EXAMINATION OF THE MOUTH AND NECK.
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.)
[Illustration:
FIG. 44.—Removal of neck-organs, when skin-incision is carried to
the chin. The same cuts through the soft palate are made, when the
knife is pushed up beneath the loosened skin of the neck. (After
Nauwerck.)
]
As soon as the floor of the mouth is opened and the tongue loosened
from the lower jaw the left hand is introduced beneath the skin,
through the incision, into the mouth, and the tongue seized by
thumb and middle finger, and drawn forcibly downward, while the
other fingers are used to lift up the skin from the knife. The long
section-knife, with cutting edge turned toward the left, is then
introduced in the median line, along the left hand, until its point
reaches the hard palate, taking care to work the point back slowly
until it reaches the border between soft and hard palate. This must
be done by feeling rather than by sight. The block under the neck
is then pushed up under the head and the chin thrown forward so
that the point of the knife is directed at right angles against the
cervical vertebræ. The soft palate is then cut to the left, while
the tongue is pulled firmly downward and toward the right, putting
the uvular arch on a stretch so that the knife passes around the
left tonsil. The knife is then turned and the same cut made on the
right, severing the right faucial pillar and tonsil, while the
tongue is pulled downward and to the left. The point of the knife
is then pushed back to the pharyngeal wall and the latter is cut
from right to left by a strong, firm stroke directed at right angles
to the surface of the upper cervical vertebræ. The cut through the
pharyngeal mucosa should be at the level of the boundary between the
laryngeal and nasal portions, at about the height of the axis. While
this cut is being made firm traction should be kept up on the tongue,
pulling it downward, and alternately to the left and right. The loose
retropharyngeal and retroœsophageal fascia tears easily and the
mouth organs can now be pulled so far downward that first transverse
and then oblique cuts through this fascia can now be made upon the
vertebræ, severing the vagi, carotids and jugulars, and working
from above downward, until the mouth and neck organs can be lifted
up through the skin-incision and the entire mass of the neck-organs
separated from the spinal column as far as the clavicles. Pulling the
mass toward the right, the left subclavian vessels and fascia are
severed by a cut directed downward and outward beneath the clavicle.
Traction is then made toward the left and the right subclavians cut
beneath the clavicle. If the thoracic organs have been removed the
œsophagus and aorta may now be stripped down to the diaphragm and
there cut off, or the neck-organs may be cut off at the level of the
bifurcation of the bronchi.
The organs, having been removed, are placed on the board, œsophagus
upward, and the tip of tongue toward the prosector. The =tongue= is
then cut in the median line and the cut surfaces examined. Transverse
cuts may be made when indicated. The uvula is then lifted up and
examined; and the =tonsils= and =palate= next examined, the former
by means of longitudinal incisions. The intestinal shears are now
introduced through the fauces into the œsophagus and the left pillar
cut between the uvula and the tonsil. The posterior wall of the
=pharynx= and that of the =oesophagus= for its entire length is
then cut in the median line, and these structures examined. After
the examination of the larynx from above, the long blade of the
intestinal shears is introduced into the =larynx= and =trachea=, and
these are cut in the posterior median line into the right bronchus.
The œsophagus is pulled to the left (prosector’s right) out of the
way. The left bronchus is opened by a special incision to avoid
cutting aorta and œsophagus. The larynx is now lifted up and held in
both hands with the thumbs on the horns of the thyroid cartilage, and
the fingers outside, and the larynx opened by forcibly bending back
or breaking the cartilage, so that the entire interior of the larynx
can be examined without touching the mucosa.
The neck-organs are now turned over, with the aorta toward the
prosector and the tongue pointing away. The right and left lobes of
the thyroid are opened by oblique cuts running from above downward
and inward, and the isthmus is cut sagittally. The =parathyroids=
must be dissected out behind and below the thyroid, along the
course of the terminal branches of the inferior thyroid artery.
The =parotid=, =submaxillary= and =sublingual glands= and the
=cervical lymphnodes= are opened by longitudinal cuts. The =aorta=,
=carotids=, =jugulars= and their branches are opened with the curved
or probe-pointed scissors. The =vagus=, =superior= and =inferior
laryngeal nerves= and the =cervical sympathetic ganglia= are to
be examined when the case requires it. The examination of the
neck-organs then closes with the inspection of the =muscles= of the
neck and the =cervical vertebrae=.
If permission cannot be obtained for the complete removal of the
mouth-organs, the neck-organs may be removed by cutting them
transversely against the vertebræ between the hyoid bone and
thyroid cartilage and then stripping them from the vertebræ and
removing them as in the method given above. The skin-incision in
such cases need not be carried higher than the collar-line, the
skin of the neck being loosened by a subcutaneous dissection.
When permission is withheld for the removal of the neck-organs
they may be examined _in situ_, by freeing the skin of the neck
by a subcutaneous dissection, cutting the lobes and isthmus of
the thyroid in place and then opening the trachea and larynx by
an anterior median incision. The salivary glands, parathyroids,
cervical lymphnodes, vessels and nerves can all be examined by this
method without removing the organs as a whole.
In cases of aortic aneurism, corrosive poisoning, carcinoma of
œsophagus, trachea or bronchi, it is best to remove the neck-organs
in connection with the thoracic, removing first the neck-organs
down to the clavicles and then stripping all down to the diaphragm,
where they may be cut off and examined outside of the body. In
cases of poisoning it is often necessary to remove the œsophagus
in connection with the stomach. The mass of neck- and thoracic
organs are removed as far as the diaphragm and then allowed to lie
over the edge of the thorax or are turned down over the abdomen so
that the œsophagus is upward and the tongue toward the prosector.
The œsophagus and aorta are then separated from the other organs
and left in the thorax to be examined later in connection with the
abdominal organs.
If the thoracic duct was not examined when the thoracic organs
were, it may be examined after the section of the neck-organs is
finished, but it is more easily found after the method given above
by turning the right lung over into the left side of the thorax and
then looking for it in the neighborhood of the diaphragm, on the
right side behind the aorta and between it and the azygos vein.
It runs upward toward the left to the body of the last cervical
vertebra, then over the left subclavian artery downward to the left
innominate vein.
II. POINTS TO BE NOTED IN EXAMINATION OF THE MOUTH- AND NECK-ORGANS.
1. =Mouth.= Contents (blood, mucus, stomach-contents, foreign-bodies,
etc.), color of mucosa (normally grayish-red), vesicles (aphthæ),
cheilitis, gingivitis, various forms of stomatitis, noma,
scorbutus, Ludwig’s angina, ulcers (syphilis, carcinoma, decubital,
tuberculosis), hyperkeratosis, macrocheilia, thrush, scars, wounds,
action of corrosives, lead-line, neoplasms, etc. Note pillars of
fauces, size, shape and condition of uvula. If the teeth have not
been inspected during the general examination they should receive
attention at this time. Note malformations, anomalies, neoplasms
(adamantoma, odontoma, dental osteoma, various forms of cysts,
epulis, giant-cell sarcoma, papilloma, fibroma, etc.)
2. =Tongue.= Mucosa normally is moist and grayish-red. Note
discolorations, coatings, crusts, scabs, exudates, various
forms of stomatitis, “geographical tongue,” glossitis, abscess,
fissures, ulcers (syphilis, carcinoma, decubital), chancre, wounds,
action of corrosives, scars (epilepsy, syphilis), tuberculosis,
neoplasms (carcinoma, lymphangioma, hæmangioma, papilloma, leukæmic
lymphocytoma, adenoma, thyroid adenoma [struma baseos linguæ], and
rarely sarcoma, congenital fibroma, lipoma, myxoma, chondroma,
osteoma and dermoid cysts), thrush, actinomycosis, leprosy, trichinæ,
cysts (lymphangiectatic), hyperkeratosis, leukoplakia, “black hairy
tongue,” macroglossia, partial or total hypertrophy. All forms of
syphilitic lesions may be found upon the tongue (chancre, condyloma,
plaques, papules, fissures, rhagades, ulcers, gumma, etc.) “Smooth
atrophy” of the base of the tongue is regarded by various authors as
pathognomonic of tertiary or congenital syphilis. Cysticercus and
echinococcus are very rare.
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.