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.)

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.

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.

3. Pharynx. Normal mucosa is smooth and gray-red. Note contents, color and character of mucosa, atrophy, congestion, œdema, exudations (mucous, purulent, croupous, diphtheritic, thrush), ulcers, scars, hyperplasia of lymph-follicles, adenoids, various forms of acute and chronic pharyngitis, retropharyngeal abscess, syphilis, tuberculosis, neoplasms (nasal polypi, lymphosarcoma, leukæmic lymphocytoma, aleukæmic lymphocytoma, carcinoma, retropharyngeal dermoids, lipoma, cysts, fibroma, chondroma, etc.), glanders, leprosy, actinomycosis, rhinoscleroma, cysticercus and echinococcus.

4. Tonsils. Size (how far do they project?), smooth or showing depressions, color (normally uniformly gray-red), atrophy, hypertrophy, hyperkeratosis, various forms of inflammation (acute and chronic tonsillitis, diphtheria, angina superficialis, lacunaris, follicularis, pseudomembranosa, purulenta and phlegmonosa, tonsillar ulcers, cysts and abscess), syphilis, tuberculosis, actinomycosis, thrush, concretions, neoplasms (carcinoma, primary is rare, secondary from primary in tongue or larynx more common; lymphosarcoma or lymphocytoma, either aleukæmic or leukæmic, is the most common neoplasm of the tonsil, other forms of sarcoma and connective-tissue tumors are rare), cysticercus and echinococcus are rare.

5. Nose. If the brain is not removed and the nasal tract not examined by the method of Harke, as much of the nose as possible should be inspected, and the various conditions noted, as described in Chapter VI.

6. Oesophagus. Contents, size (dilatation, stenosis, diverticula), color and character of mucosa (normally smooth, transparent, pale, grayish-white, often hypostatic on posterior surface), inflammation, swelling of mucosa, leukoplakia, œdema, erosions, ulcers, action of corrosive poisons, perforation, foreign bodies, varices (cirrhosis, splenic anæmia), hemorrhage, aneurismal erosion, infective granulomata (tuberculosis, syphilis and actinomycosis are all rare), neoplasms (benign are rare, sarcoma rare; carcinoma most common usually at the lower or middle third), parasites (thrush the most important infection). Postmortem softening of the œsophagus from the regurgitation of stomach-contents must not be mistaken for pathologic conditions. Oesophagomalacia is of the rarest occurrence during life.

7, 8. Larynx and Trachea. Nature of contents, character and position of epiglottis and plicæ aryepiglotticæ (the latter should be thin; greatly thickened in inflammation and œdema), mucosa (normally gray-red and smooth); vocal cords (position and relations as viewed from above; should be thin and tendon-like; mucosa thickened in inflammation and œdema; may be atrophic), œdema, inflammation, diphtheritic membranes, ulcers, syphilis, tuberculosis, leprosy, glanders, actinomycosis, rhinoscleroma, neoplasm, foreign-bodies, etc. An extreme œdema of the glottis may disappear after death, and its occurrence be shown only by the wrinkled appearance of the mucous membrane. Anomalies are rare, the most common being a laryngocele. In typhoid fever erosions and ulcers are not rare in the larynx. In small-pox ulcers, diphtheritic inflammations and hemorrhages may occur. The most common tumor is the fibroma or fibro-epithelioma (papilloma), occurring particularly in children and singers (“children’s nodule,” “singer’s nodule”). Angioma, myoma, lipoma and chondroma are rare. Thyroid adenoma, the so-called “amyloid-tumor” and adenoma of the mucous glands are rare. Sarcoma is also rare. Lymphosarcoma and leukæmic infiltrations are not common. Primary carcinoma is more frequent than sarcoma, but is relatively rare. It occurs most frequently in men, arising on the true vocal cords, and is squamous-celled. In trichinosis the laryngeal muscles usually show an early and abundant invasion. The most important pathologic conditions of the trachea are anomalies (diverticula, fistula, tracheocele), inflammation (catarrhal, membranous, pseudomembranous), tuberculosis, syphilis, secondary erosions, ulcers and perforations (tumors of thyroid, cancer of œsophagus, tuberculosis and suppurating lymphnodes, aneurisms), stenosis, compression from enlarged thyroid, thymus or lymphnodes, dilatation, tracheotomy, intubation, and neoplasms (relatively rare). The cartilages of both trachea and larynx should be examined for inflammation, pigmentation, etc.

9. Thyroid. Weight is 30-60 grms. The dimensions of the lateral lobes are: Length 5-7 cm., breadth 3-4 cm., thickness 1.5-2.5 cm. They should be symmetrical. Note variation in form, character of cut-surface (normally glassy, granular and yellowish-pink). The colloid is transparent, yellow or brown in color, and rises above the cut-surface. Cysts of varying size are very common, likewise encapsulated adenomata. A firm, yellowish, moderately enlarged thyroid is often seen in cases of pulmonary tuberculosis. Increase of the stroma with hyaline change and calcification is common. The most important pathologic conditions of the thyroid are: goitre (struma diffusa, nodosa, maligna, benigna, parenchymatosa, hyperplastica, adenomatosa, colloides, gelatinosa, cystica, vasculosa, fibrosa, hæmorrhagica, calculosa, ossea, amyloides, inflammatoria, etc.), inflammation (thyreoditis simplex, purulenta, abscess), neoplasms (carcinoma the most common form of malignant tumor, sarcoma not rare, adenoma and cystadenoma very common, combinations of sarcoma and carcinoma have been observed; other forms rare), granulomata (tubercles and gummata are rare), parasites (echinococcus). Especial examination should be made of the thyroid in cretinism, myxœdema, all forms of cachexia of unknown etiology, infantilism, lymphatic constitution, unexplained death, rachitis, chondrodystrophia, acromegaly, giantism, idiocy, etc. In marked constitutional disturbances conditions of athyreosis, thyreoplasia and hyperplasia of the thyroid may play an etiologic rôle. Accessory thyroids are not uncommon in the neck, in the supraclavicular fossæ and behind the sternum. They usually show the structure of fœtal adenomata, but may become cystic or undergo carcinomatous change.

10. Parathyroids. These organs are usually four in number, sometimes more, sometimes only one or two. They are usually paired, and are found near the inner posterior borders of the lobes of the thyroid, near the two terminal branches of the inferior thyroid artery. They vary in size from 3-15 mm. in length, 3-4 mm. broad, by 1-2 mm. in thickness. They are normally brown in color, and soft in consistence. It is often difficult to distinguish them from the hæmolymph nodes that are common in this region. The parathyroids should be examined in all cases of tetany, paralysis agitans, acromegaly, epilepsy, infantile atrophy, myotonia and obscure cachexias. Conditions of supposed hypoparathyreosis have been reported. Hypertrophy of the parathyroids has been observed in acromegaly. Adenoma has been described by several writers. Cysts, fatty degeneration, fatty infiltration, colloid degeneration, cloudy swelling and tuberculosis have been reported as occurring.

11. Cervical Lymphnodes. Note number, size, color, consistence, character of cut-surface, etc. The most important pathologic conditions are: tuberculosis, secondary carcinoma, Hodgkin’s disease, lymphosarcoma (leukæmic and aleukæmic), various forms of inflammation, dermoid and epidermoid cysts, cystic lymphangioma (congenital cystic tumor of the neck), branchiogenic carcinoma, and hyperplasia in syphilis, rachitis and status lymphaticus. In acute inflammation the lymphnodes are red and soft; in chronic inflammation they are usually grayish-white and firm.

12. Salivary Glands. The parotid, submaxillary and other salivary glands are examined as to size, color, consistence and character of cut-surface. The most important conditions are: parotitis (epidemic and secondary), chronic inflammation, calculi, cystic dilatation of ducts [ranula], Ludwig’s angina, salivary fistula, granulomata (tuberculosis, syphilis and actinomycosis), neoplasms (most common forms are the mixed tumors containing cartilage, fibrous connective-tissue and myxomatous tissue and cords or rows of cells regarded by some observers as endothelial, by others as epithelial; other less common tumors are adenoma, fibroma, carcinoma and sarcoma). Symmetrical enlargement of the salivary and lachrymal glands occurs as the result of aleukæmic or leukæmic lymphocytoma (“Mikulicz’s disease”).

13. Cervical Vessels and Nerves. Examine the arteries and veins, noting contents, thickness and character of walls, size of lumen, changes in the intima, sclerosis, atheroma, calcification, thrombosis, embolism, etc. In death from strangulation or hanging the intima of the carotids may be torn. The aorta is usually examined after the section of the neck-organs. Note size of lumen. In the adult it usually admits the index-finger or thumb. The circumference of the thoracic aorta is 4.5-6 cm.; that of the abdominal aorta is 3.5-4.5 cm. Note its elasticity, contents, thickness of wall, changes in intima, etc. Fatty degeneration of the intima, sclerosis, atheromatous plaques and ulcers, calcification and thrombosis are the most common conditions. Syphilis is a very common cause of mesaortitis, shown by linear or radiating depressions of the intima. The carotid gland (paraganglion intercaroticum) at or near the division of the carotids should be noted. It is about the size of a rice-grain, oval, vascular and of firm consistence, resembling very much the superior cervical ganglion. Alveolar tumors apparently primary in this gland have been observed by a number of writers. Its epithelial nature is denied by some observers who class it with the sympathetic system. The nerves and ganglia should be examined and any change from the normal noted, such as atrophy, effects of pressure, involvement in scar-tissue, hæmorrhage, inflammatory processes, neoplasms, etc.

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.