OT WSMOi liSSENTEaS 'jrr JfMAMH [PLE IYJ- A* S Y liXj J^ BTXS ON THE fRAOTE m Mmm, ARRANGED J» CONSORMlT* WITH The AmeMcan: Text-Book of §urge^. BY Professor of SprgeryirCfiush ^'4^>CoIlegeJ?hic£go;_aii > a in .the Chicago Polyclinic, j: CORNEL L UNIV ERSITY THE Sflouter Hetcrinaty library FOUNDED BY ROSWELL P. FLOWER for the use of the N. Y. State Veterinary College 1897 Cornell University Library RB 31.S47 Essentials of patholgoy and morbid anato 3 1924 AND OFE TOHN CHALlp^ES ftAC08T^,JVLI>., IJeinonstrator ofSuig6ry,tJeflgr«ori'"S(«dioal/C611ege; Chief ^.ssist^nt i Stiy- gical Out-Patient Department, Jeffilrson-lifedical College Hospital ; >■ ." y. -Surgical Registrar, Philadelphia Hospital. "_ A new Manual of the Pr inclples arid Practice:, of Surgery, inte^djjd^ to meet .the growing de- marid by-students and! others for a medium-sized^ work wfficb wall- embody alLthe newer methods, of procedure sorfully detailed in the larger text- books, but written in a concise, brief style. Considerable space im% be devoted to Sur- gi^aj Bacteriology^ Asepsis, and Antisepsis, with:- full details of the various methods of . disinfecting; instruments, the hands, etcy, ; as, well as the" prep^; rafjon of the vafious ; drugs Snd materials used. A The iirustratiprts are mostly new, the long and close connection" of the author with the Jefferson^; ;Medical College Hospital having ;'given. ( him tins Usual I opportunities^ for obtaining original and" thoroughly representative plates. -•-" The book^j||>be of-a handy and convenient size of about, 400 pages, -printed on fine paper, and well and substantially bound. , ~\ Y PRTBe :-Cloth, SI.04TT (hijerleaved, for taking i» ; Arranged in the form, of Questions ana An 7 5HE-:UTEST»"CHEAPEST IpBESJ ILlDSJUTBD. SERIES, (IF ^^ ifcw fori Medical Regard, Ad-OUSt 233, 18^0, -—j. ■ X'' Sfheiistlra workofj-JiiepaWng students' ManuatsVis to end we cannot »ay, ijfltt^wS&iinaei's'aeiieSi.iti our«pini»n,;bears offfb'epafm at present. ■' '^0ve%-sUf^idjcal^fagifi>in'e^-—" Beat of thsiRciass that ;have yet. appeared." SSffAlhern Cahffirni(pP/iictiti6ner -° — . * ' "M^^afi&ei'a'serieBofConipehds are the best evl3irpu;>li£hedinthls"cpijntry/'"itt No. i)j|%€sENTtALS OF PHYSIOLOGY. Third edition. Fipety illustrated . - Revise? an-dgreatiy-enlarged By H. A. Hake, M.p..'(PriceJ$l.OO, net.) N0.2.—ESSENTIALS OFSliBGERY. ;', With 'Appendix. on ^ Antiseptics; 'r Fifth edition. WilftfStratSpns/^By^irtFA'JtullAiiTiif.'lVt.D. ■„' ',. •NjO^^EaSENTIAJjSdFt-ANATOMT^ Based on Gba*; ^Ofltfth editioji,. 180 llJttstl'atioSg. By OHATtLES B^NilfOIUOTBt M.D. i •■ r NO.J.-ESSENT.IALS OF MEDICAL CHEMISTRY; ORGANIC AND INOR- ^g&Nie;, ^Fourtli Revised edition. With an~ Appendix. iBy'-LAWRENOT Nov-B^ESSENTIALS 6FJ9B.STETRtCS. 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There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31 92400021 871 3 FI&.3 ric.s UBINAKY DEPOSITS, &c. For explanation of the plate, see Sack of dedication page, and alto pages 108-121. SAUNDERS' QUESTION-COMPENDS. No. 6. ESSENTIALS PATHOLOGY AND MORBID ANATOMY. C. E. ARMAND SEMPLE, ' B.A., M.H. CANTAB. J L.S.A., M.R.C.P. LOND. ; PHYSICIAN TO THE BLOOMSBURY DISPENSAKY J PHYSICIAN TO THE NORTH-EASTERN HOSPITAL FOR CHILDREN, HACKNEY; PHYSICIAN TO THE ROYAL SOCIETY OF MUSICIANS J PROFESSOR OF VOCAL AND AURAL PHYSIOLOGY AND EXAMINER IN ACOUSTICS AT TRINITY COLLEGE, LONDON J LATE MEDICAL CLINICAL ASSISTANT AND SURGICAL REGISTRAR AT THE LONDON HOSPITAL J LATE SENIOR EXAMINER IN ARTS AND MEMBER OF THE COURT OF EXAMINERS AT APOTHECARIES' HALL. AUTHOR OF "THE VOICE MUSICALLY AND MEDICALLY CONSIDERED," " A MANUAL OF DISEASES OF CHILDREN," " AIDS TO CHEMISTRY," "MEDICINE," "MATERIA MEDICA AND THERAPEUTICS," ETC. WITH FORTY-SIX ILLUSTRATIONS. PHILADELPHIA: W. B. SAUNDERS, 925 Walnut Street. London : Henry Renshaw. Melbourne : George Robertson & Co. 1893. £8 3/ TO MY FATHER, ROBERT HUNTER SEMPLE. M.D., F.EiC.P. LOND., AS A SLIGHT TRIBUTE TO HIS SCIENTIFIC ATTAINMENTS AND LABOURS IN THE WIDE FIELD OF PATHOLOGICAL INVESTIGATION, THIS SHALL WORK IS Bffcctfonatelw E>cMcatc!> BY THE AUTHOR URINARY DEPOSITS, o dilated as to form a pouch, or series of pouches In Bronchiectasis, or dilatation of the bronchial tubes, the dilatation may be of considerable size and isolated, of a round or irregular shape, surrounded by condensed lung-tissue and connected with one of the larger tubes : or the tubes of* a part of one lung may be dilated uniformly, the walls being either thinned or thickened ; or, lactly a. large number of minute rounded dilatations of the ter minal branches of the bronchi may be present in a lung which is the seat of some morbid condition, as emphysema. In the plastic form there is an exudation of false mem- brane upon the inflamed mucous surface. "Microscopically, the same appearances arc presented as in inflammation of any mucous membrane. Inflammation of mucous membrane is described as occurring in three forms — viz., Catarrhal, Croupotts, or DiphtJieritic. The bronchi are more commonly the seat of the catarrhal form. ACUTE C&TARSHAI. EWTI.A1WMATIOI3-.— Tiki blood-vessels are engorged with blood, and, -consequently swollen, the lymph follicles are enlarged from increased cell-formation within them ; there is an increased secre- tion of mucus, showing numerous cells, in part leucocytes and in part originating in pre-existing epithelial cells. In chronic catarrh elongation of the cells of the connective tissue takes place, new structures being formed, and the thickness and density of the membrane become increased. CEOffPOBS £.» DISHTHESax'JPaC 11IS , 1,&WSS!1.&. TICK are terms applied to inflammations of mucius 6 PATHOLOGY AND MORBID ANATOMF. membranes and raw surfaces which lead to the formation of a false membrane. The terms croupous and diph- theritic are now more generally considered synonymous. The memb-ane is sometimes termed croupous when it merely involves the epithelium of the mucous membrane; and diphtheritic when the mucosa is implicated. Some authors limit the term croupous to false mem- branes which consist chiefly of coagulated fibrin, and apply the name diphtheritic to those false membranes which are composed of tissues that have undergone the so-called coagulation-necrosis, that is, in which the epithelium is entirely destroyed, together with more or less of the' sub-epithelial tissue. In this case the term croupous is really equivalent to fibrinous. Microscopically, the fibrinous membrane appears like lymph. There is a network of fibrin containing leucocytes, dehris, and desquamated epithelial cells, and this membrane is stripped ofi without difficulty. The diphtheritic mem- brane is not so easily separated — in fact, sometimes only with great difficulty. It would appear, even accepting the latter view, that in reality the diphtheritic is only an advanced stage of the croupous. FNSUMoram (Pneumonitis). — Inflammation of the lung substance exists in the three following forms :— • (1)' Acute, Plastic, Lobar, or Croupous. (2) Catarrhal or Lobular. (Broncho-pneumonia)- (3) Chronic, Interstitial, Cirrhotic, or Fibroid. LOBAR PWEUMOCTZA, called lobar, because it in- volves a large tract of the lung; croupous, from a fancied resemblance of the histological process to that of croup. — Three stages are described, as follows : — 1st stage: Engorgement, Hyperemia, Congestion, or Splenisation. 2nd stage : Red Hepatisation or Consolidation. 3rd stage : Grey Hepatisation or Purulent Infiltration. In the 1st stage, there is great congestion of lung capil- laries ; the lung is, consequently, redder and larger than usual. On section, the lung yields blood, serum, and froth. The whole organ somewhat resembles the spleen ; its sponginess and elasticity are lessened, but it still floats on water, and crepitates under the finger. In the 2nd stage the spongy character of the- lung is lost, the organ becoming hard and solid, resembling liver. The lung is much heavier, and its size is increased ; it INTERSTITIAL, CIRRHOTIC, OR FIBROID PNEUMONIA. J sinks in water, and breaks dowu when pressed by the finger, and, when cut, appears granular. Microscopically, the air vesicles are filled with exuda- tion, consisting of cells variously formed, bound together by coagulated fibrine or plastic lymph, the smaller branchial tubes being usually blocked by plugs of lymph. The walls of the air vesicles are not thickened by exuda- tion, but they are to some degree swollen by the engorge- ment of the capillaries. In the 3rd stage there is diffused suppuration of the pulmonary tissue. The tissue is dirty grey. There are cavities of pus, and pus points start from all parts of the lung on pressure ; the lung sinks in water. Microscopically, there is a great proliferation of cells of the surrounding connective tissue and of the epithelial cells lining the air vesicles ; in this manner the exudation becomes loosened from the alveolar walls. Further lique- faction of the contents ensues by alterations in the coagu- lated fibrine, and by the cells of the exudation undergoing fatty degeneration. The mass thus becomes softened, and in a condition to be removed by expectoration or absorption. Acute lobar pneumonia may end in resolution, or go on Lo gangrene, or abscess, or may leave unabsorbed deposits, becoming " caseous," and leading to consumption. In gangrene, a part of the diseased tissue becomes dark in colour, has an intensely fetid odour, and is very friable. When it ends in abscess, the inflamed portion breaks down into a cavity of an irregular shape, and filled with pus and broken-down lung structure. IHTEBSTITIAI., CIRRHOTIC, OR FIBROID pneumonia. — In this form, the lymph which is always exuded in pneumonia, and usually thrown off by expec- toration, remains in the lung, and degenerates into fibrous tissue and caseous matter. The lung substance is black or dark grey in colour, hard and dense, and permeated by whitish or black bands of fibres, often enveloping old masses of tubercle. It is usually dependent on pre- existing inflammation. As increase and hardening of the connective tissue take place, the air-cells are diminished in calibre, and are replaced by fibroid growth. Microscopically, the alveolar walls are observed to be considerably thickened by newly formed fibrous tissue, which has replaced the elastic fibres. 8 PATHOLOGY AND MOEBID ANATOMY. . This tissue frequently extends inwardly, lessening the cavity of the air vesicles, which are in some cases blocked by epithelial and other cells. The only indication in some cases of fibroid pneu- monia is an increase of connective tissue between the lobules filled with tubercular deposits. When the growth is fully developed the lung is solid, and hard to the touch; its size is diminished, and on section it appears smooth and shining, and creaks under the knife. The term cirrhotic is adopted, since the change is re- garded as the same which takes place in liver or kidney cirrhosis. ACUTE CATAESHAI OR IiOSlTLAK PNEU- MONIA (Broncho-pneumonia) frequently occurs in the lungs of children ; it is usually observed in those por- tions of lung which have become collapsed from bronchitis, single lobules with the small bronchi and the surrounding tissue being usually alone involved, these being red and firm. When cut, the lobules present a smooth, not granular surface, and bloody fluid can be squeezed from them. In this form the consolidation is limited to single lobules, and disseminated over the lung in variously sized patches. In plastic or lobar pneumonia the consolidation is massive. Microscopically, the capillaries which surround the air vesicles are dilated and engorged. Enlargement of the epithelial cells of the alveoli takes place, their numbers increase by proliferation, and, in company with serous fluid, effused from the vessels, the cavity of the air-cells becomes filled. PIiEURITIS (inflammation of the Pleura). — (1) The surfaces of the pleura are at first dry from the arrest of the ordinary secretion consequent upon inflammation, and the sub-serous areolar tissue is injected. (2) Lymph, or serum, is effused, or lymph-flakes mingled with pus, and recent adhesions are to be ob- served. (Pleurisy with effusion.) {3) The pleural sac is filled with pus. (Empyema.) Microscopically, the appearances in pleurisy are those of inflammation of any serous membrane. The first event is a dilatation of the capillaries, by which the red- PERICARDITIS. 9 ness is produced. The epithelium then falls off, the membrane being left roughened and its denuded surface coated by lymph which the dilated blood-vessels exude. The lymph is composed of fine fibres, cells, and nuclei. The cells and nuclei are exuded by the overloaded vessels, or take origin from proliferation of the epithelial cells. The fibres result from the coagulation of the fibrine of the liquor sanguinis. Should the opposite surfaces of the pleura remain touching one another, the cells entangled in fibrine become fusiform (spindle-shaped), and thus form connective tissue ; blood-vessels are de- veloped from the inflamed pleural vessels, and the false membrane is said to become organised, leading to adhe- sions. If a copious fibro-serous effusion exists between the opposed pleural surfaces, union may result by a process affecting the connective tissue of the serous membrane itself. Externally the false membrane is com- posed of coagulated fibrine, but beneath this is a layer of cells formed by the proliferation of the connective-tissue cells of the sub-epithelial structures ; vessels soon per- meate the cellular layer, the cells become fusiform, and produce connective tissue. The flakes of fibrine in the fluid by which the sac of the pleura is distended undergo fatty degeneration, soften, and are absorbed in company with the fluid, the opposed surfaces coming in contact and uniting. When suppuration takes place, the pus-cells originate, partly from the exudation of the white blood- corpuscles, and partly from proliferation of the colls of the false membrane and of the connective tissue of the structures in the vicinity. In a microscopic specimen the injected newly formed blood-vessels appear in the midst of material consisting of cells ; they vary in size, and look like channels rather than vessels. INFLAMMATORY PROCESSES IN THE HEART. PERICARDITIS (Inflammation of the Pericardium). — In recent cases lymph is observed, of a pale-straw colour, soft, tenacious and firm, and mixed with sernm and flakes of fibrine. The surfaces of the serous membrane are shaggy and rough, and present honeycomb depressions; at later periods there are exudations of lymph and fibrin- IO PATHOLOaY AND MOEBID ANATOMY. ous serosity, causing adhesions between the opposite surfaces which may obliterate the pericardial cavity ; where the powers of life are very low; there is considerable serous effusion, constituting dropsy of the pericardium (Hydropericardium). Pus is rarely, but occasionally pre- sent (Pyopericardium), and sometimes tubercles are observed (Tubercular Pericarditis). Microscopically, the appearances resemble those of a serous membrane as in plenritis (p. 8). ENDOCARDITIS (inflammation of tbe Endocar- dium). — The inflammation is usually confined to the valves of the heart. The valvular inflammation gives rise to deposit of lymph upon or beneath the lining membrane The valves thus lose their thinness and transparency, they become thick, puckered up, and adherent to one another or to opposite walls of the channel; or they may present warty vegetations or excrescences ; or they may' be the seat of atheromatous degeneration, or of calcification (deposit of carbonate and phosphate of calcium). In an early stage the endocardium is reddened and roaghened with lymph, vegetations or warty projections being found on the valves, and being most thickly situated on the lines at which the segments of the valves during their closure come into contact "with each other — i.e., where they are most exposed to friction. In some cases the valve segments become united, or the valves or chorda; tendinere are torn and softened. In rare instances perforation of a valve or ulceration of the endocardium may take place. The valves may become opaque, thick- ened, or contracted. If the inflammation becomes chronic the valves of the heart may become thickened, contracted, atrophied, or ossified. The endocardium is non-vascular, and consists of a layer of connective tissue, having an internal endothelial covering. When the process is of considerable intensity (acute), the deeper layers of the endocardium become rapidly infiltrated by young cells. The intercellular substance becomes destroyed, and a new tissue is formed, which, as it projects through the superjacent endothelium, produces minute granulations and vegetations upon the surface of the softened valve. The term papillary is applied to this form of the disease. The granulations, being roughened and stripped of endothelium, may become CHSOHIC ENDOCARDITIS. II covered by fibrinous -caps by inducing coagulation upon themselves. When the inflammatory process is of moderate in- tensity, as is usually the case, the granulating valves may become adherent to one another or to aa inflamed patch on the cardiac walls, the new tissue undergoing fatty and calcareous degeneration, and becoming more or less organised into a fibrillated structure. Consequently, thick- ening, rigidity, and shrinking of the valves are produced, leading to their insufficiency (regurgitant disease) and narrowing (stenosis). The vegetations and papillary ex- crescences are caused by the new tissue continuing to grow after the severity of the process has ceased. If, however, the inflammatory process is very intense — that is, if the cellular in nitration of the deeper layers of the endocardium is very groat — an endocardial ulcer results, the new tissue breaking down and loss of substance ensuing. The condition itself is then called ulcerative endocarditis, in rare cases small quantities of pus being observed ill the deeper layers of the endocardium. This condition is very serious, as it frequently gives rise to embolism, and sometimes to pysemia. chronic endocarditis may follow the acute form, or be of a chronic nature from the onset. It is characterised by less rapid and copious cell-in filtration ; the intercellular substance suffers far less than in the acute form, but a fibroid thickening of the endocar- dium may result, leading to induration and contraction of the cardiac valves. Occasionally, the valves become the seat of papillary growths (derived from the new tissue), in which fatty and calcareous changes may take place. A long vegetation on a segment of a valve may, by its constant rubbing upon the endocardium (situated beneath it), produce numerous inflammatory granu- lations. mtocabdstjs, or inflammation of the substance of the heart, is very rare as an uncomplicated condition, but it may accompany pericarditis. It usually occurs as a general inflammation, immediately situated beneath the endocardium or pericardium. The muscle is either soft and dark red or hard and dense, and, ... ., .„ Microscopically, the transverse stnse of the nbriliEe appear lost, the muscle apparently consisting in the main of fatty and granular matters. 12 PATHOLOGY AND MORBID ANATOMY Chronic myocarditis usually results from syphilis. The tissue is dense and hard, from the formation of fibrous tissue between the bundles of the muscular fibres. INFLAMMATION OF BLOOD-VESSELS. Inflammatory changes independently of thrombi are more frequently found in the arteries (Arteritis) than in the veins (Phlebitis), and in the. walls of the former vessels they give rise to the so-called ATHEROMA. — Atheromatous changes are found in the deeper layers of the intima or inner coat of the arteries." The fibrous and elastic lamellae of the intima become infiltrated with young cells, and as the number Fig. 2. Chronic Atheromatous Change in an Artery. The new tissue is seen in the deeper layers of the inner coat, as is also the resulting internal bulging of the vessel. The darker portions show the new tissue, which has become softened and pulta'ceous. At the lower part of the figure are shown a few of the most internal fibres of the middle coat, x 25. of these cells increases they occasion a swelling beneath the innermost layers of this coat. At first this swelling is soft, and flabby, and its lining membrane can be stripped off easily. When the inflammatory process is of great intensity (acute), the intercellular substance is CONGESTION' OF THE LIVER. I" entirely destroyed, the walls of the vessel soften, and dilatation, aneurism, or rupture may follow. The process is, however, usually of much Jess severity — i.e., more chronic — and the term "atheroma'' is cummonly ap- plied to the more chronic arterial changes (Fie;. 2). ATHEROMATOUS abscess. — When the inflam- matory process is of a chronic nature, the atheromatous swelling of the intima becomes the seat of retrogressive changes, which commence in the deeper portions of the new tissue. A soft, yellowish, pultaceous substance is thus produced, due to fatty degeneration of the young cells and softening of the intercellular substance. ATHEESaoafiATOWS ■gJIiCEK. — This is forn.ed when the lining membrane eventually gives way, and tho softened matters are carried away by the circulation. Occasionally absorption of the more fflaid constituents of the morbid tissue takes place, with the formation of cholesterin, and the deeper layers of tho inner coat be- come the seat of a mass of broken-down fibres and cell 5 !, cholesterin crystals, and fatty de'bris. This mass may ultimately become calcified, and result in a calcareous plate. The most chronic forms of the atheromatous process produce but little softening of the new tissue ; a fibrillated structure is developed from the cells, and the inner coat of the artery undergoes fibroid thickening;. The fibroid stroma, however, usually encloses more or less fatty debris. INFLAMMATORY PROCESSES IN THE LIVER. COWSESrsosf of the liver occurs under three forms —viz., (1) Active, (2) Passive, leading to (3) Biliary (Cong-estioa (a condition in which the ducts are engorged with bile). The Active form arises from an excessive supply of blood to the organ, resulting from intermittent fever, ex- cess in eating and drinking, or from residence in tropical climates. It may also be caused by morbid materials in the blood, or by the suppression of habitual discharges (catamenial orhffimorrhoidal), or by sedentary habits. Tho Passive form may occur from obstruction to the 14 PATHOLOGY AND MORBID ANATOMY. circulation through the portal and hepatic veins, or from obstruction of the blood-flow into. the heart, due to dilata- tion of tho heart or valvular disease; from emphysema and other diseases of the lungs, -in which the venous blood- flow through the right side of the heart is obstructed ; but blows on the side, and intemperance, especially when spirits have been freely indulged in, are common causes of hepatic congestion. It may precede or accompany cirrhosis and other diseases of the liver. In the first two forms the liver is enlarged, its surface is smooth and dark red, with a hard and prominent margin, and on section bloo'd flows freely. The so-called " nutmeg liver " is the result of long-standing passive congestion. Here a section of the liver presents the ap- pearance of a nutmeg — i.e., red spots or patches, which are surrounded by dirty-white or yellowish spaces. Microscopically, in passive congestion the 'hepatic veins are considerably dilated and their walls thickened. The enlarged veins press upon the surrounding parts, and thus the size of the cells in the interior of the lobules is reduced. The colour of the cells is dark yellow, whilst the cells in the exterior are large, fatty, and pale. Occasion- ally the cells in the centre -of the lobules become absorbed, leaving only dark-coloured granular matter. ACUTE HEPATITIS (inflammation of the liver) presents similar pathological changes to those observed in acute pneumonia. There is at first great Congestion of the capillaries of the liver, with consequent swelling. Then effusion of Albumino-Fibrine or Plastic Xympta takes place. The attack may end in (a) Resolution, with absorp- tion of the exudate, (6) in Purulent Infiltration, (c) in Abscess, (d) in Gangrene. CIRRHOSIS, CHRONIC OR - IHTERSTITIAI HEPATITIS is a form of chronic inflammation, re- sulting in a fibroid hypertrophy of the capsule of Glisson. In health, the hepatic artery conveys the nutrient blood to the liver, the hepatic duct carries away the bile, the portal vein conveys blood from the viscera to form the bile, and the hepatic vein carries from the liver the waste blood. In cirrhosis there is a fibroid hypertrophy of the capsule of Glisson, and,, therefore, thickening and HYPERTROPHIC OR BILIARY CIRRHOSIS. 1 5 hardening of the liver, the edges of which become Tounded, and the surface nodulated (hobnailed). The gland be- comes of a light yellow colour,. tough and leathery, and its size is much reduced, especially that of the left lobe. In the early stages of the disease the organ becomes enlarged, but it eventually becomes shrunken, and shuts off the supply of blood by the hepatic artery, producing atrophy and pallor ; this contraction of the liver obstructs the circulation through the portal vessels, producing en- largement of the veins upon the surface of the abdomen, and by compression upon the portal vein induces ascites, for, since the blood-stream is thrown back upon the in- testines, no absorption takes place, and watery fluid is thrown out into the peritoneum. From pressure upon the hepatic duct the bile-flow is arrested, and this fluid is not properly secreted. Microscopically, the chief portion of the structure is composed of connective tissue, originating from inflam- mation around the portai canals. The lobules become compressed by the new-formed tissue, the liver cells be- coming fatty, or they are absorbed and disappear. The branches of the hepatic artery are frequently en- larged, and may be seen ramifying in the thickened structure, but the branches of the portal vein are com- pressed and very often obliterated. The secreting cells are disintegrated, there is a multi- plication of the fat cells, an increase in the colouring matter, and deposit of granular matter, whilst newly- formed connective tissue is seen between the lobules. The tissue first becomes infiltrated with round cells, which eventually, becoming spindle-shaped, form a fibril- lated structure. The cells in the outer zone of the lobules are the first to become atrophied, and, ia consequence of the new tissue insinuating itself between them, the inter- cellular network is gradually involved. HYPERTROPHIC OR BILIARY CIRRHOSIS.— The organ is greatly enlarged, and hard and dense. The ascites of ordinary cirrhosis is usually absent, and jaundice is common, in consequence of obstruction of the biliary ducts. Microscopically, the disease appears to have its origin in a chronic inflammation around the smaller biliary ducts, seated between the lobules. The existence of this form of liver disease is denied by some authors. 1 6 PATHOLOGY AND MOEBID ANATOMY. INFLAMMATION OF THE BILIARY PAS- SAGES. — The gall bladder and biliary ducts are liable to the three following forms of inflammation :— (1) Catarrhal Inflammation. — In this form there is an increase ' of mucous secretion, which becomes viscid or muco-purulent. Occasionally a firm plug of mucus may obstruct, for a time, the cystic or common duct. It is generally preceded by catarrh of the stomach and duodenum. (2) Plastic or Exudative Inflammation. — In this there are fibrinous products. Oasts of the tubes are found blocking up these channels and causing dilatation. (3) Suppurative Inflammation, in which a thick kind of blood-stained mucus and pus is formed. Ulceration may follow ; it is usual to find gall-stones when the gall bladder is ulcerated, but ulceration may be induced by decomposing bile, in the absence of calculi. INFLAMMATORY PROCESSES IN THE KIDNEY. ACUTE TTBUIAR NEPHRITIS (inflammation of the Kidney), — The kidneys are increased in volume and weight, even to .twice their normal size. The surface is smooth, and the capsule readily removable. In early stage i the kidney on section is dripping with blood, from which circumstance" it has been called the chocolate blood-drip- ping kidney. The renal substance is sometimes everywhere engorged with blood, but occasionally the cortical portions are everywhere an sarnie. There is no alteration of the intertubular stroma. • Red points are generally observed upon the surface, and within the. cortical portions, being due to minute ecchyuaoses. A wheatsheaf appearance is sometimes presented, owing to. the. cones being deeply congested, and the tubes separated at their bases by swollen cortical substance. The kidneys offer consider- able resistance to pressure. In later stages they are mottled white and red. The normal weight'of each kid- ney being 3 to 5 ounces, in this disease one kidney may attain to, or even exceed, 8 ounces. Microscopically, the tubuli uriniferi are distended by largo granular epithelial cells, mixed with and bound together by blood-corpusles and fibrine, by which these CHROXIC TUBULAR NEPHRITIS. 1 7 channels are partly or entirely blocked up. If recovery does not take place at this period it is stated that the con- dition of the lavge white kidney may be established. CHRONIC TUBULAR NEPHRITIS, OR LARGE white kidney. — The kidney is much increased in size; the capsule peels readily. On section, the cortical portion is increased in volume; the surface is smooth and white, marked with blue arborescent veins, or it is of a pale yellow colour, and marked with striations. The pyramids are frequently congested. Microscopically, the renal tubes appear dilated and distended with cells, and with fatty and granular mate- rials, which block up their channels. The intertubular stroma is unaltered. In later stages the tubes lose their lining membrane, and become atrophied. intertubular nephritis (the granv- us OR CIRRHOTIC xidney). — The whole organ is much reduced in size in the advanced stage, but in an early stage its size is often somewhat increased. The capsule is thickened and firmly adherent ; when an attempt is made to peel it off, small portions of its tissue adhere to the surface of the gland- The surface is covered with small irregular prominences (granular). In other cases cysts are observed. On section, the cortical portion is found much reduced in size and thickness, the whole structure being coarse and fibrous. In the earliest stages, the changes are limited to the cortical portion of the kidney, the new growth being usually most abundant around the Malpighian bodies, and at this period the tubes and their epithelial lining are intact; as the disease advances the tubular struc- tures atrophy, and in a very advanced stage calcareous deposits may often be noticed as white streaks between the tubes of the pyramids. Microscopically, in early stages the intertubular con- nective tissue becomes abnormally vascular, and infiltrated with numerous round cells (Kg. 3). These cells as the disease advances become fusiform, and are converted into fibrous tissue. The newly-formed tissue produces pres- sure upon the adjoining parts, and hence appear atrophy of the Malpighian bodies and shrinking of the renal tubes, which are often devoid of epithelium. Some patho- logists incline to the opinion that the granular kidney is only a modification of the large white variety. B 1 8 PATHOLOGY AND MOEBID ANATOMY. PYELITIS.— In the acute form there is redness of the lining membrane, which is thickened, ulcerated, or covered by muco-purulent secretion, and there are calculi in the pelvis of the kidney. Fio. 3.* Intertubular Nephritis in the Acute and Early Stage. The figure shows tho cellular infiltration of the intertubular tissue. In an advanced stage of the process the intertubular structure becomes mixed with granular and fatty de'bris, which result from the degeneration: In a very advanced stage of the process a large amount of fibroid tissue is seen between the tubes of the cortex, with extensive atrophy of the tubes. In the chronic form, when suppuration (suppurative nephritis) has taken place, the kidneys are enlarged and congested, and scattered abscesses are observed, varying from the size of a walnut to that of a hemp-seed. The tubes are crammed with pus-corpuscles and epithelial cells. If the suppuration has resulted from a calculus, the kidney substance will be found destroyed, and its external portions converted into the sac of an. abscess which occupies its interior. CONGESTION OF THE STOMACH, ETC. 1 9 INFLAMMATORY PROCESSES IN THE STOMACH. CONGESTION OP THE STOMACH. — The gastric mucous membrane is of a deep red or purple coftur, thickened and covered by tenacious mucus. The vessels are enlarged and filled with blood, the rugae are very pro- minent ; dark-coloured small round spots' are observed chiefly at the pylorus. Microscopically, the vessels are intensely congested, and the coats of the veins are thickened. ACUTE GASTRITIS (inflammation of the Stomach). — There is unusual and universal redness of the gastric mucous membrane, which, is covered by in- flammatory patches, especially around the pylorus and cardia. The rugae are deep red, and numerous brown or soot-black spots, varying in size from a pin's head to a pea,' termed " hemorrhagic erosions," are observed, or the membrane may be softened, ulcerated, or even gan- grenous. SUB-ACUTE GASTRITIS. — The stomach is con- tracted and small. The chief appearances under the microscope are those of congestion ; the vessels are in- jected. The gastric tubes are filled with cells, fatty and granular matters, and sometimes with blood. chronic gastritis.— The whole stomach is globular and much thickened, especially at the pylorus, the walls not collapsing on section. If the inflammation is limited to the mucous membrane, this membrane is of a dark or slate-grey colour, the surface being uneven and warty — i.e., mammillated and dense. Microscopically, at early periods the gastric tubes are observed to be firmly bound together, the blood- vessels being thickened and enlarged. At later periods fibrous tissue replaces the tubes, and atrophy of the gastric tubes may result from the'pressnre of the newly- formed fibres. The changes in this form of gastric affection are analogous to those which take place in cirrhotic conditions generally. ulceration- of THE stomach.— This affec- tion occurs under four well-marked forms : (1) Superficial Erosions consequent upon the dark 20 PATHOLOGY AND MORBID ANATOMY. round spots which are frequently observed in .congestion and sub-acute gastritis. (•2) Perforating Ulcers. — These are circular in shape, and penetrate the coats of the organ, the edges being sharp, as if punched out. (3) Chronic Gastric Vlcers. — In these the edges are usually elevated; and the structures around them are dense and hard; their surfaces being formed by the un- uerforated coats, or by some other organ, as the liver, to which adhesions have extended; they are most eom- raon at pylorus. (4) Sloughing Ulcers.— These may sometimes be found in persons who have previously shown no indica- tion of disease of the stomach, but are much reduced by syphilis or renal disease. The simple perforating ulcer is rarely smaller than a fourpenny piece or larger than a five-shilling piece. In shape it is generally oval or round, and presents the appearance of a shallow level pit, with a sharp, smooth, vertical edge, as if punched out. The ulcerated space is largest in the mucous membrane, next in the muscular tissue, the shape being that of a funnel or cone ; and, if it pass though the peritoneum, the perforation then becomes a mere chink or pin-hole. The areolar tissue and mucous membrane are at times thickened by exuda- tion of lymph, and' the surrounding mucous membrane is occasionally inflamed. Perforation occurs in about one case in eight, the fatal result being often averted by adhesion of the bases of the ulcers to the liver, spleen, pancreas, mesentery, or diaphragm. INTESTINAL LYMPHATIC STRUCTURES.- -In typhoid fever the local manifestations are chiefly observed in the solitary and agminated glands (Peyer's patches") of the lower third of the ileum, near the ileo-cascal valve. These normally obscure glands are first swollen and ele- vated, pale, soft, and rounded at the margins. They rapidly become vascular, the swollen gland becomes abraded, and sloughing and ulceration soon succeed. A whole Peyer's patch may be. coated with a discoloured aphthous-looking slough. When the ulcer has advanced, or after the separation of the Blough, the surface is rugged and granular. The^ edges of the ulcers are raised and hard. Internally the ulcers are ragged with excavations, and COLITIS, DYSENTERY: 21 externally they are smooth and rounded. As the base of the ulcer approaches the peritoneum, the inflammation of that membrane increases ; when the ulcer3 are numerous, the patches become confluent, and the outer surface may be covered with plastic lymph. If this covering becomes the seat of ulceration, perforation must ensue, but it is often temporarily delayed by the adhesions of sloughy tissue within the membrane itself, or by the formation of solid lymph upon its external surface. In cases of recovery, the ulcers heal, contract, cicatrise, and eventually form a depressed smooth surface, which is less vascular and thinner than the surrounding coat. The mesenteric glands are always much swollen, and more or less inflamed. The spleen is found softened, and enlarged, and it sometimes contains little yellowish-white deposits, similar to those found in the diseased glands of the intestines. Microscopically, in a very early stage, there is catarrhal inflammation of the entire mucous membrane of the diseased parts, the lymphatic follicles being en- larged in consequence of their cells being increased in number, and the blood-vessels by which they are sur- rounded are intensely congested at later stages. The surrounding connective tissue becomes infiltrated with cells, and, by the union o£ these with the enlarged follicles, a soft medullary mass is formed. In consequence of the cells degenerating, and being absorbed, the follicles may become normal, or, through their bursting, the contents may be discharged. The characteristic termination is the separation of the dead tissue as a slough, thus forming the Typhoid Ulcer. The ulcers which arise in the solitary glands are usually of a spherical shape ; those originating from the patches are oval, and their long diameter is in the direction of the gut. The base of the ulcer is smooth and generally formed by the muscular or submucous coat of the intes- tine, the edges being thin and undermined, and consist- ing of a fringe of hyperasmic mucous membrane. colitis, dysentery, — In the acute form there is inflammation either in patches or spread over the whole extent of the mucous membrane of the colon, which is in places black, gangrenous, and softened. The mucous follicles are hard and opaque, or enlarged and trans- parent. 22 PATHOLOGY AND JtOHEID ANATOMY. In the chronic form there are ulcers commencing in the solitary glands, which spread and become at last con- fluent into large ragged patches. The surrounding tissues are much thickened. The lower part, of the small in- testines, and sometimes the stomach, may present similar appearances, and there is often softening, with swelling and redness of the mesenteric glands. In the early stages mucus, blood, and watery lymph are found in the intes- tines ; in later stages pus and blood are present. When the disease has been of long standing, the tissue in the vicinity of the ulcers is almost of the hardness of cartilage. The position of ulcers which have eventually healed is marked by tough cicatrices. Abscess of the liver is observed in the majority of fatal cases of dysentery. PERITONITIS (inflammation of tbe Peritoneum). — The peritoneal vessels are injected; the surface of "the serous membrane is covered by coagulable lymph, or flakes of lymph, floating in pus or serum ; the intestinal folds are bound by coagulable lymph to each other, or to neighbouring viscera. Plastic lymph is thrown out around the intestines, and this, becoming organised, glues them together and produces obstinate constipation, no peri- staltic movements being -capable of performance by the firmly-bound intestines. INFLAMMATORY PROCESSES IN THE BRAIN AND SPINAL CORD. IWENITCGITZS (Inflammation of the Brain mem- branes). — On post-mortem examination, the vessels of the pia mater are found to be enlarged and engorged with blood, and the arachnoid is opaque, serum and lymph being situated beneath it. CONGESTION OF THE BRAIN. — In the active form, the size of the capillaries and the large blood-vessels of the brain and of the pia mater is increased. The puncta cruenta are increased in number, and are larger than usual. The pia mater appears red or rose-coloured, either throughout its entire extent, or in spots. The hue of the grey matter is violet or red. Fluid in excess is contained in the ventricles, and there is enlargement of the choroid plexuses. In the passive form, the veins are BEAIN SOFTENING. 2J usually distended, since the amount of venous blood is increased. ENCEPHAHTIS, CEREBKITIS (inflammation of the Brain Substance), may be general, when it is espe- cially associated with meningitis, or local, in which case it may lead to red softening or to ABSCESS or THE brain. — This usually results from diseases of the ear, nose, or orbit, or other parts of the skull. Abscess of the brain may occur in the middle or posterior lobe ; the petrous portion of the temporal bone is almost always carious. The dura mater covering it is inflamed, and an abscess is found in a diseased patch of brain, the pus being green and offensive. It is not un- common to find, in recent cases, a cavity filled with reddish or yellowish fluid, bounded by r jddened, softened brain substance; in older cases, encysted pus will be observed — i.e., enclosed in walls formed by connective tissue. BRAIN SOEIEHING (Ramollissement) may be caused by inflammation or by ansemia, or by long-con- tinued intellectual exertion, and it is most liable to take place between the ages of fifty and eighty. Two Varieties are described — (1) The Red or Inflam- matory, and (2.) The White, Yellow, or Non-inflamma- tory In Red or Inflammatory Softening the brain is soft and pulpy, of a red colour, and often presents numerous blood-points (puncta vasculosa). Microscopically, the nerve-tubes are seen broken up and mixed with blood-cells, pus-cells, granular matters, and dark granular fatty bodies like mulberries, called " exudation-corpuscles." The minute arteries are also covered by fatty and granular materials. In the White, Yellow, or Non-inflammatory Soften- ing the brain is soft and pulpy, becoming ultimately of a creamy consistence, white or yellow in colour, and capil- lary haemorrhages are sometimes found upon the exterior of the affected part. To distinguish the softened part from the healthy part of the brain, a stream of water is projected against the organ, the diseased part breaking down under the stream, whilst the healthy is unaffected by it. Microscopically, softened and disintegrated nerve- 24 PATHOLOGY AND MOKBID ANATOMY. fibres, granular matters (resulting from the destruction of the nerve-tissue), the yellow colour being due to the ad- mixture Of the fat granules with the colouring matter of the blood, fatty blood-vessels, and fatty cells are observed. White softening is always the result of imperfect nutri- tion of the affected part ; it is a frequent consequence of the blocking of an artery by a plug (embolism), and it may be caused by the pressure o.f a tumour or hemorrhagic clot upon the circulation of the surrounding parts. nTDTOATSOIf OR HARDENING- OF THE brain. — This condition is usually considered to be, and often is, the result of chronic inflammation. The cerebral mass resembles wax or boiled white of egg. Some cases which during life have been regarded as softening of the brain have upon post-mortem examination proved to be really instances of induration. SPINAL ittENiNGiTWS. — The dura-arachnoid is thickened, its vessels congested, and there is effusion of puriform lymph, and serum. When Iiepto-meningltis, or inflammation of the pia- arachnoid, is present, there is an irregular appearance of the cord, due to effusion of lymph in the arachnoid space. When caused by disease of the vertebras and the struc- tures in their vicinity, the inflammation is localised in portions of the spine ; but if due to a general cause, it may extend over the whole extent of the spine, selecting the posterior rather than the anterior aspect. spinal myelitis.- On post-mortem examination, the affected tissue usually appears much softened; it is often of a creamy consistence. Small extravasations of blood are sometimes seen ; in rare cases an abscess forms. Microscopically! broken-down nerve-fibres, blood- cells, granules, and pus-corpuscles are observed. More or less spinal meningitis is always present. Sometimes the cord becomes indurated from fibrinous exudation. A Chronic Myelitis or White Softening of the cord is sometimes observed in which the cord is white or of a more or less red or yellowish colour. This may arise from acute myelitis, from gradual pressure upon the substance of the cord from injury, or from failure of nutrition from the vessels becoming degenerated. INFANTILE PARALYSIS OR SPINAL PARA- lysis. — The latest observations of these affections seem TRISMUS NASOENTIUJr. 25 to indicate an inflammation of the anterior cornua of the grey matter of .the spinal cord, from which arise the spinal nerves. Atrophy of the large cells takes place, being fol- lowed by their subsequent disappearance. Charcot is of opinion that the disease commences with inflammation of the ganglionic cells of the anterior cornua of the grey matter of the spinal cord, which by degrees extends to other situations. The cervical, dorsal, and lumbar por- tions of the cord may be affected, but the dorsal is the least often implicated. It occasionally happens that the muscles increase in bulk instead of shrinking. In cases which have proved fatal after having lasted for. some years, the posterior cornua are found healthy, the ante- rior cornua being changed and their cells disintegrated. There are flaccidity and atrophy of the muscles, which are to some extent replaced by fat, and the interstitial tissue is hypertrophied ; the bones are shorter, the tendons smaller, and there is enlargement of the medullary canal. The term Acute Anterior Polio-myelitis includes the diseases known as Infantile Paralysis and Acute Spinal Paralysis of Adults. In TRISMUS NASCENTIUIW, microscopically, according to Demme and Rokitansky, the constant ana- tomical character appears to be proliferation of the connective tissue of the cord, the striking peculiarity being the large area over which it extends. The product is a viscous mass with abundant nuclei, never advancing to a fibre-forming stage. The change is almost exclusively limited to the white medullary substance, the grey matter appearing merely to suffer secondarily. The proliferation is chiefly in the medulla oblongata, crura cerebri, inferior peduncles of the cerebellum, and in the greater part of the spinal cord. The white substance, then, of the brain and spinal cord is prone to two varieties of grey degeneration — viz., the inflammatory and the non-inflammatory. The' grey appearance is due to wasting of the white substance of Schwann, the axis-cylinder of the nerve fibres (itself of a greyish colour) being left untouched. Tbe Inflammatory Grey Degeneration is generally less extensive than the nan-inflammatory form. It causes hardness and some reduction in thickness of the part's involved. Microscopically, the external coats of the blood-vessels 26 PATHOLOGY AND MOKBID ANATOMY. appear much thickened; there is an increase in the amount of the connective tissue, with compression and degeneration of the nerve fibres. The Non-inflammatory Grey Degeneration affects the spinal cord more frequently than the preceding form, generally beginning at the lower part and extending up- wards. It usually commences at the surface, and, upon making a section of the cord, the posterior columns are seen to be transformed into reddish-grey matter, extend- ing inwards to a variable distance. Microscopically, the amount of connective tissue is considerably increased, a network of fine fibres being formed, by which the nerve fibres are compressed, their degeneration, subsequently ensuing. The white substance of Schwann first breaks down, but even late in the dis- • ease the axis-cylinder can frequently be made out. sclerosis. — In the discussion of diseases of the nervous system, a good deal of confusion has been created in connexion with that class of lesions in which hardening of the tissues is a distinctive feature. It is a little unfor- tunate, perhaps, that the word " cirrhosis " has not been more generally applied to such changes ; for, practically, the conditions which exist in such diseases as cirrhosis of the liver and sclerosis of the spinal marrow are of a similar nature. In both cases the "hardening" that ensues de- pends on an overgrowth of the connective tissue of the part, hypertrophy of which destroys the functional powers and the structural integrity of the organ involved, through pressure on the essential elements in each instance. More- over, there is no common agreement among pathologists in the terminology that is adopted ; nor is " sclerosis" com- monly used to indicate all lesions in which overgrowth of connective tissue in the nervous system is a characteristic feature. For this reason, therefore, it has seemed desir- able to give a brief description in this place of the meaning of '" sclerosis " in its application to diseases of the nervous system ; and to associate With it an account of the two affections classed as " scleroses " — namely, lateral scle- rosis and disseminated sclerosis. Overgrowth of neu- rogliomatous connective tissue in the posterior columns of the cord is also found in locomotor- ataxia, and in the anterior horns of grey matter in progressive muscular paralysis. The Pathology of sclerosis, as already indicated, in- MULTIPLE SCLEROSIS.*" 27 eludes an account of changes originating in the fine connective-tissuo network distributed throughout tho nervous structures, and .serving as a support for the more important elements — the nerve-cells and nerve- tubules. Under conditions of disease, this connective tissue, or neuroglia, undergoes an increase in bulk, and, as a consequence, the proper nerve elements are subjected to pressure and atrophy, the necessary effects of which are complete destruction of the conducting properties of the nerves, and of the activity of the central cells. According to the position and extent of the induration, so will the symptoms produced differ both in degree and in the parts affected, paralysis being a main result of the changes. The causation of sclerosis is not always easy to comprehend. In some cases it is undoubtedly a sequel of inflammation extending .from the coverings of -the cord, &c, and may result from pressure of tumours, curvature, &c. Gout, syphilis, and sexual over-indul- gence are likewise credited, probably through the agency of a vitiated blood-supply, with inducing it ; and heredity also is regarded by some as an efficient cause. The form of sclerosis affecting the posterior columns of the cord in tabes dorsalis is frequently found in syphilitic subjects. MULTIPLE SCLEROSIS. — This disease is also known under the names of Disseminated, Cerebro- spinal, and Insular Sclerosis. It is an affection of which the anatomical characters are overgrowth of the neuroglia, associated with atrophy and degeneration of the essential nerve-elements. It is often found in those who have indulged immoderately in alcoholic liquors, and sometimes it appears to originate from exposure to cold. It is most frequent between the ages of twenty and thirty, but' may be encountered in much older or younger subjects. The morbid growth is most plentiful in the white sub- stance of the brain and cord, and consists of hard round nodules having a greyish translucent appearance. On microscopical examination of a section of such a growth the neuroglia is found much increased, its nuclei and fibres beins^ distinct, and the nerve-fibres are atrophied, although their axisrfylinder can generally be made out. LATERAL sclerosis. — In this affection the seat of the lesion is in the antero-lateral columns of the cord. 28 PATHOLOGY AND MORBID ANATOMY. BULBAR PARALYSIS, OB CIOSSO-LABIAL- JABirwCEAl paralysis. — This term 18 employed when the medulla, oblongata and pons Varolii are the seat of the sclerotic change. The medullary matter of nervous tissue is unaffected by carmine, -whilst the connective tissue 'is deeply stained by this substance. The test for sclerosis of such nerve tissue is therefore the action of carmine colouring which imparts to the affected parts a deep-red staining. The disease may thus be recognised without the aid of the microscope. Thus it may be observed that the anterior cornua of the spinal cord are the seat affected in infantile spinal paralysis, the spinal paralysis of adults, or anterior polio- myelitis, and in progressive muscular atrophy or wast- ing palsy. The posterior cornua are the seat of change in locomotor ataxia, the lateral columns in lateral sclerosis, and various tracts of the cord in multiple sclerosis. SCROFULOUS INFLAMMATION.— Injuries which would scarcely affect a healthy subject will produce in- flammation in the subject of scrofula. This form is characterised by the abnormal chronicity of its processes. Inflammation in a healthy person leads to absorption of its products, or' to suppuration, or to the formation of vascularised connective tissue. In scrofulous inflamma- tion, on the other hand, the absorption of the inflammatory products takes place much less readily ; they are prone to infiltrate' and' accumulate in the tissue, obstruct the cir- culation by their pressure, and induce retrogressive and caseous changes. No organisation of the new growth ensues in consequence of the slight tendency to the deve- lopment of new blood-vessels. The cells in this form of inflammation are stated to be larger than in those of healthy inflammation ;■ it is common to find giant-cells. The large cells and their infiltration and accumulation are seen in Fig. 4. inflammation OF bone is characterised by an increase of medullary tissue and softening of the compact osseous structure. Enlargement and multiplication of the medullary spaces and Haversian canals take place. From those cells containing fat this substance is first removed, a tissue being formed which resembles that found in the medulla during its development — i.e., con- sisting of many small, round, multinucleated cells, like the so-called " myeloid cells," having a soft, scanty, inter- INFLAMMATION OF BONE. 29 cellular substance. The bony lamelte become gradually "tarHfteataoB salts are removed, the.. medullary spaces and Haversian canals enlarging and eventually Fig. i. Scm/uloiin Inflammation 0/ a Bronchus. The figure shows a section of a small bronchus in a case of bronchitis asso- ciated witli marked scrofula, which ended in miliary tuber- culosis. Extensive cell infiltration is seen in the deeper structures of the bronchial wall. Most of these cells are larger than those which occur in the loss abundant infil- tration of healthy inflammation. At the upper part of llio figure the walls of the adjacent alveoli are seen invaded by tho inflammation. At m is observed the cavity of the bronchus in which is contained a little mucus, x 200, reduced J. becoming confluent. Tne, bone becomes very spongy, soft, and vascular ; ultimately a fuugating mass of gra- nulations may appear beneath the periosteum or the articular cartilage. Pus may accumulate either within the cavities formed in the bone, or it may make its way 30 PATHOLOGY AND MORBID ANATOMY. to the surface through interference with the vascular supply, loss of vitality (necrosis) of portions of the bone may ensue, or molecular disintegration or death (caries) of the bone may take place in minute portions. When the inflammatory process is of less severity, a compact osseous structure may be formed, which is much denser than the original bone (sclerosis). THROMBOSIS AND EMBOLISM. A Thrombus is a coagulum which forms in some part of the vascular system. It usually occurs in one of the heart's cavities, or in a vein, but it may arise in an artery, as is the case with an aneurism. It may be caused by endocarditis, through the roughening of the lining mem- brane, with which it comes in contact, or it may ensue from the current of blood being retarded. A thrombus may become organised, blood-vessels being developed in it, in which case it is ultimately converted into con- nective tissue, and adheres closely to the vessel in which it arises ; or the thrombus may soften, breaking up into a pulpy mass, which microscopically presents fat globules, altered blood-corpuscles, and granular matters. An Embolus is the term given to that portion of a thrombus, or of an excrescence, which becomes detached from the valves of the heart, and, being driven on by the blood, at lasts meets with a vessel the calibre of which will not admit of its passage, and in which it therefore becomes fixed. Foreign matters introduced into the blood induce coagu- lation on their surface, such as solid metallic bodies, Iron, Mercury, Pus, y™»"»>» » II. Type of Embryonic Connective Tissue. Sarcoma . . its different varieties. I1T Type of higher Tissues. Myoma Type of muscle. Neuroma . . ., nerve. Angioma . „ blood-vessels. TV. Type of Epithelial Tissues. Papilloma . Papillae of skin or vaa- \ cous membrane Adenoma I' Y. Mixed Tumours, or Teratomata. Carcinoma ' Clands - FIBROMATA. 59 FIBROMATA (Fibrous Tumours). These trmours are growths of makture connective tissue. Both the cell and intercellular substance are it: a condition of complete development, and they resemble normal connective tissue. In addition to a constitutional predisposition, the fibrous tumours may resuH from pro- longed irritatioD, may follow inflammation, and may some- times be caused by over-nutrition, or they may be due to the blockage of the lymph channels, the tissues becoming gorged by nutritive fluids. The varieties are three in number : 1. The solid, or dense, as is seen in aponeurosis and ten do d. _ "2. The soft and sncculenl. as in s-ibcutaneous areolar tissue. 3. A cavernous form, the growth being permeated by large cavernous sinuses, having unyielding walls, ard being subject to troublesome bagmorrhage if injured. These tumours may originate from connective tissue in any situation, at first consisting of embryonic tissue, cells being abundant and intercellular substance scanty As they develop, however, the number of the cells de- creases, the intercellular substance becoming increased enormously, fibrillated, and hardened. The cells are very small and spindle-shaped, and hidden amidst the' fibres which run irregularly in all directions ; the fibres form the greater portion of the growth, being closely interlaced (Fig. 17), and often concentrically arranged around the Fig. 17. Fibrous Tumour, x 200. blood-vessels. The growth of these tumours is gradual and centrals and they are always encapsuled. They are 60 pathology and mokbid anatomy. liable to inflammation, hemorrhage, mucoid, fatty, and calcareous degeneration. They may vary in consistence from the densest dry cicatricial tissue to that of suc- culent areolar tissue, and may vary in size from the smallest to the most massive growths. They are usually painless and single, unless originating from the skin and sheaths of nerves ; harmless, except as to their locality and size. They, are benign, and non-recurrent after re- moval. The dense variety is generally found to spring from the deeper-seated structures, but the soft form usually arises from the mucous surface and the skin, and is liable to become pedunculated. MYXOMATA (Muqous Tumours). hese tumours consist of mucous tissue. Mucous tissue ,onnective tissue, the intercellular substance of which is homogeneous, translucent, and jelly-like, containing much fluid, and yielding mucin.* It is found physio- logically in one form in the vitreous body of the eye, the cells being isolated and roundish, in another form iti the umbilical cord, the cells of which are star-shaped "or fusi- form (spindle-shaped), giving off fine branched prolonga- tions, anastomosing one with- another. Pathologically the mucous tumours present the same varieties of cells as those, just described. They.usually cofltaifl one or two distinct nuclei. The cells are Ovoid, stellate; fusiform, or spherical. In consequence of the strongly refractive nature of the intercellular' substance their contour is very indistinct. The branched cells communicate with one another to'fdrm a reticulum (network), the spheroidal cells lying scattered and isolated (Pig. IS). The cells are usually distributed scantily, in which case the growth is translucent, but if the cells are very abundant and packed closely, a whitish brain-like opacity is imparted to the growths. The growth as a whole is gelatinous, soft, and trembling, somewhat translucent, and of a greyish-white or pinkish-white colour. The cut surface yields a muci- laginous, tenacious liquid, in which the cellular elements may be seen These tumours are usually encapsuled, and are met with in the. later periods of life, being most common in • Gee Mucoid Degeneration, p. 56. LIPOMATA. 6 J subserous and subcutaneous fat, intermuscular and sub- serous tissue. Growing from the perineurium of nerves they form one variety of " neuroma."' and when spring. Fig. 18. Hyaline Myxoma (mucous tumour), x 300. ing from the placenta they constitute " uterine hydatids ;" occurring in the nasal passages they constitute a form of nasal polypus. A pure myxoma is uncommon. It is usually combined with lipoma as myxo-lipoma, but myxo-sarcoma, myxo- fibroma, myxo-chondroma, and myx-adenoma are also met with. Of the secondary changes, rupture of the capillaries, haemorrhage, and formation of sanguineous cysts is most common. The cells may become the seat of fatty or mucoid degeneration and thus be destroyed, liquefaction of the intercellular substances being a usual accompani- ment. The growth may become inflamed, ulcerated, or necrosed. The myxomata are mostly benign growths, but they may attain enormous dimensions. They rarely recur after complete removal, and probably never reproduce them- selves in internal organs. With respect to their malig- nant tendency, their occasional association with sarcoma must not be overlooked. LIPOMATA (Patty Tumours). These tumours are growths of adipose tissue — i.e., com- mon connective tissue — the cells of which are infiltrated with fat. A general and diffused infiltration by fat con- 62 PATHOLOGY AND MOEBID ANATOMY. stitutes obesity ; a fatty tumour or lipoma is a localised and circumscribed formation. Lipomata originate wher- ever fat exists normally, being produced by fatty infil- tration of existing connective-tissue cells, but more frequently by proliferation and subsequent infiltration of new connective-tissue cells. Their growth is central, encapsuled, and lobulated, and it increases very slowly at first. These tumours may become the seat of inflammation or of mucoid and calcareous degeneration. The interstitial fibrous tissue increases in volume and density, or it is accompanied by other forms of connective-tissue growth, forming myxomatous, fibromatous; or chondromatous lipoma. The cells of the lipomata are larger, and the fat they contain is more fluid than that of normal adipose tissue. In shape they are round or polygonal) from pressure on one another, and are collected in clusters, forming lobules. The protoplasm and" nucleus are so compressed by the fatty contents to the cell periphery that they form a mere enveloping film. Each lobule and aggrega- tion of lobules of which the growth is constituted is thinly invested by connective tissue. The vascular supply in. general arises from one trunk, which is situated centrally, and .which pierces the capsule, giving off numerous branches to ramify in the connective- tissue septa between the vesicles and lobules. Patty tumours are liable to glide out from the deepei structures, and show themselves under the skin. They may become pedunculated. They are of all sizes, and their form, unless they are bound down by surrounding structures, is irregularly globular. The lipomata are simple or multiple, benign and painless. CHONDEOMATA- (Cartilaginous Tumours). These tumours are growths of cartilaginons tissue. Car- tilage exists in three forms — 1. As cells embedded in a hyaline basis substance (hyaline cartilage) ; 2. As cells embedded in fibrillated basis substance (fibro-cartilage) ; 3. As cells embedded in a mucoid basis substance feeia- tinoid or mncoid cartilage). To these may be adder? an osteoid form, the growths leading to ossification. The first OSTEOMATA. 63 is the most common form, the last is the rarest. Carti- lage cells are chiefly round or oval, sometimes fusiform, notably so in fibro-cartilage, or reticulated and star-shaped, as in the cornea. Chondromata occur most commonly in early life, and are supposed to take origin usually from a nidus of immature cartilage — i.e., one which has not matured pari passu with the surrounding tissues, and which in some manner has been incited to proliferation. Mixed growths may also occur — viz., fibrous, myxoma- tous, osteoid, and sarcomatous chondroma. The greater number of the chondromata arise from bone, especially the shaft of long bones — viz., phalanges and long bones of the extremities ; but it is a singular fact that few chondromata arise from cartilage proper. The growth is slow and central, usually single, and may become very great in size. The intercellular sub- stance may become the seat of ulceration, fibrillation, calcification, or mucoid degeneration, and the. cellular elements may become calcified. The growths are distinctly lobulated, and invested by fibrous tissue in which the nutrient vessels ramify. They are almost always innocent, except those softer varieties which spring from the medulla of bone. OSTEOMATA (Bony Tumours). These are growths of osseous or bony tissue ; a variety of connective tissue in which the "bone corpuscles" (cells) are embedded in calcified intercellular substance. Bone is developed originally from cartilage or fibrous membrane, and eventually from periosteum, all these substances being varieties of connective tissue. Osteomata may be produced by irritation of the peri- osteum or medulla of bone. They may be divided into two classes. 1. The Exostoses ; the growth proceeding from the bone or its membranes (homologous osteoma). 'J. osteophytes ; the growth originating m connective" tissue, more or less remote from bone (heterologous osteoma). Cancellous osteomata resemble the spongy tissue of bone. Compact osteomata resemble the compact tissue. Eburnated osteoma is exceedingly dense, and receives 64 PATHOLOGY AND MORBID ANATOiP". its name on account of its ivory consistence ; it contains no cancellous tissue or blood-vessels. The selected seats of the osteomata are the external and internal tables of the skull. The harder varieties select the periosteum and orbit ; the cancellous forms seem to prefer the articular extremities or the medulla of long bones.. Osteophytes are found in common connective tissue, tendons, or cartilage, in interstitial connective tissue of muscles in glands or organs, when it results from chronic irritation, and chiefly in the vicinity of diseased bones or joints. They are distinguished from calcareous deposits by showing osseous structure — viz., Haversian canals, blood-vessels, and bone corpuscles. A compact osteoma, which grows from the surface of a bone, is separated from it by a line of demarcation, but is notwithstanding enveloped by the Qorn^no^ peri- osteum. The growth is comparatively small in size, central, and slow; it is frequently multiple, and quite innocent. Sarcomata and carcinomata that Lave become ossified must not be mistaken for osteomata. These are, of course, malignant, and their true nature will be> exhibited in that part of the tumour in which the secondary change has] taken place. LYMPHOMATA (Lymphoid Tumours). These tumours are growths of lymphatic or adenoid tissue, and may be divided into : 1. Soft lymphomata, in which there is a preponderance of lymph corpuscles ; and 2. indurated lymphomata, with preponderance of stroma. The causes of lymphomata are so numerous and varied that any attempt at enumeration is impossible. If the exciting agent be of a specific character, as the poison of syphilis, scrofula, or small-pox, the resulting growth will exhibit specific features ; but, should the agency be in- different, the lymphatic growth that ensues will consti- tute a simple hyperplasia. It should be noticed, however; that many morbid growths that may occwin the lymphatic tissues are not properly lymphomata. ffor instance, the infectious elements of a cancer may loc&te- themselves in a lymphatic gland, and lYilPHOJUTA 65 produce a growth, possessing the structure and elements of a cancer. This would not constitute a lymphoma, for the reason that the nature of the new-formed tissue is not lymphatic; it would, in reality, -Tro. 19. be cancer of a lymphatic gland. True growths of lymphatic tissue are, however, observed in many diseases — viz., leucocy- thaemia, small-pox, syphilis, scarlatina, measles, Bright's disease of the kidneys, and in some cardiac affections Adenoid tissue has also been found in cases of chronic phthisis (Fig. 19). Soft lympnomata begin with a prolifera- tion of the lymph corpuscles, and possibly tissue a migration of white blood corpuscles. a lu "K '" ,l Many of the cells are larger than normal, ™f phtbil'is' they are increased in number, and clustered x 200. together in a reticulum. The fibres of the reticulum often become attenuated, and sometimes destroyed, in consequence of the pressure of the amassed cells. The growth en masse is pultaceous and soft, resembling brain substance in its colour and consist- ence. On section the surface is uniformly dull and white, yielding a quantity of milky juice containing copious leucocytes. Microscopically, cnin sections exhibit massive collec- tions of lymph-corpuscles, by which the stroma is com- pletely hidden. When shaken with water the corpuscles are dislodged, and a delicate filamentous reticulum is ex- posed to view. The growth of the Boft lymphoma ia rapid. It often becomes very large, and is apt to break through the structure in which it is situated, and thus to infiltrate structures in its vicinity. The Indurated lympbomata are characterised by an entirely opposite condition of matters. The branched cells of the reticulum become large and massive, and encroach upon the interstitial spaces which the lymph corpuscles occupy. Thus these corpuscles decrease both in number and size. These indurated forms are small in size, slow in de- velopment, and feel nodular and hard ; they never in- filtrate the surrounding structures ; on section they ex- hibit a cartilaginous or fibrous surface, yield no juice, and E 66 PATHOlOGY AND MOKBID ANATOMY. microscopically present a heavy barred reticulum with, few lymph corpuscles. The hard lymphoma sometimes follows the softer form after acute symptoms have sub- sided. The most frequent seats of the lymphomata are, the lymphatic glands of the neck, the axilla, the groin, the abdominal and thoracic cavities, but they may be found in the liver, kidneys, spleen, bones, muscles and serous membranes, along the intestinal tract, and in the nasal cavities, in which they form polypi. They are frequently single, occasionally multiple and lobulated. These tu- mours do not undergo any marked secondary changes, and clinically they are quite innocent. lymphailenoma. — Occasionally the lymphomata pre- sent malignant properties : especially is this the case with the soft, richly cellular, and rapidly growing forms. By these the surrounding structures are rapidly infil- trated, the neighbouring lymphatic glands are involved, and even distant parts infected. These malignant forms correspond to the lympho-sarcomata of Virchow, and to them the term Lymphadenoma has been sometimes applied. When they occur in the mediastinum they may im- plicate one or both lungs and establish the so-called "thoracic cancer" (Fig. 20). Fig. 20. Fig. 21. LympJiadenoma. Fig. 20 represents a thin section of n. lymphadenomatous tumour of the mediastinum. Fig. 21 shows a similar section to Fig. 20, from which most of the cells have been removed M?y pencilling in order to exhibit the reticulated network. This network is far more marked than that often met with, x 200. Hodg-kin's Disease : Adenie, or Anaemia lympha- tics, is characterised by enlargement of the lymphatic tYMPHANGIOMATA. 6? glands and lymphatic structures and by progressive anaemia. Histologically the new growths are exactly similar to the lymphomata 5 their course and tendency are, however, somewhat peculiar. They differ from the lymphomata inasmuch as the lymphatic structures are so very universally involved, and in the progressive anasmia, which is attributable to the loss of red blood corpuscles. Hodgkin's disease differs from leukaemia (a disease in which the white blood corpuscles are greatly increased in number), since the number of the white corpuscles is not notably increased. The lymph glands are usually first affected, the affection eventually spreading to most of the lymphatic structures throughout the body, possibly in the following order — viz., cervical, axillary, inguinal, retro-peritoneal, bron- chial, mediastinal, and lastly the mesenteric. With the advance of the growth the capsule yields and the neigh- bouring glands become fused into a lobulated mass, the adjacent structures ultimately becoming infiltrated. The spleen is notably. affected, the growth commencing in the Malpighian bodies, with the production of scattered no- dules, vrhich in size vary from a pin's-head to a walnut are of greyish or yellowish colour, not encapsuled, and somewhat firm. The spleen is somewhat enlarged, some- times uniformly so, instead of being nodular; its capsule is thickened and frequently adherent to surrounding organs. In a similar manner to the spleen, the liver, kidneys, lungs, subcutaneous connective tissue, and the medulla of bone may become involved. The growth of adenie may exhibit either the soft or in- durated forms of lymphoma. Little is known as to its pathogeny, and it is not infectious. Xiympbanglomata. — These tumours consist of lymph- atic vessels, which are larger than normal. They are divided into simple and cavernous forms, like those of the augiomata or vascular tumours. The stroma usually contains fat. It is doubtful what share simple dilatation and new formation of lymphatio vessels take in the pro- duction of these tumours. Each variety of dilatation may be acquired or con- genital. _ The latter form is seen inthe tongue as makro- glossia, in the lip, as makrocheilia, these parts becoming hypertrophied. In the skin, especially of the thorax ami thigh, acquired dilatation is not uncommon. Tumours 68 PATHOLOGY AND MORBID ANATOMY. which are sometimes the size of an orange maybe formed in the subcutaneous tissue. The part from which the lymphatic vessels pass -to the skin may become the seat of fibroid thickening, and from rupture of a vessel dan- gerous loss of lymph may result. SARCOMATA. Sarcomatous tumours consist of embryonic connective tissue, and retain that embryonic type throughout tbe whole of their growth. Amongst them are included the so-called Fibro-plastic, Fibro-nucleated, Recurrent- fibroid, and Myeloid Tumours. Many growths which were formerly described as cancers are now placed under this heading. Cells constitute nearly the whole of the growth, and present great variety of shape, form and colour. The chief varieties are the following — viz., (1) The Round ; (2) the Fusiform ; (3) the Myeloid ; and (4) the Pig- mented Cells. As several of the above-named cells may be present in the same growth, this formation takes its name from the variety which predominates. Many of the Round Cells are identical with white blood-corpuscles or lymphatic cells, whilst others are larger, present an indistinct nucleus with bright nu- cleoli, and closely resemble the granulation cells. The Spindle-shaped, Fusiform, or " Fibroblastic " cells are long and narrow, and at each end terminate in a fine prolongation; they usually contain an oval nucleus, with or without nucleoli, and exhibit a higher stage of develop- ment than the round cells. The Mother or Myeloid Cells are much larger than the two preceding varieties, and are analogous to the cells found in the inflamed medulla of bone. Their shape is very irregular, and they often have numerous off- shoots ; they contain many round or oval nuclei with bright nucleoli. All the sarcomata possess an intercellular substance (usually very small in amount) and their blood- vessels are very numerous. They always originate from con- nective tissue, usually common connective tissue, and their growth takes place in two ways — viz., by • (1) A central growth, from multiplication of their own elements : SARCOMATA. 69 (2) A peripberal growth, by the continuous invasion of t'heir matrix. The peripheral growth is very characteristic of the sarcomata. These morbid growths rarely implicate other tissues indiscriminately, hut they usually- merely displace them, and cause them to atrophy by their pressure. They extend to remote regions. of the body by the lymph and blood paths and through their wandering cells, the slender condition of the smaller vessels which supply the growth being especially favourable to the access of blood into the cells. By this channel secondary infection usually takes place, and thus is presented a marked contrast to what takes place in cancer, in which the infecting mate- rial is transmitted by the lymphatios. Amongst the secondary- changes the most important is fatty degeneration ; but inflammation, haemorrhage, calcification, ossification, and mucoid degeneration are not uncommon. Fatty degeneration occurs in the older parts of the growth, producing softening or cyst-like cavities. .Haemor- rhage may cause the formation of sanguineous cysts. Calcification and ossification are more liable to arise in tumours connected with bone, pigmentation in those which arise from the eyeball or cutis. Little is known of the causes of the sarcomata, but it is supposed that extremes of youth and of old ageandconsti- tional syphilis may predispose to, and repeated irritation may excite, these growths. From the different varieties of the cells, the following varieties of sarcoma are known : (1) Round-celled Sarcoma ; (2) Spindle-shaped Sar- coma, or Fibro-plastic Tumour ; (3) Myeloid Sarcoma ; and (4) Melanotic or Pigmented (dark granular pig- ment being deposited in the cells). Sarcomata arc sometimes combined with fatty, cartilaginous, osseous, and mucous tissue, giving rise to mixed, forms, such as Xiipo-Sarcoma, Chondro-Sarcoma, Osteo- Sarcoma, and Myxosarcoma. Clinically, sarcomatous tumours may be considered as semi-malignant. Histologically, they differ from cancers in the fact that the cells are not grouped in alveoli, but are intimately mixed with the fibrous stroma. 7° PATHOLOGY AND MORBID ANATOMY. Round-celled Sarcoma. Fig. 23. 200. Round-Celled Sarcoma. — This fcrm has been called "medullary," " encephaloid," or " soft," Barcoma. It consists chiefly of round cells embedded in fine granular intercellular substance. The fusiform cells and partial fibrillation — so common in highly-developed spindle- shaped sarcoma — are almost entirely absent. In some there is a remarkable likeness to granulation tissue (Fig. 22), the cut surface is reddish-white, and when scraped yields a small quan- tity of almost clear fluid. The blood-vessels are abun- dant, and from their liability to rupture may give rise to sanguineous cysts. These tumours maybe mis- taken for encephaloid cancers, but are recognised by the penetration of the intercellu- lar substance between the in- dividual cells and the absence of alveolar stroma. , Glioma is a form of round- celled sarcoma springing from the neuroglia, or connective A thin section of tissue of nerve, and may occur cerebellum, in the grey or white sub- stance of the brain, in the cranial nerves, and in the retina (Kg. 23). A gliomatous tumour con- sists of small round cells with a scanty granular, or slightly fibrillated, intercellular sub- stance. A somewhat reticulated structure is sometimes presented. Lympho- Sarcoma is a round-celled sarcoma, the matrix of which has developed into a reticulum similar to that of lymphoid tissue. It may commence in lymph- atic glands, or in any connective tissue. It differs from lymphoma in its course being more rapid, and in forming secondary growths by embolism Alveolar Sarcoma is a rare form of the round- celled variety— the cells are large and sharply defined, and contain prominent nuclei and are separated by fibrous Glioma. a glioma of the X .200. The celis in glioma are ex- ceedingly small and round, enclosed in a delicate -network of intercellular substance, and spring from the sheaths of the cranial nerves. •., MELANOID SARCOMA. J I stroma. In some parts the stroma forms small alveoli ifi which the cells are grouped. It is found chiefly in the skin, bones, and muscles. Spindle-shaped Sarcomata. — These tumours are the most common form of the sarcomata, and include the recurrent fibroid and fibro-plastic growths. They are divided as follows : — 1. The Small spindle shaped sarcoma in which the cells are about xJj-ir inch in length, with sometimes an imperfectly fibrillatecf intercellular substance. This growth is usually of a whitish or pinkish colour, and may grow from the periosteum, fasciaa, and connective tissues generally. It is more frequently encapsuled than other forms of sarcoma, and is very prone to cause infiltra- tion of surrounding structures, and to recur locally after being removed. 2. The X>arge spindle-shaped sarcoma. — In this the cells are larger than in the preceding form, the nuclei and nucleoli very prominent and often multiple. There is less intercellular substance, and all fibrillation is absent. The consistence is much softer than that of the small spindle-shaped variety, the growth is of a pinkish- white colour, often the seat of extensive fatty degenera- tion, grows rapidly, and is usually very malignant. Myeloid Sarcoma. — This " myeloid " tumour usually occurs in connexion with bone, frequently arising in the medullary cavity. It consists of "myeloid" cells (large and many nucleated) mixed with many fusiform cells. There is very little intercellular substance, so that the cells are almost in contact. The' growth may be so vas- cular as to occasion distinct pulsation. Springing from the upper and lower alveolar processes it constitutes a form of Epulis. When arising from the medullary cavity the compact substance becomes expanded over the growth, producing, on palpation, the so-called "egg-shell crackling." The consistence is firmer than in the other forms of sarcoma, and on section presents a uniform suc- culent appearance of a red, brown, or maroon colour, which is very typical. The myeloid are the least malig- nant of the sarcomatous tumours. Melanoid Sarcoma. — In this form the cells contain granules of dark-coloured pigment, which are distinct from that of extravasated blood. Most of the formerly styled melanotic cancers are, in reality, melanotic sarco- 72 PATHOLOGY AND MORBID ANATOMY. tnata. The eye is the seat usually selected, and, in a less degree, the skin, and the growth usually arises from nor- mally pigmented structure. It is soft and vascular, pre- senting on section a .dark-brown colour, or a mottled, streaked appearance. The cells are 'generally spindle- shaped, but in some cases they are oval or round. It may occur in almost every organ of the body, and is extremely malignant. Psammoma is a doubtful growth, thought to be sarcomatous in its nature, which springs from the brain-membranes, and is composed of corpora amylacea calcareously infiltrated, and containing a few cells and blood-vessels. MYOMATA (Muscular Tumours). A myoma is a growth of muscular tissue. It is. gene- rally accompanied by development of connective, tissue, and is seldom purely muscular. It almost always consists of aon-striated muscular fibres. The myomata always arise from muscular tissue, especially from the walls of the uterus ; in this organ, as they enlarge, they push aside the normal tissue, and. protrude into the cavity of the peritoneum or the uterus. Becoming pedunculated in the latter organ, they form a variety of uterine polypus. They may also be found in the prostate, oesophagus, stomach, and intestines. The growth is slow and central, often multiple and encapsuled. The uterine growths, in consequence of the large amount of interstitial connective tissue they contain, have been named, although improperly, uterine fibroids. The myomata are especially liable to become calcified, forming in the uterus a hard, stony lump, the so-called womb-stone. Exhaustive haemorrhage sometimes results from the presence of the intra-uterine myomata. Mucoid degeneration sometimes may occur, leading to cyst-like formations in the growth. The myomata are elastic, pear-shaped, and spheroidal. Their firmness is dependent on the amount and age of the connective tissue. Their colour varies from muscular redness to pinkish or greyish white. Microscopically, spindle-shaped cells, with rod-like NEUROMATA— ANGIOMATA. J\ nuclei, appear mixed with, or collected into, fascioili amongst the connective tissue. These tumours are innocent. NEUROMATA (Nerve Tumours). These tumours are growths of nervous tissue. True neuroma is ra'rely met with. Although the term " Neu- roma" has been given to numerous growths found in connexion with nerves — viz., fibrous, myxomatous, and gummy tumours within the nerve sheatht— the neuromata usually consist of ordinary medullated nerve fibres, and therefore their structure resembles thot of the cerebro- spinal nerves. With the nerve fibres is associated a certain amount of connective tissue. Their growth is slow, they seldom become of large size, and they usually exist in single nodules, and they are quite innocent, although very painful. They always spring from pre-existing nerve-tissue either from the spinal or cranial nerves. ANGIOMATA (Vascular Tumours). These tumours are growths consisting of blood-vessels held together by a small amount of connective tissue. Under this heading are included the various kinds of nasvi, and aneurism by anastomosis. They are divisible into two varieties : — 1. The simple or capillary angiomata ; in these the now vessels chiefly resemble normal capillaries. They usually occupy the superficial layers of the cutis, and form the well-known mother's marks (port-wine stains). They are. but slightly elevated. They may, however, lie in the submucous or subcutaneous tissue, and give rise to large tumours. In colour they are red (when superficial), violet or purple (when subcutaneous), and are probably always congenital. They are frequently associated with lipo- matous, gliomatous, and sarcomatous tumours. 2. The cavernous or venous angiomata ; in these the blood-passages are wide, tortuous; and freely commu- nicating with one another, as in normal erectile tissue, and similar to the corpus cavernosum of the penis. The angiomata originate from blood-vessels, and occur chiefly on the skin, and also on the mucous membranes. 74 PATHOLOGY AND MORBID ANATOMY. Their growth is slow, rarely large, and they are liable to ulceration and haemorrhage. They are usually of a bluish hue, and sometimes dis- tinctly pulsate. They usually occur in the skin and subcutaneous tissue, but may. be found in the orbit, muscles, liver, spleen, and kidneys. They may become developed through the dilatation of the vessels in a simple angioma, and may be congenital ; it is stated, however, that they may develop in the liver after middle-age, when atrophy of the cells has com- menced. PAPILLOMATA (Epithelio-Connective Tumours). In structure these tumours resemble ordinary papillae, and they spring from the existing papillae, especially from mucous, serous, or cutaneous surfaces. They may, however, arise de novo from the subepithelial connective tissue, as in that of the stpmach and larynx. The simple papilloma is usually small and conical, and is composed of a central connective tissue surrounded by epithelium. As in normal papillae, the vessels of the connective tissue form loops, by ascending to the apex and returning on themselves, or they may form a plexus. These growths usually owe their origin to some irri- tation. Of the secondary changes, haemorrhage and ulceration are the most common. The haemorrhage may be so severe as to endanger life, as is not unfrequent in the case with papillary growths of the intestine and bladder. Papillary growth's upon the skin include borny growths and warts. Larger and more vascular papillary tumours may occur on cutaneous surfaces — viz., venereal warts and condy- lomata — which are seen upon the external female and male genital organs and around the anus, and are pro- duced by irritating secretions. The papillomata clinically are innocent growths, but they may prove fatal from prolonged ulceration and haemorrhage. They may be mistaken (when occurring in the bladder and intestines) for epithelioma. In the papil- lomata the epithelium is homologous, since it is situated ADENOMATA. 75 only upon the surface of the papillae, and never grows within their connective-tissue ba is. In epithelioma the epithelium is heterologous, and is found at the base of the tumour in the subjacent connective tissue. It should be remembered, however, that a growth which primarily is a simple papilloma may eventually become an epithelioma. ADENOMATA (Glandular Tumours). These tumours are growths of gland tissue, and they resemble tubular or racemose glands in consisting of saccules or acini lined by epithelial cells. The acini are separated merely by connective tissue which contains the blood-vessels. Adeno-Fibroma is a term applied to the growth when the connective tissue is graatly in excess of the normal. The adenomata always take their origin in follicles and glands — viz., in the mammary gland (by far the most common seat), in the mucous follicles of the stomach, intes- tines, nares, pharynx, uterus and vagina ; also in the liver and other organs. They commence either as sacculated or cylindrical offshoots, or as proliferations of the epithelium by which the tubules or acini are lined, and resemble the normal gland structure. The epithelial growth is liable to grow in excess of the connective-tissue groundwork, and to become heaped up in the interior of the spaces until these are transformed into globes or cylinders. The growth usually becomes encapsnled, and when it is distri- buted equally through the whole gland it forms glandular hypertrophy ; it is, however, more often confined to cer- tain lobules, which, by their increase in size and by their pressure, cause blockage of ducts, formation of cysts, degeneration, and atrophy. The most common secondary change is fatty degeneration leading to caseation and mucoid softening. The adenomatous tumours are elastic, firm, and nodular, their outline is ovoid, globular, and distinctly lobulated. In colour they usually resemble that of the tissue from which they arise. Their growth is slow, and seldom becomes of any great size. When found on the mucous membrane these tumours are gelatinous and soft, and they may force their way to the surface, at which they become pendulous and form a variety of mucous polypus. 76 PATHOLOGY AND MORBID ANATOMY. On section they appear lobulated, and at times, even to the naked eye, may exhibit their glandular nature in their follicular arrangement ; gaps, fissures, and cystic cavities are often present. Microscopically, the glan- dular character is very clearly shown. The adenoma proper is always an innocent tumour, and is very rare ; other growths — viz., fibroma, myxoma, and sarcoma — which affect glandular Organs with much greater frequency, are often mistaken for adenoma. The mixed growths are known as Arteno fibroma, Adeno- myxoma, and Adeno-sarcoma. It is often very difficult to distinguish between an adenoma and a carcinoma of glandular origin, since in both cases epithelial cells are crowded in spaces formed by connective tissue ; and, again, since a sarcomatous insensibly passes into a fibrous "tissue, it is in many cases impossible to determine with perfect accuracy the exact nature of a tumour-stroma in which gland-tissue is contained. The mamma is by far the most frequent seat at adenoma, or, more correctly, adeno-fibroma, since the Fig. 24. Adenoma of the Mamma. Showing the racemose arrange- ment of acini or saccules lined with epithelial colls, x 300. mode in which the epithelium is arranged, the proportion of the stroma, the size and number of the spaces, and the number of contained cells, is mere or less abnormal. CAEOINOMATA. 77 The names of "adenoid" and "chronic mammary" have also been applied to these tumours. Their descrip- tion corresponds with what has been stated above, and their microscopic appearances are shown in Fig. 24. CARCINOMATA (Cancers). All true cancers are clinically highly malignant — i.e., they increase in size by infiltrating with cells and de- stroying the surrounding tissues, and tend to recur locally after their removal and reproduce themselves in the internal organs and lymphatic glands. Other tumours of different structure may exhibit malignant characters ; consequently, the mere recurrence of the affection after surgical removal does not prove it to have been a cancer. Microscopically, all the cancers resemble one another in consisting of variously shaped cells, enveloped in a fibrous stroma without intercellular substance (Fig. 25). Fio. 25. Fully-formed Carcinomatous Tissue. Showing the group- ing of the cells in a fibrous stroma destitute of inter- cellular substance ; at 6 a space is seen formed by the fibrous stroma, which is devoid of cell-contents. The cells are of the epithelial type, are large, and ex- hibit great diversity of form, being polygonal, round, oval, caudate, or fusiform. They' vary in size frorii fJt to T iVir of an inch in diameter, and contain large prominent nuclei inclosing bright nucleoli. There is no specific cancer-cell, since cella exactly ?8 PATHOLOGY AND MORBID ANATOMY. similar to the above are observed in other tissues, normal- of morbid, but their general nature, and their distribution in a fibrous stroma, determine their cancerous character. This absence of fibres or of any other mate- rial between the cells forms the important distinction between cancerous and many other kinds of tumours. The cancer-cells are contained in hollow spaces formed by connective tissue, and these spaces freely commuuicate one with another. The character o£ the cells varies very much, according as they arise from stratified, or columnar epithelium, or from that of acinous glands ; those from stratified epithelium may end in cornification, often ex- hibiting prickle-cells ; the outermost cells from columnar epithelium nsually retain a cylindrical form ; in acinous glands the cells may multiply and their shape become greatly altered by mutual pressure; the cancer3 are there- fore sometimes divided into squamous, and cyHndrieal- celled epithelioma, and acinous cancer. A juice exudes from the cut surface. The stroma varies in amount in different forms of cancer : if the growth be rapid, the stroma will contain numerous round, or fusi- form cells ; if it be slow, but few cells are exhibited, and the tissue is fibrous and dense. Blood-vessels are contained within the stroma, but these never encroach upon the alveoli in which the cells are contained. This fact is important in distinguishing between carcinomata and sarcomata, except some alveo- lar forms of the latter, and tumours arising from endo- thelium. Lymphatics also accompany the blood-vessels, and these, communicating -with the alveoli, may in a measure account for the tendency of cancer to involve the lymphatic glands* With regard to the development of cancer, many authors consider the epithelial cells to originate only from pre-existing epithelium, whilst others declare that they may originate from the cells of con- nective tissue, or from migrated white corpuscles. But it appears reasonable to admit that both origins may be correct, and that where the epithelium is the source, the cells are more strictly epithelial, as in epithelioma, and when the connective tissue is the origin, the epithelial characters are less observable, as in encephaloid and scirrhus. The stroma is partly made up of the connective tissue of the seat of the cancer, and is in part a new growth. SCIRRHUS. 79 Of the secondary changes, fatty degeneration is the most. important, and this always occurs in greater or less degree in all the cancerous varieties ; it is generally most marked in encephaloid. Haemorrhage, pigmentation, cancroid, and colloid degeneration may also occur, hut calcification is very rare. The varieties are the following — viz., two chief groups : — • 1. Acinous Cancer, including as varieties, Scirrhus Chronic Or Hard Cancer, Encephaloid Medullary Acute or Soft Cancer, Colloid Alveolar or Gclatini- form Cancer; and 2. Epithelial Cancer, including Squamous and Cylin- drical-celled Epithelioma. Scirrhous, Chronic, or Bard Cancer. — This variety is characterised by the chronicity of its growth, and the large amount and density of its stroma, the small size of the spaces (loculi), and the scantiness of. the epithelioid elements. The. epithelial growth quickly subsides, al- though at first it may be abundant. The stroma subse- quently becomes indurated and contracted, and takes on the character of cicatricial tissue. The central portion of the growth may consist eventually of dense fibrous jfissue, epithelial structure being only ohserved at the circumference. On section, in scirrhus a white glistening surface is presented, with fibrous bands intersecting. The moro external portions of the growth are less firm than the central, and upon scraping these they exude a juice abounding in granules, free nuclei, and nucleated cells. The exudation of this juice is very characteristic of cancer. The most common seats of scirrhun arc the female breast, the liver, and the alimentary canal, par- ticularly the rectum, pylorus, and oesophagus. It may also be found on the skin. The elements quickly atrophy and undergo retrogres- sive changes. In the external portions of the tumour, at which growth is taking place, they are most abundant, but in the central portions they may be nearly altogether wanting. Scirrhus presents a well-defined tumonr, which is hard, lobular, and uneven, the hardness and unevenness of out- lino being very characteristic. The growth is frequently depressed in the centre from the contraction of the cica- tricial tissue, and this is very typical of scirrhus of the So PATHOLOGY AND MORBID ANATOMY. mamma (breast), in which situation it occasions more or less puckering of the superjacent structures. The microscopical appearances of scirrhus are shown in Figs. 26, 27, and 28. tfrc. 26. Scirrhus of the Mamma. A thin section from the most external portions of the tumour, showing the clusters of small "indifferent" cells; more externally is seen the development of the epithelioid elements within the alveoli of the stroma. X 300. Encephaloid, Medullary, or Soft Cancer. — This cancer differs from scirrhus in the greater rapidity of its growth, the smaller amount of its stroma, and its softness of consistence. microscopically, the greater part of the growth is seen to be formed of nucleated cells of various sizes F 10. 27. Scirrhus of the Mamma. A thin section from the more central portion of the tumour, showing the cicatricial tissue of which the older portions of the growth are con- stituted. and shapes, the loculi or spaces in which they are enclosed being composed of thinner and fewer fibres than in scirrhus. The blood-vessels are frequently very numerous. There are all intermediate stages between COLLOID OR GELATINIFORM CANCER. 81 scirrhus and encephaloid (scirrho-eucephaloid), so that these can hardly be considered as distinct varieties of cancer, their only distinction being the rapidity of their growth, and their physical characters. In encephaloid the epithelial growth is rapid and luxuriant, the cells soon becoming fatty. The stroma in proportion is very Fig. 28. Scirrhiu. Showing commencing cicatrisation, and at tlio same time the relation of the stroma (c) and the cells in this form of cancer. small, does not undergo cicatricial contraction, and is less fibrous than in scirrhus. Hsemorrhage readily takes place, from the abundance of the blood-vessels, and the softness and non-resistance of the tissues supporting them. The growth may fungate and bleed, forming, the so-called Fungus Heematodes. This form of cancer is of brain-like consistence, the central portions being, frequently completely diffluent ; on section the affected part presents a white pulpy mass, very like brain substance, and it is often stained with ox, travasated blood, the unaffected parts being soft, pinkish grey, and translucent. Encephaloid cancer occurs primarily in the testis and mamma, and it is very commonly met with in internal organs as a secondary growth. Many soft sarcomata were formerly described as encephaloid cancers. Colloid, Alveolar.or Gelatiniform Cancer. — Although this is often described as a distinct variety of cancer, it is probably only one of the preceding forms which have undergone a colloid or mucoid change. The colloid 82 PATHOLOGY AND MORBID ANATOMY. growth itself may become of great size, is of mucous or gelatinous consistence, and possesses a colourless or slightly yellowish translucency. In colloid cancer the alveoli are large, and more or less spherical, and contain within them a gelatinous or colloid substance, which is translucent, colourless, or yellow, and of a thin mucila- ginous consistence. The distinctness and large size of the alveoli is due to their distension by the degeneration- products. -It is probable that the colloid change com- mences in the cells, which are gradually destroyed by the process. Within this colloid substance are contained epithelioid cells, which, in their turn; contain a similar colloid material. The most frequent seats of this variety of cancer are in the peritoneum, the ovary, stomach, and intestines. In the peritoneum the growth is either secon- dary or it is sarcomatous. Microscopically, the alveolar cavities are seen to con- tain nucleated cells, which enclose and are intermixed with gelatinous material. The term alveolar is employed, since the appearance is very like that of a honeycomb. Epithelioma (Epithelial Cancer). — This form differs from the preceding varietiesin always growing in connexion with cutaneous or mucous surfaces, and in its epithelial elements bearing a close resemblance to squamous epithe- lium. The cells are peculiarly arranged, most of them being situated in irregular tubular-shaped lobules. As the cells increase in number they become grouped con- centrically, forming globular masses, and as multipli- cation of the epithelium takes place, the peripheral cells become flattened by the pressure of the surrounding struc- tures, the central cells remaining more or less spherical in shape. Thus are formed the epithelial nests or con- centric globes, so characteristic of epithelioma. The cells may be so closely packed as to become eventually dry and hard like those of the hair and nails ; the concen- tric globes are then of firm consistence and of a yellowish- brown colour. The stroma may be very abundant or almost entirely wanting. Microscopically, then, a section exhibits numerous nests or cells, termed epithelial nests or concentric globes, the outer cells being flattened in a circular form; whilst the inner are round and oval. The first appearance presented by epithelioma is as a CYLINDRICAL EPITHELIOMA. 83 foul ulcer with indurated edges, or as a subcutaneous nodule which, eventually suppurates. On section of the tumour a greyish-white granular surface is presented, with lines of fibrous tissue intersecting. Upon pressing) the out surface turbid fluid exudes, and in general a thick curdy material is yielded, coming out in a worm-like shape resembling sebaceous matter from the cutaneous glands. This material is highly characteristic, and consists of fatty epithelial scales, and upon mixture with water it separates into small visible particles, but does not diffuse like other cancerous juices. The name cancroid, which is sometimes given ta the growth, denotes its likeness to cancer, and also that it deviates from the true cancerous type. Epitheliomata are developed by a down-growth of the surface-epithelium of certain mucous membranes or of skin into the connective tissue and deeper parts. This form of cancer seems in many cases to be due to some external irritation. It is often found on the lower lip (at the junction of the mucous membrane with the skin), on the prepuce, scrotum (chimney-sweep's cancer), the tongue, labia, cheeks, eyelids, the bladder, and in the cervix uteri, in which it constitutes the so-called cauli- flower excrescence. By its extension any tissue may become involved — viz., muscle, bone, tendon, and lymph- atic glands. It is very rare in internal organs. The malignancy of epithelioma varies with its situa- tion. On the tongue its course is very rapid, the glands are afEected early, and death is very speedy. On the skin of the face its course is very chronic, and the glands rarely, become affected. Cylindrical Epithelioma ; Adenoid Cancer- — These terms are given to certain forms of epithelial cancer which grow from mucous membranes, having columnar or cylindrical epithelium, such as those of the intestines and stomach, and especially the uterus and the rectum. The shape of the epithelial elements and their arrange- ment in these tumourB are precisely similar to the colum- nar epithelium of the mucous surface on which they are found. The morbid growths are soft and frequently of gela- tinous consistence, and are very liable to become the seat of colloid change. They induce secondary growths in the lymphatic glands, and occasionally in the bones, the 84 PATHOLOGY AND.MOEBID ANATOMY. lungs, and the liver, which present the same features as the primary cancer. The distinction between simple ade- nomata and the adenoid cancers is dependent upon the tissue invaded by the cancers. Of all the cancels by far the least malignant is epithe- lioma ; here local extension takes place, and the lymph- atics may be involved, but reproduction in the internal organs rarely takes place, probably because the size and nature of the epithelial element render them far less liable to be transmitted by the lymph streams and blood than are the cells of the other cancerous varieties. Encephaloid and scirrhus present very different degrees of malignancy ; the former being far more rapidly disseminated than the latter, in consequence of its greater rapidity of growth and its greater vascularity ; both these forms are repro- duced m the lymphatic glands and internal organs. Colloid, in its degree of malignancy, is somewhat in- ferior both to encephaloid and- scirrhus. In all cancers the secondary growth is apt to repeat the characters of the primary one. This is most observ- able in colloid, epithelioma, and encephaloid. In scirrhus, the secondary growths in internal organs are usually different to the primary one ; they are vascular and soft, and exhibit the characters of encephaloid. In some cases the different varieties of cancer may replace one another. The leading differences between Carcinomata and Sarcomata may be briefly stated as follow : — . Carcinomata usually show a much greater tendency to reproduce themselves in neighbouring lymphatic glands, and this is probably due to the communication between the lymphatic vessels and the- alveolar space's of the can- cerous formation^ The general dissemination in internal organs, per contra, frequently takes place with far less rapidity in carcinoma than in sarcoma, and therefore the course of the cancer is occasionally more protracted than in the sarcoma. This may be due to the fact that in cancer the blood-vessels are contained in the stroma and very seldom enter into contact with the cells of the growth ; in the sarcomata they ramify among the cells, and their walls, consisting of thin embryonic tissue, re- sembling the growth they supply, a rapid dissemination takes place through the medium of the blood. In car- cinoma, since the lymph is a. very ready medium of CYSTS. 85 infection, a considerable delay may occur in the repro- duction of the growths in internal organs. TEBATOMATA. Mere mention of these tumours is sufficient. They are congenital, occurring especially in the region of the sacrum (coccygeal tumours), the neck, and head, at which points double monsters are united ; they may, however, be inter- nal. Many of these tumours result from the inclusion and imperfect development of one foetus within another, but others are due to abnormal development of the tisanes of one foetus. Their constitution is extremely complex, and in them may be contained all the tissues of the body up to ganglion cells, mixed up in more or less con- fusion. At birth they may be very large. To this group belong the dermoid cysts, CYSTS (Cystic Tumours). Cysts are cavities, regular, with rounded outlines, and which contain a fluid or pultaceous matter separated by a more or less distinct capsule from the surrounding structures. The walls are usually composed of connective tissue, in some cases membranous and distinct, in others not so sharply defined, and at others consisting of the tissue of the organ in which the cyst is situated. The cyst-wall and its contents vary according to the nature and origin of the cyst. Cysts are divided into (1) simple, or unilocular, when they contain one chamber (loculus) ; and (2) compound, or multilocular, when they contain more than one loculus. The loculi of this latter form are sometimes contained one within another, and at other times ranged side by side. They may, or may not, communicate one with another. The prefix cysto- is used to designate the cystic nature of a new formation — viz., cysto-sarcoma, cysto-carcinoma. The secondary changes include an inflammatory pro- cess ending in suppuration. Calcification of the walls and contents may take place. 'cysts may be classified as follows : — A. cysts formed by the accumulation of substances within the cavities of pre-existing structures. 86 PATHOLOGY AND MOEBID ANATOMY. (i) Retention Cysts. — Besulting from the retention of normal secretions. In these are included; — (a) Sebaceous Oysts. — Formed by the retention of secretions in the sebaceous glands. (b) Mucous Gysts. — Formed by the retention of secretions in the glands of mucous membrane. (c) Gysts due to Retention of Secretions in other Parts — viz., Ranula, from occlusion of the salivary- ducts ; encysted hydrocele, from occlusion of the tu- bules of the testes ; cysts of the mammary gland, from obstruction of the lacteal ducts ; simple and certain compound cysts of the ovary, from dilatation of the Graafian follicles; simple cysts of the kidneys and of the liver. (ii) Exudation Cysts. — Resulting from excessive secretions in cavities not supplied with an excretory duct — viz., bursae, ganglia, hydroceles, meningoceles, cystic bronchoceles ; many cysts of the broad .ligaments of the uterus. (iii) Extravasation Cysts. — Besulting from extra- vasatiqn into -elosed cavities — viz., haematocele, and some other varieties of sanguineous cysts. B. CTST5 the origin of which is independent. (i) Cysts from Softening: of Tissues. — Especially common in new formations — viz., chondroma, sar- coma, &c. (ii) Cysts from Extravasation into Solid Tissues — viz., brain, soft new growths. (iii) Cysts from Expansion and Fusion of Spaces In Connective Tissue, such as — (a.) Bursae, arising from irritation and exudation into the tissues. (b) Serous cysts in the neck, as hygroma (fre- quently congenital). (c) Many compound cysts of the ovary. (iv) Cysts formed round Foreig-n Bodies. — Ex- travasated blood, and around parasites. (v) Congenital Cysts include many dermoid cysts. They often appear to be the remains of blighted ova. Their wall possesses, more or less perfectly, the struc- ture of the skin. They contain fatty matter, teeth, . bones, &o. SEPTICEMIA AXD PYEMIA. 87 SEPTICEMIA and PYEMIA These diseases arise from the absorption and dissemi- nation of substances generally derived from the septic discharge of acute inflammation or from some wound. The two diseases are often associated. The term Septicaemia now comprehends those forms of septic disease which are unaccompanied by the develop- ment of secondary inflammations. The term Pyaemia now includes cases of septic disease in which secondary or metastatic suppurations are pre- sent, and it no longer implies disease resulting from the absorption of pus into the blood. Nearly all instances of both these affections have been due to the existence of a wound to which unpurified air has gained access. Septicaemia includes two varieties — viz., septic In- toxication and septic infection. The former is non- infective and results from absorption of a chemical poison created in some putrefactive process external to the body ; the latter is caused by the entrance of specific fungi into the blood and their multiplication in this fluid. The symptoms of septicaemia in both varieties are fever, and often repeated, rigors, vomiting, diarrhoea, delirium passing into stupor or coma, great prostration, and the " typhous " condition, with jaundice and albuminuria. Death occurs in the infective form with a semi-comatose condition ; the termination of the non-infective variety being in speedy collapse. The red corpuscles drawn during life, instead of being, in rouleaux, run in clumps. The post-mortem appearances are early decomposition and feeble rigor mortis. The blood is more clotted than normally, and hypostatic congestion of the lungs and abdominal viscera appears. The spleen is swollen and pulpy, and the mucous membrane of the alimentary canal may be congested. Serous membranes and raw surfaces absorb readily, whereas granulating surfaces have been shown not to absorb the putrid material. Septic intoxication, there- fore, is most apt to take place before the commencement of granulation. Septic infection may take place from the smallest wound, and the presence of a small wound shows the inoculation of a septic poison. 88 PATHOLOGY VND MORBID ANATOMY. As the result of an injury fever may follow from three causes — viz., 1. Aseptic traumatic fever, in which the injury is subcutaneous and shielded frorn decomposition; 2. Simple inflammatory fever, inflammation taking place at the injured part without decomposition £>r infec- tion of the wound ; 3. Septic traumatic fever, the dis- charge from a wound undergoing putrefaction, and the chemical products of -the putrefaction becoming absorbed. Between this last' form and septic intoxication no dis- tinction can be drawn. In Pyaemia the secondary or metastatic abscesses are of two kinds : — 1. They may follow upon infarction, which has been caused by an infective clot lodging in a terminal artery; Embolic abscesses are most frequently found in the lungs, then in the liver, spleen, kidneys, and brain. They may be very numerous, and. are surrounded by a zone of hyper- semia. 2. The metastatic abscesses may occur as diffuse sup- purations in the intermuscular and subcutaneous con- nective tissues. HYPEREMIA or CONGESTION. The term denotes an excess of blood in the more or less dilated vessels of a part. The varieties of a local byperasmia are : — (1) Active or Arterial Hyperemia, in which the arteries are dilated, a greater supply of blood being thus distributed through the parts, and so forming^ an im- portant element in the commencement of sthenic inflam- mations. The immediate cause of this form is diminished arterial resistance pathologically produced by {a) Certain agencies having a weakening or paralysing effect upon the involuntary muscle of vessel walls. Examples : The hy.perusmia of the hands which re- sults from snowballing and is the result of fatigue due to previous prolonged contraction ; the sudden removal of pressure, leading to congestion of the> abdominal vessels which follows the withdrawal of much ascitic fluid. (6) The removal of the vaso -tonic action of the sym- pathetic, either, directly or refletely — viz., hy inhibition. HYPEREMIA OR CONGESTION. 89 Directly, as shown in the active congestion in the neck following pressure on the sympathetic by an aneurism ; and the action of certain drugs taken internally, such as amyl nitrite, tobacco, and alcohol, which are thought to paralyse the vaso-tonic nerves temporarily and 'directly. Reflexly the process is usually due to stimulation. of the sensory nerves, the resulting diminution in tonicity being limited to the locality supplied by the nerve. Collateral Hyperaemia is produced in some other part when anaamia exists in any large part,- as in the skin from cold, or the compression of a limb by a bandage. If one kidney is removed, the- other receives the main share of the blood of the lost one. (c) By excitation of vaso-dilator nerves,. sucH as the chorda tympani. To this process is referred the hyper- semia that accompanies facial neuralgia, and that of- the thyroid gland in eases of exophthalmic goitre. (2) Passive or Capillary Hypersemia. — Here the capillaries are chiefly" involved; .a condition leading to atrophic and degenerative changes in tissues which may become the seat of asthenic and chronic inflammations. (3) Mechanical or Venous Hyperaemia. — In this form there is no excessive supply of. blood; but merely a difficulty in the escape of this fluid — i.e., a retardation of the blood-flow. The causes of this form are two in number: — (a) Those which dimijiish the force by which the blood ought to be: propelled throtigh tlie veins (the vie atergo), such as diminished cardiac power and affections of the arteries, as simple atony, fatty, atheromatous, or fibroid changes. Hypostatic congestions may occur if the circulation is much retarded. (b) Those which impede directly the retiirti, of blood by the veins, such as the congestion of the chylo-poietic viscera following obstruction to the portal -circulation- in liver- cirrhosis, and that of the lung in 'mitral disease. Among the sequelae of venous hyperaamia are, transudation Of serum (oedema and dropsical effusions), haemorrhage (into the stomach in liver cirrhosis, and into the lung in mitral disease), fibroid induration, thrombosis, and necrosis. In mechanical hyperaemia of the liver, or " nutmeg liver," a condition so often resulting from disease of the heart, there is an abundant accumulation of blood in the 90 PATHOLOGY AND MORBID ANATOMY. hepatic veins which become dilated and thickened; atro- phy of the hepatic, cells takes place in the central parts of the acini; and an increase of the interlobular con- nective tissue occurs. The obstruction to the return of blood by the hepatic veins induces pressure and conse- quent atrophy of the cells in the central parts of the acini, and leads to the production of granular. pigments. Microscopically the central portions of the acini appear to consist of granules of pigment and broken-down cells. The veins are greatly dilated, and filled with red blood- corpuscles ; there also appears thickening of the venous walls, and of the intercellular network by which the central vein is immediately surrounded. In advanced stages of the affection the most central parts of the acini may appear fibrous. At the periphery of the acini is observed the new interlobular growth dipping between the nearly unaltered hepatic cells. This new growth is generally distinctly nucleated; but less so than that ob- served in cirrhosis of the liver. In the earlier stages, from the large amount of blood it contains, the liver is frequently much enlarged. A section shows a mottled appearance, the periphery being yellow-white and the centre ;of the lobules dark-red in colour. Eventually the size of the organ becomes gradu- ally diminished ; the cells in the centre of the lobules undergo atrophy from pressure of the contracting inter- lobular growth, which, as is the case in cirrhosis, tends to obstruct the portal circulation. Mechanical hyperoemia, or brown induration of the lungs, has already been described under pigmentation of those organs (see page 56). ISCHEMIA, or LOCAL AN2EMIA. This term denotes a diminution of blood in a part, duo to diminished arterial supply; It results from any condi- tion which partially or completely constricts the supplying artery, such as atheroma, calcification, or syphilitic thick- ening, or any external source of pressure. Thrombosis, embolism, or ligature may occasion entire closure of a vessel. Diminished blood-supply may also result from an increase of natural resistance, due to irritation of tlie vaso-motor nerves, as takes place from a low temperature LEUCOCYTH^JUA. 9 1 m some nervous affections, as neuralgia, and. from the action of such substances as opium and ergot. Hyperaemia of other parts, and the presence of too little blood in the system resulting from hremorrhage, may also produce anaamia. The results of anasmia in a part are atrophy, fatty degeneration, and necrosis (death). Hydrsemla is a term used to imply a state of blood in which there is a relative excess of water. This excess may be absolute, or it may depend upon a deficiency of solids, or be due to both conditions in combination. The hydra?mic condition is always accompanied by defi- ciency of albumen in the blood, and is dependent upon this deficiency. It is a constant accompaniment of anaamia, especially when this is due to sudden and pro- fuse hemorrhage, water being absorbed to restore the volume. The best illustration that can be given is Bright's disease of the kidneys, in which there is a deficiency of water eliminated by the organs, accompanied by excessive loss of the albumen of the blood. CEdema and dropsical effusions frequently go hand in hand with hydremia, but it is supposed that this condition of blood does not itself occasion the transudation into the areolar tissues or the cavities of the body, but induces them secondarily, by leading to malnutrition of the vascular walls. LEUCOCYTH^MIA.— LEUKEMIA.— LYMPH.2EMIA. This condition is characterised by the presence of an abnormal proportion of white corpuscles in the blood, a diminution of the red corpuscles, and . enlargement of eeme of the lymphatic organs. In health, the white cor- puscles are in the proportion of 1 to 300 of the red, and (to constitute this condition the relative -number of white cells must be at least 1 to 20 of the red ; 1 white to 10 red is very common, and frequently there are as many as 1 to 3. The divisions into Splenic and lymphatic were made by Virchow, who associated the former with enlarge- ment of the spleen, and the latter with a similar condition of the lymphatics. The blood becomes of a more opaque and paler appearance than in health. The white globules are sometimes unaltered, but they are frequently more 92 PATHOLOGY AND MOEBID ANATOMY. granular and somewhat larger than those of the healthy condition. This is chiefly noticeable in the splenic form of leukaemia. In the lymphatic variety many of the cor- puscles are generally smaller than normal. The red cor- puscles maybe reduced to one-half or one-quarter the normal proportion ; they appear occasionally abnormally soft, and tend to stick together instead of forming rou- leaux. The anaemia which is present in leukaemia, and in the majority of cases of splenic enlargement, is due to the diminution in the number and the impairment of the quality of the red corpuscles. The most satisfactory view of the production of leuk- aemia is that of Virchow, who thought that the normal transformation of white corpuscles to the red was per- formed imperfectly, so that not only was the number of white increased, but the number of the red diminished. Hughes Bennett regards the ductless glands as agents in the production of the corpuscular blood constituents, and considers the red corpuscles to be the free nuclei of the colourless ones, and concludes that in leucocythasmia the blood-producing function is disturbed, and that the white globules, not being transformed into the red, appear in the circulation in morbidly increased quantities. Others think, however, that there is an increased formation of the white corpuscles. It-is questionable whether leucocythaemia can be consi- dered as a special disease, or as merely incidental to certain affections. It should be regarded rather as the pathological element of a cachexia, the essential nature of which is yet to be determined. The Spleen often becomes enormously enlarged, and the enlargement is uniform. The capsule is often thick- ened. On section the surface is smooth, of a brownish- red or greyish colour, and marked by whitish lines (thickened trabeculaa). microscopically, the enlargement is seen to be due chiefly to increase of the splenic pulp. The trabecular tissue is also thickened and increased. In the lymphatic Glands the enlargement is much less in the splenic leukasmia than in those cases where the glands are primarily and chiefly affected. Extreme development of lymphatic structures some- times occurs in other parts, the medulla of bone and the follicles of the intestine being most commonly implicated. UKJGMU. 93 During the course of leukaemia a new growth of lymph- atic tissue generally occurs in non-lymphatie structures, especially in the liver and kidneys. In the leukasmic liver, the vessels ave usually enlarged and distended with white blood-corpuscles. Between the acini are seen accumulations of corpuscles and lymphoid tissue, which extend along the intercellular reticulum into the acini themselves, the lobules sometimes being clearly mapped out by greyish-white interlobular infiltra- tion. Ultimately, the hepatic cells are compressed, and undergo atrophy, until at last the lobules may be com- pletely replaced by the new growth. Small lymphoid nodules resembling grey tubercles sometimes accompany this infiltration. The liver becomes greatly increased in size. In the kidneys the changes are similar to those in the liver, and consist of infiltration, together with roundish nodules. leucocytosls. — This name is given to a condition in which there is a slight and temporary increase in the number of white corpuscles, and which is not necessarily associated with diminution in the number of the red corpuscles. The increase is never so great as, in leukoemia ; a marked excess of white corpuscles is often observed in many acute febrile maladies, especially when acute swell- ing of lymphatic structures is present, as in scarlatina, typhoid fever, and septicemia. There is also an increase after profuse discharges of blood. These are only tem- porary conditions, and the general health and circulation do not seem to be interfered wjtb, by them. This term denotes an excess of urea in the blood. In the healthy state this substance is present in the blood in very small quantities, but under any circumstances in which the renal functions are impaired, it accumulates in very large quantities, especially in structural affections of both kidneys, or when these organs have been extirpated or the ureters occluded. The symptoms of ureemic poisoning chiefly relate to the nervous system, consisting of neuralgia, delirium, blind- ness,, coma and convulsions, vomiting and diarrhesa,. 94 PATHOLOGY AND MORBID ANATOMY. There are pallor and puffiness of the fH.C9, which are due to anaemia and oedema. The symptoms indicative of uraemic poisoning have been attributed to the presence of carbonate of ammonium in the blood, to oedema of the brain, and to interference with the processes of nutrition, resulting from the accu- mulation of waste products in the blood and the tissues. The facts in connexion with uraemia maybe summarised as follows : — It is manifest that the uraemic condition is dependent upon a failure in the proper performance of the functions of the kidneys. That in consequence of this failure, certain matters accumulate in the blood and the tissues, the most important being urea. That the amount of the retained urea, all things being equal, is proportionate to the uraemic poisoning. That when urea is introduced into the blood, under conditions which preclude its elimination, it is followed by uraemic poisoning. Lastly, that the introduction of no other excrementitious matter, as far as is known, is succeeded by like symptoms. SYPHILIS, The lesions which are observed during the course of constitutional syphilis are mainly of an inflammatory nature, but certain peculiarities in the seat, distribution, and anatomical characters of some of them render them perfectly characteristic of this disease. The various lesions are the results of chronic inflammatory processes, in- duced by the syphilitic poison. The special characteristic lesions are of two kinds — viz., certain fibroid indurations and nodular growths known as gummata. These are frequently associated. 'The fibroid changes generally occur somewhat earlier than the gummy growths. The new tissue at first consists of an embryonic small-celled structure, which eventually becomes more or less fibril- lated. The resulting fibroid thickenings are characterised by great irregularity of distribution. They usually occupy small areas, and, when more extensive, they are far denser in some parts than in others. It is, therefore, not their anatomical characters, but the peculiarities in their local- isation and distribution, which makes them so charac- teristic of syphilis. In the capsules of organs the fibroid changes are very characteristic. In the liver and spleen SYPHILITIC TUMOUR. 95 • — their most frequent seat — they produce an irregularly distributed thickening and puckering of the capsule, which is very typical of an advanced stage of syphilis. Dense fibrous septa pass up to .the interior of the organs, and these are frequently connected with the thickened portions. The change in the liver is somewhat similar to that oc- curring in an ordinary cirrhosis. It generally differs in the fact that the new tissue-growth is far less uniform and regular, and that it\ takes place in certain localities or around certain branches of the portal vein. The new tissue often arises from only two or three centres, a cor- responding number of dense fibroid cicatrices being formed in the organ ; consequently the liver becomes much more contracted and irregularly puckered than in cirrhosis, and there is little if any obstruction to the portal circu- lation. From the fibrous septa gummy growths often arise. In congenital syphilis the interstitial change is far more general. THE GUMMA, SYPHILOMA, OR SYPHILITIC tumour. — Gummata, as usually met with, are yellow- ish-white nodules, of moderately firm consistence, which frequently on section present the appearance of a sliced surface of a horse-chestnut. Their size varies from that of a hemp-seed to a walnut, and they are enveloped by a zone of fibrous-looking translucent tissue, sometimes appearing like a capsule, which is so completely connected with the surrounding structure that enucleation en masse is impossible. In the most advanced stages these tumours may become distinctly caseous, in consequence of extensive retrogressive changes. Microscopically, gummata consist chiefly of atrophied and broken-down cell-products, which are -embedded in a completely fibrillated tissue. The central and the ex- ternal parts of the growth present marked structural differences. The central portions almost entirely consist of fat granules, cholesterine and close-packed granular debris, lying am d which may be a. very scanty fibrillated tissue t around this and directly continuous with it is a more completely fibrillated structure. The peripheral parts of the growth, continuous with the surrounding tissue, are composed entirely of small round cells {granu- lation or " indifferent" cells). The blood-vessels only, exist in the external parts of the growth, and are very few. Thus there are three zones. 1. The external or graau- g6 PATHOLOGY AND MORBID ANATOMY. latlon tissue zone, representing the earliest staqpe of development. 2. The intermediate or fibrous zone, or the second stage of the process, the granulatiye tissue becoming developed into fibriltated structure. 3. The central or amorphous granular zone, the oldest part of the growth which has undergone retrogressive changes. In some growths the fibrillation is very distinct; in others the tissue is of a dense and cicatricial nature. Occasionally the growth presents a reticulated structure, holding in its meshes small round cells, as shown in Fig. 29, which represents a gummatous growth in the kidney. Fig. 29. fiom a Gummy Growth in the Kidney. Showing tho adenoid stiuufcure oecasionallj met with in the interme- diate zone of these formations. Within the meshes of the reticulated structure are seen the groups of small round cells. X 200. Thus, in the formation of a gumma, the first process is the production of a granulation tissue, then follows the incomplete development of this newtissueinto a fibrillated structure, accompanied by atroph} and degeneration of the young elements. In the centre of the growth the degenerated elements become closely packed, the prolife- ration and incomplete fibrillation continuing at the cir- cumference. Grummata are observed in the skin and subcutaneous areolar tissue, in the submucous tissue, in bone, muscle, and the connective tissue of organs, espe- cially in the live*, kidney, braii;, and testicle. When HYPERTROPHY. 97 seated in the submucous tissue, destruction of the mucous membrane may take place, with the formation of a deep ulcer, as is seen in the pharynx, tongue, larynx, and soft palate. These ulcerating membranes must not, however, be confounded with the superficial ulcerations which result from inflammatory processes in the lymphatic structures and which are also met with in constitutional syphilis. HYPERTROPHY. This term denotes an overgrowth of tissue, and it may be dependent upon an increase in the size or the number of the normal constituent elements. Simple Hypertrophy is the name employed when the process is due to an increase in the size of the elements. Numerical Hypertrophy or Hyperplasia denotes an increase in the number of the elements. When an organ is hypertrophied the whole of the elements of a tissue are increased equally, the various tissues of which the organ is composed maintaining their relative pro- portions. Spurious Hypertrophy is where no equipoise is main- tained, as when certain tissues develop, others remaining quiescent. This last heading includes inflammatory pro- ducts and various forms of infiltration ; here the secreting cells in glandular organs, and the muscnlar fibres in muscles, frequently waste from the pressure of the ad- ventitious products ; and thus an organ, although much enlarged, may be deficient in the normal development of its essential constituents. An hypertrophied organ always increases in size and in weight, but no material change of form, colour, or consistence takes place, since the tissue-elements are distributed evenly in their normal proportions. This equable growth is not always possible in some situations, and thus a symmetrical development cannot take place. When a muscle is unable to elongate (its bony attachments being at a fixed distance), its deve- lopment must be lateral, and its normal symmetry is destroyed. The chief causes of hypertrophy are functional activity and increase of nutritive fluids. Functional activity is shown in the general muscular development of the athlete, in the arm of the blacksmith, and in the leg muscles of the ballet dancer. 98 PATHOLOGY AND MORBID ANATOMY. Hypertrophy of the heart occurs in obstruction of the circulation of the bowels and stomach; in obstruction of a lower portion of the alimentary tract; o£ the bladder in urethral stricture; when one kidney is disabled the opposite organ becomes enlarged in consequence of the extra work thrown upon it. A bone will even become hypertrophied, and the law of compensation extends to every structure of the body. An influx of nutritive fluids is of course a result of functional activity, but arterial excitement, venous ob- struction, and blockage of the lymph-channels may cause an inundation of the tissues of an affected locality with nutritive fluids, in consequence of which the tissues may become gorged, and thus overgrown The functional capacity of an hypertrophied organ generally increases proportionately with the increase ot size. In spurious hypertrophy the functional capacity is diminished. True hypertrophy is a beneficial process, since by it an organ is enabled to perform its functions properly, notwithstanding obstacles. When the circula- tion is obstructed, disastrous results would ensue, if it were not for the compensatory enlargement and increased power of the heart, by which efficient distribution of the blood is ensured. ATROPHY. This term denotes a waste of tissue ; it implies a de- crease in size and weight of the affected parts, and is dependent upon a decrease in the size or number of the constituent elements. Simple Atrophy is the term used when the process depends upon diminution in size of the histological elements (fibres, cells, &c.) ; Numerical Atrophy, when it depends on diminution in the number of the elements. In the latter form there is destruction of the tissue elements, and thus the size of the tissues is lessened. The name necrobiosis is given to the cell-death, which is occurring constantly in the healthy condition of the organism, the old cells being replaced by young and vigorous cells. In this form there is no loss of substance, since new elements are substituted immediately. Simple atrophy always precedes and accompanies numerical ATROPHY. 99 atrophy, and the latter may be considered a more advanced stage of the former. Atrophy may be general when the entire organism \s involved, as in general emaciation ; or partial when it is limited to certain structures. Atrophy is most often observed in the adipose tissue, the secreting cells of the glands, and in norvousand muscular tissnes. Connective tissue frequently atrophies ; but it often increases as the other elements decrease, and thus occasions an unnatural proportion of the atrophied structures. In consequence of this increase in the connective tissue elements it sometimes happens that the size of an organ does not diminish at all proportionately to the loss of its proper histological elements. In muscles, the muscular fibres, and in glandular organs, the secreting cells, may become atrophied ; but since there is a coincident increase of connective tissue, the size and weight of the muscle or the gland may be retained. In proportion to the loss of these proper constituents the physical properties of the organ are, however, altered, and the functional activity impaired. Iu Adipose tissue f which is composed of connective tissue, and the cells of which are filled with large fat glo- bules, the atrophic change is manifested by the larger globules breaking up into numberless smaller ones, and by these subsequently disappearing, either partially or entirely. The cell either returns to its primitive form, exhibiting nucleus and protoplasm, or becomes filled with serum. A fat vesicle may be occupied partly by serum and partly by fat. Muscular fibres become pliable and soft, losing their transverse markings: glandular organs diminish in size, whilst iu nerves the medullary substance becomes disin- tegrated and disappears. As a rule, the size and weight of an atrophied structure are reduced ; the structure is dryer and fi rmer th an normal,and usually comparatively bloodless. The causes of atrophy are the following . — Functional Inactivity: as in a part long diseased, in the end of a bone after amputation, in nerves and muscles of paralysed parts, and in the orbit bones after the eyeball has been removed. Pressure : as in atrophy of the bones of the skull due to hydrocephalus, of the kidney in hydronephrosis, in the vertebras and sternum from aneurismal pressure. 100 PATHOLOGY AND MORBID ANATOMY. Excessive violence or use ; as in the testicles in cases of extreme masturbation, or in a muscle which has been strained. The Use of Certain Drugs. — Ergot, by constricting the smaller arteries, and thus obstructing the blood supply, may occasion atrophy. Phosphorus, by. destruction of the red blood-corpuscles, may induce fatty degeneration and atrophy. Bromine and iodine produce atrophy of the lymphatic glands, and other glandular structures. Asa physiological process, atrophy is observed in parts the purpose of which has been served. At birth the ductus venosus and arteriosus, as also the umbilical cord, dis- appear. Another instance is the involution of the uterus after childbirth. Recovery may follow simple atrophy, since under proper conditions of nutrition the tissue returns to its natural state ; but cell-death may occur under adverse circumstances. Atrophy affecting a morbid growth is a mode of cure. Atrophy of Muscle. — The muscular fibre in simple atrophy shrinks within the sarcolemma, from which it is held apart by its attachment to the interstitial connective tissue ; as the contractile substance decreases the. inter- stitial tissue frequently grows and increases in thickness. Sometimes the cells of the interstitial substance become the seat of fatty infiltration, so that the cavity (produced by the shrinking of the muscular fibres) becomes filled. Thus in atrophy of muscle it should be noted that no fat accumulates within the sarcolemma, but outside the sheath of the fibre, and within the interstitial connective tissue. Atrophy of the Heart is evidenced by flabbiness, absence of turgescence, and by thii.ness of its walls: The weight of the organ is always diminished, but not always the size. In general marasmus, the entire heart is atro- phied. Brown Atrophy of the Heart is distinguished by the cardiac tissue being the seat of rusty-brown pigmenta- tion. The actual colour of the pigment is yellow, and it either resides in the contractile substance or forms granu- lar rows between the fibrillra. The entire heart is affected and its size reduced. It is most frequently observed in senile marasmus, and in the tuberculous and cancerous diatheses. ATROPHY OF THE LIVER. IOI Atrophy of the liver is of three kinds : 1. Simple Atrophy. — This affects only the hepatic cells, no change taking place in the blood-vessels and connective tissue. Reduction in size of the cells results, and they are covered with brown or yellow pigment; the individuality is, however, maintained, the entire liver besomes brown, shrunken, tough, leathery, dry, and anaemic, and relative, although not actual, increase of the connective tissue takes place. This form of atrophy occurs in cases of general marasmus, and results from the same cause. 2. Red Atrophy is really a pigmentary infiltra- tion, resulting from venous hyperemia, and occurs when the venous circulation is obstructed by diseases of the lungs and heart. It is most prominent in the centre of the lobule (the zone of the hepatic vein), and it gradually shades off towards the periphery ; as it is frequently accompanied by fatty degeneration' of the more external portion of the lobule, this structure appears mottled and constitutes the so-called nutmeg liver. This form of atrophied liver is large, tense, and firm, and its surface exhibits arborescent furrows in the course of the hepatic vein and its branches, by which the line of destruction of the hepatic cells is mapped out. On section, the deep red colour, the thickness, and the amplitude of the vessels are remarkable. Yellow Atrophy (acute) is generally considered to consist in a rapid non-inflammatory degeneration, and is thought to result from a specific poison, the nature of which is unknown. In this form the liver is small, ilabby, and soft, its capsule wrinkled and rough, and the whole organ is stained a deep yellow colour. There is complete disintegration of the cellular elements, with the production of a mass of stained, granular, and fatty molecules. The blood-vessels are blocked, the connective tissue being swollen and infiltrated. This disease espe- cially affects females, more particularly when pregnant. It is terribly fatal, runs a very rapid course, and com- mences insidiously. Two substances — viz., leucine and tyrosine — are found in the urine. Atrophy of the Walls of the Air-vesicles. This is a chief change in the lungs in Vesicular Emphysema. Atrophous or small-lunged Emphysema is the name given to a form which occurs in old persons, the chaDges in 102 PATHOLOGY AND MORBID ANATOMY. the walls of the air-vesicles consisting merely of atrophy of the various structures of which these are composed. The size of the air- vesicles may not be much increased, but many of these vesicles may have coalesced into one, and the walls are much thinner than normally, the connec- tive tissue, elastic tissue, and blood-vessels having ap- parently participated in the wasting process. An abnormal amount of pigmentation is generally present. Lungs in this condition are smaller than in the natural state, am! upon opening the thorax they rapidly collapse. .atrophy of Bone. This is always accompanied by decrease in weight, but not always by diminished size. There are two forms — viz. ; 1. Concentric Atrophy, in which the compact and can- cellous tissue become absorbed by degrees, the size of the medullary canal diminishing, and the entire bone be- coming smaller. This variety is found chiefly in the large bones, in anchylosis of long standing, in dislocations, or in paralysis. 2. Eccentric Atrophy. Here the -size of the bone is not diminished, but the condition consists in a gradual transformation of the compact tissue into the cancellous. The entire bone becomes very light and brittle, and thus is liable to be fractured with great ease. This is generally found as a senile change, and is usually associated with some fatty degeneration. NECROSIS OP BONE. The term necrosis denotes the death of bone en masse — i.e., the structure of the dead portion is still preserved, so that bone tissue can be recognised ; as with other structures, when the blood supply is cut off, the bone dies. An entire bone may be necrosed or the process may be confined only to portions of the bone. Iuterruption to the blood supply may take place in various ways, such as the nutrient arteries being injured by the periosteum becoming detached or injured, or it may resultfrom inflam- matory changes. Fragments of broken bone, the vascular connexion of which has been lost, also become the seat of necrosis ; the dead portion, when not already parted from the living structure, becomes so in consequence of a granulation tissue being formed between these parts, and this granulation, eventually melting down, leaves the NECROSIS "OP BONE — CAEIES. 103 necrosed part free. This process js generally tedious, and if the situation of the necrosed part is deep, its separation is long delayed ; a purulent accumulation, which con- sists of broken-down tissue debris, takes place around the dead part, and by degrees works its way to the surface, through which it discharges itself. It not un- frequently happens that an organising periostitis is established at the same time, and layer upon layer of condensed tissue becomes superadded to the old bone in which the dead part was enclosed. Sequestrum is the name given to the dead part, involucrum is the part that surrounds it. The Cloacae are the openings in the involucrum. The openings or cloacae are retained in the new forma- tion, and through these the discharge continues ; and this discharge may in time carry with it the sequestrum piece by piece. After the separation of the sequestrum, the cavity land its surrounding parts become gradually altered, and the bone may become, mainly through the agency of the granulation tissue, to a certain extent restored to its normal state. CARIES. This affection of bone corresponds to the ulceration of soft parts, that is to say, caries is a molecular disintegration of bone structure, in which no trace of structure can be distinguished. In necrosis, as has been stated, bone structure can be found. Caries results from inflammation, and it is often accompanied by a so-called Rarefying Osteitis. This is an inflammation of bone in which the medullary spaces are enlarged, and the Haversian canals widened, and often the septa between adjacent spaces are broken down, a system or series of twisting, distended, ramifying passages being produced. This cancellation or rarefaction of bone is produced by the development of a medullary granulation tissue which grows and expands within the vascular canals and the natural meshwork. This granulation tissue bores its way into the bony struc- ture, absorbing during its passage the waste products. Thus a number of winding canals are produced, which extend from the centre to the periphery or circumference. 104 PATHOLOGY AND MOttBID ANATOMY. The infiltration of cells intended for the formation of the granulation tissue becomes fixed, and the meshes of the condensed tissues in the vessels become blocked, and both the cells and the vessels decay. The bony lamellaa now slowly crumble away, the detritus collecting on the surface and in the meshes of the lamellae, since it cannot be removed by absorption. The result is an irregular superficial excavation, the base of which is friable and spongy, and is coated and infil- trated with purulent ichorous matter. In this matter is contained'the debris of tissue in a state of dissolution. Occasionally the medullary tissue bursts into the cariou3 cavity, protruding like a fungus from its sides and floor. Beneath the floor of the cavity, a layer of con- densed tissue sometimes forms, thus separating the dead parts from the living. A superficial osteitis or peri- ostitis may lead to superficial caries, independently of any deep-seated inflammation. In a carious cavity it is common to find necrosed pieces of bone, which are the result of an undermining caries. Carious products when pent up may become caseous, and this is specially the case in the subjects of scrofula. MOLLITIES OSSITJM or OSTEOMALACIA. This is a rare disease; it occurs only in adults, and notably in pregnant women who have borne many children. Its chief characteristics are a progressive loss of cal- careous salts from the bones, the marrow of which steadily increases, and becomes subsequently converted into a vascular round-celled structure. The whole bone is gradually absorbed, with the exception of a thin layer underneath the periosteum ; thus, in extreme cases, the bones become mere shells, they are very light, are cut easily, and bend or break with great facility. Fractures will unite at early stages of the affection, in which on section the Haversian canals and cancelli are found to be, enlarged and filled by a gelatinous reddish material. At later stages this material may become yellow and fatty. The nature of osteomalacia is very obscure. It is com- mon in some of the Rhine valleys, in which it is said there are women in existence' who have undergone the Caesarian operation for pelvic deformity on more than one RACHITIS — RICKETS. 105 occasion. In the osteomalacia! pelvis the weight of the body pushes down the sacrum, the resistance of the femora forcing the acetabula inwards and upwards, and in this manner the two oblique diameters are shortened. Lactic acid has been found .both in the bones and in the urine. In this secretion is generally contained an excess of calcium salts which, after removal from the bone, has become eliminated by the kidneys. KACHITIS— RICKETS. This disease apparently owes its origin to defective conditions of hygiene, particularly improper feeding and bad air. It is especially observed in children that have been brought up by hand, and is said to become more severe in the later children of poor families. Probably the absence of fresh food is the chief cause which seriously interferes with the nutrition of a child, and thus produces rickets. The most remarkable changes are those affecting the growing tissues of bones, especially the epiphyses of long bones and the margins of flat bones. By these changes undue softness and consequent bending or break- ing are produced. The accompanying symptoms are general bad health, and frequently enlargement of the spleen and liver, and sometimes of the kidneys and lymphatic glands. The alteration in the bones has been aptly said to consist in an increased preparation for ossifi- cation, but incomplete performance of the process. In a ricketty.bone the blue transition zone between the bone and the epiphysis is similar to that of health as far as its elements are concerned, but it is much wider, and affects several rows of cells, whilst its outlines towards the bone and towards the cartilage are exceedingly irregular; patches of calcification, or of young bone, may be ob- served in the transition zone separated from the shaft, and oval accumulations of cartilage cells are found amid secondary areolse, or filled with red marrow. The deposit of bony laminse is very slight in amount. An excessive number of osteoblasts form beneath the periosteum, but calcification is very backward. The soft ricketty bone breaks under slight violence, but the fracture is often in- complete. After bending has taken place, Nature may try to support the concave side by throwing out along it 106 PATHOLOGY AND MORBID ANATOMY. a new bone : and this is frequently seen in the. femur and tibia, the bone presenting a flat and somewhat razor-like aspect. The epiphyses often join the shafts early, a dwarfed stature resulting.. The Ricketty Pelvis. — There are two varieties. In the first there is shortening of the conjugate diameter only, and it is contracted in those cases in which the child is kept lying, since it is unable to walk. The second form is very similar to the osteomalacial pelvis, and the mechanism of its production is similar. THE PATHOLOGY 01" THE URINE. In health the composition of the urine in 1000 parts is, roughly speaking, the following : — Water Urea . Uric acid Fixed salts " Organic matters Chloride of sodium Salts of ammonium Alkaline phosphates Alkaline sulphates Phosphates of calcium nesium Extractive matter . Creatine and creatinine Colouring matter . and mag 950 25 1 H 10 1000 The quantity of urine normally excreted by an adult in twenty-four hours is about one to two pints and a half, or twenty to fifty ounces ; but it may exceed this average by the ingestion of large quantities of fluids, as in beer drinkers ; in winter ; and in individuals of sedentary habits. It is pathologically increased in diabetes and hysteria. It may be below the average in summer, and generally under all conditions by which the amount of perspiration and pulmonary exhalation are increased. It is pathologically diminished in acute febrile diseases, and in all diseases attended by dropsical effusions or watery discharges. The. colour of the urine varies physiologically as follows :— THE PATHOLOGY OF THE URINE. 1 07 The greater the quantity of urine voided, the lighter, as a rule, is the colour. > Urine voided in the morning is darter than that at other times. The use of certain drugs imparts a peculiar colour to the urine : rhubarb gives bright yellow ; logwood, reddish ; senna, brownish; santonin, orange-red or golden-yelloiv. Pathologically the urine is rendered pale in anaemia, and in those conditions which produce an increase in the quantity, and it is similarly heightened in colour under those conditions in which'the quantity of water eliminated by the kidneys is diminished, while the elimination of the solids remains normal, or is increased. The presence of bile may render the urine brown, or even black. The specific gravity of healthy urine varies from 1015 to 1025; but after copious drinking upon an empty stomach the specific gravity may fall as low as 1001, and again it may rise to 1030 after a full meal. The urine of females is usually slightly lower in specific gravity than that of males, except during pregnancy, at which period the specific gravity is normally about 1030. A rough estimation of the solid matter contained in the urine may be made by multiplying the last two figures of its-specific gravity by 2. Supposing the specific gravity to be 1020, and 1000 grains be taken, this amount will possibly contain 40 grains of solid matter. The entire quantity of urine passed during the twenty-four hours should be examined, since the density of this fluid varies at different periods of the day. The reaction of healthy urine is faintly acid. The colour of the urine is probably due to at least two colouring matters, Urobilin and Indican. The urine may become alkaline by exposure to air after some days, its urea being converted into carbonate of ammonium ; or it may be rendered alkaline by remedies, such as carbonate of calcium or magnesium, or its acid condition may be lessened by constant vomiting in certain diseased states of the stomach, or when the urine is loaded with pus. It may also be alkaline after a full meal, the digestion of food absorbing the gastric juice. Alkaline urine turns yellow turmeric brown. Acid urine turns blue litmus xo a red colour, whereas alkaline urine restores to red litmus its blue colour. 108 PATHOLOGY AND MORBID ANATOMY. Urea in excess gives urine a high specifics gravity (1030—103-5). This substance may be detected by adding strong nitric acid or oxalic acid to urine. It' kept cool, nitrate or oxalate of urea crystals are formed. The former of these appears in the form of scales, which are composed of numerous rhomboidal plates ; the latter also take the form of rhomboidal plates, but the angles are much less acute. From the preceding table of the composition of the urine it will thus be observed that about one-half of the solil matter of the urine consists of urea. Now, urea is theoretically formed by the oxidation of uric acid, so when this oxidation does not take place, and there is an excess of uric acid in the system, as occurs in the gouty diathesis, this disease is termed one of sub-oxidation. In considering the pathology of the urine, we may conveniently divide the subject into two sections : — (1) Tbe Morbid Deposits. (2) Tbe Morbid Constituents. THE MORBID URINARY DEPOSITS.* These are the following : — 1. Urates or Xiithates- 5. Cystine. 2. Uric Acid. 6. leucine and Tyrosine. 3. Oxalates. 7. Pus. 4. Pbospbates. 8. Mucus. •URATES OR IITHATES- These usually consist of urate of sodium and ammonium, and are the most common urinary sediments, being occasionally passed by almost everybody. They are found in the course of most fevers, in liver diseases, in rheumatism, and in gastric disturbance, but per se they do not indicate anything serious. There are two varieties — the pink and the white, the former of which forms the so-called brick-dust sediment. Tests.— (1) Lithate of ammonium is soluble in liquor potassEe with evolution of ammonia, but (2) All lithates are dissolved by heat, and thrown down in the cold. Microscopically.— Lithate of ammonium appears as feathery amorphous bodies. * See frontispiece. MORBID URINARY DEPOSITS. 109 Lithate of sodium sometimes forms spherical masses, from parts of which very small needle-shaped crystals of uric acid project. The crystals are sometimes of a hedge- hog shape. Lithate of sodium is commonly met with in children's urine in a globular form. uric OR IITKIC ACID. — An excess of this acid constitutes the uric acid diathesis, the leading characters of which are gout, gravel, and dyspepsia,. and the urine is always decidedly acid. Uric acid may occur as a deposit (gravel), forming the cayenne-pepper grain deposit, or as a concretion (calculus). The red colour of the grains is adventitious, being acquired from the colouring matter of the urine. The real appearance of uric acid is white. The urine of serpents (which consists almost entirely of uric acid) is white. Tests. — (1) Uric acid is dissolved (without evolution of ammonia) by liquor potassaa and liquor lithiije, hut not by liquor sodas or liquor ammonias. (2) The formation of the purpurate of ammonium, or murexide, is as follows : — A few grains of the deposit are placed upon a glass slide, with a drop or two of strong nitric acid, and the whole evaporated to dryness, a sub- stance termed alloxan being formed. This alloxan is now exposed to the vapour of ammonia, and the purple murexide results. Uric acid is insoluble in water, but is supposed to be held in solution in the urine bjr the action of the phosphates. Microscopically. — Uric acid usually appears as a rhombus with rounded edges (lozenge-shaped), or as a dumb-bell with fringed extremities, always of a yellow or reddish colour, but some crystals are at times halberd- shaped or needle-shaped. OXALATE OP CALCIUM. — The presence of this salt in the urine constitutes the condition known as oxaluria. It is not found in healthy urine, but its elements — carbon, oxygen, and calcium — are present, and these give rise to the so-called mulberry calculus. Oxa- luria often does not indicate anything serious, but is usually associated with dyspepsia and gastric disturbance. *It is not unfrequent to find, upon the same microscopic specimen, crystals of oxalate of calcium lying side by side with those of uric acid. IIO PATHOLOGY AND MORBID ANATOMY. Tests. — (1) Oxalates are dissolved by nitric acid, but not by acetic acid, or by liquor potassse. (2) They are converted by the blow-pipe into car- bonates. Microscopically. — Oxalates present a white deposit, consisting of square octahedra, and dumbbells without fringed extremities. The crystals are usually very small. PHOSPHATES. — These form a white deposit, aud occur in the urine under three forms, viz. : — (A) The Triple or Tribasic Pbospbate, or Am- monia-Magnesian-Phospbate, appearing under the microscope in the form of triangular prisms, with obliquely truncated ends. jTrequently the crystals are four-sided, and sometimes peculiar forms are observed in which two prisms appear united. (B) Tbe Basic, Bibasic, or Triple Pbospbate, with Excess of Ammonia, microscopically presenting stellate crystals, and thus sometimes called the star-shaped phosphate : they after a time assume the prismatic form. (C) Tbe Pbospbate of Calcium, occurring as rounded particles, usually clinging to the angles of the triple phosphate. Upon adding a few drops of liquor ammonia? to healthy urine it becomes turbid, and deposits the triple Bait with phosphate of calcium. Phosphaturia is the name applied to' the condition in which the urine contains any considerable excess of phosphates. The presence of a small deposit of phos- phates in the urine is always an indication of depression and debility, but a large quantity always shows a waste of tissue, and may be considered as caused by a breaking up of the mind and body. Tests. — (1) Phosphates are precipitated both by heat and by liquor potassas. They are thus distinguished from white lithates. (2) They are soluble in acetic and nitric acids. Phos- phates are thus distinguished from oxalates, which, although soluble in nitric acid, are not dissolved by acetic acid. cystine, or CYSTIC OXIDE. — This is an organic compound of a fawn colour, containing carbon, hydrogen, MORBID URINARY CONSTITUENTS. Til and nitrogen, with a large and equal quantity of sulphur and oxygen (26 per cent, of each). It is probably a deriva- tive of albumen, and constitutes a form of urinary calculus, but very rarely occurs as a deposit. The urine containing it usually possesses an odour of sweetbriar. Cystine is often found mixed with uric acid and the urates. ■«, Test. — Cystine is soluble in liquor ammonias, but is re-precipitated unchanged upon the spontaneous evapo- ration of the ammoniacal solution. Microscopically, the deposit exhibits six-sided colourless plates, which, if very abundant, are aggregated together so as to form superimposed plates. leucine and tyrosiwe. — These substances are very rare indeed, but are found in the urine in cases of acute yellow atrophy of the liver. Microscopically, leucine occurs in gland-like masses of leaves or scales, and tyrosine appears as shining, long needles clustered together. PUS. — This occurs as a white deposit, and is a frequent indication of chronic pyelitis, especially when mixed with blood. Test. — Pus forms a glairy or ropy mass with liquor potassse. Microscopically, the pus-corpuscles are observed. Theso resemble the white corpuscles of the blood, but are some- what rougher in outline, and contain more nuclei ; but some recent authorities regard them as identical. MUCUS. — This also forms a glairy mass with liquor potassse, but the microscope shows its true nature. In perfectly healthy urine a slight cloudy deposit of mucus is occasionally present, and microscopically the epithelial cells are apparent ; if they proceed from the bladder they are flat and scaly, if from the urethra, columnar. THE MORBID URINARY CONSTITUENTS are the following : — 1. Blood ; 2, Bile ; 3, Albumen ; and 4, Sugar. blood. — The presence of this substance in the urine is termed Hsematuria. The Causes of hsematuria are congestion of the kidneys or any part of the urinary organs, either idio- pathic, or produced by cantharidesj turpentine, &c. The 112 PATHOLOGY AND MORBID ANATOMY. most frequent cause is a calculus, but a diseased prostate, inflammation of the bladder, or tumours (cancerous and otherwise) in the mucous membrane may cause the pre- sence of blood in the urine. Again, haematuria may occur in the course of purpura, typhus, and scarlet fev^r, or it may be vicarious of menstruation. In the hemorrhagic diathesis, large quantities of blood may be discharged by the vagina or penis, or by the nose (epistaxis). Indications. — When the blood proceeds from the blad- der, it generally follows a flow of urine ; when from the kidney, it is intimately mixed with the urine. Tests for blood : — (1) Its red-colour. (2) The heightening of the colour by liquor ammonia), a crimson tint being produced. (3) The characteristic corpuscles under the microscope. (4) The dark bands in the spectrum. (5) Its coagulability by heat and nitric acid, throwing down a dirty-brown coagulum. (6) The blue colour produced with blood by fresh tinc- ture ofguaiacum and ozonised ether (the peroxide of hydrogen test); bile. — This substance gives to the urine a dark-brown colour, varying in the deptli of its shade according to the amount of bile present. Bile may be present in the urine from one of two condi- tions : either from — 1. Suppression of the biliary functions, in which case the blood is charged with the colouring matter of the bile and with cholesterine ; or, from 2. Obstruction to the bile-flow into the duodenum, in which case the matters generated in the liver itself — viz., the bile acids — appear in the urine. Tests. — (1) A few drops of nitric acid added to the bile-stained urine upon a white porcelain plate produce an iridescent (rainbow) play of colours. (2) If strong sulphuric acid, \ drachm, with a small fragment of loaf sugar is added to about 2 drachms of similar urine, suppression Will be indicated by a mere browning of the sugar, whereas obstruction will be shown by a, scarlet or purple colour at the junction of the two fluids, resulting from the oxidation of the bile acids. AlsuniEH. — The presence of this substance in the urine constitutes DIABETES. 113 AKBTJIKXirtrRIA. — The most common causes of this condition are cold, scarlatina, and intemperance ; but albuminuria may occur daring epidemic cholera, diph- theria, pulmonary tuberculosis, articular rheumatism, typhus and typhoid fevers, erysipelas, measles, and preg- nancy. Tests. — (1) Heat and nitric acid will independently coagulate or throw down albumen, but these reagents should he added together, since either, separately, may give a fallacious result. Phosphates, when in excess, are thrown down by. heat, but dissolved by nitric acid, and nitric acid may cause a turbidity in urine containing an essential oil, as of copaiba or cubebs. This oil may be separated by ether, and the urine will then have its usual reaction. (2) Place some urine in a test-tube, incline it gently, and allow -a little nitric acid to trickle to the' bottom slowly. Three strata will appear if the fluid.is albuminous : at the bottom, colourless nitric acid ; above this, coagu- ated albumen; at the top, unaltered urine. (3) Some nitric acid may be placed at the bottom of a test-tube, and the urine poured gently on the top ; at the line of junction of the fluids a white line of albumen will appear. If the urine is alkaline, heat will not affect the albumen until a drop or two of acetic acid is added ; or the pre- sence of a drop or two of nitric acid in the test-tube may, by re-dissolving the albumen, prevent its precipitation upon the subsequent addition of nitric acid. (4) Picric acid in powder precipitates albumen, a reac- tion not interfered with by the presence of phosphates or urates. This test is so very delicate that it will detect a minute trace of albumen, irrecognisable by the nitric acid or heat method. SUGAR.-— When sugar is found in the urine, the condi- tion is known as diabetes mellitus, or glycosuria, since glucose, or grape-sugar, is the variety present, diabetes. — There are two varieties of this disease described by authors, viz. :— 1. Diabetes Insipidus, Hysterical, or the I-Tc-m- Saccharine. 2. Diabetes Mellitus, Glycosuria, or tne Sac- charine-) Diabetes Insipidus occurs in hysterical persons : a 114 PATHOLOGY AND MORBID ANATOMY. very large quantity of almost colourless urine is passed, but its specific gravity is very low (1001-5), and it con- tains no sugar. It is not a condition of much pathological importance. Diabetes IWellitus. — In this disease a very much larger quantity of urine than normally is passed daily — the normal quantity being 30 to 50 ounces, in some cases there may be as many pints as there are usually ounces. To estimate the quantity of sugar passed in the twenty- four hours, the sample of urine should be fermented with yeast, the specific gravity being taken before and after fermentation. The difference in the number of degrees represents the number of grains of sugar per ounce. The pathology of diabetes mellitus is extremely obscure. The disease would appear to be one of mal-assimilation, or suboxidation, or a perversion of the healthy function of the liver. Claude Bernard's view is the following. In health, the portal circulation carries off from the stomach some of the products of digestion, i.e., starchy matters and dextrine (a modification of starch). The latter is carried to the liver, and converted into glucose, hence the origin of the glycogenic function of the liver. Since this glucose is elaborated in the hepatic cells, it receives the name of hepatin. The blood containing the hepatin is conveyed by the hepatic vein into the inferior vena cava, and thence through the right side of the heart to the lungs, and still con- tains this hepatin or glucose throughout its whole course ; but the blood returning from the lungs is found to con- tain no sugar. The assumption is, therefore, that the glucose (C 6 H 12 6 ) acquires in the lung more oxygen (O), and is burnt off as carbonic anhydride (C0 2 ) and water (H 2 0), thus— C 6 H 12 6 + 120 - 6C0 2 + 6H 2 0. In diabetes mellitus this combustion evidently does not take place, and hence the vessels passing from the lungs into the left side of the heart still contain sugar, which is found in the urine. Another theory supposes diabetes to bo a brain disease, since irritation of the fourth ventricle has produced an increase of sugar in the urine. Pavy thinks that the hydrocarbons taken up with the food are normally stored up in the liver, under the form of DIABETES MELLITUS. 1 15 glycogen, which is changed into fat, and not into sugar ; the fal serving for the formation of bile. When the condi- tions are abnormal the glycogen is converted into sugar, glycosuria being thus occasioned. It is extremely pro- bable that the greater number of cases of diabetes have a nervous origin; but it must be admitted that some cases may proceed primarily from the digestive organs. SOme hours after the administration of the vapour of nitrite of amyl the urine is found to contain sugar, dilatation of the hepatic vessels being the probable cause of this transient diabetes. Tests for diabetic urine : — The specific gravity may be from 1025 to 1050. In old persons, however, it may not exceed the limits of health. (1) (Moore's test.) Equal quantities of liquor potassae and saccharine urine, when boiled, exhibit a deep brown coloration, varying in tint with the amount of sugar present, and due to the formation of melassic acid. (2) (Trommer's test.) Equal quantities of the urine and liquor potassae, with the addition of just enough of a Saturated solution of sulphate of copper to give the mixture a blue colour, precipitate (when boiled) the sub- oxide of copper (reddish-brown). Possibly the reactions may be the following: The glucose (0 6 H ls O 6 ) reduces the black oxide of copper (CuO) (thrown down from the sulphate of copper by the liquor potassse) to the suboxide (Gu 2 0), sucrose (0 13 H2jO n ) and oxygen (O) being also formed. Thus :— 2CuO + 20 6 H 12 6 = OuHmO,, + H a O + + Cu 3 0. Pavy's solution consists of caustic potash (1280 grains) ; neutral tartrate of potassium (640 grains) ; and sulphate of copper (320 grains) ; i.e., in the proportions 4, 2, 1. The suboxide of copper is precipitated of a beautiful bright red by this solution. Eehling's solution contains sulphate of copper (90J grains) ; neutral tartrate of potassium (364 grains) ; solu- tion of caustic soda, specific gravity 1'2 (4 ounces), water being added to make up exactly 6 ounces. One grain of sugar exactly decomposes 200 grains of this solution. (3) A few grains of the white subnitrate of bismuth are placed in a test-tube, and an equal quantity of urine and liquor potassse are added, and the mixture boiled at the 116 PATHOLOGY AND MORBID ANATOMY. bottom. The white subnitrate is reduced to black metallic bismuth. (4) Some German yeast is added to the diabetic nrine and the temperature raised to 80° Fahr. Effervescence occurs with discharge of gas, a yellow liquid remains, which smells like beer and yields alcohol by distillation. One part of sugar in 1000 parts of urine of the density of 1030 may be detected by this means. It may be useful to point out the gradations of the spe- cific gravities of theurine under different circumstances. Thus the specific gravity of Hysterical urine is . . . 1001- 5 Albnminous „ 1005-15 Healthy „ 1015-25 Saccharine „ ... 1025-50 It should be remembered, however, that in acute Bright's disease the specific gravity may be as high as 1025 or 1030. URINARY CALCULI AND CONCRETIONS. Urinary concretions, -when small and numerous, and which pass readily with the urine, constitute sand or gravel. When, however, they are too large to be evacuated by the urine, they constitute calculi. The chief chemical constituents of urinary calculi are the following, viz. : — Uric acid and urates ; cystine (cystic oxide) ; oxalate of calcium ; carbonate of calcium ; phosphate of calcium ; ammonio - magnesian - phosphate ; proteine compounds (fibrine, mucus). With the above are mixed: very small quantities of earthy matters (silica, alumina, &c). Sometimes the urinary concretion consists entirely of one of these sub- stances ; at others, it is composed of several of them, and not unfrequently the concretion is formed of separate layers of the different constituents. In testing a sandy deposit, it should first be examined microscopically, then the particles should be cleared of impurities, as pus and blood, and washed with distilled UEINAEY CALCULI AND CONCRETIONS. I If water ; large particles should be reduced to powder. In testing calculi, their occasional constitution in layers must be borne in mind. They should be broken to pieces, and some of the powder from each layer carefully analysed. The best mode of proceeding analytically, is to heat some of the powdered calculus on platinum foil over a spirit lamp. Then if — (1) The_ ppvfder is entirely consumed, or only a very small amount of residue is left ; it may consist of— TJric acid, or urate of ammonium ; Cystine ; Proteine bodies ; or, (2) The powder is incombustible, or leaves con- siderable residue after being exposed to red heat ; it may- consist of — Urates with a fixed base (sodium, calcium, magnesium) ; Oxalate of calcium ; Carbonate of calcium ; Phosphate of calcium ; Ammonio-magnesian-phosphate. Tf, when the powder is acted upon by nitric acid and ammonia, a distinct murexide reaction is obtained, the concretion is formed of urate of ammonium or uric acid, and these substances are thus distinguished : uric acid is only slightly soluble in boiling water; whilst urate of ammonium is far more readily soluble, occurs in much. larger quantities, and, upon the cooling of the solution, it is again precipitated, and on the addition of liquor potassse gives off ammonia. The ITric acid calculus is of tolerably frequent oc currence. and is sometimes of considerable size. It is usually of a yellowish, or reddish-brown, colour, with a smooth surface and rather hard. The Urate of ammonium calculus is nf rare occur- rence. It is generally small, of a loamy lightish colour, and more earthy in consistence than the preceding substance. If there be no murexide reaction and the concretion is combustible, it may consist of one of the following : — The Cystine calculus. This is rare. It is of a dull yellow colour; the surface is smooth, and exhibits a glis- Il8 PATHOLOGY AND MORBID ANATOMY. temng crystalline appearance when broken. It ia softiah, and when reduced to powder communicates a soapiness to the fingers. From the large amount of sulphur contained in it, if this calculus be dissolved in liquor potassae and a little acetate of lead be added, the solution being then boiled, the mixture becomes inky from the precipitation of the black sulphide of lead. A calculus formed of proteine substances (fibrine, or blood coagula) is very rare. It is amorphous in appearance ; upon burning, it gives off an odour of burnt horn, it swells up on the addition of acetic acid, and is soluble in boiling nitric acid. Urates of sodium, calcium, and magnesium are very seldom found as the only constituents of a calculus, but they are occasionally met with in variable quantities in calculi consisting chiefly of other substances — viz., in the nric acid and urate of ammonium calculi. The powdered calculus is boiled with distilled water, and the solution filtered while hot ; if urates are present, they will be found in the -filtrate. This is evaporated, the residue being heated to redness, and should it turn moistened turmeric papers brown, will indicate sodium or potassium. Sodium imparts a yellow, potassium, a violet tinge to the blowpipe flame. Magnesium and calcium will be found in the residue, as carbonates ; these are freely soluble in diluted acids. Upon the addition of phosphate of ammonium and sodium to the solution, the ammonio-magnesian- phosphate and phosphate of calcium are precipitated. . Oxalate of calcium, when subjected to strong heat, turns black from the combustion of the organic matter often present, but becomes white again after continued exposure to heat, being converted into caustic lime (hydrate of calcium). If this last substance be dissolved in hydrochloric acid and oxalic acid added, oxalate of calcium is precipitated, which may be recognised by its microscopic appearance. The oxalate of calcium calculus is frequently met with ; it is either small, smooth, and pale in colour, or larger, with a nodular, warty surface, and of a dark-brown or' black colour (the mulberry calculus). It is common in children. A calculus composed entirely of carbonate of calcium is also rare. It is of a whitish grey colour, and chalky appearance. Carbonate of calcium is generally found, in small quan- URINARY CALCULI. 119 tity, as a component o£ other calcnli blended with the earthy phosphates and oxalate of calcium. A concretion of carbonate of calcium is infusible, and becomes black when burnt, on account of the organic matter which it often contains, but further heating renders it white. It also dissolves in hydrochloric acid with effer- vescence, carbonic anhydride being driven off. Basic pnosphate of calcium and ammonio-mag-ne- sian-pnospnate are generally found together as consti- tuents of urinary calculi. These calculi are usually whitish and often of considerable size. If phosphate of calcium is in excess, they are hard and thick ; but if the ammonio- mag nesian-phosphate predominates, they are chalky and soft. They are incombustible, and have been termed fviible calculi, since they fuse to a white enamol-like mass after exposure to strong heat; they are soluble in hydrochloric acid loitliout effervescence. These two constituents are separated by adding to the calcined powder diluted hydrochloric acid, andjiltering the solution ; then adding ammonia and oxalato of ammo- nium, by which the calcium i,s precipitated as an oxalate. After nitration, the phosphate of ammonium and mag- nesium may be obtained by the addition of ammonia in excess. Calculi of neutral phosphate, of calcium are very rare ; they resemble the earthy phosphates. The composition of urinary calculi is sometimes very complicated. Thus, some consist of uric acid, urates, and earthy phosphates; others of oxalate of calcium and earthy phosphates ; and, again, others have been met with, com- posed of six constituents —viz., uric acid, oxalate of calcium , carbonate of calcium, urate of ammonium, phosphate of calcium, and ammonio-magnesian- phosphate. These may be all mixed together, .or disposed in. concentric layers. Every calculus usually possesses a nucleus which is formed by foreign bodies, such as blood coagula, mucus, and fibrine, or by sand particles, but sometimes there may be a cavity, instead of a nucleus, the mucus having dried up by which the nucleus was originally formed. False, or spurious calculi, usually contain much silica, which will be detected by fusion with carbonate of sodium or potassium. 120 PATHOLOGY AND MORBID ANATOMY. URINARY TUBE CASTS* These are six in number — (1) Granular Casts.— These are dark and granular in appearance; are" about yj-oth of an inch in diameter, and are composed of fibrine and disintegrated epithelium; they are produced in tubes, the epithelium of which is undergoing disintegration, and are indicative of ' : chronic nephritis," especially the " intertubular " variety (granu- lar kidney). They usually occur in the urine after frequent attacks of gout, and may be found long before any other sign of renal, mischief has been exhibited. (2) Waxy or Transparent Hyaline Casts. — These are quite structureless, clear glassy cylinders, and vary in diameter from ^jth to -g^o^ °* an inch. They may easily be overlooked, and are best seen when light is thrown upon them obliquely, or when a drop of a watery weak solution of iodine is added to the microscopic specimen. They are sometimes found in the advanced stages of chronic nephritis, but also occur in acute forms of kidney disease. (8) Oily Casts, — These consist of fibrine, in which are entangled oil globules, and epithelial cells gorged with oil. When persistent and in large numbers they indicate fatty degeneration of the kidney, but even in recent cases a few casts, somewhat oily, may be found. (4) Purulent Casts. — These exhibit pus cells entangled in casts of fibrine, and occur in " suppurative nephritis." (5) Blood or Exudative Casts. — In these the blood is moulded in the renal tubes. They are observed in cases of strangury and bajmaturia, and in acute diseases of the kidney. When blood or pus cells are entangled in the tube casts, the size of the casts will vary in accordance with the particular part of the kidney in which they were formed, and also with the condition of the lining mem- braneof the tubes. If the epithelium is detached, the cast will of course be somewhat larger; but if the epithelium is still adherent, it will be small. Whenever inflamma- tion of the pelvis of the kidneys, the ureters, or the bladder is present, the epithelium of these parts may be found in the urine. The cells exhibit a great resemblance to those of cancer and may give rise to an incorrect diagnosis. ~<&) Cellular or Epithelial casts. — These are covered * See frontispiece. ANIMAL PARASITES. 121 by the epithelial cells of the tubuli uriniferi.' They indi- cate that the disease is recent, and that the tubes are as yet lined by epithelium. The cells themselves are generally opaque, and granular. ANIMAL PARASITES. ENTOZOA— VERMES-^WORMS. The worm-shaped or helminthic parasites are arranged in three orders, viz. : — Cestoda, Trematoda, and Weraatoda. 1. CESTODA (Tapeworms) may be present in two forms — (a) in the immature or larval form ; (b) in the matured form. When sexually mature, these entozoa are found in the small intestines. They are elongated, shaped like a ribbon, aud consist of separate segments or joints, male and female reproductive organs being contained in every mature joint. They possess no. mouth or alimentary canal, and in all probability exist by absorbing fluids in which they may be immersed. The head is furnished with suckers, and sometimes with booklets, which enable them to attach themselves to the mucous membrane of the in- testines. New segments take growth at the upper extremity of the worm below the head ; the older and lower segments, after their contained ova become mature, separate, and are discharged with the fasces. When a ripe ovum gains entrance into the stomach of any animal suited for its habitation, the investing capsule becomes digested by the gastric juice, and the embryo, termed at this stage the proscolex, is set free. The proscolex, by means of its spikelets, perforates the .intestinal walls, and reaches some organ fitted for its abode. In this it becomes excluded from the air and enveloped in a cyst, a colony of individuals being produced. Each of these individuals is termed a scolex, and is provided with a head and hooklets, the neck being fixed to a vesicular body containing fluid. Whilst in this condition it possesses no organs of reproduction, and undergoes no further development, unless it is received into the intestinal canal of some warm-blooded animal. 122 PATHOLOGY AND MORBID ANATOMY. No less than eight, varieties of cestod'a are found in tho human body; only two, however, are common in England — viz., Taenia solium and Tcenia mediocanellata. Taenia Solium (tbe ordinary or Pork Tapeworm) in- habits the whole track of the intestines, but especially the ileum. These worms vary in length from 4 to 24 feet, and consist of a number of square-shaped segments. The anterior extremity (head) is exceedingly small — about the size of a pin's head — and is furnished with a double row of hooklets, by which the entozoon attaches itself to the mucous membrane ; behind the hooklets are three or four suckers situated round the head (scolex)i Each ripo segment or proglottis represents the independent or adult form of the sexual animal, and contains independent female and male organs of generation. In the centre of the segment is a branched organ (the ovisac) which may contain thousands of ripo spherical eggs. To the larval form the name of cysticercus taeniae cellulosao is given, and it constitutes the measles of the pig (measly pork). The worm is liable to become developed in persons who consume underdone or raw pork. Taenia Mediocanellata or Saginata (the Beef Tape- worm) bears a close resemblance to the tasnia solium, but it is generally longer, and its segments are more numerous and larger. The head is about three times the size of the taenia solium, but it possesses no hooklets. The larval form is termed cysticercus taeniae medio- canellatae, and infests the flesh of the ox and calf ; the worm is therefore apt to be developed in persons who have eaten imperfectly cooked beef and veal. Bothriocephalus Latus (the Broad Tapeworm) i;: very rare in England, but peculiar to Poland, Russia, and Switzerland. Of all the tapeworms this is the largest which infests the human subject, having sometimes a length of 25 feet, and even more, each foot having 150 segments, and each segment possessing male and female organs. It only possesses a suctorial apparatus in the head, which is club-shaped, with a longitudinal slit, and is destitute of hooklets. The ova are developed in water ; it is thought that in the larval state the parasite in- habits the body of some mollusc or rish. Taenia Echinococcus. — The mature worm is rarely longer than a quarter of an inch, and consists of three or ENTOZOA— TREMATODA. 12% four segments. The head i3 furnished with hooklets. It has not been found in man, but occurs in the intestines of the dog. In the larval form it constitutes the Hydatid, which occurs in the human being, and espe- cially in the liver. An hydatid consists of a sac lined with a thin bladder or cyst, which is filled with a limpid, colourless fluid, ia which float; numerous smaller cysts called acephalocysts, similar to the cyst lining the sac, and varying in size from that of a pea to a pigeon's egg. These cysts contain- the echino- cocci. Microscopically, each ecninococcus is an oval-shaped animalcule having some thirty or forty minute calcareous hooklets arranged in a circle round its head, which is pointed and furnished with four suckers ; when the crea- ture is viewed with the head retracted, the circle of hooks appears like a ring in the centre of the body. The history of an hydatid is the following : — Diseased offal is thrown to a dog. The animal passes, by the bowels, either in the stream or on the field, segments of the developed worm. These segments are swallowed by sheep and cattle. Eventually tie animal by which the segments have been swallowed becomes the food of man, and then the larval tapeworm becomes developed into a bladder-like hydatid. In the sheep it- goes to the brain, producing " stag- gers ; " in the ox it soeks the peritoneal cavity ; and iu man it selects the liver. 2. TKEIWATODA (Flukes, or Fluke-like Parasites). The eutozoa which belong to this 'order are minute, flat shaped, generally pointed at each end, and are not divided into segments. They aTe furnished with two sucking discs, one situated on the abdomen and the other at the mouth. They are devoid of anus, but possess a mouth and a bifurcating alimentary canal, which is hollowed out in the substance of the. body, and is sur- rounded by no peri- visceral cavity. Both male and female organs of reproduction are found in the same individual. The larvae have no hooklets, and are never cystic, but are frequently tailed. Flukes chiefly infest the liver and intestines in man and herbivorous animals (liver flukes). The fluke disease is produced in sheep thus : — The ova 124 PATHOLOGY AND MORBID ANATOMY. pass from the gall-bladder of an infected animal into its intestines, and are voided with the excrement upon the land. A moist situation being found, they are hatched rapidly into circular ciliated embryos, which swim or move about, and before long become fixed to some moliusc, such as a slug or snail ; they ther alter their condition, and assume the form of a m.nute bladder-like htdatid, termed a cercaria-sac, from which numerous young tailed cercariaa take origin. After a number of transformations, these cercarias become pupas, which are buried in the body of the snail. In wet weather the infected snail, crawling upon the grass, is eaten by the sheep, in whom the pupa develops into a perfect fluke. When found in the human body, it has possibly been drunk with- water or eaten with an aquatic plant, such as watercress. Nine species of trematoda have been found in man ; among which are the following : — Slstoma Bepaticum, or Fasclola Hepatica, is rare in man, and it is only found in the gall-bladder and ducts. It is common in the sheep, giving rise to the disease termed the "rot." Slstoma Crassum has been found in the human duo- denum. Slstoma Xanceolatum is a very rare form, Distoma Opbtbalmobium has occurred in an eye affected by cataract. Distoma Heteropbyes has been found in the intestine of a boy at Cairo. Bilbarzia Heematobia. — In this form the male and female are separate ; the latter is much the larger. It has been discovered in the Cape of Good Hope and in Egypt in the bladder, kidneys, ureters, and mesenteric veins. Through the irritation it excites, haemorrhage and inflammation are induced in the organs it inhabits. When the kidneys are the seat of the parasite, a form of haBuiaturia is produced ; when the intestines are affected, symptoms of dysentery are set up. The presence of the bilharzia can only be determined on microscopical examination by finding the ova in the urine or in the fseces. 3. NEMATOCA (Round Worms). A number of different families are included in this order The worms are elongated and slender, and devoid KNTOZOA— NEMATODA. 1 2 5 of joints. They possess a mouth, alimentary canal, and an anas. The majority are parasitic only during part of their existence, and they are unisexual. The following are t'he most important varieties :— Ascaris Iiumbrico'ides (the Common Roundworm). — This worm varies in length from 6 to 16 inches. Its body is reddish in colour, tapering towards each extremity, and its general appearance closely resembles the ordinary earth-worm. The head is terminated by three distinct and uniform papilla?, which surround the mouth, and are capable of spreading out into a broad circular sucker during the act of suction. Each papilla is furnished internally with microscopic teeth. The posterior extremity of the male is bent round like a hook, the corresponding part of the female being pointed and comparatively slender. The fecundity of this entozoon is remarkable the body of the mature female has been calculated to contain sixty-four millions of eggs at a given time. The ova probably find their way into the alimentary canal by unripe fruits and vegetables, or by impure water. This round worm occupies chiefly the small intestines, but it may present itself in the oesophagus, stomach, and gall- ducts. Ascaris Vermicularis — Oxyuris Vermicularis (the Thread or Maw-worm). — These worms are termed col- lectively Ascarldes or Oxyurides. Ascarides resemble small pieces of thread, often massed together as round balls of considerable size. The male is small in comparison with the female. They are of a pale silver colour, with obtuse and rounded extremities. The females are more numerous than the males, and are recognised by their whiteness and thickness, and by their fine-pointed tail. The head has three papilla}. As these worms exist in large numbers, they set up great irritation at the margin of the anus. They frequently crawl out of the rectum, and may be discovered in the bed and the clothes of the patient ; they often occasion vaginitis in the female and irritation of the penis in the male. They infest the large intestines, especially the rectum. The worm, it is supposed, is admitted into the intes- tine in the embryonic condition, through eating uncooked or unripe fruits ; but water is a more probable vehicle for its introduction. 126 PATHOLOaY AND MORBID ANATOMY. Tricbocephalus Blspar (the tong Thread -worm). — The male trichocephalus is more slender and shorter than the female. These worms differ from the ordinary thread- worms in the fact that their length is greater, their anterior two-thirds extremely thin, and their posterior third of comparatively large size. They chiefly inhabit the cascum and colon. They are rare in. this country, but common in France. Ascaris Mystax has been found occasionally in the human subject, but it chiefly occurs in the cat. Its head is spear-shaped. Trichina spiralis. — This is a very small worm, which Fig. 31. Fig. 30. Trichina Spiralis coiled vp Trichina Spiralis removed within its Cyst, with groups from its Cyst. a The of fatty cells at either end. mouth ; 6, Commencement of * 60 - the alimentary canal ; c and d, Tubular sac, with .granu- lar body, extending to e, The anal extremity. may exist in the human body in a free or encysted state, and when mature is only about -i- inch in length. When encysted, it is seated between 1 the sarco- ENTOZOA — NEMATODA. 1 27 lemma of the primitive muscular fibres, the capsule becoming more or less calcified. It is frequently found in the flesh of the pig, and, when raw or insufficiently cooked pork so diseased is eaten, digestion sets free the qncysted trichinae; these then commence to develop, numberless embryos being produced in the intestines, from which they advance to the muscles, setting up violent symptoms until they become enveloped in capsules, in which condition they are harmless. The trichinaB are found in the muscular tissue, each being coiled up within an oval cyst, and appearing to the naked eye as tiny white grains. The colour of the affected muscles is pale reddish grey, speckled with small light points of trichinae, which exist in all stages of development, lying upon and within the sheaths of the muscular fibres. They have been found in all the voluntary muscles, and have been seen in the heart's substance. Microscopically, the trichina spiralis appears of a spiral form coiled up within the sarcolemma 01 the mus- cular fibre (Figs. 30 and 31). Filaria IVXedinensis (the Dranunculus, or Guinea- worm) is about -5^ inch thick, but may be 6 feet long. The female alone occurs in the human body, and the worm is only found in certain tropical regions. These filarias are thought to constitute some of the species of " tank-worms," since they are believed to per- forate the skin of persons bathing in the muddy water of tanks. The parasite seems to remain inert in the tissues for about one year, by which time it has become distended with young. It now advances to the surface, and forms a blister, upon the bursting of which its head appears, its young are discharged, and the parent worm is gradually removed. Filaria Xientls has been found in' the human eye. Filaria Sanguinis Hominis. — The embryos of a very small nematoid worm have been found in large numbers in the blood, in the urine, and other secretions of persons in India who were suffering from chylous urine and elephantiasis. They only differ from the young of other nematoda in being enveloped in a delicate transparent sheath within which they can be seen to contract. Sclerostoma xtuodenale infests the small intestines ; it occurs chiefly in Italy and Egypt. Its head is round, and furnished with hooklets. ' It exists in large numbers 128 PATHOLOGY AND MORBID ANATOMY. and, by the frequent minute haemorrhages it occasions, may set up a variety of anaemia, termed Egyptian chlo- rosis. Strongylus Gigas is rare in the humaubeing: Strongylus Broncbialis has been found in the bronchial glands. DEBMA.TOZOA— ECTOZOA. These are the animal parasites whicluare' found upon the surface of the skin. They are the following :— PEXUCVXX (lice). Of these there are three varieties, viz. : — Pediculus capitis, infesting the head; Pediculus pubis (the crab-louse), infesting the privates ; and Pedi- Fig.32. ' Fig. 39. Pediculus Pubis, found in Phthiriasis pubis. Pediculus Capitis (female), found in Phthiriasis capitis. cuius corporis or vestimenti (the body or garment louse). These parasites occasion a disordered state of the skin, termed pbtbiriasis or lousiness. The Pediculus Capitis (Mg. 32) occurs chiefly on the heads (the top and back) of badly nourished and unclean children. The " nits " on the hairs are the deposited eggs of the parasite. It usually causes an eczema or an im- petigo by its irritation, but in a healthy subject it may merely excite a pruritus; sometimes it produces a so- called " pruriginous " rash. The Pediculus Pubis (Fig. 33) generally inhabits the inguinal and pubic regions, and clings especially to the hairs close to the skin about the scrotum, mons veneris, and anus, appearing as darkish specks. It grasps the ACAEUS SCABIEI. 129 Fig. 3*. hair with its forelegs, and is not easily detached. It is found in adults", not in children, and not uncommonly results from impure connexion. The Pediculus Corporis or Vestimenti (Fig. 34) is of a whitish appearance, and may be £ line to even 2 lines in length. These pediculi do not bite, but are furnished with a proboscis, by which they extract blood, and thus pro- duce a characteristic bEBtnorrhagio speck on the skin. They are mostly found, with their whitish, shining ova, in the folds of linen next the skin. Some authors consider that the prurigo of old persons is due to pediculi, but this is denied by others. Phthiriasis corporis in the early stagesis found about the shoulders, neck, and clavicles, and in chronic cases upon the body as well, but the pediculi them- selves infest the clothes, and not the body. ACARITS SCABIEI (the Itch In- sect). — Tbis is the cause of the disease known as the itch. The disease (scabies) itself depends essentially upon the bur- rowing of the acarus scabiei. The female acarus is the more important of the two, Phthiriasis since she alone burrows, the male simply pons. wandering over the surface. The female gets beneath the skin, and establishes a cuniculus or fur- row, in which she lays her eggs. These furrows or cuni- culi may be detected in the skin. At the extremity of each furrow a minute whitish elevation may be observed, which is in reality a thin epidermal layer covering the acarus itself. By raising this layer with a penknife, the acarus and her ova may be obtained. Although papular, vesicular, and pustular scabies are described, yet the real scabies is only the acarus in its burrow. All else is secondary to the irritation occasioned by the parasite. The chief .seats of the disease are the thin skin between the fingers, the wrists, forearm, belly, thighs, and es pecially the upper line of the penis. When fully grown, the acarus has eight legs attached to a round body, and has a projecting head. The four front legs are furnished with suckers, the four hinder- most with hairs. The male acarus (Fig. 35) is smaller 1 Pediculus Corpo- ris or Vestimenti (female), found in cor- 130 PATHOLOGY AND MOKBID ANATOMY. than the female, which is about ¥ ^ to ^ inch long. The inner pair of posterior legs are furnished with suckers, and the genital organs are well marked. The young acari have six legs at first; they then cast their skin, and are provided with eight legs. The eggs are about J s line broad and J r line long. comedones, or Grubs. — These constitute the black specks observed on the 'face of adolescents and adults ; Fig. 3D. Acarus Scabiei (male). Comedones, containing a species of acarus (stca- tozoon, or acarus follicu- lorum). they are simply produced by the retention of sebaceous matter. When slight inflammation is excited, the affec- tion termed acne punctata is produced. The skin is greasy-looking and thiokish. The secretion is retained and inspissated. The dark speck or point is occasioned by the dirt collecting at the apex of each little grub. The sebaceous matter can be squeezed out of each follicle, and is supposed popularly to resemble a little maggot. The mass itself is composed of sebaceous matter, epi- thelial cells, numerous minute hairs, and one or more of a species of acarus, termed Steatozoon, or Acarus folliculorum (Fig. 36). VEGETABLE PARASITES. 1 3 1 VEGETABLE PARASITES. Bacteria, Bacilli, &c. For a long time the opinion has been held that there must be some special cause for acute specific diseases, since the poison from which each arises multiplies in a most remarkable manner, a single case possibly causing the death of millions when introduced into a community of persons. Whatever this poison, was, it was inappre- ciable to the senses, and was called the " contagion " of the disease! It would seem that the contagium must be some living organism, and this theory is termed the " contagium vivum " or Germ Theory. A close parallel may be drawn between an infective disease and a fermen- tation. The germ theory is the one more generally adopted an the present day. This view considers that the yeast plant (saccharomyces cerevisias) is the cause of the alco- holic fermentation. It must be provided with food, such as sugar, with nitrogen, and certain inorganic materials ; its life-action produces alcohol, carbonic, acid, glycerine, and succinic acid. The supposition is that the food-stuffs pass into the cells, by which is taken what is requisite for their own growth and repair, and which throw back the products of their action on to the fluid. In the same manner, then, as the bile-constituents are formed in an hepatic cell, so does a yeast cell form the foregoing sub- stances. The so-called Physical Theory holds that fermenta- tion consists in a " molecular motion" which is trans- mitted by albuminoid particles (ferment) themselves undergoing decomposition, i.e., the seat of " motor decay," to unstable organic compounds (fermentable substance). The conclusion is arrived at, however, that, although this last-named theory may be possible theoretically, evidence seems to demonstrate that the vital theory is true practically, and that all the processes which are generally recognised as fermentations and putrefaction, are due to the action of vegetable organisms. The vegetable organisms connected with diseases in man are fungi (belonging to the group of so-called achloro- phyllons thallophytes), and these pathological fungi are the following three kinds : — 132 PATHOLOGY AND MORBID ANATOMY. 1. Bacteria, or Sctaizomycetae, or Fission lunjrli 2. Blastomycetse, or Yeast fungi. 3. Hyphomycetse, or Mould fungi. The most important are the Bacteria, which include all the organisms by which the infective diseases are con- sidered to be produced. The Schizomycetes are all very small, and many approach the limits of microscopical visibility. They consist of a form of protoplasm called mycoprotein, and appear structureless, but they pro- bably possess a cell-membrane. In form they vary very much: The new cells produced by fission sometimes form chains, and sometimes lie side by side, being bonnd together by a viscid intercellular substance (zooglosa) formed of mycoprotein or of swollen cell-membrane. It has been estimated that in twenty-four hours a single bacterium may give rise to a progeny of over 16,000,000. Vegetable parasites are termed Entophytes, which are capable of living inside the body, and Epiphytes, which merely grow on the surface, just as, with animal parasites, entozoa are distinguished from ectozoa or epizoa. Like epizoa, epiphytes are frequently transplanted mechani- cally from one individual to another, and in the same manner as the tapeworm maybe said to be contagions, so also is the epiphytic disease, ringworm, contagious. Saprophytes (saprogenic, or septic species) is the name given to those vegetable parasites which live merely upon the food-substances or waste products of the body without producing any pathological changes. The Pathogenic spe- cies induce inflammation and necrotic changes at the loca- lity where they grow, as well as serious general diseases. It is clear that in some species the vitality is sustained by spores. The bacillus anthracis, after living in the blood and tissues of cattle in the form of long threads, produces spores which, after leaving the body, maintain their vitality in the soil or the grass until they arc able again to enter some animal body. As in the case of the liver flulce, the bacilli-spores of a sheep's carcase dead with anthrax infect the soil, the contagium being thus pre- served for the infection of other animals. SCHIZOMYCETES (Fission Fungi). The schizomycetes are most extensively diffused throughout nature ; no space, unless it is produced arti- ficially, is free from them ; they or their spores are con- SCHIZOMYCETES. 133 tamed in all natural waters. The conditions of growth requisite are moisture and some nitrogenous material serving as food. A certain range of temperature is also needful: although they may retain their vitality, they cannot grow under freezing-point ; all the species appear to be destroyed by a temperature of about 60° C. In some species the spores are not killed by heating them to the boiling-point, a temperature of 120° or 130° being necessary for their complete destruction. Certain species of bacteria live in dead organic matter, and are themselves the direct cause of putrefaction. In their absence the earth would be encumbered by dead carcases. The fertility of soils is directly attributable to other species, by which ammoniacal substances are con- verted into nitrates, and in this form absorbed by plants. During putrefaction certain substances termed ptomaines -(cadaveric alkaloids) are formed; these bear a strong resemblance to vegetable alkaloids, and are poison- ous. Bacteria by which putrefaction is jset up may be termed saprogenic or septic- The best-known form, the bacterium termo, probably covers many species. One group of bacteria flourish in organic fluids or solids, such as milk, butter, cheese, and bread, producing chemical changes, called fermentations — e.g., vinegar, produced from sugar by the action of bacterium aceti; lactic acid, from milk by bacterium lactis ; butyric acid, by bacillus butyricus ; ammonia, from urine by micro- coccus ureas. These bacteria are termed fermentative or zymogenic. Certain species of bacteria produce coloured substances (red, blue, green, or brown), and have been called curomogenic. Septic bacteria were at one time regarded as the cause of various diseases, but the majority cannot exist in healthy blood or tissues. They may nevertheless live in gangrenous or dead parts, and are liable to be harboured by pus or other morbid products. With regard to whether the living tissues and blood of healthy persons contain bacteria under ordinary cir- cumstances, the verdict of the large majority of experi- menters is to the contrary. The Scnizomycetes are classified as follows : — Forms of Bacteria. — Simple forma must be looked npon as single cells. United in various ways, compound forms are produced. 134 PATHOLOGY AND MORBID ANATOMY. The single-cell form is a micrococcus ; two-celled form, a diplococcus ; three or more cells, a streptococcus. When numerous cells (colonies) are found connected by an inter- cellular gelatinous substance, the zooglcea or living ]elly is produced. I. The Single-celled Forms are nnicellular, and mul- tiply by fission. They include — (a) Cocci or micrococci; (6) Kods of variable shape; (c) Spirals or corkscrew forms; and (d) Degenerative forms. In some bacteria, cilia or flagella are observed. II. Combinations of Single Cells. — No intervening substance. («) Growth in one direction only: producing rosary, thread, or spiral forms. (6) /Growth in various directions in a plane, a flat mass or lamina resulting, (c) Growth extending in all three dimensions, solid masses resulting : as sarcince. (d) Agglomerations or tierfectly irregular masses. III. Zoogloese, or Colonies.— Presence of intercellular gelatinous material, producing the form zooglcea. Eods or cocci may form a zooglcea. Some species may be ia turn a micrococcus, a bacillus, a leptothrix, and so on. Two modes of formation are observed in those varieties which produce spores — viz. : 1. Endogenous, in which the spore is formed within the cell-membrane from the protoplasm, as in bacillus anthrax. 2. External Spore Formation, in which the cell itself, or one segment of a chain, is converted into a joint-spore or arthrospore. It has been stated that in micrococci the spores are identical with vegetable cells. Bacteria by which endogenous spores are formed have been termed Endosporal Cocci, or simply Bacteria. Those by which arthrospores or no spores are formed receive the name of Arthrocoeci or Arthrobacteria. Iu the so-called Coccaceae two families are recognised according to the presence or absence of endogenous spores. Thus: A. Arttarococeaeese, in which, according to the dif- ferent modes of combination of the cells, genera are formed — viz. : 1. Streptocccc is, the cells forming chains. BACTEPJAOE^E. 1 35 2. Merhth, or Merismopedia,Vi\G cells forming plates. 3. Harcina, cells forming packets, or " bales." 4. Micrococcus, or Htaphyl ococcus, in irregular masses or clumps. 5. Ascococcus, the cocci being united in gelatinous pel- licles. B. Endosporal Coccaceee: chief genus Jjeuconostoc, Bactariaceos are divided into the following groups, according to the presence or absence of endogenous spores : — C. Spore-forming Bacteriacese, or Bacilli. — Bods of all ienjrths, but sometimes so short as to be indistinguish- able from micrococci. Genera are two — 1. Bacillus. — Rods not altering in shape during spore- formation, as in bacillus anthracis. 2. Clostridium. — Rods altering in shape during spore- formation, or always fusiform, (spindle-shaped), as in. Clostridium butyricum. D. Arthro bacteriacese. — Genera are 1. Bacterium, strictly so termed; includes straight rods, forming no spores. 2. Proteus (spirulina) shows cocci, chains, rods, and threads. In certain stages, motile. In the spiral bacteria are seen forms with and without spores. E. Spiro-bacterlacese. — Rods small and curved, re- sembling the fragments of a spiral, and known as "comma-bacilli." May unite and form corkscrew-like threads. Genera are — 1. Vibrio. — The rods enlarge, spores forming in the dilated part. 2. Spirillum. — Spores formed without alteration of shape of the rods in some non-pathogenic genera. F. leptotricheas. — Early stages, rods or cocci ; later stages, thread forms, spiral or straight. Differing from the threads formed by bacillus, &c, since the threads exhibit a distinction between the fore end and the base, at wh^ch they are attached. Genera are — 1. Crenotlirix. — Threads and rods distinctly articulated, and showing a sheath. 2. Leptothria — Threads articulated or non-articulated, without a sheath. One species occurs in the mouth, and is termed Irptothrix buccalis. G. Cladotrietaese. — In rods and sheathed threads, 136 PATHOLOGY AND MORBID ANATOMY. spiral or undulated. Genus is cladothrix ; very common in water. One variety has been dis6overed in the human lachrymal channels. Analytical Table op Bacteria. Arranged in chains Streptococcus (chain-cocci) „ „ fours or small) MeriBta ( p i a te-cocci) chains .... J „ eights or small 1 Sarcina (packet-cocci) chains ... .J „ . ( Micrococcus, ^ /„,___ Zoogtaa va- gt h '_ (mass ™ UB - -1 lococcus J cocc, > Ascococcns.fSf' ' Longer or shorter threads, without distinction of base or apex Threads, showing distinction 1 of base v V and apex °^ , j Zooglcea in' irregular masses .-\ 6p B herh , a i encapsu- lated masses ., /Threads straight or wavy; no endogenous | Arthro-bac- spores » tcrium Threads straight, wavy, or spiral; motile; ) Proteus (spi* no endogenous spores, ) rulina) Threads straight or \ without alteration of 1 ]j ac iii lia wavy; formation! shape of rods. . .[ of endogenous f rods becoming Bpindle- 1 Clostridium spores ... J shaped J Threads without a sheath Leptothrix not ramified 1 . . Crenothrix Threads with a sheath ramified . Cladothrix P ^+£ a * a ) Endogenous spores, with alteration of shape . Vibrio threads, I Endogenous spores or arthro-spores, or none, ) Rniri ii™ Amble or [ wit nout alteration of shane } Spirillum stiff ; This classification is one of forms only, and how far these forms represent actual species is uncertain. With reference merely to pathogenic bacteria, it would suffice to recognise four principal groups — viz.: J. Micrococci. 2. Bacilli. 3. Spirilla. 4. Bacteria. The term Aerobic has been applied to those bacteria which can only live, or grow where there is access of air ; Anaerobic to those where air is excluded — i.e., beneath the surface of the fluid or other nutritive medium. Artificial cultivation is employed to demonstrate certain characters derived from the mode of growth, since the forms of bacteria do not always afiord constant distin- guishing characters, and the form of numerous apparently different species is identical. Cultivation of Bacteria. — Nutrient gelatine is the CULTIVATION OF BACTERIA. 1 37 medium chiefly employed, the nutrient material being peptonised meat-juice mixed with sufficient gelatine to cause the mixture_(prepared with heat) to solidify on cool- ing; when solid, it again becomes liquid on heating to about 85° F. For use after liquefying, rt is poured into test-tubes, which are filled up to one-third and then closed at the top by a plug of cotton wool. The medium is now sterilised — i.e., heated in such a manner as to destroy any living bacteria or spores which may be pre- sent in it. This medium is transparent, thus rendering the commencing growth visible. Agar-agar, a vegetable jelly derived from certain species of algae, and imported from Japan, is employed for some purposes since it bears a higher temperature without liquefying than does nutrient gelatine. It is added to peptonised meat-juice, and the mixture prepared as in the case of the nutrient gelatine. Thus prepared, this jelly remains solid up to a temperature about 100° F. It is quite as transparent as gelatine. Coagulated blood serum is in other cases made use of. This is obtained from fresh blood, and, after being steril- ised carefully, is solidified at about 150° F., the test- tube being held obliquely, so as to obtain a sloping sur- face on. the coagulated mass. This is particularly useful for the cultivation of the tubercle-bacillus. The surface of a cut potato is very suitable for certain cultivations. The outside of the potato is sterilised ; it is then steamed and cut in half with a sterilised knife. Sterilisation. — This proceeding is absolutely necessary in order to prevent the entrance of organisms so abun- dant in the air and upon the solid objects employed. It is performed by heating to a temperature much above the boiling-point, 300° F. being the necessary minimum. The Method of Cultivation is the following : — Suppose a tube of nutrient gelatine is taken, a platinum wire is allowed to touch the material in which the micro- organism is contained, so as to bring away the smallest quantity possible; the tube is then inverted (to avoid the falling in of germs), the wire being made either to touch or being dipped beneath the surface of the gelatine, and then withdrawn. The tube may now be placed in the incubator— i.e., a hot chamber with a self-regulating gas- burner, by which a constant temperature is provided. After a time growth ensues, the gelatine becoming turbid, T38 PATHOLOGY AND MOEBID ANATOMY. or definite masses being formed. By the forms produced different species may be distinguished, regard being had as to whether the growth does or does not liquefy the gelatine, or whether bubbles of gas are evolved or not, and so on. The rapidity of the growth andthe tem- perature at which it takes place are other important features. Plate Cultivations. — The plate method is employed when there is a mixture of organisms. The original tube- cultivation is placed in a fresh-tube of gelatine, melted by heat ; from this tube a small portion may be introduced into a second tube similarl}' prepared. The contents of the two tubes are poured separately upon a glass plate, then carefully spread over it, and allowed to solidify. The plates are now. placed under a bell glass in a moist chamber. Organisms will be observed to spring as iso- lated cultivations at different parts of the plate. Another method of cultivation is to spread a single drop of gelatine on a glass slide, and allow it to solidify. The organism may then be sown in lines or streaks, and its development watched microscopically. For microscopical examination, cultivation in the so- called "hanging drop" is very useful. A glass slide with a hollow ground in it (forming a shallow cell) is required. Over the hollow is placed a cover glass, the under surface of which is moistened with a drop of nutrient liquid con- taining a minimal amount of the organism. The edges are rendered air tight by a little vaseline, a moist chamber being thus formed. Continued Cultivations. — A growth having been ob- tained which consists of one organism only — i.e., a " pure cultivation " — a minute portion can be transplanted on a fresh gelatine tube, and carried on through numerous generations. In this manner any extraneous matter is separated from the organism. The cultivation of the tubercle-bacillus has been carried through thirty-four ge- nerations in nearly two years, and even through a much longer series. The cultivated bacterium has been also introduced into the blood or tissues of a guinea-pig or a mouse. Inocu- lation may then be made from this animal into the body of another, and then through numerous generations. The identity of some specific diseases has been established by this method. BACTERIA. 139 two kinds of actions are set up when a pathogenic or- ganism is introduced into the body. The first are local, or changes in tissues, including destruction of elements and new growth; the second general — viz., fever and cachexia. _ The most perfect combination of local and general disturbance is seen in tubercle. The micro-organisms especially attack tissue-cells and migratory leucocytes. A notable increase in the size of elements is extremely characteristic of chronic bacterial inflammations. The spread of bacterial infection is said to be caused partially by the multiplication of the organ- isms; but considerable areas of change may be found which exhibit very few organisms. Many tubercles with- out bacilli may be observed in acute tuberculosis of man, other similar tubercles containing them. The majority of bacteria pass easily into the lymphatics, and from them into the lymph-glands. After passing these glands they may reach the blood by the thoracic duct, and in this manner be conveyed to all parts of the body. A special participation of the thoracic duct has been noticed in some cases of acute tuberculosis. Other forms of bacteria pass into the veins, a coagulum being formed, which is penetrated by the micro-organisms, and, the clot breaking down, these are carried into the circulation and produce pyaemia. During the circulation of bacteria in the blood they may become arrested at various points with the forma- tion of secondary deposits, thus establishing new foci of disease. A blockage is more likely to occur in the first set of capillaries passed through, as in an ordinary em- bolism. In many bacterial diseases the lungs are thns affected, as in pyaemia, glanders, and possibly in some instances of general tuberculosis. When the portal circulation is invaded by bacteria the liver will be the seat of the .earliest secondary foci of disease. The synovia of joints appear specially liable to attract wandering germs of disease. Micrococci in considerable numbers have been found in the joints in* the suppurative arthritis consequent upon scarlatina. Some of the organisms are eliminated from the system by the urine and faeces in diphtheria and pyaemia,and the micrococci of scarlatina have been traced in the kidneys, the pyaemic distinctly in the urine. Bacillus tuberculosis and bacillus anthrax have been observed in 140 PATHOLOGY AND MOEBID ANATOMY. the Malpighian tufts. It has clearly been demonstrated, however, that bacteria, whether saprophytic or patho- genic, after introduction into a healthy body, do not become eliminated by any secretion unless a diseased con- dition of the eliminating organ is present. As the symbol p (the Greek m), micromilletre, will be constantly used in succeeding pages, the following may be found useful : — The micromilletre, /x = xsoo °^ a millimetre. The metre is a unit of length, and is equivalent to a little more than 1 yard — viz., 3937 English inches. The metre may therefore, for the sake of convenience be considered as equal to 40 inches. Now, 1000 millimetres are equal to 1 metre; and since the metre = 40 inches, and — 1 — nf 40 = -48- = _*_ = -A- • d,uu - lOOO U1 * u lSffo 100 25' therefore, I millimetre = -fa inch. Again, \i = ygoo °f a millimetre, or,,} _j_ of- 1 - = i •■ aUKX. 10 00 u 25 23000' therefore, the micromilletre, p. = -^fao i n °k (roughly). Allowing for the '63 inches added above for the conve- nience of working, it may be stated that ii very nearly equals ^ TO iuch. PATHOGENIC BACILLI (HUMAN). Bacillus Anthracis. — This occurs in anthrax or splenic fever in the human subject, known as malignant pustule or wool-sorters' disease. The bacillus is of comparatively large size, andtherefore more easily seen than most bacilli. The rods present sharply truncated ends, and are from 3 to 20 n long and 1 to 1*2 n thick. When they have doubled their length they divide, but, if cultivated at 96° F. in nutrient fluids, they grow out into long, fre- bueutly convoluted threads, in which the individual elements can be sharply recognised. Spore-formation commences after a time, the spores being formed from the internal protoplasm of the rods. These bodies are oval, about 2 to 3 /* long and 1 /x thick. When exposed BACILLUS TUBERCULOSIS. 14I to a hot solution of fuchsine for twenty minutes or more they may be stained red, but they are not stained by aniline dyes with the ordinary processes. A temperature below boiling-point kills the bacillus. On exposure to moist heat at 212°, after fifteen minutes the spores are destoyed. Freezing arrests the growth, but does not de- stroy the vitality. Drying up kills the bacilli, but not the spores. The Bacillus Tuberculosis is one bacilli. It is a motionless rod, with rounded ends, 2 to 5 p in length — viz., one-third or one-half the diameter of a red blood-corpuBcle — and about one- sixth of its length in thickness. When stained with aniline dyes it exhibits at times a beaded structure, with coloured and uncoloured portions alternating. The ends are always- coloured. A spore- formation is thought to be present. The beaded bacilli are frequently observed in sputa and in caseous tubercular products. The rods in sputa are often somewhat curved fFigs. 37 and 38). Fio. 38. of the smallest Tig. 37. .'1F1.' • '- r fe Tubercle Bacilli- In phthisical spu- tum, x 300. Tubercle Bacilli in Alveolus of Human Lutig. From a speci- men of catarrhal pneumonia. The tubercle bacillus is cultivated with some diffi- 142 PATHOLOGY, AND MORBID ANATOMY. culty. When tubercular matter is implanted on solidi- fied sterilised blood serum in a shallow cell or tube, the temperature being maintained at 98'5° to 102°, it com- mences to grow Blowly, and in about ten or fifteen days small -whitish scales appear, which increase until a thin whitish layer is formed. Under the microscope this layer is seen to consist of bacilli masses disposed either in curved or spiral lines. Successive generations may be produced, and the organism kept alive even for years, unaltered in mode of growth or in form. It is unquestionable that the bacillus acts as a foreign body or irritant, with the addition of certain special pro- perties. After their introduction into the body, the bacilli multiply and extend through the surrounding tissues along the ordinary lymph spaces and channels. About the sixth day appear visible tubercles, -which at first are composed entirely of abundant epithelioid cells. About the tenth day after inoculation appear migratory leuco- cytes, forming the so-called lymphatic tubercle. The giant cells of phthisis in man seldom contain bacilli, although these are very numerous in the giant cells of some animals. In the caseous masses of human tuber- culosis, however, the bacilli are very abundant Tests for the Bacillus Tuberculosis. — The addition of liquor potassaa to the sputum dissolves other elements but does not affect the tubercle bacilli. These are distin- guished from all bacilli, with the exception of that of leprosy, by their action with the aniline colours, say, methyl-violet and f uchsine. If a section is stained of a deep red with fuehsine, and a mineral acid is added, the tubercle bacillus will remain red, although from every other part of the preparation the colour is discharged. If to the stained preparation a solution of methylene-blue be added, this colour will replace the fuehsine in all ele- ments except in the tubercle bacilli. At the present day it is believed that the bacillus tuberculosis is the cause of all tuberculous processes, and that its presence, at least in the early stages, must be the essential characteristic of tubercle. The latest investiga- tions tend to show that both in the lungs and in the sputum of every case of phthisis the tubercle bacillus is present, and therefore phthisis must be regarded as a more or less chronic pulmonary tuberculosis. Although it may be Btated that without doubt tubercular consolidation of BACILLUS LEPM. 143 the lung is the result of a-n inflammatory process, still cannot be that this process is not due to simple causes. The tendency to infect both adjacent and distant parts of the lung, and the progressive rjature of the inflammation, clearly point to the presence of some continuous irritant. Without speaking too dogmatically, this much may be stated — viz., that a special pathogenic organism con- sidered to be peculiar to phthisis finds its way to the lung mainly by inhalation, and at times by some other route. Some authorities consider such an organism as primary to the lesions of phthisis, aud in reality to be the cause of that disease. Others, however, maintain that it is an epiphyte for the generation of which the phthisical soil is especially favourable. The Bacillus leprae. — The bacillus of leprosy closely resembles that of tubercle, and is a slender rod 4 to 6 /x Fio. 39. Bacilli qf Glanders, a. Section of a nodule, x 700. b, Bacilli coloured with methylene-blue. x 1500. in length and less than 1 /* thick — i.e., about one-half or three-fourths the diameter of a red blood-corpuscle. In its reaction with colouring matters it agrees with the bacillus tuberculosis. It exhibits no movements. It occurs in a remarkable number of tissues, and it is stated that, in leprous skin, almost the larger half of the tissues consists of bacilli and their products. 144 PATHOLOGY AND MORBID ANATOMY. The Bacillus of Glanders, or Bacillus Mallei, is about the size of the tubercle bacillus, but is highly motile and thicker (Kg, 39). It forms spores. It has been found both in the human glanders and in that of the horse. When cultivated and inoculated into rabbits, guinea-pigs, horses, and mice it has produced a disease with nodules and ulcers resembling glanders. The proof is complete that the disease is caused by the bacillus, since it has been found in the diseased organs as well as in the blood and urine of these animals. This bacillus may be cultivated on gelatine, agar-agar, or blood serum at about 99° I\, but its growth is slow. The Bacillus of Typhoid Fever, or Bacillus Typho- sus (Kg. 40). — The bacilli typhosi have been found in Fig. 40. ■:< Mm W S/m, WW® wmw' Bacilli of lyphoid Fever. Section of spleen, x 800. Peyer's patches, the mesenteric glands, and spleen in typhoid fever. The bacillus itself is 2 to 3 p long, about "BACILLI OF TYPHOID FEVER, ETC. I45 one-third of its length in thickness, with rounded ends. It sometimes occurs in very short rods, and is capable of growing into pseudo-filaments. It probably possesses flagella, and is very motile. IJong action of the usual dyes is required, as it takes the stains with difficulty. Its -growth on potatoes is very characteristic. ITo visible growth is apparent after forty- eight tours, the surface having a moist and glistening aspect, but, on touching it with a platinum needle, it appears to be coated with a hard film, which, on ex- am inatio a, is found to be composed of long threads of the bacilli -containing spores. The best temperature is 90° to 104°, terminal spores being produced in three or four days within these limits. Gelatine is not liquefied by the growth. The following bacilli have sometimes been found — viz., the Bacillus CEdematis Maligni, in progressive gan- grene; Bacillus Diphtherlticus, in diphtheria; Bacillus Syphiliticus, in syphilis ; Bacillus Malarise, in ague. The Comma-Bacillus, or Spirillum Cnolerae Asia- tics, or Cholera Spirillum, has been discovered in the intestines of persons affected by Asiatic*- cholera. It appears in the shape of curved rods, one-half to two- thirds the length of the bacillus tuberculosis, varying from 08 to 2 p in thickness, about one-third to one- sixth of the length, and often united so as to make an S shape. Spirillum Finkleri has been found in the contents of the intestines in cases of "cholera nostras," or English cholera. Spirillum Obermeieri has been found in the blood in cases of relapsing fever. It appears as long, flexible, wavy threads, in spirals of from ten to twenty turns, mea- suring 16 to 40 inches in length, and exceedingly thin. It is important to note that, in order to prove a special organism to be the cause of any disease, certain conditions must be fulfilled, and these have been dis- tinctly laid down by Koch as follows : — - 1. The micro-organisms must be constantly found in the blood or tissues, or both, of the men (or animals) suffering from the disease. 2. The micro-organism must be made to grow on some medium external to the body, and by successive cultiva- te 146 PATHOLOGY AND MORBID ANATOMY. tions completely separated from all matter belonging to the body from which they came. 3. After being cultivated through several generations the organism must be inoculated into some animal, and in it reproduce the original disease. 4. In the blood or tissues of this animal the same micro-organism must be discovered which was found in the original patient. In all cases it is not possible that the foregoing condi- tions can be fulfilled, but analogy with other cases in which complete evidence can be obtained may render the pathogenic nature of such organisms in the highest degree probable. For some organisms frequently associated with certain diseases — as with bacillus leprae — no suitable cultivation medium has been found. BLASTOMYCET3! (Yeasts). These fungi consist of oval or roundish cells, and mul- tiply by simple budding. They possess no mycelium proper, nor, as a rule, do they produce spores. The most important species is the Saccharomyoes, or Torula Cerevlsise (the common beer-yeast), this being the chief agent in the alcoholic fermentation. It is composed of oval cells, the diameter of which measures 8 to 9 ft, and which occur either singly or in short chains. To the ferment of wine, frequently observed in ripe fermenting fruits, the name Saccharomyoes Ellipsoideus is applied. The cells of this are somewhat smaller than those of the sac- charomyces cerevisiaa; they occur either singly or in short chains, and measure about 6 p. Saccharomyoes Mycoderma forms the scum on fermenting beers ; it is known as the vinegar plant, and does not ferment sugar. Its cells measure 6 to 7 ft long by 2 to 3 ft broad, and form long branched chains. It presents a great similarity to the principal parasitic yeasts of the human body. The Saccbaromyces Albicans, the thrush parasite, constitutes the white patches in the mouths of children, especially those who have been fed on milk. At one time this was known by the name of O'idium Albicans, and considered to be a mould fungus allied to O'idium Lactis. The thrush parasite is composed of oval or spherical PAKASITIC YEASTS UPON THE SKIN. 1 47 cells, sometimes united in long chains, and at other times growing into threads or cylindrical cells ten or twenty times as long as they are thick. The diameter of the small cells may he 3'5 to 5 p. The growth of this fungus takes place upon the mucous membrane of the mouth, aud occasionally upon that of other portions of the alimentary canal, such as the ileum. It has been stated to have been known to- find its way into the circulation and lead to cerebral embolism. Any fermentative action the saccharomyces albicans may possess is exerted, not upon the tissues, but upon the contents of the digestive tract. The parasitic YEASTS occurring as epiphytes upon the skin are the following : — Saccharomyces Capillitii. — This is usually found amongst the scurf of the scalp (particularly when this is in abundance) and in the condition known as Seborvhma Sicca, or Pityriasis (dandrijf). Little oval cells are formed by this yeast fungus which are said to correspond exactly in form and size with the saccharomyces ellipsoideus from fermenting fruits. It must be admitted that the yeasts exert very little, it any, pathogenic effects. The Ray-Fungus, or Actinomyces. — This parasitic plant produces the disease called actinomycosis. It grows in roundish masses, the size of which varies from grains just visible to those as large as a hemp-seed, having a granular surface and a yellow colour. Microscopically, these masses appear composed of nu- merous radiating threads with club-shaped diameters some- what resembling a rosette. Sometimes narrow threads, like hyphse, are seen, either growing peripherally out of the mass, or forming coils in the central parts. These threads have been thought to be the mycelium of a mould fungus, but they are, in all probability, a form of cladothrix or leptothrix, belonging to the schizomycetes. ,The disease called Actinomycosis was first seen in cattle, and gives rise to hard tumours, which at one time were described as sarcoma, osteo-sarcoma, lymphoma, &c. The hardened masses consist of embedded nodules, which, when not softened (as they sometimes become), exhibit the structure of typical tubercle, containing epithelioid cells, leucocytes, giant cells, and fibroid tissue. The centre of irritation is the ray-fungus, and in the presence. 148 PATHOLOGY AND MORBID ANATOMY. of this alone consists the distinction between these nodules and tubercles. Actinomycosis is a rare disease in man, and in him the tendency is towards suppuration, large abscesses being formed in the liver, pus burrowing in other parts, as around the jaws, in the walls of the thorax, in the medi- astinum, or in front of the vertebraa. Mycetoma, or Madura Foot of India, " the fungus foot of India." — Here the fungus grows in the tissues of the human body. The parasite, called Cliionyphe Carteri, is usuallyconsidered to cause this disease, but some authors regard it as merely a saprophytic parasite flourishing in the necrotic tissues. The disease itself consists in a mor- bid state of the feet and hands, which are enlarged and distorted in consequence of thickening of the skin, caries of the bones being present, and sinuses forming. From the sinuses either yellowish concretions of the size of a millet-seed or dark-brown concretions like gunpowder grains are discharged. In the latter, but not in the former, are found bodies, consisting of a fungous growth, which forms a regular mycelium,. in company with black masses which have been compared to the truffle fungus. HYPOMYCETJE (Moulds). The "moulds " are fungi, and consist of mycelium and organs of fructification. The mycelium consists of fila- ments or threads, termed hyplicB, which are usually divided into septa, and are frequently branched. The organs of fructification are composed of cells called conidia, or spores, which are sometimes produced bysimple "abstriction " (cutting off) of certain parts of the hyphae. In some cases the hyphas are upright and grow into the air, being then termed conidiophores. In the parasitic and pathogenic species of the human body, the conidia are directly formed from the hyphse of the mycelium. Amongst the commoner moulds which may occur in certain pathological conditions, and are also found in external nature, are the following : — The Won-Pathogrenlc, or Saprophytic, which in- clude — Aspergillus Glaucus. — A greyish-blue mould, grow- ing on rotten wood and decaying fruit. PATHOGENIC FUNGI. 149 ^Aspergillus Niger — Sometimes found in the human ear. A similar species of aspergillus has been observed in a wound of the cornea of the eye. Aspergillus Fumig-atus has been observed in tuber- cular, gangrenous, or bronchiectatic cavities : it is, how- ever, merely saprophytic, not producing any disease. Penicillium Glaucum- — A common blue mould, grow ing on all decaying animal matter in dark and moist localities. ifflucor Mucedo. — A white mould, foand chiefly on horse-dung. pathogenic FUNGI occurring on the human .skin. — These are the following : — Trichophyton Tonsurans ; Acborion Schoenleinii.; Microsporon Furfur; Microsporon Audouini (?). Trichophyton tonsurans. — This fungus causes the Fig. 41. Trichophyton Tonsurans: showing an exaggerated form of tinea in a patch of epithelium from the arm of a man who groomed a pony affected with tinea circinata. affection known as ringworm of the scalp (tinea ton- surans), of the skin (tinea circinata), of the beard (tinea sycosis, or tinea barbae). The mycelium is composed of 150 PATHOLOGY AND MORBID ANATOMY. ramified hyphse. Upon staining with methylene-blue the central portion takes the colour more deeply than the sheath. At first the growth consists of mycelium only, but eventually the ends of, the hyphas break up into spherical cells, which after separation by abstriction con- stitute the conidia or spores. These spores are round or oval, about -js'oo of an inch in diameter, being some- times united in the form of chains, but for the most part isolated (Figs. 41, 42). This fungus has been cultivated, and after inoculation into the human skin produces Fig. 42. Trichophyton Tonsurans, from a case of Burmese ring- worm (tinea cireinata). upon it the characteristic rings of herpes circinatus or tinea circinata. The mycelium makes its way between the scales of epidermis, either causing their desquama- tion or elevating them in the form of vesicles. A ring is formed by the outward growth from a centre. A vesicular and sometimes a pustular growth results, according to the amount of inflammation. On the scalp, as soon as the mycelium reaches the hairs, it grows down inside the root-sheath, penetrating the hair-shaft, rendering it ACHORION SCHOENLEINII. 1*1 brittle and causing it to break off, thus producing the scaly patches with broken stumps. Achorion Schoenleinii. — This fungus is the cause of the disease known as " favu3." The mycelium is composed of hyphae, forming extremely dense masses of yellowish colour and exhaling a peculiar mouse-like odour. On the scale it occasions cup-shaped structufes surrounding the Fia. 43. o m AchoHon Schoenleinii, from a case of tinea favosa (com- monly called favus). hairs. This favus growth consists of a mass of mycelium and conidia entangled with granular and fatty matters. This fungus may be said to consist of spores, filaments, sporophores or fibres, aud a stroma made up of numerous small free cells. The spores are round or oval, s^sxs inch in diameter, have a slight constriction in their centre, and are mixed with a number of branched tubes, some filled with granular matter and some empty, and which vary from -j^j to -g^^ inch in diameter. Although it has been stated that in the trichophyton the number of the tubes is" smaller and the number of the spores greater than in the achorion, the great distinction between tri- chophyton and achorion is the production by the latter cf conspicuous masses (Fig. 43). The cultivated fungus, after inoculation, has produced characteristic cases of favus. {The mycelium penetrates between the scales of epidermis and occasions a ring of vesicles, but in consequence of the fungus penetrating into the hair-sheath the formation of yellow crusts and 152 PATHOLOGY AND MORBID ANATOMY. cups is superadded. The hair-shafts also break off. The growth of this fungus into the skin is far more deep than that of the trichophyton. Microsporon Furfur. — This is the fungus of tinea versicolor, chloasma, or pityriasis. It presents marked differences to the foregoing fungi. Ramified hyphse com- pose the mycelium ; the hyphaa do not, however, break up into conidia, but produce a group of round spore-like bodies by a process of budding (Fig. 44). The epidermic scales are penetrated by the mycelium, but not deeply, the epidermis assuming a peculiar fawn Fig. 44. Microsporon Fwrfiir, from a case of tinea versicolor (chlo- asma or pityriasis versicolor). colour, and desquamating slowly. The fungus selects the covered parts of the skin; particularly the abdomen, chest, and shoulders, forming the discoloured patches known as pityriasis versicolor. Microsporon Audouini. — This fungus is believed by some authorities to be the cause of tinea decalvans or MICEOSPOEON AtJDOUINI. 1 53 porrigo decalvans, and to lead to the condition some- times described as alopecia areata or localised baldness. Tinea decalvans presents oval or round patches of bald- ness, the hair being entirely removed or replaced by fine downy hairs. The skin is quite white, and there is little or no irritation.' The skin is at first somewhat reddened and wrinkled. The affection is generally confined to the scalp, but may be seen in the eyebrows, genitals, or beard. Microscopically, in some instances, collections of minute spores are seen. The hair may exhibit bulgingshere Fhj. 45. JUicrosporon Mtdouini, from a case of tinea decalvans (alopecia areata) and there due to the presence of abnormal granular matter, which is in part pigmentary, and in part the minute stromal form of the fungus. The spores are from ttsoo *° so^oo of an inCh ; the filaments being few, wavy, and desti- tute of granules. The ordinary appearance of the micro- scoporon audouini is shown in Fig. 45. Sometimes the fungus is found in the epithelium at the extending edge of the disease ; but it is believed that it frequently lodges behind in the empty follicles, attacks the epithelial struc- tures contained therein, and interferes with the proper re-formation of the hair. 1 54 PATHOLOGY AND MORBID ANATOMY. It must, however, be stated that some authorities dis- pute the existence of the parasitic fungus, and attribute the affection to a diseased condition of the nervous system. METHODS rOK RECOGNISING BACTERIA. For the proper study of bacteria, a microscope of a power of at least 600 diameters i3 requisite, and the thin nest cover-glasses that can be obtained must be employed. The bacteria exhibit a remarkable affinity for colour- ing matters, and especially for the aniline dyes. The following colours are the most important, viz. : — Fuchsine or Magenta (hydrochlorate of rosaniline) ; Methyl-violet, or a variety termed Gentian-violet; Methylene- blue ; and Eosine (a red colour, not made from aniline). The last is employed for staining parts other than bacteria, so as to produce a contrast of colour; for this purpose Bismarck-brown is also sometimes employed.' Eosine is best dissolved in water. The other colours are conveniently kept in saturated alcoholic solutions. For use they should always be much diluted. Of all the above colouring agents, methylene-blue is perhaps the most generally applicable ; moulds as well as bacteria are coloured by it. Methyl-violet is a strong purple dye, and acts with greater energy when diluted with aniline water. Fucbsine is a red dye, of which a carbolic acid solu- tion is sometimes used. This solution keeps better than the aniline solution ; the carbolic acid exercises the same action in increasing the colouring power of the dye as afforded by aniline. The colours above mentioned are chiefly employed for staining bacteria, but in order to exhibit the cells or tissues, these may be stained by some contrast colour. If the bacteria are coloured blue, eosine (red) or solution of carmine or picro-carmine may be used as a contrast stain ; if they are red, then metnylene-blue may be em- ployed. INDEX: Abscess of the brain, 23 earns. folliculorum, 130 scabiei, 129 Aohorion Schoenleinii, 151 Acinous cancer, 79 Actinomyces, 147 Actinomycosis, 147 Actions set up by bacteria, 139 Active congestion of tho liver, 13 Acute antcrior-poHo-myelitifl, 25 Adonic, 66 Adenoid cancer, 83 'tissue, 65 Adenomata, 75 Agar-agar, 137 Albumen in urine, 112 Albuminoid degeneration, 39 Alopecia areata, 153 Alveolar cancer, 81 Amyloid bodies, 48 degeneration, 89 Ansemia, local, 90 lympbatica, 66 Analytical table of bacteria, 136 Angiomata, 73 Animal parasites, the, 121 Arcus senilis, 45 ABcaris lumbrlcoldes, 125 mystax, 126 verinicularis, 125 Ascococcus, 135 Aspergillus fumigatus, 149 glaucus, 148 niger, 149 Atheroma, 12 Atheromatous abscess, 13 ulcer. 13 Atrophy, 98 general, 99 numerical, 98 of bone, 102 of glandular organs, 99 of heart, 100 of livor (simple, red, yellow), 101 of musclo, 100 of muscular nbro, 99 of nerves, 99 of walls of air-vesicles, 101 partial, 99 simple, 98 Baciixt, 131 Bacillus anthracis (of malignant pustule), i40 butyricus (butyrio acid), 133 diphtheriticus (of diphthe- ria), 145 lepra? (of leprosy), 143 malaria; (of ague), 145 mallei (of glanders), 144 ccdomatis malign! (of pro gre'sslve gangrene), 145 syphiliticus (of syphilis), 145 t uberculosls tof tuberclo), 141 tests for, 142 typhosus (of typhoid fever), 144 Baoteria, 131 Bacterium acetl, 18S lac t is, 138 *5<5 INJJl'X Bactorium tcrmo, 133 JRtMif ifLjKsw orm, IIjc, 122 Bi-basio phonphato, 110 ililu in urine, J]2 Bilhar/Ja hsp.mntoliia, 124 Hillary dri'Iio-JR, 15 WHigcM Ion of tlio liver, 13 Bismarck-brown, 154 BlaRlomycelao, 1 1G Blond in urine, 111 Ilothriocophalua latus, 122 Brain wand, 44 601(011111?, 23 red, iuflji minatory, of, 23 white, yellow, non-in- flammatory, of, 23 Broad tapeworm, the, 122 Bronchiectasis, S Broncho-pncuuionia, 8 Brown atrophy of the heart, 100 induration of the limy, 56 Bulbar paralysi&, 28 Oalcarkoub degeneration, 61 Calcification, 33 of arteries, 5 3 Calculi (urinary), 116 Cancers, , the, 77 Carcinomnta, the, 77 - contrasted with the sarco- mata, 84 Caries of hone, 103 Catarrhal inflammation, 6 pneumonia, 8 Cayenne - pepper grain deposit in the urine, 109 Ccrcaria-sac, 124 Cerebri tis, 23 Cerehro -spinal sclerosis, 27 Ccstoda, 121 Chionypho Car tori, 148 Chloasma, 152 Cholera spirillum, the, 145 Cliondromata, G2 Cirrhosis of the liver, 14 Cirrhotic kidney, the, 17 pneumonia, 7 Clostridium, 135 Coagulation-necrosis, 6 Colitis, 21 acute, 21 Colitis, chronic, 22 Colloid cancer, 81 * degeneration, ^57 Comedones, 130 Comma-bacillus, the, 135, 145 Common round worm, the, 125 Concentric globe* In epithelioma, 82 Condylomata, 74 Congestion, 88 of the brain, 22 oftho liver, 13 of the lung, 6 of the stomach, 19 Corpuscles of Glug'e, 46 l Crenothrix, 135 Croupous inflammation, 5 pneumonia, 6 Crude yellow tubercle, 33 Cylindrical epithelioma, 83 Cysticorcus tami» cellulosa, 122 taenia? mcdiocanellatte, 122 Cystic oxide, 110 tumours, 86 Cystine, 110 calculus, 117 Cysts, 85 DANDRIFF, 147 De-alkalisod fibrino, 39 Degenerations, the, 38 Dcrmatozoa, the, 128 Diabetes insipidus, 113 inollitus, 114 Diphtheritic inflammation, 5 Diplococcus, a, 134 Disseminated sclerosis, 27 Distoma crassum, 124 hepaticum, 124 beterophyes, 124 lanccolatum, 124 ophthalmobium, 124 Distropodcxtrino, 39 Dranunculus, the, 127 Duchcune's paralysis, 48 Dj'Beutcry, 21 acute, 21 chronic, 22 Kctozoa, the, 128 Embolism. 30 INDEX. 157 Empyema, 8 Encephalitis, 23 Encephaloid cancer, 80 Endocardial ulcer, 11 Endocarditis, 10 acute, 10 chronic, 11 papillary, 10 ulcerative, 11 Entozoa, the, 121 Eosiue, 154 Epithelial cancer, 79 nests in epithelioma, 82 Epithelio-counective tumours^ 74 Epithelioma, 82 Epulis, 71 Exostoses, 63 Exudation corpuscles, 46 False calculi, 119 pigmentatiou, 54 Easciola hepatic®, the, 124 Fatty degeneration, 44 of art-cries, 46 disease of the heart, 48 infiltration, 44 of the liver, 4ff of muscle, 47 kidney, the, 50 Favus, 151 Fibroid pneumonia, 7 Fibromata, the, 50 Fibre- nucleated tumours, fiS Fibro-plastic tumours, 68 Filaria lontis, the, 127 medinensis, the, 127 sanguinis hotninis, 127 Fission fungi, the. 132 Vhikes, the, 123 Fuchsine, 154 Fungus hamiatodcs, 81 Gangrena senilis, 51 f^rtatiuiforra cancer, 81 Gentian- violet, 154 Giant cells in tubercle, 33 Glandular hypertrophy, 75 tumours 75 Glioma, 70 Glosso-labinl-laryngeal paralysis, 28 Gluge, corpuscles of, 46 Granular kidney, the, 17 Granulations, 4 Grey degeneration of the brain 25 inflammatory, 25 non-inflammatory, 26 granulation tubercle, 32 miliary tubercle, 32 Grubs, 130 Guinea-worm, the, 127 Gummata, 04 HEMATURIA, 111 Hacmorrha&ic apoplexy. 31 " Hanging arop," the, 138 Hardening of the brahi, 24 Heart, fatty disease of, 48 fatty infiltration of, 48 inflammatory processes in the, 9 Hepatitis, acuto, 14 chronic interstitial (cirrho- sis), 14 Hodgkiu's disease, OR Horny growths. 74 Hydatid, an, 123 Hydraemia, 91 llydroculorate of. rosaniline 154 Hydropericardium, 10 Hyperemia, SS Hyperplasia (numerical hyper- trophy), 07 Hypertrophic biliary cirrhosis 15 Hypertrophy, 97 numerical, 97 simple, 97 spurious, 9 7 Hypha?, 14S Hypomyeeta?, 148 Induration of the brain, 24 Infantile paralysis. 24 Infective inflammation, 4 Inflammation, 1 Inflammatory effusion, 2 grey degeneration of the hraiu and spinal cord. 25 158 INDEX. Inflammatory processes in the brain and spinal cord, 22 in the heart, 9 in the liver, 13 in the lungs, 5 in the stomach, 10 softening' of the brain, 23 Insular sclerosis, 27 Interstitial hepatitis, 14 inflammation, 4 (intertubular) nephritis, 17 pneumonia, 7 Intestinal lymphatic structures, '20 inflammation and ulceration of, 20, 21 Ischsmia, 90 Itch insect, the, 129 Lardaceous degeneration, 38 disease of lymphatic glands* 43 of the alimentary canal, 43 kidney, 42 liver, 40 spleen, 43 Large white kidney, the, 17 Lateral sclerosis, 27 Leptomeningitis, 24 Loptothrix, 135 buccal is, 135 Leucine, 111 Leucocythemia, 91 lymphatic, 91 splenic, 91 Leucocytes is, 93 Leukaemia, 91 Li pom at a, the, 61 Lithatos in the urine, 108 Lithic acid in the urine, 109 Liver, congestion of the (active, passive, biliary), 13 nutmeg, 14, 56, 89, 101 Lobar pneumonia, 6 Lobular pneumonia, 8 Local anaemia (ischsemia), 90 Long thread-worm, the, 126 Lymphadenoma, 66 Lymphsemia, 91 Lymphangiomata, the, 67 Lymphoid cells,'34 Lymphomata, the,G4 indurated, 65 soft, 65 Madura foot of India, 148 Magenta, 154 Makrocheilia, 67 Microglossia, 67 Maw-worm, the, 125* Medullary cancer, 80 Melanotic cancers, the, 71 Merisniopcdia, 135 Merista, 135 Methods for recognising bacteria, 154 for tlio cultivation of bac- teria, 136 Methylene -blue, 164 Methyl- violet, 154 Micrococcus, 134 ureae, 133 Micromillctro, the ft, 140. Microsporon Audouini, 152 furfur, 152 Mollitics ossium, 104 Morbid urinary constituents, 111 deposits, 108 Moulds, the, 148 Mucin, 56 Mucoid, degeneration, 66 Mucor mucedo, 149 Mucous polypus, 76 Mucus in the urine. 111 Mulberry calcnlus, 109 Multiple sclerosis, 27 Slurexidc, 109 •Muscular paralysis, pseudo-hy- pertrophic, 48 tumours, the, 72 Mycelium, 148 Mycetoma, 148 Mycoproteiu, 132 Myeloid tumours, the, 68 Jlyocarditis, 11 Myoma t a, the, 72 Myxomata, the, 60 Necrobiosis, 98 Necrosis of bone, 102 INDEX. 159 'Xemntoda, tho, 124 ' Neutral phosphate of calcium cal- culus, 119 Non-inflammatory gray degene- ration, 26 Numerical hypertrophy, 97 Nutmeg liver, the, 14, 5C, 89, 101 Obesity, 62 , Obsolete tubercle, 83 Oidium albicans, 146 Oidium lactis, 146 Osteomalacia, 104 Ostcomalacial pelvis, the, 105 Ostcomata, the, 63 Osteophytes, 64 Oxalate of calcium, 109 calculus, 118 Oxyuris vermicularis, tho, 12S Papillary endocarditis, 10 Papillomata, tlie, 74 Parasitic yeasts ou the skin, the, 147 Parasites, tho animal, 121 the vogctablo, 131 Pathogenic bacilli (human), 140 fungi ou human skin, 149 parasites, 132 Pathology of the urine, the. 106 Podiculi, 128 Pcdiculus capitis, 128 corporis, 129 pubis, 12 8 vestimenti, 129 Penieillium glaucum, 149 Pericarditis, 9 Peritonitis, 22 Phlegmonous inflammation, 3 Phlogosis, 1 Phosphates in the urine, 110 Pigmentary degeneration, 53 Pigmentation of the liver, 96 of tho lungs, 55 Pityriasis, 147 versicolor, 152 Pleuritis, 8 Pneumonitis, 6 Tork tapeworm, the, - 122 I'orrigo decalvans, 153 Productive inflammation, 4 Proscolex, 121 Proteus, 135 Psammoma, 72 Psendo-hypertrophic muscular paralysis, 48 Ptomaines, 133 " Pure" cultivation, a, 138 Pus, 3 in the urine, 111 Pyasmia, 87 Pyelitis, 18 acute, 18 chronic, 18 Pyopericardium, 10 Rachitis, 105 Kamollissemcut of the brain, 23 Karefyiug osteitis, 103 Kay-fungus, tho, 147 Ked atrophy of tho liver, 101 softening of tho brain, 23 Rickets, 105 Rickctty pelvis, the, 106 Eonnd worms, the, 124 Saociiaromtcbs albicans. 146 capillitii, 147 serevisias, 131, 146 cllipsoideus,*146 mycoderma, 146 Sanguineous apoplexy, 31 Saprogenic bacteria, 138 Sapi'ophytes, 132 Saprophytic moulds, the, 148 Sarcomata, the, 68 contrasted with the carclno- mata, 84 Schizomycetes, the, 132 Scirrhus, 79 Sclerosis, 26 cerebro-spinal, 27 disseminated, 27 Itfsular, 27 lateral, 27 multiple, 27 Sclerostoma duodenale, 127 Seolcx, 121 Scrofulous inflammation, 2H Seborrhoea sicca, 147 i6o INDEX. Septic bacteria, 133 infection, 87 intoxication, 87 Septicaemia, 87 Simple atrophy of the liver, 101 hypertrophy, 97 Softening of the brain, 23 Specific inflammation. 4 Spinal meningitis, 24 paralyEis, 24 Spirillum, 135 cholcrx asiatieffi 145 Finkleri, 145 Obermetcri, 145 Spirulina, 135 Staphylococcus, 13», Star-shaped phosphate, 110 Stoatozoon folliculorum, 130 Streptococcus, 134 Strongylus bronchialis, 128 gigas, 128 Sugar in the urine, 113 Suppuration, 3 Syphilis, 04 Syphiloma, 95 T.XXIA echinococcus, 122 mediocanellata, 122 Baginata, 122 solium, 122 Tapeworms, tbo, 121 Toratomata, the, 85 Thorn cio cancer, 66 Thread-worm, the, 126 Thrombosis, 30 Thrush parasite, the, 146 Tinea dccalvans, 152 versicolor, 152 Torula cerovisiae, 146 Trcmatoda, the, 123 Trichina spiralis, 126 Trichbccphalus dispar, 126 Trichophyton tonsurans, 149 Triple phosphate, the, 110 Trismus nascentium, 25 Tubercle bacillus, the, 141 Tutor nil nr meningitis, 38 peritonitis, 37 ulceration of tbo intestines, 36 Tuberculosis, 32 of tho brain and its mem- branes, 37 . Tumours, classification of the, 58 Typhoid ulcer, 21 Ulceration of the stomach, 19 chronic gastric ulcers, 20 perforating ulcers, 20 sloughing ujccrs,20 superficial erosions, 19 Ulcerative endocarditis, 11 Ursemia, 93 Urates, 108 Uric acid, 109 calculus, 117 Urinary calculi and concretion 116 tube casts, 120 blood or exudative, 120 cellular or epithelial, 120 granular, 120 oily caste, 120 purulent, 120 waxy, transparent hya- line, 120 Urine, pathology of the, 106 Uterine polypus, 72 Vermes, the, 121 Vibrio, 135 White softening of the brain, 23 of the cord, 24 Womb-stone, 72 Yeast plant, the, 131 Yeasts, the, 146 Yellow atrophy of the liver, 101 softening of the brain, 2 3 tubercle, 33 Zymogenic bacteria, 133 ' Zooglcea, 134 PUBLISHED BY W. B. SAUNDERS, 925 Walnut Street, Philadelphia, Pa. PAGE •American Text-Book of Applied Thera- peutics 8 •American Text-Book of Diseases of Chil- dren 3 ♦American Text-Book of Gynecology . . 4 •American Text-Book of Nursing . . 8 •American Text-Book of Obstetrics , 8 •American Text-Book of Physiology . . 8 •American Text-Book of Practice . 2 •American Text-Book of Surgery . . 1 Ashton's Obstetrics .23 Ball's Bacteriology 27 Bastin's Laboratory Exercises in Botany . 18 Beck's Surgical Asepsis 12 Brockway's Physics 27 Burr's Nervous Diseases 12 Cerna's Notes on the Newer Remedies . .18 Chapman's Medical Jurisprudence and Toxicology 14 Cohen and Eshner's Diagnosis 26 Cragin's Gynaecology 24 DaCosta's Manual of Surgery 13 *De Schweinitz's Diseases of the Eye 5 Dorkind's Obstetrics 13 Frothingham's Guide to Bacteriological Laboratory 14 Garrigues' Diseases of Women ... .10 Gleason's Diseases of the Ear 28 Griffin's Materia Medica and Therapeutics 12 •Gross's Autobiography 7 Hare's Physiology 22 Hampton's Nursing : its Principles and Practice 15 Hyde's Syphilis and Venereal Diseases . . 12 Jackson and Gleason's Diseases of the Eye, Nose, and Throat 25 Jewett's Outlines of Obstetrics 18 •Keating's Pronouncing Dictionary of Medicine 7 Keating's How to Examine for Life In- surance . .20 Mr. Saunders, in presenting to the profession the following list of his publications, begs to state that the aim has been to make them worthy of the confidence of medical book-buyers by the high standard of authorship and by the excellence of typography , paper , printing, and binding. The works indicated thus (*) are sold by subscription {not by booksellers), usually through travelling solicitors, but they can be obtained direct from the office of publication (charges of shipment prepaid) by remitting the quoted prices. Full descriptive cirulars of such works will be sent to any address upon application. All the other books advertised in this catalogue are commonly for sale by booksellers in all parts of the United States ; but any book will be sent by the publisher to any address (post-paid) on receipt of the price herein given. {For Announcement of Forthcoming Publications see next page.) PAGE Keen's Operation Blanks 16 Kyle's Diseases of Nose and Throat . . . *2 Laine's Temperature Charts .... 9 Lockwood's Practice of Medicine . 12 Long's Syllabus of Gynecology 9 Martin's Surgery 22 Martin's Minor Surgery, Bandaging, and Venereal Diseases 25 Morris' Materia Medica and Therapeutics 23 Morris' Practice of Medicine 24 Morton's Nurses* Dictionary 9 Nancrede's Anatomy and Manual of Dis- section . . 16 Nancrede's Anatomy 22 Norris* Syllabus of Obstetrical Lectures . 17 Powell's Diseases of Children 26 Raymond's Physiology 13 Saunders' Pocket Medical Formulary . 19 Saunders' Pocket Medical Lexicon .... 19 Saunders' New Aid Series of Manuals . n, 12 Saunders' Series of Question Compends . 21 Sayre's Practice of Pharmacy 26 Semple's Pathology and Morbid Anatomy 23 Semple's Legal Medicine, Toxicology, and Hygiene 25 Senn's Syllabus of Lectures on Surgery . . 17 Shaw's Nervous Diseases and Insanity . . 27 Stelwagon's Diseases of the Skin .... 24 Stevens' Materia Medica and Therapeu- tics 20 Stevens' Practice of Medicine 17 Stewart and Lawrance's Medical Elec- tricity 28 Thornton's Dose-Book and Manual 1 of Pre- scription-Writing 14 •Vierordt and Stuart's Medical Diagno- sis . . 6 Warren's Surgical Pathology . .10 Wilson's Orthopaedic Surgery . . .15 Wolffs Chemistry 23 Wolff's Examination of Urine 26 Hnnouncement of jfortbcoming publications. AN AMERICAN TEXT-BOOK OF OBSTETRICS. By Amer- ican Teachers. (See page 8.) AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. By Amer- ican Teachers. (See page 8.) AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- TICS. By American Teachers. AN AMERICAN TEXT-BOOK OF NURSING. By American Teachers. SURGICAL PATHOLOGY AND THERAPEUTICS. By J. Col- lins Warren, M. D., Professor of Surgery, Harvard Medical School, etc. (See page 10.) A SYLLABUS OF GYNECOLOGY, arranged in conformity with The American Text-Book of Gynecology. By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Vir- ginia, etc. (See page 9.) TEMPERATURE CHART. Prepared by D. T. Laine, M. D. (See page 9.) LABORATORY EXERCISES IN BOTANY. By Edson S. Bas- tin, M. A., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. (See page 18.) A GUIDE TO THE BACTERIOLOGICAL LABORATORY. By Langdon Frothingham, M. D (.See page 14.) SAUNDERS* NEW AID SERIES OF MANUALS. New volumes in active preparation. See pages 11, 12. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- liam W. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. Forming one handsome royal-octavo volume of over 1200 pages (10x7 inches), with nearly 500 wood-cuts in text, and 37 colored and half-tone plates, many of them engraved from original photographs and drawings furnished by the authors. Prices: Cloth, #7.00 net; Sheep, $8.00 net; Half Russia, $9.00 net. The want of a text-book which could be used by the practitioner and at the same time be recommended to the medical student has been deeply felt, espe- cially by teachers of surgery; hence, when it was suggested to a num6er of these that it would be well to unite in preparing a text-book of this description, great unanimity of opinion was found to exist, and the gentlemen below named gladly consented to join in its production. 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CONTAINS : Hygiene. — Fevers (Ephemeral, Simple Con- tinued, Typhus, Typhoid, Epidemic Cerebro- spinal Meningitis, and Relapsing). — Scarla- tina, Measles, Rotheln, Variola, Varioloid, Vaccinia, Varicella, Mumps, Whooping-cough, Anthrax, Hydrophobia, Trichinosis, Actino- mycosis, Glanders, and Tetanus. — Tubercu- losis, Scrofula, Syphilis, Diphtheria, Erysipe- las, Malaria, Cholera, and Yellow Fever. — Nervous, 1 Muscular, and Mental Diseases etc. VOLUME II. CONTAINS: Urine (Chemistry and Microscopy). — Kid- ney and Lungs. — Air-passages (Larynx and Bronchi) and Pleura. — Pharynx, CEsophagus, Stomach and Intestines (including Intestinal Parasites), Heart, Aorta, Arteries and Veins. — Peritoneum, Liver,and Pancreas. — Diathet- ic Diseases (Rheumatism, Rheumatoid Ar- thritis, Gout, Lithsmia, and Diabetes.) — Blood and Spleen. — Inflammation, Embolism, Thrombosis, Fever, and Bacteriology. 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" Pre-eminently a book for those wishing a clear yet comprehensive and full knowledge of the fundamental truths which underlie and govern the practice of ophthalmology." — Med- ical and Surgical Reporter. "At once comprehensive and thoroughly up to date." — Hospital Gazette (London). PROFESSIONAL OPINIONS. "A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." William Pepper, M. D., Provost and Professor of Theory and Practice of Medicine and Clinical Medicine in the University of Pennsylvania. "Contains in concise and reliable form the accepted views of Ophthalmic Science." William Thomson, M. D., Professor of Ophthalmology, yefferson Medical College, Philadelphia, Pa. " Contains in the most attractive and easily understood form just the sort of knowledge which is necessary to the intelligent practice of general medicine and surgery." J. William White, M. D., Professor of Clinical Surgery in the University of Pennsylvania. "A very reliable guide to the study of eye diseases, presenting the latest facts and newest ideas." Swan M. Burnett, M. D. ( Professor of Ophthalmology and Otology, Medical Department Univ. of Georgetown, Washington, D. C, W. S. SAUNDERS' For Sale by Subscription. MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of Medicine at the University of Heidelberg. Translated, with additions, from the Second Enlarged German Edition, with the author's permission, by Francis H. Stuart, A. M., M. D. Third and Revised Edition. In one handsome royal-octavo volume of 700 pages, 178 fine wood-cuts in text, many of which are in colors. Prices : Cloth, #4.00 net ; Sheep, $5.00 net; Half Russia, $5.50 net. In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the bedside. It is distinctly a clin- ical work by a master teacher, characterized by thoroughness, fulness, and accu- racy. It is a mine of information upon the points that are so often passed over without explanation. Especial attention has been given to the germ-theory as a factor in the origin of disease. This valuable work is now published in German, English, Russian, and Italian. The issue of a third American edition within two years indicates the favor with which it has been received by the profession. " Rarely is a book published with which a reviewer can find so little fault as with the volume before us. All the chapters are full, and leave little to be desired by the reader. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned; nothing seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. Notwithstanding a few minor errors in translating, which are of small importance to the accuracy of the rest of the volume, the reviewer would repeat that the book is one of the best — probably the best — which has fallen into his hands. An excel- lent and comprehensive index of nearly one hundred pages closes the volume." — University Medical Magazine, Philadelphia. "Thorough and exact The author has rendered no mean service to medicine in having prepared a work which proves as useful to the teacher as to the student and prac- titioner." — The Lancet (London). PROFESSIONAL OPINIONS. " One of the most valuable and useful works in medical literature." Alexander J. C. Skene, M. D., Dean of the Long Island College Hospital, and Professor of the Medical and Surgical Diseases of Women. " Indispensable to both ' students and practitioners.' " F. Minot, M. D., Hersey Professor of Theory and Practice of Medicine, Harvard University. " It is very well arranged and very complete, and contains valuable features not usually found in the ordinary books." J. H. Musser, M. D., Assistant Professor Clinical Medicine , University of Pennsylvania. " One of the most valuable works now before the profession, both for study and reference." N. S. Davis, M. D., Professor of Principles and Practice of Medicine and Clinical Medicine, Chicago Medical College. CATALOGUE OF MEDICAL WORKS. # For Sale by Subscription. A NEW PRONOUNCING DICTIONARY OF MEDICINE, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M. 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" I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it to my classes." Henkv M. Lyman, M. D., Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." C. A. Lindsley, M. D., Professor of Theory and Practice of Medicine, Medical Dept. Yale University ; Secretary Connecticut State Board of Health, New Haven, Conn, " I will point out to my classes the many good features of this book as compared with others, which will, I am sure, make it very popular with students." JpHN Cronyn, M. D., LL.D., Professor of Principles and Practice of Medicine and Clinical Medicine; President of the Faculty, Medical Dept. Niagara University, Buffalo, N. Y. AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- fessor of Surgery in the Jefferson Medical College of Philadelphia, with Reminiscences of His Times and Contemporaries. Edited by his sons, Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price, $5.00 net. This autobiography, which was continued by the late eminent surgeon until within three months of his death, contains a full and accurate history of his early struggles, trials, and subsequent successes, told in a singularly interesting and charming manner, and embraces short and graphic pen-portraits of many of the most distinguished men — surgeons, physicians, divines, lawyers, states- men, scientists, etc. — with whom he was brought in contact in America and in Europe ; the whole forming a retrospect of more than three-quarters of a century. W. B. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK OF OBSTETRICS. By American Teachers. By Richard C. Norris, A. M., M. D.; James H. Etheridge, M. D. ; Chauncey D. Palmer, M. D. ; Howard A. Kelly, M. D. ; Charles Jewett, M. D.; Henry J. Garrigues, M. D. ; Barton Cooke Hirst, M. D. ; Theophilus Parvin, M. D. ; George A. Piersol, M. D. ; Edward P. Davis, M. D. ; Charles Warrington Earle, M. D. ; Robert L. Dickinson, M. D. ; Edward Reynolds, M. D. ; Henry Schwarz, M. D. ; and James C. Cam- eron, M. D. In one very handsome imperial-octavo volume, with a large number of original illustrations, including full-page plates, and uniform with "The American Text-Book of Gynecology." (In active preparation.) Such an array of well-known teachers is a sufficient guarantee of the high character of the work, and it gives the assurance that this work will have the same measure of success awarded it as has attended the recent publication of its companion volume, " The American Text-Book of Gynecology." The illus- trations will receive the most minute attention ; the cuts interspersed throughout the text, and the full-page plates, which will reflect the highest attainments of the artist and engraver, will appeal at once to the eye as well as to the mind of the student and practitioner. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. By American Teachers. Edited by William H. Howell, Ph. D., M. D., Professor of Physiology, Johns Hopkins University. With the collaboration of such eminent specialists as Henry P. Bowditcb, M. D. ; John G. Curtis, M. D. ; Henry H. Donaldson, M. D. ; Frederick S. Lee, M. D. ; Warren P. Lom- bard, A. B., M. D. ; Graham Lusk, Ph. D. ; Henry Sewall, M. D. ; Edward T. Reichert, M. D. ; Joseph W. Warren, M. D. In one imperial-octavo volume (with a large number of original illustrations), uniform with The American Text- Books of " Surgery," " Practice," " Gynecology," etc. (In preparation for early publication.) This will be the most notable attempt yet made in this country to combine in one volume the entire subject of Human Physiology by well-known teachers who have given especial study to that part of the subject upon which they will write. The completed work will represent the present status of the science of Physiology, and in particular from the standpoint of the student of medicine and the medical practitioner. Illustrations largely drawn from original sources will be used freely throughout the text. AN AMERICAN TEXT-BOOK OF APPLIED THERAPEUTICS. By American Teachers. (In preparation.) AN AMERICAN TEXT-BOOK OF NURSING. By American Teachers. (In preparation.) CATALOGUE OF MEDICAL WORKS. 9 A SYLLABUS OF GYNAECOLOGY, arranged in conformity with The American Text-Book of Gynecology. By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Vir- ginia, etc. (Preparing.) Based upon the teaching and methods laid down in the larger work, this will not only be useful as a supplementary volume, but to those who do not already possess the text-book it will also have an independent value as an aid to the practitioner in gynecological work, and to the student as a guide in the lecture- room, as the subject is presented in a manner at once systematic, clear, succinct, and practical. TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 8x 13^ inches. Price, per pad of 25 charts, 50 cents. A conveniently arranged chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. THE NURSE'S DICTIONARY of Medical Terms and Nursing Treatment, containing Definitions of the Principal Medical and Nursing Terms, Abbreviations, and Physiological Names, and Descriptions of the Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. Compiled for the use of nurses. By Honnor Morten, author of " How to Become a Nurse," " Sketches of Hospital Life," etc. Second and enlarged edi- tion. i6mo, 140 pages. Price, Cloth, jSl.oo. This little volume is intended for use merely as a small reference-book which can be consulted at the bedside or in the ward. It gives sufficient explanation to the nurse to enable her to comprehend a case until she has leisure to look up larger and fuller works on the subject. " Should be at the disposal of every nurse." — Birmingham Medical Review. " Maintains its reputation for brevity and simplicity." — Hahnemannian Monthly. "Though ostensibly for professional nurses, contains in a compact form just such infor- mation as almost every intelligent man would like to have at hand in these days when the interest in all matters of sanitation and medicine has become so great." — Medical Examiner. " A book which every progressive nurse must have." — Medical World. " This little volume is almost indispensable in the training school and in the library of the nurse." — New York Medical Times. 10 W. B. SAUNDERS' SURGICAL PATHOLOGY AND THERAPEUTICS. By J. Col- lins Warren, M. D., Professor of Surgery, Harvard Medical School, etc. In one very handsome octavo volume of over 800 pages, with 135 illus- trations, 33 of which are chromo-lithographs, and all of which are drawn from original specimens. (Passing through the press.) Covering as it does the entire field of Surgical Pathology and Surgical Thera- peutics by an acknowledged authority, the publisher is confident that the work will rank as a standard authority on the subject of which it treats. Particular attention has been paid to Bacteriology and Surgical Bacteria from the stand- point of recent investigations, and the chromo-lithographic plates in their fidelity to nature and in scientific accuracy have hitherto been unapproached. DISEASES OF WOMEN. By Henry J. Garrigues, A.M., M.D., Professor of Obstetrics in the New York Post-Graduate Medical School and Hospital; Gynecologist to St. Mark's Hospital and to the German Dispensary, etc., New York City. In one very handsome octavo volume of about 700 pages, illustrated by numerous wood-cuts and colored plates. Prices: Cloth, $4.00 net ; Sheep, $5-00 net. A PRACTICAL work on gynecology for the use of students and practitioners, written in a terse and concise manner. The importance of a thorough know- ledge of the anatomy of the female pelvic organs has been fully recognized by the author, and considerable space has been devoted to the subject. The chap- ters on Operations and on Treatment are thoroughly modern, and are based upon the large hospital and private practice of the author. The text is eluci- dated by a large number of illustrations and colored plates, many of them being original, and forming a complete atlas for studying embryology and the anatomy of the female genitalia, besides exemplifying, whenever needed, morbid condi- tions, instruments, apparatus, and operations. EXCERPT OF CONTENTS. Development of the Female Genitals.— Anatomy of the Female Pelvic Organs.— Phys- iology.— Puberty.— Menstruation and Ovulation.— Copulation.— Fecundation.— The Climac- teric—Etiology in General.— Examinations in General.— Treatment in General — Abnormal Menstruation and Metrorrhagia. — Leucorrhea. — Diseases of the Vulva. — Diseases of the Perineum.— Diseases of the Vagina.— Diseases of the Uterus. — Diseases of the Fallopian Tubes. — Diseases of the Ovaries. — Diseases of the Pelvis. — Sterility. The reception accorded to this work has been most flattering. In the short period which has elapsed since its issue it has been adopted and recommended as a text-book by more than 60 of the Medical Schools and Universities of the United States and Canada. "One of the best text-books for students and practitioners which has been published in the English language; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners, to whom experienced consultants may not be available, will find in this book invaluable counsel and help." Tkad. A. Reamy, M. D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio; Gynecologist to the Good Samaritan and Cincinnati Hospitals. Practical, Exhaustive, Authoritative, SAUNDERS' NEW AID SERIES OF MANUALS FOR Students and Practitioners. Mr. Saunders is pleased to announce as in active preparation his NEW AID SERIES OF MANUALS for Students and Practitioners. As publisher of the Standard Series of Question Compends, and through in- timate relations with leading members of the medical profession, Mr. Saunders has been enabled to study progressively the essential desiderata in practical " self-helps " for students and physicians. This study has manifested that, while the published " Question Compends " earn the highest appreciation of students, whom they serve in reviewing their studies preparatory to examination, there is special need of thoroughly reliable handbooks on the leading branches of Medicine and Surgery, each subject being compactly and authoritatively written, and exhaustive in detail, without the introduction of cases and foreign subject-matter which so largely expand ordinary text-books. The Saunders Aid Series will not merely be condensations from present literature, but will be ably written by well-known authors and practitioners, most of them being teachers in representative American Colleges. This new series, therefore, will form an admirable collection of advanced lectures, which will be invaluable aids to students in reading and in comprehending the contents of " recommended " works. Each Manual will further be distinguished by the beauty of the new type ; by the quality of the paper and printing ; by the copious use of illustrations ; by the attractive binding in cloth ; and by the extremely low price, which will uniformly be $1.25 per volume. SAUNDERS' NEW AID SERIES OF MANUALS. VOLUMES NOW EEADY. PHYSIOLOGY. By Joseph Howard Raymond, A. M., M. D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital, etc. Price, $1.25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M. D„ Demonstrator of Surgery, Jefferson Medical College, Philadelphia, etc. Double number. Price, $2.50 net. DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. Price, $1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- son Medical College of Philadelphia, etc Price, $1.25 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the German Poliklinik ; Instructor in Surgery, New York Post-Graduate Medical School, etc. Price, $1.25 net. VOLUMES IN PEEPAEATION FOE EAELY PUBLICATION, OBSTETRICS. By W. A. Newman Dorland, M. D., Demonstrator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispen- sary, Pennsylvania Hospital ; Member of Philadelphia Obstetrical Society, etc. Price, #1.25 net. MATERIA MEDICA AND THERAPEUTICS. By Henry A. Griffin, A. B., M. D., Assistant Physician to the Roosevelt Hospital, Out-palient Department, New York City. Price, $1-25 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M. D., Professor of Skin and Venereal Diseases in Rush Medical College, Chicago. Double number. Price, $2.50 net. NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Pro- fessor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. Price, $1.25 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., Professor of Practice in the Woman's Medical College and in the New York Infirmary, etc. Double number. Price, $2.50 net. NOSE AND THROAT. By D. Braden Kyle, M. D., Chief Laryngol- ogist to St. Agnes' Hospital, Philadelphia ; Instructor in Clinical Micros- copy and Assistant Demonstrator of Pathology in the Jefferson Medical College, etc. Price, #1.25 net. *** There will be published in the same series, at close intervals, carefully-pre- pared works on the subjects of Anatomy, Gynecology, Pathology, Hygiene, etc. by prominent specialists. 12 CATALOGUE OF MEDICAL WORKS. 1 3 Saunders' New Aid Series of Manuals. A MANUAL OF PHYSIOLOGY. By Joseph H. Raymond, A. M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; Director of Physiology in the Hoag- land Laboratory; formerly Lecturer on Physiology and Hygiene in the Brooklyn Normal School for Physical Education; Ex- Vice-President of the American Public Health Association; Ex-Health Commissioner City of Brooklyn, etc. Illustrated. Price, Cloth, $1.25 net. (Just ready.) In this manual the author has endeavored to put into a concrete and avail- able form the results of twenty years' experience as a teacher of Physiology to medical students, and has produced a work for the student and practitioner, representing in a concise form the existing state of Physiology and its methods of investigation, based upon Comparative and Pathological Anatomy, Clinical Medicine, Physics, and Chemistry, as well as upon experimental research. A MANUAL OF SURGERY, General and Operative. By John Chalmers DaCosta, M. D., Demonstrator of Surgery, Jefferson Medical College, Philadelphia; Chief Assistant Surgeon, Jefferson Medical College Hospital ; Surgical Registrar, Philadelphia Hospital, etc. One very hand- some volume of over 700 pages, with a large number of illustrations. (Double number.) Price, Cloth, $2.50 net. A new manual of the Principles and Practice of Surgery, intended to meet the demands of students and working practitioners for a medium-sized work which will embody all the newer methods of procedure detailed in the larger text-books. The work has been written in a concise, practical manner, and especial attention has been given to the most recent methods of treatment. Illustrations are freely used to elucidate the text. A MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M. D., Demonstrator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispensary, Pennsylvania Hospital; Member of Phila- delphia Obstetrical Society, etc. Profusely illustrated. Price, Cloth, JS1.25 net. (Preparing.) This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for the student and of value to the practitioner as a convenient handbook of reference. Although concisely writ- ten, nothing of importance is omitted that will give a clear and succinct know- ledge of the subject as it stands to-day. Illustrations are freely used throughout the text. 14 W. B. SAUNDERS' Saunders' New Aid Series of Manuals. DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. Illustrated. Price, Cloth, #1.25 net. But little attention is generally given, in works on Materia Medica and Thera- peutics, to the methods of combining remedies in the form of prescriptions, and this manual has been written especially for students in the hope that it may serve to give a thorough and comprehensive knowledge of the subject. The work, which is based upon the last (1 890) edition of the Pharmacopeia, fully covers the subjects of Weights and Measures, Prescriptions (form of writing, general directions to pharmacist, grammatical construction, etc.), Dosage, Incompatibles, Poisons, etc. MEDICAL JURISPRUDENCE AND TOXICOLOGY. By Henry C. Chapman, M. D., Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia ; Member of the College of Physicians of Philadelphia, of the Academy of Natural Sciences of Philadelphia, of the American Philosophical Society, and of the Zoological Society of Philadelphia. 232 pages, with 36 illustrations, some of which are in colors. Price, $1.25 net. For many years there has been a demand from members of the medical and legal professions for a medium-sized work on this most important branch of medicine. The necessarily proscribed limits of the work permit the considera- tion only of those parts of this extensive subject which the experience of the author as coroner's physician of the city of Philadelphia for a period of six years leads him to regard as the most material for practical purposes. Particular attention is drawn to the illustrations, many being produced in colors, thus conveying to the layman a far clearer idea of the more intricate cases. " The salient points are clearly defined, and ascertained facts are laid down with a clear- ness that is unequivocal." — St. Louis Medical and Surgical Journal. "The presentation is always thorough, the text is liberally interspersed with illustrations, and the style of the author is at once pleasing and interesting." — Therapeutic Gazette. " One that is not overloaded with an unnecessary detail of a large amount of literature on the subject, requiring hours of research for the essential points in the decision of a question ; that contains the most lucid symptomatology of questionable conditions, tests of poisons, and the readiest means of making them — such is the new book before us." — The Sanitarian. A GUIDE TO THE BACTERIOLOGICAL LABORATORY. By Langdon Frothingham, M. D. Illustrated. (In preparation.) The technical methods involved in bacteria-culture, methods of staining, and microscopical study are fully described and arranged as simply and concisely as possible. The book is especially intended for use in laboratory work. CATALOGUE OF MEDICAL WORKS. 1 5 NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams Hampton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital ; Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one very handsome i2mo volume of 484 pages, profusely illustrated. Price, Cloth, $2.00 net. This entirely new work on the important subject of nursing is at once com- prehensive and systematic. It is written in a clear, accurate, and readable style, suitable alike to the student and the lay reader. Such a work has long been a desideratum with those intrusted with the management of hospitals and the instruction of nurses in training schools. It is also of especial value to the graduated nurse who desires to acquire a practical working knowledge of the care of the sick and the hygiene of the sick-room. The author, who has had considerable experience as superintendent of training schools for nurses and hospital management, brings to her task a mind thoroughly equipped to make the subject attractive as well as scientific and instructive. Thoroughly attested and approved processes in practical nursing only have been given, particularly in antiseptic surgery, and the minutest details regard- ing the nurse's technique have been explained. Illustrations to elucidate the text have been used freely throughout the book, and they will be found of material help in showing the forms of modern appli- ances for the hospital ward and sick-room, the registration of temperature, daily records, etc. METHODS OF PREVENTING AND CORRECTING DEFORM- ITIES OF THE BONES AND JOINTS : A Handbook of Prac- tical Orthopedic Surgery. By H. Augustus Wilson, M. D , Professor of General and Orthopedic Surgery, Philadelphia Polyclinic ; Clinical Pro- fessor of Orthopedic Surgery, Jefferson Medical College, Philadelphia, etc. (In preparation.) The aim of the author is to provide a book of moderate size, containing comprehensive details that will enable general practitioners to understand thor- oughly the mechanical features of the many forms of congenital and acquired deformities of the bones and joints. The mechanical functions that are impaired will be considered first as to pre- vention as of primary importance, and following this will be described the methods of correction that have been proved practical by the author. Ope- rative procedures will be considered from a mechanical as well as a surgical standpoint. Prominence will be given to the mechanical requirements for braces and artificial limbs, etc., with description of the methods for construct- ing the simplest forms, whether made of plaster of Paris, felt, leather, paper, steel, or other materials, together with the methods of readjustment to suit the changes occurring during the progress of the case. A very large number of original illustrations will be used. 1 6 W. B. SAUNDERS' AN OPERATION BLANK, with Lists of Instruments, etc. re- quired in Various Operations. Prepared by W. W. Keen, M. D., LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 50 cents net. A convenient blank, suitable for all operations, giving complete instructions regarding necessary preparation of patient, etc., with a full list of dressings and medicines to be employed. At the back of pad is a list of instruments used — viz. general instruments, etc., required for all operations; and special instruments for surgery of the brain and spine, mouth and throat, abdomen, rectum, male and female genito- urinary organs, the bones, etc. The whole forming a neat pad, arranged for hanging on the wall of a sur- geon's office or in the hospital operating-room. " Will serve a useful purpose for the surgeon in reminding him of the details of prepa- ration for the patient and the room as well as for the instruments, dressings, and antiseptics needed." — New York Medical Record " Covers about all that can be needed in any operation." — American Lancet. " The plan is a capital one."— Boston Medical and Surgical yournal. ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- CAL DISSECTION, containing " Hints on Dissection." By Charles B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy ; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with handsome full-page lithographic plates in colors, and over 200 illustrations. Price : Extra Cloth or Oilcloth for the dissection-room, $2.00 net. Neither pains nor expense has been spared to make this work the most ex- haustive yet concise Student's Manual of Anatomy and Dissection ever pub- lished, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been specially drawn and engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole being based on the eleventh edition of Gray's Anatomy, and forming a handsome post 8vo volume of over 500 pages. " The plates are of more than ordinary excellence, and are of especial value to students in their wort in the dissecting-room." — Journal of American Medical Association. " Should be in the hands of every medical student." — Cleveland Medical Gazette. " A concise and judicious work." — Buffalo Medical and Surgical Journal. CATALOGUE OF MEDICAL WORKS. 1 7 A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Penn- sylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations, and includes the following sections : General Diseases, Diseases of the Digestive Organs, Diseases of the Respiratory System, Diseases of the Circulatory System, Diseases of the Nervous Sys- tem, Diseases of the Blood, Diseases of the Kidneys, and Diseases of the Skin. Each section is prefaced by a chapter on General Symptomatology. Third edition. Post 8vo, 502 pages. Numerous illustrations and selected formulae. Price, #2.50. Contributions to the science of medicine have poured in so rapidly during the last quarter of a century that it is well-nigh impossible for the student, with the limited time at his disposal, to master elaborate treatises or to cull from them that knowledge which is absolutely essential. From an extended experience in teaching, the author has been enabled, by classification, to group allied symp- toms, and by the judicious elimination of theories and redundant explanations to bring within a comparatively small compass a complete outline of the prac- tice of medicine. A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- GERY, arranged in conformity with The American Text-Book of Surgery. By Nicholas Senn, M. D., Ph. D., Professor of Surgery in Rush Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. This, the latest work of its eminent author, himself one of the contributors to the "American Text- Book of Surgery," will prove of exceptional value to the advanced student who has adopted that work as his text-book. It is not only the syllabus of an unrivalled course of surgical practice, but it is also an epitome or supplement to the larger work. SYLLABUS OF OBSTETRICAL LECTURES in the Medical Department, University of Pennsylvania. By Richard C. Norris, A. M., M. D., Demonstrator of Obstetrics in the University of Pennsyl- vania. Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, interleaved for notes, $2.00 net. " This work is so far superior to others on the same subject that we take pleasure in call- ing attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner. The author has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- tions given. No details are regarded as unimportant; no minor matters omitted. We ven- ture to say that even the old practitioner will find useful hints in this direction which he can- not afford to despise." — New York Medical Record. 1 8 W. B. SAUNDERS' OUTLINES OF OBSTETRICS : A Syllabus of Lectures Deliv- ered at Long Island College Hospital. By Charles Jewett, A. M., M. D., Professor of Obstetrics and Pediatrics in the College, and Obstetri- cian to the Hospital. Edited by Harold F. Jewett, M. D. Post 8vo, 264 pages. Price, $2.00. * This book treats only of the general facts and principles of obstetrics : these are stated in concise terms and in a systematic and natural order of sequence, theoretical discussion being as far as possible avoided; the subject is thus presented in a form most easily grasped and remembered by the student. Special attention has been devoted to practical questions of diagnosis and treatment, and in general particular prominence is given to facts which the stu- dent most needs to know. The condensed form of statement and the orderly arrangement of topics adapt it to the wants of the busy practitioner as a means of refreshing his knowledge of the subject and as a handy manual for daily reference. NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- plications and Modes of Administration. By David Cerna, M. D., Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania. Post-octavo, 175 pages. Price, $1.25. The work takes up in alphabetical order all the newer remedies, giving their physical properties, solubility, therapeutic applications, administration, and chemical formula. It thus forms a very valuable addition to the various works on therapeutics now in existence. Chemists are so multiplying compounds, that, if each compound is to be thor- oughly studied, investigations must be carried far enough to determine the prac- tical importance of the new agents. " Especially valuable because of its completeness, its accuracy, its systematic consider- ation of the properties and therapy of many remedies of which doctors generally know but little, expressed in a brief yet terse manner." — Chicago Clinical Review. "A timely and needful book .... which physicians who avail themselves of the use of the newer remedies cannot afford to do without.*' — The Sanitarian. LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, M. A., Professor of Materia Medica and Botany in the Philadelphia Col- lege of Pharmacy. With over 75 plates. (In preparation.) This work is intended for the beginner and the advanced student, and it fully covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross and microscopical structure of plants, and to those used in medicine. Illustra- tions have freely been used to elucidate the text, and a complete index to facil- itate reference has been added. The folding charts which supplement the subjects will be found useful in connection with the study of the text. CATALOGUE OF MEDICAL WORKS. 1 9 SAUNDERS' POCKET MEDICAL LEXICON ; or, Dictionary of Terms and Words used in Medicine and Surgery. By John M. Keating, M. D., editor of " Cyclopaedia of Diseases of Children," etc. ; author of the " New Pronouncing Dictionary of Medicine; and Henry Hamilton, author of "A New Translation of Virgil's ^Eneid into Eng- lish Verse ;" co-author of a " New Pronouncing Dictionary of Medicine." A new and revised edition. 32mo, 282 pages. Prices: Cloth, 75 cents; Leather Tucks, $1.00. This new and comprehensive work of reference is the outcome of a demand for a more modern handbook of its class than those at present on the market, which, dating as they do from 1855 to 1884, are of but trifling use to the student by their not containing the hundreds of new words now used in current litera- ture, especially those relating to Electricity and Bacteriology. " Remarkably accurate in terminology, accentuation, and definition."— -Journal of Amer- ican Medical Association. " Brief, yet complete .... it contains the very latest nomenclature in even the newest departments of medicine." — New York Medical Record. SAUNDERS' POCKET MEDICAL FORMULARY. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City. Containing 1750 Formulae, selected from several hundred of the best-known authorities. Forming a handsome and con- venient pocket companion of nearly 300 printed pages, with blank leaves for Additions; with an Appendix containing Posological Table, Formulae and Doses for Hypodermatic Medication, Poisons and their Antidotes, Diameters of the Pemale Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Third edition, revised and greatly enlarged. Handsomely bound in morocco, with side index, wallet, and flap. Price, JS1.75 net. A concise, clear, and correct record of the many hundreds of famous formulae which are found scattered through the works of the most eminent physicians and surgeons of the world. The work is helpful to the student and practitioner alike, as through it they become acquainted with numerous formulae which are not found in text-books, but have been collected from among the rising genera- tion of the profession, college professors, and hospital physicians and surgeons. " This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and as the name of the author of each prescription is given is unusually reliable." — New York Medical Record. " Designed to be of immense help to the general practitioner in the exercise of his daily calling." — Boston Medical and Surgical yournal. 20 W. B. SAUNDERS' HOW TO EXAMINE FOR LIFE INSURANCE. By John M. Keating, M. D., Fellow of the College of Physicians and Surgeons of Philadelphia; Vice-President of the American Pediatric Society; Ex- President of the Association of Life Insurance Medical Directors. Royal 8vo, 211 pages, with two large phototype illustrations, and a plate pre- pared by Dr. McClellan from special dissections ; also, numerous cuts to elucidate the text. Second edition. Price, in Cloth, $2.00 net. Part I., which has been carefully prepared from the best works on Physical Diagnosis, is a short and succinct account of the methods used to make examinations ; a description of the normal condition and of the earliest evidences of disease. Part II. contains the Instructions of twenty-four Life Insurance Companies to their medical examiners. " This is by far the most useful book which has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. As the proofs of these instructions were corrected by the directors of the companies, they form the latest instructions obtainable. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science." — The Medical Nevus, Philadelphia. MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. 435 pages. Price, Cloth, $2.25. This wholly new volume, which is based on the 1890 edition of the Pharma- copceia, comprehends the following sections : Physiological Action of Drugs ; Drugs ; Remedial Measures other than Drugs ; Applied Therapeutics ; Incom- patibility in Prescriptions ; Table of Doses ; Index of Drugs ; and Index of Diseases ; the treatment being elucidated by more than two hundred formulae. "The author is to be congratulated upon having presented the medical student with as accurate a manual of therapeutics as it is possible to prepare." — Therapeutic Gazette. " Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable and accurate." — New York Medical Journal. " The author has faithfully presented modern therapeutics in a comprehensive work, . . . and it will be found a reliable guide." — University Medical Magazine. " Will be of immense service to the busy practitioner." — Medical Reporter (Calcutta). " Reliable and timely/'— North American Practitioner. " Concise, up to date, and withal comprehensive." — Pacific Medical Journal. SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form. THE LATEST, CHEAPEST, and BEST ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature Students and Practitioners in every City of the United States and Canada. THE REASON WHY. They are the advance guard of " Student's Helps " — that DO HELP; they are the leaders in their special line, well and authoritatively written by able men, ■who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- come Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty- four subjects, has been kept thoroughly revised and enlarged when necessaiy, many of them being in their fourth and fifth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- ket, none of them approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence : 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Size of type and quality of paper and binding. *** Any of these Compends will be mailed on reoeipt of price. 21 22 W. B. SAUNDERS' I. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M. D., Pro- fessor of Therapeutics and Materia Medica in the Jefferson Medical Col- lege of Philadelphia ; Physician to St. Agnes' Hospital and to the Medical Dispensary of the Children's Hospital ; Laureate of the Royal Academy of Medicine in Belgium, of the Medical Society of London, etc. Third edition, revised and enlarged by the addition of a series of handsome plate illustrations taken from the celebrated " Icones Nervorum Capitis " of Arnold. Crown 8vo, 230 pages, numerous illustrations. Price, Cloth, $1.00 net; interleaved for notes, $1.25 net. "An exceedingly useful little compend. The author has done his work thoroughly and well. The plates of the cranial nerves from Arnold are superb." — Journal of American Medical Association. 2. ESSENTIALS OF SURGERY, containing also Venereal Diseases, Surgical Landmarks, Minor and Operative Surgery, and a Complete De- scription, together with full Illustrations, of the Handkerchief and Roller Bandages. By Edward Martin, A.M., M.D., Clinical Professor of Genito-Urinary Diseases, Instructor in Operative Surgery, and Lecturer on Minor Surgery, University of Pennsylvpnia; Surgeon to the Howard Hos- pital; Assistant Surgeon to the University Hospital, etc. Fifth edition. Crown 8vo, 334 pages, profusely illustrated. Considerably enlarged by an Appendix containing full directions and prescriptions for the prepara- tion of the various materials used in Antiseptic Surgery; also several hundred recipes covering the medical treatment of surgical affections. Price, Cloth, $1.00; interleaved for notes, $1.25. " Written to assist the student, it will be of undoubted value to the practitioner, contain- ing as it does the essence of surgical work." — Boston Medical and Surgical Journal. " Cleverly combines all the merits of condensation, while avoiding the errors of super- ficiality and inaccuracy." — University Medical Magazine. 3. ESSENTIALS OF ANATOMY, including the Anatomy of the Viscera. By Charles B. Nancrede, M. D., Professor of Surgery and of Clinical Surgery in- the University of Michigan, Ann Arbor; Cor- responding Member of the Royal Academy of Medicine, Rome, Italy ; late Surgeon to the Jefferson Medical College, etc. Fifth edition. Crown 8vo, 380 pages, 180 illustrations. Enlarged by an Appendix containing over sixty illustrations of the Osteology of the Human Body. The whole based upon the last (eleventh) edition of Gray's Anatomy. Price, Cloth, #1.00; interleaved for notes, $1,25. "Truly such a book as no student can afford to be without." — American Practitioner and News. "The questions have been wisely selected and the answers accurately and concisely given." — University Medical Magazine. CATALOGUE OF MEDICAL WORKS. 23 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC, containing also Questions on Medical Physics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. By Law- rence Wolff, M D., Demonstrator of Chemistry, Jefferson Medical Col- lege; Visiting Physician to the German Hospital of Philadelphia; Member of Philadelphia College of Pharmacy, etc. Fourth and revised edition, with an Appendix. Crown 8vo, 212 pages. Price, Cloth, $1.00; inter- leaved for notes, $1.2$. " The scope of this work is certainly equal to that of the best course of lectures on Med- ical Chemistry." — Pharmaceutical Era. " We could wish that more books like this would be written, in order that medical students might thus early become interested in what is often a difficult and uninteresting branch of medical study." — Medical and Surgical Reporter. 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M. D., Professor of Gynecology in the Medico-Chirurgical College of Philadelphia; Obstetrician to the Philadelphia Hospital. Third edition, thoroughly revised and enlarged. Crown 8vo, 244 pages, 75 illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. " An excellent little volume containing correct and practical knowledge. An admirable compend, and the best condensation we have seen." — Southern Practitioner. " Of extreme value to students, and an excellent little book to freshen up the memory of the practitioner." — Chicago Medical Times. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANAT- OMY. By C. E. Armand Semple, B. A., M. B., Cantab. L. S. A., M. R. C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney; Professor of Vocal and Aural Physiology and Examiner in Acoustics at Trinity College, London, etc. Crown 8vo, 174 pages, illus- trated. Sixth thousand. Price, Cloth, #1.00; interleaved for notes, $1.25. "A valuable little volume — truly a multum inparvo." — Cincinnati Medical News. "The volume is very comprehensive, covering the entire field of pathology." — St. Joseph Medical Herald. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION-WRITING. By Henry Morris, M. D., late Demonstrator, Jefferson Medical College ; Fellow of the College of Physicians, Philadelphia; co-editor Biddle's Materia Medica; Visiting Physician to St. Joseph's Hospital, etc. Fourth edition. Crown 8vo, 250 pages. Price, Cloth, $1. 00; interleaved for notes, $1. 25. "One of the best compends in this series. Concise, pithy, and clear, well suited to the purpose for which it is prepared." — Medical and Surgical Reporter. " The subjects are treated in such a unique and attractive manner that they cannot fail to impress the mind and instruct in a lasting manner." — Buffalo Medical and Surgical yournal. 24 W. B. SAUNDERS' 8, g. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D., author of " Essentials of Materia Medica," etc., with an Appendix on the Clinical and Microscopical Examination of Urine, by Lawrence Wolff, M. D., author of " Essentials of Medical Chemistry," etc. Colored (Vogel) urine scale and numerous fine illustrations. Third edition, enlarged by some three hundred essential formulae, selected from the writings of the most eminent authorities of the medical profession, collected and arranged by William M. Powell, M. D., author of "Essentials of Diseases of Children." Crown 8vo, 460 pages. Price, Cloth, $2.00. " The teaching is sound, the presentation graphic, matter as full as might be desired, and the style attractive." — American Practitioner and News. "A first-class practice of medicine boiled down, and giving the real essentials in as few words as is consistent with a thorough understanding of the subject." — Medical Brief. " Especially full, and an excellent illustration of what the best of the compends can be made to be." — Gaillards Medical Journal. 10. ESSENTIALS OF GYNECOLOGY. By Edwin B. Cragin, M. D., Attending Gynaecologist, Roosevelt Hospital, Out-Patients' Depart- ment; Assistant Surgeon, New York Cancer Hospital, etc. Fourth edi- tion, revised. Crown 8vo, 198 pages, 62 fine illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. "This is a most excellent addition to this series of question compends. The style is con- cise, and at the same time the sentences are well rounded. This renders the book far more easy to read than most compends, and adds distinctly to its value." —Medical and Surgical Reporter. " Useful not only to the student who is barely at the threshold of professional life, but to the busy practitioner as well." — New York Medical yournal. 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M. D., Clinical Lecturer on Dermatology in the Jefferson Medical College, Philadelphia; Physician to the Skin Service of the Northern Dispensary; Dermatologist to Philadelphia Hospital; Physician to Skin Department of the Howard Hospital ; Clinical Professor of Der- matology in the Woman's Medical College, Philadelphia, etc. Third edi- tion. Crown 8vo, 270 pages, 86 illustrations, many of which are original. Price, Cloth, $1.00; interleaved for notes, #1.25 net. " An immense amount of literature has been gone over and judiciously condensed by the writer's skill and experience."— New York Medical Record. " The book admirably answers the purpose for which it is written. The experience of the reviewer has taught him that just such a book is needed."— New York Medical journal. CATALOGUE OF MEDICAL WORKS. 2$ 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, A.M., M. D., author of " Essentials of Surgery," etc. Second edition. Crown 8vo, thoroughly revised and enlarged, 78 illustrations. Price, Cloth, #1.00; interleaved for notes, $1.25. " Characterized by the same literary excellence that has distinguished previous numbers of this series of compends." — American Practitioner and News. " The best condensation of the subjects of which it treats yet placed before the pro- fession." — Medical News, Philadelphia. ' " A capital little book. The illustrations are remarkably clear and intelligible." — Aus- tralian Medical Gazette. *' We have nothing but praise for the subject-matter of this book." — Bristol Medico-Cki- rurgical Journal. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M. D., author of " Es- sentials of Pathology and Morbid Anatomy." Crown 8vo, 212 pages, 130 illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. " The leading points, the essentials of this too much neglected portion of medical science, are here summed up systematically and clearly." — Southern Practitioner. *' But for the author's judicious condensation of facts, the information it contains would be sufficient to fill an ordinary octavo volume." — College and Clinical Record. 14. ESSENTIALS OF REFRACTION AND DISEASES OF THE EYE. By Edward Jackson, A. M., M. D., Professor of Dis- eases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine; Member of the American Ophthalmological Society; Fel- low of the College of Physicians of Philadelphia ; Fellow of the American Academy of Medicine, etc. ; and ESSENTIALS OF DISEASES OF THE NOSE AND THROAT. By E. Baldwin Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical College, Phila- delphia; Surgeon in charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia; formerly Assistant in the Nose and Throat Dispensary of the Hospital of the University of Pennsylvania, and Assistant in the Nose and Throat Department of the Union Dispen- sary, etc. Two volumes in one. Second edition. Crown 8vo, 294 pages, 124 illustrations. Price, Cloth, $1. 00; interleaved for notes, $1. 25. "A valuable book to the beginner in these branches, to the student, to the busy prac- titioner, and as an adjunct to more thorough reading. The authors are capable men, and as successful teachers, know what a student most needs." — New York Medical Record. " Very valuable, since in both sections is given about all that a candidate for examination is required to know." — Medical Times and Hospital Gazette. 26 W. B. SAUNDERS' 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N.J. ; late Physician to the Clinic for the Dis- eases of Children in the Hospital of the University of Pennsylvania and St. Clement's Hospital ; Instructor in Physical Diagnosis in the Medical Department of the University of Pennsylvania. Crown 8vo, 216 pages. Price, Cloth, $1.00; interleaved for notes, $1.25. " This work is gotten up in the clear and attractive style that characterizes the Saunders Series. It contains in appropriate form the gist of all the best works in the department to which it relates." — American Practitioner and News. " The book contains a series of important questions and answers, which the student will find of great utility in the examination of children." — Annals of Gynecology. 16. ESSENTIALS OF EXAMINATION OF URINE. By Law- rence Wolff, M. D., author of " Essentials of Medical Chemistry," etc. Colored (Vogel) urine scale and numerous illustrations. Crown 8vo. Price, Cloth, 75 cents. " A little work of decided value." — University Medical Magazine. " A good manual for students, well written, and answers, categorically, many questions beginners are sure to ask." — New York Medical Record. " The questions have been well chosen, and the answers are clear and brief. The book cannot fail to be useful to students."— Medical and Surgical Reporter. 17. ESSENTIALS OF DIAGNOSIS. By Solomon Solis-Cohen, M. D., Professor of Clinical Medicine and Applied Therapeutics in the Philadelphia Polyclinic, and Augustus A. Eshner, M. D., Instructor in Clinical Medicine, Jefferson Medical College, Philadelphia. Crown 8vo, 382 pages, 55 illustrations, some of which are colored, and a frontispiece. Price, $1.50 net. " A good book for the student, properly written from their standpoint, and confines itself well to its text." — New York Medical Record. "Concise in the treatment of the subject, terse in expression of fact. . . . The work is reliable, and represents the accepted views of clinicians of to-day." — American Journal of Medical Sciences. "The subjects are explained in a few well-selected words, and the required ground has been thoroughly gone over." — International Medical Magazine. 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre, M. D., Professor of Pharmacy and Materia Medica in the Uni- versity of Kansas. Second edition, revised and enlarged. Crown 8vo, 200 pages. Price, Cloth, $ I. 00; interleaved for notes, $1.25. "Covers a great deal of ground in small compass. The matter is well digested and arranged. The research questions are a valuable feature of the book." — Albany Medical Annals. " The best quiz on Pharmacy we have yet examined." — National Drug Register. "The veteran pharmacist can peruse it with pleasure, because it emphasizes his grasp upon knowledge already gleaned." — Western Drug Record. CATALOGUE OF MEDICAL WORKS. 2J 20. ESSENTIALS OF BACTERIOLOGY • A Concise and Syste- matic Introduction to the Study of Micro-organisms. By M. V. Ball, M. D., Assistant in Microscopy, Niagara University, Buffalo, N. Y. ; late Resident Physician, German Hospital, Philadelphia, etc. Second edi- tion, revised. Crown 8vo, 200 pages, 8 1 illustrations, some in colors, and 5 plates. Price, Cloth, $1.00 ; interleaved for notes, $1. 25. " The amount of material condensed in this little book is so great, and so accurate are the formulae and methods, that it will be found useful as a laboratory handbook." — Medical News. " Bacteriology is the keynote of future medicine, and every physician who expects success must familiarize himself with a knowledge of germ-life— the agents of disease. This little book, with its beautiful illustrations, will give the students, in brief, the results of years of study and research unaided."— Pacific Record of Medicine and Surgery. "Thoroughly practical, very concise, clear, well-written ; and sufficiently illustrated. . . . The best book of the kind in the English language." — Medical and Surgical Reporter. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY, their Symptoms and Treatment. By John C. Shaw, M. D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island Col- lege Hospital Medical School ; Consulting Neurologist to St. Catherine's Hospital and to the Long Island College Hospital ; formerly Medical Super- intendent King's County Insane Asylum. Second edition. Crown 8vo, 186 pages, 48 original illustrations, mostly selected from the Author's private practice. Price, Cloth, $1.00; interleaved for notes, $1.25. " Clearly and intelligently written." — Boston Medical and Surgical Journal. " A valuable addition to this series of compends, and one that cannot fail to be appreciated by all physicians and students." — Medical Brief. " Dr. Shaw's Primer is excellent. The engravings are well executed and very interest- ing.'' — Medical Times and Register. " Written with great clearness, devoid of verbosity, it encompasses in a brief space a vast amount of valuable information." — Pacific Medical Record. 22. ESSENTIALS OF PHYSICS. By Fred J. Brockway, M.D., Assistant Demonstrator of Anatomy in the College of Physicians and Sur- geons, New York. Second edition. Crown 8vo, 320 pages, 155 fine illus- trations. Price, Cloth, $1.00 net ; interleaved for notes, $1.25 net. " The publisher has again shown himself as fortunate in his editor as he ever has been in the attractive style and make-up of his compends." — American Practitioner and News. "Contains all that one need know of the subject, is well written, and is copiously illus- trated."— New York Medical Record. " The author has dealt with the subject in a manner that will make the theme not only comparatively easy, but also of interest."— Medical News, Philadelphia. *' Deserving of close investigation at the hands of students and physicians."— American Gynecological Journal. 28 W. B. SAUNDERS' CATALOGUE. 23. ESSENTIALS OF MEDICAL ELECTRICITY. By D. D. Stewart, M. D., Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson Medical College ; Phy- sician to St. Mary's Hospital and to St. Christopher's Hospital for Chil- dren, etc. ; and E. S. Lawrance, M. D., Chief of the Electrical Clinic, and Assistant Demonstrator of Diseases of the Nervous System in the Jefferson Medical College, etc. Crown 8vo, 148 pages, 65 illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. "Clearly written, and affords a safe guide to the beginner in this subject." — Boston Med- ical and Surgical Journal. " The subject is presented in a lucid and pleasing manner." — New York Medical Record. " A little work on an important subject, which will prove of great value to medical students and trained nurses who wish to study the scientific as well as the practical points of elec- tricity." — The Hospital, London. " The selection and arrangement of material are done in a skilful manner. It gives, in a condensed form, the principles and science of electricity and their application in the practice of medicine." — Annals of Surgery. " The compilation is a good one, and will be found useful both to students and to men in practice." — New Zealand Medical Journal. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia; Surgeon in Charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia; formerly As- sistant in the Nose and Throat Dispensary of the Hospital of the Univer- sity of Pennsylvania, and Assistant in the Nose and Throat Department of the Union Dispensary. 89 illustrations. Price, Cloth, $1. 00; inter- leaved for notes, $1.25. This latest addition to the Saunders Compend Series accurately represents the modern aspect of otological science. The effort has been made to state the Essentials of Otology concisely, without sacrificing accuracy to brevity, and the book, while small in compass, is logically and capably written ; it comprises up- ward of 150 pages, with 89 illustrations, most of which are from original sources. PREVENTING AND CORRECTING DEFORMITIES OF THE BONES AND JOINTS. A Handbook of Practical Orthopedic Surgery. ' j By . H r AUGUSTUS -WILSON, M.D., ; • PROCESSOR OF GENERAL" AND ORTHOPEDIC SURGERY, PHILADELPHIA POLY- CLINIC; Clin-ical Professor of' Orthopedic .SORSery; Jefferson '■ - ;'_ Medical Collehe, Philadelphia, etc.,. etc. The aim. of the ajitlior will be, to provide a book of • moderate size containing comprehensive details that wifl enable genera} prac- r ; titioners to .thoroughly .understand the mechanical features of the many •; forms of congenital arid acquired deformities of the bones andjoiafe' T ,Such a book -might well be called Orthopedic Therapeutics; as it will'adopt. as- a basis, the description, symptoms, signs, and diagnosis^- upon which to elaborate the appropriate details of treatment. The mechanical functions that are impaired will.be considered first ' as to prevention, as of primary importance, and following tbis will i be described the methodsof correction that have been proved practical by the author; ; Operative procedures will be considered fromj.-a /- mechanical standpoint as Well as surgically. Prominence will.be given.; to the mechanical requirements jfor braces and artificial limbs, etc., with description of the^ methods for constructing the simplest forms, whether made^ of plaster of Paris, felt, leather, paper, steel; or p$ier materials, together with the methods of readjdstrtenfrto suit'the changes occurring during the progress of the'case. ■.■' •'• ^ .- JLn important feature of the book will be the, practical applieartSpife .of remedial gymnastics and movements in the prevention or recovery v' of lost mechanical fpnedohsof the muscles" when they have produced .'or lead to produce bone or joint deformities. ' A'yery large number of original illustrations will bb used to make . descriptions clearer. The elimination, of theoretical, matters Still, in.-, doubt will make the book. one of practical value to busy physicians, from Whom gucb cases generally receive first- attention, ancl by'whoin . they 'may be successfuttj? treated- READY SHORTLY; Op MATERIA MEDICA ATitD BY, ,. . , _ : A, A. STEVENS, A.M:,:J\f--D^, ; .;. \,, llnstructofcdf physical Diagnosis, and lecturer on Terminology intheuni- ";.- yersity at Pennsylvania; Deinonstrator of Pathology in the -~ . Wpman'siVIedical College of. Philadelphia Pathologist- _ ~p %it» St, Agnes'^Bospital L ; and Physician to, the , . ..-- Stiuth-easteraBispensary. j An entirely new and priginal volume o^ this important Sulh- -|ept, based upon the; last (189Q) edition of .ttije Pharmacopoeia. - It,will be diyidedinto;the followmg four sections, viz. : , 1;; Physiological Action of Drugs. ' ~~ - . ~ . , ' : f ;;2. Drugs (including- the source, c'cahpositionhand desmptioiif Ihferapeutic^ application, and -administration^;} also the' ineom- patibles). '" y ' , r -> ; ''""'-" t 3., Remedial measures (counterirritation, hydro-therapy, elee-~ tricity, etc.), . ' ' ' ~ ' ~;"\ _ , ~_r - '"'-"-' :'. 4. Treatment of disease, illustrated by more than, 200 eluct Native formulae.-; '... V " »/. v Explicit directions will be given; for prescribing the .doses,-* bejrig- in both Aj?othee&ries" and , the Metric systems; " \ f toongiderable space is devoted to the reliable newer remedial. ET PREPARATION • DOSE BOOK AND MANUAL j OF BY E. Q, WOfitfTON, ajD., 'Demonstrator of Therapeutics; Jefferson Medical College, Philadelphia. ^/The aim of" tfae author has been to write a "small convenient pocket-volume thoroughly ujr to date and based : upon the "last (1890) edi-; tion of the Pharmacopoeia. % : Great care has been exercised in the de- partment of dosage, a nc i the endeavor has been shade in. all cases to make it &s safe and' re* liable as -possible. .The volume M size: and general appearance' will be uniform ivith "Saunders' Pocket Medical Formulary,