bile ducts, from the irritation of impacted calculi, or from the
presence of intestinal worms that have entered by the ductus communis;
or from the lodgment of emboli in some branch of the portal vein or
hepatic artery.
=Secondary, Pyæmic or Metastatic Abscess.= The liver is occasionally the
seat of abscesses forming as a result of _pyæmia_, induced by absorption
of pus from some wound of a joint, vein, or bone; or from a diffused
abscess or erysipelas of the skin. These abscesses usually contain a
somewhat thin and oily-looking pus. They also differ from ordinary
abscesses in the rapidity with which they form, a few days generally
sufficing to give them a large size. The insidious manner in which they
form—the tissues breaking down, as it were, without any
inflammation—constitutes a distinguishing feature of these collections.
Pyæmic abscesses of the liver are usually many in number, and varying in
size from a pea to that of a walnut. The gland is usually enlarged at
the same time, and in some cases to such an extent as to reach quite to
the umbilicus. This form of abscess is not confined to the liver, but
may be found in the lungs, spleen, in the joints, or in the serous
cavities, and sometimes diffused through the connective tissues and
muscles of the limbs or trunk.
Degenerations of the Liver.
=Waxy, Lardaceous, or Amaloyd Liver.= In this form of disease, the liver
undergoes greater enlargement than in any other disease excepting
cancer. The enlargement is uniform in every direction, so that the form
of the gland is unchanged. Pain and tenderness are never prominent
symptoms of this disease, hence the liver may be manipulated during life
with impunity, the patient complaining only of weight and tightness in
the right hypochondrium.
The progress of the disease is usually slow, extending, in most cases,
over several years. The spleen, kidneys and intestines will frequently
be found presenting this change at the same time.
The tissue of the gland in these cases is very firm, so that the organ
generally retains its form when laid with its convex surface on the
table. The external surface is smooth and free from adhesions. When cut,
a peculiar translucent substance is found infiltrated through the
tissues, giving it a firm, glistening appearance, known as waxy,
lardaceous, amaloyd, albuminous, or sometimes scrofulous liver. This
substance is stained a deep red by the action of a weak solution of
iodine.
The change appears to commence first, in the small blood-vessels,
finally extending to the lobules, appearing first in the centre, and
ultimately involving the whole lobule.
The disease is more common in males than females, and is frequently
caused by constitutional syphilis. In some instances, it would appear to
be produced by a tubercular diathesis, and coexists with some local form
of scrofulous disease, or by a long exposure to malarial influences.
=Fatty Liver.= This form of disease we find in drunkards; in persons who
have been large eaters and sedentary in habit; in several wasting
diseases, as in chronic diarrhœa, and especially in phthisis pulmonalis.
There is a moderate degree of enlargement which affects all portions of
the gland. The consistency is softer, and the resistance less than in
waxy liver, giving it a doughy feel. The color varies, but is usually
lighter than normal, approaching a yellow, and more or less mottled.
When cut, the substance presents a decidedly oily appearance, both to
the feel and sight. The disease is unaccompanied with pain from first to
last; neither is its function materially interfered with, hence jaundice
is not usually a symptom of the disease.
A microscopic examination shows the lobules of the liver filled with fat
globules, which appear to have originated in the hepatic cells. The
change appears to commence at the circumference of the lobule, the
centre remaining normal in color, thus giving a mottled appearance to
the cut surface.
Other organs are very liable to be affected at the same time by this
form of disease, as the heart, kidneys, etc., the symptoms which the
case presents, such as albuminous urine, tendency to dropsy, dyspnœa,
etc., arising from these organs, rather than from the fatty liver.
=Pigmentary Degeneration.= In cases of malarial poisoning, we sometimes
find the liver with other organs of the body, as the spleen, lungs,
brain, kidneys, etc., presenting a peculiar dark color, the result of
the presence of a black or brown pigment in the blood, filling the
vessels of these organs. The pigment appears to be formed of small
granules either free or contained in irregular cells. In the liver, this
pigment is found most abundant in the blood of the portal vein, but may
be present in the hepatic artery, and in all the venous capillaries.
The liver may be normal in size, or it may be atrophied or
hypertrophied, or may have undergone fatty or waxy degenerations.
=Granular Degeneration.= A peculiar change in the liver substance is
sometimes found after death from various acute or infectious diseases,
as the exanthemata, pyæmia, septicæmia, erysipelas, typhus, typhoid, and
yellow fever, etc.; or from thrombosis of the portal vein, abscesses or
cirrhosis, as well as in poisoning by arsenic, phosphorus or antimony.
The change in the early stage consists in an accumulation in the liver
cells, of a fine granular substance, soluble in alkalies, and apparently
of an albuminous nature; and, at a later stage, of coarser shining
particles of a fatty character, and soluble in æther or alcohol.
=Atrophy= of the liver may be divided into the following forms:
I. Simple Atrophy.
II. Acute or Yellow Atrophy.
III. Chronic Atrophy, or Cirrhosis.
=Simple Atrophy.= By this, we understand a diminution in the size of the
liver, without any alteration in its structure. In this state, the liver
may be reduced to one-half its normal weight and bulk. It is found to
occur:
1. _Old age._ Hence this form of atrophy is sometimes called “_senile
atrophy_.” With the loss of adipose tissue in advancing years, there is
also a tendency either to _degeneration_ or _wasting_ (atrophy) of many
of the organs, and especially of the liver. In this manner, the liver
may be reduced to one-half its normal size and weight without any change
of structure.
2. _Inanition_, arising either from an insufficient supply of food, or
from diseases which interfere with the assimilation of food, may result
in simple atrophy of the liver.
3. _External pressure_ may also produce the same result, as from tight
lacing, pleuritic, pericardial, or peritoneal effusions, or from
enlargement of organs, or presence of tumors near the liver.
Simple atrophy is rarely attended with jaundice unless pressure upon the
bile ducts has been such as to obstruct the flow of that fluid.
=Acute, or Yellow Atrophy.= In this somewhat rare form of disease, the
liver becomes rapidly atrophied, accompanied with jaundice and cerebral
symptoms. After death, the organ is found greatly reduced in size,
extremely soft and yellow, with no appearance of lobules, and upon
microscopic examination, the secreting cells found more or less changed
into granular matter and oil globules. The weight of the gland in these
cases, may be reduced from three to four pounds, the average normal
weight, to less than two pounds.
This form of disease is frequently attended with hæmorrhages,
particularly of the stomach and bowels, and in some instances, from the
uterus or nose.
Pregnant females suffering from this affection usually abort.
Among the causes of this form of disease of the liver may be mentioned
pregnancy, dissipation, constitutional syphilis, malaria, and the
blood-poisoning of typhus fever.
Females appear much more liable to the disease than males, and most
persons attacked are under middle age.
=Chronic Atrophy, Cirrhosis or Hob-nail Liver.= The form of atrophy of
the liver which we now have to consider, is slow in its progress, and is
usually associated with abdominal dropsy. The appearance and density of
the gland varies to a considerable extent in different cases of chronic
atrophy, yet the usual appearance is that seen in what is known as
cirrhosis,[23] or “hob-nail liver,” also sometimes called “gin-drinker’s
liver.” Here the liver has become reduced in size, from a slow
destruction of the secreting tissue, while, at the same time, the
fibrous tissue of Glisson’s capsule has become thickened and hardened,
from a chronic inflammatory action, often due to the use of spirituous
liquors. The outer surface presents a granular or nodulated character,
which has given rise to the term “hob-nail,” as applied to this disease;
while, upon section, the interior presents firm fibrous bands,
surrounding yellow patches of secreting tissue. While, in the majority
of cases, this disease is plainly owing to an abuse of spirituous
liquors, in others, it is found associated with disease of the heart, or
with constitutional syphilis, where the patient has been strictly
temperate.
The increased density, in connection with the diminution of size, and
granulated character of the surface, renders the disease readily
recognizable in a post-mortem examination.
The early stage of this disease appears to be accompanied with a degree
of enlargement of the gland, resulting from the congestion attending the
inflammation of the fibrous structure. As this structure increases in
density, by pressure it causes a gradual absorption of the secreting
lobules, and thus results in a reduction in the size and weight of the
organ.
The secreting cells of the lobules of the liver, may undergo fatty
change, or they may become entirely destroyed. Thrombi may be found in
the portal vein. The hepatic artery and its branches become increased in
size, while the interlobular hepatic veins become quite destroyed. The
obstruction to the circulation through the liver, resulting from these
changes, gives rise to the dropsical effusions usually found in this
disease.
Prominent among the symptoms attending this disease, during life, may be
mentioned:—1st. Diminished area of hepatic dulness. 2d. Ascites,
particularly in advanced stages of the disease, although patients may
die before dropsy sets in. 3d. Enlargement of the spleen—this being
present at least in about one-half the cases. 4th. Enlargements of the
superficial veins of the abdomen, from obstructed flow of the portal
blood, or from pressure upon the vena cava, from abdominal distension.
5th. Hæmorrhoids, epistaxis, hæmatemesis, etc. 6th. The rare occurrence
of decided jaundice. 7th. In all cases, the advance of the disease is
marked by progressive emaciation and debility, the patient usually dying
of exhaustion, although in some cases death is due to an attack of
pneumonia, œdema of the lungs, or acute peritonitis.
=Hypertrophy.= We sometimes find an evident increase in the size of the
liver, without any alteration of structure, or the presence of any
prominent symptoms. Such cases may be considered as instances of _simple
hypertrophy_. This condition has been observed in cases of leukæmia, and
in some exceptional cases of saccharine diabetes, heart disease and
phthisis.
Morbid Growths.
=Cancer of the Liver.= Every variety of cancer may be found in the
liver, though the scirrhus or medullary forms are more common. The
disease is invariably accompanied with enlargement, and in some
instances the increase is enormous. The progress of the disease is
rapid, a few weeks in many instances, a few months at the longest, being
required to fully develop the disease. The enlargement is not uniform.
The surface becomes irregular and uneven, nodules of various size are
found projecting from its surface and borders, which are usually harder
than those of the surrounding portions. The disease is nearly always
accompanied with pain, and considerable tenderness is felt upon touch.
Jaundice is present in many cases, but in ninety-one cases collected by
Frerichs, fifty-two showed no symptoms of jaundice. Abdominal dropsy to
any considerable extent, rarely attends the disease, although usually a
small quantity of fluid will be found in the peritoneal cavity. These
characters will usually enable us to make a correct diagnosis of these
cases during life.
The post-mortem examination, discloses, in the majority of cases, a
greater or less number of irregular, rounded masses, projecting from the
surface of the liver, and varying in size from a kernel of corn to an
orange. Through the peritoneum, these bodies present a light,
straw-colored appearance, and when divided, the interior is found of a
whitish-gray color, and of the consistence of tallow or cheese. Examined
very carefully, the substance has the appearance of infinitely minute
granules, aggregated together.
These masses may be confined to one of the lobes, or involve the whole
organ; they are of an irregularly rounded or globular form, and in some
cases two or three appear to have coalesced into one mass.
In other, and more rare cases, the cancerous matter, instead of being
collected in masses, is found more or less infiltrated through the liver
substance, as in Case I.
They may soften, and form cysts filled with a thin serous fluid, or they
may undergo a form of fatty degeneration.
In such cases the disease is liable to be mistaken for waxy
degeneration. In both, there is a uniform hard enlargement, but in the
waxy enlargement, the progress is slow, and without pain, and there is
usually enlargement of the spleen, with albuminuria, and a syphilitic
taint; while in cancer there is no enlargement of the spleen, or
albuminuria, and the course of the disease is rapid; there is pain,
cachexia, and often signs of cancer elsewhere.
Cancer of the liver, in the majority of instances, is secondary to
cancer of some other part, as of the stomach, rectum, or female breast.
In more than one-third of the cases, it is said to be secondary to
cancer of the stomach.
Cases are rare where the liver is primarily affected with cancer. Before
thirty-five or forty years of age, secondary cancer seldom occurs.
The following cases will serve to illustrate the two forms of cancer of
the liver:
CASE I.—_Primary Cancer of the Liver, with great enlargement—Rupture of
Stomach from post-mortem softening._
Mrs. K——, aged 38, light complexion, short and fleshy, commenced
complaining about New Year’s, 1868, of pain in the “stomach,” as she
expressed it, with loss of appetite, restlessness at night,
accompanied with weakness and prostration. These symptoms continued
for a couple of weeks, when she commenced to complain of soreness in
stooping, and inability to wear her clothes tight. This led to an
inspection of the abdomen in bed. I then found projecting below the
margin of the chest on the right side, a hard rounded tumor, nearly of
the size of the fist, somewhat sensitive to the touch, and evidently
springing from the liver. The pain daily increased in severity, and
coming on as it did, in paroxysms, resembled much the pain attending
the passage of biliary calculi.
After she took to her bed, which was in the latter part of January,
there was a rapid increase in the size of the liver, with a marked
aggravation of all the symptoms. The pain was most agonizing; slight
chills occurred from day to day; the flesh rapidly wasted, and the
outline of the lower border of the liver could be distinctly traced
through the abdominal walls. There were no symptoms of jaundice. The
skin was pale and waxen in hue. In the latter part of February,
frequent epistaxis, and bleeding of the gums set in, while from the
pressure upwards upon the diaphragm, the lungs were so embarrassed as
to give rise to great dyspnœa. Rapidly sinking, she died on the first
of March.
_Autopsy_, made thirteen hours after death. Anterior portion of the
body pale; posterior dark from gravitation of the blood. Rigor mortis
scarcely noticeable. Upon opening the abdomen, found four to six
ounces of serum in the peritoneal cavity.
The liver was enormously enlarged, filling a great portion of the
abdominal cavity, pushing the diaphragm high up into the chest, and
giving the lungs less than half their normal amount of room for
expansion. The upper surface of the right lobe was found adhered to
the under surface of the diaphragm, and to the anterior abdominal
walls, and the under surface to the stomach, duodenum and transverse
colon.
The surface of the liver was dark, mottled, and somewhat nodulated.
The whole gland was quite firm, yet evidently just entering upon a
softened stage at numerous points. No trace of an abscess forming at
any point.
Upon lifting the left lobe of the liver, a dark, brownish fluid
appeared behind the stomach, the origin of which was not at first
apparent. The removal of the liver, however, completely exposing the
stomach, showed the posterior wall at the large end, _softened and
ruptured_. This softening was evidently a post-mortem action of the
gastric juice; the rupture resulting from the tension upon the same,
in tearing away the adhesions between the stomach and liver.
Upon the removal of the liver, found it to weigh eighteen pounds. The
gall-bladder was empty and contracted. The only portion of the gland
not involved in the disease, was one of the small lobes, the _lobus
Spigelii_, and a portion of the left lobe. Incisions, showed the
interior presenting a similar mottled appearance as the surface; dark,
almost black spots, intermixed with spots of brown and gray. The
blood-vessels of the liver were enlarged, and filled with dark
defibrinated blood. No trace of coagulated blood, in any of the
blood-vessels of the body.
_Microscopic examination._ An examination of a small portion taken
from the right lobe, with a power of 350 diameters, showed innumerable
cells of an irregular outline, and varying in size; oil globules, and
granular matter. The action of acetic acid, rendered the nuclei of the
cells faintly visible. Many cells of a large size were found filled
with a growth of smaller ones. All other organs of the body
normal.[24]
CASE II.—_Cancer of the Liver, secondary to Cancer of the Rectum, with
diffused Abscess in the Neck._
Mr. A——, of Doylestown, Pa., aged 60, had been suffering for some
months with symptoms of disease of the rectum, with also inflammation
of the bladder. His passages were painful, and accompanied with more
or less bloody, purulent matter. His urine was thick, at first from
presence of large quantities of mucus, later of pus. His appetite and
digestion were poor; his color pale and cachectic.
Some six months previous to death, he commenced passing with his
urine, small quantities of seeds of berries, tomatoes, etc. These
gradually increased in quantity, until, for some weeks previous to
death, there was a free discharge of feculent matter from the bladder,
and at the same time much urine passed per rectum. A few days before
death, there appeared a diffused swelling upon the front of the neck,
extending from the clavicles as high as the upper portion of the
larynx. There was no discoloration of the surface. The swelling
presented a boggy feel, without any positive fluctuation.
On the 15th of July, 1871, I was called by Dr. George Wright, who had
been treating the case for the past year, and from whom I learned the
above facts, to make a post-mortem examination, the patient having
died the day before.
Found the body very thin, surface pale. No serum in the peritoneal
cavity. Upon lifting the small intestines from the cavity of the
pelvis, found the rectum closely adhered to the posterior surface of
the bladder, completely obliterating the recto-vesical _cul-de-sac_.
Considerable dense scirrhus matter, was found upon either side of the
rectum and bladder.
Upon removing the rectum and bladder, a large opening (one inch in
diameter) was found communicating between the two. The edges of this
opening were thick and ragged. The walls of the bladder and rectum
generally, were thick and hard from scirrhus deposits. The bladder
contained considerable purulent and feculent matter, with also a
cherry-stone. Upon examining the liver, found upon the under side of
the left lobe, a large cancerous mass, imbedded in the substance, but
projecting from the surface, and quite as large as a goose egg. Other
portions of the liver healthy.[25]
The lungs were healthy. The muscular walls of the heart were pale and
soft, while each of the cavities contained soft, imperfectly formed
fibrinous clots.
The right pleural cavity contained nearly a pint of serum, while the
pleura presented a red, inflamed appearance.
In removing the sternum from its position, noticed purulent matter
beneath the upper end, which appeared to come down from the neck. Upon
carrying an incision upwards to the hyoid bone, found the whole region
of the neck infiltrated with pus, without being confined by any
limiting membrane or sac, and evidently metastatic in its origin.
=Tubercles.= The peritoneum covering the liver, like other portions of
this membrane, will sometimes (more frequently with children) be found
filled with numerous minute tubercular particles, the presence of which
are liable to give rise to appearances of inflammation, such as redness,
roughness, and perhaps adhesions.
=Fibroid and Cartilaginous Tumors= are of extreme rarity in the liver.
When present, they exhibit the characters of those growths in other
parts.
=Adenoid Tumors= have been detected in this gland. They vary in size and
number, but are usually enclosed in a fibrous capsule, and appear to be
made up of glandular cells, resembling the hepatic cells, but of larger
size and greater density.
=Vascular Tumors= are sometimes found in the liver, consisting
apparently of a compact, irregular net-work of dilated veins, held
together by connective tissues. Of a dark, almost black color, they vary
in size from a few lines to two or three inches in diameter, and are
very irregular in their outline.
_Cysts_ of small size are occasionally found, developed either in the
connective tissues, or from a dilatation of bile ducts. They may be
found filled with serum, or colored mucus and epithelial cells.
=Syphilitic Tumors=, from the size of a pin’s head to that of the fist,
may be found in the liver. They are of a gray, whitish or yellow color,
made up of cells of an irregular form, which show a tendency to cheesy
degeneration, or to such softening as to give the appearance of an
abscess.
Blood-vessels of the Liver.
_The hepatic artery_ is sometimes found with aneurismal enlargements,
and rarely contains an embolus.
_The portal vein_ is frequently found containing a fibrinous clot,
constituting thrombosis. Such clots may result from pressure on the vein
from the presence of some morbid growth in the liver, or from a tumor in
the mesentery or some other part, obstructing the portal vein below the
liver; or from suppurative disease of ulceration of the several organs
from which the portal vein arises. They may be a cause, or result, of
phlebitis, and may give rise to jaundice, and sometimes to abscess of
the liver.
_Dilatation_ of the portal vein may result from obstruction of the
capillaries of the liver in chronic atrophy or cirrhosis; or from the
presence of thrombi, or pressure by various morbid growths.
_Calcification_, not only of the portal vein within the liver, but of
its various branches of origin within the mesentery, omentum, etc., may
occasionally be met with.[26]
_The hepatic veins_ may be found presenting the same abnormal conditions
as the portal vessels.
Animal Parasites.
The liver has long been known as a favorite resort for different
parasitical animals, the most common of which, is that of the larval
form of one of the tapeworms—_the Tænia echinococus_—constituting when
developed in the liver, what is known as an _acephalocyst_ or _hydatid_.
=Hydatid Tumors= of the liver, arise in the following manner:—The
several tapeworms pass through three stages of development, these never
being completed however in the same animal. The Tænia echinococus,
acquires its adult form, only in the intestines of the dog or wolf. The
mature segments, each of which are filled with vast numbers of eggs, are
voided with the fæces, into which the eggs are discharged. These soon
develop into a minute embryo, with one extremity provided with numerous
little hooks. If taken into the stomach of an herbivorous animal or man,
this embryo pierces the walls of the intestines, enters a blood-vessel,
and finally lodges in some of the tissues or organs, more frequently the
liver, where it develops into a sac-like body, known as a _cysticercus_
or _hydatid_, the second larval form. When the embryo is taken into the
stomach of other animals, no further development takes place.
While in the hydatid, or second larval form, by a peculiar process known
as alternate generation, there may be a reproduction of cysts to an
almost endless extent within the parent cyst, or secondarily in other
parts.
The adult or third stage of development, can only be attained within the
intestinal canal of the dog or wolf. These animals devouring a sheep or
other ruminant, or in some rare case perhaps a human being, within which
the hydatid has been formed, the cysts thus taken into the stomach,
develop into the perfect worm, from which segments containing the eggs
are again discharged.
It would appear almost impossible for the embryo from these eggs, to
ever enter the human stomach, but it is not difficult to understand that
the fæces of the dog containing the ova, may enter a spring or stream,
from which the minute embryo may be taken with the water, by either man
or a lower animal; or, by attaching themselves to watercresses, etc.,
they may be eaten with these by the same.
_Hydatid tumors_ of the liver, may vary, greatly, in size, according to
their age. From an extremely minute cyst, they may acquire such a size
as to fill and distend the abdominal cavity, crowding the several
viscera from their position. There may be one or several. They may be
confined to the liver, or secondary cysts may appear in other organs.
When opened, the interior is generally filled with numerous smaller
cysts of various sizes, each filled with a gelatinous fluid of varying
degrees of density and color, and within which, by a careful microscopic
examination, may be detected—many times, not always—numerous hooklets,
which have been detached from the minute heads. The walls of the parent
cyst may become greatly thickened, or even calcified. The contents may
degenerate into a purulent mass, with which may be mingled blood or
bile.
The development of these tumors is usually slow, and unattended with
pain, or functional disturbance of the liver. After they have acquired a
large size, they may induce peritonitis, resulting in extensive
adhesions.
Rupture of these hydatids sometimes take place, this accident being
followed by death, or recovery, according to the point at which the
rupture takes place. They may burst in the following directions:
1. Through the diaphragm into the pleural cavity, or into the substance
of the lungs.
2. Rarely into the pericardium.
3. Into the peritoneal cavity, resulting in acute peritonitis.
4. Through the abdominal walls, when recovery is possible.
5. Into the stomach or intestines; this being the most favorable point
of rupture. In fifteen cases of rupture into the intestines, fourteen
recovered.
6. Into the biliary passages or large blood-vessels.
CASE.—_Large Hydatid Tumor of the Liver—Death from Exhaustion._
Mr. O——, of this city, aged 75 years, noticed some two years previous
to his death that his abdomen was enlarging. An examination disclosed
the presence of a large tumor descending from the region of the liver.
It was slightly fluctuating, and unattended with pain or soreness. He
complained of nothing but weakness with vertigo. All the functions of
the body were natural.
A gradual increase of size took place, with occasional attacks of
inflammation, until the abdomen acquired the dimensions of that of a
woman at full term. The oppression now became so great, from the
crowding of the lungs, that I decided to resort to paracentisis. Some
two quarts of a thick, gelatinous fluid were drawn off from the tumor,
with several quarts of ascitic fluid from the peritoneal cavity. The
operation was followed by great relief. Rapidly refilling, the
oppression again became severe, and the operation was repeated a few
months later with similar results. Death finally followed from
exhaustion.
The post-mortem revealed an immense tumor, filling the abdominal
cavity with extensive, firm adhesions, and crowding the lungs into the
upper part of the chest. The walls of the sac were thick and
semi-cartilaginous, and the interior divided into numerous
compartments by septa passing in various directions. These
compartments were filled with a gelatinous fluid, in which were
innumerable cysts of various sizes, each filled with a similar fluid
as that with which they were surrounded. The microscope showed the
presence of numerous cholesterine scales in this fluid.
The weight of the entire tumor was over fifty pounds. A portion was
preserved and deposited in the College Museum.[27]
The following parasites are also sometimes found in the human liver, or
its ducts:
_Distoma hepaticum_, or liver fluke. Common in the bile passages of
lower animals, rare in that of man. It is flat, oval, from two to four
lines long, and a-half to one line broad. Its presence in the hepatic
ducts, may give rise to enlargement, some degree of obstruction, or
calcification.
_Distoma lanceolatum._ This parasite, something smaller than the above,
is still more rare in the bile passages of man.
_Pentastoma denticulatum._ This animal is found as a small cyst, with
calcified walls, and containing fatty and calcareous matter, with the
remains of the dead parasite. It is considered as the larval form of a
worm sometimes found in the nasal cavity of the dog, and some other
animals.
_The Ascaris lumbricoides_ may be found in some of the bile passages, it
having entered by the opening of the common duct into the intestine.
2. Affections of the Gall-bladder and Ducts.
The gall-bladder is sometimes wanting, this being the normal condition
in the horse and some other animals. When thus absent, the hepatic ducts
are so increased in size, as to be able to contain the accumulating bile
in the intervals of digestion.
=Inflammation= of the gall-bladder and common duct, involving their
mucous lining, is not uncommon. Such inflammation may be either
_catarrhal_ or _suppurative_.
_Catarrhal inflammation_ may result in thickening or calcification of
the lining membrane of the ducts and bladder, with the accumulation of
such quantities of thick tenacious mucus, as to become a source of
impediment to the flow of the bile, and thus give rise to jaundice. Such
inflammation becoming chronic in the common duct, may result in great
dilatation of the gall-bladder, from the accumulation of bile.
In many cases, this form of inflammation would seem to have originated
in the duodenum, reaching the biliary passages by extension through the
opening of the duct into the intestine. It may also result from the
presence of calculi or parasites in the passages, or from inflammation
of the liver.
_Suppurative inflammation_ may attend different forms of fevers, or
result from the presence of calculi. The gall-bladder, with the bile
ducts, in such cases, may be filled with a purulent fluid, or the same
may be found infiltrated through their walls.
Perforation of the walls of the gall-bladder may result from this form
of inflammation, with escape of contents into the peritoneal cavity,
inducing thus fatal peritonitis. Fistulous communication may also form
between the bladder and colon, duodenum or stomach, or through the
abdominal walls, adhesions having first taken place between these parts.
_Dilatation_, both of the bladder and ducts, may occur as a result of
obstruction of the gall-ducts. That of the former may be very great,
giving rise to a tumor that may be plainly felt through the abdominal
walls. Dilatation of the ducts may involve either the common, or large
hepatic ducts, or the smaller branches within the liver. Such
dilatations may be sacculated in form, or general, involving the whole
tube.
Morbid Growths.
_Cancer_ of the walls of the gall-bladder is not unfrequent, and may be
either primary or secondary. The cavity of the bladder may in this way
become obliterated, and the common duct obstructed, thus inducing
jaundice.
In a case examined for the Drs. Pettingill, the gall-bladder was as
large as the fist, from scirrhus cancer; its cavity obliterated; adhered
to the pylorus to which the disease had extended; and the bile ducts
greatly dilated and filled with a large quantity of puriform fluid. The
patient had been for many months extremely jaundiced.
_Fibroid tumors_ are very rarely observed in connection with the
gall-bladder.
_Tubercular deposits_ may be found beneath its peritoneal covering.
=Biliary Calculi.= The presence of biliary calculi, or gall-stones in
the gall-bladder, or some of the ducts, is a very common occurrence.
These bodies are composed of the elements of the bile, largely however
of cholesterine, sometimes in an almost pure state, in others, more or
less mixed with inspissated bile. In many cases, a nucleus of nearly
pure cholesterine will be surrounded by a deposit of biliary matter
mixed also with scales of cholesterine.
Cholesterine is a peculiar spermaceti, or fatty-like substance, found
not only in the bile, but also in the nervous tissues, insoluble in
water, but soluble in æther or boiling alcohol. When found in a pure
state, it is of a yellowish-white color, with the particles arranged in
the form of shining thrombic scales.
Gall-stones may occur of all sizes, from a pin’s head to that of a hen’s
egg. When small, they are generally numerous; in some instances fifty to
one hundred being found in the gall-bladder at one time. When several
are present in the bladder, they will be more or less angular or
polyhedral in form from contact and attrition with one another. Where
there are but one or two, the size may be considerable, while the form
will be rounded, oblong or pear-shaped, and more or less regular.
These bodies, when first removed, are usually heavier than water, but,
after being dried, become considerably lighter. They are inflammable,
and may be reduced to almost pure charcoal by burning. After having
being exposed to the air for some time, they are very liable to crumble
more or less completely.
_Position._ 1. _Gall-stones may be confined to the gall-bladder._ This
is the position in which they are more frequently found. There is every
reason to believe that they may remain there for a long time without
giving rise to any uncomfortable symptoms. We frequently find them after
death in the gall-bladder of persons who, during life, exhibited no
symptoms of their presence. They are liable, however, when present, and
particularly if numerous or large, to give rise to a sense of weight and
dragging in the part, and to occasional attacks of pain, derangement of
the stomach and vomiting; and may also excite inflammation and
ulceration of the walls of the bladder.
The presence of gall-stones, when in large numbers, may frequently be
detected through the abdominal walls, as a hard resisting tumor, which,
by grasping, may be made to elicit a rattling sensation, like pebbles in
a bag.
2. _Gall-stones may become impacted in the neck, or cystic duct of the
gall-bladder._ In this case, it is likely to give rise to an attack of
biliary colic, with vomiting, etc. As long as it remains in this
position there will be no jaundice. Their presence, however, may excite
inflammation; yet we sometimes, in post-mortem examinations, find the
neck of the gall-bladder blocked up by a calculus, when no symptoms of
such an obstruction existed during life.
3. _Gall-stones may form in some of the branches of the hepatic ducts
within the liver._ This is not a common point for the formation of these
bodies. They are sometimes found, however, in cases of obstruction of
the ductus communis. The concretions may be small and rounded, or
branching casts of the tubes, resembling pieces of coral.
4. _Gall-stones may be lodged in the ductus communis choledochus._ This
is one of the most common situations for these bodies, and they may
reach the point, either from the gall-bladder, or from the ducts from
the liver. While in this position, the calculus is likely to give rise
to jaundice with paroxysms of severe pain, which will be repeated from
time to time, until it passes into the intestines.
_Effects._ As already intimated, gall-stones may remain for an
indefinite period in the gall-bladder or ducts, without giving rise to
any symptoms. In many instances, also, they may undoubtedly pass the
ductus communis when small, and be discharged by the bowels, without the
knowledge of the patient. More frequently, however, the passage of these
bodies is accompanied with paroxysms of severe pain, the location and
character of which will usually serve to indicate the true cause. Where,
however, the body is too large to pass, its presence in the gall-bladder
or any of the gall-ducts, may excite inflammation and ulceration in
those parts, and thus lead to perforation and discharge of contents into
the peritoneal cavity.
CASE.—_Rupture of the Gall-bladder, with discharge of contents into the
peritoneal cavity, followed by peritonitis and death._
Mr. De K. T——, of this city, aged about 60, had suffered from several
attacks of severe pain in the region of the gall-bladder, which I had
diagnosed as biliary colic, induced by the presence of a calculus. One
morning in June, 1863, while working in his garden, he felt a
sensation of something giving away in his side, which was immediately
followed by an attack of severe pain. A chill and fever soon
succeeded; and, in twenty-four hours, a violent peritonitis set in,
resulting in death in four days.
Autopsy, thirty-six hours after death. Upon opening the cavity of the
abdomen, the peritoneal membrane was found intensely inflamed at all
points, and containing nearly a quart of greenish sero-purulent fluid.
Slight plastic adhesions were found at various points, uniting the
intestines to the abdominal walls, while old, firm and extensive
adhesions were found between the same and the liver and gall-bladder.
There were evidences that the latter had been largely distended, yet,
through a distinct opening, the contents had escaped into the
peritoneal cavity, leaving behind a single calculus of a regular oval
form, and one inch of its long diameter.[28]
From the appearance of the part, it would seem that the calculus had
excited inflammation and ulceration in the walls of the gall-bladder,
destroying the latter so completely, that the fluid contents were kept
from escaping into the abdominal cavity, only by the adhesions that
had formed, and that these had been probably torn away by the exercise
of digging with the spade.
In many cases, the adhesions which are induced by the inflammation, will
secure a more fortunate result, favoring the working of the calculus, by
the ulcerative process, either into the duodenum or colon, and thus, in
most cases, securing its passage per anum. In such instances, should an
opportunity be had of examining the parts after death, traces will be
found remaining, sufficient to indicate the point at which the escape
into the bowel was effected.
In some rare instances, gall-stones have been vomited from the stomach.
While it might be possible for such bodies to be carried from the
duodenum into the stomach by a reversed peristaltic action, it is more
probable that, in such cases, the calculus has found its way into the
stomach by a direct fistulous communication with the gall-bladder.
Fistulous communications of a permanent character are sometimes left,
after an ulcerative discharge of a gall-stone into some portion of the
intestinal canal.
Gall-stones, after entering the intestinal canal, may become impacted,
thus producing intestinal obstruction. Many fatal cases of this
character have been reported. An interesting case of intestinal
obstruction from this cause, was reported by Dr. Frieze, of Harrisburg,
at the meeting of the American Institute of Homœopathy, in Philadelphia,
in June, 1871. A lady sixty-five years of age, had been suffering severe
pain in the bowels for over a week, with symptoms of obstruction, when,
after a persevering use of injections, she passed a calculus of a
cylindrical form, one and three-quarter inches in length, and four and
one-half inches in circumference, and weighing four hundred and
thirty-seven and one-half grains.[29]
Gall-stones have, in a number of cases, been discharged upon the surface
of the body, while in some rarer instances, by the ulcerative process
they have worked into the ureter, and even into the vena cava and portal
vein.
CHAPTER II.
THE URINARY APPARATUS.
Section I. THE KIDNEYS.
[=Notice=:—Absence of either kidney, or other abnormalities. Of
each kidney, note 1. Form, size, weight, wounds, etc. 2.
_Capsule_—thickness; transparency; facility of removal. 3.
_Surface of kidney after removal of capsule_—color; smooth or
lobulated, size of lobules; puckerings; granulations; cysts, etc.
4. _Substance of kidney_—consistence; flaccidity, etc.; fracture,
granular or not? wounds, rupture. 5. _Cut surface_—color of
pyramidal and cortical portions; proportion of each; amount of
blood exuding from; thickness of cortical portion; color;
Malpighian corpuscles; their degree of visibility, color, etc.;
appearance of striæ in pyramidal portion, color, etc. 6. _Abnormal
growths and deposits_—cysts; fibrinous masses; tubercle; cancer;
chalky masses; abscesses, etc. 7. _Pelvis of kidney_—peculiarity
of form; contents; fluid, quantity, quality, purulent, etc.
_Calculi_—their size, position, etc. _Walls of pelvis_—their
thickness; transparency; fistulous openings; wounds, etc. 8.
_Ureters_—size, contents, etc. 9. _Microscopic examination_—make
section with Valentine knife, from convex border through cortical
portion, and from base to apex of cone, parallel with tubules;
place on slide and examine with varying powers, from 100 to 500
diameters. _Note condition of tubules_—contents; blood, oily
particles, fibrinous, waxy, epithelial or other casts; or denuded
of epithelium and empty. _Malpighian tufts_—gorged, ruptured,
filled with granular or oily matter, or obliterated. Are crystals
of any kind present, as uric acid, oxalate of lime, etc., minute
cysts, purulent infiltration, tubercular, cancerous or other
deposits?]
In the normal state, in the adult, each kidney will be found to be about
four inches in length, two inches in breadth, and one inch in thickness,
of a firm consistency, and of a deep, red color. The weight of the
kidney varies from four ounces to six ounces, being somewhat lighter in
the female than in the male. The left kidney is generally somewhat
longer, thinner and heavier than the right. The fibrous capsule in which
each kidney is enveloped is thin, smooth, and in a state of health is
easily removed from the surface of the gland.
=Congenital Anomalies.= Although the absence of both kidneys is of rare
occurrence, it is not uncommon to find only one. This may occupy its
usual position, and differ from the natural kidney only in being
larger—the _unsymmetrical_ kidney of Rokitansky. In other cases, we find
a more or less complete fusion of the two organs together—the _solitary_
kidney.[30] Either the lower parts of each are connected by a band of
renal substance passing across the vertebral column, constituting the
horse-shoe kidney; or there is only a single disk-like gland, lying in
the median line, and situated much lower down, even as far as the
concavity of the sacrum.
=Congestion.= This, and its consequences, are the main features of
hyperæmia of the kidneys, which is of frequent occurrence. This
condition is almost always the result of some prior general affection,
such as the scarlatinal poison, the suppression of perspiration, or
obstructive diseases of the heart.
In a simple congestion, with perfect integrity of the renal tissue, we
find the kidney enlarged, and its weight often doubled; of a dark, red
color, and dripping with blood when cut into. The cortical substance is
somewhat softened, of a dark, red color, presenting in many cases small
dark, red spots, the result of hæmorrhagic effusion into and between the
tubercles. The Malpighian tufts are distinctly visible on the cut
surface, as minute, reddish, semi-transparent grains. In the medullary
cones, the congested vessels form long dark red streaks. If the
congestions have occurred in an otherwise healthy kidney, the capsule
can be readily peeled off.
A microscopic examination shows the Malpighian and other capillaries
loaded with blood, extravasation sometimes taking place into the capsule
of the latter, and often into the channel of the fibres.
In extreme cases of hyperæmia and congestion, a fibrinous exudation
takes place, which will be found coagulated in the tubes, forming casts
of their interior, and consisting of a granular or homogeneous material,
entangling blood-globules, and often some particles of detached
epithelium.
=Hæmorrhage.= As a result of acute congestion, or from injury from
falls, blows, or wounds of the kidneys, blood may be effused, either
beneath its capsule, or within the sinus, constituting hæmorrhage of the
kidney.
=Nephritis.= This differs in no material respect from common
inflammation of other parts, and like it, often passes into suppuration.
Its most common causes are:—Excess in the use of irritating and
alcoholic drinks; abuse of diuretics; blows or falls on the loins; the
presence of renal calculi; and, according to some authors, a peculiar
morbid state of the blood, such as gives rise to carbuncles.
This disease can be distinguished from the inflammatory form of Bright’s
Disease, during life, by its generally affecting only one kidney, by the
much greater pain and tenderness in the lumbar region, by the retracting
of the testicles, and the higher degrees of febrile excitement. Then,
too, the deeply-colored urine which is voided, contains little or no
albumen.
In a case of nephritis, unattended with the formation of pus, a
_post-mortem_ would probably fail to distinguish it from the condition
of congestion just considered. Where suppuration was about taking place,
the microscope shows the cortical tubes so distended and crowded
together by infarcted epithelium, as to be scarcely distinguishable; in
some parts the basement membrane gone, and their contents a uniform mass
of nuclei and granular matter. The medullary tubes are also infarcted
and opaque.
=Pyelitis.= Inflammation of the walls of the sinus of the kidney, is
thus designated. It may exist alone, or in company with inflammation of
the kidney, constituting _Pyelonephritis_. It appears to originate, in
many cases at least, secondarily to an attack of cystitis, and would
seem metastatic in its nature, the ureter connecting the two inflamed
organs, escaping the disease. It is a very serious, and often rapidly
fatal disease.
Where the inflammation extends to the kidney tissue, suppuration is
likely to follow, resulting thus in the formation of an abscess.
=Abscesses.= Renal abscesses are found bordered by a red injected halo,
which gives rise to a friable product, thus leading to an extension of
the abscess. The mucous membrane of the calices and the pelvis,
especially when a calculus is present, is softened and inflamed, and
secretes a purulent fluid.
The process of suppuration may continue until the whole organ is
converted into a pouch of pus. Then, or even before the organ is quite
destroyed, the abscess may make its way by the usual process of
absorption, and discharge its contents into the calices, to be carried
off by the urinary passages; into the ascending or descending colon, or
the duodenum, to be passed with the fæcal evacuations; or, after
perforating the diaphragm, into the bronchi, whence they are removed by
coughing; or through the lumbar muscles; or it may burst into the
peritoneal cavity and cause rapid death.
This disease rarely attacks more than one kidney, and the other healthy
kidney generally enlarges and becomes capable of performing a double
amount of work.
It is well to remember, that a mass of softened fibrinous exudation,
bordered by a red halo, may sometimes so far simulate an abscess, that
only the microscope can distinguish the one from the other.
=Inflammation of the Capsule= may take place and cause fibroid
thickening, more or less induration, atrophy, and obliteration of the
organ. The cortical substance generally suffers most, and the surface is
sometimes overspread with purulent matter, while the tissue itself
becomes sloughy or gangrenous, or is only congested and softened.
=Morbus Brightii.= _Bright’s Disease._ _Degenerative disease of the
kidneys._ _Desquamative and un-desquamative nephritis._
In view of the impossibility of accurately defining the term _Bright’s
Disease_, we will describe it in general as including those diseases of
the kidneys which, in some stage or other of their course, are
accompanied by albuminuria, or dropsy, or both. And as it would be
foreign to the object of this work, to enter into an examination of the
respective merits of the theories, in reference to the nature and course
of this disease, we will adopt that classification which seems best
adapted to our purpose, and proceed to consider the morbid anatomy of
Bright’s Disease in its various forms and stages as first suggested by
Virchow in his Cellular Pathology, and adopted and developed by
Stewart.[31]
He distinguishes three forms—(1) _the inflammatory_, (2) _the waxy_, (3)
_the cirrhotic or contracting_; the first originating in the tubules,
the second in the vessels, and the third in the connective tissue of the
organ.
1. _The Inflammatory Form._ This has three stages: that of inflammation,
that of fatty transformation, and that of atrophy. The disease may prove
fatal at any stage of its course. In the first stage, an exudation is
poured out, and a destruction of the epithelium takes place. This
exudation, affecting a large number of tubules, leads to enlargement of
the organ, and also to fatty degeneration of the epithelium; its
absorption or removal, leads to ultimate atrophy. There is also a _fatty
degeneration_, to which we will refer later, which is unattended either
with albuminuria or with dropsy, and which does not, therefore, belong
to this category.
In this stage of inflammation, the organ is of the natural size, or
slightly enlarged; its capsule is unaltered, and can be peeled off
readily; its surface is smooth, more or less congested, often pink,
sometimes of a dark purplish color, sometimes mottled, pale and purple.
On section, the cortical substance is found relatively enlarged, and
often congested. The Malpighian bodies stand out prominently from the
surrounding tissues, the congested vessels, separated by a varying
amount of white (somewhat opaque) deposit, composed of the altered
tubules. The vascular spaces between the cones and the cortical
substance are uniformly distended with blood. The cones are usually
redder than the cortical substances, and from the engorgement of their
vessels and the altered condition of their tubules, they present a
series of alternating red and white lines, converging to the apex of the
cone, at which point the white distinctly predominates. The pelvis of
the kidney is natural.
Examination with the higher powers of the microscope shows the
Malpighian bodies dense and granular. The tubules are more bulky than
natural, and their epithelium is swollen, granular and dense, while
within them is frequently seen a transparent homogeneous exuded
material, binding into one mass, the epithelium of the tubules. Blood
corpuscles are frequently found incorporated in this exuded material.
In the stage of fatty transformation, the organ is enlarged; its capsule
natural; its surface smooth or slightly lobulated. It is pale and fatty
in color, and on its surface stellate vessels are frequently seen. On
section, the cortical substance is pale, of a yellowish-white color, and
increased in volume, while the cones are pink, and of natural color and
size. The Malpighian bodies do not project prominently as in the first
stage.
Under the microscope we find the tubules to be irregularly distended
with fatty granules, contained for the most part within the walls of the
epithelial cells, which again are imbedded in a material that blocks up
the tubules. In the Malpighian bodies, oil globules and fatty cells are
of frequent occurrence, but the capillary tuft is natural.
In the last stage of this form, that of atrophy, both the bulk and
weight of the organ are diminished, its capsule although natural, is
less easily torn off than in health, and on its removal the surface of
the gland is found to be uneven, with numerous depressions and
elevations. The color is, as in the second stage, mottled. On section we
find that, while the cones have remained nearly of their natural size,
the cortical substance is small and atrophied, and that which intervenes
between the cones is greatly diminished. In the cortical substance, the
Malpighian bodies are not prominent, while the vessels, and especially
the arteries, are thicker and more prominent.
The pathological distinction between this stage of the inflammatory
form, and the cirrhotic or contracting kidney, depends mainly upon the
condition of the tubules and the relative amount of connective tissue.
When the atrophy is a consequence of inflammation, many of the tubules
show evidences of inflammatory action, being blocked up with exudation
and epithelium in process of fatty degeneration, while in the cirrhotic
there is little or none of this. Again, in the cirrhotic the fibrous
stroma is very greatly increased, which is not the case in the
inflammatory form. In the latter, too, the capsule is more easily
stripped off, and the occurrence of cysts is less frequent than in the
former.
The form of Bright’s Disease, of which we are treating, is often
complicated with hypertrophy of the heart, affections of the lungs and
bronchi, inflammation of serous membranes, derangements of the
alimentary tract, diseases of the brain, affections of the eye, liver
and spleen.
2. _The Waxy or Amyloid Form._ This also has three stages: that of
simple degeneration of the vessels; that in which a secondary alteration
of the tubules is suspended; and that of atrophy. An increased secretion
of urine characterizes this form from its earliest stages. In all stages
the vessels present to the naked eye more or less distinctly the
appearance of boiled starch or sago, while a little of the liquor iodi
poured over the surface, produces everywhere a yellowish color, but the
degenerated parts assume a reddish-brown, mahogany-red, or orange-red
hue, and stand out very conspicuously.
In the first stage, the organs are of normal size, weight and color, the
latter being however, in some cases, a little paler than usual. Their
capsule is easily stripped off, and their surface is smooth. The waxy
degeneration begins in the capillary tufts of the Malpighian bodies, and
in the transverse fibres of the middle coat of the small arteries. On
these there are thickenings here and there, presenting the same
sago-like translucency as is seen in the tufts.
In the second stage, the kidneys are increased in bulk and weight; the
capsule is easily stripped off, and the surface smooth and pale. The
cortex is thick and white, and presents much the appearance of white
beeswax. Under the microscope, we see the Malpighian bodies and arteries
degenerated as just described, and in addition many of the tubules full
of matter, not dense and opaque as in the inflammatory form, but
tolerably transparent, consisting of hyaline tube casts. Their
epithelium is swollen, and their basement membrane may also be waxy. It
is to this form of disease that the term “waxy kidney” is most
applicable.
In the third stage, that of atrophy, the organ is reduced in bulk, from
about the natural size to a fourth or even less. Its weight is also
diminished. The capsule may be torn off without much difficulty. The
surface is rough, granular, and of a pale, waxy color. On section the
cortical substance is found much diminished, while the cones are nearly
natural. The Malpighian bodies are large and closely grouped together;
the smaller arteries dilated and their walls thickened. A few tubules
remain distended, but most are collapsed, and are represented only by
fibrous tissues.
3. _The Cirrhotic or Contracting Form._ This consists of an hypertrophy
of the connective tissue of the organ, and a consequent atrophy of all
the other structures. It has been termed also “gouty kidney,”
“intertubular or interstitial nephritis,” and “granular kidney.”
In the commencement of the process there is but little diminution in the
size of the organ, but the capsule is thickened and more adherent than
natural, and the surface is rough and granular. The color is pale or
reddish. On section, the cortical substance is found relatively
diminished, the diminution being most marked towards the surface. The
arteries are prominent, their walls thickened and their cavities often
dilated. Even to the naked eye, and to the touch, the increased density
and fibrousness of structure are evident. On the surface, and in the
substance, cysts are frequently seen. Some are produced by dilatation of
the Malpighian capsules, some by dilatation of the tubes, and others
from morbid growth of epithelial elements. The tubes are compressed and
atrophied by the new fibrous tissue. They contain little of the opaque
matter found in inflammatory cases, but translucent hyaline matter is
common. All these characteristics become more marked as the disease
progresses. In the more advanced stages, both the kidneys are much
reduced in size, but one may be more atrophied than the other.
Throughout the whole course of the disease the cones are but little
affected.
In gouty cases a deposit of chalk-like substance is occasionally found,
composed of needle-like crystals of urate of soda, situated in the
stroma of the organ, as well as in the tubules.
In distinguishing a cirrhotic kidney from one in the third stage of the
inflammatory or of the waxy disease, besides the characteristic iodine
test in the one case, the following points of comparison will be
useful:—In the cirrhotic, the capsule is more thickened and more
adherent than in the other two forms. In the cirrhotic, the surface is
very uneven, frequently studded with cysts, and presents little or no
sebaceous-looking material; in the inflammatory and the waxy, the
surface is less uneven, cysts are much less common, and in both,
particularly the inflammatory, sebaceous-looking material is very
abundant. In the cirrhotic, the stroma is greatly increased, especially
towards the surface; in the inflammatory and waxy, the stroma, although
increased relatively to the other tissues, is not absolutely above the
normal amount.
It must also be borne in mind, that both the waxy and contracting forms
may be secondarily affected with the inflammatory disease.
=Simple Fatty Degeneration of the Kidneys.= We occasionally find, along
with fatty degeneration of the liver and of the muscular substance of
the heart, a fatty degeneration of the kidney, without any trace of
inflammation. The kidneys are of about the normal size; the surface
smooth, and the capsule not adherent. The organ is more soft and
flexible than natural, and the surface is pale, and mottled with
sebaceous-looking deposits. On section, we find the abundant deposition
of sebaceous-looking material to be mainly in the tubules of the
cortical substance, but also to be found in those of the cones. The
microscope shows that the deposit is not in the free cavity of the
tubes, but within the epithelial cells.
We may have the simple fatty degeneration in connection with exhausting
disease, old age, or with excess of fatty food.
The adipose tissue in which the kidney lies embedded, may increase to
such a degree as to penetrate by the hilus into the substance of the
organ, impede its nutrition, and induce a kind of atrophy. Rokitansky
states that, in the highest degree of this change, the kidney presents
the appearance of a mere mass of fat, without the slightest trace of
renal organization; the urinary passages at the same time being
atrophied and obliterated.
=Dislocated Kidney.= As a result of over-exertion, tight lacing, or
perhaps pregnancy, the kidney sometimes becomes detached from its
connections to the surrounding structures, permitting of a change of
position, and constituting what is known as _movable_ or _dislocated
kidney_. The right kidney is said to be more frequently affected in this
manner, and the condition is more common with females than males.
Morbid Growths.
=Tubercular Disease=, though not of frequent occurrence, does sometimes
occur in the kidneys. In most cases we find a deposit of tubercle in
other organs, especially in the lungs, and often in various parts of the
genito-urinary apparatus.
This disease is most liable to occur in the middle period of life. It is
found sometimes in the miliary form, sometimes in larger masses.
In a very decided tubercular dyscrasia, we find associated with the
miliary granulations a considerable amount of hyperæmia of the organ;
but where the deposit is more chronic, the surrounding tissue is quite
pale. The large masses are remarkably bloodless. When the tubercular
deposits extend to the renal tissue from the mucous membrane of the
calices and the pelvis, these cavities become remarkably enlarged, and
the whole organ is increased in size, and appears rather pale. The
epithelial lining of the tubes is more or less opaque and granular, or
of an oily aspect. By the softening and breaking down of the tuberculous
deposits, large cavities are formed, containing a mixture of tuberculous
detritus and pus. Fibrinous casts are sometimes found in great numbers
in the tubes.
=Cancer.= Secondary, is of more frequent occurrence than primary cancer.
The scirrhus and colloid varieties are rarely, if ever, found.
Encephaloid growths, especially in children, attain in the kidneys an
enormous size.
Cancer of the liver and right kidney, or of the adjacent parts of the
stomach, or descending colon and left kidney, frequently coexist
according to the observations of M. Rayer and Dr. Walshe. The period of
life between fifty and seventy is most liable to cancer of the kidneys.
The natural character of the urine excreted by cancerous kidneys is
seldom changed until the encephaloid growth softens and breaks down,
when blood, puriform matter and detritus may appear.
=Cystic Tumors=, supposed to originate from a dilatation of the
Malpighian capsules, are sometimes found. The cysts vary in size from a
pin’s head to a small bird’s egg. They may be few or many in number, and
are filled either with a clear watery fluid, or with a gelatinous or
pigmentary substance. The walls of the cysts are thin and smooth, partly
divided into compartments by imperfect septa. They are confined to the
cortical portion of the gland, and may be imbedded in that substance, or
project from the surface. The kidney may be unchanged in size, or
considerably enlarged. The clinical symptoms of these cysts are very
obscure, and of the cause of their formation, little is known.[32]
Cysts of a congenital origin, are sometimes found in the kidney at
birth. They may be of great size, and vast number, and appear to result
from a dilatation of the uriniferous tubes, and Malpighian capsules.
_Fibroid_ and _Adenoid_ tumors of small size are rarely found in the
kidneys; the former within the tubular, the latter within the cortical
portions.
Parasites.
=Entozoa= are occasionally found within the kidneys, among which may be
mentioned the _hydatid_, or larval form of the Tænia echinococus.
_Cysticercus cellulosæ._ The larval form of the Tænia solium.
_Eustrongylus gigas._ A small cylindrical worm, with the body tinged
with red. Male—ten to fourteen inches long, three lines wide.
Female—three feet long, six lines wide.
_Pentastoma denticulatum._ Supposed to be the larval form of a worm
found in the nasal cavities of some animals, and consisting of a small
sac, with calcified walls.
The Ureters.
As a congenital defect, we find the ureter terminating in a
_cul-de-sac_, either in the vicinity of the kidney, or of the bladder.
Sometimes they are double or even triple, but they generally unite
before their vesical termination.
=Dilatation.= When the opening into or from the bladder has, from some
cause or other, become greatly narrowed or obliterated, the obstacle to
the passage of the urine causes a _dilatation of the ureters_.[33] The
sinus and calices at the same time, dilate at the expense of the renal
tissue, so that we frequently find but a thin layer of cortical
substance compressed against the investing capsule, and the kidney
converted into a number of pouches, separated by the remains of the
medullary cones. The surface of the kidney is markedly lobulated.
The distention of the ureters may reach such a degree, that they
resemble a portion of small intestines, their walls being at the same
time somewhat thickened.
From an increase in length sometimes met with, the ureters no longer lie
straight, but are thrown into coils or flexures. With dilatation of the
ureters, we not unfrequently find coexisting a state of
=Inflammation=. The mucous membrane is then found swollen and injected,
of a villous aspect, and covered with a muco-purulent fluid. Sloughing
may ensue with consequent perforation of the ureters and infiltration of
the urine into the adjacent tissues, producing an extension of the
sloughing process or circumscribed abscesses. The inflammation rarely
exists as a primary disease; its most frequent causes, are the
irritation from calculi, or the extension of vesical disease. It may
extend to the sinus of the kidney, constituting pyelitis.
Morbid Growths.
=Cancer= of the urinary passages but seldom occurs, and only when found
elsewhere at the same time.
=Tubercles= may occur in the ureters, even when the kidneys are healthy,
but most frequently where they are involved at the same time. These
usually coexist with tuberculosis of some important organ. “The deposit
takes place in the submucous tissue, and forms, when its progress is
chronic, gray granulations, which become yellow, soften, and give rise
to small circular ulcers. When the disease is more acute, larger patches
of deposit are formed, or the mucous membrane becomes infiltrated
throughout with the tubercular product of inflammation, which is at once
detached as a cheesy, purulent mass.”
=Cysts=, containing a glutinous or hard matter, about the size of
millet-seeds or peas, are occasionally found developed under the mucous
membrane of the urinary passages.
The Suprarenal Capsules.
These bodies are sometimes entirely absent. Where one of the kidneys is
absent or displaced, the capsule may still be found in its normal
position.
=Inflammation and Degeneration.= Inflammation of the bodies, either
acute or chronic, appears to result in the following changes:
First, the organs become slightly enlarged and infiltrated with a
semi-translucent material, of a grayish color, soft, homogeneous, or
slightly fibrillated, or containing a few imperfect cells. The substance
resembles what is often seen in scrofulous disease of the lymphatic
glands.
At a later period, this substance gradually changes into a soft,
putty-like substance, or into chalky concretions scattered through the
body. The whole substance of the organ may thus be destroyed. It may, at
the same time, be found more closely adherent to the surrounding organs.
Dr. Addison has associated with these changes in the suprarenal
capsules, a peculiar bronzed condition of the shin sometimes seen, and
named from him “Addison’s Disease.”
=Hæmorrhage= occasionally occurs within the substance of the capsule,
forming a kind of cyst filled with blood. It is more frequent with young
children, but is sometimes seen in adults.
Morbid Growths.
_Cancer._ Primary cancer of these bodies is rare; the secondary form may
appear in connection with the same disease in the kidneys, stomach or
liver.
_Tubercles_ of the miliary form are rarely seen.
_Cysts_, both single and multiple, and with varying contents, may be
found, generally connected with the enclosing membrane.
Section II. THE URINARY BLADDER.
[=Notice=: 1. _External Characters_—malformations; adhesions; size;
Wounds, etc. 2. _Walls_—their thickness; condition of several coats;
morbid growths, cancer, tumors, tubercles, perforations; sinuses;
rupture; wounds. 3. _Contents_—urine, its quantity and characters;
blood, its amount and source; pus; calculi, number, size, position,
etc.]
=Malformations.= Among the most common of these, may be mentioned
_extroversion_, where there is an absence of the anterior walls of the
bladder, with a deficiency in the corresponding portion of the abdominal
parietes. From the pressure of the abdominal viscera, the posterior
walls of the bladder will be crowded forward, and protrude as a rounded
tumor, covered by a vascular mucous membrane, while near the lower
portion may be seen the orifices of the ureters, through which the urine
will be more or less constantly flowing.
Malformations of the external organs of generation, are liable to
accompany those of the bladder.
_The Urachus_ sometimes fails to close before birth, leaving thus an
open passage from the fundus of the bladder to the umbilicus, through
which the urine may be noticed flowing after division of the cord.
=Dilatation.= This is of not unfrequent occurrence, and is the result
either of a paralysis of the muscular coat, or of some obstacle to the
outflow of the urine. The dilatation may be uniform, or we may find
diverticula, formed by a protrusion of the mucous membrane between the
fasciculi of muscular fibres. Such partial distensions occur most
frequently in the lateral portions, the posterior surface, or the
neighborhood of the fundus, and as we should be led to expect from the
manner of their formation, are generally destitute of a muscular tunic,
or have but a few scattered fibres. Calculi are sometimes found in these
pouches after death, the presence of which had escaped notice during
life from their concealed position.
=Hypertrophy= of the muscular coat of the bladder, will generally be
found attending cases of obstruction to the escape of the urine, either
from an enlarged prostate, stricture of the urethra, or from the
presence of a calculus. The muscular coat in these cases is greatly
thickened, the interlacing bundles of fibres appearing with great
distinctness upon the inner surface.
As a result of this condition, we usually find the bladder greatly
contracted, its capacity in some cases being reduced to one or two
ounces. Inflammation of the mucous coat, with dilatation of the ureters,
will also generally attend, hypertrophy of the muscular walls.
=Contraction= of the bladder is met with, as the result either of
irritation of the mucous membrane, or hypertrophy of the muscular coat.
=Inflammation= of the bladder is generally seen in its chronic form.
The appearances in _acute cystitis_ are “strong vascular injection of
the mucous lining, with brownish patches in the vicinity of the neck and
fundus; more or less thickening of the membrane, with exudation of
fibrin or pus on the surface, or foci of the latter in its substance.
The mucous tissue may be ulcerated at several points, softened or
affected by commencing gangrene. Abscesses may form in the substance of
the parietes, and open either into the cavity of the bladder, or upon
its external surface. Sometimes the mucous membrane is almost completely
destroyed, a few shreds or filaments being the only traces remaining,
while the muscular tunic is left as if cleanly dissected. This is
probably the result of phagedenic ulceration.” The inflammation may
spread from the mucous membrane to the muscular coat, but it very rarely
reaches the peritoneal covering. In some cases it extends back along the
ureters, and even to the kidneys. The morbid action is not often of
idiopathic origin, it is more frequently due to the extension of an
attack of gonorrhœa, to disease of the prostate, to traumatic causes, to
protracted retention of urine, or to the irritation produced by
medicines or stimulating drinks. It is sometimes owing to the
constitutional poison of rheumatism or gout. It is met with oftener in
men than women, and in adults than in children.
_Chronic cystitis_, called also catarrh of the bladder, is very common
in advanced age. The morbid process is excited by some obstacle to the
emission of the urine, either paralysis of the viscus, or a stricture,
or by presence of a stone in the bladder, or by enlargement of the
prostate gland. It may also result from successive attacks of the acute
form, or from extension of urethral inflammation.
Various degrees of vascular injection are presented, with dark-reddish,
slate-colored or bluish-black discoloration, more or less thickened
induration of the parietes, which assume an homogeneous, lardaceous
appearance. An acute attack may supervene upon a state of chronic
inflammation, leading to ulceration, suppuration, perforation and
extravasation of urine, as in the case of primary acute cystitis.
Chronic or sub-acute inflammation is often attendant upon paraplegia,
and proves the immediate cause of death.
Morbid Growths.
=Cancer= as a _primary_ disease, is but rarely met with. Encephaloid,
forming nodulated prominences or cauliflower-like excrescences, is the
form which vesical cancer usually assumes. They are developed in the
submucous tissue, but as they grow, the mucous membrane is also
destroyed, and either an ulcer is produced or a soft luxuriant fungous
mass.
=Tubercle= in the form of separate granulations are sometimes met with
about the fundus and neck of the bladder in the male, and usually are
accompanied with similar deposits in the testes, prostate, kidneys, etc.
They are surrounded by more or less hyperæmia, and by softening give
rise to circular ulcers of the mucous membrane covering them.[34]
=Tumors.= _Polypoid growths_, both of a _fibrous_ and _adenoid_
character, may be found in the neck of the bladder, both in children and
adults. They vary in size from that of a pea to a cherry.
_Cystic_ tumors of small size are sometimes found within the mucous
membrane.
Parasites.
_The Sarcina ventriculus_, a vegetable parasite, is sometimes found in
the bladder, in cases of chronic cystitis.
Of animal parasites, the Eustrongylus, Echinococus, and Ascarides, have
found their way into this organ from other parts.
Of the Urethra.
=Malformations.= As congenital malformation, we need mention only
_Epispadias_, fissure on the upper, and _Hypospadias_, on the lower
surface, from arrest of development, and complete closure of the
opening, _Atresia urethræ_.
=Inflammation= of the urethra, of the catarrhal kind, the so-called
gonorrhœa, commencing at the anterior extremity, may, in severe cases,
extend backwards, even into the bladder. The lining membrane becomes
swollen, injected, and covered with mucus or muco-purulent secretion, at
first thin, then thicker, and then, as the inflammation subsides, thin
and pale again. When a chancre coexists with gonorrhœa, “the discharge
has usually a grayish or reddish tint, or sanious aspect.” From an
extension of the inflammation deeper into the fibrous structure of the
corpus spungiosum, results, sometimes, an exudation of fibrin in the
venous cells, suppuration and abscess. Cowper’s gland, the prostate, the
vesiculæ seminales, and the testicles, may also be affected by an
extension of the inflammation along the continuous mucous lining.
The contact of unhealthy vaginal secretions, whether specific or not, is
the most frequent cause of urethritis.
=Dilatation and Contraction.= _Dilatation_ is most frequently the
consequence of obstruction to the flow of urine. It occurs generally in
the membranous portion, which is expanded into a pouch, occasionally as
large as a small orange. The mucous lining of these pouches appears
“injected and thickened, presenting fungous vegetations, and
occasionally coated with lymph.”
_Contraction_ may result from inflammation of the mucous membrane, and
finally end in stricture.
=Stricture= is a very frequent result of inflammation of the urethra. It
usually is found in the anterior part of the membranous portion.
Contusions and wounds also, often produce stricture.
The simplest form of stricture is, where the canal is partially closed
by a fold of membrane passing across it, leaving either a crescentric,
or annular opening. In the most common kind of stricture the urethra is
narrowed in a much greater extent of its course, sometimes for an inch,
or more. When the obstruction occasioned by a stricture is very great,
the urethra behind is dilated, often inflamed and sometimes ulcerated,
so as to give rise to urinary fistula or effusion of urine.
=Rupture= of the urethra may result from severe contusions, or fracture
of the bones of the pelvis, and being followed by extravasation of blood
and urine, inflammation, suppuration or gangrene may supervene, or
fistulous openings may be thus established.
Morbid Growths.
_Warty growths_ sometimes appear within the urethra near the meatus.
They are generally quite vascular, and may cause considerable
obstruction.
_Tubercles_ are of rare occurrence in the urethra.
_Cancer_ occurs only as an extension of the disease from the penis,
prostate gland or bladder.
=Urinary Calculi.= Calculi of different size, form, and chemical
composition, may be found in the urinary bladder, ureters, or sinus of
the kidneys.
_Uric_, or _lithic acid calculi_, are the most frequent in their
presence. They may vary in size, from a pea to that of a hen’s egg. In
color, also, they may vary from a fawn or light yellow, to a dark,
almost mahogany tint. The surface may be slightly tuberculated, or
smooth, and the interior, where a section is made, has a concentric
arrangement of layers around a central nucleus.
_Oxalate of lime calculi_ are next in frequency. From the strongly
tuberculated character of the surface, they are frequently known as
mulberry calculi. They are of an irregular, spherical form, and usually
single. In color, they are usually of a dark olive or brown, but may be
light and almost white. They seldom acquire so large a size as the
lithic acid variety, are very hard, and permit of a high polish.
_Phosphatic calculi_ are characterized by their softness, which
permits of their being readily crushed. They are of a grayish-white
color, and frequently composed of alternate layers of other deposits.
They may be composed wholly of phosphate of lime, or of a triple
phosphate—ammonio-magnesian phosphate—or of a combination of the two.
_Cystine calculi_ are very rare; they are yellowish in color, of a waxy
appearance, and soluble in aqua-ammonia.
_Uric oxide calculi_ are extremely rare; they resemble uric acid
calculi, but present a waxy appearance when polished.
CHAPTER III.
THE MALE GENERATIVE ORGANS.
Section I. OF THE PENIS.
[=Notice=: Malformations; size; condition of prepuce and glans;
chancres, warts, etc. Split open urethra and notice ulcers,
strictures, etc.]
=Congenital Anomalies.= The penis may be very imperfectly developed,
even with a normal development of the other organs of generation,
although it more frequently occurs when the latter are themselves
imperfect.
It occasionally happens that, from an arrest of union in the median line
of the penis, a slit or fissure is left communicating with the urethra.
This commonly occurs in the under surface, constituting _Hypospadias_;
less frequently on the upper surface, (_Epispadias_,) and only in cases
of extroversion of the bladder.
The prepuce may be wanting.
Congenital phymosis occasionally occurs, usually associated with atrophy
of the penis. It is supposed by some, to be a predisposing cause of
cancer of the penis.
=Hypertrophy and Atrophy.= In consequence of long-continued onanism, the
penis may become hypertrophied, or as the result of chronic irritation
and disease, we may have an hypertrophy of the prepuce and of the body
of the penis, sometimes attaining an enormous size. Vidal has related
and figured a case where the organ reached to below the knees, and was
as large as a thigh. Atrophy of the penis, accompanied with obliteration
of the cavernous textures, occurs with atrophy of the testicles.
=Fracture of the Penis= has occurred from the giving way of the erectile
tissue during coition, in consequence of the state of hyperæmia of the
penis. The organ appears broken, and cannot assume the erect condition
beyond the part injured.
=Paraphymosis=, by the strangulation of the glans in front of a tight
prepuce, may, if not relieved, lead to inflammation, and even gangrene.
=Balanitis= commonly occurs as the result of local irritation, not
unfrequently set up by a gonorrhœa. The prepuce is much swollen,
infiltrated and reddened. The inflammation is generally complicated with
inflammation of the internal lamina of the foreskin, and the mucous
membrane of the glans (posthitis), giving rise to excoriation, exudation
of coagulable lymph, adhesion of the prepuce to the glans, suppuration
and ulceration. “When chronic, it induces exuberant formation of
epidermis; and if the deeper parts of the parenchyma of the glans are
involved, obliteration, cartilaginous induration and atrophy follow.”
=Herpes of the Glans and Prepuce=, is characterized by the formation of
small vesicles or excoriated points upon the mucous membrane of this
region, chiefly occurring in persons of a gouty habit of body, with an
irritable mucous membrane.
_Psoriasis_ of the prepuce, produces a red, thickened, and fissured
condition of the part. Phymosis is apt to occur as a consequence.
=Chancres.= These specific ulcerations form usually upon the glans,
although they may be found in the internal surface of the prepuce, the
frænum, and near the meatus within the urethra.
The _Hunterian_ or _hard chancre_, is nearly circular, deep and
excavated; base and edges are as hard as cartilage, but the hardness is
circumscribed; its color is livid or tawny. It may occur upon the
integument, the glans, or the body of the penis.
The _non-indurated_ or _soft chancre_ is more frequently found on the
inner surface of the prepuce. It appears as a foul, yellowish, or tawny
sore. Indolent fungous granulations are subsequently thrown out, unless
it be situated upon the glans.
_Phagedenic chancres_ are of irregular shape, their edges ragged or
undermined, their surface yellow and dotted with red streaks. The
surrounding margin of skin usually looks pulpy and œdematous; but is
sometimes firm and of a vivid red.
The cicatrices left by chancres which have healed, are whitish, more or
less hard, striated and depressed.
Morbid Growths.
_Warts_, belonging to the class of epithelial tumors, sometimes form on
the glans, or on the inside of the prepuce. They are commonly the result
of repeated inflammations.
_Cancer_ of the penis is of two distinct kinds, occurring as scirrhus or
as epithelioma. According to Dr. Walshe, the disease may originate as a
warty excrescence, or as a pimple, which discharges an excoriating
fluid, scabs, and breaks out afresh, while induration, followed by
ulceration, advances at its base. Or it may infiltrate the glans, so as
to convert that part into an indurated mass; or venereal ulcers may take
on cancerous action.
When of the _scirrhus_ form, it usually springs from the ulcers behind
the glans, and may thence invade the neighboring parts of the organ.
_Epithelioma_, commencing as a tubercle in the prepuce, may after a time
give rise to a large, irregular, and sprouting mass, having a granular
fungous appearance. In other cases, it commences as a hard scirrhus
mass, of a pale, reddish-white color, situated on the glans, or between
the prepuce and the glans. This increases in size, cracks, and allows
the exudation of a serous fetid discharge. Ulceration then rapidly takes
place.
Secondary cancers, except in the adjacent glands, are not a common
occurrence. Phymosis and the irritation caused by the retained
secretion, seem to act as an exciting, and advancing age as a
predisposing cause of cancer.
_Encysted tumors_, _nævus_ and _fibro-plastic_ tumors, situated about
the prepuce, may also occur.
Section II. OF THE SCROTUM.
[=Notice=: General condition; relaxed or contracted; œdema; cancer;
tumors, etc.]
=Hypertrophy.= _Common hypertrophy_ of the integument of the corium
sometimes occurs; in this there is no alteration of the subcutaneous
tissue.
In _Elephantiasis_ of the scrotum, however, the epidermis, the corium,
and the subcutaneous areolar tissue, are all, especially the latter,
greatly hypertrophied. The areolar tissue is converted into a large mass
of fibrous material, infiltrated with an albuminous and fibrinous fluid.
“When the disease is confined to the scrotum, and the enlargement
becomes great, the penis becomes drawn in and ultimately disappears,
while the elongated prepuce is continuous at a navel-like opening in the
skin of the surface of the tumor.” The enlargement sometimes is
enormous, such a mass having been known to weigh two hundred pounds,
more than the weight of the rest of the body.
=Inflammatory Œdema= of the scrotum is an erysipelatous inflammation of
this region, giving rise to great effusion into and swelling of the
areolar tissue, with a tendency to the rapid formation of a slough, by
which the integument may become so affected as to leave the testes and
cords entirely denuded. A peculiar form of this disease occurs as a
sequence of small-pox and scarlet fever. Here there is a tendency to
speedy gangrenous disorganization of the areolar tissue, and of the
covering of the generative organs.
Morbid Growths.
_Cancer._ _Epithelial cancer_ is the common form under which it attacks
the scrotum. This disease has appropriately been called
_chimney-sweeper’s cancer_, as it appears to arise from the irritation
of the soot lodging in the folds of the scrotum. It commonly commences
as a tubercle or wart, which, after a time, cracks or ulcerates. It
spreads rapidly, involving at last the greater part of the scrotum, and
sometimes invading the testes, even extending to the groin and thigh,
destroying life by perforating the coats of some of the large vessels.
The glands of the groin are not always affected.
_Melanotic_ cancer of the scrotum has been observed.
_Fibrous tumors_ are sometimes developed in this part, and may form a
large mass when several are grouped together.
Section III. OF THE TESTICLES.
[=Notice=: Malformations; position, in scrotum, inguinal canals, or
abdomen. Size; consistence; condition of coats. _Tunica
vaginalis_—contents; serum, blood; adhesions. Abscesses; cysts;
tumors; cancer; tubercle, etc.]
=Congenital Anomalies.= There is no sufficient evidence of the presence
of more than two testicles. They are both absent when the entire sexual
apparatus is wanting, and in some rare cases they are imperfectly
developed, or only one may exist.
It not unfrequently happens that at birth there is an apparent absence
of one or both glands from an arrest or delay in their descent, so that
they lie in the groin, the inguinal canal, or the lower part of the
abdomen. Sometimes they wander into other situations, _e. g._, into the
perineum close by the anus, and through the crural canal. If the descent
does not take place within twelve months after birth it is rarely
perfectly completed afterwards without being accompanied by hernia.
The organ is sometimes retroverted, so that the epididymis is placed in
front.
The vas deferens may be absent to a greater or less extent, and even the
epididymis has been found in great part deficient.
The vas deferens frequently terminates in a blind extremity before
reaching the vesicula seminalis.
=Hypertrophy and Atrophy.= True hypertrophy of the testicles does not
occur but when attacked with inflammation, or when the seat of morbid
growths the glands may become greatly enlarged. Atrophy, congenital or
acquired, is not unfrequent. The effect of old age is very gradual, the
gland being often but very little diminished in size.
“The testicle atrophied from disease is not only of diminished size and
weight, but is altered in shape, being uneven and irregular, and
sometimes of an elongated form. There is little or no trace of the
proper glandular structure, the organ being converted into fibrous
tissue of a firm texture.
“The testicle in an advanced stage of wasting, not arising from disease
of the gland, usually preserves its shape, but feels soft, having lost
its elasticity and firmness. Its texture is pale, and exhibits few
blood-vessels; the lobuli and septa dividing the lobes are indistinct,
and the former cannot be so readily drawn out into shreds as before. The
epididymis does not usually waste so soon, nor in the same degree as the
body of the testicle. Fatty matter is also found in the glandular
substance of atrophied testicles.”
=Inflammation.= The serous covering of the testes, the _tunica
vaginalis_, is liable to acute inflammation, and is then affected as
other serous membranes. It becomes thickened and injected with blood,
and is coated with a variable quantity of fibrinous exudation. Serum is,
at same time, effused into the cavity, and rendered turbid by flakes of
fibrin. Adhesions between the opposing surfaces commonly form. The
epididymis is apt to partake of the inflammation of the tunica
vaginalis, and _vice versa_.
_Orchitis and Epididymitis_, may be acute or chronic, primary or
secondary. In _acute_ cases, the testis is congested, and of a darker
hue than natural, although not much enlarged. The epididymis, especially
its lower part, is much enlarged, and feels thick, firm and indurated.
“The coats of the vas deferens are thickened, and the adjacent vessels
injected. The tunica vaginalis is inflamed, and its cavity contains the
usual effusions.”
_Suppuration_ may occur more frequently in primary orchitis, rarely in
the secondary form. The pus is liable to burrow and disorganize the
tissue of the gland. By a subsequent absorption of the fluid part of the
pus, there is often left a whitish mass resembling tubercular deposit,
but distinguished from this by being contained in a cyst, and by the
altered condition of the adjacent gland tissue. The epididymis not
unfrequently remains enlarged, presenting a hard, knotty swelling at its
lower part. “In old cases the epididymis acquires the density and
consistence of cartilage, and sometimes even of bone.”
_Atrophy_ of the gland is a frequent result of inflammation.
_Chronic_ orchitis is characterized by the effusion of a yellowish,
homogeneous-looking matter, in the substance of the testicle, within the
tubuli. This deposit may shrink and contract, inducing gradual atrophy
of the testis, or, by adhesions and ulcerative absorption, a fungous
protrusion of the affected tissue may take place.
=Hydrocele.= _Simple Hydrocele_ is a dropsy of the tunica vaginalis. The
fluid is usually clear, and of a straw color, sometimes turbid, with
albuminous flocculi, and not unfrequently contains shining particles of
cholesterine. In old or very large hydrocele, it is often dark-brown or
chocolate colored from disintegrated blood. Its quantity is sometimes
very considerable. The position of the testicle may be altered by
adhesions formed between the two layers of the tunica vaginalis; these
latter may also produce a multilocular hydrocele. Simple hydrocele may
occur with some of the other varieties to be mentioned, and also with
inguinal hernia.
When serous effusion in the tunica vaginalis, is associated with chronic
orchitis or other diseases of the gland, we have _hydro-sarcocele_.
In _congenital hydrocele_, the dropsical tunica vaginalis retains its
fœtal communication with the peritoneal cavity.
_Encysted Hydrocele._ In this variety the fluid is contained in cysts,
which may be situated (1) beneath the visceral portion of the tunica
vaginalis, investing the epididymis; (2) between the testicular portion
of the tunica vaginalis and the tunica albuginea, which are thus
separated from each other; (3) between the layers of the loose or
reflected portion of the tunica vaginalis. The two last mentioned
varieties are of rare occurrence. The cysts have thin fibrous walls, a
lining of tessellated epithelium, and contents usually clear, although
sometimes mixed with various exudations of fibrin or even blood.
Spermatozoa are very frequently found in the fluid of these cysts. Their
presence is undoubtedly due, as pointed out by Cushing, to the rupture
of a neighboring seminal duct. They are but rarely found in the fluid of
common hydrocele.
_Diffused Hydrocele of the Cord_, gives rise to an oval or oblong,
irregular, circumscribed tumor, extending below and into the inguinal
canal. “It consists in the enlargement of the cells of the areolar
tissue, and their distension with a white or yellowish serous fluid. The
inclosing fascial sheath is condensed and thickened, and at the lower
part of the swelling, which is always the largest, separates it
completely from the tunica vaginalis.”
_Encysted Hydrocele of the Cord_ forms a tumor of oval shape, loosely
attached to the vessels of the cord which pass behind it. Instead of a
single cyst, there may be a number, forming a series along the cord.
=Hæmatocele=, is a tumor formed by an effusion of blood from the vessels
of the testis or of the spermatic cord, into the cavity of the tunica
vaginalis. It may be traumatic or spontaneous, and may attain a large
size. Coagula are formed either in separate masses, or in firm layers,
as in aneurism. Inflammation may be set up, leading to fibrinous and
serous effusion, and to suppuration, or the blood may putrify and
gangrene result. The tunica vaginalis is commonly thickened, the
testicle unaffected, or in old cases atrophied from pressure.
_Diffused Hæmatocele of the Cord_ results from the rupture of some
vessels of the cord, in consequence of which blood is effused within the
spermatic fascia. A tumor of enormous size may be formed should the
bleeding continue, or recur after having been arrested. The usual cause
is some strain or violent exercise.
=Varicocele= is a morbid dilatation of the spermatic veins. “The
enlarged veins hang down below the testicle, and reach upwards into the
inguinal canal; and when very voluminous, conceal the gland, encroach on
the septum, and extend to the other side of the scrotum.” The left veins
are more frequently affected than the right. In an advanced stage of the
disease, the coats of the veins are thickened, and do not collapse when
cut across. In cases of slight varicocele, the nutrition of the testis
is not interfered with, but when large, it produces marked atrophy.
Morbid Growths.
=Cancer= is most frequently primary, and generally attacks the body of
the testis in the first instance, the epididymis remaining for some time
unaffected.
_The scirrhus variety_, characterized by its great induration, is rarely
met with.
_Encephaloid_ is the ordinary form; it commences as one or two masses
among the tubuli, which it gradually destroys. The tunica albuginea is
absorbed by degrees, gives way, and allows the growth to project into
the scrotum and there freely vegetate. The scrotum is slow to be
involved in the disease, but at first becomes distended, sometimes to
the size of a cocoanut, and then gradually ulcerates. The spermatic
artery and the accompanying veins become greatly enlarged. The cord may
also be attacked with the disease, while secondary cancers spring up in
various places. The lymphatic glands in the neighborhood become
enlarged, especially those in the iliac fossa. The inguinal glands do
not generally become affected until the skin has become involved in the
disease.
Intermixed with the encephaloid are commonly found masses of a bright
yellow color, supposed by some to be deposits of tuberculous matter, but
by others, merely plastic matter undergoing fatty degeneration.
_Colloid and melanotic_ cancers have rarely been observed in the testes.
The tunica vaginalis is said to have been attacked with cancerous
disease, the testis remaining healthy.
=Cystic Disease of the Testis.= The cysts may be but few, or very
numerous. The testis is proportionately enlarged, indurated, of a
yellowish-white and opaque appearance, and studded with cysts varying in
size. The contents are, in the younger cysts, a clear, amber-colored
fluid; in the older ones, more thick, viscid, highly albuminous, and of
a brownish color. The cysts are sometimes imbedded in solid stroma,
probably of fibroid tissue; sometimes small masses of enchondroma are
found between them. When of an innocent character, the cystic disease is
characterized by the presence of tessellated epithelium in the cysts;
when malignant, by the presence of nucleated cancer cells.
“Occasionally cystic tumors of the testicle are met with, in which the
substance of the organ is atrophied or absorbed, and its place occupied
by one or more large thin-walled sacculi containing fluids of different
color and consistence, dark or fatty.”
=Tubercles= are not very unfrequent, and appear sometimes in the body of
the gland, but oftener in the epididymis, whence they may spread to the
testis. They occur as gray granulations, infiltrated or encysted, and
varying in size from a pin’s head to a plum-stone. They are commonly
found in all stages of development and disintegration in the same organ.
Their presence in and between the tubuli produces inflammation,
suppuration and disorganization of the structure of the testis, with
which they become mixed, so as to form a cheesy mass of a dirty buff
color. This may, by ulceration, perforate the scrotum, and protrude as a
fungous growth of a pale, reddish-yellow granular mass. This disease of
the testis is frequently found in connection with pulmonary tubercle, or
general tuberculosis.
_Tubercular syphilitic sarcocele_, described by Hamilton, of Dublin, is
a variety occurring in an advanced stage of constitutional syphilis.
“_Cretaceous matter_ is occasionally met with in the testis, doubtless
the residue of tuberculous deposit which has softened and undergone
calcareous change.”
=Tumors.= _Fibroid tumors_ of small size are sometimes found developed
within the visceral layer of the tunica vaginalis, or within the
substance of the cord.
_Fatty tumors_ may be found, which have originated within the tunica
albuginea, the dartos, or within the fibrous connective tissue of the
cord.
_Cartilaginous tumors_ of small size, originate with the substance of
the gland, and are frequently associated with cystic disease or cancer.
Section IV. THE SEMINAL VESICLES AND PROSTATE.
[=Notice=: 1. _Seminal vesicles_—present or absent; size; distended or
empty; contents. Condition of mucous lining; inflamed, thickened,
ulcerated, perforated; tubercular deposits, etc. 2. _Prostate
gland_—abnormalities; size; density; enlargement of middle or lateral
lobes; color of section; appearance of inflammation; abscess; tumors;
cancer; tubercle. _Contents of ducts_—calculi: their position, size,
etc.]
=Congenital Anomalies.= The vesiculæ seminales participate in the
defective development of the testes, being absent or imperfect when
their related glands are so.
=Inflammation.= It is not uncommon for these bodies to be attacked with
chronic catarrhal inflammation, which causes a swelling of their mucous
membrane, the secretion of unhealthy mucus, dilatation of the cavity,
and thickening of its walls. Ulceration, perforation, and the formation
of abscess in adjacent parts, may result.
=Tubercular Deposits= are occasionally met with, chiefly in cases of
extensive tuberculosis. “It appears as a thick, yellow, cheesy,
lardaceous, fissured, purulent layer, replacing the mucous membrane.” It
never occurs before puberty.
The Prostate Gland.
=Congenital Anomalies.= When the organs of generation are imperfectly
developed, the prostate gland is generally found to be so too.
=Hypertrophy and Atrophy.= _Hypertrophy_ is of frequent occurrence,
especially in connection with old age. All the lobes may be enlarged
equally, or nearly so, or one or the other of the lateral lobes alone,
or the middle lobe, without any corresponding hypertrophy of the
lateral. Hypertrophy of the middle lobe, when considerable, throws the
neck of the bladder forward, and increases the depth of its lower
region, so that calculi may lodge behind and below the prostate in its
cavity. The canal of the urethra becomes lengthened in its prostatic
portion, and may be narrowed by compression, or considerably dilated, so
that the prostatic sinus may contain two or three ounces of urine. The
retained urine decomposing, may cause irritation and inflammation of the
bladder.
The texture of the enlarged gland is generally indurated, though
sometimes it is found to be looser and softer than natural. On section,
the cut surface bulges above the level, and the shades of color are more
strongly marked than in health. Frequently single gland-lobules are
found hypertrophied. Small cavities, dilatations of the gland-follicles,
are occasionally met with, sometimes empty and sometimes containing a
yellow, pus-like fluid, the prostatic secretion in a thickened state.
_Atrophy_, with consolidated texture, is found with atrophy of the
testes.
“_Eccentric atrophy_ is occasionally met with; the cavities are dilated
and the walls thinned, in consequence of the increase in size of
calculous concretions in its follicles. Cases sometimes occur, in which
the whole of one lobe, or even the entire organ, is converted into a
thin fibrous capsule, the proper substance of the gland being almost
wasted.”
=Inflammation.= As a result of suppressed gonorrhœal discharge, the
prostate may be attacked with acute inflammation, followed by
suppuration, or chronic enlargement, or an irritable state of the gland,
with increased secretion.
_Abscesses_, single or multiple, may occur, and open into the bladder,
into the prostatic sinus of the urethra, into the rectum, or, externally
through the perineum.
Ulceration rarely occurs.
Morbid Growths.
_Cancer_ of the prostate is rare; encephaloid is almost the only form
that occurs. The gland is enlarged and the growth may perforate the
mucous membrane of the bladder, and vegetate in its cavity.
_Tubercles_ occasionally occur. Their softening and disintegration give
rise to abscesses, which pursue the same course as inflammatory
abscesses.
_Fibrous tumors_, varying in size from that of a pea to a nut, are of
frequent occurrence; sometimes but loosely attached to the hypertrophied
gland.
_Cysts_ are of extremely rare occurrence, commonly resulting from
closure and dilatation of the gland-follicles.
_Concretions._ “In greater or less numbers, they are of almost constant
occurrence in the prostatic cavities; they may often be seen on making a
section of the gland, as reddish-yellow grains. Their form varies very
much; in the smaller it approaches the oval or circular; in the larger
it is more polygonal or triangular. They are not unfrequently pale or
colorless. The contents of these semiorganized formations appear to be
earthy matter (phosphate, with a little carbonate of lime), tinged by
the ordinary yellow pigment which is so often derived from the blood.
It is most probable that, in ordinary healthy states, these concretions
undergo solution at an early period of their existence, yielding up
their contents to form part of the secretion of the gland. But, if this
does not occur, and they go on increasing in size, they become the
nuclei, or are developed into _prostatic calculi_. These are not
unfrequently very numerous; as many as fifty or sixty have been found in
an atrophied, dilated prostate. The calculi sometimes cohere, and form a
large mass, projecting into the membranous portion of the urethra, which
becomes in consequence much dilated. The smaller calculi often escape
into the bladder through the dilated prostatic ducts; if they remain
there, they excite irritation of the mucous membrane and deposition of
phosphates upon their own surface.”
CHAPTER IV.
THE FEMALE GENERATIVE ORGANS.
Section I. THE PUDENDA AND VAGINA.
[=Notice=: 1. Of the _pudenda_—malformations; condition of the labia
and clitoris; size; color; abrasions; ulcers; eruptions; tumors; marks
of violence, etc. _Orifice of urethra_—growths around, their number
and size. _Hymen_—present or absent; entire or lacerated;
imperforate.]
1. The Pudenda.
=Congenital Anomalies.= In rare cases the external organs are entirely
absent, more frequently but partially developed.
The nymphæ may be found abnormally enlarged.
The clitoris may be abnormally long, perforated, or cleft.
Many of the cases of so-called hermaphroditism are instances of an undue
congenital development of the clitoris, with an irregular development of
the other organs of generation, either external or internal, or both.
=Hypertrophy.= We may find an hypertrophy of the labia, due to a kind of
solid œdema, perhaps originally dependent upon a fissure or ulcer of the
part. The nymphæ are often abnormally enlarged, not necessarily as the
result of an abuse of sexual indulgence. In new-born infants, they
normally project beyond the labia majora. The clitoris occasionally is
enlarged, elongated and pendulous, and, in some cases, attains an
enormous size. A specimen preserved in the Museum of the University of
Bonn, is fourteen inches in circumference and weighs eight pounds. There
is no necessary connection between an habitual sexual indulgence and an
enlarged clitoris.
Varicose swellings of the labia may reach a considerable size, and,
although not generally interfering with parturition, have been known to
be lacerated at that time with fatal issue.
As the result of external violence, or during parturition, suggillations
often occur in the labia, and may give rise to considerable swelling.
The tumor presents a tense, smooth surface, of a livid color, thus
distinguished from a varicose swelling, with the peculiar vermicular
character of its contents.
=Inflammation.= The cutaneous covering, the mucous lining, the cellular
tissue, and the sebaceous and mucous follicles, may be the seat of
inflammation, resulting from external or internal causes.
Eczematous and apthous inflammations may result from derangement of the
digestive organs, from pregnancy, from a want of cleanliness, or from
excessive sexual indulgence, and are of frequent occurrence.
The loose cellular tissue is especially favorable to œdematous swelling,
and when the inflammation has a phlegmonous character, extensive
sloughing may result. It occasionally occurs as an epidemic among those
in early life.
The vulvo-vaginal glands are also liable to inflammation of a catarrhal,
herpetic or syphilitic character, resulting in chronic ulceration, or
tedious discharges. Young children are frequently liable to a benignant
inflammatory affection of these parts, giving rise to much irritation
and a muco-purulent secretion.
Morbid Growths.
_Warty excrescences_, arising from a syphilitic taint, may affect the
labia, the entrance of the vagina, and the clitoris. They consist of
groups of small pedunculated tumors, producing a sort of mushroom
appearance.
_Syphilitic mucous tubercles_ are described as round, flattened
tubercles, raised above the surrounding tissues, sometimes becoming
elongated, of a reddish-blue color, and frequently ulcerated on the
surface.
_Cystic tumors_ are also met with in the labia. They consist of a
membranous envelope, containing a transparent, glairy fluid, and often
attain a large size.
The mucous membrane surrounding the orifice of the urethra, is liable to
an hypertrophy of development, giving rise to small vascular, generally
pedunculated tumors, extremely sensitive during life, and liable to
become abraded.
_Elephantiasis_ may attack the labia majora, the nymphæ, or the
clitoris, and may attain to a great size. It consists of the loose
connective tissue of the part, infiltrated with serum, and covered
either with the smooth skin, or one which has become roughened by
hypertrophy of the papillæ. It may appear as a diffused hypertrophy, or
be furnished with a pedicle, and resemble a polypus.
_Fibrous_, _fatty_ and _scirrhus_ tumors are also met with in this part
of the system.
2. The Vagina.
=Congenital Anomalies.= The valvular fold of membrane which protects the
virgin vagina, the hymen, may be imperforate or much indurated, and of a
cartilaginous consistency. It may thus entirely close the vagina.
Besides this, we may find the vagina terminating in a cul-de-sac, either
with the uterus present or absent, and the ovaries normal or abnormal.
The vagina may also be duplicated, by a septum extending the entire
length of the canal, or only partially dividing it. There may be at the
same time a double uterus. Entire absence of the vagina is also met
with, the internal organs of generation being also absent, or but
imperfectly developed.
=Morbid States.= Occlusion or stricture of the vagina sometimes occurs
as the result of external injury, or of cicatrization of ulcers.
Dilatation, or lengthening of the vagina, also occurs.
The rigidity or laxness of the walls of the vagina, varies much in
different individuals, according to constitution, age, and the effects
of cohabitation and child-birth. Prolonged uterine or vesical disease,
often produces a very lax condition of the mucous membrane of the
vagina. In old women we often meet with this relaxed state, which may
amount to a complete prolapsus. The anterior wall is particularly liable
to be thus affected.
=Laceration and Rupture.= External mechanical injuries may produce
laceration of the vagina. During parturition, either from unusual
rigidity, or from want of care on the part of the attendant, the lower
portion of the canal is apt to give way when the labor pains are at
their height. The lesion may vary from a mere laceration of the
fourchette, to a rupture of the entire perineum, from the vagina to the
anus. Lacerations of the upper portions of the vagina also occur with
rupture of the uterus, or even independently of it.
Lacerations of the vagina are not necessarily fatal, but may result in
vesico-vaginal fistula, where a communication is established between the
bladder or urethra, and the vagina; or in recto-vaginal fistula, where
the fistula opens into the rectum.
=Inflammation.= The mucous membrane of the vagina is frequently the seat
of inflammation. The commonest form is the _catarrhal_, which may be
acute or chronic. In the first stage, the passage is reddened, heated
and dry. This is followed by an abundant secretion of white, creamy
mucus; or of a more purulent discharge, if the inflammation has anything
of a specific character.
_Croupous inflammations_, in connection with general disease, or a
similar disease of the uterus, may occur. They produce a solution of the
mucous membrane and the submucous tissue, varying in shape and depth,
and not unfrequently resembling gangrenous destruction. (Rokitansky.)
A chronic thickening of the mucous membrane, as the result of
inflammation, is occasionally met with.