7. Examination of Nose and Neighboring Cavities. Of all the methods advised for the examination of the nasal cavities the method of Harke (Fig. 32) is the easiest and gives the best views of the nasal tract. After the brain has been removed the scalp incision is carried downward to the middle of the neck on both sides, following the anterior edge of the trapezius, as for the removal of the temporal bone. The anterior flap is then carried forward as far as the bridge of the nose and the edges of the orbits, and the flap pulled down over the face. The posterior flap is carried back as far as the upper cervical vertebræ, removing the muscles with the scalp. The head of the cadaver is now raised and firmly held by an assistant or clamped in a head-holder; and with the large meat-saw the occipital bone is sawed through in the median line, cutting first the squama and then the clivus. The saw is then set anteriorly into the frontal bone, to the left or right of the septum, in order not to injure the septum narium. (Fig. 32.) The sawing then proceeds through the sella turcica, body of the sphenoid, ethmoid and frontal bones until the base of the skull is divided into halves. The cartilage-knife is then introduced through the foramen magnum and the basal ligaments cut. The right and left sides of the skull posteriorly are then taken in the two hands and with a quick, powerful tug forced outward until the nasal bones, hard palate and alveolar processes break apart. The two halves of the base of the skull then open like a book, turning on an axis, running through the inferior maxillary articulation and the occipito-atloid ligaments. If there is too great resistance in the region of the foramen magnum, the anterior and posterior arches of the atlas may be cut with a chisel. The sphenoidal sinus, septum narium, frontal sinus and the nasal cavity on one side of the septum with the nasopharynx are thus exposed, and their walls and contents may now be examined. Material for bacteriologic examination should be secured before further cutting is done. The septum may then be removed with forceps and scissors, the nasal cavity on the other side examined, the nasopharynx inspected, and the antrums opened with small bone-forceps. After the examination is complete the halves of the base are brought together and fastened with copper wire anteriorly and posteriorly, taking care that the anterior wire will not be visible through the skin of the forehead.

8. Examination of Face. When the anterior flap of the scalp is carried down to the edge of the orbits and half-way across the lower jaw as advised above for the removal of the temporal bone, the parotid region may be examined. The upper and lower maxillary bones are best examined after the removal of the neck-organs. A transverse incision is made in the skin of the neck low enough to be concealed by the clothing, and connecting with the longitudinal scalp-incisions. The facial flap is then dissected upward with great care as far as the infraorbital edges, exposing the maxillary bones, from which the soft parts must be so carefully removed that restoration of the face can be made. For the examination of the anterior nasal-cavities the upper lip must be separated from the bones.

II. POINTS TO BE NOTED IN SECTION OF HEAD.

1. Scalp. Note wounds, hemorrhages, inflammations, scars, parasites, neoplasms, number and location of bleeding-points on section, color of different portions, adhesions to periosteum or cranial bones, etc. Most common pathologic conditions are wounds, hemorrhages, wens, lipoma, squamous-celled carcinoma, syphilis, tuberculosis, favus, pediculi, tricophytia, angioma and round- and spindle-celled sarcomata. The temporal muscles should be examined for hemorrhages, œdema, purulent inflammations and trichinæ. The postmortem hypostasis of the back of the head should not be regarded as pathologic.

2. Periosteum. Subperiosteal hemorrhages, purulent infiltrations, adhesions, indurations, chronic inflammation with new-formation of bone, and neoplasms are the most common pathologic conditions.

3. Skull-Cap. The measurements (circumference, 49-65 cms.; long. diam., 18 cms.; trans. diam., 13-15 cms.), form, asymmetry, character of surface (normally smooth and moist), color of cranial bones, character of sutures and fontanels (easily traced?), supernumerary sutures and bones, consistence (softened in craniotabes, purulent inflammations, syphilis, neoplasm), new-formations of bone, perforations (syphilis, neoplasms, Pacchionian granulations, purulent inflammation), elevations, depressions, fractures, areas of erosion or absorption, thickenings of external surface (crater-like due to organized cephalhæmatoma, chronic periostitis, neoplasm or gumma), radiating scars or indurations (syphilis), red, soft, spongy thickenings (rachitis). The temporal and frontal regions are most frequently the seat of syphilitic (corona veneris) and rachitic changes (frontal and temporal bosses, square forehead, etc.) Note ease or difficulty in sawing, relation of external table, diploë and inner table, measure thickest and thinnest portions, character and amount of diploë, weight of skull-cap (heavy in sclerosis, light in atrophy), dural adhesions, examine by transmitted light (color, blood-content, presence of pus in diploë may be shown by greenish or yellow color), smooth or rough inner table, erosions (rough, more or less reddened), grooves of meningeal vessels, Pacchionian erosions, hyperostosis, exostosis, osteoma, osteophytes (not uncommon in pregnant women, also in hydrocephalus, acromegaly), atrophy (old age, craniotabes, hydrocephalus), sclerosis (syphilis). In marked cachexias (cancer of stomach) the inner table often shows a high degree of erosion and atrophy.

4. Dura. Collections of pus may be found between skull-cap and dura in purulent inflammations of scalp or diploë. Rupture of middle meningeal artery or its branches, with or without fracture of the skull, gives rise to hemorrhagic extravasations in same location. Old hemorrhages may be partly organized. In young infants the dura is adherent to the skull-cap and cannot be separated. In youth and adult life it is adherent only along the longitudinal sinus and about the blood-vessels; in old age it becomes more adherent. Extent, location and strength of adhesions should be noted. The normal dura should be grayish-red, smooth, symmetrically stretched, so that a small fold only can be taken up by the fingers in the frontal region, and just translucent enough to show the outlines of the convolutions and the pial vessels. An increased tension is caused by exudates, tumor, abscess, hydrocephalus, hemorrhage, congestion, œdema, etc. Diminished tension occurs in atrophy of the brain, especially marked in the frontal region, where the dura may be wrinkled and loose. Perforations of the dura by Pacchionian bodies are very common along the longitudinal sinus in late life, and should not be regarded as pathologic. Small osteomata are not uncommon in the same place and in the falx; they may be very numerous in acromegaly, late syphilis and cachectic conditions. Changes in the color of the surface of the dura may be due to hemorrhage, purulent or syphilitic inflammation, old thickenings, etc. Thickenings are more easily seen from the inside surface of the dura; they appear as hard, tendon-like, opaque areas. The normal inner surface is smooth, grayish and moist-shining. In pachymeningitis it may be dry, dull, roughened, and covered with blood, pus or fibrin. The most frequent pathologic condition on the inside of the dura is the organizing or encapsulated hemorrhage (pachymeningitis hæmorrhagica chronica, hæmatoma duræ), so common in chronic alcoholics. Miliary tubercles of the dura are common in meningeal tuberculosis. A gummatous pachymeningitis is not infrequent in late syphilis. Pachymeningitis fibrosa is also common in old syphilitics. Actinomycosis occurs in connection with actinomycotic encephalitis. The primary tumors of the dura are fibroma, osteoma, fibro-endothelial tumors (psammoma) and angiosarcoma, etc. Secondary carcinoma or sarcoma is rare.

5. Longitudinal Sinus. Character of walls and contents. Thrombosis, with purulent or gangrenous inflammation, is the most important condition. Note mouths of superior cerebral veins.

6. Meningeal Vessels. Note grooves, rupture, thrombosis, hemorrhage, infection, amount of blood, symmetry of distribution, etc. Traumatic rupture of middle meningeal is the most important condition.

7. Basal Vessels. Anomalies in size and distribution, thickness and character of vessel-walls (sclerosis, atheroma, aneurism, calcification). Thrombosis, embolism, aneurism, sclerosis, atheroma, calcification, obliterative endarteritis due to syphilis, are the most common conditions. The changes in the middle cerebral arteries are of especial importance in cases of apoplexy, softening, etc.

8. Inner Meninges. The arachnoid, subarachnoid space and pia are usually considered together. The arachnoid bridges over the sulci, the pia dipping down following the brain substance. The contents of the subarachnoideal space are best seen, therefore, between the convolutions. The inner meninges are gray, delicate and transparent; the pial veins show plainly, the arteries are empty and lie deeper, while the more superficial veins are uniformly filled with blood. Sclerotic arteries run more superficially and are more prominent. The removal of the skull-cap often gives rise to the presence of air-bubbles in the pial vessels, and this should not be mistaken for any pathologic condition. Hypostasis likewise should not be regarded as a pathologic condition. Normally the membranes are moist; in increased intracranial pressure (tumors, hydrocephalus, hemorrhages) they are dry and dull. Inflammation is shown by a loss of transparency of the membrane and by the presence of exudate in the subarachnoideal space. Old thickenings are white and opaque. The amount of fluid in the subarachnoideal space may be so great as to cause the arachnoid to bulge out over the sulci. Note character of exudate (purulent, fibrinous, serous or hemorrhagic). In purulent meningitis greenish-yellow or yellowish-white collections of thin pus are found in the meshes of the arachnoid; in fibrinous inflammation the exudate is grayish or milky white. The normal fluid (cerebrospinal) of the subarachnoideal space is clear and small in amount. It is increased in œdema and congestion, as well as in serous inflammations. In inflammatory conditions the membranes are dull and cloudy and the fluid more or less turbid. Pathologic adhesions may exist between dura and inner meninges, and between the latter and the brain-substance. In the latter case the meninges do not strip easily, but pull off portions of the cortex. Over tumors, gummata, areas of softening, the meninges may be so adherent that they cannot be separated from each other. In old syphilitics, alcoholics, cachexias of old age, etc., the pia may be thickened, white and opaque (leptomeningitis chronica fibrosa). Aneurisms of the pia vessels are of great importance in cases of meningeal hemorrhage. They may be very small (size of pea) and often are found only after very careful search. Atheroma, infective emboli, etc., are also causes of meningeal hemorrhage. Meningeal tubercles are very common and often hard to recognize. They are usually best seen over the basal meninges. Often they can be demonstrated by stripping off the meninges and floating the membrane in mercuric chloride or formalin fixing-fluids. After a few minutes’ fixation the tubercles appear as minute grayish or opaque points, the membrane often appearing as if sprinkled with fine sand or powder. The Pacchionian bodies of the arachnoid must not be mistaken for tubercles. They are grayish in color, and most abundant along the longitudinal sinus. The meninges over the two hemispheres should be compared as to transparency, thickness, blood-content, amount of fluid in arachnoideal space, etc.

The most important pathologic conditions of the inner meninges are anæmia, hyperæmia, stasis (asphyxia), œdema, hemorrhages (stasis, anthrax, aneurism, atheroma, infective emboli), serous, purulent and fibrinous inflammation (pyogenic cocci, bacillus pneumoniæ, pneumococcus, bac. coli, diplococcus intracellularis), chronic leptomeningitis (syphilis, alcoholism, toxæmia, etc.), tuberculosis, syphilis (gummatous meningitis), blastomycosis, actinomycosis and neoplasms. The last named are not common. Cholesteatoma, hæmangioma, lymphangioma, endothelioma, fibroma, osteoma and lipoma represent the benign tumors found here. Primary sarcoma is the most common tumor, usually angiosarcoma, perithelioma, cylindroma, round-cell-, spindle-cell- or myxosarcoma. Secondary sarcoma and carcinoma occur. Animal parasites are cysticercus and echinococcus.

8. Cerebrum. Weight of brain as a whole 1,200-1,400 grms. (15-50th year). Cerebrum averages 1,039 grms. in the female, 1,155 grms. in the male. A weight of 1,100 grms. may be taken as the minimum normal, and 1,700 grms. as the maximum for the brain as a whole. The relation of the brain-weight to that of the body is 2-100. In old age there is a loss of weight. Sagittal diameter 15-17 cm., transverse 14, vertical 12.5 cm.

Examine the convexity, comparing hemispheres, noting convolutions and sulci (size, number, symmetry, etc.) Atrophy of the gyri is shown by increased width of sulci and the narrower, sharper gyral apex. With increased intracerebral pressure the gyri are flattened and broader, and the sulci smaller. Note color and consistence of cortex, adhesions with pia, areas of fluctuation, induration, depressions, yellow softening, recent and old hemorrhages, effects of trauma, tumors, tubercles, gummata, etc. Examine median surfaces, note arching of corpus callosum. On section of the brain note color (pale in anæmia, red in capillary hyperæmia; hemorrhages, areas of softening, tumors, tubercles, gummata, sclerotic areas, abscesses, etc., all show color variation from the normal gray or white); consistence (soft in degeneration and abscess, hard in sclerosis), moisture (normally is moist-shining; moisture increased in œdema, inflammation, abscesses, soft tumors, recent degenerations; dry in old caseous tubercles and gummata, and in anæmia), blood-content (number of bleeding-points, distinguish from punctate hemorrhages), character of cut surface (normally smooth, sclerotic areas, abscesses and areas of softening are uneven and depressed, hard tumors and sclerotic blood-vessels are elevated above the surface). The absolute and relative size of cortex and medulla, and the distinctness of the boundary between them, should be noted.

Hemorrhages may occur in any part of the brain, and may be large or small. Rupture into a ventricle is always fatal. The large hemorrhages are due to rupture of a diseased artery; small punctate hemorrhages throughout cortex are usually embolic (fatty embolism). Old hemorrhages are brownish in color (pigment). Areas of softening are usually the result of embolism, thrombosis or sclerosis. They are usually yellow, yellowish-white or brownish-yellow or red.

9. Ventricles. Contain about a teaspoonful of clear fluid. This may become purulent, cloudy, hemorrhagic, fibrinous. Note size of ventricles and horns. (Fluid increased and ventricles dilated in hydrocephalus.) Character of ependyma normally gray-red, delicate; may be pale or red, indurated, thickened, roughened (chronic ependymitis), hemorrhagic, etc. Compare floors of lateral ventricles as to symmetry (corpus striatum large in hemorrhages), color, etc. Adhesions are found most frequently in posterior horns. A fine granulation of the ependyma is caused by miliary tubercles. Large solitary tubercles may be found in the ventricles. Do not mistake postmortem softening of ependyma for pathologic changes. In the third ventricle note the presence of any abnormal contents, character of wall, symmetry of corpora quadrigemina, etc. Look for same changes in fourth ventricle as in lateral. Lining is gray-white and delicate; floor should be gray-white, firm, and show anatomic structures. Gray sclerotic areas are often present in floor. Solitary tubercles, tumors (glioma, neuroepithelioma, gliosarcoma, sarcoma), dermoids and cysticercus-cysts may be found here. Examine aqueduct of Sylvius for abnormal contents.

10. Chorioid Plexus. The tela chorioidea is normally delicate and translucent. Note color (red, pale, cloudy), swelling, purulent infiltration, condition of blood-vessels, tubercles, etc. Psammoma, sarcoma, papillary epithelioma, carcinoma, fibroma, angioma, cholesteatoma, cysticercus and echinococcus may be found in the tela and plexus. Cysts due to œdema are very common, also aneurismal dilatations of the vessels. In cases of hydrocephalus the veins of Galen should be examined for thrombi or compression from without. In acute hydrocephalus the plexus is deep red; hyperæmic, its vessels distended with blood.

11. Pineal Gland. The most common pathologic findings are: psammoma, adenoma, teratoma, sarcoma, formation of cysts (hydrops cysticus glandulæ pinealis), hypertrophy, abscess (purulent meningitis), metastatic tumors. In all cases of giantism especial attention should be paid to the pineal gland as well as to the hypophysis.

12. Cerebral Ganglia. Color, consistence, moisture, blood-content, hemorrhage, degeneration, sclerosis.

13. Peduncles. As above.

14. Cerebellum. Cerebellar cortex is 2 mm. thick, grayish-red in color. Note irregularities in thickness, color, consistence, blood-content, moisture. Compare hemispheres. White substance should be shining and moist. Abscesses, tubercles (solitary or conglomerate), gummata and neoplasms are the most common pathologic conditions.

15. Pons. Consistence firm normally. Note blood-content, relation of white and gray stripes, hemorrhage, degenerations, cysts, neoplasms, etc.

16. Medulla. Color grayish-white, consistence firm. Note blood-content, hemorrhages, degenerations and cysts (syringomyelia).

17. Hypophysis. Cysts are common, also calcareous concretions. Adenomatous hyperplasia is the most common tumor (acromegaly, obesity). Carcinoma, sarcoma, lipoma and teratoma are rare. Gumma and tubercle occasionally occur; even when the gland is wholly destroyed, acromegaly does not result. Epithelial tumors of the infundibulum may occur in association with hypoplasia of the genitals. In diseases of the thyroid the condition of the hypophysis should be especially considered.

18. Basal Sinuses. Note contents (marantic and infective thrombi), especially in middle-ear disease and meningitis. Distinguish postmortem clots from thrombi, the former being dark-red, soft and moist, and are not adherent to the walls. The walls of the sinus should be gray, delicate, and shining.

19. Basal Dura. Note same conditions as in dura covering convexity.

20. Cranial Nerves. Examine and trace to exits. Note atrophy, degenerations, compression, indurations, thickenings, neoplasms (neuroma), etc.

21. Base of Skull. After the removal of the basal dura the bones of the base should be smooth and gray-yellowish-red in color. Look for fractures, caries, roughened areas, exostoses, collections of pus, hemorrhage, neoplasms, etc.

The most important pathologic conditions of the brain are congenital defects or malformations (hydrocephalus, microcephalus, etc.), anæmia, hyperæmia, œdema, hemorrhage (traumatic, spontaneous, capillary, apoplexy), embolism, thrombosis, arteriosclerosis, aneurism, anæmic infarction, encephalomalacia (white, yellow and red softening), pigmented scars, atrophy, secondary degeneration, encephalitis, (non-purulent, purulent, hemorrhagic, syphilitic, metastatic, chronic), sclerosis (diffuse, disseminated, focal, hypertrophic), tuberculosis, syphilis, actinomycosis, blastomycosis, rabies, primary neoplasms (glioma, neuroglioma ganglionare, angiosarcoma, spindle-cell sarcoma, polymorphous-cell sarcoma, perithelioma, endothelioma, angioma, myxoma, fibroma, osteoma, teratoma, lipoma), primary epithelial tumors of ventricles, pineal gland and hypophysis (adenoma, cholesteatoma, papillary epithelioma, carcinoma), metastatic tumors (all forms of carcinoma and sarcoma, malignant chorio-epithelioma), cysts, parasites (cysticercus, echinococcus) and traumatic lesions (commotio cerebri, contusio cerebri, hemorrhage, red softening, puncture and shot-wounds, infected wounds, traumatic abscess). Especial examination of the brain should be made in all cases of acromegaly, epilepsy, cretinism, congenital idiocy, degeneracy, criminal tendency, insanity, chorea, caisson disease, locomotor ataxia, paralysis agitans, syringomyelia, spastic paralysis, infantile paralysis, hereditary ataxia, rabies, all forms of paralysis, motor or sensory disturbances and neuritis.

3. POINTS TO BE NOTED IN EXAMINATION OF EYE.

The fat-tissue in the orbits should be yellowish-white; from it the red muscles and the white nerves should be easily distinguishable. On section of the eye-ball the vitreous normally is clear and the retina uniformly grayish-black and smooth. The most common and important conditions to be looked for are phlegmonous inflammations, purulent panophthalmitis, orbital hemorrhage, thrombosis of ophthalmic vein and sinus cavernosus leading to pachy- and leptomeningitis, neoplasms of orbit, wall of orbit, eye-ball or lachrymal gland (melanosarcoma, glioma, gliosarcoma, neuroepithelioma, various forms of sarcoma, angioma, lipoma, adenoma, carcinoma), affections of individual muscles (myositis, atrophy), atrophy of optic nerve, choked disk, retinitis, choroiditis, iritis, glaucoma, etc.

4. POINTS TO BE NOTED IN EXAMINATION OF EAR.

Note condition of scalp (hyperæmia, œdema, hemorrhage) about ear, condition of external canal (dry, moist, character of contents), condition of periosteum, particularly over the mastoid process (normally grayish-red), condition of bone after removal of periosteum (normally smooth). Inflammatory œdema, purulent infiltrations in the soft parts, collections of pus beneath the periosteum, roughness of bone beneath elevated periosteum, presence of pus or blood in external auditory canal, perforations of drum, etc., should be noted. Normally the drum should be grayish-white and shining. Note contents of middle ear, Eustachian tube, condition of ossicles, mastoid cells and bone. Lining of middle ear should be grayish-red and smooth; the cut edges of bone should be uniformly grayish-red. When infiltrated with pus they are brown or greenish. The mucous membrane is deep-red or greenish in purulent inflammation; yellow, creamy pus, often of very offensive odor, may be found in middle ear, Eustachian tube or external canal. Note character of perforations; old ones have smooth and thickened edges. The most important pathologic conditions are: otitis media purulenta, inflammation of mastoid cells, caries of mastoid process, sinus-thrombosis (leading to meningitis or pyæmia), otitis media tuberculosa, granulomatous polypi, cholesteatoma, sclerosis, congenital anomalies, foreign bodies, parasites, neoplasms (chiefly of external ear).

5. POINTS TO BE NOTED IN EXAMINATION OF NOSE.

The normal mucosa of the nasal tract is light grayish-red. Note character of contents of the cavities (mucus, blood, pus, dry clots or scabs), congestion, hemorrhage, erosions, ulcerations, diphtheritic membrane, diffuse or localized thickenings of the mucosa (polypi), adenoids, exostoses, caries, foreign bodies, parasites (maggots) and neoplasms (sarcoma, fibroma, carcinoma). The most important conditions are acute and chronic catarrhal inflammations, ozæna, croupous or diphtheritic inflammations, syphilis, atrophy or hyperplasia of the mucosa, polypi, and more rarely tuberculosis. Syphilis causes inflammations and gummatous infiltrations of the mucosa, gummatous periostitis, foul-smelling necrosis of the bony portions (ozæna syphilitica). Dense hard fibromata developing from base of skull may fill up the nasopharynx or erode the cranial base and press upon the brain. Softer sarcomatous growths may arise from the hypophysis, or from the lymphoid tissue of the mucosa. Squamous-celled carcinoma is not infrequently primary in the antrum and thence invades the nose. Primary malignant tumors of nasal tract not common. Leprosy, glanders, blastomycosis, and rhinoscleroma are more rarely seen.