Practical Pathology

A Manual of Autopsy and Laboratory Technique

FOR

STUDENTS AND PHYSICIANS

BY

ALDRED SCOTT WARTHIN, Ph.D., M. D.
Professor of Pathology and Director of the Pathologic Laboratories
IN THE
UNIVERSITY OF MICHIGAN,
ANN ARBOR

SECOND EDITION
Rewritten and Enlarged

Mortui Vivos Docent

310 PAGES AND 55 FIGURES

ANN ARBOR
GEORGE WAHR, Publisher
1911

Copyright 1897, by George Wahr
Copyright 1911, by George Wahr

ERRATA.

Page [155].—Thickness of gall-bladder wall 1-2 mm. instead of 1-2 cm.
Page [240].—Langhans’ for Langhan’s.
Page [264].—v. Kossa instead of Kossa.
Page [295].—v. Kölliker instead of Kölliker.

HERRN PROFESSOR ALEXANDER KOLISKO
Zur Erinnerung
an die ertragreichen, im Sektions-saale des
Wiener allgemeinen Krankenhauses
zugebrachten Sommertage
der Jahre
1893, 1894, 1895
gewidmet.

PREFACE TO THE SECOND EDITION.

The first edition of this book, in spite of numerous typographic errors beyond the control of the writer, was very soon exhausted. An apology is due the many, to whom, during the last ten years, a new edition has been repeatedly promised. The writer’s only excuse for the failure to fulfill these promises has been the pressure of other work that has prevented such fulfillment. In the final accomplishment of these promises the book has been practically rewritten and more than doubled in size.

The autopsy method given in the main text is a composite one, made up from the Rokitansky, Virchow, Chiari and Nauwerck methods, according to the judgment of the writer as to what was the best in these, and put together with modifications and additions arising out of his own experience. The aim has been to offer a method by which an autopsy can be performed with the greatest speed and ease, and at the same time with the greatest completeness, the various steps of the operation following in logical order in such a way that nothing can be lost or destroyed, and thereby revealing a complete picture of the pathologic conditions present. A choice of methods is offered whenever the aims of the examination may be so varied as to make variations in method advantageous. The general order of the autopsy is the same as that given in the Protocol Blank-book, the present book being designed as a guide and reference-book for that. The points to be noted in the examination of each region are given in connection with the method of examination of that region, and represent the condensed special pathology of the latter. This should be of great service to the beginner in autopsy work, as affording a concise but complete guide to the most important conditions of each region. A textbook on Special Pathology should be used as a reference book in connection with these condensed statements of special pathology.

The technical methods for microscopic examination given in Part II have been brought up to date, and all recent methods of value included. Original methods have been given in preference to modifications; the latter, when of value, are also mentioned. As a rule that method has been chosen which in the light of the writer’s laboratory experience has yielded uniformly the best results. An effort has been made to reduce the number of methods to the lowest number as representing the best and most indispensable ones. During the fourteen years of laboratory experience since the publication of the first edition there has been plenty of time for changes in points-of-view concerning laboratory methods. Then an ardent exponent of celloidin-imbedding as a routine method, the writer has now practically discarded it in favor of paraffin-imbedding and the celloidin-sheet made by the dextrin-sugar or molasses method. This combination method is so superior in every way to ordinary celloidin-imbedding that the latter becomes obsolete except for a limited number of conditions. A number of personal modifications of various methods will also be found in this part of the book; indeed, it is intended to be an expression of individual opinion concerning laboratory methods.

The writer’s views concerning the value of teaching by unknowns,—that is, giving the student preparations or case-material for his own analysis and independent working-out to a diagnosis—are stronger now than they were when the preface to the first edition was written. Experiments with other methods of teaching have always brought me back to this as yielding by far the best results. It accomplishes two things—it not only teaches a knowledge of pathology, but it develops objectivity and the faculties of diagnosis, and accomplishes these with more marked success than any other method of teaching pathology.

Aldred Scott Warthin, Ph.D., M.D.

Ann Arbor, Michigan, May, 1911.

PREFACE TO THE FIRST EDITION.

Pathologic Histology deals with departures from the normal in the various tissues of the body, which, occurring as the sequelæ of disease-processes, or standing in the closest causal relationship to the clinical symptoms and physical signs, constitute the foundation of all diagnostic conclusions, and of all rational therapeutic treatment. Without a definite knowledge of these abnormal changes, of their various forms, of the manner in which they arise and progress, no physician can deal intelligently with disease. The knowledge of the natural history of disease, based upon a knowledge of the normal body, makes the wise and successful practitioner; and to such, the autopsy, the microtome and the microscope must ever stand as constant aids in the satisfying of his intellectual curiosity.

It is, therefore, essential that the student in his undergraduate work should be so trained that, in addition to a broad conception of General Pathology, he may acquire also such a technical knowledge as to fit him to carry on his investigations after leaving the laboratory. Not only in everyday practice in certain lines is a knowledge of this technique necessary for diagnostic purposes, but the true physician should so hold himself toward every problem of diagnosis which presents itself to him, that with every opportunity, he will, through excision, curettage or autopsy, make use of his technical skill to further his knowledge of disease, and to aid his science toward a solution of its great problems.

It is for these reasons, that in my laboratory courses in pathologic histology, I wish to give each student a practical working knowledge of the technique of pathologic investigations. That the student become an expert as the result of such undergraduate courses is neither possible nor desirable; it is only hoped that he may be placed in a position to cope intelligently with the questions awaiting him in the field of practice.

For the guidance of the student toward this end, I have compiled this little book of laboratory methods, endeavoring to make it as practical as possible, but yet thorough and complete. The methods given are taken from the original papers, or from the compilations of Friedländer and von Kahlden, but are modified in many instances according to the writer’s own experience. The autopsy methods are, in the main, those used by Kolisko of Vienna; but methods of Virchow, Chiari, Nauwerck, and others, are also given.

It is from the study of the material itself, and not from the textbook alone, that the student can obtain a proper knowledge of pathologic changes. The most comprehensive textbook can give no adequate idea of the infinite variety of these changes; there is no absolute type, but an endless variety of appearances more or less closely related. Only from a contemplation of this variety is it possible for the student to build up a point-of-view, and to arrive at an independent and unbiased conclusion.

The student who seeks in a preparation only the appearances described in a textbook is not studying in a scientific way. He will constantly accept the author, instead of using his own impressions for the basis of deductions, guided by the experience of others. With an unbiased mind the student should take each specimen for that alone, which it, itself, presents; and upon this he should build his conclusions. He should seek in the textbook the things he finds in the material; not seek in the latter the things he reads in the former. Thus may he escape superficiality, avoid errors and hasty judgments, and build up for himself a sure foundation of knowledge. For these reasons the students in my laboratory course, having been thoroughly prepared for such work by the study of normal tissues in the histologic laboratory, are given the pathologic material as unknowns, which under careful guidance, they are enabled to work out for themselves to a satisfactory conclusion.

The student is further aided in the fixing of his impressions, and in their expression, by means of the drawings and written descriptions which he is required to make of the preparations. In this way the faculties of observation and expression receive a training that is not otherwise possible. It is true that such a course of instruction is difficult for the student whose previous training has been deficient in the cultivation of these most important faculties; for this reason it is the more necessary that he should now apply himself to work in the scientific method.

That this method of teaching takes much more of the instructor’s time is true; that it takes too much time cannot be granted when measured according to the results obtained. The frequent objection of the student that he cannot draw only emphasizes the necessity of that student’s receiving the necessary training to enable him to reproduce his visual impressions.

A greater difficulty lies with the teacher. Not only must he select his preparations with wisdom, so that in the necessarily limited time of the course, the student may receive the greatest benefit; but he must be tactful and patient in leading the student to work for himself. It is easy to give a demonstration and then tell the student to work; it is very much more difficult and nerve-consuming to make the student see and demonstrate for himself. The relation of the microscopic preparation to the gross anatomy must be shown, and, when possible, demonstrated by macroscopic preparations; further, the relation to the clinical symptoms and physical signs must be made clear, so that the student receive not a narrow conception of pathologic histology as something in itself separate and complete, but as a foundation-stone to the broadest conception of diagnosis, whereby the real unity of his studies will be revealed. Moreover, the teacher must be fully awake to individual differences and needs, and carefully shape his teaching influence upon each student accordingly. The problem of the individual equation becomes especially difficult in a course of this kind.

The laboratory course in histologic pathology, in the University of Michigan, follows the general order given in the second part of this book, beginning with the diseases of the blood and the circulation, and finishing with the special pathology of the most important organs. A preparatory training in general technique is first given. About one hundred and seventy-five prepared specimens, each illustrating some especial pathologic point, are given to the class as unknowns for diagnosis. In addition each student is required to prepare about fifty slides from fresh material, performing for himself all of the necessary technical manipulations, according to the methods given in this manual. To further the work in this course, and to meet the needs of advanced students and of practitioners, this book is primarily intended.

Aldred S. Warthin, Ph.D., M.D.

Ann Arbor, January, 1897.

CONTENTS

PART I.
THE SOURCES OF PATHOLOGIC MATERIAL AND THE
METHODS OF OBTAINING IT FOR EXAMINATION.

PART II.
THE TREATMENT OF THE MATERIAL.

LIST OF ILLUSTRATIONS

PART I.

SOURCES OF PATHOLOGIC MATERIAL
AND METHODS OF OBTAINING
IT FOR EXAMINATION.

INTRODUCTION.

The chief sources of pathologic material are the autopsy, surgical operation, diagnostic excision and curetting, the spontaneous discharge of diseased tissue, and the experimental production of pathologic conditions in animals. To these sources may be added the blood and other body-fluids, as well as pathologic fluids, exudates, effusions, cyst-contents, etc., particularly the cellular elements found in the sediment of such fluids.

That an accurate pathologic diagnosis be secured, the material must first be properly obtained, its gross characteristics carefully noted, the portion to be examined microscopically chosen with discrimination, and, finally, the microscopic examination itself carried out along the various lines indicated. All of these procedures require the knowledge of a certain amount of technique, and the general principles of such technique should be familiar to every student of medicine. While it is not possible that every medical graduate can enter into the active practice of his profession as an expert pathologist, yet the possession of the technical knowledge necessary to perform an autopsy properly and to select with discrimination the tissue for microscopic examination gives to a physician a distinct practical advantage. This advantage becomes the greater if to the possession of this knowledge there be added also a practical working knowledge of the technique necessary for the microscopic examination and diagnosis. Not that this knowledge should be so extensive as to cover the great field of special methods; all that is really essential is a knowledge of the general principles of laboratory examinations; and a very large proportion of practical work can be successfully carried out if the physician possesses this foundation knowledge. In the first days of practice a young physician so equipped often finds that his laboratory training comes to be his chief source of income and opens the way to a successful professional career. It constitutes a professional asset which the older practitioner usually does not possess.

CHAPTER I.
THE AUTOPSY: GENERAL CONSIDERATIONS.

1. AUTOPSY (Postmortem examination, necropsy, necroscopy, obduction, mortopsy, section; Latin, sectio cadaveris, sectio anatomica, autopsia cadaverica, sectio, obductio; French, autopsie cadaverique, nécropsie; German, Leichenschau, Section, Obduction) is the term preferably applied to the examination of the dead body, conducted for the purpose of ascertaining the cause of death, for the study of the pathologic conditions present with reference to their nature and cause, or for the obtaining of anthropologic, anatomic or surgical data. When carried out primarily with the view of obtaining evidence of legal importance, as in the case of a suspected crime, accidental death, the identification of a body, in damage suits for injuries received, malpractice, insurance, etc., the autopsy is usually styled medicolegal, or the German term obduction is not infrequently applied. The terms prosector and obducent, although used originally in a medicolegal sense, are now generally applied to the person performing the autopsy whether medicolegal or not.

2. IMPORTANCE OF THE AUTOPSY. The opportunity of performing an autopsy should be regarded by the physician and student as a very great privilege. Even to the prosector with an experience of several thousand autopsies to his credit, each new examination of a dead body becomes a new revelation and extends still farther his intellectual horizon. To the student and physician in practice each autopsy may, if performed in the proper spirit, become in itself an educational factor of the greatest value. In no other scientific procedure is there such a demand made upon the faculties of observation, judgment and interpretation, and in no other is there such intimate correlation between methods of technique and the higher intellectual processes. It is unnecessary to add that the ability to perform an autopsy in the proper manner presupposes a foundation of accurate anatomic and pathologic knowledge as well as a capacity for careful work.

Primarily, the aim of the autopsy is to ascertain the cause of death and to acquire knowledge of the changes produced in the tissues and organs by the disease-process. If for no other purpose than that of extending our knowledge of disease, the autopsy becomes the most valuable factor in furthering the development of medical science. We have but entered into the broad, rich fields of pathology; at any time new facts may be discovered or observations of the most far-reaching nature made. From year to year the statistics of the most common diseases must be revised in the light of new conceptions of disease. Through the autopsy there lies within the reach of every practitioner the opportunity of contributing something worth while to the general sum of medical knowledge. There is not a pathologic condition in the medical category that does not call out for illumination upon some point or other. The phenomena of malignant tumors, the earliest stages of the so-called chronic affections, as well as the majority of the infectious diseases, require further autopsy observations for their elucidation. The autopsy establishment of the diagnosis is also of the greatest importance in giving value to vital statistics. Until we have a more universal confirmation of the clinical diagnosis by the pathologic our vital statistics must of necessity be imperfect.

To the practitioner the autopsy offers further a most valuable control of subjectivity and a guide to methods of diagnosis and treatment. Without such a control no one is so likely to get into a dangerous rut as the practicing physician. The disclosures of the autopsy will enable him to correct faulty methods, and should effectually check any tendency to superficial diagnosis. Particularly is this the case with regard to such diagnostic methods as palpation, percussion and auscultation. Postmortem percussion offers a most valuable means of acquiring precision in this important branch of physical diagnosis. The percussion boundaries may be marked upon the body by pencil, or long pins may be inserted, so that when the body is opened the exact relation of the percussion area to the organ in question may be noted. In the case of palpable tumors the results of palpation before the body is opened should be carefully controlled by the findings when the actual conditions are exposed. Even when the cause of death seems obvious it is worth while to perform an autopsy at every opportunity offered, both for the sake of controlling technical methods and for the pictures of disease revealed. More accurate knowledge of the nature of the processes of disease can be obtained through one autopsy than through months of textbook reading. To the surgeon the opportunity of examining cases dying after surgical operation should be a source of great satisfaction. The review of anatomic relationships offered by the autopsy is in itself worth while, and in the case of healthy individuals killed by accident the survey of the normal appearances of the organs and tissues offers an opportunity for study too valuable to be neglected. Further, it is justifiable to practice upon the cadaver any surgical operation that does not disfigure it. Removal of the spleen, transplantation of thyroid tissue into the spleen, decapsulation of the kidney, transplantation of ovarian tissue, gastric and intestinal operations, anastomosis of blood-vessels, operations upon the uterus and cervix, prostate, vas deferens, thyroid, nose, ear, etc., and many other surgical procedures may be practiced with profit upon a cadaver during the course of an autopsy. The feasibility of a new operative method or the improvement of an old one may thus be demonstrated.

In the case of medicolegal autopsies the ends of justice as well as the life, liberty or reputation of some individual may depend upon the results of the postmortem examination. In all cases to which there is any suspicion attached, or in which the cause or manner of death is doubtful an autopsy should be legally required, but unfortunately this is not yet done in this country. Physicians individually should endeavor to create in the public mind a more healthy attitude toward the autopsy and an appreciation of its usefulness. As to his own share in the advantages derived from it, it is safe to say that no physician can perform an autopsy properly without having his experience widened, his knowledge of disease increased, his diagnostic faculties sharpened and his tendency to subjectivity controlled. Last, but far from being the least, should be his gain in honesty and humility.

3. LEGAL ASPECTS OF THE AUTOPSY. The individual cannot dispose of his dead body without the consent of his nearest heirs, except in those States (New York) providing by statute that a person may direct the disposition of his cadaver. The legal rights to the corpse are vested first in the husband or wife of the deceased; if none, then first in the father, then in the mother; after the parents, in the brothers or sisters; after them in the next of kin, according to the course of common law; and then to the remotest degree according to the law of descent of personal property. An autopsy performed with the consent of the relative having the body in custody cannot be questioned, if it is properly performed. In the case of members of societies requiring autopsies the membership cards or certificates should be endorsed by the nearest heir.

A physician who performs an autopsy without the consent of the person having the custody of the deceased does so at his own risk, except in those cases in which the autopsy is in accordance with legal statutes. In the majority of the States there are statutes providing that the Coroner or Board of Health shall order an autopsy whenever a person is found dead and the cause of his death is not apparent, and cannot be ascertained from the evidence given, or from a superficial examination of the body. In such cases no permit from the relatives is necessary, and an autopsy performed under the direction of law is never subject to legal punishment, if it has been performed according to approved methods. Nevertheless, even in these cases it is a better policy to secure the consent of the custodian of the body, when this is possible.

When consent to an autopsy is withheld and the physician feels that such an examination is necessary, he should turn the case over to the Coroner or Board of Health, and act under such direction. Conflicting decisions, however, have been made in different States. The Supreme Court of Indiana (1909) held that a Coroner cannot order an autopsy unless there was a reasonable supposition that death had occurred from violence or casualty. A suit brought by an Indiana physician to recover fee for an autopsy held on the order and under the direction of a Coroner was set aside on the ground that there was not the slightest suspicion of death from casualty or violence. Such a decision is too narrow and not framed in accordance with the actual needs of the times in so far as the protection or enlightenment of the community is concerned. Under such a decision a Coroner or Board of Health could not in safety order an autopsy in the case of a death in which the diagnosis had not been established clinically, when no suspicion of violence or casualty exists, although the establishment of the diagnosis through an autopsy might be of the greatest importance to the family or community.

On the other hand the Court of Appeals in Kentucky (1906) affirmed judgment for the defendant in a suit for damages brought against a physician for performing an unauthorized autopsy to secure a burial permit, the court holding that, if the autopsy was made in good faith for the purpose of ascertaining the cause of death in order that a burial certificate might be granted, and if the autopsy was made decently with due regard to the sex of the deceased and without unnecessary incisions or mutilations, there could be no grounds for damages. This is a reasonable and just decision and laws framed upon it should be passed in all the States. Autopsies performed under such conditions, however, should always be conducted in the presence of several witnesses competent to testify as to the methods used.

In several States legal authority is given to the Board of Health to order an autopsy whenever the health interests of the people demand such an investigation. Autopsies performed under such orders against the desire of the relatives should always be carried out with extreme care and in the presence of proper witnesses.

State and charitable hospitals cannot be made liable for autopsy performed by Coroner or Board of Health, when the consent of the relatives is withheld. It is high time that all charitable institutions in this country should require an autopsy from all patients dying within their walls. The cards of admission should contain a clause to this effect, and such cards should be counter-signed by the nearest relatives.

Inasmuch as some life-insurance policies contain clauses requiring the presence of a representative of the company at the autopsy or a forfeiture of the claims, it is best to ascertain if such policies exist in any given case, and to notify the company. The Supreme Court of Missouri has decided that an autopsy made in ignorance of such an insurance clause is no bar to recovery if the company be notified in time for a re-examination of the body.

Supreme Court decisions also hold that consent for an autopsy implies removal of organs and tissues for microscopic study, when such is necessary to fulfill the object of the autopsy.

One of the great needs of this country is a uniform autopsy law and the establishment of a proper medicolegal autopsy code, as in Germany. As conditions exist at the present, crimes may be easily concealed, the safety of the community endangered by failures in diagnosis of communicable affections, and our morbidity and mortality statistics become a shame and reproach to the nation. The majority of our medicolegal autopsies are made by ignorant and imperfectly trained coroners and coroners’ physicians, mostly political appointees of inferior material. We need in our medical schools a greater amount of attention paid to the teaching of autopsy-technique and gross pathology. The community must also be educated to a realization of the value of autopsies. It is the duty of every physician and layman to work diligently for the improvement of existing conditions. Had the ideas of a former Governor of the State of Michigan been realized there would have been compulsory autopsies upon the bodies of every person dying within the State, and far-reaching results would have been attained. The economic importance of tuberculosis and the venereal diseases would have been made clear, the profession and laity alike educated, and the progress of preventive medicine tremendously aided.

4. PERMISSION FOR AUTOPSY. It is a desirable and certainly a wise precaution to obtain a written permit for the autopsy from the next of kin or from the legal representative of the body, in case the examination has not been ordered by law. Some of the legal decisions quoted above offer sufficient grounds for this precaution. The following form is in use in the University of Michigan Hospital.

No........ Ann Arbor, Michigan..................., 19..
Professor of Pathology........................
University of Michigan.

Permission has been given by........................., who bears the relationship of..................to........................, to hold a postmortem upon the remains of..........................., with the understanding that the object of such postmortem is to ascertain the cause of death, and that you are to use such means as you deem best to make a thorough examination for the proper attainment of the object desired, excepting that...............................................

...............................Superintendent.

There can be no doubt that the public in general is beginning to appreciate the usefulness of autopsies, as it is much easier to obtain them now than it was ten years ago. The proper display of tact and a reasonable exposition of the object of the examination will practically always meet the objections urged on sentimental grounds. Aside from these the chief objection usually met with is the fear of mutilation of the body. Emphatic assurance may be given in this respect, not only as to the entire absence of any disfigurement resulting from the examination, but also as to the marked improvement in the general appearance and condition of the cadaver as the result of the autopsy.

While it is obviously difficult to give any specific rules as to the method to be pursued in seeking permission for an autopsy, there are certain arguments that can be used to advantage. Natural curiosity, the general good to humanity, the control of diagnostic and therapeutic methods, new knowledge to be gained, the question of inherited or infectious conditions, the strengthening of insurance claims, etc., are some of the lines that may be followed in working for an autopsy. Satisfaction is always expressed when definite light is thrown upon the hereditary or infectious nature of the condition. Religious scruples may often be overcome by an appeal to the pastor or priest.

In a certain number of cases the matter is hopeless from the beginning, but in the majority the autopsy may be secured by the exercise of proper tact and patience. The laity should be educated to ask for the autopsy; and even at the present time laymen often show a greater willingness in this direction than some members of the profession. That physicians and undertakers who discourage or oppose autopsies should be avoided is a principle that should be instilled into the minds of the public at large. Undertakers soon come to recognize the aid given them by the autopsy in the matter of embalming and preserving the body, and the prosecutor should always show his readiness to allow the undertaker to profit by his operations, and to render him such definite help as may be within his power.

As a last resort the offer of a small amount of financial aid in the burial expenses will secure sometimes a permission otherwise refused. In extreme cases the physician may decline to sign the death certificate, or the Coroner may be called in, or the case turned over to the Board of Health. Under suspicious circumstances such procedures are necessary, but threats to resort to these expedients should not be made without good reasons.

With the request for the autopsy should be included the right to take such portions of organs or tissues as is necessary for a microscopic examination and for the complete diagnosis. It is, of course, never necessary and certainly unwise in the majority of cases to make any definite statements as to what or how much shall be taken away or left. No specimens should be taken if this is absolutely forbidden; and, while a half autopsy is better than none, the importance of the microscopic examination should be urged, if necessary, as strongly as the performance of the autopsy. The use of a written permission, such as is given above, obviates the necessity of making a special request for material and avoids the complications that such a request often brings about. Moreover, the legal decision above quoted grants the right to microscopic examination as included in the permit for the autopsy when such an examination is necessary to complete the aims of the autopsy.

5. AUTOPSY INSTRUMENTS. An autopsy can be properly performed with very few instruments; indeed, a knife and a saw, with a needle to close up the body, would suffice for the majority of cases. But there are very great advantages in the use of certain instruments adapted especially to autopsy needs, and these the physician should gradually acquire for his work. It is not advisable to purchase the so-called “postmortem sets” sold by the dealers, but far better to start with two or three of the most necessary instruments and gradually add to these. Surgical instruments as they become discarded can often be made to do good service in the autopsy outfit. In private practice the fewer instruments one can get along with the better, as there is much less trouble in carrying them about and in taking care of them, and it is better to make the performance of the autopsy as inconspicuous as possible. In teaching institutions and in hospitals the number and variety of instruments that can be utilized in autopsy work are limited only by the financial means at disposal, but even under the most favorable conditions in this respect it is better to simplify as much as possible. The list given below will meet all requirements.

Fig. 1—Large Section, or Cartilage Knives

Fig. 2—Scalpels

Knives. The large section- or cartilage-knife is the most important cutting instrument used in autopsy work. It is a strong, heavy knife 20-22 cms. long, with handle and blade of about equal length. The blade has a heavy back, a bluntly rounded rather than a sharp point (more blunt than appears in the illustration), and bellies at its anterior third, narrowing toward the handle. In its widest part the blade should measure about 1¾ cms. The handle is heavy, 1½ cms. broad, and a little over 1 cm. in thickness toward the blade, gradually diminishing to about ¾ cm. at the posterior third, then increasing to 1 cm. toward the end. This variation in thickness gives a gentle curve to the handle that is of great importance in adapting the latter to the form of the closed hand, so that the knife becomes practically a cutting extension of the fore-arm. With this knife all the chief incisions are made, and it is rarely out of the hands of the operator during the autopsy. The handle or blade may be made shorter or longer according to preference, but the other features of the instrument are most important.

Scalpel. (See Fig. [2].) A number of dissecting scalpels of varying sizes are needed for finer dissections. They should have a metal handle, and are preferably of one-piece construction.

Long Section- or Brain-Knife. In place of the broad thin brain-knife usually advised, an amputation-knife can be used to much better advantage in the section of the brain and in making the chief incisions in the large organs. It should have a sharp point rather than a blunt one.

Fig. 3—Long Section Knife

Myelotome. This is used only for the purpose of cutting the spinal cord squarely across in the removal of the brain. It has a slender steel stalk with wooden handle, and a short, thin, narrow blade set obliquely at the end of the stalk. This instrument is not absolutely necessary, as the cord may be satisfactorily cut with the point of the long section knife.

Fig. 4—Myelotome

Scissors. (See Fig. [5].) A number of these are of service: one large and strong pair with long handles and short stout blades, another large pair curved or bent with the longer blade blunt- or probe-pointed, a small pair with a narrow, probe-pointed blade for opening small vessels or ducts.

Enterotome. (See Fig. [6].) For opening the intestine the enterotome or intestinal scissors are used. These consist of one long probe-pointed blade bluntly rounded at its end, and a shorter blade with straight end fitting into the longer blade. Neither blade should be sharp-pointed.

Costotome. (See Fig. [7].) The cartilage-shears have two short, thick blades, the upper one with a broad belly, the lower one curved. Between the strong handles a spring is placed, and the construction should be such that when the blades are closed the ends of the handles do not touch. The form in which the handles meet and are secured with a catch is a dangerous autopsy instrument because of the severe pinching that the operator’s hand is sure sooner or later to receive.

Saws. (See Figs. [8], [9], [10].) A small hand-saw (bone-saw) is necessary for opening the skull, and the same saw may be used to open the spinal canal. It is sometimes made with a rounded point (“fox-tail” saw). For sawing vertically through the base of the skull when exposing the nasal tract a larger butcher’s saw with a high frame may be used. For sawing the angles of the skull-cap Hey’s saw may be of service but is not essential. A metacarpal saw may be used for opening small bones or the long bones of an infant. Band saws are sometimes used in opening up the nasal tract.

Fig. 5—Autopsy Scissors of Various Types

Rhachiotome. (See Fig. [11].) This instrument consists of two curved saw blades placed parallel to each other in such a way that the distance between them can be regulated by screws. There are two handles, a horizontal one for the right hand, and an upright one for the left hand attached to the fixed saw blade. It is used in opening the spinal canal.

Chisels. (See Figs. [12], [13], [14].) A very convenient autopsy instrument is the T-chisel or skull-opener, used for springing off the skull-cap and in detaching the periosteum. Side- and guarded-chisels may be used for the same purpose. The hatchet-chisel may also be used on the skull or spinal column. Straight and curved bone-chisels are also necessary for the examination of the bones and bone-marrow.

Brunetti Chisels. (See Fig. [15].) These are of great service in opening the spinal canal, but require some practice for their proper use. When used with skill they are preferable to the rhachiotome. The chisels are rights and lefts, and have a long, heavy, curved blade, broadening toward the cutting end, which has on its right or left side a small blunt projection that is introduced into the spinal canal after the removal of a portion of one of the vertebræ. This projection serves as a director and lever, while the cutting edge of the chisel is driven through the lateral portions of the bony covering of the canal by means of blows from a wooden mallet received upon the heavy handles.

Fig. 6—Enterotome

Hammer. (See Fig. [16].) The steel hammer of the amputation- or bone-sets is often of great service in autopsy work. The hook at the end of the handle may be used to lift up the skull-cap after the sawing is completed.

Mallet. (See Fig. [17].) A wooden mallet is necessary for the use of the Brunetti chisels. It may be loaded with lead or the end may be covered with felt to deaden the sound of the blows.

Forceps. (See Figs. [18], [19], [20].) Dissecting forceps of various types are useful in the finer dissections. Cover-glass forceps should be at hand for use in the taking of smears. A pair of strong bone-forceps may be of occasional service in cutting ribs or small bones. When the spinal canal is opened by means of the Brunetti chisels or rhachiotome the loosened fragments of the vertebræ should be jerked off by means of lion-forceps, or a strong pair of ordinary nippers may be used for the same purpose.

Fig. 7—Costotome

Fig. 8—Large Autopsy Saw

Miscellaneous Instruments. (See Figs. [21], [22], [23], [24], [25].) Probes of various sizes, grooved and curved directors, retractors, catheters, both metal and flexible, injection-syringe, blow-pipe with valve, trocar, cannulas, hand-drill for wiring bones, an iron-vise, etc., all find a place of usefulness in autopsy technique. In institution work motor band-saws, trephining or dental engines, drills, etc., may greatly facilitate the progress of autopsies when the daily number of these is great and when special examinations of the ear or nose are required. The needles for sewing up the incisions should be large, strong and slightly curved. A strong linen thread should be used for stitching and for ligatures.

Fig. 9—Small Autopsy Saw

Fig. 10—Hey’s Saw

Fig. 11—Luer’s Rhachiotome

Fig. 12 T-Chisel or Skull-Opener

Fig. 13 Hatchet-Chisel

Fig. 14 Straight Bone-Chisel

Besides the instruments mentioned above there should be brass or nickel measuring sticks, one 10 cms. long and one 30 cms. long, a flexible metal measuring tape, graduated glass vessels for measuring fluids, graduated glass cones for orifices, etc. Suitable scales should also be provided. Rounded or triangular wooden blocks are needed to elevate portions of the body. For the display of gross specimens as they are removed from the body, agate dishes or wooden trays that have been infiltrated with paraffin should be at hand. The necessary outfit for the taking of material for bacteriologic examinations should always be present. Likewise cover-glasses and slides for smears, and reagents for the examination and preservation of tissue should be at hand. Sponges, pails, towels, tow or excelsior for filling up the body-cavities, disinfectants, etc., must be supplied.

The autopsy outfit may be extended indefinitely to suit the requirements of the conditions or the ideas of the pathologist. In actual practice, however, the physician may confine his requirements to the limits of a cartilage knife, dissecting scalpel, forceps, one small probe-pointed pair of scissors, enterotome, saw, T-chisel, needles, thread, sponge and specimen bottles. Five or six dollars would cover the initial expense, and the set may be gradually increased. It would seem unnecessary to decry the use of surgical instruments for the autopsy. Once an instrument is used in an autopsy it should be left in the autopsy set.

Fig. 15—Brunetti Chisels

Fig. 16—Steel Hammer

Fig. 17—Wooden Mallet

Fig. 18—Forceps

CARE OF INSTRUMENTS. The cutting instruments should always be kept sharp and bright. Care should be taken that when the knives are sharpened the blunt points and rounded bellies are not ground off. After use the knives should be cleaned, disinfected and wiped dry. A tight galvanized iron box containing wire trays and a bottom pan for holding formalin is very practical in institution work. In private practice the knives after cleaning and disinfection may be kept in a holder made of Canton flannel or chamois skin having pockets fitted to the instruments; the whole may be rolled up into a small and compact bundle.

6. PREPARATION FOR THE AUTOPSY. Permission having been obtained, the autopsy should be performed without delay. It is very important that the examination should be carried out before the body has become cold, if any thorough microscopic study of the tissues is to be made. Changes in the finer structure of cells and nuclei quickly take place, and certain tissues, such as parts of the nervous system, the medullary portion of the adrenals, the pancreas, mucosa of gastro-intestinal tract, etc., within an hour or so after death are usually no longer fit for microscopic study. In all cases, therefore, it is best to make the autopsy as soon as possible after death, that is, as soon as positive signs of death appear. In the majority of cases this takes place within an hour, and the most favorable time for the performance of the autopsy falls within one to three hours after death. Under certain circumstances it may be necessary to make the examination sooner, but for various reasons the operation is very repugnant when performed within the first half-hour after death. For ordinary purposes an autopsy performed within twelve to twenty-four hours is usually satisfactory. Occasionally it becomes necessary for medicolegal purposes to examine a body some days, weeks, or even months after death and burial.

Fig. 19 Bone-Forceps

Fig. 20 Bone-Nippers

Fig. 21 Probe

Fig. 22 Blow-Pipe

The body should not be frozen if microscopic studies are to be made. When the autopsy is delayed cold storage just above the freezing point produces less change in the gross pathologic picture, as well as in the finer structure. No embalming fluids, injections, punctures, etc., should be allowed, and undertakers should be instructed not to do these things until after the question of autopsy has been decided and the operation completed. If the use of an embalming fluid becomes necessary, formalin, not stronger than a ten per cent solution, should be advised, as it does not damage the tissues and hinders but little the operations of the autopsy. Strong solutions, as found in the usual embalming fluids, render the tissues stiff and hard and cause color changes, while the strong vapors are very unpleasant to the obducent. The use of arsenical embalming fluids or preparations should be wholly discountenanced. When it is desired to study the mucosa of the stomach or intestine, it may be fixed soon after death by the introduction of a fixing fluid into the stomach or intestine by means of a tube and pump. Finally, instructions should be given that the body shall not be dressed for burial until after the autopsy.

The necessity of making special preparations for an autopsy depends upon its performance in a regularly appointed autopsy room or under the conditions of private practice. In the former case the autopsy room should be constructed to meet the demands of the work. In teaching hospitals it should be a large, well-lighted and properly-ventilated room with proper facilities for teaching-staff and students, and should be so connected with the hospital wards that the conveyal of bodies may be protected from observation. In the same building there should be the pathological laboratory, library and museum, a waiting-room, and under some conditions a chapel for funeral services. The autopsy room itself should have a grooved concrete floor sloping to a central drain, the furniture should be of simple construction, and so built that the entire room may be washed with a hose. The seats should be arranged in an amphitheatre facing the northern side of the building, which should be constructed practically wholly of glass, the lower sashes containing ground glass or prisms. The northern half of the roof should likewise be of glass.

Fig. 23—Hand Bone-Drill

In the pit, in the field of strongest illumination, should be placed the autopsy table. This should be strongly built, of marble, slate, soapstone, artificial stone, copper, zinc, etc., about seven feet long, thirty inches wide, and thirty to thirty-six inches high. A high table is much preferable to a low one. It should have a top with grooves slanting toward a central perforated plate fixed in the central hollow standard in such a way that the top may be freely revolved. In the standard there should be a drain and ventilating shaft connected with a fan revolving outward. The drain from the table as well as the others from the laboratory should empty into a large catch-basin where the contents may be sterilized before passing into the main sewer. Above the table a combination gas and electric light with hot and cold water-pipes should be arranged. A sheet of blue glass of the proper tint may be used in connection with the illuminating apparatus to give daylight effects.

Extra tables, weighing and measuring apparatus, sinks, lavatories, bacteriologic outfit, sterilizer, instrument-case, etc., may be supplied as needed. In the case of delayed permission, or when the law requires that the bodies be kept a certain length of time before the autopsy, it becomes necessary to provide a proper cold-storage apparatus. The local conditions will suggest the most convenient and appropriate construction. In routine autopsy service well-trained assistants and attendants become a necessary factor in the satisfactory performance of the work.

In private practice the autopsy is usually made in a private dwelling or, more rarely, in an undertaker’s shop. Under such conditions much depends upon the ability of the operator to make the best of things. In place of a proper table, the cadaver must be examined upon the bed, undertaker’s body-rest or shutter, in or upon the coffin, on the coffin lid, box, door, shutter, table or board. It is always advisable to move the body from the bed when anything else can be found upon which it can be placed. The support should be put in front of the window giving the best light and the cadaver placed upon this with its left side toward the window. Care should, of course, be always taken that the operation cannot be witnessed from without. A piece of oil-cloth or several layers of newspapers should be placed upon the floor beneath and around the support. When it is necessary to make the autopsy on the bed or in the coffin an abundant supply of old newspapers tucked under and around the cadaver will usually prevent the escape of blood or fluids.

An abundance of cold water should be provided, also a slop-pail, several basins, towels, old cloths, sponges, etc. Before the operation is begun the instruments and utensils, specimen bottles, needle and thread, etc., should be arranged. A stick of wood may serve as a head-rest. Material for filling up the body and restoring its form should be secured, according to the need for such. Hay, bran, tow, excelsior, old cloths, paper, etc., may be used for this purpose.

Fig. 24 Autopsy Needles

Fig. 25—Brass Measuring-Stick

When all is ready for the operation members of the family or of the laity should be tactfully gotten out of the room. It is always well to ask members of the family if they desire to be present, but this invitation should be given in the expectation that it will not be accepted. The effect of an autopsy upon the minds of the laity is not always a pleasant one, and harm is sometimes done through the misinterpretation of necessary procedures and the resulting gossip. In private practice it is worth while, as a matter of courtesy, to invite several of one’s colleagues to witness or take part in the autopsy. An ideal way would be to have one of these perform the operation in expectation of future reciprocation. In the interests of objective observation a clinician should never perform the autopsies of his own cases, but should turn them over to a trained pathologist or to a colleague. The operator is usually in a better position to know what to do than the onlookers, and while the suggestions of the latter are usually futile they may be endured for the occasional great help derived from them.

As far as the obducent himself is concerned he may prepare himself simply by removing his coat and rolling up his sleeves, or he may wear an autopsy coat or apron. While an autopsy can without doubt be best performed with hands bared, the danger to the operator is sufficiently great to lead him to sacrifice the undoubtedly greater technical skill thus gained, to his own safety, by the use of some protective. Rubber gloves of a medium weight, reaching half way to the elbows, are a great protection when carefully cleaned, sterilized and cared for. The sleeves of the coat may overlap the gloves and be fastened to these by an elastic band. When gloves are not used the hands may be covered with carbolized vaseline, or a six per cent solution of guttapercha in benzin. Cuts, abrasions, hang-nails, etc., must be protected by surgeon’s-plaster, collodion, finger-cots, etc. When these are used it may be necessary to remove them during the course of the autopsy, as they are easily torn or become loose. Frequent washing in flowing water lessens the danger of infection. Blood and other fluids from the body should never be allowed to dry upon the skin or upon anything used in connection with the autopsy.

Gloves should be thoroughly washed and scrubbed; and, when clean, washed in four per cent formaldehyde and dried before they are removed from the hands. They should be then dusted inside and out with talcum powder and put away dry. When they are again used they should be tested for holes by filling them with water. After having been used several times they easily tear. If the autopsy has been performed with unprotected hands, thorough disinfection of these, particularly of the finger-nails, should be carried out. Unpleasant odors may be removed from the hands by the use of mustard, dilute tincture of benzoin, turpentine, etc., and then washing with tincture of green soap. Rubbing with cornmeal is very effective in removing discolorations of the skin, particularly the blood-stains fixed by formaldehyde that occur so often in the course of autopsies on bodies injected by the undertaker.

Postmortem infections should receive prompt surgical attention, as the smallest one is dangerous and may develop in a few hours to such an extent as to cause the most alarming constitutional symptoms. In a way all autopsy work, like surgical operations, offers a risk to the operator. This is particularly great in all cases of pyogenic infection, tuberculosis, blastomycosis, syphilis and the acute specific infectious diseases. Any of these infections may be received through the unbroken skin by way of a hair-follicle; but previous cuts, abrasions, hang-nails, etc., form a frequent avenue of entrance for the infecting agent, as well as punctures, scratches and cuts received during the autopsy from instruments, spicules of bone, needles, etc. It is particularly dangerous to allow blood, pus or exudates from the peritoneal or thoracic cavity to enter a glove through a hole. A finger or hand so bathed is very likely to develop hair-follicle infections. All wounds received during the autopsy should be allowed to bleed freely, and then should be thoroughly washed in sterile water, alcohol and ether and an antiseptic.

Tuberculous warts are very common on the hands of prosectors having a large autopsy service and not using gloves. A generalized tuberculosis may follow. These warts are easily removed by repeated painting with fuming nitric acid, just sufficient to keep the skin yellow. If this treatment fails such warts should be excised. Syphilis has been reported only a few times as due to postmortem infection; but observations tend to show that the spirochætes may remain virulent for several hours (7-24) after death.

7. AUTOPSY TECHNIQUE. The object of the autopsy is to examine thoroughly, in as short a time as possible, and in the easiest and most convenient method, all of the organs and tissues of the body, with reference to the occurrence of disease-changes, in such a way that nothing will be overlooked or obscured. The preservation of relationships becomes, therefore, a very important matter; and nothing should be done to disturb these until a complete pathologic picture has been obtained. All unnecessary handling and cutting must be avoided. No hasty or ill-advised cuts should be made. Careful deliberation is often necessary as to the proper course to be pursued in order to obtain the proper result. Each autopsy is a law unto itself in this regard. New complications constantly arise and must be studied before the right way of revealing the solution of the pathologic problem is found. Above all things nothing should be destroyed until its relationships have been fully determined. False steps taken in an autopsy cannot be retraced, and the complete investigation and the successful attainment of a diagnosis may be made impossible by improper methods of technique. As in all other technical matters there is a best way of carrying out the different steps of the autopsy; and as this best way must be altered to suit the conditions as they arise, it follows that there is both a science and art of autopsy-making. Some general rules can be laid down that apply consistently to all autopsies, but strict adherence to one method is impossible in all cases. As in everything else the prosector should be master of his technique and not let it master him.

When everything is ready for the autopsy the operator should take his place at the right side of the cadaver, unless he happens to be left-handed, when it may be more convenient for him to stand at the cadaver’s left. This position at the cadaver’s side he does not leave, except when opening the cranium, when he stands behind the head. When the spinal cord is removed posteriorly he still remains on the same side of the table, although the cadaver, having been turned over, presents its left side toward him. The instruments arranged in proper order should be on a tray close at his right hand, either on a neighboring table or placed on the autopsy table. As they are used they should be washed and returned to their proper place and not allowed to lie on the body or table.

The cutting technique employed in the autopsy is, as a rule, quite different from that employed in surgical operations or in dissection. For the large incisions the cartilage-knife is used. It should be held in the palm of the hand so that when the arm is extended the knife-blade becomes an extension of the axis of the arm, and used with a free arm-movement, fingers and hand being firmly fixed to the knife-handle. Long, sweeping cuts, adequate in pressure, and giving smooth and even incisions, are made by moving chiefly from the shoulder, with secondary movement from the elbow. The knife-blade should not be pressed or pushed into the tissues, but should be drawn through them rather quickly, cutting as it is drawn. The greater the force used, the more swift the drawing-motion should be. All cuts should be clean; if made in the wrong place they will do less damage than ragged, uneven incisions. The toe of the cartilage knife is used for the beginning and end of long incisions and for cutting in hollow or depressed surfaces. For flat surfaces the belly of the knife is employed. The heel of the blade can be used for cutting cartilages. The incisions made in the body should be directed away from the operator, especial care being taken to avoid injuring his left hand or the hands or arms of anyone assisting in the operation. When the knife is held as directed there is not much danger of a slip except at the end of the incision when, the resistance being overcome, the knife goes through with a rush. To avoid this, pressure should always be slackened toward the end of the incision. The main incisions in the organs should be made with the brain-knife or short amputation knife, by a long, sweeping cut made from heel to toe of the knife-blade and beginning at the part of the organ farthest from the operator, drawing the blade through the organ toward the operator. For finer dissections the smaller scalpels are to be employed, and in such cases the dissection-technique of fixed arm and free finger movement must be used. In many places within the body the cutting-edge of the knife should be directed outward rather than inward so that underlying structures may not be injured. Often the fingers of the left hand are used in such cases to take the place of a grooved director. The application of these and other points of technique will be elucidated in the chapters following, whenever it is of advantage to use some especial method. In general nothing should be done to disturb relationships until these have been noted, and cuts should be made into organs in such a way that they may be reconstructed in their original shape and condition.

Order and cleanliness should characterize the autopsy. Abundance of water should be at hand, and after every incision the knife should be dipped into a vessel of water standing on the autopsy table. Practically all cuts should be made with a clean wet knife; only in the case of the chief-incisions of the large organs is it of advantage to cut with a clean dry knife, when it is desirable to obtain a judgment of the moistness or dryness of the cut surface. Never cut with a dirty knife, as the cut-surface may be obscured. A gentle scraping with the knife-blade often gives a more distinct picture of the cut surface. The water-stream should not be used too freely upon cut surfaces; it should be employed only when there is so much blood or fluid that the surfaces are obscured, or when it is desired to float up certain tissues or parts of organs. A better picture of the cut-surface can sometimes be obtained by blotting it with absorbent paper free from lint. Organs and tissues removed from the cadaver should not be allowed to dry. Nor should they be left in water. Both conditions will quickly ruin material in so far as its after-use for microscopic study is concerned. They should be kept covered with moist cloth or paper. As the organs are removed from the body they may be quickly dipped into water and quickly rinsed, but beyond this the use of water is not advisable.

Blood and fluids within the cavities of the body should be quickly removed as soon as their character is determined. Stomach and intestinal fluids in particular should not be allowed to escape within the body-cavities. They should not be washed out, but removed by the aid of beakers and sponges. Drops of blood or other fluids upon the surface of the cadaver should be removed before they become dry. All respect should be paid to the dead body. The face and hair should be covered after they have been examined; and great care should be taken to prevent any accidental cuts on the surface; and the entire field of operation as well as the autopsy-table must be kept clean. In private practice the external genitals should be kept covered except for their examination. An abundance of large sponges and a gently-flowing stream of water under low pressure permit a clean and orderly autopsy. The use of a hose with water under high pressure is dangerous because of the accidental spattering that is sure to occur. Blood and fluids from a dead body should not be spattered about because of the great danger of spreading infection. When accidents do happen prompt cleaning up and disinfection should be carried out. Particularly in private practice is it of the greatest importance that no blood-stains be left behind.

The time required for an autopsy varies with the conditions of the individual case. A complete and well-performed autopsy under ordinary circumstances requires at least one hour, usually an hour and a half. It is true that all the organs can be removed from the body in a much shorter time, but the removal and inspection require at least the time given above, if properly done. Some cases present great difficulties and may require 4-12 hours for a satisfactory and complete examination. For a medicolegal examination 2-3 hours is usually necessary. No prosector should make more than two autopsies in one day, and, if he is making them every day, one daily is quite sufficient. The intellectual and nervous energy required for a good autopsy is so great that it is impossible for anyone to do justice to a large number made in quick succession. In many German laboratories this fact is recognized and the autopsies are assigned proportionately to members of the pathologic staff.

At the close of the autopsy the cadaver must be thoroughly cleaned and restored, as far as possible, to its natural appearance. Directions for the restoration and closure of the autopsied body will be given in a later chapter.

CHAPTER II.
THE ORDER OF THE AUTOPSY.

ORDER OF THE AUTOPSY. In so complicated a piece of work as the complete autopsy it is absolutely necessary that a definite order of procedure be followed at every autopsy, altered when necessary to suit the requirements of individual cases. In medicolegal examinations a definite autopsy order should be prescribed by law. For the average case, in fact for nearly every autopsy, I believe the following order, as given in my protocol book, to be the best one. It is based upon topographic and anatomic relationships, preservation of blood-content, ease and convenience of method, etc. As the protocol should follow this order, it is given here in full.

Autopsy-Protocol No.

1. Name: 2. Sex: 3. Age:
4. Nationality: 5. Status: 6. Occupation:
7. Day and Hour of Death: 8. Time of Autopsy:
Clinical Diagnosis:
Pathologic Diagnosis:
Prosector:

A. External Examination. General.

B. Internal Examination.

I. SPINAL CORD.

II. HEAD.

III. THORAX AND ABDOMEN. (Main Incision.)

IV. THORAX.

V. MOUTH AND NECK.

VI. ABDOMEN.

VII. MALE PELVIS.

VIII. FEMALE PELVIS

IX. SPECIAL REGIONAL EXAMINATION.

X. MICROSCOPIC AND BACTERIOLOGIC FINDINGS.

XI. SUMMARY OF CASE.

The organs may be inspected and opened in the body without removing them; but when weights and measures are desired they should be removed and sectioned on the table. When the spinal cord is removed posteriorly it should be done at the beginning of the autopsy, for the sake of convenience and cleanliness. If the thorax and abdomen are examined first there is a loss of solidity and resistance, making the posterior opening of the spinal canal more difficult. The head may be opened while the cadaver is face downward and the brain removed with cord attached. If the cord is examined anteriorly this should be done at the close of the autopsy after the thorax and abdomen are completely cleaned out. The head should be opened before the heart and great vessels are cut in order to avoid bleeding the sinuses and pial veins. It should be kept elevated until the heart has been examined to avoid bleeding the latter through the jugulars. The abdomen is opened before the thorax so that the position of the abdominal organs and the height of the diaphragm can be correctly noted. A complete survey of the peritoneal cavity should be made at once before the appearances are changed through the loss of blood or other fluids, or through drying or handling. The size of the liver should be estimated before the heart is cut out, inasmuch as the loss of blood through the cut inferior vena cava may reduce its size as much as one-half. The pleural cavities should be examined before its vessels are cut, as the escape of blood may alter the appearances of the pleuræ. The heart is opened before the lungs are removed, so that its blood-content may be judged. The section of the neck organs is conveniently carried out according to anatomic relationships, beginning with the tongue. In the abdomen the spleen is removed first because it is the most easily gotten out of the way. The intestines up to the duodenum may be taken next, or the adrenals and kidneys, followed then by the gastro-intestinal tract, pancreas and liver. When necessary the kidneys may be removed in connection with the pelvic organs. In the case of extensive growth of neoplasms, marked inflammatory processes, adhesions, malformations, anomalies, etc., the order must be changed to meet in the best way the demands of the situation. Such changes in the order must always be mentioned in the protocol. It is a great mistake to begin the autopsy with a local examination of a supposed fatal lesion, except in the cases of wounds, particularly in medicolegal cases, in which a most careful and minute description of the wound is necessary.

Some writers (Letulle, Heller, et al.) advocate the removal of neck, thoracic, abdominal and pelvic organs en masse and their examination outside of the body. Except in rare cases in the adult, and more frequently in the child, this method does not present any special advantages aside from the preparation of museum specimens. It may be convenient to follow it when a very short time is allowed for the autopsy, just sufficient to remove the organs so that they can be examined later. When this method is followed the order should be:

1. Organs should be turned over without twisting, so that their posterior aspect is uppermost. Then the examination in the following order: right and left azygos veins; thoracic duct; removal of adrenals; opening of ureters; removal of kidneys; opening of aorta, inferior vena cava, portal vein and branches, and common duct; examination of pancreas; removal of aorta as far as arch; opening of œsophagus; examination of mouth, pharynx, palate, tonsils, tongue and sublingual glands, epiglottis, larynx, trachea and large bronchi; roots of lungs, prevertebral lymphnodes, and the pneumogastric nerves.

2. Organs are then turned over again without twisting, and examined from anterior surface as follows: removal and examination of thymus and thyroid; opening of superior vena cava, termination of thoracic duct and right lymph-trunk; opening of pericardium, examination of cardiac plexus, opening of arch of aorta; section and examination of pulmonary arteries and veins and hilum of lung; examination and removal of heart and lungs; examination of diaphragm, liver, gall-bladder and bile-ducts; external examination and separation of spleen, stomach, pancreas and duodenum; removal of œsophagus, stomach, pancreas and duodenum; external examination, dissection and removal of intestine to the rectum; examination of peritoneum, mesentery and omentum; separation and examination of kidneys, ureters, bladder and urethra; separation and examination of genital organs (in male, prostate, seminal vesicles, vasa deferentia and testes; in the female, oviducts, broad ligaments, ovaries, vulva, vagina and uterus).

For the ordinary clinical autopsy this method is more inconvenient and time-consuming, and offers not a single advantage over the order advocated above. I use it only in young children and in adult cases of generalized carcinomatosis, sarcomatosis, pulmonary embolism, congenital cardiac lesion, tuberculosis, aortic aneurism with tracheal or bronchial erosion and a few other rare generalized conditions. For all other cases I advise that the first mentioned order be followed, varying it as occasion demands. The autopsy should be individualized. Departures from the routine order will take place chiefly in the thoracic and abdominal cavities. It is often more convenient to remove the kidneys before taking out the intestines, to examine the liver before the spleen, or to make other similar variations in the order. The order of examination of the larger divisions of the body (head, thorax, abdomen and pelvis) should always be followed strictly; but the neck and thoracic organs, or the thoracic organs alone, may be removed en masse and examined outside of the body, and the same procedure may be carried out in the case of the abdominal or pelvic organs whenever advisable. Removal en masse with examination on the table is especially indicated in the case of the neck and thoracic organs in aortic aneurism, pulmonary embolism, congenital cardiac lesions, mediastinal neoplasms, generalized carcinoma or sarcoma of thoracic organs, etc. The same procedure is indicated in the case of the abdominal organs in generalized carcinomatosis or sarcomatosis, inflammation and tuberculosis of the abdominal organs or peritoneum, aneurism of the abdominal aorta, pseudomyxoma peritonei, etc.

In my judgment it is extremely bad practice to examine first that part of the body which the clinician believes to be chiefly affected. Still worse is it to limit the autopsy to such a regional examination. Imperfect and subjective conclusions will be avoided if the regular order is followed and each organ examined objectively. In all cases a complete autopsy should be made if permission can be obtained, and the permit for an autopsy should be regarded as one for a complete examination unless definite exceptions have been made. The examination of any organ or part should never be neglected. Many prosectors habitually omit the section of the neck-organs, intestines and genital tract when there is nothing to attract especially their attention to these parts. The examination of the spinal cord, orbits, nasal tract, ears, joints and bones may be omitted in the ordinary autopsy in the absence of especial considerations directing attention thereto; all other parts should be systematically examined. The pathologist must always maintain an unprejudiced state of mind toward the clinical diagnosis—rather a doubting mind than a disposition to accept the suggestions of the clinical opinions. The best cure for subjectivity is the complete performance of the autopsy in regular routine order, and the dictation of the protocol at the autopsy table during the operation.

CHAPTER III.
THE PROTOCOL.

THE PROTOCOL. Autopsy findings should be recorded in the form of complete, concise notes, following the order of the autopsy. Such a protocol should consist of descriptive statements of the pathologic changes found, as well as of all negative conditions. It must be a guarantee that all organs have been examined and that nothing has been overlooked. Herein lies the great value of the use of a protocol blank book with printed autopsy forms. When such are used and both positive and negative pathologic findings are recorded during the progress of the autopsy the chances of omission are reduced to a minimum.

The protocol must be purely objective and exact. All appearances should be so carefully described that from the protocol itself a diagnosis may be formulated. Conclusions and diagnoses have no place in the protocol until the final summing up. It is better to describe the appearance of organs than to class them as “normal” or “negative,” “nothing notable,” etc. The only excuse for the employment of such phrases is a lack of time for the dictation of a proper protocol, but the scientific value of the autopsy is thereby impaired. As the complete description of the normal appearances would require too much time and lessen that available for the pathologic examination, the prosector should describe briefly the chief characteristics of the normal organ, any variation in any one of these characteristics being sufficient evidence that the organ had suffered pathologic change. The description of the normal organ, however, usually offers the greatest difficulty to the beginner, and so much time may be spent upon this that the pathologic changes are slighted. However, the relatively small number of points constituting the criterion for the normal organ may be learned by experience and by the study of autopsy-protocols made by experts. The latter study is also necessary for the acquisition of the extensive protocol terminology that has been developed. A knowledge of this terminology lightens greatly the difficulties of the protocol; but its misuse leads to confusion and incorrect interpretations.

It is not a good plan to write up the protocol after the autopsy has been finished. It should be dictated during the progress of the autopsy. Only in this way can an accurate and purely objective description be obtained. The use of simple, terse English and the proper employment of autopsy terminology are also chief factors in the production of a good protocol.

The importance of following a definitely-outlined routine of procedure is very evident in the case of protocol-making. The general order of the autopsy should be followed strictly in the protocol; and all deviations from the usual method noted and described. Aside from this general order, each organ or part as it is examined should be systematically described according to the following scheme:

1. Location and relation to other parts.

2. Size and weight.

3. Shape. (Contour, lobes, edges, borders, character of surface, etc.)

4. Color.

5. Consistence.

6. Odor.

7. Cut surface.

8. Blood-content.

9. Histologic features in detail. (Capsule, surface, parenchyma, stroma, vessels, etc.)

10. General and localized pathologic conditions.

For the hollow viscera and body-cavities the following points should be systematically noted in addition:

1. Size and shape of cavity.

2. Free gas or air?

3. Fluid or solid contents? (Amount, odor, color, cloudiness, consistency, precipitation or separation on standing, presence of blood, fibrin, pus, parasites, etc.)

4. Condition of wall of cavity (serosa or mucosa).

1. Location and Relation. The organs and parts should be located according to the landmarks of regional anatomy. Brain-lesions may be charted upon the printed outline sheets of the different parts of the brain. Similar outline sheets may also be used for other parts of the body.

2. Size and Weight. The exact weights and measurements should be given in the metric terms. Organs should be weighed and measured after the removal of other tissue in which they may be imbedded (fatty capsule of kidney, etc.) or to which they are attached (diaphragm from liver, blood-vessels from heart, etc.). The volume of the organ may be estimated by putting it into a graduated vessel containing water and noting the amount of displacement. In the absence of facilities or the time necessary to take weights and measurements an approximate estimate of size and bulk may be given by comparisons with well-known objects, such as peas, mustard-seed, pepper-corns, walnuts, apple, hen’s egg, etc., but such terms are only relative and not accurate, and their use should be avoided as much as possible. That the weight and measurements of any given organ fall within normal limits cannot be taken as evidence that the organ is normal. The judgment as to the size and weight of the organ must always be controlled by a consideration of the pathologic conditions present as to the exact factor in the increase or the loss of size or weight.

3. Shape. The organs should be removed with the least possible disturbance of shape. If it is not possible to do this, the shape of the organ should be noted as it lies within the body. A knowledge of the normal form of the organs must serve as the basis for judgment. Comparison of pathologic alterations in form with the shape of some familiar object is permissible (horse-shoe, hour-glass, shagreen, cauliflower, mushroom, coral, polypoid, hog-backed, etc.) Borders, contours, edges, external surfaces, etc., are rounded, sharp, flatter, thinner, saccular, lobulated, smooth, wrinkled, folded, villous, polypoid, granular, nodular, fissured, etc. All possible anomalies of form exist from the very slightest deviations up to the most marked distortions.

4. Color. The color of an organ or part should be noted as soon as possible after its removal from the body, or, better, as soon as the cadaver is opened, since oxidation, evaporation, loss of blood, and contact with water quickly cause color-changes. Venous blood may quickly become bright red, notably in the spleen and cerebral veins and sinuses. It is not to be supposed that, even when the cadaver is opened within a very short time after death, the color is that of the living body. Certain color-changes always take place as soon as death occurs, but it is necessary to create a color-standard for the different organs as seen under the conditions of the ordinary autopsy. Injections of formalin and other undertaker’s fluids destroy all color, and should not be permitted before the autopsy. Freezing likewise changes the color of many of the organs.

The judgment of the color of the tissues and organs of the human body is extremely difficult because of the fact that only rarely is a pure simple color seen. Ordinarily a combination of colors is present, and the analysis of these is often not easy. If the organ is held before the eyes at a distance of about a yard an impression of a single color-unity may be obtained, but when brought nearer to the eyes the surface presents a variegated, mottled, speckled or streaked effect of many colors, sometimes running the entire range of the spectrum. The colors most frequently seen in the body are yellow, red and brown in all possible combinations and shades. Blue, gray, slate, black, green and purple are also common in combination with these three or with one another. The analysis of the color is concerned, first with the color proper of the parenchyma, secondly with the color of the blood and the blood-content, thirdly with the color of some pathologic substance contained in the tissue, as blood- or bile-pigment, carbon, melanin, etc. In describing color-combinations use the predominant color last; as, for example, a reddish-yellow-brown means that the predominant color is brown with more yellow in it than red. Innumerable combinations of these three colors exist (light brown, chocolate, yellowish-brown, brownish yellow, brownish red, etc.). The macroscopic color will not be apparent in microscopic preparations except when due to a true pigment.

The term discolored is applied to dirty, cloudy colors, particularly gray or greenish, as in gangrene. Spotted, mottled, streaked, variegated, etc., have the same application in the autopsy-protocol that they have elsewhere. The judgment of the color of an organ should be made twice: as seen through the capsule or external covering, and again on the cut surface of the organ. In the latter case the transparency, translucency or opacity of the surface should be noted with the color. Normally translucent structures become opaque as the result of inflammatory thickening, parenchymatous degenerations, leukocyte infiltrations, tubercles, postmortem digestion, etc. An increase in translucence may be due to œdema, hydropic degeneration, amyloid, mucoid and colloid degenerations, liquefaction necrosis, anæmia, atrophy, loss of pigment, etc. (translucent, transparent, jelly-like, colloid, mucoid, lardaceous, sago, bacon, ham-fat, pearly, etc.).

5. Consistence. This is best estimated by placing the four fingers of the right hand beneath the edge of the organ as it lies on the board or in the body and lifting it slightly upward and inward toward the main mass of the organ. This should be done in several places, so that an idea of the general consistence of the organ is obtained. Hollow organs must be tested before and after opening, in the latter case, to get an idea of the consistence of the wall. Organs with capsules should be tested through the uncut capsule and also on the cut surface. After the general consistence has been determined an examination of the entire organ by thumb and fingers should be made to determine localized areas of different consistence (soft: abscess, cyst, œdema, areas of degeneration, etc.; hard: amyloid, tubercles, tumors, chronic passive congestion, fibroid indurations, pneumonic areas, etc.). The size and location of such areas should be carefully noted. The presence of fluctuation, loss of elasticity, pitting on pressure, friability, hardness, etc., should be described in ordinary terms, although a comparison with familiar objects often gives a more definite impression than the simple use of adjectives describing the condition (consistence of leather, dough, mush, pea-soup, putty, wood, jelly, stone, iron, etc.). The relaxation or softness of an organ is often judged by its flattening on the board, or by its hanging down over the index-finger when this is placed beneath its middle and the organ raised, or by the jelly-like tremors of the organ when the dish containing it is agitated.

An increased friability is noted in diseased bones, muscles, pneumonic lungs, organs showing acute congestion, etc. An increase or a loss in elasticity is to be noted chiefly in the large blood-vessels, lungs, skin, etc. In describing a condition of loss of normal firmness the German School makes frequent use of the termination malacia (softening) in such words as myomalacia, osteomalacia, gastromalacia, myelomalacia, encephalomalacia, etc. When such softening is the result of postmortem autolysis or digestion, as is so often the case in the stomach (postmortem perforations), thymus, pancreas, adrenals, brain, etc., the term postmortem softening is more frequently used in this country. Soft tumors are described as medullary, encephaloid, etc. In all judgments as to consistence the normal differences between the organs must be considered, as well as the length of time between death and the autopsy, the cause and manner of death, undertaker’s manipulations, temperature, moisture, rigor mortis, putrefaction, etc.

6. Odor. But little attention is paid in the average autopsy to the odors of the body, and very little has been written about their importance. This is probably due to the fact that the average individual more or less consciously or unconsciously suppresses the sense of smell. Yet a keen sense of odors and an ability to analyze them are of the very greatest importance in autopsy work. Certain infections, and other diseases as well, have peculiar and distinctive odors (small-pox, measles, colon-bacillus infections, pulmonary gangrene, diabetes, uræmia, acute yellow atrophy, leukaemia, etc.). The odor of many drugs and poisons may also be distinguished in the tissues, gastro-intestinal tract or body-cavities (alcohol, ammonia, amyl nitrite, aromatic and ethereal oils, assafétida, carbolic acid, chloral, chloroform, creosote, ether, hydrocyanic acid, iodoform, musk, nicotine, nitrobenzol, phenacetin, phosphorus, etc.) Many foods may be recognized in the stomach by the odor (onions, garlic, cabbage, turnips, pineapple, oranges, apples, peaches, vinegar, grape-juice, caraway and anise seeds, celery, sage, cardamom, and many others). In describing odors we should compare them with natural odors or class them as sweet, sweetish, sour, bitter, pungent, sharp, heavy, yeasty, pus-like, fruity, etc.

7. Cut Surface. The cut surface of the organs and tissues should be examined immediately after the organ is sectioned. During the examination the organ should be moved in different planes so that the light may fall upon the surface in various angles. Color-changes, differences in reflection and refraction, minute inequalities of the surface, etc., are often brought out in this way when otherwise they might be overlooked. During the examination the surface may be gently scraped over by the blade of the large section-knife held at an angle of 45° to the surface. The character and amount of the blood and fluid exuding from the surfaces and vessels should be noted; after this has been done the cut surface may be gently washed with water and examined with regard to histologic and pathologic details. During the inspection pressure may be made upon the organs to determine still further the blood- and fluid-content. The color, moisture or dryness, consistence, reflection or “shine” (dry-shining, moist-shining, fatty shine, pearly shine, etc.), cloudiness, translucency, transparency or opacity of the cut surface must also be considered. Normal organs are never perfectly dry, although they vary greatly in the amount of moisture shown on the surface. They have, therefore, always a certain degree of reflecting power. Different parts of the cut surface of the same organ should be compared as to color, moisture and dryness. (Areas of suppuration, congestion, œdema, inflammation, recent hemorrhage, hydropic degeneration, liquefaction necrosis, etc., are more moist than normal; old thrombi, fibrinous exudates, old hemorrhages, simple, coagulation, caseous and Zenker’s necrosis, dry gangrene, anæmic and hemorrhagic infarctions, amyloid, concretions of cholesterin, bile-pigment, lime-salts, urates, etc., contents of dermoid cysts and cholesteatomata, etc., are dry.) The cut surface must be described also as to its even or uneven character, finely or coarsely granular, shagreened, rough, nodular, elevated or depressed portions, fissures, folds, umbilication.

The cut surface of neoplasms is examined especially by scraping it with a dry knife held at an angle of 45°. The cells thus obtained constitute the tissue-juice (“cancer- or sarcoma-milk”). Soft medullary neoplasms yield an abundance of such cell-scrapings, hard tumors but little. The cells thus obtained may be treated according to the various methods given on Page [219], and then examined microscopically. The cut-surface of the soft parenchymatous organs (bone-marrow, spleen, thymus, lymphnodes, liver, pancreas and kidneys) also yields material for examination by this method.

8. Blood-Content. The blood-content of the organs should be estimated both before and after they are sectioned. This estimation should be based upon the color of the organ, condition of the blood-vessels, amount of blood exuded from the cut surface, number of bleeding-points (anæmia, hyperæmia, stasis). Capillary, arterial and venous hyperæmia should be differentiated when possible. Only rarely are evidences of arterial congestion seen in the cadaver. It is also necessary to observe the occurrence, location and extent of hypostasis and to differentiate antemortem and postmortem (lungs, brain, intestines, etc.). The association with œdema and inflammation, particularly in the lungs (hypostatic pneumonia) speaks for antemortem hypostasis. A red color in parts possessing no blood-vessels (heart-valves, endocardium, intima of aorta, cartilage, etc.) indicates an imbibition of diffused hæmoglobin (hæmatin-imbibition). Changes in the color of the blood (carbon monoxide, hydrocyanic acid, and hydrogen sulphide poisoning, all poisons producing methæmoglobinæmia, icterus, leukæmia, etc.) should be described and recorded; likewise all hemorrhages, extravasations, etc.

9. Histologic Features. After the general points given above have been considered the histologic features of the organ should be taken up in routine. For example, in the case of the spleen, the capsule, trabeculæ, pulp, stroma, follicles and vessels should be examined; in the liver, the capsule, trabeculæ, liver-acini, blood-vessels and bile-ducts; in the kidneys, capsules, cortical surface, cortex, labyrinths and medullary rays, glomeruli, columns of Bertini, medullary pyramids, vessels, pelvis and beginning of ureter. When the organs are thus systematically examined there is but little chance that anything visible to the naked eye has been overlooked.

10. Pathologic Lesions. Anomalies, defects, erosions, ulcers, evidences of trauma, inflammations, abscesses, tubercles, gummata, neoplasms, parasites, and all forms of pathologic changes, local or general, must be accurately located and described. The changes peculiar to certain diseases and infections must always be borne in mind during the examination of any organ in which such conditions are likely to be found. The relationship of lesions in different parts of the body must be recognized. Localized lesions must be described according to position, size, form, color, consistence, etc. Their nature must be recognized, their relation to other or to pre-existing conditions determined, the stage of the process estimated, and the part played in the causation of death ascertained.

In the examination of the body-cavities and hollow organs, as well as pathologic hollow structures, the first thing to note is the escape of gas or air under pressure. Occasionally it is best to open the organ under water to note the escape of bubbles. The odor of the gas, inflammability, etc., are to be noted. The fluid or solid contents (blood, bile, urine, féces, mucus, pus, exudates and transudates, altered secretions, food-remains, concretions, foreign bodies, parasites, etc.) are described as to their amount, color, consistence, odor, reaction, chemical nature, precipitate, presence of cellular elements, etc. The size of the cavity, monolocular or multilocular, the character of its lining (transparency, translucency, cloudiness or opacity, color, “shine,” moisture, smoothness, roughness, villous or polypoid, consistence, thickening, swelling, elevations, atrophy, incrustations or deposits on the lining, etc.) are to be considered. In the case of cystic tumors (adenocystomata, dermoid cysts, cholesteatomata, etc.) especial attention should be paid to the character of the cyst-contents (mucoid, glairy, colloid, jelly-like, pea-soup-like, pultaceous, mushy, doughy, caseous, pearly, laminated, flaky, powdery, etc.).

CHAPTER IV.
THE EXTERNAL EXAMINATION.

THE BEGINNING OF THE AUTOPSY. The autopsy begins with the examination of the exterior of the body. The cadaver should be completely stripped of clothing and examined as a whole, then as to its separate parts. Time is saved and omissions prevented if a definite order is followed in the external examination, such as follows here.

1. Identification of the Body. In ordinary cases the name of the deceased will be given upon the autopsy-permit, and this will serve as sufficient identification. In large autopsy-services, when several cadavers may be brought in at the same time, each one should be properly tagged so that no mistake is possible. It is necessary in medicolegal cases to make a more formal identification by having the cadaver positively identified by persons having knowledge of the individual during life, or by those who first saw the body, or who took it in charge. In such cases when identification is impossible at the time of autopsy the protocol should give in full details the place, time, and conditions of discovery of the body, with an accurate description of its external characteristics, clothing, articles found on the body, surroundings, etc. Bertillon measurements and finger-markings may be taken; dental work should be carefully described; false teeth and hair, eyeglasses, etc., should be preserved, and the most careful attention should be paid to bodily anomalies or peculiarities, birth-marks, tattoo, etc. Photographs, casts, Roentgengrams, etc., may be taken. Powder-marks, blood-stains, as well as those of semen and other discharges, should be described and, if necessary, preserved. Legal names, as well as aliases, should be recorded and attested in all cases of legal significance. In fact, the only proper way to conduct any autopsy is with the assumption that the results will have legal value; and such an assumption is the best safeguard against important omissions.

2. Sex. This should always be mentioned in the protocol. In the case of pseudohermaphrodism the determination of the real sex may be difficult and may eventually be decided by microscopic studies. Likewise in bodies that have been burned or mutilated the question of sex becomes a matter of anatomic and histologic study. The character of the bones, pelvis, remains of sexual organs, etc., are used as criteria to decide the question. In cases of burning, the uterus in the female and the prostate in the male may often be recognized microscopically when the head and extremities are burned off and only a charred mass of flesh and bone remains.

3. Age. When the true age is not known the apparent age must be estimated by considering the general appearance of the body, development, bones, epiphyses, sutures, blood-vessels, skin, hair, teeth, sexual organs, etc. Roentgengrams of the epiphyses, hands and feet may be made. The presence of an arcus senilis should be noted. Arteriosclerosis of the temporal and radial arteries may be determined by inspection and palpation. The determination of the age of the new-born will be considered in a later chapter.

4. Nationality. When not definitely known this may be estimated by such criteria as color of skin, finger-nails, character of hair, facies (cheek-bones, jaw, forehead, cephalic index, facial angle, eyes, etc.), hands, feet, general build, etc. For ethnologic and anthropologic data the body may be described according to the primitive type it represents (Australioid, negroid, mongoloid, xanthochroic, melanchroic, Iberian, dolichocephalic, etc., according to the different classifications).

5. Status. Unmarried, married, widow, widower, divorced, legal status, citizen of what country, state, county or town, etc.

6. Occupation. As this often throws light upon the pathologic condition present in the body, the trade or occupation should be ascertained and stated in the protocol. When no direct information is available a judgment concerning it may be made on the basis of certain conditions, occupation or industrial diseases found in the body (anthracosis, argyrosis, siderosis, silicosis, chalicosis, lead-poisoning, chronic phosphorus poisoning, nitrobenzol and other forms of poisoning, localized muscle-hypertrophy or atrophy, callus, etc.).

7, 8. Time of Death and Time of Autopsy. The day and hour of death and the time of autopsy should be noted. When the time of death is not known with certainty it can only approximately be estimated by the condition of the body with respect to such postmortem changes as rigor mortis, algor mortis, hypostasis, diffusion-spots, decomposition, etc. From no one of these signs of death can an absolute statement be made as to the time of death; so great a variation may occur with any one or with all of these so-called positive signs of death that only very relative estimates can be given. Between the actual time of death and the appearance of positive signs of this event there exists a variable period in which death announces its appearance by negative signs only; the cessation of the vital functions, respiration, circulation and nervous excitability. These functions may, however, be reduced to so low a degree of strength that their existence cannot be made out by the usual methods, and a condition of apparent death or “suspended animation” may be present. Such a condition is most frequently seen in cases of cholera, hysteria, catalepsy, hypnosis, excessive fatigue, prolonged exposure to cold or to high temperatures, concussion, severe hemorrhage, action of certain poisons, electrical currents and lightning stroke, strangulation, asphyxia, suffocation, drowning, etc. The condition of apparent death may last hours or even days, but as a rule it is one of very short duration. Granting the existence of such a possibility of apparent death before absolute signs of death appear, it follows that in all autopsies made very soon after death has occurred, the prosector must bear such a possibility in mind, and satisfy himself beyond all doubt of the actual occurrence of death before beginning the autopsy.

Tests for the Determination of the Occurrence of Death. Loss of reflexes or response to stimuli are early signs. Mirror, flame or feather held before the mouth and nose, or vessel containing fluid placed on epigastrium show absence of respiration. Opening of artery, temporal or radial; if death has occurred vessel will be empty. Tests with blood-pressure apparatus are negative in dead body. Electrical tests and Roentgengrams of heart and lungs show no movement in these organs. Subcutaneous injection of ammonia; no congestion or vesicle formed in the dead body. Subcutaneous injection of fluorescin (Icard’s test): in the living body a greenish color soon appears in skin, mucous membranes and conjunctivæ; but not in the dead body. Heat applied to the skin causes no reddening in the dead body, and, if a vesicle forms, the fluid contained in it has no albumin and the underlying skin is dry and glazed and not red. The application of caustics produces no eschar in the dead body. A steel needle inserted into the living tissues becomes quickly tarnished; in the dead body oxidation will not take place after many hours. Glazing of the eyes (if these are open) takes place very quickly after death; the eye-ball collapses ordinarily, but may remain prominent in death from hanging, suffocation, apoplexy, etc. The eye loses its elasticity; the pupils can be made oval by compressing the globe (Ripault’s test). The patch of dark discoloration on the part of the sclerotics exposed to evaporation is known as Larcher’s sign. The hands held against a strong light lose the pink tinge between the fingers, and the soles and palms become yellow. A tight ligature about a finger or limb causes no reddening (Magnus’s test). Relaxation of the sphincters occurs soon after death. It should be borne in mind in this connection that the discharge of gas and féces is not uncommon after death, that a fetus may be expelled by the increase of intra-abdominal pressure due to rigor mortis and gas-formation, that a discharge of semen or prostatic fluid almost always occurs in the adult male, that electric contractility may last several hours after death, that muscles may twitch during this period, and that atropine will dilate the pupils for some time postmortem.

9. Build. The body should be measured by stretching in a straight line a metal tape-measure from the vertex to the centre of the external arch of the instep, the foot being held at a right angle to the surface of the table. Giantism or dwarfism, partial or complete, asymmetrical development, etc., should be noted and the type determined (rachitic, cretinoid, congenital and acquired deformities of bones may cause dwarfism; giantism may be congenital or due to disease of the hypophysis as in acromegaly). In all cases of abnormal development of the skeleton the possibility of diseased conditions of the hypophysis, thyroid, thymus, adrenals and sexual glands must be borne in mind. In a general way the build of the body may be described as large, heavy, strong, medium, small, delicate, etc. Racial, sex and age differences should be noted. Roentgen-ray examination may here also be made use of in the determination of stages of skeletal development. Approximate estimates of the general build may be made when only part of the body is preserved. Such rules as nineteen times the length of the middle finger equals the approximate height, four times the length of the femur equals the height, the distance from the tip of the olecranon to the tip of the middle finger is five-nineteenths of the height, etc., are obviously very uncertain.

10. General Nutrition. The body should be weighed. Nutrition good, medium, poor, emaciated, etc. Condition of skin, muscles, panniculus, etc. Differentiate loss in fat from loss in muscle. Distinguish physiologic fat from pathologic (lipomatosis, etc.).

11. Head. The size and shape of the head should be noted, and any peculiarity or pathologic condition described (microcephalic, macrocephalic, dolichocephalic, brachycephalic, etc.).

12. Facies. Aside from individual and racial characteristics the face of the cadaver may show varying expressions (Hippocratic facies, hepatic facies, expression of peace, pain, horror, distortion, etc.). Note all anomalies and pathologic conditions (leontiasis ossea, leonine expression of leprosy, hare-lip, etc.).

13. Eyes. Closed or open, shape, size, color, deep-set, changes due to death, condition and size of pupils, arcus senilis, color of conjunctivæ and sclerotics, eye-lids. The pupils are usually dilated at death, but after a short time they contract, usually unequally, and remain so for several days. Note particularly all anomalies and pathologic conditions (corneal scars, coloboma, cataract, strabismus, etc.).

14. Neck. Short and thick, long and narrow, thin or fat, smooth or wrinkled, scars, enlargements, marks of rope, fingers, string, evidences of strangulation, hemorrhages, abrasions, etc., other forms of trauma, cysts, enlarged glands, condition of thyroid, etc.

15. Thorax. Shape, length, breadth and depth, angle of Louis, epigastric angle, symmetry of sides, prominence or depressions, pigeon-breast, shoemaker’s or funnel breast, rachitic rosary, character of ribs and interspaces, mammæ, degree of hairiness, eroding tumors or aneurisms, etc.

16. Abdomen. Depressed, scaphoid or elevated, distended, tympanitic, presence of fluctuation, symmetry, results of palpation (neoplasms), character of abdominal wall (tightly stretched or lax, wrinkled), presence of linea fusca or lineæ albicantes (pregnancy, ascites, tumor). The existence of enteroptosis or gastroptosis can often be told by inspection of the abdomen.

17. Back. General build and contour, bedsores, etc. Spine should be carefully examined (anterior, posterior or lateral curvatures, evidences of trauma, etc.).

18. Anomalies. Malformations and anomalies of any region should be thoroughly examined and carefully described. The most common ones found in adults are hare-lip, cleft palate, branchial cysts, bifid sternum, accessory ribs, malformations of fingers and toes, hypertrophy of great toe, hypospadias, cryptorchidism, pseudohermaphrodism, congenital dislocations, particularly of hip, lumbosacral meningoceles and dermoid cysts, microcephalus, club-foot and hernia, its variety, location, size and condition. Under anomalies may be considered the stigmata of degeneracy and the homo delinquens type. These should also be mentioned in the identification of the cadaver.

19. Deformities. Location, degree, character, probable cause, etc. Most commonly caused by tuberculosis, rachitis, gonorrhœa, syphilis, osteitis deformans, trauma, burns, osteomalacia, tabes, muscular atrophies, gout, rheumatism, tumors, aneurism, diseases of the lung causing asymmetry of the thorax, acromegaly, etc. Most common forms are Pott’s disease, spondylitis, ankylosis, spinal curvature, contractions and retractions of parts, bow-leg, knock-knee, changes in the pelvis, dwarfism, shortening of extremities, exostosis, drumstick or clubbed fingers, flat foot, loss of bones, amputations, occupation deformities, swelling of joints, tophi, Charcot’s joint, hygroma, ganglion, etc.

20. Signs of Trauma. Location, size, character and condition of wound (bruises, bloody suffusions, hæmatoma, erosion, denudation, lacerations, punctures, crushing, blister, fractures, dislocations, bullet-wounds, marks of hanging, strangulation (abrasions in the neck caused by hanging show minute hemorrhages in and about their edges, particularly in the upper border; section of the neck shows small hemorrhages in the cervical tissues), or drowning, burns, action of corrosives (brown spots on lips), effects of electric currents, etc. In the case of powder-markings note number, direction, burning, singeing of hairs, etc.) In medicolegal cases the description of traumatic lesions should be especially minute and complete. An effort should be made to distinguish postmortem from antemortem wounds. Recent wounds have clean cut walls and edges covered with blood; old wounds show reaction, vascularization, granulations, adhesion of edges of wound, or of exudate. Postmortem wounds are usually free from blood unless large veins are ruptured. Loss of the epidermis before or after death causes in the cadaver yellowish or brown, firm, leather-like spots.

21. Surgical Wounds. Location, size, nature of operation, state of wound, character of surgical dressings, drainage, etc., discharge from wound as blood, pus, féces, urine, etc., odor of wound, age as shown by stage of repair, evidence of infection, etc. Hypodermic marks, saline injections, blisters, venesection, cupping, exploratory punctures, recent vaccination marks, etc., should be noted.

22. Scars. Location, size, character, recent or old, pigmented or pale, rough or smooth, contractures, keloids, traumatic or surgical, nature of injury or surgical operation, hypodermic scars, vaccination, acne, cupping, small-pox, chicken-pox, shingles, “electric belt,” croton oil, burns, etc.

23. Skin. Color (racial differences), brown, gray or black pigmentations in Addison’s disease, pellagra, syphilis, vitiligo, xanthoma, chloasma, pigmented nodes or nævi, argyria, arsenical poisoning, pernicious anæmia, xeroderma pigmentosum, chronic jaundice, vagabond’s skin, tan, following blisters, plasters, cupping, use of croton oil, Roentgen irradiation, effects of violet rays, melanotic tumors, pregnancy, etc.; bronzing in Addison’s and chronic icterus; lemon yellow in chlorosis and pernicious anæmia; yellow to dark green in icterus; grayish-brown in potassium chlorate poisoning; bluish-red (cyanotic) in cardiac insufficiency; yellowish-bluish-red (“Herz-farbe”) in cases of complete loss of compensation; cherry-red or rose-red in carbon-monoxide or hydrocyanic acid poisoning, rarely as the result of an erythema, although this condition usually disappears after death; dirty sallow to grayish or greenish in tumor cachexia and poisoning with H₂S; white after severe hemorrhage, cachexia of chronic Bright’s disease, leucoderma, vitiligo, albinism, leprosy, etc.; red, yellow, green or brown in hemorrhages according to their age. Eruptions should be classified and described as to location, abundance, stage, etc. (macules, papules, wheals, desquamation, scales, blebs, bullæ, pustule, tubercles, ulcers, abscess, phlegmon, herpes, crusting, granuloma, etc.). With the exception of chicken-pox and small-pox the eruptions of the acute exanthemata disappear after death, as do all erythematous rashes except in rare instances. Emphysema of the skin should be differentiated from œdema. The most common lesions of the skin are acne, eczema and syphilis. Tuberculosis (lupus) is not uncommon; anthrax, favus, rhinoscleroma, actinomycosis and blastomycosis and Aleppo or Delhi boil are more rarely seen. Tinea versicolor and tricophyton (barber’s itch and the various forms of ringworm) are the most common parasitic affections. In the Southern states ground-itch due to the hook-worm is the most common. Leprosy should be considered in connection with individuals coming from Norway, Sweden and Finland and other leper-foci. The most common tumors of the skin are all the various forms of hæmangioma and lymphangioma (freckles, moth patches, naevi, moles, warts, birth-marks), fibroma, lipoma and squamous-celled carcinoma (horny and basal-celled types). The latter is the most common form of malignant tumor. Sarcoma of the skin is more rare; the melanotic sarcoma, arising usually in a pigmented mole, is the most common form. Next to this is the round-cell sarcoma or lymphosarcoma (mycosis fungoides, leukaemic and aleukaemic lymphocytoma, etc.). Spindle-cell sarcoma, angiosarcoma, endothelioma and other forms are less common. Sebaceous cysts (wen, atheroma, steatoma) are very common. Less frequent are molluscum contagiosum, xanthoma (endothelioma lipomatodes), myoma, myxoma, chondroma and osteoma. Adenoma sebaceum and sudoriparum are rare. Other conditions of the skin to be noted are cleanliness, elasticity, general nutrition, moisture, presence of scales, atrophy, hyperplasia (ichthyosis, horny warts, cutaneous horns, the various forms of elephantiasis), scleroderma, keloid, xeroderma pigmentosum, albinism, leucoderma, vitiligo, myxœdema, seborrhœa, alopecia, erysipelas, dermatomyositis, psoriasis, impetigo, rhinophyma, herpes, miliaria, sudamina, symmetrical gangrene, trophic changes, “goose-flesh,” hemorrhages, scars, tattoo-marks, etc. The various forms of skin-diseases should be described and recorded whenever present.

The presence of petechiæ or ecchymoses in the skin (purpura) is characteristic of all the forms of essential purpura (simplex, peliosis rheumatica, hæmorrhagica, senilis, morbus maculosis Werlhofii, scurvy, Möller-Barlow disease, etc.); such skin hemorrhages occur also as the result of trauma, congenital hæmophilia, in the course of many infections (small-pox, plague, typhus, yellow fever, endocarditis, measles, scarlet fever, septicæmia, pyæmia, rheumatism, meningitis, typhoid fever), in many intoxications (snake-bite, icterus, nephritis, iodine, bromine, phosphorus, chloroform, etc.), also in severe anæmia, pernicious anæmia, leukæmia, sarcoma, carcinoma, acute yellow atrophy of the liver, hysteria, vicarious menstruation, reflex hemorrhages, stigmatization, etc. The number, size, color and location of all cutaneous hemorrhages should be recorded.

24. Hair. Color, abundance, distribution, character, quality, condition, length, pathologic conditions (alopecia areati, senilis, præsenilis, pityrodes, syphilitica and symptomatica, trichorrhexis nodosa, hypertrichosis, parasites, etc.). In prolonged fevers and wasting diseases the diameter of the hair is diminished. Symptomatic alopecia occurs after syphilis, typhoid fever, scarlet fever, measles, erysipelas, anæmia, Roentgen irradiation, etc. The length, color and quality of the hair as well as amount and distribution vary in different races. Hypertrichosis is often associated with degeneracy, criminal tendency, epilepsy, idiocy and certain forms of insanity. An apparent growth of hair after death may be caused by retraction of the tissues; an actual postmortem growth is not conceded by the majority of authorities in spite of the numerous tales to that effect. Loss or absence of pigment is seen in albinism, leukotrichia due to infection, Graves’ disease, exposure, burns, nervous affections, fright, worry, etc. The presence on or about the body of hairs not belonging to the cadaver is a point of great importance in medicolegal cases and one that should be thoroughly investigated as to their source. Human hair can be identified microscopically, and it is possible to recognize different specimens according to their variation in color, length, quality, etc.

The nails should be considered in connection with skin and hair, with reference to the following points: presence or absence, hypertrophy, atrophy, color, condition, length, development, onychia, hyperonychia, paronchyia, onychogryphosis, longitudinal and transverse ridges, fissures and cracks, opacity, brittleness, etc.

25. Teeth. Number, character, condition, anomalies, dental work, caries, Hutchinson’s teeth, odontoma, dental osteoma, dentigerous cysts, epulis, papilloma, etc.

26. Mucous Membranes. Color, deposits or incrustations, eruptions, erosions, herpes, mucous patches, rhagades, ulcers, fissures, moisture, trauma, effects of corrosives, burns, pigmentation, as in Addison’s disease, leukoplakia, hairy tongue, hemorrhages, tumors, etc.

27. Muscles. Musculature and condition of muscles (slight, athletic, well developed, poor, flabby, soft, etc.), anomalies, etc.

28. Rigor Mortis. Postmortem rigidity is one of the absolute signs of death. It begins usually 1-2 hours after death, the involuntary muscles and heart showing it first. Externally it shows first in the muscles of lower jaw and neck, extends downward, involving the lower extremities last and disappearing in the same order. Its appearance, however, is subject to the greatest variation, and the presence or absence of rigor mortis cannot be used as a criterion for the estimation of the length of time the body has been dead. Instantaneous rigor has been reported in suicides and in people killed in battle. Intense excitement, great muscular exertion, etc., favor its rapid appearance. It also comes on very quickly after death from rabies, tetanus, strychnine poisoning, cholera and a number of other conditions. It sometimes is delayed or absent after heat-stroke; chronic alcoholism also delays its appearance. Usually the contraction lasts 24-48 hours, but under certain conditions may persist for several days. It is prolonged in muscular individuals, after death by suffocation, rabies, strychnine poisoning, etc. The stiffening of the muscles may be broken by application of heat or the use of force (removal of clothes from the body); when once broken it rarely returns. In a case of death from rabies seen by the writer the rigor was so strong that it required the united efforts of two men to straighten the limbs, and before the close of the autopsy the rigor had returned as strong as in the beginning. Rigidity due to undertaker’s injections and freezing must not be mistaken for rigor mortis. The possibility of rigidity due to ankylosis must also be borne in mind.

29. Panniculus. The subcutaneous panniculus is estimated by pinching up a fold of skin between the thumb and fingers of the right hand and the thickness determined. The amount is described as panniculus abundant, moderate, absent, etc. Estimates should be made of panniculus of upper extremities, thorax, abdomen, back and lower extremities. Pathologic conditions, such as general obesity, adiposis dolorosa, multiple lipomata, elephantiasis lipomatosa, fatty collar, etc., should be described in full.

30. Oedema. At the same time that the panniculus is being examined, the presence or absence of œdema (pitting on pressure) should be noted in the same regions. When present it may be described as slight, moderate, marked, extreme, localized, universal, etc. Emphysema of the subcutaneous tissue is shown by the presence of elastic swellings of the skin, not pitting on pressure, but giving a crepitation when palpated.

31. Body Heat. The absence or presence of the body heat is of great importance in giving some idea as to the relative length of time the body has been dead. The nose, ears and extremities first become cool, the liver region retaining the heat longest. The rate of cooling depends upon the external temperature and the conditions of the body. Nude bodies, cadavers exposed to water and cold, and bodies that have suffered severe hemorrhages lose their heat more rapidly. Under ordinary conditions the rectal temperature is the same as that of the surroundings in about forty hours. During the formation of the rigor there may be a slight increase in the temperature of the cadaver. An increase above the normal temperature has also been noted in the dead body immediately after death from tetanus, cholera, small-pox, peritonitis, electric currents, suffocation, gangrene, etc.

32. Hypostasis. After death the blood passes into the veins and very soon through gravity collects in the greatly distended veins of the lowest portions of the body, except where these are pressed upon by the weight of the body. Such a settling of the blood begins usually within 1-2 hours after death, but may take place even before death (hypostatic congestion) in cases of long-standing recumbent position, cardiac lesions with failure of compensation, wasting diseases, acute infections, death from suffocation, etc. Postmortem lividity should be described as to its extent, location and color. In anæmia the color is pale purplish red, in congestion dark purple, in cyanosis the color may be dark bluish red and the fingers, toes, ears, etc., retain the cyanotic appearance for some hours after death; in potassium-chlorate poisoning the color is chocolate, in hydrogen-sulphide poisoning grayish green, in poisoning with hydrocyanic acid or carbon monoxide it is rose or cherry red. Fresh hypostatic patches can be made pale by pressure and when cut they will bleed freely. Hemorrhages cannot be pressed out nor will hemorrhagic areas bleed as freely as hypostatic patches. In all medicolegal cases care should be taken to differentiate bruises and ecchymoses from hypostatic patches, as in the popular mind the latter are often regarded as evidences of trauma or violence. The location of the hypostasis is of importance in showing the position of the body after death; if the anterior portion of the body is hypostatic the cadaver must have been lying upon its face for some time after death; suspension of the body for some time after death by hanging causes a hypostasis of the lower extremities. Of the internal organs the brain, lungs, stomach and coils of intestine chiefly show hypostasis. Antemortem hypostasis of the lungs is distinguished from postmortem by its deeper color, firmer consistence, more marked œdema and microscopic signs of beginning inflammation (hypostatic pneumonia). Cadaveric lividity reaches its maximum in 24-48 hours, and after this time diffusion gradually occurs. In connection with the examination of hypostatic areas the condition of the superficial vessels as to size, distention, etc., should always be noted.

33. Putrefaction. The first signs of putrefaction are seen in the transformation of the hypostatic areas into diffusion spots and stripes following the course of the larger veins. The color is at first a dirty red or brownish-red, but soon becomes gray or green as a result of the action of hydrogen sulphide diffusing from the intestines. Diffusion spots cannot be made pale by pressure, nor do they bleed when cut. The greenish coloration begins first over the abdomen and lower intercostal spaces, and this gradually spreads over the body, showing first in the hypostatic areas and along the veins. The abdomen then becomes distended; gas may form in the subcutaneous tissues so that the skin becomes swollen, crackles on pressure and gives off gas-bubbles when cut. The epidermis becomes loosened in spots, forming blebs containing a dirty-brown exudate, while the tissues become soft and are easily torn. The odor of putrefaction is evident. Decomposition sets in more quickly in infants, in fat and plethoric individuals, and after death from snake-bite, active syphilis, plague, sepsis, heat-stroke, suffocation, acute infectious fevers, icterus, gangrene, diabetes, etc.; it is delayed by hydrocyanic acid and other poisons. When putrefactive bacteria are present in the body, decomposition may begin immediately after death.

34. Orifices of the Body. The mouth, nose, ears, anus, urethra and vagina are to be examined with special regard to their condition and contents (open, closed, gaping, torn, bleeding, discharge of pus, blood, mucus, féces, stomach contents, semen, urine, foreign substances, parasites, ear-wax, etc.). In cases of suspected rape an especial examination of the orifice of the vagina or anus is indicated.

35. Percussion and Palpation. The external examination may be closed by the percussion of the heart, lung, spleen, liver and stomach boundaries, and by the palpation of the abdomen. The fine opportunity for control of technique, judgment as to sound, size, consistence, shape, etc., should not be lost. Rigor mortis of the abdominal muscles can be removed by kneading the muscles or by the application of hot cloths.

CHAPTER V.
THE EXAMINATION OF THE SPINAL CORD.

1. METHODS OF EXAMINATION. The spinal cord may be opened anteriorly or posteriorly. The choice of method is largely a matter of convenience or of individual skill in using certain instruments, such as the Brunetti chisels. The method of opening posteriorly is more commonly used in this country, as it requires less skill. It necessitates, however, an additional long skin incision that must be tightly stitched together to prevent leakage of blood and fluids after the restoration of the body. For this reason it is not as clean a method as the anterior opening, which requires only the one main skin-incision. In private practice the latter method is often advisable, as by it an examination of the cord can often be secured when the relatives would not consent to its removal posteriorly, on the ground of undue mutilation of the body. The anterior examination also permits a better inspection and an easier removal of the spinal ganglia and nerves.

Examination of Cord Posteriorly. For the opening of the spinal cord posteriorly the cartilage-knife, bone-forceps, bone-nippers and rhachiotome are necessary; in place of the latter the single saw, double chisel, Brunetti chisels or single chisel may be employed. The posterior examination of the cord should take place at the beginning of the autopsy, after the external inspection of the cadaver, before the thorax and abdomen are examined. The removal of the sternum gives a loss of resistance to the manipulations upon the back of the cadaver, and the turning-over of the body after it has been opened anteriorly is usually an unpleasant procedure because of the dripping of blood and other fluids. When it is found necessary to examine the cord posteriorly after the opening of thorax and abdomen it is better to fill these cavities with tow or excelsior, replace the sternum and sew up the anterior skin-incision before turning the body over.

The cadaver is placed face downwards, with medium-sized blocks beneath the cervical and lumbar regions, the arms being folded underneath the body. With the cartilage-knife an incision is then made through the skin and subcutaneous tissues in the median line, over the spinous processes, beginning above at the occipital prominence and ending at the lower border of the sacrum. The skin and subcutaneous tissues are then dissected back by bold slashing strokes for a distance of a hand’s breadth on both sides of the spine, thus laying bare the muscles of the neck and back. The muscles may be stripped back with the skin, but the heavy flaps thus formed are very likely to fall back and cover the seat of operation. Chain retractors may be used to hold the skin flaps back, particularly in the case of a very fat individual, but usually the separate stripping of the skin and muscles is sufficient. To remove the muscles the cartilage knife is set close against the spinous processes of the uppermost vertebræ and a deep cut made on each side of the spine throughout its entire length, severing the vertebral attachments of all muscles and tendons. About four finger-breadths outside of these cuts there should now be made from above downwards on both sides another deep cut through the muscles parallel with the first two incisions. The bundles of tendons and muscles between these parallel cuts on both sides of the spine are then separated from the bones as cleanly as possible, beginning either above or at the sacral end, severing the muscle-mass at the end at which the separation begins, but leaving it attached at the other end, where it is laid over the side of the body out of the way, and replaced after the examination of the cord is completed; or the two bundles of muscle may be cut off at both ends and disposed of without further trouble. Portions of tissue clinging to the vertebræ should then be scraped or cut away with the chisel or knife.

When the vertebræ are bared the next step is the removal by saw, bone-forceps or chisel of the posterior bony wall of the spinal canal in such a manner as to expose the cord and permit of its removal without causing any damage to it, either from the instruments or from fragments of broken bone. A single-bladed saw with curved ends may be used to saw through the laminæ on both sides of the spinous processes; or even the small bone-saw (Fig. [9]) may be used for this purpose. The blade of the saw should be held obliquely against the spinous processes with the sawing edge directed outward so as to cut the laminæ close to the medial borders of the ascending and descending transverse processes. The sawing is complete when the spinous processes become movable. The straight-edged chisel may be used to cut any adhesions left after sawing, and the bone-forceps may be used to cut the atlas and axis. When the laminæ have been cut through on both sides of the spinal column for its entire length, including the sacrum, the posterior ligament between the atlas and occiput is cut with the cartilage knife; and the strip of bone and ligaments loosened by sawing is torn off from above downward by grasping it in the upper cervical region with a pair of bone-nippers and jerking it off forcibly downward toward the sacrum, thus exposing the spinal canal. It may be taken off in the opposite direction by cutting the ligament between the last lumbar vertebra and the sacrum and stripping upward.

The use of the single saw is not advised, however, as it is too time-consuming. The laminæ on both sides of the spinous processes may be cut at the same time by the use of Luer’s rhachiotome (Fig. [11]). The blades are separated according to the size of the vertebral arches and are set so as to include the spinous processes and cut the outer border of the laminæ close to the transverse processes in such a manner as not to injure the cord. Since the spinal canal is broader in the cervical and lumbar regions than in the dorsal, the distance between the saw-blades must be regulated accordingly. The dorsal portion is first sawed. The sawing should be in long cuts without too great pressure, the instrument being steadied by placing the left hand on the upright bar. As soon as the spinous processes become movable on slight pressure the sawing should be stopped. Should the blades become caught in the saw-cuts great care should be taken to avoid injuring the cord while releasing them. The straight-edged chisel may be inserted into the cuts and any parts still adherent may be carefully sprung apart. This is necessary particularly in the upper cervical region. The entire posterior wall of the canal may be loosened in this way, the sacrum being also sawed, when it is desired to open this part of the canal. When all the spinous processes are movable the attachments either above or below are cut with the cartilage-knife, and the spinous processes and laminæ torn off by the bone-nippers in one piece, either toward the head or sacrum as is the more convenient.

The laminæ may be cut by a chisel instead of a saw. The straight-edged or curved single chisel, the “tomahawk” chisel, or the double-bladed chisel of Esquirol may be employed. The latter instrument has adjustable chisel-blades that can be set to include the spinous processes. These blades are very strong and short, and have convex cutting edges. The use of a wooden mallet (Fig. [17]) is to be preferred to that of the steel hammer in driving chisels of any type. The straight, curved and tomahawk chisels are held with their cutting edges directed slightly outwards. The Amussat rhachiotome is a chisel-knife with a curved metallic handle, the cutting edge running along the length of the chisel. When set at an angle of 45° to the laminæ it is driven through them by means of blows from a wooden mallet delivered upon the chisel-back over the cutting edge. The Brunetti chisels are shown in Fig. [15]. In using these to open the spinal cord posteriorly, a block should be placed beneath the abdomen so as to raise the lumbar vertebræ above the level of the dorsal. The intervertebral ligaments of the last lumbar vertebræ are then cut through with the belly of the cartilage-knife held at right angles to the spine. The laminæ and spinous process of the last lumbar vertebra are then cut out with the straight-edged chisel or bone-forceps, exposing the canal. The right and left Brunetti chisels are then alternately used, beginning usually with the “left” chisel, the blunt probe-point being introduced into the canal, while firm pressure downward is made upon the handle, while at the same time the cutting edge is driven through the outer borders of the vertebral arches by blows from a wooden mallet delivered upon the head of the handle. Great care must be taken to keep the cut at the same level throughout. It is better, however, to cut too high rather than too low. In the latter case the cord may be injured, while in the former the bone may later be easily trimmed off sufficiently without causing any damage. The arches of three to four or even more vertebrae may be cut without removing the chisel. The same thing is then done on the other side, using the “right” chisel. The loosened portion of bone and ligaments is then cut or torn off with the bone-forceps or nippers. The cut bone should not be touched with the hands because of the danger of injury and subsequent infection from the sharp spicules and splinters of bone. As the canal is opened the block under the body is pushed towards the head, the object being always to cut down hill and not upward. When the cervical region is reached the head of the cadaver should be firmly held by an assistant so as to give sufficient resistance to the blows of the mallet. The skilful use of the Brunetti chisels is difficult to acquire and a great deal of practice is necessary, but when once the knack is obtained the spinal canal can be opened in this way more quickly than by any other method. In private practice the noise made by the hammer upon the head of the handles of the chisels is unpleasant, and should be avoided by the use of felt or something else on the head of the chisel or mallet to deaden the sound.

Another easy and convenient way of opening the spinal canal posteriorly is the cutting of the laminæ by means of special bone-forceps designed for this purpose. The cutting-edges may engage the laminæ from without or the lower blade may be introduced into the canal as a blunt probe, while the upper blade cuts down upon it through the side of the arch. Such bone-forceps should be very strong and have long handles to give sufficient purchase, as a good deal of force is necessary to cut through the laminæ. With a good instrument the canal can be opened in this way in about 10-15 minutes. It requires much less skill than is needed for good and quick work with the Brunetti chisels, and for that reason is recommended, as is also the use of Luer’s rhachiotome, for the general practitioner.

In the case of marked curvatures of the spine it may be impossible to use either rhachiotome or Brunetti chisels. The straight single chisel and small saw can be used on the concave and convex sides of the curvature respectively. In children and young adults the canal can be easily opened with the bone-forceps.

After the removal of the posterior wall of the spinal canal the peridural adipose tissue and the dural sac are exposed in the canal. The cord may now be removed with dural sac intact, and when the cord is soft this should be done, but in so doing the spinal fluid is likely to be lost; and, as it is very important to obtain a knowledge of the amount and character of this fluid, care should be taken to preserve it. With the block placed under the cervical region to keep the cervical and dorsal vertebræ higher than the lumbar the dural sac may be opened in the median line from above downward. The cervical dura is grasped with a pair of forceps and lifted so that a cut can be made in it with the small bent, probe-pointed shears. The blunt probe-point is then introduced into the subdural space and the dura cut in the median line downward toward the sacrum. With care the arachnoideal sac with its fluid may be preserved intact. What fluid there is in the subdural space will collect in the lumbar region and may be secured while the lumbar dura is cut. The fluid in the subarachnoideal space will likewise collect in the lower portion of the cord, and it is best at this stage of the operation to introduce a sterile pipette through the delicate arachnoid and draw up the fluid, preserving it for bacteriologic and microscopic examination.

The thirty pairs of spinal nerves are now cut from above downward, beginning on the right side. The cut edge of the dura or a dural fold, if the dura is left uncut, is seized with the dissecting forceps and pulled over to the left, so that as much of the nerve can be secured as possible. A long, narrow, sharp-pointed scalpel is inserted, outside of the dura, into the intervertebral foramina, as far as possible, and the nerves are cut while traction is made upon the dura to the opposite side. The same procedure is then carried out upon the left side. When all of the spinal nerves are cut, the scalpel is introduced in the spinal canal upward, as near to the foramen magnum as possible, and the cord and dura are cut transversely. The cord should be held by the dura; direct pressure with forceps or fingers upon the soft substance of the cord should never be made. If the forceps cannot be used to hold the dura with advantage, then the cord enclosed in the dural sac may be gently but firmly held in the palm of the left hand and lifted and drawn downward towards the sacrum with the greatest care. As the cord is removed the fibrous attachments between the dura and the longitudinal fascia of the anterior wall of the canal are cut with the small scalpel by means of oblique cuts upon the bodies of the vertebræ. Any fragments of bone impeding the removal of the cord should be trimmed off with the bone-forceps. The forcing of the cord through a tight aperture in the open canal may ruin that portion of the cord. In some cases it may be better to sever the dura and cord at the sacral end, below the cauda equina, and remove it toward the head, using the same method of holding the dura, and cutting the spinal nerves and peridural tissue. When this is done the importance of saving the spinal fluid should be borne in mind. Some prosectors prefer to sever the dura and cord above before cutting the spinal nerves, and to cut these and the epidural fascia while removing the cord. An experienced operator may save time in this way, but there is greater danger of injuring the cord. The cord may also be removed by severing the spinal nerves and vessels inside of the opened dura and lifting the cord out of the dura, but it is more likely to be damaged by this method. When the brain has been removed before the cord the dural attachments as high as the foramen magnum should be severed and the cord removed up to the point where it was severed from the brain. If it is desired to remove the cord attached to the brain, the cord is first loosened throughout its length from below up to the foramen. It is then carefully protected while the skull is opened; and after the brain-connections have been severed it is drawn up through the foramen as the brain is lifted out of the skull. After its removal from the body the cord is stretched out upon table or board and the dura opened in the median line both anteriorly and posteriorly, if the latter cut was not made before its removal from the body. If it is desired to make sections of both cord and dura for microscopic study the dura may be left uncut or attached to the cord after it has been opened in the median line. It then helps to hold the pieces of cord together after the latter has been cut. Otherwise the dura may be removed from the cord by cutting the nerve-roots and denticulate ligaments on both sides. The cord is now examined by making transverse cuts through it with a clean knife which is dipped into clean water before each cut. The cord is allowed to hang over the index-finger of the left hand while the knife is drawn across it, severing it down to the underlying pin which is left uncut to hold the pieces together. The cuts are usually begun in the cervical region and are made at the level of the spinal nerves. When the dura is left attached to the cord it may be laid back and the cord cut within it, or if it has not been opened, the cuts may be made through it and the cord at the same time, if a very sharp knife is used. Areas of softening should not be cut, but should be preserved intact for examination after fixation and hardening. If the segments of cord are left attached to the dura or pin the cord and membranes may be fixed and hardened en masse so as to permit future orientation.

Examination of Cord Anteriorly. After the complete examination of the neck, thoracic and abdominal organs the spinal column is divested of all remaining tissues, including the psoas muscles. A block is then placed beneath the lumbar vertebræ. With the belly of the cartilage-knife held transversely across the spinal axis the intervertebral disks on both sides of the next-to-the-last lumbar vertebra are cut down to the level of the canal. If the lumbar vertebræ are sufficiently elevated by the block placed beneath the abdomen, the cutting of the disks allows the neighboring vertebræ to spring away, so that the body of the vertebra thus separated can be cut out by the bone-forceps or chisel. The spinal canal is thereby exposed; so that the Brunetti chisels may now be used in cutting the pedicles and stripping off the vertebral bodies. As this stripping progresses upward the block is moved toward the head so that the cutting is always down hill. The chisels are driven through the pedicles of five or six vertebræ at a time; the handle is forced down until the long chisel-blade is nearly parallel with the vertebræ. At the same time the cutting-edge must be sent forward at a uniform level, just high enough to expose the canal. If the cut is too high the chisel will enter the body of the vertebra, if too low the probe-point will be pushed into the cord. When the cervical vertebræ are being cut the head of the cadaver must be steadied by an assistant. As the sections of vertebræ are loosened the intervertebral disks are cut with the cartilage-knife and the pieces of bone pulled away with the bone-nippers. When the canal is fully exposed the examination of the dura and the removal of cord and dura proceed as when the canal is opened posteriorly. The straight chisel and the bone-forceps are also used to open the spinal canal anteriorly, but the Brunetti chisels are especially recommended for this operation.

Examination of Spinal Ganglia. While these may be examined when the canal is opened posteriorly, they can be exposed with less danger of damage in the anterior examination. To expose them in the posterior examination they must either be drawn forcibly through the intervertebral foramina, or the articular processes must be cut away with the chisel.

When it is desired to remove a part of the spinal column for preservation as a specimen, the intervertebral cartilages and the cord above and below the portion to be removed are cut through with the knife, and the ribs severed with a chisel, while the adherent soft parts are cut away. The saw or chisel is then used to complete the disarticulation if necessary and the loosened portion is removed. The entire spine may be removed, if desired; and may be bisected with a band-saw. A stick of wood may be put in the place of the spine and covered with plaster-of-Paris.

After the cord and dura have been removed the inner surface of the canal should be examined. The character of the cut surface of the vertebral bodies is also noted, and the bones examined for pathologic conditions.

2. POINTS TO BE NOTED IN THE EXAMINATION OF THE SPINAL COLUMN.

1. Dorsal Incision. Note color of skin as it is cut, number of bleeding points, moisture, bedsores, amount and character of panniculus, color and blood-content of muscles, hemorrhages, purulent and tuberculous processes (usually infiltrations from diseased vertebræ) trichina in spinal muscles, etc.

2. Vertebrae. Necrosis from bedsores, surfaces smooth or rough, purulent and tuberculous processes (most common anteriorly), exostoses, curvatures, fractures, dislocations, erosions, malformations (spina bifida and supernumerary vertebræ most common), neoplasms (secondary carcinoma, primary sarcoma, myeloma and chloroma most common), actinomycosis, syphilis, rachitis, etc.

3. Dura. Note epidural tissue first, then dura, its thickness, color, translucency, blood-content, intradural pressure, character of inner surface (normally it is grayish-white, smooth and shining). defects, bone-formation, organizing blood-clots, hæmatoma, gumma, neoplasm, etc. Most common pathologic conditions are chronic pachymeningitis, syphilis, tuberculosis, traumatic lesions and secondary carcinoma. Primary tumors (sarcoma) and parasites (echinococcus and cysticercus) are rare. Teratomata occur in sacral and coccygeal regions. A diffuse formation of adipose tissue is common, as is also the development of bony plates in the dura in old chronic pachymeningitis (usually syphilitic). Note character and amount of contents of subdural space (blood, pus, serous exudate, etc.).

4. Inner Meninges. Normally gray, transparent, delicate. Note intrameningeal pressure, contents of subarachnoid space, color, thickness and translucency of arachnoid and pia, blood-vessels, presence of blood, pus, fibrinous exudates, localized thickenings, calcification, etc. Most common pathologic conditions are acute and chronic leptomeningitis, results of trauma, hemorrhage, syphilis, tuberculosis, cerebrospinal meningitis, leprous meningitis, etc. Bony plates (osteomata) are found in the arachnoid of the majority of people over forty-five years of age. In small number and size they have no pathologic significance; they are often large and very numerous in old cases of syphilitic leptomeningitis, sometimes encasing the cord. Primary tumors (fibroma, myxoma and sarcoma) are rare. Teratoid tumors (lipoma, myolipoma, neuroma) are occasionally found in the lumbosacral region, often associated with spina bifida. Secondary carcinoma and sarcoma, and metastases of the so-called glioma of the eye are also rarely found.

5. Cord. Size and form. Average length about 45 cms.; weight, 30 grms.; weight of cord to that of brain, 1:48.

Adhesions to inner meninges, consistence (should be uniform; changes in form and consistence are often the results of postmortem changes), color (gray-white, as seen through the pia), translucency (sclerotic areas in the white matter are firmer, depressed and gray or brownish-gray in color, and more translucent when present in the gray matter), moisture, color and blood-content of cut surface, relation of white and gray matter, symmetry of parts, size of central canal, presence of cavities, areas of softening (soft, yellowish-white, loss of structure), hemorrhages, congestion, anæmia, œdema, gumma, tubercle, tumors, parasites, etc. The normal consistence of the lower portion of the cord is usually somewhat firmer than that of the upper part. The “butterfly-figure” should stand out distinctly on the freshly-cut surface; the outlines between the white and gray matters should be sharp, and the gray matter should be grayish-red in color. Normally the white matter tends to rise above the gray. Inasmuch as the cord is often injured accidentally during its removal it is important to distinguish such artefacts from pathologic softenings. This can be easily done by taking a small portion of the doubtful area and examining in the fresh state under the microscope. In true softening numbers of “fat-granule” cells and also capillary walls showing fat-degeneration are seen.

The pathologic lesions of the cord easily recognized by the naked-eye are areas of sclerosis or gray degeneration, yellow degeneration, hemorrhage, anæmia, œdema, congestion, tabes dorsalis, amyotrophic lateral sclerosis, acute poliomyelitis, syringomyelia, ascending and descending degenerations, glioma, gumma, tubercle, certain malformations, neoplasms and parasites. Other important pathologic conditions are: Malformations (myelocele, hydrorrhachis interna, diastematomyelia, etc.), atrophy, myelitis, sclerosis, effects of trauma, syphilis and intoxications, infections, tuberculosis, etc. Primary tumors are: Glioma, gliosarcoma, gliomyxoma, sarcoma (spindle-cell, myxo-, angiosarcoma, etc.), neuroepithelioma, neuroma, diffuse gliosis, etc. All are rare with the exception of the gliomata. Metastatic carcinoma and sarcoma are relatively rare. Cysticercus and echinococcus are rare.

The thickness, color, consistence and translucence of the spinal ganglia should be noted. Atrophic nerves are smaller, more gray and more translucent.

6. Inner Surface of Vertebrae. The remains of the epidural tissue and the inner surface of the spinal canal should also be carefully examined, noting the consistence of the vertebræ, the character of the ligaments, fascia, periosteum, etc. The anterior wall of the canal should be smooth, the color of the vertebræ grayish-red, that of the intervertebral disks grayish-white. Caries, tuberculosis and syphilis lead to roughening of the bony wall of the canal.

CHAPTER VI.
THE EXAMINATION OF THE HEAD.

I. METHODS OF EXAMINATION.

1. Removal of Skull-Cap. For the section of the head the cadaver is placed upon its back with its head near the end of the table. The head may be elevated by a block placed beneath the neck, or it may be elevated and at the same time firmly held in position by the use of a special head-rest, different varieties of which are offered by instrument-makers. It is better to use the simple block of wood and to control the position of the head with the hands during the operation. The prosector takes his position behind the head of the table. The hair of the cadaver is then arranged in such a manner as to be out of the way, and protected by towels so that it will not become matted with blood and bone-dust. When the hair is short it is parted in a line extending from just behind the ears across the vertex. The shape of the head and the degree of baldness will determine the exact position of the primary incision through the scalp; sometimes it must be made farther back than the line connecting the ears in order that the incision may be concealed. In the great majority of cases it will be made as follows: The head is steadied with the operator’s left hand, and turned as far to the right as possible. The point of the cartilage-knife is then inserted into the scalp, just within the hair-line, behind the left ear, and with the belly of the knife the scalp is cut through to the periosteum, in the line of the hair-part, over the vertex, and as the head is turned to the left, down to the hair-line behind the right ear, the knife, as it approaches the end of the incision being raised so as to make the point finish the cut. This scalp-incision should be made with a strong and quick drawing movement, but the knife should not be pressed so firmly against the bone as to cut through the periosteum, else hemorrhages, collections of pus. etc., may escape before they are seen.