[=Notice=: 1. While _in situ_—degree of collapse; adhesions; position
and character of; wounds, etc. 2. _After removal_—external character;
color; peculiarity of shape; adhesion of lobes; puckerings at apex;
solid or compressible; crepitation; where most noticeable; effect of
inflation on color and size. _Tubercular deposits_—size; location. 3.
_Substance of lung_—solid or porous when cut; extent of solidified
portions; fluids escaping; character and quantity of.
_Abscesses_—position; number; size; character of contents; color;
odor, etc.; condition of lung around cavities; character of walls;
thick or thin; smooth or rough; crossed by bands; communication with
bronchial tubes. _Gangrene_—location and extent of. _Bronchial
tubes_—contents; contraction or dilatation; measurements at, above and
below these points; condition of mucous membrane; congested or
ulcerated; walls of tubes; thicker or thinner than natural.
_Extravasation of blood_—(apoplexy of lung;) portion and extent of
lung involved; condition of surrounding tissue; blood infiltrated or
encysted. _Adventitious deposits—cretaceous bodies_; situation; size;
density; condition of surrounding tissues. _Tubercles_—seat; size;
number; color; density, etc.; condition of surrounding tissue.
_Cancerous masses_—size; location, etc. _Carbonaceous deposits_—around
bronchial tubes; beneath pleura. _Result of placing entire lungs in
water_—do they sink or float? If they sink, is it rapidly or slowly?
If they float, is it above, below, or at the surface of the water?
Results with portions of each lung.]
The pathological conditions of the lungs, may be arranged as
follows:—_Inflammation_ and its results, _hepatization_, _suppuration_,
_abscess_, _gangrene_, _hæmorrhage_, _pulmonary apoplexy_, _emphysema_,
_tubercular disease_, _morbid growths_, and _parasitical animals_.
When in a healthy condition, the lungs will present the following
appearance:—Upon opening the chest, there will be a more or less
complete collapse of both organs, partly from atmospheric pressure, and
partly from the elasticity of the lung tissue. They will then have a
shrunken, shrivelled appearance, crepitating under pressure, and have an
ashen gray color. If inflated, the surface becomes smooth and shining,
showing an indistinct outline of the lobules, which, with the dark
pigmentary matter seen here and there, gives the surface more or less of
a mottled appearance.
Where pleurisy had previously existed, there may be adhesions preventing
the collapse of the lungs, until these have been broken up. When cut
into, healthy lung tissue has a soft, spongy character, the upper
portions will be quite destitute of blood, while the posterior portions
may be more or less filled with that fluid from gravitation, giving them
a dark congested appearance.
Inflammation and its Results.
=Pneumonia=, or inflammation of the lungs, may affect both the air
cells, when the latter become filled with fibrinous exudations, and the
connective areolar tissue, which then become increased in quantity.
The following characters present themselves, corresponding to the three
recognized stages of the disease:—First, _congestion_; second, _red
hepatization_; third, _gray hepatization or softening_.
=Congestion.= From the peculiar structure of the lungs, in connection
with the free circulation through the same, these organs are peculiarly
liable to the several forms of congestion. In many cases of death,
without any original disease of the lungs, there will be a tendency for
these organs to become loaded with blood, giving rise to post-mortem
appearances, often with difficulty distinguished from those of a
pathological origin. In this post-mortem, or, as it has been called
_hypostatic_ congestion, the posterior and inferior portions of the
lungs are chiefly affected, as the blood after death, obeying the law of
gravitation, sinks to the lowest point. The congested portion presents a
dark red color, and though firmer than other portions, crepitates under
the finger and floats in water, the latter circumstance serving to
distinguish this form of congestion from that of an inflammatory origin.
If the congestion be confined to one lung, or to the anterior parts of
either, we may safely attribute it to a pathological cause.
In all cases of congestion, upon opening the chest, although there may
be no adhesions, the lung does not collapse, or does so feebly. When
cut, it is found to be loaded with blood, and upon pressure, much bloody
serum escapes, while the divided bronchial tubes will be found filled
with frothy mucus.
=Red Hepatization.= This condition of the lungs soon follows that of
congestion. The change is a gradual one, and is first marked by an
effusion of serum and coagulable lymph into the connective tissue and
air cells, thus rendering the lungs more solid, while as the change
becomes complete, the blood itself, which had during the congestive
stage been confined to the vessels, is now found extravasated into the
interstices of the tissues. The portion of the lung thus affected is not
only of a dark red or violet color, but solid, firm, does not crepitate,
sinks when thrown into water, and when cut and washed, the section shows
patches of a rough, granular aspect, totally different from that of
healthy lung tissue. The pleura in this condition may be wholly
unchanged, even though the solidification may have been of long
standing.
=Gray Hepatization=, which characterizes the third stage of pneumonia,
is known by the lung presenting a firm, semi-solid, inelastic, and more
or less incompressible character. Failing to collapse, the lung is found
more or less completely filling the chest. The pleura will generally
present evidences of inflammation in the presence of patches of lymph
and more or less points of adhesions. The upper lobe may be soft and
compressible, while the lower is solid from hepatization. When divided
with the knife, the substance is found of a gray, red, or dirty yellow
color; compact, but friable and easily broken down with the fingers,
while the smaller bronchial tubes are filled with fibrinous plugs.
Bloody purulent matter, with much turbid serous fluid, will ooze from
the cut surfaces. Pus globules will be detected in the escaping fluids
by a microscopic examination.
_Resolution_ of a hepatized lung, consists in the gradual softening of
the effused substances within the smaller bronchial tubes and air cells,
and the discharge of the same by cough and expectoration.
Inflammation of the lung usually commences in the lower lobe, and while
the disease here may extend to complete hepatization, the middle lobe
may be found merely congested, while the upper is quite healthy.
Inflammation may attack one or both lungs. In the former case it is
known as single, and in the latter as double pneumonia. From an
examination of a large number of cases, it has been ascertained that
inflammation of the right lung is more frequent than that of the left in
the proportion of about three to one, and that single pneumonia is more
common than double pneumonia in the ratio of six to one.
Pneumonia is sometimes divided into _Catarrhal_ and _Croupous_. In the
former, the exudation contains little or no fibrinous matter, while the
bronchial mucous membranes are also involved, the disease at the same
time being confined mostly to the lobules of the lungs. In the
_croupous_ form, the exudation contains a large proportion of fibrine,
and the disease usually involves the greater part of a lobe, or may
extend to the whole of one or both lungs.
Both forms of the disease may run through the three stages of
congestion, red and gray hepatization.
A peculiar form of inflammation of the lungs, found mostly in children
and young persons, and usually chronic in character, has been described
as
_Lobular Pneumonia._ The inflammation here being confined to the
lobules, these, after the disease is perfectly developed, present the
appearance of a multitude of rounded nodules, of the size of small nuts,
scattered through the substance of the lungs. The exterior of these is
reddish, firm, and vascular, while the interior is of a grayish color,
containing effused lymph, with more or less purulent matter.
This form of pneumonia being frequently associated with diseases of the
joints and bones, as well as with inflammation and ulceration of the
glands of the intestines, it has been considered as depending upon a
strumous diathesis, and as, in fact, but the early stage of tubercular
consumption. Seldom proving fatal in the early stage, or before the
disease has extended to the whole substance of the lung, and perhaps
resulted in the formation of cavities, we much less frequently meet with
this form of pneumonia in post-mortem examinations.
=Suppuration and Abscess.= Gray hepatization must be looked upon as a
form of _suppuration_ of the lungs; as the purulent-looking fluid found
infiltrating the tissues, filling the air cells and smaller bronchial
tubes, upon a microscopic examination, is found containing undoubted pus
globules. This, however, is not an abscess, the matter not being
confined within a cavity, but diffused through the tissues of the part.
That a distinct abscess of the lungs may form, as a result of pneumonia,
is generally admitted, though they are usually small and confined to the
lower lobes. From softening of tubercular masses, abscesses not
unfrequently form in any portion of the lungs. That they do not occur
more frequently in pneumonia, may result from the fact that the disease
often proves fatal by suffocation, before there has been time for it to
have reached the suppurative stage.
The pleura over the seat of the abscess will generally be found much
thickened, and frequently adherent to the opposite walls of the chest.
Pulmonary abscess may be wholly discharged by expectoration—the cavity
communicating with the bronchial tubes—or it may discharge into the
pleural cavity, or when adhesions have first formed, it may work its way
between the ribs, and the matter escape upon the surface of the body.
=Metastatic or Secondary Abscess.= This form of abscess in the lungs, is
well understood to be the result of suppuration in some distant part or
organ, which, being attended with phlebitis of the part, purulent matter
is introduced into the circulation, and thus conveyed to the lungs or
perhaps the liver. This original suppuration may be at the uterus after
delivery, or from a fistulo in ano, psoas abscess, or any other similar
affection.
From the fact, probably, that the whole volume of the blood flows
through the lungs, at each round of the circulation, these organs are
more frequently affected with this form of abscess than any other, it
occurring next in frequency in the liver. These abscesses may be
recognized as spots of yellow pus, varying in size from a pin’s head to
a walnut, generally situated near the surface of the organ and
surrounded by a dark, well defined layer of congested tissue, while
beyond this, the structure is in a healthy condition. Several of such
abscesses may be found in various parts of the lungs.
=Gangrene.= Gangrene of the lungs, rarely results from an attack of
ordinary pneumonia, but appears more frequently to take place either as
a concomitant of pestilential fevers in general, or as an accompaniment
of certain cases of tubercular vomicæ of the lungs, or as a primary and
peculiar species of inflammatory affection of those organs.
In the first instance, a patient suffering a severe form of typhoid
fever, presents symptoms of pulmonary disorder, as hurried respiration,
livid face, cough, first dry and soon moist, with thick orange-colored
and finally dark or bloody and extremely offensive expectoration, and
fetid breath. With these symptoms are generally associated great
feebleness, delirium, with tendency to gangrene of the extremities and
prominent points of the hips, sacrum, etc.; and finally, with increased
difficulty in respiration and fetor of breath, death ensues.
In the second case, a patient suffering from clearly recognized
tubercular disease of the lungs, which has passed on to softening of
tubercular masses, and the formation of vomicæ, has an aggravation of
all his symptoms, accompanied with the expectoration of a highly
offensive dark matter, plainly resulting from a gangrenous condition of
the interior of a tubercular cavity.
In the third case, the disease comes on at first as an affection of the
lungs. The attack commences either as pulmonary inflammation, or
bronchial disease, or with spitting of blood with more or less pain in
the chest. The patient becomes rapidly worse, the cough increasing, with
reddish-brown or bloody sputa, and offensive breath. The countenance is
anxious and livid, the eye heavy, sometimes wild and glaring. The fetid
breath is not always an early symptom, but when it does appear, the
disease in general tends rapidly to a fatal termination, although
recovery sometimes takes place.[19]
The appearances after death, in cases of gangrene of the lungs, are of
two kinds, according as the disease is _diffuse_ or _circumscribed_.
“In the _first_ case, a mass of lung, two and a-half or three inches
wide, but irregular in figure and outline, is converted into a soft,
pulpy, dark, ash-colored substance, which, when it is handled or pressed
by the fingers, falls down into a loose, moist mass, emitting a fetid,
offensive odor, without trace of the usual structure of the lungs,
except a few bronchial tubes, and blood-vessels, and shreds of
filamentous tissue. This mass is generally bounded by, but it does not
terminate abruptly in, healthy lung. It is soft, dingy, and infiltrated
with a dark, ash-colored, dirty, serous liquor. Occasionally the
surrounding portion of the lung is hepatized or infiltrated with blood
or bloody serum; the bronchial tubes always contain much bloody, viscid
mucus; and sometimes the pleura is reddened, covered with lymph or
adhesions, and contains fluid in its cavity.”
The portion of the lung thus affected is usually within the lower or
middle lobe, the upper portion being rarely involved.
In the _second_, or _circumscribed_ form, a portion of the lung,
generally near the surface, presents a dark-colored, hard patch, varying
in size from a quarter, to a half-dollar piece or more, often quite
circular, and bounded all round by healthy lung. This circular hard
patch, which resembles closely an eschar produced by caustic potash, may
adhere or be easily detached. In the latter case, it generally leaves a
cup-like cavity, the surface of which is firm, granular, with the
blood-vessels and bronchial tubes closed, and with the surrounding lung
more softened, but generally presenting marks of pleurisy, pneumonia,
and bronchitis all combined, which may be looked upon as an effort of
nature to isolate and detach the diseased mass.
=Pulmonary Hæmorrhage=—_Hæmoptysis_. Discharge of blood from the lungs
by coughing, may result from a variety of causes, among which may be
mentioned: 1, mechanical shock or injury, as in falls or blows upon the
chest; 2, inflammatory action within the lungs; 3, disease of the heart;
4, disease of the arteries; 5, tubercular deposition; 6, tubercular
destruction, with ulceration of vessels.
In the first instance the expectorated blood may be copious or slight,
according to the severity of the injury. If death soon results, an
examination of the lungs will disclose one or more of the bronchial
tubes filled with blood, which has plainly arisen from a rupture of some
of the capillaries of the bronchial mucous membrane. The blood
discharged in many cases of the early stage of consumption, and in young
females after the suppression or retention of the menstrual flow, is
from the same source.
Hæmorrhage from the lungs may also take place as a result of tubercular
deposits. The presence of tubercular masses must necessarily produce
more or less pressure on the adjoining vessels, interfering with the
flow of the blood through the same, and thus inducing congestion, and
even rupture of some of the capillary branches. Again, where tubercular
masses have progressed to softening, and a cavity has been formed, the
ulcerative process may open a large vessel, and death result in a few
minutes from excessive hæmorrhage. A post-mortem will here show the
cavity, as well as the bronchial tubes and trachea, filled with
coagulated blood.
The blood expectorated during the early stage of an attack of pneumonia,
is never copious, consisting mainly of streaks of blood through the
saliva, while at a later stage, from being more uniformly diffused, it
gives the peculiar _rusty sputa_ characteristic of this disease. The
post-mortem appearances have already been given under the head of
_pneumonia_.
Certain forms of disease of the heart, as ossification of the mitral
valves, with contraction of the orifice, or in hypertrophy of the left
ventricle, with disease of the aortic valves, are frequently attended
with hæmoptysis. In either case, the obstruction to the free circulation
through the left side of the heart, must induce an over distension of
the pulmonary veins, which, upon some unusual exertion, may readily
result in extravasation through the bronchial mucous membrane, causing
the bloody expectoration which takes place during life, or into the
pulmonary connective tissue, giving origin thus to what is known as
=Pulmonary Apoplexy=. The post-mortem appearances in these cases, are as
follows:—The portion of the lung involved, fails to collapse on opening
the chest. It is firm, and of a dark red color; and when cut into, thick
blood issues from the cut surfaces. The portion involved may include
from one to four cubic inches. It will be found circumscribed with
healthy lung tissue, and looks not unlike a clot of venous blood; these
circumstances serving to distinguish it from hepatization, which
terminates more or less gradually in sound lung.
While these hæmorrhagic effusions may, in many cases, cause early death
by their size and number, in others, the clot may soften, the lung
around become inflamed, or even gangrenous, resulting in the formation
of an irregular cavity filled with dark, offensive, semi-fluid contents.
In still other cases, where the clot is small, and in part within the
air cells, it may soften and become absorbed or coughed up, and the air
again enter the cells, or these may contract into a fibrous indurated
mass.
=Emphysema.= Emphysema of the lungs, is usually described as of two
forms—_vesicular_ and _interlobular_.
_Vesicular emphysema_, consists essentially in a dilatation or
over-distension of a greater or less number of air cells, resulting in
giving the portion involved greater buoyancy in water, from diminished
specific gravity, lessening the crepitation on pressure, preventing
collapse on the opening of the chest, and rendering the affected portion
more or less dry and bloodless. From the loss of elasticity, there will
be during life, a difficulty in the lungs emptying themselves of air as
they should, hence the patient will be subject to severe attacks of
oppression upon the slightest aggravating cause. If one lung only is
affected, the corresponding side becomes enlarged and less movable than
the other; the adjoining viscera, as the heart or abdominal organs, are
more or less displaced, the intercostal spaces swell out, and the ribs
becoming more horizontal, give a barrel-shape to the chest, which is
quite characteristic of emphysema.
This distension of the air cells, is more marked along the edges of the
lungs, the vesicles at these parts being probably the least supported.
Patches of dilated cells may be found, however, at other parts, which,
if superficial, will project beyond the surface of the surrounding
healthy portions, and appear like large bladders, from the coalescing of
several vesicles.
This form of emphysema may be induced by any cause interfering with the
ready escape of the air from any portion of the lungs, especially if
accompanied with severe cough, as in many forms of bronchial disease,
enlargement of the bronchial glands, etc.
_Interlobular Emphysema_, consists in an effusion of air into the
connective or areolar tissue of the lungs, from a rupture of air cells
or smaller bronchial tubes, or from the laceration of the lungs from a
broken rib, when the air may accumulate in the pleural cavity,
constituting pneumothorax, and may also be accompanied with emphysema of
the chest, neck and head, from an escape of the air at the point of
injury into the tissues of those parts. This form of emphysema may
involve a large part or the whole of the lung, while the vesicular form
is generally limited to definite portions. By disturbing the circulation
through the lungs, emphysema is liable to induce dilatation of the right
side of the heart.
From an evolution of gases within the lungs after death, we may have
similar appearances to that above described, requiring some care to
distinguish between the two. In the latter case, the general indications
of decomposition, with the ease with which these distended vesicles may
be emptied by pressure, will aid in determining the character of the
case.
Tubercular Disease of the Lungs.
I shall not attempt to present here the various theories that have been
promulgated as to the nature and origin of tubercle, contenting myself
by giving a description of their anatomical characters, as presented in
the several stages of tubercular disease.
_Tubercle_, or tubercular matter, may be described as consisting of a
yellowish-white substance, opaque, friable and unorganized. It may be
deposited in most of the tissues or organs of the body, but its more
common seat is the free surfaces of mucous membranes, though often found
in connection with the serous.
Tubercular deposits in the lungs, are not uniformly distributed through
all parts of those organs, being in the large majority of cases confined
to the upper and back part of the upper lobes, and in those cases where
they are more or less distributed through the whole lung, they will be
found more numerous and larger in those parts.
Tubercles may exist as fine points, not larger than a pin’s head,
(_miliary tubercle_,) or the matter may accumulate in masses of the size
of a kernel of corn, of a cherry, or of a robin’s egg. In other cases,
the pulmonic exudation in some portion of the lung attending an attack
of pneumonia, may become transformed into tubercular matter, having an
irregular outline and no distinct boundary, (_infiltrated tubercle_.)
Tubercular matter is undoubtedly, in most instances, deposited within
the air cells, so filling these, as to more or less interfere with the
admission of the air, and giving greater density to the portion of lung
involved. While the secreted matter is at first soft, or semi-fluid and
partially translucent, it gradually acquires greater density, becomes
opaque and cheesy in its character, and in all respects acting as a
foreign body within the lungs. Sooner or later, the presence of
tubercles will excite inflammation in the surrounding tissues. In this
manner these bodies may become softened and their substance
expectorated. If large numbers be aggregated together, the ulcerative
process may completely destroy the tissues between, an abscess or vomica
resulting.
In the early stage of the disease, before the inflammatory and
ulcerative processes have been set up, the presence of tubercular
matter, by interfering with the capillary circulation, may give rise to
a hæmorrhage into the bronchial tubes, constituting the hæmoptysis so
frequently present in this disease; while at a later period, from a
destruction of some of the larger vessels from ulceration, a profuse and
even fatal hæmorrhage may result.
Post-mortem Appearances.
In examining the lungs of those who have died after suffering the usual
symptoms of pulmonary consumption, we shall find the upper portion of
one or both lungs, more or less indurated, and occupied by one or more
irregular shaped cavities, containing either air, or air and a quantity
of viscid, puriform, dirty-looking fluid. Generally the apex of the
affected lung, will be found firmly attached to the inner surface of the
chest, by means of a thick, firm, false membrane, which unites the two
layers of the pleura. In some instances, nearly or quite the whole
surface of the lung will be found thus adhered, while the lobes will
also be united by an interlobular false membrane. When the adhesions are
confined to the upper portions of the lungs, the pleura covering the
lower portion will frequently be found more or less rough from
albuminous exudation, while a quantity of sero-purulent fluid will be
found in the posterior part of the thoracic cavity.
The greater part of the upper lobe, may be found converted into one
irregular cavity; more frequently, the upper lobe presents two or three,
either isolated or communicating. The largest, when several are present,
is most commonly in the upper portion of the lobe. When entirely or
partially filled with matter, such cavities are usually termed _vomicæ_
or abscesses, while when empty, they are generally called _tubercular
cavities_ or excavations.
In the lower part of the upper lobes, the cavities are few and small.
The middle lobe of the right lung, rarely presents cavities, while the
lower lobes of both lungs are entirely free. The whole of these parts,
however, may be more or less indurated by the presence of hard,
irregular shaped masses, the result, probably, of inflammatory action.
_Tubercular cavities_ present a considerable variety, both in size and
shape. They may not be larger than a pea, or bean, or may reach the size
of an egg, or even of an orange. Always of an irregular shape, they
often consist of one large cavity, communicating with two or three
smaller ones. The interior will be found traversed by bands, or cords,
passing in various directions, but generally taking a longitudinal
course, and probably the remnants of blood-vessels and bronchial tubes.
The tissues immediately around a cavity, and forming its walls, will be
found firm, inelastic, almost cartilaginous in character, and of a dark
red, or brown color. The density of the structures is caused partly by
tubercular deposits in the lung, and partly by inflammatory induration.
While tubercular disease of the lungs is almost universally fatal, there
is reason to believe that, in a very small proportion of cases recovery
has taken place, and the post-mortem appearances of the lungs have
accorded with this view. These appearances may be described as follows:
We sometimes observe in examining the lungs of individuals who may have
died from diseases of other organs, that the pleura covering the upper
lobe of the lung, presents, at a certain point, a puckered, shrivelled
appearance, with a leather-like feel, and with a rounded, firm mass
beneath. Upon dividing the latter with the knife, the interior is found
composed either of a soft substance like putty, or more frequently of a
chalky nature. This is looked upon as a cicatrized or contracted vomica,
the putty or chalk-like contents being the residuary matter of the
softened tubercle, the thinner portion having been expectorated or
removed by absorption. In some instances, these bodies are of almost a
stony hardness, grating against the knife.
In other cases, cavities lined with a smooth, semi-cartilaginous false
membrane are found, containing air only, and with dilated bronchial
tubes opening into the same, no appearance of ulceration being visible,
everything indicating that a tubercular mass had once occupied the
cavity, its softening and expectoration having been followed by a
healing of the inner surface.
Morbid Growths.
=Cancer.= Malignant disease of the lungs is by no means frequent, yet we
have abundant evidence that cancer in its several forms may be developed
in these organs. Colloid cancer, has been usually found more or less
infiltrated through the substance of the lungs, while other forms appear
in nodules or isolated tumors.
It is seldom, perhaps, that cancer exhibits itself as a primary
affection of the lungs, the disease first appearing in some other part,
and more frequently, it is said, in the bones or testicles; operation
for the removal of cancer in these parts being very liable to be
followed by an early development of the disease in the lungs or other
internal organs. On the other hand, where the cancer is connected with
any organ whose veins form a part of the portal system, as the stomach,
spleen, pancreas, intestines, etc., the disease does not so frequently
extend to the lungs, while in those cases the liver is more liable to
become affected.
The _encephaloid_ form of cancer, is that more frequently met. It may be
connected either with the bronchial glands, when the diseased mass will
be mainly confined to the mediastinum, and may consist of bodies varying
in size from that of a cherry to that of a large apple, or, the disease
may commence directly in the substance of the lungs, the tumor rapidly
increasing in size, and crowding the lungs from their normal position.
After death, the encephaloid mass may be found compressing the lungs
into a very small space. The tumor presents the usual character of this
disease, some of the lobules being soft and pulpy, or brain-like, others
of a more firm, cheese-like consistence.
=Melanosis.= Two forms of melanotic deposits are observed in the lungs:
one, _true melanosis_, and frequently associated with encephaloid
disease; the other a deposit of carbonaceous matter from coal dust,
smoke, etc., which has been inhaled during life, and distinguished as
_spurious melanosis_.
_True melanosis_ consists in a deposit of a dark pigmentary matter in
the substance of the bronchial glands, found at the bifurcation of the
trachea, and along the main bronchi. The glands are at the same time
enlarged. The coloring matter may be solid, or slightly fluid, or pasty.
At the same time the melanotic matter may be infiltrated to some extent
into the substance of the lungs, or deposited in cysts within the same.
In _spurious melanosis_, the dark carbonaceous matter is diffused more
or less through the whole lung, and may be seen distinctly through the
pleura. The bronchial mucous membrane is more or less tinged with the
same substance, and generally a quantity of black-colored fluid may be
expressed from the cut surfaces.
=Hydatids.= Acephalocysts or animal hydatids, have not unfrequently been
found in the lungs, and in several instances they have been discharged
by expectoration.
These cysts vary in size from a cherry to an egg, and consist of a
double membrane containing a limpid fluid within which other hydatids
may be found, of the same character as the parent cyst. They may excite
inflammation and suppuration in the tissues around, and thus become
discharged into the bronchial tubes, the pleural cavity, or through the
diaphragm into the abdominal cavity.
_Cystic_, _Fibrous_, _Cartilaginous_, and other forms of tumors, are
occasionally found in the lungs, and, while they are generally small,
they may acquire such size as to become a source of trouble during life.
The Bronchial Tubes.
The examination of the trachea and bronchial tubes in post-mortem
examinations, is too frequently omitted. The lungs having been removed
from the chest, they may be readily opened along their posterior aspect,
and the bronchial tubes traced into the substance of the lungs. The
pathological conditions of the bronchial tubes which may claim our
attention, are _inflammation_ in its various forms, _obliteration_, and
_dilatation_.
=Bronchitis.= Bronchial inflammation has been divided into two
varieties, according to the portion of the tubes affected. In one case
the disease may be confined to the large and medium sized tubes; it is
then known as _tubular bronchitis_. In the other, it is seated
principally in the terminal ends, where the lining membrane is more
delicate, and the tubes much smaller, and from this, extending to the
air cells, forms what has been called _vesicular bronchitis_. The latter
form is closely allied to pneumonia; in fact the two diseases pass into
each other, and in most cases probably coexist.
Ordinary, or _tubular bronchitis_, is not often a fatal disease, hence
we cannot speak accurately of its anatomical characters; yet, being
frequently associated with other forms of fatal disease, we have
opportunities of examining it under those circumstances. The lining
membrane is then found thickened, rough, of a dark red or brown color,
with more or less contraction of the calibre of the tube, and covered
with a viscid, jelly-like mucus, often streaked with blood, and in some
cases of a puriform character. This form of bronchitis may occur as a
primary disease, or it may accompany tubercular consumption; is frequent
in cases of heart disease, and may arise in the course of typhoid fever,
measles, scarlet fever, and small-pox.
_Vesicular bronchitis_, from its involving the smaller tubes and air
cells, is much more frequently fatal than the tubular form of the
disease, although in fatal cases the two forms will usually coexist. In
a post-mortem examination of these cases, we find the bronchial membrane
red and injected, pulpy and thickened. In a more advanced stage, the air
cells and smaller tubes are filled with a viscid, puriform mucus, which
prevents the air from reaching the vesicles during life, and the lungs
from collapsing upon opening the chest after death. Minute ulcers are
not uncommon upon the mucous membrane, the effect of these, being that
of changing the character of the secretion from a transparent mucoid, to
an opaque purulent form.
Bronchial inflammation, as has been stated in another place, may result
in emphysema of the lungs. In these cases, a valvular-like obstruction
is produced in some of the bronchial tubes, which, offering little
impediment to the entrance of the air, interferes with its escape, and
thus by producing increased pressure upon the air cells supplied by the
obstructed tube, a gradual dilatation or rupture ensues, resulting in
the former case in vesicular, and in the latter, in interlobular
emphysema.
Disease of the heart may also result from chronic bronchial
inflammation. Not only respiration, but the circulation may be so
impeded as to exert a direct influence upon the heart. From the
difficulty which the blood encounters in flowing through the branches of
the pulmonary artery, the main trunk of that vessel becomes permanently
dilated, while the right ventricle, from the increased force required to
overcome the obstruction in the lungs, becomes gradually dilated, and at
the same time, perhaps, hypertrophied. From the union of the two
ventricles, the excessive action of the right may induce a similar
action in the left, and thus in time result in that hypertrophy of both
ventricles, which is sometimes found in persons who have suffered from
chronic bronchitis.
=Narrowing or Obliteration of Bronchial Tubes.= In some cases, in
carefully tracing the bronchial tubes, we may find either a remarkable
narrowness of the vessel, or a complete closure of the same. In the
former cases, there is a distinct thickening of the walls of the tube,
by an effusion of lymph, or blood and lymph, into the submucous tissues;
or, from induration of the lung tissue around the smaller bronchial
tubes, from tubercular or other deposits, a similar narrowing may result
from external pressure.
Complete closure may be found in any portion of the tubes, in the large
trunks, arising from the main branches, as well as in the smaller
branches. They may be detected by passing a blunt probe into the tubes.
The branches will frequently be found continuing from the points of
closure, as a fibrous cord. The most common seat of these closures is in
the upper lobe of the lung, yet they have been found in the lower lobes.
The causes of obliteration of the bronchial tubes is not well
understood, yet, they are more frequently observed in persons who have
suffered repeated attacks of bronchitis, or of chronic pneumonia.
=Dilatation of the Bronchial Tubes.= This condition of the bronchial
tubes is more frequent in its occurrence than obliteration. It takes
place in two forms, either several tubes are uniformly dilated, like the
fingers of a glove, or a single tube may form a cavity, by undergoing a
sacular enlargement. Some mechanical obstruction, by interfering with
the free passage of air through the tubes, will usually have caused the
difficulty, as an enlarged bronchial gland, pressing one of the bronchi.
Here the free exit of the respired atmosphere being prevented, an
accumulation of air takes place behind the narrowed point. Any
impediment to the entrance or exit of the air into the lungs will
produce irregular and forcible breathing, and throw a greater strain
upon those parts especially which are in the vicinity of the obstacle.
If, at the same time, the patient suffers an attack of asthma, bronchial
catarrh, or whooping-cough, the violence of the cough materially aids in
developing the dilatation.
The degree of dilatation is greatly variable. Tubes which, in their
natural state, are not larger than a crow-quill, may, especially in the
lower and middle lobes, reach the size of the finger, while at various
points, sacular dilatations may occur, which at first sight may appear
as vomicæ, but which upon more careful inspection, prove to be dilated
portions of the bronchial tubes. The tubes in this state are usually
filled with a puriform fluid, upon the removal of which the lining
membrane is seen to be reddened and softened, or perhaps ulcerated.
This condition of the bronchial tubes may frequently be detected during
life. The voice is hoarse, like a person in croup. The cough is also
hoarse and brazen, while the breathing is difficult, and mucus rattling
is heard in the middle or lower portion of the lung.
The post-mortem appearances in cases of _foreign bodies_ in the
bronchial tubes, may be readily anticipated and easily recognized.
The Mediastinum.
_Inflammation_ may arise in the anterior mediastinum, from fracture or
caries of the sternum; and in the posterior, from injury, inflammation,
caries, or necrosis of the vertebræ. This inflammation may also result
in the formation of an
_Abscess_; or, ulceration and perforation of the œsophagus, or
inflammation of the lymphatic glands may lead to the same results. These
abscesses may reach large size, resulting in displacement of the heart,
and may rupture into the pleural cavity, the trachea or œsophagus.
_Tumors_ of various kinds, may also develop within this space, including
the several forms of _cancerous growths_. The latter will frequently
have their origin in the bronchial or lymphatic glands, or, perhaps, in
the remnant of the thymus gland.
PART III.
THE ABDOMEN AND PELVIS.
CHAPTER I.
THE OPERATION.
The cavity of the abdomen, may be opened without disturbing that of the
chest. An incision from sternum to pubes, down the central line, and
through the superficial structures, should be followed by a careful
division of the tendinous portions of the muscles and peritoneum, for a
sufficient space to admit two fingers, when, by introducing the same,
the remaining portion may be divided without risk of injury to the
intestines. A cross incision having been made at the umbilicus, the
angular flaps may be turned aside, fully exposing the abdominal
contents. Where the chest is opened at the same time, the transverse
incision will not be required. The peritoneum, with any serous or other
contents having been examined, the attention may be given to any special
organ or part that may be involved, or each may be taken up seriatim.
In many instances there will be no occasion for removing any of the
viscera, while in others, one or all of the organs may require so
careful an examination, as to necessitate an entire removal from the
body.
The _small intestines_ may be removed _en masse_, or in sections. After
applying double ligatures at the lower end of the ileum, and just below
the duodenum, the bowel may be divided between these, when, by dividing
the mesentery near its intestinal border, with either the knife or
scissors, the whole mass may be removed. By means of the _enterotome_,
they may now be rapidly laid open through their entire length, the
contents removed, and the surface cleansed if desired for more careful
inspection. Occasionally, portions only of the small intestines will
require examination. By applying double ligatures, above and below the
portion to be examined, the removal is effected without escape of the
contents into the abdominal cavity.
In the removal of the _colon_, either in sections, or as a whole, the
same care should be observed in the application of the ligatures. The
rectum having been divided, it may be lifted and rendered tense, its
attachments, with those of the ascending transverse and descending
colon, being successively divided with the knife, and thus the whole gut
removed and afterwards split open with the enterotome.
The removal of the _rectum_, for the examination of its whole length,
will usually require the removal of the other pelvic viscera, directions
for which will be given further on.
In all cases where the _stomach_ is to be examined, it will be better
first to remove it from the body. To accomplish this, both omenta should
be detached from the curves of the stomach, which may be done either
with the fingers or scissors. The hand may now be carried down to the
cardiac end of the stomach and the fingers forced around the œsophagus
without the use of the knife, and a ligature placed upon that tube. A
ligature should also be placed just below the pyloric orifice, and
another an inch below this. The knife or scissors may be used to divide
the œsophagus close to the diaphragm, and the duodenum between the two
ligatures; the stomach may then be lifted from its position without loss
of any of its contents.
If the object is merely to make a chemical analysis of the contents, the
stomach should be placed immediately in the vessel prepared for its
reception, and carefully sealed and labelled. If, on the other hand, we
may wish to examine the inner surface of the organ, it may be freely
opened along one of the curves with the scissors, the contents removed,
and the mucous surface cleansed with a stream of water, for more
satisfactory inspection. Both the contents and the stomach, may still be
preserved for chemical examination, should the circumstances of the case
seem to require it.
From the manner in which the _duodenum_ is bound down to the posterior
abdominal walls by the peritoneum, some little care will be required in
its removal. Ligatures should be applied for retaining the contents, as
directed with the stomach.
_The kidneys_, with the suprarenal capsules, may be reached by lifting
the intestines, and tearing open the peritoneum with the fingers. The
gland may then be readily lifted from its position, and the vessels
divided with the knife. To examine the interior, the gland may be split
open longitudinally along its convex border, which will give a view of
the cortical and pyramidal portions, with the interior of the sinus and
pelvis. For microscopic examination, portions should be hardened in
alcohol or solution of bichromite of potassa.
_The spleen_ may be easily removed from its position, by dragging it
from its bed, in the left hypochondriac region, and dividing its vessels
and omental attachments to the stomach.
_The pancreas_ may be brought into view, by tearing open the great
omentum just beneath the stomach, when the gland may be seen behind the
peritoneum, extending transversely across in front of the aorta. To
remove it from its position will require some care, owing to its being
bound down to the posterior walls by the peritoneum, and closely
attached to the duodenum by its right extremity or head.
_The liver_ may be generally examined _in situ_. The condition and
contents of the gall-bladder, the size, color, density, etc., of the
gland, may all be noted without removal. Where, however, we may desire
to ascertain the weight of the gland, or to examine its posterior and
upper surface, its removal will be required. Where the chest has
previously been opened, this will not be a difficult operation. In other
cases, the cartilages and ribs, forming the lower boundary of the chest,
should be strongly elevated by an assistant; the operator then, by
dragging down the liver, having first divided the suspensory ligament,
may expose the coronary and lateral ligaments, which will require care
in their division, to avoid opening through the diaphragm into the
chest. The fingers should be now freely used, to peel the gland from the
diaphragm. From the close connection of the liver to the ascending vena
cava, this vessel will require to be divided at the upper border of the
liver, close to the diaphragm, and again, after the gland has been
rolled from its bed, at its lower border, with also the portal vessels,
hepatic artery and duct, which reach the transverse fissure through the
border of the lesser omentum.
The liver may now be lifted from the body, and placed in any convenient
vessel for a more detailed inspection.
The Pelvic Viscera.
The whole _pelvic viscera_, with the external organs of generation, in
either the male or female, may be removed together, in the following
manner:—Apply a double ligature to the upper portion of the rectum, and
divide the gut between. The peritoneum may now be divided around the
border of the pelvis, in the female, at the same time, cutting across
the round and broad ligaments of the uterus, when, with the hand, the
bladder may be stripped down from the inner side of the pubes, the
rectum torn from the hollow of the sacrum, and in the same manner the
parts torn off from the sides of the pelvis, using the knife only for
dividing the more closely adhering points.
Now, after flexing the thighs upon the abdomen, an incision may be made
through the skin of the mons veneris just over the anterior commissure
of the vulva of the female, and over the penis of the male, and then
carried back upon either side of the genital organs, meeting behind the
anus, near the point of the coccyx. This incision may be carried through
the superficial tissues, down to the pubic arch, when the crura of the
penis, or clitoris, may be detached from the rami of the pubes, by
carrying the knife close to the bone. The finger may now—after a slight
use of the knife—be pushed beneath the arch of the pubis, and made to
appear in the pelvis. Taking this as a guide, the knife may be
introduced at this opening, and carried deeply along the ramus of the
ischium and pubis of either side, dividing the levator ani muscle and
pelvic fascia. The bladder may now be drawn forward beneath the arch,
this followed by the rectum, deep incisions being carried back to the
tuberosities of the ischia and point of coccyx, and thus the whole mass
removed entire.
The external parts may afterwards be so drawn together by stitches, as
to make the absence of the external organs scarcely noticeable, while a
bundle of rags crowded into the pelvis from above, will prevent the
possible escape of any of the abdominal contents.
Where the _internal organs_ only, are required to be removed; after they
have been detached upon all sides as before directed, the knife may be
carried down beneath the pubic arch, and the urethra divided, in the
male, just in advance of the prostate. Incisions may now be carried back
upon either side of the bladder and rectum, dividing the levator ani
muscle, when, by drawing upwards upon the mass, the rectum, and in the
female, the rectum and vagina, may be divided near their lower ends, and
the whole removed together.
In many cases it may be desired to remove the uterus of the female
alone. This may be done by dividing the broad and round ligaments upon
either side, when, by dragging the uterus forcibly upwards, the vagina
may be cut across about an inch below the cervix, and thus the organ
removed. In all cases, a few rags should be crowded into the pelvis for
the purpose of preventing the escape of any fluids.
In hospital cases, where parts are to be exhibited to a class, and
especially if several organs are involved in the disease, the whole
thoracic and abdominal viscera may be removed together and brought
before the class on a large tray. This may be effected in the following
manner:—A single incision may be carried from the upper end of the
sternum to the pubes, and the sternum removed in the usual manner. The
trachea and œsophagus, with the large vessels of the arch of the aorta,
may now be divided at the root of the neck. Grasping the arch of the
aorta and the trachea, the whole thoracic contents may be stripped from
the spinal column. The diaphragm being now separated from its attachment
to the ribs on either side and the spinal column, the whole abdominal
contents may, in the same manner, be dragged from above downwards, the
rectum tied and divided, and the contents of the two great cavities
removed entire and with little disturbance of the relation of parts.
In closing up the cavity after the examination is completed, the viscera
having been replaced, a sufficient quantity of wheaten bran or clean
sawdust should be thrown in to absorb any remaining fluids, thus
preventing their escape after the sewing up of the incisions.
CHAPTER II.
PATHOLOGICAL CONDITIONS.
Section I. OF THE PERITONEUM.
[=Notice= in examination:—1. _Contents of cavity_—serum; amount,
color, coagulable or not; _pus_—amount, consistence, odor, source;
_blood_—amount, source; foreign bodies; gall-stones; worms. 2.
_Condition of membrane_—color, transparency, rough or smooth, moist or
dry, thickness; _adhesions_—position and strength of. Vascularity;
ulcers; perforations; tubercles; tumors; wounds, etc.]
This membrane we find liable to _congestion_, _inflammation_,
_gangrene_, _effusions_, and _morbid growths_.
=Congestion= of the peritoneum, may result from obstructed circulation
through the liver, or ascending vena cava, or from inflammatory action;
and may terminate in serous effusions into the abdominal cavity, or
thickening of the membrane. The redness of congestion, may be
distinguished from that of inflammation, by the larger vessels appearing
more involved, and by the absence of any plastic effusions.
=Inflammation= of this membrane, (_Peritonitis_,) may be either acute or
chronic.
_Acute peritonitis_, in most instances, commences at some one or more
points, and from this gradually diffuses itself over the membrane until
it becomes general. Such point of inflammation may commence immediately
over some inflamed, or ulcerated, or perforated spot in the intestines,
or in the peritoneal covering of an inflamed uterus, liver, etc., or as
the result of external injury.
In the early stage of peritonitis, the injected vessels give the
membrane a more or less red appearance, which will be more marked in
streaks and patches. From the readiness, however, with which fibrinous
exudation takes place from this membrane, this redness is seldom very
strongly marked, and in some instances will scarcely be noticed, unless
the surface is carefully scraped, thus removing the exudation.
Small extravasations of blood are occasionally found in the substance of
the membrane. The muscular coat of the intestines, where the peritoneal
covering is involved, may become infiltrated with serum, the fibres
relaxed and paralyzed, thus permitting of the great tympanitic
distension found in these cases.
_Chronic peritonitis_, is not a very common occurrence. It may, however,
follow an attack of acute peritonitis, and is sometimes found in
connection with ascites, or tubercular deposits in the peritoneum. In
examining the body of a colored woman who had died of heart disease,
accompanied with general dropsy, and who had suffered abdominal pain and
tenderness for a number of weeks previous to death, a large portion of
the peritoneum, particularly that reflected upon the abdominal walls,
was found intensely red, the blood-vessels having an arborescent
arrangement, and being beautifully injected. No plastic matter was found
effused upon the surfaces. The cavity contained some twelve quarts of
serum.
=Fibrinous Exudation=, as already observed, readily follows inflammation
of this membrane. It will often be found as a uniform layer covering the
whole surface of the peritoneum, rendered more apparent, however, by
separating parts, when it appears as delicate bands or filaments,
stretching across the interspace. In cases of acute inflammation, this
plastic effusion is often very great, and frequently intermixed with
purulent matter, while the serous fluid, which is poured out in
considerable quantities in these cases, is rendered turbid by the
presence of numerous flakes of fibrin, and quantities of pus cells
diffused through the same. More or less extensive and firm adhesion of
parts may thus be induced, the plastic matter effused becoming more and
more firm, and finally converted into dense bands of fibrous tissue.
Mechanical obstruction and strangulation of the bowels, may be induced
by the presence of these bands, stretching between parts, and forming
thus an opening through which the bowel passes, and finally becomes
incarcerated.
=Suppuration= is not an unfrequent result of acute peritonitis; the
matter being found uniformly smeared over the whole surface, or, in some
cases, confined to a single part, thus forming a circumscribed abscess.
Adhesions having taken place around the boundaries of the suppurating
surfaces, in this manner the diffusion of the matter is prevented, and
its discharge into the intestinal canal, or in some instances upon the
surface of the body, is promoted.
=Gangrene= of the peritoneum may result from intussusception or hernial
incarceration of some portion of the bowel, when the part will appear as
a softened, dark, offensive mass, limited by a band of highly congested
tissue.
=Ascites.= Dropsical accumulations in the abdominal cavity, may result
from obstructed circulation, caused by disease of the liver, kidneys,
heart or lungs; or from pressure upon the vena cava, or portal vein, by
some abnormal growth.
The fluid effused may be nearly colorless, or present various shades of
yellow, red or green, and usually coagulates on the application of heat.
The peritoneum may appear unchanged, or it may present a thickened,
opaque, white or macerated appearance, in chronic cases.
Blood may be found in the peritoneal cavity, as a result of wounds,
rupture of some of the abdominal or pelvic organs, or bursting of an
aneurism.
=Morbid Growths.=
=Tubercular Deposits=, of the miliary form, are not unfrequent in the
peritoneum. They may be diffused over the whole membrane, as
semi-transparent, gray granules, but more frequently are found on the
under surface of the diaphragm, in the neighborhood of the spleen, and
on the viscera generally, while the parietal layer is more free. The
tubercles, acting as foreign bodies, give rise to inflammation, usually
of a chronic form, but sufficient to result in exudation of lymph, and
the formation of adhesions between the adjoining surfaces. Softening of
the tubercular deposits sometimes takes place, and perforation of the
intestinal wall results, leading to an effusion of the intestinal
contents into the peritoneal cavity.
=Cancer= of the peritoneum, is sometimes seen as a primary affection,
yet it more frequently extends to this membrane from some of the deeper
parts. The encephaloid variety may be met with, but the colloid form is
that most frequently seen. The omentum is the occasional seat of this
form of cancer, the membrane in such cases becoming enormously increased
in size.
=Tumors= of various kinds, including _fibrous_, _fatty_, and _cystic_,
may be found in the peritoneal cavity, generally having had their
origin, however, in the sub-peritoneal tissues. _Fatty_ tumors may
originate within the substance of the omentum or mesentery, while
_cystic_ tumors may be found within the broad ligaments of the uterus or
ovaries.
Section II. OF THE STOMACH.
[=Notice= in examination:—1. _External characters_—position; size;
form; adhesions. 2. _Contents_—quantity, color, odor, reaction.
_Food_—its nature, degree of digestion. _Blood_—pure or mixed with
food; probable source. _Foreign substances_—powders, metallic
particles, spirits, fœcal matter, bile, pus, worms. 3. _Mucous
membrane_—general condition of; color, soft or firm, rugæ present or
absent; thickness at various points; ulcers; their position, size,
etc. 4. _Muscular coat_—thickness; visibility of fibres. 5. _Entire
walls_—transparency; wounds; perforations; ruptures; weight. 6.
_Condition of orifices_—constricted; dilated. _Tumors_—position, size,
character, etc.]
Few organs of the body are subject to such a variety, or to such early
_post-mortem_ changes as the stomach, many of which, being closely
simulative of the effects of disease, render a satisfactory examination
of this organ, in many instances, very difficult. Therefore, before
entering upon an account of the morbid anatomy of the organ, I shall
briefly notice those changes which are _post-mortem_ in their origin.
The ordinary interval which intervenes between death and a post-mortem
examination, is, in most instances, sufficient to seriously change the
appearance even of the healthy stomach. Hence our knowledge of the
healthy appearance of that organ, at least, previous to the experiments
of Dr. Beaumont upon the stomach of Alexis St. Martin, was quite
imperfect.
=Post-Mortem Changes.=
Among those changes taking place after death, which are no evidence of
disease during life, may be mentioned:
_First._ _Appearances of Congestion._ Very soon after death, or at least
within ten or twelve hours, by gravitation of the blood, the same
_hypostatic congestion_ will be found in the most dependent portion of
the stomach, that is seen in a more marked degree in the lungs, or in
the subcutaneous tissues.
_Second._ _Coloring of Tissues._ Not unfrequently, the tissue of the
stomach will be found strongly tinged by coloring matter of food or
medicine, such as the red color of wine or logwood, or the black color
of the metallic sulphurets, etc.
_Third._ _Change of Shape and Size._ Variations in the shape and size of
the stomach from the normal standard, are not unfrequently found after
death. It is sometimes found unusually small, apparently from the
influence of the _rigor mortis_, the contraction necessarily resulting
in increased thickness of the walls. What is known as hour-glass
contraction, although sometimes congenital in its origin, is frequently
but a manifestation of the _rigor mortis_, when it may be distinguished
from the former by inflation. Extreme dilatation, with thinning of the
walls, is also sometimes seen, this condition resulting apparently from
an absence of the post-mortem contraction.
_Fourth._ _Exfoliation of Epithelium._ The stomach of young adults,
dying of some acute disease, not unfrequently is found to have thrown
off the epithelial layer of its mucous lining, even when the examination
is made soon after death, and in cold weather. In many of the healthiest
animals slaughtered for food, the same change has been noticed as early
as two hours after death. The detached cells are found floating in a
thick mucus, the microscope also showing that the gastric follicles have
thrown off their epithelial lining, with their pepsinous contents. With
this change commences the post-mortem digestion of the stomach, to be
soon noticed.
The younger and healthier the subject, and the more acute the disease
causing death, as a general rule, the more rapidly and effectively does
this exfoliation take place. It may affect only the summit of the folds
into which the mucous membrane is thrown by the contraction of the
muscular coat, or it may uniformly involve the whole mucous surface.
_Fifth._ _Softening and Perforation._ It is an interesting fact, that
while the tissues of the stomach during life are unaffected by the
gastric juice—the vitality of the tissues enabling them to resist its
solvent power—after death, they immediately yield to its influence, and
hence results a greater or less degree of softening of the coats, or
even in some instances, complete perforation of the walls, the extent of
the change depending upon the quantity of gastric fluid in the stomach
at the time of death. In these cases there is, of course, no evidence of
inflammation, while the tissues present a pulpy, gelatinous appearance,
the walls being greatly thinned, and breaking down under the slightest
force. In most instances, probably the _actual perforation_ is the
result of the force employed in lifting the stomach from its position.
The opening in these cases is an irregular ragged hole, with soft, pulpy
margins, and will more frequently be found at the large or cardiac
extremity of the organ.
In some extreme cases, the process of softening has not been confined to
the _walls_ of the stomach, but has extended to the adjoining organs, as
the spleen, liver, or diaphragm.
The whitish-gray and gelatinous appearances of these cases, will enable
us to distinguish them from ordinary cases of softening and perforation
from ulceration.
This form of softening is especially observed in cases of sudden death
immediately after a meal, while the stomach contains a large quantity of
gastric juice. It is also seen much more frequently in children and
young persons than in the aged, or those dying from chronic forms of
disease. It has often been noticed in cases of consumption, however,
which is to be accounted for upon the fact that many of these patients
retain a good appetite to the last.
Brinton, is of the opinion, that the solvent action of the gastric
fluids upon the walls of the stomach, is promoted by the presence of
vegetable or starchy food:—(1) by offering little substance upon which
the fluids can expend themselves; and (2) by producing by its
decomposition, an amount of acid, favoring an energetic action of the
gastric fluids; while on the other hand, the action of those fluids is
retarded, (1) by the presence of alkaline saliva, or bile in any
quantity; and (2) by the presence of animal food upon which the juices
may act.
CASE.—_Perforation of the Stomach in a child two years of age—death from
Hydrocephalus._
A child of Mr. T——, in its second summer, had an attack of
hydrocephalus, finally dying in convulsions. The autopsy, made
twenty-four hours after death, disclosed great congestion of the
membranes of the brain, with two ounces of serum in the ventricles.
Upon opening the abdominal cavity, all the viscera appeared healthy.
In lifting the stomach from its position, a gush of colored fluid
appeared from behind it, which at once led to the suspicion of a
rupture. The whole organ was then carefully removed, when a ragged
rent, through which the thumb could readily be passed, was discovered
at the posterior portion of the cardiac end. The walls of the stomach
at this point were extremely thin, soft and jelly-like; this condition
being plainly the result of the post-mortem action of the gastric
juice, while the rupture was the immediate consequence of lifting the
organ from its position.
Pathological States of the Stomach.
=Gastritis.= _Acute inflammation_ of the stomach rarely occurs, except
as a result of some chemical or mechanical irritation. From the
experiments of Dr. Beaumont, however, we learn that the stomach is
extremely liable to various grades of inflammatory action, which passing
rapidly through their several stages, end finally in recovery. By
watching the effects of excesses in the use of alcoholic stimulants,
food, condiments, and of exercise after meals, etc., he observed that
the pale, pink color, natural to the mucous membrane of the healthy
stomach, was exchanged for a somewhat livid erythematous redness, which
was distributed throughout the organ in irregular patches of various
sizes, and in its most intense form, amounted to a kind of ecchymosis.
Again, he noticed an excessive growth of epithelium, forming patches of
false membrane like, which at various points appeared distended by an
accumulation of a puriform fluid beneath, giving the appearance of
little pustules.
The following forms of gastritis are generally recognized:
1. _Catarrhal Gastritis._ This, in its _acute_ form, is seldom seen in
post-mortem examinations. _Chronic Catarrhal Gastritis_, however, is by
no means uncommon, and may be a result of the use of alcoholic drinks,
the presence of various irritating substances taken either as food or
medicine, and may attend many forms of chronic disease of other organs,
or may be caused by obstruction to the circulation from disease of the
heart, liver or lungs.
The post-mortem appearances are neither very marked, nor constant. The
mucous membrane may be found red, or of a dark color, thickened and
sometimes roughened. The submucous and muscular coats may also be
thickened, while less frequently, small ulcers may be found.
2. _Croupous Gastritis._ This form is very rare, and seldom
diagnosticated during life, but may be found with children who have died
with croupous inflammation of the air passages, when small patches of
false membrane may be found adhering to the mucous surfaces. It may be
found in adults also, as an attendant of certain grave forms of disease,
as typhus, puerperal fever, cholera, dysentery, or in death from
irritating poisons.
3. _Phlegmonous Gastritis_, is another very rare form of inflammation of
the stomach, in which the disease involves all the coats, although
originating in the submucous, and may destroy the patient in a few days
with symptoms of peritonitis. The submucous tissues will be found filled
with an exudation of a sero-plastic, yellowish substance, which produces
thickening of the walls, and which may be confined to a portion or
involve the whole organ.
=Effects of Poisons.= The effects of caustic and other irritant poisons
upon the stomach, as exposed by a post-mortem examination, will vary
according to the nature of the substance, and the time it may have
remained in the stomach. Redness in various degrees, and of various
shades, ulceration, softening and perforation, may one or all, be
detected in different cases.
In large quantities, the mineral acids may leave the mucous membrane
black, and of a soft, tarry consistence, readily breaking down upon
handling the stomach.
The peculiar action of the several poisons will be noticed in another
place. (See Part IV.)
=Gastric Ulcer.= Ulceration of the mucous membrane of the stomach, is
much less frequent than of other portions of the intestinal canal,
except as a result of the corrosive action of poisons.[20] A peculiar
kind of ulcer, however—rare in this country, but said to be common on
the Continent of Europe and in England—is sometimes found, which is of
interest, from its occurring in tissues otherwise healthy, and often
leading to a rapidly fatal termination. Rokitansky terms it the
_perforating gastric ulcer_, from its marked tendency to perforate the
walls of the stomach. It is situated in the region of the pylorus, and
more frequently at the posterior surface and near the lesser curve. It
is of a circular form, of three to six lines in diameter, and with as
sharp edges as if a round piece of the walls had been punched out; the
edges being bevelled off, however, from within, leaving the peritoneal
opening less than that in the muscular or mucous coats. Being usually
situated near the lesser curve of the stomach, some of the larger
blood-vessels are liable to become involved, giving rise to hæmorrhage
more or less severe. While but a single ulcer of this description is
generally found, two, three or more, may be present.
A peculiarity of this form of ulcer, consists in its not being dependent
upon irritation or inflammation, but rather upon a loss of vital
assimulative power in the part affected.
This form of ulcer may heal at any time previous to perforation, and it
is not uncommon to find a cicatrix in the mucous membrane of the stomach
which has probably arisen in that way.
Gastric ulcer is much more frequent in females than males, and is mainly
a disease of middle and advanced life.
=Hæmorrhagic Erosions.= The appearance of the stomach, where there has
been frequent vomiting of blood from this cause, is thus described by
Rokitansky: “There are several roundish spots of the size of a pin’s
head or pea, or narrow elongated streaks at which the mucous membrane
appears dark red, lax, soft and bleeding, and presenting a depression in
consequence of loss of substance or slight erosion. This condition is
invariably accompanied by hæmorrhage, the effused blood being mixed, in
a more or less altered state, with gastric mucus. The erosions are often
very numerous, studding, perhaps, every part of the stomach except the
fundus, the pylorus being their chief seat.”
This condition of the stomach is not peculiar to any form of disease, or
age, but is frequently associated with intemperance. It is rarely fatal,
except by inducing some other lesion of the stomach, or by being united
with some more general malady.
=Softening of the Stomach.= We have already referred to that form of
softening of the stomach, which is attributed to the action of the
gastric juice after death. Another form is sometimes met with, which
evidently takes place during life, and in most instances is attributable
to a chronic form of inflammation. It is not always easy to distinguish
the two forms of softening without a knowledge of the previous history
of the case. The distinction may, however, generally be made by
attending to the following points:—1. The presence during life, of
symptoms of disease of the stomach. 2. Appearances of congestion or
inflammation, as well as softening, after death. 3. Extension of the
morbid change to other portions than that affected by post-mortem
softening, the latter being usually confined to the posterior portion of
the cardiac end.
=Cirrhosis of the Stomach.= In some obscure cases of gastric disease,
upon opening the abdominal cavity in a post-mortem examination, we may
at once notice a marked change in the appearance of the stomach. It
presents a peculiar whiteness and opacity, an appearance which is
partially due to a dulness of the peritoneal coat, in marked contrast
with its usual brilliancy; at the same time the organ may be either
larger or smaller than the average size. Upon removing the organ, we
find it greatly increased in weight and density, and presenting a hard,
gristly feel, and with so much elasticity as to fail to collapse. An
incision shows the walls uniformly thickened, to the extent of six or
eight times their normal condition; the whole organ is comparatively
bloodless, a condition strongly in contrast with the usual appearance
after death.
A close inspection of such a specimen, shows the several coats—muscular,
mucous and fibrous—to be remarkably alike, the thickening and increased
density, resulting from the presence of a generally diffused imperfect
fibrous structure, similar to that found in common fibrous tumors. The
several coats of the stomach will be found unequally affected by this
deposit. The submucous structure, as seen in a vertical section, being
increased from ten to twenty fold, while the serous with the subserous
may be increased seven to ten fold. The muscular tunic may be found from
five to eight times its normal thickness, while the mucous membrane
proper, is seldom more than double.
Notwithstanding the bloodless character of the walls of the stomach in
this disease, the abnormal condition is unquestionably the result of a
chronic form of inflammation. The symptoms during life are usually
obscure, and although the hard contracted stomach may form a sort of
epigastric tumor, noticeable upon the surface, the absence of acute
symptoms, with the age at which the disease makes its appearance—usually
between twenty and thirty—permits of a ready distinction being made
between this disease and cancer, with which it might otherwise be
confounded.
=Atrophy of the Stomach.= This condition of the stomach can hardly be
looked upon as an independent malady, being rather an attendant of the
general wasting of certain diseases, particularly of pulmonary
consumption, marasmus, and starvation. The organ, in these cases, may be
reduced to less than half its normal proportions, while its walls may be
thinned and frequently softened.
=Dilatation of the Stomach=, is another condition that can scarcely be
considered as a primary affection. A great variation in the size of this
organ is evidently compatible with health, large eaters having
necessarily large stomachs, yet as the result of certain other morbid
conditions, dilatation to an enormous extent may be induced.
The following conditions may result in dilatation:
1. Obstruction of the pylorus, as in scirrhus of that portion of the
stomach.
2. Destruction of a segment of the muscular coat by ulceration, or by
becoming involved in a cancerous growth. Here the loss of contracting
power, permits of a gradual dilatation, from the inability of the
segment involved to aid in carrying on the contents, their accumulation
above this point aiding in the distension.
3. An acute form of dilatation is sometimes met with, which can only be
attributed to a paralysis of the muscular and secreting structures of
the organ. It occasionally happens to a patient recovering from a fever.
He has perhaps overindulged in eating, as is not unfrequently the case
with convalescents, and is suddenly seized with intense pain in the
stomach, followed by rapid and great distension, and finally death. The
autopsy discloses the stomach enormously distended, and its contents,
including matters, in some cases, which were ingested many days before.
The mucous membrane appears but little changed, while the muscular coat
is so thinned and stretched, as to appear like a scattered net-work of
fibres.
Morbid Growths.
=Cancer.= This formidable disease occurs more frequently in the stomach,
than in any other organ of the body, excepting the uterus of the female.
The disease is usually primary in this organ, but frequently springs up
secondarily in other parts.
The disease may occur in the three following forms—the _scirrhus_,
_medullary_, and _colloid_; while Dr. Brinton adds a fourth, the
_villous_ cancer of the mucous membrane. The usual seat of the disease
is at the pylorus. It may involve a portion or the whole circumference
of this opening, and from this extend along the lesser curve. In some
cases, it commences at the cardiac orifice, and very rarely involves the
whole organ, the fundus usually remaining free. The walls of the stomach
may become greatly thickened in this disease, the inner surface
tuberculated and roughened, and the cavity much diminished in size. When
situated at the pyloric end, the disease seldom or never extends into
the duodenum, but when at the cardiac, it generally involves the lower
portion of the œsophagus.
The _fibrous_ or _scirrhus_ form of the disease, is by far more commonly
met with than any other, although it may be found occasionally combined
with the medullary, or both these with colloid. Indeed, it is not
improbable, but that in many cases, a growth originally scirrhus,
becomes gradually converted into one of the other forms.
In almost all cases, cancer commences in the submucous tissue, in the
form of a dense mass, of a white color. When cut, the surface presents a
whitish-gray appearance, contrasting strongly with the vascular mucous
membrane of the stomach, and presenting a distinctly striated
appearance. A small portion under the microscope, or the juice scraped
from the cut surface, will show the peculiar cancer cell, with granular
matter.
_Encephaloid_ or medullary cancer, may be developed upon or within the
fibrous form, or it may occur primarily as knotty tumors projecting
through the mucous membrane. The microscopic appearance is much the same
as in the fibrous variety, except that the cells are not so closely
packed, but are loosely held together by an abundant, soft, or liquid
substance.
The _colloid_ form of the disease, may originate either in the mucous
membrane itself, or in the submucous tissue. It is known by its
presenting a tough, fibrous-looking, white tissue, which, arranged in
intersecting bands, incloses irregular spaces, which are filled with a
clear, soft, or semi-liquid material, the proper colloid substance.
The _villous cancer_, Dr. Brinton describes as arising in the basement
membrane of the mucous coat, and as but a modification of the epithelial
cancer of other parts of the body.
The mucous membrane covering cancerous growths, is subject to a variety
of changes. It may become converted into a sort of fungoid growth, which
at points suppurates, showing the submucous scirrhus tissue; or it
gradually softens, giving rise to hæmorrhages.
The cancerous mass itself, may also soften or suppurate, resulting
perhaps in perforation and peritonitis; or adhesions may take place,
followed by extension of the disease to the liver, spleen, pancreas,
kidneys, etc.
Cancer of the stomach, in the great majority of cases, occurs in persons
between fifty and sixty years, although it may appear as early as forty,
or as late as sixty. Males appear to be more subject to the disease than
females, in the proportion of four to three.
The _obstruction_ which the presence of cancer of the stomach is liable
to produce, may result in one or more of the following conditions:
First, _hypertrophy_ of the muscular coat. From increased nutrition, the
muscular fibres of the stomach may become considerably increased in size
and darker in color, thus better enabling them to overcome the
obstruction, which in some cases, amounts almost to occlusion.
Second, _dilatation_. This condition frequently attends the former, and
indeed is seldom seen alone. It is confined to those cases where the
cancer is at the pylorus, and is more noticeable at the fundus of the
organ.
Third, _contraction_. This is seldom seen in connection with
hypertrophy, and is far less common than dilatation. Generally found in
connection with cancer at the cardiac orifice, it may be looked upon as
the result of the constant regurgitation which the obstruction produces,
preventing thus the cavity of the organ from undergoing its normal
distension, by the presence of any quantity of food.
=Tumors.= With the exception of cancerous growths, tumors of the stomach
are by no means common.
_Fatty tumors_ are sometimes met with, originating in the submucous
tissues, and as they increase in size, they may crowd either inwards
towards the gastric cavity, or outwards towards the peritoneum.
_Fibroid tumors_, are also occasionally met with in the submucous
tissues, generally in the line of the lesser curve, and about the
cardiac orifice.
_Polypoid growths_ may also be found springing from the mucous surface,
presenting the character of those formations usually.
Section 2. THE INTESTINES.
[=Notice= in examination:—1. _External characters_—displacements,
as in hernia; amount and condition of involved bowel.
_Invaginations_—number, position and size; dilatations or
contraction of intestines; apparent cause of. _Peritoneal
coat_—inflamed or not; adhesions; their position, strength;
perforations, etc. 2. _Contents_—gas; mucus; blood; pus; fæcal
matter; foreign substances, etc.; particulars in regard to each.
_Entozoa_—number and character. 3. _Mucous membrane_—general
condition; congested, inflamed, ulcerated. Orifice of bile duct.
_Brunner’s glands_—inflamed, enlarged or ulcerated. _Peyer’s
patches_—number, situation, general condition, ulceration, etc. 4.
_Cæcum_ with _appendix vermiformis_—length, contents, ulcers,
perforations, etc. 5. _Rectum_—prolapsus, hæmorrhoids, fistulæ.]
=Malformations.= The intestine is sometimes defective in some part of
its course, most usually near its lower extremity, and generally
accompanied with an imperforate condition of the anus, (_atresia ani_.)
This latter may be of various degrees, consisting sometimes in a simple
closure of the anus by a continuation of the integument over it; in
other cases the rectum terminates in a blind pouch at a greater or less
distance from the anus.
Sometimes the intestine is unusually short, without any distinction as
to size between the large and small intestines.
It may terminate at the umbilicus, or in a cloaca common to it and the
genito-urinary organs.
Finally, it may consist of several detached cœcal portions.
Andral notes the following malformations:—A single straight canal from
the termination of the œsophagus to the commencement of the rectum; a
double duodenum; two colons; an unusually large, and at same time,
double appendix vermiformis.
Diverticula are not unfrequent. They are cœcal appendages, resembling
the finger of a glove, one or more in number, varying in length from a
few lines to several inches, and giving off at various points. Like the
appendix vermiformis, they may become a source of danger by affording a
lodgement for indigestible matters.
In very rare instances the position of the intestines has been found
completely transposed, with a corresponding transposition of all the
abdominal viscera, or of only one organ.
=Inflammation.= Vascular injection by itself cannot be taken as a
decisive proof of the existence of inflammation. Obstruction to the free
return of blood by the veins, during life, and the gravitation of blood
to the most dependent parts, after death, especially after fevers, can
and do produce this very marked injection. In general, however, the
smaller and more isolated the patch of injection is, the more likely it
is to be inflammatory in its origin.
_Catarrhal inflammation_ may be either acute or chronic, and may either
attack the mucous membrane uniformly, or be developed mainly in the
villi and follicles.
In the _acute_ form: “There is more or less intense redness and
injection of the mucous membrane, affecting its entire surface, or
appearing as punctiform reddening from affection of the villi, or as a
vascular halo surrounding the follicles; relaxation of the tissue, and
intumescence of the mucous membrane, equally affecting the entire
surface, or only the villi and follicles; opacity of the mucous membrane
and its epithelium, from infiltration of the former and softening of the
latter; friability and softening of the mucous membrane. The submucous
cellular tissue is injected, relaxed and infiltrated with a watery
opaque fluid; the secretion is at first copious and serous; as the
affection increases in intensity it becomes opaque, viscid and
puriform.”
In the _chronic_ form, besides the above signs, we have also a dark,
rusty, livid discoloration, sometimes pervading the entire mucous
membrane; the mucous membrane and its follicles are swollen, the tissue
has become more dense, and the surface covered with an opaque,
grayish-white, or puriform mucus. Polypoid excrescences are sometimes
found upon the mucous membrane.
Both the large and the small intestines may be affected by catarrhal
inflammation, although the chronic form seems to occur more frequently
in the large.
The muscular coat of the intestines is also sometimes the seat of
inflammation, rarely if ever, however, as a primary disease, but by
extension from the serous covering or mucous lining.
_Croupous Inflammation._ The mucous membrane is also subject to a
chronic or sub-acute form of inflammation resulting in the production of
an exudation much resembling that of croup. Sometimes it forms in a
layer of some thickness, pretty uniformly over the surface, or appearing
in the stools as tubular casts of the intestines; sometimes it is very
thin, or consists of mere shreds. The anatomical changes observed will
be similar to those just noticed.
_Perityphlitis_ is an inflammation of the loose areolar tissue around
the cœcum, occurring primarily or in consequence of typhlitis. If not
checked, it ends in the formation of abscess in the right iliac fossa,
which may discharge either into the neighboring viscera, or externally
through the abdominal walls, mostly near Poupart’s ligament.
_Peripractitis_ is an inflammation of the areolar tissue around the
rectum. The resulting abscess discharges either externally, back of the
anus, or in the perineal region, or internally into the rectum, or more
rarely into the bladder, the vagina, the uterus, or into some other part
of the intestines. Fistula in ano, frequently originates in this manner.
=Ulceration.= Ulceration may occur as the result of inflammations both
catarrhal and croupous, and whether commencing in the mucous or the
muscular layer, the ulcers may perforate the intestinal walls and give
rise to an escape of the contents; or the ulcers may cicatrize with the
formation of the usual fibroid tissue, which, by subsequent contraction,
may give rise to puckering or obstruction.
_In follicular ulceration_ of the colon, after lientery or tedious
diarrhœa, the follicles are at first tumefied, and project as smaller or
larger, round, conical nodules on the internal surface of the intestine,
surrounded by a dark red vascular halo. Ulceration takes place in their
interior; an abscess with red, spongy walls appears; the follicle is
eaten away, and an ulcer of the size of a pea or lentil is formed. The
mucous membrane is extensively destroyed, and with great rapidity. The
disease is always confined to the colon, but when it runs a very rapid
course, it may be accompanied with catarrhal inflammation of the small
intestines.
_Typhus ulcers._ In continued fevers where the disease especially
attacks the intestines, we find an ulceration of Peyer’s patches and the
solitary glands, which is called _typhus ulceration_ by Rokitansky, and
is thus described by him:—“After a preceding hyperæmia around the
solitary follicles, and in and around Peyer’s patches, there is an
enlargement of the glandular structures, followed by a softening and
breaking down of the glandular mass. The cavity remaining on the mucous
membrane after the discharge of this mass constitutes the typhus ulcer.
Its form is elliptical, if a large patch has been destroyed; round, if a
smaller patch or a solitary gland has been destroyed. Partial
destruction of a patch will produce an ulcer of irregular shape. The
size varies also, according to the amount of ulceration.”
The margin of the ulcer is invariably formed by a well defined fringe of
mucous membrane, which is a line or more wide, detached, freely movable,
of a bluish-red, and subsequently of a slaty or blackish-blue color. The
base of the ulcer is formed by a delicate layer of submucous tissue,
which covers the muscular coat. The lower third of the small intestine
is most liable to be involved in the ulcerative process, the number and
size of the ulcers increasing as they advance toward the ileo-cœcal
valve.
_Dysentery_ may also produce extensive ulceration of the colon, with
considerable loss of substance. This loss may be repaired by
cicatrization. In some cases, the cicatrix tissue, condensed into
fibrous bands, forms projections into the cavity of the intestine, and
not unfrequently encroaches upon its calibre in the shape of valvular or
annular folds, giving rise to stricture of the colon.
=Dilatation.= Disease of the nervous centres, inflammation of its serous
tissue, or simple atony of the muscular fibres, may be the cause of
inaction of the intestine and consequent distension. Stricture will also
produce distension above itself, by an accumulation of the contents of
the intestine. In these latter cases, the dilatation is often enormous.
=Contraction= of the intestines may occur throughout a considerable
extent, or in a very small part.
In the former case, it results from the canal having been for some time
empty, and is most likely to occur below a stricture. It can hardly be
considered in itself a morbid condition.
The second kind of contraction or constriction, is generally morbid, and
may result either from external pressure by tumor or otherwise, or from
a disease of the tissue itself. The cicatrices of ulcers which have
assumed an annular shape, are the most frequent causes of stricture
originating in the intestine itself.
=Displacements.= The most common of these constitute the various forms
of hernia.
1. _Inguinal Hernia._ Here the intestines escape by the inguinal canal,
and it is _Scrotal_ in man, when they descend into the scrotum, and
_Pudendal_ or _Vulvar_ in woman, when into the labia majora.
2. _Crural_ or _Femoral Hernia_; when the intestines escape by the
crural canal.
3. _Hernia at the Foramen Ovalis_; when the viscera escape through the
opening which gives passage to the obturator vessels.
4. _Ischiatic_ or _Sciatic Hernia_; when it takes place through the
sacro-sciatic notch.
5. _Umbilical Hernia_; when it occurs at or near the umbilicus.
6. _Epigastric Hernia_; occurring through the linea alba, above the
umbilicus.
7. _Hypogastric Hernia_; when it occurs through the linea alba, below
the umbilicus.
8. _Perineal Hernia_; when it occurs through the levatorani and appears
at the perineum.
9. _Vaginal Hernia_; occurring through the parietes of the vagina.
10. _Diaphragmatic Hernia_; when it passes through the diaphragm.
A more detailed description of hernia belongs to works on surgery.
A hernia, if not reducible, may, by becoming strangulated, give rise to
constipation, hiccough, vomiting, and all the signs of violent
inflammation. Gangrene supervenes, with alteration of the features,
small pulse, cold extremities, and death.
=Incarceration=, is a form of mechanical obstruction of the bowels,
differing from hernia, in there being no escape of the intestine from
the abdominal cavity, as in the latter case. It may arise in various
ways, but the most frequent form is that in which a portion of intestine
becomes constricted by means of fibrous bands which have formed as a
result of peritoneal inflammation. Passing from one portion of the
intestines to another, or from the intestines to the abdominal walls, a
loop of bowel may slip beneath or between these bands, and become so
compressed, as to interfere with the passage of the contents, and result
in great dilatation of the gut above the point of stricture. Complete
strangulation may finally result, and the patient die with symptoms of
mechanical obstruction.
Another, but less frequent form of incarceration, is where a portion of
intestine slips through the foramen of Winslow, or through a congenital
opening in the mesentery, as in the following
CASE:—_Death from Strangulation of the Bowel, from becoming Incarcerated
in an opening in the omentum_.
Mary H——, aged five years, was taken suddenly with great pain in the
bowels at 2 o’clock A. M., having retired the night before in perfect
health. Vomiting soon set in, accompanied with great thirst, and the
whole body became bathed in a profuse cold perspiration. The severe
pain continued, and the vomited matter became stercoraceous. I saw the
case at 10 o’clock A. M., and then found the child in a moribund
condition. The breathing was rapid; pulse very small and frequent;
skin pale, damp and cold; eyes sunken and nose pinched. Rapidly
sinking, she died at 12 M.
Autopsy twenty-four hours after death. Upon opening the abdominal
cavity, a large portion of the intestines was found of a dark purple
or black color, while the remainder was perfectly natural in color.
Upon lifting the bowels and exposing the mesentery, there was found an
opening in the latter, of sufficient size to receive the thumb, and
through which a large portion of the small intestines had become
crowded, producing such a twist in the border of the mesentery as to
have produced complete strangulation of the bowel, which had rapidly
passed into a gangrenous state, resulting in violent shock and death
in less than twelve hours.
The opening was situated at about one inch from the intestinal border
of the mesentery, and was plainly congenital in its origin, as
indicated by its smooth and rounded edges.[21]
Another form of obstruction is sometimes found, and known as
=Volvulus=, in which a loop of bowel, generally of the small intestines,
becomes twisted upon itself, the constriction at the base of the loop,
finally resulting in complete closure.
=Intussusception=, or invagination of the bowels, consists in the
slipping of a portion of intestine into itself, and generally from above
downwards. Either the large or small intestines may be found in this
condition, but it is much more frequent in the lower portion of the
small bowels. From a few inches to a foot or more of the bowel may thus
become slipped into itself, and it may be found at more than one point.
From the constriction which must necessarily attend such a displacement,
congestion with hæmorrhage may result, or peritoneal inflammation,
gangrene, and death, with symptoms of mechanical obstruction. In some
rare cases, the inner or invaginated portion of the bowel sloughs off,
adhesion takes place at the point of commencement of the
intussusception, and the patient recovers.
This form of displacement may be found in both children and adults,
where the appearance of the parts are such as to render it apparent that
it had not been a source of trouble during life.
=Rupture= of the intestines may result from severe injury by blows, or
from a crushing force applied to the abdominal walls.
_Penetrating wounds_ of the bowels may be followed by escape of the
intestinal contents into the peritoneal cavity, acute peritonitis, and
death. If the bowel be empty at the time, adhesions may form between the
adjoining parts, the wound thus closed, and recovery follow.
_Prolapsus_ of the rectum consists in a protrusion of the mucous
membrane or entire walls from the anus. The only post-mortem change that
may be detected is a relaxed condition of the coats of the bowel, with
congestion of the mucous membrane.
=Diseases of the Anus.= These include _ulcer and fissure_ of the _anus_,
_fistula in ano_, and _hæmorrhoids_.
_Ulcer, and fissure_ of the anus, usually accompany each other, though
either may exist alone. The ulcer, when present, is found just within
the anus, while the fissure extends from this across the edge of the
sphincter. While these affections are trifling in their post-mortem
appearance, they are of great importance from the local trouble and
constitutional irritation which they may produce during life.
_Fistula in ano_, consists in the presence of a false passage along side
the rectum, usually the result of a small abscess in the ischio-rectal
fossa. It is said to be _complete_ when it opens at one end into the
bowel, and at the other through the integument near the anus; and
_incomplete_, when it has but one opening, whether that be on the
surface or in the rectum.
_Hæmorrhoids_ will be noticed under the head of
Morbid Growths.
=Cancer=, in its various forms, may be found in connection with the
intestines, where it is usually primary in its origin. The scirrhus form
is more frequently met with in the rectum, and is likely to involve the
whole circumference of the passage. From the tendency which this form
has to contract the parts, stricture of the rectum is likely to result,
which may become a source of great suffering, and finally of death.
Other forms of cancer may be found in any portion of the intestines; the
colon and rectum, however, being their more frequent location.
Cancer of the intestines is very liable to extend to the surrounding
tissues and organs, and in many cases, perforations of the bowel, or
fistulous communications between the rectum and bladder in the male, or
uterus or vagina in the female, may result.
=Tubercles=, generally of the miliary form, may be found within the
coats of the intestines, principally confined to the peritoneal covering
however. They may occasionally be found in the mucous coat, and in the
walls of follicular ulcers of that membrane.
=Tumors= of various kinds may be found in connection with the intestine.
_Fatty tumors_ may originate within the mucous membrane, and project as
polypoid growths into the cavity of the bowel; or they may commence in
the appendices epiploicæ, and degenerate into a cystic tumor with fluid
contents, or become infiltrated with calcareous matter; or the pedicle
may become atrophied and the tumor detached, and found free in the
peritoneal cavity.
_Adenoid tumors_ may result from hypertrophy of the several forms of
glands of the intestines, and appear as soft, rounded, and perhaps
pedunculated tumors, which are liable to become ulcerated.
_Fibroid tumors_ of small size and polypoid form, may be found in any
part of the intestines, and are generally considered as a result of
chronic inflammation.
_Hæmorrhoids or piles_, consist in a dilatation of the veins of the
lower portion of the rectum, with a thickening of their walls, and
increase of surrounding fibrous tissue. They may be internal or
external. The contained blood may coagulate forming a thrombus. The
walls may rupture, giving rise to hæmorrhages, or become inflamed and
suppurate.
_Abnormal contents._ The normal contents of the bowels may be found
mixed with the various products of inflammation, including mucus, serum,
blood and pus.
Biliary calculi and foreign bodies of various kinds, may be found, which
may have produced no effects, or they may have served as nuclei, around
which the salts of lime, bile, mucus, fæcal matter, etc., may have
accumulated, producing intestinal concretions.
=Parasites.= The intestinal canal is infested by several forms of
entozoa, among which may be found the following:
_Ascaris lumbricoides_; the common round worm, six to ten inches in
length. It may be single or in large numbers.
_Oxyuris vermicularis_; a small white worm, measuring from two to four
lines in length, and found only in the large intestines, and mainly in
the lower part of the rectum, where they may be present in large
numbers.
_Trichina spiralis._ This parasite is found in the small intestine, and
only in its adult form. It measures from less than a line, to two lines
in length. The embryos penetrate the walls of the intestine, and finally
locate in the muscles, where they remain encapsulated. If a portion of
this muscle is eaten by another animal, the larvæ again become active,
and acquiring the mature sexual form, reproduce, the young embryos again
migrating to the muscles.
_Tricocephalus dispar._ Found only in the head of the colon, and
measures one and a-half to two inches in length; neck long, and body of
male covered with wart-like appendages on one side.
_Distoma lanceolatum._ Flat, lancet-shaped, and transparent, a-half inch
long, one-quarter wide. Rarely found in upper portion of small
intestines, natural habitat appearing to be in the bile passages.
Of tapeworms, the following varieties may be found:
_Tænia solium._ Head about the size of a pin-head, and furnished with
sucking disk and double row of hooks; neck long and narrow; body flat
and jointed, each segment about a-half inch in length; body may be from
ten to fifty or more feet in length.
_Tænia mediocanellata._ Head truncated and destitute of hooks; body
jointed and of great length.
_Tænia flavopuncta._ Very rare. Yellow spot at the middle of each joint.
_Bothriocephalus latus_, (broad tapeworm.) Head long, unarmed; neck
inconspicuous; body composed of about two thousand joints; mature joints
broader than long.
Section IV. THE PANCREAS.
[=Notice= in examination:—1. _External characters_—malformations;
position; size; form; adhesions. 2. _Substance_—color; consistence;
wounds; abscess; tubercular deposits; cancer; cysts. 3.
_Ducts_—calibre; contents; pus or blood, etc.]
=Anomalies= of the pancreas are not common. It is wanting only in very
imperfect monstrosities. Excess of development is very rare.
Sometimes the duct is double, up to the point of its entrance into the
duodenum.
=Hypertrophy and Atrophy.= The former, when it does occur, which is
rarely the case, affects chiefly the cellular tissue which is interwoven
with the glandular tissue.
Atrophy often occurs spontaneously in old age, or it may result from
chronic inflammation or fatty degeneration. The organ may be soft, or of
a leathery consistence.
=Inflammation.= The acute form rarely occurs, and is marked by the same
signs of inflammation as are observed in inflammation of similar organs.
“Chronic inflammation induces condensation, induration of the cellular
tissue, obliteration of the acini, and either permanent enlargement, or
subsequent atrophy of the gland.”
=Fatty Degeneration= is of frequent occurrence in drunkards, associated
with fatty liver, but due to the intrusion of the surrounding adipose
tissue on the wasting organ.
=Dilatation= of the ducts of the pancreas occurs from an obstruction of
its outlets by pressure of a tumor, or by the presence of calcareous
concretions. The dilatation may be uniform or saculated, forming cysts
which may attain a considerable size.
=Cancer=, only in the forms of scirrhus and encephaloid, affects
generally the head of the pancreas. It may occur primarily or
secondarily. The ductus choledochus is frequently obstructed by the
pressure of the tumor, and jaundice produced. The disease may extend to
the duodenum, the omentum, the mesentery, liver, and even the suprarenal
capsules and kidneys. As secondary cancer, it is most frequently an
extension from a scirrhus pylorus.
Section V. THE SPLEEN.
[=Notice= in examination: 1. _External characters_—color, size,
weight, form, adhesions; surface smooth or rough; capsule thickened,
etc. 2. _Substance_—color; consistence; wounds; rupture; abscesses;
tubercle; cancer; degenerations; tumors, etc.]
=Congenital Anomalies.= In acephalous monsters the spleen is generally
absent. Occasionally in subjects otherwise well developed, it is
wanting, together with the stomach or the fundus of the stomach.
Congenital displacements have been met with.
Supernumerary spleens, varying in number and small in size, are
frequently met with.
=Hypertrophy and Atrophy.= Probably no organ of the body is as liable to
such great variations in size as the spleen. The normal spleen in the
adult, in whom it attains its greatest size, is usually about five
inches in length, three to four in breadth, and an inch or an inch and
a-half in thickness, and weighs about seven ounces. Its size is
increased during and after digestion, and varies considerably according
to the state of nutrition of the body. In typhus the spleen is enlarged,
the parenchyma exceedingly soft, its color a dirty red, of different
shades. In leukæmia it is also found greatly enlarged, but of a denser
consistence. Rokitansky states that the spleen not unfrequently measures
sixteen inches in length, seven in breadth, and four inches in
thickness, and its weight may amount to twelve or fourteen pounds, or,
according to others, to twenty or even forty pounds. (Huschke.)
Most of the hypertrophies of the spleen are accompanied not only by an
engorgement of the very numerous vessels, but by an alteration and
increase of the red, pulpy parenchyma.
_Atrophy_ may reduce the spleen to the size of a hen’s egg or a walnut.
It takes place normally in advanced age.
=Displacements.= Some of these are congenital: thus it has been found by
the side of the bladder; in the right side of the thorax; in the left
thoracic cavity when the diaphragm was absent; and external to the
abdomen in large umbilical herniæ, or where the abdominal walls had not
closed.
Other displacements are the result of disease. The enlargement or
distension of adjacent parts, or increase in its own size with laxity of
its ligaments, causes it frequently to be displaced, and even to descend
into the pelvis.
=Rupture= occasionally happens as the result of injuries. Spontaneous
rupture in intense congestions during typhus, cholera, and the cold
stage of ague, has occurred. This always proves fatal.
=Inflammation.= _Primary_ inflammation of the spleen is comparatively
rare. Unless it ends in resolution, it gives rise to the formation of
laudable pus or fibrin, which may either be contained in a circumscribed
abscess, and thence become obsolete, or the cavity may enlarge until the
pus penetrates into the left thoracic cavity, the stomach, the
transverse colon, or the peritoneum.
_Secondary_ splenitis is regarded as identical with pyæmic deposits. The
deposits are well defined, always at the periphery, cuneiform in shape,
the apex directed inwards. Their color is darker than the surrounding
tissue, and their consistence firmer. They are either converted into a
cellulo-fibrous callus, which contracts and causes a cicatrix in the
surface; or “into a puriform, creamy mass; or into a sanious greenish,
greenish-brown, or chocolate-colored pulp.” There are also fibrinous
deposits frequently found in the parenchyma of the spleen, classed by
some among the phenomena of secondary splenitis, but regarded by others
as a simple exudation of fibrin, from an excess of this in the blood.
These deposits appear as a circumscribed yellowish mass, with a margin
of darker or lighter red congestion of increased consistence, easily
recognized when handling the part, “and showing under the microscope a
confused mass of granular with more or less oily matter infiltrated
among the remains of the parenchyma. They very commonly undergo fatty
degeneration.”
=Chronic Thickening of the Capsule= of the spleen is of frequent
occurrence. It seems to take place at the expense of the parenchyma of
the organ, and may proceed to a very great extent. It is usually pretty
uniform. Ossification of the thickened fibroid layers is rare, except in
old persons.
=Amyloid Degeneration of the Spleen.= The disease may be limited to the
Malpighian corpuscles, constituting the so-called “sago spleen,” or it
may extend and implicate the pulpy parenchyma between the corpuscles.
The sago spleen is more or less enlarged; its weight and density are
increased. On section, the surface appears smooth, dry, and studded with
glistening sago-like bodies, varying in size. An iodine solution gives
them a reddish-brown color.
In the more advanced stage, where the pulp is infiltrated with the new
material, the organ generally is much larger than in the sago spleen. It
is hard and firm; the capsule tense and transparent. The cut surface is
dry, homogeneous, translucent, bloodless, of a uniform dark,
reddish-brown color. The organ can be cut like wax. The corpuscles are
obscured by the surrounding pulp.
Morbid Growths.
_Tuberculous matter_ is commonly deposited in the spleen, only in
connection with general tuberculosis. It appears in the form of gray
granulations, miliary crude tubercles, or yellowish cheesy masses of
various sizes.
_Cysts_ have been observed in the capsule of the spleen. They are small,
of conical shape, and lightish red color, containing numerous granular
cells, floating in a transparent liquid.
_Hydatid cysts_ may be found in the spleen alone, or at the same time
with one in the liver.
_Cancer_ is rare. The encephaloid is the only form met with, and
generally only with similar disease in the liver, stomach or omentum.
Section VI. OF THE LIVER.
[=Notice=: 1. _External characters_—relation to other organs and
extent uncovered by cartilages of ribs; _adhesions_—their
extent, position, firmness, etc. 2. _After removal_—weight;
measurements; form; color; puckerings; rough or smooth;
granulations; tubercles; cysts, etc. _Capsule_—thickness,
transparency; facility of removal; appearance of liver substance
beneath. 3. _Internal structure_—appearance of cut and fractured
surfaces; fluids expressible; appearance of lobules; abscesses;
fistulæ; calcareous deposits; tubercles; growths; cysts; wounds;
rupture, etc. 4. _Gall-bladder_—absent; size; shape; adhesions.
_Cavity_—obliterated. _Contents_—bile; quantity, color,
consistence; mucus; pus, etc. _Gall-stones_—number, size, form,
color, internal character. _Walls_—thickness; deposits; adipose
or calcareous; abscess; tubercle; cancer; wounds; rupture.
_Ducts_—calibre; dilated or contracted; impervious; from what
cause? contents; condition of walls and mucous membrane.]
The liver, in its _normal state_ in the adult, will measure from ten to
twelve inches in its transverse diameter, from six to seven in breadth
at its widest part, and about three inches thick at the posterior border
of the right lobe; its weight being from three to four pounds. The gland
is much larger in infants in proportion to the size of the body. In the
adult, the average weight of the liver is but one-fortieth of that of
the entire body, while in infancy, it may be as much as one-thirtieth or
even one-twentieth.
The natural color of the liver may be described as a reddish-brown or
mahogany color, yet the _shade_ may vary to a considerable degree in
different cases.
In studying the _morbid anatomy_ of this organ, we shall notice _first_,
changes peculiar to the liver itself, and _secondly_, those connected
with the gall-bladder and gall-ducts.
1. Diseases of the Liver.
=Congestion.= From the large size and extensive distribution of vessels
through the liver, this gland is capable of containing a large amount of
blood, and in cases of retarded circulation in other parts, as in the
recession of blood from the cutaneous vessels in a chill, the vessels of
the liver may become greatly distended, constituting what is known as
_congestion_. Although the gland is closely invested with the capsule of
Glisson, yet, the elasticity of this membrane will admit of considerable
distension, and hence the great enlargement attending this condition of
the gland. Congestion of the liver may be partial, confined to one or
more lobes; or general, involving the whole gland. It may also be
_active_ or _passive_.
_Active congestion_ of the liver may result from blows or injuries over
the region of the gland, from suppression of hæmorrhoid discharges, or
suppression of the menses in the female. It will then be found
presenting a deep red color, may be greatly increased in size, is more
firm, and before opening the body, may be frequently felt below the
margin of the ribs on the right side.
One of the most frequent causes of _passive congestion_ of the liver, is
organic disease of the heart, accompanied with obstruction in the
circulation through the lungs, giving rise thus to difficulty in
emptying of the right side of the heart, and of the venous system
generally. A chronic form of congestion of the liver may result from
emphysema of the lungs, large pleuritic effusions, or tumors within the
chest, and is frequently found in persons of sedentary habits who have
been “high livers,” or in those who have used large quantities of
alcoholic or fermented liquors, or in the residents of hot climates or
malarial districts.
Temporary congestion of the liver, although very extreme, does not
result in structural change; but when arising from a permanent cause, as
disease of the heart, etc., it produces the following effects:—“The
distended capillaries of the portal-hepatic plexus press on the
intervening cells; these become in part atrophied or stunted; in extreme
cases almost destroyed; in part they are gorged with yellow matter to
such a degree that they appear as opaque masses. The quantity of yellow
matter thus formed is far greater than any that exists in a healthy
state of the organ, and as some of it is doubtless absorbed and carried
into the blood, we find in this circumstance some explanation of the
icteric hue which is so often observed in such patients. Whether
long-continued congestion produces still further changes is not yet made
out clearly.”[22]
Extreme congestion of the liver may sometimes result in
=Hæmorrhagic Effusion=, the blood being either poured out near the
surface, and dissecting up the capsule, or more deeply in the substance
of the gland; or, rupturing the capsule, it may escape into the
peritoneal cavity. Such effusions may be found in new-born children
after protracted and difficult labors, or as a result of external
violence, and sometimes attend malignant fevers, scurvy, and purpura.
=Perihepatitis.= The peritoneal covering of the liver, very frequently
in post-mortem examinations, presents appearances of having been
attacked by inflammation, in the presence of bands of adhesion
connecting different portions of the surface of the gland to adjoining
organs. The whole of the upper surface will sometimes be found closely
united in this manner, to the diaphragm. Such appearances are sure
indications of the existence at one time, of an attack of peritoneal
inflammation. In a cirrhosed condition of the gland, and over the seat
of abscesses of the liver, such adhesions almost universally form.
Inflammation of the peritoneal covering of the _under surface_ of the
liver, may result from an extension of the disease from an inflamed
stomach or duodenum, or from the presence of a biliary calculus impacted
in some of the ducts; such inflammation resulting in more or less
extensive adhesion of the parts in contact. The presence of hydatid or
cancerous masses, are not usually attended with these evidences of
inflammation.
=Scar-like Marks=, are not uncommonly found on the surface of the liver.
The peritoneum at these points seems drawn into the substance of the
gland, at the centre of the mark, while radiating ridges extend in
various directions, to the distance of a-half to three-fourths of an
inch. The cause of these appearances is evidently inflammation of the
peritoneum, extending to the subserous tissue, and perhaps to the liver
substance.
=Hepatitis.= Inflammation of the liver may be _acute_ or _chronic_.
Acute inflammation of the liver, though a frequent occurrence in hot
climates, is seldom met with in cold or temperate. The gland in this
condition, is found more or less swollen and enlarged, and the tissues
somewhat softened. This condition may be confined to one or more lobes,
or involve the whole gland. Where a section is made, the turgid swollen
tissue rises above the peritoneal covering, along the edges of the
incision. As the disease advances to a later stage, the deep red color
changes to a brownish or grayish-red, patches of these being mingled
with others of a yellowish-red or pale yellow.
Acute inflammation of the liver may terminate in resolution, when there
will be a gradual restoration to a normal condition, or in suppuration,
and the formation of an _abscess_; the latter result being much more
common.
=Abscess= of the liver may involve the greater portion of the right or
left lobe. The substance of the gland immediately around the abscess,
will appear unusually red, and perhaps a little hardened, while other
portions may present the appearance of health. In some instances, from a
complete destruction of the hepatic tissue, the peritoneal covering will
form the only protection to the contained matter. The quantity of
purulent matter contained in these abscesses may vary from half a pint
or less, to one or two quarts.
The inflammation attending the formation of an hepatic abscess, will
usually extend to the peritoneum, resulting in the formation of
adhesions to the adjoining organs, and thus preventing the abscess, in
many instances, from discharging into the peritoneal cavity, as it
otherwise would be likely to do. Abscesses thus formed, may discharge:
1st, by the adhesive process through the diaphragm into the chest, and
if adhesions had previously taken place between the diaphragm and lung,
by an extension of the ulcerative process, the matter may find its way
into the bronchial tubes, and thus be discharged by expectoration; 2d,
by a similar process into the stomach, duodenum or colon; 3d, upon the
surface of the body; and 4th, within the peritoneal cavity. In the
latter case, death is inevitable; in the others recovery is possible.
The following case illustrates discharge and recovery by the first
method:
CASE.—_Abscess of the Left Lobe of the Liver, discharging through the
diaphragm, a portion of the matter expectorated, the balance discharged
upon the surface of the body—Recovery._
In the winter of 1856–7, I was called to see Mrs. B——, aged 40, of
Broad street. She had been given up by the physicians previously in
attendance. Found her greatly emaciated, suffering from a terrible
cough, and expectorating great quantities of excessively offensive
matter. Diarrhœa, hectic fever, night sweats, with occasional chills,
completed the picture, and appeared to render the case perfectly
hopeless. Upon inquiry, learned that she had been taken ill some
months previously, with what the attending physician had pronounced as
acute hepatitis. After the usual acute symptoms, the formation of an
abscess became evident from the fulness in the region of the left
lobe, accompanied with chills, hectic, etc. A violent cough, with
evidences of inflammation in the left lung, accompanying the other
symptoms, the case was supposed to be complicated with tuberculosis.
The expectoration finally became greenish, thick and exceedingly
offensive, indicating that the abscess had worked its way into the
bronchial tubes. In examining the chest, after the case had been under
my care a few days, I noticed between the ninth and tenth ribs a
fulness and slight redness. After the application of poultices for a
few days, a distinct “pointing” appeared, from which, after the use of
the lance, came a most copious discharge of the same green, offensive
matter, as was being discharged by expectoration. From this time, a
slight improvement was noticed in the patient. The external opening
was carefully kept from closing. The cough gradually improved. Little
or none of the offensive matter was raised after the establishment of
the external opening. In six months the health was fully restored, and
now, fifteen years after, she is a stout, healthy woman.
In the progress of formation of an abscess in the liver, as branches of
the portal or hepatic veins are reached, inflammation of their coats is
excited, which results in their obliteration, thus generally preventing
the admission of pus into the venous system. But as the enlarging
abscess encroaches upon the hepatic ducts, instead of these becoming
closed by inflammation, they ulcerate through, and thus establish a
communication between these vessels and the cavity of the abscess. Hence
the pus contained in these abscesses, is very likely to be mingled with
more or less bile; while at the same time, a portion of the contents may
be discharged through the common duct into the bowels.