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.
CHAPTER VII.
MAIN INCISION: THORAX AND ABDOMEN.
I. METHOD OF OPENING TRUNK.