SPECIAL REGIONAL EXAMINATION.
I. METHODS OF EXAMINATION.
1. =Bones and Bone-Marrow.= The methods employed will depend wholly
upon the indications in any given case, the anatomic relations and
the aim of the examination. Anatomic knowledge should be applied in
the removal of any bone. In the case of the extremities adequate
incisions should be made in the skin extending the entire length of
the bone which is to be removed, and the soft parts dissected from
the bone before the latter is disarticulated or cut out. When the
bone is examined _in situ_ it may be opened with hammer and chisel or
cut with a saw, either transversely or longitudinally, so as to give
the most instructive picture of the condition present. The spinal
column may be cut longitudinally. The symphysis pubis is first cut
through, a block of wood is placed beneath the lumbar vertebræ, and
the vertebral bodies are sawed through in the median line, from below
upward, moving the block toward the head as the sawing proceeds.
The cut-surfaces of the vertebræ are then inspected. The _pelvis_
may be removed whole in connection with the lumbar vertebræ and the
upper halves of the femurs. The _spinal column_ and the _pelvis_ may
also be removed entire by sawing the ribs on each side of the spine,
cutting the occipito-atloid ligaments above, and disarticulating
the femurs or sawing them at their upper half or third and removing
them with the pelvis. Of the long bones the _femur_ is the one most
frequently examined. An incision is made in the skin from the groin
in the direction of the large vessels extending to the middle of the
leg. The ligamentum patellæ is cut through and the skin and muscles
turned back at the knee until the joint is laid bare; the capsule
of the joint is opened and the femur disarticulated. The skin and
muscles are then separated from the upper part of the femur, the
hip-joint opened, and the femur disarticulated and removed. When
held in a vise it may be opened longitudinally by sawing. Other
bones are removed as indicated; the chief points to be observed in
their removal are the anatomic considerations and the making of the
incisions in such a way as to cause the least possible disfigurement.
For the examination of the _bone-marrow_ the tibia or femur,
sternum, a rib and the body of one of the vertebræ are usually opened
by means of the saw or chisel.
2. =Joints.= The joints are opened for examination with attention to
the same considerations given above for the examination of the bones.
Approved surgical incisions may be used. If fistulous openings into
the joint are present these should not be cut until the joint is
open. When bacteriologic examinations are to be made the joint should
be opened with a sterile knife, or the capsule seared and punctured
with a sterile pipette through which the contents of the joint-cavity
are secured. The articular surfaces, epiphyses and diaphyses should
be examined by transverse or vertical incisions.
3. =Lymph-glands.= The cervical, axillary and inguinal lymphnodes
can be secured for examination by carrying the skin-flaps of the
main-incision far enough back to make these regions accessible. For
the examination of other glands, such as the cubital, popliteal,
interscapular, posterior cervical, etc., the cadaver should be placed
in a convenient position, and the skin-incisions should be made so as
to expose sufficiently the part to be examined, without unnecessary
mutilation.
4. =Peripheral Blood-vessels and Nerves.= Skin-incisions are made
along the course of the vessels and nerves, and these are then
exposed by careful dissection. In the case of the upper extremity the
clavicle is removed when the entire course of the nerves and vessels
of the arm is to be exposed.
5. =Sympathetic System.= The cervical, thoracic and abdominal
sympathetic systems are examined either at the close of the
examination of each one of these regions or at the end of the
autopsy. Careful anatomic dissections are necessary for the
demonstration of the sympathetic ganglia and nerves.
6. =Organs of Special Sense.= These may be examined at the close of
the autopsy, according to the methods given above, if they have not
been examined at the close of the section of the brain.
II. POINTS TO BE NOTED IN SPECIAL REGIONAL EXAMINATION.
1. =Bones and Bone-marrow.= Note size, form, color of surface,
consistence (diminished in necrosis, osteomalacia, rachitis, senile
osteoporosis, etc.; increased in sclerosis), fragility, fractures,
separation of epiphyses, fissures, dislocations, elevation or
separation of periosteum, periosteal defects, changes in periosteum
(thickened, indurated, and showing hard white elevations in
chronic inflammation; swollen and easily stripped from the bone
in acute inflammation; hæmorrhages and collections of pus beneath
periosteum cause separation of periosteum; in chronic inflammation
the periosteum may become more firmly adherent to the bone and
contain spongy, compact, cartilaginous or osteoid osteophytes that
vary in color according to the degree of calcification [bluish-red,
yellowish, dirty-white, shining-white]; the normal periosteum is
grayish-white in color; it is reddened in hyperæmia and hæmorrhage).
The surface of bones normally is smooth and grayish-yellow in color;
it becomes red with an increase in the number and size of the
medullary spaces, and paler, grayish-white or white in necrosis;
a dull, rough, uneven surface indicates lacunar absorption. Note
localized or general thickening (exostoses, hyperostosis). On section
note thickening of the bone (osteomyelitis ossificans), thinning
(osteoporosis, excentric atrophy), enlargement of medullary spaces,
obliteration of spaces by newly-formed bone (osteosclerosis; bone
becomes heavy and solid like ivory), and caries (pyogenic infection,
tuberculosis, syphilis, actinomycosis, neoplasm). Caries occurs in
both spongy and compact bone, but more often in the former. The
necrotic bone appears as soft, friable granules (molecular necrosis)
or sequestra, between which living bone or granulation-tissue may be
found. The necrotic granules feel like fine grains of sand when the
finger is rubbed over the cut-surface. The color depends essentially
upon the amount of granulation-tissue present (gray, grayish-red or
deep bluish-red). Purulent areas are cloudy, opaque and yellowish.
Tubercles appear as round, grayish, semitranslucent areas, with
opaque yellowish centers when calcification has occurred. In young
subjects the developing portions of the bone (epiphyses, cartilages)
should receive especial examination. Note _amount_, _color_ and
_consistence_ of bone-marrow. In the young individual the marrow is
red; after puberty the red marrow gradually becomes restricted to
the flat bones and the short spongy bones, while in the long bones
there develops a yellow, fatty marrow. In old age the marrow of the
long bones may become brownish, transparent, myxomatous or soft like
colloid, or contain large cystoid spaces filled with a thin mucoid
fluid or liquid fat. Red lymphoid marrow is found in the long bones
in severe anæmias; it is grayish-red or deep red according to its
blood-content. In leukæmia the marrow may be red, violet, pink,
grayish or grayish-yellow (pyoid); in chloroma the marrow may be
greenish. In cachexias the marrow may become gelatinous as in old
age. A hyperæmic fatty marrow should not be mistaken for lymphoid
marrow; the fatty shine serves to distinguish the former. Cloudy
yellowish areas in the marrow point to purulent infiltration. Firm
sulphur-yellow masses are gummata.
The most important pathologic conditions of the bones are: atrophy,
osteomalacia, rachitis, fractures, dislocations, periostitis,
osteomyelitis, ostitis, acromegaly, necrosis, syphilis, tuberculosis,
actinomycosis, leprosy, exostosis, hyperostosis, hyperplasia,
defects, hypoplasia, dwarfism, giantism, neoplasms (primary sarcoma
the most common malignant tumor [periosteal, myelogenous, myeloma,
lymphosarcoma, chloroma, leukæmia]; secondary carcinoma [primary in
mamma, thyroid, prostate, adrenal] also relatively common; osteoma,
lipoma, exostosis cartilaginea, fibrosa and ossificans, fibroma,
myxoma, lipoma, angioma, chondroma, etc.), cysts, and parasites
(echinococcus, cysticercus).
2. =Joints.= _Capsule_ (thickness, tension, defects, tears,
perforations, adhesions), _cavity_ (contents [normally a few
drops of light-yellow, clear fluid, more in knee-joint than in
other joints; may be serous, purulent, hæmorrhagic or fibrinous],
adhesions, granulation-tissue, rice-bodies, free bodies, joint-mice,
obliteration of cavity, osseous, fibrinous or cartilaginous
ankylosis, changes in internal articular ligaments), _synovial
membrane_ (a delicate pale grayish, smooth membrane; rough from
exudate or formation of granulation-tissue; red in hyperæmia or
hæmorrhage. Note folds and villi; subserous fat-tissue), _articular
surfaces_ (loss or increase of cartilage, separation of cartilage,
newly-formed bone, granulation-tissue, deposits of lime-salts
or urates, necrosis or purulent infiltration of the cartilage,
erosions, eburnations, defects or enlargement of ends of bones; in
degeneration and necrosis the bluish-white, transparent cartilage
becomes opaque, cloudy and yellowish). The most important pathologic
conditions of the joints are: arthritis (acute, chronic, serous,
purulent, gangrenous, primary, secondary, gonococcal, pneumococcal,
streptococcal, tuberculous, syphilitic, deformans, villosa, prolifera
cartilaginea, adhæsiva, ulcerosa, sicca, neuropathic), dislocations,
deformities, abnormal position, congenital anomalies, chondritis,
spondylitis, gout, necrosis, ankylosis, tuberculosis, syphilis,
free bodies, neoplasms (rare: angioma, sarcoma, chondroma, lipoma;
secondary more common from an extension of sarcoma of neighboring
structures; metastatic tumors rare), and parasites (echinoccocus very
rare).
3. =Lymphnodes, Peripheral Vessels and Nerves, Sympathetic and Organs
of Special Sense.= The pathologic conditions of these structures have
been given above.