Complete Text (Part 23)

a coagulable albuminous material on the surface of the mucous membrane, forming a continuous and easily de- tachable membrane. It must not be thought, however, that the process involves absolutely no change in the mucous membrane itself. On the contrary, after removal of the false membrane, the mucous coat appears intensely red and swollen, often containing numerous hsemorrhages, and — as is readily seen in fresh sections with the double knife when placed under the microscope and made clear with acetic acid — is always infiltrated with cells, even in its deeper layers. This form of inflammation occurs on the palate and pharynx, and the false membranes, which are easily detached without injury to the true and underlying membrane, are often found on the posterior surface of the palate, on the uvula, and above all in the sinus pyriformes. It is by no means rare to find at the same time in other situations, and particularly on the tonsils, that species of inflammation which is known as diph- theritic. This may be either primary or secondary (in variola, scarlatina, etc.), and is characterized by the formation of a false membrane which not only covers the mucous surface but is also firmly adherent to it and extends more or less deeply into its substance. The underlying mucous mem- brane is infiltrated with fibrine and granular matter as well as with cells, and thus easily becomes necrotic ; recovery is then only possible through separation of the slough and cica- trization of the open surfaces which remain behind. A fresh yellowish-gray diphtheritic deposit may be formed over these open surfaces, constituting what are known as diphtheritic ulcers. To ascertain the depth of the diphtheritic infiltration inci- sions must be made in different portions of the affected parts. The microscope shows invariably the presence of great num- 168 DIAGNOSIS IN PATHOLOGICAL ANATOMY. bers of low organisms, the most common of which are nests of micrococci ; these are very often of a brownish shade, especially under low powers, and may occupy the mucous membrane itself as well as the diphtheritic deposit, as is well seen on the addition of glacial acetic acid or very dilute caustic potash. When colonies of micrococci have been often seen, they are not likely to be confounded with detritus or granular matter, and he who affirms the contrary has either never examined a case of diphtheritis, or else is unfit to use the microscope at all. The parasitic nature of the granules can be clearly demonstrated by boiling the specimen first in glacial acetic acid, then in a mixture of equal parts of absolute alcohol and ether, finally examining it in glacial acetic acid and glycerine. In purely fibrinous membranes they are by no means constant, needle preparations showing an albuminous substance which becomes swollen in acetic acid and is infiltrated with a variable number of cells. Mucous membrane which is the seat of the diphtheritic process is often very prone to break down, become gan- grenous, grayish-green in color and ragged, with a most of- fensive smell : these are the cases which present the most marked changes in the pharynx and fauces, and in which the swelling reaches its highest pitch. There is another form of inflammation which is not super- ficial, but attacks the deeper layers of the mucous membrane, and, especially the submucous tissue, and which from its re- semblance to phlegmonous inflammation of the external in- tegument may be called suppurative sore throat (^angina phlegmonosa'). The tonsils are the favorite seat of this form (though it occurs also elsewhere in the throat) and may be- come so swollen as to exceed a pigeon's egg in size. In the earlier stages of the affection the interstices of the tissue are filled with an opaque, grayish-yellow fluid containing large numbers of pus cells ; while in the later stages the fluid be- comes even more opaque and yellow — i. e. more purulent, — and may form abscesses, especially in the tonsils, which empty outwards. This form of inflammation may be of an infective character, as in malignant pustule, erysipelas, etc. THE ORGANS IN THE NECK. 169 The changes which are brought about by syphilis and tuberculosis next demand our consideration. That early manifestation of syphilis to which the term mucous patch has been applied is naturally not often met with in the corpse ; but when found is covered with a grayish secretion resem- bling that of the chancre. As a rule we find only the cica- trices resulting from these patches, which, as we have already mentioned, give rise to stenosis and other deformity of the parts. A cicatricial condition is often found at the base of the tongue, and, if present, may prove of material assistance in diagnosis. When the base of the tongue is found to be flattened and depressed, to have lost its follicles, and its mucous membrane is thickened and grayish-white in color, it is highly probable that we have to deal with the results of syphilis. The muscular substance of the tongue may be the seat of yellow gummy nodules as well as of the cicatrices which they occasionally leave behind them. Perforation of the hard palate, whether large or small, is almost sure to be due to syphilis, provided only that the congenital condition known as cleft palate can be excluded. Tubercular affections of the mouth and pharynx are less common than the syphilitic, though they are met with in the form of miliary tubercles, as well as in the form of tubercu- lar ulceration. The character of the latter is betrayed by its uneven edges, and the presence of small cheesy, or recent and gray nodules, both on the base and edges. The adjoin- ing tissue is sometimes considerably hypertrophied, thus causing papillary elevation of the edges of the ulcer. Tu- bercular ulcerations as well as disseminated tubercles are occasionally found in and upon the tongue in the course of the lymphatic vessels. Lupus and leprosy belong to the same group of tumors as gumraata and tubercles, and the same forms appear in the buccal mucous membrane as in the external integument. Lupus, especially, may on cicatrization give rise to great deformity. Cystic tumors occur in various portions of the mouth ; the 170 DIAGNOSIS IN PATHOLOGICAL ANATOMY. most common of these is ranula^ which is seated under the tongue alongside the fraenum, and is due to a plug in the duct of the submaxillary gland and the resulting retention of secretion. The tongue is subject to a very peculiar hy- pertrophy— macroglossia — due to enlargement of its lymph spaces and vessels. Epithelioma of the tongue, in common with the two affections mentioned, comes rather within the domain of surgery ; it starts from those portions of the tongue which are in contact with the teeth, and spreads both backwards and forwards, often very widely. The tonsils are sometimes the seat of the soft varieties of cancer. The appearances of thrush in the mouth and pharynx are the same as in the oesophagus, in connection with which they will be described. (3.) The (Esophagus. The organs of the neck should be so placed in examining the oesophagus, that the latter lies uppermost, and it may then be opened with scissors along its left border (to the right of the operator). (a.) General Morbid Conditions. The oesophagus may be either dilated or contracted. J)ilatatio7i may be either general or local, the former being usually due to stenosis lower down in the intestinal canal ; its wall, and particu- larly the muscular layer, is very apt to become hypertrophied at the same time. A relaxed condition of the muscular coat may simulate dilatation, but the flaccidity of the muscle, and the absence of any other cause of widening, will generally reveal its true nature. Local dilatation is found above a contraction, whether the latter is caused by tumors or by cicatricial tissue. The forms we have thus far considered involve the whole circumference of the tube ; limited por- tions, however, may be involved, and thus arise what are known as diverticula. These may attain considerable size, and are usually seated between the oesophagus and vertebral column. Contractions or stenoses are almost always local, resulting THE (ESOPHAGUS. 171 from cicatricial tissue or cancerous growths, and occur chiefly on a level with the cricoid cartilage or the bifurcation of the trachea ; the tube may be contracted without being ac- tually diseased, as for instance, below a marked stenosis. The color of the mucous membrane is almost always a pale gray, but may be yellowish from contact with icteric con- tents of the stomach. Hypersemia of the pharynx, however marked, very rarely extends into the oesophagus. Thicken- ing of the epithelial coat renders the surface whiter ; the post- mortem action of the contents of the stomach on the lower portions renders them brown and soft — brown softening. (h.) Special Morbid Conditions. We need not dwell long on inflammation of the oesophagus. Simple inflammation is associated with abundant desquamation of the epithelium ; the fibrinous and diphtheritic forms are rare, though they sometimes occur, especially in scarlatina and hsemorrhagic small-pox. The latter forms bear a strong resemblance to thrush. The oesophagus is not unfrequently the seat of injury^ from the accidental or intentional introduction of hard bodies (among which bougies may be included) or corrosive liquids. The latter are especially important from their frequent use as poisons. Sometimes they leave only slight traces from the rapidity of their passage, but they maj^ give rise to ex- tensive alterations. When the mucous membrane is acted on mildly by acids, it presents a grayish or yellowish discolor- ation, and is hard and wrinkled ; the action of alkalies causes it to become softened and to present a brownish discolora- tion resembling post-mortem softening, but differing from that condition by its action on test-paper. Both acids and alkalies, when very concentrated, corrode the tissue, and color it brown or black. In cases in which life is more or less pro- longed, the eschars may come away with suppuration, and cicatricial tissue be formed ; this contracts over a larger or smaller surface, producing a varying degree of stenosis. Under tumors we will mention the occasional occurrence of a varicose condition of the veins, especially in the lower 172 DIAGNOSIS IN PATHOLOGICAL ANATOMY. portion, and plilebolites. The lipomata, myomata, and fibromata are rare in this situation ; but cancer is quite frequent, and from mechanical causes is very apt to occupy that portion of the oesophagus which crosses the left primary bronchus. It is generally of the epithelial variety, soon ulcerates, and may finally lead to perforation into the trachea, pleura, pericardium, etc. Congenital oesophago-tracheal fis- tulse are sometimes met with. The parasitic affection known as thrush (mycosis oidica) occurs in the oesophagus, and derives most of its importance from the fact that it may easily be mistaken for inflamma- tion attended by the formation of a false membrane, particu- larly of the fibrinous variety. This affection, which may also occur in the pharynx, is found chiefly in cachectic adults, and in children who are ill-nourished and fed from the bot- tle ; it gives rise to the formation of a soft whitish mem- brane, which is easily stripped off the mucous surface, and often closely resembles a fibrinous false membrane, but is distinguished by its softness. Needle preparations, how- ever, when placed under the microscope, show that it is com- posed of the superficial layers of the epithelium covering the mucous surface, and of great numbers of fine, thread- like, jointed formations (oidium albicans), from which elon- gated conidia have become freely detached. (4.) The Larynx and Trachea. To lay open these parts the organs of the neck are placed in the same position as in opening the oesophagus, and, after inspection of the position of the vocal cords from above, the posterior wall is cut through with scissors along the median line, where the cartilaginous rings are defective ; the cut edge of the oesophagus, on the left, should, meanwhile, be drawn out of the way, toward the left of the operator. Tha. organs are then to be laid on the fingers of both hands, and the interior of the larynx brought clearly into view by spreading it open with the thumbs, one being placed on each corner of the thyroid cartilage. If the cartilages are ossi- THE ORGANS IN THE NECK. 173 fied, they must be forced apart, even if they are broken in the process. The morbid conditions of the larynx and trachea are, in the main, identical with those of the mouth and pharynx, which we have already described. A very important condition, to which children are espec- ially liable, is oedematous swelling of the mucous membrane of the cords and ary-epiglottic folds — oedema of the glottis. It should never be forgotten that oedema is always much less marked after death than during life ; a degree of swelling which involved danger to life may, indeed, have almost en- tirely disappeared when the section is made. The degree of tension of the mucous membrane may be of considerable value in this connection. If, instead of being smooth and even, it lies in folds and wrinkles, we can be sure that oedema has been present. QEdema is almost invariably of inflam- matory origin, and is very seldom really primary in the larynx, but is secondary either to affections of the larynx and pharynx, or to erysipelatous or phlegmonous inflammation of the face. Modifications in form. Unimportant changes in the form of the trachea may be brought about by pressure from with- out, calcification of the cartilaginous rings, cicatrices, etc., and sometimes the tube is thus flattened like a scabbard. A very remarkable condition, however, is that known as the suffocative position of the epiglottis. The surface of this organ is normally but very slightly curved from side to side, but in all forms of death from suffocation its edges are found to be more or less approximated, in extreme cases producing a wedge-shaped appearance. The color and amount of blood in the upper air pas- sages are of great interest to the medical expert, who gains information from the intensity of a green or greenish-brown discoloration as to the time at which death took place, and from the presence of a bluish tinge as to the cause of death (suffocation). The caution which we enjoined with regard to oedema applies equally here ; the color and degree 174 DIAGNOSIS IN PATHOLOGICAL ANATOMY. of injection after death may convey but a very imperfect idea of the condition of things during life. Quite commonly, particularly in children, the trifling changes which are found in the mucous membrane of the larynx in general, and of the Yocal cords in particular, afford no adequate explanation of the violent symptoms which preceded death. Although the simple superficial fibrinous inflammations are less common in the mouth and pharynx than the diphthe- ritic inflammation with infiltration, the reverse is the case in the larynx and trachea. Tubular casts of the interior of these latter parts are common enough, and small isolated patches of false membrane are still more common. The membranes vary greatly in thickness ; the more delicate often present to the naked eye a reticulated appearance even, which is yet more distinct under the microscope. This pe- culiar appearance is due to the secretion of the mucous glands, with the duct of one of which each individual de- pression in the false membrane corresponds. Fibrinous false membranes sometimes extend continuously far into the bronchial tubes, and retain the same character throughout, but, as a rule, they become thinner, and more broken as they enter the lung, being gradually merged into a simply catarrhal muco-purulent secretion. The pulmonary parenchyma itself is sometimes involved, but the resulting pneumonia, instead of being fibrinous, as the ill-chosen term croupous would lead one to expect, is always and without exception of the catarrhal form. Diphtheritic affections of the larynx and trachea, though more rare, are not uncommon. These parts, as well as the epiglottis, are sometimes the seat of a false membrane which can be detached only with the greatest difficulty, and the underlying mucous membrane presents a grayish infiltration. The parts of the trachea which are more commonly the seat of this affection are those adjoining the wound of tracheotomy. Those forms of inflammation in the larynx and trachea which complicate many infectious diseases, and particularly the acute exanthemata, often acquire a diphtheritic charac- THE ORGANS IN THE NECK. 175 ter. In variola small diphtheritic patches are often found in the trachea — chiefly over the cartilaginous rings — and have been erroneously supposed to be the peculiar eruption of that disease. Pneumonia, very often of a malignant type, and in- volving rapid destruction of tissue, is sometimes set up by the inhalation of particles of diphtheritic material from the pharynx as well as from the larynx and trachea. We need only allude to the fact that phlegmonous inflam- mation may extend from the pharynx to the entrance of the larynx. That oedema of the glottis may thus be caused has already been mentioned. Chronic inflammation is very common, and varies in appear- ance according to its intensity and duration. A trifling de- gree of the condition is often found in those whose occupation involves more or less strain of the vocal organs (singers, etc.), and is manifested by a bluish-white discoloration, and thick- ening of the vocal cords, especially their posterior portions. The thickening and discoloration are almost wholly due to a moderately tough membrane-like substance, which can be easily stripped off the mucous membrane with forceps, leaving it quite intact, and when placed under the microscope is seen to consist of epithelial cells, which have become decidedly horny. The condition is, therefore, a simple thickening of the epithelial layer ; a sort of