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.