Complete Text (Part 24)

pachyderma. In higher degrees of the process the mucous membrane itself, both that covering the cords as well as that lining the cavity, is thickened, of a grayish-white shade, and denser than normal. This condi- tion is sometimes found in children after prolonged whoop- ing-cough. The mucous glands share actively in chronic catai'rh ; they are enlarged, their ducts are dilated, and act- ual cysts sometimes result from them. Ulceration in its various forms is very common, of great importance when found in the larynx, and is generally due to phthisis, typhoid fever, or syphilis. Syphilitic ulceration is most common in the edges of the epiglottis, which may be- come extensively destroyed, but it also occurs in the larynx, and, more rarely still, in the trachea. It is characterized by 176 DIAGNOSIS IN PATHOLOGICAL ANATOMY. a yellowish, lardaceous appearance of the base and a rounded protrusion of the edges, the mucous membrane over which is often the seat of polypoid formations. The favorite seat of tubercular and typhoid ulceration is near the posterior attach- ment of the vocal cords, and both forms not infrequently at- tack the cartilage. According to Rokitansky, the typhoid ulceration is the result of gangrene, and has discolored gan- grenous edges ; while the edges of tubercular ulcers are always uneven, more or less scalloped, and of a yellowish color, like their bases. Tubercular ulcers are not confined to this limited locality, but may be found anywhere from the top of the epiglottis to the interior of the trachea. They are often, particularly on the epiglottis, so superficial, and, in common with the surrounding mucous membrane, so pale, as to be scarcely distinguishable ; sometimes, the mucous membrane at their edges is much thickened, like that around syphilitic ulcers. Ulceration, particularly when seated on the cords, is very often associated with purulent inflammation of the peri- chondrium of the arytenoid cartilages (^perichondritis arytoe- noidea), which may, however, also occur without ulceration, — in phlegmonous laryngitis, for instance. The perichondrium is separated from the cartilage by pus, and the latter is thus cut off more or less from the circulation, and becomes ne- crotic. The abscess generally breaks, without much delay, into the larynx, and leaves an opening of greater or less size communicating with a cavity within which the necrotic cartilage lies loose. If the process still persists, the arytenoid cartilage becomes detached in whole or in part, — may be got- ten rid of, a cavity the size of a cherry-stone being left in its place. Sometimes the inflammation extends to the cri- coid cartilage, and runs the same course there. Tracheal ulcers are chiefly tubercular., and may be very small and indistinct, or very extensive and confluent. Deep ulceration leads occasionally to perichondritis of the carti- laginous rings, one or more of which may become necrotic in whole or in part, and lie exposed at the base, or project from the edge of the ulcer. THE ORGANS IN THE NECK. 177 The tubercular ulcers of the larynx and trachea are often associated with miliary tubercles, although the latter may be present without the former, particularly in the trachea ; these bodies are here usually extremely minute, gray, and translucent. The appearance of miliary tuberculosis may be exactly counterfeited in cases of simple catarrh, in which the mucous glands are involved, if the glands are compressed in forcing open the parts after the longitudinal incision has been made ; a minute gray drop, consisting chiefly of cast-off epithelium, is thus forced out of the duct of each gland, but the condition is easily distinguished from tuberculosis as the drops disappear when the finger is passed lightly over the surface of the mucous membrane. Cicatrices resulting from old ulceration are found in the larynx and trachea — par- ticularly in the former, as is the case with the pharynx, — and generally point to syphilis, especially if the cicatricial bands radiate from the centre, are very thick and prominent, and have caused great deformity. The most common laryngeal tumors are polypoid, which are found near and upon the cords, are often lobulated, and possess a varying degree of consistency. Cancer also occurs in this situation, and is as characteristic here as elsewhere. The external wall of the trachea is sometimes the seat of cystic tumors of the size of a pea or cherry, having small pedicles ; these are dilated mucous glands, as is shown by the fact that they communicate with the interior of the tube by an opening which is sometimes large enough to admit the passage of a good sized probe. Small multiple ecchon- droses of the tracheal cartilages are occasionally met with. (5.) The Submaxillary Glands. The submaxillary and sublingual glands are to be laid open by longitudinal incisions, though they are but seldom the seat of important pathological conditions. Tumors, both syphilitic and other forms, often take their origin here, but the only other change which occurs with any frequency is in- terstitial suppurative inflammation (adenitis apostematosa) 12 178 DIAGNOSIS IN PATHOLOGICAL ANATOMY. of metastatic nature, in connection "with such acute infective diseases as typhoid fever, septicaemia, etc. One or both glands may be affected. They are enlarged, and in recent cases the individual lobules are separated by broad gray lines, in more advanced cases by yellow lines of pus. As the glandular tissue is usually much reddened, the appear- ance of the whole is very characteristic. If the process ad- vance still further, collections of pus may be formed both in and about the glands (^jperiadenitis aj)ostematosa)^ which may finally be more or less extensively destroyed. In very severe cases of phlegmonous sore throat or diphtheritis of the fauces the submaxillary glands sometimes become in- volved in the process. (6.) The Thyroid Glaxp. The lobes are to be laid open by longitudinal incisions. The chief pathological conditions assume the general form of ejilarcjfeynent, which may be general, or confined to either lat- eral lobe, or to the middle or pyramidal lobe: the terms hroncJiocele orcjoitre include all, and even cancer and sarcoma have in this situation been called carcinomatous and sarcoma- tous bronchocele. Bronchocele in the more restricted sense, however, comprises enlargements originating in either the glandular or interstitial tissue, or in the vessels. The first of these three varieties is called parenchymatoiis or hyper- plastic^ though in accordance with the more modern nomen- clature it should perhaps be classed among the adenomata, and consists in simple hyperplasia of the glandular alveoli. Its cut surface appeal's granular and of a uniform brownish- red color. The most common form is called gelatinous or col- loid^ and is characterized by a dilatation and distention of the alveoli with a translucent yellowish or brownish substance, the collections of which project slightly above the level of the cut surface, and are larger in proportion as the process is the more advanced. The entire gland may be affected, or only limited portions, which are usually sm-rounded by cap- sules of fibrous tissue. TUE ORGANS IN THE NECK. 179 This is cl()S(^ly iillicd with the cjjhI'k; form, iilso origiiiiiliiig in the ghiiiduhir alveoli, whicli iire filled with a soft or even fluid substance, and are greatly dilated. These cysts may be the seat of luumorrhage, wliich imparts a brownish-red color to their contents — lutntiorrliaglc hronchoeele. The variety of broncliocele v^hich is characterized as fibrous or osseous originates and runs its course chiefly in the interstitial tissue, which becomes greatly increased in amount, and dense, gradually replacing the glandular ele- ments more and more, and finally may become calcified. Any or all of the above-mentioned forms are often found in combination, and, in fact, scarcely any two bronchoceles are exactly alike. We now come to the third variety, comprising those forms which originate in the vessels. These may be further sub- divided into aneurismal and varicose bronchoceles, according as the dilatation is arterial or venous. The latter form is very apt to be combined with some one or more of the pre- ceding forms. Amyloid bronchocele is the result of amyloid degeneration of the arteries, and may also occur in the form of encapsulated nodules. Small tumors not exceeding a cherry in size, and identical in structure with true bronchoceles — supplementary bron- choceles, so called — are sometimes found, and are consid- ered by Virchow to proceed from portions of the gland which became detached during fostal life. Since, however, Cohn- heim's recent observation of the possible occurrence of a me- tastasis from bronchocele, the question must be raised whether these forms are not lymphatic glands which have becomei secondarily diseased. Tubercles are sometimes found in the thyroid as in most other glands, and purulent interstitial in- flammation, such as was described in connection with the sal- ivary glands, is found here in rare cases. (7.) The Cervical Lymphatic Glands. The pathological conditions of the cervical lymphatic glands are essentially the same as those of the bronchial and 180 DIAGNOSIS IN PATHOLOGICAL ANATOMY. mediastinal glands, and hence need not be described in this place. We will merely state that the left supraclavicular glands are sometimes secondarily affected in cancer of the stomach. 11. THE DEEP MUSCLES OF THE NECK AND THE CERVICAX, VERTEBRA. The most important changes which are found here are those which are due to caries of the vertebral column. The initial stages of this affection are often very difficult of rec- ognition, but when fully developed it may lead to retropha- ryngeal abscess seated on the anterior surface of the bodies of the vertebr«, and extending a variable distance downward, sometimes into the muscles. 12. THE HYDROSTATIC TEST. As it is at times of interest, apart from medico-legal cases, to determine whether a new-born child has breathed or not during or after birth, we will describe the modifications of procedure which are enjoined by the Regulations (§ 24) as necessary to ascertain this fact. The examination is to be begun with the thoracic and ab- dominal cavities, not with the head ; and after inspection of the abdominal cavity (particular attention being directed to the height of the diaphragm) a ligature is to be passed round the trachea just above the sternum and drawn tight. The sternum- and costal cartilages are then to be removed in the usual way, the external condition of the thoracic organs noted, and the heart examined before its removal. The lar- ynx and that portion of the trachea which is above the ligature are next to be laid open longitudinally, and the at- tention directed to the character of their contents and the condition of their walls. " The trachea is then to be divided above the ligature and its lower portion removed from the body, together with all the thoracic organs. The thymus gland and heart are next to be dissected off with care — the interior of the latter may now be examined — and the lung THE ABDOMINAL ORGANS. 181 is then to be placed in a spacious vessel filled with fresh cold water to see whether it will float. The lower portion of the trachea and the primary bronchi are then to be laid open and the character of their contents accurately noted. Incisions are to be made in both lungs and it is to be noted whether the lungs crepitate ; the quantity and character of the blood which is squeezed out over the cut surface on gentle pressure are likewise to be recorded. Incisions are also to be made in the lungs when held under water, in order to see whether any air bubbles escape from them ; they are further to bo separated into their individual lobes, these again into smaller portions, and all the pieces thrown into water to see whether they will float. The oesophagus is next to be opened, and its contents noted. Finally, in case it is suspected that the lungs contain foreign or pathological material (vernix case- osa, meconium, or an exudation), and are thus rendered im- permeable to air, they must be examined microscopically." (B.) THE ABDOMINAL CAVITY. The usual order in which the abdominal organs are re- moved is deduced from the rule already laid down, that no organ should be removed, the absence of which would mate- rially interfere with the subsequent examination of other or- gans. After examining the peritoneum of the anterior ab- dominal wall, the organs are to be removed and examined in succession as follows: (1) omentum, (2) spleen, (3) left kidney and suprarenal capsule, then the same organs on the right side, (4) urinary bladder, (5) organs of generation (in the male, prostate gland and vesiculse seminales, testes, penis and urethra ; in the female, vagina, uterus, the pelvic fibrous tissue. Fallopian tubes and ovaries), (6) rectum, (7) duo- denum and stomach, (8) the common bile-duct, and the portal vein between the layers of the gastro-hepatic omen- tum, (9) gall-bladder and liver, (10) pancreas, (11) mesen- tery, (12) small and large intestine, (13) the great blood- vessels on the anterior surface of the vertebral column, and the retroperitoneal lymphatic glands. 182 DIAGNOSIS IN PATHOLOGICAL ANATOMY. It is evident that it will often be found necessary and de- sirable to modify this order of procedure ; the operator must decide as to the best method to be pursued in any particular case, and always choose the lesser of two evils. In many cases of chronic peritonitis with extensive adhesions, and when the intestines are glued together by a cancerous forma- tion, it may be desirable to remove all the abdominal viscera, in one mass, in order to be able to examine their mutual relations from behind as well as from in front. The intes- tines, when much distended with gas or fluid, will often' be found to be in the way, and to add greatly to the difiiculty of ascertaining the precise relations of the pelvic organs, kidneys, ureters, retroperitoneal lymphatic glands, etc. It will be found advantageous, therefore, in these cases, to sep- arate the intestine from its mesentery, and remove it from the body at the very commencement of the section of the abdominal cavity, although it is better to postpone opening it till later. 1. THE PERITONEUM OF THE ANTERIOR ABDOMINAL WALL. This portion of the peritoneum is often the seat of changes of an inflammatory nature. These, when acute, are mani- fested by marked redness and injection of the blood-vessels, often followed by hsemorrhage, and a more or less abundant deposit of fibrino-purulent mateviaX (^fibrino-purulent perito- nitis^ ; when chronic, by either simple thickening of the membrane or more commonly by adhesion between the pari- etal and visceral layers [chronic adhesive peritonitis'). Ad- hesions, as well as other results of inflammation, may be either general or local. Both the peritoneum and the adhesions are often darkly pigmented from old haemorrhage, and this pig- mentation may also occur in the non-adhesive form of in- flammation. A peculiar form of inflammation, which was long thought to be confined to the recto-vaginal and recto-vesical pouches, has recently been occasionally observed in the peritoneum THE OMENTUM. 183 of tlie anterior abdominal wall. This form is completely analogous to what has already been described as chronic internal hsemorrhagic pachymeningitis, and hence may be termed chronic hcamorrhagio peritonitis ; it may be accompa- nied with profuse haemorrhage into the newly formed false membranes — JicBmatoma of the peritoneum. Portions of the membrane enclosed by local adhesions may be the seat of a suppurative or gangrenous inflammation, and the resulting ulceration may deeply implicate the sub- peritoneal tissue (^ulcerative peritonitis'), and even give rise to perforation, the most common seat of which is in the vi- cinity of the pelvis, though it also occurs over the gall-blad- der and intestine. Tuberculosis of the peritoneum is a common affection, and may occur in the form of disseminated miliary tubercles alone, or, as is more usual, inflammatory products may also be present. Such a tubercular inflammation, when acute (as has already been mentioned in connection with Abnormal Contents of the Abdominal Cavity), is usually associated with hsemorrhage ; when chronic, with adhesions in which the tubercles are deposited in great numbers. Cancer in like manner is met with in both the dissemi- nated and the inflammatory forms. Lipomata sometimes start from the subperitoneal fatty tissue, and may attain consid- erable size, projecting into the abdominal cavity. 2. THE OMENTUM. The position and color (the amount of blood which it con- tains) of the omentum having been already referred to in another place, it merely remains to describe the special mor- bid conditions of the part. The normal omentum contains a large quantity of fat, especially along the course of the blood-vessels, on either side of which it is collected in masses like minute bunches of grapes ; in all cases of general wast- ing of the body this fat disappears to a greater or less ex- tent. Atrophy is, however, not confined to the fat, but may affect also the fibrous tissue, which becomes sometimes ex- 184 DIAGNOSIS IN PATHOLOGICAL ANATOMY. tremely delicate and may disappear entirely, leaving holes of larger or smaller size. Thickening of the fibrous portion of the omentum is the result of chronic inflammatory pro- cesses (omentitis chronica fibrosa)^ which may be only local and lead to local cicatricial contractions (omentitis fibrosa retrahens')^ or band-like adhesions (omentitis adhcesiva^ in and between the omentum itself and its adjoining parts. Such adhesions occasionally form sacs, into which coils of intestine may find their way and become incarcerated. If the inflammatory process be widely extended, and if no ad- hesions have been formed with other parts, the whole omen- tum may shrivel into a thick, dense, grayish white, fibrous band lying in front of the colon. When the seat of sup- purative inflammation it is greatly reddened, opaque, and covered with a fibrino-purulent deposit ; it also shares ac- tively in tubercular and cancerous inflammation of the peri- toneum, and in these