Complete Text (Part 16)

in phosphorus poisoning, acute yellow atrophy of the liver, etc., in great number. Suppura- tive inflammation sometimes extends from the neck hither. Clinical observers have of late had their attention directed to chronic inflammations of this part (mediastinitis chronica fibrosa), leading to fibrous thickening, induration, opacity and whiteness of the connective tissue. (5.) A cheesy (tubercular) condition of the lymphatic glands of the mediastinum is not infrequently met with in adults, but is still more common in children. (c.) The thymus gland attains its full development at the end of the second year, and then begins gradually to dis- appear, though it may persist to the thirtieth year, or even longer. In still-born children it often contains numerous haemorrhages. Suppurative inflammation (syphilitic ?) and cheesy degeneration are very rare. This gland is some- times the starting point of large nodulated tumors which resemble the lymphatic glands m structure, and may oc- cupy the whole mediastinum, or even extend above the sternum (lymphosarcoma thymicum). 6. THE PERICAEDIUM. To open the pericardium a longitudinal fold should be raised at the middle point of the anterior surface and a small incision should be made through its left side. Two fingers should then be introduced into the cut, and, just as in open- ing the abdominal cavity, it should be prolonged between them as far as the diaphragm, first downwards and to the left, and then downwards and to the right. The last step in open- ing the pericardium is to draw the right border of the first cut forwards and then to carefully prolong the incision up- wards as far as the point of reflection from the great vessels. If the sac contain much fluid it is better to scoop this out before making the last incision, which would allow its escape THE PERICARDIUM. 109 and thus render accurate quantitative determination impossi- ble. As a rule, however, it is better to wait till the sac is completely opened before the fluid, which normally never ex- ceeds a teaspoonful, is removed. The fluid collects chiefly behind the heart, and to reach it the apex of the organ should be raised. (a.) Contents. What was said in connection with the contents of the peri- toneum holds good here also, but there are a few special points to which we shall refer. Though normal pericardial fluid never contains flakes of fibrine, it may coagulate on exposure to the air, so this fact alone should not induce one to diagnosticate inflammation. Hcemorrhage in the peri- cardial as in the peritoneal sac may come either from the great vessels, from the heart, or from newly formed vessels of inflammatory origin. In the latter case the blood is mingled with the fluid of exudation, while in the former it is coagulated in large masses which may completely envelop the heart. Fluid blood is never the result of simple hjsmor- rhage, but depends on injury, spontaneous rupture of the heart, or some other condition which will be revealed during the subsequent examination. (5.) Morbid Conditions of the Pericardium. The most important of these are those due to — 1. Inflammation. Simple fibrinous inflammation may be attended with the formation of a dry exudation small in quantity (dry pericarditis^)^ or of an abundant sero-fibrinous exudation (^sero-fibrinous pericarditis). The first may be hard to observe ; the second is always easily recognized. In the first form the membrane is generally much reddened, especially in the transverse furrow where minute haemor- rhages may be found, and its surface has lost its lustre and become opaque, as may be best seen by oblique light. When the effusion is slight, the fibrinous layers often have a very characteristic form in consequence of the cardiac movements. Warty and villous projections of varying height lie upon the surface, especially upon that of the posterior 110 DIAGNOSIS IN PATHOLOGICAL ANATOMY. wall of the right ventricle ; ridges are also prominent, espe- cially in front over the origin of the pulmonary artery. This condition is so peculiar that it has given rise to the term cor villosum. Suppurative pericarditis is less common, and if it can- not be attributed to injury, suppurative mediastinitis, caries of the ribs, or gangrene of the lung, when the pus is often fetid, is very apt to be of metastatic origin. In many cases we may be able to discover on either the parietal or visceral (epicardium) layer the point from which the process started, in the form of a circumscribed patch of more intense inflam- mation, or perhaps of an actual necrosis. The pericardium, normally, is a thin and perfectly trans- parent membrane, but is often the seat of a more or less cir- cumscribed thickening and milky opacity, the result of cir- cumscribed chronic inflammation : such spots are not of great importance. Sometimes, precisely at these spots, the re- mains of old and more intense inflammation are found in the form of fibrous adhesio7is between the two layers of the mem- brane, but these are not nearly so common as in the pleural cavity ; or the layers may be closely united over a consider- able, or even the whole, area (^obliteration of the cavity), at times to such a degree that they cannot be separated. If a fibrinous or purulent exudation preceded the formation of ad- hesions, it may have become wholly absorbed, or portions may have become cheesy and calcified, and thus persist as cheesy and cretaceous nodules, or bone-like masses in the midst of the fibrous adhesions. 2. Tubercles are very often found in connection with these remains of former inflammation, and are apt to be imbedded in the adhesions (^pericarditis fibrosa tuberculosa'). In gen- eral tuberculosis the tubercles may exist without giving rise to inflammation (tuberculosis pericardii), in which case the tubercles are usually scattered along the course of the vessels, but they may also be associated with fibrinous, hsemorrhagic inflammation. In the latter case they may be completely hidden by masses of fibrine, which should therefore always be THE HEART. Ill detached at several points and the condition of the subjacent membrane examined. The occurrence of tubercular pericar- ditis in old people without the existence of any discoverable cheesy focus deserves special mention. Cheesy nodules of tubercular character rarely attain great size in this situation. 3. Secondary nodules of carcinoma, sarcoma, etc., are quite rare in this locality. (c.) Changes in the Suhpericardial Fatty Tissue. The suhpericardial fatty tissue varies widely in quantity and is not always proportional to the panniculus adiposus. In cachectic states it is found to have undergone a pecul- iar change, being transformed into a soft transparent and gelatinous mass, which shows a whitish opacity on the addi- tion of acetic acid, and under the microscope is seen to consist of a transparent finely fibrillated substance which re- acts like mucine and in which are imbedded large cells con- taining either fat drops or serous fluid Qmucous metamor- Ijhoses^. Small lipomata are sometimes found, especially toward the apex. Special medico-legal interest attaches to the presence of small haemorrhages into this tissue, the so- called suhpericardial ecchymoses. They are most common at the base and on the posterior wall, and are very liable to occur in death from suffocation. 7. THE HEAKT. (a.) External Examination. Before any incision is made into the heart or it is removed from the body, its position, size and form, color and consis- tency (whether contracted or not) are to be noted, as well as the degree of fullness of the coronary vessels and of the individual compartments (auricles and ventricles) of the heart. 1. The heart may be pushed out of position by pleuritic effusion, etc., or it may be hypertrophied and its boundaries thus changed. The position of the apex is an important in- dication and is not infrequently found to be in the axillary line. 112 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 2. The closed fist of the right hand is a very good standard of comparison for the size of the normal heart. Bizot has found the average dimensions between the ages of twenty and sixty years to be as follows : length, 85-90 millimeters in the male, 80-85 mm. in the female ; breadth, 92-105 mm. in the male, 85-92 mm. in the female ; thickness, 35-36 mm. in the male, 30-35 mm. in the female. The size is diminished, sometimes excessively, in all cachectic diseases, and often in chronic pericarditis with abundant effusion ; it is increased in diseases of the heart itself as well as in those of other organs, such as the lungs, kidneys, aorta, etc. ; when due to diseases of other organs the enlargement is usually partial. 3. Alteration in form depends generally on enlargement predominating on one side or the other. In enlargement of the left ventricle the organ is elongated and relatively nar- row, conical or cylindrical ; while in enlargement of the right ventricle the chief increase is in the transverse diameter. The formation of the apex affords a good indication of the presence or absence of enlargement of the right side. In the normal heart the apex is formed solely by the left ventricle, but when the right ventricle shares in its formation an en- largement has taken place. A depression of greater or less depth is sometimes met with between the apices of the ven- tricles as a congenital deviation from the normal form. 4. The color of the heart's surface depends largely on the condition of the pericardium and its subjacent fat. The auricles are dark blue in color, especially when distended with blood ; but the color of the ventricles depends in great measure on the condition of the muscular substance, which will be considered later. 5. The consisfency of the different portions depends chiefly on the degree of muscular contraction, but in a measure also on the amount and character of their contents. In simple contraction nothing like a cavity can be felt through the muscular wall, while in simple distention the contents always yield somewhat to pressure. 6. The coronary arteries and veins are readily distinguished "*fi'3ä-^'''~'' THE HEART. 113 from each other by the difference in the thickness of their walls and in their course. Marked distention, particularly of the larger veins, points to an impeded flow of blood from the right auricle (suffocation, etc.), provided that such dis- tention be not confined to the posterior surface of the organ (hypostasis), while an almost empty condition may depend on general angemia or on calcification or endarteritis of the coronary arteries. These latter changes may often be recog- nized externally by the rigidity, hardness, and whitish-yellow color to which they give rise. 7. The degree of distention of individual portions of the heart is often indicated by the external shape. If the surface be flat or sunken, the contents must be small in amount, but if it be convex and tense, the contents must be considerable. The right heart is abnormally distended in death from suffo- cation in its various forms ; the left heart in death from cardiac paralysis. In order to determine the quantity and character of the blood contained in the individual cavities, they must be opened while the heart still remains connected with its nat- ural attachments. (5.) Opening the Heart in situ?- To open the right side the left hand should be so placed under the posterior surface of the organ that the forefinger lies in the transverse furrow, and the thumb a little behind the sharp right border of the right ventricle. By now draw- ing the heart somewhat downwards and to the left, and mak- ing it tense over the left forefinger, the points at which the vense cavse empty into the auricle are brought into view. The incision into the auricle should begin between the cavae, be prolonged as far as the transverse furrow, there intermit- ted for the space of about one centimeter, in order to avoid the tricuspid valve, and then again continued in the same di- rection as far as the right border of the right ventricle, but not prolonged as far as the apex on this side, the apex being 1 See Plate. 8 114 DIAGNOSIS IN PATHOLOGICAL ANATOMY. normally composed entirely of the left ventricle. After re- moving and examining the contents of the auricle and then of the ventricle, two fingers of the left hand should be intro- duced from the auricle into the tricuspid valve, which should be large enough to allow the introduction of still a third finger between the other two. The left ventricle should then be grasped in the left hand in such a way that the apex lies in the fold between the thumb and forefinger, the first on the posterior, the second on the anterior surface of the heart ; or else the organ may be taken in the palm of the hand with the thumb on the anterior and the fingers on the posterior surface, drawn downwards and to the right, and an incision made into the auricle in the upper of the two left pulmonary veins, which are thus clearly brought into view. At the transverse furrow the cut should be interrupted and then continued again at the left border as on the right side, except that here it is to be prolonged as far as the apex. The contents of the cavities should then be examined, and, after having overcome the rigor mortis, the size of the mitral valve is determined. This should admit two fingers with ease. ((?.) The Blood. The changes undergone by the blood are some of them gross, some microscopic ; some depend on quantitative or qualitative modifications in the constituents of the blood, others on pathological admixtures with other substances. The latter, as a rule, cannot be recognized without the aid of the microscope. 1. Coagulation is subject to the greatest variations, since the blood may be found in any condition between the ex- tremes of entire fluidity, and coagulation into very dense and firm masses of fibrine, containing scarcely any red corpuscles (polypi of the heart). The presence of firm coagula of pure fibrine, particularly when they are attached to the wall of the heart, indicates that death came on so gradually (the action of the heart growing weaker and weaker) that the fibrinous portion of the blood was deposited by degrees on the walls, THE HEART. 115 while the corpuscles were still kept in circulation. Fibrinous coagula may, however, also occur in consequence of the pres- ence of an increased amount of fibrine in the blood ; as, for instance, in acute inflammatory affections. In this case the fibrinous masses are not so strictly limited to the walls, but all the clots contain large .quantities of this substance. The amount of fibrine, moreover, varies somewhat with the situa- tion of the clot, even when the blood, as well as the coagula- tion itself, is perfectly normal. The clot which occupies the Conus arteriosus of the right ventricle and the commence- ment of the pulmonary artery is almost always very rich in fibrine. Firm and voluminous coagula are often marked with moulds of the inequalities of the wall — the sinuses of Valsalva, the musculi pectinati, etc. Coagulation may be incomplete or entirely wanting., in con- sequence either of diminution in the amount of fibrine (hy- pinosis), as in dropsical blood, or of the presence of certain substances which prevent coagulation, the first place among which belongs to carbonic acid. All processes, therefore, which overload the blood with carbonic acid diminish or pre- vent coagulation ; such are all affections which end in suffo- cation, as well as those where death is directly dependent on closure of the air passages from without. 2. Another peculiarity of the blood in these cases is its dark color., though the distinction between arterial and ve- nous blood gradually disappears after death, and the blood of the pulmonary veins even becomes dark (venous). In cases of poisoning with carbonic oxide gas, the haemoglobine unites with the gas and imparts a bright cherry-red color to the blood. Decomposition brings about marked changes in the color of the blood. The coloring matter leaves the solid constitu- ents and is taken up by the serum, the color becomes indis- tinct and dirty, and on standing, the superficial layer of clear serum which is formed in healthy blood does not appear. The microscope shows that the red blood disks have lost their color, and have become converted into pale globular bodies, which float in a yellowish-green fluid. 116 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 3. öhanges in the composition of the blood also produce a varying appearance. These are due to deviations from the normal proportion between the blood corpuscles and the serum on the one hand, and the red and white corpuscles on the other. If the serum is diminished, the blood becomes thick, even resembling tar, as in cholera; if increased, the blood becomes watery or hydrcemic, as in some affections of the heart, lungs, kidneys, and liver. A similar effect may be produced by a diminution of the cellular elements, either of both together or of the red alone, but in this case the blood mass is diminished, while in hydraemia it is increased. In either case the blood is pale in color. In no affection are the cellular elements so much diminished as in pernicious anse- mia, so called, in which disease the blood in many situations may resemble a faintly colored serum. Increase in the white corpuscles causes still other modifica- tions in the appearance of the blood ; this takes place in a moderate degree in the acute inflammatory, infectious, and other diseases, but is most marked in leucaemia. There is, however, more than a mere difference in degree under such circumstances : in the former class of affections the white corpuscles are increased merely (leucocytosis'), but in leucce- mia the'red cells are also diminished. The