THE EXAMINATION OF THE THORAX.
I. METHODS OF EXAMINATION.
1. =Thoracic Cavity.= As soon as the sternum is removed the =anterior
mediastinum= and the =pleural cavities= are examined, noting first
the =position= and =relation= of the =thoracic organs=, quantity and
character of mediastinal fat, the contents of the pleural cavities,
pleuritic adhesions, etc. Pleuritic exudates should be removed before
they have become mixed with blood from the cut vessels or heart; and
the pleural surfaces should be examined before their appearance has
been changed by exposure to the air or to fluids. Pleuritic adhesions
should be broken or cut, beginning with the left side and then on the
right, and the entire surface of both lungs wholly freed.
2. =Thymus.= The thymus is then examined by means of transverse cuts;
or, when large, is dissected from below upward, turned up onto the
neck, and removed later in connection with the neck organs. When
no traces of thymic tissue are visible to the naked eye the thymic
fat should always be cut transversely and examined for the presence
of small lymphoid nodules. In the case of hypertrophic thymus
the question of pressure upon the trachea becomes of very great
importance, and, to settle this, the trachea should be opened above
the sternum before the thymus is removed; or the thymus may be taken
out in connection with the trachea and both sectioned horizontally
at the same time. In cases of sudden death, in which the thymus may
be an etiologic factor, it is safest to examine the trachea from
above the sternum before the thorax is opened, or to fix the whole
body (infant’s or child’s) in formalin and then to remove thymus with
trachea, and examine by means of transverse sections.
The heart is examined before the lungs chiefly for two reasons:
Its blood-content can be more accurately determined, and the blood
caught in the pericardial sac, so that when the pulmonary vessels
are cut in the removal of the lungs there is no gush of blood into
the pleural cavity.
3. =Pericardial Sac.= This is next examined with respect to the
degree of intrapericardial tension. Its anterior wall is then picked
up at about its middle by the thumb and index finger of left hand,
and the point of the long section-knife, with cutting edge outward,
is pushed through the pericardium and a small slit made into the sac.
The escape of gas or air should be noted at this time. A sterile
pipette may now be introduced and the fluid contents of the sac
secured for bacteriologic examination; or before the pericardial sac
is opened the pericardium may be seared with a hot iron and a sterile
pipette pushed through it into the cavity. The longitudinal incision
through the pericardium is now extended upward to its attachment to
the great vessels, and through the opening thus made the character
and amount of the pericardial fluid are determined. The incision is
then extended to the left at its lower end by cutting the sac-wall
toward the apex of the heart. Through the three-cornered incision
thus made the heart is lifted out of the sac and the surfaces of the
parietal and visceral layers of the pericardium examined. Localized
adhesions of the pericardium may be cut or torn, extensive or
complete adhesions may be separated when this is possible; if this
cannot be done, the pericardial layers are cut with the heart wall.
4. =Section of the Heart.= The heart may be examined either in the
body or outside. The choice of several methods may be taken, and
the one most convenient and easy of performance is advised, rather
than a method based upon such considerations as the direction of
the blood-current in the normal body. The chief essential is to
expose completely the interior of the heart with the least possible
disturbance of anatomic relationships, and to accomplish this in
the simplest and easiest way. Such a method must leave the heart
in such shape that it can be reconstructed for histologic study or
utilized as a museum specimen. This can be accomplished by a modified
_Rokitansky_ method, as follows:
The heart is first carefully inspected as it lies in the pericardial
sac. The apex is then lifted in the left hand and the posterior wall
inspected. The heart is then drawn up over the right edge of the
ribs, so that the left border of the heart presents uppermost as
the line of greatest convexity. The point of the narrow brain-knife
(amputation-knife), with cutting edge upward, is then inserted
through the wall of the left ventricle at the apex, just to the left
of the septum, and the knife pushed into the cavity until the point
can be forced through the ventricular wall just below (ventricular
side) the left auriculoventricular ring, and the ventricle-wall is
then cut upward (as the heart is held) to the apex, in the line of
greatest convexity, exposing the cavity of the left ventricle. The
knife is laid aside and the ventricle is explored with the fingers
of the right hand and the size of the mitral opening estimated.
Before the fingers are introduced through the valvular openings
the flaps should be carefully examined to see that no vegetations,
thrombi, etc., are in danger of being loosened by them. With the
opening of the heart-chambers the blood, if fluid, may pour out into
the pericardial sac and flood the pleural cavity if not prevented
by sponging or by removing it by means of a beaker. The knife is
then introduced on the flat through the mitral opening into the left
auricle in a line continuing the first incision with the junction of
the left pulmonary veins. (See Fig. 38.) The knife is then turned
with cutting-edge upward, the point thrust through the upper left
pulmonary vein or between the left pulmonary veins, and the auricular
wall is cut upward (downward anatomically) to meet the first incision
below the mitral ring. The incision should pass between the mitral
segments. The left auricle, mitral ring and flaps and the greater
portion of the left ventricle are thus exposed and should be
inspected.
[Illustration: FIG. 38.—Section of left ventricle and auricle, when
heart is examined in the body. (After Nauwerck.)]
The heart is then taken in the left hand and held by the anterior
flap of the left ventricle, with the fingers inside the ventricle
and the thumb on the outer surface of the anterior wall of the left
ventricle, and lifted up vertically out of the pericardium. The
brain-knife held perpendicularly, with cutting-edge to the right, is
pushed through the right ventricular wall just to the right of the
septum, carried across the cavity of the ventricle, to engage again
in the ventricular wall in the line of greatest convexity, just below
(anatomically) the right auriculoventricular ring, and the wall is
then cut upward to the apex. The right ventricular cavity is thus
opened, the fingers are introduced to explore the tricuspid ring, and
the cavity and contents are inspected. The knife, held flat, is then
carefully introduced through the tricuspid opening into the right
auricle, the cutting edge outward, and its point thrust through the
wall of the auricle midway between the superior and inferior venæ
cavæ, and the auricular wall and tricuspid ring are cut upward toward
the apex to meet the first incision into the right ventricle. If
sufficient care is taken the incision will fall between the anterior
and posterior cusps. Right auricle, tricuspid flaps and ring, and the
right ventricle are thus exposed for inspection.
The heart is then drawn downward and allowed to lie flat in the
pericardial sac, and the pulmonary artery is then explored with the
fingers of the right hand. While the anterior wall of the right
ventricle is held by the thumb and index-finger of the left hand the
knife is then introduced, on the flat, along the right side of the
septum, into the pulmonary artery; the edge is turned upward and the
point pushed through the wall of the artery, about 3 cm. beyond the
ring, and a cut made toward the apex through the anterior wall of the
artery, pulmonary ring and anterior wall of right ventricle, just
to the right of the septum. The pulmonary artery, ring, pulmonary
flaps, and right side of auricular and ventricular septum are now
inspected. In cutting the pulmonary ring care should be taken to make
the incision between the two anterior cusps.
With the heart still lying flat in the pericardial sac, the aortic
opening is explored by the index-finger of the right hand and the
size of the ring estimated. The knife is then introduced on the flat,
into the left ventricle, along the left side of the septum, through
the aortic opening and as far as possible into the aorta. It is then
turned, with the cutting edge upward, and the point pushed through
the anterior wall of the aorta. The heart is then drawn downward and
slightly raised by the left hand, holding it at the apex by the two
flaps of the right ventricle. The knife is then drawn from above
downward toward the apex, cutting in succession the anterior wall of
the aorta, across the pulmonary artery, through the aortic ring, and
the anterior wall of the left ventricle, just to the left side of
the septum. By dissecting away the pulmonary artery from the aorta
the incision through the former may be avoided. (See Fig. 41.) When
desired this cut may be brought down through the septum instead, but
if the bundle of His is to be studied in serial sections the cutting
of the septum should be avoided. The enterotome or long straight
shears may be used for all the incisions except the first ones made
into the ventricles. For these the knife is necessary. The incision
through the aortic ring usually cuts the anterior segment, but by
making the cut more to the right the incision will pass between the
anterior and the right posterior flaps.
Before the valvular orifices are cut it is often expedient to test
the adequacy of the valves by means of water or air. The hydrostatic
test is employed to the best advantage in the case of the pulmonary
and aortic valves, either by pouring water into the vessels, or by
immersing the heart in water and then lifting it up quickly. In the
case of the auriculoventricular valves the air-test is carried out
by inserting the nozzle of a bellows through an opening made in
the ventricular wall and noting the effect of blowing and suction.
Graduated cones or balls may be used for more accurate measurement of
the orifices, or they may be measured after they have been cut.
If sufficient care is exercised in cutting the valvular rings
the incision can be carried between the flaps without injury to
the latter. This is often desirable in cases of valvular lesion,
endocarditis, etc. In such cases the valvular rings may be left
uncut, the line of incision being broken by the auriculoventricular
ring, when the mitral and tricuspid valves are concerned. The
pulmonary and aortic rings may also be left uncut; the incisions are
stopped at the rings, and then begun again in the vessel-walls beyond
the valves.
When bacteriologic examinations of the heart-contents are to be made
the wall of the auricles or right ventricles can be seared with a
cautery and a pipette introduced through the seared area; or the
heart can be opened with a sterile knife, care being taken not to
introduce the fingers into the opening or to permit the entrance of
water.
Excellent preparations for the museum or for demonstration purposes
can be made by distending the heart with alcohol or formalin. Blood
and blood-clots should first be washed out. When fixed the heart may
be sectioned in various planes, leaving the segments attached by the
epicardium posteriorly, or openings may be cut in the walls. A very
good picture of hypertrophy and dilatation is obtained by making a
transverse cut through the ventricles midway between apex and base.
Alterations in the form and position of the ventricular septum are
best seen by this method.
After the opening of the heart and the inspection of the orifices,
valves and auricular and ventricular septa, the coronary vessels
should be examined by transverse cuts, or opened by fine
probe-pointed scissors, beginning at their origin in the aorta. The
auricular septum should be carefully examined for possible defects.
While this is being done the wall should not be put on the stretch,
but should be lax. The auricular appendages should be cut open from
the auricles and examined for thrombi, which are of not infrequent
occurrence in them. The mouths of the coronary veins and the veins
of Thebesius should be examined also. The cardiac muscle is examined
by parallel, vertical or horizontal incisions. The papillary muscles
should be cut longitudinally from apex to base. The cardiac plexus
and the ganglion of Wrisberg should be examined before the heart is
removed.
When the heart is in a state of rigor mortis the contraction should
be made to pass away by kneading or by the application of heat,
before the organ is opened, or before any measurements are taken.
After the heart has been opened it may be removed for weighing.
The heart may be removed first and then opened outside of the
body. The organ is grasped in the left hand and lifted vertically
and upward toward the head as far as possible, putting all of the
attachments on the stretch. The vessels are then cut from below
upward, first the inferior vena cava, then the pulmonary veins, the
superior vena cava, pulmonary artery and lastly the aorta. (See
Fig. 39.) The vessels should be cut as closely as possible to their
exits through the pericardium, and care must be taken to get out the
auricles entire.
[Illustration: FIG. 39.—Removal of Heart. Dark line shows incision
through vessels. (After Nauwerck.)]
After removal from the body the heart is placed upon the board with
its anterior surface up, and the apex toward the operator. It may
then be opened by the same method given above, by inserting the
point of the brain-knife into the left ventricle just to the left of
the septum, and cutting first the wall of the left ventricle along
its left border as far as the mitral ring, exploring the mitral
orifice, and then cutting it and the auricular wall into the upper
left pulmonary vein with the long shears. The right ventricle,
right auricle, pulmonary artery and finally the aorta are opened
in succession, using the enterotome for all cuts except the first
opening of the ventricle. The first incisions into the ventricles
can be made very conveniently by holding the heart vertically with
apex up, and the ventricle to be opened toward the prosector. The
brain-knife is held vertically and its point inserted into the
ventricle, just to the right or left of the septum, according to the
ventricle to be opened, then carried across the cavity and pushed
through the ventricular wall below the auriculoventricular ring, and
the wall is then cut toward the apex. The remaining incisions are
most easily made with the enterotome when the heart is held flat on
the board with its anterior surface up. When the heart is opened
outside of the body the Virchow method of opening in the direction
of the blood-stream may also be used. (See below.)
Under certain conditions other methods must be employed for the
examination of the heart. In cases of suspected aneurism, pulmonary
embolism, patent ductus arteriosus, etc., the thoracic organs should
be removed _en masse_ and dissected on the table. They may be removed
in connection with the neck-organs or alone. In the latter case the
trachea is cut transversely above the sternum, the fingers of the
left hand introduced into the trachea, and, while traction downward
is being made with force, the œsophagus and cervical vessels are cut
transversely, the trachea and vessels stripped down to the level
of the clavicle, and the subclavian vessels cut on both sides. The
thoracic organs are then stripped from the vertebræ down to the
diaphragm and cut off just above the latter.
The pulmonary artery may be examined _in situ_ before the heart is
opened by thrusting a sharp-pointed scalpel through the wall of the
artery just beyond the valves and cutting upward to the branches
going to the right and left lungs. This incision may be extended
downward through the pulmonary valve and the anterior wall of the
right ventricle, and the right side of the heart first exposed.
=Virchow Method.= The heart is rotated toward the left side
of the cadaver so as to bring the venæ cavæ into view, and is
held by the index-finger and thumb of left hand. An incision is
then made in the wall of the right auricle, beginning midway
between the two cavæ and extending downward as far as the right
auriculoventricular ring, in the direction of the right ventricular
ridge. The tricuspid is examined from above. The tricuspid ring
may be left uncut and an incision made in the ventricle-wall,
beginning just below the valve and extending downward along the
right ventricular ridge to the septum, or the incision may be
carried down in the same line passing through the tricuspid ring.
The long narrow-bladed knife or the enterotome is introduced into
the right ventricle and an incision made from the middle of the
first incision, just above the insertion of the anterior papillary
muscle, through the pulmonary orifice into the pulmonary artery,
passing between the two anterior leaflets of the pulmonary valve.
The heart is now drawn up on the right edge of the ribs so that
the left ventricular border presents uppermost. The left auricle
is then opened by an incision beginning in, or just below, the
lowermost pulmonary vein and extended in the direction of the left
ventricular ridge as far as the auriculoventricular ring. Beginning
just below the ring an incision is made through the entire length
of the left ventricular ridge as far as the apex and to the septum,
which lies usually beyond the apex. A second incision is then made
in the left ventricle from the apex, extending through the anterior
ventricular wall close to the septum, parallel to the descending
branch of the anterior coronary artery and about 1 cm. from it,
and passing through the aortic opening between the anterior and
the right posterior cusps. This is the more easily accomplished
if the pulmonary artery has been dissected away from the aorta, so
that the incision can be carried well over to the right. (See Fig.
41.) As the chambers of the heart are opened the contents should
be inspected, clots removed, and the valvular orifices examined
from the upper side. The coronary arteries are then opened with the
fine probe-pointed scissors. When the heart has been removed from
the body it may be opened on the board by following the method as
given above. The heart is held very conveniently for the Virchow
incisions by putting the four fingers of the left hand beneath it
and the thumb on the anterior surface; complete pronation puts
the heart in the position for opening the right side; complete
supination gives the position for opening the left side.
[Illustration: FIG. 40.—Section of right auricle and ventricle,
according to Nauwerck.]
[Illustration: FIG. 41.—Incision for opening of aortic ring; same
for all methods described in text. (After Nauwerck.)]
=Nauwerck Method.= By this method the left auricle, left ventricle,
right auricle and right ventricle are opened in succession. The
heart is seized in the left hand, and without rotation is drawn
upon the right edge of the ribs. Beginning in the upper left
pulmonary vein or between the veins an incision is made through
the wall of the auricle to the sulcus circularis, avoiding any
injury to the coronary vessels. Beginning below the mitral ring
an incision is carried along the left ventricular ridge to the
apex. The left auricle and ventricle are then cleared of blood
and the mitral opening examined. The heart is then put back into
its natural position; the left thumb is placed in the apex of the
left ventricle and the four fingers passed over the right border
of the heart to its posterior surface, rotating the heart to the
left until the right auricle is brought uppermost. (See Fig. 40.)
Then an incision is made through the wall of the right auricle,
beginning midway between the superior and inferior venæ cavæ and
extending to the tricuspid ring, then begun again 1 cm. below, is
carried along the right border of the heart, or slightly anterior
to it, as far as the septum. (See Fig. 40.) The contents of right
auricle and ventricle and the tricuspid valves are now inspected.
The heart is then removed from the body by lifting it up vertically
as far as possible and cutting the vessels from below upward as
close as possible to their exits through the pericardial sac. The
hydrostatic test is then applied to the aortic and pulmonary valves
by pouring water into these vessels, or by immersing the heart an
water and then lifting it out. The heart is then laid flat on the
board with apex toward the operator. The enterotome is introduced
into the right ventricle and through the pulmonary orifice and an
incision made through the anterior wall of the right ventricle,
beginning just above the anterior papillary muscle at about the
middle height of the ventricle, and cutting through the pulmonary
conus and pulmonary valve well to the left, close to the septum,
following the narrow ridge of fat at the base of the artery so as
to pass between the left anterior and posterior segments. The heart
is then rotated on its vertical axis so that the right auricle is
turned toward the prosector, and the tricuspid ring is opened with
the intestinal shears. The auricular appendage is then cut open
from the auricular incision. The heart is then held in its former
position and an incision is made in the anterior wall of the left
ventricle just to the left of the septum, from the apex through the
aortic ring and the left wall of the aorta, while the pulmonary
artery is pulled to the right. (See Fig. 41.) Care must be taken
not to damage the right border of the base of the mitral; the cut
should pass half way between the pulmonary orifice and the left
auricular appendage, cutting the left aortic flap. If it is desired
to save the cusps the pulmonary artery may be dissected from the
aorta and the incision carried between the right posterior and the
anterior valve-flaps. The heart is again rotated toward the right
and the mitral ring is cut with the enterotome, which is introduced
from the left auricle into the left ventricle. The left auricular
appendage is then cut open. The heart-wall is then examined by
means of parallel vertical or horizontal incisions. The papillary
muscles are cut longitudinally from apex to base. The coronary
vessels and their branches are then examined, partly from the aorta
and partly from the incisions through the muscle.
=Prausnitz Method.= The heart is removed and held in the palm of
the left hand and two vertical incisions are made on either side
of the septum, parallel with it, and extending from base to apex.
Two other incisions are then made from base to apex on the outer
borders of the ventricles, connecting at the apex with the first
incisions. The ventricles are opened by the triangular flaps of
the anterior wall thus formed, these flaps being attached at the
base of the heart. The contents of the cavities are examined and
removed; the valvular orifices and flaps are examined, and the
pulmonary and aortic rings are cut through with the shears by
extending the two incisions made on each side of the septum, taking
care to pass between the cusps.
The heart can also be opened with the long shears alone. The
openings of the two cavæ in the right auricle are connected by
an incision. The auricular appendage is opened by a second cut.
The shears are then put through the tricuspid ring, and this with
the right ventricle is cut, the incision following the right
ventricular border. The pulmonary orifice is then opened by a cut
made along the right side of the septum. The left heart is opened
through the pulmonary veins, cutting first the auricle-wall, then
the mitral ring and ventricular wall to the apex. An incision is
then made along the left side of the septum, through the aortic
orifice into the aorta.
5. =Section of the Lungs.= The general inspection of the pleural
cavities and pleural surfaces is made as soon as the thoracic cavity
is opened, as indicated above. If a pneumothorax is present the
pleural cavity on the affected side is filled with water, the neck
organs are exposed and a tube inserted into the trachea. When air
is forced through this bubbles will escape from the perforation
and the opening can be easily located. When extensive or complete
pleural adhesions are present, so that they cannot be separated, it
becomes necessary to remove the costal pleura in connection with
the visceral layer. This is accomplished by loosening the costal
pleura and subpleural fascia at the cut edge of the ribs with the
blade of the knife, until the fingers and, finally the hand, can be
worked in between the costal pleura and the chest-wall, gradually
separating the two until the entire lung is freed with both layers
of pleura adherent. Firm adhesions at the apex may have to be cut
with the knife. Similar adhesions with the pericardium or diaphragm
may make it necessary to cut out the adherent portion with scissors
or knife and remove it in connection with the lung. When the pleural
adhesions are very firm upon the right side the prosector may find
it most convenient to stand at the left side of the cadaver and
from this position separate the right costal pleura from the chest
wall. An assistant may be of great service in pulling the thoracic
wall outward. The edge of the ribs or cartilages may be covered
with a towel or the skin may be drawn over it to protect the hands.
In extreme cases it may be necessary to saw the ribs and remove
them in connection with the lungs. Sometimes the adhesions may be
separated more easily if the neck-organs are first removed down to
the clavicle, and then, in connection with the lungs, are removed _en
masse_, by means of powerful tugs, from above downward. The apical
and posterior adhesions may be torn fairly easily in this way when
ordinary manipulations in the thoracic cavity have no effect upon
them.
When the pleural surfaces are free the =left lung= is lifted out
of the cavity onto the right edge of the chest-wall, pulling it
forcibly over to the right so that its posterior surface becomes
uppermost. In this position the lung may be sectioned by one or more
main incisions made with the long section-knife, cutting the organ
from apex to base, down upon the ribs in the direction of the main
bronchi and vessels. After the examination of the cut surfaces the
organ may be returned to the cavity. It is better, however, to remove
the lung, and section it outside the body. This is done by cutting
the mediastinal pleura, pulmonary vessels and main bronchus with the
cartilage-knife, while the lung is held upon the right edge of the
thoracic opening, holding the knife so that its blade strikes the
edge of the costal cartilages.
[Illustration: FIG. 42.—Section of left lung. (After Nauwerck.)]
The lung, when free, is placed upon the board with its hilus downward
and base toward the prosector. (See Fig. 42.) It is then held in the
left hand, as shown in the illustration, the thumb holding the lower
lobe, the index-finger between the lobes with its tip upon the main
bronchus, the other fingers holding the upper lobe. With the long
section-knife held slightly obliquely toward the anterior edge the
main-incision is now made in one sweeping cut from apex to base,
along the line of greatest convexity, down upon the main-bronchus
and its chief branches and the large vessels. Care should be taken
not to cut off the bronchi of the two lobes from the main bronchus.
Incisions parallel to the main one may be made, if desired. Usually
it suffices to go carefully over the remaining part of the lung,
feeling it carefully for airless solid areas; if such are present
they may be sectioned separately. The =bronchi= are then opened from
the cut surface by means of the probe-pointed scissors, cutting as
near to the pleura as possible. The sound or director may be used
with advantage in opening up cavities from the bronchi. The position
of the lung should be so changed that the bronchi always extend
away from the prosector in a straight line. The portion of the lung
containing the uncut bronchus should be left hanging over the left
hand to put it on the stretch, thereby facilitating greatly the
opening of the bronchus. The =pulmonary vessels= are opened with
fine probe-pointed scissors from the cut surface. The bronchial
lymphglands are then sectioned with the knife.
[Illustration: FIG. 43.—Section of right lung. (After Nauwerck.)]
The =right lung= is then lifted up out of the thorax onto the
right side of the thoracic opening, and is either sectioned in
this position, or the mediastinal pleura, pulmonary vessels and
bronchus are cut from below upward with the knife, its edge being
directed against the ribs. When freed the lung is placed on the
board, root downward and apex toward the prosector. (See Fig.
43.) The index-finger is put between the upper and lower lobes,
the thumb holds the upper lobe, the other fingers are spread out
over the surface of the lower lobe. The main-incision is then made
in a sweeping cut, from base to apex, along the line of greatest
convexity, the knife-blade being held slightly obliquely toward the
anterior border (see Fig. 43), cutting down upon the main bronchus
and its first division. Other parallel cuts may be made. The middle
lobe is then sectioned by a sagittal incision on its anterior
surface, directed toward its anterior border. The =bronchi, pulmonary
vessels= and =bronchial lymphnodes= are then opened as in the case of
the left lung.
Bacteriologic examinations may be made from smears or cultures made
from the cut surfaces; or, to avoid contamination, the surface
may be seared with a hot iron and the material obtained by means
of a sterile pipette pushed through the seared surface into the
lung-tissue.
The lungs may also be removed by drawing them downward and outward,
away from the root, while the bronchi and pulmonary vessels are
cut, the knife being directed against the vertebræ, care being
taken to avoid cutting the aorta and œsophagus. The lungs are then
lifted up toward the middle line, while the mediastinal pleuræ are
cut. The section of the lungs may be carried out, if so desired,
from the root, the main bronchus and then all of the branches as
far as the pleuræ being opened up by means of the probe-pointed
scissors. Other incisions may be made if desired.
As mentioned above, it is sometimes more convenient to remove the
thoracic organs _en masse_, either alone, or in association with
the neck organs. When this is done the dissection follows the
method of Letulle (see above), or the organs may be separated and
sectioned according to the methods just given.
The section of the heart usually precedes that of the lungs, in
order that the blood-content of the former may be more correctly
estimated. Under certain conditions it may be more convenient or
expedient to section the lungs first, beginning with the left one.
When the neck-organs are not removed the section of the thorax closes
with the examination of the =aorta, oesophagus=, =thoracic duct= and
=thoracic vertebrae=. The blood-vessels and œsophagus are opened
with the curved scissors, from above downward, the contents noted,
and the walls examined. The thoracic duct is best dissected out
from the right side, by cutting along the right side of the aorta
and turning the latter over to the left. The duct is more easily
recognized at its lower end. It may be inflated with the blow-pipe,
or opened with a probe and fine probe-pointed scissors. Sometimes
the duct can be most easily found by removing the left lung and
then turning the right lung over into the left pleural cavity. The
posterior mediastinal tissues are put on a stretch, so that the duct
can be recognized through the pleura. For the examination of the left
subclavian vein the left clavicle should be removed.
II. POINTS TO BE NOTED IN THE EXAMINATION OF THE THORAX.
1. =Thoracic Cavity.= Presence of gas or air (pneumothorax,
infections with colon bacillus, gas-forming bacillus, proteus,
etc.), relative degree of pressure, odor, etc. Measure contents of
each pleural sac; note character of fluid (clear, turbid, bloody,
chyliform, chylous, purulent, fibrino-purulent). Normally the pleuræ
are moist-shining, smooth, grayish, transparent; only a few drops
of fluid found in the cavities. In cases of slowly progressive
cardiac insufficiency large amounts of clear fluid may collect in
the cavities just before death. Non-inflammatory collections of
fluid also occur in general œdema. In these conditions the pleuræ
are not cloudy or dull, while in the case of inflammation the
pleural surfaces are dry, cloudy, dull-shining, injected, rough
or covered with fibrinous or purulent exudate. Examine pleural
surfaces particularly for evidences of inflammation, recent and old
tuberculosis, primary and secondary neoplasms (carcinoma).
2. =Position of Thoracic Organs.= Locate anterior borders of lungs,
apex and borders of heart. The normal lung collapses after the
removal of the sternum. How much of the pericardial sac is left
uncovered by the lungs?
3. =Anterior Mediastinum.= Note character of connective-tissue,
amount and color of fat-tissue, number and size of lymphnodes,
occurrence of œdema or emphysema. An artificial œdema may be caused
by the injection of large quantities of salt solution in the pectoral
region just before death. An artificial emphysema may be produced by
the removal of the sternum. The condition of the large veins in the
upper portion of the mediastinum should be noted before the heart
is removed. Are they lax, moderately full, or distended? Secondary
tumors, hemorrhages, abscesses, œdema and emphysema are the most
common pathologic conditions.
4. =Thymus.= The writer believes that the weights usually given
for the thymus in the new-born are too high, and that 7-10 grms.
represents the usual normal weight. A gland weighing 20 grms. or
more must be regarded as enlarged. The organ reaches its fullest
development at the end of the second year. Atrophy begins then,
developing slowly up to the age of puberty, after that more rapidly.
In adults the thymus normally consists of a mass of adipose
tissue containing lymphoid nodules, in some of which corpuscles
of Hassall persist to old age. Postmortem softening should not
be mistaken for abscesses. The most important pathologic change
is hypertrophy. Pressure of the enlarged gland upon the trachea,
nerves or great vessels may cause thymic stridor, asthma, or thymic
death (“lymphatic constitution”). Enlargement of the thymus may
occur in “status lymphaticus,” exophthalmic goitre, cretinism,
myxœdema, Addison’s disease, acromegaly, myasthenia gravis, epilepsy,
scorbutus, rachitis, tonsillar hyperplasia, adenoids, congenital
syphilis, Hodgkin’s disease, leukæmia, anencephaly, anæmia, acute
infections, or it may exist as an independent affection. Oedema,
congestion, inflammation, tuberculosis, neoplasms, etc., may also
cause an enlargement. Absence of the thymus has been observed.
Primary and secondary forms of atrophy in association with marasmus
occur in children. Note relation of size of thymus to condition of
child; atrophy of the organ is usually coincident with marasmus.
Inflammation, tuberculosis, cysts, primary and secondary neoplasms,
gummata, etc., are not common.
5. =Pericardium.= Note tension of sac, fluctuation, adhesions,
thickness, character of inner surface, contents (amount, color, odor,
presence of fibrin, blood or pus, gas). Normally there are about 5-10
c. c. of clear yellow fluid in the sac. Both peri- and epicardium
normally are moist-shining, smooth, grayish and transparent. Large
amounts of clear watery fluid may collect in the pericardial
sac in slow death in cases of chronic valvular lesions, chronic
nephritis, bronchitis and emphysema, but the surface of the peri-
and epicardium remains smooth and shining. In inflammatory increase
of the pericardial fluid the serous surfaces are dull, cloudy or
dry, and may be covered with a layer of fibrin, the fluid is more
or less cloudy and contains flakes or strings of fibrin, or may be
purulent. The fibrinous exudate may be very extensive and from the
movement of the heart be drawn out into bands, threads or villus-like
prominences (cor hirsutum or villosum). Pericarditis is common in
acute rheumatism, septicæmia, pyæmia, puerperal fever, osteomyelitis,
pneumonia, and as a terminal infection in cardiac and renal
disease. Tuberculosis is one of the most common causes of purulent,
fibrinous and hemorrhagic pericarditis, particularly of the cor
villosum. Examine surfaces for tubercles. The presence of blood in
the pericardial exudate points usually to tuberculosis or malignant
neoplasm, but in small amount may be found in various infections
and intoxications. The age of the pericarditis may be judged by the
amount of organization of the exudate, adhesions, thickenings, etc.
“Milk spots,” “soldier’s spots,” “tendinous patches” or “friction
scleroses” represent hyaline thickenings of the pericardium due
to old pericarditis. Total synechia or atresia of the cavity may
occur. As the result of calcification of an old pericarditic exudate
the heart may be surrounded by a calcareous sheath (“stony heart,”
“petrified heart”). Hæmopericardium results from the rupture of the
heart, aorta, pulmonary artery or coronary vessel. Petechiæ of the
peri- and epicardium are found in pyæmia, septicæmia, hæmophilia,
scurvy, severe anæmia, leukæmia, chronic nephritis, and death from
suffocation and various intoxications. Pneumopericardium may be due
to perforating wounds, or to perforations from lungs, stomach or
œsophagus, or to infections with gas-forming bacilli. Malformations
are rare (diverticula, ectopia). Tuberculosis is usually secondary.
Gummata are rare. Actinomycosis is usually secondary to actinomycosis
of the neck or lungs. Primary neoplasms are rare. Secondary
carcinoma and sarcoma (especially lymphosarcoma) are more frequent.
Cysticercus, trichina and echinococcus are rare.
6. =Heart.= Note more carefully its position, whether displaced to
right or left, location of apex, borders, etc. Relative size compared
to cadaver’s right fist, which is usually a little smaller than the
heart. Weight and measurements:—(The heart should be weighed after it
has been opened, and its cavities freed from blood and clots.)
Average weight in adult male, about 300-350 grm.
Average weight in adult female, about 250 grm.
Normal limits, 200-350 grm.
Weight of heart to body-weight in adult male, 1:169; in the female,
1:162.
Circumference at base of ventricles 25.8 cm., length of ventricles
8-9 cm., breadth 8.5-10.5 cm., thickness 3-3.6 cm.; minimal
measurements are for the female. Auricles are 5-6 cm. in length.
Compare ventricles as to size.
Note form (long, cylindrical, pyramidal, broad, short, round, etc.)
In hypertrophy of the left ventricle the heart is longer and more
cylindrical; in hypertrophy of the right it is broader and more
rounded. Normally the apex is formed by the left ventricle, the
sulcus longitudinalis running to the apex and nearly dividing the
heart into halves. In hypertrophy of the right ventricle the apex
is formed by this ventricle, the sulcus longitudinalis passing to
the left of the apex; in hypertrophy of the left ventricle the
longitudinal sulcus runs to the right of the apex. What part of the
heart lies anteriorly? (Normally a large part of the right ventricle.)
The consistence of the organ, particularly that of the ventricles,
should be noted (firm, flabby, soft, etc.). Condition of the
heart-chambers (empty, contracted, dilated, full). Rigor mortis
should be removed by kneading or by the application of heat. The
amount of subepicardial fat, its color, translucency, occurrence
of serous atrophy, œdema, subepicardial hemorrhage, etc., are
to be noted. In marasmus a serous or mucoid degeneration of the
subepicardial fat is not uncommon. The subepicardial fat increases
with age, and is normally most abundant along the grooves and
blood-vessels, particularly the auriculoventricular grooves and
on the right ventricle. Normally the color of the heart-muscle
of the ventricles should be seen through the epicardium. The fat
is increased in obesity, chronic alcoholism, chronic anæmia,
tuberculosis, etc. When the fat-infiltration is so marked that
the muscle cannot be seen the condition is known as adipositas or
obesitas cordis, or in extreme cases as _lipoma cordis capsulare_.
7. =Right Heart.= Note amount of blood contained in right chambers
(over-distended in death from asphyxiation, pneumonia, etc.), also
its consistence (thick, thin, watery), color (light, dark, red,
yellowish, chocolate, purplish), blood-clots (size, color, cruor,
lardaceous clots, chicken-fat clots, pus-like clots, consistence,
moisture), presence of free fat, gas or air, diffusion of hæmoglobin,
presence of bile-pigment in blood. Note also amount and character
of blood in venæ cavæ. The size of auricular and ventricular
cavities should be estimated, noting condition of trabeculæ and
papillary muscles (atrophic, flattened, hypertrophic, fatty,
fibroid, calcification). The musculature of the ventricular walls
is examined as to its thickness (normally the right ventricle wall
is 4-5 mm. thick). Postmortem contraction should not be mistaken
for hypertrophy. The color of the heart-muscle normally is pinkish
in infants, flesh-red in adults, and brownish-red in old age and
in atrophy following compensatory hypertrophy (brown atrophy).
Under normal conditions the muscle is translucent. In cloudy
swelling the heart-muscle appears cloudy and opaque as if cooked.
Fatty degeneration appears as yellowish, opaque patches or streaks
(“tiger-heart”), particularly in the papillary muscles and trabeculæ.
In severe intoxications the process may be diffuse, and the entire
musculature appear cream-colored or yellowish and opaque. The
consistence may be firm, flabby, soft, putty-like; localized areas
may be caseous. Infarcted areas are soft when fresh (myomalacia
cordis). The consistence is increased in atrophy, fibroid heart,
chronic interstitial myocarditis, syphilis, etc. Cloudy swelling and
fatty degeneration make the heart muscle softer and more friable. In
postmortem decomposition the heart as a whole becomes soft. Normally
the endocardium should be gray, delicate, thin and transparent. The
chordæ tendinæ are long, narrow and delicate. Note thickenings of
endocardium and chordæ tendinæ, presence of thrombi (dry, brick-red,
yellowish or gray, firmer than clots and adherent to the endocardium,
often show simple softening, which should not be mistaken for pus;
may be parietal, polypoid, valvular or free). The endocardium may be
stained diffusely yellow (bile) or brown (methæmoglobin). Creamy or
yellowish opacities of the intima are due to fatty degeneration.
8. =Left Heart.= Note same things in left side of heart as on
right. In cardiac paralysis left ventricle is filled with blood
if rigor mortis has not set in. Left ventricle wall is 10-15 mm.
thick normally; may become 30 mm. thick in hypertrophy. Papillary
muscles and trabeculæ may be markedly hypertrophic, but in the
greatly dilated heart (aortic insufficiency) may be much flattened.
The septum of the ventricles may share in the hypertrophy of either
ventricle and when hypertrophic bulges into the cavity of the
unaffected side. Examine wall of left ventricle, particularly near
the apex, for infarcts, fibroid patches, aneurismal dilatation,
rupture, fatty degeneration, thrombi, etc. Look particularly for
pathologic conditions involving the atrioventricular bundle.
9. =Orifices and Valves.= Orifices should measure as
follows:—Tricuspid (12-12.7 cm.), mitral (10.4-10.9 cm.), pulmonary
(8.9-9.2 cm.), aorta (7.7-8 cm.). Rough measurements may be
taken with the fingers, tricuspid admitting three, mitral two,
pulmonary one and a half, aorta thumb. The orifices may be measured
by graduated cones, or in the ordinary way after the heart is
sectioned. Normally the edges of the valve-flaps should be delicate,
smooth and thin. Examine for vegetations, thrombi, induration,
thickening, contractions, ulcerations, tears, perforations, defects,
calcification, atheroma, valvular aneurism, etc. Note thickening,
contraction, adhesion, shortening, etc., of the chordæ tendinæ. When
the tendons are long, narrow and thread-like, and without adhesions,
the probabilities are that a lesion of the mitral orifice was not
present.
10. =Coronary Vessels.= Walls should be uniformly delicate and
thin, and the intima should be delicate, gray and transparent.
Note contents of arteries and veins. Examine arteries especially
for thrombi, emboli, arteriosclerosis, atheroma, calcification,
obliteration of lumen, thickening of wall, loss of elasticity,
opacity of intima and increased tortuosity of course.
The most important pathologic conditions of the heart
are:—endocarditis (ulcerosa, maligna, verrucosa, simplex, chronica
fibrosa, sclerosing), valvular insufficiency and stenosis,
hypertrophy, dilatation, atrophy, fatty infiltration, fatty
degeneration, cloudy swelling, anæmic infarction, calcification,
acute and chronic myocarditis, abscess, fibroid heart, cardiac
aneurism, rupture, thrombosis, embolism, malformations (septum
defects, patent ductus arteriosus, stenosis or atresia of orifices),
tuberculosis (not rare, in association with tuberculous pericarditis,
or general miliary tuberculosis), syphilis (gumma not common,
localized or diffuse interstitial myocarditis the most common
manifestation), actinomycosis, cysticercus, echinococcus, trichina
and neoplasms (primary rare, in part congenital, fibroma, lipoma,
angioma, myxoma, rhabdomyoma; secondary sarcoma less rare than
secondary carcinoma, most common forms are melanotic sarcoma and
lymphosarcoma).
11. =Left Lung.= Weighs 350-500 grm. _Size_ (voluminous, collapsed,
compare lobes); _form_ (edges rounded, sharp, nodular, saccular or
cystic, contractions, depressions, emphysematous enlargements);
_pleura_ (examine again more closely. Circumscribed dull-shining
or cloudy areas point to some pathologic condition of the lung
beneath. Look for evidences of healed tuberculosis, particularly
in the pleura of the apices. Secondary carcinoma of the pleura is
very common. Primary tumors are rare; endothelioma and sarcoma are
the most common forms. Small circumscribed areas of pigmentation
usually represent old tubercles); _color_ (depends upon degree of
anthracosis, blood-content and condition of pleura, areas showing
especial color should be examined closely; most common colors are
pinkish-gray normally, grayish, slaty, black, red, brown, dark-red
to black); _size of air-cells_ (normally can be seen with naked
eye, best seen at apex and borders, about size of pin-points, when
larger than the head of a pin they are emphysematous); _lobules_ can
also be seen with naked eye, usually polygonal in shape, 2-3 mm. in
diameter; _consistence_ (estimate by going over entire lung, pressing
the lung-substance between thumb and fingers; air-containing lung is
soft, elastic and crepitates; airless areas are hard, firm and do not
crepitate).
On the cut surface the following points should be noted:
_Blood-content_ (anæmia, hyperæmia, hypostatic congestion), _color
of cut-surface_, _air-content_, _exudate_ (serous, purulent),
_consistence_ (hard, soft, elastic, caseous, brittle, crumbling),
_character of surface_ (smooth, granular, nodular, cavities).
Cavities should be described according to their position, size,
shape, contents and character of their walls.
12. =Right Lung.= Weight 420-620 grms. Note size, form, color,
surface, size of air-cells, lobules, consistence, blood-content,
air-content, exudate, consistence and character of cut-surface, as in
case of left lung.
Evidences of healed tuberculosis are found in practically all
adult lungs in the form of localized thickenings or puckering
of the pleura, especially at the apices, hyaline or anthracotic
nodules, encapsulated, caseous or calcified tubercles. Old scars
and indurations are firm, hard and usually black in color. Caseous
areas are smooth, dry, white or grayish, and opaque. Very young
tubercles are elevated, grayish and translucent. Atelectatic areas
are depressed and bluish-red in color. Areas of hepatization are red
or gray, elevated, granular, crumbling, moist in early stage, dry in
caseous hepatization. In bronchopneumonia the areas of hepatization
are usually sharply circumscribed. Metastatic abscesses lie usually
beneath the pleura, are usually multiple and distributed over both
lungs. Bronchopneumonic areas are usually found in the dependent
portions, particularly in right lung. An abundance of foamy, watery
fluid on the cut-surface indicates œdema; when very bloody there
is usually a marked stasis or beginning hepatization present. In
atelectasis and fibrinous hepatization the exudate from the surface
is not foamy. Emphysematous areas are white or grayish-white and
are most frequently found along the borders. Large air-spaces are
often found along the interlobular septa (interstitial emphysema),
particularly in children following trauma, croup, whooping-cough,
etc. In chronic passive congestion the lung is firmer than normal,
deep-red or brownish in color. Hemorrhagic infarcts lie usually
beneath the pleura, are wedge-shaped, with base toward pleura, firm,
smooth on section, or granular, and when fresh are nearly black;
older ones are lighter and brownish. Cavities in the lung occur in
tuberculosis, embolic and primary abscesses, actinomycosis, gangrene,
bronchiectasis, primary and secondary tumors, etc. Gangrenous
areas have diffuse borders, are gray or greenish in color, with
central softened areas, with ragged borders and stinking smell. In
bronchiectatic cavities the smooth mucosa of the bronchus passes
directly into the wall of the cavity. Primary carcinomata of the
lungs appear as cavities having a white medullary wall, or as
medullary strands running along the bronchi. Tuberculous cavities
have caseous walls, are more or less encapsulated, and usually
show younger tubercles in the neighborhood of the wall. Antemortem
hypostasis is usually darker and firmer than postmortem, and is
usually associated with inflammation (hypostatic pneumonia).
The most important pathologic conditions of the lungs are:—Anomalies
(anomalous lobes common, infradiaphragmatic accessory lungs,
agenesia, congenital bronchiectasis), atelectasis (fœtal,
compression, obstruction, paralytic, etc.), emphysema (acute,
chronic, vicarious, senile, atrophic, hypertrophic, interstitial,
gangrenous), hyperæmia, stasis, brown induration, hypostasis,
œdema (universal, stasis, hypostatic, atelectatic, acute, chronic,
terminal), hemorrhage, hemorrhagic infarction, thrombosis, embolism,
fatty embolism, pneumonia (croupous, atypical, bronchopneumonia,
acute and chronic interstitial), abscess, gangrene, tuberculosis
(acute miliary, caseous pneumonia, peribronchial, tuberculous
bronchopneumonia, indurative, fibroid, phthisis pulmonum), syphilis
(gumma, white pneumonia), actinomycosis, neoplasms (primary
adenoma, lipoma, papilloma, chondroma, osteoma, sarcoma, carcinoma
and teratoma are rare; metastatic sarcoma and carcinoma are
common; malignant chorio-epithelioma is not infrequent), parasites
(echinococcus, cysticercus, hook-worm embryos, pentastomum and
distomum pulmonale).
13. =Bronchi.= Note size, contents, thickness of wall, color and
thickness of mucosa. Normally the bronchi are empty, and the mucosa
grayish-red. In pulmonary œdema they contain clear, foamy fluid;
in bronchitis they may contain a mucous, mucopurulent, purulent,
fibrinous, hemorrhagic or putrid exudate. In acute bronchitis the
mucosa is red; in chronic bronchitis the mucosa may be red or
brownish, and thickened or folded. Material from the stomach may
enter the bronchi postmortem and cause a postmortem digestion of the
mucosa or wall.
The most important pathologic conditions of the bronchi
are:—Inflammation (acute and chronic catarrhal bronchitis, fibrinous,
putrid, atrophic, obliterans), bronchial asthma, tuberculosis,
syphilis, stenosis, bronchiectasis, perforation (aneurisms, abscess,
carcinoma, tubercles, etc.), bronchial calculi, foreign bodies,
neoplasms (adenoma, papilloma, carcinoma, chondroma, osteoma),
parasites (cysticercus, echinococcus, hook-worm embryos, distomum
pulmonale, pentastomum).
14. =Bronchial Glands.= Note size, pigmentation (gray, dark-gray,
black), consistence, character of cut-surface, caseation, fibroid
induration, calcification, œdema, congestion, abscess, neoplasm.
Tuberculosis and secondary neoplasms are the most common conditions.
Lymphosarcoma is the most frequent primary tumor.
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.