3. Abdominal Cavity. Watch carefully for the escape of gas when the first cut through the peritoneum is made. A lighted match may be held over the opening, or the skin incision may be filled with water and the peritoneum opened through the water, noting the escape of bubbles. The odor (sour, sweetish, yeasty, fécal, putrid, etc.) should be noted. Abnormal contents of the peritoneal cavity are to be measured and described as to color (amber, greenish-yellow, color of bile, red, bloody, brown, gray, creamy, milky, opalescent, etc.), consistence (thin, clear, watery, serous, pea-soup-like, gruel-like, creamy, jelly-like, colloid, semi-solid, etc.), odor (fécal or foul, due usually to the presence of the colon bacillus; acid or yeasty in perforation of stomach; fruity in diabetes, acute hemorrhagic pancreatitis; odor of ether, chloroform, alcohol, etc.), contents (blood, bile, féces, stomach-contents [distinguish perforations due to postmortem digestion], fibrin, fat, chyle, pus, foreign-bodies, mucin or pseudomucin, parasites) and reaction (acid, alkaline). Non-inflammatory ascites occurs in portal stasis, hepatic cirrhosis, thrombosis or compression of portal or splenic veins, chronic passive congestion, chronic valvular lesions with incompensation, nephritis, severe anæmia, obstruction or rupture of thoracic duct, etc. The fluid of transudates is usually clear, odorless, alkaline, low specific gravity (below 1.016), small albumin- and fibrin-content, few flocculi, and relatively small number of white cells. Inflammatory exudates are turbid, often foul-smelling, usually acid, specific gravity over 1.016, high albumin-, fibrin- and urea-content, numerous thick flocculi and numerous cells. In early peritoneal tuberculosis the fluid may be clear and resemble that of a transudate. Milky and opalescent fluids are found in diabetes, lipæmia, new-growths of the peritoneum, obstruction or rupture of thoracic duct or receptaculum. Hemorrhagic exudates may be traumatic (rupture of spleen, liver, intestines, extra-uterine pregnancy, etc.), inflammatory (severe acute peritonitis), or due to new-growths or tuberculosis of the peritoneum, extreme portal stasis, perforation of gastric or typhoid ulcers, severe intoxications, chronic icterus, etc. Red effusions may be due to diffused hæmoglobin. In such cases there is no settling of the color, and coagulation may not occur. When red cells are present settling takes place on standing. Rupture of gall-bladder or bile-ducts may lead to presence of free bile in the peritoneal cavity. Postmortem diffusion of bile through the gall-bladder wall should not be mistaken for a pathologic condition. In normal conditions there is just enough fluid in the peritoneal fluid to make the surfaces moist, and about a teaspoonful in all may be collected from the flanks and pelvis. The amount may be greatly increased just before death in all cases of slowly progressive cardiac weakness. Note character of peritoneum (normally moist-shining, grayish, translucent, cloudy, dry, lustreless, thickened, hyaline (“iced” or “Zuckerguss”) in chronic inflammation.)
4. Omentum. Note position of lower border, amount of fat, condition of blood-vessels, dry or moist-shining surface, adhesions (to appendix, cæcum, oviducts), indurations, contractions (edges rolled up), character of lymphnodes, cysts, tubercles, secondary tumors, snared-off tumors from ovary or uterus (parasitic cysts, fibroids), encysted foreign bodies, etc., exudates on surface, fat-necrosis, accessory spleens, encysted parasites, hernia, etc. Most common pathologic conditions are inflammation (secondary to appendicitis, salpingitis, etc.), metastic carcinoma and tuberculosis.
5. Position of Abdominal Organs. Note situs viscerum inversus, gastro-enteroptosis, displacements due to spinal curvatures and deformities, and hernia, anomalies or malformations, locate organs by usual landmarks (edge of ribs, ensiform, umbilicus, etc.), position of lower and left borders of liver, gall-bladder, spleen, pylorus and fundus of stomach, appendix, colon, etc. Malposition of transverse colon especially common. Note volvulus, ileus, invaginations, etc. Examine stomach and intestines carefully for perforations. Differentiate postmortem perforations and those due to pathologic conditions. (Edges of postmortem perforations soft, slimy, without evidences of disease.) The appendix should also be carefully examined at this time. Note also peritoneal surface (color, thickness, translucency, tubercles, adhesions), color and blood-content of all abdominal organs before acted upon by exposure to air. In the female examine pelvic organs. Do not mistake postmortem perforations of stomach or intestine, postmortem imbibition and diffusion of bile in region of gall-bladder, postmortem contraction of intestines, dilatations of lymphatics with lymph or chyle, agonal transudates, accessory spleens, etc., for pathologic conditions.
6. Position of Diaphragm. Normally fourth rib or interspace on right, fifth rib on left, higher in the young, lower in old age. Raised in conditions of increased abdominal pressure (pregnancy, ascites, enlargement of liver or spleen, subdiaphragmatic abscess, dilatation of stomach, urinary or gall-bladder, tumors of any abdominal or pelvic organ, especially ovarian cysts, etc.), low in increase of intrathoracic pressure (pleuritic effusions, pneumothorax, pericardial effusion, hypertrophy of heart, tumors, aneurism, etc.).
7. Mammae. Condition varies according to age, pregnancy, lactation, etc. In resting glands the structure is lobulated, connective-tissue white with yellow fat between; in the white connective-tissue are small grayish-red nodules of gland-tissue (“breast-grains”). During lactation the fat disappears entirely or to a large extent, the entire organ consisting of a more homogeneous grayish-white glandular tissue, distinctly granular on section, and resembling the section of a salivary gland. Note size of ducts, presence of secretion (colostrum or milk) on pressure, congestion, œdema, abscess, fistula, caseous tubercles or gummata, cysts (milk, “soap,” “butter,” senile, new growths), neoplasms, atrophy, hypoplasia, hypertrophy, accessory nipples, parasites (echinococcus). The most common tumors are adenofibromata and carcinomata. Tuberculosis is not rare. In the male breast hypertrophy has been noted in association with malignant chorio-epithelioma of the testis; and in the female with pseudopregnancy and tumors of the genital tract. Adenofibroma, gumma and tuberculosis are the most common conditions of the mammæ in males.
8. Costal Cartilages. Note color (ochronosis), degree of ossification, anomalies, separations, fractures, caries, tuberculosis, alteration in shape (pigeon-breast, emphysema, Pott’s Disease, erosions of tumors or aneurisms, rickets, etc.). The costochondral edges are thickened as a result of rachitis (rachitic rosary). In old age the costal cartilages may undergo the so-called “asbestos-like” degeneration, becoming yellowish- or grayish-brown, streaked with shining whitish granules, with calcification or ossification and new-formation of blood-vessels. Degeneration cysts (senile) are not infrequent, and the cartilages sometimes appear as if soaked with oil, soft and translucent. Fibroid or calcified areas may be present. Spaces and clefts within the cartilage may be filled with new-formed bone-marrow.
9. Sternum. Note shape (pigeon-breast, “shoemaker’s,” rounded, scaphoid, bifid, anomalies of ensiform, etc.), fractures (in marked osteoporosis the bones may break during removal), erosions (aneurisms, tumors), tuberculous and syphilitic caries, gummata, perforations, etc. Under surface of sternum should be smooth, shining, translucent and grayish. In chloroma the under surface may present a uniform greenish layer ½-1 cm. thick. Bone-marrow of sternum is normally red and lymphoid in character; may be green in chloroma, pyoid in leukæmia, hyperplastic in severe anæmias. Sclerosis and osteoporosis of sternal bones are not rare. In the former condition the marrow may be entirely absent; in the latter hyperplastic.
CHAPTER VIII.
THE EXAMINATION OF THE THORAX.
I. METHODS OF EXAMINATION.
1. Thoracic Cavity. As soon as the sternum is removed the anterior mediastinum and the pleural cavities are examined, noting first the position and relation of the thoracic organs, quantity and character of mediastinal fat, the contents of the pleural cavities, pleuritic adhesions, etc. Pleuritic exudates should be removed before they have become mixed with blood from the cut vessels or heart; and the pleural surfaces should be examined before their appearance has been changed by exposure to the air or to fluids. Pleuritic adhesions should be broken or cut, beginning with the left side and then on the right, and the entire surface of both lungs wholly freed.