Complete Text (Part 42)

may cause a very considerable en- largement of the organ. They appear as grayish nodules of varying size, which are wholly composed of granvüation cells. Even when they are absent in leucaemia, the liver is usually 330 DIAGNOSIS IN PATHOLOGICAL ANATOMY. considerably enlarged ; and the cut surface, after being ex- posed to the air, is soon covered with a white film, which is composed of crystals of tyrosine. Colorless octahedral crys- tals are also found in great numbers, both upon the cut sur- face and in the substance of the organ, of the same character as those which have been spoken of in connection with the spleen. (c?.) By far the most interesting of the other tumors of the liver, are the caroinomata. Both primary and secondary forms occur, the latter being further divided into continued and true metastatic growths. Primary cancer, which is ex- tremely rare, takes its origin, as a rule, from one spot ; a large maternal nodule is surrounded by a number of smaller accessory growths, and as the latter increase in size they gradually become united with the former. Cancers which are continued from some other point present a similar ar- rangement, and consequently often appear as if primary ; all the more so because the new formation in the liver is often much more extensive than at its point of origin. On this account, before taking it for granted that a tumor is primary in the liver, it is necessary to examine carefully the neigh- boring organs, especially the gall-bladder, and the primary tumor will often be found in them. In the case of metastatic cancers there are usually a num- ber of isolated tumors present ; they do not stand in the re- lation of maternal and filial nodules, but are of uniform size, so that no one of them can be looked upon as giving rise to the others. They proceed from primary tumors of different varieties ; most frequently from cancer of the stomach, also from cancer of the uterus, rectum, breast, oesophagus ; in fact, metastases from almost all recognized forms of cancer have been observed in the liver. Their microscopic structure consequently varies, as the cells and often the entire struct- ure of the secondary nodules possess the same characteristics as those of the primary growth. The metastatic nodules arising from cancer of the stomach, uterus, rectum, and ova- ries possess, therefore, cylindrical cells ; those arising from THE LIVER. 331 cancer of the oesophagus, cervical portion of the uterus, etc., are the so-called cancroids, while those arising from cancer of the breast are composed of irregular cancer cells resem- bling glandular epithelium. Carcinoma of the liver may also be divided into hard can- cer, v^hich possesses an abundant stroma (scirrhus)^ and the soft or medullary forms ; the telangiectatic growth, which is a subdivision of the latter, also occurs here. All these, especially scirrhus, are liable to undergo central fatty degen- eration and atrophy, in consequence of which the superficial nodules possess an umbilicated depression corresponding to the atrophy caused by the absorption of the fatty detritus from the centre. These fatty degenerated nodules present a peculiar variegated appearance on section, as yellow streaks alternate with medullary or gray ones (the cancer reticulatus of Johannes Müller). The cancer stroma may be easily demonstrated by brushing the alveolar contents from thin sections ; the resemblance is thus often seen between the stroma of the smaller nodules, and the network of liver capillaries with its minute quantity of surrounding fibrous tissue. It has already been proved that the growth of a great number of cancers takes place within the vessels. The cancerous growth sometimes extends from the larger nodules into large branches of the hepatic vein ; these then become filled with a cancerous thrombus., which may be pro- longed into the vena cava. (e.) The metastatic sarcomata., melanomata., etc., which occasionally occur in the liver, do not differ in any respect from similar growths existing elsewhere. The small cavern- ous tumors (cavernomata), which are easily recognized by their dark red color and bloody contents, have already been spoken of. Occasionally small cysts lined with ciliated epithelium, are found even in large numbers. These are supposed to be congenital and due to the cutting off and dilatation of portions of the bile-ducts. Cysts formed after birth also originate from partial dilatation of the bile-ducts 332 DIAGNOSIS IN PATHOLOGICAL ANATOMY. and are characterized by their tough fibrous walls, and by their contents ; in the latter are found, at first at least, bile, Cholesterine, and less frequently, concretions. Both forms are always situated directly beneath the capsule. 7. Parasites of the liver. (a.) The most important of these are echinocoeci, the most common form of which is the eehinococcus unilocularis that sometimes occurs alone and again in numbers, the size of the cyst varying from that of a small nut to that of a man's head. The substance of the liver appears to be arranged in concentric la3^ers about the parasite, owing to the compres- sion of the lobules, but it is separated by a fibrous tissue cap- sule of not more than one millimeter in thickness. This capsule is lined with a translucent, gelatinous eehinococcus membrane, which is frequently several millimeters in thick- ness. The cyst contains a clear, watery fluid, and often a varying number of smaller cysts, usually as large as cherries,, which are either sterile or dotted upon their inner surface with very small white points (the same occur in single cysts). These points are the scolices, within which, by the aid of the microscope, the head provided with suckers and a double row of booklets may be seen inverted within a little cyst. It is possible in many cases, by slight pressure, to cause the head to protrude, so that the typical form of the cestoid, composed of head, neck, and cyst, is obtained. This is the appearance of living echinocoeci. When dead their appear- ance varies according to their age. The fluid first disappears and then the cyst is filled with a confused mass of membrane, which is always the most important guide in making a diag- nosis from the gross appearances. Later, fatty degeneration follows, which begins at the periphery and finally leads to the filling of the cavity with a soft, yellow pulp in which remnants of membrane are still to be recognized. The fat then becomes absorbed, and lime salts appear in its place, a large or small cretaceous nodule being the sole remnant. The importance of this mass is indicated by the eehinococcus booklets, which are easily found by means of the microscope. THE PANCREAS. 833 The whole sac may suppurate or become putrid as a result of various external causes (trauma, puncture, etc.), in which cases also the microscope is to be resorted to in making a correct diagnosis. In many cases, either recent or old haemorrhages (hsematoidine), pus, fibrous thickening, or cal- cification, are found upon the inner surface of the fibrous capsule, that is, between it and the actual cyst. Another and much rarer form is the echinoeoccus multiloc- ularis., which appears as a very firm, and rarely prominent tumor. This is composed of numerous cysts which are sur- rounded by a thick fibrous capsule, and contain a gelatinous mass in the form of lamellae, but scolices are not always present. According to Virchow these cysts are developed within the lymph vessels. (h.) A small worm, the pentastomum denticulatum, is occa- sionally met with upon the surface of the liver, and deserves merely a passing notice. It occurs as a little white cyst, with a very tough wall, one millimeter in thickness, flattened upon the surface but arched as it extends into the parenchyma ; within this is a crumbled calcareous mass in whicli it is pos- sible, after adding hydrochloric acid, to find the chitinous shell of the parasite, studded with rows of spines. (c.) In closing the subject of parasites in the liver, the distoma may be mentioned. This occurs in the bile-ducts and usually gives rise to a severe fibrous inflammation. 9. THE PANCREAS. After the removal of the stomach and the displacement downward of the transverse colon, the pancreas appears ; both the outer surface and the interior are to be examined, the latter by making a longitudinal incision through the organ. The excretory duct is easily found in making this incision, and may then be laid open with the scissors ; it is also easily found when the duodenum is examined. On account of the slight pathological importance of the pancreas, only the most important changes which occur in the glandular tissue or the ducts will be considered. 334 DIAGNOSIS IN PATHOLOGICAL ANATOMY. (a.) Morbid Conditions of the Parenchyma. The norynal pancreas like all the salivary glands, possesses a coarsely granular appearance, firm consistency, and also a light yellow color ; the latter has, however, a faintly reddish tinge soon after death, owing to an infiltration with blood- coloring matter. 1. A relatively frequent change in this organ is atrophy^ which may be so extreme that onXj a thin band of fibrous tissue remains in its place, within which, possibly by the use of the microscope, small traces of the normal glandular tissue are still to be found here and there. The relatively frequent occurrence of atrophy in diabetes mellitus deserves mention. An ititerstitial formation of fat, similar to the fatty infiltra- tion of muscle, occurs here, especially in cases where there is a general increase of the fatty tissue. This causes an atro- phy of the gland substance, which is of a dirty yellowish-red color whenever it is still present. 2. A parenchymatous change similar to that occurring in the other abdominal glandular organs, takes place in the pancreas (in typhoid fever, etc.). In the earlier stages (during the first or second week) it is large, much red- dened, and firm ; later, however, it is pale, grayish-yellow, or even pure yellow, and very flaccid. In the latter stages the gland cells become fatty. Zenker has recently described peculiar cases, where sudden death was apparently caused by a hcemorrhage into the pancreas, which, in certain in- stances, had undergone complete fatty degeneration. 3. Purulent interstitial inflammation seldom occurs, but suppuration around the gland is more frequent (proceeding from lymphatic glands, peripancreatitis apostematosa). Fi- brous interstitial inflammation on the other hand {pancrea- titis inter stitialis chronica fibrosa) is quite common in cases of hereditary syphilis. Under such circumstances the gland loses more or less of its granular structure, its surface being smooth and usually of a grayish color, and its consistency so firm that it grates under the knife. It has already been THE PANCREAS. 335 mentioned, in speaking of gastric ulcer, that the pancreas frequently become adherent to the stomach, thus preventing perforation. A circumscribed inflammation is set up in it by the extension of the ulcer, so that its contiguous surface becomes converted into a smooth fibrous mass. 4. Among the different variations of tumors which occur in the pancreas, are tubercles and gummata, both of which are extremely rare, and carcinoma^ which is the most com- mon. The latter is seldom metastatic, but usually extends from neighboring parts, especially the stomach, or is primary. The favorite seat of the latter form is in the head, and it is very liable to extend from here to the duodenum. The epigastric glands then quickly become involved, and the py- lorus lies so near that it often requires a very careful exami- nation in order to discover the true seat of the growth. Sev- eral incisions must therefore be made through the head of the pancreas, in order to see if the normal granular structure may not still be observed. Most of these cancers belong to the scirrhous variety, and their microscopic examination is made in the usual manner. 5. Peculiar congenital malformations sometimes occur here in the form of small supplementary spleens inclosed within its head, or of isolated portions of the pancreas in the walls of the duodenum (supplementary pancreas), and less fre- quently in those of the jejunum or stomach. 6. Amyloid degeneration of the pancreas occurs under the usual conditions, and affects principally the vessels of the interstitial tissue. (h.') Morbid Conditions of the Excretory Ducts. The most frequent affection of the excretory ducts is the formation of cysts. First, those liable to be confounded with abscesses, which are small, varying from the size of a millet- grain to that of a bean, and are sometimes filled with a clear, water j'^, and at other times yellow and even thick con- tents. These are often multiple and arranged in groups, — retention cysts of the interlobular ducts which are filled with 336 DIAGNOSIS IN PATHOLOGICAL ANATOMY. catarrlial secretion (acne panereatica). Then tlie chief ex- cretory duct becomes dihited, usually owing to its being closed by a tumor, or by the contraction of a cicatrix (ranula pancreatica). This dilatation may iuTolve either the entire duct (varicose dilatation), or only that portion lying behind the constriction (cystic dilatation). The glandular tissue is usually atrophied in such cases. Frequently the dilated duct contains small concretions (j)ancreatic calculi)^ which are chiefly composed of phosphate aud carbonate of lime. 10. THE CCELIAC GANGLION. The examination of the coeliac ganglion follows that of the pancreas ; it lies above this organ, around the coeliac axis, and upon the aorta, below and in front of the aortic opening in the diaphragm. Generally there is but little to see with the naked eye; still it is important to notice the condition of the sur- rounding fibrous tissue (chronic inflammation), and the color of the ganglion, which is brown when there is great pigmen- tation of the ganglion cells. According to Rokitansky, it is very hyperaämic, and even haemorrhagic at times in typhoid fever, cholera, etc. Atrophy of the ganglion accompanies chronic inflammation of the fibrous tissue about the neighbor- ing supra-renal capsules in certain cases of Addison's disease, and has already been referred to in connection with the latter affection. It has also been found atrophied in diabetes melli- tus. In all cachexias the nerve cells present a considerable increase in the brown pigmeyit granules, which they normally contain, and the cells are also atrophied, the nuclei disap- pear, etc. The pigment is also increased in old age. The vessels of the ganglion become afiiected by amyloid degener- ation, but only in extreme cases where the disease is general. 11. THE ]MESENTEIIY. The examination of the mesentery is to be made before that of the large and small intestine. It varies in thickness, according to the amount of fat present, and may become as thick as the fingers. It varies greatly in form and length. THE MESENTERIC GLANDS. 337 along the large intestine, where it is not attached through- out. In many cases it is even a foot in length, especially at the sigmoid flexure, and then readily becomes twisted. (a.) Morbid Conditions of the Mesenteric Fibrous Tissue. The mesentery, like all the abdominal connective tissue, is the seat of hcemorrhage in poisoning with phosphorus, in acute atrophy of the liver, etc., and of phlegmonous swelling in malignant pustule, etc. One of the commonest affections is circumscribed chronic inflammation (mesenteritis), leading to the formation of radiating, contractive, cicatricial tissue, which occurs in the mesentery of the small, and especially of the large intestine. That of the sigmoid flexure is very marked in this respect. The affections of the peritoneal covering, especially tuber- culosis and carcinoma., have already been considered in con- nection with the parietal peritoneum, and they are only mentioned here to prevent their being confounded with small multiple, fatty papillse, which so stud the mesentery in some cases, that the latter has a velvety appearance. The mesentery is occasionally the seat of larger tumors, among which are the fibro7na., fibrosarcoma, dermoid and vascular tumors (^chi/langioma'), etc. (5.) Morbid Conditions of the Mesenteric Grlands. The lymph apparatus within the mesentery of the small intestine, both vessels and glands, is possessed of great interest, as it takes part in nearly all affections of the intes- tinal canal. All the inflammatory intestinal diseases may be accompanied by swelling and marked redness (hypersemia) of these mesenteric lymph-glands ; these alterations occur most frequently in typhoid fever and tuberculosis, where the changes in the glands are of a like specific character. The typhoid process leads to extreme swelling, which involves the glands in succession, beginning with those in the neigh- borhood of the ileo-cgecal valve (ileo-ccecal chain'). Typhoid glands attain the size of pigeons' eggs, are very soft, juicy, 22 338 DIAGNOSIS IX PATHOLOGICAL ANATOMY. sometimes much reddened, and again paler and more grayish, so that they present the so-called medullary appearance. The enlargement is due to a hyperplasia of the cells, as may be easily seen by teasing bits of gland in a one per -cent, solution of common salt, and examining them with the microscope ; an abnormally large number of multinucleated cells are also found, especially large round forms which often contain from twelve to fifteen nuclei. Beside these, there are the very peculiar cells containing red-blood corpuscles, probably due to the continued hypergemia and consequent slight hemor- rhages. The typhoid process usually causes no other changes than the medullary swelling, but still cases occur where larger or smaller portions of the glandular parenchyma become of a yellow color, and are sometimes in a state of complete soften- ing. This partial necrosis of the parenchyma is the result of a compression of the blood-vessels by the constantly increas- ing number of cells. In microscopic preparations made from such parts, fatty degenerated cells and fat granules (fatty detritus) are found. In tuberculous affections of the mesenteric glands, the manner in which the process advances from the intestine towards the root of the mesentery may also be easily seen ; it is always the row of glands which