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William Osler
William Osler

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Arthur Keith
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Almroth Wright
Almroth Wright

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M.D., B.S. LaND., F.R.C.P.
M.B .. F.R.C.S.
(I.. PreI_Ii.... )
1\\ \ \05931
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THE demand for another edition of this book has afforded
the Author an opportunity for the careful revision of its
contents. Much new ma.terialhas also been added; many
sections (notably those dealing with the Wassermann
Reaction, Rickets, Vitamines, Wound-Shock, Gas Gangrene, etc.) have been entirely rewritten, and every effort
made to embody the most recent views bearing on pathological teaching and research.
Septemlm, 1920.
Huoh philosophy is wanted for the
oorreot observation of things whieh
are before our eyes.
• 103
• 106
• 154
- 100
- 178
- 179
• 183
• 2i4
- 245
The Cell.-The organism is built up df -a. number of struc·
tural units known as cella, which bea.r the same relu,t:!'lJl
to the body that the bricks do to the house. The natural
cell is composed of 'life·stuff,' technically known as
oytoplasm (C)/toa-the cell). a Bubstanoo resembling in
appearance the white of egg, and when magnified, seen
to be studded with a number of minute granules. If
treated with certain reagents (alcohol, mercuric chloride,
formalin, eto.) the cell dies, and what was the oytoplasm
becomes a coagulum showing a retioulated framework.
Whether the latter exists as suoh during life, but in an
invisible form, it is impossible to say. It may be a.
natural condition or it may be an artefact. Recent
researches suggest that the oytoplasm is colloid in com·
position (=intermedia.te between that generally reoognized
as sus.JlCnded in a :fluid and that in a true solution,l.
In typioal cases the cytoplasm is surrounded by a cell
wall, and contains a nucleus and nuoleoli. The whole
substance of the cell is conveniently oalled bioplasm.
The nuclel£8, the most highly specialized part of the
bioplasm, is the dynamic oentre, for it direots and controls
its many activities. Deprived of its nucleus, the cell can
neither grow nor reproduce itself, and soon dies. Like
the cell itself, the nucleus is bounded by a membrane,
the nuclear wall, which is achromatic-i.e.. having no
affinity for basic dyes (chruma= colour)-and oontains a.
network of interlaoing fibrils.
The nuclear network is achromatio, but embedded in it
are oertain small granules, which, because they stain a
oharacteristic yellowish.brown colour by chromium salts,
are ca.lled chrumatin. This chroma.tin is regarded as the one
indispensable'life.stuff,' Md the bearer of the hereditary
qualities of the cell. At the points where the threads of the
network intersect, the chromatin granules may be heaped
up into larger masses, called' net-knots,' or karyosome8.
The nucleol'U8, contained within the nucleus, is usually
single, but there may be 8S many as five. It is oxyphil
(i.e., stains with acid dyes). Within it is a minute body,
the endonucleua, the function of which is unknown.
The centrosomfl8 lie in the cell cytoplasm, just· outside the nucleus. Usually there are two pl~ side by side
FIa. 1.--a, Cell wall; b. reticulum; c. nuclear wall; d. karyosome; e. J. nuolear reticulum; o. nuoleolus; k. astral system.
with centrosomes.
enclosed within a membrane from the exterior of which
radiate delicate fibrils-the aatralSY8tem of the CeD.trosome.
The centrosomes appear to be connected with cell
reproduotion, iItitiat ng the prooess (by separa.ting to the
opposite poles of the oell) in ~itotio division.
Cell Division.-The nucleus dhides. This division may
be-I. Dirf/!t (simple or amitotic). The nucleus becomes
constricted at its middle, and then by simple fission
separates into two parts. The cell cytoplasm now divides,
each half carrying a nucleus. The result is the production of two cells.
2. Indirect or mitotic. The chromatin granules 001-
lect into threads (mito8=a thread), whioh subsequently
undergo a oomplox series of ohanges (known as karyokinesis) prior to the ultimate division of tho cell into two
Mitotic division i8 the rule. amitotio division is the
exoeption. It is said to occur in malignant tumours.
The cells lie bathed in lymph, which, though at times
tending to stagnate locally. as in the muscles during rest,
may be regarded as more or less oontinually on the flux,
flowing both through and around them. The lymph-fl0f)
to the cell oarries the oxygen. proteins. oarbohydrates, fats.
salts, hormones, vitamines. and other substanoes neoe3sa
for the bioohemioal ohanges that oonstitute oell life:{
the lymph. ebb carries away from the oell the waste produots
of cell metabolism.
}-a1D·t f
'd d
Dl Y or 001
eosinophil Basophil
=afDnityfor basic dyes.
A.mphophll =afDnity for both.
Neutrophil =no afDnity for either.
Cell Disease.
The structure of thc various cells of the body depends primarily upon the oonstitution of the zygote (=fertilized ovum)
which gives origin to them. Their behaviour during life dopends upon their struoture as thus hereditarily determined.
and upon the inflllonces brought to bear upon them from witbout. These influences are plasmic and fW1I-plasmic.
Hon-Plasmic Infiueuce3.-These consist for tbe most part of
nerve stimuli, which, originating In sen~Qry end·organs, oither
on the surfaoo, or in the deepor tissuOB, of the body, are continually reverberating throughout the entire nervous system,
and thus influencing not only individual neurones, but nonnervous cells (such as muscle cells and gland cells) attached to
tho ends of etlerent norvc fibres. It we refl.cct that tho humo.n
organism consists essentially of a nervous systom from the onds
of \vhose etlerent norve twigs so many musclo and gland cells
depend, the wholo being held together by oonnoctivo tissue,
and permeatcd by 0. complex system of ohannols for tlle oirculatlon of the body flulds, and that nerve stimnli aro oeaselossly
reverberating throughout the nervous system, we shall tho
bettor reall~e how potontly that system must influonoe the individual colis of tho body.
Plasmio Influences.-These operate through tho lymph
bathing tho oolls, and depond upon the composition of that
IYlllph, which, again, Is ossontially determined by tho oomposl-
tlon of the blood·plasma. This is a highly oomplox fluid-the
mOijt oomplex In nllturo-oontaining an endless variety ot sub·
stanoes-food'stulfs, oxygon, hormonelJ, ferment&--most ot
whioh defy tho most Ollrotul and dolicate mothods ot ohomical
researoh; and let the faot over be remembered that it is in a
fluid of this kind that, from the beginning to the end oUts eareer,
every cell in the body lies bathod and is through it subjected
to an endless variety of influences, both good and bad.
Cell Environment.-E60h 0011 may be regardod as surrounded
by three zones: (a) A zono ot lymph, whioh foods the 0011; (b) II
zone of blood, whioh toods the lymph; and (c) a zone of air
(= lungs) u.nd food pu.bulum (=alimentary c!anal), which feed
the blood.
Now, the oolls ot the body dJsplay little or no intrinsio ten·
dency to disease: the cell environment, notably the plasmic en·
mronment, is chieftll res-ponBible lor whateuer disease mall al/ect
the ceu. Even senile 0011 dosoneration is largely extrinsio in
nature, tor though doubtless it is in part intrinsic--due to the
running·~own or wearing·out ot the 0011 microcosm-it. is even
more the result of spooiflc changes in the plu.smio environment
of the cell Senility is, in fu.ct, mainly of plasmio origin, the
in(lividual being slowly destroyed by means of his plasma:
not, indeed, by any suoll simple and pathologioal proooss as that
suggested by lIIetohnikoff""""",-e., by the absorption of baotoria
toxins from the large intestine--but by the operation of oomplex
physiologioal mechanisms, the obJoot of which is to put II de:tlnite
torm to tho vital cyole, and thus obviate the innu.te tendonoy
to immortality bolonging to all living matter. In some animals
-e.g., the dog-these meobanisms oome Into operation soonor
than In othors~.g., maD. Sometimes in man they come into
-prema.t\ue e-perat1en, the arteries becoming sclerosed, the skin
wrinklod, and the hair grey as ea1"ly, it may be, as the second
decade; at others their operation is dolayed, the nonogonarian
boing as youthful, it may be, liS the average man of fifty or
If we exoept oases of intrinslo senile degeneration, it but very
seldom hal'pens thBt a coli primarilll becomes diseased. Tho
nearest approaoh to such a phenomenon Is afforded by tho
family palsies, in which de:tlnite systoms of neuronos undergo
early degeneration.
HeDce, in every oase ot cell disease we should suspect the
oxistence of some morbid influence operating on the cell trom
without. This influeneo may be nerv01t8 or plasmic.
Cell Disease from Nervous Causes.-A familiar instanco is the
degenoration which takos place in the striped muscle flbre when
its motor twig is disoased. All the instances of genl'lne trophic
lesions are due to some interference with the normal flow of
nerve impulses Into the colis ' trephically , danlagod.
Degeneration from Plasmio Causes.-l\fuch the most common
06UIHI of disease ot the 0011 is 80me abnormality in respeot of the
plasma bathing it.
Abnormalities 01 tbJa kind tall under tlfo
1. Detects in tile O£reu.latiIm oJ tile PlaBma.-Those may bo
oentml. as In heart and lung disease; or looal. as in embolism
and degeneration of the smaller blood vossels.
Any sudden and pronounoed interference with the 10001 elroulation leads to profound degenerativo oho.nges. as in Infarot (see
p. 67). Moro ohronlo defoots of tho olroulation. as in ohronio
hoort disease and senile degeneration ot the arteries, lead to
gradual atrOPhy of tile parenehyma cells and increase ot the
fibrous elements. In the former ooso the sluggish eiroulation
oouses damage of tllo oopillary walls, with escapo ot tho chromocytes into tho tlssuos and subsequent staining at tho tlssuos
from their disintegration. as iIIllstmted in tho well-known' nutmeg liver.' In the lattel case tba fibrous ohange may be tormed
senile .fibroN, and it is ohiefly responsible for tho toughening
of the tissues observed in old ago.
2. Detecta in the OompOBititm oJ t1!BPlaBma.-The composition
of the plasma may depart from the normal In an untold number
ot ways. Thus the plasma may vary in respeot of its nutrient
constituents. its fermonts. its hormones. and its normal waste
produots. Furthermore. It may be poisoned (0) as the result
of morbid metabolism, as In diabetes; (b) by tho introduotion
ot a poison, suoh as lead or aloohol, into tho body; and (c) by
bactorial and other toxins formed within the body.
Tho vast majority of non-traumatlo djsO&sos result from tho
action of a morbid plasma upon tho tlssuo oells. How wido Is
tho rlllo which tho plRsma plays in disease Is evident from the
faot that a toxio stato of tho plasma Is tho sole oausa of inflam·
ma.tion; and how largely this process bulks among the diseases
whioh the physiolan is oalled upon to treat Is evident from a
casual porusal of any on medlolne.
But morbid plasma. induoes many lesions other than the inflammatory. Thus tho blood may contain substances whioh
exert a -noxious action chlofly or entirely upon oertain kinds
or colis. ploking thom out. as we say. by solootive aotlon. mlloh
as tho pigmonts usod for staining mioroscoplo seotlons pick out
Bomo colIs rather than others. It.. famUiar instanco of this is
aftorded by tabes dorsalis. This is a sequela of syphilis.
and is due to tho aotion of a polson whloh oauses degenoration
In c~rtain sensory neurones; and It fs probable that most of the
• systom lesions' of tho norvous system-i.e.. sypunotrloal
losions of partioular traots--lI,ave a Similarly plasmio origin.
In suoh oo.S08 tho degenerative ohanges a~ for the most Part
chronio. Morbid plasma may, however, sot Ull acute dostruotivo changes in special kinds of oolls. Experiments have shown
that the tissues of animals. such as the dog and the rabbit. can
be made to elaborate substaneos eapable of oausing rapid destruction of speoial oell types. snoh as obromooytos, hepatic
cells, and renal oelIs; and there oan be little doubt that substanoos
at this kind play an important part in disease. Thus. aoute
yellow atrophy of the liver is producod by the action ot some
toxin which is to all intonts and purposes a hepatolysin (soo
p. 46), and oortain forms of • acute panoreatltis' probably own
a similar pathology.
Strictly speaking, degeneration is simI)ly the reverse of
evolution; it is an undoing, so to speak, of evolution.
Thus, when the dendrites of a neurone diminish in number,
as they do in old age, or when the transverse strire of a
muscle disappear, degeneration takcs place.
The pathologist, however, uses the term 'dcgeneration • in the chemical rather than in the structural sense.
For him it means, not the actual death of the cell, but the
replacement of its complex cytoplasm, partial or complete.
by a material of a simpler type, such as fat.
As already stated (p. 4), cell degeneration is rarely
spontaneous, but almost always due to some morbid influence operating on tho cell. Such morbid influences
operate. above a.ll. through the cell environment.
To trace out the various degenerative changes which
may be produced in the tissues by morbid conditions of
the plasma would be impossible, even did space permit.
When we 'fejltd that eve:ry abnormality of the plasma must
tend to produce its own parlitmIa'f chp.nge in the ti88UIl8 whicl&
that plasma bathll8, it i8 obtJiO'UB that the degeneration8 which
p'l"otoplasm undergoes mU8t be far more numerOUB than th08e
a8 yet ducribed by pathologists.
Degeneration must be distinguished from inliltrationi.e., tho deposition of some new substance in an otherwise
unaltered cell.
Some of the more common forms of innltration and
degeneration will now be considered.
I njiltf"ationB.
Glycogenic infiltration.
Cloudy swelling.
Fatty infiltration.
Fatty degeneration.
Amyloid degeneration.
Hyaline degeneration.
Mucoid degeneration.
Colloid degenerati<m..
Glycogenic Infiltration.
Glycogen is normally present in the liver, in embryonio
tissues, and indeed to some extent in most cells (absent
from their nuclei), but not in the nervous system, pancreas, salivary glands, thyroid, hypophysis, adrenoJs,
or bone-marrow. As a morbid process, infiltration of
glycogen ocours in malignant tumours, and in the leucooytes in cases of suppuration, pneumonia, and other IIo01lte
In diabetes mellitus the convoluted tubule of the kidneys. the heart-muscle, spleen, and leucooytes, are loaded
with it. Glycogen stains a mahogany-brown colour
with iodine (the iodide of glyoogen). and a bright red with
Bost's carmine method.
FaitJ Inilltration.
In fatty infiltration tiny globules of fat appear in the
cell, the protoplasm of which, however, remains heaUhy.
The globules may coalesce and push the protoplasm against
the cell wall. Fatty infiltration is the nornial condition
of many connectivo tissues (e.g., of the medulla of the long
bones) and, to a less extent, of the liver. It i8 only when
the number of fat globules exceerla the normal limit that the
term' fatty infiUration • i8 applicable.
The causes are excessive (liet, espeoially if coupled with
insufficient exercise, and alcoholism, partioularly beerdrinking. Excessive deposit of fat may also occur from an
anabolio habit of body, as in the monstrously fat people
seen in shows, and in myxmdema. In all such oases the
causo is probably a peculiar condition of blood, in consequence of which the fat is not properly metabolized.
'Adiposa doloroan.' 1s a condition in which a nodular
deposit of fat is associated with considerable superfi.cial
An excesaive local deposit of fat may result from disuse,
as in the case of the muscles of a fraotured limb which has
been put up in splints.
Caloification is the deposition of lime salts (phosphate
Land carbonate) in degenerated or dead tissues.
Aocording to Klotz, 0. necessary preliminary to caloification is the formation of 80ap8 in the degenerated or dead
Bites.-Arteries, especially the aorta and coronary (very
rarely the veins), valves of the heart, old tubercular lesions, tumours (e.g., fibro-myomata. of the uterus), the
capsule enclosing the Triek&na BpiraZis, adherent pericardium, the walls of old absoesses, the fcetus of an eotopio
gestation (forming lithopmdion or peritoneal oalculus), the
thyroid, oostal, and other cartilages in old people.
Cloudy Swelling.
In oloudy swelling the oells beoome swollen, their
oytoplasm • oloudy' from the presenoe of fine granules,
and their nuolei obsoured. 'l'he granules, whioh are
probably albuminous in nature, are dissolved by acetio
acid and alkalies, but, unlike fat, are insoluble in ether
and do not stain blaok with osmic acid. If the degeneration has not advanced too far, the cloudiness may clear up
and the cell resume its normal appearance, but if it continues to advance it may pass into fatty degeneration.
Cloudy swelling occurs in connection with febrile states
(pneumonia, diphtheria, soarlatina, enteric, eto.). It i8
prod/aced by tk6 action of bacteriaZ toxi7l.8, its distribution
being detemlined by the nature of the toxin, the organs
most frequently affected being the kidney, liver, and heart.
One of the first signs of degenerative ohange in the
neurone is the absorption of the stainable Nissl granules
(ohromatolysis). The ohange begins in the neighbourhood
of the nucleus. The granules are first converted into fine
dust, and ultimately disappear.
Fatty Degeneration.
Practically all the tissues of the body and, with the exception
....f the urine, all thc body fluids contain fat.
In fatty degeneration the cell protoplasm is replaced by
fat, the fat being split off from the protoplasm molecule.
The fat first appears as minute, highly refractile gmnules,
which gradually increase in number until, it may be, the
whole cell is converted into a mass of fat. Thc fatty
contents stain black with osmic acid, and reddish-orange
with Sudan III., and dissolve in alcohol and ether, but not
in acetic acid.
In the majority of cases cf fatty dogeneration, the proBllnce
of Zipoids can be demonstrated. These are fat-like bodies
soluble in fat solvents, and normally found In minute quantities
in all tho tissues and blood, being ebPeclally abundant in tho
nervous system, particularly in tho myelin of the whitc matter.
Thore are three classes: (a) Tho phosphailides, C, H, 0, N, and P;
(b) the galacfocides, C, H, 0, and N; (c) tho choZesterols, C, H, and
O. Leoithin, whioh belongs to (a), is the most important of all
Fatty degeneration is typically found: In severe and
prolonged anremins-e.g., fatty degeneration of the heaI1
always occurs in pernicious anremia; as the result of
certain poisons. notably alcohol, chloroform, iodoform,
~"ulf, &M &i"l!\l)b'.T, f."ti'm' jf-,n,. ,£\l'lt,\m .:Jl ol\l'l"lkl)r
bacterial toxins-e.g., pneumonia, diphtheria, enteric,
tuberculosis. It is also found in diabetes and jaundice,
and is often an accompaniment of amyloid degeneration.
Hearl, liver, and kidneys, are the organs principally
WUy, Lardaceous, or Amyloid Degeneration.
This is a condition in which peculiar changcs occur in
the cytoplasm of certain connective tissues, whereby they
become homogeneous, translucent, and 'waxy.' The
change involves more especially the connective tissue of
the middle and inner coats of the arterioles, and the subendothelial layers of the capillaries. The endothelium
itself is never affected, nor are parenchyma cells of any
sort (muscle, gland).
Of 250 caeos examined by Litten. the frequency In whlch the
various organs were aflocted was as follows: Spleen. 99 per eent.;
kidfUlY. 98 por oont.; efidocardiJ"m. 76 per oent.; liver. 65 ler
oont. ; imestifUl8. 67 per oont. The skin. bones. lungs. and oentral
nervous system. are exempt from It.
The waxy material stains a deep mahogany brown
(quiokly fades) with iodine, turning blue or violet if 10 per
oent. sulphurio aoid is afterwards applied. With methyl
violet it gives a deep rose pink (normal tissues are stained
This degeneration is found in connection with chronic
suppuration, when no free dr.unage can occur, particularly
that due to tuberculosis. It also ocours in syphilis, both
acquired and congenital. Of 189 cases quoted by Lubarsch,
98 were due to pulmonary tuberculosis, 25 to bone and
joint tuberculosis. while 35 were due to syphilis.
The waxy material is a glyco-protein, linked with
chrondroitin-sulphuric acid (Krakow). It is not a. preoipitate from the blood or lymph. but in all probability
results from the action of bacterial or cellular tOxins, for
the organs most affected, (kidneys, spleen, liver, and intestines) are those most ooncerned in the elimination and
neutralization of toxins. Some authorities hold that it
is due to an enzyme found in the spleen, giving as their
'reasons: (a) the spleen is the first organ to be attaoked;
(b) the disease cannot be produced in dogs whose spleen
has been removed.
In the Liv6T.-The organ is greatly enlarged, smooth,
firm, and heavy, with its edges rounded. The out surface
is pale, translucent, and wax-like. 'l'he change commenc68
in the subendothelial layer of the capiUari68 01 the intermediate zone 01 the l~ver lobule (flee Diseases of the Liver),
the lining endothelial cells of the capillaries remaining
unaffected. The pressure of the new material upon the
liver cells causes them to become fatty and to undergo
In the KidneY8.-These organs become pale and enlarged, and the capsule strips off readily. The cut section
has a translucent, bacon-like appearance. The ohange
begins in the 1J688el8 01 the glomerular tults and in the
arteriIB rectIB. Later on, the basement membrane of the
tubules (especially of the oortex) may suffer. The lining
epithelium of the tubules tends to undergo fatty degeneration, owing to interferenoe with the oirculation.
In the Sploon.-There are two varieties of lardaoeous
The sago-spleen, commonest in phthisis. In this the
organ is but slightly enlarged. On section it is seen
studded with small, translucent, sago-like bodies, which
vary in size from a millet-seed to a hemp-seed, and give
the ordinary amyloid reactions. The change begins in the
arterioles and capillaries of the Malpighian bodies.
The d~ffuse waxy sploon, commonest in syphilis. The
organ is greatly enlarged, and becomes hard and firm.
On section it shows a uniform translucent appearance.
The walls of the sinuses of the splenio pulp specially
exhibit the .change.
Hyaline Degeneration.
This term is applied to those conditions in which certain
oell elements are converted into a substance like glass
(hyalU8, glass). When affecting epithelium, the Van
GillSon stain is yellowish-brown; whe:Q. affecting connective
tissue, it takes the red fuchsin stain. It is only of importance when it affects blood vessels, in which case it is
the intima of the arteri!>les that shows the degeneration.
Mucoid Degeneration.
The glyco-protein mucin is a normal secretion of the
mucous mem branes, and is poured out in inoreased quantity when they become inflamed. As met with as a
degenerative process, it is probably a pseudo-mucin. It is
found as part of a degenerative process in chondromata,
sarcomata, carcinomata, and other tumours. The affected
cells and fihres swell up, and become transformed into a
jelly-like substance.
In water the muoin swells up; it is soluble in dilute
alkalies, from which it is precipitated both by alcohol and
acetic acid. Thionin blue stains the mucin red and the
surrounding tissues blue.
In ovarian oysts an allied substanc6-j)seudo-mucinis found. This differs from muoin in not being precipitated
by acetic acid.
Colloid Degeneration.
Colloid (kolla, glue) is a normal constituent of the
thyroid gland and the pituitary body, blling derived from
epithelium, the cells of which become detached and glued
together into a solid mass. As a degeneration, it is most
frequently met with in cancers of the abdomen, especially
of the stomach, intestinc, ovary, and peritoneum. In rare
instances it occurs in cancer of the breast, and in congenital
cystio disease of the kidney.
The material resembles mucin in appearance, but is
insoluble in water, and is not precipitated by alcohol nor
by acetic acid.
, Pigmentation' (pingo, paint) is the term used to denote
an abnormal deposit of oolouring matter in the tissues.
The pigment usually lies within the cells of the pigmented
Melanin.-This is the most common normal pigment
of the body. It oontains nitrogen, hydrogen, carbon,
and sulphur, but no iron. It is bleaohed by chlorine,
a feature which distinguishes it from carbon. It is not a
product of the disintegration of hmmoglobin, bu~ it is
elaborated by oel~ action from an albuminous substance,
and is normally present in the skin, hair, iris, choroid, and
cardIac muscle. The quantity of melanin in the skin is
augmented by solar rays, at the elimactello in women,
and often during pregnancy; also in leucoderma, Addison's
disease, Graves' disease,- granular kidney, rheumatoid
arthritis, and chronic tuberculosis: Melanin constitutes
the pigment met with in melanotio sarooma; in certain
cases of this disease it may be found in the urine (melanuria).
Lipochromcs.-These are pigmcnted fats containing
melanin, and are normally found in the corpus luteum.
Pathologically, they are present in xanthoma and ohloromao It is not yet decided whether the pigment in brown
atrophy of the -heart is due to ordinary melanin or to the
presence of lipochromes. (Lipochromes are also found
normally in oertain ganglion cells, and sometimes in degenerated nerve oells.)
Oe'hronosiB.-In this rare condition a dark pigment,
allied to melanin, is deposited in the cartilages throughout
the body (sometimes also in the aorta and kidneys).
rendering the patient conspicuous on account of the bluish
colour of his nose and ears. It often accompanies alkaptonuria. It has been observed to occul" after the treatment of wounds or sores by carbolic acid.
The 'hrematoge:nO'UB pigments are derived from the
breaking up of the chromocytes.
The hQlmoglobin meleoule is VIll"y complox. It is represented
approximately by CrMHIII1l3NIIIIl021SFeSs (Mann). Whon of no
further use, thc chrcmocytoa are broken down in the livor,
spleen. bone·marrow, and kidneys, the residual pigment being
decomposod into (a) the iron·containing Awfn08i,derin, which is
uaod in tho manufacture of new chromocytes; and (b) the iron·
free A_Iota'", whioh is ohiefly excreted as a waete product
by the liver in the torm ot bilirubin.
Hremosiderin. or iron·containing pigment. is found in
those diseases (e.g., pernicious anremia and malaria) in
which there is a pathological destruction of the chromocytes. In pernicious anremia large quantities may be
found. in the form of minute granules. in the cells of
the intermediate zone of the liver lobules. as well as in
the spleon. renal epithelium. and bone-marrow. In the
kidll&Ys it may be present in a diffuse form.
Hamtatoidin, or ironJree pigment. is generally derived
from ~xtravaBated blood, the hremoglobin being first converted into hrematin and then into hrematoidin. It is
often seen in the remains of old blood-clots in the form
both of granules and orange-coloured rhombic cry8tals.
which may remain unaltered for years.
Living cells appear to be neccssary for the elaboration
of hll'mosiderin. but not of hrematoidin.
Piumentation from Bile.-Jaundice is genorally due
to come form of obstruction to the outflow of bile from
thc liver and to its subsequent absorption into the circulation, by which it is carried throughout the body. The
pigmentation is the result of a diffu8e 8taining of the
tisRucs with bilirubin and biliverdin. and is specially
marked in tho conjunctiva. the skin. and beneath the
tongue. (The toxic effects of jaundice are probably referable to the bile salts.)
Extrinsio pigment8 are those introduoed into the body
from without. The chief examples areThrough the lungs {Carbon. cOld. Iron. or grit. depositod in
tho lungs and bronchial glands.
Through the ali-}
mcntary tract Arsemc. silver. deposited in the skin.
Through the skin: Tattooing.
The term 'necrosis' (neoru8i8, deadness) signifies death
of a limited portion of the bodily tissues. (When a considerable area of tissue is involved, the term gangrene is
l'he principalforrns of necrosis are: focal necrosis, fat
necrosis, coagulation necrosis, and caseation.
Focal Necrosis.-ln this condition numerous minute
areas of tissue--generally in the liver, 8pleen. lcidneY8,
or lymph glands-undergo a focal necrosis. The protoplasm of the part disintegrates. the cell walls disappear,
and a 'granular substance replaces the original tissue.
The necrotic foci may be pither absorbed or converted
into fibrous tissue.
The most probable cause is a toxin, which may act
directly by killing the cells outright, or indirectly by
causing capillary thrombosis. Focal necrosis occurs in
enteric f('lver, diphtheria, and probably in most of the
other microbic infections.
Fat Necrosis.-This is a condition in which localized
patches of necrosis are found in the fatty connective
tissues of the abdomen. In a large majority of cases it
is associated with pancreatic disease (e.g., hrcmorrhage,
abscess, gangrene). It is supposed that tlu fat.splitting
ferment (steapsin) of the pancreatic juice escapes, and
acts directly upon the parts affected. It is met with
typically in the BubperitoneaZ fat, in t,he omentulll,
mesentcry, and under-surfacc of the diaphragm, and is
most mal ked in the immediate neighbourhood of the
I)ancreas, often occurring in that organ itself_ Occasionally it is found in the pericardial fat and the medulla of
bone, in which situations it is probably due to emboli of
dctachtd p'tncreat.ic cells. In all these maces are to be
seen, scattered throughout the normal fat, small opaque
foci, ranging in size from a pin's head to a pea. The
affected areas stain with osmic acid and molt on heating.
Coagulation Necrosis.-This ocours when an area of
tissue suddenly dies and becomes converted into a homogeneous, solid, firmly-compacted mass. It is probably
always toxic in origin, and the cells in dying give rise to
coagulins, which, uniting with the lymph, cause it to
coagulate. The tissue must be a very cellular one, and
an abundant supply of lymph must be present. The
cmbolio infarction in the spleen and kidney form the most
typical example.
Zenker's Degeneration is now regarded as a form of ooagulation necrosis. It aJleots musole fibres: theso swell and loso
their transverse striation, while the muscle-proteim ooagulate
into II. olear homogeneous material., whioh soon breaks up into
shiny masses of irregular shape. Zenker's degeneration is met
with in oontinued tevers, notably onterio, and is ohiefly met
with in the abdominal musoles.
Caseation (caaeua, cheeso).-This is a post-necrotio
change in whioh the cells disintegrate, lose their outline
and nuclei, and are converted into a yellow, homogeneous
cheesy mass, composed of desiccated cells, fatty dbbris,
and cholesterin orystals. It is most often met with in
tubercular and gummatous formations and in certain
rapidl~-growillg tumours, and is due in part to the cutting
off of the blood-supply by thrombosis, and in part to toxio
By atrophy is meant decrease in the size alone, or in
both the size and number, of the elements of a normallydeveloIl6d tissue. The condition has to be distinguished
from hypoplasia, in which there is defective development.
It affects essentially the functionating elements (i.e., tho
parenchyma) of an organ. Thus, in muscles it is the contractile substance; in glands, the secreting oells; in n~rves,
the nerve fibres. The connective-tissue stroma either
escapes or 'becomes hypertrophied.
Physiological atropby, Buch as ocours in tho thymus, in tho
uterus after parturition, in tho ovaries atter tIle menopause, is
known as inllOlulion.
The protoplasm of an atrophying oell becomes un.
wontedly clear, staining less tha.n norma.lly, and the
nucleus disappears. Often there is increased pigmentation
__ phenomenon well seen in brown atrophy of the senile
Atrophy may be general or local.
Causes of General Atrophy.-General wasting of the
tissues may be caused either by:
Decreased, anaboli8m, the result of impoverishment of
the blood, such as occurs in starvation-e.g., that caused
by cancer of the <Esophagus and stomach; or by:
Increased, katabolism, such as occurs in severe fevers,
tuberculosis, congenital syphilis. In these cases the
general wasting is chiefly to be ascribed to the action of
toxins in augmenting katabolism. The wasting which
occurs in Graves' disease and from the administration of
thyroid extract is also due to heightened katabolism, the
thyroid yielding, to the blood some substance which plays
the part of a vital bellows, causing the vital fire to blaze,
as it were.
The Causes 01 Local Atrophy ar&L688ened, Funr.tional Activity-e.g., atrophy of the
muscles of an arm or leg encased in splints.
EXC68Biv6 Functional Activity.-Usually this is pre·
ceded by hypertrophy. Exo.mples are: the sterno·
mastoids and other cervical muscles in emphysema, and
the biceps hrachialis in file-grinders.
P"688ure-e.g., atrophy of the bodies of the vertebrm or
sternum owing to the pressure exerted by an aneurism;
atrophy of the liver cells caused by the pressure of the
fibrous tissue in alcoholic cilThosis.
Defective Neurotrophic Influence-e.g., facial hemiatrophy. We are still in the dark as to the pathology of
this curious affection, but it is probably nervous in origin.
The cha.nges which take place in the muscles in consequence of disease of the lower motor neurones are rather
of the nature of degenera.tion than atrophy.
Dimini8hed Blood-Supply-e.g., atrophy of the testis
caused by pressure on the spermatic artery by a tumour.
Here, again, the changes are degenerative rather than
simply atrophio.
Normal growth is determined by impulses inherent in
the zygote.
By hypertrophy is meant an abnormal increase in the
BUB of the tissue elements. If the tissue elements increase in number the term hyperpla8ia is employed. As
a rule, hypertrophy and hyperplasia go hand-in-hand.
True hypertrophy must be distinguished from pseudo·
hypertrophy. In the. former there is hJPertrophy principally of the parenchyma; in the latter, of the connective
tissue only. Thus, in pseudo-hypertrophio paralysis some
of the muscles may appear to be enormously enlarged,
but the enlargement is brought about by the increase of
fatty and fibrous elements, the muscle fibres themselves
having largely disappeared.
The usual cause of hypertrophy is increased functional
use, which is always accompanied by increased bloodsupply. Familiar examples are hypertrophy of the heart
in valvular disease, of one kidney when the other is removed, of one leg when the other is crippled or paralyzed.
Muscular hypertrophy, if excessive, is liable to be followed
by atrophy.
In some cases hypertrophy is due to the influenoo of an
internal secretion (hormone), of which acromegaly and
gigantism are examples (see Hormones, p. 190).
The blood, which constitutes about 5 per cent. of the
body-weight, consists of the plasma, in which Hoat the
The plaBma contains oxygen, nutrient proteins, carbohydrates, fats, and salts, as well as a multiplicity of other
less-understood substances necessary to normal nutrition
(such as hormones and vitamines), and waste products.
It is continually oozing through the thin walls of the capillaries to replenish the lymph.
The lymph, which is a diluts plasma, forms a vast
irrigation system between all the cells of the body, being
the medium of exchange between the blood and the tissues,
conveying to these latter nutrient material, and carrying
off their waste products. It provides the cells of the body
with a saJine medium reminiscent of that inhabited by
their far-off ammboid ocean ancestors.
The blood-corpuscles are of three kinds:
The coloured, called Ck1'O'TllQCyt68 (or erythrocytes);
The blood-platelets "
The colourless, oalled leucocyt68.
The Reds.
The red blood -corpuscles are cBllod byvnriousna.m~hromo­
cytes, erythrocytcs, etc. For convenience tbey nre referred to
The reds of all mammals in health are non-nucleated
(except in embryonic life and immediately after birth),
I and their numbers approximately are 5,000,500 per cubic
millimetre. The average diameter of each is 7·5 II(lr!hm inch), and in health does not vary more than 1 p in
extent. (,]~ho micron [p] is the microscopic wlit of length
_=0. micromillimetre=nllii'l part of a millimetre=nlioo
inch.) Their shape in all mammals (except the camel) is
that of a biconcave disc. This shape is due to· the fact
that the original spherical body of the parent cell shrinks
with the disappeaxance of its nucleus. Their average duration of life is about three weeks.
Bource.-The immediate ancestor is the normoblast of
the red bone-marrow. As it passes into the blood-stream
the nuclous becomes extruded, and the original spherical
body col\apses int) a biconcave disc. In the fmtus all the
reds are normoblastB.
Bt.ooa-Platelets (Thrombocytes).-These are discoid. bodies,
measuring about a quartor of the diameter of the red blood-ceIl.
Some regard thlllIl as a third kind of blood-ceIl, others but as
artefacts. Probably thc latter view is eorrect, because in a
recently-made blood-111m few are scen, whereas they inereaso
in number after tho blood is shod.
Pathological Reds.
Undel' certain pathological conditions the rods oro subjeet
to variations In sizc, shape, and structure. Also, tho eolour
may vary-tile cell may be llndercoloured (hypochromasia),
or overoolourod (hllPerch.romasia). 1Il0reover, witll the Roman-
oskl's stains, Instead of a roddish·plnk (as with tho normal
reds), it may be uniformly purplo (polttMromaBia), or show
minute bluo granulos (punctate basopkilia).
Non·nuoleated{ Gigantooytes.
Nuoleated, or MegaJoblo.sts.
erythrobl&sts { Glgantoblasts.
M icrocytes vary in diameter from 3 p, to 6 p,. They are
found in most forms of 8llIIlmia.
M egalocytes vary in diameter from 8 p, to 16 p,. They are
typically met with in pernicious a.n.almia, but they may
be present in any kind of severe anremia.
GigantOC'l,Jtes are enlarged forms of megalocytes. They
may exceed 20 p, in diameter.
Poikilocytes (oval, pear·shaped, or fiddle·shaped) are
present in many varieties of anmmia.
I, Normal red; 2, mlm-ooyte, 3, maorooyte; "
5, normoblast; U, megaloblast; 7. glgantoblast.
Nucleated Retl8 only display thoir nuolei when stained;
they are present during intra·uterine life, but are never seo~
in healthy blood after birth, exoept for tho first few days of
life. They are found especially in pernioious anremio.,
but thoy mo.y occur in any severo kind of anremia. They
are of four varieties. according to their size:
Normoblasts (blastos= bud} are of the same size as the
normal reds. They are normal to the red marrow, and
pass into the blood minus their nuclei, to become reds.
In the faltus the reds are all normoblasfis. They are
fonnd in allanremias, with the exception of chlorosis.
Megaloblasts are of greater size, and even doublo that
~f the normal chromooytes (10 '"
to 16 '" in diameter).
The nucleus. which may occupy two-thirds of the cell.
stains faintly with the nuclear dyes. Megaloblasts occur
in pernicious anremia. and in the anremia of Ankylostomum duodrmale and of Dib:JthriocephaZu8 latU8•
•GigantoblaBts.-These resemble the preceding, but are
larger. sometimes exceeding 20", in diameter.
Microblasts are small nucleated chromocytes. They are
found in all forms of anremia, and are of but little diagnostic importance.
Colour Index-Estimate of the Amount of
Decrease in the number of the chromocytes and
decrease in the amount of hrem~lobin in. the blood do
not necessarily go hand-in-hand. The severity of most
anremio.s is better estimated by the quantity of hremoglobin than by the number of reds; in chlorosis, for
oxample. the number of reds may be .but little, if at all.
diminished, while the amount of hremoglobin in ·each
individual red may be much reduced.
The amount of hremoglobin (Bb) in each individual
red (R) is called the colour index. It is the ratio of tho
hremoglohin percentage to the corpusole percentage.
The oolourindexis obtained by means of the formul_
Percentage of
In hcaltp - 100
In chlorosis 60
In pernioious
Percontage of
t&S. or 1
1&, or 0-5
fS, or 1'0
Leucooytes (or Whites).
In fmtallife the leucocytes make their appearance later
than the reds.
, In normal blood the proportion of leucocytes averages
8,000 per cubic millimetre. their ratio to tho reds being
thus as 1 to 600 or 700.
The lcucooytes dlaer amongst themselves both with regard to
tho form of the nuoleus and the oharacter of tho cytoplasm.
In some the nucleus is single aud the cytoplasm non-granular;
in others the nucleus is multiple or polymorphic and the cytoplasm granuIa.r (either fine or coarse). Ehrlich has divided the
granules into throe. according as they stain with o.oid. al.lmline.
or mixed dyes. naming them respectively eosinophile, basophile.
and neutrophile granules.
Tho leueocytes are namod elther aceordlng to tho' cbaraotor
of the nucleus or aocordlng to the oharacter of tho granules.
so that more than ono name has been given to the same coIl.
The following classitlcation is based on nucleation:
Pe,. Oent.
Small mononuolears = 22 to 25
Large mononuolears = 2 to 4
=70 to 72
= 2 to 4
(,,) Dasoph!le(mastcolls)= -r5
Some authorities describe a hyallne leucocyte Intermediate
between (a) and (b).
{ (b)
Polymorphonuelears { (IJ)
Thc 8mall mononuclear is 6 I' to 12 p. in diameter.
Cytoplasm is non-granular. It contains a large. spherical.
deeply-sta.ining nucleus. which oooupies almost the entire
cell. It is non-amreboid and non-phagocytic••
'.1 •.,::•
1. Small mononuolear; 2. largo mononuclear; 3. neutrophile;
4. eosinophile; 5, basophllo.
The large mononuclear is 10 f.t to 20 p. in diameter (the
macrophage of Metchnikoff). Cytoplasm is non-granular.
Its nucleus stains less intenscly than that of the sma.ll
lymphooyte. It is amreboid and phagoopw. In malaria
QUs variety is usually abundant.
The neutrophile (the miorophage of Metohnikoff) is 9 f.t
to 12 I' in diameter. Cytoplasm is finely granular. the
Pathological Leucocytes,
The mllelocute8. normally tound In bone·DUIorrow. but never
present In healthy blood, are regardod as tho parent colls of all
tho polymorphonuolears (00le diagram).
Neutroph1le MlleIocute (15 to 20 ,...).-Tho parent 0011 of tho
neutrophile. Contains numerous fine neutrophile granules.
The nuoleus Is largo, single, and stains feebly. Charaoteristio
of myelmmlu..
EosilllOph1le MlIeIOCl/le.-The parent oell ot the oosinophlle.
Similar in size and shape to tho formor. but tho granulos are
large and ooslnophile. Found in IDyelmmia.
BaBOphile .lIf1lelocvte.-The parent cell ot the basophile.
Smaller than tho two former. with basophile oytoplasm. Found
in myolannla.
Myeloblast (10 to 20 ,...).-Largo nucleus. cytoplasm·
lar, and dyes 0. • pigeon's egg' bluo with Leishman's stain.
Probably tho parent coli of the myolooytos (Vide diagram).
Found in abundance in myelrumla.
Plasma Cell (' InfIammo.tory Leucecyte ': 10 to 20 ,...).Usually peo.r-shaped, with a single nucleus placed at one end.
By the Unna·Pappenheim method the cell oytoplasm stains 0.
brilliant red. Often found in largo numbers in subacute In·
i'flammatory fooi. Probably derived frOm the lymphooyte, and
iPorhaps elaborates a digestive terment.
Origin 01 Blood-Corpuscles.
According to Pappcnhoim, tho oommon ancestor of all the
blood colls is the lymplwidocyte, the rods and most of tho whites
being born In the marrow, the largo mononuoloars in tho spleen,
and the small mononllclears in tho lymphatio tissue genoralllY
Up to tho sixth month oUcetalllfe tho lympholdooyte is the onI
blood-oell found in tho lymph nodos and marrow. After blrt
it is nover tound In tho periphora.l olrculatlon in health, bu
ma.y be present in certain dlsooses. Tho accQJD.panyln
dfagram (Fig. 4) illustrates the pedlgrco of the blood-ooUs.
In Inlanoy and ohlldhood bone-marrow Is composed of a tissuo
rosembling the splenio pulp, tho red or lymphoid marrow. By
the ago of publlrty tho red marrow In the shafts of long bonos
has beon largely oonvortod into fat-tho yellow or fatty marrow
-that in tho epiphyses, tho flat and tho short bonos, still remaining red. Interspersed thronghout the reil marrow are
Isolated oOIOnl08 01 oells, some composed 01 normoblasts and
others of myoloo;rtes, In various stages of evolution. In old
ago tho fat Is to a considerable oxtent replaoed by fibrous and
gelatinous tissue, and the same r08uIt may be bronght about by
dobllitatlng diseascs.
Fuootions.-Bone-Inarrow Is tIm manufaotory and storehous6
for all the rod blood·oolls, and most of tho white. If thero Is an
urgont call tor more reds, there Is an • er;rthrobIastlo' r08p0ll86;
It the oallis tor moro whltos, thore is 0. ' loueoblastlo ' respODse.
Pho.gooytlo--'.e., for I'neumoooool, streptooocci, staphylocoooi.
By this term is meant an increase in the total number
of leucocytes in the blood. Any number over 10,000 per
cubic millimetre may be regarded as constituting leucooytosis, so long as tho increase lasts sufficiently long. (A
physiological leucocytosis occura from three to four hours.
after every meal, when the leucocytes may reach from
10,000 to 12,000 per cubio millimetre, but this soon passes
off.) It may also occur after the administration of certain
drugs-e.g., salicylates, chlorate of potassium, and phenacetin. as also after giving thyroid extract, bone-marrow,
and nucleic acid. It ha.s been observed after opemtions.
Leucocytosis is natura.l in pregnancy and childhood
(lymphocytosis), just before death, and after exercise and
I \
Apart from these conditions, it may be affirmed as a
general principle that a leucocytosis means an infection.
The presence or absence of loucocytosis may be of
material aid in forming a diffcrential diagnosis, as, for
example, between pleural effusion and empyema, a leucocytosis reabhing to 20,000 per cubic millimetre being
indicative of the latter; again, a leucocytosis of 20,000 per
cubic millimetre )Jas lcd to the deteotion of an hepatic
abscess or a pyosalpinx.
Again, a rising leucocytosis in a local disease like appendicitis means that the inflammation is spreading, and
that an operation is imperative, even though the abdominal symptoms are slight.
Leucocytosis may assume either (a) a. general or (b) a
Bingle type.
(a) General ltucocytosi8 occurs in all the general infections,
except enteric (provided there are no complications),
paratyphoid, measles, German measles, }lalta fever,
malaria, mumps, influenza, miliary tuberculosis (when unaccompanied by a mixed infoction), and leprosy. The
leucocytosis in all these cases begins early; its degree
depends on tho severity of tho infection, on the nature
of the infective agent, and it increases until the disease
has reached its full development. If, however, the infeotion be of great severity, the leucocytosis may be slight or
absent, owing to toxic paralysis of the leucoblastic function of the bone-marrow. It a.lso occurs in certain cases
of malignant growths (especially of the thyroid and
panoreas), and after hmmorrhages.
(b) Bingle-type leucocyto8is :
All local inflammations, cspoolally
When accompaniod by suppuration; pneumonia; the incuba(I.) Neutrophile
tlon period of the speeifio foVorB,
{ except thoso in whioh thoro is
no louoooytosis.
Whooping-cough, rickets, scurvy,
himnophUia, s?'P~lis, ~ympho(Il.) Small mononu.,loar
{ sarooma, cortam infantile dlarrhmaB.
This form suggests a protozoon disease, suoh as malaria, trypano(ID.) Largomonolluoloar
somiaBie, kala-azar, ammboid
{ dyS8I1tory, relapsing tever. also
Asthm.a. emphysem~. eozema. urticarla, psoriaBis, lupus. pomvhlgus. triChinosis. ankylostomln.-J
{ sis. Hilbarzia hmrn.atobia. goutt
IIrlllIDia, muoous colitis.
Basophile leuoooytosis is unknown.
(iv.) Eoslnophilo
i'he ,Purpose of Leucocytosis. L/
The essen~ial purpose of leucooytosis is to aid the
resistance of the body against bo.oterial invasion by
inoreasing the number of phagocytes, and the gr~a.ter
!JIihe degree of leucocytosis the better the prognosis. It is
(evident that during the course of an infection the bonemarrow (and in tha case of lymphocyto3is the lymphoid
tissues) is stimulated to increased leucoblastic activity,
and, accordingly, we must postulate that the bacteria give
off a substance which, passing to the bono-marrow,
induces there an augmented produotion of leucocytes (see
Chomotaxis, p. 42).
In this condition there is a decrease in the Dumber of
leucooytes. It ooours in pernicious an;emia, in very severe
anmmias, in splenio an;emia, in the early stages of enteric,
in measles, in pneumonia (if alcohol, or fatal), in kala-azar,
in dengue, in Banti's disease, and in malignant disoase of
the c.esophagus (= starvation leuoopenia). It has also been
observed after the administration of large doses of quinine,
atropine. otc.
The term' an;emia j·.-li~?a.lly means' want of blood.'
but in the following it more partioularly refers to abnormal
conditions of the red blood-cells.
(l'he red bfood-celllives but a few week", and then, its
duty done. its mission fulfilled, dies of senile deoay.)
It is obvious that an anremia may result either from
interfrgence with. h.omwgenesi&--i.e., dofective blood formation; or from lumnolyai&--i.e., blood destruction. These
two faotors may co-operate.
Oligmmla= a In tho total qnantlty of blood.
Oligooythmmia= a decrease In the number of reds.
Oligoohrommmla==& deorease in the amount of hlllID.oglobln.
Chlorosis is almost entirely confined to young women.
The disease commonly begins about puberty-that important period of lifo when the girl-child is being transformed into the young woman. Want of fresh air and sunlight, defioientexeroise, unsuitable feeding, ooourring at the
most oritioal epoch in a woman's life, appear to be the most
important contributory oauses. It is likely that the actua~.
oause is an infection that throws out of order the bloodforming elements of the bone-marrow. Suehinfectio
possibly originates in the alimentary tube. (Certainly
many oases can be oured by the administrd.tion of purgatives alone.)
Blood Changes.-The specific gravity and composition
of the plasma are normal. The outstanding feature of the
disease is that the amount of hremoglobin in eaoh in·
dividual J:Bd cell is below the normal standard (anochro·
masia), the hlllIIloglobin being ohiefly colleoted in a ring
around the margin of the cell, the centrd.l portion oontaining
but little. The colour index may fall as low as 0·3.
Th~ plasma is increased in amount, the volume of blood.
being greater than, in, health (plethora). Notwithstanding
the faot that the number of ehromooytes per cubio millimetre is generally reduced (sometimes to as few as
2,000,000), their entire number must be increased, for,
as Lorrain Smith has shown. the total quantity of hremoglobin in the blood is normal in amount.
l'tIicrocytes and poikilocytes are often present, and in
severe eases megalooytes, normoblasts, and even megaloblasts.
Although the number of leucocytes per cubic millimetre
of blood is reduced, there is no leucopenia in the proper
sense of the word, owing to the increase in the volume
of the plasma.
Oomplicatio1Ul.--<Edema, venous thrombosis, fatty de·
generation, visoera.l inflammations, optio neuritis.
Pernicious Anmmia.
This disease was originally described by Addison under
the namo of idiopathic anremia, and is charaoterized by
remarkable changes both in the blood and bone·marrow.
Blood Changes.-These changes are of the nature of
reversion to the embryonal type of blood. Specifio
gravity is lower than normal; the total quantity of the
blood is normal. The chromoeytea are much decreased
in number; when the case first comes under observation they may number only 2,000,000, and towards the
end may sink to 500,000, per cubic millimetre. In a
case of Quincke's they were only 143,000 per cubic millimetre. The number, however, often oscillates within
wide limits. Under treatment periods of temporary improvement may ollcur.
Each individual red blood"ceil contains an excessive
amount of hremog!ob·n (hyperchromaaia), the hremoglobin
index sometimes being as high as 1·S.
Every possible form of abnormal red blood-cell is to
be found-microcytes. poikilocytes, megalocytes, megaloblasts, gigantocytes. and gigantoblasts. Megaloblast8
are generally abundant, and on this oircumstance the
diagnosis of pernicious anremia is usually founded. The
nucleated red cells may appear suddenly (= blood crisis).
Leucocytea.-As a rule there is leucopenia, especially
noticeable with respect to the decrease in the number
of polymorphonuclear neutrophiles (occasionhlly myeloblasts are present). The number of leucocytes in somo
cases is as low as 1,000 per cubic millimetre.
HCBmOBide:rin (or iron-containing p;gment) is found in
the liver, spleen, and kidneys (the kidneys may contain
fifty times more iron than usual).
Bloodve8sel8.-There is a great tendency to hillmorrhages in the skin, retina, brain, uterus, and sorous mombranE's.
Bone-Marrow.-The yellow marrow of the long bones
reverts to the megaloblastic fmtal type--i.e., is transformed into a red lymphOid tissue, suggesting red-ourrant
jelly in appearance, and containing a large number of red
~nuoleatcd cells and megaJoblasts. The myelooytes are
[diminished in number. Tho yellow marrow Jargt"ly disappears, and much of the surrounding bone is absorbed, so
as to make room for the new marrow.
Bean.-Fatty degeneration always oceurs, the' thrushbreast' markings usually being eonspicuous on the left
Liver.-Usually enlarged from fatty degeneration. If
the cut surfaco be treated with ferrocyanide of potassium,
and afterwards with hydrochloric acid, the lobules become
mapped out by TingS of Prussian blue, owing to the
presence of free iron (hoomosi'derin) in the peripheral and
middle zones.
8pleen.-Oocasionally shows the presence of hromosiderin.
Kidneys.-Usually show fatty degeneration (especially
of the convoluted tubules) and the presence of hremosiderin.
Tho gastro-intestillal mucous membrane usually shows
N ervoua 8ystem.-Sclerosis of tho posterior columns of
the cord may be present.
The actual causo is unknown. It may be due either
to somo form of malignant disease of the bone-marrow
causing the Ied cells to be turned out higgledy-piggledy,
or to some hwmolytic poison in the blood (in the infectious
pernicious anremia of the horse the blood-picture is much
the samo). The disease is generally fatal within two years
Amongst the causes of Bevore anmmia. which may be BO intenso
as to simulate pernicious o.nmmia.·standlng small
10ss68 of blood (blooding piles. bleeding' ftbreids,' otc.); chronie
septio infection (ulcerative endocarditis septic bladders from
enlarged prostate, eto.); carcinoma. of tho stomach; syphills;
phthisis; mo.larla; infection with tho Bolh'l'iocephaJus latus a.nd
Ankyloatomum duodenale.
Splenio AnlBmia (or Primary Splenomegaly).
This very chronic discase is characterized by a great
enlargement of the spleen, progressive a.memia of the
chlorotic type. and leucopenia. There is 0. tendency to;
lumnatemesis. melama. and epistaxis. The lymphatic
glands are not enlarged.
The chromocytes are diminished in number, frequently
fa.lling to 2,500.000 per cubic millimetre, and occasionally
to a smaller number. The hremoglobin index is considerably below the normal, varying between 0·5 and 0'7. The
leucocytes may fall to 800 per cubic millimetre.
The enlargement of the spleen is uniform~ and may be
considerable; there is great increase of the stroma, and
the Malpighian bodies are atrophied and transformed jnto
fibrous tissue.
Banu's Disease.
This is a combination of splenic anmmia with multi·
lobular cirrhosis of the liver, causing jaundice and ascites.
Hremorrhages from the skin and mucous membranes are
According to Bantl (who has collected fifty oases), thero are
throe stages: (a) The pre-ascitic, characterized by splenomegaly.
This stage generally lasts throe to five years. (b) The intel'·
mediate, characterized by anmmia, leucopenia, with relative
Increase ot the The liver is somewhat enlarged,
and diarrhroa may come on. This stage lasts trom twelve to
oighteen months. (c) The final stage is characterized by
ascites, shrinkago of the liver, general wasting, and gastrointestinal hremorrhages. The duration ot this stage varios from
a tow months to a year.
Leukremia. is a disease characterized by an enormous
'and persistent increase in the number of leucocytes in the
:blood as the result of pathological changes in the spleen.
[bone-marrow, or lymphatic glands, or in any two or in all
three of these. Hughes Bennett, in 1845, first drew atten·
tion to it, describing his case as one of 'suppurationof the
blood.' Later in the same year Virchow recorded a
similar case.
Two chief forms are recognized-Cal myelremia and
(b) lympktBmia. and there are probably many in~rmediate
(a) lIyelmmia (Spleno-MedulIary).
In some cases the blood is merely thin and pale, with
coagulation imperfect. or it may look like a mixture of
blood and pus, while in extreme cases it may resemble pure
pus. The leucocytes are enormously increased. ranging
in number from 50,000 to over 1,000,000 per cubic millimetre (but this is ro:ubjeot to fluotuations). All types are
represented. both the normal and abnormal. At first the
polymorphonuclear neutrophiles are the most conspicuous,
but as thc disease advances myelocytes become predomin.
ant (basophile. neutrophile. eosinophile myelocytes amI
myeloblasts), constituting from 30 to 60 per cent. of all
leucocytes present. Basophile leucocytes (mast cells)
are also abundant. Sometimes the lymphoidocyte-the
original ancestor of the blood-corpuscles--may be found.
During the earlier stages there is no reduction in the number of reds, but later on they diminish, and normoblasts
and megaloblasts appear on the scene.
The 8pleen increases enormously, and may wcigh
18 pounds. It is often adherent to the surrounding
viscera. On !fection it is pale, the splenic pulp and fibrous
stroma are-seen to be greatly increased, and the l-lalpighian
bodies are indistinct. Numerous yellowish necrotic areas
of infarctions (probably thrombotic) may be seen in its
The bone-ma"ow is hypertrophied and highly vascular,
and, owing to the presence of enormous numbers of myeloeytes (in all stages of development), it presents a oreamy
'.rhere are accumulations of fat in the heart, liver, and
The urine contains an excess of urie acid-probably
derived from the disintegration of the leucocytes.
Charcot-Leyden cry8tals are sometimes found in the
blood after its removal from the body. They are octahedral in shape, and are probably a crystalloid product of
either the plasma or the leucocytes.
Hremorrhages, especially from mucous membranes and
retina, are common.
Acute MlIelwmia.-This runs a rapid coursc, with a great
tondonoy to profuse hromorrha.ges. The most striking bJoodohange is the predominance of myeloblasts.
(b) Lymphmmia (Lymphatic LeukIBmia)
This form of leukremia is associatcd with onlargement
of the lymphatic glands throughout the body, and often
of the lymphatic tissue of Peyer's patches. and of other
parts where this tissue is found. These may attain the
size of walnuts. Examined microscopically, the glands
show a uniform hyperplasia of their lymphoid tissue,
which is packed with lymphocytes. The spleen is also
enlarged. There is a great increase in the number of
leucocytes (100,000 to 500,000 per cubic millimetre), of
which theZymphocytea constitute from 80 to 98 per cent.•
in somEl cases the small mononuclears and in others
the large mononuclears preponderating. In most instances the reds are reduced in number. and in the acute
forms the hl8moglobin index falls below the normal
(between 0'5 and 0'7).
Lymphmmia may be either acute or chronic. but there
are ~ransitionnl forms. The acute is much the more
common, anti may occur at any age from birth to over
se'fenty. more than two-thirds being maleS. The blood.
picture is variable, and changes widely from week to week
in many of the patients. The rule is that the moro acute
t_he course, the more immature the prevailing typ3 of
leucocyte; thus. in rapidly-fatal cases the prevailing type
is the common parental form-the lymphoidooyte. The
blood-platelets are strikingly few in most •oases. The
bone-marrow is red and difRuent. There are often
hmmorrhages into the skin, from mucous membranes, and
into the various viscera. and there is little doubt that
many oasos have been mistaken for the 'hl8morrhagio
diathesis.' In many ways acute lymphmmia resembles an
acute infection, or septicmmia, though. 8.S yet, no causal
organism. has been detected.
Hodgkin's Disease.
Described by Hodgkin in 1832. Cha.ra.cterized by a
'progressive, painless enlargement of many groups of
lymphatic glands throughout the body, with which is often
associated the growth of scattered patches of lymphoid
tissue in the spleen. liver, kidneys, testes, lungs, and
medulla of bones.
The disease genemlly starts in a single group of glands
(frequently those of the neck). and then extends to other
groups, more particularly selecting those in the axilla.
groin, and mediastinum (but no group is exempt). The
enlargement differs from inflammatory affections in that
the glands generally remain free and distinct, forming
smooth, rounded, or egg-shaped, firm, elastic swellings,
the skin over them retaining its natural colour and remaining non·adherent. (In exceptional cases the glands
fuse together to form a large lobulated mass.)
On section, the gland appears greyish-white, and a
microscopio examination shows that the normal tissue is
largely replaced by a delicate reticulum, in the meshes
of which are numerous mononuclears, eosinophiles, and
endothelial cells. Occasionally a few giant cells containing
one or two large nuclei (with nucleoli) are present. At a
later stage the reticulum organizes into dense fibrous tissue.
The Blood.-At the' commencement of the disease the
blood is normal; later on anmmia of the chlorotic type
develops. Except when the glands inflame, there is no
leucocytosis. The disease is much commoner in men than
in women, and is alwaIB fatal-either from pressure on
important structures (veins, nerves, trachea, msophagus,
etc.), or from asthenia.
Judging by the way the disease begins in one group
of glands, and then gradually extends to involve other
groups, the probable cause is an infection.
This is a very rare disease. A.ccordlng to Sternberg, It is
distinguished by the following clml.'8cters:
The presenco of lymphoid (:rowths In the orbits, temporal
fOSSDl, dura mater, and mediastinum; the greenish colour of
these growths; the studding of the bone-marrow, spleen, lympba.tlo glands, and viscera. with lymphoid deposits; an cnormous
Increase of the lymphocytes. The growths resemble lymphosaroomata In structure (Ilide p. 88).
Inflammation is essentially a defensive prooess, being
Nature's carefully-planned and cunningly-executed fight
against the action of noxious irritants. In the large
majority of cases the irritants are the soluble toxins of
micro-organisms. Cases of inflammation resulting from
the action of non-bacterial toxins-e.g., gout, and the
pericarditis of Bright's disease (but even here it is impossible absolutely to exclude the presence of bacterial toxins)
-may perhaps be explained on the supposition that the
tissues mistake, as it were, a non-bacterial poison for a
bacterial one. Such agents as heat, electrioity, Rontgen
rays, mechanical irritation, initiat,e inflammation, probably by facilitating the play of toxic forces, especially
of those produced by the innumerable microbes which
always lie buried between the celfs of the epidermis.
(More than 100 different varieties of bacteria have been
demonstrated on the skin.)
Seeing that bacteria play such a dominant part in
setting up inflammation, anything which diminishes the
bactericidal power of the body necessarily predisposes to
it. It is in this way that sbtes of so-called 'lowered
vitality,' such as may result from privation, fatigue,
chronic alcoholism, Bright's disease, diabetes, may coopero.te in the causation of inflammation (vide Immunity).
Phenomena of Inflammation.
(1) First an initial contmction of the arterioles, immediately followed by
(2) Dilatation of the same arterioles (probably due to a
toxic paralyzing of the muscular tunica mcdia) with
flushing of the capillaries and widening of the venules,
with acceleration of the blood-stream; then
(3) Retardation of the blood-stream, with accumulation
of the leucocytes along the walls of the bloodvessels, the
endothelial cells of which swell up.
(4) Active migration of the ltJUCOCytes, especially of the
neutrophiles, into the surrounding tissues. (Metahnikoff
regards this as the essential feature of all inflammations,
because they ingest the causal bacteria.)
(5) Synchronous with the escape of the loucocytes is the
exudation of the lymph into the surrounding tissues in
abnormal abundance· (' inflammatory redema '), the
amount of which is determined by the nature of the
particular toxin causing the inflammation. (The exuded
lymph is richer in proteins than the ordinary lymph, and
is usually coagulable.)
, (6) Late in the process, the' :reds,' which do not possess
the power of independent locomotion, are squeezed
through the capillary walls.
(7) Stagnation of the blood-stream. The blood-cells now
cease to pass out.
(To compensate for the loss to the blood of so many
leucocytes tha.t have migrated to the inflamed area, there
is an inoreased output of leucocytes from the bone marrow.)
Me.r.nwhile, the fixed tissue cells of the part swell up,
dud may undergo cloudy 8'U!elli'tl{j, and even/atly and mucoid
Should the bacteria be easily exterminated, the e:mdate
and leucocytes are absorbed by the lymphatics, passed on
to the nearest glands, where they are disposed of; thc
damaged cells of the inflamed area recover, and the part
resumes its normal condition (r68olution, or r68fJitutio ad
Inflammation i8 a defensive operation. The neutrophiles
and the large mononuclears possess the power of ingesting
bacteria. and for this reason they have been named by
Metchnikoff phagocytes (phagein. to eat). • The phago.
cytes, having arrived at the spot where the intruders
are found, seize them after the manner of the amrebm, and
within their bodies subject them to intracellular digestion'
(Metchnikoff). Seeing that the purpose of inflammation
is the extermination of bacteria, the migration of the
leucocytes thus tends to remove the cause of the inflo.m·
mation and bring it to an end. The exuded lymph serves
two useful purposes-(i.) it dilutes the toxin, and also,
neutralizes it by supplying antitoxins; (ii.) it acts as IL
bactericide ("ide Immunity).
Other Sequels 01 Inflammation: Fibrosis, Suppuration,.
Absoess, Uloer, Slough.
Fibr08i8.-If the. inflammation is mild but persistent,
the fixed cells of the area proliferate-notably the connective-tissue corpuscles and endothelium (muscle and
nerve cells do not proliferate, though their nuclei may);
and in course of time the derivatives of these cells organize
into fibrous tissue.
Suppuration.-If the phagocytes and tissue cells are
beaten and the fight won by the bacteria, then suppuration occurs. The phagocytes, notwithstanding their large
output from the bone-marrow, are unable to cope with the
virulence of the infection, and die; the vessels become
thrombosed, the tissues are dissolved (histolysis) by the
peptonizing action of the bacterial products, and pU8 is
formed-i.e., a fluid composed of exuded lymph and of the
liquefied and digested tissue, holding in suspension dead
polymorphonuoleal'll (mononuolear pus is very rare). If the
process now ends and the pus is evacuated, the cavity
up by the orga.nization of granulation tissue (see Repair).
Probably suppuration is always due to bacteria. In the
few oases in which they are not found, the likely explanation is faulty teohnique.
The usual organisms causing suppuration areStaphlll0c0caua PlIogeneB aUreuB{
StaphlllocoOCUB PlIouenes albus
75 perce~t. ot PUB
Staphlll0C00CUB PlIogenes cUreuB
StreptocoOCUB p1/OUenes.
Ba~us PlIOC1/aneus.
BacUlus typ1&osus.
BacillU8 coli communi&,
In all cases of suppuration there is an early polymorphonuolear leucocytosis which is of great diagnostic importance, as it can often be discovered before the patient
feels ill. To explain this leucocytosis we must asswne that
some substance is given olf from the inflamed area which
stimulates the bone-marrow to the production of large
quantities of leucocytes (positive chemotaxis). This must
be so, for an ordinary-sized abscess would contain all the
leucocytes normally contained in the blood.
Ab8ces8, UZcer.-If the pUB is pent up in the tissues, the
condition is termed an ab8t;688. If, on the other hand, the
Jnfiamed tissue yielding the pus abuts on a surface, and the
Skin or mucous membrane breaks, the r.esult is an 'Ulcer.
Slough, Gangrene, N6Cf'08i8.-H the inflammation is of
such virulence that there is not time for the tissues to
undergo liquefaction and they die qUickly en bloc, while still
retaining their structure, the resulting condition is termed
a 8lough. If the dead part be of large size, the term
gangrene is applied. A portion of dead bone is called
The body temperature varies in different species of
Monkey ..
Leucooytosis ocours in all specifio fevers, with the excep-,
tion of enterio, measles, influenza, German measlest
malaria, Malta fever, dengue, and acute miliary tuberctJlosis. The absence of leucocytosis in lobar pneumonia
usually means death.
The rash of a fever is probably due to the irritation produced by the elimination of toxin by the skin, being thus
similar to the rashes sometimes found after the administration of oertain drugs-e.g., bromides, iodides, and
Changes occnrring in Fever.
Tho temperature is raised. Very exceptionally this
classical symptom is absent-e.g., in certain cases of diphtheria, septicamrla, typhus, and enteric, when there is
generally profound prostration, early coma, and doath.
The elevation of the temperature is in part due to increased
produotion of heat, and in part to defioient heat loss.
The pu18e·rateis accelerated, the average being4i beats
for each 1° F.
The respiration. is accelerated, and usually maintaining
the ratio in health-i.e., 1 to 4--except in pneumonia and
The 8ecretions tend to dry up--i.e., those of the skin,
mouth, alimentary tube, liver, pancreas, and kidneys.
The urine is scanty, concentrated, of high specific
gravity, deposits urates on cooling, and not infrequently
contains albumin (febrile albuminuria).
Metaboliam.-There is (a) i'llCreased kataboliam (the
nitrogenous waste-produots, urea, uric aoid, etc., are increased in quantity, as likewise is the CO2 ); and (b) les8ened
anaboliam (the tissue cells are less able to absorb nourishment).
Tissue Ohanges.-The body fat tends to disappear, the
liver loses its glyoogen, the muscles shrink, the're is cloudy
swelling of the epithelium, and often focal necrosis of the
liver, spleen, and kidneys. In some fevers, notably diphtheria, there is a marked tendency to fatty degeneration of
the heart. In rheumatio fever the heart (espeoially the
left ventricle) is probably always dilated.
Death in fevers generally takes place from heart
Oontagion is probably conveyed via. tho secretions, and
by these a.]on&-il.g., spraying the air during the acts of
coughing, sneezing; by the evacuations, fmcal and urinary.
No ono can be sa.ved unlos8 Na&lll'8 oonquers the disease; and
no one dios unles8 Nature succumbs (Galen, A.D. 130).
No ono recovers from a chronlo or acute bacterial disease
unless it be by the production of protective substances In bis
organism; no one acquires proteotion against disoase except,
again, by the production ot protective substanoos; and, finally,
no one llvosln the presenoo of infection and repels that infeotlon
oxoopt by the aid of protective substances in his blood (Sir
AJmroth Wright).
In the technical sense in which the term is employed,
immunity mea.ns the power the human body posseBBes of
protecting itself against the invasion of certain microbial
foes. 'rhe body, indeed, wa.ges a perpetual wa.rfare aga.inst
these foes, and it is only by unceasing vigilance on the part
of the tissues that their attacks can be repelled. (N.B.-In
tho following description, the term • microbe' is used in
the generic sense to include all micro-organisms, whether
bacterial orprotozoal.)
Infection is the term emPloyed When a dlseaso-producing
microbe enters tho body and Inultiplies therein.
Tho influence of miore-organlsms on the body depends mainly
upon the tozinB which thoyproduce.
The bacterial toxins (~ polson) ara poisonous substances allied to colloids. Just as oormin plants possess their
special allmloids (strychnine, morphin~. a.conltlne. otc.), so each
species of bacteria elaborates its own particular products. Bome
ot which may be useful to thoir host, Bome innocuous, and some
harmful. It is to those latter poisonous produots that Brieger
gave the name ot tozins.
It is to be understood that in speaking at tho toxins of a
particular bacterium IDe are re/erri1U} to solutions 0/ them, no
toxin having as yet boon isolated and analyzed as the vegetable
alkaloids have been.
It is probable that there are two kinds ot baeterial toxins:
(a) Those confined to the Interior of living bacteria, and only
liberated on their death (imraceUular, or endo-toxins); and
(b) Those yielded by living bacteria. to the medium outside
them Ce:z:tracellulal'. or exo·toxins).
(a) Intracellular TOJ:ins.-In this group, whloh Includcs tho
toxins of tho greater number of baoteriogenio diseases (amongst
others, thoso of lobar pneumonia, enterio fever, Malta fover,
cholora, plague, and gonorrhtea), tho toxin is looked up in tho
bodies of tho bactoria, not being liberatod till these degenerate
or dio, and then only whon tho baoIlli disintegrato. It is found,
In tho partloular diseases just roierred to, that It the baoterla
oausing them are grown in a roitable oulture medium no toxin
separates out 'by filtration through porcelain, whereas It the
bacteria aro frozen at the lowest of tomperaturos, and then
crushod, tho result is a highly toxio Bubstanco.
(b) Eztracellular T0J:i1l8.-In this group, whioh Includos ·the
toxins of B. diplotherim, B. telani, B. botulinus, too toxin
appoors to be of the natur~ of an exoretlon. U, for examplo,
the diphtheria or tho tetanus baolllus Is grown In a suitable
modiwn, soluble to:Din8 am/ouM to pass rna into the medium• ./'I"Um
which. theu can be separated by filtration thf'O'U(/h porcelain, tho
inferenoo being that tho baoilli in question exorete them (unless
we suppose that they produce thom by promoting some ohango
in the extcrnal medium).
Soma species of bacteria appear to produce both Intraoollular
and oxtrooolluIar toxins-e.o.• tubercle baoillus (probably).
Ehrlich assumes that 0. moleoulo of toxin oonsists of two
groups of atoms: ono tho haptophore [(h)apto=I fastenl, which
oombincs with the antitoxin; and another, tho to:t:Ophore, on
which tho toxic action depends (soo diagram of Ehrlloh's sldechain theory, Fig. 6). J!'or example, if diphtheria toxin be kept
for Bomo time it loses its toxic property, but retains its power of
combining with antitoxin-it has lost its toxophoro, and retained
Its haptophoro, group of atoms. Suoh a toxin Ehrlioh oalls a
ACtiOn of1'"OZi'ns.-·l'"o~lils appear tio um't!e Wil:ii tiiie protiopihsm
of tho tissues. In many of their properties, however, they
resemble ferments. ThusThey are destroyed by a temporature or from 140,0 to 11111 0 F.
They are preolpltatod by alcohol; they are unaffected by ohloroform and eth~r. Thoy can be swallowed with Impunity. Thoy
do not aot until aftor a latent period. They aot Irrespeotlvoly
of thequantityemployod--i.e.. an infinitesimal doso Is e1reotive;
6.11., r.A.. gramme of tetano-toxin will kill a horse 600,000,000
tlmoslts mvn woight.
FaI.e 0/ To:i:lns.-Ultimately toxins are partly oxoreted as
suoh (ohielly by tho kidnoys Bnd liver), partly burnt up in the
tissuos, and partly neutralizod by antitoxin.
Against infection the organism puts forth supreme
efforts. bringing into play various mechanisms which have
been laboriously evolved throughout millions of years
of time, Nature acting, so to speak, as her own physioia.n,
treating eaoh infeotion in a different way.
1. The physical resistance oflered by healthy and
intact skin and muoous membrane.
2. The phagocytio aotlon ot the tissue cells at the
site of infection.
S. IntiaIDllUl.tlon at the site of infection.
4. The extinction of the invading mlorobes and
their produots by the action of plmgocytos and
1. The Physical ReaiBtance offered by H.,et.utky and
Intact Skin and Mucous Membrane.--80 long as the
epidermis remains healthy and unfissured, bacteria may
oome into oontaot with it almost with impunity. To a.
less extent, the same remark applies to mucous membranes; microbic invasion of, or through, a mucous
membmne is more likely to occur when there has been
a preceding catarrh, or injury, of its I!Ilrface. (The gone<l0CCUS can invade the healthy urethral mucous membrane.)
Epithelial cells may, in a minor degree, exert a phagocytic
2. The Phagocytio Action of the Ti88ue ceUl at the Site
of lnfection.-Probably all tissue cells which contain
oytoplasm are oapable of exercising a phagocytio influenoe.
Certainly this is so in the case of endothelial oells, espeoially
those at the !MOUS lnem.'on.nes, 'ol.oodvesscls, and lympha.tics. In fact, phagooytosis may be regarded as one of
the primordial funotions of protoplasm, from the amc:eba
upwards. •
3. Inflammation ooourring at the aite of Infection.As pointed out in 8. previous page, infla.mmation is to be
looked upon as a local battle fought by Nature against
infection, for its effect is essentially bacterioidal and
4. The E~inction of the I nvad;,ng Microbe by PhagOOyt68
and Antibodies.
Should tho invadiog mforobe break through theee various
lilies of defence and gain admlttanoe to the-Inside of the body,
'Nature brings into play various defensive agenoies.
There wore tormerly two chiet theories to account for
generallm.mUDit,.-the • ceUular' theory of Metchnlko1! and the
• Immoral' theory ot Nuttall It Is now established that the
body employs both her • oell•• and her • humour. ' fD dealing
with Infectlollos. They are oommonly ]mown as phllgoo;vtes and
Phagocytosis (phagein=to eat; cyt08=a cell).-Metchnikoff believed that phagocytes ( = leucocytes and most
timme cells) are the essential agents in the destruction of
bacteria-the warriors which deal with the invading
army of microbes-and that other agencies play but a
subordinate part in the process. • It is the phagocyte,'
he says, • which delivers us from our enemies. Sometimes
the phagocytes devour at one swoop whole masscs of the
organisms.' He admit", however, the existence of a complementary substance-cytase--which is probably iden.
tical with the opsonin of Wright.
The phagocyte, as it were, • recognizes in the microbe
a foe to the organism; scents it from afar; hunts. seizes.
and digests it; and then, its duty done, its mission in
life fuHillei, it withdraws its pseudopodia and dies contentedly' (Adami).
The bacteria. engulfed by the phagocytes either undergo
intracellular digestion or are destroyed by a chemical
poison, probably related to nucleic acid and secreted by the
cell nucleus.
H the invading bacteria are very, virulent, thQY may kill
the phagocytes, or, if their spores have been taken up by
the phagocytes, these may develop within the phagocytes
and destroy them.
All leuoocytes possess phagocytio properties, but the
polymorphonuolears and the large lymphocytes are by
far the most powerful in this respect. Beside tne_leuco.
oytes, most tissue cells are phagocytic, especially the
endothelial cells of serous membranes, bloodvessels, and
Phagocytosis takes place chieHy in the blood.
spleen, bone-marrow, lungs, liver, and lymphoid tissue
The number of the leucooytes in the blood increases
(leucocytosis) in most infections, the bacterial toxin
stimulating the bone-marrow to increased production of
Chemotasis.-Tho migration of tho loucooytos from tho bonomarrow is oXplained on tho hypothesis of chomotaxis. by which
is meant the property possessed by a cell ondowed with the
power oC locomotion to move towards or away from a stimnlus
• The phagooytes possess a kind of BOnse of taste. cr chomoto.xls.
which enables them to distinguish the ehomloal composition of
the substances with whioh they come into contact· (Metahnlkofl).
In the case of the less vlrulentlnlootions. thelnvndingmlcrobos
secrete a. substance which attracts the phagooytes (= positi'116
chemota:r:is). whereupon the latter ingest and destroy them.
In the case of virulent InJections. such as tho acute septlcmmias. the microbes secrete a substance which ropels or paralyzes tho phagocytes (=fIeI1aH'OO chemotaa:i8). thus enabling the
invaders to multiply witllout hindrance.
-The antibodies are protective substances generated
within the body a.nd brought into operation by the action
of the antigen. The antigen (=antibody generator) is
the agent which ca.lls forth the action of the antibody, and
it may be either a. microbe, alien cell, or chemica.l substance.
1'he antibodies are named in reference to the mecha.nism
by which they are supposed to antagonize the pa.rticular
antigen, the following list comprising the ohief ones:
'I.'he upsonins.
The Agglutinins.
The Prooipltlns.
{ Hmmolyslns.
Opsonins.-It was In Soptembor, 1003, that Sir Almroth
Wright and ()Qptain Douglas, 1.1II.S., contributed to the Proceedings cHho Royal Socioty (vol. lxxil.) their now famous papor,
In which they showed by a series of eXperiments that the rate_
and activity of phagooytosis are determined by the presenco
in tho blood-plasma of a substanoe whioh aots on tho Invading
bo.c~eria in It IDanner which renders thom 0. roady proy to tho
pbago es.' To this substanoe they gave· the name of ()psooin
0 Greek bl/l.,,,.., and the Latin opsono-I convert into
le pabulum). and it is dlstlnotly to bo understood that the
efleo"t thoy olah' for it is produced upon the bacteria. and not
upon tho pho.gdriytos.
Suppose thoro is an Infoction by one or other dlsease·oauslng
miorobe; gradually the appropriate opsonin is elaborated In
the plo.sma. and becomes attaohed to tho invading ntiorobes.
rendering them palatable Qike sauce applied to foods). The
{ The LTSlns
phagooytes oan now 8wallow them greedily, and 80 make an
end of tho invasion.
Thus, while acoeptlng tho main theilis of Motohniko1f-vlz.,
that the final destruotion of tho baoterla is brought about by
the phagooyt_they eOlltend that these latter are incapablo
of ingesting bacteria unless thoso havo been aotod on by this
pa.rtioular substanoo gonerated In the plasma; for they find that
If leucooytes are separated from the blood and W8.shed they
possess little or no power of Phagooytosis, but that, if to the
wa.shed leucooytes blood-serum Is addod, phagooytosis at onco
takes plaoo, thus showing that tho serum contains a •somothlng'
which is essential to that process. MetobnikotT admits this,
but ho affirms that this something Is derived from tho louoooytos:
• Either the absorption of the miorobos may bo etTcoted without
the help of the opsonin, or, should sueh help be indispensable,
the opsonin may be supplIed by tho louoooyte Itself.'
Normal blood-plasma contains opsonin, tho amount inoroaslng
with every baotorial Invasion, and Wright goeS so far as to
assume that the body POSBCSSOS tho power of elaborating a
8peciJlc opsonin for almost evary kind of bacteritun. It will
thus bo soon that, aooording to this viow, tho rosisting power
to baotoriogenio disease is largely determined by the quantity
of the right kind of opsonin which the host can provide. Tho
blood ot 0. patient sull'ering from bacterial Invasion may contain
an army of lusty pbagooytos, and yet these may be powerless to
attaok the Invaders. Their striking forco 'll'ill depond upon tho
oxtent to whloh tho baotoria are first aoted on by tho opsonim.
Just as the preliminary artillery bombardment in a battle, by
demoralizing the enemy, r-reparos the way for the advanoe of
the infantry, so do the opsonins prepare the way for the phagocytio attack.
By injeoting the Infected pa~lent with a sterilized emulsion
of the bacteria oausing a particular disease, the quantity of tho
opsonin is increased, and the resisting power of the patient thus
raised for tha.t diBeaso, but far 710 other.
The • opsonio index' of a patient oxpresB6s the power of his
opsonins to Infiuence the ingestion of miorobos by
as compared with that of the opsonins ot a heslthy
It is obvious then that, when an individual i8 8
Jug from
a baoterlog6nio disease, a knowledge of bis opsoni ldex glvOB
valuable Information as to his powers of combatl
e discasc,
and that this information is essential in our endeavo to assist
him by tho Inoculation of a bacterial vaccine.
The Opsonic IndtJ:IJ tm!y a Partial Mea8'Urll~hll.A.
IH/1l'IWtJ& of the Body.-Wright Is careful to
nt out t
it Is
Impossible to estimate oxactly • all the facto which make up
the resisting power ot the organism to bacter I invasion '; to
enumerate all tho leuoocytos, to messuro their individual phagooytlc powers and the extent to whioh these powers are av:o.ilable
for application, and to estlma.te all the known-to say nothing
of the unknown-antlsubstaucea whioh havo afleoted the microbe
\v.blch the patient is su:fleriDg. The measurement of the
DPsonic power of the blood leads admittcdly to only a partial
estimate of the antibacterial defences of the body. He claims
for It, however, (a) that it can be accurately measured, and
(b) that it increaees and diminishes In responee to inoculation
by vaccine and In correlation with the patient's clinical con-,
Wright's Law of the Ebb and Flow, Back Flow, and S'UBtai1l6t1
H{,gA TIde oJ Imm..,.Uy.-The lIrst eUect of a bacterial Infection
Is to cause a fall in the opsonio index-the negativo·phase (ebb),
owing to the taking up by the bodies of tho bacteria of Homo of
the ava1lablo opsonin. This is followod by a rise to a point
above its original level-the positive phase (flaw), owing to
fresh supplies of opsonin being generated. A sooond, and this
time moderate, fall then occurs (rejlow), after whioh the Index
remains for a variable time at this higher level (maintained AiDA
tide 0/ imm"nity):
This law holds good both for oases of ordinary baoterial infection and also for oases In whioh the products of dead baoterla
(vaooines) are Introduced into the body by inoculation.
By a series of properly timed Inooulations with the appropriate vaooines, the opsonio index of the blood can be gradually
inoreased to a lovol at which it tends to remain permanently
The property of the body in virtue of whioh it can guard itSll1f
against infection V!{right oalls Its pk7llactic power (p"IwJasso=
guard). The transport of the phylactio agents to the site of the
infection he oalls kalaph7lla:t1ls, and any oondltion whioh interferes with SUch-e.D., stoppage of adequate arterial bloodsupply (oollapse, extreme cold, eto.~atapA7Ilazis, for undor
suoh circumstanoos, the movements of leuoooytes and the
transport of lIlood·f1uids being interrupted, pathogeniC organisms·
can flourish unopposed.
Agglutinins.-It the serum of a patient oonvalesoent from
enterle fever bo addod to a living culturo of theBa.cUlw typkosu,s,
the organisms lose their motility and become massed into clumps
(Wldal's reaction).
This phenomenon Is known as • agglutination,' and is supposed
to be due to tho dovelopment in the lymphoid tissues, bone·
marrow, and spleen, of a substanoe--agglutlnin-whioh, by
aUectlng tbe surfaoo tension (=the foroe with whioh a fluid
strives to recfuoe Its free surfaoe to a minimum), causes the
olumplng. In this respeot it Is analogous to the running together
Of bubbles on the surface of a fluid.
The proooss of agglutination does not appear to play any,
important part)n Immunity, for the ohange Is a physioal one,
and the vitality. of tho bacteria is not a1lBcted by its occurrenoe,
although their dissemination Is (and in this way it may favour
llhagocytosis). Nor is it a certain test tor enteric fever, some
oascs failing to give it; while It Is found In Malta fever, In the'
dysentery due to Shiga's baoillus. and In Aslatio oholera.
PrecipitiDs.-If an old oulture of typhoid baoilli be filtered. and
tho filtrate be then added to some typhoid serum. a precipitate
forms. Suoh a precipitating substance is known as a • precipitin.'
Preoipitins are allied to. 11 not identioal lvlth, agglutinins. and.
like these latter, probably play no important part in immunity.
4ggressina.-It a mixture of tubercle bacilli with sterilized
tubercular exudate is injected into the peritoneum ot a guinea'
pig. the a.nimo.J dies rapidly. It, however, each be injected
separately. nothing happens. From this Ball argues tbat there
Is something in the exudate whioh increascs the virulence of the
bacteria by paralyzing tho phagocytes (negative chemotaxis).
and thus permitting the Invading microbe to exist without
hindrance. To this speciflo substance. tormed by the bacteria
to inhibit Phagocytosis. he gives the name of • aggressin.' In
this sense, aggressins are to the bacterium what opsonins are
to the animal.
Antitollins.-An antitoa:in is a speoifio neutralizing substance
elaborated by the blood. lymph, or tissue.s, as the result ot the
presence in the body of a toxin, neutralizing quantitatively the
toxin and thusouttingshortthedl~
The greater part of our knowledgo of antitoxins has been
aequired with respect to dlphtherla antitom. whioh can be
prooured in the following way: The diphtheria baoillus is oul·
tivated bymilllons in beef-tello, and the fluid is then filtered. The
filtrate is free of microbes. but loaded with their toxin. A horse
is then injected with graduated doses of this filtrate. The
tissues of the horse reply by the production of large quantities
of antitoxin whioh flows into its blood. It the horse be now bled.
and the blood be allowed to ooagulate. the resulting serum is
rioh in diphtheria antitoxin, whioh then oonstitutes the commercial preparation.
Tllat tile neutraJizlilg anti'toxin acts upon tile baoterial tOXJ'n~
and not upon the bacteria themselves, is proved by the faot tha
the bacilli oJ diphtheria .mu grow readily in diphtheria amitomn
It a similar oxperiment be performed, but tetanus toxin use
instead of diphtheria toxin, it is found that the resulting tetanus
antitQxin·fg not an antidote for diphtheria toxin. nor trice ~.
Each antitozic serum. then, is apeciJlc. neutralizing only the toxin
of the oorresponding organism.
It Is to be olearly understood that by adminlsterlng an antitoxin the free tom only is neutralized. Henoe the urgent need
oJ giving, the antitoa:in early. for tho toxin whioh has entered into
combination with tho tissues is boyond the reach of tho remedy.
In the treatment of tetanus, for example. antitoxin is of little
praotiool value unless immediately lnleoted into the nerve
leading from the wound. for the tetano-toxin rapidly disappears
from tho blood and travels along the axis cylinders of the nerve
to the central nervous system, to the elements of whioh It
becomos • flxed,' thus being inaccessible to the action of the
InJeoted antitoxin.
With regard to diphtheria it has been demonstrated that
when antitoxin has been administered on the first day of tho
disease the mortality is praotically nU. and that it increases
rapidly as oaoh suooecding day elapses.
These are substances whloh have a solvent (lvo= I dissolve)
action on certain bacteria and certain cells. The chief are-Bacterio)Jsins.-These are formed in the blood and lymph.
and possess the power of dissolving bacteria (IVO= I dissolve).
The t'pooh'making experiment of Pfeill'er is the foundation of
our k"llo,"ledge of the bacteriolyBinB.
Pfe1Jfer's Reacti<m.-If a guinea·plg is immunized against
oholera by injecting it with small and gradually increasing quantities of the cholera. vibrios. vibrios subsequently injected Into
tho peritoneal cavity ot suoh an animal first become motionless.
then die. and ultimately disappear. Seeing that tew. If any.
leucocytes are present In tho peritonoal cavity. Pfci1l'er regards
the substance causing these phenomena. as an cxoretion from
the ondothellum lining the peritoneum. and Inasmuch as it dissolves the organisms. it is spoken of as a bacteriolysin.
Hmmo)y$ins (haima= blOOd; 1'/10= I dlssolve).-If the chromocytes of one species of ma.mmaI~.o.• the horS& Introduced
Into the body ot another species ot mamma.l~.g.• the dog-the
latt~r animal elaboratos a serum oapable of dissolving the
chromocytes of horses In general. Such a serum is said to
contain hmmolysins.
Oytolysins.-In a similar way the sorum may be made to acquire the property of dissolving other cells, Buch as those of the
kidney. liver. and testes. and such sera are said to contain
rrutolysins (kyto8. a cell; Ivo. I dissolve). ot which"llephro-. hupato-.
and spormato-Iysins are examples.
Mechanism of Lysis.
Three factors are essential:
1. Antiaen{=antlbody generator).
2. Amboceptor (also known as Immune Body and Sensltlzer).This does not exist normally in the blood. but Is elaborated solely
for the oceasion"""",.e.• no antigen, no amboeeptor. It Is specific
"""",.e.• for ollch different antigen present there Is produced the
appropriate amboceptor. It is thermostabll~.e.• It is not
destroyed by heating to 56· C. (Twenty hours heating to 00· C.
scarcely injures it. Resists putrefaction. and has boon kept
for as long as eight yoars. Non-dialyzable.) It has t,vo aftlnities, one for the bacteria and one tor the complement: hence thu
3. Oomplement (also known as Alexin or Cytase).-This Is
always present In thc blood. both in health and dlseasc. and is
non-speoUlc. It Is thermolablle-i.e.. it is destroyed at 50· O.
Sei'um which has been so hee.to04. and there10re contains no
complemont, is said to bo inadillated. The complement is so
named because it complotes tho action of the ambooeptor; one Is
powerless without the other.
Accordingly, lysis of the antigen takes plaoe only in the
presence both of the speei1l.e amboceptor and the non,spooiflc
complement. Neithor can produce It alone. Let A= Antigen,
B= Amboceptor, and O=Comploment.
Then A+ B+ 0= Lysie of A.
A+B Dr A+O=no Lysis.
An Illustration of these processes, and also of their practical
value In diagnOSis, Is afforded by the Wasscrmann reaction, now
to ·be desoribed.
The Wassermann Test (Fixation and Deviation 01
The materIals required are-1. SIiPhilitio antigen (=A). This may be a solution obtainod
oither from a syphilitio fmtalliver, or (slnee the antigen is really
a lipoid) from cortaln other substances, such as human heut
or that of a horse, ox liver, ete.
II. Oomplement (=0). That "ontained in fresh gninea·plg's
blood Is generally used.
3. Serum/rom the patient swpected ofsuphiliB. This, of oourse,
contains oomplomont, but tho amount is uncertain and liable
to wide variation. '.rhe serum is therefore inaotivated, the
required complemont being mQre oonveniently supplied by (2).
It the patient is syphllitlo, his serum will also contain the specifio
amboceptor (= B). If not, thon thera will be no amboceptor '= 0).
4. Inaotivated sorum from a rabbit whioh has been rer tedly
InJeoted with slleep's red oells. These oelie havo aotell' as an
antigen, and the sorum, therefore, new oontalns a hmmolytio
amboceptor (= Bg), whioh is speciflo for the reds, and whloh, in
tho presence of oomploment, oan destroy them by hmmolytlc
5. Sheep's red reUs, ,vashed in isotonlo saline (= ~).
Experiment-Incubate I, 2, and 3 togother for an hour at
37· C.
Oase t.-The patient is syphilitic.
Then A1+0+B1=(A10Bl). That is, thero is fixation of
oomplement, all of which Is used up in the intoraotion between
the three substanoes, and none is lelt free.
Case 2.-The pationt ie non-syphilitio.
Then AI + 0+ 0= Al + O. Here the oomplement Is not affeoted
and is still available.
Next, add (4) and (5) and Inoubate for another hour.
In Case 1 we now havo-(AICB)+ B.+ ~~ no hrem.olysl~.
'l'he reds (~) are not destroyed by thc amboceptor in tho rabbit
serum (B.), since there is no free oomplement. They sottle at
the bottom, with a olear, oolourless 6upc!rnatant flilid.
In Case 2-.4.1+ 0+ Bs+ ~ lUl!molysis of reds CAa) by speolflo
amboceptor CBs) In presenco of fl'ee complement. There is no
deposit of reds, beoauBo, the stroma of the corpuscles having
been dissolved and their contents liberated, the test·tube oon·
tains a olear, transparent, bright red solution of hmmoglobln
(' laking 'I. Deviation of tho c01llploment hal! oocurred.
After , Hour.
I (+)
~ ~ Syph,lit,c
After'/!. Hours
No haemo-
Clem,. colou,.·
with deposi-t
(A, C 8,)
of unAlter'l1ll
Complement (e)
~" Syphllit'c
Amlloceptor (BJ
t3" tlllIemolytic
Amlloceptor (Be)
o " Sheep's reds
(Anfiqen, A2)
of com-
(A£C Bd
of reds, giving
no deposit.
PIG. 5.
The Wassermann rea.otlon is positive (but only after two to six
weekS from the first appoaranoe or the primary sore) In syphilis
as follows:
66·4 per cent
Secondary (untl'Dated)
Seoondary (all cases) •.
'l'ertiary (untreated)
'l'ert!a.ry (all oases)
Geneml pa.mly1lis
'l'abes dorsalis ••
(Oolw:ted by McIntosh and Fildes.)
A positive WaBBermann Is also found in yaws, trypanosomJasis,
relapsing tever, malaria, scarlatina, leprosy, and tropioal
Ehrlich's Side-Chain Hypothesis,
Bacterial tOxins are, as already statcd, allied to proteins, and
as such possess a highly complex chemloalcomposltion, in contradistinction to the ordinary vegetable alkalolds--e.g., strychnine,
morphine, etc. These two classes of poisons further dHler as
regards their chemical action on the tissuos, the former entering
into more intimate ohemical union with them than the latter--so
much so that, while it is impossible to recover a bacterial tOxin,
sllch as that of tetanus, from the tissues after death, it is qUite
possible to recover such poisons as strychnlno and morphine.
This, according to Ehrlioh, Is because the former olass of poisons
enter Into firm chemical union with the living protoplasm, being
FIG. 8.-P=Protein-receptor; O=carbohydrate-receptor; F=
fat-receptor; T=toxln mol"culo, witn baptophore (A) and
toxophore (e); P'=prote1n-recoptor linkod to haptophore;
T'=toxin molooule dotaohed from oell, with protein-receptor linked to it.
actually built up Into or assimilated by it, while the latter llIIite
only with the fatty and other substanoes entangled In tho protoplasmio network, and not with the actual protoplasm Itself.
Ehrlich assumos that the moleoules of which protoplasm Is
oonstitutod oODsist of II central part furnished with numerous
side-chains or • receptors,' adaptod to unite wlth-' fitting like
a key fits a look '-and thus aSSimilate the various food-stulfs
ciroule.ting in the lymph, there being protein receptors (P) for
proteins, carbohydrate receptors (0) for carbohydrates, fat
reoeptors (F) for fats, and so on.
Now, when toxins are present, they, being aIllcd to certain
food-stuffs, are, as it were, mistaken by the tissues for them,
and are oaught up by tho recoptors.
It tho reoeptor possess no affinity for tho toxin, the animal
will be naturally immune. Imagine, howover, a cell to be
attacked by a toxin for which It has a1ll.nlty. As already explained (Ilide p. 38). the toxin molecule (T) consists of two
groups of atoms: a oombining group. the haptophore (h). ane'{ a
pois~n1ng group. the toxophere (I).
The haptophoro booomes
Joined to a toxophile receptor. Imd the toxophore then exerts its
poisoning influenoe.
In this way a oertain nwnber of the receptors are thrown out
of action. and are no longer available to oarry on the nutrition
of the cell. In addition to this. the 0011 is partially poisoned.
Under the stimulus of the abnormal assimilation. the cell protoplasm buds olf fresh receptors to meet the extra demand, the
collin oourse of time becoming cducated. so to speak. to produco
an abundanoe of reoeptors. some of which are in oxoess of Its
needs. The surplus receptors are then oast olf. and. though
tree of the parent OI'JI. still retain their power of combining with
toxin. These Il'Urplus reuptors it is that constitute the circulating
antittXllin, whioh, by uniting with the toxin. neutralizes it. and
thus protects the living protoplasm from Its aotlon. In this way
lite tends to be prolonged until the organillIIl has had time t.o
destroy the bacteria from whioh the toxin had Its origin.
Should receptors not be formed In su1Dcient number. tIle
animal dies.
Natvtral SUSceptillUitll.-It a mouse is inoculated with anthrax
at the tip of its tail. even though the tail bo amputated within
one minute of the Inoculation. the animal will succumb to
anthrax-a striking instance of natural susceptibility.
Man Is similarly susoeptlble to certain bacterially induoed
diseases, suoh as hydrophobia and syphilis.
Acquired Susceptibilitll.-Tho hen is naturally insuscoptible
to anthrax; when. however, its foot are Immersed in cold water
It becomes susceptible. and experiments have proved that not
only cold, but hunger, thirst. improper feeding. fatigue, and loss
of blood, all tend to Increase susceptibility to bacteriogenic
diseases. White rats. tor example. whioh are ordinarily insusceptible to anthrax. become susoeptlble after fatigue. or whon
red upon a purely vegetable diet. Agai'n. while healthy swine
ilo not oontraot glanders. young and debilitated pigs may some~lmOB be a1fected with it.
Immunity may be(a) Natural, or
(b) Acquired.
(a) Natural Immunity.-This is the resistance to an
infection that is innate. For example. pigeons and other
fowl are quite immune from the pneumonococcus. Rinderpest is essentially a dise¥,.ltof rwp.inants; horses never
oontraot it. Tubercu\ps4I/¢.ough common in cows and
pigs, is very rare in horses, asses, sheep, goats, and dogs.
Dogs are immune from o.nthrax, fowls from tetanus.
Again, Algerian sheep are immune against anthrax,
a.l though ordinary sheep are susceptible to this disease.
In all these cases we must assume that when the specific
microbe enters the system, it is at once exterminated, and
so cannot breed there.
Immunity, like susceptibility, is 0. relative term. With
few exceptions, no animal which has been made the subject of observation possesses absolute immunity against
any given microbial disease under every possible circumstance. For instance, the fowl, though immune to tetanus,
if refrigerated, loses its immunity to this disease.
(b) Acquired Immunity.-Of this there are two chief
(a) Active or Direct.
(b) Passive or Indirect.
(a) ActivB lmmunity.-In active immunity defensive
mechanisms have been created in response to a former
infection. Examples of this are1. Immunity due to a previous attack 'of an infectious
disease-B.g., measles, scarlatina, mumps-the patient
acquiring freedom from the same disease for a certain
period of his life.
2. Immunity induced by the inoculation of the virus
of a disease which is either an allied condition or a weakened form of the disease against which protection is sought,
as in the case of vaccination for smallpox.
3. Immunity due to repeated inoculations with sublethal doses of living micro-organiams, which in course of
time produce an immunizing, substance in the blood, so
that the animal can ultimately tolerate a dose which
would at first have been fatal, as in the case of Pasteur's
method for fowl oholera (now seldom employed).
In all these cases the body is stimulated to elaborate
its own antibodies.
(b) Passive lmmunity.-If the blood-serum of an
animal rendered immune against a partioular disease by
any of the above methods is injected into a second susceptible animal, this animal also becomes immune against
that disease. In such oases the process of immunization
is :Pa8SiV8 80 far as the second anima.! is ooncernel!, for the
antibodies are not elaborated by the animal itself, but
are supplied ready-made_ An infant fed a.t the breast is
less lialile to contract disease than one brought up by
hand, one reason for this being that it derives immunizing
substances from its mother's milk, and in this way is rendered passively immune_
Anaphylaxis (Hypersensitiveness).
Riehm, Who coined the word In 19011, de.flnos allaphylu.xis
as • the peculiar attribute posscsscd by oertaln poisons of Increasing, Instead of diminishing, the sensib!llty of an organism to
their ILctton.' Delille describes It as ' a state of aoquired vuInera.bility in an organism to a second Injeotion of a SUbstance to
which, at the time of Its first Injection, It was indlf'fepent.'
The first injeotion is known as the se7lBitising dose; the
second, as the reacting dose. The Injections may be made
intravenously, intracardially, intrapllritonea.lly. or subcutaneously. As u. rule they are made intraperitoneally.
OondititmBnecetJllarufO"ltheProductiono!Aflaph.ylazis.-(a) The
substanoe used must bo a protein (serum, milk. egg-white,
plant-albumins, bacterial extracts, etc.). (b) The protein must
be foreign to the animal e:r:per.lznented on; e.g., guinea-pig
slll"llm cannot hypersensitize either the same or another guineapig. (c) Between the first injection (' sensltiz:lng dose ') and
the second injection (' reacting dose ') there must elapse a
latent period. The shortest latent period Is ~ dan; ie., if a
second dose be administered within ten days of the first dose,
anaphylax:ls does not occur. (Il) The 'reacting dose' must be
introduced by the same channel as the' sensitizing dose'; e.g.,
it the first dose be Injected Into the peritoneal cavity, and the
second dose into the jugular vein, anaphylaxis Is not estabiished. (e) The ' sensitizing' and the' reacting' proteins must
be derived from tho same souroe; e.g., If you start with horsegorum on a guinea-pig, yoU must continue with horse-sel'1lD>.
(Thc serum of closely-related, however, can be used
vicariously, as that of the horse and donkey.)
Once established, ana.phylaxis may last for months or yea1'8.
Anaphylaxis, 118 oliserved In the rabbit, Is thus described by
&.rthus: • One or two minutes atter the administration of the
!econd dose, the animal begins to shake Its head, and then lies
iO'VD. Respiration Increases greatly In frequency, but there is
[1.0 actual dyspncea.
Solld f_l matter Is freely evacuated.
The animalroUs over on Its side. and, a.fter taking foul' or five
heavin8' breaths. dies within four or five minutes of the injection.' In the post-mortem examlna.tlon the blood Is noticed
to be dark in colour, and to show little tendenoy to coagulate.
The lungs are swollen and congested. The mucous membrane
of tho Intostlnes Is oongested, and numerous hl8lllorrhages are
Anaphylaxis can be induced by feeding on foreign proteins,
though less readily than in the case of injeotlons, and this is
how Hutlnel eXplains the toxio aocidents sometimes oaused in
Infants by milk. (Alimentary anaphylaxis Is of great Interest,
since there are people to whom moh things as eggs, shelltlsh,
.eto., are anathema.) The mother oan transmit the anaphylaxis
either through the placental olroulation or through her milk.
If a pregnant guinea-pig be inooulated with horse-serum, and
afterwards one of its o1fspring be Inoculated with tho samo
serum, it will develop anaphylaxis. It has been suggestod that
puerperal eolampsia is a manifestation of anaphylaxis evoked
by some substance of placental origin. Epilepsy, urmmla, and
diabetlo coma, oan be explained on muoh the BOome ground~.
Also, It is probable that an attaok of spasmodlo asthma is an
anaphylaotlo phenomenon.
Mechanism. oj Anaphllla:riB.-This still remains somewhat of
a blologloel puzzle. The simplest eXplanation is that suggested
by Richot. Acoording to him, the • sensitizing dose' oauses the
production in the blood of a new substance, whioh, while in
itself non-toxic, yields an intensely toxio substance by combination with the' reacting dose.'
A vaoolne Is a substanoe oontainlng the endotoxin of a particular mierobe, the microbe In question having been previou~ly
Iso1ated and cultured.. The vaeoine must be »repared from tho
oausal organism: e.g., In a streptoooccal Inteotion the vaccine
must be prepared from !Po oulture of streptoooooi ;'In a staphyloOOCCIC lil!ecllfon, trom a cufture of stapftyCooooof. TIle action of
tho vaooine is to stimulate the natural meohanlsm of i=unity
inherent in the body~.e., to exoite the manufacture, by the
blood and tissues, of the appropriate antibody. Most of the
vacolnes are prepared from killed baotoJia; a few, however, are
prepared from living haoteria whioh have had their virulence
attenuated either by repeated suboulturing or by heat. Vacoines can be !Lffld De e pro,pludqc:HC to preyept intectiOD (e.o.,
smallpox, enterie, hydrophobia, and plague), er lor curativll
~8eA In the QMO of OJ) Aetnel integtj9~.a., furunculOSIS due
~ phylocoool, enterio, malignant endooardltls). With regard
to the proteotion afforded by vaccination against enterio, note
the faots given by Sir William Osler in a reoent speech (September 15, 1914): • Above all ether, one disease had proved most.
ratall)). modern warf&l'O-illlterlc, or typhoid fever. Over and
over again It had killed thousands before they over J;eaohed th'l
fighting line. The United States troops had a terrible OXperienoe in the Spanish-Ameriean War. III six months, between
June and November inclusive, among 107,973 officers and men
in 92 volu!_1teer ~D1entjl. 20,738. praoticallv ou-flfth of the
cntfrenUDlber, bad typhoid fever, and 1,580 died. Fortunately,
In this oountry typhoid tevor was not prevalent In the dletricts
In which oaIOps were placed. The danger was ohlefly from per'
eons who had nlree.dy had the disease, and who earrled the
germs in their intestlnos, harmless messmates in them, but
oapable of infooting barracks 01' camps. They could easily
understand how flies oould convey the germs from theso oarrler.
far and wide. It was hi this way probably, and by dust, that
the bacilli werc so fatal In South Africa. There were 67,684oases of typhoid fever, of whioh 19.454, were Invalided and 8,029
dlcd. More died from the bacilli of this disease than from the
bullets of the Boers. Let this terrible roooril Impress upon
them the importanoe of carrying out with rellglous oare the
sanitary regolations. lie Wished to ask them to take advan·
tpge of the kno\vledge that the human body oan be protected
b)r vacolnation against typhoid fever. Discovered through the
resoorohes of Sir Almroth Wright, the measure had been Intro'
dnood suocessfully Into our own Regular Army, Into the Army
of France, the United States, Japan. and Germany. The appal·
ling Incldonce of typhoid fevor in the volnnteer troops in
America during the Spanish-American War resulted IB.l'l!'IllY
trom the Wide prevalence of the disease In country districts,
and the camps became Infected; and because we did not then
know the Impol'tanoe of the fly as a oarrier, and other points of
great moment. Hut In the ltuglilar Army of tbe United States.
where inoculation had been practised now for several years,
the number of cases had fallen from 3'63 per 1,000 men to prao,
tloally nU. In a strength of 90.640 there were, in 1913, only
3 CaBBS of typhoid fev8l'. In France the enterio rate among
the unvaco.inated was 168'44 per 1,000, and among the vaool·
nat'ed 0'18 per 1,000. In Indio., where the disease had been
very prevalent, the succesa of the meILmre had been remarkable.
In the United States. In France, and In some other oountries. this
vaocfnatlon against the disease was compuls017.'
The property of tho body in virtue of whloh it guards Itself
against inrootion is tOl'lDed by Wright its ph'Vlactic power
(pllulll8BO=guard). The conveyance ot the phylaotlo agents to
the slto ot the infootion is oalled kalaph'Vla:r:i8, and anything which
Interfores with this transport ami·kalaphllla:z:i.s--e.g., diminution
of tlifl artorial blood -supply (from oollapse, extreme oold, eta.).
In anti·kataphylaxis t)1e transport of leuooc)'tes and antibodies
is inton-upted, 80 that pathogenio organisms can grow unopposed
In addition to phylaxis and Imtaphylaxla there are resei'Ve foroel
-the epiphlllactic reinforcements or response. A response 01
this kind oocurs after the administration of an a.ppropriate
vacoine (positive Phase). preceded, however, by a negative phase
or apoph7l14ctic phase. (Yide lecture by Sir Almroth E. Wright,
F.R.S.• reported in Lancet. Mareh 29, 1919.)
Tho action of a SC1'UJD. is to supply a ready·mado antIbody.
In the easo or diphtheria, for example, the antibody (antItoxIn),
prepared from the serum ot a horse (see p. (6). is used to neu'
tralize the toxin of diphtheris. Somotimes a serum is ueed tor
tho purpose of actually killing the causal microbe. such being
caUed a bactericidal serum. 'The sick body Is itselt put to no
expenso for its defenoe; It has no army to raise. equip, and train
for the struggle upon which it is entering. We. so to speak,
place at Its disposal an army ot meroenarles ready equipped.
prepared. and trliincd, abroad. As the organism is at no troublo
to prepare an antIbody. it is eaar to understand why it is not
exhausted' (Profossor Louis mnon. • Lo Traitoment de Ie.
Tuberoulose Pulmonaire par les Serums ').
A serum may be employed either tor (a) proph'UlacUc or
(II) eumti'DB purposes. In (a) it is Injeoted Into a healthy indf~
vidual who is likely to bo exposed to an infeotion. In (b) th~
sorum is Injected into a patient Ji'ho Is at tho tiDle suttorlng trom
an attack ot the disease.
Borum-siolmess develops In about a third ot all people Inocu·
lated. and Is oharaoterized by rashes. joint-palm. adenitis. fever
and transient albuminuria. The rash. which may be assooiated
with violent itohing of tho skin. usually appears between the
seventh and tenth days. and lasts tram three to seven, days. It
Is oommonly urticarial. and Is usually first notioed on the tront
of the abdomen. sometlmos spreading to tho tace. arms. and
legs. Occasionally there Is redema of the lips and eyelids.
Tho Joint-pains are ohiefly felt in the large joints (Imees. elbows
and shoulders). Thoy are lIeeting In chlll'aoter. and as a rule
there Is neither rodn~s nor swelling. The glands draining the
area into whloh the serum was injected may enlarge and become
tender. The fever Is usually lillght (rarely above 100· F.). and
acoompanyfDe It there may be transient albuminuria.
By gangrene is mea.nt the of the
tissues in
Bums, corrosive poisons, otc. (Infiam·
matol'Y gan~Des are pro~ablY in pari
due to the direct destructive action of
the toxins on tho protoplaSm of the
RI1Pture. ligature, embolism, or
thrombosis, of maIn IIo1'terYi
arterial spasm (6,g., trom
{ ergotlsm, frost • bIte. Ray·
From vascular ob.
naud's disease).
Tight bandage, plaster 01 Paris,
Venous { • splint· pressure, thrombosiH.
strangula.tcd hernia.
From acute Sllptio{Cla.rbUDale. cat;'crum oris, sloughing ~hage·
inA mmations
dmna, malignant cedema, mo.llllnant
FromiDterruptionof{ Acute bedsores after injuries to spinal
trophlo inlluenoo
From destruction of
the tissues outright
Clinically there are two main varieties of gangrenethe' dry , and the • moist.' The former only ocours when
the arterial afflux is obstructed, lIB when a main artery
is thrombosed or plugged with an embolus; the latter
when the venous efflux is obstructed, as from thrombosis
of a main vein. .All gangrenes resulting from inflamma·
tions are of the' moist' variety.
Dry Gangrene is well illustrated ih the case of the
ordinary variety of senile gangrene. The arteries of the
leg, narrowed and rigid from calcareous degeneration,
become gradually thrombosed, and the blood· supply being
thus cut off, the most distal parts suffer fil'Bt. One of the
toes (geners.lly the great toe) present.s a tallowy. white
colour. La.ter on it becomes purple or mottled, owing to
extra.vasation of hmmoglobin from the veBBels. In conse·
quence of the evaporation which takes place from the
surlace, the tissues become dry and shrivelled, and the
skin assumes the appearance of parchment, u1ti~ately
becoming covered with an oily film from transudll<ti.QI\ qi
the underlying fat.
IJ tke prOC68S i8 arrested, the dead part acting as an
irritant to the adjacent living tissues, a dusky red zone
of infl.a.mmation forms, called the line oj demarcation.
Finally, the dead part is separated from the living by
ulceration. As a rule,. however, the Hne of demarcation
is imperfect; the disease spreads from toe to toe, then
advances up along the foot, and ultimately involves the
Constitutional infection is rare in dry gangrene, the
dried up. shrunken tissues not proriding a suitable soil
for the growth of organisms.
Moist Gangrene is well illustrated in cases of septic
inflammatory gangrenes. The veBBels are thrombosed as
the result of toxic action, and the gangrenous part becomes
soaked in an albuminous fluid containing many disintegrated chromocytes. The dissolved-out htemoglobin,
diffusing itself through the dead tisBues, stains them a
greenish-black (= FeS). Later on, buZZQl, containing a
blood-tinged fluid, form. Still later, gases are generated
from infection by *e BaciZhUi o,ij1"ogenes capsuZat'U8 of
Welch, giving rise to emphysematous crackling. mti·
. mate1y the part putrefies, and oonstitutional infection
Senile Gangrene may be eitber (a) df'1l or (lI) moist. (a) Has
been described on the previous page; (b) generally occurs as tho
result of SOIDe slight injm'Y, suob as knooking the foot against
8. hard substanoo, wearing too tight boots. cutting a oorn. eic.
The injured part becomes and a slough forms which
Boon gets dry and blaok. The Infiammo.tlon spreads slowly,
and all the phenomena ot moist gangrene supervene.
Gas Gangrene.-This occurs in oonnection with wounds causcd
by high explosive, trench mortar sholls. bombs. oto. (very rarely
from rlfie bullets). and 1IIfually develops within forty-eight hours
of the receipt of the injury-whieh Is most often of the lOlver
limb. The spread of Infection varies considerably. The gangrene
may be: (a) localized; (lI) SPread slowly; or be of the (c) fulminating t)~e. in which the spread is so rapid that the gangrene
has boon lmown to rOllch the umbilicus from the thigh in eight
hours from the tlmo of injury. It Is essentia.lly an alfection of
muscles. and may be oonflned to a. single muscle or groUP of
mUJIcles. 8.nd vory rarsly begins In tissues other than musoles.
The injured musoles stunned. bruised, present a crushed
o.ppeo.rance, and look like 0. piece of uncooked meat, neither
bleeding when out nor oontraoting when irritated (' musclestuDor • ot the Frenoh). In addition to the damaae caused by Its
impact, thc missile drives in front of it a 'Volume of compressed
air, which splits the muscle lIbres In the direction of their grain
for some distance above and below the seat of inju.ry. Along
these microscopic fissures aerobic and anacrobic organisms can
travl.'l, and the medium being suitable for their growth, they
Inultlply and generate toxins. These toxins, diffusing rapidly,
cause tho dwth ot the tissues to whloh they gain aooese.
Whilst those events are happening, the part qulokly swells,
bocomes tense, and the skin discoloured (the hue varying from
a brlck·red to u blo.ckish-green). Blebs contalnlng fiuld and gas
form, and omphysematous craokling can soon be elicited. At
the advancing edgo Is a pale zono, more translucent and firmer
than the normal skin. In a certain number of cases, gas forms
in the liver--made apparent by squeezing (' toaming liver ').
An Intense toxmmia occurs in the later stages preceding
EUolorll/.-The predisposing causes are (a) fatigue. and (II) In·
llufficient ddbridement (= the Immediate and completo mechanical
cleaning of the wound and the exeislon of o.ll devitalized tissue).
Tho aotual eauso is the contamination of the wound with certain
a,naerobic organisms.
Bacteriolow.-From the oxperionoe gained in the recent war.
I L hi generaJly admitted that the gangrene is caused by the
combined influenee of a mixed infection. the most notablo
organisms being: (a) BacUl'IUI welchii, (II) Bacill'IUI lBdematiem:
and (I:) the Vibrion septique of Pasteur.
Carbuncle.-Thisls due to inooulation with tho StaphllloctJCCU8
pyogenea aUf'eu8 of patlonts with lowered vitallty--e.q.• from
undor·feedlng, over·feedlng, ohronlo alcoholism, albuminuria,
and diabotos mellitus. It is most common In men over forty.
and Is generally situated at the lower part of the nape t)f the
neck. It begins with a primaf'1/ inflammation oj the subcutaneous
tissues, the skin being secondarily Involved. At 1Irst there Is
noticed a roundod dusky·red swelling, hard to the feel, and with
well·deflned margin. SoOD a number of pustules form on tbe
surface, whieh, bursting, loave the skin riddled \'I'lth pus-exudlng
Many of the apertures ooalesce, and so exPo~e the
underlying ashy·grey slough. This Is ultlmstely thrown otr,
often laying bare musole or fascia. Healing is slow. The
average size of a. (lsrbunole is about 2 Inches In diameter, but It
Inay oover an area as large as a soup·plate.
Bedsoros.-There are two kinds of bedsores-the ordinary
and tho a.cuJe.
The ordinaf'1/ bedsore forms In parts exposed to pressure when
tho patlont is In the recumbent position, the usual positions
being the sacrum, the troohnntors. the elbows, the spines of
soapulro, the malleoli. and the heels. It Is partioularlyliable to
develop in tho old and feeble. Negligent nursing (leading to
oontamination With urine and flllOes) is an important oontributory oaU8e. The allected part becomes red. smo.ll blisters form,
and flno.lly sloughing and ulceration supervene. In severe caBell
the underlying bone is exPosed. The dangers are from spinal
meningitis and se"pticlIlIIlia.
Acute Bed80re.-This OCOlll'S in 0. caso in which 0. part bas
boen deprived of nerve influence. It is typically soon after
fracture-dislocation of the spine, and in aoute myelitis_ The
gangrene is moist; it comes on very suddenly, and spreads
Cancrum Oris.-This Is a quickly -spreading in1lammatory
gangrene attaoking the inside of the cheek of unhealthy ohildron
oonvo.1eseent from some speeifle fever, notably measles. The
cheek beoomes rcd and brawny. On opening the mouth a
slough is observed. This on separating loaves a. toul, excavated
ulcer, whieh may perforate tho choek and destroy a large
portion of It. The gangrene sometimes extends to the gums
and tho floor of the mouth. It is a vBry fatal malo.dy. Should
recovery take plo.ce, a serious deformity of tho face is 1IB11&lIy
Malignant Pustnle.-This, whioh is met with amongst workers
in foreign wools and hides, Is due to the Inooulatlon of somo
oxPosod part of the body with tho Bacilllull anthraci& Tho
patient oither soratches 'Or prioks himself, and aftor a short
period of Inoubation a red plmple-suggestive of tho sting of
lin insooli-appeo.rs_ The pimple enlarges, and at Its oentre II
vesiole fllrms whioh, bursting, leaves a scab. The margins of
the • pustule' are now indurated, the surrounding tissuos
oodematoUB, and the lymphatio glo.nds enlarged. A. second orop
of vesicles soon form In the Indurated margin; the central biaok
scab meanwhile beoomes dry and sunken below the level of tho
surrounding parts. In the oourse of a few days the malignant
pustule attains the size of a florin, and presents the following
four zones:
(a) A oentral depressed black scab.
(b) A zone of vesioles.
(c) A. zone of dusky-red Induration.
(d) A. zone of mdema.
The danger to life is from general infeotion (antAl'actUmia).
Sloughing Phageena.-This, Which in the pro-antlseptio days
was very oommon under the name of • :hospital gangrene,' Is now,
happily, very rare. Although it may complicate any wound, it
Is at tho prosent day ohiefly met with in IIasos ot venereal sores.
The tissues at the infected site booome acutely Inflameil., and
IL contral grey slough soon appears surrounded by an angry red
margin. When the slough separatos, a toul, excavated ulcor Is
lett. A. largo area ot tissuo may be destroyed in this way.
Diabe&ic Gangrene.-Vide p. 182.
Gangrene from Embolism.-This is commonor in the log than
in tho arm, the latter having a freer collateral circulation. The
embolus generally lodges at the bifurcation of the popliteal
artery. The gangrene is at first always of the • dry' kind; tho
11mb assumes a tallowY oolour, and become" Clold_ numb. and
Insensitive. wjth arrest of pulsatIon In the ar~ below the _ t
of obstruction.
Should the part become septic. the gangreno changes into
the' moist' variety.
Gangrene from Ligature of III Arterr.-This. though possible,
rarely results from a ligature per Be. there being asually an
associated thrombosis of the oomplllion vein as the reBUlt of
injury at the time of the operation. Henco the gangrene ill
generally moist.
RQnaud'a Diseaae.-Vaso-motor spasm affeoting the outlying
cutaneous vascular regions (hands. foot, nose, ears) is very
lommon. In the hands especially every dogree of spasm may
be observed. from slight temporary blanohing to spasm so severe
and protraoted as to cause aotual gangrene.
Transient spasm of the 1Ingers causes them to become suddenly pale or tallOW-like. This condition Is known as • dead
lingers,' and is common in women during the reproductive period
of life. It Is probably assooiated with the vaso-motor fluctuations peeullar to menstruation.
Spasm of the venules of the hands and teet causes them to
become cyanotic. This is the condition obtaining in those who
Illlffermuehfrom cold hands ando feet. It is nearly as common
In mon as in women, and although a purely looal phenQmenon,
is popularly supposed to indicate a • feeble ciroulation ' of cardiac
origin. The oyanosis results from the sluggish capillary oiroulation consequent on the venular spasm; the sluggish flow allows
deoxygenation to proceed beyond the normal. and the capillary
blood thus becomes blue. In oourse of tlmo the soft tissues of
the affected region thicken. apparently from flbrous overgrowth,
lust as happens in the case of the sluggish eapillary oirculation
oharaoterizing passive ocngostlon. It is only In minor degrees
of this condition that ohilblalns are apt to ooeur.
Raynaud's disBase was first described by Raynaud under the
name of 'la gangrlme sym6trique des extrimit6s.· It is more
common in women than in men, and occurs most frequently
between tho ages of eighteen and thirty. Characteristic
featuros are its symmetry and periodiolty. In typical oaBBS
there are. as described by Raynaud, three stages:
(a) Looal synCOpe (pale stage).
(b) Looal asphyxia (blue stage).
(c) Lo&.l gangrene.
(a) Local S1/ROOP6.-In this. the affeeted region (hands. foot,
ears, nose, eto.) becomes pale and exsanguine from spasm of
the arterioles and venules.
(b) Local ABphllxia.-In this, the affected region becomes
swollen and blue. The condition may be brought about in two
ways, either by arteriolar spasm and secondary vcnous regurgitation into the capillaries, or by spasm of the venules alone.
In either oase, the blood stagnates in the capillaries, and conIIIderable efl'usion is apt to ooeur.
(0) L~l Gant/t6M.- Blebs form, and these on bursting expose
small superfioial sloughs, seldom extending deeper than the skln.
The resulting uloers are slugglsh and slow to heal.
The attaok may stop at stage (a) or (b).
The attack is probably caused by the aotion ot some vaBO·
constrictor toxin, generated either In the aUmentary oanal,
uterus, ovaries, or Fallopian tubes, or as the result ot some
violous metabolism of the tissues.
Frost-Bite.-The first etreot or severe cold Is arterial spalllDt
the part becoming bloodless and shrivelled. Should the ex
posure oontinue, the result is complete freezing of the part, the
tissues being sti1lened and the blood coagulated, BO that some·
times portions can be broken 011 like glass. It, however, tho
patient be brought into warm surroundings betore this occur!!,
the blood may re·enter tho frost· bitten area, and aU the
phenomena of infiammatlon then devolQP. Suoh infla.mmatlO11
may either end In resolution or in • moist' gangrene.
Gangrene from Erlotism.-Thie is only tound in thoBO
countries In whioh rye bread is eaten. It tho arterial spasm
induced by the ergot oontinuos tor a long time, the gangrene i.
dry; but should it bo succeeded by vaso·dilatation, or the part
become septio, the gangrene is moist.
All the tissues are bathed in an alkaline tluid-Iymphwhich is a very dilute kind of blood.plasma (see table)
The lymph is conttnually oozing through the thin capillary
walls and diffusing itself slowly among the tissues, to
w.b.ic.b .it .!Il1J\.lllw t.bto ,r.u.rlro;ul.lllllllltAlll'~.Ilf'nlfuI toO tJW.r
vitality; it collects the waste products of metabo~ism, and
ultimately flows into the venous system by the thoracic
Though the question is not yet settled, we may pro·
visionally assume that the separation of the lymph from
the blood is in part
Filtration,{ Osmosis.
in part
Yilal {
The endothelial cells of tho capillary
walls actively secrete the lymph
from the plasma;
and in part
lIfbiticmal{ The tlssue cells suck fluid from
the ca.pillaries.
An undue acoumulation of lymph in any part of the
body is known as redema. It may collect either in a body
oavity, or between the individual cells of 0. tissue causing
it to swell and to beoome puffy.
<Edema. of the subcutaneous tissues is known as
:maaarca .. of the lateral ventrioles of the brain, as hydro.
~epkalu8 j of the peritoneum, as a8oite8; of the pleura, as
~ydrothorag;; of the pericardium, as hydropericardium;
!Iond of the tunica vaginalis, as hydrocele.
The degree of oodema is determined by the looseness or
denseness of the tissue o.1fected; e.g., the subcutaneous
tissues and the lungs are capable of great distension,
whereas the solid organs possessing dense capsules, such
as the. kidneys and testes, can swell but little.
<Edematous fluids much richer in proteins than is
norma.llymph (see table).
The following table from Halliburton shows the c(lmposltlon
01 dropsical fluids as compared with the normal :fluIds ot tho
Pa.rta per 1,000.
Blood.~sma •__
Norma l)'lIlJ!h
Pleuritic :flUId ___
Ascitio lI.uid
Hydrocele fluici"
.... -.--.-.
------ --28'50
Tl£oorWl tCJ ea:plai·1/, lEdema.-The whole lymphatics of
a. limb may be ligo.tured without producing oodema,
the explanation being that the powers of absorption pos·
sessed by the capilla.ries is very great. <Edema was
origina.lly thought to be due to an abnormally watery
condition of the blood, but that this per 8e is no.t a. suffi·
cient cause is proved by the fact that the injection of
large qua.ntities of solution does not produce it. It
is highly probable that the essential cause of redema. is
some ohange in the capillary wa.ll, so that it becomes
abnormally permeable to fluid. This Dlay be due to
deficient oxygenation, as in the prolonged venous engorgement of heart disease; to the irritation of toxins; to
impaired nutrition of the wo.lls of the capillaries from the
absence of vitamines (which is the likely explano.tion of
the' famine dropsies' of India).
The chief conditions under which redema occurs are as
follows: (a) inflammatory, (b) mechanical, (c) toxic, and
(d) neuropathic.
(a) Injlammatory.-Here the redema is due to exudation
through damaged capilla.ry walls_
(b) Meehanical.-Examples of this are: tight bandages
o.pplied to the arm or leg (and thus interfering with the
return of blood from the veins, which are more easily
compressible ~han the arteries); pressure of tumours on
veins (e.g., mediastinal sarcoma on superipr vena cava);
thrombosis of a main vein; obstruction to the portal circulo.tion in the liver (cirrhosis. co.ncer) co.using ascites.
(c) Paxic.-This cause operates in such diseases as
nephritis and beri-beri. It is supposed that the toxin
causes some damage to the endothelium of the capillary walls,
wltereby their permeability to fluids is increased, certain
capillaries, such as those of the face, being more susceptible
to this influence than others. Hence the early occurrence
of redema. of the face in :J3right's disease (see chapter on
Kidneys). The mdemo. of anremia is either toxic or due
to impaired nutrition of the capillary wall. The redema
of beri-beri is either toxic, or due to the absence of
(d) Neuropathic.-This is seen in herpes zoster (due to
irritation of ganglion on posterior root of spinal nerve).
Acute Circumscribed (Edema (Angioneurotic) is characterized by the sudden appearance of transient, sharplydefined, tense and shiny redematous swellings in the
eyelids, and of the face, hands, genitals, or other parts.
It was first desoribed in 1880 by Quincke, and would
a.ppea.r to be due to some form of alimenta.ry toxremio.,
or a manifestation of anaphylaxis.
Thromboai8 (thromboa. a clot) means the coagulation
of blood. during life, in any part of the cardio-vascular
system-heart, arteries, capillaries, or veins; the resulting
clot is called a thromb'U8.
The essential primary change in the formation of a
thrombus appears to be the aocumulation and fusion into
a mass of blood-platelets, and their adhesion to the damaged
vascular lining. According to Greenfield, the leuoocytes
usually take no active part in thrombus formation.
Oa'U8e8.-Changes in the vessel walls; changes in the
oomposition of the blood; retardation of the blood-flow.
Frequently two or all of these causes co-operate.
OOOngea in the Vea8eZ WallB.-Damage to the IlUdothelial lining of the vessel walls is the most important
factor here. Atheroma, primary oalcification, varix,
phlebitis, eto.. do not cause thrombosis, um888 the endotheZiallining i8 injured or deBtroyed.
OOOng88 in the Blood.-These are suoh as oause increaaed coagulability. For example. in lout of every
100 cases of enterio fever, and in lout of every 150 oases
of lobar pneumonia, thrombosis of the femoral vein oocurs.
This may be in consequence of increased coagulability of
the blood, or, on the other hand, it may be the result of
lI.amage \0 'lfJl6 en~o'l;'Jlellm. fuimg by 'lfJle 'oac\eiI1lJ. 'wxim.
Certain poisons may also operate btl increasi.f&/I eM fibrin/erment--e.g .• toxins. proteosos, snake-venom.
OOOng68 in the Blood-FlOtD.-Retardation, or even
arrest, of the blood-flow is by itself incompetent to cause
thrombosis, for it haa been proved that if a bloodvessel
isligatured in two places under strict antiseptic precautions, and oare is taken not to injure the endotheliaJlining,
the stagnant blood may remain fluid for weeks or even
months together. Nevertheless, it is an important contributory factor in thrombosis. Witness the effect of oompressing or ligaturing the artery supplying an aneurism,
and the tendency to thrombosis of the intracranial venous
sinuses when the circulation is languid, os in the aged and
moribund, and, again, the clotting of blood within the
auricular appendices in mitral sten03is.
Thrombosis ocours most frequently in the veins. Venou.
thrombosis is fifty times more common in the leg than in
the arm.
Septicremia, pyoomia., and other infootive diseases,would
appear tG oause thrombosis, in part by increasing the
coagulability of the blood, and in part by damaging the
endothelial lining of the bloodvessels.
Appearance of a Thrombus.-If it forms slowly, it is
laminated and of greyish-white colour (=pale thrombus);
if it forms quickly, it is non-laminated and red (=red
thrombus). Intermediate forms may occur.
Post-mortem clots difier from thrombi in being softcJ,
never laminated, and non-adherent to the vessel wa.lls.
Sequels of Thrombosis:
Calcifioatlon (phleboliths).
Disintegration. causing aseptic emboli.
Septlo Infection. This rosults from mloroblc invasion of
the thrombus and Its subsequent diSintegration. with
the formation of septio emboli.
Emboli6m significs the lodgment of some solid BUb·
stance, or of an air-bubble, in a vessel too small to allow
it to pass on. The impacting body is carried into position
by the blood-stream. and is ca.lle9 an embolus. Emboli
occur in the arteries, as these diminish in size in the
direotion of the blood-flow; also in the intrahepatio
branches of the portal vein which, within the liver, divides
like an artery. They are most frequently observed in the
splenic, renal. and cerebral arteries.
An embolus of a systemio artery is derived from ijle
left heart, or systemio arteries; an embolus of the pulmonary artery is derived from the right heart, or systemio
veins. A very small embolus may pass through the pulmonary oapillaries into the general CIrCulation.
Embolus consisting of a detaohed portion of a thrombus.
Embolus oonsisting of a vegetation detaohed from a
heal t val ve.
Embolus from detachment of an atheromatous patch in
an artery.
Embolus from detachment of a portion of a tumour
(e.g., sarcoma).
Embolus consisting of masses of vegetable parasites
(e.g., Bacillua antkraeia).
Embolus consisting of animal parasites (e.g., Fwri«
Janguini8 lwmini8).
FaJ, EmboZi.~All fractures and vlolont 3ars to bones produce.
in all probability. Bome tat-emboli. by far the greater number
of which Is IIltcred oft in the lUllgs, but In some ca80ll the emboli
may be driven through the 11lllll'sinto the general clrculaUolI, to
be held up In some distant organ_
Air embo'i.
Eoeaa 0/ EmboliBm.-I1 the collateral circulation is
sufficient to compensate for the obstruction, as in the case
of the muscles, skin, and bone, secondary thrombosis takes
place on each side of the plug, and extends up and down
the blocked vessel as far as the nearest branches. Tho
clot then organizes, and a small portion of the artery
becomes obliterated. but the tissues do not Buffer in nutrition because the collateral vessels carry on the circulation.
If a large and important vessel, such as the pulmonary
or coronary artery, is blocked, sudden death may result.
If the collateral circufation fs Insufficient to compensa.fe
for the obstruction, the nutrition of the blocked area
suffers, and the degenerated area. of tissue, thus bereft of
ita normal supply of blood. is spoken of DB an infarct.
• Eud' or • Terminal' Artery.-By this Is meant an artery
whloh, though it hilS capil!aru anastomosis, has no /'rei!. arlerl.aZ
araastomoBis with flei(i/Kiourina _Belli. Such arteries exist In the
spleen. kldnoys. Intestlnos. brain (base). spinal cord (grey
matter). retina, heart (coronary arteries). The peripheral
branohes of the pulmonary and superio:r mesenterlo arteries are
also to som.e oxtent end-arteries. It should be noted that the
hepatlo arteries are not ond-arteries. An end-artery genera.lly
supplies a cone-shaped area. of tissue. the base ot the oone being
au the surfaoe of the orll"an.
An infarct (jarcio, I stufi) may be defined aa 8 mass of
tiBBue that has undergone degeneration heeause the endartery which supplies it has been blocked by an embolull
(and sometimes by a. thrombus). The aJfeoted area is
usually cone-shaped, the baae of the CODe being at the
surface of the organ, and the apex at the point of obstruction.
An infarct may be red or white. Virchow regarded
the latter aa a later stage of the former. Much controversy haa taken place on this still debatable question,
whioh after all is of trifling importance except to pedants.
Probably the changes which take place in an infarct ao;e
somewhat as .follows: At the moment of ooclusion the
artery beyond the embolus contracts and drives muoh of
the blood out of the infarcted area.. The infarot is now.
in a. sense, white. In COlI1'S6 of time the minute collateral
ohannels enlarge, and blood in ~uantity enters the area
in question, whioh is now • st~ed. Meanwhile the tissues.
including the capillaries, having been temporarily deprived of blood, undergo 8. certain amount of diSintegration, and the damaged capillaries thus allow the inflowing
blood to extravaaate into the substance of the infarot,
whioh acoordingly beoomes red. The entire mass then
becomes solid from coagulation of the blood and lymph
contained in it. In course of time leuoooytcs absorb the
colouring-matter and the infarct becomes white again.
It is now dead tiBSUe. Eventually this dead tiBBue is
removed and its place taken by fibrous tissue, whioh in
time contracts into a small scar.
Embolism oj an. e,nrl-artery in the brain (oommonly due
to 0. detached portion of a olot formed in the dilated left
auricle in connection with mitral stenosis) gives rise to
necrosis of the blocked area, followed by , softening' and
liquefaction and the formation of a oyst contaihing milky
Infarot of the liver does not occur, because, although
the portal vein is like an end-artery as regards its intra·
hepatic distribution, and emboli may thus lodge within
the liver, these intrahepatio branches connect freely'
with the hepatic artery through the medium of the
Infarct of- the heart is generally caused by tkromb08is
in 110 diseased coronary artery.
Fat Emboli are composed of globules of liquid fat.
They are most frequently met with in the arterioles and
capillaries of the lungs, generally in connection with
injuries of the long bones, especially of those nea.r the
epiphyses, the veins in the cancellous tissue of which,
being large and patent, allow the liberated marrow cells
to enter·the circulation and thereby to reach the lungs.
Some of the smaller particles may pass through the lungs
and lodge in the brain, heart, or kidneys.
Air Emboli may result from wounds about the root of
the neok (the' dangerous area '). The blood. pressure in
the large veins entering the thorax being negative, air
is sucked into the right heart, and the bl'anohes of the
pulmonary artery are found full of frothy blood.
It is probable that most of the alleged cases of air
embolism are the work of glIB-producing bacteria.
An Incised Wouna.-:Blood and lymph escape from
the severed vessels; in time the bleeding stops on account
of thrombosis of the out vessels. This is followed by
coagulation, which glues together the opposing surfaces.
The' reds' disintegmte, their remains being carried away
by phagocytes. The now decolorized elot is replaced by
a new tissue, which consists of (a) fibroblasts and (b) newlyformed blood-capillaries.
(a) Fibroblam.-These are large fusiform cells, having
a single ovoid nucleus. AB they are concerned in tho
formation of the future perma.nent tissue, they are sometimes called 'formative cells.' Though probably derived
from the. pre-existing connective-tissue cells, by somo
authorities their origin is ascribed to the endothelial cells
lining the 'lymphatics and bloodvessels.
(b) N e:wly-formed Blood-Oapillaries.-Coincident with
the appeamnce of the fibroblasts, certain of the endothelial
cells of the neighbouring capillaries throw out projeoting
buds. These elongate, become hollow, join with other
similar buds from a.djacent vessels, and so form loops of
new thin-walled capillaries.
In this way the original blood-clot is tmnsformed into
a richly vascular material known as grtJnulation tiMue,
which may be aptly termed embryonic repair tissue.
Later on the loops of the new capillaries on the opposite
sides meet and unite, the fibroblasts enlarge, fibrils develop in their interior, and ultimately fibrous tissue
In oourse of time the newly-formed fibrous tissue contracts and obliterates most of its bloodvessels, a fact which
explains the dead-white appearance of the ordinary soar.
It was once thought that primary union-i.e., direot
union of divided fibres and cells-took plaoe. It is now
known that, in the higher animals at least, this docs not
In. all forms of wO'Il/nil-healing the prOC688 i8 Ju1filamentally the 8ame-i.B., by means oj granulation tis8ue.
Healing by first intention ocours when the sides of an
aseptio wound are brought into apposition and maintained
there, and is the method of healing always aimed at by
the surgeon in the treatment of wounds.
The process is precisely the same as that described above
under the heading of ' An Inoised Wound.' The repair of
the divided epidermis takes place by a growth from the
oells of the rete Malpighii.
Healing by second intention occurs when the sides of a
wound have not been brought into apposition, or when
sepsis has interfered with healing by first intention, or
when the pa.rts have been so damaged that suppuration
or sloughing has supervened.
As in healing by first intention, granulation tissue forms.
The new tissue projeots from the base of the wound in the
form of a number of small round red points, or granulations, eaoh granulation oonsisting of loops of oapillaries
embedded in fibroblasts. The new tissue organizes in its
deeper parts, and, pari pa88U with this, fresh granulations
form on the raw surface, and in this way the wound heals
up from the bottom. Finally, the epithelium grows in
from the surrounding margin and covers the cioatrix, and
contraotion of the newly-formed fibrous tissue then takes
place. Hair and~andB are not regenemted 111.<1
In tke '1ieiiZing 0 fractured bOne the pJ,'Ocess is tne samo
as in the healing of soft tissues, with the exoeption that '
08teoblaBts from the periosteum and endosteum take the
place of, and subserve the same function as, the fibroblasts,.
the result being the formation of dense osseous tissue
instead of dense 6.brou8 tissue.
The essential part of the cell is the nucleus, and when a
portion of the oo]J-body is severed, the nucleus romaining, it
tcndsio regenerate the part lost.
When a musole flbre is out aoross, the divided ends oannot
directly unite. Such lUlion -as takes place between the ends of a
dividod muscle is efreoted by granulation tissue.
Tho neurone Is peculiar in regard to its power of repairing
injury (soo p. 146).
~a£,. is II mode o/_ f/1'OWtlt. Dot an inflammation. _
f i questIon wli6tnerrnflammation is a necessary part in the
process ot repair ot wounds Is one ot historical Interest. Oldtlmo surgeons, notloing that inflllIIllD.ation frequently oocurred
during the healing process, camo to regard infiammatlon as a
necessary antecedent to repair. 'VIlen, however, with the
advent of aSOPSIS' it was found that tho edges ot a healthy wound,
if kept closely together, unite without any. ot the olasslcal
Bymptons of inftllIIllD.atl0¥i t~o4 ruD~ ~d
iffiitt eM heIIHnrnlt wOiiilds 18 sat18fl!!lt,ory
~e~;!!f!!!:pto~.!! ~rii ibseiit", Qoubt arose as to whether inll8,lllmatlOn li Tn any wo~tio.I to repair. At the present
time we may regard it as an acoepted canon that aseptio wounds
heeJ without inflammation. Repair, then, is to be regarded
as 0. mode of growth, and it Inflammation acoompanies it, it is
to bo eonsidered an epiphenomenon resulting from bactorial
Diseases of Scars•
.E:rt1(Wlln- lWIt.r.scrJDD,- LlImIU.IIV pam aDd defl.l1'J.lJJtJ$
Keloid growth (= hyperplasia of fibrous tissue).
Varieties 01 Fibrosis.
Hyperplasia of eonnootive tissue, or ftb1'ON, ooours under tho
following oonditions:
AS Part of II Reparati1l6 Process.-When·a tissuo has sutTered
a solution of oontinulty, an ombryonio connective tissue (=granulation tissue) torms, and this, by developing into soar tissue,
ro-establishes the oontinuity.
8econdarily to In/fammation.-Tho fibrosis whieh oecurs In
this caso Is not to be regarded as part of the Inflammatory
prooess, but as a soquel to, or aooompaniment ot. it. Examl,los:
'l'he generalized fibrosis whlel!. takes place in ohronlo infiamm",tlons (e.g., fibroid phthisis); tho formation of adheSions in
pleurisy, pericarditis. and peritonitis; the formation ot a fibrous
capsule round a foreign body, a ollronlo absoess, or tuberoular
86COf1,darUy to Disappearance 0/ the Parenchyma.-Whenever
the parenchyma (=epithellal cells, neuroncs, musclc cells)
su1fers destruction, llyperpl.a.sla of the connootive tissu!) of the
part occurs. Thus, In descending l.a.tcral solerosis in the spinal
cord, the IIXOns, or nerve fibres, undergo atrophy, lind the
neuroglia takes on lIotlve growth, thus filling up tho SPII008
previously ocoupied by tho axona. Agllin, in tho strugglo for
existence whieh alWilYs takcs pilloe among the several elemellts
of tho tissuos undor conditions of detective nutrition, the hardy
oonneotive tissue displ.a.ys a marked tondonoy to inorellse at the
exponse of the more delicate parenohymatous oells. This Is
well shown in the progressive fibrosis and oonsequent hardening
of the tlssuos which takos pliloe with IIdvllUoing years (=sonile
fibrosis), and In tho fibrosis whioh ooours In passive venous con·
gestion (= brown induration).
It Is often dllHcult to determine how far fibrosis is of this
'socondary kind, and how far it is due to the direct IIction of an
irritant. 'rhis difficulty prosents Itself in suoh II malady as
granular kidney, for Instanoe. Somo hold thllt ovon in those
oaSElS in whioh fibrosis mo.nif08tly ocours scoondarlly to atrophy
of the po.renohyma (e.g., In tho symmotrioal spino.! SOleroS08),
It is produoed by irrito.tlon---t.e., by tho ehemioal irritation
caused by tho disintegrating parenohymo..
'rhe term granuloma is now more or less obsolescent, but
is co:g.venient to retain as 0. generic name to embrace the
following lesions. which bear 0. broad. genoml histological
resemblance to one another:
The characteristio lesion in all these diseases is the
presence of 0. tissue somewhat similar to granulation
tissue, developed round a spot at whiM certain 8pecific
organisms MV6 lodged.
When fully developed, an individual or 'anatomical •
tubercle consists of(a) The giant· celled or inner zone, composed of one or
more large cells, with radiating processes extending out·
wards between the cells of the next zone. The giant cell
contains numerous large nuclei, which are disposed peripherally-often in the form of a crescent. The giant cells
are most abundant in slowly-growing tubercles; they are
rarely found in rapidly-growing ones. They are not distinctive of tubercle, being also found in ordinary granulation tissue, as well as in syp.!rllomata, in leprosy, in actinomycosis, in glanders, and in certain cases of Hodgkin's
disease. (The giant cells of myelomata belong to a differentorder.)
(b) The e:ndotltelioid-ceUed or middle zone, composed
of several layers of large cells each having a large and
distinct nucleus.
(.c) The lymphoid-celled or outer zone, composed of.
layers of cells identical with lymphocytes.
.As regards the bacilli, most of them lie free between the
cells, but some are seen lying inside the giant cells" and'
in the endothelioid cells also.
The anatomioal tuberole thus desOl'ibed is a minute rounded
body scarcely visible to the naked eye (a pin's point), semitransparent, and' grey in oolour. By the fusion of several
anatomical tubercles small millet-seed bodies are formed, and
it is these that constitute the so-called' miliary' tuborcles. By
the coalescence of largo numbers of miliary tubercles. a big
conglomerate mass may form, such as is sometimes found in
the cerebellum of children.
Eooluticm oj the Tubsrcle.-This is probably somewhat
as follows: The tubercle .bacilli, having gained entrance
into the lymph-stream (fJ. p. 74), ultimately form plugs in
certain lymph-capillaries. The latter now oonstitute so
many incubating chambers, in which the baoilli proceed to
multiply. Some of the bacilli die, and in so doing dis,charge their speoific toxin. This toxin, being highly
irritant, induces a local tissue reaction, and causes(a) Swelling and proliferation both of the endothelial
and connective-tissue cell~.
(b) Lymphocytes to be attraoted to the infected area,
forming ronnd_it a. belt, which is probably proteotive.
By the further 'action of the bacillary toxins, the cells
at the oentre undergo hya.line degeneration, lose their
distinotness of outline, and fuse into a homogeneous mass,
constituting the ' giant oell.'
wlcijication may occur.
Sometimes a tuberoular area. becomes infected with pyogenic organisms. which. by oausing
suppuration. leads to the formation of an ab8C688. and thi!:'.
if it happens to open on to a. surfa.oe. to an ulcer (skin.
bladder. reotum, ileum, larynx).
.A tubl!fl'cle MIII!fI' organiz68, for, apart from other con.
siderations, no new tissue can organize unless it possesses
new blood-capillaries. If the case be a chronio one, a.
ca.psule of fibrous tissue forms outside and around the
tubercle as the result of a chronio inflammatory proceBB,
whioh is distinot from the tubercula.r process proper.
This new tissue in course of time oontracts upon the
tubercle, which finally COIneS to be represented by a
lamina.ted fibrous nodule, in the interior of which a. giant
oeIl mayor may not be distinguishable.
Bites.-Let it be clearly understood that tubercles only
form in lymphatics, for the bacilli cannot survive for any
time in the blood-stream, and, as before stated, each anatomical tubercle is to be regarded at first as an incubating
chamber for living bacilli, and subsequently, if the disease
is arrested, as the tomb of dead bacilli.
The favourite sites for tubercles are-the tonsils, the
lymphatic glands, the lungs, the synovial membrane of
joints, the pleural, the peritoneum, the pia mater of the
brain, the epididymis, the Fallopian tubes, and the cancellous tissue of bones.
An important characteristio of tuberculosis is its tendency to difiusion, either locally, or by tranllferenoe to
distant organs.
There are two entirely different typos of tuberculosis in the
human subject--{a) the human and (b) tho bo1line-the former
havIng a predilection for the respiratory organs, and the latter
(convoyed by milk) for the cervical and mesenteric glands, the
peritoneum, the bones, the loiJl,ts, the skin, and the pla mater of
the brain. It is significant that bovine tuberculosis occurs, par
ezeeZlence, during the mllk·drinking period of llfe. • They
lVould generally find the germs whioh caused consumption in
one in every ten samples of milk taken at random' (Prof.
Kenwood), Sometimes both types ocour together. PractiDally every man or woman over thirty·five on whom searoirlng
post-mortams have been done (no matter what disease caused
death) bears evidence of having suffered from tuberculosis.
Acute Miliary Tubercu1D:r1S.-A primary deposit of
lubcrcle-as, for example, in the bronchial glands, in
~he lung, bones, or epididymis-although it may remain
.ocalized, yet at any timemali
)f the s lit ,c arac
the fo
. n of thou
.th . u
II of them,
) ana omica tu
lUore or leRs, -olthe same age. The tubercle baoilli in these
Jases are probably distributed by the blood-stream (by
~rosion through the walls of Il. branch of the pulmonary vein
)r thoracic duct), the bacilli subsequently passing through
the thin capillary wa.lIs into the lymph-stream. When
this happens, the condition is known as acute miliary
tubercUlosia, of which there are two main types: that affecting the lungs. the pia mater of the brain, and the peritoneum and abdominal viscera in combination; and that
a.ffecting the pia mater of the brain by itself. The indi-
vidual tubercles are of small size, because the progress of
the disease is so rapid that there is no time for the fusion
of neighbo11ring anatomical tubercles.
Lupus is ohronic tuberculosis of the skin (outis vera)
and muoous membranes. Typical tubercles are presen~,
but the baoilli are few and very diffioult to find. Tlie
common situation of lupus is about the nose and oheeM,
but it may occur in the skin and mucous membrane of
almost any part. When .it involves the muoous membranes, it generally does so by extension from the skin.
The lupus patch may cicatrize under treatment, or
may ulcerate deeply, destroying the skin, mucous membrane, muscle, cartilage, etc., but not bone.
The disease rarely begins after the age of puberty, but
it may r6IJ'Ur at any age.
For a full aocount of the lesions found in syphilis, see
Leprosy is characterized by the formation of granulomata arising in connection with the presence of the
Bacillus "leprm.
The granuloma is composed principally of endothelioid
cells, with oocasional giant cells, and may oocur either in
the form of (1) distinct nodules, or (2) as a diffuse infiltration.
The tissue tends to degenerate, being either absorbed
or leaving a oicatrix. Therei", no ca8eation a8 in tubercle.
Sites.-Skin, mucous membranes, nerves, testioles,
liver, and spleen.
Glanders Is a highly oontaglous disease due to the BacUlus
maUei, and attaoking primarily horses, mulcs, and asses, but also
oommunicable to man from the diseased animal.
In the horse two va~eties are recognizod--glandors proper and
farcy_ch of whioh may occur in the samo animal ILt the same
time. Tho lesion is a ~ra.nuloma. the oells of whioh are almost
I101~~nUOlear leucooytes, bet'l1'c( n
which are the specifio oaol ; no [email protected] OfilIA Q,tft PmtlQDt" iu
course of time necrosis takes place. GIa.nders proper begins (In
tho horse) in tho septum nasi and neighbouring parts; the lymphatio glands of the neok and thorax soon become a:freoted, and
subsequently the lungs, l1ver, and spleen.
In the variety known as faEc)' the infeotlon takes place through
the skin, the disease then beginning In the superftclallymphatio
vessels 8nd glands. Seoondary nodulel\form In Internal orga.ns,
8S in glanders proper.
In man tho diseaso occurs ohi&fly in grooms, knaokors, and
those who work amongst horses, Infection taking place through
an abrasion of the Skin, or through tho mucous membranes of tho
mouth, nOBO, or eyes. The sYmPtoms may be either aouto or
ehromo, wh1le, 8S in tuberculosis, a chromo attack may at any
time take on the characters at tho acute form and rapidly prove
entirely composed of
Actinomycosis is a disease usually of cattle (oxon), occasion:
ally of man, and is due to the growth of tho actinomyces, or raytuDgns. It is probably seldom transmitted directly from ona
animal to another. The fungus is common on Buch ceresls as
barley, and a man may be inooulated by ohewing the raw grain
or by inhaling the tuDgus during threshing, etc.
Tho granuloma Is at first oomposed prlnolpally of lymphocytes.
olymorphonuclear leuoocytes thon appear. and giant cells are
ot infrequent. In the central part are olumps ot the ray·fungus.
, Around the granuloma there Is otten considorable fibrous
thickening, and thus the condition may be mistaken for a sar.ruuna. In OODrse of time softenilul:. Sllll.uuratioq. .and si.nwl
formation occur. The pus Is oharacterlstic; It may be serous or
viscid, and in either case contains the golden-yellow oolonies of
the parasites.
The most usual site In the ox is on tho tongue (and somotlmoS
In the 3aws), where It forms large masses which soon break down
and suppurate.
In mIlD the common sites are tho face, mouth, 3aWlil, and neck.
The infection may spread to the mediastinum. The intestines
may also be attacked, and from them the disease may spread to
the mesenteric glands. peritoneum, and lI"Ver. The lungs may
be a primary Beat ot Infection, 118 In threshers.
A definition should inolude everything pertaining to the
thing defined and exolude everything'not pertaining to it.
It is not possible. in the present state of our knowledge,
to frame a definition of a. tumour which satisfies these
requirements. It must suffice to say that UumQu.I .9_CID::.
s~s1e of a, ,:oncentrated..JIIM!I of Jtew tissue, nOIl,-!nfl.a.Dup-atory in ongrn.. that lives a parasitIc Ure a~ the expense of
its host, giving nothing in return for the nourishment it
receives, and is outside the control of the nervous system. I
There are two chief varieties-the innocent and the
malignant-the main distinction between which is that the
former va.riety, after a variable period of time, ceases to
grow and does not reproduce itself in distant parts; while
the latter alwa.ys oontinues to grow during the life of the
patient, and does reproduce itself in distant parts.
In the following classification it is assumed tha.t the
tumours originate in tissues of their own nature.
Classification of TomourL
Mesoblastlo Connective-tissue Osteoma.
Eplbla.stJo adenoma.
esoblastl0 { Endothelioma?)
Squamous OPithllllomal
Epiblastlo Rodnet ulcer
{ Spheroidal oancer
Malignant (M
Duct ca.noer
. e
Hypoblastio: Columnar OPithelioma. JoarolDomata.
i'he Innocent Tumours.
An innocent t'l.lll1UYUr is one consisting of a. tiBBue for the
~ost pa.rt normo.! in type, ~b)iDg more or less the
,jwue of the part from whjch it originates, Its growth i8
generally slow; it is usually oircumscribed and encapsuled.
does not involve the lymphatic glands. nor reproduce
itself in distant pa.rts. Docs not recur after removal.
A Myxoma is composed of stellate connective-tissue
cells which by the union of their processes form a delicate
network, within the meshes of which is a clear mucoid
material containing a small number of round cells. The
tumour thus resembles in structure the tissue which pre·
forms all the connective tissues of the fmtus, also the
vitreous humour of the eye a.nd the Whartonia.n jelly of
the umbilic~l cord.
Sites.-The suboutaneous tissues, bladder, rectum,
nerves, and spinal cord. A myxoma may also occur in
IIoBsociation with ca.rtilaginous tumou~ of the parotid and
the testicle, and sometimes in conneotion with sarcomata.
(The so·called 'mucous' polypus of the nose is probably
a mass of hypertrophied and mdemo.tous muoous memo
A Fibroma is a tumour composed of connective·tissue
cells and white fibres arranged in wavy bundles. It is
round or lobulated in form. and generally enclosed in 0
distinct capsule. On section, and viewed obliquely, it
looks like ' watered silk.'
Fibromata may be hard or 80ft, 8(lcording as the elements
composing them are loosely or closely packed.
Sites.-The hard fibroma is met with on the gums
(fibrous epulis); the soft fibroma, in the skin. as a pedun.
culated mass (molluscum fibrosum). Other situations are
-fascim, tendon sheaths, periosteum, base of skull, nerves,
and uterus.
Most Bo-oalled neuromata. are in reality fibromata. involving nerve trunks.
A Papilloma (sometimes olassed as an epithelial tumourl
consists of a stalk of connective tissue, giving oft
primary and sometimes secondary processes, the whole
being capped by the normal epithelium of the part. This,
however, never invcules tke u1u1e,rlying tissue (thus differing
from carcinoma).
The connective tissue of papillomata is more cellular
than normal oonnective tissue, _being sometimes even
myxomatous, and the blood vessels are more dilated. In
certain situations-e.g., the bladder-pa.pillomata. arc
prone to bleed.
8ites.-The skin (warts), larynx, rectum, bladder.
A Glioma is a tumour growing from the delicate connective tissue (neuroglia) of the nervous system. (The
true position of the gliomata amongst tumours is uncertain,
inasmuch as embryologists have not decided whether the epiblastic or mesoblastic in origin.) It is soft
and translucent, not unlike the grey matter of the brain.
and not sharply demarca.ted from the surrounding pa.rts.
Structurally it consists of a large number of closely
packed stellate cells, with numerous branching process s
which interlace to form a network. It is often very
vascular, and its vessE'ls, having thin walls, arl" liable to
rupture; hence the frequeTICIJ of kmmorrhages within it. It
is non-malignant and dangerous only on account of the
pressure it ('Ixerts (v. Glio-sarcoma, p. bO).
8ites.-Brain, spinal cord.
The so-called glioma of the retina is a tumour 8ui generis,
and quite distinct in structure from glioma of the brain.
It contains, among other cells, some which resemble
epithelium, and for this reason the growth is sometimes
classed among the epithelial tumours. It is very malignant, for it is liable to extend along the optic nerve and
to recur after removal. It is only found in infants, and is
probably always congenital, although it may remain undetected for some years.
A Lipoma is composed of ordinary adipose tissue. It
is the commonest of all the tumours in man, and may
attain to an enormous size (60 pounds). and is most
common in adult life. It may be either circumscribed or
A CircftmlJC'ribed Lipoma (the usual kind) is a rounded,
lobulated tumour of elastic or doughy consistency, contained within a distinct capsule: It is gen6l'll.1ly single,
but two, ten, or more, may coexist.
8ites.--The common situation is in the subcutaneous
tissues. (shoulders, back, and nates), but it may occur in
the subserous tissues (e.g., of peritoneum, pleura), in the
subsynovial and submucous tismes, between orin muscles,
in tho periosteum, and in the meninges of the brain and
spinal cord.
A Diffme Lipoma is a diffuse syrnmetrico.l overgrowth
of subcutaneous adipose tissue, not encapsuled, generally
occurring beneath the chin or at the back of the neck. It
is said to be most frequently met with in beer-drinkers.
A lipoma may oontain other tissues besides fatt.y.
Exa.mples of such are myxo-lipoma., fibro-lipoDllL, DJ.9VOlipoma.
Xanthoma.-Tbis Is a modified form of lipoma, Its substanoo
rosembliJlg embryonio tatty tissue. with an admiXture ot small
round oells. It oeOUrli on the eyelids In the fol'Il1 of 1lat elevations oJ: a yellow colour. It may also be tOUJId in diabetes (but
rarely on the eyelids or faoo).
A Chondroma is a tumour composed roainly of hyaline
cartilage, though it may also contain a certain aJD,ount of
fibro-cartilage. It Il18.y consist either of a single mass of
cartilage, or be composed of lobules bound together by
a. vascula.r fibrous tissue. Occa.siona.lly, caloification
occurs in patches. Sometimes cavities are found filled
with a gelatinous material.
Site8.-The most common situation of chondromata. is
the interior of the pha.langes of the band, where they are
often multiple. forming rounded knobs, which may attain
the size of walnuts, or even larger. They are alllO found
attached to the extremity of the diaphysis of So long bone
in young subjects (lower end of femur. heads of tibia and
humeEus). They are only IJlet with in the bones which
develop from, probably originating eitber from
misplaced islets of cartilage or from the epiphyseal
Chondromata. also occur in the parotid gland (where
they prol: bly originate from Meckel's cartilage) a.nd in
the iesti8; but in these situations tbe tumour is ~nerally
associa,ted with an endothelioma, and occasionally 'With
myxomatous or sarcomatous elements (or with both).
Pure chondroma. of the testis is exceedingly rare.
An OsteoDla is a tumour compcsed of bone tissue.
There are two chief varieties: (a) Cancellous, or spongy;
and (6) compact, or ivory.
(a) OIJ/ItCeUO'UB.-TbiS is usually met with as a pedunculated, 'cauliflower' mass of about the size of a walnut,
growing near the extremity of along bone.
It appears to originate from the epiphyseal cartilage. and
consists of II. mass of spongy bone limited by a shell of
compact bOIle. During its growth the tumour ia encased
in a thin layer of oontinually growing hyaline O&l'tilage,
and it is by the ossifioation of this that it inoreases in size.
When the epiphysis beoomes united to the diaphysis,
growth oeases and the tumour remains stationary. The
affeoted bone, as a rule, loses in length what it gains in
, new growth.'
8itea.-Lower end of femur, ungual phalanx of great
toe, upper ends of tibia and humerus. Sometimes the
tumours are multiple and hereditary..
Multiple Exostoses.-Accordiog to Professor Arthur Keith,
these ought to bc removed from the catogory of tumours and
placed amongst the disorders of growth. They are probably
congenital in origin, but not usually becoming obvious until the
child Is of fair size.
(b) 1fJory.-This is composed of very dense bony tissue,
of the consistence of ivory. It is rounded in form and
usually sessile.
8itea.-Although a tumour of this variety may develop
in any bone, its most frequent sites are-Frontal sinus,
orbit, external auditory canal, anglo of the lower jaw,
mastoid proceSB, ilium, and scapula.
Odontomes (Tooth 'l'umoars).-· Odontomes are tumours oom·
posod of dental UsBUeS in va.rying proportions and dilforent
degrees of development, arising from teeth germs or tecth still
In the progress of growth ' (Bland-Sutton).
Tho two most important are-(a) Epithelial odontom08.
(b) Follicular odontom09.
(a) EpitluJliaZ Odontomes (Multilocular Oustic Tumours) are
oomposed of 0. number of small cysts lined by cubical epithelium,
and embedded in o.flbrous stroma. They oontain a viscid ftuld,
and appear to originate in branehing columns of opithellal cells
derived from the enamel organ, which cells break down in their
more central parts. The jaw becomes expanded, but growth is
slow. These cysts are non-malignant, showing no tendcncy to
dect thc glands or to disseminate.
(b) FoIZit:u.Zar Odontomll8 (=' dentigerous cysts ') arc oysts
which form in connection with misplaced and non-erupted teeth.
The expa.nded dental BOO represents tho cyst wall. The interior
contains a viscid fluid and the crown of the non-ol'1lpted tooth.
tho fang of which Is uBually ftx.ed to the cyst wall, though
sometimes the tooth is loose. With rare exceptions follicular
odontomes form only in connection with the permanent teeth,
and morc partloularly with the canine of tho upper jaw. The
tUD10ur ~rows slowly. Owing to expansion of the surrounding
bone. • eggshell ora.ckling· may In course of time bo felt on
pressure. (These oysts must be distinguished from • dental
cysts' which develop tram the tangs of normally erupted teoth.>
A Myeloma is a tumour growing from the red marrow of
bone and corresponding to it in structure. Characteristic
of the growth is the presence of numerous large cellsmlleloP la:leB-the nuclei of which (twelve or more) are
arro.nged centrally.or distributed throughout the interior.
In appearance the cut surface often suggests a piece of
liver, owing to the presence of extravasated blood which
has undergone pigmentary changes. Cysts are common.
The tumour is often very vascular, and as it enlarges and
the surrounding bone becomes expanded, it may pulsate
and thus be mistaken for an aneurism. (Myelomata were
formerly classed am:mgst the sarcomata, under the head
of C myeloid sarcomata,' but, inasmuch as they show no
tendency to the formation of secondary deposits. they are
now classed amongst the innocent tumours.)
Sitll8.-Upperend of tibia, lower end of femur, upper end
of humerus, and the lower jaw.
A Neuroma is composed of ne!""e cells, and is extremely
rare. Cases have been described as occurring in the skin
of children and in the sympathetic ganglia.
(A • false' neuroma is a fibroma growing from the
sbe&t.b of JI, nerve; JIJl • .a.mput.u.t.ion ' neurODlJl. .is' JDarely
a mass of fibrous tissue on the cut end of a nerve.)
A Myoma is a tumour composed of muscle tissue.
Two varieties occur: the (a) rhabdomyoma, consisti;ng
of striated muscle; and the (b) leiomyoma, consisting of
non-striated muscle.
The Rhabdomyoma is very uncommon and usually
congenital. Its usual seat is the kidney, where it probably
arises from inclusion of some of the fibres of the lumbar
muscles during fretal development. The component
elements rarely present the characteristics of normal
striated muscle, but consist chiefiyof spindle-shaped cells,
together with a large number of embryonio cells and only
0. few striated fibres.
The Leiomyoma only develops from pre-existing unstriated muscle fibre, and occurs most commonly as the
• uterine fibroid'; but it occasionally occurs in the
oosophagus, stomach, intestines, and prostate. IfJ hap
also bcen found in connection with the broad ligaments
and the ovaries.
When occurring in the uterus, this tumour is composed
of bundles of spindle·shaped unstriated muscle fibres,
which interlace in various direotions. In places the fibres
are arranged concentrically, presenting the appearance of
tiny balls of cotton. There is generally a fair amount of
fibrous tissue present, so that the tumour is often called a
The Angiomata are tumours composed of dilated bloodvCBBelS. They are of three kiI?-dsSimple nmvus.
Cavr.rnous nmvus.
Plexiform angioma.
A Simple N retIU8 consists of a mass of dilated and
t'lrtuous capillaries and venules bound tJgether by a scanty
amount of oonnective tissue. It is nearly-always congenital, and usually tends to inorease in size for a few months
after birth.
A Caverno'lUl NaJlJU8 resembles in structure iihe corpus
cavernOBum of the penis, and consists of a series of intercommunicating spaces lined by endothelium, and Qound
together by a delicate connective tissue sometimes containing fat. Small arteries open directly into the spaces, and
veins carry the blood away. It is generally subcutaneous,
but sometimes is seated beneath a mucous membrane.
Tlle tumour may be provided with a distinct capsule, or
it may merge gradually into the surrounding tissue.
It may be congenital, or may develop in later life.
Sitea.-Lips, skin of face, scalp, trunk, limbs, and liver.
Plexijorm, Angioma.--When a single artery becomes
dilated, thinned, elongated and tortuous-resembling a
varicose vein-the condition is known as arterial vam.
When the same condition affects several neighbouring
arteries, it is known as cir80id aneurism. The muscular
and elastic elements in the walls of the affected arteries
are partially atrophied. H the dilatation involves the
capillaries and veins as well, so as to form a pulsating,
bluish, spongy tumour (like a bundle of pulsating worms
under the skin), the condition is termed plezijorm angioma.
Sitea.-May be found on any part of the body, the
usual seat being the soalp, where it affeots the temporal,
posterior aurioular, and oooipital arteries.
A Lymphangioma is a tumour oomposed of dilated
lymphatios, with hyperplasia of the intervening oonneotive
tissue. The dilatation may be so extreme as to oonstitute
large oysts. They are mostly oongenital, and form a large
proportion of the' oongenital oystio tumours.' Three kinds desoribed-(i.) l{I.rmphatic nal1JU8 (ooourring in the skin
and tongue); (ii.) cavemDuslympliangioma (ooourringin the
neok as '·oystio hygroma' and 'hydrooele '); (iii.) lymphatic
cyst, whioh may ooour anywhere.
The Adenomata are tumours oonsisting of normal
gland tissue (thus differing from the o8orcinom8ota., which
consist of a perverted type of gland tissue) 80rising in oonneotion with, and constructed on the model of, the secreting gland from which they grow, but their duots do not
onter those of the gland. and they contribute nothing to
its normal funotions.
Imitating the structure of the gl80nd from whioh it
springs, an adenoma. consists, when growing from a. compound tuliular gland, of aoini and duots, and, when growing from a simple tubul80r gland, of tubules. The aoini
80nd tubules 8oliko are lined by regular epithelium which
daea not infiUrate into. bu.t is sharply demarcated from, the
8'U"ounding tis8'Ue.
Pure adenomata arc rare. The oonnective-tissue stroma
varies in amount; in some cases it is so oonsiderable th80t
the growth is oalled 80n adeno-fibroma. In the quioklygrowing forms, myxomatous and sarcomatous elements
may be intermingled with the stroma.. Such mixed forms
are known 80S my:r:o-adenoma, sarco-adenoma, ete. Further,
the tubes and aoini may become distended into oysts,
forming a cysto-adenoma, and oooasionally the stroma may
projeot into the lumen of the acini. when the growth is
known as a papillary adenoma.
Adenomata are generally encapsuled and not infrequently multiple. They never reproduoe themselves in
distant organs., parotid, thyroid, ovary, rectum, and
A cyst is a closed sac of abnormal development, the
contents of which are fluid or semi-fluid.
The different varieties areRetention Oysts constitute the majority of cysts; they
are caused by obstruction to the outflow from a gland or
cavity. Muoons, sebaoeous, mammu.ry, renal, and pancreatic cysts, and ranula, are examples. They are lined
by a layer of epithelium.
Oysts formed by the Dilatation of a FCBtaZ Tube which
normally is obliteratedt-e.g., parovarian oysts, cysts in
connection with the thyrogtoBll&I duct, urachus, Wolffian
duct, and l\{iillerian duct.
Oysts containing an AnimaZParasite-e.g., hydatid.l
Distension 6ysla, resulting from hernial prot;;&iolls
of the synovilil membrane of a joint, and hernial protrusions of tendon sheaths (ganglion). Also cysts of the
NPfUral Oysts. of which meningocele and spina bifida
are examples.
Oysts r68UZting from Degeneration in the OentraZParl of c4
TumO'lJ,r-e.g., in sarcomata.
Oysts forming round Foreign Bodies.
Blood Oysts.-These are due either to extravasated I
blooa beoomlng.encapsulea. or to luemorraage occurrIng}
into any ordinary oysts.
Lymphatic Oysta (see Lymphangioma, p. 84).
Implantation Oysts are caused by the implantation of
tho epidermis. conjunctiva, or other mucous membrane.
into the deeper tissues. after such an injury as 0. stab with
0. hatpin. fork. etc. In ~ts new situation the epithelia.l
cells proliferate and form a oyst.
The term teratomata (teras, a monster) is applied to tumollrs
oomposcd of an aRsortmont of many difteront tissuos (eplblastio,
mesoblastio. and hypoblastic), mixed in varying proportions.
Somo oontaln dermal structuree--e.g., skin. 116ils. hair, and
toeth {= dermoid oyst)---and others may oontain musole, cartilago, bone, nerve, visom'a, or, Indeed, any tissue of the body.
They appear to result from tbe disPlaoement of a germ ooll
within the tissues ot an embryo-
Dermoid O,sls ooOUl' most commonly in the ovaries, but aI€o"
in tho testioles, about the angles of the orbit, oorneal JDal'gin, in
tho nock, and elsewhere. The oyst wall is oomposed ot skin, a.nd
insidc the Cyst are hair, na.!ls, or teeth, a.nd sebaceous matter.
In many oases they se(lJIl to result from inclusion of the epiblast
during tho closure of the embryonlo olefts. In the case of the
ovary, thoy probably cl~her develop from the Woltrlan body-a.n
cpl blastic strueture-i)r result from the a bort3d growth of an
ovum. The • mixed' tumour of tho testiole (the so-oolled
, fibro·cystlo ') is probably a. teratoma.
'!'he Malignant Tumours.
The distinguishing charaoteristics of malignant tumoul'll
/trd: (r.J) unceasing local growth, and (b) repr.>duction in
distant parts of similar tumours which develop from cells
detaohed from the mother tumour.
There are two chief kinds-the saroomata, which grow
from oonnective tisaue; and the carcinom.ata, which grow
from epithelium.
.A Sarcoma is a tumour which originates in one or other
of the connective tissues (mesoblast), but differs in structure from the parent tissue in that the cells, instead of
attaining to adult growth, remain permanently embryonal.
Moreover, the cells, like those of all malignant tumoul'll,
lJ1JQe~D jJlc.e.saant. .multJpl.iL'.a.tJOOJ,. whic.h LU!Jy c.eases
(unless removed) with the death of the host. Furthermore, some of the cells, by becoming loosened from their
bed, pass as emboli into the effluent blood-stream, and
being arrested in the capillaries of the lungs, form secon·
dary tumours there which repeat th!3 characters of the
mother-tumour. These, then, are the cardinal facts of
a sarcoma: Origin from mesoblast, embryonal nature of
the composing cells with unceasing powers of multiplication, reproduotion of the tumour in distant parts.
Broadly speaking, the more embryonic the cells, the
more malignant is the tumour.
Structure.-The varieties of sarcoma represent stages
in the ordinary development of oonnective tissue, from
the round cell to the spindle cell, but 8topping 8hort offully-
formed c01~nective ti8sue.
[ntlll'cellular sub8tance-is always present, but though
very evident in some cases, it is difficult to distinguish in
others. It may be fluid and homogene011ll, granular or
finely fibrillated, and sometimes cartilaginous or osse011ll.
Sometimes the stroma seems to consist of little more
than thin-walled bloodvessels.
Ths bloodv688els, owing to the active growth of the
tumour, are usually very numerous, and generally embryo:lic in structure. Often they are mere channels
or sp:wes between the cells of the tumour. This explains
the frequent occurrence of hmmorrhage into the Bubstance
of the growth; also the way in which the tumour cells can
be carried into the circulation and deposited in distant
organs, there to set up secondary growths.
Owing to their rapid growth there is no time for a
efinite capsule to form, but in a slowly-growing tumour
here may be a condensation of the surrounding tissues,
but this is generally infiltrated with the sarcoma, cells.
Mode of Spreading.-Sarcomata spread locally by in-filtrating the surrounding tissues. At the growing border
of the tumour there is a great excess of small round cells;
these advance in all direct.ions, absorbing the normaf
tissues (histolysis) in the immediate vicinity.
The most common channel of dissemination in distant
parts is the blood-8tream: detached groups of the cells
pass into the circulation, and are carried by the veins into
distant organs (notably the lungs), there reproducing the
structure of the original growth in all its details.
They may also spread by the lymphatics; this happens
in the case of melanotic sarcoma, sarcomata of lymphglands. tonsil. thyroid. testis. as likewise all quicklygrowing sarcomata.
The classification of the sarcomata is based upon the
prevailing type of constituent cell:
Ordinary Forms.
Special Forms.
Small round-celled.
Large round-celled.
Small spindle-celled.
Large spindle-celled.
EJldothelial sarcoma.
Small Round~celled Sarcomata are the commonest
form of sarcoma, and, next to the melanotic, the most
malignant. They grow rapidly, infiltrating the surrounding tissues, often attain a great size, and disseminate
through the bloodvessels. They are encephaloid in
appeamnce, being to the naked eye very like the encephaloid carcinoma.
Sitea.-They may occur in any organ: in the bones,
glands (especially the mamma and testis), muscles, and
subcutaneous tissues.
Large Round~celled Sarcomata are rarer and less
malignant than the last-named variety. l'he cells are
large, and have a round and distinct nucleus.
• Spindle-celled Sarcomata consist of oat-shaped or fUSi
form cells, tapering to a point, which often bifurcates
They are arranged in bundles, which take different direo
tions, so that in section under the microscope some of them
appear rounded, and others spindle-shaped.
They are firmer than the round-celled sarcomata, and
they may contain an admixture of myxomatous tissue
(myxo- Barcoma), cartilage (f1umdo-ilarcoma), and bone
(08teo-mrcoma). In slow-growing forms some of the
spindles may be converted into fibrous tissue (fibro-
Sitea.-Bones, subcutaneous tissues, fasoilB.
The L:vmph~Saroomata are com_posed of cells identical
with. those of the round-celled sarcomata, and they contain a delicate, fibrillated, intercellular substance.
Sitea.-Their common seat is in the bronohial and mediastinal lymphatio glands, but they are also found in thCl
mesenteric and other lymphatic glands.
The tumours found in chloroma (v. p. 33) are probably
Alveolar Sarcomata, which are very rare, grow from the
skin. Their round or oval cells are grouped in alveoli
formed by fibrous tissue. Between the cells is a delicate,
fibrillated, intercellular substance.
Melanotic Sarcomata are usually oomposed of interlacing
bundles of large spindlEl. cells oontaining an intracellular
brown pigment in the form of highly·refracting amorphous
granules (melanin), elaborated by the cells, and
differing in composition from the ordinary blood-pigments
in containing sulphur, but usually no iron. An ironcontaining pigment may, however, sometimes be found
between tbe cells as the result of blood extravasation. They
vary in colo.ur from a sooty brown to an intense black.
Sometimes the urine contains melanogen.
Most of the cells are spindle-shaped, but others are
epithelioid, and sometimes the stroma is so distinct as to
map the growth into alveoli. When 0. melanotic sarcoma
grows from the skin, the alveolar structure with epithelioid
cells is the rule, and, according to Unna, this form should
be considered as a melanotic carcinoma.
Although locally far less malignant than many other
kinds of sarcomata, the melanotic sarcomata are the mos~
malignant of all tumours on account of their rapid dissemination. Thus, by the time the primary growth has
reached the size of a filbert, secondary growths are generally to be found in the lungs, liver, kidneys, and brain.
(The liver may contain hundreds of small tumours scattered
throughout its substance.) They di88eminate by the
Zympkatica as well as by the bloodvea8elB.
They IIore 'Very rare, about one cllose each year being seen
at a large London hospital.
Bitea.-'l'he primary seats are the tissues which normally
contain pigment-i.e., the skin and the uveal tract of the
eye (iris and choroid).
It is gener& aocepted that melanotio I!8l'COmata devoloD
from cbromatophores, but it is not yet settled whether theso
latter are derived from epiblast or b)'I>oblast, but inasmuch as it
is unusual for mesoblastio oells to elaborate pigment, tbe InferenOil
Is that melanotlo sarcomata belong to tho carcinomata.
The Osteo-Sarcomata, as primary growths, are met
with almost exclusively in bone. .As a rule, calcification
is more common in them than true ossifioation, but
spioules of true bone oan genera.lly be deteoted. In these
mixed tumours it is most important to examine the growing pa11i at the circumferenoe, because this region always
shows the true sarcoma elements. (For Sarcomata of
Bone, see p. 205.)
The Glio-Sarcomata grow from the neuroglia of the
nervous system, a.nd composed of cmbryonio neuroglia.
They are a. oommon form of cerebral tumour.
Endothelial Sarcomata.-These are probably examples
of simple endotheliomata which have undergone malignant
transformation. Some parts show the structure of an
endothelioma, and other parts that of a sarcoma.
The Endotheliomata are tumours which appear to grow
from the endothelium of serous membranes (pleura, peri.
toneum, meninges of brain, synovial membrane of jOints,
and tendon-sheaths), lymphatios, bloodvessels, and sometime!\ from the endothelium in the parotid gland, testicle,
and .ovary. (Such tumours growing from serous membmm s are sometimes called mesotheliomata, and when
growing from the perivasoular lymphatics peritheliomata.)
The cells are large, round, and sometimes' epithelioid' in
shape, with no intercollular substance, and they are contamed in alveoli formed by fibrous tissue. The structure
of the endotheliomata thus resembles that of the oarcinomata.
(If tho crolum theory bo correct, tho llnlng colis of tho plouro,
peritonoum, etc., aro epltholial, and as In no case has the origin
of a tumcur from ondotholium boon pre,·od, many of the reputod
cases of cndotholiomata may bo examples of carcinomata.)
The endotheliomata, as a rule, develop very slowly;
they are only occasionally malignant, seoondary growths
and recurrence after removal being rare. W.hen aficcting
the dura mater, for example. they do not infiltrate the
brain, but push it before them, compressing the nerveelements.
Psammomata are endotheliomata which grow from the
pia mater of the brain and the choroid plexuses. The
cells are arranged in groups lying in a fibrous stroma.
E~ch group of cells is composed of concentric layers, in
the CI:>Iltre of which is a calcified sand-like particle due to
the degeneration of the -most central cells. In the brain a
psammoma rarely exceeds the size of a shelled wahiut.
Many tumours classed as ondotlloliomata are probably not so,
for, as Ribbcrt points out, the continuity of the tumour colIs with
endothelium at the margin. is no proof that it springs from the
latter. Som_s, for instance, the so-called peritheliomataare probably sarcomata.
The Carcinomata.
A carcinoma is 0. malignant tumour growing from and
oontaining as its essential elements epithelial cells (epiblastic and hypoblastic), and charaoterized by all the
special qualities which pertain to 0. malignant growth-viz., continuous local extension, and reproduction of its
own likeness in distant pa.rts.
The epithelial cells-which constitute the malignant
part proper-manifest extraordinary powers of reproduction and survival. No longer simply covering a
surface or maintaining the arrangement of normal glandu.
lar tissue, the cells (at one particular place) multiply and
send out processes which, breaking their natural bounds
(i.e., basement, force their way into the surrounding tissues.
l'his activity of the epithelial cells is aocompanied by a
proliferation of the adjacent connective tissue, whioh is
either the result of mere mechanica.lirritation, or Prc;'v0lnd
b:iJsomo chomjgai Hub!ltiijlce liberated from the~oJ
oe s. The bloodvessels are confined to the stroma-ill'Oonformity with the rule throughout the body generally
that no bloodvesselslie between epithelial. cells.
There is thus developed 110 tumour the architectural
plan of whioh is a connective-tissue framework( =8troma
containing irregularly-shaped intercommunicating oham
bers (= alveoli) in which lie the essential carcinomatou
elements, groups of epithelial cells. If II. thin section b
made and gently brushed, or sha.ken in a test-tube hILl
filled with water, the cells are removed and thl' stroma
remains (v. Fig. 8). In general structure then, 0. carcinoma may be roughly with a sponge the spaces in
the interior of which are filled with grains of sand; then the
sponge-fibres would stand for the stroma, the spaces inside
the sponge for the alveoli, while the graina of sand would
represent the epithelial cells.
The alveoli may be plLcked with epithelial oells, as is
the case with the epibllLstic carcinomata, or they may be
simply lined with epithelial cells, as is the case with the
ordinary hypoblastio carcinoJllata.
The'n rcommunicatin alveoli aTOm reali
dilate ~ t ID.& w
and are directly continuous with tho neighbouring lymphatic vessels.
This explains how it is(a) That the extension of the tumour peripherally takes
IPlace along the course of the marginal lymphatics.
(6) Tha.t the lymph which flows between the carcinoma
cells can carry away some of these cells and lodge them
as emboli in the lymphatic glands draining the tumour
area, there to set up secondary growths which reproduce
the features of the primary growth. From these, secondary
growths in detached cells may be carried to other parts,
such as the liver and bones, and so cause oancer growths
in these places. The looser the cells, the greater will be
Y.l!I. .lI•....,.'h'rulW OF f'.ARIllNlUU,. JIllI).\UNG
the tendency for them to be thus carried away; for example, secondary growths occur more n,adily in the case.
of the breast and testis than in the case of epithelioma of
the skin.
Wherever these secondary growths occur, their composing epithelial cells are the genealogica.l descendants of the
cells of the parent tumour. The stroma, on the other
hand. is always derived from the local connective tissue.
The secondary growths, developing as they usually do
in situations with a free blood-supply. often attain to a
size l!luch larger than the parent tumour. Thus the liver
may be the seat of bulky seoondary tumours. while the
primary one is comparatively small.
The epithelil;\l cells of a carcinoma. within certain limits
tend ttl resemble those of the pa.rt from which they or:gina.te. Thus, a carcinoma of the lip contains squamcus cells;
of the intestines, columnar cells. H, however, they are
subjected to much pressure from abundant stroma formation, they are liable to deviate from the original type.
When the tumour has reached a certain size, degeneration commences in, the central parts, while growth continues at the circumference. The most common is 'fatty'
degeneration of the epithelial cells. The degenerated cells
shrivel up, or are absorbed, and this often leads to a
relative preponderance of the stroma, which, contracting,
causes a. dimpling of the surface. When the tumour
involves a surface, such degeneration leads to the formation of an ulcer. In this case (and often in cases of a
tumour unattended with ulceration) a bacterial infection
ta.kes place, leading to toxmmia. Cancerous cachexia
(anremia, emaciation, and pigmentation of the skin)
results chicfly from this, and partly from long-continued
discharge, and pa.rtly also from the appropriation by the
tumour of nutriment which should go to nourish the normal tissues. Whether the ma.lignant tumour before it
degenerates, or becomes the seat of a bacterial infection,
gives off poisons capable of producing cancerous cachexia
is doubtful.
Oolloid degeneration of the cells is not infrequent, and
sometimes the stroma is tho seat of myxomatous changes.
The transference of ,cancer from one human being to
another has never been satisfactorily observed, neither
h!l.9 Ii. tumour from man ever been inoculated successfully
into a lower animal.
• Primary cancers occurring in mice are similar in oliDical
history and mlcroJccploally to those occurring In mell- Bomo
of them may be transferred to other mioe by grafting the
living tumour cells In suitable positions. Upon grafting from
a primary tumour in the first Instance, only a small percentage
of the grafts are as 0. rlllo suooessful. This peroentage Increases in subsequent grattlngs, and the tumour is said to
become more .. viable," until a stage may be reo.ehed when the
usual percentage of successes Is nearly or quite J.OO. The
rapid passage of the tumour through successive hosts Inoreases
the rapidity of the growth of the tumour. But these things
only happen when the same broed of mice Is used. It unrelated
breeds are used, tho percentage of successful graftings Is sma1l,
If, Indeed, the tumour Is viable at all; though, If any grafts are
successful, thc same" viability" in thc new brced of mice may
bo attained in the same \vay as before. These mouso cancers,
no matter how readily they may be tranS]Jlantcd into other
1nice, can never be established in another spccies of animal.
Though the cells may live and multiply for a short time in 'the
body of another species oJ' animal--e.o.• a rat-they always die
0:6' eventuallY. and can never be established' (C. F.. Walker).
The following are the chief forms of carcinomata, a
classification based on the type of cell from which they
grow and the shape which they tend to maintain:
A Squamous Epithelioma grows from parts covered by
stratified squamous epithelium (skin, mouth, tongue.
pharynx, <:esophagus, larynx, vulva, vagina,lower part of
cervix uteri, bladder, penis, and anus). They also frequently originate from chronic ulcers, sinuses, and scars
(particularly those from. burns).
The tumour first appears as a small warty growth or
tubercle, ·which soon breaks down in the centre, leaving an
ulcer with hard, raised, everted edges and indurated floor
(on the penis the tumour may attain a large size before
breaking down). The ulcer slowly spreads. destroying all
the ti88ues in its Although differing in certain
details, the structure of an cpithelioma i~. in the main,
similar to that of cardnoma g~ner,~lly, being composod of a.
oonnective-tissuestroma enclosingalveoli which are packed
with epithelial cells.
A nota.ble feature of epithe!iomah gr.:>wing from
cutaneous surfaces (lip. anus, etc.) is the presence of cellnests, which are onion-like masses of ceils Ila.\rjng the
following structure: In the centre are flattened, dried-up
cells; around these are layers of crescent-shap3d cells. and
on the outside columnar-shap3d cells resembling those of
the rete Malpighii. (This order represents the tendency of the cells to undergJ their normal epidermic
evolution.) In course of time the whole cell-nest becomes
a mass of Battened cells arrang.:ld concentrically around
the cornified centre. The fibrous stroma. is scanty, riC'h
in cells, and often shows leucocyte infiltration.
The group of lympha.tic glands draining the area of the
growth are infected more rapidly when the primary growth
is situated in soft vascular parts (e.g .• tongue) than when
occurring in the skin. The affected glands enlarge, and
if reaching the surfa.ce become adherent to the skin. which
finally gives way, exposing an excavated foul ulcer.
Although occasionally found in the viscera, as a rule the
secondary growths are confined to the neighbouring lymphatic glands, probably because the intercepted epithelia,
being comparatively large, cannot escape beyond the infected glands.
When growing from scars, an epithelioma may remain
localized for a long time. When preceded by a chronic
irritation (e.g., leueoplakia), the growth is usually very
Chorio-Epithelioma.-Thls occurs In the ull!rus after preg.
nancy, and whon found is generally associated with hydatiform
molo. It originatos from tho cpitllelium of the cllorionio villi,
and is composed of similar coils groupod in columns, along with
which are solid areas of protoplasm containing many nuclei.
There may be abundant secondary growth in the lungs and other
organs. Cystic enlargement of tho ovaries ofton accompanies it.
A Rodent Ulcer (basal-cell carcinoma) is a species of
epithelioma growing from the sebaceous glands. sweat
glands. or hair follicles, and generally occurring above
aline drawn from the angle of the mouth to the lobe of the
ear. Common situations the root of the nose and
inner canthus of the eye (does not develop at mucocutaneous junctions). The growth begins as a small
pimple in the skin, and may remain as such for In
process of time this breaks down into an ulcer with a
smooth, depressed fioor, and a hard, mised, everted,
sharply-cut, sinuous edge. The ulcer extends very slowly,
and may go on for many years, but gradually destroying
the tissues both superficially and in depth. In this way
it may eat its way through bone, and even penetmte the itself.
It is not uncommon for thc ulcer to make abortive
attempts at healing. but the scar tissue :which forms BOon
breaks down.
Structumlly a rodent ulcer resembles an ordinary
epithelioma. It differs. however, from it in that thereat
are sma r nd rounder, an
at the ro h
supe cia ra er an
e stroma is a wa.ys
WI sma roun cells. In most ~mens cell.
nests are absent, or, when R~;I:t, {ledrn!
"'Its mlthgnancy IS purelYoc ,and although it slowly
invades and destroys all structures in which it comes
into 'contact, it never infects the nei hbourin 1 m hatic
nt :l.rts its epl e 801
ce s eing fixed.'
Spheroidal-celled Carcinoma only grows in oonnection
with glands, and is typically represented in cancer of the
breast. A fibrous-tissue stroma (Fig. 8) encloses welldefined intercommunicating alveoli packed with epithelia.l
cells, spheroidal or polygonal in shape. according to the
pressure of adjacent cells upon each other. In course of
time the growth invades the pectoral fascia and skin,
eventually ulcemting on the surface.
There are two chief varieties (with intermediate forms),
depending upon the relative proportions of oellsand stroma.
n the stroma is dense and abundant, while the cells are
not plentiful, the tumour is hard and is called (a) scirrhu8 ,if the stroma is sparse and the cells are abundant, the
tumour is soft. and from its resemblance to brain tissue
is termed (b) encephaloid.
Although from the clinical signs the growth may
appear localized, yet widely beyond the limits of the actual
tumour the tissues are found to be infected with small
masses of epithelial cells; in faot, in all cases of carcinoma
of the breast, and from an early period, the entire mammary
region is to be regarded as sown with the cancer cells.
(a) Scirrhus is the commonest form, constituting about
95 per cent. of a.Il oases of carcinoma of the breast. When
first coming under notice, it forms an indurated lump with
long processes extending in various direotions. As it
enlarges, the skin beoomes adherent, then gives way,
exposing a foul ulcer. When removed, the cut surface of
the tumour has been aptly compared to that of an unripJ
pear in tint, and is slightly concave from shrinking of its
fibrous elements. The stroma is especially abundant at the
central pa.rt, and here the tumour often shows but little
else than a dense feltwork of connective tissue, with a few
a.trophied cells enclosed in shrunken alveoli. At the oirference, however, the typical carcinomatous structure
is evident.
..J.t1'Opkie So€IT1ws.-In. this very ram form. tho stroma. is very
abundant and contraots to such an extreme degroe that the breast
becomes largely replacod by a puckcrcd. scar·like InBSS. With
perhaps a small superficial ulcor in thc position of tho nipplt'.
It is very ohronio. tho patient often living many yoars (evon up
(b) Encephriloiil is the opposite extreme to soirrhuB, for
it is much more rapid in its growth, quickly developing into
a bulky, soft, and elastic tumour, which soon becomes
adherent to the skin. eventually protruding from the
surface as 0. bleeding fungating mass (fungu8 luBmatodea
of Hey). The out surface resembles brain-substance,
and shows here and there dark-coloured blotchos due to
blood extravasation. In conformity with its rapid growth,
the amount of stroma is small and the colIs numerous; the .
stroma, moreover, is less fibrous and more vascular than
that of scirrhus.
Encephaloid is very much less common than scirrhus
as 0. primary growth. being most often met with as 0.
secondary growth-e.g., given a primary scirrhus, the
secondary growths are encephaloid. In addition to
glandular involvement, these secondary growths may occur
in the liver and the interior of bones (more particularly
the femur and the lumbar vertebrre).
Cancers ot the breast have metastasing spoeds whioh vary with
the activity of thc primary growth, encephaloid ot the lactating
breast, for example, metastasing very rapidly, aud atrophic
scirrhuB very Blowly; 12·5 pcr cont. ot all recorded cases ot
cancers of the breast appeared betwoon thc twentieth and thirty·
fifth year of life.
Duct Cancer (or Villous Cancer) grows from the epithelium of the ducts of the breast (generally not far from
the nipple). It is composed of a fibrous stroma enclosing
alveoli. The alveoli are lined with (i.e., not, as in scirrhus
and encephaloid, entirely filled by) columnar epithelium,
and into their interior vascular papillary processcs are seen
to project. Owing to the rupture of the bloodvessels in
these processes, the alveoli often much extra.
vasated blood, which may escape by the nipple.
Duet cancers are of slow growth; they are not so liable
8S other forms of carcinoma to affect the glands or to
recur after removal.
Paget's 01 the Nipple resembles chronic eczema
in its naked-eye Iloppearance, but is· in reality a slowlygrowing carcinoma, commencing around tho orifices of
the lactiferous ducts, and gradually spreading along the
skin and into the deeper structures.
A Columnar-celled Carcinoma is a tumour growing
from the positions where normally columnar cells are met
with-e.g., the mucous membrane of the stomach, intestines, liver, pancreas, and uterus (body and upper part of
the cervix), the cells retaining their morphological resemblance to the epithelium in which their growth bega.n
(hence the name).
It consists of alveoli lying in a fibrous stroma; but,
instead of the alveoli being pa.cked with cells, as in ordinary
epiblastic carcinoma, they are, as in ' duct' cancer, lined
with columnar epithelium enclosing a central space; a
columnar-cellcd carcinoma in this respect resembles an
adenoma; hence the old name of adenoid cancer applied
to it. (If the growth be rapid the alveoli are Med up
with cells.)
It differs, however, from an adenoma in that it lacks
definition, is devoid of a capsule, infiltrates the neighbouring tissues, ulcerates early, tends to recur after removal,
and gives rise to secondary growths.
In the alimentary traot it generally grows as a ring
around the canal, constituting the so· called 'ring carci·
Columnar-celled carcinomata show a marked tendency
to coUoid degenemtion, especially when occurring in the
Colloid Cancer is simp'y one of the preoeding forms
(generally the encephaloid or columnar-celled), the epithelial cells of which have undergone colloid degeneration.
This is common in the cancers of the stomach; intestines,
and ovary.
Carcinoma.-Sarcomatodes.-Thesll aro mixed tumours in which
the stroma is saroomatous and the remaining part carcinomatous.
They arc extremely raro. I1ertheimer publishod the history of
a caSe oocurring in the (Esophagus. Saltykotr demonstrated
three cases betore the German Pathological Sooiety at Munich,
The PaJholoOl/ of Malignant .1JiBease.-Pcrilaps tho greatest
problem confronting the pathologist is the nature and causation
of malignant disease.
The one thing t.hat stands out pre'emlnently is tho influence
of chronic local irritatirm.
As instances: Caroinoma of tho alimentary tract occurs mOJ!t
frequontly in those parts whlch are most subjected to irritation
-e.g., the lower lip, the tongue, the oosophagus (at its beginning
and end, and where it is crossed by the lett bronchus), the pyloric
orifice of the stomaoh, the large intestine, espeoially at thll.:fto:xurell
(tho liability inoreasing trom omoum to reotum----i.e., \vlth the
increasing hardness, and tendenoy to stagnation, ot the fmoos;
wWlo, on the other hand, oaneer ot tho small intestines Is rarely
met \vith, the oontents being :ftuld. .Acoording to Bland·Sutton,
in ovary 100 eases ot intestinal cancer, 76 occur In the reotum,
23 In the large intestine, and only II In tllC small intestine).
Cancer of thG gall-bla.dder Is almcst unknown except in connection with gall-stoncs. Witness, again, the occurrence of chimneysweop's canoer in the sorotum, and tho frequenoy 01 oaneer in
tILe cervix uteri. 'Out of 1,876 cases of carcinoma of thc cervix
utari investlgatod at the Middlesox Hospital Research Laboratorics, no less than 1,796 had been married. Of thcsc, only
9 per cent. had not borne children. Cilnically, a cllse in an undoubted virgin was a.lmost unknown. Tho roason ot tlLis
remarkable relationship between the diseaso and sexual lifo
\Vas found by pathology to be due to tILe fact that oVllry caBO
of carcinoma of the oervix appeared to bo founded on a elLronio
oervicitis' (Bonnoy). Fournier says that ollithelioma of the
tongue Is raroly found except In those who havo syphilltlo
leuooplakla and who at the sam~ time smoko In excess. Few
syphilitics, ho\vover, who do not smoke ever develop lingual
canoer, and still fewer cases of this disease ar~ found In smokers
wlLo are non"llYPhllltic. Dr. Chalmers, In his paper' On tlLo
Inoldence of Canoer in Ceylon,' says that tile Cingaleso women
are almost without oancer of tho, and Ile attributes tho
great di:fference between them and European \vomen in tlLis
respect to tho proper use of this organ, and the entire disuse of
corsets. External canoer most ofton grows from cicatrices,
warts and moles-parts specially liable to chronic irritation.
Per comra, in tho case of organs protected from chronic
irritation, primary malignant growtlils rarc. 'Vltness the caso
of the liver. This organ is a hugo mass of about 50 ounces of
epithelial cells (an outgrowth of tllo alimentary hypob"last), and
yet if wc takc 100 cases of hepatiC carcinomata, only a1.lOut
4, por oent. of tllese aro primary. Again, primary sarcomata
of the liver are so rare that but fow authentic oases are on record.
PrCQisoly the same argumcnt applios to the sploen, kidneys, ctc.
'l'he irritation, in many cases at loast, would appear to act
by inducing a ohronio Intlammatlon, and somo olinicians have
spoken of a 'precanoorous inflammatory' phase.
It should be observed that the various forms of looollrrltatioll mentionod morely act by preparing tho solI. Once the
malignant proccss is startod, It goos on independently of such
Some of the sq.liont facts in the pathology ot malignant dlsea~e
will now bo oonsiderod.
(a) The rapid multiplication and survival, at the expellSO of
the normal tissues, of tho • malignant' cells (epithelial cells in
tho case of the oarcinomata, ombryonic connective-ti881.1e cclls
In tho case of tho sarcomata). It is by virtue of this rapid and
unceasing multiplication, and tho ability of the now-born oells to
shift for themselves, that oonstitute the phenomonon of mallgnanoy.
(b) The 'looseness' of the malignant cells. The rapidly
multiplying malignant cells aro not, liko tho fixed oells of a
normal tissue, seourely held In place. On tho eontrary, thoy
are more or less loose, and are thus liable to be eonveyed to distant parts. 8'10h loose oells can, in the case of carolnomata,
pass straight into the Iymphatlos (whloh are oontlnuous with tho
intercellular spaoes throughout the body), or, In the ease of
saroomata, they onter tILe blood-stream through tho walls of
Imperfeotly·formed bloodvessels.
(c) The brooding true of the seoondary growths. These always
reproduce, tILe same typo of oell as that belonging to tho parent
tumour;' a squamous epithelioma of the tongue produoos a
similar growth in the local lymplLatlo glands, whloh normally
oontaln no epithelial oells: carcinoma of the reotum, oontalning
tho charaoteristio columnar colls of tho part, gives rise to
secondary growths displaying tho samo type of ooll, whether
thoy form In the lIvor, Insldo the slLatt of a long bone, or else·
whero; a melanotio sarooma of tho skin or tho eye reproduCDs
itself as a melanotlo sarooma of tho lungs and liver.
(d) Tho transferenco of the clLaracteriatlc malignant cells to
secondary s(l;es. This is r!lI1dorod posslblo by the loosenoss of
the cells. Tha.t the transforonoo ooours Is sho\vn by tho fact
that the tumour breeds truo.
(e) The faot tlLat tho transferred malignant coils can survive
and multiply in thc secondary slto, giving rlso to a tissuo
similar to that of the primary tumour. It is very doubtful It
a oell of tho normal tissuo--say tho IIver--oven If it bocame
dotached and convoyed to a distant tlssuo, oould Burvive In its
new habitat, much less multiply and form new tissue. The
ability of maligna.nt cells to multiply In distant tissues is on
a par with Its abillty to multiply in the tissues Immediately
surrounding a malignant tumour.
(f) Tho multiplication of malignant colIs is associated with
a solvont action (histolysis) on tho normal collii of the part.
Fat and mnsoIo, eto., disappcar. In tho oaso of the carcinoma,
woll·markod hyperplasia of tho Invadod oonnoctivo tissuo occurs.
Evidently there arc developed, in connection with thc malignant
cells, (a) solvcnt and (b) irritant substances, and it scorns probablc that by tho disturbing action which thoso exert on thc
normal colis of thc part tho survival of thc malignant ceUs is
sooured; otherwise it is doubtful whcther thoycould snrvivo In
thc struggle for exlstenec with the normal cells.
(g) The fact that malignant tlssuc Is a morbid tlssuo, nowhore
normally mot with In thc body: that of tho sarcomata is a pormanently embryonio form of connectlvc tissuo; that of tho carcinomata a porvorted type of epithelial tissue.
(h)'The tendoney tor malignant tissue to degencrate.
(i) The tendenoy for malignant tissue to be Invaded by
bacteria. 'Owing. no doubt. to that defootivo rosistanoo whJoh
seems to be a looturo of all neoplastic tissuos, canoor. very oorly
In its hJstory.long beforo It has burrowed its way to tho sul."face.
booomes the soot of a staphylocoODus infcction_D infection by
the so·oallod Microc0CCU8 moformalllJ cf Doyen. And thero is
rcason to belicve that muoh of thO pain and swelling and ill'
tlammation in connoction with tho tumour. and much. it not
all. of tho so-called oaneereus cachexia. is due to this micro·
organism' (Sir A. E. Wright).
To sum uP. it maybe said that tho malignant cells. at one time
orderly members of the ocll community and harmoniously co·
operating with tho other tissues of the body for its welfare as a
whole, become Bolsheviks. and traitorously turning on that of
which they were fonnerly useful parts. cause its ultimate de·
structlon. and incidentally they sign tholr own death!warrants
So far as the above statements are concerned. we arc on fairly
certain ground coneernlng the pathology of malignant diSOBse.
How far do they give us an insight into tho real nature of tho
malignant process' ;rt Is obvious that the crux of the problem
of malignanoy is how to explain the abundant multiplioatlon
and survival of the malignant cells. It is noteworthy that the
only fixed cells of the body which nOhllallyarc capable of multi·
plying are 'ust the very cells wbich qonstltllte 'malignant· oclls
--GJ)ithOlial cells. connective· tissue cells. and endothollal cells.
The neuronos and musele flbJ,'Os are inoapable of proliferation.
and se malignant growths can nevor originate In them. What
wo have to ask Is. how theso cells come to multiply so extrava·
gantly as they do in malignant diseaBO. and how they are ablo
to survive at the expense ef the normal tissue. Their rapid
multiplication can cnly be due to one of two causes: olther (a) to
som~ ooll. or a fow cells. spontanoously boooming endowed with
unwonted reproduetive activity, and so giving riso to colonIos of
malignant cells (we can concolve that a cell. or a limited number
of oells. might. under speoiallnflucnces. throw back to somc
remote phylogenetic ancestor. and. dissociating themsolves from
thc vast cell community of which thcy form part. assume tho
rOle of rebols. which would virtually constltutc parasitos); or
(b) to the action of some irritant in their interior constantly
mshing the malignant cells into Inordinate reproductive activity.
The kind of irritation whieh sometimes initiates malignancy
\vould not sufficc; \VO should need to postulate a contin'U01I8
irritant acting on each indi11idual cell in tho grO\v:!ng portions of
both the prlma.ry and secondary tumours. It is that
many of the phenomona of mallgn&nt dlsoasc can be explained
on tho parasitio theory. Thus: local irritation. by loworlng
vitality. diminishes resistance to parasitfoin vasion; the paraSites
provide alastinglrrita.nt(probably of a chomiOal nature). Under
this continued specifio irritation t.hO malignant colIs undergo a
ceaseless multiplication. produolng a degraded typo of tissue.
containing loose cells. and dlsplo.ying a liability to degenerate;
the loose cells are carricd away with the parasites to the secondacysltes, and, being thus subjected to the samo kind ofirrita.tion
as in tho primary growth, behavo in the same way; tho chGmical
irritation causGd by the ,Parasltos so disturbs tho nutrition of tho
normal tissues that tho malignant cells aro able to survivo in tho
struggle for oxlstenoe with tho normal colls.
The Incidence of Cancer in Relation to Age, Sex, and
On analyzing 6,732 casos of cancer occurring at the Middlosex
Hospital bctween tho years 1746 and 1904, Dr. Lazarus-Barlow
found that tho mean age of incidenco in malos woos 65·2 years,
and In females 49·9 years. In malos 80 por oont. of all cases of
cancer oocurred in tho alimentary traot, while IJl females 80 por
cent. were found in tho generative organs aud breasts. Cases
of cancer of the alimentary tract wore soven timos as froqucnt
In males as in females (soo Fourth Report from tho Oancor
Research Laboratories, r.nddlosox HospltaI).
After tho ago of thirty-fivc, ono In olght fomalos, and aDO in
twelve males, die from carcinoma.
Varix (Varicose Vein).
Varix consists of 0. permanent yielding of the venous
wall, both laterally and longitudinally, in consequence of
which the vcin becomOB dilated and elongated-it may
even become as large as the wrist, and three times its
normal length. The dilatation is specially marked where
the intermuscular veins open into the superficial. In
consequence of the elongation the vessel is tortuous. The
walls undergo a. compensatory thickening, and when cut
crosswise the vessel gapes like 0. divided artery. Occasionally, calcareous plates are met with in the thickened walls.
It is probable that the essential cause of va.rix, when it
OCCUIS idiopathically, is a defect in the venous muscular
coat, which normally, by its tonic contraction, resist8 the
di8tending action of the blood-pressure more effectually than
any mere passive tissue can. This is, indoed, the essential
function of the venous muscular coat, which is thickest
where venous blood-pressure is greatest-i.e., the lower
limbs (Campbell). Either we must suppose that there is a
congenital defect of the musoular ooat in those predisposed
to varicosis, or that its muscle fibres remain unduly
relaxed, and thus fail to brace up the venous walls in
normal fashion. The mpst notable change observed in
the wall of the varicose vein is the replacement of its
normal elements (especially the muscle fibres) by fibrous
tissue, which is chiefly located in the middlo coat and to a
loss oxtent in the outer. Here and there tho wall is
thinned and dilated into pouches, over which the skin may
become adherent. The valves undergo cicatrioial con·
traction, ultimately shrinking to mere ridges or fibrous
cords. In course of time there may be no competent valves
between the affected vein and the right heart, and this
explains the' impul86' on coughing then to be felt in a
varicose vein. '
OomplicaUlms :
Pigmentation of overlyiug skin.
AdhesiOn to skin.
Ulceration (varioose ulcer).
<Edema of the ankle.
A dilated poueh adherent to the skin (whioh is thinned by
pressuro) may give ,val' by ulceration, or evon' by bursting
without previous uloeratlon. Dangerous bleeding then onaues,
"hiob may prove fatal In a few minutes. This bleeding takes
place in a di1l'erent way from ordinary hlllIllorrhago; for, tho
dilated vein being rigid Md not collapsing, and the valves being
Inoompetent, the blood eomes largely--indeed, ch.ieftU--/rOm
the cardiac Biil8 of the perforated vessel: it is a reflux.
Occasionally calcareous plates are met with In tho thlekenl',l
waJJl of a varicose vein, and In rare cases p'AlebolUks may fo'rm
In the Interior.
The volns commonly afteoted by varix are the Internal and
external saphenous, tho pamplnilorm plexus of the spermatio
oord, and the hllllJlrrohoidal veins.
Sometimes a varicose vein is not muoh lengthened: e.o., the
internal saphenous vein may stand out as a more or less straight
dilated tube from the ankle to the groin. In suoh oases we
must assume that the lOngitudinal musole flbres are funotlon'
atJng normally.
Phlebitis is inflammation of the venous wall, and is
aJways associated with thrombosis.
There are two classical forms of phlebitis-Cal the
inJective or suppurative, and, (b) the simple or non·
(a) In In!edi"e Phlebiti8 the venous wall becomes
inoculated with pyogenio organisms. and a clot soon
forms inside the vessel. The cause ma.y be I\, septio
woun4. extension of inflammation from some neighbour.
ing septic focus. such as acute infective osteomyelitis.
middle·ear disease, or carbuncle-especially when it occurs
on the face.
The vein wall, the surrounding tissues, and the thrombus
inside the vein. arc crowded with scptio micro· organisms.
The clot breaks down. and scptic emboli may be dis·
charged into the blood-stream, and so lead to pymmia.
unless a ligature be placed on the proximal side of the
in favourable cases infection of the blood·stream is
prevented by the portion of the olot at the proximal end
remaining firm instead of disintegrating.
(b) Simple Pltlebiti8, like tho infective variety. is always
associated with thrombosis. The thrombosis may cause
the phlebitis. or the phlebitis may cause the thrombosis,
but the two pathological conditions always coexist.
The causes are thrombosis (see Thrombosis), injury,
extension of surrounding inflammation, and certain blood
states-the 'gouty phlebitis' of Paget, for example.
Varicose veins, espccially when superficial, are more liable
to inflammation than healthy ones.
The coats of an inflamed vein are infiltrated with small
round cells, the endothelium is swollen and may become
detached, and, in the case of superficjal veins. mdema. of
the surrounding iissue- is observed.
In all inflamed aroas the walls of the small veins are
involved in the inflammatory process.
Terminations oj Phlebitis :
Organization of the olot and obliteration of the vessel.
'fnnnelling-i.e.• the axial part of the thrombus is
absorbed. and the peripheral part organizes.
The formation of phlebollths.
Aoute inflammation of an artery may be the result of
trauma, infeotion from septio wounds, or by emboli.
Excluding these. the olaBBioal forms of arteritis areAcute endarteritis-Acute aortitis.
Arteritis in Inflamed area.
Atheroma. or {!!eoondaey calolficatlon.
endarteritis Atheromatous absoesll.
detormans Atheromatous ulcer.
Chronio endarterItis Primary oalolfication.
( Endarteritis syphlllti08.
Endarteritis tuberoulosa.
Acute Endarteritis.-The best example ot this rare disease Is
acute aorlUiII, which Is usually the result at Wootlon tram the
aortlo valves in mallgnant 8lLdocardltis. In other oases it
results from blood Infection (e.g., enterlo). Ita uBUaI situation is
at the beginning ot the aoUa and round the oriBin ot .•tll b~nohes.
Tho prooess commences as B small round-oelled Inllltratien
of the inner coat, producing sharply-defined. raised. gelatinous
patches. eireul",r or ovoid ill outline. and soft and elastlo in oonslst8llce. The infiltrationlUay extend into the middle and outer
ooate. in whioh oase the Dew elements may orgBllizeinto fibrous
t;ssue. The endothelium, as a rule, remains intact.
Tho disease maY lcad to aneurillDl. or pass into ondarterltlB
Arteritis in Inflamed ArelL.- Wh811 an area. of tiBSUe is iII1I.aIDed,
the tissues oonstitutlng the walls ot tbo arteries &lid veins within
the infiaIDed area share in the iuftamma tory proccss_ Tho
tnfio.mmatory ohanges are ovon more marked in the venous walls
than in tho arterial. Tho arterial and venous walls. notably the
adventitia &lid intima. beoome infiltrated with cells. and in this
way the lumen ot the all'eoted vessels beoomes narrowed. and
eveD obliterated. thrombosis being thereb, induced. At a later
stago the new oell formation may organize into oonneotive
tiSaue. causing a PllIDlanent hardening ot the vessels.
Atheroma* (Endarteritis Deformans 01 Virchow).~ome
authorities designate this disease arteria-8clerosis, but inasmuch as the torm embodies the conception of 0. strengthening instead of a weakening of the vessel-wall, the name
arterio-sclerosis is best employed in the sense as described
on p. no. Another objection to the term is that, during
lifo. the affeoted parts are not hard, but soft, the hardening
being a post-mortom process.
u8~P1I= 1,l0rrldgo
or moaJ.
Atheroma is common in men over forty; in fact, it is
very rare after middle life to find it absent from the large
The disease has a notable conneotion with high bloodpressure (espeoially in aBBOQiation with granular kidney).
Except as a senile change, it is, indeed, rarely lnct with in
subjects displaying low blood-pressure. The conneotion
between atheroma and high blood-pressure is further
shown by the fact that the former is seldom met with in
the pulmonary artery, exoept when, from disoase of the
Jeft heart and obstructive disease of the lungs, the bloodpressure in that circuit has been chronically augmentede.g., mitral stenosis and emphysema. (According to the
French teaching, the most likely cause is sonle poisonous
agent acting on the intima.)
The- disease occurs in those arteries which are exposed
to the greatest strain, as in the aroh of the aorta, and it
shows a special predilection for the points at which largo
branches are given off, or where a trunk bifurcates. the
most frequent sites beingThe aortic arch.
Round the orifice ot Its largo branches.
Tho oorono.ry arteries.
Round the orifice ot tho omlJao axis.
At tho bifuroatlon Into the lIlaos.
The eerebral arteries.
The ronal arteries and tholr branohes.
As u affecta tlle Aorta and Large V888el8.-Bmall round
coIls and branched coIls containing fat infiltrate the intima
in tho form of scattered foci, replacing the normal clements
of the part. In course of time these foci coalesce. At
this stage, when we examine the interior of the vessel,
wo see it studded with hard, yellowish, circumscribed
patches, slightly elevated, which range in size from mcre
pin-points to plaques as large as a shilling, with more or
Icss abrupt edges. (In the arch of the aorta the appearance sometimes suggcsts a crocodile-skin.) On careful
inspection the endothelium is generally found to be intact,
however advanced the process. The further progress may
bo in one of two direotions: the patches may (a) calcify,
or they may (b) soften and break down.
(a) In the former fatty degeneration of the cells
takes place; the contents afterwards dry up, and limesalts and oholeBterin are deposited in the shrivelled mass,
which is thus ultimately converted into a hard, calcareous
plate. (During life the material is of soft, putty-like
consistency.) This is !mown 0.9 8econdary or laminar calcification (so called to distinguish it from the primary calcifioation found in the middle ooat of suoh arteries 3S the
radials and tibials).
(6) On the other hand, the contents of the patches,
instead of drying up, may liquefy and form an atheromatoUB ab8eeBB, which, upon the endothclium giving way,
may become converted into an atheromato'U8 ulGer. In the
lattercaso, a small coagulum forms over the roughened part.
Later on, cellular infiltration into the middle coat takes
place. similar in character to that which started in the
intima, resulting in the slow destruction of its muscular
fibres. (Some conaider this to be the primary change in
atheroma.) The outer coat usually shows 110 varying amount
of compensatory fibroid thickening.
The middle coat is the Btrong coat of an artery, for it
is by the active contraction of its muscular fibres that the
vessel is prevented from expanding to the blood-pressure.
Once it is seriously damaged, the vessel-wall yields slowly
to the blood-pressure, the artery becomes dilated, elongated, tortuous, and a fUBifarm aneurism is liable, to develop.
AB it aflectB the Smaller Jl1J88el8 (Oorona1'1J, Oerebral,
Renal, etc.).-The process here is essentially the sapIo as
in the case of the huge vessels. The patches. however,
are often in the form of nodes, sometimes suggesting' in
appearance a' signet-ring,' whioh may projeot so far into
the lumen as partially to occlude it.
It is specially to be noted that in atheroma there is no
formation of new bioodvIJ88els in the patches; this explains
why the new tissuo degenerates and does not organize.
in this respeot being in marked oontrast to syphilitio
endarteritis, where the opposite is the case.
Effects 01 .A.theroma on the Ciroulation.-Tho diseaso causes
(a) rigidity of tho vessal walls, o.nd (b) narrowing of the lumen.
Rigidity of the aorta causes hypertrophy of tho left ventricle.
Narrowing of tho lumen has a spoeial significance with respect
to suoh arteries 88 the ooronary and cerebral on acoount of tho
Interforonce with the oirculation which it entails.
Primary Calcification affects the medium-sized arteries
--e.g., those distributed below the elbow and knee, and
the circle of Willis. The process begins in the middle coat,
tlie muscle fibres of which beeome infiltrated with limesalts, and, as these fibres run circularly round the vessel,
the deposit takes the form of a suocession of rings, causing
the artery to assume the appearanoe of ipecacuanha.
lTItimo.tely the artery may be converted into a rigid tube.
In the oase of the tibial arteries, the intima may aotually
beoome detaohed, and as a result of this, thrombosis and
gangrene may ooour (see Senile Gangrene). Symmetry is
a markeiJ Jeature oj the di8eaae.
Endarteritis Sypbilitica.-Disease of arteries is the most
important manifestation of syphilis. The usual pathologica.l change is identical, in prinoiple, with the syphilitio
affeotions of other mesoblastic structures (v. p. 196).
There may be either (a) a diffuse gummatous inmtration
of the intima extending both around the veseel and along
its course for some distance, which in process of time develops into ooncentric l~inm of fibrous tissue; or (b) small
greyish-yellow patches may develop on the intima; these
are tiny gummo.ta. In both instances the intima. becomes
greatly thickened, and the lumen oorrespondingly
Owing to the development of capillaries in the new
tissue, fatty or calcareous degenemtion does not occur.
The disease is most oommon in the arteries at tke base
oj the brain and in the arteries oj gummata (see Gummata).
In consequence of the narrowing of their channels. thrombotic occlusion is liable to occur; this is the most frequent cause of hemiplegia (especially in men) under forty
years of age, and also explains the tcndenoy of ordinary
gummata to slough, by deprivation of their blood-supply.
In another class of case the disease begins in the tunica
media, setting up a -mesarteritis which, by destroying
the muscular fibres (the chief source of the strength of the
middle coat), leads to the formation of 110 'sacculated'
aneurism, the common site of which is the arch of the
aorta. and the big vessels which arise from it.
So there are three ways in whioh syphilis may affect
arteries, viz.: (1) diffuso gummatous, infiltration of the
intima; (2) gummata of tho intima; and (3) mesarteritis.
Endarteritis Obliterans is probably aD advanced stage
of endarteritis syphilitica. There is great subendothelial
proliferation, the change involving also the middle and
external coats. New capillaries are formed, and the final
result is the formation of fibrous tissue, which narrows
the lumen and may ultimately occlude it. In some cases
occlusion is brought about by thrombosis.
Endarteritis Tuberculosa generally involves the peri.
vallCular lymphatic sheaths, but tubercles may also
develop in the arterial walls themselves. Under these
circumstances the intima becomes greatly thickened, and
the lUDlen reduced in size, and even obliterated.
Apart from the disea~os just doeJt With, there is a condition of
tho arteries as~ooillted with adV61lcing years which i~ commonly
known as arterlo·8CIef"oriB.
Old age Is a relative term, and, mel\1oally considered, Is to a
large extent detormlned by the condition 01 the arterl~e.,
wllethor thoy are soft a.nd elastlo, or hard and rigid.
After a oertaln period ot lite the arteries, In common with tho
other tissues, tend to barden. This results trom 0. general
fibrosis, whioh impairs the nOl"IIla.l elastiCity of tho vcssel walls
and makes them rigid. This inorease in the fibrous (J]ements of
tho vessel wall is espeoially obscr"ed In the intima, the thick·
noss 01 which tends to increase from about the ago of thirty until
tho end of life. The test of 0. healthy artery is that, If suoh 110
vcssel as the radial or temporal be pressed by the fIn~'(lr,itmelts
away into, o.nd oan be scarcely differentiated from. the surround·
ing tissues. whereas a thiekened vessel can be distinctly felt
under the examining finger. Sometimes the arterio·fibrosis sets
in early. (It may bo peculiar to certain families.) A maJi of
thirty. for iJistanee. may have arterios as rigid as those whieb are
natural to I) man at Sixty, and tJice _ . lIonce tho aphorism •
• A man is as old as his arterie~.' Thomas Parr is said to
have had artories wluch at tho time ot death showed nothing
Premature arterio·sclerosis is due to some abnormal bloodstates. either a detect as rega.r(ls the hormonlc content (It is
known. e.o.• that athoroma can be artifioially induced by tho
inJeotion of adrenaJin). or an actual toxremia--sueh as may result.
6.0•• from defective Intestinal digestion. tho toxins in this case
boing duo to the abnormal transformation ot food (Indol, scatol.
phenol)-or to bacterial agency. Tho morbid blood·state. what·
evor bo its nature. may act upon tho vessels in one of two ways:
(a) It may oause fibrosis by Its direct action on the arterisJ
tUllics; or (b) It may. like adronalin. cause vaso-oonstrletloD.
which. it long continued, would cause hypertrophy of the mus-
culal' IDIdla, and in proeess of timo the hypertrophicd mnscle
fibres would be replaced by fibrous tissue. in accordanco with
tho law that. wilen muscular h)'llcrtrophy rcaches a oortahl
timlt. the musolo fibros atrophy and are rcplaood by fibrous
Issuo. Probably both theso mechanisms arc operative.
In connection with thls subjoot of artcrio-sclel'osis. the student
Is referred to pp. 160. 161. dealing with the arterial ehanges
observed in granular kidney.
An aneurism (aneurisma. a dilatation) is 0. cavity com·
munioating with an artery and containing blood, either
fluid or coagulated. The walls of the cavity are formed
either of the expanded portion of the vessel wa)l, or of the
tissue around.
It is during the middle period of lifo, between tho ages
of thirty and fifty. tho.t non· traumatic aneurism is most
frequently met with. Thore are but few cases recorded
in medical literature as oecurring before the age of twenty
and most of theso are probably due to embolism, which
sets up arteritis.
, Dissecting' aneurism is more common in women than
in men; aneurism of the carotid is equally common in the
two sexes; otherwise aneurism is thirteen times more
common in men than in women.
{ Miliary.
Artorio.venous {An~riBmal va~IX.
Varloose aneurIsm.
A Spontaneous Aneurism is one that develops in con·
sequence of pre·existing disease of an artery.
A Fusiform Arteuriam is a dilatation involving the
entire circumference of the artery. the result of.exte7l8ive
atheromat0'U8 di8ea8e of its walls. The usual seat is the
arch of the aorta. As a rule. the vessel is involved for a
considerable portion of its length. In addition to the
dilatation there is elongation. whieh may be considerable
Thus, the arch of the aorta may be increased in length
by some inches. From the main dilatation small • saccular'
aneurisms may spring.
On examining the strueture of a fusiform aneurism, it
will be found that the iuternal eoat shows widespread
atheromatous changes; it is stiff and rough, calcareous
plates are frequently scattered over the internal surface,
and in places where the endotheliwn is injured shreds
of fibrin are adherent. The middle coat is atrophied in
proportion to the dEgree of dilatation. The outer coat
is compensatorily thickened and strengthened by the
_formation of new fibrous tissuc. It is owing to thh.
thickening that the course of an uncomplicated fusiform
aneurism is usually chronic-either remaining stationary
or increasing very slowly, and thus oontinuing for many
years without causing death.
A Sacculated. Aneuri8m is one in which the dilatation
involves only a part of the circumference of the artery.
the result of a localized. disease of its middle coat, which
is degenerated. The arterial wall now having lost its
support, yields at this spot, and a bulge forms which tends
to get larger and larger (viele Mosllrteritis). When the
aneurism is of very small size, the three arterial coats are
spread out over it; when larger, the internal and middle
coats are wanting, Ilnd as it increases in size the sac comes
to consist almost cntirely of the thickened and condensed
surrounding connective tissues (the aneurism acting as
a foreign bedy). Usually the interior of a saccubted
aneurism contains fibrin arranged in concentric, overlapping layers, no single layer reaching over the whole sao.
l'he older layers on the outside are of a pale buff colour;
those towards the interior are darker.
Organization of the clot is rare, because of the forcible
stream of blood through the aneurismal sac. No organization can take place in the aneurism unless the artery from
whick it springs is occluded.. Occlusion may occur either
by extension of the clot from the sac into the artery, by 0.
detached. piece of clot plugging the artery, or as the result
of surgical compression or ligature.
Complete arrest of the circulation leads to the formation
of an ordinary soft blood-clot (clot en ma88e); this is very
.rare, however, and is only possible when the mouth of the
aneurism, or the main trunk of the artery immediately
beyond it, becomes plugged by a detached piece of clot.
00,11.868 oj Death from Aneuri8m.-Tho tendency of
aneurisms is to rupture, either into the perica.rdium,
plema, tmchea, msophagus, peritoneum, or externally
(vers rarely). Aneurism of the intrapericardial portion
of the aortic arch (a favourite site) may be so small as
to elude the most careful examination, and may causa
unexpected death by rupture into the pericardium.
EmbOlism (e.g., of the cerebral arteries) may occur in
consequence of the detachment of a portion of the olot into
the blood·stream. Death may also result from p7"68sur6
on vital parts.
lEtiolotm 0/ Spontaneous Aneurism.-It can bo dc1lnitely stated
that the essential cause ot lVIIi/arm aneurism Is a preoedlng
wldespread athercmatous change in the artery (especially such
as destroys the middle coat), for evidence of this is always
present in the walls of the dilated portion. Syphilis appears
to be tho ossential cause of sacculated aneurism, alcohOl and
physicsl strain sometimes acting as coefficients. The trepo·
nemes probably settle in the tunica media (the vasa vasorum
roaching thus far), a.nd thoro set up a. 81/P"ilitic mesarterUia.
Tho tunioa. media being the main support of the artery, and this
being locally destroyed, it can readily be understood how the
vessel yields to the Intravascular pressure at thet partieular
spot. In tho grcat majority of cases of spontaneous aneurisms
of the smaller o.rteries. such as the radial, ulnar, and tibials,
as well as aneurisms under the age of twenty, ombolism (by
settlug up a local softening of the arterial wall) is the cause. Suoh
Is especially likely to be the esse If the embolus be septio, as in
mal.lgn&nt endooarditls.
A Dis8ecting Aneurism is one in which there is a.longitudinal rupture of the internal coat, the blood being
forced between the layers of t_he middle coat. It is
generally the result of the bursting of an atheromatous
abscess. The blood may escape by an aperture in the
outer coat and become diffused externally, or it may open
again into the lumen of the artery through another
atheromatous spot. It is most common in the arch and
thoracic portion of the aorta, and occurs more frequently
in women than in men.
Miliary .A.neurismB are about the size of a &maJI pin's head,
and arc met wlth In the cerebral artorlos, more especially those
coming oft trom the olrclo of Willis-i.e.• t·he central as disS
I I..
tingutBhed trom the cortU:al arteries. It is trom rupture ot sueh
miliary o.neurism toot ' spontllolloous ' corobrol hmmorrhage is
practioe.lly always duo. (When this oocurs In a child. howover.
it is generally from an lIoIlourism which has developod socondarily
to a septie embeJism.)
The pathology ot miliary anourisms is still somewhat doubtful.
Charcot taught that they do not occur secondarily to o.thoroma;
that. whereas this condition sto.rts in the intimo. and spreads outwards, the artorial chango which leads up to miliary aneurism
begins in the external eoat ot the artery and spreads inwo.rds.
Certain it is that athoroma of·the corebral vessels may be extensive o.nd mllio.ry aneurisms conspicuous by their o.bsence trom
them. and tJice 11erBa. One clinloal fact stands out prominently
in connootion with miliary lIoIleurisms: they never occur in
o.ssoclatlon with low blood-pressuro. Hence the low bloodpressure individual does not die from "orebral hromorrhage.
MIliary lIoIleurisms. if they do not rupture. tend In course
ot time to become occluded. trom thrombosis ot their contained
blood and subsoquent shrinkage.
A Traumatio Aneurism is a cavity oontaining blood,
either :O.uid or coagulated, oommunicating with an artery.
and produced by an injury dividing all the coats of the
If the blood escapes slowly, compression of the tissues
around leads to the formation of an adventitious 110.0-,
and the result is a circumscribed traumatic aneurism.
On the other hand, if the blood escapes quickly and in
o.bundance, it finds its way along the oonneotive tissue
planes, travelling in the direction of leastresista.nce, and,
the distending force being too great to allow of the formation of a sao, a diffu8e traumatic aneuri8m results.
An Arteria-Venous Aneurism is the result of a oommunication between an artery and a vein lying in juxtaposition.
It is generally of traumo.tic origin-e.g.• when the braohial
artery and the medio.n-basilic vein at the bend of the
elbow are wounded simulto.neously.
H the two vessels are in close contact and become
adherent, the blood passes directly from the high bloodpressure artery into the low blood-pressure vein, and the
latter becomes dilated into a pulsating. fusiform, or
globular pouch, with thickened walls, the dilatation extending also into the venous tributaries, which become
varicose and tortuous. This is known as aneurismaZ varix.
Instead of the blood passing directly from the artery
into the vein, it may well out between the two tubes, o.nd
become enclosed in a.n adventitious so.o communicating
with both. This condition is known as variC086 aneurism.
(For Oirsoid Aneurism, ete., t.. p. 83.)
Shock is characterized by a. lowering of the a.rterial
blood·tension, thready and quickened pulse (sometimes
intermittcnt and irregular). pallor, cold and olammyskin,
with rapid and shallow breathing. There is usually, in
addition, a general state of museular limpness, and the
sphincters may relax. It may be either (a) Primary, or
(b) Secondary,
(a) Primary.-This immediately follows the in1liction
of the wound, and is allied to 'fainting.' It is probably
due to a reflex inhibition of the vaso-motor centres govern:
ing the splanchnic area, which allows more blood than
usual to determine to the portal system of veins (' bleeding
into one's own veins '). The accumulation 'of a large
quantity of blood in the abdominal veins reduces, pro
tanto, the amount of blood in the arterial tree. This involves both a decreased output from the left heart, and
Ilo decreased flow through the coronary arteries.
arteries are therefore underfilled and the hearl's action
(b) Secondary.-This may follow the primary shock,
or occur independently. In either case it is of slow
development, and only appears some two or three hours
after the infliction of the wound. but too quickly to be
due to bacterial infection.
According to recent investigations, secondary shock
is the result of the absorption from the wound area of an
injury toxin, histamine. formed from one of the amidoacids, histidine. present in nearly all proteins. (H Justamine be given in minute doses it produces a condition
practically identical with shook.)
The first effeet of the diffusion of the histamine throughout the body is to cause a universal dilatation of the
ca.pillaries, with partial stagnation of the blood in thom
(but no dilatation of the arterioles). In consequenoe of
this the heart is relatively empty and less blood flows
through the lungs, and BUb-oxygenation 0/ tM ti8BUe8 is
tke result. The second effect of the histamine is to make
the capillary walls more permeable, thus allowing muoh
of the fluids of the plasma to escape by filtration into
the surrounding lymph-spaces, the patient, in a sense,
bleeding into his own lymphatios. (Dale and Laidlow
have shown that by the action of histamine there may be
in this way a loss of as much 0.8 half the volume of plasma
in five minutes.) In consequence of the great loss of
plasma-fluid there is a redaction of the volume of blood
in effective circulation-hence the low arterial tension
and the other phenomena.
In all cases of shook thore is great sensltivenoss to ethor and
ohloroform anmsthesla, the administration of whioh would ca~
a further tall In an already low blood-preasure.
Per ormlira, there is a tolerance of nitrous oxide and oxygon
'anmsthesia, without a furthor tall of blood -pressure.
N.B.-Shook is not to be mistaken for the symptoms of latombolism, whioh Is so particularly oommon after jars to bones
Ilnd fraotures. (BUrger, in 100 oonsecutive oases of death from
accidonts associated with fractur~s, found tat-embolism In the
lungs in all of them except one.)
The pathology of collapse, which is much the same as
that of shock, consists essentially in the 1088 of fluid from
the blood. In the one case the fluid passes into the ~jssues;
in the other, out of the body.
Collapse accompanies such diseases as are attended
by constant vomiting or diarrhma, examples bcing the
diarrhma of young ohildren, Asiatio cholem, and the
profuse and prolonged vomiting of stmngulated hernia
and acute peritonitis. It may also result from severe
hremorrhage. Owing to the abstmotion of such largo
quantities of fluid, the blood becomes inspiBSated and
resembles tar, and the muscles, liver, spleen. and kidneys,
become tough and leathery.
Tho pericardium oonslsts of two parts: (a) A fibrous part,
analogous to the capsule of a joint; and (b) a serous part, 0.11610goUB to tho synovial membrano.
By AcutePericarditi&is meant an inflammation beginning
in the aeroU8 pericardium, spreading to the fibrous pericaJidium, and often to the surface of the heart. It occurs
in about 20 per eent. of oases of rheumatio fever (beginning about five to seven days from the onset of tho
attack). About 70 per cent. of cases of perioarditis are
duo to this oause, about 50 per cent. of the cases occurring before the age of twenty-one. (Endooarditis is about
three times more common than pericarditis in rheumatic
fever.) Other causes anr-septieromia, pymmia, the speeifio
fevers (notably scarlatina), pneumonia, tubercle. It also
occurs in Bright's diseaSe (when it is very fatal), and as
the result of extension of inflammation from surrounding
parts, as from burns on the thorax, a. mammary cancer
that has ulcerated, fractured rib.
In the following description the pericarditis of rhcumatio
fever is taken as the type:
The inflammation starts at the base of the heart, travels
downwards, and involves, more or less, the entire pericardial sao.
Tho smooth, glistening serous surface becomes dull and
sticky from swelling of the lining endothelium (many of the
cells of which are shed) and the exudation of inflammatory
lymph. Coagulation of the lymph now takes place, fibrin
is deposited, and by the rubbing together of the opposed
surfaces, the interior of the pericardium. comes to present
& 'shaggy' appearance-not unlike tripe.
'rhe fibrin is
usually thickest over the heart surface. It is whitish
in appearance and of soft, gelatinous consistence. The
pericarditis may be 'dry,' or fluid may collect in the
pericardial sao. The effusion rarely exceeds 2 to 3 ounces
in quantity. (The increased area of cardiac dulness found
in rheumatic fever is mainly due to cardiac dilatation, and
not to pericardial effusion.) Although the fibrin may
become absorbed, yet in the great majority of cases after
a timc new bloodvcssels penetrate it, and connective tissue
forms, so uniting the visceral and parietal layers of the
The adhesions thus formed may be of mere spidcr'a-wob
consistency, or so extensive as to obliterate the entire
pericardiac sac (about 17 per cent. of the cases). These
adhesions are most ma.rked at the base, at the a.pex.
They are specially liable to form when the patient is
allowed to get up too soon.
From repeated attaoks, the perioardium may beoome
greatly thiokened-even to the extent of 1 inch. The
preBBure of the fibrous tissue on the ooronary arteries, by
impeding the circulation may give rise to fatty degenera.
tion of the myooardium. In rare oases the pericardium
becomes calcified.
Sometimes there is an 3BBociated mediastinitis, and
when this happens the pericardium may beoome matted
to the lungs, diaphragm, sternum, and ribs, and the
phrenic nerves may lie embedded in the newly.formed
tissue. The adhesions in such cases may so hamper the
movements of the lungs lJ.)ld diaphragm that cyanosis,
dyspnma, enlargement of th~ liver, ascites, and even
general mdema, may result.
The heart, Il8peciaZly the left ventricle, is alway8 dilated
in rheumatic pericarditis, and thi8 constitutll8 its main
danger. This has been asoribed to direct extension of
the inflammation to the myooardium; others with
more probability, attribute it to the paralyzing
action of the rheumatic toxin on the cardiac muscle,
for dilatation is absent in other forms of pericarditis
(e.g., tubercular, suppurative), while it is always
present in rheumatic fever, even when there is no
periea.rdi tis.
Should the patient be allowed to get up too soon, there
is great risk of the dilatation becoming permanent. (It
cannot be too much emphasized that tho heart has least,
work to do whcn a person is lying down.) Such dilatation
of necessity leads to hypertrophy, as, the oubic capacity
of the ventriole being increased, more work is required of it.
TIllS dilatation with secondary hypertrophy mainly
accounts for the enormous hearts sometimes found ill
adherent pericardium, the adherent perioardium, per 8e,
playiItg but a subordinate part. If, on the other hand,
. the patient has been allowed adequate rest in bed, so that
tho dilatation and the hypertrophy which it entails
have had time to subside, and if the perioardium is not
greatly thiokened, there may be no permanent cardiac
To Bum up, then, the cardiac enlargement some·
times found after an attaok of rheumatio fever may be
due to-(a) A dilatation remaining permanent.
(6) A muoh thiokened pericardium.
(c) A oombination of both.
It is to be remembered that endocarditis and myocarditis often ooexist with pericarditis.
PuruI8IIt pericarditis is raro. It oooasionally OOOUl'll in oonnootlon with empyemo., septlolllmio., pyremia, pneumonia, oud
scarlatina, or It may rosult from extension of malignant growths.
It Is extremely rare in the rheumatlo pericarditis, and is thon
Ilrobably due to a • mixed' Infeotlon.
Blood is sometimes found In the pericardium as the result ot
JlUlcarditls, septiOOlIllia, pymmio, sourvy, and purpura, as also
from rupture or an aneurism.
Tuberculosis of the Pericardium.-Thls is very rare, evon
when tubercles abound elsowhere. When fonnd, It generally
ooeurs In assooiatlon with tubercular pleurisy, and tubercular
mediastinal glands.
Tho effusion may be serous, purulent, or hmmorrhagio.
In old-standlng cases, caloifled plates may torm In tho wolls
of the pericardium.
Milk-Patches.-The pericardium is locally thickened,
opaque, and dense. The patches are most oommonly
found in elderly persons, especially over the right ventricle,
and are probably caused by the ·movements of the hea.l'b
against the sternum and ribs, as they are very rarely found
on the parts covered by the lungs.
Weight 0/ heart:
Adult malo, 101 ounoes.
Adult fomole, 9t ouncos.
• The thloImIlR of the walls of tho various cardioo ohambers
is as follows:
• That of tho Zeft 'D6'1ltricle varies from :t Inoh at the apex to
I or t inoh at tho auriouio-ventricuIa.r furrow.
• That of the right ventricle va.ries tram l inoh at tho a.pex to
! inch at t.ho auriculo·ventrioular furrow.
• That of tho Wt auricle measures about! inch.
• That of tho right aur!ck measures about ,,\ inch' (Box).
The hoavIest hoart on record weighed 66 annoes; the lightest
vrll-S lJIlder II ounoos.
Cardiology.-The sino-auricular fIOde, or • pacemaker: lies in
the wAll of the right auricle (the part which correspends to the
sinus venosus in the frog) at its junction with the superior vena A seeond and similar node--the auriculo-1le1&triculal'
nodc--lies in the coronary sinus at the base of the interalll'feular
septum. The two nodes arc connected by muscle fibros. They
both censist of aOoemplioo.tcd network of very na.rrow musclo
fibres with numerous nuolel, transverse striation, and rioh ill
glycogen. The sino-aurioular node recelvos Important :fIJamonts
trom tho vagus nerve_
The aurioulo-vontrioular node below is conneoted with tho
(invertod) v-shaped bundle oj. His, whioh, beginning in tho
intorall.rioular septum, passes down to tho Interventrioular
septum, at the bettom of ,vhioh It bifurcates, one portion
BPl'eadlng over the interior of the loft ventricle, and the other
over the Interior of the right vontriole. The fibres of the
• bundle of nls' oonneot with the general heart museulature
through tho medium of Purkinie's network of fibres (which are
only striated on their periphery). The various links In this
anatomlcalohain, then, aro--(a) Tho sino-aurioular node; (b) the
aurlculo-vcntrlcular nodc; (c) the' bundle of His '; (d) Purklnje's fibres; (e) the heart musoulature.
The myogenUJ hypothesis of Gaskell assumes that the rhythmic
aotlvlty of. tho hoart resides In the fibros of the oardlac muscle
themselvos, and that the nervous system possesses merely the
secondary function of rogulation. It also assumes that the
transmiss:on of stimuli botween the Individual parts of the heart
does not occur through nerve fibros, but through mus<.'UIar
fi bros. What happens is supposed to bo this: Tho slno-aurloular
node generates (at tho rate of about 70 per minute) rhythmical
impulses, which, desccndlng along tho • bundle of llis,' oventually flow into the general myocardium via Purkinje's 'fibres.
Tho result Is tho oontraotion, in ordprly sequonce, of the cardlao
chambers, from the base to the apex of the heart, culminating in the contmotion of the musouli papiilares. It is further
assumed that tho myooardia.l flbrOtl manufacture and storo up
a • stimulus substanoe' which, when under suflicicnt tension,
evokes their contraction. This' stimulus substance' Is used
up during systole, and reaooumlllatos during dlastolo.
The hoart muscle fibres, evcn When relaxed during diastolo,
are ahvays in a stato of slight permanent oontractlon (=' tonicity').
The motto of the hoart is • All or nono '; In health it oontracts
to its fullest possible extent. During rest the heart uses but a
BUlall portion of its energy to earry on the oirculation. That
kept in roservo Is known as • reserve energy.' It is this reserve
NlOl'8'Y whloh diminishes in heart fa.lluro.
Simple Endocarditis.
This disease is usually confined to the endocardium of
the valves, and may be either(a) Acute, or
(b) Ohronic.
(a) Acute Simple Endocarditis.-Except when occurring
during fretallife, it is almost alwa.ys confined to tho valves
of the left heart.
It is 0. disease mainly of early life, and probably 90 per
cent. of the cases are due to rheumatic fever. (In the case
of children it is not improbable that acute endocarditis
may be the sole manifestation of rheumatic fever.) Each
succeeding attack of rheumatic fever involves an increased
risk of endocarditis. Any other infection, however-e.g.,
scarlatina-may cause it.
The liability to endocarditis in rheumatio fever may be
expressed thus: It begins at the age of two years (it is
almost unknown in infancy), is crescendo from two to
ten years, and diminuendo from ten to forty years, after
which period the liability practically disappears. A first
attack is rare after thirty.
Order of Incidence:
Mitral valve alone.
Mitral valve and aortic valve.
Aortic valve alone.
It begins on, and is generally oonfined to, that surface of
the valve which faces the blood-ourrent-i.e., the aurioular
surface of the mitral and the ventricular surface of the
aortic valve.
At first there are scattered foci of subendothelial
infiltration (probably caused by micro-organisms brought
by the lymph-stream), which raise the surface of the valve
into rows of minute glistening beads situated a short distance from its free edge. Later, the endothelium over
the beads swells up, becomes sticky and covered with
fibrin, which, owing to the swinging to and fro of the valves,
assumes the appearance of vegetations. By continued
acoretion of fresh fibrin the vegetations may attain a
large size, and by detaohment of partioles. from their
surfaoes, emboli may pass into the blood-stream.
Result8 of Acute EndooarditiB :
Organization, contraction, and hence regutgitation.
Fusion of valve edges, and hence stenosis.
Aneurism of valve.
Rupture of a valve aneurism.
Detachment of vegetations, and so embolism.
Contraction of chordre tendinem.
(b) Chronic Endocarditis.-(This condition must be
distinguished from the damaged condition of the valve
left by acute endocarditis.) It is a chronic, progressive
process from the start, leasling to fibrosis and often
atheromatous changes. It is rarely found under the age
of thirty.
The Aortic Valv68 are those par e:coeJ1tmC6 affected.
The causation may be expressed thus: SyphiliB, alco.
holi8m, physical strain, acting either singly or in conjunction, and high arterial blood-pressure (an almost
constant factor).
The valve segments, more particularly at their free
margins, become thickened, opaque, puckered, and distorted from the formation and contraction of scar tissue.
This causes the valve to ' leak.' Calcareous material may
be deposited in the valves, especially near their a.ttached
Disease of Individual Valves.
Mitral Valve.-Disease ot this valve is generally the result ot
rheumatie fever in a person under thirty, the usual sequel being
retraction of tho valvo edge. with consequent ' back-wash' of
the blood-i.e., mitral regurgitation.
MUrat Reourgitation.-This is 0. residual condition resulting
from former acute endocarditis. The left auricle is dilated and
somewhat hypertrophied; the left ventricle is dilated and hyp_ertrophicd. If, in course of time, cempensation fails from degeneration of the heart tissue, the result is that the lungs have 0.
difHculty in emptying thoir blood into the Jaft heart, 8lld thoro
result--venous congestion of the lungs (with' red' or 'brown'
induration from fibrosis and pigmentation); dilatation and slight
hypertrophy of the right ventricle; triouspld regurgitation:
dilatation of the right auricle; impeded portal circuIo.tion,
oausing venous congestion of the liver (' nutmeg' llver), which
may pulsate; asoltes; congestion of the mucous membrane ot
the gastre-intestinal tract; consrestion of the kidneys (and thus
albuminuria and dimlnished flow of urine); mdemo., beginning
in the lower limbs and mounting upwards. As the redemo.
increases so the urine decreases. 'AurieuJruo fibrillation' may
now be noticed. Should the valve guarding the junction of tho
internal jugular and subolavian veIns 'leak,' t:qare is pulsatien
ot the veins in the neok.
As tho venules are badly emptied tho p.l.tlents tend to cyanosis.
The splocn Is generally small, tough, and firm. Sometimes
it is enlarged, but this Is usually the result of Infarction.
In tho dilated right heart a thrombus may form, which, if it
breaks up, causes embolism of the lungs (pulmonary apoplexy).
It is a ourious faot that pulmonary tuberculosis is exception·
ally rare in mitral regurgitation.
M;tral Stenosis.-WJ!<m ooming under obsorvation tho plLtient
is generally 0. young woman. As in mitral regurgitation, the
ohief oause is rhoumat.ic tever, although a history ot this disease
oannot always be obtained (the joint symptoms in the rheumatio fever of ohildren are otten vague, and may be entirely
absent). The valves are thiok, smooth, ll.brotio, free from vegetations, and glued together at their margins, produoing eit.l:\er
the • button-hole' orill.ce or the • funnel-shaped' orlll.oe of
Corrigan. Tho orill.oe may bo so oontracted as soarcely to allow
the Insertion of the tip of one finger (instead of the index and
middle finger,s as far as the ll.rst joint). The apox of the funnel
looks in the diroction of the blood-ourrent--i.e., into the ventriole. Tho ohordlll tondinem are oommonly thiokened.
The obstruotion at the mitral orifice oauses hypertrophy
(whioh In early oases may be oonsiderable) of the left auriolo;
la.ter dilatation, often oxtreme, OOQUl'S; finally, • auricular fibrilla.tion' Is established, A clot is liable to form In the left
aurioular appendix. a portion of whioh, if it beoomes detaohed,
givos rise to ombolism. (This is the oommonest causo of ombolism of tho middle oerebral artery.) Tho lungs congested,
as in mitral regurgitation. but the tendenoy to hlllllloptysis is
muoh greater. (Sometimes suoh cases of hIlIm.optysis mistakon for phthilris.) The pulmonary arteries aro ofton atheromatous.
The right vontriclo is dilated and hypertrophied. In ooursoof
time trlcnspid regurgitation ensues with all its sooondary oonsequenoes on the abdominal viscera and legs.
(The most pronounced instances of •nutmeg' liver occur in
mitral stenosis.) Asoites may be the first sign of cardill.O dropsy.
Many contradlotory statements have been made regarding
the condition of tho left ventricle in mitral obstruction. In pure
oases it is of normal size. The fingers are more apt to become
olubbed than in mitral regurgitation. Patients rarely reaoh
the age of forty-live. It is a well-known taot that pulmonary
tuberoulosis is praotically never found in oonnection with mitral
stenosis. (Rokltansky taught that all eonditions which brinll
about passive congestion of the lungs impart an immunity
against pulmonary tuberculesis.)
Mitral stenosis is
common CAuse or undor the ago of
The Aortin of this valve alont, though som.,·
times & sequel oI rheumatio tever. Is more otten of tile nature or
a ehronie ondooardJtls, in which ease tIloro is usually atheroma
of tho aorta a.t tho saUle time. Isolatod aortio valve disoase
(i.6., Without a:l!eollon of the mitral valve) is raro as the result
at rheUDlatie fever; it present. In a young woman, it. Is noorly
always of syphilitio origin..
Aortic regurgitation is the usual sequel, aortio stenosis being
In aortlo regurgitation the blood is not only suoked back into
the left ventriole durlog diastolo. but is also squirted baokwards
into the heart by the recoil at the stretched aortic walle. thG
initial rosult being dilatation of the loft ventriolo (more room
having to be found for the additional blood, the ventriole ha.ving
to aooommodate both the auricular blood and tho locgurgltant
blood). to be immedJa.tely foIlo,ved by compensatory hypertrophy. This dilatation and hYJIortrophy tend to be progressive,
ond it is for this reason that the heart may assume enormous
dimensions (cor bovinum). A.s the result of ineroosed intraventrioulo.r pressure, the mitral orifice may 'le&k ' (oither from
stretching of the orlfios or curling up 01 the valve Ol1l'tains).
whon all tho sequolm of mitral regurgitation onsuo. The endooo.rdium lining the septum of tho left ventricle at tho point of
impaot of tho regurgitant blood often shows patchos of thickenillll. The arch of the a(lrta is usually atIleromatous.
The OBpillo.ries belog badly filled. the patient tonds to
A.t a lo.tcr stage fibroid degeneration of tho hoort muscle is
liablo to ooeur, in aceordanoe with the genora.I law that a muso1o
is capablo only of a oert.ain amount of hypertrophy, WId \vhoJl
tllis limit is reached musouIar atrophy and fibroid degeneration
follow. As 0. result, do-compensation ensuos.
As in. aU disuz8eB oj the huJrl. the mea8'111'6 oj the patien.Qs
danget' U t1l6 cmtdition oj the eardiac muscle.
IIeart.failuro proooede muoh more rapidly in aortio than in
mitral regurgitation, owing to the greater burden thrown on
the left vontriole .
.4arfiic stcnosis.-This by itself is rare, and when found results
from either an acute endocarditiS or from atheroma.tous thickoning. ThO loft v6Iltriole Is hypertrophied, dUo.ta.tion bolng superadded in course of timo. (N.B.-Wha.t is olinl0811y ofien called
aortic stenosis Is generally nothing more than 0. murmur. caused
either by 'roughening' of tho valves, or atheroma of the a4rtie
Tricuspid Valve.-' Leakage' at the right aurioulo-vontriculo.r
orifice Is generally the result of the 'book-wash' of mitral
disease (regurgitation or stenosis). or of chronic lung disoasee.1I•• emphysema and bronohleotaals. Slmplo endocarditis of the
valve rarely (I()(lUl'B exeept during footal llfo. U tho triouspid
booomes dIsoased during oxtra-uterino life, It is generally from
Dl&lignant endocarditis_
The Pubnonary Valve.-Tho OODlDlon lesion of this valve Is
sknosiB, whioh is praotioally always oongenital, the result either
of a fmtal endocarditis or of a dovelopmental defeot. If occurring _Zu in fmtal life, It Is liablo to be associatod with a doficiency of thll upper part of the intervontriouln.r septum (pars
i~ema), the two ventrlclos thon cODlDlunlcating. Endocarditis of the pulmonary valvo ocourrlng during extra-uterine
life is almost always of the malignant variety.
Summary of the Heart AftectiOD9 in Rheumatic Fever.
Pory,arditis oocurs in about 20 por cont.; 60 pcr cont. of tho
cases eocur under the- age of twenty-one.
Dilatation.-The heart, especially the lett ventrlele, Is dilated
(toxlo). The dilatation may bo temporary or permanent.
Endocarditis (aoute) Is oaused by rheumatio fever in about
90 p~r oont. of cases. Praotlcally all children with rhoUDl&tlo
tever, up to the age of ten, have endocarditis. After this age
the tendenoy to endocarditis Is diminuendo up to forty, after
whloh It dies out. In the typical rheumatic heart of a child
dying from the disease, there will generally be found mitral
reglll'Q'itatlon, mitral stenosis, aortio regurgitation, an adherent
perioardium, and the heart may weigh as muoh as dve times the
.Malionant Endocarditis may occur in rheumatlo fover.
Tho degree of damage Inflioted on the heart largely depends
upon the patient being allowed to get up too soon.
Auricular Fibrillation.
When oompensation is tailing In an old-standing case of
mitral disease, the lungs, right heart, and vonous syetem generally become engorged with blood, and ovontually dropsy supervenes, with scanty urine. Under suoh oircumstances tho pulse
Is noticed to become markedly irregular, tho sphygmogram
~howing that two beats of the Bame length or oharacter rarely
follow.each other. At the same time, in the majority of casos,
the rato Is much too frequent, the average being between 90 and
ltO, strong and weak beats being mixed up in complete oontusion. A pulse of this eharacter was oaiIcd by the older writers
the' mitral pulse,' and, when In an exaggerated form, •delirium
eordis.' Thanks to the introduction of the polygraph and the
electrio eardiograph, the mystery of tho • mitral pulso' has at
last been oleared up. It Is now known that the auriolo in £heso
cases Is a spent force, being In a condition of semi-paralysisi.e., it oannot oontract properly, but makos, as it wore, abortivc
attempts to do 80, its walls merely quivering, like the tongne ot a
patient with • bulbar paralysis'; oo-ordtnate contraction Is
replaced by inco-ordinate contraotlon. the ohamber IIdl a whole
not ccntracting_ The condition is well summed up by Lewis_
• The muscular walls are maintalncd in a position of diastole;
systole, either ccmplete or partial, is never accomplished; the
structure as a wholo rests Immobllc, but o1oso observation of the
musclo surfacc revoals Its extreme and Incosso.nt activity; rapid
and minute twttchings, and undulatory movements are visiblo
ovor tllO whole.' This inactivity ot tlle auriole is responsible tor
tho irrogular beating of the ventriole. and the irregularity of tho
beating of the lattar exPlains the irregolarity of the pulse.
Tho loft auricle is much dllated-sometimes to twioe its natural
size. As tho result of the impaired action of the heart. thero·is
usually mdema. ot the feet and legs, enlargement of the liver.
ascites. and albuminuria. ftbr.ill&tlon is present in aboqt 65 par cont. 'ot all
pationts admittod to hospital su1ferillll from cardiac fallure, and
in about half of those mitral sl8fW8£s is tound. In all these casos
tho commonest pathological change Is a chronio myocarditis
going on to a patchll ftbrosi8. most marked in tho auricular wall.
but also as a rulo involving tho ventriclos. In tho rheumatio
CBSOS, degoneration ot the • bundle of His ' is !!roquent.
Fibrillation of tho ventricle is fatal In a fow minutes, but
fibrillation of the aurlclo may continue for weeks or years; few
patients. however, survive its onset for more than ten years.
(Aurioular ftbrmatlon is oocasionally found in pneumonia.
diphtheria, and othor infections. Here the oouso is tCDC.)
Malignant Endocarditis.
This disease is due to the implnn~tion of pathogenic
organisms on the endoca.rdium, the most important of
which are pneumococcu8. Streptococcus pyogene8 aur6U8,
gonococcus, and tho influenza bacillus. (There appears to
be a malignant form of rheumatio endooarditis, but whether
this is duo to tho organism of rheumatic fever or to a
mixed infeotion is unoertain.)
Special Oharacl6T8.-The disease attacks by preference
damaged valves (i.e., those affected by an old endocarditis);
the vegetations are large, numerous, and highly friable;
tho valves may become aneurismal, and even rupture.
Sometim68 the valV68 oj the right heart are involved. The
infeotion ma~ spread to tho walls of the hoart, the aorta,
and the chordal tendineal. There may be burrowing
abscesses in the heart walls. Owing to the brittleness of
the vegetations, portions are very liable to become detached, causing embolism of various organs, notably of tho
Bpleen, kidneys, and brain.
The heart tissue genemlly shows a polymorphonuclear
infiltmtion, with cloudy swelling and granular degonemtion of the muscle fibres.
Diseases of tbe Beart Musculature.
The myocardium Is tho vital part 01 tho heart. Diseases 01 tho
valves and pericardium are relatively trivial compared witll
dlseaso 01 the myocardium .
• It is In the vital and anatomico.l condition of tho muscular
fibres that we find tho kcy 01 cardiac pathology. for no matter
what tho alfectlon may be. its symptoms mainly dopend on tho
strength or weakness. the irritability or tho paralysiA. tho anatomic health or dis6llso of the cardlne muscle' (Stokes. 1836).
Atrophy.-Thili occurs in old age and in certain wasting
diseases. such as phthisis and diabctes. The muscle
fibres shrink, granules of golden· brown pigment aro
deposited in their interior (chieft.y around the nuclei), tho
heart assumes 0. brownillh colour-hence the name brown
atrophy 01 the heart applied to this oondition.
The nature of tho pigmcnt in brown atrophy of tho heart Is a
disputed point. It appears to be either melanin or II plgmentod
fat (Zipochrome).
Bypertrophy.-This develops in response to the neccssity for increased work on tho part of the cardiac pump.
and i8 orily p08sible when the nutrition of the heart is good.
Hypertrophy without dilatation is rare. Apparent
hypertrophy with diminution of the oardiac chambers is a
post-mortem effect.
Hypertrophy of the Heart as a Whole.-Tbis is typically
seen in certain of adherent pericardium.
Aortic regurgitation.
Aortic stenosis.
causes of hypor- Mitral rogllrgitation.
trophy of tile Increased perlpll?ral roslstance--e.g.. In
leIt untriclB
ohronlc renal dJsoase.
{ Exoessive muscular exorclso.
Exophthalmic goitre.
Mitral dlsoase.
Causes of hypor- Emphysema } An~ othor ohronio hlllg
trophy of tile Bronohlectasis
fWntricZe of the pulmonary valvos.
Pressure on pulmonary artery (anourlsm,
Pure hypertrophy of tho right ventricle never lasts long.
This is probably due to the comparatively low reserve
power of its musoulature.
Hypertrophy of the ventricles is said to be concentric
when it occurs without dilatation, and, except in pure
aortic stenosis, is but rarely seen. When the hypertrophy
is associated with dilatation, it is said to be eccentric, and
such is the usual form.
Hypertrophy of tho auricles is always associated with
dilatation, the left auricle being most affected in mitral
stenosis, and the right auricle in emphysema and disease
of the mitral valve.
Dilatation, or increase in the cubic capacity of one or
more of the heart chambers, may either precede or succeed hypertrophy, the two conditions then coexisting.
If a heart of good reserve power is exposed to conditions
imposing on it increased work, the initial result is hypertrophy, followed by dilatation if the cause be long continued. For examplo, the greatly hypertrophied left
ventricle of chronic Bright's disease tends in colirse of
time to dilate. (Most cases of hypertrophy are, however,
from the very beginning accompanied by some degree of
dilatation.) If, on the other hand, a heart of low reserve
power be exposed to conditions of increased strain, the
tendenoy is rather to dilatation pure and simple.
Sudden cardiac dilatation may occur. For example, it
is probable that the acute pain of an attack of angina
pectoris is due to the stretching of the heart walls arising
from a sudden mechanical dilatation of the left ventricle.
Acute toxic dila.tation of the left ventricle is the rule in
rheumatic fever, and particularly so in the case of children.
Mechanism of Cardiac Dilatation.-The essential factor
in the mechanism of cardiac dilatation is excessive distension of 0. cardiac chamber during diastole. (It is manifest
that a cardiac ohamber cannot yield during its systole.)
The causcs of such excessive diastolic distension are-(a) Regurgitation of blood into a chamber, which thus
receives blood from two direotions.
(b) Inadequate systole, leading to an excess of residual
blood in the inadequately systolizing ohamber. This is
the great cause of cardiac dilatation in failing heart-e.g.,
in the later stages of granular kidney. Degeneration ot
the cardio.o walls leads to dilatation in this way. and also
by rendering them liable to yield.
(I:) An excessive supply of blood from the normal direction-e.g., in sprinting, the blood may be driven into th9
right heart by the rhythmical contractions of the musoles
more rapidly tho.n it can be delivered into the lungs. The
dilatation of the left ventricle in mitral regurgitation
result!! from the extra supply of blood this' ch!l.lllber reoeives from the dilated left auriole.
Diseases of the Coronary Arteries.
Althongh the artories of tho heart anastomoso to 0. slight
oxtent. thoy ma.y. for a.ll pmoti0011 purposes. be l'(lgardod a.s
AtkeromtJ.-The ooronary arteries are espeoially liablo
to this disease. Their channels are narrowed, and the
heart substance, receiving an insuffioient supply of blood,
tends to undergo fatty and fibroid degeneration, (In
angina. pectoris the cor.:>no.ry arteries are generally ath')romatous. particularly at their orifices.)
Thromboaia.-This is a. not infrequent comp iC'l.tion of
atheroma. Its results are the same as those of embolis'U
(see below).
EmboUBm.-If a large vessel is blocked, the usua.l result
is srdd3n death; if a small vessel is blooked_hort of
causing dcath~ infarct results. Should the rati( nt
live suffioiently long, the infaret is oonverted into fibrous
tissue. This, subsequently yielding to the ir.tracarJia\
pressure, causes an aneurism of the heart, the common
site of which is in the region of the apex of the lelt
8yphilitit; Endarteritia.-This causes great narrowing
of the channels of the affected vessels, and, like atheroma,
is liable to be complicated by thrombosis. Acoording to
Osler, it, is the commonest lesion to be found post mortem
in angina pectoris.
Fibroid 'Bearl,
This form of ~Iao degeneration ooours as 0. termln..'l.l evont
In the hypertrophy and 'dUatation of vlI.lvltlnr disoose, general
arterial IIbrosls. 6B wall 68 tn syphilis. When IOCI.IU?.e(l. it Is
generally ot BflIhillGic origin and a.s8ociated with the
definite gummllta. In the~e c~sos thoro Is usually syphllitio
ondarteritls ot tllo surrounding arteries.
Fibrous tlssuo forms· botWOOD the muscle fibres, in part
roplaeing them. Thc change is usually confined to the lett
ventrlolo, and occurs mON particularly In tho neighbourhood
of its apox. It Is one of the causes of sudden death.
Degeneration of the Heart.
In this disease fa.t globules, often a.rranged in transverse
a.nd longitudinal rows, appear in the muscle fibres. The
condition is most common in the left ventricle, less so in
the right, and rare in the auricles. The left ventricle
suffers most in the anromias and aortie valve disease. In
phthisis and mitral disease the right ventricle is chiefly
implicated. In typical cases the heart looks 'mottled.'
like the thrush's breast, or presents tho • faded leaf'
Three main faotors (whioh may act singly or in 0011·
junction) are proba)'ly concernod in its causation-the
action of some toxin, interference with the blood·supply,
from diselllle of the coronary arteries, and the want of an
adequate supply of oxygen. It is to be remembered tha.t
the heart requires more oxygen than any other tisj:luo in the
Chronio a.lcoholism is perhaps the commonest of 0.11
causes. Alcohol is not only a protoplasmio poison-it
has been called the • genius of degeneration '-but it
interferes with the oxygena.tion of the tissues. Other
causes are: prolonged a.nd severe anrelpias (it is aJways
present in pernioious anmIDia), phthisis, and phosphorus·
pOisoning, and as a termina.l stage in valvular disease.
Ail am acute condition, it is found in diphtheria.
By k(!o'rl·bloc1c is meant that condition in which the
oontraction from auricle to ventricle is 'blocked,' the
rhythm of the auricle being maintained, .but tha.t of the
ventricle not following in proper sequence. The' block'
may be slight, the ventricular beat merely lagging behind
the auricular, or so marked that the a.uricleBIand ventricles
beat quite independently of oach other. For example,
the jugular tracings ma.y show tha.t the auricle beats twice
to the '\'entriclo's once-that is, every alternate oontractit,n
wave is blocked, or only one of every three may get through.
Temporary hcltrt·block may occur in certain fevers,
notably rheumatic fever, pneumonia, and enteric, in whioh
cases it must be regarded as toxic. PersiBtent heart· block
implies 0. gross pathological lesion of the' bundle of His,'
but not necessarily limited to it, forit may bo widely spread
throughout the heart. Gummata, fibrosis, atrophy, calci·
fication, and diseaae of brancluu of the coronary arteries, are
the most constant lesions. In exoeptional cases 0. neo·
plasm may be the cause.
The Stokes-Adami S:vndrome.-ThiB oonslsts of persistent
slow pulso (bradycardia), with occasional attacks ot synoope,
vertigo, and opileptlform fits. 'rhe Stokoe·Adams syndrome
always indicates heart-block. but it is to be clearly understood
.that only 0. minority of the cases of hoart·blook exhibit the
The. lungs are devoloped as outgrowths of the (l)soph.
agus. 'rho epithelium lining the air cells, bronchi, and
trachea, is derived from the hypoblast, and the rest of
the lung tissue from the mesoblast.
.CoUapse of the Lung.
Ato\oo\a81B 18 'Lbo cunMUun u\ 'Lbo rongs in 'LbD s\;JWDom.
SUell IUDgs are completely alrlcss and sink in water.
The causes of collapse of the lunge areair,
1. Pressure from without
the lungs
2. Obstruction from within the lungs, caused by
blockage of the bronchial tubCII.
The chief cause of such obstruction is ' capnIary bron·
chitis,' in whioh the small tubes become plugged with
visci~ mucus. Tho imprisoned ~ir is absorbed by the
blood, and the alveolar walls, faIlmg together, ultimately
110 in contact.
Collapsed lung is reduced in aize, of a dark red colour,
and non-01'6pitant; it sinks in water.
Pulmonary Emphysema.
TI:.ere are two main varieties-the spurious and the
SpuriO'UB emphysema (insumation, acute emphysema)
occurs chiefly in children, as the result of capillary bronchitis and broncho-pneumonia. In these diseases excessive stretching of the uncollapscd air vesicles occurs as
the combined result of widespread vesicular collapse, and
of the thoracic expansioll (from prepondcrating action of
the inspiratory muscles) resulting from dyspnrea. As a.
result the vesicles arc so greatly stretohed as temporarily
to lose their power of recoil, and the lung tiBBue involved
may remain unduly oxpanded for somo days; but there isno rupture of the vesicles.
Of true emphysema there arc two kinds: the interZobular, in which, under the influence of a violent expiratory e1fort, such as occurs during 0. paroxysm of whoopingcough, actual rupture of tho vesicles takcs place, the air
c:Jcaping into the interlobular spaces, \vhenco it may gain
aCC099 to the mediastinum, and thence to the subcutaneous
tissue of the neck and chest; andVesicula, Emphysem!l.-This is the varicty whioh is
generally meant when pulmonary emphysema is referred
to. It may ocour in a localized or gonoralized form. In
the former it is met with in the neighbourhood of pleuritic
adhesions, or in parts of the lungs which have been
rendcred airlcBB-e.g., by tuberclo or collapse-when it is
generally known as compe1UJatory emphysema. In these
localized forms the essential cause is unduo traction on
the vosioular walls, in consequenco of which their nutrition
fails and the sopta botween adjac~nt vesicles give way.
In generalized vesicular emphysema a degcnoration of
the vesicles takes place throughout tho entiro lungS; their
bloodvessols and epithelial lining atrophy; they lose their
elastioity; and the septa between adjacent vesiclos give
way. At tho same time the vesioular walls lolle their
wavy outline, presenting under the microscope a stretched
This variety of emphysema. is essentially due to prima'71
aerop'h,ic degeneration. Suoh degeneration takea plaao in
everyone with advanoing years, quite independently.of
cough, but in some it is met with in early adult lifo or
even before this. Its occurrence is favoured by certain
diseases, suoh as gout and granular kidney.
The second, but much less imPortant, factor in the
production of this form of emphysema is long-con.Unued
over8tretching 0/ the vesicular wal18. Such overstretching
may result from (a) exoeasive pressure from within, as
happens when a powerful expiration is made while egress
to the air is impeded, as by a completely or partially
elosed glottis (muscular effort, coughing), or in blowing
wind instruments. Or it may result from (ll) excessive
traction from without. We have seen that the latter is
the chiof factor in determining localized emphysema.
Such traction may alae be a minor factor in causing
generalized emphysema: in all forms of breathlessness
other t·han those due to obstruotion in the respiratory
passages (as by the diphtheritio membrane or by
throttling), the mean size of the chest is increased by the
preponderating action of tho inspiratory muscles (the
expiratory muscles remo.ining in partial or complete
abeyance). This is because the inspiratory position of
the chest is the one most favourable to the pulmonary
circulation and the aeration of the blood. Hence what·
ever promotes breathlessness predisposes to emphysema,
whether it be physiologica.l breathlessness, suoh as results
from athletio pursuits, or patbologioa.l breathlessness,
such as ocours in asthma and heart disease.
In generalized emphysema. the lungs may be unduly
expanaed (hypertropholIs, or 'large-lunged,' emphysema),
or (much leBS frequently) not more than their average
size (atrophous, or • smaJl-Iunged,' emphysema). In the
latter case it is probable that tho disease has not occurred
until the thoraeic cage has undergono senile fixation.
When it occurs before this. the mean sizo of the chest
(owing to the favouring influence of tho inspiratory
position on pulmonary circulation) undergoes steady increase from overaction of the inspiratory musoles. AS a
result, these latter shorten (just as the overacting muscles
do in talipes). and ae fix the chest in the inspira~ry posi.
tion. Moreover, the bones and joints of the thorax tend
to become 'set' in this new position. In this way the
chest, in the latter stagcs of the disease, may be fi:l:ed in a
poaition of BUper ea:traordinary inapiration-i.e., the patient
is unable, by the most powerful oxpiratory effort, to reduce
his thorax to normal dimensions. Under these circumstances the chest appears barrel-shaped and the neck
It will be observed that the enlll1"gement of the chest
in ' hypertrophoUB' emphysema is compensatory. A reduction of the chest to the normal size in this condition
would soon cause death.
It wm generally be found that the chnst expands as
middle life is reached, especially in stout people. Men
arc apt t.o pride themselves then on possessing a 40-inch
chest, ignorant of the fact that such 0. mcasurement
gcnerally indicates degeneration. The progressive enlargement takes place in obcdience to the principle already
cnunciatod, and is in large measure due to loss of pulmonary elasticity. In order to maintain physiological
conditions it is necessary that the pulmonary tissue shall
be kept in a certain degree of tautnCBB (for otherwise not
only will 'pulmonary suetion ' fall below the normal; but
the slack, wrinkled vesioles will unduly encroach upon
the air spaces), and lUI the pulmonary fibres length6n they
need to be tightened up-tuned up to the nermal pitoh, so
to speak-by an increase in the mean size of the chest.
Though generalized vesioular emphysema involves the
ontire lungs, the emphysema is usually most marked at the
parts least supported during occasions of heightened intrapulmonary prossure - i.e., the apices, anterior margins,
lower and posterior margins (which may present an
appoamnce which has been likened to the fur on a lady's
mantle). It must not be forgotten that under ordinary
conditions the lungs, far from being supported by the
structure eircumjacent to them, actually exercise suotion
upon them.
Owing to the 10BB of their elast.icity, the lungs in
generalized emphysema. collapse but little when the thorax
is opened, or when they are removed from the body.
The anterior borders are found to have lost their sharp
edges and to be rounded, showing emphysomatous bulb
('frog's lung'). They may also overlap in front, and
by covering the hcart obliterate the area of superficial
cardiac dulness.
The pulmonary tissue is palo and blo.odless, pits more
easily than healthy lung tissue, and feels like eiderdown.
The &ir can be squeezed from one part to another with
greater facility than normally.
As the emphysemo. progressea, tho obstruction to the
pulmonary circulation resulting from obliteration of the
amaller vessels causes the branches of the pulmonary
artery to dilate, and its main trunk often to become
atheromatoUII. Eventually tl,e rigke heart becomes dilated.
and general vonous congestion supervenes (enl&r&oment
of liver, redema of lower oxtremities, albuminuria, eto.).
In this condition there ito permanent distension of the
bronchi, which in consequence may bccome:
Fusiform, or
The IIltiology of bronohiectasis is much tho same as
that of emphysema - viz., increased stretching of the
bronchial walls, cither from augmented internal pressure
(an unimportan~ factor) or increased traction from without
(the eBSential factor). In bronchiectasis, however. another
factor comes into operation--i.e., weakening of the bronchial walls from degeneration of their muscular fibres
which (as in the case of all tho muscular tubes of the
body), by their o.otive contraction, normally tend to prevent overstretching.
Bronchiectasis is the usual aocompaniment of all ohronio
diseases of the lungs. and is typically met with in fibroid
phthisis. I~ this disease the contraction of the fibrous
tissue, attached, on the one hand, to the adherent pleura,
and to the bronohi on the other, has been hold to be
an important factor in causing the dilatation. Though
such contraction plays its part, the chief traction comes
from the powerlul action of the inspiratory musoles. which.
in accordanoe with the prinoiple already mentioned, are in
dyspnrea continually striving to inorease the mean. size ot
the chest. It is evident that, were the normal amount of
vesicular structure present without any fibrosis, such inspiratory action would simply lead to emphysema, because
the delicate vesicul&- walls would necessarily yield before
the stouter bronchi. When, however, the lungs &"e seamed
with comparatively non-yielding fibrous tissue, the effect
of the constant inspiratory efforts will be to expand the
bronchi as well as the vesicles.
In bronchiectoais the muscular coat of the dilated
bronchi is in large measure replaced by a fibrous tissue,
and the muoous membrlUle tends to lose its sensibility_
As a result, the secretion of the tubes is apt to accumulate
IPdld to undergo putrefaction:, not being expelled until it
reaches a level at which the mucous membrane is sufficiently sensitive to excite the act of coughing.
Bronchiectasis may give rise to abscess in the brain.
There are two classical forms of acute pneumonia,
which have different exciting causes, run different olinical
C01lI'88B, and present different morbid appearances. These
Lobar pneumonia, and
Lollar Pneumonia (CroupoasJ.-Pi\e pneumoooccus oj
Fraenkel is eke eB86ntial cau8e, though occoaionally the
pneumo·bacillus of Friedlander, streptococci, and staphylococci &"e also present. The pneumococci are constantly
found in large numbers in the mouth, pharynx, and nasal
cavities, of man in health, and it is orily when vitality is
depressed (e.g., by chronic alcoholism) that they' can set
up inflammation of the lungs. They are most numerous
in the advanoing area of disease.
The lesion usually begins at the root of one l)Ulg, extending thence to tho base, and in typica.l cases involves tho
whole of the lobe in a uniform manner. Exceptionally,
it may occur in scattered areas.
The constitutional symptoms are the result of absorption
of the pneumo-toxin into the system.
Lobar pneumonia. is alwa!J8 a pleura-pneumonia, arm
passos throu$h tile follo~ stages:
The Stage o/Oongeation.-The affected area of lung is
swollen, of a deep red colour from vaacular engorgemont,
and it is less orepitant and less elastic to the feel than
normally. It floats in water. The capillaries in tho
0.1 veolar walls are distended, the lining epithelial cells
swell up, lI.nd exudation of inflammatory lymph begins.
Signs of pleurisy are evidl'nt.
The Stage of Red Hepatization.-The inflamed portion
of lung, usually a whole lobe, is now solid, like 0. piece of
liver; the inBo.mmatory lymph hIlS completely filled the
alveoli and undergone eoagulation, the clot being com·
posed of a fibrinous network. entangling in its meshes
polymorphonuoleo.l'B, chromocytes, and shed epithelial
cells. In consequence of this the inflamed lung is distended, a.nd its p]eumlsurface may ije indented by the ribs.
(This is probably a post-mortem phenomenon, as during
life the inspimtory muscles enlarge the chest on the
affected side, a.nd thus proteot the in1l.amed lung from
pressure.) The affected tissue does not crepitate, is very
friable, and sinks in water. On section it looks like red
granite, being dry and granular. Tho pleura is sticky
and covered with a dolicate layer of fibrin.
The Stage of Resolution is the normal sequence to red
hepatization if recovery takes place, in which case the
coagulum disintegrates, to be in part absorbed by' the
lymphatics, and in part removed. by expectomtion, after
which the alveolar walls become relined with epithelium.
Instead of resolution the stage of red hepatization may
pass on toThe Stage 0/ Grey Hepatization.-The lung remains
solid; is still more friable than in the second stage, and
sinks in water. Ou section it looks like grey granite, and
may yield a purifOJ/lll :fluid. The fibrinous network has
partially dissolved, the chromooytes disintcgmted,
and the alveoli are packed with granular leucooytes.
If at this stage a section of the lung is made from apex
to base, the organ will be seen to bc mapped out into
zones. At the bottom is the zone of grey hepatization,
while above this are three others-first, a. zone of red
hepatization, above tho.t a zone of congestion, ILIld above
that, a.gain, a zone of ccdcma.
AbBCe88.-In some cases of pneumonia the alveola.r walls
disintegrate, leaving a cavity filled with dead leucocytes.
This is 110 very rare phenomenon.
Gangrene.-In persons whose tiBBUes are very muoh
weakened by, e.g., alcoholism, the intensity of the inflammation may be such as to cause gangrene.
Oomplicati01l8.-The pneumococoi entering tho circulation may set up pericarditis, malignant endocarditis,
meningitis, peritonitis, synovitis, or otitis media. The
pleurisy may pass on to empyema (whioh is generally on the
left side).
The absence 0/ leucocytosis in pneumonia usually J;Ileans
0. fatal termination. The expeotoration of prune-juioeooloured sputum is also a bad sign, as it indicates much
pulmonary mdema. At the time of the orisis the opsonio
index undergoes a matked rise.
BroDcho-Pneumonih (Catarrhal, Lobular Pneumonia).This is par excellence a disease of the e_xtremes of life
(childhood and old age) and of influenza. It is also the
essential lesion of pulmonary tuberculosis. It is alwaya
preceded by a preliminary capillary bronchitia, of whioh
it is the direct outcome.
It is microbic (pneumooocci, streptococci, and staphylococci) in origin, and an example of point-to-point infection. Thus, it occurs in children as the result of measles,
whooping-cough, and scarlatina, and in adults after influenza and operations on the mouth and windpipe (' aspiraLion' and 'deglutition' brancho-pneumonia). The inspired air rendered septio by passing over the infected
mucous membrane of the mouth, nose, or pharynx, sets
up a capillary bronohitis; subsequently, patches of pneumonia devolop around the affected bronchioles, in consequence ofDirect extension of the inflammation; or
Inoculation with septic material sucked in from the
bronohioles; or
Collapse of the alveoli from plugging of their bronohioles
with tough mucus, and subsequent absorption of the
air imprisoned in the alveoli.
Possibly all thcse factors co-operate.
A seotion of suoh a lung in an oarly stage of the disease
shows small, dark red, ill-defined patches, ranging in size
from a pin's head to 0. pea, and Il'Urrounding inflamed
bronchiolfl8, separated by healthy intervening lung tisBue.
At a. later stage neighbouring patches may coa.lesce into
!lone-shapecl areas (with the base of the cone at the surface
of the lung and the apex at the aff~ted bronchi). Still
later, by furthcr coalescence, such large areas of consolidation may result that the appearance suggests loba.r
pneumonia. Pleurisy is le88 common than in lobar pneumonia., and is found only in those cases in which the pa.tches
lie adjacent to the surfaee.
The bronchiolcs a,re inflamed. and choked with muco-pus
and shed epithelium. The ait-vesicles are filled with
large and swollen epithelial cells; also loucocytes in variable numbers, and a few chromocytes.
During resolution, the collapsed portions may remain
uninfiated, ca.using much shrinking of these areas of the
lung. In some cases tho inflammation involves the connective tissue of tho hmgs, resulting in much perma.nent
induration. Moreovor, tuberculosis may develop out oE
a bronoho-pneumonia, but this is exoeptional.
P~ercular Broncko-Pneumonia is par excellence the
leSion of phthisis.
Broncho-Pneumonia and Inftuenza.-Tho tcrm bronchopnournonlals otton uscd to Includo all oases of pulmonary complications occurring in influonza. Many cascs sho\v post-mortem
oxtensiVt' oonfiuent bronoho-pneumonia; others SlIO\V bronchiolitis, extremo oongestlon of tllo lungs, oollapso, Illdema, plllurlsy,
and consolidu.tion. OtlLOfS would bo mora oorrectly termed
streptococcal soptllll'Omla. In all those O"S08 tho mechanical
obstruction to tho Intako or oxygen oxplains tho cha.ra.otorJstlo
• holiotrope cyanosis.' Bactorlal culturas show tho
prescnooof FriedlAnder's bacillus,streptococci,and sto.phylooocci.
Chronic Pneumonia.-Thls is a merc frequent soquonoo to
brancho-pneumonia tllan to lobar. Tho alveolar \voJls bocome
Inllitrated with small raund oolls, wllich by organizing Into
fibrous tIssue may load to progressive obliteration of tho airspaces. It is generally assoolated with vosioular omphysema
and bronohlectasls.
Phthisis, or Pulmonary Tuberculosis.
Tubercle bacilli are expelled from tho body of II. tuberculous patient: (a) in the sputum (and perhaps with the
expired air during coughing and sneezing); (b) in tho
urine; (c) in the freces; (d) in the discharge of a tuberculous
sinus. The lungs may be infeoted:
(1) Via the inspired air.
(2) Via the tonsils. the cervical glands. the mediastinal
and the bronohial glands. and thenoe to the peribronchial
(3) Via the alimentary tube and thoracic duct.
Babies are born free of tuberoulosis. but post-mortems of
'ehildren nearly ahvays reveal the prosonee ot tuberole. ne
matter \vho.t disease oaused death; post-mortems of adults
praotioallyal\vo.ys sho\v healed lesions. The comparative immunity of adults to new infection,may perhaps be aecounted for
by the immunizing effect of the arrested infeotion acquired in
early litc. • It one develops active tuberoulosis, it is not a new
infection. but an activation of latent tuberoulous losiens he has
been oarrying since ohildhOod' (Woodruff). Something has
happened to weaken the defenoes of the bedy against the tubercle
baoilli. It wo.s formllrly taught that pulmonary tuberculosis
bogan at the apex, the 'line ot march' being down\vards; but
recent pathological observations. ooupled with radiographie
evidence showing heavy reot shadows with distinet mottling
In the neighbouring lung tissue, indica.te tho.t the diseaso
often begins in the bronchia.! glands at the root of tho lung (the
largo majority of all bodies examined post mortem reveal tho
presence of old-standing disease of these glands), the infection
thence spreading along the hilus to the peribronohial lymphatlos. Whon the o.pex is reaohed, the disease here may progress
80 rapidly that this region appears to be the aotual startingpoint of the disease. (Also. it is te be romemborod that the
lung apex is comparatively superfleial. and 80 with the stethoseope fine Bounds can readily_ be detected.)
The tubercle bacilli at length settle in the lymphatics of
the lung (peribronohial. perialveolar. and perivascular),
where. liberating their toxins. ano.tomical tuberclos form
as explained on p. 72.
The cardinal initial lesion in all casu 0/ phthisis is
probably a tubercular broncho-pneumonia.
Although no two oases of phthisis are ever precisely
identical. we may in a general way describe four chief
1. Ordinary phthisis.
2. Acute phthisis.
3. Aoute miliary tuberculosis.
4. Fibroid phthisis.
1. Ordinary Phthisis.-This is the oommon form of
pulmonary tuberculosis. There are four stages:
(a) Deposition of tubercll's in the peribronohial perialveolar, and perivascular lympho.tics, the presence of
which casues the setting up of 80 chronie broneho-pneumonia. This is the initial lesion.
(b) Consolidation.-As a consequence of the bronchopneumonia, the alveoli and bronchioles of the affected area
become choked with intlamm.a.tory products and the part
becomes solid.
(0) E:t:cavation.-The pressure exerted by the perivascular tubercles, plus the aotion of the bacterial toxins.
cause thrombosis of tb.e bloodvessels in the con~J'jd"\ted
area. From the cutting off of the blood-supply there results
necrosis and ca.seation. By the softening and. brea.king
down of the caseous material a cavity (=lIomioa) is
formed. (A ca.vity ma.y also be ea.used by the yielding
of the softened tuberoular bronohial walls-bronchiectasis).
Recently-formed cavities hllove irreglllll.r walls of softened
necrotio tissue, while older ones are lined with a smooth
pus·yielding membrane, often da.rkly pigmented. They
oontain pus, degenerated endothelial oells, lung debris,
and caseous ma.tter. A cavity sooner or later opens into
a bronchus adll its contents disoharged.
(d) Fibroo8.-Pari plU8'IJ with excavation new fibrous
tissue forms on the outside of the diseased 0.1"(1.10. tho
adjacent pleuta thiokens, and by beooming adherent to
its opposite layer seals up the intrapleural space.
The disease may now beoome arrested. Then more
fibrous tissue forms which, contracting. partially or complet3ly soals up the cavity,oonverting it into a pigmented
fibra-cicatrioial mass enolosing calcareous matter.
If, on the othcr ha.nd, the disease progresses, fresh
areas of lung tissue are infectcd in succession, the processcs of consolidation. excavation, and fibrosis are repeated a.gain and again, the lung is o~ively hollowed
out by adjac~nt oavities mnning into one another. and
sooner or later the other lung beoomes similarly affected.
If a branch of the pulmonary artery passcs along the
wall of a cavity or across its lumon, it is generally obliteratcd by thrombosis. Sometimes. however. it remains
plI.wnt, and in this case an aneurism may form in the
vessel, and by rupturing give rise to severe. even fatal.
2. Acute Phthisis (GallopiDg CODSumption).-This is 0.
form of pulmonary tubetoulosis that runs a rapid oourse,
the patient dying within a few months.
Tho tubercular broncho-pneumonia is intense from the
start, and numerous small cavities soon form, the interior
of which ~onsists of softened, necrotic, and caseous material.
There is little or no tendenoy to the formation of an
organized wall, the time being too short. Suooe88ive areas
of pulmonary t·is8ue are rapidly affected. If a oavity lics
close to tho surface, it may ulcerate into the intraplcural
Bpace and cause pneumothorax and pyopncumothorax,
the process being too rapid for proteotive pleural adhesion,
to take place.
3. Acute Miliary Tubercnlosis.-In this disease an
cruption of innumerable tubercles in the form of minute
grey dots (especially numerous bencath the pleura) ocours
throughout the Bubstance of both lungs, from apex to base.
lt is probably never primary, but alwa1P a final stage oj a
pre-existing tubercular lesion. In this sense it is an auto·
infeotion, the source of infection being, as a rule, caseating
bronchial glands in the case of children, and in the case of
adults an old tubercular deposit in the lung. •
In acuto millney tuborculosis the
nla thougllt to be
carried by the blood-stream. thuB differing trom other ferms of
tuberculosis, in which infeotion is conveyed by the lymphu.tics.
The baeilli roaoh tho blood oither by tho caseation of n gland
tlll'ough the walls of an adherent pulmonary voln, or'1ly the
perforation of a tubercle which has formed on the outside of a
vessel. Sometimes tho orosion Is through tho thoru.cio duct.
The bacilli cannot multiply while ill the blood-stream, but only
after coming to rest in tho lymphu.tlcs of Bomo organ.
Patches of broncho-pneumonia are scattered throughout the lungs, but death occurs before any marked dcstruction of tissue can take place. Owing to the rapidity of
the process, no giant cells can usually be seen in the
anatomical tubercle. :Many other organs may be affected
simultaneously with the lungs, notably the liver, spleen,
kidneys, peritoneum, and membranes of the brain. Tk6
dis(J(J86 is liable to be mistaken lor enteric lever.
4. Fibroid Phthisis (Cirrhosis of the Lung) is a very
ohronic form of pulmonary tuberculosis, not usually
developing until after the age of thirty. and lasting from
ten to twenty years.
Fibrosis predominates over necrosis, the affeoted lung
tissue being replaced to. a greater or less extent by connective tissue, embedded in which are tubercles-often difficult
to detect on account of the density of the new tissue; in
most cases, indeed, the only evidenco of their presence
is the ocourrence of one or two giant cells. Thi8 form of
pAtkiBis i8 always associated with marked lrronckieetasis,
and, to a leBB extent, with cmphysema. In a. fully-developed case the lung is shrunken, hard, fibrous, and
pigmented; the pleura is thickened and adherent over the
affected parte, whioh nearly always includes the apexwhich is then usually covered by a dense leathery ca.pand the organ feels like 0. cirrhotic livcr. On section, the
fibrous tissue is found to havc penetrated both the alveolar
walls and tho interlobular septa, obliterating many of the
air-vesicles. In the midst of the new tissue, ai'OlloB presenting a honeycombed appearance are often seen
( .. emphysema). There is marked -dilatation of the
bronchi, and this is the most active factor in the formation
of the cavities, the bronchi often opening into spaces lined
by a smooth, pus-secreting membrane. The pleura outside
these bronohiectatic cavities is flattened, for banda of
fibrous tissue pass to it from tho walls of the cavities, and
by contracting cause depression of its surface (see Bronchiectasis). The shrinking of the lung, combined with adhesions Of the pleura, often gives rise to drawing in of the
In all cases of phthisis the lym phatic glands at the
bifurcation of the trachea and those at the root of the
lung are tuberculous.
The liver and heart arc usullolly fllotty in all forms of
active phthisis.
T1/pelf 0/ Ba"uzi met with in Tuberculosis.-In a total of 938
cases In which tho sputum was examined, only four bovine
types wore found. tho rest being human. In primary abdominal
tuboroulosls the !>ovlno typos constitnte about 50 per cent.
Tubercular adenitis of the cervJcal glands In cbildren give '"
percentage of BOV8llty-ftve bovine: In adolosconco, 50 per cent.
(Abridged from Cobbott's Oawes oj Tuberculosis.)
Pneumokoniosis (leonis, dust).
This la a form ot ohronlo interstitial pnoumonla sot up by tile
inhalation of Irritating partiolos-coo.l-dust In miners (anthracosis), motllol-dust In noodle and knife grinders (siderosis), stone-
dust In stone-masons (silicosis), which, passing into tho perlbronchiallymphatics of the lungs, is deposited in various parts ot
these organs_ Dronchial catarrh, patehos of chronlo catarrhal
pneumonia, an inerease--Bometimes considerablG--Ot the IIbrous
tissue, pigmentation, pleural adhesions, and bronchiectasis, arc
the chief pathological features. These cases are lia.blo to be compIicated by tubercle, and arc then examples of IIbroid phth's!s.
Dr. J. S. Haldane, at the annual mooting of the Institution of
Mining Engineers, 1919, In an address on • The Health of Old
Colllors,' said the phthisis doath-rate among colliers was not
only much lower than In nearly all other occupations, but WlLS
evon lower than In the exceptionally healthy occupation of
fann-labourer. Coal-dust cor4l.inly did not kill germs, buL
It had come to be regarded by medical men as a preventive or
Syphilis of the lung Is very rare, and, when found, is usually
In the form of gummata in tho neighbourhood of tho root.
White pneumonia is the name given to the condition met with
in Infants with congenital syphilis. Extensive tracts of lung
tissue are condensed and inmtratod by a new formation o~
connective tissue.
Glanders.-The Baci1.l'UII mallei may cause a bronoho-pneu-'
mcnia. The consolldated arOlLs resemble soptio infarcts.
Actinomycosis oonsists of grey nodules oontalnlng pus, In
which arc found the yellow grains of the streptothrJT. It ma.y
extend to pleura, pericardium, muscles of the chest, ~kin, etc_
Tumours of the lung may be primary or Booond&ry, and are
practically ahvays malignant_
Primary tumours are: carcinomata, which grow from the
bronchial epltheliuni, and sarcomata, which grow from the lymphatic glands at the root, and inmtrato tho connective-tissue
planes of the lung in all directions.
Secondary growths (caroinomata and sarcomata) are multiple,
and causo tho lungs te assume B marbled appearanoe.
Acute Pulmonary <Edema.
The outstll,nding features of this disease are dyspnooa
cyanosis, and incessMlt coughing, accompanied \>y a continuous frothy discharge from the mouth and nostrils.
The cause is sudden failure of the left ventricle, the right
ventricle continuing to aot. Hence the capillaries,of the
lungs beoome engorged Mld the alveoli filled with exuded
serum, the patient being' drowned in his own secreti9n.·
The predisposing factors are: Aortic dissase, ohronic
nephritis, and arterio-sclerosis, the exhausted loft ventricle
losing its driving power and suddenly ceasing to act.
& cell proV:lded with one or mol'S process08 and
traversed by neuro-fibrUs. which oonstltute the strands along
which • nerve currentlJ' travel. Each nauro-fibrll enters the
neurone through one of its prooeSS8IJ, traverses the oell-body.
and leaves the oeD by anothor process. or, If there Is but a single
prOC88S (as in tho case of the sensory neurones of sensory nerves).
by the same process.
It will thus be seen that the essentlel elements of the neurone
prooesses are neuro-ftbrlls. Two kinds ot such prooesses are
met with: (a) Shorter naked proeessos, or dendrites, whieh,
after arboresolng. terminate in tree extremities within the grey
matter of the brain and spinal oord: and (b) longer medullaooated procosslfS. or wrons. TI10SO latter oonstitute the ordinary
medullated nerve tlbros mot with in the white matter of the
A. DeuroDe is
.eml-orytl'n in
I" ~1IIfNII:Y 11.",&.
S';"D~OfIt ganglia cIa
li'Ia. H.-This diagram mows tho ClOurso of tho nerve impulses
In & simple spinal reftox_ For the ·sake of slm.pUeity, the
sensory root-gangUon oell (proteneurone) is represented 80S
having two proOS8Ses instood of one procoss, and the
Intermedlo.ry cell between the sensory root-ganglion cellsnd
the anterior horn motor ecll Is omitted.
brain and spinal eOI'd, and In the cerebro-splnal nerves.
In the
tatter case, the medullated fibres have an additional sheath in
the shape of the nettrllemma. whioh. unliko the neurone proper
(which 18 of epiblastio origin), is derived from tho mesoblast,
and Is of the nature of oonnective tissue. The function of the
modullary sheatllIs probably partly to protect, o.nd partly to'ald
In the nutrition of, thB nouro-tlbrlls oonstltuting the oentral. "lm!
or axis cylinder, ot the long axens. The neurJlommll has slmllll'
functions, and, further, ailis in the regeneration of nerv;: IIbrue
atter their division, whether by trauma or by disease (e.g.,
anterior poliomyelitis).
Neurones are contigDOUB, but not continuous; tho neuro-flbrH.s
do not pass from one neurone to anoLhe... Each neuro-flb1·j)
begins at the extremity of a neuro2te prooess, tJoiIverses the cell
body, and ends at tho extremity of 8 neurone process. One of
these extremities Is rOOllIltive (a1lerent) and adapted, to be
sUmulated... the other is emissive (efferent) and adapted to
The afferent extremity Is proVided with an end -Ol"ll"BD, whioh i~
adapted to be stimulated by a. specifl.ctorm otstimulus, and,thus
to start a nerve current a.Jong the lleuro-flbril, Thore arc two
chief olo.1Ises of suoh a.fferent end-orgaw: those belonping to the
neuro-flbrils 01 the sensory and special-sense nerve fibres. and
LllOse belonging to the dondritio nem-o-flbrlls situated in the
grey matter of the brain and spinal oord.
The efJerent extremities have simllarly two modes ot termination: The neuro-flbrlls belenging to the axons fi.I efferent nerves
terminate in muscle fibres. or epithelial oells; those belonging
to DXons whicl end in the grey matte! ot the brain BDd spinal
oord have lIec extre:nities, whioh are plaoed in relation with the
reoeptive end-organs of neighbouring dendritic neuro-flbrlls. '
Observe that on this view tho funcGlon of tho terminals ot
efferent nouro-fibrils (tho~e. i.e.. which I'un in efferent axons) la
to initiate a chemioa.J process (for the most part of a disruptive
natlIPO) either in a muscle fibro or gland cell, or In the reoeptlve
cnd-o-rgan ot a dendritiC neuro-fibril pe-rta.1nfng to a neigbbouring neurone.
The interval between the trca extremity of an ctrehmt axonlc
neoro-fibril and the end-organs of its related dendritlo neurafibrils Is spoken of as a synapse. It 1s hore that the real mystery
of narvous reaction resides; it is here that the complex prooesses
ot co-ordination (ineludiDg inhibition) are offeotod, and It is
probably in this region also that the physical 001Te1ativcs ot
psychio processes take place.
Nerve currents, it wUl be observed. originate In tho endorgans ot afferent neuro-flbrils. The old View or the oell-body
of the neurone being a kind of battery discharging nerve
currents its processes must be abandoned. It should bc
observed that some authorities do not bellevo In the o:Dstenoo of
neura-flbrils.lnasmuoh as these cannot be detected In the liVing
neurone. Strong argumonts can. howover, be advancod in
tavour of their existence.
Changes in Neurones which fonow upon Division of
Cerebro-Spinal Nerve.
Peripheral Portion_-The changes here have for their
object the emptying of the neurilemmal sheath, so as t.o
make way for a new down-growing axis-oylinder from the
central end_ The contents are gradually absorbed by the
action of substancea (ferments, lysins) developed within
the sheath; the neuro-fibris of the axis-oylinder beoome
separated, break up into granules, whioh are absorbed;
the medullary sheath breaks up into blooks ( =fragmentation), and these into smaller particles, whioh beoome
absorbed; the nuclei of the neurilemma multiply_ Tkese
changes constitute Wallerian degeneration_
Gentral Portion-Cal Gell-Body.-Within twenty-four
hours of the seotion changes in the oytoplasm of tho oellbody are observed: it and its processes swell somewhat
from the imbibition of fluid; the chromophyl particlcs
(Nissl's granules) break up into fine dust, and may disappear (chromatolysis). The nuoli'us moves towards the
periphery of the cell-body.
Changes similar to these have been observed in the
large oortioal motor cells of Betz after transverse section
of the cord.
(b) The A:.:on.--Just above the point of section nota.ble
changes occur: tho neuro-fibrils become separated, presenting the appearance of a tress of hair; soon they take
on active growth, throwing out branches ha.ving bulbous
extremities. The growing fibrils are directed by chemotaxis through the new-formed granulation tissue, which
unites the divided ends of the nerve, towards the emptying
sheaths of the distal portion. By the time the fibrils
roach the neurilemmal aheaths, the latter have rid them,
selves of their oontents, and are ready to reoeive them.
The fibrils penetrate the sheaths, forming new axis.
cylinders; thereafter new medullary sheaths are formed.
This remarkable power of :repair possessed by the
medullated fibrea of the cerebro-spinal nerves is not
shared by those of the brain and cord, a cireumstance
whioh has been attributed to the faot that the latter laok
a definite ne:orilemmal sheath. These fibres are probably
endowed with some power of repair, however, for when
severed by disease the neuro-fibrils of the oentral end
ahow a tendency to sprout and form terminal bulbs, as
in the case of divided nerves.
In acute aDections of the neurone body--e.g., acute anterior poliomyelitis-the ohanges are very similar to those
just described, but more pronounced; there occur tume·
faction, vacuolation, complete chromatolysis, distortion
and dislocation of the nucleus, which may be extruded
from the cell, in which oase the entire neurone suffers
permanent dissolu~ion, and can never be replaced. Every
neurone in the organism is laid down in the embryo, and
is adapted to last a. lifetime : it ma.y thus outlast a century.
In chronic affections of the neurone body (e.g., chronic
anterior poliomyelitis) there is simple atrophy-diminu.
tion in the size of the cell and its processes, ending, it
JDI_y be, in complete dissolution of the entire neurone.
In such oases • pigmentary atrophy' may ocour, the body
of the cell being reduced to a maas of pigment, bordered
by a layer of protoplasm.
The neuronic changes, both central and peripheral,
which occur in peripheral, neuritis are similar to those
whioh occur after soction of a peripheral nerve; also the
secondary degenerations of the cerebro·spinal medullated
fibres, save that in this case there is -no neurilommal to share in tho changes.
The name periazial neuritis has been given to a disease
of the axon involving the medullary sheath in parte,
but leaving the MOns intact. It haa been observed in the
neuritis produced by lead and diphtheria, in the posterior
spinal roots in cases of tabes, and in the sclerosed nodules
of disseminated sclerosis.
Secondary Sclerosis.-When the proper nervous tissue
of the central or peripheral nervous system degenerates
and disappears, a secondary hyperplasia of the connective
tissue takes place. In the case of the central nervous
aystem this is spokon of as sclerosis. A familiar instance
is the secondary lateral sclerosis of hemiplegia or para.plegia: the peripheral portions of the severed motor MOns
disintegrate, and the neuroglia grows into and fills up the
spaces left by them. At fil'Bt the new tissue consists of
a large.meshed reticulum, but this in time is gradually
converted into dense tiesue.
Weigert's stain tints the myeline sheath deep blue;
therefore, if a section of sclerosed cord is stainedDY this
method, the sclerosed patches show up by their absence
of coloration. Marchi's method of staining is b88ed OD
the faot that osmic acid stains fat black.
Toxic Degenerations of the Nervous System.
A large number of diseases of the nervous system,
both functional and organic, are due to the selective action
of toxins on neurones. Thus, the convulsions of rickets
are due to the action of a toxin (or toxins) probably
generated in the alimentary tract, while all the organic
'system' lesions (e.g., tabes dorsalis) are the direct result
of specific toxins. Indeed, putting aside the primary
senile degenerations of the neuron.e--those, naInely, due
to a genuine wearing.out process-neurone degeneration
is very rarely spontaneous. It is practically always refcrablc to an ext$lsic cause, such as cireulatory defect-e.g.,
syphilitic endarteritis-or toxic action.
Selective Action.-Tho selective action of toxins on
tissue elements is in no case so remarkably displayed as
in that .of the neurones. Not only is this selective action
displayed as regards different groups of neurones, but
also as regards different portions of the same neuronecell·body, axon, axonic terminal, dendrite, dendritic endorgan. Thus, progressive muscular atrophy is due to tho
action of a toxin upon the cell-body of a lower motor
neuronef lead palsy, to the action of lead upon the axon
of such a neurono; while curari causes paralysis by acting
upon the motor end-plate.
The distribution of toxic nervous lesions is, however.
not due merely to a selective action between neurone and
toxin. but may result in Il,Lrge measure from a concentration of' the poison in certain parts of the nervous system.
l'hus, in lead palsy the muscles chiefly affected arc
situa~ed below the elbow, possibly because the poison is
• largely absorbed from skin of the hands. Again. the subarachnoid space appears to offer a favourable breedingground for the Treponema pallidum, and it is probable
that the concentration of thesc organisms in the cerebrospinal fluid determines the occurrence of syphilitic meningeal affections of the brain and spinal cord, and possibly
also of general paralysis of the insane and tabes dorsalis.
Okannel8 of Toxia lnfection.-(a) Through the blood.
This is the usual mode of infection. Thus, the toxins
which produce acute and subacute myelitis are transported in this way. (b) Through the cembro-spinal auid
Ce) Along the spinal nerves; there is evidenoe that infeotion of the spinal oord may take l'lace in this manner.
Homen injected streptooocci into the sciatic nerve of the
rabbit. Some days after he found the miorobes in the
spinal roots and the spinal oord; again, after injeoting the
virus of tetanus and hydrophobia, the transferenoe of
the poison to the oord oan be cheoked by dividing the
nerves between the seat of inoculation and the cord. Experiments also tend to show that the diphtheria toxin
reaohes the oord by way of the nerve trunks.
Trophic Lesions.
By 0. trophlo leBlo~ Is understood 0. gross structural oha.uge
brought about by faulty nervous activity.
The norvous meoha.niBms by whioh trophio lesions are produood Q,re ot severQ,l di:i!erent kinds:
1. Interruption of e:trorent nervous itnpule6S to muscle or
gland oells oauseB the oells. thus bereft ot their nervo·BlJ.pply. to
atrophy. Thus division of 0. motor nerve to a muscle oausos
atrophy of the musole; diviSion of the chorda tymp8Jli
oanses atrophy of the subm.a.xilllu'y gland; division of tho
tostioular nerves, atrophy of thO testis.
II. Intorruption of derent IronulBes a:l!eots nutrition in II. twofold way:
(0) The a:i!ecteil res;ion. boreD all itt ia of the defensive rooobJmism atrorded by sensibility. ls'lla.ble to burns. cuts, and bruises.
whioh readily become Infected and undergo ulceratIon. Similarly. a 'oint whIoh has lost sensibility to pain is liable to injurious oonoussions and twists. a olrownstanoe whIoh may help
to ex:plain theartbritio ohanges whioh ooour in tabes and syringomyolia.
(b) Owing to interruption ot the a:i!erent portion of thevlIoBomotor aros. tho normal reflexes oan no longer take plaoe in the
a..I!eeted region. This mlilY lead to olrculatory disturbanoe. and
thus to nutritional deteot.
3. Irritant nervous lesions are more apt to CBllSe trophio
lesions than others. Suoh are neuritiS. partial. as distinguished
from oomplete, section of a outaneous nerve. Inflammation of a
root ganglion (resulting in herpes zoster).
4. Disturbed Vaso-motor action. by modifying tho olrou1a.tion
locally. may give rise to struotural ohanges. Thus protracted
hypermmia gives rise to hypertrophy; protraoted ischlmllia to
overgrowth of the oonnectlve tissues, or if pronounoed to-necrosis.
as IDay happen in Raynaud's disease.
6. Nutrition may be modill.ed locally as the rosult of psyohlc
Influence. It 1s a.n Incontestable fact that concentration of the
attention upon-a. portion of the skin may cause II. blister t'o form
The following among the more common eXlloIllples of
trophlc loslons:
Glossy skin; sclerodormia; overgrowth of bair; alopecia;
bianohlng ot hair; redema; ulceration; herpes zoster; thinning,
splitting, thiokening, striation, lamination of nails; thickening
and nodulation of aponeuroses (e.g., palmar fasoia) and synovial
Rarefaction and overgrowth of bone, polypoid ovorgrowth of
synovial mombranes, degeneration of cartilage.
The aClIto bedsore (whioh may dovolop a fow hours after the
onset of myelitis). homl hemiatrophy.
Cerebra-Spinal Fluid.
Composition o! Cerebro-Spinal Fluid.-This fluid surrounds
the brain, spinal cord, and origin of nerves in unbroken oontinuity. Total quantity, about 3 ounces (60 : 80 0.0.; hence
abstraction of more than 10: 15 o.e. is held to be dangerons,
unless, as in oerebro-spinal meningitis, the amount be increased).
It is secreted by the ependyma covering the two ohoroid plexuses
of the lateral ventrloles. Thenoe it runs through the foramina
of Munro into the third ventriole, then into the fourth ventricle
by way of the aqueduot of Sylvius, and eventually Into the subamolmoid spaoe through the foramen of Magendie and the foramina of Lusehka. The subarachnoid space is thus oontinuons
with the 'lateral ventrioles, and, aoeordingly, any increase of
pressure inside the lateral ventricles will be registered in the spinal
subarachnoid space, unless thero be olosure of the aforesaid foramina.. (Acoordlng to some authorities, the oerebro-splnal lluid
IB also sooreted by the endothelial lining ot tho subaraohnold
&paee.) In hoalth the lIuid is of orystal olearness, with a
speoiflo gravity of 1006 to 1008, and sllghtly alkaline in reaotion.
It oontains a faint traoe of sero-globulin and of albumose, in
quantity equal to about
per cent. (with variations from
.~, to .~~ per cent.).
There is also 0. trace of a copper-reduoing
substance which yields gluoosBZone crystals and a few endothelial cella, with an occa.sionallymphocyte. It is therefore of
very low immune value. Its ohlef salt is sodium ohloride;
thel'o al'e tl'aces of carbonateA and phosphates. The normal
pressure of the lluid in the recumbent position supports a
oolumn of water 2 inches high (or about 15 mlllimetres of Kg);
in disease the pressure may ten times. When withdrawn with the trochar and oannula, the :flow should not be in
a steady stream, but • drop by drop,' generally at the rat!! of
one drop per seoond. Anything approa.ohing a oontlnuous
stream indicates all abnorma.l pressure.
Morbid Conditions of the Fluid-P1'e8suu-Doos the lluld
come away from the end of the cannula drop by drop, or does
it eaeape quickly' In hydrocephalus, all forms1lf aoute meningitis, seme tumours (if large), obronio meningitis, the :fluid may
run away in jets. or even pshos.
15 2
Oolour.-Is the 1luid clear. bloody. opalcscent. or purul~nt ,
Blood.-It towards the start of the 1low. it may be due to
aocidental rupture of a vessel. It. howevcr. it Is intimatoIy
mixed with thc cerebro-splnal 1luid. then it IDBY be due to
injuries to the skull or spinal column causing rupture of a vessal
into the subarachnoid spaco. or to Into thc ventricles. or hromorrhago from tumours. ctc.
Opalescence.-This IDBY be due to the presenoo of cells or
bacteria. and a microscoplo examination must bo made to
determine their nature.
Pus.-If the 1luld Is distinctly purulent. tho causo Is a purulont moningitis, or a ruptured abscess.
In rare eases of extreme jaundico the fiuid may be bllestained. In urmmia. urea. ammonia, and other nitrogeneus,
products may be found. In diabetes mollitus, an appreciable
amount of sugar IDBY be detected.
Oyt0si8.-After staining. noto the following:
Presenoe of red blood-colls, and thoir number.
Is there a preponderanoe of polymorphonuelears or of mononuclears' Are bactoria prosont ,
Polymorphonuclear oytosls is usually present in acuto meningitis (pneumoeoocal. mon,1ngocoooaI. staphylococcal. streptococcal. etc.). and in aeute anterIor poliomyelitis; while lymphooytosis (small mononuclear) is usually a marked feature of
tubercular meningitis. cerebro-spinal syphilis, general paralysIs
of the insane, tabes dorsalis, trnIanosomillsis. and Is sometimes
f011I!d in herpes zoster.
Bacteria.-It bacteria are found. their morphologloal oharaoters should be noted-i.e.• whether ooeol or baoillI. diploooool.
staphylooooei, streptococci, long bacilli or short baoilli. etc.
In sleeping sickness. trypanosomes are found In the later stages.
Prote:ins.-As before stated. in nOrIOBl cerebro-spinal1luld the
amount of protein present is Infinitesimal; in disosse it may
rise very high. In most acute a1fections of the nervous system
-e.g., acute myolltls, acutc anterior poliomyelitis-thore is a
oomparatively large amount of albumin present. assoclatod with
a lcuooeytosis (polymorphonuclear- and lympho-cytosis).
whoreas in syphilitic a:ffections of the nervous system tho
ineroase in albumin is usually accompanied by a lympho-oytosis
alone. In tabes dorsslis and general paralysis of the insane.
choline, a produot of ncrve dogoneration, may be detected.
A positive Wasserm8lUl's reaction of the fluid is invaluable
In diagnOSing syphilitio a:ffeetions of the nervous system.
It is found In about 97 per cent. of <lBBOS of goneral paralysiS
of the insane. and in about 70 per coot. of cases of tabes dorsalis.
(The reason that the vercentago Is not higher in tabes is that
this disease may become stationary. whereas in general paralysis
of the insane the disease is always a.etive.)
Surgical A'Ultom1l.-The oord in early fretal Ufe extends the
entire length of tho spinal oanal At birth it tormiI14to6 at tlLo
level of the .third lumbar vertebrm; in the adult, opposite the
lower border of the first lumbar vertobrro, more raroly opposite
the border of the sooond lumbar vertebrlll.
The depth of the spinal subaraohnoid space from the surface
varies in ohildren and adults. In children it Is about 1 inch;
in adults 2 to 21 inchos, or even 3 inches in some cases.
Lumbar puncturo is done botwoon the third and fourth lumbar
vertebrm (or botwoon the fourth and fifth) for the following
l'OOosons: The spot is well below the termination of tho spinal
cord; any pathologioal elements tond to gravitate in this region;
tho dura mator is horo more firmly attached to tho laminm than
it is higher up, and thorefore the needlo more easily pieroos it.
Operation.-'I.'ho procedure is quite harmless. The instruments roquired are a stout oxplorlng needle about 4, inohos in
longth, provided with a platino-iridium point, and e. stilette,
several sterillzod test-tub08.
The patient is either pla.ced on hls loft side, close to the odge
of the bed, with his back :flexed as much as possible by drawing
up the knees towards tho chin, or, it his condition permits It,
in the sitting poeture, with the head dopressed botween tIm
knees. Flexion at the spino slightly elevates the cord, widens
the space betwoon the neural archeR, and makos taut tho ligament~ and membranes to be pierced by the noedle•
.A generalanmsthetic Is advisable in both adults and children.
The operator having sterlllzed bls hands. and tho skin over
tho area. having been painted with. tincture of Iodine (so as to
bottle up the organisms burled in the opidcrmiR), selects a point
in tho spaoe between the fourth and fifth lumbar vertebrre.
Tbls is easily found by taking the highest points of the iliae
orests: a line joining these orosses tho fourth lumbar spino.
The third or fourth lumbar spine having been do:ll.nod, the
thumb of the loft hand should be placed on the one or the other,
aocording to whioh space it is propesed to enter, and used as a
The needle, having been sterilized, is held firmly and entered
i ot an ineh to the lett of the middle line, and i of an ineh below
tho selected spine, boing pushed, but not stabbed, in a direction
towards the umbilious, upwards, inwards, and torwards. Altel'
tho needle has been inserted 2 to 2i inches in an adult (and 1 inch
in ohildren), it will bo felt to go suddenly through a resistant
layor, and if tho stilette be now withdrawn, oerebro-spinal fluid
should drip from the oann1llo.. If the point strikes against bone,
it should be withdrawn for e. short distance, and again pushed
forwards in a slightly e.lterod direction.
If, after several attempts, the operator falls to gain tho
interior of the canal, it is advisable to withdraw the needle
altogether, and to insert it, either between the second and third.
or the third and fourth lumbar vertebrro. Somc prefer entering
the necdle in the middle line, as here there is no risk of hitting
the bonc. It no fluid oomes away whcn the needle is apparently
within the subarachnoid space, It may mean that Its bore is
blooked; the stilette should then be pushed gently along it, and
any obstruction thus removcd. In some cases failure to obtain
fluid may arisc from the fact that the needle has not pieroed the
meninges, but has pushed them in tront of it. Assuming this
to be so, it is a good plan to perforate the membranes by means
of the stilette, thus allowing the needle to entcr along the tract
opencd up.
The fluid withdra.wn should be received into sterilized testtubes. A fow drops of blood derived trom the accidental puneture of II> vessel may come away with the first drops of fluid; If Sll,.
it should bc oolleotod in a separato test-tUbe, as for mioroscopical
cxamination It is desirable that the fluid should be tree from
Aftor withdrawing the fluid and the needle, the wound should
be closed with a dab of oollodion and ootton-wool. The patient
Is then to rest for some hours.
The normal kidney is about' inches long, 21lnohes brood,
11 inches thick, and its weight is about 41 ounces. The corle:1;
oonstitutes a little less than a third of its substance.
As regards structure, the main point tu understa.nd is that
there are not two kidneys, but thousands of kidney&-in the
sense that eaoh individual tubule is in reality a separate kidney.
This Is important in view of the foot that disease may desvGT
many tubules and yet leave others unharmed.' Another- Item
of interest is the faot that there is no Intertubular oonnoctlve
tissue, tho tubules lying in oontaot with eaoh other.
The kidneys are essentially tllters, their principal function
being the oxoretion from the blood of the nitrogenous w&s~­
products of the tissues--urea, uric aoid, eto. Thoyalso eliminato sulphates, olilorides, phosphates, and other salts; these,
however, do not represent tissue metabolism, but are simply the
sruts contained in tho food swoJlowed. The urea, urio acId, etc.,
are not manufaotured in the kidney trom raw material, but preexist as such in the blood, and are removed trom it by the renal
epithelium (chiefly of the oonvoluted tubules) by a vital prooOBP
of excretion. The salts and water are passed through the glomeruli by a biophysical prooess of tlItration.
Uroto:J:ins.-The kidneys are also concerned' in the elimination, both in heruth and disease, of a largo munber of di1l'crent
toxins. Thus, according to Bouohard, normal urine contains
(a) a diuretio, (b) a narcotic, (c) a salivant, (d) a pupll-oontracting,
(6) a heat-reduolng, if) an organio convulsant, and (g) an inorganlo ocnvulsa.nt. AnythiDg whioh interferes with the proper
action of the kidneys may oause the retention of ono or more 01
these substances. The toxins ot tho various infeotious diseases
are largely excrotod in tho urine. It is, moreover, suggested tha~
a groot number of other diseases-e.g., epilepsy, aoute maniasare toldc in naturo; it this view is oorrect, we may suspect that
their specific toxins may be presont in tho urine. and itis probable
that one day suitable tests will be devised for their detection there.
The existence of an internaZ BeC7"etiIm has not been satisfaotorily
proved. nor has that of secretory nerves, but the kidneyS are
abundantly supplied with 'IlaBO-motO'l" nenes.
I, Interlobular artery; 2, Malpighian body; 3, convolutod
The term 'nephritis' is used in the generic sense to
include in:fl.a.mmations of both kidneys, whether acute or
It is probable that all forms are caused by the action of
poisons (distinot for each variety) oonveyed by the bloodstream to the kidneys. Quickly-aoting poisons oause acute
nephritis; slOWly-acting poisons chronic nephritis.
These poisons may be derived from baoteria, be absorbed
from the oro-a.limentary tube, or they may be produot
of a. vicious meta.bolism of the tiBBues.
15 6
Inasmuch as acute nephritis is a frequent sequel of
scarlatina, and sometimes of other fevers, it would indicate that in other cases of acute nephritis a bacterial toxin
is the probable cause.
As the tubular epithelium is more especially involved,
we must assume that these poisons are particularly
irritating to it. Possibly the great exoretory oapacity
of the kidneys may lead to an &ooumulation of suoh poisons
in the renal substance.
In both acute and chronio nephritis the most conspicuous morbid changes are to be seen in the cortex
of the kidney, especially in those parts of it where physiological aotivity is greatest-that is, in the glomeruli and
C01woluted tubules.
The wdema which is assooiated with many forms of
nephritis is due to the circulation through the tissues of
an aldema-produoing toxin. (Renal aldema is more
marked in the early morning; cardiao aldem.a in the
Various subdivisions of nephritis have been made by
different authors, which has rendered the subject very
complicated, but it is doubtful if the disease ha.s not been
over-classified. Au lond, inflammation of the kidneys is
the same in principle as inflammation of other p&fIIs of tba
body, the dlfferenoes in the phenomena arising from the
peculiar struoture of the kidney substance which is
composed essentially of a closely-packed mass of epithelial
oells. Reduced to simple principles, &oute nephritis is
characterized by hyperremia, exudation, and swelling up,
with subsequent detachment of the epithelial cells; and
chronic nephritis by fatty degeneration of the epithelial
cells and the forma.tion of new connective tissue.
Acute Nephritis (Acute Parenchymatous, Desquamative).
-The kidneys are swollen, their capsule!! stretohed,
sometimes bursting. The swelling is the outcome of:
(a) Congestion, (b) exudation, (c) swelling of the tubular
The exudation is partly intertubular, but ohiefly intratubula.r (this being the path oflcast resistance). ~he intratubular exudate, by coagulating, forms a cylindrioal
mould, or ' cast,' of the interior. If the cast oonsists solely
of the coagulated colourless exudate it is known as a
hyaline ca8t; if detached epithelial cells adhere to its
outside, it is termed an epithelial Ca8t; if the adherent
epithelial cells have undergone fatty or granular degeneration, it is called aJatty or grantda'l' cast.
The damaged tubules a.llow the esoope into the urine of
the serum-albumin and serum-globulin of the blood (but
never :fibrinogen). The casts and shed epithelium tend to
block some of the tubules, and this largely explains the
scanty urine of acute nephritis.
There are two classical forms of acute nephritis, each
varying with the nature of the partioular toxin that
causes it.
(a) Glomerular Neph'l'uia.-The stress of the inflammation falls more espooially on the glomeruli, the vessels
becoming much distended and often rupturing (so allowing
blood to pass into the urine). The cells inside Bowman's
capsule proliferate, in some cases to such a degree as almost
to fill up its interior, and by compressing the glomerular
tuft cause it to atrophy.
(b) Tubular Nephriti8.-Here the stress of the inflammation falls more espeoially on the epithelium of the oonvoluted tubules, the cells lining which swell up, proliferate,
and beoome detaohed. The tubules are sometimes choked
with these detached cells. The swelling of the epithelium
often oauses the tubules to present a v~ricose appearance.
By dislodgment of the epithelium, portions of the tubules
may become ohoked with the cells.
When recovery scts in, the inHammatory produots are
in part expelled into the urine and in part absorbed.
Some of the tubules are rendered kor8 de combat and
atrophy, whilst others, hitherto imperfeotly developed,
attain full physiologica.l maturity, and functionally com.
pensate for those irreparably damaged.
!rhe Large White Kidney.-lf, however, recovery does
not ensue and the disease becomes chronio, we have the
condition known as 'large white kidney,' which is also
known as chronio parenrilt/llmaJoU8 nephritia (as it is a
further stage of acute parenchymatous nephritis).
The organ is now enlarged (the two kidneys together
may weigh 28 ounces, as against 9 ounces in health). The
surface has a pale appearance and the capsule readily
section, the cortex is seen to be enlarged.
strips off.
and bosides a general paleness there is an opaque
mottling. The convoluted tubules are much dilated
and filled with detached vacuolated epithelial calls in a
state of fatty and granular degeneration; fatty and
grnnular casts occupy the straight tubules, and proliferated
epithelium is seen within Bowman's caspule. Smo.ll embryonal cells (which may later develop into fibrous tissue)
make their appearance between the tubules. Albuminuria
is profuse, but cardio - vascular changes are not a pronounced feature.
The patient is water-logged, and generally dies within
two years, either from urmmia or some visccral inflammation (pericarditis, pneumonia, pleurisy). If, however, he
continues to live, the embryonal cells lying between the
tubules organize into connective tissue, and the disease
now passes into the stage ofThe Pale Granular Kidney (Secondary Chronic Interstitial Nephritis)_ In a typical case of this disease the
organ is pale, fibrous, shrunken, and granular on the
surface. The cortex may be of normal thickness, or
much reduaed in size, according tQ the time the disease
has lasted. The fibrous tissue is chiefly intertubular,
many of the tubules and glomerular tufts are atrophied,
whilst other tubules are blocked with detached epithel~al
It is very rare, the writer having seen but three cases,
all of whom died from acute urremia within a few months
of the development of' albuminuric retinitis.' (Ede:rna is
generally absent, and so the disease is often overlooked
until the onset of urremia, or failure of vision. (Sir Rose
Bradford contends that the pale granular kidney is a
chronic disease from the beginning, and not a development
from a preceding stage. If this is so, it is .manifestly due
to the action of a chronic renal poison quite distinct from
that causing the next form of Granular kidney.)
Red Granular Contracted Kidney (Primary Chronic
Interstitial Nephritis).-Red granular contracted kidney
is not a sequel to acute nephritis, but is ab initio a chronic
disease, due to the long·continued action of a. specific
renal poison, generated either within the alimentary canal
or from some faulty metabolism of the tissues. The poison
in question appears to operate coincidentalty both on the
kidneys and the cardio-vascular system. The kidneys
are small, sometimes remarkably so, Hilton Fagge quoting
0. case in which the two together weighed under 1t onnces.
The colour is usually 0. dark red. The capsules are
thickened and adherent, and, when removed, portions of
kidney tissue are pulled off with it, the exposed surface
showing small granulations, varying in size from
1- inch. On seotion, the cortex is seen to be shrunken, often
being reduced to 0. mere shell of but I to t inch in thickness. Cysts, both macroscopic and microscopic, are often
fo_und in the shrunken cortex; they arise by obstruction of
the tubules.
The pathological changes are essentially:
A fibr08is, with tubular and glomerular degeneration.
Concerning these changes two explanations are offered:
(a) That the renal poison causes a primary fibrosis, the
tubular degeneration being due to the pressure-effect of
the newly-formed tissue; (b) that the renal poison causes
a primary tubular degeneration, and the cpithelium, in
process of disintegration liberates So poison which, diffusing
through the kidney substance, provokes a seoondary
The fibrosis is markedly different from the normal connective tissue, being tough and coarse, and is specially
charaoterized by its tendency to oontract. It has tile
following distribution:
(i.) Periarterial.
(ii.) Periglomerular.
(iii.) Peritubular.
(i.) The periarterial fibrosis occurs especially in conneotion with the interlobular arteries. The strands of
fibrous tissue aronnd these vessels contract, and this
explains the depressions between the granUlations on the
surface of the organ. The arteries are sometimes so
greatly compressed by the shrinking connectivo tissue as to
become almost obliterated.
(ii.) The capsule of Bowman is greatly thiokened by
the formation of ooncentrio layers, and in advanced oases
the entire glomerulus is oonverted into a laminated fibrous
(iii.) Instead of the tubules being in direct oontact, as
in the normal kidney, they are separated by bands of
fibrous tissue.
Many of the t.ubules are a.trophied; others sllow an
enlarged lumen, the epithelium of whioh is either doto.ohed
or degenerated.
The oysts seen in tho oortex are caused by the distension
of tubules, the ohannels of whioh have been oonstrioted
by fibroid contraotion.
Tho diseaso is of froquont occurrenco aftcr tho o.go of forty,
and very insidious in its courso, sometlmos not boing dlagnosod
until noor its fatal tormination, whioh is usually from cerebral
i&mmorrhag6 or from cardiac Ia:UW6 (dllo.ted loft ventrioio).
The patient may go first to the ooulist booause of faJluro of his
eyesight (albuminuric retinitis). Many oases of cardlo.o tnllure
arc ofton regarded as oo.se9 of primary heart disease, and not due
t.o reno.l disease, iuasmuch o.s during lifo the ma.1n symptoms
cardlao. Urmmio oonvulslons arc rare. (Of 126 oases oollected
by llilton Faggo, only 15 ended iu oonvulsions.)
Correlative Pathological Changes in Chronio
Whcn onoo nephritis ho.s boooomo chronic, there occur, with
rare oxceptions, cardio·1JQ8ctdar changea, whioh are most markod
in tho 'Intorstitial' forms. Tho loft vontriolo of tho heart
becomos hypertrophlod, tho smallor arterics are thiokened by
inoroaso In their musoular and flbrous tlssuo, and atheroma is
ofton presont in tho larger o.rtorios, and in those a.t tho base of
the brain.
Theso ohanges are most oharaotoristlcally soon In tho two
kinds of granular kidney. 'l'heir pathology has exoitod muoh
controversy, and no two authorities appear to o.groo OD the
subJoct. It is, perhaps, somowhat as follows:
In tho oarly stage of granular kidney a substanoo having a
vaso·oonstrictor aotion olrculates in the blood. What this
Bubsto.noo Is, or whether it is the OUll whioh is responsible for
the progJ"OSsive renal disorganization \vhioh oha.racterizes this
diseaso, it is impossible to say; but it is probably not the result
of defeotlve ronal excretion, Booing that its oJloots are observecl
long before tho kidneys arc seriously disorganizod.
The substanoe in question Co.usos 0. widespread constriction
(hyportonus) ot tho systemio arterioles, the intraronal arterioles
roDUlining relaxed. Now, those are the vaso·motor oonditions
most favourablo for diurosls--i.e., an Inoreased pressure in tho
systemio artorios, IIoIId 0. diminution in tho resistanoe otrered by
the Intro.ronal arterioles, tho oonjoint efCeot being to oauso a
great augmentation in the pressure, and a oorrespondlng In'
oreased rato of blood·fiow. within the renal capillo.rles. In
short, the vaso-oonstriotor substanoo, whioh Is ever present,
brings about lust those vaso-motor oonditions whioh aro most
favourablo to its elimination.
(It Is 0. mistake to IIoBsume, as many writers do, thll.t mere
inorell.8o In the systemlo blood -pressure neoossarlly inoroll.Bes the
urinary tiow_ A genera.lized arteriolar oonstriotion, including
tho renalaroo., would oause a diminished flow In spite ot tho
augmented blood-pressure. Hence, to explain the polyuria of
granular kidney we must assume that a generalized arteriolar
eOWltriotion oausing the high blood·pressure is acoompanied by
a dilatation of the intraronal arterioles.)
The constriction involves the arterioles essentially. It Is hero
that tho augmented vascular resistance of ronal disease resldos;
the view that it is situated In tho oaplUo.ries is untenable.
Both under physiological and pathologioal conditions' periph·
eral rMistance • resides ossentlally In the region of the arterioles.
Tho writer has shown that the oontribution of the capillaries to
peripheral resistance Is pra.otlcally negligible. The hypertonus
tends, however, to Involve the entire systemio arterial tree, the
pro·arteriolar oonstriction--i.e., of the arteries proximal to the
artorioles--being probably of a compensatory no.ture, tending
as It does to protect the arteries fl'om the distending effeot of
the heightened blood·pressure. One ef the most important
functions of tho mnsoulo.r eloments of bloodvessels is by their
active oonstrlctlon to provent tl)e vessel walls from undergoing 0. progressive dilatation and elongation. Thus. tho
radial artorios In granular kidnoy often feel small, • tlghtenod
up,' and incompressible. Those may. however, be largo and Incompressible, and In suoh oases the hypertonus, in the upper
oxtremities at least, Is llmited to the arterioles.
Th!s oondltlon ot arterial hypertonus loads to hyportrophy
of tho media of tho hypertonic arteries, and to 'hypertrophy ot
the left ventrlole, whioh. owing to the augmented peripheral
resistance, has inoreascd lvork put upon ft. On tho othor hand,
the media of tho hypotonio intraronal art.eries tends to atrophy
(W. Russell).
In the hyportonio arteries tho intima IDld adventitia stand in
sharp contrast as regards the induenoes they are subjected
to, for wbile a hyportonio melUa protects the onvoloplng
advontltia from tho augmented blood-pressure, tho intima
recoives the full brunt of that pressure. as does also the endocardium of tho left ventriele. This state of things eontlnulng
hour by hour, by day and by night, year aftor yoar, it is not
SUl-prising that both those struotures should undergo some
responsive change; b1'lolly, they tend to thicken. whUe the largo
arteries and the loft Vllntriole, espeolally II. the region of th('l
valves, booomes atheromatous.
A further effect ot tho augmented blood-pressure is that the
lett vontrlcle and entire systemic arterial tree tend to dilato, the
extent to which they do so depending upon the bebavipur of
their musoular eioments.
So long as t.he musouIar tissue of the heart remains sound, it
is oapablo of otfeotual systole; but when it dogonerates, as in
procoss of timo it does, the degeneratod musele tlbres being
replaood by fibrous tissue, the left ventricle falls to empty itsclf
adequately during systole, an oxcess of residual blood romaina
after systole, and thus by dei:roos it comes about that the left
ventriele, overdistended during its stretchable llhase of diastolic
relaxation by this load of residual bloed plus toot flewing in
from the lungs, boccmes unduly stretched, and yields--i.e.,
dilateB-sueh dIlo.tatien being 0. oemmen oause of death after
In like manner, the extent to \vhieh the IIrteries become
stretched, giving rise te tertueslty and dilatation, depends upon
the cendltion of the muscular media. Let us suppose hypertonus to be maintained fairly generally throughout tile arterial
tree; It is probable that In such a case little or no perftJ.u.nent
yielding wID occur until the muscular elements have been to a
large extent replaood, as in advanced oases they tond to be, by
a hyaline fibrOid material. In thoso arteries, however, which
do not become hypertonic, carly yielding is likely to occur.
Thus, In the cases in which the radiu.larterios aro tightly eontraoted, those vossels may long remain quito straight and undila.ted.-even, Indood. throughout the entire ClOurse of the disease; but In those oasos in which the radials tend towards 0.
state of hypotenus, they early become dilated and tortuous.
It is probable also that the oceurrence or absoneo of a dIlo.tcd
aorta In granular kidney largnly· depends upon the dogroo ot
tonieity of the vossel.
The adventitla tends to romaln unalreotod in granular kidney
so lOng as it IS proteeted--i.e., so long as the blood-pressuro is
borne of! from it by a hypertonie media. If the media does not·
beoome hypertenio, or if, In preeoss ef time, a hypertonlo media
degeneratos, the adventitia yiolds before the augmonted bloodpressure, and undergoes compensatorythiekenlng.
Among the other rosults of the heightened blood-pressure in
granular Iddney are the formation of miliary aneurisms In tho
oorebroJ arteries, • granular kidney' being the cause par excellence of cerebra.l apoplexy. The <edema of granular kidney
is genorally a torminaJ ovent, and Is then usuaJly • cardiac ' .i.e., duo to dilatation of the left ventriele.
In any form of ohronic nephritis, but especially in
granular kidney, there is 0. marked tendency to hmmor,hags. AB Hale White puts it: 'A per80n with nephritiB
may bleed from anywhere-e.g., from the brain, retina,
lobe of the ear, nose, lungs, alimentary and urinary tratlts.'
Patients with' granular kidney' generally have emphysematous lungs.
Pleurisy, pericarditis, and pneumonia are common
complications of Bright's disease, whether acute or
Albuminuric retinitis is met with in about 28 per oent.
(Gowers) of all cases of Bright's disease; it is muoh com·
moner in the ohronic forms of ranal diseasc. The prog·
nosis is very unfavourable, most of the pa.tients dying
within a few months of the first appearanoe of retinal
changes. The condition suggasts some virulent form of
Scarlatinal Nephritis.
In this torm ot Bright's dlsoaso the genoral phenOlnono. are
the sarno as those described unde\' acute glomcrular nephritis,
but thore somo special pOints to be mentioned ill oonnectlon
with it. Tho scarlatinal polson has a special atHnity for tho
lIalpighian bodies and tho small artorlcs connccted thero\vlth.
The intima ot theBO arterioles undergoos hyaline degencratlon
Bowman's oa.psule is swollon, the cells ot its epitbolia.llillillg
proliferate, In some cases to suoh a. degree as almost to till up Its
Intorlor, and, by compressing the glomerular tuft, to causo its
Should the diseaso become chronie, by ono to throe years' time,
tho wholo Me.lpighlan body may be seen to be oomposed of
concentrlo lamlDm of fibrous tissue, with complete obliteration
of tho glomorular vesscls. The branches of the renal artery
become thickened from abronie endarteritis and periarteritis.
War (Trench) Nephritis.
An acute disease which takes the form of blocking of the
glomerular capillaries with changes in tho epithelium of the
convoluted tubules, In association with this there Is often
desquamation of the eplthslium of the terminal bronchioles IUld
the connooted alveoli, a tact which explains tho important
BYIDptem-dYBPnrea. Hugh l!oIac'\ean adduces evidence suggestIng the oonveyance of an infcotion by moans ·of body·vermin,
probably lioe.
Tuberculosis of Kidney.
This is usuBlly B diseBse of 2arly adult life, and in the
largo majority of cases is primary-due, i.6" to infection
throllgh the blood-stream. It is unilateral in 92 per cent.
of cases (KrOnlein). Sometimes it is associated with
tuberculosis of the epididymis. the vas deferens, the
vesiculro seminales, and the trigone of the bladder.
It may begin in any part of the organ, but more com-
monly starts near the apices of the papilllll (this accounts
for the hiematuria, which is often the firat sign), sprcading
thence into the kidney substance, on the one hand, and
into the calices, pelvis, and ureter, on the other. Caseatiop
and ulceration take place, and the curdy pus and necrotic
debris thus resulting are expelled with the urine. If at
this stage the interior of the bladder be viewed with the
cystoscope, the opening of the ureter is seen to be everted
and to ' pout,' and the urine trickling from it to be turbid.
If the thickened and contracted ureter becomes blocked
by the caseous material, pyonephro8is results, and this in
tum may be complicated by the formation of a perinephritic absces8 in the loin. In many cases the urine
contains, in addition to the tubercle bacillus, the Bacillus
coli, the staphylococcus, and the streptOi!occus.
At the post-mortem examination of an advanced case
the following changes are found: The kidney is greatly.
enlarged; the perinephritio fat, thickened by chronic infiammation, is adherent to the capsule; the cortex is
represented by a toughened shell; the medulla and papilllll
have disappeared; the pelvis is dilated; its walls are
thiokened, and its interior may present a characteristic
'mouse-nibbled' appearance. 'lhe dilated cavity is filled
with a curdy pus, which in some cases is transformed
into a putty-like mass. The ureter is adherent to the
neigbbourjng parts; its walls are infiltrated with tubercles,
and its lumen is contracted.
Proteinuria without Nephritis.
The chief prctein present In the urine of nephritis Is serum
albumin; globulin-cf which there are two kinds: (a) ouglobulin
o.nd (b) pseudoglobulin-also occurs, but the amount is relatlvoly low.
The term • proteinuria without nephrit,is' Includes all thosc
conditions described as functional albuminuria, physiological
albuminuria, Intermittont o.lbuminuria, transient albuminuria,
orthostatic, cyclic, adolesccnt, etc., in nono of which are there any
signs of organiC kidnoy disease. In all these casos thero Is poth
albumin and euglobulin present in tho urine (in tho ra£io of
about 2: 1). In that form of functional protoinuria, howevor,
known as • leaky' kidney, the condition is essontially that of
olobinuria (the globulin being euglobulin, with whioh is
assooiatod lipolds and fatty acids), the ratio of albumin to glo·
bulln being 1: 2 to 6. The turbid urine somotimos found in
• leaky , lddney is due to the presenoe of lecithin-globulin,
TraDBitoQ' Nephritis.
In the albuminuria of pneumonia, enterlca, diphthoria., and
other febrile disorders, a toxin must In Homo way damago the
tubules, allowfng the escape of the albuminous oonstituonts or
the ·blood. When this happeWl, the condition Is known as
transitory nephritis.
The ingestion of turpentine, oantharides, mer01ll"Y, and other
poisons, may e.lso cause albumlnmla. Cantharides in somo
oases Induces a marked glomerular nephritis, in many resp60ts
rosembling soa.rlatlnal nephritis.
In aeute alcoholism temporary albuminmia Is common.
Syphilis of the Kidney.
In secondartllll/Philis there may be albuminuria (often in tho
form of looithin-globulin), due, probably, to an injury Infliotod
on the renal epithelium by tho sp60iflc toxin.
In tertiary B1/Philill thero may be elthor a diffuse gummatous
infiltration ot the kidneys, or the development in them of definite
gummata (as in the of tho liver). Tho urine in thoso
syphilitic oases may oontain abundant albumin. yet dropsy amI
the other symptoms of Bright's disease may be absent.
Congenital Oystic Disease.
This is a oonditlon met wfth In new-born children, In whieh
the kidneys are greatly enlarged and eonverted Into a of
oysts, suggQstlng In appearance a bunoh of grapes. Tho cysts,
separated by the remains of the ronal tissUll, are lined with
epithelium, and oontaln an albuminous fluid. The propor kidney
substanoe Is atrophiod. The dlsoase has boon attributod to
somo anomaly in developmont, or to an Inflammation of tho
pa.pl11l1), oauslng occlusion of the duots. It often oooxists with
other oongenltal defeats, Bueh as hydrocopha.lus. defeotive
urinary bladder, oto.
A similar oondition Is sometimos, but very rarely. mot wfth
in adults. In this form also the kidneys are greatly enlarged.
and may weigh from 1 to 6 pounds.
Hydronephrosis is tho oonilition in whioh tho kidnoy is oonvertod, partially or ontlrely, into a oyst, as the result of some
obstrnotlon to the urinary outflow. A sudden and absolute
bloek never causes it; the obstruction must be Blowly applied. 'l'ho
pelviS IUld the oa.lloos undergo dilatation; the medulla beoome~
atrophied, the proeess of atrophy starting at the papillm and
spreading outwards; and ultimately tho kidney is transformed
Into a ~ero oyst. whioh may be either small or of o!lnslderablo
size. The ureter is dilated, and In extreme Cll.B<lB mo.y resemble
a portion of the small intestine.
The condition may be congenital or acquired, and, according
as the obstruction affects ona or both Sides, unilateral or bilateral.
Tho oongenital causos arc dovalopmontalabnormalitios of the
ureter and imperforate urethra; the causes in lator lite are such
conditions as the presence of a oalculuB In the ureter, cicatricial
contraction of the ureter, prossure on tho ureter by a growth
(e.g., carcinoma of the uterus), enlarged prostate, and strieture
of the urethra.
Tumours 01 the Kidneys.
Theso are very rare. They alO adenomata, rhabdomyomata.
sarcomata, and composite tumours. '!'hOBO la.ttor contain fat,
unstriated muscle, myxomatous tissue, and epithelium; they
may attain an enormous size and metatasize. Hypernephro.
mata, composed of a tissuo similar to that of tho oortox of tho
suprarenalB, may be found embodded in the cortex ot tho kidnoy
(thoy are also found In the suprarenoJs,llvor, panereas, spermatlo
oord, epididymis, eto.). The larger ones are vary malignant-.
Avarage weight In adult= 50 to 60 ouneos, being ono'fortieth
of tho body·weight. At birth=one·twontieth ot bodY'welght.
Tho liver is doveloped as a diverticulum of tho primitive gut.
Tho liver colIs are therefore hypoblastic, and the stromata moso.
blastio in origin. The orga,n is composed of lobules, each 01
which is about r. inch in dls.meter. Botween the lobules is a eo1mOOl:.ive t.issue ca.rrying the, b100U.vwsels, and blle-duots. Within thG lobules 1\1:'0 th~ liver colIs,
closely packed. in form polyhedral from mutUal Pl'OSBure. and
separa.ted from one another by a sparso and very delioato tiBBue,
oontinuous with the interlobular connective tiosue. The portal
vein drains the blood from the capillaries of the wholo of the
alimentary mucous membrane between the lower end of tho
cesophagus and tho lower end of the rectum. It terminates in
the capillaries of the liver lobules, where a junotion is effooted
with the eapillarios of the hepatic a:.;tery.
The blood is carried from the liver lobules by the
hepatic system oj 'IIeim, and thence to the right heart.
The portal circulation is pecuIiarin that it begins anq ends
in capillaries, and is destitute of valves. All the substances
absorbed from the gastro-intestinal tube (with the excep.
tion of most of the fat), pass into the portal system, aud
therefore have to be subjected to the influence of the
liver before they can enter the general circulation.
Tho livlll' ill the groo.t biochomioa.lla.boratory of the body. It
normallyreduces IIlIIJlY nitrogenous wa.ste produots to substanoea
ur08, uric a.cid) which the kidneys oxcrote; it destroYB
ptomaines and other poisonQus bodies, is strongly Phagooytio,
and. ia the greoI. deto3:inaJIBr or blood-purifier. lnterteronoe with
those tunotioIUI l~ds to Buto·lD,toxioa.t1on a.nd impa.irment of
tho general health.
Inl:t1'ttobut ..r
The portal vein ia soon to diVide and subdlvldo, and to br~k up
into tho interlobular veins which run betwoon the hepatic
lobulos. From the interlobular veins capillarIes (portall to tho Intra.lobular veins. Theac gatlaered up into
the sublobuJa.r which enter the hepatio veins (of which there
'lm1~~,""II'lMIu ~ ~ 'My, 'i1la. ~'ml __"'ft>. 'iUb
intralebular brnnchos of the hepatio a.rtoriea form capilla.ries, whloh unite with the pOrtal oa.plUaries.
Ja'ltndics is a condition in which the bile enters the
geneml ciooula1iion, and stains the fluids and tissues of tho
body yellow. It may be due to: (a) Bome ob8t1"lldicm td
the O'Utjlow oj bile i"to tke duodenum, in consequenoe of
which it is fh'St absorbed by th& lymphatics of the liver,
and thence passes into the blood·stream through the
iympha.tic duct. The obstruction may arise from (i.)
caUBeS acting within the lumen of the ducts (gall.stones);
(ii.) causes primarily involving the duct waJls (ca.tarrh of
the muoous lining); (iii.) pre9SUre from without (tumours,
espeoially malignant disea8e of the liveror panorelloli). and
hepatio oirrhosis.
(b) Some affection of the secreting cells of the liver, as in
hypertrophic biliary cirrhosis, alcoholic cirrhosis, the
various forms of toxic jaundice (delayed chloroform
poisoning, phosphorus, etc.).
Toxic Jaundice produced by the Action oj Chemical
DUring thE' war cases of toxic jaundice were brought to light
amongst munition workers and those engaged in work involving
the use of dangerous poisons, absorption taking place through the
skin. Amongst the most important poisons are: tetrachloride
of ethane, trinitrotoluene, dinitrobenzene, dinitrophenol, and
picric acid. Post·mortem examination showed that an invariable condition is intense degeneration of the liver-colis with
great deposit of fat in them, similar changes being also found in
the kidneys and heart.
Fatty Degeneration.
For pathological purposes the liver lobule may be divided
into three zones. Fatty degeneration begins in the outer zono,
amyloid disease in the intermediate zone, and' nutmeg' liver in
the central zone.
The organ is enlarged, light brown, and in advanced
cases even yellow in colour; on section it presents a
greasy appearance. In the slighter cases the fat globules
are limited to the cells of the peripheral zone; in fullydeveloped cases the fatty degeneration affects all the cells
of the lobule. The liver may become markedly fatty
in phthisis; chronic alcoholism; phosphol'1ll.s, arsenic, or
chloroform poisoning; in pernicious anremia, and all other
forms of severe anremia. Fatty livers may be caused, like
the foie gras of Strasburg geese, by over-feeding, underexercising, and a heated atmosphere. Cloudy swelling
is liable to pass into fatty degeneration; hence fatty degeneration of the liver may be found in diphtheria and all
other acute infections.
Lardaceous or Waxy Liver.
The organ is much enlarged-even to three times its
normal size-and though its general contour is preserved,
the edges become thick and rounded, and the whole mass
is 110 compact toot it outs like raw baron. The out surfaoe
has a waxy appearano&-henoe the name. The neighbouring livel' oella are often atrophied, and fatty degeneration is oommon. A wlllLk solution of iodine renders the
amyloid material mahog~y- brown, while gentian v.iolet
stains it a deep rose-pink and the normal tissues blue.
The ohange begins in the intermediate zone.
The disease is always associated with lardaceous de·
generation of the spleen and kidneys.
Chronio Venous Congestion (' Nutmeg Liver ').
This condition is caused by obBtruction to the free flow
of the blood from the hepatic veins, as the result either of
heart disease or of primary obstruction in the pulmonary
circuit-e.g., emphysema of the lungs. or fibroid phthisis.
(The most pronounced forms are found in mitral stenosis.)
A fact to boar in: mind in connection with this disease
is that no va;lves intervene between the central intralobular hepatio veins and the right heart. Thus, when
compensation fails-6.g., mitral regurgitation-the ' backwash' from the left heart will produce its effects first on the
lungs, then on the right heart, and then very readily on
the ValTelOSS hepatio veins.
Oour8e of Ihe DiBease.-The central intralobular vein
becomes much distended and thickened, and the capillaries
opening into it become dilated and tortuous. The liver
cells atrophy from the centre of the lobule outwards. The
centrol zone of the lobule becomes pigmented (the pigment being derived either from the blood or the bile),
while at the periphery of "the lobule the cells tend to
undergo fatty degeneration, so that on section there is seen
a dark innor zone alternating with a pale peripheral one.
Hence the liver presents a marbled, or 'nutmeg,' appearance.
Soon or later some fibrosis occurs, first in the contre
and then at the periphery of the lobules.
In advanoed cases the cells of the inner zone are completely destroyed.
In the early stages the liver is enlarged as the result
of the mechanical congestion; later on it becomes smaller
from atrophy of the liver cells, and the capsule undergoes
thickening, and may present a wrinkled appearance.
On section much blood ma.y gush ou1l; on washing the
surface the characteristio 'nutmeg' appeara.nce is displayed.
Abscess of the Liver.
Ab8IJes8 oj eke Liver is always due to infection by microorganisms. The two principal types are the PYOJmio and
the Tropical.
Pymmic Absce&se&.-In ordinary pymmia. abscesses
rarely occur in the liver. the more usual Bites being the
lungs and the joints. When pyremic abscesses do involve
the liver. they are small and multiple, and contain a
putrid yellow pus.
In 81J,ppurative pylephlelJitiB (' portal pyOJmia ') the infection comes from some part drained by the portal system
of veins, generally from an ulcerated portion of the alimentary tube; abscesses ma.y also follow operations for
hremolThoids. They are small and numerous, and lie
in the course of the distribution of the portal vein, the
bra.nches of which are seen to be filled with puriform
Tropical Abscess.-This disease is due to infection by
the Entamwba hiBtolytioa, conveyed by the portal circiJlation, and in lihe majority of cases is secondary to a
dysentery owning the same cause. "Alcohol is probably
the most important' soil preparer.' The pus is of a. slimy,
gummy consistenoe, of chocolate colour, and composed of
necrosed and liquefied liver cells, with an admixture of
blood, ordinary pus cells being either few or absent. II
i8 8terile, no cultures of bacteria being obtainable by the
ordinary methods. As pointed out by Manson, the
entammbm are numerous in the spreading margin of the
abscess, and though absent in the pus when first drawn off,
they make thoir appearance in the discharge about three
days later-that is. when the walls of the abscess begin
to granulate and to contract.
The abscess is generally situated deep in the right lobe,
and may contain several pints of fluid. After a time the
pUB tends to make its way to the surface of the liver,
oausing adhesiorus to neighbouring structures; and if the
condition is untreated, the pUB ultimately escapes into
the pleura. lung. peritoneum. or externally through tho
abdominal walls, and in rarer cases into the stomach,
gall-bladder, hepatic duct, portal vein, inferior vena. oava,
pelvis of right kidney, perioardium, or other parts.
Oocasionally the abscess becomes surrounded by a thick
fibrous ca.psule_
In rare instances absoesses in the liver are caused by a
auppuratt'1l{l hydatid, and by the 8treptothriz aonnomycea.
Subphrenic Abacess.
Owing to the cruoitorm arrangoment of the laloitorm, ooronary.
and Iateralllgaments ot the liver, there are six possible situo.tlons whloh a subphrenio absooss may ooonpy-four intraperitoneal and two extraperitoneal (between the layers of the
coronary ligament). The following table (takon from Barnard's
• Contribntions to Abdominal Surgery ') gives the position in
seventy-two cases:
Gastrto Ap'l'OD- Hepatio denal
mcer. diCltis. Abscess.
Intraperitoneal, right anterior
Intraperitoneal, fe1ht posterior
Intraperitoneal, 1 t anterior
Intraperitoneal, left ~sterior
Extraperitoneal, ~h
Extraperitoneal, Ie t
--- - - - - --4
Cirrhosis of the Li'ter.
Of this disease there are three classical forms. The
oause in each would appeo.r to be some irritant, probably
toxic in nature, _present in the liver, and brought thereBy the porta}, blood (alcoholio cirrhosis);
By the bile-dulJt8 (hypertrophio cirrhosis); or
By th..e general circulation (syphilitic cirrhosis).
Alcoholic Cirrhosis (' Hobnail Liver,' 'Gin-Drinker's
Liver,' Chronic Interstitial Hepatitis, Atrophic CirrhosiB).--The esaontia! pathological change in this disease is an
inorease in the oOIUleotive tissue around the inteTlobulot
bro/TWMs 0/ tke portal vein. An irritant, oirculating in
the portal blood, first starts a periphlebitis " there then
ocours a small round-celled infiltration, which ultimately
beoomes organized into fibrous tissue. This tissuc tends
to surround groups of several lobulcs rather than to envelop each individual lobule. In course of time the new
tissue contracts and strangles the branches of the portal
vein within the liver, and as a consequence there results
great distension of the portal radioles in the gastro-intestina.! tract and mesentery; hence ensue hrema.temesis,
melama, ascites, and enlarged spleen.
(Aooording to some pathologists, the irritant primarily
acts upon the liver cells, these cells, in process of disintegration, liberating a diffusible poison which excites the
growth of the connective tissue.)
The irritant which provokes the cirrhosis consists either
of the alcohol itself, impurities in the alcohol, or of certain
toxins liberated in the alimentary canal as the result of
chronic gastro-intestinal cata.rrh-a. condition so common
in drunkards.
The oirrhotio liver varies considerably in size, aocording to the stage the disease has reached. The organ is
always enlarged at first. sometimes to more than twice its
normal size; on the other hand, it may ultimately be
reduced to less than half its normal size, but in most CBses
this stage of contraction never arrives, the patient dying
oither from pneumonia. pulmonary tuberculosis. fatty
degeneration of the heart, Illsophageal hmmorrhage. pertal
thrombosis, or from some infeotion-pneumonoccal,
• As seen in tbe post-mortem room, the typioal oirrhotic
liver presents the following appearances: Its surface is
irregular, boing marked by elevations whioh suggest the
hobnails of a boot (' hobnailed • liver), and often by large
round bosses as well. The capsule is usually thiokened,
and adherent to the surrounding peritoneum. On sco·
tion the organ shows bands of fibrous tissue• ..which form
a network throughout the liver substance. dividing it into
, islands' of various sizes, each of which contains
groups of lobules: hence the name of 'polylobular' oirrhosis applied by Charcot. The fibrous bands from the
interior can be traced to the peritoneal Burface, where
they are seen to pass to the depressions between the
'hobnails.' The' hobnails,' in fact. are portions of liver
substance which have been thrust outwards by the oontraction of these fibrous bands.
The new tissue consists of round cells, delioate spindle
cells (fibroblasts), and wavy bundle!! of fibrous tissue, the
rcl.ative proportions of which vary with the duration of
the process.
In the fibrous bands are numbers of new-formed bloodvessels, which anastomose with the branches of the hepatic
artery. In some cases double rows of cubillal cells are
seen, suggesting a new- formation of bile-ducts, but the
significance of these is still doubtful. The liver cells
undergo atrophy, and in beer-drinkers fatty degeneration
of the peripheral zone of the lobule is common. Wheft
the atrophy of the cells is advanced, toxic symptoms
supervene not unlike those which occur in acute yellow
The oollateral vessels between the portal and systemio veins
beoome dila.ted, and thus relieve tho oongostlon of the porta.l
area. This oompensa.tory ana.stomosls is carried out principally
between the following sets of veins: The (Bsopha.goal and gastric;
the epigastric and internal mammary; the inferior mesenterio
and hmmorrhoidal branohes of the Internal ilIao; the portal
branohes In the round Iigl10ment of the liver, and the epigastrlo
and internal mammary at the umbilious (oaput MeduslB);
branohes of the portal vein in the mosentery, with the inferior
vena. cava &nd its branohes (veins of Retzius).
Bypertrophio or Biliary Cirrhosis (BanDt's Disease).In this very rare disease the liver is greatly enlarged,
firm, and smooth. The newly-formed. connective tissue
is more delicate than in the other kinds of cirrhosis. and
surrounds each individual lobule.. hence the name of
, unilobular' cirrhosis applied to it by Charcot.
In tho new tissue are numerous so-called 'bile-ducts'
-remarkable for the absence of any regular lumen. .As
there is no obstruction to the portal circulation, hrematemesis, melama, and ascites, are not present, unless there
is an associated portal cirrhosis. Jaundice, on the other
hand, is a oonstant feature.
The cause is unknown. The theory has been advanced
thai it is due to a microbic infection of the bile-ducts
aacendingfrom the duodenum, cauaingretention witWn the
liver of bile, wWch, in conjunction with the infecting
agent, irritates the interlobular tissue.
Obstruotive BililL1'J Cirrhom.-In certain CIlB08 of biliary
obstruction, Buoh as thoso duo to impacted calculus, cancer of
the lIvor or pancreas, lUI interlobular oirrhosis is mot witll,
B'ISOeiated with dilated ·blle-ducts, and the tormat.lon ot what
look like bllo-oapillaries, but whioh probably oODsist simply ot
double oolumns ot altered liver cells. There is marked jaundice.
Syphilitic Cirrhosis-Oongenital SyphiliB.-In infants
dying three or four months after birth it is not uncommon
t) find an interlobular cirrhosis uniformly affecting the
whole liver. In ma.ny cases the new tissue penetrates
into the lobules, and so bllCOmes peritJellular. The liver
cells are degenerated. Gummata may also be present.
Acquired Syphilis.-In this disease tho liver may become infiltrated with 0. diffuse gummatous matorial, which
by organizing causes it to be seamed with fibrous bands.
Definite gummata may also occur. but these are always
connected with a preceding syphilitic cirrhosis. The
gummata form pale yellow. well-defined. rounded masses,
generally springing from the surface, which is often adherent to the neighbouring structures, such as the dillphragm. They are surrounded by a fibrous eapsulu_
When fresh they may be soft and pulpy; later they ml'y
become hard, like cartilage.
Sometimes a gumma undergoes absorption, and in such
a case the surface of the liver shows a characteristic
The Drunkard's Liver.
This subject has given rise to much confusion, soma
authoritics maintaining that the liver is enlarged. and
othets that it is contracted. As ordinarily seen in thc
out-patients' department of a London hospital, it is
certainly milarged. and oftcn very much so. This ep.largement is proba.bly the resultant of three distinct
pathological conditions:
(a) Blood and lymph engorgement ;
(b) Fatty infiltration and jatty degeneration:
(0) A small embryonGl-oelled infiltration.
The drunkard usually dies from some complication (as
previously explained, p. 172) before (c) can organize into
connective tissue and contract.
Tuberculosis of the Liver.
Tubercles form bcth beneath the capsule and in the
interior of the liver. By ooalescence they may attain tile
size of a hazel-nut (rare). Sometimes they develop along
the walls of the hepatio ducts, Md, by compressing them,
oause jaundice (very rare).
Tumours 01 the Liver.
Oavernoua Angioma is the commonest of the non·
malignant tumours of the liver. It may rangl3 in size from
a pea to an orMge.
Aden01TUlla are very rare. They occur in the form Qf
nodules, composed of acini lined with cubical epithelium.
Primary Sarcomata are also very rare. Secondary sa.rcomata, particularly the melanotio variety, are not uncommon.
Halo Whito reoords that not a singlo MBO of primary sarooma
of tho liver was Jnot with at Guy's Hospital during the twonty
years. 1870-89. both Inclusive. Byrom Bramwell and Leith were
only able to collect twenty-five published oasos. and they came
to the ooncluslon that. few of those were genuine examples.
Primary Oarcinoma is rare, constituting only about
per cent. of hepatic cancers.
Secondary Oarcinoma is common; indeed, it is the only
hepatic tumour which is at all common. ' Of all persons
in whom at death malignant disease of My organ is
found. about 60 per cent. have secondary deposits in the
liver' (Hale White). The primary growth may be situated in any part of the body (and is often overlooked
clinically), but its usual seats are the alimentary tract,
the head of the pancreas. the gall-bladder, the uterus,
or elsewhere. AB the cancer-cells are sown in every part
of the liver, these secondary tumours are usually multiple;
the superficial ones occur in the form of bosses, or large
nodules, and often present an umbilicated appearance from
the breaking down of their central parts. Owing to the
great vascularity of the liver, they grow quickly, the dura4,
tion of life being seldom more tha.n eight months after the
diagnosis is first established. The liver is sometimes so
enormously enlarged as to weigh as much as 10 or 12
pounds (tho heaviest livers on record are cancerous).
Hmmorrhago into the interior of the tumours often takes
place. Jaundice is present in about half the cases.
Acute Yellow Atrophy.
This is a very rare disease (not more than 300 cases on
record). It is probably toxic in nature, due to the action
of a hepato-lysin--i.e., a substance capable of dissolving
the livereells (see p. 46). This causes so rapid an atrophy
of the liver that in the course of a. few days the organ
may be reduced to half its original bulk. The malady
is commonest in women, usually occurring in conneotion
with pregno.ncy.
As seen after death, the liver is much shrunken. No
longer preserving its norma.l shape, it flattens out when
placed upon the table, lying loose in its wrinkled capsule
(like a half-filled ba.g). On section the surface presents
a bright yellow colour-hence the name-the outlines of
the lobules are indistinct, and the liver cells are for the
most part broken down and replaced by a granular debris,
though here and there olumps of oomparatively healthy
cells are to be seen.
The disease bears a olose resemblance to phosphoruspoisoning. As Vivian Poore pointed out, it is found in
young pregnant prostitutes who have oommitted suicide
by phospliorus-poisoning. and a.ceording to him ms.ny
alleged cases of acute yellow atrophy have been in reality
cases of phosphorus-poisoning.
Acute yellow atrophy has been observed to succeed
Enlargements of the Liver.
Reoultu'=nutlJ16g liver, tatty inftltration, lardaceous disease,
biliary cirrhosis, Polylobular oirrhosis (early stage), louklllD1ia,
lymphadenoma, diffuse OBIloeroUB inftltration, portal pymmla.
lweoular= malignant growths (secondary), hydatid, abscess,
Inflammation of the gall-bladder is tenned cholecY8titis, and of the bile-duots. cholangiti8. The oause is
a miorobio infeotion. whioh probably travels up from the
duodenum, the oommonest organism being the BaciUu8
coli. next to whioh appears to be the B. typh08U8. If
oholeoystitis be suppurative, the condition is known as
empyema of the gall-bladder; in suoh oases there is gener.
ally impaotion of the oystio duot by a gall-stone.
FIG. U.-l and II. Right and left hepatlo ducts; 3. the hepatlo
duot; '. the oystio duct; 6. tIle common bile-duct; 8. the
duot ot the pan_B; 7. the ampulla and papilla ot Vater.
In old-standing oases of oholeoystitis the gall-bladder is
usually muoh thiokened and oontraoted, being drawn up
and buried under the liver, and adherent to the surrounding
Oarcinoma of the galZ-bladder, when found. is almost
invariably assooiated with gall-stones.
Gall-Stones (Cholelithiasis).
In a typioal speoimen a gall-stone is found to be oomposed of three zones: (a) A small oentral nucleus, dark in
colour, oontaining epithelial cells, muous, bile-pigments.
and dead microbes, the presence of whioh is, strong evi·
dence in favour of the hypothesis of infection; (h) a middlo
zone, composing 90 per cent. of the entire sUbstance of
the stone, and formed of cholesterin; (c) a peripheral
zone, very thin, and formed of lime salts, but insufficient
in amount to throw a. definite sha.dow with the X rays.
In most cases the stones are formed in tho gall-bladder
(even when found in the hepatic ducts); in rare instances,
however, they may form primarily in the ducts. Gallstones vary in size from small grains of Band to masses as
large as a walnut. They are often multiple, and as many
as 7,802 (Otto) have been found in the go.ll-bla.dder. 1£
multiple, they often present smooth, flat facets froUl
mutual friction. When dry, the calculi float in water;
otherwise they sink. They are most common in women
over forty_
The first stage in the production of gall-stonos is a
microbial infection which sets up a catarrh of the mucous
membrane. As the result of this catarrh, the epithelium
becomes shed, and this, in conjunction with the infecting
microbes, forms a nucleus round which thedlard matter
is deposited. 'Gall-stones are tombstones ereeted to the
memory of dead bacilli lying within them.'
They are three or four times as common in women
as in men, and their incidence reaches its maximum
between the ages of thirty and forty-five.
COIII,plicatioM :
Obstruotlve Jaundloe.
Empyema of tho gall-bladder.
Ulceration into duodonum (Intestinal obstruction).
Ulceration into hopatlo tlexuro of oolon.
carolnoma of gall-bladder.
Stenosis of the oommon' duot.
Olrrhotio changes in liver and pancreas.
Subphrenlo absoess.
Acute Pancreaiitis.-As the panoreatio duot (In oonjunction
with the oommon blle-duot) opons into the duodenum (Vide
FJg. 14)-whioh Is ofton tho soat of bactorial aotivity.-it is
probablo that this disease Is genorally due to an Infootion dorived
from this source. ThOBe not so oocasioned must be due to blood
Intootlon. Gall-stones. by fretting tho epithelial llning of tho
terminal part of the duot. strongly prodlspose to it. There aro
three ohlef forms. oaoh of Wllioh probably OVillS 0. dlll'orent
infecting agent:
Acute Bannorrhagio Panoreatitis.-In thiS disease the greater
portion. It not the whole, of the gla.nd bocomos InOltra.ted with
blood, and its oells undorgo QCorosis. Them may also bo tilt
nocrtllJis in the panorea.s, ementmn, and olscwhoro.
Suppurative PanereaWis.-This Is oharactarizod by the
prosonee at either a single abscoss or or sm"ll multiple onos.
Gangrenous PanareatitiB.-This may elrClet a part or tllo
wholo of thCl gland. the tissue being oonvertod Into a dark s1l1OOcoloured mass.
In Chronic Pancreatitis thore is IIIl ovorgro,vth of tho tl brous
tissue ot the e-rge,n, with a.trophy ot t.he glo.ndula.f elements. In
extreme casos the oondltion is known as cirrhosis oj the pancreaB.
The usual caUBO is III partial obstruction to tho outflow ot tho
panorootio juice, arisiDgtrom thO lodgment of a gall-stono In tho
torminal part of tho OOIDIDOll bUe-duot.
TumoUl'S of the Panoreas.
Pancreatic Cysts may be of soveral kinds: &Jtention. cysts,
whioh may be as big WI a ohild's lUlO.d, rosult-from obstruction
to the outtlow ot tho pancreatiC sooretion--e.o., from Impaotecl
jlRlculus or prossure, from wl.thout. as trom chronic paneroo.tltis;
cysts in connection w~ (lI"OW~.o., adenoma. carcinoma:
hOJ11l()1'rhall'i4; q/st8 ; hydatltl cysts.
Adenomata may oeour, but they arc extremely rarc.
Carcinoma is by:tar tho most important tumour of the pan-
creas, and occurs usua.lly as a dense growth at fibrous appoo.rance
(soirrhus). Its most oommon slto Is the hoad, rarely in tho body
or tail. Bomo 01 t.ho CIlBOS start In tho neighbouring glands,
and involve the panoreaB sooondarlly. (Of 2,005 OOB08 of oaroinoma oxaminoo post mortem by Biaoh ot Vionna. tho pancreas
was the seat at the di_so In 29.)
Pancreatic CalouU are somotimos met with. Thoy consist
prinCipally of oalcium oorbonate, and they mllY (lanSIl obstruotion in any part at tho main panoreatlc duet. Thoy are usually
Normal urino contruns a BUliIoll quantity at de:elrose, tho total
amount excretod par twenty-tour hours bolng about 1 grammD.
(Exoess or sugar In tho blood= hyperolycannia. Excess of
sugar in the urino= OlYOO8Uria.)
The blood in health contains on Wl a.veroge 0·10 per
cent. of sugar (0·16 pez: cent. is to be regarded as the maximum normal blood-sugn.r level; anything over that amount
cOllBtitutes hyperglycro.mia), and
to this amount the renal
apparatus is impermeablo. In health, the formation Wld
consumption of sugar in the body are ovenly balanced,
for a.e it is.metabolized by the tissues it is concurrently
raplenished from the glycogen stored in the liver; in this
way there is Ill3intained a state of stable sugar equilibrium.
Diabetes mellitus is that morbid condition of the system
in which the blood and the urine habitually contain sugar
in excess (hyperglycremia. and glycosuria), whioh excess
is not the consequence of any excess in thc consumption
of sugar-forming foods. rhe essential fa.cts of the disease that the carbohydrates of the food are not stored up in
the liver and muscles as glycogen. but circulate in the blood
as sugar, and that the tissues are unable to utilize this
sugar placed at their disposal. It thercfore aecumulates
in the blood. whence it is exereted by the kidneys. (U
the sugar in the blood exceeds 0·15 per oent., the patient
should be regarded as a potential, or actual, diabetic.)
The tissues then, in spite of an abundance of sugar lying
at their door, are sugar-starved.
How is this to be explained f According to Minkowski.
diabetes is due to the absence of the hormone of the Pan"crcas. This hormone is the co-ferment which aotivates
the ferment proper that metabolizes sugar in the tissues.
This failure of activation results in the accumulation of
sugar in the blood. and its consequent appearance in the
urine. Forsbach has shown that if two dogs united
by skin. muscle. and peritoneum. and the pancreas of one
is removed, the glycosuria that would otlierwise occUl'is
checked; on separating them, however, sugar appears in
the urine of the depancreatized dog. Carlson and Drennen,
who experimented with pregnant dogs, found tha.t when
the panereas is removed from an animal towa.rds the end
of gestation, glycosuria does Dot occur. The subsequent
extraction of the faltus is, however, followed by diabetes.
suggesting that the hormone of the faltal pancreas can
replace that of the mother.
Ryporglycmmla without glyoosuria Is oommon in obesity.
Joslin found decided obesity to Pl'IlOedod tho ol18et of
diabetes in over 40 per oent. ot his cases.
ExPerimentally glyoosuria CIUl be induoed in animals by any
of tho folloWing mothods:
Puncturing the Floor oJ lhe Fourlh Yentricle.-DiBbotes thus
"induoed is thought to 1fo duo to w.mage of 0. centro in tho
JnedullB which oontrols the gJ.yeogenio o.ctlon ot the liver oel1!.
IUld resUlts fll q. ~oo rapid oonVlll'llion of glycc1Ben fllto dextrose.
• Thora aro oxperimonts recorded wlliob show that tbo livor
nerves hn.vo a dIreot inftuonoo on the liver colls, quito apart from
thoir Infiuonco on the bloodvessoIs' (Halliburton): in othor
words. that tho liver Is provided with' trophio • nerves;
Re1IIOI!i1\jl U\e Pancreas.-Remava.l at too entire paneroa.a in
alli.ul61a causes severe and total gIyoosuria: if. hO"-OVDr. even R
very small portion of the gland is loft behind. glyoosuria does
not ensue.
_ Administerlnu PAlotitbi'l&.-By tho administration of this
glucoside a very severo form of diabetes is Induoed. characterized by the prescmoo of abundant sugar in the urine. though
tho blood oontalns DO more than the normal quantity; it is
gl1/cosuria 'W'itlwut glycrmniq. the sugQr being formed in tho
kidnoy by somo Bubsta.n('o brought to it by tho blood.
• If tho phloridZin is directly injected into one ronal artory.
sugar rapidly appears In the socretion or that kidnoy. and, lawr.
ill that of tho other kidney' (Halliburton).
Admi1loiBterina AMeoolin.-In the diabetes thus induoed thore
ia both gl1lCfEmia and UI1lCOS'Uria. 'J'h'llf'Oid Emacl.-Glyoosnria Is oo08sionally
noticed after tho administration of thyroid extraot. IGlyoosuria also sometimes oecurs in oxophthalmic goitre.)
HlIPoglUcannic Glucosuria.-This Is a condition in whlcb. with
a subnormal quantity of sugar in the blood, there is exoess in
tho urine. It is apparently due to an eXOOBslve pnrmeability of
tho kidneys as rega.rds sugar.
Paekological.-As regards the pathology of diabetes.
the only fact definitely known is that in tIo proportion of oases (about 75 per cent.) the panoreas, post mortem, is found to be diseu.eed. In these the che.nges
consist of an increase of ehe connectille-tiasu6 8troma, aecom·
panied by atrophy of ehe parenchyma.
It is quite impossiblo to make anY dogma.tic statement a.s to
whother a disturba.noe of the funotlons of the • islands ot LalJgorhans' is to bo roga.rded as a taotor in tho prQduction of glyoo·
suria. MallY observers oonsider these • Islanlis' .to be merely
exhausted groups of ordinary secreting aoini.
The liver is devoid of glyoogen, or contains but a.
Exoept the heart. glycogen is absent from all the musoles.
Glycosuria is uncommon in carcinoma. of the pancreas,
the reason being that the growth mrely destroys the entiro
In the earlier stages of diabetes the urine contains an
excess of urea and uric acid; in the later stages, when
the system is breaking down, there is a progressive diminution of thc urea a.nd uric acid.
Diabetic Coma.-The occurrence of this symptom is
probably due to the presence in the blood of the fatty acid.
{:J.o:tybutyric acid.
This aold Is a normal product of fat DlotaboUsD1; It Is n()t.
however. found In hoolthy urine. It is probably exidizod into
dJo.ootio aeld. whloh. by losing C<>z, beoomos aoetone «AHaOa00.,= OJlftlO). Of the~ various bodiO$. acetone alono is fOlln<l
In healthy urine. (Tho term acetonuria Is only applied whon tho
amount of acetono Is ~s8ive.) In diabetio coma tho oxidation
of ,g·oxybutyrio acid seams to tail, and it thcreforo aocumulo.~os
In tho system (Wte Aoldosls).
In diabetes, wOlmds heal badly; inflammations nre
generally very BOvero. often going on to suppumtion and
gangrene; phthisis pulmonalis often oloses the sceno; and
double cato.mct is not uncommon.
Diabetic Gangr8ll.8.-This takes place chielly in elderly
diabetics (about the age of sixty). and it is often the first
indication of the existence of diabetes. Its exciting cause
is commonly a slight injury, such 0.8 may result from
wearing tight boots. or pressure on a corn. Its most
frequent sito is the foot. The1'6 are two chief types:
Perforating ulcer.
Mummification.-The toes become cold and discoloured,
and in course of time mummified. They may now be cast
off, tho'parts healing ur' In other cases the gangrene
extends to thc dorsum 0 the foot.
Perforating Ulcer.-·Jn this form the disease usually
starts in the ball of the great toe, often around a com.
The corn suppurates and leaves & painless ulcer, having
stoep edges. bordered by heaped-up and thickened epidermis. a condition very similar to that sometimes met with
in tabes dorsnlis. A dusky purple areolo. Boon surrounds
the ulcer, which in time becomes gangrenous; the gan·
grene slowly spreads along the foot, until it may even
extend as far as the calf of the leg. Whilst confined to
the foot it usually remains' dry,' but once it invades the
soft tissues of the calf it tends to become' moist,' and may
at any time lead to septio infection.
In aU 00888 o/diabetic gangrene tAe arteriea 8'/J.pplyillU
ths part ars di86a8e1i, the endothelium tieing greatly
thickened and the arterial channels reduced in size, or
even obliterated.
In oerta.ln disooses, such WI meningitIs, S'!IgM is found in the
urine. It may also be present in oaeos of Graves' disoase,
""hooplng-oough, and disease of the hypophysis. As 0. transient
phenomenon it may ooour In indigestion. but horo it is probably
dao to 0. sllgllt attack of pancreatitis.
'fho normal reaction of ~he blood is neutraL Though Its
reaotion te litmus paper is slightly alkalino, oiootrloa.l and othor
tests provo it to be praotloe.lly noutral.
By aoidosis is meant tho oondition in which thoro Is an
alteration in tho reaotivity of the blood owing to tho proeonoo
therein of abnormal quantities of II-oxybutyrio and diaaetio
ooids (wbloh fail to be oxidized Into aootone). Thero arc two of the roeulting symptoms: (a) Under ordinary
olrcumstanoes the alkalies of the blood oo.rry the COg from
the tissues to tho air in the lungs. Should, hOWBvor, tho
aforesaid aolds be present, they, by oomblning with tho alkalies,
prevent tho removal of tho COg. Aeoordingly, the COg stag·
nates in tho tissues, setting up tlssuo-asphyxla. (b) The respiratory contro in tho modulla, owing to tho reduced. alkalIno
reaotivity of its neurones. becomes hypersonsitivoto tho aotion
of C02 (whioh is their norma.l sthrtulus). If alkalies are admln'
istered. tho oondition is rolieved. Aoidosis is present In dlabotio
coma, In tho oyolical vomiting of ohildren, in the pnetuiLonias
of ohlldren, in the pernleious vomiting of pregnanoy, In doiayod
chloroform-poisoning. in poisoning by salicylio acid, phosphorus.
tetanus. ohronio nophritis. In starvation. and In oortaln casos
of oa.ncor.
The activities of tho body-oolls are largely oontrolled by
hormones. Those spooifto substanoos olaborated by partlcu·
lllr glands \'V'hlch have the funotIon of oxorcislng 0. controlling
influenoe on (a) metabolism; (b) tho aotion of ocrtain tlssuos
(~.U., uustripod musole·flbres); (c) tho devolopment of Important
structures; (Il) the sooretion ot other glands; (e) the psyche.
A good oxample of hormonlc action Is affordod by pregnanoy.
It a watery extraot of 0. rabhit tl»tus be Injooted Into a virgin
rahbit, rapid growth of its mammm takes plaoe. and mUk is
formed. To olimlnate the possible offect of norve Influenoo, the
mammary gland of u. rooontly pregnant guinea-pig was trans·
planted to the region of Its ear: hypertrophy of tho gland ensuod.
and milk was secrotcd. Thl) Inference Is that the fmtus in utero
oiaborates II somethi.'I&{} whloh. ofroulating in the mother's blood,
excites tllo growth and functional activity of hor mammary
glande. This somothing is oalled a hormone, • chemical m0880nger,' or endocrino.
.Again, if an animal bo castrated in early life, tho malo seeondary sexual characters' fall'to develop, owing to tho doprivatlon
of the testionlar hormone. For example, Jolm Hunter shewed
that thO antlers do not groW on stags eastrated when quite
young. Also It is woll known that, if a boy is castratod In OIIrly
lifo, he approximates, when grown up, to a type intermedlato
betwoon the two BQXOII. The hair on the face is eitller a.bsent or
scanty, thl.' voice remains hoy-liko (in past timl.'s castration was
practised in order to preserve tho voice of ohorIsters; tho choirmaster in Vienna. wanted Haydn to be gelded so that he would
retain his tine soprano voice). Thcre ill a tendoncY to tho
laying on of tat, the disposition booomes moro placid, and thoro
is a IMk of courage to meet danger. According to Hlgler, tho
interstitial SUbstance of the testicle is conccrned in tho SOOl"Stion
of a lilJidogenoiJ,s hormone, which Inspires tho instincts of solfpreservation and race propagation. Tho Influence of the ovarian
hormone is oqually proneunced. Removal of tho ovari~s In
early lifo prevents tho developmcnt of the female • secondary
soxllal characters'; tho individual, when grown up, approximaws
to a type intormodiato betwoon tbo two SOXOII, wblle tbo uterus
and IllAlIlIDAry glands do not dovelop. (It is thought that the
Interstitial cells [embcdded in the ovarY]lJroduce one hormone
and the corpora lutca anothor. The ovary also controls tht!
functions of the uterus.)
'The action ot hormonos on tho PB7/CM Is equally potent. Consider, for oxamplo, tho apathY of tbo myxcedematoUB patient,
tho Intense JlOl"VOUsneS8 and agitation of the sufferer from
Graves' disease (whiob Dlay change the most caIm,level-holldod,
self-diSCiplined, strong-willed woman into an exoitable, nervous
being, startled by tho loost noiso), tbe vIolent emotionalism
exhibited at tbo period of the rut, tho altered emotional tone at
tho menstrual periods and the epoch of the climacterio. In taot,
the action of tho thyroid hormono bas exeroised a vary potent infiuenc!) upon thc history of tho human raco.
• La genese ot l'oxercise dcs plus hautes tacult6s de l'homme
sont conditionn6s par I'Mtion lJuremo:iJ.t ohimiquo d'uu produit
de sooretion. Que lea psyebologuos m6dltont 00II faits'
(M. Gloy).
Normal growtb is largely controlled by hormones, Which are
poured out at definite perJods (infancy, childhood, and pubcrty),
and determine the developmontBI changes incidcntal to these
periods. It tbese particular hormonos are not duly seoreted,
development may be arrested at anyone of thorn, giving I.'i&c to
infantilism, arrestod puberty, and aJllcd condltions. On Lhe
other band. it thoy are formod In OXCOSB, or aro perverted, they
may lead to hypertrophy; both aoromegaly and gJgtmtJsm
Bra to be explainod in this way.
Hormcnes are known to bc elaborated by the following
organs: tho thyroid. tho parathyroids, tllo thymus (I). tho pituitary, the pineal gland (l), tho panoreas, the duodonum, tlto
suprarenals, the testos, and tlto ovaries.
Chemical Nature.-HormoDos aro orJranlo bodios, in composi·
tlon less complex titan protoins. They are dialyzable, readily
soluble In wator, insoluble in aloohol, and "are net destroyed by
boiling. Tho hormono derivod from tho modulla of tho supraronals (adronalin) has boen proparod synthotioally.
The Thyroid Gland.
Tho thyroid, which weighs about] ounoo, III a duotloss gland,
oomposed ot acini lined by a single layor or cubical opithollum,
and tlllod with the so-oalled 'colloid matorlal.' Tho stroma is
abundantly supplied both with bloodvossols and lymphatlos.
The gland is developod from the ventral wall of the mnbryonle
pharynx, and In fretal lile is a eompound tubular gland, It&vlll8
a duct-the thyro-glossal-whioh opens into tho foramen CUlCtlm
ot the tongue. The oooasional porsistenoo ot this duot oxplains
many ef tho oysts whioh dovelop In tho middlo lino of tho nook.
Tho gland attains its full development at puberty, and tends
to atrophy in old age.
From the ' colloid material ' of the acini Kendall has
isolated a pure crystalline substance which is to be regarded
as the active principle of the gland, having the formula
CuHIOOaNIa. It contains an organic nucleus (indol) and
oxygen. which he calls thyro-oxy-indol, shortened into
thyroxin. Plummer's observations show that the thyroxin
is a.most active factor in bodily metabolism, stirring up
the fires of life everywhere, the metabolic ratc being raised
or lowered by the activity or non-activity of the thyroid
(measured by the intake of and the output of CO2 in
respiration). The total amount of thyroxin in a normal
person is approximately 13 mg.. Each increase of 0·033 mg.
(approximate) of the thyroxin increases the rotc of energy
output 1 per cent. Accordingly, in hyperthyroidism
there is a.n increase in the metabolic ra.te, and in hypothyroidism a. decrease.
Julian IIuldey has found that by giving a propara.Mon of the
tbyroid (from any animal) to tadpoles lie could change them Into
frogs in thrao weeks or so, inst,cad of three months odd, whloh
is the natura.l period. On the other hand, they (lould be kept
as tadpoles till he gave them thyroid. wben they began to develoll
Into frogs. Also, by giving thyroid to tho axolotl he has macio
it develop Into a sort of frog or salamander, and to produoe
oertain joint obaractoristios never before seen.
Exophthalmio Goitre (Graves' Disease, Hyperthyroidism, etc.).
The most probable explanation of the symptoms of
exophthalmio goitre is that they result from an excessive
formation of the normal, or the formation of an abnormal,
secretion, which increases the katabolism of the tissues,
causing an increased output of carbonio acid and Ul1la,
together with losll of weight. Most of the characteristio
symptoms-the emaciation, the sweating. the pigmentation of the skin, the tachycardia, the nervous agitationare referable to this augmented kabbolism.
The commonest time for the disease to develop is be·
tween twenty and forty, and there is a vast preponderance
of women over men.
Cretinism is a physical and mental defect of develop.
ment associated with a oongenitally defective thyroid.
The gland may be either smaller or larger than normal,
but in all cases the acini are ill developed.
The symptoms are rarely noticed until the child has
reached the age of six months. The teeth erupt late,
walking and talking are long delayed, and by the time
adult life is reached the cretin may be mentally and
physically as undeveloped as a child of five.
The head in cretins is large and broad; the hair is scanty,
coarse, and lustreless; the nose flat; the eyes are widely
separatcd; the lips greatly thickened, as is also the tongue,
which usually protrudes from the mouth. The skin is
dry, coarse, and rough. The nails are brittle. The abdomen is pendulous, and there is often knock-knee. The
genital organs remain infantile.
Myxmdema (hypothyroidism) was first described by
Gull as 'a cretinoid state supervening in adult life in
women.' In it the thyroid is always diseased, the acini
being atrophied and the oonnective tissue hypertrophied.
The symptoms are due either to auto-intoxication, the
result of the accumulation in the blood of substances
normally destroyed by the thyroid, or to abl{ence of the
secretion. The latter view is the more probable.
The organism tends towa.rds lion anabolic rather thllon
a katabolic condition; the vital fire glimmers rather than
blazes (as in exophthalmic goitre), the output oI carbonia
acid and urea being diminished. H a. large amount of
sugar be ingested. no glycosuria results. She bccomes
much stouter, and her whole disposition changes.
The skin of the body becomes dry, hard, and rough,
and pads of fat forming the clavicular regions, over the
cervical area, lower ribs and flanks. The alre nasi, eyelids,
tonb'lle, and lips, become swollen, as also the fingers and
toes. These changes depend upon an inorease in the
connective and adipose tissues of the parts.
As Halliburton points out, the mucin is not necessarily
in excess in the tissues, for in only two out of ten cases
of myxoodema examined by him did he find an excess.
Hence the name by which the disease is genemlly known
is not well chosen.
Tho following Is Sir WillilU'\ Gull's description of his original
Miss D., after tho oessation of tho oatamonial porlod, bocamo
insensibly more Bnd marc languid with goneral inol"CBSO of
bulk. TWs ohango went on from yosr to yoar, hor face altering
from oval to round, much like the full moon at rising. With a
complexion soft and fair, the skin, presenting a pecullarly smooth
and fino texturo, was aimost PQreelalnouB in aspect, tho oheeks
tinted of a dolicate rose·purple, the collular tissuo under the
eyes being iooso aDd folded, aDd that UDder tho jaws and in tho
nook becoming heavy, thickoned, and folded. The lips largo
and of a rose·purple, aIm thick, oorneo. and pupil of tho oye
norma], but tho dlstanco' botWOOD tho oyes appearing dislJrOportionatell' wide, and the rest of the nose depressed, giving the
wholo faco a flattened broad charaoter. Tho hair llaxcn and
soft, tho whole oxPresslon of tho taco remarkably placid. The
tongue broad and thlok, voico guttural, and tho pronuncIation
as It the tongue were too largo tor tho mouth (oretinoid). The
hands peculIarly broad and thiok, spade-liko, as it the wholo
textures ,vcre inftltratod. The IntcgQJDonts ot tho ohest and
abdomen loaded with subcutaneous fat. Tho upper and lower
oxtremitlos also largo and fat, with slight traees of aldoma ov~r
tho tfbiw, but this Is not dlstlnot, and pitting doubtfully on
pressure. Urine normal. Heart's aotion and sounds normal.
Pulso 72: broathing 18.
Cachexia Strumipriva is the condition which results
from complete extirpation of the thyroid. The symptoms
closely resemble those of myxoodema, but run an acute
Parathyroids.-These were first described by Sandstroom
in 1880, and are four minute bodies, each being of tho
size of a pin's head, and embedded in the posterior
of the thyroid. They are developed from the epithelium
of the third ahd fourth bronchial clefts, and are composed
of 0. connective-tissue stroma in which are embedded
closely-packed polygonal cells. Their hormone exerts &
powerful influence on the nervous system. If removed,
tetany results, and from this it must be inferred that
occupation-tetany, tetany of children, tetany of maternity, stomach-tetany, tetany in infectious diseases, depend
upon insufficiency of the parathyroids.
Suprarenal Capsules, or Adrenals.
The adrenals belong to the cllromaJlln Bystem, a namo applied
to various cell-aggregates bocsuse with ohromium salts thoy
stain a yellowish-brown e010ur. (Other members of tho systom
are: Tho Intercsrotld body, the aortlo paraganglion of tho
f03tUS, the accessory adrenals, and some oells in the anterior lobo
of tho pituitary.)
Eaoh gland is composed of (a) corIe:l:, and (b) medulla.
(a) The eurte:e oonstitutes 90 per oent. of tho gland, and is derivod
from the mesodermal tissue ot tho embryo. It is thought to
seorete B hormone whioh influences the development of the
sexual glo.nds (the oortex and sexual glands originate trom
groups of oells in juxtapOSition). Aooording to some authorities,
tho oortex also acts as a dotoxinator, partieularly with regard
to tho wasto products of muscular activity. (b) The medulla
oonstitutes 10 per cont. of the glandJ and is derivod from tho
8ame blastema. as the 00311ac plexus of the sympathetlo. It is
stated that in man it Is Dot found untll Bome little time
birth. .&dl'efWlin is the actlvCl principle of the medulla, its
secretion being under the control of the splo.nchnio sympathetic.
(AccordIng to Takamine its constitution Is: Ortho-dioltY-phonyl·
ethanol-methylamine.) The action of adrenalln is to ra.lse tho
blood-pressure by Musing an intense contraction of the musculo.r
fibres of the peripheral artcrioles (by stimulation of the sy:tnpa.thetic nervo-endings). The kldnoy-artorlcles at the same timc
dllato-hence diuresis; also tho coronary a.rterioles
more blood is supplied to the heart musculature. (Tile pulmona.ry vessels are refractory to its influence.) It Is thus seen tha,t
the adrenals. like the pituitary. aTo of double origin a.nd repretent two distinot sots of organs (in certain fishes tho two pa.rts
are separate), having quite di1ferent functions.
Addison's Disease is characterized by great mUSQular
weakness, low blood-pressure, rapid, feeble pulse, a tendency to syncope, vomiting, and pigmentation of the skin,
which varies in intensity from & hue &s da.rk as tha.t of
the negro to a faint sunburn. while sometimes it is absent.
In the grea.t majority of cases, if not all, the change consists in a tubertJ'Ular tkstruction of the gland tissue, and
especially of the medulla.
New growtha sometimes oceur, but they are rare, a.nd
it is very doubtful if they are ever the cause of genuine
Addison's disease, inasmuch as they do not, like tubercle,
destroy the suprarcnals on both sides,
The pigmentation of Addison's disoose must not bo mistaken
for tho pigmentation ot pregnancy, of ohronlo tuberoulosls,
of arsenio, or silver, of vagabond's disease, of von Reoklinghausen's disease, of hBsmocllromatosis, of exophthalmic goitre,
of workers in oertain kinds of ohemical factories (especially
a.nthracene compounds), of mela.naBma in connection with
melanotic sarcoma.
AccesSOry AdrenalJ are not uncommon. They nre In the
form of solid lumps, near the main glands, or In the capsule of
tho kidney. They havo also been found in difforent parts of
the abdominal oavity (liver, broad ligaments, spermatio oord,
epididymis). Tumours may devolop from these accessory
alirellllols,luore ospecially \vhen they are situated In the kidney.
The Pituitary Body (HypoPhysis).
This BtruOturo is peeullar In being developed in part from tho
alimentary oanal, and in part from the brain. It oonsists of
throe parts: (a) Anterior, (b) intermediate, and (c) posterior.
(a) and (b) are derived from the pharynx (' Rathke's pouch ');
(c) Is a diverticulum. of the third ventriolo. (a) and (b) are
composed of a reticulum onclosiDg masses of epithelium-like
oells (some of whiclL belong to thecllromafDn system); (c) is com·
posed almost entirely of neuroglia with an entire absencc of
ncrve-elements. In the meshes of the fibres Ie a hyaline material.
Extracts from the anterior lobe are without effect. Extracts
from the posterior lobo and pars intermedia raise the blood·
pressure by vaso·constriction (after an initial fall) and slow
the heart's action; at the same time the rellllol arterioles dilate
(= diuresis). (The activo prinoiplo of tho pesterlor lobo may
be B·lmlnozolyl-ethyIamine. In the anterior lobo Robertson
considers tetholin the active principle.) Tho rapid growth
(especially of the skeleton) which takes place at puberty Is
largely due to the hormone secreted by tho anterior lobe. In
some obseure way the pituitary sooms oloeoly related to the
genital glands, for its destruotion causes amenorrh<ea and arrest
ot spermatogenesis. Defeotive aotion of the pituitary ooming
on before puberty causes stunting of the staturo, arrest of
development of the sexua.l glands. greo.t obesity, and high sugar
Diabetes inslpiduB appears, in most 'Clloses, to bo due to Borne
lesion of tho pltuitllory.
Acromegaly is a disease ohamcterized by hypertrophy
of certain bones, notably of the face, hands, and feet. In
the face, the lower jaw especially is affected, projecting in
advanced cases beyond the upper. The soft part of the
nose, the lobe of the ear, the lips and tongue, the hands
and feet, also become thickened, and the patient in many
respects reverts to the simian type.
In all cases which have been examined after death, the
pituitary body has been found hypertrophied, or the seat
of a tumour. Probably the disoose results from an excess
of, or some alteration in, the secretion of this, gland.
(GiantiBm is due to an enlargement of the pituitary body
in the growing years of youth, and acromegaly to an enlargement when the normal period of growth has ceased.)
The pituitary gland, in fact, appears to be one of the
most important factors in determining mcial ohamcters,
suoh as stature, oast of features, texture of skin, peculiarity
of hair, etc.
The acromega)ous man takes on many of tile features of the
anthropoid ape, tile former resembling the latter In the following
among other particulars: In the possession of cranial crests,
prominent supra-orbital ridgeS and maIars, and rnllosslve jllows; in
tho prominence of the oyes, wrinkling of the lids, furrowing of tho
forehead, breadth and fleshiness of the nose, and thickness of the
lips; in tho shortness and thickness of the neck; in the backward
convexity of tho cervico-dorsalsplne and consequent stoop; in
tho long sagittal diameter of tho thorax and the abdominal
character of the breathing; In the bowing of the legs and massivenoss of tho skeletal and muscular systems; in ihe existence of
pads, separated by deep furrows, on the palms and Boles, and In
tho longitudinal striation of the nails; in the coarseness and
looseness of the skin and tendency to pigmentation, and in the
coarseness and excessive growth of bair; In the depth of the
voice; In the aetlvity of the outaneous glands, and susoeptibility
to cold (H. (',ampboll).
Frohlich's Syndrome (Dystrophia Adiposo-geDitalis).-Thls is
an example of hypopitUitarism. Adiposity is marked (especially over pectoral regions and hips). Hair is absent from the
faco and scanty over the body. Sexual activity is subnormal.
If beginning before puberty, the stature is small. Napoleon I.
wa8 probably lJU:fI'ering (rom hypopituitarism during the latter
period of his ute.
The Thymus Gland.
This gland is devoloped 80S Do bilateral hypoblastio dlvortlcuhun mo.lnly from tho third visoeral arch, and when fully formed is
ehiefly composed of lymphoid tissue, the corpuscles of Hassal
ropresenting the original hypoblastio elements. Eosinophile
leuoocytos are fairly abundant along tho fibrous septa. (In Ulan
and rabbit it Is ontodermal in orfgin; in tho mole oetodermal; in
the guinea-pig and pig It has a dual origin.) 'rhe gland attains
Its full development at puberty, after whleh It undergoes a
gradual Involution. and after about the twenty-ftfth year is
represented by a mass of fatty cmmcctlve tissue spread out over
tho superior mediastinum and front of the pericardium. •
Of the functions of the thymus nothing definite is
known. According to some authorities, it is concerned
with the regulation of the lime-salts of the body. Hypertrophy of the gland is found in Graves' disease, Hodgkin's
disease, leukmmia, acromegaly, 'thymic asthma,' and
myasthenia gravis (90 por cent.). In none of these,
however, can the hypertrophy be regarded as essential,
because it is not always present.
Status Lymphaticus is the condition sometimes met
with in children and young adults, characterized by
delayed involution of the thymus, hypertrophied lymphatic gla.nds, and in the lymphoid tissue of the
tonsils, base of the tongue, of Peyer's patches, and of the
Malpighian bodies in the spleen. Fatty degeneration of
the heart sometimes coexists. The condition has been
found in a number of cases in which sudden death had
oceurred during the administration of anresthetics, as well
as in certain cases of death from trivial causes, but there
is no actual proof that tho sudden death is connected with
the existence of a persistent thymus.
Lympho-Barcoma.-The thymus gland iii a not uncommon
site tor mediastinal sarcomo.ta.
• Weights at DiJlerent A(168 (Hammar):
6 to 10 years
11 to 15
111 to 25
66 to 66
66 to 76
Other Hormonic Affections.
Premature PubertJ".-Puberty may make its appearance 8S
oarly as the second year, owing to tho premature entrance
into the blood of some hormone or hormonos which nornwJly
bring it about. In somo of these cases there may bo consider·
able musoular dovelopment and a largo deposit of fat.
Infantilism.-In this condit.ion dovclopmont does not proceed
boyond tho infantUo stage. Ib is probably due to the absence
from the blood of somo hormone or hormones necessary to
normal dovelopment.
Premature SenilitJ".-This is due to the premature ontrance
iuto tho blood of subsLancoa which promote senile ehanges in
tho tlssuos. or to tho absonoo from the blood of substanoes which
koep tIlO tissues youthful.
Deforo tho patient has reachod the ago of t,vonty, it may bo,
tho skin beoomes wrinklod, the hair blanched, the spine rigid,
tho arteries thiokonod. and tho tissues genorally exhibit other
featuros oharacteristic of old age.
The degonerative ohanges oocurring in what may be termed
normal Benil'Uy aro not so mucll due to a wearing out of the
tissues as to tho presence ill the blood of substu.nces which
bring tllem about.
Goitre (Bronchocele).
Goitre is a clinical rather than a pathologica.l term, and
embraces a.ll enlargements of the thyroid gland of non·
neoplasmic origin.
ClD.SSi1loatiOIl{pareIlChymatous { ~r:!~~.
Parenchymatous Goitre consists of an overgrowth of
the acini of the gland, and to Borne extent of the stroma.
The acini may become cystic (' cystic' goitre), or the
stroma may be abundant (' fibrous' goitre). It is usually
bilateral. The iodine-content is low, and this is probably
the chief cause of the disease.
Exophthalmic Goitre is largely a re"erBio1~ to the fmtal
Btate, being characterized by three sets of changes:
(a) Alteration in the alveoli.
(b) Increase in the connective-tissue stroma.
(e) Dilatation of the bioodvessels.
(a) The outline of the acini, instead of being uniform,
are irregular-due to the cubical epithelium lining their
interior becoming cylindrical and so being larger and
requiring more room, causing an infolding of the walls.
New acini are formed by diverticula from old ones. Thero
is little or no colloid, its place being taken by a thin, granular coagulated fluid.
(b) In the newly-formed connective tissue of the stroma
nodules of lymphoid tissue arc often found.
(c) The blood vessels (more particularly the veins)
become greatly distended and their walls friable, so that
during an operation on the gland hromorrhage is apt to be
copious. The gland presents a solid, almost homogeneous, appearance, not unlike the pancreas.
The Blood.-The polymorphonuclears are reduced, and
the small lymphocytes increased in number.
The Thymus Gland is peraistent and enlarged in about
75 per cent. of the cases (Capelle and Muth).
Tumours.-Adenoma of the thyroid is characterized
by the formation of large acini, which are enclosed w'ithfn
a distinct capsule separating them from tho rest of the
gland. In some cases the acini are converted into cysts
containing a thin brownish fluid. The tumour is generally
As tho thyroid gland contains both mosoblastic and hypoblastic elements, sarcomata and carcinomata may occu~, but thoy
arc extromely rare.
'Syphilis constitutes one-third of human pathology'
Schnudinn and Hoffmann were the first (1905) to show
that syphilis is due to the presence of the Treponema
pallidum. The organism is foundIn the primary soros.
in tho skin losions.
in tho mucous membranolesions.
Acquired iu the lymphatic glands.
syphilis in the blood and lymph.
in gummata.
( in .the brain in general paralysis of the
,in tho spinal cord in tabos dorsalis.
In congenital syphilis tho treponcmes aro found in tho blood
and in noarly all tho organs and tissues of tho body. In the
livc~ and sIl1cen moro Ilarticularly thoy congregate in enormous
numbers. They are also found in the urino, frocos, bile, bronchial secretion, and n:1sal dischargos.
The organisms are found most abundantly in situations
where infectivity is most intense-e.g., mucous tubercles
and oondylomata.
Metchnikoff and Roux discovered them in the syphilitio
lesions of the higher apes inoculated with the virus taken
from human beings.
Neisser was the first to demonstrate their presence in
tertiary lesions. At the Lisbon Congress he exhibited a
specimen showing five or six treponemes in the periphery
of 0. gumma of the liver.
Noguchi was the first to demonstrate their presence
in the local lesions of general paralysis of the insane and
tabes dorsalis.
The Treponema pallidum (so named by Schaudinn) Is supposed
to be a prolozOOI1., and, as seen In the living condition by means
ot the dark· ground illumination, Is a long thrcad·like organism,
about 20,. In leQgth and 0'25,. in broadth, tapering at both ends,
with eight to sixteen corkBorow·lIke spirals, which are viBiyle
both while inmevement and atrost, and whichgivo It a' twisted'
appoaranoo. It moves slugglshly across the mlcrosoopie 1I.eld
(most other splroohetes move morc rapidly), the movements being
ot feur kinds-viz., rotation onltslong axis, bending and lashing,
flexion and extension of its spirals, slow progression.
The organism has been kept alive In a drop ot Its own serum
under a cover·glass In tho laboratory of tho military hospital,
Chlseldon, for a period ot torty·three daYR. Nogucbl has grown
them in pure culture, with which he produced BYllhilitlc lesions
In rabbits. The majority ot observers considf.>r that multiplication takes place by transverse division, though others asse~
that longitudinal division Is the rule. It is killed by exposure
tor halt an hour to a temperature of 51 0 c.
Although the customary division of syphilis into throe
stages is in a sense misleading, inasmuch as all the lesions
contain and are caused by the treponemas, yot it is so
generally used that it may be allowed to stand, especially
in view of the fact that it has 0. distinct olinicalsignificance.
Primary LeBion.-An abrasion of tho surface is necessary for the introduction of the treponemes into the
system. Even the mucous memb:ranes. if intact. resist
inoculation. 'The orifices of the sweat-glands and hair
follicles. into which staphylococci and streptococci easily
penetrate. do not in their normal state appear to 0llen
the door to infection' (Neisser). The chancre. or 'hard
Bore,' occurs at the site 9f inoculation, being the local
195 '
expression of the reaction of the tissues to the
pallidum. (Of 10,000 cases seen by Fournier, 850 were
on extra-genital regions, 50 per cent. of which were on
the lips.) It is generally in the form of a papule, with
an indurated base. (In men it is generally single; in
women it is often multiple.) Slight ulceration of the
surface takes place, and in about six weeks' time (under
treatment) the cntire chancre disappears by absorption,
leaving little or no scarring. Inasmuch as it is painless,
and yields but a slight discharge, it may pass unobserved
by the patient. The chancre is composed of mononuclears,
prolifcrated connective tissue and endothelial cells, with
occasional giant cells, between which arc great numbers
of new blood vessels. Should the sore become phagedrenic,
it indicates a mixed infection. (A genital sore may be
syphilis, chancroid, scabies, herpes, or traumatic.)
General infection of the system takes place by the
lymphAtics and bloodvessels long before the appearance of
the primary lesion; it is probably a matter of a few hours
from the time of infection. Neisser failed to arrest general
infection of the system by excision of the inoculated area
after only eight hours from the time of inoculation.
The Wassermann roo.ctlon is of no value in the diagnosis of
oo.rly syphilis, as it does not beoome positive for from two to
six weeks after the appoorance of the primary sore.
During the period of quioscence which precedes tile secondary
stal,re, tho parasites are chiefly located in the bone·marrow.
sploen. and testicle (Nelsscr).
Secondary Le8ions.-These are essentially epithelial
(epiblastio and hypoblastio), being oharacterized by
cutaneous eruptions, mucous patches, and shallow
ulcers on the tonsils. tongue, soft palate, and pillars of tho
fauces. They are to be regarded as breeding-grounds of
the specific organism. The' mucous patches' are the
commonest of all secondaries, and their discharge the most
contagious. During this stage the blood contains the
treponemes in small numbers.
TertianJ LesionB.-By the time this stage is reached,
which may be as early as six months after the primary
infection, the treponema has probably undergone some
ohange ill" form, and produces a different toxin. This
would account for the difference in the lesions of the
tertiary stagi? as compared with those found in the secon·
dary stage. Although Neisser and OtheN have found
the treponemes in various tertiary affections, yet in tho
great majority of cases their presence cannot be detected.
'l'hey are certainly absent from the blood in any recognjz.
able form during this stage. Experimental an~ clinical
obllervations have shown tho.teontagion, though less probable, is still possible during the tertiary stage.
Ter~iary lesions affect par ucellence the mesoblastic
tissues, and the history of this stage of the disease is the
history of a particular form of granulation tissue, the
61JPMloma or gumma, composed of lymphoid eells, con·
nective-tissue cells, endothelial cells, a.nd sometimes giant
cells; between the cells new bloodvessels. This
granulation tisaue may occur in two forma: (i.) in concentration, when it is called the gumma .. or as (it) a
diffused gummato'U8 i'lljiltration.
(i.) The gumma is most liable to form in parts exposed
to injury-e.g., round about the knee and on the liver. Its
future ca.reer varies according to circumstances-e.g., it
may resolve under treatment (if begun early), or it may
undergo necrosis from syphilitic endarteritis and subsequent thrombosis of tho supplying arteries. A gumma.
situated on an exposed surface is specially liable to ulcerate
and to destroy the tissues deeply.
Living treponemes Dore only sometimes found, in gum.
ma.ta.. The expla.ns.tion of their absence may be that a.
gumma is the tomb of numerous treponemas, which melt
away and'so diss.ppear from the soene.
(ii.) A diffused gummatous in.1iltration may involvo
any of the viscera, the bloodvessels. bones ann joints,
and nervous system. Its tendenoy is to organize into
fibrous tisBue, but, like the gumma, it may resolve under
treatment if begun early.
The two conditions may coexist; for oxample, there
may be a diffused gumma.tous infiltration of the livor, and
gummata. on its surface. a.nd this applies to all th~ viscera,
to the nervous system, to the bones and joints, and to the
bloodvessels. describes syphilis when he makes Timon
of Athens say t!l the two prostitutes, 'Oonsumptions sow
in hollow bones of man; strike their sharp shins and mar
men's spurring. Orack the lawy~r's voice that.he may
never more false title plead, nor sound his quillete shrilly;
hoar the tlamen that scolds against the quality of flesh;
down with the nose, down with it tlat; take the bridge
quite awa.yof him that smells from the general weal; make
curI'd pate ruffians bald, and let the unscarred braggarls
of the war derive some pain from you; plague all; that
your ootivity may defeat and quell the source of all
crection '-o.s it docs when syphilis is followed by tabes
According tc tho statIstics of ins1ll"&noo offioos. syphllls
sliortons lIfe five to six years. Of 1.009 persons of ntnatoon years
and upwards who visited the London Hospital for reasons
wholly unconnected with syphilis and on whom Fildos performed
the WassCl"lllann tost. 8·3 per oent. were positive. Excluding
197 aliens with 13 positivos. thoro remain 803 Dritisil CIlSOS with
7111ositlv6 rosults= 8·8 per cent.
Syphilitic affections of the various organs are doalt with
under their respective headings; those of the nervous
system 00.11 for special notioe.
Syphilis of the Nerveus System.
Syphilis may attack the nervous system a.t any time
between three months and twenty-five years (or even
longer) after infection. According to 1\[ott, 'it most frequently occurs within the first two years after infootion,
and the frequency of its ocourrence diminishes with each
successive year.'
All the syphilitic diseases of the central nervous system
are due to the direct action of the treponeme. They fall
into two sharply-sepa.rated olasses-the interstitial and
the parenchymatous. In the former the treponemas infe!~t interstitial structures, such. as the walls of the arteries
and the meninges, producing such lesions as ondarteritis
and chronic meningitis. In the latter tho parasite takes
up its abode between the individual neurones, causing a.
primary parenchymatous degenemtion. Geneml paralysis
of the insane, tabes dorsalis, and syphilitic prima.ry optic
atrophy belong to this category. Clinically, the interstitial differs from the parenchymatous variety in being
amenable to the action of mercury and arsenio administered through the blood. This difference is probably due
to the f3$lt that the oapillaries whioh supply the neurones
of the central nervous system with blood q,re impermeable
to both of these drugs.
Among the :p1ore important forms of the interstitial
variety are the following:
Syphilitio Enilarleriti8, either in the form of nodular
thickeni~ (gummata), or of a diffuse gummatous infil·
tration of the arteries of the brain, especially at the base
(which, if complicated by thrombosis, may give rise to
hemiplegia), and of the spinal cord.
, I have not seen a case of syphilis of the oentral nervous
system post mortem in which the vessels have been per·
f3ctly healthy; usually they were extensively diseased'
(l\lott). In fact, endarteritis may be said to dominate
the histo.pathology of all stages of syphilis.
MyelitiB.-Eighty per cent. of oases of myelitis (so
called) are due to syphilis. The disease begins as llJl
endarteritis: this may go on to thrombosis and end in
• softening.'
Gummatous MeningitiB, espeoially at the of the
brain (involving the oranial nerves, more particularly the
oculo·motor), and of the spinal cord.
GUlmlnmta, beginning in the meninges and spreading to
the brain surface, are specially (lommon at the base,
notl!.bly in the region of the chiasma, but they may be
found in any part.
General ParalYsis of the Insane.-Syphilis is the essen·
tial cause of this disease. Mott has been able to demon·
strate the existence of the specific organism in 66 per
cent. of the cases examined by him. He adds:.
Sometimes they oan be found In ten mlnutos, sometimes only
after a day's searoh; but inasmuoh as looking for these minute
organisms in a largo organ like the brain may be llke looking
lor the proverbial needle in 0. haystaok. it is not surprising that
they cannot be found in overy oase. The oxistence of tho positive Wassermann reaotion in the cerebro-sPinal fluid in every
case. however, strongly supports this oonolusion.
The essential pathological changes occur in the oerebral
cortex, and consist of:
Thickening and adherence of the meninges.
Thickening of the neuroglia.
Thiokening of the walls of the arteries.
Atrophy of the neurones. (This is thought to be a
primary ohange.)
On removing the membranes, the surfaoe of the brain
tears away with them (, deoQrtization '), leaving a oharacteristio worm-eaten appearanoe, especially marked over
the frontal and oentral oonvolutions.
Changes in .the oord similar to those met with in tabes
dorsalis are generally found. They would doubtless be
still more frequent and pronounced if the disease did not
run such a rapidly fatal course. Thore is always lymphooytosis of the oerebro-spinal fluid.
Tabes Dorsalis.-This also is a manifestation of syphilis,
the treponemes being found in the local lesion. The
morbid changes are, mutatis mutandis, the same as those
found in general paralysis. The disease uBUlIolly starts
as what appears to be a. meningo-neuritis of the posterior
roots in the dorso-Iumbar region of the oord, a.lthough
the process is probably to a. large extent a primary atrophy
of the sensory nerve fibres oonstituting the posterior
roots. The continuations of these fibres in the posterior
columns of the oord undergo seoondary atrophy. Other
regions of the oord are also sometimes involved. In oourse
of time the posterior roots, like the posterior oolumns,
lmdergo marked atrophy.
The Argyll Robertson phenomenon (= pupils react to
accommodation, but not to light) is thought to be due to
a lesion of the oiliary ganglion within the orbit. (With
very rare exceptions, it indicl).tes syphilis of the nervous
system.) Lymphooytosis of the oerebro-spinal lluid is
always present.
In oases complicated by • Charcot's joint disease' and
• perforating' ulcer of the foot, the nerves supplying the
affected parts have been found degenerated.
Lymphooytosls of the oerebro-splnal fluid ooours In cerebrospinal syphilis, in tabes dorsalis, and in genoral paralySis ol
the insane.
Wassermann Reaclitm in 8I1philis.-Up to t-wo to six -weeks
tram tho first a.ppoaranoo of tho prima.ry BOfe tho rea.otion is
genemlly nega.tive. It is in the ea.rlll sooonda.ry (untrea.ted)
stage that the highost poroentage at positive roa.otions is found,
in whioh it ra.nges from 96 to 100 per oent. (For further partloulars, 11ide p. 48.)
.Alcohol has been termed the' genius of degeneration.'
The morbid changes obseryed in chronic alcoholism
An increase of the fibroUB at the expense of the higher
e1ements of the tissues. This is particularcy marked in
the liver, arteries, and nervous system.
A tendency to fatty degeneration, especially of the heart.
At the coroners' inquests held in London, the common
cause of sudden death in drunkards is found to be fatty
degeneration of the heart.
A tendency to inflammations, notably to catarrh of the
mucous membranes, alimentary and bronchial. .Alcoholic
peripheral neuritis is not uncommon.
.The tendency of alcoholics to inflammations is largely
due to their diminished resistance to pathogenetic bacteria.
It is for this reason that the mortality from such diseases
as pneumonia is so high among them.
The above·mentioned changes may be caused either by
the direct action of the alcohol on the tissues, or by bac·
terial toxins developed in the oatarrhal alimentary tract.
Probably both factors co-operate.
'When the eot hae dll60el1dOd through hie ohoson oourso of
ImbeoUity or dropSY to the dead-houso, l\{orbtil Anatomy is
ready to reoeivo him-knoW's him well. At tho post-mortem ahe
WQuld eay: .. Liver liard and nodulatod; brain dllD.BO and small,
Its ooverings thick." And if yay would listen to hor unattraotive
but interesting taw, she would traco througbout tho sot's body
Ii series of ohanges whioh leave unaltered no part of him worth
s:peaJdpg of. She would tell yOU that the onoo dolloate, filmy
texture whlob, when he was young, had surrounded llko a pure
atmollPhore overy fibre and tube at his mechanism, making him
lithe and supple, has now beoome rather 0. dense fog tllan 0. pure
o.tmoSllhere-denso stu:tr whioh, Instead of lubricating, has
closed In upon and orushed out ot existonoo moro and more of
tho fibl."OB and tubes, espooially in tho brain and Iive__whenoo
the imbeoility and the dropsy' (Moxon).
, Alcohol aots partloul&rly on the higher centros of tho b!'lloln,
and a drunken man may exhibit the abstraot and brief ohronlole
of Insanity, going through its successive phases In a short period
of tlltle ' (Ma.udBley).
The struoture of bono is that of a specialized connective
tissue impregnated with lime-salts_ The periosteum on
the outside of a bone is continuous with the endosteum
(marrow) of the inside, and numerous bloodvessels pass
from the one to the other_
This vascular continuity explains how inflammation,
beginning primarily in either periosteum, bone, or endosteum, is lia.ble sooner or later to involve all three_
Osteitis is always due to microbic infection of the soft
tissues of bone, the usual organisms being: Staphylococci,
8treptococci, pneumonococci, BacillUB typho8U8, bacillUB of
tubercZe, and the treponemB8 of 8yphili8.
Fir8t Stag e.-The bloodvessels dilate, then exudation
begins accompanied by the escape of leucooytes, the
bone assuming a pink colour.
Second Stage.-Exudation continues, the lime-salts
are dissolved out, and the bone-substance is partially
absorbed, the compact tissue becoming eaten away,as it
were, and the cancellous becoming still more cancellous.
'l'his ' rarefying' process is effected in part by the action
of phagooytes, in part by the peptonizing action of bacterial
toxins, and possibly in part also by the solvent action
of the inflammatory lymph imder high pressure. In the
dry specimen the bone at this stage presents a 'wormeaten' appearance.
'l'hird Stage.-Osteitis, like inflammation of soft parts,
may terminate in one of several ways. Thus, resolution
may take place, and the bone resume more or less its normal
condition. On the other hand, should the • rarefying'
process continue, the whole of the affected bone dissolvcs
away by a process of molecular death, or cariB8. If, after
this has occurred, the inflammatory exudate, consisting
largely of pus, becomes imprisoned by the surrounding
bone, the result is an abSCes8. If, however, the exudate
poured out during the period of rarefaction organizes,
sclerosis results, the cancellous spaces and the medullary
canal becoming ill this way obliterated by the formation
of hard, dense bone resembling ivory. This is the usual
condition of the terminal portion of bone in stumps after
Acute Infective Osteomyelitis (Pan-Osteitis).
This disease attacks the long bones, the larger more
frequently than the smaller. In the great majority of
cases the Staphylococaus aurew is the oause (other causes
=pneumonococcus, BaciZZ'1J8 typhosu8, etc.), the organisms
entering the body either through an external wound, or in
consequence of some infeoting focus in the mouth, throat,
or other part. It is essentially a disease of young people
(thirteen to seventeen years), and lowered vitality is an
important predisposing faotor.
The disease is characterized by the rapid formation of
pus. It presents three types, according to the position
of the initial lesion, which may be either:
1. In the periosteum,
2. In the interior of the shaft, or
3. In the epiphysis (aoute epiphysitis).
1. If the disease begins in the periosteum (favourite site
= femur, usually starting at baok part oflower end), the pus
spreads over a wide area and strips the periosteum ftom
the bone. The latter, having its blood-supply cut off,
dies, unless the pus is let out by a timely incision. In this
way a portion, or, it may be, the whole shaft, of the bone
perishes, the condition being known as acute necroN 0/
bqne. This form is generally limited to the shafll, for the
disease does not usually spread to the epiphysis, which is
protected by the intermediate cartilage; for a like reason
the neighbouring joint also escapes as a. rule.
2. H the disease begins in the interior of the shaft,
necrosis is brought about partly by a strangulation of the
bloodvessels and partly by the toxio action of the baoteria.l
products. This is the ordinary Acute Infective OsteomyeZitiB. Should it remain untreated, pymmia is very likely
to occur, as the infective thrombi in the veins are liable to
disintegrate and be discharged into the blood-stream as
septic emboli.
3. If the disease begins in the epiphysis, it is genemUy
localized to this part, and is known as Acute Epiphysitis.
In these cases the head of the humerus and the upper and
lower epiphyses of the femur are the parts most usually
involved. The disease often spreads to the joints, giving
rise to acute septic arthritis. It is essentially an affection
of infants and very young children.
Infections of the middle ear are genorally caused by' the
Caries is the molecular dissolution of a portion of bone,
resulting from the continuation of the rarefying proccss of
osteitis, being analogous to ulceration of the soft tissues.
It may occur in any bone, but is commonly met with
in tke ca7lCelloU8 tiBBtt6 of the epiphyses, the bodies of the
vertebral, the carpus, and the tarsus. By far the commonest cause is tubercle, and when thus originating it
may be regarded as a phthi8iB of bone. When dead bone
separates, it does so by caries taking place in the adjacent
portions of the surrounding living bone.
Dru Caries.-The absorption ot bone resulting from presSllr&B.g., ot an aneurism-is sometimes spoken of as • dry caries.'
The prooess is of tho nature of a simple atrophy.
Neorosis is the death of bone in mass, and is analogous
to gangrene of the soft ·parts. It commonly affeots the
compact ti8sue of bones, particularly of the tibia and femur;
also lower jaw, bones of skull, and phalanges. In all cases
the cause is a cutting off of the, either by
injury or inflammation (periostitis, osteitis, or osteomyelitis, syphilis, scarlatina, mercury and phosphorus
poisoning). Necrosed bone is bloodless, dry, and white in
colour, but on exposure to the air it· often becomes brown.
Separation of Dead Bone.-The surrounding bone
becomes inflamed, caries results, and the loosened dead
bone, now called a sequfJ8trum, lies bathed in pus in a
cavity bounded by granulation. tissue, and lined with
a • pyogenic membrane.' The periosteum covilring the
20 4
sequestrum may form a new Ia.yer of bone over it-the
involucrum. This is perforated by holes-cloacal-to
allow of the escape of pus.
Tuberculosis of BOlle.
Tubercle may form in the p~riosteum. in the epiphyses,
or in the diaphyses. Its favourite position is the cancellous tissue of the epiphyses, the bodies of the vertebrm,
the carpus, and the tarsus. The bones of the skull are
rarely involved, and those of the face and jaws praotically
never. The disease runs a ohronio oourse, shows a marked
tendenoy to suppuration and progressive destruction of
the parts, with but little tendency to repair. The bovine
ba.oillus is the probable oausal organism.
Syphilitio Diseases of Bone.
In the Becondary Btage of syphilis there may be 0. fleeting
In the tertiary Btage the bone affeotions are similar to
those oharacterizing this stage of the elsewhere.
Gummatous material may form in either the periosteum
or the bone. and give rise to caries, necTOBis. or 8dflTOBi.s.
Caries and necrosis may oocur together (cario-ntlCr08iB).
Gummata are most likely to form on parts exposed to
injury. and hence they are most often met with on the
subcutaneous surfaces of bones, leading to the formation
of 'nodes.' Syphilitic caries is commonest in the skull.
Syphilitic sclerosis may be widely diffused throughout the
whole shaft of a. long bone, and it may also occur in the
bones of the oranial vault.
In both acquired and congenital syphilis the fingers and
toes may be affected with periosteal gummata, giving rise
to the condition known as Byphilitic dactylitiB.
In congenital ByphiliB the diseases of bone, according
to Parrot, assume two prinoipal f{)rms:
1. Atrophlo { Ostoochondritis.
_. {Osteoid.
9. Hypertrophlo. or Ostooph...10 Fibro-epongiold.
1. In gelat1:nllorm atropl'1I the bOlle tfssue fs replaoed by a
gelatinous substance.
In osteochondritls (sometimes oollod syphilltio epiphysitis)
the cartilage between the epiphysis and tho diaphysis becomes
abnormally thick and loses Its rogular outline; ossification stops
short at oololfloatlon, tho zono of oaloltlod matorlal being dense
and brittle. As 110 result, fracture Is liable to occur, and, as the
symptoms may resemble paralysis, Parrot has named this oonditlon SlJPhilitic pseudo-paralysis.
2. In the hypertrophio varioty the new bone of the growing
child :m.ay be hard and ivory-like, when it is termed osteoid;
or it may be fibroid In struoture and vory vascular, when it is
tormed /i/n"o-spongioia.. The two conditions may be combined;
thus, the osteoid and spongioid material may be arranged in
alternating layers. The most eommon sites for these ohanges
0.1'0 the ends of the humerus, femur, and tibia.
In the skull • bosses' of new bone may form around the fontanolles (. Parrot's nodes '), and these may become bridged over,
and so give rise to the rounded, prominent forehead observed
in later life in the subjeots of this disease. In the occipital and
parietal bones circumscribed areas of extremely thin bone, or
evon of membrane only, arc sometimes met with. To this condition the name of craniotabes has been given. (In the Museum
of the Uoyal College of Surgeons, London, are specimens prosonted by M. Parrot showing all those ehanges.)
Tumours of Bone.
The m08t common primary tumours of bone are the
enchondromata, the osteomata, the myelomata, and the
sarcomata. Secondary tumours may be either sarcomatous or carcinomatouB.
Saf'Comata oj Bone.-These may be either periosteal or
Peri08teal 8arcoma is of extreme malignancy, so muoh so
that, of sixty-eight cases collected by Butlin, a oure was
effected by amplltation in but one case, and even here
there was an element of doubt as to whether the growth
did not start in the endosteum.
Besides the erdlnary food oonstituents, such as protein. fats,
carbohydrates, IIpoids, and inorganlo salts, 0. number of Bubstances oan be found In small quantities whleh are as indispensable to life 0.8 the former constituents. These substances I have
designated vitami1le8, and the diseases whioh arise from their laok
as' de.!l.olency diseases,' or aVitaminoses (Casimir Funk).
Vitamines are the product of the plant world on whleh ultimately all animals Uve. So far as is known, animals are una!;le
to synthetize them. Their absence from food eauaes eertaln
diseases, the following being thoso definitely known: rlckots,
BOl1rVY, berl.-berl, and pellagra.
There are different kinds of vitamlnes, Dach playing a definite
rOle in metabolism, and they are dilforently distributed amongst
natural food-stutrs as instinotively oonsumed by men amI
o.nimals. Their chemical composition is unknown. Three
olasses bave boon dltrerontiatod:
1. Fat Soluble A.-COntained in the :majority of animal fats
(boof fat, fat of kidney, ete.), abundant in buttcr (but destroyell
by hcat1D.g to 100 C.l, egg·yolk, :fish oUs (eod-liver oU), heartmuscle, liver, and the raw green leavos of plants. Not present
ill lard, and only in small quo.ntlty In margarine made from
vegetable oils. Its absence causes riokets.
2. Water Soluble B.-Present In the cuticle of the husked
grain of rice. Yeast is rich in it; also eggs. Its absence causes
s. Water Soluble C.-The antiscorbutic vitamine present in
lemons, oranges. raw cabbage-loaves. the raw juiee of swedes.
germinated sCQds. and most edible vegotables. Destroyed by
moderatcly high temperatures, alkalies, desicootion. and canning
processes. Ronoe the importanoe of fresh fruit and salad. It
is important to emphasize that drIed vegetables have lost almost
tho whole of their antiscorbutic properties.
Riokets, first desoribed by Glisson in 1650, is a' defioienoy
disease' affecting the nutrition of the entire organism,
being due to the absence from the food of the antirachitic vitamine (fat soluble A). Deformities are
the later and graver manifestations of the disease, and
occur in but a small proportion of all cases. (Schmorl's
histological investigations on ehildren dying before the
age of four showed that 90 per cent. had rickets.)
Lawson Dick found 80 per cent. of the children in the
L.C.C. schools had rickets. The condition commonly
attmcts attention at about the sixth month after birth.
The child is anromic; it is very irritable, and cries when
handlell on account of a diffuse tenderness of the body;
it is restless during sleep, sweats freely about the head,
and a slight degree of fever is often present; besides being
irritable, the child is nervous, and liable to 'fits.' There
is also a much lowered resistance to infection. (In the
West of Ireland, where rickets is very mre, the infantile
death-rate is only 30 per 1,000. In the poor urban districts of England, where rickets is common, the infantile
death-rate varies from 100 to 300 per 1,000.)
The most characteristio bone changes ooour at the
epiphyses and beneath the periosteum of the long bones.
Thus, the cushion of oartilage between the epiphysis and
the diaphysis is thicker than normal, and the plane of
ossification on the diaphyseal side of the cartilage, instead
of being even, is irregular. The cartilage cells divide with
cxcessive rapidity, suggesting the action of an irritant.
The newly-formed bone is unduly soft, chemioal examination showing it to be very deficient in lime-salts.
Similar changes take beneath the periosteum, the
new bone laid down by this membrane being softer and
more spongy than in health, and as 0. consequence the
bones bend, giving rise to various charo.eteristic deformities. These are molO marked in some bones than in
others. although the entire osseous system is affected.
The anterior fontanelle remains open longer than the
normal eighteen months after birth, and the teeth erupt
late. ]j'rom pressure by the pillow, soft, deoalcifi.ed areas
arc liable to form in the occipital and parietal bones
( = craniotabes), though this oondition generally (some say
always) indicates congenital syphilis.
H the child lies much on its back, the occipital bone is
liable to become flattened and the frontal bone to become
prominent; for the bones of the cranium are easily displaced on account of the late closure of the fpntanelles
and the yielding nature of the sutures. The oranial vertex
is, and the coronal suture may be 'keeled.'
In the spine there is usually some kyphosis, and the child
may not begin to sit up until after tlie first year, instead
of, as normally happens, at about the seventh month.
The sternum is thrown forward (' pigeon-breast'), and there
is considerable thickening of the ribs at their junction
with the cartilages ('beaded' ribs). It should, however,
be remembered that a small degree of beading is normal.
Rickets is the commonest oause of deformed pelvis.
The sacral promontory projects forwards from the downward pressure of the weight of the body, and the brim is
• kidney-shaped.' Sometimes the symphysis pubis is
pulled backwa.rds by the a.bdominal recti, giving rise to
the' hour-glass' pelvis.
The most notable ohanges in the long bones are: enlargement at the junction of the shaft with the epiphysis
from swelling of the epiphyseal cartilage, exaggeration ot
the normal curvatures, and the developmen~ of curves
due to the traction of powerful muscles-e.g., an outward
curve of the humerus, corresponding to the insertion of
the deltoid. The bones of the forearm are bent outwards
in their lower thirds. The femur shows a long forward
curve. The bones of the leg are bent outwards and
forwards in their lower thirds. Strong bony buttresses
usually develop in the concavities of the curvatures, where
the new rickety bone is laid down most abundantly.
Caloification at the human teeth oontinues till the eighteenth
year, and this caloification depends largely upon an adequate
supply at tat soluble A in the diet. Henoe dental oaries is often
evidence of riekets.
Infantile Scurvy (Scurvy-Rickets; Barlow's Disease).
This disease is unknown in breast-fed infants. It is
probably a 'deficiency disoase' due to the absence of
vitamines in the food. There is acute tenderness of the
limbs, the child screaming when moved. HlIlmorrhagio
effusions take place beneath the periosteum of the long
bones, more particularly of the femur and tibia. Hmmorrhages may also .occur in the interior of the long bones
and ribs. Sepamtion of the epiphyses is not uncommon.
Spongy gums, and hmmorrhages from mucous membmnes.
and into the skin and the joints, are usually also f~und.
This disehse is due to a deteot in development at the bODes
whioh are tormed from oartilage, more partieularly of the long
bones and those of the base at the slrull. It is sometimes inaccurately called treta! rlokets, diflering from ordinary riokets In
that it is always congenital. The bones whioh develop tram
membrane are unaffected.
Tbe development in length. of the diapbyses at tbe long bones
is defootive, though they are normal in thiokness; bence the
limbs are short and stunted. There is no bending, and there
are no abnormal CUl'Ves. The bones at the base of tho skull
ankylose early, and as those at the valdt grow naturally, tJ,le
holtlt looks unusually big. The bridge of the nose ill depressed.
The boneS which develop tram membrane being unaffected, the
ol,tvicles, ribs, sternum, and vertebral column, Bra all at normal
size. Death ocours in most cases a tew days after birth. Those
who survive grow up dwarfs, but with tho intolllgelloe unimpd.lred (thus d11fering tram cretins).
Osteomalacia (Mollities Ossium).
This disease is essentially one of progressive decalcification, the lime-salts being absorbed and the bones in consequence becoming soft, bent, and liable to spontaneous
fractures (which do not unite)_ . It occurs only in adults,
is almost entirely confined to women, and generally develops during pregnancy. The bones usually affeoted are
those of the pelvi8, the vertebral column, and the rib8.
The morbid ohange begins in the interior of the bones,
the medulla being replaced by a tissue resembling the
splenic pulp. The decalcification proceeds gradually from
within outwards, until all that is left of the original bone
is a thin layer of compact tissue beneath the periosteum.
The pelvi8 is flattened from side to side, the acetabula are
approximated, and the symphysis pubis projects forwards
in the form of a beak.
Osteitis Deformans.
This disease was first described by Sir James Paget.
'The disease affects most frequently the long bones of
the lower extremities and the skull, and is usually symmetrical. The banes enlarge an~ soften, and those bearing weight yield and become unnaturally curved. Th!l
spine may sink and seem to shorten, with greatly inoreased
dorsal and lumbar curves; the pelvis may become wide;
the necks of the femora may become nearly horizontal,
but the limbs, however misshapen, remain strong and fit
to support the trunk' (Paget).
The calvarium may become enormously thickened, the
patient notioing that he has to use larger and larger hats,
while his stature becomes less and less. The disease
begins after middle life, and its progress is very slow,
sometimes lasting as many as twenty years. The enlargement and softening of the bones are due to the
development of soft, spongy, and highly vascular new bone.
This disease is charaoterized by excessive growth of
the bones (as well as the soft tissues) of the hands, feet,
face, and other parts. The lower jaw is inoreased in
eize and projeots forwards; the supra-orbital ridges are
prominent (see p. 190).
Leontiasis Ossea.
In this disease the bones of the faoe and cranium
become greatly thiokened.
Hypertrophic Pulmonary Osteo-Arthropathy.
This disease is oharacterized by enlargement of the
terminal pkalange8 of the fingers and toes and neighbouring bones. with incurvation of the nails. It is assooiated with bronchieotasis, empyema, and pulmonary
tuberculosis, and is probably caused parMy by absorption
of toxic material from the diseased lung or pleura. and
partly by the sluggishness of the circulation resulting from
the pulmonary obstruotion.
Tuberculosis of the .Toints.
Tuberculosis of a joint may be compared with tuberculosis of the lung. The disease may begin in the synovial membrane. whioh is the morphologioal equivalent of
the pleura (tubercular synoviti8); or in -"the liead of tho
bone, which is the morphological equivalent of the lung
(t-ubercular o&teitiB). It never begins in the a.rticular
oartilage. The disease is generally chronic. and resembles
tubercle elsewhere in its course and termination. ending
either in recovery by the formation of fibrous tissue, or
going on to abscess formation and the destruotion of the
Tubercular synovitis affeots, o.s " rule, the hinge-joints
-viz., the elbow, wrist, knee, and ankle. Tubercles
form in the synovial membrane, causing it to beoome
thickened, gelatinous, and pulpy. The synovial fringes
spread over the artioular surfaces. covering them like a
veil, and from the under-surface of this veil small processes penetrate into the underlying, a condition
compared by Billroth to ivy creeping over a wall and
becoming gradually attached by its roots. The cartilage
now beoomes ulcerated. and, finally, unless the tubercular
process is a~ested, the underlying bone is inva.ded and
becomes canous.
Should the disease progress, tubercular fungoid· processes, derived from the synovial fringes. burrow through
the capsule and infect the tissues around the joint. causing
periarticular abscesses. the contents of which generally
find their way outwards. A fistulous canal. lined with
exuberant granulations. and forming a communication
between the inside of the joint and the skin. is the result.
In an early period of the disease recovery may take place
under treatment. but after the occurrence of suppuration
tho jOint becomes partly or completely obliterated, and
fibrous ankylosis occurs. if in the meantime the patient
does not die from the lighting up of tubercle elsewhere. or
from lardaceous disease.
T1Ibercular o8teitiB affects the ball-and-sooket joints,
and is well illustrated in the case of tubercular disease
of the hip-joint. The process here usually starts in the
epiphysis of the femur. either olose to the intermediary
cartilage or just beneath the articular cartilage of tho
head. Caries supervenes. ILlld the inflammatory products
escape into the cavity of the joint. The synovial membrane
and ligaments become secondarily affected. and the whole
joint IDldergoes disorganization, the acetabulum being inoculated by contact with the carious head of the femur. (It
may even become perforated.) In some cases the epiphysis
gets detached and lies loose in the joint. The pus generally
escapes through the thinnest part of the capsule-i.e., 0.&
its posterior part. It then burrow!! forwards beneath tho
gluteus minimus, the medius, and the tensor vaginm
femoris, ILlld Ultimately forms 0. swelling beneath the
anterior superior iliac spine.
Oomplications of Tubercular Arthriti8.-If an abscess
bursts and becomes septio. amyloid di8ease is likely to
develop. At any tim~ during the progress of tubercular
arthritis acute miliary tube.rculosia (either of the pia mater,
lungs, or abdominal viscera) may be set up.
As previously stated, complete disorganization does not
of necessity follow tubercular joint disease. In favourable
oases, espeoially if treatment has been begun early, the
disease may be arrested, the inflammatory produots being
absorbed; ankylosis (fibrous, or bony), however, is often
a sequel under these circumstances.
In rare oases tubercular arthritis starts from a ttWerculous
periostitis or from a tubercul0't&8
Tuberculosis of joints. like that of bones. is probably d1l6 to
thc bovine bu.oUlus.
Arthritis Deformans.
This is a generic term, and embra{)cs severa'! types illstinot alike in their etiology, pa.thological features, and
clinical course. The cause, in certain of them at least, is
probably a toxin, which may be generated in t,he nasal
sinuses, around the teeth, in the aliment,ary canal, in the
uterus, or in the FalIopi::tn tubes, and operating through
the synovial fluid. As seen in museum specimens, the
disease gives the impression of having boon a chronic one,
but the clinical history of cases suggests that whatis seen
pest mortem is the result of the frequent recurrence of
acute or subacute a,Uacks. The disea,se presents two
main types (though numerous intermediary forms are
Dlot, with): DSleo-Arthritis, in which the changcs are most.
ma.rkcd in the articular cartilages and bones; and Rheumatoid ArtJlritis. in which the synovial membrane, ligaments, and periarticular structures, are most affect,ed.
DSleo-Arthritis is a chronic and progressive disease of
middle and advanced life. The morbid changes invohroThe articular cart£lages.
The underlying bones.
1.'he synovial membrane,
The iniemrticula·r ligaments.
TIle sU!rrmmdin(J muscles.
The hyaline matrix of the articular cartilage becomcs
fibri'lat,ed, and the cartilage cells proliferate and escape
into the joint. The surface.of the cartilage now loses its
polish, assuming a velvety appearance, and in course of
time its central part is worn down, and the tmderlying
bone, highly polished like porcelain or ivory, is exposed.
While these chang(ls are in progress, the marginal cir·
cumference of the cartilage becomes irregularly tlrickened
(' lipping '), sometimes dcveloping flange-like outgrowths
or ecchondroses, which have been likened to the guttl'rings
of a wax candle. These ecchondroses may in course of
time beeomo ossified, when they are known as o8ieophytes.
(In a carwus joint the {)steophytes have the jagg8d form
of staJactitcs.)
The 8ynovial membrane thickens, its fringes hypertrophy, and eyentuaf[y the whole membrane nmy assume a
shaggy aplIeamnce. Oooasionally oartilago develops in
the fringes, forming pedunoulated nodules. and thos.e may
subsequently become detached and form 'loose bodies' in
the joint.
Tho interarticular Zigamtmt8 in oourse of time degenerate
and wear away. In this way the ligamentum teres dis·
appears from the hip-joint, the intrascapular par~ of the
long tendon of the biceps from th~ shoulder-joint, and
the crucial ligaments and interarticular cartilages disappear from the knee-joint.
AB a final result, the contour of the joint becomes considerably altered. This is most characteristically seen
in the hip, the acetabulum being widened, tho head of the
femur flattened and expanded at the oircumferenoe, its
neck shortened and sct more at right angles with the shaft.
The muscles around the joint tend to atrophy, a ohange
often well marked when the disease attacks the shoulder,
hip, or knee.
The disease generally attacks the large joints, such as
the hip, knee, and shoulder, but it may involve a numbcr
of joints. When the spine is attacked (8pondylitis deformans), there is often so much new bone formed that the
individual vertebroo become fused together.
Rheumatoid Arlkriti~ generally comes on in early adult
life, involving many joints symmetrically. It is much
commoner in women, and is probably caused by an infection, for it is often associated with uterine or tubal troublo.
All the joints of the body may be affected. (N.B.-In gout
and rhewnatic fever the temporo-maxillary joints and
cervical spine are practically never attacked.) Those of
the fingers are apt to be involved early, causing these
latter to be fusiform from swelling of the interphalangeal
joints. There is great thickenipg both of the Rynovial
membrane and ligaments, as well as a periarticular effusion,
which in time tends to organize. 'Lipping,' ehondrophytes, and osteophytes. are absent. The muscles about
the affected joints undergo marked atrophy. and the contractions of the wasted muscles may cause oonsiderable
A feature of this malady is its oonstitutional nature.
It is manifestly a blood disease. for the p:ttiont is aDoomio,
her vitality is low, and she is apt to be febrile-o.ll of whioh
suggest an infeotion.
Still's Disease is allied to the last, if it is not aotually
the same disease, but, in addition to the joint affection,
enlargement of the spleen and of the lymphatio glands is
apt to ooour. It occurs in children.
Neuropathic Arthritis.
This group of joint diseases is found in oonnection with
certain diseascs of the spinal cord and nerves, the most
notable being-tabes dorsalis, syringomyelia, sl>ina bifida.
hemiplegia, paraplegia., periphera.l neuritis, and injury to
peripheral nerves.
Charcot's loint Disease develops in connection with
tabea dorsa i8, generally during the pre-ataxic stage. The
disease may affeot one jOint only, or may oocur successively
in several.. Tho usual joints to be involved are those of
the knee, hip, and shoulder. The onset is generally
sudden; there is considerable swelling of the part (which
is sometimes enormous), but neither pain nor fever is
present. A patient may go to bed well, and wake up
in the morning with the joint dilltended, without any
apparent cause. After a few days the general swelling
disappears, but the joint remains distended with fluid.
This swelling is due in part to effusion into the joint,
and in part to Gldema. of the soft tissues outside it (the
, Gldema without pitting' of Char~ot).
Although in a. few cases the effusion may be absorbed
(the 'benign' form of Charcot), the articulation returning
to its normal state, it generally proceeds to rapid and
complete non-inflammatory destruction of the articulation
(the' malign • form of Charcot). and culminates in the production of a. • flail joint,' movable in all directions. Dislocation of the joint may take place. especially in the hip
or shoulder.
It is essentially a trophic lesion, the nerves going to the
jOint being found diseased.
The morbid changes characterizing it are--effusion into
the joint, early disappearance of the ligaments and carti·
lages, and great atropky of tke articular ends of tke 6ones.
OstetJphytes may form, sometimes in large numbers.
In Cha.rcot's disease of the knee it is not Uncommon to
find bursal 8Welling8, espeoially of the bursa which so
frequently communicates with the joint--viz., that under
the semimembranosus tendon.
Syringomyelia may be associated with 0. form of joint
disease similar to that occurring in tabes dorsalis, but the
seat is 'U8ually in the upper limb. In this disease trophio
lesions may be also found in tho skin, such as whitlow8,
ulcer8, and gangrene of the fingers. The pathology is the
same as that observed in Charcot's joint disease. A similar condition of the soft parts occurs endemically under
the Mme of' Morvan's disease.'
GonorrhreaI Rheumatism.
This disease, sometimes called young man'8 rheumatiBm,
is caused by the entrance into 0. joint either of the gonococcus, the gonococcus-toxin, or the organisms, or toxins,
of a • mixed' infection. One or several joints ma.y be
affected, as also sometimes fascim, tendon sheaths, bul'llre,
and the fibrous sheaths of nerves. The knee is most
often attacked. (Of 376 cases recorded by Finger, the
incidooce was as follows: Knee 136, ankle 59, wrist 43,
fingers 35, elbow 25, shoulder 24, hip 18, jaw 14, other
joints 22.) A very troublesome form is that which affects
the ankle, the tarsal joints, and the fibrous struc~uree in
the sole, causing a severe form of fiat-foot. In some
cases there is • iritis.' The disease seldom sets in until
the third or fourth week after contagion. It may be
acute, BUbacute, or chronic.
In the acute form there may be suppuration (very rare),
and even complete disorganization of the joint. Sometimes it simulates rheumatic fever. The more oommon
aubacutll or chronic form is o4aracterized by a plastio
exudation involving the ligaments and periarticular 8tructUTIl8, with but oomparatively little effusion into the
joint. This accounts for the oharaoteristio solid feeling
of the joint. The exudation shows a marked tendenoy
to the formation of new" fibrous tissue, which leaves the
joint permanently stiff. In those cases in which the
larger joints are affeoted the patient may become quite
Affection of th~ fourth metatarso-phalangeal articulation is said to be diagnostio of gonorrhma.
In a oortain number of cases of arthritis and tonosynovltis
following gonorrhma, pure cultures of the gonococcus can be ob·
tained from the local parts; in other cases, no organisms can be
Arthritic gout is characterized by the deposit of mono·
sodium urate in the matrix of the articular cartilage.
P,st mortem it is found in the form of crystals lying just
beneath the surface, not extending deeply, and but
exceptionally involving the underlying bone. In advanced cases the surrounding ligaments, tendons, and
synovial membranes and bursro may be likewise involved.
The sites of election are the great toe, the fingers. and knee.
Occasionally, the deposit affects thc ears, eyelids, larynx,
and kidneys. The most common complications of gout
are emphysema of thc lungs and granular kidney.
Branchial Fistula, Cleft-Palate, and Bare-Lip.
In order to understand the nature of these deformities,
it is necessary to recall some points in the normal develop.
ment of the upper jaw and neighbouring parts. In early
FIG. 16•.
fmtallife the anterior portion of the alimentary tube com·
municates with the exterior 011 either side by 0. number
of slit-like openings-the branchial defts,. between wh;ich
are the branchial arc"h68. The first branchIa.l cleft persists
as the external auditory meatus, the tympanum, and the
Eustachian tube. All the others should close. In some
rare cases, however, the third or fourth remains partioJly
unclosed, the result being a. fistula (branchial fi,Btula)
opening on the surface of the body near the sternal head
of the sterno-mastoid muscle. Similar nstulw have also
been met with below the glottis.
As development proceeds, the (irst branchial areh on
either side divides, fOrming the two superior and the two
inferior ma.xillary processes_ The two inferior processes
unite in the middle line to form the lower jaw and the
lower lip.
The two superior processes grow forwards to form the
superior maxillw, with the hard and the soft palate, tho
cheeks, and ihe lateral parts of the upper lip. They do
not, however, unite anteriorly, but between them there
grows downwards from the front of the skull the 1IIJ80frontal pr0Ge8s. from which are" developed the nose, the
vomer, the nasal septum, and the premaxillw carrying the
incisor teeth and the central portion of the upper lip.
These various parts should unite by the ninth week
of freta) life; should union be defective, tho following
deformities, which are always situated in the linos of
fissures norma.lly present in intra-uterine life, may oocur:
Blfld uvulo..
FislJUre ot the soft palate, with bl1ld uvula.
]!'ilsure ot both the soft and the hard palate.
Fissure ot the hard Dala.te only (very rare).
FIssure ot the hard and the 80ft pft,Iates, combined with fissure
of the alveolus and the lip on one side_
The same as tho preceding, with fissure 0t the &lveolus and
lip 00& both sides.
Simple hare-lip.
Double hare-lip.
In the rare case of oleft of the hard palate the nasal
septum is usually attached to one side of the palate,
shutting off the nose from the mouth on that side. In
only very rare cases is the lower border of the nasa)
septum free, so that both nasoJ cavities communicate with
the mouth.
In double hare-lip the premaxillw and the central por.
tion of the upper lip may be oarried forwards &8 an appendage of the nose.
Very rarely the fissure of the hare·lip extends upwards
on one side of the nose towards the inner side of the orbit
(patenl orbilal gtOO'lJs).
Meningooele and Enoephalooele.
A meningocele is a protrusion of the dura mater and
the arackfUJid through a congenital aperture in the skull,
.where it forms a. soft Huctua.ting swelling, which conta.ins
cerebra-spinal fluid, and which increases in size on expiration, coughing, or crying_ The most common site is the
occipital bone, just a.bove the foramen ma.gnum, but it
may also oocur in the anterior fontanelle, at the root of
the noae, at the base of the skull (protruding into the
nasaJ. passages or pharynx), and a.t the external angle of
the orbit. It is often assooiated with hydrocephalus.
An encephalocele is a meningocele conl;aining brain
mbstance. It pulsates with the heart-beat.
A hydrep,cep1udoceJe is an encephalocele enolosing a
oavity filled with fluid continuous with that in the ventrioles.
Spina Bi1ida.
Spina bifida is a congenital defect of the posterior part
of the spinal canal, due to arrested development of the
laminoo of one or more vertebne, and generally accompanied by protrusion of the meninges and cord through
the gap. in the form of a oystio tumour varying in size
from a walnut to an orange. The usual position is the
lumbo-sacral region. the laminal of this part being the
last to olose in fretallife. It is sometimes aasooiated with
hydrocepha.!.us and ta.lipes.
Varieties.-Meningocele, meningo-myelocele, syringo.
myelocele, myelocele.
A meningocele consists of a protrusion of the dum
mater and the araohnoid through the gap in the spina.!.
oana.!.; it contains cerebro-spinal fluid.
A meningo-myeJoceJe is the most common form of spina
bifid&. It consists of a meningocele plus a portion of the
spina.!. cord and nerves.
A syringo-myelocele is rare. It is similar to the last,
but the centra.!. canal of the spinal cord is distended, the
posterior part of the cord being spread out over the
interior of the sac.
A myelocele is the condition resulting fram non-olosure
of the primitive medullary groove, the central canal opening 011 the surface.
21 9
Tortioollis is a deformity caused by contraction of one
of the sterno-mastoid muscles (often of other muscles
also), by which the head is drawn downwards towards,
and rotated away from, the afiected side.
The deformity may be congenital, or it may appear soon
after birth. IIi the former case it is due to an arrest of
development, and in the latter to partial rupture of the
sterno-mastoid during the second stage of labour. In
childhood it may come on after measles and scarlatina,
usually as the result of inflamed cervical glands. In some
cases it arises.from irritation of the spinal accessory nerve.
Occasionally it is spasmodic, disappearing when the patient
is a.nresthet.ized.
If torticollis lasts for any length of time, the sternomastoid, the deep cervical muscles, and the anterior
portion of the trapezius, become shortened, and the cervical vertebne rotated, and lateral curvature of the spine
may set in.
The congenital variety, unless surgically treated, ,tends
to produce asymmetrical growth of the head.
Cervical Rib.-This is mainly composed of cartilage.
The condition is commoner in women, and in only 5 per
cent. of cases does it give rise to symptoml!l. It arises
most frequently from the transverse process of the seventh
cervical vertebra, and passes down oehind the nerves of
the brachial plexus to unite with the central portion of
the first rib. It may compress both the branches of the
brachial plexus (often giving rise to atrophy of the small
muscles of the hand) and the ilubclavian artery. The condition is usually bilateral.
Lateral Curvature 01 the Spine (Sco6osis).
This deformity commonly results from weakness of tke
spinal muscles, and commences in almost all such cases at
about the period of puberty. It may also be due to the
shortening of a limb, or the falling in of the ribs after
an empyema..
There is a primary curve, generally in the dorsal region
and convex to the right, with secondary or compensatory
curves above and below, in a direction opposite to that of
the primary ourve, and with the object of ma.nt&ining the
body in the upright position. In addition to the lateral
curva.tute, the verteiJrm are rotated on their vertical aa:e8,
the front of their bodies moving towards the convexity of
the curve, and the spines towards the concavity. In this
way the ribs on the convex side, together with the shoulder
(. growing-out shoulder ') are thrown baokwards and
widely separated, while on the concave side they are
thrown forwards and crowded together.
If the oondition remains untreated, the intervertebral
disos become permanently wedge-shaped, the base of the
wedge being directed towards the convexity of the curve.
In old-standing and advanoed oases the bodies of the
vertebrre also become wedge-shaped.
Lateral curvature is common in Friedreioh's disease, a.nd
in syringomyelia.
Angular Curvature 01 the Spine.
This deformity, also oalled Pott's ourvature, is caused
by the destruction of one or more of the bodies of the
vertebrre by tubercular earill8 before adult life is reached.
The disease may occur in any part of the spine, but its
usua.! sta.rting-point is the dorao-lumbar region, the caries
beginning either beneath the periosteum on the anterior
surface of the vertebral bodies, or in the cancellous tissue
at their intmior. The a\Ieuted bodies and. adja.cent intervertebral disos being destroyed, a. ga.p is left, and in the
case of the growing individua.l the upper part of the spina.!
oolumn then bUs forward upon the lower to form an
angle-the so-oa.lled • a.ngular curvature' of the spinewhile the lower portion moves backward in compensation. Tubercular disease of the spine rarely oauses
a.ngular ourvature in the adult.
If repair takes placo, the gap is :filled in by a. buttress of
new bone or by fibrous tissue, and at the same time the
laminre and spines of the neural arches usua.lly become
ankylosed, and so a.ct as a kind of splint.
Spinal abacll8s is the usual accompaniment of oaries of
the vertebroo. As the pus accumulates it travels aJong
the lines of least resistance, either following the COU1'Be of
110 bloodvessel or burrowing beneath fascioo.
When the
disease is seated in the cervical region, the pus may point
in toe pharynx (post-pharyngeal absce8s), or pass along
the back of the cesophagus into the posterior mediastinum,
or it may work its way' into the posterior triangle of the
neck, and even sometimes extend into the ILXilla.
Whfln the disease is seated in the upper or the mid-dorsal
region the pus usually passes baokwards along'the posterior branches of the intercostal arteries, and forms a
swelling olose to the spinous processes (dorsal ab8Ce8s).
When the disease is seated in the lower dorsal or lumbar
region, the pus may pass backwards and form a swelling
just external to the erootor spinal muscle (lumbar ab8Ce88).
As a. rule, however, when the disease attaoks the dorsolumbar region, the pus burrows into the psoas muscle and
forms a
P80as ab8Ce88, the oourse of which is determined by the
attachmenta of the ilio-psoas fascia..
The ilia-pseas fasela. whieh invests beth the psoas and the
iliaeus musoles. Is attached above to the ligamentum arcuatum
Internum.. below to the iliac orest and brim of the true pelvis.
internally to the front of the bodios of the lumbar vertebrm.
externally to the transverse processes ot the same vertebrm. amI
it ultimately follows the ilio-psoas tendon to its insertion Into
the small trochanter at the femur.
The abscess destroys the psoas muscle, extends downwards into the false pelvis over the iliaous musole, and
forms a large fluctuating swelling in the iliao fossa.
Travelling still farther, the pus passes by a narrow neck
beneath Poupart'li ligament, just external to the femoral
vessels, and then works its way behind the femoral
vessels towards the insertion of the ilio-psoas tendon into
the small trochanter of the femur, pointing at or olose to
the saphenous opening.
A typical psoas abscess, then, when fully developed,
consists of four parts: a narrow track in the psoas muscle.
an expanded. portion over the iliac fossa, a narrow neck
beneath Poupart's ligament,and a second expanded portion
in the upper part of the thigh. Oooasionally the psoas
abscess is double.
In some oases th" pus tracks down the thigh. and it has
been known to travel as low down as the popliteal space,
and even as far as the side of the tendo Achillis.
Oocasionally the pus may enter the true pillvia, pasil
through the grea.t sacro-sciatio notoh, and form a gluteal
abscess, or it may work its way along the side of the
rectum and point in the ischia-rectal fossa.
Paraplegia occurs in but a small percentage of cll8es of
angular ourvature, the spinal oord generally ellcaping compression because the bending of the vertebral column takes
place slowly; also beca.use the spinal canal is considerably
larger than the cord, which, moreover, is protected by the
dura mater. When paraplegia does occur it is due to
the pressure of inflammatory products which cause an
oodema of the spinal cord. These products tend to
beoome absorbed in process of time; hence the paraplegia
is rarely permanent.
Coxa Vara.-The normal angle of elevation of the neck
of the femur varies between 120 and 140 degrees. Coxa
vara. is that condition in which the angle is le88 than
120 degrees. In marked oll8es the head of the bone lies
below the level of the great trochanter. The anterior
surfaoe of the neok of the femur becomes oonvex, so that
the whole of the lower limb is rotated outwards. The
deformity is generally due to separation of the upper
epiphysis of the femur, partial or complete, and the subsequent reunion in a faulty position. It may also be due
to rickets.
Coxa Valga is the antithesis of coxa vara, the angle of
elovation being over 140 degrees. It may result either
from separation of the upper epiphysis and its subsequent
reunion in a. faulty position, or from rickets.
Genu Valgum, or • Knook-Knee, • is a deformity in which
the tibia is de:B.ected outwards from the femur, so that the
external angle at the junction of the leg with the thigh is
smaller than normal.
The deformity is alway8 acquired, and usually double.
Knock-kn,ee develops at two periods of lifoDuring early childhood.
During adolesoence.
During Early Ohildhood.-The oause here is ric'fceta.
The lower end of the diaphysis of the femur and the upper
endof the diaphysis of the tibia, being soft, bend inwards.
The result is an OIJYlK'renl lengthening of the internal
condyle of the femur.
During Adoleacence.-The strength of the knee-joint,
like that of the arch of the foot. depends not only upon
the ligamenm, but also on tho bracing o.ction of the surrounding muscles. Normally, the weight of the body
is transmitted more through the outer than through the
inner condyle of tho femur; if tho muscles are weak. the
weight is thrown still more upon the outer condyle, the
growth of which is retarded, while that of the inner is
accentuated. This inoreases the downward and inward
obliquity of the femur.
In whichever way the deformity of knook-knee is produced, stretching of the internoJ lateral ligament. occurs,
while the extemal lateral ligament, the ilio-tibialoand of
the fascia lata., and the biceps, undergo shortening. The
patella is thrown outwards.
Genu Varum.-This. deformity is the antithesis of genu
valgum. It is {lro.ctically aJways bilateral, and is due to
Deformities of the foot may be congenital or acquired,
and they may occur in both extremities or in one only.
T he following are the different varieties:
Talipes Equinus, in which the heel is drawn up so that
the patient walks on his toes, which are at a right angle
to the foot. This condition is rarelyoongenital . .A oommon
oause is infantile paralysis of the dorsi-flexors of thefoot,
oausing a seoondary shortening of the musoles at the baok
of the leg. It may also occur in connection with hemiplegia,
lateral sclerosis, abscess in the calf, or even simply lying in
Talipes Calcaneus, in which the anterior part of the
foot is drawn up, forcing the patient to walk on the heel.
It may be congenital, or .the result of infantile paralysis
of the muscles of the calf. It is rare.
Talipes Varua, in which the anterior part of the foot
is twisted inwards at the calcaneo-cuboid and astragaloscaphoid articulations, the pationt walking on the outer
border. ~ It is generally associated with talipes equinus,
pure talIpes varus bcing of extreme rarity, and, when
found, usually congenital.
Talipes Valgus, in which tho anterior part of the foot
is twisted outwards at the oalcaneo-ouboid and astragalo.
scaphoid articulations, the plantar arches being obliterated
and the sole flattened. It may be either congenital or
acquired, and when the latter is generally the result of
infantile paralysis.
Talipes Equino-Varus is muoh the most frequent variety
of talipes. The hoel is drawn up and the. foot twisted
inwards. the patient walking on its outer border, where a
bursa tends to form. The twisting takes place at the
oalcanea.cuboid o.nd astragalo-scaphoid articulations. In
ordinary cases there is an inorease in the obliquity of the
neok of the astragjlolus.
Seconjary contraction of the muscles, ligaments. and
fasoim, ta.kes plaoe on the concave side of the foot. The
tendo Achillis, and the tendons of both the tibalis anticus
and the tibialis postious, are shortened.
With the exoeption of the altered obliquity of the neck
of the astragalus just mentioned, the tarsal bonea are at
first quite normal. In old-standing oases, however, those
on the inner side of the foot, being compressed, remain
The most frequent cause is infantile paralysis. It may
also be congenital when it affects both feet. The most
probable explanation of this latter form of talipes is that,
owing to some malposition of the fretus in utero, or to
deficienoy of liquor amnii, or the presence of adventitious
ba.nds, there is an a"est of the 1.£nfoldi1lfJ pr0C688 of the
, If the inversion of the foot, which is normal during the
early periods of fretal life, be maintained beyond the
normal period of time, the musclcs and ligaments will as
a. consequence be adaptivoly short on one aspect of the
limb, and too long on the other; a normal position of
inversion will finally become a. deformity' (Parker and
Talipes Calcanea-Valgus, in whioh there is a combina.:tion of talipes calcaneus with talipes vo.lgus. It is a very
rare deformity.
Talipes Cavus, in whioh the main arch of the foot is
a.bnormally developed. It is always an aoquired condition,
and is due to paralysis of the interossei musoles, with towo
contraotion of the opposing musoles, in oonsequenoe of
whioh the proximal phalanges beoome hyperextended upon
the metarsal bones, and the two distal onosflexoo towards
the sole.
The deformity is almost always combined with either
talipes equinus or talipes equino.varus.
Flat-Foot, or Talipes Planus.-The plantar arches do
not exist in the infant, but are acquired by exercise of the
deep muscles of the calf (flexor longus digitorum, tibialis
pomcus, and flexor longus hallucis) and that of the tibialis
antious and the peroneus longus. The ligaments (more
particularly the inferior calcaneo-scllophoid and the long
and short plantar ligaments) simply help to koep the
bones in position when the arch is finally established.
The primary oause of flat-foot would appear to be
m'U8cular weakness; this throws an extra strain upon
the ligaments, which, lengthening, allow the instep
gradually to sink, 80 that the sole becomes quite flat
and displays 0. tendency to eversion. The head of the
astragalus, which forms the keystone to the main plantar
arch, is displaced downwards, and in bad cases may rest
upon the ground, the internal malleolus being perceptibly
lowered. The inner side of the foot becomes lengthened.
The deformity frequently comes on in early adult life,
when the body-weight increases out of proportion to
muscular development, and it is especially liable to occur
in those who have to carry heavy weights, as for instance,
in the girl who has to carry an infant.
BaUus: Valgus consists ~f an outward displacement of the
great toe, so as to form a sharp angle with its metatarsa.l
bone. It results from wearing fa.ultily-shaped boots. As
a consequence, the toes are crowded together, and the
distal end of the first metatarsal bone becomes prominent,
being usually covered by a burs~ (bunion).
Hammer-Toe is the deformity in which there is hyperextension of the proximal phalanx, with flexion of the
second and extension of the third. Corns or bursro usually
form over the points of pressure. The deformity generally
Involves the second toe.
Although sometimes congenital, it is usually acquired
aa the result of the toes being crowded together from
wearing pointed boots or high heels.
Dupuytren's Contraction is & shortening a.nd thicken·
ing of tho digital processes of the palmar fascia. inserted
into the middle phalanges. It oommonly begins in the
little finger, thenoe extending to the ring and middle
fingers, all of which Me drawn down into the palm.
The cause is generally some long-continued pressure on
the palm of the hand, such as ma.y result from the use of tools, from pla.ying golf, rOwing, or from lea.ning
on a walking-stick. In some contraction occurs
without any apparent exciting cause, and it is then
ascribed to gout or rheumatism.
'On examining the hand, projecting ridges can be felt
extending from the palm to the fingers and if an attempt
is made to strengthen the fingers these ridges become
taut. The skin over them is at first free, but subsequently becomes adherent.
The deformity can be readily diagnosed from contraotion of the flexor tendons by the fact that the tendons
above the wrist do not become tense when an attempt is
made to stra.ighten the fingers.
Volkmann's Contracture.-This is the result of auremia
of muscles due to the pressure of bandages or
splints applied in the treatment for: (a) separation of the
lower epiphysis of the humerus j (b) fractures of the radius
and ulna.. Contraction of the fingers occurs, and some·
times of the wrist. The contraction and paralysis come
on simWtane0U8ly, a circumsta.nce that differentiates it
from the condition arising from injuries or diseases of the
nerves of the brachial plexus.
Adenoid Disease.
A.denoid disease (. adenoids ') consists ot a hypertrophy
ot the adenoid tissue in the naso·pho.ryn:s:. The growth may
entirely fill this cavity, causing 0. of the Eustaohian
tubes and ot the posterior nares, thus oompelliDg the patient to
breathe through the mouth.
The diseaso, though in rare instances oongenital, does not
generally begin until atter the first year of life. It seldom
begins after puberty, and, if already existing at puberty, tends
spontaneously to get well after this period.
Should tho nasal passages be ohronioally blocked before the
upper :law (maxllla) has 1Inlshed growing, this latter fails to
develop properly, and there results what may be termed • the
mouth-breather's ;law.'
The MouJh-lJreather's JatD.-This deformity essentially In,"olves tho ~la, the mandible being a1fected only In so far
as Its shape Is moulded by that of the maxilla. Thill falll to II'1'Ow
to its normal dimensions, and it is oompressed laterally, so that
the front portion proJeots unduly, while the palate is vaulted,
and, though aotually less than the normal height, appears
abnormally high.
The alveolar ridge being less than the normal length, while
the teeth tend to grow to their normal dimensions, these are
unable to take up their proper pOSitions, and are thus irregularly
disposed. Proo01£nud dental i,.,.egu!ari!lI, indeed, is palhoUnoinonio 0/ tke momk-bf'ea!ker'B law, and in nineteen oases out
of twenty (like the mouth-breather's :law itself), Is indicative of
the existenoe of adenoids, past or present.
Defeotive development of the maxilla leads to alteration in
the shape, not only of the mandible, but even of the skull.
Though adenoid disease Is muoh the most frequent oause
nasal blockage In the young, and thus of the mouth-breather's '
Jaw, ohildren may, of oourse, sWfer from nasal obstruotion
from other oauses, so that a typioal mouth-breather's jaw may
sometimes bo met with In a person who has never su1fered from
adenoids, but this Is rare. Congenital syphllis, being a oause of
nasal obstruotion, may lead to the deformity; In this oase, however, owfng to the Imperfeot development of the teeth, dental
Irregularity is less apt to ooeur.
The pathology of this deformity has exolted muoh oontroversy. Probably the ohief faotor In its production Is a negative
on--'.fl., the absence of the normal stimulus supplied by nasal
breathing. Clearly, ~e dally passage of some 1Ifty thousand
respiratory currents through the nasal passages must ln1Iuence
the development of the surrounding parts. Another oausatlve
factor which has been suggested Is the unduly low Intranasal
negative pressure produoed b,.. inspiration through partially
obstruoted nasal passages.
Palholow 0/ AdenoidB.-Adenolds Is essentially a disease of
olvfUzed pooples. That it must be very rare among primitive
oommunlties Is shown by the faot that, amoug the vast oolleotlon
of skulls of non-clvfUzed raoes In the Hunterian Museum, the
writer oould not lInd a single mouth-brea.ther's Jaw.
One known factor In the produotion ot adenoids Is oatarrh
of the naso-pharynx, and, this being otten the result of mlcroblo
Infeotion, the frequency of adenoids among the olvillzed may
perhaps partly be explained by the prevalence among them of
Infective' colds In the head,' In oonsequenoo of their being so
orowded together. There is, however, a muoh more potent
cause of catarrh In children-namely, Improper feeding,leading
as It does to toxmmfa of gastro-Intestinal origin-' alimentary
toxmmia,' as we may call it; Improperl'y-fed children su1!er
greatly from gastritis, enteritis, bronohitis, pharyngitis, and
rhinitis. The chief defeot In the modern syStem of feeding
ohildren is that their food oontains an excess of pultaceous
starchy material, whloh both faUs to a1ford su1llolent exerciso
for the jaws and allows the stomach to be swamped with 8.Il
excess of starch whioh has not been properly Insalivated. In
oonsequence of thls, not only does the chUd suffer from perennial
alim.entary toxremla, whloh !,"enders him liable to catarrh, but
the jaws and neighbouring parts, Including the nasal apparatus,
faU to develop properly. Now, an ill·developed naso-pharynx,
lined by a catarrhally-disposed mucous membrane, affords
conditions peculiarly favourable to the growth of adenoids.
A further faotor In causation Is the absence of the stimulus
to the flow of blood and lymph in this region normally aftorded
'tIy vigorous mastication; the close proxlmlty to the nasopharynx of the powerful pterygOid muscles is worthy of note In
this oonnection.
Adenoid disease Is, In short, essentially a dietetio disease
(R. Campbell), and mlght be practloally eradloated by the adoption of a rational system ot feeding ohildren.
The baoterla whioh, living on dead organio matter, cause
putrefaotion are known as saprophytes (sapros, putrid, rotten),
and are described as non-pathogenic, beoause they are unable to
grow on or In healthy living tissues. The baoteria whioh
develop in living tissues are known as parasites. and are do·
lI<'.ribed at path.ogenic.
Bactlll'ial Proaucts.-The most important of these are the
tomns, whioh are the essential oause of the symptoms- of baoterially·induced disease.
8epsis.-Thls term is generally ased In oonnection with
wounds. A wound is said to be In a oondition of sepsis. or to
be septic, when it has become Inoculated with pathogenic or
non-pathogenio bacteria.
In/ecIlion is the term applied when pathogenic organisms,
having entered the llvlng body, develop therein.
Sapremia. or Septic lDtomation.
If putrid blood. serum, or the fluid of decomposing tissue,
is carefully filtered, and injected into an animal, there
resultr-rigor, pyrexia, muscular twitchings, vomiting,
diarrhcea, and eventually, if the dose is sufficiently large,
death from cardiac failure.
On examining the dead anima.!, the blood is found to be
tarry and imperfectly coagulated, but free from micro·
organi81ll8 : the endothelium of the heart and bloodveBBels
is stained by pigment derived from disintegrated chromooytes; small petechia.! hmmorrhages are noticed
the serous membranes; the lungs are engorged; the liver,
spleen, and kidneys, are soft, pulpy, and friable; and the
intesliiDal mucous membraD,!l is intensely congested.
l'he term Saprremia is applied to the constitutional
symptoms similar to those just indicated resulting from
the absorption into the system of toxins generated by
organisIIls, either pathogenic or non-pathogenic, existing
in a. septic wound. No organisms entering the body, the
poison is not self-multiplying therein, and its effects are
strictly proportional to the dose absorbed. As found
in man, examples are: Absorption of poisons from the
pent-up discharges between the flaps of an amputation
stump, and the decomposed retained matter in the uterus
after parturition.
POllt-mortem Ohange,.-Death rarely results. The
post-mortem changes are similar to those found after
injecting putrid blood· serum into an animal (see above).
Septicamtia., or -Septic Infection.
If Wllfiltered putrid fluid is injected into an animal, the
result is the setting up of a train of symptoms·very similar
to those found in saprmmia.; but the animal soon dies,
even after very smaJl injections, and large numbers of
micro-organisms are fownd in· the blood.
The term Septicmmia is applied to the condition which
results from the entrance into the system of pathogenic
organisms from a. septic wound. The wound may be of
the most trifling nature, but if it permits pathogeniC
organisms to enter, these may multiply in the system
ad infinitum, and this being so, the symptoms are not
proportional to the dose absorbed. In man septicmmia
most frequently results from punctured, dissecting, and
post-mortem wounds, and from infection during the
puerperium. Most cases are due to streptococci.
P08t-mortem Ohange8.-These are the same as those
observed in saprmmia.
If a. putrid fluid, holding in snspension not merely
pathogenic micro organisms, but decomposing solid particles, is injected into an animal, death takes place, and
secondary abscesses are then found in the lungs, spleen,
kidneys, and brain.
The term' pyremia ' is applied to the condition in which
there occurs the passage of septic emboli into the bloodstream, giving rise to rapidly-forming scattered abscesses.
These emboli are derived from the breaking down of a
septic thrombus in a vein, the .sequence of events
(a) Septic phlebitis in connection with a wound.
(b) Inoculation of the contained thrombus with pathogenio organisms.
(c) The breaking down of the thrombus into emboli.
(d) Dissemination of the emboli by the circulation.
(8) The plugging up of the terminal arterioles of the
lungs, spleen, kidneys, etc., by such emboli.
(/) The formation of septic infarcts, in whioh are reproduced the conditions existing in the original wound
(= pYlelD.ic abscesset;).
The mioro-organisms are the same as those found in
septicmmia, streptococoi being the most abundant.
Py.mia WILB, in pre-Listerian da.ys, a very common
cause of death after operations and oertain injuries,
especially those implicating veins, bones, or joints; now
it is but rarely seen, except in the form of .eptic tkrombosia
of the ZatsraZ Binu. in conneotion with middle-ear disease.
Po.t-mortem Cha.ngBB.-The veim lea.ding from the
infected wound show suppurative phlobitis and periphlebitis, and they contain thrombi in various stages of
deoomposition a.nd disintegration.
The lungs are congested, a.nd scattered thrqughout their
substance are septio infarcts, ra.nging in size from a pea
to a walnut, and having their bases beneath the pul,
monary pleura. In the neighbourhood of the infarots are
patohes of bronoho-pneumonia. The pleural sacs contain a quantity of a dark-coloured turbid fluid mixed with
The heMt muacle is flabby, and often the seat of small
abscesses. The pericardium may contain fluid similar to
that found in the pleura. The interior of both the heart
and the aorta is generally deeply stained with pigment
derived from broken.down ohrcmocytes.
The spleen, kidney8, and brain usually show septic
infarcts similar to those found in the lungs.
The joints, particularly those of the knee and shoulder,
are often affected, and contain a thin purulent liquid.
23 1
Abscesses may form in other parts of the body. such as
the parotid gland. and interior of the eye (panophthaZmiti8).
Portal pyamia, or suppurative pylephlebitis, is that form of
JlYEmia. which ooonra in connection with ulceration of the gutro·
mtestinaJ. traot or gaJ.I·blo.dder, or infia.mmation of the uuibilica.l
vein in newly-born infanta. Multiple septio info.rota are found
scattered throughout the liver, corresponding in situa.tion to the
terminaJ brancliea of the portal vein.
Malarial para.Bite,.
Treponema. "allidum.
Leishman's body.
Tami" ,olium.
Oestoda, or
Tamia. medioc"nellatll.
taLpe-worma{ Tcmia echinococcus.
Bothriocephalus lGtus.
.AscariB lumbricoides.
TnchocephalUIJ dispa.f'.
.Ankylostoma duodeaaf.e.
thread-worms Trichitsa Ipir..ZiB.
{ Filari• • a'll(JUiwi8 Itominis.
Dracunculus medinensi,.
m.._ t d
or {SClti8toSomum, or BilAar:na ItlBmMo5ia.
"'~uka. 0 a.,
Schiatolomllm callo;.
.. e-worms SchiBtosomumjaponicum.
Nema.toda., or
The term Protolloa is applied to the lowest group of the
animal kingdom, a group which is sharply distinguished
iTom others (M8tasoa) by the fact that its members are
simple unicellular maSBes of protoplasm.
Most of the parasites found in circulating human blood
a.l"e protozoal; the only metazoal are the embryos of the
order Filariidre (FiZ. Banerofti, etc.).
Ammba coli is found in the upper part of the la.rge
intestine; it does not penetrate the mucous membrane,.
and is probably quite harmless.
Entamceba. histolytica. is found in the dejeota and in
the ulcers of the disea.sed bowel in Asiatio dysentery, also
in the walls of a tropical absoess of the liver.
The erganism measures 25 " to SO ". in diameter, and
consists of an outer translucent part, the tleto,arc, and an
inner granular part, the tmdOBarc. It is colourless, throws
(lut pseudopodia, is actively motile, and in its general
charaoters resembles the ordi,nary ammba. Reproduotion
is by fission.
Trypa.nosomata. are minute protozoal organisms shaped
like an elongated spindle, with 110 long or flagellum at
one end, and 110 delioate finlike swimming membrane
running from the attachment of the flilogellum to the other
end of the spindle. .They swim very aotively in the
blood-plasma, with a wriggling sorew-like movement, the
flagellum being usually in front' (Manson). They are
never contained in the blood-cells. Their average size is
three to four times the diameter of me red blood-oorpuscle.
One speoies, the Trypanoaoma Gambitm,c, is probably
the cause af tho.t scourge of Africa, the aleeping Bicknell
(in which disease there is a well·marked cerebro.spinal
meningitis), as it is found in the blood, cerebro-spinal
fluid, and lymphatic glands of patients suffering from this
disease, being conveyed from the sick to the heo.lthy by
means of a biting l1y-the GIOBSina palpali,. (Another
fly, the Glol8ma mor8itana, ill now also suspected. 1$ is
found much farther south-as far as Rhodesia.)
~other speoies, the Trypanosoma Bruoei, causes the
tsetse-l1y of horses, dogs, sheep, and the large
game of Africa, the l1y aoting as the intermediary which
carrieG the pa.rasite from one mammal to another.
A third species, tho Trypano,oma Lewisi, infests the mt.
Mala.riaJ. Pa.ra.sites.-Malarie.l fevers are caused by the
presence in the blood of small, colourless, amreboid
proto.zoa. The para.sito has two cycles of existence,
one pa.ssed in man, the other in the mosquito.
Into. the human host the organism is introduced by
the }lite of the mosquito. Taking up its habitat in
the red blood-corpuscle, it lives at its expense, and
'lJlultiplies asexually by simple division. In a.ddition
,to this method of a.sexual reproduction, the parasite
a.lso produces orescent - shaped sexulll forms which
under ordinary circumstanccs perish in the blood (being
probably engulfed by phagocytes); but if they are transfcrred into the stomach of the mosquito, Il.S when the
insect bites a man whose blood contains these foms, they
undergo further development there, and reproduce themselves sexually.
In the proboscis of the mosquito thero are t1vo separate tubes.
one UP. which blood Is sucked, the other down which the intooted
So.lIvu. Is injected.
Of the three to four hundred described species of mosquito.
only a limited number arc malaria-carriers. and these belong to
the subfamily .4 nophelina.
In common with other Insects. the mosquito passes through the
follo\vlng stages of development: The adult female lays her eggs
in still water. In tho course of from two to four days thoso arc
hatched Into laM/aI. which in about ten days' time are transformed
Into the pupm. these two days later becoming full-grown insects.
or imagos. Atter hatching they must have air, which is breathed
through 0. hole near the tall. The normal position of the little
animal is lust below the surface with the tail pointing upwards.
Eventually they burst their pupa-casos. and flyaway from the
The female impreonated aneplloles is tho blood-sueker. and
then Only during night-time.
The vitality and growth of the mosquito aro favourod by
warmth, and retarded. or altogether arrested. by cold.
The malaria.! parasite, once introduccd into the blood of
man, may persist for months. sometimes for a year or two.
After this it dies out, unless reinfection by the mosquito
~s place. Whilst in the blood, it lives entirely at the
expense of the red corpusQles of its host.
The life-history of all is pJ'8.~tica.lly the same, and consists of two cycles: (a) The human cycle, and (b) the
mosquito cycle.
(al The Human Cycle.-At the time of infection by the
bite of the mosquito, minute rod-shaped bodieB-8porozoiteJ
(IS)-are introduced into the blood of the human host.
Each sporozoite at once bores its way into 110 red bloodcorpuscle (I), in the interior of which it develops ~ally
in the following manner: The rod-shaped sporozoite assumes a spherical shape. forming a minute unicellular mass
of protoplasm, 8ckizont (2). exhibiting ammboid movement
and occupying but a small po.rt of tho corpuscle. Gmdually it increases in size until it occupies nearly the whole
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1, Boa lIoEpnaele with sporozoite entering; 1', red OOl'pllscle
with merozoite enle.riD(; SI. 8••tagtS of developJDeut within
red corpuscle (lIIlhinll;t); 4, rosette body; 6, Jorma.tlon of
merozolteai 6~ libere.tlon of merozoite. into I!ls.sma by
bllHting at rea eotp1llCle; S', merozoite, whiclJ 6_8& (7)
erescenti body; 8. meJe _cent; 9, female creacent;
10. male ga.tJIetocyte; 11. female gametocyte; 12, forma.tion
of microgWletes in male gametocyte; 1S. formatiOli of
me.crogametll in female gametocyte; 14. fertiliza.tiOli of
macrogamate of female gametocyte bye. microgamete of the
male gametocyte. whiob now becomes a zygote i 15. O(lkinet·
16. oocyet; 11, developlllGnt of aporoblsatB; 1S,llbeta.tion J
corpusole (3). the hlllllloglobin of which is oonverted into
gmnules of pigment, whioh ultimately collect into clumps.
The parasite now undergocs segmentation, arranging
itself in a cluster of minute spherules (15 to 25), and form.
ing what is known as the rosette body (4). These segmented
bodies soon break up into separate parts, merozoites (5), and
by the end of forty·eight hours the corpuscle ruptures
and liberates these into the plasma (6). Eachmerozoite
then inva.des a fresh red corpuscle (1), in which it repeats
the same forty-eight hours' cycle of development.
This asexual process of multiplication by simple division
is known as sckizogony.
The setting free of the merozoites into the plasma
coincides in time with the onset of the febrile attack, and
it is proba.ble that a fever-producing poison is also liberated
when the corpuscle bursts.
The completion of this asexual oyole takes forty.eight
hours in tertian fever, and seventy·two hours ill quartan.
(b) The Mosquito Oycle.-In addition to the above
asexual multiplication, some of the parasites in the red
corpuscles develop (as before explained) into crescent·
shaped sexual forms (7).
The crescents contain pigment, and are of two distinct
kinds: The female crescent (9), 0. long and narrow cres·
cent, round the centre of which the pigment is arranged
in a circle; the male crescent (8), Do shorter and thicker
crescent, throughout which the pigment is scattered
Each of these bodiee remains enclosed within the thin
shell of its respective red blood-corpuscle, and if left in
the blood of man does not proceed to segmentation, and
undergoes no further development. Should, however,
a mosquito bite a person in whose blood these crescents
exist, they are then conveyed int:> the insect's stomach,
where, escaping from the red blood·corpuscles: they become
The crescents now beooIlle spherical, and are known as
the female (11) and male (10) gamel.ocytes respeotively.
From the outside of the male gameMcyte (12) whiplike
filaments (microgame!e3) now protrude, and becoming
detached, swim about in the stomach of the mosquito
until. meeting a female ga.metocyte (13). one of them
fertilizes the large cell (macrogamete) oontained in it (14),
and gives rise to a zygote.
The zygote, at first spherical, becomes ovoid with Il
pointed end (ookinet, 15). and, acquiring powers of locomotion, burrows through the epithelial lining of tho
stomach, a.nd comes to rest between the epitheIia.1 and the
muscular layers.
Here it forms a capsule round itself, becomes spherical.
and begins to grow (oiieyst, 16), until by the end of from
ten to fourteen days it has attained a comparatively large
size. 'During this time the contents have become converted into a number of rounded masses (8poroblaat8, 17),
each of which, when the process of subdivision is completed, becomes covered with a pile of thickly-set, minute,
elongated, spindle-shaped rods (8porozoites, 18), arranged
like the spines on a hedgehog' (l\:[anson). Finally, the
capsule ruptures, a.nd the sporozoites, escaping into the
lymphatics on the outer surface of the stoml!-ch, enter tho
oircull),tio~, and are ultimately convElyed to the salivary
gla.nd. When the mosquito bites a man, the spqrozoites
travel down the probosois with the salivary or poison
fluid and are injected into their human hest (1), and there
meeting red blood-cells, function as the merozoites did.
There are three kinds of malarial parasites:
1. Plasmodium malqritB.
2. Plasmodium fJif)lJ3; (tertian).
3. Plasmodium Jalciparum (malignant).
Variations in oyoles may be produced by mosquitoes
biting on sucoessive nights, so that one crop will mature
and sporulate twenty-four hours before the other= quotidian type of fever.
Summary of Sexual ·Cycle.
The Jemak gameWcyU encloses a. single cell, called tho
macrooameie. which Is the homologue of the ovum.
The male gametlJC'Ute develops ,upon its exterior whipliko
proccsBOs. oalled microga:tlUllu. whioh are tho homologue ot tho
One of these mlorogam.otes fortiliJI:es a. maorogamete. the
result being a. Z1Ig~.
The zygoto. when It has acquired powers of looomotloJI, is
termed an o(Jkinet. The enoysted oilkinet in the stomach wall
is called an OIJC1/Bt.
In the 06cyet aro developed tIle 8JlorOOlastB. and from these
lInallY are formed the BpCfI'Ozoite8.
In the oourse of a report on the risks of the spread of malaria
in relation to demobilization. Lieutenant-Colonel James says
that tho factor whioh determines whether the disease will spread
or not is neither tho number ot anopheline mosquitoes in tho
district nor tho number ot human malaria oarriers_ It depends
on the closo and oontinuous association between the malariB
carrier. the anopheline. and tho susoeptlble porson. This is only
IIkoly to ODDur in the type of dwolling ,vhioh tho mosquito solects
as its pormanent feoding Bnd J:ostlng place.
It has been found that tho malaria-boaring mosquito does ROt
stau in a ~1'-lightM house or modem hOBPital. Clean baro walls
and ooilings. large windows. and littlo furniture Bro not suited
to it. On tho contrary. it selects cottages or old-fashioned houses.
where the rooms are ' stufJ'll • and hot, ill-lilJllkd. il'-1lemilated. 1I1iO&
dark recesses. C1I.pboards. old drapery. and much furniture. Hero
tho mosquito takes up its abodo. and it there is restrictod living
or sloeping acoommodation. intootion is very likely to bo oBrriccl
from tho malaria-oarrier to tho susceptlblo porson.
Treponema Pallidum.-Vide p. 194.
Leishman's bodies (or Leishman-Donovan) are found
in the spleen and bone-marrow of tropiCBI splenomegaly,
or 1cala-aza,.. Each is ovoid in outline, with a. large
deeply-staining nucleus, and a tiny rod-shaped, still more
deeply-staining nucleolus_
Tho disease is transmlttod by tho blto ot the common bug
Captain Patton (!.llf.S.) has sucoeeded in observing tho oomplete dovelopment ot tho )mIa-azar parasite both In Indian bedliugs Bnd in the European SpOOiOB. Species: Leishman-Dono'Vani, causes kaIa-unr (India); Leisl~man tropica, oauses Delhi
lioU; Leishman infantum, oauses infantUe splenic anlllIllla.
Cestoda (keltol, a girdle).
The members of this group have a life-history whioh is
peculiar in tha~ it embraces two dis~inct stages of exis~ence
-the adult BtagB, generally found in one species of
animals (the host), and the embryonic dagB, found usually
in another species (the intermediate host).
The adult tape-worm occupies the intestines. It consists of a head, a narrow neck, and a series of lIattened
segments, or proglottides.
The head at its widest part is provided with four suokers,
by means of which it fastens itself to the intestinal
mucous membrane of the host, and anteriorly it is pro-
longed into 80 f'08tell1,m, or proboscis, surrounded by two
rows of hooklets.
Commencing at the a.nterior part of the body and running
ba.ckwards aJong each side are two 10ngitudinaJ tubes-the
water fJa8cular Bystem. Tllere is no aJimenta.ry C&naJ.
Ea.c.h progiottill is bisexuaJ, the respeetive senaJ ducts
opening at the genital papilla, which is placed at one edge of
each proglottis, the papillm being at alternate sides of successive
The teats8 consist of smaJl vesioles, the ducta of which uuite
into a vas deferens, whioh enters the penia.
The uterua is branched, having a centr-.J, canal with lateral
diverticula; it is connected at one end with two ooariea by
means of two oviducts, and at the otlaer end with a vagina.
The Bpermatozoa travel from the pellis, enter the vagina. at the
genitaJ pore, and then fertilizo the ova. The di8taJ proglottides,
holding the embryos, become deta.ched, ,.and escape from the
intestines with the fmces.
The proglotlis then decomposes and liberates 'he
embryos, each of which is provided with six hooks and
surrounded by a capsule. If the embryos are now
swallowed by another animal (ths intsTmetUate koat) ,
their capsules are dissolved ~~x!ts digestive juices, and
the embryos esoape into the . entary canal of the new
host. They then bore their way through the walls of the
alimentary canal, and finally settle in the viscera, or the
musclE\ll. After this, the further development of the
embryo is as follows: The hooklets disappear, and at the
caudal end a cavity develops, in the interior of which an
immature head (.cole",) appears, the whole organism
being afterwards enclosed by 0. fibrous capsule formed by
oondensation of the surrounding connective tissues of the
host. This intermediate stage is known as the Oysticfff'CUI
CellUWBtB, or bladder-worm. Should the flesh of the
animal harbouring the Oy8tic6TCUI ceUulo.tB now be
consumed by another animal, the head of the cysticerous
becomes everted, and, losing its bla.dder-like appendage,
fastens itself to the .intestine of the new host by means
of its foUl" BUckers, and develops proglottides frdm ita
caudal end.
Hydatid Cyst.-The intermediate stage of the TtBnia.
"MnoOOCCUI is known as the hydatid.
The embryos,
proviaea witb tbeir six books, enter tbe alimentary canal
of some animal-aay man-and their capsules being
dissolved by the digestive juices of the bost, they are set
free. They then bore their way into the tributaries of the
portal vein, and so reach the liver or other organ, where
they come to rest.
17 .-BROOD
'Ea.cb embryo now loses its booklets, and is connried
into a cyst, the wllllll of which are composed of concentrio
lamina lined by granular cells-the gernWnal memll'rlm6and filled with a non· albuminous lluid rich in sodium
Lendh •••
- ProiJ,ottldes
10 feet
15 feet
-n inch
Booklets ..•
•• ,
.. .
.. .
Intermedia.te hOlt
3, B%clu·
sive of
20 feet
Me a.nd Sturgeon,
eheep pike, trout
N.B.-Avenzgelength a.nd number of proglottides given.
chloride and containing the hooklets, which are of great
diagnoltic va.1ue. They are insoluble in acids. Within
the cyst are b"ooa CapBUle. j these are small vesicles
which, originating from the germinal membrane, contain
immature heads (,colicell) orowned with hooklets, and are
analogous to the Oy.tiCfJf'()'U' cellulo.tB of the other tape.
Tile entire hydatid oyst is surrounded by an adventitious
capsule of fibrous tissue.
Nematoda. (nema, a thread).
These "are slender, elongated worms tapering at the
extremities. Each has an alimentary oanal, with mouth
and anus. The sexes are distinct, the female being the
larger. A few typioa.1 members of the class alone need be
Ankylostoma Duodenale. - The female is about
! inch in length, the male slightly shorter. The mouth
is furnished with teeth, by which the worm fastens itseU
to the duodena.1 muoous membrane of the hosr. The egg
ill enclosed within a thin transparent capsule, and is voided
with the freces. It then matures in d~p earth the
ep:l,bryos invading the body of the new hoat, probabiy by
penetrating the skin, generally that of the feet or leg!!.
From the likin they enter the blood, ultimately rea.ching
the lungs. Up to this time they retain their original size,
but once in the air.passages of the lung!! their growth Is
rapid. They then travel up from the air· vesicles into
the bronchi, trachea, and glottis, whenoe they pass into
the resophagus, and thenos into the duodenum, where they
attain maturity.
These parasites, in virtue of their leechlike habits,
suck a great quantity of blood from the duodenal mucous
membr~e, causing 8 serious form of aDlemia (oooli6
antBmia), which is associated with a great increase in the
eosinophile leucooytes in the blood. The worm in 1908
made its appearance amongst the miners engaged in the
Da.1coath tin.mine in Cornwall. It is oommon in Egypt,
Brazil, Italy, and other hot countries.
Trichina. SpiraJis.-The fema.1e is about 1 inch long,
and the ma.1e about
inch. The mature worm is
found in the intestines of man and other anima.1s; the
Immature form is found in the mUsoles. The ova aN
hatohed into embryos in the uterus, tM 'Y0'IIII'IfI bmt,g born
in tke free stGte. The life-history of this is BI
follows: When infected pork, e.g., is eaten, the capsulel
containing the em bryos are dissolved in the stomach by the
digestive juices, and the liberated young worms pails into
the intestines. Here, in the course of a. few days, they maturity and pm. the females afterwards boring
their wa.y through the mucous into the lymphatics, where they liberate their young (each female
giving birth to thousands), whioh are then oarried into
the general circulation. Ultimately they reaoh the
voluntary musoles (especially the abdominal, thore.cia,.
pharyngeal, and tongue), and piercing the sarcolemma,
coll themselves up in the interior of the fibres, and become
encysted, in this position undergoing no further development until the infected flesh is eaten by a new host.
After a time the cyst wall may calcify. The cysts are
visible to the naked eye as minute whit,e speoks, firs'
observed by Sir James Paget, when a student in the
disseoting-room of St. Bartholomew's Hospital.
They have been found in all striated muscle except that
of the heart.
The disease is conveyed to man by. the ingestion of
imperfeotly oooked trichinosed .pork. The pig is usually
infeoted by eating triohinosed rats.
FUaria Sanguinis Hominis.-The adult form of this
worm is known as the, BamoroJU, and the ombryonio form as the FilairiG noohwnG.
FiZtvriG BcmoroJti.-This form is confined to the lymphatios. The female is about 81 inches long, the' male
only about half this size.
Reproduction is viviparous, the female disoharging her
embryos into the lymph, by which they are carried into
the blood-stream by way of the thoraoio duct.
FilaJriG NootumG.-The snakelike embryo is about
..\ of an inoh long, its breadth about the diameter of a
red blood-corpuscle. The head is provided willi a ahort
spine, and a circlet of hooked lips.
The organism is imprisoned within a long loose SBO,
inside which it oan be seen to wriggle, but from which it
is powerless to escape, BO long lIB It remains in its human
The embryos are present in the surface bloodvessela
during sleeping hours only-whence the name F. nooturna; when the patient awakes they gradually retire to
the lungs and larger bloodvessels. The cause of this remarkable periodicity is unknown. If a :filarial patient
changes hiJI hours of sleep from nigh~ to day, the periodicity
changes correspondingly.
As theae :filarilB cannot further develop in the human
host, they probably soon die, unless they are removed to an
intermediate hoat. This latter is a species of mosquito
(OuZez ft£tigrLns), which swallows the filaria. when
sucking humm blood. In the mosquito's stomach the
embryo escapes frOID the Bac which has hitherto enclosed
It, and bores its way through to the thoracic muscles,
where it comes to rest. By about four weeks' time it has
grown considerably, and then, resuming its travels, it
reaches the proboscis, and returns to another human host
when the insect stings. Ii now passes to the lymphatios,
where it matures into the Filaria Ba;ncrofti. The sexes
then come together, and the young are born.
Yllariasis.-In the large majority of CaBes the presence
of filarilB in the human ,!>ody gives rise to no obvious
symptoms. Occasionally, however, the mature worm
may block the lymphatics, or the femaJe may disoharge,
instead of embryos, unhatched Qva which are large enough
~o obstruct the lymph-streloID, and 80 give rise to lymph.
,ta..U. When this happens, any of the fonowing tropicoJ
disease. may result:
OhIY7luria, due to ruptured lymphatios in the urina.ry
tract, the urine beooming milky in appearance and coagu·
lating into • jelly after standing. Analogou. conditions
OhyloUl dianT'hma.
OhylOUl IUcite••
Lymph .erotum, characterized by the presence in the
scrotum of dilated and varicose lymphatios; these some·
times bunt.
ElepAantituU .drabum, characterized by hypertrophy
of the tissues, the result of blocked lymphatics. It is most
CIOD1IDOIIly met with In the legs aDd genitals. Enormous
tumours may thus form, the scrotum alone, for inlltance,
having been-known to weigh as muoh as 100 pounds.
Vanoole ligmpn.afM glMr.l", giring rise to soft, painless
tumours, over which the skin oan be freely moved.
AbBC6IBIJI, from the irritation caused by blooked lymphatics or by dead filaril1!.
In a.ddition to the FilMia BMJtJrofti and its emblyonio form,
FilMia noet"ma, which are found all over the tropics, there are
at leut three other a.llied s~ found in the tropics-viz.,
Filaria diuf'fIG (West Africa), Filaria _pll1'stans (Africa. and
Demerara), and Filaria demarqvcIi (West Indies and Demerara).
The only member of this group at &ll oommon in man
is the BiZhalrna,,tobia. The parasite is found in
Natal, the Transvaal, Egypt, Madagascar, and the West
Indies (particularly Porto Rico).
The female worm is about 1 inoh long, the male
about l inch. They inhabit the portal vein and its tributaries, also the ve~caJ veins.
The ventral surface of the male is concave, and during
oopulation the lateral borders become infolded 60 lioii to
enclose the female in a 'gynlllcophorio cana.I.' The ova
are shaped like melon.seeds, being provided at the pointed
end with a spin., by means of whioh they work their way
through the walls of the &mall veins; they thus gain
entrance into the rectum or bladder, whence they are
discharged with the flecee and urine. A good deal of
oozing of blood from the muoous surfaoes may be caused
by the migration.
The Ova cannot mature)whilst in the body, but if placed
in water, or if the urine oontaining them be diluted with
water, the oapsules burst, and the ciliated embryos are set
As regarcls the intermediate host nothing iI brown.
Analogy with the history of the other nematodes would
suggest that the embryo antere lome fr~lh-w&ter animal,
in whose body U undergoes a further developmental
change.. Infeotion in man is probably through drinking
contaminated water. Some maintain that the embryo.
enter the urethra or anus during the act of bathing.
The effect of the parasite is to cause mdemic /r,m_
tUM, as also the passage of blood from the rectum.
Condylomata may develop both inside and outside the
anuB, and for 1.hiB reason the condition ma.y be mistaken
for syphilis.
The period of incubation which elapses between infection and the appea.ra.noe of ova in the urine, would appear
to exoeed feur months.
Fatigue is due to (a) using up of tho enorgy pabulum within the
musole; (II) to the aocumulatio,n of fatlglle produots, whioh are
acid in nature, chiefly laotlo acid. If a muscle is made to
oontmot in the presenoe of oxygen,laotio aoid does not appear,
and the onset of fatigue is retarded or absent altogether.
Tho oauses are the aooumulatlon of fatigue produots, produced
by exoessive musoular exertion, aoting in oonjunotion with Insu1ll.olont oxygenation of the blood. Those addiotcd to alcohol,
or who are over-indulgent in feeding, and su1l'erers from malaria,
are particularly prone. Previously healthy men are rarely
Tho post-mortem findings are: mdema. ot the leptomeninges,
braiD, and lungs; oloudy swelling of the myocardium, liver, and
kidneys; fatty ohanges in the liver; peteohialluemorrhages in
thc brain, viscera, and skin. Rigor mortis sots In early, and the
body decomposes qulokly.
of liver!. 170
Acetone, IBlI
Achondroplasia, 208
Acidosis, 183
Aoromegaly, 200
Actinomycosis, 76
Acute yellow o.tropby, 178
AddiBoIt s disease, 188
Adenoids, 228
Adenomata, Sf.
Adrenalln, 188
Agglutinins, 44
Aggressins, 46
Ague, 232
Albuminuric retlnltls, 183
Alcoholism, 200
Amboc~tor, 46
Amitotic, 2
Ammba coli, 281
Amphophil, 3
Amyloid degeneration, 9
AUlllmia 26
Anaphylaxis, 62
Anasarca, 62
Aneurism, 111
Angina pectoris, 129
Angiomata, 83
Angio-neurotic cedema, 63
A_ngular curvature, 220
Ankylostoma, 240
Anopheles 233
Anthracosis, 143
Antibodies, 42
AntitoxIns, 46
Apoplexy, 114
Arteries diseases of, 106
Arterlo-sclerOllis, 110
Arthritis, deformans, 212
Ascaris lumbricoides, 231
Ascites, 62
Astral s,f3r.m,-2
Atelectasis, 181
Atheroma, 108
Atrophy, 16
Auricular ftbrlllation. 125
Avitaminoses, 205
Dactp.rlolyslns, 46
Bantl's disease, 80
Basophil, 22
Bed-sore, 58
Berl-berJ, 208
1illharzla hromatobla, 243
Blood-platelets, 18
Bone, 201
Bone-marrow 23
Bothtiocepiiaius latus, 239
Branchial ftstula, 218
Bronchieotasis, 135
Bronchocele, 192
Broncho-pneumonia, 188
Cachexia stmmiprlva, 187
CalclOcatlon, 8
Cancer Incidence, 103
duc~, 08
Cancrum oris, 69
Oarbuncle, 68
Oaroinomata, 91
columnar, 98
encephaloid, 97
scirrhus, 97
spheroidal, 98
squamous, 94
Carles, 203
CaBeation, 16
Cell-nesta, 96
Centrosome, 2
Cerebral hremorrhage, 114
Cerebro-spinal ftuid, 161
Cervical rib, 219
Cestoda, 237
Chancre, 104
Charcot's joint disease, 214
Chemotaxis, 42
Chlorosis 27
CholeliihIaSis.t 177
Chondroma, 110
Chorio-epithelloma, 06
Chromaflln system, 188
Chromatin, 1
Chromatoiyais, 8
Chromocytes, 18
Chyluria, 242
Cirrhosis of liver, 171
CIrsoid aneurism, B3
Cleft palate, 218
Cloudy swelling, 8
Coagulation neorosls, IIi
ColiapRe, 116
CollOid cancer, 09
degeneratioD, 12
Colloids, 1
COlour-Index, 20
Oolumnllr-oelled carcinoma, 98
Oomplement. 48
Ooronll1'Y arteries, 129
Ooxa vaiga, 222
vara, 22.2
Oraniotabes, 207
OretinlRm, 186
Oulex fatlgans, 242
Cysts, 85
Oytolysins, 46
DefIciency diseases, 205
DeformltteB, 218
Degenerations, 6
Delhi boil, 237
Dermoid cysts, 86
Dextrose, 179
Diabetes mellitus~ 179
Diabetic coma, 11S2
gangrene, 182
Diphtheria, 45
Dropsy, 61
Drunkard's liver, 174
Duct cancer, 98
Dupuytren's contraetlon, 225
Dysentery, 282
Echinococcus, 288
Ehrlich's theory of Immunity, 49
Embolism, 65
Emphysema, 132
Encephaloid carcinoma, 97
Endarteritis, 106
Endocarditis, 121
Endocrines, 183
Endotheliomata, 90
"Endo-toxins, 88
Entammba hlstolytioa, 232
Eoslnophlles, 22
Eosinophilia, 26
Epithelioma, 94
Ergotism, 61
ErythrocyteR, 18
ExophthalmiC goitre, 186
Exostoses, 81
Exo-toxlns, 88
Fat embolism, 66
necposis, 14.
Fatigue, 244
Fatty degeneration, II
Inftltration, 7
Fevers, 86
Fibroid phthisiS, 142
FIbroma, 78
Fibrosis, 85, 70
Filariasis, 241
Flat-foot, 226
Focal necrosis, a
Fractures, repair 01, 89
Frost-bite, 61
Frohlich's syndrome, 1.0
Gall-stones, 177
GametocyteR, 236
Gangrene, 66
Gas gangrene, 67 .
G~n'ra1 paralysis of, 19S
Ganu valgum, 222
Giant cells, 71
Giants, 190
Gigantoblasts, 20
Glgantocytes, 19
Glanders, 76
Glioma, 711
GUo-sarcoma, 89
Glossina paJpalis, 232
monitan8, 232
Glycogenic infIltration, 7
GIYcosurio.~ 179
Goitre, 1911
Gonorrhmal rheumatism, 21&
Gout, 218
GranUlation tissue, 68
Granulomata, 71
Gumma, 196
Hmmatoidln, 13
Hmmoglobin Index, 20
Hmmolf!ius, 46
Hmmoslderin, 13
Hallux valgns, 226
Ho.mmer-toe, 22';
Hanot's disease, 178
Haptophore, 99
Hare-lip, 217
Healing, 68
Heart, 119
Heart-block, 129
Heat-stroke, 244
Hepatolysin, 48
Histolysis, 36
Hodgldn's disease, 32
Hormones, 183
Hyaline degeneration, 11
Hydatlds, 238
HYdronephrosla, 165
Hyperplasia, 17
Hypertonus, 160
Hypertrophy, 17
Hypophysis, 190
HypopltlJ1tarilm, 190
Hypoplasia, 16
Hypotonu~, 180
Immune body, 48
Immunity, 98
Infantilism, 192
Infarcts, 86
Infection, 88
Inftltmtiona, 6
Inllammation, 88
Influenza, 139
Involniaon, 16
diseases of, 210
Kala-azar, 2ST
Karyosomes, 2
Kidneys, diseases of, 164
Lardacoous degeneration, II
Lateral curvature, 219
Leiomyoma~ 82
Leishman's DOdy, 237
Leontiasis 0888&, 210
Leprosy, 76
Leucocytes 10
Lencocytosis 23
Leuoopema, 26
Lenkmmia, 30
Lipochromes, 12
Lipoma, '19
Liver, diseas08 of, 166
Locomotor ataxla, 199
Lumbar_puncture, 153
Lungs, diseases or, 131
Lupus~ 76
Lymjlhmmia, SI
Lymphangeioma, 84.
Lymphocytes 10
Lymphocytosis, 26
Lymphoidocyte, 23
Lympho-s&rcoma, 86
l\Ialarla. 232
Mal1IIinant pustule, 69
Mamma, 97
Marrow 29
Mast ceils, 22
HogJiJol1bI.fU, 19
lIlegalooytes, 19
Melanin 12
Melanotio sarcoma, 88
Meningocele, 218
Menlngo-myelocele, 218
Merozoltel 235
Mlcroblasr.s, 20
Miorocytes, 19
MlUary aneurislllll, 113
Milk-patches, 119
Moist gangrene, 57
Mollities ossium, 209
Mosquito, 238
Mucoid degeneration, 11
Myelmmla, 80 L& t'
Myelitis 1'18 1...- u
Myeloceie, 218
Mye'/ocrtBB. .BlI
Myeloma, 82
Myoma, 82
Myxmdema 186
NlBvu. 88
N ecr08is, lOS
Nematoda, 240
Neoplasms, 76
Nepbritis, 166
Nerve degeneratiOll, 146
Nervous system, 145
Neuroma, 82
Neurone 145
NeuropathiC arthritis, 2U
NeutrOpblle, 21
Normoblasts, 19
Nutmeg liver, 169
Odontomtlll, 81
<Edema, 61
anglo-neurotic, 63
Ollgmmia, 26
OIlgocbrommmiaL 26
OligocythlBmia, l!:6
Opsonlns, 42
Osteitis, 209
deformans, 209
Osteo-artbropathy, 210
Osteomalacia, 209
Osteomata, 80
Osteomyelitis, 202
Oxypbil, 3
OxYUrIs vermloulat1s, 231
Paget'. disease of
pl8, 98
Panoreas, diseases 0 , 178
Papillomata, 78
Parasites, 1191
Parathyroids, 187
Pericardium, 116
Pernicious allIBmia, 27
Pfeiffer's reaction, 46
PbagedlBna, 69
Phagocytosis, U
Phlebitis, 10"'
Phyluis, "
Pigmentation, III
Pituitary body, 189
Plasma cell, 22
Pneumonia, 136
Poikilooytes, 19
Polymorphonuclean, 111
Port&!. pymmi.., 2S1
Preclpitlns, 4&
Premature puberty, ]92
Benillty, 192
Proteinurl.., 164
Protozoa, 231
PBoas abscess, 221
Pulmonary tllberculOllla, 139
PYlllmla, 229
Ranul.., Jl6
Raynaud's diileaae, 00
Recet>tolBii 49
:ll.epall, I>
Rhabdomyoma, .82
Rbeumatold arthritis, 218
Riokets, 206
Rodent llicer, 95
Rosette "ady, 23&
Saprlllmia 228
Saprophyte8L 228
Sai'eonmte, 1:18
Sean, 70
Schizont, 235
Sclrrhus, 97
Sourvy rlcketAl, 208
SeDlitizer, 40
SepRIS, 228
SeptiCQImia, 229
Tabes dorsalis, 199
Taluia ecllinococcus, 239
medlocaneUata, 239
solium, 239
Talipes, 223
T, 239
Teeth, 208
Teratomata, 86
Tetanus, 39
Thrombosis, 64
Thymul gland, 101
Thyroid gland, 186
TortlcolllA, IUD
ToxIus, 38
Toxophore, 89
Trematoda, 248
Trench nephrltla 163
Treponema p ..llldum, 193
TrlChinat!lfaliB, 240
Tricboce alua diapar, 231
Trophic. lous, 160
Tropical abscllIl8, 164
Trypanosomata, 232
Tubercle, '11
Tuberculoeia l .139
acute mulary, 74
TomoUl'll, '16
Ulcer, 36
rodent, 96
Union, prImary1 69
secondary, .,9
Sera, &5
~~l:' ~~;ness, 55
Uro-toxlus. 164
Side·o~ theory, 49
Uterine ftbroid, 82
Slderosil, 143
Silicosis, 144
Sleeping sickness, 232
Spina biftda, 218
Splenic BnIIImia, 29
8pleno-medullary, 30
Splenomegaly, 119
SqUAmous epithelioma,
Status lymphllticus, 191
StlU'B dl!jfABe, 214
Stokea-A ~ syndromo, 131 abscess, 171
Suppuration, 86
SuprarenaIs, 188
Surface tenSion,
SUBCeptibUity, 50
Synnl!se, 13'
Syphilis, 193
Syringomyelia, 215
ByilngolllYeioeeie, 218
Veins, diseases at, 103
VilloUB cancer, 98
Viteminea, 206
Volkmann'S contracture, 226
WaaBarmann rea.ctlon, 47
Waxy degeneration, II
Widal's reaction, 44
Wound shock, 116
xanthoma, SO
Zenker's degeneratiOll, 16
Znote, 8
.um SOliS,

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