Complete Text (Part 15)

the intestinal canal and thus obstruct the passage of its contents. The same result may, however, ensue on some other and still rarer malpositions ; as, for instance, when coils of intestine become displaced into pouches of peritoneum within the abdominal cavity (the cav- ity of the lesser omentum, fossa duodeno-jejunalis, fossa sub- coecalis), into holes in the great omentum or mesentery, or between peritonitic adhesions, etc. Whenever symptoms of intestinal obstruction have been present during life the intes- tine itself and its position must be examined minutely and carefully, since the seat of obstruction is often very difficult to find. In this connection we will also mention that rare condition, transposition of the viscera, in which the position of all the organs is laterally reversed. (5.) Color of and Amount of Blood in the Presenting Parts. The color depends chiefly on the amount of blood, and in order that we may be enabled to inspect the whole 100 DIAGNOSIS IN PATHOLOGICAL ANATOMY. small intestine from every side, it must be raised out of the true pelvis. This is best done as follows : the right hand, with its palmar surface toward the pelvic wall, should be introduced into the pelvis on a level with the coecum, the thumb, meanwhile, remaining outside to the right of the root of the mesentery ; the fingers are then to be passed over to the left side of the vertebral column between the rectum and intestines and the whole hand passed up the vertebrse until the entire mesentery lies between the thumb and fingers. The small intestine can then be removed from the pelvis and examined thoroughly with ease. The most dependent coils show evidences of passive con- gestion in proportion to the degree of general congestion or ansemia. (c.) Abnormal Contents. It is necessary to remove the small intestine from the pelvis for the additional reason that any abnormal contents are most likely to be found in this part of the abdomen, though one must not neglect to examine the hypochondria as well. If abnormal contents are present their quantity is to be noted, and, if it seem desirable, measured. So also their color^ pale yellow, icteric, reddish, milky, brownish, etc. ; their con- sistency— watery, semi-fluid, pultaceous, firm, etc. ; and their admixture., — clear, containing large or small flocculi, blood, etc. 1. It is very important to distinguish between simple se- rous transudation and inflammatory, sero-fibrinous exudation. The presence of pus or large quantities of fibrine point to ex- udation, but it is not so easy to determine the character of a fluid which contains small flocculi. The question is in such a case whether these flocculi are fibrine or only shreds of free endothelium such as are found also in transudations. Flakes of fibrine are generally larger and thicker, more or less opaque and grayish-white in color, while shreds of endothe- lium are thin, of a transparent gray color, and often are not distinct until the fluid is examined by transmitted light of moderate intensity. The microscope shows the former to THE ABDOMINAL CAVITY. 101 consist of delicate fibrils which become greatly swollen on the addition of acetic acid, while the latter are found to consist of a membrane composed of closely apposed flat cells with large nuclei and nucleoli and perhaps large numbers of fat granules. 2. Purulent exudations are of a yellow color and are fluid ; pyo-fihrinous exudations are yellow and soft in proportion to the amount of pus they contain, and usually assume the form of membranes covering the peritoneal surface. Fetid and faecal exudations are betrayed by their odor and dirty brownish or gray color. The microscopical examination pre- sents no difficulties. In the latter form great numbers of bacteria or faecal matter are always found. In the exuda- tion of puerperal peritonitis great numbers of micrococci are always found, which may be joined together in the form of a long rosary, and the pus corpuscles are in process of fatty degeneration. 3. A red color may be imparted to the fluid either by the blood disks or by the coloring matter of the blood. A dis- tinction is easily made with the microscope, but may also be generally made with the naked eye. Uniformity in color and the absence of even the smallest coagula indicate the coloring matter of the blood ; all the more if the color of the fluid does not change on standing, inasmuch as the blood disks always sink more or less to the bottom, which therefore becomes of a deeper shade than the upper portions. HcemorrJiage into the abdominal cavity may be inflamma- tory or non-inflammatory. The latter is usually the result of injury but may depend on other causes — spontaneous rup- ture of the spleen, for instance. Haemorrhagic, inflamma- tory exudations, on the other hand, show that inflammation has existed for some time or else is recurrent, and are very apt to be associated with tubercular and carcinomatous pro- cesses. 4. When particles of undigested or semi-digested food are found in the abdominal cavity the greatest care should be used in order to determine whether an ulcerative process or 102 DIAGNOSIS IN PATHOLOGICAL ANATOMY. the so-called post-mortem digestion has perforated the wall of the stomach. 5. Small lipomata, fibromata, and chondromata are some- times found as free bodies in the abdominal cavity, having become detached from the wall of the intestine (appendices epiploicas), and sometimes entozoa, particularly the lumbri- cus, escape through a perforation. Before closing these remarks on the contents of the ab- dominal cavity — and they apply equally to all serous cav- ities — we will mention the peculiar slippery feel, which indicates a diminished secretion from the peritoneal surface, resulting from disordered circulation in general and obstruc- tion to the venous current in particular. It is most marked in cholera, and is due to the presence of a large amount of albumen in the fluid, causing it to become frothy when inti- mately mixed with water. (c?.) Position of the Diaphragm. The preliminary examination of the abdominal cavity is closed by the determination of \hQ, position of the diaphragm. This is to be done by introducing the right hand, with its palmar surface outwards, under the margin of the ribs as far as the highest point of the diaphragm, the finger tips then being pressed against the corresponding portion of the ab- dominal wall. It is well always to take the measurement in the line of the junction of the costal cartilages with the ribs, if possible, for the sake of a standard of comparison. The normal position of the highest point of the diaphragm in this line on the right side, on account of the presence of the liver, will be found at the fourth rib, or the fourth intercos- tal space, while on the left side it is at the fifth rib. If the contents of the abdomen are greatly increased in volume, the vault of the diaphragm may rise as high as the second rib or even higher, and on the contrary an increase in the thoracic contents may depress the diaphragm more or less, and even invert it. It cannot always be determined with absolute certainty whether the low position of the diaphragm is due to enlargement of the lungs or to abnormal accumu- THE THORACIC CAVITY. 103 lations in the pleural cavity, though if fluctuation can be ob- tained fluid must be present. Depression of the diaphragm when due to diseases of the heart or pericardium is generally more or less local. In new-born children who have never breathed, the usual position of the diaphragm is at the fourth rib on the right side and the fifth rib or 'fourth intercostal space on the left ; if respiration, however, has taken place it is at the fifth or sixth rib on the right and the sixth on the left. {A.) THE THOEACIC CAVITY. Before the chest is opened it should be inspected from the outside. 1. INSPECTION OF THE THOEAX. (a.) Enlargement may be brought about by many different affections, and may be general, unilateral, or circumscribed. General enlargement is found in emphysema, and unilateral enlargement may depend on an accumulation of fluid alone, or of fluid and air together. The chest may undergo a general diminution in size, on the other hand, in chronic phthisis, the contraction being more marked at the apex and the clavicles being very prominent. Chronic pleurisy, and still more fre- quently empyema, often give rise to unilateral contraction or even incurvature. There is a peculiar deformity called pectus carinatum or pigeon-bo^east, which consists in a great prominence of the sternum with trough-shaped depressions at the junction of the ribs with their cartilages. It is usually — in children always — the result of rachitis, but in adults may be due to osteomalacia. (5.) Sternum and Ribs. 1. The sternum presents occasionally curvatures and in- dentations varying in degree, which may depend on a devia tion from the perpendicular in the skeleton as a whole, or be due to the occupation of the person (shoemakers, etc.). Con- genital defects in the bone also occur, and may assume the form of genuine fissures, or, what is more common, of small 104 DIAGNOSIS IN PATHOLOGICAL ANATOMY. round holes in the median line, which are sometimes multiple. The ensiform cartilage is very often cleft and hence double. 2. The rihs are not infrequently the seat of congenital fissure which may involve the cartilage alone, the bone alone, or both at the same time ; the second is perhaps the most frequent. Ecchondroses and exostoses occur both on the car- tilages and bones and may unite contiguous ribs. This is often the case after fractures. Fractures of the cartilages may heal by either bony or fibrous union. 2. OPENING THE THORAX.^ We can now proceed to remove the anterior wall of the chest. The cartilages of the ribs are to be divided with a stout knife a few millimeters from their insertions into the bony ribs, the knife being kept as nearly parallel with the surface as possible to avoid injuring the lungs or the heart. If pneumo-thorax be suspected it should be noticed whether there is any escape of gas at the first cut. A lighted match held over the opening will either flare up or be extinguished if gas is present, and its escape can thus be demonstrated to lookers on. If the cartilages have become calcified., it is better to divide the ribs themselves just outside of the insertion of the carti- lages with a saw or bone-nippers. The clavicles are then to be disarticulated from the manubrium of the sternum by semilunar incisions with the convexity directed inwards, and in the latter part of the incisions the handle of the knife is to be somewhat depressed backwards to avoid the lower and inner prominence of the articular surface of the clavicles. The cartilage of the first rib, which lies somewhat farther from the median line than those of the other ribs on account of the greater width of the upper piece of the sternum, is then to be divided with the knife, or, if ossified, with the for- ceps. If the knife be used its point should be inserted ver- tically into the first intercostal space close up to the cartilage and the handle then depressed. If this be done carefully injury to the subjacent great vessels may be avoided. 1 See Plate. ■^X L **-. w. THE THORACIC CAVITY. 105 The attacliments of the diaphragm, which are included be- tween the two great lines of incision, are then to be severed close to the false ribs and the ensiform cartilage, and the sternum being drawn strongly upwards, the mediastinum is separated from the bone by transverse cuts, great care being taken not to injure the pericardium and great vessels. In ease, however, the vessels should be cut, they must be imme- diately tied, or, at all events, closed with a sponge, to pre- vent the escape of blood into the pleural cavity. 3, THE INNEB SURFACE OF THE BONE. (a.) The chief affections of the inner surface of the ster- num are caries and erosion (fibrous atrophy). The former is usually of a tubercular character, and starts from cheesy mediastinal lymphatic glands, while the latter is often the result of pressure of an aneurismal tumor, and may go on to perforation. The marrow of the sternum can be exposed by a longitudinal incision ; it is of a red color even in adult life, and often presents leucaemic, tubercular, and other changes, identical with those found in the bones of the ex- tremities. (5.) The portions of the ribs which contain the centres of ossification, are decidedly enlarged and swollen in rickety children, and these swellings, taken all together, form what has been termed the rosary of rickets. On cutting into these enlargements they are seen to consist chiefly of a soft, gray tissue, into which the normal, milk-white, hyaline cartilage has been converted, and, instead of the narrow, white line which normally exists close to the bone, a broad, irregular, and indented stripe is to be seen. In longitudinal sections, prepared for the microscope, and examined in a solution of common salt, or, still better, in iodine, very marked hyper- plasia of the cartilage cells is seen, and both the cells and the intercellular substance are more transparent than in the normal condition. The zone of ossification between the en- largements and the bone (normally very narrow and with perfectly even edges) is converted into a broad, usually, 106 DIAGNOSIS IN PATHOLOGICAL ANATOMY. thougii not necessarily, calcified, layer, with irregular pro- jections into the cartilage. Great numbers of medullary spaces and vessels, both of which are here entirely out of place, are seen to have made their way from the medullary spaces of the bone far into the cartilage. Caries of the ribs as well as of the sternum, may also be found, and often takes its origin from inflammations of the pleura. This seems a suitable place for a brief description of the changes which take place in the costal cartilages as age advances. These changes can be studied to great advantage in fresh sections, and are t^^pical of pathological processes of great importance. The cartilage early acquires a brownish shade which be- comes gradually deeper, and is due to a finely granular opac- ity of the intercellular substance ; the cells are enclosed in a thick capsule, which is often seen to consist of several lay- ers, and to show active proliferation. Here and there the naked eye can discern small spots with a lustre like that of asbestos, in which the intercellular substance has under- gone fibrous degeneration, while the cells have increased greatly in numbers, and form large, elongated masses. This fibrous degeneration of the intercellular substance is the forerunner of mucous degeneration of the same, and the last change is calcification, which also takes place in small spots appreciable to the naked eye; these differ from the spots of fibrous degeneration in being hard and of a chalky whiteness. The microscope reveals the presence of very minute collections of lime salts which are black by transmit- ted and white by reflected light, are readily soluble in hy- drochloric acid, and appear first at the extremities of the somewhat elongated capsules, and later completely fill the cells. (c.) The sterno-clavicular articulation is often the seat of chronic rheumatic arthritis, and often of purulent (metas- tatic) inflammation, with caries of the articular ends. The clavicle should also be examined for fractures, whether re- cent or old, tumors, etc. TEE MEDIASTINUM. lOT 4. INSPECTIOlSr OF THE THOKACIC CAVITY. (a.} After the sternum has been removed, the degree of distention and general appearance of the lungs as far as ex- posed, should be noted. Healthy lungs collapse from their inherent elasticity when the thorax is opened. They may, however, be prevented from collapsing by loss of elasticity, by inflammatory adhesion to the chest wall, by the presence in the alveoli of solid or liquid substances, or by pent-up air — as in stenosis of the larynx or trachea. Complete distention of the lungs, as seen in those dead of drowning or suffocation, is very characteristic. The color of the lungs depends on the amount of pigment (carbon) they contain in the first place, and in the second on the amount of blood and the presence of certain pathological products. (h.) The condition of the pleural cavity .^ and the presence of any abnormal contents (the description given in connec- tion with the abdominal cavity applies also here) are then to be noted. If, as is so very often the case, the pleural surfaces be united by inflammatory adhesions of connective tissue, these should be torn if of moderate extent and tough- ness, for it often happens that they cover an exudation in the inferior and posterior portions of the cavity. If, how- ever, the adhesions are very extensive and tough, as they become with age, it is better to postpone further manipula- tion until, after having removed the heart, the lungs are removed in their turn. The mediastinum should also be examined, including the thymus gland, and the external appearance of that portion of the great vessels which lies without the pericardium ; the degree of fullness of the veins should also be noted, but the vessels must on no account be opened as yet. 5. THE MEDIASTINUM AND ITS CONTENTS. (a.) Artificial emphysema of the connective tissue of the mediastinum is very apt to be caused by the removal of the sternum, and is chiefly marked over the heart, while patho- 108 DIAGNOSIS IN PATHOLOGICAL ANATOMY. logical emphysema, from rupture of tlie pulmonary tissue, is generally found higher up, and very often extends into the neck. Hcemorrhages^i apart from those of traumatic origin, are found in this situation