A
PRACTICAL GUIDE
FOR MAKING
POST-MORTEM EXAMINATIONS,
AND FOR THE STUDY OF
MORBID ANATOMY,
WITH
DIRECTIONS FOR EMBALMING THE DEAD, AND FOR THE PRESERVATION OF SPECIMENS
OF MORBID ANATOMY.
BY
A. R. THOMAS, M. D.
Professor of Anatomy in the Hahnemann Medical College of Philadelphia;
Lecturer on Artistic Anatomy in the Pennsylvania Academy of Fine Arts,
and Philadelphia School of Design; Member of the American Institute of
Homœopathy; General Editor of American Journal of Homœopathic Materia
Medica, Etc., Etc.
FOR SALE BY
BOERICKE & TAFEL,
NEW YORK: | PHILADELPHIA:
NO. 145 GRAND STREET. | NO. 635 ARCH STREET.
1873.
Entered according to Act of Congress, in the year 1873, by
A. R. THOMAS, M. D.,
In the Office of the Librarian of Congress at Washington.
JAMES E. KRYDER,
PRINTER,
32 SOUTH SEVENTH STREET,
PHILADELPHIA.
PREFACE.
The following work has been prepared with a view of supplying a want,
the existence of which has long been felt by the author, both in his
private practice and public teaching. No pretension is made of offering
a complete work on Morbid Anatomy, the object having been, merely to
present the practitioner and student with a practical guide for making
post-mortem examinations, to give them hints as to what they are to look
for in such cases, and, finally, to aid them in recognizing the various
morbid appearances as they are exposed to view.
The work is divided into four parts. Parts I, II and III, corresponding
to the three great divisions of the body—the Head, Chest and Abdomen.
Part IV, is devoted to miscellaneous subjects, and contains chapters on
the Bones; Joints; Tumors; Effects of Poisons; Medico-Legal Autopsies;
On Embalming the Dead; and On the Preservation of Morbid Specimen.
A few illustrative cases have been introduced, and occasional reference
made to morbid specimens in the Museum of the Hahnemann College.
The following works have been consulted in the preparation of the book,
and as few references have been made, this general credit is felt to be
due the several sources of information: Rokitansky’s, Craigie’s, Jones
and Sievecking’s, and Green’s Pathological Anatomy; Rindfleish’s
Pathological Histology; Paget’s Surgical Histology; Raue’s Pathology;
Murchison, on the Liver; Hope, on the Heart; Brinton, on the Stomach;
Stewart, on the Kidney; Gross’ Surgery; Christison on Poisons; Casper
and Taylor’s Medical Jurisprudence.
Acknowledgment should here be made of the valuable assistance rendered
by Drs. W. H. Bigler and John N. Mitchell, in carrying the work through
the press; and of the kindness of Mr. J. H. Gemrig, in the loan of the
electrotype plates which embellish the preliminary chapter.
Conscious that the work is not without defects, it is still presented to
the profession, with the hope that it may be found to answer the purpose
for which it was designed.
A. R. THOMAS,
_937 Spruce Street_.
MARCH, 1873.
CONTENTS.
PAGE.
PREFACE, 15
INTRODUCTION, 17
PRELIMINARY CHAPTER.
Instruments and General Directions, 21
PART I.
THE HEAD AND SPINE.
CHAPTER I.
THE OPERATION.
On the Head and Spine, 27
CHAPTER II.
PATHOLOGICAL CONDITIONS.
SECTION I.—OF THE SKULL, 34
Fracture; Caries; Thinning; Increased Thickness, 35
SECTION II.—THE MEMBRANES OF THE BRAIN.
1. _The Dura Mater_, 36
Inflammation; Thickening; Fibrinous Clots, 37
Tubercular Deposits; Tumors, 38
2. _Arachnoid and Pia Mater._
Pacchionian Bodies; Inflammation; Serous Effusions;
Sanguineous Effusions, 38
SECTION III.—OF THE BRAIN.
What to notice; Inflammation; Softening; Abscess;
Hardening; Hypertrophy; Atrophy; Tumors of the Brain;
Adenoid Tumors; Scrofulous Tumors; Adipose Tumors;
Cholesteroma; Cartilaginous Tumors; Calcareous Deposits;
Encysted Tumors; Blood Cysts; Cancer; Melanosis;
Syphilitic Tumors; Obstruction of Arteries; Degeneration
and Calcification of Arteries, 47
SECTION IV.—OF THE SPINAL CORD.
1. _The Membranes._
Inflammation; Tubercular Deposits; Serous Effusion, 60
2. _Spinal Marrow._
Inflammation; Softening; Hardening; Atrophy; Morbid
Growths, 62
PART II.
THE NECK AND CHEST.
CHAPTER I.
OPERATION ON THE NECK AND CHEST.
CHAPTER II.
PATHOLOGICAL CONDITIONS OF THE ORGANS.
SECTION I.—OF THE TONGUE.
Cancer; Syphilitic Ulcer; Tumors; Ranula; Hypertrophy, 68
SECTION II.—OF THE LARYNX AND TRACHEA.
Inflammation; Ulceration; Œdema; Necrosis of Cartilages;
Abscess; Tumors; False Membranes, 69
SECTION III.—OF THE PHARYNX AND ŒSOPHAGUS.
Inflammation; Ulceration; Stricture; Dilatation; Tumors, 72
SECTION IV.—OF THE PERICARDIUM.
Inflammation; Adhesions; Effusions; Morbid Growths, 73
SECTION V.—OF THE HEART.
1. _Inflammatory Affection._
Pericarditis; Endocarditis, 76
2. _Valvular Affection._
Thickening; Calcification; Atrophy, 77
3. _Changes Affecting Size._
Hypertrophy; Dilatation; Atrophy, 79
4. _Morbid Condition of the Walls._
Fatty Degeneration, 82
5. _Morbid Growths._
Tumors; Cancer; Melanosis; Hydatids; Ossification of
Coronary Arteries; Abscess; Malformations; Aneurism;
Rupture, 84
6. _Displacements._
Ectopia Cordis; Transposition, 87
7. _Contents of Cavities._
Heart Clots, 88
SECTION VI.—THE AORTA AND ARTERIES GENERALLY.
Inflammation; Fatty Degeneration; Ossification; Aneurism;
Rupture, 98
SECTION VII.—OF THE PLEURA.
Inflammation; Plastic Effusion; Adhesions; Serous
Effusion; Sero-Purulent Effusions; Pneumothorax, 103
SECTION VIII.—OF THE LUNGS AND BRONCHIAL TUBES.
Pneumonia; Congestion; Red Hepatization; Gray
Hepatization; Suppuration and Abscess; Metastatic
Abscess; Gangrene; Pulmonary Hæmorrhage; Pulmonary
Apoplexy; Emphysema, 106
_Tubercular Disease of the Lungs_, 117
_Post-mortem Appearances in_, 118
_Morbid Growths._
Cancer; Melanosis; Hydatids, 120
_The Bronchial Tubes._
Bronchitis; Narrowing of; Dilatation of, 123
_The Mediastinum._
Inflammation; Abscess; Tumors, 126
PART III.
THE ABDOMEN AND PELVIS.
CHAPTER I.
THE OPERATION, 127
CHAPTER II.
PATHOLOGICAL CONDITIONS OF THE PERITONEUM AND ALIMENTARY TRACT.
SECTION I.—OF THE PERITONEUM.
Congestion; Inflammation; Fibrinous Exudations;
Suppuration; Gangrene; Ascites; Morbid Growths, 133
SECTION II.—OF THE STOMACH.
Post-mortem Changes; Gastritis; Effects of Poisons;
Gastric Ulcer; Hæmorrhagic Erosion; Softening;
Cirrhosis; Atrophy; Dilatation; Morbid Growths, 137
SECTION III.—THE INTESTINES.
Malformations; Inflammation; Ulceration; Dilatation;
Contraction; Displacements; Incarceration; Volvulus;
Intussusception; Rupture; Ulcer and Fissure of the Anus;
Fistulæ; Hæmorrhoids; Morbid Growths; Parasites, 149
SECTION IV.—THE PANCREAS.
Anomalies; Hypertrophy and Atrophy; Inflammation; Fatty
Degeneration; Dilatation of Ducts; Cancer, 160
SECTION V.—THE SPLEEN.
Congenital Anomalies; Hypertrophy and Atrophy;
Displacements; Rupture; Inflammation; Thickening of
Capsule; Degeneration; Morbid Growths, 162
SECTION VI.—OF THE LIVER.
Normal state of; Congestion; Hæmorrhagic Effusion;
Perihepatitis; Scar-like Marks; Hepatitis; Secondary,
Pyæmic or Metastatic Abscess; Degenerations of the
Liver; Waxy, Lardaceous or Amyloid Liver; Atrophy;
Simple Atrophy; Acute or Yellow Atrophy; Chronic
Atrophy; Cirrhosis, or Hob-nail Liver; Hypertrophy;
Morbid Growths; Parasites, 165
_Affections of the Gall-Bladder and Ducts._
Inflammation; Dilatation; Morbid Growths; Biliary Calculi, 189
CHAPTER II.
THE URINARY APPARATUS.
SECTION I.—THE KIDNEYS.
Congenital Anomalies; Congestion; Hæmorrhage; Nephritis;
Pyelitis; Abscesses; Inflammation of Capsule; Morbus
Brightii; Fatty Degeneration; Dislocated Kidney; Morbid
Growths; Parasites, 193
_The Ureters._
Dilatation; Inflammation; Morbid Growths, 205
_The Suprarenal Capsules._
Inflammation and Degeneration; Hæmorrhage; Morbid Growths, 207
SECTION II.—THE URINARY BLADDER.
Malformations; Dilatation; Hypertrophy; Contraction;
Inflammation; Morbid Growths; Parasites, 208
_Of the Urethra._
Malformations; Inflammation; Dilatation and Contraction;
Stricture; Rupture; Morbid Growths; Urinary Calculi, 212
CHAPTER III.
THE MALE GENERATIVE ORGANS.
SECTION I.—THE PENIS.
Congenital Anomalies; Hypertrophy and Atrophy; Fracture;
Paraphymosis; Balanitis; Herpes; Chancres; Morbid
Growths, 215
SECTION II.—OF THE SCROTUM.
Hypertrophy; Inflammatory Œdema; Morbid Growths, 218
SECTION III.—OF THE TESTICLES.
Congenital Anomalies; Hypertrophy and Atrophy;
Inflammation; Hydrocele; Hæmotocele; Varicocele; Morbid
Growths, 219
SECTION IV.—THE SEMINAL VESICLES AND PROSTATE.
Congenital Anomalies; Inflammation; Tubercular Deposits, 226
_The Prostate Gland._
Anomalies; Hypertrophy and Atrophy; Inflammation; Abscess;
Morbid Growths, 226
CHAPTER IV.
THE FEMALE GENERATIVE ORGANS.
SECTION I.—THE PUDENDA AND VAGINA.
1. _The Pudenda._
Congenital Anomalies; Hypertrophy; Inflammation; Morbid
Growths, 230
2. _The Vagina._
Anomalies; Occlusion; Dilatation; Laceration and Rupture;
Inflammation; Morbid Growths, 230
SECTION II.—THE UTERUS.
Anomalies; Hypertrophy and Atrophy; Hydrometra;
Malpositions; Hæmorrhages; Peri- or Retro-Uterine
Hæmotocele; Inflammation; Ulceration; Morbid Growths, 235
_Morbid Conditions following Parturition._
Rupture; Puerperal Inflammation, 241
_Extra-Uterine Pregnancy_, 244
SECTION III.—THE OVARIES AND FALLOPIAN TUBES.
1. _The Ovaries._
Malformations; Inflammation; Abscess; Morbid Growths, 247
2. _The Fallopian Tubes._
Anomalies; Inflammation; Morbid Growths, 251
SECTION IV.—THE MAMMÆ.
Anomalies; Hypertrophy; Atrophy; Inflammation and Abscess;
Morbid Growths, 252
_The Male Mammæ_, 257
PART IV.
MISCELLANEOUS SUBJECTS.
CHAPTER I.
OF THE PERIOSTEUM AND BONES.
SECTION I.—OF THE PERIOSTEUM.
Inflammation; Ulceration; Malignant Disease, 258
SECTION II.—OF THE BONES.
Inflammation and Abscess; Caries; Necrosis; Rachitis;
Mollities Ossium; Morbid Growths, 259
_The Medulla_, 267
CHAPTER II.
DISEASES OF THE JOINTS.
Malformations; Morbid Condition of Synovial Membranes;
Morbid Condition of Bursæ; Morbid Condition of
Cartilage; Ulceration of Cartilage; Chronic Rheumatic
Arthritis; Scrofulous Arthritis, 268
_Diseases of the Spinal Column_, 272
CHAPTER III.
OF TUMORS.
1. _Benign or Non-Malignant Tumors_, 274
2. _Malignant Tumors_, 286
CHAPTER IV.
POST-MORTEM APPEARANCES IN DEATH FROM UNNATURAL CAUSES.
1. _Death from Poisoning_, 294
2. _Death from Suffocation_, 300
3. _Death from Hanging or Strangling_, 301
4. _Death from Drowning_, 302
CHAPTER V.
MEDICO-LEGAL QUESTIONS.
1. _Method of Conducting a Medico-Legal Autopsy_, 304
2. _Questions Relating to New-Born Children_, 307
3. _Supposed Period of Death_, 312
4. _The Probable Cause of Death_, 317
CHAPTER VI.
ON EMBALMING THE DEAD, 320
CHAPTER VII.
PRESERVATION OF SPECIMENS OF MORBID ANATOMY, 326
INTRODUCTION
Before entering upon the study of any subject, it is of moment that the
student be thoroughly convinced of the importance of the knowledge which
he is about seeking to acquire, since his zeal in its pursuit will, in
most cases, be in proportion to this conviction. We will, therefore,
before entering upon the subject proper of this book, present in few
words, some considerations on the _importance of a study of morbid
anatomy as revealed by post-mortem examinations_.
The necessity of a study of anatomy and physiology by a medical student,
is now so universally recognized, that an attempt to prove its
importance would seem deserving only of ridicule; but the ignorance of
many practitioners on the subject of morbid anatomy, shows that this
study has yet to vindicate its claim as a necessary branch of a medical
education.
From a purely theoretical standpoint, the educated physician—one whose
motto is _Esse, non videri_—after combating a disease in vain, should
not feel content to remain in ignorance of its real nature, so far as
discoverable by anatomical changes, capable of being recognized after
death, even had he no prospect of adding thereby one jot to his
practical acquaintance with disease or to his power to combat it; yet
his scientific conscience (if we may be allowed the expression) ought
not to rest satisfied until, in all doubtful cases, his _ante-mortem_
diagnosis be confirmed or overthrown, and his conception of the case
completed in all its details by a _post-mortem_ examination.
Besides this purely individual scientific interest, there are weightier
practical reasons for an acquaintance with this branch of medical
science by the physician as practitioner.
Among the almost innumerable questions upon medical, theological, and
miscellaneous subjects which the American public feels at liberty to
propound to its medical advisers, none are of more frequent occurrence
and none are more justifiable than the two: “What is the matter with the
patient?” and “Will he, or can he, recover?” and to none is an answer
more imperatively demanded. The public very naturally, and with reason,
requires on the part of a physician the ability to make a diagnosis and
a prognosis. It will not be satisfied with being told that the name of
the disease is of no importance, that the doctor only wants to hear the
symptoms; that he does not cure _diseases_, but removes the symptoms of
disease, &c. Only an exceedingly well-trained public will accept these
truisms as an equivalent for diagnostic skill. Hence, it is the
physician’s interest, as well as his duty, as we shall see, to seek, in
all cases, to make a diagnosis, no matter how difficult the task may
prove to be. The question how far his treatment will be modified by his
diagnosis is a question of therapeutics, and does not belong here; but
certain it is, that a mere combatal of the symptoms as isolated
phenomena cannot be regarded as fulfilling the whole duty of a
conscientious physician.
The ability to make a diagnosis, and consequently prognosis, depends
upon a knowledge of pathology, with a knowledge of symptoms as signs of
pathological states and changes; and as such they must be critically
examined and their true import discovered, if possible. Thus treated, we
arrive, by various processes of reasoning, at a diagnosis, under which
the symptoms fall into their natural order of importance, and we run but
little risk of contending with remote subjective symptoms (of great
importance in differential therapeutics) to the neglect of more
important, though perhaps less prominent ones.
Besides this, we are, in a measure, prepared to foretell the probable
course of a disease, and can, therefore, in many cases, adopt
anticipatory measures, while in all we will be guarded against the
error, so often committed, of ascribing to the remedy used the so-called
“_aggravations_,” which are often only natural symptoms of the unchecked
and, perhaps, entirely uninfluenced morbid process. Such knowledge
serves thus, by purifying our experience, to guard us against
self-deception, and to prevent us from misleading others by reports of
cures of diseases existing only by virtue of a false diagnosis.
A knowledge of pathology, furthermore, places in our hands a thread
which can guide us through the labyrinth of our vast materia medica, and
which enables us, from the myriad of symptoms, to eliminate the
non-important ones. It shows us the “bearings” of the medicines and
their various specific ranges, thus materially facilitating the choice
of a remedy.
Again, medical science is virtually based upon pathology, and we see,
therefore, how important, nay, how absolutely necessary, to the progress
of the former is the study of the latter. The practice of medicine as an
art can never be advanced knowingly by those who neglect its cultivation
as a science. While each one may practice the art according to his own
convictions, true medical science stands above all the belittling,
bigoted prejudices of the schools. Here, every one claiming the name of
an educated physician can and ought to work.
The wild vagaries of former ages, when philosophy set up purely
theoretical views, under which observed phenomena were compelled to
arrange themselves, have warned the present age to be guided solely by
sober and exact observations and investigations; and it needs no proof
that, in the advancement of our knowledge of disease, these are best
accomplished by frequent post-mortem examinations, which thus become a
necessary adjunct to a proper study of pathology.
In all cases of interest, therefore, the physician should feel it a duty
which he owes to himself and the profession at large, to seek permission
to make a post-mortem examination; but in order that the fullest benefit
may be derived from the same, he must know how to look for what he is in
search of, and how to recognize it when found.
To furnish this knowledge is the object of the following pages, to which
we herewith introduce the reader.
PRELIMINARY CHAPTER.
INSTRUMENTS AND GENERAL DIRECTIONS.
=The Post-mortem Case=, as prepared by the instrument makers, will be
found to contain, usually, the following instruments:
[Illustration: [Scalpels]]
1. A set of ordinary dissecting scalpels, four or five in number, and of
graduated sizes, including one heavy cartilage knife.
[Illustration: [Knife]]
2. A brain knife with a long blade, for slicing the brain.
[Illustration: [Chisels]]
3. Chisels, of one or both the accompanying forms, for use in opening
the head or spine.
[Illustration: [Hammer]]
4. An iron mallet or hammer, with a hook on the end of the handle for
tearing off the culvarium.
[Illustration: [Enterotome]]
5. An enterotome, or scissors with blunt, hooked point, for splitting
open the intestinal canal.
[Illustration: [Saw]]
6. A saw with movable back; this arrangement permitting of a deeper cut,
in dividing large bones.
[Illustration: [Rachitome]]
7. The rachitome, a chisel-like instrument, to be used with the hammer
in opening the spinal canal.
[Illustration: [Saw]]
8. The double saw, used for dividing the laminæ of the vertebræ. A side
view of the instrument being given in the cut, one blade only is seen.
The two are attached to one handle, placed parallel with one another,
and about one and one-fourth inches apart. After the soft tissues have
been removed, this saw is used by passing the spinous processes between
the two blades, and thus dividing both laminæ at once.
[Illustration: [Clamp]]
9. A skull clamp, for steadying the head while removing the calvarium.
After the removal of the scalp, this instrument may be employed, and be
of much service for the above object. It is applied by placing the open
end of the instrument over the crown of the head, turning down the
screws, and thus fastening it just above the line of division of the
bone. The arched end of the instrument now serves as a handle for
turning or steadying the head.
10. Rib-shears, for dividing the ribs where that operation is found
desirable.
11. A tube for inflating the lungs, and an ordinary blowpipe.
12. Dissecting forceps, tenacula in handle and with chain, grooved
director, and assorted needles, straight and curved.
While a post-mortem case with all of the above instruments is very
convenient, and important even, where there is frequent occasion for its
use, still its absence should never deter the physician from making an
examination where the ordinary dissecting case may be had; and with the
country physician generally, this case is all that is absolutely
essential, as a common carpenter’s saw and chisel may at any time be
found, in cases where the head is to be opened; while for opening the
chest and abdomen, the dissecting case contains everything that is
essential.
Instruments used in post-mortem examinations should never be employed
for operating upon the living, without first being repolished by the
instrument maker, and the handles disinfected by careful cleaning in a
solution of permanganate of potash.
PRELIMINARY PREPARATIONS.
=The Preliminary Preparations= at the place of the operation should
consist in providing a sponge for absorbing fluids; newspapers and old
cloths for filling cavities or wrapping up any morbid specimen that it
may be desirable to preserve; a couple of quarts of clean sawdust or
wheaten bran for throwing into the cavities before closing them up, and
thus absorbing any excess of fluids; stout thread or twine for tying
intestines and closing the cavities; lard or sweet oil for oiling the
hands; a couple of empty slopbuckets for receiving the fluids, bloody
water, &c., and plenty of water, hot and cold, with towels and soap. If
the floor of the room is carpeted, to protect it from accident, a piece
of old carpet, or quilt, or oilcloth should be spread alongside the
table or box where the examination is made. Care should be observed to
have all these matters provided before the operation is commenced, when
the door should be fastened, that there may be no intrusion, by accident
or otherwise.
In preparing the body for examination, if the head is to be opened and
the body is in an ice-box, it will be absolutely necessary that it be
removed. Placing the cover of the box on the floor, the body may be
lifted out and placed on the same, when both may be again placed on the
top of the box or on a table, for the examination. If only the chest and
abdomen are to be examined, it will hardly be necessary to lift the body
from the box. In all cases, the sheet in which the body is placed, with
the underclothing, (the latter having been split down the centre,)
should be carefully turned aside, and care observed during the operation
to avoid as much as possible soiling them with blood-stains.
=Precautionary Measures.= That there is a certain amount of danger from
absorption of virus in case of cuts or scratches received while
conducting a post-mortem examination, cannot be denied; yet this danger
is by no means common to every case. In the great majority of instances,
probably no mischief whatever would follow such an accident, the danger
being confined almost wholly to cases of peritoneal inflammation,
erysipelas, and certain malignant forms of disease. In all cases,
however, it will be well to look for any scratch, cut, or abraded point
on the hands or fingers, and first touching them with nitrate of silver,
cover them finally with collodian. Smearing the hands well with lard or
olive oil will also aid much in preventing absorption.
Should an accidental cut be received during the operation, it will be
prudent, in all cases, to wash the hands at once, squeeze and suck the
part, to favor bleeding, and, finally, touch with a crystal of nitrate
of silver. Punctures with a needle or slight scratches which do not
bleed are, probably, more dangerous than a free cut; hence, in cases of
suspected danger, when a puncture has been received, it would be safer
to make a free incision with a knife, thus inducing bleeding, which will
favor the washing out of any virus, and finally, use the caustic.
=Time for Making the Examination.= As a rule, post-mortem examinations
should be made as soon after death as a due regard to the feelings of
friends will permit, say within twelve to twenty-four hours; a longer
delay would give time for such decomposition as not only to make the
examination extremely disagreeable, but, from change of structure in
tissues and organs, much less satisfactory. In cold weather, however, or
where the body has been placed in ice soon after death, as is the custom
in most cities, the examination may be postponed to any convenient time
before the burial.
=Notes.= In all important cases, notes should be taken down by an
assistant, on the spot, as dictated by the operator; heading these by
the name and age of the patient and a brief sketch of the disease. In
medico-legal cases, this is to be conducted with particular care, as
will be pointed out hereafter.
=Consent of Friends.= Much difficulty will sometimes be met in obtaining
the consent of friends for a post-mortem examination, the idea of the
mutilation of the body of the deceased striking many with particular
dread. With a little tact and management, however, consent may, in the
majority of instances, be obtained. Instead of speaking to a single
member of the family and leaving him or her to bring the subject before
others, in all doubtful cases it will be better for the physician to see
all the interested parties himself, either together or separately, and
endeavor to interest them in the case, by pointing out the peculiar
character of the disease, the satisfaction which the friends will
themselves derive from a verification of the diagnosis of their
physician, while, when too late, they may regret having withheld their
consent; also the scientific interest which attaches to the case, and
the benefit which will no doubt accrue to medical science through a
post-mortem examination, and the possibility that the lives of others
may depend upon a knowledge of the true state of this case. These, with
like considerations, adapted with ready tact to the class of persons to
be persuaded, will, in the majority of instances, be enough to overcome
all scruples, especially when joined to the assurance that the
examination will be so conducted as to leave no visible trace of the
operation with which to embitter the remembrance of the well-known
countenance.
PART I.
THE HEAD AND SPINE.
CHAPTER I.
THE OPERATION.
In opening the head for a post-mortem examination, let a thick block be
placed beneath the occiput, when, after having carefully parted and
turned aside the hair, an incision may be made through the scalp, over
the top of the head, from ear to ear. The back of the scalpel being
placed next the head, the point may be pushed in advance, thus dividing
the tissues without danger of injuring the edge of the instrument by
bringing it in contact with the bone.
From the loose connection of the tendon of the occipitofrontalis muscle
to the periosteum, by the use of the handle of the scalpel, the flaps of
the scalp may readily be turned aside, the anterior over the face, the
posterior on the back of the neck. The _skull clamp_ may now be applied,
which will be of great service in steadying the head while using the
saw. Instead of dividing the skull in a circular manner, as is usually
done in the dissecting-room, it will be better to start the saw above
the frontal eminences and run obliquely down towards the mastoid
process, meeting this line by another commencing at the occipital
protuberance and carried horizontally forwards, thus giving a wedged
form to the portion removed. The advantage of this method consists in
our being better able to hold the parts in position as they are
replaced, as in the old method, from the readiness with which the parts
move upon one another, the calvarium is liable to slide forwards or
backwards from its position, thus producing an unsightly ridge across
the forehead, which will more or less plainly show through the
integument. With young children, a strong pair of scissors may be used
instead of the saw in dividing the calvarium.
In using the saw, care should be observed not to injure the dura mater;
hence it will be better not to attempt to divide both tables with that
instrument, but rather depend upon the chisel or rachitome for breaking
away the inner table. To avoid the sound which would attend the use of
the iron hammer, which, if heard by members of the family, might excite
unpleasant feelings, a billet of wood or wooden mallet may be used; or,
these not being at hand, the head of the iron hammer may be muffled with
a towel, so as materially to deaden the sounds. The inner table having
been divided, the calvarium may be pried off with the chisel, or torn
away with the hook on the handle of the hammer. This, from the close
adhesion of the dura mater to the bones, will generally require
considerable force.
The calvarium having been removed, and the superior longitudinal sinus
opened, and the condition of its contents noted, the dura mater, after
its careful examination, may be cut through with the knife or scissors
in the line of the division of the bone. The membrane may now be lifted
up, when adhesions will be found between its under surface and the pia
mater, along either side of the falx cerebri. These should not be
mistaken for results of inflammation, as they sometimes are, they being
simply the points of entrance of the veins of the pia mater into the
superior longitudinal sinus. These having been divided, with the falx
near its attachment to the crista galli, the whole may be turned back,
exposing the brain.
To remove the latter, take away the block from beneath the head, and
lifting the anterior lobes of the brain, divide successively the several
pairs of nerves as they appear in sight, with also the tentorium on
either side, and as the brain falls back into the left hand, the knife
may be passed down into the foramen magnum, and the medulla oblongata
and vertebral arteries divided, when the whole may be lifted from its
position. More or less blood with the _cerebro-spinal fluid_ will
necessarily flow off during this operation, to secure which, a bucket
should be placed beneath the edge of the table, over which the head
should slightly project. In dropsy of the brain, although the fluid is
mainly in the ventricles, it may escape during the operation and be
caught in the same manner.
The external surface of the brain having been carefully examined, the
hemispheres may be sliced off to a level with the corpus callosum, when,
by removing the latter, the cavities of the lateral ventricles will be
exposed. After a careful inspection of the several objects seen here,
the fornix and velum interpositum may be removed, opening thus into the
third ventricle. Slices may now be taken off the corpora striata and
optic thalami, with deeper portions of the hemispheres, and sections
made of the crura cerebri cerebellum and medulla oblongata, thus giving
an opportunity of judging of the condition of all those parts.
After the removal and examination of the brain, attention should be
given to the _base of the skull_. The lateral and other sinuses should
be laid open, the dura mater, as far as possible, torn away, and the
bones examined for fractures, caries, abnormal growths, etc.
“_The simplest method for removing the ear_ for the sake of dissection
is, after the removal of the calvarium in the usual way, to take out
both the petrous bones together by means of two transverse vertical
sections, one in front of the two petrous bones and the other posterior
to them. The anterior of these sections should pass in a line a little
anterior to the anterior clinoid processes, and the posterior in a line
through the posterior third of each mastoid process. By means of these
two sections, the trumpet-shaped extremity of each Eustachian tube, a
portion of the mucous membrane of the fauces, and the whole of each
petrous bone, together with the mastoid processes, can be taken out.
“The disadvantage of this procedure is the disfigurement which is apt to
ensue from the falling in of the face. To avoid this disadvantage,
another mode of removing the ear may be resorted to. This consists in
taking out each petrous bone separately in the following manner: The
calvarium having been sawn off, an anterior section is to be made in
each side in the same line as in the above plan, but extending only as
far as the outer part of the body of the sphenoid bone; a posterior
section in each side is then to be made, as in the first plan, but not
extending farther inwards than the basilar process of the occipital
bone. These two sections are to be made with a saw or with a chisel and
hammer. The apex of each petrous bone is then to be separated from the
sphenoid and occipital bones, and each petrous bone (the outer ear and
integument being detached and reflected downwards) is to be drawn
outwards, taking care, by inserting the scalpel deeply, to remove as
much of the soft parts as possible.
“The organ of hearing having been removed, the dissection may be
conducted in the following manner: The auditory nerve in its meatus
should be first carefully examined, presuming that a previous inspection
has been made of the portion of the brain to which the portio mollis and
portio dura nerves are attached. The size of the external meatus having
been ascertained by allowing a strong light to fall into it, its
anterior wall is to be removed by the cutting forceps.
“The state of the epidermis, the ceruminous glands and secretion, the
dermis, periosteum and bone is to be noticed. The outer surface of the
membrani tympani is then to be examined; also the state of its
epidermoid and dermoid laminæ, its degree of tension, and the amount of
motion possessed by the malleus when pressed upon by a fine point. The
next step is to ascertain the condition of the guttural portion of the
Eustachian tube, to lay open the cartilaginous tube with the scissors,
and then to expose the cavity of the osseous portion by means of the
cutting forceps. In doing this, the tensor tympani muscle is exposed;
its structure should be examined, and if it has not a healthy
appearance, portions of it should be submitted to microscopic
inspection. The upper wall of the tympanum is next to be cut away by
means of the cutting forceps. In doing this, great care must be taken
not to disturb or disconnect the malleus and incus, which lie
immediately beneath it. After the tympanic cavity has been exposed, the
first step is to pull the tensor tympani muscle and ascertain how far it
causes a movement of the membrana tympani and ossicles. The incus and
stapes are now to be touched with a fine point, so as to ascertain their
degree of mobility; the tendon of the stapedius muscle is also to be
pressed upon. The condition of the mucous membrane of the tympanum and
of the mastoid cells is then to be ascertained, and any peculiarity of
the cavity, the existence of bands of adhesion, etc., to be noted.
“The most delicate parts of the dissection, viz., that of the internal
ear, must now be undertaken. The cavities of the vestibule and cochlea
are to be exposed by removing a small portion of the upper wall of each.
Before reaching the vestibule, the superior semi-circular canal will be
cut through and removed; the membranous canal should be drawn out and
inspected. As the cavities of the vestibule and cochlea are laid bare,
it is desirable to see that the quantity of perilymph is natural, as
well as its color and consistence. The outer surface of the membranous
labyrinth having been observed, it should be opened so as to expose the
endolymph and otoliths, portions of all which parts should be removed
for microscopic inspection. This having been effected, the remaining
membranous semi-circular canals are to be exposed, and the connection of
the base of the stapes to the fenestra ovalis carefully examined. The
last stage of the dissection consists in removing parts of the lamina
spiralis, in examining them microscopically, and in exposing from
within, by following the course of the scala tympani, the membrane of
the fenestra rotunda.
“The only part which now remains unexamined is the stapedius muscle; in
order to expose it, the course of the aquæductus Fallopii, beginning at
the stylo-mastoid foramen, should be followed until the base of the
pyramidal eminence containing the muscle is reached.”[1]
_The Eyes, with the optic nerves_, may be most conveniently removed for
examination, by breaking up the roof of the orbit with the hammer, and,
after the removal of the fragments of bone, dissecting away the fat and
muscles until the ball is exposed, when, with the scissors, the tunics
of the latter may be divided just behind the conjunctival attachment,
and the ball removed with the optic nerve. The front portion of the eye
being left in position, by filling the cavity behind with a little
cotton or paper, any flattening may be prevented, and thus any
appearance of loss of parts avoided.
The examination having been completed, the brain may be replaced, the
calvarium put in position, the scalp brought over the same and united
with stitches, the arranging of the hair effacing all traces of the
operation.
THE SPINAL CORD.
For the removal of the _spinal cord_, place the body in a prone
position, and make an incision the whole length of the back, over the
spinous processes of the vertebræ. Then raise up and turn aside all the
muscles with the integument, exposing the laminæ of the vertebræ. The
latter may now be divided with the single or double saw, the rachitome
or chisel being used to complete the operation, when the laminæ, with
the spinous processes, may be removed in one strip, exposing the cord
enclosed in its membranes.
The roots of the nerves may now be divided, and the cord, enclosed in
its sheath, removed; care being observed not to handle the parts roughly
while so doing. The dura mater may now be split open for the examination
of the cord. Should it be desired to preserve any portion for
microscopic examination, it may be suspended in a solution of bichromate
of potass, xx to xxx grs. to the ounce of water, and in a few days
transferred to a solution of chromic acid, ij grs. to the ounce of
water, where it should remain until sufficiently hardened to be cut into
thin sections.
The examination completed, the parts may be replaced and the incision
sewed up.
CHAPTER II.
PATHOLOGICAL CONDITIONS.
Section I. OF THE SKULL.
[=Notice= in examination, condition of _scalp_; cuts, bruises,
extravasation of blood, &c. _Cranium_—Color, smoothness or roughness
of exposed surface; fractures, their position and relation to injuries
of scalp. _Removal of Calvarium_—Adhesion of dura mater; inner surface
of; smooth or rough; seat of same; deposit of new bone; depression of
inner table; thickening or thinning of. State of fontanelles in
children; condition of frontal sinuses; condition of base of skull
noted after removal of brain; fractures; condition of petrous portions
of temporal bones, &c.]
=Fracture.= In a post-mortem examination of the head, after death from a
blow or fall upon that part, a fracture may be disclosed of which there
was no external trace. Owing to the greater thinness and brittleness of
the inner table, it is possible for this to be fractured without any
corresponding injury to the external; such fracture may possibly rupture
some of the branches of the meningeal arteries, which will be followed
by the formation of a clot between the bone and dura mater, the pressure
of which may be sufficient to produce death. Owing to the same
cause—greater brittleness of the inner table—when fracture of the outer
exists, that of the inner table will be likely to be more extensive,
accompanied perhaps with depression, of which there is no external
evidence.
Again, it will sometimes be discovered that fracture exists at a point
opposite to that upon which the blow was received, on the principle of
the “_contre coup_” of the French; thus, the blow having been received
on the occiput, the fracture may be found in the frontal region; or,
received on the top of the skull, fracture may result at the base. In
falls from a height, upon the top of the head, the weight of the body,
acting through the cervical vertebræ as a propelling force, is very
likely to produce fracture of the occipital bone.
=Caries= may affect any of the bones of the head, but in the majority of
cases it will be the result of syphilitic or mercurial poisoning.
Following an attack of periostitis, the inflammation extends to the bone
and gradually develops the carious ulceration. While the condition is
usually confined to, or at least, most strongly developed upon the outer
table, it may involve the entire thickness. In syphilitic ulceration of
the bones of the nasal cavity, the disease may destroy the cribriform
plate of the ethmoid bone, and thus extend to the membranes of the
brain.[2] So also, in caries of the petrous and mastoid portions of the
temporal bone, which sometimes results from scarlet fever, the disease
may extend to the inner surface, resulting in the accumulation of pus
within the cranial cavity.
Along either side of the central portion of the inner surface of the
calvarium may be usually seen, at least in the heads of aged persons, a
number of irregular, rough pits, varying in size and depth, which are
not to be mistaken for disease of the bone, they being simply
impressions of the _Pacchionian glands_.
=Thinning= of the bones of the head will always indicate _increased
pressure_ from within, induced by hypertrophy of the brain, or, as is
more frequent, hydrocephalus. In the latter case, not only thinning, but
complete absorption of the parietal and other bones may result.[3]
=Increased Thickness= will also sometimes be found. This condition
indicates _diminished pressure_ from within, as in atrophy of the brain.
The thickening results from a gradual remodeling of the inner table and
diploe, so that while the exterior of the skull may retain its normal
size and form, the inner table following the retiring and shrinking
brain, the interval between the two becomes filled with the thickened
diploe. It has been observed that this hypertrophy is greatest at those
parts of the bones where ossification first commences, as at the
parietal and frontal eminences. It is not confined to old persons,
though perhaps more frequent with them.[4]
Section II. THE MEMBRANES OF THE BRAIN.
1. The Dura Mater.
[=Notice= color and general character of surface; blood between it and
bone; position of; quantity; coagulated or not. Condition of
bone—necrosed or fractured; pus between dura mater and bone.
Tumors—their position, size, &c. Wounds—their position, extent, &c.
Open longitudinal sinus and note contents.]
This membrane, serving both as a periosteum to the inner surface of the
cranial bones and as a support to a serous membrane—the reflected layer
of the arachnoid—is subject to affections of a two-fold character, those
peculiar to the fibrous and serous portions.
=Inflammation= of this membrane, may involve either the outer fibrous,
or the inner serous layer. In the former case, the membrane appears
congested, red and more or less softened. The inflammatory process may
result in the formation of pus between the bone and dura mater, and even
in gangrene. The disease may also extend to the adjacent portions of the
pia mater and brain substance. External injuries, fractures of the bones
of the skull, inflammation of the periosteum, otitis, resulting in
caries of the temporal bone, may all be causes of inflammation of the
outer portion of the dura mater.
Inflammation of the inner surface of this membrane, is marked by the
presence of a net-work of delicate red vessels, while the surface is
covered by a soft, grayish or yellow semi-purulent matter, and may
attend cases of pyæmic poisoning, puerperal peritonitis, or some of the
exanthemata.
=Thickening= of the fibrous portion of the dura mater may be found as a
result of chronic inflammation, either spontaneous or as the result of
external injury. From the identity of structure between this and other
fibrous tissues of the body, it is not unlikely that this thickening is
often the result of a rheumatic form of inflammation.
External violence is, however, most commonly the cause of the change. In
one case, the patient fell down stairs in a state of intoxication,
striking the head on the steps. He continued in a state of insensibility
for nine days, when he began to show signs of returning consciousness,
taking food and drink, but memory, judgment, and all the mental
faculties were gone. Death ensued in about two years. The dura mater of
the left hemisphere was found greatly thickened. The pia mater
infiltrated with a large amount of serous fluid. The convolutions were
atrophied, and about four ounces of serous fluid found in the
ventricles. The _fornix_ was softened and the _septum lucidum_ entirely
destroyed.
=Fibrinous Clots, or Thrombi=, will be occasionally found within the
sinuses of the dura mater, where they may have given rise to congestion
of the brain, with apoplectic effusions, paralysis, convulsions, coma,
etc. They may originate from injuries of the head, inflammation of the
dura mater, pulmonary disease, etc.
=Tubercular Deposits= are also sometimes found in this membrane,
appearing, however, mainly upon the arachnoid surface. They present the
usual character of tubercle, having a whitish or grayish appearance,
with the consistence of cheese, and scattered in small particles upon
the surface. They are found in _tubercular meningitis_, (a disease
common with children but rare with adults,) and in most of those cases
of so-called acute hydrocephalus.
=Tumors= of various kinds are occasionally found in the dura mater,
including _cystic_, _fibrous_, _fatty_, _osseous_ and _cancerous_
growths. The latter may cause such absorption of the bones of the skull,
as to appear on the exterior of the head.
In one case which came into the dissecting-room some years ago, thin
_bony formations_ of the size of a silver quarter dollar were found in
the tentorium, and smaller ones in the falx cerebri. Nothing could be
learned of the previous history of the case.
2. Arachnoid and Pia Mater.
[=Notice= in examination, contents of cavity of arachnoid; serum or
blood; if former, amount, color, odor; if blood, situation, quantity,
fluid or coagulated; adhesion of surfaces of arachnoid; tubercles,
their position, &c.; color of membrane; vascularity, transparency, or
opacity. _Sub-arachnoid_ fluid—quantity, position, color, &c. _Pia
mater_—vascularity, in points and entire; serous effusion into
substance of; blood, &c.; position, size, &c., of clots; granulations,
(tubercles,) number, position, &c.; Tumors—size, position, and
character.]
As morbid conditions of the arachnoid membrane are more common with its
visceral layer, and as these conditions usually involve the pia mater,
the two membranes are here noticed together. They will be found
presenting various degrees of congestion after death, which will not
necessarily be a positive indication of the extent of congestion during
life.
=Pacchionian Bodies.= Along either side of the great fissure may be
noticed within the pia mater of adults, several small white bodies,
varying in number and size—the _Pacchionian bodies_. They may cause
absorption and perforation of the dura mater, and even of the bones of
the skull. Being looked upon as the result of mere senile changes, they
do not indicate the presence of disease, though repeated congestions of
the brain appear to favor their more rapid development.
=Inflammation= of these membranes, or _meningitis_, is a very common
affection, and is accompanied with an accumulation within its substance
or beneath its layers, of serum, lymph, or fibrine in various
proportions. It may be confined to circumscribed portions, or involve a
large portion of the membrane, and even extend to the spinal cord.
Adhesions between the two surfaces of the arachnoid sometimes result
from this form of inflammation.
Insanity in its various forms is most frequently accompanied with some
morbid condition of these membranes. In twenty-two cases of insane
persons whose brains were inspected by Dr. Marshall, in twenty-one,
serous fluid, varying in amount from one to twelve ounces, was found in
the ventricles, and in seventeen of these twenty-one cases, similar
effusion was found in the sub-arachnoid space, or within the substance
of the pia mater. While red injection of the membrane was found only in
four cases, yet other conditions—the effusions, &c.—were evidently the
result of previous inflammation. In nine cases were the arteries of the
brain opaque, thickened, steatomatous, or ossified; conditions highly
favorable for deranging the capillary circulation of the membranes or of
the brain.[5]
The following statement gives the principal morbid changes of these
membranes which have been found in cases of insanity:
1. Injection, more or less intense, of the _pia mater_, giving a red or
scarlet appearance; or, where infiltrated with serous fluid, presenting
a pale gray color and increased in thickness.
2. The arachnoid (the visceral layer) becomes opaque and thickened,
resembling the dura mater or macerated parchment.
3. The meningeal injection may terminate in serous effusion, either from
the free surface of the arachnoid into the sub-arachnoid tissue, (pia
mater,) or from the choroid plexus into the ventricles.
4. Albuminous exudations may be found upon the free surface of the
arachnoid of the _dura mater_, covering its whole extent, or confined to
definite portions.
5. Adhesions of the two surfaces of the arachnoid may rarely be found.
It is most common in the great fissure, and has been found in the
ventricles.
6. Blood may be effused upon the surface of the arachnoid or in the
substance of the pia mater.
=Serous Effusion.= As has been already intimated, this may be found
either in the cavity of the arachnoid—between the reflected and visceral
layers—or within the ventricles. In the former position, the quantity is
never large, while in the latter, it may amount to twelve or sixteen
ounces, and be present for many years. When in such large quantity,
there will be great distension of the ventricles and thinning of the
corpus callosum and fornix, with destruction of the septum lucidum, as
well as more or less separation of the cranial bones. It is only in
children and before the bones of the head have become united, that such
large accumulations are possible, as at a later period, from the
unyielding condition of the walls of the skull, the presence of a single
ounce, particularly if suddenly formed, would produce death. In all
cases, the danger to life will be in proportion to the rapidity of the
formation; a very slow and gradual accumulation permitting either of an
expansion of the cranial bones, or a gradual absorption of brain
substance, thus preserving an approximation to the normal pressure on
the brain tissue.
Serous effusions, like sanguineous, are generally the result of over
distension of the cerebral vessels, either from mechanical obstruction,
or a weakened condition of the coats of the vessels, with increased
force in the action of the heart. It generally attends tubercular
meningitis, and may be favored by an anæmic condition of the system. The
symptoms during life, attending a rapid effusion of serum, are not so
readily distinguished from those of sanguineous effusion, as to enable
us to pronounce with certainty in any given case as to the cause of the
cerebral pressure.
=Sanguineous Effusion—Apoplexy.= Effusions of blood may be found between
the bones and dura mater; between the two layers of the arachnoid;
within the substance of the pia mater; within the ventricles, or within
the brain substance. Blood clots will seldom be found between the bone
and dura mater, except as a result of mechanical injury, and in the
majority of cases as an attendant upon fracture. If a fragment of the
bone at the same time, be driven through the dura mater, then a clot may
be found in the arachnoid cavity. But in another class of cases, where
death has resulted from blows upon the head without producing fracture
of the bones, the whole surface of the brain in the region of the
injury, and not unfrequently in distant parts, after the removal of the
dura mater, is found covered with a layer of blood, which at first sight
appears to be outside of the membranes; but on close examination, it is
found that the blood is effused or infiltrated into the sub-arachnoid
tissue, and that it has escaped from the lacerated vessels in the pia
mater. The thickness of the layer varies. It is generally in greater
quantities at the sides and base of the brain, and the inferior lobes
and cerebellum may be covered by it. It is usually thickest over the
crura, the pons Varolii and medulla oblongata.
In the same class of cases the blood may be also effused into the
ventricles. These appearances are so uniformly the result of violence,
as to form a valuable piece of evidence in medico-legal inquiries, to
prove that such hæmorrhage and death could not be the result of internal
causes.
In the greater number of _still-born_ children, an examination of the
head will show a similar condition of things. The surface of the
cerebrum generally, with sometimes that of the cerebellum, will be found
covered with a layer of coagulated blood effused into the pia mater,
while the ventricles will often be filled with clots. Where the history
of the case is not known, it might at first be suspected that death was
the result of violence inflicted after birth. Violence has, to be sure,
been the cause of death, but it is such violence as attends a protracted
case of labor, with, perhaps, a large head, and a contracted pelvis of
the mother. The wonder is, that from the great pressure to which the
head is subjected during labor, that so few children are still-born or
do not die soon after birth, from rupture of the cerebral vessels.
Effusions into the ventricles, may also be frequently the result of
external violence. The pia mater, the vascular membrane of the brain, we
find carried into these cavities by means of the velum interpositum,
which forms the roof to the third ventricle, while its borders extend
into the lateral, forming the choroid plexuses. The effused blood may,
therefore, extend along this membrane into the cavity of the ventricles.
Again, blood may be effused in any portion of the _brain substance_,
constituting true sanguineous apoplexy. Certain parts are much more
frequently the seat of these effusions than others. They are more common
in the striated bodies or optic thalami—probably from the greater
vascularity of those parts—but may be found in the corpora quadrigemina,
the pons Varolii, the crura cerebri, or in the cerebral hemispheres, and
occasionally in the cerebellum. The symptoms during life will vary
according to the location of the effusion; when in the pia mater, or in
other words, outside of the brain, paralysis will seldom attend, though
the coma may be profound, with relaxation of the muscular system and
sometimes convulsions. When the hæmorrhage is in the optic bed or
striated body of one side, from the decussation of fibres in the medulla
oblongata, paralysis of the opposite side of the body will follow; while
if the effusion has taken place in both hemispheres, the palsy will be
double-sided, though probably more complete on one side than on the
other.
Effusions of blood into the corpora quadrigemina, will most frequently
be attended with muscular tremblings or convulsions, and probably
impaired sight, with some change in the pupil. When in the medulla
oblongata, convulsions, followed by palsy, deep coma, and early death;
greater fatality attending effusions at this point, probably, than at
any other. When the effusion takes place in the cerebellum, the loss of
consciousness will be very temporary; there may be relaxation of muscles
without palsy or loss of sensibility, and, it is said, frequent
vomiting.
The _amount_ of blood effused is subject to the greatest variation.
Clots may be found as large as a hen’s egg, or smaller than a pea.
Indeed, violent apoplectic attacks, ending in death, may occur, where
the most careful examination will fail to detect _any_ effused blood,
death being the result of extreme congestion of the membranes. On the
other hand, the presence of a clot is not necessarily fatal, evidence
being abundant that they may be so far reabsorbed as to be followed by
at least partial recovery.
The following cases will serve to illustrate these several conditions:
CASE I.—_Sudden Death from Cerebral Congestion._
Mr. M——, aged thirty-five years, had always enjoyed good health. For
some months previous to death, had been working very hard, with a good
deal of anxiety, in arranging the affairs of a company of which he was
secretary. On the evening previous to his attack, he retired at eleven
o’clock, well and in good spirits. At three o’clock A. M., his wife
was wakened by his heavy, stertorous breathing, attended with slight
convulsive movements of the limbs. In less than a half hour he was
dead. The post-mortem showed the heart, lungs, and abdominal organs to
be in a perfectly healthy condition, while the most careful
examination of every portion of the brain failed to expose the least
effusion of blood. The ventricles and sub-arachnoid space contained a
moderate amount of serum, while the vessels of the pia mater were
strongly engorged with blood.
CASE II.—_Apoplectic Attack, followed by Death in Three Days; Clot found
in Thalamus._
Mr. J——, aged sixty-one, a butcher, abstemious in his habits but
plethoric in temperament, was suddenly stricken down with an attack of
apoplexy, which left him with paralysis of the right side of the body,
with impaired speech and memory. He gradually and almost entirely
recovered. Ten months after, while in the street, he fell with another
attack. He partially recovered consciousness, but had complete palsy
of the _left_ side, and died in three days. Here, the post-mortem
revealed excessive congestion of the pia mater, and a large clot, the
size of a hickory nut, in the _right optic thalamus_. In the _left
thalamus_ was a distinct trace of a clot, (nearly absorbed, however,)
which had undoubtedly been effused in the attack ten months
previously.
CASE III.—_Apoplectic attack, followed by Hemiplegia, and Death in Five
Years._
Charles E. W——, at the age of forty-seven had a sudden apoplectic
stroke, in January, 1867, followed by partial paralysis of right side.
In May following, he had a second attack, which greatly increased the
hemiplegia, impaired the articulation, and weakened the memory and
intellect. His general health and strength gradually failing, he died
August, 1872, five years after the original attack.
Post-mortem revealed a greatly thinned and dilated condition of the
walls of the arteries of the base of the brain and the remnants of the
original clot imbedded in the left optic thalamus, the brain substance
around being of a dark color and much softened. From the appearance of
the dark, ragged remnant of the clot, it must have been originally of
about the size of a robin’s egg.
CASE IV.—_Death from Congestion, with Serous Effusion and Softening._
Mr. F. H——, aged thirty, had an attack of brain fever at twenty-three,
followed by attacks of severe pain in the head, recurring every few
days, weeks or months. These attacks were accompanied with slight
convulsive symptoms and delirium, the pain being of a most
excruciating character, and lasting from a few hours to two or three
days. The attacks were gradually increasing in severity, but without
any impairment of the faculties of the mind. On a Saturday night, he
was brought home with one of his worst attacks. When I first saw the
patient on Sunday evening, I found him in a half-delirious, stupid
condition, yet when roused up, giving satisfactory answers to
questions, but immediately sinking into his former condition, and
every one to five minutes starting suddenly up and, with staring eyes
and distorted face, uttering piercing shrieks and screams, and calling
to those around to shoot him, split open his head with a
hatchet—anything to release him from his sufferings. These paroxysms
would sometimes be followed by a convulsive action of the diaphragm
and abdominal muscles, ending in his sinking into the same dull,
stupid condition as before. In the interval of calm, the respiration
was remarkably slow and feeble, with a slow irregular pulse of forty
beats to the minute. These symptoms becoming gradually worse, he sank
into a comatose condition early Tuesday morning, expiring at daylight,
sixty hours after the commencement of the attack.
The post-mortem revealed greatly enlarged Pacchionian glands, with
extreme thinning of the skull over the same. The pia mater was
considerably congested. Upon turning the brain back for removal from
the base of the skull, there was a sudden gush of water from the
ventricles, sufficient of which was secured to show that the quantity
could not have been less than two ounces. Upon opening the lateral
ventricles, these cavities were found unusually large from distension
by the fluid, while the _septum lucidum_ and _fornix_ were found in a
soft, pulpy condition, the former being completely broken down and
detached from the corpus callosum above. The gray portions of the
corpora striata were also softer and more easily broken up than was
natural.
The appearance presented by a clot, as well as the brain substance
immediately around it, will vary according to the time the patient
survives the attack. When death follows in a few days, the clot will
have a soft, blackish appearance; after a month or six weeks, it becomes
firm, and assumes a deep brown color, and at a still later period, it
becomes still more firm, and of a pale red tint; lastly, it may become
entirely absorbed. Peculiar changes also take place in the brain
substance immediately around the clot, which vary according to the time
intervening between extravasation and death. The portion immediately in
contact with the clot is generally of a dark red or wine color, or, at a
later period, of a chocolate brown, and of a soft, pulpy consistency.
Exterior to this, the color is paler and of an orange tint, and still
further on, of a bluish-white or yellow. The change in _structure_ and
_consistence_ of the brain, immediately around the clot, constitutes one
form of softening soon to be noticed.
Section III. OF THE BRAIN.
[=Notice= _before removal_—size; form; symmetry; space between surface
of brain and calvarium. _After removal_—parts at base, their size,
symmetry, color on surface, infiltration with serum or blood. _Removal
of pia mater_—degree of adhesion; appearance of convolutions; color;
consistence; effect of stream of water. Ulcers—condition of brain
around. Sloughs—relation to membranes, condition of brain around.
Deposits; tumors, wounds, etc. _After section, notice_ breadth and
character of gray portions of convolutions; color, vascularity, etc.
_Consistency_—softened or hardened; of white substance; color.
_Blood-vessels_—number and size of red points in different portions.
_Extravasation of blood_—its situation; fluid or coagulated; amount or
size of coagulum; color, etc. Cavities in brain substance; their
number, shape and contents. Blood, purulent, or fluid; its quantity
and color. Condition of brain around; cicatrices; wounds; adventitious
substances, as tumors, calcareous masses, tubercle cancer, etc.
_Lateral ventricles_—note any difference in the two; contents; amount
of serum or blood. _Choroid plexus_—pale or congested; cysts;
calcareous bodies; their size and situation. _Lining membrane_ of
ventricles; its vascularity, roughness, opacity, etc. _Septum
lucidum_—entire or lacerated; consistence. _Fifth ventricle_—size,
contents, etc. _Third ventricle_; contents. Commissures—their
condition; middle, broken or double. _Optic thalami and corpora
striati_—size, symmetry; character of surface and interior; if
softened, extent; extravasation of blood, etc. Condition of _pineal
gland_; _corpora quadrigemina_; _valve of Vieussens_, _etc._ _Medulla
oblongata_—degree of adhesion of membranes; softening, exact locality
of; condition about origin of nerves; appearance upon section. _Fourth
ventricle_—contents; condition of floor, etc. _Cerebellum_—examine
with same care, and note same points as in cerebrum.]
=Inflammation.= Acute inflammation of the brain substance is a rare
disease, except as the result of mechanical injury. In such cases, the
disease is generally quite circumscribed, being confined to the
immediate region of the injury. The brain becomes very vascular,
acquiring a red color, which, at a later period, changes to a brown or
greenish hue, and becomes much softer than natural.
If a foreign body be lodged in the brain, as a piece of bone, or a
bullet, then the inflammation is likely to result in an _abscess_, which
will give rise to head-ache, delirium with intolerance of light,
succeeded by convulsions, coma and death.
_Subacute, or chronic_ inflammation of the brain, is much more common,
yet is accompanied with pathological changes similar to those of the
acute form. At first, the inflamed portion becomes red and congested,
the color gradually changing to a crimson, purple, brown, or claret
color, with more or less change of consistence.
The symptoms attending inflammation of the brain substance, or
_cerebritis_, are not readily distinguishable from those of meningitis;
indeed, in most instances the two diseases are, to a certain extent,
combined; as, from the vascular connection between the brain and pia
mater, there might be a ready extension of inflammation from one to the
other. When, however, there is any sudden perversion of the sense of
vision or hearing; or if there are convulsions, affecting mainly one
side of the body; or if coma succeeds the convulsions and is accompanied
by one-sided paralysis, we may expect to find evidence of inflammation
of the cerebral substance, with possibly that of the membranes also. It
is a fact to be borne in mind, however, that while in typhus and
typhoid, and perhaps some other forms of fever, we may have symptoms
strongly resembling those of idiopathic inflammation of the brain or its
membranes, still the post-mortem will reveal no trace of any such morbid
condition.
=Softening.= To be able to recognize readily any change in the
consistency of the brain, clear ideas must first be had of the normal
density of this organ. This may be obtained from an examination of the
brain of some of the lower animals—as the sheep or ox—that has been
killed in a state of health. We shall then find that the brain presents
sufficient firmness to permit of its being handled without rupture of
its substance, and to allow of its being sliced into thin sections which
will support their own weight. The gray portion is somewhat softer than
the white, yet the fibrous character of the latter, becomes apparent
only after hardening in alcohol. If put into pure water, it continues
unchanged for eight or ten hours, and without any portion becoming
dissolved, or rendering the water any degree turbid. The consistence of
the brain varies, normally, at different periods of life. In the fœtus
and at birth, its softness approaches to semi-fluidity. From this to the
fifteenth or twentieth year, it gradually acquires the firmness of the
brain of the adult.
=Softening=, one of the most common variations from the normal
condition, is generally a mere result of inflammation of a chronic or
sub-acute form, accompanied with a fatty degeneration of nerve
substance. Under the microscope, the change is seen to consist in a
disintegration of the nerve fibres, the medullary substance breaking up
into large masses, and undergoing fatty metamorphosis. It may take place
either on the _external surface_ of the organ, or in the _septum
lucidum_ and _fornix_, the _corpora striata_, or _optic thalami_ of the
ventricle, the central parts of the _hemispheres_, the _cerebellum_, or
the _crura cerebri_, in the order mentioned.
While this change is usually the result of inflammation, as already
mentioned, it may accompany or succeed the following morbid conditions
of the organ: 1. It may be the result of congestion of the vessels of
some portion of the brain. In this case, the softened portion is
reddish, crimson, or brown in color. 2. It may follow the effusion of
blood in apoplexy. The softened portion is then of a brownish color, or,
if considerable time has elapsed, it may be of a dirty ash color,
tending to green. 3. It may accompany or follow the process which
terminates in serous effusions. It is then of a milky-white color. 4. It
may take place in the brain substance immediately around tumors, when
its color may present a variety of tints.
Among the causes tending to induce this condition of the brain, may be
mentioned a diseased state of its blood vessels, or their obstruction by
fibrinous clots; constitutional syphilis; excessive mental labor, or
frequently repeated epileptic convulsions. The consistency will be found
to vary from a slight change from the normal condition, to that of a
soft, pulpy, or even cream-like condition.
The symptoms accompanying softening of the brain, present a considerable
variation. Among the more prominent, may be mentioned an unsteady or
tottering gait, partial palsy, thick and inarticulate speech, feeble
memory, disordered intellect, dull pain or heaviness in the head,
frequent drowsiness, formication, numbness or rigidity, or occasional
involuntary contraction of the muscles of the upper extremities.
=Abscess= of the brain, differs from softening, to which it may have
some points of resemblance, in the purulent matter being contained in an
irregular cavity, lined with a more or less distinct membranous cyst.
Flakes of lymph are frequently found in these abscesses, giving the
matter much the appearance of that contained in scrofulous abscesses,
and they are most commonly found in subjects who present the usual
symptoms of the strumous diathesis.
While these collections are unquestionably often the result of
inflammation, yet it has been claimed that they may result from previous
disease of a suppurative character in the lungs, and perhaps other
organs, the purulent matter being taken up by the veins and carried into
the general circulation, and finally deposited in the substance of the
brain. Abscesses may be found in any portion of the brain substance, or
the purulent accumulation may be found between the bone and dura mater,
or between the two layers of the arachnoid. In the latter cases, the
disease may generally be traced to caries of some of the bones of the
head, as of the petrous or mastoid portions of the temporal, or of the
bones of the nasal cavity, involving the cribriform portion of the
ethmoid.
Again, abscesses in the brain may result from external violence, as from
a blow or fall upon the head. It is remarkable, that in these cases,
some months may elapse between the date of the injury and death.
=Hardening.= Induration of the cerebral substance, is a condition not
readily distinguished during life from that of softening, the two states
being accompanied by symptoms of a similar character. Dr. Jones, who has
charge of the male department of the Pennsylvania Hospital for the
Insane, and has had many opportunities for examining the brains of
insane patients, tells me that he found hardening, nearly as frequently
as softening, in these cases, and never could tell beforehand, with
certainty, which condition might be present.
In hardening of this organ, its density may be increased to that of
boiled white of egg, or it may approach in consistence to that of a
brain that has been hardened in alcohol, losing much of the sticky,
adhesive character when broken up by the fingers, which marks the brain
substance when in its normal state. The cause of the change is not well
known, yet it is conjectured to be one of the results of inflammation,
inasmuch as it is generally found with its capillaries greatly loaded
with blood, while more or less fluid is found beneath the arachnoid and
in the ventricles. The induration may affect the greater part or even
the whole of the cerebral mass, or may be confined to particular
portions or regions.
In a case recently examined for Dr. Toothaker, of this city, where
insanity of some years’ duration, and finally death, had followed a
severe injury of the head, the brain was found so hard as to permit of
fracture in the direction of the fibres, thus readily tracing their
course.
The symptoms that have most frequently been observed to accompany this
change are, defect and gradual loss of memory, apathetic indifference,
slight difficulty of articulation, followed by loss of sexual desire,
partial palsy, fatuity, wasting and death.
Extreme induration is often found in the brains of idiots. The whole
organ may be found resembling in color and density boiled white of egg,
or even cheese. The cerebral substance is shrunken, dense, and
apparently quite void of vessels.
=Hypertrophy= of the brain, is a condition in which there is usually
increased hardness as well as increased volume, and is distinguished by
flattening of the convolutions, narrowing of the ventricles, and a
remarkable dryness of the whole organ with its membranes, the change
involving both the cerebrum and cerebellum, and accompanied with an
increase of weight, all indicating increased nutrition, or the deposit
of new matter in the tissue of the brain. Thinning of the cranial bones
may attend this condition, increased internal pressure resulting in
their partial absorption.
The causes of this form of disease are not generally understood. The
symptoms, though always present, are not uniform. Among them may be
mentioned intense head-aches, a weakened or perverted state of the
intellectual faculties, fits of giddiness, accompanied with stupor;
finally, convulsions, with perhaps loss of sensation and motion, the
patient being unexpectedly cut off by an epileptic attack. The disease
has not been observed in persons over fifty. In most cases, the patients
were between twenty and thirty. In one instance, however, it was
developed in a young girl of thirteen. Lead poisoning would seem to be
an exciting cause, it having, in several instances, been developed in
painters and manufacturers of white lead.
=Atrophy.= In this condition, there is found a general diminution of the
volume of the brain, and especially of the convolutions. The latter are
shrunk, narrow, and sometimes softened, while the sulci are large and
open, the brain receding from the skull, and the pia mater greatly
injected with serous fluid, giving the appearance of a jelly-like
investment to the whole brain.
The brain substance is at the same time soft, the ventricles enlarged
and filled with fluid, while a large amount of serum will flow from the
sub-arachnoid space at the base of the brain, and from the spinal canal.
While this condition of the brain might be looked upon as a result of
pressure from the accumulated serum, the absence of the usual symptoms
of hydrocephalus, with the known history of these cases, renders it
quite probable that the change commences as an actual loss of brain
substance, the place of the latter being supplied with serous fluid.
Resulting from atrophy of the brain, there will often be found an
increased thickness of the cranial bones, this being another
conservative effort of nature to preserve the normal support and
pressure upon the brain.
Atrophy of the brain is sometimes found in old age and in various
enfeebling diseases, where all the organs suffer more or less waste from
improper nutrition, but it is so frequently found with drunkards,
especially those who have died with _delirium tremens_, that this
condition may, in the large majority of cases, be considered as the
effect of intemperance.
Several forms of atrophy may also be observed. It may be confined to
some portion of the convoluted surface, or to one of the striated bodies
or optic beds. Atrophy of the optic tracts, or nerves of one or both
eyes, is not unfrequently associated with loss of sight from amaurosis.
Tumors of the Brain.
The brain, like other parts of the body, is subject to morbid growths of
a great variety of forms. The symptoms of tumors in the brain, in many
points, present such resemblances to other forms of disease, that it is
usually the post-mortem alone, that will determine the fact of their
presence or character. It may be said in general, however, that the
effects of morbid growths in the brain will vary according: 1. To the
changes in the surrounding cerebral substance; 2. To the size of the
growth; and 3. To the position of the brain in which it may be
developed.
1. The changes induced in the brain substance surrounding tumors are
usually, first, derangement of the circulation, and second, as a result
of this, effusion of serum, or finally, softening of a greater or lesser
amount of contiguous cerebral substance. Head-ache, with epileptic
attacks, loss of memory, irregular contraction of the muscles and
partial paralysis may accompany the vascular derangement, while as
softening or pulpy destruction supervenes, a general aggravation of all
the symptoms will follow, ending in death, either with coma or by a
sudden apoplectic attack.
2. Tumors of the brain of a _small size_, may be found after death from
other causes, that have evidently produced no symptoms during life; and
in other instances, they have induced no change until a few days before
death, in which cases, the convulsions, paralysis and coma which
precedes this result, must be attributed to the vascular disturbance in
the surrounding brain tissue.
3. The position of the tumor, will modify to some extent the character
of the symptoms manifested. When in the anterior lobes, loss or
impairment of speech is said to attend. While, when in the _corpus
striatum_, the motions of the legs and arms are disordered.
The following are the more commonly recognized tumors of the brain:
=Adenoid, or Glandular-like Tumors.= These are generally described as
resembling an enlarged lymphatic gland, both in color and density. They
may vary in size from a filbert to that of an orange. There may be a
single growth of this kind, or several, and they may be found in any
part of the brain.
=Tubercular or Scrofulous Tumors.= Under this head may be placed certain
bodies of a white or pale yellow color, firm, like soft cheese,
sometimes granular and friable, and consisting chiefly of a large
proportion of albuminous matter. They may be found first, as one or more
individual masses of considerable size; or second, sometimes as many
minute rounded bodies, distinct and separate from one another.
In examining the head of a hydrocephalic child of four years, with Dr.
von Tagan, we found attached to the underside of the middle lobe of the
left hemisphere, a body of a white cheesy consistence, and of the size
of half a hen’s egg. Connected with the cerebellum, was another tumor of
the same character, but smaller in size.[6]
Tubercular masses of this kind, may be found on the surface, or imbedded
in the substance of any portion of the cerebrum or cerebellum.
The second form of tubercular deposits, are confined almost wholly to
the gray matter of the surface. In one case, over two hundred of these
bodies were found scattered through the gray matter of the cerebrum and
cerebellum, of the size of a pea or bean, and of a pale yellow or bluish
color. When cut open, the interior of the bodies was found to resemble
boiled potatoes in consistency.
This form of disease is confined principally to children. Of thirty
cases collected by Dr. P. H. Green, of London, all were between the ages
of nineteen months and twelve years.
=Adipose Tumors.= Under this name, has been described a peculiar and
quite rare form of disease of the brain, in which either some portion of
the brain itself, or growths attached to or imbedded within the cerebral
substance, present a fatty appearance, which by some has been
denominated _lardaceous degeneration_. The exterior of the tumor is
smooth, of a yellow color, and the interior composed of adipose matter
of ash color, and semi-solid consistency.
=Cholesteroma.= This is another rare form of tumor of the brain,
consisting of white pearl-like, glistening bodies, varying in size from
that of a pea, to a walnut or small orange. They are found mostly at the
back of the brain, and in the sub-arachnoid tissue. When examined
chemically, the substance of these tumors is found to consist almost
wholly of cholesterin.
=Cartilaginous Tumors.= These are often spoken of as _scirrhus_ in their
nature. They may be described as irregular in shape, sometimes
lobulated, the interior yellowish in color, of a cartilaginous hardness,
and arranged sometimes in streaks or bands, in other cases, in rounded
masses. At a more advanced stage, from softening of the interior,
cavities begin to form, which are filled with a semi-fluid or jelly-like
substance. Death will generally ensue before this process is far
advanced.
=Calcareous or Bony Deposits.= _Osseous_ formations are not unfrequently
found connected with the membranes of the brain, but rarely, if ever,
with the brain substance. _Calcareous_ deposits, on the other hand, have
been found in almost every part of the brain. In the brain of an idiot
of sixteen, the pons Varolii, crura cerebri and cerebellum, contained so
much earthy matter, as to give difficulty in cutting with a knife (_Sir
E. Home_.) In the brain of a man who had long suffered from acute pain
in the head, a hard plaster-like concretion was found as large as a
filbert.
These bodies are, therefore, not to be looked upon as genuine bony
formations, but rather as an infiltration of chalky substance into the
brain tissue. Of the same nature, are the calcareous deposits found in
the pineal gland, which, although very constantly present after the age
of eight or ten years, can hardly be considered as normal products,
although it is well established that they exert no influence on the
functions of the brain.
=Encysted Tumors, Hydatids.= A variety of tumors of the encysted form
have been found in the brain by different observers, varying in size
from a pea, to that of an egg or orange. Their contents also, have
presented a great degree of variation. While some have been filled with
the cheesy substance of the ordinary steatome, others have contained
blood, a jelly-like, or even a limpid watery fluid.
It has been claimed by some, doubted by others, that the _animal
hydatid_, the _cysticercus_, has been found in the human brain. Having
unquestionably been observed in the eye, the heart, and other parts of
the body, it may also, possibly, sometimes be found in the brain. This
curious animal is now known to be but the larval form of one of the
cestoid entozoa, the _Tænia solium_. Its position in the brain, can only
be accounted for, by supposing that the embryo, which in its first stage
is very minute, by piercing the coats of the stomach, into which the egg
has been taken with the food, enters a blood-vessel, and being carried
into the brain, lodges in some of the capillaries, the walls of which it
penetrates. Entering thus the brain substance, it develops into the
second larval form, which consists of a small bag or cyst, filled with a
limpid fluid. Developed within the cyst, yet capable of being thrust
out, is the head, which presents four sucker-like processes, surrounded
by a circle of minute hooks, which give it the power of active migration
through the tissues. In the pig, the presence of these cysticerci
constitutes measly pork, which if taken into the stomach in a raw state,
the contained larvæ at once develop into the perfect worm, the _Tænia
solium_.
=Blood Cysts=, though not common, have been found in the brain. They
consist of a membranous cyst, which may be lobulated or contain smaller
cysts, the inner surfaces of which are lined with a vascular membrane,
from which escapes a bloody fluid.
=Cancerous Tumors= may be found in any portion of the brain, and may
present the several varieties of these malignant growths, including
_fungus hæmatodes_. While they are generally secondary with similar
tumors in other parts of the body, they may be primary in their origin.
They may acquire such a development as to cause absorption of both the
dura mater and skull, and thus appear upon the outside of the head. In
_fungus hæmatodes_, the enclosed substance consists of soft spongy
matter, of a brain-like consistency, divided into lobular masses, of a
reddish shining aspect. They are mainly found in young subjects,
sometimes in adults.
=Melanosis.= This form of morbid growth is occasionally found in the
human brain. The middle lobe of the left hemisphere of the brain of a
subject in the dissecting-room, was found to be attached to the dura
mater by a melanotic mass, resembling the dark bodies frequently found
around the bronchial tubes. Its attachments were such as to render it
doubtful whether it had its origin in the brain or in its membranes. The
gray substance of the brain of persons who have suffered malarial
diseases, is sometimes found presenting a blackish appearance from the
dark pigment within its substance, or within the pia mater.
=Syphilitic Tumors= are occasionally found in the brain, situated near
its surface. Their characters are not such as to permit of their ready
recognition, except when associated with syphilitic growths in other
parts of the body. They may vary in size from a pin’s head to a cherry.
They present a rounded or irregular form, a yellow color, and are
composed of spindle-shaped or round cells, which may undergo a cheesy
degeneration.
=Obstruction of Cerebral Arteries.= Patients suffering from endocardial
inflammations, or from aneurism of the arch of the aorta, or from any
cause having fibrinous deposits forming in the heart, are liable to have
the same washed along the carotids, and thus carried into the vessels of
the brain, thereby deranging the circulation through this organ. The
symptoms resulting, are generally those of apoplexy. Hemiplegia, with or
without loss of consciousness, follows. Softening of the cerebral
substance follows as a result of the accident, and it is not impossible
but that the presence of these bodies is the general cause of this
structural change of the brain.
The position of the embolus, in fatal cases, is usually in one of the
middle cerebral arteries; these vessels being in a more direct line with
the internal carotids. They may lodge, however, in the vertebrals or
basilar, yet through the circle of Willis, the several parts of the
brain will still receive a partial supply of blood.
=Atheromatous Degeneration, and Calcification of Cerebral Arteries.= The
coats of the arteries of the brain in old people, are liable to become
infiltrated with atheromatous and calcareous matter to such a degree, as
to render them rigid, and inelastic.
While the arteries of the base of the brain, as the basilar, the
cerebrals, or the communicating of the circle of Willis, are more liable
to this change, it may involve the smaller branches as well. The
increased thickness of the coats of the vessels, results in a diminution
of the calibre, while they are enlarged in external circumference.
Resulting from this state of the vessels, we shall have disturbed
circulation, followed by effusion, and in some cases by atrophy of the
brain. Attending this condition, are frequent attacks of stupor and
insensibility, lasting for several hours or even days.
Again, from the weakened condition of the coats of the vessels in these
cases, we may have an _aneurism_ resulting, the walls of which suddenly
giving away, death from hæmorrhage speedily follows.
Section IV. OF THE SPINAL CORD.
[=Notice= in examination. 1. _Vertebræ._—Condition of several parts;
caries, etc. 2. _Vertebral Canal._—Proportion to cord; contained
fluid; serum, pus or blood; amount, etc.; condition of spinal veins.
3. _Membranes of cord._—Bulging of any part; thickening; congestion;
morbid growths, etc.; fluids within; amount, color, etc. 4. _Spinal
cord._—Weight; size; condition of fissures; of interior, as seen on
section; softening; exact point of; roots of nerves; pressure upon,
etc.]
From the continuity and identity of structures, the spinal cord is
subject to essentially the same diseases as those of the brain.
1. The Membranes.
=Inflammation= of the latter may exist alone, or in connection with that
of the membranes of the brain, constituting _cerebro-spinal meningitis_.
Inflammation of the dura mater is an uncommon occurrence. The
inflammation in spinal meningitis is almost wholly confined to the pia
mater, this being the more vascular of the membranes. A pale reddish, or
sometimes purple color, with a bloody jelly-like infiltration,
characterizes the earlier stage, while at a later period the membrane
presents a greyish or dirty yellow appearance, from the presence of a
thick pus-like substance covering the surface. Such inflammations may be
either idiopathic, rheumatic or traumatic in their origin.
In _spotted fever_ the inflammation extends to the pia mater of the base
of the brain, and is remarkable from the epidemic form which it
sometimes assumes.
=Tubercular= deposits, as well as _tumors_ of various kinds, may be
found connected with the spinal membranes, so similar to those described
with the cerebral membranes, as not to require separate notice.
=Serous effusion= may be found in the spinal canal, in the same cases
when it exists in the cranial cavity, and may be either a diffusion of
fluid through the sub-arachnoid space, that has been effused in the
brain, or it may originate from the membranes of the cord itself. The
fluid may be either between the vertebræ and dura mater, or between the
latter and the pia mater.
A peculiar form of dropsy of the spine is sometimes found, congenital in
its nature, and accompanied with a deficiency in the spinal column, by
means of which a cleft remains in the arch of one or more of the
vertebræ; hence the name, _Spina bifida_, as applied to this disease.
The effusion in these cases, taking place before the vertebræ are fully
developed, the pressure from within prevents the final closure of the
canal posteriorly; when, from want of support at that point, the
membranes and covering tissues, yielding to the pressure from the
accumulating fluid, gradually protrude at that point, producing a
rounded fluctuating tumor. The disease is more frequently found in the
lumbar region, although it may occur in the dorsal or cervical, and in
some cases may involve the whole spinal column.
2. Spinal Marrow.
=Inflammation= of this structure, (_myelitis_,) presents the same
character, and may be followed by the same results as inflammation of
the brain. From the distension and engorgement of the capillaries of the
inflamed part, a bright red color may be presented, not only on the
surface, but in the substance of the cord when exposed by division.
Blood may also be found effused in the substance of the cord, or between
its membranes, or between the bony walls and the dura mater.
=Softening= of the spinal cord, may arise either spontaneously, or as a
consequence of injury. When spontaneously taking place, a large portion
of the cord may be involved. The appearance presented, is most usually
that of a soft pulpy mass, which easily breaks down upon the opening of
the membranes. When the result of injury, the softening is generally
confined to the portion involved in the original violence.
=Hardening= of the spinal marrow, (_sclerosis_,) may be one of the
results of inflammation, yet the accompanying symptoms may vary so
slightly from those of other forms of spinal disease, that the
post-mortem alone, will disclose the true nature of the difficulty. In
_locomotor ataxy_, the posterior columns of the cord are usually
affected with this change.
=Atrophy= of the spinal cord, differs from hardening, in the _shrinking_
which attends the progress of the disease, although there may be
increased density, as in the former case. The essential peculiarity of
atrophy, consists in an increased development of the fibrous elements of
the cord, which by pressure, gradually destroys the elementary nerve
constituents. This disease is confined chiefly to men of a middle age,
and is generally the result of venereal excesses; muscular
over-exertion, exposure to cold, &c., may also be exciting causes.
=Morbid Growths=, of various kinds, and closely resembling those found
in the brain, as well as _animal parasites_, are sometimes found in the
spinal cord.
PART II.
THE NECK AND CHEST.
CHAPTER I.
OPERATION ON THE NECK.
The parts which we may wish to examine in the region of the neck in a
post-mortem examination, include the tongue, the larynx, the trachea and
the œsophagus. These may be removed together, by first making a single,
straight incision from the chin, down the central line of the neck to
the sternum. Next turn aside the integument with the superficial
structures, separate the muscles of the tongue from their attachment to
the jaw, and divide the mucous membrane of the floor of the mouth on
either side of the tongue, when, with the tenaculum, the latter may be
drawn down beneath the jaw. The neck being well extended and the tongue
forcibly drawn down, the knife may be carried back on either side of
that organ, dividing the muscles and mucous membranes, including the
palatine arches and tonsils, when the tongue may be so drawn down as to
permit the knife to reach the posterior walls of the pharynx. This being
divided, from the slight adhesion to the spinal column, the whole may
now be drawn down and removed together, the trachea and œsophagus being
divided at the upper end of the sternum.
By the use of the enterotome, the pharynx, larynx and trachea may be
laid open from behind, which will fully expose their interior for
careful examination.
After the examination of the parts is completed, if it is desired to
preserve the specimen, the cavity remaining may be so filled with paper
or rags, as, upon the closing of the part, to leave little or no
evidence of the absence of any portion.
Through the mouth, the buccal cavity may be examined, when there may be
noted the condition of the teeth, gums, tonsils, palate, etc.; the
presence or absence of ulcers on any of these parts, or of food or other
foreign substances within the cavity.
OPERATION ON THE CHEST.
In opening the thoracic cavity for an examination of its contents, a
straight incision may be made along the central line, through the skin
and superficial tissues, from the upper end of the sternum, to near the
umbilicus. If it is desired to examine the abdomen at the same time, the
incision may be carried on to the pubis; otherwise, ending just above
the umbilicus, a transverse cut may be carried from its lower end, to
the border of the chest upon either side. These incisions being
carefully carried through the muscles and peritoneum, the flap thus
formed may be lifted and turned up upon the chest, and the peritoneum
divided along the cartilages of the ribs. The integument with the
pectoral muscles may now be dissected up together, and turned back as
far as the union of the cartilages with the ends of the ribs. With the
heavy cartilage knife, the former may now be divided near their union
with the ribs; care being observed not to permit the knife to pass into
the chest, and thus injure the lungs. In aged persons, and sometimes in
the middle aged, the cartilages will be found so ossified, as to require
the use of the saw or chisel in the place of the knife; this being more
frequently required with the first ribs, than with any other. The
ligaments uniting the clavicle with the sternum, having been divided,
the latter may be removed by commencing at the lower end, and separating
the diaphragm from its connections to the sternum and costal cartilages.
The sternum being now lifted from below, the mediastinum may be divided,
this forming the only bond of union to the parts beneath, except in
cases, where, from pleuritic inflammation, adhesions may exist between
the lungs and costal cartilages.
The sternum having thus been removed, the lungs will be found more or
less collapsed from atmospheric pressure, unless adhesions be so
extensive as to prevent.
The attention may now be given to the pericardium and heart. By making a
small opening into the cavity of the former, any dropsical fluid present
may be removed and measured. This may be accomplished, by introducing
the point of a syringe into the opening, and carefully drawing the fluid
into the same, and then forcing it into some vessel. Or, it may be
carefully absorbed by a sponge, and then squeezed out and measured.
The _heart_ may be removed for examination, by dividing the large
vessels springing from its base. In examining the cavities, valves, &c.,
the right auricles should first be opened, by an incision along its
base, another meeting this at right angles, thus making two angular
flaps, which may be turned aside, exposing the interior. In opening the
ventricle, let one incision be made parallel with, and about one-third
of an inch from the groove in the anterior surface dividing the right
from the left ventricle, commencing at the base and extending to the
apex; and another along the posterior groove, meeting the former at the
apex, thus making a triangular flap, which may be lifted, exposing the
interior of the cavity, without injury to the tendonous cords. The
semilunar valves of the pulmonary artery may readily be exposed, by
splitting open that vessel, and turning aside its walls. The left side
of the heart may be examined in the same manner.
The examination of the _lungs_ may often be made _in situ_. Deep
incisions may be made into their substance at various points, or
portions may be removed for examination. If a more careful inspection is
desired, or if we wish to examine the bronchial tubes or aorta, the
whole thoracic viscera may be removed together. To accomplish this,
divide the trachea and œsophagus, as they enter the chest, with also the
branches arising from the arch of the aorta. Carry the hands around
either lung, breaking up any adhesions which may be found, and then by
grasping the trachea and arch of aorta, and dragging down upon the same,
the posterior mediastinum may be divided from above downwards, the aorta
and œsophagus divided as they pass the diaphragm, and the whole of the
contents of the chest thus removed _en masse_. Placed upon a large tray,
they may now be examined in detail. The bronchial tubes may be best
inspected from behind, laying open the passages with the scissors at
their posterior walls. By means of deep incisions, extending from apex
to base upon the anterior surface, the condition of the interior of the
organs may be carefully noted.
The examination completed, all blood should be sponged from the cavity,
the organs replaced, and any remaining vacancy filled with bran or
sawdust. The sternum now being placed in position, the incision may be
sewed up.
CHAPTER II.
PATHOLOGICAL CONDITIONS.
Section I. OF THE TONGUE.
[=Notice= in examination: size; form; surface coated or clean;
furrowed or fissured; marks of bites, stains; color generally;
vesicles; ulcers; sloughs; tumors, wounds, etc.]
The diseases of the tongue, the appearance of which we may wish to
examine after death, include _cancer_, _syphilitic ulcers or tubercle_,
_tumors_, _hypertrophy_, _etc._
=Cancer= is the only disease of this organ likely to result in death. It
is said to occur more frequently in females than males. It may assume
the various forms of this disease, but is more frequently epithelial or
scirrhus, than medullary.
=Syphilitic Ulcers or Tubercle=, may be confounded with cancer, and in
some instances, only a previous knowledge of the history of the case,
assisted by a microscopic examination, would positively determine the
diagnosis.
=Tumors= of various kinds—encysted, fatty, fibrous and erectile—may be
found in the substance of the tongue, or underneath it in the floor of
the mouth.
=Ranula= is a peculiar form of tumor found under the tongue, often
attaining the size of a pigeon’s egg, and filled with a watery or
albuminous, or sometimes cretaceous matter. The tumor is usually
considered as arising from a dilatation of Wharton’s duct, but of this
there is doubt in some cases.
=Hypertrophy= of the tongue is sometimes found, where, from an increase
of the connective or areolar tissue, without any change in the muscular
fibres, the organ has become greatly enlarged, so as to cause deformity
of the mouth, or even of the whole lower part of the face. This
condition may involve the whole or a portion only of the tongue.
Section II. OF THE LARYNX AND TRACHEA.
[=Notice= in examination: 1. _Contents_—mucus; lymph; pus or blood;
amount; foreign bodies; false membranes, etc. 2. _Larynx_—condition of
epiglottis; œdema, ulcers, sloughs, polypi; same of superior opening
to cavity. _Ventricles_—condition of mucous membranes, etc. _Vocal
Cords_—thickness, color, œdema, ulcers, etc. _Cartilages_—condition
of; ossification; caries, etc. 3. _Trachea_—contents; mucous membrane;
cartilaginous rings; ossification of; caries; denuded of mucous
membrane, etc.]
_Inflammation_, _ulceration_, _œdema_, _necrosis of the cartilages_,
_tumors_ and _false membranes_ are the more usual pathological
conditions of these parts that may claim the attention in a post-mortem
examination.
=Inflammation= of the mucous membrane of the larynx (laryngitis) and
trachea, will appear as a diffused redness, with some thickening of the
membrane, and within which may be traced many _small, congested
blood-vessels_. It may be important to distinguish the redness of
inflammation, from that attending the early stage of decomposition,
which, it is an interesting fact to know, first appears in these parts.
Immediately after death, the mucous membrane is _pale_, except in death
from suffocation or laryngitis. In a day or two it becomes of a dusky
red, which is distinguished from that of inflammation by _the absence of
congested vessels_; the redness of decomposition, also, having a
superficial filmy appearance, as if washed with dirty wine.
=Ulceration= of the larynx commences in the mucous membrane, but may
extend to the deeper parts. The more usual location is upon the
epiglottis, or on the margin of the glottis and vocal cords. Impairment
of the voice to a greater or less degree, will have attended either
inflammation or ulceration of the vocal cords. It is to be borne in
mind, however, that aphonia may arise from some impairment of the nerves
of the larynx, in which case, a post-mortem examination will fail to
reveal any morbid condition of the mucous membrane or vocal cords.
Pulmonary consumption we sometimes find accompanied with the presence of
ulcers upon the posterior walls of the larynx, with evidence of
inflammation in the surrounding parts. Whether these arise from
tubercles in the mucous membrane, or ulceration of the mucous follicles,
is uncertain.
=Œdema= of the larynx, is attended with great swelling of the mucous
membrane, from serous effusion into the submucous tissues, and
frequently attends chronic inflammation of the parts, with ulceration.
It may, however, be of an erysipelatous character, occurring as the
result of exposure to infection. The surface appears red, pulpy and
swollen, from infiltration of the submucous tissue. Œdema of the larynx,
is confined to the parts around the epiglottis, and margins of the
glottis, never descending below the true vocal cords, owing to the close
adhesion of the mucous membrane to the fibrous structure of the cord,
without any intervening areolar tissue.
=Necrosis of the Cartilages= of the larynx, may occur in the advanced
stage of laryngitis with ulceration. In this manner the epiglottis, with
the arytenoid, the cricoid, and even thyroid cartilages may, to a
greater or less extent, be destroyed.
=Abscesses= may also form, where the cartilages are so much involved,
these in some cases breaking upon the outside, and establishing
fistulous communications through which air may escape during
respiration.
=Tumors= of the larynx, may be found _first_, outside of the cavity,
imbedded in some portion of its tissues; and may include encysted, fatty
or fibrous tumors; or, _second_, they may be found in the interior,
springing from the mucous membrane, and resembling polypi in their form
and structure. They are sometimes granular or cauliflower-like in
appearance, and vary in size from a pea to a hazel-nut.
=False Membranes= may be found in the larynx and trachea in fatal cases
of croup or diphtheria. In croup, the membrane adheres but slightly to
the mucous structure beneath, which will be found red and congested, but
may form a complete tubular lining to both larynx and trachea, extending
also into the bronchial tubes.[7] It is usually tougher in the larynx
and upper portion of the trachea, becoming softer and more gelatinous in
the lower portion of the trachea and bronchial tubes. Much difference of
opinion has been entertained as to the nature of this substance. It may,
however, be considered as a morbid secretion from the inflamed mucous
surfaces, in a semi-fluid form, which, in consequence of the presence of
albuminous matter, coagulates upon exposure to air.
The false membrane of croup may generally be distinguished from that of
diphtheria by the fact, _First_, That the latter is usually confined to
the fauces, sometimes extending to the larynx, rarely to the trachea.
_Second_, That diphtheritic membrane occurs more in patches, is tougher,
is more directly incorporated with the mucous surface beneath, and is
removed with more difficulty. _Third_, A microscopic examination shows
the membrane to be composed mainly of fibrine in a fibrillated
condition, with granular corpuscles and pus cells.
Section III. OF THE PHARYNX AND ŒSOPHAGUS.
[=Notice= in examination: displacements; their cause, as by tumors,
etc.; dilatation; contraction or stricture, seat of; calibre at
stricture; above, below; condition of mucous membrane; ulcers, etc.
Contents of œsophagus; food, foreign bodies, wounds.]
These parts are liable to _inflammation_, _ulceration_, _stricture_,
_dilatation_ and _new growths_.
=Inflammation= of these passages, rarely occurs, except as the result of
mechanical injury, as from the lodgment of a foreign body, or from
swallowing some caustic or highly irritating substance. Catarrhal or
croupous inflammation of the mouth and tonsils, may, however, involve a
portion of the walls of the pharynx.
=Ulceration= may result from the same causes, and hence may be confined
to a small portion or may involve the greater part of the tube.
=Stricture= of the œsophagus may be either _spasmodic_ or _organic_. The
former usually occurs in hysterical women, and may result from the
irritation following the removal of some foreign body lodged in the
canal. Never proving fatal of itself, we seldom have the opportunity of
examining a case of this kind.
_Organic stricture_ is found usually at the commencement of the canal,
sometimes at its lower end. It may result from contractions attending
the healing of an ulcer, but is more frequently induced by a cancerous
affection of the walls, or by the projection of some morbid growth into
its interior, as from aneurism of the aorta, or tumors, abscesses, &c.,
in the lungs or left lobe of the liver.
=Dilatation= of the œsophagus may result from the presence of stricture.
When the latter is near the cardiac orifice of the stomach, the entire
length of the tube may be involved. The walls in these cases may be
either thickened or thinned. From the accumulation of food above the
point of stricture, the walls gradually yield to the distending force,
until a degree of dilatation is attained that is quite remarkable.
=Tumors= of various kinds are occasionally found within the walls of the
pharynx or œsophagus including cystic, fatty and fibrinous tumors of a
polypoid form.
_Malignant or cancerous_ growths may appear in any part of the tube, the
epithelial form being more common. Beginning in the submucous tissue,
the disease will soon involve the whole circumference of the tube, to
the extent of from one to three or four inches, producing a hardness of
the tissues with more or less contraction. Ulceration ultimately taking
place, a dilated cavity may take the place of the original stricture.
Section IV. OF THE PERICARDIUM.
[=Notice=: 1. _External characters_—shape; measurement; amount of fat,
etc. 2. _Contents_—serum; quantity; color; how affected by heat;
blood; quantity; character; source. 3. _Internal surface_—adhesions;
their position, extent and character; as firm, soft, etc.]
The pericardium is subject to the same affections as other serous
membranes, including _inflammation_, _adhesions_, _effusions_ or _morbid
growths_.
=Inflammation= of the pericardium or _pericarditis_, is characterized by
an unusual dryness of the surface, with injection of the vessels in the
early stage, while at a later period a layer of plastic lymph will be
found adhering to the surfaces. The deposit may be limited to some small
portion, or be distributed over the whole inner surface of the membrane
and upon the exterior of the heart, giving them the appearance of having
been smeared over with some sticky substance. Often the surfaces are
rough or villous in appearance, like the mucous membranes of the
intestines. Irregular calcareous patches are sometimes found in old
chronic cases, developed within the thickened portions of the membrane.
=Adhesions= may also form between the surfaces in contact. The whole
cavity may in this manner become obliterated, or bands of adhesion may
be found here and there.
=Effusions= may be found in the pericardium, as in other serous
cavities. When the result of _pericarditis_, the fluid will often
contain floating shreds of lymph. Sometimes the fluid will be found
highly albuminous, and again bloody or mixed with pus. This effusion may
have taken place so early as to have prevented any adhesion of parts; or
it may not have commenced until union had taken place at certain parts,
when, from the distension of the sac, these bands may be found greatly
elongated, and stretching across the cavity in various directions. When
the effusion is but part of a _general dropsy_, it will be clear, while
the surfaces of the membrane will be smooth and destitute of evidences
of inflammation. In quantity, the fluid found in these cases may vary
from a few ounces to a pint or more.
_Blood_ may sometimes be found filling the pericardium, either from a
wound of its walls, rupture of the heart, or from the bursting of an
aneurism. In scurvy, purpura, etc., small patches of extravasated blood
may be found in its walls.
=Morbid Growths.= The more common of these, found in connection with the
pericardium, are _cancers_. They are usually secondary in their
appearance, and generally will have first developed in the mediastinum.
_Fibrous_ or _cystic_ tumors have been noticed in a few rare cases,
while _tubercles_ of the miliary form, are not uncommon within this
membrane.
Section V. OF THE HEART.
[=Notice=: 1. _In situ_—exact position and relation to surrounding
organs; shape; size; degree of firmness or flabbiness. 2. _After
removal_—amount and kind of blood discharged from divided vessels;
shape of heart; round or elongated; apex formed by which ventricle;
amount of fat on surface; relative size of each cavity. 3. _Right
auricle_—character and quantity of blood contained; fibrinous clot.
Lining membrane; general condition of; foramen ovale; open or closed;
thickness, consistence, etc., of muscular walls. Auriculo-ventricular
opening; its shape; estimate of size by introducing fingers; rough or
smooth; fibrous or calcareous deposits; circumference. 4. _Right
ventricle_—nature and quantity of contents; fluid blood; blood clot;
fibrinous clot; size; attachments of same to muscular columns; firm or
soft; size of cavity; thickness and condition of muscular walls;
color, firmness, etc. 5. _Tricuspid valves_—natural, thickened,
thinned or contracted; granulations; patches of calcareous matter;
degree of flexibility; can they close the opening? Condition of chordæ
tendineæ; length, thickness, flexibility, rupture, etc. 6. _Pulmonary
opening_—size and shape; smooth or rough. Semilunar valves; thin and
smooth, or thick, rough and inflexible; power of closing the opening;
will water pass through when poured in from above? 7. _Left side of
heart_—observe same as on right. 8. _Generalities_—weight after
removal of blood; wounds; morbid growths; abscesses; malformations;
aneurism; rupture, etc.]
The several morbid conditions of the heart may be classified as follows:
1. Inflammation │of muscular walls. │Carditis.
„ │of serous membranes. │Pericarditis.
„ │ „ │Endocarditis.
│ │
2. Diseases of valves. │Thickening.
„ │ „ │Ossification.
„ │ „ │Atrophy.
│ │
3. Changes in the walls of the heart, │Hypertrophy.
influencing the size of the cavities. │
„ │ „ │Dilation.
„ │ „ │Atrophy.
│ │
4. Morbid conditions of the walls alone. │Fatty degeneration.
„ │ „ │Morbid growths.
„ │ „ │Ossification of
│ │ coronary arteries.
„ │ „ │Malformations.
„ │ „ │Abscess.
„ │ „ │Aneurism.
„ │ „ │Rupture.
│ │
5. Displacements. │Congenital. │Ectopia cordis.
„ │Pathological. │Transposition.
│ │
6. Contents of cavities. │Heart clots.
1. Inflammatory Affections.
=Carditis.= Inflammation of the muscular substance of the heart is by no
means a common disease, and when present, is probably always associated
either with endocarditis, or more frequently pericarditis. We may
recognize this condition after death, by the light yellow color of the
heart; with a relaxed, flabby, and in some instances a softened
condition of the walls. Upon cutting into the muscular walls, there will
be found exuding a semi-purulent fluid and often small cavities, varying
in size from a pin’s head to a small pea, will be found filled with pus.
This condition may involve the whole heart, or may be confined to one or
more portions. Inflammation of the muscular substance of the heart, may,
undoubtedly, be one of the primary causes leading to aneurism or even to
rupture. The symptoms of this disease are not readily recognized during
life, being always combined with inflammation of the peri- or
endocardium.
=Pericarditis.= Affections of the pericardium have been noticed in the
previous section.
=Endocarditis.= Inflammation of the lining membrane of the heart
(_endocardium_) most frequently occurs in connection with an attack of
articular rheumatism. It may, however, result from blows or injuries of
the chest, and has been induced by violent muscular efforts. It is said
also, to be often connected with some vitiated condition of the blood,
as in pyæmia or Bright’s disease of the kidneys, and has been noticed
also in cases of measles, typhus and puerperal fever.
Endocarditis more frequently attacks the left, than the right side of
the heart. The anatomical appearances, are a loss of smoothness and
transparency of the membrane, with an injected condition of its vessels.
Deposits of lymph may be found adhering to the free surface at various
points, or to the tendinous cords or valves, giving a roughened, or even
warty appearance to all those parts. These may become detached, and
swept on with the blood, and finally lodging in some of the arteries of
the head or extremities, where they are known as _emboli_, they may
become a source of serious trouble. The inflammation may extend to the
muscular structure, resulting in softening or the formation of purulent
cysts.
It is, however, upon those folds of the lining membrane constituting the
valves, and particularly upon the left side of the heart, that the
effects of endocardial inflammations are especially manifested. In this
way originates most of the so-called
2. Valvular Affections of the Heart.
One of the most common of the results of inflammation extending to the
valves, is
=Thickening.= This may depend either upon a deposit of lymph beneath or
between the layers of membrane constituting the valves, thus rendering
them thick and inflexible while the surface is left smooth, or, at the
same time, a deposit upon the exterior may be found, rendering them
rough and even warty in appearance, and so stiffened and irregular upon
their borders as to greatly interfere with the performance of their
functions, and thus permitting _regurgitation_ to take place at the
imperfectly closed opening.[8] The tendinous cords, at the same time,
may be found thickened, hardened, and contracted, or even ruptured,
while the auriculo-ventricular openings may also be found greatly
contracted from the thickening of the base of the valves and the fibrous
tissues forming the borders of the openings. In one case the contraction
on the left side of the heart was so great as scarcely to admit the
little finger, while the thumb should readily pass that opening.
The semilunar valves of the aorta are liable to the same changes, their
thickened condition preventing their folding back completely into the
sinuses of the artery during the systolic action of the heart, or of
completely closing the vessel upon pressure from above.
=Calcification.= This condition of the valves may result from a
progressive change from simple thickening with fibrinous deposits, to a
cartilaginous state, accompanied with so-called bony, or more properly
_calcareous_ patches, which may involve large portions of the valves.
Ossification of the valves upon the right side of the heart, is but
rarely found; upon the left, both the mitral and aortic valves are
liable to this affection.
=Atrophy.= The aortic, pulmonary, and sometimes mitral valves, are
occasionally found greatly thinned; and this condition may result either
in a gradual stretching of the central portion of the valve from
pressure of the blood, giving rise to _aneurism_ of the valves, or, it
may become _perforated_ with small irregular openings, or, from its
weakened condition, _rupture_ may take place, producing sudden death.
This condition appears to consist in a gradual wearing away of the
substance of the valves, from unusual brittleness of their structure,
the result probably of chronic inflammation.
Again, the valves may be found greatly contracted, (_stenosis_) hard and
rigid, which will be attended with imperfect closure and consequent
regurgitation. Dilatation of the orifices without any change in the
valves, may also be found, resulting in the same imperfect closure.
Disease of the valves of the heart, by obstructing the orifices, is
likely to result in
3. Changes Affecting the Size of the Cavities.
=Hypertrophy.= Hypertrophy of the heart, is a condition in which there
is an increased thickness of its walls, and generally also enlargement
of its cavities. Yet there may be thickening—very rarely however—with a
diminution in the size of the cavities. It may affect both sides of the
heart, but is frequently confined to the left ventricle.
The main cause of hypertrophy of the heart, is the existence of some
obstruction to the circulation, either in the heart, or some portion of
the arterial system, as by aneurism, pressure of tumors, etc., or by
disease of the kidneys. It is most frequently, however, associated with
disease of the valves or large arteries. It may sometimes result from
continued functional excitement, and generally accompanies cases of
partial adhesion of the surfaces of the pericardium, while complete
adhesion is more likely to be followed by dilatation or atrophy. On the
right side of the heart, hypertrophy is usually the result of some
obstruction to the circulation through the lungs, as in an emphysematous
condition of that organ.
The following measurements, &c., of the normal heart, will serve as a
guide in judging of cases of enlargement:
_Size._ Lænnec has stated, that the heart in its normal condition, is
about the size of the closed fist of the individual. This comparison,
however, is not very satisfactory. It will be usually found to measure
about 5 inches in length, 3½ in its greatest width, and 2½ in its
extreme thickness, from its anterior to its posterior surface.
_Weight._ From an examination of four hundred cases, the average weight
was found to be 9½ ounces in the male, and 8¼ ounces in the female. In a
robust, muscular male, the heart may, however, be found to weigh as much
as 12 ounces, and still be normal in all its parts.
_Thickness of Walls._ Right auricle, 1 line; left, 1½ lines. Right
ventricle, 1½ lines, and left, a little over 5 lines, or half an inch,
at its middle, being a little thinner both at the base and apex.
_Size of Orifices._ Circumference of auriculo-ventricular opening of the
right side, nearly 4 inches; of left side, 3½ inches; of the pulmonary
artery, 2⅝ inches; of aorta, 2⅜ inches.
When enlarged, the heart may be found measuring 6 to 7 inches in length,
as much in breadth, and 12 to 16 inches in circumference. The weight may
also be increased to 15, 20 or 25 ounces, and the walls may increase in
thickness to nearly a-half inch, and upon the left to over an inch.
Hypertrophy of the heart, has been divided into three forms:—1st,
_simple_ hypertrophy; 2d, _eccentric_; and 3d, _concentric_ hypertrophy.
In the first form, the walls are thickened, while the cavities remain
unchanged. (Simple hypertrophy.)
In the second form, the thickening of the walls is attended with an
_enlargement_ or _dilatation_ of the cavities. (Eccentric
hypertrophy.[9])
In the third form, the thickening is attended with a _diminution_ in the
capacity of the cavities. (Concentric hypertrophy.)
It has been observed in cases where an examination has been made very
soon after a sudden, violent death, attended with loss of blood, as in
decapitation, etc., that the cavities have been nearly obliterated,
while the walls were greatly thickened. By maceration for a few days,
the ventricles have become relaxed to their natural size and capacity.
This state of the heart has been observed in persons in whom, during
life, none of the symptoms of disease of the heart had been manifested,
and hence the condition is to be considered as the immediate effect of
the peculiar character of the cause of death.
=Dilatation.= Dilatation of the cavities of the heart, is a condition
which may also result from the presence of obstacles or impediments to
the circulation, as from ossification of the valves; narrowing of the
pulmonary or aortic orifices; employments requiring powerful muscular
efforts; and in consolidation, tubercular induration, emphysematous
condition of the lungs, or fatty degeneration.
The muscular substance is usually soft and flaccid, sometimes of a
violet color, again pale and yellowish. The thinning may be so great, as
to reduce the thickest part of the left ventricle to two lines or even
less, when the walls will appear to be composed of but little more than
a thin layer of fat covered with the pericardium.
Three forms of dilatation are recognized: _active_, _simple_ and
_passive_.
Active dilatation is associated with _hypertrophy_ of walls,
constituting eccentric hypertrophy.
In simple hypertrophy, the walls retain their _normal thickness_, while
the shape may be changed according to the cavity affected.
Passive dilatation, on the other hand, is accompanied with _thinning_ of
the walls, and usually results from fatty degeneration, atrophy, or some
other change in the muscular fibre.
=Atrophy.= In this condition there is a uniform decrease in the size of
the heart. Its cavities becomes small, and its walls thin. It usually
attends diseases accompanied with great impoverishment of the blood, as
in cancer, diabetes, etc., or may result from obstruction of the
coronary arteries from calcification, atheroma or thrombi.
Paget mentions a case where the heart of a cancerous man, fifty years
old, weighed only five ounces, four drachms; and that of a diabetic
woman, which weighed only five ounces, one drachm. It is usually
accompanied with a general wasting of the tissues and organs of the
body, and frequently will be found associated with fatty degeneration,
which will now be noticed.
4. Morbid Condition of the Walls Alone.
=Fatty Degeneration.= Two forms of fatty diseases of the heart have been
recognized. In the first, which should be known as “_fatty growth_,” to
distinguish from “_fatty degeneration_,” there is an unusual quantity of
adipose matter in those parts of the heart where more or less is usually
found, viz.:—Along the furrows through which the vessels run, and
particularly about the base of the heart. The fatty masses may dip more
or less into the substance of the walls, displacing the muscular fibres,
although the latter are generally normal in color and density, even when
imbedded in masses of fat. This condition may be found in persons who
are otherwise thin, as well as in the obese.
But the more frequent form of fatty disease, is that known as _fatty
degeneration_. In this, we find upon opening the heart, that it has lost
the reddish-brown color characteristic of the muscular fibre in its
normal condition, and is pale, soft and flabby. The whole organ feels
soft, doughy and inelastic, much like a heart beginning to decompose. If
the wall of the left ventricle be partly cut through, the remainder is
easily torn, and the surfaces have a granulated appearance.
Upon the inner surface, beneath the endocardium, numerous small thickly
set spots, or sometimes wavy lines, of a pale buff, or light yellow
color, may be noticed. This appearance does not depend upon a deposit of
fat among the muscular fibres, but rather upon a change in that tissue;
and an examination with the microscope, will show fatty degeneration of
the fibre.
This condition of the heart, may involve the whole organ, or may be
confined to one or more portions. It is much less common in the
auricles, than in the ventricles, and more frequent in the left
ventricle than in the right. It will be generally found more advanced in
the upper portion of the septum of the ventricles, and in the large,
fleshy columns of the left side; or it may be found in these columns
alone, which accounts for the occasional rupture of the latter.
_Fatty Degeneration_ may be associated with _fatty growth_, or with
hypertrophy, or thinning and dilatation, and may be the cause of
rupture. The general character of softness, paleness, and mottled color,
should lead to _suspicion_ of the existence of this disease, when a
microscopic examination being resorted to, the conclusion would be
decisive. A small portion of fibre, examined with a power of 300 or 400
diameters, will present, in fatty degeneration, instead of the striated
appearance of the normal fibre, a granular appearance, with numerous
minute oil globules scattered through the fibre. In the palest part of
the heart, the disease will be generally most advanced; but even here,
the microscope will show some fibres in a healthy condition, while
others around them are rendered completely granular.
Exhausting diseases of various kinds, typhus and other severe fevers,
phosphorus poisoning, etc., may result in this peculiar condition of the
heart.
5. Morbid Growths.
Under this head may be placed _tumors_, _cancers_, _melanosis_, and
_hydatids_.
=Tumors= of various kinds are occasionally found in connection with the
heart. _Fibrous_ tumors of a small size may develop within the muscular
walls, while _syphilitic_ growths, _cysts_, and _tubercular_ deposits
may also, in rare cases, be discovered.
=Cancer.= Cancer of the heart has been noticed in two forms—_epithelial_
and _medullary_. A man, fifty-eight years old, had an epithelial cancer
of the eye, which was removed. Two years after, the man died with a
large cancerous tumor over the parotid gland. A post-mortem examination
revealed a cancerous mass, about an inch and a-half in diameter,
imbedded in the apex of the right ventricle and septum of the heart. A
microscopic examination revealed its epithelial character.[10]
_Medullary_ cancer of the heart has been usually found associated with
the same disease in the lungs and liver, and forms an investing mass
which may involve the whole organ.
=Melanosis= of the heart presents the same character as in other parts
of the body, and is considered but a variety of the medullary cancer,
pigmentary matter being added. It may be developed upon the surface, or
may infiltrate the substance of the whole organ.
=Hydatids= have been occasionally found in the heart, the most of which
have probably been animal in their character, (_acephalocysts_.) A
female, forty years old, who had been suffering pain in the region of
the heart for some months, suddenly died, after running rapidly up
stairs. One ounce of fluid was found in the pericardium. A considerable
tumor was found at the apex of the heart, which slightly fluctuated.
This tumor was about three inches in diameter, globular in form, and
encroached considerably upon the cavity of the right ventricle. When
laid open, it was found to contain a large number of small cysts or
hydatids, varying in size from that of a small pea to that of a pigeon’s
egg, the space between which was filled with a soft curdlike substance,
of a yellow color.[11]
=Ossification of Coronary Arteries.= That condition of the arteries of
the heart usually termed _ossification_ is more properly one of
_calcification_, consisting of a deposit of hard, gritty, calcareous
matter, in which there is none of the true character of real bone, no
trace of bone-corpuscle or vascular canals ever being discovered in
them. Chemical analysis has shown the deposits to be composed of 50
parts of animal matter, with 47½ of the phosphate and 2 of the carbonate
of lime in every 100. This matter being deposited in circular layers,
the artery becomes gradually converted into a hard, bony-like tube,
which may be traced with the finger along the grooves of the heart
through which the coronary artery runs. This is peculiarly a disease of
old people, and may accompany a similar condition of the arch of the
aorta or of the semilunar valves, and by interfering with the proper
nutrition of the heart may result in other forms of disease, as fatty
degeneration, dilatation, &c.
=Abscess.= Abscess of the heart, may unquestionably follow an attack of
carditis, or inflammation of the muscular substance. The cut surface of
the heart in these cases, not unfrequently shows small cavities
containing a purulent fluid, and in some instances a distinct abscess is
found.
A man, sixty years old, was suddenly attacked, while at work, with coma
and great feebleness, followed by death on the third day. The left
ventricle being opened, an abscess was discovered near the apex,
irregular in form, and containing a bloody, purulent-looking fluid. The
coronary arteries were much ossified.
=Malformations= of the heart, are extremely rare in adults, or even in
children that have passed the early days of infancy. They consist
frequently in arrest of development of the auricular septum, or, in
other words, of a patulous foramen ovale, which, by permitting of a
mixture of arterial and venous blood upon the left side of the heart,
results in early death. I have in several instances found this foramen
imperfectly closed in the adult heart, but the opening has been so
small—barely sufficient to permit the passage of a probe—as to offer
little or no obstacle to the proper performance to the heart’s function.
Malformation of the heart is undoubtedly one of the many causes of death
in utero, which might be demonstrated by a post-mortem examination.
=Aneurism.= Partial aneurism, or false aneurism of the heart, consists
in the formation of a sac or pouch, in some portion of the walls of the
organ, communicating with the cavity of the chamber, in the walls of
which it has been formed. They may form in any part of the muscular
walls of the heart, but are more frequent in the left ventricle. They
would seem to result from a separation of some of the muscular fibres,
when, by their retraction, a cavity or pouch, of a rounded or oval form
results, which, in some instances, has its walls composed of the
pericardium alone, there being a complete destruction of the muscular
fibres.
The interior of these pouches, may be found filled with layers of
coagulated fibrinous deposits, as in the case of aneurism of arteries;
or, if they communicate with the ventricular cavity by a large opening,
they may be filled with a simple soft clot of blood.
The size of these aneurismal pouches, vary from that of a cherry, to a
pigeon’s egg, or larger, when they change much the usual figure of the
heart, by their projection upon the external surface.
The following conditions have been supposed to favor the formation of
these aneurismal sacs:—1st, softening of the muscular tissue of the
heart; 2d, ulceration of the lining membrane; and 3d, rupture of the
muscular fibres.
=Rupture= of the walls of the heart sometimes happens, producing sudden
death. It may result from severe contusions of the chest, in which case,
the auricles are more likely to give way. More frequently, rupture will
result from softening of the walls in fatty degeneration or ulceration,
or from the bursting of an aneurism of the heart, or from stenosis of
the aorta. In the latter cases, the left ventricle will be usually the
seat of the rupture.
6. Displacements.
_Changes of Position_ of the heart, are by no means unfrequent. They may
be congenital in their origin, or the result of disease in the
surrounding organs. Of congenital displacement, we may mention first:
_Ectopia Cordis_, where, from some arrest of development, in the
inclosing parts, the heart may be found in some position other than its
normal one. From deficiency of the sternum and ribs, the heart has been
found protruding from the chest, (_ectopia pectoralis_,) or from absence
or deficiency of the diaphragm, it may be found in the abdomen with the
abdominal viscera. Such cases live but a short time after birth.
_Transposition_ of the heart is found in those cases where all the
viscera, abdominal and thoracic, are exactly reversed in position. A
case of this kind was discovered in the dissecting-room a few years ago,
by Dr. R. B. Weaver, demonstrator of anatomy, in the Hahnemann Medical
College. The heart was here upon the right side, the aorta curving to
the left; the liver upon the left; the stomach with its pylorus to the
left; the colon commencing in the left iliac fossa; in short, everything
completely reversed in position. The subject was a female of about
thirty years, and undoubtedly suffered no inconvenience from the
abnormal positions.
The more frequent displacements of the heart, however, are those
resulting from disease in the surrounding structures. It may be crowded
from its normal position, by pleuritic effusions, accumulations of air
(pneumothorax), or even by a highly emphysematous lung. Displacements
may also result from the presence of aneurismal or other tumors in the
chest; curvatures of the spine; or from a hernial protrusion of some of
the abdominal viscera through an opening in the diaphragm; or the
presence of tumors, enlarged viscera, dropsies, etc., within the
abdomen.
7. Contents of the Cavities.
=Heart Clots.= This subject is one that has until recently, been but
imperfectly understood; and now even, our knowledge relating to it, is
by no means complete. Enough is known, however, to convince us that
_heart clots_, are a more frequent cause of sudden death, than has been
heretofore supposed.
Having in a recent paper, read before the Philadelphia County
Homœopathic Medical Society, quite fully treated of this subject, I
shall here merely transcribe the leading points of the same.[12]
_Fibrinous heart clots_, _polypus of the heart_, _or fatty deposits_, as
they are sometimes called, differ from ordinary clots of blood, in the
absence of the blood corpuscles, and hence, presenting the buff color
characteristic of the coagulated fibrin of the blood. Ordinary blood
clots, with the corpuscles entangled with the fibrin—and hence
presenting the red color of blood—are usually found in the cavities of
the heart and large blood-vessels after death, but in greater quantity
upon the right side.
_Color._ The shade of color presented by the fibrinous clot varies in
different cases. While _buff_ is the prevailing color, the shade varies
from a light drab to a decided yellow.
_Consistency._ In this respect a good deal of variation is also found;
the difference depending, probably, in part upon the character of the
disease, and in part upon the rapidity or slowness of the formation;
those of a rapid or very recent formation, having a soft, fatty, or
jelly-like character;[13] while, on the other hand, those of a more
gradual formation, and with more sthenic forms of disease, acquire a
considerable degree of density, the surface presenting a smooth
appearance, as if acted upon by a current of blood, and in all respects
resembling the dense fibrinous masses, found blocking up the cavities of
aneurismal tumors.
_Position._ In every case reported below, the clot has been on the
_right_ side of the heart, although in some, a small, soft clot has been
found on the _left_. I am not sure that I have ever found one of these
clots on the left side of the heart of such a size and consistency, or
under such circumstances, as to have led me to suppose that it might
have been a cause of death.
The body of the clot is usually found in the ventricle, extending from
this, either up into the pulmonary artery, or through the opening into
the auricle. In all cases, the clot has been more or less entangled with
the tendinous cords of the valves and muscular columns of the heart,
requiring, in some instances, considerable force to tear it away from
its attachments.
_Time of formation._ An important question to be decided in regard to
these heart clots, is the time of their formation. Are they _ante_ or
_post_-mortem in their origin? And upon the solution of this query
depends the conclusion as to whether they are the _cause_ or the
_result_ of death in the cases where found. That a fibrinous clot may
sometimes be formed in the coagulation of the blood _outside_ of the
body, is a fact well known; as in the blood drawn from patients
suffering from acute inflammatory affections, where, from the retarding
of the coagulation, the blood corpuscles, from their greater specific
gravity, have time to fall towards the bottom of the vessel, thus giving
the “buffy coat” to the upper portion of the clot. The same
cause—retarded coagulation—unquestionably may give rise to a clot _in
the heart_ after death, presenting the same character, viz., with the
upper portion, of the buff, fibrinous character, while the lower
portion, from the presence of corpuscles, will present the appearance of
an ordinary blood clot. Such clots are not unfrequently found after
death.
But have we any evidence that the fibrin of the blood may be deposited,
forming clots within the vessels during life? In proof of this, we have
only to refer to the result of the application of a ligature to an
artery; where the interval between the point of application and the
first vessel coming off above, will be filled with a fibrinous clot,
which performs an important part in the closing up of the vessel; or, to
the well-known deposits of fibrinous layers within aneurismal tumors,
sufficient, in many cases, to so fill up the sac as to result in a cure;
therefore, the favoring conditions being present, it is not unreasonable
to claim that fibrinous clots _may_ form within the heart, of such size
and in such positions as to be an immediate cause of death.
_Causes._ In looking for the causes, or conditions promoting the
formation of these fibrinous deposits, we have to consider, first,
variations in the character of the blood itself; and secondly,
peculiarities in its circulation and in the circulatory apparatus.
Fibrin, one of the normal constituents of the blood, is estimated by
physiologists as forming from 2 to 3 parts in 1000, while it may fall as
low as 1, or rise to 7½ parts. We find it reduced to the minimum
quantity in all diseases which present a hæmorrhagic tendency, as in
true typhus, yellow fever, certain malignant forms of disease, and as
the effect of many poisons, both animal and vegetable. In these cases,
the loss of fibrin results in the effusion of blood into the tissues,
producing petechial spots, or upon the mucous surfaces, giving rise to
epistaxis, black vomit, hæmaturia, etc., while very feeble, if any,
coagulation of the blood will be found after death.
In scurvy, however, where we have a condition of the blood not unlike
that above referred to, there appears to be a marked tendency to the
formation of clots, as has been noticed by many observers, and as has
been verified by Dr. J. C. Morgan, in several cases which came under his
notice while in the army.
But it is in cases where there is at least a _relative increase_ of
fibrin, that heart clots are more liable to form. Such a condition we
find in cases where, while the fibrin remains normal in quantity, the
water of the blood, the menstruum in which the fibrin is held in
solution, is below the normal standard, this reduction favoring the
tendency to deposit. Thus, in all cases where there has been an
exhausting and rapid flux from the bowels, as in cholera, or excessive
purging from drastic cathartics, or from the colliquative sweating of
phthisis, we have the favoring condition, and death may be the immediate
result of a fibrinous clot in the heart.
The _most_ favorable condition, however, for the formation of heart
clots, is undoubtedly that in which there is an _absolute_ increase of
fibrin, and this we find in a large number of diseases marked by acute
inflammatory symptoms; as in pleurisy, pneumonia, diphtheria, croup,
acute rheumatism, erysipelas, puerperal fever, etc. In a large number of
deaths from these diseases, a post-mortem examination would undoubtedly
bring to light a heart clot, which has at least served to hasten, if it
has not been the immediate cause of the fatal termination.
Again, the formation of heart clots is evidently promoted by any
circumstances or conditions, resulting in great feebleness or languor of
the circulation, independent of variations in the amount of fibrin. A
complete stasis of the blood is certain to be followed by coagulation;
as in employment of pressure in the treatment of aneurism; so in cases
of great prostration of the powers of life, attended with extreme
feebleness of the circulation, as 1st. In cases of shock, where life is
not immediately destroyed; 2d. In certain cases of poisoning, as by
opium, where the action of the heart is greatly depressed; and 3d. In
syncope, either with or without loss of blood. In all of these cases the
danger of the formation of the heart clot is very great, and probably in
a large number this is the immediate cause of death.
It is a fact well established, that loss of blood, either by hæmorrhages
or venesection, is followed by an increased coagulability of that fluid;
hence, the fearful hæmorrhages which sometimes attend parturition, if
accompanied with syncope, are in great danger of being followed by the
formation of the heart clot, and thus ending in death.[14]
Another circumstance tending to promote the formation of fibrinous clots
in the heart, is evidently to be found in the peculiar formation of the
valves guarding the auriculo-ventricular openings. It is well known how
fibrin may be collected from fresh blood, by beating the same with a
bundle of twigs, the latter soon becoming coated with shreds of fibrin;
so the _chordæ tendineæ_ and fleshy columns of the heart, between which
the blood is continually being driven, affords convenient points for
collecting the same from the feebly circulating or overcharged blood;
and from the close intermingling of the tendinous cords, with the
substance of the clot, it is probably upon these that the deposit first
begins to form.
In explanation of the fact that fibrinous clots are almost universally
found on the _right_ or _venous_ side of the heart, notwithstanding that
arterial blood is richer in fibrin than venous, the following has been
suggested to my mind: _First._ While venous blood contains a smaller
proportion of fibrin, may not its deoxydized condition favor the more
ready deposit of this substance, than by the more highly vitalized
arterial blood? _Second._ The feebler muscular power of the right side
of the heart would necessarily be attended with a slower circulation
through its cavities, the partial stasis of the blood giving another
condition favorable for the formation of a clot; and _Third._ The valves
of the right side of the heart, present three flaps or folds, instead of
two as on the left, and hence, with their numerous tendinous cords,
offer an increased number of obstructing points, around which the
deposit may be made. These several circumstances would seem sufficient
to account for the admitted fact.
_Symptoms._ The symptoms attending the formation of fibrinous clots in
the heart, are usually sudden in their accession, frequently attended
with a chill, and marked by great oppression in breathing, coldness of
surface, and _pallor of face and lips_, the latter symptom
distinguishing from the dyspnœa attending croup, asthma, pneumonia,
etc., where the face is _livid_ from venous congestion. The pulse is
usually rapid and feeble; the action of the heart labored, palpitating,
and sometimes intermitting, while auscultation will reveal a tumultuous
churning-like action, the normal sounds being quite undistinguishable.
Pulsation of the jugulars will be present in most cases, and where the
clot greatly obstructs the play of the tricuspid valves, a double
pulsation will be likely to be noticed. In the last stage, a copious
cold perspiration appears upon the whole surface of the body.
As might be anticipated, fibrinous formations, while of small size, are
sometimes washed away from their attachments and swept on with the
current of blood into the arteries and carried to distant parts of the
body, as is sometimes the case also in aneurism, thus producing the
embolic masses often found blocking up arteries in different parts of
the body. When upon the right side, the embolus would be carried into
the pulmonary artery, obstructing the circulation through the lungs, and
producing symptoms more or less grave, according to the size of the
clot. Upon the left side of the heart, from the greater force of the
circulation, these bodies are probably more frequently swept away from
their attachments and carried into the aorta, and thus on, perhaps,
through the carotids to the head, or into the subclavian, or down the
aorta, finally lodging in some of the branches of the lower extremities.
Convulsions, paralysis, etc., are not unfrequently produced by the
lodgment of emboli in some of the arteries of the brain, while, when
carried into the arteries of the extremities, pain, falling of
temperature, impairment of sensation, contraction of muscles, atrophy,
and even gangrene may result.
The following examples will serve to illustrate the class of cases to
which I refer:
CASE I.—_Death from Heart Clot in Anæmia._
A lad, 11 years old, and very anæmic, went to school in the morning in
his usual health; while there was taken with a chill. On his way home
vomited freely. The chill lasted for a long time, and was accompanied
with an oppression in breathing, which gradually increased through the
day and night, and until the time of my first visit at 11 o’clock A.
M. the next day. I then found him extremely pallid, lips bloodless,
perspiring freely, suffering from great restlessness and distress,
with extreme dyspnœa; mind wandering, pulse irregular and feeble;
action of the heart very tumultuous, the normal sounds being
unrecognizable. In the neck noticed a rapid rolling pulsation of the
jugulars, which presented two beats to one of the artery at the wrist.
At my second visit, made at 4 o’clock P. M., the patient had just
expired.
The autopsy, made twenty hours after death, gave the following
results: Upon opening the abdomen found the liver presenting a dark
mottled appearance, and highly congested; other abdominal organs
natural; pericardium contained about one ounce of serum. Upon opening
the right auricle of the heart, found a firm fibrinous mass, extending
downwards through the ventricular opening, and which, upon the latter
cavity being opened, was found firmly attached to the tricuspid
valves, and entangled with the fleshy columns and tendinous cords.
The presence of such a body in this position, and with such
attachments, it was evident, must have so interfered with the passage
of the blood from the auricle to the ventricle, as, upon the
contraction of the former cavity, to have caused a backward pressure
into the veins, and thus have produced the _first_ of the double
pulsations of the jugulars.
Again, the position of this clot, preventing the closure of the valves
upon the contraction of the ventricle, there would have been a
regurgitation into the auricle, and the same backward flow into the
veins, thus producing the _second_ pulsation of the jugulars seen
during life.
CASE II.—_Death from Heart Clot in Pregnancy._
A lady, 28 or 30 years old, also very anæmic, and three months
pregnant, had been suffering occasional fainting spells. For some days
before her decease she had suffered from dyspnœa, and on that day,
after ascending a flight of stairs, fell upon the floor, and before a
physician could be obtained breathed her last. A post-mortem showed
all the thoracic and abdominal viscera in a healthy condition, while
the right side of the heart contained a large fibrinous clot, with
attachments similar to those found in Case I.
CASE III.—_Death from Heart Clot in Diphtheria._
A boy, 3 years old, had an attack of diphtheria. The case presented no
unfavorable symptoms until about the fourth day, when he was taken
with great restlessness and oppression in breathing, and while sitting
on the chamber at stool, suddenly died. The autopsy here again
revealed the heart clot, as in the other cases.
CASE IV.—_Death from Heart Clot in Consumption._
A man, 30 years of age, a furrier by trade, was suffering from
tubercular disease of the lungs. He had never given up his work,
though he was much reduced in flesh, had a bad cough, diarrhœa, and
night sweats. While at his employment, he was one day taken with great
oppression, increased cough, etc., and in twenty-four hours expired.
The post-mortem showed that, while the upper portion of both lungs
contained large deposits of tubercles, there were no abscesses, and
the lower portions presented sufficient sound lung tissue to have
maintained life. Upon opening the heart the usual fibrinous clot was
found in the right ventricle, extending upwards into the auricle.
CASE V.—_Death from Heart Clot in Rheumatism._
A strong colored man, of 25 years, had an attack of inflammatory
rheumatism. The disease presented the usual characters, the
inflammation wandering from joint to joint. During the second week he
was suddenly attacked with great difficulty in breathing, violent and
irregular action of the heart, and great distress, followed by rapid
prostration and death. The post-mortem examination revealed thickened
tricuspid valves, with a firm clot of large size adhering to the same.
CASE VI.—_Death from Heart Clot in Debility._
A gentleman, 55 years old, who had been for some time in feeble
health, was taken, upon rising in the morning, with oppression and
distress in the region of the heart, dying in twelve hours. The heart
clot was found here, as in the other cases, upon the right side of the
heart.
CASE VII.—_Heart Clot in Death from Over-dose of Morphia._
A gentleman, of about 50 years, a physician, was found one morning
dead in his bed. His health had been previously good, excepting that
he was troubled with neuralgia which gave him sleepless nights, and
for which he sometimes took morphia. On the night previous to his
death he came home and retired at a late hour. An open bottle of
morphia and small spatula were found on his desk next morning, the
spatula showing evidence of having been thrust deeply into the
morphia, and probably a large and over-dose carelessly removed and
taken. The autopsy here again revealed a large and firm fibrinous
heart clot.
CASE VIII.—_Death from Heart Clot in Acute Gastritis._
A lady of about 60 years, had an attack of acute gastritis, but was
considered convalescing, and her physician (Dr. Martin) made his last
visit in the evening. The next morning she was found dead in her bed.
The post-mortem showed the spleen somewhat enlarged, and its capsule
greatly thickened.[15] Other organs healthy, while the heart contained
an unusually large fibrinous clot, which has been preserved in the
College Museum.[16]
The above include the more marked cases of death that have come under
my notice, where that result could, in my mind, be fairly attributed
to the formation of fibrinous clots in the heart.
The following inferences may, we think, be fairly deduced from the
several cases reported:
_First._ In some instances the fibrinous clots are apparently the _sole
cause_ of death. (Cases 1, 2, and 3.)
_Second._ In other, and a larger number of diseases, as in acute
rheumatism, pneumonia, croup, etc., which otherwise would recover, a
fatal termination results from the formation of heart clots. (Cases 3
and 5.)
_Third._ In still other diseases, which are of themselves necessarily
fatal, as in phthisis, cholera, etc., death is often hastened by these
formations. (Case 4.)
Section VI. THE AORTA AND ARTERIES GENERALLY.
[=Notice=: 1. _Before Opening Vessel_—size; course; condition of
external coat and surrounding tissues. 2. _After Opening
Vessel_—character of blood within; coagulated or not; size, color,
consistence, etc., of clot; size of canal; thickness of walls; rigid
or flexible. _Lining Membrane_—smoothness; transparency, etc.;
readiness of detachment; thickness, etc.; if rough, the apparent
cause; fibrinous, atheromatous or calcareous deposits. _Middle
Coat_—its thickness; color; deposits within, and their character.
_External Coat_—general condition.
ANEURISMS:—1. _External Characters_—size; shape; is the dilatation
lateral or general in its relation to the vessel? Openings as seen
externally; size, position, etc.; blood effused; quantity, etc. _After
opening, notice_—contents; blood fluid or coagulated; fibrinous
contents; laminations; their thickness; number; density; dryness;
difference between outer and inner layers. Channel for blood: size;
character of inner surface; how formed? Walls of aneurism: how formed;
by all, or one coat of artery. Size of artery above and below
aneurism.]
The diseases of the aorta, and of arteries generally, which may claim
attention in a post-mortem examination, are _inflammation_, _fatty
degeneration_, _calcification_, _aneurism_, and _rupture_.
=Inflammation.= This process may be found involving either the outer or
inner coats of arteries. In the former case the walls appear thickened
and infiltrated with a soft, jelly-like substance, which appears, at a
more advanced stage in some cases, to degenerate into a purulent
condition, while in others, great thickening of the coats, or even
obliteration results. Inflammation of the inner coat generally precedes
atheromatous or calcareous deposits, and is mostly confined to old
persons. The roughened inner surface thus produced, may serve to collect
fibrinous shreds from the blood, and thus be the occasion of the
formation of emboli.
Inflammation of arteries may result from injuries, from the presence of
emboli, or may be spontaneous in its origin. While the more frequent
seat of the disease is in the aorta, it may occur in any other artery.
=Fatty Degeneration=, or atheromatous disease of arteries, is an
important affection of those vessels, and is usually associated with
aneurism. It is seen more frequently in the arch of the aorta, and
consists in the presence of fine white streaks, situated in the
substance of the lining membrane. The disease may be found in children
as young as from three to seven years of age, but is more common with
adults. As the disease advances, the middle coat becomes involved. The
streaks gradually change into large, white, opaque patches. The middle
coat becomes thinned, loses its elasticity, assumes a gray,
semi-transparent appearance, and, at a later stage, becomes soft and
cheesy, and sometimes even undergoes a form of liquification into a
creamy fluid resembling pus, but dependent upon the abundant formation
of fat globules, with scales of cholesterine and granular matter.
While these destructive changes are going on in the inner and middle
coats, and tending to their rupture, by a conservative process, the
outer coat, upon which the strength of the vessel mainly depends,
becomes thickened and strengthened by the accumulation of plastic
matter.
=Ossification.= Ossification of the aorta, like that of the coronary and
other arteries, consists rather in a process of _calcification_. The
deposits are largely confined to the arch, and consist mainly of patches
of calcareous matter of various sizes. We seldom find the whole
circumference of the vessel involved, as in the case of smaller
arteries. The aortic valves will generally be found more or less loaded
with the same deposits.[17]
=Aneurism.= This disease is said to occur more frequently in the aorta,
than in any other artery. It may be developed in any portion of this
vessel or its principal branches, but is more commonly found in the
arch. The walls of the vessel being weakened by fatty degeneration, they
become less and less able to resist the pressure of the contained blood,
and gradually yielding to the systolic force of the heart, become more
and more distended, until the complete aneurismal sac is formed.
Aneurism may be either _true_, in which there is a dilatation of all the
coats of the vessel, or _false_, where there is rupture of the inner,
and perhaps also of the middle, and dilatation of the outer coat alone.
The latter form, when developed upon the aorta, may become very large,
and by pressure, cause absorption of the sternum, costal cartilages and
ribs, and even of the clavicle.
In some cases, the inner and middle coat having ruptured, the blood
instead of being confined in a sac formed by the outer coat, becomes
diffused between the middle and outer, or between the layers of the
middle coat, thus constituting what is known as _dissecting_ aneurism.
In these cases, the blood may extend the whole length of the aorta, and
even upwards upon the carotids to their bifurcation.
In an examination of an aneurismal sac, the _true_ aneurism will be
recognized by the walls presenting all the coats of the artery, and
generally by the indication of the presence of atheromatous and
calcareous deposits, which are confined to the inner and middle coats.
In these cases also, the communication between the sac and the aorta is
large and free. If the aneurism be _false_, however, there will be an
absence of those deposits, the opening into the artery will be
comparatively small, and the inner and middle coats will terminate
abruptly at its margin.
The interior of aneurismal sacs will usually be found containing a
quantity of fibrine deposited from the blood, and arranged in concentric
layers. In color, these fibrinous layers are of a light buff, the outer
layers being dry and firm, while the inner ones are softer and more
moist, and the central portion, at the same time, filled with a dark
mass of coagulated blood. A spontaneous cure will sometimes be effected
by a complete blocking up of the sac with fibrinous deposits, thus
preventing further dilatation or danger of rupture.
The following case, which has been before reported,[18] shows a
combination of both true and false aneurism, with spontaneous cure of
the latter:
CASE.—_Spontaneous cure of aneurism of ascending portion of arch of
aorta, with death from bursting of aneurism of descending portion into
the œsophagus._
Mr. H——, of this city, aged sixty years, while walking in his yard one
day after a hearty dinner, was taken with a sudden sensation of
faintness and nausea, which was soon followed by vomiting the contents
of his stomach, with a considerable quantity of blood. After entering
his house, the vomiting was frequently repeated, and at each effort
large quantities of pale blood ejected. Sinking rapidly, in an hour he
was dead.
Twenty-four hours after, I made a post-mortem examination. Upon
exposing the chest, found at the right border of the sternum, just
below the clavicle, a hard, inelastic tumor beneath the skin, of the
size of a small orange. While not adherent to the integument, it
appeared firmly attached to the walls of the chest beneath. Upon
turning aside the integument and pectoral muscles, the tumor was found
connected by a long pedicle to parts within the chest; absorption of
considerable portions of the sternal ends of the first and second
ribs, with the side of the sternum, having resulted from pressure of
the tumor upon those parts, and finally permitting its appearance
beneath the skin.
The removal of the sternum at once demonstrated the aneurismal
character of the tumor by showing its connection with the ascending
portion of the arch of the aorta, while a section of the same,
exhibited the interior filled with dense concentric layers of
fibrinous matter, separable from one another, the outer layers being
dry and hard, while the inner portion was less firm and moist. This
aneurism was plainly of the _false_ variety. The neck of the tumor was
not much larger than the thumb, and of sufficient length to reach from
the arch of the aorta to the dilated sac beneath the skin, outside the
chest.
A further examination of the aorta brought to light a second and
_true_ aneurism of the descending portion of the arch, the dilatation
involving all the coats of the vessels, and which, having _burst into
the œsophagus_, explained at once the cause of the hæmorrhage and
sudden death.
Upon inquiring of the family, I learned that the tumor upon the chest
had been known to have existed for fifteen or twenty years; that for
some years the pulsations of the tumor were strong, but that for many
years all beating had ceased; that he had never discontinued his work,
that of a carpenter, and in fact, it had given him so little trouble
that he had never consulted a physician in regard to it. For a year or
so previous to death, he had been troubled with a cough, particularly
upon exercising, but otherwise had been in good health.
A remarkable and interesting feature of this case was, the little
inconvenience experienced by the patient from so grave a malady, and
one usually attended with great suffering.
=Rupture.= Spontaneous rupture of the aorta is a very rare occurrence,
and probably never happens except the coats have first been weakened by
disease. Hence, in all of these cases, there will be found atheromatous
softening, and generally thinning of the walls by dilatation. In this
condition, some violent muscular effort may result in rupture at the
most weakened point, and this will be generally at that portion of the
aorta within the pericardium, the external coat being weaker here than
at any other point.
Where the dilatation of the diseased and weakened vessel has resulted in
the formation of an aneurism, rupture of this will be the more frequent
termination. This may take place into the œsophagus, as in the case
reported, or into the trachea, the pericardium, either pleural cavity,
or upon the surface of the body.
Rupture of the coronary arteries, of the arteries of the brain, various
branches of the abdominal aorta, and arteries of the extremities, have
occasionally been found, when softened by fatty degeneration or
atheromatous disease.
Section VII. THE PLEURA.
[=Notice=: _Condition of membrane_—inflamed; extent and position of;
thickened; transparent or opaque; rough or smooth. _Contents_—blood,
gas, serum, pus, amount and probable source of. _Adhesions_—general or
local; firmness of, etc.]
Like other serous membranes, the pleura is liable to _inflammation_,
both acute and chronic, with their results—_plastic_, _serous_, or
_purulent effusions_, _adhesions_, etc.
=Inflammation.= The first change which is observed in inflammation of
the pleura (pleurisy) is a loss of the shining, transparent appearance
of that membrane, it becoming dull and opaque. Red injected vessels, in
minute ramifications, sometimes radiating from single points, in others
more uniformly diffused, will be noticed. Often the surface will present
a red mottled appearance, with here and there small points of
extravasation. This condition having existed for from six to twenty-four
hours, certain results follow—at least in the acute form—which give rise
to what is known as
=Plastic Effusion.= Soon after the inflammatory process is fully
established, there will appear upon the surface a small quantity of
clear fluid, which, as it increases in quantity, undergoes coagulation,
and thus gradually covers the surface with a jelly-like layer of
variable thickness and honey-comb surface. A thin fluid of a straw
color, will be found oozing from the surface, which is increased as the
coagulated membrane is cut or torn. This condition may be extended over
the whole surface of both the costal and pulmonary pleura, or may be
confined to a limited portion.
=Adhesions.= The two layers of the pleura being in immediate contact,
the consequence of this effusion of coagulated lymph will be an early
adhesion of the applied surfaces. This is accomplished by a blending of
the layers of coagulated matter in contact, and a gradual organization
of the same by an extension of blood-vessels from the pleura into the
new formation. At the same time that these changes are progressing, the
watery part of the exudation trickles down to the most dependent portion
of the cavity, and there forms a serous or sero-purulent accumulation.
Adhesions are more frequent at the upper portion of the lungs, but may
be found at any point, as between the inner surface and the mediastinum,
or the lower surface and diaphragm; or, from repeated attacks of
pleuritis, involving different portions of the serous membrane, the
whole of the exterior of the lung may become united to the adjoining
surfaces.
The strength of the adhesions will be somewhat in proportion to their
age, those of long standing requiring considerable force to break them
up, and in many instances the lung tissues becoming lacerated before the
attachments can be torn away.
Unusual thickness of the pleura is often found at points where no
adhesions exist, this being unquestionably the result of the effusion of
plastic matter into the subserous tissue during an attack of
inflammation.
=Serous Effusion.= While in the majority of cases of pleuritic
inflammation, we shall find _plastic effusions_ followed by adhesions of
the inflamed with the adjoining surface, in some instances a serous or
watery fluid is rapidly poured out, and, accumulating in the pleural
sac, constitutes _hydrothorax_ or dropsy of the chest. The fluid in
these cases may present a variety of shades of color, from a pinkish or
light straw color, to a dark brownish shade. It may be transparent or
opaque, and generally will be more or less albuminous. The quantity may
vary from a few ounces to three, four, or five pints, or more. When in
large quantity, the lung will be found more or less collapsed, shrunken,
and pressed against the posterior walls of the chest and spinal column.
In the general dropsy attending diseases of the heart, kidneys or liver,
effusions may take place into the pleural cavities, to such an extent as
to give rise to great dyspnœa from compression of the lungs.
=Sero-Purulent or Puriform Effusions=, consist in the presence of a
quantity of granular particles with albuminous matter, which subside to
the bottom of the vessel when drawn off, and always contains floating
flakes of lymph. It may be found in cases of both acute and chronic
pleurisy, and, like serous effusions, may be found in large quantity.
=Purulent Fluid=, as found in the cavity of the chest, consists of a
white or cream-colored, opaque, and homogeneous fluid, combined with
more or less albuminous matter, in the form of shreds and flakes, yet
destitute of the granular matter of the sero-purulent fluids, and not
separating into a fluid and solid portion when at rest, as is the case
with the latter.
It is a fact well established, that genuine purulent matter may be
formed in the pleural cavity, as well as in other serous cavities,
without ulceration of any portion of the surface, or discharge of an
abscess into the same, it being the result of a more advanced stage of
the process which gives rise to the serous or plastic effusions. It may
be secreted directly from the capillaries of the inflamed surface, or,
in some instances, it would appear to be derived from the organized
false membranes, which have taken on a suppurative action.
=Pneumothorax.= Air may enter the pleural cavity, by perforation of the
walls of the chest from external injury, or, as is more common, by the
destruction of the pulmonary portion of the membrane, from the bursting
of a distended air-cell, or from softening of tubercular deposits, or
bursting of an abscess. If there are but few or no adhesions, the
accumulation of air in the cavity may be accompanied by a more or less
complete collapse of the lung, as in hydrothorax. This condition, during
life, is not readily distinguished from emphysema, both being
accompanied with similar oppression in breathing, distension of the
chest, and displacements of the heart, and with increased clearness on
percussion. Serous or sero-purulent effusions will frequently accompany
the presence of air in the cavity, and thus give rise to many of the
peculiar physical signs which may have been noticed during life, as
metallic tinkling, a splashing sound on shaking the chest, etc.
Section VIII. THE LUNGS AND BRONCHIAL TUBES.
[=Notice=: 1. While _in situ_—degree of collapse; adhesions; position
and character of; wounds, etc. 2. _After removal_—external character;
color; peculiarity of shape; adhesion of lobes; puckerings at apex;
solid or compressible; crepitation; where most noticeable; effect of
inflation on color and size. _Tubercular deposits_—size; location. 3.
_Substance of lung_—solid or porous when cut; extent of solidified
portions; fluids escaping; character and quantity of.
_Abscesses_—position; number; size; character of contents; color;
odor, etc.; condition of lung around cavities; character of walls;
thick or thin; smooth or rough; crossed by bands; communication with
bronchial tubes. _Gangrene_—location and extent of. _Bronchial
tubes_—contents; contraction or dilatation; measurements at, above and
below these points; condition of mucous membrane; congested or
ulcerated; walls of tubes; thicker or thinner than natural.
_Extravasation of blood_—(apoplexy of lung;) portion and extent of
lung involved; condition of surrounding tissue; blood infiltrated or
encysted. _Adventitious deposits—cretaceous bodies_; situation; size;
density; condition of surrounding tissues. _Tubercles_—seat; size;
number; color; density, etc.; condition of surrounding tissue.
_Cancerous masses_—size; location, etc. _Carbonaceous deposits_—around
bronchial tubes; beneath pleura. _Result of placing entire lungs in
water_—do they sink or float? If they sink, is it rapidly or slowly?
If they float, is it above, below, or at the surface of the water?
Results with portions of each lung.]
The pathological conditions of the lungs, may be arranged as
follows:—_Inflammation_ and its results, _hepatization_, _suppuration_,
_abscess_, _gangrene_, _hæmorrhage_, _pulmonary apoplexy_, _emphysema_,
_tubercular disease_, _morbid growths_, and _parasitical animals_.
When in a healthy condition, the lungs will present the following
appearance:—Upon opening the chest, there will be a more or less
complete collapse of both organs, partly from atmospheric pressure, and
partly from the elasticity of the lung tissue. They will then have a
shrunken, shrivelled appearance, crepitating under pressure, and have an
ashen gray color. If inflated, the surface becomes smooth and shining,
showing an indistinct outline of the lobules, which, with the dark
pigmentary matter seen here and there, gives the surface more or less of
a mottled appearance.
Where pleurisy had previously existed, there may be adhesions preventing
the collapse of the lungs, until these have been broken up. When cut
into, healthy lung tissue has a soft, spongy character, the upper
portions will be quite destitute of blood, while the posterior portions
may be more or less filled with that fluid from gravitation, giving them
a dark congested appearance.
Inflammation and its Results.
=Pneumonia=, or inflammation of the lungs, may affect both the air
cells, when the latter become filled with fibrinous exudations, and the
connective areolar tissue, which then become increased in quantity.
The following characters present themselves, corresponding to the three
recognized stages of the disease:—First, _congestion_; second, _red
hepatization_; third, _gray hepatization or softening_.
=Congestion.= From the peculiar structure of the lungs, in connection
with the free circulation through the same, these organs are peculiarly
liable to the several forms of congestion. In many cases of death,
without any original disease of the lungs, there will be a tendency for
these organs to become loaded with blood, giving rise to post-mortem
appearances, often with difficulty distinguished from those of a
pathological origin. In this post-mortem, or, as it has been called
_hypostatic_ congestion, the posterior and inferior portions of the
lungs are chiefly affected, as the blood after death, obeying the law of
gravitation, sinks to the lowest point. The congested portion presents a
dark red color, and though firmer than other portions, crepitates under
the finger and floats in water, the latter circumstance serving to
distinguish this form of congestion from that of an inflammatory origin.
If the congestion be confined to one lung, or to the anterior parts of
either, we may safely attribute it to a pathological cause.
In all cases of congestion, upon opening the chest, although there may
be no adhesions, the lung does not collapse, or does so feebly. When
cut, it is found to be loaded with blood, and upon pressure, much bloody
serum escapes, while the divided bronchial tubes will be found filled
with frothy mucus.
=Red Hepatization.= This condition of the lungs soon follows that of
congestion. The change is a gradual one, and is first marked by an
effusion of serum and coagulable lymph into the connective tissue and
air cells, thus rendering the lungs more solid, while as the change
becomes complete, the blood itself, which had during the congestive
stage been confined to the vessels, is now found extravasated into the
interstices of the tissues. The portion of the lung thus affected is not
only of a dark red or violet color, but solid, firm, does not crepitate,
sinks when thrown into water, and when cut and washed, the section shows
patches of a rough, granular aspect, totally different from that of
healthy lung tissue. The pleura in this condition may be wholly
unchanged, even though the solidification may have been of long
standing.
=Gray Hepatization=, which characterizes the third stage of pneumonia,
is known by the lung presenting a firm, semi-solid, inelastic, and more
or less incompressible character. Failing to collapse, the lung is found
more or less completely filling the chest. The pleura will generally
present evidences of inflammation in the presence of patches of lymph
and more or less points of adhesions. The upper lobe may be soft and
compressible, while the lower is solid from hepatization. When divided
with the knife, the substance is found of a gray, red, or dirty yellow
color; compact, but friable and easily broken down with the fingers,
while the smaller bronchial tubes are filled with fibrinous plugs.
Bloody purulent matter, with much turbid serous fluid, will ooze from
the cut surfaces. Pus globules will be detected in the escaping fluids
by a microscopic examination.
_Resolution_ of a hepatized lung, consists in the gradual softening of
the effused substances within the smaller bronchial tubes and air cells,
and the discharge of the same by cough and expectoration.
Inflammation of the lung usually commences in the lower lobe, and while
the disease here may extend to complete hepatization, the middle lobe
may be found merely congested, while the upper is quite healthy.
Inflammation may attack one or both lungs. In the former case it is
known as single, and in the latter as double pneumonia. From an
examination of a large number of cases, it has been ascertained that
inflammation of the right lung is more frequent than that of the left in
the proportion of about three to one, and that single pneumonia is more
common than double pneumonia in the ratio of six to one.
Pneumonia is sometimes divided into _Catarrhal_ and _Croupous_. In the
former, the exudation contains little or no fibrinous matter, while the
bronchial mucous membranes are also involved, the disease at the same
time being confined mostly to the lobules of the lungs. In the
_croupous_ form, the exudation contains a large proportion of fibrine,
and the disease usually involves the greater part of a lobe, or may
extend to the whole of one or both lungs.
Both forms of the disease may run through the three stages of
congestion, red and gray hepatization.
A peculiar form of inflammation of the lungs, found mostly in children
and young persons, and usually chronic in character, has been described
as
_Lobular Pneumonia._ The inflammation here being confined to the
lobules, these, after the disease is perfectly developed, present the
appearance of a multitude of rounded nodules, of the size of small nuts,
scattered through the substance of the lungs. The exterior of these is
reddish, firm, and vascular, while the interior is of a grayish color,
containing effused lymph, with more or less purulent matter.
This form of pneumonia being frequently associated with diseases of the
joints and bones, as well as with inflammation and ulceration of the
glands of the intestines, it has been considered as depending upon a
strumous diathesis, and as, in fact, but the early stage of tubercular
consumption. Seldom proving fatal in the early stage, or before the
disease has extended to the whole substance of the lung, and perhaps
resulted in the formation of cavities, we much less frequently meet with
this form of pneumonia in post-mortem examinations.
=Suppuration and Abscess.= Gray hepatization must be looked upon as a
form of _suppuration_ of the lungs; as the purulent-looking fluid found
infiltrating the tissues, filling the air cells and smaller bronchial
tubes, upon a microscopic examination, is found containing undoubted pus
globules. This, however, is not an abscess, the matter not being
confined within a cavity, but diffused through the tissues of the part.
That a distinct abscess of the lungs may form, as a result of pneumonia,
is generally admitted, though they are usually small and confined to the
lower lobes. From softening of tubercular masses, abscesses not
unfrequently form in any portion of the lungs. That they do not occur
more frequently in pneumonia, may result from the fact that the disease
often proves fatal by suffocation, before there has been time for it to
have reached the suppurative stage.
The pleura over the seat of the abscess will generally be found much
thickened, and frequently adherent to the opposite walls of the chest.
Pulmonary abscess may be wholly discharged by expectoration—the cavity
communicating with the bronchial tubes—or it may discharge into the
pleural cavity, or when adhesions have first formed, it may work its way
between the ribs, and the matter escape upon the surface of the body.
=Metastatic or Secondary Abscess.= This form of abscess in the lungs, is
well understood to be the result of suppuration in some distant part or
organ, which, being attended with phlebitis of the part, purulent matter
is introduced into the circulation, and thus conveyed to the lungs or
perhaps the liver. This original suppuration may be at the uterus after
delivery, or from a fistulo in ano, psoas abscess, or any other similar
affection.
From the fact, probably, that the whole volume of the blood flows
through the lungs, at each round of the circulation, these organs are
more frequently affected with this form of abscess than any other, it
occurring next in frequency in the liver. These abscesses may be
recognized as spots of yellow pus, varying in size from a pin’s head to
a walnut, generally situated near the surface of the organ and
surrounded by a dark, well defined layer of congested tissue, while
beyond this, the structure is in a healthy condition. Several of such
abscesses may be found in various parts of the lungs.
=Gangrene.= Gangrene of the lungs, rarely results from an attack of
ordinary pneumonia, but appears more frequently to take place either as
a concomitant of pestilential fevers in general, or as an accompaniment
of certain cases of tubercular vomicæ of the lungs, or as a primary and
peculiar species of inflammatory affection of those organs.
In the first instance, a patient suffering a severe form of typhoid
fever, presents symptoms of pulmonary disorder, as hurried respiration,
livid face, cough, first dry and soon moist, with thick orange-colored
and finally dark or bloody and extremely offensive expectoration, and
fetid breath. With these symptoms are generally associated great
feebleness, delirium, with tendency to gangrene of the extremities and
prominent points of the hips, sacrum, etc.; and finally, with increased
difficulty in respiration and fetor of breath, death ensues.
In the second case, a patient suffering from clearly recognized
tubercular disease of the lungs, which has passed on to softening of
tubercular masses, and the formation of vomicæ, has an aggravation of
all his symptoms, accompanied with the expectoration of a highly
offensive dark matter, plainly resulting from a gangrenous condition of
the interior of a tubercular cavity.
In the third case, the disease comes on at first as an affection of the
lungs. The attack commences either as pulmonary inflammation, or
bronchial disease, or with spitting of blood with more or less pain in
the chest. The patient becomes rapidly worse, the cough increasing, with
reddish-brown or bloody sputa, and offensive breath. The countenance is
anxious and livid, the eye heavy, sometimes wild and glaring. The fetid
breath is not always an early symptom, but when it does appear, the
disease in general tends rapidly to a fatal termination, although
recovery sometimes takes place.[19]
The appearances after death, in cases of gangrene of the lungs, are of
two kinds, according as the disease is _diffuse_ or _circumscribed_.
“In the _first_ case, a mass of lung, two and a-half or three inches
wide, but irregular in figure and outline, is converted into a soft,
pulpy, dark, ash-colored substance, which, when it is handled or pressed
by the fingers, falls down into a loose, moist mass, emitting a fetid,
offensive odor, without trace of the usual structure of the lungs,
except a few bronchial tubes, and blood-vessels, and shreds of
filamentous tissue. This mass is generally bounded by, but it does not
terminate abruptly in, healthy lung. It is soft, dingy, and infiltrated
with a dark, ash-colored, dirty, serous liquor. Occasionally the
surrounding portion of the lung is hepatized or infiltrated with blood
or bloody serum; the bronchial tubes always contain much bloody, viscid
mucus; and sometimes the pleura is reddened, covered with lymph or
adhesions, and contains fluid in its cavity.”
The portion of the lung thus affected is usually within the lower or
middle lobe, the upper portion being rarely involved.
In the _second_, or _circumscribed_ form, a portion of the lung,
generally near the surface, presents a dark-colored, hard patch, varying
in size from a quarter, to a half-dollar piece or more, often quite
circular, and bounded all round by healthy lung. This circular hard
patch, which resembles closely an eschar produced by caustic potash, may
adhere or be easily detached. In the latter case, it generally leaves a
cup-like cavity, the surface of which is firm, granular, with the
blood-vessels and bronchial tubes closed, and with the surrounding lung
more softened, but generally presenting marks of pleurisy, pneumonia,
and bronchitis all combined, which may be looked upon as an effort of
nature to isolate and detach the diseased mass.
=Pulmonary Hæmorrhage=—_Hæmoptysis_. Discharge of blood from the lungs
by coughing, may result from a variety of causes, among which may be
mentioned: 1, mechanical shock or injury, as in falls or blows upon the
chest; 2, inflammatory action within the lungs; 3, disease of the heart;
4, disease of the arteries; 5, tubercular deposition; 6, tubercular
destruction, with ulceration of vessels.
In the first instance the expectorated blood may be copious or slight,
according to the severity of the injury. If death soon results, an
examination of the lungs will disclose one or more of the bronchial
tubes filled with blood, which has plainly arisen from a rupture of some
of the capillaries of the bronchial mucous membrane. The blood
discharged in many cases of the early stage of consumption, and in young
females after the suppression or retention of the menstrual flow, is
from the same source.
Hæmorrhage from the lungs may also take place as a result of tubercular
deposits. The presence of tubercular masses must necessarily produce
more or less pressure on the adjoining vessels, interfering with the
flow of the blood through the same, and thus inducing congestion, and
even rupture of some of the capillary branches. Again, where tubercular
masses have progressed to softening, and a cavity has been formed, the
ulcerative process may open a large vessel, and death result in a few
minutes from excessive hæmorrhage. A post-mortem will here show the
cavity, as well as the bronchial tubes and trachea, filled with
coagulated blood.
The blood expectorated during the early stage of an attack of pneumonia,
is never copious, consisting mainly of streaks of blood through the
saliva, while at a later stage, from being more uniformly diffused, it
gives the peculiar _rusty sputa_ characteristic of this disease. The
post-mortem appearances have already been given under the head of
_pneumonia_.
Certain forms of disease of the heart, as ossification of the mitral
valves, with contraction of the orifice, or in hypertrophy of the left
ventricle, with disease of the aortic valves, are frequently attended
with hæmoptysis. In either case, the obstruction to the free circulation
through the left side of the heart, must induce an over distension of
the pulmonary veins, which, upon some unusual exertion, may readily
result in extravasation through the bronchial mucous membrane, causing
the bloody expectoration which takes place during life, or into the
pulmonary connective tissue, giving origin thus to what is known as
=Pulmonary Apoplexy=. The post-mortem appearances in these cases, are as
follows:—The portion of the lung involved, fails to collapse on opening
the chest. It is firm, and of a dark red color; and when cut into, thick
blood issues from the cut surfaces. The portion involved may include
from one to four cubic inches. It will be found circumscribed with
healthy lung tissue, and looks not unlike a clot of venous blood; these
circumstances serving to distinguish it from hepatization, which
terminates more or less gradually in sound lung.
While these hæmorrhagic effusions may, in many cases, cause early death
by their size and number, in others, the clot may soften, the lung
around become inflamed, or even gangrenous, resulting in the formation
of an irregular cavity filled with dark, offensive, semi-fluid contents.
In still other cases, where the clot is small, and in part within the
air cells, it may soften and become absorbed or coughed up, and the air
again enter the cells, or these may contract into a fibrous indurated
mass.
=Emphysema.= Emphysema of the lungs, is usually described as of two
forms—_vesicular_ and _interlobular_.
_Vesicular emphysema_, consists essentially in a dilatation or
over-distension of a greater or less number of air cells, resulting in
giving the portion involved greater buoyancy in water, from diminished
specific gravity, lessening the crepitation on pressure, preventing
collapse on the opening of the chest, and rendering the affected portion
more or less dry and bloodless. From the loss of elasticity, there will
be during life, a difficulty in the lungs emptying themselves of air as
they should, hence the patient will be subject to severe attacks of
oppression upon the slightest aggravating cause. If one lung only is
affected, the corresponding side becomes enlarged and less movable than
the other; the adjoining viscera, as the heart or abdominal organs, are
more or less displaced, the intercostal spaces swell out, and the ribs
becoming more horizontal, give a barrel-shape to the chest, which is
quite characteristic of emphysema.
This distension of the air cells, is more marked along the edges of the
lungs, the vesicles at these parts being probably the least supported.
Patches of dilated cells may be found, however, at other parts, which,
if superficial, will project beyond the surface of the surrounding
healthy portions, and appear like large bladders, from the coalescing of
several vesicles.
This form of emphysema may be induced by any cause interfering with the
ready escape of the air from any portion of the lungs, especially if
accompanied with severe cough, as in many forms of bronchial disease,
enlargement of the bronchial glands, etc.
_Interlobular Emphysema_, consists in an effusion of air into the
connective or areolar tissue of the lungs, from a rupture of air cells
or smaller bronchial tubes, or from the laceration of the lungs from a
broken rib, when the air may accumulate in the pleural cavity,
constituting pneumothorax, and may also be accompanied with emphysema of
the chest, neck and head, from an escape of the air at the point of
injury into the tissues of those parts. This form of emphysema may
involve a large part or the whole of the lung, while the vesicular form
is generally limited to definite portions. By disturbing the circulation
through the lungs, emphysema is liable to induce dilatation of the right
side of the heart.
From an evolution of gases within the lungs after death, we may have
similar appearances to that above described, requiring some care to
distinguish between the two. In the latter case, the general indications
of decomposition, with the ease with which these distended vesicles may
be emptied by pressure, will aid in determining the character of the
case.
Tubercular Disease of the Lungs.
I shall not attempt to present here the various theories that have been
promulgated as to the nature and origin of tubercle, contenting myself
by giving a description of their anatomical characters, as presented in
the several stages of tubercular disease.
_Tubercle_, or tubercular matter, may be described as consisting of a
yellowish-white substance, opaque, friable and unorganized. It may be
deposited in most of the tissues or organs of the body, but its more
common seat is the free surfaces of mucous membranes, though often found
in connection with the serous.
Tubercular deposits in the lungs, are not uniformly distributed through
all parts of those organs, being in the large majority of cases confined
to the upper and back part of the upper lobes, and in those cases where
they are more or less distributed through the whole lung, they will be
found more numerous and larger in those parts.
Tubercles may exist as fine points, not larger than a pin’s head,
(_miliary tubercle_,) or the matter may accumulate in masses of the size
of a kernel of corn, of a cherry, or of a robin’s egg. In other cases,
the pulmonic exudation in some portion of the lung attending an attack
of pneumonia, may become transformed into tubercular matter, having an
irregular outline and no distinct boundary, (_infiltrated tubercle_.)
Tubercular matter is undoubtedly, in most instances, deposited within
the air cells, so filling these, as to more or less interfere with the
admission of the air, and giving greater density to the portion of lung
involved. While the secreted matter is at first soft, or semi-fluid and
partially translucent, it gradually acquires greater density, becomes
opaque and cheesy in its character, and in all respects acting as a
foreign body within the lungs. Sooner or later, the presence of
tubercles will excite inflammation in the surrounding tissues. In this
manner these bodies may become softened and their substance
expectorated. If large numbers be aggregated together, the ulcerative
process may completely destroy the tissues between, an abscess or vomica
resulting.
In the early stage of the disease, before the inflammatory and
ulcerative processes have been set up, the presence of tubercular
matter, by interfering with the capillary circulation, may give rise to
a hæmorrhage into the bronchial tubes, constituting the hæmoptysis so
frequently present in this disease; while at a later period, from a
destruction of some of the larger vessels from ulceration, a profuse and
even fatal hæmorrhage may result.
Post-mortem Appearances.
In examining the lungs of those who have died after suffering the usual
symptoms of pulmonary consumption, we shall find the upper portion of
one or both lungs, more or less indurated, and occupied by one or more
irregular shaped cavities, containing either air, or air and a quantity
of viscid, puriform, dirty-looking fluid. Generally the apex of the
affected lung, will be found firmly attached to the inner surface of the
chest, by means of a thick, firm, false membrane, which unites the two
layers of the pleura. In some instances, nearly or quite the whole
surface of the lung will be found thus adhered, while the lobes will
also be united by an interlobular false membrane. When the adhesions are
confined to the upper portions of the lungs, the pleura covering the
lower portion will frequently be found more or less rough from
albuminous exudation, while a quantity of sero-purulent fluid will be
found in the posterior part of the thoracic cavity.
The greater part of the upper lobe, may be found converted into one
irregular cavity; more frequently, the upper lobe presents two or three,
either isolated or communicating. The largest, when several are present,
is most commonly in the upper portion of the lobe. When entirely or
partially filled with matter, such cavities are usually termed _vomicæ_
or abscesses, while when empty, they are generally called _tubercular
cavities_ or excavations.
In the lower part of the upper lobes, the cavities are few and small.
The middle lobe of the right lung, rarely presents cavities, while the
lower lobes of both lungs are entirely free. The whole of these parts,
however, may be more or less indurated by the presence of hard,
irregular shaped masses, the result, probably, of inflammatory action.
_Tubercular cavities_ present a considerable variety, both in size and
shape. They may not be larger than a pea, or bean, or may reach the size
of an egg, or even of an orange. Always of an irregular shape, they
often consist of one large cavity, communicating with two or three
smaller ones. The interior will be found traversed by bands, or cords,
passing in various directions, but generally taking a longitudinal
course, and probably the remnants of blood-vessels and bronchial tubes.
The tissues immediately around a cavity, and forming its walls, will be
found firm, inelastic, almost cartilaginous in character, and of a dark
red, or brown color. The density of the structures is caused partly by
tubercular deposits in the lung, and partly by inflammatory induration.
While tubercular disease of the lungs is almost universally fatal, there
is reason to believe that, in a very small proportion of cases recovery
has taken place, and the post-mortem appearances of the lungs have
accorded with this view. These appearances may be described as follows:
We sometimes observe in examining the lungs of individuals who may have
died from diseases of other organs, that the pleura covering the upper
lobe of the lung, presents, at a certain point, a puckered, shrivelled
appearance, with a leather-like feel, and with a rounded, firm mass
beneath. Upon dividing the latter with the knife, the interior is found
composed either of a soft substance like putty, or more frequently of a
chalky nature. This is looked upon as a cicatrized or contracted vomica,
the putty or chalk-like contents being the residuary matter of the
softened tubercle, the thinner portion having been expectorated or
removed by absorption. In some instances, these bodies are of almost a
stony hardness, grating against the knife.
In other cases, cavities lined with a smooth, semi-cartilaginous false
membrane are found, containing air only, and with dilated bronchial
tubes opening into the same, no appearance of ulceration being visible,
everything indicating that a tubercular mass had once occupied the
cavity, its softening and expectoration having been followed by a
healing of the inner surface.
Morbid Growths.
=Cancer.= Malignant disease of the lungs is by no means frequent, yet we
have abundant evidence that cancer in its several forms may be developed
in these organs. Colloid cancer, has been usually found more or less
infiltrated through the substance of the lungs, while other forms appear
in nodules or isolated tumors.
It is seldom, perhaps, that cancer exhibits itself as a primary
affection of the lungs, the disease first appearing in some other part,
and more frequently, it is said, in the bones or testicles; operation
for the removal of cancer in these parts being very liable to be
followed by an early development of the disease in the lungs or other
internal organs. On the other hand, where the cancer is connected with
any organ whose veins form a part of the portal system, as the stomach,
spleen, pancreas, intestines, etc., the disease does not so frequently
extend to the lungs, while in those cases the liver is more liable to
become affected.
The _encephaloid_ form of cancer, is that more frequently met. It may be
connected either with the bronchial glands, when the diseased mass will
be mainly confined to the mediastinum, and may consist of bodies varying
in size from that of a cherry to that of a large apple, or, the disease
may commence directly in the substance of the lungs, the tumor rapidly
increasing in size, and crowding the lungs from their normal position.
After death, the encephaloid mass may be found compressing the lungs
into a very small space. The tumor presents the usual character of this
disease, some of the lobules being soft and pulpy, or brain-like, others
of a more firm, cheese-like consistence.
=Melanosis.= Two forms of melanotic deposits are observed in the lungs:
one, _true melanosis_, and frequently associated with encephaloid
disease; the other a deposit of carbonaceous matter from coal dust,
smoke, etc., which has been inhaled during life, and distinguished as
_spurious melanosis_.
_True melanosis_ consists in a deposit of a dark pigmentary matter in
the substance of the bronchial glands, found at the bifurcation of the
trachea, and along the main bronchi. The glands are at the same time
enlarged. The coloring matter may be solid, or slightly fluid, or pasty.
At the same time the melanotic matter may be infiltrated to some extent
into the substance of the lungs, or deposited in cysts within the same.
In _spurious melanosis_, the dark carbonaceous matter is diffused more
or less through the whole lung, and may be seen distinctly through the
pleura. The bronchial mucous membrane is more or less tinged with the
same substance, and generally a quantity of black-colored fluid may be
expressed from the cut surfaces.
=Hydatids.= Acephalocysts or animal hydatids, have not unfrequently been
found in the lungs, and in several instances they have been discharged
by expectoration.
These cysts vary in size from a cherry to an egg, and consist of a
double membrane containing a limpid fluid within which other hydatids
may be found, of the same character as the parent cyst. They may excite
inflammation and suppuration in the tissues around, and thus become
discharged into the bronchial tubes, the pleural cavity, or through the
diaphragm into the abdominal cavity.
_Cystic_, _Fibrous_, _Cartilaginous_, and other forms of tumors, are
occasionally found in the lungs, and, while they are generally small,
they may acquire such size as to become a source of trouble during life.
The Bronchial Tubes.
The examination of the trachea and bronchial tubes in post-mortem
examinations, is too frequently omitted. The lungs having been removed
from the chest, they may be readily opened along their posterior aspect,
and the bronchial tubes traced into the substance of the lungs. The
pathological conditions of the bronchial tubes which may claim our
attention, are _inflammation_ in its various forms, _obliteration_, and
_dilatation_.
=Bronchitis.= Bronchial inflammation has been divided into two
varieties, according to the portion of the tubes affected. In one case
the disease may be confined to the large and medium sized tubes; it is
then known as _tubular bronchitis_. In the other, it is seated
principally in the terminal ends, where the lining membrane is more
delicate, and the tubes much smaller, and from this, extending to the
air cells, forms what has been called _vesicular bronchitis_. The latter
form is closely allied to pneumonia; in fact the two diseases pass into
each other, and in most cases probably coexist.
Ordinary, or _tubular bronchitis_, is not often a fatal disease, hence
we cannot speak accurately of its anatomical characters; yet, being
frequently associated with other forms of fatal disease, we have
opportunities of examining it under those circumstances. The lining
membrane is then found thickened, rough, of a dark red or brown color,
with more or less contraction of the calibre of the tube, and covered
with a viscid, jelly-like mucus, often streaked with blood, and in some
cases of a puriform character. This form of bronchitis may occur as a
primary disease, or it may accompany tubercular consumption; is frequent
in cases of heart disease, and may arise in the course of typhoid fever,
measles, scarlet fever, and small-pox.
_Vesicular bronchitis_, from its involving the smaller tubes and air
cells, is much more frequently fatal than the tubular form of the
disease, although in fatal cases the two forms will usually coexist. In
a post-mortem examination of these cases, we find the bronchial membrane
red and injected, pulpy and thickened. In a more advanced stage, the air
cells and smaller tubes are filled with a viscid, puriform mucus, which
prevents the air from reaching the vesicles during life, and the lungs
from collapsing upon opening the chest after death. Minute ulcers are
not uncommon upon the mucous membrane, the effect of these, being that
of changing the character of the secretion from a transparent mucoid, to
an opaque purulent form.
Bronchial inflammation, as has been stated in another place, may result
in emphysema of the lungs. In these cases, a valvular-like obstruction
is produced in some of the bronchial tubes, which, offering little
impediment to the entrance of the air, interferes with its escape, and
thus by producing increased pressure upon the air cells supplied by the
obstructed tube, a gradual dilatation or rupture ensues, resulting in
the former case in vesicular, and in the latter, in interlobular
emphysema.
Disease of the heart may also result from chronic bronchial
inflammation. Not only respiration, but the circulation may be so
impeded as to exert a direct influence upon the heart. From the
difficulty which the blood encounters in flowing through the branches of
the pulmonary artery, the main trunk of that vessel becomes permanently
dilated, while the right ventricle, from the increased force required to
overcome the obstruction in the lungs, becomes gradually dilated, and at
the same time, perhaps, hypertrophied. From the union of the two
ventricles, the excessive action of the right may induce a similar
action in the left, and thus in time result in that hypertrophy of both
ventricles, which is sometimes found in persons who have suffered from
chronic bronchitis.
=Narrowing or Obliteration of Bronchial Tubes.= In some cases, in
carefully tracing the bronchial tubes, we may find either a remarkable
narrowness of the vessel, or a complete closure of the same. In the
former cases, there is a distinct thickening of the walls of the tube,
by an effusion of lymph, or blood and lymph, into the submucous tissues;
or, from induration of the lung tissue around the smaller bronchial
tubes, from tubercular or other deposits, a similar narrowing may result
from external pressure.
Complete closure may be found in any portion of the tubes, in the large
trunks, arising from the main branches, as well as in the smaller
branches. They may be detected by passing a blunt probe into the tubes.
The branches will frequently be found continuing from the points of
closure, as a fibrous cord. The most common seat of these closures is in
the upper lobe of the lung, yet they have been found in the lower lobes.
The causes of obliteration of the bronchial tubes is not well
understood, yet, they are more frequently observed in persons who have
suffered repeated attacks of bronchitis, or of chronic pneumonia.
=Dilatation of the Bronchial Tubes.= This condition of the bronchial
tubes is more frequent in its occurrence than obliteration. It takes
place in two forms, either several tubes are uniformly dilated, like the
fingers of a glove, or a single tube may form a cavity, by undergoing a
sacular enlargement. Some mechanical obstruction, by interfering with
the free passage of air through the tubes, will usually have caused the
difficulty, as an enlarged bronchial gland, pressing one of the bronchi.
Here the free exit of the respired atmosphere being prevented, an
accumulation of air takes place behind the narrowed point. Any
impediment to the entrance or exit of the air into the lungs will
produce irregular and forcible breathing, and throw a greater strain
upon those parts especially which are in the vicinity of the obstacle.
If, at the same time, the patient suffers an attack of asthma, bronchial
catarrh, or whooping-cough, the violence of the cough materially aids in
developing the dilatation.
The degree of dilatation is greatly variable. Tubes which, in their
natural state, are not larger than a crow-quill, may, especially in the
lower and middle lobes, reach the size of the finger, while at various
points, sacular dilatations may occur, which at first sight may appear
as vomicæ, but which upon more careful inspection, prove to be dilated
portions of the bronchial tubes. The tubes in this state are usually
filled with a puriform fluid, upon the removal of which the lining
membrane is seen to be reddened and softened, or perhaps ulcerated.
This condition of the bronchial tubes may frequently be detected during
life. The voice is hoarse, like a person in croup. The cough is also
hoarse and brazen, while the breathing is difficult, and mucus rattling
is heard in the middle or lower portion of the lung.
The post-mortem appearances in cases of _foreign bodies_ in the
bronchial tubes, may be readily anticipated and easily recognized.
The Mediastinum.
_Inflammation_ may arise in the anterior mediastinum, from fracture or
caries of the sternum; and in the posterior, from injury, inflammation,
caries, or necrosis of the vertebræ. This inflammation may also result
in the formation of an
_Abscess_; or, ulceration and perforation of the œsophagus, or
inflammation of the lymphatic glands may lead to the same results. These
abscesses may reach large size, resulting in displacement of the heart,
and may rupture into the pleural cavity, the trachea or œsophagus.
_Tumors_ of various kinds, may also develop within this space, including
the several forms of _cancerous growths_. The latter will frequently
have their origin in the bronchial or lymphatic glands, or, perhaps, in
the remnant of the thymus gland.
PART III.
THE ABDOMEN AND PELVIS.
CHAPTER I.
THE OPERATION.
The cavity of the abdomen, may be opened without disturbing that of the
chest. An incision from sternum to pubes, down the central line, and
through the superficial structures, should be followed by a careful
division of the tendinous portions of the muscles and peritoneum, for a
sufficient space to admit two fingers, when, by introducing the same,
the remaining portion may be divided without risk of injury to the
intestines. A cross incision having been made at the umbilicus, the
angular flaps may be turned aside, fully exposing the abdominal
contents. Where the chest is opened at the same time, the transverse
incision will not be required. The peritoneum, with any serous or other
contents having been examined, the attention may be given to any special
organ or part that may be involved, or each may be taken up seriatim.
In many instances there will be no occasion for removing any of the
viscera, while in others, one or all of the organs may require so
careful an examination, as to necessitate an entire removal from the
body.
The _small intestines_ may be removed _en masse_, or in sections. After
applying double ligatures at the lower end of the ileum, and just below
the duodenum, the bowel may be divided between these, when, by dividing
the mesentery near its intestinal border, with either the knife or
scissors, the whole mass may be removed. By means of the _enterotome_,
they may now be rapidly laid open through their entire length, the
contents removed, and the surface cleansed if desired for more careful
inspection. Occasionally, portions only of the small intestines will
require examination. By applying double ligatures, above and below the
portion to be examined, the removal is effected without escape of the
contents into the abdominal cavity.
In the removal of the _colon_, either in sections, or as a whole, the
same care should be observed in the application of the ligatures. The
rectum having been divided, it may be lifted and rendered tense, its
attachments, with those of the ascending transverse and descending
colon, being successively divided with the knife, and thus the whole gut
removed and afterwards split open with the enterotome.
The removal of the _rectum_, for the examination of its whole length,
will usually require the removal of the other pelvic viscera, directions
for which will be given further on.
In all cases where the _stomach_ is to be examined, it will be better
first to remove it from the body. To accomplish this, both omenta should
be detached from the curves of the stomach, which may be done either
with the fingers or scissors. The hand may now be carried down to the
cardiac end of the stomach and the fingers forced around the œsophagus
without the use of the knife, and a ligature placed upon that tube. A
ligature should also be placed just below the pyloric orifice, and
another an inch below this. The knife or scissors may be used to divide
the œsophagus close to the diaphragm, and the duodenum between the two
ligatures; the stomach may then be lifted from its position without loss
of any of its contents.
If the object is merely to make a chemical analysis of the contents, the
stomach should be placed immediately in the vessel prepared for its
reception, and carefully sealed and labelled. If, on the other hand, we
may wish to examine the inner surface of the organ, it may be freely
opened along one of the curves with the scissors, the contents removed,
and the mucous surface cleansed with a stream of water, for more
satisfactory inspection. Both the contents and the stomach, may still be
preserved for chemical examination, should the circumstances of the case
seem to require it.
From the manner in which the _duodenum_ is bound down to the posterior
abdominal walls by the peritoneum, some little care will be required in
its removal. Ligatures should be applied for retaining the contents, as
directed with the stomach.
_The kidneys_, with the suprarenal capsules, may be reached by lifting
the intestines, and tearing open the peritoneum with the fingers. The
gland may then be readily lifted from its position, and the vessels
divided with the knife. To examine the interior, the gland may be split
open longitudinally along its convex border, which will give a view of
the cortical and pyramidal portions, with the interior of the sinus and
pelvis. For microscopic examination, portions should be hardened in
alcohol or solution of bichromite of potassa.
_The spleen_ may be easily removed from its position, by dragging it
from its bed, in the left hypochondriac region, and dividing its vessels
and omental attachments to the stomach.
_The pancreas_ may be brought into view, by tearing open the great
omentum just beneath the stomach, when the gland may be seen behind the
peritoneum, extending transversely across in front of the aorta. To
remove it from its position will require some care, owing to its being
bound down to the posterior walls by the peritoneum, and closely
attached to the duodenum by its right extremity or head.
_The liver_ may be generally examined _in situ_. The condition and
contents of the gall-bladder, the size, color, density, etc., of the
gland, may all be noted without removal. Where, however, we may desire
to ascertain the weight of the gland, or to examine its posterior and
upper surface, its removal will be required. Where the chest has
previously been opened, this will not be a difficult operation. In other
cases, the cartilages and ribs, forming the lower boundary of the chest,
should be strongly elevated by an assistant; the operator then, by
dragging down the liver, having first divided the suspensory ligament,
may expose the coronary and lateral ligaments, which will require care
in their division, to avoid opening through the diaphragm into the
chest. The fingers should be now freely used, to peel the gland from the
diaphragm. From the close connection of the liver to the ascending vena
cava, this vessel will require to be divided at the upper border of the
liver, close to the diaphragm, and again, after the gland has been
rolled from its bed, at its lower border, with also the portal vessels,
hepatic artery and duct, which reach the transverse fissure through the
border of the lesser omentum.
The liver may now be lifted from the body, and placed in any convenient
vessel for a more detailed inspection.
The Pelvic Viscera.
The whole _pelvic viscera_, with the external organs of generation, in
either the male or female, may be removed together, in the following
manner:—Apply a double ligature to the upper portion of the rectum, and
divide the gut between. The peritoneum may now be divided around the
border of the pelvis, in the female, at the same time, cutting across
the round and broad ligaments of the uterus, when, with the hand, the
bladder may be stripped down from the inner side of the pubes, the
rectum torn from the hollow of the sacrum, and in the same manner the
parts torn off from the sides of the pelvis, using the knife only for
dividing the more closely adhering points.
Now, after flexing the thighs upon the abdomen, an incision may be made
through the skin of the mons veneris just over the anterior commissure
of the vulva of the female, and over the penis of the male, and then
carried back upon either side of the genital organs, meeting behind the
anus, near the point of the coccyx. This incision may be carried through
the superficial tissues, down to the pubic arch, when the crura of the
penis, or clitoris, may be detached from the rami of the pubes, by
carrying the knife close to the bone. The finger may now—after a slight
use of the knife—be pushed beneath the arch of the pubis, and made to
appear in the pelvis. Taking this as a guide, the knife may be
introduced at this opening, and carried deeply along the ramus of the
ischium and pubis of either side, dividing the levator ani muscle and
pelvic fascia. The bladder may now be drawn forward beneath the arch,
this followed by the rectum, deep incisions being carried back to the
tuberosities of the ischia and point of coccyx, and thus the whole mass
removed entire.
The external parts may afterwards be so drawn together by stitches, as
to make the absence of the external organs scarcely noticeable, while a
bundle of rags crowded into the pelvis from above, will prevent the
possible escape of any of the abdominal contents.
Where the _internal organs_ only, are required to be removed; after they
have been detached upon all sides as before directed, the knife may be
carried down beneath the pubic arch, and the urethra divided, in the
male, just in advance of the prostate. Incisions may now be carried back
upon either side of the bladder and rectum, dividing the levator ani
muscle, when, by drawing upwards upon the mass, the rectum, and in the
female, the rectum and vagina, may be divided near their lower ends, and
the whole removed together.
In many cases it may be desired to remove the uterus of the female
alone. This may be done by dividing the broad and round ligaments upon
either side, when, by dragging the uterus forcibly upwards, the vagina
may be cut across about an inch below the cervix, and thus the organ
removed. In all cases, a few rags should be crowded into the pelvis for
the purpose of preventing the escape of any fluids.
In hospital cases, where parts are to be exhibited to a class, and
especially if several organs are involved in the disease, the whole
thoracic and abdominal viscera may be removed together and brought
before the class on a large tray. This may be effected in the following
manner:—A single incision may be carried from the upper end of the
sternum to the pubes, and the sternum removed in the usual manner. The
trachea and œsophagus, with the large vessels of the arch of the aorta,
may now be divided at the root of the neck. Grasping the arch of the
aorta and the trachea, the whole thoracic contents may be stripped from
the spinal column. The diaphragm being now separated from its attachment
to the ribs on either side and the spinal column, the whole abdominal
contents may, in the same manner, be dragged from above downwards, the
rectum tied and divided, and the contents of the two great cavities
removed entire and with little disturbance of the relation of parts.
In closing up the cavity after the examination is completed, the viscera
having been replaced, a sufficient quantity of wheaten bran or clean
sawdust should be thrown in to absorb any remaining fluids, thus
preventing their escape after the sewing up of the incisions.
CHAPTER II.
PATHOLOGICAL CONDITIONS.
Section I. OF THE PERITONEUM.
[=Notice= in examination:—1. _Contents of cavity_—serum; amount,
color, coagulable or not; _pus_—amount, consistence, odor, source;
_blood_—amount, source; foreign bodies; gall-stones; worms. 2.
_Condition of membrane_—color, transparency, rough or smooth, moist or
dry, thickness; _adhesions_—position and strength of. Vascularity;
ulcers; perforations; tubercles; tumors; wounds, etc.]
This membrane we find liable to _congestion_, _inflammation_,
_gangrene_, _effusions_, and _morbid growths_.
=Congestion= of the peritoneum, may result from obstructed circulation
through the liver, or ascending vena cava, or from inflammatory action;
and may terminate in serous effusions into the abdominal cavity, or
thickening of the membrane. The redness of congestion, may be
distinguished from that of inflammation, by the larger vessels appearing
more involved, and by the absence of any plastic effusions.
=Inflammation= of this membrane, (_Peritonitis_,) may be either acute or
chronic.
_Acute peritonitis_, in most instances, commences at some one or more
points, and from this gradually diffuses itself over the membrane until
it becomes general. Such point of inflammation may commence immediately
over some inflamed, or ulcerated, or perforated spot in the intestines,
or in the peritoneal covering of an inflamed uterus, liver, etc., or as
the result of external injury.
In the early stage of peritonitis, the injected vessels give the
membrane a more or less red appearance, which will be more marked in
streaks and patches. From the readiness, however, with which fibrinous
exudation takes place from this membrane, this redness is seldom very
strongly marked, and in some instances will scarcely be noticed, unless
the surface is carefully scraped, thus removing the exudation.
Small extravasations of blood are occasionally found in the substance of
the membrane. The muscular coat of the intestines, where the peritoneal
covering is involved, may become infiltrated with serum, the fibres
relaxed and paralyzed, thus permitting of the great tympanitic
distension found in these cases.
_Chronic peritonitis_, is not a very common occurrence. It may, however,
follow an attack of acute peritonitis, and is sometimes found in
connection with ascites, or tubercular deposits in the peritoneum. In
examining the body of a colored woman who had died of heart disease,
accompanied with general dropsy, and who had suffered abdominal pain and
tenderness for a number of weeks previous to death, a large portion of
the peritoneum, particularly that reflected upon the abdominal walls,
was found intensely red, the blood-vessels having an arborescent
arrangement, and being beautifully injected. No plastic matter was found
effused upon the surfaces. The cavity contained some twelve quarts of
serum.
=Fibrinous Exudation=, as already observed, readily follows inflammation
of this membrane. It will often be found as a uniform layer covering the
whole surface of the peritoneum, rendered more apparent, however, by
separating parts, when it appears as delicate bands or filaments,
stretching across the interspace. In cases of acute inflammation, this
plastic effusion is often very great, and frequently intermixed with
purulent matter, while the serous fluid, which is poured out in
considerable quantities in these cases, is rendered turbid by the
presence of numerous flakes of fibrin, and quantities of pus cells
diffused through the same. More or less extensive and firm adhesion of
parts may thus be induced, the plastic matter effused becoming more and
more firm, and finally converted into dense bands of fibrous tissue.
Mechanical obstruction and strangulation of the bowels, may be induced
by the presence of these bands, stretching between parts, and forming
thus an opening through which the bowel passes, and finally becomes
incarcerated.
=Suppuration= is not an unfrequent result of acute peritonitis; the
matter being found uniformly smeared over the whole surface, or, in some
cases, confined to a single part, thus forming a circumscribed abscess.
Adhesions having taken place around the boundaries of the suppurating
surfaces, in this manner the diffusion of the matter is prevented, and
its discharge into the intestinal canal, or in some instances upon the
surface of the body, is promoted.
=Gangrene= of the peritoneum may result from intussusception or hernial
incarceration of some portion of the bowel, when the part will appear as
a softened, dark, offensive mass, limited by a band of highly congested
tissue.
=Ascites.= Dropsical accumulations in the abdominal cavity, may result
from obstructed circulation, caused by disease of the liver, kidneys,
heart or lungs; or from pressure upon the vena cava, or portal vein, by
some abnormal growth.
The fluid effused may be nearly colorless, or present various shades of
yellow, red or green, and usually coagulates on the application of heat.
The peritoneum may appear unchanged, or it may present a thickened,
opaque, white or macerated appearance, in chronic cases.
Blood may be found in the peritoneal cavity, as a result of wounds,
rupture of some of the abdominal or pelvic organs, or bursting of an
aneurism.
=Morbid Growths.=
=Tubercular Deposits=, of the miliary form, are not unfrequent in the
peritoneum. They may be diffused over the whole membrane, as
semi-transparent, gray granules, but more frequently are found on the
under surface of the diaphragm, in the neighborhood of the spleen, and
on the viscera generally, while the parietal layer is more free. The
tubercles, acting as foreign bodies, give rise to inflammation, usually
of a chronic form, but sufficient to result in exudation of lymph, and
the formation of adhesions between the adjoining surfaces. Softening of
the tubercular deposits sometimes takes place, and perforation of the
intestinal wall results, leading to an effusion of the intestinal
contents into the peritoneal cavity.
=Cancer= of the peritoneum, is sometimes seen as a primary affection,
yet it more frequently extends to this membrane from some of the deeper
parts. The encephaloid variety may be met with, but the colloid form is
that most frequently seen. The omentum is the occasional seat of this
form of cancer, the membrane in such cases becoming enormously increased
in size.
=Tumors= of various kinds, including _fibrous_, _fatty_, and _cystic_,
may be found in the peritoneal cavity, generally having had their
origin, however, in the sub-peritoneal tissues. _Fatty_ tumors may
originate within the substance of the omentum or mesentery, while
_cystic_ tumors may be found within the broad ligaments of the uterus or
ovaries.
Section II. OF THE STOMACH.
[=Notice= in examination:—1. _External characters_—position; size;
form; adhesions. 2. _Contents_—quantity, color, odor, reaction.
_Food_—its nature, degree of digestion. _Blood_—pure or mixed with
food; probable source. _Foreign substances_—powders, metallic
particles, spirits, fœcal matter, bile, pus, worms. 3. _Mucous
membrane_—general condition of; color, soft or firm, rugæ present or
absent; thickness at various points; ulcers; their position, size,
etc. 4. _Muscular coat_—thickness; visibility of fibres. 5. _Entire
walls_—transparency; wounds; perforations; ruptures; weight. 6.
_Condition of orifices_—constricted; dilated. _Tumors_—position, size,
character, etc.]
Few organs of the body are subject to such a variety, or to such early
_post-mortem_ changes as the stomach, many of which, being closely
simulative of the effects of disease, render a satisfactory examination
of this organ, in many instances, very difficult. Therefore, before
entering upon an account of the morbid anatomy of the organ, I shall
briefly notice those changes which are _post-mortem_ in their origin.
The ordinary interval which intervenes between death and a post-mortem
examination, is, in most instances, sufficient to seriously change the
appearance even of the healthy stomach. Hence our knowledge of the
healthy appearance of that organ, at least, previous to the experiments
of Dr. Beaumont upon the stomach of Alexis St. Martin, was quite
imperfect.
=Post-Mortem Changes.=
Among those changes taking place after death, which are no evidence of
disease during life, may be mentioned:
_First._ _Appearances of Congestion._ Very soon after death, or at least
within ten or twelve hours, by gravitation of the blood, the same
_hypostatic congestion_ will be found in the most dependent portion of
the stomach, that is seen in a more marked degree in the lungs, or in
the subcutaneous tissues.
_Second._ _Coloring of Tissues._ Not unfrequently, the tissue of the
stomach will be found strongly tinged by coloring matter of food or
medicine, such as the red color of wine or logwood, or the black color
of the metallic sulphurets, etc.
_Third._ _Change of Shape and Size._ Variations in the shape and size of
the stomach from the normal standard, are not unfrequently found after
death. It is sometimes found unusually small, apparently from the
influence of the _rigor mortis_, the contraction necessarily resulting
in increased thickness of the walls. What is known as hour-glass
contraction, although sometimes congenital in its origin, is frequently
but a manifestation of the _rigor mortis_, when it may be distinguished
from the former by inflation. Extreme dilatation, with thinning of the
walls, is also sometimes seen, this condition resulting apparently from
an absence of the post-mortem contraction.
_Fourth._ _Exfoliation of Epithelium._ The stomach of young adults,
dying of some acute disease, not unfrequently is found to have thrown
off the epithelial layer of its mucous lining, even when the examination
is made soon after death, and in cold weather. In many of the healthiest
animals slaughtered for food, the same change has been noticed as early
as two hours after death. The detached cells are found floating in a
thick mucus, the microscope also showing that the gastric follicles have
thrown off their epithelial lining, with their pepsinous contents. With
this change commences the post-mortem digestion of the stomach, to be
soon noticed.
The younger and healthier the subject, and the more acute the disease
causing death, as a general rule, the more rapidly and effectively does
this exfoliation take place. It may affect only the summit of the folds
into which the mucous membrane is thrown by the contraction of the
muscular coat, or it may uniformly involve the whole mucous surface.
_Fifth._ _Softening and Perforation._ It is an interesting fact, that
while the tissues of the stomach during life are unaffected by the
gastric juice—the vitality of the tissues enabling them to resist its
solvent power—after death, they immediately yield to its influence, and
hence results a greater or less degree of softening of the coats, or
even in some instances, complete perforation of the walls, the extent of
the change depending upon the quantity of gastric fluid in the stomach
at the time of death. In these cases there is, of course, no evidence of
inflammation, while the tissues present a pulpy, gelatinous appearance,
the walls being greatly thinned, and breaking down under the slightest
force. In most instances, probably the _actual perforation_ is the
result of the force employed in lifting the stomach from its position.
The opening in these cases is an irregular ragged hole, with soft, pulpy
margins, and will more frequently be found at the large or cardiac
extremity of the organ.
In some extreme cases, the process of softening has not been confined to
the _walls_ of the stomach, but has extended to the adjoining organs, as
the spleen, liver, or diaphragm.
The whitish-gray and gelatinous appearances of these cases, will enable
us to distinguish them from ordinary cases of softening and perforation
from ulceration.
This form of softening is especially observed in cases of sudden death
immediately after a meal, while the stomach contains a large quantity of
gastric juice. It is also seen much more frequently in children and
young persons than in the aged, or those dying from chronic forms of
disease. It has often been noticed in cases of consumption, however,
which is to be accounted for upon the fact that many of these patients
retain a good appetite to the last.
Brinton, is of the opinion, that the solvent action of the gastric
fluids upon the walls of the stomach, is promoted by the presence of
vegetable or starchy food:—(1) by offering little substance upon which
the fluids can expend themselves; and (2) by producing by its
decomposition, an amount of acid, favoring an energetic action of the
gastric fluids; while on the other hand, the action of those fluids is
retarded, (1) by the presence of alkaline saliva, or bile in any
quantity; and (2) by the presence of animal food upon which the juices
may act.
CASE.—_Perforation of the Stomach in a child two years of age—death from
Hydrocephalus._
A child of Mr. T——, in its second summer, had an attack of
hydrocephalus, finally dying in convulsions. The autopsy, made
twenty-four hours after death, disclosed great congestion of the
membranes of the brain, with two ounces of serum in the ventricles.
Upon opening the abdominal cavity, all the viscera appeared healthy.
In lifting the stomach from its position, a gush of colored fluid
appeared from behind it, which at once led to the suspicion of a
rupture. The whole organ was then carefully removed, when a ragged
rent, through which the thumb could readily be passed, was discovered
at the posterior portion of the cardiac end. The walls of the stomach
at this point were extremely thin, soft and jelly-like; this condition
being plainly the result of the post-mortem action of the gastric
juice, while the rupture was the immediate consequence of lifting the
organ from its position.
Pathological States of the Stomach.
=Gastritis.= _Acute inflammation_ of the stomach rarely occurs, except
as a result of some chemical or mechanical irritation. From the
experiments of Dr. Beaumont, however, we learn that the stomach is
extremely liable to various grades of inflammatory action, which passing
rapidly through their several stages, end finally in recovery. By
watching the effects of excesses in the use of alcoholic stimulants,
food, condiments, and of exercise after meals, etc., he observed that
the pale, pink color, natural to the mucous membrane of the healthy
stomach, was exchanged for a somewhat livid erythematous redness, which
was distributed throughout the organ in irregular patches of various
sizes, and in its most intense form, amounted to a kind of ecchymosis.
Again, he noticed an excessive growth of epithelium, forming patches of
false membrane like, which at various points appeared distended by an
accumulation of a puriform fluid beneath, giving the appearance of
little pustules.
The following forms of gastritis are generally recognized:
1. _Catarrhal Gastritis._ This, in its _acute_ form, is seldom seen in
post-mortem examinations. _Chronic Catarrhal Gastritis_, however, is by
no means uncommon, and may be a result of the use of alcoholic drinks,
the presence of various irritating substances taken either as food or
medicine, and may attend many forms of chronic disease of other organs,
or may be caused by obstruction to the circulation from disease of the
heart, liver or lungs.
The post-mortem appearances are neither very marked, nor constant. The
mucous membrane may be found red, or of a dark color, thickened and
sometimes roughened. The submucous and muscular coats may also be
thickened, while less frequently, small ulcers may be found.
2. _Croupous Gastritis._ This form is very rare, and seldom
diagnosticated during life, but may be found with children who have died
with croupous inflammation of the air passages, when small patches of
false membrane may be found adhering to the mucous surfaces. It may be
found in adults also, as an attendant of certain grave forms of disease,
as typhus, puerperal fever, cholera, dysentery, or in death from
irritating poisons.
3. _Phlegmonous Gastritis_, is another very rare form of inflammation of
the stomach, in which the disease involves all the coats, although
originating in the submucous, and may destroy the patient in a few days
with symptoms of peritonitis. The submucous tissues will be found filled
with an exudation of a sero-plastic, yellowish substance, which produces
thickening of the walls, and which may be confined to a portion or
involve the whole organ.
=Effects of Poisons.= The effects of caustic and other irritant poisons
upon the stomach, as exposed by a post-mortem examination, will vary
according to the nature of the substance, and the time it may have
remained in the stomach. Redness in various degrees, and of various
shades, ulceration, softening and perforation, may one or all, be
detected in different cases.
In large quantities, the mineral acids may leave the mucous membrane
black, and of a soft, tarry consistence, readily breaking down upon
handling the stomach.
The peculiar action of the several poisons will be noticed in another
place. (See Part IV.)
=Gastric Ulcer.= Ulceration of the mucous membrane of the stomach, is
much less frequent than of other portions of the intestinal canal,
except as a result of the corrosive action of poisons.[20] A peculiar
kind of ulcer, however—rare in this country, but said to be common on
the Continent of Europe and in England—is sometimes found, which is of
interest, from its occurring in tissues otherwise healthy, and often
leading to a rapidly fatal termination. Rokitansky terms it the
_perforating gastric ulcer_, from its marked tendency to perforate the
walls of the stomach. It is situated in the region of the pylorus, and
more frequently at the posterior surface and near the lesser curve. It
is of a circular form, of three to six lines in diameter, and with as
sharp edges as if a round piece of the walls had been punched out; the
edges being bevelled off, however, from within, leaving the peritoneal
opening less than that in the muscular or mucous coats. Being usually
situated near the lesser curve of the stomach, some of the larger
blood-vessels are liable to become involved, giving rise to hæmorrhage
more or less severe. While but a single ulcer of this description is
generally found, two, three or more, may be present.
A peculiarity of this form of ulcer, consists in its not being dependent
upon irritation or inflammation, but rather upon a loss of vital
assimulative power in the part affected.
This form of ulcer may heal at any time previous to perforation, and it
is not uncommon to find a cicatrix in the mucous membrane of the stomach
which has probably arisen in that way.
Gastric ulcer is much more frequent in females than males, and is mainly
a disease of middle and advanced life.
=Hæmorrhagic Erosions.= The appearance of the stomach, where there has
been frequent vomiting of blood from this cause, is thus described by
Rokitansky: “There are several roundish spots of the size of a pin’s
head or pea, or narrow elongated streaks at which the mucous membrane
appears dark red, lax, soft and bleeding, and presenting a depression in
consequence of loss of substance or slight erosion. This condition is
invariably accompanied by hæmorrhage, the effused blood being mixed, in
a more or less altered state, with gastric mucus. The erosions are often
very numerous, studding, perhaps, every part of the stomach except the
fundus, the pylorus being their chief seat.”
This condition of the stomach is not peculiar to any form of disease, or
age, but is frequently associated with intemperance. It is rarely fatal,
except by inducing some other lesion of the stomach, or by being united
with some more general malady.
=Softening of the Stomach.= We have already referred to that form of
softening of the stomach, which is attributed to the action of the
gastric juice after death. Another form is sometimes met with, which
evidently takes place during life, and in most instances is attributable
to a chronic form of inflammation. It is not always easy to distinguish
the two forms of softening without a knowledge of the previous history
of the case. The distinction may, however, generally be made by
attending to the following points:—1. The presence during life, of
symptoms of disease of the stomach. 2. Appearances of congestion or
inflammation, as well as softening, after death. 3. Extension of the
morbid change to other portions than that affected by post-mortem
softening, the latter being usually confined to the posterior portion of
the cardiac end.
=Cirrhosis of the Stomach.= In some obscure cases of gastric disease,
upon opening the abdominal cavity in a post-mortem examination, we may
at once notice a marked change in the appearance of the stomach. It
presents a peculiar whiteness and opacity, an appearance which is
partially due to a dulness of the peritoneal coat, in marked contrast
with its usual brilliancy; at the same time the organ may be either
larger or smaller than the average size. Upon removing the organ, we
find it greatly increased in weight and density, and presenting a hard,
gristly feel, and with so much elasticity as to fail to collapse. An
incision shows the walls uniformly thickened, to the extent of six or
eight times their normal condition; the whole organ is comparatively
bloodless, a condition strongly in contrast with the usual appearance
after death.
A close inspection of such a specimen, shows the several coats—muscular,
mucous and fibrous—to be remarkably alike, the thickening and increased
density, resulting from the presence of a generally diffused imperfect
fibrous structure, similar to that found in common fibrous tumors. The
several coats of the stomach will be found unequally affected by this
deposit. The submucous structure, as seen in a vertical section, being
increased from ten to twenty fold, while the serous with the subserous
may be increased seven to ten fold. The muscular tunic may be found from
five to eight times its normal thickness, while the mucous membrane
proper, is seldom more than double.
Notwithstanding the bloodless character of the walls of the stomach in
this disease, the abnormal condition is unquestionably the result of a
chronic form of inflammation. The symptoms during life are usually
obscure, and although the hard contracted stomach may form a sort of
epigastric tumor, noticeable upon the surface, the absence of acute
symptoms, with the age at which the disease makes its appearance—usually
between twenty and thirty—permits of a ready distinction being made
between this disease and cancer, with which it might otherwise be
confounded.
=Atrophy of the Stomach.= This condition of the stomach can hardly be
looked upon as an independent malady, being rather an attendant of the
general wasting of certain diseases, particularly of pulmonary
consumption, marasmus, and starvation. The organ, in these cases, may be
reduced to less than half its normal proportions, while its walls may be
thinned and frequently softened.
=Dilatation of the Stomach=, is another condition that can scarcely be
considered as a primary affection. A great variation in the size of this
organ is evidently compatible with health, large eaters having
necessarily large stomachs, yet as the result of certain other morbid
conditions, dilatation to an enormous extent may be induced.
The following conditions may result in dilatation:
1. Obstruction of the pylorus, as in scirrhus of that portion of the
stomach.
2. Destruction of a segment of the muscular coat by ulceration, or by
becoming involved in a cancerous growth. Here the loss of contracting
power, permits of a gradual dilatation, from the inability of the
segment involved to aid in carrying on the contents, their accumulation
above this point aiding in the distension.
3. An acute form of dilatation is sometimes met with, which can only be
attributed to a paralysis of the muscular and secreting structures of
the organ. It occasionally happens to a patient recovering from a fever.
He has perhaps overindulged in eating, as is not unfrequently the case
with convalescents, and is suddenly seized with intense pain in the
stomach, followed by rapid and great distension, and finally death. The
autopsy discloses the stomach enormously distended, and its contents,
including matters, in some cases, which were ingested many days before.
The mucous membrane appears but little changed, while the muscular coat
is so thinned and stretched, as to appear like a scattered net-work of
fibres.
Morbid Growths.
=Cancer.= This formidable disease occurs more frequently in the stomach,
than in any other organ of the body, excepting the uterus of the female.
The disease is usually primary in this organ, but frequently springs up
secondarily in other parts.
The disease may occur in the three following forms—the _scirrhus_,
_medullary_, and _colloid_; while Dr. Brinton adds a fourth, the
_villous_ cancer of the mucous membrane. The usual seat of the disease
is at the pylorus. It may involve a portion or the whole circumference
of this opening, and from this extend along the lesser curve. In some
cases, it commences at the cardiac orifice, and very rarely involves the
whole organ, the fundus usually remaining free. The walls of the stomach
may become greatly thickened in this disease, the inner surface
tuberculated and roughened, and the cavity much diminished in size. When
situated at the pyloric end, the disease seldom or never extends into
the duodenum, but when at the cardiac, it generally involves the lower
portion of the œsophagus.
The _fibrous_ or _scirrhus_ form of the disease, is by far more commonly
met with than any other, although it may be found occasionally combined
with the medullary, or both these with colloid. Indeed, it is not
improbable, but that in many cases, a growth originally scirrhus,
becomes gradually converted into one of the other forms.
In almost all cases, cancer commences in the submucous tissue, in the
form of a dense mass, of a white color. When cut, the surface presents a
whitish-gray appearance, contrasting strongly with the vascular mucous
membrane of the stomach, and presenting a distinctly striated
appearance. A small portion under the microscope, or the juice scraped
from the cut surface, will show the peculiar cancer cell, with granular
matter.
_Encephaloid_ or medullary cancer, may be developed upon or within the
fibrous form, or it may occur primarily as knotty tumors projecting
through the mucous membrane. The microscopic appearance is much the same
as in the fibrous variety, except that the cells are not so closely
packed, but are loosely held together by an abundant, soft, or liquid
substance.
The _colloid_ form of the disease, may originate either in the mucous
membrane itself, or in the submucous tissue. It is known by its
presenting a tough, fibrous-looking, white tissue, which, arranged in
intersecting bands, incloses irregular spaces, which are filled with a
clear, soft, or semi-liquid material, the proper colloid substance.
The _villous cancer_, Dr. Brinton describes as arising in the basement
membrane of the mucous coat, and as but a modification of the epithelial
cancer of other parts of the body.
The mucous membrane covering cancerous growths, is subject to a variety
of changes. It may become converted into a sort of fungoid growth, which
at points suppurates, showing the submucous scirrhus tissue; or it
gradually softens, giving rise to hæmorrhages.
The cancerous mass itself, may also soften or suppurate, resulting
perhaps in perforation and peritonitis; or adhesions may take place,
followed by extension of the disease to the liver, spleen, pancreas,
kidneys, etc.
Cancer of the stomach, in the great majority of cases, occurs in persons
between fifty and sixty years, although it may appear as early as forty,
or as late as sixty. Males appear to be more subject to the disease than
females, in the proportion of four to three.
The _obstruction_ which the presence of cancer of the stomach is liable
to produce, may result in one or more of the following conditions:
First, _hypertrophy_ of the muscular coat. From increased nutrition, the
muscular fibres of the stomach may become considerably increased in size
and darker in color, thus better enabling them to overcome the
obstruction, which in some cases, amounts almost to occlusion.
Second, _dilatation_. This condition frequently attends the former, and
indeed is seldom seen alone. It is confined to those cases where the
cancer is at the pylorus, and is more noticeable at the fundus of the
organ.
Third, _contraction_. This is seldom seen in connection with
hypertrophy, and is far less common than dilatation. Generally found in
connection with cancer at the cardiac orifice, it may be looked upon as
the result of the constant regurgitation which the obstruction produces,
preventing thus the cavity of the organ from undergoing its normal
distension, by the presence of any quantity of food.
=Tumors.= With the exception of cancerous growths, tumors of the stomach
are by no means common.
_Fatty tumors_ are sometimes met with, originating in the submucous
tissues, and as they increase in size, they may crowd either inwards
towards the gastric cavity, or outwards towards the peritoneum.
_Fibroid tumors_, are also occasionally met with in the submucous
tissues, generally in the line of the lesser curve, and about the
cardiac orifice.
_Polypoid growths_ may also be found springing from the mucous surface,
presenting the character of those formations usually.
Section 2. THE INTESTINES.
[=Notice= in examination:—1. _External characters_—displacements,
as in hernia; amount and condition of involved bowel.
_Invaginations_—number, position and size; dilatations or
contraction of intestines; apparent cause of. _Peritoneal
coat_—inflamed or not; adhesions; their position, strength;
perforations, etc. 2. _Contents_—gas; mucus; blood; pus; fæcal
matter; foreign substances, etc.; particulars in regard to each.
_Entozoa_—number and character. 3. _Mucous membrane_—general
condition; congested, inflamed, ulcerated. Orifice of bile duct.
_Brunner’s glands_—inflamed, enlarged or ulcerated. _Peyer’s
patches_—number, situation, general condition, ulceration, etc. 4.
_Cæcum_ with _appendix vermiformis_—length, contents, ulcers,
perforations, etc. 5. _Rectum_—prolapsus, hæmorrhoids, fistulæ.]
=Malformations.= The intestine is sometimes defective in some part of
its course, most usually near its lower extremity, and generally
accompanied with an imperforate condition of the anus, (_atresia ani_.)
This latter may be of various degrees, consisting sometimes in a simple
closure of the anus by a continuation of the integument over it; in
other cases the rectum terminates in a blind pouch at a greater or less
distance from the anus.
Sometimes the intestine is unusually short, without any distinction as
to size between the large and small intestines.
It may terminate at the umbilicus, or in a cloaca common to it and the
genito-urinary organs.
Finally, it may consist of several detached cœcal portions.
Andral notes the following malformations:—A single straight canal from
the termination of the œsophagus to the commencement of the rectum; a
double duodenum; two colons; an unusually large, and at same time,
double appendix vermiformis.
Diverticula are not unfrequent. They are cœcal appendages, resembling
the finger of a glove, one or more in number, varying in length from a
few lines to several inches, and giving off at various points. Like the
appendix vermiformis, they may become a source of danger by affording a
lodgement for indigestible matters.
In very rare instances the position of the intestines has been found
completely transposed, with a corresponding transposition of all the
abdominal viscera, or of only one organ.
=Inflammation.= Vascular injection by itself cannot be taken as a
decisive proof of the existence of inflammation. Obstruction to the free
return of blood by the veins, during life, and the gravitation of blood
to the most dependent parts, after death, especially after fevers, can
and do produce this very marked injection. In general, however, the
smaller and more isolated the patch of injection is, the more likely it
is to be inflammatory in its origin.
_Catarrhal inflammation_ may be either acute or chronic, and may either
attack the mucous membrane uniformly, or be developed mainly in the
villi and follicles.
In the _acute_ form: “There is more or less intense redness and
injection of the mucous membrane, affecting its entire surface, or
appearing as punctiform reddening from affection of the villi, or as a
vascular halo surrounding the follicles; relaxation of the tissue, and
intumescence of the mucous membrane, equally affecting the entire
surface, or only the villi and follicles; opacity of the mucous membrane
and its epithelium, from infiltration of the former and softening of the
latter; friability and softening of the mucous membrane. The submucous
cellular tissue is injected, relaxed and infiltrated with a watery
opaque fluid; the secretion is at first copious and serous; as the
affection increases in intensity it becomes opaque, viscid and
puriform.”
In the _chronic_ form, besides the above signs, we have also a dark,
rusty, livid discoloration, sometimes pervading the entire mucous
membrane; the mucous membrane and its follicles are swollen, the tissue
has become more dense, and the surface covered with an opaque,
grayish-white, or puriform mucus. Polypoid excrescences are sometimes
found upon the mucous membrane.
Both the large and the small intestines may be affected by catarrhal
inflammation, although the chronic form seems to occur more frequently
in the large.
The muscular coat of the intestines is also sometimes the seat of
inflammation, rarely if ever, however, as a primary disease, but by
extension from the serous covering or mucous lining.
_Croupous Inflammation._ The mucous membrane is also subject to a
chronic or sub-acute form of inflammation resulting in the production of
an exudation much resembling that of croup. Sometimes it forms in a
layer of some thickness, pretty uniformly over the surface, or appearing
in the stools as tubular casts of the intestines; sometimes it is very
thin, or consists of mere shreds. The anatomical changes observed will
be similar to those just noticed.
_Perityphlitis_ is an inflammation of the loose areolar tissue around
the cœcum, occurring primarily or in consequence of typhlitis. If not
checked, it ends in the formation of abscess in the right iliac fossa,
which may discharge either into the neighboring viscera, or externally
through the abdominal walls, mostly near Poupart’s ligament.
_Peripractitis_ is an inflammation of the areolar tissue around the
rectum. The resulting abscess discharges either externally, back of the
anus, or in the perineal region, or internally into the rectum, or more
rarely into the bladder, the vagina, the uterus, or into some other part
of the intestines. Fistula in ano, frequently originates in this manner.
=Ulceration.= Ulceration may occur as the result of inflammations both
catarrhal and croupous, and whether commencing in the mucous or the
muscular layer, the ulcers may perforate the intestinal walls and give
rise to an escape of the contents; or the ulcers may cicatrize with the
formation of the usual fibroid tissue, which, by subsequent contraction,
may give rise to puckering or obstruction.
_In follicular ulceration_ of the colon, after lientery or tedious
diarrhœa, the follicles are at first tumefied, and project as smaller or
larger, round, conical nodules on the internal surface of the intestine,
surrounded by a dark red vascular halo. Ulceration takes place in their
interior; an abscess with red, spongy walls appears; the follicle is
eaten away, and an ulcer of the size of a pea or lentil is formed. The
mucous membrane is extensively destroyed, and with great rapidity. The
disease is always confined to the colon, but when it runs a very rapid
course, it may be accompanied with catarrhal inflammation of the small
intestines.
_Typhus ulcers._ In continued fevers where the disease especially
attacks the intestines, we find an ulceration of Peyer’s patches and the
solitary glands, which is called _typhus ulceration_ by Rokitansky, and
is thus described by him:—“After a preceding hyperæmia around the
solitary follicles, and in and around Peyer’s patches, there is an
enlargement of the glandular structures, followed by a softening and
breaking down of the glandular mass. The cavity remaining on the mucous
membrane after the discharge of this mass constitutes the typhus ulcer.
Its form is elliptical, if a large patch has been destroyed; round, if a
smaller patch or a solitary gland has been destroyed. Partial
destruction of a patch will produce an ulcer of irregular shape. The
size varies also, according to the amount of ulceration.”
The margin of the ulcer is invariably formed by a well defined fringe of
mucous membrane, which is a line or more wide, detached, freely movable,
of a bluish-red, and subsequently of a slaty or blackish-blue color. The
base of the ulcer is formed by a delicate layer of submucous tissue,
which covers the muscular coat. The lower third of the small intestine
is most liable to be involved in the ulcerative process, the number and
size of the ulcers increasing as they advance toward the ileo-cœcal
valve.
_Dysentery_ may also produce extensive ulceration of the colon, with
considerable loss of substance. This loss may be repaired by
cicatrization. In some cases, the cicatrix tissue, condensed into
fibrous bands, forms projections into the cavity of the intestine, and
not unfrequently encroaches upon its calibre in the shape of valvular or
annular folds, giving rise to stricture of the colon.
=Dilatation.= Disease of the nervous centres, inflammation of its serous
tissue, or simple atony of the muscular fibres, may be the cause of
inaction of the intestine and consequent distension. Stricture will also
produce distension above itself, by an accumulation of the contents of
the intestine. In these latter cases, the dilatation is often enormous.
=Contraction= of the intestines may occur throughout a considerable
extent, or in a very small part.
In the former case, it results from the canal having been for some time
empty, and is most likely to occur below a stricture. It can hardly be
considered in itself a morbid condition.
The second kind of contraction or constriction, is generally morbid, and
may result either from external pressure by tumor or otherwise, or from
a disease of the tissue itself. The cicatrices of ulcers which have
assumed an annular shape, are the most frequent causes of stricture
originating in the intestine itself.
=Displacements.= The most common of these constitute the various forms
of hernia.
1. _Inguinal Hernia._ Here the intestines escape by the inguinal canal,
and it is _Scrotal_ in man, when they descend into the scrotum, and
_Pudendal_ or _Vulvar_ in woman, when into the labia majora.
2. _Crural_ or _Femoral Hernia_; when the intestines escape by the
crural canal.
3. _Hernia at the Foramen Ovalis_; when the viscera escape through the
opening which gives passage to the obturator vessels.
4. _Ischiatic_ or _Sciatic Hernia_; when it takes place through the
sacro-sciatic notch.
5. _Umbilical Hernia_; when it occurs at or near the umbilicus.
6. _Epigastric Hernia_; occurring through the linea alba, above the
umbilicus.
7. _Hypogastric Hernia_; when it occurs through the linea alba, below
the umbilicus.
8. _Perineal Hernia_; when it occurs through the levatorani and appears
at the perineum.
9. _Vaginal Hernia_; occurring through the parietes of the vagina.
10. _Diaphragmatic Hernia_; when it passes through the diaphragm.
A more detailed description of hernia belongs to works on surgery.
A hernia, if not reducible, may, by becoming strangulated, give rise to
constipation, hiccough, vomiting, and all the signs of violent
inflammation. Gangrene supervenes, with alteration of the features,
small pulse, cold extremities, and death.
=Incarceration=, is a form of mechanical obstruction of the bowels,
differing from hernia, in there being no escape of the intestine from
the abdominal cavity, as in the latter case. It may arise in various
ways, but the most frequent form is that in which a portion of intestine
becomes constricted by means of fibrous bands which have formed as a
result of peritoneal inflammation. Passing from one portion of the
intestines to another, or from the intestines to the abdominal walls, a
loop of bowel may slip beneath or between these bands, and become so
compressed, as to interfere with the passage of the contents, and result
in great dilatation of the gut above the point of stricture. Complete
strangulation may finally result, and the patient die with symptoms of
mechanical obstruction.
Another, but less frequent form of incarceration, is where a portion of
intestine slips through the foramen of Winslow, or through a congenital
opening in the mesentery, as in the following
CASE:—_Death from Strangulation of the Bowel, from becoming Incarcerated
in an opening in the omentum_.
Mary H——, aged five years, was taken suddenly with great pain in the
bowels at 2 o’clock A. M., having retired the night before in perfect
health. Vomiting soon set in, accompanied with great thirst, and the
whole body became bathed in a profuse cold perspiration. The severe
pain continued, and the vomited matter became stercoraceous. I saw the
case at 10 o’clock A. M., and then found the child in a moribund
condition. The breathing was rapid; pulse very small and frequent;
skin pale, damp and cold; eyes sunken and nose pinched. Rapidly
sinking, she died at 12 M.
Autopsy twenty-four hours after death. Upon opening the abdominal
cavity, a large portion of the intestines was found of a dark purple
or black color, while the remainder was perfectly natural in color.
Upon lifting the bowels and exposing the mesentery, there was found an
opening in the latter, of sufficient size to receive the thumb, and
through which a large portion of the small intestines had become
crowded, producing such a twist in the border of the mesentery as to
have produced complete strangulation of the bowel, which had rapidly
passed into a gangrenous state, resulting in violent shock and death
in less than twelve hours.
The opening was situated at about one inch from the intestinal border
of the mesentery, and was plainly congenital in its origin, as
indicated by its smooth and rounded edges.[21]
Another form of obstruction is sometimes found, and known as
=Volvulus=, in which a loop of bowel, generally of the small intestines,
becomes twisted upon itself, the constriction at the base of the loop,
finally resulting in complete closure.
=Intussusception=, or invagination of the bowels, consists in the
slipping of a portion of intestine into itself, and generally from above
downwards. Either the large or small intestines may be found in this
condition, but it is much more frequent in the lower portion of the
small bowels. From a few inches to a foot or more of the bowel may thus
become slipped into itself, and it may be found at more than one point.
From the constriction which must necessarily attend such a displacement,
congestion with hæmorrhage may result, or peritoneal inflammation,
gangrene, and death, with symptoms of mechanical obstruction. In some
rare cases, the inner or invaginated portion of the bowel sloughs off,
adhesion takes place at the point of commencement of the
intussusception, and the patient recovers.
This form of displacement may be found in both children and adults,
where the appearance of the parts are such as to render it apparent that
it had not been a source of trouble during life.
=Rupture= of the intestines may result from severe injury by blows, or
from a crushing force applied to the abdominal walls.
_Penetrating wounds_ of the bowels may be followed by escape of the
intestinal contents into the peritoneal cavity, acute peritonitis, and
death. If the bowel be empty at the time, adhesions may form between the
adjoining parts, the wound thus closed, and recovery follow.
_Prolapsus_ of the rectum consists in a protrusion of the mucous
membrane or entire walls from the anus. The only post-mortem change that
may be detected is a relaxed condition of the coats of the bowel, with
congestion of the mucous membrane.
=Diseases of the Anus.= These include _ulcer and fissure_ of the _anus_,
_fistula in ano_, and _hæmorrhoids_.
_Ulcer, and fissure_ of the anus, usually accompany each other, though
either may exist alone. The ulcer, when present, is found just within
the anus, while the fissure extends from this across the edge of the
sphincter. While these affections are trifling in their post-mortem
appearance, they are of great importance from the local trouble and
constitutional irritation which they may produce during life.
_Fistula in ano_, consists in the presence of a false passage along side
the rectum, usually the result of a small abscess in the ischio-rectal
fossa. It is said to be _complete_ when it opens at one end into the
bowel, and at the other through the integument near the anus; and
_incomplete_, when it has but one opening, whether that be on the
surface or in the rectum.
_Hæmorrhoids_ will be noticed under the head of
Morbid Growths.
=Cancer=, in its various forms, may be found in connection with the
intestines, where it is usually primary in its origin. The scirrhus form
is more frequently met with in the rectum, and is likely to involve the
whole circumference of the passage. From the tendency which this form
has to contract the parts, stricture of the rectum is likely to result,
which may become a source of great suffering, and finally of death.
Other forms of cancer may be found in any portion of the intestines; the
colon and rectum, however, being their more frequent location.
Cancer of the intestines is very liable to extend to the surrounding
tissues and organs, and in many cases, perforations of the bowel, or
fistulous communications between the rectum and bladder in the male, or
uterus or vagina in the female, may result.
=Tubercles=, generally of the miliary form, may be found within the
coats of the intestines, principally confined to the peritoneal covering
however. They may occasionally be found in the mucous coat, and in the
walls of follicular ulcers of that membrane.
=Tumors= of various kinds may be found in connection with the intestine.
_Fatty tumors_ may originate within the mucous membrane, and project as
polypoid growths into the cavity of the bowel; or they may commence in
the appendices epiploicæ, and degenerate into a cystic tumor with fluid
contents, or become infiltrated with calcareous matter; or the pedicle
may become atrophied and the tumor detached, and found free in the
peritoneal cavity.
_Adenoid tumors_ may result from hypertrophy of the several forms of
glands of the intestines, and appear as soft, rounded, and perhaps
pedunculated tumors, which are liable to become ulcerated.
_Fibroid tumors_ of small size and polypoid form, may be found in any
part of the intestines, and are generally considered as a result of
chronic inflammation.
_Hæmorrhoids or piles_, consist in a dilatation of the veins of the
lower portion of the rectum, with a thickening of their walls, and
increase of surrounding fibrous tissue. They may be internal or
external. The contained blood may coagulate forming a thrombus. The
walls may rupture, giving rise to hæmorrhages, or become inflamed and
suppurate.
_Abnormal contents._ The normal contents of the bowels may be found
mixed with the various products of inflammation, including mucus, serum,
blood and pus.
Biliary calculi and foreign bodies of various kinds, may be found, which
may have produced no effects, or they may have served as nuclei, around
which the salts of lime, bile, mucus, fæcal matter, etc., may have
accumulated, producing intestinal concretions.
=Parasites.= The intestinal canal is infested by several forms of
entozoa, among which may be found the following:
_Ascaris lumbricoides_; the common round worm, six to ten inches in
length. It may be single or in large numbers.
_Oxyuris vermicularis_; a small white worm, measuring from two to four
lines in length, and found only in the large intestines, and mainly in
the lower part of the rectum, where they may be present in large
numbers.
_Trichina spiralis._ This parasite is found in the small intestine, and
only in its adult form. It measures from less than a line, to two lines
in length. The embryos penetrate the walls of the intestine, and finally
locate in the muscles, where they remain encapsulated. If a portion of
this muscle is eaten by another animal, the larvæ again become active,
and acquiring the mature sexual form, reproduce, the young embryos again
migrating to the muscles.
_Tricocephalus dispar._ Found only in the head of the colon, and
measures one and a-half to two inches in length; neck long, and body of
male covered with wart-like appendages on one side.
_Distoma lanceolatum._ Flat, lancet-shaped, and transparent, a-half inch
long, one-quarter wide. Rarely found in upper portion of small
intestines, natural habitat appearing to be in the bile passages.
Of tapeworms, the following varieties may be found:
_Tænia solium._ Head about the size of a pin-head, and furnished with
sucking disk and double row of hooks; neck long and narrow; body flat
and jointed, each segment about a-half inch in length; body may be from
ten to fifty or more feet in length.
_Tænia mediocanellata._ Head truncated and destitute of hooks; body
jointed and of great length.
_Tænia flavopuncta._ Very rare. Yellow spot at the middle of each joint.
_Bothriocephalus latus_, (broad tapeworm.) Head long, unarmed; neck
inconspicuous; body composed of about two thousand joints; mature joints
broader than long.
Section IV. THE PANCREAS.
[=Notice= in examination:—1. _External characters_—malformations;
position; size; form; adhesions. 2. _Substance_—color; consistence;
wounds; abscess; tubercular deposits; cancer; cysts. 3.
_Ducts_—calibre; contents; pus or blood, etc.]
=Anomalies= of the pancreas are not common. It is wanting only in very
imperfect monstrosities. Excess of development is very rare.
Sometimes the duct is double, up to the point of its entrance into the
duodenum.
=Hypertrophy and Atrophy.= The former, when it does occur, which is
rarely the case, affects chiefly the cellular tissue which is interwoven
with the glandular tissue.
Atrophy often occurs spontaneously in old age, or it may result from
chronic inflammation or fatty degeneration. The organ may be soft, or of
a leathery consistence.
=Inflammation.= The acute form rarely occurs, and is marked by the same
signs of inflammation as are observed in inflammation of similar organs.
“Chronic inflammation induces condensation, induration of the cellular
tissue, obliteration of the acini, and either permanent enlargement, or
subsequent atrophy of the gland.”
=Fatty Degeneration= is of frequent occurrence in drunkards, associated
with fatty liver, but due to the intrusion of the surrounding adipose
tissue on the wasting organ.
=Dilatation= of the ducts of the pancreas occurs from an obstruction of
its outlets by pressure of a tumor, or by the presence of calcareous
concretions. The dilatation may be uniform or saculated, forming cysts
which may attain a considerable size.
=Cancer=, only in the forms of scirrhus and encephaloid, affects
generally the head of the pancreas. It may occur primarily or
secondarily. The ductus choledochus is frequently obstructed by the
pressure of the tumor, and jaundice produced. The disease may extend to
the duodenum, the omentum, the mesentery, liver, and even the suprarenal
capsules and kidneys. As secondary cancer, it is most frequently an
extension from a scirrhus pylorus.
Section V. THE SPLEEN.
[=Notice= in examination: 1. _External characters_—color, size,
weight, form, adhesions; surface smooth or rough; capsule thickened,
etc. 2. _Substance_—color; consistence; wounds; rupture; abscesses;
tubercle; cancer; degenerations; tumors, etc.]
=Congenital Anomalies.= In acephalous monsters the spleen is generally
absent. Occasionally in subjects otherwise well developed, it is
wanting, together with the stomach or the fundus of the stomach.
Congenital displacements have been met with.
Supernumerary spleens, varying in number and small in size, are
frequently met with.
=Hypertrophy and Atrophy.= Probably no organ of the body is as liable to
such great variations in size as the spleen. The normal spleen in the
adult, in whom it attains its greatest size, is usually about five
inches in length, three to four in breadth, and an inch or an inch and
a-half in thickness, and weighs about seven ounces. Its size is
increased during and after digestion, and varies considerably according
to the state of nutrition of the body. In typhus the spleen is enlarged,
the parenchyma exceedingly soft, its color a dirty red, of different
shades. In leukæmia it is also found greatly enlarged, but of a denser
consistence. Rokitansky states that the spleen not unfrequently measures
sixteen inches in length, seven in breadth, and four inches in
thickness, and its weight may amount to twelve or fourteen pounds, or,
according to others, to twenty or even forty pounds. (Huschke.)
Most of the hypertrophies of the spleen are accompanied not only by an
engorgement of the very numerous vessels, but by an alteration and
increase of the red, pulpy parenchyma.
_Atrophy_ may reduce the spleen to the size of a hen’s egg or a walnut.
It takes place normally in advanced age.
=Displacements.= Some of these are congenital: thus it has been found by
the side of the bladder; in the right side of the thorax; in the left
thoracic cavity when the diaphragm was absent; and external to the
abdomen in large umbilical herniæ, or where the abdominal walls had not
closed.
Other displacements are the result of disease. The enlargement or
distension of adjacent parts, or increase in its own size with laxity of
its ligaments, causes it frequently to be displaced, and even to descend
into the pelvis.
=Rupture= occasionally happens as the result of injuries. Spontaneous
rupture in intense congestions during typhus, cholera, and the cold
stage of ague, has occurred. This always proves fatal.
=Inflammation.= _Primary_ inflammation of the spleen is comparatively
rare. Unless it ends in resolution, it gives rise to the formation of
laudable pus or fibrin, which may either be contained in a circumscribed
abscess, and thence become obsolete, or the cavity may enlarge until the
pus penetrates into the left thoracic cavity, the stomach, the
transverse colon, or the peritoneum.
_Secondary_ splenitis is regarded as identical with pyæmic deposits. The
deposits are well defined, always at the periphery, cuneiform in shape,
the apex directed inwards. Their color is darker than the surrounding
tissue, and their consistence firmer. They are either converted into a
cellulo-fibrous callus, which contracts and causes a cicatrix in the
surface; or “into a puriform, creamy mass; or into a sanious greenish,
greenish-brown, or chocolate-colored pulp.” There are also fibrinous
deposits frequently found in the parenchyma of the spleen, classed by
some among the phenomena of secondary splenitis, but regarded by others
as a simple exudation of fibrin, from an excess of this in the blood.
These deposits appear as a circumscribed yellowish mass, with a margin
of darker or lighter red congestion of increased consistence, easily
recognized when handling the part, “and showing under the microscope a
confused mass of granular with more or less oily matter infiltrated
among the remains of the parenchyma. They very commonly undergo fatty
degeneration.”
=Chronic Thickening of the Capsule= of the spleen is of frequent
occurrence. It seems to take place at the expense of the parenchyma of
the organ, and may proceed to a very great extent. It is usually pretty
uniform. Ossification of the thickened fibroid layers is rare, except in
old persons.
=Amyloid Degeneration of the Spleen.= The disease may be limited to the
Malpighian corpuscles, constituting the so-called “sago spleen,” or it
may extend and implicate the pulpy parenchyma between the corpuscles.
The sago spleen is more or less enlarged; its weight and density are
increased. On section, the surface appears smooth, dry, and studded with
glistening sago-like bodies, varying in size. An iodine solution gives
them a reddish-brown color.
In the more advanced stage, where the pulp is infiltrated with the new
material, the organ generally is much larger than in the sago spleen. It
is hard and firm; the capsule tense and transparent. The cut surface is
dry, homogeneous, translucent, bloodless, of a uniform dark,
reddish-brown color. The organ can be cut like wax. The corpuscles are
obscured by the surrounding pulp.
Morbid Growths.
_Tuberculous matter_ is commonly deposited in the spleen, only in
connection with general tuberculosis. It appears in the form of gray
granulations, miliary crude tubercles, or yellowish cheesy masses of
various sizes.
_Cysts_ have been observed in the capsule of the spleen. They are small,
of conical shape, and lightish red color, containing numerous granular
cells, floating in a transparent liquid.
_Hydatid cysts_ may be found in the spleen alone, or at the same time
with one in the liver.
_Cancer_ is rare. The encephaloid is the only form met with, and
generally only with similar disease in the liver, stomach or omentum.
Section VI. OF THE LIVER.
[=Notice=: 1. _External characters_—relation to other organs and
extent uncovered by cartilages of ribs; _adhesions_—their
extent, position, firmness, etc. 2. _After removal_—weight;
measurements; form; color; puckerings; rough or smooth;
granulations; tubercles; cysts, etc. _Capsule_—thickness,
transparency; facility of removal; appearance of liver substance
beneath. 3. _Internal structure_—appearance of cut and fractured
surfaces; fluids expressible; appearance of lobules; abscesses;
fistulæ; calcareous deposits; tubercles; growths; cysts; wounds;
rupture, etc. 4. _Gall-bladder_—absent; size; shape; adhesions.
_Cavity_—obliterated. _Contents_—bile; quantity, color,
consistence; mucus; pus, etc. _Gall-stones_—number, size, form,
color, internal character. _Walls_—thickness; deposits; adipose
or calcareous; abscess; tubercle; cancer; wounds; rupture.
_Ducts_—calibre; dilated or contracted; impervious; from what
cause? contents; condition of walls and mucous membrane.]
The liver, in its _normal state_ in the adult, will measure from ten to
twelve inches in its transverse diameter, from six to seven in breadth
at its widest part, and about three inches thick at the posterior border
of the right lobe; its weight being from three to four pounds. The gland
is much larger in infants in proportion to the size of the body. In the
adult, the average weight of the liver is but one-fortieth of that of
the entire body, while in infancy, it may be as much as one-thirtieth or
even one-twentieth.
The natural color of the liver may be described as a reddish-brown or
mahogany color, yet the _shade_ may vary to a considerable degree in
different cases.
In studying the _morbid anatomy_ of this organ, we shall notice _first_,
changes peculiar to the liver itself, and _secondly_, those connected
with the gall-bladder and gall-ducts.
1. Diseases of the Liver.
=Congestion.= From the large size and extensive distribution of vessels
through the liver, this gland is capable of containing a large amount of
blood, and in cases of retarded circulation in other parts, as in the
recession of blood from the cutaneous vessels in a chill, the vessels of
the liver may become greatly distended, constituting what is known as
_congestion_. Although the gland is closely invested with the capsule of
Glisson, yet, the elasticity of this membrane will admit of considerable
distension, and hence the great enlargement attending this condition of
the gland. Congestion of the liver may be partial, confined to one or
more lobes; or general, involving the whole gland. It may also be
_active_ or _passive_.
_Active congestion_ of the liver may result from blows or injuries over
the region of the gland, from suppression of hæmorrhoid discharges, or
suppression of the menses in the female. It will then be found
presenting a deep red color, may be greatly increased in size, is more
firm, and before opening the body, may be frequently felt below the
margin of the ribs on the right side.
One of the most frequent causes of _passive congestion_ of the liver, is
organic disease of the heart, accompanied with obstruction in the
circulation through the lungs, giving rise thus to difficulty in
emptying of the right side of the heart, and of the venous system
generally. A chronic form of congestion of the liver may result from
emphysema of the lungs, large pleuritic effusions, or tumors within the
chest, and is frequently found in persons of sedentary habits who have
been “high livers,” or in those who have used large quantities of
alcoholic or fermented liquors, or in the residents of hot climates or
malarial districts.
Temporary congestion of the liver, although very extreme, does not
result in structural change; but when arising from a permanent cause, as
disease of the heart, etc., it produces the following effects:—“The
distended capillaries of the portal-hepatic plexus press on the
intervening cells; these become in part atrophied or stunted; in extreme
cases almost destroyed; in part they are gorged with yellow matter to
such a degree that they appear as opaque masses. The quantity of yellow
matter thus formed is far greater than any that exists in a healthy
state of the organ, and as some of it is doubtless absorbed and carried
into the blood, we find in this circumstance some explanation of the
icteric hue which is so often observed in such patients. Whether
long-continued congestion produces still further changes is not yet made
out clearly.”[22]
Extreme congestion of the liver may sometimes result in
=Hæmorrhagic Effusion=, the blood being either poured out near the
surface, and dissecting up the capsule, or more deeply in the substance
of the gland; or, rupturing the capsule, it may escape into the
peritoneal cavity. Such effusions may be found in new-born children
after protracted and difficult labors, or as a result of external
violence, and sometimes attend malignant fevers, scurvy, and purpura.
=Perihepatitis.= The peritoneal covering of the liver, very frequently
in post-mortem examinations, presents appearances of having been
attacked by inflammation, in the presence of bands of adhesion
connecting different portions of the surface of the gland to adjoining
organs. The whole of the upper surface will sometimes be found closely
united in this manner, to the diaphragm. Such appearances are sure
indications of the existence at one time, of an attack of peritoneal
inflammation. In a cirrhosed condition of the gland, and over the seat
of abscesses of the liver, such adhesions almost universally form.
Inflammation of the peritoneal covering of the _under surface_ of the
liver, may result from an extension of the disease from an inflamed
stomach or duodenum, or from the presence of a biliary calculus impacted
in some of the ducts; such inflammation resulting in more or less
extensive adhesion of the parts in contact. The presence of hydatid or
cancerous masses, are not usually attended with these evidences of
inflammation.
=Scar-like Marks=, are not uncommonly found on the surface of the liver.
The peritoneum at these points seems drawn into the substance of the
gland, at the centre of the mark, while radiating ridges extend in
various directions, to the distance of a-half to three-fourths of an
inch. The cause of these appearances is evidently inflammation of the
peritoneum, extending to the subserous tissue, and perhaps to the liver
substance.
=Hepatitis.= Inflammation of the liver may be _acute_ or _chronic_.
Acute inflammation of the liver, though a frequent occurrence in hot
climates, is seldom met with in cold or temperate. The gland in this
condition, is found more or less swollen and enlarged, and the tissues
somewhat softened. This condition may be confined to one or more lobes,
or involve the whole gland. Where a section is made, the turgid swollen
tissue rises above the peritoneal covering, along the edges of the
incision. As the disease advances to a later stage, the deep red color
changes to a brownish or grayish-red, patches of these being mingled
with others of a yellowish-red or pale yellow.
Acute inflammation of the liver may terminate in resolution, when there
will be a gradual restoration to a normal condition, or in suppuration,
and the formation of an _abscess_; the latter result being much more
common.
=Abscess= of the liver may involve the greater portion of the right or
left lobe. The substance of the gland immediately around the abscess,
will appear unusually red, and perhaps a little hardened, while other
portions may present the appearance of health. In some instances, from a
complete destruction of the hepatic tissue, the peritoneal covering will
form the only protection to the contained matter. The quantity of
purulent matter contained in these abscesses may vary from half a pint
or less, to one or two quarts.
The inflammation attending the formation of an hepatic abscess, will
usually extend to the peritoneum, resulting in the formation of
adhesions to the adjoining organs, and thus preventing the abscess, in
many instances, from discharging into the peritoneal cavity, as it
otherwise would be likely to do. Abscesses thus formed, may discharge:
1st, by the adhesive process through the diaphragm into the chest, and
if adhesions had previously taken place between the diaphragm and lung,
by an extension of the ulcerative process, the matter may find its way
into the bronchial tubes, and thus be discharged by expectoration; 2d,
by a similar process into the stomach, duodenum or colon; 3d, upon the
surface of the body; and 4th, within the peritoneal cavity. In the
latter case, death is inevitable; in the others recovery is possible.
The following case illustrates discharge and recovery by the first
method:
CASE.—_Abscess of the Left Lobe of the Liver, discharging through the
diaphragm, a portion of the matter expectorated, the balance discharged
upon the surface of the body—Recovery._
In the winter of 1856–7, I was called to see Mrs. B——, aged 40, of
Broad street. She had been given up by the physicians previously in
attendance. Found her greatly emaciated, suffering from a terrible
cough, and expectorating great quantities of excessively offensive
matter. Diarrhœa, hectic fever, night sweats, with occasional chills,
completed the picture, and appeared to render the case perfectly
hopeless. Upon inquiry, learned that she had been taken ill some
months previously, with what the attending physician had pronounced as
acute hepatitis. After the usual acute symptoms, the formation of an
abscess became evident from the fulness in the region of the left
lobe, accompanied with chills, hectic, etc. A violent cough, with
evidences of inflammation in the left lung, accompanying the other
symptoms, the case was supposed to be complicated with tuberculosis.
The expectoration finally became greenish, thick and exceedingly
offensive, indicating that the abscess had worked its way into the
bronchial tubes. In examining the chest, after the case had been under
my care a few days, I noticed between the ninth and tenth ribs a
fulness and slight redness. After the application of poultices for a
few days, a distinct “pointing” appeared, from which, after the use of
the lance, came a most copious discharge of the same green, offensive
matter, as was being discharged by expectoration. From this time, a
slight improvement was noticed in the patient. The external opening
was carefully kept from closing. The cough gradually improved. Little
or none of the offensive matter was raised after the establishment of
the external opening. In six months the health was fully restored, and
now, fifteen years after, she is a stout, healthy woman.
In the progress of formation of an abscess in the liver, as branches of
the portal or hepatic veins are reached, inflammation of their coats is
excited, which results in their obliteration, thus generally preventing
the admission of pus into the venous system. But as the enlarging
abscess encroaches upon the hepatic ducts, instead of these becoming
closed by inflammation, they ulcerate through, and thus establish a
communication between these vessels and the cavity of the abscess. Hence
the pus contained in these abscesses, is very likely to be mingled with
more or less bile; while at the same time, a portion of the contents may
be discharged through the common duct into the bowels.
Abscess of the liver may result from inflammation and ulceration of the
bile ducts, from the irritation of impacted calculi, or from the
presence of intestinal worms that have entered by the ductus communis;
or from the lodgment of emboli in some branch of the portal vein or
hepatic artery.
=Secondary, Pyæmic or Metastatic Abscess.= The liver is occasionally the
seat of abscesses forming as a result of _pyæmia_, induced by absorption
of pus from some wound of a joint, vein, or bone; or from a diffused
abscess or erysipelas of the skin. These abscesses usually contain a
somewhat thin and oily-looking pus. They also differ from ordinary
abscesses in the rapidity with which they form, a few days generally
sufficing to give them a large size. The insidious manner in which they
form—the tissues breaking down, as it were, without any
inflammation—constitutes a distinguishing feature of these collections.
Pyæmic abscesses of the liver are usually many in number, and varying in
size from a pea to that of a walnut. The gland is usually enlarged at
the same time, and in some cases to such an extent as to reach quite to
the umbilicus. This form of abscess is not confined to the liver, but
may be found in the lungs, spleen, in the joints, or in the serous
cavities, and sometimes diffused through the connective tissues and
muscles of the limbs or trunk.
Degenerations of the Liver.
=Waxy, Lardaceous, or Amaloyd Liver.= In this form of disease, the liver
undergoes greater enlargement than in any other disease excepting
cancer. The enlargement is uniform in every direction, so that the form
of the gland is unchanged. Pain and tenderness are never prominent
symptoms of this disease, hence the liver may be manipulated during life
with impunity, the patient complaining only of weight and tightness in
the right hypochondrium.
The progress of the disease is usually slow, extending, in most cases,
over several years. The spleen, kidneys and intestines will frequently
be found presenting this change at the same time.
The tissue of the gland in these cases is very firm, so that the organ
generally retains its form when laid with its convex surface on the
table. The external surface is smooth and free from adhesions. When cut,
a peculiar translucent substance is found infiltrated through the
tissues, giving it a firm, glistening appearance, known as waxy,
lardaceous, amaloyd, albuminous, or sometimes scrofulous liver. This
substance is stained a deep red by the action of a weak solution of
iodine.
The change appears to commence first, in the small blood-vessels,
finally extending to the lobules, appearing first in the centre, and
ultimately involving the whole lobule.
The disease is more common in males than females, and is frequently
caused by constitutional syphilis. In some instances, it would appear to
be produced by a tubercular diathesis, and coexists with some local form
of scrofulous disease, or by a long exposure to malarial influences.
=Fatty Liver.= This form of disease we find in drunkards; in persons who
have been large eaters and sedentary in habit; in several wasting
diseases, as in chronic diarrhœa, and especially in phthisis pulmonalis.
There is a moderate degree of enlargement which affects all portions of
the gland. The consistency is softer, and the resistance less than in
waxy liver, giving it a doughy feel. The color varies, but is usually
lighter than normal, approaching a yellow, and more or less mottled.
When cut, the substance presents a decidedly oily appearance, both to
the feel and sight. The disease is unaccompanied with pain from first to
last; neither is its function materially interfered with, hence jaundice
is not usually a symptom of the disease.
A microscopic examination shows the lobules of the liver filled with fat
globules, which appear to have originated in the hepatic cells. The
change appears to commence at the circumference of the lobule, the
centre remaining normal in color, thus giving a mottled appearance to
the cut surface.
Other organs are very liable to be affected at the same time by this
form of disease, as the heart, kidneys, etc., the symptoms which the
case presents, such as albuminous urine, tendency to dropsy, dyspnœa,
etc., arising from these organs, rather than from the fatty liver.
=Pigmentary Degeneration.= In cases of malarial poisoning, we sometimes
find the liver with other organs of the body, as the spleen, lungs,
brain, kidneys, etc., presenting a peculiar dark color, the result of
the presence of a black or brown pigment in the blood, filling the
vessels of these organs. The pigment appears to be formed of small
granules either free or contained in irregular cells. In the liver, this
pigment is found most abundant in the blood of the portal vein, but may
be present in the hepatic artery, and in all the venous capillaries.
The liver may be normal in size, or it may be atrophied or
hypertrophied, or may have undergone fatty or waxy degenerations.
=Granular Degeneration.= A peculiar change in the liver substance is
sometimes found after death from various acute or infectious diseases,
as the exanthemata, pyæmia, septicæmia, erysipelas, typhus, typhoid, and
yellow fever, etc.; or from thrombosis of the portal vein, abscesses or
cirrhosis, as well as in poisoning by arsenic, phosphorus or antimony.
The change in the early stage consists in an accumulation in the liver
cells, of a fine granular substance, soluble in alkalies, and apparently
of an albuminous nature; and, at a later stage, of coarser shining
particles of a fatty character, and soluble in æther or alcohol.
=Atrophy= of the liver may be divided into the following forms:
I. Simple Atrophy.
II. Acute or Yellow Atrophy.
III. Chronic Atrophy, or Cirrhosis.
=Simple Atrophy.= By this, we understand a diminution in the size of the
liver, without any alteration in its structure. In this state, the liver
may be reduced to one-half its normal weight and bulk. It is found to
occur:
1. _Old age._ Hence this form of atrophy is sometimes called “_senile
atrophy_.” With the loss of adipose tissue in advancing years, there is
also a tendency either to _degeneration_ or _wasting_ (atrophy) of many
of the organs, and especially of the liver. In this manner, the liver
may be reduced to one-half its normal size and weight without any change
of structure.
2. _Inanition_, arising either from an insufficient supply of food, or
from diseases which interfere with the assimilation of food, may result
in simple atrophy of the liver.
3. _External pressure_ may also produce the same result, as from tight
lacing, pleuritic, pericardial, or peritoneal effusions, or from
enlargement of organs, or presence of tumors near the liver.
Simple atrophy is rarely attended with jaundice unless pressure upon the
bile ducts has been such as to obstruct the flow of that fluid.
=Acute, or Yellow Atrophy.= In this somewhat rare form of disease, the
liver becomes rapidly atrophied, accompanied with jaundice and cerebral
symptoms. After death, the organ is found greatly reduced in size,
extremely soft and yellow, with no appearance of lobules, and upon
microscopic examination, the secreting cells found more or less changed
into granular matter and oil globules. The weight of the gland in these
cases, may be reduced from three to four pounds, the average normal
weight, to less than two pounds.
This form of disease is frequently attended with hæmorrhages,
particularly of the stomach and bowels, and in some instances, from the
uterus or nose.
Pregnant females suffering from this affection usually abort.
Among the causes of this form of disease of the liver may be mentioned
pregnancy, dissipation, constitutional syphilis, malaria, and the
blood-poisoning of typhus fever.
Females appear much more liable to the disease than males, and most
persons attacked are under middle age.
=Chronic Atrophy, Cirrhosis or Hob-nail Liver.= The form of atrophy of
the liver which we now have to consider, is slow in its progress, and is
usually associated with abdominal dropsy. The appearance and density of
the gland varies to a considerable extent in different cases of chronic
atrophy, yet the usual appearance is that seen in what is known as
cirrhosis,[23] or “hob-nail liver,” also sometimes called “gin-drinker’s
liver.” Here the liver has become reduced in size, from a slow
destruction of the secreting tissue, while, at the same time, the
fibrous tissue of Glisson’s capsule has become thickened and hardened,
from a chronic inflammatory action, often due to the use of spirituous
liquors. The outer surface presents a granular or nodulated character,
which has given rise to the term “hob-nail,” as applied to this disease;
while, upon section, the interior presents firm fibrous bands,
surrounding yellow patches of secreting tissue. While, in the majority
of cases, this disease is plainly owing to an abuse of spirituous
liquors, in others, it is found associated with disease of the heart, or
with constitutional syphilis, where the patient has been strictly
temperate.
The increased density, in connection with the diminution of size, and
granulated character of the surface, renders the disease readily
recognizable in a post-mortem examination.
The early stage of this disease appears to be accompanied with a degree
of enlargement of the gland, resulting from the congestion attending the
inflammation of the fibrous structure. As this structure increases in
density, by pressure it causes a gradual absorption of the secreting
lobules, and thus results in a reduction in the size and weight of the
organ.
The secreting cells of the lobules of the liver, may undergo fatty
change, or they may become entirely destroyed. Thrombi may be found in
the portal vein. The hepatic artery and its branches become increased in
size, while the interlobular hepatic veins become quite destroyed. The
obstruction to the circulation through the liver, resulting from these
changes, gives rise to the dropsical effusions usually found in this
disease.
Prominent among the symptoms attending this disease, during life, may be
mentioned:—1st. Diminished area of hepatic dulness. 2d. Ascites,
particularly in advanced stages of the disease, although patients may
die before dropsy sets in. 3d. Enlargement of the spleen—this being
present at least in about one-half the cases. 4th. Enlargements of the
superficial veins of the abdomen, from obstructed flow of the portal
blood, or from pressure upon the vena cava, from abdominal distension.
5th. Hæmorrhoids, epistaxis, hæmatemesis, etc. 6th. The rare occurrence
of decided jaundice. 7th. In all cases, the advance of the disease is
marked by progressive emaciation and debility, the patient usually dying
of exhaustion, although in some cases death is due to an attack of
pneumonia, œdema of the lungs, or acute peritonitis.
=Hypertrophy.= We sometimes find an evident increase in the size of the
liver, without any alteration of structure, or the presence of any
prominent symptoms. Such cases may be considered as instances of _simple
hypertrophy_. This condition has been observed in cases of leukæmia, and
in some exceptional cases of saccharine diabetes, heart disease and
phthisis.
Morbid Growths.
=Cancer of the Liver.= Every variety of cancer may be found in the
liver, though the scirrhus or medullary forms are more common. The
disease is invariably accompanied with enlargement, and in some
instances the increase is enormous. The progress of the disease is
rapid, a few weeks in many instances, a few months at the longest, being
required to fully develop the disease. The enlargement is not uniform.
The surface becomes irregular and uneven, nodules of various size are
found projecting from its surface and borders, which are usually harder
than those of the surrounding portions. The disease is nearly always
accompanied with pain, and considerable tenderness is felt upon touch.
Jaundice is present in many cases, but in ninety-one cases collected by
Frerichs, fifty-two showed no symptoms of jaundice. Abdominal dropsy to
any considerable extent, rarely attends the disease, although usually a
small quantity of fluid will be found in the peritoneal cavity. These
characters will usually enable us to make a correct diagnosis of these
cases during life.
The post-mortem examination, discloses, in the majority of cases, a
greater or less number of irregular, rounded masses, projecting from the
surface of the liver, and varying in size from a kernel of corn to an
orange. Through the peritoneum, these bodies present a light,
straw-colored appearance, and when divided, the interior is found of a
whitish-gray color, and of the consistence of tallow or cheese. Examined
very carefully, the substance has the appearance of infinitely minute
granules, aggregated together.
These masses may be confined to one of the lobes, or involve the whole
organ; they are of an irregularly rounded or globular form, and in some
cases two or three appear to have coalesced into one mass.
In other, and more rare cases, the cancerous matter, instead of being
collected in masses, is found more or less infiltrated through the liver
substance, as in Case I.
They may soften, and form cysts filled with a thin serous fluid, or they
may undergo a form of fatty degeneration.
In such cases the disease is liable to be mistaken for waxy
degeneration. In both, there is a uniform hard enlargement, but in the
waxy enlargement, the progress is slow, and without pain, and there is
usually enlargement of the spleen, with albuminuria, and a syphilitic
taint; while in cancer there is no enlargement of the spleen, or
albuminuria, and the course of the disease is rapid; there is pain,
cachexia, and often signs of cancer elsewhere.
Cancer of the liver, in the majority of instances, is secondary to
cancer of some other part, as of the stomach, rectum, or female breast.
In more than one-third of the cases, it is said to be secondary to
cancer of the stomach.
Cases are rare where the liver is primarily affected with cancer. Before
thirty-five or forty years of age, secondary cancer seldom occurs.
The following cases will serve to illustrate the two forms of cancer of
the liver:
CASE I.—_Primary Cancer of the Liver, with great enlargement—Rupture of
Stomach from post-mortem softening._
Mrs. K——, aged 38, light complexion, short and fleshy, commenced
complaining about New Year’s, 1868, of pain in the “stomach,” as she
expressed it, with loss of appetite, restlessness at night,
accompanied with weakness and prostration. These symptoms continued
for a couple of weeks, when she commenced to complain of soreness in
stooping, and inability to wear her clothes tight. This led to an
inspection of the abdomen in bed. I then found projecting below the
margin of the chest on the right side, a hard rounded tumor, nearly of
the size of the fist, somewhat sensitive to the touch, and evidently
springing from the liver. The pain daily increased in severity, and
coming on as it did, in paroxysms, resembled much the pain attending
the passage of biliary calculi.
After she took to her bed, which was in the latter part of January,
there was a rapid increase in the size of the liver, with a marked
aggravation of all the symptoms. The pain was most agonizing; slight
chills occurred from day to day; the flesh rapidly wasted, and the
outline of the lower border of the liver could be distinctly traced
through the abdominal walls. There were no symptoms of jaundice. The
skin was pale and waxen in hue. In the latter part of February,
frequent epistaxis, and bleeding of the gums set in, while from the
pressure upwards upon the diaphragm, the lungs were so embarrassed as
to give rise to great dyspnœa. Rapidly sinking, she died on the first
of March.
_Autopsy_, made thirteen hours after death. Anterior portion of the
body pale; posterior dark from gravitation of the blood. Rigor mortis
scarcely noticeable. Upon opening the abdomen, found four to six
ounces of serum in the peritoneal cavity.
The liver was enormously enlarged, filling a great portion of the
abdominal cavity, pushing the diaphragm high up into the chest, and
giving the lungs less than half their normal amount of room for
expansion. The upper surface of the right lobe was found adhered to
the under surface of the diaphragm, and to the anterior abdominal
walls, and the under surface to the stomach, duodenum and transverse
colon.
The surface of the liver was dark, mottled, and somewhat nodulated.
The whole gland was quite firm, yet evidently just entering upon a
softened stage at numerous points. No trace of an abscess forming at
any point.
Upon lifting the left lobe of the liver, a dark, brownish fluid
appeared behind the stomach, the origin of which was not at first
apparent. The removal of the liver, however, completely exposing the
stomach, showed the posterior wall at the large end, _softened and
ruptured_. This softening was evidently a post-mortem action of the
gastric juice; the rupture resulting from the tension upon the same,
in tearing away the adhesions between the stomach and liver.
Upon the removal of the liver, found it to weigh eighteen pounds. The
gall-bladder was empty and contracted. The only portion of the gland
not involved in the disease, was one of the small lobes, the _lobus
Spigelii_, and a portion of the left lobe. Incisions, showed the
interior presenting a similar mottled appearance as the surface; dark,
almost black spots, intermixed with spots of brown and gray. The
blood-vessels of the liver were enlarged, and filled with dark
defibrinated blood. No trace of coagulated blood, in any of the
blood-vessels of the body.
_Microscopic examination._ An examination of a small portion taken
from the right lobe, with a power of 350 diameters, showed innumerable
cells of an irregular outline, and varying in size; oil globules, and
granular matter. The action of acetic acid, rendered the nuclei of the
cells faintly visible. Many cells of a large size were found filled
with a growth of smaller ones. All other organs of the body
normal.[24]
CASE II.—_Cancer of the Liver, secondary to Cancer of the Rectum, with
diffused Abscess in the Neck._
Mr. A——, of Doylestown, Pa., aged 60, had been suffering for some
months with symptoms of disease of the rectum, with also inflammation
of the bladder. His passages were painful, and accompanied with more
or less bloody, purulent matter. His urine was thick, at first from
presence of large quantities of mucus, later of pus. His appetite and
digestion were poor; his color pale and cachectic.
Some six months previous to death, he commenced passing with his
urine, small quantities of seeds of berries, tomatoes, etc. These
gradually increased in quantity, until, for some weeks previous to
death, there was a free discharge of feculent matter from the bladder,
and at the same time much urine passed per rectum. A few days before
death, there appeared a diffused swelling upon the front of the neck,
extending from the clavicles as high as the upper portion of the
larynx. There was no discoloration of the surface. The swelling
presented a boggy feel, without any positive fluctuation.
On the 15th of July, 1871, I was called by Dr. George Wright, who had
been treating the case for the past year, and from whom I learned the
above facts, to make a post-mortem examination, the patient having
died the day before.
Found the body very thin, surface pale. No serum in the peritoneal
cavity. Upon lifting the small intestines from the cavity of the
pelvis, found the rectum closely adhered to the posterior surface of
the bladder, completely obliterating the recto-vesical _cul-de-sac_.
Considerable dense scirrhus matter, was found upon either side of the
rectum and bladder.
Upon removing the rectum and bladder, a large opening (one inch in
diameter) was found communicating between the two. The edges of this
opening were thick and ragged. The walls of the bladder and rectum
generally, were thick and hard from scirrhus deposits. The bladder
contained considerable purulent and feculent matter, with also a
cherry-stone. Upon examining the liver, found upon the under side of
the left lobe, a large cancerous mass, imbedded in the substance, but
projecting from the surface, and quite as large as a goose egg. Other
portions of the liver healthy.[25]
The lungs were healthy. The muscular walls of the heart were pale and
soft, while each of the cavities contained soft, imperfectly formed
fibrinous clots.
The right pleural cavity contained nearly a pint of serum, while the
pleura presented a red, inflamed appearance.
In removing the sternum from its position, noticed purulent matter
beneath the upper end, which appeared to come down from the neck. Upon
carrying an incision upwards to the hyoid bone, found the whole region
of the neck infiltrated with pus, without being confined by any
limiting membrane or sac, and evidently metastatic in its origin.
=Tubercles.= The peritoneum covering the liver, like other portions of
this membrane, will sometimes (more frequently with children) be found
filled with numerous minute tubercular particles, the presence of which
are liable to give rise to appearances of inflammation, such as redness,
roughness, and perhaps adhesions.
=Fibroid and Cartilaginous Tumors= are of extreme rarity in the liver.
When present, they exhibit the characters of those growths in other
parts.
=Adenoid Tumors= have been detected in this gland. They vary in size and
number, but are usually enclosed in a fibrous capsule, and appear to be
made up of glandular cells, resembling the hepatic cells, but of larger
size and greater density.
=Vascular Tumors= are sometimes found in the liver, consisting
apparently of a compact, irregular net-work of dilated veins, held
together by connective tissues. Of a dark, almost black color, they vary
in size from a few lines to two or three inches in diameter, and are
very irregular in their outline.
_Cysts_ of small size are occasionally found, developed either in the
connective tissues, or from a dilatation of bile ducts. They may be
found filled with serum, or colored mucus and epithelial cells.
=Syphilitic Tumors=, from the size of a pin’s head to that of the fist,
may be found in the liver. They are of a gray, whitish or yellow color,
made up of cells of an irregular form, which show a tendency to cheesy
degeneration, or to such softening as to give the appearance of an
abscess.
Blood-vessels of the Liver.
_The hepatic artery_ is sometimes found with aneurismal enlargements,
and rarely contains an embolus.
_The portal vein_ is frequently found containing a fibrinous clot,
constituting thrombosis. Such clots may result from pressure on the vein
from the presence of some morbid growth in the liver, or from a tumor in
the mesentery or some other part, obstructing the portal vein below the
liver; or from suppurative disease of ulceration of the several organs
from which the portal vein arises. They may be a cause, or result, of
phlebitis, and may give rise to jaundice, and sometimes to abscess of
the liver.
_Dilatation_ of the portal vein may result from obstruction of the
capillaries of the liver in chronic atrophy or cirrhosis; or from the
presence of thrombi, or pressure by various morbid growths.
_Calcification_, not only of the portal vein within the liver, but of
its various branches of origin within the mesentery, omentum, etc., may
occasionally be met with.[26]
_The hepatic veins_ may be found presenting the same abnormal conditions
as the portal vessels.
Animal Parasites.
The liver has long been known as a favorite resort for different
parasitical animals, the most common of which, is that of the larval
form of one of the tapeworms—_the Tænia echinococus_—constituting when
developed in the liver, what is known as an _acephalocyst_ or _hydatid_.
=Hydatid Tumors= of the liver, arise in the following manner:—The
several tapeworms pass through three stages of development, these never
being completed however in the same animal. The Tænia echinococus,
acquires its adult form, only in the intestines of the dog or wolf. The
mature segments, each of which are filled with vast numbers of eggs, are
voided with the fæces, into which the eggs are discharged. These soon
develop into a minute embryo, with one extremity provided with numerous
little hooks. If taken into the stomach of an herbivorous animal or man,
this embryo pierces the walls of the intestines, enters a blood-vessel,
and finally lodges in some of the tissues or organs, more frequently the
liver, where it develops into a sac-like body, known as a _cysticercus_
or _hydatid_, the second larval form. When the embryo is taken into the
stomach of other animals, no further development takes place.
While in the hydatid, or second larval form, by a peculiar process known
as alternate generation, there may be a reproduction of cysts to an
almost endless extent within the parent cyst, or secondarily in other
parts.
The adult or third stage of development, can only be attained within the
intestinal canal of the dog or wolf. These animals devouring a sheep or
other ruminant, or in some rare case perhaps a human being, within which
the hydatid has been formed, the cysts thus taken into the stomach,
develop into the perfect worm, from which segments containing the eggs
are again discharged.
It would appear almost impossible for the embryo from these eggs, to
ever enter the human stomach, but it is not difficult to understand that
the fæces of the dog containing the ova, may enter a spring or stream,
from which the minute embryo may be taken with the water, by either man
or a lower animal; or, by attaching themselves to watercresses, etc.,
they may be eaten with these by the same.
_Hydatid tumors_ of the liver, may vary, greatly, in size, according to
their age. From an extremely minute cyst, they may acquire such a size
as to fill and distend the abdominal cavity, crowding the several
viscera from their position. There may be one or several. They may be
confined to the liver, or secondary cysts may appear in other organs.
When opened, the interior is generally filled with numerous smaller
cysts of various sizes, each filled with a gelatinous fluid of varying
degrees of density and color, and within which, by a careful microscopic
examination, may be detected—many times, not always—numerous hooklets,
which have been detached from the minute heads. The walls of the parent
cyst may become greatly thickened, or even calcified. The contents may
degenerate into a purulent mass, with which may be mingled blood or
bile.
The development of these tumors is usually slow, and unattended with
pain, or functional disturbance of the liver. After they have acquired a
large size, they may induce peritonitis, resulting in extensive
adhesions.
Rupture of these hydatids sometimes take place, this accident being
followed by death, or recovery, according to the point at which the
rupture takes place. They may burst in the following directions:
1. Through the diaphragm into the pleural cavity, or into the substance
of the lungs.
2. Rarely into the pericardium.
3. Into the peritoneal cavity, resulting in acute peritonitis.
4. Through the abdominal walls, when recovery is possible.
5. Into the stomach or intestines; this being the most favorable point
of rupture. In fifteen cases of rupture into the intestines, fourteen
recovered.
6. Into the biliary passages or large blood-vessels.
CASE.—_Large Hydatid Tumor of the Liver—Death from Exhaustion._
Mr. O——, of this city, aged 75 years, noticed some two years previous
to his death that his abdomen was enlarging. An examination disclosed
the presence of a large tumor descending from the region of the liver.
It was slightly fluctuating, and unattended with pain or soreness. He
complained of nothing but weakness with vertigo. All the functions of
the body were natural.
A gradual increase of size took place, with occasional attacks of
inflammation, until the abdomen acquired the dimensions of that of a
woman at full term. The oppression now became so great, from the
crowding of the lungs, that I decided to resort to paracentisis. Some
two quarts of a thick, gelatinous fluid were drawn off from the tumor,
with several quarts of ascitic fluid from the peritoneal cavity. The
operation was followed by great relief. Rapidly refilling, the
oppression again became severe, and the operation was repeated a few
months later with similar results. Death finally followed from
exhaustion.
The post-mortem revealed an immense tumor, filling the abdominal
cavity with extensive, firm adhesions, and crowding the lungs into the
upper part of the chest. The walls of the sac were thick and
semi-cartilaginous, and the interior divided into numerous
compartments by septa passing in various directions. These
compartments were filled with a gelatinous fluid, in which were
innumerable cysts of various sizes, each filled with a similar fluid
as that with which they were surrounded. The microscope showed the
presence of numerous cholesterine scales in this fluid.
The weight of the entire tumor was over fifty pounds. A portion was
preserved and deposited in the College Museum.[27]
The following parasites are also sometimes found in the human liver, or
its ducts:
_Distoma hepaticum_, or liver fluke. Common in the bile passages of
lower animals, rare in that of man. It is flat, oval, from two to four
lines long, and a-half to one line broad. Its presence in the hepatic
ducts, may give rise to enlargement, some degree of obstruction, or
calcification.
_Distoma lanceolatum._ This parasite, something smaller than the above,
is still more rare in the bile passages of man.
_Pentastoma denticulatum._ This animal is found as a small cyst, with
calcified walls, and containing fatty and calcareous matter, with the
remains of the dead parasite. It is considered as the larval form of a
worm sometimes found in the nasal cavity of the dog, and some other
animals.
_The Ascaris lumbricoides_ may be found in some of the bile passages, it
having entered by the opening of the common duct into the intestine.
2. Affections of the Gall-bladder and Ducts.
The gall-bladder is sometimes wanting, this being the normal condition
in the horse and some other animals. When thus absent, the hepatic ducts
are so increased in size, as to be able to contain the accumulating bile
in the intervals of digestion.
=Inflammation= of the gall-bladder and common duct, involving their
mucous lining, is not uncommon. Such inflammation may be either
_catarrhal_ or _suppurative_.
_Catarrhal inflammation_ may result in thickening or calcification of
the lining membrane of the ducts and bladder, with the accumulation of
such quantities of thick tenacious mucus, as to become a source of
impediment to the flow of the bile, and thus give rise to jaundice. Such
inflammation becoming chronic in the common duct, may result in great
dilatation of the gall-bladder, from the accumulation of bile.
In many cases, this form of inflammation would seem to have originated
in the duodenum, reaching the biliary passages by extension through the
opening of the duct into the intestine. It may also result from the
presence of calculi or parasites in the passages, or from inflammation
of the liver.
_Suppurative inflammation_ may attend different forms of fevers, or
result from the presence of calculi. The gall-bladder, with the bile
ducts, in such cases, may be filled with a purulent fluid, or the same
may be found infiltrated through their walls.
Perforation of the walls of the gall-bladder may result from this form
of inflammation, with escape of contents into the peritoneal cavity,
inducing thus fatal peritonitis. Fistulous communication may also form
between the bladder and colon, duodenum or stomach, or through the
abdominal walls, adhesions having first taken place between these parts.
_Dilatation_, both of the bladder and ducts, may occur as a result of
obstruction of the gall-ducts. That of the former may be very great,
giving rise to a tumor that may be plainly felt through the abdominal
walls. Dilatation of the ducts may involve either the common, or large
hepatic ducts, or the smaller branches within the liver. Such
dilatations may be sacculated in form, or general, involving the whole
tube.
Morbid Growths.
_Cancer_ of the walls of the gall-bladder is not unfrequent, and may be
either primary or secondary. The cavity of the bladder may in this way
become obliterated, and the common duct obstructed, thus inducing
jaundice.
In a case examined for the Drs. Pettingill, the gall-bladder was as
large as the fist, from scirrhus cancer; its cavity obliterated; adhered
to the pylorus to which the disease had extended; and the bile ducts
greatly dilated and filled with a large quantity of puriform fluid. The
patient had been for many months extremely jaundiced.
_Fibroid tumors_ are very rarely observed in connection with the
gall-bladder.
_Tubercular deposits_ may be found beneath its peritoneal covering.
=Biliary Calculi.= The presence of biliary calculi, or gall-stones in
the gall-bladder, or some of the ducts, is a very common occurrence.
These bodies are composed of the elements of the bile, largely however
of cholesterine, sometimes in an almost pure state, in others, more or
less mixed with inspissated bile. In many cases, a nucleus of nearly
pure cholesterine will be surrounded by a deposit of biliary matter
mixed also with scales of cholesterine.
Cholesterine is a peculiar spermaceti, or fatty-like substance, found
not only in the bile, but also in the nervous tissues, insoluble in
water, but soluble in æther or boiling alcohol. When found in a pure
state, it is of a yellowish-white color, with the particles arranged in
the form of shining thrombic scales.
Gall-stones may occur of all sizes, from a pin’s head to that of a hen’s
egg. When small, they are generally numerous; in some instances fifty to
one hundred being found in the gall-bladder at one time. When several
are present in the bladder, they will be more or less angular or
polyhedral in form from contact and attrition with one another. Where
there are but one or two, the size may be considerable, while the form
will be rounded, oblong or pear-shaped, and more or less regular.
These bodies, when first removed, are usually heavier than water, but,
after being dried, become considerably lighter. They are inflammable,
and may be reduced to almost pure charcoal by burning. After having
being exposed to the air for some time, they are very liable to crumble
more or less completely.
_Position._ 1. _Gall-stones may be confined to the gall-bladder._ This
is the position in which they are more frequently found. There is every
reason to believe that they may remain there for a long time without
giving rise to any uncomfortable symptoms. We frequently find them after
death in the gall-bladder of persons who, during life, exhibited no
symptoms of their presence. They are liable, however, when present, and
particularly if numerous or large, to give rise to a sense of weight and
dragging in the part, and to occasional attacks of pain, derangement of
the stomach and vomiting; and may also excite inflammation and
ulceration of the walls of the bladder.
The presence of gall-stones, when in large numbers, may frequently be
detected through the abdominal walls, as a hard resisting tumor, which,
by grasping, may be made to elicit a rattling sensation, like pebbles in
a bag.
2. _Gall-stones may become impacted in the neck, or cystic duct of the
gall-bladder._ In this case, it is likely to give rise to an attack of
biliary colic, with vomiting, etc. As long as it remains in this
position there will be no jaundice. Their presence, however, may excite
inflammation; yet we sometimes, in post-mortem examinations, find the
neck of the gall-bladder blocked up by a calculus, when no symptoms of
such an obstruction existed during life.
3. _Gall-stones may form in some of the branches of the hepatic ducts
within the liver._ This is not a common point for the formation of these
bodies. They are sometimes found, however, in cases of obstruction of
the ductus communis. The concretions may be small and rounded, or
branching casts of the tubes, resembling pieces of coral.
4. _Gall-stones may be lodged in the ductus communis choledochus._ This
is one of the most common situations for these bodies, and they may
reach the point, either from the gall-bladder, or from the ducts from
the liver. While in this position, the calculus is likely to give rise
to jaundice with paroxysms of severe pain, which will be repeated from
time to time, until it passes into the intestines.
_Effects._ As already intimated, gall-stones may remain for an
indefinite period in the gall-bladder or ducts, without giving rise to
any symptoms. In many instances, also, they may undoubtedly pass the
ductus communis when small, and be discharged by the bowels, without the
knowledge of the patient. More frequently, however, the passage of these
bodies is accompanied with paroxysms of severe pain, the location and
character of which will usually serve to indicate the true cause. Where,
however, the body is too large to pass, its presence in the gall-bladder
or any of the gall-ducts, may excite inflammation and ulceration in
those parts, and thus lead to perforation and discharge of contents into
the peritoneal cavity.
CASE.—_Rupture of the Gall-bladder, with discharge of contents into the
peritoneal cavity, followed by peritonitis and death._
Mr. De K. T——, of this city, aged about 60, had suffered from several
attacks of severe pain in the region of the gall-bladder, which I had
diagnosed as biliary colic, induced by the presence of a calculus. One
morning in June, 1863, while working in his garden, he felt a
sensation of something giving away in his side, which was immediately
followed by an attack of severe pain. A chill and fever soon
succeeded; and, in twenty-four hours, a violent peritonitis set in,
resulting in death in four days.
Autopsy, thirty-six hours after death. Upon opening the cavity of the
abdomen, the peritoneal membrane was found intensely inflamed at all
points, and containing nearly a quart of greenish sero-purulent fluid.
Slight plastic adhesions were found at various points, uniting the
intestines to the abdominal walls, while old, firm and extensive
adhesions were found between the same and the liver and gall-bladder.
There were evidences that the latter had been largely distended, yet,
through a distinct opening, the contents had escaped into the
peritoneal cavity, leaving behind a single calculus of a regular oval
form, and one inch of its long diameter.[28]
From the appearance of the part, it would seem that the calculus had
excited inflammation and ulceration in the walls of the gall-bladder,
destroying the latter so completely, that the fluid contents were kept
from escaping into the abdominal cavity, only by the adhesions that
had formed, and that these had been probably torn away by the exercise
of digging with the spade.
In many cases, the adhesions which are induced by the inflammation, will
secure a more fortunate result, favoring the working of the calculus, by
the ulcerative process, either into the duodenum or colon, and thus, in
most cases, securing its passage per anum. In such instances, should an
opportunity be had of examining the parts after death, traces will be
found remaining, sufficient to indicate the point at which the escape
into the bowel was effected.
In some rare instances, gall-stones have been vomited from the stomach.
While it might be possible for such bodies to be carried from the
duodenum into the stomach by a reversed peristaltic action, it is more
probable that, in such cases, the calculus has found its way into the
stomach by a direct fistulous communication with the gall-bladder.
Fistulous communications of a permanent character are sometimes left,
after an ulcerative discharge of a gall-stone into some portion of the
intestinal canal.
Gall-stones, after entering the intestinal canal, may become impacted,
thus producing intestinal obstruction. Many fatal cases of this
character have been reported. An interesting case of intestinal
obstruction from this cause, was reported by Dr. Frieze, of Harrisburg,
at the meeting of the American Institute of Homœopathy, in Philadelphia,
in June, 1871. A lady sixty-five years of age, had been suffering severe
pain in the bowels for over a week, with symptoms of obstruction, when,
after a persevering use of injections, she passed a calculus of a
cylindrical form, one and three-quarter inches in length, and four and
one-half inches in circumference, and weighing four hundred and
thirty-seven and one-half grains.[29]
Gall-stones have, in a number of cases, been discharged upon the surface
of the body, while in some rarer instances, by the ulcerative process
they have worked into the ureter, and even into the vena cava and portal
vein.
CHAPTER II.
THE URINARY APPARATUS.
Section I. THE KIDNEYS.
[=Notice=:—Absence of either kidney, or other abnormalities. Of
each kidney, note 1. Form, size, weight, wounds, etc. 2.
_Capsule_—thickness; transparency; facility of removal. 3.
_Surface of kidney after removal of capsule_—color; smooth or
lobulated, size of lobules; puckerings; granulations; cysts, etc.
4. _Substance of kidney_—consistence; flaccidity, etc.; fracture,
granular or not? wounds, rupture. 5. _Cut surface_—color of
pyramidal and cortical portions; proportion of each; amount of
blood exuding from; thickness of cortical portion; color;
Malpighian corpuscles; their degree of visibility, color, etc.;
appearance of striæ in pyramidal portion, color, etc. 6. _Abnormal
growths and deposits_—cysts; fibrinous masses; tubercle; cancer;
chalky masses; abscesses, etc. 7. _Pelvis of kidney_—peculiarity
of form; contents; fluid, quantity, quality, purulent, etc.
_Calculi_—their size, position, etc. _Walls of pelvis_—their
thickness; transparency; fistulous openings; wounds, etc. 8.
_Ureters_—size, contents, etc. 9. _Microscopic examination_—make
section with Valentine knife, from convex border through cortical
portion, and from base to apex of cone, parallel with tubules;
place on slide and examine with varying powers, from 100 to 500
diameters. _Note condition of tubules_—contents; blood, oily
particles, fibrinous, waxy, epithelial or other casts; or denuded
of epithelium and empty. _Malpighian tufts_—gorged, ruptured,
filled with granular or oily matter, or obliterated. Are crystals
of any kind present, as uric acid, oxalate of lime, etc., minute
cysts, purulent infiltration, tubercular, cancerous or other
deposits?]
In the normal state, in the adult, each kidney will be found to be about
four inches in length, two inches in breadth, and one inch in thickness,
of a firm consistency, and of a deep, red color. The weight of the
kidney varies from four ounces to six ounces, being somewhat lighter in
the female than in the male. The left kidney is generally somewhat
longer, thinner and heavier than the right. The fibrous capsule in which
each kidney is enveloped is thin, smooth, and in a state of health is
easily removed from the surface of the gland.
=Congenital Anomalies.= Although the absence of both kidneys is of rare
occurrence, it is not uncommon to find only one. This may occupy its
usual position, and differ from the natural kidney only in being
larger—the _unsymmetrical_ kidney of Rokitansky. In other cases, we find
a more or less complete fusion of the two organs together—the _solitary_
kidney.[30] Either the lower parts of each are connected by a band of
renal substance passing across the vertebral column, constituting the
horse-shoe kidney; or there is only a single disk-like gland, lying in
the median line, and situated much lower down, even as far as the
concavity of the sacrum.
=Congestion.= This, and its consequences, are the main features of
hyperæmia of the kidneys, which is of frequent occurrence. This
condition is almost always the result of some prior general affection,
such as the scarlatinal poison, the suppression of perspiration, or
obstructive diseases of the heart.
In a simple congestion, with perfect integrity of the renal tissue, we
find the kidney enlarged, and its weight often doubled; of a dark, red
color, and dripping with blood when cut into. The cortical substance is
somewhat softened, of a dark, red color, presenting in many cases small
dark, red spots, the result of hæmorrhagic effusion into and between the
tubercles. The Malpighian tufts are distinctly visible on the cut
surface, as minute, reddish, semi-transparent grains. In the medullary
cones, the congested vessels form long dark red streaks. If the
congestions have occurred in an otherwise healthy kidney, the capsule
can be readily peeled off.
A microscopic examination shows the Malpighian and other capillaries
loaded with blood, extravasation sometimes taking place into the capsule
of the latter, and often into the channel of the fibres.
In extreme cases of hyperæmia and congestion, a fibrinous exudation
takes place, which will be found coagulated in the tubes, forming casts
of their interior, and consisting of a granular or homogeneous material,
entangling blood-globules, and often some particles of detached
epithelium.
=Hæmorrhage.= As a result of acute congestion, or from injury from
falls, blows, or wounds of the kidneys, blood may be effused, either
beneath its capsule, or within the sinus, constituting hæmorrhage of the
kidney.
=Nephritis.= This differs in no material respect from common
inflammation of other parts, and like it, often passes into suppuration.
Its most common causes are:—Excess in the use of irritating and
alcoholic drinks; abuse of diuretics; blows or falls on the loins; the
presence of renal calculi; and, according to some authors, a peculiar
morbid state of the blood, such as gives rise to carbuncles.
This disease can be distinguished from the inflammatory form of Bright’s
Disease, during life, by its generally affecting only one kidney, by the
much greater pain and tenderness in the lumbar region, by the retracting
of the testicles, and the higher degrees of febrile excitement. Then,
too, the deeply-colored urine which is voided, contains little or no
albumen.
In a case of nephritis, unattended with the formation of pus, a
_post-mortem_ would probably fail to distinguish it from the condition
of congestion just considered. Where suppuration was about taking place,
the microscope shows the cortical tubes so distended and crowded
together by infarcted epithelium, as to be scarcely distinguishable; in
some parts the basement membrane gone, and their contents a uniform mass
of nuclei and granular matter. The medullary tubes are also infarcted
and opaque.
=Pyelitis.= Inflammation of the walls of the sinus of the kidney, is
thus designated. It may exist alone, or in company with inflammation of
the kidney, constituting _Pyelonephritis_. It appears to originate, in
many cases at least, secondarily to an attack of cystitis, and would
seem metastatic in its nature, the ureter connecting the two inflamed
organs, escaping the disease. It is a very serious, and often rapidly
fatal disease.
Where the inflammation extends to the kidney tissue, suppuration is
likely to follow, resulting thus in the formation of an abscess.
=Abscesses.= Renal abscesses are found bordered by a red injected halo,
which gives rise to a friable product, thus leading to an extension of
the abscess. The mucous membrane of the calices and the pelvis,
especially when a calculus is present, is softened and inflamed, and
secretes a purulent fluid.
The process of suppuration may continue until the whole organ is
converted into a pouch of pus. Then, or even before the organ is quite
destroyed, the abscess may make its way by the usual process of
absorption, and discharge its contents into the calices, to be carried
off by the urinary passages; into the ascending or descending colon, or
the duodenum, to be passed with the fæcal evacuations; or, after
perforating the diaphragm, into the bronchi, whence they are removed by
coughing; or through the lumbar muscles; or it may burst into the
peritoneal cavity and cause rapid death.
This disease rarely attacks more than one kidney, and the other healthy
kidney generally enlarges and becomes capable of performing a double
amount of work.
It is well to remember, that a mass of softened fibrinous exudation,
bordered by a red halo, may sometimes so far simulate an abscess, that
only the microscope can distinguish the one from the other.
=Inflammation of the Capsule= may take place and cause fibroid
thickening, more or less induration, atrophy, and obliteration of the
organ. The cortical substance generally suffers most, and the surface is
sometimes overspread with purulent matter, while the tissue itself
becomes sloughy or gangrenous, or is only congested and softened.
=Morbus Brightii.= _Bright’s Disease._ _Degenerative disease of the
kidneys._ _Desquamative and un-desquamative nephritis._
In view of the impossibility of accurately defining the term _Bright’s
Disease_, we will describe it in general as including those diseases of
the kidneys which, in some stage or other of their course, are
accompanied by albuminuria, or dropsy, or both. And as it would be
foreign to the object of this work, to enter into an examination of the
respective merits of the theories, in reference to the nature and course
of this disease, we will adopt that classification which seems best
adapted to our purpose, and proceed to consider the morbid anatomy of
Bright’s Disease in its various forms and stages as first suggested by
Virchow in his Cellular Pathology, and adopted and developed by
Stewart.[31]
He distinguishes three forms—(1) _the inflammatory_, (2) _the waxy_, (3)
_the cirrhotic or contracting_; the first originating in the tubules,
the second in the vessels, and the third in the connective tissue of the
organ.
1. _The Inflammatory Form._ This has three stages: that of inflammation,
that of fatty transformation, and that of atrophy. The disease may prove
fatal at any stage of its course. In the first stage, an exudation is
poured out, and a destruction of the epithelium takes place. This
exudation, affecting a large number of tubules, leads to enlargement of
the organ, and also to fatty degeneration of the epithelium; its
absorption or removal, leads to ultimate atrophy. There is also a _fatty
degeneration_, to which we will refer later, which is unattended either
with albuminuria or with dropsy, and which does not, therefore, belong
to this category.
In this stage of inflammation, the organ is of the natural size, or
slightly enlarged; its capsule is unaltered, and can be peeled off
readily; its surface is smooth, more or less congested, often pink,
sometimes of a dark purplish color, sometimes mottled, pale and purple.
On section, the cortical substance is found relatively enlarged, and
often congested. The Malpighian bodies stand out prominently from the
surrounding tissues, the congested vessels, separated by a varying
amount of white (somewhat opaque) deposit, composed of the altered
tubules. The vascular spaces between the cones and the cortical
substance are uniformly distended with blood. The cones are usually
redder than the cortical substances, and from the engorgement of their
vessels and the altered condition of their tubules, they present a
series of alternating red and white lines, converging to the apex of the
cone, at which point the white distinctly predominates. The pelvis of
the kidney is natural.
Examination with the higher powers of the microscope shows the
Malpighian bodies dense and granular. The tubules are more bulky than
natural, and their epithelium is swollen, granular and dense, while
within them is frequently seen a transparent homogeneous exuded
material, binding into one mass, the epithelium of the tubules. Blood
corpuscles are frequently found incorporated in this exuded material.
In the stage of fatty transformation, the organ is enlarged; its capsule
natural; its surface smooth or slightly lobulated. It is pale and fatty
in color, and on its surface stellate vessels are frequently seen. On
section, the cortical substance is pale, of a yellowish-white color, and
increased in volume, while the cones are pink, and of natural color and
size. The Malpighian bodies do not project prominently as in the first
stage.
Under the microscope we find the tubules to be irregularly distended
with fatty granules, contained for the most part within the walls of the
epithelial cells, which again are imbedded in a material that blocks up
the tubules. In the Malpighian bodies, oil globules and fatty cells are
of frequent occurrence, but the capillary tuft is natural.
In the last stage of this form, that of atrophy, both the bulk and
weight of the organ are diminished, its capsule although natural, is
less easily torn off than in health, and on its removal the surface of
the gland is found to be uneven, with numerous depressions and
elevations. The color is, as in the second stage, mottled. On section we
find that, while the cones have remained nearly of their natural size,
the cortical substance is small and atrophied, and that which intervenes
between the cones is greatly diminished. In the cortical substance, the
Malpighian bodies are not prominent, while the vessels, and especially
the arteries, are thicker and more prominent.
The pathological distinction between this stage of the inflammatory
form, and the cirrhotic or contracting kidney, depends mainly upon the
condition of the tubules and the relative amount of connective tissue.
When the atrophy is a consequence of inflammation, many of the tubules
show evidences of inflammatory action, being blocked up with exudation
and epithelium in process of fatty degeneration, while in the cirrhotic
there is little or none of this. Again, in the cirrhotic the fibrous
stroma is very greatly increased, which is not the case in the
inflammatory form. In the latter, too, the capsule is more easily
stripped off, and the occurrence of cysts is less frequent than in the
former.
The form of Bright’s Disease, of which we are treating, is often
complicated with hypertrophy of the heart, affections of the lungs and
bronchi, inflammation of serous membranes, derangements of the
alimentary tract, diseases of the brain, affections of the eye, liver
and spleen.
2. _The Waxy or Amyloid Form._ This also has three stages: that of
simple degeneration of the vessels; that in which a secondary alteration
of the tubules is suspended; and that of atrophy. An increased secretion
of urine characterizes this form from its earliest stages. In all stages
the vessels present to the naked eye more or less distinctly the
appearance of boiled starch or sago, while a little of the liquor iodi
poured over the surface, produces everywhere a yellowish color, but the
degenerated parts assume a reddish-brown, mahogany-red, or orange-red
hue, and stand out very conspicuously.
In the first stage, the organs are of normal size, weight and color, the
latter being however, in some cases, a little paler than usual. Their
capsule is easily stripped off, and their surface is smooth. The waxy
degeneration begins in the capillary tufts of the Malpighian bodies, and
in the transverse fibres of the middle coat of the small arteries. On
these there are thickenings here and there, presenting the same
sago-like translucency as is seen in the tufts.
In the second stage, the kidneys are increased in bulk and weight; the
capsule is easily stripped off, and the surface smooth and pale. The
cortex is thick and white, and presents much the appearance of white
beeswax. Under the microscope, we see the Malpighian bodies and arteries
degenerated as just described, and in addition many of the tubules full
of matter, not dense and opaque as in the inflammatory form, but
tolerably transparent, consisting of hyaline tube casts. Their
epithelium is swollen, and their basement membrane may also be waxy. It
is to this form of disease that the term “waxy kidney” is most
applicable.
In the third stage, that of atrophy, the organ is reduced in bulk, from
about the natural size to a fourth or even less. Its weight is also
diminished. The capsule may be torn off without much difficulty. The
surface is rough, granular, and of a pale, waxy color. On section the
cortical substance is found much diminished, while the cones are nearly
natural. The Malpighian bodies are large and closely grouped together;
the smaller arteries dilated and their walls thickened. A few tubules
remain distended, but most are collapsed, and are represented only by
fibrous tissues.
3. _The Cirrhotic or Contracting Form._ This consists of an hypertrophy
of the connective tissue of the organ, and a consequent atrophy of all
the other structures. It has been termed also “gouty kidney,”
“intertubular or interstitial nephritis,” and “granular kidney.”
In the commencement of the process there is but little diminution in the
size of the organ, but the capsule is thickened and more adherent than
natural, and the surface is rough and granular. The color is pale or
reddish. On section, the cortical substance is found relatively
diminished, the diminution being most marked towards the surface. The
arteries are prominent, their walls thickened and their cavities often
dilated. Even to the naked eye, and to the touch, the increased density
and fibrousness of structure are evident. On the surface, and in the
substance, cysts are frequently seen. Some are produced by dilatation of
the Malpighian capsules, some by dilatation of the tubes, and others
from morbid growth of epithelial elements. The tubes are compressed and
atrophied by the new fibrous tissue. They contain little of the opaque
matter found in inflammatory cases, but translucent hyaline matter is
common. All these characteristics become more marked as the disease
progresses. In the more advanced stages, both the kidneys are much
reduced in size, but one may be more atrophied than the other.
Throughout the whole course of the disease the cones are but little
affected.
In gouty cases a deposit of chalk-like substance is occasionally found,
composed of needle-like crystals of urate of soda, situated in the
stroma of the organ, as well as in the tubules.
In distinguishing a cirrhotic kidney from one in the third stage of the
inflammatory or of the waxy disease, besides the characteristic iodine
test in the one case, the following points of comparison will be
useful:—In the cirrhotic, the capsule is more thickened and more
adherent than in the other two forms. In the cirrhotic, the surface is
very uneven, frequently studded with cysts, and presents little or no
sebaceous-looking material; in the inflammatory and the waxy, the
surface is less uneven, cysts are much less common, and in both,
particularly the inflammatory, sebaceous-looking material is very
abundant. In the cirrhotic, the stroma is greatly increased, especially
towards the surface; in the inflammatory and waxy, the stroma, although
increased relatively to the other tissues, is not absolutely above the
normal amount.
It must also be borne in mind, that both the waxy and contracting forms
may be secondarily affected with the inflammatory disease.
=Simple Fatty Degeneration of the Kidneys.= We occasionally find, along
with fatty degeneration of the liver and of the muscular substance of
the heart, a fatty degeneration of the kidney, without any trace of
inflammation. The kidneys are of about the normal size; the surface
smooth, and the capsule not adherent. The organ is more soft and
flexible than natural, and the surface is pale, and mottled with
sebaceous-looking deposits. On section, we find the abundant deposition
of sebaceous-looking material to be mainly in the tubules of the
cortical substance, but also to be found in those of the cones. The
microscope shows that the deposit is not in the free cavity of the
tubes, but within the epithelial cells.
We may have the simple fatty degeneration in connection with exhausting
disease, old age, or with excess of fatty food.
The adipose tissue in which the kidney lies embedded, may increase to
such a degree as to penetrate by the hilus into the substance of the
organ, impede its nutrition, and induce a kind of atrophy. Rokitansky
states that, in the highest degree of this change, the kidney presents
the appearance of a mere mass of fat, without the slightest trace of
renal organization; the urinary passages at the same time being
atrophied and obliterated.
=Dislocated Kidney.= As a result of over-exertion, tight lacing, or
perhaps pregnancy, the kidney sometimes becomes detached from its
connections to the surrounding structures, permitting of a change of
position, and constituting what is known as _movable_ or _dislocated
kidney_. The right kidney is said to be more frequently affected in this
manner, and the condition is more common with females than males.
Morbid Growths.
=Tubercular Disease=, though not of frequent occurrence, does sometimes
occur in the kidneys. In most cases we find a deposit of tubercle in
other organs, especially in the lungs, and often in various parts of the
genito-urinary apparatus.
This disease is most liable to occur in the middle period of life. It is
found sometimes in the miliary form, sometimes in larger masses.
In a very decided tubercular dyscrasia, we find associated with the
miliary granulations a considerable amount of hyperæmia of the organ;
but where the deposit is more chronic, the surrounding tissue is quite
pale. The large masses are remarkably bloodless. When the tubercular
deposits extend to the renal tissue from the mucous membrane of the
calices and the pelvis, these cavities become remarkably enlarged, and
the whole organ is increased in size, and appears rather pale. The
epithelial lining of the tubes is more or less opaque and granular, or
of an oily aspect. By the softening and breaking down of the tuberculous
deposits, large cavities are formed, containing a mixture of tuberculous
detritus and pus. Fibrinous casts are sometimes found in great numbers
in the tubes.
=Cancer.= Secondary, is of more frequent occurrence than primary cancer.
The scirrhus and colloid varieties are rarely, if ever, found.
Encephaloid growths, especially in children, attain in the kidneys an
enormous size.
Cancer of the liver and right kidney, or of the adjacent parts of the
stomach, or descending colon and left kidney, frequently coexist
according to the observations of M. Rayer and Dr. Walshe. The period of
life between fifty and seventy is most liable to cancer of the kidneys.
The natural character of the urine excreted by cancerous kidneys is
seldom changed until the encephaloid growth softens and breaks down,
when blood, puriform matter and detritus may appear.
=Cystic Tumors=, supposed to originate from a dilatation of the
Malpighian capsules, are sometimes found. The cysts vary in size from a
pin’s head to a small bird’s egg. They may be few or many in number, and
are filled either with a clear watery fluid, or with a gelatinous or
pigmentary substance. The walls of the cysts are thin and smooth, partly
divided into compartments by imperfect septa. They are confined to the
cortical portion of the gland, and may be imbedded in that substance, or
project from the surface. The kidney may be unchanged in size, or
considerably enlarged. The clinical symptoms of these cysts are very
obscure, and of the cause of their formation, little is known.[32]
Cysts of a congenital origin, are sometimes found in the kidney at
birth. They may be of great size, and vast number, and appear to result
from a dilatation of the uriniferous tubes, and Malpighian capsules.
_Fibroid_ and _Adenoid_ tumors of small size are rarely found in the
kidneys; the former within the tubular, the latter within the cortical
portions.
Parasites.
=Entozoa= are occasionally found within the kidneys, among which may be
mentioned the _hydatid_, or larval form of the Tænia echinococus.
_Cysticercus cellulosæ._ The larval form of the Tænia solium.
_Eustrongylus gigas._ A small cylindrical worm, with the body tinged
with red. Male—ten to fourteen inches long, three lines wide.
Female—three feet long, six lines wide.
_Pentastoma denticulatum._ Supposed to be the larval form of a worm
found in the nasal cavities of some animals, and consisting of a small
sac, with calcified walls.
The Ureters.
As a congenital defect, we find the ureter terminating in a
_cul-de-sac_, either in the vicinity of the kidney, or of the bladder.
Sometimes they are double or even triple, but they generally unite
before their vesical termination.
=Dilatation.= When the opening into or from the bladder has, from some
cause or other, become greatly narrowed or obliterated, the obstacle to
the passage of the urine causes a _dilatation of the ureters_.[33] The
sinus and calices at the same time, dilate at the expense of the renal
tissue, so that we frequently find but a thin layer of cortical
substance compressed against the investing capsule, and the kidney
converted into a number of pouches, separated by the remains of the
medullary cones. The surface of the kidney is markedly lobulated.
The distention of the ureters may reach such a degree, that they
resemble a portion of small intestines, their walls being at the same
time somewhat thickened.
From an increase in length sometimes met with, the ureters no longer lie
straight, but are thrown into coils or flexures. With dilatation of the
ureters, we not unfrequently find coexisting a state of
=Inflammation=. The mucous membrane is then found swollen and injected,
of a villous aspect, and covered with a muco-purulent fluid. Sloughing
may ensue with consequent perforation of the ureters and infiltration of
the urine into the adjacent tissues, producing an extension of the
sloughing process or circumscribed abscesses. The inflammation rarely
exists as a primary disease; its most frequent causes, are the
irritation from calculi, or the extension of vesical disease. It may
extend to the sinus of the kidney, constituting pyelitis.
Morbid Growths.
=Cancer= of the urinary passages but seldom occurs, and only when found
elsewhere at the same time.
=Tubercles= may occur in the ureters, even when the kidneys are healthy,
but most frequently where they are involved at the same time. These
usually coexist with tuberculosis of some important organ. “The deposit
takes place in the submucous tissue, and forms, when its progress is
chronic, gray granulations, which become yellow, soften, and give rise
to small circular ulcers. When the disease is more acute, larger patches
of deposit are formed, or the mucous membrane becomes infiltrated
throughout with the tubercular product of inflammation, which is at once
detached as a cheesy, purulent mass.”
=Cysts=, containing a glutinous or hard matter, about the size of
millet-seeds or peas, are occasionally found developed under the mucous
membrane of the urinary passages.
The Suprarenal Capsules.
These bodies are sometimes entirely absent. Where one of the kidneys is
absent or displaced, the capsule may still be found in its normal
position.
=Inflammation and Degeneration.= Inflammation of the bodies, either
acute or chronic, appears to result in the following changes:
First, the organs become slightly enlarged and infiltrated with a
semi-translucent material, of a grayish color, soft, homogeneous, or
slightly fibrillated, or containing a few imperfect cells. The substance
resembles what is often seen in scrofulous disease of the lymphatic
glands.
At a later period, this substance gradually changes into a soft,
putty-like substance, or into chalky concretions scattered through the
body. The whole substance of the organ may thus be destroyed. It may, at
the same time, be found more closely adherent to the surrounding organs.
Dr. Addison has associated with these changes in the suprarenal
capsules, a peculiar bronzed condition of the shin sometimes seen, and
named from him “Addison’s Disease.”
=Hæmorrhage= occasionally occurs within the substance of the capsule,
forming a kind of cyst filled with blood. It is more frequent with young
children, but is sometimes seen in adults.
Morbid Growths.
_Cancer._ Primary cancer of these bodies is rare; the secondary form may
appear in connection with the same disease in the kidneys, stomach or
liver.
_Tubercles_ of the miliary form are rarely seen.
_Cysts_, both single and multiple, and with varying contents, may be
found, generally connected with the enclosing membrane.
Section II. THE URINARY BLADDER.
[=Notice=: 1. _External Characters_—malformations; adhesions; size;
Wounds, etc. 2. _Walls_—their thickness; condition of several coats;
morbid growths, cancer, tumors, tubercles, perforations; sinuses;
rupture; wounds. 3. _Contents_—urine, its quantity and characters;
blood, its amount and source; pus; calculi, number, size, position,
etc.]
=Malformations.= Among the most common of these, may be mentioned
_extroversion_, where there is an absence of the anterior walls of the
bladder, with a deficiency in the corresponding portion of the abdominal
parietes. From the pressure of the abdominal viscera, the posterior
walls of the bladder will be crowded forward, and protrude as a rounded
tumor, covered by a vascular mucous membrane, while near the lower
portion may be seen the orifices of the ureters, through which the urine
will be more or less constantly flowing.
Malformations of the external organs of generation, are liable to
accompany those of the bladder.
_The Urachus_ sometimes fails to close before birth, leaving thus an
open passage from the fundus of the bladder to the umbilicus, through
which the urine may be noticed flowing after division of the cord.
=Dilatation.= This is of not unfrequent occurrence, and is the result
either of a paralysis of the muscular coat, or of some obstacle to the
outflow of the urine. The dilatation may be uniform, or we may find
diverticula, formed by a protrusion of the mucous membrane between the
fasciculi of muscular fibres. Such partial distensions occur most
frequently in the lateral portions, the posterior surface, or the
neighborhood of the fundus, and as we should be led to expect from the
manner of their formation, are generally destitute of a muscular tunic,
or have but a few scattered fibres. Calculi are sometimes found in these
pouches after death, the presence of which had escaped notice during
life from their concealed position.
=Hypertrophy= of the muscular coat of the bladder, will generally be
found attending cases of obstruction to the escape of the urine, either
from an enlarged prostate, stricture of the urethra, or from the
presence of a calculus. The muscular coat in these cases is greatly
thickened, the interlacing bundles of fibres appearing with great
distinctness upon the inner surface.
As a result of this condition, we usually find the bladder greatly
contracted, its capacity in some cases being reduced to one or two
ounces. Inflammation of the mucous coat, with dilatation of the ureters,
will also generally attend, hypertrophy of the muscular walls.
=Contraction= of the bladder is met with, as the result either of
irritation of the mucous membrane, or hypertrophy of the muscular coat.
=Inflammation= of the bladder is generally seen in its chronic form.
The appearances in _acute cystitis_ are “strong vascular injection of
the mucous lining, with brownish patches in the vicinity of the neck and
fundus; more or less thickening of the membrane, with exudation of
fibrin or pus on the surface, or foci of the latter in its substance.
The mucous tissue may be ulcerated at several points, softened or
affected by commencing gangrene. Abscesses may form in the substance of
the parietes, and open either into the cavity of the bladder, or upon
its external surface. Sometimes the mucous membrane is almost completely
destroyed, a few shreds or filaments being the only traces remaining,
while the muscular tunic is left as if cleanly dissected. This is
probably the result of phagedenic ulceration.” The inflammation may
spread from the mucous membrane to the muscular coat, but it very rarely
reaches the peritoneal covering. In some cases it extends back along the
ureters, and even to the kidneys. The morbid action is not often of
idiopathic origin, it is more frequently due to the extension of an
attack of gonorrhœa, to disease of the prostate, to traumatic causes, to
protracted retention of urine, or to the irritation produced by
medicines or stimulating drinks. It is sometimes owing to the
constitutional poison of rheumatism or gout. It is met with oftener in
men than women, and in adults than in children.
_Chronic cystitis_, called also catarrh of the bladder, is very common
in advanced age. The morbid process is excited by some obstacle to the
emission of the urine, either paralysis of the viscus, or a stricture,
or by presence of a stone in the bladder, or by enlargement of the
prostate gland. It may also result from successive attacks of the acute
form, or from extension of urethral inflammation.
Various degrees of vascular injection are presented, with dark-reddish,
slate-colored or bluish-black discoloration, more or less thickened
induration of the parietes, which assume an homogeneous, lardaceous
appearance. An acute attack may supervene upon a state of chronic
inflammation, leading to ulceration, suppuration, perforation and
extravasation of urine, as in the case of primary acute cystitis.
Chronic or sub-acute inflammation is often attendant upon paraplegia,
and proves the immediate cause of death.
Morbid Growths.
=Cancer= as a _primary_ disease, is but rarely met with. Encephaloid,
forming nodulated prominences or cauliflower-like excrescences, is the
form which vesical cancer usually assumes. They are developed in the
submucous tissue, but as they grow, the mucous membrane is also
destroyed, and either an ulcer is produced or a soft luxuriant fungous
mass.
=Tubercle= in the form of separate granulations are sometimes met with
about the fundus and neck of the bladder in the male, and usually are
accompanied with similar deposits in the testes, prostate, kidneys, etc.
They are surrounded by more or less hyperæmia, and by softening give
rise to circular ulcers of the mucous membrane covering them.[34]
=Tumors.= _Polypoid growths_, both of a _fibrous_ and _adenoid_
character, may be found in the neck of the bladder, both in children and
adults. They vary in size from that of a pea to a cherry.
_Cystic_ tumors of small size are sometimes found within the mucous
membrane.
Parasites.
_The Sarcina ventriculus_, a vegetable parasite, is sometimes found in
the bladder, in cases of chronic cystitis.
Of animal parasites, the Eustrongylus, Echinococus, and Ascarides, have
found their way into this organ from other parts.
Of the Urethra.
=Malformations.= As congenital malformation, we need mention only
_Epispadias_, fissure on the upper, and _Hypospadias_, on the lower
surface, from arrest of development, and complete closure of the
opening, _Atresia urethræ_.
=Inflammation= of the urethra, of the catarrhal kind, the so-called
gonorrhœa, commencing at the anterior extremity, may, in severe cases,
extend backwards, even into the bladder. The lining membrane becomes
swollen, injected, and covered with mucus or muco-purulent secretion, at
first thin, then thicker, and then, as the inflammation subsides, thin
and pale again. When a chancre coexists with gonorrhœa, “the discharge
has usually a grayish or reddish tint, or sanious aspect.” From an
extension of the inflammation deeper into the fibrous structure of the
corpus spungiosum, results, sometimes, an exudation of fibrin in the
venous cells, suppuration and abscess. Cowper’s gland, the prostate, the
vesiculæ seminales, and the testicles, may also be affected by an
extension of the inflammation along the continuous mucous lining.
The contact of unhealthy vaginal secretions, whether specific or not, is
the most frequent cause of urethritis.
=Dilatation and Contraction.= _Dilatation_ is most frequently the
consequence of obstruction to the flow of urine. It occurs generally in
the membranous portion, which is expanded into a pouch, occasionally as
large as a small orange. The mucous lining of these pouches appears
“injected and thickened, presenting fungous vegetations, and
occasionally coated with lymph.”
_Contraction_ may result from inflammation of the mucous membrane, and
finally end in stricture.
=Stricture= is a very frequent result of inflammation of the urethra. It
usually is found in the anterior part of the membranous portion.
Contusions and wounds also, often produce stricture.
The simplest form of stricture is, where the canal is partially closed
by a fold of membrane passing across it, leaving either a crescentric,
or annular opening. In the most common kind of stricture the urethra is
narrowed in a much greater extent of its course, sometimes for an inch,
or more. When the obstruction occasioned by a stricture is very great,
the urethra behind is dilated, often inflamed and sometimes ulcerated,
so as to give rise to urinary fistula or effusion of urine.
=Rupture= of the urethra may result from severe contusions, or fracture
of the bones of the pelvis, and being followed by extravasation of blood
and urine, inflammation, suppuration or gangrene may supervene, or
fistulous openings may be thus established.
Morbid Growths.
_Warty growths_ sometimes appear within the urethra near the meatus.
They are generally quite vascular, and may cause considerable
obstruction.
_Tubercles_ are of rare occurrence in the urethra.
_Cancer_ occurs only as an extension of the disease from the penis,
prostate gland or bladder.
=Urinary Calculi.= Calculi of different size, form, and chemical
composition, may be found in the urinary bladder, ureters, or sinus of
the kidneys.
_Uric_, or _lithic acid calculi_, are the most frequent in their
presence. They may vary in size, from a pea to that of a hen’s egg. In
color, also, they may vary from a fawn or light yellow, to a dark,
almost mahogany tint. The surface may be slightly tuberculated, or
smooth, and the interior, where a section is made, has a concentric
arrangement of layers around a central nucleus.
_Oxalate of lime calculi_ are next in frequency. From the strongly
tuberculated character of the surface, they are frequently known as
mulberry calculi. They are of an irregular, spherical form, and usually
single. In color, they are usually of a dark olive or brown, but may be
light and almost white. They seldom acquire so large a size as the
lithic acid variety, are very hard, and permit of a high polish.
_Phosphatic calculi_ are characterized by their softness, which
permits of their being readily crushed. They are of a grayish-white
color, and frequently composed of alternate layers of other deposits.
They may be composed wholly of phosphate of lime, or of a triple
phosphate—ammonio-magnesian phosphate—or of a combination of the two.
_Cystine calculi_ are very rare; they are yellowish in color, of a waxy
appearance, and soluble in aqua-ammonia.
_Uric oxide calculi_ are extremely rare; they resemble uric acid
calculi, but present a waxy appearance when polished.
CHAPTER III.
THE MALE GENERATIVE ORGANS.
Section I. OF THE PENIS.
[=Notice=: Malformations; size; condition of prepuce and glans;
chancres, warts, etc. Split open urethra and notice ulcers,
strictures, etc.]
=Congenital Anomalies.= The penis may be very imperfectly developed,
even with a normal development of the other organs of generation,
although it more frequently occurs when the latter are themselves
imperfect.
It occasionally happens that, from an arrest of union in the median line
of the penis, a slit or fissure is left communicating with the urethra.
This commonly occurs in the under surface, constituting _Hypospadias_;
less frequently on the upper surface, (_Epispadias_,) and only in cases
of extroversion of the bladder.
The prepuce may be wanting.
Congenital phymosis occasionally occurs, usually associated with atrophy
of the penis. It is supposed by some, to be a predisposing cause of
cancer of the penis.
=Hypertrophy and Atrophy.= In consequence of long-continued onanism, the
penis may become hypertrophied, or as the result of chronic irritation
and disease, we may have an hypertrophy of the prepuce and of the body
of the penis, sometimes attaining an enormous size. Vidal has related
and figured a case where the organ reached to below the knees, and was
as large as a thigh. Atrophy of the penis, accompanied with obliteration
of the cavernous textures, occurs with atrophy of the testicles.
=Fracture of the Penis= has occurred from the giving way of the erectile
tissue during coition, in consequence of the state of hyperæmia of the
penis. The organ appears broken, and cannot assume the erect condition
beyond the part injured.
=Paraphymosis=, by the strangulation of the glans in front of a tight
prepuce, may, if not relieved, lead to inflammation, and even gangrene.
=Balanitis= commonly occurs as the result of local irritation, not
unfrequently set up by a gonorrhœa. The prepuce is much swollen,
infiltrated and reddened. The inflammation is generally complicated with
inflammation of the internal lamina of the foreskin, and the mucous
membrane of the glans (posthitis), giving rise to excoriation, exudation
of coagulable lymph, adhesion of the prepuce to the glans, suppuration
and ulceration. “When chronic, it induces exuberant formation of
epidermis; and if the deeper parts of the parenchyma of the glans are
involved, obliteration, cartilaginous induration and atrophy follow.”
=Herpes of the Glans and Prepuce=, is characterized by the formation of
small vesicles or excoriated points upon the mucous membrane of this
region, chiefly occurring in persons of a gouty habit of body, with an
irritable mucous membrane.
_Psoriasis_ of the prepuce, produces a red, thickened, and fissured
condition of the part. Phymosis is apt to occur as a consequence.
=Chancres.= These specific ulcerations form usually upon the glans,
although they may be found in the internal surface of the prepuce, the
frænum, and near the meatus within the urethra.
The _Hunterian_ or _hard chancre_, is nearly circular, deep and
excavated; base and edges are as hard as cartilage, but the hardness is
circumscribed; its color is livid or tawny. It may occur upon the
integument, the glans, or the body of the penis.
The _non-indurated_ or _soft chancre_ is more frequently found on the
inner surface of the prepuce. It appears as a foul, yellowish, or tawny
sore. Indolent fungous granulations are subsequently thrown out, unless
it be situated upon the glans.
_Phagedenic chancres_ are of irregular shape, their edges ragged or
undermined, their surface yellow and dotted with red streaks. The
surrounding margin of skin usually looks pulpy and œdematous; but is
sometimes firm and of a vivid red.
The cicatrices left by chancres which have healed, are whitish, more or
less hard, striated and depressed.
Morbid Growths.
_Warts_, belonging to the class of epithelial tumors, sometimes form on
the glans, or on the inside of the prepuce. They are commonly the result
of repeated inflammations.
_Cancer_ of the penis is of two distinct kinds, occurring as scirrhus or
as epithelioma. According to Dr. Walshe, the disease may originate as a
warty excrescence, or as a pimple, which discharges an excoriating
fluid, scabs, and breaks out afresh, while induration, followed by
ulceration, advances at its base. Or it may infiltrate the glans, so as
to convert that part into an indurated mass; or venereal ulcers may take
on cancerous action.
When of the _scirrhus_ form, it usually springs from the ulcers behind
the glans, and may thence invade the neighboring parts of the organ.
_Epithelioma_, commencing as a tubercle in the prepuce, may after a time
give rise to a large, irregular, and sprouting mass, having a granular
fungous appearance. In other cases, it commences as a hard scirrhus
mass, of a pale, reddish-white color, situated on the glans, or between
the prepuce and the glans. This increases in size, cracks, and allows
the exudation of a serous fetid discharge. Ulceration then rapidly takes
place.
Secondary cancers, except in the adjacent glands, are not a common
occurrence. Phymosis and the irritation caused by the retained
secretion, seem to act as an exciting, and advancing age as a
predisposing cause of cancer.
_Encysted tumors_, _nævus_ and _fibro-plastic_ tumors, situated about
the prepuce, may also occur.
Section II. OF THE SCROTUM.
[=Notice=: General condition; relaxed or contracted; œdema; cancer;
tumors, etc.]
=Hypertrophy.= _Common hypertrophy_ of the integument of the corium
sometimes occurs; in this there is no alteration of the subcutaneous
tissue.
In _Elephantiasis_ of the scrotum, however, the epidermis, the corium,
and the subcutaneous areolar tissue, are all, especially the latter,
greatly hypertrophied. The areolar tissue is converted into a large mass
of fibrous material, infiltrated with an albuminous and fibrinous fluid.
“When the disease is confined to the scrotum, and the enlargement
becomes great, the penis becomes drawn in and ultimately disappears,
while the elongated prepuce is continuous at a navel-like opening in the
skin of the surface of the tumor.” The enlargement sometimes is
enormous, such a mass having been known to weigh two hundred pounds,
more than the weight of the rest of the body.
=Inflammatory Œdema= of the scrotum is an erysipelatous inflammation of
this region, giving rise to great effusion into and swelling of the
areolar tissue, with a tendency to the rapid formation of a slough, by
which the integument may become so affected as to leave the testes and
cords entirely denuded. A peculiar form of this disease occurs as a
sequence of small-pox and scarlet fever. Here there is a tendency to
speedy gangrenous disorganization of the areolar tissue, and of the
covering of the generative organs.
Morbid Growths.
_Cancer._ _Epithelial cancer_ is the common form under which it attacks
the scrotum. This disease has appropriately been called
_chimney-sweeper’s cancer_, as it appears to arise from the irritation
of the soot lodging in the folds of the scrotum. It commonly commences
as a tubercle or wart, which, after a time, cracks or ulcerates. It
spreads rapidly, involving at last the greater part of the scrotum, and
sometimes invading the testes, even extending to the groin and thigh,
destroying life by perforating the coats of some of the large vessels.
The glands of the groin are not always affected.
_Melanotic_ cancer of the scrotum has been observed.
_Fibrous tumors_ are sometimes developed in this part, and may form a
large mass when several are grouped together.
Section III. OF THE TESTICLES.
[=Notice=: Malformations; position, in scrotum, inguinal canals, or
abdomen. Size; consistence; condition of coats. _Tunica
vaginalis_—contents; serum, blood; adhesions. Abscesses; cysts;
tumors; cancer; tubercle, etc.]
=Congenital Anomalies.= There is no sufficient evidence of the presence
of more than two testicles. They are both absent when the entire sexual
apparatus is wanting, and in some rare cases they are imperfectly
developed, or only one may exist.
It not unfrequently happens that at birth there is an apparent absence
of one or both glands from an arrest or delay in their descent, so that
they lie in the groin, the inguinal canal, or the lower part of the
abdomen. Sometimes they wander into other situations, _e. g._, into the
perineum close by the anus, and through the crural canal. If the descent
does not take place within twelve months after birth it is rarely
perfectly completed afterwards without being accompanied by hernia.
The organ is sometimes retroverted, so that the epididymis is placed in
front.
The vas deferens may be absent to a greater or less extent, and even the
epididymis has been found in great part deficient.
The vas deferens frequently terminates in a blind extremity before
reaching the vesicula seminalis.
=Hypertrophy and Atrophy.= True hypertrophy of the testicles does not
occur but when attacked with inflammation, or when the seat of morbid
growths the glands may become greatly enlarged. Atrophy, congenital or
acquired, is not unfrequent. The effect of old age is very gradual, the
gland being often but very little diminished in size.
“The testicle atrophied from disease is not only of diminished size and
weight, but is altered in shape, being uneven and irregular, and
sometimes of an elongated form. There is little or no trace of the
proper glandular structure, the organ being converted into fibrous
tissue of a firm texture.
“The testicle in an advanced stage of wasting, not arising from disease
of the gland, usually preserves its shape, but feels soft, having lost
its elasticity and firmness. Its texture is pale, and exhibits few
blood-vessels; the lobuli and septa dividing the lobes are indistinct,
and the former cannot be so readily drawn out into shreds as before. The
epididymis does not usually waste so soon, nor in the same degree as the
body of the testicle. Fatty matter is also found in the glandular
substance of atrophied testicles.”
=Inflammation.= The serous covering of the testes, the _tunica
vaginalis_, is liable to acute inflammation, and is then affected as
other serous membranes. It becomes thickened and injected with blood,
and is coated with a variable quantity of fibrinous exudation. Serum is,
at same time, effused into the cavity, and rendered turbid by flakes of
fibrin. Adhesions between the opposing surfaces commonly form. The
epididymis is apt to partake of the inflammation of the tunica
vaginalis, and _vice versa_.
_Orchitis and Epididymitis_, may be acute or chronic, primary or
secondary. In _acute_ cases, the testis is congested, and of a darker
hue than natural, although not much enlarged. The epididymis, especially
its lower part, is much enlarged, and feels thick, firm and indurated.
“The coats of the vas deferens are thickened, and the adjacent vessels
injected. The tunica vaginalis is inflamed, and its cavity contains the
usual effusions.”
_Suppuration_ may occur more frequently in primary orchitis, rarely in
the secondary form. The pus is liable to burrow and disorganize the
tissue of the gland. By a subsequent absorption of the fluid part of the
pus, there is often left a whitish mass resembling tubercular deposit,
but distinguished from this by being contained in a cyst, and by the
altered condition of the adjacent gland tissue. The epididymis not
unfrequently remains enlarged, presenting a hard, knotty swelling at its
lower part. “In old cases the epididymis acquires the density and
consistence of cartilage, and sometimes even of bone.”
_Atrophy_ of the gland is a frequent result of inflammation.
_Chronic_ orchitis is characterized by the effusion of a yellowish,
homogeneous-looking matter, in the substance of the testicle, within the
tubuli. This deposit may shrink and contract, inducing gradual atrophy
of the testis, or, by adhesions and ulcerative absorption, a fungous
protrusion of the affected tissue may take place.
=Hydrocele.= _Simple Hydrocele_ is a dropsy of the tunica vaginalis. The
fluid is usually clear, and of a straw color, sometimes turbid, with
albuminous flocculi, and not unfrequently contains shining particles of
cholesterine. In old or very large hydrocele, it is often dark-brown or
chocolate colored from disintegrated blood. Its quantity is sometimes
very considerable. The position of the testicle may be altered by
adhesions formed between the two layers of the tunica vaginalis; these
latter may also produce a multilocular hydrocele. Simple hydrocele may
occur with some of the other varieties to be mentioned, and also with
inguinal hernia.
When serous effusion in the tunica vaginalis, is associated with chronic
orchitis or other diseases of the gland, we have _hydro-sarcocele_.
In _congenital hydrocele_, the dropsical tunica vaginalis retains its
fœtal communication with the peritoneal cavity.
_Encysted Hydrocele._ In this variety the fluid is contained in cysts,
which may be situated (1) beneath the visceral portion of the tunica
vaginalis, investing the epididymis; (2) between the testicular portion
of the tunica vaginalis and the tunica albuginea, which are thus
separated from each other; (3) between the layers of the loose or
reflected portion of the tunica vaginalis. The two last mentioned
varieties are of rare occurrence. The cysts have thin fibrous walls, a
lining of tessellated epithelium, and contents usually clear, although
sometimes mixed with various exudations of fibrin or even blood.
Spermatozoa are very frequently found in the fluid of these cysts. Their
presence is undoubtedly due, as pointed out by Cushing, to the rupture
of a neighboring seminal duct. They are but rarely found in the fluid of
common hydrocele.
_Diffused Hydrocele of the Cord_, gives rise to an oval or oblong,
irregular, circumscribed tumor, extending below and into the inguinal
canal. “It consists in the enlargement of the cells of the areolar
tissue, and their distension with a white or yellowish serous fluid. The
inclosing fascial sheath is condensed and thickened, and at the lower
part of the swelling, which is always the largest, separates it
completely from the tunica vaginalis.”
_Encysted Hydrocele of the Cord_ forms a tumor of oval shape, loosely
attached to the vessels of the cord which pass behind it. Instead of a
single cyst, there may be a number, forming a series along the cord.
=Hæmatocele=, is a tumor formed by an effusion of blood from the vessels
of the testis or of the spermatic cord, into the cavity of the tunica
vaginalis. It may be traumatic or spontaneous, and may attain a large
size. Coagula are formed either in separate masses, or in firm layers,
as in aneurism. Inflammation may be set up, leading to fibrinous and
serous effusion, and to suppuration, or the blood may putrify and
gangrene result. The tunica vaginalis is commonly thickened, the
testicle unaffected, or in old cases atrophied from pressure.
_Diffused Hæmatocele of the Cord_ results from the rupture of some
vessels of the cord, in consequence of which blood is effused within the
spermatic fascia. A tumor of enormous size may be formed should the
bleeding continue, or recur after having been arrested. The usual cause
is some strain or violent exercise.
=Varicocele= is a morbid dilatation of the spermatic veins. “The
enlarged veins hang down below the testicle, and reach upwards into the
inguinal canal; and when very voluminous, conceal the gland, encroach on
the septum, and extend to the other side of the scrotum.” The left veins
are more frequently affected than the right. In an advanced stage of the
disease, the coats of the veins are thickened, and do not collapse when
cut across. In cases of slight varicocele, the nutrition of the testis
is not interfered with, but when large, it produces marked atrophy.
Morbid Growths.
=Cancer= is most frequently primary, and generally attacks the body of
the testis in the first instance, the epididymis remaining for some time
unaffected.
_The scirrhus variety_, characterized by its great induration, is rarely
met with.
_Encephaloid_ is the ordinary form; it commences as one or two masses
among the tubuli, which it gradually destroys. The tunica albuginea is
absorbed by degrees, gives way, and allows the growth to project into
the scrotum and there freely vegetate. The scrotum is slow to be
involved in the disease, but at first becomes distended, sometimes to
the size of a cocoanut, and then gradually ulcerates. The spermatic
artery and the accompanying veins become greatly enlarged. The cord may
also be attacked with the disease, while secondary cancers spring up in
various places. The lymphatic glands in the neighborhood become
enlarged, especially those in the iliac fossa. The inguinal glands do
not generally become affected until the skin has become involved in the
disease.
Intermixed with the encephaloid are commonly found masses of a bright
yellow color, supposed by some to be deposits of tuberculous matter, but
by others, merely plastic matter undergoing fatty degeneration.
_Colloid and melanotic_ cancers have rarely been observed in the testes.
The tunica vaginalis is said to have been attacked with cancerous
disease, the testis remaining healthy.
=Cystic Disease of the Testis.= The cysts may be but few, or very
numerous. The testis is proportionately enlarged, indurated, of a
yellowish-white and opaque appearance, and studded with cysts varying in
size. The contents are, in the younger cysts, a clear, amber-colored
fluid; in the older ones, more thick, viscid, highly albuminous, and of
a brownish color. The cysts are sometimes imbedded in solid stroma,
probably of fibroid tissue; sometimes small masses of enchondroma are
found between them. When of an innocent character, the cystic disease is
characterized by the presence of tessellated epithelium in the cysts;
when malignant, by the presence of nucleated cancer cells.
“Occasionally cystic tumors of the testicle are met with, in which the
substance of the organ is atrophied or absorbed, and its place occupied
by one or more large thin-walled sacculi containing fluids of different
color and consistence, dark or fatty.”
=Tubercles= are not very unfrequent, and appear sometimes in the body of
the gland, but oftener in the epididymis, whence they may spread to the
testis. They occur as gray granulations, infiltrated or encysted, and
varying in size from a pin’s head to a plum-stone. They are commonly
found in all stages of development and disintegration in the same organ.
Their presence in and between the tubuli produces inflammation,
suppuration and disorganization of the structure of the testis, with
which they become mixed, so as to form a cheesy mass of a dirty buff
color. This may, by ulceration, perforate the scrotum, and protrude as a
fungous growth of a pale, reddish-yellow granular mass. This disease of
the testis is frequently found in connection with pulmonary tubercle, or
general tuberculosis.
_Tubercular syphilitic sarcocele_, described by Hamilton, of Dublin, is
a variety occurring in an advanced stage of constitutional syphilis.
“_Cretaceous matter_ is occasionally met with in the testis, doubtless
the residue of tuberculous deposit which has softened and undergone
calcareous change.”
=Tumors.= _Fibroid tumors_ of small size are sometimes found developed
within the visceral layer of the tunica vaginalis, or within the
substance of the cord.
_Fatty tumors_ may be found, which have originated within the tunica
albuginea, the dartos, or within the fibrous connective tissue of the
cord.
_Cartilaginous tumors_ of small size, originate with the substance of
the gland, and are frequently associated with cystic disease or cancer.
Section IV. THE SEMINAL VESICLES AND PROSTATE.
[=Notice=: 1. _Seminal vesicles_—present or absent; size; distended or
empty; contents. Condition of mucous lining; inflamed, thickened,
ulcerated, perforated; tubercular deposits, etc. 2. _Prostate
gland_—abnormalities; size; density; enlargement of middle or lateral
lobes; color of section; appearance of inflammation; abscess; tumors;
cancer; tubercle. _Contents of ducts_—calculi: their position, size,
etc.]
=Congenital Anomalies.= The vesiculæ seminales participate in the
defective development of the testes, being absent or imperfect when
their related glands are so.
=Inflammation.= It is not uncommon for these bodies to be attacked with
chronic catarrhal inflammation, which causes a swelling of their mucous
membrane, the secretion of unhealthy mucus, dilatation of the cavity,
and thickening of its walls. Ulceration, perforation, and the formation
of abscess in adjacent parts, may result.
=Tubercular Deposits= are occasionally met with, chiefly in cases of
extensive tuberculosis. “It appears as a thick, yellow, cheesy,
lardaceous, fissured, purulent layer, replacing the mucous membrane.” It
never occurs before puberty.
The Prostate Gland.
=Congenital Anomalies.= When the organs of generation are imperfectly
developed, the prostate gland is generally found to be so too.
=Hypertrophy and Atrophy.= _Hypertrophy_ is of frequent occurrence,
especially in connection with old age. All the lobes may be enlarged
equally, or nearly so, or one or the other of the lateral lobes alone,
or the middle lobe, without any corresponding hypertrophy of the
lateral. Hypertrophy of the middle lobe, when considerable, throws the
neck of the bladder forward, and increases the depth of its lower
region, so that calculi may lodge behind and below the prostate in its
cavity. The canal of the urethra becomes lengthened in its prostatic
portion, and may be narrowed by compression, or considerably dilated, so
that the prostatic sinus may contain two or three ounces of urine. The
retained urine decomposing, may cause irritation and inflammation of the
bladder.
The texture of the enlarged gland is generally indurated, though
sometimes it is found to be looser and softer than natural. On section,
the cut surface bulges above the level, and the shades of color are more
strongly marked than in health. Frequently single gland-lobules are
found hypertrophied. Small cavities, dilatations of the gland-follicles,
are occasionally met with, sometimes empty and sometimes containing a
yellow, pus-like fluid, the prostatic secretion in a thickened state.
_Atrophy_, with consolidated texture, is found with atrophy of the
testes.
“_Eccentric atrophy_ is occasionally met with; the cavities are dilated
and the walls thinned, in consequence of the increase in size of
calculous concretions in its follicles. Cases sometimes occur, in which
the whole of one lobe, or even the entire organ, is converted into a
thin fibrous capsule, the proper substance of the gland being almost
wasted.”
=Inflammation.= As a result of suppressed gonorrhœal discharge, the
prostate may be attacked with acute inflammation, followed by
suppuration, or chronic enlargement, or an irritable state of the gland,
with increased secretion.
_Abscesses_, single or multiple, may occur, and open into the bladder,
into the prostatic sinus of the urethra, into the rectum, or, externally
through the perineum.
Ulceration rarely occurs.
Morbid Growths.
_Cancer_ of the prostate is rare; encephaloid is almost the only form
that occurs. The gland is enlarged and the growth may perforate the
mucous membrane of the bladder, and vegetate in its cavity.
_Tubercles_ occasionally occur. Their softening and disintegration give
rise to abscesses, which pursue the same course as inflammatory
abscesses.
_Fibrous tumors_, varying in size from that of a pea to a nut, are of
frequent occurrence; sometimes but loosely attached to the hypertrophied
gland.
_Cysts_ are of extremely rare occurrence, commonly resulting from
closure and dilatation of the gland-follicles.
_Concretions._ “In greater or less numbers, they are of almost constant
occurrence in the prostatic cavities; they may often be seen on making a
section of the gland, as reddish-yellow grains. Their form varies very
much; in the smaller it approaches the oval or circular; in the larger
it is more polygonal or triangular. They are not unfrequently pale or
colorless. The contents of these semiorganized formations appear to be
earthy matter (phosphate, with a little carbonate of lime), tinged by
the ordinary yellow pigment which is so often derived from the blood.
It is most probable that, in ordinary healthy states, these concretions
undergo solution at an early period of their existence, yielding up
their contents to form part of the secretion of the gland. But, if this
does not occur, and they go on increasing in size, they become the
nuclei, or are developed into _prostatic calculi_. These are not
unfrequently very numerous; as many as fifty or sixty have been found in
an atrophied, dilated prostate. The calculi sometimes cohere, and form a
large mass, projecting into the membranous portion of the urethra, which
becomes in consequence much dilated. The smaller calculi often escape
into the bladder through the dilated prostatic ducts; if they remain
there, they excite irritation of the mucous membrane and deposition of
phosphates upon their own surface.”
CHAPTER IV.
THE FEMALE GENERATIVE ORGANS.
Section I. THE PUDENDA AND VAGINA.
[=Notice=: 1. Of the _pudenda_—malformations; condition of the labia
and clitoris; size; color; abrasions; ulcers; eruptions; tumors; marks
of violence, etc. _Orifice of urethra_—growths around, their number
and size. _Hymen_—present or absent; entire or lacerated;
imperforate.]
1. The Pudenda.
=Congenital Anomalies.= In rare cases the external organs are entirely
absent, more frequently but partially developed.
The nymphæ may be found abnormally enlarged.
The clitoris may be abnormally long, perforated, or cleft.
Many of the cases of so-called hermaphroditism are instances of an undue
congenital development of the clitoris, with an irregular development of
the other organs of generation, either external or internal, or both.
=Hypertrophy.= We may find an hypertrophy of the labia, due to a kind of
solid œdema, perhaps originally dependent upon a fissure or ulcer of the
part. The nymphæ are often abnormally enlarged, not necessarily as the
result of an abuse of sexual indulgence. In new-born infants, they
normally project beyond the labia majora. The clitoris occasionally is
enlarged, elongated and pendulous, and, in some cases, attains an
enormous size. A specimen preserved in the Museum of the University of
Bonn, is fourteen inches in circumference and weighs eight pounds. There
is no necessary connection between an habitual sexual indulgence and an
enlarged clitoris.
Varicose swellings of the labia may reach a considerable size, and,
although not generally interfering with parturition, have been known to
be lacerated at that time with fatal issue.
As the result of external violence, or during parturition, suggillations
often occur in the labia, and may give rise to considerable swelling.
The tumor presents a tense, smooth surface, of a livid color, thus
distinguished from a varicose swelling, with the peculiar vermicular
character of its contents.
=Inflammation.= The cutaneous covering, the mucous lining, the cellular
tissue, and the sebaceous and mucous follicles, may be the seat of
inflammation, resulting from external or internal causes.
Eczematous and apthous inflammations may result from derangement of the
digestive organs, from pregnancy, from a want of cleanliness, or from
excessive sexual indulgence, and are of frequent occurrence.
The loose cellular tissue is especially favorable to œdematous swelling,
and when the inflammation has a phlegmonous character, extensive
sloughing may result. It occasionally occurs as an epidemic among those
in early life.
The vulvo-vaginal glands are also liable to inflammation of a catarrhal,
herpetic or syphilitic character, resulting in chronic ulceration, or
tedious discharges. Young children are frequently liable to a benignant
inflammatory affection of these parts, giving rise to much irritation
and a muco-purulent secretion.
Morbid Growths.
_Warty excrescences_, arising from a syphilitic taint, may affect the
labia, the entrance of the vagina, and the clitoris. They consist of
groups of small pedunculated tumors, producing a sort of mushroom
appearance.
_Syphilitic mucous tubercles_ are described as round, flattened
tubercles, raised above the surrounding tissues, sometimes becoming
elongated, of a reddish-blue color, and frequently ulcerated on the
surface.
_Cystic tumors_ are also met with in the labia. They consist of a
membranous envelope, containing a transparent, glairy fluid, and often
attain a large size.
The mucous membrane surrounding the orifice of the urethra, is liable to
an hypertrophy of development, giving rise to small vascular, generally
pedunculated tumors, extremely sensitive during life, and liable to
become abraded.
_Elephantiasis_ may attack the labia majora, the nymphæ, or the
clitoris, and may attain to a great size. It consists of the loose
connective tissue of the part, infiltrated with serum, and covered
either with the smooth skin, or one which has become roughened by
hypertrophy of the papillæ. It may appear as a diffused hypertrophy, or
be furnished with a pedicle, and resemble a polypus.
_Fibrous_, _fatty_ and _scirrhus_ tumors are also met with in this part
of the system.
2. The Vagina.
=Congenital Anomalies.= The valvular fold of membrane which protects the
virgin vagina, the hymen, may be imperforate or much indurated, and of a
cartilaginous consistency. It may thus entirely close the vagina.
Besides this, we may find the vagina terminating in a cul-de-sac, either
with the uterus present or absent, and the ovaries normal or abnormal.
The vagina may also be duplicated, by a septum extending the entire
length of the canal, or only partially dividing it. There may be at the
same time a double uterus. Entire absence of the vagina is also met
with, the internal organs of generation being also absent, or but
imperfectly developed.
=Morbid States.= Occlusion or stricture of the vagina sometimes occurs
as the result of external injury, or of cicatrization of ulcers.
Dilatation, or lengthening of the vagina, also occurs.
The rigidity or laxness of the walls of the vagina, varies much in
different individuals, according to constitution, age, and the effects
of cohabitation and child-birth. Prolonged uterine or vesical disease,
often produces a very lax condition of the mucous membrane of the
vagina. In old women we often meet with this relaxed state, which may
amount to a complete prolapsus. The anterior wall is particularly liable
to be thus affected.
=Laceration and Rupture.= External mechanical injuries may produce
laceration of the vagina. During parturition, either from unusual
rigidity, or from want of care on the part of the attendant, the lower
portion of the canal is apt to give way when the labor pains are at
their height. The lesion may vary from a mere laceration of the
fourchette, to a rupture of the entire perineum, from the vagina to the
anus. Lacerations of the upper portions of the vagina also occur with
rupture of the uterus, or even independently of it.
Lacerations of the vagina are not necessarily fatal, but may result in
vesico-vaginal fistula, where a communication is established between the
bladder or urethra, and the vagina; or in recto-vaginal fistula, where
the fistula opens into the rectum.
=Inflammation.= The mucous membrane of the vagina is frequently the seat
of inflammation. The commonest form is the _catarrhal_, which may be
acute or chronic. In the first stage, the passage is reddened, heated
and dry. This is followed by an abundant secretion of white, creamy
mucus; or of a more purulent discharge, if the inflammation has anything
of a specific character.
_Croupous inflammations_, in connection with general disease, or a
similar disease of the uterus, may occur. They produce a solution of the
mucous membrane and the submucous tissue, varying in shape and depth,
and not unfrequently resembling gangrenous destruction. (Rokitansky.)
A chronic thickening of the mucous membrane, as the result of
inflammation, is occasionally met with.
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.
=Arsenic.= This is the poison most frequently chosen for the purpose of
committing both suicide and murder.
Arsenic produces two classes of phenomena, one is purely irritant, by
virtue of which it induces inflammation in the alimentary canal and
elsewhere; and the other consists in a disorder of parts of organs
remote from the seat of its application. It is absorbed by the blood,
which in most cases of acute poisoning, is found in a remarkable state
of fluidity, and can be detected in the liver, the spleen, and in the
urine. It acts with nearly the same energy, whatever be the organ or
tissue to which it is applied.
From two to three grains have proved fatal, but an instance is recorded
of recovery after a dose of sixty grains. Death may ensue in half an
hour, or may be delayed for nearly three weeks; the usual time is
perhaps from twelve to forty-eight hours. There are some cases in which
little or no morbid appearances are to be seen.
Usually, however, traces of irritation will be discoverable. In the
mouth and throat they are often wanting. The inner surface of the
stomach may be red and inflamed, or blackish from the extravasation of
blood, or softened, or in some cases thickened, with the rugæ raised and
corrugated. Ulceration of the coats of the stomach is but rarely met
with, unless the patient have survived nearly two days. The mucous
secretion is generally increased in quantity, sometimes thin, and
viscid, as in its natural state, but sometimes solid, as if coagulated.
In the latter case, it forms either a uniformly attached pedicle, or
loose shreds floating among the contents.
A very common appearance, is the presence of a sanguinolent fluid, or
even actual blood in the cavity of the stomach.
The poison itself may also be found within the stomach. The intestines
may be congested and inflamed throughout their whole length, but most
frequently only in the duodenum and rectum.
Within the chest, redness of the pleura, redness and congestion of the
lungs, have been noticed.
In general, arsenic retards the process of putrefaction after death.
The forms in which arsenic is most frequently used for the purpose of
poisoning, are arsenious acid, and the arsenite of copper, Scheele’s
green.
=Corrosive Sublimate.= The appearances observed in the bodies of persons
killed by this poison, are very similar to those excited by the irritant
poisons already noticed.
The mouth and throat are more frequently affected than by arsenic. The
tongue is often shrivelled, and the papillæ at its root greatly
enlarged. The mucous membrane is swollen and whitened. The same
appearances are generally noticed in the œsophagus. The coats of the
stomach and intestines, more particularly the colon and rectum, have
been found congested and inflamed, and sometimes destroyed, either by a
chemical decomposition of the tissues, or by ulceration.
The bladder is often excessively contracted; the kidneys usually much
congested and inflamed. Inflammation of the peritoneum, and effusion
into its sac are frequent results of poisoning with corrosive sublimate.
=Hydrocyanic Acid.= The poisons whose energy depends upon the presence
of this acid, surpass almost all others in rapidity of action, and the
minuteness of the quantity in which they operate.
The lesions produced are uncertain. The spine and neck are stiff, the
abdomen retracted, the skin usually livid.
The body, generally the blood, serous cavities, stomach and the various
tissues usually exhale, for some time after death, the characteristic
odor of the acid. Turgescence of the venous system, and emptiness of the
arterial system, are commonly remarked throughout the body. The stomach
and intestines are congested and red. The liver and lungs are gorged
with blood.
=Strychnia—Nux vomica.= In poisoning with this substance, the rigidity
of the body which exists during life, is frequently retained for hours
after death. There is congestion of the membranes of the brain and
spinal cord.
The stomach is frequently quite natural in appearance, as also the
intestines, although occasionally signs of irritation are noticed in
both.
=Alcohol.= In death from alcohol, the body is slow to putrify, and the
internal organs exhale no cadaveric odor, but rather that of recent
flesh, or in some cases a faint odor of brandy. The appearances
constantly found are, hyperæmia of the brain, sometimes cerebral
hæmorrhage; hyperæmia of the large abdominal veins, or hyperæmia of the
lungs and heart, and always visible fluidity and dark color of the
blood.
=Carbonic Oxide.= This is the poisonous ingredient of illuminating gas,
and is generated by burning charcoal. It is usually in one of these
forms that it is the cause of death.
The most characteristic appearance after death, is the bright cherry-red
color of the heart. There is, also, hyperæmia of the lungs and of the
right side of the heart.
=Opium.= In cases of death from this substance, lividity of the skin is
usually present.
Turgescence of the vessels of the brain, and watery effusion into the
ventricles are generally met with.
The lungs are sometimes found gorged with blood. The stomach is
occasionally red, but decided inflammation is rare. The blood is always
fluid, and the body is apt to pass rapidly into putrefaction.
2. Death from Suffocation.
By suffocation is meant that condition in which the system is prevented
from receiving the necessary amount of oxygen through the lungs. The
term is generally restricted to a condition arising from the obstruction
of the air passages, either internally, or from without, or from the
breathing of irrespirable gases. (The latter form being attended also by
blood-poisoning, which we have already noticed.)
The appearances noticed are the following:
The face may be more or less bluish-red, swollen, with protruding eyes,
or differing in no respect from that observed after other kinds of
death. Froth is often observed coming out of the mouth.
There is a universal and unusual fluidity and dark color of the blood.
Hyperæmia of the right side of the heart, while the left is either
entirely empty or contains only a few drachms of blood, hyperæmia of the
lungs and congestion of the pulmonary artery, are seldom wanting.
In the case of new-born children, Caspar has noticed capillary
ecchymoses, resembling petechiæ, beneath the pulmonary pleura, upon the
aorta, or the surface of the heart, and even upon the diaphragm, which
gives the parts a spotted appearance.
The mucous membrane of the larynx and trachea are more or less injected,
of a cinnabar-red, either in patches or uniformly over the whole
surface. A deposit of soot upon the tracheal membrane, points to
suffocation in smoke. There is usually present in the trachea a greater
or less amount of fluid, consisting of a mixture of air, mucus, and
blood, in the form of frothy vesicles, or colorless, or bloody foam. The
more gradual the suffocation has been, the greater the quantity of this
fluid. It may exist also in the bronchial tubes, and can be forced out
by careful pressure on the lungs. Foreign bodies of every kind may be
found in the trachea.
We find also as secondary results of the foregoing, hyperæmia of the
abdominal and cranial organs.
3. Death from Hanging, Throttling and Strangling.
In these cases, death may result from simple cerebral congestion
(apoplexy), from simple congestion of the thoracic organs (cardiac or
pulmonary apoplexy), from a combination of the two (apoplexy and
asphyxia), or, as is very frequently the case, from neuro-paralysis
(nervous apoplexy).
The internal appearances will therefore vary, or, as in the last case,
no lesions can be detected.
The face may in some cases be livid, with protruding eyes and tongue;
but in many cases the countenance is like that of any other corpse.
Turgescence of the male and even of the female genitals has been noticed
in some cases.
The mark of the cord about the neck may be wanting, and is nearly always
more or less interrupted, and presents many varieties of appearance. It
maybe of a dirty, yellowish-brown color, cutting hard and leathery; or
of a bright blue or dirty-reddish color, soft to cut; or it may have
little or no color, and also soft to cut. Patches of excoriation are
also sometimes visible, if the cord have been hard and rough. A similar
mark of the cord may be produced after death.
In cases of throttling, the marks of fingers may often be recognized, as
round or semi-circular, or perfectly irregular patches, of a dirty,
brownish-yellow color, hard to cut, and not ecchymosed. Rarely they are
of a dirty-bluish color and ecchymosed.
4. Death from Drowning.
Physiologically considered, death from drowning is to be regarded as
identical with death from asphyxia or strangling, and hence the results
of the dissection, do not differ from those just mentioned. Those
drowned may die from cerebral hyperæmia, the rarest form; from pulmonary
hyperæmia; from both combined; or from neuro-paralysis. Death from
hyperæmia of the thoracic organs, and death from paralysis, are of
almost equal frequency in cases of drowning. The countenance is pale, in
most cases not swollen, the eyes shut, and when asphyxia has been the
cause of death, there is commonly froth over the mouth. If the body has
been in the water for two or three days in summer, or eight to ten in
winter, the face is rather reddish, or bluish-red—the commencement of
putrefaction, which in bodies in water, begins in the head and extends
from above downwards, and not in the abdominal coverings.
An almost constant appearance is the cutis anserina, a phenomenon
entirely independent of the temperature of the water in which the person
has been drowned.
The hands and feet have a livid, grayish-blue color, and the skin is
corrugated in longitudinal folds, provided the body has not been taken
out of the water within about eight hours after death. Sand, gravel,
mud, etc., are often found under the finger-nails.
Contraction of the penis and scrotum in men who have fallen into the
water alive, is an almost constant appearance.
The lungs are greatly increased in volume, completely fill and distend
the cavity of the chest, and are not firm and crepitating like healthy
lungs, but feel like sponge. The trachea and large bronchial tubes are
frequently filled with frothy mucus. The spasmodic closure of the
glottis, will prevent the entrance of water into the lungs while life
continues, but after death it may enter in small quantities.
In the stomach is often found some of the fluid in which the drowning
has taken place.
CHAPTER V.
MEDICO-LEGAL QUESTIONS.
1. Method of Conducting a Medico-Legal Autopsy.
In making medico-legal examinations of human bodies, the greatest care
must be taken not to omit the examination and recording of any of the
appearances presented; since a point trifling in itself, may, in the
course of the subsequent legal process, prove of great importance.
It may sometimes be necessary for the physician to examine the exact
spot and the locality in which the body has been found, to ascertain the
position in which it was discovered, etc., and also to inspect the
clothing.
In cases of suspected poisoning, the utmost precautions are to be used
in making the autopsy. All the viscera are to be carefully examined, and
the stomach and intestines, with their contents, are to be removed in
the manner already described. They are then to be opened, examined in
separate vessels, either entirely new, or thoroughly cleansed
immediately before being made use of. After a careful examination, they
are to be placed in perfectly clean or new glass jars, without the
addition of any foreign substance; the jars are then to be securely
corked and labelled, and handed over to the chemist for analysis. Should
the jars have to remain any time in the hands of the physician, they are
to be kept under lock and key, in some place to which none but himself
has access. Portions of other organs, especially of the liver, spleen,
kidneys and brain, should also be preserved with the same care for
future analysis.
The results of the examination are to be taken down on the spot, by an
assistant, in ink, and after having been read through by the physician
at the close of the examination, are to be signed by him.
All these precautions will be found of great value, in saving from
innumerable petty annoyances, at the hands of the “learned members of
the bar,” if the case should be brought before court.
In the _external_ inspection of the body, we should notice:
1. _The Sex._ Even after the external parts of generation have been
completely destroyed, the sex may still be ascertained by a reference to
the growth of hair around these parts. A circumscribed arc of hair on
the _mons veneris_, is distinctive of the female, while its
prolongation, however slight, from this point towards the umbilicus,
marks the male.
2. _The Age._ In the case of known bodies this is not of any importance,
in unknown bodies it is, however, necessary. The physician can only
conjecture from appearances, which, even in the living body, are very
deceptive, and he will do well, therefore, to allow tolerably wide
limits to this conjecture.
3. _The Size._ The length of the body must be ascertained by actual
measurement in a straight line, from the crown of the head to the sole
of the heel.
4. _The General Condition of the Body._ Lean or fat, etc.
5. _Color and Condition of the Hair._
6. _Color of the Eyes_, if still recognizable.
7. _Number and Condition of the Teeth._ In the case of unknown bodies,
an accurate description is always advisable, with a view to future
identification.
8. _Special Marks or Deformities._ Scars, tattoo-marks, excess or
defects of limbs, marks of disease, as ulcers, etc., should all be
accurately noted.
9. _Injuries or Wounds_, which appear to have been the cause of death,
should be carefully described. In the case of wounds, their position and
direction with reference to the neighboring fixed points of the body,
and their exact length and breadth, must be recorded.
10. _Of the Body itself_, the parts deserving of particular examination
are the natural openings of the ears, nose, mouth, anus and female
genitals; the neck and the hands.
In the _internal_ examination or dissection, the three great
cavities—the head, thorax and abdomen—should all be opened. In some
cases, it may be important to open also the spinal canal.
The first thing to be observed on opening each of these cavities, is the
position of the organs they contain; next, whether there be any fluid
effusions present; and lastly, the external and internal appearance of
each separate organ. In every case, that cavity should be opened first,
in which there is the greatest probability of finding the cause of
death. In the case of new-born children, however, the abdomen must be
first opened in order that the natural position of the diaphragm may be
observed undisturbed.
In examining the base of the skull for injuries, we must not omit to
remove the periosteum, which might otherwise conceal small fissures.
In examining the thoracic organs, if it be particularly desired to
observe the amount of blood contained in them, and we do not wish to
apply ligatures, we examine the heart first, leaving it in its natural
horizontal position, and opening it by a lateral longitudinal incision
on both sides. This gives us a distinct idea of the actual amount of
blood in all the cardiac cavities. The lungs are next cut into, and last
of all the large blood-vessels. This procedure is to be followed, _e.
g._, in cases of suffocation, where it is of particular importance to
determine the amount of blood in these organs, and where the blood is
peculiarly fluid.
In determining the amount of blood in the venous trunks, it will be
sufficient to examine the _vena cava ascendens_.
In penetrating wounds, the wound is of course to be examined as far as
possible before disturbing any of the organs.
The result of the external and internal examinations, thus thoroughly
conducted, are to be noted down at the time, and are not to be trusted
to memory. It is of the utmost importance that this rule be observed.
In presenting a written or verbal report before court, the physician
should be careful to furnish merely a description of the post-mortem
appearances, and not to give an opinion as to their probable or possible
cause or causes, unless called upon to do so. He should also avoid
prolixity and, as much as possible, the use of technical terms,
unintelligible to nonprofessionals.
His answers to direct questions should be concise and decided if
possible, but where this is not possible, he should not hesitate to
state that the dissection has not afforded him any facts which could
enable him to give a positive answer.
2. Questions relating to New-Born Children.
The body of a dead infant is found, and the physician may be called upon
to answer the following questions, one or all:—Was the child mature? Was
it born alive? If so, what was the cause of its death?
_Was the child mature?_ Among the various signs of fœtal maturity, such
as the firm, tense skin, of the usual pale corpse-color, the hair upon
the head, the weight and length of the body, the diameters of the head,
shoulders and hips, the horny nails reaching to the tips of the fingers,
the absence of the pupillary membrane, etc., the most infallible, is the
presence of the centre of ossification of the inferior femoral
epiphysis. “The easiest way to find this, is to make a horizontal
incision through the skin and superficial tissues over the knee-joint
down to the cartilages. The patella is then to be removed, and the end
of the femur made to protrude through the incision. Thin horizontal
sections are then to be removed from the cartilaginous epiphysis, at
first more boldly, but so soon as a colored point is observed in the
last section, then very carefully, layer by layer, till the greatest
diameter of the osseous nucleus is attained. This appears to the naked
eye as a more or less circular bright blood-red spot in the midst of the
milk white cartilage, in which vascular convolutions can be distinctly
recognized.” When there is no visible trace of this centre of
ossification, the fœtus can be no more than from thirty-six to
thirty-seven weeks old.
In still-born children, the commencement of this nucleus indicates a
fœtal age of thirty-seven to thirty-eight weeks; when it possesses a
diameter of from three-quarters to three lines, it shows the fœtus must
have attained a uterine age of forty weeks. When the osseous nucleus
measures more than three lines, we may conclude that the child has lived
after birth.
Isolated exceptions are occasionally met with, when, however,
concomitant appearances, such as, in the one case, defective
ossification of the skull, or in the other, peculiarly advanced
development, will guard us against mistakes.
_Was the child born alive?_ or, _Did it live during and after its
birth?_ and, _If so, how long?_
These questions are intimately connected, and in order to be able to
answer them, we must in our examination note the following points:
_The position of the diaphragm_, is a good diagnostic sign. The
diaphragm will necessarily be higher where there has been no
respiration, natural or artificial, than where the child has actually
breathed. “Its position is most easily ascertained by making a
longitudinal incision through the skin and superficial cellular tissue,
from the chin to the pubis, in the mesial line, dissecting these from
the thorax on both sides, next carefully opening the abdominal cavity,
introducing the finger of one hand into it, and pressing it up to the
highest point of the concavity of the diaphragm, and then with one
finger of the other hand reckoning off the intercostal spaces from above
downwards till both fingers correspond. The rule is, that the highest
point of the concavity of the diaphragm in children born dead, is
between the fourth and fifth ribs, and in those born alive, between the
fifth and sixth.” Where respiration has been but transitory, the
diaphragm will remain very nearly in its fœtal position.
_The lungs_, from lying quite posteriorly in the fœtus, come to fill the
cavity of the chest, the more perfectly respiration has been
established. In the fœtus, the left lung is never found even partially
covering the heart. Where respiration has been but transitory and
imperfect, the volume of the lungs will not be much increased.
The presence of dark bluish-red, insular patches in the lungs, no matter
what may be their ground color, proves that respiration has taken place.
The crepitant spongy consistence of the lungs of a live-born child, is
readily distinguished from the compact, resistent liver-like lungs of
one still-born.
The hydrostatic test for the presence of air in the lungs, is of all,
the surest for deciding whether respiration has taken place. The vessel
used should be at least one foot in depth, eight or ten inches in
diameter, and filled with pure cold water. The buoyancy of the lungs
depends upon the greater or less completeness with which the pulmonary
tissue is permeated by the air. Only one lung may float, generally the
right one, or only single lobes, or only a few pieces into which the
lung has been and must be divided, in order accurately to apply the
test. Artificially inflated fœtal lungs, may be distinguished from those
lungs which have respired, by the presence, in the case of the latter,
of the bluish-red mottling above referred to, and the escape of bloody
froth when the substance of the lungs is cut into, and slight pressure
applied.
The general appearance of putrescence in the lungs, will serve to
distinguish the buoyancy arising from the gaseous products of
putrefaction, from that due to respiration.
Careful attention to the foregoing points, will enable us to answer with
certainty whether the child was born alive.
_How long did the child live after its birth?_ The question can be
approximately answered with reference to the first few days, by
attention to the following points:
If there are no traces of blood, or of that peculiar unctious substance,
the _vernix caseosa_, on the body, sufficient time must have elapsed
since its birth, to have afforded leisure and opportunity for cleansing
it.
The contraction of the umbilical arteries in living children, does not
occur sooner than after eight or ten hours. The mummification of the
cord commences after two, three, or even four days, and the putrefaction
only after a much longer time. Mummification of the cord takes place as
well after death as before, but not in water, nor in the liquor amnii.
If the umbilicus has already cicatrized, the child must be at least five
days old.
The stomach immediately after birth, contains a small quantity of quite
white, transparent, seldom somewhat bloody, inodorous mucus, very tough,
or a trifling quantity of the colorless liquor amnii. If milk be found,
it shows that some time must have elapsed since the birth.
In the large intestines meconium is still to be found, two, three, or
even four days after birth.
The age of a child, evidently older than five or six days, can only be
determined by general appearances.
_What was the cause of death?_ We will here refer only to those injuries
and kinds of death as can only occur in new-born children, and to those
_post-mortem_ appearances which might lead to error in regard to them.
During labor, death to the child may result from cerebral hyperæmia, or
from injuries to the cranium, which are then unattended by traces of
violence on the body, and are frequently due to imperfect ossification
of the bones, detected by holding the bones up to the light after
removal of the periosteum.
Prolapse and pressure of the cord, and coiling of the cord around the
neck, may produce all the appearances of death by suffocation.
The mark of the cord runs uninterruptedly round the neck, is broad,
circularly depressed, grooved, never excoriated, and everywhere quite
soft. A mummified, parchmentlike, unecchymosed depression, with or
without excoriations, points to intentional strangulation.
Subsequent to birth, the child may have been killed by falling on its
head on the floor, if the birth has been very rapid. The probable
results of such a fall, would be rupture of the cord; premature
separation of the placenta, with its consequences; concussion of the
brain and hyperæmia, or actual hæmorrhage within the skull; and fracture
of the skull bones. The fractures are almost exclusively confined to the
parietal bones, one or both, chiefly in the region of the vertex.
Comminuted fracture of several bones of the skull, speak against an
accidental death by a fall. The absence of any signs of violent usage on
other parts of the body, or about the head, with simple fracture of the
skull, speaks for an accidental death.
The child may also have been suffocated by the mother in violent
attempts at self-delivery. The visible signs of this will consist merely
of scratches and nail-marks upon the face or neck. Very severe injuries
are never produced in this way.
We must be careful not to mistake the common blood-coagulum usually
found under the aponeurosis on the child’s head for the result of
violence; nor the folds of the skin, in fat children particularly in
winter, produced by the movements of the head, and which remain strongly
marked in the solidified fat, for the mark left by the cord in a case of
actual strangulation.
3. Supposed Period of Death.
The answer to the question as to the probable time of death, is often of
the utmost importance. To be able to determine this, we must have regard
to the various appearances following death, previous to putrefaction,
and to the chronological succession of the phenomena of external and
internal putrescence.
=A.= _Signs of Death previous to Putrefaction._
Respiration and circulation have entirely ceased.
The eyes have lost their lustre.
There is no vital reaction to stimulants.
The body grows ashy-white. A particularly florid complexion may retain
its color for some days after death.
Neither the red or livid edges of ulcers, nor red, black or blue
tattoo-marks disappear after death.
An icteric hue existing at death never becomes white, and ecchymoses
retain in every case, the hue they had at the time of death.
Most bodies become quite cold in from eight to twelve hours. Fat bodies
and those of persons killed by lightning, or by suffocation, retain the
heat longer than others; in water, bodies cool rapidly.
A general relaxation of the muscular system occurs immediately after
death.
A body presenting only the above signs, has been dead from eight to
twelve hours at the longest.
In from twelve to eighteen hours the eye-balls become soft and
inelastic, and feel flaccid.
The muscles on those parts of the body on which it lies, become
flattened by the weight of the body.
In from eight to twelve hours after death, hypostases resulting from the
gravitation of the blood in the capillaries, begin to form on all the
depending parts of the body.
The most important are the external hypostases—for they are liable to be
confounded with ecchymoses, and consequently with traces of violence
committed previous to death. An incision into the discolored spot should
always be made, when, if it be an hypostasis—a post-mortem stain—there
will be no escape of effused fluid or coagulated blood, as there will be
if it be an ecchymosis, the result of violence previous to death.
The color of these post-mortem stains varies from a livid or coppery-red
to a reddish blue. They are extremely irregular in form, and are never
elevated above the surrounding skin. They are formed after every kind of
death.
Internal hypostases occur in the brain, in the sinuses and veins of the
pia mater of the posterior hemispheres, even after death from
hæmorrhage. They must not be confounded with cerebral hyperæmia.
In the lungs, hypostases are of constant occurrence, and are carefully
to be distinguished from the signs of ante-mortem pulmonary congestion
and pneumonia.
In the intestines and kidneys, hypostases are also noticed.
In the heart we find no hypostasis, but clots, or “cardiac polypi,”
which are the coagulated fibrine of the blood, formed in most cases
after death. Their presence proves that coagulation of the blood may
take place after death.
The last sign of the earliest stage of death is the _rigor mortis_. It
passes from above downwards, beginning on the back of the neck and lower
jaw, passing on into the facial muscles, the front of the neck, the
chest, the upper extremities, and last of all, the lower extremities. It
begins variously after eight, ten, or twenty hours, and may last from
one to nine days. In the mature new-born infant it is feeble and very
transitory. A low temperature, and the existence of alcoholization,
favor the long duration of cadaveric rigidity. A frozen body is stiff as
a board from head to foot, whereas in rigor mortis the extremities,
particularly at the elbows and knees, preserves a certain amount of
mobility. A body in which only the signs thus far mentioned are present,
may be presumed to have been dead from two to three days at the longest.
=B.= _The Process of Putrefaction._ The progress of putrefaction is
modified by the following conditions:
By age. The bodies of new-born children putrefy more rapidly than
others; those of very aged persons much more slowly.
By the condition of the body. Fat, flabby and lymphatic corpses putrefy
more quickly than lean ones, for an abundance of fluid is very favorable
to decomposition.
By the kind of death. The process is rapid after death from exhausting
diseases, from injuries attended with much mutilation, from suffocation,
from narcotic poisons. It is slower after sudden death in healthy
persons, after death from poisoning with phosphorus, sulphuric acid and
alcohol.
By the access of atmospheric air. Whatever prevents this, retards
decomposition. Thus, bodies buried in the earth, or lying in water, or
clothed, putrefy less rapidly than those exposed to the direct influence
of the air.
By the quantity of moisture, which in addition to its own, can and does
reach the body from without. The more moisture, the more rapid the
process.
By the temperature of the air, or of the water in which the body is
lying. “At a tolerably similar average of temperature, the degree of
putrefaction present in a body after lying in the open air, for one week
(or month), corresponds to that found in a body after lying in the water
for two weeks (or months), or after lying in the earth in the usual
manner for eight weeks (or months.”) (Caspar.)
In bodies lying in the air, external putrefaction begins with a greenish
coloration of the abdominal coverings, in from twenty-four to
seventy-two hours after death, according to the modifying conditions
just noticed. (In bodies lying in water, the process of putrefaction
begins in the face, head as far as the ears, and the upper part of the
neck, with a livid, bluish tinge, rapidly becoming a brick-red, and
proceeds downwards in the same relative manner as about to be
described.) Within the same period, the eye-ball becomes soft, yielding
to the pressure of the finger.
After three to five days from the period of death, the discoloration has
spread over the whole abdomen and external genitals, and spots make
their appearance on other parts.
In from eight to ten days the discoloration has spread over the whole
body, and the peculiar odor is developed. The abdomen is distended with
gas; the cornea has fallen in and become concave. The nails are still
firm.
In fourteen to twenty days after death, the whole body is of a
bright-green, mixed with red and brown. The epidermis is raised here and
there in blisters, and in other parts patches of it are quite stripped
off. Maggots cover the body. From the continued development of gas, the
whole body is bloated, and has a gigantic appearance. The nails are
detached at their roots and lie loose, and are easily separable. The
hair is loose and easily pulled out.
Since this stage may continue many weeks or even months, we cannot
distinguish a body in this state after one month, from one in the same
condition after from three to five months.
After from four to six months, or sooner in the case of bodies that have
lain in warm and moist media, the cavities of the body are opened by the
continued development of gas; the skull has separated from the neck, and
the brain has run out; the orbital cavities are empty; all the soft
parts have commenced to break down into a soft pulp, or are partly
already broken down and dissolved, leaving entire bones exposed. The
bones of the extremities are often separated by the destruction of the
fasciæ and ligaments. No trace of a physiognomy is discernible. The
doubtful sex of the deceased can only be determined from the external
peculiarities of form, or the hair about the pubis, or by the presence
of a uterus, which withstands decomposition longer than any other soft
organ of the body.
_Internally_, the process of putrefaction begins in the trachea and
larynx. The brain in children up to the end of the first year, is next
attacked. Next the stomach, intestines and spleen, and then the omentum
and mesentery. The liver is usually compact and firm, even some weeks
after death. Putrefaction commences on its convex surface. The brain of
the adult follows next in the succession of putrefying organs. Several
months usually elapse before putrefaction of the heart has advanced very
far. In the lungs decomposition begins about the same time as in the
heart, sometimes earlier. The kidneys, urinary bladder, œsophagus,
pancreas, diaphragm and larger arterial trunks then succumb, and last of
all the uterus.
4. The Probable Cause of Death.
Although in general, a careful examination of a body found dead, will
readily reveal the true cause of death, yet instances frequently occur
where attempts at concealing it, or peculiar circumstances in connection
with the death, may render the task more difficult.
We confine ourselves here to a brief notice of some of the more
important points to be kept in view, in rightly estimating the relative
value of post-mortem appearances, and in guarding against possible
mistakes.
Rough handling, falls and blows, occurring a short time after death, may
produce excoriations and pseudo-ecchymoses, which cannot by sight be
distinguished from such as are the result of violence inflicted during
life.
_Wounds_ inflicted during life are distinguished from those inflicted
after death, by the entire absence in the case of the latter, of any
signs of vital reaction, as inflammation, hæmorrhage, suppuration,
swelling or cicatrization of the edges of the wound, etc. But in the
case of very sudden death from wounding of an important organ, these
traces of vital reaction may also be wholly wanting. Again, injuries are
often produced on dead bodies, by the instruments used to recover them
from the places in which they have been discovered.
_Contused wounds_ seldom represent the exact dimensions of the weapon
employed.
Blunt weapons may merely contuse and disfigure, or lacerate, or fracture
bones, or produce rupture of internal organs. Healthy organs never
rupture spontaneously, and can only be ruptured by external violence.
The inspection of the position, direction, depth, breadth, and number of
wounds, compared with the weapon with which they have been inflicted,
often furnish the means of approximately judging of the position of the
perpetrator when he committed the deed, and even his object and bodily
strength.
In judging whether _fractures_ have been produced before or after death,
we must remember that it is very difficult to fracture the bones of a
dead body. Hence, for example, considerable injuries of the cranial
bones, particularly of the base of the skull, have most probably been
produced during life. A fracture of the ribs in the dead body is never
splintered.
In deciding whether a case is one of _suicide_ or _homicide_, besides
the previous state of mind of the deceased, the posture and position of
the body, hands, etc., the appearance of the clothing, and the character
of the wounds or injuries, are the points to be particularly noted, as
well as the absence or presence of evidences of robbery.
_Gunshot wounds_ produced upon dead bodies, are never as deep as similar
ones would be in a living body; the track of the bullet can be
distinctly traced; and the edges of the wound show no appearance of
vital reaction. Hence they can readily be distinguished from such as
have been produced during life.
_Burning_ of a dead body does not in general produce vesication; by
exceedingly intense heat it may, however, be produced. The bullæ,
however, last but a few minutes, never contain serum, but only watery
vapor, and never exhibit any trace of the bounding line of redness, nor
any trace of color on their basis. They are, therefore, easily
distinguished from burns inflicted during life.
In distinguishing between spontaneous apoplexy and _cerebral hæmorrhage_
the result of injuries, it will be sufficient to note that, in the
former case, but a very small amount of blood is effused, so that the
discovery of very extensive and considerable extravasation of blood
within the cranial cavity, can be regarded as a proof of the application
of external violence.
In the case of a dead body found _hanging_, it is in most instances to
be regarded as a case of suicide, unless the examination of the body
should show external marks of violence, or internal signs of death from
another cause.
_Where a body has been found in the water_, the question may arise
whether it was alive or dead when it entered the water. The
investigation of the body will reveal the cause of death. The surest
sign that the body was alive when it was thrown or fell into the water,
is the presence in the stomach of some of the fluid in which it was
lying, if this fluid be such as is never voluntarily drank. Whether the
drowning was a case of suicide or homicide, it is sometimes impossible
to determine. All the various circumstances of time and place, and
concomitant appearances, must be minutely investigated, in order to hope
to arrive at a probable conclusion.
In the case of _supposed poisoning_, where the fact of the
administration of poison has been proved, and the person has died with
symptoms attributable to poisoning, and the post-mortem appearances
reveal no other cause of death—then the death is to be regarded as the
actual results of the poison, whether its existence in the body can be
proved by chemical analysis or not. Only such poisons are used by
suicides as a general thing, as are known to be _certain_ poisons, and
such as have a very disagreeable taste are, from this fact, hardly ever
used for the purpose of murder, except in the case of very small
children, or persons rendered insensible by any means. (Caspar.)
CHAPTER VI.
ON EMBALMING THE DEAD.
From the earliest times, the attention of mankind has been given to the
preservation of the bodies of the dead. With the ancient Egyptians, the
art was carried to its highest degree of perfection. The motive which
led these people to devote so much care to this object, is still
conjectural; yet it would seem to have originated, in part at least, as
a sanitary measure, for preserving the purity and healthfulness of the
atmosphere.
While so little is known of the method by which they produced such
wonderful results, as to have placed the process among what have been
termed the “Lost Arts,” yet, from a careful examination of a large
number of mummies, it would appear that the operation consisted:
_First._ In the removal of the abdominal and thoracic viscera, through
an opening in the left side beneath the ribs; and of the brain through
the nostrils, by breaking through the crebriform plate of the ethmoid
bone; or through the mouth, by boring through the basilar process of the
occipital bone.
_Second._ Subjecting the body for a long time to the action of an
alkali, (natron,) after having filled the cavities with various gums and
spices, etc., and thus removing the fatty portions.
_Third._ A rapid desiccation, after further additions of balsams,
resins, etc.
_Fourth._ Enveloping the whole body in numerous bandages saturated with
gum or bitumen.
Modern nations, have long practiced evisceration, in connection with the
use of various substances for preserving bodies. In the middle ages, the
art of embalming consisted in mixing aromatic substances with salt, and
filling the bodies with the same. Henry I. of England, is said to have
been thus embalmed in 1135. Long and deep incisions were made in various
parts of the body, these filled with the composition, and then carefully
sewed up, the body afterwards enveloped in a beef’s skin, and enclosed
in a coffin.
Louis C. Bils, a nobleman of Holland, and Ruysch, a Dutch physician, in
the latter part of the seventeenth and beginning of the eighteenth
centuries, acquired great celebrity from their success in embalming
bodies. Both died, however, without imparting their secrets to others.
The discovery of the preservative properties of corrosive sublimate in
1762, was soon followed by its employment by Chaussier, Beclard and
Larrey, in the preserving of bodies. Dr. Franchina of Naples, employed
arsenic also, with considerable success; but from the danger to
dissectors, where these poisons had been employed, their use after the
discovery of the preservative properties of chloride of zinc, was quite
discontinued.
The latter substance, with carbolic acid, constitutes the best
antiseptis known at the present time, and these are more generally
employed than any other for preserving dead bodies.
The objects of the process of embalming at the present day, are
threefold: 1st. It permits the delay of burial where this is desirable
from the absence of friends; or of the ready transportation of the
bodies of those who may have died a long distance from home, and that
free from decay and post-mortem change. 2d. As a sanitary measure in
large towns and cities, where many bodies are placed in family vaults,
instead of being buried in the ground. 3d. For the preservation of
bodies for the purpose of anatomical study.
For either of these objects, it is desirable that the process be simple,
easy, quick and inexpensive.
Frequently in the large cities, and occasionally in the country, the
physician will be called upon to perform this operation, but without
some information upon the subject, he will be unable to comply with the
request.
The operation at the present time, consists simply in filling the
vascular system with a preserving fluid, by injecting the same into some
one or more of the arteries; the substance employed being either
carbolic acid or chloride of zinc in solution; the latter, from
possessing greater preserving power without the disagreeable odor of the
carbolic acid, being much more frequently employed.
_Preparation of the Zinc._ In the large cities, the chloride of zinc may
be obtained of the manufacturing chemists ready made; but in the
country, the physician may manufacture the solution himself, by the
following process:
Place in an open stone jar, ten pounds of muriatic acid, and add to the
same, old scrap sheet zinc, _ad libitum_. It should be frequently
stirred, and allowed to stand in the open air for from twelve to
twenty-four hours, or until the acid has so acted upon the zinc as to
have become thoroughly neutralized, forming thus a saturated solution of
the chloride of zinc.
The quantity required of this solution to preserve a body, will depend
upon the state of the weather, in connection with the size of the body,
cause of death, etc.; more being required in hot weather, or in a large
body, or in such diseases as are followed by a tendency to rapid
putrefaction. In all cases, however, the rule should be to _throw in as
much as the vessels will hold_, varying the strength according to the
weather, character of the body, etc. With young, thin subjects, and cool
weather, the chloride may be diluted one-half with water; but in warmer
weather, and with a large body full of fluids, a proportion of
two-thirds zinc, or even stronger may be required. It will be well to
commence by throwing in a weaker solution, which, by not constringing
the small vessels, will pass more readily into the extremities, and
follow by a stronger for filling the large vessels of the trunk.
Dr. Vivodtsef of St. Petersburg, employs a mixture of carbolic acid and
alcohol. Taking alcohol of about ninety degrees, he adds one-fifth its
weight of carbolic acid; there being required of this mixture, a
quantity equal to about one-half the weight of the body to be injected.
It may be thrown into the vessels in the same manner as the solution of
the chloride of zinc. The high price of alcohol in this country, would
constitute an objection to the use of this substance, even if it afford
advantages over the zinc, which it probably does not.
_Instruments Required._ For the satisfactory performance of this
operation, there will be required the _anatomical syringe_. This
instrument consists of a brass cylinder and piston, of a capacity of
twelve to sixteen ounces, with a movable stop-cock, and series of
graduated pipes for arteries of different size. Each pipe has a small
rim or shoulder at the point to be introduced into the vessel, above
which the ligature is applied, which thus holds the pipe more securely
in its position.
The absence of the anatomical syringe should not, however, deter the
physician from attempting this operation, as, by a little preparation,
the common gum-elastic family syringe, of the Mattson or a similar
pattern, may be made to answer the purpose. The point of the small or
child’s rectum pipe may be reduced with a file, and a shoulder prepared,
about one-fourth of an inch from the end, for securely holding it when
tied in the vessel.
An apparatus of a complicated character, and working by atmospheric
pressure, has been devised for this purpose; but while it possesses very
few advantages over the syringe described, it is expensive and not
easily managed.
_The Operation._ In the dissecting-room, it is usual to open the chest
and inject through the arch of the aorta; but in other cases, one of the
common carotids, and better the right, may be selected. Extend the head,
placing thus the muscles upon the stretch, and along the inner border of
the right sterno-cleido-mastoid muscle, make an incision two inches in
length, through which may be exposed the upper portion of the common
carotid artery. After detaching the vessel from the surrounding
structures, it should be raised upon the handle of a scalpel and two
ligatures passed around, one of which is to be tightly tied, high up,
upon the vessel. Below this, a longitudinal slit, one-half inch in
length, should be made in the vessel, for receiving the pipe of the
syringe, which, when in position, should be securely tied with the
second ligature, just above the rim. The stop-cock joint may now be
fitted to the pipe.
To permit of the escape of as much of the blood as possible, an opening
may be made into the jugular vein, ligatures being passed beneath the
vessel—one above and one below the opening—that it may be closed at the
proper time.
The antiseptic fluid having been prepared in a convenient vessel, the
syringe, after having been carefully examined and found in good working
order, should be slowly filled, adjusted to the stop-cock joint, the
cock opened, and the syringe slowly discharged. Shutting off the cock,
to prevent escape of the fluid, the syringe may now be detached,
refilled and again discharged, the process being repeated until the
vessels are filled with the fluid, which may be known from the
resistance offered to its introduction. After a few syringefuls have
been thrown into the vessels, the blood will be seen flowing more or
less freely from the jugular, and which will gradually change to the
clear antiseptic fluid; then the vessel may be tied, to prevent any
further loss.
To facilitate the flow of the fluid into the vessels of the extremities,
free flexion and extension of all the limbs should be made; and after
some minutes, another effort made to force in more of the fluid. A
successful filling of all the vessels may be known by the distension of
the superficial veins of the chest and arms, accompanied with an escape
of a dark fluid from the nostrils and, perhaps, mouth, from an oozing of
the fluid through the capillary vessels of the mucous membranes of the
head.
If the extemporized gum syringe be used, its pipe should be tied in the
vessel as in the other case, the opposite end of the tube placed in the
vessel of fluid, and the same thrown in by pressure of the ball. The
operation being completed, a ligature should be tightly placed around
the artery below the pipe, the latter removed and the incision sewed up.
_Changes Resulting from the Operation._ As the vessels become filled
during the operation, the abdomen will gradually swell, the chest become
more round and full, the face and eyelids become puffy, while the
superficial veins will appear full and dark from the contained blood. In
a few hours the skin assumes a pale, ashen hue, with a parchmentlike
feel, which will be a sure indication of the success of the operation.
In a few days the puffed appearance of the face will have disappeared,
when no further change will be noticed, until after several weeks the
ears, with the tip of the nose, and ends of the fingers, begin to
shrivel and dry up.
CHAPTER VII.
PRESERVATION OF SPECIMENS OF MORBID ANATOMY.
Many valuable and interesting pathological specimens are continually
being lost, from a want of knowledge, or a careless neglect on the part
of the physician. That the fullest benefit may result from a post-mortem
examination, any rare or interesting specimen should be carefully
preserved. Should the physician feel no interest in forming a cabinet of
morbid anatomy for himself, he should then deposit the specimen in the
anatomical museum of some medical school, where it may be permanently
preserved, and the profession thus benefited.
All specimens of _soft tissues_ designed for preservation, should first
be soaked in water which is changed daily, until all blood is removed.
If the weather be warm, it will be necessary to add to the water each
time, either a small proportion of alcohol, or some antiseptic, as
carbolic acid, chloride of zinc, corrosive sublimate, or common salt.
After all blood is removed, the specimen may be put into alcohol of a
strength proportionate to the size of the specimen, and then allowed to
remain until thoroughly “cured.” Small specimens are dried up, shrunken
and nearly spoiled in many cases, by the use of too strong alcohol,
while on the other hand, large ones, by diluting the alcohol with the
large amount of water contained, would be likely to spoil in a weak
preparation. Large specimens, particularly in warm weather, should have
deep incisions made at a few points, for the better penetration of the
preserving fluid.
Before being permanently put up, the specimen should be carefully
trimmed, and everything interfering with the best display of the
essential point removed.
While either of the antiseptics mentioned above will answer for “curing”
a specimen, for permanent suspension, there is no substitute for
alcohol. Other fluids may preserve, but they will also become turbid,
throw down a precipitate, and in cold weather are liable to freeze,
while from their high specific gravity, many light specimens will float
on or near the surface. If the specimen has been thoroughly “cured”
before suspension, very dilute alcohol will answer for that purpose:
equal parts of pure water and alcohol of ninety-five degrees, in all
except the larger specimens, being abundantly strong. Delicate, light
specimens will sometimes float in such a dilution, in which case it
should be made stronger.
The best form of anatomical jar is made with ground glass stoppers, with
a hook on the under side of the latter for suspending the specimen.
Although expensive, these jars, by effectually securing the alcohol from
evaporation, as well as from the greater facility with which the spirits
may be changed, which will sometimes be required, will give better
satisfaction than any other.
Where the common jar without a stopper is used, great care will be
required in closing up, to prevent loss by evaporation. There should
first be prepared a circular plate of thick sheet lead, to rest on the
top of the neck of the jar. The specimen having been suspended by a
string, carried through by a large needle, and at two different points,
is to be fastened to the disk of lead by means of two holes, punched by
an awl, about half an inch apart, near the centre. The portion of string
above the lead, with the holes also, should now be carefully covered
with sealing-wax, otherwise, by capillary attraction, the alcohol will
keep the bladder covering continually wet, and finally rot it out. Over
the lead is now to be stretched a piece of moistened bladder, and wound
with twine around the neck of the jar. When dry, this is to be covered
with a coat of black varnish; this again when dry, being followed by a
second layer of bladder and varnish.
Wet preparations should be kept where they may have a free exposure to
sunlight. If placed in a dark closet, they become damaged in texture,
and acquire a dark and unpleasant color; this is particularly the case
with the ligamentous and nervous tissues.
Dr. Brunetti of Padua, who has invented a new process for preserving
certain kinds of specimen, and who received a gold medal some years ago
at the Paris Exposition, gives the following particulars of his method:
“The process comprises four several operations, viz.: 1, the washing of
the piece to be preserved; 2, the _degraissage_, or eating away of the
fatty matter; 3, the tanning, and 4, the desiccation.
“1. To wash the piece M. Brunetti passes a current of pure water through
the blood-vessels and the various excretory canals, and then he washes
the water out by a current of alcohol.
“2. For destroying the fat he follows the alcohol with ether, which he
pushes, of course, through the same blood-vessels and excretory ducts;
this part of the operation lasts some hours. The ether penetrates the
interstices of the flesh and dissolves all the fat. The piece, at this
point of the process, may be preserved any length of time desired,
plunging it in ether, before proceeding to the final operations.
“3. For the tanning process M. Brunetti dissolves tannin in boiling
distilled water, and then, after washing the ether out of the vessels
with distilled water, he throws this solution in.
“4. For the drying process Dr. Brunetti places the pieces in a vase with
a double bottom filled with boiling water, and he fills the places of
the preceding liquids with warm, dry air. By the aid of a reservoir, in
which air is compressed to about two atmospheres, and which communicates
by a stop-cock and a system of tubes, first to a vase containing
chloride of calcium, then with another heated, then with the vessels and
excretory ducts of the anatomical piece in course of preparation, he
establishes a gaseous current which expels in a very little time all the
fluids. The operation is now finished.
“The piece remains supple, light, preserves its size, its normal
relations, its solid elements, for there are no longer any fluids in it.
It may be handled without fear, and will last indefinitely.”
For the preservation and hardening of tissues for microscopic
examination—as sections of tumors, glands, membranes, spinal cord or
brain, etc.—Müller’s fluid may be employed, which is prepared as
follows: bichromate of potassa, 75 grains; sulphate of soda, 35 grains;
dissolved in six ounces of water. The specimen should be suspended in
this fluid until sufficiently hardened to permit of a satisfactory
examination.
Preparation of Bones.
Pathological specimens of bones, may be prepared either by boiling or
maceration. The method by boiling should be employed, however, only
where the texture of the specimen is firm and solid, as in cases of
united fracture, etc.; and in these cases, care will be required to
avoid injuring the specimen by too long exposure to the process.
Maceration, however, is the better method for all cases, and the only
one to be employed in cases where the bone is softened by caries or
necroses.
The specimen having been roughly stripped of the soft tissues, is to be
thrown into a vessel of water, the latter being changed every day, as
long as it becomes colored by the blood. It is now to be left until the
putrefactive process has so softened the tissues that they may be easily
removed, when, after being thoroughly washed in soda water, it may be
dried and mounted. If the weather be cold, it will be absolutely
important that the macerating be conducted in a warm room, else the
process will be so slow as to convert the tissues into a form of
adipocere, quite arresting the putrefactive process, and greatly
damaging the specimen in its beauty and value.
In this connection, it may be observed that bones from a subject that
has been injected with chloride of zinc, can never be successfully
macerated, the zinc having a sort of tanning effect upon the tissues,
which enables them to resist the putrefactive process. Boiling is the
only method by which such specimens can be cleansed.
Where a bone has been properly macerated and dried, and especially if
from a young subject, it will be found white and quite free from grease;
but when taken from old subjects, or when prepared by boiling, it may be
required to be subjected to a bleaching process for removing the grease
and improving the color. By exposure to the sun, with frequent washing
in chlorine and soda water, the appearance of the specimen may be
greatly improved, or what is still better, by covering the specimen for
a few days in sulphuric ether, which will effectually dissolve out all
the grease, and then washing and exposing to the sun for a few days, it
will be left beautifully white and clean.
For permanent preservation, the specimen should finally be mounted on a
block or board, in such a manner as best to expose its interesting
points.
INDEX.
PAGE
Abdomen, method of opening, 127
Abdominal dropsy, 135
Alcohol, poisoning by, 299
Anatomical syringe, 323
Anus, diseases of, 157
fistula of, 157
hæmorrhoids, 159
ulcer in, 157
Aorta. (See _Arteries_.)
Apoplexy, cerebral, 41
pulmonary, 115
Arachnoid, examination of, 38
Arsenic, poisoning by, 297
Arthritis, chronic rheumatic, 271
scrofulous, 271
Arteries, aneurism of, 99
calcification of, 99
examination of, 98
fatty degeneration of, 99
inflammation of, 98
ossification of, 99
rupture of, 102
Arteries, cerebral.
atheromatous degeneration of, 60
calcification of, 60
obstruction of, 59
position of clot in obstruction of, 59
Atresia ani, 149
urethræ, 212
Autopsy, medico-legal, method of conducting, 304
Biliary calculi, 188
effects of, 190
position of, 189
Bladder, gall-. (See _Gall-bladder_.)
Bladder, urinary.
contraction of, 210
catarrh of, 210
cancer of, 211
dilatation of, 209
examination of, 208
hypertrophy of, 209
inflammation of, 210
malformations of, 208
parasites in, 212
removal of, 131
tubercles in, 211
tumors in, 211
Bones, abscess of, 259
cancer of, 266
caries of, 260
examination of, 259
inflammation of, 259
morbid growths in, 263
necrosis of, 260
rickets in, 261
suppuration of, 259
tumors in, 263
tubercles in, 265
Brain, appearance of, in health, 48
abscess of, 50
atrophy of, 53
blood cysts in, 59
calcareous deposits in, 56
examination of, 29
hardening of, 51
hypertrophy of, 52
hydatids in, 57
inflammation of, 47
membranes of, 36
removal of, 29
softening of, 48
tumors of, 54
Bright’s disease, 197
cirrhotic or contracting form, 201
inflammatory form, 197
waxy or amyloid form, 200
Bronchial tubes, dilatation of, 125
examination of, 106, 122
inflammation of, 123
narrowing of, 124
obliteration of, 124
Bronchitis, 123
Buccal cavity, examination of, 65
Burning, ante-mortem distinguished from post-mortem, 318
Cancer, of bones, 266
black, 291
colloid, 292
encephaloid, 291
epithelial, 293
of gall-bladder, 188
Cancer, of heart, 84
hard, 290
of intestines, 158
of kidneys, 204
of liver, 177
of lungs, 120
of mammæ, 256, 257
of mediastinum, 126
medullary, 291
melanotic, 291
of ovaries, 250
of œsophagus, 73
of penis, 217
of prostate gland, 228
of pancreas, 161
of peritoneum, 136
of spleen, 165
of suprarenal capsules, 208
of scrotum, 219
of stomach, 146
of scirrhus, 290
of testicles, 224
of tongue, 68
of ureters, 206
of urinary bladder, 211
of urethra, 214
of uterus, 240
of vagina, 234
Calculi, urinary, 214
Calvarium, removal of, 28
Carbonic oxide, poisoning by, 299
Carditis, 76
Cerebral arteries, 59
Cerebritis, 48
Cerebro spinal meningitis, 61
Chest, examination of, 65
Children, new-born, medico-legal question relating to, 307
Chloride of zinc, preservative properties of, 321
Colon, removal of, 128
Corrosive sublimate, poisoning by, 298
preservative properties of, 321
Cystitis, 210
Death, signs of, previous to putrefaction, 312
probable cause of, 317
Diphtheria, false membranes in, 71
Disinfectants for instruments, 24
Dropsy of abdomen, 135
of brain, 40
of chest, 103
of heart, 74
of ovaries, 248
of testes, 222
Drowning, death from, 302, 309
Duodenum, removal of, 129
Dura mater, inflammation of, 36, 61
fibrinous clots in, 37
thickening of, 37
tubercular deposits in, 38
tumors in, 38
Ear, examination of, 31
removal of, 29
Embalming, method of, by ancients, 320
objects of, 321
instruments required, 323
the operation, 324
changes resulting from, 325
Embolism of cerebral arteries, 59
Endocarditis, 77
Enteritis, 149
Epididymitis, 221
Epispadias, 212, 215
Exostoses, 263
Eyes, removal of, 32
Fallopian tubes, anomalies of, 251
inflammation of, 251
morbid growths in, 251
Fistula in ani, 157
Fractures, ante-mortem distinguished from post-mortem, 318
Ganglions, 270
Gall-bladder and ducts, 187
cancer of, 188
dilatation of, 188
gall-stones in, 189
inflammation of, 187
tumors in, 188
tubercles in, 188
Gastritis, 141
catarrhal, 141
croupous, 141
phlegmonous, 141
Gums, examination of, 65
Gunshot wounds, ante-mortem distinguished from post-mortem, 318
Hanging, death from, 301, 319
Hæmatocele, 223
Hæmoptysis, 114
Hæmorrhage, pulmonary, 114
uterine, 237
Hæmorrhoids, 157
Head, caries of bones of, 35
examination of, 27
removal of membranes of brain, 28
removal of calvarium, 28
removal of brain, 29
thickening of bones of, 35
thinning of bones of, 35
Heart, atrophy of, 82
abscess of, 86
aneurism of, 86
cancers in, 84
displacements of, 87
dilatation of, 80
ectopia cordis, 88
examination of, 66, 75
fatty degeneration of, 82
fatty growth of, 82
hydatids in, 86
hypertrophy of, 79
inflammation of, 76
melanosis of, 84
malformations of, 86
morbid condition of, 75
normal size of, 80
ossification of arteries of, 85
rupture of walls of, 87
stenosis of, 79
tumors in, 84
transposition of, 88
valves of, 77
Heart clots, causes of, 91
color of, 89
consistency of, 89
time of formation of, 90
position of, 89
Hepatitis, 168
Hernia, 154
Hydrarthrosis, 268
Hydrothorax, 104
Hydrocele, 222
congenital, 222
diffused, 223
encysted, 222
simple, 222
Hypospadias, 212, 215
Hydrocyanic acid, poisoning by, 298
Instruments, 21
disinfectants for, 24
Intestines, cancer of, 158
contraction of, 153
dilatation of, 153
displacement of, 154
examination of, 149
inflammation of, 150
incarceration of, 155
malformations of, 149
obstructions of, 155, 156
parasites in, 159
rupture of, 157
tubercles in, 158
tumors in, 158
ulceration of, 152
wounds of, 157
Intussusception, 156
Joints, bursæ of, morbid conditions of, 269
cartilage of, morbid conditions of, 270
inflammation of synovial membrane, 268
malformations of, 268
rheumatic inflammation of, 271
scrofulous inflammation of, 271
Kidneys, anomalies of, 194
abscesses of, 196
Bright’s disease of, 197
congestion of, 194
cancer of, 204
cysts in, 204
dislocation of, 203
examination of, 193
fatty degeneration of, 202
hæmorrhage of, 195
inflammation of, 195
inflammation of capsule of, 197
parasites in, 205
removal of, 129
size and weight of, 193
tubercles in, 203
Larynx, abscesses of, 71
examination of, 64, 65, 69
false membranes in, 71
inflammation of, 69
necrosis of cartilages of, 70
œdema of, 70
tumors of, 71
ulceration of, 70
Liver, abscess of, 169, 171
atrophy of, 174
blood-vessels of, 182
congestion of, 166
cancer of, 177
degenerations of, 171
examination of, 130, 165
effusion hæmorrhagic of, 167
fatty, 172
hypertrophy of, 177
inflammation of, 168
parasites in, 183, 186
removal of, 130
size of, 165
tubercles in, 181
tumors in, 182
Lungs, appearance in health, 107
appearance, post-mortem, 118, 120
abscess of, 111
apoplexy of, 115
congestion of, 107
cancer of, 120
examination of, 67, 106
emphysema of, 116
gangrene of, 112
hepatization of, 108
hæmorrhage of, 114
hydatids in, 122
inflammation of, 107, 109
melanosis of, 121
suppuration of, 110
tubercles in, 117
tubercular cavities in, 119
tumors in, 122
Mammæ, anomalies of, 252
atrophy of, 252
abscesses of, 253
cancer of, 256, 257
examination of, 252
inflammation of, 253
tumors in, 254
ulcers in, 254
Medico-legal questions, 304
external inspection of body, 305
internal examination, 306
Mediastinum, abscess of, 126
cancerous growths in, 126
inflammation of, 126
tumors of, 126
Medulla, spinalis, 62
oblongata, effusions in, 43
of bone, disease of, 267
Membranes of the brain.
appearance of, in meningitis, 39
examination of, 36
morbid changes of, in insanity, 40
removal, of 28
serous effusion into, 40
sanguineous effusion into, 41
Membranes, spinal, tuberculous deposits in, 61
tumors in, 61
Meningitis, 39
cerebro-spinal, 61
tubercular, 38
Metritis, 237, 242
Metrophlebitis, 243
Morbus Brightii, 197
Mouth, catarrhal or croupous inflammation of, 72
examination of, 64
Myelitis, 62
Müller’s fluid, 329
Neck, examination of, 64
Nephritis, 195
Nitric acid, poisoning by, 295
Nux vomica, poisoning by, 299
Œsophagus, cancer of, 73
dilatation of, 73
examination of, 72
inflammation of, 72
stricture of, 72
tumors in, 73
ulceration of, 72
Opium, poisoning by, 300
Orchitis, 221
Osseous growths, 263
Osteomalacia, 262
Osteophytes, 263
Ovaries, abscesses in, 247
cysts in, 248
dropsy of, 248
examination of, 247
inflammation of, 247
malignant disease of, 250
tumors, tubercles, etc., of, 251
Oxalic acid, poisoning by, 295
Palate, examination of, 65
Pacchionian bodies, 39
atrophy of, 161
Pancreas, anomalies of, 160
cancer of, 161
dilatation of ducts, 161
examination of, 160
fatty degeneration of, 161
hypertrophy of, 161
inflammation of, 161
removal of, 129
Parasites in bladder, 212
in brain, 57
in heart, 86
in intestines, 159
in kidneys, 205
in liver, 183, 186
in lungs, 122
in spinal cord, 63
Pelvic viscera, removal of, 130
Penis, anomalies of, 215
atrophy of, 215
balanitis of, 216
chancres on, 216
cancer of, 217
examination of, 215
fracture of, 216
hypertrophy of, 215
herpes of, 216
paraphymosis of, 216
psoriasis of prepuce, 216
tumors of, 218
warts on, 217
Pericardium, adhesions in, 74
blood in, 74
examination of, 73
inflammation of, 73
morbid growths in, 75
Peritoneum, blood in result of violence, 135
congestion of, 133
cancer of, 136
dropsical accumulation in, 135
exudation, fibrinous, on, 134
examination of, 133
gangrene of, 135
inflammation of, 133
suppuration of, 135
tubercular deposits in, 136
tumors of, 136
Peritonitis, 133
puerperal, 243
Perihepatitis, 167
Peripractitis, 151
Perityphlitis, 151
Pharynx, examination of, 65, 72
inflammation of, 72
tumors in, 73
ulceration of, 72
Phosphorus, poisoning by, 296
Pia mater, examination of, 38
inflammation of, in spotted fever, 61
Pleura, adhesions in, 103
examination of, 103
effusions into, 103
inflammation of, 103
Pleurisy, 103
Pneumonia, catarrhal, 109
croupous, 110
double, 109
lobular, 110
single, 109
Pneumothorax, 105
Poisoning, death from, 294
Post-mortem examinations, 24
preliminary preparations for, 24
in medico-legal cases, 304
Pregnancy, abdominal, 244
extra-uterine, 244
tubal, 245
utero-tubal, 245
Preparation of bones, 329
by boiling, 329
by maceration, 329
bleaching of, 330
Preservation of specimens of morbid anatomy, 326
process of Dr. Brunetti, 328
Prolapsus of rectum, 157
Prostate gland, anomalies of, 227
atrophy of, 228
cancer of, 228
cysts in, 228
concretions in, 229
examination of, 226
hypertrophy of, 227
tubercles in, 228
tumors in, 228
anomalies of, 230
Pudenda, examination of, 230
elephantiasis of, 232
hypertrophy of, 230
inflammation of, 231
tubercles in, 232
tumors in, 232
warty excrescences on, 231
Putrefaction, process of, 314
Pyelitis, 196
Pyelonephritis, 196
Questions relating to new-born children, 307
was the child mature?, 307
was it born alive?, 308
how long did it live?, 310
what was the cause of death?, 311
Rachitis, 261
Rectum, prolapsus of, 157
removal of, 128
Sclerosis of spinal cord, 62
Scrotum, cancer of, 219
examination of, 218
elephantiasis of, 218
hypertrophy of, 218
inflammation of, 219
Seminal vesicles, anomalies of, 226
examination of, 226
inflammation of, 226
tubercles in, 227
Signs of death, 312
Skull, caries of bones of, 35
examination of, 34
fracture of, 34
thinning of bones of, 35
thickening of bones of, 35
Spinal cord, atrophy of, 63
examination of, 60
inflammation of membranes of, 60
morbid growths in, 63
parasites in, 63
preservation of specimens of, 33
removal of, 33
softening of, 62
Spinal column, disease of, 272
Spinal canal, serous effusions in, 61
Spina bifida, 61
Spleen, anomalies of, 162
atrophy of, 162
cysts in, 165
cancer of, 165
displacements of, 163
degeneration of, 164
examination of, 162
hypertrophy of, 162
inflammation of, 163
removal of, 129
rupture of, 163
size of, normal and abnormal, 162
thickening of capsules of, 164
tubercles in, 164
Spotted fever, inflammation of pia mater in, 61
Stomach, atrophy of, 145
Beaumont’s experiments on, 140
cirrhosis of, 144
cancer of, 146
cancer in, results of, 148
dilatation of, 145
examination of, 137
erosions, hæmorrhagic, of, 143
inflammation of, 140
post-mortem changes in, 137
poisons in, and their effects, 142
softening of, 143
tumors in, 148
ulcers in, 142
Strangling, death from, 301
Strychnia, poisoning by, 299
Suffocation, death from, 300
Sulphuric acid, poisoning by, 294
Suprarenal capsules, 207
cancer of, 208
cysts in, 208
hæmorrhage of, 208
inflammation of, 207
tubercles in, 208
Testicles, atrophy of, 220
anomalies of, 219
cancer of, 224
cystic disease of, 225
dropsy of, 222
examination of, 219
hæmatocele of, 223
hypertrophy of, 220
inflammation of, 221
tubercles in, 225
tumors in, 226
varicocele of, 223
Teeth, examination of, 65
Throttling, death from, 301
Thrombi in sinuses of dura mater, 37
Tongue, cancer of, 68
examination of, 68
hypertrophy of, 69
ranula of, 68
syphilitic ulcers of, 68
tubercles of, 68
tumors of, 68
Tonsils, catarrhal or croupous inflammation of, 72
examination of, 65
Tubercular disease of lungs, 117
tubercular cavities in, 119
meningitis, 38
Tumors, adenoid, 285
benign, 274
in brain, 54
in bones, 263
in bladder, 211
classification of, 274
cystic, 274
cartilaginous, 280
carcinomatous, 288
in dura mater, 38
fatty, 279
fibrous, 279
in Fallopian tubes, 251
in gall-bladder and ducts, 188
hydatid, 277
in heart, 84
in intestines, 158
lipomatous, 279
lymphatic, 285
in larynx, 71
in lungs, 122
in liver, 182
myxomatous, 278
myomatous, 284
malignant, 286
in mediastinum, 126
in mammæ, 254
neuromatous, 284
osseous, 281
in œsophagus, 73
in ovaries, 251
papillary, 282
polypoid, 283
in pharynx, 73
in pericardium, 75
in peritoneum, 136
in pudenda, 232
in prostate gland, 228
in penis, 218
sarcomatous, 286
in spinal cord, 63
in stomach, 148
in tongue, 68
in testicles, 226
in uterus, 238
in vagina, 234
vascular, 284
Ureters, cancer of, 206
cysts in, 207
defects of, 205
dilatation of, 206
inflammation of, 206
tubercles in, 207
Urethra, contraction of, 213
cancer of, 214
dilatation of, 213
inflammation of, 212
malformations of, 212
rupture of, 213
stricture of, 213
tubercles in, 214
warty growths in, 213
Uterus, anomalies of, 235
atrophy of, 236
cysts in, 240
cancer in, 240
examination of, 235
excrescences, cauliflower, etc., 241
hæmatometra, 236
hypertrophy of, 236
hydrometra, 236
hæmorrhages of, 237
inflammation of, 237, 242, 243
malpositions of, 236
removal of, 132
rupture of, 241
tubercles in, 240
tumors in, 230
ulcerations of, 238
Vagina, anomalies of, 232
dilatation of, 232
examination of, 230
gangrene of, 234
inflammation of, 233
laxity of, 232
laceration of, 232
rigidity of, 232
rupture of, 233
stricture of, 232
tumors of, 234
Valves of heart, aneurism of, 79
atrophy of, 78
calcification of, 78
contraction of, 79
thickening of, 77
Volvulus, 156
Vulva. (See _Pudenda_).
White swelling, 271
Wounds, death from, 317
contused, appearance of, 317
post-mortem distinguished from ante-mortem, 317
Zinc, preparation of, for embalming, 322
quantity of, required, 322
ERRATA.
On page 21, last line, for “culvarium,” read calvarium.
„ 25, fifteenth line, for “collodian,” read collodion.
„ 79, last line, for “that organ,” read those organs.
„ 93, thirteenth line, for “affords,” read afford.
-----
Footnote 1:
Toynbee on the Ear.
Footnote 2:
See No. 509, College Museum.
Footnote 3:
Id, 473.
Footnote 4:
See No. 490, College Museum.
Footnote 5:
“Morbid Anatomy of the Brain, in Mania, &c.,” by Andrew Marshall, M.
D.
Footnote 6:
See No. 1386, Case T, College Museum.
Footnote 7:
See No. 1295, Case R, College Museum.
Footnote 8:
See No. 1385, College Museum.
Footnote 9:
See No. 1387, College Museum.
Footnote 10:
Paget’s Pathology, p. 586.
Footnote 11:
Medico-Chirurgical Trans. xvii. p. 507.
Footnote 12:
See Hahnemannian Monthly for May, 1871.
Footnote 13:
In one case, the clot presented a marked resemblance to the abdominal
fat of the goose, both in color and consistency.
Footnote 14:
Meigs’ Treatise on Obstetrics, p. 308.
Footnote 15:
No. 1470, College Museum.
Footnote 16:
No. 1344, College Museum.
Footnote 17:
No. 1385, College Museum.
Footnote 18:
See article on Spontaneous Cure of Aneurism, with cases in New York
Transactions of Homœpathic Medical Society for 1868, page 170.
Footnote 19:
See case of recovery reported by Dr. R. Koch, in American Jour. of
Hom. Mat. Med., Vol. IV., p. 123.
Footnote 20:
See Nos. 1309 and 1351, College Museum.
Footnote 21:
See No. 1506, College Museum.
Footnote 22:
Jones and Sieveking’s Pathological Anatomy.
Footnote 23:
Cirrhosis, as applied to this condition of the liver, has reference to
the yellow color, due to the presence of large quantities of yellow
pigment contained in the secreting cells; hence the application of the
term to diseases of the lungs, kidneys, etc., which resemble cirrhosis
of the liver, not in color, but in density of the tissues, is
obviously inappropriate.
Footnote 24:
See No. 1495, College Museum.
Footnote 25:
See No. 1496½, College Museum.
Footnote 26:
See report of case of “Ossification of Veins,” by James Kitchen, M.
D., in American Journal of Homœopathic Materia Medica for December,
1871, page 143.
Footnote 27:
See No. 1500, College Museum.
Footnote 28:
Specimen No. 1329, College Museum.
Footnote 29:
See No. 1336½, College Museum.
Footnote 30:
See No. 1259, College Museum.
Footnote 31:
Bright’s Disease, by T. Grainger Stewart.
Footnote 32:
See No. 1507, College Museum.
Footnote 33:
Specimen No. 1260, College Museum.
Footnote 34:
See No. 1261, College Museum.
Footnote 35:
See No. 359, College Museum.
Footnote 36:
See No. 329, College Museum.
Footnote 37:
See No. 331, College Museum.
Footnote 38:
See Nos. 335 and 360, College Museum.
Footnote 39:
See Nos. 325 and 326, College Museum.
Footnote 40:
See No. 1476, College Museum.
Footnote 41:
See Nos. 1340 and 1341, College Museum.
------------------------------------------------------------------------
TRANSCRIBER’S NOTES
Page Changed from Changed to
237 defect in the excretion of the defect in the excretion of the
menses, or form a morbidly menses, or from a morbidly
300 oxygen though the lungs. The oxygen through the lungs. The
term is generally restricted term is generally restricted
● Typos fixed; non-standard spelling and dialect retained.
● Enclosed italics font in _underscores_.Project Gutenberg
A practical guide for making post-mortem examinations : $b and for the study of morbid anatomy, with directions for embalming the dead, and for the preservation of specimens of morbid anatomy
Thomas, A. R. (Amos Russell)
Chimera65
Academic