Изображения страниц
PDF
EPUB

are moderately pigmented and congested. In the apex of the left, however, which is oedematous, a small sharply demarcated caseous area is observed. The heart presents normal appearances. The thyroid gland is enlarged, and on cutting into it numerous small areas of gelatinous degeneration are discovered. In the larynx and trachea nothing special is observed.

At the base of the brain, in the region of the infundibulum, there is an abundant heaping up of miliary nodules, without, however, any injury of the pia mater. The nodules extend into the left fissure of Sylvius, and over the left island of Reil. The right side, however, has very few nodules. The granulations, also, are generally quite discrete. The ventricles are moderately dilated, but nothing else special is noted.

The spleen is firmly adherent to the diaphragm, and partly also to the liver. It weighs 150 grammes, and is quite normal in appearance. The kidneys weigh respectively 135 grammes; in each the capsule is easily removed, the surface is smooth and without granulations, and the pelvis free. In the stomach and duodenum nothing special is noted. The liver weighs 1250 grammes; its lobules are large and brown, brighter at the periphery than at the centre, but not sharply defined from one another.

The small bowels are in part firmly soldered to the margin of the true pelvis, but can be loosened with a little care. The great omentum is here also firmly adherent. After loosening these adhesions, an abundant thick pus flows from Douglas pouch. The great omentum is specially examined, but no tubercles are found in it. In the cavity of the bowels nothing special is noted until the rectum is reached; and the urinary bladder is perfectly free. In the rectum, about 115 cms. above the anus, an opening about the size of a mark is discovered, in the mucous membrane surrounding which abundant white nodules are situated. The opening leads into Douglas' pouch, which is filled with pus, and whose walls are beset with very abundant caseous nodules, varying in size from a millet seed to that of a pea.

The vagina is free, but from the mucous membrane surrounding the os uteri a little somewhat broken nodule projects. The cervix is still partly covered with mucous membrane, but in some places is beset with fatty and caseous masses. The cavity of the uterus itself is filled with pus, the mucous membrane is fatty and caseous, and on section of the wall here and there, distinct miliary nodules are seen. The left Fallopian tube is greatly thickened and elongated.

On section thick caseous material flows out, and the wall is studded with caseous fatty masses. The right tube is less severely involved filled with thinner pus, and its walls are not so caseous. The glands in the neighbourhood are muck swollen, and in them scattered miliary caseous nodules are discovered.

Diagnosis. Tuberculosis of the uterus and of the tubescircumscribed peritonitis-tuberculosis in Douglas' pouchulcer in the rectum-tuberculosis of the retro-peritoneal glands-tubercular meningitis.

Such is the account of the post-mortem examination and the naked eye appearances. The parts subjected to a more detailed microscopic investigation were the uterine wall, the Fallopian tube, and the sub-peritoneal glands, and in what follows is given an account of their minute structure:

The sections examined were cut for the most part by a inicrotome known as the "Cohnheim machine," and made by the mechanic attached to the Institute. It possesses, as it appears to me, two great advantages over the microtomes ordinarily in use in this country-viz., hardened tissues are not frozen before they are cut, and thus one of the greatest obstacles to thorough staining of the section is removed; and, secondly, the instrument is provided with a most accurate apparatus for graduating the thickness of the sections cut. The staining agents employed were Bismarck brown, Gentian violet, eosin, and picrocarmine.

In the uterus the morbid changes were found to be almost entirely limited to the region of the mucous membrane. Here and there areas of normal mucous membrane, consisting of masses of small, somewhat elliptical-shaped epithelial cells, could be made out, and sometimes remains of the uterine glands could be seen. For the most part, however, the mucous membrane was found to be replaced by, or converted into caseous masses, which often at their marginal parts were surrounded by a dense fringe of cells partly round and partly spindle-shaped. Where caseation was not so advanced, areas of almost simple granulation tissue were noted, and in a few situations distinct tubercles were found. The morbid conditions did not extend to any great extent, if at all, into the muscular part of the uterine wall, which was mostly normal. No changes were noted in the serous coat of the

organ.

In the Fallopian tubes, almost precisely the same conditions as were noted in my previous case were found. The whole process was almost entirely confined to the mucous membrane,

the serous and muscular coats being free. In place of the mucous membrane, large areas of caseous material, which were often separated from the muscular coat by a layer of granulation tissue, were observed. Unlike the last case, however, no tubercules were observed on the serous coat. As has been noted in the post-mortem report the tubes were considerably enlarged, but they were not nearly so much so as in the former

case.

The much enlarged pelvic lymphatic glands were next examined. The true gland tissue was found to be very largely replaced by caseous masses, and here, as in the mucous membrane of the uterus, these masses were often surrounded by a very dense fringe of variously shaped cells, looking indeed as if it was in them that the advancing caseous changes were taking place. In some situations the normal gland tissue could be made out, and also arrangements of cells very suggestive of the occurrence of discrete tubercles.

The next step in the investigation was to institute a very careful search for the tubercle bacillus. The method adopted for this purpose was that of Dr. Huber, one of the assistants to Professor Cohnheim, which consists in the use of a solution of gentian violet in aniline oil water of the strength of 1 to 30. The section is immersed in this for twelve or more hours, then treated with nitric acid (which extracts the colour from everything except the bacilli, leaving them of a deep violet colour), and mounted in the usual fashion. For a long time the search was like to prove fruitless, but at length, after I had examined a large number of sections treated in the above manner, I discovered in some of the sections a few very minute rodshaped bodies of a violet colour, which I had no doubt were the bacilli. I submitted one of these sections to Professor Weigert, who examined it with one of Zeiss' oil immersion lenses. His opinion was that, although very scarce, the bacilli were present. Thus, both by its anatomical characters, and the presence of bacilli, the case has been proved to be one of true tuberculosis of the uterus, Fallopian tubes, and surrounding structures.

I have now briefly to compare the case just described with that which I formerly recorded. First of all then, as regards the nature and character of the morbid changes present in the tissues, the cases may be said to be almost identical. In both the appearances were typically those of tubercular disease, and the tissue mainly involved in the morbid change was the mucous membrane of the affected organs, although there were also tubercular nodules on the serous coverings. This, how

ever, is nearly all that can be said for the similarity of the two cases, as in most other points they differ considerably. In the former case the disease was confined very largely, if not entirely, to the mucous membrane of the Fallopian tubes, excepting always the miliary nodules present on their serous coats and on the peritoneal covering of the uterus, the latter organ, with this exception, being free. In the present case the disease had invaded the mucous membrane of the uterus as well as the tubes, the uterus being more involved than the tubes, and had largely spread to neighbouring structuresDouglas' pouch, the rectum, lymphatic glands, &c. Again, with regard to the general nature of the two cases, there are very striking differences. In the first case there was very grave tubercular disease, involving very extensive condensation of both lungs, and in one excavation, with, in addition, severe general tubercular peritonitis and enlargement of the mesenteric glands. In that now under review, the only situations excepting the pelvis, where evidences of tubercular disease were detected (and the whole body was carefully examined), were the apex of the left lung, where a small and well defined caseous nodule was found, and the base of the brain, the disease of the latter, however, having been so slight as not to have caused "injury to the pia mater." Lastly, it is to be noted that in the former case the Fallopian tubes were much more extensively diseased towards their free extremities than nearer the uterus. In the present this was not so.

The comparison, then, of the two cases proves, I think, the following points-viz. (1) that, as I have shown in my previous paper, a tuberculosis of the Fallopian tubes, and of them alone, may arise from the action of infective material sucked into them from the peritoneal cavity, and this, which may be looked upon as a secondary condition, is most likely to occur where grave tubercular disease exists elsewhere; and (2) that a tuberculosis of the internal female generative organs may occur primarily in them, or at least, throughout the entire case, may remain most severe in them, and this is likely to be the condition when no, or as in our case only very slight, evidences of tubercular disease exist elsewhere. Only the latter form of the disease is likely to be of importance in practical medicine, as in the former the tubercular lesions elsewhere than in the generative organs occupy the whole attention of the physician. With regard to the latter, then, I would conclude this paper with the practical remark that possibly the diagnosis of such cases might be greatly aided by the examination of the discharge for the tubercular bacillus.

We know that the bacilli, when proper reagents are used, and moderate care exercised, are easily demonstrated in the sputa of patients suffering from tubercular lung affections, and, although I have not yet had an opportunity of carrying out such an examination, I think they could be demonstrated in the discharges from a tubercular uterus.

ON SOME OF THE ADVANCES WHICH HAVE BEEN MADE IN SURGERY DURING THE LAST DECADE.

BY JAMES WHITSON, M.D., F.F.P.S.G.,

Surgeon to the Dispensary of Anderson's College; late Extra Dispensary Surgeon, Glasgow Royal Infirmary.

(Read before the Glasgow Royal Infirmary Medical Society,
18th November, 1882.)

MR. PRESIDENT AND GENTLEMEN,-During the last few years surgery has advanced with rapid strides, the practices of our forefathers having in many instances been laid aside, while new and improved methods of conducting operations and of subsequent treatment have been adopted in their room.

The introduction of antiseptics is undoubtedly one of the most potent factors in effecting these changes, and it is but just to state that Lemaire was the first to use carbolic acid in the treatment of wounds, and to realise the truth of the germ theory, in regard to which he says, "The wound which suppurates, as I hope to demonstrate presently, is a secreting surface, the products of which become altered under the influence of air, and give birth to a series of phenomena due to one and the same cause-fermentation.' Lemaire, however, did not systematise his method of procedure, and, as Cheyne points out, he had no definite aim, no clear purpose in his work. To Mr. Lister we owe the gradual development and improvement in the antiseptic treatment, and those of you who are now familiar with the almost perfect exemplification of this system in the wards, can have little idea of the difficulties which attended its early stages, or of the crude methods which were then devised for its being carried out. Mr. Lister used to tell his class that his attention was first * Antiseptic Surgery, by W. Watson Cheyne, M.B. Page 356.

« ПредыдущаяПродолжить »