- Aneurisms ....... 377 (Aneurysma Serpentinum, Cylindriform, Fusi- form, Sacculatum, Dissecans, Traumaticum, Varicosum.) 5. Congenital Alterations ...... 379 (Stenosis and Atresia; Hypoplasia [Aorta Chlo- rotica].) c. Retroperitoneal Lymphatic Glands 380 (Inflammation ; Tumors, etc.) d. Thoracic Duct ........ 380 (Receptaculum Chyli.) 14. Internal Muscles of the Trunk 381 a. Diaphragm ......... 381 (Trichinae; Diaphragmatitis.) h. Psoas . . . 381 (Psoas Abscess ; Tumors.) 15. Front of the Spine 382 a. General Characteristics 382 (Scoliosis; Kyphosis; Lordosis; Pott's Disease.) b. Special Morbid Conditions 384 (Fractures and Dislocations; Spondylarthrocace ; Prever- tebral Abscesses ; Cheesy Osteomyelitis ; Supracarti- laginous Exostoses ; Sarcoma ; Carcinoma.) 16. Pelvic Bones . 385 a. General Characteristics ....... 385 (Deformity ; Narrow Pelvis ; Pelvis altered in Osteo- malacia and Rickets.) h. Special Morbid Conditions 386 (Fractures; Caries; Exostoses [Spinous Pelvis]; Enchon- droma; Osteoma; Sarcoma; Carcinoma.) iv. extremities . . . . 387 1. Lymphatic Glands 387 (Lymphadenitis and Periadenitis Apostematosa Chronica; xxxiv TABLE OF CONTENTS. PAGB Cheesy Inflammation ; Syphilis ; Leuc^mia ; Lymphosar- coma ; Cancer.) 2. Lymphatic Vessels . . . ■ 388 (Enlargement ; Elephantiasis ; Lymphangitis ; Perilymphan- gitis.) 3. Blood-vessels 389 4. Nerves ' . . 389 (Atrophy; Inflammation; Neuroma; Fibroma; Myxoma; Sar- coma ; Carcinoma.) 5. Muscles 390 a. General Characteristics 390 (Size ; Color ; Consistency.) h. Special Morbid Conditions 390 1. Hypertrophy 390 (True Hypertrophy ; Fatty Infiltration.) 2. Atrophy 391 (Atrophy from Fatty Infiltration ; Atrophia Fusca ; Atrophy from Fatty Degeneration ; Atrophia Sim- plex.) 3. Hcemorrhages 392 4. Inflammation . . 392 a. Parenchymatous 392 (Typhoid Fever; Hyaline Degeneration.) b. Interstitial 393 (Purulent, Chronic Fibrous, Ossifying; Parosteal Exostoses.) 5. New Formations . . . . . . . .394 (Tubercles ; Gummata ; Sarcoma ; Myxoma ; Carci- noma; Fibroma; Lipoma.) 6. Parasites ......... 395 (Trichinae; Cysticercus; Echinococcus.) 6. Joints 395 a. External Examination . . . . , ' . . 396 (Distention of Capsule; Anchylosis; Perforation; Disloca- tion; Partial Dislocation.) b. Internal Examination . . . . . . . .397 1. Contents ......... 397 (Serous; Fibrinous; Purulent Exudation ; Free Bodies.) 2. Internal Ligaments ....... 398 3. Synovial Membrane ....... 398 (Haemorrhages ; Tubercles ; Villi ; Lipoma Arbores- cens ; Ulcerations.) 4. Articular Surfaces . . . . . . .399 TABLE OF CONTENTS. XXXV PAGE a. Cartilage 399 (Excrescences ; Atrophy ; Chondromalacia ; Erosions-; Necrosis ; Fibrillation ; Fibrous Degeneration.) h. Ends of the Bones . 400 (Caries ; Attrition.) c. Articular Sockets 402 (Erosions; Disappearance.) 5. Special Morbid Conditions 402 a. Inflammation ....... 402 (Arthritis Rheumatica Sicca, Fibrinosa, Adhse- siva, Chronica Deformans, Arthritis, Syphili- tica; Arthritis Purulenta Acuta; [Perforation ; Periarticular Abscess ; Caries ;] Arthritis ; Purulenta Chronica vel Tumor Albus; Caries Fungosa ; Arthritis Urica.) h. Dislocations . .407 Bonf:s 407 ( Removal of the Femur ; Centre of Ossification in the Lower Epiphysis of the Femur of the New-born.) 1. The Bones in General ........ 409 (Number; Size; Shape; Color; Consistency; Fractures; Dislocations.) 2. The Component Parts of Bone ...... 411 a. Periosteum . . . 411 1. General Appearances 411 (Separation ; Injuries ; Defects ; Thickness ; Color; Consistency.) 2. Special Morbid Conditions . . . . .411 (Periostitis Ossificans; Osteophytes ; Callus ; Pui-ulent, Cheesy, Gummy Inflammation ; Ex- ostoses; Osteosarcoma; Osteoid Tumors; Car- cinoma.) b. Osseous Tissue 414 1. General Appearances ...... 414 a. Surface . ... . . . 414 (Thickening ; Atrophy.) "^ b. Interior . . . . . . . . 415 (Osteosclerosis ; Ostitis Ossificans ; Osteo- porosis ; Rarefying Ostitis ; Osteomalacia.) ' 2. Special Morbid Conditions 416 a. Inflammation . . . . . . .416 (Caries ; Necrosis.) xxxvi TABLE OF CONTENTS. PAGB h. Tumors 417 (Enostoses ; Enchondroma ; Rachitis.) c. Changes in the Cartilage of the Epiphyses . 417 (Sj'philis; Cartilaginous Exostoses.) c. Marrow 418 1. General Appearances 418 (Amount; Color; Consistency). 2. Special Morbid Conditions . . . . . 419 (Fatty Marrow ; Red and Gelatinous Marrow.) a. Inflammation . . . . . .419 (Osteomyelitis Ossificans, Purulenta, Iclio- rosa, Caseosa.) b. Tumors ....... 420 (Gummata ; Tubercle ; Sarcoma ; Myxo- ma ; Carcinoma.) 3. Morbid Conditions of the Bones in General .... 422 a. Fracture 422 (Periosteal, Myelogenous, and Parosteal Callus; False-joint.) b. Rickets 423 c. Inflammation ........ 424 (Necrosis; Sequestrum.) d. Syphilis . . . . ... . . 424 e. Tumors ......... 425 Index ....... .... 427 DIAGNOSIS m PATHOLOGICAL ANATOMY. INTRODUCTION. The method of examination of the human body after death may vary according to the object in view. If this object be merely to confirm a diagnosis or to obtain more accurate knowledge of the condition of one or more special organs, the parts in question may be simply removed and examined out of the body ; but if we wish to obtain a clear and broad idea of the change in the general organism brought about by any disease, of the effects of the combination of different dis- eases, of latent morbid changes in this or the other organ, it is only by a thorough and methodical examination of the whole body that we can obtain our end. Again, our object may be to ascertain the cause of death. In this case, too, the examination must be thorough and methodical ; otherwise an important point might be easily overlooked. Finally, medico-legal cases may be put in a class by themselves, though they are partially included under the preceding divis- ion. It was formerly the custom to separate medico-legal from the so-called pathological autopsies, and in forensic cases to limit the examination to those changes which were imme- diately connected with the legal question at issue. But this was all wrong, for one can never know beforehand how im- portant the morbid condition of any special organ may be- come during the course of the investigation, nor is one in a position to give a final and weighty opinion as to the fatal disease, the cause of death, or the condition of particular organs, unless each and every organ in its individual and 2 DIAGNOSIS IN PATHOLOGICAL ANATOMY. associated capacity has been accurately studied and made out. For these reasons the new Regulations for procedure in medico-legal cases in Prussia prescribe a careful and method- ical examination and description of all parts of the body in their several relations, and, at the present time, a medico- legal is only distinguished from a pathological autopsy in that everything which may serve the ends of justice is treated with even greater accuracy and detail than is the case in an ordinary autopsy. In order to make a thorough examination, it is absolutely essential to note accurately the relative position of each part to neighboring parts before disturbing them, and to take care that no part be removed if its removal interfere with the subsequent examination of other parts. The method prescribed in the Regulations is practically that which Virchow ^ introduced into the Pathological Insti- tute at Berlin ; it meets the above named requirements, and has, therefore, been used as the basis of the present volume. A few words only on necessary preliminaries and instruments. PRELIMINARIES. A room to be suitable for autopsies should be spacious, well ventilated, and well lighted, good light being indispen- sable for the recognition of the finer changes in the structure of organs. Artificial light is bad on account of its yellowness, which modifies the natural color of parts ; indeed, the Regu- lations do not allow an autopsy to be made by artificial light unless circumstances are such that it cannot be postponed. The best position for the operator is on the right of the body, and the table should be high enough to render much stooping unnecessary. It is true that in private houses, and in medico- legal cases, the external surroundings are often very unfavor- able, and it is not always easy to comply with these con- ditions, some ingenuity being necessary to contrive a suitable 1 During the progress of this work, and in time to be available in its revision, Virchow himself has published a description of his method of conducting autopsies, — Die Sectionstechnik im Leichenhause des Charite-KranJcenhauses, etc.. Berlin: Hirschwald, 1876. INSTRUMENTS. 3 support for the body out of tables, chairs, blocks of wood, planks, etc. ; but one can nearly always get a table and an old door or some boards to lay upon it. The head, during the examination of the brain, or the back, during the examination of the neck, should be supported on a block of wood, with one edge rounded and hollowed at the middle, but if this be not at hand, any block of wood, or even a brick may be made to serve the purpose. In moving the body, and especially in moving it from one place to another, care should be taken that it be done gently, and that the great cavities be kept in the horizontal position as nearly as may be, lest a part be ruptured or dislocated. INSTEUMENTS. Section five of the Regulations contains a list of those which are most needful. Four to six scalpels, two small with a straight edge, and two larger with a bellied edge, a section-knife, two stout car- tilage knives, two pair of forceps, two double hooks, a pair of large scissors, with one blade blunted and the other sharp at the point, a pair of smaller scissors, one blade being probe- pointed, an enterotome, one coarse and two fine probes, a saw, a mallet and chisel, a pair of bone cutters, a blow-pipe with stopcock, six curved needles of different sizes (sail- needles), a pair of callipers, a meter or yard measure with fine divisions, a large graduated vessel for measuring fluids, scales with weights up to ten pounds, a good magnifying glass, blue and red test paper. Besides these it is desirable to have a double saw for opening the spinal canal (rachi- tome), one or two tenon saws which are very convenient in examining the bones at the base of the skull, sponges, and a little cup for scooping up small quantities of fluid. The sharper the knife the better, and it is not to be held like a pen, as in the dissecting room, but grasped firmly in the hand ; incisions should be begun with the heel of the blade, not the point, and the knife swept along from the shoulder rather than the wrist, thus making a long, smooth cut. The 4 DIAGNOSIS IN PATHOLOGICAL ANATOMY. " larger an incision tlie more surface does it expose, and Vir- chow even affirms, ' that a large cut, though made in the wrong place or direction, is, as a rule, preferable to one or many small cuts which are correct in these respects^ It is also very important that incisions should be smooth, as may be insured by avoiding excessive pressure on the organ or part and drawing the knife firmly and steadily through it. This latter remark applies with especial force to the softer organs, and above all to the brain, in connection with which Virchow says, " better false cuts, if smooth, than jagged ones which are correct J'^ The utmost possible neatness should be observed in every- thing, and a vessel of clean water should be constantly present to rinse the knife and hands when soiled ; the body also should be kept as clean as possible. Besides the vessel of water for the knife and hands, the use of which should be reserved exclusively for them, means should be provided for cleansing the organs as they are removed from the body ; a common watering-pot, from which the nose has been removed, answers this purpose remarkably well, and has the further advantage of enabling one to regulate the force of the stream of water at will. A special receptacle should be pro- vided for such waste as blood, exudations, transudations, etc. Shallow wooden dishes with raised edges are very con- venient ; one for receiving an organ during its examination, and a larger one for those organs which have already been examined. APPLIANCES FOR CHEMICAL AND MICROSCOPICAL EXAM- INATION. It is often convenient to have a microscope at hand for immediate use, though generally it will be found better to take home anything which requires the use of the microscope and there examine it at leisure. The following are the chief instruments necessary to pre- pare specimens for microscopic examination. A razor, sev- eral scalpels, scissors, forceps (those intended for coarser INSTRUMENTS. 5 pathological work are rather clumsy, but may be used in default of better), a pair of stout needles set in handles, watch-glasses, object and cover glasses, a camel's hair-brush, bibulous paper, and a double knife, the latter almost indis- pensable for fresh specimens. Such a knife consists of two parallel blades, one of which is fixed in a handle and the other movable. The movable, by an arrangement of springs and screws, can be approximated as desired to the fixed blade, and both blades are ground plane on the juxtaposed surfaces. In using it care should be taken that the blades be as nearly parallel as possible, to insure uniform thickness of the section, and the degree to which they are approximated depends on the thickness of the section which is desired and the consistency of the organ to be cut. In general, if the organ be lax in structure the blades should be more widely separated than if it be dense. The knife should be dipped before using in a mixture of alcohol two parts, and water and glycerine in equal proportions one part, to prevent the section from adhering to the blade and being torn ; water alone does not moisten the knife uniformly enough. After the knife has been thus moistened it should be held like a fiddle bow, and the anterior extremities of the blades laid on that portion of the oi"gan from which it is desired to obtain a section, and which should be put on the stretch in some way ; the section is then made by pushing the knife forward its whole length with moderate pressure downwards, and drawing it backwards again as far as necessary. Sometimes the section remains sticking in the organ after the knife has been drawn through it, but this may be obviated by giving the knife a slight sideward turn before withdrawing it. The character of the fluids in which a section is examined has much to do with its usefulness. Liquids can generally be examined in their natural condition, and for fresh sections, especially if reference be had only to relatively coarse path- ological changes, common water usually suffices. But if more delicate examination be desired, and especially if it be the object to preserve blood corpuscles in as natural a con- 6 DIAGNOSIS IN PATHOLOGICAL ANATOMY. dition as possible, a so-called " indifferent " fluid must be made use of. This fluid may be one which is found already- formed in the organism, as the aqueous humor or serum, or may be artificially prepared. A one half to one per cent, solution of common salt usually answers very well. Both iodine and osmic acid have the property of hardening pro- toplasm, and hence are often of great value, especially when the cells are very delicate and easily broken up ; the latter may be used in very dilute solution — one eighth to one tenth of one per cent. Tincture of iodine being in frequent demand as a reagent, it is well to keep the following solution ' on hand : Iodine one part, potassic iodide three parts, water one hundred parts. Before addition to a microscopic prep- aration this solution should be diluted to a pale yellow color with water. Stained specimens are generally examined either in glycerine or a concentrated solution of potassic acetate ; the parts whicb are not acted upon by the coloring matter are thus rendered more transparent, and the stained parts become still more prominent. One of the most important reagents., on account of its prop- erty of rendering connective tissue more transparent as well as of contracting the nuclei and thus bringing them out more clearly, is acetic acid, which should always be on hand both in the anhydrous (glacial acetic acid) and in the di- lute form (one to five per cent.). Caustic soda or potassa should also be on hand ; their chief use is in the detection of fatty granules which they do not dissolve, while they do dissolve all soft tissues except elastic tissue. It is well to have two solutions of the alkali, one of one per cent., and one of thirty-three to thirty-five per cent. Finally, one should have a five to ten per cent, solution of muriatic acid as a solvent of the salts of lime. The best way of using these reagents is to allow a few drops to flow from one side of the cover glass to the preparation while a bit of bibulous paper on the other side absorbs the fluid which is under the glass ; the action of the reagent on the preparation can thus be fol- lowed step by step under the microscope. If a current be REAGENTS. 7 thus developed strong enough to carry the specimen out of the field, one of the following methods must be resorted to : one drop of the reagent may be placed at the edge of the cover glass and allowed to diffuse itself gradually underneath, in which case somewhat stronger solutions should be used ; or else, abandoning the idea of watching the actual action of the reagent, the preparation may be from the commence- ment examined in a drop of the solution. Much may often be gained, even in the examination of fresh specimens, by the employment of various coloring
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historical survival diagnosis pathological anatomy post-mortem emergency response 1878 public domain
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