Practical pathology

by Aldred Scott Warthin

14. Deep Muscles of Neck. Note same conditions in these muscles as mentioned above for abdominal and thoracic muscles. Retropharyngeal abscesses and hemorrhages resulting from fractures and luxations of the vertebræ are the most common conditions.

15. Cervical Vertebrae. Anterior surface should be smooth. Fractures, luxations and tuberculosis are the most common conditions. In caries of the vertebral bodies the surfaces become rough and sharp. In luxations irregular prominences and deviations are found. The prominent portion usually shows sharp edges.

CHAPTER X.
THE EXAMINATION OF THE ABDOMEN.

I. METHODS OF EXAMINATION.

The preliminary general inspection of the peritoneal cavity was made after the main incision. (See Chapter [VII].) After the examination of the neck and thoracic organs has been completed, the abdominal organs are removed and examined separately. The method to be followed must be varied to meet the conditions. In the case of extensive carcinomatosis, general peritonitis, peritoneal tuberculosis, pseudomyxoma peritonei, etc., when adhesions are numerous and the abdominal organs matted together, the examination becomes very difficult, and it may be necessary to remove the abdominal organs en masse and dissect them on the table. If the œsophagus and aorta have not been removed from the thorax they are stripped down to the diaphragm, which is cut on both sides, so that aorta, œsophagus and the abdominal organs en masse can be stripped down to the brim of the pelvis and there cut off to be examined outside the body.

For the ordinary autopsy the following order of examination of the abdominal organs is recommended: The spleen is first examined. It is lifted up from beneath the left under-surface of the diaphragm by tearing or stretching the ligamentum phrenico-lienale and the gastrosplenic omentum. In the case of wandering spleen the technique of removal must be modified to suit the conditions. When the spleen is very soft great care must be taken not to tear or rupture it. When adhesions to the diaphragm are present these must be torn or cut. The spleen is then laid upon the left edge of the ribs. In this position it may be sectioned by an incision made from upper to lower pole, and then, after it has been examined, it is allowed to slip back into the abdominal cavity, when its removal from the body is not desired. If it is to be removed and examined outside of the body, its ligaments and vessels are cut with the knife directed against the edge of the ribs, taking care not to cut the stomach or tail of the pancreas. It is then weighed and measured, and examined by means of a chief incision through its convex surface, from upper to lower pole, and reaching to the hilus. Parallel sagittal or transverse cuts may be made as desired. The cut surface is then thoroughly examined. Bacteriologic examinations should be made when indicated, before the organ is sectioned. A portion of the capsule is seared and the pipette introduced through the seared area.

The intestines are examined next. They may be opened inside the body without separating them from the mesentery, but the best method by far is to remove and open them outside of the body. The middle portion of the transverse colon is lifted up by the left hand and the ligamentum gastrocolicum and the mesocolon transversum cut close to the intestine, toward the left, separating the left half of the transverse colon, then the splenic flexure and the descending colon and the sigmoid flexure to the rectum. After the splenic flexure has been separated the descending colon can usually be stripped down to the sigmoid by the hands without using the knife. When the sigmoid has been freed from its mesocolon two ligatures are put around the upper portion of the rectum, about an inch apart, and the intestine is then cut between the ligatures. The freed portion of the large intestine is then carried over into the right side of the abdomen and as much of the lower portion as is possible is put into a pan or tray resting upon the cadaver’s right thigh. The right half of the transverse colon, the hepatic flexure and the ascending colon are now freed down to the beginning of the ileum, care being taken not to cut off the appendix when loosening the cæcum. The entire large intestine is then gathered into the tray resting on the cadaver’s thighs, and the intestine is pulled down firmly by the left hand in a line corresponding to the main axis of the right thigh. The coils of small intestine are left in their natural position. The ileum is then severed from the mesentery as follows: The intestine is pulled by the left hand straight down in the middle line of the right thigh, putting the mesentery on a stretch. The long section-knife is used by the right hand to cut the mesentery close to the intestine in a manner resembling the use of the bow in violin-playing. The blade of the knife is held slightly obliquely against the mesenteric insertion of the intestine, and as the left hand pulls up the coils of intestine against the knife, the latter in the bowing or sawing movement severs the mesentery from the intestine as close to its insertion as is possible without cutting the intestine. The freed portions of intestine are caught in the tray resting on the thighs, and the left hand grasps in succession new portions of the small intestine and pulls them against the knife until the entire intestine is freed up to the duodenum and the root of the mesentery. A double ligature is put around the jejunum and the intestine severed between the ligatures, and the freed jejunum, ileum and large intestine are now removed in the tray for examination. The severing of the intestine from the mesentery in this manner can be carried out very quickly after a little practice. Care must be taken to cut the mesentery as close as possible to the intestine without nicking the latter. If too much mesentery is left on the intestine it cannot be laid out straight and its opening is made more difficult. If the coils of the small intestine are left in their natural position, and if the ileum when it is first taken up by the left hand is not twisted, the coils will unroll before the knife without any difficulty. Some prosectors begin with the jejunum, ligating it at the point where it comes out from beneath the mesentery, cutting it between the ligatures and separating it from the mesentery downward until the entire intestine as far as the rectum has been freed. The latter is ligatured and the freed portions removed. When the saving of time is of great importance the large intestine may be freed as described above, a ligature put around the upper end of the jejunum, and the mesentery severed at its root, so that the entire mass of small intestine with its mesentery is removed for further separation from the mesentery outside of the body. When peritoneal adhesions that cannot be easily torn are present it may be necessary to remove the intestines with mesentery attached.

After the removal of the intestines from the body they are opened by the intestinal shears, beginning either with the jejunum or the large intestine, the cut being made in the line of the mesenteric attachment. As the intestine is opened careful attention should be paid to the contents of each portion. It is very poor technique to dilate the intestine with water or to run water through it before it is opened. There is danger of washing away parasites, blood, etc. When the intestine is distended the opening is easy, but when collapsed it can be more easily opened if an assistant straightens it out and holds it on the stretch in advance of the enterotome. It may be opened on the table, in the tray, or in a pail. The latter method is a clean and convenient one. As the intestine is opened it is passed on the flat beneath the handle of the pail as it rests on the rim, so that the intestinal contents are scraped off into the pail and the clean mucosa examined as it is pulled from the pail into a basin or tray. The ileocæcal valve should be carefully examined from above before it is cut through. The appendix may be opened from the intestine by the small probe-pointed shears, the cut being made on the side opposite the mesenteric attachment. Transverse sections can be made, if desired. When the intestines are opened within the body, the enterotome is introduced into an opening made in the ileum just above the ileocæcal valve and the intestine is cut upward to the duodenum, along its mesenteric attachment, the coils being drawn upon the probe-pointed blade of the enterotome with the left hand. After the small intestine is opened the enterotome is introduced through the ileocæcal opening and the large intestine cut in the anterior tænia as far as the rectum. The opening of the intestine within the body should be left until all the other abdominal organs have been examined, because of the disagreeable mess made by the escape of the intestinal contents into the cavity.

The duodenum is opened next. The curved scissors, or the enterotome, is introduced into its lower end through an opening made above the ligature, and the inferior and descending portions of the duodenum are cut in the middle line of the anterior wall. The superior portion is then cut up to the pylorus, the cut passing through the inferior wall of this portion, the enterotome being held in the axis of the canal and pylorus, while the duodenum is pulled over to the right by the left hand. Before the pylorus is cut it should be explored, as to its width or constriction, by the index-finger of the left hand. The duodenum may also be opened first in the lower part of the descending portion. The root of the mesentery is pushed over to the left and a fold of the anterior wall is picked up by the thumb and index-finger of left hand and cut with the shears, so that when let free by the left hand there is formed a longitudinal incision in the duodenal wall large enough to admit the long blade of the enterotome. The duodenum is then cut up to the pylorus as described above. The inferior part of the duodenum is then opened from the point where the first incision is begun. The duodenum may also be opened downward, beginning at the pylorus, a small transverse cut being first made in the stomach wall just above the pylorus and the stomach opened along the greater curvature as far as the cardia. The enterotome is then placed through the pylorus and the duodenum cut in the median line of its anterior wall throughout its entire length. When the duodenum is opened, the papilla, the ductus choledochus and the ductus Wirsungianus are to be carefully examined. The papilla can usually be easily found by stretching the duodenal mucosa transversely over the head of the pancreas. It lies below the middle of the head of the pancreas, and about four finger-breadths below the pylorus. Pressure should be made upon the gall-bladder to force bile through the duct and papilla, and thus demonstrate their patency. When this cannot be done a sound should be introduced, and the common duct opened into the hepatic and cystic ducts. If the duodenal mucosa just below the papilla be stretched forcibly downward the duct can usually be opened by the small scissors without the aid of a grooved director. The duct of Wirsung may be explored with the sound from the papilla to the left of the common duct, or from its separate opening when the two ducts do not open in common. Both the bile-duct and the duct of Wirsung may be opened in the opposite direction, from the liver and pancreas respectively.

The stomach is opened from the pylorus after the size of the latter has been ascertained. The anterior wall may be cut midway between the greater and lesser curvatures, or the cut may follow the greater curvature, extending through the cardia into the œsophagus. As the stomach is opened its contents are inspected and removed. They should not be allowed to escape into the abdominal cavity. When the organs are removed en masse the stomach may be opened from the cardiac end. The organ may also be opened by an incision through its posterior wall or along its lesser curvature, as occasion may demand. If it is desired to save the pyloric ring the incision may stop above or below it and begin again on the other side. The stomach, with the lower portion of the œsophagus and the superior portion of the duodenum, may be separated from their attachments and examined outside of the body.