Practical pathology

by Aldred Scott Warthin

The pancreas is examined by turning the stomach toward the thoracic cavity, cutting or tearing the gastrocolic omentum, and cutting the exposed organ by a longitudinal incision through head, body and tail, or by means of parallel transverse incisions made through the different parts of the organ. The ducts of Wirsung and Santorini should be explored. It must be freed from the duodenum before it is weighed. The pancreas may be removed in connection with stomach, duodenum and liver and examined outside of the body. This is advisable in all cases of perforation of the stomach, ulcer, carcinoma and surgical anastomoses, carcinoma of pancreas, acute pancreatitis, obstruction of common duct, duodenal ulcer, etc.

The liver may be examined in the body without removal. The left hand is put between the diaphragm and the convex surface of the right lobe of the organ, and the liver raised up out of the cavity. With the long section-knife a main incision is made deep into the organ, from left to right, about a hand’s-breadth above the lower border. Parallel incisions to the main incision may be made. After the examination of the cut surface the organ is dropped back into the abdomen. When the liver is to be weighed and measured it is removed from the body by cutting first the ligamentum hepatoduodenale, examining, as they are cut, the common duct, hepatic artery and the portal vein. The left lobe of the liver is then taken in the left hand and raised as high as possible. The left triangular ligament, the left half of the coronary ligament, the suspensory ligament, the right half of the coronary ligament and the right triangular ligament are cut from left to right. The inferior vena cava is cut at the same time. In the case of adhesions between liver and diaphragm these must be cut or the diaphragm itself removed in connection with the liver. In such a case the diaphragm must be trimmed off before the liver is weighed. The liver may also be removed in the opposite direction, raising up the right lobe and severing all connections as far as the median line of the spinal column. The right lobe is then pulled upon the right edge of the thorax-wall, and the connections with the left lobe are severed. In separating the under surface of the right lobe care must be taken not to damage the right adrenal. The liver is then weighed and measured, and placed upon the board with the right lobe toward the prosector. A long, deep cut is then made by drawing the long-section-knife across the left and right lobes, extending the cut through to the porta. Additional cuts may be made parallel to this chief-incision. When occasion demands a number of sagittal incisions may be made instead. As mentioned above, it is often best to remove the liver with stomach, pancreas and duodenum and examine on the table.

The gall-bladder is opened from its fundus with the fine probe-pointed shears; its contents are caught in a vessel and examined. The cystic, hepatic and common ducts may be explored from the gall-bladder, if they have not been from the intestine. The gall-bladder may be dissected from the liver and removed in connection with the duodenum.

The portal vein is opened into its radicles; the examination of the splenic vein is of especial importance. The portal lymphnodes are examined at this time.

The mesentery and the mesenteric lymphnodes are now examined. The former may be cut off at its root and examined outside of the body. The lymphnodes may be opened by longitudinal or transverse incisions.

The left adrenal and kidney are now examined. If the pancreas and stomach have not been removed from the body they are turned over toward the thoracic cavity, so as to expose completely the left adrenal. The movability of the kidney is then tested. Beginning above the adrenal an incision is made through the peritoneum and underlying tissue, curving outward around the kidney and downward to its lower pole, taking care not to bring the incision too far around the lower pole of the organ for fear of cutting the ureter. The knife is then laid aside, and the adrenal and kidney are pulled upward toward the median line until they are entirely free save for the blood-vessels and ureter. The loose tissue about the fatty capsule of the kidney is usually easily separated. The blood-vessels are then cut from above downward against the spinal column, the ureter being left uncut. Holding the kidney in the two hands, it is pulled downward toward the pelvis, stripping the ureter free as far as the pelvic brim. At this level the ureter may be cut, or, if it is desired to remove the kidneys in connection with the pelvic organs, the ureter is left uncut and the kidney laid over the pubis until the pelvic organs are removed. When the kidney and adrenal are removed they are placed upon the board and the adrenal separated. The latter organ is then examined by means of parallel transverse incisions, or by an incision in its longest axis in the middle of its flat surface. When the adrenal is left in the body it may be examined by means of the same incisions. The fatty capsule is then stripped from the kidney and the organ weighed and measured. It is then held in the palm of the left hand with the ureter between the middle fingers, the convex border up, the thumb placed on one flat surface, the fingers on the other, holding the organ tightly. The kidney is then opened by means of a long incision made with the long section-knife, beginning at the upper pole, drawing the knife through the convexity, to the lower pole, and extending the cut through the organ to the pelvis. As the knife approaches the hilus the grasp of the left hand upon the organ is loosened and pressure upon the knife lessened so as not to cut through the hilus. The edges of the fibrous capsule are then caught by the fingers or forceps and the capsule stripped from the cortical surfaces. The external surface and the cut surfaces are then examined. When indicated other incisions into the kidney substance may be made. The ureter is sounded from the pelvis, and opened with the fine probe-pointed shears. The renal artery and vein may be examined now, or better when the kidney is being removed.

The right adrenal and kidney are removed in the same way, by making a curved incision around the outer border of the organs, pulling them up toward the median line and cutting the blood-vessels from above downward against the spine, and then stripping the ureter downward to the pelvis. After removal the adrenal is separated from the kidney and examined as directed above for the left adrenal. The kidney and ureter are then examined in the same way as on the left. When it is desired to remove the right kidney with the pelvic organs the same procedure is carried out as advised above in the case of the left one. In the removal of the right adrenal care should be taken not to injure the vena cava. In the case of displacement of either kidney the incisions for the removal of the organ must be altered to suit the case.

When the kidneys are removed before the examination of the intestines and liver, the removal of the left adrenal and kidney usually follows the examination of the spleen. The small intestines are pulled over to the right; the peritoneum is incised over the left kidney between the descending colon and the spinal column so that the right hand can be worked beneath the peritoneum up above the adrenal and kidney, freeing them, and lifting them toward the median line. The vessels are then cut as directed above, and the ureter stripped down to the pelvis. On the right side the cæcum and ascending colon are raised and a cut made through the peritoneum at the brim of the pelvis. The cæcum, ascending colon and peritoneum are now stripped upward with the left hand until the right hand can be passed up above the right adrenal to loosen it and the kidney toward the median line. When this is accomplished the adrenal and kidney are held in the left hand, while the right cuts the blood-vessels from above downward against the spine, sparing the ureter, which with the two organs is stripped downward to the pelvic brim. The close proximity of the right adrenal to the under surface of the liver makes the removal in this way much more difficult than when the liver is removed first. Usually, when the method of removing the kidney after the spleen is adopted, the adrenal is left in the body until after the removal of the liver.

So many variations in the order of section of the abdominal organs are given by different writers that it is impossible to escape the conclusion that the best order is the one best adapted to the individual case. A very common order is spleen, left adrenal and kidney, right adrenal and kidney, duodenum, stomach, pancreas, liver, intestines, pelvic organs and genitalia. Beneke advises the removal of spleen, then the removal of the entire intestines, stomach and pancreas, in connection with the gall-bladder, which is stripped from the liver and removed in connection with common duct and duodenum, the whole mass removed from the body and examined outside. Other prosectors begin with the liver, then the spleen, urinary bladder and kidneys and genital organs, the gastro-intestinal tract being left to the last. It may then be opened inside the body without inconvenience resulting from the escape of its contents into the peritoneal cavity. After surgical operations when permission for autopsy is refused, the abdominal, and also the thoracic organs, may be removed through the laparotomy wound.

After the examination of the abdominal viscera is completed the abdominal aorta is opened in the median line of its anterior wall and followed into its branches, the iliacs and hypogastrics. When occasion demands it may be stripped from the spine and opened outside of the body. The inferior vena cava is also opened throughout its length and followed into its branches. The abdominal portion of the thoracic duct should receive attention before the aorta is removed. The receptaculum chyli is found by lifting up the right edge of the aorta at the level of the second or third lumbar vertebra and dissecting out the duct up to its thoracic portion. It may then be opened by the fine probe-pointed shears. The retroperitoneal lymphnodes and haemolymphnodes are examined in situ, or removed with the blood-vessels and examined outside of the body. The sympathetic ganglia, particularly the suprarenal and the cœliac plexuses, and the splanchnic nerves are to be examined, especially in cases of Addison’s disease. The section of the abdomen closes with the examination of the ileopsoas muscles and diaphragm by means of longitudinal or transverse incisions, and the inspection of the vertebrae. Pathologic conditions in the latter are examined according to indications.