ear as far as the neck, and then to dissect off the integument forward after subcutaneous division of the external ear. (a.) The Parotid Gland. The most common affection of this gland is interstitial inflammation and suppuration (suppurative parotitis'), in THE FACE. 83 which affection the connective tissue surrounding the lobules becomes infiltrated with pus, and may even be converted into abscesses into which the lobules project. <Callout type="warning" title="Warning: Infection Risk">Infections can spread rapidly; treat promptly.</Callout> The salivary glands in general and the parotid in particular, are not infrequently the seat of encJiondromata or myxochondromata^ which are recognized by their cartilaginous appearance, and by the presence of disseminated gelatinous spots which acquire a whitish opacity on the addition of acetic acid. That peculiar new formation which has received the name of cystosarcoma^ is also found here. Its cut surface looks very much like a transverse section through a cabbage head, and the papillary growths can easily be extracted from the cavities which they fill out more or less completely (vide Cystosarcoma of the Breast). (J.) The Bones of the Face. If it be necessary to examine the maxillary bones also, a new incision must be made from behind the ear along the depression between the neck and the under jaw ; the reason for choosing this situation is to avoid any injury to the face. There are independent affections of the maxillary bones as well as those which they share in common with neighboring parts ; we have already mentioned, for instance, that epithelioma of the lip sometimes involves the lower jaw. The independent affections are chiefly new formations of various kinds, and are very apt to come under the surgeon's knife. The most common varieties are carcinoma and fibro- ma, both of which are more common in the upper jaw ; cystoid disease, starting generally from a tooth-germ, sometimes from a fibroma ; and sarcoma, especially giant-cell sarcoma, in this situation known by the name of epulis. A peculiarity of this latter growth is that it often becomes brownish in color on exposure to the air. Microscopically it is composed of round and spindle cells, between which enormous many-nucleated giant cells are often found : these can be readily isolated in needle preparations, and generally present numerous irregular notches and processes of variable size on the periphery. The above named tumors often 84 DIAGNOSIS IN PATHOLOGICAL ANATOMY. spring from the antrum, which they may gradually fill out and distend, thus giving rise to great deformity of the face. Passing mention must also be made of periostitis and necrosis, so often met with in the lower jaws of those whose employment brings them in contact with phosphorus ; and of the inflammatory processes (periostitis) which may originate from the teeth, and are included under the term parulis. 13. THE NASAL CAVITY. Thorough examination of the cavity of the nose is only possible after removal of the ethmoid bone and the parts which are attached to it. To do this the bone must be sawn through on either side of the ethmoid from the great occipital foramen as far as the frontal bone, and then these two saw-tracks should be united anteriorly by a third. If only the mucous membrane of the anterior nares is to be examined, this may easily be done by separating the upper lip from its bony attachments, and then cutting away as much of the cartilaginous septum and of the sides as may be desired. A rare but important affection, the chief seat of which is the mucous membrane of the nose, is glanders. This is characterized by inflammation which may be more or less intense and even hemorrhagic ; also by the presence of small uniformly yellow nodules, and ulcers with yellow, somewhat transparent base, and scanty secretion ; the ulcers increase in size and become confluent by the breaking down of nodules which are often present in their edges. Gummy formations occur both in the mucous membranes and the nasal bones, and by destroying the septum and the nasal bones may cause the nose to fall in near its root. The chief new formations which occur in this situation are polypi of the nose, so called. Some of these are due to hypertrophy of the mucous membrane — mucous polypi — while others are firm fibromata, and may arise from the base of the skull ; in this case they are called naso-pharyngeal polypi. The mucous membrane of the nose participates in many THE EYES. 85 affections of the throat — diphtheritis, for instance ; but not in any peculiar manner. 14. THE EYES. The daily increasing importance which is assumed by changes in the eyes, not only for their own sake, but also for the sake of their diagnosis during life, renders it often desirable to examine the retina and choroid, at least. This can easily be done without injuring in any way the external portions of the eye, by removing the roof of the orbit with the mallet and chisel from the inside of the skull ; the orbital fatty tissue and the muscles are then to be removed, and the globe to be drawn backwards, when the posterior half should be cut through with the scissors. The anterior portion of the globe, which is left behind, may be kept in place by plugging the orbit, and thus all deformity be avoided. If one does not happen to have a mallet and chisel at disposal, the bone scissors generally serve the same purpose. (a.) The important changes which take place in the papilla of the retina can be seen better with the ophthalmoscope during life than after death, but the degree of fullness of the vessels, the size and number of hemorrhages, if present, and the presence of those white spots which are due to fatty degeneration of the tissue, and occur in retinitis albuminurica, are all easily seen in the retina after its removal. Hemorrhages are almost always present in ulcerative endocarditis, often in chronic nephritis, basilar meningitis and other affections of the brain. The retina is so transparent that a preliminary microscopic examination is easily made by spreading out a bit of it in water, or, better still, in the aqueous humor. (5.) The condition of the choroid which is of greatest interest to the practicing physician, is the presence of tubercles., which appear as small, gray nodules projecting into the cavity of the eyes ; they also are readily prepared for the microscope by simply spreading out the membrane after having brushed off the pigment epithelium, which, indeed, should be done before the microscopic examination, in order to avoid being deceived by small yellow spots which are due merely to defects in the pigment. In ulcerative endocarditis we almost always find, both in the retina and choroid, minute metastatic foci of inflammation which look very much like tubercles ; their centre is occupied by a collection of micrococci, which may be brought out more clearly by the addition of glacial acetic acid. For a description of the other changes which are met with in the eye, and are of less general interest, the reader is referred to the text books of ophthalmology. (c.) The most important modification of the optic nerve is gray atrophy., which, as the name indicates, consists in a diminution in size, and a change from the normal white color to a transparent gray. The atrophy is seldom uniform, but the nerve is generally flattened or ribbon-like, and the degeneration may be either complete or partial. As in the spinal cord, one may be deceived as to the color, unless great care is exercised. In some cases of hemorrhage at the base of the brain I have found effusion of blood between the nerve and its sheath. 15. THE INNER EAR. It is but seldom that the inner ear presents conditions which are of interest to the general practitioner ; but if an examination be desired, it may be made as follows : The whole petrous portion should be separated from its attachments by two saw-cuts which come together in the sella turcica, and it may then be removed from its place, put into a vise, and sawn through from the posterior border of the external, to the anterior or inner border of the internal, auditory canal. The internal parts are thus laid open, and the drum membrane left nearly intact. In the anterior portion maybe seen the tympanic cavity and the external canal; in the posterior the vestibule, the posterior wall of the tympanic cavity with the fenestrae, etc. The stapes is generally left in place, the cochlea is divided in the middle, and the anterior portion of the mastoid cells laid bare. An admirable view of THORAX AND ABDOMEN. 87 the inner ear may be obtained by removing the roof of the tympanic cavity, which is easily done with either bone scissors, or mallet and chisel.^ Caries is almost the only affection for which it is necessary to examine the inner ear. We have already alluded to the disastrous effect which this affection sometimes has on the membranes of the brain, the brain itself, and the transverse sinus. Varying with the duration and intensity of the process, more or less extensive mischief is to be found ; such as perforation of the drum membrane, or enlargement of the tympanic cavity and vestibule, and the formation of a large cavity containing the ossicula freed from their attachments ; or a considerable portion of the bone — the cochlea, for instance — may have become necrotic, and more or less completely detached by peripheral inflammation. It is in those who are predisposed to scrofula and tuberculosis — and above all in children — that these changes are generally found, though chronic catarrh may also result in caries ; in the latter case the mucous membrane of the tympanic cavity, which normally is extremely thin, is very much thickened, covered with granulations, and contains masses of a dry whitish substance (cholesteatoma, so-called) consisting of desquamated epithelial cells which have become cornified. III. THE THORACIC AND ABDOMINAL CAVITIES. The usual method of opening the neck and the thoracic and abdominal cavities is by means of a single long incision, extending from the chin to the symphysis pubis, and passing to the left of the umbilicus ; this incision should be made with the belly of the knife rather than the point, the latter being apt to penetrate too deeply and cause mischief. At the root of the neck, where there is generally a more or less deep depression, especially in thin subjects, it is well to put the skin on the stretch with the thumb and forefinger of the 1 Eor more minute directions the reader is referred to Prof. Lucae's article, Klebs' Handbuch der Pathologischen Anatomie, 1, 12. 88 DIAGNOSIS IN PATHOLOGICAL ANATOMY. left hand. Over the thorax the incision should be made at once completely down to the bone, but over the abdomen only into the muscular layer. The right flap should then be grasped firmly below the ensiform cartilage, the abdominal wall drawn upwards, and a small incision made with care completely through the still undivided tissues into the peritoneal cavity. In thus opening the peritoneum any escape of gas — as evinced by a hissing noise — or of fluid should be noted. Two fingers should then be introduced into the cavity one after the other, the wall drawn away from the viscera and, the fingers being spread apart like the arms of a V, the incision prolonged between them as far as the symphysis. In order to get more space for working, it is well to sever subcutaneously the attachments of the recti muscles to the pelvis, especially if cadaveric rigidity is still present. In new-born children the surroundings, contents, and walls of the umbilical vessels are first of all to be carefully examined. In order to do this conveniently, and at the same time to alter the relative position of the parts, as little as possible, a second cut should start from the main incision a little above the umbilicus, pass round the other (right) side of that point, and join the main incision, again a little below that point, thus separating it completely from the rest of the anterior abdominal wall. The vein and ligamentum teres can then be examined and divided, and the arteries may afterwards be followed up by turning downward the flap which lies between the two incisions. The pathological conditions which are found here are chiefly of inflammatory origin, and occur generally in the children of mothers who are the subjects of puerperal disease. In umbilical arteritis the walls are thickened and the vessels filled with a puriform mass, which is often limited by a healthy thrombus near the urinary bladder. Thrombophlebitis and periphlebitis derive their importance chiefly from their connection with the portal vein and liver, and will be treated more in detail in another place. THORAX AND ABDOMEN. 89 First on one side and then on the other, the abdominal wall is now to be lifted and drawn tight over the margin of the ribs, and a long incision, reaching from the ensiform cartilage to the eleventh rib, made completely through the muscles. Now, with the thumb of the left hand on the cut surface, and the fingers on the external integument, after having divided the anterior attachments of the muscles, the soft parts are to be drawn away forcibly from the ribs and the submuscular tissue which is thus made tense, cut through in long sweeping incisions. The cuts should always be made where the tension is greatest, and begun with the heel of the knife. As a general thing it is not necessary to dissect off the soft parts farther than the junction of the cartilaginous with the bony portions of the ribs ; but this may be done if it is desired to examine the mammary gland from behind, or if external inspection has given grounds for suspecting the presence of changes beyond this line. In the neck, only the superficial muscles are to be dissected off with the skin, and in cutting the lower attachments of the sterno-mastoid muscles, care is to be exercised not to injure the great vessels. I. THE SOFT PARTS. As in the skull, so here, the soft parts are to be first examined. (a.) The thickness of the panniculus adiposus can be more accurately estimated now than during external inspection ; its color becomes deeper and sometimes orange or reddish-yellow, when it is the seat of atrophy. Its most important modifications have been already described in connection with the skin. (5.) The muscles of the neck, thorax, and abdomen are next to be examined, and 1. Their General Characteristics, such as size, color and consistency, noted. Atrophy of the muscles, which may reach its highest degree on the thorax, has been already described ; the color of healthy muscle is a deep red, but in angemic and emaciated subjects it becomes pale, or even grayish-red, and in some diseases — typhoid fever, for instance — is very dark red. In typhoid fever, acute mania and some other affections, the muscles of the abdomen, in particular, sometimes present a grayish, semi-translucent appearance. The consistency usually stands in a direct ratio to the color ; pale muscles are generally flabby, dark muscles firm and hard. The cut surface is sometimes very dry and dull — as in typhoid fever, again — sometimes very moist and oedematous. 2. Special Morbid Conditions. (a.) Hemorrhage is not uncommon and may be due to injury, the application of cups, etc. Extensive hemorrhage sometimes occurs in the abdominal muscles, and particularly in the recti in typhoid fever (hematoma recti abdominis). <Callout type="warning" title="Warning: Risk of Infection">Hemorrhages can lead to infection; treat promptly.</Callout> Those changes which reach their highest development in many cases of typhoid fever, and which consist sometimes in granular opacity and disappearance of the transverse strise of the muscular fibres, sometimes in that peculiar form of degeneration to which Zenker has given the name loaxy., are to be regarded as due to parenchymatous inflammation (^parenchy- matous myositis). As in all parenchymatous inflammations the granules are at first of an albuminoid nature, as is proved by their disappearance on the addition of dilute caustic potash, but later are converted into fat and are unaffected by potash (^fatty degeneration'). In waxy or hyaline degeneration, the relation of which to the fatty form is still obscure, the fibres are converted into a translucent substance which retains for a time traces of transverse striation but later becomes perfectly homogeneous and presents transverse cracks. These cracks finally extend completely across the fibres, and the sheath of sarcolemma contains only isolated masses of this hyaline substance. Although hyaline degeneration may produce an appearance bearing the very closest resemblance to that produced by amyloid degeneration, it never presents those reactions with iodine and aniline violet which we shall describe in detail in connection with amyloid degeneration in THORAX AND ABDOMEN. 91 the spleen. Microscopically, the hyaline change is betrayed by a grayish homogeneous and transparent look, as has been already hinted at. To prepare for the microscope muscle, which is the subject of this or almost any other morbid condition, a small bit should be snipped out with scissors, parallel with the course of the fibres, and should be teased with needles in a solution of common salt. In order to isolate the primitive fibres in as long strips as possible, it is well to put the needle points close together in the middle of the bit.
Key Takeaways
- Examine facial structures for signs of inflammation and tumors
- Use caution when examining the inner ear to avoid damaging delicate structures
- Understand muscle changes in various diseases, especially typhoid fever
Practical Tips
- Always prioritize safety and minimize risk during examinations by using appropriate tools and techniques.
- Be aware of potential infections from hemorrhages and treat promptly.
- Understand the importance of detailed examination for accurate diagnosis.
Warnings & Risks
- Infections can spread rapidly; treat promptly.
- Hemorrhages can lead to infection; treat promptly.
- Examinations should be performed with caution to avoid damaging delicate structures.
Modern Application
While the techniques described in this chapter are rooted in historical practices, many of the principles of examining and diagnosing pathologies remain relevant. Modern survival preparedness emphasizes quick, accurate assessments using portable diagnostic tools and prioritizing safety during examinations. Understanding muscle changes and signs of infection can still be crucial for triage and immediate care.
Frequently Asked Questions
Q: What are some common signs of inflammation in the parotid gland?
Common signs of inflammation in the parotid gland include swelling, pain, and the presence of pus. The connective tissue surrounding the lobules may become infiltrated with pus, potentially forming abscesses.
Q: How can one differentiate between a benign tumor and a malignant growth in the maxillary bones?
Benign tumors like fibromas are typically firm and well-defined, while malignant growths such as carcinomas may be more aggressive and irregular. The presence of hemorrhages or ulcerations often indicates malignancy.
Q: What is cystosarcoma, and how can it be identified?
Cystosarcoma is a peculiar new formation that appears in the parotid gland. It has a cartilaginous appearance with gelatinous spots that become whitish when treated with acetic acid. Its cut surface resembles a cabbage head.
Q: What are the risks of examining the inner ear without proper tools?
Examinations of the inner ear can be risky if not performed carefully, as they may damage delicate structures like the drum membrane or lead to infections. It is crucial to use appropriate tools and techniques.
Q: How can one identify signs of typhoid fever in muscle tissue?
In typhoid