas,  OMI 
ing  gradual  absorptirm  of  its  muscular  fibres,  working  il«  V" 
beneath  Poupnrt's  ligament,  taking  the  counw  of  the  profan 
artery,  passing  thmugli  the  adductor  magniis  into  the  p<i| 
space,  penetnvting  between  the  su|ierficial  and  deep  posterioi 
muscles,  and  finally  pointing  by  the  inner  malleolus.  Sot 
abscess  is  contained  in  a  dense  fibrous  sheath  formed  by  infta 
torv  thickening  of  the  natural  connective  tissue.  This  *b« 
Sometimes  strong  enough  to  be  dissected  out  and  dried.  The  ari 
is  crossed  by  stoutish  bands,  many  of  which  contain  voweU,  M 
care  must  be  taken  lest  a  finger  introduced  during  life  irar  ihri 
The  inner  surface  of  the  cavity  is  but  slightly  vascular,  the  coi 
between  the  chronic  and  acute  abscess  in  this  respect  bvinj 
marked.  It  is  usually  coated  with  a  cheesy  deposit  of  ir 
thickness,  beneath  which  lies  a  very  thin  layer  of  granQUiiti 
sue.  At  the  upper  extremity  is  the  diseased  bone — tbe/oM 
nDilomm. 

In  the  pus  of  these  abaces.se8  no  organisms  can  be  discover 
the  means  at  present  iu  use,  yet  the  pus  is  infective  ami 
general  tuberculosis  when  injected  into  animals. 


RESULTS. — Recovery  may  occur  after  the  tiischi 
pletc  removal  of  all  tubercular  tissue.     I'nder  tbc««  ciirm 
healthy  granulation  tissue  springs  up  and  develi>ps  into  ai 
ing  up  and  drawing  together  the  cavity    of   the  alMceta  ur 
There  is  alwa^'s  loss  of  substance. 

In  the  condition  known  as  obeolesoenoe  the  caaeoM 


TUBERCLE  AUTD  TUBERCULOSIS. 


413 


jiiirrounded  by  a  dense  fibrous  capsule,  often  with  radiating  bands 
liwing  from  it  into  the  siirroundini;  tissues.  It  is  often  seen  at  the 
apices  of  lungs,  and  may  serve  as  a  practical  cure;  but,  theoreti- 
cally, it  is  not  one  unless  the  tubercular  organisms  are  dead,  for 
tliev  may  at  any  time  be  carried  from  the  focus  into  the  system  at 

hiTgV. 

Lantly,  death  frecjuently  results  from  tubercular  processes,  both 
general  and  local.     The  acute  general  tuberctiloses,  afiectiug  chiefly 
meninges,  lung.i.  and  peritoneum,  kill  by  their  general  to.\ic  effect, 
by  fever,  and  by  interference  with  the  functions  of  vital  parts;  c. ;/. 
the  functions  of  essential  cerebral  centres  may  be  arrested  by  the 
compression  of  the  effusion.     Chronic  local  tuberculoses  kill  either 
by  leading  to  a  general  outbreak  or  by  e.xhuu.stion  from  fever,  pain, 
•nd  profuse  and  prolonged  discharge,  especially  when  septic  pro- 
cectes  are  supera<lded  (p.  347).     Indirectly,  a  tubercular  process 
may  open  the  door  to  some  infective  wound  disease,  such  a.s  erysip- 
elas or  pyiemia. 


ETIOLOGY  AND  GENERAL  PATHOLOGY.— In  18.*)7.  Buhl, 
commenting  on  the  very  frequent  presence  of  caseous  foci  in  general 
tulierculosis,  anil  on  the  local  infection  which  often  occurs  round 
socb  foci,  promulgated  the  view  that  a  jroisnn  capable  of  giving  ri.se 
•o  tuberculosis  was  generated  during  the  caseation  of  infiauiiuatory 
products.  CdSfation  was  the  one  essential  feature.  Virchow,  how- 
ever, pointe<l  out  that  caseation  occurred  in  new  growths  and  under 
•^'•MUmstances  in  which  all  connection  with  tubercle  could  be  nega- 

III  I860,  Villemin  made  numeroiis  experiments  which  seemed  to 
•***ttionstrate  the  infective  nature  of  tuberculosis.  He  placed  tuber- 
*^»*lttr  material  beneath  the  skin  of  rodents,  and  general  tubercle 
'^ovolopeil.  Villemin  believed,  therefore,  that  tuberculosis  was  a 
''oasc  due  to  a  sj)ecific  poison  contained  in  the  foci  of  the  diseiuse. 


<1 

M 


•s    experiments  were  repeated  by  Cohnheim  and  Friinkel,  Wilson 

•^X,  Sanderson,  and  others,  who  found  that  tuberculosis  followed 

"G  inoculation  of  cheesy  material  which  was  jtresutiiuldy  mit  tuber- 

*^^lur.  and  even  such  simple  inrtammatiou  as  resulteil  from  the  inser- 

''»li  of  setons,  of  vaccine  virus,  and  bits  of  cork  or  paper.     Sander- 

^*»,  however,  condutled  that  nothing  induced  tuberculosis  m'th  such 

^'^taititt/  as  material  taken   fnuii  iin  iiudiitibtcdiy  tubercular  source. 

Klebs  pointed  out  that  possibly  the  non-tubercular  material  might 


414 


THE  ISFECTIVE  GRANULOMATA. 


Lave  become  contaminated  by  the  tubercular  virus,  as  at  that  date 
])recnntions  were  not  vcrv  strinppnt.  It  wiis  probable,  too.  that  in 
many  cases  where  septic  materials  were  used  the  process  iinlun 
was  pyflemic. 

It  tlien  occurred   to    Cohnhcim   and    Salomonsen   to  select  tlif 
anterior  chamber  of  the  rabliit's  eye  as  the  point  of  inoculutio 
Here  the  results  of  the  inoculation  could  be  watched  from  dav 
day,  and,  as  primary  spontaneous  tuberculosis  of  the  iris  had  ik 
been  seen  in  rsibbits,  the  possibility  of  this  couhl  be  excluded, 
was  thus  pntvcd  that  wliilst  inoculation  of  >um-tuberrular  miitera 
into  tlie  anterior  chamber  of  the  eye  invariably  failed  to  indi 
tubercuhisis,  the  inoculatiiui  of  fulifi-culnr  material  jiroduced  tnl 
ck'S  in  the  iris  and,  a  little  later,  in  the  body  at  large.     The  ji 
of  the  infective  nature  of  the  tubercular  process  was  thus  complet 
and   it   was   further  shown    (hat   tubercular  materials  from   wiiiclj 
different  sources  containeil  the  same  virus.     Tappeiner  caused  liugt, 
to  inhale  daily  for  fourteen   days  si.x  grammes  of  tubercular  s|H 
delivered  during  six  hours  from  a  s[)ray  into  a  narrow  box  contail 
ing  the  ajiiniul :  all  beeatne  tuberculou.s,  the  twenty-third  day  bi'il 
the  earliest  upon  wliieh  tubercles  were  found.     Thus  tubercle  cat 
to  be  regar<led  as  a  »penji<-  iiifectiniiK  di»ra»e. 

Many  of  those  who  held  this  belief  suspected  that  the  virii.s  «ra»i 
vegetable  parasite,  and  seiirclied  for  it.  Between  1877  anil  1^^ 
several  premature  announcements  were  made. 

The  next  publication  was   Koch's  paper.'     By  a  special  pi 
of  staining  he  first  demonstrated  the  constant  presence  of  pecnlil 
bacilli  in  eleven  cases  of  acute  tuberculosis,  twelve  cases  of  chwsy 
bronclio-pneurtmnia.  one  of  tubercular  nodule  in  the  brain,  and  t*" 
of  intestinal  tuberculosis  in  man.     Ten  cases  of  perlsucht  and  ra«* 
of  spuntuiieivus  tubercle  in  monkeys  and  other  animals  were  invc#- 
tigated  with  a  like  result,  and  finally  the  bacilli  were  found  in 
large   number   of   rodents   and    five  cats   artificially    infected, 
proving  that  the  tuberculosis  resulted  from  the  inoculation  and 
not  accidental,  there  was  (1)  the  invariable  coincidence;  (2) 
more  rapid  development  of  the  artificial   than  of  the  spontaneoi 
tulierculosis ;  (3)  tlic  early  infection  of  the  glands  nearest   the  seat 

'  "  D.  JEtioloRJe  d.  Tubercnloae,"  Btrl.  klin.  WoehrnDfir^  Nn.  15,  1R«)2.  Hin  papw 
on  the  8anie  subject  in  the  Mitihril.  niui  lUm  Grtundhrilmmle,  vol.  ii.,  1884,  lnu»- 
lateJ  ill  the  New  Sydeiihaui  Society's  Microixtrantet  in  Diatoie,  is  fuller,  and  < 
be  read  liv  nil. 


TUBERCLE  AND  TUBERCULOSIS. 


415 


of  iDoculntioD,  whereas  the  bronchiul  glands  usuuUy  enlarge  first  in 
>|wiiit:iut'iiiis  riiscase ;  an<i  (4)  roiitriil-cxjR'riim'iitt'  in  whivh  animals 
wiw  treiitfd  exactly  as  the  iiioctiJMted  iininials  were,  witii  the  single 
pxce|)tion  that  no  living  bacilli  were  introduced:  in  these  no  tuber- 
niliwis  occurred. 

Finftlly.  the  bacilli  were  cultivated  at  'J8°  F.  to  10<l.4°  F.  (;J7°  to 

•'<'*'('.)  in  sterilized  blood-serum.    After  thus  passing  through  many 

Xeserationa.  these  bacilli  were  su.sfiended  in  distilled  water  and  in- 

j«ti>(l;  thcv  then  jirodiu'eii  tuberculosis  as  surely  as  did  the  original 

"wtcrial. 

These  results  have  since  been  fully  confirmed,  and  their  truth  is 


FiQ.  137 


Fto.  138. 


!€._ 


41 


mm 


[••Iwrclc  tiaclUi  In  triinitH-fU  ift-um  tiilier- 
>i>iir  horwi.     •  WKI.    ((.'hejrne.* 


X&OO 


Tubercle  bitrilU  (fniin  a  rolnny  on 
hlood-«eruni),«hiiwln(f  the  wavjr  paral- 
lel lines.    X 'VIO.    (.ifter  Koch.) 


►^"^  nnqnestioned.     We  are  therefore  jiistifieil  in  believing  that  the 
illus  tuberculosis  is  tlie  cause  of  nil   tubercular  [ircicesses.     Its 
*ence.  rather  than  any  anatomica)    stnicture,  is,  at  least  in  the 
***"ly  stages,  the  essentia!  characteristic  of  tubercle. 

Characteristics  of  the  Bacillus. — The  bacillus  i«  2  to  6  /i  long, 
^i^o  or  three,  placed  end  for  end,  making  n]>  the  disinieter  of  a  red 
^BlcKkl-corpuscle.  It  is  very  thin  (i  to  J^  of  lengtli).  niottonleiis.  and 
H^'ihded  at  the  ends.  It  can  be  stained  with  Zielil's  fluid  (ji.  :150) 
"■*r  W  (iraiii's  method  (p.  349).  It  has  genenilly  ii  bciuled  appcar- 
tiice — clear  spots  (four  to  eight)  alternating  with  stained  parts. 
'^i  bacilli  are  usually  straight,  but  may  be  curved ;  they  occur 
*"ig|y.  but  sometimes  in  pairs.  Mu!ti]>lic!ition  is  very  slow,  and 
•>ke!»  place  by  fission,  and  poissibly  by  spore-fornintion.  though  this 
:  i»  uncertain.     As  a  rule,  the  bacilli  are  found  in  the  cells  of  the 


41  r, 


m.iTA. 


tubercle,  especially  in  giant-cells  opposite  to  the  nuclei.     The?  u» 
we!)  shown  in  the  accompiinying  dnnving  (Fig.  137). 

The  organisms  can  be  ciiiiivali'il  on  nieilia  containing  glycerin  or 
litoinl-serura.  They  are  aerobii-,  but  as  they  grow  only  at  higb  !«»• 
peratures  (82°  to  108°  F.),  they  probably  do  not  multiply  oat*vit 
the  body,  but  live  a  wholly  parasitic  life.  To  the  nakc<l  eye  !*«■ 
Frontispiece)  the  colonies  have  a  hcapod-up,  scaly  appoiramr. 
AVlieii  cxiimiiu'd  under  the  micro.scope  the  margins  of  the  colouiw 
show  a  peculiar  wavy  form  due  to  parallel  chains  of  organism*  fol- 
lowing the  same  curve  (Fig.  138).  Although  the  bacilli  do  art 
)«/(/^/i/// outside  the  body,  they  can  Iht'  for  a  long  time,  having  l»tn 
found  to  retain  their  virulence  after  existence  for  forty -three  ilaj»m 
putrid  sputtini  and  for  one  hundred  and  eighty-six  in  the  dry  sutf. 
In  putrid  fluids  they  do  not  long  hold  their  own  against  the  rapiiiW- 
multi])lyiiig  sejitic  organisms,  which  are  specially  adapiwl  for  thf 
ordinary  conditions  external  to  the  body.  It  is  in  the  sutr 'if 
"  dust  "  that  we  are  most  likely  to  meet  with  tubercle  bacilli  in  m 
surroundings,  and  obviously  this  is  the  state  in  which  thoy  »renii»* 
fit  to  cause  a  fresh  infection. 

With  regard  to  the  origrin  of  the  tubercle  bacUluB  from  wne 
non-pathogenic  fomi.  no  other  bacterium,  even  under  such  favowMf 
conditions  as  the  bodies  of  rabbits  and  guinea-pigs  present,  ImstHfn 
found  to  develop  any  of  the  peculiarities  of  the  tuherculnr  orpu'- 
ism.  Nor  are  there  at  present  any  facts  known  as  to  circiiiii!*tati(»» 
under  which  its  virulence  can  be  modified — increased  or  attt-nuaic'l. 
Nearly  two  years"  cultivation  external  to  the  body  caused  no  chan|.'f  i" 
the  latter  direction  (Koch).  We  must  conclude,  therefore,  that  tlirn- 
tubercle  bacilli  lutiltiply  only  in  the  body  of  man  or  some  other  aiiira^'- 
and  that,  cousei|Uently,  the  bacilli  which  cause  a  fresh  infection  Ci'D" 
either  directly  or  indirectly  from  some  tubercular  individual. 

Obviously,  all  cases  of  tubercular  disease  in  man  are  not  «iu»ll.'^ 
prone  to  disseminate  the  bacilli.     These  may  be  eliminated  wil" 
the  .sputum,  the  fieces,  the  urine  (in  tuberculosis  of  the  genito-orintff 
tract),  and  discharges  from  tubercular  ulcers  and  abscesses,  hut  tbf 
first  is  the  only  common  source  of  infection.     When  we  conwilrt 
that  about  one-seventh  of  mankind  die  of  phthisis,  and  that  in  all 
cases  in  which  cavities  form  the  patients  for  weeks  or  mouths  vn 
expectorating  large  quantities  of  bacilli,  we  see  that  this  one  soon* 
'b  capable  of  keeping  u(t  an  ample  supply.      The  bacilli  expelled  by 
ah  with  small  particles  of  mucus  may  be  directly  inhaled  bv  tlit 


TUBERCLE  AND  TUBERCULOSIS.  417 

healthy;  but  »putum,  which  dries  upon  handkerchiefs,  bed-clothes, 
«n(l  woollen  garments,  thence  to  be  detached  as  dust,  appears  to  be 
tie  most  fertile  source  of  infection.     Bacilli  found  in  the  air  are 
iiraally  adherent  to  some  bit  of  vegetable  fibre,  hair,  or  epidermis. 
Tnbercular  disease  in  animals  is  also  a  frequent  source  of  infec- 
tion to  man.     It  is  true  that  they  produce  no  sputum,  that  few  or 
no  bacilli  are  expelled  from  their  lungs,  and  that  bacilli  are  not  fre- 
quent in  their  excreta ;  but  the  milk  of  tubercular  animah  may  give 
rise  to  infection.     As  it  contains  bacilli  only  when  the  mammae  are 
tnbercular,  this  cause,  is  easily  preventible  if  dairies  are  efficiently 
inspected.    Lastly,  there  is  ianother  possibility  of  infection — through 
the  ingestion  of  tubercular  meat.     This  can  undoubtedly  occur,  as 
has  been  proved  by  feeding  animals  on  tubercular  flesh,  but  many 
things  militate  against  its  occurrence  in  adults,  in  whom  primary 
intestinal   tuberculosis  is  not  at  all  common.     The  flpsh,  if  visibly 
diseaised,  is  usually  rejected ;  it  is  generally  raised  above  100°  C. 
before  being   eaten ;   the   disease   in   animals   used  for  food,  and 
especially  in  cattle,  is  usually  localized,  and  infection  could  follow 
only  upon  eating  the  tubercular  parts,  such  as  the  lungs  or  glands. 
'Vhile,  therefore,  the  domestic  animals  are  possible  sources  of  infec- 
>ion,  in  the  majority  of  cases  the  disease  is  conveyed  from  man  to 
Dan. 

The  bacilli  are  readily  destroyed  by  boiling,  by  sunlight,  by 
'erchloride-of-mercury  solution,  and  by  carbolic  acid;  but  they 
esist  the  action  of  a  1  per  1000  solution  of  the  perchloride  for 
t>ine  minutes.  A  five  per  cent,  solution  of  carbolic  acid  acts  more 
apidly.     Desiccation  without  sunlight  does  not  destroy  them. 

Modes  of  Entry  of  the  Bacillus  into  the  Body. — The  sound 
tan  would  seem  to  be  impossible,  and  but  a  few  cases  have  been 
ecorded  in  which  infection  through  toound«  has  occurred.  One  of 
ue  most  conclusive  is  the  following :  A  perfectly  healthy  woman, 
»ith  no  tubercular  history,  cut  her  finger  with  a  broken  vessel  con- 
fining sputum  swarming  with  bacilli.  Acute  inflammatory  symp- 
toms followed,  but  subsided  under  carbolic  fomentation.  In  the 
mean  while  a  small  subcutaneous  nodule  of  granulation  tissue 
developed,  and  was  removed  at  the  end  of  a  month,  the  wound 
healing  by  first  intention.  Then  came  pain  in  bending  the  finger, 
» swelling  extending  along  the  tendon  into  the  palm,  and  swollen 
glands — two  above  the  elbow  and  two  in  the  axilla.  All  these 
parts  were  completely  removed,  the  wounds  healing  at  once,  and 
27 


418 


THE  INFECTIVE  GRANVLOMATA. 


no  further  spread  took  place.  Tlie  tendon-sheath  was  full  of  inn- 
uhition  tissue  containing  numerous  tubercles;  the  glamU  «e 
simply  hypcrpliustic.  Bacilli  were  fairly  common  in  both. 
eral  observers  have  stated  that  dissecting  warts  arc  tuberciil 
because  they  have  constantly  found  tubercle  bacilli  in  ginnt-p 
taken  from  degenerating  UDtiiiles  in  the  aflccted  skin.  MorwiT. 
these  warts  have  commonly  arisen  after  contact  with  tnbercnUr 
subjects.  Riehl  ami  F'altauf  regard  the  warty,  inflamed  papill.T.i« 
resulting  from  a  mixed  infection,  cocci  having  been  inociil.ii"l 
with  the  bacilli.  Volkmann  examined  one  case  of  scrofiilnn* 
eczema,  and  discovered  tlie  bacillus  of  tubercle  in  the  epithcli*! 
and  other  cells.  lie  therefore  believes  that  these  catarrhs  of  ibf 
skin  and  the  more  frequent  catarrhs  of  mucous  membranro  »rf 
due  to  the  irritation  of  this  organisiu.  Certainly,  lesions  of  lli* 
kind  lead  to  the  development  of  utrumous  glands;  and  in  onlcrt" 
account  for  the  np]iiirently  firimary  enlargement  of  suporficul 
glands  Koch  |iut  furward  the  now  generally  accepted  view,  thit 
the  swelling  bus  really  been  preceded  by  some  scratch  or  !tli|ili< 
sore  (on  the  skin,  whence  lyuipbatics  pass  to  the  gland),  iipo« 
which  tubercular  bacilli  have  fallen,  and  whence  they  have 
conveyed  into  the  lyni|diafics  too  siK'e<lily  to  interfere  much 
healing.  Lastly,  tuberculosis  is  said  to  have  been  c"oiiveve<l  by 
tmecination.  The  evidence  is  of  the  usual  pout  hoc  kind,  and  ik* 
statement  has  probability  against  it,  for  the  hhod  of  tubrrciil»r 
animals  is  only  infective  in  the  most  acute  cases  of  general  tutifrcu- 
losis,  and  the  children  from  whom  the  "  lymph  "  was  taken  wfw 
probably,  to  all  appearances,  healthy. 

Lupus  is  possibly  another  illustration  of  tubercular  infection  I 
the  skin  (p,  4:J8). 

The    mucx>UB    membranes  —  pulmonary    and    digestive — Bi<| 
therefore  ordiiuinty  Jiflurd   passage  to  the  bacilli :  the  possibility! 
this  has  been  demonstriited  by  the  success  of  inhalation  erprriti 
with  tubercular  sputa  and  cultivations,  nai  o{  feeJinff  f^rpfrin 
with  tuberculiir  tissues.      Pulmonary  tuberculosis  being  much  m"" 
frecpient    than   intestinal,   wo   may  assume  that  bacilli  more  ofirt 
pass  into  the  tissues  through  the  pulmonary  than  through  tbcftlin 
tary  mucosa.     The  difliciilties  in  both  cases  are  considerable, 
regards   the   thora.x.   tlie   bacilli  are  drawn   most   deeply  into 
lungs  by   deep   inspirations   through  the  open  mouth.     Evidently- 
they  cannot  be  carried  beyond  the  regions  of  the  tidal  and  coid|iI*- 


TT7SKRCLE  AND  TUBERCULOSIS. 


419 


menial  air.  ami  will  therefore  be  <leposited  in  the  smaller  l»n>nchi ; 
tint  they  nuiltijdv  m  shiwly  tlint  tliev  iire  usiiiilly  exjielU'il  by  fiiiiiry 
Mlioii  and  i-oiighing  before  they  can  sorioiisiy  injure  any  spot  jinil 
vfTect  an  entranee.  To  enable  them  to  do  this  8)ieeially  favarftl)le 
tirfumstances  are  necessary,  such  as  the  removal  of  much  of  the 
kniiirhial  epithelium  (after  measles);  the  presence  of  broncliitis, 
»illi  tenacious,  ami  therefore  retHine<l,  secretion :  ami  the  exist- 
wiff  of  pleural  adhesions  or  of  a  badly-formed  thorax,  preventing 
fiill  expansion  of  the  lunfr,  and  therefore  lemliiiji  to  local  retention 
<if  secretions.  Primary  intestinal  tuberculosis  (which  would  occur 
fri>m  tubercular  food)  is  rare,  except  in  children  ;  but  ulceration  of 
till' iinwels  occurs  in  every  three  cases  of  plithisis,  beiuvj  sipfmrent- 
Iv  line  to  infection  by  the  bacilli  in  swallowed  sputum.  Koch  says 
tbal  the  intestinal  mucosa  offers  n  less  favorable  point  of  attack 
•li»n  the  pulmonary — that  the  a<lult  buciJii,  like  anthrax  bacilli, 
•re  usually  destroyed  in  the  stomach,  whilst  the  spores  escape:  so 
"Illy  spore-bearing  bacilli  can  infect  the  bowel,  and  these  only  on 
I'  •"omlition  that  they  are  not  hurried  throurrh  the  canal.  Lastly,  it 
•*eeins  that  just  as  a  superficial  gland  niuy  be  infected  from  some 
^lesion  of  tlio  skin  so  sliglit  as  to  escape  notice  and  t<i  leave  no 
H^i^ce,  80  the  bronchial  and  mesenteric  glands  may  be  infected  by 
^Hnpili  which  pass  through  their  respective  mucosa;  without  leaving 
^Mi^' permanent  trace  of  their  passage.  Instead  of  settling  in  the 
F^ultuonary  or  intestinal  tissue,  they  are  evidently  curried  on  by  the 
iijph-stream.  and  in  the  majority  of  cases  arrested  in  the  tit'drcgt 
•ind,  though  the  arrangement  of  lymphatics  is  such  that  they 
aj  be  at  once  conveyed  to  more  <listant  parts.  The  affected 
inds  enlarire,  caseate,  and  often  infect  others.  Such  caseous 
ands  act  as  reservoirs  of  bacilli  and  their  spores,  and  too  often 
'*"ovc  sources  of  more  or  less  wides|ireu(l  infection. 
It  is  well  known  that  in  young  children  t!ie  liin(/»  are  not  affect- 
in  the  same  proportion  as  they  are  in  hiter  life,  that  the  disease 
not  so  locali/efl,  ami  that  the  lyu)|)hatic  gluiids  especially  are 
ore  universally  aflTected.  The  intestine  seems  in  a  large  number 
f  cnsw  to  be  the  part  primarily  attacked  (jt.  42H),  ev<'n,  as  Wood- 
"««d  insists,  in  those  cases  iu  wliicli  patients  ultimately  succumb 
from  disease  of  the  lung.  Thus  we  can  often  trace  the  infection 
from  an  old  calcified  gland  in  the  mesentery  to  the  retroperitoneal, 
[ulterior  mediastinal,  and  bronchial  glands,  and  thence  to  the 
'uags;  in  which  organs  the  disease  radiates  from  the  root. 


THE  INFECTIVE  GRANVLOM.ITA. 


Having  no  power  of  locomotion,  tbe  tuborcle  bacilli  iuu«t  hf 
carrit'd  tbrou;!;ii  tlie  puimonary  mucosa  by  leucocytes  like  carbno 
particles.  The  leucocytes,  wandering  short  distances  t'roni  llrf 
Iyin|)lioid  tissue,  may  easily  reach  the  surface,  and  thcrr  mttt, 
enclose,  and  carry  back  bacilli.  If  the  cells  sicken  while  i\ut 
bacilli  survive,  the  latter  may  find  theui-selves  in  some  plncc  wh«rr 
they  can  thrive  and  multiply,  and  thus  tubercles  may  iirisr.  In 
catarrhal  states  nmre  [ihagocytes  will  reach  the  inflanied  siirfaw, 
and  more  bai'itli  are  therefore  likely  to  be  introduced  into  ilw 
tissue. 

A  somewhat  straineil  analogy  may  be  drawn  between  the  ciillct^ 
tious  of  iyni])hoid  tissue  distributed  along  the  mucous  t-urfncc*  aiiJ 
the  fortified  towns  which  guard  a  fnmticr.  The  lymphoid  iirnwrt 
serve  as  garrisons  from  which  leucocytes  issue  out  and  deal  «iili 
any  organisms  they  may  chance  to  meet.  I'nfortunaiely,  tlic  iIb- 
criuiinating  [lower  of  the  phagocytes  is  not  eiiual  to  the  iiofssi'iti, 
and  they  sometimes  C4irry  back  bacilli  whose  subsequent  lirvfloft- 
nient   rcminils  one  of  the  oltl  story  of  the  Trojan   Horse. 

Predisposition. — Nothing  is  more  certain  than  ihaf  iii(liviiln«Ii! 
vary    in  their   liability  to    tubercular    diseases,  for   these  an?  f'f 
coninmnt'i'    in    the    young   thnii    in    the  old,   and    run   mnrkcilv  "' 
families.      ^Ve  have  no  knowledge  of  what  constitutes  this  prf*'"" 
position,  which  may  be  inherited  or  acquired,  local  or  general.    ^ 
small  flat   chest   and  a  tendency   to  catarrh  are  ot^en  prtwni  "> 
people   who   ultimately  develop   phthisis,   and   the   absence  of  fr** 
respiratory  n»ovement8    is   often   hehi    to    favor    the   entry  of  '■'' 
bacilli.     Often,  too,  members  of  tubercular  families  are  spcciiH/ 
exposed  to  infectiot»  in  nursing  a  sick  relative.     But.  even  all<i«ii'? 
for  these  facts,  it  seems  impossible  to  believe  that  there  is  no  Jiffcf' 
ence  between    the   predis|(osed   and    the   immune,   save  that  in  lb' 
latter  the  bacilli  do  not  gain  ontr.ince  ;  for  it  is  so  much  more  pr'l'- 
able  that  in  many  cases    they   enter,   but    fail   to  grow,  being  >l«- 
stroyed  by  the  tissues.    How  can  we  e.x)dain  acute  meniugcal  tabtr- 
ciilosis  or  tuberculosis  limited  to  the  peritoneum,  in  both  of  «hic\» 
multitudes  of  bacilli   must  have  been   thrown   into   tbe  cirouUtios 
from  some  bronchia!  gland   or  other  focus,  unless  we  assume  thtt 
the  bacilli   could  not  develop  elsewhere   than  in  the  tneuinget  (if 
peritoneum  respectively  ? '     How,  loo,  should  we  otherwise  expUil 

'  It  is  powiible  (Iml  n  mingle  infoction  of  the  pleiirn,  pericardiiini,  nr  (irrila 
might  liv  Hpn.-!ul  more  or  lees  nt]iiilly  over  the  whole  uiembmne  tbniiurtt  it* 


TUBERCLE  AND  TUBERCULOSIS. 


421 


fhi'  recovery  of  some  people  from  plithisis,  except  by  assuming  that 
tb«  noil,  which  was  at  mic  tiiiio  favorable  to  lliv  growth  nf  the 
tiacJIlus,  became  later  ou  iinfavoriiblf  '  The  precljsipositiori  seems 
to  vjrr  from  time  to  time  in  the  life  of  the  same  individual. 

Development  in  the  Tissues. —  liiiving  found  a  spot  at  which  it 

cmi  grow,  the  baeillu.s  proceeds  to  multiply  :  most  bacilli  are  taken 

lip  b_v  cells  which  enlarge  into  giant-cells  and  become  the  centres 

rtf  typical  "tubercles  "  (p.  404).     The  presence  of  these  in  a  tissue 

Mcites  more  or  less  inflamnintion.  often  so  much  that  we  find  the 

tiwoeg  diftusely  infiltrated,  distinct   niiditles  being  scarce  or  absent 

tuijHtratint/  varieti/).     Caseation  at    the   non-vascular  centres  soou 

follows,  being   preceded  by  coiigtilativf  iiccrosi.s  of  the  cells,  due, 

(10  doubt,  to  the  liirect  action  id'  the   prodiicts  of  the  bacilli.     The 

nearest  lymjihatic  glands  often  become  affected.    The  primary  lesion 

may  become  localized,  as  before  explained  (p.  408),  or  it  may  act  as 

a  starting-point  for  fresh  infection. 

Modes  of  Spread. — (1)  By  Continuity  of  Tissue  and  by  Lym- 
phatics.— This  is   the  way  in   which  the  masses  of  conglomerate 
yellow  tubercle  are   formed,   and   in  which   jmtches  of  infiltrating 
tubercle — such  as  of  the  skin.  HrrnModrrmn — s])rcad.      It  is  sup- 
posed that  leucocytes  enter  the  primary  focus,  take  up  a  bacillus  or 
*  Kpore,  and  wander  out  again  along  fine  lym))hatics   into  the  sur- 
rounding tissues,  there  to  sicken  auil  swell  into  a  giant-cell  not  far 
frwm  Uie  parent  mass.     A  fresh  tubercle  thus  forms  an<l  caseates, 
audits  margin  coalesces  with  that  of  the  [isircnt  mass,  which  in  this 
w«v  gradually   enlarges.     The  young   tubercles   form   the  grayish 
trnnslucent  ring  round  the  conglomerate  ma.ss  (|).  40r)),  with  here 
*>»d  there  an  offshoot  of  slight  length.      But  occasionally  a  leuco- 
cyte containing  a  bacillus  finds   its  way  into  a  lymphatic,  and  is 
<'arricd  by  the   lymph-streatn  to  the   nearest   gland.     The  situation 
lieing  a  favorable  one  for  observation,  the  process  of  infection  of 
•nesenteric  glan<ls  from  an  intestinal  ulcer  may  sinnctimes  be  traced 
".V  tubercles  along  the   track.     I'oiifiek   lias  described    tiilKTcles  in 
'Iw* thoracic  duct  in  cases  of  acute  tuberculosis:  this  he  regards  as 
""dence  that  the  bacilli  had  pas.sed  by  this  channel  to  the  blood.' 

PMlio)  and  liv  means  of  the  iiiovi>iiient.<  of  tin-  orfpin.  It  ist  iliffienll  to  (M)nceive  an 
"iffctinn  of  lx)th  Sylvian  srlerics  ;nid  s|>reiid  agiiioft  the  lymph-nlrcain  from  the 
"*  I'J  the  convexity  of  the  brain. 

'  TliF  Irmphoid  tiiwneisnotnnly  the  medium  l>y  which  thedisen«e!<]>read.s;  it  isaliio 
I'lf  pl»(v  where  Ihe  tubercle  bacilli  are  ino-»t  actively  attaeked,  and  where,  therefore, 


422 


THE  IXFKCTlVt:  Gl 


mA  TA. 


(2)  By  Infection  of  One  Part  from  Another. — Examplo'  of  tlri* 
are  eusily  f'ouiul.      I'erliajis  the  bi-st  is  Been  when  a  Fiiddoo  iiwpirt- 
tioii  follows  the  Itiirsting  of  a  tubercular  focus  into  a  bronchnit.  *oi 
draws  the  infective  runterial  into  many  other  bronchi,  with  the  n->iilr 
that  a  ca.seoiis  pncutuuiiia  devdops,  beginning  in  numerooB  p»ida 
of  •"  racemose  tubercle  " — /.  t.  the  tubercular  tinnue  is  moulded 
racemose  forms  by  the  alveoli  in  which  it  grows.     Otkrr  rxaai| 
are  the  infection  of  the  j>alnte  from  the  tongue,  of  the  '■ 
swallowed  .^[Mituiii,  and  of  the  lower  urinary  tract  frniii  :..     ...  ....  __ 

(3)  By  Veins. — Miigge  described  tubercidar  infiltration  of  -»:V 
walls  of  pulmonary  vei«»el».  especially  veins,  in  pulmonary  tnber-'^''' 
losi.s,  and  Wcigert  believe*  that  this  actual  growth  of  the  bacil 
into  the  circulation  is  frequently  the  source  of  general  infection. 

(4)  By  Arteries. — In  two  cases  of  death  from  acute  tabernili 
examined   respectively   by    Koch   and  Cheyne  there   were  pi 
cnseuted  bronchial  glands.      In  each  case  a  perviuim  mtriy  wn  fiw 
with  it*  wall  infiltrated  inth  tubercle.     This  was  the  assigned 
of  the  general  infection. 

In  one  or  more  id'  these  different  ways  the  virus  reaches  the 
and  is  carried  all  over  the  body,  developing  when  and  where 
conditions  are  suitable — in   the  lungs.   nieuinge«,  joint*,  or  u<l 
parts.      If  the  supply  of  virus  is  plentiful,  the  cose  is  likely  U» 
acute.     Laeunec  used  to  teach  that  the  tubercles  appeared  in 
distinguished  by  the  amount  of  degeneration  they  hail  nnd< 
This  would   indicate  un   intermittent  supply. 

Oeneralization. — An  acute  miliary  tuberculosis  of  the  niei 
lungs,  peritoneum,  and  various  abdominal   viscera  plainly  tnj 
that  a  large  number  of  bacilli   have  found  their  way  »ilb 
space  of  time  into  the  blmul :   the  result   is  just  such  ii."i  {<•:  "■ 

intravenous  injection,  in  rodents,  of  a  gyringeful  of  a  pure  ealtiva  ' 
tioii  of  the  bacilli.      .\s  it  is  ineonceiviiblc  that  ba<-illi  in  xnrh  onoi-^ 
bers  coubl  be  ab.s(irbed  so  rapidly  through  a  mucous  membrane  int<r 
the  blood,  it  is  necessary  to  assume  the  existence  of  some  primart 
focus,  where  bacilli  have  multiplied  and  whence  they  can  be  ftoarnl 
into  the  bloo<|. stream,      'i'he   pulmoniiry   mucous  tnembninr  b«Df( 
that  through  which    bacilli    commonly  enter  the  system,  it   follov* 
that  the  focus   in   which   this  multiplication    uccure.   and   vIwimf 
generalization   usually  takes  place,   is  a  caseous  bronchial  gland, 

ihry  nri'  iiiimi  likvlv  lo  lie  ilcxtroyeil.     If  tb«  orpuiimiu  pa*  \him  l}rm}>hnU  !{•«>  ia 
the  luuvoua  UHin)l)nnv,  l\wy  have  iilill  to  ileal  wilh  the  l/niiihsllc  gland* 


TUBERCLE  AND  TUBERCULOSIS. 


i 


tliougb  generally  there  is  evidence  of  tubercular  disease  of  one  or 
Wh  lungs  as  well.  But  acute  miliary  tuberculosis  may  spread 
from  any  localized  focus  containing  living  bacilli.  Extension  by 
moans  of  any  lymphatic  vessel  leads  to  the  formation  of  tubercles 
»loDg  this  ve.«sel  or  in  glands  through  which  tin-  lymph  pas.^es.  If 
the  thoracic  or  right  lymphatic  duct  be  affected,  the  orgaui.sms  may 
ilw)  find  their  way  into  the  systemic  veins.  They  would  ne.xt  reach 
file  lungs,  and  the  bacilli  are  so  small  that  they  would  easily  pass 
through  the  pulmonary  capillaries  into  those  of  the  systemic  circu- 
lation. 

Limited  Infection. — We  have  spoken  of  acute  (jeneral  miliary 

tuWrculosis,    using    the    term    in    Cdutradistinction    to    a    /onilizrd 

tuberculosis — e. //.  a  mass  of  cungluiiicnite  tubercle  in  tlie  brain  or  a 

caseous  gland.     But  even  a  "  general  "  tuberculosis,  due  apparently 

to  the  rapid  entrance  of  numbers  of  orgjiiiisms  into  tlie  blood,  is  far 

from  being  really  general ;  for  while  the  lungs,  spleen,  and  liver 

»r«  ftrry  frequently  affected,  the  voluntary  muscles  and  mammiB 

(}*.  40.'))  nearly  alwriys  escape.      'I'lius   wo  have  ;i   series  of  regular 

/gradations,  commencing  with  the  most  widespread  miliary  tiibereii- 

'oai»,   and    including    successively    ciuses    of    miliary    tuberculosis 

''niitcd  to  the  meninges  or  peritoneum  ;  eases  of  multiple  infiltrated 

tuberculosis — /.  >■.  tubercle    limited   to   glands,   skin,   or  bones  and 

J*>»nts;  and.  linally,  cases  in  which  ii  single  spot  of  skin,  a  single 

J«int,  or  a  single  gland  seems  to  be  affected. 

As  we  have  before  said  (p.  422),  the  selection  of  speeinl  organs 

***  '"general  "  tuberculosis  seems  to  indicate  special  predisposition 

****  the  part  of  these  organs.     There  is  no  reason  for  assuming  that 

bacilli  are  arrested  in  tlu^m  rather  thiin  in  r)ther  parts.     The 

e    explanation    would    appear    applicable    to    cases    of    limited 

"'iliary  tuberculosis,  and  may  possibly  be  the  reason  why  tnher- 

•^lUr  meningitis  affects  the  base  rather  than  the  conve.vity  of  the 

Irain.     Again,  there  seems  no  other  explanation  to  offer  of  what 

teems  to  be  a  well-established  clinical  fact — viz.  that  cliildren  who 

taSer  from  multiple  lesions  of  skin,  glands,  bones,  and  joints  do  not 

develop  visceral   tuberculosis  ueiirly  so   often   as   those  in  wIikiu  ;i 

single  joint   is  affected. 

Xext  with  regard  to  the  dose  of  organisms:  this  may  be  largo 
or  .small.  It  may  be  single  or  it  may  be  repeated  at  longer  or 
shorter  intervals.  The  different  do.ses  may  come  from  the  same  or 
frooi   different   foci,   giving   rise    to   the    successive   "  crops "   of 


424 


TUE  ISFECTPTE  GRANVLOMATA. 


tubercIcB  to  ivhich  Lnenucc  drew  attention — the  more  recent  b«iiK 
sniiill  !iii<l  pray,  and  the  older  large  nn<l  yellow.     When  niil 
bacilli  enter  the  eircuhition  at  one  time  the  infiltrations  whi'. 
excite  reaeh  a  far  larger  size  than  tber  could  pumiMT  attain  id  tlw 
speedily  fatal  general  eases.      Many  of  the  ciwie»  in  which  «injlf 
gland.1  are  aflfeeted  are  doubtles.s  due  to  infection  from  Kmall  wounil* 
or  tubercular  sores,  either  of  the  skin  or  of  the  mucous  nn'mbrn" 
from  which  they  obtain  their  lyn)|di-sup|)ly.     But  many  i-aMo  >i 
localized  tuberculosis,  especially   of   bone  and  joint,  admit  of  b" 
such  exjdanatiou  :  these   Koch  believes  to  be  due  to  the  entrv  nS» 
the  circulation,   and  lodgement   in   the  affected  part,  of  a  hd|J* 
bacillus:  and  he  thinks  that  in  these  eases — a»  in  those  of  wi*^*" 
ttpread    infection — the    organism    is   o)>tained    from   some   prin**'! 
foeua,  usually  a  bronchial  gland,   whence  it   haj<.  as  it  were  mC*^ 
dentiilly.  slipped  by  the  lyni|ilt-path  into  the  bbrnd.      lie  think*" 
biglily  improbable  that  even  a  single  organism  could   pa.-**  ini**  ' 
cnpillary  of  the  lung  from  an  alveolus  without  cauning  a  inberci^  •■ 
focus  in  tlie  lung  itself. 

The  seat  of  infection  may  not  be  without  effect  in  explain^' 
some  peculiarities  of  the  disea.se,  and  should  be  borne  in  mind.  A 
to  heredity,  tubercle,  unlike  syphilis,  very  rarely  extend*  in  nt^^ 
from  the  ])arent  Ut  the  f<etus :  Koch  found  that  guinea-pip>  pr"^H 
nant  at  the  time  of  infection  or  becoming  pregnant  soon  after  t--^ 
not  transmit  the  disease  to  their  young. 

It  is  impossible  to  explain  why  some  tidierculnr  prorcwe*  rrm 
local,  whil-st  others  generalize.  Blocking  of  lymphatics,  uon-in 
sion  of  the  walls  of  blood'Veasel.s.  feeble  local  growth  of  the  bai 
ius.  healthy  resistance  on  the  part  of  the  tissues  in  geaend,  a 
afford   hypothetieal  explanations. 

.Mthoiigii  ill  the  great  majority  of  caseH  of  acute  tubercaloaii 
primary  chee.iy  focus  is  fouml,  it  mui>t  be  remembered  that  riu 
llitii,  pi-r  if.  has  nothing  whatever  to  do  with  the  produetiom  of  t^ 
tubercular  virus. 

TtJBEBClTLOSIS  OF  THK  PlA   MaTEB    AND   BrAM 
Tubercular  Meningitis. —  In  the  pia  maler  the  tnbernilutu 
MM  is  aiw>ciated  with  inflammatiim  of  the  meninges*  and  mtf 
parti'  of  the  brain,  constituting  the  <-onditioii  known  a>  tul 

meningitis  (really  nieniugo-eneephaliti.i^.    'I'Mi  !■>  uli t  lrivari»b" 

a  part  of  u  general  tubereulo.si!*. 


TUBERCLE  AND  TUBERCULOSIS. 

The  process  is  almost  exclusively  confined  to  the  pia  inater  at  the 

base  of  the  brain,  anil  the  graif  tiihcri'les — wliidi  may  easily  escape 

observation — are  seen  in  connection  with  tlie  small  arteries  in  the 

Sylvian  fissures  and  are  deeply  seated  between  the  convolutions.    A 

fv*  scattered  granulations  are  fre'|neiit!y  visible  on  tlie  upper  sur- 

fai-c  of  the  hemispheres.     (To  see  the  tubercles,  strip  off  ti  ))iece  of 

mc-mlirane  with  a  Sylvian  artery  and  its  branches,  float  it  in  water, 

and  sjtread   it   out  on  a   glass   jilute :  examitie  over  a  dark  baek- 

grriimd.)     The  inflauiruatory  growth   originates  in  the  perivascular 

Iriophatic  sheaths  which  enclo-se  the  small  arteries  of  the  pia  mater 

(Fig.  139),  and  by  a  double  process  of  |»roliferation  and  (j).  407) 

Fio.  139. 


\ 


::^^. 


■y 


,  **'Hnr)-  tubercle  In  the  pl«  m«tcr.  Tht-  drifted  Hne  indlfiites  the  nrii^nal  size  of  the 
"^'i-'uUr  uodule:  j1,  the  Ij-mphHtic  sheath:  V,  the  bloodvessel;  /',  elements  within  tlie 
*"**U».    >  100.    (Comll  and  Knnvlcr.) 

'^filtration,  commencing  at  several  centres,  numerous  small  gray 

'*Oilules  are   produced   around   the   vessel.     These,    which   are  di.s- 

'iictly  visible  to  the  naked  eye,  cause  an  external  bulging  of  the 

"Death,  and  a  diminution  in  the  calibre,  or  even  couijdete  oWitera- 

^"^^i  of  the  enclosed  vessel. 

The  localized  obstructinns  to  the  circulation   which   result  from 

^"•^  pressure  of  the  perivascular  luidiiles  increase  the  by|ier;eiMiu  at 

^■'P  la*e  f>f  the  brain,  which  thus  becomes   exceedingly    vascular, 

there  being  in  some  cases  rupture  of  the  vessels  and  extravasation 

'i  blood.     A  tifiritioitx  frinisiiffiitio}!  takes  place  from  the  hy|ter;emic 

Mil  iujured  vessels;  blood-corpuscles  escape;  and  thus  the  meshes 


426 


rnr.  infective  giianulomata. 


of  the  pia  mater  become  infiltrated  with  u  sero-fibrinouji  or  puri- 

sirooves 


form  li<mid,  wliicfi  tends  to  eolloft  in  tlie 


betweon  tiiecun- 


volutions,     'i'hf  siibnriu:hnot(l  fluitl  is  turbid  an<l  ini-n 


.1 


n  (jiiii 


tity:  pressure  within  the  dura  mater  rises  steaiiily. 

These  ehanges  in  the  pia  mater  at  the  base  of  tiie  iiraiu  irt 
attended  by  iiypeneniiu,  infiitrution  with  leucocytes  and  tluid.  sail 
softening  of  the  subjacent  cortical  substance,  accounting  fortbcturh 
delirium  and  hypersensitiveuc.ss  of  the  special  senses.  The  rjifii- 
dyma  and  choroid  jilexus  also  become  exceedingly  vascidar.  »hile 
the  waU»  of  the  t'cnfrirlex,  tho  /ornix,  and  the  iiot't  cittninUmirt  luijif*. 
The  lateral  ventrieh-»  become  progressively  dwtemh'il  witli  fluiJ 
{ai'uti'  Iii/<lr<>ci'ft/iiiluii).  so  fhut  the  roin'olutirnis  on  the  surface  of thf 
hemisj)heres  are  found  presseil  against  tlie  skull  aiu\  jlnttrned.  U 
is  uncertuin  huw  f;ir  this  fluid  is  ilue  to  local  inflammatory  cxv 
tiou  and  how  far  to  drnjisy.  The  exudation  generally  niiw* 
marked  pressure  upon  the  veins  of  Galen  near  their  entry  mto  tlif 
straight  sinus.  All  trace  of  fluid  is  driven  from  the  subdural  »pKt 
and  the  arachnoid  is  dry  niid  nfirkj/. 

The  insensibility,  dee|)er)iiig  into  coma  which  precedes  doatli,  i» 
accounted  for  by  the  rise  in  intracriiniul  pressure,  and  Ity  the  injurv 
to  the  cells  of  the  cerebral  centres  which  results  from  the  inflanii 
tory  process  atid  the  prolonged  high  pressure  to  which  they  arc 
jected. 

Tuberculovis  Masses  in  the  Brain. — Large  musses  of 
glomerate  tubercle  (p.  40;"))  arc  occusionally  met  with  in  the  brnifir 
unassociated  with  any  general  tuberculous  process,  yet,  ciiriowij. 
in  spite  of  their  considerable  size,  they  rarely  give  rise  to  svinptontf 
indicative  of  pressure.  The  explanation  is  that  their  growtli  i» 
verv  slow,  and  other  cells  assume  the  functions  of  those  dcKtroyi'"- 
whilst  fresh  conducting  paths  are  opened  up,  compensation  li*'"? 
thus  effected.  The  masses,  which  vary  in  si/e  from  a  hajtleiiiit  W 
hens  egg,  commonly  occur  in  the  cerebral  sub.stance,  especially 
the  ba.se  of  the  brain,  'i'hey  are  of  a  pale-yellow  color  auil  ni 
consistence,  and  usually  fitrni  round  ghibular  tumors.  Their  """ 
face  is  often  seen  to  Ite  covereil  with  minute  gray  nodides.  wl"' 
extend  into  the  surrounding  tissue;  and  on  section  similar  noJi 
are  sometimes  visible  scattered  through  the  substance  of  the  tutnor 
In  most  cases  only  one  or  two  such  ma.sses  are  found,  but  occvi''"' 
ally  they  are  more  numerous.  They  occur  especially  in  chilill'**"'' 
Near  the  edge,  where  the  structure  of  the  tubercles  is  recogniu'''' 


TUBERCLE  AND  TUBERCULOSIS. 


427 


Kio.  HO. 


•ml  typical  (p.  4U5),  coiujjresseJ  or  obliterated  blood-vessels  may  be 
iHccD.     Attention   has  already  been  drnuu  to  the  infective  nature 

I  (p.  422)  of"  these  masses. 

Tuberculosis  of  Lymphatic  Glands. 

Ill  the  lymphatic  glands  tuberculous  processes  give  rise,   in  the 

first  place,  to  changes  in  the  cortical   portions  of  the  gland,  inas- 

mnrh  as  it  is  with  these  that  the  iiif'octivo  material  which  is  brought 

liy  the   lymphatic  vessels  first    couies  into  contact  (Fig.  140).      In 

the  earlier  stage  of  the  process  siuall   pale  gray  nodules  are  often 

risible.     These  are  scattered  through   the  warmer-colored  vascular 

cortex.     They  grndually  increase  in  size  and  become  caseous.     The 

Igiaud     menu  while    enlarges     from 

the    addition    to    its   substance  of 

lhe!«c  "tubercles,"  which  gra<lnjilly 

Ipread  in  along  the  lymph-sinuses 

tint  medullary   portion. 

By    this    tinie     the    distinction 

►etween  the  medullary  ami  cortical 

►Ttions  is  lost  in  consequence  of 

he  infiltration  and  filling  up  of  the 

niph-sinus.     <(n    section    at    this 

tn-ge  the    gland    presents  a   gray- 

»h  homogeneous  surface  on  which 

IT"*?  blotches   of  caseous    material. 

ibroid  changes  frequently  follow,  and  the  capsule  thickens,  so  that 

^ut'  caseous  masses  become  surrounded  by  dense  fibroid  tis.sue.     The 

^liole  glaml    may   be    ultimuicly   converted    into   a   cnseoiis    mass. 

•be  caseous  portions   niav   .>iitbse(|uentiy  soften,  dry   up.  or  calcify 

(p.  409). 

Sometimes  no  "tubercles"  are  visible,  and  a  section  in  the  early 
'••ge  has  a  pulpy,  swollen  appearance,  and  may  be  ilistinctly  more 
Wcular  than  normal :  micnisc<)])icully,  a  round-celled  infiltration, 
«ith  a  few  large  cells.  \k  found.  Tlie  result  of  the  infection  has 
ieen  a  more  acute  and  diflusi-  infiainmation  tiian  tluit  above  de- 
ncribed.  Caseous  jiatchcs  iiinl  fibro'ul  cliiinges  ultimiUely  appear. 
As  before  stated,  the  affection  of  lymphatic  glands  is  in  most 
indary  to  a  tubercular  inllanuiiation  in  the  area  whence 
their  lymph  ;  but  soinetiiiics  it  n/)/n'(irg  to  be  jirimary, 
bacilli  having  entered  through  mucous  membrane  or  skin  without 


W0^ 


T 


TiilwroulosU  of  *  lymphKtii'  iilmid. 
The  eMrlfiwt  tftafff  of  the  procetui,  show- 
ing till'  Klmit-ci'U.    :■  ■JM. 


THE  WFECnVE  ORAHULOMATA. 

exciting  any  marked  inflammation.      The  glands  most  couinionlr 
affected  are  the  bronchial,  mesenteric,  anil  cervical. 


Tuberculosis  of  Mucous  Membranes. 

The  alinieiitavy,  gciiito-iiriiiary,  arrd  respinitory  mncouc  me 
branes  way  all  be  .'<eat8  of  tubercular  infiltrutioii  and  ulceration:  it 
IB  extremely  probable  that  some  catarrhal  affectioDH  of  the  tnR»ib 
and  |)harvnx.  of  tlic  Eiis*tat'liiaii  tube  ami  middle  ear,  as  well  a»  ff 
the  intestine,  are  due  to  the  irritutiou  of  the  tubercular  orgaiiifm. 

Tubercular  ulceration  or  fissure  of  the  lip,  ueually  with  iuarli«i 
thickening,  is  not  uncommon  in  children  and  young  adult*,  'hi 
the  tongue  and  pharynx  tubercular  ulceration  is  rare,  and  i* 
usually  secondary,  at  lea.st  in  point  of  time,  to  phtbi^s.  The 
occurrence  of  tubercles  in  the  nesophagus  and  stomach  is  very  nn, 
but  cases  have  been  described.  The  course  and  the  microwipif 
and  naked-eye  iiniituniy  nf  all  these  ulcers  is  the  same.  Thov  «ill 
therefore  be  describfd  under  the  heading  of  "Intestine,"  in  vM 
part  td'  the  aliun'iii;iry  tract  they  arc  most  fre(|uently  found. 

Intestine. — Priniitry  tuberculo.^is  of  the  intestine  is  rair  m 
adults.  It  is  probably  caused  by  infection  from  tubercular  milk  w 
meat.  Secondary  infection  of  the  intestine  occurs  in  from  oni4»lf 
to  two-thiriLs  of  the  fatal  cases  of  phthisis,  and  is  caused  by  i'»'»l- 
lowed  tubercular  8])Utum.  The  small  ami  the  large  intestine  »w 
said  to  be  affected  with  about  efjual  fretpiency.  and  t>ot?i  are  gener- 
ally involved.  The  morbid  prot-e.ss  begins  in  the  sohlarv  m" 
agminated  follicles,  and  is  most  marked  where  these  arc  niOf«t 
numerous — namely,  at  the  lower  end  of  the  ileum  and  in  the  cfff"" 
— but  any  part  may  be  affected  (p.  419). 

The  tirst  stage  of  the  |»rocess  eonsist.s  in  the  appeamncf  "' 
tubercles  in  some  solitary  glands  and  in  certain  follicles  {not  all) "' 
some  Peyer's  patches.  The  affected  lymphoid  tissue  swelb.  *" 
therefore  projects  too  much  above  the  surface  of  the  nicnitr*"'" 
The  new  elements,  consisting  largely  of  leucocyte.s,  then  nnJci'?* 
fatty  changes  and  soften.  The  degeneration  in  Peyer's  imKb* 
commencing  at  a  number  of  separate  centres,  is  foUowwl  I'J  * 
patchy  ulceration  of  the  mucous  membrane,  and  the  procc**  <'' 
tends  by  the  appearance  and  subsequent  breaking  down  of  ff'' 
tubercles  at  the  margin  until  a  consiilerable  part  of  the  r'  '  " 
<lcstroyed.  As  the  result  of  these  changes  an  ulcerated  m. 
produced,  the  floor  and  edges  of  which  are  more  or  letw  thickcneti. 


TUBERCLE  AND  TUBERCULOSIS.  429 

jwing  to  the  production  of  tubercles  and  tubercular  infiltration  in 
the  surrounding  tissues.     In  the  floor  of  the  ulcer — formed  usually 
by  the  submucous,  sometimes  by  the  muscular,  and  rarely  by  the 
peritoneal  coat — small  tubercles  are  developed,  principally  in  con- 
nection with  the  blood-vessels  and  lymphatics,  and,  as  these  are 
arranged  transversely  around  the  intestine:  the  new  growth  pro- 
ceeds in  the  same  direction.     These  nodules  also  soften  and  become 
caseous,  and  thus  the  process  of  ulceration  gradually  extends  trans- 
versely until  a  complete  ring  of  the  mucous  membrane  may  be  de- 
stroyed (annular  ulcer).    These  appearances,  together  with  the  dila- 
tation of  the  neighboring  vessels,  may  reveal  the  position  of  the 
ulcers  before  the  bowel  is  opened.     By  the  blending  of  adjacent 
ulcers  most  irregular  figures  are  formed,   and  in  extensive  cases 
mere  islets  and  bands  of  mucous  membrane  only  are  left  in  wide 
Keas  of  the  bowel.     The  ulcers  thus  produced  (Fig.  141)  present  a 

Fig.  141. 


U 

A  tDbercular  nicer  of  the  Intestine  (diagrammatic) :  a,  epithelial  lining ;  b,  aubmucoua 
Oaae ;  c,  moBCUlar  coat ;  d,  peritoneum. 

Strong  contrast  to  those  of  typhoid  fever.  Bacilli  are  usually 
nnnaerous,  and  may  be  recognized  in  the  stools  by  suitable  staining. 

The  tubercular  ulcer  rarely,  if  ever,  heals,  but  an  ulcer  may  heal 
«t  one  place,  while  it  spreads  at  another,  and  the  contraction  of  any 
■^^r-tissue  that  forms  will  lead  to  marked  narrowing  of  the  gut. 
O^ing  to  the  thickening  of  the  tissues  at  its  base,  perforation  is  an 
*^ceptional  occurrence.  This  takes  place  more  commonly  into  a 
neighboring  viscus,  to  which  the  ulcer  has  become  adherent,  than 
•i»to  the  peritoneal  cavity. 

The  lymphatic  glands  in  connection  with  tubercular  ulcers  are 
generally  affected.  The  lacteals  leading  from  the  ulcers,  and  even 
toe  thoracic  duct  itself,  may  be  irregularly  swollen  by  tubercles, 

TUBBBOULOSIS  OF  THE  BeSPIBATOBT  TbACT. 

The  larynx  and,  to  a  less  extent,  the  trachea  both  suffer  from 
tubercle  in  its  miliary  and  infiltrating  forms. 

Tubercle  of  the  Larynx  (Laryngeal  Phthisis)  may  be  primary, 
but  is  often  secondary  to  disease  of  the  lungs.  It  is  said  to  com- 
mence as  subepithelial  tubercles  situate  chiefly  in  the  ary-epiglottic 


430 


THE  INFECTIVE  GRASVLOUATA. 


foldn,  on  the  cords,  ami  on  the  under  surface  of  tbo  epiglottic 
These  may  he  few  or  numerous,  and  may  ulcerate  early — eapecul/f 
on  the  cords — or  may  multiply  and  form  a  diffuse  iDfiltr&tioD,  wbici 
in  the  ary-epiglottic  fold  pri>diice8  a  pear-shaped  awellinie  nitii  ia 
lar^e  end  toward  it8  fellow  in  the  miii-line.  ^^preadiug  ulci-ntKW 
ultimately  occurs,  perhaps  leading  to  the  formation  of  abi««M«iLto 
necrosis  of  cartilage,  and  hence  to  hectic  fever.  exhauAtion,  vtA 
death.  Tubercular  ulcers  are  distinguished  from  thow  dtte  tn 
syphilis  or  to  new  growths  by  the  small  amount  of  new  tiMue  i> 
their  floor  an<l  margins  and  by  the  absence  of  cicatricial  iitsw- 

Tracheal  Ulcers  are  usually  superficial.     Occaisionally  tbrr  •>* 
very  extiMuiive. 

TuberctiloBia  of  the  Lungs  (Acute  Miliary). — Tnbcrcnioiw  f"* 
cesses  occur  in  the  lungs  as  part  of  a  general  tuberculosis,  and  *"' 

Fio.  142. 


>y   - 


A  tmoll  x-n  icray  tii>i«rcle  fKim  thr  luiif  In  «  cur  of  •riilx  IntixrruUail*.    Tb*  •* 
(lir  tiiU-n-ln  l>  kIiiiuil  III  llu'  >lniwiiiK,  >ii>l  U  l«n|iil)r  roiutltiiU-d  "f  lolmaHvatef  | 
X  IW.  rv<liu-c<t  tn  i. 

in  pulmonary  phthisis.     The  nature  of  the  resulting  iuilamiuni.*  *Tl 
lesions  i.<  similar  in   both.      It  will  be  well,  however,  in  the  pit^-**( 
place  more  particularly  to  describe  these  lesions  as  they  oorar  *• 
the  general  infective  disease.      The  more  limited   proceaaea  wbiC* 
take  place  in  phthisis  will  be  again   refern  <l  to  in  u  miImmiM 
chapter.     (Sec  "  Pulmonary  Phthisis.") 

The  pulmonary  lesions  met  with  in  general  tuberculo-^        . 


TUBERCLE  AND  TUBERCULOSIS. 


431 


the  Tnost  part,  of  tbosc  dissctuinatc<t  iioilular  growths  which 
c  been  already  described  as  gray  and  yellow  tubercles  (p.  404). 
loth  the  f/rai^  and  the  iffVow  nodules  are  often  fuuud  associated 
tlie  same  lung ;  in  other  eases  the  gray  nodules  only  arc  met 
1.  whilst  less  frenuently  nearly  all  the  growths  are  of  the  yellow 
ety.  The  condition  of  the  pulmonary  tUsdU'  which  is  situated 
•un  the  nodules  varies  considerably.  It  may  be  (1)  perfectly 
nal:  (2)  more  or  less  congested  and  (edematous ;  or  (-i}  it  may 
ent  varying  sized  tracts  of  grayisii,  grunuhir,  friable  coiisolida- 
.  A  perfectly  normal  condition  of  the  intervening  pulmonary 
le  is  found  in  many  <>f  those  cases  in  which  all  the  growths 
of  the  firm,  gray  variety ;  but  when  there  are  numerous  yellow 
loft  gray  nodules  the  lungs  are  nearly  always  more  or  less  con- 
ed or  consolidated.  Although  the  virus  is  ilistributcd  by  the 
Illation,  the  tubercles  are  usually  present  in  greatest  number  at 
loar  the  apex — like  the  lesions  in  ordinary  phthisis, 
"hen  these  nodules  are  examined  microscopically  they  are  seen 
xhibit  ilifferent  kinds  of  structure.  8ome  consist  mainly  of 
mt-cell  systems'"  as  already  described  (p.  4^5),  while  others  are 
acteristed  by  accumulations  of  epithelial  cells  within  the  pul- 
iry  alveoli.  There  is,  however,  this  marked  diference  between 
'arious  kinds  of  nodules — that  whereas  the  mnnlJ  Jinn  (/raif  ones 
3on.<)tituted  almost  entirely  of  the  first-named  structure,  the 

r  toft  qrmi  and  most  of  the 

'      -^     "   .  .    ,       .  ,,  Fio.  143. 

'«•  ones  consist  mainly  ot  the 

-alveolar  accumulations. 

rst,  with  regard   to  the  soft 

and  tffllow  noiluleg:  most  of 

'  when  examined  with  a  low 

lifying  power  present  the  ap- 

ince  represcnte<l  in  Fig.  142, 

nodules    evidently  consisting 

iy  of  accumulations   within 

alveolar     cavities.        When 

>  highly  magnified  their  con- 

tion  becomes  more  apjiarent. 

I  then  .seen  that  the  nlevo!,ir 

lies  are  filled   with   epithelial 

0Dt«  and  small  cells  resembling  leucocytes,  whilst  the  alveolar 

^  are  more  or  less  cxtensivelv  infiltrated  and  thickened  with 


A  portion  of  a  uninll  sotl  gray  tubercle 
ft-iiin  tilt'  liiiii;.  Tlil!^  i>  fWirii  ii  nuso  nfucute 
ItilH'nMiIoyiH,  f>rohttMy  In  un  ejtrller  slu^e 
Umii  that  rriiiu  whli'h  Fi^ir.  11'^  was  druwn. 
The  Niirnrv  show*  one  nf  the  alveoli  filled 
with  e|»ilheiiiil  eleinentH  un<i  a  few  xinaU 
felln.  with  miino  oellular  Inflltration  of  the 
iiiveoittr  Willi.     >:  3)0. 


432 


THE  INFECTIVE  QRANULUMATA. 


lymphoid  cells  (Fig.  143).  In  many  casc3  tlio  central  ponioiis  of 
the  nodules  have  undergone  extensive  degenerative  cbangc».  aiul 
consist  merely  of  a  structureless  granular  debris,  so  that  the  sau- 
mulutiuns  within    the   alveoli   and  the  cellular  infiltration  of  liie 

Fig.  144. 


A  portion  of  a  jrellnw  tii)irrr|p  (toin  the  lung  In  a  «im  of  srute  lubemilosti,  iboitM  <^ 
dcgunuratiun  of  llic  n-ntrnl  iKirtiiiiis  iif  the  nixlulv  r,  ami  the  celliiUr  ihlcki-nliK  nf  *** 
alveolar  walls  and  uc-cumuhiUinui  within  the  alveolar  caritU-s  at  the  pi-rlpticrj.  p.  '  •'" 


tlieir  periphe 


»lw»r9 


Fia.  145. 


alveolar  wsli.s  are  only  visible 

the  case  in  the  distinctly  yellow  tubercles  (Fig.  144). 

The  histological  characters  of  the  firmer  grut/  nodulen  differ  -"i"- ' 

what  from  the  preceding.  In  the'?* 
the  cellular  infiltration  and  coi)*** 
iiHcnt  thickening  of  the  nhec\*^ 
wall  are  much  more  markeil,  lU** 
many  of  the  alveolar  cavities  **^ 
occupied  by  giant-cells.  The  i'"^' 
gin  of  these  is  still  uncertain.  •^*^ 
cording  to  some,  they  are  furm*^ 
from  the  alveolar  epithflium  eito*^*' 
by  fusion  of  contiguous  cells  or  •*, 
partial  necrosis  of  the  cell  Brrest»**» 
its  attempted  proliferation  (p.  4"*  ^ 
Others  regard  them  as  due  *'•' 
degenerative  change  of  a  gio*'*^ 
nature  in  the  epithelioid  cell*.     - 

cording  to  Metchnikoff,  they  are  due  to  the  fusion  of  mOHonu^''**^ 


f-  '■  ■•  -~kC  ■ 

A  portion  of  the  mon.-  rxtvmal  part  of 
ftgray  tulK'rcle  trtnn  the  lunt:  In  a  ease 
of  acute  tulx-rculosifi.  BhowlnR  the  ex- 
tensive Inflllmtion  and  thlckenluK  of 
the  alveolar  waUa,  and  the  ^anl-eolU 
within  the  alveidur  oavillci.    X  lUU. 


TUBERCLE  AND  TUBERCULOSIS. 

[(ucocyft^d.     In  otlifi"  cases  the  alveolar  stnictiire  has  completely  dis- 

l»^>\>eared,   ami  the  tubercle,  when  exaiiiiued  with  a  low  magnifying 

po^'^r.  np|icar.s  as  a  little  spheroidal  mass,  the  cellular  elements  of 

Tiliicli   are  grouped  around   separate  centres  (Fig.   146).      VVheu 

Fjo.  146. 


^J^  "rm  itt»y  tubercle  frDtn  tlie  Uuig  lu  n  <n!ii>  of  nciitc  talierculostg, sbowlnir  the  grouping 
^  *Hc  (iionu-uU  around  aepuiite  cvutreH,  lliv  uudule  connisting  uf  (event  glantKicU  lyiitenui, 

^<>re  highly  magnified  these  centres  are  seen  to  corre.spond  with 

i    ^®  ginnt>ceils  already  dctcriijed  ami  with  the  small-celled  structure 

Ki"on|,^.,l  around   them,   as   is  well   shown    in  Fijr.  14;"i.      This  is  a 

**>lJv-develope<l  tubercle  of  the  lung.      The  small-eellecl  structure  at 

*"C  peripheral  portions  of  the  nodules  is  replaced  by  a  thickening 

'  "'   the  walls  of  the  alveoli   with   whicli  the  iiodiile  is  incorporated 

V^Jg.  147).     In  the  tubercles  thus  constituted  e.\tensive  retrogres- 

*Ve  changes  rarely  occur.     Degeneration  is  slow  and  very  incora- 

P'ete.  and  the  nodule  often  becomes  ini[H'rfectly  fibroid. 

Respecting  the  cause  of  these  differences  in  the  histological 
"Haracters  of  the  miliary  lesions  in  the  lungs,  it  may  be  stated  that 
*liile  they  de]»end  to  some  extent  upon  diflercnces  in  the  age  of  the 
titHluh.*,  they  are  mainly  due  to  rapidity  of  growth  of  the  organisms. 
If  these  be  num<'rous  and  juulliply  ratiidly.  the  noilides  will  consist 
ia  the  main  of  accumulations  of  epithelium  within  the  |»ulmonary 
ah'Cdli,  and  will  rapidly  (itiderg<»  disintegration  (see  Fig.  143.) 
If  the  growth  of  the  biicilli  be  less  active,  typical  "giant-cell  sys- 
temt"  will  form  and  the  nodules  will  attain  a  more  advanced  age, 


434 


THE  INFECTIVE  GRAKVLOMATA. 


while  degencnition  will  be  less  rapid  and  complete.     (See  Fig.  14i.) 
Lastly,  if  the  orgiinisms  be  few  and  their  multiplication  slow,  m  in 


Vw.  147. 


A  small  tor"""  "•  ttic  nii»l  oxtornnl  jmrt  of  h  tinn  (trajr  tuherole  frinii  llic  luort  ls<n» 
of  Bcutv  liilivri'uloslK,  aliiiuInK  the  incorpuration  «r  Ihv  nuilulu  with  tlip  HlvvoUf  f"  ' 

xaro. 

the  Ifiist  intense  and  most  <'lirnnic  prncesseH,  the  develdpiiioiii 
inultiuiiclfatfd  elements  und  the  proliferation  of  the  tiwiii'-it'llt 
rcaeh  tlieJr  niaximuui.  (See  Fig».  IS.*)  and  14H.)  Degcnemtf 
takes  place  very  slowly  aiid  is  limited  to  the  central  portion!"  fif  tn* 
nodule.  There  is  often  ciinsidenible  fibroid  induration  of  tlif  W^ 
tissue.  A  close  analogy  can  thus  be  drawn  between  the  tis 
changes  resulting  fmui  tuberculosis  of  the  lungs  antl  those  sh* 
result  from  other  chronic  iiiflainniatory  proee.sses  (p.  2i>4). 

Tubercular  Disease  of  Bonbb  and  Joints. 

These  structures  may  be  conveniently  taken  together,  as  tiilieri'Oaf 
disease  of  a  joint  is  freijuently  seeoiulary  to  similar  disea.se  of  h  b«uc. 
and  ince  versit.  The  primary  disease  is,  of  course,  due  to  infecB 
through  the  blood;  the  secondary,  to  extension  from  the  prin 
focus. 

In  cases  of  acute  general  tuberculosis  both  bones  and  j<iiut»  im.t 
be  the  seats  of  miliarif  tuherclcH.  In  hom'fi  the  tubercles  are  hi 
chiefly  in  cancellous  parts;  in  joints,  in  the  synovial  ami  suh 
novial  tissues.  Tlu-y  present  no  peculiarities  and  cause  uo  Ifl 
symptoms.  It  is  said  that  miliary  tubercles  may  be  watt*^ 
through  a  bone  without  any  general  tuberculosis  being  preseni.  "i'' 
certainly  multiple  foci  are  not  uncommon  in  the  synovial  wi'iDfin"? 
of  a  single  '"• 


TUBERCLE  AND  TUBERCULOSIS.  435 

beroular  Periostitis  and  Osteomyelitis. — Periostitis  and 
myelitis,  when  due  to  "tubercle,"  often  coexist,  just  as  they  do 
caused  by  other  irritants.  Periostitig  cannot  exist  without  a 
ficial  ostitis,  but  the  converse  is  not  true,  for  a  deep  bony  focus 
bercular  inflammation  may  be  present  without  any  obvious 
t'ement  of  the  periosteum. 

Eits. — Among  the  bones  which  are  affected  primarily  are  the 
s  of  the  vertebrae,  the  ends  of  the  long  bones,  the  bones  of  the 
s  and  tarsus,  the  phalanges,  and  less  often  the  metacarpal  and 
larsal  bones  and  the  ribs.  The  shafts  of  the  typical  long  bones 
irely  affected  by  tubercular  processes.  The  same  may  be  said 
e  cranial  bones,  but  certain  bones  of  the  face  not  uncommonly 

e  tubercular  process  more  often  starts  in  the  bone  than  in  the 
steum.  Periosteal  changes  occasionally  predominate  in  the 
of  the  ribs,  phalanges,  and  bodies  of  the  vertebrae :  when  this 
t  case  early  abscess  almost  always  leads  to  their  recognition, 
in  the  vertebrae,  and  probably  in  the  phalanges,  primary  cen- 
changes  are  much  the  commoner. 

orbid  Changres. — The  order  of  events  is  much  as  follows: 
111  are  deposited  at  a  certain  spot,  say  in  an  epiphysis.  Miliary 
rcles  next  develop ;  a  group  of  these  becomes  surrounded  by  a 
I  of  granulation  tissue,  and  this,  again,  in  cases  which  are  not 
ressing  rapidly  and  where  irritation  is  not  intense,  by  a  zone 
brous  tissue.  In  this  outer  zone  it  is  common  to  find  the  bony 
jculae  becoming  thicker  at  the  expense  of  the  spaces — i.  e.  the 
becoming  sclerosed ;  more  centrally,  in  the  area  of  greater 
ition,  the  trabeculae  are  undergoing  absorption. 
t)m  the  primary  focus  infection  of  the  surrounding  tissue  occurs 
leans  of  fresh  tubercles  which  form  in  the  granulation-tissue 
As  these  increase  in  number  they  gradually  blend  with  the 
It  mass,  which  meanwhile  has  probably  undergone  caseation, 
this  widening  of  the  area  of  infection  leads  to  a  corresponding 
ling  of  the  area  of  irritation ;  the  granulation  zone  extends 
and  replaces  the  zone  of  fibrous  tissue  and  of  bony  sclerosis, 
1  in  its  turn  reappears  farther  from  the  centre.  Thus  the 
9S  spreads — now  quickly,  now  slowly.  Cure  may  be  effected 
e  encapsulation  of  the  caseous  masses  in  fibrous  tissue.  This 
metimes  followed  by  their  calcification.  On  the  other  hand, 
lisease  may  spread  till  a  surface  is  reached  and  the  soft  parts 


136 


THE  INFECTIVE  GRAyVLOMATA. 


have  become  infected.  Caseation  of  the  tissue  is  synonynioun  wilb 
death,  and  any  portion  of  bone  separated  fii  hhtf  by  fnimuindiuij; 
caseation  foruis  a  sefiuestruui.  Usually  only  small  frn^jinriib  of 
tiabecula'  are  tlius  separated ;  but  sometimes  i*sention  follo»» 
infiltration  ,so  riijiidly  that  masses  of  bone  as  larfie  as  a  fillM-rt.  nr 
even  larj^er,  are  detuuhed.  A  whole  epiphysis,  sucii  n.s  the  hcidof 
the  femur,  may  thus  die.  As  Cheyue  has  stated,  the  trabecul«iif 
the  .sequestra  are  often  thickened,  showing  that  a  chronic  ijilliin- 
mation  precedeil  the  change  which  caused  the  nccroi'is.  Tlin 
effectually  disposes  of  Kbnig's  hyjtothesis  that  the  seijuestra  (wliicli 
for  .some  reason  arc  oflen  wedged-sliaped)  are  due  to  cnibitli«m 
Sometimes  the  sequestra  consist  of  rarefied  bone,  and  arc  sof^  »uJ 
crumbling;  soiuctimus  the  contents  of  the  spaces  are  calcified.  Ai 
abscess  often  forms  with  or  without  necrosis. 

When  the  periostniti)  is  priniarily  affected  the  bone  soon  .■jppriif* 
enlarji;ed,  owing  to  the  growth  of  tubercles   imbedded   in  iuflnnmu- 
tory  tissue  in  the  deeper  layers  of  the  periosteum  and  in  the  »B|xr- 
ficial  Hiiversinn  canals.     This  growth  may  cxtcn<l  over  a  wiilr  .irf* 
of  bone  or  may  penetrate  deeply  at  one  or  more  spots,  erodio;;  tbr 
bone  as  it  grows,  even  after  causing  a  preliminary  sclerosia.    Com- 
monly an   abscess   forms,  and    either   bursts   or    is  opened.    Tb« 
rough  surface  of  the  infiltrated  bone  is  then  exposed.     The  ««** 
ipf  this    softening  of   the    tubercular  tissue  into  a   cold  abKf*  »• 
unknown,  but  it  seems  certain  that  it  is  not  due  to  infectioD  «itn  i 
pyogenic  organisms.      Fluid  ami  leucocytes  find  their  way  inWi  the  j 
cheesy  mass,  which  is  broken  uji.      We  thus  get  a  space  filled  *it»* 
a  milk-like  fluid,  often   containing  obvious  cheesy  raa-sses  and  bit*  I 
of  bone.      The   wall  of  such   an  abscess  is  formed  of  dense  fibro***' 
tissue  lined  by  a   layer  of  granulation  tissue   which   cjm  lir.-\»il*" 
detached. 

On  section  this  wall  shows,  from  without  inward,  a'tlfiimii**** 
fibroid  tissue,  iii-oliablv  coiitaininff  tubercles  with  central  isi»»** 
cells;  then  granubition  tissue  with  numerous  but  lew  tyi''^*  j 
tubercles;  and  lastly,  a  layer.  chieHy  of  epithelioid  cells.  «bi**  < 
becomes  more  and  more  caseous  as  the  cavity  is  approached.  ' 

Hyaline  cortilaere,  being  a  rion-vasculer  tissue,  is  never  atta^»*" 
primarily.     Destruction  of  cartilage  is  sometimes  due  to  the  #/"*"" 
inward  over  the  surface  of  the  cartilage    of    tubercular  prm''**** 
from  the  synovial  membrane  :  these  proces.ses  adhere  like  iv_V.  •" 
gradually  erode  the  cartilage,   producing  a  cribriform  appesr*"'' 


437 

(Fig.  148).  Similar  destruction  may  also  be  due  to  the  perfiiration 
of  the  cartilage  by  a  uiu^»  nf  tubercular  tissue  sjirouting  tbrougb 
jl  from  a  focus  in  tbe  subjacent  bone,  or  to  tbe  spread  henealh  the 


Vui.  148. 


'vp 


'■f 


iS'^'T' 


iT.-- 


Vtmt  c»ni\iifK  of  kniH'  in  luliornilar  arthritis,  rcstini;  iip<in  Inflnmril  bone,  unci  miirk- 
•"r^roded  (111  tills  af.p<'i-i.  Tin-  (n-v  surfuri'  i>f  tin-  I'urtiiitj;!-  1>  nvi'rgri.wn  hy  «  sotl  nynovikl 
*■'''  "J^  .s«'vi'ml  cimnni'lii.  Iiy  inean>  iifwhlrli  cell*  have  reached  the  capsules  of  cartilage- 
""•.harc  iK-cn  liii<l  "pon.    y  S6,    (F.  T.  I'uul.) 

'"'tilage  of  similar  tissue  from  a  bony  source.  Large  pieces  of 
•^•^ilajre  may  be  thus  loosened  fi'om  the  linne  while  still  retaining 
*  'lormal  appearance  on  the  side  toAvard  the  joint  It  is  in  one  or 
*"'»er  of  the  above  ways  that  tiiherciil;ir  caries  i»f  the  .surfaces  of 
"'e  joint  is  established. 

TtJBERCITLAB   SYNOVITIS. 

The  tuberculous  changes  met  with  in  the  synovial  membrane  are 
II  ' 

I '''o  following :  (1)  acute  miUarji  lulit'rriiluKix,  as  lueulioned  above; 
||-)  diffiue  thiekeninfi  (tumor  albus) — by  far  the  most  frequent  and 

"•'portant   condition;  (3)  noiliilnr  t/iirkfnini/  (synovitis  tuberosa); 

'■»)  hydropK  :  iiui\  (Ti)  cmfn/i'iiiii. 

Diffuse  thickening  niny  lie  primary  or  secondary.  When  j>ri- 
y'l'trji^  it  is  due  to  tbe  settlement  of  bacilli  at  one  or  iriore  spots  in 
Ithe  synovial  or  subsynovial   tissue.      Tubercular  masses  grow  and 

'pPead,  while  the  tissues  round  about  become  more  or  less  swollen 


438 


TJIt:  INFECTIVK  ilRASVLOMATA. 


antl  ^eliltinoll^«-l<J(lkin^  from  (imIi'iiiii  iitid  coll-iiifiltriilioii.      CTIcar  or 
purifurm  fluid  may  be  iutn.^i'd  iutu  tlie  joiut.      The  tuhercuUr  foa 
muy  soften,  ami  upeti  citlier  iuto  the  joiut  or  iutu  the  prrtarticular 
tissues,  or  inav  form  un  abscess  in  the  thickeue<l  syiicivtnl  mciiiliranr 
When  »evouiinrif,  the  diffuse  thickening  way  be  due  to  burstiugi^f  a 
focM8  from  the  bone  into  tlie  joint  and  infection  of  the  wholr  urttorki 
membrane  from  within.     Aftvrii  little  time  this  membrane  prwrnu 
the  stnicture  of  the  wall  of  a  chronic  abscess,  and  its  cnvitr  pn>fc»- 
bly  contains  turbid  or  purifurm  fluid.     At  other  times  thr  thirlrs- 
ing  may  be  due  chiefly  to  oedema  of  the  synovial  luenibrane  rxrit(«) 
by  the  presence  of  a  foeus>  in  the  bone  which  has  reached  thc«llrfn>^ 
at  the  reflection  i(f  the  synovial  membrane,  and  which  ha»  thuK  l>c-ci 
shut  off  from  the  cavity  of  the  joint.     But  at  this  poiut  tbc  mrtn 
brane  has  been  infecte<l.  aiul  the  tubercular  tissue  invading  it  cxcil«.*» 
much  irritation  and  awelling  iu  its  neighborhood.     L'heyui*  «t«t.^ 
that  iu  such  canes  he  has  been  unable  to  discover  atty  evidence  o* 
infection  in  the  ccdematous  synovial  membrane  at  a  distance 
the  focus — a  point  of  niu<'h   practical  importance. 

In  synovitie  tuberoea  fungous  masses  of  tubercular  struct**' 
from   the  si/.e  of  a  chestnut  downward,  hang  in  greater  or  ft 
numbers  from   the  synovial  meiubrane  into  the  joiut,  which  al 
always  contains  fluid :  this  is  often  blood-stained.     Tho  menibi 
may  be  thick  and  deeply  blood-stained  toward  the  joint.     lufeir** 
is  through  the  blood  jjrimarily.     Secondary  infection  fn»m  theB»**^ 
brane  is  unusual. 

Tubercular  hydrops  is  not  distinguishable  from  the  simple  fof*^ 
until   thickening  i^i  the  synovial   membrnne  begins.      Konig  ttait^ 
that   in  early  stages  a  thin   layer  of  tubercular  tissue  can  be 
on  the  surface  toward  the  joint. 

Tubercular  empyema  is  in<listingiiishnble  from  tnbercaUr 
hydro[)s  until  fiie  flui<l  is  <irawn  off":  it  occtirs  in  old  people  and  la 
highly  tubercular  subjects. 

LUPOS    VtTLOARIS. 

This  diiM^ase  is  characterized  by  the  appearance  of  red'lidi- 
nodules  of  granulation  tissue  u(>on  the  »kin  (chiefly  of  the  faoej.  aai 
much  mori-  rarely  upon  the  mucou»  vifmltranfi  of  the  C"'  a, 

pharynx,  vulva,  and  vagina.     The  nodules  are  situate  pi.; .  la 

the  coriuni,  and  at  first  are  smaller  than  a  pin's  head,  thonjrh  lh*T 
may   reach  the  sixe  of  a  pea ;  these  blend  to  form  a  more  tir  l«» 


LUPUS  VULGARIS.  439 

diffiise  masa,  while  fresh  foci  appear  at  the  periphery.  The  disease 
generally  appears  hetw«en  the  age  of  two  years  and  puberty,  and  is 
especially  common  in  the  obviously  scrofulous:  recurrences  may 
occur  again  and  again,  and  the  disease  may  thus  last,  off  and  on, 
throughout  a  lifetime. 

Structure. — The  nodules  consist  of  granulation  tissue  containing 
epithelioid  cells  and  often  a  good  many  giant-cells.     They  differ 
from  true  tubercles  in   being  rather  richly  vascular.     The  inter- 
cellular substance  is  scanty  and  homogeneous.     It  is  not  uncommon 
to  find  that  long  anastomosing  processes  of  epithelium  have  grown 
down  into   the   round-celled  growth,  the  physiological  resistance 
(p.  140)  of  which  would   seem  to   be   less   than   that  of  normal 
-■orium. 

Course. — Spread  occurs  by  the  production  of  fresh  nodules  at 
he  margin  of  the  primary  focus.  The  course  is  always  chronic. 
V^hen  the  patch  has  reached  a  certain  size  it  may  remain  quiescent ; 
lie  nodules  and  infiltration  may  end  in  degeneration  and  absorp- 
Lon — a  white  scar  being  left^-or  in  ulceration.  After  eating 
Way  the  tissues  to  varying  depths,  sometimes  destroying  large 
oirtions  of  the  nose,  lip,  or  eyelid,  the  ulcers  may  heal,  or  heal- 
»g  may  go  on  at  one  point  and  destruction  at  another.  There 
'  little  or  no  tendency  to  caseation  and  glands  rarely  become 
ffected. 

Dtiolosry. — The  tubercle-like  structure  of  the  nodules  has  long 
•een  held  to  favor  the  surmise  that  lupus  was  a  tuberculosis  of  the 
'Vin.  This  explanation  of  its  pathology  is  now  very  generally 
accepted,  though  the  proof  is  incomplete.  In  favor  of  its  tubercu- 
lar origin  it  may  be  urged — (1)  that  a  few  tubercle  bacilli  are,  in 
the  large  majority  of  cases,  found  in  the  affected  tissues ;  (2)  that 
pore  cultures  of  tubercle  bacilli  have  been  obtained  from  such  tis- 
sues ;  (3)  that  the  inoculation  of  these  cultures  or  of  the  lupus  tissue 
itself  will  give  rise  to  tuberculosis ;  (4)  that  injection  of  tuberculin 
is  followed  by  an  inflammatory  reaction  in  lupus  tissues ;  (5)  that 
the  structure  of  the  tissue  is  such  as  would  result  from  the  very 
^dnal  growth  of  the  tubercle  bacillus ;  and  (6)  that  the  tempera- 
;ure  of  the  skin  of  the  face  is  only  a  little  above  the  lowest  limit  at 
vhich  the  bacillus  will  grow. 

We  may  add  that  the  bacilli  have  been  found  in  tubercles  excised 
>efore  ulceration  has  begun.  Some  scrofulous  lesion  is  often  pres- 
ent in  cases  of  lupus,  and  it  is  asserted  that  patients  suffering  from 


THE  INFECTIVE  GRANVLOMATA. 

liipua — perhaps  even  the  majority  of  them — die  of  some  tubercu 
disease:  c.  </.  phtliisis  or  uu-uiugifis. 

The  truth  of  die  above  is  suliiiitted  by  Kaposi,  who.  neverthele 
dissents  from  the  view  that  lupus  is  a  tuberculosis  of  the  skin.    " 
jirincipril  nriruiiieiits  a^siiiist   it  are — that  even  the  frei|neiit  colnH- 
deuce  of  scrofula  and  liqius  proves  nothing ;  that  the  bacilli  arevm 
few  in  number,  and  that  p^rhapg  the  mode  of  staining  is  not  reilly 
distinctive   of  tlie   tubercle  bacillus ;  that  tuberculngin  result*  fn 
inoculation  witli  lupus  tissue,  but  Inpu*  never:  that  there  is  rm  er 
dence  tif  the  coiitAgiousnens  of  lupus  ;  and,  la.>(tly,  that  lupus  rcinail 
lupus  throughout   its  course,  atid  never  passes  into  scrofulcnifims 
and  true  tuberculosis  of  the  skin.     This  statement   is  contmiliclfdf 
by  niiiriy  observers,  and  the  balance  of  evidence  certainly  seems  to 
fivor  the  tubercular  theory  of  the  nature  of  the  dise-nsc. 

ScBOFtJLA. 

The  constitutional  condition  known  as  Scrofula  is  chanictcri«e<l ' 
by  11  lijiliility  of  ccrtuin  tissues  to  become  the  seat  of  chronic  infl«ir»- 
luations,   the  causes  of  such   infljinnnations    being  very  slight  aoJ 
sometimes  wholly  hypothetical.     It  is  generally  believed  that  thcs»* 
tissues  either  po.ssess  congenitally,  or  aci{uirc  as  s  result  of  abnnr- 
nnal  conditions  of  life,  an  cnf'i-cbled  i-enistitiff  power  ngainft  inj» 
According  to  this  view,  slight  or    undiscoverable   injuries,  wliii 
have  no  effect  ujion  a  healthy  subject,  produce  inflammation  in 
scrofulous.      In  this  way  the  iiiitmnnal  ttutcepUbility  to  tnflammalf 
is  explained. 

The  explanation  given  of  the  abnormal  chronieitif  of  the  procfsse 
is  very  similar.  Chronic  inflaiiimation  always  implies  the  prolon] 
or  fretiuent  action  of  a  cause.  It  is  almost  imjwssible  to  keep 
inflamed  |iart  out  of  reach  of  every  possible  cause  of  inflaummti' 
such  as  friction,  jiressure.  tension,  and  contact  with  foreign  boJi' 
The.se  may  be  insufficient  tn  keep  up  an  inflammation  in  a  heal 
person,  but  in  the  vulnerable  tissues  of  the  scrofulous  they  are  t^j*!  , 
posed  to  be  sufficient  for  this  purpose :  and  doubtless  they  do  ^H 
in  rendering  the  process  chronic.  ^^ 

This  xim-iptibilitii.  altliougli  more  or  less  general,  is  comnio". 
most  marked  in  the  mucous  membranes  and  in  the  lymphatic  glaa"* 
It  is  especially  frci|iicnl  in  those  glamls  which  stand  in  direct 

'  A  special  tV|K'  of  coiinU'iinnoe  and  InhIv  Ihl.,  I>>ng  lieen  lielJ  to  clianuviiir  ' 
KTofiilouH  (liutliesiH.  but  it8  M'ientiti<!  value  w  iloubtful. 


mill 


SCROFULA. 


441 


hip  to  tlio  Bcaip,  fauces,  tonsils,  aud  pharynx  (cervical);  with 
ungs  (bronchial);  and  with  tht?  inti-stinf  (mesenteric).  These 
.lie  glands,  it  nmv  be  remarked,  to  whicii  organisms  are  most 

Fi(i.  119. 


*  , ' 


ulonj  fiiflamnintion  ofa  brunchUH :  nerllon  nt»  uniall  bninrhii>  i>rii  markedly  acroni- 
lld,  Ihe  HUhicct  iiriirunrhitlc.  which  termlnoti-il  In  inUinry  tulit'riMtliii>i<i.  The  divptT 
res  of  tlu'  broiH'hiiil  wall  ure  §ec*ii  to  tn.*  t'Xtt'usivi.ly  InhUruttMl  with  i>i'1ls,  iiitiHt  of 
ire  largiT  thun  tho«i'  iiicc  with  in  tho  li'»  i-xti'ii»ivf  innitrittinnorhi-althy  inflammu- 
'be  liiHltnitiiMi  i'Xl«ii<U  til  uiiil  liivadvn  the  \riiUi>  of  the  Hiljni'ciit  alveoli,  whii'h  are 
Ihv  iippvr  part  of  the  druwiiii;.  The  cavity  of  the  hn>n('liiiH  enntalii!*  a  little  miieuii. 
00,  re<luced  t. 

to  be  carried.  The  skin  (ec/enia  inipetifiinode.H),  bones,  and 
t  (caries  and  chronic  arthritis)  ure  aI.<o  very  liiible  to  be  affected, 
lart  which  suffers  varies  in  diffrent  ca.nes.  ami  »//<////  injury  (p. 
s  often  the  deteriTiiiiinj;  cause. 

til  regard  to  ilie  tissiie-cliatiiies  occurring  in  scrofulous  inflam- 
a.  It  uiu.st  be  remembered  thiit  wIkii  inHamniation  occurs  in  a 
ly  inilividiitil  nnd  does  not  <*iutsc  the  dcjttli  of  tlie  part,  the 
iniatory  products  eitlier  beeoiue  absorbed  or  tho  process  leaiis 
ppurntion  or  to  the  formation  of  :i  vascularized  connective 
t.  In  scrofulous  intlniiiinnlion.  nu  the  "tiu>r  IkuhI,  tlie  iihiior/i- 
fthe  inflammatory  j)roducts  is  much  less  readily  effected:  they 
M  aerumulati'  in  the  ti.>;sues.  where  by  their  pressure  they  iuter- 
»ith  the  circulation,  and  thus  lead  to  retroo;ressivc  and  caae- 
"littnge.'t.  Blood-vessels  do  not  develop,  and  hence  there  is  no 
•izalion  of  the  new  jrrowth. 


442 


THE  INFECTIVE  0RANUL03TATA. 


The  tissues 

usually  infiltratot 
ciiwous  [latclif!* 


f  a  part  affected  by  scrofulous   inflatnniation 
ere  ami    there  are  opaijue  vi 


I  witli   cells,      lit 


elfo* 


witli    et> 

Di^Jiuet  tubercles  are  often  recognizable  by  (lir 
naked  eye.  (Jiant-cells  are  especially  frerjuenl  (Figs.  141  lunl  14!'), 
Tbe  iiifiltrnted  |i:irt  t-ontuins  but  few  vessels  ;  lience  tbo  pair  |iiir|ili'b 
Inuk  'if  tile  j^niuuliUion  tissue  whicb  lines  a  chronic  ("senifiilnm  • 
abscess,  nnd  the  pallor  about  a  scrofulous  joint  (p.  438)  ns  coiiira*li'<l 
■witli  the  vivid  red  vuseiibir  layer  round  a  focus  of  acute  suppunitinn. 
The  anatomy  of  a  scrofulous  infliiuitnatiou  corresponds  In  tliut  mvt 
with  in  the  uiibler  forms  of  tuhercubir  irritation,  in  which  pniiifi'ra- 
tion  of  the  tissue-cells  forms  the  tiinst  marked  change.  Furthrr. 
the  course  of  a  scrofu!(ms  iul!iimmati<iri — chronic,  with  little  icii'l- 
ency  to  resolution,  organi/.ution.  or  suppuration,  but  with  iiKirirl 
teudeucy  to  progressive  degeneration,  caseation,  and  softeuing— >» 
precisely  that  which  we  see  in  tuberculosis  of  the  lungs. 

Moreover,  scrofulous  inHaniMations  not  uncornniouly  end  in  <itttl< 
uiiliary  tuberrulosu.  This  is  readily  explained  by  the  ob8emti<« 
that  tubercle  bacilli  are  cninmonly  present  in  small  number*  in  thf 
chronic  inflammations  of  scrofulous  type.  From  these  pure  culti- 
vations have  been  obtained,  and  successful  inoculations  have  bwD 
made  both  with  the  cultivations  thus  procured  and  with  |mrtioD>«f 
the  diseased  tissues  (p.  418).  The  proof  would  theref'ire  semi  i*<iiii- 
plete  that  mniic  Hvrofiiloiiii  h->tioti»  are  tuherciiUir.  In  all  prolmbililf 
the  Ki'i'oftihnm  dinthfoi's  is  identical  with  the  tuhercuhnit  tiialhin*- 
It  is  well  known  that  consumptive  parents  have  scrofulous  chiltlrfn- 
and  vice  ivrtid. 

Thus  the  abnormal  mtHceptihility  of  scrofulous  tissues,  to  »liic" 
reference  has  been  made  (p.  440),  appears  in  many  cases*  t»  •* 
reducible  to  this — that  certain  tissues  or  organs  in  the  scrofulo"* 
are  e.\cessively  predisposed  to  serve  as  hosts  to  the  bacillus  fnbfr* 
culosis.  That  this  ithmirinal  mitreptibilitji  does  not  always  !''"'* 
itself  seems  certain  for  many  reasons.  After  serious  operstw* 
for  strumous  disease  speedy  union  can  be  rcmlily  obtained;  •'"'^ 
prolonged  tearing  and  cutting  operations  upon  disensed  sni"*'* 
membranes  the  results  are  excellent,  provided  that  somotbing  ''*' 
coiiijileleness  is  attained  in  removing  the  morbid  and  morbnU.^' 
inclined  tissue;  and  after  scooping  out  the  contents  of  scrofii'""'" 
glands  the  inflatiiiimtory  process  ijuickly  subsides.  No  morf  "" 
or  freedom  t'roui  irritation  is  obtained  for  the  wounded  tissues*"'' 
such  operations  than  is  given  in  other  cases ;  often,  indeed,  !«**  •* 


m 


LEPROSY.  443 

btained,  and  sepsis  may  be  added ;  and  yet,  if  the  removal  of  the 
lected  tissue  has  been  complete,  the  parts  do  not  again  become 
t«  seats  of  the  same  intractable  inflammation.  And  this  is  the 
ueeven  when  large  portions  of  such  "vulnerable"  parts  as  epiph- 
ses  are  left. 

Against  the  view  that  scrofulous  lesions  are  really  tubercular, 
id  that  the  scrofulous  and  tubercular  diatheses  are  identical,  has 
sen  urged  the  extreme  frequency  with  which  the  mucous  mem- 
•anes  and  lymphatic  glands  in  scrofulous  children  become  the 
«ts  of  obstinate  and  protracted  inflammations  which  ultimately 
\d  in  recoverif.  But  recovery  is  possible  even  from  phthisis 
'.  413).  It  is  no  essential  part  of  a  tubercular  process  that  it 
lould  end  fatally,  as  experiments  on  animals  and  observations 
)on  man  fully  show.  Some  of  the  catarrhs  to  which  allusion  has 
!en  made  are  due  to  the  irritation  of  the  tubercle  bacillus,  but  the 
ithology  of  most  of  them  is  unknown.  To  admit  that  in  scrofu- 
U8  children  the  alimentary  tract  is  especially  liable  to,  and  irri- 
ted  by,  abnormal  fermentations,  and  that  the  bronchi  are  pecu- 
»rly  prone  to  catarrh,  is  only  to  admit  for  the  scrofulous  what  we 
ive  already  allowed  for  the  tubercular.  Moreover,  there  can  be 
:tle  doubt  that  chronic  bronchial  catarrh  facilitates  tubercular 
fection.  This  would  be  a  case  of  grafting  a  tubercular  affection 
vm  a  simple  chronic  inflammation.  To  assume,  however,  that  all 
rofiilous  glands,  bones,  and  joints  have  begun  as  simple  inflam- 
ations,  and  that  if  they  recover  they  have  continued  simple,  but 
tve  become  tubercular  if  they  take  an  opposite  course,  is  a  con- 
usion  unsupported  by  evidence,  and  not  in  accordance  with  the 
ct  that  the  products  of  many  long-quiescent  scrofulous  inflamma- 
ons  will  excite  general  tuberculosis  if  inoculated  upon  animals. 

LEPROSY. 

This  disease  is  endemic  in  many  parts  of  the  world,  especially  in 
'e  East  and  West  Indies,  China,  South  America,  and  E(juatorial 
^^  Southern  Africa.     From  the  fourth  to  the  fourteenth  century 

Was  widely  spread  over  Europe,  reaching  its  highest  point  at  the 
■He  of  the  Crusades,  when  thousands  in  England,  France,  Ger- 
*nv,  and  all  round  the  Mediterranean  suffered  from  the  disease, 
id  numerous  leper-asylums  for  the  isolation  of  the  afl[licted  were 
nnded.  It  began  to  die  away  at  the  beginning  of  the  fifteenth 
ntury,  and  was  relatively  extinct  by  the  end  of  that  century. 


THE  INFECTIVE  ORANULOMATA. 


when    sypliilis  first  become   prominent.      Leprosy  still  linger*  in 
miiny  spots  in  Europe,  particularly  in  Norway,  Sweden,  and  let- 

hud. 

VARIETIES. — Tiicre  are  two  chief  varieties  of  this  •liwiw'- 
tubercular  jiiul  anaesthetic.  In  the  former  the  lesions  afftrt 
chiefly  the  skin,  in  the  latter  cliiefly  the  nerves. 

Ill   tubercular   ieproKV   pjitclie.s    of  hyjuTivniiii  are  followoil  I'V 
tliickening  of  the  .skin  and   tiie  formation  of  nodules,  which  nuy 
reach  the  size  of  walnuts.     These  changes  are  especially  develniH-d 
on  parts  exposed  to  the  air — face,  hands,  and  feet — and  app«f 
sometimes  singly,  soiiietimes  in  proiij)s.     They  may  begin  as  dis- 
tinct eruption.'!,  sepurateil  by  long  intervals  of  time.      The  allofteil 
skin  is  first  firm   aiirl   red  or  browni-sh  ;   it   then   becomes  soft  jn«i 
jijile;    unless  injun-il,   it    doe.';    not,   as    a  rule,  ulcerate  until  Km^ 
afterward.     Wiieii   ulcers  do  form,  they  cause  great  destruction  of 
features  and  other   parts  {lepra  mutil(Uii)).       Healing  maif  occa*"-! 
The   nodules   may   aifeot   other   parts   of   the  body,    especinlK  tb« 
extensor  aspects  of  the  limbs  and  the  mucous  membranes  "f  (!»« 

eve,  nose,  mouth,  and  larvnx. 

*  » 

In  ansBsthetic  leprosy  cylindrical  or  fusiform  swelling*  occv«*^ 
upon  nerves,  esjicciajly  the  ulnar  and  external  [loplitcnl.  Tlie=* 
swellings  surround  long  portions  of  the  nerves,  afl'ecting  priaiahl.^ 
the  cutaneous  and  later  thi'  muscular  branches.  At  first  the #k»«* 
is  often  painful  and  liypcnvsthetic ;  later  on  it  becoine-s  auacs'lhetj < 
pale,  and,  together  with  the  )iaraly/.ed  muscles,  wastes,  A  hiiilo*** 
eruption  {pemphigns  Ivprngiis)  in  the  area  of  the  affected  nerve  tam^ 
be  the  first  sign  of  the  disease :  the.te  bulhe  may  either  dry,  le«vii»^ 
pale  insensitive  patches,  or  they  may  be  followed  at  once  by  ulcer"»^ 
Sooner  or  later  ulcers  form  u]ion  the  anaesthetic  parts,  leading  •* 
e.xtensive  destruction,  and  even  to  ilropping  off.  of  fingers,  to<8,*>*( 
large  portions  of  limbs  {li-prn  mutilitnn). 

The  two  forms  may  run  their  course  separately,  but  often  occ«»^ 
together.  The  anaesthetic  variety  occurs  chiefly  in  hot  climat««.  '■* 
eai'h  form  the  glands  receiving  lymjih  from  the  di.wased  pAf** 
enlarge — first  the  su|>erficial  luies,  then  the  deeper.  Vi»wr» 
especially  the  liver,  spleen,  and  testes — may  be  also  enlarged.  *" 
the  tubercular  form  death  results  from  exhaustion  or  some  interna^' 
n-nt  diseue  -ourse  of  eight  or  ten  years ;  in  the  anie*tb*f  * 


fot- 


iiut  twice  as  long. 


LEPROSY. 


446 


LSTOLOQY. — To  the  naked  eye  the  new  tissue,  wherever  sitn- 
»U\  \ius  the  grayish  or  yellowish,  semi-trauspureiit,  uuitbrui  appear- 


Fic).  150. 


v\4^ 


»  .  ^*^  ft 

'    »       '  * 


Tnbvri'ttliir  U* pros y—arr tit >n  throiiRh  ttkin  :  n,  nliuwiiiff  InflUriitiou  with  lppn>s]r  IjtiotUf, 
*  i:  h, showing  bttc'ltli  In  thvoelU.  x  ^300;  r,  iiidlvUlual  baciltt  shuwlug  sport-a  0')*  >  ^X). 
(TTtlii  I 


^ 


itice  common  to  so  many  structures.     Tiie  loose  areolar  tissues  are 

chiefly  aftVeted,  and,  in  a  less  degree,   lymphoid    tissue.     Micro- 

Kcopicaily.  the  nodules  consist  of  four  principal  clcnients  :  (1)  Larjie 

"limbers  of  small  and  often   vacuolati'd   fpitlic)ii)i(I  ('clis.  generally 

containing   bacilli  [iride  infra),  and  frequently  found  in  the  lymph- 

"pacM.    from    the    endothelial    cells    of    wliicli    they    are    possibly 

■it'rivctl;  (2)  large  masses,  known   as  •' lepra-cLdls,"  containing  one 

large  vacuole  and  often  a  number  of  smaller  ones,  as  well  as  liacilli, 

graiiuies,  and  occasionally  many   nuclei ;  these   lepra-cells  may  be 

lound    inside    lymphatics    or    encircling    ]yn)|)hatics    or    atrophied 

«We»t-glands:    according    to  Metchnikofl',  these  are  large  monuiiu- 

••'leated  leucocytes  which   have  ■■' engulfed  "  the  bacilli;  (3)  clumps 

"f  free  bacilli    in  the  lynipliutics  or  elsewhere ;  (4)  an  overgrowth 

*f  filirous  tissue. 

The  new  tissue  in  the  skin  ultimately  undergoes  degeneration, 
*nri  is  absorbed  or  breaks  down.  'Die  foci  run  together,  anil  the 
'•iseasod  part  appears  on  section  to  be  divided  into  noihilar  m.osses 
*y  fibrous  bands.  Other  tissues  may,  on  account  of  the  interference 
'^ith  tlieir  nutrition,  necrose  or  atrojdiy. 

■I'lie  lynjpbatic  glands  contain  small  fibrous  patches.  As  Del^- 
P'ne  points  out,  the  liver,  spleen,  and  nerves  all  show  signs  of 
•^nronic  interstitial  inflammation.  Tlie  lungs  are  often  said  to  be 
tubercular.  They  certainly  have  the  a[ipearances  of  organs  under- 
^"ig  caseous  broncho-pneumonia,  but  that  this  condition  is  really 
'*^    to  a  »iparate  cause,  such  as  tubercle,  is  doubtful. 


446 


THE  ISFECTIVE  ORASVLOMAIA. 


ETIOLOGY. — From  time  immemorial  leprosv  liiis  been  look 
upon  a>  a  contagious  disease,  and  lepei*s  Lave  been  rigorumli 
excluded  from  social  coinmiiuitics.  A  very  superlieial  exauiiuslifl^ 
throws  doubt  npon  this,  for  in  many  cases  lepers  bare  been  knutr 
to  live  in  tbe  closest  association  with  healthy  people  without  "'hid- 
niunieuting  the  disease.  Many  observers  have  maintained  tliiit  tlic 
ilisea.se  is  communicable  under  eertuiti  conditions  which  are  rarely 
realizeil.  It  seems  more  dilhcult  to  prove  the  eoutagiousnes*  "f 
leprosy   than   that   of  plitbisis,  and   it   eertaiidy   is  not  so  great. 

It  may  be  noted  that  lepro.sy  flourishes  in  all  climates  and  apm 
Jill  siiils  :  that  poor  diet  and  salt  fish  do  not  a]ipear  to  be  spfcial 
factors  in  its  etiology,  as  some  have  thought ;  and  that  the  (lis*** 
does  not  seem  to  be  hereditary,  although  Ilirsch  held  finnh  to 
the  op|iosite  conclusion.  Children  horn  of  leprous  parent*  in  lep- 
rous places  may  acquire  the  disease,  but  so  may  outsiders  eiitt'ring 
such  places.  Po.ssibly  there  may  be  some  slight  hereditary  |ire- 
<li8])osition  analogous  to  lli.nt  believed  to  exist  in  the  rasp  i 
jihthisis. 

Observers  are  agreed  that  there  is  con.stantly  present  in  all  lb« 
recent  primary  lesions  of  leprosy  a  bacillus  very  closely  resenibling 
in  its  chiiracters  the  tubercle  bncillus  (p.  415).  So  close  i?  tbis 
resemblance  that  the  chief  point  of  interest  in  the  pathology  of 
this  disease  at  the  (ircseut  mouiciit  is  to  determine  whether  the  tw 
organisms  are  xi-jinrntf  species  or  only  modifictttions  of  n  ««,'/'' 
species. 

The  bacilli  found  iu  leprosy  may  vary  in  shape,  size,  and 
ing  affinities.      Delepine  showed  that  in  a  single  patient  the  barilT 
free  in  the  tissues  were  shorter  an<l  more  readily  slainetl  than  tb« 
in  the  lepra-cells.  while  those  in  the  skin  an<l  mucous  meiiibniB 
were  longer  and  more  rapidly  stained  than  those  in  the  liver 
spleen.     The  biicilli    are  difficult  to  find,  both  in  the  la-ighborbo 
of  ulcerating  surfaces  and  in  the  lungs.     They  are  said  to  occur! 
definite  chimps  (Hansen),  and  to  be  thus  distinguishable  from  tub 
cle  bacilli. 

Attempts  to  cultivate  the  organism  have  so  generally  failed  *!' 
the  few  recorded  exceptions  are  of  little  value  until  more  fully ' 
firmed.      Amid   conditions  under   which    the  tubercle  bacillus 
fiourish  the  lepro.sy  bacillus  will  not  even  grow  at  all. 

Nor  do  inoculation-experiments  give  decisive  results.     In  the* 
of  a  criminal  the  diseaise  followed  inoculation — offered  as  an  ftltern*' 


SYPHILIS.  447 

^  to  execution — but  the  man  had  up  to  this  point  been  in  frequent 
itact  with  lepers.  Whether  the  infected  tissues  be  introduced  into 
er  parts  of  leprous  patients  or  into  animals,  the  results  are  nni- 
nly  unsuccessful,  though  the  bacilli  themselves  are  not  destroyed, 
■  they  can  be  found  months  afterward  in  the  tissues. 
The  constancy  of  the  association  between  (1)  a  certain  set  of 
nical  manifestations,  (2)  a  fairly  definite  series  of  pathological 
anges,  and  (3)  the  invariable  presence  of  a  special  bacillus  con- 
tntes  the  greater  part  of  the  evidence  in  favor  of  the  view  that 
is  organism  is  a  distinct  species  and  the  specific  cause  of  the  dis- 
se.  It  at  present  remains  uncertain  whether  the  organism  is  a 
adified  form  of  the  tubercle  bacillus  or  not.  Delepine  thus  sums 
>  the  evidence  in  favor  of  the  view  that  it  is  such  a  modification : 
(1)  The  characters  of  the  bacillus  and  its  staining  reactions ;  (2) 
e  nature  of  some  of  the  lesions ;  (3)  the  frequency  of  phthisis  and 
Tofiila  in  leprous  patients  (over  twenty-five  per  cent.)  or  in  their 
itecedents ;  (4)  the  difficulty  of  obtaining  any  result  from  inocu- 
tion  with  the  most  typical  and  advanced  leprotic  lesions ;  (5)  the 
ccess  of  inoculation  with  products  obtained  from  organs  less  typi- 
lly  affected,  such  as  the  lungs ;  (6)  in  cases  of  successful  inocula- 
n  the  production  of  a  disease  which  is  generally  tuberculous  or 
listinguishable  from  tuberculosis."' 

It  seems  strange,  if  this  view  be  correct,  that  the  reversion  to  the 
ginal  type  does  not  take  place  more  frequently,  and  that  leprosy 
a  chnical  entity  does  not  disappear. 

SYPHIIilS. 

The  lesions  occurring  in  the  course  of  constitutional  syphilis  also 
long  to  the  class  of  Infective  Granulomata.  They  are  inflamma- 
ry  in  their  nature,  but  in  their  seats,  distribution,  sequence,  and 
sto'.ogical  characters  present  certain  peculiarities  which  make 
em  characteristic  of  this  disease.  The  primary  syphilitic  lesion 
SBslly  the  indurated  chancre)  occurring  at  the  point  of  inocula- 
m  is  followed  by  enlargement  of  the  neighboring  lymphatic  glands, 
d  later  on,  when  the  virus  becomes  generalized,  by  a  series  of 
inges  in  the  skin  and  mucous  membranes.  At  a  still  later  period 
se  may  be  succeeded  by  changes  in  the  nervous  system,  bones, 
I  internal  organs,  most  of  them  the  results  of  inflammatory  pro- 

rhe  student  is  referred  to  a  very  able  description  of  a  case  of  this  disease  by 
Ipine  in  Tratu.  Path.  Soe.  of  London,  vol.  xlii.  p.  386, 1891. 


448 


THK  lyFECTIVE  GRASULOMATA. 


cesses  iiidui.'eil  \\\  the  .svphilitic  poison.  Though  not  yet  certaiiily 
recognizeil,  the  nodular  nature  of  the  lesions  deinonstrnli-si  tie 
|iarticu1atc  uuture  of  the  cuuse,  and  the  multiple  foci  of  diiieaM 
prove  its  power  of  uiultiplicution.  Syphilis  hus  now  taken  \lx  pi»rt 
in  the  classification  of  disease  as  a  "chronic  general  iufectiTf 
disease." 

APPEARANCES.— I.  Early  Lesions. — Many  of  thi-jii-  arr  aiij- 
toniically  iiiili>tiii}.niishulili'  from  simple  intluuiuiations  of  the  ."au« 
parts.     The  rashes,  for  exumpje.  are  due  to  intlainniatory  hypcne 
with  more  or  less  infiltnition  of  the  superficial   layer  of  iLi' 
eulargeuient  of  the  jm|iilUe,  and  often  excessive  epithelial  inulti] 
cation.     As  a  rule,  these  inflamniations  end  naturally  ill  n^uiioD. 
but  in  tissues  id'  feeble  resisting  fiower  they  may  ulceralr.    Earlj 
syphilitic    periostitis   {nodes)   is    indistinguishable    from    truumaw 
intlamnratinii,  iuid  syphilitic  iritis  is  diagnosed  from  rbeunintic oolt 
liy  concomitiint  circumstances. 

II.  Later  LesionB. — The  most   friMjiieiit,   but   not  the  ui'i*t  'Ha- 
racteristic,  of  these  changes   is  fibroid  induration.      Aumouiially. 
this  is  ordinary  |)roductive  inllammation.  ending  in  8car-tis«uoip- 
294).     When  the  fibrous  ti.ssue  is  gradually  developed  without  i"*'- 
dence  of  any  cluuige.  except  .such  degeneration  and  atrophy  as  may 
depend  on  the  stihseipient  contraction  of  this  tissue,  it  is  «ionietin>f» 
spoken  of  as  an  overgrowth  of  connective  tissue.      Its  appesraiic*- 
however,  varies  in  difl'ereiit  cases  and  in  different  parts  of  the  *»iO* 
organ.     Sometimes  the  new  tissue  consists  almost  wholly  of  nfl** 
with  but  little  intercellular  substance,  sometimes  of  cells  in  a  vuT*-' 
ediv  fibroid  matrix,  and  at  others  ofden.se  fibrous  tissue  only.     1*^*  , 
infiltration   maii  be  general,  but  much  more   commonly  the  fibroi** ' 
areas  are  separated  by  comparatively  healthy  portions  of  the  ory*"" 
It   is  the  irrfiiiihir  i/intrihiition  of  these  lesions  which  makei 
so  pixirttfleriittir  of  gi/pfiilix. 

The  capsules  of  organs  are  irrfijularly  thickene«i ;  any  periton* 
coverings  they  may  jiossess  are  sure  to  be  involved:  and  tuoff  *^'* 
less  general  adhesion  to  surrounding  parts  occurs.  Thesf  cliiinp 
are  seen  in  syphilitic  hepatitis,  splenitis,  and  orchitis.  In  ori"h«*'*| 
the  coincidence  of  hydrocele  proves  during  life  the  afTectinij  of  ***  j 
tunica  vaginalis.  The  irregular  thickening  of  the  caf>suli'  i'  ***  i 
moiit  marked  feature. 

As    the    fibrous   tissue   contracts    the   organ  shrinks,  and  u'*** 


SYPHILIS.  449 

kcomes  of  stony  hardness ;  but  the  irregular  distribution  of  the 
exudation  often  causes  unequal  contraction  and  puckering  of  the 
surface,  amounting  in  some  cases  to  the  formation  of  deep  fissures 
which  almost  divide  the  organ  into  lobes.  In  these  cases  the  diffuse 
growth  has  probably  been  combined  with  the  gummatous,  and  the 
thickened  capsule  is  connected  with  fibrous  rays  which  extend 
deeply  into  the  surrounding  tissue. 

Naked-eye  examination  of  a  testis  which  has  undergone  these 
changes  shows  adhesions  between  the  layers  of  the  tunica  vaginalis, 
with  intervening  spaces  containing  fluid,  marked  thickening  of  the 
tunica  albuginea,  and,  extending  from  it  into  the  organ  toward  the 
mediastinum,  dense  bands  of  fibrous  tissue.  The  natural  reddish- 
hrown  color  of  the  tubules  is  replaced  by  a  much  paler  whitish- 
yellow  tint,  in  which  islands  of  normal  tissue  may  remain.  The 
consistence  of  the  gland  is  greatly  increased.  One  or  two  gum- 
mats  may  also  be  present. 

When  occurring  in  bone,  formations  of  this  kind  often  ossify. 
Under  the  periosteum  they  cause  thickening  of  the  bone.  In  the 
Haversian  canals  and  cancellous  spaces  they  lead  to  increase  in  its 


These  cell-formations  do  not  always  go  on  to  fibroid  induration ; 
they  may  resolve,  and  under  the  influence  of  iodide  of  potassium 
generally  do  so  with  marvellous  rapidity,  provided  they  are  at  ail 
wcent.  Probably  the  inflammatory  products  undergo  fatty  degen- 
eration previous  to  absorption. 

Qmninsta,  Syphilitic  Tumors,  Syphilomata. — Anatomically, 
"•ese  are  the  most  characteristic  lesions  of  syphilis ;  they  are  fre- 
l^ently  associated  with  the  fibroid  induration  just  described.  As 
"^Qally  met  with,  they  are  moderately  firm  yellowish-white  nodules, 
■■•ving  on  section  an  appearance  suggestive  of  the  cut  surface  of  a 
"Orse-chestnut.  They  vary  in  size  from  a  hempseed  to  a  walnut, 
••^d  are  surrounded  by  a  zone  of  translucent  fibrous-looking  tissue, 
*hich  sometimes  has  the  appearance  of  a  capsule,  and  which  is  so 
'tttimately  associated  with  the  surrounding  structures  that  enuclea- 
tion of  the  mass  is  impossible.  The  outline  of  the  growth  is  gen- 
erally irregular,  owing  to  the  number  of  fibrous  processes  which 
^Hdiate  from  it  along  the  natural  septa  of  the  organ.  In  the  earlier 
stages  of  their  development,  when  they  less  commonly  come  under 
observation,  gummata  are  much  softer  in  consistence,  more  vascular, 
sod  of  a  reddish-white  color,  whilst  in  their  most  advanced  stages, 

29 


450 


THE  INFECTIVE  ORAl 


owing  to  extensive  degenerative  changes,  thej  may  be  op&tiue.  yt^ 
low,  an<l  fjitty. 

E.xaiuineJ  inicroscopieaUy,  gummata  are  found  to  vary  it>  tbvix 
minute  structure  according  to  their  age.     When  recent  they 
divisible  into  three  xones.     The  central  portions  are  conif 


Via.  151. 


Via.  \b'l. 


*!<  • 


m 


Gnmmy  growth  fW>in  Ilrcr :  a, 
central  portlon.i  of  urowth.  con- 
ilatini;  ot  invniilnr  debris;  b, 
pcrlplirral  ^anulatluii  tltwue;  r, 
«  bliMHl-vesBt'I.  X  l*^'  (Comil 
Bnit  UsiirkT) 


The  peri|ilirral  portion  of  ■  gntaai 
icrowth  In  Ihp  klilney,  thnmint  ll» 
•ninll-cpll  puniiUtlon-gmwlh  In  llii' 
Intcrtiibnliir  ilrsue.     y  3». 


closely-paektHl  sunken  cells  hikI  nuclei,  fiit-grnnule.«.  and  cholestpriD. 
nmon^st  which   is  fienenillv  ii  little  fibrillated  tissue  (Fig.  1.51. ''•■ 
Surrouuiling  this,  and  directly  coutiniious  with  it,  is  the  intenn'ih- 
lite  Knne,   consisting  of  epithelioid  cells  in  a  distinctly  fihriilaf^ 
matrix.     The  periphvrnl  portion   nf  the  growth  (Fig.   l-'il.  h.if^ 
Fig.  l.'>2),  whicli  is   in    direct  histologicil  continuity  with  the  sur- 
rounding structures,  consists  mainly  of  leucocytes,  though  epitk^ 
lioid    and  even  giant-cells   are  also  found.     Giant-cell.*  nre  mufli 
rarer  than  in  tulierde.     The  cells  are  separated  by  a  scanty,  lionio^^ 
geneous,  intercellular  material  and  numerous  new  blood-vessels.    ^H 
In  older  guininiita  only  two  zones  may  be  apparent — an  inner <^ 
ciueituii  zone  and  an  outer  or  Jibroun  r.oaf.     The  origin  of  the  cell' 
in  each  case  is  most  likely  the  same  as  in  tubercle.     It  seems  pf"'>' 
able,  however,  that  the  chemical  effects  of  the  syphilitic  vini-*  *^ 
less  deu<Ily  to  the  life  (if  tlie  new  cells  than  are  the  correB|H)udin| 
effects  of  the  tubercular.     The  further  development  of  the  nr»  "^ 
sue   therefore   proceeds,  and  vessels   are   formed.     The  cascut'"" 
which  next  occurs  is  not  so  much  due  to  the  direct  action  of ' 
virus   a,s  to  the  8iib8e()uent  sliutting  off  of  the  blood-supply, 
means  of  changes  presently  t<)  be  described  the  walls  of  the  bl« 


^ 


SYPHILIS.  451 

"vessels  in  the  centre  of  a  gumma  become  thickened,  and  in  thicken- 
ing encroach  upon  and  nearly  obliterate  the  lumen.     Subsequent 
thrombosis  in  the  affected  vessels  completes  the  interference  with 
the    blood-stream.     To    these   changes   must    also   be  added   the 
strangulating  effect  on  the  blood-vessels  produced  by  the  contrac- 
tion of  the  new  fibrous  tissue.     The  parts  thus  gradually  deprived 
of  blood  must  degenerate,  and  this  occurs  at  a  comparatively  early 
stage,  although  not  so  early  as  in  tubercle.     When  the  gumma  is 
Urge,  and  particularly   when  the  epithelioid  cells  are  present  in 
large  numbers,  the  mass  may  be  seen  to  be  made  up  of  an  agglom- 
eration of  smaller  growths,  each  having  the  characteristic  structure, 
^'hen  the  leucocytes  especially  predominate  the  foci  run  together 
*nd  their  outlines  are  lost. 

In  earlff  stages,  before  they  have  produced  marked  destruction 

<*f  tissue,  gummata  may  disappear.     In  later  stages  their  central 

^tty  portions  are  frequently  absorbed,  leaving  a  radiating  puckered 

*<^r:  calcification  is   rare.      Not  uncommonly,   under   conditions 

fflich  are  not  understood,  gummata  soften  and  excite  suppuration 

•WunJ  them ;  the  abscess  bursts  and  a  yellow  slough  is  exposed. 

This  has  a  very  characteristic  appearance,  like  "  wet  wash-leather  " 

—tough  and  coherent,  very  unlike  the  dead  tissue  thrown  out  from 

"^^    caseous  centre  of  a  tubercular  focus.     It  gradually  becomes 

"ftached,    leaving   a   larger    or   smaller   cavity   with    soft   ragged 

"^■^•■gins.     These  changes  can  often  be  seen  in  the  tongue.     Gum- 

""***  of  the  skin  and  mucous  membranes  are  the  mcst  prone  to  take 

^'s    course.     These   ulcerations   must   be   distinguished  from  the 

'^Perficial  ulcerations  connected  with  the  early  rashes. 

Crummata  are  met  with  in  the  skin  and  subcutaneous  cellular 

'**sue;  in  the  submucous  tissue,   especially  of  the  pharynx,  soft 

P*late,  tongue,  and  larynx ;  in  muscle,  fascia;,  and  bone ;  and  in 

1*6  connective  tissue  of  organs,  especially  of  the  liver,  brain,  tes- 

.'^le,  and  kidney.     Gummata  also  occur,  but  much  le.<<s  frecjucntly, 

**    the  lungs,   especially  in   con^jenital  syphilis:    simple  localized 

^"•X)id  indurations  are  found  under  the  same  circumstances.     They 

E^Oerally  form  late,  or  "  tertiary,"  manifestations,  but  they  may 

'^cur  at  (juite  an  early  stage.    No  hard  line  can  be  drawn  clinicalhf 

"etween  the  secondary  and  tertiary  stages,  and  none  can  be  drawn 

Hthologieally  between   the   products   of  these   stages.     Most   are 

•iflammatory :   of  these  some  are  circumscribed  and  some  diffuse. 

£ren  the  hard  chancre  has  the  same  structure  as  the  first  stage  of  a 


452 


THE  INFECTIVE  ORANVUmATA. 


giiinina — leucocytes,  epithelioid  cells,  and  giiint-cells  in  a  fibhl! 
uiatrix. 

At  Viiriiiii.s  pluce.s  attention  lias  beeu  drawn  to  resemblances  ■ 
dititiuctiuus   betweeu   tiiberculiir    nud   syphilitic   fomialious.      Tbi 

Fio.  163. 


PyjihllltK'  <1Im'»i<c  of  ct-rvbnil  artrrlM:  .1,  wenuMit  of  niUMW  eetvi>n«i  •"»«. 
•rnlon  :  i.  thU  ki-iinl  InniT  iimI  ;  r,  vuilotlivUum : /,  inrnibtAn*  ffiit- '  im 

A.  Mlrviillllii.      ■  J>>.  mliKHHl  |.     /(.Ktnall  artery  uf  |>lu  iimli'r,  Inr.-  n   sb 

U>lrki-iU'<l  Inner  i-iuit,  •tlinlnlthpil  liinicn  <>r  vi'mrl.  onil  mn>l<1rrBi>lr  im 
tltia.    The  r»vlly  of  the  vrsnel  In  ix-i>ii|ilrd  by  •  clot.    X  1"".  r«luml    , 


points  of  c-outra8t  may  be  thus  suuiniarixed :  In  sypkilin  (1)  tha| 
coDta<riun  is  more  easily  traceable;  {'!)  the  foci  are  larger,  and  ilw  i 
a  greater  tendency  to  orgiinizution,  while  endarteritis  of  thti^ 
vessels  is  invariable;  and  (•-()  tlw  lesions  are  alway*  lo«.*»l  and  P>i^ 
mentittion  is  coniuion.  I 

Chaofree  in  VesselB. — Certain  changes  in  the  «rt«ri(«.  knows  ■■ 
ruihirtfritin  ohlitfriiti*.  ocnir  in  syphilis.  | 

In  the  cerehrni  arteries  the  changes  produce  opacity  and  mark^H 
thickening  of  the  vessel,  with  consideral>le  diminution  in  its  e»lik»^ 
It  is  this  diminution  of  the  lumen  of  the  vessel  which  is  efptdll^ 
oharaetrristit!.  The  smaller  vessels,  iirteries  and  vein*,  are  lAI^W 
affectetl,  and  their  lumina  may  be  ^uite  oblitemtetl.  ' 

When  transverse  sections  of  the  veasela  are  examineil  mn  ■'  '  •  T'" 
cally  the  principal  change  is  seen  to  be  situated  in  thei^ioJ"'^ 
(Fig.    158).     This    coat    is    considerably   tliickcued   by  a  erUt 


SYPHILIS.  453 

grovftli.  The  growth,  which  is  limited  internally  by  the  endothe- 
Wum  of  the  vessel  and  externally  by  the  membrana  fenestrata,  seems 
to  consist  of  "  productive  "  inflammatory  tissue  (p.  294). 

Itt  addition  to  this  change  in  the  intima,  the  outer  coat  is  abnor- 
mally vascular  and  infiltrated  with  small  cells  (Fig.  153),  and  this 
cellular  infiltration  usually  invades  the  muscular  layer  as  well.  The 
marked  diminution  of  the  lumen  of  the  vessel,  and  the  consequent 
interference  with  the  circulation,  coupled  with  the  changes  in  the 
enilothelium,  frequently  lead  to  coagulation  of  the  blood  (thrombositi) 
*'i»l  cerebral  softening  (pp.  76  and  267). 

EnOLOQY. — Strong  as  is  the  clinical  evidence  of  the  infective 

"^tnre  of  syphilis,  nothing  positive  is  known  of  its  cause.     The 

general  similarity  between  the  lesions  of  syphilis  and  those  of  the 

otHer  infective  granulomata  lends  weight  to  the  supposition  that  the 

virus  is  an  organism  which  enters  through  a  mucous  membrane  or 

through  an  abraded  surface  of  skin,  and  is  carried  into  the  blood 

indirectly  by  the  lymphatics,  and  directly  by  the  blood  itself;  for 

<b^  early  destruction  of  an  infected  surface  fails  to  prevent  the 

goneral  disease. 

The  poi.son  exists  in  the  primary  sore,  in  mucous  tubercles,  and 
«1 1  secondary  sores,  and  in  the  blood  during  the  eruptive  period. 
It  is  doubtful  whether  it  is  present  in  pure  lymph,  such  as  may  be 
ol>t:»ined  from  a  vaccine-vesicle.  It  is  not  present  in  normal  secre- 
tions, as  saliva,  mucus,  semen.  The  discharge  from  tertiary  or 
giainmatous  ulcers  is  not  infective. 

Klebs  inoculated  apes  with  portions  of  syphilitic  tissue,  and  pro- 
duced a  disease  closely  resembling  syphilis. 

During  recent  years  many  observers  have  described  organisms 
*"l»icli  they  have  found  in  syphilitic  lesions.  None  of  these  results 
■la-ve  up  to  the  present  time  been  sufficiently  confirmed.  Lustgarten, 
'**  particular,  has  described  a  bacillus  very  similar  if  not  identical 
*">tfi  that  usually  present  in  the  .smegma  preputii.  But  in  this,  as 
'w  other  cases,  nothing  certain  is  yet  known. 

Syphilitic  Disease  op  the  Liver. 

The  liver  is  one  of  the  most  frequent  seats  of  syphilitic  lesions. 

"^e  most  common  change  is  the  development  of  fibroid  and  gummy 

^'^W'ths  in  the  substance  of  the  organ.     In  the  spreading  .^tage  the 

'*'*'"gin8  of  gummata  are  ill-defined  round-cells  infiltrating  the  sur- 


454 


THE  INFECTIVE  GRAXVLOMATA. 


riiiimlin;:;  liver-tisiJiie.  The  growths — whicli  uri-  ui^uallr  connccfr(f 
with  fibroid  thiL-keiiings  of  the  capsule  and  iiiljaeeiit  iieritoneum — 
sometiities  consist  siinjily  of  ii  dense  fibroid  structure.  More  foni- 
monly,  however,  gummata  are  found  imbedded  in  this  fibroid  gniwtli- 
In  the  former  case  it  is  possible  thut  the  guuun»t<')  may  have  become 
absorbed.  In  congenital  syphilis  ircrnt  gumuiatu  are  fretjuentlv  mrt 
with. 

Tiie  ilevelopment  of  these  growths  produces  very  marked  alten- 
tious  in  the  fm-ni  of  the  liver.  Scur-like  depressions  are  seen  nn 
its  surface,  and  the  organ  is  irregularly  and  often  very  deepir 
puckered. 

A  more  general  fibroid  change,  not  associated  with  the  formation 
of  gummata,  is  occasionally  met  with   in  the  liver  in  congciiit*\ 
syphilis.     This  change  closely  resembles  ordinary  cirrhosis,  altbongis 
the  intercellular   network  of  the  liver  is  usually  more  extennin-l'J 
involveil. 

Lastly,  it  must  be  mentioned  that  the  liver  in  syphilis  is  freqaont^  J 
Jardaceous. 

It  is  unnecessary  to  describe  the  syphilitic  lesions  which  occt — ^ 
in  other  orgnris,  as  they  all  present   the  same  general  charuclcru 
viz.  cell-itifiltrations,  scars,  fibroid  indurations,  and  guniuiata.  slii; 
or  combined. 

Certain  clironir  degenerative  changes  in  the  nervous  systeni  a 
attributed  to  syphilis  among  other  causes.     The  degeneration  of  tb^f 
nerve-tissue  is  accompanied  by  an  apparent  overgrowth  of  neurogli^^' 
The  syphilis  probably  acts  by  interfering  with  the  nutrition  of  the  eel-  I- 
demlrites,  and  atrofdjy  of  the  fibre  follows.     (See  Chapter  XX.XI^-) 

GLANDERS  AND  PAROY. 
These  are  varieties  of  one  disease,  due  i)robably  to  difference    in 
the  point  of  entry  of  the  [loi.sou.      In  Qlanders  the  nasal  uiucott« 
membrane  and  its  pnilongations  are  the  seat  of  the  earliest  le«ion*; 
in  Farcy,  the  skin  and  subcutancnus  ti.<sue.     Each  form  may  run  » 
rapid  or  a  slow  course,  and  in   man  it  is  usual  for  the  sytnjiloius  of 
the  one  to  supervene  sooner  or  later  upon  those  of  the  other.    Tkr 
diseases  are  common  among  enuine  animals,  especially  Ijorsw.  MU 
are    communicable   fipom    tbcm   to   otiier   animals,    inclmliag  miU- 
This  happens  but  rarely.     The  disease  is  also  transferable  fron 
man  to  mn* 


GLANDERS  AND  FARCY.  455 

Nature  op  the   lesion. — The   characteristic  lesions  in 
farcy  correspond   to   some   intermediate  stage   between   an   acute 
abscess  on  the  one  hand  and  a  typical  tubercle  on  the  other.     They 
»re   best  seen   in   the   more  chronic  varieties.     A  circumscribed 
nodule  (fiaroy-bud)  appears,  varying  in  size  from  a  just  visible  point 
to  that  of  a  pea  or  bean.     On  section  this  is  found  to  consist  of  small 
round  and  epithelioid  cells :  vascularization  is  at  best  very  imper- 
fect.   Degeneration  occurs  early,  and  more  or  less  acute  suppuration 
follows.     When  a  farcy-bud  forms  near  a  free  surface,  an  ulcer  with 
*  sharply-cut  indurated  margin  and  a  very  foul  base  usually  results. 
^Uch  ulcers  may  heal,  but  their  course  is  generally  very  chronic. 
Itt  the  more  acute  forms  of  the  disease  the  poison  sets  up  ordinary 
suppuration  at  the  spots  where  it  develops.     The  inflammation  is 
not  always  circumscribed :   sometimes  it   is  diffuse,  giving  rise  to 
infiltration  of  muscles,  subcutaneous  tissue,  and  the  connective  tis- 
sue of  the  orbit.     This  is  succeeded  by  suppuration  at  several  points 
or   throughout  the  infiltrated  tissue. 

C30URSE  OF  THE  DISEASE. — A  wound  is  a  common  place 
01  entry ;  mucous  membranes,  especially  the  conjunctival  and  nasal, 
*^^  also  seats  of  primary  infection.  In  many  cases  there  is  no  evi- 
•*^*»ce  to  show  how  the  poison  has  entered. 

Xn  acute  erlanders,  after  a  variable  period  of  incubation,  inflam- 
matory nodules  appear  in  the  mucous  membrane  of  the  nose,  frontal 
*»*Mige8,  or  other  places,  and  run  on  more  or  less  rapidly  to  suppura- 
"Ou  and  ulceration.     The  submaxillary  and  cervical  glands  swell 
■''Obi  infection  through  the  lymphatics.     The  fever  and  muco-puru- 
'^H,t  or  bloody  discharge  from  the  nostrils  are  thus  explained.     The 
P^^ison  now  enters  the  blood  and  is  carried  to  distant  parts,  giving 
''*Se  to  metastatic  inflammations  in  the  lungs  and  other  internal 
***"§ans,  in  the  skin,  and  in  the  mucous  membranes  of  the  respiratory 
***d  alimentary  tracts.     Abscesses  in  the  subcutaneous  and  inter- 
^•Hscular  tissues  are  common,  and  suppuration  in  joints  occurs.     In 
^<5t,  the  disease  resembles  pyaemia  in  many  respects,  being,  like  it, 
^**«  to  the  dissemination  by  the  blood  of  a  poison  capable  of  exciting 
**  J)puration.     The  abscesses  in  organs  are  generally  small,  but  may 
.-  ^^^Mh  a  large  size.     The  respiratory  and  alimentary  mucous  mem- 
*"^ne8  are  perhaps  directly  infected  from  the  nose.     On  the  skin 
^<3  papules  and  larger  patches  of  inflammation  appear.     On  these 
^sicles  and    then   pustules— often   with   hemorrhagic   contents — 


THE  INFECTIVE  ORANULOVATA. 

qnickly  develop.     These  constitute  the  ni»k  of  the  di84>«fi«.     The 
earliest  stage  is  a  collection  of  round  cells  in  the  8a|>rrficuil  par 

Kio.  154. 


tlon  throiiKh  a  "bu<l"  In  tbi>  >klii  (hnn  •  ■■am-  at  arulc  Ottvf.  Tlw  (mmjr  Ut^irl 
itirmtly  ili«A|i|i«>ttnNl  mul  tin'  Mal|»tirltUti  layt>r  U  ihhiIhmI  u)twnn1  hy  ttir  «iit>)««^rnt  ate^A 
Ouftt  ticlow  a).  The  niiia*  itf  |>u^-for|iiiM-U-*  1*  Ju»l  hri-akliitf  (li>wii  to  £i>nn  •  rmtkir.  Ik» 
Wkllii  of  wlilvli  uu  ItillltnitMl  with  uluilUr  crlU.    iPri>m  •  aptH-lmrn  lijr  Mr.  Iki^it , 

t>f  II   |i!i|iillii :  It   little  Inter  a   jiiistiilc  is  fimnd  t"  hnvo   fle»rlnpnl 
under  llie  rete.     The  fever  is  hijrii  tlirouglioiit  the  dii»erii»c.  »Tia 
of  pro.striition   appear  early,  mid  death  occurs  with  all  the  M| 
septic  poisoning. 

In  chronic  farcy  larfre  "  hiids "  appear  in  the  subcntain 
i^iibinucous.  and  iiitorniuscular  tissues.  The  "bud*"  near  the 
face  break  down  hIowIv  and  form  foul  alcera;  the  lyuiphatioi 
becouie  much  swollen,  hard,  and  knotted ;  the  glanilii  are  gre«llr 
enlarged.  The  general  syraptouis  are  much  milder.  This  ft»nii 
often  ends  in  recovery.  The  symptoms  of  acute  glanders  fn^iueatlr 
Bupcrvene  before  death. 

ETIOLOQY. —  In  the  pus  of  absceBsea  in  glandem  Schuli  »a4 
Loefllfr  found  slender  rods,  smaller  than,  but  resembling  generally, 
the  bacilli  of  tubercle.  Cultivated  in  the  serum  of  horae'ii  hioiid, 
tbe»e  rods  forme<l  colonies,  maintaining  their  initial  form.  After 
repeateil  cultivation  to  ensure  purity  from  the  original  put,  ilifletvBl 
animals  were  inoculated.  The  result  varied  with  their  ftiuc«pti> 
hility.  In  all  an  indurated  ulcer  appeared  at  the  sitv  of  ioocala- 
tion,  and  cordy  lymphatics  ran  thence  to  swollen  glands.  la  aome, 
metastatic  alisct^sses  foriiietl  in  internal  organs:  in  others  dealk 
occurred  rapidly,  with  syinptoins  of  septic  poisoning.  In  all  Um 
•bove  bacilli   were   founiL     Two   horses  were   inoralated   fnMB  a 


RHIN08CLEB0MA.  457 

fourth  cultivation:  after  some  days'  incubation  the  symptoms  of 
glanders  set  in,  and  the  older  horse  died  in  fourteen  days.     The 
other  was  extremely  weak  and    was  killed  next  day.     The  post- 
mortem signs  were  the  same  in  both — viz.   a  sore  the  size  of  a 
shilling  at  the  site  of  inoculation;  hard  and  swollen  lymphatics, 
leading  thence  to  glands ;  abscesses  in  the  lungs,  from  the  size  of 
a  pea  dow^nward ;  farcy-buds  and  ulcers  studding  the  nasal  mucosa. 
3?y  this  one  series  of  experiments  it  would  seem  that  this  bacillus 
)xsLS  been  proved  to  be  the  cause  of  glanders  and  farcy. 

An  extract  of  the  cultures  has  been  prepared  and  is  known  as 
ntftllein.  When  injected  subcutaneously  in  cases  of  glanders  it 
gives  rise  to  an  inflammatory  reaction  at  the  seat  of  the  disease.  In 
doubtful  cases  animals  are  therefore  injected  with  mallein  as  an  aid 
to   diagnosis  (p.  364). 

RHINOSOLBROMA. 

This  disease  was  first  described  in  1870.  It  is  equally  dis- 
tributed between  the  sexes,  and  occurs  in  people  of  all  ranks  of  life 
between  the  ages  of  fifteen  and  forty.  The  only  case  recorded  in 
England  occurred  in  the  person  of  a  Guatemalan  under  the  care  of 
Semon  and  Payne.  There  has  been  no  reason  for  suspecting  any 
connection  with  tubercle,  syphilis,  or  other  widespreading  diseases : 
antisyphilitic  treatment  has  always  been  without  efiect. 

APPBARANOES. — The  disease  consists  in  the  formation  of  flat 
or  elevated,  sharply-defined  plaques  or  masses  of  new  growth  which 
are  hard,  tender,  and  elastic.  Their  primary  seat  is  in  the  skin  or 
mucous  membrane  near  the  anterior  nares,  which  they  obstruct. 
They  first  force  the  alje  nasi  apart,  and  render  them  so  rigid  that 
little  impression  can  be  made  upon  them :  indeed,  the  nose  below 
tne  bones  has  been  compared  to  ivory  or  plaster  of  Paris.  From 
tte  front  of  the  nose  they  may  spread  to  the  upper  lip  and  even 
™ind  the  whole  mouth — greatly  narrowing  the  orifice — and  thence 
™  the  gums.  More  commonly,  however,  they  spread  from  the 
"•Sal  orifices  back  through  the  nasal  cavities  (both  sides  being  soon 
inected),  block  the  lachrymal  ducts,  and  reach  both  hard  and  soft 
P'lftte,  which  become  infiltrated,  while  the  latter  is  also  disfigured 
°y  Scar-contraction.  The  infiltration  may  spread  to  the  pharynx 
*"*<i  glottis,  inducing  rigidity  and  closure  of  the  latter  orifice,  and 
consequent  aphonia  and  dyspnoea.     In  a  case  reported  by  Kaposi 


458 


THE  TSFECTIVE  GRANUtOMATA. 


oiif  of  the  ebt'eks  was  involved  to  such  an  extent  that  the 
seeini'il,  by  coni])arisoii,  dejirei^seil.  Similar  changes  bavo 
described  in  both  external  unilitory  uauaU  and  in  the  e 
auditory  meatus.  The  growth  has  never  been  known  to  gcnermliie. 
mill  for  years  the  health  remains  unaffected.  When  the  liiseuc  is 
not  interfered  with  extension  is  .slow,  but  continuous.  ItccurmicY 
ha.*  invariably  and  rapidly  followed  even  coni|>artttively  compUfr 
removal. 

The  masses  muiid  the  no.^tril  are  like  kelniil  nr  ii_\  pfrtp>|  ' 
scars.  They  are  light  or  dark  brownish-red  in  color,  antl  berv 
there  smooth  and  fissured.  The  skin  around  is  i(uite  nonaaL 
There  is  little  or  no  temleney  to  ulceration — after  yean*  it  may  j««l 
be  excoriated.  Injuries  excite  little  or  no  reaction:  after  reumta} 
of  a  piece  it  recurs  and  skins  over. 

HISTOLOGY.— Dense  infiltration  of  the  corium  with  Mnall 
round-cells  is  found.  The  cells  lie  in  a  stroma  which  is  freqacntlr 
(ibrillated,  and  usually  presents  some  dense  bands,  U|M)n  nhicli 
I'ayne  sup|)oses  the  great  hardness  of  the  growth  to  depend;  la 
some  ca.ses,  however,  cartilage  and  bone  have  been  found  in  tl»» 
stroma.  Many  of  the  cells  are  spindle-shaped,  and  a  few  mar  ba 
epithelioid,  but  large  cell-forms  are  the  exception.  The  grnwtli  ia 
tolerably  vascular  an<l  presents  no  tendency  to  fatty  degrni 
Cornil  describes  some  of  the  cells  aa  containing  "hyaline  m: 
wliich  may  also  be  f)resent  in  the  tissue. 

.\s  in  lupus,  down-growth  of  cpithclinl   proces<i«s  into  fbr 
lation  tissue  of  the  corium  is  usual. 

ETIOLOGY. — The  question  of  contagion  has  not  been  raiaed. 
but  the  disease  is  regarded  by  most  authorities  as  an  iafertiTe 
granuloma  on  account  of  its  morbid  anatomy,  coupled  with  the 
ctjnstant  presence  of  a  bacillus  (Fri.sh),  saiil  by  different  iibservna 
to  occur  in  the  cells,  lymphatics,  or  tissues.  Payne  figure«  tbvm  la 
all  three  situations.'  The  bacilli  are  short  and  thiek.  ot-oid.  ar 
even  round,  and  two  are  often  boun<l  together  as  fliplococci  in  aca|»- 
sule.  The  organism  has  been  cultivate<l :  if  grows  rapiilly  at  8T" 
to  100°  V.  Inoculations  made  with  the  cnlture  or  with  piece*  of 
the  growth  upon  the  noses  of  dogs  have  always  failed.  Prwof  of 
the  etiological  relationship  between  this  germ  and  the  diaeaae  ia 
■  TVmu.  Path.  Saritty  </  /^niAio,  XHMt. 


ACTINOMYCOSIS. 


459 


therefore  defective.  It  has  been  suggested  that  the  organism  is 
possibly  a  modified  fonn  of  Friedlander's  pneumo-bacillus.  Accord- 
'Dg  to  Mibelli,  the  "hyaline  masses"  consist  of  the  "shed"  cap- 
soles  of  the  organisms. 

AOTINOMYOOSIS. 

This  disease  consists  in  the  formation  of  small  sarcoma-like  tumors 

or  abscesses  containing  a  peculiar  ray-like  fungus — the  actinomyces. 

''his  fungus  is  supposed  to  be  the  exciting  cause.  The  commonest 
*eats  are  the  lung  and  liver,  but  the  fungus  may  be  found  in  any 
pu~t.  It  is  more  commonly  met  with  in  animals  than  in  man.  In 
<»ttle  the  disease  most  often  affects  the  jaws. 

I»  1878,  Israel  described  a  case  of  multiple  superficial  abscesses, 
witli  one  large  intrathoracic  abscess  opening  by  fistulse  on  the  sur- 
fec^.  The  pus  from  all  contained  parasites  which  corresponded  to 
tk«  above  description.  The  dis- 
ease had  begun  six  months  be- 
fore with  fever  and  joint-pains. 
TDi'ee  weeks  after  admission  the 
woman  died.  A  large  abscess 
"as  found  in  the  left  lung,  and 
countless    abscesses   existed   in 

we  liver,  spleen,  intestine,  and 

itidneys :  most  of  them  were  very 

B'Oall,  but   some  were  as  large 

Man  apple.     All  contained  the 

fiuigi,  and  in  the  glomeruli  of 

tie  kidney  were  found  organ- 
isms which  had  not   yet   excited         Actmomycei,  (from  the  tongue  of  the  ox). 

inflammation.  Two  masses  of  club-shaped   radiating    fila- 

ments are  seen. 


FlQ.  155. 


APPK  A  R  A  NOBS. — On  section  these  nodules  have  a  spongy, 
open  appearance,  and  a  puriform  or  cheesy  fluid  can  be  squeezed 
from  them.  Besides  fatty  cells,  this  contains  many  pale-yellow 
granules  as  large  as  millet-seeds.  These,  when  gently  squeezed 
and  cleared  up  by  potash,  are  seen  to  consist  of  filaments  radiating 
from  a  common  centre,  and  bearing  at  their  free  ends  club-shaped 
swellings,  often  branched  and  frequently  calcified  (Fig.  155). 
Threads  and  spherical  bodies  are  found  less  frequently.  The 
nodules  and  abscesses  also  contain  granulation  tissue,  inter.sected 


?CT/r/?  GRA 


here  and  there  by  hands  of  fibrous  tissue.     In  the  oWor  Bp 
there  are  foun<l.  round  each    fiingus.  the  usaal   signs  of  a 
iiidaniniation  ciiii)<ed  by  n  slight,  constant  irritant  (p.   2mK| 
Israel  states  that  the  fungus  mny  enter  in  three  ways: 

1.  From  the  Mouth,  tlirough  a  earious  tootJi  i>r  extraction-w^ 
By  one  of  tliesc  <'hnnnel»  it  reaches  the  interior  of  tlie  jaw  and  i 
there.     It  next  bnrsts  through  the  outer  plate,  and  give*  riae  j 
abscess  in  the  glands  or  connective  tissue  of  the  neck.     It  is 
ble  that  infection  may  take  place  through  the  folliclco  of  the  i 
in  tonsillitis  or  of  the  pharynx  in  pharyngitis  {yrertrifhral  at 

2.  From  the  Respiratory  Pasaages. — In  one  aum  only  ci 
bronchitis    secnietl    to  be  present,   but   the    sputum   citntaiur 
Actinomyces.     I'sually  the  fungus  sets  up  a  casi-ous  bnin('hi><| 
nionia,  similar  to  that  met  with  in  pbtbisiK,  bnt  shut  off 
healthy  lung  by  a  layer  of  healthy  granulations  which  Hre  succ< 
by  dense  fibrous  tissue.      The  cavities  run   togt-ihor.  the  sym^ 
being  very  like  those  of  phthisis,   though   marked  hiemopty 
uncommon.     Then,  adhesions  having  formetl  nvj-r  the  itiseiu<e<ll 
the  fungus  spreads  to  the  posterior  mediiistinum,  thr<iugh  tbtj 
phragm   into  the  peritoneum  (causing  peritimitit),  liv«r  or 
(rtiswxM),  or  into  the  anterior  meilinstinum  nn<l  pericardium,    l**! 
some  of  these  abscesses  after  much  burrowing  find  their  way  Ui, 
curface.     It  is  noteworthy  that,  though  the  acfinomyct-s  alTtfCi 
lungs  from  above  down,  like  the  tubercle  bacillus,  it  l«a<« 
apex — above  the  davicK- — uninvolved. 

3.  From  the  Intestine. — The  inti>stiue  may  be  affeetr<l  pnn 
from  within,  or  secondarily  by  embolism  or  by  extension  from  ( 
organs.     The  primary  form  may  lend   merely  to  catarrh,  or  tt 
development  of  foci  in  tlic  submucous  tissue  or  mucosa,  chichi 
down   into  ulcers  with  undermined   edges  reaching  dnwn 
inuscularis.     Perforation   into   the    j)eriioneum,    into   other 
viscera,  or  through  the  abdominal  wall  may  result. 

In  a  good  many  cases  the  channel  of  infection  remains  doub 
Actinomycotic  embolism  may  lead  to  abscesses  accompanil 
symptoms  of  pysvmia :  secondary  growths  may  occur  anyi 
I'oiifick  hiis  seen  a  granulation-mass  growing  into  the  jagul 
in  a  case  in  which  there  were  growths  in  the  right  auricle  an4 
iriolf. 

For    Nome    time  all  attempts    tu   cultivate    the    organism 
This  failure  has  been  attributed  to  the  fact  that  only  thv  r/H6j 


SEPTICEMIA  AND  PY.EMIA.  461 

'fere  used,  and  that  these  are  incapable  of  cultivation.  If  the 
threads  be  taken,  amber-like  beads  appear  on  the  culture-ground. 
The  colonies  thus  obtained  consist  of  threads  and  spheres,  but  no 
tilths.  Inoculation  of  the  cultures  gives  rise  to  the  characteristic 
lesions,  including  the  presence  of  both  the  dab  and  thread  forms 
of  the  parasite.  The  exact  botanical  position  of  the  fungus  has  not 
yet  been  determined. 

SOURCES  OP  INFECTION.— Israel  thinks  that  in  some  of  hia 
cases  he  has  been  able  to  eliminate  the  possibility  of  infection 
through  diseased  beef  or  pork,  and  that  the  germ  must  have  entered 
with  water  or  vegetables.  Water  is  unlikely  as  a  nidus,  for  it  soon 
destroys  the  adult  fungus ;  but  Jensen  has  traced  an  epidemic  of 
actinomycosis  in  Iceland  to  eating  rye  grown  on  soil  recently 
reclaimed  from  the  sea.' 


CHAPTER    XXIII. 
SEPTIC  ffiMT  A    AND    PYEMIA. 

The  diseases  known  as  Septicaemia  and  Pyaemia  result  from  the 
■hsorption  and  dissemination  of  substances  usually  derived  from  the 
septic  discharge  of  some  wound  or  acute  inflammation.  The  two 
diseases  are  frequently  associated. 

By  "  septicaemia  "  is  now  generally  understood  those  forms  of 
*®ptic  disease  which  are  unaccompanied  by  the  development  of 
**condary  inflammations.  "  Pyaemia,"  on  the  other  hand,  is  a 
*ei''m  used  to  denote  those  causes  of  septic  diseases  which  are  cha- 
racterized by  the  presence  of  secondary  or  metastatic  abscesses. 
These  two  maladies  are  the  chief  elements  in  the  excessive  mortal- 
ity in  large  surgical  hospitals,  and  nothing  is  more  clearly  estab- 
lished than  that  overcrowding  of  patients  with  septic  wounds  is, 
indirectly,  their  chief  cause.  By  this  process  the  disease  may 
speedily  be  generated  anywhere.  In  almost  every  case  of  each 
disease  there  exists  a  wound  which  has  been  infected  by  some  germ- 
bearing  air,  finger,  instrument,  or  dressing,  or  which  may  have  been 
•  nocniated  directly  from  a  similar  case. 

'  f  srael,  Nea  Sydenham  Soeiely,  vol.  civ. ;  Del^pine,  Trans.  Path.  Society  of  London, 
1889. 


46! 


SEPTICEmA  ASD  PTMMTA. 


SEPTICEMIA. 

EXPERIMENTAL  RESEARCHES.— Koch  injtetfd  fire  mta- 
ims  of  blood,  or  meut-infusion,  in  uii  early  sUgr  of  putrcfactioo, 
iiinlfr  tlif  .»kin  of  hoiiito-niice.     In  oacL  ciuic  the  nniroal   at  ooe* 
grew  restlc«.s  and  ceatied  oating,  \l»  niovi-tncut^  bi'Ciuno   wivk  and 
uncertain,  its  respiration  irregular  and  ^low,  and  «lcsth  ocoairvd 
in  four  to  eight  hours  or  eveu  earlier,  the  time  of  it*  orcarrrnre 
varying  with    the   amount   of   putrefactive   material    injected.      No 
pathological  change  wu8  found  in  the  body,  and  no  effect  waa  pro- 
duced by  inoculating  healthy  animals  with   the    blood.      Thus  tbe 
disease  was  not  infective.      It  was  clearly  due  to  the  abimriitiiin  into 
the   blood  of   putrid    material    unaccompanied    by   any    M-iMndarr 
inflammation:    it    was    therefore    a    gepticcemin.     Kiirthcrmnrp,    it 
seems  to  have  been  due  to   the  jiresence  of  a  chemical    poimn  in 
the  blood,  for  the  result   is  comparable  to  th<'  injection  tif  n  poiMio- 
OU8  alkaloid.     Such  a  substance  would  exercise  its  specific  action 
upon  the  organism,   and   would  not  mitUipUi  in   the  body.  «i  tbat 
the  effect   would  naturally  vary  with  the  amount   injecte<l ;   while, 
even  in  a  rapidly  fatal  case,  a  few  drops  of  the  blood  wuuld  cod- 
tnin  so  small  a  fraction  of  the  original  dose  that,  if  injecft**!  inton 
healthy  animal,   they   would   have  no  effect.     This  form    of  scpti- 
c:emia    is    called    Septic    Intoxication    or    S&prsemia.      From  an 
extensive   series  of  experiments  Burdon  Sanderson  gtvtw  ibr  fiil- 
lowing  as  its  symptoms :  Hestlessness  and  muscular  twit  '  '^•l- 

l(nve<l  by  weakness  increasing  till   the  animal   falls;   vol  od 

profuse  diarrhoea,  the  fteces  being  at  first  loose  and  whitish-ftnij, 
but  later  bloody,  a  temperature  at  first   raised  some   d- 

often    subnormal    before    death;    grodually  failing  respuii    ._ 

cardiac  action  ;  and  death,  sometimes  preceded  by  crsmpfl.  Tlie 
corresponding  post-mortem  appearances  are  —  blood  dark  a&d 
feebly  clotteil  ;  pi-techiie  beneath  pericardium,  emlocardiMiu,  aad 
pleura;  intense  staining  of  the  endocardium  and  lining  meinbrann 
of  the  great  ve.s.'«eU,  and  of>en  a  little  blood-tinged  serum  in  tbe 
serous  cavities,  both  orcurring  so  sooti  nft<'r  death  as  to  indicate 
destruction  of  tin-  rrd  corpuscles  even  during  life;  inliMise  ci>nf!c»- 
tion  and  ecchymosis  of  the  mncous  membrane  of  tbe  stomaeb  and 
intestines,  with  shedding  <>f  the  epiflifliiim  ;  spleen  swollen,  soft, 
and  pulpy  ;  liver  often  swolli-n  »ii<l  iMtiii»ested. 

When  less  poison  was  introduced  tlie  resulting  symptoms  wtfB 


SEPTJCJEMIA.  463 

less  marked,  and  when  only  one  or  two  drops  of  putrid  blood  were 
VMeulated  no  change  was  immediately  apparent.     Indeed,  after  the 
introdaction  of  such  small  quantities  of  blood  the  mice  often  re- 
mained permanently  well.     But  after  an  interval  of  some  twenty- 
four  hours  about  a  third  of  them  sickened,  the  symptoms  being 
characteristic  and  constant  and  not  preceded  by  the  above  toxic 
effects.    The  eyes  became  dull ;  the  conjunctival  secretion  increased 
until  the  lids  seemed  glued  together ;  the  animal  moved  little  and 
'aoguidly,   and   generally  sat   still    in  some   peculiar  attitude;    it 
ceased  to  eat ;  its  respirations  became  slower ;  its  weakness  steadily 
increased ;  and  death  came  on  almost  imperceptibly  forty  to  sixty 
iours  after   inoculation.      Post-mortem   there   were  found   slight 
«edema,  which  is  often  absent,  at  the  site  of  the  injection  or  inocu- 
lation, and   considerable   swelling   of   the   spleen :    other   organs 
api>«ared  normal. 

To  cause  death  with  these  symptoms  in  about  fifty  hours  it  is 
01*1  J  necessary  to  touch  with  a  knife  the  subcutaneous  tissue  of  a 
'DOnse  dead  of  the  disease  at  any  point  however  remote  from  the 
s^^t  of  inoculation,  and  then  with  this  knife  to  scratch  the  ear  of  a 
he^ltliy  animal. 

ttere,  again,  we  have  a  disease  which  must,  according  to  our  def- 

^'^ition,  be  called  Septiccemia.     But  it  differs  from  that  form  first 

fl«8cribed  in  being  intensely  infective.     Only  a  minute  quantity  of 

Prison  is  introduced — (juite  insufficient  to  produce  toxic  effects — 

^^t  it  multiplies  enormously  in  the  blood.     Some  twenty-four  hours 

*f  incubation  pass  without  symptoms  until  its  development  reaches 

«  certain  stage.      Then  symptoms  appear,  and   with  the  further 

increase  of  the  virus  the  symptoms  also  increase  proportionately. 

This  form  is  known  as  Septic  Infection. 

The  blood  of  animals  which  died  after  the  injection  of  1  to  10  11^ 
of  putrid   blood  generally    contained    varying   numbers   of  cocci, 
bacteria  and  bacilli,  but  the  blood  of  those  that  died  after  the  in- 
oculation last  described  contained  only  small  bacilli.     These  were 
present  in  large  numbers,  most  white  corpuscles  containing  one  or 
more  of  them.     Koch  thinks  they  grow  into  the  vessels  about  the 
seat  of  inoculation,  and  thus  become  generalized;    he  has  never 
seen  them  in  lymphatics.     They  occur  in  all  parts,  and  are  not 
more  numerous  in  the  swollen  spleen  than  elsewhere. 

Under  the  heading  Septicaemia  we  have,  therefore,  two  diseases : 
(1)  aeptio  intoxication,  or  sapreemia,  a  non-infective  disease,  due 


464 


SEPTICJBMTA  ASD  PYJgmA. 


to  the  absorption  of  a  chcinicnl  poison  nianufacturod  in  some 
factive  process  cxtiitial  t<>  tlio  boJy,  and  often  fni]in;i  fataUy 
any  organisms  iutroduooil  have  titno  to  »ifvoi<)[)  to  an  extent 
ficient  to  produce  »jiuptoin»,  and  (2)  septio  infection,  ilnc  tii 
entry  of  specific  fungi   into  tlio  Motid  and  to  tlieir  niultiplic 
there.      'l"hc  organisnii*  act  by   producing   poisonous  siibstane 
their  growth,  but  these  products  are  not  "  irritantn.'  and  tb«rtfc- 
no  secondary  inflatuinations  arise.     The   fungi   which  charartrri- 
the  septicaemia  of  one  animal  differ  from  those  which  ocror  in 
of  anotlier — e.  </.   bacilli    in    mice,  oval  cocci  in  rabbits.      Et 
putrid  liuid  does  not  necessarily  contain  the  organisms  of  each 
these   diseases.     The   production    of  septic    infection    fron 
Huiils  is  therefore  uncertain.     Many  different  organisms  are 
ably  capable  of  producing  septictemia. 


OBSERVATIONS  ON  MAN. — In  man  the  occurrene»  of 
gouB  forms  is,  a  priori,  likely,  and  cases  might  be  ijuoted  in  wl 
the  e.xistcnce  of  m'/ftic  intoxication  or  xeptic  infection  was  very 
able  ;  but  the  subject  has  not  been  at  all  fully  workeil  out.  CU 
cally,  it  is  usually  im|Kissiblc  to  diagnose  between  tbeu,  ami 
post-morteiu  signs  are,  very  similar.  The  symptoms  nf  iK>ptiann 
in  man  often  begin  with  a  rigor,  which  may  be  rt^peattnl.  i»pe«iall 
in  the  infective  form;  this  is  accouipanieil  by  rix  of  trnpvi 
and  all  the  symptoms  of  fever,  with  delirium  passing  on  to 
or  even  coma.  These  are  followed  by  groat  loss  of  stretif;th 
rapid  emaciation  ;  a  dry  tongue  and  a  rapid,  fet'ble  palse  eoi 
the  phenomena  characteristic  of  the  "  typhoid  state."  Vomitiog  i* 
frei|uent  and  much  commoner  than  diarrb<i*a,  but  cases  do  occur  ta 
which  tlie  symptoius  and  pathological  changes  of  gastro-cnttritu 
are  well  marke<l.  \  jaundice<l  tint  of  skiu  is  not  nnrommon.  and 
petechial  spots  may  occur.  Albuminuria  is  frequent.  In  the  i»f* 
titf  form  death  occurs  i)uietly  in  a  semi-comatose  state.  In  th* 
tutn-inffciit'f  form  the  ending  is  more  rapid.  The  {uttieut  b««oi 
collapsed,  and  dies  with  dyspncca  and  all  the  syroptooM  u(  rapid 
car<liac   failure. 

The   red   corpuscles,   in   bloo<t  withdrawn  during   lifr,   nu 
clumps  iniitead  of  rouleaux  ;    and   Hiiter  states,  as  the  rwmh 
observation.H  on  the  palpebrji  tertia  of  infected  aniniiiU  and  oo 
lip  of  luaii,  that   iu  septiciemia  there  in  Hide.Hprca<l  capillary 
In  severe  cases  the  blood  in  half  the  ca]iillari(>a  of  a  district  naj 


SEPTICjEMIA.  466 

stationary.     Frequently,  too,  small  clumps  of  red  corpuscles  pass 
tcross  the  field  or  stick  in  some  vessel. 

Post-mortem. — The  rigor  mortis  is  feeble  and  decomposition  sets 
ia  early.     The  blood  may  be  dark  and  fluid,  but  is  more  often  clotted 
in  the  usual  manner ;  soon  after  death  there  is  deep  staining  of  the 
endocardium  and  lining  membrane  of  the  great  vessels,  and  any 
serous  fluid  in  the  pleural  or  pericardial  cavities  will  be  blood- 
tinged:   this  is  owing  to  rapid  disintegration  of  red  corpuscles, 
which  begins  before  life  ceases.     Petechise  occur  beneath  the  serous 
membranes,  and  are  commonest  on  the  back  of  the  heart  and  under 
the  pleurae.     Hypostatic  congestion  of  the  lungs,  congestion  of  the 
abdominal  viscera,  swelling  and  pulpiness  of  the  spleen,  and  con- 
gestion, or,  much  more  rarely,  inflammation,  of  the  mucous  mem- 
brane of  the  alimentary  canal  complete  the  list  of  changes. 

Organisms,  especially  cocci,  have  been  found  in  various  places  in 
about  half  the  cases  of  septicaemia.  Even  in  these  cases  no  charac- 
teristic form  has  been  shown  to  be  present. 

Marcus  Beck  calculated,  from  the  result  of  experiments  on  dogs, 
that  one  to  two  ounces  of  putrid  serum  or  pus  would  be  re([uired  to 
l^ill  an  adult  man  by  septic  intoxication.     This  form  can,  there- 
fore, occur  only  where  large  cavities  exist  and  are  imperfectly  drained 
— e.g.  in  bad  compound  fractures,  in  wounds  of  joints  or  pleurae, 
»n  abdominal   sections,  or  in  the  uterus  after  labor.     Sometimes 
8nch  cavities  cannot  be  efficiently  drained :    hence  the  necessity 
for  preventing  putrefaction  of  their  contents.     Raw  surfaces  and 
serous  membranes  are  well  known  to  be  excellent  absorbent  sur- 
faces.    A  large  quantity  of  poison  may  be  taken  up  by  them  in  a 
short  time.     Granulating  surfaces,  on  the  other  hand,  as  demon- 
strated by  Billroth,  do  not  absorb  the  putrid  poison.     Hence  septic 
intoxication  will  be  most  likely  to  occur  before  granulation  begins. 
It  may  occur  later  if  the  granulation  tisisue  is  destroyed  in  any 
way.     No  line  can  be  drawn  between  it  and  septic  traumatic  fever 
(p.  278). 

Septic  Infection  may  occur  from  the  smallest  wound,  and  there 
may  be  distinct  evidence  that  some  poison  has  been  inoculated. 
The  presence  of  only  a  small  wound  is  evidence  of  septic  infection 
as  opposed  to  septic  intoxication. 

With  regard  to  the  cause  of  septic  intoxication :   many  of  the 
products  of  putrefaction  are  capable  of  producing  fever.     Bergmann 
sacceeded  in  obtaining  from  putrid  fluids  an  alkaloidal  body  which 
30 


SEPl'ICXMJA  ASD  PY ACUTA. 


he  called  sepnin.     This  body  crystallizes  in  fine  needles,  anii 
sesses  in  a  ]iii;li  licgroe  the  property  of  exciting  fever. 

PYiEMIA. 

PyBBmia  tlifiVi's  from  tiepticirmui  in  this  respect,  that  i^l 
absorption  and   ilisseniiniition  of  the  jioison  give  rise  not  r>nJ('  tot 
general  disease,  but  also  cause  the  formation  of  secondary  fc 
inflnraniiition — so-called  metastatic  abscessee.     These  are  tJic  ^ 
tinctive    pathological    characteristics   of  the   disease.      Its  clinic*! 
symptoms  are  well   marked,  the  very  irregular  temperature  being 
most  important,  but  it  is  confessedly  com|)licated  with  moreorlcM 
septic  poisoning. 

Like  septic  infection,  the  disease  is  essentially  a  hospital  dmut. 
and  their  poisons  are  probably  similar ;  some,  indeed,  believe  them 
to  be  tlic  same.  The  sonrce  of  infection  is  almost  always  tomn 
intiiiiuniiition  nr  su|)purating  wound,  with  septic  discharge.  Bni 
there  may  be  no  wound,  as  is  seen  in  acute  infective  poriostiti», 
infective  endocanliti.-i,  und  those  rare  cases  of  "•  spontJDeow 
pyaemia  in  whicli  nn  jirimary  lesion  can  be  found.  In  these  cts* 
the  poison  has  probaldy  entered  through  some  healthy  mucou* 
memlinine.  .\s  in  septiciemia,  it  gains  access  to.  and  is  distrilutw 
by,  the  blood. 

Besides  the  secondary  abscesses,  the  following  signs  may  be  fiiiu"' 
post-mortem :  As  in  all  septic  disease,  rigor  mortis  is  ffihlo  in"" 
decomposition  early.  Emaciation  is  generally  marked.  audtbeH'" 
yellow  or  jiiiiiulicud.  I'otcchiie  may  he  present.  The  wounu, " 
there  be  one,  is  sloughy,  perhaps  surrounded  by  diffuse  inflntiii'i*- 
tion.  and  offensive.  Any  bone  which  has  been  divided  sho**""' 
appearances  of  septic  ostemnyelitis.  The  thrombi  in  the  vein?  It*''' 
ing  from  the  focus  of  infection  are  extensive,  and  are  auderiP""? 
infective  pnriform  softening  {p.  2.''tO) ;  the  ends  of  i>ne  or  n>"f' 
thrombi  perhaps  project  into  a  large  vein  in  which  the  circuiat"''' 
was  not  arrested.  The  blood  is  generally  normal  to  the  naked  e)'** 
but  microscoiiicullv  it  contains  an  excess  of  leucocytes.  Hviwist*"' 
congestion  of  tlie  lung.-t  is  generally  present,  the  spleen  is  large  »"" 
pulpy,  and  tlie  liver  and  ki<lneys  show  "gratiiilar  degeoenition. 

The  secondary  abscesses  are  of  two  kiiuh :  (1)  those  Hi 
follow  upon  infarction,  ami  (2)  those  in  which  there  is  no  eviii( 
of  siieh  an  antecedent  change.  In  either  case  the  occnrrem 
suppuration  implies  the  ]ire.sence  of  a  strong  irritant  acting  for 


PYEMIA.  467 

time,  and  it  has  already  been  pointed  out  (p.  310)  that  most  irritants 
of  this  kind  are  fungi.  It  is  probable  that  several  fungi  are  capable 
of  exciting  suppuration,  and  any  one  of  them  might,  if  generalized 
bvthe  blood-stream,  produce  the  abscesses  of  pysemia.  It  seems 
possible,  therefore,  that  the  organism  which  produces  acute  necrosis 
is  Dot  always  the  same  as  that  which  gives  rise  to  ordinary  pya;mia 
from  wounds.  The  streptococeus  pyogenes  (p.  369)  is  the  organism 
most  often  present. 

However  this  may  be,  in  the  first  kind  of  abscess  infarction  is 
induced  by  the  lodgement  in  a  terminal  artery  of  a  portion  of  an 
infective  clot.     The  mode  of  formation  and  characters  of  the  infarct 
and  abscess  have  been  described  on  pp.  258  and  299.     A  probable 
flource  of  embolism  has  been  noted  above  in  the  account  of  the  veins 
leading  from  the  focus  of  infection.     These  embolic  abscesses  are 
most  fre(|uent  in  the  lungs,  but  may  be  found  in  the  liver,  spleen, 
Itidneys,  and  brain.     They  may  occur  in  any  vascular  part.     They 
lie  generally  upon  the  surface  of  organs,  with  their  bases  immedi- 
ately beneath  the  capsule.     They  vary  in  size  between  that  of  a 
-chestnut  and  that  of  a  split  pea,  are  usually  multiple,  and  may  be 
very  numerous.     They  are  surrounded   by  the  usual   hypersemic 
ring.     Often  more  than  one  organ  is  affected,  and  these  abscesses 
may  occur  with  others  of  the  next   kind.     Sometimes   the  lungs 
«8cape,  while  other  organs,  lying  beyond  them  on  the  blood-path, 
»e  affected. 

The  second  kind  of  abscess  is  a  diffuse  suppuration  occurring  in 
the  subcutaneous  and  intermuscular  connective  tissue,  in  the  joints, 
And  in  the  serous  membranes.  In  these  oases  the  irritant  must  be 
conveyed  to  the  spot  by  the  blood  and  lodge  there,  either  because 
tie  nidus  is  suitable  or  because  some  capillary  embolism  has 
occurred.  This  form  of  suppuration  may  occur  alone  or  be  com- 
bined with  the  first  variety. 

Pyaemia  has  never  been  produced  in  animals  by  the  injection  of 
blood  or  pus  from  pysemic  patients.  Cocci  and  zoogloea-masses  are 
found  in  abundance  on  the  surface  of  the  focus  of  infection,  the 
intensity  of  the  process  often  varying  with  their  number.  They 
have  been  traced  into  the  surrounding  tissues,  and  have  been  seen 
piercing  the  wall  of  a  vein.  They  have  been  found  in  the  nearest 
lymph-glands,  in  all  metastatic  abscesses,  and  in  many  organs. 
They  lie  primarily  in  capillaries  or  small  arteries,  but  soon  pass  out 
into  the  surrounding  tissues. 


468 


MALARIA. 


Kocb  iujccted  10  TTl  of  putriil  fluid,  in  which  n  (wrtioit 
htttl  been  nmcevated.  into  ii  nilibit.      No  i«yiup(uiii»  follnwiii 
duys ;    then    the    aniniul    ate    less,  becunio  weukor. 
hours  nfter  the  injection.     A  purulent  infiltration  o 
wall  around  the  jioiiit  of  injection  wa.*  found;  the  ii 
extended  to  the  peritoneum  and  there  was  jtenernl 


luid 
f  thr 

d 

l\V                 '>■ 

1 

!'• •••>  1 

n>|M)rtiMi 
arts,      iw 


tonitis.  The  Kplceu  was  much  euiarged,  the  liver  bnd  a  gr«^'i 
mottle<l  apftearance,  and  gray  wed;;e-!<hape<l  piitelii>  appt^nH 
.section.  In  the  lungs  were  ssonie  dark-ro<i  nirles*  patche*  aboff 
large  as  a  pea.  Animals  inoculate<i  with  the  liloo<l  diet!  of  pm-iwi 
the  same  disease.  The  smaller  the  dose,  the  longer  the  time  brfii 
death.  This  is  explicalde  only  on  the  supposition  that  thr  inf(Frt« 
particles  in  the  blood  uiu.>«t  reach  a  certain  number  in  pr<)|M)rtiM| 
the  body-weight  before  they  can  cause  death.  Micnn 
found  (•\erywliere,  especially  in  obviously  altered  ]\»Tt» 
a<lhcred  to  the  interior  of  vessels,  often  plugging  them.  Red  (X 
puscles  adhered  to  the  coccus  colonies,  which  seemed  able  to  indv 
coagulation  ;  small  thrombi  were  thus  formed,  which  could  be  *^nr 
away  to  form  infective  emboli,  t'erhaps  something  of  thu  kil 
may  account  for  the  second  kind  of  abscess,  but  against  this  is  tl 
fact  that  iiyogenie  cocci  ure  sometimes  found  in  human  bl<K)d,fl 
ing  no  such  aggregations  and  no  abscesses  (p.  343).  In  such  t3l 
however,  the  eoeci  are  introduced  without  any  pabulum  oti  vlw 
thoy  can  thrive.  The  resemblance  of  the  whole  disease  l<i  pj^m 
is  very  marked.  It  is  not  certain,  however,  that  pysemia  in  wBf 
ahvay*  infective.  In  other  words,  secondary  absceases  ttnty 
to  emboli  derived  from  putrid  clots  containing  only  non-pat 
organisms  incapable  of  growing  among  active  tiiane*  or 
blood. 


CHAPTER    XXrV. 

MALARIA- 

Malaria  is  the  name  which  for  many  years  has  b«>en  cmi 
to  denote  the  virus  of  a  fref|uently   fatal  di.sea-se,  occurriog  pn« 
pally  in  tropical  climalt's  and  cliaracteriKed   by  periodic  att« 
fever.     When  thete  attacks  recur  liailt/,  the  diaeate  u  kB« 


IfALABIA.  469 

fttotidian  ague;   when  on  alternate  days,  as  tertian  ague;   when 
«very  f^irrf  day,  as  quartan  ague.     The  periodicity  is  not  always  so 
Regular  or  so  simple,  nor  the  intervals  so  short,  as  in  these  exam- 
plea.     When  the  individual  febrile  recurrences  run  into  each  other, 
So  that  there  are  no  apyretic  intervals,  but  only  slight  remissions, 
tte  term  "  remittent  fever  "  is  applied  to  the  attack.     Pathologically, 
the  disease  is  associated  with  great  enlargement  of  the  spleen  and 
■narked  pigmentation  of  many  parts — e.  y.  spleen,  liver,  and  brain. 
It  is  the  type  of  an  endemic  disease :  it  is  strictly  limited  to  par- 
ticnlar   localities;    that   is   to   say,   it   can   be   acquired   in  these 
iocalities   only,   although   its  clinical    manifestations  may  develop 
efaewhere.     It  is  never  communicated  directly  from  person  to  per- 
son  except  by   the  direct   intravenous  inoculation  of  blood  taken 
from  an  individual  in  whose  blood  the  germ  is  present. 

Laveran  first  pointed  out  that  if  a  careful  examination  be  made 
of  &  drop  of  blood  taken  from  a  malarial  patient  during,  shortly 
before,  or  in  certain  types  of  the  disease,  some  time  after  one  of 
these  febrile   attacks    certain    characteristic   appearances    will    be 
found.     No   staining  is  necessary,  or   indeed  advisable,  but  it  is 
essential  that  very  thin  layers  of  blood  be  obtained,  so  that  the  cor- 
puscles may  be  in  a  single  layer,  lying  flat,  and  not  forming  rou- 
leaux.   An  oil-immersion  lens  should  be  used.    It  may  be  necessary 
to    spend  an  hour  in  the  search  before  the  organism  is  discovered, 
but    osnally  it  can  be  seen  in  every  second  or  third  field  of  the 
microscope,  and  sometimes  even  five  or  six  parasites  are  present  in 
«ach  field.     In  this  way  the  observer  will  be  able  to  demonstrate 
the  presence,  especially  in  the  red  corpuscles,  of  one  or  more  of  the 
following  bodies :  (1)  circular  or  ring-shaped  amoeboid  disks,  pale 
and  apparently  structureless,  lying  on  or  in  the  red  corpuscles,  and 
not  unlike  vacuoles  (Fig.  156,  2,  3) ;  (2)  pigmented  amoeboid  bodies 
occupying  from  a  sixth  to  almost  the  whole  of  the  affected  cor- 
puscle, which  usually  contains  only  one  such  body  (4,  .5) ;  (3)  well- 
yefined  rosette-shaped  or  clustered  bodies,  the  segments  surround- 
ing or  radiating  from  a  clump  of  pigment  in  or  about  the  centre  of 
*ne  figure  (6) — these  may  be  free  in  the  plasma  or  may  be  encircled 
"y  the  remnant  of  a  red  corpuscle ;  (4)  pigmented  crescentic  bodies 
*  '  **);  (5)  flagellated  organisms  and  free  flagella  (5,  d,  e,f;  6,  <, /; 
v")  leucocytes  containing  black  pigment ;  (7)  all,  any,  or  fragments 
***  the  above  which  have  escaped  or  have  been  expressed  from  the 
'^n>'J8cle8. 


470 


MALABfA. 


The  appearances  will  b©  better  understood  by  reference  to  the 
accompanying  drawings.  The  horizontal  series  is  arranged  accord- 
ing to  the  views  first  formulated  by  Golgi,  and  now  held  by  Mansutu 
and  others,  concerning  their  life-history  in  the  blood,  though  it 
must  be  remembered  that,  as  development  does  not  progre!«s  when 
the  bodies  are  removed  from  the  circulation,  the  complete  cycle 
cannot  be  actually  observed.    The  two  parallel  vertical  series  repre- 


0 


Fio.  136. 


S.e 
^      S.il 


«.» 


6.e 


ynnritey  tt»m  the  MimmI  iir|Ni(i<'iii!<  Milt'criiii;  frum  malaria,    i  An  pxplanatlmi  i>l  tin-  ataixo 
tiKiiro.  Hlilch  Imvi'  Ix-t-n  taki'ii  from  varloUH  mium-ii,  in  i-mlHMllod  In  the  U'Xt.> 

sviit  observed  cliaii;res.  bt-lieved  to  be  j>08sible  development.x  of  the 
pijiinciitcil  iiiiKcboid  botlies  (">).  As  the.««e  only  occur  after  thf 
parasite  lias  liccn  removed  from  the  circulation,  they  are  c<»nsidere<i 
by   .Maiisoii   to   form   a   provision   for  carrying  on   the  life  of  the 


MALARIA. 


471 


malaria]  organiHin  outside  the  human  body  and  during  its  passage 
from  one  liiimtin   l)eing  to  iinothtr. 

1  represents  the  most  minute  forms  which  ure  found  free  in  the 
plasma;  2  and  3  are  believed  to  show  that  these  minute  botiies 
hecoine  attached  to,  and  penetnite.  the  corpuscles;  4  luid  5  show 
the  growth  of  the  intracor[)usuular  disks  and  tlie  development  and 
•iistributiou  of  the  pigment.  During  these  stages  ama'boid  move- 
incnt«  may  be  easily  observed  in  the  parasite,  as  well  as  distinct, 
extensive,  and  sometimes  rji])id  motion  among  the  pigment-particles, 
manifestly  not  of  the  nature  id'  "  Umwuiun  "  moveuK'nt.  The  pig- 
ment is  believed  to  be  tin  excreiuentitious  product — the  unused 
remains  of  the  hsemogluhin  digesteil  by  the  parasite.  The  next 
figure  (fj)  represents  the  organism  as  a  prefectly  circular  disiv, 
almo«t  completely  filling  the  corpuscle.  The  pigment  is  now  aggre- 
gated in  the  centre,  and  fainf  iinlications  of  commencitig  segmenta- 
tion are  discernible.  A  little  later  this  circular  disk  divides  into 
distinct  segments,  and  these  form  an  almost  perfect  rosette  (7). 
The  remains  of  the  corjuiscle  in  the  uiean  time  fall  away,  while  the 
segments  separate  and  are  thrown  into  the  general  circulation. 
They  are  then  supposed  to  form  the  minute  circular  bodies  first 
mentioned,  and,  if  they  e8cn|ie  the  (thagocytes,  to  seek  inclusion  in 
red  c'irpuscles,  as  before  described. 

Ill  tiie  first  of  the  two  vertical  columns  are  represented  different 
stages  that  have  been  observed,  showing  that  under  'Some  circum- 
stances certain  of  the  parasites  have  the  jiower  of  leaving  the  cor- 
,puscde  and  of  developing  into  a  Hagellated  organism.  The  flagella 
}pear  quite  suddenly,  as  if  they  had  developed  beneath  a  capsule, 
which,  giving  way,  allows  them  to  spring  out  and  obtain  room  to 
»ct.  These  HageUa  lasii  ttie  surrounditig  Huicl  and  cause  much 
imniotion ;  they  then  become  detached,  swim  about  for  a  time,  and 
.nlowly  disappear.  They  exhibit  two  kinds  of  movement — the  one 
slower  an«l  undulating,  the  other  ipiicker  an<l  (piivering.  as  of  a 
stiffened  rod. 

In  the  parallel  column  another  sequence  of  changes  from  the 
«*me  body  (.0)  is  shown.  The  erescentic  bodies,  according  to  Man- 
son's  view,  seem  to  be  a  result  of  the  circular,  centndly-iiigmented 
flisks  becoming  curved  on  the  flat,  their  ft»rm  depending  on  mechan- 
ical necessities  accruing  from  continued  enlargement  of  the  parasite 
in  an  unyielding  red  corpuscle ;  hence  the  position  of  the  pigment. 
The  crescents  first  become  .straight  and  cylindrical,  then  oval,  and 


472 


MALARIA. 


finally  spherical.     The  pigment  then  becomes  diffused,  all  trftco  of 

the    enclosing  corpuscle   disHjipears.  iind  a  flai;cllated  organism  i» 
formed  as  in  tbe  previous  case.      The  crescent.i  and  tbeir  progenr 
are  the  most  persistent  of  all,  and  resist  the  attack  both  of  fYiAfp- 
cyte.<  and  of  i|uiTiinc.     Fia^iellated  nrgaiiisiins  are  never  found  until 
the  blood   has  been   withdrawn   for    about  a   ijuarier   of  an  hour. 
They  are  therefore  supjiosed  not  to  exist  as  such  in  the  bo«ly  at  all, 
but  to  form   stages  in  tbe  life-history  of  tbe  parasites  outside  thf 
body.      In  wbiit  forms  and  in  what  places  this  existence  is  pattsed  it 
unknown.      Manson  draws  a  parallel  between  tbe  condition*  »n«^ 
requirements  of  tbe  malarial  jiarasite  in  tbe  circulating  blmxl  anA 
those  of  the  filaria  sanguinis  bominis.  and  argues  that,  as  tbe  jm^t- 
asite  does  not  escape   with  any   of  the  secretions,  it   can   only     ^** 
removed  by  some  suctorial  insect,  such  as  the  mosquito,  just  w*    *" 
the  case  of  tbe  filaria. 

There  can  be  no  reasonable  doubt  that  the  bodies  described     :^»-^ 
phases  in  the  life-history  of  a  protozoal  parasite;  hence  it  is  km 
as   tbe    "  hivniato/onn    malariie,"    sometimes    as   tbe    '•  plasniod^    ""-^ 
nialariic."      Until  the  life-history  outside  the  body  has  been  tr*- 
and  malarial  disease  induced  by  the  inoculation  of  it  in  this  ph 
tbe  proof  that  it  is  the  cause  of  malarial  disease  must  be  conside 
imperfect,  although  tbe  jiresumption  is  strongly  in  its  favor.     T 
it   is  invariably  foun<l  during  the  paro.xysm ;  it  is  never  founti- 
persons  not  suffering    from   malaria  ;    and  blood  containing  it 
alone  transmit  the  disease. 

The  adiiiinistnitiori  of  ipiinine  ia  followed  by  the  di.'fsiipeara 
of  the  intracorpuscular  parasites :  the  crescentic  bodies  arc  the 
to  go.     TieiH-dcytes  have  been  seen  to  approach  and  touch  tbe  in 
corpuscular  forms,  though  they   never  cncloae  any  but  tbe  ex 
corpuscular. 

The  commcnceinent    of  tbe    fever-paroxysm  coincides    with 
breaking  up  of  the  rosette-body.     In    ilifl^erent   forms  of  mala 
fever  the  duration  of  the  lifr  of  each  generation  of  parasites  coi 
sponds  with  the  cycle  of  the  fever;  thus  it  is  forty-eight  hours^ 
tertian,  seventy-two  hours  in  i|uartan,  and  in  quotidian  there  i 
double  infection  of  two  or  more  generations  of  parasites. 

The   severer  types   of  malaria,   found    in    warm   countrice. 
generally  associated    with   the  furuiatiou  of  tbe  crescentic  Im"*'   " 
while  the  early  stage  of  the  parasite  iissunics  a  ring-shape;  in  th   - 
the  rosette-body  is  rarely  fouml  in  finger-blood,  but  may  be  prwcD' 


INFLAMMATION  OF  THE  CONNECTIVE  TISSUES.         473 

in  that  withdrawn  from  the  capillaries  of  the  spleen,  brain,  and 
other  organs  during  life  or  after  death. 

The  malaria  of  more  temperate  latitudes  is  never  associated  with 
the  formation  of   crescents,   the    flagellated    body   being   formed 
directly  from  intracorpuscular  disks  which  escape  from  the  red  cor- 
puscles.     In  the  severer  and  more  malignant  types  of  malarial 
fever,  many  of  the  affected  corpuscles  appear  to  necrose,  shrivel, 
and  deepen  in  color :  these  constitute  the  "  brassy  bodies ;"  of  the 
Italian  writers.     In  such  fevers  small  ring-shaped  parasites,  cres- 
cents, these  "  brassy  bodies,"  and  pigmented  leucocytes  may  be  the 
only  bodies  found  in  finger-blood,  the  large  quantity  of  pigment  in 
the  leucocytes  indicating  the  extensive  formation  of  rosette-bodies 
'n    the  viscera.' 


CHAPTER    XXV. 

tNPLAMMATION  OF  THE  CONNBOTIVE  TISSUES. 

T^B  process  of  inflammation  is  much  the  same  wherever  it  may 
pociir.  Every  tissue  in  the  body  may  be  inflamed,  but,  whilst 
**»flainniation  is  common  in  some  organs  and  tissues,  it  is  rare  in 
***■'> ers.  Certain  forms  of  inflammation  occur  with  especial  fre- 
^**^Hcy  in  certain  parts,  and  the  appearances  will  necessarily  vary 
^^*tll  the  part  involved. 

Tie  student  should  be  perfectly  familiar  with  the  different  forms 
*  •  irnflammation,  so  that  their  names  may  at  once  revive  in  his  mcm- 
*"J''  a  picture  of  the  special  changes  already  ilescribed,  as  well  as  of 
*^i»  causes  and  consequences. 

Inflammation  of  Oonnbotivb  Tissue. 

.        ^-^ommon  connective  tissue  accompanies  blood-vessels  everywhere. 

**«n  vessels  are  injured  this  tissue  is  more  likely  than  any  other 

,         ^laare  in  that  injury,  and  if  the  vessels  alone  are  damaged,  it  will 

^    tie  first  structure  to  experience  the  effects  of  the  lesion.     Thus, 

a^^*"v  form  of  inflammation  occurs  in  connective  tissue ;  the  whole 
^^iription  of  the  process  applies  to  it. 

Q  ^"or  farther  information  the  student  is  referred  to  vols,  exlvi.  and  cl.  of  the  Xew 

jr"    '^^Jiham  Society's  works,  and  to  articles  by  Manson  in  The  Lancet  and  Brit.  Med. 
**•*»-».,  1894. 


474  INFLAMMATION  OF  TEE  COySECTIVE  TISSUES. 

Wilb  regard  to  special  vurieties  of  connective  tissue,  the  non- 
vascular— cornea  inid  cartilage — arc  t'»j)cciallv  intercs<ting  &•>  tVic 
Imttlr-gnnmds  ujioii  wliiolj  tbc  origin  of  the  new  cells  in  inflamuia- 
tiiui  iitive  been  foiigbt,  Senftleben's  experiments  (p.  2H4)  lia.v^ 
sliiivm  that  injiirv  of  tlie  cornea  produces  none  of  tbe  vusculrtr  sig:n« 
of  iufluuiiiiiition  unless  the  marginal  vessels  are  affected  or  unit 
leucocytes  are  admitted  from  the  conjunctival  sac.  About  tl3« 
third  day  after  destruction  of  cells  regenerative  procest>ejJ  set  i 
Observations  on  cartilage  are  more  difficult,  but  tbey  show  that  t^ 
above  results  hold  good. 

Inflammation  of  the  Cornea. 

Anteriorly  and  posteriorly  tbe  cornea  is  limited  by  mcmbmn 
sufficiently  stout  to  resist  the  passage  of  leucocytes:  bat  in  infla' 
matioii   leucocytes  and  fluid   exudation  from  tbe  vessels  enter  free^^ 
from    tile  margin,  pa.ssing  along  the  lymph-channels  in  which  C— 
cells  and  nerve.x  lie.     The  leucocytes  thus  accumulate   in  elustfl 
around    the    torueal    cells.     Such    exudation    is   accompanied 
.softening   and  oiiiunty  of  the  cnrneal  structure,  and   may  lead 
alteration  in  it.s  rurvature.     This  happens  in  vascular  keratitis  a- 
the  interstitial  iutianimation  of  congenital  syphilis.      When  a  sli^S 
vascular  exudation   forms  beneath   the  rniighoned  epithelium  a^ 
consequence   of  the    irritation  of  granular    lids,  the   condition 
known  as  /uniting.     Pus  forming  betw^een  the  layers  of  thecorr»' 
constitutes  lo/yj,  and  ulcers  in  all  stages  are  common.      They  h< 
by  scar-tissue,  and   leave  au  opacity  and   a  more    or    less  alte«- < 
corneal  curve.     Any  keratitis  may  be  "productive"  and  re.'«ult       ia 
o]iacity  and  altereil  curve. 

Inflammation   of   Oahtilaoe. 
In  the  most   acute    inflatnniations   of  joints    the  cartilagr  'Mnar 
.slough  bodily,  as   the   cornea    does   in    the    worst    cases  of    tx«n- 
junctivitis,  from   injury  and  lack  of  nourishment.      It  either   tbra 
peels  off  in  flakes  or  softens  and  wears  away  at  points  of  prettmvn. 
In  Ie.'»s  acute  cases  it  may  be  invaded  by  leucocytes  from  the  joint- 
cavity  or  from  the  bone  (p,  i'-l~).     .Multiplication  of  cartihgc-relU 
may  be  Been,  even  though   leucocytes  naturally  tend  to  collrtt  in 
if  c8[Mwile«  (Fiu'    l^'iT);  but   in  rheumatoid  arthriti.« — if,  inilivl. 
irJl  immatory — multiidicrvtion  of  the  curliUge-cW/t  « 
•  siou,  and  is  continued  until  the  distendd  fflp- 


INFLAMMATION  OF  BONK 


475 


I*»le8  burst  into  the  cavity  of  the  joint.  Regenerative  changes 
Vrobably  occur  in  chronic  ca.^es.  In  a  joint  with  infldincil  carti- 
'4|{w  the  fluid  is  always  turbiil  from  ilegencrating  leucocytes  ami 
'tiwr  products,  thus  differing  from  that  of  serous  synovitis ;  and 


Fio.  157. 


^^^vttfiu  of  inilaniofi  cnriilwBr:  n,  ihc  nnmiHl  rHrUlatn.'-rvllK :  h,  iho  Riiinc  enUrKctl :  rf^ 
"'ultltvdrtUon  of  (■ells  vtrlihin  thi'lr  cii|Kiik-«:  r,  oriKlltiK  liiycr  of  i^runiilntloii  tlMUc.  XiiO- 
'(''••rnll  and  Kmnrler.)    Some  of  the  cclln  itre  probabl]-  Invadiag  lenmoyte*. 

"nder  certain  conditions  the  transition  to  pus  is  easy.     Healing 

'**«?s    place    by   the   formation   of  .scar-tissiip   from    the   new   cells. 

t>noi-t.,  extremely  strong,  and  wide  adliesion.s  nfteii  bind  tiie  surfaces 

''*S<^t,ljer.    producing  fibroma    avkyloKix.      If   the    bone  is  involved, 

*<»tr»e    or  all  "f  the  adhesions  will  ossify — huny  ankyloni*. 

I  Inflammation  of  Bone. 

* '^  fiammation  of  bone  always  originates  in  its  vascular  structures 

"*-l»e  periosteum  and  mt-dulla.     Periostitis  imjilies  that  the  perios- 

'''»*»»«,    is  inflamed,  but  the  adjacent  layers  of  the  bone  are  always 

"*^*»l\ed.      When  the  intlammiition   chiefly  affects  the  medulla  and 

otLt^j.  soft  parts  lying  iu  tlu-  llaviTsian  canals  or  cancellouH  spaces, 

*■    **     csomlitioii  is  calle<l  ostitis,  but  when  the  me<lulla  in  the  canal 

**•     long  bone  is  most  markedly  involved,  the  term  myelitis  is 

^'JJfiloyed.     Inflammation  is  never  strictly  limited  to  either  of  these 

P**"*t*  :  hence  the  term  osteomyelitis. 

^SRIOSTITIS. — .V  serous  form  is  described.      It  is  rare,  and  is 
^"*^    Miildest  form  of  infective  inftammatiun  of  (he  ftart.     The  exuda- 
>i«U   jg  highly  albuminous. 

fibrinous  and  productive  inflammations  are  common  an  the 
n^uU  of  injury  and  syphilis.  A  projecting  node  is  formed.  This 
consists  of  proliferated  cells  froiri  the  deeper  layer  of  the  periosteum, 
tA  Well  as  of  emigrated  leucocytes.  These  cells  may  disappear,  or 
iiiay,  as  in  other  cases,  be  succeeded  by  fibrous  tissue.  This  may 
omh :  it  very  rarely  breaks  down.     Ussification  begins  in  that  part 


47G 


ISFLAMMATloy  OF  THE  COSyECTIVE  TISSVES 


of  the  new  tissue  which  ia  in  contact  with  the  surface  of  the  boof. 
The  vessels  entering  the  Haversian  canals  in  the  latter  are,  uo 
account  of  the  elevation  of  the  periosteuni.  more  or  less  vertical  to 
t lie  surface:  hence  the  new  Iluversian  canals  have  the  same  iJinr- 
tion.     Thexe  new  canals  are  at  first  well  ileHneil  ami  easily  iH'|)arablf 
from  the  old.  but  both  ultimately  become  indistiu^uishably  \i\v\M. 
Later  on.  in  svfihilis.  when  guniinata  form  beneath  the  perioNifum. 
it  is  common  for  su)i)iuration  and  superhcial  caric»  to  occur.    Tit 
subcutaneous  bones  are  chiefly  aftccted.     Inflammatory  thickeniDg 
of  a  biiiie  is  always  due  to  periostitis. 

Suppurative  periostitiB  i.s  generally  a  part  of  the  infective  Ai»- 
ease  known  as  ax:ute  necrosis  and  osteomyelitis.     TIum  disease  '\* 
generally  associated    with    injury.      It   aftects  growing   bone.s.   ai*'^ 
rarely,  if  ever,  occurs  after  union  of  the  epiphyses.     It  i.s  ^ener»^V 
believed  that  pyogenic  organisms  lodge  in  the  medulla,  excite  e»*"V" 
puration,  and  then  spread  tliroiigli  the  Haversian  canals  to  the  f»*!'*' 
osteum,  anti  there  set  uji  the  same  process:  possibly  the  organ i **^"*''* 
may  aft'ect  the  jieriostcum  primarily  and  alone.    I'us  forming  ben^^** 
this  membrane  rajiidly  separates  it  from  the  bone.    The  vessels  |-*  ■•  *" 
ing  inward  from  the  periosteum  are  thus  greatly  stretched,  and  «.^^''' 
together  with  the  |inmary  damage  to  the  vessels,  induces  thromt-^*^"* 
in  many  of  them.     Hence  guperfieial  necrosis  is  the  usual  re*-*^*"* 
and  if  the  iiieditllH  also  has  suppurated,  the  necrosis  will  \)v-  ><it-^^ -^^ 
i.e.  will   involve  the  whole  thickness  of  the  shaft.     I'yjemia  r»*  ■**" 
follows  before  the  abscess  is  opened,  and  this  is  the  conditi»«*^  '" 
wliicli    infecliv*'   fsit-enibolism   is   most    likely  to  occur.      In  8»»-^'**' 
osteomyelitis  following  operations  in  which  the  medullar}'  c»  "*■'    ' 
has  been  openeil  a  diff"use    suppurative    inflammation   attacks       *^ 
iiicdtilla  an«l    periosteum,   causes  total   necrosis  of  large   jiorti**^ 
of  liiiiie,  and  very  freipieutly  produces  a  fatal  result  from  pyic*"*^'* 

(p,  4f;i;). 


I 


OSTITIS   (Osteitis). — The   mildest    form    described    is   tha«      '° 
«liii-li   gnumliition  tissue  is  pniduced.     This  occurs  much  oft***'* 
in  cancellous  (vertebrje,  tarsus,  carpus,  epiphyses  of  long  \»f**^' 
than    in   ciiuipact  bone.     A  round-celled  infiltration  takes  plac«-'  '" 
the  medulla   and   presses   intft   the  Haversian   canals;    the  fat-<*'"'*^* 
and  the  hard  substance  of  the  bone  disappear  before  it ;  canccll'"'-'' 
trabecula?   are  eaten   thrntrgh   and   Haversian    canals   widened.    ■» 
section  shows  spaces  crowded  with  cells,  id'ten  developing  herv  »nii 


INFLAMMATION  OF  BONE.  4tn 

there  into  fibrous  tissue.     On  the  surface  of  the  bone,  bordering 
these  spaces,  are  seen  semilunar  erosions,  as  if  small  bites  had  been 
taken  out  of  it.     These  are  called  Howship's  lacunae.     Each  con- 
tains leucocytes  and  epithelioid  cells,  and  often  a  giant-cell.     The 
giant-cells  erode  the  bone.     The  normal  bone-corpuscles  remain 
unchanged  so  long  as  they  are  distinguishable.     This  process  is 
called  rarefyiner  ostitis,  and  is  an  ulceration  of  caries  of  bone 
without  formation  of  pus  {caries  sicca).     Nothing  is  more  natural 
than  that  a  bone  thus  weakened  should  yield  to  pressure ;  thus  the 
bodies  of  vertebrae  may  almost  disappear,  those  above  and  below 
becoming  approximated,  while  the  shafts  of  long  bones  bend,  as  is 
seen  in  ostitis  deformans  and   other   diiTuse   inflammations.     The 
•nflammatory  tissue  may  pursue  any  of  the  courses  mentioned  on 
pp.  294  et  seq. 

In  a  very  early  case  absorption  of  the  inflammatory  exudation 

noay  occur  and  regeneration  make  good  any  loss.     But  when  marked 

destruction  of  bone  has  occurred  scar-tissue  must  form  and  ossify  if 

*  cure  is  to  be  effected.     This  is  what  happens  in  cases  of  spinal 

curvature  without  abscess.     Too  often,  however,  the  cells  degenerate 

.    »nd  soften,  more  or  less  "  suppuration  "  occurs,  and  a  cold  abscess 

results  (p.  297).     When  this  is  opened,  the  ulcerating,  cariotis  sur- 

•*<5e  of  bone  is  exposed.     If  healing  occur,  it  is  by  tlie  development 

***"  healthy  granulation  tissue,  followed  by  scar-tissue,  which  subse- 

*l^eiitly  ossifies.     Tubercles  are  almost  always  found  in  such  carious 

P*"ocesse8.     Syphilis  is  another  cause. 

X>eath  and  breaking  down  of  the  infiltrating  granulation  tissue 
'^atjg  to  death  of  the  infiltrated  bone :  the  pieces  which  come  away 
^'^G  generally  of  small  size — caries  necrotica. 

Ib  the  most  chronic  forms  of  ostitis  no  rarefaction  of  bone  occurs ; 

**ie    new  growth  slowly  ossifies  and  the  Haversian  canals  and  can- 

*^^ll«)us  spaces  diminish.     The  bone  consequently  becomes  extremely 

_^«."vy  and  ivory-like ;  it  is  generally  thickened  irregularly  from  coin- 

*^**^ent  periostitis.     Syphilis  may  induce  this  change,  especially  in 

.  **^  long  bones  and  in  the  bones  of  the  skull.     It  is  called  condens- 

^**Sr  ostitis  or  sclerosis.     It  is  said  that  simple  closure  of  a  large 

^•^Hiber  of  Haversian  canals  may  lead  to  death  of  the  affected  bone. 

.  **    syphilitic  necrosis  of  the  skull  the  8e(iuestrum  is  often  very  dense ; 

*»a8  probably  been  killed  by  degeneration  and  death  of  the  inflam- 

^^  ^•"tory  products  in  the  bone  around  the  sclerosed  patch,  and  con- 

^^Sluent  destruction  of  the  few  vessels  which  entered  it. 


478  INFLAMMATION  OF  THE  CONNECTIVE  TISSVES. 


Nothing  is  connnoner  tliiui  to  find  rarefying  and  condensing  ostitis 
conibint'd.  (>st('(»i)l«stie  ju-riostitis  and  condensing  ostitis  frci)iienlk 
exist  arunnd  carimis  jiatclies:  tlie  surnoitiding  bone  is  tbus  rendiTinl 
thicker  and  denser.  It  may  be  that  this  less  acute  inflammatory  i>r"- 
cess  is  loiijileil  with  true  hyperplasia  of  the  bony  tissue. 


NECROSIS. — It  lias  alreutly  been  shown  that  death  of  bone  im,' 
follow,  in  sevenil  witys,  difl'i-rcnt  forms  of  inflammation,  cm-li  Icati- 
ing,   liowevLT,   to  destruction  of  vessels  and  arrest  of  nutrition. 

This  result  ituiy  be  brought  about  by  injury  stripping  off  the 
[reriosteutn  aird  brciikiug  up  the  medulla;  but  tlie  extreme  raritv  "^ 
necrosis,  even  in  the  most  serious  simple  fracture,  sliows  that  iujurj 
alone,  with  such  inttauimation  as  it  excites,  is  scarcely  to  be  regard*^ 
as  a  cause.  It  may  act  indirectly,  however,  by  preparing  the  ni*^**' 
for  septic  (in  compound  fractures)  and  infective  organisms.  TUc*" 
constantly-acting  and  severe  irritants  so  diminish  the  vitality  tt*^ 
more  or  less  extensive  thrombosis,  with  death  of  the  parts,  ensii*?^*" 

Suppuration   beneath  the  jieriosteuin  ynd   in  the  me<lulla  is     ^-^ 
cause  of  necrosis.     This  result  is  much  commoner  in  compact  tt»  * 
in  cancellous  tissue,  owing  to  the  greater  ease  with  which  exndati*"^ 
comjiress  tiie  vessels  in  the  unyielding  eliannels  of  the  former. 
rarefying  and  condensing  ostitis  (jt.  477)  ileath  of  the   infiltrat  5  ' 
may  produce  necrosis,  but  in  a  less  violent  way. 

The  piece  of  dead  bone  is  called  a  sequestrum :   it   is  ejt*t     •« 
by  a  process    of   caries  (j).   3SI).       It    may  be  total,  involving    "*- 
whole  thickness,  iiiijxrfiriaf,  or  central,  the  last  being  much    "^^ 
rarest. 

Considerable  difllculty  is  often  experienced  in  the  removal  of  ^^^- 
se(juestruu),   espeetiilly   if  it   be  tleejily   seated.      This  difficulty 
occasionally  (in  mitfiil  iitrro»u)  due  to  the  persist^MJce  of  a  la,^' 
of  the  obi  bone  enclosing  the  rieerosed   portion.     Much  more  f^"*~*" 
(|uently,  however,  it  is  owing  to  the  pi»rticipation  of  the  iK'riosie*-**" 
ill  tlie  inflammatory  process.     The  inflamed  periosteum  prodo*^"*^ 
new  bone,  and  the  bony  capsule   thus  formed   encloses  the  scqu  ***" 
trum.      Ojienings  ((/((((ff/)  exist  in  this  cafisule  leading  to  the  dt"!*" 
bone,  and   through  these  openings  the  inflammatory  product*  »'* 
discharged.     When  the  seijuestrum  is  ([uite  superficial  its  reiDova' 
is,  of  cour.ie,  more  readily  eflected. 

There  are  two  other  morbid  conditions  of  bone  which,  althon^i 
probably  not  coming  witliin  tlie  category  of  inflammation,  may  W 


MOLLITIES  OSSTUM.— RICKETS.  479 

conveniently    described   in    the    present    chapter — viz.    Mollities 
Ossiam  and  Rickets. 

MOIJJTIBS  OssiUM. 

Mollities  Ossium,  or  Osteomalacia,  is  a  rare  disease,  occurring 

ouly  in  adults,  and  especially  in  pregnant  women  who  have  borne 

•nany  children.     It  is  characterized  by  progressive  decalcification 

of  the  bones,  whilst  the  marrow  increases  steadily  and  becomes  con- 

ferted  into  a  vascular  round-celled  structure.    All  bone  is  gradually 

absorbed  except  a  thin  layer  beneath  the  periosteum,  so  that  in 

extreme  cases  the  bones  become  mere  shells.     They  are  very  light, 

easily  cut  with  a  knife,  and  bend  or  break  readily.     Early  in  the 

^/isease  fractures  unite.     On  section,  in  early  stages,  the  cancellous 

spaces  and  Haversian  canals  are  enlarged  and  full  of  a  reddish,  ge- 

'»tinous  substance,  which  at  a  later  period  may  become  yellow  and 

fatty. 

The  nature  of  the  disease  is  obscure.  The  pelvic  deformity  is  of 
<5nief  importance;  the  sacrum  is  pushed  downward  by  the  weight 
***  the  body,  and  the  acetabula  upward  and  inward  by  the  resistance 
^^  the  femora,  thus  greatly  shortening  the  two  oblique  diameters 
(p.  482). 

L&ctic  acid  has  been  found  in  the  bone — the  reaction  of  which  is 
**id  to  be  acid — and  in  the  urine.     The  latter  usually  contains 
excess  of  calcium  salts  which  have  been  removed  from  the  bone  and 
«xcreted. 

Rickets. 

This  disease  of  children  is  so  frequent  in  the  large  towns  of  Eng- 
land that   it  has   acquired   on    the    Continent   the    name   of   the 
"English  disease."     It  appears  to  be  caused  by  defective  hygienic 
conditions,  especially  by  bad  air  and  improper  feeding.     It  is  par- 
ticularly common  in  children  brought  up  by  hand.     It  may  proba- 
bly be  said  that  all  conditions  which  materially  interfere  with  the 
nutrition  of  a  child  aid  in  the  causation  of  rickets ;  among  these  the 
absence  of /re«A  food  ranks  highest.     Diets  deficient  in  fats  or  in 
carbohydrates  seem  sometimes  to  be  sufficient  causes. 

The  disease  is  mainly  characterized  by  changes  affecting  the 
growing  tissues  of  bones,  and  is  therefore  most  marked  where 
growth  is  most  active — viz.  at  the  epiphyses  of  long,  and  at  the 
margins  of  flat,  bones.     These  changes  produce  undue  thickness 


480 


ISFI.AMilATIOS  OF  THE  COyXECTIVE  TISSVBS. 


and  Hoftiioss,  which,  iu   tlu-ir  tiiru,  lead  to  projections  aud 
according  to  tlic  pressure  on  the  softened  bones.      The  boa* 
arc  accompanied  by  symptoms  of  geneml   ill-health,  and 
enlargement  of  the  liver,  spleen,  and,  less  often,  of  the  kidi 
lymphatic  glands,  due  fhit-Jh/  to  increa.se  of  their  inlcrstiti^ 
nective  tissue. 

The  alteration  in  the  bones  may  be  briefly  described  as 
iu   "an  increa»vil  itrcfiaration  for    ossilicutioii.    but    an 
performanfe  of  the  process"  (Jenner).      Jtwill  be  retnenl 
if  a  section  of  the  end  of  a  heultfij/  growing  lung  bone  be  ei 
a   straight    line  is    seen   where   the    white    cpiphyse.il    c.irtfl 
adherent  to  the  shaft,  which  here  consists  of  loose  euncellq 
sue  with  spaces  filled  with  red  marrow.     Between  the  bone  i 
epiphysis    is  a    blue,  semi-transhiccnt    band    about  one  uiil 
liroad  with  practically  straight  margins.     Microscopically, 
line  is  found  to  consist  of  the  one  or  two  layers  of  cartilaj 
which  normally  multiply  and  enlarge,  forming  the  well-knoi 
groups    among    which    os,sification    proceeds.     The    septa 
tiiese  groups  bccnuu'  very  thin,  and  in  the  immediate  neighl 
of  the  shaft  they  calcify.     A  sinlden  transition  from  the 
cells   to  those  of  the  vascular  reil  marrow  is  seen   in   these 
As  S4)on  as  these  spaces  (i>rimnri/  areuhr)  with  calcified  walls  j 
occupied  by  the  round-celled  marrow,  absorption  begins, 
cent   spaces  open   into  each  other  and  fortii  the  larger 
iiffolcr.     On    the    walls    of   these    lamiuie    of   bone  are  d( 
including    osteoblasts    in     the    lacunae    between    tbein,    at 
Haversian  systems  are    gradually  develojted.     The  culriSt 
lage-matrix  is  darker  and  more  granular  than    the  bone   laij 
by  the  medulla,  which  gradually  replaces  it. 

In  a  rickety  bone  the  blue  transition-xone  is  much  wiil< 
normal,  affecting   several    rows  of  cells,    while    its   uuiliof 
toward    the    bone  and    toward    the    cartilage,   are    very    irr 
The  calcification  of  the  matrix  in  the  formation  of  primary  j 
occurs  without  any  regularity.      Hence  pnlches  of  cnlcifioi 
or  of  young  bone  may  be  found  in    the  tran.sition-xonr  <U 
from  the  shaft,  and  oval  collections  of  carttlage-celU  may 
among  secondary  areohe  full  of  red  marrow.     Speedy  fusion] 
|>rimary  into  secondary  areohe  occurs,  but  the  deposit  of  Lan 
bone  is  insignificant. 

Beneath    the   periosteum    an    excess   of    osteoblasts  for 


mCKETS. 


481 


osteogenic  fibres  appear,  but  calcification  is  very  backwiird.  Tbe 
iiK'iliillary  cavity  i*  Joriiiod  as  usual  by  !ihsi)r]»tion  from  tbe  centre, 
uiid  tliua  tbe  soiinil  bone  wbieb  mus  laid  down  before  the  onset  of 
the  disease,  and  which  was  distinguished  from  the  rickety  bone  by 
its  greater  density  and  less  opacity,  is  gradually  removed.  The 
bone,  now  consisting  only  of  the  .soft  rickety  structure,  yields  more 
or  less  raj)idly  under  pressure  or  breaks  under  slight  violence. 
The  fracture,  however,  is  often  incomplete.  As  bending  occurs  a 
buttrt'.ss  of  bone  is  dej)o.sited  along  the  concave  side  of  the  curve. 
This  is  often  seen  in  the  femur  and  tibia,  giving  the  bone?*  a  Hat, 
someirhat  razor-like  appearance. 

The  thickening  of  ei>i|>liy>!es,  the  dis]diict*inerits  which  occur  about 
the  junction  of  shafts  with  epiphyses,  the  thickenings  ol'  tbe  edges 
of  cranial  bones  (c.  y.  the  parietals),  and  the  abnormal  curvatures 

Flo.  158. 


-^*<jn  »t  rli-koty  mdliia,  nhowtnK  cxoMnlve  miiltlpUoation  of  onrtlliifiMvUB  ami  tliolr 
**»f*m«nl  III  rii»>,  mid  HliKht  (KHUIculiuii  of  osleiiiti-nlr  rilirea  i-xtcmUni;  irri'nulttrly  lulo 
^'^mingc.    iMotl.l 

**<jne8  under  pressure  are  readily  explained  by  conditions  such  aa 

^bove. 
■*  lae  process  just  described  seems  to  be  injurious  to  the  subse- 
^*^t  growth  of  the  epiphyses.     They  often  join  the  shafts  prema- 
^ly,  dwarfed  stature  being  the  result. 

SI 


482       lyFLAMMATIOH  OF  BLOOD-VESSELS  AND  HEART. 

Amoug  the  most  important  of  the  deformities  resulting  from  tlii« 
diseasf  is  the  rickety  pelvis.  There  are  two  forms.  The  fint 
shows  ishorteniiiq  of  the  conjiiijalt:  diameter  only,  and  occurs  in  cm« 
in  which  the  cliihl,  being  unable  to  walk,  is  kept  lying  down.  The 
second  resembles  the  ogteimialaeic  pehng,  both  in  its  shope  aii<l  in 
the  mechanism  of  its  production,  for  it  occurs  in  children  who  arc 
able  to   walk  about  (p.  479). 


CHAPTER   XXVI. 


INFLAMMATION  OF  BLOOD-VHSSELS  AND  HEART. 
Inflammation  of  Arteries. 

It  is  generally  taught  that  the  middle  and  inner  coats  of  arter^ 
are  non-vascular,  the  vata  vasoruni  not  penetrating  beyond  the  i« 
ternal  coat,  and  that  the  intinia  is  nourished  by  the  bloo<l  in  ^ 
lumen  of  the  vessel.     But  Mott  has  shown  that  the  vasu  vasor 
may  enter  the  media,  even  in  normal  arteries,  and  has  suggcs* 
that  the  apertures  in  the  ineuibnina  fenestratn  nuiy  allow  fluid* 
pass  from   the  vasa  vasorum  into   the   intima.     In  support  of  ■ 
view  that  the  intima  is  not  nourished  solely  by  the  blood  urithin  t 
lumen    of  the    vessel   Mott   has   shown  that   it  may   persi.tt   roia 
thrombi,  which  must   have  cut  off  that  .source  of  supply  (Fig.  iP 
Jloreover,  if  it  be  true  that  the  cells  of  the  intima  multiply  m 
form  anastomosing  processes  in  organizing  thrombi,  this  eonclus" 
receives  additional   supymrt.     It  is  ipiite  certain    that   in  chro 
inflammation  of  the  arteries  vasa  vasorum  fretiuently  penetrate  ia 
the  middle  coat  (Fig.  161). 

As   in  other  tissues,  inflammation   of  arteries  may  be  acute 
ehnmic. 


ACUTE  AETBRITIS. — One  form  of  acute  arteritis  especi 
affects  the  aorta.     It  leads  to  the  formation  of  small,  pearly,  pink, 
patches  slightly  raised  above  the  surface  of  the  intima.     Under 
mieroseopo  these  are  seen  to  be  mainly  due  to  a  proliferation  uf 
cells  of  the  jtart. 

Acute  inflammation  may  also  be  produced  by  ix^jury,  as  whe***  * 


If 

* 


INFLAMMATION  OF  AIITERIES. 


'483 


vessel  is  tied,  twisted,  or  damaged  by  some  irritant  formed  or  iiti- 

pac<vil  in  it;!  lumen  (tlironibus  or  embolus),  or  it  may  be  the  result 

of   extension  from  sjurrounding  partt!.     The  changes  in  traumatic 

a.i*t;«riti8  are  ileseribed  at  p.  248,  and  the  efl'ects  proiluced  by  simple 

tliroinbosiis  are  similar.     Plugging  of  an  artery  by  a  simple  embolus 

causes  u  chronic  inflammation,  but   infective  emboli,  as  in  eases  of 

olcerative  endocarditis,   are   believed  to  produce  acute  infiltration 

^Ti<l  softening  and  to  be  the  chief  cause  of  aneurysm   in  young 

j>«ople. 

Xu  arteritis  by  extension  the  miter  coat  is  first  and  chiefly 
^■ffieeted.  If  the  process  extends  to  the  iutima.  the  entlothelium 
l>o<roines  detaehe<l  anil  thrombosis  results.  Thus  destruction  of 
■ves^HcIa  by  ulceration  does  not  cause  hemorrhage  unless  the  tlirom- 
bua  breaks  down,  aa  it  m;iy  if  infected  from  a  foul  wound:  this 
^ptic  arteritis  is  the  commonest   cause  of  secondary  hemorrhage. 


CHRONIC  ENDARTERITIS. — Whilst  the  acute  inflammations 

Fio.  159. 


Ti*!  fiuit  i)f  mirlii  In  an  early  stitgo  ol  nrtt'rillii,  shnwIiiK  iK-rliirterllU 

Tn  itii-  vnnii  viiHiiniiii.    Thi'  walU  of  the  viutuni  viuurum  hmvu 
"'^ed.    It  was  II  rnarki'dly  ►yjilillltli-  mnv.    (Mott.) 


^,  *^^*-  more  or  less  generally  the  whole  thickness 
^       **»»»>  inflammations  aff'ect    primarily,  and  som 
^^Pfef  layers  of  the  intima;  hence  the  term  chronic 


484        IN  FLA  MM  A  TlOt 

Chronic   eniliirtciitis   is   to   some   oxtoiit    a   senile  degenerative 
change:  its  advent  is  aeeelerated  by  undue  mcrJianical  utrainjij 
si/jj/uHh,   uud  hy  chronic  nh-oholiism.     MecbAoical  strain  Is  sup- 
posed to  have  a  special  influence  in  the  production  of  that  vanctt 
of  chronic  endarteritis  whicli  goes  by  the  names  of  arteritis  defor- 
mans and  atheroma.     The  proofs  adduced  are — tlie  niiu-li  fjrcaitr 
frequency  of  tlicse  changes  in  tlie  aortic  tiuin  in  the  puhminiry 
system  :  llicir  occurrouee  in  the  hitter  when  tiie  j)ressure  is  r»i»'''l' 
as  in  mitrai  obstruction ;  their  relative  frequency  in  those  jystoiuic 
arteries  which  are  most  exposed  to  strain,  especially  the  arch  of  ti* 
aorta;    and  their    presence    in  conditions  accompanied  by  rise   "* 
blood-pressure.     Thus,  athletes  are  very  liable  to  the  disease.       ^^ 
is,  moreover,  common  in  chronic  Bright's  disease,  which  is  usui*'^^? 
accompanied    by   a    high-tension    pulse.     Syphilis    as    a   cause       *' 
endarteritis  has  been  considered  in  a  preceding  chapter  (p.  4^^»'*i 
and  a  sjiecial  change  in  tiie  arteries,  met  with  in  chronic  iuiC^  "^'^ 
tial  nephritis,  will  be  described  when  that  disease  is  discu; 

Atheroma  affects   chiefly   the   larger    vessels   of   the   trunk 
limbs  and  those  at   the  base  of  the  bruin.     It  ol\en  forms  ri:r 


Fio.  160. 


.\tlieroinn  of  the  aorlA,  ^howinf;  llu'  l'<<-nU/t'<l  Ihlrkv-niitK  ot  th*'  iniL<  r  <  '<u>.  ami  ihr  f 
•lucnt  Iml^lnK  iiiwanl  nf  tht*  vckscI.     Snnif  df  Dm*  new  liuiie  has  iint1'.'n;oiio  faltj'  (Set 
tloii.    Tbcrc  in  iibio  snmr  thickvulng  of  Itii:  miildk'  uuat:  i,  UiU-niAl,  m.  nildillr.  r,*z 
owt  of  vcwd.    X  fiO,  reduced  1. 


rouii'l  ''■  ■  '•  MTitiis  of  branches  leaving  a  main  trunk,  but  the  «hi'/i' 
circ"  is  not  uniformly  affected.       It    appears   as   sligW".' 

yellowish  patches,  covered  by  a  normal  endotheliaui :  m 


INFLAMMATION  OF  ARTERIES.  485 

fact,  this  and  the  superficial  layers  of  the  intima  may,  in  the  early 
stages,  be  stripped  off,  leaving  the  diseased  tissue  beneath.  It  thus 
contrasts  strongly  with  the  superficial  fatty  patches  which  result 
from  fatty  degeneration  of  the  endothelial  and  subendothelial  con- 
nective-tissue cells  (p.  77). 

In  the  earliest  stage  of  the  process  a  grayish,  semi-translucent 
mass  of  cells  is  found  between  the  laminae  forming  the  deeper  part 
of  the  intima.  The  origin  of  this  is  doubtful.  It  is  probably  due 
to  proliferation  of  the  original  tissue-cells,  and  this  again  may  pos- 
sibly be  the  result  of  the  presence  of  some  organism  or  other  irritant. 
The  new  cells  may  develop  into  fibrous  tissue,  resulting  in  a  dense 
fibroid  plaque  or  a  more  diffuse  thickening.  More  often  formation 
of  fibroid  tissue  and  fatty  degeneration  are  found  together  (Fig- 
160),  or  fatty  degeneration  and  calcification  may  occur,  or  the  fatty 
degeneration  may  lead  to  complete  softening.  In  the  latter  case 
a  soft,  yellowish,  pultaceous  material,  consisting  of  fatty  debris  and 
cholesterin  crystals,  is  found  beneath  the  intima.  This  has  been 
termed  an  atheromatous  abscess.  If  the  lining  membrane  perishes 
or  is  torn,  the  softened  matters  are  carried  away  by  the  blood- 
stream and  an  atheromatous  ulcer  is  left.  The  middle  and  external 
coats  become  more  or  less  infiltrated  with  new  cells  and  the  result- 
ing fibrous  tissue,  especially  in  the  aorta. 

It  is  not  uncommon  to  find  the  arch  of  the  aort«  so  studded  with 
small,  thickly-set,  raised  plaques  that  it  looks  somewhat  like  "  croco- 
dile skin."  The  plaques  are  yellow,  and  many  of  them  are  calcified. 
These  calcareous  plates  may  be  quite  bare  or  covered  by  endothelium 
or  a  little  fibrin:  atheromatous  abscesses  and  ulcers  may  also  be 
present.  The  orifices  and  the  branches  of  the  coronary  arteries  are 
often  narrowed  by  these  changes,  while  the  blood-supply  to  the 
heart  is  proportionately  lessened  and  the  tendency  to  fatty  degen- 
eration of  its  muscular  walls  increased. 

The  cause  of  the  fatty  metamorphosis  of  the  new  cells  is  also  in 
dispute.  Kijster  and  Kraft  believe  that  a  meearteritis.  or  infiltra- 
tion of  the  media,  is  the  primary  change  in  atheroma,  and  that  con- 
version of  the  cell-infiltration  into  fibroid  tissue  causes  constriction 
of  the  vasa  vasorum,  which  send  fine  branches  into  the  infiam- 
•natory  patch  in  the  intima :  this  consequently  degenerates.  But 
Orth  and  most  authors  deny  that  a  mesarteritis  either  precedes  or 
eyen  accompanies  the  infiltration  of  the  intima.  Mott  believes  that 
fatly  changes  in  the  latter  result  from  an  endarteritis  of  the  vasa 


486        INFLAMMATION  OF  BLOOD-VESSELS  AND  HEART. 


\'\u.  1«1. 


vasnruiii,  U'liding  to  progressive  narrowing  of  their  luniina:  tlii>  i« 
illustrated  in  Fig.  1(52. 

It  is  obvious  that  atheromatous  changes  will  greatly  impair  tlir 
elasticity  of  a  vessel,  and  render  imperfect  the  circulatiou  in  lhi> 
parts  beyond.     Moreover,  the  itirlaHtlr.  vessel-wall  tends  slowly  t" 

yield  under  the  oimt>t<uit  pressure  to  which 
it  is  subjected.     General  dilatation  of  the 
vessel  results :   when   this  is  extrcnii'  it    i* 
known  as  u  fusiform  aneurysm.     Wh*:*'* 
an  atheromatous  ulcer  forms,  the  vessel     ^ 
specially  weakened  at  one  8|tot,  and  a  loc^  *' 
dilatation  or  sacculated   aneurysm  niac*? 
occur.      When   this   has  reached  a  ccrta. — -* ! 
size  the  wall  may  rupture,  and  fatal  lif^a 
orrhugo  result.     If  the  external  coats  b«      — " 
been  unifortiily  strengthened  by  the  fonii^c^J* 
tiou    of    chronic    inflammatory    tissue 
them,   this  result  will    he    proportionately   lielayed.      If  an  atbcr-a 
matous   abscess   bursts  before   the   tis.sues    round  its  margins  ha   ^ 

Fio.  162. 


Miliary  aneliry^mi!  on  a 
!tnmrh  nl'  llu-  inMiIlr  rt-n-lirnl 
wrU-ry  (fniiu  a  vativ  of  rt' rchml 
hemuirhuKfi.  They  urc  unl 
unUkr  blnla'  nettf  In  n  tn-v. 
(Krom  a  »p<!c)mcn  l>y  IT- 
MoH). 


SroUnn  of  an  athpronia(nii«  aoru:  Un-  iiitiiiwi  i^  iiiiii'lt  thickcnrtl  m ,  pualng  In  troa 
cxtcrnn  tli rough  Ihi'  nii-ili«  iirt-  vetwls  aUmi  which  hfniurrliaKV  iti  ha*  twcurpfl. 
lumlna  of  the  innln  trunks  of  thexe  (c)  In  the  exUTiiti  urt'  nlmi«t  nlitllvnh-4  \i) 
cndanvrltla.    (Mull.) 


tllr 
la 


INFLAMMATION  OF  THE  HEART.  487 

been  matted  together  by  fibroid  growth,  the  blood  mav  find  its  way 
into  the  substance  of  the  media,  and,  making  for  itself  a  cavity 
between  the  coats  of  the  vessel,  form  a  disseotdngr  aneurysm. 
This  occurs  only  in  the  aorta  and  its  largest  branches.  Ulti- 
mately the  blood  may  burst  through  the  externa  into  the  surround- 
ing tissues  or  through  the  intima  into  the  lumen  of  the  vessel. 

Inflammation  of  Veins. 

Acute  inflammatory  processes  are  more  frequent  in  veins  than  in 
arteries.  In  veins  they  are  generally  secondary  to  thrombosis, 
and  are  due  to  the  irritating  effect  of  the  thrombus  upon  the  coats 
of  the  vessel.  These  inflammations  have  already  been  described 
(p.  250).  They  are  localized  or  spreading  according  as  the  clot  is 
simple  or  continued. 

Other  causes  of  phlebitis  are  violent  ii\jury  and  extension  of 

infl&mmation  from  adjacent  tissues.      Paget  describes  a  recurrent 

gouty  phlebitis  especially  common  in  the  internal  saphenous  vein. 

Tte  structural  changes  closely  resemble  those  in  the  arteries.    In 

phlebitis  from  injury  or  from  extension  the  external  and  middle 

coafcts  become  infiltrated  with  cells,  the  vitality  of  the  intima  is  sub- 

seqiiently  impaired  or  lost,  and   thrombosis  follows.     In  phlebitis 

^OEn  thromhom  the  intima  suffers  first. 

I.*«88  commonly  than  in  arteries  the  veins,  especially  in  the  lower 
'»Dal>,  may  be  studded  internally  with  irregular  calcified  plaques. 

AVhen  a  clot  undergoes  infective  puriform  softening  (Fig.  97)  the 
^^in-wall  becomes  densely  infiltrated  with  cells,  and  presents  much 
tli^  same  appearance  as  when  it  becomes  infiltrated  by  extension 
from  a  foul  wound  {acute  septic  phlebitis). 

AT'arioose  Veins. — In  some  persons,  especially  predisposed,  con- 
stant but  comparatively  slight  increase  of  the  venous  pressure  in 
*"®  ^6gs,  scrotum,  or  rectum  will  produce  an  irregular  dilatation, 
leng'thening,  and  tortuosity  of  the  vessels  in  (juestion.  Portal 
obstj-iiction  will  produce  the  same  result  in  the  veins  of  the  hemor- 
rnoicial  plexus,  apparently  without  any  predisposition.  Other  veins 
*''*  similarly  but  less  frequently  affected.  The  dilatation  and  other 
".  *'**^«8  are  accompanied  by  thickening  of  the  walls,  mainly  due  to 
®   **^^rmation  of  chronic  inflammatory  fibroid  tissue. 

initjAmmation  of  the  heart. 
•*  ^mmatory  processes  in  the  heart  may  affect  the  substance  of 


488       INFLAMMATION  OF  BLOODVESSELS  AND  HEART. 

the  organ  or  the  endocardium.     They  are  much  more  frequent  ii 
the  last-named  situation. 


Inflammation  of  the  Endocabdixtm. 

Endocarditis  is  for  the  most  part  limited  to  the  valves  of  th 
heart,  although  it  is  occasionally  found  on  the  adjacent  parts  of  th 
walls.     After  birth  the  process  is  almost  exclusively  confined  to  th 


Fio.  1(53. 


Fig.  164. 


Inflnminatloii  uf  aortic-  valves, 
Iho  oarlitT  ntafrc  <>f  tin*  imH'esH, 
showiiiic  the  situation  of  the  lii- 
flainniBtury  Kranulatloiis. 


Inflammation  of  mitral  valve, 
the  earlier  stage  of  the  proceia. 
Valve  gecn  <tom  the  aurionUr 
Durface,  showing  the  situation 
of  the  inflammatory  graoula- 
tions. 


left  siile  of  the  organ,  and  in  the  great  majority  of  ca.«08  it  coi 
mences  in,  and  comparatively  rarely  extends  beyond,  the  confine 
of  the  aortic  and  mitral  valves  and  the  corresponding  orifices.     Bi 
during  fa'tal  life  cndocarditLs  is  as  exclusively  confined  to  the 
side,  giving  rise  to  congenital  lesions,  and  thus  often  interferi 
with  the  normal  developineiit  of  the  organ.     It  is  those  portions 
the  valves  which  come  into  contact  in  the  act  of  closure,  j>nd  a 
thus  iiio»(  cx/M>»<'il  to  fn'rfioii,  which  are  especially  involve<l  and 
which  the  changes  usually  coininonce.     Thus,  in  the  aortic  valves 
is  the  rininj-  surface  of  the  segments   which   is  most  liable  to 
affccti'<l.     The  change  does  not  commence  at  the  free  edge  of  tl 
segment,  but  along  the  little  band  of  tissue  which  pa.«8es  from  tl»- 
attached  l)or<lcr  to  the  corpus  Arantii  in  the  centre  (Fig.  163).     I 
the  mitral   valve  tlie  auricular  surface  of  the  segments  at  a  littl 
tlistance  from  the  attachment  of  the  chordie  tendineae  is  first  i 
volved  (Fig.  1<!4).     When  portions  of  the  endocardium,  apart  froi 
the  valves,  arc  !iffi<tcd.  it  may  sometimes  be  due  to  the  irritatioi 
caused  by  the  friction  of  vegetations  or  fibrinous  clots  situated  oi 


INFLAMMATION  OF  THE  HEART.  489 

tie  valves  themselves ;  but  it  is  probable  that  infection  by  organ- 
h\iis  deposited  from  the  original  valve-lesion  is  the  commoner  cause 
{Fig-  165). 

The  histological  changes  accompanying  endocarditis  resemble 
those  already  described  as  occurring  in  arterial  inflammation.  The 
en«Iocardium  and  the  inner  coat  of  an  artery  are  very  analogous  in 
their  structure,  both  being  non-vascular  and  consisting  of  a  layer 
of  connective  tissue  with  an  internal  endothelial  covering.  The 
inflammatory  process  may  be  acute  or  chronic. 

-A.CUTB  ENDOCABDITIS. — If  the  process  be  acute,  the  deeper 
^^^'era  of  the  endocardium  become  rapidly  infiltrated  with  young 
cells,  and  as  these  increase  in  number  the  intercellular  substance 
oeconnes  softened  and  destroyed,  and  thus  is  produced  a  soft  tissue 
*^*>ip08ed  almost  entirely  of  cells,  such  as  always  results  from 
inflanjjQatory  processes  in  connective  tissue.  The  new  tissue,  as 
'*  increases,  projects  through  the  superjacent  endothelium  in  the 
"*»*CQ  of  minute  granulations  and  vegetations  upon  the  surface  of 
the  Softened  valve.  (See  Figs.  163  and  164.)  The  endothelial  ele- 
'"^'^ts  probably  participate  in  the  active  process.  This  is  the  papil- 
*  "*^   form  of  the  disease. 


-■lie  above  changes  take  place  in  an  almost  non-vascular  tissue, 

'*-*     although  there  is  more  or  less  increase  of  vascularity  in  the 

*^*"nal  endocardial  layers,  where  the  capillaries  are  more  numer- 

^■»   there  is  rarely  any  redness  or  injection  of  the  endocardium  seen 

,       ^''   death.     The  granulations,  rough  and  bereft  of  endothelium, 

•^ Gently  induce  sufficient  thrombosis  to  provide  them  with  fibrin- 

,     **    «5aps.     These  caps  must  not  be  confounded  with  the  vegetations 

^»*»  selves  (Fig.  166). 

-*-  l»e  results  of  this  cellular  infiltration  vary.     If  the  process  be 

^   intense,  the  new  tissue  may  break  down  and  a  loss  of  substance 

^      **l.t — an  endocardial  ulcer.    This  usually  takes  place  without  any 

^_^  ^  «nulation  of  cells  sufficient  to  form  an  abscess,  the  new  tissue 

^^/~*l>ly  undergoing  rapid  softening  and  disintegration:  but  in  rare 

^^  small  quantities  of  pus  are  found  in  the  deeper  endocardial 

.^^^  ^*8  (abecess).     The  ulcer  is  irregularly  defined,  and  its  edges 

^  Tisuallv  swollen  and  thickened.     The   ulccratiim  mav  lead  to 

^VDration  of  the  valve  or  to  a  considerable  destruction  of  its  sub- 

**«3e.     Laceration  or  aneurysm  of  the  valve  may  also  ensue  from 

jiressure  exercised  by  the  blood  against  the  danuiged  tissue. 


490       ISFLAMMATION  OF  BLOOD-VESSELS  AA'D  IIEAi 

8ometiinos  tlie  iilceruU!  process  exteuiLi  so  as  to  involve  Ui« 
substance.  Ulcerative  endocarditis  is  ii  j;rave  affection,  a( 
iijg  rise   t"   i'iiil)i>lisiii,  iiud  -sotuctiiues  to  u  pyiviiiic   pro 


I-  ri..  itiii. 


Fio.l«l 


Kii(lnc«rilltli>  <lno  to  fHrtlon.  Tho 
itninliiK  n'|in-n'iil>  «  lotiit  voKi'titlInn 
nil  tHir  t»f  thf  wtftn«'Mt)«  of  \hr  iinrtlr 
%'iilvc'.  whit'h  Ijy  niMilriff  «in  thr  en- 
ilm'arUliiiii  Ix'Iou  lirw  pnNliiiiral  nii' 
invmiu  InHanimutnrr  imiiiitatl»n* 
(A). 


Ariitc     rnilnnm 
Kniiiulnliaiii  OiiB 
v«lv",  •!.  ni 

riMiiriil' 

of     thr     ^,- .UM 

XIU.    |Riu<UlvlM!ll.t 


tunately,    this    ulcerative   endocarditis  is   infrof|Ucnt.    the 
usually   beinj;  less  acute. 

When  the  inflninmatorv  process  is  less  intense  the  pmi 
valves  may  adhere  U>  each  other  or  to  an  intlanieil  patch  on 
of  the  iieurt.  The  new  tissue  beiitnies  incoiupletely  ur^niied 
a  fibriiiated  structure,  whilst  it  undergoes,  in  part,  fiittr  and  a 
reoiis  de;ieiier:ili<ni.  These  changes  always  priMlucc  penMt 
thickening,  ri^dity,  and  shrinking  of  the  tissue,  with 
itiHuffirii'ncy  of  the  valves  or  uti-NoniM  of  the  orificea,  or 
new  tissue  may  continue  to  grow  after  the  severity  of  ibe 
has  subsided,  and  thus  are  produced  the  vegetations  and 
excrescences  on  the  valve  which  are  so  imiuiuonly  met  wit 
Fig.  1  •>."».)  These  consist  of  a  lowly-organized  tissue  whic 
to  undergo  fatty  ami  calcareous  changes.  The  offecj 
changes  is.  in  general  terms,  to  impair  the  action  of  tite  he 
some  caoea  this  is  doe  to  the  difficulty  in  propelling  blood 
A  constricteil  or  partially  obntructed  o[)ening.  in  otln  -  ' 
gitatiiin  of  blood  wliicb  may  take  place  tlinnigb  orifiif  ■ 
by  damaged  or  imperfectly  approximated  valves  ^»p.  lltf. 


INFLAMMATION  OF  THE  HEART.  491 

Btiolo£r7' — Endocarditis  occurs  especially  in  acute  rheumatism. 
It  is  an  occasional  complication  of  pyaemia,  puerperal  fever,  gonor- 
rhoea! rheumatism,  scarlatina,  typhoid  fever,  and  chronic  Bright's 
disease.     The  papillary  form  is  by  far  the  commoner.     The  ulcera- 
tive may  occur  primarily,  but  as  a  rule  supervenes  upon  the  papil- 
lary or  chronic  forms. 

The  relation  of  endocarditis  to  the  above  disease  and  the  course 
of  the  ulcerative  form  suggest  an  infective  origin.  In  ulcerative 
endocarditis  many  observers  have  found  micrococci  on  the  vegeta- 
tions and  in  the  substance  of  the  valves.  The  forms  most  fre- 
quently found  are  the  staphylococcus  pyogenes  aureus,  the  strepto- 
coccus pyogenes,  and  less  commonly  Frjinkel's  diplococcus  pneumo- 
nia and  other  forms  of  bacteria.  These  organisms  have  been  culti- 
T»ted  and  the  cultures  inoculated.  Ulcerative  endocarditis  has  fre- 
'luently  been  produced  by  a  very  large  dose  of  the  cultures.  If  the 
vaJves  be  previously  injured,  a  much  smaller  dose  suffices  to  pro- 
duce s  similar  effect.  Corresponding  organisms  are  demonstrable 
m  the  secondary  inflammations. 

CHBONIC    ENDOCARDITIS.— This    may   be   the   sequel  of 

*cute  inflammation,  or  the  process  may,  from  its  commencement,  be 

*^''ronic  in  its  nature.     Conditions  of  mechanical  strain,  such  as 

***i   to   chronic   endarteritis,  are   the  most   important  causes  of 

<5nronjg  inflammation  of  the  endocardium.     Hence  chronic  disease 

^^  the   cardiac  valves  is  frequently  associated   with  atheroma  of 

"6  arteries.     The  cell-infiltration  is  much  less  rapid  and  abundant 

^Qan  in  the  acute  form ;  the  intercellular  substance  consequently 

•^Odergoes  less  softening  and  disintegration,  and  the  new  tissue  ha» 

*    much  greater   tendency  to  develop  into  a  fibrillated  structure. 

^  »ie  result  of  these  chronic  processes  is  the  production  of  a  fibroid 

^^^ckeniner  of  the  endocardium,  with  more  or  less  induration  and 

'^utraction  of  the  valves,  narrowing  of  the  orifices  from  the  pro- 

^*"*8sive  adhesion  (from  the  bases  toward  their  apices)  of  adjacent 

*^'**P8,   and  shortening  and  thickening  of  chordce  tendinece.     The 

®^ect«  on  the  circulation  are  the  same  as  those  produced  by  acute 

^•^docarditis.     The  new  tissue  sometimes  forms  papillary  growths 

**    the  valves,  which  undergo  partial  fatty  and  calcareous  changes 

(^•g.  165). 

Inflammation  of  the  MYOCABDroM. 
^Myocarditis,  or  inflammation  of  the  cardiac  substance,  is  much 


Acute  rliuuiiiiiUv  royocHnlltiB,  suociuttil  uUli  eliilo-  uul  tMsrlvmnllliii.    To  th»  iuk.«^ 
the  inyocanliiini  »aj!"riut>"  iiiily.    The  tl)»ii«  Hrvuii'l  the  artery,  setn  In  Ii>ii«ii«»^" 
section,  are  liillltrated  wiili  leueiK^ytes.  and  lieiuorrliiit-'C  hun  wcurreil  in  ibc  U|i|er  |»T*- 
KafQ  of  NUiIdiMi  ileutli.    (Mult.)  ' 

as  the  ri'fiult  of  a  pyjvniic  process.     Less  intense  an<l  more  il ilTo* 
Ibniis  of  onnliar  intlaiiiniation  are  also  not  infret|uentl_v  nn-t  *iiliiii 
'  From  "  MyiXJirditL-,"  In  l>r.  Kruec,  in  Kt-ating'*  //umias  ^ CM<n«- 


UfFLAMMATJUS  OF  THE  HEART. 


493 


association  with  jiericaiditis.  and  less  comiuonly  witli  enilocarditia. 
llerf  till*  inflummatory  process  appears,  by  exteiisiuri,  to  iiivolvt  tlie 
iTiimf<liatcly  adjacent  muscular  layers  of  the  organ,  wliicli  are  found 
infihralcd  witL  small  cells,  the  fibres  tbemselves  being  softened  and 


Fio.  168. 


I 


a  6 

*nit*m]rocardltlii  (&om  srasf  of  acute  rheumatism):  a,  a  thin  section  of  the  left  vcntriale 
"■••IHn  the  dlrv-ctlon  of  the  musoular  Hhrm.  nhuwlim  thi-  Kniniilur  and  Kwnllpn  oomntlon 
'*«  the  nhtvn  iiinl  the  prominence  of  tlielr  imrlei;  h,  ulrniisverpse  sei'tion,,  {^liowfng  IheceUular 
'"llttitlim  of  the  IntcrmuKcular  tlsmic.     y.  200. 

P^nlar  from  degeneration  or  clear  and  structureless  from  coagiila- 
'lon-necrosis. 

Ill  addition  to  the  above,  a  diffute  form  of  myocarditis  must  bo 

''"•'ognized  in  which  the  substance  of  the  heart  Itc-enmes  more  jrcn- 

^^  *^''aUy  involved.     In  certain  cases  of  acute  rlieuinatism  the  nmseular 

^1  *'88ne  of  the  heart  is  found,  after  death,  to  liave   undergone  tlie 

H^Qauges  characteristic  of  clouili/  suudlim]  (p.  7i^).     When  examined 

^B*'*'cro8copically,  the  nuclei  of  the  fibres  are  often  seen  to  be  larpe 

BJ^'Jfl   prominent,  while  small  cells  in  varying  numbers  infiltrate  the 

• '•  ttMTnuscular  tissue  (Fig.  168).     The  change  is  most  marked  in  the 

't?ft  ventricle,  and  is  usually  associated  with  endocarditis  or  periear- 

*l»tiH  (Fig.  1«7). 

^t     fibroid  Induration  of  the  Heart. — This  change  is  character- 

^P^er]  by  the   presence  of  a  fibrillatud   tissue  between   the  muscular 

^pienients.     The    process    commences    in    the   intermuscular   septa 

^^**ound  the  blood-vessels  (Fig.  169).     The  affected  parts  may  be  so 

•**r«l  as  to  cut  like  a  piece  nf  tendon  (Fig-  17<l)- 

The  condition  generally  de])cnds  upon  iliseuse  of  the  coronary 
**^erie8.  It  is  usually,  therefore,  a  lr)calized  change.  Sometimes 
'^    occurs  as  a  final  result   of  embolism   or  thrombosis  of  a  small 


494        ISFLAMMATION  OF  BLOOD-VESSELS  ASU  UEART. 


artery,    and  merely    consists  of  the  scar-tis^sue   nliicL    ultimately 
replaces  the  destroyed  fibres  (p.  2G4).     At  other  tiuie«  the  cLange 


Fig.  169. 


Fig.  ITii. 


Kibroid  iiidiimtton  of  (tiv  hNrt. 
A  Bcclliiii  friini  the  wnll  nftlic  li-ft 
ventricle,  xhnwinit  llie  «nial|. 
celled  (friiwtli  (n  the  InterimiM'ii- 
lur  neptii  «rmind  the  bloodves- 
iiels :  a,  n,  vcweb,    X  'XO. 


Fibi^nid  indiirntlon  of  thf  heart.    A  < 
fri)ln  led  veiitrlele  nf  the  sainehivn  "■  i 
HhowthE  n  llinre  iidvi%rir»'d  «tJMn-     1' 
tifMtiie    isiirrniiTid»    the    imllvldnAl    iiiii«-iiur 
tUires,  whieh  lire  iinderKxIiiK  ftttj  i1e»rii"» 
tlon.     •  am. 


may   be   secimdiiry  to   cndarteriti.s   and    atrophy  of  thn  tmiscniif 
fibres.     (See  "  Interstitial  Nepliritis,"  ami  p.  Tri.) 

Fibroid  induration  of  the  lienrt,  like  acute  myocarditis,  sppesnin 
sonic  ca."»ps  to  be  induced  by  inflaninmfory  processes  coiumnicin* 
in  the  pcricHnliiini  or  eiidiK-ardinni.  Wlien  secondary  i"  I"'f" 
carditis,  the  i  linnge  is  usually  most  ailvanced  in  the  more  externw 
portions  of  tlic  curdinc  wiills.  mid  it  commonly  affects  Wl  tli' 
right  and  left  ventricles.  When,  on  the  other  hand,  an  I'li*!"^ 
carditis  is  the  precursor  of  the  indurHtive  process,  the  chanp'  w 
more  miirkcil  in  the  intenial  muscubir  layers,  and.  inasmucli  *> 
inflauuniitory  processes  in  the  endocardium  occur  almost  cxflu- 
sively  in  the  left  cardiac  cavities,  the  left  ventricle  is  priDci|iiII.^ 
involved.  Even  in  these  ca.ses  it  is  probable  that  the  chansreW- 
lows  atrojihy  of  the  fibres,  which,  again,  is  dependent  on  n  (lefifif"' 
supply  of  blood.  'I'lie  change  is  by  no  means  confini'd  to  thoi'« 
parts  affected  by  the  endocarditis.  In  other  cases  the  fiht""* 
growth   Jippears  to  be  the  result  of  .syphilis.     (See  "  Syiiliili"   ' 

Whatever  the  cause,  the  heart  is  usually  enlarged,  ami  thehn^ 
degeneration  of  the  niuscular  fibres  is  found  outside  the  fil'i'ia 
areas.     Moreover,  tlie  function  of  the  heart   is  mafcrially  i« 
and  fibroid  iinlmiition  iircordlngly  constitutes  one  of  tlic  'jr: 
all  cnrdiM! 


kMyo"* 


term  applied    to   the  prcscuf* 


of 


INFLAMMATION  OF  LYMPHATIC  STRUCTURES.  495 

necrosed  areas  which  result  from  embolism  or  thrombosis  of  large 
branches  of  the  coronary  arteries. 


CHAPTER   XXVII. 

INFLAMMATION  OF  LYMPHATIC  STRUCTURES. 

Inflammatiox  of  lymphatic  structures  usually  results  from  their 
injury  by  substances  conveyed  to  them  through  the  lymphatic 
veggek  They  include  acute  and  chronic  inflammations  and  the 
specific  inflammations  associated  with  tsrphoid  fever.  Each  of 
these  must  be  considered  separately. 

AcDTB  luruAUMATiort  OP  Lymphatic  Struotubbs. 

Examples  of  acute  inflammation  of  lymphatic  structures  are  fur- 
BisLed  by  the  inflammation  of  the  axillary  glands  which  may  follow 
«  wound  on  the  hand ;  of  the  inguinal  glands  in  a  ca«e  of  soft 
tnancre;  and  of  the  lymphoid  follicles  of  the  intestine  in  inflamma- 
tion of  the  intestinal  mucous  membrane. 

Inflammation  of  lymphatic  glands  is  almost  always  due  to  absorp- 
''on  of  some  infective  sttbatance  from  a  primary  focus  of  inflamma- 
"On  (diphtheritic,  erysipelatous,  scarlatinal,  chancrous,  etc.) :  micro- 
organisms, especially  micrococci,  have  frequently  been  demonstrated 
"*  the  inflamed  glands.  A  gland  affected  by  acute  inflammation 
^<*njes  intensely  vascular  and  the  seat  of  free  exudation.  The 
^'^ping  leucocytes  accumulate  in  its  tissues  and  sinuses  until  all 
*"*tinction  between  medulla  and  cortex  has  disappeared,  while  the 
"^od-substance  is  soft  and  pulpy  and  often  dotted  with  hemor- 
^*ges.  Leucocytes  in  the  lymph  coming  from  the  primary  focus 
**'®  also  detained  in  the  gland. 

*^-pon  the  removal  of  the  injurious  influence  the  process  may 
o*"'4uually  subside,  and  the  new  elements  undergo  disintegration 
**   absorption,  the  gland  gradually  returning  to  its  normal  con- 
*"*»on  (regolution). 

^^  other  cases  the  process  goes  on  to  suppuration,  the  trabecula; 

^    tiestroyed,  many  of  the   cells  become  disintegrated,  and  the 

***»  of  the  gland  become  filled  with  pus.     This  is  usually  associ- 

^   "with  inflammation  and  suppuration  of  the  surrounding  connec- 


496 


lyFLAMMATIOy  OF  LYMI'HATIC  STRVC 


five  tissue.      In  tin-  ^Iniid.s  of  u  mucous  uiciuhriint' 
rise  lo  what  is  known  as  a  follicular  {iWvkk.     In  still 
ciutcM  the  inflnnnnation  mar  be  truly  boitiorrhitgic. 

Chronic  Inflammation  of  Lymphatic  Stsu( 
Chronic  iufiiininmtious  of  lyniphstic  structares  rosul 
ries  which,  while  less  severe,  arc  more  prolonge<l  iu 

thiin    thotse    which    give 
•*''"•  '^'-  acute  form.     These  chronj 

tory  procc»»e«  differ  Htill 
the  acute.  inai>mucli  it.'*  th^ 
gradually  increasing  dev« 
the  reticular  ttrueture 
The     reticulated      nctwor 
thicker  and  more  fihr<»u»»J 
becoming   smaller   and 

rhriitili'    tnllanitiintlon   of  a   Ivm-      i  i        n       i*     •    -   i     • 

,.ii.t.c  «u..-i.  ..,nw.,.K  the  incrx:««     lymph-ccll^  dinunish   in  i 

III  the  •tronm  hikI  the  diminution  In      the   gland    IiccomC!^     hard 
It))'  nuinlicf  iif  the  lyiuiitiDid  celU.       ,_.       ,.,,       t«     i    i  ■      • 

Xjx),  (Fig.  1(1).    Probably  in  t 

cases  the  cells  of  the  gla: 
and  the  flat  connective-tistsiie  cells  covering  the  trabecu 
and  a!<.siMt  in  forming  the  infiltrating  cells.  Fatty  pat 
i{uent  in  chronically  inflamed  glands. 

Scrof\iloua   Qlanda.  —  In    those    chronic    inflammati 
lympliiitic  ghiiiils   which  i>ccur  in  scrofulous  subjects,  a 
the  glands  tend  to  become  caaeous,  the  changes 
already    described    its    characteristic    of    scrofulous    i 
(ji.  440).     'I'he  iiccumuliition  of  new  cells  is  considembl 
but  little  tendency  to  absorption ;  and  many  of  the  cell 
size,    and    even    form    multinucleated    elements.      The 
becomes  ejilarged.  soft  and  cla-stic  in  consistence,  and  ol 
grayish-white   c(dor.      Retrogressive    changes  and 
(p.  (»!>).     The  caseous  material  may  subseijiiently  liquef^ 
infiltrated  with  calcareous  particles.     The  great  majority 
lyiii]>liiitic  glands  are   tuberculous,  and  the  bacillus  tul 
found  in  them  in  small  numbers. 

Invuucmation  op  Lymphatic  Struotcbks  in 

Fever. 
Typhoid  fever  is  an  acute  infective  disease,  gcncrmlij 
to  the  action  of  bacteria  (p.  379). 


INFLAMMATION  OF  LYMPHATIC  STRUCTURES.  497 

The  ordinary  duration  of  the  fever  is  three  or  four  weeks,  and 
the  temperature  a«  a  rule  both  rises  and  falls  (/y«i»)  gradually.     The 
most  characteristic  lesions  are  found  in  li/inphoid  tiasue,  especially 
the  solitary  and  agminated  follicles  of  the  intestine,  the  correspond- 
ing lymphatic  glands,  the  spleen,  and  sometimes  the  red  marrow. 
The  intettinal  lesions  are  the  most  constant,  and  their  various  stages 
80  often  correspond  with  definite  clinical  conditions  that  we  can, 
not  infrequently,  judge  of  the  state  of  the  intestine  from  the  symp- 
toms and  the  day  of  the  disease. 

Many  believe  that  infection  occurs  from  the  intestine,  and  that 
the  intestinal  lesions  are  points  of  inoculation,  but  there  is  no  con- 
liant  relationship  between  the  severity  of  the  intestinal  ulceration 
and  the  severity  of  the  symptoms.  Patients  with  extensive  ulcera- 
tion are  sometimes  able  to  attend  to  their  business  until  suddenly 
struck  down  by  perforation  of  the  intestine  or  by  hemorrhage  from 
M  ulcerated  vessel. 

The  pathology  and  morbid  anatomy  of  typhoid  fever  include  more 
than  the  lesions  of  the  above-mentioned  organs.  First,  there  is  the 
evidence  of  general  poisoning  in  the  shape  of  the  continued  fever, 
which  may  assume  a  septic  type,  and  even  be  accompanied  by  septic 
abscesses,  probably  resulting  from  a  mixed  infection.  Naturally,  in 
«o  long  a  fever  cloudy  swelling  (p.  79)  of  organs  is  marked.  Not 
incommonly  waxy  degeneration  of  muscle  (p.  84)  is  found.  Endo- 
carditis is  rare.  Ulceration  of  the  larynx,  es])ecially  about  the 
epiglottis,  is  occasionally  present.  This  may  lead  to  (edema  of  the 
glottis  or  to  necrosis  of  the  cartilages.  Bronchitis  is  usual,  and 
broncho-pneumonia  may  supervene;  a-dema  of  the  lungs  is  com- 
mon in  fatal  cases,  and  lobar  pneumonia  is  a  rather  frecjuent  com- 
plication in  some  epidemics. 

The  Spleen. — In  the  spleen  the  change  resembles  that  which 
'X^curs  in  many  of  the  acute  febrile  diseases,  although  it  reaches  its 
''Jaximum  in  typhoid  fever ;  but  it  may  be  absent,  es])ecially  in  the 
<*'<ier  class  of  patients.  The  splenic  tissue  becomes  exceedingly  vas- 
''ular;  the  lymphatic  elements  increase  rapidly  in  number,  so  that 
'he  organ  often  attains  two  or  three  times  its  natural  size ;  and  the 
*^Psule  becomes  intense.     The  consistence  is  fairly  firm  during  the 

orst  week,  but  softening  occurs  in  the  second  or  third.     <  »n  section 

th  • 

"6  Organ  is  dark  red  and  opaque-looking,  and  the  Malpighian  bodies 

"""^  often  prominent  and  enlarged.     Many  of  the  new  elements  are 

"Apposed  to  enter  the  blood  and  thus  cause  slight  leucocytosis  (p. 

32 


58 


nrFLAMMATION  OF  LYMPHATIC  STRUCT VBE8. 


220) ;  but  the  increase  is  generally  said  to  be  mainly  of  tlie  muK- 
niicleiitt'J  leuuofvtc-s,  not  of  the  lifmphonfteii  or  their  progeny,  ( 
nwuonuchated  leucocytes  (ji.  315).  Large  corpuscles,  cout»iiiiB 
normal  or  altered  red  corpuscles,  may  be  numerous,  and  siuiil 
cells  have  been  found  in  the  blood.  As  the  fever  subside.?  (fmirl 
week)  the  hypenvmia  diniinisLes,  and  many  of  the  new  elenii-i 
undergo  disintegration  and  absorption ;  thus  the  organ  regain:*  i 
normal  characters  and  dimensions. 

The  Intestine. — The  most  cliaracteristic  changes  in  typhoid  fi>»* 
take  place  in  the  solitary  glands  and  I'ej'er's  patches.  lu  must 
cases  the  process  is  limited  to  those  in  the  ileum  and  csecnm.  oud 
those  glands  are  always  most  affected  which  are  situated  nearM  to 
the  ilco-ca'cal  valve.  The  ciccum  is  involved  in  one-third  of  liu* 
cases:  ulcers  may  be  present  even  in  the  rectum,  but  in  thrgrwat 
majority  nf  uuscH  they  arc  not  found /'<'/o«'  the  ascending  colon.  It 
is,  moreover,  unusual  to  find  ulcers  higher  than  nine  feet  ii4"iv 
the  valve,  hut  they  »m»/ extend  even  into  the  upper  part  ofth* 
duodenum. 

The  first  change  ol)served  is  a  hypenvmia  and  cell-infiltratiuD  of 
the  glands.     Many  of  the  cells  increase  considerably  in  »i/.e.  »•»" 

multinucleated  forms  are  esjiecisll.^ 
common.       Both     I'eyer's    [mtdn'* 
and  the  solitary  glands  thus  becoii"' 
consitlerably   enlarged   and   prniui- 
neut,  iiiid   stand  up  as  shiirplv  f if' 
cuinscrilMMl  areas  above  the  surface 
of  the  intestine  (Fig.  172).    Some- 
titiu's  tliey  slightly  overlap  iln' 
joining  mucous  membrane  smi ' 
surrounded  by  a  hyperivniic  xoO 
They    are    of    a    grayish-white  "'^ 
pale-reil  color,  and  of  a  soft.  bn»i»" 
like    c^jnsistenee — the    larger 
size  the  paler  the  color.     The  surrounding  mucous  menil>r»ii('  '* 
also    e.xeeedingly   vascular,  and   is  the  seat  of  an   acute  gene" 
catarrh,  wliicb  is  most   ])ronounced  before  the  glands  swell- 
cellular  infiltration  in  many  parts  rapidly  extends  beyond  the ' 
fines  of  the  glamls  info  the  iuuuedjiitely  surrounding  and  subjar*" 
tissues,  and  in  some  cases  even  tutu  tlie  muscular  and  serous  wat*^ 
This  stage  ends  in  the  first  half  of  the  second  week  of  the  di«' 


Fio.  172. 


■■-'^\!iiqiM™i|Mj 


*^^ 


BweUlngofPeyer'n  patchennndsrilltary 
glaiidanflhc  intcittinc,  osuveii  in  l}'|>h<il<) 
(bvor. 


\JShLMIMATIOX  OF  LYMPHATIC  STRUCTURES. 


499 


Fio.  173. 


A  typhoid  uli^ur  of  tbe  tiitea- 

tliio. 


process  now  passes  into  the  second  stage — that  of  the  death 
isititegration  of  the  nowly-fornied  tissue.  Many  of  tlie 
mI  glands  subside,  the  new  elcnieut.s  become  fatty  and  are 
ml,  and  the  iuflamtuatinu  thus  undergoes  u  gniduu]  process 
dution.  But  in  other  jihinds  the  intensity  of  liie  viru.s — 
y  typiiolo.xiii  or  .>*ouie  other  bacterial  prodtict  (p.  381) — 
death  of  the  intlaiued  lyniplioid  tissue.  The  necrosed  tis- 
len  separate.  If  a  few  scattered 
»  in  each  iiatcli  have  alotu;  been 
j|d,  only  small  .-iioughs  will  be 
■and  after  the  separatiim  of  these 
fver's    patches    thus    aft'ectcd    will 

a  peculiar  reticulated  ajijicariiiH-c. 
the  (ither  hand,  as  is  most  usual, 
tire  lymphoid  miiss  is  killed,  this 
)arate  as  one  or  more  large  sloughs. 
e  typical  typhoid  ulcer  will  be 
(Fig.  173).  Kesolution  or  necrosis 
luring  the  latter  half  (if  the  second  week.  Tn  the  ca.se  of 
s  the  sloughs  Hc/itinite  toward  the  end  of  the  third  or  during 
inning  of  the  fourth  week.  This  is  the  period  of  danger,  in 
rither  severe  hemorrhagre  or  perforation  into  the  peritoneal 
nay  take  place, 
ough,    as    already   stated,   the    cell-infiltration    may    extend 

the  confines  of  the  glands,  this  is  rarely  the  case  with  the 
on.  The  peripheral  infiltration  undergiies  resolution,  and 
ibe  ulcers  have  the  same  eonfi«;nriilinn  as  the  orijiinal  glands 
feriginatiug  from  the  patches  being  mal.  with  their  long 
^rs  in  the  direction  of  the  gut.  ami   those  originating  in  the 

glan<Is  being  spherical  in  shape,  like  those  fmm  partial 
Qg  of  a  patch.     In  rare  cases,  when  there  is  much  infiltra- 

tfie  surrounding  mucous  membrane,  the  ulceration  may 
slightly  beyond  the  confines  of  the  glands.  .\u  ulcer  from 
<  I'eyer's  patch  may  be  five  inches  long,  and  the  blending  of 
!d  patches  ami  foliicles  in  the  neighborhood  ai'  the  ileo-ciccal 
ay  affect  so  large  an  area  that  this  jiart  of  the  intestine  may 

have  lost  almost  all  its  raucous  membrane. 
■the  sloughing  ami    disintegration    of  the  new  tissue  the 
of  infiltration  ceases,  and   hence  there  is  no  induration  or 
iug  of  the  base  or  edges  of  the  ulcer.     The  base  is  smooth, 


500 


INFLAMMATION  OF  LYMPHATIC  STRUCTURES. 


and  is  usually  formed  of  the  submucous  <>r  luusculur  coat  uf  tlir 
iutesitinc.  Tlie  f(ij;os  iire  uttuaily  thiu  au<i  unilcnniued.  ami  pm- 
sist  of  a  well-deliucd  fringe  of  congested  mucous  lufuibrauf  iFi;; 
174).     TbiB  is  best  seen  when  the  gut  is  tlouted  in  water.     In  Miur 

KiQ.  174 


Atypical  ulcer  of  the  inu-stlnr  (dingrammatic),  showing  thpnndemilD<<<tm]Kr>afllu'iilnr 
and  the  feluugb  DtUl  ftUlKTeiit :  a,  epltlurliul  lining:  f>,  i^ubinueoiui  tlMUv,  r.  luoii'uUr ni>l - 
d,  pcrltuucum. 

cases,  especially  where  there  is  surrounding  infiltration,  the  edg** 
are  firm  and    tlii<.-k.      In    others,    again,    the  sloughing   is  di'oper. 
and  extends  through  tiie  muscular  layer  to  the  peritoueiira.    Thi* 
may    eilht-r    slough    or    give    way    under    some    mu»cular    effort, 
either  of  the  bowel    when  stimulated   by  improper  food,  or  of  the 
abdoniiniil  miisclen  when  the  jmticnt  is  allowe<l  to  use  them  Btrongly- 
The  perfonition  is  generally   small.      As  a  rule,  diffinn-  pfritonitw 
(purulent)  results :  rarely,  adhesions  form  and   localize  thp  inll«o>* 
matiou.      Peritonitis  may  al.so  occur  by  simple  extension  fVtim  tn^ 
gut,   from  Hu   inHamed  gland,  or  from  a  sjilenic  abscess.     Hemor- 
rhage may  occur  from  any  vessel  divided  during  the  separatioD  *>' 
the  slough.      It  is  due  either  to  insuflieient  plugging  by  fhroniltt>*'* 
or  to  mechaniciil  displacement  of  the  thrombus  after  it  is  fonned. 

The  third  stage  of  the  process  is  that  of  cicatrization,  which  ohu»I'5^ 
begins  in  the  fourth  week.     This  takes  place  by  the  resolution**' 
the    peripheral    infiltration,    the    approximation  and   uuiou  of  tt>*^ 
nnderiniiu'd   edges    with    the   floor  of  the  ulcer,  and   the  gnil**' 
formation  from  the  margin  of  an  epithelial  covering.     The  gUa*^" 
Structure    is   not    regenerated.      The   resulting    cicatrix   is  sliglit** 
depressed,  and  less  vascular  tliiin  the  surnnuiding    mucous  iiie«»'" 
brane.     It  is  pigmented  either  miirormly  or  only  round  the  mwg"'* 
There  is  no  puckering  or  diuiiiiutiiiTi   in  the  calibre  of  the  gut.     *" 
some  cases,  however,  eicHtrizalinn  docs   nut  take  place  so  rosi'l''?' 
and  the  floor  of  the  ulcer  becomes  the  seat  of  a  secondary  iii'fra- 
tiiMi.      This  may  fake  place  after  the   general   disease  ha*  r«"   '*' 
course  or  during  a  relap.se.     I'rofuse  hemorrhage  and  pcrfor»H' 
more  commoulv  result  from  the  secondary  ulceration  than  from  •'" 
primary  slougliing  of  the  glands.     Only  one  ulcer  may  ht"  affoc'''" 
by  this  secondary  process,  the  rest  having  either  healed  or  bfi"-  '" 
a  fair  way  to  become  so. 


« 


INFLAMMATION  OF  LYMPHATIC  STRUCTUSES.  501 

mparison  between  Typhoid  and  Tuberculax  Ulceration. — 
;  the  foregoing  descriptions  of  typhoid  and  tubercular  (p.  428) 
ition  of  the  intestine  it  will  be  noted  that  these  two  conditions 
one  important  character  in  common — viz.  the  uniformity  with 
1  both  arise  in  the  lymphoid  tissue.  Hence  in  both  cases  the 
I  are  most  marked  in  the  ileum  opposite  the  mesenteric  attach- 

and  may  be  limited  to  the  Peyer's  patches  and  the  solitary 
9.  There  are,  however,  two  characters  possessed  by  tubercu- 
cers  which  generally  suflSce  to  distinguish  them  from  typhoid 
.  The  first  is  the  much  greater  tendency  of  tubercle  to 
1  by  means  of  the  vessels,  and  the  second  is  the  presence  of 
ng  tubercles  which  invariably  precede  the  advance  of  the 
tion.  Thus,  the  typhoid  ulcer,  remaining  limited  to  Peyer's 
;s,  has  its  long  axis  parallel  to  that  of  the  intestine.  On  the 
hand,  the  tubercular  ulcer,  often  spreading  transversely  with 
ssels  before  it  has  involved  more  than  half  the  patch,  has  its 
ixis  at  right  angles  to  that  of  the  intestine,  round  which  it 
3rm  a  band.  Again,  as  the  slough  separates  the  floor  of  the 
id  ulcer  tends  to  become  cleaner  and  smoother  and  its  edges 
;r  and  more  undermined.     On  the  other  hand,  the  floor,  base, 

and  adjacent  peritoneum  in  the  case  of  the  tubercular  ulcer 
ways  thick  and  irregular  from  the  presence  of  developing  and 
crating  tubercles. 

»  Mesenteric  QIands. — The  change  in  the  mesenteric  glands 
)bably  secondary  to  that  in  the  intestine.  These  glands 
le  the  seat  of  an  acute  cellular  infiltration,  and  are  enlarged, 
nd  vascular.  Usually,  like  the  spleen  and  many  of  the  glands 
5  intestine,  they  undergo  a  gradual  process  of  resolution.  In 
!ases,  however,  the  capsule  of  the  gland  is  destroyed,  and  the 
ed  matters  may  escape  into  the  peritoneal  cavity,  and  so  cause 
nitis.  The  enlarged  glands  may  also  become  caseous  and 
^uently  calcified. 

9  Marrow. — Ponfick  has  shown  that  in  typhoid  fever  the  mar- 
)f  bones,  like  the  splenic  pulp,  may  contain  large  cells  in 
I  may  be  as  many  as  twenty-five  red  corpuscles :  these  break 
,  and  in  the  convalescent  stage  the  large  cells  only  contain 
mt. 


602 


lyFLAMMATlOy  OF  MUCOUS  MEMBRASES. 


CHAPTEU    XXVIII. 

INFLAMMATION   OF   MUCOUS  AND    SEROUS 
MEMBRANES. 

MUOOUS    MEMBRANES. 
Infl.\mmatiiins  ^^\'  uuuou.s  lufnibruiic'S  are  diviileil  into  catar- 
rhal, croupous,  ami  diphtheritic. 


CATARRHAL  INFLAMMATION.— This  may.  according  ti. 
its  intoiisitv.  lu'  mTons,  mucous,  uiiico-jmrulent,  or  )iiiriik'iit- 
Acute  eases  begin  witli  redness,  slight  swelling,  and  abnornial  lirj - 
ness  of  the  mucous  membrane,  some  tenderness  of  the  part,  |ii'i'li»i>- 
eveu  ])iiin.  These  changes  are  followe<l  by  exudation  from  tin'  !•'"■- 
face,  and  the  symptoms  are  then,  as  a  rule,  relieved.  lu  chronic 
cases  the  early  changes  are  less  marked,  the  exudation  being  tiMisHy 
the  first  thing  noted.  Post-mortim,  no  hyperaemia  can  gctiiTally 
be  found,  and  the  membrane  may  look  even  paler  than  nntiinil : 
but,  after  repeated  inflammation  of  any  intensity  more  or  less  ilarl- 
gray  pigmentation,  from  extravusated  blood,  will  in  most  situations 
bear  evidence  of  the  former  attacks  (p.  1(14).  These  appcurancf* 
cull  be  readily  .seen  in  an  inflamed  bladder  from  a  case  of  slrictnn" 
of  the  ttrethra  or  enlarged  prostate. 

Serous  Catarrh. — Free  serous  effusion  occurs  from  the  vcs»ew 
and  escapes  upon  the  surface :  this  is  often  seen  in  the  early  »t*t?* 
of  colds  in  the  head. 

Mucous  Catarrh  is  characterized  mainly  by  increased  |im<i"*- 
tion  of  mucus,  which  escapes  with  the  serous  exudation  or  rcnHH"* 
adherent  to  the  surface,  as  is  often  seen  in  chronic  jdinryiig'"" 
Sometimes  the  sero-niucous  discharge  is  tolerably  clear,  at  otbtr!"  i' 
is  more  or  less  opa(|ue:  in  the  former  case  only  a  moderate  niitubcf 
of  cell-forms  are  present;  in  the  latter,  many.  The  cells  are  •'it''*'' 
escaped  leucocytes  or  des((Uamftted  epithelial  elements. 

Purulent  Catarrh. — If  the   inllaiumniion   be  more  intcnfif,  '*"' 
escape  of  leucocytes  will   be  still   greater  and   the  secretion  *'" 
therefore  be  purulent.      The  more  closely  the  exudation  rcteuili 
true  pus  the  le.ss  mucus  and  desijuamated  epithelium  will  it  codI»H 
An  intermediate  muco-purulent  stage  usually  occurs. 

A  section  tbnmgh  a  mucous  membrane  thus  affected  (Fig.  '<< 


INFLAMMATION  OF  MUCOUS  MEMBRANES. 

bIiows  desqunumtion  of  the  superficial  epithelial  cells,  which  are 
Hwollen  and  often  contain  Uroods  of  young  cells.  Leucocytes  lie 
here  and  there  between  the  deeper  cells,  iu  which  evidence  of  uiulti- 


Fio.  176. 


^tarrlul  inHanimntion  of  llir  I'onjiim'tlrn :  a,  i-pIlBii'niiin  :  b,  liillltnitcil  subppltlu'llnl 
***«in»<iivo  tL"isiii-.  »lii>wiiiK  llie  il<.t>i|uaiiisti»ii  of  Ihe  c|>ithcUiiiu  iin>l  lliu  young  vIeicivnU 
**«*»ln  the  epItheUal  ieU«.    ( Rinatletoch.) 

F*lication  will  be  found.  The  basement  membrane  becomes  tcdema- 
***Us  and  the  mucosa  is  swniicn.  The  svielling  is  at  first  mainly  due 
^^  the  leucocytes  ami  e.xuded  fluid — later  on,  if  the  process  has  been 
**>fliciently  prolonged,  to  the  resulting  fibroid  tissue. 

^Simultaneously  all  hpiij>hi>iiJ  structure*  in  the  mucous  membrane 

•■•■e    affected.     The   lymph-foliicles   swell,   jin<l   their  contents  may 

^oflen  and  form  minute  abscesses,  which  burst  ami  leave  the  small 

*»I<»frs  (follicular)  so  often  s('<'ii  in  ciitarrbal   conditions  of  the  itites- 

*'»es  and  pbaryn.x.     The  ulceration   in  some  cases  extends  beyond 

*he  confines  of  the  follicle.     The  proper  glandular  9trueture»  also 

•»i»»,v  become  involved.     Their  eiiitlieliuui  nuiltiidics  and  their  lumen 

^■*ocomes  choked  with  the  pnvducts.      The  glands  may  8ubse(iuently 

'■*^**ophy ;  this  is  seen  in  catarrh  of  the  stomach. 

The  acute  process  may  i|uickly  subsi<le  or  it  may  become  chronic. 
-"■■1    the  latter  case  the  bypenemiii  diminishes,  but  the  escape  of  leuco- 
'3'"te»  and  the  multiplication   of  the   epithelial   elements  continue, 
^l^*ilethe  subepithelial  tissue  becomes  more  extensively  infiltrated 
^^*"">t:li  .small  cells. 

^B  111  the  case  of  the  stomach  and  upper  part  of  tlie  duodenum  fvl- 

^r"^tilar  ulcem,  unattended  by  any  general  inflammation,  may  spread, 

~ *'■■'* •'1  form  the  "acute  perforating  ulcers"  wliicli  fri'(|uently  occur  in 

''■*<^e  situations.     Their  extension  in  this  way  pmbabSy  depends  on 

**>H)e  interference  with  the  local  blood-supply ;  on  errors  in  the  com- 


504 


ISFLAMMATIOS  OF  MUCOUS  MEMBBANES. 


position  of  the  blootl ;  on  an  ini-reacod  pcTcentuge  of  free  Lydro- 
chloric  acid  in  the  gastric  juice;  or  on  aiij  combination  of  the»r 
factors. 

Chronic    cntiirrbal    rnilnnunutions   of  mucous    uienibraue*  differ 
fri)ni    till.'   ficutc.   iniisimiuli   as  tlu'  jjliinds,  at    first   cnlargt**!.  "fton 
iirnliTgo  iitropliv,  wliili'  the  ssiibejtitiR'liul  connective  tissue  id  more 
often  and  more  exteusivelv  infiltrated  with  small  c«ll8,  which  alti- 
niati'lv  fnciii    an   iiiiperFcftlv  fibrJliuted  structure.      Here  ami  then? 
the  contraction  of  tliis  new  ti-ssue  may  lead  to  the  formation  uf  ^inall 
retention-cysts  (]).  21 1>).     These  changes  in  the  subepithelial  c<)Iiiip<^ 
tive  ti.«.«ue  are  tisiuilly  turoinpiinieil  by  enlargement  of  the  lyniplitii" 
structures — an  ertlargenient  wiiich  sometimes  give.«i  to  the  inerabnir»« 
a  nodular  or  granular  appearance.     This  is  well  seen  in  the  ph»rTl»  ^ 
i  t'nllifuliir  ii/inn/niiifis).      The  enlarged  lymphoid   structures  nu*^ 
ulcerate,  and  constitute  the  .stiirtirig-point  of  an   infective  priK'P*^* 
(p.    419).     In   chronic   catarrh    the    muscular  and    ela.stic   tissnff^- 
although  some  distance  from  the  surface,  may  be  so  far  wenkenc^^" 
that  when  considerable  pressure  is  put  upoii  them — as  in  the  cougT^" 
of  clnonic  broncliitis — tiicy  may  give  way  and  permit  dilatation  i^^*' 
the   tubes  they  siirroimd.      In   some  situations,  as  in  the  stomtn — -" 
and  intestine,  the  membrane  ofti'ti  becomes  pigmented  andtliewtl     — *' 
thinned. 


CROUPOUS    AND    DIPHTHERITIC    INFLAMMATION- 

These   terms   are  applied  to  those  intlammations  of  mucous  men 
branes  and  raw  surfaces  which  lead  to  the  production  of  a  so-cslie 
feilse  membrane,  such  as   is  seen    in   diphtheria.     The  foruntii^:^^^^^! 
of  this  fibrituuis  layer  upon  the  surface  of  the  membrane  is  qui        WJ 

characteristic,  and  at   once  distingui.shes  this  form  <tf  inflauituiili< *  | 

from  a  simple  catarrhal  process.     On  mucous  surfaces  the  mciubra^B^* 
may  exi.st  in  little  patches  or  may  cover  a  large  area.     It  is  iisunl     */ 
of  a  yellowisli  nr  griiyish-wliite  colur,  and  in  consistence  varies  frc»  ■*" 
a  firm  and  tcmgb  to  a  suft   pnltaceous  material :  it  may  he  d«!f>'.r 
blond-stained.     It  is  more  iir  less  ea.sily  se|iarable  from  th''  -  '         -''' 
tissue,  and  when  removed  carries  at  least  the  .surface  epithii  '' 

it.     In  thickness  it  may  vary  considerably  in  difTereut  part*.    The 
tvvri  words — crnnjious  and  diphtheritic — owe  their  origin  to  flicli'''"> 
still  held  by  some,  that  there  is  an  idi"pntliie  mcmbranoua  inll»i«i'»' 
tion  of  the  larynx  (croup)  distiiot  from  diphtheriat.     The  adjeotn* 
are  often  used  as  synonymous,  bo*  ^k  of  a  menibnine « 


INFLAMMATION  OF  MUCOUS  MEMBRANES.  505 

croupous  when  it  involves  no  more  than  the  epithelium  of  a  mucous 
membrane,  and  as  diphtheritic  when  it  involves  the  whole  mucosa. 
These  differences  in  the  depth  of  the  tissue  involved  are  probably 
due  to  variations  in  the  intensity  of  the  process ;  and,  according  to 
Cohnbeim,  the  process  is  more  likely  to  be  superficial  in  those  situa- 
tions where  a  distinct  basement  membrane  exists,  as  in  the  pharynx 
and  respiratory  tract,  than  in  those  where  this  is  not  the  case,  as  in 
the  intestines  and  conjunctiva.     A  false  membrane,  superficial  to 
the  basement  membrane,  is  much  more  easily  detached  than  one 
■which  involves  this  structure. 

Others  limit  the  term  croupous  to  false  membranes  formed 
chiefly  of  coagulated  fibrin,  whilst  diphtheritic  is  applied  to  those 
<ionsisting  of  tissues  which  have  undergone  coagulation-necrosis 
^p.  39).  This  division  renders  "  croupous  "  eijuivalent  to  "  fibrin- 
ous." It  must  be  remembered,  however,  that  the  two  processes — 
Urination  of  fibrin  and  coagulation-necrosis  of  cells — are  closely 
allied,  and  that  one  may  succeed  the  other  in  the  same  case. 

The  relative  rarity  of  fibrinous  inflammations  of  mucous  as 
^^topared  with  serous  membranes  led  Weigert  to  investigate  the 
fej^son  of  the  difference.  He  found  that  inflammatory  exudations 
**"om  mucous  membranes  coagulated  as  soon  as  the  epithelium  was 
<lestroyed,  and  he  started  the  hypothesis  that  living  epithelium, 
**ke  endothelium,  prevents  the  formation  of  fibrin. 

Now,  an  injury  which  causes  destruction  of  epithelium  must  be 
'^^ore  intense  than  one  which  does  not,  and  it  is  likely  that  the 
^^Udation  in  the  former  case  will  be  more  highly  fibrinous  than  in 
*«e  latter.  Thus,  in  a  case  of  true  diphtheria  a  patch  of  epithe- 
■•Utn  and  more  or  less  of  the  subjacent  tissue  are  killed  by  the 
**'>"itant  and  undergo  coagulation-necrosis,  and  if  the  false  mem- 
^'■^ne  thus  formed  be  removed,  a  fre.sh  one  will  appear,  which, 
^^'iless  the  destruction  of  tissue  extends,  can  hardly  consist  of 
"^^*»3.'thing  but  coagulated  fibrin. 

The  two  kinds  of  membrane  differ  microscopically.     The  fibrin- 

^»««  has  the  appearance  of  "  lymph  " — a  network  of  fibrin  contain- 

***g  in  its  meshes  a  greater  or  less  number  of  leucocytes,  des(jua- 

***^ted  epithelial  cells,  and  debris :  it  is  easily  stripped  off.     The 

'^*f>htheritic  membrane  is  separated  less  easily,  and,  if  deep,  only 

^*'it.h  great  diflScnlty.     Superficially,  it  closely  resembles  the  croup- 

■'^^s  membrane,  but  the  deeper    parts  consist   of   raudi  swollen, 

»*OTBogeneou8  cells   from  which  the  nuclei  have  disappeared.     In 


608  ISFLAMMATIOS  OF  MUCOVS  MEMBRASES.  ■ 

u*Ivanciiig  eases  tjiere  is  no  sharp  line  between  the  coagulnU'ilmd 
the  liviiif^  tissui'-i'k'iut'iits.  Tliese  membranes  resist  acetic  »fi<l 
ijiucli   loiigor  tlmii  tin  the  .siiujilt"  fibrinous  ones. 

False  UR'Riljraues  can  probably  form  upon  any  mucous  siirfsc*. 
The  (rji|mrent  ciiuses  are  very  varied.     Such  membrani's  nri-  fimficl 
(1)  ou   the  tonsils,   larynx,  and  other   parts  in   true  diphtheria,  or 
as  a  result  of  scalds  and  tlie  ap]ilicuti<in  of  caustic  chemical.H:  |2> 
in    the   bljuMer   after   parturition   (when   a    complete   ca.st  ni»v  be 
exfiellei])  iUid   in    the    most    acute   cystitis;    (3)  in   the   verniifunn 
uj)|)eiidi.\,  sometimes  from  the  irritation  of  a  concretion;  (4)  in  the 
lower  part  of  the  large  intestine  in  dysentery;  and  (5)  in  thr  sir- 
tubes    in    plastic    bronchitis.       It    may   be   noted    here    that    f»l»« 
iiieiiiliraiK's    ,'<umuttines    form    upon  granulating   wounds,   and  il    »* 
held  by  some  that  there  is  no  real  distinction   between  such  Mt 
and  those  of  true  (li])hth('ria  of  wounds  and  of  hospital  gMnjrren* 
Il  seems  most   prob.ible,  however,  that   there  is  an  etiolngieal  iliffc 
ence,    fur    false    meudiriine    on    granulations    may  be    induceil  \* 
merely  blistering  the  surface. 

Althougii  the  above  facts  show  that   false  membranes  may  renu 
from  the  action  of  simple  irritants,  the  great  majority  met  with  i 
man   are   ilue   to  infective    poisons — e.  _</.  diphtheria,   diphtherit 
conjunctivitis,  ejiidemic  dysentery. — all  highly  contagious.     Org«* 
isms  are  found    in   almost   all  ca.ses.     The   etiology   of   diphlheri 
has  already  been  considered  (p.  383). 

Dysentery. 

The  inHammatory  processes  occurring  in  dysentery  are  for 
most  part  limited    to  the  large    iiitestifie.  although   the  ileum  im»'- 
cHTusioitully   involved.     The   intlammaiion    is  always  most  uisrlt 
in  the  rectum  and  descending  colon,  and  it  may  be  stated  gcnenL     Jrl 
that   it  is  cliaracterized  by  ulceration  and  sloughing  of  the  luuc**-  «<* 
membrane,  tlmujih  the  inthuiniiution  mav  be  mainlv  of  the  cataiTli««'- 
crouj)ous,  or  suppurative  variety. 

The  intestinal  changes  vary  considerably  according  to  the  iDti-o- 
sity  of  the  inflammatory  process.  In  the  milder  forms  of  tin- 'l'^ 
ease  the  changes  are  most  ujarked  on  the  summits  of  the  fob!.''*' 
the  mucous  membrane.  These  are  found  covered  with  a  grtvi-*''' 
white  layer  of  fibrous-looking  material,  which,  when  scrapc'l  ""• 
leaves  a  stiperficial  loss  of  substance.  The  mucous  membrano  gr"' 
erally  is  iiyperivmic  and  softened.     The  submucous  tissue  «1»  * 


INFLAMMATION  OF  MUCOUS  MEMBRANES.  o07 

infiltrated  with  inflammatory  products,  and  the  solitary  glands  are 
enlarged  and  prominent. 

When  the  process  is  more  severe  the  submucous  tissue  becomes 

more  extensively  involved,  and   the   superficial  layer  of  fibrinous 

material  extends  over  wider  areas  and  implicates  more  deeply  the 

mucous  membrane.     The  thickening  of  the  intestinal  wall,  however, 

is  much  greater  in  some  parts  than  in  others,  so  that  projections  iire 

produced  upon  the  inner  surface  of  the  intestine  corresponding  with 

'hose  parts  which  are  the  most  affected.     The  enlarged  solitary 

glands  usually  slough,  and  so  give  rise  to  circular  ulcers,  which 

rapidly  increase.     When  the  process  has  reached  this  stage  the 

Diuscular  and  serous  coats  are  implicated,  the  latter  being  covered 

*'itli  layers  of  fibrin  which  form  adhesions  with  adjacent  parts.    The 

intestine  is  much  dilated,  and  contains  blood  and  disintegrating 

inflammatory  products. 

In  the  most  severe  forms  of  the  disease  the  necrosis  is  more 
extensive.  According  to  Rokitansky,  large  portions  of  the  mucous 
membrane  are  converted  into  black,  rotten  sloughs.  The  sub- 
mucous tissue  is  infiltrated  with  dark  blood  and  serum,  but  subse- 
quently it  becomes  a  seat  of  a  reactive  suppurative  inflammation,  by 
means  of  which  the  necrosed  portions  of  tissue  are  removed. 

If  death  does  not  occur  and  if  the  inflammatory  process  subsides, 
the  ulcers  may  gradually  heal.  When  the  loss  of  substance  has  not 
been  considerable,  the  edges  of  the  ulcers  may,  by  the  contraction 
*>f  the  submucous  tissue,  become  completely  approximated.  More 
*^Bamonly,  however,  the  loss  of  substance  is  so  great  that  portions 
**f   the  membrane  are  left,  consisting  simply  of  connective  tissue. 

^hen  the  inflammatory  process  becomes  chronic  the  changes  in 
*tte  submucous  connective  tissue  become  more  marked,  and  the  new 
"»>l"oid  growth  gives  rise  to  considerable  thickening  and  induration 
***  the  intestinal  wall  and  to  more  or  less  contraction  and  narrowing 
***  the  cavity.  Sometimes  it  forms  fibrous  bands  which  project  into 
*ne  gnt.  Abscesses  and  fistulous  passages  occasionally  occur  in  the 
*«ickened  intestinal  wall. 

The  etiolosry  of  dysentery  is  unknown.  By  some  it  is  attrib- 
uted to  the  presence  of  amoebse  (amoeba  coli) ;  by  others,  to 
Wteria. 

Sxtenaive  ulceration  of  the  colon  is  sometimes  met  with  apart 
from  true  dysentery.  In  these  cases  the  internal  surface  of  the 
colon  is  made  up  of  sinuous  islets  of  mucous  membrane  with  thick- 


608  INFLAMMATION  OF  MVCOVS  MEMBRANES. 

ened  submucous  tissue.     These  islets  are  separated  by  large 

of  exposed  muscular  wall  from  which  all  trace  of  mucous  membra  -me 

has   disappeared.     Any    solitary  glands   present  in  the  islets     ^re 

unaffected. 

SBR017S    MEMBRANES. 

Inflammatory  processes  in  serous  membranes  vary  in  their  im  «  *;n- 
sity  and  in  the  amount  and  character  of  the  effusion. 

As  in  mucous  membranes,  the  process  commences  with  hv  §.  ^w- 
semia.     Exudation,  both  of  fluid  and  of  corpuscles,  into  the  (;e«r««->tt* 

Fig.  176. 


Inflamrd  epiploon  of  a  ral>l>it.  showing  changes  In  the  endOtheUam.    Y  290.    (Coraftl  *" 

Ranvier.) 

cavity  quickly  follows,  with  proliferation  and  desquamation  of      "^^f 
endothelial  cells  (Fig.  176). 

In  the  mean  time  the  surface  of  the  membrane  has  lost  its  pol «  ■*''• 
This  is  due  to  the  presence  of  the  new  cells  and  a  little  fibricft       "" 
the  surface.     The  moistening  of  the  surface  with  the  albumir**^^"* 
exudation  renders  it"groa.sy."     As  the  inflammation  goes  on      "•'" 
surface  becomes  opacpie,  roughened,  and  exceedingly  vascular :    i  "*  '* 
nf>w  covered  with  a  thick  fibrinous  layer,  whilst  more  or  less  li«-4  ** 
tran.sudes  into  its  cavity.     The  coagulable  material  which  exi.»  *^'* 
from  the  vessels  forms  a  soft,  elastic,  membranous,  or  reticnl^^*" 
investment,  enclosing  in  its  meshes  numerous  small  cells.     Sc*'  **"■ 
times  this  glues  the  two  surfaces  of  membrane  together,  collet  Mr  •  "P 
especially  where  pressure  is  least — viz.  in  the  angles  between  t^r~*^^' 
tigiious  coils  of  intestine,  where  the  hypersemia  is  also  most  mar^^^  * 
If  the    surfaces   are    sejiarated  by   liquid    eflfusion,   the    coagul.^^ 
exudation  forms  a  slightly  adherent  layer  (Fig.  177).     The  exi^»-  * 
liuuid   varies  considerablv  in   amount,  and  is  alwavs  turbid.  ^^  ^  , 
<liffcrin"'  from  non-inflammatorv  effusions.     It  contains  flakes         ^ 
masses  of  coagulated  fibrin  and  innumerable  cells,  the  latter  be^  "*     * 
in  the  earliest  stages  of  the  process,  almost  entirely  emigrants. 


INFLAMMATION  OF  SEROUS  MEMBRA SES. 


509 


The  nature  of  the  subsequent  changes  will  depend  ujron  the 
intensity  of  the  inHaniinatitm  and  u]nm  the  anioiint  of  lii(iiid  exuded 
into  the  serous  cavity.  If  tiie  inflammatory  process  subsides  and 
the  li(|uid  exuded  is  not  sufficient  to  prevent  the  two  surfaces  of  the 

Fio.  177. 


'"Itjiiinwtfoii  of  the  dlnphragiuutlr  pleura,  kHowIiik  the  adlierent  flhriimtipi  layer:  n,  nrns- 
^'•r  dm  i,f  (lluphrAgm ;  6,  lubnerou*  tisttuu ;  c,  sorotis  memhrane ;  e,  tlbrinoiu  layer.     .\  400. 

"*<*iiihrane  from  coming  int"  contact,  they  grow  together  and  form 
*■'!  adhesion.  This  constitutes  the  so-called  adhesive  inflamma- 
^On.  The  union  is  effected  by  the  formation  of  connective  ti.ssue 
M*-  295).  This  is  by  far  the  most  frei|iient  form  of  inflammation  of 
***'*'ou8  membranes.  The  process  is  ])recisely  similar  to  that  which 
**kes  place  in  the  union  of  an  incised  wound.     It  is  probable  also 

K"*«».t,  in  some  cases,  union  may  take  place,  without  the  intervention 
**•    anv  fibrinous  laver.  hv  the  formation  and  growiurr  togetlier  of 
•*T"egular  papillary'  outgrowths  from   the  siibendothclial   tissue. 
I     If,  however,  the  inflammatory  process  is  severe  or  the  surfaces  of 
^**©  membrane  are  sejjarated  by  a  large  (|uantity  of  liquid  effusion, 
"^•"Iganization  and  adhesion  cannot  be  effected.      If  a  large  ((uantity 
^f*''  liquid  exists  in  the  serous  cavity,  the  removal  of  this  becomes 
^P^cessar}'  before  union  can  take  place.      If  the  intensity  of  the  irri- 
'^^tit  is  considerable  and  its  action  prolonged,  union  is  prevented  by 
**»e  formation  of  pus.     These  two  conditions  must  be  considered 

(^^--parately. 
1.  The  existence  of  a  large  amount  of  effusion  prevents  appro.x- 
•Hiation,  and  therefore  adhe.^ion.  of  the  serous  surfaces,  and  before 
*uis  can  be  effected  absorption  of  the   liquid  becomes  necessary. 
^m  *  he  presence  of  the  liquid  itself,  however,  interferes   with   its  ab- 
B***n''ion  (p.  306).     The  removal  of  some  of  the  liipiid  by  artificial 
^neans  consequently  facilitates  absorption  of  the  remainder.     When 


510 


TNFLASmATION  OF  THE  LIVER. 


the  proceat*  is  protracted  the  siibendothelial  connectire  timw  Y^<>- 
comes  involvetl  iind  infihrntod  with  small  coils.  A  richly  ra«e«alar 
granulation  tii^suc  is  formeii  beneath  the  layer  of  proliferating  eKBc]<»- 
thelium.  which  gradually  disappears.  As  the  liquid  is  absorbed  *li« 
two  surfaces  come  into  contact  and  j^row  tojicther  a»  in  the  preT"i«>ii« 
ea«c.  the  new  vessels  becoming  gntdiially  obliterated. 

2.   If  the  inflammatory  process  does  not  subvidc,  or  if  (tobb     >» 
commencement  it  is  of  considerable  intensity,  it  may  be  altera  •J*' 
by  the    formation  of  large    ipinntities    of  pus.     In  this    case       *■" 
exudation  of  blooil-corpiisclcs   is    so   considerable   that   the  t<>«««>II 
elements    exist    in   large    enongh    numbers  to  give  to  the  exim<i** 
liquids  a  [turiilent  character.     The   condition  is  then   termed 
pyema.     As  the  connective  tissue  becomes  involved  a  granula*-**'* 
tissue   is  formed,  and  this  way  continue  to  generate*  pas  Iik9      "9 
ordinary  granulating  woun<l.     If  the  pus  be  removofl  ami  the  ca'*'  »  *,*^ 
drained,  suppunition   will   gradually  cease,   the  granulation  tl?*--*  ***■ 
develop  into  a  fibrous  structuri',  atid  the  union  of  the  uppooing  j**^*** 
faces  take  place.     The  serous  membrane  becomes  greatly  thickeo<  ^* 
and  the  new  tis.sue  undergoes  considerable  contraction  in  the  pf» 
cess  of  it«  organization,  producing  more  or  less  retraction  of  tlr 
chest-wall. 

Calcareous  plaques  of  considerable  size  may  develop  in  an  ailbi 
rent  ()arietal  pleura. 


CHAPTER  XXIX. 

INFLAMMATION  OP  THE   LIVKU. 

IxKi..\.MM  vTiiRV   procos-ses   in   the    liver   comprise   pedbei 
abscees,  and  cirrhosis. 


PEatlHBPATITIS. 

Inflammation  nf  the  capsule  of  the  liver,  leading  to  more  or  l««« 
thickening,  and  often  to  adhesions  with  adjacent  partM,  \»  mrt  with 
under  various  circumstances.  Its  most  common  caosM  arr  tb« 
chronic    peritonitis  of    Bright's    diseiu<e.    chronic    ale  '    ''  and 

syphilis.     The  changes  are  ui>UHlly  slight  and  of  bui  ]>«th- 

ological  import. 


CIRRHOSIS  OF  THE  LIVER.  511 

In  some  cases,  however,  especially  in  cases  of  chronic  peritonitis, 

the  process  is  more  extensive  and  leads  to  marked  interference  with 

tbe  functions  of,  and  circulation  in,  the  liver.     The  whole  capsule 

becomes    considerably   thickened    and    gradually    contracts,    thus 

causiog  compression  of  the  organ,  which  assumes  a  globular  form. 

The  portal  circulation  is  often  interfered  with  by  the  squeezing 

process,  and  ascites,  with  other  symptoms  of   portal  obstruction, 

may  result.     The  liver  itself,  with  the  exception  of  some  atrophy 

•and    fatty  degeneration  of  its  cells,   may  show  no  changes,  but 

sometimes  it  is  intersected,  and  even  divided  into  lobe-like  masses, 

by  bands  of  fibrous  tissue  passing  inward  from  the  capsule.     This 

suggests  syphilis  as  the  cause  (p.  453). 

Hbpatio  Abscess. 

A.cute  inflammation  of  the  liver  leads  to  the  formation  of 
«kl3Bcee8.  The  abscess  may  be  sinerle  or  multiple.  The  latter 
&re  usually  small,  but  a  solitary  abscess  may  attain  an  enormous 
size. 

Xffxiltiple  abscesses  are  most  frequently  due  to  pyaemia  or  to 
some  inflammatory  lesion  in  connection  with  the  portal  system, 
sach  as  dysentery.  In  these  cases  the  abscesses  are  due  to  infective 
embolism  of  branches  of  the  portal  vein.  External  violence  and 
ioflainmation  of  the  bile-ducts  from  gall-stones  are  other  causes  of 
wppvrative  hepatitis. 

The  solitary  or  tropical  abscess  is  supposed  by  many  to  be 
secondary  to  some  inflammation  of  the  portal  viscera.  It  is  known 
to  be  often  associated  with  dysentery.  It  is  thought  by  many  to  be 
due  to  a  primary  hepatitis  excited  by  some  unknown  irritant,  and 
doubtless  cases  often  occur  in  which  no  intestinal  ulcer  or  other 
obvious  cause  is  discoverable.  The  pathology  of  this  disease  is 
at  present  obscure. 

ClBBHOSIS   OP  THE  LiVBB. 

Chrooic  inflammation  of  the  liver  con-stitntes  the  condition 
known  as  Cirrhoeis.  This  is  characterized  by  a  gradual  increase  in 
the  connective  tissne  of  the  organ  and  by  the  subHe^jnent  atrophy 
of  the  liver-cells,  so  that,  when  examine<I  with  a  low  magnifying 
power,  the  lobales  are  seen  to  be  s«parate<l  by  new  int«rKtitial 
^wth  (Fig.  178). 

HISTOLOGT^ — The  process,  like  that  of  chronic  infiammstioo 


512  INFLAMMATION  OF  THE  LIVER. 

in  other  organs,  consists  essentially  in  a  cellular  infiltration  of  the 
interlobular  connective  tissue  of  the  liver,  and  in  the  subsequent 
development  of  a  more  or  less  highly  organized  fibroid  stmctore, 

Fio.  178. 


% 


'i/^ 


drrhcwiii  of  the  liver,  nhowing  the  KTOWth  of  connective  tluuc  between  the  hepatic  lobuta: 
a,  lobules ;  b,  new  growth  of  Interlobular  connective  tlaiuo.    X  1& 

the  number  of  cells  being  proportionate  to  the  activity  of  the  pro- 
cess. The  new  tissue  is  supplied  with  new  blood-vessels  deri%-ed 
from  branches  of  the  hepatic  artery. 

In  addition  to  this  cellular  infiltration  of  the  interlobular  con- 
nective tissue,  a  proliferation  of  the  bile-ducts  is  supposed  to  (Mvur 
frecjuently  in  some  forms  of  cirrliosis.  Charcot  believed  that  in 
these  ea-ses  there  e.xidted  some  obstruction  of  the  ducts — the  so- 
called  "biliary  cirrhosis."  Other  observers,  however.  Mtate  that 
the  columns  of  cubical  cells  or  so-called  new  ducts  are  met  with 
under  such  various  circumstances  that  their  existence  is  of  no 
value  as  an  indication  of  the  cause  (p.  515).  Goodhart  doubt*  the 
formation  of  new  ducts,  and  thinks  the  old  ones  simply  Innxme 
more  conspicuous  owing  to  the  atrophy  of  the  liver-cells.' 

The  liver-cells  are  stated  by  many  to  undergo  active  change*, 
and  to  contribute  to  the  formation  of  the  "  new  ducts,"  and  even  <«f 
tlic  cicatricial  ti.xsue  (Hamilton).  They  are  in  most  cases  infiltrated 
with  fat,  fatty  infiltration  being  a.ssociated  with  the  cirrhosis  (Fij:. 
180). 

The  general  distribution  of  the  new  tissue  is  described  by  Charr.«t 
as  multilobular,  unilobular,  and  intercellular.  In  the  niultili>l>- 
ular  form  groups  of  lobules  are  surrounded ;  in  the  unilobular,  each 

'  The  Milijfct  is  ably  ilisciimed  liy  Dr.  ( ioodhart  in  his  "  K(aam(  of  DiHetuw  of  ilw 
Liver,"  Sev  i>y<Unham  Hoc.  AUaji.  </  I'ath.,  faoc.  iv. 


CTRRHOSrS  OF  THE  LIVER. 


.■ilS 


lobule  5  and  in  the  intercellular  tlie  growth  invades  the  intercellulitr 
netwoi-l.     These  several  modes  of  distribution  are  freijuently  asso- 

Fio.  179. 


rirrhoaBli  nf  tUi-  llvi-r.  A  thin  section  fWra  lhi>  cxloriml  portion  of  one  of  the  hepHllo 
lotiiilM  .  ishowlnif  tlic  m-wKTowth  iif  rnniK-rtlve  tls-iui:  ami  llii' way  In  which  It  luvolvea  the 
inlrrre  I  X  xx\u  nctwurk  anil  cmiso!  iitmphy  nf  the  IIvit-cl-II.     -.  'JK). 

ciatetl,  all  perhaps  being  funnel  in  different  parts  of  the  same  organ; 
and,  sm.  Itbough  8uj)posed  by  Charcot  to  indicate  etiological  varieties, 

Jiu.  ISO. 


Liver.    CirThMis  with  (httyinflltratlon.    X  lOO,  rc<luce<)  I. 

the  liifforenccs  are  prnbably  to  be  ascribed  rather  to  differences  in 
tlic  sitf  of  the   irritant.     This   may    be   conveyed   niiiiuly    in   the 


614 


nfFLAMSfATTOy  OF  THE  LIVER. 


branches  of  tbe  portal  vein,  the  radicals  of  the  bile-dact«.  or  the 
ramificatioDS  of  the  hepatic  artery. 

The  effect  of  the  uew  growth  is  ultimately  to  cause  atrophy  of 
tbe  hepatic  cells,  and  to  obstruct  the  circulation  through  the  {wrtal 
c:i]iill:irics  atiil  the  passage  of  bile  through  the  bile-ducts.  The  first 
of  these  effects  is  giiieraily  tuore  marked  than  the  s<>CfiD(i.  The 
blood-pressure  in  the  portal  vein  rises.  an<l  after  a  time  a«citr» 
follows.  The  pressure  is  materially  increued  by  the  |>rTK*rw  of 
contraction  which  tbe  uew  tissue  undergoes.  Thi-  hcjiatic  O'lU  ia 
the  outer  zone  of  the  lobules  are  the  first  to  ntropby.  Tlic  ctlU 
shrivol  or  become  distended  with  fat  (Fig.  IKO).  nn<i  ultimately  arc 
coinplitely  destroyed  (Fig.  179).  Those  in  the  ceiilral  part*  of  the 
lolxile  are  in  the  earlier  stages  but  little  nltcreil,  iilthongb  they  an 
often  stained  with  bile.  As  the  growth  extends,  however,  tbfW 
also  become  annihilated,  and  the  whole  lobule  may  be  n-plar^tl  by 
connective  tissue.  The  atrophy  of  the  cells  may  depend  luirth  <io 
the  direct  pressure  of  the  new  tissue,  and  partly  on  the  indirict 
effect  by  which  this  cuts  off  their  blood-supply. 

PHYSICAL  CHARACTERS. — The  physical  characters  of  tJi« 
cirrhoscd  liver  vary.  In  the  earlier  stages  of  the  disease  the  orgoa 
is  probably  always  more  or  less  increased  in  si/.e.  the  eulargcnent 
being  almost  uniform  and  tbe  edge  rounded  and  thickened.  TUt 
enlargement  very  often  exists  up  to  the  end  of  the  disease,  but  is 
many  eases  the  atrophy  of  the  liver-crlls  and  the  contraction  of  tlw 
new  tissue  lead  to  considerable  diminution  in  sixc.  The  <urfaee<if 
the  organ  is  nsnally  more  or  less  irregular,  sometimes  ''  hobDailfd,** 
the  extent  of  the  irregularity  depending  upon  fhf  distribution  of  the 
new  tissue  and  the  amount  of  atrophy  that  has  taken  place.  Multi- 
lobular distribution,  as  compared  with  unilobular,  leads  to  less 
enlargement  of  the  liver,  but  to  much  greater  unevennrwn  of  the 
surface.  The  consistence  of  the  organ  is  always  more  or  leal 
inen-ased,  although  in  many  cases,  where  the  process  is  veiT 
rapid,  the  increase  is  so  slight  as  easily  to  escape  obserration. 
Hot))  irregularity  of  surface  and  induration  are  usually  OMMt 
marked  along  the  anterior  edge,  especially  on  the  left  lobe,  Om 
section  the  new  tissue  surrounding  the  lobules,  and  in  many  parte 
completely  replacing  them,  is  often  visible  to  the  naked  eye.  Th» 
gives  to  the  cut  .'Surface  a  mottled,  granular  appearance,  tbe  lobalei 
themselves  contrasting  with  the  new  interlobular  tissue  and  appear- 


ACUTE  YELLOW  ATROPHY.  515 

ing  as  yellow  foci  in  a  pink  network.     The  capsule  may  be  thick- 
ened, and  the  organ  is  frequently  stained  with  bile. 

The  great  increase  in  the  size  of  the  liver  which  exists  in  some 

cases  is  due  in  part  to  the  fatty  infiltration  of  the  liver-cells  (Fig. 

180).    In  those  cases  in  which  the  process  is  rapid,  and  the  new 

growth  consequently  very  general    in  its  distribution — unilobular 

*nd  often  intercellular — the  organ  is  usually  large,  death  probably 

supervening  before  time  has  been  allowed  for  much  atrophy  and 

wntraction  to  take  place.     Some  of  the  large  livers  are  supposed  to 

te  due  to  "biliary"  cirrhosis,  to  which  reference  has  already  been 

made  (p.  512). 

Etiology. — The  cause  of  cirrhosis   of  the  liver  is  alcohol. 

•v  ith  the  exception  of  syphilis,  no  other  cause  can  be  regarded  as 

proven.     The  question  of  a  biliary  cirrhosis  must  at  present  remain 

*n  open  one.     Cirrhosis  from  syphilis  has  already  been  described 

\P-  332).     In  the  congenital  form  the  process  is  often  so  general  in 

'*8  distribution  as  closely  to  resemble  some  cases  of  acute  alcoholic 

cirrhosis. 

It  is  important  to  remember  clinically  that  cirrhosis  not  only 
obstructs  the  portal  circulation,  thus  giving  rise  to  ascites,  haemat- 
emesis,  diarrhoea,  enlargement  of  the  spleen,  and  hemorrhoids,  but 
that,  owing  to  the  destruction  of  the  liver-cells,  the  functions  of  the 
■organ  are  so  much  impaired  that  marked  interference  with  general 
^antrition  results.  Jaundice  is  usually  slight,  probably  because  the 
oile-ducts  are  not  obstructed  at  various  points  in  their  course,  but 
»Te  pretty  uniformly  compressed  from  their  origin  onward. 

Acute  Yellow  Atbopht. 
This  rare  disease  of  the  liver  is  characterized  by  a  rapid  diminu- 
*'on  in  the  size  of  the  organ,  accompanied   by  destruction  of  the 
■■^Patic  cells,  and  is  often  associated  with  pregnancy.     The  liver 
""^y  in  the  course  of  a  few  days  be  reduced  to  less  than  half  its 
natural  bulk,  being  especially  diminished  in  thickness.     It  is  soft 
and  flabby  in  consistence,  bloodless,  and  of  a  dull  yellow  or  yellow- 
isn-red  color.     The  lobules  are  indistinguishable.     When  examined 
microscopically,  most  of  the  liver-cells  are  found  to  be  completely 
destroyed,  being  replaced  by  granular  di'hris,  fat-granules,  and  pig- 
ment.   Tyrosin  and  leucin  have  been  found  in  the  disintegrated 
Jirer-tissae.     Branched  tube-like  collections  of  cubical  cells,  sug- 


f 


516  INFLAMMATION  OF  THE  KIDNEY. 

gestive  of  bile-ducts,  are  frequently  seen    among  the  survivinj 
stroma  (p.  512).     The   pathology   of  this   disease  is  exceedingly 
obscure.     By  some  it  has  been  regarded  as  a  passive  degeneration, 
by  others  as   an  acute  infective    inflammation.     Micrococci  h»."ve 
been  found  in  the  organ  in  early  stages  of  the  disease  by  Dresch- 
feld  and  others. 


CHAPTER    XXX. 

INFLAMMATION  OP  THE  KIDNBY. 

Inflammatory  processes  in  the  kidney  present  certain  variatio"' 
according  to  their  intensity.     They  comprise  suppurative,  parenrA.t 
matous,  and  interstitial  nephritis.     Of  these,  suppurative  nephri*'* 
is  an   intense   inflammation    leading  to  the  formation   of  absoe-^"- 
and,  although  this  form  of  inflammation  is  practically  limited  to  1 1'^ 
interstitial    tissue,   the  term  "  interstitial   nephritis  "   is  genera  1  ^}' 
reserved  for  chronic  processes.     Parenchymatous  nephritis  is   J»" 
inflammation   of  considerable    intensity,   involving   glomeruli  awi'^ 
tubules.     Interstitial  nephritis  is  the  name  applied  to  a  chrom»»«' 
process   in   wliich    atro])liy   j)robably  plays  a  more  important  ]>i»rt 
than  infliimmation.     As  in  chronic  inflammations  of  otlicr  orga  «•■^• 
the  principal  structural  clianges  take  place  in  the  conm-ctivt'  tis.— "'■ 
around  the  blood-vessels — /.  <■.  in  tlie  intertubular  connective  ti.*^'"" 
(p.  297).     It  must,  however,  be  distinctly  borne   in  mind  that   r  li«- 
histological  clianges  in  the  tubes  and  in  the  intertubular  connect  >  v«' 
tissue  <irc  rcri/  coiistantli/  associated.     Parenchymatous  and  int«-r- 
stitial  nephritis  cannot  therefore  be  separated  from  one  another    f'y 
any  distinct  line  of  demarcation. 

StjppuBATivE  Nephritis. 
Renal  abscesses  result  from  the  transmission  of  infective  par- 
ticles from   some   primary  focus.     They   may  occur  as  oue  ol  tne 
lesions  in  pi/iriiiia  or  they  may  be  associated  with  some  inflivin'i''' 
tori/  conditio))  (if  the  loircr  iiri))an/  passiufes.     In  pyjemia  tlie  ii"''"'" 
tive  particles  are  transmitted  by  the  blood-vessels.     In  the  "ther 
cases  tlu'v   reach  tlie  kidney   by   direct  extension  from  the  In*^'' 
urinary  passages.     The  latter  condition  forms  one  of  the  varietif* 
of  the  so-called  "  Surgical   Kidney." 


SUPPVRATIVE  NEPHRITIS.  517 

The  abscesses  met  with  in  the  kidney  as  the  result  of  pyaemia  are 
confined  principally  to  the  cortex,  and  resemble  pysemic  abscesses 
in  other  organs.  They  are  usually  multiple,  and  are  often  sur- 
rounded by  a  thin  zone  of  red  hypersemic  tissue.  Their  size  varies 
irom  a  mere  point  to  that  of  a  filbert.  These  characters  have  been 
already  described  (p.  467). 

SURGICAL  KIDNEY. — This  is  the  name  commonly  given  to 
those  inflammatory  conditions  of  the  kidney  which  result  from 
obstructive  and  inflammatory  diseases  of  the  lower  urinary  pas- 
sages. They  occur  in  association  with  renal  and  vesical  calculus, 
obstructed  ureter,  urethral  stricture,  and  enlargement  of  the  pros- 
tatic. These  and  similar  conditions  may  act  upon  the  kidneys  in 
tliree  ways: ' 

H.  By  obstructing  the  outflow  of  urine  from  the  pelvis  of  the 
kidney. — Actual  regurgitation  from  the  bladder  into  the  ureter  is 
unlcnown.  When  the  flow  of  urine  from  the  ureter  into  the  bladder 
i»  prevented  by  any  form  of  obstruction,  the  full  force  of  secretion, 
aided  by  gravity,  seems  to  expend  itself  in  dilating  and  irritating 
ttie  ureter,  the  pelvis,  and  the  pyramids,  and,  finally,  the  tubules 
even  to  their  closed  ends.  When  the  obstruction  to  the  outflow  is 
coTifined  to  one  kidney,  that  organ  is  alone  affected. 

2.  By  producing  reflex  changes  in  the  circulation  through  the 
Icitiney. — A  close  relationship  seems  to  exist  between  the  deeper 
portions  of  the  urethra,  the  prostate,  and  the  trigone  on  the  one 
'•and,  and  the  kidneys  on  the  other.  An  intense  hyperaemia.  due 
^  irritation  of  the  nerves  of  these  parts,  as  in  some  operations, 
"^^y  in  extensively  diseased  organs  lead  to  arrest  of  the  circulation 
*D<1  death  from  suppression  of  urine. 

3.  By  extension  of  decomposition  from  the  bladder  to  the  kidneys, 
***d  irritation  of  the  latter  by  septic  products.  As  regurgitation 
*oes  not  occur,  decomposition  often  remains  limited  to  the  bladder, 
''hen  extension  occurs,  it  is  probably  due  to  the  presence  of  ropy 
^ttcus  lying  as  a  cord  in  the  opening  of  the  ureter  when  this  has 
become  inflamed  from  other  causes.  Such  mucus  acts  as  a  culture- 
gfoond  along  which  organisms  can  grow. 

The  morbid  changres  in  the  kidney  vary  from  the  most  chronic 

productive  inflammation  to  an  acute  suppurative  process. 

'  The  views  here  eipresBed  are  in  accordance  with  the  teaching  of  Marcus  Beck, 
"^'ephriti8  and  Pyelitis  consecutive  to  Affections  of  the  Lower  Urinary  Tract," 
Sx^nMU  Syttem  of  Medians,  vol.  v. 


518 


INFLAMMATION  OF  THE  KIDNEY. 


Simple  li:>ng-('(iiitiiiiu'<l    iiicTfiisf   of  iirinurv   preasurp.   rosultii 
from   some   obstructioti  to   tliy   flow  of  urine,  gives  rise  to  clirouB^ 
renal  eimnges  which  are  characterizeil  miiinly  by  more  or  less  cclltx- 
lar  infiltriitioii  of  the  intertiibular  connective  tis.sue  ami  atrojiliv  of 
the  tubular  oiiitlicliiim  (p.  o24).     This  cellular  infiltration,  which  is 
exceedingly  irregular  in  its  distribution,  occurs  both   in  the  pyram^ 
mids  and  corte.x.     The  tubulen  are  in  some  parts  found  block^><l 
with   epithelinni,    whilst    in   utlier,-*  tliey  are  wasted  or  obliterate<l. 
The  Willis  of  the  .sniall  arteries  are  not  thickened.     Owing  to  tlii-$«o 
changes,  the  kidneys  are  somewhat  enlarged,  the  capsule  is  slight!  v 
iulherenl,  the  cut  surface  is  paler  than  natural,  and  the  consistenoe 
of  the  organs  i.s  abnormally  tough.      .\s  the  process  advances  tLie 
jjvramidal  portions  gradually  become  absorbed,  the  absorption  coxmi- 
meneing  at  the  [lapilhe,  and  extending  until  ultimately  not  only  tVie 
pyramids,  but   also  tlio  thickened  corte.x,  may  disapjtear,  and  tt»e- 
kidney  be  converted  into  a  large  cyst  divided  into  sacculi  by  filin>»»* 
se|ita.     If,  on  the  other  hand,  the  nrinary  obstruction  be  retiwver^l.. 
the   processes  of  inflammation  and  absorjition   may  cease,  mid  tla© 
iuduratctl  kidney  will   then  become  contracteil. 

lu  other  case^,  when  the  urinary  obstruction  is  associated  « 

Fio.  181. 


Surfilml  kidney.  At  the  Inwor  jmrt  of  tlii'  lliniro  \s-  sveu  the  rvlliiliir  InflUrUlcaof  ff  "*' 
tfrtiilmlar  tissue  and  tlie  bliH'kliif;  of  llie  tiil»t>s  with  epItheUiitn  iiiul  Icucocytw.  *l  *** 
uit|*r  i>iirt  there  la  the  eninmenrlii^  funnntloii  of  an  rtliceoiii.     ■•  100.    (Boyd.) 

inflammation  of  the  lower  iiriniiry  |ia8sages,  the  process  i»  ntu^'i 
more  acute,  the  cellular  infiltration  of  the   intertubular  ti»uc  i* 


* 


TDnch  more  abiinilnnt.  and  in  certain  situations  k-ucocytes  accuinu- 
inte  in  such  nuiul)ers  as  to  give  rise  to  abscesses  (Fig.  181).  The 
cortex  of  such  a  kidney  is  thickened,  soft,  and  pale  as  comjiared 
writli  the  deep  red  pyramids;  its  consistence,  however,  will  vary 
»  itii  the  presence  or  absence  of  chronic  interstitial  changes.  The 
capsule  strips  easily,  often  tearing  the  substance  a  little  and  expoa- 
iag  on  the  surface  groups  of  yellow  spots.  These  yellow  dots  are 
aever  larger  than  a  lentil ;  each  is  surroumled  by  a  red  zone,  and 
m&uy  of  them  contain  a  drop  of  pus.  On  .section  yellow  streaks 
are  often  seen  extending  from  the  sujierficiiil  lesions  into  the 
cortex;  others  e.\i.st  in  the  [lyratnids.  The  jielvis  is  generally 
int«nsely  inflamed. 

Klebs  found  many  of  the  convniuted  tubes  crainiued  with  micro- 
cocci.    These  seem  to  ascend  t'roui  the  pelvis  along  the  tubes,  dia- 

Fio.  182. 


r..,^7v    ■ — ■- 

^'^ral  kldnvy,  Nhduiuit  crowds  of  microcorcl  HM't'iKliiiK  aluni;  tin- tubules.    Alinoatall 
i"^'**  In  iheir  vicinity  hnvi'  dUappvared.    Thoy  soom  to  have  caused  coagiilatlve  necmla 
*•>*  tlnna.    x  "buut  90.    (Boyd.) 

titling  them  and  setting  up  irritative  and  degenerative  processes 
•'ong  i\i(,\f  line  of  passage.  When  stained  with  an  aniline  dye  the 
appearance  .shown  in  Fig.  182  is  seen.  It  is  extremely  probable 
•'at  these  organisms  are  the  cause  of  the  8upj)uration.  The  urine 
"*   the  pelvis  of  such  kidneys  is  uaually.  but  not  always,  septic. 

Pabenchymatous  Nephritis. 
'*lirenchvTnatous   nephritis  may   be  drutf  or  chronic,  primanf  or 

The  primary  variety  comprises  the  common  forms  of  acute  and 
'^•^'"Otiic  Bright's  disease — forms  characterized  by  a  distinct  onset, 
^®nty  and  highly  albuminous  urine,  and  drop.sy.  In  its  more 
***Vaaced  stages  it  is  the  large  white  kidney  of  Bright's  disease. 


520 


IVFLAMMATTOS  OF  TTTK  KIOyET. 


H  These  varieties  are  termed  primari/  becau»e  their  exact  cauMtion^^f 

H  unknown.  ^^B 

H  The  secondary  fomiH  of  parenchymatous  nephritifi  occur  a*  co-safl 

H  plications  of  infective  diseases,  especially  scarlatina.     In  pncamocsW 

H  and  SOUR'  iithcr  disease!*  the  or^iiiiisiii   tissociiitt-d  with   the  priok^^^fl 

H  condition  has  heen  found  in  the  iniiained  kidney,  and  the  neph'r^H^| 

H  is  in  these  caseM  supposed  to  be  duo  to  the  action  of  the  or^nai^^velfl 

H  and  their  products.  ■ 

^1  The   |)arts   in   vthich   changes    have   hrcn  observed   arc — il^i     K-3fl 

^m  glomeruli:  (l!)   tlu>  couvoIuIimI    tubes;    (8)  the  ^ninll   arteries:    a^-^H 

H  (4)  the  iDt«rtubutar  tissue.  I 

H  In  thr  nioHf  iiriiti-  ruHi-K  of  primary  Hrii;lit'n  disease — tho^'c  wKiBfl 

H  occur  jiiiddeniy.   as  after  cx|iosiire   to  ridd — rmn-uhir  liHatiitmr*         ■ 

H  wark'ul.     In   these  cases  the  contraction  of  the  cutaneous  veois^^M 

H  and  the  check    to  the  function  of  the  skin   caused   by  the  chilli       fl 

H  of    the   surface    lead    to    considerable    hypenruiia    of  the    org^^^^^l 

H  There  is  abundant  exudation  into  the  tubes:  at  the  same  time  iit»»-'^ 

H  of  the  capillaries    forming  the    Malpighian    tufts  rti|itur(*,   so   t Wfc^ 

H  there  is  also  an  escape  of  blood-corpu.sdes  and  of  lii^uor  sanpai:^^fl 

H  into  the  tubes  of  the  cortex  :   hence  the  blood  anil  "  b)Qod>ciu'C^^| 

H  in  the  urine  which  are  so  characteristic  of  the  early  stages  of    '^Kki 

H  most  acute  forms  of  the  disease.     In  the  kidneys  of  persons  djr^BOg 

H  at  this  staj^e  large  numbers  of  red   corpuscles  may  be  seen  in       "^fc* 

H  Malpighian  bodies,  pushing  to  one  side  the  vascular  tufls,  aia 

H  the   tubes,  which    may  be   eoiisoituently  distended.      .\t   tliist  «4 

H  the  process  may  <|uickly  siibsiile,  and.  with   the  exception  of 

H  swelling  and  des<|namation  of  the  tubular  epithelium,  uo  far 

H  nlternti<ins  take  place  in   tlie  kidney. 

"  //)  till'  li»»  acuti-  ritxim — those  known  as  subacute  Bright**  Ak 

with  large  kidney — the  vascular  phenomena  are  less  marked 
the  rhiini/nt    in   thr  liifnilur  f/nthrliuni  art   more  prvminfnt. 

^m  epithelial    elements    undergo   cloudy  swelling    (p.    7f>;  Fig.    I 

H  Many  small  cells  are  seen  partially  tilling  up  the  tubes.     These 

^1  supposed    to    be   mainly    the    products  of  epithelial    prolifenil 

^1  though  some  of  them  are  in  all  probability  leucocytes  c»aipe<I  I 

^B  the   Vessels  (p.  AOi).     (Iwing  to  these  changes  the    tnlxii    l>« 

H  distended  with  cellular  elements  (Pig.   \M).     A  varying  nntm 

H  of  new  cells  are  alw  found  around  the  Malpighian  tufts  (p.  4- 
^1  lu  addition   to  the  cell-forms,    many  of  the   tubes  also  cor 

^^  hyaline  c^'linders  or  coats,  which  are  commonly  rcgiuxlvd  as 


Sirr 


PARENCHYMATOUS  NEPHRITIS.  521 

Brting  of  coagulated  exudation.     By  inauy  pathologists,  however, 

Fu).  183. 


*»i«J 


tiihiilnr 


Fid,  184. 


•'•s  hyaline  material  i.s  supposed  to  hp  tlio  product  of  ;i.  tmicoid  nr 
^^  **»iHe  allied  inetaniorphosis  of  tlie  cjiitholitiui.  The  eell-fnnns  eou- 
^B  *>tied  within  the  tubes  adhere  to  tliis  liyaline 
^■■^•* bstance,  and  some  of  them  are  washed  away 
^■*'*f|  appear  in  the  urine  as  "  epithelial  casts." 
^^_  'I'he  alterations  whieh  these  chaiijies  produce 
**  the  nakeil-efif  r/innifffrti  of  tlie  kidneys  vary 
■'^■'icording  to  the  extent  of  the  hyperiemia. 
He  organs  are  always  eoiisiderntdv  increased 
_I  *^  size  ami  more  or  less  abiii>rni;illy  viisciiliir. 
He  capsule  separates  readily,  exposinj:  a  per- 
'*-*crtlv  smooth  hut  yasenlar  sirrfsice.  Ttie  ei»n-  Tuiui  nephriii.«-«  »in- 
'•-*stence  is  diminishe-l,  the  tissue  breaking  .u-oiimuitttum  within  ii.« 
f'^^ith  a  soft,  friable  fracture.     On   section  the     i"i>e  i<>ti«if.H,piu..ii.ii 

5  •  .  p     ,  rclls  wlili'li  havi?  fsiii|ii<l 

**»crease  m  the  size  of  the  organ  is  seen  to  bo     tiu- Kranninrtoiiaitinn  ..r 
T»»-incipallv  due  to  the  increased  tliiikitess  of     H"'   •"■"••■vi'"""  i»  "•«-n. 
^««  cortex.     This  is  either  of  a  red<lisli-browii 
***■   of  an  opaiiue-white  or  ])ale-l)ufr  color  :  these  differences  depend 
**pon  the  relative  pro|)ortton   <d'  blood   and  of  acriiniulated.  intra- 
lobular elements.      Altlioii;rli  in  the  earliest  staire  of  flie  most  acute 
***rni8  of  the  disease  the  color  is  redder  than  natural,  it  soon  becomes 


ISFLAMMAriON  OF  THB  KtOifEY. 


pale  and  opaque.  This  is  owing  to  the  swelling  of  the  <rpttlirltftt 
elements  uud  tn  tbe  accuniiiliitioti  uf  cells  in  the  cortical  tabes. 
Tiie  blood  beconiC8  ex|)re!SHe<l  from  tbe  intertiibular  Teasels,  aad 
hence  the  increased  vasculuritv  is  most  evident  in  the  MnlpighUn 
corpuscles,  beneath  the  capsule,  and  in  the  pvrnmidal  iK>rti«>n?  »f 
the  organ.  Tbe  Malpigbiuu  corj)u.-icies  stand  out  a«  prominent 
red  points,  and  the  pyramidal  cones  are  of  a  deep-red  color,  thus 
contrasting  strongly  with  the  pale  opaipie  cortex. 

The  termination  of  tbe  process  varies.  The  increased  vaacolar- 
ity  and  epithelial  change  may.  as  already  stated,  subside,  and  on 
tbe  inflammatory  products  passing  away  in  the  urine  the  organ 
will  gradually  return  to  its  normal  condition.  In  other  cases  the 
disease  continues,  and,  although  the  vascularity  diminishes,  thr 
vitality  of  the  epithelial  elements  is  so  much  impaire<i  that  xhtj 
undergo  retrogressive  changes.  In  these  eases  the  cells  still  con- 
tinue to  come  away  with  the  urine,  but  instead  <d'  pre.nvnting  a 
swollen  granular  ajipcarance,  as  in  the  earlier  stage  of  the  dii>ease, 
they  now  contain  molecular  fat.  This  fat  grailually  tncrCAsen  in 
amount  as  tbe  degeneration  proceeils,  until  ultimately  the  cells  are 
destroyed  and  the  fat  appears  as  free  molecules  and  granules  od  the 
tube-casts. 

Thi.'*  fatty  degeneration  of  the  epithelium  is  attended  by  corrtr- 
sponding  changes   in  the  a])pearanee  of  the  organ.     Tbe  re«liicM 
diminishes  and  the  Malpighian  corpuscles  are  less  prominent.     The 
enlarged    corte.x    presents   a    yellowish-white    tinge,    studded   with 
minute  yellowish  streaks.     This  is  owing  tn  the  presence  of  fat  la 
tbe  tube«of  the  cortex.     This  fatty  stage,  if  only  slightly  adtantwi^ 
may  undoubtedly  pass  nff.     Tbe  degenerated  cells  are  carri«tl  awiji 
by  the   urine.      From   those  which   remain   in   the  tuheH  tbe  fat 
probably  partially  absorbe<l.    Thus  the  retrograde  process  gradually* 
ceases,  and  the  organ  returns  to  nearly  its  normal  sixe  anil  cob»5 
tion.      In  other  cases  the  degeneration  continues,  and.  owing  to  \     d 
loss  of  epithelium,  the  kidney  becomes  somewhat  diininisbcl  iuva — :^ 
This  atrophy  is  always  accompanied  by  changes  in  the  intertill 
connective  tissue. 

When  tbe  inflammatory  process  \»  af  HtiUloitfjtr  duration,  orw 
the  kidneys  arc  the  seats  of  repeate<l  attacks  of  subacute  inflam 
tion,  the   intertuhuliir  eonnertire    tiimnr   iunirinhh/  heriimea  ih 
This   tissue   becomes   infiitrated  with  small  cells  which   uiti 
tend  to  form  a  tibrillated  structure  (Fig.    185).     The  new 


PARENCHYMATOUS  NEPHRITIS. 


623 


^Wlar  growth  may  gradually  increase,  and  so  lead  to  more  or  less 
irregular  atrophy  of  the  organ,  such  as  will  be  described  as  occur- 
ring in  interstitial  nephritis  (small  white  kidney).  The  new  tissue 
>*  more  uniformly  distributed  and  the  contraction  is  less  marked  in 
^ttose  Cases  following  tubal  nephritis  than  in  those  presently  to  be 
described  (p.  524).  In  other  cases  death  ensues  before  any  marked 
"trophy  has  taken  place,  and  thus  the  organ  may  remain  smooth 
>nd  large  to  the  termination  of  the  disease  (large  white  kidney). 
*"lie  intertubular  growth  is  sometimes  found  thickly  studded  with 
fatty  granules.     Attacks  of  subacute  inflammation  not  infrequently 

Fio.  18.5. 


'^W 


rent- 
cell  " 


nephiitla.    Duration  of  disease,  six  months.    Kidneys,  large:  capsules,  non-adhe- 
snrbce,  smooth;  tissue,  soft— showing,  in  addition  to  the  intratubular  change,  the 
*»Ur  infiltration  of  the  Intertubular  connective  tissue,     x  200. 

^iir  in  the  course  of  the  more  chronic  ca.ses  of  primary  parenchy- 
*tou8  nephritis. 
Ihe  secondary  forms  of  acute  parenchymatous  nephritis  (scar- 
^*ina/  nephritu)  are  mainly  characterized  by  changes  expressed  by 
**«  term  glomerulo-nephritis. 

The  earliett  and  most  marked  changes  are  often  confined  to  the 
"^*«lpighian  bodies.  These  are  found  to  contain  a  number  of  new 
^^Ht,  the  exact  origin  of  which  is  uncertain.  According  to  some, 
"^ey  are  derived  from  the  endothelial  cells  of  the  vascular  tufts; 
^*i«ording  to  others,  they  are  accumulated  leucocytes ;  and  in  the 
^t»inion  of  others,  again,  they  are  the  progeny  of  the  epithelium 
'^'^"vering  the  glomerulus.  The  new  cells  are  sometimes  accompanied 
^^^^  so  much  exudation  that  the  vascular  tuft  is  compressed  and  the 
^>*"cnlation  through  it  more  or  less  interfered  with  (p.  520). 

The  mtima  of  the  minute  arteries,  especially  of  those  supplying 


524  TKFLAMMATIOK  OF  TTTE  KWyET.      ^^^^H 

Htbe  gloineriili.  i;*  f're({iientlr  awollen  (hyaline  degeneratiou).  an<l  an 
^Krie;;iiliir  ii:in<)W iiij;  i)f  thf  lumen  of  the  affecteti  veMeln  is  thereby 
Wpnidiiced.  This  cliange  may  also  be  present  in  the  enpillarir*  of  the 
glomeruli,  in  con8e<{ueuce  of  which  many  of  them  heeoute  impmn^ 
jililc.  Tiie  iiiitMntfiir  inilh  of  tlie  mintiti-  arteries  are  ali^i  thirkenrd 
anil  the  nuclei  multiplied.  Cloudy  HMelling  of  the  cpilhrlium  ia 
the  convoluted  tuhes  is  commonly  superadded. 

Later  on,  a  cellular  infiltration  of  the  intertuhular  oonnccttrv 
tissue  of  the  cortex  may  occur,  together  with  an  increase  in  the 
epithelial  degeneration  and  a  crowding  of  the  tubes  with  rinaW 
round  cells.  The  cellular  infiltration  commences  nmnml  the  Urger 
Vascular  trunks,  nheiicc  it  s|ireads  rapiiily  into  the  biMics  of  the 
pyramids,  and  eHpc<-ialiy  into  the  cortex.  .As  it  incrouir«  the  c|m- 
thelium  underg(n's  fatty  degeneration  and  the  urinc-tube«  prs'Inallr 
become  oliiiterated. 

'J'o  the  naked  ei/r  in  the  arutrr  varieties  of  glomerulo-ncphritb 
no  change  is  visible.  In  the  hiUr  ittaijeM,  when  the  dimnuc  has  Uat«d 
s<'veral  weeks,  the  glomeruli  may  be  unduly  prominent,  the  inter- 
pyramidal  portions  of  tlie  organ  enlarged,  and  yellow ijb  streftlu 
visible  in  the  cortex. 

Interstitial  Nephritis. 

\Vc  have  already  Heen  that  an  increa.He  in  the  intemtitial  tii«M 
of  the  kidney  occurs  in  the  more  advanced  stage.'*  of  fiArencbrmatiM* 
(p.  r>2-)  and  of  chronic  consecutive  nephritis  (p.  418).  Bat  tbw 
change  is  most  frequent  and  prominent  in  that  most  chronic  of 
nil  varieties  of  Bright's  disea.se  which  is  known  as  contTsct««i 
kidney,  granular  kidney,  cirrhosis  of  the  kidney,  gouty  kiiloey,  or 
interstitial  nephritis.  This  disease  is  associated  pathologically  witk 
atrophy  of  the  glomeruli  ami  tubules  and  changes  in  the  walls  of  the 
arteries.  Clinically,  it  is  characterized  by  an  insidious  onact,  aa 
increased  ldiMiil-prHs,>iure.  a  large  secretion  of  urine,  and  the  gradual 
development  of  hypertr'>|>hy  of  the  left  ventricle  of  the  lu»n- 
Albuminuria,  if  present,  is  slight,  and  dropsy  is  abaeat. 

NAKED-EYE  APPEARANCES.— In  a  wellmarke<l  eaae  tlM 
kidney  is  much  diminished  in  tize.     Its  capsule  is  thick  ao<l  totj 

adherent;  it  cannot  he  removetl  without  tearing  the  suTnttaoce. 
The  surface  is  coarsely  granular  anil  of  a  reddish-gray  tint.  On 
section  the  color  of  both  pyramids  and  cortex  is  seen  tn  elo««!T 


rSTERSTtTIAL  NEPHRITIS. 


525 


resemble  that  of  the  surface,  the  distinction  between  cortex  and 
pyramid  being  ofti-n  by  no  means  clear.  The  cortex  is,  however, 
mure  mottleil,  and  Hiiiall  [latcbescan  sometimes  be  made  out,  cor- 
responding to  the  depression  between  the  minute  nodules  on  the 
surface.  Moreover,  it  is  much  narrower  and  tou<.dii'r  than  miniinl, 
«dJ  small  cysts  are  often  found,  especially  on  its  surface.  Calca- 
reous deposits  may  occasionally  be  seen  as  white  streaks  among  the 
tubes  of  the  pyramids.  In  the  earlier  stages  of  the  disease  all 
t&c8e  changes  will  be  much  less  marked. 

MICROSCOPIC  CHARACTERS.— If  one  of  the  depressions  just 
Qientioned  be  e.\amined,  it  will  be  found  to  consist  of  a  number  of 
shrunken  Malpighian  bodies  and  a  few  atrophied  or  distended  tubes 

Vm.  186. 


yf       — 'i>lJil<il  tipphrUl!).    \  very  ttiivaiii'i'il  •.Iuki' <>r  the  |irii«'ii».  showing  the  iHrRr  amount 
m—       **»Wc  tielwfvii  the  tube*  nf  tin-  cortex  niiil  llie  fxtciislve  »tniphy  of  the  lutits.    The 
*^«.'raieil  )'piihi-hum  which  ww  conuiiied  In  Home  of  the  tubes  bus  fiiUun  out  in  Uie 
»>ilun  iif  the  tertUin.    x  l.V). 

•^^dded  in  a  mass  of  fibroid  tissue  (Fig.  186).     Bowman's  capsule 


y"  in  each  case  he  more  or  less  thickened. 


^fcy^  -■^lie  rest  of  the  cortex  is  by  no  means  uniformly  affected.  Tn 
^P^***J  parts  the  tubes  are  tliminished  in  si/.e  or  completely  oblitcr- 
■  '^^i :  in  others  they  are  dilated  and  filled  with  degenerated 
^*tliclial  products  (Fig.  187).  Their  walls  are  often  thickened, 
'*<i  intertubular  tissue  is  increased  througliout.  but  by  no  means 
"'urtjrnilv.  The  new  tissue  mav  be  largely  cellular  or  densely 
"">"oid.  The  atrophy  of  the  Malpighian  liodies  and  adjoining  tubes 
^^y  be  out  of  proportion  to  the  amount  of  fibrous  overgrowth. 
Attention   must   now  be  turned  to  the  interlobular  arteries  and 


52U  INFI.AHMATIOS  OF  THE  KIDSET. 

the    smaller    cortical    vessels.       The    walls   of    liu^e    are    aim 
invariably  thickened.     Soiiietiiues  the  e-xterniil  coat  is  princi^^  Jlj 


iDltnttCliil   nt'T'lirltl*     An  lulvniircil  itnec  nf  iho  pn^M-».  >luiwiui!  ihc  liiiiitubalar  I 
wltli  lliv  Kirnnuliir  rinil  fntty  <U^lri^  wliich  rvniilt  (Viiai  ilir  ilcKi'Mcrnlloii      •,   l<M> 

involved,  and  iippears  t<i  he  lontiniioiis  witii  the  new  intertiihu.  '*''J 
tis.mic.  Sometimes  the  iiiid<lle  coat  is  tliickeric<l,  as  in  the  .■>pcciiE"^*"« 
from    whieh   the  accumininyitig  illnstrntion   was  taken  (Fig.    18^^^ 

Via.  ISH 


Arirti)-  friitn  r<«ilr«rl«-tl  kitlu<-y  of  adv«ncc<l  chniiin    lu  ii  lonjni***-* 

Miction ,  vhi'wInK  Om'  irn'ul  IhU-krtiltij;  of  Ihr  rln-iilar  tnUM'ulu;  ft 

COM  and  thv  Intrninl  ('<innr<-t|Ti<  ilun<'  Uyer:  h.  IntiinvrrM-  ■•-iiioii  -n  ■raiUiwt  ^ 
rtlwimi      il«'nt  U  M'cn    Ibr  thlckenlns  of  ttir  clrruUr  niiuciiJu  uul  cxtorakl  Bl 

Johnson  attrihutes  thiti  to  liyjMTtro|ihy  of    the  circnlar  musc^*  *" 
fibres.     Recent  observers  em|iliii«i/.e  the  frequency  with  whidi 
intima  is  involve<l:    tho  endarteritis   tints   iiniditoed   most  rioi 
reaembles  that  form  already  described  as  syphilitic  (p.  4o2). 


INTERSTITIAL  NEPHRITIS. 


527 


iges  in  the  arteries  are  by  no  means  limited  to  those  of  the 
eys,  but  are  found  in  the  arteries  of  almost  any  part  of  the 


&.THOLOOY. — The  relationship  these  changes  bear  to  one 
her  must  now  be  considered.  It  is  by  no  means  certain  that 
relationship  is  in  all  cases  the  same.  Two  explanations  have 
suggested.  According  to  the  first  and  older  view,  the  changes 
due  to  the  action  of  some  unknown  irritant  conveyed  by  the 
d  to  the  kidneys,  thus  giving  rise  to  proliferation  of  the  con- 
ive  tissue  in  the  immediate  neighborhood  of  the  vessels 
;.  189).     According  to  this  explanation,  a  granular  kidney  is 


!ntltlal  nephritis,  showing  marked  increase  of  the  intertubolar  connective  tissue. 
'Pithelium  baa  fcUen  out  of  some  of  the  tubes  durini;  the  preparation  of  the  sec- 

X  aoo. 

)gons  to  a-  cirrhotic  liver.  The  thickening  in  the  vessels  and 
ncrease  in  the  intertubular  tissue  are  the  earliest,  and  practi- 
simultaneous,  changes,  while  the  atrophy  of  the  secreting 
J  is  due  to  the  results  of  the  contraction  of  the  chronic 
amatory  tissue. 

cording  to  the  more  recent  and  now  more  generally  accepted 
the  order  of  events  is  reversed.  The  secreting  tissues,  from 
ork  and  from  the  premature  exhaustion  of  their  inherited 
capacity,  are  unable  to  utilize  such  nourishment  as  is  supplied 
e  blood,  which  in  most,  if  not  all,  cases  is  defective  or  even 
srious.  The  secreting  tissues,  constituting  the  most  highly 
lized  part  of  the  kidney,  will  have  the  greatest  difficulty  in 


628 


INFLAMMATIOS  OF  THE  KJDyEY. 


assimilating  nourishment  uniler  abnortnal  cunditions,  and  iu  inj 
geueriil  interl'ercufe  with  nutrition  will  therefore  be  those  mi»i 
likely  to  sufler.  Thus,  the  shrinking  of  the  •'loiueruli  and  tubulin 
from  the  initial  change  (Fig.  I8(i).  The  changes  in  the  hW- 
vessels  and  the  increase  in  the  interstitial  tissue  follow.  The  luttfr 
is,  in  niaiiy  cases,  more  aptiai'ent  than  real,  being  partly  due  to  the 
mere  condensation  ••!'  the  previously  existing  but  wore  »iiiel» 
separated  tissue.  Tu  some  extent  it  may  be  the  result  of  irritstion, 
and  he  partly  inllanimatory  in  its  origin. 

The  subsequent  contraction  of  the  new  tis-siie  necessarily  con- 
Btricts  many  duets.  The  arrest  of  the  flow  in  those  supplied  bt 
glomeruli  whose  vessels  are  still  jicrmeable  will  lead  to  ih* 
formation  of  small  retention-cysts,  such  as  have  been  previon»lT 
described. 

Sometimes  the  arterial  ehiinges  are  more  marked  than  the 
atrophy  of  the  glomeruli  and  tubules.  In  these  cases  the  oihIm- 
teritis,  by  diminishing  the  lumen,  and  hence  the  b]ood-su|i|ily.  it 
jiossibly  res[)onsible  for  tlic  production  of  the  atrophy. 

(.'liuically,  i/rdiiuliir  kliliivif  is  a  disea.se  generally  but  nnl 
exclusively  Jiiuited  to  tlie  declining  period  of  life.  It  is  oM 
as.soeiate*!  with  gout,  ehrouio  lead-piiisuning.  anil  over-iiidiilj.'''"''' 
in  alcohol,  and,  perhaps  niore  (jften  than  is  generally  bclit'H'l. 
with  syjihilis.  In  :ill  the  uuirked  cases  it  is  acconipiinie<i  hj 
liy|iertropliy  tif  the  left  ventricle  of  the  heart,  inereasetl  ai^riu 
tension,  and  degenerative  changes  in  other  tissues.  Cohnlii'im  boM 
tliat  the  supply  of  blooil  to  the  kidneys  varied  with  the  nriinuiit '» 
the  blood  of  those  substances  which  the  kidneys  are  noruially  '" 
the  haliit  of  eliminating.  Atrophy  of  j)art  of  the  exfrrl^f? 
ap)mratiis,  by  tlii'owing  more  work  on  the  remainder.  mi);hi  not 
im[irobably  lead  to  an  increase  iu  the  percentage  of  tbiije  *^"' 
stances  in  the  blootl.  Now.  the  only  way  in  which  the  elimin*'"'"' 
of  these  by  the  kidneys  can  be  proportinnately  increased  is  by  "■" 
increased  action  of  the  left  ventricle,  an<l  a  simultaneous  inCTf** 
in  the  resistance  in  the  arterinlcs  of  other  parts.  By  this  mean'' 
larger  amount  of  bluod  might  be  supplied  to  the  kidneys,  ami  il"'" 
excretory  functions  thereby  assisted.  This  might  renult  from  jo"' 
reflex  mechanism. 

The  enlargement  of  the  left  ventricle  is  a  true  hypertroph.^' 
though  it  is  often  combined  with  a  small  amount  of  chronic  my*' 
carditis. 


ACUTE,  CROUPOUS,  OR  LOBAR  PNEUMONIA.  529 

CHAPTER  XXXI. 

INFLAMMATION  OP  THE  LUNGS. 

In  the  lungs  inflammatory  processes  comprise  the  three  following 
principal  varieties:  (1)  Croupous,  lobar  or  acute  pneumonia;  (2) 
catarrhal,  lobular  or  broncho-pneumonia;  and  (3)  interstitial,  ur 
chronic  pneumonia.  Of  these,  the  first  occurs  as  an  independent 
sffection,  whereas  the  last  two  are  usually  the  result  of  some  ante- 
•Wdent  bronchial  or  pulmonary  inflammation. 

ACDTB,   ObOUPOUS,    OR   LOBAB  PNEUMONIA. 

Acute  Pneumonia  is  an  infective  disease  characterized  by  inflam- 
JDation  of  the  parenchyma  of  the  lung,  leading  to  the  solidification 
of  a  considerable  area  of  that  organ.  It  is  usually  limited  to  one 
lung,  and  the  right  is  most  frecjuently  aflfected.  The  inflammation 
starts  in  the  substance  of  the  lung  from  a  focus  which,  in  the 
majority  of  cases,  is  in  the  lower  part  of  the  lower  lobe.  The 
•iisease  extends  by  continuity  of  tissue  from  this  primary  focus,  and 
necessarily,  in  most  cases,  in  an  upward  direction,  although  it  may 
begin  at  any  point  and  extend  in  any  direction.  There  is  no  reason 
to  suppose  that  the  disease  spreads  by  the  bronchial  tubes.  The 
consolidated  area  may  exactly  correspond  to  the  boundaries  of  a 
*>ngle  lobe,  though  quite  as  often  it  fails  to  reach  them  or  oversteps 
them. 

The  inflammation  of  the  lung  is  always  accompanied  by  inflam- 
•"lation  of  the  pleura  over  the  inflamed  area,  and  sometimes,  owing 
to  the  spread  of  the  infection,  by  that  of  the  peritoneum  and  peri- 
cardium. The  bronchial  glands  are  inflamed  and  swollen,  the 
"Mediastinal  connective  tissue  is  frequently  oedematous,  and  acute 
*©condary  meningitis  occasionally  supervenes.  The  disease  is  ac- 
companied by  high  fever,  beginning  usually  with  a  sudden  rise  and 
**»arked  symptoms  (p.  272),  and  ending  by  crisis :  cloudy  swelling 
^f  organs  results.  Death,  when  it  occurs,  seems  to  be  due  to 
Cardiac  failure  induced  by  general  poi.soning. 

ETIOLOGY. — This  disease  was  formerly  attributed  to  a  chill, 
*ttd  in  certain  cases  the  origin  of  the  disease  in  connection  with 
exposure  to  cold  and  damp  is  very  striking.     It  is,  however,  impos- 
sible to  regard  cold  as  more  than  a  predisjtosing  cause,  for  exposure 

34 


530 


INFLAMMATION  OF  THE  LVNOS. 


to  col<l  i»  alleged  as  a  cause  in  only  a  small  minority  of  tbv  csut. 
Moreover,  tbe  disease  does  not  especially  affect  those  wLo  an-  mwt 
exposed  to  vicissitudes  of  weatlier.  nor  iloes  its  prevalence  Hsm;  wiJ 
fall  with  that  of  bronchitis  Finally,  pneumonia  cannot  b«  pro- 
duced bv  ex|)osiire  to  cohl  or  by  the  infliction  uj)ou  the  lung  of 
any  mechaiiicid  or  cheiuical  injury.  Similarly,  depressed  licultli 
is  only  a  predisposing  cause.  Typically  healthy  people  are  ufun 
affected. 

In  the  present  state  of  our  knowledge  we  should  naturally  expert 
to  find  that  some  organism  is  the  cause  of  such  a  disease  iu>  pueu- 
moiiia,  ciiiecially  when  we  know  that,  though  there  is  not  tbe  Iciut 
evidence  of  coiitagiou.sne.ss.  yet  in  some  years  it  i»  so  prevulent « 
to  be  practically  epidemic.  Again,  small  outbreaks  occa.si'iii»ll» 
occur  in  wards,  prisons,  and  similar  places,  and  the  disease  \>*  »»w(- 
times  endemic  in  a  hou.se.  from  time  to  time  attacking  difTennt 
people  in  it.  In  the  large  majority  of  cases  the  disease  is  prMI) 
due  to  tbe  growth  of  the  diplococcus  pncumoniie  (p.  374).  It  il 
not  certain  that  all  cases  of  primary  acute  pneumonia  arc  due  to 
one  and  the  same  jiarasite,  and  it  is  still  more  doubtful  whetlit'f 
secondary  acute  pneumonia,  arising  in  the  course  of  such  di8M«* 
as  typhoid  or  erj-sipelas,  always  owes  its  origin  to  tbe  .'«»nif 
organism. 

By  most  pathologists  the  disease  is  regarded  as  an  infcctivr 
inflammation  of  the  lung,  just  as  erysipelas  is  of  the  .skin,  tbe 
fev'jr  being  secondary  to  tbe  inflammation  and  due  to  the  pasatg" 
into  tbe  Idood  of  pyrogenic  ferments.  Others  believe  it  to  b«  • 
general  infective  disease,  like  scarlatina,  the  lung-infiatumatini) 
being  the  characteristic  local  le.sion.  corresponding  to  tbe  rasli  '•n'' 
throat  of  scarlatina.  The  "typical"  course  of  the  fever.  euJiig 
usually  iu  a  crisis  between  the  fifth  and  eighth  days,  and  'I"" 
absence  td"  any  coiL'^tant  relationship  between  the  extent  nf  ''"' 
local  infliuiiuiatiim  and  the  intensity  of  the  fever,  are  gi'DcrsHv 
regarded  as  being  in  favor  of  the  latter  view.  The  results  of  inoc»- 
lation-cxperinients  sufipurt  the  former.  The  essential  difTcreiiOP 
lietwecn  the  two  views  vsould  seem  to  be  that  the  blood  is  inlVctw 
frmn  titc  Iniig  according  to  the  first,  whilst  in  the  second  the  if' 
tant  reaches  the  lung  from  the  blood,  having  entered  perb«p* 
through  the  alimentary  mucosa. 

Pneumonia  is  prone  to  recur  in  a  person  who  has  once  suffertHl 
from  it. 


i 

f 


ACUTE,  CROUPOUS,  OR  LOBAR  PNEUMONIA.  531 

MORBID  ANATOMY. — The  local  process  is  characterized  by 
intense  inflammatory  hyperasmia  of  the  lung  and  by  the  exudation 
*f  a  large  amount  of  coagulable  material  into  the  pulmonary  tis- 
sue. It  is  termed  "  croupous "  from  the  fibrinous  character  of 
'he  exudation.  The  term  "lobar"  is  applied  to  it  because  it 
iloiogt  invariably  aflfects  an  extensive  portion  of  the  lung.  The 
process  is  commonly  described  as  consisting  of  three  stages:  (1) 
that  of  engorgement ;  (2)  that  of  red  hepatization ;  and  (3)  that  of 
gray  hepatization. 

In  the  first  stage,  that  of  engrorerement,  the  lung  becomes 
•exceedingly  vascular,  the  changes  in  the  blood-vessels  and  circula- 
tion being  those  already  described  as  characteristic  of  inflammation 
(p.  279).  The  organ  is  of  a  dark-red  color,  its  specific  gravity  and 
absolute  weight  are  increased,  its  elasticity  is  diminished,  its  sub- 
stance is  less  crepitant  and  more  friable  than  natural,  and  its 
surface  pits  upon  pressure.  On  section  it  yields  a  reddish,  frothy, 
tenacious  liquid. 

In  the  second  stage,  that  of  red  hepatization,  there  is  an  exuda- 
tion of  liquor  sanguinis  and  migration  of  blood-corpuscles  into  the 
Pnlmonary  tissue.     Some  of  the  vessels  may  also  rupture,  and  thus 
"mall  extravasations  occur.     The  exuded  liquids  coagulate  within 
the  air-vesicles  and  terminal  bronchioles  to  form  a  semi-transparent 
coagulum  enclosing  red  corpuscles   and  leucocytes  in  its  meshes 
"(**jg.  190).     The  fibrin-filaments,  according  to  Weichselbaum,  are 
''•Uch  thicker  and  more  numerous  in  cases  due  to  the  diplococcus 
Pneumoniae.     Contrary  to  the  usual  rule  in  acute  inflammations, 
~toe  mononucleated  leucocytes  are  as  plentiful  as  the  multinucleated. 
^He  pneumococci  may  be  found  in  both.     The  lung  is  now  much 
heavier  than  in  the  preceding  stage,  and  is  increased  in  size,  so  as 
**>  be  often   marked   by  the  ribs.     The   aff"ected    portion    can  be 
Recognized    before  a   section   is    made,   for   the   pleura    over  it  is 
"yperaemic,  opaque,  and  covered  with  lymph,  while  the  di.stcntion, 
oriimess,  and  dark  purple  color  of  the  lung  beneath  cannot  escape 
T>otice.     It  is  quite  solid,  sinks  in  water,  and  cannot  be  artificially 
inflated.     It  does  not  crepitate  under  the  fingers,  and  is  rcmark- 
*My  friable,  breaking  down  readily  with  a  soft  granular  fracture. 
The    cut    surface    has    a    markedly    granular    appearance,    seen 
especially  when    the  tissue  is  torn.     This  is  owing   to  the   plugs 
of  coagulated  exudation  which  project  from   the   alveoli  they  fill. 
Tbere  is  no  lobulation  of  the   margin   of  the   inflamed   area,  no 


IKFLAMMArrON  OF  THE  LVSaS. 

outlying  racemose  oodules  or  other  indication  of  infection  spread- 
ing by  the  broiiubi.     The  color  is  of  a  dark   rcddisb-browu,  uftcn 
here    and    there    passing    into  gray.     This  adi(ii.\iiire    «ith  gtajf 
sometimes    gives  a   iimibU'il    ajjpearance.     The    red    color  is  dac 
chiefly  to   vascular  eii;;()rgetiu'nt,    but    partly    to   exiraviisati'd  rf<I 
corpuscles.     Tbroughuui  this  stage  there  up|iears   In  be  but  little 
altenttiou  either  in  the  alveolar  walla  or  in  the   alveolar  epitlie- 
liuui.      In   the  former  are  often  seen   a   few  leucocytes,  while  tl»* 
latter  is  usually  swollen  and  granular  (,Fig.  190).      If  a  scctiutt  ot 

Kio.  1!)0. 


■A  :j 


rroniimis  imi-umoiiiii— red  bf|>atlnition-ehowlng  the  fltirlnou*  cnnuutoiri  l»  ««i»  <if 
puliiioimr}-  alvri>H  eiiulimliic  within  lu  iiirnhi-s  niimcroiu  Icucorytot,  uh    > 
L'4iiniiu'iu*in)f  l(»  underKO  fnlty  DielniiiorphitfU.    A  fi'W  IciiciM-ytos  an'  sot^ii 
wiinn.Hnd  IIk'  alvcolitr  rpilholhiin  IbawmUimi  niiM  iTTnnular.    Tht»  noparntlon  >»i  tn.  .■  -*  — 
ftDin  the  nlveulnr  wall  la  due  to  the  mcthud  of  iirriuirnllon.    y  200. 


the  spreading  edge  be  examined  at  this  stage,  it  will  be  fnnf' 
intensely  hyperiemie.  The  hypenemia  e-xtends  somewhat  irreiH 
larly  into  the  adjacent  ti.ssuo,  which  is  otherwise  of  noriuul  ii(>pwf- 
ance. 

The  third  stage,  tliat  of  gray  hepatization,  is  chnracterixrJ  by  • 
continunnce  in  the  eiuigration  of  leucocytes  and  by  more  ni»rli« 
changes  in  the  epithelium.  The  white  blood-corpuscles  conf iiW'' •" 
escape  from  the  vessels  until  they  seem  to  fill  the  alveoli.    Tb» 


ACUTE,  CROUPOUS,  OR  LOBAR  PNEUMONIA. 


533 


epithelial  cells  lining  the  alveolar  walls  become  more  swollen  and 
granular,  and  the  walls  themselves  become  more  or  less  infiltrated 
with  leucocytes.  The  walls  and  the  contents  of  the  alveoli  now 
assume  a  uniform  appearance,  and  the  granular  appearance  of  the 
red  stage  is  lost  (Fig.  VM)).  The  fibrinou;*  niaterial  next  disinte- 
gratcB.  and  the  white  cells  rapidly  undergo  fatty  changes,  whilst 
the  red  are  decolorized ;  so  that  the  alveoli  are  seen  to  be  full  of 
granular  eleTiient.><,  which  in  many  parts  have  lost  their  distinctive 
outlines  (Fig.   191).     Uccaeiouully,   when    this  stage  is   unusually 

Fig.  191. 


_JfjlH|Wiii  '  :i>i— imT  hppalU>tion-*ho«rin^the  UtgeMcnmnUtion  of  cellulaxcle- 

"'"  ■■  ptilmoniir;  alreuU,  wbirh  In  Mime  puta  bATe  underRone  aueh  ext«a- 

.' ^1   1.1  .    i.  Ihat  tlu-ir  ilistlnrtive  uutline*  arean  loni^r  rixUilv.    X  3*. 

*uvaiiced,  the  alveolar  walls  may  be  found  here  and  there  partially 
•iMtroyed.  The  weight,  density,  and  friability  of  the  lung  now 
ticcome  even  greater  than  in  the  stage  of  red  hepatization,  although 
the  granular  aspect  of  the  cut  surface  is  much  less  marked.  The 
t««ue  is  soft  and  pulpy,  and  a  pnriform  liquid  exudes  from  its  cat 
surface.  The  most  prominent  feature,  however,  is  the  alteration 
which  takes  place  in  the  color  of  the  organ.  This  gradually  changes 
from  a  dark  reddish-brown  to  a  gray  or  yellowish-white,  marble<I 
by  the  tracts  of  pigment-bejiring  connective  tissue.  The  pallor  is 
Effing  partly  to  tiie  fatty  degeneration  which  the  celU  have  nnder- 


634 


lyFLAMMATION  OF  THE  LUHQS. 


gone,  and  partly  to  the  pressure  exercised  upon  the  blood- 
by  the  exu<led  Huhstances  and  newly-formed  celld ;  but  since 
iioiseh   has  shown   that   it   is  always  easy  to  inject   thv  vctbcU.  i| 
would  9eeni   likely  that   a  good  deal  of  the  pallor  \*  dur  to 
mortem  expression  of  blood.      The  stage  of  ^^ray  h('{)atixntion. 
far  advanced,  has  bei-n  termed  "suppuration,  or  purulent   in( 
tioa,  of  the  lung."     This  stage,  in  all  probability,  only  occaf 
fatal   cases. 

Althougli  these  three  stages  of  the  pneumonic  procew  haw 
describe*!  as  succeeding  one  another  in  orderly  succession*  it 
be    remembered    that    each    stage    does    nut    occur   simultRnt 
throughout  the  whole  of  the  affected  area  of  the  lung.     The  cha 
advance  irregularly,  so  that  whilst  one  portion  of  the  lung  is  it 
stage  i)f  red  hepatization,  another  may  be  in  the  gray  stage; 
the  mottlc<l.  marbleil  a|i|)earancc  of  the  cunsoliilution.     The  rap! 
also  with  which  the  several  stages  succeed  one  another  is  snHjt 
marked   variations.     In  some   cases  the    pneumonic    eoRMtliil 
very  rajiiilly  becomes  gray,  whilst   in  others  the  time  ocrnpif 
the  transition    is  several  days  longer. 

The  bronchi  of  the  affected  area  are  always  inflamed,  and  asnallt 
contain  a  viscid,  blood-stained,  rust-crdored  mucus,  which  forms  tha 
characteristic  expectoration.  Sometimes  the  sputum  is  dark 
watery,  like  pnine-juicc.  This  is  probably  owing  to  the  adtt 
of  (vdema-fluid  from  neighboring  parts  of  the  lung. 


TERMINATIONS. — The  pneumonic  process  may  end  in  og 
four  ways: 

1.  In  Resolution. — The  gradual  return  of  the  lung  to  it»  n<D 
condition  is  ilit-  mitural  and  much  the  most  frei|uent  tcmiina 
of  crou{M)us  pneumonia.  This  is  effected  by  the  fatty  and  macoiti' 
degeneration  of  the  inflammittory  products  which  have  ttci'uniiilalF«l | 
within  the  alveoli.  Thus  altered,  they  can  be  removtMl  by  absorj'-t 
tion.  This  process  is  assisted  by  the  return  of  the  blood-reMcb  t»  ■< 
normal  eomlition  and  the  re-cstablisliment  of  the  circulation.  Granm 
ulnr  pigment,  deriveil  from  the  escaped  red  corpusclw.  ia 
mixed  with  the  softeneil  nuitters  and  appears  in  the  ezpcctor 
It  is  usually  taught  thot.  where  this  process  of  resolution  w  ta 
place  in  the  lung,  the  granular  appearance  of  its  cut  sat 
completely  lost:  that  if  is  of  a  ycllnwi>h-gray  color:  and  l\ 
tenacious    puriform    li(|uid   can    be  expressed  from   its  >ab«t 


LOBULAR,  CATARRHAL,  OR  BRONCHO-PNEUMONIA.      535 

But,  obviously,  we  do  not  know  the  appearances  of  cases  which 
recover.  The  sputum  gives  no  support  to  the  view  that  resolution 
takes  place  by  the  cell-intiltration  and  general  softening  of  gray 
hepatization,  and  it  seems  probable  that  those  pathologists  are  right 
who  hold  that  from  the  stage  of  advanced  gray  hepatization  no  lung 
ever  recovers. 

2.  In  Abscess. — The  formation  of  abscess  is  a  rare  result  of 
pneumonia.  Such  a  result  appears  to  be  favored  by  a  bad  constitu- 
tion and  by  any  circumstances  which  tend  to  impair  the  general 
health,  especially  the  abuse  of  alcohol.  The  abscess  is  more  com- 
mon in  the  upper  than  in  the  lower  lobes.  Circumscribed  gangrene 
of  the  lung  also  may  occasionally  terminate  in  abscess.  This  takes 
place  by  the  expulsion  of  the  necrosed  tissue  through  the  bronchi, 
and  the  formation  of  a  layer  of  granulation  tissue  upon  the  walls  of 
the  cavity,  which  generates  pus.  The  cavity  may  ultimately  close 
^y  granulation  and  cicatrization.  These  abscesses  of  primary 
Tigin  are  usually  single,  and  thus  differ  from  those  due  to  pyaemia. 

3.  In  Oangrrene. — This  result  is  also  rare,  and  is  also  chiefly 
"*ond  in  drunkards  and  in  persons  of  debilitated  constitution.  Two 
conditions  appear  to  be  principally  concerned  in  bringing  about  this 
result :  (1)  the  interference  with  the  supply  of  blood  by  extensive 
'Ornjation  of  coagula  in  the  pulmonary  and  bronchial  vessels, 
**>getljer  yi\i\x  considerable  hemorrhage  into  the  pulmonary  tissue; 
***<i  (2)  the  injurious  influence  of  septic  inflammatory  products. 
^  «e  gangrene  is  usually  limited  to  a  small  area  of  the  pneumonic 

'^Ig,  and  is  either  diffuse  or  circumscribed. 

4.  In  Chronic  Pneumonia. — If  the  inflammatory  process  does 
***^t  subside  and  the  exuded  substances  are  not  absorbed,  the  alveo- 

**■  walls  gradually  become  involved.  These  become  thickened  by 
*•  *lew  growth  of  fibro-nucleated  tissue,  and  thus  is  produced  more 
***■  less  fibroid  induration  or  cirrhosis  of  the  organ.  This  termina- 
tion of  croupous  pneumonia  is  comparatively  rare  (p.  540). 

LoBuiiAB,  Catarrhal,  or  Broncho-pnbttmonia. 

Broncho-pneumonia  is  an  inflammation  of  the  parenchyma  of  the 
**g>   due  to  an  irritant  entering  and  spreading  by  the  bronchi. 
^bis  irritant  generally  gives  rise  to  a  catarrh  of  the  smaller  bron- 
chi, to  which  the  pneumonia  is  secondary. 

ETIOLOGY. — Simple  or  non-specific  broncho-pneumonia  signifies 


536 


TSFLAMMATION  OF  THE  LtTJfOS. 


the  extension  of  aimple  bronchitis  to  the  alveoli.  It  is  verr  »pt  to  | 
occur  in  young  cliildren  nnd  in  afroil  persons,  and  often,  in  siieh  I 
cases,  ends  fatally.  Tliis  result,  imwevcr,  must  not  be  sittribnt*.-"!  to  I 
the  mere  supervention  of  ii  few  siuiill  patches  of  inHainmatory  eon-  I 
Milidiitiou  in  the  luni;s,  though  t)iis»  doubtles!*  raises  the  teinpcrntiirr  I 
and  int-rcases  the  dyspna-ii.  It  is  due  rather  to  the  prccoiling  I 
extension  of  the  brotichitis  to  the  finer  tubes,  for  death  i»  due  I 
to  exhaustion  and  jiJiphyxia.  I 

The  exciting  cause  of  simp/r  limnchitis  is  unknown,  althrnifrh  I 
cold  is  such  a  strong  predisponent  that  it  often  gfeinn  an  excitant-  I 
There  are  many  irritants  which,  gaining  access  to  the  air-pa«n^;ee«  I 
can  excite  bronchitis  and,  less  fref|uc-ntly,  broncho-pneumonia  «*  I 
well.  Among  them  may  be  mentioned — irritant  gasen :  >{uiit  of  I 
various  kinds,  such  as  particles  of  carbon  (p.  109).  steel,  iron,  OT  I 
stone,  all  of  which  differ  much  in  their  irritant  power;  and  nri/*i'*'  I 
isrna.  of  which  by  fur  the  most  im(M>rtant  is  the  bacillus  of  tuberol*  I 
— for  tubercular  broucho-pneumonia  is  the  lesion  of  phthi***  I 
Among  other  organisms  which  may  enter  the  lungs  by  aspimt  i*"*"  I 
are  the  actinomyces  and  the  bacillus  of  glanders,  and  apparent*  J  J 
also  the  specific  causes  of  the  bronchitis  of  measles  ami  jtertusi^**l 

Lastly,  [lortions  of  food  or  saliva,  carrt/inij  septic  germ*,  ixi  **n 
enter  the  air-passages,  especially  when  the  glottis  is  insensit !"*'"«•  I 
During  operations  on  the  mouth  or  nose,  or  as  a  conseinience  *^M 
wounds  or  diseases  of  these  parts,  blood  and  putrid  discharges  a^^n 
also  be  sucked  into  the  bronchi.  Any  of  these  may  give  rise  '^ 
suppurative  or  gangrenous  broncho-jmeumonia.  Simple  bnuicl**"*^ 
and  those  specific  forms  due  to  measles,  whooping  cough,  vario**! 
diphtheria,  and  tubercle  are  by  far  the  commonest  varieties  *^  1 
lirnin-ho-jtneumonia.  Tubercular  broncho-pneumonia  frequen*'.'! 
affords  an  instance  of  the  occurrence  of  this  form  of  pneiimot*  *•  I 
witliout  any  ajijireciable  bronchitis,  though  signs  of  bronchitis  *'  J 
the  apices  are  often  some  of  tiie  earliest  indications  of  tubcrc*!*-  I 
Tubercular  broncho-pneumonia  also  affords  frequent  exceptions  *"  I 
the  rule  that,  being  consecutive  to  bronchitis,  both  lungs  will  ^  I 
affected.  I 

All  conditions  depressing  the  general  health  and  strength  pre-  ■ 
dispose  to  broncho-pneumonia.  They  do  this  by  weakening  'b*"  I 
resistance  of  the  (i.-isues.  ami  ihiis  permitting  the  primary  infection  I 
as  well  as  the  subsecpietit  -plead  of  the  inflammatinn.  Pos-Hib/y.  I 
they  may  also  act  by  diminishing  the  power  of  the  respiraton'  mitf-       M 


LOBULAR,  CATARRHAL,  OR  BRONCHO-PNEUMONIA.      537 

cles,  and  thus  favoring  the  occurrence  of  pulmonary  collapse,  as  the 

finer  tubes  become  blocked  by  the  swelling  of  the  mucous  membrane 

*n<l  the  presence  of  the  catarrhal  secretion.     Collapse  often  seems 

to  precede  the  inflammation,  but  evidence  of  its  importance  as  a 

predisponent  to  broncho-pneumonia  is  unsatisfactory  :  it  may,  by 

interfering  with  the  circulation  in  the  collapsed  alveoli,  still  further 

Weaken   the  resistance   of  the  tissues   and   thus   render  infection 

easier.     But   whenever  bronchitis   has    reached   the  finest   tubes, 

extension  of  the  inflammation  to  the  alveoli  seems  natural  without 

assistance  from  collapse,  such  extension  being  probably  assisted  by 

the  act  of  inspiration,  which  would  tend  to  draw  the  contents  of  the 

bronchioles  into  the  alveoli. 

PATHOLOGY. — Broncho-pneumonia  has  been  studied  experi- 
zn«ntal]y.  Animals  have  been  made  to  inhale  irritant  gases  or 
suspended  particles  of  various  kinds.  Further,  by  division  of  the 
"v-agus,  saliva  and  food  have  been  permitted  to  enter  the  air-passages. 
Tie  resulting  changes  vary  (1)  with  the  size  of  the  inhaled  parti- 
<5les,  and  (2)  with  the  intensity  of  the  irritation  they  are  capable  of 
•«acciting.  Thus,  very  fine  particles  cause  widely-scattered  miliary 
foci  of  inflammation;  larger  ones  block  the  smaller  bronchi  and 
"<2^uge  collapse  and  secondary  inflammation  of  lobules — a  result 
"'^■lilch  has  led  to  the  name  of  "lobular  pneumonia."  The  aspira- 
"ticn  of  a  quantity  of  septic  discharge  or  other  fluid  into  a  bronchus 
*iaay  aflfect  many  lobules  or  even  a  whole  lobe.  According  to  the 
^  Intensity  of  the  inhaled  irritant  the  result  may  vary  from  mere  col- 
l«.p8e,  accompanied  by  slight  inflammatory  oedema,  through  all 
^♦ages  of  inflammation  up  to  gangrene.  In  the  tubercular  form 
^"p.  547)  the  inflammatory  products  caseate. 

MORBID  ANATOMY. — From  the  above  considerations  it  will 
l>«  readily  understood  that  the  post-mortem  appearances  of  the 
"Ungs  present  many  variations.  The  hrom-hi  are  always  more  or 
less  inflamed  and  contain  thick  mucus.  Ordinarily,  the  lung- 
tissue  contains  a  varying  number  of  .solid  patches.  These  are  due 
either  to  collapse  or  to  inflammatory  consolidation.  Emphysema, 
^*ith  more  or  less  congestion  and  oedema,  is  commonly  found  in 
tlieir  neighborhood.  Patches  of  coUapsf  are  particularly  common 
"1  the  lower  lobe,  especially  along  its  thin  border.  Sometimes  a 
'arge  portion  of  a  lobe  is  thus  involved ;  at  other  times  only  a  few 


538 


ISFLAMMATION  OF  THE  LUNOS. 


small,    isolated    patches.     The   surface   of  the    collapsed  part  i? 
depressed  below  the  general  surface  of  the    lung.     It  has » lUrk 
bluish  color,  and  is  easily   inflated  from  the   bronchi.     Un  wUion 
it  is  dark-retl,  smooth,  and  shiny.     It  is  tough  and  non-ercpitsut- 
Portions  of  it  sink  in  water.     On  closer  inspection  the  patcbwir* 
seen  to  bo  more  or  less  conical,  witli  their  bases  toward  the  mirfic* 
of  the  Iiiug  jMiil  tlieir  apices  toward  the  bronchi  with  which  they  ^r* 
in  connection.     The  pleura  over  a  patch  of  collapsed  lung  is  Donii»l- 
A  pneumonic  patch  is  of  conical  form,  and  is  airletis  like  the  ci*!- 
lajised  jmrt;  moreover,  it  is  similarly  distributed.      Uut  its  ban-  »* 
raised  above,  never  depresscil  below,  the  surface,  while  it  fonw  * 
less  pliable  and  more  nodular  mass.     Occasionally,  when  it  i?  f»^ 
considerable  size,  its  pleural   covering  may  be  opaque  with  inllow- 
matory  exudation.     On  section  the  pneumonic  patches  may  bt-  ili*- 
tinct  or  ill-defined ;  they  usually  range  in  size  from  a  small  pw  to 
a  hazelnut.     The  surface  of  the  section  tends  to  rise  slightly  »1ki»-c 
the   surrounding  tissue:   its  substance  is  soft,  friable,  opaquc-U'k- 
ing,  smooth  or  faintly  granular,  at  first  dark-red  in  color,  then  [iw.*- 
iug  through  grayish-red  to  grayish-yellow,  the  lighter  color  l*iiig 
central.     A  turbid   red  or  grayish  juice  can   be  prested  from  it- 
Neighboring  lobiibir    patches  often  blend,  and  as  the  diffuse  wo- 
solidation    thus  formed    becomes    paler,    firmer,    and    drier,  it  not 
infreiiuently  resembles   in  appearance  ordinary  gray   hepatizJlion- 
Sometimes  the  pneumonic    process  is  found  involving  patchcn  <•• 
collapse.  These  consequently  become  swollen,  opaque,  and  ledemitou*- 

When  broncho-pneumonia  is  so  extensive  that  the  consolidatioti  •* 
practically  "lobar,"  it  is  difficult  to  distinguish  it  from  acute  pnei«* 
monia.  Evidence  of  the  blending  of  lobular  masses,  and  especial'^ 
the  presence  of  outlying  nndules  in  the  neighborhood  of  them*!" 
mass,  arc  the  most  important  points  to  look  for.  Absence  of  iulln"** 
matory  lymph  from  tite  pleural  surface  is  evidence  against  scut' 
jmeumonia,  but  it  must  be  remembered  that  such  lymph  wiflV  f"!""*" 
over  a  bronclio-iinetiniunie  ar-ea. 

In  cases  of  Hiptii-  broiuho-pneumonia — the  commonest  canK*" 
death  after  operations  <in  the  jaws,  mouth,  and  pharynx — inst«'»*' 
of  the  ab()ve  solid  patches  abscesses  occur.  These  often  eoni*'" 
sloughs  of  lung-tissue  and  are  sometimes  foetid :  such  sloughs  •'* 
surrounded  by  more  or  less  extensive  consolidation,  and  intlanmiiiloC^ 
hypersemia  and  redema  of  the  lung  are  marked. 

Microscopically,  in  the  early  red  stage  the  alveoli  contaiu  ""'"• 


LOBULAR,  CATARRHAL,  OR  BRONCHO-PyEmfONTA.      539 
T«d  corpuscles,  aurl  a  few  leucocytes,  while  the  alveolar  epithelium 


Fio.  192. 


'>^^;■.\;    %>yv 


"a  - 


"'"itlio-pncumonl*  (from  «  chIM  ORcrt  four,  with  capillary  hronchttti).  A  scctlou  ol  ono 
^bt  [Mtchvi  or  ct)i»(>tl>Utlnn,  HlmwinK  IhcatiinWiK  of  tlii'  itlviKilI  witli  what  apiivam  to  the 
tn  to  \ni  tnliiiliKl  tironrhful  rtocn.'liori.    X  '^n*. 


Fio.  193. 


it' 


**    swollen  and  griinuliir:   this  latter  change,  according 

'•tiilfr,  is  due  merely  to  imbibi- 
*'On.  anil  does  not  indif^ate  any 
^^^tivity  on  the  part  of  the  epi- 
^^»elial  cells.  Next,  tlic  alveoli 
■■*«>corae  filled  witii  a  eeil-inass 
insisting  of  leiicoo vtes  and  t-ast- 
**^  epithelium  in  varying  propor- 
**on.s — leucoi'vte.s  heinii;  in  excess 
*»*  the  more  acute  (Fig.  192),  and 

pithelial  cells  in  the  more  chronic 
*oruis(Fig.  inS).  In  theraost  acute 
•^^**8es  (septic  broneho-pneumoniu) 
*sither  suppuration  ami  sloughing 
r,  or  hemorrhagic  exudation 
ith  subsequent  gangrene. 


to  Fried- 


CKtBrrhnl  pnpiimnnl*  (from  a  rnsH-  of  anilo 
phthlnlHi.  khxwfiii;  the  htrge  I'pithullul  cells 
whith  HU  the  iilveuU.    X  200. 


TERMINATIONS. — Resolution  is  the  most  common  termina- 
*^»on.     The  contents  of   the   alveoli    undergo  fatty  metamorphosis, 
"Mid  are  removed  by  expc'ctnratioii  and  alisiirptiou,  ttjc  lung  grad- 
ually regaining  its  nciriim!  ciiaraeter.     This    process,   however,   is 
less  readily   eftected   tiian    in    (•ri>iip<Mis    pnoumonin.   and    it    often 
"wupies  such   a  lengthened    period    tlial   .<onie    tliiekeiiing   of  the 
'"■onehial  and  alveolar  walls,  with  dilatation  of  the  smaller  bronchi. 


HiFLAMMATIOlf  OF  THE  LVKOS. 

remains.  In  chronic  cases  this  fibroid  thickening  is  much  more 
nitirktMl ;  nriil  coiisidfraMe,  irregularly  distributed,  }iij;nieiitcilinilii- 
riition  mid  bronchial  dilatation  may  be  j)roduoed  (p.  542).  in  thi-w 
chronic  forms  cfiseation  sometimes  affects  the  contents  of  the  nhwli, 
which  then  heronie  encnpsulod,  or,  in  <|uitc  exceptional  ciw"?,  lii.*- 
integrated  :  but.  unless  tiie  coutriirv  is  demoustrated,  all  sudi  iu^m 
may  reasonably  be  regarded  as  tubercular. 


Hypoetatic  Pneumonia. — Alttisidii  must  be  made  toafonuof 
lonji-i'onsiilidatioii  which  is  often  described  as  pneumonic,  but  nliich. 
in  rcalily,  is  for  the  most  part  not  inflammatory  in  its  nature.  This 
is  the  so-called  hypostatic  pneumonia.  This  condition  i.''  met  with 
at  the  ba.scH  and  imtsf  dcjiciidcnt  portions  of  the  lungs  in  tin-  cnurH' 
of  both  chronic  and  acute  diseases,  and  also  ia  the  aged  and  debili- 
tated. It  consists  in  the  msiin  of  colia])sp.  mechanical  hypcneniia. 
jind  ledcuia  of  the  lung-ti.ssue.  resulting  from  weak  inspiniinn 
])owcr,  feeble  circulation,  and  gravitation.  The  consolidation  tlm» 
mechanically  induced  is  increased  by  more  or  less  exudation  of 
liquor  sanguinis  and  blood-corpuscles  into  the  alveoli.  This  est 
tion  is  due  to  the  damage  of  the  walls  of  the  capillaries  cauHwl 
the  imperfect  circulation. 


Intebstitial  OB  Ohbonic  Pneumonia. 

Interstitial  or  chronic  pneumonia  is  characterized  by  a  gr»ilu»l 
increase  in  the  connective  tissue  of  the  lung,  which  lead*  I"  «" 
induration  of  the  pulmonary  texture  and  to  progressive  obliteretiiin 
of  the  alve<dar  cavities.  It  is  eomnionly  associated  with  catarrh  tt"! 
dilatation  of  the  bronchi,  and  often  with  ulceration  of  the  brond 
walls  and  excavation  of  the  indurated  lung. 


ETIOLOGY. — It  is  very  doubtful  if  interstitial  pneumniiu 
ever  a  primary  and  iudei)cndcnt  affection.  In  the  large  ninj'"'"}' 
of  cases  it  is  secondary  to  sonic  inllammation  of  bronchi.  aUfoli-  •" 
pleura:  it  resnlt.'s  also  from  persistent  atelectasis  or  collapse,  linny 
be  stated  generally  that  all  inflammatory  proce.<.se8  in  the  lung*,  »l"^ 
they  become  chronic,  lead  to  an  increase  of  the  connective  tn 
and,  cousei|Uently,  to  fibroid  induration  of  the  organs. 

Syphilis  certainly  gives  rise  to  a  gummatous  and  probaliW 
to  a  diffuse  interstitial  pneumonia  in  children  suffering  fn'm 
congenital  form  of  the  disease:  of  the  latter  variety  very  lit''"''' 


1 


INTERSTITIAL  OR  CIIROyiC  PyEUMONlA.  541 

Jfnown.  In  adults  syphilitic  changes  in  the  lung  are  rare:  it  is 
very  difficult  to  be  absolutely  certain  of  the  nature  of  some  localized 
fibroid  changes. 

"Brown  Induration"  (p.  235)  has  been  already  described,  and 
^"ill  not  be  further  discussed.  The  chief  causes  of  interstitial  pneu- 
monia are — 

1.  Croupous  Pneumonia. — The  consolidation  of  acute  croupous 
pneumonia  usually  undergoes  complete  and  rapid  resolution,  but 
occasionally  this  is  more  protracted.  Then  the  hcpatized  lung 
tends  to  become  slightly  indurated,  mainly  owing  to  thickening  of 
the  walls  of  the  alveoli.  This  indurated  hepatization  differs  but 
little  in  its  physical  characters  from  ordinary  red  and  gray  hepatiza- 
tion :  it  is  simply  somewhat  firmer,  more  resistant,  and  less  granu- 
lar. In  very  exceptional  cases  this  small  amount  of  induration, 
commencing  in  the  alveolar  walls,  may  gradually  increase,  so  as 
ultimately  to  give  rise  to  that  extensive  fibrosis  of  the  lung  which 
constitutes  what  is  usually  known  as  interstitial  pneumonia. 

2.  Broncho-pneumonia.  —  Broncho-pneumonia    is   a   somewhat 
more  frequent  cause  than  the  preceding.     The  greater  liability  of 
this  form  of  pneumonia  to  lead  to  pulmonary  induration  is  to  be 
accounted  for  partly  by  its  longer  duration  and  greater  tendency  to 
**ecome  chronic,  and  partly  by  the  existence  of  bronchial  dilatation 
^"■ith  which  it  is  so  frequently  associated.     The  existence  of  this 
**ilatation  favors  the  persistence  of  the  catarrhal  and  pneumonic 
P^'ocess.     The  removal  of  secretion   is  rendered  difficult,  and  the 
""stained  secretion  tends  to  keep  up  and  increase  the  irritative  pro- 
*^®8a  both  in  the  dilated  bronchi  and  the  pulmonary  alveoli ;  and 
'•ois  persistence  of  the  bronchial  and  pulmonary  inflammation  leads 
**^    fibroid  thickening  of  the  bronchial  and  alveolar  walls.     In  this 
^''*y  areas  of  fibroid  induration  are  produced,  which,  as  the  process 
®*tends,  may  ultimately  involve  large  portions  of  the  lung.     The 
P*"ogre88ive  tendency  of  the  process  is  probably  partly  to  be  ex- 
plained by  the  fact  that  pulmonary  fibrosis  is  itself  a  cause  of  bron- 
'^Qial  dilatation:  when,  therefore,  fibrosis  is  once  established  the 
"^^vr  tissue  in  contracting  induces  further  dilatation  of  the  bronchi, 
*•**<!  this  again,  as  before  explained,  favors  the  still  further  extension 
*^f  the  bronchial  and  pulmonary  induration. 

Under  this  head  may  also  be  included  those  cases  of  induration 
*1<1  ulceration  of  the  lung  which  result  from  obstruction  of  a  main 
*>i"onchus,  such  as  is  produced   by  the  pressure  of  an  aneurysm. 


542 


ISFLAMMATIOX  OF  THE  hVSOS. 


Ht're  the  rctiiineil  livi.iiiliisil  secrctifUi  si-ts  up  infljuumatnry  chnngM  I 
in  tbc  broiicliiiil  uiui  iilvvcilar  walls,  which  grailuiiliv  lead  tn  imlura-  I 
tion  and  ulceration  of  the  lung.  1 

3.  The  Inhalation  of  Solid  Irritatingr  Particles. — This  hourw  I 
of  irritation  is  the  cause  of  the  tibro.sia  of  the  lung  co  common  I 
amongst  miners,  potters,  stonemasons,  grinders,  and  others.  The  J 
continuous  irritation  of  the  inhaled  particles  induces  a  bronchiil  I 
and  alveolar  inlhinimation.  and  ultiniatelv  a  progre.osive  fibrwi*,  1 
with  ililatatiou  and  ulceration  of  the  bronchi.  iSuch  cases  uftcn  I 
become  tuberculous. 

4.  Pleurisy. — This,  in  exceptioiuil  cases,  leads  to  tiie  ilevi'l()|i- 
ment  of  an  interstitial  pncuniutiiii.     Such  a  result  is  most  likely  to       I 
occur  in  those  cases  of  pleurisy  which  are  more  or  less  chninic  «im1       | 
111  which   the   eflu.sion   reuinins   long   unabsorbed.     The  indiinitidU 
thus  induced   is  often   partial,  consisting  merely  in  an  increase  nf 
the  interlobular  connective  tissue,  originating  and  extending  inward 

as  dense  bauds  from  the  thickeneil  visceral   [dciira.      In  other  cww 
pleurisy  gives  rise  to  a  much  more  general  fibrosis.  ' 

5.  Atelectasis,  or   failure  of  part  of  the  lung  to   e.xpami  sfl*' 
birth,  and  persistent  collapse,  lead  to  marked  cirrhosis  of  the 
affected  area.     Later  on,  broncliiecta-sis  and  obliteration  of  uiost '" 
the   alveoli    occur.     'J'lie   original    positions  of   the   hitler  may  be 
merely  imlicateil  by  a  few  epithelial  cells. 

MORBID  ANATOMY. — Tbc  appearances  presented  by  ibe  lunH 

when  the  fibrosis  is  general  and  well  advanced  are  very  cUamct**" 

istie.     The    organ    is    diuiitiisheil    in    size;    the    tissue    is  smo<>*-** 

dense,  firm,  in  parts  almost  cartilaginous  in  consistence,  and  i*     ' 

irregularly  mottled  with  black  jiiginent.     The  alveolar  structure   ** 

the  lung  is  in  most   parts  comjiletely  destroyed,  anil  on  section    **^ 

<lilated  bronchi  are  .seen  as  numerous  large  openings  scattered  "^*"*. 

its  surface.      These  ililated  bronchi   freouentlv  become  the  scat*    ** 

secondary  inflammatory  processes,    which  may  lead  to  ulcerat**-* 

and  ultimately  to  e.vtensive  excavation  of  the  indurated  tissue;    t^" 

there  is  a  complete  absence  of  any  of  those  caseous  changes  wli**^ 

are  so    characteristic  of    phthisis.      This  secondary   inflammati**" 

..."  ■  / 

of  the  dilated  bnniciii  is  induced  by  the  irritating  and  often  piif/" 

secretion  which  they  contain,  and  which   is.  as  a  rule,  incomjilelt''.'' 

removed  by  expectoration.     The  pleura  is  considerably  thiclicli<« 

and  generally  adherent. 


INTERSTiriAL  OR  CHROSIC  PNEUMOSrA. 


043 


licroscopicallv,  a  distinct  fibro-niK'lcate<l  tissiio  is  fountl  iu  tlie 
interalvcolar,  j)cribroucbial.  and  interlobular  connective  tissue. 
This  Dew  growth,  as  it  increases  and  contracts,  gradually  replaces 
«nd  obliterates  the  alveolar  structure.  The  character  of  these 
changes,  however,  varies  somewhat  according  to  the  nature  of  the 

Fe<;     I'M. 


'"l^^- 


n. 


loteniilKl  i>iifuiiiuiiiri  (ft^iin  *  caiK'  nf  iiiii1ati<ral  "  clrrboHin  "  iif  ihi-  luug).    The  bronchi 

'TT  mijrh  (tiUliMl,  uiiil  thiTc  wiiK  a  roinpteto  ulN4«'nf'e  of  any  cufi04iu»  chiiniet'.    The  drawing 

_^'»»  the  new  tlbrn-nuili'iitcd  uniwth  Imth  in  the  ttlvciilnr  wails  and  in  Ihi-  inUTioliuinr 

"'•  •!»"  the  piinniMitallcin.     At  ii  n  divided  vi-ssol  In  neeii.     Willi  a  hlithiT  power  h  delii'Ute 

rminilura  1«  vlBllik-  l>etwet>n  Hi*  cvllvli'iDenhi.     -.  100. 

'"flaminatory  antecedents   in    which    they   originate.      When    the 
•■Mult  of   a  vroujxiHis   f>nvumoniii,   the    primary,   and   usually   the 

Pio.  195. 


H^^^'^nlc  (ineumonia.  Vancnlariutlinn  and  fllirold  dcvflopnicnt  of  inlra-nlveolar  cxuda- 
yg^'J**tt<liirt».  l^lcK«l-ve»«el^  art*  Keen  diHtriliuted  in  tlie  exu<lntiiin-priHlurL.i ;  tlieae  bliHkl- 
u,?*^'*  odmniunlcate  with  llii*e    in  thi<   alverdar  »all«.      The  ftlvcol«r  w»U«  mi  slio 


**nci!  by  a  ribro-nnrlealeil  growth. 


too,  and  rednred  {. 


*'"»cipn],  change  takes  pliiie  in  the  wi»ll.-<  of  the  alveoli  (Fig.  194), 
*«iOugh   ultimately   the    interlobular    tissue    is    involved.      The 


644 


jyFLAMMATIOy  OF  THE  LUXGS. 


alveolar  wiills  beconu'  thiekt'iie<l  by  the  growth  of  a  smoll-ct'llf<l 
tissue,  Mliieli  j»reM'nta  all  the  appearauces  fouuil  iu  euilirvimii' 
tissue  which  is  uudergoiug  fibroid  develojiineut.  The  new  pnmih 
iti  its  earlier  stages  contains  new  blood-vessels,  but  later  oii  iW 
tissue  eoutraets  and  many  of"  these  are  destroyed.  The  abfolar 
Fig.  lUti.  cavities    which    arc   not   oblitvntrii 

are  either  empty  or  contain  cxmla- 
tioii-|)roduet8    or    a    few    cpitliclisl 
cells.     Iu  addition  to  the  grovtii  in 
the   alveolar    walls   the   author  liu 
met  with  three  cases  in  which  min- 
ttlveolar      exudation-products     "eri' 
undergoing     fibroid      developnum' 
There  were  nothing  peculiar  in  tl"' 
macroscojiic  ciiaracters  of  the  liiiii:^ 
but  the  alveoli  were  found  filkil  »iili 
a  fibrinous  nieshwork  and  Icuciicvtw 
BOiiiewhat  similar  to  those  nift  »ill> 
in     red     hepatization     (Fig.    If-')- 
They     differed,    however,    in    this 
respect — that  many  of  the  cells  »••'* 
long  and  spindle-shaped,  and  blood-vessels  were  distributed  auioug^t 
them,  these  blood-vessels  communicating  with  those  in  the  bIv«>1»' 
walls  {Figs.  IJI.')  and  10(5).     The  :dveolnr  walls  also  were  lliickcneU 
by  a  fibro-hucK'iited  growth.     It  was  therefore  perfectly  obviuu^th** 
in  these  lungs  the  products  of  a  previous  acute  croupous  piiemiwnW 
were   becoming  vasenlari/ed    and    undergoing    development   into    • 
fibroid   structure,    and    that    this    intra-alveolar    change   was  tbc 
principal  cause  of  the  fibroid  induration  of  the  organs. 

When  the  fibrosis  is  secxvndary  to  an  ordinary  hroncho-pncuno****' 
or  to  that  induced  by  the  inhalntion  of  irritnfhu/  solitl  pnrtieltt.  th* 
new  growth  also  originates  principally  from  the  alveolar  i*!"*- 
Here,  however,  the  growth  in  the  earlier  stages  is  less  uniform. a"" 
the  jieribrnnchial  and  interlobular  connective  tissues  play  a  lu"^ 
prniniiictit   part   in  the  process  (Fig.  107). 

The  pleurogenic  form  results  chiefly  from  empyemata.  Hff<*  "" 
new  fibrous  tissue  exten<l8  inward  in  bands  along  the  inn'rlnwn'*'' 
lymphatic  vessels,  which  communicate  freely  with  those  (if  thi'tn)'*" 

•*  indelitol  tii  Dr.  0<i<)<lhart,  »h« 
r.  p.  33. 


(Thnmlr  pnciimniilii  A  lu'tton  of 
the  Intraulvmilnr  cxiiiliitlciiipriKliicls 
(Flu.  19.">)  mon>  hiKlily  niiiutilflol,  kIiiiw- 
Ing  thi>  elonenli'i).  spimiu-ci-ni'.  tlio 
(llirlllstion.  and  hIcMMl-vctaWs  ruiilalii- 
Itiff  lilnod-CMrpusolcJi.    X  200. 


'  For  one  of  tlie»e  bikw"- 
tile  ease  in  the  7Va 


PULMONARY  PHTHISIS. 


546 


entd  pleura ;  thence  it  8preads  to  the  peribronchial  tissue.     The 
lung  is  thus  surrouudeil  by  a  deuse  capsule,  aud  a  meshwork  of 

Fio.  197. 


I 
I 


dunnlc  hronrhltls.nhowlniitthe  ncwRTOwthof  fibm -narlcatcd  Umuc  aronnd  the  bronchus, 
ft.  and  the  wayiuwhirh  thiH  tixsue  i«  iuvBUhiglhu  whIU  uf  the  udjacent  alTCoU :  ti.s divided 
talood-Teucl.    X  100,  reduced  1. 

sMiaatomosing  fibrous  bands  permeates  its  substance,  compresses  the 
alveoli,  and  deforms  the  bronchi.  More  or  less  bronchitis  is  usually 
present. 

Atelectasis  and  collapse  are  said  to  lead  first  to  slight  hemorrhages. 
The  subse(|uent  changes  in  the  lucmoglobin  lead  to  tlie  formation 
(p.  104)  of  some  of  the  black  pigment  usually  found  in  fibroid  areas 
*>-wning  this  origin.  The  alveolar  walls  become  fibroid,  the  epithelium 
>8  more  or  less  shed,  and  the  surfaces  of  the  walls  ultimately  cohere. 

PULMONARY  PHTHISIS, 
By  Pulmonary  Phthisis  is  understood  a  disease  of  the  lungs 
Vfhich  is  characterized  by  progressive  consolidation  of  the  pul- 
*fconary  texture  and  by  subser|uont  softening  and  disintegration  of 
%liuch  of  the  consolidated  tissue.  The  upper  [lortions  of  the  oi'gans 
^re,  in  almost  all  cases,  the  first  to  become  involved. 

Respecting  the  nature  of  the  morbid  processes  which  lead  to  this 
■consolidation  and  clisintegration  various  opinions  have  from  time  to 
^me  been  held  by  pathologists.  According  to  the  older  views,  which 
"Vere  based  upon  the  teaching  of  Laennec,  phthisis  was  regarded  in 
<U1  cases  as  a  tuberculous  disease.  Tubercle  was  looked  upon  as 
«  non-inflammatory  growth  which  was  characterized  by  the  caseous 
<legeneration  which  it  invariably  underwent ;  and  this  caseous  meta- 
xnorphosis  was  held  to  be  such  a  distinguishing  peculiarity  of  the 

35 


646 


INFLAMMATIOy  OF  TEE  LVSOS. 


growtlj  tliat  all  caseous  masses  came  to  be  rcgiirded  us  tubiTculoiu, 
anil  jihiliLsis.  iu  which  cajseution  plays  such  a  promiueiU  jiArt,  km 
consequently  regarded  as  a  tuberculous  disease.     The  varioiu  con- 
solidations of  the   pulraonary  tissue   in   phthisis  were   describtii  u 
"infiltrated  tubercle,  '  and  tubercle  in  some  form  or  other  ww  r^ 
garded  as  so  essential  a  constituent  of  the  disease  that  "  pbtbisis" 
and    "  pulmonary    tuberculosis  "   came    to    be    synonymous  torni*. 
When  the  iifi|)lieation  of  the  term  tubercle  became  limited  hv  Vir- 
chow  and  his  followers  to  the  ynij/  granulation,  it  was  cvidcnl  iliii 
these  views  were  no  longer  tenable,  and  many,  in  accordance  »itb 
the  advocacy  of  Nicnieyer,  regarded  phthisis  as  a  form  of  projrrt'M- 
ive  caseous   pneumonia   whici)   was  quite  independent  of  tulicrile. 
although  tubercle  might  occur  as  a  secondary  and  accidenul  cmii- 
j)licutioii.     It  was  then  said  that  some  cases  of  phthisis  were  tiiU'r- 
culiir,  and  that  others  were   not.   uwl  attempts  were  made  to  .«iili- 
divide  the  disease  into  distinct  pathological  varieties  according  t>^> 
their  unatomiciil  ami   histological  characters.     In   this  way  tukrcu- 
lous,  jtiteii/iiiiiiif,  uud  filiroul  phthisis  were  distinguished  frooi  une 
another.     Our  present  knowledge  of  tuberculosis,  and  cspeciBllyo' 
its  etiology,  necessarily  involves  considerable  modificatiou  of  thc^" 
views.     Before  consideritig  the  pathology,  however,  it  will  he  «ell 
to  study  the  histoloi;v  of  the  disease. 


HISTOLOGY. — The    histological    changes    in  the   lungs  »hicl> 
occur  iu  pnlnjonary  jihtliisis  are  similar  to  those  met  with  in  tlie»«" 
organs  in   acute  miliary  tuberculosis.     They  differ  mainly  in  tbi* 
respect — that    whilst    in     miliary    tuberculosis    these    changwJ  a'* 
limited  to  small  areas  (being   due  to  the  distribution  of  hucilli  l»5 
the  blood  and  to  their  deposit  here  and  there  in  the  pulmonarv  ti»* 
sue),  in  phthisis  they  uUimatcly  involve  much  larger  tract*  uf  tiwu*- 
Further,   phthisical    consolidation    is  lohulateil  in   its   distributit**** 
owing  to  the  fact  that  the  irritant  causing  the  inflammation  gP*** 
erally  gains  access,  and  is  often  redistributed,  through  the  niediu*" 
of  the  bronchi.     This  lobulated  distribution  of  the  consolidation  «* 
c.xceeilingly  characteristic;  and  even  iu  those  acute  cases  in  «hi«-**' 
owing  to  the  rajiid  and  extensive  implication  of  the  lung,  the  cwn* 
solidation   may  to  the  naked  eye  appear  aliuust  as  uniform  ss  'l**' 
in  croupous  piieunionia.  the  microscope  will  usually  reveal  a  \"h»'*^ 
distribution  (Fig.  198). 

The  structural  changes  met   with  in  the  lungs  in   pbthisii*  »f* 


pulmosarS 


647 


mainly  of  four  kinds:  (1)  an  accuinnliUion  of  epithelial  cells  within 
tLe  pulmonary  alveoli,  (2)  the  presence  within  tlie  alveoli  of  a  fibrin- 
ous exudation  ami  leucocytes;   (3j  a  celluljir  inliltrution  and  thick- 
[■ening  of  the  alveolar  walls,  together  with,  in  most  cases,  a  similar 

Viv,.  198. 


Acute  phtblsla.  A  trungvenw  «e<'llon  of  h  u-rmlnnl  hmnrhiu  (alr-iMmaiie)  »nd  the  inr- 
""Umliiig  alvt>oll.  Fhtmins  the  Inbulntol  ohururtor  of  the  pulmomiry  consolidation:  A, 
^*vuy  of  bronchtu  ccintalniny  n  little  niiicun.    >:  .'.0,  rcdiiced  t. 

^^hange    in    tlie    wntla   of   the    terminal    hrouchioles ;    and   (4')  an 

"ureaao  in  the  interlobular  connective  tissue.     These  four  kinds  of 

''^^irbid  change  are  very  constantly  associated,   iilthtmjih   in   very 

"jffi-rent    degrees,    ami    some    of   them    are    more    prominent  and 

^**aracteristic  than  others.     The  preponilerance  of  one  or  other  of 

'»fin  j»roduce8  those  variations   in  the  j)hy8ical  characters  of  the 

'^ngs  which  arc  met  with  in  the  iliffereiit  stages  and  in  the  different 

^■•irieties  of  the  disease.     These  various  structural    chiniges    must 

"*«w  be  considered  separately,  together  with  the  more  important 

'^^Iterations  which    they  produce  in  the  physical  characters  of  the 

**»gans. 

1.  An  accumvilation  of  epithelial  cells  within  the  pulmonary 
■^Iveoli. — This  is  one  of  the  most  freijuent  tliaiiges  met  witli  in 
)>Lthisis,  and  is  precisely  similar  to  that  which  has  been  already 
*i«^cribed  as  occurring  in  catarrhal  )>ne)imonia  (Fig.  1S>3).  The 
'*-JveoU  are  found  filled  with  largo  nucleated  elements,  apparently 
*-Vse  offspring  of  the  epithelial  cells  normally  lining  the  alveolar  walls 
\"Fig.  lOlt).  In  some  acute  cases  of  phthisis  this  alveolar  accumu- 
•miion  may  constitute  almost  tlie  only  morbid  change,  and  although 


PULMONARY  PHTmSIS. 


I 


phosis,  and  the  alveolar  walls  destroyed,  while  in  those  tracts  of 
tissue  in  which  the  process  is  most  ailvanetnl  all  trace  of  structure  is 
lost  and  nothing  is  seen  but  a  gnuiuhir  iK'-bris.  Tliese  changes  are 
precisely  analogous  to  those  met  with  in  many  of  the  larger  nodular 
lesions  of  acute  tuberculosis  (Figs.  14:2  and  143). 

2.  The  presence  within  the  alveoli  of  fibrinous  exudation 
a-nd  leucocytes. — This  is  less  frecjucnt  than  the  preceding  (Fig. 
201).  The  exudation-products  are  similar  to  those  which  fill  the 
alveoli  in  ordinary  croupou.s  pneumcmia  {Fig.  19(t).  The  coaguliim, 
however,  is  usually  not  so  abundant,  neither  is  the  fibrillation  quite 

Fio.  201. 


'^cute  phthlsU,  showing  unv  of  llu'  iUvl-uU  Ullud  with  libriuuut  cxudnliuu  and  leucocyte*, 
*****  «nme  ccUuliir  Intl  It  ration  of  the  alveolar  waU.    :<  200. 

**^  distinct.  In  the  most  acute  forms  of  phthisis  this  may  constitute 
*'«e  principal  caii.se  "f  the  pulmoiiarv  cimsrtlidation,  but  it  is  usually 
**8ociated  with  more  or  less  epitlicliiil  pi-oliforation. 

The  appearances  presented  by  the  itings  in  those  cases  in  which 
^hp  pulmuiiary  coiisididfition  is  due  iiiiiinh/  to  any  of  the  intra- 
*lveolar  changes  above  described  arc  very  characteristic.  The  con- 
solidated tissue  is  soft  and  friable,  breaking  down  very  readily 
under  the  finger,  and  there  is  complete  absence  of  any  induration. 
The  consolidation,  altliou^li  sometimes  almost  uniform,  generally 
presents  a  somewhat  lobulated  outline,  indicating  the  implication 
of  different  groups  of  the  jtuiuionary  lobules  (p.  538).  The  color 
varies  from  a  reddish  to  a  ycIlowish-gray,  while  small  portions  of  a 
more  decidedly  yellow  tint  are  often  scattered  thruugh  the  consoli- 


560 


INFLAMilATIOH  OF  THE  LUSOS. 


tinted  mass.  These  scattered  ureas  currcspoud  with  those  p«rts  id 
wliicb  the  retrogressive  chan<ie8  are  the  most  ndvanced.  and  thor 
are  eveu  softer  in  eousisteiicc  than  the  surrounding  tissue.  It> 
tnauv  parts  the  consolidated  tissue  will  he  found  broken  down  so  as 
to  form  cavities  of  various  sizes.  These  usually  jM>sses»  irrt>);iilar 
walls,  which  are  ijuite  soft  and  friable,  like  the  solid  tissue  aor- 
rounding  them. 

3.  A  cellular  infiltration  and  thickening  of  the  alveolar 
walls,  and,  in  most  cases,  of  the  wall.'*  of  the  terminal  liroucbiolea. 
This  is  the  most  characteristic  phthisical  lesion  ;  for  while  it  ia  ctm- 
gtatitli/  associated  with  the  above  i'n/ra-alveolar  changes,  it  ia  onlj 
exctptioniilly  present  in  the  more  acute  pulmonary  inflaiuiiiatiouii 
previously  (lescribcil.  its  extent  varies  rotisiderably  in  dilTervot 
cases.  The  change  is  precisely  similar  to  that  which  has  been 
already  described  as  occurring  in  acute  miliary  luberciiIo.''is  (p.  431). 
In  its  earlier  stages  a  few  small  cells  are  seen  infiltrating  the  alre- 
olar  septa,  which  are  thus  slightly  thickened  (Figs.  199  and  201)^ 
As  the  change  proeeedi  the  number  of  these  cells  increase*,  and 
from  them  an  imperfect  tibro-nucleatcd  structure  is  «levclop«'d  (Fig. 
202).     This   structure    is   always    imperfectly    supplieti    with    new 

Fio.  202. 


w 


l»«*.« 


S-o, 


Sertlon  of  Uinie  tmm  m  riwtf  nf  ••iinvnlMil  rhn>iili-  |>hthl»l»,  •hnttiiic  thi-  • 
lilt'  alvroUr  walln  l>r  •  flbrunuclnitoil  Utaiic  rTM'nilillii«  lymph»l>l  iImuk,  l  . 
an  uociimiilAlinn  <>f  xiiitlii'llnl  i-vlli  wlUilii  Uu>  iilvrolar  cavity.    Th«  Uutrr  uvua 


bl(iod-vess<'ls.      .\h   the   new  ti.«siic   ilcvclups   in  tiic  nlttHdar  waiU  il 
gradually   obliterates   and    replace*    the    alveolar   cavttia^   »o  ibat 


PUL.yrOi\AIiY  PHTHISIS. 


651 


tlie  tiiick-walli'il  alveoli 


be  foumi  still 


whilst  in  some  jiortions 
containing  epithelial  elements,  exudation-products,  or  even  giant- 
cells  in  others,  large  tracts  will  be  seen  consisting  almost  entirely 
(if  the  small-celled  growth.  The  development  of  this  new  non- 
Tiscular  tissue  in  the  alveolar  walls  leads  to  the  partial,  or  even 
complete,  obliteration  of  the  pulmonary  capillaries,  which,  as  will 
be  seen  subsequently  (p.  o57),  constitutes  an  important  element  in 
the  causation  of  the  retrograde  changes. 

The  changes  which  may  subsequently  take  phuc  in  this  alveolar 
groBtli  varv.  The  infiltrated  septa  nuiy  readily  break  flown  before 
anv  iimrked  thickenius;  or  develoiuneiit  of  new  tist^ne  hiis  iiad  time 
Ui  occur,  whilst  in  other  less  acute  cases  there  is  a  considerable 
licvplopmcnt  of  the  imperfect  (ibro-nuclcated  tissue.  Yet,  although 
this  may  rttmain  as  a  more  or  less  permanent  structure,  it  usually 
andergoes  in  its  turn  retrogressive  metamorphosis  (p.  /i.^).  These 
t»o  kinds  of  change  are  very  often  found  siiniiltaneously  in  the 
»luHilar  walls  of  different  parts  of  the  same  lung.  In  those  portions 
in  which  the  new  tissue  is  undergoing  ihu/rufratioH  it  will  be  .seen 
tfl  have  become  converted  into  a  structureless  granular  debris, 
together  with  any  cells  which  may  be  contained  within  the  alveoli, 
•hil.Ht  in  the  immediate  vicinity  of  these  degenerated  portions  a 
iiiofi'  permanent  fihro-nucleated  Dtrueture  may  be  found. 

Kespccting  the  alteration  which  the  growth  of  this  stiiall-celled 
"»»ut'  produces  in  the  physical  characters  of  the  lungs,  it  may  bo 
"Stated  generally  that  it  usually  leads  to  more  or  less  induration  of 
"'L'  pulmonary  texture.  The  extent  of  this  induration  will  vary 
wconling  to  the  characters  of  the  new  tissue.  If  the  tissue  remain 
•Iniost  entirely  cellular — as  is  the  ca.se  when  it  is  very  rapidly 
'"fined  and  when  new  vessels  do  not  develop — it  will  produce  little 
'"■  no  induration  of  the  pulmonary  consoliilation  :  and  this  con.soli- 
"l»tion,  consisting  mainly  of  degenerating  cells  both  in  the  walls 
"111  cavities  of  the  alveoli,  will  he  soft  and  friable  in  consistence, 
"inch  resembling  that  already  described.  When,  on  the  other  hand, 
M  IS  more  freijueutly  the  case,  there  is  any  considerable  develop- 
Sientof  the  imperfect  fibro-nucleated  growth,  when  the  reticulum  is 
•Itnae  and  abundant,  and  when  vessels  develop  and  persist,  there 
*ill  be  a  corresponding  induration  of  the  consolidated  tissue.  In 
■"iny  eases  these  changes  produce  uniform  tracts  of  indurated  con- 
"^liilation  of  a  grayish  color  mottled  with  black  pigment.  Scattered 
wrc  and  there  among  them  may  be  seen  yellowish  patches  corre- 


662 


INFLAMMATION  OF  THE  LUNGS. 


sponding  to  the  portions  which  have  undergone  retrogressive 
changes. 

4.  An  increase  in  the  interlobular  connective  tiseue.— 
is  met  with,  to  a  greater  or  less  extent,  in  nil  the  more  <7iri/HiV  fori 
of  phthisis.  This  tissue,  which  surrounds  the  bronchi  and  blood- 
vessels  and  contributes  to  the  foruiiitioii  of  the  alveoli,  is  found  not 
only  increased  in  amount,  hut  also  iiltereil  in  character,  in  the 
earlier  stages  of  its  development  it  contains  numerous  small  cells; 
and  althoufrh  many  parts  of  it  may  resemble  the  growth  in  the 
alveolar  wall.'*,  its  structure  is  more  like  that  met  with  as  the  result 
of  chrouic  indurative  processes  in  other  organs.  It  has  a  much 
greater  tendency  to  become  develojied  into  a  fibroid  tissue  than  tbn 
interalveolar  growth,  and  it  is  rarely  the  seat  of  those  retrograde 
changes  which  are  so  frerjucnt  in  the  tissue  originating  in  the  alve- 
olar walls.  As  usually  met  with,  it  consists  either  of  wavy  fibres  or 
of  a  more  or  less  reticulated  structure,  with  a  varying  number  of 
rouud,  spindle-shaped,  or  branched  cells  (Fig.  203).      Intermingled 

Fia.  203. 


Chronic  pluhlplt.,  Dhnwine  the  new  Intorlohiilur  flbrald  Krowlh  »urToun<llwt  iB^  "* 
■ulalliig  a  dcKcni-niti-il  uml  cuneoua  portlun  uf  the  ciinauUdalcd  luug.    X  '".  riHlne**'- 

with  these,  in  most  cases,  are  granules  of  black  pigment.  The* 
differences  in  the  patholojrical  tendencies  and  structure  of  the  i""''' 
alveolar  and  interlobular  growths  vary  with  corresponding  diw'" 


PULMONARY  PHTHISIS.  553 

ences  in  the  amount  of  their  vascular  supply.  Whereas  in  the 
interalveolar  growth  the  pulmonary  capillaries  become  obliterated 
and  new  vessels  are  rarely  formed,  or,  if  formed,  are  often  subse- 
<iuently  destroyed,  in  the  interlobular  growth  the  new  vessels 
formed  generally  persist.  In  the  most  chronic  cases  of  phthisis  this 
mterlobular  fibrous  growth  may  constitute  the  predominant  struc- 
tural change,  and  large  tracts  of  the  pulmonary  texture  may  be 
found  completely  replaced  by  it  (p.  542). 

An  increase  in  the  interlobular  connective  tissue  in  phthisis — 
inasmuch  as  the  new  tissue  tends  to  become  dense  and  fibroid — leads 
to  extensive  induration  of  the  pulmonary  texture;  and  further, 
owing  to  the  contraction  which  the  new  tissue  undergoes,  its  growth 
ultimately  produces  a  corresponding  contraction  of  the  diseased 
lung.  In  all  those  cases  of  phthisis  in  which  there  is  either  a 
marked  thickening  of  the  alveolar  walls  or  an  increase  in  the  inter- 
lobular connective  tissue,  any  cavities  which  may  exist  in  the  con- 
solidated and  indurated  tissue  are  characterized  by  the  tough  and 
fibroid  structure  of  their  walls.  These  present  a  marked  contrast 
to  the  soft,  friable  tissue  surrounding  the  cavities  in  cases  where  the 
pulmonary  consolidation  is  due  mainly  to  intra-alveolar  changes. 

Changee  in  the  Bronchi. — Allusions  must  now  be  made  to  cer- 
tain changes  in  the  bronchi.  These  tubes  are  invariably  involved 
in  pulmonary  phthisis.  Some  catarrh  of  the  bronchi  is  constantly 
present  in  phthisical  lungs.  The  catarrh  is  sometimes  general,  but 
Oauch  more  commonly  it  is  limited,  and  more  strictly  confined  to 
s«ch  portions  of  the  lung  as  are  becoming,  or  have  already  become, 
'Consolidated.  In  many  cases  there  is  a  marked  tendency  of  this 
bronchial  catarrh  to  lead  to  extensive  cell-infiltration  of  the  deeper 
structures  of  the  bronchial  wall.  This  cell-infiltration  sometimes 
l«ads  to  the  production  of  small  ulcers.  These  have  thickened, 
Qpaque  edges,  and  when  once  formed  they  tend  to  increase.  In 
addition  to  these  changes  in  the  bronchial  mucous  membrane,  there 
ia  often  a  cellular  infiltration  of  the  peribronchial  tissue,  and  here 
Small  nodules  of  new  growth  are  frequently  met  with,  especially 
Ground  the  smallest  bronchi. 

Chaneree  in  ttie  Arteries. — Bands  of  tissue  containing  arteries 
frequently  extend  from  side  to  side  of  a  large  cavity.  When  such 
an  artery  traverses  a  newly-formed  cavity,  it  generally  happens  that 
Inflammation  of  the  walls  of  the  vessel  leads  to  thrombosis  and 
subsequent  obliteration  of  the  lumen  before  the  advancing  disease 


564 


INFLAMMATION  OF  THE  LUNOS. 


can  destroy  its  walls  and  give  rise  to  hemorrhage.  But  occasioiiftlij. 
in  the  case  of  a  small  cavity,  the  wall  of  the  vessel  may  be  weak- 
ened at  one  spot,  and  an  aneurysm  result  before  any  thrombosin 
occurred.  .Such  an  uneurv.-'ni  iniiy  fill  the  cavity  and  for  a  tie 
increase  pari  pa»»u  with  it.  But  before  such  an  aneurysm  has 
attained  a  diameter  of  an  inch  it  will  in  all  probability  mptnre.  uid 
fatal  hciuorrluigc  into  the  iiir-pussufjeji  iniiy  follow. 


PATHOLOGY. — Ilavinj;  thus  bricHy  <lescribed  the  various  stmcv 
turai  changes  met  with  in  the  lun;;.s  in  phthisis,  there  remains  tu  be 
con.sidereil  the  nature  of  the  morbid  proces.scs  upon  which  they 
depend.  In  the  first  place,  it  is  evident  that  those  cbangM  are 
.•structurally  analogous  to  those  we  have  met  with  in  the  several 
forms  of  pulmonary  inflammation.  Thus  the  exudation  of  fibrin 
and  leucocytes,  the  accumulation  of  epithelial  cells  within  the  alvi*> 
oli.  un<l,  in  the  more  chronic  cascs,  the  ultimate  infiltration  of  tbt> 
alveolar  walls,  are  the  usual  lesions  found  in  croupous  and  eatarriial 
pneumonia,  while  an  increase  in  the  interlobular  connective  ti.'^ue 
is  the  characteristic  change  in  interstitial  pDcumntiia.  The;«e  c<in- 
siderations,  together  with  others  derived  from  the  study  of  the  eti- 
ology of  the  disease,  are  sufficient  to  justify  the  conclusion  that  the 
morbid  processes  which  lend  to  the  consolidation  and  sul>se(|aent 
ilisintcgration  of  the  lung  come  within  the  category  of  inflannni^ 
tion,  and  that  the  ilifl'erences  in  the  histological  changes  to  whiefa 
they  give  rise  arc  due  mainly  to  differences  in  the  nature  of  tbe 
irritant  and  in  the  duration  of  the  inHanimatory  proceta. 

liut  although  |>hthisical  consolidation  td°  the  lung  is  the  rewilt  n( 

inllammation,  it  is  obvious  from  our  previous  considerations  (p.  SIO) 

tliuf  tin*  proce.ss  does  not  owe  its  origin  to  "simple"  cnu!ie».      The 

pro^reitive  character  of  the  intiammation.  and  its  tendency  to  infect 

Kro  304         adjacent  and  <listant  portions  of  the  lung.  »how  the 

•  -.>.•>.       existence  of  some  irritant  capable  of  mult  n 

'^t'.','^'^^,-     'I'f  body  and  of  spreading  from  primary  to  >. .ly 

^*'-^'.'-i!     foci.     Since  Koch's  disc<iverv  of  the  tuberele  b«cilla» 
.,  .     .*  .    ,.„   ft'l  investigations  have  tendeil  to  show  that  the  bacil- 

Tulirrric    tKi-Ult  .... 

In  piiiiiuicai  •pu.    lus  tubrreiiUt.sis   is   invariably  present,  both   in    tbe 
turn.    /aw.  Iiinjrs  uiid    in    the  sputum,  in  all  cases  of  phtbuta 

(Fig.  204),  and  wo  mnst  therefore  regard  phthisis  as  a  more  or  liaia 
chronic  pulmonary  tuberculoBis.     Thus  moilern    opinion 
with  Laennec  in  believing  that  all  phthisis  i8  tubercular,  and 


PULMONARY  PHTHISIS.  555 

Niemeyer  in  his  conclusion  that  phthisis  is  a  progressive  caseous 
pneumonia. 

To  understand  the  differences  in  the  histological  changes  just 
described,  it  is  important  to  bear  in  mind  what  has  been  stated 
respecting  the  variations  in  the  character  of  the  structural  altera- 
tions in  inflammation  produced  by  differences  in  the  intensity  and 
duration  of  the  inflammatory  process.  When  studying  the  process 
of  inflammation  it  was  seen  that  the  most  intense  forms  of  the  pro- 
cess were  characterized  by  abundant  fluid  and  corpuscular  exuda- 
tion, whereas  in  inflammations  of  less  intensity  and  longer  duration 
tissue-formation  played  a  prominent  part.  These  structural  changes 
also  varied  according  to  the  duration  of  the  inflammation.  In  the 
least  severe  and  most  chronic  forms  there  was  a  tendency  for  the 
changes  to  be  limited  to  the  elements  immediately  adjacent  to  the 
blood-vessels  and  lymphatics,  whereas  in  inflammations  of  somewhat 
greater  intensity  more  distant  elements  become  involved.  Further, 
whereas  in  the  former  case  the  changes  usually  resulted  in  the  for- 
mation of  a  small-celled  tissue  which  tended  to  become  fibroid,  in 
the  latter  the  more  distant  elements — being  in  most  cases  incapable 
of  further  development — tended  to  undergo  retrogressive  changes. 
In  the  lungs  the  truth  of  these  propositions  was  borne  out  by  the 
differences  which  were  seen  to  exist  in  the  histological  characters 
of  the  lesions  in  the  various  forms  of  pulmonary  inflammation,  and 
also  of  those  in  acute  tuberculosis. 

If  the  above  facts  be  kept  in  view,  it  will  be  seen  that  the  same 
sequences  characterize  the  lesions  in  pulmonary  phthisis.  In  those 
cases  in  which  the  inflammatory  processes  are  of  slight  intensity  and 
of  long  duration  the  most  marked  structural  change  will  consist  in 
the  development  of  a  small-celled  growth  in  the  alveolar  walls  and 
in  the  interlobular  tissue — a  growth  which  tends  to  develop  into  a 
fibroid  structure ;  whereas  in  those  cases  in  which  the  inflammation 
is  of  greater  intensity  fluid  and  corpuscular  exudation  and  prolifer- 
ation of  the  alveolar  epithelium  will  constitute  more  prominent  parts 
of  the  process. 

The  intensity  of  the  inflammatory  process  not  only  determines  the 
histological  characters  of  the  pulmonary  consolidation,  but  also,  to  a 
great  extent,  the  subsequent  changes  which  take  place  in  it.  In 
those  cases  of  phthisis  in  which  the  intensity  of  the  inflammatory 
process  is  considerable  not  only  do  the  epithelium  and  exudation- 
products  which  have  accumulated  within  the  alveoli  (quickly  degen- 


556 


UtFLAMMATIOy  OF  THE  LVSOS. 


erate  and  break  down,  but  any  small-celled  tissue  which  mar 
been  developed  in  the  alveolar  walls  or  aromul  the  teriuinul  bi 
chicles  also  softens  and  dies,  and  thus  the  vitality  of  large  tract* 
the  pulmonary  consolidation  may  become  destroyed.  In  thoee 
on  the  other  hand,  in  which  the  process  is  less  iuteutte  the  *m 
celled  growth  produced  in  the  alveolar  and  bronchial  wa1i«  in  ni< 
permanent,  and  there  is  an  increat<e  iu  the  interlobulnr  eonncci 
tissue.  It  is  these  two  kinds  of  change,  the  one  tvtiding  to 
death,  and  the  other  toward  the  production  of  new  tis.«ue.  wkti 
produce  the  cai«eation  nnd  softening  on  the  one  hand  and  liii*  i 
ration  ou  the  other;  and  these,  again,  associated  in  su«l> 
degrees,  make  up  the  diverse  physical  characlcTS  of  the  {ihth 
lung,  and  have  given  rise  to  a  classification  of  phtlitsin  itito  «/. 
the  and  imiitralire  varieties. 

These  various  secondary  changes  which  may  take  place  in  t 
pulmonary  consolidation  of  phthisis  must  be  considm-d  more  ful 
They  are  of  three  kinds — resolution,  development  into  an  iw|KTfi 
fibroid  tis.sue,  and  retrograile  metamorphosis. 

Resolution. — Much  of  that  consolidation  of  the  lung  which  L«  I 
most  rapidly  induced,  and  which  is  conse<jiiently  owing  to  the  p 
cnce  of  intra-alveolar  e.xiidation,  may  become  absorbed.     The 
liition   of   the  consolidation    may    thus   be   complete,  or    after   I 
absorption  of  the  intra-alveolar  products  there  may  remain  more 
lewi  infiltration  of  the  alveolar  walls. 

Fibroid  Development. — This,  ns  hn.*  been  seen,  may  m 
the  growth  in  the  alveolar  walls,  and  also  I'oriu  the  nv«  interlubo 
tissue.  The  tissue  which  originates  in  the  walls  of  tiie  ftl*i 
being  for  the  most  part  destitute  of  blood-veMelit,  ie  incapable 
forming  a  very  mature  structure,  but  it  may  develop  iuti»  au 
perfect  tissue,  and  remain  for  .<*ome  time  permanent,  thu*  cimtrib 
ing  to  the  induration  of  the  lung.  In  the  new  interlobular 
there  is  not  the  same  interfereiK'c  with  the  vascular  supply 
hence  this  forms  a  much  more  lully-develi>ped  and  pennan 
structure,  and  is  the  principal  source  of  the  pulmonary  fibi 
The  extent  of  this  fibrosis  is,  for  the  most  part,  in  ilirect  pm|ioi 
to  the  chroiiicity  of  the  disease. 

Retrograde  Metaxnorpboeis. — This  is  the  change  which,  leadj 
to  the  caseation,  softening,  and   ilisintegration   so  chanioieriatic 
phthisis,  distinguishes   phthisical   from   other   fonus   of  pneamni 
consolidation.     A  retrograde  change  iu  the  inllammatury  pro«ia- 


PVLMOXARY'  PHTmsrS. 


557 


H    's  an  invariable  accom]ianiiiicnt  of  acute  non-j)litliisiciil  pneiinioniii. 

H    ^lucli  of  the  exudation  and  epithelium  which  HU  the  alveoli  under- 

H  ^oes  fatty  and  mucoid  changes,  and  as  the  circulation  becomes  re- 
stored in   the  {lulraonary  capillaries  the  degenerated   products   are 

^  ttljsorhcd  and  the  lung  reniiiins  intact.      In  [ihthisical  consolidation, 

^  However,  this  removal  of  the  inHamniatorj  products  does  not  take 
{ilace.  The  contents  of  the  alveoli  degenerate,  but  the  degenerated 
■products  are  not  absorbed,  and  the  !ung-tissuc  itself  undergoes  a 
rapiil  or  gradual  process  of  disintegration. 

In  studying  the  causes  of  this  retrograde  metamorphisis,  which 
constitutes  so  essential  a  feature  of  the  disease,  we  find  that  it  has 
usually  been  attributed  to  conditions  interfering  ivitli  the  circubi- 
/fcion.  The  most  important  of  these  are — (1)  the  pressure  upon  the 
null  blood-vessels  of  the  new  cells  infiltrating  the  walls  of  the 
Jveoli  and  small  bronchi ;  (2)  the  pressure  exercised  upon  the 
pulmonary  capillaries  by  the  inflammatory  products  which  have 
akccumulatcd  within  the  alveoli ;  and  (.3)  that  temlency  to  stagnation 
of  the  bloorl-streani  which  is  an  invariable  accompaniment  of  every 
intense  inflammation. 

H  This  explanation  is.  however,  clearly  insufficient,  as  all  these 
■^lionditions  may  exist  without  producing  the  degeneration  and  soffen- 
i  ng  shown  to  be  so  characteristic  of  phthisis.     The  death,  degenera- 

H~^OD,  and  caseation  seem  to  be  mainly  due  to  the  direct  action  of  the 
'J'lroducts  of  the  bacillus.     The  new  cells  are  thus  often  killed  before 

I'Nressels  would  normally  ilevelop  among  them,  while  the  original 
"•issues  gradually  succumb  as  the  products  of  the  advancing  organ- 
isms act  more  and  more  powerfnlly  upon  them.  The  organism  and 
5t8  products  are  everywhere  met  by  inflammatory  changes.  What 
determines  the  successful  development  of  fibroid  tissue,  how  far  its 
formation  depends  upon  the  nature  of  the  tissue  attacked,  and  how 
far  upon  the  vitality  of  the  invading  organism,  are  uncertain. 
These  difficulties  have  been  alreatly  discussed  {p[>.  342,  42i*,  423). 
H  The  development  of  fibroid  tissue  is  a  favorable  result  in  two  ways : 
it  is  evidence  of  the  recuperative  power  of  the  tissues,  and  it  forms 
a  barrier  against  the  advance  of  the  liacillus. 

I  In  addition  to  the  above,  an  element  of  probable  importance  in 
the  causation  of  the  retrograile  changes  of  phthisis  is  inherent  weak- 
neat  of  the  lungs  (possibly  inherited),  which  not  only  renders  them 
especially  susceptible  to  injury,  but  which  reduces  their  recape- 
rative  power  to  a  point  below  the  normal  average. 


558 


ISFLAilMATIOy  OF  THE  LVSCt;. 


In  the  Inter  stages  of  many  cases  of  chrouii-   [i)itiiii«i]i 
inilntnuiiition  ami   iilcenition  of  the  pulmonary  conAoliilatiot 
tribute  to  the  destruction  of  the  lung.     These  rcMult  from 
jurious  influence  of  retained  secretions  and  iutlauuiiutory  pr 
which   uiuy  contain    other    organisms — sucii    a.H    the    stt 
I tyogene*— besides  the  bacillus  tuberculosis. 


ETIOLOGY. — In  studying  the  etiology  of  phthisis  it  is  ul 
in  the  first  place,  that,  accepting  the  tubercle  bucilhi.t  as  an 
element,  something  more  is  necessary  for  the  production  of  tl 
cose.     The  bacillus,  as  has  been  seen,  must  in  some  sitnati 
constantly  entering  the  lungs  by  means  of  the  respiri'd  air  (pj 
In  hospitals  sot  a])art  for  the  treatment  of  consumption  the 
of  infection  abound,  yet  the  instances  iti  which  phthisi*  dirrrlii 
the  tyjiically  healthy  are  rare.     The  other  necessary  fartor  i»  m 
thing  inherited  or  acijuired — inherent  in  the  individual. 

The  influence  of  hereditary  predisposition  is  so  iiiurk<-<l 
must   necessarily   occupy  a   proiiiiiieiii    pliice   in    the   pnthoiiij 
])htliisi8.     As  to  the  nature  of  what  is  trsinsmitti-d — althv 
t(uite  exceptional  cases  this  may  |Kissibly  be  tin-  tulu-rcle  hacj 
speaking  generally,  it  is  in  all  probability  simply  »  tcndc 
disease.     It  may  be  said  that  this  tendency  consists  in  some  \ 
iioss  of  the  constitution  in  general,  and  often  of  the  lungs  sd^ 
organs  in  particular.      As  a  result  of  this  feebleness  the  p<»^ 
resistitig  injurious  intluene<^s  is  diminished,  uiiil  ihr  lungs,  i 
other  organs  and  ti.ssues  which  are  especially  weak,  are,  in 
<|Ueti(!e,  iibnoruially   liable  to   become  suitable  culture-groni 
the    bacillus    tulterculosis.      Further,    this    inherited    ^teakn« 
only  renders  certain  organs  abnormally  liable  to  tuvasinu. 
less  capable  of  recovering  from  the  effects  of  the  cons«M|uent  ti 
matory  process. 

Another  important  factor  in  the  development  of  phihiais 
state  of  the  greneral  health.     <,>uite  apart  frotu  any  inheritc^l 
ness.  there  can  be  no  iluuht  that   an   impaired  state  of  ibi* 
health  greatly  favors  the  development  and  progress  of  the 
It  is  when  hvth  these  obtain   that  we  have  the  most  faronih| 
ditions.     Dampness  of  soil  and  atmosphere,  want  of  sunligl 
lack  of  frt-»fi  air  seem  to  contribute  especially  to  the  |iruduc 
this  "  impaired  health." 

In  these  two  conditioiu,  therefore,  hfr,<iitary  predi 


PATHOLOGY  OF  THE  NERVOUS  SYSTEM.  559 


W       **<»<«  of  general  health,  we  have  the  other  factor — the  something 

W        i-ixlierent  in  the  individual  which  appears  to  be  necessary  for  the 

r       p^^K-oduction  of  phthisis.     It  is  this  inherent  condition  which  must 

t>^s^  regarded  as  constituting  a  soil  favorable  to  the  development  of 

^  'ir^  e  bacillus,  and,  whatever  it  may  be,  its  importance  is  difScult  to 

<*  "^i^er-estimate. 

Attention  has  already  been  drawn  to  the  frequency  with  which 
f:*^  "ftithisis  commences  in  the  apices  of  the  lungs.  The  causes  of  this 
^fc.  ^re  probably  to  be  sought  for  in  the  diminished  range  of  respiratory 
r-mr-m  ovement  which  obtains  in  the  highest  portions  of  the  lungs.  As 
^K.  result  of  this  diminished  movement  there  is  diminished  aeration 
cz^  "M  blood,  and  in  certain  conditions  of  health  a  tendency  to  stagna- 
fc  m  on  of  the  blood-stream  in  the  pulmonary  capillaries.  The  stagna- 
C-.  s  «n  of  the  circulation  may  lead  to  more  or  less  injury  of  the  walls 
cr»  "^  the  vessels,  and  a  slight  leakage  be  thus  induced. 

It  is  obvious  that  any  inherited  or  acquired  weakness  must  favor 

fc'Kae  occurrence  of  these  apical  changes.     General  feebleness  and 

^^ie~XD.t  of  vigor  lead  to  loss  of  muscular  strength  and  weakness  of 

t"l::»e  heart,  and  thus  tend  to  prevent  the  full  expansion  of  the  chest, 

t<=»  cause  a  stooping  posture  of  the  body,  and  to  impair  the  blood 

^X3d  air  circulation — all  conditions  favoring  blood-stagnation  in  the 

tm  i^hest  portions  of  the  lungs.     Further,  the  success  which  attends 

ar^Midence  in  a  rarefied  atmosphere  is  probably  dependent  on  the 

■  '■icreaaed  rhythmical  expansion  of  the  lungs. 


CHAPTER    XXXII. 
^ATHOIiOaT  OP  THE  CENTRAL  NERVOUS    SYSTEM. 

The  central  nervous  system  is  made  up  of  cells  and  their  pro- 
^^tut,  and  of  a  connective-tissue  neuroglia  with  blood-vessels  and 
*^mphatic8.  The  Golgi  method  has  demonstrated  that  every  nerve- 
^^\l  has  one  nerve  process,  termed  the  axis-cylinder  process  or  iieu- 
*'<'»,  which  gives  off  collaterals,  and,  after  a  short  course  from  the 
'^ll,  is  covered  with  myelin.  The  myelin  sheath  remains  until  near 
^oe  termination  of  the  neuron,  which  breaks  up  into  a  brushwork 
**f  fibrils  in  the  neighborhood  of  other  nerve-cells.     A  number  of 


560  PATHOLOGY  OF  THE  NEBVOVS  SYSTEM. 

Other  processes   arise  from    the    ganglion-cell   termed  dei 


F1Q.2O0. 


CO. 


Diagnmmatlc  repre«entatlon  of  the  motor  (eOt!icnt>  and  ■ensor;'  (afferent)  timcU. 

Ramon  y  Cajal.) 

The  ^emU  Tnui:  CO.  i»  a  pyramidal  cell  of  thi-  cortex  of  the  motor  an-a  with  Ita 
protopla«mlc  procesacs  or  dendrite*.  From  the  centre  of  the  ba»e  of  the  cell  U 1 
the  neuron  or  axis-cylinder  prorean,  C.H.T..  which  decu»iate«  in  the  pyrai 
terminates  in  a  bniahwork  of  flhrllx  In  the  anterior  comu,  .1.''.,  where  it  Is  broi 
physioIoKical  connection  with  a  spinal  motor-<-ell.  This  is  also  represento<I  a 
protoplasmic  pnx-esses  and  one  axis-cylinder  pn>cess  or  neuron,  which  passes  o 
anterior  root  to  terminate  In  a  motorial  end-plate  of  a  miiscle-flbre,  .V. 

TV  Afferent  IViuf.'  A  xanitllon  on  the  posterior  nM>t.  P.il..  (fives  off  a  T-shaped  pro 
branch  koIuk  to  the  periphery  to  terminate  in  an  cndnirKan  or  plexus :  the  otbi 
the  |>osterl»r  column  of  the  spinal  cord :  some  Hbres  (lass  into  the  gray  matt 
posterior  horn.  Thence  tha  Impulses  are  conveyed  onward  by  fhesh  neurons  aril 
cells  In  the  irray  matter,  while  other  lonit  fibres  continue  their  course  onward  to  t 
CS.  T;  by  the  posterior  column  of  the  same  sl<le.  The  len-flhres  enter  fJoll's  nncl 
ann-flbres,  Burdach's  nucleus.  From  the  KanKlion-cells  of  thc8i>  nuclei  the  ujni 
to  the  cortex  after  decussation  in  the  medulla  is  l>y  the  flllet  of  the  oppixite  side, 
to  the  o|>tlc  thalamus.  R  r«-presents  a  simple  reflex  arc  consistinK  of  an  affere 
deriviMl  (Wim  a  posterior  spina]  mnKlioii-it'll  trnnlnatinit  In  the  nelKhborho 
anterior-horn  cell,  fh>m  which  an  efferent  flbre  is  idven  off. 

which,  projected  into  correspondinji;  lymph-spaces,  serve  to 
nourishmeut  for  the  cell  (Fig.  205). 


PATHOLOGY  OF  THE  NERVOUS  SYSTEM. 


561 


The  neuroglia  consists  of  fine  fibrils  and  branched  cells,  termed 
fflia-cells.  It  serves  to  hold  the  nerve-cells  and  their  processes 
together  and  to  carry  the  blood-vessels  and  lymphatics. 

The  grai/  nuitter  consists  of  ganglion-cells  and  their  processes 
and  neuroglia.  The  white  matter  consists  of  axis-cylinders  covered 
vrith  myelin,  to  which  it  owes  its  color,  the  nerve-fibres  being  held 
together  with  neuroglia.  The  grai/  matter  has  a  pink  tint,  which 
offers  a  striking  contrast  to  the  dead  white  of  the  white  matter :  the 
difference  is  accounted  for  by  the  much  greater  vascularity  of  the 
former. 

Nerve-fibres  may  be  divided  into  three  systems : 

(1)  Afferent  or  sensory — those  which  conduct  impulses  from  the 
periphery  to  the  central  nervous  system. 

(2)  Afferent — those  which  conduct  impulses  from  the  central 
nervous  system  to  the  periphery  (Figs.  205  and  206). 


Scheme  to  repreaent  the  ascending  and  deacendlng  degenerations  In  transverse  lesions  of  the 
*l>tiiil  cord :  A,  ascending ;  Z>,  descending ;  1,  crossed  pyramidal  tract ;  '2,  direct  pyramidal  tract ; 
^  comma-shaped  tract ;  4,  Intermediary  bundle  of  the  lateral  column :  5,  (ioll's  column :  6, 
^onlach's  column  ;  7,  direct  cerebellar ;  8,  antero-latcral.  Ussauer's  tract  at  the  base  of  the 
(■■onerlor  bom  Is  not  shown.  The  root-zone  (bandelette  of  Charcot)  Is  the  portion  of  the 
)>Oilerlor  column  between  Burdach's  column  and  the  posterior  horn.  (F.  W.  Mott,  after 
)bile.) 

(3)  Intraeentral  Commissural. — (1)  Fibres  which  run  trans- 
mersely,  uniting  the  two  halves  of  the  central  nervous  system — e.  g. 
the  corpus  callosum,  the  middle  cerebellar  peduncle,  and  the 
anterior  and  posterior  commissures  of  the  spinal  cord,  etc. ;  (2) 
fibres  which  run  longitudinally — e.  g.  association-fibres  of  the 
cerebral  hemispheres  and  the  ground-fibres  (ascending  and  descend- 
ing) of  the  spinal  cord. 

The  normal  and  morbid  anatomy  of  the  central  nervous  system  is 
3C 


562  PATHOLOOT  OF  THE  NERVOUS  SYSTEM. 

in  great  measure  founded  upon  the  discovery  of  Waller,  that  a  uer\  e- 
fibre  is  dependent  for  its  nutrition  upon  the  nerve-cell  of  which  its 
axis-cylinder  process  is  an  outgrowth.  The  series  of  changes  which 
occur  in  a  nerve-fibre  of  the  peripheral  or  central  nervous  system 
when  cut  off  from  its  seat  of  nutrition  experimentally  or  by  disease 
is  termed  WaJlerian  degeneration. 

The  methods  employed  for  studying  Wallerian  degeneration  of  the 
central  nervous  system,  taking  (for  example)  the  spinal  cord,  where 
the  afferent  and  efferent  tracts  are  clearly  defined,  are  as  follows : 
If  posterior  spinal  roots  be  cut  or  there  be  a  transverse  lesion  of  the 
spinal  cord,  it  would  be  |K>ssible,  after  ten  days  have  elapso^l,  to 
recognize  naked-eye  changes  in  definite  tracts  of  the  spinal  conl. 
provided  the  spinal  cord  be  suspended  in  Miiller's  fluid  for  a  month 
or  so.  The  cord  thus  hardenwl  is  cut  transversely,  and  the  degen- 
erated tracts  are  recognized  by  their  lighter  ifellotc  color  as  compartil 
with  the  healthy  white  matter,  which  is  now  stained  a  brownish- 
yellow.  For  microscopical  examination  of  such  an  early  degenera- 
tion there  is  no  method  to  compare  with  that  of  Marchi.  It  con- 
sists in  placing  thin  transverse  slices  of  the  central  nervous  system, 
thus  hardened,  in  a  solution  of  oni'  part  of  a  one  per  cent,  stdutinn 
of  osmic  acid  and  tipu  parts  of  Miiller's  fluid  for  a  week,  then  wash- 
ing with  water  and  cutting  by  the  celloidin  method.  ."Sections 
should  be  cut  longitudinally  and  transversely.  The  early  changes 
in  the  axis-cylinder  and  myelin  sheath  are  beautifully  shown,  and 
even  single  degenerated  fibres  can  be  followed  the  whole  length  of 
the  spinai  cord.  The  healthy  fibres  are  stained  a  light  gray  by  the 
osniic  aciil,  but  both  the  axis-cylinder  process  and  the  breaking-up 
myelin  are  stained  black,  owing  to  fatty  degeneration.  This 
method  is  most  suitable  for  varlif  degenerations  one  week  to  one 
njonth  after  the  lesion.  For  later  degenerations  the  Weigert  and 
Weigert-Pal  methods  are  most  suitable.  When  sclerosis  has  taken 
place  it  is  better  to  adopt  one  of  the  latter  methods :  the  healthv 
white  matter  is  then  stained  blue,  and  the  nclerogeil  tissue  is  yellow 
or  unstained,  according  to  the  metliod  adopted.  Wallerian  degen- 
eration of  the  nerve-fibres  of  the  central  nervous  system  must  occur 
in  all  organic  lesions,  and  its  extent  and  distribution  will  depen«i 
entirely  upon  tlie  ganglion-cells  destroyed  or  upon  the  filtres  which 
have  been  interrupted  in  their  continuity  with  the  cells  of  whicb» 
thev  are  outgrowths.  The  morbid  conditions  which  may  give  ris«'  t*.:^ 
Wallerian  degeneration  may  be  then  classified  into  three  headings    ■= 


PATHOLOGY  OF  THE  XERVOUS  SYSTEM.  563 

^1^  loflammatoi^  lemons,  circumscribed  or  diffuse:  these  will 
include  meningitis,  encephalitis,  abscess,  myelitis  circumscribed  or 
diffuse. 

(2)  Local  diseases,  due  to  iscbsemia.  to  softening  produced  by 
embolism  or  thrombosis,  and  to  hemorrhage,  causing  secondary 
degenerations,  but  not  necessarily  inflammation  except  at  the  seat 
of  injury. 

(3)  Primary  Degeneration. — It  is  a  debatable  question  i^hether 
the  chronic  inflammatory  changes  which  are  always  associated  with 
these  systemic  degenerations  are  secondary  to  the  atrophy  of  the 
nerve-fibres,  or  whether  they  are  primary,  and  therefore  the  cause 
of  the  degeneration.  The  opinion  is  steadily  gaining  ground  that 
the  primary  cause  is  a  retrogressive  nutritional  change  in  the  gan- 
glion-cells— consequently  there  is  a  progressive  degeneration  of 
their  axis-cylinder  processes,  commencing  at  their  terminations. 

The  microscopical  changes  in  the  fibres  as  a  result  of  degeneration 
are  a  breaking  up  of  the  myelin  sheath  (there  is  no  neurilemma),  an 
alteration  in  its  chemical  composition,  and  swelling  of  the  axis-cyl- 

FiG.  207. 


"^mention  of  creased  pyramidal  tract  at  the  tenth  dorsal  scfnnent.  forty  days  after  heml- 
"♦"lon  of  the  fpinal  cord  In  the  mlddorsal  rcirion.  The  drawing  was  made  from  a  photo- 
■•Iwgraph  of  a  section  of  the  posterior  part  of  the  lateral  column,  stained  hy  the  Pal 
"""lod.  The  condition  is  one  of  rommcncinB:  sclerosis.  The  black  dots  ore  the  swollen 
"iHyllnder  processes,  mingled  with  the  degenerated  myelin ;  here  and  there  are  parts 
■""Wned,  showinK  that  the  uervc-fibrcs  have  "lisappcarcd  and  ncnroglia  alone  is  left.  A 
**  empty  spaces  are  seen  scattered  alKiut.  showing  the  previous  existence  of  nerve-llhres  at 
r'*'  points.  A  large  nnmbcr  of  healthy  fibres  are  seen  mingled  with  the  dcgi-ncrated 
™*;  these  are  the  fibres  of  the  direct  cerebellar  tract  on  their  way  to  the  periphery  of  the 
*"i   (Mott,  PhO.  Tnau.,  1892.) 

'"aer  process,  owing  to  a  fatty  degeneration,  the  clear  distinction 
**tween  the  central  axis-cylinder  and  surrounding  myelin  thus  being 


PATHOLOGY  OF  THE  NERVOl 

lost.     Later,  as  the  altered  myelin   is  carried  nway  by  phagi)«Ttc«, 
spaces  may  be  seen  with  the  swollen  axis-eyliuder  in  the  (uidille;  or 
empty  spaces  in  the  ueiirogliu-tissue   occur,  owing  to   ruptiiri'  arkil 
absorption  of  the  degenerated   axis-cylinder  processes  (Fig».  207 
and  208).     As  the  atrophy  of  the  nervous  structures  proceed*  (b 

Kio.  208. 

•  ^''^:  '■•"^' 


1.* 


encratlun  of  crossed  pyramldnl  trii<-t  at  tlu-  viKlith  dorenl  n-Kincnl.  wvnilj  il*)»  i 
ctloii  r)f  the  splnnl  i'i)r<l  In  the  mld-dnnial  ronimi.  i  I'reimn'd  und  •Iniwn  In  thci* 
way  s«  Kig.  au". )  Miieh  uiore  itelerosit  uui]  ntrnphy  in  seen.  The  <lei;riK'n»l<'d  iii'n«  '« 
fiir  the  most  purt  disappeared,  empty  spacef  >ii  the  neuniKlla  beln^  left :  mine  f«w  t>l«cl " 
are  shdwn— Indleatliiiis  reiiiHliiliiK  of  deituiienited  tierveflhrei.  .VI  the  pcrlpbrry  Ui»  hi««*^ 
(ilire*  uf  the  direct  cerebellar  tract  arc  ae«ii.     (Mutt,  Vhll.  TVnaj.  I6W.) 


is  t)  hyperpliisia  of  tlic  neuroglia  and  proliferation  of  the  gli»-cfl  *^ 
The  profcss  during  the  early  stages  has  been  one  of  softening;  it 
now  a  true  sclerosis  with  shrinking,  but  there  is  no  tendency  ^'^ 
nncoin(iliuiited  priinnnf  or  Hi-i-imdniy  systemic  tlegeneration)  fori 
sclerosis  to  extend  its  limits,  and  it  may  even  be  limited  to  a  mi<* ' 
sopic  transverse  area.     The  connective-tissue  overgrowth  shot* 
its  own    nutrition  hy  changes   in    the  wnlls  of  its   nutrient  ves.**?** 
Eventually,  u  cicatricial  tissue  may  be  formed,  and  the  presence     of  j 
this  impenetrable  tissue  may  be  the  reason  why  in  theTiighcr  aD^ 
mills  there  exists  no  definite  proof  that  nijeneration  of  nerv(vfibr«» 
can  take  pl.-ice  in  the  centrnl  nervous  .'system. 

Some  of  the  physiolog^ical  effects  of  degreneration  of  ibe  cen- 
tral nervous  system  are  voluntary  pnrali/in'ii  when  the  upper  ocgmr/)/ 
ft''  'i      mrttor  path  is  degenernfeil,  and  paralysis  with  w-T^ting  aiiit 
iin'clf<i  when  the  lower  .segment  is  affecteil.    Whrn 
uorntcd,  sensory  disttirlmnces  occur— ^.^ 


PATHOLOGY  OF  THE  NERVOUS  SYSTEM. 


565 


Fig.  209. 


Joss  of  the  muscular  sense,  thcrmo-ansesthesia,  analgesia,  tactile  anaes- 
thesia, and  hjpersesthesia.  Sometimes  tactile  and  painful  impressions 
may   produce    tingling  and  thrilling 

sensations:    this  perverted  sensation 

has  been  termed  parsesthesia  or  dysaes- 

thesia.     When  an  impression  on  one 

part  of  the  body  is  referred  to  a  sim- 
ilar   spot  on   the  opposite  side,  the 

condition  is  known  as  allocheiria :  it 

occurs  especially  in  aifections  of  the 

posterior  columns  of  the  cord. 

Kyhanges  in  the  Superficial  and  Deep 

li^Jlexei. — Both  superficial  and  deep 

reflexes  are  usually  exaggerated  when 

tbe  pyramidal  tracts  are  degenerated, 

sho-wing  that  the  cerebral  cortex  of 

the    motor   area,   from   which   these 

fibres  originate,  exerts  an  inhibitory     _,  .         ,  .    .v     ■ 

.                                                    .                    .  Diagram    to    explain   the    knee-jerk 

•nfluence   upon   the   simple   spinal  re-  (SherrlnRton) :  E.e.,  external  cutaneous 

g- -_    ^pi_  nerve ;  A.f..,  anterior  crural  nerve  with 

if,  cutaneous,  and  m',  muscular  branches 

The  knee-jerk  is    the  best    example  eomlnst  from  the  third  and  fourth  lum- 

-.^                  11     1  1              n         1     .      1.1           1  bar  segments  of  the  spinal  cord;  06., 

«t  a  so-called  deep  reflex,  but,  although  obturator:  .%.,  sciatic  nerve  with  I.P., 

<lependent  upon  the  integrity  of  the  '"te™"!  popliteal;  e.p.,  external  pop- 

A  ^li-         i_ji.'j    "'®*'  branches ;  Vo.  O.,  the  vastl  and 

"^©tlex    arc    of    the    fourth    and    third    thecrurcusmusclef.thelntemalportion 

lumbar   segments   of  the   spinal  cord,  being  especially  concerned  in  the  knee- 

o      ^  ^  '  Jerk.    Destruction  of  the  reflex  arc  of 

yet     careful    time-measurements   have  the  third  and  fourth  lumbar  segments  in 

«i|,^__    4.i,_x    ji    •      _„!,  „ (i„„        Ti  ;~  either  its  efferent  or  aflTercnt  portions 

atlCwn   that    it    is    not  a  reflex.       It  is  wiiiabolishtheknee-jerk.becaureltwiU 

produced    by    striking   the  (lUadricepS  cltherparalyjiethevastuscrureusmiiscle 

-t^a^j  .  .J         ..71       n       •  or  destroy  its"  myotatic"  Irritabllity.i 

*ciidon|w<  on  th^  $tretch  by  flexing 

the  knee,  and  thereby  at  the  same  time  relaxing  the  hamstring 
oiuscles,  which  Sherrington  has  shown  to  have  a  correlative  antag- 
<>ni8tic  action  to  the  quadriceps.  This  is  not,  however,  so  much 
**'*©  to  the  fact  that  relaxation  of  the  flexor  muscles  of  the  knee 
leaves  that  joint  more  free  to  move  when  the  (juadriceps  extensor 
**  excited  to  contraction  by  tapping  its  stretched  tendon,  as  to  the 
'®n»oyaI  of  an  antagonistic  tonic  influence  through  afferent  nerves 

^^  ^yolatic  vmtabUUy  is  the  term  used  l)y  Gowers  to  embody  Iiig  view  that  the 
^°***j«A  and  other  deep  reflexes  depend  on  the  increa.se<l  irritability  of  a  stretched 
^''•cle.    If  the  tension  is  sudden  and  forcible,  not  only  increased  irritability,  but 

T^We  contraction,  occurs.    This  is  especially  evident  when  cerebral  influence  has 

^****  Xcinored  by  pyramidal  degeneration. 


566  PATHOLOGY  OF  THE  NERVOUS  SYSTEM. 

(fifth  and  sixtb  lumbar  roots)  which  the  flexor  group  of  mascles 
exert  through  the  spinal  reflex  arc  upon  the  correlated  extensor 
group  (Fig.  209).  Absence  of  the  tendon  reflex  without  wasting 
and  degeneration  of  muscle  indicates  degeneration  of  the  posterior 
columns  of  the  cord.  Absence  of  the  tendon  reflex  with  wasting  of 
muscle  and  sensory  disturbance  indicates  peripheral  nerve-degen- 
eration or  destruction  of  central  gray  matter  of  anterior  and  pos- 
terior horns.  Absence  of  the  tendon  reflex  with  wasting  and  de- 
generation of  muscle,  but  without  sensory  disturbance,  indicates 
degeneration  of  the  anterior-horn  cells  or  primary  progrensite 
myopathy. 

By  muscular  degeneration  is  not  meant  disuse-atrophy,  bot  a 
wasting  accompanied  by  changes  in  electrical  excitability  of  the 
nerve  and  muscle.  Bastian  has  pointed  out  that  complete  destruc- 
tive transverse  lesions  of  the  spinal  cord  high  up  in  the  dorsal  or 
cervical  regions  (and  in  which  presumably  therefore  the  reflex  are  i« 
intact)  are  often  followed  by  absence  of  the  knee-jerk.  Of  coarse 
the  pyramidal  tracts  will  be  degenerated,  and  it  is  difficult  therefore 
to  understand  why  the  knee-jerks  arc  lost.  It  cannot  be  explained 
by  the  removal  of  cerebellar  influence,  for  the  statement  of  Marchi. 
that  there  exists  a  descending  cerebellar  tract,  has  been  disprove*!. 
The  knee-jerk  is  diminished  in  old  age,  during  sleep,  and  in  anaemia 
of  the  spinal  cord. 

In  cases  where  the  knee-jerk  is  exaggerated  from  removal  of 
cortical  influence  by  degeneration  of  the  pyramidal  tracts  another 
phenomenon  is  often  obtainable — namely,  if  the  calf-muscles  which 
extend  the  ankle-joint  are  suddenly  put  on  the  stretch  by  pressing 
the  hand  against  the  sole  of  the  foot,  a  quick  contraction  occurs, 
and  by  keei)ing  uj)  the  pressure  there  is  a  recurrence  of  the  con- 
tractions at  a  regular  rate  (about  eight  per  second) ;  the  foot  is  thus 
thrown  into  a  series  of  clonic  spasmodic  contractions  terme<l  the 
fnot-elontiH  or  ankle-fhuii*.  Conditions  which  give  rise  to  ankle- 
clonus  are  u.^ually  accompanied  or  followed  by  contracture,  a  state 
of  permanently  increaseil  muscular  tonus. 

Exam|>les  of  nfler  spinal  tonus  are  also  afforded  by  the  action 
of  the  sphincters  of  the  bladder  and  rectum.  The  tonic  contrac- 
tion of  these  nuiccles  is  abolished  by  destruction  of  the  lumbar 
enlargement  of  the  spinal  cord ;  hence  incontinence  of  fseces  an<l 
urine. 


INFLAMMATION  OF  THE  MENINGES.  567 

INFLAMMATION  OF  THE  MBNINQES. 

Three  membranes  enclose  the  central  nervous  system,  but,  owing 
to  the  intimate  connection  of  the  pia  mater  and  arachnoid,  these 
always  suffer  together.  Inflammation  of  the  tough  fibrous  dura 
mat^r  is  termed  Pachymeningitig.  Inflammation  of  the  soft  pia 
arachnoid  is  termed  Meningiti»,  or,  more  precisely,  as  the  antithesis 
to  pachymeningitis,  Leptomeningitis. 

PACHYMBNINainS. 

The  dura  mater  consists  of  two  layers — a  thick  outer  layer  which 
is  periosteal  in  its  functions,  and  a  thin  inner  layer  with  a  smooth 
epithelial  surface.  Either  layer  may  be  the  seat  of  inflammation, 
which  is  usually  chronic. 

External  Pachymeningiti*  is  frecjuently  caused  by  caries  or  necro- 
sis of  the  bones  of  the  skull  due  to  syphilis  or  wounds. 

Internal  Pachymeninitis  is  characterized  by  the  formation  of  a 
false  membrane,  usually  very  vascular  and  consisting  of  several 
superimposed  layers.  Owing  to  rupture  of  vessels,  blood-cysts  are 
found  between  the  layers,  known  by  the  name  of  hceinatomata  of 
the  dura  mater.  This  membrane,  which  usually  causes  adherence  of 
the  dura  mater  to  the  arachnoid,  extends  generally  over  the  greater 
part  of  one  or  both  hemispheres,  It  is  rare,  and  met  with  usually 
in  general  paralysis  of  the  insane  and  chronic  alcoholism. 

MBNmains  or  LsPTOMENiNaiTis. 

Inflammation  of  the  pia  arachnoid  is  in  nearly  all  cases  due  to 
infective  inflammation  by  micro-organisms.  The  most  important 
form  is  tubercular  (p.  424).  A  number  of  other  causes  of  infection 
exist  which  may  be  considered  under  the  headings  local  and  general : 

Local. — (1)  Traumatic  injuries  of  the  head  with  direct  infection. 

(2)  Adjacent  disease  outside  the  dura  mater,  suppurative  otitis, 
chronic  ear  disease  with  caries  of  the  mastoid  or  petrous  portions  of 
the  temporal  bone,  and  occasionally  disease  of  the  bones  of  the  nose 
or  orbit.  The  infection  in  these  cases  may  spread  directly  or  along 
the  course  of  lymphatics  or  blood-vessels. 

(3)  Tumors  and  abscesses  of  the  brain  may  cause  adjacent  inflam- 
mation of  the  meninges. 

General. — Meningitis  may  occur  in  the  course  of  certain  infective 
diseases — e.  g.  small-pox,  scarlet  fever,  mea.slc.t,  septicaemia,  and  in 
pneumonia  and  acute  rheumatism.     Cercbro-spinal  meningitis  may 


668 


PATHOLOGY  OF  THE  XER} 


also  occur  in  an  tjiidcmic  form.     Meningitis  in  rnrc  >n»taoci*»  hi 
foliowi'il  a  blow  not  causing  any  ivound,  anJ  it  liiis  been  fouDil  |io«!|- 
morti'Ui  in  some  cases*  of  sunstroke. 


MORBID  ANATOMY. — When  the  infection  is  local  the  ni«>tiiu. 
gitis  niiiv  be  eircuuiseribeil.  but  ulieii  the  cause  is  sowe  iufttrtire 
blood-condition  it  is  usually  geueralixcd,  and  may  in  sw>mc  ca.«rM  aStt't 
the  sjiinal  as  well  as  the  cerebral  meninges — r.  tf.  ineningitin  otrar- 
ring  in  the  course  of  imeumonia  may  in  many  ways  resvinblc  tiie 
epidemic  form.  Tubercular  meningitis  usually  affects  thr  bate  prim** 
rily  and  especially,  whereas  in  other  forms  the  voiiveritiet  of  the 
hemispheres  are  affected.  Certain  changes  are  common  to  all  fomu 
of  meningitis.  The  pia  mater  is  intensely  hy]ienemic  and  rr<l,  m 
if  the  vessels  had  been  artificially  injected.  Soon  opacity  and 
thickening  of  the  membranes  occur,  recognixable  most  readily  in 
the  arachnoid;  and  along  the  course  of  the  vessels  ther»'  \*  an 
opacity  owing  to  distention  of  the  perivascular  lymphatic  shoatha. 
An  inflammatory  exudation  from  the  blood-vessels  of  the  pia  maUrr 
occurs :  this  may  be  serous,  sero-jiurulent,  or  purulent,  and  is  tnani- 
fest  especially  over  the  sulci  of  tlic  convexity  and  the  space*  at  the 
base  of  the  brain.  In  severe  cases  pus  mixed  with  fibrin  ftirros  a 
continuous  opaipie  yellowish  layer  under  the  visceral  layer  of  the 
arachnoid.  The  inflammation  usually  spreads  to  the  adjacent 
structures,  causing  neuritis,  encephalitis,  and,  later  on,  adheaious. 
The  ventricles  of  the  brain  and  the  interpeduncular  subarachnoid 
space  may  be  distended  with  a  turbid  serous  fluid,  and  the  diomid 
plexus  as  ^vell  as  the  velum  interpositum  is  usually  congested  and 
swollen.  This  fluid,  examined  microscopically,  may  be  found  to 
contain  large  granular  epithelial  cells,   leucocytes,  or  pus-cella. 

The  Ruppurative  process  is  extremely  marked  and  oAen  very  rapid 
in  formation  in  epidemic  cerebro-spinal  meningitis. 

PATHOLOGY. — The  first  stage,  or  period  of  exeitation,  is  cha- 
racterized by  htaiiiiehe,  delirium,  rii/i<lih/.  (jenrral  i>r  local  ruuvulM 
and  these  symptoms  can   be  accounted  for  by  the  general  hj] 
lemia  of  the  cortex  cerebri. 

The  si*cond  stage,  or  period  of  depre»*um,  occurs  a!»  the  inflam- 
mation extends  into  the  cortex  ami  motor  nerve.s,  paraliftf*  of 
various  kinds  npjiearing.  In  the  final  stage  the  increasing  cffusiua 
into  the  skull  and  the  rising  intracranial  pressure  induc«  muna. 


INFLAMMATION  OF  THE  NERVOUS  SYSTEM.  569 

INFLAMMATION  OP  THE  CENTRAL  NERVOUS  SYSTEM. 

Encephalitis. — Inflammation  of  the  brain  may  arise  from  three 
causes :  traumatic  injury,  inflammation  of  adjacent  structures,  and 
acute  infective  diseases — erysipelas,  typhoid,  typhus,  and  diphtheria. 
Striimpell  considers  that  infantile  cerebral  hemiplegia  is  due  to  a 
primary  systematic  inflammation  of  the  gray  matter  of  the  motor  cor- 
tex analogous  to  anterior  poliomyelitis;  hence  he  terms  it  Polio- 
encephalitis. Very  probably  the  two  diseases  have  an  identical 
cause.  Anatomically,  the  alteration  in  the  brain-tissue  which  results 
from  acute  inflammation  is  a  process  of  red  softening  (p.  78). 

Cerebral  Abscess. — The  causes  may  be  divided  into  local  and 
distant.  By  far  the  most  frequent  local  cause  of  cerebral  abscess  is 
chronic  ear  disease.  Inflammation  of  the  middle  ear  or  mastoid 
cells  is  often  followed  by  a  purulent  discharge  and  caries  of  the 
hone:  not  infrequently  arrest  of  the  discharge  is  followed  by 
abscess.  Occasionally  there  may  be  no  bone  disease,  only  suppu- 
rative inflammation  of  the  middle  ear  or  mastoid  cells,  and  in  such 
cases  the  infection  probably  passes  by  the  perivascular  lymphatics 
along  the  veins  which  connect  the  tympanic  eavity  and  mastoid  cells 
respectively  with  the  superior  petrosal  and  lateral  sinuses.  Disease 
of  the  nose  and  orbit,  syphilitic  caries  of  other  bones,  tumor  of  the 
brain,  and  injury  are  among  the  rarer  causes  of  cerebral  abscess. 
iHttant  causes  are  pyaemia,  gangrene  of  the  lung,  foetid  bronchitis, 
bronchiectasis,  and  empyema, — all  rarely  met  with. 

Morbid  Anatomy. — Abscess  is  usually  single,  but  there  may  be 
several,  and  in  pyaemia  sometimes  many.  Owing  to  ear  disease 
I'eing  such  a  common  cause,  abscess  is  met  with  most  frequently  in 
adjacent  portions  of  the  brain — viz.  the  temporo-sphenoidal  lobe 
and  the  lateral  lobe  of  the  cerebellum.  In  na.sal  and  orbital  dis- 
ease it  is  usually  in  the  adjacent  frontal  lobes. 

The  process  of  suppuration  commences  with  inflammatory  soften- 
ing ;  cell-infiltration  increases  greatly,  replacing  and  destroying  the 
normal  structure.  Pus  is  formed,  which  in  the  case  of  ear  disease 
is  usually  of  a  greenish  color  and  frequently  of  foetid  odor  and  acid 
reaction.  It  is  made  up  of  pus-corpuscles,  degenerated  cells,  fat, 
cholesterin,  hsematoidin,  and  micro-organisms,  usually  staphylococci. 
The  size  of  the  abscess  varies  greatly,  but  the  average  size  is  be- 
tween a  walnut  and  a  hen's  egg.  The  pus  is  contained  at  first  in 
an  irregular  cavity,  and  there  is  a  tendency  for  the  abscess  to  in- 
crease by  a  necrosis  of  portions  of  the  limiting  tissue ;  it  may  thus, 


870  PATHOLOGY  OF  THE  NERVOUS  SYSTEM. 

by  spreading,  burst  into  the  lateral  ventricles  or  externally.  It 
may,  however,  become  cncapsuled  by  connective  tissue,  and  the 
pus,  undergoing  mucous  degeneration,  becomes  thick  and  visei*!. 
It  is  thought  that  pus  thus  eneapsuled  may  dry  up  and  caseatv  or 
calcify,  or  even  be  completely  absorbed,  leaving  little  more  than  a 
scar. 

Myelitis. — The  term  myelitia  has  been  usetl  for  all  forms  of  do- 
generation  of  the  spinal  cord,  and  thus  we  have  the  subdirisioDS 
acute,  subacute,  and  chronic ;  or  it  may  be  considered  according  to 
its  localization,  and  then  the  terms  transverse  myelitis,  diflai« 
myelitis,  leucomyelitis,  poliomyelitis,  and  meningo-myelitis  are 
used. 

The  evidence  showing  that  primary  myelitis  does  not  occur  is 
accumulating,  and  the  true  causes  nre  probably  infective  organisms 
or  toxic  agencies.  Cold,  injury,  etc.  may  of)erate,  tt»  they  do  in 
pneumonia,  us  factors  in  lowering  the  vital  resistance. 

Of  all  the  infective  diseases  which  lead  to  these  various  forms  of 
myelitis,  syphilis  is  the  most  important ;  but  tuberculosis  (in  the 
production  of  Wai'a  disease  and  meuingo-myelitis).  epidemic  cerebnv 
spinal  meningitis,  gonorrh(ea,  measles,  diphtheria,  influenza,  scarlet 
fever,  small-pox,  un<l  typhoid  offer  examples  of  infective  diseaM-* 
which  have  been  fr)lIowed  bv  various  forms  of  myelitis.  Probably 
the  inflammation  is  due  to  the  toxinet  produced  in  the  blood  by  the 
infective  orjfanisnis.  Other  toxic  agencies,  such  as  in  ergotism, 
pellagra,  and  lathyrism,  offt'r  examples  of  reijetable  poiaoHB .-  lead 
and  arsenic,  of  minernl  poigotix, — any  of  which  may  cause  myelitiii. 

Acute  Myelitis. — The  naked-eye  appearances  are  variable :  the 
spinal  tissue  is  sometimes  s<>ftene<l,  pinkish-white  in  appearance. 
yellowish,  or  brownish-red,  according  to  the  condition  of  the  bl<HM|- 
vessels  and  the  amount  and  change  in  the  extravasatetl  red  bltMid- 
corpusdes.  (Vide  "Softening,"  p.  76.)  Very  early  one  finds  a 
large  number  of  granular  corpuscles  and  amyloid  bodies:  the  axis- 
cylinders  are  either  swollen  uj),  granular,  or  destroyed,  and  the 
myelin  sheaths  of  the  white  matter  are  rapidly  broken  up  and 
destroye<l.  The  ganglion-cells  undergo  degeneration :  their  pro- 
cesses are  seen  broken  off".  In  the  first  stages  they  become  globular 
and  |»ignu'nte(l ;  they  then  (iresent  signs  of  atrophy,  and  eventually 
may  oomjiletely  disappear. 

The  vv»*fh.  thrombosis  of  which  appears  in  many  cases  to  be  the 
determining  cause  of  the  above-mentione<l  changes,  are  gorged  with 


INFLAMMATION  OF  THE  NERVOUS  SYSTEM.  571 

blood,  and  their  lymphatic  sheaths  distended  and  filled  with  leu- 
cocytes, and  when  the  inflammation  is  very  intense  hemorrhages 
may  be  found.  There  is  an  increase  of  nuclei  and  small  round-cells 
in  the  gray  matter,  and  the  stellate  (or  Deiter's)  cells  arc  more 
numerous  than  normal. 

Later  the  connective  tissue  undergoes  proliferation,  and  there  is 
rapid  progressive  softening  of  the  nervous  elements,  owing  to 
granulo-fatty  degeneration.  The  process  thus  passes  into  the 
chronic  stage,  constituting  gray  softeninff.  Hemorrhages  may  occur 
in  these  foci  of  softening,  and  eventually  the  process  ends  in  a 
♦eferow*. 

Diffuse  Myelites  have  a  common  pathological  anatomy,  but  the 
cUnicai  symptoms  will  of  necessity  vary  according  to  the  seat, 
extent,  and  distribution  of  the  inflammatory  process.  In  the 
ordinary  acute  dortal  myelitis  phenomena  of  exaggerated  sensibility 
— such  as  pain,  numbness,  and  tingling — mark  the  onset,  which  is 
followed  by  paraplegia,  and  later  on  by  contracture,  with  exaggerated 
superficial  and  deep  reflexes,  due  to  the  removal  of  the  cerebral 
influence  by  degeneration  of  the  pyramidal  tracts  :  there  will  prob- 
ably also  be  wasting  of  muscles  and  the  reaction  of  degeneration 
due  to  destruction  of  anterioi'-horn  cells.  The  hyperaesthesia 
and  pain  are  due  to  inflammation  and  irritation  of  the  gray  matter 
of  the  posterior  horns,  and  the  aiioesfhesia,  which  later  on  replaces 
the  exaggerate<l  sensibility,  to  de.'^truction  of  this  gray  matter  and 
the  adjacent  commissural  white  fibres  of  the  lateral  column. 

Retention  of  urine  and  faeces,  due  to  tonic  spasm  of  the  sphincters, 
invariably  precedes  the  incontinence. 

Trophic  troubles,  especially  bed-sores  over  the  sacrum,  arise,  and 
these,  together  with  bladder  complications,  are  usually  the  cause  of 
death.  Rapid  wasting  of  the  muscles  of  the  leg  would  indicate  the 
invasion  of  the  lumbosacral  region,  also  the  absence  of  tonic  con- 
traction of  the  sphincters,  the  centres  of  which  are  situated  in  this 
region.  Involvement  of  the  arms  points  to  inflammation  of  the 
cervical  enlargement. 

Periependymal  (or  Central)  Myelitis  occasionally  occurs,  but 
the  effects  depend,  like  syringomyelia,  upon  the  amount  and  seat  of 
destruction  of  the  gray  matter. 

Menin^o-myelitiB. — Lately  Erb  has  called  attention  to  the  fact 
that  in  syphilis,  very  frequently  in  the  early  secondary  stage  of  the 
disease,  a  focal  myelitis  occurs  characterized  by  paraplegia,  with 


572 


PATHOLOar  OF  THE  yEHrOVS  STSTKSr. 


exaggerated  reflexes,  girdle  sensation,  retention  of  urine  and 
and  other  signs  of  a  lociil  transverse  lesion  of  tite  ennl.     The 
caae  is  rarely  fatal,  but  bed-sores  and  bladdt-r  coinplieationa 
ensue.     In  fatal  caaes  no   gumma  was  found,  only  a  tmiMiverM 
myelitis,  the  principal  feature  of  whieh  were  diffuse  niyolilix  of  the 
white  matter  (not  involving  definite  tracts),  local  thickening  of  Ui« 
meninges,   and  a  periphlebitis,   but  no  syphilitic  change*   in    tha 
arteries. 

Transverse  Myelitis,  pro<luced  by  Pott's  diseivsr,  nni-ury 
growtiis,  and  thickening  of  the  dura  mater.  The  syniptoras 
according  to  the  seat  of  the  lesion.  1'he  nie<diHni8m  of  the  «Ui 
to  the  cord  is  twofold — vix.  comjirvnnion  ami  infltninuatinn. 
cord  may  (iit  the  seat  of  compression)  be  tlnttene<l.  indented,  or 
«ven  reduced  very  greatly  in  size ;  on  section  it  baa  usnally  a  gny 
afipeanince.  The  microscopical  appenrancex  of  inflammation  corrr- 
spoud  to  those  already  describe*),  and  the  changes  in  the  con! 
altove  and  below  the  seat  of  injury  are  described  under  .SVrom/irry 
Degenerationt. 

The  pathological  effects  may  be  considered  under  two  distinct 
headings — liont-xi^mptoint  and  t'ord-^i/mptomt.  The  former  usaiJljr 
develop  first  in  the  form  of  ahootint/  painu,  owing  to  irritation  of 
the  sensory  roots  involved.  With  the  pain  there  is  osoallj 
hifpfrifHthifia  of  the  skin.  Irritation  of  motor  roots  cansc*  ptih^fmi 
contracture.  CWd-ttftnptontt  are — paresis  or  paralysis  below  Icmoos, 
inrrea»e  of  »uperfirial  rrflfrfu  and  of  mi/otatic  irrituhilitif.  Th'Tr 
may  be  no  loss  of  sensibility  discovcrnlde  in  the  parts  below  the 
lesion,  although  there  is  complete  paralysis,  but  there  msj,  on  the 
other  haiiil.  be  delay,  and  in  severe  eases  ab.solut«>  loas,  of 
The  ct)n<lition  of  the  sphincters  and  the  tendency  to  bed 
depend  U{ton  the  integrity  of  the  lumbar  enlargemenL  If  the 
lesion  is  in  the  lower  cervical  region,  the  pupils  may  be  affected 
from  implication  of  the  cilio-spinal  centre,  and  the  pnlse-rate 
diminished  from  damage  of  the  ac<'i-lerator  fibres  of  the  heart. 

Poliomyelitis. — An  acute  inlliimmation  of  the  anterior  eomua  it 
the  morbid  change  which  afl'ccts  the  spinal  cord  in  it^fantiU 
panilif»i»  and  iwute  tpimil  pantli/xix  of  the  adult.  Singer  and 
Munzer  have  shown  that  they  can  produce  a  d««truction  of  the 
anterior-horn  cells  of  the  rnbbit  by  coinpressioli  of  the  alMlominal 
aorta,  thus  cutting  oflT  the  supply  of  blood  to  the  lower  end  "f  the 
cord.     It  is  highly  probable  that  anterior  poliomyelitis  is  due  to 


lyPLAMMATIOy  OF  THE  NERVOUS  SYSTEM. 


673 


AJI 


DlaKTaminatlc  representation  of  the  supply  of  the  groups  of  anterior-horn  rclls  by  the 
radicular  branches  of  the  anterior  median  arteries,  showing  one  group  of  cells  completely 
deatroyed  by  occlusion  of  one  of  these  small  vessels,  and  thus  explaining  why  in  polio- 
myelitis there  is  usually  permanent  loss  of  movement  in  some  one  or  more  muscles.  (F.  W. 
Mott.> 


FlQ.   211. 


blocking  of  the  anterior  radicular  arteries  by  inflammatory  throm 
bosis,  possibly  of  infective  origin  (Fig. 
210),  by  which  one  or  all  the  groups 
of  cells  in  the  anterior  horn  are  de- 
stroyed, according  to  the  extent  of 
occlusion ;  thus  patches  of  softening 
arise  in  the  anterior  cornua  on  one 
or  both  sides.  The  appearances  pre- 
sented by  the  spinal  cord  may  vary 
very  considerably,  according  to  the 
length  of  time  which  has  elapsed  since 
the  onset  of  the  disease.  In  an  old 
case  examination  of  the  segments  of 
the  spinal  cord  corresponding  to  the 
nmscular  paralysis  (lumbar  and  cervi- 
cal enlargements  usually),  exhibits  a 
more  marked  translucency  of  the  gray 
matter  of  the  anterior  horns,  and, 
if  limited  to  one  side,  as  it  often  is, 
a  diminution  in  size  of  the  anterior 
horn  as  compared  with  the  opposite 
healthy  side.  The  anterior-horn 
cells  are  either  absent  or  here  and 

there  obtuse,  or  rounded  protoplasmic  Descending doKcncratlon  Inthepyr- 

1    J.            •»!        i                                    J      i    •  amidal  tract    following  hemorrhage 

bodies    without    processes,    and    stain-  into  the  internal  capsule.    The  direct 

ing    well    with     carmine,    are    seen —  tract  is  wcU  marked,  and  is  represent- 

.                          .                1.        1                        1  >■<' "'  0  lower  level  than  It  Is  usually 

probably     vestiges     oi      degenerated     seen.   (F.  w.  Mott.) 


574  PATHOLOGY  OF  THE  NERVOUS  SYSTEM. 

ganglion-cells  (Fig.  218).  The  fine  nerve-plexus  around  the  cells 
is  either  greatly  diminished  or  completely  absent,  and  only  neur- 
oglia and  Deiter's  cells  may  be  visible.  The  vessels  are  thickened. 
When  the  lesion  is  bilateral  it  is  rarely  symmetrical ;  more  frequently 
it  is  unilateral,  and  it  \rill  then  be  observed  that  there  is  secondary 
atrophy  of  correlated  structures  of  the  same  half  of  the  cord — vix. 
of  the  posterior  column,  antero-lateral  column,  and  posterior  horn, 
and  some  observers  have  described  atrophy  of  the  corrcsjionding 
motor  convolutions  of  the  brain.  Atrophy  of  anterior  root-fibres 
must  occur.     Atrophy  of  the  bones  has  also  been  found. 

Landiry's  Paralysis  (acute  ascending  paralysis):  no  definite 
lesion  has  been  described ;  it  may  be  due  to  the  efiects  of  a  toxine 
acting  upon  the  central  or  peripheral  nervous  system.  Hie  ab$enre 
of  troubles  of  nutrition  and  sennbility  points  to  the  poison  acting, 
like  curare,  especially  upon  the  motor  tract,  and  serves  to  dis- 
tinguish the  disease  from  acute  myelitis  (p.  570). 

ObbebkaIi  Hemobbhaob. 
The  various  forms  of  softening  which  follow  vascular  occlusion 
have  already  been  described.  Cerebral  hemorrhage  is  the  most 
fre»juent  cause  of  hemiplegia  in  subjects  who  have  passed  forty, 
and,  according  to  Gowers,  it  seldom  occurs  under  that  age  unless 
Bright's  disease  or  aneurysm  exists — the  latter  produced  by  infective 
embolism  and  subsequent  infective  inflammation  of  the  walls  of  the 
artery,  which  may  eventually  lead  to  '\K»  rupture.  The  association 
of  granular,  contracted,  or  gouty  kidney  with  apoplexy  has  long 
been  recognized,  the  conditions  being  favorable  to  the  rupture  of 
the  delicate  cerebral  vessels.  It  has  been  shown  by  Charcot  that 
in  most  of  these  cases  of  hemorrhage  minute  miliary  aneurysm.s  are 
found  on  the  small  vessels  entering  the  substance  of  the  brain 
(p.  17H):  but  there  is  one  artery  in  particular,  the  left  lenticulo- 
striate  artery,  which  is  especially  liable  to  disease  and  rupture,  and 
which  has  therefore  been  called  "  the  artery  of  hemorrhage."  In 
Bright's  <lisease  there  is  high  arterial  tension,  due  to  hypertrophy 
of  the  left  ventricle  and  increased  peripheral  resistance.  The  small 
arteries  which  supply  the  basal  ganglia  come  ofi"  directly  at  right 
angles  from  the  large  arteries  at  the  base  of  the  brain :  they  are 
terminal  arteries,  and,  like  all  the  intracerebral  vessels,  they  are 
not  supported  by  the  substance  of  the  brain,  being  surroundetl  by  a 
perivascular  lymphatic  sheath.     It  is  easy  to  understand,  therefore. 


^MORRHAOE. 


576 


•why  aneurysms  should  form  and  rupture  on  these  delicate-walled 

Fio.  212. 


Hocrndlnit  dei^ncrntfon  in  the  commH-iihspeil  tract  and  In  the  Intcrmcdlo-latcrnl  anil 
Ihcrniwi'cl  pyrainUlal  trxi'tx.  The  ilniwhiK  Is  mudo  fnim  a  sui-tlon  of  the  spinal  curd  in 
Uu  upixT  ilonai  rcglim  Jiisl  Ix'Iow  the«o»t  of  rompreodlon  of  a  smali  giiuina.  The  direct 
locti  wurv  in  ttiib  Instance  snittll,  not  reaching  into  tiie  dorsal  region.  The  darkne«a  of  the 
utmr't  iiiexai!][eratcd,  and  the  other  deaceudlng  degeneration  la  liuufflcieutly  repre- 
(K.  W.  MoU.) 

vessels.     Moreover,  most  authorities  state  that  the  vessel-walls  are 
Jiseaiied.     Charcot  heM  that  it  wa.s  a  Fiu.  213. 

periarteritis,  while  others  affirm  that  it 
is  an  endarteritis. 

'•ther  conditions  which  {>redi.'<|iose  to 
t'crehi-al  hcrai>rrhaf:o  aru  load,  alcohol, 
syphilis,  an<l  inherited  tendency  to  arte- 
rial iliscase.  It  may  occur  aLso  in  tumors. 

The  effffts  jrrodueiHi  by  hemorrhage 
<iepend  upon  its  situation  and  aiw :  the 

most  frequent  seat  is  the   untericn-   part      the  spinal  cord    in  the   mld-dor«al 

*  ,  .  .        ,  ,       region.     The    ncctioii    shows   well- 

Of  the  OptO-Striate  nias.^f   Ul  the  external       marked  degern'ratlon  oftJoiracol- 

capdule,  hut  when  paralysis  occur.s,  as  it     "™"'  "f  ">'•  '"f"'  "•«■'*""  «™ci, 

'  •  and  of  thi^  anterolateral  tract*  on 

usually  does,  the  cause  is  damage  of  the       the  same  Bide  a*  the  lealon.     (K.  w. 

pyramidal  fibres  of  the  hinder  liinl)  of     *•""> 

the  internal  cajisiile.     If  tlic  lo.nion  be  not  severe  enough  to  cause 

death,  various  changes  occur  in   the   effused   blood  and  damaged 


The  awendlnir  Iracu  of  dcgenent- 
tion  In  tlie  ccrvloiil  enlargement 
after  cxperimentnl  heminectlon  of 


676 


PATHOLOGY  OF  TUB  XERVOVS  SYSTEM. 


Vm.  214. 


nerve-tissues.  For  the  first  few  days  flic  clot  AUh  the  whole  cantT 
and  does  not  undergo  shrinkage ;  then  n  grnnulo-ttttty  dcgt^Dcmiiua 
takes  place,  with  absorption  of  the  products  (p.  106). 

In  severe  cases  of  hcuiorrhitge  cnusing  death  irruption  of  hl«Kt4 
may  take  place  into  the  lateral  ventricle  of  the  Miaie  sjilf ;    thra 

it  uiay  pass  through  the  fontmrn   of 
Munru  into  the  opposite  latcrnil 
triclc.     Occasionally    it    may  Sod  r 
way  from  tlie  third  ventricle  throaf^ 
the  aqueduct  nf  Sylvius  and  into  tlte 
fourth    ventricle,  and,   in    rare 
theme   through  the  fornnien    of  M»- 
;j;endie  into  the  subarachnoid  Bpaoe. 

Secondary  Deoenvbationb. 

As  a  result  of  destniction  of  brain 
substance  secondary  degcncratioiu 
arise,  the  most  characteristic  of  which 
is  the  secondary  degeneration  arising 
from  destruction  of  the  pvninidal 
cells  of  the  luotor  area,  or  of  tKetr 
fibre:*  in  the  anterior  two-third*  af 
the  posterior  half  of  the  ititrraal 
capsule,  such  as  occur*  in  our^-bral 
hemorrhage.  It  is  quite  obvious, 
however,  that  a  similar  deg\*tirratiwh 
may  arise  as  a  result  of  M>nening  tb 
emijolism  or  thrumb<wii»  of  the  mid- 
dle cerebral  artery  or  it"  branches, 
in  meningeal  hemorrhage  anil  tumors, 
or.  in  fact,  in  any  lesion  which  cause* 
destruction  of  the  pyramiilal  cells  of 
the  eortox  of  the  central  oinvolutiorfs 
or  which  cuts  off  the  connection  i»f  the 
nerve-fibres  from  the  cells  of  wkicb 
they  are  tho  outgrowths  (Fig.  211)t 
As  a  rule,  rerrfirnl  letioH*  IcadiSf 
are  unilnterol,  and  nfimtl  are  hilatend, 
of  pyramidal  fibres  are  degchiTalnl  ia 
proceeding  from  one  hemisphere  by  the 


SrrtWin  of  (puul  oonl  sboal  the 
vlillilli  •tiinal  acKiiiviit  inrum  •  cms 
of  liKvimoUir  «tii»yi  Then>  l»  nrloro- 
■1*  of  ilir  iKDiUTDcxtrmitl  culiimn 
■ii<t  alnipliy  of  (l>r  flnc  |ilrxii»  of 
nmi-  tllirllt  •iirr<iim<Uiii{  Uir  nOU  nf 
Clitrku  «<-oIiinin  :  mnrcovir.  *  twiirt 
nf  i>4*l«>rtNlt  U  wrw  rnt.'rltiK  thr 
c«»ltiinii  IhMti'Nil  <^f  thr  htiitfUt*  (if 
nervi' niirc*.  Tlu-  rrlU  ilii'inwlvi'" 
■tv  >tr<i|>lil»l  linil  ihclr  phk-omm 
dMlmyi-)!  Tlil«  <•»»«'  *«»of  liitrnvt 
tKH>«tuc.  In  njiinrcllon  with  Ihiiu' 
Imliitm,  Ilm  |iallrtil  tiftil  wrll  niHrkrd 
vlnrrrnl  »yin|i(Hiiii»— Kii»lrii*  rri»**», 
tU<l<l<'r  trfiiiWi-«.«ii'l  lurviiict'iil  <ri«l« 
—  III  rulilltloii  Ui  tlu'  onlinary  aUilr 
nymiitoniK.  v  ic«i(U«iucWr».  (K.  W. 
MoU.) 

to  wcondary  degenerations 
In  the  former  only  one  set 
the  »pinal  cord — viz.  thos* 


SECOyDAIiY  DEGENERATIONS. 


677 


internal  capsule,  the  middle  jwrtion  of  the  crus  cerebri,  the  pons, 
and  the  luodiiihi,  where  the  greater  miiiiber  ik'cu.s-iate  in  the  ante- 
rior pyramid  to  form  the  crossed  pyraiiiidiil  tract  i>f  the  opposite 
side ;  some  (about  one-tenth)  pass  in  the  direct  tract  down  the  cord, 
decussating  at  hjwer  levels. 

Secondary  degene^lti<^us  arising  from  lesions  of  the  spinal  cord 
are,  in  nearly  all  cases,  bilatenil,  and  affect  not  only  the  dvKrf.nding 
tracts,  which  have  their  centres  of  nutrition  in  the  cortex  cerebri, 
but  also  the  ngrenJinif  tracts,  which  have  their  centres  of  nutrition 
in  the  posterior  spina!  ganglia  and  gray  matter  of  the  cord.  The 
ascending  and  descending  yround-jibreis,  whicii  unite  the  different 
segments  of  the  crus.  pons,  niediilla.  and  cord  tugetLer  in  co-ordi- 
nate retlex  action,  degenerate  both  above  luid  below  the  lesion  for  a 
variable  distance ;  and,  besides,  there  is  a  small  tract  in  the  pos- 
terior eoliinm  wliich  degenerates  downward  in  transverse  lesions  of 

Ft';.  2Ii. 


Belenolitoi  iln-  |M».tvrUir  iiiLiliuii  I'liliimnr  In  tlic  trrNual  rt'^l»ii>,,  <lur  t»«|>lnal  menlnirt- 
*^  Involving  tliu  fKiiitorlor  nervo-rootj*,  Hbn*fi  fmiu  whirh  lUirend,  iininterru|>lc(l  1»>  cfUs,  ia 
^K^^r  (Kigterior  meillaii  culiiiunii.    (SiK'clmt>n  aiid  photograph  liy  F.  W.  Mutt.) 

^■^hc  cord  in  the  dorsal   region  ;   it  is  termed,  on  account  of  its  cha- 
■^^acteristic  form,  the  romma-Hhaped  tract  (Fig,  "212). 
H       The  ascending  degenerations  come  under  two  classes  : 

(1)  /;*  the  Pogtertor  Coluinii*. — Short,  medium,  and  long  coursing 

fibres,  having  their  origin  in  the  central  portion  of  the  T-shaped 

Process  of  the  posterior  spinal  ganglion-cells. 

37 


678 


PATnOLOOr  OF  THE  yERVOUS  srsTE3r. 


Tilt'  short  fibres  form  Lissauer's  tract,  at  the  base  of  the  posterior 
Lorn ;  the  mt'<liinii  fibres  cuter  the  postero-external  column,  aad 
after  a  short  c■ollr^<e  disnppcar  in  the  gray  mattt-r:  and  the  long 
fibres,  after  eutering  the  pcwterior  column,  are  iiushe*!  b»ck»anl 
and  towunl  the  tnediiui  line  to  form  tlie  posterior  uifdian  (<i»ir*) 
column.  Secondary  degeneration  limited  to  the  poftfrior  <.*ulumd 
indicates  a  root-lesion,  such  as  from  tumor  of  the  cnuda  o«|iiin«  or 
injury  of  posterior  spinal  rooU  (Fig.  21.*)). 

(2)  Jn  the  Antero-latvral  Cvhimii. — There  are  tliree  .»eii«  of  fibm 
occupying  the  periphery.  'I'hey  all  arise  firom  evil*  in  the  grttr 
matter.  The  posterior  tract  consists  of  large  fibrti*  jirobahlr  deriTcd 
from  axis-cylinder  projections  of  the  cells  of  Clarke's  (Hilumn.  and 
termed  liirect  or  dursal  rrrrhrVar  tract ;  the  nnUrutr,  conxi«>tiDg  "f 
two  sett)  of  fibres,  iu  all  probability  arising  frtmi  cvlla  of  the  fpvf 
matter  of  llic  opjwsite  horns,  the  deeiissiiilion  taking  place  in  the 
anterior  commissure.  It  has  several  mimes — viz.  (towers'  tract, 
antero-lateral  tract,  and  ventral  cervhelhtr  tract,  because  most  of  th« 
fibres  can  be  traced  by  a  curious  course  to  the  midille  1oIh»  of  the 
cerebellum.  The  less  numerous  fibres  enter  into  the  fillet  and 
probably  end  at  the  corpora  quadrigemina. 

The  functions  of  these  tracts — that  is  to  nay.  the  kind  of  impultea 
they  conduct — is  not  known.  At  one  time  it  was  t'  '  that  all 
sensory   iuipulses.  except   those  of  the  muscular  sii-  na^atetl 

immediately  on  reaching  the  cord;  and  this  view  was  held  beea«M 
in  most  eases  of  heiuilesion  of  the  spiiml  cord  a  group  <if  *ympt^^^| 
occurs  termed  Jirowii-SetjuarJ  paraly»i;  which  briefly  is  hjffl^ 
etsthesia  and  parali/tU  on  thr  tide  of  the  letion.  mid  aiitfutkeria  «m 
the  »ide  opjwsite  to  if.  Latterly,  Brown-S(5i(Uard  gave  up  the  thoorr 
of  immediate  decussation  of  sensory  impuUes.  but  tuaintaiur-*!  ju^r 
that  as  a  means  of  diagnosis  the  Hr<»wn-Se<juar<l  phenomenon  was 
most  valuable.  Ilemisection  of  the  spinal  cord  in  monkeys  and 
other  animals  is  followed  by  paralysis  on  the  side  of  the  lesion,  bat 
most  recent  observers  have  been  unable  to  fin<l  either  hy|)enesthiecia 
of  the  same  side  or  aniesthesia  of  the  opposite  side  (Fig.  218).  (For 
further  information  upon  the  conduction  of  sensory  impolaca.  Me 
p.  5H6.) 

The   common    causes   of    ascending   and    descendioft   Mdondary 
degenerations  of    the    spinal    cord    are   forni    lesions    prtwineed   by 
injury,  pachymeningitis  in   I'ott's  disease,  meningitis,  and  t 
causing  a  local  transverse  myelitis  (p.  572). 


PRIJUARY  PATHOLOGICAL  DEGENERATIONS. 


579 


Primary  Pathological  Deoenebations. 
Primary  systemic  degenerations  may  affect  either  the  afferent 
sensory  paths  or  the  efferent  motor  paths,  and  not  infrequently  the 
two  are  combined. 


Fig.  216. 


1.  DBQBNBRATIONS  OP  AFFERENT  TRACTS.— These 
systemic  degenerations  have  been  looked  upon  as  primary  scleroses, 
the  atrophy  of  the  nerve-fibres  being  secondary  to  overgrowth  of 
the  neuroglia  connective  tissue  and  changes  in  the  vessels.  It  is, 
however,  more  probable  that  the  sclerosis  is  secondary  to  a  progres- 
sive atrophy  of  the  nerve-fibres,  brought  about  by  retrogressive 
ishanges  in  the  nutrition  of  the  ganglion-cells  of  which  the  nerve- 
fibres  are  projections. 

The  causes  of  the  nutritional  degradation  of  the  nerve-cells  are 
inherited  defect  and  various  functional  excesses,  by  which  they  are 
unable,  under  altered  conditions  of  the  medium  of  nutrition,  to 
maintain  the  nourishment  of  their  axis-cylinder  processes;  hence 
their  degeneration. 

The  nutrient  medium  and  its  supply  are  especially  liable  to  be 
affected  by  the  poison  of  syphilis, 
alcohol,  and  lead,  but,  inasmuch  as 
each  and  all  of  these  may  also  pro- 
duce changes  in  the  vessel-walls, 
it  is  difiicult  to  decide  whether  in 
many  cases  the  vascular  changes 
may  not  be  primary  to,  or  at  any 
rate  simultaneous  with,  the  nutri- 
tional changes  of  the  nerve-cells 
and  their  processes. 

Locomotor  Ataxy,  or  Tabes 
Dorsalis,  is  the  commonest  exam- 
.  pie  of  primary  systemic  degenera- 
tion of  the  afferent  tract.  Recent 
observations  have  shown  that  the 
peripheral  nerves,  as  well  as  the 
posterior  columns  of  the  cord, 
undergo  degeneration ;  and  this 
supports  the  view  of  Marie  that 
the  primary  change  is  a  nutritional 
defect  of  the  ganglion-cells  on  the  posterior  root. 


-C_A^^ 


Diagram  to  represent  the  lesion  in  an 
advaneod  ciwe  of  locomotor  ataxy.  The 
light  parts  indicate  the  sclerosis.  It  will 
be  observed  that  nearly  the  whole  poste- 
rior column  is  alTecled.  and  there  is  an 
atrophy  of  the  fibres  of  the  root-zone  and 
of  the  plexus  around  the  cells  of  ("larke's 
column,  which  appears  clear  in  conse- 
quence of  the  absence  of  the  nervous 
reticule  which  exists  in  healthy  spinal 
cords.  The  number  of  cells  has  not 
diminished.     (F.  W.  Mott.) 


In  this  disease 


680 


PM'UOLOOY  OF  THE  NERVOUS  SYSTEM. 


there  ia  not  Iom  of  motor  power,  but  inco-onlinntioii;  ami  tiif  motiir 
effi-rent  fibres  of  the  pcripht-ral  uorves  are  intact,  which  tend*  t<i 
prove  that  the  sensory  fibres  are  seleoted ;  but  in  urdiuiiry  periph- 
eral neuritis  from  alcohol  both  motor  and  sensory  (ihres  anWvr. 
A  primary  vascular  ciiiinge  in  the  nerve-fibre*  would  ■ffiH-t  ba<k 
motor  and  sensory  paths.  Again,  it  is  difficult  to  understand  how  • 
primary  vascular  change  in  the  cord  should  be  confine*!  tu  aueh 
narrow  Iimit«  as  the  ])osterior  column.  If  reference  b«  made  l« 
Fig.  205,  it  will  be  seen  that  nutrient  changes  in  the  |;augli<iu-c«Ua 
could  produce  simultaneous  degeneration  of  the  teriuiniilKin  of  their 
T-shaped  processes.  It  has  been  ascertained  that  the  gsingliou-ceiU 
of  the  |>osterior  spinal  ganglia  are  not  ib'Stroyt'd  in  tabes,  hut  ihrir 
axis-cylin<ler  prolongations  in  the  cord  umlergo  liegciieratiou  and 
atrophy ;  consequently,  a  aclerogia  occurs  in  the  thret>  a.HC4<nding 
tracts  of  the  spinal  cord  previously  mentioned — vi/..  Listsnuer'K  imct, 
the  jiostero-external  colutun  an<l  root-xoue,  and  (iidj'n  column. 
There  will  also  be  atrophy  of  the  fine  nerve-network  formed  by  ibe 
terminals  of  the  j)ostero-extcninl  coliiiiin  around  the  cell*  <>f  Clarke'* 
column  (Fig.  214).  In  advanced  ataxy  almost  the  whole  piV'iterior 
column  may  uiulergo  atrophy  or  sclerosis  (Fig.  21lS). 

Morbid  Anatomy. — To  the  naked  eye  the  jMntterior  rolumns  have 
a  gray  transparent  up[)earunce  on  trnnsver.oe  section.  The  pi»  msltf 
is  usually  thickened  and  adherent  to  the  disea-sed  part*.  Oq  mier»- 
scopical  examination  two  stages  of  degeneration  may  b«  rrcu^isad* 
corresponding  more  or  le<<«  to  the  j>rr-a(tij-ir  and  ^l^'  '"*dt. 

The  first  is  characterized  by  increase  in  the  neui^  .  -^vm 

slight  swelling  of  the  diseased  parts ;  the  second,  by  tflerotie  atmpMjf. 
It  is  especially  the  Inmbo-sacral  regions  f»f  thr  spinal  cord  which  are 
alTecteiL  The  earliest  jMjrtions  of  the  posterior  columns  to  unilcrgo 
degeneration  are — (1)  the  part  rxtemal  to  Iiurdacb'»  culuinn  \tlng 
in  contact  with  the  posterior  horn  (the  root-/.one);  (2)(ioirs  ttdumn; 
(3)  Lissauer's  tract.  In  an  advanced  eaxe  the  remainder  of  lixr 
|M>sterior  columns  and  the  network  around  the  cell*  of  Clarke'* 
column  are  affected. 

J/iHto/oi/iriillij,  the  process  consists  of  wasting  of  the  uervc-fibn* 
in  the  tracts  mentioned  and  overgrowth  of  neiiroglia-ltHHne  ;  a*  thr 
disease  progres.ses  the  nerve-fibres  waste  and  <liiuippe«r.  and  the 
overgrowth  of  connective  tissue  which  proceeds  from  thr  rtttrl' 
walls  and  the  trabecuhc  coming  in  from  the  periphery  gradnalljr 
replaces    the    nerve-fibres,   and,  by   shrinking,  prtMloces   •r&nrftr 


PRIMARY  PATHOLOGICAL  DEGENERATIONS.  581 

atrophy    of   the   posterior   columns.      There   is   simultaneously   a 
wasting  of  the  peripheral  nerve-fibres. 

The  first  or  pre-ataxic  stage  is  characterized  by  absence  of  the 
knee-jerk,  lightning  pains,  Arggll-Robertson  pupils,  frequently  vis- 
ceral crises,  gray  atrophy  of  the  optic  nerves,  and  ocular  paralyses. 

The  ataxic  stage :  motor  inco-ordination,  variou.s  sensory  dis- 
turbances— notably  numbness  in  the  soles  of  the  feet  and  inability 
to  itand  with  the  eyes  shut — trophic  disturbances,  such  as  perforating 
ulcer,  joint  affections,  and  atrophy  of  bones,  etc. 

The  visceral  crises  have  been  as."?ociated  with  affection  of  Clarke's 
column,  but  it  is  highly  probable  that  they  may  be  due  to  nutri- 
tional disturbances  in  the  sympathetic  ganglia,  just  as  the  other 
symptoms  are  supposed  to  be  due  to  nutritional  disturbances  of  the 
spinal  ganglia  of  the  posterior  root.  The  loss  of  the  knee-jerks  is 
tbe  earliest  and  most  constant  symptom  :  since  the  root-zone  (ban- 
delettc  of  Charcot)  is  the  earliest  an<l  most  constant  lesion  of  ataxy, 
it  is  highly  probable  that  the  loss  of  the  knee-jerk  is  connected  with 
the  atrophy  of  those  fibres  derived  from  the  third  and  fourth  pos- 
terior lumbar  roots,  which  on  entering  the  spinal  cord  take  up  this 
position  for  a  short  distance  before  entering  the  gray  matter  (Fig. 
206).  Changes  have  been  found  in  certain  cerebral  convolutions. 
Jt  is  possible  that  tabes  dorsalis  is  a  degenerative  disease  of  the 
*hole  afierent  tract. 

Ataxic  Paraplegia  is  a  disease  in  which  there  is  a  combination 
of  symptoms  of  lateral  sclerosis  and  ataxy.  The  knee-jerks  are 
exaggerated.  The  combined  sclerosis  of  the  lateral  and  posterior 
columns  explains  this  condition. 

Friedreich's  Disease,  or  Hereditary  Ataxy,  is  a  lesion  of  the 
posterior  columns,  as  in  ataxy,  but  also  an  atrophy  of  the  cells  of 
Clarke's  column,  and  consecjucntly  degeneration  of  the  direct  cere- 
bellar tract ;  moreover,  in  some  ca.ses  the  crossed  pyramidal  tracts 
are  affected.  Beyond  the  hereditary  history  nothing  is  known  of 
Its  etiology.  It  may  therefore  be  considered  due  to  an  inherited 
developmental  defect  by  which  certain  nervous  .structures  undergo 
atrophy,  and  the  neuroglia,  hyperplasia. 

2.  DBQBNBRATIONS  OP  EFFERENT  TRACTS.-  The  most 
"nportant  are — (1)  primary  lateral  sclerosis ;  (2)  amyotrophic  lateral 
*<^lero8i8 ;  (3)  progressive  niuscular  atrophy.  In  all  these  di.seases 
*y*teinic  degeneration  of  tracts  of  nerve-fibres,  vascular  changes, 


682  PATBOLOar  OF  THE  NERVOUS  SYSTEM. 

and  overgrowth  of  connective  tissue  occur.  Which  is  the  primary 
process — the  atrophy  of  the  nervous  elements  or  the  vascular  changes 
and  sclerotdt?  The  protoplasmic  processes  of  the  ganglion-cells 
project  into  a  lymph-space  which  is  in  connection  with  lymph- 
ca|)illaries  or  with  the  perivascular  lymphatics  of  the  small  ve«isels. 
It  is  common  to  find  in  chronic  degenerative  processes  of  the  central 
nervous  system  periarteritis  and  distention  of  the  perivascular  lym- 
phatics with  leucocytes.  It  might  be  reasonably  argued,  therefore, 
that  the  poisons,  such  as  alcohol,  lead,  and  of  syphilis  (the  most 
potent  factor  in  the  production  of  nervous  disease),  produced  their 
effects  by  direct  action  upon  the  vessels.  There  are,  however, 
instances  of  degeneration  by  no  means  uncommon — e.t/.  amyotn>- 
phic  lateral  sclerosis  and  progressive  muscular  atrophy — in  which 
none  of  these  factors  may  exist,  and  the  changes  in  the  vessels  and 
neuroglia  must  be  considered,  therefore,  due  to  a  primary  atmphy 
of  the  ganglion-cells  and  their  processes.  Strychnine  and  the 
toxines  produced  by  the  bacillus  of  tetanus  and  diphtheria  are  ex- 
amples of  pctisona  which  act  directly  uiK)n  the  nerve-cells  or  their 
processes;  and  Langley  has  shown  that  nicotine  has  a  specially 
poisonous  effect  upon  the  cells  of  the  peripheral  ganglia.  It  is 
possible  that  syphilitic  toxines  may  vary  in  different  individuals,  or 
that  hereditary  defects  may  determine  the  seat  of  action  of  the  toxic 
agency.  In  scmie  people  the  vessels  suffer  first,  in  others  the  nerve- 
cells,  while'  in  others,  again,  both  vessels  and  Der^e-eleuients  may 
be  affected  simultaneously. 

Primary  Lateral  Sclerosis — termed  "  idiopathic  "  when  there  is 
no  local  disease  affecting  the  jjath  of  the  pyramidal  fibres  from  the 
cortex.  It  is  in  all  probability  due  either  to  a  proc<'8S  of  softening 
from  vascular  occlusion  or  retrogressive  nutritional  changes  in  the 
cells  of  the  cortex  of  the  motor  area  by  which  the  pyramidal  trm-tt 
df;li'ner»ti\ 

Proerreseive  Mviscular  Atrophy  and  Amyotrophic  Lateral 
Sclerosis  are  probably  one  and  the  same  disease.  In  the  former, 
the  more  conuiion.  the  degeneration  commences  in  the  lower  segment 
of  tlie  motor  |mtli.  and  the  primary  change  is  in  the  anterior-horn 
cells  (Figs.  217  an<l  21X):  but  sooner  or  later  the  up{)er  pyramidal 
segnu-nt  of  the  motor  patii  is  affected.  The  changes  in  the  anterior 
coriuiii  and  muscles  resemble  tho.se  met  with  in  old  anterior  |K>lio- 
m\elitis  alnmly  described.  Clinically,  the  affection  of  the  pyramidal 
tracts  is  not  demonstrable,  owing  to  the  primary  wasting  of  the  an- 


PRIMARY  PATHOLOGICAL  DEOEtrERATIOXS. 


583 


terior-horn  cells  and  their  corresponding  muscles.     In  the  amyotro- 
phic form  the  process  commences  in  the  upper  pyramidal  segment 

Fio.  218. 


Fio.  217. 


Anterior  eomini  from  n  ra»e  of  pollomirellti!!,  "bowing  atrophy  of  the  i;fineUon.ocUii.    For 
>in{Mriiion  the  iippi'iinuicf  of  ii  hvaltliy  anterior  corimalf  shown.    Thi'BmnU  black  trlaugtes 
**pr<3vQt  the  cclla  as  thvy  appear  iiiuU-r  a  low  inaie;iiincatiou.    (F.  W.  Mult.) 

of  the  motor  path      There  are,  therefore,  exaggerated  deep  reflexes, 
accompanied  or  followed  by  a  progressive  and  characteristic  wasting 

Fta.  219. 


l^r^'**o-tnl<-roKr«ph  ofanection  of  the  cervirul  siplrial  cord  (from  a  case  of  amyotrophic 
j^.  '*'  fclertais).  Degviieration  of  the  cr(«gf(l  pyrnnildal  ami  direct  tracts  and  the  anlero- 
^^'•l  fround-rtljrei!.  The  direct  eerelR'Hur  trHcts,  the  untcniluleral  aaeendini:  traeta,  and 
"*^ally  the  [Kisterlor  eolumris.are  iinHlteeted     There  waj>  almotd  complete  alweiire  of  eelU 


'•le  nerve-Hhrc  n-tlculiim  In  the  anterior  honis :  this  1»  obacrvable  by  the  diflerence  in 


^B        "•■  *»  compared  with  the  posterior  liom!(.    (F.  W.  Mott.) 

of 


> 


groups  of  muscles,  owing  to  degeneration  of  the  anterior-horn 
"^^Ib.     Ivide  Figs.  219,  220,  221.) 

*liefle  cases  of  amvotropliic  liiU'ral  sclerosis  strongly  siipport  the 
*cw  that  there  may  be  a.  priiiiary  retrogressive  nutritional  change 


684  PATHOLOOT  OP  THE  yKRVOVS  SYSTEif. 

in  the  ganglion-cells,  fullowptl  by  n  i>rogre8i!«ive  wasting  of  rhc  nru- 

Fio.  220. 


TlMibHStiMTloiia  ftenri',  rxt-rH  ilini  (hi-  >i-ctluu  u  «l  tlw  waalh  ki  ciclitli  ihiifl  m^  ] 
'  Bivnl*.    Thr  vynmliUI  trarU  iiri'  iirK'rviiwil,  iinil  thrrv  U  c<in>titM»bl*  d«(nwrat<aii  I 
lnt«rnio<llo  Intrral  lr»ct      iK.  W.  Molt.) 

rnng.  commencing  at  the  terminals  and  gradually  spreaiiing  up  tbe 
pyramidal  tract,  because  in  some  cases  tiie  degeneration  haa  bvm 

Pici.  321. 


r>ni. 

<  '  — ftliin  i>f  •  fH" 

!■!   H    , 

r  i>f  IJic   til 

Vlllt'l     '■ 

.iiicn*  H'i*rv  1  • 

■f  Ou'  tilimr  ni<rvi>  (Vtiiii  llii^  miik*  t-juc.  uttli 
with  CHtnlr  Arlil.    \Y<m  nrrount  t%t  tlir 
(.•  iiiN.  v<il.  I.,  IxC.  1    iF.  W   M.<l  1 


found  to  extend  only  a.t  hi^h  hj*  tlie  nti^dnlln,  in  otbfn*  to  the 

or  crua,  while  in  others,  again,  the  internal  enpstule  and  the  oirtvt 


PRIMARY  PATHOLOGICAL  DEGENERATIONS.  685 

have  been  aflFected.  Bulbar  paralysis  is  the  same  disease  as  pro- 
gressive muscular  atrophy,  and  is  due  to  a  degeneration  affecting 
tlie  motor  nuclei  of  the  medulla,  particularly  a  group  of  cells  known 
as  the  glosso-labial  laryngeal  nucleus.  It  often  forms  the  final  stage 
of  progressive  muscular  atrophy. 

General  Paralysis  of  the  Insane  is  considered  by  many  author- 
ities to  be  due  to  a  primary  nutritional  change  in  the  cells  of  the 
cortex  cerebri.  The  etiological  factors  of  the  disease  are  hereditary 
defect,  alcohol,  syphilis,  mental  overwork,  sexual  excess,  and  anx- 
iety. The  pathological  process  in  the  brain  bears  a  resemblance  to 
the  changes  in  the  cord  in  tabes.  There  are  chronic  thickening  and 
opacity  of  the  membranes,  pert-encephalitis ;  the  vessels  are  often 
gorged  with  blood,  and  their  walls  thickened  and  in  a  state  of 
chronic  inflammation.  The  perivascular  lymphatic  sheaths  are  dis- 
tended and  filled  with  leucocytes.  The  ganglion-cells  of  the  cortex 
are  degenerated ;  some  are  swollen  up,  others  atrophied,  and  there 
is  an  overgrowth  of  connective  tissue  and  increase  of  the  glia-cells. 
Generally  the  frontal  lobes  of  tiie  brain  suffer  first :  the  symptoms 
are  varied  and  depend  in  a  great  measure  upon  the  portions  of  the 
cortex  which  are  most  affected.  Second- 
ary degenerations  of  the  spinal  cord  fre-  Fw-  222. 
quently  occur.  In  some  cases  general 
paralysis  may  be  associated  with  ataxy. 

Insular     Sclerosis. —  Disseminated 

throughout  the  central  nervous  system  in 

the  gray  and  white  matter,  more  often  the       „   ..        ,  ,^       ,,  ,      ■, 
"     ■'  .  _'  Softion   of  the    mid -dorsal 

latter,  are  varying  sized  islets  of  sclerosis,  spinal  cord  (from  a  ca«e  of  in- 
consisting  of  a  feltwork  of  fine  neuroglia-  -''Lrrned  ",!  ^^ 
fibrils  (Figs.  222  and  223).     This  sclero-     ciipying  no  definite  tract,  is 

,  ,  .  ,        .      -.XT   1        sffn  In  the  posterior  column. 

SIS,  however,  does  not  cause  systemic  vV  al-     (p  w.  Mott.) 
lerian  degeneration,  because,  although  the 

myelin  sheath  disappears,  the  axis-cylinders  persist  in  the  sclerosed 
tissue.  The  characteristic  rhythmical  tremors  in  intentional  move- 
ment may  be  due  to  the  absence  of  the  myelin  sheath,  by  which 
voluntary  impulses  are  not  insulated  in  their  passage  along  the 
pyramidal  tract. 

Syphilis  may  produce  multiple  disseminated  patches  of  soften- 
ing and  sclerosis,  but  the  axis-cylinders  are  destroyed  in  the  dis- 
eased foci,  and,  consequently,  there  is  always  secondary  degen- 
eration. 


686  PATHOLOGY  OF  THE  XER^ 

Flo.  1%\. 


TBM. 


i-v 


Inrnilar  soK-ro^!'.  \  «iiinll  |>ortlon  of  ttu  ■■•Vi--  •■{  'ui  i»|pinil  ■  ■ 
Tin-  wtilim  nhiittii  i'»fri[T"»tli 'if  ihr  luMimtclla  tiMiiio  «l  the  oii 
Ahcuth.  Thi'  ncuri>Kllii  nIhIiim  ilri'itty  with  mrmliHt  NiitttlM'n  I'l 
lln  the  ncunifilln;  Ihfsi'  htv  w<rii.>iiii  of  imkiHl  ■xUin'lliiili'r  pr" 
kavlnut  (llMippparpil.  Thcrv  iiro  >omr  viii|>ty  (iMU'Ct  In  the  tcci 
probability  kccliU-iiUl.    Mauiiinixl  INMllnravlvn.    iF.  W.  Mont 


niT«Ua  I 

>•■«•  ■»  te^ 


Syrinoomtbua- 

This  is  a  central  glioi<i!(  of  the  spinul  cnrd.  canning  deotmctioD  of 
the  gray  matter  ami  ercavatUm.  The  usual  neat  is  amunil  the  cen- 
triil  ranal  in  the  peri-epfiiih/nml  tissue,  generally  behind  the  caual, 
in  the  gray  substance  of  the  posterior  commissure ;  thence  it  inrsde* 

Kk..  224. 


\ » 

rll»     The  feotlcn  l»  ftrini  the  cen'lrnl  nislmi.  inrt  •hnura  ■  i 
t,  Willi  irxntvutloii  of  the  tmrnr  of  ihe  rlilil  (naicrlor  horn.    Lawut  dmra  Iha  I 
vatlon  txtundvd  lnli>  lht<  •nivrlur  hortu  <iii  h<iih  kIiIm     i  K.  W.  MiHt.) 

the  anterior  »n<l  pimterior  horns.  It  is  nsunlly  a  neoplastic  fomift- 
tion,  but,  aeconling  to  Cliarcot,  it  may  arise  from  a  central  nivo' 
litis.  It«  cause  is  unknown.  The  resulting  8yui|itoms  are  ojmjn'M' 
Ifir  tpantint)  ui*i  loss  of  sensation  to  heat  and  cold  and  {Miinfuf 
impressions,  but  preservnlion  of  touch.  This  »fn»oiy  di»»<- 
is  peculiarly  characteristic  of  the  disease,  and  gooB  to  prt' 
Schifl'  was  right  in  asserting  that  the  gray  matter  condacta  painful 


PRIMARY  PROGRESSIVE  MYOPATHIES.  587 

sensations,  and  the  posterior  columns  tactile  and  muscular  sense 
impressions.  The  destruction  of  the  anterior  horns  produces  the 
iDQScular  wasting,  while  that  of  the  posterior  horns  the  sensory 
disturbance,  and,  pog»ibly,  the  trophic  affections  that  often  occur 
(Fig.  224).  Of  course  the  distribution  of  the  motor,  sensory,  and 
trophic  changes  will  depend  entirely  upon  the  segments  of  the 
itpinal  cord  affected.  There  may  be  unilateral  destruction  of 
anterior  and  posterior  horns  of  the  same  side ;  and  this  has  been 
found  associated  with  motor  paralysis  and  sensory  disturbance  of 
the  same  limb  or  side  of  the  body. 

Pbimabt  Pbogbessive   Myopathies. 

The  etiology  of  this  group  of  muscular  atrophies  is  still  obscure. 
Heredity  plays  a  prominent  part,  especially  through  the  maternal 
side.  No  definite  pathological  lesion  of  the  central  nervous  system 
has  been  observed,  and  the  disease  is  said  to  be  a  primary  atrophy 
of  the  muscle-fibres.  PseiuJo-hypertrophic  parali/sis  (p.  113)  and 
Erb'g  juvenile  paralysis  are  the  best-known  types. 


INDEX 


y^BSCESS,  298 
_^i    etiology  of  acute,  311 
formation  of  acute,  299 
cerebral,  569 
chronic,  297 
meta8tati(^  265,  466 
micrococci  in,  299 
of  bone,  177 
of  brain,  569 
of  kidneys,  516 
of  liver,  511 
of  lungs,  535 
of  lymphatic  glands,  495 
•^ciaoug  cancer,  197 
^ctmomycoeis,  400,  402,  459 
>.ctivity,  functional,  21 
nutritive,  21 
reproductive,  21 
vital,  21 
kCQte  tuberculosis,  404 
kdenoid  cancer,  205 
kdeno-fibroma,  185 
kdenoma  of  liver,  188 
of  mammary  glands,  187 
of  mucous  membranes,  188 
of  ovary,  188 
of  parotid,  188 
of  prostate,  188 

of  sebaceous  and  sweat-glands,  188 
of  testis,  188 
of  thyroid,  188 
^^^denomata,  184 
— «^deno-myxoma,  185 
— «^deno-sarcoma,  185 
—Adipose  tissue,  atrophy  of,  47 

regeneration  of,  121 
—Aerobic  fungi,  330 

—Alimentary  canal,  lardaceous  degenera- 
tion of,  97 
Alveolar  sarcoma,  175 
Amoeba  coli,  507 
Amyloid  degeneration,  86 
-Amyotrophic  lateral  sclerosis,  582 
-Anmnia,  213 
local,  225 
splenic,  222 
Anaerobic  fungi,  330 
Aneurysm  bv  anastomosis,  153 
from  arteritis,  486 


Aneurysm  from  embolism,  486 

miliary,  574 
Angiomata,  151 

Angio-sarcoma  myxomatodes,  181 
Ankylosis,  bony,  475 

fibrous,  475 
Ante-mortem  thrombi,  or  clots,  246 
Antheridium,  399 
Anthracosis,  111 
Antitoxin,  364 
Apoplexy,  pulmonary,  268 
Arteries,' atheroma  of,  102,  484 

calcification  of,  102 

fatty  degeneration  of,  71 

in  chronic  Bright' s  disease,  484 

inflammation  of,  482 

in  syphilis,  452,  484 

terminal,  258 
Arteritis,  acute,  482 

chronic,  483 
Artery  of  hemorrhage,  574 
Arthrosporous  organisms,  326 
Asci,  399 
Ascogonium,  399 
Aseptic  traumatic  fever,  278 
Atavism,  32 
Ataxic  paraplegia,  581 
Atelectasis,  542 
Atheroma,  102,  484 
Atrophy,  25,  46,  226 

causes  of,  48 

numerical,  45,  47 

of  adipose  tissue,  47 

physical  characters  of,  47 

simple,  45 

BACK-TELLING,"  34,  264 
Bacillus  anthracis,  377 
coli  communis,  382 
of  diphtheria,  383 
of  glanders,  377 
of  influenza,  386 
of  leprosy,  377 
of  rhinosoleroma,  377,  457 
subtil  is,  356 
syphiliticus,  377,  447 
tetanus,  388 
tuberculodis,  377,  415 
of  typhoid,  379 

589 


590 


INDEX. 


Bacteria  or  schizomycetes,  322 

arthrobporouK,  326 

dawiiicatioD,  353 

conditions  of  life  of,  327 

distribntion  of,  in  Nature,  332 

endooporousj  326 

monomorphic,  327 

mutability  of,  356 

non-patbogenic,  338 

pathogenic,  366 

polvmorphic,  327 

prodiictK,  338 

reproduction,  325 

specific  clarification  of,  353,  366 

gpontaneouK  generation  of,  338 
Bacterium  termo,  366 
Bed-sores,  acute,  23 
Blastomycetes,  323,  396 
Blood  and  circulation,  changes  in,  234 

ante-mortem  coagulation  of,  246 

p<i«t-mortem  coagtilation  of,  246 
Blood-coagulation,  240 
Blood-corpuKcles,  migration  of,  289 
Blo«d-cy»t«,  156,  181 
Blood-vesseU,  calcification  of,  102 

fatty  degeneration  of,  71 

inflammation  of,  279 

in  l(Kiil  anH-mia,  226 

lanlaceoiiM  degeneration,  88 

new  formation  of,  151 

regeneration  of,  121 
Bono,  atrophy  of,  51 

caries  of,  477 

intlnnmiation  of,  475 

necnwis  of,  478 

rcgenerutiiHi  of,  13(» 

sclenwin  of,  477 
Brain,  ahmxiw  of,  569 

emIxiliKm  in,  267 

fatty  dt-genenUion  of,  76,  267 

influmnuition  of,  5<>9 

iuHumnialory  softening  of,  582 

rc<l  Hoftening  of,  78,  2f'>7 

softening  of,  from  embolism,  267 

Hclerohis  of,  5X2 

thromlxwis  of,  267 

tiilHTcle  of,  424 

while  softening  of,  77 

vi'llow  softening  of,  7S 
Bntwn  atro|)hy  of  heart,  75 

inihiration  of  lungH,  '£ii> 
Hr<)wii-S«'i)uiir«i's  paralysis,  578 
ItullHir  panily!.is,  .">S3 

/  1A(  HKXIA,  cancenais  i:«5 
'        Calcantrtis  degeneration,  99 

of  arleri<-!<,  102 
CaUitirntioii,  '.I'.t 
CaiKvr.  IM'.t 

acinous,  197 
<  iuiivr-UKlii-s,  191,  195 

chninii',  I'.'H 

colloid,  206 


Cancer-bodies,  grstic,  209 

epithelial,  197 
Capillaries,  fatty  degenerattoo  oS,  78 
Carcinoma,  189 

adenoid,  176 

blood-vessels  of,  195 

cells  of,  190 

clinical  characteni  of,  197 

colloid,  206 

development  of,  193 

encephaloid,  200 

epithelial,  201 

genesis  of,  193 

lymphatics  of,  193 

melanotic,  177 

osteoid,  178 

scirrhuH,  198 

secondary  changes  in,  196 

stroma  of,  193 

stnuturc  of,  190 

varietieij,  189 
Can-inomata,  189 
'  Cardiac  failure,  229 
j  Caries,  477 
I     necrotica,  477 
,  Cartilage,  inflammation  of,  474 

regeneration  of,  121 
Caseation,  69 

of  products  of  scrofulous  inflammati 
440 

of  tul)ercle,  408 
Caseous  masses,  pathological  signifies 

of,  (>9 
Casts,  520 
Catarrh,  502 

mucous,  502 

punilent,  502 

s«-rous,  502 
Cell,  detiuition  of,  18 

nucleus  of,  420 

protoplasm  of,  18 
Cells,  5<S 

constitution  of,  18 

eoHiuoiihile,  315 

epithelioid,  294 

functions  of,  19 

ganglia,  5«0 

giuiglion,  5t*0 

gent»is  of,  27,  193 

"  inilitJerent,''  13:? 

ninltipli<iUion  of,  '1~ 

neutrophile,  316 

nutritive  exchange  of,  23 

|>hysi<>liipy  of,  20 

re<iuin-ments  of,  19 

siKvialize<l,  19 
Cell-wall,  nature  of,  18,  20 
Cerebral  al»n'e!*s  ■''69 

lienx  irrhsige,  574 

S4>ftening,  76,  267 
Cerebro-spinal  meningitis,  568 
( 'hlosisnia,  402 
Chloroma,  171 


INDEX. 


591 


Chlorosis,  213 

pathology  of,  214 
fholera,  390 

tipirillum,  391 
C'hondromata,  158 
Cliromopla«in,  20 
C'icatricial  tissue,  296 
OirrhoHis,  biliary,  512 

«f  liver,  oil 
C.'loacff,  478 
Ol«t  or  coagulum,  240 
C'lcts,  ante-mortem,  246 

post-mortem,  246 
<JJl<mdy  swelling,  79,  493 
d^os^lation-necrosis,  36,  39 
CVald  abscess,  477 
OToUateral  circulation,  22t'> 
CJiolloid  cancer,  82,  197,  20t) 
cells,  83 

d^eneration,  81 
CITolamnar-celled  epithelioma,  205 
<l?-oncentric  globes,  202 
C^ondensing  ostitis,  477 
C-T-ondylomata,  182 
CJVinijestion,  22(i 
<->:>nidia,  398 
<_^onidiophore,  398 

CVMnective  tissue,  fatty  infiltration  of,  58 
inflammation  of,  473 
regeneration  of,  120 
tumors,  153 
<  'ontagion,  317 

*  Jord-symptoms,  572 

*  Jornea,  inflammation  of,  474 
*-<>rpora  amylacea,  98 

*r orpuscles,  exudation,  281 

I^.^Hip,  504 

?^ ; 'J' ptogenetic  inflammation,  310 

Cultivation  of  germs,  methods  of,  :?50 

*:;yimdroma,  181 

'->"Htic  adenomata,  187 

*<Jeno-sarcomata,  187 

<=a.ncer,  209 


classification  of,  210 
^ngenital,  212 
**«tnnoid,  207,  212 
*^  travasation,  211 
«3c»idation,  211 
**»s»mmary,  210 
'*»ode8  of"  origin  of,  'i08 
^^♦•Varian,  212 
I*»Xjliferou8,  210 
'■^tention,  210 
**^HguineoU8,  211 
*'<>oondary  changes  in,  210 
*'*«*iple  or  componnd,  205) 
***-»-Bcture  of,  209 


T\  HXiENER  ATION, 
■^-^       amyloid,  86 


44,  572 


Degeneration,  calcareous,  99 
colloid,  81,  82,  197 
fatty,  56 
granular,  79 
hyaline,  85 
lardaceous,  86 
mucoid,  82,  207 
pigmentary,  104 

of  nerves,  primary  pathological,  679 
ascending,  578 
descending,  578 
grannlo-fatty,  576,  571 
physiological  effects  of,  564 
pigmentary,  104 
primary,  563 
secondary,  572,  676 
Wallerian,  562 
early,  562 
later,  562 
Dendrites,  560 
Dermoid  cysts,  207,  212 
Desmobacteria,  377 
Development,  errors  of,  142,  681 
Diphtheria,  383 
Diplooocci,  325 
Disease,  17,  28,  29 
acquired,  30 

and  micro-organisms,  358 
effects  of  previous,  33 
etiology  of,  31 
exciting  causes  of,  33 
general  and  local,  31 
germ-theoiT  of,  318 
inherited,  29,  30 
mode  of  extension  of,  33 
predisposing  causes  of,  31 
structural  and  functional,  31 
terminations  of,  34 
Diseases,  contagious,  317 
infective,  358 
varieties  of,  29 
Dropsy,  236,  238 
Dysentery,  506 
E^stropodextrin,  90 

ECCHONDROSE8, 161 
Emboli,  capillarv,  2<'>5 

fat,  266 

infective,  264 

sources  of,  254 
Embolic  or  metastatic  abscesses,  265 
Embolism,  254,  269,  461 

arterial,  260 

in  brain,  263 

irritant  effects  of,  264 

later  changes  in,  264 

results  of,  257 

softening  from,  264,  267 
Embryonic  remains,  theory  of,  142 
Emigration  of  blood-corpuscles  in  inflam- 
mation, 281 
Emphysema,  52 

atrophous,  53,  64 


692 


INDEX. 


Enipliyeema,  etiolcgy,  6a 

hyi<ertn)i>hou»,  53 

primarj',  54 

pulnuHiuiy  veidcalar,  52 

secondarj',  55 

varieti«t,  53 
Empyema,  510 
EncephalitiB,  567 
Kncephaioid  uancer,  200 
Encliondromitta,  158 
Endarteritis,  chronic,  483 
Endocarditis,  488 

acute,  4«!t 

chronic,  41*1 

papillarA',  489 

ulcerative,  490 
EndoHporium,  398 
EnduH]K>n>U8  oif^iiuiig,  326 
EntMttiHeM,  163 
EoHin<>]>hile  cellH,  315 
EpiblaHt,  28 
Epithelial  cancer,  197 

nmtK,  202 
Epithelioid  cellH,  294 
Epithelioma,  197,  201 

columnar,  197 

xqnamiMui,  197 
Epithelium,  regeneration  of,  126 

tumons  182 
EpuliH,  154,  180 
Erh'K  juvenile  paralyids,  587 
Erj'«ijH.'laH,  370 
F'x<M)M>riiim,  398 
F^xoHtoHw,  162 
ExtravoMitionx,  fate  of,  106 
F'xudation  in  inflammation,  281 

FARCY,  454 
Fat,  aliBorjition  of,  57 
ai*  cauNO  of  emholuim,  254 
necrrwiH,  41 
Hourciit  of,  57 
Fatty  deKonemtion,  66-76,  226 

caiiiHw  of,  (io 

of  arteriex,  71 

of  blixxl-vtt«K>lH,  71 

of  brain,  76,  2<i7 

of  capillariex,  72 

of  heart,  73 

of  kidnevH,  76 

of  mUHcle,  72 
infiltration,  57 

of  conuwtive  timie,  58 

of  hnirt,  <■>(» 

of  liver.  59,  61^  62 

of  niuwie,  59,  72 
metanioqilidoiH,  56,  64,  67,  79 
FavuN  4<n 
FernH'iitullon,  3H> 
eliolom-  of.  318 
(rvnii-ilitMiry  of,  317 
of  nriiir,  3t'.7 
physical  theory  of,  318 


Fermentation,  productti  of,  322 

vital  theorj-,  320,  321 
FermentH,  otj^anized,  318,  321 

unorf^uized,  318,  321,  340 
Fever,  270-278 

aKcptic  traumatic,  278 

delinition  of,  270 

esfieiitial,  277 

hyxterical,  278 

infective,  277 

inflammat«)ry,  277 

nervous,  278 

non-infective,  278 

pathology-  of,  275,  276 

primani-,  277 

secondary,  277 

simple  traumatic,  278 

MtaKcs  of,  272 

Hymptonw  of,  272 

tem|)erature  in,  272 
Fibroblastd,  294 

Fibroid  induration,  as  remit  of  inflmn 
tlou,  297 
as  result  of  mechanical  hvpeiw 

231 
as  remilt  of  svphilis,  448 
of  heart,  493' 
Fibromata,  153 
Fibromyoma,  l.'>3 
Fibroplastic  tumor,  178 
Formative  cells.  2S>4 
Friedreich's  disease,  581 
Func-tional  activity,  21 

GANtiREXE,  35 
circiimscrilml,  30 

inflanmiatorv',  41 
moist,  38 

senile,  .%,  .•J7,  40,  103 
{      traumatic  spreadinf;,  369 
,  (ielatiniform  cancer,  197,  207 
!  (ieneral  paralvsis  of  the  inaane,  585 
I  (ienesis  of  cells,  27,  1914 
'  <  iemi-theorj'  of  disease,  317 
I  (iiant-cells,  405 
;  (iiant-BTowth.  116 
I  (iibhes'  diHible  stain  for  tubercle  fa« 
I  349 

(■landers,  454 

(ilands.  s<Ti>fulous.  496 

(il.imhilar  tumors,  184 

(ilioma.  174 

(tliuiicnilo-nephritis,  .524 

(ilossy  skin.  24 

<  i  lu)fe.  i-orjmscles  of,  67 

(Mmorrhu-a,  micriKiK-ci  in,  371 

(■nun's  uiciIkmI  of  stainiuK  micro-ni 
isms.  349 

(iranular  (Kveneration,  79 
itiranulaliuns,  294,  :««,  :im 

(iranulalion  tiwue,  2i*4 
growth,  :i04 


INDEX. 


593 


.n.,.u.u...»i»,  ....,riH..j,  403 

•ray  degeneration,  578 
niiitter,  501 
C  Jummata,  29(5,  44!»,  450,  451 

H.KMATK;  pigments,  104 
Ifematoidin,  78,  105,  107 
X  lieningeneiiis,  219 
Un-molvsis,  202 
Hiemosidcrin,  105 
Healing  of  wounds,  126-129 
Ilealtli,  standard  of,  17,  29_ 
Heart,  brown  atrophy  of,  75 

changes  in  pyrexia,  81 

oloudy  swelling,  81 

fatty  degeneration  of,  73 
inKItration  of,  59 

fibroid  induration  of,  493 

hyj)ertrophy  of,  116-118 

innammation  of,  491 
Hemorrhagic  infarct,  259 
Hepatic  aliwcess,  51 1 
Hepatization,  grav,  531,  532 

red,  531 
Heredity,  32 
Herjies,  24 
Heterologous,  134 
Heterotopic,  134 
Hodgkin's  disease,  166,  221,  223 
Homologous,  134 
Horns,  183 
Hyaloplasm,  19 
Hydrocele,  encysted,  211 
Hygrumata,  212 
Hypenemia,  226 

acute,  227 

mec-lmnical,  227,  228,  233 

of  liver,  233 

of  lungs,  235 

post-mortem  evidences  of,  232 

results  of,  228,  230 
lly|)eri)liisia,  113 
Hyi>erpyrexia,  273 
Hypertro|>liy,  25,  110 

comjHjnsatorv,  114 

false,  113 

IJseudo,  113 
Hyplue,  397 

Hvphomvcetes,  323,  397 
HyiM>bla.st,  28 
HyjKistatic  congestion,  230 

TCTKKl'S  NEOXATORI'M,  108 
X  Immimity,  ao(|uire<l,  360,  361 
from  infective  diwascs,  360 

inherited  or  natural,  360 

theories  of,  365 
Infarct,  258 

hemorrhagic,  259 

large,  265 

small,  264 
»8 


Infarct,  white,  259 
Infarction,  258 

pathology  of,  259 
Infective  diseases,  316,  358 
immunity  from,  360 

granulomata,  403 

poisons,  506 
Inliltrations,  45 

albuminous,  79 

fattv,  61 
Inflammation,  36,  279,  286 

etiology  of,  307 

changes  in  bhxxl-Tessels  and  circulation 
in,  279,  280 
in  inflamed  tissues,  285 

clinical  signs  of,  290 

croupous,  504,  505 

cryptogenetic,  310 

definition,  279 

diphtheritic,  377,  504,  505 

emigration  of  blood-corpuscles  in,  281 

essential  lesion  of,  286 

explanation  of  microscopic  phenomena 
of,  287 

eztravascular,  316 

exudation  in,  288 

fibrinous,  293 

formation  of  pus  in,  298 

gangrenous,  307 

hemorrhagic,  304 

histologv  of,  279 

idioimtliic,  307,  310 

infective,  298 

intravascular,  316 

membranous,  293 

modes  of  arrest  of,  313 
sjiread  of,  312 

necrotic,  307 

phagocytosis  and,  315 

phanerogenetic,  307,  308 

process  of,  279 

productive,  294 

punilent,  298 

si-rofulous,  440 

sero-fibrinous,  293 

serous,  292 

simple,  307,  308 

stasis  in,  289 

suppurative,  298 

terminations  of,  305 

traumatic,  307,  308 

ulcerative,  302 

varieties  of,  291 

of  arteries,  482 

of  blo(Kl- vessels,  482 

of  bone,  475 

of  brain  and  spinal  cord,  568 

of  cartilage,  474 

of  central  nervous  system,  569 

of  connective  tissues,  473 

of  cornea,  474 

of  heart,  487 

of  kidneys,  524 


694 


INDEX. 


Inflammation  of  liver,  510 

of  lungH,  529 

of  lymj)liatic  Mnicturef),  495 

of  meiiuiKos  5"" 

of  raucoUH  membraneg,  502 

of  McrtHiH  incmbraneo,  502,  506 

of  Ki)«cial  nen-o),  287 

of  tiMKuus  279 

of  veinH,  4S7 
luflummatoty  fever,  277 
Influenza  tmoilluM,  386 
Insular  HcleroHis,  585 
IntcrHtitial,  29S 

hepatitiH,  510 

nephritiM,  524 

pneumonia,  540 
Intestine,  lardaccnuH  de||;eneration  of,  97 

tubereiiluHiH  of,  428 

typhoid  uloerati<m  of,  498 

KARYOKIXESIS,  27 
KeratitiH,  trif;eminnl,  24 
Kidney,  abrtcem  of,  51(i 

rl<Hidy  Kwellinir.  81 

fatty  dojfenerati<Hi,  76 

Klonienilo-nephritiii,  524 

xnuuilar,  528 

infarction,  261 

interstitiul  nepliritiH,  524 

lanlaevouH  dtvencmtioii  of,  92 

leiioliii  niio,  324 

dcarlalinal  nfpliriti»,  52:i 

wippunitivi'  no|)liritihs  oUi 

Huriirical,  517 

tubal  nepliritiH,  519 
Knee-jerk,  5(i5 

LANDKYS  I'AKALYSIS,  574 
I/iirdac-eoUM  <U'>ft>neration,  86,  89 

nature  nf,  x\ 
of  aliuKittar>'  canal,  97 
of  ItUKxI-vewels,  SS 
of  kiiliicVH,  92 
of  liver,  '.Ml 
of  lynipliHti)-  Klanilx,  97 
of  splwn,  95 
Hulxtancv,  nature  of,  S6 
reactionn  of,  86 
I^eeitliiu,  »!5 
1^-pniny.  443 
aniivtlietif,  444 
tuliennilar,  444 
l^'ploineniiiiritii*,  567 
I^'plollirix,  32-"> 
Loucliivinia,  219 
Mc.hI  in.  221 
kiiliii-vs  in,  224 
liv.rin.  221 
lyni|.halir.  22(l,  223 
niarniw  in.  223 
iiiycliiimiic.  22<l 
liuiliolivy,  2211 
Kplfen,  in.  222 


LeuccxrtiottiK,  220 

Li|)omata,  157 

Lithopa-dion,  101 

Littcn'H  explanation  of  inferction,  261 

Liver,  abneetw  of,  51 1 

acute  yellow  atrophy  of,  515 

adenoma  of,  188 

chanKCM  in,  in  pyrexia,  81 

cirrhoHia  of,  51 1 

fatty  infiltration  of,  61,  512 

inflammation  of,  511 

in  H])lenic  ana-mia,  224 

laruiu-eouK  <lefceneration  of,  90 

leuchicmio  frmwtlw  in,  224 

nutmep;,  63,  233 

Hyphilltic  dim'a»e-i  of,  453 
lAH^iniotor  ataxy,  579 
I>pftler'K  Ktain,  .184 
LuiiKM,  ahacvM'  of,  535 

broncho-pneumonia,  .536 

brown  induration  of,  2:t5 

catarrhal  ]Nieunionia,  .529 

cirrhuHix  of,  529 

cnaiixnix  puc<im<mia,  .^29 

enipnynema  of,  .52,  53 

KanKrene  of,  .535 

hyiK'TH-mia  of,  235 

hypo!<tatic  i'ongeKtitm,  230 

induration  of,  235 

infarction  of,  2t>8 

inllanimation  of.  .524 

intemtitial  pnenni<mia,  .'>40 

plithiHiK,  ."(45 

pigmentation  of,  101) 

tuU'n-nloHix  of,  4.'W 
LupuH  niMlules,  296 

vulKiiriH,  4:W 
Lymph,  236,  293 
Lyuiphadfiioma,  KMS 
LympliiMP)»nieH,  237 
Lym|>han);ioniata,  168 
Lymphatic  Khuidx,  inflammation  of,  495 
lanlaceouK  de]i!<>nerati<Hi  of,  97 
leucliiciiiic,  2£t 
non-iiillainmatory,  \*Vi 
enlanrement  of,  lliti 
KcrofuliMis,  440 
tnU-rculosis  of,  427 

structuH's,  inflammation  of,  in  l\i>hoid 
fever.  4'.M! 
LynipluKyti-s  315 
Lyniphurnata,  lli.3 
Lynipho-Hiin'oniata,  16.5,  174 

MAIU'HA  VtHYT,  400 
MaknKheilia.  116,  168 
Makn>i;l<>*'ia,  116,  168 
Malaria,  4l'>8 
bliMxl  in.  4<>9 
pliL-<in<Klium  of,  472 
Maliuni!in<y.  i:»6,  141 
c:iclicxia  of.  I*) 
caUM-M  of,  139 


INDEX. 


595 


MalififDancy,  diAerent  degrees  of,  137 

Hecondary  Ki^wths,  137 

thenries  of,  142,  144 
Malignant  ipdema,  389 

piuitule,  378 
Mallein,  457 

Mammary  gland,  adenoma  of,  186 
adeno-tibroraa  of,  1 86 
adeno-sareoma  of,  185 
cystic  sarcoma  of,  187 
scirrhns  of,  I'JSI 
Marclii'K  stain,  5«'2 
Measles,  micrococci  in,  376 
Melanin,  1()6_ 
Melanosis,  177 
Melanotic  sarcoma,  177 
Menin)jrcs,  intlammation  of,  567 
Meningitis,  567 

tubercular,  424 
Mesarteritis,  485 
MeHobla.Ht,  28 
Metamorphoses,  45 
Metastatic  abscesses,  265,  466 
Microbacteria,  376 
Micrococci,  366,  376 

of  atrophy  of  liver  (acutei,  376 

of  dysentery,  506 

of  erj'sipelas,  370 

of  gangrene  (spreading  traumatic),  369 

of  gonorrhoea,  371 

of  intlammation,  367 

of  measles,  376 

of  meningitis  (cerebro-spinaH,  376 

of  osteomyelitis  (acute),  475 

of  pneumonia,  373 

of  pyiemia,  461 

of  iiepti«emia,  461 

of  suppuration,  367 

of  typlioid,  379 

of  typhus,  376 
Micro-organisms,  cultivation  of,  350 
in  fluids,  350 
in  solids,  351 
in  plate-cultures,  352 
in  tul)e-cultures,  351 

demonstration  of,  in  fluids,  348 

disease  and^  358 

growth  of,  347 

m  tissues,  349 

staining  of,  348 

virulence  of,  346 
Micm«poron  furfur,  402 
MoUities  ossiuni,  479 
Molliiscum  tibrO'ium,  154 
Mortitit^tion,  35 
Moulds,  323,  397,  4(KJ 
Mucin,  characters  of,  81 
Mucoid  degeneration,  81,  207 
Mucous  <Tsts,  210 

membranes,  adenomata  of,  188 
catarrhal  inflammation  of,  502 
crouiMxis  inflainmntion  of,  502 
diphtheritic  inflammation  of,  502 


Mucous  membranes,  tubercnlosb  of,  428 
Mummiflcation,  38 
Muscle,  atrophy  of,  51 

cloudy  swelling  of,  81 

fatty  Regeneration  of,  72 

inflltration  of,  59 
.  in  typhoid  fever,  81 

regeneration  of,  123 

Zenker's  degeneration  of,  84 
Mycetoma,  402 
Mycoprotein,  323 
Myelitis.  571 

acute,  570 

central,  571 

difltise,  571 

meningo-,  571 

transverse,  571 
;  Myelogenic  leuchiemia,  220,  222 
Myeloid  tumor,  180 
I     "celK  180 
i  Myocarditis,  491 
Myomalacia  cordis,  494 
Myomata,  149 
Myoma  of  utenis,  149 
Myotatic  irritability,  572 
MyxoMlema,  82 
Myxomata,  155 
Myxo-sarcomata,  181 

NASAL  I'OLYPUS,  154 
Necrobiosis,  39 
Necrosis,  35,  226,  232,  306,  478 

coagulation,  36,  39 

course  of,  39 

fat,  41,42 
Nephritis,  516 

glomcrulo-,  524 

interstitial,  524 

parenchymatoiLs,  519 

scarlatinal,  523 

suppurative,  516 

tubal,  519 
Nerve-fibres,  systems  of,  561 
Nerves,  regeneration  of,  124 

section  of,  51 
Ncrroiis  system  as  cause  of  atrophy,  51 

and  nutrition,  23 
Neuromata,  150,  155 
Neuron,  559 
Neutrophile  cells,  316 
New  formations,  112 
Non-i)athogenic  organisms,  338 
Nucleus,  18,  20 
Nucleoplasm,  20 
Nutmeg  liver,  63,  233 
Nutriti<m,  arrested,  35 

impaired,  44 

increase<I,  112 
Nutritive  e<iuilibrium,  21 

exchange,  23 


,0 


BKSITY,  56,  59 
Obstruction  in  arteries,  35 


596 


INDEX. 


Olwtruction  in  capillarieH,  35 

in  veiny,  30 
CEdemo,  inflammatory,  292 

malignatil,  3K9 
Oidiuni  albii'unii,  397 
OiwiJieres,  399 
Uixanisms,  31 H 

arrmt  of,  ."42 

oiltivation,  3*50 

fate  of,  340 

metliody  of  inveHti^ation,  348 

virulence  of,  34(i 
Osteomalacia,  479 
Oxtcomatu,  Itil 
(Jxteocliondroua,  ltK( 
OHteomyelitix,  3tt9,  47o,  470 
()Hteoi(l  Hiircoma,  178 
Oatitiu,  475,  470 

condenxing,  477 

dcfomianH,  477 

rarefying,  478 
Ovarian  cvKtM,  211 

PA<'HYMKNIN(HTIS,  567 
I'apillomata,  182 
Para|>K>f;ia,  571 

ataxic,  581 
PaniMitcx.  vegetable,  310,  322 

conditionM  of  life  and  growth,  327 
PallioKciiic  Iracteria,  30<> 

onrinisniK,  Xix 
I'atliiilogy,  nxNlcm,  17 
IVIvIo,  <it<t<-«inalaf'lc,  482 
I'eri-c|K-mlynia,  571 
I'cri-cnccpiiaruis,  585 
IVriliciHititis,  51(1 
IVriiwlilic,  475,  470 
IVrillicciiun.  3".nt 
]'enii<'i<>iis  anicniia,  210 
MihmI  in,  210 
heart  in,  21« 
niiirniw  in,  217 
IKilhology  of,  219 
I'hiigiH'vto,  ;!ll> 
I'hatriK'vtiisiK,  :tl5 
I'hlcl.itls.  242,  25;<,  487 
I'lilclH>litlis,  1IK» 

I'hiiKiihoniii,  (•fli'«1»  of,  05,  00,  74,  70, 
I'livsiolojrical  n-i-iMancc,  47,  \M> 
I'liltViiiaKJa  (lolfOH,  25:{ 
I'lilhi^is,  ••I'ollicr'si,"  111 
"  kiiifi'-irrindcr's,"  111 
inilnioiiary,  545 
clioloify  of,  .558 
liiMoloity  of,  .540 
piltllolii|;y  of,  .5.54 
tiiU'ri'lt'  liacilli  in,  415 
I'ia  iiiaicr,  iiilnTi'iilioi*  of,  124 
I'iuiiifni,  M.iiro-s  of,  lnl 
I'iirnH-niary  lUtrcncnilion.  H'l 
rii;im-iil:ilion.  2.5,  '>\.  I'.tH,  23:'. 
fmiii  ill,.  Iiiji.,  1(17 
from  ilic  IiIinhI,  1(^7 


219 


Pigmentation,  extraneooa,  108 

of  limgK,  lOit 

of  xpiitum,  1U8 
PityriiiKiH  versii-olor,  402 
Plaitniixlinm  malariu-,  472 
Ihieumonia,  broncho-  or  catarrhal.  M 
.541 

croupous,  .52SI,  541 

hyjMiKtatic,  .540 

intvrxtitial  or  chronic,  .540 

micnKixri  In,  373 
i'olypiis,  n:ii<al,  154 
INxt-niorteni  changC!>,  42,  44 

diHcoloration,  42 

Mtaining,  42 
Polio-encephalitiH,  .509 
PoliomychtiH,  .572 
Primary  myopathio*,  5.'<7 
Pmgwwive  muMiilar  atrophy,  .V«2 
Proloplasm,  18 
,      coiigulatlon  of,  after  death,  44 

metamonihoKCK  of,  19 
Protoxoa  ol  malaria,  l'.l.5 
.  PHammoma,  1.55 
PiH>iido-hviM>rtrophic  muxciilar  |iaralv> 
5.>i"7 
,  Pulmonary  aiMtplexy,  2((8 

plithisiM,  •54.5 
I'liH,  chan>cton<  of,  .TOO.  301 
Pya-mia,  40(> 

and  Kcptincniia,  4(il 

metii-ialic,  309 
I  aliMH^iwesi  in,  4(iO 

Pvclitii.,  24 
Pyo-is,  .•ti;7,  370 
Pyrt'xia,  tisKUe-clianges  in,  79 

Ri;( i i:n kk ati(  >n.  i i8,  2.>*«5 
of  adi|MM- tissue,  119 
of  Umc,  121,  123 
of  carlilai;!-.  121 

of  itrtnmou  i-onuivtivo  tissue,  119 
of  epithelium,  120 
of  nuis<-le.  123 

of  McrvfHflls  and  nerves,  124 
of  V..SS..N.  119 
ICel,'i|>sinL'  fever,  SitO 
Kepair,  2:t 
Keli-ulioii-cysts,  210 
.  KliiiKc^'lenmia,  4-57 
Ui.kcis,  479 
Hickely  (K-lvis  482 
KiKor  mortis,  43 

nalure  of  clianire  in  muscle,  4.H 
KiMleut  ulivr,  204 
UiHit-»yniploins,  .572 

•'0.\(;(»SPI,KKN."  90 

►  '  Sapnemia,  402-4<>5 
Sarciiia,  .">7(i 
."^aroMlf,  IH 
SiuiiHiiaCi,  l(>9 

alveolar,  175 


INDEX. 


697 


Siironiata,  clinical  characten  of,  172        I 

cystic,  20l»  I 

lympho",  174 

melanotic,  177 

mixe<l-celle<l,  170 

mycloid-celled,  170 

iKteoid,  178 

niiintl-celletl,  170,  173 

spindle-celli-d,  170 

varietie),  170,  171 
vcarlatma,  kidney  changes  in,  523 
>« -ar-tissiie,  296  ^ 

•<-irrlioiw  cancer,  198  | 

^sirrlius,  19S  I 

of  mamniii,  109  ' 

kiliizomycctes,  32;J 
«_-liTo»i8,  aniyotriiphic  lateral,  582  j 

aswnding,  077 

(leflcendinp,  5^2  I 

(liss'.-minate<l,  585  | 

insular,  585  I 

(irimark',  579  I 

lateral,  582 

scccindarv,  579  I 

of  lx)ne,  477 

of  brain,  57B 

of  cord,  579,  582,  586 

of  gray  matter,  57S 

of  nerve,  573 

;rof»la,  440 

riifiiluns  inflammation,  440 

baceoiH  cysts,  210 
-"iiile  pmjjrcne,  30,  40,  103 
<.!ptic  infection,  463,  464,  4t)5 

of  intoxication,  462,  463,  465 

traumatic  fever,  278  ^ 

'|Hica-mia,  461,  462  i 

of  mice,  387 
*^|ue>itr»m,  478 

^rons  menibRuie^,  inllammation  of,  -508    . 
^nim  thera])eiitici<,  364  I 

Nllciwi!!,  Ill 
Sliln,  bronzing  of,  107  I 

kIoshv,  24  I 

wart'  182 
Sloujfb,  separation  of,  303  ; 

Softening,  cerebral,  76 

gniv,  571 

red",  78,  267  ] 

yellow,  78  I 

iSjKfciliis,  acute,  403 
Si)ennatic  influence  of  cells,  134,  147 
S](erniatozoids,  399 
Spha-robacteria,  366 
Sphacelus,  39 
.Spinal  cord,  inflammation  of,  570 

sclerosis  of,  571 
Spirillum  of  cholera,  391 
Spirolacteria,  390 
SpirfKha-ta,  325,  390 
Splwn,  lardaceouH  d^eneration  of,  95,  96 
leuchieraic,  222 
in  typhoid  fever,  497  I 


Splenic  ana>mia,  222 

fever,  377 
S|M)ntancous  generation,  333 
Siiorangiophore,  398 
S(Kirangiuin,  398 
Staphylwocci,  325 
Stcrigmata,  398 
Streptococci,  325 

Suppuration,  297,  298,  301,  307,  311,  367 
Syphilis,  447,  484 

arterial  changeH  in,  452 

tibroid  changes  in,  448 

gummata  in,  450 

nature  of  lesiions  in,  447 
Syphilomata,  449 
Syringotnyelia,  586 

1UBES  lK)ltSALIS,  579 
.   Tattooing,  108 
Temperature  in  health,  270 

paradoxical,  273 

jKWt-mortem,  rise  of,  275 
Teratomata,  207 
Tetanine,  389 
Tetano-toxine,  389 
Tetanus  bacillus,  :i88 

toxalbuniose,  389 
Thallophytes,  322_ 
ThcrnKjgenesis,  276 
Thermotaxis,  277 
Thrombosis,  240-24(i,  269 

causes  of,  240 

of  brain,  267 

results  of,  251 
Thrombus,  240,  254  • 

calciKcation  of,  250 

canalization  of,  251 

characters  of,  246 

later  changes  in,  248 

organization  of,  248 

red,  246 

secondary,  25(i 

softening,  250 

white  or  mixed,  246 
Thrush,  397 
Tinea  circinata,  401 

kerion,  401 

sycosis,  402 

tonsurans,  401 

unguium,  402 
Toxines,  340 

Transplantation  of  tissues,  130 
Traumatic  fever,  27H 
Trichophyton  tonsurans,  401 
Trophic  influence,  23-35,  571,  581 

nervt's,  25 
Trophoneuroses,  61 
TuK-rcU',  404 

Willi,  415 

giant-cells  in,  405 

gray  and  yellow,  404 

histology  of,  405 

in  pulmonary  phthisis,  546 


698 


INDEX. 


Tubercle,  naked-eye  appeanuiceo  of,  404 

older  doctrineti  respecting,  413 

aeab)  of,  405 

Mcondarv  chanxeH  of,  40ft 

aource  of  cells  in,  40fi 
Tubercular  dixeaxe  of  bones  434 

empvema,  438 

hydiope,  438 

lepnmy,  443 

mcningitiH,  424 

osteomyelitii*,  43d 

perioMtitiii,  43d 

Hvnovitix,  437 
TuderculoMiH,  acute,  404 

artiticial  producti<ni  of,  413 

etiologr^'  of,  413 

of  cartilage,  437 

of  intextine,  428 

of  lungs,  43U 

of  lymphatic  glandH,  427 

of  muciMiH  luembrnneH,  4'.*8 

of  nia  mater,  424 

IMitliology  of,  413 
Tuberculous  diathesis,  442 
Tulwrosa,  s,\iiovitis,  438 
Tumors,  131 

causes  of  malignancy,  137 

classification  of,  147 

clinical  uHinie,  \'M 

connective  tissue,  153 

cvstic,  208 

<{efinition,  131 

development  of,  132 

etiology  of,  141-147 

niallgnanl)  \'M\ 

Iianisitic  theory-,  144 

recurrence  ancf  generalization,  1.37 

retrogressive  changes  in,  1*5 

simple,  13<) 

theory-  of  embrvonic  remaiim,  142 
Typhoicl  fever,  3f» 

niicro-oi||;anisms  in,  379 


Typhoid  fever,  muscular  change  in,  t 
Typhus,  micrococci  in,  376 

ULCEKATION,   tubemilar,   of  ii 
tine,  428 
typhoid,  of  intestine,  408,  501 
I'nne,  fennentaticm  of,  3(i7 
Uterus,  myoma  of,  14tt 

VACCINIA,  micr<xoc«'i  in,  37«i 
Vacuoles,  1« 
Vegetable  parasites,  31«,  322,  :<23 
classiKoation  of,  X>'A 
conditions  of  life  of,  327 
distriljution  of,  in  Nature,  332 
methods  of  demonstratinic,  ">48 
morphology-  and  life-histor>-,  32! 
Veins,  inflammatiiHi  of,  487 

varicose,  487 
Vibrio,  325 
Virchow's  dictum,  27 
Vital  a«-tivity,  21 

energy,  21 
Vitality,  dcprci«<cd,  343 

WALLERIAN     DKCENERATK 
o(i2 
Warts,  182,  183 
Waste,  23,  48 
Weigert's  stain,  :M8,  5«2 
Wens,  154 
White  matter,  561 
W(Hilsorf  or' s  dixease,  .378 
Wounds,  healing  of,  I2(i-12i> 

'  yEASTS,  .32.3,  3<.W 

yENKKR'S    I)ECJEN1'J{ATH»N 
/j     MISCLE,  84 
/iehl's  fluid,  3.)0 
Z<Migl<i-a,  325 
Zygi»<|)ores,  .398 


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CHAPMAN  (HENBY  C).    A  TREATISE  ON  HUMAN  PHYSIOLOGY.    la 

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OHABLES  (T.  CBANSTOUN).  THE  ELEMENTS  OF  PHYSIOLOGICAL 
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OHUBOHILL  (FLEETWOOD).    ESSAYS  ON  THE  PUERPERAL  FEVER. 

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CLINICAL  MANUALS.    See  Serie*  of  CUnieal  Manuab,  page  13. 

CLOUSTON  (THOMAS  S.).  CLINICAL  LECTURES  ON  MENTAL  DIS- 
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175  pages.    Cloth,  $1.50. 

DDNQLISON  (ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCIENCE.  Con- 
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Cloth,  $3;  leather,  $4. 

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EBIOHSEN  (JOHN  E.).    THE  SCIENCE  AND  ART  OF  SURGERY.    A  i 

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volumes  containing  2316  pages,  with  984  engravings.    Cloth,  $9 ;  leather,  (IL 

ESSIO  (OHABLES  J.).  PROSTHETIC  DENTISTRY.  See  Ameneam  Ttxt-Mb 
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FABQUHABSON  (BOBEBT).  A  GUIDE  TO  THERAPEUTICS.  Fomtk 
American  from  fourth  EnglLth  edition,  revised  by  Fbank  Woodbubt,  M.D.  In  OM 
12mo.  volume  of  581  pages.     Cloth,  $2.50. 

FIELD  (OEOBQE  P.).  A  MANUAL  OF  DISEASES  OF  THE  EAR.  Fonitfc 
edition.  In  one  octavo  volume  of  391  pages,  with  73  engravings  and  21  coloicd  platan 
Cloth,  13.75. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND  PSACTICS 
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A  MANUAL  OF  AUSCULTATION  AND  PERCUSSION;  of  the  Ph; 


'hjril. 
Fihk 


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A   PRACTICAL   TREATISE  ON  THE  PHYSICAL  EXPLORATION 


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MEDICAL  ESS  A  YS.    In  one  12mo.  volume  of  210  pages.    Cloth,  $1.38. 

ON  PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOG  Y,  ETC.    A  Seti« 


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F0L80M  (0.  F.).  ^A'  ABSTRACT  OF  STATUTES  OF  U.  S.  ON  CUSTODY 
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FOBMTTLABT,  THE  NATIONAL.    See  StUU,  Maitek  &  Caspari^t  Natioiud  Ditptmm' 

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FOSTEB  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  New  (6th)  mad 
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pages,  with  257  illustrationB.    Cloth,  $4.50;  leather,  $5.50. 

FOTHEBOILL  (J.  MILNEB).  THE  PRACTITIONER'S  HAND-BOOK  OF 
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FULLEB  (HENBY).  ON  HlfKASES  OF  THE  LUNGS  AND  AIR-PASSAGES. 
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QIBBES  fHENEAOE).  PRACTICAL  PATHOLOGY  AND  MORBID  HIS- 
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mostly  photographic.    Cloth,  $2.75. 

OIBNEY  (V.  P.).  ORTHOPEDIC  SURGERY.  For  the  use  of  Practitioners  and 
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GOULD  (A.  PEARCE).  SURGICAL  DIAGNOSIS.  In  one  12mo.  volume  of  589 
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GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY  AND  MOB- 
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GREENE  (WILLIAM  H.).  A  MANUAL  OF  MEDICAL  CHEMISTRY.  For 
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of  310  pages,  with  74  illustrations.     Cloth,  $1.76. 

GROSS  (SAMX7EL  D.).  A  PRACTICAL  TREATISE  ON  THE  DISEASES, 
INJURIES  AND  MALFORMATIONS  OF  THE  URINARY  BLADDER, 
THE  PROSTATE  GLAND  AND  THE  URETHRA.  Third  edition,  thoroughly 
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with  170  illustrations.     Cloth,  $4.50. 

HABERSHON  (S.  0.).  ON  THE  DISEASES  OF  THE  ABDOMEN,  compriang 
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ican from  the  third  English  edition.  In  one  octavo  volume  of  554  pages,  with  11  engrav- 
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HAMILTON  (ALLAN  McLANE).  NER  VO  US  DISEASES,  THEIR  DESCRIP- 
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698  pages,  with  72  engravings.     Cloth,  $4. 

HAMILTON  (FRANK  H.).  A  PRACTICAL  TREATISE  ON  FRACTURES 
AND  DISLOCATIONS.  Eighth  edition,  revised  and  edited  by  Stephen  Smith, 
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Cloth,  $•■).  50;  leather,  $6.50. 

HARDAWAY  (W.  A.).  MANUAL  OF  SKIN  DISEASES.  In  one  12mo.  volunw 
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HARE  (HOBART  AMORY).  A  TEXT-BOOK  OF  PRACTICAL  THERA- 
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PliACTICE   OF  MKOICiyE.    Fifth  edition.     In  one  12nio    Tolame,  M9 
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HAYDEN  I  JAMES  R.).    A  MANUAL  OF  VENEIiEAL  DISEASES. 

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HATIIM    OEOROES)  AND  HARE  iH.  A.i.    /'/' 
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uheriv  PrcsBure,  Climates  and  Mineral  Watcnt.     EditvJ  bv    I'ruf.  IL 
In  one  octavo  volume  of  414  pages,  with  113  engravings.     Cloth,  ^ 

HERMAN    (O.   ERNEST).    FIRST  LINES  IN  Mll>^  taw 

volume  of  lUfS  pagers,  with '"JO  engravings.     Cloth,  (1.25.     Si'  ^trittifi 

page  H. 

HERMANN  (L.).    EXPERIMENTAL  PHARMACOLOGY.    A  Ha 

Method*  for  Determining  the  Phyiiiological  Actions  of  Drnn.    TfBnalaird  by  Kit 
Meade  Smith,  M.  i>.     In  one  12m'o.  vol.  of  190  pagea,  with  SS  (ognrin^     CUWk,  fLI 

HERRICK  (JAMES  B.).  .1  HANDROOK  OF  DIAGNOSIS.  In  cam  kwukM 
12nio.  vuluuie  ut'  4°J'J  pages,  with  80  cngraringi)  and  2  colotvd  phuot.  CIOlk,9ltl 
Jiut  reorfy. 

HILL  (BERKELEY).    SYPHILIS  AND  LOCAL  COyTAOtOUS DOOMDl 

In  ooi-  Hvo.  volume  of  479  page*.     Clolh,  $3.25. 

HTTJ.TyR  (THOMAS).    A  HANDBOOK  OF  SKIN  DISEASES. 
In  line  royal  12mo.  volume  of  363  pages,  with  two  platea.     Cloth,  9S,S& 

HIRST  (BARTON  C.)  AND  PIERSOL    OEOROE  A.t.    Ill  ' 

ITIES.     .Mugoilicenl  fulio,  contuiuin):  21'0  pllXL•^  uf  leil  und  illu>ti 

iogii  and  39  large  photographic  plat«»  from  nature.     In  four  palla,  pnc«  (acJi,  ^:>. 

editioH.     For  nut  oy  aiiA<erip(ion  only. 

HOBLYN  'RICHARD  D.).    A  DICTIONARY  OF  THE  TERMS  VS 

MFlHriSE  A.\l>  THE  COLLATERAL  SCIENCES.     In  one  Ubna 

62U  doulilvd-oolumDi'il  (iage».     Cloth,  $1.50;  leather,  $2. 

HODQE  iHUOH  L.).     oN  DISEASES  PECULIAR  TO  WOMEN,  IXCLUDI» 


DISPLACEMENTS   OF   THE    UTERUS.    Second  and  »«Ti«!d 
Sto.  volume  of  •MO  page*,  with  illuotrations.     Cloth,  f4.50, 

HOFFMANN  ( FREDERICK i  AND  POWER  (FREDERICK  B.l.    A 

OF  t'UKMIi.WL  ASALYSlS.a..  Appliiil  to  thv  Kxiimitiaucu  of  Medicia.. 
and  their  I*reparati<iii>i.     ThinI  orniuii,  entirely  rewritten  antl  much  iBllfiaJL 
bandaome  octavo  volume  of  U21  pii{;<'!<,  with  179  vnioaviiigv     Cloth,  M-SB. 

HOLDEN   (LUTHER).    LANDMARKS,  MEDICAL   AND  SVIl 

the  third  Kngli-h  ('<litiou.     With  additions  by  W.  W.  KfJcs,  M.I>.     In 
volume  of  14.>t  [ttigif.     Cloth,  ?1. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY 
Practice.  A  new  American  from  the  liftb  English  edition.  £<< 
I*ICK,  F.  Ii.C.S.  In  one  handsome  octavo  volume  of  1008  pa^e', 
Clolh,  16 ;  leather,  $7. 

A  SY.<iTE.V  OF  SURGERY.    With  not«  and  aadlllooa  bv  radow- 

autbom.     K<iiied  liv  John  H.  P.(ckaki>,  M.P.     In  ihrea  roy  haiMMim*  flvn. 
containing  3137  double-columned  pagvs  with  979  engravlll0  and  IS  Ul' 
Per  volume,  cloth,  fit ;  leather,  $7  ;  half  «>•---  ••'  '•'^      «^ 


lialf  KuMda,  $7.60.     For  mle  by 

HORNER  (WILLIAM  E.).   SPECIAL  ANATOMY  AND  HISTOLOOT. 

editinn,  rvvixeil  and  modified.     In  two  large  8to.  volume*  of  1007  pagn, 

rngmvinir".      Clolh,  f'l.  

Hiiladtlphia,  706.  708  and  710  Santom  St.~IUm  fork.  111  Fihh  4r«.  (car.  1»ih  St.), 


LEA    BROTHERS   i    CO.'S   PUBLICHTIOKS. 


HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER.  In  one  octavo 
volume  of  308  pages.     Cloth,  $2.50. 

HUTCHINSOK  (JONATHAN).  SYPHILIS.  In  one  pocket-size  12mo.  volame  of 
542  pages,  with  8  chromo-lithographic  plates.  Cloth,  $2.25.  See  Series  of  Clinical  Man- 
uaU,  page  13. 

HYDE  (JAMES  NEVINS).  A  PRACTICAL  TREATISE  ON  DISEASES  OF 
THE  SKIN.  Third  edition,  thoroughly  revised.  In  one  octavo  volume  of  802  pages, 
with  108  engravings  and  9  colored  plates.     Cloth,  $5 ;  leather,  $6. 

JACKSON  (OEOEOE  THOMAS).  THE  READY-REFERENCE  HANDBOOK 
OF  DISEASES  OF  THE  SKIN.  New  (2d)  edition.  In  one  12mo.  volume  of  589 
pages,  with  69  engravings,  and  one  colored  plate.     Cloth,  $2.75.     Just  ready. 

JAMIESON  (W.  ALLAN).  DISEASES  OF  THE  SKIN.  Third  edition.  In  one 
octavo  volume  of  656  pages,  with  1  engraving  and  9  double-page  chromo-lithographic 
plates.     Cloth,  $6. 

JONES  (0.  HAITDFIELD).  CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
NER  VO  US  DISORDERS.  Second  American  edition.  In  one  octavo  volume  of  840 
pages.     Cloth,  $3.25. 

JT7LEB  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE  AND 
PRACTICE.  Second  edition.  In  one  octavo  volume  of  549  pages,  with  201  engrav- 
ings, 17  chromo-lithographic  plates,  test-types  of  Ja^er  and  Snellen,  and  Holmgren's 
Color-Blindness  Test.     Cloth,  $5.50;  leather,  $6.50. 

KIBE  (EDWARD  C).  OPERATIVE  DENTISTRY.  See  American  Text-book*  <^ 
Dentistry,  page  2. 

KINO  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Sixth  edition.  In  one  12mo. 
volume  of  532  pages,  with  221  illustrations.     Cloth,  $2.50. 

KLEIN  (E.).  ELEMENTS  OF  HISTOLOGY.  Fourth  edition.  In  one  pocketoxe 
12mo.  volume  of  376  pages,  with  194  engravings.  Cloth,  $1.75.  See  Students  Seriet  t^ 
Manuals,  page  14. 

LANDIS  (HENRY  O.).  THE  MANAGEMENT  OF  LABOR.  In  one  handsome 
12mo.  volume  of  329  pages,  with  28  illustrations.     Qoth,  $1.75. 

LA  ROCHE  (R.).  YELLOW  FEVER.  In  two  8vo,  volumes  of  1468  pagei. 
Cloth,  $7. 

PNEUMONIA.    In  one  8vo.  volume  of  490  pages.    Cloth,  $3. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C).  A  HANDY-BOOK  OF 
OPHTHALMIC  SUROER  Y.  Second  edition.  In  one  octavo  volume  of  227  pages, 
with  66  engravings.     Cloth,  $2.75. 

LAWSON  rOEORQE).  INJURIES  OF  THE  EYE,  ORBIT  AND  EYELIDS. 
From  the  last  English  edition.  In  one  handsome  octavo  volume  of  404  pages,  with  92 
engravings.     Cloth,  $3.50. 

LEA  (HENRY  C).  CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF 
SPAIN;  CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMINATI; 
THE  ENDEMONIADAS ;  EL  SANTO  NINO  DE  LA  GUARDIA;  BRI- 
ANDA  DE  BARDAXI.    In  one  12mo.  volume  of  522  pages.     Cloth,  $2.50. 

A  HISTORY  OF  AURICULAR  CONFESSION  AND  INDULGENCES 


IN  THE  LATIN  CHURCH.    In  three  octavo  volumes  of  about  500  pages  each. 
Per  volume,  cloth,  $3.     CompUle  work  just  ready. 

FORMULARY  OF  THE  PAPAL  PENITENTIARY.    In  one  octavo  vol- 


ume of  221  pages,  with  frontispiece.    Cloth,  $2.50. 

SUPERSTITION  AND  FORCE;  ESSAYS  ON  THE  WAGER  OF  LAW, 


THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND  TORTURE.  Fonrth 
edition,  thoroughly  revised.  In  one  handsome  royal  12mo.  volume  of  629  pages. 
Cloth,  $2.75.  

Philadtlphia,  108,  708  and  710  Smtom  St.—Mtw  York,  111  Fifth  An.  (cor.  tSth  St.). 


10  LE*    BHOTHEKS   »    COJS   PUBLICHTIOMS. 


liEA  (KENBT  0).    STUDIES  IN  CHURCH  HISTORY.    The  Bise  of  the  T«» 

poral  Power — Benefit  of  Clergy — Exoommimication.     New  edition.     In  one  hsndioB* 
12mo.  volume  of  605  pages.     Cloth,  12.50. 

AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIRACY  IN  THE 


CHRISTIAN  CHURCH.    Second  edition.    In  one  handsome  ocUto  rolume  of  685 
pages,    aoth,  14.50. 

LEE  (HENBY)  ON  SYPHILIS.    In  one  8to.  volume  of  246  pages.    Cloth,  $2.i&. 

LEHHANN  (0.  O.).  A  MANUAL  OF  CHEMICAL  PHYSIOLOGY.  In  one 
Svo.  volome  of  327  pages,  with  41  engravings.     Cloth,  $2.25. 

LBISHMAK  (WILLIAM).  A  SYSTEM  OF  MIDWIFERY.  Including  the  Die- 
eases  of  Pregnancy  and  the  Puerperal  State.     Fourth  edition.     In  one  octavo  volomc^ 

Looms  fALFBEO  L.)  AND  THOMPSON  (W.  OILMAN),  Edtton.  A  SYS- 
TEM OF  MEDICINE.  In  Contributions  by  Various  American  Anthoia.  In  four 
very  handsome  octavo  volumes  of  about  900  pages  each,  fully  illustrated  in  bladk  and 
colors.     Volume  I.,  in pre*$for  early  un<«. 

LTTDLOW  (J.  L.1.  A  MANUAL  OF  EXAMINATIONS  UPON  ANATOMY, 
PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDICINE,  ORSTBTRICS, 
MATERIA  MEDICA  CHEMISTRY,  PHARMACY  AND  THERAPEUTICS. 
To  which  is  added  a  Medical  Formulary.  Third  edition.  In  one  royal  12mo.  volnnc 
of  816  pages,  with  370  engravings.     Cloth,  13.25;  leather,  $3.75. 

LUFF  (ASTHUB  P.).  MANUAL  OF  CHEMISTRY,  for  the  use  of  Stadeni*  of 
Medicine.  In  one  12mo.  volume  of  522  pages,  with  36  engxmvings.  Cloth,  12.  See 
Sbtdenb/  Series  of  Manuals,  page  14. 

LTMAN  (HENRY  M.).  THE  PRACTICE  OF  MEDICINE.  In  one  very  hand- 
some octavo  volume  of  925  pages  with  170  engravings.     Cloth,  f4.75;  leather,  $5.75. 

LYONS  (BOBEBT  D.).  A  TREATISE  ON  FEVER.  In  one  octavo  volume  of  363 
pages.    Cloth,  $2.25. 

MACKENZIE  (JOHN  NOLAND).  THE  DISEASES  OF  THE  NOSE  AND 
THROAT.  In  one  hand^iome  octavo  volume  of  about  600  pages,  richly  illostrated. 
Preparing. 

MAI8CH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA  MEDICA. 
New  (6th)  edition,  thoroughly  revLied  by  H.  (\  C.  Maisch,  Ph.G.,  Ph.D.  In  one  very 
handiiome  12mo.  volume  of  509  pages,  with  285  engravings.     Cloth,  $3. 

MANUALS.  See  Studentif  Quit  Series,  page  14,  Studenti  Series  of  MantuUs,  page  14,  and 
Series  of  Clinical  Manttals,  page  13. 

MABSH  (HOWABDI.  DISEASES  OF  THE  JOINTS.  In  one  12mo.  volume  of 
468  pagas  with  04  engraving!*  and  a  colored  plate.  Cloth,  $2.  See  Series  ^  CUnieal 
Manuals,  page  13. 

MAY  (0.  H.)  MANUAL  OF  THE  DISEASES  OF  WOMEN.  For  the  use  of 
Studentrt  and  Practitiunen.  Second  edition,  revised  by  L.^S.  Bau,  M.D.  In  one  12dio. 
volume  of  360  pages,  with  31  engravings.     (3oth,  f  1.7*5. 

MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  INJURIES  OF 
NERVES  A.\D  THEIR  TREATMENT.  In  one  handsome  12mo.  volume  of  239 
pageK.  with  12  illastrations.     Cloth  $1.7-'3.     Just  ready. 

MOBBIS    (HENBY).    SURGICAL   DISEASES  OF   THE  KIDNEY.     In  ooe 

12nio.  volume  of  ■'>54  pages  ^'>th  40  engravings  and  6  colored  plates.     Cloth,  $2.25.    St* 

Serifs  III'  CI iniriil  MnnwiJii,  page  13. 


miadtlphia,  706,  708  and  710  Santom  St—^»w  York,  111  Fifth  Mr:  {cor.  IStk  St.). 


L£A    BKOTHEHS   «    CO.'S   PUBLICMTIOMS.  11 


MOBBIS  (MALCOLM).  DISEASES  OF  THE  SKIN.  In  one  square  8vo.  volume 
of  572  pages,  with  19  chromo-Uthographic  figures  and  17  engraTings.     Cloth,  $3.50. 

MULLEB  (J.).  PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY.  In  one 
large  8to.  volume  of  623  pages),  with  538  engravings.     Cloth,  $4.50. 

MUSSEB  (JOHN  H.).  A  PRACTICAL  TREATISE  ON  MEDICAL  DIAG- 
NOSIS, for  Students  and  Physicians.  New  (2d)  edition.  In  one  octavo  volume  of 
about  950  pages,  illustrated  with  about  200  engravings  and  many  colored  plates.    Inpreu. 

NATIONAL  DISPENSATOBY.    See  SlilU,  Mai»ch  &  Catpari,  page  14. 

NATIONAL  FOBMULABT.  See  StilU,  Maiaeh  &  CasparCs  Natumal  Diepmiaimy, 
page  14. 

NATIONAL  MEDICAL  DICTIONABY.    See  BiUings,  page  3. 

NETTLESHIP  (B.).  DISEASES  OF  THE  EYE.  Fourth  American  from  fifth 
English  edition.  In  one  12mo.  volume  of  504  pages,  with  164  engravings,  test-types  and 
formulte  and  color-blindness  test.     Cloth,  $2. 

NOBBIS  (WM.  F.)  AND  OLIVEB  (OHAS.  A.).  TEXT-BOOK  OF  OPHTHAL- 
MOLOGY. In  one  octavo  volume  of  641  pages,  with  357  engravings  and  5  colored 
plates.     Cloth,  $5 ;  leather,  $6. 

OWEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN.  In  one  12mo. 
volume  of  525  pages,  with  85  engravings  and  4  colored  plates.  Cloth,  $2.  See  Saria  cf 
Clinical  Manuals,  page  13. 

PABE  (BOSWELL),  Editor.  A  TREA  TISE  ON  S  URGER  Y,  by  American  Authora. 
For  Students  and  Practitioners  of  Surgery  and  Medicine.  In  two  magnificent  octavo 
volumes,  containing  1600  pages,  with  about  850  engravings,  and  about  40  full  page  platee 
in  colors  and  monochrome.  Volume  I.,  ready  in  a  few  dayt.  Volume  II.,  rea<2y  thortly. 
Price  per  volume,  cloth,  $4.50;  leather,  $5.50.     Net. 

PABBT  (JOHN  B.).  EXTRA-UTERINE  PREGNANCY.  ITS  CLINICAL 
HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREATMENT.  In  one  octavo 
volume  of  272  pages.     Cloth,  $2.50. 

PABVIN  (THEOPHILUS).  THE  SCIENCE  AND  ART  OF  OBSTETRICS. 
Third  edition  In  one  handsome  octavo  volume  of  677  pages,  with  267  engravings  and 
2  colored  plates.     Qoth,  $4.25 ;  leather,  $5  25. 

PAVT  (F.  W.)  A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION,  ITS 
DISORDERS  AND  THEIR  TREATMENT.  From  the  second  London  edition. 
In  one  8vo.  volume  of  238  pages.    Cloth,  $2. 

PAYNE  (JOSEPH  FEANK).  A  MANUAL  OF  GENERAL  PATHOLOGY. 
Designed  as  an  Introduction  to  the  Practice  of  Medicine.  In  one  octavo  volume  of  524 
pages,  with  153  engravings  and  1  colored  plate     Cloth,  $3.50. 

PEPPEB'B  SYSTEM  OF  MEDICINE.    See  page  2. 

PEPPEB  (A.  J.).    SURGICAL  PATHOLOGY.    In  one  12mo  volume  of  511  pages, 
";  with  81  engravings.    Cloth,  $2.    See  Students  Seriet  of  Manuals,  page  14 

PICK  (T.  PICKEUmO).  FRACTURES  AND  DISLOCATIONS.  In  one  12mo. 
volume  of  530  pagus,  with  93  engravings.    Cloth,  $2.    See  Series  of  Clinieal  Manucds,  p.  13. 

PIBEIE  (WILLIAM).  THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY. 
In  one  octavo  volume  of  780  pages,  with  316  engravings.     Cloth,  $3.75. 

PLAYFAIB  (W.  a.\  A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE 
OF  MIDWIFERY.  Sixth  American  from  the  eighth  English  edition.  Edited,  with 
additions,  by  R.  P.  Habris,  M.D.  In  one  octavo  volume  of  697  pages,  with  217  engrav- 
ings and  5  plates.    Cloth,  $4 ;  leather,  $5. 

THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRATION  AND 


HYSTERIA.    In  one  12mo.  volume  of  97  pages.    Cloth,  $1. 


Philadtlphia,  706,  708  and  710  Santom  St.—»»w  fork,  W  Fifth  4re.  (cor.  18th  St.). 


12  LEM    BROTHERS   i    CO.' S   PUBLICHTIOKS. 

POLITZEB  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE  EAR 
AND  ADJACENT  ORGANS.  Second  American  from  the  third  German  editioa. 
Translated  by  Oscau  Dodd,  M.D  ,  and  edited  bv  Sib  Wiluajc  Daut,  F.B.CJBk  Is 
one  octavo  volume  of  748  pages,  with  330  original  engravings.    Cloth,  ^.60. 

POWEB  (HENRY).  HUMAN  FHYSIOLOOY.  Second  edition.  In  one  IZmo. 
volume  of  396  pages,  with  47  engravings.  Cloth,  $1.50.  Bee  Studatft  Stria  «f  MammiJ», 
page  14. 

PURDY  (OHASLES  W.).  BRIQHT'S  DISEASE  AND  ALLIED  AFFEC- 
TIONS OF  THE  KIDNEY.  In  one  octavo  volume  of  288  pages,  with  18  engrav- 
ings.   Cloth,  $2. 

FYE-SMITH  (PHILIP  H.).  DISEASES  OF  THE  SKIN.  In  one  l2nM.  TolanM 
of  407  pages,  with  28  illustrations,  18  of  which  are  colored,    (loth,  |2. 

QUIZ  SiiBIES.    See  Student^  Quiz  Serier,  'ptige  14. 

RALFE  (CHARLES  H.).  CLINICAL  CHEMISTRY.  In  one  12ma  toIobm  of 
of  814  pages,  with  16  engravings.     Cloth,  11.50.    See  Student^  Stria  t^  MmnaiM,  fge  14. 

RAM8B0THAM  (FRANCIS  H.).  THE  PRINCIPLES  AND  PRACTICE  OF 
OBSTETRIC  MEDICINE  AND  SURGERY.  In  one  imperial  ocUvo  volume oT 
640  pages,  with  64  plates  and  numerous  engravings  in  the  text.  Strongly  bound  in 
leather,  #7. 

REICHERT  (EDWARD  T.).    A    TEXTBOOK  ON  PHYSIOLOGY.     In  ooe 

handsome  octavo  volume  of  about  800  pages,  richly  illustrated.     Preparing. 

BEHSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEMISTRY. 
Fourth  edition,  thoroughly  revised  and  much  enlarged.  In  one  12ma  volume  of  32S 
pages.    Cloth,  $2. 

REYNOLDS  (J.  RUSSELL).  A  SYSTEM  OF  MEDICINE.  Edited,  with  nolo 
and  additions,  by  Uexry  Hartsiiokne,  M.I).  In  three  large  8vo.  volumes,  contoining 
3056  closely  printed  double-columned  pages,  with  317  engravings.  Per  volume,  cloth,  15 ; 
leather,  $6. 

RICHARDSON  (BENJAMIN  WARD).    PREVENTIVE  MEDICINE.    In  ooe 

octavo  volume  of  729  pages.    Cloth,  ii ;  leather,  $5. 

ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  In  one  octavo  volume  of  780  pagex,  with  501  engravings.  Cloth,  $4.50; 
leather,  $5.50. 

THE  CO  MP  END  OF  ANATOMY.     For  use  in  the  IHwecting  Room  and  in 

preparing  for  Examinations.     In  one  Itimo.  volume  of  W>  pages.     Limp  cloth,  75  cents. 

BOBERTS  (SIR  WILLLAM).  A  PRACTICAL  TREATISE  ON  URINARY 
AND  RENAL  DISEASES,  INCLUDING  URTNARY  DEPOSITS.  Fourth 
American  from  the  fourth  London  edition.  In  one  very  handsome  8vo.  Tolume  of  609 
pages,  with  81  illustrations,    (loth,  ^..'>0. 

ROBERTSON  (J.  McQREOOR).  PHYSIOLOGICAL  PHYSICS.  In  one  12mo. 
volume  of  537  pages,  with  219  engravings.  Cloth,  $2.  See  Sdidentt'  Stria  o^  itanuala, 
page  14. 

ROSS  (JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE  NERVOUS 
SYSTEM.  In  one  hand.-«ome  octavo  volume  of  726  pages,  with  184  engravings.  Cloth, 
H50;  leather,  $5.50. 

8AVAOE  (aEOROEH.).    INSANITY  AND  ALLIED  NEUROSES,  PRACTL 
CAL  AND  CLINICAL.     In  one  12mo.  volume  of  fWVl  pages,  with  18  typical  engtav- 
Cloth,  $2.     Sec  Seritt  of  Clinical  Manualu,  page  13. 

\FBK  (EDWARD  A.).  THE  ESSENTIALS  OF  IlISTOLOG  Y,  DESCRIP- 
7  AifJ)  PRACTICAL.  For  the  use  of  StudenU.  New  (4th)  ediUon.  In  oo« 
■M  ooteTO  volume  of  311  pages,  with  288  illustrations.     Cloth,  $3. 

70e,  708  md  710  8m$om  St.—Ktw  fork,  W  Fifth  »n.  (ew.  18Ht  «r.). 


LEA    BROTHEHS   H    CO:S   PUBLICMTIOMS.  18 

80HMITZ  AND  ZXJMPT'S  CLASSICAL  SEBEBS. 

AD  VANCED  LA  TIN  EXERCISES     Cloth,  60  cents ;  half  bound,  70  cents. 
SCHMITZ'S  ELEMENTARY  LATIN  EXERCISES.    Cloth,  50  cents. 
SALL  UST.     Cloth,  60  cents ;  half  bound,  70  cents. 
NEPOS.    Cloth,  60  cents ;  half  bound,  70  cents. 
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ij79  An  introduction  to 
1695  pathology  and  morbid 
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