Complete Text (Part 47)

little finger. The artery should then be opened throughout its whole length, along the anterior wall, and the incision carried directly into the iliac and hypogastric arteries. Attention should be paid to the contents (often wanting), diameter of the canal, thickness and elasticity of the walls, and the alterations which result from the special diseases. 1. Gieneral Characteristics. The width increases with age, the average in the adult male being, in the ascending portion from seven to eight centimeters, in the thoracic portion from six and a half to five and a half centimeters, in the abdominal portion from four and one half to four centimeters (in the female it is somewhat less) ; it is subject to great variations. Circumscribed dila- tations may occur, attaining the size of a man's head, and others are found which involve the whole length or a large portion (thoracic or abdominal aorta), so that it is one third or one half larger than normal. On the other hand, it may be so narrow, for instance in the female, as hardly to per- mit the insertion of the little finger. The thickness of the wall is in general proportional to the size of the vessel, the average being two millimeters, while the thickness of the wall of small aortee is often scarcely one 874 DIAGNOSIS IN PATHOLOGICAL ANATOMY. millimetre. Exceptions occur in dilatations, where a thin- ning sometimes takes place despite the enlargement. The elasticity usually varies inversely with the size, a dilated aorta being always perfectly inelastic, while the elas- ticity is increased in those which are narrow. This fact is very important in connection with the measurement of the length of the vessel after its removal. As an inelastic ves- sel does not contract in the least, it appears very long, while those which are elastic shrink considerably, and con- sequently diminish in length. Another result is that the inelastic vessels can be stretched but little, while the elastic ones may be stretched like India-rubber, quickly contracting afterwards. • 2. Special Morbid Conditions., particularly of the Intima. The normal inner surface of the aorta is perfectly smooth and uniformly yellow, but may undergo various changes, all of which may essentially result from two conditions : first, simple retrograde metamorphoses, which occur principally in the layers nearest the blood-current ; secondly, the chronic in- flammatory processes (commonly called atheromatous) which are situated in the deeper layers. 1. The retrograde metamorphoses include the transfor- mation of the intima into a soft, gelatinous material, which resembles mucous tissue, even when examined with the microscope (^gelatinous metamo7yhosis^, and the very com- mon fatty degeneration of the cells of the intima. The latter produces a white or lemon-yellow color of the surface, ap- pearing in the form of spots, streaks, or irregularly reticu- lated and striated figures. This change is very often seated in the posterior wall of the aorta about the orifices of the intercostal arteries, and longitudinal lines also usually appear in this region. Sections may be easily made for microscopic examination by stretching the aorta over the forefinger, and cutting parallel to the surface with a sharp razor, or by tearing off thin layers with a small pair of forceps. In such preparations, great numbers of large and small fat drops THE ARTERIES. 375 are seen in the centre of the yellow patch, irregularly dis- tributed throughout the intima. At the edge, however, and in those parts where the change is less advanced, the fat granules are fewer, of much more uniform size, and are arranged in triangular or stellate groups, which correspond with the enlarged and more plump stellate cells of the in- tima. Such an object is especially fitted to illustrate the differences between fat granules and micrococci. Although these fat granules are in general of uniform size, they never possess that perfect uniformity belonging to the micrococci, and may be made to disappear entirely by boiling the prep- aration in equal parts of absolute alcohol and ether, and in glacial acetic acid, which is never the case when micrococci are similarly treated. Simple fatty degeneration of the cells of the intima pro- duces merely a slight elevation of the surface, but may re- sult in very important secondary changes, through the de- tachment and transportation of the endothelium and layers of the fatty patch, by the mechanical effect of the blood- current. Superficial losses of substance (fatty erosion) thus arise, which do not in general materially affect the resistance of the aorta. When this change takes place in smaller ves- sels, for instance those of the brain and pia mater, which is especially the case in drunkards, rupture may result, as the blood forces its way among the cells of the media and forms a dissecting aneurism, the outer wall of which, together with the adventitia, may be subsequently torn through. 2. The second form, the inflammatory processes, leads to greater deformities. At the outset, small, multiple, smooth elevations of the surface arise, which often have abrupt edges and usually feel very firm (sclerosis). Such thicken- ings are frequently found in the arch of the aorta and at those points where the lateral branches are given off, which localization is perhaps due to some mechanical cause. The microscopic examination of vertical sections readily shows that the most superficial layers of the intima are least al- tered, while there is quite an accumulation of small cells in 376 DIAGNOSIS IN PATHOLOGICAL ANATOMY. the deeper layers and a thickening of the fibrous lamellas. Fatty degeneration of the cells very quickly follows this thickening, and begins in the lowermost layers of the intima, in consequence of which the sclerotic patches present a spot- ted, yellow appearance. At a later stage the fatty degenera- tion results in a complete disintegration of the tissue, and the formation of a cavity filled with a pulpy mass composed of fat granules, Cholesterine crystals, and detritus. This is the atheromatous abscess, which constantly increases in size to- wards the cavity of the vessel, till it breaks through at the thinnest point. The mass is then washed out by the blood current, and an irregular atheromatous ulcer results, resem- bling the follicular ulcer of the intestine, which may be easily distinguished from the fatty erosion by its depth and over- hanging edges. These ulcers necessarily exert an influence upon the blood flowing over them, and numbers of thrombi are often found (^pai'ietal thrombi), which constantly increase in size, and are floated away and give rise to embolism. The thrombi which fill up these ulcers may become organized, and the latter are then replaced by scars, the origin of which is usually indicated by the slaty color. Another result of the atheromatous process is the conver- sion of the sclerotic and fatty masses into correspondingly large calcareous plates, which are usually smooth on the sur- face facing the canal of the vessel, and irregular externally ; they are thus distinguished from the occasional calcified pari- etal thrombi, the entire surface of which is irregular. These plates are sometimes of a slaty color, owing to the absorption of blood-pigment and the formation of haematoidine. When the calcification occurs at a part where there is great thick- ening, large, irregular, calcified excrescences may result. Each of the changes which have heretofore been described may occur separately, or, as is usually the case, in conjunction, so that the inner surface of the aorta presents an exceedingly diversified appearance, and the outside is very uneven and misshapen Qendaortitis chronica deformans). In these ex- treme degrees of the affection the vessel is always consider- THE ARTERIES. 377 ably dilated and its walls are thickened and deprived of their elasticity. 3, Calcification of the media must not be confounded with the calcification in the intima just mentioned. This pro- cess does not take place in the aorta, but is often found in the arteries supplying the extremities, especially in old people. The vessels are converted into long, rigid tubes, which often crack under even slight pressure. This change is caused by a calcification of the un striped muscular tissue of the media, while the intima may remain relatively intact. Its origin in the media may often be directly recognized by the annular deposition of the yellowish-white calcareous mass. It is very evident that arterial walls thus altered must greatly obstruct the flow of blood, and the predisposition of old people to gangrene (senile) from slight injuries is thus ac- counted for. The blood clots which are present in such cases are due to secondary venous thrombosis. The arteries take part in the origin of still another variety of gangrene, the embolic form, in which the clot plugging the vessel is often situated at a long distance from the gangrenous part (for instance, in the popliteal artery in gangrene of the foot), while in the senile form the thrombus extends upwards from the seat of the gangrene. The collective alterations in any individual case are com- posed of those already described, and are to be sought for accordingly. Circumscribed dilatations of the vessels, aneu- risms, remain to be considered, and also the congenital alter- ations of the aorta, to the importance of which Virchow has recently called attention. 4. Dilatations of the arteries (aneurisms) are either lim- ited to a small portion of the vessel, or involve large sections, and even entire vascular territories (^serpentine or cirsoid aneurism^. The last, as its name implies, appears as a tor- tuous winding of the elongated and widened vessel, and is met with in the peripheral arteries (frontal, occipital, etc.), and very frequently in the iliacs. The other forms produce 8T8 DIAGNOSIS IN PATHOLOGICAL ANATOMY. either a general dilatation (^cylindrical or fusiforrri)^ or one limited to a part of the wall (sacculated) ; they are most commonly found at the arch of the aorta and the adjacent portions, though not alwaj's confined to these, but extend to the branches which are given off from the arch, especially the innominate. The direction followed in the growth of the aneurismal sac may vary greatly, and neither soft parts nor bones can offer any permanent resistance. Great losses of substance may take place, both in the sternum and spine, from an advancing aneurism. The bone is destroyed by a fibrous metamorphosis, as may be easily seen by microscopic exam- ination of small bony spiculse removed from the eroded sur- face. In the majority of cases the whole aneurismal sac is not empty, but more or less filled with thrombotic deposits from the blood, which are usually very firm and dry, of a pale-red color, and, upon section, are evidently composed of layers. Microscopic examination shows that the lamellae contain fibrine, red and white corpuscles, and also hsematoidine. The early stage of the aneurism is likely to be overlooked, as there is only a slight partial dilatation of the walls, whereas the fully formed aneurism cannot escape notice. Slight an- eurismal dilatations are often found in the ascending portion of the aorta, and should always be looked for when this part is examined. In searching other places, assistance is obtained from the changes taking place in the intima of the dilated part, which are similar to those in large aneurisms, and con- sist of the sclerotic and atheromatous conditions already de- scribed. These are probably of causal importance in the origin of the aneurism (by diminishing the elasticity and power of resistance of the walls). Circumscribed atrophy of the mus- cular coat (chronic fibrous inflammation ?) may be found instead of the inflammatory process in the intima, and, like the similar affection in the heart, may be looked upon as a cause of the dilatation. In all large aneurisms the media has almost wholly disappeared, and often the intima also. Traumatic injury may be mentioned as an occasional exter- THE ARTERIES. 379 nal cause for the development of aneurisms. Syphilis holds a prominent position among the causes which result in the endaortitis antecedent to aneurismal dilatation. There is a peculiar variety of (false) aneurism, the dissect- ing aneurism of the aorta, which consists in a separation of the outer from the middle coat by a current of blood, which has entered through a rent in the intima and media at the upper part of the vessel ; the blood is now forced downwards, even as far as the aortic opening in the diaphragm, splitting the two coats apart, and then often returns to the interior of the aorta through a second rupture of the intima. In this form also, atheromatous changes in the intima, or fatty degeneration of the media, are probably the cause of the rupture. These aneurisms are classified among the so-called false aneurisms, as are also those of traumatic origin, in which the blood-sac lies wholly outside of the artery, and is composed of the surrounding fibrous tissue. The varicose aneurism, which is also usually of traumatic origin, and con- sists of a sac between an artery and vein communicating with each, comes under this head also. 5. Congenital alterations of the aorta include the rare stenosis or atresia which usually results in immediate death, and the very important aplasia, or more correctly speaking, hypoplasia, which manifests itself in the first place by a narrotvness of the vessel. Such a hj^poplastic aorta in adults is often scarcely large enough to admit the little finger, the diameter of the thoracic portion being from three to four centimeters and that of the abdominal portion from two to three centimeters. A thinness of the walls is present, and also an increase of the elasticity, so that when the aorta is re- moved it shrinks very much and may be stretched out like braces. There is also present an irregularity in the origin of the intercostal arteries, which are absent at one point, too numerous at another, etc., and further, a bright-yellow, figured appearance and wavy thickening of the intima, especially on the posterior wall, along and between the orifices of the intercostal arteries. Virchow has demonstrated the connec- 380 DIAGNOSIS IN PATHOLOGICAL ANATOMY. tion between tliis hypoplasia of tlie aorta (observed espe- cially in the female), which sometimes occurs with, and sometimes without, a similar alteration in the heart, and general disease ^chlorosis'), also with disease of the heart (^endocarditis'). (c.) THE RETROPERITONEAL LYMPHATIC GLANDS. The lumbar lymphatic glands, which are situated about the aorta and inferior vena cava, are subject to many changes, which do not differ greatly in their nature from those of other lymphatic glands, so that it will be sufficient to give them a passing notice. Sivelling results from inflammatory affections of any sort situated at the origin of the afferent lymphatic vessels (true pelvis, etc.), and especially in syphilis, in which affection suppuration, like that observed in the inguinal glands, may take place. The lumbar glands also undergo degeneration in connection with tumors, especially tumors of the testis, though less frequently in consequence of cancer of the uterus, etc. They become involved, moreover, in the leuccemic and pseudoleuccemic affections (lymphosarcoma), also in malig- nant jmstule and other similar general diseases. Syphilis gives rise to chronic swelling and induration of the glands. They undergo amyloid degeneration as a result of the general amyloid process, and become cheesy in connection with a sim- ilar change in other organs, especially the intestinal and mes- enteric glands. Finally, there are a number of 'primary tumors (fibromata, sarcomata, lipomata, carcinomata [?]), which originate in part from these lymphatic glands, and in part from the surrounding (retro23eritoneal) fibrous tissue. (c?.) THE THORACIC DUCT. The examination of the thoracic duct and receptaculum chyli, which by the way is seldom necessary, naturally follows that of the glands. The receptaculum chyli lies to the right and behind the aorta, upon the second or third lumbar ver- tebra ; the duct lies behind and to the right of the aorta. THE INTERNAL MUSCLES OF THE TRUNK. 381 The changes to which it is subject are dilatations, either throughout its whole length or limited to a small portion, and are usually due to pressure. Partial obliteration may also be found, and may possibly result from inflammation, fresh signs of which have been but very rarely found. The duct may sometimes contain bloody fluid or a clot. 14. THE mTEENAL MUSCLES OF THE TRUNK. In order to complete the examination of the thoracic and abdominal cavity, the internal muscles and the bones must not be omitted. (a.) The diaphragm may be first mentioned, although its alterations are essentially dependent upon those of its serous coverings, which have already been sufficiently treated of. There are three conditions, however, yet to be noticed : in the first place, the diaphragm is earliest and most affected by trichince, and is therefore always to be examined when their presence is suspected. Secondly, the muscular fibres of the diaphragm often undergo fatty degeneration (also brown atrophy), and then the process is often associated with a similar change of the heart. Finally, the diaphragm is especially adapted, from its richness in lymph-vessels, to illustrate the advance of inflammatory processes along the course of the lymphatics. The observation made by Wal- deyer is quite characteristic in this respect, namely, that in puerperal peritonitis the lymph-vessels were completely plugged with micrococci. Actual purulent inflammation (diaphragmatitis phlegmonosa') is more rare ; where it occurs a marked thickening of the diaphragm is also present. 6. The muscles belonging to the pelvis are next to be ex- amined, the most important of which is the ilio-psoas, from its being the very frequent seat of purulent inflammation (psoas abscess'). This affection is always secondary, some- times to trouble in the spine (caries), and again to trouble in the pelvis (caries, coxitis), and may be unilateral or bilat- eral ; when the latter is the case, affections of the spine must always be thought of. The presence of the disturbance 382 DIAGNOSIS IN PATHOLOGICAL ANATOMY. may be suspected, even before the muscle is cut into,