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.

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, H₂S, 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.