Complete Text (Part 25)

latter affections is very often greatly retracted. On cutting into the mass, it is not uncommon to find that most of the tubercular or cancerous nodules are superficial, while the interior consists chiefly of the normal fat. These as well as other new formations are also met with in the omentum without inflammation ; in general mil- iary tuberculosis, indeed, this is a favorite seat of the tuber- cles. It is not always an easy matter to distinguish between the larger tubercular nodules and the smaller aggregations of fat, especially when the latter are somewhat atrophied, and, instead of being yellow, have become rather grayish in color. The localization of the bodies in question sometimes throws light on their nature, collections of fat always follow- ing the course of the vessels, while tubercles are often iso- lated in the midst of the fibrous net-work. Tubercles, more- over, are always round and usually distinctly spherical, while collections of fat are generally oval and somewhat flattened ; the smallest tubercles, again, though translucent, are never so translucent as collections of fat. If the tubercles are of the true miliary type there can be no doubt whatever as to their nature. THE OMENTUM. 185 Small lipomata, and single or multiple echinococcus cysts, are occasionally met with in the omentum. There are few structures the pathological changes in which, are so easily examined microscopically as in the omentum ; it is only necessary to cut out a small bit from a portion containing the least amount of the fat and spread it out in water, — or in glycerine, or a solution of potassic acetate, in case it has been thought best to stain the specimen with hsematoxyline, aniline, etc. In the foetus which has become decomposed in the uterus as well as in the icteric new-born child, the presence of yellowish-brown rhombic and needle- shaped crystals, both within and without the vessels, is thus easily demonstrated, as is also the inflammatory infiltration with granulation cells, taking place especially along the course of the vessels, and which possess a marked affinity for stain- ing fluids. Beautiful specimens may, in like manner, be ob- tained of the individual nodules in the disseminated forms of tuberculosis, carcinoma, or other new formations. If the rules which have been laid down in another place are strictly followed, no great difficulty should be encountered in determining the nature of a new formation ; it should be remarked, however, that tubercles in this situation do not invariably contain giant-cells, and that they are, as a rule, not so distinctly reticulated here as elsewhere, their ground- work being formed of the fibres of the omental tissue itself, which are forced apart by collections of tolerably large cells. When, in describing the gross appearances, it was asserted that tubercles in the omentum are found at a distance from the vessels, the remark was not meant to imply that they are never found along the course of the vessels also ; on the con- trary, the microscope shows active proliferation of the fat cells with loss of their fatty contents, and the substitution of tubercles in many places for the normal collections of fat. The study of tubercular as well as of purely inflammatory affections of the omentum affords an excellent opportunity for verifying another fact which has an important bearing on 186 DIAGNOSIS IN PATHOLOGICAL ANATOMY. general histology ; namely, that the endothelial cells, with which the whole fibrous framework of the omentum is in- vested, increasö in size, while their protoplasm becomes granular and their nuclei are multiplied, thus forming large multinucleated giant-cells. That these may develop into tubercles, appears to me questionable, or, at all events, to re- quire further proof than has yet been given. I have never been able to satisfy myself that pus corpuscles are devel- oped from proliferating endothelial cells in inflammatory processes ; the great numbers of fat-drops which are always found in these cases suggest rather that the endothelial cells undergo fatty degeneration and disappear. 3. THE SPLEEN. After freeing the omentum from its attachment to the transverse colon, the next step is to remove the spleen, which lies behind the fundus of the stomach, and is attached to it by delicate areolar tissue. The organ is to be firmly grasped in the left hand and drawn far enough forwards to admit of severing its vessels near the hilus, attention being directed meanwhile to the amount of blood which they contain or the presence in them of any pathological change, such as cal- cification, aneurismal dilatation, etc. If, as is very often the case, the spleen is firmly adherent to the diaphragm, care must be exercised in breaking up the adhesions lest the cap- sule be torn off and left behind. The gastro-splenic omen- tum sometimes contains one or more rounded bodies, from the size of a pea up to that of a cherry — accessor^/ spleens — which generally present the same pathological changes as the main organ. (a.) External Examination. 1. G-eneral Appearance. (a.) The position of the spleen may be modified by tu- mors in its neighborhood, and in rare instances the organ lies primarily much lower than normal — the movable or wan- dering spleen : the splenic vessels in these cases are in every THE SPLEEN. 187 way normal, except that — in common with the fibrous at- tachments of the organ — they are much lengthened, and oc- casionally are twisted on their axes, obliterated, etc. The possibility of the escape of the spleen into the left pleural cavit}^ through a diaphragmatic hernia has been already al- luded to. (6.) It is often of great importance to determine the size of the organ with accuracy. In the adult its average weight is 250 grams, its length, eleven to thirteen centi- meters, its breadth, eight to nine cm., its thickness, four to five cm. The following method should be followed when it is de- sired to ascertain the exact dimensions of the spleen as well as of other organs. Laying the organ on a wooden table or board, it should be firmly fastened down by passing a scalpel through it vertically, after which the transverse and longi- tudinal diameters can be easily measured. The thickness may be ascertained by passing the scalpel vertically through the thickest portion of the organ, marking the part of the knife to which it penetrates with the finger, withdrawing the knife, and determining the distance by a measure. The spleen may be either increased or diminished in size, the former being relatively more common. Diminutiovi in size is usually the result of atrophy of the pulp, in consequence of which a small spleen is very apt to be at the same time dense and hard, and to have a thickened capsule. It occurs in old people and those who have been the subjects of gen- eral atrophy. The spleen may be enlarged to two, three, four, or more times its normal size. Acute enlargement oc- curs in all the acute infective diseases (typhoid and typhus fevers, relapsing fever, pyeemia, etc.), the organ being soft and swollen, with a thin and tense capsule, while the en- largement which occurs in intermittent fever (ague-cake), leucaamia, and pseudoleucsemia is chronic, and is associated with induration of the organ. In amyloid degeneration the enlargement is considerable, and the consistency resembles that of dough ; in passive congestion, dependent on disease of 188 DIAGNOSIS IN PATHOLOGICAL ANATOMY. the liver, lungs, or heart, the enlargement is only moderate and the tissue is usually dense. New formations of various kinds and echinococci are occasional causes of enlargement. (c.) The modifications in form which may be undergone by the spleen are manifold, but most of these are of no great importance. Congenital fissures of varying depth are some- times found on the anterior border, but the chief causes of deformity are circumscribed lesions, such as infarctions, tu- mors, or echinococci, which generally produce local elevation of the surface. Local depressions, and constrictions divid- ing the organ into lobes, are sometimes met with as results of cicatricial formation which, in its turn, may be the result of infarction, syphilis, or injury. ((?.) The color of the surface is largely dependent on the thickness of the capsule, which transmits the color of the parenchyma in an inverse ratio with its thickness. If the capsule be thin some idea may be gained of the amount of blood contained in the organ, the color being due in a great measure to this. The coloration of the surface as a whole is less important than that of circumscribed lesions, the nature of which can often be determined from their color alone. Hsemorrhagic infarctions, for instance, when recent are al- most black, but with the lapse of time grow more and more yellow at the centre, and become surrounded by a narrow zone of deeply congested tissue. (e.) The consistency of the spleen varies within wide lim- its— from that of a mere pulp to that of a dense fibrous struc- ture — and depends on the condition of the capsule as well as on the composition of the parenchyma. If the former be tense, as in acute enlargement, the organ is firmer than if it be relaxed, as is the case when an enlarged spleen is return- ing to its normal size. The thickness of the capsule may also have much to do with the consistency of the organ. The condition of the parenchyma, on the other hand, is not without its efi!ect in this regard, a spleen which is the sub- ject of chronic enlargement being as a rule firmer than one which is acutely swollen. THE SPLEEN. 189 2. The Cafnule. The normal capsule is smooth, thin, and transparent ; but it is very liable to thickening, which may be either general or local. There is a form of thickening (|^griS/pZt;/iiY2s chron- ica fibrosa) which is generally confined to a portion of the surface, and in its higher degrees — amounting to several millimeters — results in the formation of whitish homogene- ous masses as hard as cartilage, which may further be largely calcified. Such thickening, in its lower degrees, is extremely common, and appears in the form of nodules or as a network. These nodules are so irregularly shaped and, however small they may be, of so opaque a gray color, that they are easily distinguished from tubercles, which are met with here as on all other serous surfaces. In the place of nodules small papil- lary growths are occasionally found, often merely the re- mains of pre existent adhesions which have been ruptured. Adhesions of greater or less extent are very common {pe- risplenitis chronica adhoisiva), particularly to the dia- phragm, and may be either very close and firm, or long and lax. Suppurative inflammation (^ ijerisplenitis purulenta) occurs here as elsewhere in the peritoneum. The changes which are met with in the capsule over the seat of circum- scribed affections of the spleen, have already been described ; rupture sometimes follows the softening and necrosis which occasionally takes place over the seat of softened infarctions or abscesses, but may also occur independently of changes in the capsule, as after injury, and rarely after marked acute enlargement. (5.) Internal Examination. The parencht/ma is to be exposed by a longitudinal incision extending completely to the hilus, and by such subsequent smaller incisions as the circumstances of the case may re- quire. 1. General Conditions. The most important of these is the amount of Mood contained in the organ, — a point which must always be noted in medico-legal cases. It is indicated 190 DIAGNOSIS IN PATHOLOGICAL ANATOMY. by the freedom with which the blood flows from the cut surface of the larger vessels, and by the color of the par- enchyma, which, in the spleen more than in any other organ, by reason of its peculiar anatomical structure, is dependent on the amount of blood. The color of the normal spleen is dark red, darker and more inclining to purple in children than in adults, but it varies pathologically from a light red- dish-gray or reddish-brown to a reddish-black. There are also certain other coloring matters which may modify the appearance of the organ : hgematoidine imparts a brownish shade, the coloring matter of the bile a yellowish tint, and in intermittent fever the spleen is deeply pigmented with a black material which is derived in some way from the blood. There are finally some pathological processes, which render the organ almost uniformly gray, among which the hyperplasia of iho, fibrous framework which is met with in chronic enlargement (intermittent fever, leucjemia) is the most worthy of mention. In studying pathological changes in the parenchyma its three chief component structures must be borne in mind — pulp, follicles, and trabeculte — for the reason that they may be affected independently of one another ; all three may be the seat of hypertrophy, either singly or conjointly. The follicles vary in size, from that of a poppy-seed to that of a pin's-head ; the traheculce appear as delicate gray lines, as a rule, but are rather coarser at their junctions with the capsule or the larger vessels. General hyperplasia of the fibrous framework is most marked when due to passive con- gestion ; local hyperplasia of the superficial portions of the organ is rather the result of a chronic perisplenitis. The follicles vary considerably both in size and number, and often participate in the enlargement of other lymphoid structures in the body. When the pulp is the seat of acute enlarge- ment, it projects from the cut surface, rendering it somewhat uneven, and hides the follicles and trabecul^e more or less from view. Careful examination shows that the irregularity of the cut surface is due to isolated prominences, the size of THE SPLEEN. 191 a split pea, each one of which represents an arterial twig, and the tissue supplied by it. The pulp is without question the most important of the three constituents of the organ, since its hyperplasia plays the chief part in the formation of most of the so-called splenic tumors. Even acute swel- ling, though due in considerable measure to accumulation of blood in the organ, depends essentially on genuine hyper- plasia, or cellular growth, as may readily be seen in fresh needle preparations ; the large splenic cells with single clearly defined nuclei are those which especially show signs of an active growth, many of them becoming multinucle- ated, especially in the spleen of typhoid fever. In this dis- ease, as well as in others which are associated with acute swelling of the spleen, the organ contains great numbers of cells with red blood disks imbedded in them ; these cells are also found in the normal spleen, particularly of j^oung people, but in vastly fewer numbers. In relapsing fever, es- pecially, the blood of the splenic vein contains many granular corpuscles, and fatty degenerated endothelial cells derived from the walls of the smaller veins. In the hyperplastic spleens of infective parasitic diseases — and above all, in malignant pustule, — the parasites are found in abundance in the tissue. In chronic hyperplasia of the pulp we find in the place of round cells a formation of fibrous tissue which encroaches on and destroys the pulp itself; but in these cases it is im- possible to draw a close distinction between hyperplasia and inflammation. In chronic enlargement we find almost inva- riably numbers of cells containing granules of pigment. Atrophy also may involve any or all of the structures which enter into the composition of the organ, but is most common and most marked in the pulp. It often happens that the trabeculse are thus rendered more prominent than they are in the normal condition, and one might easily be led to consider them the seat of hyperplasia, as indeed they sometimes are in atrophy of the pulp and follicles. Atrophy of the pulp is indicated by a brownish-red or rust-colored 192 DIAGNOSIS IN PATHOLOGICAL ANATOMY. appearance, and the presence of cells containing granules of brownish-red pigment. 2. Special Morbid Conditions. («.) One of the most common and characteristic of these is amyloid degeneration, which occurs in two separate forms, easily distinguishable by the naked eye, though both cause more or less enlargement of the organ, and a change in its consistency. In both the organ is firm, and so inelastic as to pit very markedly on pressure, but this change is more pronounced in the second of the two forms which we are now about to describe. The first form, and the easier of recognition, is amyloid degeneration of the follicles, a de- generation which starts in the arteries, but subsequently in- vades the whole structure of the corpuscles, which are en- larged beyond the size of a millet-grain, and project above the level of the cut surface as glossy, translucent nodules, bearing a close resemblance to boiled sago — hence the term sago-spleen. The centre of each of these nodules sometimes appears as a small gray point, corresponding with the position of the arterial twig to which the follicle is attached, and the enlarged follicle is not uncommonly surrounded by a narrow red zone of collateral hyperaemia. Amyloid change occurs not only in follicles surrounded by otherwise normal splenic tissue but also in those imbedded in diseased tissue — in haemorrhagic infarction, for instance. The reaction with iodine presented by a tissue which has undergone amyloid degeneration is very peculiar and charac- teristic. All albuminous substances, when brought in contact with this reagent, become of a yellow color, which is more or less deep according to the intensity of the reaction; but the tissues which have undergone amyloid degeneration be- come dark mahogany-red, at times almost brown, and are thus clearly brought into view, especially when acetic acid has been poured over the cut surface to render it more