15. Pulmonary Vessels. Character of walls and contents. Normally the intima is smooth, grayish-white and translucent. Fatty degeneration of the intima is not rare (acute infections and intoxications); atheroma and aneurismal dilatation are infrequent. Occasionally parietal thrombi and thickening of the wall due to organization of a thrombus are seen. The pulmonary arteries are normally empty or contain soft cruor or agonal white clots. These are not adherent to the wall, do not fill the lumen and are soft and moist. Emboli fill the lumen as if forced into it (at the branchings of the artery they form “rider’s” emboli); they are more dry and brick-red, brownish or grayish in color. Occasionally they may be unrolled into long fibrinous strands. Older emboli may show more or less organization and adherence to the vessel-wall. In air-embolism the pulmonary arteries contain a mixture of blood and air looking like a stiff-beaten white of egg of red color. Large emboli of liver-tissue or liver-cells may be found in the pulmonary arteries after traumatic rupture of the liver. Fat-emboli of the smaller arteries can be recognized by the naked-eye. Thrombosis of both pulmonary arteries and veins is very common in chronic valvular lesions, pneumonia, terminal infections, burns of the skin, poisoning with hemolytic agents, etc.
16. Great Vessels of Thorax. Note size of lumen, condition of walls, particularly of intima, and the contents. Circumference of thoracic aorta 4.5-6.0 cm., thickness of wall 1.5-2 mm. Test elasticity of wall by stretching; note if it retracts and becomes shorter than the œsophagus, which was cut at the same level. Note consistence of wall (stiff and hard in sclerosis and calcification). Normally the intima of the aorta is smooth, grayish-white and semitranslucent; the wall is elastic. Fatty degeneration, sclerosis, atheroma and aneurismal dilatations are the most common pathologic findings. Fatty degeneration shows itself in yellowish spots or streaks, more opaque and slightly elevated. Sclerotic areas are hard, white and tendon-like. Atheromatous “plaques” and “ulcers” are white or yellowish, elevated, rough, scaly, with loss of substance, often more or less calcified. Thrombi are frequently formed upon such atheromatous patches. Hemorrhage into the intima may occur (aneurysma dissecans). Radiating or linear sclerotic folds and depressions in the intima, with or without dilatation of the lumen, usually result from syphilis (mesaortitis). A dirty brownish discoloration of the intima is due to an imbibition of diffuse hæmoglobin, usually postmortem. In chronic icterus the intima may be bile-stained. Thrombosis of the aorta is not common. Congenital or acquired stenosis at the isthmus is rare. Tuberculosis of the aorta-wall is also very rare.
17. Thoracic Portion of Oesophagus. Note size (stenosis, dilatation, diverticulum), contents (food, stomach-contents, blood, pus, foreign-body), thickness of wall, color of mucosa (normally grayish-white), neoplasms (carcinoma), perforations, erosions (aneurism, abscess, neoplasm), inflammation. Anomalies, tuberculosis, syphilis, actinomycosis and neoplasms (with the exception of carcinoma) are rare. The most common location of carcinoma is toward the cardia. Thrush is the most common parasite. Varices of the œsophageal veins are common, and from these fatal hemorrhages may occur. In the thoracic portion they are usually the result of collateral distention to offset a portal stasis (hepatic cirrhosis, Banti’s disease, thrombosis of splenic or portal veins). The passage of stomach-contents through the cardia into the œsophagus may cause a postmortem softening or perforation of the œsophageal wall.
18. Thoracic Duct. Note size, contents and character of wall. Tuberculosis, malignant neoplasms, obstruction, rupture and purulent inflammations are the most important pathologic conditions. In miliary tuberculosis the thoracic duct may be the primary focus or the avenue by which the bacilli enter the blood. The duct also plays an important part in the dissemination of malignant tumors and infections from the abdominal cavity and pelvis. Chylothorax and chylopericardium are usually caused by the blocking of the thoracic duct by malignant neoplasms (lymphosarcoma, carcinoma), or by rupture of the duct.
19. Thoracic Vertebrae. Note surfaces of vertebræ (normally smooth), curvatures, softening, erosions, exostoses, neoplasms, fractures, dislocations. Tuberculosis, curvatures and malignant tumors (secondary carcinoma, primary sarcoma, myeloma, chloroma) are the most common conditions. Aneurismal erosions are not rare.
CHAPTER IX.
EXAMINATION OF THE MOUTH AND NECK.
I. METHODS OF EXAMINATION.
1. Removal of the Neck-Organs. The block is left beneath the neck, and the chin pulled upward by an assistant, so as to put the skin of the neck on a tight stretch. If the main-incision cannot be extended to the symphysis of the chin, the cartilage- or long section-knife is run up beneath the skin in the median line to the point of the chin, and, with the blade held nearly flat, the skin is loosened from the tissues of the neck, first on the left side, then on the right, as far back as the mastoid processes and the spinal column and to the ends of the clavicles. Great care should be taken not to cut through the skin. The long section-knife, with blade flat, is then pushed through the floor of the mouth, to the left of the median line, taking care not to damage the tongue, and with the blade of the knife closely hugging the inner border of the lower jaw, the floor of the mouth is cut through as far as the angle of the jaw. The knife is then turned with its cutting edge toward the right and a similar cut made through the floor of the mouth as far as the right angle of the jaw. The knife must be held at right angles to the floor of the mouth to avoid cutting the tongue. When the mouth is open the course of the knife can be seen, but usually the mouth is tightly closed in rigor mortis. When cutting the floor of the mouth it is better to make short sawing movements with the knife than to attempt to cut it with one sweeping cut. Instead of cutting from the median line the knife may be inserted at the right or left angle of the jaw and the cut extended upward to the chin and thence toward the other angle. (See Fig. [42].)
Fig. 44.—Removal of neck-organs, when skin-incision is carried to the chin. The same cuts through the soft palate are made, when the knife is pushed up beneath the loosened skin of the neck. (After Nauwerck.)