As soon as the floor of the mouth is opened and the tongue loosened from the lower jaw the left hand is introduced beneath the skin, through the incision, into the mouth, and the tongue seized by thumb and middle finger, and drawn forcibly downward, while the other fingers are used to lift up the skin from the knife. The long section-knife, with cutting edge turned toward the left, is then introduced in the median line, along the left hand, until its point reaches the hard palate, taking care to work the point back slowly until it reaches the border between soft and hard palate. This must be done by feeling rather than by sight. The block under the neck is then pushed up under the head and the chin thrown forward so that the point of the knife is directed at right angles against the cervical vertebræ. The soft palate is then cut to the left, while the tongue is pulled firmly downward and toward the right, putting the uvular arch on a stretch so that the knife passes around the left tonsil. The knife is then turned and the same cut made on the right, severing the right faucial pillar and tonsil, while the tongue is pulled downward and to the left. The point of the knife is then pushed back to the pharyngeal wall and the latter is cut from right to left by a strong, firm stroke directed at right angles to the surface of the upper cervical vertebræ. The cut through the pharyngeal mucosa should be at the level of the boundary between the laryngeal and nasal portions, at about the height of the axis. While this cut is being made firm traction should be kept up on the tongue, pulling it downward, and alternately to the left and right. The loose retropharyngeal and retroœsophageal fascia tears easily and the mouth organs can now be pulled so far downward that first transverse and then oblique cuts through this fascia can now be made upon the vertebræ, severing the vagi, carotids and jugulars, and working from above downward, until the mouth and neck organs can be lifted up through the skin-incision and the entire mass of the neck-organs separated from the spinal column as far as the clavicles. Pulling the mass toward the right, the left subclavian vessels and fascia are severed by a cut directed downward and outward beneath the clavicle. Traction is then made toward the left and the right subclavians cut beneath the clavicle. If the thoracic organs have been removed the œsophagus and aorta may now be stripped down to the diaphragm and there cut off, or the neck-organs may be cut off at the level of the bifurcation of the bronchi.
The organs, having been removed, are placed on the board, œsophagus upward, and the tip of tongue toward the prosector. The tongue is then cut in the median line and the cut surfaces examined. Transverse cuts may be made when indicated. The uvula is then lifted up and examined; and the tonsils and palate next examined, the former by means of longitudinal incisions. The intestinal shears are now introduced through the fauces into the œsophagus and the left pillar cut between the uvula and the tonsil. The posterior wall of the pharynx and that of the oesophagus for its entire length is then cut in the median line, and these structures examined. After the examination of the larynx from above, the long blade of the intestinal shears is introduced into the larynx and trachea, and these are cut in the posterior median line into the right bronchus. The œsophagus is pulled to the left (prosector’s right) out of the way. The left bronchus is opened by a special incision to avoid cutting aorta and œsophagus. The larynx is now lifted up and held in both hands with the thumbs on the horns of the thyroid cartilage, and the fingers outside, and the larynx opened by forcibly bending back or breaking the cartilage, so that the entire interior of the larynx can be examined without touching the mucosa.
The neck-organs are now turned over, with the aorta toward the prosector and the tongue pointing away. The right and left lobes of the thyroid are opened by oblique cuts running from above downward and inward, and the isthmus is cut sagittally. The parathyroids must be dissected out behind and below the thyroid, along the course of the terminal branches of the inferior thyroid artery. The parotid, submaxillary and sublingual glands and the cervical lymphnodes are opened by longitudinal cuts. The aorta, carotids, jugulars and their branches are opened with the curved or probe-pointed scissors. The vagus, superior and inferior laryngeal nerves and the cervical sympathetic ganglia are to be examined when the case requires it. The examination of the neck-organs then closes with the inspection of the muscles of the neck and the cervical vertebrae.
If permission cannot be obtained for the complete removal of the mouth-organs, the neck-organs may be removed by cutting them transversely against the vertebræ between the hyoid bone and thyroid cartilage and then stripping them from the vertebræ and removing them as in the method given above. The skin-incision in such cases need not be carried higher than the collar-line, the skin of the neck being loosened by a subcutaneous dissection.
When permission is withheld for the removal of the neck-organs they may be examined in situ, by freeing the skin of the neck by a subcutaneous dissection, cutting the lobes and isthmus of the thyroid in place and then opening the trachea and larynx by an anterior median incision. The salivary glands, parathyroids, cervical lymphnodes, vessels and nerves can all be examined by this method without removing the organs as a whole.
In cases of aortic aneurism, corrosive poisoning, carcinoma of œsophagus, trachea or bronchi, it is best to remove the neck-organs in connection with the thoracic, removing first the neck-organs down to the clavicles and then stripping all down to the diaphragm, where they may be cut off and examined outside of the body. In cases of poisoning it is often necessary to remove the œsophagus in connection with the stomach. The mass of neck- and thoracic organs are removed as far as the diaphragm and then allowed to lie over the edge of the thorax or are turned down over the abdomen so that the œsophagus is upward and the tongue toward the prosector. The œsophagus and aorta are then separated from the other organs and left in the thorax to be examined later in connection with the abdominal organs.
If the thoracic duct was not examined when the thoracic organs were, it may be examined after the section of the neck-organs is finished, but it is more easily found after the method given above by turning the right lung over into the left side of the thorax and then looking for it in the neighborhood of the diaphragm, on the right side behind the aorta and between it and the azygos vein. It runs upward toward the left to the body of the last cervical vertebra, then over the left subclavian artery downward to the left innominate vein.
II. POINTS TO BE NOTED IN EXAMINATION OF THE MOUTH- AND NECK-ORGANS.
1. Mouth. Contents (blood, mucus, stomach-contents, foreign-bodies, etc.), color of mucosa (normally grayish-red), vesicles (aphthæ), cheilitis, gingivitis, various forms of stomatitis, noma, scorbutus, Ludwig’s angina, ulcers (syphilis, carcinoma, decubital, tuberculosis), hyperkeratosis, macrocheilia, thrush, scars, wounds, action of corrosives, lead-line, neoplasms, etc. Note pillars of fauces, size, shape and condition of uvula. If the teeth have not been inspected during the general examination they should receive attention at this time. Note malformations, anomalies, neoplasms (adamantoma, odontoma, dental osteoma, various forms of cysts, epulis, giant-cell sarcoma, papilloma, fibroma, etc.)
2. Tongue. Mucosa normally is moist and grayish-red. Note discolorations, coatings, crusts, scabs, exudates, various forms of stomatitis, “geographical tongue,” glossitis, abscess, fissures, ulcers (syphilis, carcinoma, decubital), chancre, wounds, action of corrosives, scars (epilepsy, syphilis), tuberculosis, neoplasms (carcinoma, lymphangioma, hæmangioma, papilloma, leukæmic lymphocytoma, adenoma, thyroid adenoma [struma baseos linguæ], and rarely sarcoma, congenital fibroma, lipoma, myxoma, chondroma, osteoma and dermoid cysts), thrush, actinomycosis, leprosy, trichinæ, cysts (lymphangiectatic), hyperkeratosis, leukoplakia, “black hairy tongue,” macroglossia, partial or total hypertrophy. All forms of syphilitic lesions may be found upon the tongue (chancre, condyloma, plaques, papules, fissures, rhagades, ulcers, gumma, etc.) “Smooth atrophy” of the base of the tongue is regarded by various authors as pathognomonic of tertiary or congenital syphilis. Cysticercus and echinococcus are very rare.