THE EXAMINATION OF THE ABDOMEN.
I. METHODS OF EXAMINATION.
The preliminary general inspection of the peritoneal cavity was made
after the main incision. (See Chapter VII.) After the examination
of the neck and thoracic organs has been completed, the abdominal
organs are removed and examined separately. The method to be followed
must be varied to meet the conditions. In the case of extensive
carcinomatosis, general peritonitis, peritoneal tuberculosis,
pseudomyxoma peritonei, etc., when adhesions are numerous and the
abdominal organs matted together, the examination becomes very
difficult, and it may be necessary to remove the abdominal organs
_en masse_ and dissect them on the table. If the œsophagus and aorta
have not been removed from the thorax they are stripped down to the
diaphragm, which is cut on both sides, so that aorta, œsophagus and
the abdominal organs en masse can be stripped down to the brim of the
pelvis and there cut off to be examined outside the body.
For the ordinary autopsy the following order of examination of the
abdominal organs is recommended: The spleen is first examined. It
is lifted up from beneath the left under-surface of the diaphragm
by tearing or stretching the ligamentum phrenico-lienale and the
gastrosplenic omentum. In the case of wandering spleen the technique
of removal must be modified to suit the conditions. When the spleen
is very soft great care must be taken not to tear or rupture it.
When adhesions to the diaphragm are present these must be torn or
cut. The spleen is then laid upon the left edge of the ribs. In this
position it may be sectioned by an incision made from upper to lower
pole, and then, after it has been examined, it is allowed to slip
back into the abdominal cavity, when its removal from the body is not
desired. If it is to be removed and examined outside of the body,
its ligaments and vessels are cut with the knife directed against
the edge of the ribs, taking care not to cut the stomach or tail of
the pancreas. It is then weighed and measured, and examined by means
of a chief incision through its convex surface, from upper to lower
pole, and reaching to the hilus. Parallel sagittal or transverse cuts
may be made as desired. The cut surface is then thoroughly examined.
Bacteriologic examinations should be made when indicated, before
the organ is sectioned. A portion of the capsule is seared and the
pipette introduced through the seared area.
The =intestines= are examined next. They may be opened inside the
body without separating them from the mesentery, but the best method
by far is to remove and open them outside of the body. The middle
portion of the transverse colon is lifted up by the left hand and
the ligamentum gastrocolicum and the mesocolon transversum cut close
to the intestine, toward the left, separating the left half of the
transverse colon, then the splenic flexure and the descending colon
and the sigmoid flexure to the rectum. After the splenic flexure has
been separated the descending colon can usually be stripped down to
the sigmoid by the hands without using the knife. When the sigmoid
has been freed from its mesocolon two ligatures are put around the
upper portion of the rectum, about an inch apart, and the intestine
is then cut between the ligatures. The freed portion of the large
intestine is then carried over into the right side of the abdomen
and as much of the lower portion as is possible is put into a pan or
tray resting upon the cadaver’s right thigh. The right half of the
transverse colon, the hepatic flexure and the ascending colon are
now freed down to the beginning of the ileum, care being taken not
to cut off the appendix when loosening the cæcum. The entire large
intestine is then gathered into the tray resting on the cadaver’s
thighs, and the intestine is pulled down firmly by the left hand in
a line corresponding to the main axis of the right thigh. The coils
of small intestine are left in their natural position. The ileum is
then severed from the mesentery as follows: The intestine is pulled
by the left hand straight down in the middle line of the right thigh,
putting the mesentery on a stretch. The long section-knife is used
by the right hand to cut the mesentery close to the intestine in a
manner resembling the use of the bow in violin-playing. The blade
of the knife is held slightly obliquely against the mesenteric
insertion of the intestine, and as the left hand pulls up the coils
of intestine against the knife, the latter in the bowing or sawing
movement severs the mesentery from the intestine as close to its
insertion as is possible without cutting the intestine. The freed
portions of intestine are caught in the tray resting on the thighs,
and the left hand grasps in succession new portions of the small
intestine and pulls them against the knife until the entire intestine
is freed up to the duodenum and the root of the mesentery. A double
ligature is put around the jejunum and the intestine severed between
the ligatures, and the freed jejunum, ileum and large intestine
are now removed in the tray for examination. The severing of the
intestine from the mesentery in this manner can be carried out very
quickly after a little practice. Care must be taken to cut the
mesentery as close as possible to the intestine without nicking the
latter. If too much mesentery is left on the intestine it cannot be
laid out straight and its opening is made more difficult. If the
coils of the small intestine are left in their natural position,
and if the ileum when it is first taken up by the left hand is
not twisted, the coils will unroll before the knife without any
difficulty. Some prosectors begin with the jejunum, ligating it at
the point where it comes out from beneath the mesentery, cutting it
between the ligatures and separating it from the mesentery downward
until the entire intestine as far as the rectum has been freed. The
latter is ligatured and the freed portions removed. When the saving
of time is of great importance the large intestine may be freed as
described above, a ligature put around the upper end of the jejunum,
and the mesentery severed at its root, so that the entire mass of
small intestine with its mesentery is removed for further separation
from the mesentery outside of the body. When peritoneal adhesions
that cannot be easily torn are present it may be necessary to remove
the intestines with mesentery attached.
After the removal of the intestines from the body they are opened
by the intestinal shears, beginning either with the jejunum or the
large intestine, the cut being made in the line of the mesenteric
attachment. As the intestine is opened careful attention should be
paid to the contents of each portion. It is very poor technique to
dilate the intestine with water or to run water through it before
it is opened. There is danger of washing away parasites, blood,
etc. When the intestine is distended the opening is easy, but when
collapsed it can be more easily opened if an assistant straightens
it out and holds it on the stretch in advance of the enterotome. It
may be opened on the table, in the tray, or in a pail. The latter
method is a clean and convenient one. As the intestine is opened it
is passed on the flat beneath the handle of the pail as it rests on
the rim, so that the intestinal contents are scraped off into the
pail and the clean mucosa examined as it is pulled from the pail into
a basin or tray. The ileocæcal valve should be carefully examined
from above before it is cut through. The appendix may be opened from
the intestine by the small probe-pointed shears, the cut being made
on the side opposite the mesenteric attachment. Transverse sections
can be made, if desired. When the intestines are opened within the
body, the enterotome is introduced into an opening made in the ileum
just above the ileocæcal valve and the intestine is cut upward to the
duodenum, along its mesenteric attachment, the coils being drawn upon
the probe-pointed blade of the enterotome with the left hand. After
the small intestine is opened the enterotome is introduced through
the ileocæcal opening and the large intestine cut in the anterior
tænia as far as the rectum. The opening of the intestine within the
body should be left until all the other abdominal organs have been
examined, because of the disagreeable mess made by the escape of the
intestinal contents into the cavity.
The =duodenum= is opened next. The curved scissors, or the
enterotome, is introduced into its lower end through an opening
made above the ligature, and the inferior and descending portions
of the duodenum are cut in the middle line of the anterior wall.
The superior portion is then cut up to the pylorus, the cut passing
through the inferior wall of this portion, the enterotome being
held in the axis of the canal and pylorus, while the duodenum is
pulled over to the right by the left hand. Before the pylorus is
cut it should be explored, as to its width or constriction, by the
index-finger of the left hand. The duodenum may also be opened
first in the lower part of the descending portion. The root of the
mesentery is pushed over to the left and a fold of the anterior wall
is picked up by the thumb and index-finger of left hand and cut with
the shears, so that when let free by the left hand there is formed
a longitudinal incision in the duodenal wall large enough to admit
the long blade of the enterotome. The duodenum is then cut up to
the pylorus as described above. The inferior part of the duodenum
is then opened from the point where the first incision is begun.
The duodenum may also be opened downward, beginning at the pylorus,
a small transverse cut being first made in the stomach wall just
above the pylorus and the stomach opened along the greater curvature
as far as the cardia. The enterotome is then placed through the
pylorus and the duodenum cut in the median line of its anterior
wall throughout its entire length. When the duodenum is opened, the
_papilla_, the _ductus choledochus_ and the _ductus Wirsungianus_ are
to be carefully examined. The papilla can usually be easily found
by stretching the duodenal mucosa transversely over the head of the
pancreas. It lies below the middle of the head of the pancreas, and
about four finger-breadths below the pylorus. Pressure should be made
upon the gall-bladder to force bile through the duct and papilla,
and thus demonstrate their patency. When this cannot be done a sound
should be introduced, and the common duct opened into the hepatic
and cystic ducts. If the duodenal mucosa just below the papilla be
stretched forcibly downward the duct can usually be opened by the
small scissors without the aid of a grooved director. The duct of
Wirsung may be explored with the sound from the papilla to the left
of the common duct, or from its separate opening when the two ducts
do not open in common. Both the bile-duct and the duct of Wirsung
may be opened in the opposite direction, from the liver and pancreas
respectively.
The =stomach= is opened from the pylorus after the size of the latter
has been ascertained. The anterior wall may be cut midway between
the greater and lesser curvatures, or the cut may follow the greater
curvature, extending through the cardia into the œsophagus. As the
stomach is opened its contents are inspected and removed. They
should not be allowed to escape into the abdominal cavity. When the
organs are removed _en masse_ the stomach may be opened from the
cardiac end. The organ may also be opened by an incision through its
posterior wall or along its lesser curvature, as occasion may demand.
If it is desired to save the pyloric ring the incision may stop
above or below it and begin again on the other side. The stomach,
with the lower portion of the œsophagus and the superior portion of
the duodenum, may be separated from their attachments and examined
outside of the body.
The =pancreas= is examined by turning the stomach toward the
thoracic cavity, cutting or tearing the gastrocolic omentum, and
cutting the exposed organ by a longitudinal incision through head,
body and tail, or by means of parallel transverse incisions made
through the different parts of the organ. The ducts of Wirsung and
Santorini should be explored. It must be freed from the duodenum
before it is weighed. The pancreas may be removed in connection with
stomach, duodenum and liver and examined outside of the body. This
is advisable in all cases of perforation of the stomach, ulcer,
carcinoma and surgical anastomoses, carcinoma of pancreas, acute
pancreatitis, obstruction of common duct, duodenal ulcer, etc.
The =liver= may be examined in the body without removal. The left
hand is put between the diaphragm and the convex surface of the
right lobe of the organ, and the liver raised up out of the cavity.
With the long section-knife a main incision is made deep into the
organ, from left to right, about a hand’s-breadth above the lower
border. Parallel incisions to the main incision may be made. After
the examination of the cut surface the organ is dropped back into the
abdomen. When the liver is to be weighed and measured it is removed
from the body by cutting first the ligamentum hepatoduodenale,
examining, as they are cut, the _common duct_, _hepatic artery_
and the _portal vein_. The left lobe of the liver is then taken in
the left hand and raised as high as possible. The left triangular
ligament, the left half of the coronary ligament, the suspensory
ligament, the right half of the coronary ligament and the right
triangular ligament are cut from left to right. The inferior vena
cava is cut at the same time. In the case of adhesions between liver
and diaphragm these must be cut or the diaphragm itself removed
in connection with the liver. In such a case the diaphragm must
be trimmed off before the liver is weighed. The liver may also be
removed in the opposite direction, raising up the right lobe and
severing all connections as far as the median line of the spinal
column. The right lobe is then pulled upon the right edge of the
thorax-wall, and the connections with the left lobe are severed. In
separating the under surface of the right lobe care must be taken not
to damage the right adrenal. The liver is then weighed and measured,
and placed upon the board with the right lobe toward the prosector. A
long, deep cut is then made by drawing the long-section-knife across
the left and right lobes, extending the cut through to the porta.
Additional cuts may be made parallel to this chief-incision. When
occasion demands a number of sagittal incisions may be made instead.
As mentioned above, it is often best to remove the liver with
stomach, pancreas and duodenum and examine on the table.
The =gall-bladder= is opened from its fundus with the fine
probe-pointed shears; its contents are caught in a vessel and
examined. The cystic, hepatic and common ducts may be explored
from the gall-bladder, if they have not been from the intestine.
The gall-bladder may be dissected from the liver and removed in
connection with the duodenum.
The =portal vein= is opened into its radicles; the examination of the
splenic vein is of especial importance. The =portal lymphnodes= are
examined at this time.
The =mesentery= and the =mesenteric lymphnodes= are now examined. The
former may be cut off at its root and examined outside of the body.
The lymphnodes may be opened by longitudinal or transverse incisions.
The left =adrenal= and =kidney= are now examined. If the pancreas
and stomach have not been removed from the body they are turned over
toward the thoracic cavity, so as to expose completely the left
adrenal. The movability of the kidney is then tested. Beginning
above the adrenal an incision is made through the peritoneum and
underlying tissue, curving outward around the kidney and downward to
its lower pole, taking care not to bring the incision too far around
the lower pole of the organ for fear of cutting the ureter. The knife
is then laid aside, and the adrenal and kidney are pulled upward
toward the median line until they are entirely free save for the
blood-vessels and ureter. The loose tissue about the fatty capsule
of the kidney is usually easily separated. The blood-vessels are
then cut from above downward against the spinal column, the ureter
being left uncut. Holding the kidney in the two hands, it is pulled
downward toward the pelvis, stripping the ureter free as far as
the pelvic brim. At this level the ureter may be cut, or, if it is
desired to remove the kidneys in connection with the pelvic organs,
the ureter is left uncut and the kidney laid over the pubis until the
pelvic organs are removed. When the kidney and adrenal are removed
they are placed upon the board and the adrenal separated. The latter
organ is then examined by means of parallel transverse incisions, or
by an incision in its longest axis in the middle of its flat surface.
When the adrenal is left in the body it may be examined by means
of the same incisions. The fatty capsule is then stripped from the
kidney and the organ weighed and measured. It is then held in the
palm of the left hand with the ureter between the middle fingers, the
convex border up, the thumb placed on one flat surface, the fingers
on the other, holding the organ tightly. The kidney is then opened by
means of a long incision made with the long section-knife, beginning
at the upper pole, drawing the knife through the convexity, to the
lower pole, and extending the cut through the organ to the pelvis.
As the knife approaches the hilus the grasp of the left hand upon
the organ is loosened and pressure upon the knife lessened so as not
to cut through the hilus. The edges of the fibrous capsule are then
caught by the fingers or forceps and the capsule stripped from the
cortical surfaces. The external surface and the cut surfaces are then
examined. When indicated other incisions into the kidney substance
may be made. The ureter is sounded from the pelvis, and opened with
the fine probe-pointed shears. The renal artery and vein may be
examined now, or better when the kidney is being removed.
The =right adrenal= and =kidney= are removed in the same way, by
making a curved incision around the outer border of the organs,
pulling them up toward the median line and cutting the blood-vessels
from above downward against the spine, and then stripping the ureter
downward to the pelvis. After removal the adrenal is separated from
the kidney and examined as directed above for the left adrenal. The
kidney and ureter are then examined in the same way as on the left.
When it is desired to remove the right kidney with the pelvic organs
the same procedure is carried out as advised above in the case of the
left one. In the removal of the right adrenal care should be taken
not to injure the vena cava. In the case of displacement of either
kidney the incisions for the removal of the organ must be altered to
suit the case.
When the kidneys are removed before the examination of the
intestines and liver, the removal of the left adrenal and kidney
usually follows the examination of the spleen. The small intestines
are pulled over to the right; the peritoneum is incised over the
left kidney between the descending colon and the spinal column so
that the right hand can be worked beneath the peritoneum up above
the adrenal and kidney, freeing them, and lifting them toward
the median line. The vessels are then cut as directed above, and
the ureter stripped down to the pelvis. On the right side the
cæcum and ascending colon are raised and a cut made through the
peritoneum at the brim of the pelvis. The cæcum, ascending colon
and peritoneum are now stripped upward with the left hand until the
right hand can be passed up above the right adrenal to loosen it
and the kidney toward the median line. When this is accomplished
the adrenal and kidney are held in the left hand, while the right
cuts the blood-vessels from above downward against the spine,
sparing the ureter, which with the two organs is stripped downward
to the pelvic brim. The close proximity of the right adrenal to
the under surface of the liver makes the removal in this way much
more difficult than when the liver is removed first. Usually, when
the method of removing the kidney after the spleen is adopted, the
adrenal is left in the body until after the removal of the liver.
So many variations in the order of section of the abdominal organs
are given by different writers that it is impossible to escape
the conclusion that the best order is the one best adapted to the
individual case. A very common order is _spleen_, _left adrenal_
and _kidney_, _right adrenal_ and _kidney_, _duodenum_, _stomach_,
_pancreas_, _liver_, _intestines_, _pelvic organs_ and _genitalia_.
Beneke advises the removal of spleen, then the removal of the
entire intestines, stomach and pancreas, in connection with the
gall-bladder, which is stripped from the liver and removed in
connection with common duct and duodenum, the whole mass removed
from the body and examined outside. Other prosectors begin with the
_liver_, then the _spleen_, _urinary bladder_ and _kidneys_ and
_genital organs_, the _gastro-intestinal tract_ being left to the
last. It may then be opened inside the body without inconvenience
resulting from the escape of its contents into the peritoneal
cavity. After surgical operations when permission for autopsy
is refused, the abdominal, and also the thoracic organs, may be
removed through the laparotomy wound.
After the examination of the abdominal viscera is completed the
=abdominal aorta= is opened in the median line of its anterior wall
and followed into its branches, the iliacs and hypogastrics. When
occasion demands it may be stripped from the spine and opened outside
of the body. The =inferior vena cava= is also opened throughout
its length and followed into its branches. The abdominal portion of
the =thoracic duct= should receive attention before the aorta is
removed. The receptaculum chyli is found by lifting up the right edge
of the aorta at the level of the second or third lumbar vertebra
and dissecting out the duct up to its thoracic portion. It may then
be opened by the fine probe-pointed shears. The =retroperitoneal
lymphnodes= and =haemolymphnodes= are examined _in situ_, or removed
with the blood-vessels and examined outside of the body. The
=sympathetic ganglia=, particularly the _suprarenal_ and the _cœliac
plexuses_, and the _splanchnic nerves_ are to be examined, especially
in cases of Addison’s disease. The section of the abdomen closes
with the examination of the =ileopsoas muscles= and =diaphragm= by
means of longitudinal or transverse incisions, and the inspection of
the =vertebrae=. Pathologic conditions in the latter are examined
according to indications.
II. POINTS TO BE NOTED IN THE EXAMINATION OF THE ABDOMEN.
1. =Peritoneum.= Normally the peritoneum is moist-shining, grayish
and translucent. It is cloudy, dry, lustreless, injected, swollen
or covered with exudate in acute inflammation; thickened, hyaline
(“iced” or “Zuckerguss”) in chronic inflammation. Note degree,
character and location of adhesions. The most common pathologic
conditions are inflammation, tuberculosis, secondary carcinoma
and pseudomyxoma peritonei. Lymphomata are found in cases of
typhoid fever and in leukæmia. Primary neoplasms (lymphangioma,
endothelioma, carcinoma, lymphosarcoma, angiosarcoma, etc.) are
rare. Ovarian cysts of the structure of cystadenoma may give rise
to implantation-metastases over the peritoneum. The parasites are
echinoccocus and cysticercus.
2. =Spleen.= Weight 150-250 grms., length 12 cm.; breadth 8 cm.,
thickness 3 cm. Varies greatly in size and weight. Describe shape,
character of borders, number of notches, etc. Accessory spleens
are common in the gastrosplenic omentum. _Capsule_ should be
delicate, smooth, shining and transparent. Note _tension of capsule_
(loose, wrinkled, tense), adhesions, hyaline thickenings, exudates
or neoplasms. _Color_ of spleen through capsule is bluish-red.
Fresh anæmic infarcts appear as yellowish or reddish-yellow areas
surrounded by a darker red zone. Cicatricial depressions on the
surface of the spleen are usually the result of healed infarcts.
_Consistence_ of spleen normally is that of muscle. In acute
hyperplasias and congestions the spleen is softer and more friable
(acute infections, typhoid fever). In chronic hyperplasias and
congestions, atrophy, amyloid degeneration, etc., the consistence is
firmer than normal, even to that of a wooden hardness in advanced
amyloid disease. (Apply iodin test.) The large, firm spleen is
characteristic of leukæmia, splenic anæmia, syphilis and chronic
malaria. On section note the _pulp_, _follicles_ and _trabeculæ_. In
the normal spleen the cut surface is dark red or bluish-red, smooth,
and the trabeculæ and follicles easily seen. In acute hyperplasias
the pulp swells up over, the trabeculæ as a thick red or grayish-red
gruel-like substance. In chronic hyperplasias the pulp is atrophic,
grayish-red, and firm. In subacute hyperplasias the cut-surface often
presents a shagreened appearance. The _color_ of the cut-surface
is blood-red in typhoid fever, grayish-red in septicæmias,
chocolate-brown in potassium-chlorate poisoning and hemosiderosis
due to other causes. In amyloid spleen the amyloid portions are
glassy; when confined to the follicles the latter look like grains
of boiled sago. The _follicles_ are about the size of medium
pin-heads, grayish in color, not elevated and cannot be scraped
out with the knife. They are more numerous and larger in young
individuals than in adults. Note size and number, degenerations,
etc. The _trabeculæ_ appear as fine gray lines, sharply outlined,
increasing in size toward the hilus and capsule. They are more
distinct in atrophy and chronic hyperplasias. In anthracosis of
the spleen black granules are seen in the pulp, particularly about
the trabeculæ. Tubercles appear as grayish-white, semitranslucent
nodules, elevated above the surface, and can be scraped out with the
knife-point. When caseation has begun their centres are opaque and
yellowish. Gummata are grayish-white, with opaque centers, and have
a periphery of vascular granulation-tissue or hyaline scar-tissue.
The most important pathologic conditions of the spleen are: acute
and chronic passive hyperæmia, embolic infarctions, abscess, acute
and chronic hyperplasias (typhoid, malaria, plague, pneumonia,
septicæmia, leukæmia, pseudoleukæmia, splenic anæmia, hepatic
cirrhosis, syphilis, Kala-azar, other forms of tropical splenomegaly,
tuberculosis, rachitis, idiopathic splenomegaly of the Gaucher type,
etc.), wandering spleen, absence of spleen, amyloid disease, atrophy,
syphilis, tuberculosis, actinomycosis, traumatic rupture, cysts
(peritoneal), neoplasms (primary are rare [angioma, angiosarcoma,
fibroma, chondroma, osteoma, lymphangioma, endothelioma]; secondary
sarcoma [chiefly lymphosarcoma and melanosarcoma] and carcinoma
are also infrequent; secondaries of malignant syncytioma are
more frequently found), parasites (echinococcus, cysticercus and
pentastomum).
3. =Intestines.= In the examination of the _large intestine_,
_appendix_ (average length about 9 cms.), _small intestine_ and
_duodenum_ note the _contents_ of the various portions with respect
to amount, color, odor, consistence, presence or absence of bile,
food-remains, parasites, foreign-bodies, blood, pus, concretions,
etc. Note _character of wall_, _size of lumen_, _color_ (normally
gray) and _character of mucosa_, _folds_ and _villi_, _solitary
follicles_, _Peyer’s patches_, _mouths of bile-duct_ and _pancreatic
ducts_, _ileocæcal valve_ and _opening into appendix_. Postmortem
digestion of the mucosa, often leading to perforations, postmortem
hypostasis, imbibition of bile, pseudomelanosis, and contractions
of portions of the bowel must not be mistaken for pathologic
conditions. Redness of a portion of the intestine does not in itself
mean inflammation; the latter condition is shown by excess of mucus,
swelling of the mucosa, hyperplasia of the follicles, hæmorrhage,
etc. The contents of the small intestine are usually gruel-like in
consistence, thinner in the upper part, thicker toward the ileocæcal
valve. The _hook-worm_, _ascaris lumbricoides_ and _intestinal
trichina_ occur in the duodenum; _tænia solium_, _saginata_ and the
_bothriocephalus latus_ in the jejunum and ileum, _tricocephalus
dispar_ in the cæcum, and _oxyuris vermicularis_ in the large
intestine and rectum. _Ulcers_ of the intestine may be due to typhoid
fever, tuberculosis, carcinoma, dysentery, embolism or thrombosis
of mesentery vessels, etc. Diphtheritic ulcers are caused by a
variety of infections and poisons. They are usually found in the
large intestine, but occasionally occur in the small intestine in
cases of uræmia. Typhoid ulcers usually have their longest diameter
parallel with the longitudinal axis of the intestine; tuberculous
and carcinomatous ulcers usually encircle the intestine, forming
“ring ulcers;” diphtheritic and dysenteric ulcers are irregular,
involving the surfaces of the folds. Solitary round or peptic ulcers
occur in the duodenum and jejunum. Decubital ulcers, associated
with fécal concretions, gall-stones or foreign-bodies are found in
appendix and rectum most commonly, more rarely in other portions of
the intestines. _Perforations_ of the intestines may be traumatic, or
due to infections (typhoid, tuberculous, purulent, dysenteric, etc.),
neoplasms (carcinoma), embolic gangrene, ileus, fécal impaction,
erosion of calculus or foreign-body, parasites (round-worm?),
over-distention, etc.
The most important pathologic conditions of the intestines are:
anomalies (atresia, diverticulum, stenosis, dilatation, hernia),
acute and chronic passive congestion, hæmorrhage, stasis, embolism
and thrombosis, hæmorrhagic infarction, gangrene, traumatic
injuries, ileus, volvulus, strangulated hernia, enteritis
(catarrhal, follicular, hyperplastica, cystica, purulent, ulcerative,
croupous, diphtheritic, dysentery, cholera, typhoid, etc.),
appendicitis (catarrhal, ulcerative, perforative, obliterative),
tuberculosis, syphilis (chiefly in rectum, ulcers, stenosis and
perforations), actinomycosis, anthrax, intestinal sand, concretions,
foreign-bodies, and neoplasms (primary carcinoma the most
important [adenocarcinoma, colloid, scirrhous, medullary, etc.],
most frequent in large intestine and rectum, secondary carcinoma
is rare; adenomatous polypi are common, particularly in rectum;
primary sarcomata [lymphosarcoma chiefly] are much less common than
carcinoma, secondary sarcoma more common than primary [melanotic
sarcoma, lymphosarcoma]. Benign connective-tissue tumors [lipoma,
fibroma and myoma] are relatively rare. Primary carcinoma and sarcoma
occur in the appendix, as well as secondary carcinoma). Leukæmic
infiltration is common in leukæmia.
4. =Bile-passages.= Note patency, character of mouth, contents,
etc. The most important conditions are inflammation, gall-stones,
obstruction, stenosis, dilatation, perforation, carcinoma, and
anomalies (in the new-born). Round-worms may obtain entrance and
block the duct.
5. =Stomach.= On the external examination the size (dilatation,
contractions due to scirrhous carcinoma or scars), shape (hour-glass,
etc.), position, color of surface, consistence of wall, presence of
adhesions, etc., should be noted. When the stomach is opened note
presence of _gas_ (odor), _character of contents_ (fluid, gruel-like,
food-remains, curds, foreign bodies, mucus, pus, blood, parasites,
drugs, etc.), _odor_ (yeasty, sour, acid, sweetish, foul, H_{2}S,
odor of foods or drugs), _reaction_ (acid or alkaline), _color_
(yellow, greenish, grayish, brown, black, bloody, etc.) Describe
the character of mucus on the mucosa (tough, glassy, difficult to
remove in acute catarrh; softer, grayish or grayish-red, often
containing small black blood-specks in chronic catarrh). Bile gives
a yellow or greenish color. The presence of blood may give to the
stomach-contents the appearance of “coffee-grounds;” in hæmorrhage
by diapedesis the contents may be brownish. Cloudy swelling of the
glands is common in sepsis, chronic anæmia and various poisonings.
It affects cells in deepest portion of glands, as shown by excising
a bit of the mucosa and examining microscopically. The brownish or
black discoloration of the mucosa associated with softening of the
latter (gastromalacia, postmortem digestion) must not be taken for a
pathologic condition. The mucosa becomes soft, cloudy or jelly-like
and strips easily from the whitish submucosa. Softening of the entire
wall leads to perforations that must not be mistaken for pathologic
ones. Their edges show no signs of disease. The normal mucosa is
grayish in _color_. In chronic passive congestion the color may
be dark red. Hypostatic congestion is common in the large veins
of the fundus. Hæmorrhages occur chiefly in the fundus and along
the greater curvature (caused by vomiting). In potassium cyanide
poisoning the mucosa is often rosy-red in color and has a soapy
feel. The normal mucosa is nearly smooth when the folds caused by
contraction are spread out. Localized hyperplasias occur in chronic
gastritis (etat mamelonné) and cannot be smoothed out by stretching.
Erosions (common in chronic passive congestion) and ulcers (round or
peptic, carcinomatous, due to corrosives, very rarely to tuberculosis
and syphilis) are to be carefully examined and described. The
different layers of the stomach wall are to be examined with
respect to their absolute and relative thickness. Thickening of the
submucosa may be caused by œdema, purulent infiltration, increase
of connective-tissue, carcinomatous or sarcomatous infiltration.
Hyperplasia of the muscular coat occurs chiefly at the pylorus in
cases of stenosis.
The most important conditions of the stomach are anomalies
(congenital stenosis of pylorus, situs inversus), acute and chronic
passive congestion (portal stasis), hæmorrhages, hæmorrhagic erosions
(portal stasis), gastritis (acute, chronic, catarrhal, purulent,
fibrinous, diphtheritic, phlegmonous, atrophic, hypertrophic),
tuberculosis (rare), syphilis (rare), anthrax, action of corrosive
poisons (acids, concentrated lye, carbolic acid, mercuric
chloride, silver nitrate, oxalic acid, potassium cyanide), round
or peptic ulcer, perforation, neoplasms (carcinoma the most common
[adenocarcinoma, medullary, scirrhous, colloid]; primary sarcoma rare
[lymphosarcoma], secondary are less rare; metastases of malignant
syncytioma may occur in the stomach wall; benign tumors are rarely
important. The most common are adenomatous polypi, fibroma, myoma and
fibromyoma), stenosis, dilatation, contraction, wounds, concretions,
foreign bodies and parasites (temporary as gordius, round-worms
occasionally enter, intestinal form of trichina).
6. =Pancreas.= Weight 60-100 grms.; measures 17-20 cm. long, 3-4.5
cm. broad, and 2.5-3 cm. thick. _Color_ reddish-grayish-yellow;
_consistence_ firm; _lobules_ distinct. Postmortem change occurs
quickly. The most common pathologic conditions are: atrophy, fatty
infiltration, hyperæmia, hæmorrhage, inflammation (degenerative,
parenchymatous, hæmorrhagic, necrotic, gangrenous, purulent, chronic
fibroid or interstitial [inter- and intra-acinar], cirrhosis of
pancreas), tuberculosis (very rare), syphilis (gumma not common,
interstitial pancreatitis most common form), fat-necrosis, cysts,
congenital cystic pancreas, concretions in duct, hæmosiderosis,
neoplasms (primary carcinoma the most important [scirrhous,
medullary, adenocarcinoma]; primary sarcoma rare; secondary melanotic
sarcoma and lymphosarcoma occur, secondary carcinoma less frequently;
benign tumors rare, cystadenoma being the most common), and parasites
(echinococcus, round-worm in duct). In fat-necrosis or acute
pancreatitis the pancreatic ducts should be examined for obstruction
due to calculi or stenosis. Areas of fat-necrosis appear as opaque,
white, yellow or brown, firm nodules. Accessory pancreatic tissue not
rare in wall of intestine. May occur more rarely in stomach-wall,
omentum or abdominal wall.
7. =Liver.= Weight 1,500 grms.; measures 22 cm. sagittally, 30
cm. transversely and 8 cm. thick. A dimension of over 30 cm. is
enlarged; when all dimensions are under 20 cm. the liver is smaller
than normal. Note _size_ (enlarged in congestion, cloudy swelling,
fatty infiltrations, leukæmia, neoplasms; smaller in atrophy,
acute yellow atrophy, cirrhosis), _changes of form_ (congenital
furrows, deep furrows with thickened capsule in syphilis, fine or
coarse granulations and contractions in cirrhosis, edge rounded in
fatty and amyloid liver, sharper in atrophy, capsule wrinkled in
acute yellow atrophy), _capsule_ (normally smooth and transparent;
thickened, white, and opaque in chronic inflammation, the thickening
being usually most pronounced along the ligaments, blood- and
lymph-vessels. Small, hyaline nodules or patches may be scattered
over the capsule, or the entire capsule may be tendon-like [“iced”
or “Zuckerguss-leber”]. Adhesions with diaphragm, stomach, omentum,
spleen, intestine and abdominal wall may occur. Fibrinous and
purulent exudates may be found on the capsule, particularly on the
diaphragmatic surface; when encapsulated by adhesions they form
the so-called subdiaphragmatic abscess), _consistence_ (increased
in fat-infiltration, cirrhosis, atrophy and amyloid; diminished
in acute parenchymatous degenerations, leukæmia, acute yellow
atrophy, acute congestion; fluctuation is present over abscesses,
echinococcus cysts and softened tumors), _color_ (normally brown-red;
dark-brown in atrophy, dark red or bluish-red in passive congestion,
“nutmeg” appearance in chronic passive congestion, chocolate-brown
in hæmosiderosis, greenish in chronic icterus, yellow in acute
icterus, fatty liver, leukæmia and anæmia, grayish-white or yellow
in cloudy swelling and fatty degeneration; sharply circumscribed dark
bluish-red areas are caused by cavernous angiomata), _cut-surface_
(normally smooth and of uniform color, blood-content abundant, before
the age of puberty lobules are seen with difficulty; in adults
they are recognizable from their yellowish-brown periphery and red
central zones. They are about 1-2 mm. long by 1-1.5 mm. broad. Note
size of lobule, color of central, intermediate and peripheral zones,
distinctness of boundary of lobules, elevation of lobules above
surface. Lobules are elevated in fatty infiltration and in cirrhosis,
depressed in atrophy. In acute yellow atrophy they cannot be made
out. Fatty infiltration begins usually in the peripheral portion
of the lobules, fatty degeneration in the central zone, amyloid
in the intermediate zone, hæmosiderin is found in the peripheral
and hæmatoidin in the central zone. In extreme fatty infiltration
affecting the entire lobule the outlines of the lobules cannot be
made out. The normally shining surface is dull, cloudy, appearing as
if cooked in cloudy swelling and fatty degeneration). Note amount
of stroma; it is increased in cirrhosis, so that the lobules may be
entirely surrounded by connective-tissue, or the connective tissue
may invade the lobules. Note also size and contents of hepatic and
portal blood-vessels and bile-ducts.
The most important pathologic conditions of the liver are acute and
chronic passive congestion, thrombosis of portal veins, atrophy
(simple and brown), fatty infiltration, cloudy swelling, fatty
degeneration, acute yellow or red atrophy, amyloid, phosphorus-liver,
abscess (metastatic, tropical, purulent cholangitis), cirrhosis
(Lænnec’s or atrophic, Hanot’s or hypertrophic, fatty, biliary,
cardiac), pericarditic pseudocirrhosis, tuberculosis, syphilis
(very common: gummata, interstitial hepatitis, cirrhosis, hepar
lobatum), actinomycosis, leukæmic infiltrations, glycogen
infiltration (diabetes), pigmentations (hæmosiderosis in pernicious
anæmia, malaria, hæmolytic poisons, etc., hæmatoidin in atrophy,
bile-pigment in icterus, anthracosis, argyrosis, malaria pigment,
melanin), neoplasms (most common tumor is the cavernous angioma,
usually in old people, rarely of clinical significance; primary
carcinoma and sarcoma rare; secondary very common [melanotic sarcoma,
lymphosarcoma, metastases from carcinoma of gall-bladder and duct,
stomach, pancreas and intestine, metastases of malignant syncytioma],
adenoma and cystadenoma are rare), cysts, congenital cystic liver,
parasites (echinococcus hydatidosus, granulosis and multilocularis,
cysticercus, distomum hepaticum, pentastomum denticulatum, coccidium
oviforme).
8. =Gall-bladder.= Note _size_ (length 8-17 cm., diameter 3 cm.,
thickness of wall 1-2 mm.), _amount_ and _character of contents_
(clear and watery in hydrops, seropurulent or purulent in
inflammation, excess of mucus in catarrhal inflammation), calculi,
bile-sand, thickening and indurations of wall, œdema, character of
mucosa, carcinoma (adenocarcinoma, squamous-celled). Note size,
contents, thickness of wall and character of mucosa of ducts.
9. =Portal Vein.= Note contents, character of wall, occurrence of
stenosis, thrombosis, pylephlebitis, thrombopylephlebitis, syphilitic
changes, calcification, pressure from without.
10. =Mesentery.= Amount of fat, color, condition of vessels,
blood-content, occurrence of œdema, inflammation, abscesses,
hæmorrhages, infarction, gangrene, fat-necrosis, aneurism,
embolism, thrombosis, cysts, parasites (bilharzia hæmatobia),
tumor-infiltrations and primary tumors (lipoma).
11. =Mesenteric Glands.= Size, appearance on section (rose-red
in acute inflammation, grayish-white in chronic), occurrence of
tubercles, secondary tumors, calcification, abscesses, pigmentation,
typhoid necrosis, primary lymphosarcoma, leukæmic hyperplasia,
Hodgkin’s, etc.
12. =Adrenals.= Weight 4-7.5 grms. measurements are 5-6 cm. long,
2.5-3.5 cm. broad, 0.5-1 cm. thick. Normally the consistence is firm;
it is increased in amyloid degeneration, tuberculosis, syphilis,
fibroid induration and atrophy; diminished in hæmorrhage, soft
caseating tubercles, degenerating tumors. Postmortem autolysis
of the medulla takes place very quickly, the cortical portion
remaining as a hollow capsule. On section note the relations of the
grayish-white cortex (more yellow and opaque in adults from the
amount of fat contained in the cells), the intermediate brown zone
and the central grayish, translucent portion of the medulla. The
most important pathologic conditions are tuberculosis, syphilis,
atrophy, compensatory hypertrophy, hæmorrhage, infarction, thrombosis
of adrenal vessels, secondary tumors (melanotic sarcoma, carcinoma),
primary neoplasms (hypernephroma, accessory adrenals typical and
atypical, lipoma, glioma, neuroma, sarcoma), parasites (echinococcus).
13. =Kidneys.= Right kidney weighs 110-145 grms., and measures
10-12 cm. long, 4.5-5.0 cm. broad, and 3-4.5 cm. thick. Left kidney
weighs 150-180 grms. and measures 12 cm. long, 5-6 cm. broad, 3-4.5
cm. thick. The left kidney is usually larger and heavier than the
right. Note position and movability of kidneys, thickness and color
of fatty capsule (increased in lipomatosis, atrophy of kidney),
purulent infiltrations and fibroid thickenings of the perirenal fat.
Normally the fibrous capsule is thin and translucent, easily stripped
off, the inner layer remaining attached around the blood-vessels
passing from capsule into cortex. The capsule is adherent in chronic
inflammations and over healed infarcts and localized inflammatory
processes, tubercles, tumor-nodules, etc. Note alterations in
_shape_ and _size_ (“horse-shoe kidney,” “hog-back,” round, fœtal
lobulations, fissures; enlarged in acute parenchymatous nephritis,
pyelonephritis, hydronephrosis, chronic passive congestion, etc.;
diminished in atrophy, chronic interstitial nephritis, etc.).
_Character of cortical surface_ (normally smooth, grayish-brown in
color; a fine or coarse, regular or irregular granulation of the
surface occurs in chronic nephritis, the elevations corresponding to
the preserved portions of the parenchyma, the depressed portions to
the areas of connective-tissue increase; localized depressions or
fissures may be caused by old or recent scars of infarcts, abscesses,
rupture, etc. Distinguish fœtal furrows from pathologic depressions.
Flat, puckered or radiating scars point to syphilis. Elevations of
the surface may be due to fresh infarcts, tubercles, abscesses,
neoplasms, etc. Accessory adrenal tissue (resembles adipose tissue)
and small papillary adenomata are very common on the cortical
surface. Retention- and degeneration-cysts are also very common,
particularly in the kidneys of adults). In atrophic kidneys the
glomeruli can be seen through the cortical surface. Note condition
of superficial vessels (stellate veins). The _color_ of the cortical
surface depends essentially upon the blood-content and the condition
of the parenchyma. In acute or chronic parenchymatous nephritis the
color is whitish or grayish-white. Localized fatty degeneration and
cloudy swelling cause pale, grayish-yellow, opaque spots or streaks.
Hæmorrhages appear as red or brown-red spots. In extreme passive
congestion the kidney may be a dark purplish-blue (cyanotic kidney).
In hæmorrhagic nephritis the surface may be covered with pin-point
or pin-head hæmorrhages. In pyæmia or acute ascending pyelonephritis
the surface may be dotted with gray or yellowish pin-head abscesses.
Metastatic abscesses are uniformly distributed; others are arranged
in groups. In miliary tuberculosis the surface may contain numbers
of grayish translucent miliary tubercles, with opaque centers when
caseation has taken place. They cannot be so easily scraped out with
the knife as the abscesses. Calcified glomeruli may also appear as
white spots. Proliferations of the interstitial tissue cause large,
red kidneys. Anæmic infarcts are yellow, brick-red or rusty, with
a deeper red zone about them. Pseudomelanosis (usually postmortem)
gives a gray-green color to the kidney. In icterus the color may vary
from brownish-yellow to deep bronze. The _consistence_ of the kidney
is increased in chronic passive congestion, atrophy, interstitial
nephritis and amyloid degeneration; decreased in acute degenerations
and inflammations.
On section note _color_, _blood-content_ and _consistence of
cut-surface_, _relations of cortex and medulla_. The cortex is
normally 0.5-1.0 cm. broad (increased in acute degenerations and
inflammations, diminished in chronic inflammation and atrophy).
Note number, size and color of the _glomeruli_. They appear as
red pin-head points in congestion; in anæmia as small colorless
granules; in the normal kidney as small reddish points against the
lighter color of the labyrinths. In amyloid disease they are enlarged
and glassy. Calcified glomeruli are white and opaque. In venous
congestion the interlobular veins appear as bluish-red stripes;
hæmorrhages appear as red points in the glomeruli and convoluted
tubules, as red stripes in the collecting tubules. The blood-content
is increased in chronic passive congestion and chronic alcoholism. On
the cut-surface anæmic infarcts are usually wedge-shaped, with the
base toward the cortical surface. The color of the kidney-parenchyma
is usually gray; in fatty degeneration and cloudy swelling it
becomes yellow or grayish-yellow. The areas of greatest degeneration
appear as cloudy, opaque, yellowish points and stripes. Slight
degenerations are shown by slight cloudiness of the cortex. The
contrast between the grayish-white cortex and the dark-red medulla is
often very striking in severe parenchymatous nephritis. In uric-acid
infarction of the new-born ochre-yellow or vermilion-red stripes
or lines are seen in the medullary pyramids; white lines indicate
chalk-infarction; golden-yellow lines a bilirubin infarction. In gout
whitish deposits of urates occur in the kidney; they are usually
surrounded by scar-tissue. In purulent pyelonephritis yellow stripes
of pus surrounded by hæmorrhage occur in the pyramids. Tuberculosis
begins usually in the papillæ, destroying the pyramids first and then
the cortex, forming a multilocular sac lined with caseating tissue.
In hydronephrosis due to obstruction of the ureter the kidney becomes
converted into a multilocular sac without ulceration or caseation of
its papillæ. Note size of _pelvis_ and calices, contents, character
of mucosa, concretions, etc. The normal mucosa is grayish-red and
delicate; it is rose-red in inflammation and often shows petechiæ.
In severe inflammations grayish-white sloughs encrusted with urates
are often found. Concretions of urates, phosphates or oxalates may
be present, often associated with decubital ulcers of the mucosa.
Tuberculous ulcers of the pelvic mucosa are common. The _ureters_ are
straight and about 4 mm. thick. Note size, contents, thickness of
wall, changes in the mucosa, obstruction, dilatation, concretions,
etc.
The most important pathologic conditions of the kidneys are anomalies
(horse-shoe kidney, dystopia, double ureters, congenital lobulation),
floating kidney, congestion, anæmia, infarction, thrombosis and
embolism of renal vessels, atrophy (simple, arteriosclerotic),
hydronephrosis, nephrolithiasis, nephritis (parenchymatous,
hæmorrhagic, secondary contracted, primary contracted), rupture,
amyloid degeneration, abscess, pyelonephritis, tuberculosis,
syphilis, actinomycosis, uric-acid infarct, hæmatoidin- and
hæmosiderin-infarct, bilirubin-infarct, chalk-infarct, argyrosis,
retention- and degeneration-cysts, congenital cystic kidney,
neoplasms (hypernephroma and adenoma the most common; carcinoma
infrequent, sarcoma more common, particularly the congenital
adenosarcoma or rhabdomyosarcoma; fibroma, leiomyoma, lipoma and
angioma are relatively rare. Secondary carcinoma and sarcoma are
common), pyelitis, ureteritis (cystica, polyposa, diphtheritica,
purulenta), pyonephrosis, parasites (distomum hæmotobium,
echinococcus, filaria, cysticercus, pentastomum and dioctophyme
renale).
14. =Abdominal Aorta=, =Iliacs= and =Vena Cava=. Note size of lumen,
thickness of wall, character of endothelium and contents. Sclerosis,
fatty degeneration of intima, atheroma, calcification, aneurism,
inflammation, thrombosis, stenosis, dilatation, compression, and
infiltrations with pus or neoplasm are the most important conditions.
15. =Lymphatic Vessels.= Inflammation, obstruction, rupture,
tuberculosis and invasion by malignant neoplasms are the most
important conditions. (See also Thoracic Duct, Chapter VIII, Page
130.)
16. =Lymphnodes.= The retroperitoneal _lymphnodes_ and _hæmolymph
nodes_ are described as to their number, size, color, consistence,
occurrence of hyperplasia, lymphadenitis, atrophy, congestion, œdema,
hæmorrhage, pigmentation, tuberculosis, metastatic tumors, primary
tumors (lymphosarcoma), leukæmic hyperplasias and Hodgkin’s disease.
17. =Sympathetic.= The solar plexus, semilunar ganglia and adrenal
plexus should be examined, particularly in Addison’s disease, for
atrophy, degenerations, involvement in inflammatory processes,
hæmorrhages, tumor-infiltrations, etc.
18. =Psoas Muscles and Diaphragm.= Examine for purulent, phlegmonous
or gangrenous inflammations, tuberculosis, actinomycosis,
trichinosis, atrophy and scar-tissue. Pus from carious processes in
the thoracic and lumbar vertebræ burrows downward along the psoas
muscle.
19. =Vertebrae.= Fractures, dislocations, curvatures, deviations,
tuberculosis, caries, actinomycosis, etc.