Practical pathology

by Aldred Scott Warthin

1. The Main Incision. After the examination of the cranium has been completed, the skull-cap is replaced and the anterior flap of the scalp drawn up over it, to hold it in place until the close of the autopsy. The head is then wrapped in a towel to protect the face and hair.

The prosector then stands at the right side of the cadaver (if left-handed, on the left side), the body being brought as near as possible to the edge of the table. The cartilage-knife is then held in the palm of the right hand and with it an incision is made through the skin in the median line of the body, extending from just below the thyroid cartilage to the base of the penis in the male, and to the anterior commissure in the female, passing to the left of the umbilicus. If pathologic conditions (hernia, surgical wound, tumor, etc.) are present in the median line the main-incision should deviate to right or left as expedient. The incision in the suprasternal notch is made with the point of the knife, the thumb and fingers of the left hand being used to put the skin of the neck on a stretch. Over the sternum the knife is held horizontally and the tissues cut to the bone. As soon as the epigastrium is reached less force is used, and the cut should not be deeper than through the skin and subcutaneous tissue over the abdominal portion of the incision. At the end of the incision the knife is raised, vertically and the cut finished with the point of the knife. The incision is then carefully deepened in the epigastrium, just below the ensiform, until a small opening is made through the peritoneum into the abdominal cavity. To determine the presence of gas within the peritoneal cavity the peritoneum should first be nicked with the point of the knife to make a very small opening through which the escape of any free gas within the cavity can be easily noted. When bacteriologic examinations of the peritoneal fluid are to be made, the incision should be extended down to the peritoneum, which should then be seared, and the fluid secured by means of a sterile pipette forced through the seared portion. If it is more expedient to secure the fluid through an incision, the opening should be made with a sterilized knife and the fingers should not be put into the cavity, but are used to lift up the abdominal wall at the sides of the incision. In cutting through the peritoneum great care should be taken not to injure the stomach or intestines, which, often greatly distended, are pressed tightly against the peritoneum. If the opening is made just below the ensiform the knife, should it slip through unexpectedly, usually strikes the liver without causing any damage.

Fig. [36].—The main incision completed. Lines show incisions through costal cartilages, and for disarticulation of sternoclavicular joints. (After Nauwerck.) The incision in the neck is begun higher than is usual in this country.

The abdominal incision is now extended downward to the pubis. The first and second fingers of the left hand are introduced into the peritoneal cavity and used as directors to lift up the abdominal wall and to keep the intestines from the knife, the latter cutting between them in the line of the first incision through the skin and subcutaneous fascia. When the main incision is complete the knife is introduced into the abdominal cavity with cutting edge directed outward and the abdominal muscles are divided on either side just above the pubis by cuts extending outward to the skin. (See Fig. [36].) Care should be taken not to cut the latter. These transverse cuts made from the peritoneal surface permit the opening of the peritoneal cavity to the necessary extent, so that transverse incisions through the skin are not necessary.

The main incision is carried to the left of the umbilicus and then back to the median line, in order not to injure the umbilical vessels, the ligamentum teres of the liver, or a concealed hernia or persistent omphalomesenteric duct. In the case of the new-born the incision to the left of the umbilicus is extended to the pubis in an oblique line diverging from the median line. After the examination of the umbilical vessels through the main incision a second diverging cut is made from just above the umbilicus, passing to its right, across the umbilical vessels and hepatic ligament down to the pubis, forming a triangular flap including the umbilicus, urachus and umbilical arteries.

The abdominal flaps are now held back and a thorough inspection of the cavity made, noting particularly the position of the abdominal organs, contents of cavity, condition of peritoneum and appendix, occurrence of perforations, etc. The position of the diaphragm is then determined on both sides, by passing the right hand up under the ribs to the highest part of the dome of the diaphragm and then pressing outward against the chest-wall so that the height can be estimated by rib or interspace.

The skin and muscles are now stripped from the thoracic wall on both sides of the median incision, beginning first on the right. (See Fig. [36].) The right flap of the abdominal wall is taken in the left hand just above the umbilicus and turned over the right lower border of the ribs, and pulled forcibly upward and outward to the right, putting the peritoneum, the ligamentum teres of the liver and abdominal muscles upon a stretch over the edge of the ribs. These are then cut by the cartilage-knife in an incision extending from the median line along the edge of the ribs deep down into the flank. The loosened flap of skin and muscle is then pulled over to the right with the left hand, while the right hand holds the cartilage-knife, with its cutting edge turned obliquely to the surface of the ribs, and makes long, sweeping cuts from above downward, severing the thoracic muscles and fascia as closely as possible to the costal cartilages and ribs. The skin and muscles are thus stripped off from below upward until the right side is laid bare as far back as the anterior axillary line and to the middle of the clavicle above. (See Fig. [36].)

In stripping the muscles from the ribs it is necessary only to do it sufficiently to show the costal cartilages and their articulations with the ribs. Too clean dissecting is not necessary. On the other hand, careless slashing cuts should be avoided, as they might cut through into the pleural cavity.

The right mammary gland is next examined. The index-finger of the left hand is put upon the nipple, the skin-flap turned over, and an incision made from the inner surface, extending through the gland to the nipple. Parallel incisions may then be made. The axillary glands may be examined by carrying the skin and muscle flap farther down into the axilla. The thoracic wall is then laid bare on the left side, in exactly the same way as on the right, except that the right hand works underneath the left, as the latter pulls the flap over to the left. When the left side is stripped, the left mamma is examined in the same way as the right.