than the right spermatic vein. How rarely it affects the right side is shown by the fact that, in one hundred and twenty cases operated upon by Breschet, all but one occurred on the left. It is important, on account of the atrophy of the testicle, which it is likely to induce, from its causing hæmatocle, by hemorrhage into the tunica vaginalis, and from the influence which, in common with all sexual diseases, it exerts on the mind of the patient. The form of varicosity in the female sex, corresponding to varicocele in man, is enlargement of the vaginal and pudendal veins, which, especially during the advanced periods of pregnancy, are the cause of much suffering, and may, during labor, give rise to very severe hemorrhage.

Hæmorrhoids, or piles, consist in an enlargement and varicose condition of the veins surrounding the anus, and may occur in terminal branches of the inferior mesenteric, a tributary of the portal vein, or of the internal iliac. They protrude in the form of bluish nodes, or form flat sessile tumors. From their position, and the frequent pressure and congestion they are subject to when once formed, they are liable to inflammatory attacks; in consequence of which the surrounding cellular tissue condenses and hardens. Small cysts are formed in the latter, into which blood is effused, and they then exhibit a complex structure, which has been the source of much disputation. Abernethy and Kirby have even gone so far as to deny that they were owing to varicosity of the veins, and have asserted them to be mere sacculated prolongations of the condensed submucous tissue. The sequelæ to which they give rise are hemorrhage, ulceration, and prolapsus of the rectum. The periodical character that is often observed in the sanguineous flow, is one that peculiarly deserves the attention of the physician. In man the affliction is common in persons of the middle of life, who have followed a sedentary pursuit; in women they are more apt to occur during pregnancy, and as a substitute for the menstrual discharge at the period of the climacteric.

Of all forms of varix, none is, probably, of so frequent occurrence as that which affects the superficial veins of the lower extremities, and more particularly the ramifications of the saphena. It is not peculiar to either sex, but is decidedly more common in females than males. This remark does not appear to apply to the continent, however, for we learn from the statistics of Briquet, as well as from the statements of Hasse, that, with them, the male sex is the most liable. Another statement of Briquet's, that it is more frequent in the right than in the left leg, is not confirmed by British experience. Hasse observes that, in men, the dilatation generally arises from the trunk, or the principal branches of the saphena, while he states that, in women, it commences in the minute twigs. It is especially at the ankle, and at the inner side of the popliteal space, that the veins are seen and felt, in the shape of an accumulation of tortuous vessels, of a more or less resistant feel.

A varicose state of the veins of the pia mater is a condition upon which Rokitansky lays some stress, as found after repeated attacks of delirium tremens. Oculists treat of dilatation of the veins of the eye in various forms; and instances of varix in other parts of the upper half

of the body are recorded by authors. Thus, Cruveilhier' delineates two cases of varix affecting the arm.

Varicose veins may prove dangerous, by giving rise to hemorrhage, in consequence of ulceration or rupture. They are not, like the arteries, subject to atheromatous disease, though occasionally they become obliterated by the formation of a coagulum, or spontaneous inflammation and cohesion of the parietes.

An obliteration of portions of the venous system, from spontaneous coagulation of the blood during life, is a not unfrequent occurrence, either from the pressure exerted by morbid growths, as aneurisms or cancerous tumors, or without such mechanical causes, from sheer cachectic debility, as, for instance, in a case of empyema that fell under our notice, in which, from the inferior cava downwards, the veins were plugged up with a fawn-colored coagulum. They are not, however, limited to the veins of the inferior half of the body, though most frequently met with in the vena cava inferior, and the portal vein. Dr. Bright records a case in which the longitudinal sinus was filled in a child of twenty months, another of a female aged seventeen, in whom the left jugular and subclavian veins were plugged with a firm coagulum, terminating abruptly just as they entered the cava, and a third, in a female aged twenty, in whom a white, fibrinous coagulum was found in the subclavian vein, extending two or three inches up the jugulars. In both the last cases the hardened veins were traced during life; the subjects were all in an extreme state of exhaustion. In these cases, the coagulum can be easily removed from the channel of the vessel, and the coats of the latter present no evidence of inflammation in the shape of thickening or interstitial deposit, or roughening of the lining membrane. Another form of obliteration is that resulting from a chronic inflammation and consequent adhesive process, set up by the advance of degenerative disease, such as tubercle or cancer. Thus Dr. Lee records two cases of abdominal phlebitis resulting from malignant disease of the uterus; and another of inflammation of the iliac veins in a man, from carcinoma, is related by Mr. Lawrence. Tubercle never directly affects the vessels; it is not found deposited in the coats, nor is it found in their channels. Carcinomatous matter, on the other hand, is very frequently discovered within the veins, either as an immediate extension of the disease, external to them, or as an absorption of the morbid product. Thus, in cancer of the stomach and liver, it has been found in the vena portæ; in renal cancer, in the corresponding vein and the vena cava inferior; in uterine cancer, in the vena cava and its branches. Few of the observers of the cases on record have verified the fact of the cancerous nature of the contents of the vessels by microscopic examination, and in many instances fibrinous coagula have been mistaken for cancer, when coincident with the latter. Langenbeck3 has, however, established the possibility of the occurrence of cancer within the vessels, by observing cancer-cells in the blood of individuals affected with malignant disease of the uterus. We

1 Anatomie Pathologique, Livr. xxiii. and Livr. xxx.

2 Medical Reports, p. ii. pp. 60, 64, 65.

* Essai sur l'Anatomie Pathologique. Par. 1816, vol. ii. p. 70.

Fig. 172.

Calcareous deposit

in the coats of a vein. seum, F. a. 12.

must not, however, regard the presence of any one variety of cell as essential to determine the malignant character of a morbid growth. The inherent tendency of a certain blastema or matrix is to lead to the production of appearances which are commonly denoted as tubercle, or as cancer, but that blastema in itself need not present any microscopic signs to distinguish it from healthy albuminous or fibrinous deposits. Hence it is not absolutely necessary that we should meet with what are commonly called cancer-cells in the cancerous contents of the veins, in order to justify the conclusion as to their malignant character. Ossification very rarely affects the veins, but cretaceous deposits are occasionally discovered. under the lining coat, as in the case of which we have given a delineation. Cruveilhier1 relates the case of an old man who died of gangrena senilis, in whom the veins accompanying the popliteal artery were studded with phosphatic deposit. This must not, however, be confounded with that variety of concretions termed veinstones, or phlebolithes, which are met with free in the cavity of the vessels. These are formed of concentric laminæ, of which the internal are hard and brittle, while those forming the outer layers present a softer consistency. They closely resemble the concentric corpuscles so frequently met with in the choroid plexus, where, however, the formation is external to the vein. They are found most frequently in the pelvic veins, and in varices, and appear to result from a stasis in the blood, first giving rise to a coagulum of fibrin, within which a process of cretification takes place; chemically they are found to consist of phosphate and carbonate of lime, bound together by animal matter. The theory of their formation agrees with the mode of explanation which suggests itself for other concentric corpuscles, and is confirmed by what we occasionally see in diseases. Thus, in a case of a large cyst in the kidney, containing, within an inner sac of false membrane, a large black coagulum of blood, we found concentric corpuscles in the false membrane, of exactly the same character as those observed in the brain. Here, too, it seemed reasonable to assume the primary deposition of fibrin, and the secondary precipitation within its lamina of the phosphate of lime. It is not impossible that phlebolithes may in some instances be the residuary traces of former phlebitis. Dr. Lee observes, that in the spermatic and hypogastric veins of females advanced in life, calcareous concretions and disorganizations of various kinds have frequently been observed, which must have been the consequence of attacks of acute inflammation at remote periods.

-St. George's Mu

ENTOZOA.

Before quitting the pathology of the veins, we have to allude to the presence of entozoa, and of gaseous contents within them. Of the

1 Medico-Chirurgical Transactions, vol. xvi. p. 418.

2 Ibid.

former, instances are recorded by various of the older authors, from Pliny the elder downwards. This writer states, in his Historia Naturalis, that animals form in the blood of man, and destroy his body. The most recent observation of parasitic animals in the blood is recorded by Dr. Bushman;' but it is liable to objections which tend to invalidate the conclusions arrived at. The observation of the presence of distoma. hepaticum in the trunk of the vena portæ in a man aged forty-nine, by Duval, is more valuable and trustworthy. Andral3 recounts the only instance known of hydatids found in the venous system. They occurred in the pulmonary veins of a man aged fifty-five, and twenty-three occupied the small ramifications shortly before their transition into the capillary network. They varied in size from a pea to a nut, and were symmetrically distributed through both lungs. They had all the characters of acephalocysts.

AIR IN THE VEINS.

The entrance of air into the veins is one of the most formidable occurrences complicating operations about the neck, that the surgeon has to deal with. Death ensues rapidly, and atmospheric air is found in the right side of the heart. Air has been traced in some of these cases in the aorta, the crural arteries, the arteries of the brain, the inferior cava, the iliac veins, and the coronary veins of the heart. It has been suggested that, in some cases of sudden death after delivery, the cause might be found in an introduction of air into the circulation by the open mouths of the veins, when the uterus contracted imperfectly. Another question is the possibility of the spontaneous evolution of gas within the veins during life. Many of the cases on record are undoubtedly mere instances of rapid putrefaction; but we are justified both by the constitution of healthy blood, and by post-mortem observation, in admitting the reality of such a change before death. Numerous authors, among whom we would mention Dr. Baillie," have met with air in the veins of the pia mater in cases of apoplexy, before any traces of decomposition were to be perceived. Dr. Bright attributes the presence of air in these cases exclusively to accidental injury of the veins, or to insipient putrefaction. The evolution of gas during life, though difficult of absolute proof, is entirely within the range of probability, when we consider that venous blood contains an excess of carbonic acid gas, which is discharged on reducing the atmospheric pressure, as demonstrated by Magnus. "Perhaps," as Professor Puchelt remarks, "it happens more frequently than we are aware, that a bubble of air forms in the venous blood, and again disappears. I am acquainted with at least one variety of palpitation, which produces the sensation; and, I am almost inclined

The History of a Case in which Animals were found in Blood drawn from the Veins of a Boy, London, 1833.

2 Gazette Médicale de Paris, 1842, No. 49.

Magendie, Journal de Physiologie, vol. iii. 69.

See Puchelt, das Venensystem, Liefing, 1843, vol. iii. p. 328.

6 Morbid Anatomy, p. 430.

• Medical Reports, vol. ii. p. 668.

to assert, the noise, as if a bubble passed through a fluid. It occurs generally with but one beat of the heart, and I have met with it in venous subjects with an hemorrhoidal tendency, and a liability to flatulency."

THE CAPILLARIES.

The importance of the capillary circulation in its bearings upon disease, and the relation borne by the blood to the coat of the vessels, and by both to the nervous terminations and other surrounding tissues, can scarcely be over-estimated; and yet we are inclined to think that in most of the experiments performed with a view to determining their functions or ascertaining the part they bear in disease, as in inflammation, the most important of all morbid processes, the share taken by the vessels has been regarded more than the changes occurring in the circulating medium itself. A great physical difficulty presents itself in the examination of the ultimate radicles of the vascular system in most of the organs of the body, from our inability sufficiently to isolate them. Where we are able to do so, as in the brain or pia mater, we may, in inflammation, trace the evolution of the morbid product in the shape of minute molecular spherules, but the coats of the vessels must be looked upon rather as the passive agents of percolation, than as the active promoters of the diseased action. Calcareous deposits are also seen, as in cases of cerebral apoplexy, upon very minute vessels, but we do not possess any means of determining in how far the vascular coats are liable to anything like an idiopathic morbid condition. We need not enter into the question of the part played by the capillaries in nutrition and inflammation, as that is discussed in the general pathology. There are few morbid processes in which they are not involved, though at the same time we must not forget that they are not essential to diseased action, and that, as many healthy changes of the body are affected by metamorphoses directly from the blood, or through the intervention of non-vascular tissue, so, in disease, the capillary system is one of several of the agents of the morbific influence. We must here allude to a form of inflammation which, from presenting somewhat peculiar characters, has been termed by Cruveilhier, capillary phlebitis. It depends upon the same causes as those to which we have traced metastatic abscesses, or purulent deposits, viz: a poisonous infection of the blood, and hence is most commonly met with in organs to which there is a great afflux of blood, as in the lungs, the spleen, the kidneys, and the liver. The form in which it appears, is that of a circumscribed patch of injected and inflamed tissue, which, by itself, may pass through the various stages of inflammation; or it may, in its turn, excite active inflammation in the surrounding parts, which will present different features, in color and consistency, by which the two may be distinguished. Rokitansky observes that capillary phlebitis is not essentially a true inflammation, but that it consists in a coagulation of the blood in some portion of the capillary system, and is analogous to the phlebitis caused by coagulation. He states that the coagulum at first appears as a dark red infarctus of the affected parenchyma; that it subsequently may undergo