The follicular, syphilitic and carcinomatous ulcer also affect this

part.

_Suppurative inflammation_ may result from injuries, ending in the

formation of an abscess in the fibrous structures, which may burrow

within the pelvic areolar tissue, or extend into the labia.

_Gangrene_ sometimes results from injuries received during parturition,

or from a degeneration of croupous inflammation in a vagina affected

with blenorrhœa of a gonorrhœal or syphilitic origin.

Morbid Growths.

_Polypi_ and _cysts_ are the varieties most frequently met with in this

situation. The polypi may be either fibro-vesicular, or

cellulo-vascular, varying greatly in size. The encysted tumors,

originate in an obstruction of the follicles of the part, and contain a

glairy, transparent, greenish, or dirty-brown albuminous fluid.

_Myomatous_ tumors may be found developed within the muscular coat of

the vagina, the posterior wall being their usual position.

_Carcinoma_ may occur primarily, or by an extension of the disease from

the cervix uteri.

The form in which it appears is the encephaloid kind, the appearance of

which is described in connection with the uterus.

Malignant _epithelial_ growths are not met with in the vagina.

Section II. OF THE UTERUS.

[=Notice=: 1. _In situ_—absence or malformations. Size, and relation

to surrounding organs and walls of pelvis; high or low in pelvis;

versions; flexions; adhesions, etc. 2. _After removal_—os; size and

shape, round, oval, irregular, etc. _Lips_—size; form; color;

condition of surface; soft or firm; rough or smooth; abrasions;

granulations; ulcers; tumors, etc. _External characters of body_—size;

measurements; weight; tumors; rupture; consistence, hard or soft.

_After section_—thickness of walls; density; condition of

blood-vessels; abscesses; tumors, etc. _Uterine cavity_—size and form.

Contents; serum; size and condition; blood; mucus; pus; tumors.

Condition of mucous lining, cancerous growths, etc.]

According to the measurements of Kilian, the uterus in the virgin adult,

varies in length from twenty-four to twenty-six lines; the greatest

breadth is eighteen lines; the thickness nine lines; the cervix is from

ten to twelve lines long; its breadth from six to eight; its thickness

from five to six lines. The length of the uterine cavity is twelve

lines, and its breadth nine lines. After one or more births all these

measurements increase from one-fifth to one-quarter. The weight of the

uterus varies from eight to twelve drachms, and may, after several

pregnancies, amount to two ounces.

=Congenital Anomalies.= The entire absence of the uterus is an

exceedingly rare occurrence, and need not affect the health of the

individual. A seeming multiplication of the organ is occasionally met in

the _bilocular_ and _horned_ uterus. In the former, a more or less

perfect septum extends through the organ in the median line, while in

the latter, the uterus is divided into two lateral portions, by a

prolongation of the angles or cornua, giving a resemblance thus to a

permanent form seen in many of the lower animals.[35] We may also find

the so-called _uterus unicornis_, where only one of the two rudimentary

bodies from which the normal uterus is developed arrives at maturity.

All these kinds of uteri are capable of becoming impregnated, but

parturition, although not necessarily fatal, seriously endangers the

life of the patient; owing, according to Rokitansky, partly to the want

of the necessary dimensions of the part that undertakes the functions of

the entire organ, and partly to the obstacle opposed to the uniform

development of the impregnated half by the unimpregnated half. These

circumstances favor rupture of the uterine walls.

=Hypertrophy and Atrophy.= These are in part normal at the periods of

puberty and change of life; as a morbid state, the first is of more

frequent occurrence than the last. Either may affect the entire organ,

or only a part. After the climacteric period the cervix often disappears

entirely.

=Hydrometra.= As the result of inflammatory processes, the os internum

or the os externum may become occluded, causing a retention of the

secretions from the diseased mucous membrane of the uterus. This

secretion gradually changes into a sort of thin serum. The uterus

becomes dilated, and we have hydrometra.

_Hæmatometra_ is a condition where the uterus is dilated with serum

mixed with blood, or exclusively with retained menstrual blood. This

latter state is more frequently the result of congenital than of

acquired atresia.

The amount of dilatation may vary greatly.

=Malpositions of the Uterus.= These may be of two kinds: (1) where the

direction of the axis is changed; or (2) the organ becomes altogether

displaced, so that its relation to all the pelvic viscera is altered. Of

the former class, are ante- and retro-versions, with flexions, and

lateral obliquities; of the latter, prolapsus procidentia and inversion.

Inversion may occur spontaneously or as the result of manual

interference in the removal of the after birth. The fundus may pass but

a short distance into the cavity of the organ, or the uterus may be

turned completely inside out. Inversion may also result in an

unimpregnated uterus from the presence of fibrous polypi, growing from

the inner surface of the fundus. These growths, when complicating

pregnancy, favor inversion by disturbing the regular expulsive

contractions.

=Hæmorrhages.= An effusion of blood into the cavity of the uterus,

occurs normally at every period of menstruation; from some morbid

condition of the vessels of the uterus, it may at times amount to an

hæmorrhage. Attending parturition, it may be due to placenta prævia; or

following, to atony or defective contraction of the uterine walls, where

we find the uterus maintaining its dilated condition with flabby and

soft walls; or to spasm or irregular contraction, to which the term,

“hour-glass contraction,” has been applied.

The presence of polypoid tumors is frequently attended by hæmorrhages.

=Peri- or Retro-uterine Hæmatocele=, is an accumulation of menstrual

blood, generally in the utero-rectal _cul-de-sac_. It may arise from

rupture of a blood-vessel, from defect in the excretion of the menses,

or from a morbidly profuse exhalation of blood from the genital organs.

The extravasation may be reabsorbed, or may by perforation be discharged

by the rectum or vagina, or may lead to suppuration and the formation of

an abscess.

=Inflammations.= The traces of _acute catarrhal_ inflammation are but

seldom to be discovered. They present the same features as catarrhal

inflammations of other mucous membranes, congestion and swelling, with a

more or less abundant secretion of muco-pus.

In _chronic catarrhal inflammations_, the membrane is found thickened,

of a brownish or slate-gray color, with a more or less purulent

secretion, often blood-streaked. The walls of the uterus may be

atrophied or hypertrophied.

_Catarrhal erosions_, and follicular ulcers, the result of the bursting

or suppuration of the stopped-up follicles, usually accompany catarrhal

inflammations.

_Acute Metritis._ Here we find the organ swollen and congested, and its

substance of a darker color. The mucous membrane shows symptoms of a

catarrh, and the peritoneal covering is also congested. Occasionally

extravasations of blood are found in the substance or cavity of the

uterus. The inflammation may lead to the formation of abscesses within

the uterine walls.

In _Chronic Metritis_ the organ is generally much enlarged. The walls

are remarkably pale and dry, thick and hard. The mucous membrane almost

always presents the appearances described under chronic catarrhal

inflammation, while the peritoneal covering frequently shows numerous

adhesions to the neighboring organs.

=Ulcerations= may be catarrhal, with superficial erosions or follicular

ulcers; or syphilitic, in the form of the hard and soft chancre; or we

may, in rare cases, have the corroding ulcer, described by Dr. John

Clarke, and differing from genuine carcinoma only in the absence of an

indurated deposit.

Morbid Growths.

_Fibroid tumors_ are of most frequent occurrence. They are found either

imbedded in the texture of the uterus, or protruding from its inner

surface into the cavity, or from some part of its external surface.

Those projecting into the cavity of the uterus, called also _fibrous

polypi_ or submucous tumors, are most frequently met with. Their

pedicles are generally situated just below the openings of the Fallopian

tubes, although they spring also from the posterior wall and from the

fundus, less frequently from the anterior wall, and still more rarely

from the cervix uteri.

Recent investigations go to show that these tumors are to be classed

with the homologous, rather than heterologous productions, and that they

are developments of true muscular tissue. To the naked eye this

structure varies in some respects; at times they present a concentric

disposition of fibres, but more commonly an irregular, wavy appearance,

without any uniformity of arrangement, and in the latter case,

frequently with cavities containing blood, a dark-colored gelatinous

fluid, or a clear serum. Under the microscope, a fibrous structure is

scarcely perceptible, but elongated nuclei are seen, imbedded in an

amorphous stroma.

The vascularity of fibrous tumors varies. The majority are but scantily

provided with vessels. The tumors imbedded in the uterine tissue form

globular, white, glistening, dense tumors. There may be only one, or

they may be numerous, and may vary in size from that of a pin’s head to

that of a melon. These growths are subject also to secondary changes;

thus we may find abscesses in the very centre of fibroid growths, or

they may contain encysted melanotic tumors, or a species of

calcification may be developed.

Fibrous tumors have not been observed before puberty, but occur,

according to Lee and Bayle, most frequently in virgins.

=Polypi and Polypoid Growths.= These growths—not to be confounded with

the fibrous tumors, as is frequently done—are soft and succulent, and

project into the cavity of the uterus, or hang into the vagina. They are

attached by a pedicle of greater or less width, to the surface from

which they spring, and are covered with the mucous membrane of the part.

They are essentially a morbid condition of the structures of the

surface, the mucous membrane, the follicles, or sebaceous crypts of the

different parts of the uterus.[36]

Polypoid tumors may give rise to hæmorrhages. They may become inflamed,

suppuration or even gangrene supervening. In this way the pedicle may be

destroyed, and the tumor be expelled.

=Cysts and Tubercular Deposits= are extremely rare in the uterus. The

latter affect primarily the lining membrane, where it occurs in the

miliary form, or accumulated in masses, aggregated into nodules, or

forming a cheesy layer over the entire surface. The uterine tissue may

be secondarily affected, and is then liable to become infiltrated with

the morbid product. Traces of the disease are found also in the vagina

as spots of ulceration, and in the Fallopian tubes.

=Cancer.= Carcinoma of the uterus is of frequent occurrence. The period

of life in which it is most frequently met with, is that between the

fortieth and fiftieth years. Although met with in single women, it is

found most frequently among the married.

In general, this disease attacks the cervix first, whereby it is

distinguished from fibroid growths.

Many instances of supposed cancers, prove on microscopic examination, to

be nothing more than an irregular thickening and induration of the

cervix, consequent upon chronic inflammation.

According to Rokitansky, the prevailing form of uterine cancer is the

medullary carcinoma, appearing as an infiltration of a white

lardaceo-cartilaginous, or loose encephaloid matter, in which the

uterine tissue is lost, and giving rise to the characteristic nodulated

surface of the cervical portion of the organ.

Of rarer occurrence is the fibrous cancer, consisting of dense, whitish,

reticulated fibres, containing in their meshes a pale-yellowish

translucent substance. Its limits are not sharply defined, but are lost

in the uterine tissue.

Nowhere does the destructive character of the cancerous disease manifest

such virulence, as when attacking the uterus. The degeneration spreads

more or less rapidly to the adjoining parts, and, in extreme cases, the

whole contents of the abdomen are matted together, and present a

frightful spectacle of disorganization and destruction.

=Cauliflower Excrescence= of the cervix, is regarded by both Rokitansky

and Renaud, as a modification of encephaloid growth. It appears as an

irregular projection, with a base as broad as any other part of it,

attached to some part of the cervix. The surface has a granulated feel.

On removal from the body it collapses, owing to its vascular

character.[37]

Morbid Conditions following Parturition.

=Rupture of the Uterus= is not unfrequent as a concomitant of pregnancy

in the horned or bilocular malformation of the organ. It is also met

with in the normal uterus.[38] A laceration of the os tincæ occurs at

every birth, and so long as it does not extend beyond the circular

fibres of the cervix is not dangerous. The result is generally more

disastrous when the rupture extends beyond this point. It may penetrate

the entire thickness of the organ, so as to allow of the escape of the

fœtus into the abdominal cavity, or only one layer of the walls may give

way, or only the peritoneal investment may be lacerated, while the

uterus itself remains uninjured. Rupture of the uterus may also result

from external injury before parturition. It is not necessarily fatal.

Primiparæ are more liable to this accident than multiparæ.

=Puerperal Inflammations.= Where the uterus has itself been the main

seat of inflammation, we find that an exudative process has given rise

to the formation of a yellowish or greenish, more or less, gelatinoid

lining on its internal surface, causing a ragged, patchy appearance.

This exudation may be easily detached from the subjacent mucous

membrane, which, according to the intensity of the disease, is more or

less reddened, tumefied and softened. This condition may penetrate to

the deeper tissues, and involve the entire thickness of the uterus,

which will then, also, be more or less softened and discolored,

infiltrated with a thin sanious product, and even converted into a mere

pulp.

The dirty-colored, brownish, flocculent matter that is found investing

the inner surface of the uterus soon after delivery, and which is merely

the residue of the decidua, must not be mistaken for the product of

disease. The ragged appearance of the part to which the placenta was

attached, due, according to Dr. John Clarke, to the remains of the

maternal portion of the placenta and the coagula of blood left after its

separation, is also liable to be the source of error. In both cases,

however, if the apparent exudation be scraped off, which can easily be

done, we find the _healthy_ surface underneath.

In _putrescence_, the lowest form of uterine inflammation, we find the

internal layer of the organ covered with a thin, opaque, or more dense

product, varying in color from pale green to dark brown, beneath which

the tissue to a greater or less depth is converted into a similar pulp.

We sometimes find small abscesses within the muscular tissue without any

perceptible change in the surrounding parts; in most cases, however, the

structure of the muscular fibre is entirely destroyed.

_Metrophlebitis._ Inflammation of the venous channels and lymphatics of

the uterus, is a very frequent cause of the fatal termination of cases

of puerperal fever. Tonnellé found it present in one hundred and

thirty-two cases out of two hundred and twenty-two. Besides the

appearance of the vessels common to ordinary phlebitis, we find the

uterus studded with small abscesses which may be traced to the vessels.

The lymphatics may be primarily and coincidently affected, or they may

be attacked separately and secondarily; the former is the more frequent.

They present the same varicose appearance as the veins, and are

thickened and distended with the purulent or sanious products of the

inflammation.

_Puerperal Peritonitis_, is the lesion most commonly associated with

puerperal fever. It may be confined to the surface of the organ,

particularly to the part surrounding the neck, or may involve more or

less entirely the whole sac. In the sthenic forms, the appearances

presented, resemble those of ordinary peritonitis. In the low typhoid

forms, there is a peculiar absence of congestion and redness. The

ordinary character of the exudation, is a copious effusion of an

aplastic character, of a dirty-yellow, greenish, or brownish hue, in

which flocculent particles of lymph are found floating, while but small

patches of a thin, non-coherent exudation, are observed in the

peritoneal sac. The smell of the fluid is distinctive, differing from

anything found in the human body in health or disease, and after having

been once noticed, cannot fail to be recognized.

Extra-uterine Pregnancy.

This species of gestation may be considered under the following

varieties, receiving their names according to the part of the passage

where the ovule becomes fixed:

1. Abdominal Pregnancy.

2. Tubo-abdominal Pregnancy.

3. Tubal Pregnancy.

4. Interstitial Tubo-uterine Pregnancy.

5. Utero-tubal Pregnancy.

1. _Abdominal Pregnancy._ This includes all cases in which the

fecundated ovule fails to engage in the tube. Three varieties may occur.

The ovule may remain in the ruptured ovisac and there be developed,

giving rise to an _internal ovarian_ pregnancy. Should it after escaping

from the Graafian vesicle adhere to the surface of the ovary, we have an

_external ovarian_ pregnancy. Finally, if the ovule, escaping from the

ovary, fall into the peritoneal cavity, and there undergo development, a

_peritoneal_ pregnancy results. In the last class, the points to which

the ovule may attach itself are exceedingly numerous. The placenta has

been found attached to the peritoneum covering the right or left iliac

fossa, sometimes to a part of the small or large intestine, and

sometimes to the anterior wall of the abdomen.

2. _Tubo-abdominal Pregnancy._ This name is applied to those cases where

the ovule having but just entered the tube, is arrested by an

obliteration or constriction of the canal, and there undergoes

development. The placenta is attached in the interior of the tube, and

the fœtus developed in the abdominal cavity, and both are surrounded by

a cyst, the walls of which are partly made up by the walls of the

dilated tube. This includes also what has been described as

_tubo-ovarian_ pregnancy.

3. _Tubal Pregnancy_ is the most frequent of all varieties of

extra-uterine pregnancy. The ovule is here arrested and developed at

some spot within the tube, between its abdominal extremity and the point

where it enters the uterine walls. The fibres of the enormously

distended tube constitute the envelope of the fœtal cyst.

4. _Interstitial Tubo-uterine Pregnancy._ Here the ovule is arrested in

that part of the tube that traverses the thickness of the uterine walls.

It may remain, during its development, enclosed by the tube, or it may

make its way through these and be developed within the muscular fibres

of the womb itself.

5. _Utero-tubal Pregnancy_ is a very rare but possible form of

extra-uterine pregnancy. The ovule may ingraft itself just at the

internal orifice of the canal. “In this variety, the fœtus is found in

the abdominal cavity; the cord leaving the umbilicus enters the

Fallopian tube, traverses its whole length, and is inserted in the

placenta, which is itself attached to the internal surface of the

uterus.” The tube has evidently been ruptured, allowing the passage of

the fœtus into the peritoneum, while the placenta remained in the

uterus.

In all these pregnancies, the ovule has originally its proper membranes,

the chorion and the amnion. The structure of the walls of the enclosing

cyst varies according to the species of extra-uterine pregnancy. As a

general rule, the fœtus exhibits nothing peculiar in its development.

The most common of the numerous alterations which it may undergo, are

putrescent dissolution of its soft parts, and the separation of the

various pieces of its skeleton; a complete drying-up or mummification;

and transformation of all its tissues into an osseous or cretaceous

substance.[39]

In the tissues of the mother, new or increased vascularity of those

parts where the ovule is attached will be noticed, while the womb will

be found to have sympathized with the development of the fœtus by an

hypertrophy of its mucous membrane, which, however, does not last more

than a few months. A gelatinous substance, a kind of thick, ropy mucus,

is also frequently found in the neck of the uterus. These appearances

are generally wanting in the womb, where the pregnancy has advanced

beyond term.

Extra-uterine pregnancy generally terminates fatally. In the abdominal

form, the pregnancy may progress to the later months of gestation, when,

losing its vitality, the fœtus may decompose, producing peritonitis and

death, or it may become encapsulated and gradually absorbed; or by the

ulcerative process, the remains may be discharged into the intestinal

canal, or through the abdominal walls. Where the case has been diagnosed

before death, the dead fœtus has been successfully removed by abdominal

section.

In the varieties of _tubal_ pregnancy, rupture of the tube, and death

from hæmorrhage usually takes place in the early months, as in the

following case:

CASE.—_Tubal Pregnancy, with Rupture of the Fallopian Tube—Hæmorrhage

and Death._

Mrs. C——, aged thirty-three years, four years married, but childless,

had been indisposed for two weeks. Early in the morning of July 9th,

she was taken with severe pain in the lower abdomen, nausea and

vomiting, rapid prostration, increasing tumidity of the abdomen, and

death at 7 o’clock P. M.

Thirty-six hours after death, assisted by the attending physicians,

Drs. H. J. Sartain and E. Calvin, I made a post-mortem examination. “A

quart of bloody serum was sponged out of the abdominal cavity, then a

pint and a-half of black coagula was removed, when the pelvic viscera

were exposed. The right Fallopian tube was found _enlarged and

ruptured_, within an inch of its connection with the uterus. The ovule

had lodged in the tube, about half an inch from its outlet, and there

formed its attachments. The oozing blood from the ruptured arterioles

and venules of the tube, had destroyed the outline of the embryo,

leaving a sort of granular debris lying in the fragments of the

membranes, which were detached from the inner surface of the tube. The

nidus measured externally about an inch in length, and three-quarters

of an inch in transverse diameter. The walls of the uterus were

slightly softened, and the decidua had formed.”[40]

Section III. THE OVARIES AND FALLOPIAN TUBES.

[=Notice=: 1. _External Characters_ of ovaries; size; color;

consistence; soft and boggy, or firm and hard; surface smooth, or

rough, irregular and fissured; cysts beneath the surface, or

projecting from same. _Characters on section_—color, density;

condition of stroma, consistence, etc. Corpora lutea: number, size,

situation; cysts; tumors; abscesses; tubercles; cancer, etc. 2.

_Fallopian tubes_—absent or malformed; length; size of canal;

thickness of walls; condition of fimbriated extremity; tumors,

tubercle, cancer, etc.]

1. The Ovaries.

=Malformations and Malpositions.= The absence or arrest of development

of one or both ovaries is occasionally met with.

The ovaries may be found in the labia majora as a congenital defect, or

in the inguinal or crural canal, or in the foramen ovale, as congenital

or acquired herniæ.

=Inflammation= is but rarely met with in post-mortem examinations in an

isolated form. It generally is associated with affections of the uterus

or its appendages, in connection with the puerperal condition. It does,

however, occur as an idiopathic disease, and then generally attacks but

one ovary. In the congestive stage there is more or less engorgement

with blood, even amounting to extravasation, enlargement and softening

of the organ.

=Abscesses.= As a result of acute inflammation, abscesses may form in

the substance of the ovary. These may reach considerable size, and may

burst into the peritoneal cavity, resulting in death; or they may

discharge into the rectum, vagina or bladder, and end in recovery.

Morbid Growths.

=Ovarian Tumors= or _Ovarian Dropsy_, are generic terms for a class of

affections characterized by the formation of cysts, which have a

tendency to excessive development. The disease affects married females

more frequently than the single, and the age from thirty to forty years

is that most subject to it. According to statistics, the right ovary is

more frequently the seat of the malady. Various forms of the disease are

met with. The cysts may be simple or unilocular, compound or

multilocular, or cancerous.

_Simple cysts_ have but a single, undivided cavity, containing fluid,

and enclosed within the ovary or external to it. We may find one or

more, varying greatly in size, some being no larger than a pin’s head or

pea, while others contain several gallons of fluid. The contained fluid

also, presents great varieties; it may be clear, straw-colored, highly

albuminous, or present a viscid, glairy, more or less opaque character;

or we may find it of a coffee color, or greenish, with a large quantity

of oily matter floating on the surface. In the latter cases the

appearance is due, as shown by the microscope, to the presence of blood

corpuscles and cholesterine plates.

These simple cysts may acquire an enormous size, filling the abdominal

cavity, and crowding the viscera from their position. In a case examined

for Dr. B. Berens, in 1855, a free incision was made through what

appeared to be the abdominal walls alone, when the cavity was found

filled with a straw-colored, slightly gelatinous fluid, of which several

gallons were removed.

Upon extending the incisions and looking into the cavity, it presented

the appearance of an entire absence of all the abdominal viscera; the

spinal column projected at the posterior portion, while above was seen

what appeared to be the concave, under surface of the diaphragm, with no

trace of liver, stomach, or other viscus. A careful examination of the

edges of the incision disclosed the divided walls of the cyst, closely

adhered to the abdominal parietes at all points. With a little care,

these were gradually torn away, when, behind the tumor, was found the

atrophied viscera, crowded and displaced upwards and backward into the

smallest possible space.

_Pilo-cystic_ or _Dermoid cysts_ may be found containing hair and fatty

matters. These appear, in many cases, to be the remains of blighted ova

enclosed in the body. They are congenital in their origin, and usually

contain some fœtal _debris_, such as portions of bone, teeth, etc.

CASE.—_Ovarian Cystic Disease—fatal termination. Autopsy revealing

presence of bone and teeth in small cyst._

The following interesting case occurred in the practice of Dr. William

A. Read, of this city, from whom the appended statement has been

received:

Miss ——, aged 42 years, after having been treated by several

physicians, came under the care of Dr. Read for the treatment of what

was diagnosed as an ovarian tumor. Paracentesis was resorted to, with

the result of drawing off a considerable quantity of gelatinous fluid,

but without any permanent benefit. The disease pursued the usual

course, and the patient finally died of exhaustion.

The autopsy revealed a large multilocular tumor, filling a large

portion of the abdominal cavity. Upon removing the same from its

pelvic attachments, and opening one of the smaller cysts within the

broad ligament, the latter was found filled with a quantity of highly

offensive fluid, and containing one large, irregular mass of bone, in

which were imbedded two well-formed teeth, a smaller piece with one

tooth, and nine detached teeth found in the same sac, making twelve in

all.[41]

The first impression upon the discovery of such remains would

naturally be, that the case was one of _extra-uterine pregnancy_; but

in this instance, the well known character of the lady was such as to

preclude such a theory; while the presence of the unbroken hymen was

further evidence of virginity. From the impossibility of conception

having been the source of the bony and dental remains found in this

and similar cases, the problem can only be solved, by supposing that,

two ova had been impregnated when this woman was conceived, one of

which, in some manner, became imbedded within the other, so that at

her birth this lady had within her abdomen the remains of her

_undeveloped twin_. These became encapsulated within the pelvis, and

finally induced the local disease, which resulted in death.

That this is the correct explanation of such cases, is confirmed by

the fact that similar remains have been found within the bodies of

males.

_Multilocular cysts_ disclose, instead of a single cavity, numerous

chambers, containing secondary, and even tertiary cystic growths, either

sessile or pedunculated, and with varying contents.

By the complicated form, we understand that in which, to some other

diseased state of the organ—as hypertrophy, fibrous tumors, or

carcinomatous growths—the cyst formation is superadded.

_Fibrous growths._ These are developed in the tissue of the ovary, and

present a globular form, with well defined outline. They may attain an

enormous size; the largest one on record, occurred in the practice of

Dr. Simpson, and weighed fifty-six pounds. We occasionally meet with

proofs of a tendency to so-called ossification, in the presence of

calcareous matter, into which a portion of the tissue has been

converted.

_Malignant disease_ of the ovary, is by no means a rare affection. It is

generally limited to one side, and appears as scirrhus, encephaloid,

hæmatoid, melanotic, or alveolar cancer, either as an isolated growth,

or in the infiltrated form, and generally as an addition to some other

morbid formation. It runs a rapid course, although it has been met with

even before puberty; forty-one years was the average age at death

according to the statistics collected by Dr. Walshe.

_Cartilaginous tumors_ are extremely rare in the ovaries.

_Tubercles_ are occasionally found as small, cheesy deposits.

2. The Fallopian Tubes.

=Congenital Anomalies.= One or both of the tubes may be imperfectly

developed, in connection with an unsymmetrical development or total

absence of the uterus. The tubes may be occluded by the closure of one

or both ends, and the point of insertion into the uterus may be

abnormal.

=Inflammation.= Catarrhal inflammation is of not unfrequent occurrence,

and may lead to partial or total, temporary or permanent closure of the

channel of the tubes. Thus the fimbriated extremities may become

agglutinated to the ovaries, the broad ligament, or the uterus itself;

or obliteration may occur at one or more points within the passage.

The continued accumulation of the secretion of the mucous membrane will

cause distension, either simulating a cyst formation, or presenting the

appearance of several saccular dilatations. The dilatations, containing

mucus matter of a more or less purulent character, or fluid of an

heterogeneous constitution, are rarely of large size, although an

instance is on record in which the distension amounted to five inches in

diameter. The morbid contents may be poured into the uterus, or in less

favorable cases the sac is ruptured, and the contents are effused into

the abdominal cavity.

Morbid Growths.

_Cysts_ of small size frequently affect the fimbriated extremities of

the tubes.

We may also find _fibroid growths_, _carcinoma_ and _tubercle_; the two

latter commonly, although not invariably, secondary to similar diseases

of the uterus.

Section III. OF THE MAMMÆ.

=[Notice=: 1. _External Characters_—abnormalities; silvery lines on

integument, indicating previous enlargement; sinuses; firm, or soft

and flabby. _Nipple_—its size, color, retracted, ulcers; excoriations,

etc. _Areola_—size and color. 2. _Appearance on section_—color of

substance; consistence of gland and fluids exuding; abscesses; tumors;

cysts; cancer, etc.]

=Anomalies.= Supernumerary mammæ, with the power of secreting milk

during lactation, have been observed in a number of instances.

The cases of absence of one or both mammæ are rather to be classed as

the result of arrest of development or atrophy.

A too early development of the glands in young children is occasionally

met with, where there is a precocious development of the organs of

generation.

While the mammary glands in the male usually remain in a rudimentary

state during life, cases have occurred where they have acquired an

increased size, and have been stimulated to such a functional activity

as to permit of the suckling of an infant.

=Hypertrophy and Atrophy.= When puberty occurs, the breasts naturally

enlarge and often become tender; and such a temporary enlargement very

commonly accompanies menstruation.

An increase of size, such as normally takes place during pregnancy,

between the fourth and ninth months, will occasionally commence at

puberty, and go on until the organ attains an enormous size. In some

cases the breast has been found, after death, to weigh as much as twenty

pounds, the tissue being perfectly normal.

Both breasts are usually affected, although one is commonly more so than

the other.

After the cessation of the menses, the breasts normally begin to

atrophy.

We may also have an atrophy of the breast following upon lobular

hypertrophy, as described by Sir A. Cooper.

=Inflammation and Abscess.= _Inflammation of the Nipple and Areola_,

preceding or following a fissured state of the nipple, usually occurs at

an early period of lactation, and especially with the first child.

Abscess of the areola is often a consequence.

_Inflammation of the Breast_, generally terminating in suppuration, may

occur in three positions: either in the subcutaneous areolar tissue,

_supramammary abscess_; or in the areolar tissue, in which the gland is

imbedded, _submammary abscess_; or in the gland itself, _mammary

abscess_.

_Chronic Abscess of the Breast_ may be of two kinds: the diffused and

the circumscribed or encysted. The former may occur at all ages, and in

the single as well as in the married. It usually appears in the

submammary areolar tissue, and may acquire a very large size; and by

pushing the mammary gland before it, gives the breast a pointed, conical

shape.

Chronic encysted abscess, so closely simulates various tumors in this

situation, as to render a diagnosis in some cases very difficult during

life. It usually commences as a result of pregnancy; sometimes as a

consequence of lacteal inflammation; but usually without any injury or

other direct local cause. An indolent, indurated swelling forms, and

this may gradually soften in the centre, although fluctuation may for a

long time be very indistinct, and even absent, owing to the thick wall

of plastic matter that is thrown around the collection of pus. It is not

unfrequently attended with retraction of the nipple.

Syphilitic ulcers are also found affecting the nipple; while eczematous

and erysipelatous inflammation in this situation are of frequent

occurrence.

Morbid Growths.

The mammæ are frequently the seat of adventitious growths, presenting

the characters of non-malignant and malignant formations. The most

common of the benignant tumors is, perhaps, the

=Adenoid Tumor or Adenocele=. This is most frequently met with in young

women under thirty years of age, seldom commencing at a later period

than forty. It may remain stationary for years, or it may slowly

increase or grow very rapidly to a great size. It has frequently been

mistaken for cancer, but the otherwise good health of the patient, the

mobility of the mass, the absence of all implication of the skin or

glands, the want of hardness and its circumscribed character, are points

of diagnostic value.

On removal, it appears irregularly lobulated, is encapsulated, and its

cut surface has a bluish or grayish-white color, which, on exposure to

the air, assumes a rosy tint. On pressure, drops of thick, creamy fluid

will often exude. According to Birkett, the microscope shows it to

consist of imperfectly developed hypertrophy of the glandular tissue,

the terminal cells of which are filled with epithelial scales. This

tumor sometimes simulates malignant disease by its extreme rapidity of

growth, especially where it developes later in life. It then, after

section, presents a lobulated, glistening appearance, somewhat

resembling a mass of rice or sago jelly, often having cysts interspersed

throughout its substance containing fluid or semi-solid glandular

tissue.

In rare cases, the adenocele may return, even after extirpation of the

entire mammary gland.

=Cystic Tumors.= These may occur as the unilocular cyst, or as the

cysto-sarcomatous tumor.

_Unilocular cysts_ usually occur as a small, thin sac, of about the size

of a filbert, containing a clear, serous fluid, imbedded in the

glandular structure of the breast, and movable under the skin. As they

increase in size or become multiple, their contents may assume a

greenish-brown or blackish tinge from effused blood. According to

Brodie, they are originally formed by a dilatation of the lactiferous

tubes.

Unilocular cysts occasionally attain an immense size at the same time

that their walls remain thin and supple. In some of these instances, the

fluid continues to the last, of a truly serous character; while in

others, it becomes more or less glairy or mucilaginous.

Sometimes the walls of the cysts have been found to have undergone

calcareous degeneration.

_The cysto-sarcoma_, occurs as an isolated, globular or oval, and more

or less movable cyst; or there are numerous growths of this kind,

varying in size from a pin’s head to a hen’s egg. The inner surface is

smooth, or it presents a broad-based, lobulated, cauliflower growth or

warty excrescences, and the substance of the surrounding gland is

indurated and atrophied. A retraction of the nipple may also be

observed. A transverse section shows a double sheath: one proper to the

cyst, and the other the result of condensation of the adjoining

textures. The contents are either fluid, of a limpid, opalescent,

non-albuminous, or a grumous, brownish, highly albuminous character; or

solid, approaching the character of a fibroid deposit, composed of a

pale, compact substance, traversed by undulating fibrous lines, which

imperfectly divide it into lobes of various sizes and shapes.

_Hydatid cysts_, containing the echinococus, occur in the female breast.

The tumor is firm to the touch, and contains a clear fluid, in which the

microscope detects the tenacula of the echinococus, the animalculum

itself being attached to the internal wall of the cavity.

_Fibrous_, _cartilaginous_ and _osseous tumors_, are of doubtful or very

rare occurrence.

=Carcinoma.= Cancer affects the mammæ more frequently than any other

organ of the body. The age from forty to fifty years seems most liable

to its occurrence. According to Dr. Walshe, the left side is more

frequently affected than the right, and both are but rarely involved.

All varieties of carcinoma have been met with in the breast; but

scirrhus is by far the most frequent form in which it occurs primarily.

The encephaloid variety is generally engrafted upon the scirrhus,

although it may also be primary. The colloid form is the most rare.

_Scirrhus_ appears as a hard, lobulated tumor, imbedded in the adipose

tissue of the gland, causing adhesion to the skin and retraction of the

nipple. Although at first movable, it soon becomes firmly adherent to

the subadjacent parts, and involves more or less the gland tissue, the

muscles of the thorax, and the adjoining glands. Instead of an isolated

tumor, there may be an infiltration of the various structures of the

part from the commencement. It will then have an ill-defined outline,

sending out branches into the adjacent tissues, and involving in its

mass the lacteal tubes and lymphatics. These become contracted and

flattened into many bands, giving a peculiar appearance to this form of

mammary cancer not observed in any other.

Ulceration of the skin gradually follows near the nipple; the edges of

the sore are raised, everted and puckered. The surface is of a

bluish-red color. A purulent, ichorous fluid, of a faint, fetid odor, is

secreted; hæmorrhage may ensue, and the patient sinks from exhaustion.

The average time occupied by a scirrhus in reaching its full development

is from two to three years. When the ulcerative stage has once begun,

the system is soon broken, and the disease proves fatal in from six

months to two years. The older the individual is at the first appearance

of scirrhus, the more slowly does it pass through the various stages of

its growth.

The axillary lymphatic glands are also in most cases found swollen,

hard, and infiltrated with cancerous matter.

The pectoral muscles, ribs and costal cartilages are also found more or

less involved; and a secondary affection of the pleura and lung is not

unfrequent. We may also look for œdema of the extremity on the affected

side, caused towards the termination of the disease by direct

interference with the venous circulation.

The encephaloid form occurs earlier in life, and commonly runs a more

rapid course. Its margin is less defined, the base of the tumor being

diffused among the healthy cellular membrane, or other parts where it

may be situated. It differs from scirrhus also in this: that the disease

may advance to ulceration without any affection of the glands of the

axilla.

The Male Mammæ.

The structure of the male mammæ resembles that of the female gland,

though in a rudimentary state; hence we may find anomalies and morbid

conditions in them similar to those found in the latter.

An increased number of mammæ have been met with.

Hypertrophy sometimes occurs.

There have been well authenticated instances of the secretion of milk by

men.

The male breast may be the seat of non-malignant and malignant growths.

Cancers, simple cysts, compound cysts, and other tumors occur, but

exceptionally.

PART IV.

MISCELLANEOUS SUBJECTS.

CHAPTER I.

OF THE PERIOSTEUM AND BONES.

Section I. OF THE PERIOSTEUM.

[=Notice=: degree of vascularity; thickness; density; detached or

adhered; effusions beneath; serum or pus; ulcerative destruction of;

condition of bone beneath, etc.]

=Inflammation= of the periosteum occurs in the vicinity of chronic

ulcers; as essential to the reproduction of bone after fractures; in

consequence of syphilis or its mercurial treatment; in rheumatism; and

as a manifestation of a scrofulous cachexia.

In incipient inflammation, the membrane has a reddish tinge, a humid,

succulent appearance, and there is more or less of a serous effusion,

causing a slight separation from the bone. As the inflammation advances,

the connection between the membrane and the bone becomes more lax, and

the effusion assumes a purulent character.

Syphilitic inflammation of the periosteum is apt to appear in detached

spots, causing swelling, induration, the formation of new osseous matter

and necrosis. The periosteum of the skull, sternum and tibia are most

frequently attacked.

A malignant disease of the periosteum, the consequence of long-continued

or repeated attacks of inflammation, is described by Stanley. It occurs

on the bones of the hips, and gives rise to the growth of a fungous

excrescence upon the membrane. “This is sometimes soft and flocculent on

its surface, with a firm, grayish, gelatinous base; at others it

consists throughout of a firm, gelatinous substance.”

Section II. OF THE BONES.

[=Notice=: 1. _Surface of bone_—smooth or rough, firm and hard or

soft; periosteum present or destroyed; caries; necrosis; tumors, etc.

2. _Whole bone_—weight and size increased, or diminished? bent or

fractured? 3. _Appearance on section_—density of different portions;

condition of cancellated portion; destroyed, or softened; abscesses;

caries; necrosis; tumors, etc. 4. _Medulla_—density, color,

vascularity, morbid growths.]

=Inflammation and Abscess.= Acute inflammation rarely takes place except

in connection with mechanical injury.

Inflammatory processes in bone, give rise for the most part, to an

increase of medullary tissue, and to softening of the osseous structure.

Haversian canals and medullary spaces increase in size, and ultimately

become confluent by the gradual absorption of the surrounding osseous

lamellæ. The results of progressive inflammation are congestion,

exudation, suppuration, caries and necrosis. An enlargement of the

affected portion is invariably met with.

In case the exudation be absorbed, or the inflammatory process be

arrested, the parts may return to their normal condition, or the bone

retains a permanently disorganized condition, which may present either

an increased condensation and induration, as in gouty bone, or an

abnormal rarefaction of the bone, as in the bones of rickety

individuals.

The same state of rarefaction, or _osteoporosis_, according to Lobstein,

is occasionally met with in advanced life, as an effect of

mal-nutrition.

_Suppuration_, with the formation of _abscess_, may be diffused or

circumscribed. In circumscribed abscess, we find a cavity generally in

or near the epiphyses, lined with a vascular membrane, and thickening of

the adjoining periosteum, and of the surrounding cellular tissue.

=Caries.= Caries, a process of molecular disintegration, may occur in

all bones, and in every part of their structure, though it generally

affects the cancellous tissue. The carious bone is porous and fragile,

of a gray, brown, or blackish color, partly broken down in softened

masses, and partly hollowed out into cells, which contain a

reddish-brown and oily fluid. Small portions of dead bone lie detached

in the carious cavity. The periosteal and medullary membranes, and the

bone around the carious portion, will be found extremely vascular, and

in many cases, compact masses of osseous tissue are deposited around the

carious cavity.

Caries of bone occurs as a result of inflammation, and corresponds to

ulceration of the soft tissues. It frequently results from chronic

suppurative arthritis, when, from destruction of the articular

cartilages, the disease attacks the cancellated structure of the

extremity of the bone.

=Necrosis.= The death of a portion of osseous tissue, or necrosis,

although frequently accompanied with caries, is entirely distinct from

it. It attacks principally the compact tissue, and is met with,

therefore, most frequently in the shafts of long bones. The necrosed

portion is of a dirty, yellowish-white color, and has a dull, opaque

look; after exposure to the air, it gradually becomes of a green, deep

brown, or black tint. Its boundaries are usually distinct, but sometimes

are so imperceptibly lost in the healthy tissue, that it becomes

difficult in the dead body to determine its exact limits.

Necrosis results from causes which interfere with the nutrition of bone,

as from suppurative periostitis, traumatic destruction of the

periosteum, or osteitis. Ulcerative destruction of the surrounding soft

parts, or the diminished vitality attending certain general diseases, as

typhus, etc., may also result in necrosis.

The death of a portion of bone is followed by inflammation at the

dividing line, which finally results in the separation of the dead

portion or sequestrum. This change is soon followed by the production of

new bone, in which process the periosteum and medulla may take part.

=Rachitis or Rickets=, is essentially a disease of mal-nutrition, most

frequently affecting children between the first and third years,

although it does also occasionally occur later. The lower extremities

are the first to show the effects of the disease, by a curvature

commonly referred to too early attempts at walking. A contortion of the

bones of the pelvis, of the spine, the thorax, the upper extremities,

and malformations of the skull, may follow in the course of the disease.

The bone on analysis, shows a decided diminution in the quantity of

phosphate of lime, and a uniform increase of fatty matter; fluoride of

calcium always present in healthy born, is also wanting.

The joints are usually swollen, and the epiphyses of the bones enlarged

by the exudation of a reddish serum into the enlarged cancelli and

canals, the osseous corpuscles, at the same time, showing a deficiency

or entire absence of earthy matter. The periosteum is pulpy and

thickened, and more than usually adherent to the bone.

If a reparative process have been set up, the deformity may have been

greatly diminished, or even entirely removed; or a new deposit of bone

taken place, so as to afford a useful limb during life. “This

supplementary ossification is found, on vertical section of a long bone,

chiefly on the concave side, so that this part of the shaft may present

double and treble the thickness of the opposite side. The structure, at

the same time, is very dense, and of ivory texture.”

In flat bones, as in those of the skull—which is commonly unduly large

in rickety subjects—there is a uniform thickening. In some cases the

thickening affects the capacity of the foramina.

In a peculiar form of disease of the cranium described by Elsasser, the

bone is atrophied, soft and porous; numerous openings are found along

the lambdoidal suture, and in the body of the bone, with the exception

of the occipital protuberance. The perforations are filled up only by

the dura mater and pericranium, which are adherent to one another. This

disease is commonly met with between the third and sixth months of

infant life.

=Mollities Ossium, or Osteomalacia=, is regarded by some as a form of

atrophy, by others as identical with rachitis, except that it attacks

adults instead of children, and by others as an essentially distinct

osseous disease.

It is of rare occurrence, and consists in perverted nutrition of the

skeleton, whereby the earthy phosphates are eliminated from the system

by the kidneys, while a deposit of fat takes place in the cartilaginous

matrix.

As the bones of the trunk are especially liable to be attacked, the

individual affected becomes reduced in size by the collapse of the

vertebral column.

It attacks females more frequently than males, and the former chiefly

after they have commenced child-bearing.

The disease presents two varieties—the _waxy_, in which the bones,

especially those of the pelvis, present a dirty, dark-yellow color, and

remain greasy after drying; and the _fragile_, where the bones are of a

snowy whiteness, and of a light, transparent, open texture, and so

fragile that they give way under the mere pressure of the finger.

Under the microscope, we find the corpuscles and their canaliculi empty

and transparent, and only faintly visible, and the Haversian canals

unnaturally enlarged.

Morbid Growths.

=Enchondromatous Tumors=, are usually found in connection with some of

the short bones, more particularly those of the fingers and toes, though

the ribs, vertebræ, sternum, tibia and femur are sometimes attacked.

They may originate on the surface of the bone, or within the cancellous

tissue. In the former case, they exhibit a lobulated arrangement, and

are surrounded by a fibrous sheath; in the latter, the bone gradually

expands with the development of the tumor. The rapidity and extent of

their growth vary. In their microscopic characters, the enchondroma

resembles normal cartilage.

The central variety presents a semi-elastic feel, and, on section, the

knife passes through a thin, crackling shell of bone, and then exhibits

a white, cartilaginous mass, which is occasionally found to contain some

small cells; while in some tumors there is an interlacement of fibrous

tissue, in which cartilage is imbedded.

The superficial variety is microscopically and chemically identical with

the central form, but has no osseous shell. It is met with chiefly in

the pelvis, on the cranium, and on the ribs.

There may be a partial ossification.

The disease is chiefly met with in early life.

=Osseous Growths=, consisting of true bone, are divided into _exostoses_

and _osteophytes_. The surface of the former is smooth; their outline

generally a segment of a circle or of an ellipse; their cause: an

idiosyncracy of the individual, not referable to any definite

constitutional taint. Of the latter, the surface is rough; they do not

form any well defined _local_, circumscribed tumor; are referable to

rheumatic or gouty inflammation, to syphilis or other causes.

Exostoses are of two kinds: the one, hard and compact; the other, softer

and more spongy. The _hard_ or _ivory exostosis_ is extremely dense, and

whiter than the bone from which it springs, but possesses a true bony

structure. It generally grows from flat bones, and is of small size. It

has been known to necrose and to slough away from the parts on which it

has been situated.

_Spongy exostoses_ often attain a considerable size, and are very

commonly multiple. They differ from the compact variety in being

composed of cancelli, containing medullary matter, and surrounded by a

shell of bone. They spring from the cancellous, or compact tissue of the

bone, and their surface is continuous with that of the latter. In some

cases the cavity of the exostosis communicates directly, or is

continuous, with the medullary cavity of the bone. Their most common

seats are the tibia, fibula and humerus.

The _osteophyte_ chiefly affects the more vascular portions of bones, as

their articular ends, their rough lines, or, in the skull, the sutural

cartilages; being generally the product of an inflammatory process in

the superficial part of the bone, and in the periosteum.

=Fibrous Growths= always develop in the cancellous structure. All the

long bones and many of the flat bones are liable to this disease. They

present more or less elasticity, are of a gray and opaque appearance,

and yield gelatin on boiling. They may attain an enormous size.

=Cystic Tumors= are of rare occurrence, and are generally met with in

adults.

They may be unilocular, usually filled with a solid mass of a

fibro-cellular or fibro-cartilaginous character; or multilocular, with

thin and serous, sero-sanguinolent, viscid or dark-colored contents,

often associated with central, fibrous growths.

_Hydatid cysts_ have been met with. According to Stanley, both the

acephalocyst and the cysticercus cellulosæ have been found, but more

frequently the former.

=Tubercles= are occasionally present in bone, as the yellow, opaque

tubercles, deposited chiefly in the spongy bones and the cancellous

portions of long bones. They may soften or become cretified.

=Vascular Tumors= are of not very frequent occurrence. They are met with

most commonly in the cancellous articular ends of the long bones;

although they have also been found in the pelvic bones, the bones of the

skull, and in the ribs.

In the most frequent class of cases, a new tissue is developed in the

osseous structure, and the tumor partakes of an encephaloid character. A

creamy, curdy or brain-like, soft, and very vascular mass, is formed as

the essential constituent. This will be found to present every shade of

transition, from a purely vascular tissue, of an erectile character, to

true encephaloid cancer.

In a second, more rare form of disease, there is developed in the bone a

_vascular_, _erectile_ growth, closely resembling capillary nævus in its

structure, composed of an infinity of blood-vessels, interlacing in

every possible way, so as to form a soft, reddish-yellow tumor.

In a third form, a hollow cavity is formed in the bone, scooped out of

the cancellous structure and filled with blood, partly liquid and partly

coagulated, and having arterial branches freely opening into it.

According to the stage of the disease, the blood is found in cells,

intersected by fibres, or laminæ and fibres, the remains of the original

osseous structure; or in a more advanced stage, in a single cavity. The

shell of bone surrounding the cavity is very thin and expanded, being

usually absorbed at one point, where it often becomes at last

perforated. This last class constitutes _true aneurism_ of bone.

_Cephalohæmatoma_, met with in infancy on the cranial bones, as a result

of pressure during parturition, is an effusion of blood between the

pericranium and the bone, commonly occurring on one of the parietal

bones, most frequently on the right side. Rare cases of internal

cephalohæmatoma have been recorded in which the effusion took place

between the dura mater and the bones.

=Cancer= of bone most frequently occurs in the head of the tibia and the

lower end of the thigh bone, occasionally in the humerus and in the

jaws, more especially about the antrum.

The encephaloid variety is the most frequent. It is of two distinct

forms: in the one, the morbid growth is central, springing from the

medullary canal; in the other, it is peripheral, being attached to the

compact osseous substance.

In the _central_ form, it is usually situated at or about the articular

ends, but always affects the whole of the bone by infiltration.

In the _peripheral_, the more common form of cancer of the bone, the

osseous tissue is not so completely invaded; for although the disease

may be located upon, or in intimate contact with the outer layers of the

bone, which are incorporated in it, it does not extend into the

cancellous tissue or the medullary canal. In this form, the muscles

attached to the affected portion of bone will often be found extensively

infiltrated with cancer cells.

Encephaloid of bone is harder and more fibrous looking than the same

affection elsewhere. The cancer cell also is not so well marked, and may

indeed be absent altogether. Occasionally some colloid, and more rarely

melanotic matter, is intermixed, but scirrhus is never found in bone.

Of the Medulla.

“It is yet to be determined in how far the medulla is liable to be

primarily affected. It varies in consistency according to the vigor of

the individual; while in dropsical and phthisical cases we find it thin

and serous, or yellow in icterus, or very scanty in ivory condensation

of a bone. It exhibits greater firmness, and a richer pink hue, in

habits tending to an inflammatory character. The real seat of

inflammation in bone is the membrane that lines its cavities. It is,

therefore, fair to infer that, in all diseases dependent upon the state

of the vascular system, whether of an ordinary or of a malignant

character, the medulla is affected coincidently with, if not previously

to, the bony tissue itself.”

_Morbid growths_, of various kinds, may be found within the medulla.

The Cysticercus cellulosæ, and Echinococcus, are said to have been

detected within the medulla and periosteum.

CHAPTER II.

DISEASES OF THE JOINTS.

=Malformations.= Cases of congenital anchylosis, the joints being

absent, have been met with; also imperfectly developed joints, with a

partial or total absence of the ligaments. Supernumerary joints also

occur, either with the normal, or with an excessive number of bones.

=Morbid Conditions of the Synovial Membrane.= _Inflammation_ may be

acute, sub-acute or chronic. It usually results from exposure to cold,

especially in rheumatic or syphilitic constitutions.

There is at first a congestion and increased vascularity of the

membrane, and a loss of its satiny polish; the synovia is increased in

quantity, but becomes thin and serous, and at a later period, mixed with

plastic material. If the disease progress, the vascularity and swelling

of the membrane increase, and it becomes turgid and distended with blood

and effused fluids; a thin, purulent-looking fluid, composed of granular

corpuscles, floating in a serous liquid, is poured out, and

disintegration, with thinning and erosion of the cartilage, ensues; or

granulations are thrown out on the looser portions of the membrane, and,

becoming injected with blood-vessels, form fringed membranous

expansions, in contact with the ulcerating part of the cartilage.

In chronic synovitis, the swelling from the accumulated serous fluid may

become so considerable as to constitute a true dropsy of the

joints—_hydrarthrosis_. This same accumulation may, however, take place

without any evidence of preceding inflammation.

_Pulpy Degeneration of the Synovial Membrane_ is peculiar to the

articular lining membranes, nothing analogous having been found in the

serous sacs. The reflected portions of the synovial membrane are first

attacked, and converted into a light-brown, pulpy substance, from a

quarter to a half, or even a whole inch in thickness, intersected with

white membranous lines and red spots, formed by small injected vessels.

The membrane of the cartilages are then invaded, ulceration in the

cartilages going on at same time, till the ulcerating surfaces of the

bone are exposed.

The disease almost always occurs before the middle period of life,

frequently can be traced to no cause, but is occasionally the

consequence of repeated attacks of inflammation. It generally occurs in

the knee, but has been met with in the ankle and in a joint of the

finger.

A growth of large villous processes, presenting a shaggy appearance, is

sometimes observed. “They have sometimes the form of simple threads or

flattened shreds, or their free extremities are split into filaments or

have a club shape, or resemble melon-seeds hanging singly, or in

clusters from each stalk. In many cases, the healthy texture of the

articulation is not materially affected.”

=Morbid Conditions of Bursæ.= “These small synovial sacs are liable to

be affected much in the same way as larger ones. They may be attacked by

inflammation more or less acute or quite chronic, resulting from

rheumatism, the abuse of mercury, or some other constitutional

affection; or excited by violence or long-continued pressure. The

effusion which takes place may, in cases of a chronic kind, be a simple

synovial or serous fluid; but when the inflammation is more acute, it is

either a turbid serum, with flakes of fibrinous matter floating in it,

or actual pus.” The walls of an inflamed bursa sometimes become very

much thickened by the organization of layers of fibrinous effusion.

In cases of long-standing inflammation, flat oval bodies, resembling

melon-seeds, of a light-brown color, are not unfrequently met with.

Their origin is no doubt to be traced to the coagulated lymph effused in

the beginning of the disease.

In the synovial sheaths surrounding the flexor tendons of the fingers,

as they pass under the annular ligament, small bodies, resembling grains

of boiled rice, are also occasionally found.

The so-called _ganglions_ are small collections of fluid in bursal

cavities of new formation, and occur principally on the back of the

wrist and forearm. In the sheaths of the tendons of the hand, these

synovial accumulations may become so excessive, as to greatly damage the

usefulness of the member.

=Morbid Conditions of Cartilage.= The thickness of cartilage may be

greatly increased, while the tissue becomes soft and yielding. In

advanced age, the articular cartilages become considerably thinned;

ossification of the cartilage occurs, sometimes gradually with advancing

years, at others in connection with chronic rheumatic arthritis. In

joints apparently not diseased, we sometimes find the cartilages more or

less deficient at one or more points, due to pressure and consequent

partial atrophy. Sometimes its place is taken by a hard,

semi-transparent substance of a gray color, with an irregular granulated

surface, the result of a fibrinous exudation.

The free surface of cartilages is occasionally found covered with a thin

layer of lithate of soda, as the result of gout.

_Loose cartilages_ may be found in the knee and other large joints; they

never contain any of the characteristic cells of cartilage, and appear

to consist solely of compressed fibrillating exudation. They vary in

size and number, are more or less oval and flattened, with a smooth

surface, and are sometimes attached to the synovial membrane by a

pedicle of varying length. In the latter case, they are invested by a

serous covering. Calcareous deposits are occasionally met with in them.

=Ulceration of Cartilage= may occur as an acute or sub-acute affection.

The cartilage corpuscles, instead of being of their usual form, will be

found larger, rounded or oviform; and instead of two or three nucleated

cells in their interior, they contain a mass of them. The cavities of

the enlarged corpuscles open on the ulcerated surface, by orifices of

various sizes. The texture of the ulcerating cartilage, shows no trace

of vascularity. In most cases, a vascular false membrane is found in

opposition to the diseased part. The membrane generally adheres with

some firmness to the ulcerating surface, in other instances it is

loosely applied to it; but in all cases the two surfaces are accurately

moulded to each other. If a portion of the false membrane be torn slowly

off, the cartilage will be found to be rough and honeycombed, and into

each depression on its surface, a nipple-like projection of the vascular

membrane will be seen to have penetrated.

=Chronic Rheumatic Arthritis= is very frequent in the hip, the shoulder,

the knee, and the articulations of the hand. The process consists

essentially, first, in an hypertrophy of the articular cartilage,

generally at the margin, and principally near to the articular surface.

Secondly, in the development of true osseous tissue in the hypertrophied

cartilage. We will, therefore, find irregular enlargement of the

articulating head of the bone; an absence of the articular cartilages,

or new osseous growths surrounding their margins; and the synovial sacs

presenting evidences of having been the seat of chronic inflammation.

=Scrofulous Arthritis=, or _White Swelling_, attacks primarily the

articular extremities of the bones. They become very vascular and

softened, so that they can be readily cut with a knife, while a

characteristic transparent and afterwards a yellow, cheesy substance is

deposited in their cancelli. As the disease advances, the cartilage

ulcerates, and the osseous tissue gradually wastes and undergoes a true

caries. Abscess forms in the joint, and finds its way by ulceration to

the external surface, causing numerous and circuitous sinuses in the

neighboring soft parts.

In some cases, the disease may commence in the synovial membrane,

extending finally to the cartilages and ultimately to the bone.

The disease affects principally the joints of children, and rarely

occurs after the age of thirty. The existence of scrofulous disease in

other parts, and the deposition of the yellow, cheesy matter within the

cancelli, will serve to distinguish this disease from simple caries,

resulting from inflammation.

=Disease of the Spinal Column.= The joints of the vertebræ are liable to

nearly the same affections as more perfectly developed articulations.

The scrofulous disease just described may attack the cancellous tissue,

causing caries and the deposition of cheesy matter. The first effects

are generally perceptible where the intervertebral cartilage is

connected with the bone, or in the intervertebral cartilage itself,

although ulceration may commence on any part of the surface, or even in

the centre of the bone. In some cases, of rarer occurrence, the bodies

of the vertebræ are affected with chronic inflammation, with ulceration

of the intervertebral cartilages as the consequence.

If not checked, the disease proceeds to the destruction of the bodies of

the vertebræ and of the intervertebral cartilages, leaving the posterior

parts of the vertebræ unaffected. The necessary consequence is a

curvature of the spine forward, and a projection of the spinous

processes posteriorly.

Chronic inflammation of the bones sometimes extends to the membranes of

the spinal cord; and when the curvature is very great, the cord may be

so compressed that it cannot properly discharge its functions.

Suppuration may take place at different stages of the disease, sometimes

earlier, sometimes later. “The soft parts in the neighborhood of the

abscess become thickened and consolidated, forming a thick capsule, in

which the abscess is sometimes retained for several successive years;

but from which it ultimately makes its way to the surface, presenting

itself in one or another situation, according to circumstances. In the

advanced stages of the disease, new bone is often deposited in irregular

masses on the surface of the bodies of the neighboring vertebræ; and

where recovery takes place, the carious surface of the vertebræ above,

coming in contact with that of the vertebræ below, they become united

with each other, at first by soft substance, afterwards by bony

anchylosis.”

Where the bones are affected by scrofula, bony anchylosis does not so

readily take place as where they retain their natural texture and

hardness. Occasionally, portions of the ulcerated or carious bone lose

their vitality, and having become detached, are found lying loose in the

cavity of the abscess. The pressure of a large abscess on the surfaces

of the contiguous vertebræ may cause an extensive caries far beyond the

limits of the original disease.

CHAPTER III.

OF TUMORS.

In giving a brief description of tumors, the following classification

has been adopted from Gross, as presenting the most practical and

convenient arrangement of the subject:

I. _Benign or Non-Malignant Tumors._

1. Cystic Tumors.

_a._ Simple Cysts; including Serous, Mucous, Synovial, Colloid,

Sanguineous, Salivary, Milk, Oil, Seminal, and Dermoid

Cysts.

_b._ Compound or Proliferous Cysts.

2. Hydatid Tumors.

3. Myxomatous „

4. Lipomatous „

5. Fibrous „

6. Cartilaginous „

7. Osseous „

8. Papillary „

9. Polypoid Tumors.

10. Myomatous „

11. Vascular „

12. Neuromatous „

13. Adenoid „

14. Lymphatic „

II. _Malignant Tumors._

1. Sarcomatous Tumors.

_a._ The Round Celled.

_b._ The Spindle Celled.

_c._ The Giant Celled.

2. Carcinomatous Tumors.

_a._ Scirrhus Tumors.

_b._ Encephaloid „

_c._ Melanotic „

_d._ Colloid Tumors.

_e._ Epithelial „

I. Benign or Non-Malignant Tumors.

1. =Cystic Tumors.= These are of very frequent occurrence, and may

acquire an extraordinary size. Their structure may be simple or very

complex, and we may accordingly divide them into simple or barren, and

compound or proliferous cysts. They may be new formations or, as in most

cases, merely hypertrophies. They occur in nearly every organ and tissue

of the body, but are most frequently met with in the skin and mucous

membranes, the glandular organs, and in the subcutaneous cellular

tissue.

=A.= _Simple Cysts_ generally consist of a thin sac or cyst filled with

contents, varying according to the structure and function of the

affected part. The cyst itself may be solitary or multiple, generally

composed of a single layer, its external surface being rough and

adherent to the surrounding tissues, while the internal surface is

shining or glossy, and in immediate but loose contact with the contents

of the tumor.

According to the nature of their contents, we may find the following

varieties of simple cysts:

_Serous Cysts._ Their contents are generally of a thin, watery

character, slightly saline in taste, and consisting largely of

albuminous material. The walls are thin, and at first translucent; as

they grow older they become thicker and denser.

_Mucous Cysts_ generally contain a thick, ropy, glutinous material,

intermixed with epithelial matter. Sometimes the contents are thin and

clear; occasionally they resemble the fluid contained in a synovial

bursa. Such tumors occur chiefly in connection with the mucous

membranes, are generally spherical or pyriform in shape, and may attain

the size of a fœtal head.

_Synovial Cysts_ are generally small in size, rounded, globular, or

hemi-spherical in shape, with contents of a serous, mucus, glutinous,

colloid, or of a jelly-like consistence, and of a whitish, opaque

appearance. They occur generally in the synovial sheaths of the tendons

of the wrist, and on the front of the patella. The most characteristic

types of synovial cysts are those known as ganglions and bursæ.

_Colloid Cysts_ are rarely met with as independent structures; they

usually occur as accidental constituents of various kinds of morbid

growths. Their contents vary in consistence between mucus and the

thickest jelly, “their color being generally whitish or pearl-like, not

unfrequently blended with shades of pink, yellowish-brown, or

olive-green.”

_Sanguineous Cysts_, or hæmatomata, may be entirely new formations, or

may occur in a normal cavity. Their contents may consist either of pure

blood or of blood mingled with serum and other substances. “The cyst

wall is usually very thin and smooth; but in some cases the inner

surface has a peculiar fasciculated appearance, not unlike that of the

right auricle of the heart.” The cyst is commonly small, and of a

rounded or hemi-spherical shape.

_Salivary Cysts_ are most frequent in connection with the sublingual

gland, constituting the so-called ranula. The contents of these cysts

are thick and ropy, like the white of egg, and consist essentially of

saliva, mixed with mucus and epithelial matter.

_Milk Cysts_ are liable to be formed in the mammary gland during

lactation. Their size varies. Their contents may be pure milk and

perfectly liquid, or mixed with caseous and epithelial substances.

_Oil Cysts_ are of rare occurrence, and usually of quite small size.

They occur most frequently in the skin or in some glandular organ,

especially the breast. Their contents are generally fatty matter, with

epithelial and other substances.

_Seminal Cysts_ are never of independent growth. They contain a fluid,

mostly serum, with the characteristic spermatozoa held in suspension,

and only to be detected by the microscope. The only true tumors of this

kind are hydroceles of the spermatic cord.

_Dermoid Cysts_ are usually congenital, and, in the majority of cases,

contain the debris of a blighted ovum, such as hairs, teeth and bone.

Sebaceous tumors are a variety of dermoid cysts, and contain sebaceous

matter, combined with epithelium and even hair, oil or fat.

=B.= _Compound or Proliferous Cysts_ are “characterized by the existence

of subordinate cysts, occupied by different organized substances, and

giving rise to that peculiar arrangement known as multilocular or

polycystic, generally so conspicuous in this class of tumors.” When a

number of cysts are crowded together, their walls are frequently

absorbed, and irregular cavities, varying in size and shape, are thus

formed. Their contents are of the most diversified character. The cyst

wall is thin at first, but becomes thicker and firmer in a later stage.

Proliferous cysts sometimes take on a malignant character, of the

encephaloid or epithelial type, years after their origin. They occur

most frequently in the ovary, the mammæ, and the thyroid gland. In the

first situation, they not unfrequently attain an enormous size.

2. =Hydatid Tumors.= These tumors occur most frequently in the liver,

ovary and uterus. They consist of a distinct sac, enclosing an entozoon,

parasite or vesicular worm, “varying in volume between a mustard-seed

and a small orange. The entozoon is of a globular figure, of a whitish,

semi-opaque appearance, and composed of a vesicle or bladder, filled

with serous fluid, and surrounded by a cellulo-fibrous capsule.”

Generally a number of them are found in a common cyst. “The contents of

the animal are of a clear, limpid character, remarkably saline to the

taste, but destitute of odor and coagulability. Between the cyst and the

parasite there is commonly a soft, pulpy, dirty-looking substance, the

precise nature of which is undetermined. Large hydatids sometimes

contain several smaller ones, one within the other.”

“The inner surface of the parasite is studded with numerous little

bodies, resembling diminutive fish-spawn, hardly as large as a grain of

sand, of a spherical shape and of a grayish color, each consisting of a

delicate cyst, filled with echinococci.”

“Each echinococcus consists of a body and a head, the latter being

encircled by a row of teeth, naturally concealed in a narrow cleft, but

capable of projecting itself. The body, composed of solid, granular

matter, has a curiously speckled appearance, due to the presence of

numerous ovoid spots immediately beneath its outer coat. The teeth, or

hooklets, are spinous, sharp, and perfectly characteristic.”

3. =Myxomatous Tumors.= The _Myxomata_ or mucous tumor, consists of

mucous tissue, a translucent and succulent connective tissue, the

intercellular substance of which yields mucin. Their characteristic

features are elasticity and softness; the older growths, however, are

harder than the more recent ones. They are of a pale, greyish or

reddish-white color. They consist of a basement structure, the proper

stroma of the tumor, and an intercellular substance, pervaded by

distinctly visible blood-vessels. On being cut, they yield, on pressure,

the tenacious, mucilaginous, intercellular liquid, in which may be seen

the cellular elements of the growth. The majority of the cells, under

the microscope, are found to be angular and stellate, with long,

anastomosing prolongations and trabeculæ. Others are isolated and

fusiform, oval or spherical in shape. They usually possess one, in some

cases two distinct nuclei. Fat cells, fibrous tissue, both white and

elastic, and cartilage in varying proportions, are often met with in the

morbid mass.

They occur chiefly in the subcutaneous and intermuscular cellular

tissues, in the mucous cavities, in the hilus of the kidney, and in the

nerves and bones. When situated in superficial parts they may become

pedunculated. In the submucous tissue of the nose they constitute the

gelatinoid polypus. Other perfect types of mucous tumors are seen in the

polypi of the ear and the uterus.

4. =Lipomatous Tumors.= The _Lipomata_ or fatty tumors are very common,

and may occur in any part of the body. There may be but one, or they may

appear in very large numbers in different parts of the body. They

sometimes attain an enormous size. They are lobulated, and are usually

surrounded by a fibrous capsule, which separates them from the adjacent

structures. Their consistence varies according to the amount of fibrous

tissue that enters into their formation. They frequently become

pedunculated, or assume a pyriform shape, no doubt by reason of their

weight, by which they are gradually dragged out of their original shape,

as well as position. They resemble in structure, as also in appearance

on section, adipose tissue. They consist of more or less round or

polygonal cells, distended with fluid fat, and united into masses or

lobules of various sizes by connective tissue, which also forms a sort

of capsule around the tumor, and connects it more or less firmly to the

parts around.

Inflammation, suppuration, ulceration, and even gangrene may occur in

these growths. They may also undergo at certain points, fibrous,

cartilaginous or osseous degeneration. Cysts filled with various kinds

of substances may also occasionally occur within them.

5. =Fibrous Tumors.= The _Fibromata_ appear in very different parts of

the body, commonly in those which normally contain much fibrous tissue.

Several may exist in the same organ, more particularly in the uterus,

rarely do they coexist in separate organs. Their form is mostly

spherical, generally with a smooth, even surface, although not

unfrequently it is lobulated, or marked by numerous elevations and

depressions. They feel heavy and incompressible. Near a free surface

they are prone to become pedunculated. They may attain a very great

size. Their vascularity is in proportion to the density of their

structure, some having but few vessels, while others are highly

vascular. A distinct capsule is but seldom met with, although the

tissues around the tumors will usually be found a great deal condensed

and thickened.

They consist essentially of fibres, resembling those of areolar tissue.

“Sometimes the fibres are tolerably distinct and separate, more often so

interlaced and blended together, or so imperfectly evolved that they

cannot be made out as such. Yellow elastic fibres are not unfrequently

mingled with the white.”

Growths of this kind are not, in general, liable to any great degree of

change. Inflammation, with injection and softening of the part may take

place. Cretification may occur, by which either the whole tumor may be

converted into a calcareous mass, or only the outer stratum surrounding

the rest as a kind of shell.

6. =Cartilaginous Tumors.= The _Enchondromata_, histologically resemble

cartilage, and like it consist of cells and an intercellular substance,

presenting all the variations observed in the normal tissue. The

intercellular substance may be hyaline, fibrous, or mucoid, or as most

frequently is the case, all combined. The cells are round, oval,

spindle-shaped or stellate, and may be very numerous, or few in

proportion to the matrix. They enclose one or more nuclei, and slightly

granular contents; sometimes a cell-wall cannot be distinguished.

In addition to the intercellular tissue, the growth is usually divided

into several lobes by bands of fibrous tissue. The fibrous tissue in

most cases, forms a capsule around the tumor, and separates it from the

surrounding structures.

The enchondroma is met with most frequently in early life, and occurs

chiefly in connection with the osseous system, principally the

metacarpal bones, and phalanges of the fingers, where it may grow either

from the periosteum or from the medulla. It is met with also in the

parotid and submaxillary glands, in the testicle, mammæ and ovary, and

occasionally in the subcutaneous and intermuscular cellular tissue.

They may attain an enormous size. “To the hand, it imparts the sensation

of unusual firmness and solidity; it is destitute of elasticity, is

generally distinctly circumscribed, and is nearly always strongly

adherent to the tissues from which it springs.”

Calcification and ossification of these tumors may occur. In rare cases,

the skin covering the tumor ulcerates, and a fungating mass protrudes.

Although in general an innocent growth, the enchondroma in some

instances, assumes a malignant form, and recurs after extirpation.

7. =Osseous Tumors.= The _Osteomata_ are tumors consisting of osseous

tissue, met with chiefly as outgrowths of the skeleton, especially of

the external and internal surfaces of the skull, and of the thigh bone.

There are three classes, the soft, spongy or cancellous, the compact,

and the eburnated osteoma.

The _spongy_, which is the most common, consists of cancellous osseous

tissue. The medullary spaces may contain embryonic tissue, a fibrillated

tissue, or fat. “In its earlier stages, it is often invested by a layer

of cartilage, of a greenish, whitish, slightly bluish, or pearly aspect,

and of a hyaline character. Sometimes it is enclosed by a thin, fibrous,

or fibro-cellular capsule, a form of synovial bursa, lubricated by

serous or sero-oleaginous fluid.”

The _compact osteoma_ is generally more or less rounded, with a

nodulated surface, and a broad base. It is of a firm, bony consistence,

and resembles, as nearly as possible in structure, the compact tissue of

the long bones, differing only in the arrangement of the Haversian

canals and canaliculi, which is less regular than in normal bone.

The _eburnated osteoma_ consists of dense osseous tissue. The lamellæ

are arranged concentrically and parallel to the surface of the tumor.

Blood-vessels and cancellous tissue are both absent. The tumor is of

small size, rounded, globular or hemi-spherical in shape, and generally

smooth, or slightly nodulated.

8. =Papillary Tumors.= The _Papillomata_ resemble in structure ordinary

papillæ, and like these grow from cutaneous and mucous surfaces.

They consist of a basis of connective tissue, supporting blood-vessels,

which terminate in a capillary net-work, or in a single capillary loop,

the whole being enveloped in a covering of epithelium, varying in

character according to the surface from which the new formation springs.

These growths are sometimes very vascular.

On the skin we may have these growths as _warts_ and _horny_ growths.

These are commonly firm, with a dense epithelial covering, and are less

liable to ulceration and hæmorrhage, than those growing on other parts.

But we have, in the _condylomata_ and _venereal warts_, occurring around

the anus and upon the external male and female genital organs, instances

of larger and more vascular forms on cutaneous surfaces.

On the mucous membranes, the papillomata are softer and more vascular,

and have a less dense epithelial covering. Many of them constitute

so-called mucous polypi. They are met with on the tongue, in the larynx

and nose, in the gastro-intestinal mucous membrane, on the cervix uteri,

and in the bladder.

9. =Polypoid Tumors.= These growths occur exclusively in the mucous

cavities of the body, and may attain a large size.

They occur most frequently in the nose and the uterus, but are also met

with in the ear, maxillary sinus, vagina and rectum, while their

presence in the larynx and throat is exceedingly rare.

They are usually solitary, varying in size and shape according to the

locality which they occupy.

Four varieties are met with, differing essentially in their structure.

The _gelatinoid polypus_, the most common of all, occurs almost

exclusively in the nose. It is of a jelly-like appearance, irregularly

pyriform in shape, with a narrow pedicle, sometimes nearly an inch in

length. It is nourished by a few straggling vessels, which are often of

considerable length and thickness.

The structure of the _fibrous polypus_ is exceedingly dense and composed

of fibres, interlacing with each other in all directions. It is tough,

hard and incompressible; of a reddish, purple or livid hue. It is nearly

always solitary, may attain a large size, and is usually attached firmly

by a broad base, and not by a pedicle. The uterus, nose and maxillary

sinus, are its most common sites.

The _granular polypus_, is of rare occurrence. It is met with chiefly in

the uterus and in the ear. It is generally small, of a pale, greyish, or

whitish color, soft and fragile in consistence, and globular, conical,

or ovoidal in shape. Its structure is granular, homogeneous and

inelastic.

The _vascular polypus_, attached usually by a narrow base, is of a

florid color, of a soft consistence, and not very large in size. On

section we find numerous vessels interspersed throughout a

fibro-cellular tissue.

Carcinomatous disease is more liable to supervene in the case of the

fibrous growths, than in the other of these formations.

10. =Myomatous Tumors.= The _Myomata_ are tumors consisting of muscular

tissue, either of the striated, or nonstriated variety. The former are

exceedingly rare and generally congenital, the latter are quite frequent

and are never congenital; but occur principally in elderly subjects.

They are met with most frequently in the uterus, where they sometimes

attain an immense size. They form either distinctly circumscribed tumors

of a globular, conical, or pyriform shape, or ill-defined masses in the

uterine walls. When projecting into the cavity of the uterus, or into

the abdominal cavity, they assume the shape of polypi, with a narrow

pedicle.

Myomata may also occur in the prostate gland, in the œsophagus, stomach

and intestines.

“In structure they consist of elongated spindle-shaped cells, more or

less isolated, or grouped into fasciculi of various sizes, with a

varying amount of connective tissue.”

Maceration with dilute nitric acid, is often necessary in order to

isolate and display the muscular elements.

11. =Vascular Tumors.= The _Angiomata_ are tumors consisting of

blood-vessels, held together by a small amount of connective tissue.

They include the various forms of nævi, the erectile tumors, and

aneurism by anastomosis.

They are generally met with as congenital affections. Their ordinary

sites are the skin and mucous membranes, especially about the head, face

and tongue.

They are soft and spongy, easily compressible, and very elastic, varying

in color according to the nature of their contents, whether venous or

arterial, or both combined.

12. =Neuromatous Tumors.= True _Neuromata_ are tumors consisting almost

entirely of nerve tissue. The term has also been applied to growths of

other kinds, found in connection with nerves; these are false or

spurious neuromata. True neuromata are of very rare occurrence. They

consist mainly of a new growth of nerve fibres. “They resemble in

structure the cerebro-spinal nerves, consisting of tubular fibres, with

a varying quantity of intertubular connective tissue, and in some cases

a few gray, gelatinous fibres.” They usually exist as small, single

nodules, solid to the touch, firm, inelastic, and developed within the

neurilemma of the affected nerve.

The most frequent seat of these growths is the extremities of divided

nerves, where they sometimes occur after amputation. They may also exist

in the course of the nerves, in any situation, singly, or in great

numbers.

13. =Adenoid Tumors.= The _Adenomata_ are new formations of gland

tissue, resembling in structure the racemose, or tubular glands. “They

consist of numerous small saccules or tubes filled with squamous or

cylindrical epithelial cells. These are grouped together, being merely

separated by a small, though varying amount of connective tissue, in

which are contained the blood-vessels.” They are essentially local

hyperplasias. The new growth may remain in intimate relation with the

adjacent gland, or it may gradually become separated from it by the

formation of a fibrous capsule.

The adenoma is usually a solitary tumor, of a firm, dense, inelastic

consistence, of a whitish, grayish, or pale straw color, seldom larger

than a hickory nut. On section, the cut surface has a glistening

appearance, and in recent cases never yields any fluid on pressure.

It occurs in the mammary, thyroid, prostate, and parotid glands, and in

the mucous follicles. In mucous surfaces, it gradually projects above

the surface of the membrane, so as to form a polypus, and thus

constitute the most common form of mucous polypus.

14. =Lymphatic Tumors.= “The _Lymphomata_ are new formations consisting

of lymphatic, or as it is more commonly called, _adenoid_ tissue. This

tissue consists essentially of a delicate reticulum, within the meshes

of which are contained the so-called lymph corpuscles. The reticulum is

made up of very fine fibrils, which form a close net-work, the meshes of

which are only sufficiently large to enclose a few, or even a single

corpuscle in each. The fibrils usually present a more or less

homogeneous appearance, and amongst them there are a few scattered

nuclei.”

The lymphatic tumor is most frequently met with in the lymphatic glands

of the neck, axilla, groin, and mesentery, and usually consists of

several enlarged glands, fused into one common mass of variable size,

shape, and consistence. The sectional surface is of a grayish, light

pink, or reddish-yellow color, and yields on pressure a whitish,

lactescent juice, not unlike that of certain forms of carcinoma,

containing cells with one or more nuclei.

II. Malignant Tumors.

1. =Sarcomatous Tumors.= The _Sarcomata_ are tumors consisting of

embryonic connective tissue. This differs from the fully developed

tissue, in consisting almost entirely of cells, which are also larger

and rounder than those of mature tissue. Its intercellular substance,

instead of being fibrous, is soft and amorphous or only obscurely

fibrillated.

The cells of sarcoma are round, spindle-shaped or stellate, and exist

either separately or in conjunction in the same tumor. The latter is

most frequently the case; but one form generally predominates, and

according to the preponderance of one or the other kind of cell, these

tumors can be most conveniently classified as round-celled,

spindle-celled, and giant-celled sarcomata.

Round cells are found in all sarcomata, and are often very small,

scarcely distinguishable from lymphatic cells, or white blood

corpuscles. Others are larger, and contain an indistinct nucleus, with

one or more bright nuclei.

The fusiform or spindle-shaped cells are the so-called fibro-plastic

cells. They are long, dimly granular, pale bodies, terminating at each

end in a fine prolongation. They are slightly granular, and enclose a

long, oval nucleus, with or without nucleoli. In size they vary.

The giant or mother cells are the largest of human cells, irregular in

shape, though usually more or less spherical. They are finely granular,

and contain numerous round or oval nuclei, each with one or more bright

nucleoli.

The intercellular substance exists usually in small quantities. “It may

be perfectly fluid and homogeneous, or firmer and granular, or, less

frequently, more or less fibrillated. Chemically, it yields albumen,

gelatin and mucin.”

These growths may occur at any period of life, but are most frequently

met with between the twentieth and fortieth year. It is most common in

the skin and subcutaneous and intermuscular connective tissues of the

extremities. The periosteum and bones, particularly the epiphyses of the

long bones and the maxillæ, the female breast, the testicles, and the

eye, are also liable to be attacked.

They usually arise as nodules, single or multiple, firm or soft, and

often attain an enormous size by their characteristic rapidity of

growth. They are liable to fatty degeneration, with the production of

cyst-like cavities. Calcification, ossification and mucoid degeneration

are also common.

Sarcomata are decidedly malignant, and are characterized by their rapid

growth, their great tendency to extend locally, and to recur after

removal, and by their power of reproducing themselves in internal

organs.

The _Round-celled Sarcoma_, called also from its resemblance in many

cases to encephaloid, _medullary_, _encephaloid_ or _soft_ sarcoma, is

of a uniform, soft, brain-like consistence, and of a somewhat

translucent, greyish, or reddish-white color. The sectional surface, on

being scraped, yields a juice rich in cells. It is exceedingly vascular,

with the vessels often dilated and varicose. “It can be distinguished

from encephaloid cancer by the absence of a fibrous stroma, by the

uniformity in the character of its cells, and by the absence of any

invasion of the surrounding structure in their growth other than the

connective tissue from which they grow.”

The _Spindle-celled Sarcoma_, called also the fibro-plastic and

recurring fibroid, is most closely allied to the fibroma. It consists

essentially of fusiform cells, with well-marked nuclei and thin

processes, sometimes split at the end. They are nearly in close contact,

there being but little intercellular substance. The cells are parallel

and arranged in bundles, which pass in all directions through the

growth. “When cut, this sarcoma grates under the knife, and the surface

exhibits a firm, tough, greyish or pale-yellowish appearance, similar to

that of ordinary fibrous growth. After removal, they are softer and more

succulent when they recur.”

They grow from the periosteum, the fasciæ, and from the connective

tissue in other parts. They are more frequently enclosed in a capsule

than the other varieties.

The _Giant-celled Sarcoma_, called also the _myeloid_ sarcoma, most

frequently occurs in connection with bone. They consist of large, many

nucleated cells, mingled with round or spindle forms, nearly in contact,

there being but a sparse intercellular substance. On section, the

surface appears smooth, compact, shining, greyish-white or greenish,

with blotches of a dark crimson, brownish or pink hue.

The giant-celled sarcoma is not a benign affection, but is the least

malignant of the sarcomas.

2. =Carcinomatous Tumors.= “The _Carcinomata_ are new formations,

consisting of cells of an epithelial type, without any intercellular

substance, grouped together irregularly within the alveoli of a fibrous

stroma. The cells are characterized by their large size, by the

diversity of their forms, and by the magnitude and prominence of their

nuclei and nucleoli. In size they vary from ¹⁄₆₀₀ to ¹⁄₁₅₀₀ of an inch

in diameter, the majority being about five times as large as a red

blood-corpuscle. They are round, oval, fusiform, caudate,

polygonal—exhibiting, in short, every diversity of outline. The nuclei,

which are large and prominent, are round or oval in shape, and contain

one or more bright nucleoli.” There is generally but a single nucleus,

two, however, are often met with, and they are even still more numerous

in the soft varieties of cancer.

The stroma varies in amount. It consists of a fibrillated tissue,

forming by their peculiar arrangement, alveoli of various sizes and

shapes, in which the cells are grouped. The stroma varies in character

according to the rapidity of its growth. Where its growth is rapid, it

will contain numerous round and spindle-shaped cells; where it is slow,

or has ceased altogether, the tissue will contain but few cells, and

will be dense and fibrous in character. The latter condition is most

frequently met with.

The blood-vessels are sometimes very numerous, and are always limited to

the stroma, and never encroach upon the alveoli. This serves to

distinguish the carcinomata from the sarcomata, since in the latter the

blood-vessels ramify amongst the cells of the growth.

The carcinomata also possess lymphatics, and it is owing to this that

the lymphatic glands are so constantly involved in the disease.

Cancers very rarely become encapsuled, but generally invade the

surrounding structures. The epithelial elements are found infiltrating

the tissues for some distance around the tumor, so that there is no line

of demarcation between it and the normal structures.

Carcinomatous tumors are liable to certain alterations and

transformations, like other morbid growths.

Fatty degeneration is the most common of these. This occurs to a greater

or less extent in all the varieties of cancer. It produces softening of

the growth, which is often reduced to a pulpy, cream-like consistence.

Calcareous degeneration has been occasionally met with in encephaloid,

and in carcinoma invading bone.

Inflammation, softening, and consequent ulceration, are not unfrequent.

The varieties of carcinomata are:

(_a_.) _Scirrhus._ Scirrhus, fibrous, hard or chronic cancer, seldom

occurs before middle age, and more frequently in the female than male.

The liver, mammæ and uterus, are particularly liable to be attacked. It

also occurs in the alimentary canal, and in the skin.

Scirrhus is characterized by the large amount of its stroma, and its

slow growth. The tumor is firm, hard and inelastic, of variable shape,

and is often depressed in the centre, owing to the contraction of the

cicatricial tissue.

On section, especially in the more matured stages, the tumor exhibits a

whitish, glistening aspect, intersected with fibrous bands, the remains

of normal tissue, changed by disease. It yields on being scraped, a

peculiar fluid, the so-called cancer juice, generally of a pale,

grayish, turbid appearance, rich in cells, nuclei and granules,

sometimes of a whitish, creamy hue. This juice is evidently the result

of disintegration, and is hence but sparingly present in recent

specimens. It readily mixes with water, and often contains a quantity of

free oil.

Scirrhus has but few blood-vessels. Nerves and lymphatics also exist. It

has a tendency to ulcerate, and to contract adhesions with the

structures surrounding it. The lymphatic glands are also liable to be

infected, by the conveying of cancer elements to them through the

lymphatic vessels situated in the scirrhus mass.

(_b._) _Encephaloid._ Encephaloid, medullary, soft or acute cancer,

differs from the preceding, in the small amount of stroma, the

consequent softness of consistence, and its rapid growth.

It is most common in the mammæ, eye, testicle, uterus, liver, lymphatic

glands, periosteum and bones. The greatest number of cases occur between

the twentieth and fiftieth years.

The cells are exactly similar to those of scirrhus, but far more

numerous, while the stroma is not so well marked, and much less fibrous,

and does not undergo a similar cicatricial contraction.

Blood-vessels are very abundant.

The tumor varies in size from a pea to that of an adult’s head, its

shape being generally ovoidal, and its surface more or less lobulated.

“It is of a soft, brain-like consistence, the central portions; where

fatty degeneration is most advanced, often being completely diffluent.

On section, it presents a white, pulpy mass, much resembling brain

substance, which is often irregularly stained with extravasated blood.”

Occasionally these tumors contain serous cysts of small size, as well as

other adventitious products. When ulceration takes place; the sore is

characteristic. “Its edges are thin, undermined, jagged, or irregular,

while its bottom has a foul, bloody, fungous appearance. The parts

around are of a deep red, livid, or purple color.”

(_c._) _Melanosis._ Melanotic, or black cancer, is probably merely the

result of a pigmentation of the encephaloid. It occurs most frequently

in the eye and skin, and is occasionally met with in the viscera. The

melanotic matter occurs in small masses, of a rounded, ovoidal, or

irregular shape, with or without a cyst, from the size of a pin’s head

to that of a walnut; of a dull, sooty, brownish, or black color. They

are generally invested by a distinct capsule, formed out of the cellular

tissue in their immediate vicinity.

“Under the microscope, it is seen to consist of a fibrous net-work,

including numerous alveoli, filled with free, unadherent pigment cells,

occupied by colored granules, a few of the larger or older ones

containing sometimes a nucleus with its nucleolus. Free pigment granules

are also found in great abundance.”

(_d._) _Colloid._ The colloid, alveolar, gelatiniform cancer, is the

most uncommon form of heterologous formations. It is regarded by some,

as simply one of the preceding forms which has undergone mucoid or

colloid change.

It is most frequently met with in the stomach, the intestines, and the

periosteum; and can appear at any age, but is most common between the

thirty-fifth and fiftieth year.

The tumor varies in size, from the size of a marble to an adult head, is

globular or irregular in shape, of a firm, dense consistence, with a

rough, knobby, or distinctly lobulated surface.

The stroma, of a fibrous character, of a dull, whitish, grayish, or

pale-yellowish color, and great density, is so arranged as to form

numerous alveoli of various sizes and shapes, communicating with each

other. Within these cavities is contained the gelatinous or colloid

material, which is a glistening, whitish, greenish, or yellowish color,

and of the consistence of thin mucilage or ordinary jelly. In the older

cells it becomes more firm and opaque. “In the main, it is perfectly

structureless; within it, however, are imbedded a varying number of

spherical cells, which also contain the same gelatinous substance. These

cells present a peculiar appearance; they are large and spherical in

shape, and are distended with drops of the same gelatinous material as

that in which they are imbedded. Many of them display a lamellar

surface, their boundary consisting of concentric lines.”

(_e._) _Epithelioma._ Epithelioma, cancroid, or epithelial cancer, grows

in connection with cutaneous and mucous surfaces.

The cells, usually containing a single nucleus, resemble very closely

those met with in the cutaneous surfaces, and in the mucous membrane of

the mouth, only that they are larger, their average being about ¹⁄₇₀₀ of

an inch. In shape they are either rounded, oval, angular, or elongated,

according to the pressure to which, in their growth, they are subjected.

They are closely packed together into nests, assuming a concentric

arrangement, like the layers of an onion.

Mixed up with the cells, especially if the growth have made much

progress, are great numbers of free nuclei and granules, and sometimes

also crystals of cholesterine, pigment cells and blood corpuscles.

“The tumor itself is firm in consistence, more or less friable, and on

section presents a grayish-white granular surface, intersected with

lines of fibrous tissue. The cut surface yields on pressure, a small

quantity of turbid fluid, and in most cases also a peculiar thick,

crumbling, curdy material, can be expressed, which comes out in a

worm-like shape, like the sebaceous matter from the glands of the skin.”

The ulcer formed has a foul, fungating appearance, with irregular

granulated edges, and a hard rough base.

The disease is more common in men than women, and seldom occurs before

the age of thirty-five or forty. It is most frequently met with in the

lower lip, in the tongue, prepuce, scrotum, (“chimney-sweep’s cancer,”)

labia, eyelids, cheeks, in the uterus and bladder. As it extends it may

involve any tissue.

CHAPTER IV.

POST-MORTEM APPEARANCES IN DEATH FROM UNNATURAL CAUSES.

1. Death from Poisoning.

In speaking of the lesions produced by poisoning, we will confine our

attention to the more common poisonous substances which are given, or

taken, either intentionally or by accident, and which may result in

death.

=Sulphuric Acid.= Death from poisoning with this acid, commonly results

in from twelve hours to three days, but sometimes life is prolonged for

a week or a fortnight, or for months, and sometimes death may take place

in an hour.

The morbid appearances met with will vary according to the quantity of

the acid taken, and the manner of its administration. The appearances

are in general as follows:

On the lips, fingers, or other parts of the skin, spots and streaks of a

brownish, or yellowish-brown color are met with, where the acid has

disorganized the cuticle.

The mucous membrane of the tongue and fauces is white; the pharynx is

only in the rarest cases carbonized like the stomach, is generally hard

to cut, as if tanned, and of a gray color; the vascular injections of

its mucous membrane may be recognized.

The rima glottidis is sometimes contracted, the epiglottis swelled, and

the commencement of the larynx inflamed. The œsophageal membrane is

often completely detached, or comes off in shreds; and the passage shows

traces of the corroding effects of the poison.

The outer surface of the abdominal viscera is commonly either very

vascular or livid.

The stomach, if not perforated, is commonly distended with gases, and

contains a quantity of yellowish-brown or black matter, and is sometimes

lined with a thick paste, composed of disorganized tissue, blood and

mucus. The pylorus is contracted. If the acid has been taken diluted,

the mucous membrane is merely excessively injected, with blackness of

the vessels, and usually a softening of the rugæ, or actual removal of

the villous coat.

If the stomach be perforated, the holes are commonly roundish, with

thin, colored and disintegrated margins, and surrounded by vascularity

and black extravasations. The inner coat of the duodenum often presents

appearances closely resembling those noticed in the stomach. Sometimes,

especially in cases which are rapidly fatal, it is not at all affected,

probably owing to the spasmodic contraction of the pyloric orifice.

The urinary bladder is commonly empty.

The blood is thickened, and of an acid reaction.

=Nitric Acid.= The appearances observed in cases of poisoning by this

acid, are similar to those noticed under sulphuric acid. A difference of

tint in the color produced by nitric acid on the skin, lips and mucous

lining of the mouth and œsophagus, being the only distinguishing mark.

Whereas in the case of sulphuric acid the color is brownish, in the case

of nitric acid, it is most frequently yellow.

=Oxalic Acid.= This is a poison of great energy, and so more frequently

used for committing suicide than for purposes of murder. It has often

been taken by accident for Epsom salt, (sulphate of magnesia,) which it

greatly resembles in general appearance.

It is the most rapid and unerring of all the common poisons, and

produces death generally within an hour, although a large dose may prove

fatal in two or three minutes, and a smaller one may be survived for as

long as twenty-three days.

The mucous membrane of the throat and œsophagus look as if scalded, and

can easily be scraped off. The stomach contains a thick fluid, commonly

dark, like coffee-grounds. The inner coat of the stomach is pulpy, in

some points black, in others red.

The mucous membrane of the intestines is usually similarly, but less

violently affected. In some cases, the stomach and intestines have been

found healthy.

=Phosphorus.= This substance has frequently, in the form of heads of

lucifer matches, been the cause of death; more frequently taken by

accident, or with the intention of committing suicide, than with the

design of destroying the lives of others.

The symptoms of phosphorus poisoning vary during life, and after death

the morbid appearances are not constant, depending much upon the length

of time that has elapsed before death.

In cases which have proved rapidly fatal, the main appearances are those

of irritation, somewhat similar to those already described, and due to

the direct action of the poison. In more protracted cases there is

generally jaundice, the blood is found in a state of complete fluidity,

non-coagulable, and with very few corpuscles, while ecchymoses and

sanguineous effusions appear everywhere.

Sometimes the stomach is distended with gas, which stinks of garlic. The

mucous membrane is partly ash-colored, partly of a dark, purplish-red,

and exhibits gangrenous ulcers which penetrate deeply into the muscular

coat. In recent cases, the whole contents of the stomach shine in the

dark, especially when gently warmed.

The liver is greatly altered, an acute fatty degeneration is found to

have taken place in its secreting structure. The acini are sometimes

found filled with fat, even to bursting; but more commonly they are

wholly destroyed, and oil and fat globules fill their place.

The secreting structures of the kidneys are also found in a state of

fatty degeneration, and the ducts are sometimes filled with exudation

matter. The heart and the muscles generally also show signs of the same

fatty degeneration.