Imágenes de páginas
PDF
EPUB

It may be seen from this how numerous are the sources of error in those delicate researches in hematology; and how cautious one should be in asserting the presence of micro-organisms in the blood, when the fact is not established positively by staining, and especially by culture experiments. It is creditable to Straus to have made so candid an admission of his error, after he had himself claimed for these pseudo-organisms the importance of a new and perhaps valuable discovery.

The Lungs are found collapsed and shrunken. When the thorax is opened they appear to lie far back, as if pressed against the spine. They are dry and generally pale in their anterior and upper portions. The cut surface here looks pinkish or gray. Dark blood oozes slowly and sparingly from the larger veins.

Posteriorly there may be more or less hypostatic congestion and oedema. The pulmonary tissue there is friable, contrasting in this respect with the toughness of the other portions of the lung. The actual weight of the organs may be reduced to one-half the normal standard.

In about fifty per cent. of the cases examined by Sutton, he found the lungs congested throughout, and of a dark red color.

Macnamara reports out of a whole number of sixty-four post-mortems, of which he has kept careful notes, pulmonary congestion thirty-six times. This was when death had occurred in collapse. Dr. Chuckerbuty' found the lungs congested in more than one-half of his cases.

In 1854 Baly and Gull,' stated that the hypostatic engorgement was, in some instances, so profound as to cause portions of the lung to sink in

water.

On the other hand, Parkes said that "the most common appearances in the lungs are the collapse and the deficient crepitation, arising from the more or less complete absence of air and blood."

As regards the Larynx, Trachea, and Bronchi, they show little alteration save some pallor or lividity of their mucous surfaces. At times, however, exceeding dryness, at others a slight coating of frothy fluid, and again, patches of hyperemia and even ecchymosis have been observed.

The occurrence of diphtheritic and pseudo-membranous processes has been recorded by Lebert and others. But all such changes are secondary and do not belong to the specific cholera-process. Moreover, they

have been only quite exceptionally seen after death during collapse.

The Diploe.-On opening the cranium the diploë presents an unusually red appearance. Like other osseous structures it is found to be abnormally friable.

The Meninges are seen to be gorged with dark blood; in the sinuses of the dura this is especially prominent. A few extravasations are found

here and there, at the base or over the cortex.

The arachnoid often shows a viscid coating, and appears moist and sticky, whereas the pia mater is generally dry. At times, however, it appears dematous and studded with patches of ecchymosis. The ventricles of the brain are either empty or only moderately distended. The cerebro-spinal fluid is absent or diminished, and, when present, more sticky than normal. According to Voit the encephalic fluids, either

1 Indian Annals, 1867.

Reports on Epidemic Cholera. Drawn up at the desire of the Cholera Committee of the Royal College of Physicians. London, 1854.

Researches into the Pathology and Treatment of Asiatic Cholera. London,

those belonging to meningeal cedema or those found in the ventricles, and even the substance of the brain, contain the largest relative accumulation of urea discoverable in the bodies of cholera patients. Lehmann and Buhl have confirmed these observations.

The Encephalon is drier than normal, especially the white substance. Punctate hyperemia is at times observed. Buhl also found pigmentary deposits in the smaller cerebral blood-vessels.

The Spinal Cord shows the same meningeal hyperemia that exists in the brain, and in all other respects its condition corresponds to that of the encephalon. Buhl states that he has found the pneumogastric nerve surrounded with a plexus of dilated blood-vessels, at its point of entrance into the chest. He also describes a hyperamic condition of the ganglia of the sympathetic. The solar plexus is frequently reddened throughout, and occasionally shows ecchymosis.

These appearances are not without interest, especially when considered in connection with Chapman's peculiar views on the neurotic origin of cholera, fuller reference to which will be found in the chapters on etiology.

CHAPTER XXXIV.

MORBID APPEARANCES AFTER DEATH FOLLOWING REACTION.

It is but natural that the post-mortem appearances are found to vary in accordance with the time that has passed between the first establishment of reaction and the death of the patient. Should the latter occur at the very incipience of reaction, there will be little or no difference from what is seen in death from collapse. On the other hand, after death during or following fully established reaction, some noteworthy modifications of the appearances characterizing collapse are constantly observed.

In the first place the General Appearance of the Body is much less shrunken indeed there may be apparent plumpness. Rigor mortis is far less pronounced; it also begins later and ends sooner. Lividity, cyanosis, and extensive cadaveric blotches are less marked and not infrequently absent. A post-mortem rise of the temperature does not take place. Muscular contractions are not observed after death. In a word, there is nothing decidedly characteristic about the external appearance of a cholera corpse, when reaction was fully established at the time of death. The lips, teeth and gums show a dark brown or blackish scum, and often a thick creamy substance coats the conjunctiva.

On opening the cadaver the connective tissue is found of natural moisture, the blood is again more fluid; the muscles, however, are still dark, dry, and hard. According to Hamernjk' an urinous odor often issues from the cut organs, a statement that has been in turn denied and accepted by other writers. At times the buccal mucous membrane, the palate, pharynx and larynx, are found coated with grayish diphtheritic membranes, which reveal underlying ulcerations. Generally, however, the upper respiratory passages present a nearly normal appearance.

The Peritoneum is but rarely injected and covered with products of inflammation. It has regained its natural moisture. A viscid scum is not

seen.

The Stomach is commonly found somewhat contracted, holding a moderate amount of dirty-looking fluid. Its mucous membrane may be injected and in a catarrhal condition. A croupous exudation has been described by Pirogoff and others, but its presence is quite exceptional. The "patches of denuded mucous membrane, resembling in apppearance superficial ulceration of this organ," together with "numerous pus-like cells-abortive epithelial products, which have been ineffectually formed to supply the lost epithelium," these appearances which are made so much of by Macnamara, are doubtless largely the result of cadaveric

Die Cholera epidemica. Prag, 1850.

? Anatomie pathologique du Cho!éra. St. Petersburg, 1849.

THE ABDOMINAL ORGANS.

changes, although as will appear presently, diphtheritic processes with But even then they are found tissue-necrosis may occur in certain cases. in the intestine rather than the stomach. The Small Intestine does not contain rice-water or gruel-like fluid, The internal surface is but gas is usually present in some abundance. When this is removed the mucous membrane coated with bilious mucus. Low down in the may be found apparently normal, or faintly injected. ileum, and quite generally in the colon, the presence of fecal matter is noticed. But this is not the invariable condition of things. When death has supervened after a prolonged typhoid condition of the patient, the small intestine generally shows very decided and advanced lesions. Engel' and Hamernjk" found extensive superficial destruction of the mucosa, producing the appearance of a network with wide meshes.

Reinhardt and Leubuscher describe appearances resembling dysenteric intestines, with the usual hyperæmic condition, diphtheritic membranes, necrosis, and jagged ulcers. (The latter in rare instances have led to perforation and peritonitis.) Bouillaud observed decided gangrene in only one instance out of a large number of cases.

3

The Large Intestine.-According to Griesinger, diphtheritic or dysenteric ulcerations are not infrequently encountered in the large intestine. The solitary glands are commonly involved in this destructive process. The same writer also observed similar changes in the small intestine, and he says that when Peyer's patches were affected, the resemblance to typhoid intestines was so complete as to be misleading. Yet these secondary lesions are in no way characteristic of cholera. They are mentioned here, however, because some writers have laid much stress on their ocA singular circumstance connected with them is their relative frequency in some epidemics, and their almost entire absence in others. The Mesenteric Glands appear but slightly enlarged, except in those cases where destructive lesions in the intestine are far advanced, when they may be much swelled and congested.

currence.

The Spleen has regained its normal appearance, or is increased in Its color is quite generally darker than in volume, hyperemic, and soft. the stage of collapse. Infarctions have been repeatedly observed, but must nevertheless be regarded as exceptional. Splenic rupture, as reported by Niemeyer and others, is a rare accident.

He

The Liver has resumed a darker and more natural appearance. Tholozan' asserts that he found it congested in one-half of his cases. also noticed softening. This statement is at variance with the observations of the majority of competent writers, who agree in pronouncing the liver substantially normal after death during the period of reaction. The gallbladder is only slightly or not at all distended with fluid. At times its mucous membrane is in a catarrhal state. Ecchymoses, diphtheritic patches, ulcerations and even perforation have been described by Pirogoff. they are exceptional occurrences.

But

The Kidneys, while showing no single constant lesion, are nevertheless At times there is merely hyperamic swelling, always more or less altered. with slight parenchymatous degeneration. Frequently, fatty changes of the tubular epithelium are pronounced and widespread, particularly so in

1 Prager Vierteljahrschrift, vol. iii., 1851.

3 Quoted by A. Mouchet, Observations d'accidents gangreneux, chez es cholériques, in Archives générales, 1867.

4 Op. citat.

Op. citat.

Op. citat.

the cortical substance. Many tubules are seen to be filled with casts or epithelial débris.

In a considerable proportion of cases, the changes are those of acute infectious nephritis, with an unmistakable resemblance to the scarlet-fever kidney. This circumstance is in agreement with the clinical fact that cholera convalescents are but rarely known to develop chronic albuminuria. Still Hamernjk and others have reported a few cases, illustrating the possibility of such an event.

The descriptions of Leubuscher, Reinhardt, Virchow, Drasche, and indeed most of the earlier writers on cholera, are inadequate as regards he pathological histology of these interesting renal lesions. And Eichhorst, writing in 1880, publishes a very meager account of them. Griesinger, Laveran', and especially Lebert' give more satisfactory descriptions.

But it is not necessary to reproduce the views of these various writers here, in order to point out wherein their opinions differ and in what respects there is substantial agreement among them. Quite recently, however, Straus' has made careful and elaborate investigations regarding the renal alterations of cholera. The great interest and importance of the subject warrants our presenting a summary of his researches.

In order not to interrupt the continuity of his descriptions, it has been thought advisable to consider the renal changes found by him after collapse, together with those of reaction, that alone properly belonging here.

Straus did not find the increase in the size of the kidneys of those dying during algid collapse or shortly after, which several authors have described. Like Bartels, he generally saw a diminution of volume. The capsule was not adherent, except when there was antecedent renal disease. On longitudinal section he finds the cut surface moist, the cortical substance of a dull grayish red color, with here and there points showing congestion and others of a yellowish brown color. The glomeruli are readily visible to the naked eye, prominent and congested, with the interlobular vessels presenting as sunken lines. The medullary rays of the cortical substance present a dull grayish color, contrasting with the deeper tint of the pyramids. The vascular arches of the intermediate substance are strongly congested. Pressure made with the back of the scalpel upon one of the papillæ causes an exudation of a suspicious looking fluid resembling pus. The mucous membrane of the pelvis is sometimes pale and sometimes strongly congested, and of a bluish or violet color.

Examined under the microscope, the epithelium of the convoluted tubules is seen to be profoundly altered even in very acute cases in which death has occurred in from twenty-four to thirty-six hours after the commencement of the disease. The cell markings are effaced and Heidenhain's striation is not present. The protoplasmic substance is swollen and contains irregularly shaped granules of varying size, refractive to light, and colored brown by osmic acid, the cloudy swelling of Virchow. In consequence of the cellular tumefaction, the lumen of the secretory tubules is almost completely effaced, while their diameter is greatly increased. The free border of the

1 Article Cholera, in Eulenburg's Real-Encyclopädie.

2 Article Infections-Krankheiten in Virchow's Handbuch der speciellen Pathologie und Therapie. Erlangen, 1864.

3 Dictionnaire encyclopédique des sciences medicales. Paris, 1874.

4 Article on cholera in Ziemssen's Cyclopædia. New York, 1874.

1 Le Progrès Médical, January 10 and February 14, 1885.

« AnteriorContinuar »