■ n u in ■i i SH I ! ■p III t III u I I ii 11 111 hoi ■ m mm ii ■r B 1 ■ mi in HIS 1 IlBl III ■■ n ft lllfl WW IP Willi I I! r ■Hn . i i JL u il 1 ii i ifti ■i I II iim tin I I > ■nHHH i I- a mmm I 1111 n In In 1 nil i m 1H 11 I I Hi ii it ■ Hi weHiHHHimiwiniimmimifTmnTT lIRuttf Glass _ 2JT^_ Book £L ._V1 ._. Copyright N° COPYRIGHT DEPOSIT. Post-mortem Pathology A MANUAL OF POST-MORTEM EXAMINATIONS AND THE INTERPRETATIONS TO BE DRAWN THEREFROM A PRACTICAL TREATISE FOR STUDENTS AND PRACTITIONERS BY HENRY W. CATTELL, A.M., M.D. PATHOLOGIST TO THE PHILADELPHIA HOSPITAL AND THE WEST PHILADELPHIA HOSPITAL FOR WOMEN, AND SOMETIME DIRECTOR OF THE JOSEPHINE M. AYER CLINICAL LABORATORY OF THE PENNSYL- VANIA HOSPITAL ; SENIOR CORONER'S PHYSICIAN OF PHILADELPHIA ; PATHOLOGIST TO THE PRESBYTERIAN HOSPITAL ; PROSECTOR OF THE AMERICAN ANTHROPOMETRIC SOCIETY ; DEMONSTRATOR OF MORBID ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. WITH 162 ILLUSTRATIONS " Rotto dal mento insin dove si trulla. ' Tra le gambe pendevan le minugia; La corata pareva, e iltristo sacco Che merda fa di quel che si trangugia.' -Dante PHILADELPHIA AND LONDON J. B. LIPPINCOTT COMPANY 1903 «3 -S ■* o ft U '3 -5 ft «• ■i § 3 en S 3 u s 3 CD X — a a «*-( ,d "Ph „ Ph ^ CJ X 2 >p a V <*- o 1 OJ X c d 1 en ft ri nJ 1 3 OJ o u 1. - CT 1 1 o 1 CO o X 1 cu p CD boo c T t/3 '5 1-4 CD c/T CD en d d i u CD td CD CJ lg 5 'X 5 i CI i o CD r. 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In fact, the instruments that are really indispensable are very few in number, as a complete autopsy may be performed with a penknife and an ordinary wood-saw. Of course, in this field, as in surgery, ample opportunity has been offered for the exercise of me- chanical ingenuity, and many instruments have been devised for fa- cilitating post-mortem work that save much time and render greater neatness and exactitude possible. The following list contains the instruments, apparatus, and chemi- cals most commonly used in the performance of an autopsy. Knives. — Section- or Cartilage-Knives. — These should be made very strong, with a broad back, blunt rounded ends, and a bulge or belly at the outer third (Fig. 10), and should be narrower at the Fig. io. — Section- or cartilage-knife, with rounded end. (One-half natural size.) attachment of the blade to the handle. For general purposes the length of the entire knife should be from seven to seven and a half inches (about eighteen centimetres), the handle measuring about four inches. The Germans use knives even as long as eleven inches (twenty-eight centimetres). A separate rounded expansion for the index-finger found on the back of some section-knives is unnecessary (Fig. n). The sharp-pointed knife should emphatically be con- demned (Fig. 12). When the knives are sent to be sharpened, the instrument-maker should be cautioned not to grind them to a point. Scalpels, such as are used in dissecting. Those made of a single piece — i.e., without wooden, bone, or ivory handles — are to be preferred. The brain-knife (Fig. 86) should have a thin blade about ten inches (twenty-five centimetres) long, one and a half inches (four centi- 24 POST-MORTEM INSTRUMENTS AND THEIR USE 25 metres) broad, and blunt at the end like a table-knife. This instru- ment may also be used for incising the large organs and in opening Fig. 1 i.— Cartilage-knife with projection on back upon which the index-finger rests when making incisions. (Two-thirds natural size.) Fig. 12. — Post-mortem knife with faulty point and without proper belly. (Two-thirds natural size.) the cavities of the heart. The brain-knife may be marked in the form of a rule and thus serve a double purpose (Fig. 13). An ampntation- iirfiiii|;iii|!!i!i ! ii|!'iir''|iir; ir; V['~ |'iiiii!!|ii!i|iiii|iiipi|!iii|!iiipiiiiii|iiii| rte-sp^ I 7. 3 4- 5 6- 7 ' B 9 10 II 12 13 'A 15 Fig. 13. — Coplin's brain-knife marked in centimetres on one side and in inches on the other. (Reduced.) knife may be employed in place of a brain-knife, or in removing the brain through a trephine opening made in the skull. A Waring bread- knife (Fig. 14), which also does good work, may be used for incis- FiG. 14. — Bread-knife, useful in incising large organs, as the brain, the liver, etc. It comes in two forms, — with both sides meeting at the cutting edge like an ordinary knife, or with one side perpendicu- lar and the other slanting for about three-eighths of an inch above the sharp edge, as shown near the handle in the illustration. (One-third natural size.) ing the larger organs. . A Valentine knife (Fig. 15), which has two parallel blades adjustable by screws to keep them the desired distance apart in order to cut at will thick or thin sections, is now rarely seen, but was much employed before the freezing microtome came into com- mon use. Pick's myelotome (Fig. 16) is an instrument with a short blade bent nearly at right angles to the shaft, for cutting the spinal 26 POST-MORTEM EXAMINATIONS cord squarely across instead of in an oblique direction. A curved probe-pointed bistoury is used in cutting the dura mater, spinal cord, Fig. 15.— Valentine's knife. (One-half natural size.) Fig. 16.— Pick's myelotome. This little instrument is useful for severing the spinal cord in the removal of the brain. (One-half natural size.) etc. A razor was formerly included in all lists of post-mortem instru- ments, but is now discarded. Saws. — The saw should possess a strong blade solidly attached to the handle (Fig. 17), as the two-piece jointed ones, kept in place by a screw, are very liable to become loosened. A butcher's meat-saw, Fig. 17. — A very desirable saw for post-mortem work ; it is solidly constructed, and the teeth on the curved end are useful in sawing out the angles in the removal of the skullcap by the angular method described on page 166. (Slightly less than one-half natural size.) which is arranged like a scroll-saw (Fig. 18) with its teeth pointed towards the front, its cutting surface measuring from ten to fourteen inches (twenty-five to thirty centimetres) for an adult and six inches (fifteen centimetres) for a babe, or a large cross-cut carpenter's saw, does the quickest work in removing the calvaria. Hey's saw (Fig. 19) is useful in sawing the angles when opening the skull. A metacarpal saw (Fig. 20) is often of service, especially in examining the femur POST-MORTEM INSTRUMENTS AND THEIR USE 27 of a babe for syphilitic osteochondritis. Liter's double rhachiotome (Fig. 21), used for opening the spinal column, consists of two parallel Fig. iS. — Butcher's saw, very useful for quick work in opening the calvarium. (One-quarter natural size.) Fig. 19.— Hey's saw. (Two-thirds natural size.) Fig. 20. — Metacarpal saw. (Slightly less than two-thirds natural size.) Fig. 21. — Luer's double rhachiotome. This instrument is held in the right hand and steadied by means of the handle attached to the fixed blade, the other blade being movable by clamps, so that the distance between the parallel blades may be varied at the will of the operator. saws with curved blades, the distance between which can be regu- lated by screws, and a very firm handle with a strong central support. 28 POST-MORTEM EXAMINATIONS Various forms of dental and trephining engines, usually driven by electricity, have recently been introduced and are useful in saving time Fig. 22. — Cryer's electrical surgical engine for cutting bone. A, spiral osteotome, with guard, for removing section of skull ; B, spiral osteotome ; C, trephine ; D, guard for osteotome ; E, electric motor ; F, crank for hand propulsion ; G, driving wheel for hand propulsion. and labor. Among such engines may be mentioned those of Cryer 1 ( Fig. 22 ) , de Vilbiss, Wright, etc. These instruments are high-priced 1 Medical News, January 30, 1897. POST-MORTEM INSTRUMENTS AND THEIR USE 2 g (from one hundred to three hundred dollars), on account of the in- frequent demand for them. Hand-driven instruments may be pur- chased for twenty-five dollars and upward. Scissors. — One pair of scissors should be large and strong, with long handles and short, stout blades (Fig. 23) ; the other pair should Fig. 23.— Strong scissors with short blades. (One-half natural size.) Fig. 24. — Scissors with one rounded blade and with bent handles. (One-half natural size.) have rounded ends with bent handles (Fig. 24). A pair with one probe-pointed blade is frequently useful. The enter otome is a scissors with one short and one long blade (Fig. 25), the latter being blunt and curved on itself at the end. Be sure that there is no sharp-pointed end, as this is the form usually supplied (Fig. 26). The costotome (Fig. 27) is an expensive instrument, with short, thick blades, the under one being curved and having a strong spring between the handles. Dangerous blood-blisters are sometimes produced by pinch- ing the skin with the ends of the handles, which usually meet and 30 POST-MORTEM EXAMINATIONS Fig. 25. — Proper form of enterotome. (One-half natural size.) Fig. 26. — Improper form of enterotome, with pointed ends. (One-half natural size.) Fig. 27. — Proper form of costotome ; the handles do not meet by one-quarter of an inch and the ends are not pointed, but rounded. (One-half natural size.) POST-MORTEM INSTRUMENTS AND THEIR USE 3T fasten with a catch (Fig. 28). The ends should not meet and there is no necessity for the catch. Fig. 28. — Improper form of costotome, with pointed blades and a catch, the handles meeting when they are closed. (One-half natural size.) Hammers. — The most useful hammer is made of solid steel (Fig. 29). One end of the head or striking portion is cuneiform, and there may be a hook on the end of the handle which is of service in spring- Fig. 29. — Steel hammer with proper handle. (One-half natural size.) ing off the calvarium. Lead filling in a hammer muffles the sound of its impact and prevents rebounding. A wooden mallet is preferred by some pathologists. Chisels. — There are chisels of various patterns devised for use in different regions. The straight cliisel is the most serviceable, as it can be used in any region. The T-shaped chisel is also generally useful; it has one arm placed perpendicular to the other, and the arm which serves as a handle has one sharp and one blunt end so that it can be hammered upon. The chief use of the T-shaped chisel is in springing off the calvarium and in elevating the periosteum from it. Guarded, hatchet-shaped, and other chisels (Figs. 30 and 31) and spinal 32 POST-MORTEM EXAMINATIONS chisels (Fig. 32) are useful in opening the spinal canal, and a chisel with a guard about half an inch, or 1.25 centimetres, from the edge m»v'----' — *%£& ■S'v -w Ife. ,#§a '- ' •-'■..' ; •- ■N \;T;0 >.: 1 'lj "\| , mm m Fig. 31.— Cur\-ed chisel, used for the same purposes as Fig. 30. (One-half natural size.) Fig. 30. — Solid steel side chisel for breaking through any unsawed portions of bone in re- moving the calvarium. The pointed end is used as a pry and retractor for pulling out the sawed-off portion of the skull. (One-half natural size.) Fig. 32. — Brunetti's curved spinal chisel, of use in opening the vertebrae. (One-half natural size.) will not injure the brain while springing off the calvarium from the dura mater. The raspatory of Chiara has a broad, spoon-shaped end, four centimetres wide, with which the periosteum from a large surface POST-MORTEM INSTRUMENTS AND THEIR USE 33 can easily be removed; the other end is of the shape of a lance, one inch (2.5 centimetres) long, and is used for deep separation. Forceps. — Dissecting forceps are indispensable when it is neces- sary to trace small structures; pointed, straight and curved forceps are the forms in use. Bone-forceps, large and strong and with rough handles, are necessary. One blade is blunt, so that it can be shoved against soft tissues without injuring them, as in cutting the ribs. Lion-forceps of special type may be used when removing the bodies of the vertebra?. Dura-tongs, for pulling the dura mater away from the calvarium when it is adherent, may save the fingers from being injured by the bone. Grooved and curved directors are frequently necessary. Chain hooks and a tenaculum may be of use, but they are dan- gerous instruments. Hooked retractors are more desirable than a tenaculum or chain hooks. Various Instruments. — A metal catheter and several flexible catheters, all of size number 8, may be needed for withdrawing urine. Fig. 33.— Satterthwaite's calvarium clamp, closed and in use. A blow-pipe with a stop or valve, a trocar and cannula, probes, some of which have eyes, and some form of injecting syringe are also 3 34 POST-MORTEM EXAMINATIONS useful. A vise is serviceable in firmly holding bone preparations in course of dissection, and in fixing a saw that is being sharpened. A skull clamp is considered by some to be of use in removing the calva- Fig. 34. — Iron clamp to be applied to the skull before the removal of the brain ; especially used in dissecting rooms. rium (Figs. 33, 34, and 35). Iron tripods and other special devices for holding the head are shown in Figs. 36 and $J. Fig. 35. — Bigelow clamp for holding the head in the removal of the brain. Fig. 36. — Folding iron head-rest Weights and measures of various kinds are frequently found to be indispensable. These should include scales, a steel tape measure, grad- '' VPS Mt < J _ Jf - — y^~ Fig. 37. — Cornell folding clamp for the secure holding of the head in the removal of the calvarium. p IG _ 38.— Cones for measuring orifices. (Actual size.) Fie;. 39. — Glass balls to which handles are attached, for measuring orifices. POST-MORTEM INSTRUMENTS AND THEIR USE 35 nated calipers, graduated glass cones, glass balls, and graduated meas- uring vessels of glass. The scales should have a capacity of twenty pounds, or ten kilogrammes, and be supplied with weights from a gramme upward. They are needed in weighing organs. The steel tape measure and the two-feet rule are marked in both centimetres and inches. Graduated calipers are useful in determining diameters. Graduated wooden cones are used in measuring orifices (Fig. 38). Glass balls are serviceable in determining the size of apertures and canals (Fig. 39). Graduated measuring vessels of glass are desirable The larger vessels should be marked at every hundred cubic centi- metres up to one or two litres, and the smaller for every two cubic centimetres up to a hundred. A stomach-pump is especially useful in withdrawing fluids from cavities. Ladles w r ith a lip or spout, made of enamelled or agate ware, and with a capacity of half a pint, or two hundred and fifty cubic centimetres, are needed in dipping fluid from cavities. A magnifying- glass that enlarges at least ten diameters should be in the hands of every one making postmortems. Other Supplies. — Enamelled trays or basins are useful for re- ceiving removed organs, and the basins are also required in cleansing the hands and instruments. Blocks of wood are required to support the body. Some of these should be prismatic in form, others excavated to fit under the neck during removal of the brain. All wooden utensils should be finished with oil so as to be non-absorbent. Earthenware plates or zvoodcu boards are useful during the dissection of organs. Needles and coarse flax thread or fine twine are needed in closing in- cisions made through the skin. The thread is also required in ligating the intestines before removing them. Sponges are a necessity readily procured, and should always be moist when in use. Pins are useful in fixing small structures in course of dissection. Special tables of zinc-covered wood, slate, iron, or glass are desirable in a pathological department. Rotating tables are convenient, but weighing tables are expensive. The table should be constructed so as to carry off all fluids into a receptable provided, for them. Rubber gloves that reach well up the wrist and finger-cots afford protection to the pathologist, particularly in cases where the danger of infection is great ; but the operator can work more swiftly with bare hands, the abrasions upon which have been protected with flexible col- lodion containing two per cent, of iodoform. It is also an advantage ^6 POST-MORTEM EXAMINATIONS to introduce cosmoline into the crevices around the finger-nails. The gloves are more readily put on and are preserved by dusting them freely with ground soapstonc kept in a dusting bottle. Quart museum jars are useful for holding specimens to be preserved, and two-ounce, wide-mouth bottles, for microscopic specimens. A clean glass bottle with a glass stopper and sealing-wax to keep it closed are needed to receive the contents of the stomach in a case of poisoning. Bromin in a strong bottle with a ground-glass stopper that fits well serves a good purpose in disinfecting fresh wounds. Pails are needed as containers for water and to receive fluid re- moved from the body. Cotton wool, sawdust, or tow placed in the large cavities of the body before they are closed prevents the escape of fluid from them. Plaster of Paris and sand serve a similar purpose in the cranial cavity. Disinfectants and deodorants should not be for- gotten, as it is desirable to destroy or neutralize odors emanating from the body, and to disinfect and deodorize the hands of the pathologist after the examination has been completed. Bellows are occasionally useful in inflating hollow viscera. A hand-bag which can be cleansed is required in carrying instruments to and from private houses. The chemical, bacteriological, and microscopic supplies required in the work of the pathologist at the postmortem are red and blue litmus paper, turmeric paper, Lugol's solution, solution of sulphid of ammo- nium for detection of free iron derived from bile pigment, as in perni- cious anaemia, Gabbett's solution, carbol-fuchsin, Loerner's alkaline blue, absolute and commercial alcohol, ethyl chlorid or methyl chlorid, culture-tubes containing blood-serum, agar, and gelatin (bouillon is troublesome to carry), an alcohol-lamp, glass slides and covers for microscopic specimens, filter-papers three or four inches in diameter, an old scalpel which can be heated, a platinum wire three inches (or eight centimetres) long, set in a solid glass rod six inches (or fifteen centimetres) long, for making cultures (called an ose), a microscope, a freezing microtome, and easy access to an incubator. In my own experience it has been found desirable or convenient to discard one instrument after another until now my satchel for private work weighs with its contents but nine pounds, and con- tains the following articles: two section-knives in good condition; a scalpel; a pair of medium-sized, strong scissors; a pair of bone- forceps; a dissecting forceps; a saw; an enterotome; a hammer with a hook on its handle; a pelvimeter; a new rubber catheter; POST-MORTEM INSTRUMENTS AND THEIR USE 37 gummed labels; various kinds of litmus paper; sealing-wax; a dissecting-apron and sleeves ; a pair of rubber gloves, with plenty of ground soapstone in an iodoform dusting bottle; finger-stalls; a piece of thin rubber sheeting forty-five by thirty inches; a piece of oiled silk, or a rubber bag (sixteen by ten by four inches) from which fluid will not escape; two medium-sized bath-sponges; a quart museum jar graduated into ounces or cubic centimetres, into which some of the smaller articles are placed and which can be used for the removal of gross specimens later, if desired; a large needle and flax twine, cut and wrapped (Fig. 40) into three lengths, for sewing the Fig. 40. — Hemp twine cut of the proper length and ready for use. body with single thread (forty-five inches), for sewing the head ( twenty-five inches ) , and for tying the intestines ( ten inches ) ; some bromine in a strong bottle with a well-fitting ground-glass stopper; two per cent, iodoform celloidin solution ; a small roll of cotton ; four two-ounce, wide-mouth bottles for microscopic specimens, one of which should be filled with seventy per cent, alcohol, one with ten per cent, formalin, one with Muller's fluid, and the fourth with a saturated solution of mercuric bichlorid; two ounces of creolin; a cake of one per cent, bichlorid of mercury soap ; an ose ; an alcohol-lamp ; several culture-tubes properly packed; incense powders; matches; pins, saf ety and ordinary ; a steel tape-measure marked in inches and centi- metres ; a hand lens magnifying about ten diameters ; a pair of spring scales weighing up to fifteen pounds ; and last, but not least, a note- book and several pencils, one of which will write on glass. To this list may be added other articles as the necessities of the case may demand. For the private use of the general practitioner, a large section- knife, a scalpel, an enterotome, a saw, a chisel, a mallet, a pair of scissors, and a large needle may be purchased for about five dollars. These should be kept rolled up in a piece of chamois-skin, preferably made with pockets into which the instruments fit, and if the latter be 38 POST-MORTEM EXAMINATIONS put away clean after use they are always ready for service; or a leather case (Fig. 41 ) may be employed. The proper handling of post-mortem instruments is not acquired in a day, and the beginner will find that experience teaches many lessons which are not likely to be forgotten. A well-ground, keen-edged knife is a great desideratum, the advantages of a dull knife being simply that it is less likely to injure a beginner or care- less operator and to disfigure the exposed portions of the body. 1 In opening the body the free incisions should be made by an easy, untrammelled movement, executed by the muscles of the I shoulder rather than by those of the arm or hand. It is essential that the knife be grasped firmly (Fig. 42), and not held like a pen, as is a scalpel in the act of dissect- ing. Virchow says that the knife should be held in the whole hand, so that when the arm is stretched out the blade extends with it. The fingers and hands are fixed, if not absolutely, at least relatively, and execute the motion with the whole arm, so that the movement is principally in the shoulder- joint and secondarily in the elbow- joint. Thus the whole strength of the arm and shoulder muscles is brought into play, and long, smooth incisions, so essential to proper inspection, are made. In cutting, pressure should be uniform, and the greater the pressure the quicker will the knife pass through the tissues. A clean cut made in the wrong place does less harm than a ragged one in the right place (Virchow). The portion of the blade near the handle should be used for work which dulls a knife, as cutting Fig. 41. — Formad's leather pocket-case, holding the Instru- ments usually employed in making a postmortem. (One-half natural size.) 1 The method of holding and using the instruments will be seen illustrated by reference to the pages treating of the examination of the various organs. POST-MORTEM INSTRUMENTS AND THEIR USE 39 the ribs. This also applies to scissors, the part near the pivot being em- ployed in all cases in which considerable force is required. When held as shown in Figs. 47 or 49, but preferably as in Fig. 47, the operator is sure to have a firm grasp of the knife-handle, so that there will be little likelihood of a dangerous slip. The actual cutting is properly and mainly done with the belly of the knife about one inch from its end, for which reason this part of the blade is always the thickest. The direc- tion of the incision should invariably be from the operator, especial care being taken not to wound the left hand, and from those portions of the subject in which disfigurement would be most likely to be noticed. Care must also be taken not to injure the assistants or those standing near. When the resistance of a tissue is unexpectedly overcome, the knife will sometimes travel a considerable distance before it can be stopped by an effort of the will. The blade of the knife must be kept free from blood by frequent washing. This is especially necessary when incising organs, as the brain, in which incisions are made with much more satisfaction if the knife-blade be previously moistened. A pointed knife may be used for the removal of the tongue and the larynx, and a scalpel for fine dis- section, as in tracing the spermatic or thoracic duct. CHAPTER IV THE CARE OF THE HANDS AND THE TREATMENT OF POST-MORTEM WOUNDS Before beginning the autopsy, especially in a purulent case, the pathologist should carefully examine his hands ; if these be not in good condition, the notes may be dictated by him while some one else can usually be found to do the actual cutting. For the protection of their patients, residents during their term of service in the surgical and gynaecological wards of our hospitals should be forbidden to make autopsies, and they should not be tempted to break this rule by a request to assist at a postmortem, even though no one else be available to do the routine work of opening the body. Slight wounds on the hands may be protected before beginning- the necropsy by placing a small piece of absorbent cotton upon them and then applying the ordinary thick celloidin used in bacteriological work, or the iodoform celloidin referred to on page 37. Before starting work upon the body, many pathologists anoint their hands with some antiseptic salve, such as vaseline containing- boric acid, ten grains to the ounce, a ten per cent, carbolic acid oint- ment, or a solution of the balsam of Peru. If these be used, they should be renewed several times during the progress of the autopsy. It is, however, doubtful whether the advantages gained by their em- ployment are not more than offset by the fact that the hold upon the instruments is thereby rendered less secure. This can to a certain extent be avoided by anointing the entire left hand (which comes in contact with the tissues of the body) and only the back of the right hand (the instruments being held by the palm of this hand) with the ointment, as it is here that infection usually takes place when no mechanical injury to the hand is inflicted. Frequent washing of the hands in clean water is regarded by many as decidedly better. Of course, when digital examinations are necessary, as in exploring fistu- lous tracts, examining the vagina and os, and in certain cases of peri- tonitis, antiseptic unguents are desirable; in such cases it is necessary to anoint only that portion of the hand which comes in contact with the tissues under examination. 40 CARE OF THE HANDS 4I An equally efficient and in many respects a much better safeguard against infection is the use of rubber gloves. Post-mortem gloves made of thin gum elastic and provided with long sleeves may be found in the rubber stores and at instrument-makers'. They fit snugly, and are especially desirable in opening the stomach and intestines, as it is most frequently the intestinal contents which impart the odor that adheres so persistently to the hands. They do not prevent, though they to a certain extent hinder, the production of post-mortem wounds. Rubber finger-stalls, especially the variety known as the seamless rolled finger-cot, which unrolls as it is placed on the finger, are useful if the operator have any hangnails or other abrasions of the fingers. Blood, pus, or other cadaveric fluid should not be allowed to dry upon the instruments used nor upon the hands, for it not only impairs the deli- cacy of touch so desirable in this work, but it also may cause unsightly stains upon the skin, which are difficult to remove, especially when certain preservatives have been employed in embalming the body. Odor can usually be removed from the hands by applying to them, while still wet, either a few drops of turpentine, formic aldehyde, from one to three per cent., aromatic spirit of ammonia, listerine, paregoric, or mustard, and then washing them thoroughly with a good glycerin soap. Neelsen (quoted by Nauwerck) states that, if the odor can be removed in no other way, equal parts of fuming hydrochloric acid and glycerin should be used. The employment of equal parts of hypo- bromite solution (used in the quantitative estimation of urea) and of water, while severe, is also very effective for this purpose. For disinfection of the hands after the postmortem one may use creolin water, made by placing about an ounce of creolin in a basin of tepid water, 1 or a concentrated solution of potassium permanganate, and the removal of the brownish discoloration can be accomplished with oxalic acid or an antiseptic soap. Of the latter, I prefer the one per cent, bichlorid of mercury soap. A post-mortem wound as usually referred to means not only a cut or injury received at a postmortem, but the additional inoculation of any break in the continuity of the skin by means of which pathogenic bacteria derived from the dead bodies of human beings or of animals gain entrance to the system and there multiply. Wounds presenting similar appearances may, of course, be derived from many sources, as 1 Or, more exactly, a two per cent, creolin solution. 42 POST-MORTEM EXAMINATIONS from surgical operations and from other post-mortem wounds. The intact skin of the hand is a perfect protection against the invasion of bacteria. In order that the organisms may infect the body, there must be both a point of entrance and a predisposition of the individual. While any of the infectious diseases may be contracted in making a postmortem, those most to be feared are tuberculous warts, syphilis, gonorrhceal ophthalmia, tetanus, anthrax, glanders, plague, actinomy- cosis, typhus fever, diphtheria, yellow fever, cholera, and smallpox. Inoculations from serous surfaces are especially to be guarded against, as from some of the varieties of peritonitis due to criminal abortion, and other forms of septic peritonitis, meningitis, or pleurisy. Among other virulent forms of post-mortem wounds may be men- tioned those derived from cases of pyaemia, of septicaemia, of puer- peral fever, of malignant oedema and diffuse cellulitis, of erysipelas, and of gangrene. Personally, I have the most wholesome respect for the Bacillus pyocyaneus, with which I became inoculated from a case of cancer of the gall-bladder with secondary infection by this organism. For a number of days my temperature was above 105 F. It is often asked why post-mortem wounds and injuries received in the performance of similar operations are more dangerous than those which are otherwise inflicted. Their greater virulence may in part be due to the fact that they are usually punctured wounds, and thus afford a favorable opportunity for the deep implantation of pyo- genic organisms. Again, it is a well-known bacteriological fact that many organisms become more virulent by passing through successive animals, and finally, an organism which has overcome the resistance of the tissues and killed them is naturally more destructive than one which has not had such favorable opportunities for growth. Post-mortem wounds are generally caused in one or other of four ways: first, by cuts from instruments used in the making of the autopsy, especially sharp-pointed knives and the saw; second, by scratches or punctures from ragged bones or calcified tissues, as the ribs or atheromatous patches of the aorta which have undergone cal- careous infiltration; third, by inoculation of pre-existing wounds, abrasions, small eruptions, especially at the roots of the hair-follicles, hangnails, blisters, fissures in chapped hands, etc. ; and, fourth, by cuts and scratches accidentally inflicted by the operator on his assistant, as in opening the head. Indeed, so frequently does the latter occur that I always dispense with a helper to steady the head unless his hands TREATMENT OF POST-MORTEM WOUNDS 43 "be thoroughly protected by some covering, such as a towel. Ragged wounds, such as those caused by the saw or by bones, are especially to be dreaded, for, being both punctured and lacerated, they are par- ticularly prone to become infected. Then, too, it has been shown experimentally that bone marrow possesses marked bactericidal properties. Hence wounds produced by sharp spicules of bone are usually severe, for the reason that they introduce into the wounded tissues large numbers of bacteria by which this resistance of the bone marrow has already been overcome. The micro-organisms found at a postmortem made several days after death are apt to be less virulent than those encountered soon after dis- solution, the saprophytes having now gained the upper hand. Other things being equal, the more quickly the patient died after infection, the more severe will be the post-mortem wound; but the character of this lesion and the nature of the organism must always be con- sidered. Undoubtedly, persons making many postmortems become immune to inoculation by the ordinary Staphylococci and Streptococci. When toxins are introduced along with the bacteria, the constitutional symptoms are apt to be more severe, as the toxins overcome a certain amount of reserved force of the tissues which might otherwise be used in combating the organisms themselves. Some of the usual ways of producing wounds which are especially worthy of mention are : by the operator cutting towards instead of away from himself or his assistant ; by leaving the knife in one of the cavities and forgetting its presence; by placing his instruments in a dangerous position on the body, the table, or the ice-box; by the use of sharp-pointed knives; by punctures from the needle, made during the sewing up of the body; and by the too rapid passage of thread through the hands producing a sort of brush-burn. The great protection afforded by the bleeding of a wound is well known; hence the immediate closing of the latter by the application of caustics or of celloidin is worse than useless. If the finger be wounded, it should be wrapped with a miniature Esmarch bandage and then allowed to bleed freely under running zvater for at least five minutes. Sucking of the wound may then be practised, and, if a caustic be required, there is probably nothing better than glacial acetic acid or pure formalin. The use of the actual cautery is advisable in some cases, but must be so thoroughly applied that no organisms are left behind, as otherwise the necrosed tissue may afford a favorable 44 POST-MORTEM EXAMINATIONS medium for their growth. An antiseptic dressing may then be applied r which should be renewed every twelve hours. On the slightest indica- tion of pus or a deadish-gray appearance of the wound, it should be freely incised, thoroughly cleansed with hydrogen peroxide, bromine, or formalin, and dressed with iodoform and a wet bichloride bandage ; or a solution of silver nitrate may be applied with benefit. I have seen no good effect from the local use of the unguentum Crede (ointment of soluble metallic silver). The injection of formalin in cases of septi- caemia is well spoken of. The frequent application of hot flaxseed poultices containing a teaspoonful of Labarraque's solution is most grateful when the wound is discharging. Several inches above the wound a ring of iodine should be plentifully painted. Involvement of the lymphatics, as seen by red lines running up the arm, usually on the inner surface, and tenderness in the axilla, indi- cates danger. Inflammation of the lymph-glands of the axilla may cause the glands in this region to become tender and swollen, so that an incision is necessary ; and in cases of axillary cellulitis, even though the wound of inoculation be small, early incision should be employed. Quinine is useful in these cases, and iron may be prescribed later. The affected arm should be carried in a sling, tonic treatment with changes of air instituted, and a surgeon consulted, who will treat the case according to the character of the wound, the nature of the infection, and the constitution of the patient. When healing has commenced, massage has made many a useful finger or hand out of what would otherwise have been a stiff and useless one. The general health has much to do with the severity of the wound, and, other things being equal, severer symptoms and slower convales- cence may be expected in those who are habituated to the use of alcohol. The anatomical wart is a local tuberculous lesion, often multiple, and situated on the back of the hand or at the flexor joints of the fingers. There is a warty thickening of the papilla of the skin, accom- panied by a discharge of thin serous pus, but with no true ulceration, The sensation produced is similar to that caused by a splinter, which, however, subsides for several days after the removal of the fluid con- tents. The lesion sometimes heals spontaneously, but may give rise, as in one of my cases, to general tuberculosis. Wet dressings, com- bined with an application of equal parts of glycerin and extract of belladonna, may be employed, or the following mixture applied : TREATMENT OF POST-MORTEM WOUNDS 45 R Salicylic acid, 10 parts ; Extract of cannabis indica, Cocaine hydrochlorate, of each 1 part ; Oil of turpentine, 5 parts : Glacial acetic acid, 2 parts ; Collodion, 100 parts. It would be interesting to try the hypodermic injection of tuberculin, or some of the newer forms of treatment for lupus of the face, as that recommended by Dr. Finsen. 1 In one of my cases I thought that an anatomical wart was rendered worse by the use of the X-rays. One of my patients evidently contracted a tuberculous wart from a cow, thus adding another case against Koch's dictum which he announced at the meeting of the Tuberculosis Congress in 1901. When tuberculous warts have lasted several months, surgical treat- ment should be instituted, care being taken not to open them into trie circulation, and that sufficient healthy tissue be removed to make a .good cicatrix. Guinea-pigs injected with such material linger a long time, and in one of my cases over six months elapsed before the animal died from general tuberculosis. Suppuration of the matrix of the nails can often be cured only by the removal of the nail, though frequent soaking of the finger in a hot saturated solution of boric acid or a strong solution of lead sub- acetate may be tried. Diffuse cellulitis should be treated by early and free incision and the application of cold compresses. When the hand itself is involved in spreading gangrene, amputation should usually be practised. I have seen septicaemia, pyaemia, general tuberculosis, ulcerated endocarditis, purulent meningitis, boils, whitlows, etc., fol- low post-mortem wounds. If the knives used in post-mortem work were thoroughly sterilized after each necropsy, there would be fewer infected wounds. The making of autopsies is undoubtedly dangerous, and therefore those who are in the habit of doing so should insure themselves in one or other of the' accident companies which contain a clause giving a claim for benefits in case of wound-infection. As these companies show a disposition to dispute claims, any injury, no matter how slight it may be, should be reported to them as soon as possible after its occurrence. 1 Bie. International Clinics, Vol. iii., Eleventh Series, 1902. CHAPTER V EXAMINATION OF THE EXTERIOR OF THE BODY After carefully considering the clinical history and weighing the evidence derived from an examination of the surroundings and from questioning the persons who have been brought in contact with the corpse, the nude body should be minutely inspected, first as a whole and then with regard to its component parts. 1 This external examina- tion is of especial value in medicolegal cases or when the postmortem is about to be performed upon an unidentified body. The noting of certain details, such as moles, birth-marks, angioma, tattoo markings, scars, condition of the teeth, and anomalies of the ear and eye, may be of great importance, and may even later on be the sole means of identifying the body. Should the clothes be preserved for any reason, as for purposes of identification or for showing the entrance of a bullet, camphor or tar camphor should be added previous to their being securely wrapt up and properly labelled, in order to prevent their de- struction by moths. In handing them over to the proper legal officers it is well to get a receipt for such articles and to have the transaction take place in the presence of a witness. The knowledge acquired by inspection of the surroundings and the exterior of the body must, however, in no way bias the examiner in his internal examination, as the unexpected happens here as elsewhere. The sex, the race, and the apparent age 2 are first carefully noted. The height is now determined by measuring in a straight line from the vertex of the head to the centre of the external arch of the instep. If a scale is not marked on the table and no other means of measuring is at hand, a piece of inelastic string or tape may be employed for this 1 It would be well if the living body were more frequently made the subject of careful study in the nude state, as the information thus obtained is often of great value to the clinician or surgeon. 2 By apparent age is meant the age of the body as it appears to the judgment of the observer at the time of making the postmortem. Thus, a person may look younger or older than his or her real age, suffering, mental depression, etc., often making the body seem many years older than it really is. Per contra, the signs of suffering may pass away and the features become relaxed and appear in better condition than for years before death. 46 EXAMINATION OF THE EXTERIOR OF THE BODY 47 purpose and measured later. The writer would suggest the use of a measuring apparatus modelled on a shoe-measure. A simpler form can readily be made by taking two one-foot rulers, or other sticks of about the same size, and attaching, one inch from one end, a seventy- eight inch tape-measure, 1 which is made to run through a transverse slit one inch from the top of the other ruler. The first ruler is held close to the foot, which is placed in a vertical position, and the other stick is held parallel to the first stick by an assistant at the head and the tape drawn until it is taut. When not in use the tape-measure is wound around the sticks. Next measure the circumference of the head and shoulders. Should there be shortening of a limb, or atrophy, as in infantile paralysis, full measurements of both limbs are to be made, i^g/zf -handed adults can commonly be told by the fact that the left hand is more apt to show the presence of scars and other signs of traumatic injury. Note the development of the skeleton, also any deformities and peculiarities, such as rickets, pigeon-breast, Pott's disease, etc. Estimate the weight and observe particularly the state of nutrition of the body; if emaciation be present, note whether it is due to defi- ciency in fat (panniculus adiposus), to muscular atrophy, or to a combination of both. This can usually be readily determined by pick- ing up a fold of skin over a muscle and rolling it between the thumb and fingers. One may practise this on himself, noting the differences in thickness found in the front, the back, and the sides of the neck. Post-mortem lividity, or hypostatic congestion, produces a bluish- red discoloration of the skin in the dependent parts of the body. This condition may resemble a bruise made during life, but the discolora- tion in post-mortem lividity disappears on pressure while that due to a bruise does not. Ante-mortem bruises and post-mortem lividity may also be differentiated by incising them. From a patch of post-mortem lividity blood will flow quite freely, because the vessels in the dependent parts are engorged with blood, while from a bruise there is little or no oozing, as the original hemorrhage is circumscribed and the discolora- tion is due mainly to staining of the tissues and not to the presence of blood. If the part be washed with running water, blood will appear again and again in hypostatic congestion. Should the two conditions 1 If a tape-measure of this length is not at hand, forty-two inches of double inelastic tape may be sewed together and this attached to a measure of the ordinary length. 48 POST-MORTEM EXAMINATIONS be combined, it is well to free the area from the hypostatic congestion before describing the bruise. Thus, if the lesion be situated on the back, it is well to let the body rest on the stomach for a time. As a rule, the more fluid the blood, as in cases of death from suffocation, the acute infectious fevers, poisoning by hydrocyanic acid, etc., the more marked will be the post-mortem lividity. In the latter case, as well as in poi- soning by illuminating gas, the lividity may be of a characteristic rose- red color. It is important to distinguish between post-mortem lividity and the greenish discoloration of commencing decomposition, usually first seen over the abdomen. The greenish color is due to the precipitation of the iron of the haemoglobin by the hydrogen sulphid arising from the decomposition of the tissues under the influence of bacteria. In one of my cases such discoloration was mistaken for a bruise, and serious allegations based upon this error were made against the hus- band of the deceased. Bodies which have been kept for a long time (or a shorter time under unfavorable conditions) after death, especially during cold weather, present another form of cadaveric lividity which is charac- terized by a uniform reddish tint. This is caused by the diffusion of haemoglobin from the blood-vessels into the surrounding tissues (im- bibition). This form of lividity is most conspicuous along the course of the superficial veins and is not affected by pressure. Much discussion has arisen in regard to the means at our command for distinguishing wounds made before and after death, and which is the fatal wound in case there are more than one injury. On these and similar questions I have heard experts testify in court in a manner utterly unsupported by the facts of the case. Great caution should, therefore, be used in the expression of dogmatic statements in regard to such findings. Post-mortem rigidity commences in the muscles of the jaw and spreads downward, disappearing in the same order. In ordinary cases it begins about two hours after death, is complete in from seven to nine hours, and ends in three or four days. The stronger the indi- vidual and the shorter the duration of the fatal disease, the more prompt and marked will be the rigidity. The bodies of soldiers killed by being shot in battle after forced marches sometimes retain the posi- tion they occupied when they were hit, in certain instances even re- maining erect when standing. Rigidity often sets in very early in EXAMINATION OF THE EXTERIOR OF THE BODY 4 q those who die suddenly, as while reading or while at table. It is very marked, especially in the abdominal muscles, after death from cholera. The body of one who has just died from tetanus or strychnine poison- ing may lie supported only by the head and heels, or when placed upright may stand erect with little or no support. It should be remem- bered that in the preparation of the body by the undertaker the rigidity may have been overcome by force ; this is especially true of the elbows. Be careful, on the other hand, not to be deceived by previously existing ankylosis. Rigidity disappears more quickly in cachectic subjects, and is some- times almost entirely absent in heat-stroke. It may be overcome by the use of hot applications, but when it has once disappeared it seldom returns and is never again so pronounced as at first. Strychnine and other spinal poisons, as veratrum viride, and suffocation cause long- continued post-mortem rigidity. In one of my cases of strychnine poi- soning rigor mortis was present on disinterment twenty-four days after death. The color of the skin varies : it rarely possesses the rosy hue of health, but is rather of a light grayish white, most conspicuous in cases of poisoning by the chlorate of potassium. The skin on those parts which have been exposed to the sun is generally more or less tanned. The color in jaundice varies from the faintest tinge of yellow to a dark yellowish brown. The pallor due to loss of blood is often so marked as to suggest the possibility of internal hemorrhage, as from the rupture of an aneurism or of the sac in extra-uterine pregnancy. The cachexias of cancer, argyria, etc., are at times peculiarly con- spicuous in the dead body. The color of the integument in argyria is similar to that of living persons when they are exposed to the light produced by burning a solution of salt and alcohol in a dark room. The patches of bronzed skin, alternating with affected areas, seen in Addison's disease, may be scattered over the entire body, but are espe- cially well marked on the abdomen; they are also sometimes found upon the mucous membrane of the mouth. This bronzing may occur when the suprarenal bodies are still apparently normal. Moles, tattoo- marks, and certain cutaneous diseases, such as vitiligo, leucoderma, etc., cause discolorations of the integument peculiar to themselves. Redness of the skin may be due to the wearing of red underclothes. Parchment-like spots are often seen on the body where the epi- dermis has been robbed of its protecting epithelium. Such areas are 4 5 POST-MORTEM EXAMINATIONS due to drying of the part, and if produced during life there will usually be found some ecchymotic spots surrounding them. When seen around the mouth, they suggest the possibility of the previous introduction of such agents as strong acids (including carbolic) and alkalies. The drawn-up and wrinkled appearance of the skin known as " goose- flesh," or cutis anserina, is especially conspicuous after drowning. The scrotum here is markedly contracted and the testicles are drawn up. Note the presence of bed-sores, blisters (remember that blisters found on dead bodies are sometimes due to carelessness in the use of hot-water bags or bottles during the final illness), the marks of saline injections (dermatolysis), hypodermatic injections, and cupping. In a recent case posted by me the trocar had penetrated the lung and given rise to abscesses, which resulted in the death of the patient. In another case the exploratory needle used in searching for a right-sided pleural fluid penetrated the liver and gave rise to a fatal hemorrhage. Scars made by the hypodermic needle in persons addicted to the use of mor- phine are usually found on the arms and thighs, — i.e., in those situa- tions which are hidden by the clothes and yet are easily accessible to the individual. Small abscesses containing pus are often present in these cases. Hypodermic injections by physicians shortly before death are usually made over the deltoid muscles or the breast, this region being selected owing to the quickness with which the drug is here absorbed into the general circulation. The punctures may be sur- rounded by an elevated white or reddish area similar to that produced by the application of cups. Many signs of inflammation, especially of the mucous membranes, disappear soon after death. Enlargement of the superficial lymph glands (especially in the inguinal region as found in syphilis) should be noted. Even an extreme eruption of measles may disappear after death. If it is desired to study such lesions, or others which disappear post mortem, it will be necessary to mark their location during life with a dermographic or anilin pencil or by the use of silver nitrate. General or local oedema is noted, especially as to its extent and the character of the pitting on pressure. Ask if the eyes and mouth were open or closed when death oc- curred, and find out if the expression was peaceful or the countenance distorted. Note the color of the eyes. Look at the pupils, cornese, and conjunctivae, taking care to close the eyes after they have been exam- ined. Jaundice, especially in the negro, may best be seen in the con- EXAMINATION OF THE EXTERIOR OF THE BODY y junctivae. Examine the eyes for arcus senilis. The size of the pupils is best estimated in millimetres. In death from chloroform the pupils may remain enlarged; in opium poisoning the pupils often expand shortly before or after death. Note the color, length, quality, amount, distribution, etc., of the hair on various parts of the body, as the scalp, eyebrows, eyelashes, axillae, pubes, breasts in the male, etc. Pass your fingers through the hair, if it be at all thick, to discover injuries, tumors, etc., which it may conceal. Should these be discovered the hair may be parted so as to examine them more carefully, or it may be cut or partly shaved off; in injuries to the head, however, it will usually be found that this has already been done by the surgeon. The region of the neck should be carefully inspected for finger markings, scratches, rope markings, etc. The neck should be rotated so as to see if a fracture or a disloca- tion exists. The condition of the teeth and gums should next be determined. Hutchinson's teeth may be discovered. Look for linese albicantes, and always examine the breasts of women and note the presence of fluid or tumors. The character of the fluid in abortion is especially to be noted. Supernumerary nipples are not uncommon, and a well-formed breast with its nipple may be found in the axilla. In cases of death by electricity the points of entrance and exit of the current ought to be carefully sought for, and the shoes should be examined for the burns which are usually seen near the nails in the heels. Examine the skin for any abnormal marks, such as eruptions, scars, wounds, bruises, blood, dirt, etc. ; it is possible for a wagon or even a street-car to pass over the body without leaving any trace on the skin other than a brush-burn. Discharges from the ear, nose, mouth, vagina, urethra, or rectum should not be overlooked, and foreign bodies found in any of these orifices should be noted. 1 See if the secretion is fluid or dried, watery or purulent. Xote its color and odor. In rape any vaginal secretion should be examined microscopically for spermatozoa and Gonococci and the condition of the hymen noted. 1 The creation of the office of coroner in England was due to the pouring of molten lead into the ear with homicidal intent. 52 POST-MORTEM EXAMINATIONS Do not neglect the examination of the back, which may readily be made by turning the body on one side. The anal region should be inspected for fissures, fistulse, eruptions, etc. The part is often dis- torted by the previous introduction of cotton by those who have had charge of the body. Examine for scars on the genitalia (when on the glans penis or prepuce they are usually of syphilitic origin) and on the mucous mem- brane of the mouth. Look for herniae, hydrocele, etc., and for external parasites, such as pediculi. Lice upon the body or head are often asso- ciated with alcoholism ; pediculi crack with a loud noise when thrown into a hot fire. These annoying parasites may be quickly and effect- ually disposed of by saturating a towel with chloroform 2 or kerosene and placing it upon the head for a few moments preparatory to re- moving the brain. See if the penis is erected ; it is often found in this condition after death by hanging. Injuries to the spinal cord may give rise to similar conditions. I have often seen after drowning erection of the penis due to the formation and collection of gases from decomposition in the loose areolar tissue. Note if the prepuce is moist from the escape of urine; if the discharge is purulent, search for the Gonococcus. Observe the condition of the extremities, especially as regards the presence of injuries, dislocations or fractures, deformities, gouty de- posits, etc., and the lobes of the ear for tophi. Examine the tibiae for thickening of its periosteum, etc. After the body has been carefully inspected it should be examined by palpation and percussion, but in handling it care should be taken not to disturb the relations of the contained viscera. Consolidation of the lungs, enlargement of the spleen, liver, etc., may be revealed by palpation or percussion even when the organs are not in their normal positions. The odors of many drugs, such as carbolic acid, oil of bitter al- monds, etc., may be detected from the mouth. The odor of alcoholic beverages can best be noted from the brain. Certain diseases, as small- pox, have characteristic odors. In one of my cases of poisoning by ammonium hydrate a rod dipped in hydrochloric acid when held near the mouth gave off fumes of ammonium chlorid. 1 Formalin may be used if it can be applied several hours previous to the post- mortem, but its fumes are so irritating as to forbid its application when the autopsy is to be made immediately afterwards. EXAMINATION OF THE EXTERIOR OF THE BODY 53 In a male infant observe whether the testicles have descended. In a female child see if the ovary lies in the canal of Nuck. Examine the regions where hernia is apt to occur. In a new-born babe look for vernix caseosa and pay special attention to the umbilicus and its vessels. An entire chapter might easily be written on the significance and value of scars induced by various means. Those made by the surgeon are often from their location self-explanatory. 1 It would, however, certainly facilitate matters, in this age of numerous hospitals and fre- quent operations, if the absence of organs removed by operation were indicated by some method which would be generally understood. Thus, the first letter of the Latin name of the part excised followed by the sign minus might be tattooed on the skin near the initial incision ; e.g., A — would show that the appendix had been removed, R — that nephrectomy had been performed, etc. The presence of scars may lead the obducent to think of herpes zoster, cupping, smallpox, chicken-pox, various skin diseases, as acne and syphilis, explosions, setons, certain occupations, etc. 1 The writer once desired to secure for a friend some fresh testicular tissue, and hurried to a recent suicide for the purpose of obtaining the testes. Finding scars on the scrotum, but no testicles, it was learned on investigation that these organs had been removed several years previously, and the young man had committed suicide because for this reason he was unable to marry. CHAPTER VI TECHNIC OF EXPOSING THE ABDOMINAL CAVITY AND THE TOPO- GRAPHICAL EXAMINATION OF THE PARTS CONTAINED THEREIN After the completion of the preliminary examination of the exte- rior of the body, having placed all necessary instruments in order upon a board or tray, 1 and having plenty of basins and water, with sponges and towels, the operative part of the autopsy may be begun. The operator should stand so that when facing the body the in- cisions from the head towards the feet can be made with the greatest ease. Thus, it is best for right-handed operators to stand on the right side of the supine subject. The body should be drawn well to the side of the table nearest the operator, the head resting at the top of the table and the shoulders supported by a block. With the knife held in the manner previously described (page 38), as nearly horizontal as possible, a clean incision (Fig. 43) should be made by a single sweep from the interclavicular notch (A) to the symphysis pubis (B), passing to the left of the umbilicus (C) in order to avoid the round ligament and any vessels going to and from the navel, care being taken not to penetrate the abdominal cavity and thus injure the contained viscera, or extend the incision to the external genitalia (Figs. 46 and 47). On the chest this primary incision goes down to the bone, whereas on the abdomen it penetrates only to the muscle-sheath. In Europe the initial incision is usually made at the middle of the chin, — i.e., starting at the symphysis menti and ending at the symphysis pubis; for there, as a rule, only those who die in the hospitals reach the post-mortem table, autopsies being seldom performed on the bodies of persons belonging to the upper classes, who would naturally object to the disfigurement entailed by this method. In this country the longer incision should be used only when great haste is necessary, as in cases of contagious diseases, such as diphtheria, or when the body is not to be seen again by relatives or friends. 1 A towel may be laid over the external genital organs and the upper parts of the thighs, upon which the instruments to be used in the performance of the autopsy are placed with their handles towards the obducent. 54 Fig. 46.— Method of making the initial incision over the sternum, as seen from above. Fig. 47.— The same incision as in Fig. 46 somewhat extended, as seen from the side. Fig. 48. — Method of raising flap on right side so as to expose sternum and ribs, as seen from above. Fig. 49. — Same incision as in Fig. 48 somewhat extended, seen from the side. .£ be q 3 a 5 c j= q, in O _tn O C en .&> ■ O 3 /-' en EXAMINATION OF THE HEART y 1 Ordinarily it is advisable that certain incisions be begun while the organ is still in situ and completed after it has been removed from the body. As each cavity is opened, careful note should be made of the quantity, color, and consistence of the contained blood and of the size and character of any clots that may be present. If the opening is occupied by a clot, this should be at once removed. Bacteriological examinations may be made while the heart is in situ, or in some cases may be facilitated by removing the heart before incising it. Primary Incisions. — After breaking up pericardiac adhesions, if present, the heart should be gently rotated on its long axis by slight pressure between the index-finger and thumb of the left hand, at the same time that slight traction is made downward and to the left of the body. This will bring the points of entrance of the superior and in- ferior venae cavae into view ; midway between which the first incision is begun and then carried downward in the direction of the right ven- tricular ridge until the right auriculoventricular septum is reached (Fig. 61, A B, and Fig. 64). Next make an incision in the right ventricle, just below the auriculoventricular septum, passing down the right ventricular ridge to the interventricular septum, which is a little to the right of the apex (Fig. 61, CD). On the left side make an incision in the auricle, beginning in or slightly below the lowermost pulmonary vein and continuing in the direction of the left ventricular ridge as far as the auriculoventricular septum (EF). Open the left ventricle along the entire length of the left ventricular ridge, and, as this ventricle normally forms the apex of the heart, the incision will be carried to and through that point before the ventricular septum is reached (Fig. 61, G H, and Fig. 65). This incision must not join that of the other ventricle, but should be separated by an interval of about one-half inch. From the fact that these incisions are made while the heart is still in situ, they may be called primary incisions. In cases of sudden death in which an embolus of the pulmonary artery is suspected, it is best to open that blood-vessel before re- moving the heart. This assures the finding of the embolus, which might otherwise be obscured in cutting the pulmonary artery for re- moval of the heart. By this method, also, the ductus arteriosus and' congenital heart lesions in infants may be investigated. Removal of the Heart from the Body. — To remove the heart, introduce the index-finder and thumb of the left hand into the left 72 POST-MORTEM EXAMINATIONS and right ventricles respectively, grasp the ventricular septum near the apex, and elevate the heart sufficiently to make slight traction on the great blood-vessels (Fig. 66). Then, if no aneurism be pres- ent, sever all the normal attachments as near their point of passage through the pericardium as possible, and in the following order, — viz., the inferior vena cava, the superior vena cava, the pulmonary artery, the aorta, and lastly the pulmonary veins. Avoid injury to the oesopha- gus during the removal of the heart from the body. Or, the heart is drawn outward preparatory to severing the vessels, as seen in Fig. 67. Fig. 67. — The pulmonary veins are placed on a stretch, and are ready to be incised. Measuring and Testing the Valves. — Immediately upon the re- moval of the heart from the body, the blood and clots should be care- fully removed from about the valves. The valvular openings are then to be measured. Their size is usually estimated by the number of fingers that the ostium will admit. Normally the mitral ostium will admit the index and middle finger, whereas through the tricuspid open- ing the index and middle finger of one hand and the index-finger of the other hand can be introduced. This method is, of course, convenient, but is very unscientific and inaccurate and should be superseded by the Fig. 64. — Method of opening the right auricle ; incision is made down to the auriculoventricular septum of the right side. This incision is usually made while the heart is in situ, but for the sake of clearness is here shown as being made outside of the bodv. Fig. 65. — Method of opening left ventricle. The heart is being opened outside of the body. The left hand steadies the heart while the knife cuts along the left ventricular ridge, starting just below the auriculoventricular septum and ending at the apex. Fig. 66. — Method of removing the heart from the body. The index-finger is placed in the left ven- tricle and the thumb in the right ventricle, and the ventricular septum is grasped. The heart is then raised-i'upward and towards the chin, placing on a stretch the blood-vessels which enter the heart. These are cut, starting with the lower pulmonary vein and going from left to right in a circular direction until the upper pulmonary veins are reached, or the initial incision may be made at the inferior vena cava and end with the pulmonary veins. Fig. 68. — The pulmonary artery is made tense with the left hand, while from the centre of the right ventricular incision the anterior portion of the right ventricle is cut in the direction of the thumb and middle finger which mark the junction of the two anterior pulmonary semilunar cusps. Fig. 69. — The left auricle and ventricle are fully opened, exposing the mitral valve, chordae tending papillary muscles, endocardium, etc. Fig. 70.— Completed incisions of the heart, the organ having been reconstructed after the examination of all its cavities and parts. EXAMINATION OF THE HEART 73 use of a constant unit of measure. Graduated cones, or balls of defi- nite sizes (Figs. 38 and 39), placed on rods, answer the purpose very well. They are gently inserted in the direction of the blood-current, and the exact size of the opening can then be given in millimetres or inches. Vegetations upon the valves may be injured by their careless use. An equally scientific method is to measure the attached margins and to determine the diameter by dividing by 3.14 (tt). The competency of the valves should now be tested. To do this, trim the great vessels down so that the valves may be seen. The heart is then evenly supported by each of the vessels in turn, — i.e., held in air and in such a way that the semilunar valves will be as nearly hori- zontal as possible, at the same time receiving no unnatural support from beneath. Water or mercury is then gently poured in by a second person until the vessel is filled, and note is made of the action of the valve. In case no one else is present, the heart is to be held under water and then quickly taken out, and the valve being tested observed. If there is any leakage from the aorta, make sure that it is not from a branch of one of the coronary arteries. The best result of the water- test is seen in the semilunar valves, the competency of the auriculo- ventricular valves not being accurately determined by this method, which has of late rather fallen into disuse. Should it be necessary or desirable to ascertain the competency of the auriculoventricular valves, the primary incisions above described are not made until the heart has been removed from the body, and the test is begun by cutting a transverse slice from the apex and exposing the ventricles. The heart is now everted and each ventricle is filled separately with liquid. This method of removing the organ before opening is also useful in examining the heart of a child or when it is desired to make a bacteriological examination of the valves. In the latter event no water should be used, lest some of the vegetations be washed out or other bacteria than those present be introduced, thus creating more or less serious confusion. Hamilton advises the use of air for testing the competency of the valves, and gives the- method as follows: 1 " An incision is first made into the left auricle, and any post-mortem clots are carefully removed from the left chambers through it. Another incision large enough to admit the nozzle of a half-inch tube is made into the ventricle near its 'Hamilton, Text-book of Pathology, vol. i. p. 9. 7 4 POST-MORTEM EXAMINATIONS apex and in the line of that required for laying it fully open. The tube is joined to a bellows, and air is driven intermittently into the ventricle by means of it, the aorta having been meanwhile closed. The valve will be seen to open and close, according as the air is aspirated or driven out of the bellows. A like procedure is adopted for the dem- onstration of the tricuspid. To test the aortic valve, the incision Defore described as necessary to lay open the left ventricle is continued up as close to the valve as possible without injuring it. The tube is tied into the aorta, and the action of the valve is watched from below. The same method is used to test the competency of the pulmonary artery valve. As a matter of fact the tricuspid, in the human heart, will always be found more or less incompetent." Secondary Incisions. — Place or hold the heart with its posterior surface downward. This can be told by the situation of the pulmonary artery, which is situated anteriorly. Insert a pair of probe-pointed scissors or the blade of the enterotome (now a cardiotome) in the in- cision in the right ventricle, and cut from the centre of that incision through the centre of the attachment of the two anterior leaflets of the pulmonary artery (Fig. 62, I J, and Fig. 68). The point of junction of the anterior leaflets can usually be seen from the outside, but, if not, it can very easily be determined by looking into the vessel or feeling it with the index-finger. This incision is to be continued until it opens up the entire portion of the pulmonary artery which has been removed from the body. Some pathologists advise making this incision towards the left of the pulmonary artery, so as to cut between the left anterior and posterior cusps. The right ventricle is now exposed so that the condition of the pulmonary valves, endocardium, myocardium, chordae tendinese, etc., of this side of the heart may be noted. Now dissect away the connective tissue binding together the pulmonary artery and the aorta. In opening the left ventricle, cut the anterior wall as near the ven- tricular septum as possible, starting from the apical extremity (H) and stopping at the point overlapped by the left auricular appendix (K). Then, using the cardiotome, the incision is completed (either from the aorta or from the ventricle) by cutting between two leaflets (L K). In the aorta there is but one anterior leaflet, consequently the incision should be to either one or the other side, but preferably as close as possible to the curves of the pulmonary artery. After ex- amining the valves, myocardium, aortic intima, etc., dissect out the coronary arteries with probe-pointed scissors. EXAMINATION OF THE HEART y- Lastly, unite the auricular and the ventricular incisions of each ■side by cutting through the auriculoventricular septa (Fig. 63). In Fig. 69 is shown how well the auricle and ventricle of the left side may be examined after the completion of the incisions. The heart now freed from blood and clots is to be weighed. The valves will not be injured by this method and the entire heart can be folded together so as to show its original contour (Fig. 70). In extreme mitral stenosis it is often advisable not to complete the left auriculoventricular incision. The simplest method of opening the heart, and one which yields fair results, is to place two fingers on the anterior ventricular septum, which is recognized by the situation of the anterior coronary artery, and make two parallel incisions into each ventricle. Incisions may then be made through the pulmonary artery and the aorta. If it be desired to follow out the subclavian vessels, the entire clavicle of that side should be removed by careful dissection. The situation of the mitral and pulmonary valves can be easily re- membered by the mnemonic Martin Luther, The Reformer, — mitral on the /eft side, tricuspid on the right. There is but one posterior cusp to the pulmonary and one anterior cusp to the aorta, which fact affords an easy way to recall this oft-forgotten point. CHAPTER VIII LESIONS OF THE HEART, BLOOD, AXD BLOOD-VESSELS Characteristics. — The gross appearance of the heart, as well as the thickness, color, and consistence of the various parts of the cardiac muscle, can now be observed. The wall of the right ventricle is normally from 2 to 3 millimetres thick (in women slightly less than in men) and may pathologically be from 7 to 10 millimetres thick. The thickness of the wall of the left ventricle is from 7 to 10 millimetres, and may be increased to 25 millimetres or more by pathological changes. The estimation of the weight of the heart is one of the means of determining whether or not a true hypertrophy is present. The normal heart weighs about 250 grammes in women and about 300 grammes in men; but when hypertrophied it may weigh over a kilogramme. The color of the heart muscle varies according to the amount of blood it contains, but is always lighter and more grayish, red than the skeletal muscles. The heart muscle may be of a brownish red or even brown, as in anaemia and brown atrophy of- the heart, where. with its tortuous vessels and mucoid covering, in some cases it varies from yellowish to a distinct yellow, which color is usually not uni- form, but scattered in patches throughout the muscle, or in bands making a sort of net-work (wren's breast or tiger markings). This yellow streaking is often most conspicuous on the papillary muscles of the left ventricle. In septic conditions the heart is of a dirty-red color. Light-gray spots or streaks indicate the formation of fibrous- tissue. The consistence of the heart muscle varies with the color: brown hearts are hard and dense, while those of a yellowish tinge are soft and flabby. After dilatation of an hypertrophied heart sets in, the muscle becomes softer by the process of fatty degeneration. The heart muscle is very soft in sepsis, also in cases of heart weakness- developing after an infectious disease, especially after typhoid fever and diphtheria. Anomalies. — Abnormalities in the development of the heart vary exceedingly. Dextrocardia may be the only abnormality of the chest,. or a part of a general situs inversus confined to the thoracic organs. An increase or decrease in the number of the semilunar leaflets may 76 LESIONS OF THE HEART, BLOOD, AND BLOOD-VESSELS 77 be met with, and a circumscribed thickening of the muscle may occur, . and may cause a stenosis of the aorta if there situated. There may be an insufficient development of the whole heart, hypoplasia, found in cases of chlorosis; or a patulous foramen ovale. In the examina- tion of the auricles an aperture in the foramen ovale may be over- looked if the heart is so held as to put the auricular wall on the stretch. As the openings most frequently come off from the sides, this method of holding the heart will very often prevent their discovery. All sus- picious cracks or orifices should be searched for with a pointed probe £*while the heart is relaxed, care being taken not to tear or puncture the tissues or to mistake the mouths of veins for pathological open- ings. With a defect or an opening in the interventricular septum is often associated a stenosis of the conus pulmonalis, with a narrowing of the pulmonary valve. In these cases the ductus arteriosus may be patulous. Atresia of the mitral or tricuspid valves may be due to faulty development or to inflammation. Fenestration of the semilunar leaflets is of frequent occurrence and has no particular significance. Blood. — Many of the changes which the blood undergoes are macroscopical and can be studied at this point, especially if the in- nominate veins be opened. 1 There may be observed all degrees of coagulation, from an almost absolutely fluid condition of the blood to a hard and dense fibrinous clot, — the so-called heart polyp, — which contains almost no red blood-corpuscles. The firm, yellowish "" chicken-fat" clots may adhere to the walls of the heart, and indicate slow death, with gradual paralysis of the heart's action. When all the coagula are rich in fibrin, some acute inflammatory process has caused an increase in the leucocytes and blood-plaques, the generators of fibrin. Normally the clots in the beginning of the aorta and of the pulmonary artery contain a large percentage of fibrin. In the left auricle they at times assume polypoid or ball shapes. The ordinary post-mortem coagulum is the red clot, the so-called currant- jelly clot, which is not attached to the endocardium, though it may adhere to the interstices of the heart. Hyperinosis, or increased capability for fibrin formation in the blood, is met with at times, in certain anaemic affections and infectious diseases. Hypinosis, or decreased capability for fibrin formation, occurs in leukaemia, in hydraemia, and when the 1 A small spectroscope and a Tallqvist haemoglobin scale are very useful for studying the blood at the postmortem. yS POST-MORTEM EXAMINATIONS blood is overladen with carbonic acid, as in cases of suffocation, or intoxication with gases, and in many of the infections. Blood satu- rated with carbon dioxide. is very dark in color; in cases of poisoning- by that gas the blood when exposed to the air quickly oxidizes. Methae- moglobin, found in cases of poisoning by chlorates, nitrites, toad- stools, etc., gives a brownish tinge to the blood. The blood in cholera, where anhydrsemia is present, is very thick, while in diseases of the heart, lungs, kidneys, and liver in which hydraemia is present the blood is thin and watery (Orth). In chlorosis and pernicious anaemia the blood is pale, particularly so in the latter, where it is even raspberry red,^ while in lipaemia, in which fat occurs free in the blood-plasma, and leukaemia a milky appearance of the blood may be noted. In putrefac- tion if the blood be left standing the clear serum separates and the sediment is yellowish green. Under the microscope shadows of red cells are seen. Pathological Conditions. — (a) Plethora Vera. — A condition in which all the elements of the blood are proportionately increased, (b) Plethora Serosa. — A marked increase in the watery constituents, (c) Olygcemia. — A diminished amount of blood; occurs only as a tempo- rary condition, (d) Hydrccmia, Anhydrccmia. — Abnormal increase or decrease in the watery portion of the blood. In anhydraemia the blood becomes thick and even tarry, as in cholera. In hydraemic plethora there is an absolute increase of serum. If relative it is an oligocythaemia. (e) Hemolysis. — Destruction of red corpuscles ; occurs after burns, cer- tain poisons, infectious fevers, etc. (/) Polycythemia rubra is an abso- lute increase in the reds, (g) Anccmia. — A diminution in one or more of the constituents of the blood, (h) Primary, Essential, or Idiopathic Anccmia. — An anaemia, the cause not definitely known, usually attrib- uted to the blood-making organs, and characterized by a dispropor- tionate reduction in the elements of the blood. (/) Secondary, Simple, or Symptomatic Anccmia. — An anaemia due to a definite cause, as an infectious fever, and characterized by a proportionate reduction in the elements of the blood. (/) Poikilocytosis. — Alteration in the shape of red corpuscles (crenated, reniform, and pyriform are most common). (k) Leucocytosis. — Increase in the number of white blood-cells without alteration of the relative numbers of each variety. (/) Leucopenia. — ■ A diminution in number of white blood-cells; seen most characteristi- cally in typhoid fever, (m) Lipccmia. — Fat in the blood. Diabetes. (n) Urccmia. — The presence in the blood of an excess of chemical com- LESIONS OF THE HEART, BLOOD, AND BLOOD-VESSELS yg pounds, as urea, which should be eliminated by the kidneys or other excretory organs. There may be an increase in blood-plaques, as is supposed to occur in purpura. Abnormal Constituents of the Blood. — (a) Tumor cells, as in renal sarcoma, the cells growing into the veins, (b) Pigment particles, as in malaria, (c) Haematoidin crystals, (d) Bilirubin crystals. These may be so considerable as to produce to the naked eye an orange-red color, or when the buffy coat of a clot or when a clot well washed in water is seen microscopically, usually in the shape of needles. Occur in icterus neonatorum, in pernicious anaemia, acute yellow atrophy, pyaemia, but not in ordinary icterus, (e) Gas bubbles, — due to putre- faction, to air-producing bacteria which develop very rapidly after death. In fresh blood air bubbles, particularly when seen in the right heart and surrounded by a clot, are due to the entrance of air into the veins during life. (/) Charcot-Leyden crystals, — leukaemia. (g) Lower organisms, — I. Spirochaetae of relapsing fever (not always found after death). 2. Anthrax. 3. Cocci, — micro-, strepto-, diplo-, etc. 4. Plasmodia. 5. Filaria sanguinis hominis. 6. Distoma haema- tobium. 7. Trypanosoma. Many names have been given to such conditions, as septicaemia, where there are pyogenic micro-organisms in the blood and tissues, without areas of suppuration; pyaemia, where metastatic or pyaemic abscesses are found in the tissues and organs of the body, and saprae- mia, where the symptom-complex is produced by the presence in the blood and tissues of the vital chemical products known as toxins. These toxins may be formed by the action of pyogenic or saprophytic micro- organisms. Blood-Diseases. — Anccmia, Progressive Pernicious. — An idio- pathic, chronic anaemia characterized by definite blood-changes, by a lemon-yellow coloration of the skin, and by progressively developing weakness without corresponding- emaciation. Etiology : (a) Most common in the male sex. (b) Overwork, (c) Bad hygiene, especially poor teeth and unclean mouth, (d) Adult life, though the disease may occur in children, (e) Intestinal parasites. (/) Pregnancy and par- turition, (g) Atrophy of the gastric tubules. I. Blood. — (1) Marked reduction in number of red corpuscles (to one million or less per cubic millimetre). (2) Alteration in their shape, — poikilocytosis. (3) Alteration in size, — microcytes, macrocytes, megalocytes. (4) Nu- cleated reds, — normoblasts, megaloblasts. (5) Increase of neutro- g Q POST-MORTEM EXAMINATIONS philic whites. (6) Haemoglobin markedly decreased, but color-index usually high. II. Miscellaneous Lesions found Post Mortem. — (i) Muscles resemble horse-flesh. Heart usually large, flabby, empty, and tawny-brown. (2) Spinal cord may show posterior sclerosis with hemorrhagic foci. (3) Skin and serous membranes commonly reveal hemorrhages ; these may, however, be present only in the retina. (4) All organs exhibit fatty changes. (5) Iron is deposited in excess in the lobules of the liver, especially in the outer and middle zones. (6) The bone-marrow — best seen in the humerus or femur, though also found in the clavicle — is red (lymphoid) in character. Chlorosis. — Chlorosis is a primary anaemia which occurs usually in girls, and is characterized by marked diminution of haemoglobin and sometimes by hypoplasia of the circulatory and generative organs, (a) Female sex. (b) Age from fifteen to twenty, (c) Bad hygiene and overwork, (d) Shock or fright, (e) Absorption of intestinal poison. Cases of simple chlorosis rarely come to autopsy. The blood shows marked diminution of haemoglobin. In severe cases there may be great alterations in the number, shape, and size of the red corpuscles. The white rarely show much variation. The flesh is usually well preserved. The skin is pale and of a greenish hue, and there may be other evidences of anaemia. The internal organs will be found pale and flabby. The heart and larger blood-vessels and the generative organs show hypo- plasia. Leucocythcumia (or Leukaemia). — A form of primary anaemia characterized by great increase of the white corpuscles and by marked structural changes in the lymphatic glands. Cause: Not definitely known ; usually ascribed to changes in the blood-making organs. Clas- sification. — (a) Splenic, (b) Medullary, (c) Lymphatic, (d) Com- binations of the three forms. As a rule, the patient is apparently well preserved, but in some cases emaciation may be extreme. The skin has a peculiar lemon-yellow color. The mucous membranes are blanched. The amount of adipose tissue is frequently increased and of a peculiar punctate appearance, owing to the presence of petechial hemorrhages. The blood is pale in color, — often milk-white. It rarely clots with any rapidity. The organs in general are pale; the liver, spleen, and lymphatic glands are usually markedly enlarged. The heart is pale, flabby, and frequently fatty in appearance, (a) In splenic anaemia, which is a comparatively rare form of the disease, the spleen is markedly enlarged, somewhat firm in consistency, and of a reddish- LESIONS OF THE HEART. BLOOD. AND BLOOD-VESSELS 8l brown color. The Malpighian bodies are frequently obliterated, their place often being taken by grayish-white, circumscribed tumors throughout the organ. The hyperemia in some cases is excessive, and rupture of the spleen is said to have occurred from this cause. Dropsy from pressure on the abdominal viscera may result. As in other forms of leukaemia, the bone-marrow may show decided changes, especially in the long bones. Instead of fatty tissue there may be splenization, or it may resemble the consistent matter which forms the core of an abscess. Microscopical examination of the blood shows that the in- creased white corpuscles are largely myelocytes, (b) Medullary leukae- mia very seldom occurs as an inflammatory process. Where the marrow changes are excessive, the flat bones — as, e.g., the sternum — undergo alterations similar to those occurring in the long bones, (c) In lym- phatic leukaemia the lymphatic glands throughout the body, especially those of the neck, the axillary and inguinal regions, and the glands of the mesentery and the intestines, show marked involvement. The liver, as well as the spleen, is enlarged and may exhibit marked structural changes. The lymphatic glands in general are swollen, pale in color, firm to the touch, and seldom suppurate or show any tendency to run together. The spleen, liver, and other lymphatic glands often show marked thickening of their capsules. On section the glands are some- what resistant, and often exhibit nodule-like bodies, which are firm in consistence and largely composed of proliferating leucocytes and con- nective tissue. Microscopical examination of the blood shows that the marked increase of the leucocytes is in the lymphocytes, (d) The blood in leukaemia in general shows somewhat marked diminution of the amount of haemoglobin ; it is light raspberry-red in color and may in the severest cases be yellow ; small balls of corpuscles, especially in the pulmonary artery, are sometimes seen ; the red corpuscles are reduced in number, sometimes markedly so. The white corpuscles are enormously and permanently increased, so that one white to twenty red, or even one to one, is not uncommonly found. The characteristic feature of leukaemic blood is the alteration of the relative proportions of the various white corpuscles the one to the other. Haemophilia. — An- hereditary constitutional disease characterized by a marked tendency to excessive hemorrhage from very slight causes. It is transmitted through the females of a family to the males. Little regarding the morbid anatomy is definitely known. The vessel-walls are unusually thin, brittle, and do not readily retract. In some cases 6 82 POST-MORTEM EXAMINATIONS the blood itself presents marked alterations. Hemorrhages have been found about the capsules of joints, with inflammation of the synovial membrane. Purpura. — A disease characterized by the appearance on the skin of numerous blotches of extravasated blood and by great debility. Very little is known of its origin. It is apparently more common in males than in females and more frequent in the young than in the old. Clas- sification. — The forms are (a) Purpura simplex, (b) purpura hemor- rhagica, (c) purpura rheumatica, (d) iodic purpura, (e) Henoch's purpura. Among the points revealed by autopsy are : ( i ) The exist- ence and extent of hemorrhagic effusions with evidences of anaemia. (2) Occasionally the skin presents erosions or ulcerations. (3) The hollow viscera and serous cavities may contain considerable quantities of blood-stained serum. (4) The serous membranes and solid organs, as well as the skin, may reveal hemorrhages varying in size from a pin's head to the palm of the hand. (5) Congestion and oedema of the lungs are frequently present. (6) Slight degrees of acute diffuse nephritis may occur. (7) Ulcerations of the intestines with enlargement of the solitary and agminated glands are sometimes present. In one of my cases the husband was accused of beating his wife and thus causing her death. Scurvy. — Caused by: (a) Deficiency of fresh vegetables, (b) Bad hygienic surroundings. (1) After death decomposition sets in rapidly. The hemorrhagic patches observed in the skin during life are soon obscured by post-mortem lividity. (2) The subcutaneous tissues, especially those of the lower extremities, contain a blood-stained fluid with here and there discolored patches, some black and others of a pale color. (3) About the back of the thigh and knee the muscles and tendons may be embedded in a thick, firm clot, and themselves contain numerous hemorrhagic foci. (4) The blood is dark and fluid. Hemor- rhages may be present in any of the serous membranes or internal organs. (5) The gums are swollen, sometimes ulcerated, and the teeth may have fallen out. (6) Hemorrhages in the mucous membranes are extremely common. Rarely there may be ulcers in the intestines. (7) The spleen is enlarged and soft, while fatty changes are constant in the liver, kidneys, and heart. (8) There is very little wasting of the subcu- taneous fat of the muscles. This disease is by no means so frequent as formerly, owing to better hygienic conditions and to the proper feeding of those in ships, prisons, work-houses, etc. LESIONS OF THE HEART, BLOOD. AND BLOOD-VESSELS 83 Scurvy, Infantile. — Usually associated with improper food, such as malted or condensed milk. Cases, however, have been reported in breast-fed children. ( 1 ) The most important lesions are increased vas- cularity and extravasation of blood affecting the periosteum and bones, especially those of the lower limbs. Extensive hemorrhages are fre- quently found between the periosteum and the bone. They may also occur in the cavity of long bones, forming masses of blood-clots. (2) These deep-seated extravasations may give rise to muscular swellings and in some cases to extravasations in the joints. (3) Smaller extrava- sations have been observed in the pleura, lungs, spleen, intestines, and kidneys. (4) Fractures are not uncommon. In fact, in the majority of cases there are bone changes analogous to those of rickets. (5) The gums are spongy, sodden, distended with serum, and sometimes covered with blood. (6) One of the most characteristic lesions is extravasation of blood into the orbital cavity, causing displacement of the eyeball downward and forward. The report of the American Pediatric Society on this condition is of a most interesting character. Diabetes Insipidus. — A constitutional condition characterized by the passage of large amounts of pale urine, of low specific gravity, con- taining neither albumen nor sugar. It occurs more often in the male sex and during early life. Heredity may be a causal factor. The uri- nary system may merely show the signs of the passage of an abnormal amount of liquid. — enlarged and congested kidneys, dilated pelves, dilated ureters, and an hypertrophied bladder. Diabetes Mellitus. — A constitutional disease characterized by the passage of large amounts of pale urine, of high specific gravity, con- taining sugar. It occurs most frequently in adult males, Hebrews being specially predisposed. Mental strain or Avorry may be a cause. There are no constant lesions of the nervous system, but tumors of the medulla, injury of the floor of the fourth ventricle, or sclerosis in various areas have been found. The sympathetic ganglia may be en- larged and sclerosed and a secondary multiple neuritis is not rare. The cceliac ganglion is atrophic in this disease (Orth). Neuroretinitis is very common, and there may be hemorrhages in the retina and opacities in the vitreous. The most usual change is thickening and congestion of the membrane. Croupous pneumonia, bronchopneumonia, and tubercu- losis are common complications ; any of them may terminate in gan- grene. Fat embolism of the pulmonary vessels has been described. The lung may soften (malacia) and, becoming mixed with stomach secre- 84 POST-MORTEM EXAMINATIONS tions post mortem, forms the so-called pneumomalacia acida. It has a sour but not a gangrenous odor. The pancreas is often diseased, espe- cially the islands of Langerhans. There may be simple atrophy, pig- mentary cirrhosis, cancer, calculi, cystic disease, or fat necrosis. The spleen is usually small, pale, and soft, but may be enlarged and con- gested. Diffuse nephritis with fatty degeneration occurs frequently, also glycogen degeneration, most marked in pyramids. Boils, carbun- cles, onychia, eczema, and gangrene of the extremities are common. The blood generally appears normal, but may be loaded with finely divided fat which floats on the surface in a cream-like layer. The liver is usually enlarged, often congested, abnormally firm to the touch, and gives the glycogen reaction ; fatty degeneration is common. ' The myo- cardium is pale and soft; rarely it may be hypertrophied. Advanced fatty degeneration of the muscular fibres is the characteristic change in long-standing cases of diabetes. The urine is of high specific gravity, of a pale, somewhat cloudy appearance, always containing sugar and sometimes acetone and diacetic acid. Do not mistake for alkaptonuria. Gout. — A constitutional disease characterized by deposits of uric acid or its salts in the joints of the extremities. Predisposing causes are: (a) Male sex. (b) English race, (c) Heredity, (d) High living. Anatomical changes are found most frequently in the great toe. though the disease shows a marked tendency to involve the smaller joints, both of the feet and the hands. In acute stages there are notable hyperemia and round-celled infiltration and diffusion into the joint. Macroscopically the joint is swollen, tense to the touch, of a purplish color, and glazed. In the chronic form the ligaments and fibrocarti- lages of the joint become infiltrated with chalky deposits (tophi). These consist of sodium urate in the form of crystalline needles or rhombs. The addition of hydrochloric acid causes their immediate dis- appearance, but later whetstone crystals of uric acid make their appear- ance. Necrosis in the cartilage always precedes the formation of tophi (Ebstein). These deposits may be slight or may lead to enormous distortion of the joint. In some cases the skin may ulcerate and the tophi be extruded. The deposits may be found in the cartilages of the ear, the nose, the eyelids, and occasionally the larynx. The kidneys usually show chronic interstitial inflammation with deposits of urates in the form of small flakes or stripes, chiefly in the pyramids. Arterio- sclerosis, with hypertrophy of the left ventricle, is very common. Cuta- neous affections, such as eczema, are not infrequent. LESIONS OF THE HEART, BLOOD, AND BLOOD-VESSELS 85 Hemorrhages. — Disturbances of the circulation of the endocar- dium are rare, as this membrane possesses no blood-vessels of its own. A diffuse redness in this situation may, however, be the result of imbibition, and in the case of long-diseased valves, in which there are newly formed blood-vessels, reddish streaks and spots may be ob- served, which are due to small hemorrhages. In the myocardium larger hemorrhages may be met with, as a result of the rupture of small aneurisms of branches of the coronary arteries or as a hemor- rhagic infarct. Anaemic infarct is also found as a result of a partially obstructing embolus or the formation of a thrombus. The condition of softening of the heart, or myomalacia cordis, is 'most frequently situated in the anterior wall of the left ventricle, near the apex. The degenerated tissue may form a scar, but more frequently leads to an aneurismal dilatation, which may subsequently rupture. Aneurisms of the sinus of Valsalva may form and rupture in unexpected places ; I have seen, for example, an aneurism of an aortic sinus ruptured in the right ventricle. Varieties of Hemorrhage. — The following terms are applied to hemorrhages from various parts of the body : Epistaxis, hemorrhage from the nose; haemoptysis, pulmonary hemorrhage; haematemesis, or gastrorrhagia, hemorrhage from the stomach ; metrorrhagia, uterine hemorrhage not occurring during the regular menses; menorrhagia, excessive menstrual flow ; post-partum, hemorrhage from uterus after delivery; complementary, hemorrhage occurring in some place other than that in which the original bleeding occurred ; consecutive or sec- ondary hemorrhages; extrameningeal, a hemorrhage external to the cerebrospinal meninges ; hemorrhage per diapedesis ; hemorrhage per rhexis. Hemorrhages, Causes of. — (a) Traumatism, (b) Acute inflam- mation, (c) Passive congestion, (d) Corrosive poisons, (e) Malig- nant growths. (/) Diseases of the vessels, (g) Rupture of an aneurism, (h) Cachectic disease. (/) Dyscrasias. (y) Nervous dis- turbances, (k) Vicarious menstruation. Hypertrophy and Dilatation. — These conditions are usually associated with each other. In concentric hypertrophy the walls are thickened and the cavities are smaller than normal. As this condition is often due to post-mortem contraction or to marked systole, the heart should be soaked in tepid water before the measurements are taken. One may also distinguish simple hypertrophy, where overgrowth of 86 POST-MORTEM EXAMINATIONS the walls is found associated with normal cavities; eccentric hyper- trophy, or hypertrophy with dilatation ; and pure dilatation without hypertrophy. The highest degrees of hypertrophy occur in cases of double aortic disease, where, too, moderator bands are sometimes found. Infiltrations and Degenerations. — In fatty infiltration, or obesitas cordis, there is an increase of fat in those places where it is normally deposited ; it starts from the outside and goes inward along the trabecular of connective tissue; while in fatty degeneration the change originates from within. In fatty infiltration the heart may be embedded within such an enormous deposit of fat as to leave no muscle exposed to view. Hyaline and amyloid degeneration may also occur, as well as calcareous infiltration, fragmentation, and segmenta- tion. Myocarditis. — Parenchymatous myocarditis may be diffuse or limited. When the inflammatory process involves all of the muscu- lature of the heart, as is frequent in the infectious diseases, it is char- acterized at first by the flabbiness and the turbid grayish-red color of the heart muscle. In the later stages there is much fatty degenera- tion. Segmentary parenchymatous myocarditis is marked by a cloudy appearance of the heart muscle, which is flabby and friable. (Orth.) Acute circumscribed interstitial myocarditis, or abscess of the heart, is usually a part of a general pyaemic disease, with infection through the coronary circulation. These metastatic abscesses occur in cases of puerperal sepsis, in osteomyelitis, and other intensely septic diseases, but particularly in cases of malignant endocarditis. There may be only a few abscesses or the heart substance may be studded with in- numerable suppurating points. In size the abscesses vary from the merest dots to cavities of the size of a cherry. Acute diffuse interstitial myocarditis occurs in various forms of infectious fevers. The affected heart muscle is soft and often distinctly friable ; there may be spots of hemorrhagic infiltration, but, as a rule, the color is rather lighter than that of the normal organ. The cavities of the heart are frequently dilated, particularly the left ventricle. Chronic interstitial myocar- ditis or fibrous myocarditis may also be diffuse or localized, though the circumscribed form is the most common. This fibroid overgrowth is very commonly met with at the tips of the papillary muscles, on the trabecular, or in the substance of the heart muscle, and often at the apex of the left ventricle, where it may lead to such a degree of atrophy LESIONS OF THE HEART. BLOOD, AND BLOOD-VESSELS 87 that a chronic localized aneurism of the heart may be formed by the constant pressure of the blood upon this thinned area. The process is usually secondary, and is dependent upon primary disease of the coronary arteries, or disturbances of the circulation in the coronary arteries, consequent perhaps upon old age, alcohol, gout, syphilis, and ■ the like. The characteristic change is the formation of dense, grayish sclerotic areas, which appear either as more or less irregular spots or as 'streaks or lines running in the direction of the fibres of the heart. The entire substance of the heart may be involved and thickening of the walls may result. (Stengel.) Endocarditis. — In the foetus endocarditis is usually situated in the right side of the heart; during extra-uterine life the lesion is most common in the left side. In the great majority ofcadult patients acute endocarditis affects the endocardium of the valves. — the mitral, the aortic, and the pulmonary valve in order of frequency ; but it is some- times found in the endocardium of the cavities of the heart, — in the left ventricle, the left auricle, and the right ventricle. Various names have been applied to these conditions, as simple, or verrucose, benign, ulcerative, septic, mycotic, rheumatic, syphilitic, diphtheritic, or malig- nant endocarditis. Such cases differ much in their appearance, even when produced by the same organisms. Endocarditis starts on the endocardium as a minute, roughened area, which is red in color and slightly elevated. This can easily be scraped off, but. if the spot where it was found is carefully examined, a small ulcer will be seen. More and more fibrin is deposited, and the corpuscular elements are caught in its meshes ; the organisms multiply, and the clot undergoes a lique- faction necrosis, the process not stopping" in the newly formed tissue but often penetrating the valves or even the walls of the heart. Endo- carditis is frequently a secondary affection, dependent upon inflam- matory disorders in other organs, such as suppurating wounds, puru- lent peritonitis, and pneumonia. Sometimes, however, the endocar- ditis forms the first local manifestation of an infection, the exciting- agent of which has left no recognizable traces at the seat of its entrance into the body. Embolic occlusion of certain vessels and metastatic inflammations in other organs, especially the kidneys, spleen, brain, and skin, are not infrequently associated with endocarditis (Ziegler). Such hemorrhagic areas are to be sought for in the palpebral con- junctiva; their discovery therein during the external examination of the body has more than once led me to suspect ulcerative endocarditis, 88 POST-MORTEM EXAMINATIONS even where there was no clinical history of its existence. This obser- vation is of special value when a bacteriological examination of the heart is desired. These ulcerative areas on healing are replaced by scar tissue, which, by contraction and by various degenerative changes, such as necrosis, fatty degeneration, and calcification, gives rise to the most fantastic shapes and appearances of the parts affected. Valvular Diseases. — An extreme degree of mitral stenosis is seen in the so-called buttonhole mitral, which causes hypertrophy of the left auricle, followed by dilatation. Brown induration of the lungs, cyanotic induration of other viscera, and dropsical effusions may fol- low mitral incompetence. In aortic stenosis the valves are usually thickened, rigid, and cartilaginous; later they become calcified and the division betweenjjthe different cusps is lost. First there is ventricu- lar hypertrophy, later right-sided enlargement, and finally dilatation with pulmonary congestion. In aortic incompetency arteriosclerotic changes are marked, being seen not only in the valves but also in the aorta. Syphilis, Tuberculosis, Actinomycosis, Tumors, etc. — Syph- ilitic gummata appear in the heart as rather large yellow foci sur- rounded by fibrous tissue; they may also be found in the arch of the aorta. Miliary tubercles, when present, are usually subendocardial or situated in the large vessels coming off the heart. At a postmortem in Ziegler's mortuary I once saw where a caseating peribronchial gland had eaten its way through the pulmonary artery and given rise to a most marked local and general miliary tuberculosis. Actinomycosis has been observed. Tumors are rare ; myxomata, lipomata, fibromata, sarcomata, and rhabdomyomata may be met with as primary tumors of the heart, while, as secondary, carcinomata, sarcomata, and espe- cially multiple melanotic sarcomata may be observed. Foreign bodies, as needles, pieces of bone, etc., have been found in the cardiac wall and even in the cavities of the heart. Cysticerci, echinococci, and very rarely pentastomata are sometimes discovered in the various parts of the heart. Arteries, Morbid Changes in. — Arteriosclerosis. — A hardening of the arteries, characterized by a diminution in elasticity of the vessels and marked alterations in blood-pressure. It may be local or general. Due to: (a) Old age. (b) Chronic disease, — e.g., gout, rheumatism, syphilis, etc. (c) Overwork, especially early in life, (d) Chronic poi- soning, — by lead, arsenic, alcohol, etc. (o Fig. 123.— Method of removing the cerebellar lobes from the pons Varolii and the medulla oblongata. Fig. 124. — Method of sectioning the cerebellum. Fig. 125.— The whole brain after it has been sectioned. Descending fornix Descending fornix Fig. 126. — Section of the brain. The lines and arrows show the position and direction of the various incisions. (After Nauwerck.) Fig. 128. — Sectioning of the brain. A £, incision practised by Flechsig ; C JD, that' of Brissaud ; E F y that of Dejerine. (After Dejerine.) Fig. 129. — Incisions made by Dejerine in a case of cortical'lesion previous to^hardening. (After Dejerine.) EXAMINATION OF THE SKULL AND BRAIN ^5 roof of the ventricle and the basal ganglia, to avoid injuring the latter. The basal piece is now lifted until the anterior crura of the fornix and the septum lucidum may be severed, and the basal section thereby completed. The basal piece thus separated includes the island of Reil, the basal ganglia, the crura, pons, medulla, and cerebellum. (Fig. 127.) Pitres's Method. — The lateral ventricles are exposed as in Vir- chow's method. The hemisphere lies on its internal surface and a series of transverse vertical sections are made parallel to the fissure of Rolando. Pitres's method is very useful for localizing lesions in the centrum ovale, but not at all adapted to studying the internal capsule nor for subsequent microscopical work. The same is true of the closely similar method of Nothnagel. Some operators do not even take the trouble to remove the brain from the skull, but merely make a number of transverse incisions across the cerebral structures. This method is only mentioned to be con- demned, though it may diagnose a hemorrhage, a tumor, or an abscess. The next method to be described, that of Dejerine, gives the best results of any of the methods now in vogue. Method of Dejerine. 1 — The brain is examined upon all its sur- faces to see if there be any cortical lesion. The inferior surfaces of the crura are carefully inspected for secondary degenerations. The cere- brum is separated from the cerebellum by sectioning the pons hori- zontally in a plane directly parallel with the inferior surface of the hemispheres and passing just above the great root of the trifacial. Fig. 128 shows the direction of the incisions adopted for this purpose by Flechsig, Brissaud, and Dejerine. This divides the brain into two portions. The upper one contains the two hemispheres, the cerebral peduncles, and the superior portion of the pons, while the corpora quadrigemina is preserved intact by the obliquity of the incision. The lower portion contains the rest of the pons, the cerebellum, and the medulla. The surfaces of the section through the pons are carefully examined for degenerations in the pyramidal tracts, and the two hemi- spheres are separated after determining in which one the lesion is situ- ated, which is often decided by the appearance of degenerations in the cut surfaces of the pons. While Dejerine regards this as important to determine, because the corpus callosum should be sectioned as closely 1 Anatomic des centres ncrveux, pp. 22 et seq. 1 76 POST-MORTEM EXAMINATIONS as possible to the normal hemispheres, and the incision should not pass through the interpeduncular space but encroach at least a centimetre upon the sound peduncle and corresponding portion of the pons, other neuropathologists object to this mode of procedure as being apt to cause disfigurement of the parts. The method of examining the hemispheres is determined by the situation of the lesion, — whether it is central or cortical. If central the only degenerations that are of importance are those of the tracts of the internal capsule and in the region of the tegmentum (dorsal portion of the crus cerebri). Divide each hemisphere by a horizontal incision passing through the superior third of the optic thalamus, harden, prepare a drawing of the part, and section with a microtome. If the lesion is cortical the brain is sectioned by ( i ) a vertical transverse incision (Fig. 129, CD) passing just posterior to the sple- nium of the corpus callosum, and (2) a vertical transverse incision (A B) just anterior to the knee of the corpus callosum. In this way the hemisphere is divided into three segments. The posterior segment is composed of the occipital lobe and part of the parietal. The anterior is the forepart of the frontal lobe. The central is the largest and con- tains the regions adjacent to the fissure of Rolando, the middle portion of the temporal convolutions, the posterior portion of the frontal con- volutions, the basal ganglia, the cerebral peduncle, and the correspond- ing part of the pons. The anterior and posterior segments are hardened as they are, and the central segment also if the cortical lesion is exten- sive and deep so that the fluid can penetrate easily ; if not, a horizontal section (E F) is made through the superior third of the optic thalamus. In either event the pieces are hardened and cut with a microtome, pre- ferably of the Gudden type. The anterior and posterior segments are cut vertically transverse and numbered. The central segment or seg- ments are incised horizontally. In this way a cortical lesion can be localized with great precision not only, but traces of degenerating fibres may be studied throughout their whole extent, which is not practicable by any other method. Hamilton's Method. — Hamilton injects the vessels of the brain 1 as follows : The brain is freed from the dura, but not from the pia and arachnoid, weighed, and injected through the vessels at the base with Miiller's fluid or any other hardening fluid desired. It is well to 1 Text-book of Pathology, 1889, vol, i. p. 56. EXAMINATION OF THE SKULL AND BRAIN 177 have a round stoneware jar with a lid of sufficient size, three fair-sized cannulas, several feet of good rubber tubing of a caliber to receive the ends of the cannulas, and a three-tubed " distributer." A piece of the rubber tubing about eighteen inches long having been firmly tied on one end of a cannula, its other end is tied into an artery, — viz., one into each carotid and one into one of the vertebrals, the opposite ver- tebral being securely ligated. The brain, with its attached tubes, is now placed in the jar, which is partly filled with the hardening fluid. The weight of the cannulas and tubes is taken off the vessels by sus- pending the tubes over the edge of the jar. Tie the other ends of the rubber tubes to the three arms of the distributer, and connect the com- mon tube with the stopcock of a tank filled with the preservative fluid, which can be conveniently raised or lowered at will, and is now placed about four feet above the brain in the jar. When certain that all attachments are secure, the stopcock is grad- ually opened, allowing the tubes to become filled and the fluid to per- colate slowly through the brain. Care should be taken that the can- nulas do not bend the arteries short upon themselves, thus occluding their lumina. The first fluid which passes through will be mixed with blood and should not be used again, but when it has become clear it may be used over and over. It usually runs through very quickly, and the tank should be refilled at least every day for the first week, and oftener if convenient. The brain should always be in an excess of the fluid and a vessel provided for the overflow. For refilling the tank it is best to draw some of the liquid out of the jar w T ith a siphon, which will not disturb the brain or the position of the cannulas. A week or two will suffice in urgent cases, but the longer the brain remains in the fluid the better will be the hardening. Some of my most beautiful specimens are those which were kept in Miiller's fluid for five or six months. Haste and thoroughness are incompatible in this process. No padding should be used to keep the organ in position, the best and surest agent for this purpose being a plentiful excess of the liquid and an occasional change in its position. If it seems unnecessary to inject the vessels, the following method may more easily be carried out and gives most excellent results. An open jar, bucket, or wash-basin is one-quarter filled w T ith absorbent cotton, and Miiller's fluid — to which one per cent, of formalin may be added with great benefit — is poured in until the vessel is about half full. The brain, after being weighed, is carefully placed in the centre of !^8 POST-MORTEM EXAMINATIONS the vessel and more fluid is added until the organ is well covered, when it is placed in a refrigerator. If this be done, even though the arteries have not been injected nor any incision made into the ven- tricles, there is no danger that the brain will decompose, even in sum- mer. On the next day the position of the brain is altered and the fluid changed. The renewal of the fluid can best be accomplished with a siphon, only a part of it being removed at one time. The fluid is changed again on the third day, then every other day for three times, twice a week for the next three weeks, and once a week for the final three weeks. Remember that the jar is uncovered, and this allows of the evaporation of the fluid and possible spoiling of the specimen. The brain can then be thoroughly washed and put in 80 per cent, alcohol, or the Mullers fluid can after the fifth or sixth week be diluted with one-fifth alcohol, then with one-quarter, one- third, one-half, and finally three-quarters alcohol, where the brain can be kept for several months until it is transferred to the alcohol of 80 per cent, strength. Instead of Muller's fluid a 2.5 per cent, solution of bichromate of potassium may be employed. It is important to remem- ber that nervous tissue preserved for the purpose of study by the Nissl method should not be placed in Muller's fluid, but in alcohol or for- malin. About two thousand cubic centimetres of a 10 per cent, forma- lin solution are used and changed every third day. The solution must be kept in a tightly closed jar. Giacomini's Method. — This is well adapted for the macroscopical study of the brain, but, on account of the zinc chlorid used, the tissue is rendered unfit for microscopical work. If the specimen is a brain tumor, a small portion of it may be placed in a hardening fluid for microscopic study and the remainder then treated by this process. The brain, in as fresh a state as possible, is put into the Liquor zinci chloridi (U. S. P.). It will be found to float at first and should be turned several times the first day. On the second day the pia and arachnoid, which until now have been useful in keeping the brain intact, are removed while the organ is under water or floating in the fluid; if allowed to remain longer, they become so adherent to the cortex as to be separated with difficulty and more or less damage to the cortical substance. The brain is left in the fluid for from six to ten days, then removed, well washed with water, and put in 95 per cent, alcohol for ten days or two weeks and next in glycerin for another ten days or more. After this it is placed in absorbent cotton and EXAMINATION OF THE SKULL AND BRAIN iyg exposed to the air in a dark place free from dust. Any exudation should be carefully removed, and when no more appears (which may be in from several weeks to as many months) the surface is to be well coated with the best mastic varnish applied with a soft camel's- hair brush. To prevent flattening of the surface upon which it rests, it must be well packed in absorbent cotton and its position frequently changed. Kaiserling Method. — See page 261 for the preparation of brains with the object of preserving their natural coloration. In the coroner's work it is often necessary to make a diagnosis between heart-disease and apoplexy, when, because of baldness of the individual or for lack of time, it is impracticable to open the head. In such cases I have found it feasible to trephine just above the ear and from this point tap the ventricles and other situations liable to be the seat of hemorrhage, using an instrument resembling an apple-corer to remove brain substance for examination, though enough clotted blood may be brought out attached to a long thin brain-knife passed into the places where hemorrhage usually occurs — i.e., the ventricles and the cerebellar lobes — for the purpose of establishing a diagnosis. The base of the skull and its sinuses are next to be examined. Study the dura at its base for ( 1 ) inflammation resulting from frac- ture or caries, (2) tubercles, (3) gummata, (4) thrombosis of lateral sinus, (5) pachymeningitis and leptomeningitis, and (6) tumors. A fracture may be hid by the dura, but its situation will usually be shown by the presence of hemorrhage. The dura must be stripped oft, though this often consumes considerable time, so that the surface of the bone may be exposed. Unless this is done, a linear fracture — one near the foramen magnum, for example — might readily be overlooked. Special examinations should now be made of the orbit, internal ear, and nasopharyngeal cavities. CHAPTER XVI THE SPINAL CANAL AND CORD The spinal cord may be removed either anteriorly or posteriorly, — i.e., by excising the bodies of the vertebrae through the thorax and abdomen freed from their viscera or by severing the laminae and spinous processes of the vertebrae through an incision posteriorly. The latter route is decidedly the more convenient and is used whenever possible. Generally it is best to remove the cord before the abdomen is opened, this being a much cleaner operation, an important factor in private practice. The cadaver is placed prone upon the table, with the head hanging over the end or, better, with a block under the chest and neck and, if desired, one under the lumbar region. Beginning at the external occipi- tal protuberance, an incision is carried along the spinous processes to about the fourth lumbar vertebra, dividing all the tissues down to the bone. (Figs. 130, A B, and 131.) The superficial and deep structures are then dissected from the bones, exposing the vertebral groove on either side of the spinous processes. Or, after incising the skin over the spinous processes, insert the knife, with its back down, at the lower end of the incision and cut upward along the column, keeping the blade pressed against the spinous processes. In this way the fibrous attach- ments are cut close and the vertebral groove is clean and free from troublesome soft tissues. The soft parts should be very thoroughly removed, as they would interfere considerably with the subsequent sawing. This can be quite well done by scraping with a chisel or an old knife. In cases of luxation, fracture, Pott's disease, etc., it may be desirable to remove portions of the vertebral column en masse. This can readily be done by the proper use of a saw after severing the inter- vertebral cartilages above and below the lesion. The space is then filled by inserting a stick and pouring plaster upon it. The canal is easily opened with Luer's rhachiotome, an adjustable, double-bladed saw devised for the purpose ( Fig. 21). It does the work more quickly, but has the serious fault that it is liable to become im- pacted and injure the cord in its release. The same object may be 180 Fig. 130. — Lines for removing the spinal cord and the brain through a small triangular occipital incision. A B, initial incision for removal of the cord ; CD. curved incision for the purpose of avoiding division of the skin above the dressed portion of the body ; E A F, angular incision in the occipital bone through which to remove the brain without elsewhere opening the skull. Fig. 131. — Position of the body in removal of the spinal cord. The primary incision is being made. Fig. 132. — Removal of spinal cord. The primary incision has been made and the vertebral column freed from muscle, fascia, etc. The angle at which the saw should be held is well shown. w — o 3 o fj; re 1 c c s r H p c '- < 7: £ 3 3 ^ c =• 3- r. re < 2 ill T V .- - > ~ 4J nfl D -: o u £ "3 ~o THE SPINAL CANAL AND CORD l8l accomplished with a single-bladed saw having curved ends (Fig. 17). The lamina should be sawed close to the transverse process, with the saw teeth held away from the spine at an angle of about thirty degrees (Fig. 132). Unless this direction is taken there is some danger that the canal will be missed or that the blade may enter it and the cord be injured. Orth calls attention to the fact that one can tell when sufficient sawing has been done by the mobility of the spinous processes. Other instruments which may be used are the double chisel of Esquirol, the knife-shaped chisel of Brunetti, and the rhachiotome and hammer of Amussat, the latter being much preferred in France to Luer's rha- chiotome, which is not approved of. After the canal has been opened in the dorsal region with the saw, a pair of bone-nippers is used to pry up the portions of vertebra thus loosened, and the dura is exposed (Figs. 133, 134). The sawing can then be continued in both directions until the entire canal is opened, except the atlas and axis, which had better be cut with bone- forceps (Fig. 135). In using either bone- forceps or pliers be very careful not to produce artefacts of the cord. The cord at the first dorsal vertebra is then tied with a string, so as to have the situation accurately determined, or the first dorsal nerve may be dissected out and left attached to the cord. The spinal cord covered with its membranes may now be studied in situ, after which the dura and the spinal nerves are divided below the cauda equina. The dura being elevated with the fingers or forceps and pushed to one or the other side, the spinal nerves are cut, with a long, thin, narrow-pointed, sharp knife, close to their points of entrance into the intervertebral foramina. (Fig. 136.) The dura at the foramen magnum can best be severed from the bony margin above after the brain has been removed. The cord may be taken away with the brain attached if so desired. The spinal ganglia may be extracted with the nerves and cord by cutting away the articular processes and gently pulling the cord, by the dura, to the opposite side and severing the nerve as far in the foramen as possible. By making a median incision in the dura mater the cord is exposed, and can, of course, be removed. This procedure, however, is more liable to cause injury to. the cord than the method given above. After freeing all points of attachment the cord must be very gently transferred to the table or tray for further examination. Study the dura for ( 1 ) thickness, ( 2 ) color, ( 3 ) blood, the cerebrospinal fluid for (1) pus, (2) blood, and the pia for (1) expansion, (2) thick- 1 82 POST-MORTEM EXAMINATIONS ness, (3) contained blood, and (4) color. Gentle palpation may reveal areas of softening or sclerosis. The further manipulation of the part will depend upon the extent of the examination required. If the cord is to be preserved for future study, the dura is opened in the median line throughout its entire extent, the blade being inserted at the lower end, and transverse incisions about one inch apart down to the pia are made in the cord. It may be hardened at the same time and in the same jar as the brain by curling it around that organ; but it is better to suspend it by the dura, with a small weight attached, in a long jar, or it may be kept in such a jar lying upon its side. In summer the jar should be placed in the refrigerator. If the examination is to be completed immediately, the cord is laid out on the table and the dura opened throughout its entire length as already directed. Note is made of the conditions observed. Much valuable information can be obtained by the macroscopic examination, especially if a hand-glass be used and diagrams made at the time. Then, with a sharp, thin knife, which should be moistened with water after each incision, transverse sections about an inch apart are made through the cord and membranes ; the under surface of the dura, how- ever, is left uncut, in order that the cord may be replaced in its entirety. Areas of softening should not be incised, because of the inevitable dis- turbance thus produced in the relations of component parts. Where the avoidance of disfigurement above the parts covered by clothing is a matter of great importance, sufficient room for opening the cervical canal can be obtained by making a crescentic incision from the centre of one shoulder to the other, with the concavity towards the head, and dissecting up the skin. (Fig. 130, CD.) Sometimes it is advantageous to open the canal by removing the vertebral bodies through the long anterior incision. Brunetti's chisels were devised for this purpose. After removal of the thoracic and ab- dominal viscera, the pointed guard is inserted in the vertebral canal, and the instrument, held parallel with the long axis of the spinal column, is driven forward with a mallet, thus severing the pedicles and removing the bodies or anterior wall. By this method the spinal ganglia are said to be rendered more easily accessible. The remaining steps are about the same as those described for the posterior incision. CHAPTER XVII DISEASES OF THE BRAIN AND CORD Abscess of the Brain. — There is a circumscribed collection of pus in or upon the brain substance, with or without a pyogenic mem- brane, (a) Micro-organisms, — e.g., Staphylococcus pyogenes, Strep- tococcus, the diplococci of pneumonia, gonorrhoea, and cerebrospinal fever, Bacillus coll communis, the bacillus of typhoid, influenza, etc. (b) Traumatism, (c) Extension of disease from the middle ear or mastoid cells and cranial bones, (d) Septic emboli from distant foci, — e.g., abscess of the liver, ulcerative endocarditis, putrid bronchitis, localized bone-disease, etc. (e) Actinomycosis and other mycotic germs (rare). Classification. — (a) Primary (rare) or secondary (common), (b) Single (from extension) or multiple (metastatic). (c) Large (size of a walnut or an orange) or minute (then usually multiple). Seats. — (a) Cerebrum, usually in the temporo-sphenoidal lobe (most common), (b) Cerebellum, especially in middle-ear dis- ease, (i) Acute abscesses, usually about blood-vessels; are minute, with no definite wall; contain pus mixed with reddish debris and softened brain matter. (2) Chronic abscesses, may be superficial or deep; have a pyogenic membrane, which develops in from three to five weeks; pus has a greenish tint, an acid reaction, and may have a peculiar odor depending on micro-organisms. It may undergo fatty degeneration, but cystic formation is doubtful. Acromegaly. — A chronic disease of nervous origin, occurring most frequently in adults, and characterized by an overgrowth of the bones, especially those of the face and extremities, by malnutrition, and by impairment of the senses. Morbid changes are always found in the pituitary body (hypertrophy, colloid degeneration, tumors, etc.) and usually in the thyroid and thymus glands. There are marked hypertrophy of the bones of the face (especially the maxillae) and osteophytic growths on the bones of the hands and feet, with exag- geration of the normal ridges and tubercles. The thorax is enlarged and kyphosis may be present. The sternum is thickened, lengthened, and widened, as are also the ribs and clavicles. There may be hyper- trophy of the pharynx and larynx, leading to marked dyspnoea. In 183 184 POST-MORTEM EXAMINATIONS one of my cases there was found after death a sarcoma of the pituitary body; in another, all of the glands of the body appeared to be hyper- trophied. I have removed post mortem the pituitary body through the orbit. Under acromegaly may also be classed osteitis deformans, an affection which causes softening and distortion of the long bones of the body; hypertrophic pulmonary osteo-arthropathy, where there is antecedent lung disease and the bones of the skull are not involved, and leontiasis ossea, an overgrowth of the bones of the cranium. In micromegaly the condition is the reverse of that found in acromegaly. Anaemia Cerebri. — A condition in which the brain is temporarily or permanently deprived of part of its blood-supply. Due to: (a) Mechanical obstruction to the circulation, — e.g., valvular heart-lesions, thrombosis, embolism, or ligation of a vessel. (b) Hemorrhage. Classification. — (a) General or local. (&) Acute, subacute, or chronic, (c) Partial or complete. The membranes are pale ; small arteries over the gyri are empty, though large veins are full. The brain substance is anaemic, the surface moist, few puncta vasculosa are seen, and the cere- brospinal fluid is increased. Aneurism of Cerebral Arteries. — Classification. — (a) Single or multiple, (b) Large or minute. Seats. — (a) Most frequent in branches of the middle cerebral artery, especially those of anterior perforated spaces, (b) May be cortical. The aneurisms are usually very small, varying in size from that of a pea to a cherry-stone (sel- dom larger), multiple, and may resemble bunches of grapes. If hemorrhage occurs in basal aneurisms, the internal capsule and basal ganglia are injured, the lesion usually being extensive. On the cortex the result of hemorrhage is much less grave. Apoplexia Neonatorum. — A form of hemorrhage of the brain occurring in the new-born, usually the result of traumatism, (a) Accidents during labor, from forceps, etc. (b) Congenital defects in blood-vessels, brain, or skull, (c) May result from prolonged and severe normal labor. Seats. — (a) Meninges (piarachnoid) most fre- quently, often bilateral, and usually at the base. (&) May be between dura mater and skull; is accompanied by cephalsematoma. (c) May occupy the ventricles, (d) May occur in brain substance about basal ganglia, (e) Sometimes found in parietal region and Sylvian fissure, (i) Generally the hemorrhage is meningeal primarily, producing brain-lesions secondarily, such as atrophy and softening, by pressure. DISEASES OF THE BRAIN AND CORD ^5 (2) Cortical hemorrhage is represented by a clot, which may be encysted, softened, or organized, causing more or less injury to the brain. (3) When the hemorrhage is between dura and skull, fracture is said to be always present. Ataxia, Hereditary (Friedreich's). — A form of ataxic para- plegia occurring in children and congenital in origin, (a) Heredi- tary, not common, (b) More common in males than in females, (c) Early life, (d) A specific lesion of the cord. (1) There is a gliosis of the posterior column of the spinal cord, due to developmental errors (Osier). (2) Talipes equinus occurs in both feet. (3) Lateral curva- ture is common. Ataxia, Locomotor (Tabes Dorsalis). — A chronic disease of the nervous system, characterized by sclerosis of the cord and brain, and by incoordination, with motor, sensory, and trophic disturbances, (a) Male sex. (b) Adult life, (c) Syphilis, (d) Wet and cold. (e) Sexual excesses, etc. (1) Spinal Cord. — Externally the men- inges are thickened and adherent. Posterior roots are atrophic and of a grayish tint. Internally sclerosis of the cord begins in the pos- terior-root zone, involving the outer layers of posterior columns in the lumbar region. The sclerosis gradually extends inward, involving successively the columns of Burdach and Goll; when the process reaches the upper dorsal region, it is confined to the column of Goll. The cord presents a flattened appearance posteriorly, the sides being somewhat contracted. The diseased areas are firm, grayish or grayish red in color, and the whole cord is often firmer in consistency. (2) Brain. — Changes of less consequence than in the cord may be sclerosis in restiform bodies, inferior peduncles of cerebellum, and certain cranial nerves, — the oculomotor, optic, and auditory. Atrophy of the optic nerve and hemiplegia may occur. Some recent writers con- sider paralytic dementia to be such a disease of the brain as locomotor ataxia is of the cord. (3) Peripheral nerves may show degeneration or even neuritis. (4) In later stages occur dermopathies and arthro- pathies, — e.g., perforating ulcer of foot, herpes, etc., Charcot's joint, etc. There may be evidences of loss of control of sphincters. Caisson Disease.— A peculiar nervous affection, the result of a sudden reduction of atmospheric pressure. Occurs in bridge-builders, divers, etc., who, after working for hours under a pressure of two or three atmospheres, have suddenly returned to air of normal density. In fatal cases there is a marked destruction of nerve tissue in the pos- !86 post-mortem examinations terior columns and the posterior portions of the lateral columns, forming fatty detritus and compound granular cells. Chorea, Acute. — (a) Female sex. (b) Early life (before the fifteenth year), (c) Heredity, (d) Bad hygiene, (e) Fright, (f) Bad habits. No constant lesions are found. Vascular changes, such as hyaline degeneration, leucocytic infiltration, minute hemorrhages, and thrombosis of small arteries, have been described. Congenital Anomalies. — Cranioschisis, rhachioschisis, hydro- meningocele, encephalocele, myelomeningocele, hypoplasia of different parts, as of the cerebellum, micrencephaly, hydrocephalus, internal and external porencephaly, idiocy, cretinism, micromyelia, total absence of parts, and anomalies of distribution. Cretinism. — A low form of idiocy, either congenital or acquired during the early years of life, and associated with anatomic changes in the thyroid gland, as absence, hypoplasia, atrophy, or goiter. It is endemic in certain localities, notably Switzerland, where goiter is prevalent. Heredity bears a causative relation. The condition usually appears at birth. The child is stunted and dwarfish in appearance. The trunk is large in proportion to the development of the head, hands, and feet. The head is flat, the face broad and expressionless, the eyes are dull and stupid, the nose is flat and depressed, the lips are thick, and the tongue is large and usually protrudes. The teeth are carious ; the hair is thin, brittle, and harsh to the touch ; the skin about the hair is dry and scurfy. The abdomen is prominent ; the legs are short and thick, the hands and feet undeveloped. The skin is yellow, leathery, and rough to the touch. Delirium, Acute. — The post-mortem findings are usually nega- tive. There may be great venous engorgement of the meninges, and the cortex and blood-vessels may show exudation and leucocytic infil- tration into the lymph-spaces and sheaths. Careful examination of the lungs and ileum should be made in fatal cases. Encephalitis, Acute. — Due to: (a) Acute infectious disease. (b) Traumatism, (c) Intoxications. The minutest foci of inflam- mation are not recognizable by the unaided eye; later stages have a pinkish appearance or are represented by clusters of small dark-red hemorrhagic foci. When suppuration follows, these areas take the form of yellowish-white patches whose tissue soon liquefies and becomes purulent. DISEASES OF THE BRAIN AND CORD 187 HLematomyelia. — Hemorrhage into the cord, (a) Traumatism. (b) Exposure, (c) Convulsions, (d) Tumor, (e) Syringomyelia. (/) Myelitis, (g) Male sex. (h) Middle life. The cord is usually enlarged, occasionally lacerated. The blood is generally confined to the gray matter, but may escape beneath the membranes. Hemiplegia in Children. — Causes: (a) First or second year. (b) Traumatism, (c) Embolism or thrombosis, (d) Congenital defect. Classification. — (a) Embolism, thrombosis, or hemorrhage. (b) Atrophy and sclerosis, (c) Porencephalon. (1) The results of embolism, thrombosis, or hemorrhage depend on the extent and rapidity of the formation and on location. When the process is an acute one and extensive, it is either immediately fatal or leads to more or less extensive destruction of the brain substance; there is a ten- dency to softening or suppurative change. (2) Atrophy and sclerosis may involve a group of convolutions, an entire lobe, or even a whole hemisphere. The affected gyri are firm, hard, and atrophied, con- trasting sharply with the normal tissue. They may be uniform in appearance or there may be nodular projections. In porencephalon there is loss of substance, with the formation of cavities or cysts at the surface of the brain. Hemorrhage, Cerebral. — The most common cause (sixty per cent.) is rupture of the lenticulostriate artery. Classification. — (a) Basilar. (&) Cortical. In basilar hemorrhage section of the brain substance frequently shows miliary aneurisms, which are seen as small dark bodies along the course of the blood-vessels penetrating the ante- rior perforated spaces. Aneurism of a branch of the circle of Willis may be found. Endarteritis and periarteritis are found in the cerebral vessels. At the seat of a recent hemorrhage the brain has a dark-red, softened appearance, the tissue being reduced to a coagulated or pulpy mass of detritus. When the hemorrhage has been extensive, the remainder of the brain is anaemic. The gyri are more or less flattened, from extravasated blood, and the sulci are indistinct. Hemorrhages are most common near the corpus striatum towards the outer section of the lenticular nucleus. They may be small and limited to the lenticular body and internal capsule or may break into the lateral ventricle. Ven- tricular hemorrhage is rare. It is usually bilateral. Meningeal hemor- rhage is usually caused by fracture of the skull or rupture of a blood- vessel. The hemorrhage may be small or large. It may be above or below the dura or between the pia and the arachnoid. ^8 POST-MORTEM examinations Hemorrhage into the Spinal Membranes. — Extrameningeal hemorrhage may be extensive, without compression of the cord. Rup- ture of an aneurism into the spinal canal may produce profuse and rapidly fatal loss of blood. There may be little demonstrable morbid change. Intrameningeal hemorrhage usually occurs in scattered areas as the result of acute infectious fevers. More extensive hemorrhages result from epilepsy, tetanus, and strychnine poisoning. Occasionally hemorrhage into the spinal meninges may ascend to the brain. Hyperemia, Cerebral. — This may be: (a) Active, (b) Passive. ( i ) The cerebrum is congested, the blood-vessels are somewhat dis- tended, and petechial hemorrhages are numerous. On section the gray substance contrasts very markedly with the white; the former is of a brick-dust color; the latter shows many punctate hemorrhages. (2) In passive congestion the veins of the cortex are distended; the gray matter has a deeper color and its vessels are full. The gray mat- ter shows distention of the smaller veins, which on section allow their contents to exude as drops of blood of various sizes. Excessive passive hyperemia may result in cerebral oedema. Leptomeningitis, Acute Cerebrospinal. — Acute inflammation of the pia and arachnoid of the brain and spinal cord. Causes: (a) Acute infectious fevers, (b) Injury or disease of the base of the skull. (c) Extension of disease from nose, ear, or Eustachian tube, (d) Pyaemia. The organisms most commonly found are the meningo- coccus, the pneumococcus, the tubercle bacillus, and the cocci of in- flammation; more rarely, the bacilli of influenza and of typhoid, the colon bacillus, and the gonococcus. Classification. — (a) Simple or traumatic, (b) Purulent, (c) Tuberculous. (1) In simple or puru- lent meningitis the membranes are thickened, the blood-vessels dilated, and there is more or less exudation, which may be serous, serofibrin- ous, or purulent. The exudation may be so extensive as to cover up the convolutions. The inflammatory process is most marked in the basilar portions. It may be unilateral or bilateral. In the former the condition is due to extension from neighboring parts. (2) The tuberculous form of the disease is ususally cortical as well as basilar. It begins as a miliary tuberculosis, and in the early stages exudate is not extensive. The ventricles also may be involved and present consider- able distention and softening; they seldom suffer in other forms of the disease. DISEASES OF THE BRAIN AND CORD 189 Meningitis, Acute Cerebrospinal. — An acute infectious dis- ease, especially of early life, characterized by inflammation of the membranes of the brain, with an exudation of fibrinopurulent material, chiefly towards the base, and due to the Diplococcus intracellular is. (1) Membranes of the Brain. — In acute fatal cases there is intense injection of the pia and arachnoid, with a little exudate. In more chronic cases there is a formation of fibrin or of pus, or of both; this is most marked at the base of the brain. The meninges are much thickened and opaque. The larger blood-vessels are overfilled and many of the smaller ones are obliterated. Sometimes the entire cortex is covered with a thick purulent exudate, and there may be much lymph along the larger fissures and in the sulci. In acute cases the ventricles are dilated, the ependymse are inflamed, and the cavity may contain pure pus. (2) Cranial Nerves. — The nerves usually involved are the second, fifth, seventh, and eighth. They are often embedded in the exudate. Micro-organisms may be found in the fibrin. (3) Brain Substance.— -This is softer than normal, has a pinkish color, with foci of hemorrhage and of brain softening. (4) Lungs. — Pneu- monia and pleurisy may occur. The lungs are often congested, with evidences of bronchitis. (5) Abdominal Organs. — The liver is rarely altered. Acute nephritis is sometimes present, and the intestines may show swelling of the follicles. (6) Skin. — There may be rose-colored, hypersemic spots, resembling the typhoid rash, urticaria or pemphigus, and in rare instances gangrene. (7) Eye. — Neuritis is common, and there may be acute papillitis. Purulent chorioido-iritis or even kera- titis sometimes occurs. (8) Ear. — Otitis media develops from direct extension, and frequently leads to abscesses. In one of my cases the bacillus of tuberculosis was found associated with the meningo- coccus. In two fatal cases examined by me there was a history of traumatism, though no sign of this was found at the postmortem. During an epidemic domestic animals, as the goat, should be watched for signs of disease. Menigq-en cephalitis ; Chronic Diffuse or Deep Chronic Leptomeningitis.— (a) Male sex. (b) Early adult or middle life, (c) Syphilis, (d) Alcoholism, (e) Certain occupations, as those of artists, navy and army officers, etc. The membranes of the brain are thickened and opaque and more or less extensively adherent to the cortex, which is torn on attempting to remove them. The convolu- tions of the brain are atrophied, especially in the frontal and parietal 190 POST-MORTEM EXAMINATIONS regions. The gray matter may be obscurely outlined. The white matter is firm in consistency. The ventricles are dilated and the ependymae granular; frequently there are areas of hemorrhage or softening associated with chronic arteriosclerosis. There is an increase in the cerebrospinal fluid. Usually sclerosis of the posterior columns, with involvement of the lateral, is found. There may be an extraor- dinary development in the lymph connective system of the brain, with a parallel degeneration and disappearance of the nerve-elements and the axis-cylinders, and finally shrinking and extreme atrophy of the parts involved. Muscular Atrophy, Progressive (Spinal). — (a) Male sex. ( b ) After the thirtieth year. ( 1 ) Macroscopically there is great mus- cular wasting, beginning usually in the thenar and hypothenar emi- nences and thence extending to the general muscular system. In marked cases the subject may be reduced " to skin and bone." De- formities and contractures result and lordosis is almost always present. (2) Microscopically the muscles undergo fatty and sclerotic change and the terminal ends of the motor nerves are degenerated. (3) Examination of the cord shows the anterior roots corresponding to the diseased muscles to be atrophied. Neurogliar tissues show marked increase, most conspicuous in the anterolateral tracts. The degenera- tion of the gray matter extends to the medulla. Large ganglion-cells in the motor cortex may be wasted. In a case at Elwyn which I examined post mortem the diaphragm was easily seen through when held up to the light. Myelitis, Acute. — (a) Traumatism, (b) Exposure, (c) Cer- tain infections, (d) Disease of the spine, (e) Disease of the cord. (1) The cord is swollen and soft and the pia injected. On incision a diffluent fluid may escape. The distinction between gray and white matter is often lost. Hemorrhages are frequent. (2) Histologically the nerve-fibres are swollen, the axis-cylinders beaded, myelin droplets abundant, and corpora amylacea may be seen. The ganglion-cells are swollen, irregular in outline, and exceedingly granular and vacuo- lated. In the removal of the cord in these cases great care must be taken not to produce artefacts. Myelitis from Compression. — (a) Caries of the spine, (b) New growths, (c) Aneurism, (d) Parasites, (e) Distention of central canal with inflammatory liquid or blood. Changes appear first DISEASES OF THE BRAIN AND CORD 191 in the white matter, the fibres of which may within six hours swell up and disintegrate. Poliomyelitis, Acute Anterior. — (a) Early life, (b) Boys more susceptible than girls, (c) Acute infectious fevers, (d) Proba- bly a specific micro-organism. ( I ) The seat of the lesion is in the part supplied by the anterior median branch of the anterior spinal artery. Cervical or lumbar portions of the cord are most often affected. (2) In the early stages the lesion is an acute hemorrhagic myelitis, with rapid destruction of the large ganglion-cells. (3) The nerve-fibres of the anterior roots corresponding to the ganglion- cells destroyed break down and disappear. (4) Certain anterior nerve-roots are atrophied, and the muscles innervated by them waste and become fatty and sclerotic. Raynaud's Disease. — A form of symmetrical gangrene, affecting especially the fingers and toes, caused by spasm and constriction of the small blood-vessels. Sclerosis, Insular (Disseminated Sclerosis). — Its cause is not definitely known. Is more common in the young than in the old. Sclerotic areas are usually small, of a grayish or whitish color, widely distributed in the brain and cord and in the gray and white matter. They are more abundant about the ventricles, the central canal, the pons, the cerebellum, and the basal ganglia. The patches are firm, dry, and sharply defined from the surrounding tissue; in some cases they may be less firm and not so well defined. Microscopically there is a marked increase of neuroglia, the medulla of the nerves is de- stroyed, and the axis-cylinders persist. Syringomyelia. — Syringomyelia is a chronic affection of the spinal cord characterized anatomically by the pathological formation of cavi- ties in its gray matter, and clinically by peculiar disturbances of sensi- bility associated with trophic disorders. Causes: (a) Embryological- malformations, (b) A gliosis, (c) Traumatism, (d) Development of embryonal neurogliar tissue in which hemorrhage or degeneration takes place with the formation of cavities. ( 1 ) The characteristic lesion is a cavity which forms in the cord in or near the central canal and extends into the gray matter of the anterior, or more frequently the posterior horns. It is most often situated in the cervical and tho- racic portions of the cord. (2) On transverse section the cavity may be oval, circular, or narrow and fissure-like, or it may present the appearance of two or more cavities independent of each other or inter- I9 2 POST-MORTEM EXAMINATIONS communicating. ( 3 ) The contents of the cavity are usually a colorless liquid. Occasionally it may be a yellow or brown gelatinous substance, or it may consist of blood and the products of its degeneration. The white matter of the cord in moderate cases is unaffected, but where the cavity is large and pressure from the sclerotic tissue has become great, the white matter is in its turn involved, being crowded to the periphery and more or less unable to carry on its functions. CHAPTER XVIII EXAMINATION OF THE NASOPHARYNX, EYES, AND EARS EXAMINATION OF THE NASOPHARYNX. In order to expose to view the upper air-passages, nasal, pharyn- geal, laryngeal, and accessory cavities, epiglottis, etc., Harke's 1 method has come into general use. If the procedure is properly carried out, the parts when returned to their normal position present no noticeable deformity, though during the examination such a result seemed almost impossible. Harke's Method. — The brain having been removed and the ex- amination of the skull completed, the anterior skin flap is dissected away from the frontal bone down to the root of the nose, while the posterior flap is dissected away some distance below the foramen magnum. It is not necessary that the primary incision of the scalp behind the ears be made lower than the mastoid process on each side. Next, directly in the median line, the skull is cleft with a small saw into two lateral portions. For the sake of convenience the saw markings may be divided into two sets (Fig. 137), the first starting from the front in the frontal bone, ex- tending down to the nasal bone, and continuing to the foramen magnum (A B), and the other starting at the occipital bone and extending to the foramen magnum (CD). The atlas and axis are sawed through if much room be desired. The sawed portions are now separated by means of a chisel and hammer, any portions of mucous membrane that may appear being severed with a knife or scissors. By means of strong lateral traction the two segments may be pulled apart, and the entire region down to the vocal cords will thus be exposed. Usually the in- cision passes to one or the other side of the nasal septum. The walls of the accessory cavities are readily cut away with strong scissors, and a plain view is obtained of the maxillary sinuses as well as the frontal, sphenoid, and ethmoid. Even the epiglottis and vocal cords can be examined by this method (Fig. 138). In order to view the parts better, light may be thrown in by means of a mirror. Another method is to drill holes just in front of the sphenoid and a little behind and to the right and left of the crista galli, and then with a 1 Berliner klin. Wochenschrift, 1892, No. 30; Virchow's Archiv, 1891, Vol. 125. 13 193 194 POST-MORTEM EXAMINATIONS saw or a chisel make an ovoid incision extending almost to the foramen magnum, and remove the portion of bone which hides the nasopharyn- geal cavities. (Fig. 137, P Q.) The two lateral halves are then brought together and wired as in Fig. 139. EXAMINATION OF THE EYES. For this purpose a triangular piece of the orbital plate of the frontal bone is broken through with a hammer or chisel, care being taken not to injure the optic nerve in the optic foramen, the remaining portion of the eye and the nerve being well protected. (Fig. 137, E and F.) The direction of the nerve can be determined by observing the situation of its exposed portion, and the chiselling done a small distance on either side of its normal position. The pieces of bone are removed with the nippers and the optic nerve is carefully dissected out, its cut end being held with the fingers or forceps. The capsule of Tenon and the fat are removed, and the entire eye is excised or, if this is not permitted, an incision is made in the sclerotica posterior to the conjunctival attach- ment. This requires a very sharp knife, as the tissue is extremely tough. A circular incision is made around the entire eye, and the fundus is exposed. A piece of dark cloth or cotton dipped in ink is placed in the remaining portion of the eye and the cavity is packed with cotton. If only a macroscopic examination of the retina and other structures is desired, the retina may be floated out in normal salt solution and then separated from the choroid. If the retina is to be fixed for microscopic examination, the incision should be as nearly equatorial as possible and the fundus placed immediately in Orth's or Miillers fluid or ten per cent, formalin, or fixed by exposing for three minutes to the fumes from a one per cent, osmic acid solution heated just to the boiling point. The eye is then put for twelve hours into Lindsay Johnson's mixture : Potassium bichromate, two and one-half per cent. . . '. 70 parts. Osmic acid, two per cent 10 parts. Platinic chlorid, one per cent 15 parts. Acetic or formic acid (to be added just before using) .... 5 parts. The gloss of the cornea disappears as soon as death comes on. After twenty-four or thirty hours, and often earlier, the bulbus softens and the cornea and retina become dull. The conjunctiva is now re- moved more easilv from the cornea, and the sclera which is not covered Fig. 137. — Method of examining nasopharynx, eyes, and ears. The sawing for opening the nasopharynx is done in the median line from the frontal bone, A, to the anterior portion of the foramen magnum, B, and from the occipital bone, Z?, to the posterior portion of the foramen magnum, C. The sawing can best be accomplished by standing on the table directly over the head, the finger-saw being especially use- ful at the beginning and the end of the operation. E and F, lines of incisions for the removal of the eyes ; G, situation of the ear-ossicles ; KJ I and LMNO, lines for removal of the ear-ossicles ; P and Q, drill- holes for saw-markings in the oval method of examining the nasopharynx. <-, o O w 3 " (U "c «.- © ^ 5 2 ^ rt a 5 33 ~ as - : tfi 9 2 S s Fig. 140.— Examination of the umbilical vessels. (After Nauwerck.) Right pulmonary arterj Pulmonary valves Left pulmonary artery Papillary muscle and tricuspid valve Fig. 141. — Examination of the ductus arteriosus. The sound is represented as introduced into the ductus arteriosus Botalli ; this duct usually closes about the fourth day after birth. (After Nauwerck.) Fig. 142. — Removal of the spinal cord of a child. EXAMINATION OF THE EARS 195 by lids becomes brownish black and dry. (Orth.) According to Rnnge, several days after death a diffuse redness occurs in. the trans- parent media of the eyes of a foetus that has died in utero. The redness affects first the cornea and then the lens, — extending from without inward, — in this way indicating approximately the date of death. The position of the eye may be altered. Exophthalmus, or pro- trusion of the eye, may be caused by a retrobulbar tumor, oedema, hypertrophy of fat, collection of blood from hemorrhages, emphysema, inflammatory exudates, Basedow's disease, etc. Enophthalmus, or re- traction of the eye, may take place in atrophy of the fat, loss of liquid, as in cholera, deformity from scars, etc. The consistency of the eye varies, being increased in glaucoma and diminished in certain forms of degeneration. EXAMINATION OF THE EARS. A fair idea of the condition of the middle ear may be obtained simply by chipping away the roof with a chisel or biting it off with bone-forceps, but if a closer inspection is desired the petrous portion of the temporal bone and the mastoid process had better be removed together. Carry the incision from its original point back of the ear and along the anterior border of the trapezius about half-way down the neck. Reflect the flaps with their soft tissues so as to leave the bone clear. Begin at the apex of the petrous portion of the temporal bone and with a chisel laid flat break through the petrobasilar suture to the jugular foramen, and chisel or saw through the skull on a line from the jugular process of the occipital to a point about five centimetres posterior to the base of the mastoid process. Anteriorly chisel or saw through the skull on a line from the apex passing posterior to the spinous process of the sphenoid; or between the foramen ovale and the foramen spinosum and well anterior to the external meatus, just cutting off the root of the zygoma. Woodhead 1 uses the following method : '* The temporal bone, with its petrous portion containing the in- ternal ear, may be taken out and examined after removal of the brain, by stripping off the dura mater from the base, dissecting off the skin and muscle, detaching the external ear from the bone, and disarticu- lating the jaw; then, taking the margins of the temporal bone as the 1 Practical Pathology, p. 28, 1892. 196 POST-MORTEM EXAMINATIONS base of a pyramid, the apex of which is a little beyond the inner extremity of the petrous portion, two saw-cuts are carried almost vertically downward so as to bound the pyramid, and then with a bone-chisel and mallet the whole temporal bone may be removed, after which it may be softened in a decalcifying fluid; or the internal ear may be dissected out with a small saw, a pair of sharp well-fitting bone- forceps, and a sharp gouge and chisel. The internal ear or tympanic cavity and mastoid cells may also be opened up with the aid of the above instruments." By sawing or chiselling as in Fig. 137, K J I or L M N 0, the ear- ossicles and internal ear may readily be reached. CHAPTER XIX POST-MORTEM EXAMINATIONS OF THE NEW-BORN 1 In performing a postmortem on a child it is sometimes advan- tageous to remove the viscera en masse. To practise evisceration the trachea and oesophagus are divided as high up as practicable and then elevated with the free hand. All the posterior attachments are cut as close as possible to the vertebral column until the diaphragm is reached. This is excised laterally and posteriorly, adhesions being severed with the knife as before. The crura being cut loose, the diaphragm is free. Two ligatures are now applied to the rectum, which is then divided between them. When everything which holds the abdominal organs in place has been loosened with the hand, the organs of both the thorax and the abdomen can readily be removed, leaving only the bladder and organs of generation in situ; these may be excised later, in the same manner as that described for the adult on page 132. By this method the viscera can be more conveniently examined both anteriorly and posteriorly, and, as they are all attached, their normal relations are preserved. The body of a child thus disembowelled can be kept for a long time, especially if the abdominal cavity be packed with a mixture of equal parts of bran and salt, to which a little white arsenic may advan- tageously be added. The cadaver should then be surrounded with cotton and a circular bandage applied to the chest and thorax. Parental consent to the performance of an autopsy may sometimes be obtained by suggesting the employment of this method of preserving the body. The methods of examining the umbilical vessels and the ductus arte- riosus are readily seen by referring to Figs. 140 and 141 respectively. The removal of a child's brain is more difficult than that of an adult, because, first, it is much softer, and, second, the dura is normally adherent to the cranium. But it is easier in one thing, — the fact that the bones and sutures are not ossified. In a new-born child the brain 1 For the sake of convenience, references are here added to other portions of this work which may be consulted when making postmortems in the new-born. To ascertain the intra-uterine age of a stillborn child see page 313. To determine whether the child was dead or alive see page 312. For weights and measure- ments of the child at birth see page 269. 197 198 POST-MORTEM EXAMINATIONS is so soft that its removal without injury is almost impossible. In such cases it is advisable to lay the body for a short time on ice sprin- kled with salt, in order that the brain may become hardened by the cold. Another method, and one in which I have obtained the best results, is to place the child in a large basin or tub containing a strong solution of common salt (about half a bucketful to four or five times this amount of water) and conduct the final operation of removing the brain beneath the surface of the liquid, where the body is held by an assistant. Brine of the above strength has a specific gravity slightly greater than that of the brain substance, thus affording more general and even support and lessening the liability of damage. The method is as follows : The scalp is incised across the vertex and the flaps are turned forward and backward as in the adult. With scissors having well-rounded points cut through the sutures and dura well down to the floor. The five flaps thus formed are pulled outward and if necessary cut partly across their base by strong scissors. While the brain is being removed the body should preferably be held in the salt solution. Begin by removing the falx cerebri and longitudinal sinus, then the frontal lobes, olfactory bulbs, etc., in the usual order. W r hen the tentorium and falx are cut through, the brain can be pushed out into the solution, where it will float. If it is desired to harden the brain, it will be well to place a jar of Miiller's or other hardening fluid under it, the transfer being made from the salt solution to the preservative fluid without much of the solution passing into the jar, though the fluid should afterwards be changed for a fresh supply. The spinal cord may be removed from the body of a baby with scissors alone, as the parts are easily cut through. The lines for the incisions through the skin and the vertebrae are made in the same manner as in the adult, but neither knife nor saw is required, the scissors being strong enough easily to penetrate the soft bony structures of the vertebral column in a child under fifteen months of age. (Fig. 142.) In babes the spinal cord is relatively much more firm than the brain. In autopsies on babes suspected of being the victims of hereditary syphilis it is often important to look for the fatty changes produced by that disease at the junction of the cartilage and the bone in the femur. For this purpose a longitudinal incision is made directly over the head of the os femoris and the soft parts are dissected until the bone is reached. The ligaments are then incised and the head is disarticu- lated. The shaft is held by the left hand securely wrapped in a towel POST-MORTEM EXAMINATIONS OF THE NEW-BORN 199 while a perpendicular incision through the cartilaginous head is made down to the bone; should this be much ossified, the incision may be continued with a saw. After sawing for about two inches, a knife is introduced and one segment is broken off. The presence of a yellowish area of fatty degeneration, more conspicuous in the osseous portion than in the cartilage, show r s an interference in the nutrition of the part which is quite characteristic of hereditary syphilis. (Figs. 143 and 144- ) CHAPTER XX RESTRICTED POST-MORTEM EXAMINATIONS In case permission to open the thorax is refused, the diaphragm may be severed from its anterior attachments, and the lungs, the heart, and even the tongue and adjacent parts may be removed en masse through an abdominal incision or a laparotomy wound. Should the avoidance of visible mutilation be imperative, it is pos- sible to examine and, if necessary, to remove both the abdominal and thoracic viscera through the rectum or perineum in males or through the vagina in females. In the male this procedure is performed in the following manner : 1 The body is placed on the back, with the buttocks very near the end of the table and the thighs widely separated and flexed upon the body. The scrotum is then well drawn up, and an incision is made from the perineo-scrotal junction to the margin of the anus and down to the bulb. The knife is carried around this and through the sub- jacent tissue to the pelvic fascia underlying the vesicorectal pouch, without injuring the bladder or rectum. The left arm being bared to the shoulder, the hand is introduced through the incision, and gradually forced up between the parietal peritoneum and the rectus muscles to the diaphragm. The peritoneum may be opened, but the intestines will invest the hand like a tightly fitting glove and make the manipulation more difficult. If unable to perforate the diaphragm with the fingers, a scalpel may be carried up, with the blade flat against the index-finger, and a nick made in the muscle, the knife being then withdrawn and the opening enlarged with the fingers. The lungs may be examined by palpation, any adhesions broken up, and the organs dragged into the abdominal cavity, the roots being severed with a knife, after which they may be removed. The heart can be examined in a similar manner, except that, before it can be moved very far, scissors or a knife will be necessary to sever the large vessels. The kidneys, adrenals, spleen, stomach, etc., may be removed in this manner, but the liver must gen- erally be divided into its lobes in order to get it through the incision. The organs are examined in the usual manner and returned to the body; some wads of oakum may then be pushed into the abdominal cavity and the perineal incision very carefully closed by hidden sutures. 1 H. A. Kelly, Medical News, June 30, 1883. RESTRICTED POST-MORTEM EXAMINATIONS 2 OI It is also possible to make the examination through the rectum, but the sphincter is left dilated and gaping, presenting a much more con- spicuous and unsightly appearance than the perineal incision. This method is most difficult of accomplishment when the operator's arm measures more than ten or eleven inches around the biceps, espe- cially in subjects of only average size. The work is very arduous, because of the strained and cramped position which the hand and arm must assume in order to pass the promontory of the sacrum. Coplin suggests the use of the photographer's thimble in tearing the tissues within the abdominal cavity. Access to the interior of the trunk may readily be had from the dorsum by making a longitudinal incision to one side of the spinal column and sawing the ribs close to their vertebral attachments. When the examination is made through the vagina, an oval incision such as is described on page 132 may be made, or a vaginal hysterectomy may first be performed (Figs. 89 to 93 inclusive). The brain may be removed almost intact (in two or three pieces) by making a transverse four-inch incision across the fifth cervical ver- tebra, dissecting up the soft tissues, and cutting a V-shaped segment out of the occipital bone by introducing a saw through the foramen magnum and sawing towards the ears and then across transversely. (Fig. 130, E A F.) My rapid method of diagnosing hemorrhage also permits of the removal of the brain in small pieces. (See page 1 79-) An examination of the bones of the face is sometimes desirable, but the circumstances and conditions under which it may be required are so variable that the method must be left entirely to the judgment of the operator. Disfigurement is so readily noticed that nothing further than a superficial examination should be attempted without the per- mission of those interested. The simplest and most unobjectionable method of procedure is to introduce the knife through an incision pre- viously made from the ear to the neck and dissect subcutaneously the tissue investing the bony structures. If the bones of the face are to be removed, it may be necessary to make a transverse incision, the point of election being the furrow between the inferior maxilla and the neck. If the oral cavity must be examined through the orifice of the mouth after rigor mortis has set in, the rigidity may be overcome by placing towels soaked with hot water over the muscles of the jaw. Such appli- 202 POST-MORTEM EXAMINATIONS cations repeated for about five minutes usually suffice. Do not use a chisel to pry the jaws apart, as is sometimes recommended, because of the danger of breaking the teeth or knocking them out. As the rigidity rarely returns, it is advisable at the end of the examination to close the mouth with a few sutures through the mucous membrane of the upper and lower lips. The nasal cavity may be exposed and examined by detaching with a knife the upper lip from the maxilla from within and then removing with a saw such portions of the superior jaw-bone as will afford room for inspection of the parts under consideration (Figs. 145, 146). By the removal of the eye the pituitary body, Gasserian ganglion, etc., are rendered easily accessible. Indeed, it is surprising what extensive dis- sections may be made in the region of the face and neck in the ways just mentioned, thus affording an opportunity for thorough digital examination of areas not open to ocular inspection. 3 5 ~ 3 -- = $ - 2 E. «- — o *~ - • rr n 3 rt w 2* I- -• =* £ » ju ^ n> Z. w 2. =■ 5' Ml u 2 J 3:.- 2 w UJ fl) 2 2 H 5 _ o n 2. 3 g Fig. 145. — Method of examining nasal cavities, antrum of Highmore, etc. By means of a knife the uppermost mucous membrane between the lip and the superior maxilla is incised, the upper lip being elevated with the left hand during the incision. Vertical sawing is now done in the median line, and the tooth extracted at the point where the lateral sawing is to take place. The bone-forceps readily bring the desired portion of bone away, or it can be loosened by means of a chisel. Fig. 146. — Appearance of the part after removal of a portion of the superior maxilla for the purpose of examining the nasal cavities, antrum of Highmore, etc. Fig. 147. — Method of sewing up the body. Fig. 148.— Appearance of body after it has been sewed with base-ball stitch. The sewing has been done from above downward, and there is no puckering at the point of starting. Fig. 149. — Slee's method of fixing the skullcap. Fig. 150. — Author's method of holding skullcap in place. Four holes are drilled [in the hones on each'side, two to the right and left of the angle in the temporal bone and two in the skullcap just above the angle. Saw-cuts to hold the wire or string are made in the vertex, the string being thrust in and out of the openings and tied at any convenient spot. CHAPTER XXI RESTORATION AND PRESERVATION OF THE BODY When the examination has been completed, the cavities of the body should be thoroughly sponged out, all blood and other fluids removed, and bleeding vessels tied to prevent leakage. The organs should then, as nearly as possible, be returned to their respective positions, and the cavities filled with dry bran, absorbent cotton, sawdust, sea-weed, or shavings, in sufficient quantity to restore the original contour of the body, covering the abdominal contents with old cloth or papers to pro- tect the under surface of the seam. The brain is generally put into the abdominal or thoracic cavity, owing to the great difficulty in returning it to the skull. If several postmortems be made at the same time and place, care should be taken to return the organs to the proper body, nor should a cadaver be used as a convenient receptacle for the disposal of specimens which are no longer of any use. The late Dr. Formad told me of a case where three livers were found in a body previously posted in one of our Philadelphia hospitals and disinterred for suspected poi- soning. In the case of a child a small bag may be packed with sand or sawdust so as to assume the shape of the brain and placed inside the calvarium ; the brain itself, after dissection, is placed in the abdominal or thoracic cavity. In all private cases it is important to secure the skullcap in position, tc prevent the unsightly disfigurement produced when it slips after the scalp has been sutured. A number of efficient methods have been devised, but the one selected usually depends upon circumstances or upon ingenuity. The fossae of the skull as well as the calvarium may be filled with plaster of Paris, and while the plaster is still soft a short, stout stick of wood is pushed through into the foramen magnum, the upper end extending to the skullcap, which is then adjusted. When the plaster hardens, the calvarium is well fastened in good position. If in removing the calvaria the precaution is taken to crack at least a part of the inner table with the chisel and hammer, projecting pieces of bone are usually left, which interlock and hold the calvaria snugly in position when it is replaced. 1 If the edges of the temporalis have not been too badly lacerated, sutures may be passed through the muscle and fascia 1 Mallory and Wright, Pathological Technique. 203 204 POST-MORTEM EXAMINATIONS with very satisfactory results. Small holes may be drilled in the skull and sutures passed through them, or a wide staple (or double-pointed carpet- tack) may be used for the same purpose. Another method is to drive a small wire pin, or a wire nail with its head cut off, about half an inch long, half-way into the diploe of the skull and insert the other end in a hole, made to correspond, in the calvarium. Two of these pins should be enough. Still another method is that described by Slee. 1 The posterior line of sawing, instead of stopping at the angle, is continued an inch or more into the temporal bone; a piece of ordinary roller bandage is then stretched across the skull and inserted in the saw-cut ; the calvarium is replaced, the ends of the bandage are brought together over the vault and securely sewed, pinned, or tied (Fig. 149) . A ready and efficient method of my own for fixing the skullcap is to make in two or three places on the thickest portions of the skull vertical pencil-marks across the line of sawing and extending an inch above and below it, saw these for three-quarters of an inch or so, and into each pair of saw- cuts insert the ends of a thin double-wedge-shaped piece of iron or steel so made that it will be tightly pushed into place when the skullcap is affixed. Any portion projecting beyond the bone is hammered down. For another method see Fig. 1 50, If the vault of the cranium is to be retained by the physician and a substitute cannot be found, take a square piece of pasteboard about three millimetres thick (thinner for children) and soak it in warm water for a quarter of an hour, or until it is soft enough to be easily moulded over the skullcap. Having done this, cut the paste- board parallel to the edges of the saw-cuts and overriding them from ten to fifteen millimetres. Then fill the skull cavity with wadding or plaster of Paris. Remove the pasteboard from the skullcap just as soon as it becomes so dry that when it is applied to the base of the skull the edges will adapt themselves to the border thereof. With a knife the edges of the pasteboard are cut obliquely, any folds which are formed therein are incised along their crests, one edge is tucked in under the other, and the surface smoothed by the use of the knife. Strong twine is bound twice around and the pasteboard thus securely fastened to the base of the skull. The temporal muscle is drawn up- ward and the skin stitched over the whole as in the usual way. ( Nau- werck. ) 1 Medical News, December 31, 1892, p. 737. RESTORATION AND PRESERVATION OF THE BODY 205 The skullcap being secured, the scalp is replaced and sutured with glover's or base-ball stitches, — i.e., those made by repeatedly passing the needle from within outward. By careful use of black or dark thread the incision may be so neatly closed as to escape even fairly close inspection. It sometimes happens that by stretching the skin becomes baggy. A small portion of the hairy scalp may then be re- moved previous to the sewing. After the organs are returned, the sternum should be supported by paper, or, still better, by old linen. Bran and fine sawdust are very useful to fill in with, as they absorb the moisture. Oakum makes the sewing difficult. Formad used to tell of a disastrous though amusing- result which occurred from the use of a large quantity of self-raising buckwheat flour for this purpose. If the organs have been removed through the vagina or rectum, these outlets should be doubly sewed, some absorbent material having first been introduced to prevent leakage. A round stick or a piece of gas-pipe may be placed in the spinal canal after the removal of the cord, with the upper end pushed through the foramen magnum, especially if any of the vertebrae have been taken away, and plaster of Paris may be poured in until the cavity- is well filled. An old cloth or some paper is then placed on top and the whole sewed together. The line of the incision may be covered with a strip of adhesive plaster. The abdominal incision is closed by sewing from the pubes to the sternum, passing the stitches from within outward, about three- eighths of an inch from the cut edges and about half an inch apart, alternating on the two sides so that each needle-hole on one side will be midway between two on the opposite side. The twine should be about half a millimetre thick. Both ends of the suture should be securely tied. For the closing stitch it is well to cut the thread near the needle, withdraw one end, and tie in a surgeon's knot. Roughly estimated, the thread required is twice the length of the incision to be closed. Carefully crowd in any extruding fascia and avoid pucker- ing of the part. (Figs. 147, 148.) If the mouth has been opened, or any of the tongue removed with the structures of the neck, the lips may be held together by a few sutures passed through the oral mucous membrane. If any portions of bone have been excised, their place may be sup- 206 POST-MORTEM EXAMINATIONS plied by using a properly shaped piece of wood, which is held in position with sutures, wire, or strong cord, or by plaster of Paris. Lastly the body should be very carefully cleaned and returned to the place and position in which it was found. The characteristic " post-mortem odor" is very persistent and de- fies allkinds of soap. It usually results from handling the intestines, and can best be removed by washing the hands with aromatic spirit of ammonia or, in the absence of that, by rubbing them with dry mustard and then washing with soap and water, or, still better, with some of the newer liquid antiseptic soaps. Ammonia or the aromatic spirit thereof will remove iodin stains, while carbol-fuchsin and other anilin stains yield to a weak solution of sodium hypobromite. EMBALMED AND FROZEN BODIES. It has become an almost universal custom to preserve bodies by embalming or freezing very soon after death, a process which often interferes with the work of the pathologist as well as with that of the toxicologist. The appearance of the body in such cases will, of course, depend very largely upon the fluid used. Fortunately, the old zinc, mercurial, and arsenical combinations have been very largely superseded by formalin, a much more desirable preparation, although it may irritate the eyes, deaden the sensibility of the finger tips, and even produce an eczema of the hands. If it is impossible to make the autopsy at once, preservatives may be injected into the body to keep it until such time as convenient. For this purpose, about three hundred cubic centimetres of a five per cent, solution of formalin are sufficient. The fluid may be introduced through the arteries (arterial embalming), or a coarse trocar and cannula may be driven deeply into the tissues and the cavities and organs injected (cavity embalming). The former method is usually practised by opening one of the large superficial arteries, as the femoral, and forcing the fluid through the vessels. Nauwerck uses the following instruments : an injection- syringe with a capacity of five hundred cubic centimetres; long can- nulas of different calibers, with pear-shaped ends and with stopcocks or, preferably, with double stopcocks; strong twine; scalpels, scis- sors, forceps, grooved director, hsemostats, an aneurism-needle, and ordinary needles; basins and buckets; several packages of absorbent EMBALMED AND FROZEN BODIES 207 cotton ; cloths and sponges ; and ten litres of a one per cent, watery solution of corrosive sublimate, which may be kept in one-litre bot- tles. His method of embalming is begun by exposing the lower part of the abdominal aorta and the two iliac arteries. Two ligatures are placed beneath the aorta, about two finger-breadths apart, and the aorta is obliquely incised to allow the entrance of the cannula, which is secured by tying the distal ligature over it. The injection into the upper part of the body is then begun carefully and slowly, pausing occasionally when the counter-pressure becomes too great. About three litres are injected, more or less, depending upon the appearance of swelling of the face, seen first about the eyes and chin. The can- nula is removed, both proximal and distal ligatures are tied, and the aorta is cut through. In like manner a litre of the solution is injected into each leg through the common iliac artery. A cannula with a double stopcock can be used to inject both the upper and lower parts of the body at the same time. The mesentery is ligated, and the intes- tines, from the beginning of the jejunum to the end of the sigmoid flexure, are removed, opened, washed out, and put in a one per cent, solution of bichloride of mercury, and later replaced in the abdominal cavity, wrapped in sublimated cotton, or, where practicable, disposed of by cremation. The stomach, duodenum, and rectum are cleaned out with sublimate solution and packed with sublimated cotton. The bladder, vagina, external ear, and nose are similarly treated. The abdominal cavity is carefully wiped with a cloth wrung out of the bichloride solution and dried, and the abdominal incision is sewed. The surface of the body, with the exception of the hair, is also wiped with the solution and dried. If this method fails, Nauwerck injects into the carotid and axillary arteries. Hewson x recommends the following preservative injection for the embalming of human bodies : & Sodium arsenate 2 kilogrammes. Boiling water 7850 cubic centimetres. Boil until complete solution, then add Glycerin 2000 cubic centimetres. Formalin 100 to 150 cubic centimetres. About two and one-half gallons of this fluid are introduced into an artery — say the common carotid — by gravity, openings having pre- 1 Philadelphia Medical Journal, October 27, 1900. 208 POST-MORTEM EXAMINATIONS viously been made in the toes or in several of the veins if they be distended with blood. After injection the body is thoroughly greased, covered with paper, bandaged, and placed in cold storage until wanted for dissection. Frozen bodies should not be thawed hastily by the addition of warm objects, but should be allowed to remain in a warm room for some twelve hours previous to the post-mortem examination. Figs. 151 and 152 show the refrigeration room of the Medical Department of the University of Pennsylvania, planned by Dr. Holmes, in which when teaching in that institution I kept the cadavers used in illustrating my lectures. The bodies were removed during the afternoon pre- ceding the performance of the autopsy the next morning. In cavity embalming the instrument is thrust preferably through the umbilicus, so that the wound of entrance will not be conspicuous, and efforts are made to puncture the intestines in as many places as possible and to penetrate the heart, lungs, and liver; blood is then withdrawn, the gas escapes, and the fluid is injected. The disad- vantages of this method are : first, in cases of abortion with peri- tonitis there may be considerable difficulty in determining whether the markings were made before or after death; secondly, such punc- tures may also complicate matters by opening up abscess-cavities, cysts, aneurisms, etc. ; and thirdly, in cases of poisoning, besides allowing the stomach contents to escape, the fluid may contain the same substance as that which caused death. Even when formalin has been employed, as in the recent Haines case in New Jersey, the syringe may have been previously used for injecting an arsenical preparation. Fig. 151. — Refrigerating room. A, recording thermometer and middle tier of shelving; B and D, tiers of shelving ; C, brine tank ; E, pipes of refrigeration apparatus. ig. 152.— Preparation of bodies after removal from refrigerating room. A< bath ; B, air-condenser and injecting apparatus; C, pulley suspension apparatus ; I), exterior of refrigerator box ; E, odorless excavator barrels. Fig. 153.— Post-mortem examination of guinea-pig, made in Ravenel pan. Near the four corners (not seen in the illustration) are hooks upon which the chains are fastened in order to hold the animal in position. CHAPTER XXII DISEASES DUE TO MICRO-ORGANISMS, PARASITES, AND H^MATOZOA The number of diseases known to be due to vegetable and animal parasites is constantly on the increase, the study of tropical diseases especially having in recent years received marked attention and added much to our knowledge on this subject. The lesions which are pro- duced by these agencies and found post mortem are varied, though rarely characteristic, and require special bacteriological and histological training for their study and elucidation. Actinomycosis. — A chronic, infectious disease, which occurs most frequently in cattle (as "lumpy jaw" or "wooden tongue"), but is found also in man; it is characterized by the formation of small nodules, which break down and infiltrate the surrounding tissue. The exciting cause, the Streptothrix actinomyces (ray- fungus), is found in the form of yellowish opaque granules, — called sulphur balls, — which measure from one-half to two millimetres in diameter. When these masses are crushed and placed under the microscope, they give the appearance so beautifully depicted (in 1856) by Lebert in his Atlas. The organism is introduced into the body with food, often through the medium of carious teeth. In one case reported the patient had been accustomed to pick his teeth with a straw. The most common loca- tions of the lesions are: I. Alimentary canal. II. Lungs (lesions are usually unilateral), (a) Chronic bronchitis, (b) Miliary nodules formed by masses of fungi surrounded by granulation tissue, (c) These nodules may fuse, forming abscesses and finally cavities, (d) Bronchopneumonia. III. Heart, emboli and localized parenchymatous myocarditis. IV. Thorax, (a) Erosion of vertebras, (b) Necrosis of ribs and sternum. V. Skin, (a) Subcutaneous abscesses, (b) Chronic ulceration, which may last for years. VI. Primary infections of the brain, liver, and vermiform appendix have been described. The characteristic primary lesion is a small nodule resembling that seen in an anatomical wart. Later there occurs, especially in the lower jaw, proliferation of cells into surrounding tissues similar to those seen in osteosarcoma; this is followed by suppuration. The abscesses are at first multiple, spherical, and discrete; later they coalesce and give a 14 209 2io POST-MORTEM EXAMINATIONS reticulated and honeycombed appearance to the part affected. Metas- tases may occur. Anthrax. — An acute, infectious, contagious disease, more com- mon in the lower animals than it is in man, caused by the Bacillus anthracis, and having for its characterstic lesion a pustule. Certain animals are predisposed, especially sheep and goats, though the An- gora sheep is apparently immune. In man the disease is contracted in certain occupations, as wool-sorting, tanning, etc., and by the inges- tion of the flesh or milk of an infected animal. The Bacillus anthracis is a rod-shaped micro-organism, from two to twenty-five microns in length, non-motile (thus distinguished from the similarly shaped but motile Bacillus subtilis) , often united, and grows with great rapidity. Characteristic cultures may be made on gelatin plates at ordinary tem- peratures. The bacillus is easily killed, but the spores are very resist- ant. For seven successive years Ziegler was able to produce anthrax in mice by inoculations from similarly prepared pieces of dry catgut which contained the spores. Two sets of lesions are found, depending upon the method of invasion, — by skin or mucous membranes. I. External Anthrax. — (i) Malignant pustule. At the site of inoculation appears a papule which rapidly becomes a vesicle; later a brown eschar is formed, surrounded by small vesicles and an extensive area of brawny induration. The neighboring lymphatics are swollen, tender, and hard. (2) Malignant anthrax oedema. This is an extensive oedema affecting the eyelids, the head, arm, and often the entire upper extremity. It may terminate in gangrene, enteritis, peritonitis, or endocarditis. II. Internal Anthrax. — (1) Thorax. Very soon after death the upper extremities, both anteriorly and posteriorly, become dark purple, the nails are blackish blue, and dark chocolate-colored fluids issue from the mouth and nose. The cellular tissues of the upper part of the chest are emphysematous and crackle on pressure. On opening the thorax these tissues are often found infiltrated with blood and a gelatinous effusion. The pleurae contain much serum (two or three pints), the right more than the left. The pericardial fluid is also increased (six or eight ounces). The lungs are engorged with dark-colored blood. Some portions are cedematous, others harder than normal and of a darker-red color. The bronchial glands are swollen, hemorrhagic, and friable. The heart-muscle is dark colored, soft and flabby; the heart may be empty or contain dark, semifluid blood in all its cavities. The lining membranes of the heart and larger blood-vessels are stained a MICRO-ORGANISMAL DISEASES 211 color varying from cherry-red to dark chocolate, according to the time which has elapsed since death. The serous membranes throughout show extravasations of blood. (2) Abdomen. The intestines show lesions consisting of dark infiltrated spots (phlegmonous inflamma- tion), about the size of a dime, with a greenish or grayish slough in the centre, which are composed mainly of anthrax bacilli situated chiefly in the lumen of the blood-vessels (Strumpell). The cavity contains considerable serum or there may be gelatinous cedema; hemorrhages appear in the serous membrane. The liver shows less change than any other organ ; it may be normal. The spleen may be larger than natural or normal in size and appearance. (3) Kidneys. The parenchyma is gorged with dark blood, and hemorrhages appear in the capsule. (4) Brain and spinal cord. Extravasations of blood are discovered between the membranes and sometimes small infarcts are found. In a recent case which I had the opportunity of studying with Dr. Morton, the pustule was on the palm of the hand. The disease was probably contracted from a bone fertilizer while working with a trowel in the garden. Early excision of the pustule, with the application of carbolic acid to the wound, was followed by recovery. (5) Retropharyngeal abscess may be of this origin. Beriberi. — An infectious disease of tropical and subtropical coun- tries, characterized by muscular pains and weakness, disseminated neuritis, cardiac failure, and general anasarca. Little regarding its origin is definitely known. Various micro-organisms have been sug- gested. Overcrowding and a fish diet may predispose. Two types, the cedematous and the paralytic, are recognized. The special lesion appears to be in the peripheral nerves. They are swollen and hemor- rhagic, but at times appear normal. The lesion is a parenchymatous neuritis. Atrophy of striated muscles may appear, in which case they are dry and shining, or the affected muscles, including the heart, are pale, flabby, and fatty. Evidences of general anasarca, affecting the upper extremities most, are present. Cholera Asiatica. — An acute infectious disease originating in Eastern countries, characterized by the presence of spirochseta and by a profound inflammation of the bowel. The comma bacillus of Koch is a motile, screw-shaped micro-organism about half the length of a tubercle bacillus, but thicker. The bacilli are found in large numbers in the rice-water stools, but rarely in the vomit. The position of the body is characteristic, the extremities being flexed, the fists 212 POST-MORTEM EXAMINATIONS closed, and the abdomen scaphoid. There is cyanosis of the skin. ( i ) In very acute cases the intestinal lesions are not characteristic, but the bowel contains large quantities of " rice-water." In more protracted cases the bowel presents a mapped appearance, — some areas hypersemic and some anaemic, some hypertrophic and others ulcerated. The inflammation is well marked in the Peyer's patches. The serous membrane is sticky and of a rosy color. The blood-vessels are prominent and the body looks thin and shrunken. The mesenteric glands are swollen, soft, and of a reddish color. (2) The stools 'are largely serous and contain masses of columnar epithelial cells and almost pure cultures of the micro-organism. (3) The kidney is swol- len, of a violet hue, and shows the changes of acute diffuse nephritis. (4) The liver shows little alteration except cloudy swelling, with minute areas of focal necrosis. (5) The heart is flabby. Its right side is usually distended with tarry blood. The left heart is usually empty. (6) The lungs are collapsed and show marked congestion at their bases. Pneumonia and pleurisy may develop, and abscesses are not uncommon. (7) There is a decided tendency to the formation of diphtheritic exudate on mucous membranes, particularly in the throat. (8) The cceliac ganglion is hyperaemic or even hemorrhagic (Roki- tansky). (9) All the abdominal organs are very 'dry. Dengue. — An acute infectious disease, prevalent in our Southern States, and generally known as " break-bone fever." It is bacterial in its origin; a therapeutic serum being now made like the antitoxin of diphtheria. The large and small joints become red and swollen. There is commonly a rash, but this has no distinctive character. General enlargement of the lymphatic glands is not uncommon. Being rarely fatal, no detailed observations have been made regarding the patholog- ical anatomy of this disease. Diphtheria. — An acute infectious, contagious disease, charac- terized by the presence of the Klebs-Lofner bacillus and of a false mem- brane. This bacillus is a non-motile micro-organism which, when grown on blood-serum, assumes a great variety of shapes. It is easily cultivated on albuminous media in from twelve to sixteen hours. The bacillus is fairly resistant, and will live for months under favorable conditions. Many other organisms produce a similar membrane, and the identity of this organism with the pseudobacillus of diphtheria, the bacillus of scleroderma, and the organism of ozsena is believed by many, but the subject is still sub judice. The presence of the organism M1CRO-ORGANISMAL DISEASES 213 in well persons is a fact of great interest. The forms of the disease are nasal, pharyngeal, laryngeal, and cutaneous. The characteristic lesion of diphtheria is a false membrane, beginning early as a slightly raised, opaque, whitish-yellow spot on the mucous membrane. As a rule, it grows rapidly, becoming thicker, of a grayish or greenish hue, and firmly adherent to the underlying tissues. In the early stages if an attempt be made to remove it, there is left behind a raw bleeding sur- face. In the later stages the membrane becomes less firmly adherent, soft, shreddy, and somewhat easily detached. The diphtheritic patches may become hemorrhagic, the color being then dirty brown or grayish green. The blood not only infiltrates the submucous layer but also the pseudomembrane. When the submucous layer and the surround- ing connective tissue become markedly infiltrated, the inflammation is said to be phlegmonous. There is great swelling and pus soon forms. A retropharyngeal abscess may be of diphtheritic origin. In nasal diph- theria the membrane may be slight in extent or may entirely block up the nasopharynx. It is apt to lead to extension of inflammation to the membranes of the brain. In the pharyngeal form the exudate is usually first seen on the tonsils. It is apt to be very extensive and extend into the mouth, the oesophagus, and even the stomach. In the laryngeal form the amount of exudate is often very great : it may entirely occlude the air-passages and extend to the lungs and the bronchial tubes, even to those of the third and fourth dimensions, but as it extends it gets softer and thinner. In this form the pharynx may be entirely free from membrane. The cutaneous form is somewhat less common; it is apt to occur about wounds, the false membrane being seldom extensive. In nearly all cases of diphtheria there is marked inflammation of the neighboring lymphatic glands and often of the salivary glands. There is apt to be a bronchopneumonia. There are small atelectatic patches surrounded by areas of inflammation. Should the diphtheritic membrane become gangrenous, the process is liable to extend to the lung. Klebs-Loffler bacilli are usually not found, but cocci of various kinds are numerous. Endocarditis is extremely rare, but changes in the fibres of the heart-muscle are comparatively common. The serous -membrane often shows ecchymoses. The kid- neys always show more or less diffuse inflammation, which may be hemorrhagic, and albuminuria is a constant symptom of the disease. The other organs show the ordinary febrile changes. In malignant cases the micro-organisms may be found in the bladder and the internal 214 POST-MORTEM EXAMINATIONS organs. As a rule they do not penetrate below the submucosa at the site of the lesion. Orth describes an enteritis nodularis in which the follicles and Peyer's patches are markedly swollen and hypersemic. Growths may occur in various mucous membranes, as in the eye, the oesophagus, the vagina, in exstrophy of the bladder, etc. Erysipelas. — An acute contagious disease, characterized by a rash, and due to the Streptococcus or Diplococcus erysipelatis. The micro-organisms gain entrance through a wound or abrasion of the skin or mucous membrane. Three types of erysipelas are noted, — sim- plex, ambulans, and phlegmonosum. In uncomplicated forms little more than an inflamed oedema is seen. The micro-organisms can be found post mortem in the lymph-spaces and in the zone of spreading inflammation. In severe forms the face is enormously swollen, the eyes are closed, the lips ©edematous, the ears thickened, and the scalp swollen. Blebs and vesicles often appear upon the eyelids, ears, and forehead. Small cutaneous abscesses about the cheeks, forehead, and neck are common, while beneath the scalp large quantities of pus may accumulate. There is enlargement of the cervical glands, but this is masked by the oedema. Erysipelas of the phlegmonous type may ex- tend to the intermuscular fascia. It is then likely to be gangrenous, particularly when following hemorrhagic contusions. This form, be- sides being the cause of acute purulent oedema, may result in emphy- sematous inflammation when gas-producing germs are associated. Infarcts often occur in the lungs, spleen, and kidneys ; these are usually septic in character. Endocarditis ulcerosa is particularly common. Albuminuria is a constant complication, but true nephritis is only occa- sionally seen. Septicaemia, septic pericarditis, and pleuritis are of com- paratively frequent occurrence. Acute atrophy of the liver sometimes occurs. Fever, Glandular. — An infectious disease of childhood, charac- terized by marked enlargement of the cervical glands. It is bacterial in origin and occurs between the ages of one and ten years. The dis- ease is rarely fatal. The cervical glands are swollen and softened; they seldom suppurate, and the adjacent skin and mucous membrane show no marked changes. Foot-and-mouth Disease. — Stomatitis aphthosa epizootica is an acute contagious disease, occurring most frequently in cattle and sheep, but found also in persons who come in contact with the disease in ani- mals. It begins as a small vesicle (which is at first clear, later grayish) MICRO-ORGANISMAL DISEASES 21 5 on the lips, cheeks, or pharyngeal mucous membrane. When the vesicle reaches a diameter of from one and a half to three centimetres, it bursts, leaving a shallow ulcer, with oval, circular, or irregular edges. The affected mucous membranes are inflamed, swollen, and cedematous, and there is considerable exudate. The lesions are also found on the udder and feet, usually appearing after the eruption in the mouth. The post- mortem appearances are most varied, consisting in cedema, hemor- rhagic infiltrations, fatty changes in the parenchymatous organs, etc. Loftier and Frosch consider the disease to be due to an organism so minute that it passes through the finest filters and is even not visible with the best of our present microscopes. A colored illustration of the lesion is seen in Kitt's Atlas der Thierkrankheiten, 1896. Frambcesia. — Yaws is a contagious disease of the skin, character- ized by an indefinite period of incubation and the presence of dirty or bright red-raspberry-like tubercles. It is presumably of microbic origin. The eruption begins as a papule, usually at the site of an old wound. In a few days the papules are scattered over the body; they rapidly enlarge and become tubercles, which are generally circular in shape, and vary in size from that of a pin's head to a small apple. The epidermis splits or cracks, exposing a raw granulating surface, which rarely ulcerates. The disease is by some supposed to be a modified form of syphilis. In his excellent work on Tropical Diseases, Man- son states that the question of their identity is certain to be debated until the respective germs of yaws and syphilis have been separated, cultivated, and inoculated, though he considers them to be specifically distinct diseases. Glanders. — A contagious disease occurring most frequently in horses and asses, the exciting cause being the Bacillus mallei. Two forms are recognized : (a) Glanders proper, (b) Farcy. (1) Glan- ders proper is an acute disease, essentially a necrotic alteration (Unna), occurring most frequently on the mucous membrane of the nose and upper respiratory tract. Its characteristic lesion is a node or tubercle, which is at first spherical, later becomes flattened, then breaks down and presents more or less extensive ulcerations which tend to run together. The mucous membrane is swollen, is of a purplish or dark- red color, and there rs considerable exudate from the ulcerating sur- faces. The process may extend to the lungs, the most prominent lesion being a catarrhal pneumonia, in which the diseased areas show a marked tendency to break down, with the formation of abscesses. An 2i6 POST-MORTEM EXAMINATIONS eruption of papules, which soon become pustular, frequently appears upon the face and about the joints. The cervical glands are usually much enlarged. A dirty-yellow pasty mass of pus in the gastrocnemii is probably due to glanders. Chronic glanders usually occurs in the nose and is often mistaken for a chronic coryza. There are frequently ulcers about the turbinated bones. ( 2 ) Farcy may be acute or chronic. The acute form is of the nature of a phlegmonous inflammation at the point of inoculation. The process may be very extensive and lead to rapid suppuration of the surrounding parts. Metastasis to the sur- rounding tissues is common, accompanied by the formation of ab- scesses in the muscles. In chronic farcy localized tumors are found, usually in the skin, the subcutaneous tissue, and the muscles. These tumors result in abscesses and may form deep ulcers. The disease in man has been described as a chronic specific pyaemia, characterized by eruptions on the skin and nasal mucous membranes, with frequent intramuscular abscesses. Gonorrhoeae Infection. — Lesions due to the presence of the gonococcus. That organism has been found in the blood, which after death may be fluid or semiliquid and tarry-black in color. Manifesta- tions of the infection include: (1) Arthritis. — The inflammation is acute, periarticular, and extends along the sheaths of the tendons. It is a synovitis which rarely becomes purulent. (2) Conjunctivitis. — This occurs most frequently in the new-born. It leads to thickening and ulceration of the conjunctivae; erosions or entire destruction of the cornea may result. The skin of the lids may be destroyed. ( 3 ) Endo- carditis. — An acute form of simple or ulcerative endocarditis, from which pure cultures of the gonococcus have been made. (4) The results of gonorrhoeal infection are periurethral abscess, prostatitis, vaginitis, salpingitis, iritis, pericarditis, pleurisy, etc. All these lesions show a marked tendency to suppurative change. Hydrophobia. — Rabies is a convulsive disease due to the action of the toxins of the bacillus of hydrophobia on the higher nervous centres. The cerebrospinal system shows congestion of the blood-vessels. There are minute hemorrhages, most numerous in the medulla. The mucous membrane of the pharynx is congested and not infrequently covered with blood-stained mucus. This is true of the larynx, trachea, and larger bronchi, also of the lungs, oesophagus, and stomach. Experi- ments have shown abundant virus in the spinal cord, brain, and periph- eral nerves, but it has not been found in the liver, spleen, or kidneys. M1CRO-ORGANISMAL DISEASES 217 When a dog that is supposed to be mad has bitten a human being, the animal should not be at once killed, but permitted to live and kept under close observation until it shows unmistakable signs of rabies. It should then be killed and its body sent to a competent bacteriologist for microscopic study and inoculation experiments on rabbits. While the recent so-called rapid method of diagnosing rabies is not abso- lutely characteristic of the disease, it affords a most valuable and early means of tentative diagnosis, to be confirmed or disproved by subse- quent animal inoculation. The method employed is that of Babes, van Gehuchten, and Nelis, and is as follows : 1 Several intervertebral ganglia or a portion of the bulb are put at once into absolute alcohol, in which they are left for twenty-four hours. They are then transferred for one hour to a mixture of absolute alcohol and chloroform, next put for one hour into pure chloroform, then for one hour into a mixture of chloroform and paraffin, and lastly for an hour into pure paraffin. The sections are put in the oven for a few minutes, then passed through xylol, absolute alcohol, and ninety per cent, alcohol, after which they are stained for five minutes in methylene-blue, according to Nissl's for- mula, differentiated in ninety per cent, alcohol, dehydrated in absolute alcohol, and cleared in essence of cajuput and xylol. Other methods of preparing the tissues may be used, as the rapid fixation with ten per cent, formalin, subsequent freezing, and staining with hematoxylin and eosin. The microscopical changes are chromatolytic and capsular. The " rabic tubercle" of Babes consists in the pericellular accumulations of the embryonal cells described by Kolesnikoff. The prolongations of the cells of the bulbar nuclei are shortened, the nuclei are altered or even obliterated, and the nerve-cells are invaded by the embryonal cells and small corpuscular elements. Atrophy, invasion, and destruction of the nerve-cells of the intervertebral and plexiform ganglia of the pneumogastric take place by cells newly formed from the capsule, which appear between the cell body and its endothelial capsule, in advanced cases the field even resembling an alveolar sarcoma. Influenza. — The grippe is an acute, epidemic, contagious disease, due to Pfeiffer's bacillus, and characterized by abrupt onset, great depression, and many sequelae. The bacillus is found in the nasal and bronchial secretions. It is one of the smallest organisms known, non- 1 Ravenel and McCarthy, Proceedings of the Pathological Society of Phila- delphia, 1 901, p. 93. 2i8 POST-MORTEM EXAMINATIONS motile, and stains well with Loffler's methylene-blue. On culture media it grows best in the presence of haemoglobin, (i) Lesions of the respiratory form are those of an acute inflammation of the mucous membrane of the upper respiratory tract and bronchial tubes. Lobular pneumonia is common, and is probably due to a mixed infection. Pleurisy is more rare, but may lead to empyema. Tuberculosis is apt to be exaggerated by an attack of influenza. (2) In the gastro-intestinal form the inflammation extends to the mucous membrane of the stom- ach and the intestines. It is seldom of a severe type. The spleen is usually enlarged in this form. The recent large number of cases of appendicitis is attributed by some to the wide-spread prevalence of this disorder. (3) In the nervous form mild degrees of meningitis and encephalitis are not uncommon. Abscesses of the brain have occurred in severe acute cases. In some epidemics accumulations of pus in the nasopharynx are exceedingly common. Complications. — Acute diffuse nephritis is quite frequent. Endocarditis, pericarditis, and thrombosis have been reported. Occasionally purpura is seen and also catarrhal conjunctivitis and iritis. In an autopsy on a child dying from meningitis following the grippe Dr. Kneass isolated for me the influenza bacillus. Leprosy. — Leprosy is an infectious disease characterized by the formation of a node or nodule, and due to the leprosy bacillus. The Bacillus leprce has many points of resemblance to the bacillus of tuber- culosis. It, however, stains more readily, is more easily decolorized, and is present in far greater numbers in the lesions which it causes. ( 1 ) The tubercular form starts as a small red spot in the corium, which either disappears or gives rise to the formation of inflammatory nodules of a brownish-red color, somewhat soft in consistency, and resembling a strawberry. The primary lesion is found most frequently in the skin of the face and on the surfaces of the knees, the elbows, the hands, and the feet. It may also involve the conjunctiva and the mucous membrane (particularly the nasal), the cornea, and the larynx. This form of the disease is apt to be exceedingly chronic, the surrounding tissues showing marked fibroid changes. The tubercles at times undergo fatty disintegration and in this way become swollen. (2) In the anaesthetic form the leprous process gradually involves the periph- eral nerves, first causing a perineuritis, then obliterating them and producing marked trophic changes, consisting in necrosis and ulcera- tion with extensive loss of substance, as of fingers, toes, and even MICRO-ORGANISMAL DISEASES 219 limbs. There is great loss of hair and the face often shows marked ravages of the disease. Death results not infrequently from laryngeal complication or aspiration pneumonia. That leprosy may be cured in the sense of the lesions not advancing is now an established fact. Van Houtum 1 claims to have cultivated successfully the Bacillus lepra, while several investigators have recently given promising reports of the discovery of a curative serum. Malta Fever. — Mediterranean fever is a chronic disease, resem- bling in its clinical course typhoid fever and malaria, occurring most frequently in the Mediterranean region, and due to the Micrococcus melitensis. It is often followed by swellings of the joints, profuse diaphoresis, anaemia, orchitis, and neuralgia. Young and previously healthy adults who are unacclimated are most frequently attacked, and it is a serious disease in the British garrisons. The micrococcus is found in large numbers in the spleen. The visceral changes are those common to all infectious diseases with high temperature. The small intestine is usually anaemic except in the upper part, where it may be intensely congested. The mesenteric glands show little change. The spleen is much enlarged and dark in color ; its pulp is soft and friable, and sections show an increase in the lymphoid elements. The average weight is eighteen ounces. The liver is congested and its surface on section is pigmented. The kidneys are usually congested and may be slightly hemorrhagic. The agglutinative reaction can be obtained with the micrococcus and the blood of a patient affected with Malta fever. It should be remembered that this disease occurs in our new possessions, and that soldiers on their return home may bring the affection with them. Measles. — Morbilli or rubeola is a markedly contagious disease, attended with a skin eruption and catarrh of the mucous membranes, and due to a micro-organism the identity of which is not yet definitely settled. This affection, as well as scarlet fever and German measles, must be distinguished from Duke's fourth disease, a malady having characteristics in common with all three disorders. Lesage, Canon and Pielicke, Czajkowski, and others have described organisms as causes of the disease. The post-mortem appearances in measles are chiefly those of its complications and sequelae. The skin, especially about the face, may be swollen and slightly ©edematous, and may show 1 Journal of Pathology and Bacteriology, September, 1902. 220 POST-MORTEM EXAMINATIONS the remains of the characteristic rash, especially in the hemorrhagic type. Desquamation, when present, is in the form of fine branny scales The gastro-intestinal mucosa is usually hyperaemic; Peyers patches are frequently swollen, sometimes markedly so. The lungs invariably show evidence of bronchitis, and almost invariably lesions of broncho- pneumonia with areas of collapse; less frequently lobar pneumonia may be found. The bronchial glands are invariably swollen. Pleurisy is less common. In debilitated infants severe stomatitis, cancrum oris, or ulcerative vulvitis may develop. In the middle ear catarrhal inflam- mation, which may go on to abscess formation, is not uncommon. Of the sequelae tuberculosis is the most important; it is either miliary or a caseous pneumonia. Severe forms of conjunctivitis and ulcer of the cornea are not uncommon. Nephritis is exceedingly rare. There is cloudy swelling of the organs. Mumps. — An acute, infectious, contagious disease, characterized by a marked cellular infiltration of the parotid glands, which do not tend to suppurate or to become fibroid, and frequently complicated with metastases to the ovaries and mammary glands in females, and the testicles in males, (a) Probably due to a coccus infection, (b) Childhood and adolescence. Very young infants and adults are seldom attacked. Uncomplicated mumps is rarely fatal. Of the complications meningitis, acute mania, endocarditis, gangrene, and optic atrophy are the most important. Plague. — An acute, infectious, contagious, epidemic disease, due to the Bacillus pestis, occurring usually in the far East, but at present (1903) widely distributed over the earth's surface, and characterized by marked glandular enlargements which tend to suppuration and by a general septic condition. The bacillus was discovered by Kitasato and Yersin. It is a short rod with rounded ends, and is found in the blood, glands, and viscera. Hossack found no buboes in thirty per cent, of his cases in Calcutta in 1900. Varieties . — (a) Bubonic, (b) Pneumonic, (c) Septic, (d) Intestinal, (e) Meningeal. (/) Car- buncular. Lesions : ( 1 ) At the point of inoculation, which usually occurs on the lower extremities, there appears a small spot (plague- corpuscle) which soon becomes a vesicle and then a pustule. (2) Fol- lowing primary inoculation, the inguinal glands become swollen, suc- ceeded in order by the axillary, cervical, popliteal, and then any of the glands in the body may become affected. The diseased glands swell rapidly and are at first tense and firm to the touch, but soon undergo a MICRO-ORGANISMAL DISEASES 221 suppurative change, and in rare cases gangrene ensues. It may be stated that it is the periglandular tissue which becomes cedematous and undergoes septic inflammation. (3) Carbuncles may develop in the skin of the legs, hips, and back. Subcutaneous hemorrhages are very com- mon and may also occur in the mucous membranes. (4) The central nervous system, especially the brain, is deeply congested. The brain substance may become softened and the blood-vessels, especially the veins, are engorged. (5) The lungs are deeply congested, especially posteriorly., and are at times the primary seat of the disease. (6) The pericardium contains an excess of blood-stained fluid. The right heart is dilated with black, imperfectly coagulated blood, and the whole venous system is engorged. The heart-muscle is pale and somewhat softened. (7) The stomach and small intestine contain blood or blood- stained fluid. There may be ulceration, but Peyer's patches are not affected. The spleen is greatly enlarged in all cases. (8) The dorsum of the tongue is coated, but the edges, the tip, and often the median raphe remain pink and clean ; sometimes, however, becoming red and dry (Hossack). The disease must be distinguished from puerperal fever, septicaemia, pyaemia, smallpox, influenza, cerebrospinal menin- gitis, diphtheria, erysipelas, measles, gonorrhoea, syphilis, mumps, ma- laria, scrofulous glands, Hodgkin's disease, etc. In a recent case of a Chinaman suspected of having the plague, the writer found almost complete occlusion of the prepuce, with a discharge containing the gonococcus, and in the suppurating bubo a fat diplo-bacillus which did not stain by Gram's method. Relapsing Fever. — An acute, epidemic, contagious disease, not found at the present time in America unless imported, occurring in the same class of persons as typhus fever, giving rise to a fever which lasts from five to seven days, followed by relapses, and due to the Spiro- chete? of Obermeier, which are found in the blood only during the paroxysms of fever. Due to a specific, motile organism, which is rarely discovered post mortem. No characteristic or constant lesions are found after death. The following are sometimes present. ( 1 ) If death occurs during the paroxysm, the spleen is large and soft; the pulp is purple. The follicles are enlarged and often obliterated, though they may be gray or whitish yellow in color. Infarcts are not uncom- mon. (2) The heart is flabby, of a pale dirty-gray color, and very friable. (3) The liver is more enlarged in this than in any other infectious fever. Its color is uniform gray-red. Fatty degeneration 222 POST-MORTEM EXAMINATIONS may be marked. (4) The kidneys may retain their normal weight. The renal parenchyma is soft and flabby; the cortical substance is increased and shows cloudy swelling. Hemorrhagic spots or lines radiating to the pyramids are often observed. (5) The lungs may be the seat of pneumonic infiltration, bronchitis, or bronchiectasis. (6) Hyperplasia of the bone marrow has been found. Complications. — (a) Pneumonia is frequent, (b) Rupture of the spleen, (c) Nephri- tis and hematuria, (d) Ophthalmia in certain epidemics, (e) Abor- tion usually takes place. (Osier.) Rheumatic Fever. — (a) Follows exposure to cold and wet. (b) Usually regarded as a coccus infection, though a bacillus has also been described as the etiologic factor. (1) The affected joints are swollen, tense to the touch, and somewhat hyperemia The fluid in the joint is turbid, and contains albumin, leucocytes, and a few flakes of fibrin, but rarely pus. There may be slight erosion of the cartilages. (2) Endo- carditis occurs in about sixty per cent, of all cases. The verrucose variety is most common. The mitral valve is most frequently involved. (3) Pericarditis may occur, with or without endocarditis. It may be fibrinous, serofibrinous, or, in children, purulent. (4) Myocarditis occurs most frequently in association with endopericarditis. It leads to weakening and dilatation of the heart-muscle, and is the most com- mon cause of sudden death in rheumatic fever. (5) Pleurisy and pneumonia occur in about ten per cent, of all cases. (6) Rheumatic nodules, varying in size from a small shot to a large pea, are found on the fingers, hands, and wrists. They may also occur about the elbows, knees, spines of the vertebrae, and scapulae. (7) Meningitis is extremely rare. (8) Purpura may be present. Rheumatism, Chronic. — (1) The synovial membranes are in- jected. There is usually not much effusion. The capsules, ligaments, and sheaths of the tendons are thickened. There may be erosion of the cartilages. As a result of these changes, the joints are often deformed and ankylosis may occur. (2) Muscular atrophy, especially about the joints, frequently follows. (3) Valvular heart-lesions, due to sclerotic changes, are of common occurrence. Rubella (Rotheln, German Measles). — This disease is rarely fatal in uncomplicated cases. There is no distinctive lesion other than the rash, which may fade entirely after death. Scarlet Fever. — (a) The majority of cases occur before the tenth year, (b) Infants and adults are usually exempt, (c) Cocci are fre- MICRO-ORGANISMAL DISEASES 223 quently found in the throat-lesions and in the blood. Class, of Chi- cago, claims to have isolated a specific coccus, which has also been described by Baginsky. (1) Rigor mortis is usually well marked. Decomposition may set in early and develops with exceptional rapidity, cadaveric lividity usually appearing before death. (2) The blood is dark in color, thin, and coagulates imperfectly. The vessel-walls are usually stained. (3) Except in the hemorrhagic form the skin after death rarely shows a trace of the rash. (4) In the throat follicular tonsillitis, diphtheritic membrane, or suppuration may be present. Punctate hemorrhages, especially about the mouth, are always ob- served. (5) Catarrhal inflammation of the gastro-intestinal mucous membrane is not uncommon. The follicles of the small intestines are swollen, red, and may even be hemorrhagic. (6) In severe cases an intense lymphadenitis, with much inflammatory cedema, is found in the neck. This may lead to suppuration or even gangrene, and in rare cases to ulceration of the carotid artery and fatal hemorrhage. (7) The kidney lesions are most important. Acute diffuse nephritis is present in a majority of cases. It is frequently of the glomerular type and may be hemorrhagic. This lesion is not infrequently fol- lowed by the changes observed in chronic parenchymatous nephritis. (8) Endocarditis, which may be either simple or malignant, is not infrequent. Pericarditis and myocardial changes are less common. (9) The spleen is often enlarged, and shows the changes which char- acterize acute splenic tumor. (10) Hemorrhages into the subserous tissues beneath the pericardium, endocardium, and pleura are quite frequent. There is more or less cloudy swelling of all the organs. Complications. — (a) The most important is nephritis. The urine is small in quantity, of a high specific gravity, cloudy, and of a dark blood-color. It contains large amounts of albumin, free blood, and epithelial cells, with hyaline and epithelial tube-casts. (Edema may be slight or marked; in a few cases cedema of the glottis has caused sudden death. ( b ) Heart complications are next in importance. There may be endocarditis, pericarditis, or myocarditis, (c) Catarrhal pneu- monia, more rarely croupous pneumonia or pleurisy, may occur, (d) Involvement of the middle ear may lead to thrombosis of the lateral sinus, meningitis, abscess of the brain, or necrosis en masse of the middle ear. (e) Adenitis may result. The glands of the neck are those most frequently involved. There may be great destruction and loss of tissue, (f) Arthritis of a rheumatic type or more closely resembling 224 POST-MORTEM EXAMINATIONS the gonorrhceal variety may be found. In the latter affection only one joint is involved and suppuration may supervene. The toxin seems to act especially on the epithelial cells. In one of my cases death occurred in convulsions twenty- four hours after the onset of vomiting and with- out the appearance of any rash. The diagnosis was confirmed by a sister being attacked with the disease later on. Scleroderma (Hide-bound Skin). — (i) Circumscribed Form. — On the skin are found patches varying in size and of a waxy or dead- white appearance. They are brawny, hard, and inelastic. (2) Dif- fuse Form. — This form usually occurs in the extremities or on the face. Gradually a diffuse brawny induration develops. The skin becomes firm, hard, and so closely united to the subcutaneous tissue that it can- not be picked up or pinched. The color may be natural. The skin is commonly glossy, drier than normal, and unusually smooth. Smallpox. — (a) Overcrowding, (b) Improper food, (c) Sea- son, fall or winter, (d) Streptococci are found in the characteristic lesions. Councilman 1 has announced the discovery of a protozoon. ( 1 ) The characteristic lesion of smallpox is a rash. On the skin may be seen papules, umbilicated vesicles, pustules, and crusts. A shot-like feel of the papules upon the forehead and wrist is quite characteristic. (2) The rash may also be found upon the mucous membranes from the mouth to the rectum, but on account of the moisture the pocks are not quite so characteristic in these situations as upon the skin. In some cases there is deep ulceration, especially in the larynx, which may be followed by necrosis of the cartilages. ( 3.) Swelling of Peyer's patches is not uncommon. (4) In the hemorrhagic form of smallpox extrava- sations of blood are found on the serous and mucous surfaces, in the parenchyma of the organs, in the connective tissue, and about the nerve-sheaths. They have also been observed in the bone-marrow and in the muscles. (5) As a rule, the spleen is markedly enlarged, but it may be small, very dark, and firm. The liver shows evidences of parenchymatous inflammation. (6) The heart is flabby and pale. The myocardium shows cloudy swelling and fatty degeneration. It is often dark brown in color and may be firm to the touch. The cavities contain little or no clotted blood, and the arterial trunks are nearlv 1 See Ziegler's General Pathology, translation by Cattell, 1895, p. 39 : " It is not impossible that other infectious diseases — for instance, smallpox — are caused by parasites that belong among the protozoa." MICRO-ORGANISMAL DISEASES 225 empty. (7) Lesions of the kidney are not common. It may show cloudy swelling and areas of focal necrosis, or the pelvis may be blocked with dark clots which sometimes extend into the ureters. (8) Absence of the scar resulting from vaccination is very often noted. (9) The epidermis of the hands and feet may be shed entire. The skin is sometimes plum-colored. (10) The face may be swollen. In black smallpox there may be found hemorrhages in all the numerous membranes and in joints. The cornea may be sunken. Complications. — (a) Bronchopneumonia is almost invariably present in fatal cases; lobar pneumonia and pleurisy less commonly, (b) Albuminuria is frequent, but true nephritis rare, (c) Purulent changes in the arteries, bones, conjunctiva, and middle ear are common, (d) Ulcerative laryn- gitis with oedema sometimes causes death, (e) Myocarditis, endocar- ditis, and pericarditis are comparatively common. At the postmortem the odor is so characteristic that the disease may be recognized by this means alone. The physician should always vaccinate himself both be- fore and after making an autopsy on a smallpox case. Sprue (Psilosis). — A chronic remittent inflammation of the whole or part of the mucous membrane of the alimentary canal, occur- ring principally in persons residing, or who have resided, in tropical or subtropical climates. Apparently nothing is known of its origin. At postmortem the thoracic organs, the abdominal viscera, and the tissues generally are found to be much wasted, giving the body a mum- mified appearance. The bowel is exceedingly thin, and on opening it a thick layer of dirty viscid gray, tenacious mucus is seen. On re- moving this, areas of congestion, ulceration, pigmentation, or thicken- ing may be found. The mesenteric glands are generally enlarged. Syphilis. — Lustgarten and van Niessen have described specific or- ganisms, neither of which has been definitely accepted. Classification. — I. Acquired Form. — (a) Primary, (&) Secondary, (c) Intermediate period, (d) Tertiary. II. Hereditary Form. — (a) Primary, (b) Secondary. The following lesions should be looked for in making a postmortem: (1) The initial lesion or its scar. (2) Lymphatic en- largement, especially of the groin, neck, and elbow. (3) Various skin lesions and thinness of the hair. (4) Mucous patches. (5) Onychia and dactylitis. (6) Gumma in the viscera, skin, subcutaneous tissues, muscles, etc. (7) Parotitis. (8) The bones for periostitis or osteo- myelitis. (9) The eye for iritis or choroiditis. (10) The bowels for stricture, especially the rectum. (11) The nervous system for tabes, 15 22 6 POST-MORTEM EXAMINATIONS dementia paralytica, and other forms of sclerosis. I. The lesions found in the primary stage are : ( i ) The chancre. This begins as a small red papule, usually situated at the junction of the skin and mucous membrane. It gradually enlarges and breaks in the centre, leaving a small ulcer with indurated edges and base. (2) The neighboring lym- phatic glands are enlarged and hard. II. Secondary Stage. — ( 1 ) Cuta- neous eruptions of all forms. As a rule, the syphilide is polymorphous, varying in form from an erythema to a pustular eruption. It is sym- metrically distributed and of a reddish-brown or copper color. It appears most frequently on the chest, abdomen, and flexor surfaces of the arms. (2) The mucous patch is a softened and macerated epithe- lium, and appears on the mucous membrane or on the moist regions of the skin. It is most frequently found in the mouth, in the throat, and about the anus. The mucous patch is irregularly shaped, non- inflammatory, and does not discharge pus. (3) The hair of the scalp is decidedly thin. (4) Ulcers may be seen on the tonsils and larynx. (5) There may be warts about the vulva and anus. (6) Iritis is com- mon; retinitis rare. (7) The finger-nails may be diseased, forming dry or moist onychia. (8) Periostitis may be present. III. In the intermediate stage there are but few lesions: (1) Gumma of the tes- ticles and (2) choroiditis are the only ones found. IV. Tertiary Stage. — ( 1 ) The late syphilides show a tendency to ulcerate and destroy the deeper layers of the skin, leaving scars. Rupia may de- velop. (2) The gummata are the characteristic lesions, and may be hard or soft. The former develop in the internal organs and in the mucous membranes. They most frequently terminate in cicatrization, forming stellate scars which often cause marked deformities. Soft gummata are found in bones, skin, etc. They tend to break down and ulcerate, leaving chronic indolent, often serpiginous, sores. ( 3 ) When there has been prolonged suppuration, amyloid degeneration of the liver, spleen, and kidneys often occurs. This is especially true with regard to rectal syphilis in women. (4) Circulatory System. — The heart frequently shows sclerotic changes of the valves, especially about the aorta. ( 5 ) The blood-vessels present arteriosclerosis or atheroma- tous changes. (6) In the central nervous system scleroses of the brain and cord and gummata are common. V. Congenital Syphilis. — (1) At birth the infant is usually apparently healthy, but it may present well-marked lesions. (2) There is wasting, and pemphigus is noticed on the hands and feet. (3) The lips may be ulcerated and MICRO-ORGANISMAL DISEASES 227 the mouth and anus fissured. (4) There is inflammation of the nasal mucous membrane; hyperemia with papillary infiltration is present and necrosis of the bone may occur. (5) The spleen and liver are enlarged. (6) The lungs may present the lesions of white pneumonia or miliary gummata. (7) The long bones usually show characteristic changes, and the epiphysis may be separated. (8) Later the child looks prematurely old. The teeth are wedge-shaped and the cutting edges notched (Hutchinson's teeth). (9) Eye lesions may be seen as interstitial keratitis. (10) Dactylitis is not uncommon. Syphilis of the Brain and Cord. — (1) Gummata are usually mul- tiple, varying in size from a pea to a walnut. In the cerebrum they occur along the sulci. Heubner describes two forms. In the first variety they are grayish or grayish red in color, soft, and not sharply defined. On section they are moist and exude a small amount of juice. In the second form they are quite hard and dry. Their outline is dis- tinct. On section they may be cheesy and look not unlike tubercular growths. An enarteritis around them exists and causes softening. (2) Gummatous arteritis and sclerosis of both arteries and nerve tissue may exist. (3) There may be softening due to obstruction of the blood-vessels. Recently in Philadelphia a man was condemned to death for killing a person in cold blood. A commission of experts pro- nounced him sane. The man committed suicide by hanging, and I found at the postmortem numerous gummata of the brain, situated especially in the right temporal and frontal regions. Syphilis of the Circulatory System. — (1) Gummata are rare. (2) Fibrosis of the heart-muscle is common. (3) Sclerosis of the valve is frequent. (4) Arteriosclerosis, aneurism, and endarteritis obliterans are common. Syphilis of the G astro-Intestinal Tract. — (1) The oesophagus is rarely affected. Ulceration or stenosis may be present. (2) Ulcers, phlegmonous inflammations, or abscesses may be found in the pharynx. (3) Ulcers may occur in the small intestine and caecum. (4) The rec- tum is not infrequentlv the seat of cicatricial contraction. This lesion is most frequently seen in women. The lesions that syphilis produces in the gastro-intestinal tract are (a) chancre, (b) ulcers, (c) localized fibrous patches, (d) gummata, (e) miliary nodules, (f) condyloma- tous masses. Syphilis of the Kidneys. — (1) Gummata are not infrequent. (2) Acute syphilitic nephritis may occur. (3) Chronic interstitial nephri- 22 8 POST-MORTEM EXAMINATIONS tis is more common. This is a localized nephritis caused by the result- ant shrinking and marked irregularity of the surface of the kidney. It is sometimes hard to distinguish it from old infarcts, but the change in color, which in syphilis is gray, in infarcts is brown, is a pretty certain point of differentiation. Syphilis of the Larynx. — (a) Congenital, (b) Acquired, which may be secondary or tertiary. ( i ) In the secondary form there is erythema, with symmetrical, superficial, whitish ulcers on the cords or ventricular bands. (2) Mucous patches are occasionally seen. (3) In the tertiary form true gummata may appear towards the base of the epiglottis. These break down, producing deep flask-shaped ulcera- tions, which may heal by connective tissue that shrinks and produces stenosis. (4) Islands of connective tissue commonly appear between the cicatrices and form inflammatory excrescences. (5) The neigh- boring cartilages may show necrotic changes. (6) A fatal termination may result from perforation of an artery. Syphilis of the Liver. — (1) In diffuse syphilitic hepatitis there is marked fibrous change. The organ is hard, firm, and resistant. The disease usually begins with a perihepatitis, which frequently causes adhesions to the surrounding structures. With contraction of the fibrous tissue great deformities of the liver become manifest. Capillary bile ducts may be present in abundance in the cirrhosed portion. (2) The smaller gummata are pale-grayish nodules, the larger ones pale yellowish in color. Usually they are multiple (miliary). Although they may be present in any part of the organ, the most common situa- tion is at the junction of the right and left lobes. Great deformity results from healing and contraction. Syphilis of the Lung. — (1) In white pneumonia of the foetus the affected lung is heavy and airless. On section it presents a grayish- white appearance (white hepatization). (2) Hereditary gummata are small in size, grayish in color, firm in consistence, and more or less symmetrically distributed throughout the lung. (3) Acquired gum- mata vary in size from a pea to a goose's egg. They are grayish yellow in color and are embedded in connective tissue. The parts around them are hard and brawny and of a glossy lustre. These gummata may break down and form cavities. This condition is called syphilitic phthisis. (4) There may be a fibrous interstitial pneumonia in which the lesions are hard, large, and pale or dark grayish red in color. The middle of the right lung or either apex is the part most frequently MICRO-ORGANISMAL DISEASES 229 involved. (5) The pleura is thickened. (6) Endocarditis may extend to the hepatic artery and portal vein. Syphilis of the Testes. — (1) Gummatous growths usually involve the epididymis, which becomes a hard mass, from the size of a bean to that of a walnut. It affects the head more commonly than the body of the epididymis. (2) In interstitial orchitis the progress of the disease is slow. The organ is larger than normal and distinctly harder to the touch. The overlying skin is not adherent and there is no tendency to suppuration. Tetanus. — The bacillus of tetanus is a slender rod usually grow- ing in long threads. It is motile, grows on ordinary media at ordinary temperatures, and is anaerobic. It stains readily, but does not retain the stain very well. (1) The bacilli . develop at the site of the wound, which is usually of a penetrating character, and do not invade the blood or organs, except very rarely late in the course of the disease. (2) No characteristic lesions have been found. (3) The condition of the wound depends upon the kind and extent of the injury. (4) The central nervous system shows congestion, with perivascular exudations and granular change in the nerve-cells. Some investigators have found swelling and areas of disintegration in the gray matter of the cord ; with exudation of a finely granular material and disintegrated blood. (5) In tetanus neonatorum the umbilicus may be inflamed. (6) The rectus muscle has been found ruptured as the result of a spasm. (7) Death may occur from heart-failure or asphyxia. Thrush. — This disease is due to the O'idiiim albicans, or thrush fungus. Parts affected: (1) The mouth, tongue, cheeks, etc., are more or less densely covered with minute, slightly raised, white spots, which are quite firm and adherent to the mucous membrane. When scraped off and examined microscopically, the characteristic fungus is seen. (2) Occasionally the fungus invades the oesophagus and grows to such an extent as seriously to obstruct its lumen. Tuberculosis. — Any morbid lesion produced by or through the agency of the tubercle bacillus, which is a rod-shaped micro-organism, measuring in length about one-half the diameter of a red corpuscle and in width two-tenths of a micron. It is bent upon itself, grows best on agar containing glycerin, stains with difficulty, but retains the stain tenaciously. The best method of staining is by carbol-fuchsin and Gabbett's solution. When stained it often has a beaded appear- ance. It is morphologically similar to the bacillus of leprosy and the 230 POST-MORTEM EXAMINATIONS smegma bacillus. Tuberculous lesions are: I. Acute. — (a) Miliary tuberculosis, (b) Caseous pneumonia or phthisis florida. (c) Tuber- culous ulcerations. II. Chronic. — (a) Diffuse tuberculosis, ulcerative phthisis, or caseous tuberculosis, (b) Fibroid phthisis, (c) Cold abscesses. III. Modes of Invasion. — (a) Aerogenous. (b) Lympho- genous, (c) Hematogenous. IV. Characteristic Lesions of Tubercu- losis. — (a) Miliary tubercle, (b) Caseation, (c) Cold abscesses. (d) Ulceration. Characteristics of Tuberctrfous Lesions. — (i) Miliary tubercle is a small nodule about the size of a millet-seed, grayish white in color, semi-translucent, raised above the surface, and primarily ad- herent to the surrounding structures. (2) In caseation or diffuse tuberculosis two or more miliary tubercles agglutinate, isolating the intervening healthy tissue and cutting off its blood-supply. The necrosed area loses symmetry of shape and arrangement and undergoes fatty degeneration. The area is yellowish in color, soft or firm in con- sistence, and is surrounded by an inflammatory zone. There is an almost complete absence of blood-vessels. (3) Cold abscess is most frequently found in association with tuberculosis of the vertebras. It is frequently seen as a " psoas" abscess. The capsule of this abscess is more or less imperfect. It does not present the ordinary charac- teristics of a pyogenic membrane, the limiting wall being composed mainly of broken-down tuberculous tissue with more or less perfectly formed tubercles. The contents of the abscess are pale and of a some- what watery consistence, composed mainly of broken-down cells, fatty debris, and water. Bacteriologically the contents of the abscess are usually sterile. V. Distribution of Tubercles in the Body. — (a) The lungs are most commonly affected. In two hundred and seventy-five cases out of a thousand autopsies, the lungs were, with two or three exceptions, involved in all. Other organs were affected as follows : (b) Intestines in sixty-five cases, (c) peritoneum in thirty-six, (d) kidneys in thirty- two, (e) brain in thirty-one, (/) spleen in twenty- three, (g) generative organs in twenty, (h) liver in twelve, (i) peri- cardium in seven, and (/) heart in four. (Osier.) VI. Fate of Tuber- culous Lesions. — Tuberculous lesions may terminate: (a) In resolu- tion, which is rare, (b) In fibroid changes. This sometimes occurs in the small intestine and may cause stenosis, (c) In caseation or sup- puration, (d) In calcification. (1) Resolution sometimes takes place when the area of tuberculosis is small, the blood-supply good, and the patient under favorable conditions, especially when leading an out-door MICRO-ORGANISMAL DISEASES 23 1 existence. (2) In healing by fibroid change the area affected is first encapsulated and then by gradual pressure and absorption the affected area is removed, leaving a scar. (3) Caseation is by far the most common result of all tuberculous lesions. The process has been already described. Suppuration in tuberculous lesions is the result of the intro- duction of pyogenic organisms. (4) Calcification is the most fortunate ending of the tuberculous process, and it is estimated by careful ob- servers that seventy-five per cent, of all persons who die after the age of forty years show this form of tuberculosis in their lungs or pul- monary glands. Tuberculosis of the Alimentary Tract. — This form may be: (a) Primary in the mucous membranes, (b) Secondary to disease of the lungs or eating infected food, (c) It occurs rarely through extension from the peritoneum. I. Mouth. — (1) Primary tuberculosis, which is usually miliary. The tonsils are more often affected primarily than was formerly supposed. (2) Secondary to tuberculosis of the face, larynx, or lung. It may attack the tongue or cheeks and be miliary or caseous. II. (Esophagus. — (1) Primary tuberculosis is very rare. (2) Secondary tuberculosis through extension from the lungs or larynx is comparatively common. ( 3 ) The lesions may be miliary, caseous, or ulcerative. III. Stomach. — Tuberculosis of the stomach is compara- tively rare ; Orth never saw a case. IV. Intestines. — The lesions occur in the ileum, caecum, colon, and rectum. The most frequent seat is in the ileum, just above the ileocecal valve, as it is here that stasis of the intestinal contents occurs and a favorable opportunity is given for the growth of the tubercle bacillus. ( 1 ) The large bowel is less fre- quently involved than the small bowel. (2) Small, firm, gray nodules develop, which soon soften and become yellow in the centre. If cut into at this stage, pus does not exude as in an ordinary abscess, but a thick caseous material may be pressed out. The mucous membrane over these nodules finally breaks down and the cheesy material is erupted. There remains an ulcer with swollen cheesy base and edges (primary tuberculous ulcer of Rokitansky), which soon combines with others and enlarges irregularly (secondary tuberculous ulcer of Roki- tansky). Miliary tubercles in the form of small gray nodules now appear at the base and edges of the ulcer and its immediate vicinity. Through the caseation of these, the ulcer enlarges both downward and laterally. The round ulcer becomes a long one, with its longer axis usually at right angles to the long axis of the intestine; it may 2^2 POST-MORTEM EXAMINATIONS extend around the bowel. Hemorrhages may occur, particularly at the edges. The submucosa and muscularis are usually involved, and colonies of young tubercles may be scattered over the serous mem- brane. Perforation is rare. Gangrene may occur in a very rapidly developing ulcer. Healing sometimes takes place. (3) There may be solitary or multiple areas of cicatricial tissue. (4) Fistula in ano is quite common. V. ( 1 ) The liver is constantly involved in general tuberculosis. It is pale in color, often fatty, and presenting miliary tubercles or caseous masses which may break down into numerous small abscesses, especially about the smaller bile-ducts. (2) There may be a slight increase in the connective tissues, leading to tubercular cirrhosis. Tuberculosis of the Brain and Cord. — (a) Acute miliary infection. (b) Chronic meningo-encephalitis. (c) Solitary tubercles. I. Acute Miliary Tuberculosis. — (1) This is usually secondary to tuberculosis of the lungs, bronchial glands, or bones. (2) Miliary tubercles occur most frequently in the pia and arachnoid of the cerebellum, next in the cerebrum, then in the pons. They follow the direction of the blood- vessels. They are apt to lead to obliteration of the vessels and thus cause softening and necrotic changes. Serous, seropurulent, or sero- fibrinous exudate is also present. (3) This acute process may result in acute inflammation of the meninges, principally the pia and arach- noid. It is spoken of usually as acute hydrocephalus. This is most pronounced towards the base of the brain and occurs most frequently in children. I have found tubercle bacilli in fluid removed by Quincke's lumbar puncture. II. Chronic Meningo-Encephalitis. — The mem- branes at the base of the brain are most often involved, next in fre- quency the optic chiasm, the Sylvian fissure, and the interpeduncular space. The membranes are thickened, firmly adherent, and covered with a fibrinous, purulent exudate. The convolutions are flattened and the sulci obliterated. The cerebral substance is more or less cedematous. The lateral ventricles are dilated and contain a turbid fluid. III. Tuberculous Tumors of the Brain. — (1) Solitary tubercles are found most usually about the cerebellum. As a rule, they are attached to the meninges, often to the pia mater. (2) Cerebral soften- ing from pressure is not uncommon. The tubercles vary in size from a pea to a small orange. They are grayish yellow in color, caseous, and usually firm and hard, but the centre may be semi-fluid. They may be surrounded by submiliary tubercles, but are, as a rule, surrounded by a soft translucent tissue. (3) They may calcify. MICRO-ORGANISMAL DISEASES 233 Tuberculosis of the Circulatory System. — (1) Primary tubercu- losis of the larger vessels is unknown ; secondary lesions are not infre- quently found if carefully searched for. (2) In the lungs, brain, and other organs the smaller arteries are usually involved in acute infiltra- tion which leads to thrombosis. (3) Tubercles may develop in the walls of the vessels, particularly the muscularis, and undergo softening, which may result in hemorrhage or a wide-spread distribution of the tuberculous infection. Tuberculosis of the Genito-Urinary System. — (a) Most common in males, (b) Age from twenty to forty years. I. The Kidneys. — ( 1 ) These organs are frequently the seat of an acute miliary infection, which may be primary or secondary. The disease is most marked in the cortex. It may be limited to the areas supplied by a single blood- vessel. Necrosis and caseation rapidly follow. The miliary tuber- cles may be seen in a row in the direction of the vasa interlobularia. One or both organs may be affected, but at autopsy both are found to be enlarged. (2) Not infrequently one kidney may be completely destroyed and converted into a series of cysts ; these contain a cheesy substance, and lime salts may be deposited in their walls. This is a chronic form of the disease and frequently starts at the apices of the pyramids. ( 3 ) The walls of the pelvis may be thickened and cheesy, and the mucous membrane converted into a necrotic ulcerating mass. The ureters are usually thickened, caseous, or ulcerated. II. The Blad- der. — Tuberculosis here is most common in men. ( 1 ) Infection of this organ is nearly always secondary to infection elsewhere, particularly in the pelvis of the kidney. The bladder is small, shrunken, thick- ened, and surrounded by sclerosed tissue. Ulcer formation is most common. It is lenticular in shape and is surrounded with red mucous membrane. Its seat of predilection is the trigone and fundus. Minute gray tubercles may be seen. In advanced cases ulcers are found. (2) To find tubercle bacilli in the urine centrifugation should be employed, and the precipitate stained in the usual manner for showing these organisms. Care must be taken not to get the smegma bacillus ; it is, therefore, advisable that the urine be collected with the strictest pre- cautions. III. The Testes. — Infection may occur before the second year. It may be secondary to peritoneal tuberculosis. At times the greater part of the testis is destroyed, its stroma being replaced by a softened or still firm caseous deposit, which may be softened in the centre. IV. Tuberculosis of the ureters is very rare. V. Salpingitis. — 234 POST-MORTEM EXAMINATIONS The oviducts are enlarged, the walls thickened and infiltrated, and the contents cheesy. It is usually bilateral. Tuberculosis of the Larynx. — The lesions may be primary or sec- ondary, usually the latter. The lesions found are : ( i ) Miliary tuber- culosis. (2) Diffuse tuberculosis. (3) Ulceration. In early cases the epithelium is intact, the tubercle starting in the mucosa or sub- mucosa. Tuberculosis of the Lung. — I. Acute. — (a) Miliary tuberculosis. (b) Phthisis florida, showing itself as bronchopneumonic tubercles, as lobar-pneumonic tubercles, or as a combination of both. II. Chronic. — (a) Ulcerative phthisis, (b) Fibroid phthisis. I. Acute. — ( 1 ) In acute miliary tuberculosis the lesions are usually present in both lungs. They are frequently so small and transparent that they may be overlooked on macroscopic examination. At other times they are aggregated in localized spots or even become diffuse. In the latter case the lung is increased in size, is firm in consistence, in color is a darker shade of red, is heavier, and crepitates. The pulmonary vessels should be opened with the scissors, and seldom in the pulmonary arteries but often in the veins miliary tubercles can be seen, the infection having been brought through the circulation. Such tubercles may, however, be localized near an old caseous mass, the lymphatic system then being the transmitter. Local spots of emphysema are seen if the condition is not very acute. The tubercles may be peribronchial, peri- vascular, or in the parenchyma. There is a chronic miliary tubercu- losis which presents a combination of lesions of both acute miliary tuberculosis and phthisis and is the connecting link between the two. (2) Phthisis florida, or acute phthisis with formation of cavities, pre- sents a varied appearance. One lobe only, or more or less of the whole lung, may be affected. The organ is heavy; the implicated portions do not collapse and are firm and airless. The pleura is covered with a thin exudate. On section the condition may resemble red or gray hepatization or an intermediate stage between them. In other instances the lung presents a mottled appearance, some areas being intensely congested, others exhibiting a characteristic pale-gray gelatinous exudate, others caseous degeneration and not infrequently cavity formation. Recently affected areas of pulmonary tissue with croupous pneumonia are often seen. II. Chronic. — (1) In ulcerative tuberculosis apical involvement in relation to implication at the base exists in the proportion of five hundred to one, according to Kidd. MICRO-ORGANISMAL DISEASES 235 There are varied lesions. First, there are caseous nodules, which are grayish, white, or yellow in color. Second, cavities may exist, which, if the case is acute, have walls made up of soft caseous masses. In the more chronic cases these walls are replaced by pyogenic membranes of greater or less density, at times covered with granulations. Fre- quently trabecular are seen in the walls; these are the blood-vessels, branches of the lung artery, which have resisted the tuberculous pro- cess. The arteries sometimes become aneurismal. Their rupture may be followed by hemorrhage severe enough to cause death. Frequently they are contracted and empty, due to a previous endarteritis or throm- bosis. Third, pneumonic areas and evidences of chronic bronchitis are seen. Fourth, some thickening of the pleura is constant. This may be merely an acutely inflamed area rubbing against a corresponding area on the parietal pleura or it may be tightly adherent to it. Not infrequently perforation causes a pyopneumothorax. Fifth, enlarged bronchial glands are discovered which are caseous and often pig- mented. Lastly, the bronchi are thickened and the lumina of the smaller ones frequently obliterated. The larger tubes show caseous deposits in the submucous and- fibrous coats. (2) In fibroid phthisis the organ is permeated with interstitial overgrowth. In some cases the interstitial change is most prominent; in others the tuberculous process is slightly more marked. The unaffected portions of the lung are largely emphysematous and pigmentation is considerable. The right ventricle and sometimes the whole heart are hypertrophied. Tuberculosis of the Lymphatic Glands. — (1) Location, most fre- quent in the cervical chain. (2) Extension opposite that of the lym- phatic stream. (Treves.) I. Chronic Form. — (1) Hard. (2) Non-adherent. (3) Yellowish white in color. (4) Little tendency to break down and suppurate. (5) Tendency to be localized. (6) Overgrowth of connective tissue considerable. In tabes Virchow compared them to a sectioned potato. II. Less Chronic Form. — (1) Not as dense. (2) Tendency to become adherent. (3) Gray or grayish white in color. (4) Tendency to liquefy and suppurate. (5) Connective tissue less in amount. (6) Tubercle bacilli more abun- dant. When tuberculous lymphatic glands are associated with phthisis, they are sometimes found to have opened into a bronchus and caused the disease. This is particularly common in children, and especially when the middle and lower lobes are involved. 236 POST-MORTEM EXAMINATIONS Tuberculosis of the Mammary Gland. — (a) Female sex. (b) Strumous temperament, (c) Age from the fortieth to the sixtieth year. The seat of predilection is the gland duct. (1) Induration is at first small and very slowly increases in size. (2) The nipple may be retracted. (3) The skin over the gland becomes riddled with sinuses with indurated edges. (4) Associated with lymphatic en- largement, tuberculosis of bone, or other tubercular involvement near the gland. Tuberculosis of the Peritoneum. — I. Miliary Form. — (1) On opening the abdominal cavity the serous membranes seem to be cov- ered to a greater or less extent with miliary tubercles, which are present in the mesentery and the omentum also. Frequently the gray nodules follow the distribution of the blood-vessels. (2) In many cases there is little or no inflammatory exudate, although petechial hemorrhages are common. (3) The peritoneum, howeyer, has not its normal shining surface, but is usually pale, somewhat sticky, and lustreless. (4) In many cases there is an effusion of straw-colored or bloody fluid which may amount to a litre or more. It contains a considerable amount of albumin and some cells. The exudate is rarely purulent. II. Chronic Diffuse Form. — (1) The abdominal viscera and peritoneum are bound together by tough, firm, membranous bands of organized exudate and the peritoneal cavity is obliterated. (2) The intestinal coils are shortened and contracted, while the mesenteries and omentum are enormously thickened. (3) The capsules of the liver and spleen undergo extreme thickening, varying from a few millimetres to several centimetres. The organs are rough and irreg- ular in outline. III. Ulcerative Form. — (1) There is a formation of caseous masses that vary in size from a pea to a marble, and which tend to run together and break down, forming more or less extensive ulcerating surfaces. (2) Adhesions are formed of a ' serofibrinous or seropurulent character. (3) The new tissues are apt to become pig- mented and of a gray or almost black color. (4) The intestinal walls are very friable. (5) Fistulse, opening at various points, are not infrequent. Tuberculosis of Serous Membranes. — There are three groups of cases: (1) Acute miliary tuberculosis, which may develop very rap- idly and is accompanied by more or less serous but turbid exudate. (2) A chronic form characterized by exudation, the formation of cheesy masses, and a tendency to suppuration. (3) Cases in which MICRO-ORGANISMAL DISEASES 237 the tubercles are hard and fibroid, the membranes much thickened, but with little or no fluid exudate. In these cases there may be no visceral tubercles. Tuberculosis of the Skin. — Anatomical warts are small papillary outgrowths frequently seen on the hands of those who make many autopsies. The process is chronic, and, as in the case of one of my helpers in the post-mortem room at Blockley, may give rise to general tuberculosis. The bacilli are few, and are best demonstrated by inocu- lation of some of the secretion into a guinea-pig. The animal lives for a longer period of time than is usual when it is inoculated with tuber- culous material taken from other sources. Lupus vulgaris is a cuta- neous form of tuberculosis, characterized by the formation of nodules, which tend to break down, producing more or less ulceration. The tubercle bacillus is found in very few numbers. ( 1 ) The lesion begins as a small nodule, reddish brown in color and of soft consistence. These nodules vary in size from a pin-head to a cherry and quickly break down and ulcerate. The ulcers are more or less rounded and have a red base covered with granulations. The intervening tissues show diffuse infiltration and fibrous hyperplasia. Warty excrescences may develop in the epidermis or in the floor of the ulcers. The face is the most common seat of the disease. (2) In lupus of the larynx the lesion is surrounded by hypersemic, cedematous tissue. In the course of time smooth, hard nodules appear, causing great deformity of the parts. Softening and ulceration give the larynx a worm-eaten appear- ance. The disease follows the lymphatic channels. Typhoid Fever. — The intestinal lesions are: First week, intense catarrhal inflammation of the mucous membrane of the intestines and in the first few days only moderate swelling of the follicles. Towards the end of this week, however, there is more decided medullary swelling. Second week, the medullary swelling goes on to resolution or formation of eschar or, third week, ulcer formation. In the fourth week there is beginning cicatrization. The lesions are most marked in the lower ileum, but they also exist in the caecum and large intestines, rarely in the jejunum. Hyperplasia of the mesenteric lym- phatic glands and the spleen develops early in the disease. Cloudy swelling and fatty degeneration of the heart, liver, and kidneys may be present. Waxy degeneration and bleeding in the voluntary muscles should be looked for. Other lesions are lymphoma of the liver, acute nephritis, bleeding of the skin, hypostatic or catarrhal pneumonia, 238 POST-MORTEM EXAMINATIONS purulent bronchitis, perforation, and peritonitis. The Widal test and the diazzo-reaction may be determined post mortem. Paratyphoid or paracolon infections are more common than was formerly supposed, and furnish most interesting cases for thorough study. Yellow Fever. — The chief lesions are: (1) Bleeding from the mucous membranes. (2) Tarry blood. (3) High-grade fatty degen- eration of the liver. (4) Acute hemorrhagic inflammation of the stomach and intestinal mucous membrane. (5) Icterus. The inter- esting work done by Reed, Carroll, and Agramonte in Havana, in showing that this disease is dependent on the Stegomyia, a variety of mosquito, is one of the most important contributions to medical litera- ture of the past decade. The bacillus X of Sternberg and the bacillus icteroides of Sanarelli are by some supposed to be identical, by others not to be the cause of yellow fever. There is an interesting illustrated article on this subject in the New Orleans Medical and Surgical Jour- nal for January, 1902. PARASITES. Pediculi. — (a) Pediculus capitis. — The female louse measures from one and eight-tenths millimetres to two millimetres in length, the male being somewhat smaller. The darker the skin of the person infested the darker is the color of the parasites. So marked is this peculiarity that some writers are of the opinion that different species affect different races. The ova are grayish glistening specks enclosed in a membrane firmly adherent to the shaft of a hair not far from its root, and coming off at an acute angle, with the opening away from the scalp after the exit of this parasite. Considerable irritation is caused by these animals, and when this is severe the hair on the back of the head may be found matted with soft yellow crusts. The scalp is covered with moist red granulations. The cervical lymphatic glands posteriorly are enlarged. This condition is most frequently seen in children, (b) Pediculus pubis. — It differs slightly from the above in that it is smaller and infests regions, as the axillary, the pubic, and the periocular, where the hair is short, (c) Pediculus corporis is the largest form of the parasite. It lives in the clothing, when not in search of food on the body. By its constant irritation it causes dermatitis, and if present for a long time, pigmentation and thickening of the skin. (d) Cimex lecHdarius (common bedbug), (e) Pulex irritans (the common flea), (f) Pulex penetrans (sand-flea, jigger). The latter PARASITIC DISEASES 239 is common in tropical and subtropical countries. It is smaller than the common flea. It burrows under the skin and produces a pustular swelling, (g) Sarcoptes (Acarus) scabiei. — The female itch-mite is .45 of a millimetre long and .35 of a millimetre broad; the male is about one-half the size. Its color is pearly white. The burrow in the skin, wherein may be found the excrement and the eggs of the parasites, is about one centimetre in length, and is present where the skin is moist, as in the webs of the fingers and toes. Cutaneous lesions result from the scratching instigated by the irritation caused by the parasite. Cestodes. — Instestinal Cestodes. — (a) Tcenia solium in the ma- ture form may reach to twelve feet or even more in length. It is composed of numerous segments about one-third of an inch long and averaging a fourth of an inch wide. The head is very minute, being no larger than the head of a pin. In front is a rostellum and at the base of this is a fringe of hooklets. It has four suckers. The worm is hermaphroditic. When mature thousands of ova are passed by the rectum. The embryo has six hooklets. It penetrates the walls of the stomach and burrows into the tissues of the animal that has swallowed it. ( b ) Tcenia saginata is larger, longer, and of more frequent occur- rence than the preceding. The head is nearly square and measures more than two millimetres in breadth, but has no hooklets. The seg- ments are larger than those of the Tcenia solium. The reproductive organs are on the ventral aspects of the segments in the median lines. (c) The Bothriocephalic lotus is larger and longer than any of the flat worms. In the mature state it is twenty-five feet or more in length. It has no hooklets, but is furnished with slit-like fossae on the head, which act like suckers. The larvae develop in the peritoneum of fish. (d) Tcenia ilavopunctata is very rare. It is about sixteen centimetres long, (e) The Cysticercus cellulosce is the larval form of the Tcenia solium. It is found in the muscles, brain, cord, peritoneum, or almost any other tissue of the affected animal. The surrounding capsule is frequently calcified. In the making of many autopsies it is surprising how few taenia are found in the intestinal tract. My experience is lim- ited to but two cases. One of these was that of a man who committed suicide with opium. Two Tcenice saginatce were found, the head of the first one being firmly attached beneath a fold of one of the valvulae conniventes high up in the jejunum and the other five or six feet far- ther down the intestine, the segments of both worms then continuing on down to near the ileocaecal valve. 240 POST-MORTEM EXAMINATIONS Nematodes. — (a) Ascaris Lumbricoides. — It is a cylindrical worm with both ends pointed. The female is from ten to sixteen inches in length, the male considerably smaller. It is brownish yellow, reddish, or white in color. The head ends in three lips, (b) The Oxyurus vermicularis (seat-worm) is a very small round worm, about ten millimetres long, (c) The Trichina spiralis in the mature state lives in the intestine; in the immature state in the muscles. The em- bryo is surrounded by a capsule, which quickly calcifies. Under the microscope the embryo can be seen coiled up in its capsule; it is less than a millimetre in length. (d) The Anchylostomum diiodenale lives in the upper part of the intestine. The female is the larger, and varies from ten to sixteen millimetres in length. At the anterior por- tion of its head are hooklets, with which it attaches itself to the intes- tinal walls. It is frequently associated with Egyptian chlorosis. Stiles and Harris have recently called attention to the wide distribution of uncinariasis in the South; the disease may be readily recognized by finding the ova in the faeces, (e) The embryo of the Filaria sanguinis hominis is a round worm one-seventy-fifth to one-one-hundredth of an inch long. It is enclosed in a delicate sac. It circulates freely in the blood, but only at night. The adult parasite is located in the lym- phatic vessels and is three or four inches in length. According to Manson, it is introduced into the body by the mosquito. Distomiasis. — (a)' Liver-flukes. (b) Blood-flukes. These worms are lanceolate in shape, quite flat, and possess a distinct head and neck. They are three- fourths of an inch long and about half an inch broad. The color is dull brown. The female blood-fluke has a grooved channel posteriorly for the reception of the male. They have two suckers, one near the mouth and the other near the ventral portion of the body. The liver-fluke infests the upper intestine and the bile- ducts. It causes the " liver-rot" in sheep. The blood-fluke is found chiefly in the portal system and the veins of the bladder. The ova may be seen in the urine as elongated ovoid bodies, sharply pointed at one extremity, and containing black pigment. They can easily be seen with a low power of the microscope. Parasitic haemoptysis now occurs in America as well as in Asia, and is due to the Paragonimus Westermanii. The eggs are found in the sputum, the fluke measuring from eight to sixteen millimetres long by four to eight millimetres across. Myiasis. — By this term is meant a condition in which a diseased H/EMATOZOIC DISEASES 241 part becomes " living," as it is called. It is caused by the larvae of certain flesh-flies, of common house-flies, or of the bot-flies of oxen or sheep. The ova of these flies may be deposited in the nostrils, ears, conjunctiva, open wounds, or even in the vagina during the puer- perium. Echinococcus Disease. — A parasitic disease, found most fre- quently in those countries, as Iceland and Australia, where the dog lives in intimate association with man; it is characterized by the formation of endogenous or exogenous multilocular cysts in various portions of the body. The Tamia echinococcus is a very small, thread- like tape- worm (length from three to six millimetres), having only three segments. The head has four suckers, a rostellum, and a double row of hooklets. The adult worm is found in the dog. The embryos (scolices) are found in the ox, hog, sheep, horse, and man. Distribu- tion in Man. — (a) Liver (most common), (b) Lung and pleura. (c) Intestinal tract, (d) Kidney, brain, etc. The embryo, freed from the cyst by digestion in the stomach, burrows through the intestinal wall and is carried to the various organs; it then loses its hooklets and is gradually converted into a cyst (hyatid) having two walls, ex- ternal laminated, internal granular or parenchymatous, containing blood-vessels and muscle-fibres. The interior is filled with a clear non- albuminous fluid, specific gravity 1005- 1009, usually containing sugar and hooklets. From irritation of surrounding tissues a fibrous capsule generally develops on the outside. The cysts vary in size from that of a small pea to that of a child's head. From the inner (parenchyma- tous) layer may develop brood capsules, which in their turn produce numerous scolices. The cysts grow slowly; when the embryo dies, the whole becomes calcified. Sometimes the cysts suppurate; occa- sionally they rupture into adjacent structures. H^EMATOZOA. Malaria. — This widely distributed and much-studied disease is due to a true haematozoon, transmitted to man by the bite of the ano- pheles mosquitoes. Three varieties have been described: (a) Tertian. (b) Quartan, (c) iE'stivo-autumnal. Classification. — (a) Acute ma- larial fever, which may be quotidian, tertian, or quartan, (b) Per- nicious malaria, (c) Chronic malarial cachexia. In the blood of the cadaver the plasmodium is seldom visible, but it may be found in sec- tions of the brain, liver, and spleen. ( 1 ) Cases of simple malarial fever 16 242 POST-MORTEM EXAMINATIONS are rarely fatal. The blood shows disintegration of red corpuscles and an accumulation of pigment is thereby formed. The spleen is enlarged, dark in color, and may show pigmentary deposits. (2) In pernicious malaria the blood contains enormous numbers of the parasites. The red corpuscles are in all stages of destruction and the serum is tinged with haemoglobin. The spleen is moderately enlarged. The pulp is soft, chocolate-colored, and turbid; it contains large numbers of red corpuscles and parasites and the amount of pigment is greatly in- creased. The liver is swollen and presents areas of focal necrosis and capillary thrombosis. Pigmentary deposits are also common. The kidneys present more or less parenchymatous change with only mod- erate pigmentation. (3) In malarial cachexia the blood presents all the characteristics of an advanced anaemia, often distinguishable from pernicious anaemia only by the presence of the parasite and icterus. The spleen is greatly enlarged : it may weigh from seven to ten pounds. The organ is firm and resistant to the knife. The capsule is thickened and the parenchyma brownish or slate-colored, with areas of pigmen- tation. The kidneys are enlarged and of a grayish-red color. The peritoneum is thickened, opaque, and of a deep slate-color ; the gastric and intestinal mucous membrane may have the same hue. The gray matter of the brain is of a deep reddish-gray color or in very chronic cases a chocolate-brown. The meninges are congested. (4) Among accidental and late lesions is cirrhosis of the liver. Very extensive pigmentation may occur. Pneumonia is believed to be common ; mod- erate albuminuria is frequent; acute nephritis is not uncommon; chronic nephritis may follow long-continued or repeated infection. Rupture of the capsule of the spleen may occur, followed by bleeding into the peritoneum and even peritonitis. In pernicious malaria the brain may show thrombosis, due to the parasites, with secondary soften- ing of the surrounding tissue. The same thing may be found in the gastro-intestinal mucosa and be followed by superficial ulceration. There may be advanced fatty degeneration of the heart. Psorospermosis. — A condition produced by the presence of oval, transparent bodies belonging to the coccidia, to which class the mala- rial organism also belongs. I. (1) In the majority of cases of the internal form the psorosperms have been found in the liver. (2) Whitish growths resembling tubercles and containing the coccidia have been found upon the peritoneum, omentum, and pericardium. (3) Similar masses are sometimes seen in the ileum, liver, spleen, and H^EMATOZOIC DISEASES 243 kidneys. The liver may be enlarged and contain caseous foci which are surrounded by areas of congestion. (4) The spleen may be simi- larly affected. II. ( 1 ) In cutaneous .affections the lesions closely resemble those of tuberculosis of the skin. They occur in Paget's disease of the nipple and by some are believed to be its cause. ( 2 ) A case has been reported in which at autopsy nodules were found in the lungs, adrenals, testicle, spleen, on the surface of the liver, and on the pleurse. Great numbers of psorozoa were found in the lesions. (3) Successful inoculations were made into rabbits and dogs. Trypanosoma. — Four animal diseases are caused by varieties of trypanosomes, nagana, surra, mal de caderas, and dourine. Recently Nepveu, Dutton, and others have found them in man. CHAPTER XXIII THE PRESERVATION OF TISSUES FOR MICROSCOPIC AND MACROSCOPIC PURPOSES 1 When tissues are to be preserved for microscopical study, the method of fixing and hardening them should be decided upon at the time of their removal from the body. The objects of fixation and hardening are permanently to solidify the structural elements of a part as nearly as possible in their original form and situation. All our present methods, however, fail to give an accurate picture of the living cell, and not enough attention is now paid to the microscopical exami- nation of unstained fresh scrapings removed during the performance of the autopsy. The best slides are secured by the use of different processes for various purposes. The use of perfectly fresh tissues is essential, for many structural details disappear on molecular death. Fortunately, this does not occur until several hours after molar death, so that it is often possible to obtain tissues still living. 2 Our choice of reagents also is constantly being enlarged. The method of wrapping tissues in paper or cloth and transporting them to a distance is only to be regarded as a last resort. When this is done, pieces of sufficient size to insure preservation of their interior intact are enveloped in an abundant supply of clean cotton (antiseptic gauze causes markings on them), moistened very slightly with a bichloride-tablet solution, and thoroughly protected from pressure ; these segments are cut down to a proper size before they are put into the fixing agent in the labo- ratory. The careless wrapping of tissues in cloth or paper is mentioned only to be condemned. Bottles containing the more common fixatives should be ready, and as soon as the tissues are exposed and described — before the part 1 Based on the works of Lee, The Microtomist's Vade Mecum; Mallory and Wright, Pathological Technique ; Apathy, Die Mikrotechnik der thierischen Mor- phologic; Fischer, Fixirung, Fdrbung, und Bau des Protoplasmas ; Szymono- wicz, Lehrbuch der Histologic ; Stohr, Text-book of Histology ; Bohm and Von Davidoff, Text-book of Histology, and the Encyklopddie der mikroskopischen Technik, 1903. 2 A most inviting field of investigation is opened up by the experimental stain- ing of tissues during life and their fixation while the animal is still living. 244 PRESERVATION OF TISSUES 245 becomes distorted, fluids escape, or surfaces dry — they should be cut with a clean, sharp knife into pieces about two centimetres in length and breadth and one centimetre thick. Sections of organs should in- clude their characteristic structures, — cortex, capsule, hilum, endocar- dium, etc. Sections of tumors should be taken from the centre, where degenerative changes are most marked, and from the growing periph- eral margin, if possible including some normal tissue; this is of espe- cial importance in the case of malignant tumors. Mucous and serous membranes are pinned out on cork, or wood that will give no stain when soaked in the preservative fluid to be used, with their secreting surfaces uppermost. Muscle-fibres are best preserved by being tightly stretched upon and tied at the ends of a piece of wood. The segments of tissue, without being touched by either fingers or forceps, ai e lifted on the blade of the scalpel and dropped immediately into a bottle con- taining an amount of fixing fluid far in excess of their bulk. Of energetic fixatives, such as Flemming's or Hermann's, about fifteen times the volume of the object introduced will suffice, while of milder fluids, like the bichromate of potassium or picric acid solutions, one hundred times such volume will be required. If the different tissues are distinguishable macroscopically, they may be placed in the same jar ; if not, separate bottles are better. Tags may be attached, the writing being done with a lead-pencil, as they are not acted upon by the usual preservatives. The jars are labelled with the date, the number or name of the autopsy, and the fixative used. It is often of importance to add the exact locality from which the pieces have been removed and the plane on which they are to be cut when placed in the microtome. The fluid should always be changed after it becomes turbid; or in the case of alcohol or formalin, preferably after three hours, whether it is turbid or not. If the specimens are to be sent away, they should not go until the fluid remains clear; if the time necessary for trans- portation exceeds that of the proper action of the fixative, they should be worked on up to 80 per cent, alcohol and shipped in that fluid, firmly packed in absorbent cotton. The choice of a fixing agent is determined by the nature of the object to be preserved and the purpose for which the investigation is undertaken. The characteristics of different pathological conditions are better preserved in some fixatives than in others. Thus, fatty degenerations are well preserved by an osmic acid, bichromate, or 246 POST-MORTEM EXAMINATIONS formalin solution; oedematous and parenchymatous changes, by cor- rosive sublimate ; fibrin and hemorrhagic conditions, by absolute alco- hol, etc. Moreover, different tissues require different treatment; the fixation of a lymph-node is quite a different matter from that of a retina. Then the purpose for which the examination is made will largely influence the choice. If it be simply a question of general diagnosis, Orth's fluid and alcohol will answer every purpose; by the use of alcohol we can preserve the specific staining properties of micro-organisms and haemoglobin and various important chemical re- actions, and by the use of Orth's fluid colloid and mucoid material retain their transparency, fat is preserved, etc. If we undertake the investigation of pathological processes and the comparison of abnormal with normal cellular anatomy, then special fixatives must be used. The advantages and disadvantages of the fixing solutions most in use will first be given, next a list of pathological conditions and the solutions best calculated to preserve their characteristics, and finally a list of staining solutions requiring certain fixatives for their use. Fixatives ; Insolubility. — To preserve soluble cell contents they must first be rendered insoluble, and the transformation must be equable throughout. The colloid or fluid material must harden homogeneously and enclose the more solid structures without loss of former relation- ship : there must be no shrinkage, no condensation, no expansion ; but everything should be precisely as it was when manifesting vital activi- ties, except this change into a compound that will remain undissolved and persist through subsequent necessary manipulations. This insolu- bility is supposed to be due in some cases to a sort of clotting process ; and if the coagulating property be stronger in absolute alcohol than its dehydrating power and less in alcohol of lower percentage, this fact ex- plains why more shrinkage is caused by 96 per cent, than by absolute alcohol, and why the shrinkage increases with the lowering of the alcoholic strength. Other fixing agents, such as osmic acid, chromic acid, potassium bichromate, and corrosive sublimate solutions, seem to form a chemical union with the cell contents and so produce an extremely durable insolubility. Others, such as picric acid and nitric acid, harden well, but form such unstable compounds that the fixation is easily removed by washing in water and must be preserved by placing the specimens in alcohol. It is evident that any solvent action by the reagent — e.g., the action of alcohol on fat and that of acetic acid on protoplasm — forbids its use. PRESERVATION OF TISSUES 247 Optical Differentiation. — Some agents in producing insolu- bility effect another change which is equally valuable and which is known as optical differentiation. The various cell structures respond differently to the fixative. Their indices of refraction are altered; some are raised, some lowered, and marked contrasts in refractive properties are developed throughout the cell. In this way structures become visible that were before unseen. Bichromate of potassium stiffens very equably, with neither shrinkage nor expansion, but has no power of optical differentiation; while osmic acid possesses this in a high degree. Since observation with the microscope is directly dependent upon differences in refraction, it is evident that this is a most valuable property of a fixative. Penetration. — The ability to reach all points of the tissue at the same time is another important characteristic of a fixing agent and one clearly connected with securing optical differentiation. Osmic acid has but little penetration. If pieces placed in its solutions are too thick or remain therein too long, the superficial layers become over-exposed, the indices of refraction are all equally raised, and differentiation disappears. This is true not only of- cells in mass, but also of intracellular structures. Prompt and uniform action, the sharp fixation of tissues at the precise moment, insures good optical differ- entiation ; slow, unequal action results in loss of definition. Fixing Fluids. — All acids apparently possess fixing properties, and every fixing fluid should be acid, with possibly the exception of alcohol. Of the organic acids acetic and formic are those most used; of the inorganic, nitric, sulphuric, picric, hydrochloric, osmic, and chromic. Acetic Acid. — By this term is always meant glacial acetic acid, which has very great penetrating power and aids in optical differen- tiation. It causes swelling and solution of protoplasm, and hence is not used alone, but with fixatives such as osmic acid to aid in penetra- tion and prevent excessive blackening, with alcohol and corrosive sub- limate to prevent shrinkage, and with chrome salts to aid in optical differentiation. It is usually added to these various solutions in strengths varying from 0.5 to 5 per cent. All liquids containing a large percentage of acetic acid should be allowed to act only for a short time. Acetic acid should not be used for connective tissue. Alcohol (95 per cent, or absolute; 2-24 hours; 5 mm. thick). — Alcohol has certain important advantages. It can be readily procured, 248 POST-MORTEM EXAMINATIONS does not have to be made up, tissues are hardened as well as fixed by it, and, since it represents one of the last stages preparatory to embedding, its use saves much time and trouble, and the material for a general diagnosis is easily and promptly prepared, which is often a great convenience. It penetrates well, preserves the specific staining properties of micro-organisms and various important chemical reac- tions, permits the use of most stains and is demanded by others, — e.g., Nissl's, Lenhossek's, Weigert's, Ribbert's phosphomolybdic haema- toxylin, Unna's orcein, etc. It is especially good for glands, skin, and blood-vessels, mast-cells, plasma cells, fibrin, and hyperaemic con- ditions, since it preserves the color-reactions of haemoglobin. On the other hand, it sometimes causes shrinkage and exerts a bad solvent action, so that the cells come out lean and empty, with foamy, vacuo- lated protoplasm and with distortion or loss of original structure. Tissues should not remain too long in absolute alcohol, as they sometimes stain very poorly after as short a time as twenty-four hours. Alcohol is not a good fixative for van Gieson's stain. Alcohol of lower percentage than 95 causes excessive shrinkage. The shrinkage of alcohol is corrected by the use of acetic acid. Carnoy's fluids (for nuclear structures) : 1. Glacial acetic acid 1 part. Absolute alcohol 3 parts. 2. Glacial acetic acid 1 part. Absolute alcohol 6 parts. Chloroform 3 parts. Leave pieces in for from fifteen to thirty minutes; wash out in alcohol. Avoid aqueous liquids. (For acetic alcohol with sublimate see " Gilson's solution" and " Ohlmacher's solution" under Corrosive Sublimate.) After the use of alcohol as a fixing agent, tissues must either be embedded in celloidin or paraffin as soon as hardened or left in cedar oil, or put through 95 per cent, alcohol and finally preserved in 80 per cent. Chromic Acid. — Chromic acid is a powerful and rapid coagulating agent, but, on account of its lack of penetration and tendency to cause shrinkage and make tissues brittle, it is seldom used alone. Its de- fects are remedied by adding acetic, formic, osmic, or nitric acid to its solutions. All tissues fixed by chromic acid solutions are to be washed in running water and hardened in graded alcohols in the dark. PRESERVATION OF TISSUES 249 Chromo-acetic acid (Rabl) : Acetic acid, 0.1 per cent, in water 1 part. Chromic acid, from 0.2 to 0.25 per cent 1 part. Chromo-formic acid ( Rabl ) : Chromic acid, 0.33 per cent 200 cc. Formic acid, concentrated from 4 to 5 drops. Use at once, fix for from twelve to twenty-four hours. Chromo-nitric acid (Perenyi) (4-5 hours) : Nitric acid, 10 per cent 4 parts. Alcohol 3 parts. Chromic acid, 0.5 per cent 3 parts. Transfer directly to 70 per cent, alcohol for twenty-four hours, to 95 per cent, for some days, and to absolute alcohol from four to five days. Chromo-osmic acid has been superseded by Chromo-aceto-osmic acid (Flemming) : Chromic acid, 1 per cent 45 cc. Osmic acid, 2 per cent 12 cc. Glacial acetic acid 3 cc. Objects may stay in this solution for hours or even several days. The pieces should be perfectly fresh and not thicker than 4 mm. It should be made up shortly before using. When all the condi- tions are fulfilled, it is unequalled as a fixative and in producing optical differentiation. The most delicate structural details are brilliantly shown. Especially used for mitotic figures. Bichromate of Potassium. — The simple aqueous solution is used in gradually increasing strengths from 2 to 5 per cent, for harden- ing purposes, for which it is excellent, but, on account of its lack of penetration and tendency to cause the chromatin to swell, it is not suitable for a nuclear fixing agent without being reinforced. The addition of glacial acetic acid gives a fluid which acts nearly as well as Zenker's and is much more convenient to use. The excess of bi- chromate is to be well washed out in running water and the tissues hardened in alcohols in the dark. Acetic bichromate (Tellyesniczky) (1-2 days) : Bichromate of potassium 3 grammes. Glacial acetic acid 5 cc. Water 100 cc. Begin hardening with 1 5 per cent, alcohol. 250 POST-MORTEM EXAMINATIONS Osmic, bichromate, and platinum chlorid (2 hours) (Dr. Lindsay Johnson) : Potassium bichromate, 2.5 per cent 70 parts. Osmic acid, 2 per cent 10 parts. Platinic chlorid, 1 per cent 15 parts. . Acetic or formic acid (just before using) 5 parts. A fine fixative for delicate objects, such as a retina. Leave objects in for two hours. Wash in running water. Harden in alcohol. The slow, mixed, and rapid methods of Golgi stain the cells with their prolongations, the nerve-fibres with their terminal ramifications, and the neuroglia cells. Golgi's slow method : Harden pieces of tissue in a 2 per cent, solution of bichromate of potassium from two to six weeks. Keep in the dark and change often. Transfer to a 0.75 per cent, aqueous solu- tion of silver nitrate. Golgi's mixed method : Harden small pieces of tissue for from three to five days, or longer, in a 2 per cent, solution of potassium bichromate at 25 ° C. in the dark. Place in the following solution for from three to eight days. Osmic acid, 1 per cent 2 parts. Bichromate of potassium 8 parts. Then into a 0.75 per cent, silver nitrate solution. Golgi's quick method : Tissues should be absolutely fresh, and the pieces not more than three millimetres thick. Osmic acid, 1 per cent 1 part. Bichromate of potassium, 3.5 per cent *. 4 parts. Leave pieces of neuroglia in the solution for two or three days, nerve- cells from three to five days, nerve-fibres and collaterals from five to seven days. Then place in 0.75 per cent, silver nitrate solution. Miiller's fluid (6-8 weeks) : Bichromate of potassium 2.5 grammes. Sulphate of sodium 1. gramme. Water 100. cc. This fluid, once so universally used, is now largely replaced by better fixatives. It has all the faults of the plain bichromate solution and the same need of being reinforced. (For acetic acid and sub- PRESERVATION OF TISSUES 25 1 limate additions see " Zenker's fluid" under Corrosive Sublimate; for formalin see " Orth's fluid" under Formalin.) It hardens evenly without shrinkage and gives very good consistency to tissues, but it is in no way a nuclear fixative. As a hardening agent for nervous tissue it has been almost entirely replaced by formalin. Pieces of tissue not larger than two centimetres are hardened in from six to eight weeks. Change daily for seven days, then once a week. Wash in running water twenty-four hours. Nervous tissue is placed directly in alcohol. Erlicki's Solution. — Potassium bichromate 2.5 grammes. Copper sulphate 0.5 to 1. gramme. Water 100. cc. This is an extremely good agent for hardening voluminous ob- jects. Its action is much more rapid than that of Muller's fluid. For microscopical work, however, it gives precipitates likely to be mis- leading and difficult to remove. It is used as a fixative for Freud's gold stain for nerve-fibres. Chlorid of Iron (Mallory) (3-5 days). — For peripheral nerve- fibres. Chlorid of iron 1 part. Distilled water 4 parts. Wash out thoroughly in water. Transfer to a saturated solution of dinitroresorcin in 75 per cent, alcohol for several weeks. Wash, dehydrate, etc. This stain may be used after Flemming or Muller. Corrosive Sublimate (Bichlorid of Mercury). — This is a very active penetrating and hardening agent, and since tissues are suffi- ciently affected by it in from three minutes to two hours and are then placed directly into alcohol, the process is a quick and convenient one. Carmin and van Gieson stains are particularly brilliant after it. The Heidenhain-Biondi triple stain requires its use. It is an especially good fixative for the alimentary tract; for cedematous tis- sues and albuminous degenerations, since it coagulates nearly as well as boiling water; it is used for connective-tissue fibrillar with Mal- lory's anilin-blue stain. Its disadvantages are that it causes shrink- age and the formation of precipitates which must be removed. If tissues are too long exposed to its action they become brittle, and if 252 POST-MORTEM EXAMINATIONS kept too long in alcohol they are very difficult to cut. Unless corrected by the addition of some other agent, poor optical differentiation is obtained, so that corrosive sublimate should be used only for general and not for cytological work. Pieces of tissue should not be larger than five millimetres, and must be removed as soon as they become thor- oughly opaque, otherwise they will be too brittle. All solutions con- taining this salt act much better when freshly made, as they deteriorate by standing. Sodium chlorid and bichlorid of mercury (Heidenhain's solution) : A saturated solution of bichlorid of mercury in 0.5 per cent, solution of sodium chlorid. Acetic sublimate : A saturated solution of corrosive sublimate in 5 per cent, glacial acetic acid. Gilson's solution: Absolute alcohol 1 part. Glacial acetic acid 1 part. Chloroform 1 part. Sublimate to saturation. This liquid is one of the most penetrating and rapidly acting of any, if not the most. Wash out with alcohol containing tincture of iodin. Ohlmacher's solution (15-30 minutes) : Absolute alcohol 80 parts. Chloroform 15 parts. Glacial acetic acia 5 parts. Sublimate to saturation (about 20 per cent.). A cerebral hemisphere sectioned by Meynert's method is hardened in from eighteen to twenty- four hours. Zenker's fluid : Corrosive sublimate 5 grammes. Glacial acetic acid - 5 cc. Miiller's fluid 95 cc. Add the sublimate and acetic acid just before using. Leave tissues in from twenty-four to forty-eight hours. This fluid is comparable to that of Flemming in perfect fixation. It has better penetration, over-fixation is not so likely to occur, it gives better staining results, and is much cheaper. It is altogether most satisfactory. Eosin stains are especially brilliant after its use. Its one disadvantage is that the sublimate must be removed by placing PRESERVATION OF TISSUES 253 sections in 70 per cent, alcohol containing enough tincture of iodin to give it the color of a dark sherry wine ; but this is true of all sub- limate solutions. Bensley's solution (^2-2 hours) : Potassium bichromate, 1 to 2 per cent, solution in water. . 1 part. Corrosive sublimate, saturated solution in alcohol 1 part. Mix the two solutions just before use. Leave tissues in from one- half hour to two hours. Wash well in water. This solution is especially useful for the gastro-intestinal tract. Formalin. — This agent acts very rapidly; it causes no shrinkage. Cytoplasm and nuclei are well preserved. Mitotic figures are fixed. Haemoglobin and micro-organisms retain their specific staining re- actions. Fat is not dissolved; mucin is not precipitated, but remains transparent. Formalin is an especially valuable fixative for nervous tissues: an entire brain may be hardened in a 10 per cent, solution in from a week to ten days. It gives great toughness and elasticity to tissues, and is required for many methods of staining nerve-fibres. Pieces of nerve tissue ten millimetres thick may first be fixed in for- malin and then subjected to the action of any mordant desired. It is used in a standard solution of ten cubic centimetres of for- malin to ninety cubic centimetres of distilled water. Change after three hours. Tissues are fixed in from one to two days, but may re- main in the fluid indefinitely if the percentage of formalin is main- tained. Orth's fluid (1-2 days) : Potassium bichromate 2.5 parts. Sodium sulphate 1. part. Water 100. cc. Formalin 10. cc. Add the formalin just before using. This is Miiller's fluid with 10 per cent, formalin. It is one of the best general fixatives in use. Nitric Acid (3 per cent. ; 6 hours; 70 per cent, alcohol). — It gives toughness to tissues and is especially suitable for organs rich in con- nective tissue. Bichromate of potassium may be used after fixation in nitric acid. Osmic Acid. — This is one of the finest fixatives known, especially for cytoplasm. It has great power of rendering cell constituents in- 254 POST-MORTEM EXAMINATIONS soluble and of developing optical differentiation, thus bringing to view structures previously unknown. As it has very little penetration, superficial cells may be overfixed and homogeneous. Carmin stains badly after its use, but hematoxylin is not affected. It is seldom used alone except for fixation by vapors. Very delicate objects are pinned out on the well-fitting cork of a wide-mouthed bottle and exposed to the vapors of a small quantity of a i per cent, solution poured into the bottle. A retina needs an exposure of some hours and is more equally fixed than when placed in the solution. Osmic acid solutions do not keep well and must be carefully protected from dust. Lee recommends a 2 per cent, solution in 1 per cent, chromic acid. This serves for vapor fixation and Flemming's solution. It may also be kept as a 1 per cent, solution in distilled water. (For Flem- ming's solution see " Chromo-aceto-osmic acid.") In making osmic acid solutions the capsule containing this acid is broken within the bottle containing the solution. Tellyesniczky 1 suggests as the best substitute for osmic acid the following : Potassium bichromate 3 grammes. Acidi aceti 5 cc. Aquas 100 grammes. Platinico-acetico-osmic-acid solution (Hermann's solution; 1-8 days) : This celebrated reagent is Flemming's solution with platinic chlorid instead of chromic acid. Platinic chlorid, 1 per cent 15 parts. Glacial acetic acid 1 part. Osmic acid, 2 per cent 2 to 4 parts. Its action is comparable to that of Flemming's solution. The most delicate structures are faithfully preserved and well shown. Pianese's solution (36 hours) : Chlorid of platinum and sodium, 1 per cent, aqueous solution 15 cc. Chromic acid, 0.25 per cent, aqueous solution 5 cc. Osmic acid, 2 per cent, aqueous solution 5 cc. Formic acid, C. P 1 drop. For karyokinesis and the so-called cancer bodies. Pieces of tissue 1 Arch. f. mikrosk. Anat., 1898, vol. Hi. p. 202. PRESERVATION OF TISSUES 255 must not be more than two millimetres thick. It gives very inter- esting results histologically. Picric Acid (2-24 hours). — Picric acid is an extremely pene- trating and delicate fixative. It hardens very slightly, and the insolu- bility caused by its action may be easily removed by washing in water ; hence its preparations should always be placed in alcohol. It is used as a saturated aqueous solution and in large quantity, — about one hundred times the bulk of the object. It is an excellent fixative for delicate serous membranes, which may be floated in it without retrac- tion or distortion. The omentum and peritoneum are well fixed in it. Picro-acetic acid : A saturated solution of picric acid in one per cent, acetic acid ; a very good fixative. Picro-sulphuric acid (Kleinenberg) : Add 1 cc. of concentrated sulphuric acid to 100 cc. of a saturated aqueous picric acid solution. Let stand for nearly four hours ; filter ; add double its volume of dis- tilled water. This is an excellent fixative for delicate embryos. Picro-nitric and picro-hydrochloric acid solutions are also used, but their action is essentially the same as that of picro-sulphuric. The advantages of picric acid solutions are that they give a very delicate fixative with excellent cutting qualities, and delicate mem- branes are not thickened excessively as with stronger reagents. Hardening. — To give to tissues a proper cutting consistency they are gradually hardened by being passed through a series of graded alcohols. For general diagnosis tissues may go from water into 70 per cent, alcohol, then 95 per cent., and finally absolute alcohol, usually remaining twenty-four hours in each grade. Corrosive sublimate and Golgi tissues are to be placed for only a few hours in 95 per cent, and absolute alcohols, without passing through the lower grades. For finer work begin with 30 per cent, or even 15 per cent, alcohol, then use 50, 70, 80, 95, and absolute. When the tissues are passed from a lower to a higher grade of alcohol, surplus moisture should be re- moved with blotting-paper to avoid lowering the percentage of the next grade. Preservation. — After being fixed and hardened, tissues are usu- ally preserved in 80 per cent, alcohol. Those fixed by formalin may remain in a 10 per cent, solution thereof. Golgi preparations keep indefinitely in the silver nitrate solution. Corrosive sublimate tissues will not cut well if kept too long in any kind of alcohol; they had better be kept in cedar oil. 256 POST-MORTEM EXAMINATIONS Pathological Conditions suggesting Certain Fixatives. — Acute in- fectious processes : Alcohol. Acute inflammatory exudates : The fibrin, leucocytes, and red blood-corpuscles of hemorrhagic conditions are preserved especially well in Zenker's fluid. Albuminous degenerations : Corrosive sublimate, Zenker, or boil- ing water. Amoebae coli : Stain especially well with Mallory's chlorid of iron haematoxylin ; any fixative may be used except perhaps formalin. Amoebae coli may be studied either in the faeces or in the tissues. Col- lect the faeces in a perfectly clean dry vessel, warmed in cold weather, and keep them at the temperature of the room. Add a drop of a weak solution of toluidin blue to a particle of the faeces, make a cover-slip preparation, and preserve in Farrant's medium. For the tissues fix in Heidenhain's or Bensley's solution, stain with iron haematoxylin or with a weak solution of toluidin blue. If a contrast stain is desired, stain first with eosin or benzo-purpurin, then for fifteen or twenty minutes with a weak solution of toluidin blue ; differentiate with alcohol. Amyloid degenerations : Corrosive sublimate, Zenker, alcohol. Blood : Make thin films on cover-glasses ; dry in air ; then place in absolute alcohol and ether, equal parts, for half an hour. Bone : For infectious processes, alcohol ; for histological purposes, Zenker, Orth. Bone must always be fixed before decalcifying. Bone marrow : Make smears on cover-slips. Fix pieces of bone marrow in Zenker or formalin. Cartilage: Alcohol, Zenker, Orth. Central nervous system : A whole brain may be hardened in about three thousand cubic centimetres of Muller's fluid. Change every day for a week, then every week for four weeks, and every two weeks thereafter; it takes about three months to complete the hardening. Keep in a refrigerator if the weather be very warm. Erlicki's fluid hardens better and its action is more rapid, hardening being accom- plished in about four weeks. In a 10 per cent, solution of formalin a whole brain may be hard- ened in from ten days to two weeks. Change the solution every day for three days, then every third day. Cerebral hemispheres may be sectioned by Meynert's method and hardened in twenty-four hours in Ohlmacher's solution. These methods are not recommended for fine work. Pieces not larger than one centimetre may be hardened PRESERVATION OF TISSUES 2 $J in formalin and then subjected to any bichromate or osmic acid mor- dant, including Golgi's methods. Ganglion cells : For Nissl's method fix in 96 per cent, alcohol. For Lenhossek fix in 90 per cent, alcohol (or 10 per cent, formalin) and follow with 96 per cent, alcohol. For Golgi methods use Golgi fixatives. Myelin sheaths : For Weigert fix with 5 per cent, bichromate until " ripe," — that is, until color contrasts between white and gray matter are well developed. For Marchi use Miiller's fluid. Use formalin for Busch-Mallory, Weigert, Weigert-Pal, and Heller. For Exner use 1 per cent, osmic acid; change second day; leave pieces in for five or six days. Neuroglia fibres : These are not well preserved by chromates. For Weigert methods fix in formalin. For Mallory fix in ten per cent, formalin in a saturated aqueous solution of picric acid. Medulla, pons, and basal ganglia : They may be removed together en masse and hardened entire in formalin for from one to two weeks, then cut into parallel slices not over one centimetre thick, and mor- danted by Weigert's quick method or Mallory's or in any way de- sired. Golgi stains are not very applicable to the medulla. Axis-cylinders and their terminal processes : For Freud's or Stroebe's gold stain fix in Erlicki or Miiller. For Gerlach's method harden in 0.5 per cent, solution of bichromate of ammonium for from one to three weeks. (For Golgi see " Golgi methods" under Bi- chromate of Potassium. ) Degenerated nerve-fibres : Harden in Miiller or Erlicki for Marchi or Algeri methods, or harden in 10 per cent, formalin followed by Miiller and Erlicki. Peripheral nerve-fibres : Fix in chlorid of iron. Retina : The retina may be fixed in a 10 per cent, solution of for- malin; in Zenker's, Orth's, or Lindsay Johnson's solution, as given under Bichromate of Potassium; in equal parts of glacial acetic acid and osmic acid (2 per cent.) ; in equal parts of chromic acid and pla- tinic chlorid (each 1.4 per cent.) ; or it may be pinned out on a cork and exposed to the vapor of a 1 per cent, solution of osmic acid. Colloid material : Formalin or Orth. Connective tissue: For Ribbert's phosphomolybdic hematoxylin stain for fibrillar fix in alcohol. For Mallory's anilin-blue stain fix in corrosive sublimate or Zenker. 17 258 POST-MORTEM EXAMINATIONS Elastic fibres : For Unna's orcein method fix in alcohol. For Wei- gert fix in alcohol or formalin. Fatty changes : Flemming, Orth, Miiller, Erlicki, or formalin. Fibrin: For eosin hematoxylin, methylene blue, and Mallory's anilin-blue stain fix in Zenker or corrosive sublimate. For infectious processes and Weigert's method fix in absolute alcohol. Glands : Fix in absolute alcohol. Granulation tissue: Fix in Zenker, Flemming, or Pianese for at- tendant degenerations. Hyaline degenerations : Zenker, corrosive sublimate, Orth. Liver: For pernicious anaemia and amyloid degenerations fix in alcohol. For bile capillaries use Golgi method. Mast-cells : For Ehrlich's or Unna's methods fix in alcohol. Mucoid material : For Mallory's anilin-blue stain fix in Zenker or corrosive sublimate. For other stains use Orth or 10 per cent, for- malin. Myxomas: Zenker or corrosive sublimate. (Edematous conditions : Throw small pieces of tissue into boiling water for a minute or two, or fix in corrosive sublimate. Ovaries : For follicular degenerations use Flemming or Hermann if tissues are fresh, if not use Zenker, Orth, Carnoy, or Ohlmacher. Pancreas : For Altmann's granules fix in equal parts of a 5 per cent, solution of bichromate of potassium and a 2 per cent, solution of osmic acid. Plasma cells : Zenker is especially favorable for showing eosino- philes. Pus or purulent conditions : Orth, Zenker, or corrosive sublimate. Skin is best fixed in alcohol. Spleen : For Heidenhain Biondi triple stain fix in corrosive sub- limate. For eosinophiles or Ehrlich's triacid use Zenker or alcohol. Suprarenal : If fresh fix in Flemming or Hermann ; if not, in Ohl- macher, Zenker, or Orth. Thyroid : For colloid degeneration fix in Orth or 10 per cent, formalin. Fixatives. — The following list gives the fixatives used for the various stains. Alum hematoxylin : Stains very slowly after chromic solutions. Anilin blue (Mallory) : Succeeds best after Zenker or corrosive sublimate. It may be used after formalin. PRESERVATION OF TISSUES 259 Biondi Heidenhain (see " Heidenhain Biondi"). Eosin and methylene blue : Best after Zenker. Freud's gold stain : For axis-cylinders and nerve terminals ; used after Miiller or Erlicki. Gold stains : Freud's, Stroebe's, after Miiller or Erlicki ; Gerlach after 0.5 per cent, bichromate of ammonium for from one to three weeks. Golgi chrome silver preparation : After Golgi fixing solutions. Heidenhain Biondi triple stain : Only after corrosive sublimate. Lenhossek : For ganglion cells 90 per cent, alcohol or 10 per cent, formalin, both followed by 96 per cent, alcohol. Nissl : For ganglion cells 96 per cent, alcohol. Orcein (see " Unna's orcein stain"). Phosphomolybdic acid hematoxylin : Best after alcohol. Phosphotungstic acid hsematoxylin : After 10 per cent, formalin. Thionin (Lenhossek's ganglion-cell stain) : 90 per cent, alcohol followed by 96 per cent, or formalin 10 per cent. Triple staining : Heidenhain Biondi only after corrosive subli- mate. Unna's alkaline methylene blue : Alcohol. Unna's orcein stain : For elastic fibres, alcohol. Weigert's stain : For fibrin and elastic fibres, absolute alcohol. Macroscopical Specimens. — If a microscopical examination of the organ to be preserved is desirable, portions of tissue therefor should be removed before anything is done towards preparing it as a gross specimen. If for any reason it be desirable to keep the specimen for a short time, it should be kept moist by being wrapped in cloths wet with a 10 per cent, formalin solution. If the specimen is to be shipped, wrap it in a cloth wet with such solution and pack it in parchment-paper, rubber cloth, or sawdust. Parenchymatous organs of slaughtered animals will keep for a week packed in this way and, when sectioned, the tissues appear fresh. The organs of deceased animals do not keep as well. If the specimen is to serve for a bacteriological investigation and for inoculations, it should not be wrapped in any disinfecting agent, but simply packed in parchment-paper or rubber cloth. By a percentage solution of formalin is meant such a dilution of the commercial 40 per cent, (which is sold as formalin) as will reduce it to the desired strength. For instance, ten cubic centimetres of 2 6o POST-MORTEM EXAMINATIONS commercial formalin added to ninety cubic centimetres of water pro- duce a 10 per cent, solution of formalin or a 4 per cent, solution of formaldehyde. The percentage of formalin must be maintained, as it is quickly exhausted; when there is no odor of formalin, the fluid should be renewed. It is not always necessary to save the entire organ to be examined, but enough should be preserved to show its relationship to the lesion. General Considerations. — Washing. — If alcohol be used as the preserving solution, blood and other impurities may be removed by a thorough washing with water. In other cases the parts should be carefully sponged with the preservative to be employed. Cavities should be distended with tow or absorbent cotton. The lungs should be placed in a jar and the jar filled by pouring the fluid through the trachea. Mucous and serous membranes should be pro- tected from the distortion caused by shrinkage by being pinned out on cork or on wood which will impart no color in soaking. A more elegant method is to sew the membranes over the edges of frames made of glass rods. The secreting surfaces of these membranes should always be uppermost. Compression of any part of the specimen should be avoided by the use of a soft cushion of absorbent cotton placed in the bottom of the jar. Jars made especially for museum preparations are prefer- able, but if necessary they may be replaced by such as are used by grocers and druggists for candy, etc. Preserving Fluids. — Alcohol is a convenient and efficient agent. It preserves form relationships very well, as in tumors, typhoid ulcers, invagination of the intestine, etc. ; but it destroys all contrasts in a pathological organ, such as a diseased lung or kidney, and makes recognition of the lesion very difficult. It bleaches the tissues and causes much shrinkage, so that natural appearances are not retained. The specimen is to be washed in water, then immersed in 60 per cent, alcohol (which is changed every day until it remains clear), and finally kept in 80 per cent, alcohol. To preserve the natural appearance of tissues, formalin followed by alcohol is used, and the specimen is finally placed in glycerin solution containing some salt of acetic acid, usually potassium. Formalin converts the haemoglobin into methsemo- globin and a brown color is developed ; alcohol changes the methaemo- globin into a red pigment, so that the flesh-color is restored. The tissues are so thoroughly hardened that they may be kept in the PRESERVATION OF TISSUES 2 6l glycerin solution without being thereby softened. The principles in- volved are simple, but their application requires experience and inge- nuity. All tissues do not respond equally to the treatment, and to retain some color peculiar to a certain pathological condition — such as prevails in icterus, for example — requires careful management. There are various formulae and different methods of applying them, but the two following are perhaps as simple and useful as any. It must always be remembered that if the tissues are placed in too strong formalin, or remain too long even in a weak solution, the alcohol will fail to transform the brown or gray pigment back into red. i. Place the fresh organ or a segment as large as the hand for from twenty-four to forty-eight hours in one of the following solu- tions. Kaiserling fluid : Formalin 200 cc. Water 1000 cc. Potassium nitrate 15 grammes. Potassium acetate 30 grammes. Melnikow-Raswedenkow : Formalin 10. parts. Sodium acetate 3. parts. Potassium chlorate 0.5 part. Distilled water 100. parts. It is well to wrap the specimen in wadding and pour the fluid over it. The wadding protects the organ from distortion due to com- pression. If the organs are very thick, incise them or inject the blood- vessels, ureters, etc., with the fluid. This should be done very gently, in order not to wash out the blood. Formalin is very injurious to the respiratory tract and the skin. Hence it is better when using it to wear rubber gloves and to keep the jars covered. 2. After two days place the specimen in 60 per cent, alcohol, first removing the wadding. Two or three days later change to 80 per cent, alcohol, then to 90 or 93 per cent. 3. The specimen is finally placed in the preserving fluid: Glycerin 400 grammes. Potassium acetate 200 grammes. Water 2000 grammes. 2 6 2 POST-MORTEM EXAMINATIONS The solutions may be used several times, but a fresh preserving fluid is better, and it is even advisable to change it occasionally. Pick adds at once to the formalin solution 5 per cent, of Carlsbad salts, which prevents the formation of acid hsematin, while Marpmann uses fluorsodium both in the formalin solution and in the glycerin. The use of ten parts of an 0.8 per cent, salt solution with one part of the 40 volume strength formalin is also recommended. Little John 1 recommends that fresh specimens or those preserved by any well-known method be kept in glass jars made air-tight by sealing their covers with gold size and putty. The one objection to this method is the vapor which collects in the jars. To avoid this the preparations are soaked for several weeks in glycerin and water and afterwards placed on wool to which some formalin glycerin is added. Perfectly washed stomachs from cases of poisoning, such as carbolic acid and the corrosive acids, require no preservative whatever, and when prepared in this manner retain their natural and characteristic coloring for many years. 1 Journal of Pathology and Bacteriology, September, 1902. CHAPTER XXIV BACTERIOLOGICAL INVESTIGATIONS It frequently happens that the bacteriological investigation is a most important factor in the ultimate value of a post-mortem exami- nation, but, because of the lack of facilities or of knowledge of technic, it is neglected. In the first place, the cost of equipment, as in post-mortem sets, is very largely limited by the conveniences, rather than the necessities. Culture-tubes can be obtained from the larger pharmaceutical manufacturing companies and their agencies quickly and at reasonable rates. In the second place, the technic is not so complicated as to require especial skill, except in the finer manipula- tions and diagnoses. It is not unreasonable to expect the general prac- titioner who is not within easy reach of a pathological laboratory or of a board of health to be sufficiently equipped with apparatus and ade- quately trained to make cultures and even inoculations for diagnostic purposes. Of course, it is impossible under such circumstances to do the work of well-endowed laboratories and skilled bacteriologists, but the material can at least be studied until the time arrives for placing it in the hands of those devoting their especial attention to the study of bacteriology. As stated elsewhere, every operator should go to the autopsy pre- pared not only to save and to preserve morbid specimens, but also to provide for proper bacteriological investigation. The important factor in the technic of a bacteriological examina- tion is that all instruments shall be scrupulously clean and absolutely sterile, and all sources of contamination carefully guarded against in every possible manner. The fluid contents and accumulations in abscess and serous cavi- ties, especially meningeal, pericardial, peritoneal, and pleural, the blood, endocardial vegetations, ulcerated surfaces, and the cut surface of solid organs may present foci of bacterial invasion which are examined by " smear preparations" and cultures. Smear Preparations. — These are made in the following man- ner: Having a number of carefully cleaned and dried cover-slips in 263 264 POST-MORTEM EXAMINATIONS readiness, 1 with a platinum wire, which has just been sterilized by heating to a red glow in an alcohol flame or the upper (hottest) part of a Bunsen burner, a drop of the fluid is put in the centre of one slip and another slip is placed upon it; the two are very gently pressed together and then separated by sliding one over the other until they come apart, thus leaving the material thinly and quite evenly distributed over both slips. The same result may be accom- plished, though not so satisfactorily, by placing the drop near the edge of the slip and spreading it out by drawing a smooth-edged slide broad-side over it. Or the fluid may be spread with the platinum wire zigzag over the slide, instead of the cover-slip, because the former is easier of manipulation, not so readily broken by subsequent handling, and allows a larger field of observation. Should there not be sufficient fluid to make a satisfactory smear preparation, a little distilled water or physiological salt solution may be added to the glass before performing the above manipulations. The cover-slip or slide may be touched directly to a freshly cut surface of the solid organ, which has been incised with a scalpel sterilized by heat, or the material may be removed by a specially con- trived platinum spear having a hole in its end or in the ordinary manner with the ose. The " smear" being dried with very little or no heat, there yet remains to " fix" it on the glass. This is done by the routine method of passing the glass three times through a flame, with the smeared surface upward to avoid burning the material. In this way the albuminous organic matter is dried or coagulated and the bacteria are thus caused to adhere to the glass surface. In " fixing" very great care must be used to avoid the application of too high a tem- perature, — -shown by a brownish coloration, — which would seriously distort the bacteria, especially if the film had not been thoroughly dried previously. Such a preparation will keep for a considerable length of time, and can be safely and easily protected by gumming the clean surface to a piece of card-board cut to the size of the ordinary glass slide, on which also may be written all necessary data. The cards may then be packed in an ordinary pill box, care being exer- 1 It is well to use new cover-slips which have been cleansed in strong nitric acid, washed in distilled water, and kept in alcohol to which a few drops of ammonia have been added. When wanted for use, they must be wiped dry between the fingers with a clean handkerchief. BACTERIOLOGICAL INVESTIGATIONS 265 cised that the films do not come in contact with anything that will be liable to rub or scratch them. A diagnosis made from the study of smear preparations must often be corroborated by cultures, though such study will frequently offer valuable suggestions as to the kind of culture-media to employ. The negative value of a slide from a suspected syphilitic sore may be considerable and is not sufficiently appreciated. Inoculating Culture-Media. — For the formulae and methods of preparing culture-media and tubes the reader is referred to any standard work on bacteriology. Test-tubes containing any of the solid or liquid media may be inoculated at the place where the autopsy is performed when it is not so far from the laboratory as to endanger the growth of the culture by exposure to extremes of temperature. Sufficient heat is secured, however, by placing the tubes after inoculation, securely wrapped, in an inside coat-pocket. The culture-tube is held in the left hand, in an almost horizontal position, if the medium be liquid, between the thumb and index-finger. Should the tube contain a solid medium, such as blood-serum or agar, it is inverted. The ose, held in the right hand, is now sterilized by heat and cooled, while the cotton plug is removed from the test-tube by a cork-screw motion and held, inner part outward, between the index and middle fingers of the left hand in such a manner that it does not come in contact with any portion of the hand. With the tip of the platinum wire a small portion of the substance to be inoculated is now placed on the surface of the medium ; if this surface is slanting the fluid is rubbed gently over it, thus making a " smear" or " stroke" cul- ture, while the needle is thrust deep down into the medium if a " stab" culture is to be made. The ose is then withdrawn, the cotton plug reinserted, the needle sterilized, and the tube labelled and put in a warm place until it can be sent to the laboratory. If the culture is to be made from the surface of a solid organ, the method is the same, except that the organ is incised with a very sharp and absolutely sterile knife, and in addition it is well, as a precau- tionary measure, to sterilize the surface again before plunging the needle deep into the tissue. Post-mortem examination of animals dying from diseases pro- duced by experimental inoculation should always be made as soon as possible, so as to prevent the invasion of the tissue by other bacteria 266 POST-MORTEM EXAMINATIONS than those causing the fatal malady; it may usually be done within twelve hours after death. Fig. 153 shows the position generally adopted for the performance of necropsies upon the smaller animals, such as the guinea-pig. It will there be seen that the body is placed on a board in the same position as in crucifixion and securely held there by nails driven through the feet and the tip of the nose. An external examination is first carefully made, the weight determined, temperature taken, etc., especial attention being paid to the wound of inoculation. Numerous smears and cultures are produced from cutaneous lesions and from the initial incisions, which are usually made with sterilized scissors, the parts having previously been moistened with alcohol or with a 1 to 500 solution of the bichloride of mercury. The skin is then dissected away and tacked to the board, so as not later on to contaminate the field of operation. After the strictest precau- tions — heat being* the agent employed for the sterilization of the instruments — the thorax and abdomen are opened. This is done by heating a knife to a red heat and bringing it in contact with the por- tion of the body or organ in which the culture is to be made. Nuttall's platinum spear may be used, instead of the platinum wire, for the purpose of removing the material. Every precaution should be taken to prevent dispersion of the bacteria, as, e.g., by the dropping of cover-glasses, which on becoming broken might cause infection later on. Portions to be preserved for microscopic study are put in fixing solutions, such as those mentioned in Chapter XXIII. When the postmortem is completed, the animal should be placed in a cloth wrung out with formalin and immediately cremated. The pan and all implements employed should be thoroughly sterilized by heat, and nothing should be left behind which in any way has come in contact with the blood or other portions of the body in which the pathogenic germs are to be found. CHAPTER XXV WEIGHTS AND MEASURES It is customary in this country and in England to give the weights of the organs in avoirdupois ounces, their dimensions in inches, and their capacity in cubic inches, though the metric system has more to commend it and is fast gaining favor in English-speaking countries. Troy weight is sometimes used and may give rise to much confusion. The grain is the same in both Troy and avoirdupois weights. The ounce avoirdupois is 437.5 grains, or 28.34 grammes. The ounce Troy is 480 grains, or 3 1 . 1 grammes. To convert grammes into avoir- dupois ounces divide by 28.34, into Troy ounces divide by 31.1. Con- versely, to convert ounces avoirdupois into grammes multiply by 28.34 ; Troy ounces multiply by 3 1 . 1 . A kilogramme equals one thousand grammes, or 2.2 pounds. A gramme equals one thousand milligrammes, or 15.433 grains. A metre equals one thousand millimetres, or 39.37 inches. A litre equals one thousand cubic centimetres, or 61.027 cubic inches, and is equiva- lent to 2.1 13 American pints or 1.76 English pints. I. Average height (European standard) : Adult male 172 centimetres, or 5 feet 7.7 inches. Adult female 160 centimetres, or 5 feet 3 inches. New-born male 47.4 centimetres, or 18.66 inches. New-born female 46.75 centimetres, or 18.4 inches. When a child is two years old, it is about one-half as tall as it will be when fully grown. II. Average weight (European standard) : Adult male 65 kilogrammes, or 143 pounds (av. ). Adult female 55 kilogrammes, or 121 pounds. New-born child 3250 grammes, or 7.15 pounds. The American Insurance standard : 1 A man of five feet and one inch should weigh 120 pounds. A man of five feet and three inches should weigh 130 pounds. A man of five feet and six inches should weigh 143 pounds. A man of five feet and nine inches should weigh 155 pounds. A man of five feet and eleven inches should weigh. . . . 165 pounds. 1 From Finlayson's Clinical Manual. 267 268 POST-MORTEM EXAMINATIONS A child may be born weighing less than a pound and live. The greatest recorded weight attained by man is some iooo pounds. According to Orth, the mean length of a full-term, sound child is between fifty and fifty-one centimetres, the male being slightly longer than the female. The average weight of a full-term boy at birth is thirty-six hundred grammes, that of a girl thirty-two hundred and fifty grammes. For the last five lunar months of fetal life, if the height expressed in centimetres be divided by five, the approximate age of the child in lunar months will be obtained. For example, if the child measures thirty-five centimetres, we divide this by five, and we have seven, which is the number of months which the child has passed in ittero. The fetal age of the child in the first five months about equals the square root of the height expressed in centimetres. For example, if the height is sixteen centimetres, the child is four lunar months old. In terms of the English system the length of the new-born child is twenty inches, which divided by two will give approximately the number of lunar months the child has passed in ntero. According to Hirst, the following are the dimensions of a full- term, healthy child : Length of hair, from two to three centimetres ; anterior fontanel, from two to two and one-half centimetres ; occipito- frontal circumference, thirty-four and one-half centimetres ; occipito- frontal diameter, eleven and three-fourths centimetres ; occipitomental diameter, thirteen and one-half centimetres; bisacromial diameter, twelve centimetres; intertrochanteric diameter, nine or ten centi- metres. Lambinon 1 gives the following figures, obtained at the Liege Ma- ternity, as to the weight of the placenta in cases of miscarriage. The average weight of the placenta at six weeks was 20 grammes (about 5 drachms) ; at ninety days, 67 grammes (17% drachms) ; at one hun- dred and twenty days, in grammes (28% drachms) ; at one hundred and sixty-five days, 262 grammes (67% drachms) ; and at two hundred and thirty-five days, 330 grammes (8514 drachms). Nauwerck gives the following measurements and weights of the healthy infant at full time: Average length, from fifty to fifty-one centimetres (boys generally larger than girls) ; maximal length, fifty- 1 De la determination de I'age du foetus d'apres le poids du placenta dans les cas de fausse couche. Paris, 1898. WEIGHTS AND MEASURES 269 eight centimetres ; minimal length, forty-eight centimetres ; average weight (v. Hecker), thirty-two hundred and seventy-five grammes (boys thirty-three hundred and ten grammes, girls thirty-two hundred and thirty grammes) ; maximal weight, fifty-five hundred grammes; minimal weight, twenty-five hundred grammes. Weight of the different organs and measurements of various parts : Brain 380 grammes ( Bischoff ) . Brain 348 grammes ( Meynert) . Thymus 14 grammes (Friedleben). Heart 20.6 grammes (Thoma). Lungs 58 grammes. Width of the large fontanel 2-2.5 centimetres. Head : circumference 34.5 centimetres'. Occipitofrontal diameter 11. 5 centimetres. Biparietal diameter 9.0 centimetres. Bitemporal diameter 8.0 centimetres. Occipitomental diameter 13.5 centimetres. Trachelobregmatic diameter 9.5 centimetres. Spleen 11. 1 grammes. Kidneys (together) 23.6 grammes (Thoma). Testicles 0.8 gramme. Liver 118 grammes. The rule 1 that a child has usually attained double its birth weight at the fifth month and triple at from the twelfth to the fourteenth month is convenient and useful in estimating an infant's probable age. III. Table of approximate weight of the internal organs : 2 Adult, New-born, grammes, grammes. Brain 1397 385 Heart 304 24 Lungs . . 1172 58 Liver 1612 118 Pancreas 201 11.1 Right kidney 141 Adult, New-born, grammes, grammes. Left kidney 150 Both kidneys 299 23.6 Testicles 48 0.8 Muscles 29,880 625 Skeleton 11,560 445 IV. The body weight by percentage Adult, New-born, per cent. per cent. Heart - 0.52 0.89 Lungs 2.01 2.16 Stomach and alimen- tary canal 2.34 2.53 Pancreas 0.346 0.41 Adult, New-born J per cent. per cent. Liver 2.77 4.39 Brain 2.37 14.34 Thymus gland 0.0086 0.54 Skeleton 15-35 16.70 Muscles 43-09 23.40 1 Graham, Archives of Pediatrics, January, 1899. 2 Tables are from Vierordt, quoted by Ziegler, 7th German ed., vol. i. p. 181. 270 POST-MORTEM EXAMINATIONS In measuring an organ its length, breadth, and thickness may often be more quickly and accurately ascertained by thrusting the steel rule through it than in any other manner. THE SKULL AND ITS CONTENTS. Shape. — Even in members of the same race the form of the skull is subject to marked variations, and these are still greater when indi- viduals of different races are compared. The characteristic measure- ments of the cranium are its length, height, and breadth. The cephalic index is the ratio of its length (taken as one hundred units) to its breadth. The altitudinal index is the ratio of its length to its height. The accepted horizontal plane is that passing through the upper edges of the external auditory meatus and the lower orbital margin. According to the variations of the cephalic index, we distinguish the dolichocephalic (index less than 75) and the br achy cephalic (index more than 80) types. Intermediate forms are called mesocephalic. If the ratio of the breadth to the height is less than 70, the skull is platycephalic; if between 70 and 75, or tho cephalic; if above 75, hypsi- ccphalic. The character of the facial profile is indicated by the facial angle of Camper, — namely, the angle between a line on the level of the external auditory meatus and the floor of the nasal cavity and a line touching the middle of the forehead and the anterior portion of the alveolar process of the superior maxilla. If this angle be 80 de- grees or more, the skull is called orthognathous; if it is between 80 degrees and 65 degrees, prognathous (Gegenbaur). Pathological types of skull are due in part to premature synostosis. Among them we distinguish the hydrocephalic type (from dropsy of the ventricles), the cephalonic (or big head), the microcephalic (or small head), the dolichocephalic (or long head), the spheno cephalic (or wedge-shaped head, due to compensatory development of the ante- rior fontanel), the leptocephalic (or narrow head), the clinocephalic (or saddle-shaped head), the trigono cephalic (or triangular head, due to narrowing of the frontal bone from fetal synostosis of the frontal suture), the br achy cephalic (or short head), the pachycephalic (in which the bones of the cranium are thickened), the oxycephalic (or pointed head), the platycephalic (or flat head), the trochocephalic (or round head), and the plagiocephalic (or unsymmetrical oblique head). 1 1 Ziegler's Text-Book of Special Pathological Anatomy, English Translation by MacAlister and Cattell, vol. i. pp. 206, 207. WEIGHTS AND MEASURES 27 1 Weight. — The maximum weight of the adult male encephalon is about 2222 grammes, or 74 ounces, and the minimum is about 960 grammes, or 34 ounces. The average is about 140G grammes, or 49.5 ounces. The maximum weight of the adult female encephalon is about 1585 grammes, or 56 ounces, and the minimum is 880 grammes, or 31 ounces. The average is from 1230 to 1245 grammes, or from 43^ to 44 ounces. Thus it will be seen that the adult male brain is on an average four or five ounces, or about nine per cent., heavier than that of the female. See also American Medicine, May 17, 1902, p. 830. Table showing in grammes the mean weights of the brain at dif- ferent ages in the two sexes : Male. Female. Children stillborn at term 393 347 Children born alive at term 330 283 Under three months of age 493 45 1 From three to six months 602 560 From six to twelve months 776 727 From one to two years 941 843 From two to four years 1,095 99° From four to seven years 1 ,138 i, 135 From seven to fourteen years 1,301 x , J 54 From fourteen to twenty years i,374 1,244 From twenty to thirty years i,333 i, 2 37 From thirty to forty years 1,364 1,220 From forty to fifty years 1,35* 1,212 From fifty to sixty years i,343 1,220 From sixty to seventy years I ,3 I 3 1,208 From seventy to eighty years 1, 288 1, 168 Over eighty years 1,283 I , I2 5 By the above table it appears that the brain is relatively heavier between fourteen and twenty years of age than at any other period; but according to Broca, and also Peacock, the maximum is attained between the ages of twenty-five and thirty-five. Orth quotes Meynert, whose results were obtained from the inves- tigation of 157 cases in the Vienna insane asylum. He gives the mean weight of the brain, in men between the ages of twenty and sixty-nine years, as 1296 grammes; in women, 11 69 grammes. He says the maximal weight is attained during the fourth decade in men and the fifth decade in women. The average weight of the cerebrum is 10 18 grammes in men and 917 grammes in women; of the brain stem, 143 grammes in men and 129 grammes in women; of the cerebellum, 135 grammes in men and 123 grammes in women. Weisbach found that 272 POST-MORTEM EXAMINATIONS in sane German- Austrians the brain weighed 13 14.5 grammes in men and 1179.52 grammes in women, while the cerebrum weighed 1154.97 grammes in men and 1038.90 grammes in women, the cerebellum 142.2 grammes in men and 125.56 grammes in women, and the pons 17.33 grammes in men and 15.06 grammes in women. Bischoff found the weight of the pia and arachnoid to be from 25 to 40 grammes. Nauwerck quotes Vierordt, who found the mean weight of the brain in men within the ages of twenty and eighty years to be 1359 grammes, in women 1235 grammes. The weight of the encephalon relative to that of the body is subject to great variation, but may approximately be put down as 1 to 36.5 in the adult male and 1 to 35.2 or 1 to 36.46 in the female. These figures are based on observations upon persons dying from more or less pro- longed disease, but in the cases of a few individuals who died suddenly from disease or accident the average ratio was found to be 1 to 41. The proportion to body weight is much greater at birth than at any other period of extra-uterine life, being about 1 to 5.85 in the male and 1 to 6.5 in the female. The weight of the human cerebrum also bears a somewhat definite relation to the stature of the individual. The weight in ounces may be obtained for a male by dividing the height in inches by 1.6, and for a female by multiplying the quotient thus obtained by ff-. The weight in grammes may be obtained by multiplying the height in centimetres by 7 for a male, and the product again by ff for a female. Thus, Weight in ounces of the mean cerebrum . _ height in inches ~~ i~6 Weight in ounces of the mean female cerebrum = — - X Weight in grammes of the mean male cerebrum . . = height in centimetres X 7 Weight in grammes of the mean female cerebrum = height in centimetres X 7 X These proportions are slightly deficient for the higher and ex- cessive for the lower statures. Dimensions. — The mean cubic capacity of the male cranium is 1450 cubic centimetres; that of the female is 1300 cubic centimetres (Welcker). The length of the male brain is from 160 to 170 milli- metres, or from 6| to 6f inches, and that of the female brain is from 150 to 160 millimetres, or from 6 to 6f inches. The greatest trans- verse diameter is 140 millimetres, or 5f inches, and the greatest ver- WEIGHTS AND MEASURES 273 tical diameter is 125 millimetres, or 5 inches. The volume is about 1330 cubic centimetres, or 81 cubic inches. The specific gravity of the brain is from 1035 to 1040. THE HEART. Weight. — The mean weight of the heart in the adult male is about 310 grammes, or 11 ounces; its proportion to the body weight is 1 to 169. That of the adult female is about 255 grammes, or 9 ounces; proportion to body weight, 1 to 149. According to Krause, the pro- portion of the heart weight to the body weight is as 1 to 169 in men and as 1 to 162 in women. The weight of the heart increases with the body weight, but in a gradually decreasing ratio, until the seventieth year, when it begins to diminish. At birth it is about 24 grammes: proportion, 1 to 130 (Quain). Dimensions. — The heart is generally of about the same size as the right fist of the individual. Its extreme length is about 125 milli- metres, or 5 inches ; width, 87 millimetres, or 3 inches ; thickness, 62 millimetres, or 23/2 inches. The thickness of the wall of the right ventricle is from 2 to 3 millimetres, or Yt to Y% of an inch ; of the left ventricle, from 7 to 10 millimetres, or J4 to -§■ °^ an inch. Patho- logically these measurements may be increased threefold. Nauwerck and Orth quote Bizot as follows : The weight of the heart is 300 grammes in men and 250 grammes in women. The length in men is from 85 to 90 millimetres, in women from 80 to 85 milli- metres; the breadth in men is from 92 to 105 millimetres, in women from 85 to 92 millimetres; the thickness in men is from 35 to 36 milli- metres, in women from 30 to 35 millimetres. The thickness of the right ventricle without the trabeculse is from 2 to 3 millimetres in men and slightly less in women; the left ventricle is from 7 to 10 milli- metres thick. The dimensions of the orifices of the heart are shown in the fol- lowing tabular statement. r\-r\&^^ r,;, mDfor Circumference. Area. Orifices. . Diameter. Male Female. Male. Female. Aortic 24 to 25 mm., or 81 mm. 76 mm. 530 sq. mm. 452 sq. mm. 0.9 to 1 in. Mitral 30 to 35 mm., or 103 mm. 101 mm. 855 sq. mm. 804 sq. mm. 1.2 to 1.4 in. Pulmonary 27 to 30 mm., or 91 mm. 89 mm. 660 sq. mm. 615 sq. mm. 1.1 to 1.2 in. Tricuspid 37 to 45 mm., or 122 mm. 115 mm. 1194 sq. mm. 1017 sq. mm. 1.5 to 1.8 in. 2J4 POST-MORTEM EXAMINATIONS Volume. — In the new-born this is about 22 cubic centimetres, which is increased to 250 centimetres at twenty years and about 280 centimetres at fifty years, after which it gradually decreases. Up to the age of puberty it is about the same in both sexes, but after that it is from twenty-five to thirty centimetres larger in the male. Because of obvious difficulties, these figures can only be regarded as approxi- mate. THE LUNGS. Weight. — Obviously the lungs are subject to great variation in weight, depending upon the amount of blood or other liquid and of air in their cavities. Their combined weight ranges from 850 to 1370 grammes, or from 30 to 48 ounces, the average being from 1020 to 1 190 grammes, or from 36 to 42 ounces (1300 grammes in the male and 1023 grammes in the female. — Krause). The right is generally 2 ounces heavier than the left. The weight of the right lung is from 360 to 570 grammes: that of the left lung, from 325 to 480 grammes (Schmaus quoted by Nauwerck). The lungs are absolutely heavier in the male and also appear to be heavier in proportion to the body weight. Dimensions. — The extreme length of the right lung in the male is 271 millimetres, or rof inches, and that of the left is 298 milli- metres, or 12 inches: and in the female. 216 millimetres, or 8f inches, and 230 millimetres, or 9-5- inches, respectively. The extreme outer and posterior diameters in the male are, of the right, 203 millimetres, or 8 J /g inches, and of the left. 176 millimetres, or 7 inches; and in the female, 176 millimetres, or 7 inches, and 162 millimetres, or 6^2 inches, respectively. The transverse diameter at the base is, in the male, 135 millimetres, or 5I inches, for the right, and 129 milli- metres, or 5 1 6 inches, for the left. In the female the measurements are 122 millimetres, or 4]/$ inches, and 108 millimetres, or 4 J- inches, respectively. (Krause, quoted by Vierordt.) The specific gravity of the healthy adult lung varies from 345 to 746. When fully distended with air it is about 126. while that of the lung tissue itself, entirely deprived of air. is about 1056. THE LIVER. Weight. — The liver weighs from 50 to 60 ounces in males, a little less in females. Its mean weight is 1600 grammes. — from a minimum of 1247 grammes to a maximum of 1981 grammes, — according to WEIGHTS AND MEASURES 275 Vierordt, quoted by Nauwerck. In a four-months foetus it is about one-tenth of the body weight ; at birth it is one-twentieth ; in the adult male it is one-fortieth ; in the adult female it is one-thirty-sixth. Dimensions. — (Ouain.) The transA^erse diameter is from 150 to 200 millimetres, or 6 to 8 inches; vertical diameter, from 125 to 175 millimetres, or 5 to 7 inches; and anteroposterior, from 100 to 150 millimetres, or 4 to 6 inches. (Morris.) Transverse, from 175 to 250 millimetres, or 7 to 10 inches; vertical, from 150 to 175 millimetres, or 6 to 7 inches; and anteroposterior, from 75 to 150 millimetres, or 3 to 6 inches. (Gray.) Transverse, from 250 to 300 millimetres, or 10 to 12 inches; vertical, 75 millimetres, or 3 inches; and anteroposterior, from 150 to 175 millimetres, or 6 to 7 inches. Right lobe, from 18 to 20 centimetres. Left lobe, from 8 to 10 centimetres. Longitudinal diameter ; right, from 20 to 22 centi- metres ; left, 15 or 16 centimetres. According to Orth. the transverse diameter is from 25 to 30 centi- metres, that of the right lobe being from 18 to 20 centimetres and that of the left from 8 to 10 centimetres. The anteroposterior diameter averages from 19 to 21 centimetres, — from 20 to 22 centimetres for the right lobe and 15 or 16 centimetres for the left. The greatest ver- tical diameter is from 6 to 9 centimetres. Volume. — This varies from 1475 t0 J 638 cubic centimetres, or from 90 to 100 cubic inches. The mean volume is 1574 cubic centi- metres. The specific gravity is between 1050 and 1060, which in fatty de- generation may be reduced to 1030 or even less. Supernumerary livers may weigh an ounce or more. THE KIDNEYS. Weight. — Each kidney weighs from about 127.5 to 1 7° grammes, or 4^2 to 6 ounces, in the male, and from 113 to 156 grammes, 4 to $y 2 ounces, in the female. The left kidney is usually a little heavier than the right, — from 5 to 7 grammes heavier, according to Orth, who states that one kidney weighs about 1 50 grammes, while both kidneys after the removal of the connective tissue of the hilum weigh 320 grammes in men and 293 grammes in women. At the end of the first year the kidneys together weigh 62 grammes. The ratio of the weight of the kidneys to the body weight is as 1 to 200. The mean proportion 276 POST-MORTEM EXAMINATIONS of the weight of the heart to the weight of the kidneys between the ages of twenty and thirty-five years is as 1 to 1.1 (Thoma). Dimensions. — Length about 100 millimetres, 2^ inches; breadth and thickness, from 30 to 35 millimetres, 1^ to i/ 2 inches; or in the proportions of about 1 to y 2 to %. The left kidney is usually a little longer and narrower than the right. Nauwerck states that the kidneys are from 11 to 12 centimetres long, 5 or 6 centimetres wide, and 3 or 4 centimetres thick. Specific Gravity. — About 1050. The following points serve to distinguish between the right and left kidneys. Right Kidney. Left Kidney. Impression from liver. No impression from spleen. Shorter and broader. Longer and narrower. From five to seven grammes lighter. About five to seven grammes heavier. The spermatic or ovarian vein empties The spermatic or ovarian vein empties into the inferior vena cava. into the renal. In both kidneys the posterior surface is the natter, the external border is convex, the internal border concave, and the upper portion is more expanded than the lower. At the hilum the attachment of ves- sels and ureter is, from above downward, the body being in the erect posture, artery, vein, ureter ( AVU) ; and from before backward, vein, artery, ureter (VAU). Place the organ on the table, with its pos- terior surface down, the lower extremity (the ureter pointing down- ward) being towards the observer. The ureter is then behind and below the other vessels, and the hilum will be directed towards the side of the operator to which the kidney belongs, — i.e., towards the left hand if it is the left kidney, and towards the right hand if it is the right kidney. SUPRARENAL BODIES. Weight. — Each suprarenal weighs about 4 grammes, or 1 drachm, the left being slightly the heavier. They are nearly as large at birth as in adult life. Orth gives the weight in adults as from 4.8 to 7.3 grammes. Dimensions. — Vertical length is from 30 to 50 millimetres, or ij4 to 2 inches; breadth, from side to side, about 30 millimetres, ij4 inches ; thickness, from 5 to 6 millimetres, \ to ]/^ inch. Nauwerck states that the mean diameters are from 4 to 5 centimetres, 2.5 to 3.5 centimetres, and 0.5 centimetre. WEIGHTS AND MEASURES ^77 THE SPLEEN. II 'eight. — This organ varies within wide limits in both size and weight. Ordinarily its weight is between 100 and 300 grammes, or 3^2 and 10 ounces, with the average at about 170 grammes, or 6 ounces. In intermittent and some other fevers it may weigh 18 or 20 pounds. Orth states that the normal weight varies between 150 and 250 grammes. Its weight in proportion to the body weight is at birth about 1 to 350; in the adult, 1 to from 320 to 400; and in old age, 1 to 700. Dimensions. — Generally the spleen is from 125 to 150 millimetres, or 5 to 6 inches, in length; from 75 to 90 millimetres, or 3 to 3^2 inches, in breadth; and from 25 to 40 millimetres, or 1 to 1J/2 inches, in thickness. According to Orth, the length is from 12 to 14 centi- metres, the breadth 8 or 9 centimetres, and the thickness 3 or 4 centi- metres. Volume. — This does not usually exceed from 200 to 300 cubic centimetres, or 12 to 18 cubic inches. Orth gives 221.5 cubic centi- metres as the mean volume. THE PANCREAS. Weight.* — The weight is very variable, — from 30 to 100 grammes, or 2 to 3^ ounces, and may even be 170 grammes, or 6 ounces; in adults, from 90 to 120 grammes (Orth). Dimensions. — From 120 to 150 millimetres, or 5 to 6 inches, in length; and from 12 to 25 millimetres, or / 2 to 1 inch, in thickness. Length 23 centimetres, breadth 4.5 centimetres, thickness 3.8 centi- metres (Orth). Specific Gravity. — 1046. THE THYMUS GLAND. Weight. — At birth this gland weighs about half an ounce. In twenty adult cases it was found to average 5 grammes (Quain). Nauwerck quotes Friedleben, who says that the thymus weighs at birth 14 grammes and at nine months of age 20 grammes. Up to the second year it weighs a little more than 6 grammes, and from the third to the fourteenth year a little less than 26 grammes. Dimensions. — At birth the length is about 60 millimetres, or 2 inches; width, 37 millimetres, or i}4 inches; and thickness, from 6 278 POST-MORTEM EXAMINATIONS to 8 millimetres, or J4 to Vs °f an inch. From birth to the ninth month the length is 5.91 centimetres (Friedleben) ; from the ninth month to the second year, 6.96 centimetres, and from the third to the fourteenth year, 8.44 centimetres. The breadth across the middle is from 2.7 to 4.1 centimetres; above and below, from 0.7 to 0.9 centi- metre (Nauwerck). THE THYROID GLAND. Weight. — From 28 to 56 grammes, or 1 to 2 ounces, being larger in the female. Orth gives the weight as from 30 to 60 grammes. Dimensions. — Each lateral lobe is about 50 millimetres, or 2 inches, in length; from 18 to 30 millimetres, or % inch to ij4 inches, in breadth; and from 18 to 25 millimetres, or y± to 1 inch, in thickness. The right lobe is usually the larger. The isthmus is nearly 12 milli- metres, or y 2 inch, in breadth, and from 6 to 18 millimetres, or % to J4 inch, in depth. According to Orth, each lateral lobe is from 5 to 7 centimetres long, from 3 to 4 centimetres broad, and from 1.5 to 2.5 centimetres thick. THE TESTES. Weight. — Each testicle weighs from 18 to 25 grammes, or 6 to 8 drachms, the left being slightly the heavier. Orth gives 18 to 26 grammes as the weight; Nauwerck says the testicle and epididymis weigh from 15 to 24.5 grammes. Dimensions. — Length, about 37 millimetres, or iy> inches; breadth, anteroposterior, 30 millimetres, or 1 J4 inches; thickness, from side to side, 24 millimetres, or 1 inch. THE OVARIES. Weight. — From 4 to 8 grammes, or 1 to 2 drachms. Orth gives 5 to 7 for the weight, and Nauwerck quotes Puech, who puts the mean weight at 7.0 (from 5 to 10) grammes. Dimensions. — Length, usually about 37 millimetres, or 1^2 inches; breadth, 18 millimetres, or % inch; thickness, 12 millimetres, or y 2 inch. The right is usually a little larger than the left. According to Orth, the ovary is from 2.5 to 5 centimetres long, from 2 to 3 centi- metres broad, and from 7 to 12 millimetres thick. Nauwerck gives the following dimensions, quoted from Puech. WEIGHTS AND MEASURES 279 Length, maidens from 4.1 to 5.2 centimetres. Length, women from 2.7 to 4.1 centimetres. Breadth, maidens from 2.0 to 2.7 centimetres. Breadth, women from 1.4 to 1.6 centimetres. Thickness, maidens from 1.0 to 1.1 centimetres. Thickness, women from 0.7 to 0.9 centimetre. THE UTERUS. Weight. — Generally from 28 to 42 grammes, or 1 to 1^ ounces Orth quotes Huschke, who gives from 33 to 41 grammes as the weight of the uterus in virgins and 105 to 120 grammes as the weight in multiparas Nauwerck gives 33 to 41 grammes as the weight in vir- gins, and 102 to 1 17 grammes as the weight in multiparas Dimensions. — Length, about 75 millimetres, or 3 inches; breadth, 50 millimetres, or 2 inches; thickness, nearly 25 millimetres, or 1 inch. The virgin uterus is from 5.5 to 8 centimetres long, from 3.5 to 4 centimetres broad, and from 2 to 2.5 centimetres thick; in multiparas the womb is from 9 to 9.5 centimetres long, from 5.5 to 6 centimetres broad, and from 3 to 3.5 centimetres thick. The walls of the virgin uterus are from 1 to 1.5 centimetres thick; of the cervix, from 0.7 to 0.8 centimetre thick. In multiparas the uterine walls may be as thick as 2 centimetres, and the cervix is from 0.8 to 0.9 centimetre thick. (Orth.) The length of the virgin uterus, from the fundus to the external os, is from 7.8 to 8.1 centimetres and the breadth of the fundus is from 3.4 to 4.5 centimetres; the thickness below the fundus is from 1.8 to 2.7 centimetres; the length of the cervix is from 2.9 to 3.4 centimetres; the breadth of the cervix is 2.5 centimetres ; the thickness of the cervix is from 1.6 to 2 centimetres. In multiparas the length of the uterus is from 8.7 to 9.4 centimetres, the breadth 5.4 to 6.1, and the thickness 3.2 to 3.6 centimetres. The length of the uterine cavity in virgins is 5.2 centimetres, after the menopause 5.6 centimetres; in multiparas 5.7 centimetres, after the menopause 6.2 centimetres. (Nauwerck.) THE PROSTATE. Weight. — Average, from 18 to 20 grammes, or /\.y 2 to 4^4 drachms. Orth gives 17 to 18.5 grammes as the weight; and Nau- werck quotes Krause and Bischoff, who give 19 to 20.5 grammes as the weight. Dimensions. — Transverse diameter, about 7,7 millimetres, or i T / 2 inches ; vertical, 30 millimetres, or 1 % inches ; anteroposterior, nearly 2 8o POST-MORTEM EXAMINATIONS 1 8 millimetres, or y± inch. These measurements are subject to great variation, according to the fulness of the rectum and bladder. Ac- cording to Orth, the prostate measures from 32 to 45 millimetres in its transverse diameter, 14 to 22 millimetres in thickness, and 25 to 35 millimetres from apex to base. Nauwerck gives the following dimen- sions: Transverse diameter (breadth), from 3.2 to 4.7 centimetres (mean, 4.5 centimetres) ; sagittal diameter (thickness), from 1.4 to 2.3 centimetres (mean, 2 centimetres) ; from apex to base (height), from 2.3 to 3.4 (mean, 2.y centimetres). Embryos 1 about one millimetre long are about twelve days old ; 2.5 mm., fourteen days old; 4.5 mm., nineteen days old; seven mm., twenty-six days old; 11.5 mm., thirty- four days old; seventeen mm., forty-one days old. For all embryos from one to one hundred mm. long, multiply the length of the embryo from the vertex to the breech in millimetres by one hundred and extract the square root; the result will be the age in days. For embryos from one hundred to two hun- dred millimetres long, measure from vertex to breech; this length in millimetres will equal the age expressed in days. 1 Mall, Bull. Johns Hopkins Hosp., vol. xiv., No. 143, February, 1903 ; abstracted in Medicine, vol. 9, No. 3, 1903, p. 240. CHAPTER XXVI COMPARATIVE POSTMORTEMS 1 The great number, importance, and variety of diseases which human beings may contract from the lower animals are more and more coming to be recognized. Our domestic animals suffer from nearly all the contagious maladies found in man, and impart to him various disorders from which he would otherwise be exempt, such as glanders, actinomycosis, anthrax, hydrophobia, foot-and-mouth disease, echino- coccus cysts, trypanosomatosis, etc. The rat disseminates bubonic plague, the mosquito malaria, yellow fever, and dengue, and the pig trichinosis, and were it not for the rat, the mosquito, and the pig these diseases would probably cease to exist. Many of the suggestions made in the previous chapters apply with equal force to the performance of necropsies upon the lower animals. Such comparative examinations are of two distinct classes, — veterinary postmortems and laboratory postmortems. For laboratory study small animals, such as the guinea-pig. rabbit, mouse, and rat. are generally chosen, while in veterinary investigation the subject is usually a dog, a horse, a cow, or a cat. So intense is the interest now taken in com- parative pathology that all classes of animals come to section, even reptiles (especially snakes) receiving no small amount of attention. Instruments. — In post-mortem examinations of the large domes- tic animals (cow, horse, mule, etc.) the instruments used must neces- sarily be larger than those employed in human autopsies. The following is a partial list. ( I ) Large butcher's knife, to expose the thorax and abdomen and remove the skin; (2) large cleaver; (3) large butcher's saw, to open the thoracic and cranial cavities, expose the nasal septum, etc.; (4) large chisel, to remove the cord; (5) hammer, for the same purpose; (6) bone-forceps (costotome) ; (7) enterotome ; ' ( 8 ) scissors; (9) brain-knife; (10) dissecting forceps ; (11) large needle; (12) strong twine, etc. Utensils. — Buckets, pitchers, large and small enamelled plates, . * Much of the material and all the illustrations except Figs. 163 and 164 in this chapter are taken from Kitt's Lehrbuch der pathologischen Anatomie der Haus- thiere. 1900, vol. ii. pp. 1-54. 2S1 282 POST-MORTEM EXAMINATIONS sponges, soap, towels, and disinfectants, and green soap or lysol are especially useful. Clothing. — An operator's apron may be drawn over the clothes or an ordinary rain-coat worn, but a special suit for operating is better. General Suggestions. — In many cases the necropsy must be made at the place where death occurred, be this in the fields, stable, slaughter-house, or veterinary morgue. The procedure will vary with the conditions and conveniences, but the end in view should be care- fully considered and certain general rules observed. If the animal is alive, the method of killing to prepare for the desired investigation should be one that will not injure the organs involved. In cerebral trouble the animal should not be killed by a blow upon the head, but by poison or chloroform ; in inflammatory conditions all loss of blood should be avoided; if the trouble is in the digestive system, no poison should be used; and in pulmonary affections the animal must not be shot through the heart (Csokor). The skin, extremities, joints, excessive functionation of the mam- mary gland, and the frequency of parasitic lesions in the muscular tissue are so often subject to pathological conditions that they present a rich field in post-mortem examinations of lower animals. Malfor- mations are also quite common. There has recently taken place an interesting discussion as to Koch's statements that human tuberculosis differs from bovine and cannot be transmitted to cattle,- and that man does not, except possibly in the rarest instances, contract tuberculosis from the cow. Both sides admit, however, that there is a great difference between the virulence of various forms of the tubercle bacilli. From a careful study of the work of Koch, Schutz, Ravenel, Jong, Chippolina, and others, it would seem that bovine and human tuberculosis may be intercommunicated and cannot always be distinguished the one from the other, and that man may, and children often do, contract tuberculosis from the cow. In Switzerland and in this country the writer has been struck with the freedom from tuberculosis of districts in which cow's milk is not used. Operative Technic. — In opening the cadaver the normal position of the intestines should be retained as far as possible, and they should be carefully examined to see that they are uninjured and are suffi- ciently exposed. Horses, large and small ruminants, and the larger swine are usually placed upon the left side of the body so that the right side may be opened. A dorsal position may be chosen for dogs and COMPARATIVE POSTMORTEMS 283 cats, and even for swine or larger animals if sufficient assistance be present, as it gives a better view of the abdominal cavity. The postmortem is begun by removing the hide, which has a market value and must not be injured. As scalpels and straight-edged knives are apt to button-hole the skin, a butcher-knife with rough cutting edge is to be preferred. Beginning at the angle of the chin a longitudinal incision is made down the median line the whole length of the body, avoiding the udder, prepuce, and scrotum, and the navel in the case of young animals. A transverse incision is made perpendicular to the first along the median surface of the foreleg and the skin is drawn back from the edges up over the dorsal surface. A similar cut is made upon the median surface of the thigh and leg down to the tuberosity of the os calcis. On both the limbs and the body the hair-seams will serve as a useful guide for the knife. A circular incision is made around the head from angle to angle at the lips. If the head is to be preserved, as in the case of a deer, the circular incision is made at the manubrium. The skin may be detached either with the hands or with the handle of a chisel. Removal of the Extremities. — After the animal has been skinned, it is placed on its side, and the uppermost limbs are removed in order to secure more room for subsequent manipulation. First the foreleg is held up by an assistant and the shoulder- joint disarticulated. The mass of common muscle is cut through in the median portion by a butcher-knife grasped firmly by the whole hand. During the exsec- tion the extremity should be constantly raised by an assistant and the blade of the knife should be held somewhat towards the thorax so as to cut obliquely to the ribs. To remove the posterior extremity make a deep circular incision through the hip muscles, beginning with the broad crural fascia and above the large trochanter, passing up over and through the muscula- ture of the croup and downward and outward into the ischiatic fossa, but not behind the tuberosity of the ischium; raise the foot; cut through the adductors in a line with the acetabulum, open its capsular ligament, and section the round ligament. The incision of the capsular ligament is accompanied by a snapping sound, due to the entrance of air into the joint. The limb can now be drawn backward, the remain- ing fascia and muscles sectioned, and the whole removed. Exposure of the Abdominal Cavity. — Before opening the ab- dominal cavity of a filly the udder should be entirely removed from the 284 POST-MORTEM EXAMINATIONS • abdominal wall, and in geldings and stallions the scrotum and the penis should be isolated and thrown back. It should be remembered that in herbivora meteorism occurs soon after death, so that the intes- tines are pressed up closely against the abdominal wall and may easily be injured. The operator should stand in the space between the remaining extremities with his face towards the breast of the animal. An incision is made through the median line of the body, beginning with the ensiform cartilage of the sternum, extending as far as the pubic region, cutting through the muscles and fascia only and not injuring the peri- toneum. This will not be difficult if the blade of the knife be held flat and the ball of the thumb placed near the edge and close to the point. As the peritoneum is carefully torn through with the ringers, the exit of gases, liquids, or abnormal contents of the abdominal cavity should be noted, as well as the position of the intestines. The index and middle finger are then separated so as to form a V-shaped space, in which the knife is placed and its point thrust through the abdominal wall along the line of the linea alba, the fingers following. At the posterior end of the longitudinal incision a second incision is made, perpendicular to the first, extending from the pubic region to the lumbar. The right upper half of the abdominal wall is held up by its edges with the left hand. The assistant pulls on the lower ribs in order to make the abdomen tense, and its covering is cut through with sawing strokes of the knife as far as the costal processes. The knife is so held by the whole hand that the point is shoved away from the operator towards the lumbar region and the lower part of the blade is used instead of the point. We have now a large anterior and a small posterior segment of the abdominal wall. They may easily be drawn back and a view of the abdominal organs obtained. The ribs of the horse extend so low down that a sufficiently extensive view for pathological purposes cannot be obtained; therefore, before removing the abdominal contents the tho- racic cavity is exposed. Then, by thrusting the hand well up under the lower ribs, we notice whether the diaphragm is tightly vaulted forward or is more or less relaxed. Exposure of the Thoracic Cavity. — A small incision is made between two of the true ribs and note is taken whether or not air enters the thoracic cavity and the diaphragm becomes relaxed. If the ab- dominal examination showed the diaphragm drawn down posteriorly, COMPARATIVE POSTMORTEMS 285 the incision should receive special attention; instead of air entering, there may be an exit of gas from the pleural cavity, indicating some essentially pathological condition. The direction for cutting the ribs is through the costal angles fol- lowing the course of the iliocostal muscle. An incision is made Temporomaxillary articulation Fig. 154.— Equine viscera, the animal resting on its right side, the anterior and posterior left limbs having been removed,, and the abdominal, thoracic, oral, and pharyngeal cavities opened. The double lines show the places in the intestines which are to be tied previous to being cut. between the true ribs and the blade of the saw introduced, an assistant making the breast tense while the sawing is done ; very little pressure should be used or the bone will splinter. When the ribs have been sawed through, they are turned over towards the median line and removed by severing the costal cartilages. The situation of the organs and the pathological contents should be carefully noted. (Fig. 154.) 286 POST-MORTEM EXAMINATIONS Removal of the Abdominal Contents in the Right Lateral Position. — After exposing the abdominal cavity by the longitudinal and transverse incisions, pull the two left coils of the colon either up over the thorax or out across the body on the right side, so that the sigmoid flexure looks towards the head or lies on the ground and the body and tip of the caecum come into view. Spread the mesorectum out over the left flank and pelvic region. Stroke back the faeces, doubly Duodenum Rectum Fig. 155. — Further dissection of animal seen in Fig. 154.. Appearance of the parts after removal of the rectum, ileum, and jejunum. ligate the rectum at its entrance into the pelvis, and section. Cut away the mesorectum up to its origin at the rectoduodenal ligament, doubly ligate the rectum, section, and remove. The ileum is easily recognized by its thicker walls and its entrance into the caecum. Apply a double ligature, section, and, holding the intestine in the hand, cut away all the mesentery from the whole of the small intestine as far as the rectoduodenal ligament, divide this, doubly ligate the duodenum, and section. The junction of the colon COMPARATIVE POSTMORTEMS 287 with the rectum is now exposed, — the so-called stomach-like or gas- troid dilatation, — under which lies the anterior root of the mesentery. Grasping the dilatation with the left hand (Fig. 155), pull it towards the caecum, and with the right hand work loose or cut partly away the connections between the gastroid dilatation and caecum and the omental sac, kidney, and pancreas. In this way better access to the portal vein and anterior root of the mesentery is obtained. With the ringers work through the cellular tissue surrounding the root of the mesentery, grasp it with the hand, and together with the portal vein cut it away close to the intestine, leaving as much of it as possible with the aorta. The colon and caecum are now drawn out of the cavity, all the remaining sections being easily torn or cut away, while the right branch of the pancreas which lies upon the caecum and the root of the mesentery must be carefully dissected away. Grasp the spleen, section the suspensory (gastrosplenic) ligament and the gastrosplenic omen- tum, and free the spleen from the stomach. Separate the branches of the pancreas from the larger blood-vessels and the kidneys, so that it hangs only by its body from the liver, and leave it in this position or, after examining its excretory duct, cut it away. Next remove the stomach and duodenum by cutting along the sigmoid curvature and the smaller curvature of the stomach and by sectioning the duodenorenal ligament, the hepatic and pancreatic ducts, the diaphragmatic and gastrohepatic ligaments, and the oesophagus, after pulling the latter down as far as possible from the diaphragm. Excision of the liver is an easy matter : section first the left lateral ligament, then the coronary and suspensory ligaments, the vena cava on the anterior surface of the liver, the right lateral portion of the coronary ligament, and the right hepatic and renal hepatic ligaments. Removal of the Abdominal Contents in the Left Lateral Position. — The rectum is sectioned at its entrance into the pelvis after pressing back the faeces with the fingers, applying a double ligature, and cutting between them. Seize the colon at its anterior curvature and pull it carefully out of the abdominal cavity as far as possible. The left folds' of the colon will fall out with very little assistance. (Fig. 156.) In the region of thejkidney will be seen the arch of the duodenum lying between the anterior and posterior roots of the mesentery and covered by the ribs. Cut through this arch and its mesentery, after applying a double ligature, and remove. The cellular tissue lying 288 POST-MORTEM EXAMINATIONS between the caecum and psoas muscle and the right kidney should be carefully worked loose and the pancreas separated from the caecum and the colon; this is done by tearing or cutting through the peritoneum covering the intestine and pancreas, getting the hand in under the pancreas, and working it loose. Beginning posteriorly, cut away the mesorectum from behind forward and any connections that may remain between the caecum and colon and the region of the kidney, Duodenum Iliac spinal column Root of the mesentery and portal vein Line for sawing ischio- pubic suture Fig. 156. — Further dissection of animal seen in Fig. 155. Appearance of the parts after removal of the large intestine. grasp as much as possible of the attachment of the mesentery, pull the intestine back away from the kidney, and section the root of the mesen- tery in front of the left hand, as far from the aorta as possible. With the exception of a small portion of the duodenum and the pelvic por- tion of the rectum the large and small intestines can be drawn out from the abdominal cavity by cutting or tearing away any attachments which may remain ; the operator stands alternately at the back and in front of the cadaver while removing these portions. Removal of the Kidneys, Stomach, Liver, and Spleen. — The removal of the kidneys leaves a freer field for the stomach, spleen, and liver. With the hand and fingers separate first the right and then the left kidney and the suprarenal capsules from the surrounding cellular COMPARATIVE POSTMORTEMS 289 tissue. If the ureters and kidneys are intact the kidneys may at once be cut away together with their vessels. In case of any abnormalities they should be left hanging or a sufficient length of the ureters removed with them, together with the surrounding tissues, or they may remain attached to their ureters and placed in the pelvic region. The pancreas, spleen, and stomach are freed from the mesentery and sectioned. The assistant pulls on the right side of the diaphragm, and the inferior vena cava between it and the liver is cut through together with the oesophagus. The stomach is turned backward. The left and right hepatic ligaments are sectioned and all the three organs removed together in a mass. If the kidneys are left in place, the exenteration of the stomach, pancreas, and liver is more difficult and demands more caution, espe- cially if the animal has not been bled, because the field is obscured by blood and other impurities. Dissect away carefully the attachments of the right kidney to the suprarenal capsule and left branch of the pancreas, which lies deep down, covered by the branches of the mesen- teric arteries ; next the adrenals, then the fundus of the stomach from the crurse of the diaphragm, the suspensory ligament of the spleen, the splenorenal ligament, the right coronary and lateral ligaments of the liver, the hepatic renal ligament, the vena cava, with the falciform ligament, the oesophagus, and the left lateral and coronary ligaments of the liver. All these organs may be removed with the diaphragm, and, when there are adhesions to its posterior surface, this is the preferable method. The right lobe of the liver is first separated from the kidney ; the pancreas, spleen, and stomach are worked loose from the spinal column in the thorax; the posterior vena cava, the oesophagus, and the pulmonary attachments to the diaphragm are sectioned; the dia- phragm is freed from the thoracic wall by a circular excision, and the whole mass removed together. Finally, the aorta and the venae cavae with their branches are dissected off the spinal column from the dia- phragm to the pelvis. Exenteration in the Dorsal Position. — The body may be kept on its back by tying the feet to rings in the wall or to posts or poles. The extremities remain attached to the body, of course, and the broad muscles of the chest are only to be sufficiently incised to permit the anterior extremities to spring out a little and give access to the chest. If during the postmortem the extremities are released too 19 290 POST-MORTEM EXAMINATIONS much, the body will fall to one side and make the exenteration more difficult. A longitudinal median incision is first made, then a bilateral trans- verse incision just posterior to the last ribs. The two left folds of the colon are drawn up over the right side of the body. The rectum is pulled out and spread over the left thigh and left ventral wall and the small intestine spread out over the region of the lower ribs. The ileum is found at its insertion into the caecum; it is thicker than the rest of the small intestine. It is tied off and sectioned, remaining in the hand after its mesentery is severed close up to the intestine. In this way the whole of the right lateral small intestine is removed from the abdomi- nal cavity and its mesentery left hanging by its root. When it passes into the duodenum between the two roots of the mesentery, doubly ligate and section. Doubly ligate and section the rectum at its entrance into the pelvis and again at its junction with the colon. The pancreas and first part of the duodenum are dissected away from the colon as in the first method. The roots of the mesentery and both the branches going to the large intestine are sectioned close up and the large intestine is removed. The stomach, spleen, etc., are removed as in the first method. Many operators prefer to excise the spleen and open the stomach along its greater curvature and the duodenum on its inferior surface, where- upon the pathway of the bile ducts may be determined and then the empty organs cut away. In the dorsal position the thoracic organs may be ablated by draw- ing them down towards the abdominal cavity. An incision is made between the rings of the trachea, two fingers are inserted, the trachea is grasped firmly, and the larger vessels are sectioned at the thoracic inlet ; the aorta is dissected away from the vertebrae and the posterior vena cava and oesophagus are sectioned. If it be desired to remove the thoracic viscera together with the trachea and cervical organs, the first rib is sawed through and excised; the cervical organs are then ablated according to the method to be described later. Vienna Method of Exenteration in the Left Lateral Posi- tion. — Csokor's quick method for removing the thoracic and abdomi- nal contents is as follows : The extremities are removed and the abdominal cavity is exposed by a longitudinal and a transverse incision as in the first method ; then the muscles of the back are cleared away and the sectioned abdominal wall is drawn up by a hook. With a COMPARATIVE POSTMORTEMS 2 CjI hatchet each rib is cut away from the spinal column and then from the breast-bone. The whole right wall of the thorax and abdomen is now drawn up over the head of the animal and the contents of both cavities are exposed. The right kidney is next removed and then the thoracic contents. After their ablation the cardiac end of the stomach is freed from the diaphragm and the duodenum is detached from the liver and its surroundings and excised together with the stomach and spleen. The abdominal aorta is separated from the spinal column, the rectum sectioned, and. all the intestines removed. The remaining organs are extirpated as in the other methods. This modification permits a very rapid necropsy, but the removal of the stomach and spleen is somewhat difficult. Discission of the Abdominal Contents. — To ascertain the macroscopical conditions of the abdominal contents it is necessary to make a few special incisions. The aorta is first examined and its dorsal wall slit up with the shears to expose the entrances into its branches, which are then cut open. On account of its great frequency, close search is to be made for an aneurism in the root of the mesentery. It is usually felt externally as a thick, cystic expansion. The branches to the small intestine — the duodenal, jejunal, and iliac arteries — are first given off from the short trunk of the artery lying in the root of the mesentery (the anterior mesenteric artery) ; next a large vessel, the ileocolic artery, which gives off a large branch, the inferior colic, and the ileocecal artery with its three branches. The superior colic comes off above the root of the mesentery on a level with the anterior rectal artery. After examining these branches slit the inferior and superior colic arteries in the mesocolon from their origin to the sigmoid flexure, If it seems necessary, examine the arteries of the small intestine in the same way and observe the mesenteric lymph-nodes. The bowel is opened with the shears along the line of the attachment of the mesen- tery so as to get a good view of Peyer's patches; keep the intestine lying flat, for if held up the contents run down into the lower portions, which is a nuisance. If the stomach is sufficiently full, cut it open with a knife along its greater curvature. If the duodenal portion remains with the stomach and liver, open it with the shears on its inferior surface in such a way that the termini of the hepatic and pancreatic ducts will not be injured and their patency may be demonstrated. Press and push along the course of the ducts so as to force out their contents. If there is any 292 POST-MORTEM EXAMINATIONS suspicion of abnormalities in these ducts, it is better to leave the stomach and duodenum in place and to open them before removal. Removal of the Thoracic Contents. — First carefully examine for sharp points of bone and excise them with cutting forceps. The pericardium should then be examined and worked free with the hands. The posterior vena cava is tied off and divided between the ligature and the diaphragm; the attachments of the liver and heart to the diaphragm are sectioned and an incision is made obliquely through the aorta down to the vertebral column. Thrust the finger into the pos- terior aorta, pull it up, and cut along the spinal column in the line of the vena azygos and the attachment of the longus colli. Now make an oblique section through the oesophagus, trachea, anterior aorta, and anterior vena cava along the line of the first rib, so that the thoracic organs may be removed. This avoids cutting the large veins, which bleed so freely as greatly to obstruct the view of the parts under ob- servation. Section of the Oral Cavity and Cervical Organs. — This is begun by removing the ramus of the lower jaw on one side. Cut the buccal parietes and the cheek at the angle of the lips up to the zygo- matic arch, between the molar teeth and the space between the lower jaw and the large maxillary swelling, dividing the masseter and saw- ing through the bones. The ramus of the jaw may now be worked up and down, its muscular connections severed by a knife introduced along its median surface, and an incision made between the parotid gland and the posterior border of the bone. The temporal muscle is cut through above the coronoid process and the ligaments and capsule of the joint are sectioned, the jaw being moved up and down to find the joint. After examining the local conditions, sever the left connec- tions of the tongue with the jaw and the soft palate; saw through both to the large branches of the hyoid bone. The larynx, trachea, and oesophagus are easily freed from their loose cellular tissue by cutting into the channel of the external jugular vein, between the longus colli muscle and the oesophagus, so that the thyroid gland is not injured. Dissection of the Thoracic and Cervical Organs. — In order more closely to inspect these organs, cut through the vault of the velum palati with the shears and continue down into the oesophagus, section- ing it dor sally. With the knife grasped firmly incise the larynx in the median dorsal line between the arytenoids. Pushing the oesophagus COMPARATIVE POSTMORTEMS 293 aside, cut the posterior muscular ligament of the trachea with shears throughout its whole length and thrust the cartilages apart to get a good view of the interior. The lobes of the lungs are laid open with long, deep, bisecting strokes, and portions of each lobe are tested by throwing them into water to see whether they contain air and will float or will sink because of collapse or the presence of an exudate. The lymph-nodules around the roots of the bronchi must always be examined and sectioned. If the heart is hacked into or improperly opened, the distinctive appearance of any abnormality that may be present is destroyed, and these anomalies are of great importance to the whole organism. First make an incision into the right ventricle along the septum, insert the shears, and cut up into the pulmonalis. Holding the heart by this flap, lengthen the incisions towards the apex and the flap so as to get a better view of the ventricle. In the same way incise the left ventricle close to the septum and on the anterior surface ; insert a finger through the opening, find the entrance into the aorta, and with the shears cut down between the pulmonalis and the left auricle. It is true that in this way both semilunar valves are sectioned, but the auriculoventricular valves are spared and they are much more likely to present abnormali- ties than the semilunar. The size of the openings can be tested by inserting a finger, and the thickness of the walls measured, after which each auricle is cut through up into its vessels and a good view of their openings obtained. Exenteration of the Pelvis. — The removal of the pelvic organs is preceded by the previously described excision of the kidneys and ureters and in males by the exposure of the testicles and the external genitalia. The scrotum and penis were then turned back, and now their dorsal suspensory ligament and surroundings are divided as far as the ischiatic notch and all the flesh lying ventrad to the ischiatic suture is carefully cleaned away. The scrotum and the right and left inguinal canals are split open and the testicles together with the sper- matic vessels pulled up into the abdomen. It is especially necessary to cut the tendinous ligament which binds the corpora cavernosa to the ischium close to the bone, as well as the strong ischiopenile muscle. Two sections made by sawing will remove the right wall of the pelvis. The first one is made through the ischiopubic suture over the aceta- bulum to the iliac spinal column ; the second, through the thin part of the iliac bone, after cutting away the flesh that lies over the acetabulum »94 POST-MORTEM EXAMINATIONS on the iliac column. By cutting the bone loose from the pelvic cellular tissue, it is easily pulled away. . The lateral wall of the pelvis being removed and a good view of the organs obtained, divide the connective tissue between the rectum and the superior pelvic wall ; free the uterus and ovaries, the neck of the bladder, the vagina, and the accessory sexual glands ; cut through the strong rectococcygei and the skin between the tail and the anus; and make a circular incision around the anus and the vulva (or the region of the penis). Remove the whole mass and section the organs dorsally. Exenteration of the Cranial Cavity. — To remove the head from the trunk we may either cut around the joint as if the throat were being cut or puncture the capsule ventrally and amputate between the condyles and the atlas. It is best to remove the whole of the lower jaw and let the skull, wrapped in a cloth, rest on its base and the molar teeth; it may then be held much more steadily than if the inferior maxillae had been left in place. The cranial attachments of the cer- vical and temporal muscles are next cut away and the soft parts re- moved from the roof of the skull. There are three lines for sectioning the cranium. The first lies transversely across the forehead about a thumb's breadth above the upper border of both superciliary ridges. The two other lines begin at the ends of the frontal incision, pass backward across the temples and petrous bones, and converge to the condyloid apophyses (Figs. 157, 158). The first section can be made continuously, but the second and third will have to be done in several portions on account of the convexity of the cranium. The walls of the cranial vault are not equally thick, and care must be taken not to penetrate too deeply into the middle of the parietal bones and the squamous portion of the temporal bones. The frontal section passes through the frontal sinuses, so that there is very little danger here; and the same is true of the vertex and the pyramidal region above the condyles. The plates are not usually sawed clear through along the whole line, but the connections are broken with a chisel. Rest the palm of the hand upon the skull, grasp the chisel firmly near its edge so that it cannot enter too deeply, and tap gently with the hammer. When the bones are completely severed, pry the piece off by rocking the chisel backward and forward, first in the frontal and then in the condylar region. A sudden strong pull on the COMPARATIVE POSTMORTEMS 295 pericranium, grasping it at the edge of the frontal section, will gen- erally separate it from the other parts of the head; sometimes the Fig. 157. — Lines to guide the saw in ope le cephalic cavities of a horse. whole brain will come away at one jerk, together with the root of the skull. If the dura is too closely held or is adherent to the inner table of Fig. 158. — Lines of sawing for opening the cranial cavity of a horse. the skull, with the shears incise it in the line of the section in such a manner that the dorsal portion will come away with the calvarium. 296 POST-MORTEM EXAMINATIONS Next excise the longitudinal and transverse blood-vessels in the duras. That part of the dura lying over the hemispheres is held up with forceps and cut with scissors so that it may be thrown back on both sides. The tentorium is sectioned anteriorly and posteriorly and re- moved. The membranous transverse septum which is torn away from the falx is incised laterally and pulled out from the transverse fissure, due attention being paid to its vascularity. Dissection of the Brain. — After examining the pia mater and the superficial surface of the brain, the hemispheres should be separated so as to expose the corpus callosum. The interior of the brain may either be examined now or after its removal. A horizontal incision is made immediately over the corpus callosum, starting at the median surface, and using preferably the so-called " brain-knife" or a long, flat scalpel. If the incision is not quite deep enough to enter the lateral ventricle, you will come first to the so-called " egg-shaped middle point" (centrum semiovale Vieussenii) ; press this gently with the finger and you will find a yielding point which, when incised, opens into the lateral ventricle. Follow the finger with the knife and slit open the roof anteriorly and posteriorly. Look for a collection of fluid, and examine the choroid plexus, corpora striata, horns of the ventricle, and median septum. This is seized in the middle, raised a little, sectioned transversely, and thrown back, the connections holding it to the peduncles being severed. Now carefully insert four fingers into the transverse fissure and raise the posterior lobes in order to expose the corpora quadrigemina, optic thalami, pineal gland, and middle choroid plexus. By separating the two thalami a little, you can divide the commissura mollis and see into the third ventricle. To remove the brain, support the skull upon the incisors in such a position that the condyles look upward and the brain would fall out if it were free. Into the space thus obtained between the medulla and the base of the skull, insert a finger, the closed scissors, or the handle of a scalpel, and sever the nerves one by one as they appear. The olfactory bulbs, which are unusually large in comparison with those of man, are worked out from the ethmoidal depressions by a circular thrusting motion of the handle of the scalpel. When they are all sepa- rated, the brain will fall into the waiting hand, which must steady it constantly or the olfactory bulbs would be torn away by its falling out too soon. After the brain is removed, the inferior surface is first examined, COMPARATIVE POSTMORTEMS 297 then, turning the brain over, the cerebellum is cut into halves. Expose the fourth ventricle and incise the floor longitudinally. With a thin- bladed knife cut radially to the cortex and transversely to the crurae, making numerous narrow incisions to detect the presence of any small hemorrhage or other lesion. Removal of the Spinal Cord. — This requires much time and labor when properly done, but is managed in various ways. But little time is spent in routine work when you have a butcher to assist you. The animal is suspended and the vertebrae are split off from their bodies by a hatchet; when this is cleverly done, the line of cleavage being kept a little to one side, the cord is but slightly injured. It is better, however, to proceed as follows : Saw off the ribs at their angles, separate the ilium from the sacrum, and clean off all the flesh. Laying the spine upon the table, begin at the pelvis and chisel off the vertebral arches, remembering that two chisels are necessary, one for each side, as the two instruments have different curves (Fig. 32). If an ordi- nary chisel is used, the arches should be partially sawed through to make their division easier. The hand holding the chisel supports itself on the spine, and the chisel is held as flat as possible while an assistant grasps the spinous processes and springs the arch apart. You may also expose the spinal canal ventrally by sawing through the vertebral bodies and arches on one side only. Section the nerves at their points of exit laterally to the intervertebral ganglia and lift out the cord enclosed in its membranes. Cut open the dura with the scissors and section the cord transversely with a sharp, thin knife. Exposure of the Accessory Sinuses. — To expose the nasal fossae saw the head in two, after removing the brain, a little to one side of the median line so as not to injure the septum on either side. These fossae may be sectioned transversely or their walls chiselled away to show the accessory sinuses. Csokor saws through the osseous struc- ture of the nose transversely from the level of the malar or lachrymal bone to the roots of the molars; a section is then made horizontally beginning at the anterior nares and joining at the first section (Fig. I 57)- O n raising this cap you have the maxillary, nasal, and frontal fossae well exposed. One or two long bones should be sawed through to judge of the condition of the bone marrow. Postmortems on Ruminants. — There are certain peculiarities in the skulls of ruminants which must be remembered when exposing 298 POST-MORTEM EXAMINATIONS the cranial cavity. It is only in very young animals that the cranial bones possess diploe, and in necropsies on hornless cattle the incisions are the same as for horses. On account of the prominent crests, which fall away very abruptly, and because a calf's head is somewhat rounder, Fig. 159. — Lines used in sawing in order to expose the cranial and nasal cavities in a ruminant. the sawing will have to be done in more segments, and great pains must be taken on account of the thinness of the bones. The older the animal the larger are the hollow places between the internal and ex- ternal plates; the diploe disappears and only a few crusts and plates %J*£^ Fig. 160. — Appearances of cranial cavity of a cow after removal of the bony vault. of bone interrupt the hollow spaces. The lateral and posterior portions of the skull are very prominent because of two large crests. The transverse section is nearly coincident with the posterior border of the superciliary ridges. The lateral sections are made in two segments, COMPARATIVE POSTMORTEMS 299 beginning at the ends of the transverse frontal incision and passing back over the temples to the foramen magnum. Clement has devised a better method (Figs. 159 and 160). First clear away all that part of the calvarium formed by the frontal eminence and the lateral depressions by sawing through the skull in a line passing from just in front of the horns obliquely backward and downward to the condyles or foramen magnum. After removing this plate of bone the whole of the posterior portion of the brain is exposed. Next make a transverse incision on a level with the superciliary ridges across the anterior end of the cranial cavity. Finally make two short longitudinal incisions, one on each side, about three centimetres from the median line; with mallet and chisel remove the oblong piece enclosed, and the whole brain is exposed. The curved horns of a sheep or a goat serve as convenient handles for removing the calvarium and may very well be left on, while the horns of neat cattle should be knocked off. Postmortems on Swine. — With the body lying on its left side, the right extremities are removed, the abdomen is exposed by longi- tudinal and transverse incisions, the diaphragm observed, and the lateral thoracic wall divided by cutting with the bone-shears or sawing through the angles of the ribs and severing the cartilages close to the sternum. To remove the abdominal contents, first find where the duodenum is attached to the rectum; sever the duodenorectal liga- ment, separate the pancreas from the mesentery, and section the duo- denum. The anterior root of the mesentery is loosened by working it free with the hand and pulling on it, then sectioned, the whole of the mesentery excised from before backward, and the rectum divided. Now cut away the spleen from the stomach, examine the opening of the bile duct, section it and the oesophagus, and separate the stomach from the diaphragm, leaving the liver freed from its suspensory liga- ment. The thoracic and cervical organs are removed as with other animals. In old quadrupeds the brain lies very deep, because of the immense air-spaces in the cranial bones which surround the brain on all sides except the temporal region. The transverse section is made a full thumb's breadth above -the superciliary ridges (the eyes being first removed) and the lateral sections run back to the occipital foramen. Instead of a transverse section we may make two oblique ones, begin- ning at the posterior border of the frontal process and joining each other and the lateral incisions in the anterior frontal region. 3oo POST-MORTEM EXAMINATIONS Postmortems on Dogs and Cats. — The necropsy of a dog is easily and quickly made in either the dorsal or the left lateral position. The procedure is the same as for the horse, but it is not necessary to remove the extremities entirely or to take off the hide; simply cut through the muscles enough to allow the limbs to fall away a little and the body will be sufficiently steady. (Figs. 161, 162.) The thick- Fig. 161. — Postmortem of the dog. Double lines show places at which the intestines are to be tied; the dotted line indicates the direction for incising the mesentery. ening at the junction of the cartilages with the ribs is easily felt, the articulations are cut, and the sternum is pushed upward and forward after freeing the pericardium and the" pleura. Section the tracheal COMPARATIVE POSTMORTEMS 301 vessels and oesophagus at their entrance into the thorax and remove the thoracic organs. The removal of the abdominal contents of a dog is easy. Divide the rectum at the pelvis and the two mesenteric roots, and the abdomi- nal aorta and inferior vena cava behind the liver; thrust the hand in between the liver and the diaphragm, and with scissors section the suspensory ligament of the liver, the vena cava, and the oesophagus after it is pulled down from the diaphragm and tied off or compressed with the fingers. All the abdominal contents may now be removed together. Spread them out, examine each again, test the patency of the bile ducts, and straighten out the bowels. It is, however, better first to remove the intestine, which is sectioned through the duodenum jf Fig. 162. — The left ramus of the mandible has been removed and the tongue pulled outward and down- ward, thus exposing the oral and pharyngeal cavities in a dog. at the pancreas and through the rectum at the pelvis. You may next either remove the liver with the stomach, or after inspecting the bile ducts you may cut away the stomach from the oesophagus and duo- denum and then remove the liver. To expose the cranial cavity we have the same three lines as usual, the transverse section lying directly posterior to the rudimentary super- ciliary ridge, crossing the frontal sinuses and the anterior lobes of the brain. The anterior temporal and the parietal bones are not thick and contain diploe, so that the sawing must be carefully done. Since the petrous portion of the temporal bone has deep impressions upon its internal surface, in which convolutions of the cerebellum lie, and since 302 POST-MORTEM EXAMINATIONS the bony processes project from the adjacent bones, great care must be taken not to tear the cerebellum. In small dogs with round heads the line for sectioning is more nearly a circular one. The postmortem of a cat is made in the same way. Post-mortem Examination of Birds. — Plug up the nostrils, mouth, and vent with cotton; make an incision from the point of the breast-bone, or a little above, backward to and through the anterior portion of the anus, leaving the uropygium (pope's nose). Loosen each leg to the knee (above the femur) by tearing the soft parts with your thumb and fingers, then cut with a knife until they meet around the pelvis at the rump. With your thumb-nail work the wings loose, hold the skin firmly, and, pressing your nail towards the body, cut off the wings at the elbow. Make a V-shaped slit with its apex towards the median line at the foramen magnum, running up towards the centre of the skull ; the brain is thus removed attached to the body and the skin is kept whole for taxidermic preservation. Post-mortem Records. — Kitt suggests the following scheme for the more intelligible recording of the findings in postmortems on the lower animals. RECORD OF NECROPSY. Species Gender Age Color of hair Owner Clinical history Treatment Mode of death Date of death Necropsy performed by Where performed Date Order of Persons present A. — External Examination. Position of the cadaver (on back, right or left side, hanging) Nutritional condition (weight) Removal or absence of parts Rigor mortis Condition of the skin and its appendages (the skin around the head, trunk, and extremities; the horns, claws, hoofs, ears, scrotum, prepuce, udder) The natural body openings and visible mucous membranes (the discharge of foam, fluids, and excrementa ; the color of the lips, nasal mucous membranes, con- junctivas, anal and vaginal mucosae) B. — Internal Examination. Facts obtained in removing the hide Condition of subcutaneous tissues, fat, lymph-nodules, vessels, extravasated blood, muscles, ligaments, tendons, and bones Abdominal and thoracic data Condition of diaphragm, position of organs, appearance of peritoneum, mediasti- nal and costal pleurae, and pericardium COMPARATIVE POSTMORTEMS 303 The oral cavity, tongue, soft palate, salivary glands, pharynx, Eustachian tubes, oesophagus, retropharyngeal and laryngeal lymph-nodules The larynx, trachea, thyroid, and surroundings The lungs, bronchi, bronchial lymph-nodes The pericardial sac, heart, and thoracic vessels The liver and bile ducts, portal vein, and periportal lymph-nodules The spleen (capsule, pulp, trabecular, Malpighian bodies, and vessels) The stomach and crop The pancreas ; the large and small intestines The mesentery, omentum, posterior aorta and its branches, and vena cava The kidneys, adrenals, ureters, capsule and pelvis of the kidney, and its half section The urinary bladder, urethra, and accessory sexual glands The pelvic portion of the rectum The genitalia: uterus, vagina (pregnancy, foetal membranes, embryo), and the male genitals The cranial cavity and the brain : calvarium, sinuses, cavities at the base of the skull, dura, cerebral superficies, ventricles, gray and white matter The eyes; the middle and internal ears The fourth ventricle and the spinal cord with its membranes The nasal fossse and accessory sinuses The udder and supramammary lymphatic nodules The bone marrow The microscopical report Inspection of Special Organs. — The essentials for diagnosis which are to be looked for and recorded are about as follows : 1 . Name of the organ; from what animal; whether it died or was killed; whether the organ was entire or fragmented; whether parts, lobes, etc., have been amputated; and if there are any adhesions to adjacent parts. 2. Weight. 3. Length and breadth of the part. In the ab- sence of a tape measure we may ascertain these dimensions approxi- mately by comparison with the breadth of the hand and the length of the finger. Every person should know the length of his index-finger, which is usually about ten centimetres and may be used to measure organs, pathological spots, streaks, canals, etc. 4. Surfaces : whether smooth, even, wavy, granular, corrugated, rough, transparent, or cloudy. Color of the surface: general and primary color, special deviations and shades. The external contour of the organ and any prominences, with especial reference to their size as compared with grains of sand, millet-seeds, lentils, peas, beans, hazel-nuts (or filberts), a pigeon's, a hen's, or a goose's egg, the fist, the thickness of a child's arm, a child's head, a man's head, etc. 5. The consistence as deter- mined by palpation: soft, elastic (like the lungs), doughy, splenified, hepatized, tough, inelastic, carnified, indurated, leathery, like the kid- 3°4 POST-MORTEM EXAMINATIONS neys and skin, as hard as wood, cartilage, bone, or stone. 6. Section- ing of special parts : through the compact, so-called parenchymatous organs (muscles, liver, kidneys, lungs) large dissecting incisions are made. Through the brain and heart sections must be made in a certain way in order properly to expose certain cavities. On sectioning notice the resistance of the tissue, whether it cuts easily or is tough and pulls, whether the knife creaks as it goes through, whether the tissue is so hard that a saw is necessary, and observe if any fluid follows the sec- tion or if there are any abnormal contents. The surfaces of the section must be noted, their color, thickness, consistence, fluidity, and vascu- larity, as well as any other peculiarities which may be present. The pathological diagnosis is made by considering the details gained in this way, which lead to one conclusion and exclude another. A gross ana- tomical diagnosis is often only provisional and dependent upon micro- scopical and chemical confirmation. CHAPTER XXVII MEDICOLEGAL SUGGESTIONS Although a physician is not expected to have a profound knowl- edge of legal matters pertaining to his profession, yet every doctor should be more or less familiar with the medical laws of the State or county in which he is practising. He should be well acquainted with the regulations of the board of health, of the coroner's office, 1 of the criminal court, etc., and do all in his power to aid in their rigid enforcement. A synopsis of such laws and regulations is usually readily obtainable in book form, and nearly every physician has among his patients or friends a lawyer who is glad to discuss legal questions in return for medical information. Some of the salient points relating to medicolegal investigations and autopsies will here be briefly con- sidered, though many references to these matters will be found else- where throughout this work, especially in Chapter XXVIII. Obligations of Physicians to their Patients. — The obliga- tion of a physician to society in the practice of medicine is in a certain sense voluntary. His is the right to refuse any and all cases that may apply to him for treatment or advice. Services once begun, however, he must, after giving notice of his intention to discontinue them, allow his patient reasonable time to fill his place, as otherwise he renders himself liable for damages. This obligation is equally binding in the case of charity patients. Contracts between a physician and a patient may be either implied or express. In the former neither party specially promises anything. An express contract may specify any- thing not contrary to public policy. Contracts making the payment contingent upon successful treatment are valid, but, should the patient fail to follow the doctor's directions or to give him sufficient oppor- tunity for treatment, the Court would probably allow the latter reason- able compensation. If the physician fail to exercise ordinary skill, 1 The office of coroner is an old and important one. It was established during the reign of King Athelstan, 925 A.D., and more clearly denned after the Norman conquest. The institution was brought to America by the colonists. The authority of the coroner to hold an inquest is not confined to the body of a person who may have died within his jurisdiction, but extends to all bodies brought within his territory, no matter where death may have taken place. (Witthaus.) 20 305 306 POST-MORTEM EXAMINATIONS he renders himself liable for malpractice. In law malpractice consists in wilful or negligent acts or acts which are expressly forbidden by statute and by which a person suffers injury or death. It is a criminal offence to practise medicine or surgery while intoxicated. Expert Testimony. — Applying these principles pertaining to medical practice to our subject, no Court can compel a physician to give expert testimony, to make autopsies, or to conduct laboratory investigations without his consent, but any knowledge which the doctor may possess pertaining to an individual criminal case must be given to the Court in the same manner as if he were an ordinary witness. His scientific training is, however, his own personal property, the result of many years' study, careful research, and expenditure of money, and he is entitled to commensurate remuneration for the expert use of his knowledge. For the good of society, any facts pertaining to a given criminal case which are known to him should be freely and willingly given to the Court, though he thereby may be put to consider- able loss of time and money. Whether the Court may compel him to divulge professional secrets is a debatable question. In some states and countries such confidences of the patient are held sacred, as are the confessions to a priest ; while in other places such confidences (wrongly, we believe, in civil cases, but rightly in first-degree criminal cases) must be divulged to the Court should questions be asked the physician pertaining to the same while on the witness stand. An expert is one who, by reason of his peculiar experience, special study, or performance of certain duties, is in a position to form an opinion or judgment such as could not be expected from the judge or jury. No regular witness is permitted to express a mere opinion, as this is supposed to be the province of the members of the jury. Thus, in one of my cases, where infanticide was suspected, an iceman had found the dead body of the baby in an ash-barrel, and the judge would not permit the iceman to act as an expert in giving the approxi- mate weight of the child, though it would seem that, on account of his frequent weighing of ice, he would be more fitted to give a correct estimate of the weight than an ordinary person. The weight of the child (nine pounds) was desired in order to show that it was born at or near full term. A medical man should refuse to testify as an expert unless he is thoroughly qualified. In no case should he go on the witness stand MEDICOLEGAL SUGGESTIONS 307 without being as fully informed as is possible on the subjects on which he is to be examined, nor should he allow himself to be questioned on subjects on which he is not prepared. He should be honest and candid with those securing his services before the trial, and, no matter what may by the consequences, his answers while on the witness stand must be made with absolute impartiality. The medical expert should at all times confine himeslf to purely medical topics and never become involved with matters that will place him in the light of an ordinary witness, of a detective, or of an attorney, and he should carefully avoid acting as a champion of the parties who are paying for his services or attempting to plead one side of the case. His language should be as free as possible from technicalities and such as can readily be followed by the least educated of the twelve jurymen, many of whom are, unfortunately, unfit for the performance of their duties. Some judges carry this plainness of language to an extreme. Thus, while acting as an expert in a murder trial, the writer was once requested by the judge not to use the word " hemorrhage" in testifying, as this term was too technical for the jury to understand. I at once substituted " bleeding" for the objectionable word and pro- ceeded with my testimony. When not positively certain of a point he should unhesitatingly acknowledge the fact; thus harm and the pos- sible endangering of a human life will be avoided. But when sure of his ground he should undeviatingly adhere to it. At the close of his testimony, especially if long and exacting, an opportunity is almost always given him to correct any misstatements which he may inadver- tently have made, and to make clear the meaning of any dubious points of his original testimony which may have been clouded by the cross- examination of the opposing counsel. Too much is often expected from the expert, as the following instance shows. While testifying as an expert in a country town on a case where the postmortem revealed beneath the left eye a small incision closed with two stitches, ecchymosis about the eyeball, and a fracture of the skull, the district attorney and the judge criticized me severely because I would only state that the man had died from hemorrhage of the brain due to fracture of the skull. They desired me to say that the man had been knocked down with the fist of a person who had a ring upon his ring-finger, and that in this manner the fracture had been produced. I was naturally willing to say that it 308 POST-MORTEM EXAMINATIONS could have been produced in this manner, but would not say, much to their apparent disappointment, that it was so caused. Identification of the Body. — Before a postmortem is begun, the remains should, if practicable, be positively identified to the obdu- cent by one or more persons who knew the individual during life. If this is impossible, the one finding the dead body or those having seen it in its original situation after death and those removing the cadaver from one place to another may act as identifiers. Persons who have gone under several names should be recorded under their legally correct name, any other aliases which had been used being also recorded. That the place where an unidentified body is found should be care- fully stated is shown by one of my cases. A colored woman con- fessed the placing of the corpse of a new-born male bastard wrapped in a shawl in an ash-barrel on the corner of A Street, Philadel- phia, Pennsylvania, in which State the concealment of the death of an illegitimate child is a penal offence. The body identified at the post- mortem was that of a new-born colored babe wrapped in a shawl, but found in an ash-barrel situated at the corner of B Street, some two blocks away. On the plea of the lawyer for the defence that there was no corpus delicti, as the body found at B Street was not shown definitely to be the body left at A Street, the judge decided that the trial should not proceed and ordered the jury to acquit. This was at once done, and, though new evidence might later be secured, it could not be used, as the woman could not have her life put in jeopardy a second time, though, as in the Mollineux trial, a man might once be condemned but on a new trial be acquitted. Should personal identification be impossible, a cast of the face, a photograph, an accurate description of the body, with a full and clear statement of any peculiarities, should be made. Clothing alone is not sufficient for purposes of identification, as bodies have been substituted and clothed in the wearing apparel of the alleged deceased, such substi- tutions being made in order to defraud life insurance companies or change succession to titles and estates. As the person whose body is being examined may have been a crim- inal and thus during life have had the Bertillon system applied for pur- poses of future identification, these measurements and finger-impres- sions should be secured in important cases. Skiagraphs of old osseous lesions might also lead to identification. MEDICOLEGAL SUGGESTIONS 309 Care of Clothing and of Surroundings. — Where the clothing has not been already removed by responsible persons, as is done in certain places (though this is scarcely justifiable), the examiner should observe the condition of the articles and their position, whether torn or soiled, displaced or reversed. If any irregularity is observed, he must determine, if possible, any significance that may be attached thereto. For example, singeing about a small recent bullet hole, with the powder markings pointing upward, would indicate that the powder used was black and not smokeless, that the weapon was discharged at close range, and that the trigger was held in the opposite direction, — i.e. 3 down. 1 Again, recent seminal stains on or marked disarrange- ment or tearing of the clothing of a female would strongly suggest — at least an attempt to commit — rape. When he has satisfied himself by this examination, the obducent may remove the clothing, which, where necessary, should be disinfected and preserved from destruction by moths or other injuries agencies. Thus, in a suit of clothes pre- served to show the entrance and the exit of a bullet, it is disappointing at or just before the trial to find the material so badly moth-eaten as to be useless for demonstrative purposes. As one's memory is treacher- ous, spots to be remembered, such as those showing blood, should be marked with thread or ink and a careful note made as to their exact location. The desire of the police to be on friendly terms with the reporters often renders the study of the surroundings impossible or misleading. In one of my cases, a brutal murder by violence, the scene had been visited by dozens of persons and the body removed to an undertaker's before the writer was summoned to perform the autopsy. The im- portance of ascertaining the nature of the substance upon which the body rested is shown by my finding at the postmortem in the rectum of a four-year-old boy " needles" from a Christmas-tree, and the later securing of a similar " needle" in the hat of the murderer and sodo- mist many blocks from the place where the crime was committed. The Corpus Delicti. — In many cases where homicide has been committed and the murderer has attempted to destroy the evidence of his guilt, or in destructive accidents, the corpus delicti has been proved by the finding of a part or member of the body or a portion of the clothing, as a piece of charred bone, a tooth, a ring, or a button. 1 Brinton, International Clinics, October, 1902. 3io POST-MORTEM EXAMINATIONS On the other hand, instances are on record where deluded individuals made confessions of murder which were proved to have been un- founded by the subsequent appearance in life of the person said to have been killed. So important is this point that time and time again juries have failed to convict where the moral evidence was wellnigh conclusive. It is only upon irrefutable evidence that the fundamental principle concerning the corpus delicti is disregarded. Where only a part of the body is available for examination, con- siderable difficulty is apt to arise as to the best method of procedure. The examiner will then need to possess a wide knowledge of com- parative and pathological anatomy and to exercise great ingenuity in order satisfactorily to demonstrate the identity of the parts submitted. Should the only proof of the corpus delicti be a skeleton or a portion of one, the expert will be asked to determine the age, race, and sex of the person and the probable date at which death took place, — whether the bones are old or recent. Thus, in the case of Wakefield Gaines the trunk alone was found, the head and limbs having been severed from the body. With limitations, the age would be known by the condition of the epiphyses, whether or not united; by the cranial sutures, whether or not closed; and by the state of dentition. Race would be indicated by the different racial characteristics and peculiari- ties : thus, the negro by his splay-foot, projecting heel, and prog- nathous jaw; the Caucasian by his higher forehead, wider facial angle, and larger cranial capacity. Evidence of this character is not, however, absolutely conclusive. The determining of sex, after the age of puberty, presents less difficulty. In man the size of the cranium is greater and all the bony points are heavier and more prominent, the angle of the neck of the femur with the shaft is greater, and the lower jaw is heavier; in woman the ribs are lighter and more compressed, the patella is smaller, and the articular surface of the femur and tibia is narrower. The characteristic differences are, however, found in the broad female pelvis, the diameters of which are all greater with the exception of the vertical ; the sacrum and coccyx are more curved and there is greater spread of the arches of the pubes. The probable age of the bones would be indicated by their condition and appearance. The presence of the marrow and the periosteum is the most conclusive evidence of a recent state. The soft parts are usually destroyed within two years. Under ordinary conditions the body skeletonizes in about ten years, although this period is subject MEDICOLEGAL SUGGESTIONS 3H to wide variations, depending upon the cause of death, the chemical properties of the soil in which the body was found, and whether or not preservatives were used. Medicolegal Postmortems. — The objects of a medicolegal post- mortem include the finding out of the cause and mode of death, the establishment of a corpus delicti, the determination as to whether a crime has been committed, and if so the discovery of a motive therefor and the exact nature of the process employed therein. In such legal investigations the pathologist should protect his reputation in every possible manner, and he should hesitate to make a postmortem with- out the presence of a witness, who should, if possible, be a professional brother. Never forget that the findings of the autopsy should be dictated to an amanuensis during its progress, verified at its comple- tion, and the record signed. In general the medicolegal post-mortem examination does not differ materially from the pathological, except that in the former greater precautions are necessary in order to avoid sources of error or confusion, and that the cranial contents are examined before opening the large blood-vessels, as signs of congestion disappear after the severance of the aorta and venae cavae. The importance of examining the vertebrae in all autopsies was illustrated recently by an article in the Lancet. Two cases were reported of fracture of the cervical vertebrae without external signs of violence, and in each case there was present a lesion of the heart which would have been assigned as the cause of death had not the real cause been demonstrated in the inspec- tion of the vertebral column. In some cases after a most rigid and painstaking inspection no cause of death can be ascertained, but with care and systematic examination mistakes and inaccuracies will be reduced to a minimum. In case of suspected poisoning the primae viae should be tied at each end and removed. Double ligatures should then be applied at the junction of the duodenum and the ileum and at the end of the small intestine, dividing the viscera into three portions. The contents of the stomach and those of the intestines should be emptied into separate jars. Many poisons are extremely volatile and without great care traces of them may be lost and justice defeated. Each organ should be received in a separate receptacle, and each receptacle should be marked, sealed, dated, and deposited where tam- pering with it would be impossible. 312 POST-MORTEM EXAMINATIONS The form of report used by the writer in medicolegal cases is as follows : " I made a post-mortem examination of the body of Walter Foster on April 10, 1898, at St. Agnes Hospital, Philadelphia. The body was identified by George Bell, 636 Siegel Street, and Michael A. Bruder, 1847 Sartain Street, both of Philadelphia. I find that death was caused by shock and hemorrhage from stab- wound of the heart." While acting as coroner's physician I rarely volunteered more than this, but waited for the district attorney to ask questions in regard to the nature of the wound and as to other facts of interest. By this method the jury is not confused by an enormous amount of irrelevant testimony, though the expert must be prepared to give, under cross- examination by counsel for the defence, the minutest details as to how the postmortem was performed. Autopsies on Infants. — The first question to determine in the examination of a babe ts, was it born alive? If so, was it a full-term child or a premature birth ? If born dead, how many months of uterine gestation caused it to reach its present development, and after attain- ing its maximum growth was it carried as a foreign body in the uterus ? Determination of the Viability of a Child from the Post- mortem Appearances. — The reader is advised carefully to read Paragraphs 23 and 24 of Virchow's regulations for the perform- ance of medicolegal postmortems. To discover the ductus arteriosus remove the thymus gland, incise the right ventricle along its septum, and extend the incision into the pulmonary artery along the middle portion of its anterior wall. The orifice is situated between and beyond the two openings of the right and left pulmonary branches. If the duct is open, a sound will readily pass into the aorta. If in the hydrostatic test the lungs float on top of the water, they have been completely aerated,- a strong proof of breathing at or after birth; if they float beneath the surface, aeration is incomplete; and if they sink, no respiration has occurred. Decomposition of the lung tissue may cause it to float. A very valuable sign of the viability of the child is the presence of uric acid crystals in the kidneys. Ante-natal rigor mortis may be met with, and does not prove, as has sometimes been asserted, that the infant was born alive in the legal acceptation of this phrase. Rigidity of the fcetus may unduly prolong labor by interfering with delivery. 1 1 Lancet, February 14, 1903, p. 460. MEDICOLEGAL SUGGESTIONS ^3 The Lancet of April 26, 1902, raises the query whether the dead body does not possess properties akin to radio-activity,, and alludes to the photographs taken by Vignon and exhibited by him, with the wind- ing sheet preserved at Turin and traditionally said to be that of Christ, which seem to justify the belief that the human body is either radio- active or that it gives off vapors which exhibit a similar action to light upon sensitive surfaces. Peroxide of hydrogen may be the main factor concerned. Period of Intra-uterine Gestation. — In deciding the age or period of development of the infant the external evidences of value are : ( 1 ) Length and weight of the child ( for tables of dimensions and weights of the new-born see page 268). (2) Conditions of the skin and its appendages. In the healthy babe at full term the skin is white and covers the body smoothly; woolly hairs are present in perceptible numbers only on the shoulders; the hair of the head is from two to three centimetres long; the nails are hard and horny, extending beyond the ends of the fingers, but not of the toes. (3) Condition of the umbilical cord, which at term is fifty centimetres in length and is inserted somewhat below the middle of the abdomen, falling off by inflammatory demarcation on the fifth or sixth day. (4) State of the cartilages of the nose and ear, being hard in the mature infant. (5) Presence or absence of the membrana pupillaris, which disappears after the eighth month. (6) Condition of the genitals in both sexes; as descensus begins at the seventh month, the testicles of the full-term male should be in the scrotum ; in the female the labia are generally found closed. (7) The measurement of the fontanels, of the cranium, and of the transverse diameter of the body at the shoulders and hips. (8) The size of the centre of ossification (Beclard's) in the lower epiphysis of the femur. To reach this the leg is flexed on the thigh, a transverse incision is made below the patella, which is removed, and the femur is then exposed. Thin, transverse sections of the cartilage are made until the greatest diameter of the centre of ossification, if present, is reached. The centre is absent before the thirty-seventh week, and in the child at full term has a diameter of from two to three lines, though it may even then be absent. If the diameter is more than three lines, the child has very likely lived for a certain length of time. ( Reese. ) The osteochondral line is also to be examined for syphilitic changes. From the internal examination important evidence as to the age 3H POST-MORTEM EXAMINATIONS of the child and especially as to respiration is secured. Upon ex- posing the abdominal cavity, which is to t>e done before opening the thorax or cranium, the position of the diaphragm in its relation to the ribs is immediately noted, as especially urged by Virchow. If the lungs do not contain air or are but partially distended, the diaphragm reaches to the fourth rib; when the lungs are fully dis- tended, the diaphragm is at the fifth or sixth rib on the right, and at the sixth rib or intercostal space on the left. To facilitate the examination of the umbilical vessels, Nauwerck recommends a division of the usual abdominal incision, shortly before reaching the navel, into two diverging incisions extending to the pubes. The abdomen is opened, and the umbilical vein, made promi- nent by traction on the triangular flap, is traced along its course, opened with small scissors, ligated, and divided. Turning down the flap over the pubes exposes for examination the umbilical arteries to either side of the remains of the urachus. (Fig. 140.) Criminal Abortion. — Formerly abortion was not legally a crime if performed with the consent of the mother prior to the viability of the foetus. It was at one time not regarded as murder even to take the life of a child at any period of uterine gestation. The barbarousness and danger to society of this view were early recognized, both abroad and in this country, and various laws with different penalties attached thereto were enacted making it a crimi- nal offence to practise abortion at any period of gestation, unless for the express purpose of saving life. (Witthaus and Becker.) There is no other class of cases so trying to the patience, ingenuity, and skill of the pathologist as those of abortion, which is accom- plished by numerous methods. Many respectable women expose themselves to cold, falls, and douches with the hope of relieving themselves of their offspring apparently by accident. Many pills and potions are sold to induce a resumption of the menstrual dis- charge, and one often finds them on sale in drug-stores of the first rank. These nostrums are sometimes composed of poisons that may cause the death of the mother. The use of instruments, especially the spiral douche advertised in so many papers, is a very common method of procedure. Indeed, the most successful criminal abor- tionists operate so that, unless through accident, no evidence of the operation is left. Usually all that can be found is evidence of a recent pregnancy. MEDICOLEGAL SUGGESTIONS 315 When violence is clone to the child, the nature of the injuries must be carefully noted. When violence is done to the uterus, some form of infection usually follows. Care must be taken in examina- tion to exclude the possibility of previous disease of the uterus or adnexa as a cause of the infection or possibly as a cause of abortion. In former days, when curettage was more used than it is now in the treatment of abortion, an additional factor was added, making it difficult and often impossible to distinguish dilatations of the os due to the instrument producing the abortion and to the passage of the foetus from those induced by the introduction of the curette and the subsequent packing with iodoform gauze. Care should be taken to compare the vital history of the foetus with the physical condition of the mother, the history of sexual life of the parents, specific disease, etc. Signs of Death. — Space permits only brief mention of the signs of death; the reader interested in this subject is referred to Brouardel's work on death and sudden death. The positive signs of death in an unmutilated body are decom- position, complete loss of temperature, and cadaveric lividity and rigidity. The negative signs are : ( 1 ) Cessation of respiration, determined by holding before the nostrils a down feather, a small flame, or a cooled mirror, or by placing a glass containing water on the epigastrium. (2) Cessation of circulation, ascertained by obser- vation, palpation, section of a small artery, transmitted light through web of fingers, loss of vasomoter constrictors, acupuncture of the apex of the heart, emptiness of the arteries, etc. (3) Cessation of nervous and muscular irritability, determined by application of light to eye, or of cold, heat, force, electricity, irritants, etc., to skin. (-4) Cessation of tissue vitality, abolition of reflexes, etc. Respirations usually cease by a moment before the heart-beats stop, but sooner in the new-born than in others. In the last agony or shortly after death the pupils dilate, but within an hour contraction sets in, which lasts from three to four days, the contractions of the pupils often being unequal. Spermatozoic movements may be found in those dying suddenly more than twenty-four hours after death in suitable cases. Lowering of temperature occurs first on the surface, requiring, accord- ing to good authority, twenty-three hours to become complete. Premature Burials. — That premature interment has occurred is undoubted. In Munich the popular belief in such instances is so great that the body is placed in a specially prepared room, with a 3 i6 POST-MORTEM EXAMINATIONS bell in the hand of the corpse ready for use in case of an emergency ! Such notions usually originate from careless handling of the coffin, from the expulsion of a foetus by the formation of gases in the body of a pregnant woman, from real or apparent growth of hair, from conver- sion of bodies into adipocere, etc. Usual Causes of Death. — In Chapter XXIX. will be found a list of all the recognized causes of death, and it is recommended that this classification be used by every one in order that uniformity of nomenclature may be secured throughout the world. Sudden death is usually due to failure of the circulatory apparatus, to cessation of respiration, to disturbance of the nervous system, to deficient nutri- tion, to poisons either produced within the body or introduced from without, or to violence by physical or chemical forces, heat or cold, electricity, wounds, missiles, etc. Many conditions that have existed a long time may cause sudden death by breaking the balance of life. Thus, in chronic nephritis uraemia may develop suddenly and cause death after only a very slight illness. Again, an aneurism may rupture without sudden increase in the symptoms or any violence, simply by a natural slow progress of the lesion. All mortal diseases and many that by themselves do not end fatally may contribute to the causing of sudden death as well as to the slower dissolution. No disease causing severe disturbance of heart, kidney, lung, nerve, or digestion can be ignored in estimating the factors that brought about the death of the patient. Certain maladies of common occurrence should be in our minds in making examinations, though never so prominently as to prevent a proper search for other con- ditions. Thus, in children think of pneumonia, enteritis, bronchitis, meningitis, congenital syphilis and other hereditary diseases, infec- tious fevers, malformations, etc. ; in young adults, infections, local and general, violence, typhoid fever, and tuberculosis; in middle life, diseases of the lungs, kidneys, heart, and blood-vessels, hepatic and gastro-intestinal conditions, infections, violence, occupation neuroses, pneumonia, tuberculosis, cancer, etc. ; in old age, nephritis, carcinoma, sarcoma, aneurism, cerebral hemorrhage, embolus, throm- bosis, tumor or abscess, arteriosclerosis and obstruction of the coro- nary arteries, heart lesions, etc. In coroner's cases death very commonly results from heart ex- haustion, due, as the case may be, to intrinsic disease, to excitement, MEDICOLEGAL SUGGESTIONS ^jy or to poisons. Care should be taken to determine the cause of this exhaustion, whether it was due wholly to heart disease, such ' as a valvular lesion, or to one of the exciting causes. In kidney con- gestions consider whether death was due to failing heart causing passive congestion, to poisons, or to inflammatory congestion, such as would be part of an acute nephritis. Ascertain if the oedema of the lungs is dependent upon cardiac, renal, or cephalic lesions or primarily upon a lung condition principally. Decomposition. — The bodies of infants decompose more quickly than those of adults. The process begins earlier in plethoric and fat adult bodies than in thin aged persons. It is more rapid after muscular activity and in those dead of acute diseases, fevers, heat- stroke, sepsis, suffocation by gases, etc., while it is longer delayed in cases where the system is exhausted and muscular irritability retarded, and in the bodies of those fatally poisoned by hydrocyanic acid, carbonic acid, sulphuric acid, etc. Arsenic may or may not prevent decomposition. At the same temperature a body which has been for one week in the air, one which has been two weeks in water, and one which has been eight weeks buried will show similar degrees of decomposition. (Brown-Sequard.) Hofmann recommends in cases where decomposition is much ad- vanced the removal of the brain in the ordinary manner, the making of some openings in the skin, the washing of the entire body in running water for twelve hours, and the further bathing of the corpse in a con- centrated alcoholic sublimate solution or chlorid of zinc for an equal period. The green coloration due to decomposition disappears to a marked degree under this treatment. The length of time which has elapsed since death has to be deter- mined by the circumstances peculiar to each case. So many considera- tions may apply that in many instances it is dangerous to be too dogmatic. Violent Death. — When there is doubt as to homicide, all the precautions necessary for such cases must be strictly observed. The sort of violence, its mode of application, and something of an estimate as to the amount, direction, and conditions of application of force can usually be made from post-mortem examination. In the inspection of wounds the condition of the tissues and the position and direc- tion of all lesions discovered are to be very carefully noted, as some- times the instrument with which they were inflicted may safely be 318 POST-MORTEM EXAMINATIONS inferred therefrom, and at times the findings will point to the cir- cumstances under which the injuries were received. A minute descrip- tion of the injuries is absolutely necessary, so that if called upon in court an exact account of them can be given. The amount of con- tusion, laceration, extravasation of fluids, and damage to any vessels must be carefully noted. In gunshot wounds the projectile should be found : this is imperative. About the wound of entrance look for powder marks, singeing, and smudge. If the projectile struck a bone, a splinter may have been detached and caused injuries not along the line of the main wound. Death is frequently due to shock, which may result from a blow that leaves no mark visible at the post- mortem. This is quite uncommon. Injuries to the head make it necessary to estimate the structural and tensile strength of the skull in each case. When a fracture of the skull is found or suspected, the skullcap must be cut away with the saw only, not using the chisel. Contrecoup must always be considered in hunting for fractures and lacerations of blood-vessels. Burns and Scalds. — Burns are produced by dry heat and show when fresh no maceration of the tissues. When inflicted by intense heat or by flame, there will be found scorching or singeing of clothing and. hair, and possibly of flesh. When resulting from contact with a hot surface, note especially the shape of the burn, and, if the supposed hot object is to be obtained, a corresponding mark may be found upon it. In burning the hair often reddens. Scalds are produced by vapor, steam, or a liquid, and usually show some trace of the action of the fluid on the mucous membrane or skin. In plain scalds singeing is absent, but where fire has fol- lowed an explosion both scalds and burns may be found. In such cases the mucous membrane of the air-passages should always be examined. In cases of scalds and burns the extent of the injuries must be determined both in breadth and in depth, with a careful observation of secondary changes, such as sepsis, internal congestions, and inflam- mations. There is probably produced by these means a product poisonous to the organism, which acts as in other forms of auto- intoxication. Death by Electricity. — There are no absolute and constant indications. In some cases the point of entrance or of exit can easily be made out by the change in tissues or in clothes. Frequently there MEDICOLEGAL SUGGESTIONS 3^ is marked burning of the skin. In many instances the only evidence is an unnatural rigidity of the muscles, sometimes with distortion, due to a coagulation of the muscle substance by the current, which, if found in one part and not in another of the same body, may be of signifi- cance. There may be evidence of electrolytic action in the blood and organs, as in the brain and cord. There may be livid areas, even hemor- rhages, though after sudden death they are not usual. The face is sometimes distorted. The heart is usually flaccid, although the left side may be hard or tense. On the right side dark fluid blood is often found distending both auricle and ventricle. The same condition exists in the left auricle, but the ventricle is almost empty. The pupils are invariably widely dilated immediately after death. The blood is usually fluid, but clots have been found in the heart and large veins. Jellinek 1 finds that the anatomical changes in the tissues resulting from the passage of a powerful electric current diminish the resistance of future currents. Mice are killed with a weak current, but pigs show the greatest resistance. Death by electricity occurs more quickly after administration of morphine or cocaine, but is retarded by chloroform anaesthesia. A dose of morphine might therefore be administered with benefit before an electrocution. Microscopically, degenerations are found in the gray matter of the spinal cord along with dilatation of the central canal and hemorrhages. Death from Heat or Cold. — After fatal heat-stroke the body is often very hot for hours and decomposition may be uncommonly rapid. There may be general internal congestion. It is usually necessary to know somewhat of the history of the case before a verdict can be rendered of heat-exhaustion, sunstroke, or thermic fever. In cases of death from cold we often find pallor or dislocation of the skin and a congestion of the viscera with blood of rather bright color. No single characteristic lesion results from exposure to moderate excess of either heat or cold. When no pathological lesions can be found, death is probably due to shock. Any chronic disease of viscera tends to reduce the power to resist severe temperature changes. There is no significance in the freezing of the body beyond showing that considerable time may have elapsed since death. The 1 Wiener klin. Wchnschr., Nos. 16 and 17, 1902. 320 POST-MORTEM EXAMINATIONS frozen flesh of the mastodon sometimes found in the Siberian plains is good eating, though it must be thousands of years old. There are no characteristic changes in sunstroke. Rigor mortis comes on early. Lividity and putrefactive changes develop rapidly after and even before death. Venous engorgement is extreme, particularly in the cerebrum. The left ventricle of the heart is contracted ; the right is dilated and may be full of blood imperfectly coagulated and deficient in oxygen. The blood is fluid, dark in color, acid in reaction, and prob- ably contains, as in burns, a poisonous substance which acts on the more highly specialized cells of the body. Petechial patches may appear in the subcutaneous and subserous tissues. The elevation of temperature is often remarkable, and it is extremely disagreeable to make an autopsy in these cases, as I have done, soon after death, with a temperature of 106 F. In a case of mine of stramonium poisoning, with a tempera- ture of nearly no° F., the clinician had diagnosed sunstroke. Infanticide. — Many methods have been resorted to, as exposure to cold, smothering in various ways, strangulation either by the hands or by a ligature around the neck, and wounding with various instru- ments, sometimes accompanied by efforts to conceal the act. The child may be intentionally drowned in a vessel containing fluids discharged from the vagina at the time of birth. Gross violence or poisons may be employed. Death by Starvation. — There is usually extreme emaciation, which is shown especially by a sinking of the eyes and an unfilled condition of the skin. It is sometimes necessary to determine whether starvation resulted from disease or neglect, especially in cases of those children which have been reared in foundling homes and hospitals. Suffocation; Strangulation; Hanging; Drowning. — All these produce death by asphyxia, or carbon-dioxid poisoning, com- bined with oxygen starvation, the signs of which are more or less marked. In death from asphyxia there are usually hemorrhages into the thymus gland, as well as Tardieu ecchymoses in the pleura and pericardium. Plain suffocation may show no marks of violence. The dark fluid blood, possibly hemorrhages from increased blood pressure, gen- eral congestion of the lungs, frequently congestion of viscera, often blue nails and lips, occasionally suffusion of the face with dark venous blood, and an absence of other pathologic conditions, give a general MEDICOLEGAL SUGGESTIONS 321 type of finding that is not easily mistaken when clearly marked but is difficult to recognize when not conspicuous. Strangulation adds the factor of mechanical arrest of respiration, and may result from the presence of food, some foreign substance, or a growth or swelling in the throat. When due to throttling the marks about the neck are of great importance. There may be com- pression of veins. Hanging may cause death by injury to the spinal cord as well as by compression of the blood-vessels and air-passages. The parch- ment-like appearance of the skin on the sides of the neck and the rupture of the intima of the carotids afford valuable evidence. Wachholz 1 has shown experimentally that in acute suffocation there may be found, along with the soft currant-jelly clots in the heart, solid white clots embedded in the meshes of the cardiac muscle. La Cas- sagne and Martin have described a method, called docimasie hepatique, of diagnosing sudden death by a marked increase in the sugar contents of the liver of persons who ha\ r e died suddenly. Wachholz finds from his experiments that no such relation exists. Reuter, working with Kolisko, 2 from a study of twenty-two cases of throttling and two hundred cases of hanging, thinks that these two very similar modes of death may be differentiated from each other. In throttling there is ( 1 ) cyanosis of the face, with ecchymoses of the eyelids and conjunctiva. (2) The scalp, the coverings of the brain, and its membranes are always rich in blood. (3) As a rule, hemorrhages in the soft tissues of the neck, especially in the muscles, occur. (4) There is marked injection of the upper air-passages, combined with numerous small hemorrhages. ( 5 ) Injuries to the larynx and hyoid are rare. (6) Rupture of the intima of the carotid is never noted; in only three cases were there suffusions into the adventitia. In hanging ( 1 ) cyanosis of the face is usually not noted ; ecchymoses are seen in twenty per cent, of typical and in thirty per cent, of atypical strangulations. (2) The amount of blood contained in the organs in the skull varies, but usually consists only of that which was present in these parts at the time the circulation was interrupted. (3) Hemorrhages in the muscles are rare, — two per cent., in typical and fourteen per cent, in atypical cases. (4) Injuries to the laryngeal and hyoid structures are com- 1 Vrtljschr. f. gerichtl. Med., 1902, p. 34. 2 Zcitschr. f. Hcilk., 1902, vol. xxii. 21 322 POST-MORTEM EXAMINATIONS mon, — sixty per cent, in typical and thirty per cent, in atypical cases. (5) Rupture of the intima of the carotids occurs in five per cent, of typical and four per cent, of atypical hangings. The external markings on the neck are also often different. In a case of drowning water or foreign substances may be found in the openings of the body, in the respiratory organs, or in the stomach, or death may be due to spasmodic arrest of respiration. The froth from the air-passages is coarser than that seen in cases of oedema. Very soon after death we often find watery fluid in the pleura. The spongy condition of the lungs is found only where there has been inhalation of water, which does- not always happen. After decomposition has set in, the evidence of drowning gradually dis- appears until it is impossible to make the diagnosis. Blood-Stains. — When any suspicion of violence occurs, look carefully for blood-stains. If possible, determine whether any stains found are blood. If in doubt, treat them as if they were, unless some special reason exists for not doing so. Such stains should be most critically examined in the privacy of the laboratory. Try to ascer- tain : (1) Their connection with the person examined. (2) Their source. (3) Their extent, using great care in determining the nature of the substance stained and whether there has been flowing or run- ning, to be judged partly by shape and direction of the stains. (4) Conditions, — whether fluid or clotted, wet or dry, cracked or caked, etc. (5) How made, — whether by smear, by splash, by flow, by soaking up as in cloths, etc. (6) Connect, if possible, the amount, shape, and condition of the stains with their probable source and note any peculiarities. When practicable, preserve parts or all of stains. It is often well to saw off an entire step or remove a panel, in order to produce the same as evidence in court. In the present state of our knowledge it is not safe to state from what part of the body the blood came and the age of the stain, though the more recent, the more soluble. Two illustrations from my case-book will show the importance of this line of research. A man committed rape on a child, and blood was seen on the fly of his trousers by his room-mate. In order to divert suspicion from himself, he accused his room-mate of the crime. The trousers of both men were sent to me for examination. In the pair of pants belonging to the perpetrator of the crime the lining of the fly had been cut away and neatly sewed, but there remained a MEDICOLEGAL SUGGESTIONS 323 few telltale threads containing blood, which was found to possess the characteristics of human blood. On the trousers of the other man was found a red substance, which examination showed to be lumber- man's red chalk, the crime having been perpetrated in the backwoods. In the second case blood splashes on a white curtain were stated by a murderer to be red paint which one of his children had put there with a paint-brush. • The presence or absence of blood is determined by the ( 1 ) physi- cal examination; (2) chemical tests; (3) spectroscopical examina- tion; (4) microscopical examination; and (5) the hemolytic serum test. One of the most recent and valuable books on this and kindred medicolegal subjects is that of Glaister. 1 I am unaware as yet of any murder trial in which the new aggluti- native reaction for the diagnosis of human blood has been applied. It will certainly be a feature of all such trials in the future, as when used in conjunction with the other tests it would seem to afford positive proof of the presence of human blood. Uhlenhuth 2 was put to a severe test by the German Department of Justice. Various objects stained with the blood of man and of different animals were sent to him, the nature of the blood being known to the Department of Justice, but not to him. When the blood was furnished in sufficient quantities, his results in each case were positive. One method of applying the test is as follows : Ten cubic centimetres of defibrinated human blood are injected into the peritoneal cavity of a rabbit at intervals of six days, and after five such injections an effective serum should be obtained. The blood to be tested is then diluted with water, one to one hundred, and filtered. Of this clear, slightly red solution, two cubic centimetres are placed in a small tube and mixed with an equal quantity of 1.6 per cent, salt solu- tion; six to eight drops of the serum of the rabbit are then added to each tube about to be tested, but all will remain perfectly clear except the tube containing human blood. The reaction is extremely delicate and can be obtained with very slight traces of even old dried blood. Deutsch, 3 Wassermann and Schultze, 4 and Dieudonne 5 describe prac- 1 A Text-book of Medical Jurisprudence, Toxicology and Public Health, 1902. 2 Deutsche med. Wchnschr., September 11 and 18, 1902. a Orvosik Lapja, 1901, No. 11. 4 Berl. klin. Wchnschr., 1901, vol. xxxviii., No. 7. 5 Munchen. med. Wchnschr., 1901, No. 14. 324 POST-MORTEM EXAMINATIONS tically the same method as Uhlenhuth and have obtained the same results. The first of these claims to have been the first to use this method of differentiating human blood, while the last found that the same result could be obtained with human urine and human pleural exudate, although to a less degree. Corin * believes that the active principle of the serum in the bio- logical differential diagnosis of the blood is paraglobulin, for not only may blood-serum be used for this purpose, but also transudates con- taining globulin. The paraglobulin in an ascitic fluid was precipitated by magnesium sulphate, dried, and injected into animals in an aqueous solution. In like manner the paraglobulin can be precipitated from the blood of the animal experimented upon and preserved in pulverized form. This powder when wanted for use is dissolved in water and employed in testing the blood under examination. Biondi 2 finds that the reaction occurs with the semen, so that human and animal sper- matic fluid can be differentiated. The reaction was also secured from many of the normal and abnormal secretions and excretions of the body. Butza 3 prepares the animal by injecting from ten to twenty cubic centimetres of a centrifugated human pleural exudate intraperitoneally into a rabbit for five or six successive days. The Bremer- Williamson reaction of diabetic blood may be obtained a considerable time after death ; 4 the procedure is as follows : Forty cubic millimetres of water are placed in a small, narrow test-tube; to this are added twenty cubic millimetres of blood, one cubic millimetre of a one to six thousand aqueous solution of methylene blue, and forty cubic millimetres of liquor potassse. The test-tube is placed in boiling water for four minutes, at the end of which time, if the blood is diabetic, the blue color will have disappeared and a dirty-green color will have taken its place. Williamson obtained the reaction in forty-three cases of diabetes tested and thinks it is due to an increase of glucose in the blood. The reaction is of especial value in coma where urine cannot be obtained. Cryoscopy. — The determination of the osmotic pressure of liquids at their freezing-points is being studied extensively. The lowering of 1 Vrtljschr. f. gerichtl. Med., 1902, p. 61. 2 Ibid., Suppl.-Heft, 1902, p. 1. 3 Spitalul., 1902, xxiii. p. 2>77- 4 T. R. Brown, International Clinics, January, 1903. MEDICOLEGAL SUGGESTIONS 325 the freezing-point is directly proportionable to the osmotic pressure of the liquid. Cryoscopy is a method introduced by Raoult, of Greno- ble, for the purpose of measuring the urinary toxicity as well as furnish- ing enlightenment upon the metabolic changes in the blood, cerebro- spinal fluid, and other fluids of the body. It has been found that the freezing-points of these fluids of the body present certain appreciable differences in certain diseases. The method has a wide field of useful- ness both in experimental research and in diagnosis and prognosis of disease. Those interested in the clinical applications of cryoscopy and their possible application to pathology are referred to Widal and Lesne's admirable paper in Vol. vi. of Cornil's Traite de pathologie generate, p. 661. Space permits but a single example of the possible use of this method. Revenstorf 1 determines the freezing-point of the blood from both sides of the heart, as more or less of the fluid in which an animal is drowned usually passes through the capillaries of the lungs and dilutes the venous blood. He concludes that the method, when positive, — i.e., when it can be shown that the freezing-point of the blood from the right side of the heart is higher than that of the blood from the left side, — is valuable as additional evidence of drowning, and is very easily car- ried out ; but decomposition rapidly removes any difference which may have existed, and the blood is not necessarily diluted during death by drowning. Cytology. — The different kinds of cells found under various con- ditions in the serous cavities form a most inviting field of study. Thus, in syphilitic hydrocele we have endothelium, in gonorrhceal hydrocele, marked polymorphonuclear leukocytosis, in tuberculous hydrocele, lymphocytosis, in mechanical hydrocele, few or no leuko- cytes. Naturally, the age of the process has much to do with the num- ber and variety of the cells. Toxicology. 2 — The presence of poisons in the animal economy may be recognized by clinical, chemical, pharmacological, and patho- logical methods. While we have chiefly to do with the latter method, the success of the chemist and the pharmacologist depends largely upon the procedures adopted for the preservation of material by the pathologist at the time of the performance of the autopsy.- There are certain poisons which may kill without leaving in the tissues any 1 Mimchen. med. Wchnschr., No. 45, 1902, p. 1880. 2 Much of the material in this section is taken from Robert's Lehrbuch der Intoxikationen, Stuttgart, 1902, and Glaister's Medical Jurisprudence, 1903. 326 POST-MORTEM EXAMINATIONS specific alterations to be found post mortem, especially when the examination is postponed for several days. A poison is any substance which, when taken into the system and either being absorbed or by its direct chemical action upon the parts with which in contact, or when applied externally and entering the circulation, is capable of producing deleterious results. (Wormley.) Poisoning commonly results from alcohol, morphine, lead, arsenic, phosphorus, oxalic acid, carbolic acid, etc. ; from food (bromatotoxis- mus) ; from meat (kreotoxismus) ; from milk products (galactotoxis- mus) ; from fish and shell-fish (ichthyotoxismus, mytilotoxismus) ; and from grain (sitotoxismus) ; of the latter poisoning there are three kinds, — ergotism, lathyrism, and pellagra. It should always be remembered that conditions which we are apt to regard as being alone produced by strictly pathological processes are often due to poisons. Thus, toxic inanition may be produced by chronic poisoning with mercury, lead, arsenic, etc. ; fatty degenera- tion, by phosphorus, alcohol, Amanita phalloides, etc. ; calcification of the renal epithelium, by corrosive sublimate ; and amyloid degenera- tion, by repeated injections of turpentine. Suspicious undissolved foreign bodies may be found in the vomit and in the contents of the alimentary tract, as arsenic (white, metallic, and various salts), antimony, sulphide of antimony, mercury and its preparations, as calomel, oxid, and bichlorid, chrome salts, oxalates, cantharides, nux vomica beans, heads of matches, and parts of poison- ous plants. In one of my cases diagnosed as a heat-stroke, with a temperature of over no° F., the finding of leaves of datura stra- monium in the stomach led to the correct diagnosis. Morphine even when given hypodermically may be found in the stomach contents. Certain chemicals may be detected by odors coming from the body or from the various cavities when opened, as alcohol, ether, chloroform, aromatic oils, formalin, phosphorus, turpentine, nitrobenzol, benzene, wood alcohol, hydrocyanic acid, paraldehyde, camphor, chloral, car- bolic acid, nicotine, bromin, chlorin, iodin, ammonia, hydrochloric acid, oxalic acid, opium, sulphuretted hydrogen, etc. When the acidity or alkalinity of the gastric contents is abnor- mally increased, certain reagents are to be suspected, such as acids, alkalies, and potassium cyanid. The liver especially shows poisoning by phosphorus, antimony, arsenic, and toxins, while the kidney is affected by hemolytic and methaemoglobinic poisons, by oxalic acid. MEDICOLEGAL SUGGESTIONS 327 oxamid, mercury, silver salts, preparations of cantharides, etc. The spectroscopic picture of the blood should always be obtained as soon after death or removal from the body as possible. The addition of a little distilled water is admissible in methgemoglobinsemia, but even here it is better at once to seal hermetically in glass tubes with exclu- sion of air as far as practicable. If the blood coming from veins is fluid and scarlet, suspect carbon monoxid poisoning; if a laky purple fluid, not changing on the exposure to oxygen, suspect cyanid. If the muscles of the abdominal walls are drawn and contracted spirally, we may suspect any of the instant poisons, as strychnine or potassium cyanid. I have for a long time had a bottle of blood from, a case of cyanid poisoning, and have many times exposed it to the air by re- moving the cork, yet it is apparently still in a perfect state of preser- vation. The left heart is found markedly contracted in death from over- doses of members of the digitalis group, veratrine, and barium salts. As already stated, the odor of the poison may sometimes be detected on exposing the brain. In one of my cases of ammonia poisoning a rod dipped in hydrochloric acid gave off fumes when introduced into the cranial cavity after removal of the brain. Much attention has been paid to the actions of poisons on the central nervous system, and the rapid diagnosis of hydrophobia by this method should not be forgotten. The joints are alleged to be inflamed after poisoning by colchicum. Testicular atrophy is said to be induced by the long- continued use of capsicum, solanus pseudocapsicum, and conium maculatum. The mucous membrane of the stomach is irritated and stained by many poisons, as sulphuric acid (black), nitric acid (yellow), oxalic acid (white), bromin (red), iodin (purple), and by a large number of metallic salts, as sulphid of arsenic (yellow), chromate of potas- sium (red), etc. I have, however, seen several cases of arsenical poisoning with but little inflammation of the gastric mucosa. Among the questions to be answered in every case of suspected poisoning are : Was death caused by a poison originating within or without the body? What poison caused death? Is the substance found by the chemist the poison which killed the person in whose body it was found? Might not the poison have been administered as a medicine? Is the poison present in such quantity as always causes death? Were there attendant circumstances which conduced to the 328 POST-MORTEM EXAMINATIONS fatal result? Was more than one poison given? How and when was the toxic substance administered? Could poison have been given and yet not be discovered? Was the fatal dose taken for purposes of suicide? Was it administered with the object of killing? Was it ad- ministered accidentally? Did the person for whom it was intended receive the poison? Could the toxic symptoms be simulated? Was cremation practised in order to destroy evidences of poisoning? Was there any motive for homicide? Are there any accomplices? What became of the vehicle in which the poison was administered? Was there any poison found ? Was any poison destroyed ? Nearly every toxicologist has his own classification of poisons. Thus, one divides them into mineral, vegetable, animal, and mechanical groups, another into irritants, narcotics, and narcotic irritants, a third into chemical and vital poisons, etc. All such divisions are arbitrary, as quickly becomes evident on attempting to place the various poisons in their proper subclasses. Inorganic Organic Irritant SCHEME FOR THE DIVISION OF POISONS. Irrespirable gases : carbon monoxid, coal gas, chlorin, bromin, hydrofluoric acid, sulphur dioxid, etc. Chemical : sodium hydrate, sulphuric acid, etc. Irritant : arsenic, antimony, mercury, phosphorus, etc. Irrespirable gases : chloroform, ether, formalin, etc. Chemical : carbolic acid, acetic acid, pyrogallic acid, etc. Vegetable : gamboge, colchicum, squill, etc. Animal : cantharides, etc. Narcotic : opium, hyoscyamus, belladonna, can- nabis indica, etc. Alkaloidal -| Sedative : digitalis, hydrocyanic acid, aconite, conium, etc. Excitomotor : strychnine, ergot, etc. Antiseptics : creolin, lysol, etc. Synthetical -J Antipyretics : antipyrin, acetanilid, etc. Hypnotics : sulphonal, trional. {Bacterial : toxins, hemolysins, cytolysins. Animal : snakes, scorpions, ptomaines, etc. Vegetable : ricine, abrine, etc. Acids. — Poisoning may be produced by mineral and vegetable acids, the corrosive action depending largely upon the strength of the acid at the time of its introduction into the body. Naturally, those parts are most affected which remain longest in contact with the acid. MEDICOLEGAL SUGGESTIONS 329 The mucous membrane of the lips rarely escapes, and often the skin of. the lower lip is discolored. The mucous membranes of the mouth, oesophagus, and stomach are acted upon, and oedema of the glottis is common. The tissues are softened ; sometimes there is actual destruc- tion followed by necrosis, which may lead to perforation. Around these areas of corrosion is a more or less marked hemorrhagic inflam- mation. If the acid w r ere diluted, this inflammation is more marked and the corrosion less so. The blood in the external veins of the stomach is usually black. In all cases where death does not occur quickly, changes are seen in the parenchymatous organs, especially the kidneys. The color produced by different acids is somewhat charac- teristic. In carbolic acid poisoning the oesophagus is of a silver-gray color, the stomach is thrown into rugae, and the mucosa is of a rough, brownish, cracked appearance. The urine may be dark in color and smell strongly of phenol. In poisoning by sulphuric acid the mucous membrane of the upper intestinal tract is brownish or even black, due to the extraction of water from the tissues and the action of this acid on the coloring matter of the blood. It is often difficult or impossible to say whether perforation occurred during life or after death. The effects of hydrochloric acid are similar to those of sulphuric acid, but less marked, corrosive action on the skin being almost absent. Nitric acid imparts to the skin and mucosa a yellowish tinge, owing to the for- mation of picric acid. In oxalic acid and oxalate of potassium poison- ing white to grayish corrosion of the upper intestinal tract occurs, crystals of oxalates of lime being found in the blood and kidneys. Con- centrated acetic acid may also cause death. Aconite. — In aconite poisoning the physiological test should always be applied. No characteristic lesions are found post mortem. Alcoholism. — There are no really characteristic lesions. I. Gastro- intestinal Tract. — (1) Chronic hypertrophic gastritis may be followed by (2) atrophic gastritis with dilatation. (3) Hypertrophic or atrophic cirrhosis of the liver. Orth says, " Most drinkers have no cirrhosis of the liver, but a fat liver, and many with liver cirrhosis are not drinkers of alcohol." II. Vascular System. — ( 1 ) The heart is usu- ally enlarged and its muscle often thin, fatty, and friable. (2) The blood-vessels are frequently sclerosed, especially those arteries exposed to much strain. (3) The venules of the cheek and nose are often dis- tended. III. Central and Peripheral Nervous System. — (1) The pia- rachnoid is thickened, with wasting of its convolutions. (2) The blood- 330 POST-MORTEM EXAMINATIONS vessels are thickened, tortuous, and may show miliary aneurisms. ( 3 ) The motor nerves of the muscles are sometimes altered (multiple neu- ritis). IV. Genito-urinary Tract. — (1) The kidneys are enlarged, cyanotic, and indurated. ( 2 ) The bladder is thickened and often shows signs of chronic cystitis. Alkalies and Caustic Salts. — Alkalies, potash, soda, and am- monium hydrate act much the same as acids except that the involved areas are brown and less brittle. The epithelium is shed in threads and there are ecchymotic folds of the mucosa. Capillary bronchitis is com- mon ; so is stricture of the oesophagus in patients who recover. In one of my cases cancer followed at the seat of stricture due to the accidental drinking of lye. Antimony. — Poisoning is usually due to tartar emetic. The mu- cous membrane from the mouth to the duodenum inclusive is usually inflamed, and often ulcerated and covered with stringy mucus. In chronic cases there is considerable emaciation ; chemical tests will deter- mine its true character. Arsenical Poisoning. — This may be: (a) Acute. (&) Subacute. (c) Chronic. In acute arsenical poisoning there is generally a marked gastro-enteritis, which differs in severity according to the amount taken. The mucous membranes are intensely swollen, cedematous, and present small emphysematous bullae or diphtheritic exudate. Petechial erup- tions may occur in both the stomach and intestines. The contents of the stomach are usually of a brownish color. In subacute arsenical poison- ing or where large doses have been taken, patches varying in size from a dime to a silver dollar, consisting of an opaque white, yellowish, or even violet coagulated lymph mixed with arsenous acid and firmly fixed to the mucous membrane, with signs of intense inflammation around them, may be found in the bowels. White spots of arsenic are some- times discovered between the rugae, and fatty degeneration of the intes- tinal epithelium and of the viscera is also present. Chronic arsenical poisoning is characterized by wide-spread fatty degeneration, affecting especially the heart, liver, spleen, and kidneys. Marked changes are also found in the voluntary muscles, which show wasting, fatty degen- eration, and often cirrhosis. Trophic changes are common, such as overgrowth of hair and nails, both of which are harsh and brittle. The skin is harsh, dry, and frequently shows eruptions. Although arsenic is rapidly eliminated from the body, enough usually remains for pur- poses of identification. The urine should always be saved. The white MEDICOLEGAL SUGGESTIONS ^l material should be examined microscopically for the octahedral crys- tals, and in England for soot and indigo, as the law there requires the retailing pharmacist to mix his arsenic previous to selling with one or the other of these substances. There are no characteristic lesions post mortem. It is a disputed question as to whether bodies keep a longer time after death in arsenical cases. The manifold ways in which arsenic may accidentally get into the system and thus cause death should always be remembered. From wall-paper it enters the system as diethylarsin. In England there were recently thousands of cases of arsenical poison- ing, with many deaths, due to the drinking of beer made from glucose containing arsenic. Gautier, a celebrated French chemist, claims, con- trary to general belief, that arsenic is a normal weighable constituent of the thyroid gland. Rough-on-rats and Paris green are favorite preparations for use by would-be suicides. Atropine. — Fatal cases of atropine poisoning, either suicidal or homicidal, are rare, though accidental poisoning by the Datura stra- monium is common. Death is caused by asphyxiation, the symptoms resembling those seen in heat-exhaustion. Careful search should be made in the stomach for any seeds, leaves, or berries. Chloral Hydrate. — Urine should always be preserved for chem- ical examination. Chloral is often taken with other drugs, as morphine, and after a debauch ; this renders it difficult or even impossible to tell just what the effect of the chloral on the system actually is. Chloroform and Ether Poisoning. — The saying of Tait, that the coroner has to do with chloroform death while the physician signs the death certificate in ether cases, is well known. Fright may have something to do with death in these cases. Signs of asphyxia are usu- ally present and the characteristic odor is capable of determination. But then the ether may have been given, yet death be due to other causes. Cocaine Poisoning. — At postmortem the heart is found in diastole and the nerve-centres are said to be congested. Cocaine should be tested for before making the diagnosis. Copper. — The lining walls of the stomach often have a bluish or greenish tinge. On the application of ammonia the coloration deepens into a darker shade of blue, or the green is converted into this color. Part of the toxic effect of the arsenite of copper is due to the copper. Zinc, tin, and barium salts may also cause death in an overdose. Ergot Poisoning. — After death from ergot poisoning the arteries are found contracted and the abdominal viscera inflamed. In the 332 POST-MORTEM EXAMINATIONS chronic form the posterior columns of the cord are sclerosed and micro- scopical sections resemble those characteristic of locomotor ataxia. Formaldehyd. — Bock * reports a case of poisoning by formalin in an imbecile twenty-six years of age. From one to three ounces of a four per cent, solution were taken. Death occurred thirty-two hours later. The stomach was necrotic, dark, tough, and cut like leather. Kliiber 2 and Zorn 3 have also reported cases of poisoning by formalin. Hydrocyanic Acid and Cyanid of Potassium Poisoning. — The mucous membrane of the stomach is markedly and uniformly injected and congested. The odor of bitter almonds is detected at once on open- ing the abdomen. It should always be remembered that, if the post- mortem is not made for thirty-six hours after death, all the hydrocyanic acid may be converted into formic acid. The blood is dark and fluid and keeps for a long time without undergoing decomposition. Illuminating Gas and Carbon Monoxid Poisoning. — These two poisons are not quite alike in their action, though the poisonous properties of illuminating gas are largely due to the considerable amount of carbon monoxid which it contains, especially if of the variety known as " water gas." The body may appear quite life-like, with even a rosy hue upon the cheeks. After death the blood retains its bright cherry-color for some time, seen especially in the brain, and when shaken forms a froth of a violet color. All color reactions should be studied at once, before giving time for the oxygen of the air to act upon the blood. The skin and internal organs, as also the patches of post-mortem congestion, are bright red. The lungs are frequently con- gested. Carbon-monoxid haemoglobin produces two absorption bands near D and E like oxyhemoglobin, the latter, however, being reduced by the addition of the sulphid of ammonium. The blood should not be taken from the heart for this purpose, but from the smaller vessels in the muscles. It is well to remember that the spectroscopic test may even be secured several months after death in favorable circumstances. To detect a small quantity of carbon monoxid in the air of a room fresh normal blood is added to distilled water until the latter is faintly tinged ; about five cubic centimetres are placed in a flask of some one hundred and fifty cubic centimetres' capacity and agitated several 1 Fort Wayne Medical Journal Magazine, July, 1899, p. 249. 2 Munchen. med. Wchnschr., October 9, 1900. 3 Ibid., November 13, 1900. MEDICOLEGAL SUGGESTIONS 333 minutes in the suspected atmosphere; if the noxious gas be present, the liquid assumes a rose tint and gives the characteristic spectrum. In cases which live a day or so and then die bilateral softening may occur in the region of the inner capsule and the caudate and lenticular nuclei. The victim may die from a dose of some other poison taken with suicidal intent before turning on the gas. Lead Poisoning. — In acute lead poisoning there is marked gastro- enteritis, and the bowels usually contain a large amount of blackish fluid. The kidneys show evidence of acute diffuse nephritis. In chronic lead poisoning the distinctive features are a marked fatty degeneration affecting the muscles, kidneys, spleen, and liver. There is often marked cirrhosis with atrophy of these organs. Arteriosclerosis with hyper- trophy of the heart is also marked. Distinct gouty deposits are often found, particularly about the big toe. The brain is sometimes shrunken and dry, the blood-vessels being constricted; or these organs may be pale and extremely firm, or pale and cedematous, as in cases of uraemia. The small intestines may show areas of extreme contraction. Mercurial Poisoning. — The mucous membranes of the gastro- intestinal tract, especially the small intestine and caecum, show exten- sive desquamation, with hyperaemia, ecchymoses, and grayish-white eschars. The bowel generally contains large quantities of liquid of a yellowish-brown or blood-stained character. The macroscopic appear- ances are those of dysentery. In some acute cases decalcification of the bones occurs, with a deposit of lime elsewhere in the body, especially in the kidneys. The number of mercurial salts is legion, many forming with albumin an insoluble albuminate of mercury. Chronic cases of poisoning occur, ulcerative stomatitis being one of the chief lesions. Methyl Alcohol. — Blindness or impairment of vision may occur not only from the ingestion of wood alcohol, but also from inhalation of its fumes, as methyl alcohol seems to have a predilection for the retina and the optic nerve. A number of cases of poisoning from this source have recently occurred in New Orleans from the use of a pro- prietary medicine. Nitrobenzol Poisoning. — Besides the odor of the artificial oil of bitter almonds, the blood and muscles are of a brownish color and the mucous membrane of the stomach is ecchymotic and injected. The body is cyanosed and of a leaden hue. Opium Poisoning. — In acute poisoning there is nothing to distin- guish the condition of the brain from that in other cases of cerebral 334 POST-MORTEM EXAMINATIONS congestion. Extreme passive congestion of the bases of the lungs may- take place, as in cerebral apoplexy (Osier). Cases of uncomplicated chronic poisoning are rare. The most important lesion is fatty degen- eration of the heart. The liver may show similar changes. If lauda- num has been used, the characteristic odor may be determined. I know of no drug which is more apt to escape detection at the postmortem than morphine, as there are absolutely no characteristic lesions and chemical analyses are difficult and at times inaccurate. It seems strange that one of the most common and easily accessible poisons is thus so hard to detect. The pupillary reaction is of no value after death, and the clotting of blood in the right heart is by no means constant. Pellagra Poisoning. — The lesions found are in the posterior col- umns and the crossed pyramidal tract. The cells in the anterior horn are deeply pigmented, and pigment is found in the internal organs and the skin. The brain presents general wasting; the ventricles are somewhat distended and contain an excess of fluid. Phosphorus Poisoning. — In acute phosphorus poisoning the gastro-intestinal tract, especially in the stomach, shows an intense degree of inflammation. Hemorrhages are common and the stomach may contain grumous (coffee-ground) blood. The mucous mem- brane is the seat of numerous ecchymoses as well as more or less exten- sive necroses. The skin, the serous membranes, the muscles, and the adipose tissues all show numerous small hemorrhages. The blood is liquid and dark. The skin is jaundiced. The liver, in the early stages increased in size, soon — in from ten to fourteen days — becomes small (from one-half to one-third of the normal bulk), the capsule is wrin- kled and shrunken, the color is pale yellowish, and on section the organ presents yellowish patches in the midst of which are areas of deep congestion. Drops of fat are seen upon the knife. The kidneys are large, their cortex pale, and the medullary portions congested. The epithelium often shows marked granular degeneration. As a rule, the spleen is not markedly altered. In chronic poisoning by phosphorus wide-spread fatty degeneration is the rule. In cases of workers in phosphorus having defective teeth, necrosis of the jaw is not uncom- mon. It is the yellow phosphorus that is poisonous and not the red variety. Bug exterminators often contain phosphorus. The coating from the ends of matches is often taken with suicidal intent. Potassium Chlorate Poisoning. — The blood has the color and consistence of chocolate, the oxyhemoglobin having been reduced to MEDICOLEGAL SUGGESTIONS 335 methsemoglobin. There is usually a hemorrhagic nephritis, especially of the glomeruli. Ptomain and Toadstool Poisoning. — Such cases are of especial interest to the toxicologist, as the symptoms produced and the lesions found at the postmortem are similar to those caused by many alkaloidal and irritant poisons, and the possibility of the case under considera- tion in a trial being due to one or other of these substances is always suggested by the defence. Silver Nitrate Poisoning. — I have been fortunate enough to see one case of this rare form of poisoning. The darkening of the necrosed mucous membrane on exposure to light was the chief diag- nostic point. The child had an inspiration pneumonia. Snake Poisoning. — After death caused by cobra bite rigor mortis occurs as usual. The areolar tissue in the region of the bite is infil- trated with a pinkish fluid and the vessels are injected. The blood presents no demonstrable change. The veins of the pia mater are usually engorged, and the ventricles often contain turbid fluid. The lungs are generally congested and the lining of the bronchi injected. The appearance of the kidneys varies from normal to one of intense congestion. After death following the bite of an Australian snake the appearances are much the same as those just described. The blood may contain soft coagula, the lungs are sometimes the seat of hemor- rhages, and the mucous membranes may be intensely congested and hemorrhagic. The central nervous system shows engorgement of the blood-vessels. At autopsy, after the bite of a viperine snake, the region of the wound is seen to be the seat of intense oedema and extra- vasation of blood, and the underlying muscles are frequently disorgan- ized and even diffluent from the latter cause. Hemorrhages may also be found in any of the organs and along the alimentary tract. The kidneys are acutely congested or hemorrhagic. The blood is fluid. Strychnine Poisoning. — Rigor mortis is intense and persistent and the blood is dark and fluid as in asphyxia. Be sure to save the urine if any be present; a frog placed in it will have convulsions, even if but a small amount of strychnine be present. CHAPTER XXVIII THE PRUSSIAN REGULATIONS FOR THE PERFORMANCE OF AUTOPSIES IN MEDICOLEGAL CASES The Prussian regulations governing the performance of postmor- tems by the legally appointed officers of the court are of great historic interest, as they bear the imprint of Virchow, and, though put in force February 13, 1875, are still observed throughout Prussia. These regu- lations also form the basis of similar statutes in other German states and in many countries throughout the world ; indeed they are so well defined that it is advisable, though one may chafe under their appar- ently unnecessary restrictions, to depart from them only in exceptional instances. This is especially the case if the one performing the autopsy is a beginner in medicolegal work. I. GENERAL CONSIDERATIONS. \ 1. According to the present law, an examination of a corpse The Physicians £ or medicolegal purposes may be made only in the presence of making the Autopsy, . , , , , ,.-. , . , < , , and their Duties ^ magistrate by two practitioners, one of whom should be a state-appointed physician and the other a district surgeon. Those performing the autopsy are empowered with the duties of medicolegal experts. If doubt should arise in the technical performance of the autopsy, the physician or his deputy decides the question under consideration conditionally upon the right of the surgeon to state upon the protocol his dissenting opinion. $ 2. The medical officers are permitted to appoint substitutes only when unavoidably detained from the performance of their medicolegal duties. If possible, the deputy chosen is to be a physician who has passed his pro physicatu examination. Time after Death $ 3- As a ru ^ e ' postmortems should not be performed until at which the Post- twenty-four hours after death ; the mere inspection of a corpse, mortem is to be however, may be made earlier than this, performed \ 4. As a rule, post-mortem examinations must not be neg- The Examination of lected nor their performance refused by the legally appointed Decomposed Bodies physicians because of the presence of decomposition, for even in a badly decomposed cadaver abnormalities and injuries to the bones may still be detected; many facts of value in the identification of a body may be ascertained, such as the color and appearance of the hair, the absence of limbs, etc. ; and substances which have entered the body from without may be discovered, as well as unsuspected pregnancy or poisoning. On the same grounds, when for one reason or another the advisability of disinterring a body is under consideration, the physicians are to approve of such exhumation without regard to the time which has elapsed since death. 336 PRUSSIAN MEDICOLEGAL POSTMORTEMS 337 \ c. The legally appointed physicians are to be careful to have , , „ 7 ' . , . , ... Instruments the following instruments in readiness and in good condition : from four to six scalpels, of which two are to possess a straight and two a rounded cutting edge ; one razor ; two strong cartilage-knives ; two forceps ; two double hooks ; two pairs of scissors, — the stronger pair should have one blade pointed and the other rounded, while the smaller pair should possess one probe- pointed and one sharp-pointed blade; one enterotome ; one injecting nozzle with stopcock ; one coarse and two fine sounds ; one saw ; one chisel and one hammer ; one costotome ; six curved needles of different sizes ; one pelvimeter ; a one-metre rule divided into centimetres ; one measuring-glass divided into one hundred, fifty, and twenty-five cubic centimetres ; one pair of scales capable of weighing up to ten pounds ; one good magnifying-glass ; blue and red litmus paper. The cutting instruments must be perfectly sharp. Those performing the postmortem are recom- mended to have ready for use a microscope with two objectives, so as to be able to magnify at least four hundred diameters, and the required instruments, glass- ware, and reagents necessary for the preparation of microscopical slides. \ 6, A sufficiently large well-lighted room is to be chosen for the autopsy, and all possible care is to be taken in the selection of Place for the Autopsy a suitable place on which to lay the body and in the avoidance and its Lighting of all disturbing surroundings. Post-mortem examination by artificial light, except where postponement is impracticable, is not allowed ; should it be done, the reason therefor must be expressly stated in the protocol ($ 27). § 7. If the body be frozen, it must be brought into a heated „ ,. 1 * * 1 -1 1 11 rr - 1 Frozen Bodies place and the autopsy postponed until the cadaver has sufficiently thawed ; the employment of warm water or other warm articles to hasten the thaw- ing process is forbidden. §8. If possible, when for any reason the body is moved, espe daily if transported from one place to another, there is to f corpses ^ be no excessive pressure made upon any of the individual parts, nor any marked departure from the horizontal position of the organs in the larger cavities. II. TECHNIC OF THE POSTMORTEM. $ 9. Those performing the postmortem must hold steadfastly to the object in view, which is to make the investigation with accuracy and completeness. All important findings must be shown to the magistrate by the obducents before they are entered in the protocol Medicolegal Aspects of the Postmortem \ 10. In those cases in which this appears to be necessary, the Duties of the Obdu- examiners are required, as early as feasible before the perform- cents in regard to ance of the autopsy, to ask the magistrate for permission to visit the Ascertainment 11 1111 r ■. 1 1 .of Special Circum- the place where the body was found, and they are to ascertain stances connected the position in which the body was discovered and be given an with the Case opportunity to examine the clothing which the deceased wore und er Investigation at the time of his or her death. As a rule, however, it is sufficient for them to await the solicitation of the magistrate to undertake these investigations. They are also obliged to ask for information from the magistrate in regard to any disclosures which might be of use to them in the performance of the autopsy or in helping them to make up their deductions therefrom. 22 33§ POST-MORTEM EXAMINATIONS $ ii. In cases in which a doubtful finding is to be quickly Examinations anc * definitely settled, — as, for example, the differentiation be- tween a fluid containing blood and one which is merely stained with haematin, — a microscopical examination is to be then and there undertaken. When circumstances render this impossible or when difficult microscopical investi- gations which cannot be made at once are required, — as, for example, of certain tissues of the body, — portions of such tissue are to be preserved under legal pro- tection and as quickly as possible thereafter to be thoroughly examined. It is to be distinctly stated in the report of such findings when the examinations were performed. \ 12. The postmortem is divided into two main parts : A. Exter- The Postmortem : its , . . , . N _ T , . . , two main divisions examination (inspection). B. Internal examination (sec- tion). External §13. In the external inspection of the body its appearance in Examination general and that of its individual parts in particular are to be noted. In this general examination of the body the following points, if possible, are to be brought out and recorded. 1. Age; sex; size; devel- opment; general condition of nutrition; any signs of previous illnesses, — e.g., ulcers of the foot ; special abnormalities, — e.g., moles, scars, tattoo markings ; in- crease or absence of limbs. 2. The signs of death and the changes that have already taken place from decomposition. After removal by washing of any contaminations of the body in the way of blood, faeces, dirt, etc., record is to be made of the presence or absence of post- mortem rigidity ; the general color of the skin of the corpse ; the manner and degree of coloration and discoloration brought about by putrefaction ; and the color, situation, and extent of any areas of hypostatic congestion, which are to be incised and then examined and described, in order to prevent their being mistaken for extravasations of blood. The following particulars are to be considered in the study of the individual parts. 1. In unidentified persons, the color and other appearances of the hair (head and beard), as well as the color of the eyes. 2. The possible presence of foreign substances in the normal openings of the head, the arrangement of the teeth, and the situation and appearance of the tongue. 3. An examination is next to be made of the neck, the breast, the abdomen, the back, the anus, the external genitalia, and finally of the limbs. If an injury is found in any of these parts, its shape, situation, and direction with relation to fixed points of the body are to be described and the length and breadth of the injury given in the metric system. In solution of continuity of tissue, probing is, as a rule, to be avoided in the external inspection, because after the internal examination of the body and of the injured spot the extent of the injury is to be described. Should the obducents decide that the introduction of a sound is necessary, this procedure is to be done with great care and special mention of the reason therefor is to be made in the protocol (§ 27). When wounds are present, a description of their borders and the adjacent tissues is to be given, and after such an examination and description of the lesions in their original con- dition the same are to be enlarged in order that the appearance of the borders and of the bottom may be disclosed. As to wounds and injuries which clearly did not conduce to, originate from, or have any connection with death, — for example, mark- ings produced in the endeavor to restore life, gnawing by animals, and the like, — a summary description of the findings is sufficient. PRUSSIAN MEDICOLEGAL POSTMORTEMS 339 § 14. In the internal examination the three main cavities of the body— the cranial, the thoracic, and the abdominal— are to be ^ n ^^ aina " opened. Opening of the vertebral column or of the individual considerations joints is not to be omitted in cases where important findings might be secured thereby. When there is a definite suspicion as to the cause of death, the postmortem is to be commenced with that cavity in which the chief changes are suspected. Otherwise the head is to be examined first, the thorax next, and the abdominal cavity last. 1 The situation of the organs found in each of the above-named cavities is first to be determined, then the color and the appear- ance of the exposed surfaces. The presence is to be noted of any unusual con- tents, such as foreign bodies, gases, fluids, or clots, and in the last two cases measured and weighed, and finally each individual organ is to be examined exter- nally and internally. I 15. When no injuries are present, the opening of the cranial „ . , „ . . . ,. . . , , . .... , Cranial Cavity cavity is accomplished by making an incision from one ear to the other directly over the skull, after which the skin-flaps are displaced forward and backward. (In case such injuries are found, they should be as much as possible circumvented by the knife, thus giving rise to a different procedure.) As soon as the appearance of the soft parts and the surface of the bony cranium has been de- scribed, the latter is cut through with a saw by a circular incision, and the calvarium, the inner table, and the part removed are described. The external surface of the dura mater is next examined, the longitudinal sinus opened, and its contents esti- mated. The dura mater is then to be separated on one side and laid back, and the internal surface of the same described, as well as the appearance of the exposed pia mater. After this has been done on the opposite side, the brain is to be removed in as perfect a condition as possible, and the presence of abnormal contents in the skull is to be noted, and the appearance of the dura and pia mater at the base and sides of the skull and the condition of the large arteries are to be described. After the opening of the transverse sinuses (and, in case reason therefor exists, of the remaining sinuses), the size and shape of the brain are noted and an examination is made of its individual parts by means of a series of well-ordered incisions. Such parts include both cerebral hemispheres, the large ganglia (optic thalamus and corpus striatum), the corpora quadrigemina, the cerebellum, the pons Varolii, and the medulla oblongata, in the description of which are to be included especially the color, the fulness of the vessels, the consistency, and the structure. In addition, the tissue and the vessels of the choroid plexus are always to be described. The size and the contents of the different ventricles as well as the appearance and fulness of the different vascular plexuses in the individual sections of the brain are constantly to be kept in mind, and especial note is to be made of the presence of any clotted blood outside of the blood-vessels. The dura mater over the base of the skull and the sides is then to be removed and the condition of the bones in these regions described. \ 16. When it is required to open the internal portions of the j- -1 -iii • ,,1 J-.L Face, Parotid face, to examine the parotid gland, or to inspect the auditory Gland and Ear apparatus, the initial incision extending over the skull is continued behind the ear and down the neck, and the skin, for appearances' sake, is dissected 1 As to autopsies on the new-born see §§23 and 24. 340 POST-MORTEM EXAMINATIONS away from beneath towards the part to be investigated. In this examination special attention is to be paid to the condition of the large arteries and veins. § 17. The opening of the spinal column (§ 14) is usually made and Cord from behind, the skin and the subcutaneous fatty tissue being cut directly over the spinous processes and the musculature dissected away from the side of the latter and from the vertebral arches. During this exam- ination hemorrhages, lacerations, and similar changes, especially fractures of bones, are to be carefully searched for. Then a chisel, or, if one is at hand, a vertebral saw (rhachiotome) is used for the purpose of separating the spinous processes with the adjacent portions of the arches throughout their entire extent. When they are removed, the external surface of the dura mater, which is now brought into view, is examined. It is next to be carefully opened by means of a longitudinal incision, and any abnormal contents, especially fluid or extravasated blood, are to be described, also the color, appearance, and similar characteristics of posterior portions of the pia mater, and by means of a gentle passage of the fingers over the spinal cord its degree of consistency is to be determined. Next, on both sides, by means of a longitudinal incision the nerve-roots are cut through ; then with one hand the lower end of the spinal cord is carefully grasped, and, after dividing the anterior attach- ments one after another, its upper end is finally drawn out of the occipital foramen. In all these proceedings special care should be taken not to make pressure on the spinal cord or to bend it. When the cord has been removed, the anterior surface of the pia mater is to be examined ; next the external appearance of the cord as to size and color is to be described, and finally, by a considerable number of trans- verse incisions with a sharp and thin knife, the internal appearance of the spinal cord, both as to its white and its gray matter, is to be noted. Finally the dura mater of the vertebral bodies is to be removed, and they are to be examined in order to determine if there have been any hemorrhages, injuries, or changes in the bones or in the intervertebral discs. § 18. The neck and the thoracic and abdominal cavities usually Neck, Thoracic and are p e ned by means of a single long incision from the chin to Gener™i n cl>rfs?dera- S ' the pubic s y m P h y sis > Passing to the left of the navel. Most t j ons commonly the incision in the abdomen is made deep enough to penetrate the abdominal cavity, care being taken to avoid injuring the organs contained therein. This is best begun by cutting a small nick in the peritoneum, at the same time observing whether any gas or fluid escapes. One finger is introduced into the opening and then another, the abdominal wall is ele- vated from the intestines, and the further opening of the peritoneum is made between the two fingers. The situation, the color, and other appearances of the intestines are to be immediately observed, as well as any abnormal contents within them, and the condition of the diaphragm is to be determined by palpation of its under surface. The examination of the abdominal organs is to be proceeded with at this time only where a strong suspicion exists that the cause of death may be found within the abdomen ( \ 14) . As a general rule, the thorax is to be opened and inspected before any further scrutiny of the abdominal cavity. \ 19. In opening the thoracic cavity the soft parts of the breast Thoracic Cavity are dissected slightly beyond the junction of the osseous and cartilaginous portions of the ribs. Next with a strong knife PRUSSIAN MEDICOLEGAL POSTMORTEMS 341 the cartilages are incised a few millimetres within their attachment to the ribs, care being taken to avoid cutting the lungs or the heart. If the cartilages be ossi- fied, the ribs are to be separated with a saw or a costotome somewhat beyond the cartilaginous junction. The attachments of both clavicles to the sternum are then separated by vertical semicircular sections, and the junction of the first rib, be it cartilaginous or ossified, is loosened with the knife or costotome, great care being taken to avoid injuring the vessels which lie beneath. The diaphragmatic attach- ments along the line of incision are severed close to the false cartilages and the ensiform process. The sternum is turned upward and the mediastinum is cut through, with careful avoidance of any injury to the pericardium or the large blood-vessels. When the sternum has been separated, the condition of the pleural cavity is to be determined, especially as to any abnormal contents, which are to be measured and their characteristics described ; also the extent and the appearance of any portions of the lung which are in view. If any vessels have been injured in the removal of the breast-bone, they are to be tied or a sponge is to be placed beneath the bleeding points to catch the blood which if it were allowed to enter the pleura would later obscure the observation of the parts therein. The condition of the mediastinum and especially that of the thymus gland are to be noted, as well as the appearance of the large blood-vessels lying outside of the pericardium, which are not yet incised. The pericardium is next to be opened and examined and the exterior of the heart inspected. Before the heart is incised or removed from the body its size, the filling of the coronary vessels and its individual cavities (auricles and ventricles), its color, and its consistency (rigor mortis) are to be estimated. While the organ is still in its natural position, the ventricles and auricles are to be separately opened and the contents of each chamber determined as to their amount, condition, coagulation, and appearance, and the dimensions of the auriculo- ventricular openings are to be ascertained by the introduction of two fingers through the auricle. The heart is then to be removed from the body and the condition of the arterial vessels tested, first by filling them with water and next by incising their walls. Finally the color and exact appearance of the heart muscle are to be described. In every case wherein it is suspected that extensive changes — e.g., fatty degeneration — have occurred in the muscular tissue a microscopical investigation is to be made. To this examination belongs that of the large vessels, with the single exception of the descending aorta, which is to be examined after the lungs have been excised. A minute inspection of the latter is not undertaken until they have been removed from the thoracic cavity. During this procedure great care is to be taken to avoid tearing or pressing upon the tissues. Should there be any extensive, especially old, adhesions, these are not to be broken down, but the attached pleura at this point is to be excised at the same time. When the lungs have been removed, their surface is again to be carefully examined for recent changes, so that nothing shall be overlooked, — for example, the commencement of inflammatory exudations ; then the air contents, color, and consistency of the individual lobes are to be given. Finally large, smooth sections are to be made in order to determine the appearance of the cut surface and the air, blood, and fluid contents, as well as any solid con- tents of the air-vesicles, the condition of the bronchi and the pulmonary arteries, the latter being examined with special care to detect any obstructions, etc. For this purpose the air-passages and the large pulmonary vessels are to be opened with scissors and their finer ramifications followed out. When the suspicion arises that foreign materials are present in the air-passages or substances are therein found the nature of which cannot with certainty be determined by the naked eye, a micro- scopical examination is to be made. 3 4 2 POST-MORTEM EXAMINATIONS $ 20. The examination of the neck may, according to the nature of the case, be made either before or after the opening of the thorax or the removal of the lungs. The obducents may also sever the larynx and the bronchus before the further inspection of the remaining parts when it seems to them especially desirable so to do, as is the case in drowning or hanging. As a rule, it is wise next to examine the large vessels and the nerve-trunks, then the larynx and trachea, by means of an anterior incision, and note their contents. If this observation should appear to be of especial importance, it is to be made before the removal of the lungs, which are at the same time to be carefully pressed upon to see if any fluid, etc., arises in the trachea. The larynx, the tongue, the velum palati, the pharynx, and the oesophagus are to be removed together; the individual parts are to be carefully opened and their contents and the mucosa thoroughly examined. At the same time the thyroid, the tonsils, the salivary glands, and the lymph glands of the neck are to be observed. In every case where injuries of the larynx or of the bronchus have been found or important changes therein are sus- pected, the air-passages are to be opened after their removal from the body and they are then to be examined from their posterior aspect. In cases of hanging or in suspicious cases of strangulation the carotids are to be opened in order to ascer- tain whether or not their inner coats have been injured. This examination is to be undertaken while the vessels are still in their natural situation. Finally the condi- tion of the cervical vertebrae and of the deep musculature is to be determined. $ 21. The abdominal cavity and its viscera are now to be critically Abdominal Cavity inspected in such order that the removal of one organ does not prevent the exact determination of its relations to another. Thus, the duodenum and the gall-ducts are to be examined before the scrutiny of the liver. As a rule, the following order of examination commends itself : I. Omentum. 2. Spleen. 3. Kidneys and adrenals. 4. Bladder. 5. Organs of generation: in the male, prostate, seminal vesicles, testicles, and penis with the urethra ; in the female, ovaries, Fallopian tubes, uterus, and vagina. 6. Rectum. 7. Duodenum and stomach. 8. Gall-ducts. 9. Liver. 10. Pancreas. 11. Mesentery. 12. Small intestine. 13. Large intestine. 14. The large blood-vessels in front of the vertebral column, whose condition as to blood contents is to be ascertained and noted. In every case the spleen is examined in regard to its length, breadth, and thickness, not while held in the hand, but when placed on a solid surface and without pressure by the instrument used in measuring. It is to be divided throughout its entire length, more incisions being made in different directions if diseased areas are suspected. Each of the kidneys is to be removed after cutting vertically Kidneys . ..,..,,. through the peritoneum externally and behind the ascending or descending colon, which is shoved back. The capsule is then incised longitudinally through its convex border and slowly peeled off, and the exposed surface of the kidney is examined in regard to size, form, color, condition of blood, and other appearances. Next a longitudinal incision is made through the entire kidney to its pelvis, and the cut surfaces are washed with water and described, in which descrip- tion medullary and cortical substances, vessels, and parenchyma are to be distin- guished. The pelvic organs (bladder, rectum, and genitalia in connection Pelvic Organs therewith) are removed en masse, but preferably the bladder is opened and its contents are examined while it is in its natural sit- uation. After their removal these organs are again inspected, the reproductives PRUSSIAN MEDICOLEGAL POSTMORTEMS 343 being examined and opened last. The slitting of the vagina is to precede that of the uterus. In puerperae the venous and lymphatic vessels both in the internal surface of the uterus and in its walls and adnexa require special attention as to their width and contents. When their external condition has been determined, the stomach and duodenum are with a pair of scissors opened in their natural Duodenum situation, the duodenum on its anterior surface and the stomach along its greater curvature. After a careful inspection of their contents, the per- meability and the presence of any matter in the opening of the gall-passages are determined and these parts are then removed for further examination. The liver is first described externally in its natural situation, and after its secretory ducts have been examined (as mentioned in the preceding paragraph) the gland is excised. Smooth incisions are now made through the entire length of the organ and its capacity for blood and the condition of the parenchyma determined. In the description a short account is always to be given of the general relations of the individual lobes, noting especially the relations of the inner and outer portions. The small and large intestines, after their individual portions have been examined externally as to dimensions, color, and other Small and Large peculiarities worthy of mention, are removed together, their Intestines mesenteric attachments being severed with a knife close to the bowels, which are then opened with a pair of scissors at the place where the mesen- tery was attached. During these incisions the contents of the several parts are observed and described. Next the intestines are cleansed and the condition of the individual portions, especially of the small intestine, is inspected with special regard to the Peyer's patches, the solitary follicles, the villi, and the intestinal folds. At least in every case of inflammation of the peritoneum the appendix is to be carefully examined. § 22. In those cases in which poisoning is suspected the internal examination is to begin with the abdominal cavity. Before any- Cases of Poisoning thing else is done the external appearance of the upper abdominal viscera, their situation and extent, the filling of their vessels, and the presence of any odor are to be determined. In regard to the vessels, here as in other important organs, we are to ascertain whether we are dealing with arteries or veins, whether the smaller ramifications or both the main trunks and their branches are filled to a given degree, and whether the extent of the vascular thinning is considerable or otherwise. Then to the portion of the oesophagus just above its entrance into the stomach and to the duodenum just below the entrance of the gall-duct double liga- tures are to be applied and both parts incised between them. Next the stomach with the duodenum attached is carefully removed from the body and opened in the manner described in \ 21. The contents are immediately examined as to their amount, consistency, color, composition, reaction, and odor, and placed in a clean porcelain or glass vessel. Then the mucosa is washed and its thickness, color, surface, and condition are determined, the state of the blood-vessels and the struc- ture of the mucous membrane being particularly noted and each individual portion separately described. Of especial importance is it to ascertain whether the blood which is present lies within the vessels or is exuded therefrom, whether it is fresh or changed by decomposition or by digestion, and whether in these conditions the neighboring tissues are permeated therewith. If such imbibition has occurred, its location is to be determined, also whether upon the surface or in the tissue, whether 344 POST-MORTEM EXAMINATIONS it is coagulated or not, etc. Finally it is of especial importance to decide, in the inspection of the surface, whether loss of substance, erosions, and ulcers are present. The question whether these changes might not have resulted from natural processes of decomposition after death, especially from the action of the fermentative juices of the stomach, is always to be considered. After the completion of this examina- tion, the stomach and duodenum are to be placed in the same vessel with the gastric contents (see above) and given to the magistrate for further investigation. An anatomical examination having been made of the oesophagus, it is tied high up in the neck, severed above the ligature, and placed in the same vessel. In those cases in which but a small amount of stomach contents is present the contents of the jejunum are also to be preserved. Finally other substances and portions of organs, as blood, urine, pieces of the liver and of the kidney, etc., are to be removed from the body and given to the magistrate for further examination. The urine is to be placed in a separate vessel, and the blood is to be preserved separately only in those cases where spectroscopic examination might disclose facts of interest. All of the remaining portions are to be placed together in a single receptacle. Each of these vessels is closed, sealed, and labelled. In every case where the macroscopical ex- amination shows special alteration and swelling of the mucous membrane of the stomach, a microscopical examination thereof is to be made as soon as possible, especial attention being given to the condition of the peptic glands. Whenever suspicious bodies are found in the stomach contents, as portions of leaves or other parts of plants, remnants of animal food, etc., these also are to be viewed with a microscope. Where trichinosis is suspected, not only a microscopical examination of the contents of the stomach and of the upper portion of the small intestine is to be made, but portions of muscular tissue from the diaphragm, the neck, and the thorax are also to be laid aside for future study. § 23. In postmortems on the new-born, besides the points pre- The New-born; viously given, there are to be determined, first of all, the data Determination of the n w ^ j c h t h e maturity and the intra-uterine developmental Maturity and Period . . , , of Intra-uterine period of the child depend, .bor these purposes consider the Gestation length and weight of the body, condition of the general coverings and of the umbilical cord, length and appearance of the hair of the head, size of the fontanels, longitudinal, transverse, and diagonal measurements of the head, appearance of the eyes (pupillary membrane), condition of the nasal and auricular cartilage, length and characteristics of the nails, transverse diameter of the shoulders and hips ; in boys the situation of the testicles and the appearance of the scrotum, and in girls any peculiarities of the external genitalia. It still remains to be noted whether there be present, and if so to what extent, an ossifying centre in the inferior epiphysis of the femur. To determine this the patella is removed through a horizontal incision made just below it while the knee-joint is strongly flexed, and thin transverse sections are made continuously through the cartilage until the greatest transverse diameters of any centres of ossification which may there be present are found, which are then to be measured in millimetres. When from an examination of the offspring it seems to have been born before the thirtieth week, the postmortem may be discontinued unless a special request is given by the magistrate for its completion. \ 24. If it be determined that the child was born after the thir- The Determination feft*. week, the following data must be obtained in order to the Child has decide whether it breathed during or after birth. For this pur- breathed P os e the respiratory tests are to be applied in the following order : (a) Immediately after the opening of the abdominal cavity the PRUSSIAN MEDICOLEGAL POSTMORTEMS 345 condition of the diaphragm in relation to the corresponding ribs is to be determined. Hence in every case of examination of the new-born the abdominal cavity is to be opened first and afterwards the thoracic and cranial cavities. 1 (b) Before opening the thoracic cavity the trachea is to be once ligatured above the sternum, (c) The thoracic cavity is next to be opened and the extent and the degree of the over- hanging portions of the lungs, the latter especially in regard to the pericardium, determined both as to the color and as to consistency, (d) The pericardium is to be incised and both its condition and the external appearance of the heart are to be described, (e) The individual cavities of the heart must be laid open, their contents noted, and other appearances determined, (f) The larynx and the portion of the trachea above the ligature are to be slit, and their contents as well as the appearance of their walls determined, (g) The trachea is to be cut through above the ligature and removed in connection with the other organs of the thorax, (h) After the removal of the thymus gland and the heart, the lungs are to be tested as to whether or not they float in a large vessel filled with pure cold water, (i) The lower por- tion of the bronchus and its branches are to be opened and their contents specially examined. (/) Incisions are to be made into both lungs, the presence or absence of crepitation being carefully noted as well as the amount and appearance of any blood which may exude under slight pressure upon the cut surfaces, (k) The lungs are also to be incised under water in order to determine if any air-bubbles arise from the cut surfaces. (/) The lobes of both lungs are next to be cut apart, each lobe subdivided, and every separate portion tested as to its sinking or floating in water, (m) The oesophagus is to be opened and its condition ascertained, (n) Finally, in those cases where it is suspected that the pulmonary tissues may have been filled with the products of disease (hepatization) or with foreign bodies (vernix caseosa and meconium), so as not to permit of the entrance of air, the same are to be examined microscopically. \ 25. Lastly, it is the duty of the obducents to examine all organs , . , ... ... , Further not mentioned in these regulations in case injuries or other Examinations abnormalities are discovered. § 26. The district surgeon, with the second physician acting as . ,• , , ,. , \ 1 Closure of the Body a consultant, is required, after the ending of the autopsy and as far as possible the removal of waste, to undertake the proper closure of those cavi- ties of the body which have been opened. III. THE DRAWING UP OF THE PROTOCOL OF THE POSTMORTEM AND THE FINAL REPORT OF THE SAME. \ 27. A post-mortem protocol is to be made by the magistrate, at the time and place of performing the autopsy, concerning all Protocol matters relating thereto. The medical officer must, therefore, be careful that the technical findings which have been determined at the examination are faithfully recorded in the protocol. In order to accomplish this, it is recom- mended to the magistrate that the description and findings of each individual organ be written down before another part is examined. 1 But in no case shall section of the organs of the abdominal cavity be undertaken before the opening and examination of those of the thorax. 346 POST-MORTEM EXAMINATIONS £ 28. The technical findings given in the post-mortem protocol Arrangement and by the medical officer must be stated clearly, definitely, and in Form of the Protocol such a manner as to be understood by one who is not a physician ; for this purpose the use of foreign expressions is to be avoided except where these may be needed to make clear the description of the findings. Both chief divisions, the external and internal examinations, are to be designated with capital letters (A and B). The findings for the openings in the cavities are to be given, in the order in which they were examined, with Roman numerals (I., II.) ; but the organs in the thorax and abdominal cavity are to be entered under a single number. The descriptions of the organs of the thorax and abdominal cavity, named in § 18, are to be designated by the letters a and b. The results of the examination of each individual part are to be designated with Arabic numerals, such numbers running consecutively from the beginning to the end of the protocol. The record of the examination must be given in the protocol with special reference to the actual observations, and not in the form of mere statements, — as, for example, inflamed, gangrenous, healthy, normal, wound, ulcer, and the like. The obducents have the option, however, in those cases in which it seems necessary for clearness, to add such observations, inclosed in parentheses. In every case a note must be made of the blood contents of each important part, and a short description thereof must be given, and not simply a name, — as considerable, moderate, middling amount, much reddened, rich in blood, poor in blood. Before any part is incised its size, form, color, and consistency are to be noted, in the order here named. '$ 29. At the close of the postmortem the obducents are to give Provisional Opinion in the protocol their provisional opinion of the case, without stating their reasons therefor. If anything be known by means of Vv'hich the diagnosis is influenced, in the way of previous history or the like, this must be briefly noted. Should the magistrate ask any special questions, the answers should be distinctly entered in the protocol, with the statement that they are given at his request. In every case the opinion as to the cause of death is to be stated, first with special reference to the facts bearing on the objective findings and then as to the question of criminal motive. If the cause of death is not determined, this fact must be recorded. It is never sufficient to say that death resulted from internal causes or from disease. The latter, whatever it is, must be specifically named. Special mention is to be made, with the reason therefor, in cases where further technical examinations are needed or where doubtful conditions exist. \ 30. Should injuries be found on the body which were presuma- Supplemental ^j y ^ cause f death, and if suspicion be aroused that a specially Observations on ,. , . , . , , , . n . J , .... , Instruments discovered instrument might have inflicted such injuries, the obducents, at the request of the magistrate, are obliged to investi- gate and to express an opinion as to which and what injuries might have been caused by the instrument, and what conclusions from the situation and appearance of the wound are to be drawn as to the manner in which the one performing the act might have committed the deed, and also as to the strength with which it was performed. When definite weapons are not found, the obducents, as far as it is possible from the conditions present, are to give their opinion as to how the injuries were caused and especially as to what instruments might possibly have been used. PRUSSIAN MEDICOLEGAL POSTMORTEMS 347 g 31. If the obducents be requested to present a report, this should give, without useless details, a condensed but exact review of Post-mortem Report the case, with the conclusion reached by them and the facts on which it is based. So much of the post-mortem protocol as they think necessary for the explanation of the case is to be given verbatim, with the number of the protocol. Any change made therein must be expressly stated. The style of the post- mortem report must be plain and concise, and the proof which led to the formation of the opinion therein expressed so set forth as to be understood by and convincing to one not a physician ; for this purpose, the obducents are to use, as far as possible, German expressions and ordinarily accepted meanings. Especial attention to literary sources of knowledge is, as a rule, to be avoided. When as medical experts the obducents are asked certain questions by the magistrate, these are to be answered fully but as concisely as possible, or, if this cannot be done, the reasons therefor are to be given. Both obducents must sign their report, which must also bear the official seal of the district physician if he has taken part in the autopsy. When such a post-mortem account is requested, it must be delivered by the obducents within four weeks at the latest. CHAPTER XXIX USUAL CAUSES OF DEATH; THEIR NOMENCLATURE, COMPLICATIONS, AND SYNONYMS As morbidity and mortuary statistics are intimately associated the one with the other, uniformity in their nomenclature throughout the world is greatly to be desired. At the Eighth International Con- gress of Hygiene and Demography, held in Paris, August 18 to 21, 1900, a modification of the old Bertillon classification was adopted and called the " International System of Nomenclature of Diseases and Causes of Death." 1 It is here added complete as to its essential parts and but slightly altered in a few minor particulars. I. GENERAL DISEASES. 1. Typhoid Fever (Abdominal Typhus). Include: Dothienenteritis ; mucous, continued, enteric, ataxic, or adynamic fever; abdominal typhus. — Do not include: Adynamia (179) ; ataxo-adynamia (179). — Frequent complications: Pneumonia; pulmonary congestion; intestinal perforation ; peritonitis; in- testinal hemorrhage; sloughing; albuminuria. 2. Exanthematous Typhus. 2 Include : Petechial fever; petechial typhus. — Do not include: Abdominal typhus. 3. Recurrent Fever. Include: Relapsing fever; recurrent typhus. 4. Intermittent Fever and Malarial Cachexia. Include: Paludal fever; per- nicious fever ; accesso pernicioso ; remittent fever ; malaria. 4a. Malarial Cachexia. Include: Paludism ; pernicious cachexia; paludal anaemia. 5. Variola. Include: Smallpox, varioloid. — Do not include: Varicella (19). — Frequent complications: Meningitis; endocarditis; suppuration; albumin- uria. 6. Measles. Include: Eruption of measles. — Do not include: Rubeola (19). — Frequent complications: Bronchitis; bronchopneumonia. 7. Scarlatina. Include: Puerperal scarlatina; scarlatinous angina. — Frequent complications: Albuminuria; eclampsia; oedema of the glottis; hemor- rhage ; endocarditis ; pericarditis ; paralysis ; convulsions. 8. Whooping Cough. Frequent complications: Bronchitis; convulsions. 9. Diphtheria and Croup. Include: Diphtheritic, buffy, pseudomembranous, infectious, malignant, or toxic angina. Diphtheria under all its forms, espe- cially diphtheria of wounds, cutaneous diphtheria; conjunctival diphtheria; 1 Supplement to Public Health Reports, vol. xv., No. 49. Translated by Passed Assistant Surgeon H. D. Geddings. 2 The word "typhus," without qualification, will be taken in the sense which is usual to it in each country, — viz., in the sense of " abdominal typhus" in German-speaking countries, or as " exanthematous typhus" in French-speaking ones. 348 USUAL CAUSES OF DEATH ?>A9 buccal diphtheria. Pseudomembranous bronchitis ; pseudomembranous lar- yngitis ; malignant laryngitis; diphtheritic paralysis. — Do not include: Stridulous croup (88) ; spasmodic croup (88). — Frequent complications: Pneumonia ; albuminuria ; paralysis. 9a. Diphtheria. 10. Grippe. Include: Influenza; grippe pneumonia ; grippe bronchitis, and grippe bronchopneumonia. 11. Sweating or Miliary Fever. 12. Asiatic Cholera. Include: Indian cholera; cholera (without qualification) ; epidemic cholera. 13. Cholera Nostras. 1 Include: Sporadic cholera; cholerine; choleriform en- teritis or diarrhoea. — Do not include: Cholera infantum; antimony cholera (175) ; hernial cholera (108). 14. Dysentery. Include: Choleriform dysentery; Chinese dysentery; dysentery of tropical countries. 14a. Epidemic Dysentery. 15. Pest (Plague or Bubonic Plague). 16. Yellow Fever. Include: Vomito negro; fiebre amarilla. 17. Leprosy. Include: Elephantiasis Graecorum. — Do not include: Elephantiasis Arabum (143d) ; Morvan's disease (63) ; syringomyelias (6s). 18. Erysipelas. Include: All surgical erysipelas or medical erysipelas, without regard to seat. — Do not include: Gangrenous or phlegmonous erysipelas (144) ; erysipelatous phlegmon (144). 19. Other Epidemic Affections. 2 Include: Mumps; rubeola; acrodynia; vari- cella ; beriberi ; and any other epidemic affections which may not be in- cluded in this nomenclature. — Do not include: Epidemic dysentery (14a) ; epidemic cerebrospinal meningitis. 20. Purulent and Septicemic Infection. 3 Include: Pyohaemia; purulent ab- sorption ; putrid absorption ; putrid infection ; putrid fever ; anatomical wounds; streptococchaemia. — Do not include: Puerperal septicaemia (137); infectious fever (55). 21. Glanders and Farcy. 22. Malignant Pustule and Charbon (Anthrax). 23. Rabies. Include: Hydrophobia. — Do not include: Sitiophobia (68). 24. Actinomycosis, Trichinosis, etc. Include: Dystoma hepaticum; cysticerci. — Do not include: Cyst or hydatid tumor of the liver (in) or of the lungs (99) ; intestinal parasites (107). 25. Pellagra. 26. Tubercle of the Larynx. Include: Tuberculous laryngitis; laryngeal phthisis. 27. Tubercle of the Lungs.* Include: Pulmonary tuberculosis; pulmonary phthisis; phthisis (without qualification) ; phymia ; phymatosis ; pneumo- nophyma ; acute, galloping, or miliary phthisis or tuberculosis ; granulia ; pulmonary cavities ; consumption ; caseous pneumonia ; tuberculous, bacil- 1 The word " cholera morbus" will be taken in its ordinary signification in each country, as in the sense of " cholera nostras" in North America, and as " Asiatic cholera" in France and in other countries. 2 In cases where epidemics arise, it will be necessary here to adopt a special provisional title. 3 When an adult female is returned as having been stricken with " septicaemia," send the report back in order that the physician may state whether or not the disease was puerperal. 4 See observation on No. 93, relative to " apical pneumonia." 350 POST-MORTEM EXAMINATIONS lary, specific, granular, neoplastic, or heteroplastic bronchitis or pneumonia; bacillosis; tuberculous pleurisy; tuberculous haemoptysis; tuberculosis (without qualification). — Do not include: Haemoptysis (without qualifica- tion) (99) ; pulmonary hemorrhage (99) ; bronchorrhagia (without qualifi- cation) (99) ; apical pneumonia (93) ; laryngeal phthisis (26) ; pulmonary anthracosis (99). — Frequent complications: Hemorrhage; pneumonia; pleu- risy; incontrollable diarrhoea. 28. Tubercle of the Meninges. Include: Meningeal tuberculosis; tuberculous meningitis ; granular, miliary, caseous, bacillary, specific, neoplastic or heter- oplastic meningitis. — Do not include: Meningitis (without qualification), even for children of tender age. 29. Abdominal Tubercle. Include: Tuberculous, granular, bacillary, or specific peritonitis ; peritoneal tuberculosis ; tuberculous enteritis. 30. Pott's Disease. Include: Vertebral caries ; vertebral disease; vertebral poly- arthritis. — Frequent complications: Cold abscess, or abscess by congestion. 31. Cold Abscess and Abscess by Congestion. Include:- Ossifluent abscess. 32. White Swelling. Include: Fungous growths of joints; coxalgia; scapu- lalgia. Z2,. Other Tuberculous Affections. Include: Tuberculosis of the skin; tuber- culous nephritis ; lupus ; esthiomene ; bacillary abscess ; tuberculous ulcer ; osseous tuberculosis. — Do not include: Pott's disease (30). 34. Generalized Tuberculosis. Include: Tuberculosis showing itself simulta- neously in any two or more organs. 35. Scrofula. Include: Lymphatism; scrofulides. — Do not include: Blepharitis; or conjunctivitis, or scrofulous keratitis, or lymphatic keratitis (75). 36. Syphilis. Of which are recognized: (1) Primary, (2) secondary, (3) ter- tiary, (4) hereditary. These divisions are intended for mortuary statistics alone. Include: (1) Indurated or infecting chancre; chancre of the mouth or face; primary accident or infection; (2) Secondary manifestations — mucous plaques ; syphilitic amygdalitis ; angina or laryngitis ; (3) Tertiary manifestations — specific manifestations ; gummata ; ulcerations ; exostoses, etc. Osteocopic pains ; all these diseases to be specified as " syphilitic." — Do not include: Soft, simple, or phagedenic chancre (36a). 36a. Soft Chancre. Include: Chancroid; chancrelle; simple chancre; phagedenic chancre or bubo ; bubo of soft chancre ; venereal, virulent, or absorption buboes. — Do not include: Infecting or syphilitic chancre or bubo (36, 1) ; chancre of the mouth (36, 1) ; scrofulous bubo (35) ; suppurating bubo (144) ; plague bubo (15) ; bubo without qualification (144). (Morbidity statistics only.) 37. Blennorrhagia of the Adult. Include: Blennorrhoea ; gonorrhoea; ardor urinae ; urethritis ; military drop ; balanitis ; balanorrhagia ; balanopos- thitis, vaginitis ; gonorrhoeal cystitis, orchitis, buboes, arthritis, rheumatism, or conjunctivitis of the adult; or gonorrhoeal or blennorrhagic ophthalmia of -the adult. — Do not include: Vaginismus (132); vaginalitis (126). — Fre- quent complications: Bubo; adenitis; cystitis ; orchitis. 38. Gonorrheal Affections of the Child. 1 Include: Blennorrhagic or gonor- rhoeal conjunctivitis of the child (under five years of age) ; gonorrhoeal vulvitis (of the child under five years). This title takes no account of children over five years of age. USUAL CAUSES OF DEATH 35 1 39. Cancer and other Malignant Tumors of the Buccal Cavity. Include: Cancer of the month or lips, or of the tongue, or the roof of the mouth, or the velum of the palate ; cancer of the maxilla ; epithelioma, or carcinoma., or cancroid of these organs ; smokers' cancer. 40. Cancer and other Malignant Tumors of the Stomach and Liver. 1 In- clude: Cancer of the oesophagus; cancer of the cardia; cancer of the py- lorus ; carcinoma or scirrhus, or colloid or encephaloid tumor of these organs; gastrocarcinoma ; tumor of the stomach. — Do not include: Haema- temesis (104). 41. Cancer and other Malignant Tumors of the Peritoneum, Intestines, and Rectum. Include: Cancer of the colon ; cancer of the anus ; carcinoma, or scirrhus, or encephaloid, or cancroid, or epithelioma of these organs. 42. Cancer and other Malignant Tumors of the Female Genital Organs. Include: Cancer of the uterus; cancer of the womb; cancer of the vagina; cancer of the vulva ; carcinoma, or encephaloid, or colloid tumor, or hetero- morphous or neoplastic growth, or cancroid, or sarcoma, or epithelioma of these organs. 43. Cancer and other Malignant Tumors of the Breast. Include: Carcinoma, or scirrhus, or encephaloid, or heteromorphous or neoplastic growth, or can- croid, or epithelioma of the breast or nipple. 44. Cancer and other Malignant Tumors of the Skin. Include: Cancroid (without qualification) ; epithelioma or epitheliomatous tumor (without qualification) ; cancer of the ear, of the face, or cervicofacial ; " noli me tangere." — Do not include: Esthiomene (33) ; lupus (33). 45. Cancer and other Malignant Tumors of other Organs, and of Organs not classified. Include: Abdominal cancer; pelvic cancer; cancer of the lung, of the kidney, of the bladder, and of the prostate ; cancerous goitre ; thyro- sarcoma ; sarcohydrocele ; cancer of the bone ; osteosarcoma ; cancerous or sarcomatous tumor of the neck ; carcinoma, or scirrhus, or encephaloid, or cancerous ulcer, or malignant tumor, or sarcoma, or malignant fungus of these organs, or of other organs not specified. — Do not include: Cancer of the oesophagus (40) ; cancer of the anus (41) ; cancer of the ovary, vagina, or vulva (42). 46. Other Tumors (Tumors of the Female Genital Organs excepted). Include: Tumor (without qualification); abdominal tumor; intestinal tumor; vas- cular or erectile tumor ; angioma ; lymphoma ; lymphadenoma ; lymphato- cele ; adenoma ; chondroma ; osteoma ; myoma ; lipoma ; wen ; grub ; sebaceous tumor; cystoma. — Do not include: Cancer and its synonyms (40- 45) ; tumor of the stomach (40) ; stercoraceous tumor (108) ; tumor of the uterus (129) ; hydatid tumor (in) ; cyst of the ovary (131) ; aneurismal tumor (81) ; varicose tumor (83) ; polyp of the ear (76) ; polyp of the nasal or nasopharyngeal fossae (87) ; uterine polyp (129). 47. Acute Articular Rheumatism. Include: Rheumatic arthritis; rheumatic meningitis; abdominal or cerebral rheumatism; rheumatic vertigo; rheu- matic endocarditis, pericarditis, pleurisy, or peritonitis. — Do not include: Organic diseases of rheumatic origin (79, etc.) ; rheumatic iritis (75) ; arthritis deformans (48) ; gonorrhceal rheumatism (37). 1 In countries where the words "organic lesion of the stomach" always signify "cancer of the stomach" classify these diagnoses under No. 40. In countries where, on the contrary, this is not always so, classify them under No. 104. 352 POST-MORTEM EXAMINATIONS 48. Chronic Rheumatism and Gout. Include: Arthritis deformans. 49. Scorbutus. Include: Werlhoff's disease. 50. Diabetes. Include: Glycosuria. — Frequent complications: Pneumonia; an- thrax ; gangrene ; cerebral hemorrhage and cerebral softening ; tubercu- losis. 51. Exophthalmic Goitre. Include: Exophthalmia ; Basedow's disease; Graves's disease; exophthalmic cachexia. — Frequent complications: Hypertrophy of the heart ; cachexia. 52. Addison's Disease. Frequent complications: Cachexia; ascites. 53. Leukaemia. Include: Adenoleukaemia ; leucocythaemia ; Hodgkin's disease; pseudoleukemia. — Frequent complications: Hemorrhage; ascites; apoplexy; cachexia. 54. Anaemia; Chlorosis. Include: Pernicious anaemia. — Do not include: Cere- bral anaemia (74b). 55. Other General Diseases. Include: Autointoxication; infectious fever ; viru- lent disease (without explanation); visceral steatosis; acromegalia; amy- loid or generalized fatty degeneration. 56. Alcoholism, Acute or Chronic. Include: Drunkenness; ethylism; alcoholic intoxication ; alcoholic delirium ; alcoholic dementia ; delirium tremens ; absinthism; absinthaemia ; dipsomania. — Do not include: Alcoholic cirrho- sis (112) ; general alcoholic paralysis (67) ; atheroma (81) ; or any other disease attributable to alcohol; intoxication amblyopia (75). 57. Saturnism. Include: Saturnine colic; lead colic; painters' colic; lead en- cephalopathia ; lead paralysis; chronic lead poisoning; all conditions char- acterized as '' saturnine." 58. Other Trade or Occupation Intoxications. Include: Mercurial (hydrar- gyrism) ; phosphorus, arsenical, or other intoxication, when special mention by the physician makes it clear that the intoxication is the result of a trade. Failing in this specific declaration, it should be classed in one of the condi- tions under No. 59. 59. Other Chronic Poisonings. 1 Include: Morphinism; cocainism; chronic er- gotism. — Do not include: Amblyopia by intoxication (75). II. DISEASES OF THE NERVOUS SYSTEM AND OF THE ORGANS OF SPECIAL SENSE. 60 Encephalitis. Include: Cerebral fever. 61. Simple Meningitis. Include: Meningitis (without qualification) ; meningo- encephalitis ; pachymeningitis. 61a. Epidemic Cerebrospinal Meningitis. Do not include: Tuberculous menin- gitis (or other synonym) (28) ; rheumatic meningitis (47). 62. Progressive Locomotor Ataxia. Include: Duchenne's disease. 63. Other Diseases of the Spinal Cord. Include: Disease of the cord; sclerosis in plaques; symmetrical sclerosis; lateral sclerosis; sclerosis (without qualification); Charcot's disease ; Morvan's disease; syringomyelitis ; spas- modic tabes dorsalis ; hemorrhage into the spinal cord ; haematomyelitis ; haematorrhachia ; myelitis ; medullary congestion ; affections of the bulb ; bulbar paralysis ; spinal paralysis ; paralysis agitans ; trembling paralysis ; Note the observation under the preceding title. USUAL CAUSES OF DEATH 353 ascending paralysis; essential paralysis of infancy; fatty or amyloid degen- eration of the cord ; Parkinson's disease ; Friedreich's disease ; medullary compression or compression of the cord ; progressive muscular atrophy ; fatty degeneration of muscles ; atrophic muscular paralysis ; amyotrophia ; amyotrophic paralysis ; atrophic paralysis ; pseudohypertrophic paralysis. 64. Cerebral Congestion and Hemorrhage. Include: Apoplexy; cerebral apo- plexy ; meningeal apoplexy ; serous apoplexy ; cerebral atheroma ; cedema of the brain ; cerebral effusion ; cerebellar hemorrhage ; meningeal hemor- rhage; cataplexia ; apoplectic dementia. — Frequent complications: Hemi- plegia ; paralysis. 65. Cerebral Softening. Do not include: Senile dementia. — Frequent complica- tions: Hemiplegia; paralysis; pulmonary congestion. 66. Paralysis without Specified Cause. Include: Paralysis (without qualifica- tion) ; hemiplegia; facial paralysis; generalized paralysis (not to be con- founded with general paralysis). — Do not include: Diphtheritic paralysis (9) ; atrophic muscular paralysis (63) ; general paralysis (67) ; paralytic cachexia or marasmus (67) ; paralytic dementia or idiocy (67) ; shaking or trembling paralysis (6s) ; bulbar paralysis (63) ; ascending paralysis (63) ; essential paralysis of infancy (63) ; labioglossolaryngeal paralysis (74b) ; paralysis of the velum palati (101) ; paralysis of the muscles of the eye (53). 67. General Paralysis. Include: Paralytic lunacy; paralytic dementia; para- lytic cachexia ; paralytic marasmus ; diffuse meningoencephalitis ; diffuse peri-encephalitis. — Do not include: Generalized paralysis (66). 68. Other Forms of Mental Alienation. Include: Dementia; lunacy; un- soundness of mind ; hallucinations ; mania ; megalomania ; monomania ; delusions of persecution ; melancholia ; lypemania ; nostalgia ; spleen ; noso- phobia ; necrophobia ; sitiophobia ; lycanthropy ; homesickness ; andro- mania; nymphomania; priapism; satyriasis; mental disease. — Do not in- clude: Alcoholic dementia or delirium (56) ; delirium tremens (56) ; de- lirium (179) ; uraemic delirium (120) ; apoplectic dementia (64) ; paralytic dementia (67) ; choreic dementia (73) ; senile dementia (154) ; hysteria (74a). 69. Epilepsy. Include: " Haut mal;" disease of Hercules. — Do not include: Epi- leptiform convulsions (70). 70. Eclampsia (Non-puerperal). 1 Include: Epileptiform convulsions (of adults). — Do not include: Scarlatinous eclampsia (7) ; ursemic eclampsia (120) ; eclampsia of young infants (71). 71. Convulsions of Children. 2 Include: Eclampsia of young children; con- tractures of children. — Do not include : Trismus nascentium. 72. Tetanus. Include: Opisthotonos; emprosthotonos ; pleurosthotonos ; tris- mus nascentium. 73. Chorea. Include: Choreic dementia ; Bergeron's disease. 74. Hysteria. Include: Hysterical anorexia; hysterical colic; all diseases classi- fied as "hysterical." (Morbidity statistics alone.) 74a. Neuralgia. Include: Tic douloureux; sciatica. (Morbidity statistics alone.) 74b. Other Diseases of the Nervous System. Include: Cerebral compression, cerebral tumor ; acquired hydrocephalus ; neuroma; encephalopathia (with- 1 When a female of child-bearing age is designated as having been stricken with " eclampsia," return the report to have the physician state whether or not the disease was puerperal. 2 This title only applies to children under five years of age. 23 354 POST-MORTEM EXAMINATIONS out qualification) ; idiocy; imbecility; cretinism; gatism ( ?) ; amnesia; paramnesia; loss of speech; aphasia; nervous or cerebral accidents; cere- bral anaemia ; neurosis ; tic ; convulsive tic ; contracture ; anaesthesia ; neu- rasthenia; migraine; vertigo; somnambulism; catalepsy; boulimia; Lan- dry's disease ; symptomatic or Jacksonian epilepsy ; athetosis ; labioglosso- laryngeal paralysis ; amyloid or fatty degeneration of the nervous system. — Do not include: Senile dementia, imbecility or gatism (?) (154) ; syringo- myelias (63) ; myxcedema (89) ; congenital or undescribed hydrocephalus (150). 75. Diseases of the Eye and its Adnexa. Include: Ophthalmia; foreign bodies ; conjunctivitis (not including diphtheritic conjunctivitis); xerophthalmia; xerosis; pterygion; Pinguecula; keratitis of every description; staphy- loma ; diseases of the cornea ; arcus senilis ; diseases of the sclerotic ; dis- eases of the iris; iritis; diseases of the choroid; choroiditis; iridocho- roiditis ; sclerochoroiditis ; glaucoma ; diseases of the retina ; retinitis ; optic neuritis ; amaurosis ; amblyopia ; amblyopia by intoxication ; hemio- pia; hemeralopia; nyctalopia; diseases of the lens; cataract; aphacia; parasites of the eye ; ophthalmozoa ; coloboma ; strabismus ; strabotomy ; paralysis of the muscles of the eye ; nystagmus ; styes ; chalazion ; blephar- itis; blepharoconjunctivitis; scrofulous blepharitis ; blepharophimosis ; ble- pharoplastia ; ectropion ; entropion ; trichiasis ; dacryoadenitis ; diseases of the lachrymal gland and lachrymal sac ; dacryocystitis ; dacryolithiasis ; dacryoma; lachrymal fistula; diseases and tumors of the orbit (cancer ex- cepted). — Do not include: Diphtheritic conjunctivitis (9) ; cancer of the eye (45) > ocular tuberculosis (33) ; exophthalmic goitre (51) ; exophthalmia (51). 75a. Follicular Conjunctivitis. (Morbidity statistics alone.) 75b. Trachoma. (Morbidity statistics alone.) 76. Diseases of the Ear. Include: Otitis; otorrhcea ; catarrh of the ear ; hydro- titis ; foreign body in the auditory canal ; obstruction of the auditory canal ; polyp of the ear ; inflammation of the tympanum ; " vertigo ab aure laeso ;" Meniere's disease, or vertigo; caries of the labyrinth (?) ; deafness; deaf- mutism. — Do not include: Mumps. III. DISEASES OF THE CIRCULATORY APPARATUS. 77. Pericarditis. Include: Cardiopericarditis ; hydropericarditis ; hydropneumo- pericarditis ; pericardial adhesions. — Do not include: Rheumatic pericarditis (47) ; endopericarditis (78) ; pleuropericarditis (94) ; pneumopericarditis (93). 78. Acute Endocarditis. Include: Endocarditis (without qualification) ; myo- carditis, acute or without qualification; endopericarditis. — Do not include: Rheumatic endocarditis, or the other cardiac accidents which may supervene in the course of an attack of rheumatism. 79. Organic Diseases of the Heart. Include: Aortic, mitral, tricuspid, or car- diac affection or lesion; cardiac or valvular insufficiency or stenosis of the valves of the heart ; cardiac cachexia ; hypertrophy of the heart ; dilatation of the heart ; cardiectasis ; steatosis of the heart ; degeneration of the heart ; cardiopathy ; cardiosclerosis ; cardiovascular sclerosis ; cardiomalacia ; car- diostenosis; labored heart; tachycardia; rupture of the heart; cardior- USUAL CAUSES OF DEATH 355 rhexia ; cardiac palpitations; asystole; cardiac asthma. — Do not include: Cardiac accidents (undetermined) (86) ; persistence or patency of the fora- men of Botallo (150). — Frequent complications: Dropsy; bronchitis and pneumonia ; albuminuria ; embolism ; thrombosis. 80. Angina Pectoris. Include: Cardialgia ; sternalgia; neuralgia of the heart. 81. Affections of the Arteries, Atheroma, Aneurism, etc. Include: Arteritis; fatty degeneration of arteries ; arteriosclerosis ; atheroma of arteries ; arte- riectasis ; aortic ectasis ; Hodgson's disease ; atresia of the pulmonary ar- tery ; aortitis; aneurismal tumor.— Do not include: Aortic affection (79). 82. Thrombosis and Embolism. Include: Thrombosis (non-puerperal) ; phleg- masia alba dolens (non-puerperal). — Do not include: Embolism (puerperal) (140). 83. Affections of Veins (Varices, Hemorrhoids, Phlebitis, etc.). Include: Pneu- mophlebitis; varicose ulcer; varicocele. — Do not include: Puerperal phle- bitis (137) ; vascular or erectile tumor (46) ; angioma (46). 84. Affections of the Lymphatic System. Include: Angioleucitis ; adenopa- thia; lymphangeitis. — Do not include: Suppurative adenitis (144); adeno- phlegmon (144) ; leucaemic adenitis (53) ; lymphatism (36a) ; bubo (36a) ; adenoma (46) ; lymphoma (46) ; lymphadenoma (46). 85. Hemorrhages. Include: Hemorrhage (without qualification) ; internal hem- orrhage ; haemophilia ; epistaxis ; stomatorrhagia ; cutaneous hemorrhage ; purpura haemorrhagica. — Do not include: Cerebral hemorrhage (64) ; cere- bellar hemorrhage (64) ; meningeal hemorrhage (64) ; pulmonary hemor- rhage (99) ; haemoptysis (99) ; haematemesis (104) ; intestinal hemorrhage (109) ; haematuria (121) ; uterine, hemorrhage (135 or 128, depending on whether it is or is not puerperal) ; metrorrhagia (128 or 135) ; umbilical hemorrhage (152) ; traumatic hemorrhage (166). 86. Other Affections of the Circulatory Apparatus. Include: Cardiac acci- dents (undetermined); angiectasis; angiectopia; affections of the great vessels; permanently slow pulse. — Do not include: Vascular naevus (150). IV. DISEASES OF THE RESPIRATORY APPARATUS. 87. Diseases of the Nasal Fossje. Include: Coryza; cold; polypus of the nasal or nasopharyngeal fossa; ozaena; abscess of the nasal fossa; adenoid vege- tations. — Do not include: Epistaxis (85) ; syphilitic coryza (36). 88. Affections of the Larynx. Include: Acute, chronic, erysipelatous, cedema- tous, phlegmonous, or stridulous laryngitis ; aphonia ; loss of voice ; false croup ; spasmodic croup ; stridulous croup ; oedema of the glottis ; spasm of the glottis ; polypus of the larynx ; stricture of the larynx ; laryngotomy. — Do not include: Tuberculous laryngitis (26) ; laryngeal tuberculosis (26) ; croup (9) : diphtheritic laryngitis and its synonyms (8) ; foreign bodies in the larynx (176). 89. Affections of the Thyroid Body. Include: Goitre; pulsating thyrocele; myxcedema ; pachydermic cachexia. 90. Bronchitis, Acute. 1 Include: Capillary bronchitis; tracheitis; tracheobron- chitis; broncho-alveolitis. — Do not include: Bronchopneumonia (92); spe- cific bronchitis or other synonym of pulmonary tuberculosis (see No. 27) ; fetid bronchitis (96); summer bronchitis (99). 1 See note on No. 91. 356 POST-MORTEM EXAMINATIONS 91. Bronchitis, Chronic. 1 Include: Mucous bronchitis (pituitous) ; catarrh (without qualification) ; bronchial, pituitous, pulmonary, or suffocating bron- chitis ; bronchorrhcea ; dilatation of the bronchi; bronchiectasis. — Do not include: Fetid bronchitis (96) ; tuberculous bronchitis (27). 92. Bronchopneumonia. Include: Catarrhal pneumonia. — Do not include: Capil- lary bronchitis. 93. Pneumonia. 2 Include: Croupous pneumonia; fluxion of the lung; pleuro- pneumonia ; pneumopleurisy ; splenopneumonia ; apical pneumonia ; peri- pneumonia; pneumopericarditis ; typhoid pneumonia. — Do not include: Caseous pneumonia (27) ; specific, bacillary, or any synonym of pulmonary tuberculosis (27) ; pulmonary congestion (95). 94. Pleurisy. Include: Pleuropericarditis ; pleuritic or thoracic effusion; pneu- mothorax ; hydropneumothorax ; pyothorax ; pleural vomica ; pneumopyo- thorax ; hemothorax ; thoracentesis ; empyema ; pleural adhesions. — Do not include: Pleurodynia (99). 95. Pulmonary Congestion and Pulmonary Apoplexy. Include: QEdema of the lungs. 96. Gangrene of the Lung. Include: Fetid bronchitis. 97. Asthma. Do not include: Cardiac asthma (79) ; suffocating catarrh (91) ; hay fever (99). 98. Emphysema of the Lungs. Include: Emphysema (without qualification). — Do not include: Subcutaneous emphysema. 99. Other Diseases of the Respiratory Apparatus (Phthisis excepted). In- clude : Tracheostenosis ; pleurodynia ; pneumopathy ; hydatids of the lung ; pulmonary calculus ; abscess of the lung ; pulmonary anthracosis ; inter- stitial pneumonia ; cirrhosis of the lung ; secondary sclerosis ; hay fever (summer bronchitis or catarrh). To be also included when their nature is not indicated: Organic lesion of the lung; pulmonary accidents; haemop- tysis ; spitting of blood ; pulmonary hemorrhage ; pneumorrhagia ; bron- chorrhagia; tracheotomy. — Do not include: Cancer of the lung (45). V. DISEASES OF THE DIGESTIVE APPARATUS. 100. Affections of the Mouth and its Adnexa. Include: Diseases of the gums; epulis; gingivitis; ulorrhagia; glossitis; diseases of the tongue (except cancer); parotid tumor; parotiditis; salivary fistula; ranula; thrush; diseases of the teeth; odontalgia; dental caries; staphylitis ; staphylo- plasty; staphylorrhaphy. — Do not include: Cancer of the lips or tongue (39) ; chancre of the mouth (36a) ; noma (142) ; mumps (19) ; gangrene of the mouth (142) ; diseases of the palate (146 or 36) ; fracture of the maxilla (164) ; necrosis of the maxilla (146) ; paralysis of the velum palati (101). 101. Affections of the Pharynx. Include: Angina or Ludwig's disease; anginas of all descriptions (except diphtheritic angina and its symptoms; see Diph- theria, No. 9); amygdalitis; quinsy; abscess of the fauces, throat, or 1 Return to the physician the reports given in as " bronchitis," in order that he may specify acute or chronic. When the physician fails thus to answer, classify under No. 90 all reports of children under five years of age, and under No. 91 all reports of those of greater age. 2 In countries where " apical pneumonia" is always synonymous with " phthisis," class this diagnosis under No. 27. In countries, on the contrary, where this is not constant, class under No. 93. USUAL CAUSES OF DEATH 357 retropharynx ; paralysis of the velum palati ; elongation of the uvula ; pharyngitis. — Do not include: Angina pectoris (80) ; cardiac angina (80) ; scarlatinal angina (7). 102. Affections of the CEsophagus. Include: Foreign bodies in the cesophagus; wound of the cesophagus; stricture of the cesophagus (except from can- cer) ; spasm of the cesophagus; cesophagotomy. — Do not include: Cancer of the cesophagus (40) ; stricture of the cesophagus, syphilitic (36). 103. Ulcer of the Stomach. Include: Round ulcer. — Frequent complications: Haematemesis ; perforations of the stomach ; peritonitis. 104. Other Affections of the Stomach (Cancer excepted). 1 Include: Dilata- tion of the stomach ; paresis of the stomach ; dyspepsia ; apepsia ; gas- tritis ; gastrohepatitis ; foreign body in the stomach ; gastrotomy ; perfora- tion of the stomach (non-traumatic); gastralgia; "vertigo a stomacho laeso ;" catarrh of the stomach ; indigestion. To be also included when their nature is not indicated : Gastrorrhagia ; hsematemesis ; gastric hemor- rhage. — Do not include: Gastro-enteritis (105 or 106, according to age). 105. Diarrhcea and Enteritis (under two years). Include: Gastro-enteritis or gastrocolitis of children ; infantile enteritis ; cholera infantum ; athrepsia. This title only considers these ailments in children under two years. 105a. Diarrhcea and Enteritis, Chronic Include: Athrepsia. 106. Diarrhcea and Enteritis (two years and over). Include: Gastro-enteritis or gastrocolitis of adults ; enteritis of adults ; diarrhcea of adults ; lien- enteritis ; intestinal ulcerations ; colitis ; intestinal colic ; flatulent colic ; inflammatory colic. Do not include: Tuberculous enteritis. 107. Intestinal Parasites. Include: Helminthse; oxyuri; taenia; solitary worm; ascaris lumbricoides ; trematodes ; trichocephalus ; ankylostomes ; colic from worms. 108. Hernias and Intestinal Obstructions. Include: Internal strangulation; intestinal invagination ; stercoral tumors ; ileus ; intestinal occlusion ; volvu- lus ; hernial colic ; hernial gangrene. The following to be included when their nature is not specified : Merocele ; sarco-epiplocele ; sarco-epiplom- phalitis ; kelotomy ; herniotomy ; artificial anus ; stercoraceous vomiting. — Do not include: Laparotomy (without other qualification) (46). — Fre- quent complication: Peritonitis. 109. Other Affections of the Intestines. Include: Paralysis or paresis of the intestine ; enteroptosis ; constipation ; stercoraemia ; intestinal calculi ; in- testinal perforation ; foreign bodies in the intestine or rectum ; rectitis. Include also the following diseases when their nature is not indicated, and these operations when their cause is not specified : Enterotomy ; artificial anus ; enterrhagia ; intestinal hemorrhage ; melaena ; prolapsus of the rec- tum; stricture of the rectum. — Do not include: Stercoral tumor (108); intestinal invagination and its synonyms (108); typhlitis (118); peri- typhlitis (118). 109a. Diseases of the Anus and Fecal Fistulas. Include: Proctitis; periproc- titis ; proctocele ; proctoptosis ; fissure of the anus ; abscess of the margin of the anus; fistula of the anus, either fecal or rectovaginal. — Do not in- clude: Urinary fistulae, even when these involve the rectum (124) ; artifi- cial anus (108) (morbidity statistics alone) ; unnatural anus (108) ; im- perforate anus (150). (For morbidity statistics alone.) 1 See observation under No. 40 as to " organic lesion of the stomach." 358 POST-MORTEM EXAMINATIONS no. Icterus, Grave. Include: Pernicious icterus; acute yellow atrophy of the liver; parenchymatous hepatitis; Weil's disease. — Do not include: Icterus (without qualification) (114); chronic icterus; icterus of the new-born (I5i). in. Hydatid Tumors of the Liver. Include: Hydatid cyst; hydatids; echi- nococci. 112. Cirrhosis of the Liver. Include: Cirrhosis (without qualification) ; alco- holic cirrhosis ; interstitial cirrhosis ; biliary cirrhosis ; amyloid or fatty degeneration of the liver ; slow atrophy of the liver ; steatosis of the liver ; alcoholic, interstitial, or chronic hepatitis. — Do not include: Organic lesion of the liver (114); hypertrophy of the liver (114). — Frequent complica- tions: Dropsy; hemorrhage; pneumonia; tuberculosis. 113. Biliary Calculi. Include: Hepatic calculi; biliary lithiasis ; hepatic colic. 114. Other Affections of the Liver. Include: Abscess of the liver; hepatitis; hepatitis, acute ; angiocholitis ; cholecystitis ; hepatocystitis ; choluria. To be also included when their precise nature is not indicated : Organic lesion of the liver ; tumor of the liver ; hypertrophy of the liver ; acholia ; cho- laemia; icterus; chronic icterus; jaundice; hepatic congestion. — Do not include: Grave icterus (no) ; icterus of the new-born (151). 115. Affections of the Spleen. Include: Splenitis; splenopathia ; megalosple- nia; splenocele. — Do not include: The affections of the spleen due to leukaemia or malaria. 116. Peritonitis, Simple (Puerperal excepted). 1 Include: Peritonitis (without qualification); peritonitis, chronic; peritoneal adhesions; epiploitis ; metro- peritonitis, pelviperitonitis. — Do not include: Tuberculous peritonitis (29) ; cancer of the peritoneum (41) ; puerperal peritonitis (137) ; rheumatic peritonitis (47). 117. Other Affections of the Digestive Apparatus (Cancer and Tubercle ex- cepted). Include: Diseases of the pancreas (cancer excepted). 118. Appendicitis and Phlegmon of the Iliac Fossa. Include: Iliac phlegmon or abscess; typhlitis; perityphlitis; typhlodicliditis ; appendicitis. — Do not include: Pelvic abscess (130) ; periuterine abscess (130) ; pelvic suppura- tion (130). VI. DISEASES OF THE GENITO-URINARY APPARATUS AND ITS ADNEXA. 119. Nephritis, Acute. Do not include: Scarlatinous nephritis (7) ; chronic nephritis (120) ; tuberculous nephritis (33) ; nephritis of pregnancy (138). 120. Bright' s Disease. Include: Chronic, albuminous, interstitial, or parenchy- matous nephritis ; albuminuria ; amyloid or fatty degeneration of the kid- ney; amyloid kidney; steatosis of the kidney; renal sclerosis. To be in- cluded when their precise nature is not indicated: Uraemia; uraemic eclampsia; ursemic delirium; ursemic coma. — Do not include: Organic lesion of the kidney (121) ; puerperal uraemia (138) ; cardiac albuminuria (79). — Frequent complications: Anasarca; dropsy; convulsions; hemor- rhages ; cerebral apoplexy ; pneumonia. 1 When an adult female is returned as having been stricken with " peritonitis," without other ex- planation, the report should be returned in order that the physician may specify whether or not the condi- tion was puerperal. USUAL CAUSES OF DEATH 359 121. Other Diseases of the Kidneys and their Adnexa. Include: Pyelitis; anuria ; renal congestion ; renal ectopia ; nephroptosis ; floating, motile, or displaced kidney; movable kidney ; renal cysts ; polycystic kidney ; hydro- nephrosis ; hematuria ; perinephritis ; perinephric abscess ; pyelone- phritis ; nephropyosis. To be also included when their nature is not speci- fied : Organic lesion of the kidney ; nephrorrhagia. 122. Calculi of the Urinary Tract. Include: Renal, ureteral, nephritic, vesical, or urinary calculus ; nephritic colics ; nephrolithiasis ; gravel ; stone ; cal- culary affections ; urinary lithiasis ; lithotrity ; lithoclasty. — Do not in- clude: Prostatic calculus (125). 123. Diseases of the Bladder. Include: Cystitis, acute or chronic; vesical or ureteral catarrh ; cystorrhagia ; tumor of the bladder ; cystocele ; cystop- tosis ; foreign body in the bladder ; section ; cystotomy ; retention of urine ; dysuria ; paralysis of the bladder ; vesical inertia ; incontinence of ' urine; tenesmus of the bladder. — Do not include: Hematuria (121) ; uri- nary fistulae, even when they involve the bladder (124) ; cystosarcoma (45). 124. Diseases of the Urethra. Include: Urinary abscess, etc.; ankylurethria ; foreign bodies; urethrotomy; urinary fistula (urethral, urethrorectal, vesi- corectal, or vesicometrorectal) ; urinary infiltration ; urinary intoxication ; urethralgia ; urethrorrhagia ; urinaemia ; stricture of the urethra ; urethro- stenosis; urethroplasty; urethrorrhaphy. — Do not include: Urethral catarrh (123) ; retention of urine (123). 125. Diseases of the Prostate. Include: Hypertrophy of the prostate; prosta- titis; abscess of the prostate; prostatic calculus. — Do not include: Cancer of the prostate (45) ; tubercle of the prostate (33). 126. NON-VENEREAL DISEASES OF THE GENITAL ORGANS OF THE MALE. Include: Phimosis ; paraphimosis ; amputation of the penis ; seminal losses ; sper- matorrhoea ; orchitis ; epididymitis ; funiculitis ; hydrocele ; hematocele of the testicle, cord, or scrotum; castration (in man) ; Malassez's disease. — Do not include: Cancer of the testicle (45) ; tubercle of the testicle (33) ; sarcohydrocele (45) ; syphilitic sarcocele (36) ; varicocele (83). 127. Metritis. Include: Ulcer of the uterus; ulceration of the neck (of the womb). 128. Uterine Hemorrhage, Non-puerperal. Include: Metrorrhagia; monorrha- gia; tamponage of the vagina or uterus. 129. Uterine Tumor (not cancerous). Include: Fibroid tumor, or fibroid body of the uterus ; hysteromyoma ; uterine polypus ; fungus or fungoid tumors of the uterus. 130. Other Diseases of the Uterus. Include: Ulcerations of the neck ; uterine or vaginal catarrh; deviation, anteflexion, retroflexion, anteversion, falling or prolapse of the uterus; prolapse of the vagina; uterine prolongation; amenorrhcea; hypertrophy of the neck of the uterus; dysmenorrhoea ; organic lesion of the uterus ; hysterectomy ; hysterotomy ; metrotomy ; ablation of the uterus; abscess of the pelvis; periuterine or retro-uterine abscess or phlegmon ; pelvic suppuration ; Huguier's disease ; leucorrhcea ; fluor albus (whites; vaginal flow; white flux). — Do not include: Puerperal diseases; abscess of the iliac fossa (95). 131. Cysts and other Tumors of the Ovary. Include: Ovariotomy; castration (in the female). 360 POST-MORTEM EXAMINATIONS 132. Other Diseases of the Genital Organs of the Female. Include: Vaginis- mus ; tumors of the vagina ; ovaritis ; salpingitis ; salpinx ; metrosalpin- gitis ; hematosalpinx ; pyosalpinx ; abscess and tumors of the vulvovaginal glands; vulvitis; periuterine or retro-uterine hematocele. — Do not include: Urinary fistulse (124); stercoral fistule (109a); even when they involve the genital organs. 133. Non-puerperal Diseases of the Breast (Cancer excepted). Include: Mam- mitis; abscess of the breast (non-puerperal); cyst of the breast; cystic diseases of Reclus ; tumor of the breast (without qualification, or non- cancerous) ; amputation of the breast. — Do not include: Fistula of the breast (puerperal, or without qualification) (43). VII. THE PUERPERAL STATE. Remarks. — It often happens that physicians neglect to note the puerperal char- acter of the disease ; hence the following rule for the guidance of those whose duty it is to collect statistics. " Whenever an adult female is noted as having been af- fected with a disease which may be puerperal, the report should be returned to the reporter, in order that he may state explicitly whether or not the disease was puer- peral." The following are these diseases : Peritonitis ; pelviperitonitis ; metroperi- tonitis ; septicaemia ; hemorrhage ; metrorrhagia ; eclampsia ; phlegmasia alba dolens ; phlebitis ; lymphangeitis ; embolism ; sudden death ; abscess of the breast. 134. Accidents of Pregnancy. Include: Miscarriage (death of mother) ; abor- tion (death of mother) ; hemorrhage of pregnancy; incoercible vomiting; rupture of tubal pregnancy; ablation of the pregnant tube; difficulties and fatigues supervening in the course of pregnancy. 134a. Labor, Normal. (Morbidity statistics only.) 135. Puerperal Hemorrhage. Include: Metrorrhagia, puerperal. 136. Other Accidents of Labor. Include: Dystocia; Cesarean section; rupture of the uterus ; metrorrhexia ; laceration or rupture of the perineum ; peri- neorrhaphy; placenta previa; malposition, retention, detachment, or apo- plexy of the placenta; cephalotripsy ; embryotomy (adult); symphyseot- omy; version; application of forceps; uterine inversion. 137. Puerperal Septicemia. Include: Puerperal fever; puerperal infection; puer- peral endometritis ; puerperal salpingitis ; perimetrosalpingitis, or phlegmon of the broad ligament, or diffuse pelvic puerperal cellulitis ; puerperal peri- tonitis, metroperitonitis, phlebitis, lymphangeitis, or pyohemia. — Do not in- clude: Septicemia (without qualification) (20). 138. Albuminuria and Puerperal Eclampsia. Include: Puerperal uremia; ne- phritis of pregnancy ; eclampsia of women in labor ; epileptiform convul- sions of women in labor ; puerperal tetanus. 139. Phlegmasia Alba Dolens, Puerperal. Do not include: Phlegmasia alba dolens, non-puerperal (82). — Frequent complications: Gangrene; embolism. 140. Other Puerperal Accidents; Sudden Death. Include: Puerperal embo- lism ; puerperal thrombus ; sudden death in the puerperium ; consequence of labor (without other explanation). — Do not include: Sudden death, non- puerperal (178) ; puerperal scarlatina (7). 141. Puerperal Diseases of the Breast. Include: Fissure of the nipple (puer- peral) ; circumscribed abscess; abscess of the breast (puerperal); fistula of the breast (puerperal or without further indication). USUAL CAUSES OF DEATH VIII. DISEASES OF THE SKIN AND CELLULAR TISSUE. 361 142. Gangrene. Include: Eschar; sphacelus; gangrene, dry; gangrene, senile; gangrene of the extremities ; gangrene of the mouth ; gangrene of the vulva, etc.; noma; Raynaud's disease. — Do not include: Gangrene of the lung (96); hernial gangrene (108); gangrenous erysipelas (144). 143. Furuncle (Carbuncle). 1 Do not include: Biskra, Aleppo, or Medina button. 144. Phlegmon; Warm Abscess. Include: Abscess (without qualification); phlegmonous tumor ; adenophlegmon; suppurative adenitis ; bubo (with- out qualification) ; suppurating bubo ; diffuse phlegmon ; phlegmonous or gangrenous erysipelas ; panaris ; whitlow ; abscess of the mediastinum ; vomica (without any other indication). — Do not include: Bacillary abscess (33) ', abscess of the fauces, throat, or retropharynx (101) ; of the liver (114) ; of the iliac fossa (118) ; of the pelvis (130) ; of the prostate (125) ; urinary (124) ; periuterine (14) ; of the breast, non-puerperal (130) ; cold (31) ; by congestion (31) ; ossifluent (31) ; angioleucitis (84). 145. Tinea Favus. (Morbidity statistics alone.) 145a. Tinea Tonsurans, Trichophyton. Include: Tinea (without qualification). (Morbidity statistics alone.) 145b. Pelades. (Morbidity statistics alone.) 145c. Itch. (Morbidity statistics alone.) I45d. Other Diseases of the Skin and its Adnexa. Include: Erythema; urti- caria ; prurigo, pityriasis ; lichen ; psoriasis ; dermatitis ; eczema ; im- petigo ; aphtha ; herpes ; ecthyma ; elephantiasis Arabum ; pachyderma- titis ; polysarcia ; scleroderma ; cheloids ; fungoid mycosis ; seborrhcea ; trophoneuroses ; zona ; Wardrop's disease ; Biskra, Aleppo, or Medina button ; ' Pendine ulcer ; Cochin-China ulcer ; pemphigus ; myiasis. — Do not include: Pachydermatous cachexia (89) ; elephantiasis Grsecorum (17). IX. DISEASES OF THE ORGANS OF LOCOMOTION. 146. Affections of the Bones (Non-tuberculous). Include: Periostitis; perios- tosis ; osteitis ; osteoperiostitis ; osteomyelitis ; caries ; necrosis ; seques- trum; perforation of the palatine vault; necrosis of the maxilla (non- phosphoric or without qualification) ; exostosis (without qualification) ; osteoma ; osseous tumor ; cranial tumor ; foreign bodies in the frontal or other sinuses; mastoiditis; abscess of the frontal or maxillary sinus; osteomalacia; softening of bone ; rhachitis; scoliosis; lordosis; kyphosis. — Do not include: Caries of the petrous bone (76) ; dental caries (100) ; osteocopic pains (36c) ; osteosarcoma (45) ; phosphorus necrosis (58). 147. Arthritis and other Diseases of the Joints (Tuberculosis and Rheumatism excepted). Include: Arthritis; polyarthritis (non-vertebral); hydrarthro- sis; foreign bodies in joints; arthrodynia; arthropyosis ; arthrophytis ; ankylosis; arthralgia; arthrocele; genu valgum. — Do not include: Rheu- matic arthritis (47). 148. Amputation. Include: Only those cases in which the lesion, the cause for amputation, is not specified. — Do not include: Amputation of the breast 1 The word " anthrax" will be taken in the sense in which it is ordinarily employed in each country, as for example : in French-speaking countries, as " an aggregation of furuncles" (143) ; and as " malignant pustule" (22) in Russia. 362 POST-MORTEM EXAMINATIONS (133) ; amputation of the penis (126). — Frequent complications: Septi- caemia ; erysipelas ; tetanus ; hemorrhage. 149. Other Affections of the Organs of Locomotion. Include: Hygroma; peri- chondritis; disarticulation; tarsalgia; painful talipes valgus; retraction of the fingers or of the palmar aponeurosis; Dupuytren's disease; non- traumatic muscular rupture ; muscular diastasis ; myodiastasis ; non-trau- matic rupture of a tendon ; diseases of tendons ; tenophytes ; tenosynovitis ; tenotomy; tenorrhaphy; torticollis; lumbago; curvature. X. MALFORMATIONS. 150. Malformations (Stillbirths not included). Include: Malformation; mon- strosity ; anomaly ; arrest of development ; congenital hydrocephalus ; hydro- cephalus (without qualification); megalocephalus ; hydrorachia; spina bifida ; encephalocele ; podencephalia ; congenital eventration ; omphalo- cele ; exomphalos ; ectopia ; imperforate anus, etc. ; hare-lip ; cleft palate ; anaspadias ; hypospadias ; cryptorchid ; vascular nsevus ; polydactylia ; syn- dactylia ; congenital club-foot ; talipes valgus, varus, or equinus, congenital ; congenital deafness or blindness ; persistence of the foramen of Botallo (foramen ovale). — Do not include: Coloboma (75); painful flat-foot (149) ; acquired hydrocephalus (74b). XL EARLY INFANCY. 150a. The New-born and Nurslings departing from Hospitals without having been Sick. (Morbidity statistics alone.) 151. Congenital Debility, Icterus, and Sclerema. 1 Include: Premature birth; atrophy (infantile) ; icterus or hepatitis of the new-born; atelectasis of the lungs in the new-born; cedema of the new-born. 152. Other Diseases of Early Infancy. Include: Umbilical hemorrhage; in- flammation of the umbilicus; cyanosis of the new-born. (This title has reference to children not more than three months old.) 153. Lack of Care. XII. OLD AGE. 154. Senile Debility. Include: Senility; old age; cachexia (of the old); senile exhaustion; senile dementia. — Do not include: Senile gangrene (142). XIII. AFFECTIONS PRODUCED BY EXTERNAL CAUSES. Among suicides there should only be classed those in whom suicide or attempted suicide is clearly demonstrated. In collective suicides there should only be counted those who have attained their majority. Minors ought to be regarded as the victims of assassination. 155. Suicide by Poison. Include: Voluntary poisoning; voluntary absorption of sulphuric acid (or any other corrosive substance). 156. Suicide by Asphyxia. Include: Suicide by the vapor of charcoal. 157. Suicide by Hanging or Strangulation. Include: Hanging. 158. Suicide by Drowning. 159. Suicide by Firearms. 160. Suicide by Cutting Instruments. USUAL CAUSES OF DEATH 363 161. Suicide by Jumping from High Places. 162. Suicide by Crushing. 163. Other Suicides. 164. Fractures. Include: Separation of the epiphyses; fracture of the cranium. 165. Sprains. Include: Strains; stretching of ligaments. (Morbidity statistics alone.) 165a. Luxations. Include: Subluxations. 166. Other Accidental Traumatisms. Include: Stabs; contusion; bites (non- venomous, non-virulent) ; crushing; railroad accidents (suicide excepted) ; wounds by cutting instruments (suicide not demonstrated) ; accidental falls ; concussion of the brain ; perforation of the cranium ; traumatic hemorrhage ; traumatic fever ; traumatic eventration ; perforation of the abdomen or chest ; all acute affections designated as " traumatic ;" wounds by firearms. 167. Burns and Scalds. Include: Burns and scalds; burns from steam; from petroleum. — Do not include: Conflagration. 168. Burns from Corrosive Substances. Include: Burns by vitriol. 169. Insolation. Include: Sunstroke. 170. Freezing. Do not include: Effects of cold (new-born) (153). 171. Electrical Disturbances. Include: Death from lightning. 172. Accidental Submersion. Include: Drowning (non-suicidal). 173. Prostration. Include: Fatigue. (Morbidity statistics alone.) 173a. Inanition. Include: Hunger; insufficient food (new-born excepted); mis- ery. — Do not include: Lack of care (new-born) (153) ; lack of nutrition (new-born) (153) ; sitiophobia (68) ; hysterical anorexia (74a). 174. Absorption of Deleterious Gases (Suicide excepted). Include: Asphyxia, accidental (pathological asphyxia and suicidal asphyxia excepted) ; as- phyxia by illuminating gas; asphyxia by stoves (fixed or portable); absorption of carbonic oxid ; conflagration ; absorption of ammonium sul- phid ; asphyxia by night-soil ; absorption of chloroform ; absorption of nitrous oxid. — Do not include: Asphyxia of the adult (without qualifica- tion) (179). 175. Other Acute Poisonings. Include: Every acute poisoning (suicide ex- cepted) ; antimony cholera; acute ergotism; absorption of venom; bite of serpent; accidental absorption of sulphuric acid or other corrosive sub- stances. — Do not include: Saturnism (57) ; hydrargyrism, etc. (58 or 59) ; morphinism, chronic ergotism, etc. (59). 176. Other External Violence. Include: Accident (without other qualifica- tion) ; bad treatment (upon a child) ; capital punishment ; foreign body in the larynx ; foreign body in the trachea. XIV. ILL-DEFINED DISEASES. The following titles will include only those conditions ill-defined by the phy- sician, whether from lack of sufficient data, or because the disease was ill-defined, or because the physician was negligent in making a complete diagnosis. 177. Dropsy. Include: Anasarca; ascites; oedema of the extremities or gener- alized oedema; organic lesion (not defined). — Do not include: (Edema of the new-born (151) ; oedema of the glottis (88) ; oedema of the lungs (95) ; oedema of the brain (64). 364 POST-MORTEM EXAMINATIONS 178. Sudden Death. Include: Syncope (followed by death). — Do not include: Puerperal sudden death (140), nor sudden death followed by an explana- tion, as "diabetic" (30) or "apoplectic" (64). 179. Ill-defined or Unspecified Causes of Death. Include: Exhaustion or cachexia or debility (of adults); asthenia; adynamia; ataxo-adynamia ; coma; asthenic, hectic, colliquative, synochal, gastric, bilious, or pituital fever; gastric involvement; fever of detention; paralysis of the heart (in German " herzlahmung" or " herzschlag," in English "heart failure"); cyanotic asphyxia (without indicated cause, the new-born excepted) ; or any other insufficient diagnosis. — Do not include: Exhaustion, cachexia or debility of the old (154) ; fever, ataxo-adynamic, continued, summer, or hay (99) ; asphyxia by external cause (156 or 174) ; cyanosis of the new- born (152). An endeavor is now being made to adopt the following death cer- tificate throughout America. RETURN OF A DEATH IN THE CITY OF PHILADELPHIA Physician's Certificate. 1 . Full Name of Deceased, f Cninese, *• Color, Stateif |fiS se ' = 3- Sex, ( Widow, 4. Single, Married State if {SS: Years, 5. Age, J Months, «■££?: Days, (If age is less than one day, give hours. f Chief, No Certificate will be accepted which is MUTILATED, ILLEGI- BLE, INACCURATE, or any por- tion of which has been ERASED, INTERLINED, CORRECTED, or ALTERED, as all such changes im- pair its value as a Public Record. £ 7. Cause of Death, ( Contributing, 4®= This Certificate must not be issued for any other purpose than as a report to the Board of Health. Should the Physician issue a duplicate, it must be distinctly marked " Duplicate," andstate why issued. Residence, M.D. INDEX ¥¥ (The Roman numeral letters refer to chapters ; the Arabic numeral figures to pages.) Abdominal cavity, diseases of organs of, vi, xi, xii, xiii, xiv, xxii, xxvii, xxviii, xxix exposure of, vi removal of organs of, xi, xix, xx superficial examination of organs of, vi Abortion, criminal, 314 Abscess of brain, 183 liver, 162 lung, 97 perinephric, 149 subdiaphragmatic, 144 Acarus scabiei, 239 Acromegaly, 183 Actinomycosis, 209 Addison's disease, 130 Adrenalin, 129 Adrenals, diseases of, 129 examination of, 129 measurements of, 276 removal of, 129 situation of, 124 weight of, 276 Air-embolism, 99 Air-passages, upper, examination of, 93, 193 Amyloid kidneys, 145 liver, 157 Anaemia cerebri, 184 of brain, 184 lungs, 99 progressive pernicious, 79 Anatomical wart, 44, 237 Anchylostomum duodenale, 240 Aneurisms, 90, 184 Angular method of removing skullcap, 166 Anomalies of brain, congenital, 186 cord, congenital, 186 Anopheles, 241 Anthracosis, 108 Anthrax, 210 Aorta, 144 Apoplexia neonatorum, 184 Apoplexy, cerebral, 187 of lungs, 102 Appendicitis, 120 Arachnoid, 169 Arteries, morbid changes in, 88 Arteriosclerosis, 88 Asthma, 97 Ataxia, hereditary, 185 locomotor, 185 Atelectasis, 97 Atrophy, acute yellow, of liver, 157 progressive spinal muscular, 190 Autopsy, see Postmortem B Bacteriological investigations, xxiv Basedow's disease, 102 Beriberi, 211 Bertillon classification, 348 Bile ducts, 136, 138 Biologic blood-test, 323 Bladder, diseases of, xiii Blood-diseases, 79 Blood, lesions of, viii Blood-stains, 322 Blood-tests, 323 Blood-vessels, lesions of, viii Bodies, examination of exterior of, v frozen, 207 identification of, 308 pecuniary value of, 4 preservation of, 206 removal of portions of, 5 restoration of, 203 right to dispose by will of, 4 Bothriocephalus latus, 239 Bowel, inflammation of large, 124 Brain, abscess of, 183 365 3 66 INDEX Brain, anaemia of, 184 diseases of, xvii examination of, xv Dejerine's method, 173 Giacomini's method, 178 Hamilton's method, 176 Meynert's method, 173 Pitres's method, 175 Virchow's method, 172 hyperemia of, 188 preservation of, Kaiserling's method, 178 removal of, 169 in child, 198 syphilis of, 227 tuberculosis of, 232 weight of, 271 Bronchiectasis, 98 Bronchitis, 98 Brown atrophy of heart, j6 induration of lungs, 99 Brunetti's chisels, 32 Bucket method of opening intestines, 116 Burials, premature, 315 Burns,. 320 Caisson disease, 185 Calcicosis, 108 Calculi, renal, 150 vesical, 152 Calvarium, clamps for holding, 34 removal of, 166 Capsule of kidney, removal of, 128 Cephalic cavity, inspection of, xv Chantemasse, bacillus of, 122 Charcot-Leyden crystals, 97 Chisels, 31 Chloroform narcosis, 144, 331 Chlorosis, 80 Cholecystitis, acute infectious, 158 Cholelithiasis, 159 Cholera Asiatica, 211 Chorea, acute, 186 Cimex, 238 Circular method of removing skullcap, 165 Circulatory system, syphilis of, 227 tuberculosis of, 233 Cirrhosis of liver, 159 Clamps for holding calvarium, 34 Clothing, care of, 309 Cceliac plexus, 130 Cold, death from, 319 Colitis, 124 Colon, dilatation of, 125 Color of parts, 16 Common bile duct, 138 Comparative postmortems, xxvi Complications of diseases causing death, xxix Congenital defects of kidneys, 145 Congestion of kidneys, 145 liver, 161 passive, of lungs, 100 Considerations, general, i Cord, diseases of, xvii examination of, xvi removal of, xvi syphilis of, 227 tuberculosis of, 232 Cornell head-rest, 34, 164 Coronary arteries, 70 Coroner's cases, 5 office, establishment of, 305 Corpus delicti, 309 Cretinism, 186 Cryoscopy, 324 Culture media, inoculating, 265 Curschmann's spirals, 97 Cystic disease of kidneys, 146 Cysticercus cellulosse, 239 Cystitis, 151 Cytology, 325 Death, ascertainment of the cause of, 2 no cause found for, 2 signs of, 315 usual causes of, 316, xxix violent, 317 Decomposition, post-mortem, 48, 317 Delirium, acute, 186 Dengue, 212 Diabetes insipidus, 83 mellitus, 83 Diabetic blood, reaction for, 324 Diaphragm, 144 Diarrhoea, summer, cause of, 122 Differentiation, optical, 247 Diphtheria, 212 Diseases, nomenclature of, 348 INDEX 367 Diseases of adrenals, 129 aorta, 144 arachnoid, 169 bile ducts, 136 bladder, xiii brain, xvii common bile ducts, 138 cord, xvii coronary arteries, 70 diaphragm, 144 duodenum, 138 * dura, 168 ears, xviii eyes, xviii Fallopian tubes, 153 gall-bladder, 136 gall-ducts, 157, xiv heart, viii intestines, xi kidneys, 145 larynx, 95, 228, 234 liver, 157 lungs, x meninges, 189 mesentery, 121 nasal cavities, xviii new-born, xix oesophagus, 140 omentum, 112 orbits, 194 ovary, 154 oviducts, 153 pancreas, 142 pericardium, 67 peritoneum, 112 pharynx, 95 portal vein, 136 prostate, 134 psoas muscle, 144 retroperitoneal glands, 144 semilunar ganglia, 130 spermatic vessels, 134 spinal canal and cord, xvi spleen, 114 stomach, 140 testicles, 156 ureter, 130 urethra, 134 uterus, 154 vagina, 156 Dissecting wounds, iv Disseminated sclerosis, 191 Distomiasis, 240 Dourine, 243 Duke's disease, 219 Duodenum, 138 Dura mater, 168 Drowning, 320 Dysentery, 122 acute catarrhal, 122 amoebic, 123 chronic, 123 complications of, 123 gangrenous, 123 Ears, examination of, xviii Echinococcus disease, 241 Electricity, death by, 318 Embalmed bodies, 206 Embolism, air, 99 fat, 99 Embryos, length of, at different ages, 280 Emphysema of liver, 161 lungs, 100 Encephalitis, 186 Encephalon, examination of, xv Endarteritis obliterans, 89 Endocarditis, 87 Engines, dental and trephining, 28 Enterotome, 29 Epiglottis, examination of, 95 Erysipelas, 214 Expert testimony, 306 Exterior of body, examination of, v Extra-uterine pregnancy, 153 Exudate, 59 Eyes, examination of, xviii F Face, examination of, xx Fallopian tubes, diseases of, xiii Fat embolism, 99 Fatty changes in liver, 161 Fever, glandular, 214 paratyphoid, 119 typhoid, 118 Filaria sanguinis hominis, 240 Fixatives, 246, 256 Foot-and-mouth disease, 214 Formad pocket-case, 38 3 68 INDEX Frambcesia, 215 Friedreich's ataxia, 185 Fright, 144 Frozen bodies, 206 Gall-bladder, 136 Gall-ducts, diseases of, xiv Gall-stones, 159 Gangrene of lungs, 101 Gastritis, 141 Gastro-intestinal tract, syphilis of, 227 General considerations, i Genitalia, female, removal of, 132 male, removal of, 134 Genito-urinary system, tuberculosis of, 233 German measles, 222 Glanders, 214 Goitre, 101 exophthalmic, 102 Gonorrhceal infection, 216 Gout, 84 Graduated cones, 35 Graves's disease, 102 Hsematomyelia, 187 Hsematozoa, diseases due to, xxii Haemophilia, 81 Haemoptysis, causes of, 99 Hammers, 31 Hands, care of, iv Hanging, 320 Hardening, 255 Harke's method, 193 Hay fever, 97 Heart, actinomycosis of, 88 amyloid degeneration of, 89 anomalies of, 76 characteristics of, 76 degeneration of, 86 dilatation of, 85 dimensions of, 273 diseases of, viii examination of, 69 hypertrophy of, 85 infiltration of, 86 lesions of, viii removal of, 71 syphilis of, 88 tuberculosis of, 88 Heart, tumors of, 88 valvular diseases of, 88 volume of, 274 weight of, 273 Heat, death from, 319 Height, 267 Hemiplegia in children, 187 Hemorrhages, 85 cerebral, 187 into spinal membranes, 188 of lungs, 102 pulmonary, 102 Hepatitis, suppurative, 162 Hereditary ataxia, 185 Hey's saw, 26 Hide-bound skin, 224 Hydronephrosis, 146 Hydrophobia, 216 Hydrostatic lung test, 345 Hyperemia, cerebral, 188 Identification of the body, 308 Illumination, 12 Infanticide, 320 Infants, autopsies on, 312 Infarcts of kidney, 146 lungs, 99, 102 Influenza, 217 Injection, preservative, 207 Instruments, proper and improper, iii to be taken to postmortem, 2>^> use of, iii, 24 Insular sclerosis, 191 International system of nomenclature of diseases and causes of death, 348 Interstitial nephritis, 147 Intestines, diseases of, 116 gall-stones in, 120 hemorrhage of, 120 removal of, 115 worms in, 120 Intra-uterine gestation, period of, 313 Kaiserling method, 261 Kidneys, 125 amyloid changes in, 145 congenital defects of, 145 congestion of, 145 cystic disease of, 146 INDEX 369 Kidneys, diseases of, xii examination of, 128 hydronephrosis of, 146 infarcts of, 146 movable, 148 opening of, 127 parasites of, 148 removal of, 126 stones of, 150 syphilis of, 227 tuberculosis of, 233 tumors of, 150 weights and measures of, 275 Knife, method of holding, 38 Knives, 24 Koch controversy, 282 Kromskopic pictures, 2 Large bowel, 125 •Laryngitis, cedematous, 102 Larynx, removal of, 95 syphilis of, 228 tuberculosis of, 234 Leontiasis ossea, 184 Leprosy, 218 Leptomeningitis, acute, cerebrospinal, chronic diffuse, 189 deep chronic, 189 Leucocythaemia, 80 Leukaemia, 80 Light, artificial, 7 Lithosis, 108 Liver, 136 abscess of, 162 acute yellow atrophy of, 157 amoebic abscess of, 123 amyloid degeneration of, 157 cancer of, 158 cirrhosis of, 159 congestion of, 161 dimensions of, 275 disease of, xiv emphysema of, 161 fatty changes in, 161 sarcoma of, 162 syphilis of, 228 tumors of, besides cancer and coma, 163 volume of, 275 weight of, 274 188 Lividity, post-mortem, 48 Longitudinal sinus, 168 Luer's rhachiotome, 27 Lungs, abscesses of, 97 air-embolism of, 99 anaemia of, 99 apoplexy of, 102 atelectasis of, 97 brown induration of, 99 circulatory disturbances of, 99 dimensions of, 274 diseases of, x emphysema of, 100 examination of, ix fat embolism of, 99 gangrene of, 101 hemorrhage of, 102 infarcts of, 99, 102 oedema of, 99 passive congestion of, 100 removal of, 93 syphilis of, 109, 228 tuberculosis of, 109, 234 tumors of, no volume of, 274 weight of, 274 Lupus vulgaris, 237 Lymphatic glands, tuberculosis of, 235 Lymph-glands, retroperitoneal, 144 M Malaria, 241 Mai de caderas, 243 Malta fever, 219 Mammary gland, tuberculosis of, 236 Measles, 219 German, 222 Measures, xxv Medicolegal postmortems, 311, xxviii suggestions, xxvii Meningitis, acute cerebrospinal, 189 Meningo-encephalitis, 189 Mesentery, disease of, 121 Micromegaly, 184 Micro-organisms, diseases due to, xxii Miliary tuberculosis of the lungs, no Morbilli, 219 Movable kidney, 148 Miiller's fluid, 250 Mumps, 220 Muscular atrophy, progressive spinal, 190 24 37° INDEX Myelitis, acute, 190 from compression, 190 Myelotome, 25 Myiasis, 240 Myocarditis, 86 N Nagana, 243 Narcosis, 144, 331 Nasal cavity, examination of, 201 Nasopharynx, examination of, xviii Necropsy, see Postmortem Nematodes, 240 Nephritis, interstitial, 147 parenchymatous, 148 New-born, examination of, xix Noma, 109 Nomenclature of causes of death, xxix Notes, taking of, 1, 2, 14 Obligations of physicians to their patients, 305 Odor of parts, 17 (Edema of lungs, 99 (Esophagus, 140 examination of, 95 Omentum, 112 Oral cavity, examination of, 201 Orbits, examination of, 194 Organs, characteristics of, 14 Osmic acid, 253 Osteitis deformans, 184 Osteo-arthropathy, hypertrophic pulmon- ary, 184 Ovaries, diseases of, xiii weight and measures of, 278 Oviducts, 134, 153 Oxyurus vermicularis, 240 Pancreas, 142 weight and measures of, 277 Pancreatitis, 143 Parasites, 148, 238 diseases due to, xxii Paratyphoid fever, 119 Parenchymatous nephritis, 148 Pediculi, 238 Pelvic organs, 132 Penetration, 247 Pericarditis, 68 Pericardium, 67 Perinephric abscess, 149 Peristalsis, reversed, 119 Peritoneum, 112 cancer of, 112 tuberculosis of, 236 Peritonitis, 112 Permission to perform postmortem, 4 method of obtaining, 4 Pharynx, 95 Phthisis, no Pia mater, removal of, 169 Pick's myelotome, 25 Placenta, weight of, at different ages, 268 Plague, 220 Pleurae, diseases of, x examination of, ix Pleurisy, 102 Pneumonia, 104 catarrhal, 107 and croupous, differences be- tween, 107 chronic interstitial, 104 croupous and catarrhal, differences between, 107 complications of, 105 lesions of, 105 terminations of, 105 lobar, 105 Pneumonoconiosis, 108 Pneumothorax, 108 Poison, definition of, 326 Poisoning by acids, 328 aconite, 329 alcohol, 329 alkalies and caustic salts, 330 antimony, 330 arsenic, 330 atropine, 331 carbon monoxid, 332 chloral hydrate, 331 cocaine, 331 copper, 331 cyanide of potassium, 332 ergot, 331 formaldehyd, 332 hydrocyanic acid, 332 illuminating gas, 332 lead, 333 mercury, 333 methyl alcohol, 333 INDEX 371 Poisoning by nitrobenzol, 333 opium, 333 pellagra, 334 phosphorus, 334 potassium chlorate, 334 ptomain, 335 silver nitrate, 335 snakes, 335 strychnine, 335 suspected, 311 toadstool, 335 Poisons, classification of, 328 Poliomyelitis, acute anterior, 191 Portal vein, 136 Postmortems, additions to account of, 2 cleanliness at, 8 comparative, xxvi definition of, 1 general considerations of, 1 in hospital, 8 morgues, 8 private house, 8 instruments for, 36 interval to elapse before performance of, 6 legal right to perform, 3 made before dressing, 7 by artificial light, 7 medicolegal, 311 on anatomical cases, 5 operations at, 3 order of examination, 18 permission for, 4 method of obtaining, 4 place of making, 7 preparation for, 8 Prussian regulations for the perform- ance of medicolegal, 336 purpose of, 1 record books, forms for, 20, 22 restricted, xx room, furnishings of, 9 study anatomy at, 3 synonyms of, 1 time of making, 6 treatment of wounds at, 40 Post-mortem decomposition, 48 instruments, i lividity, 48 note-taking, i records, i, 14 Post-mortem rigidity, 48 table, 8 wounds, iv Potassium bichromate, 249 Preservation of bodies, xxi tissues, xxiii Prostate, 134 weight and measures of, 279 Prussian regulations, 336 Psilosis, 225 Psoas muscles, 144 Psorospermiasis, 242 Pulex, 238 Purpura, 82 Pyelitis, 149 Pyelonephritis, 149 K, Rabic tubercle, 217 Radio-activity of dead bodies, 313 Raspatory, 32 Raynaud's disease, 191 Records of postmortems, 14 Rectal enema, reversed peristalsis after, 119 Rectum, 115, 132 Regulations, Prussian, 336 Relapsing fever, 221 Restoration of body, xxi Retroperitoneal lymph-glands, 144 Reversed peristalsis, 119 Rhachiotome, 27 Rheumatic fever, 222 Rheumatism, chronic, 222 Rigidity, post-mortem, 148 Rigor mortis, ante-natal, 312 Rotheln, 222 Rubber gloves, 35 Rubella, 222 Rubeola, 219 S Salpingitis, 154 Sarcoma of the liver, 162 Sarcoptes scabiei, 239 Satterthwaite's calvarium clamp, 33 Saws, 26 Scalds, 320 Scalp, 164 Scarlet fever, 222 Scissors, 29 37 2 INDEX Scleroderma, 224 Sclerosis, disseminated, 191 insular, 191 Scurvy, 82 infantile, 83 Semilunar ganglia, 130 Serous membranes, tuberculosis of, 236 Serum blood-test, 323 Shiga, bacillus of, 122 Siderosis, 108 Silicosis, 108 Skin, tuberculosis of, 237 Skull and brain, examination of, xv examination of, 165 shape of, 270 thickness of, 166 types of, 270 Smallpox, 224 Smear preparations, 263 Spermatic vessels, 134 Spinal canal and cord, xvi Spine, 225 Spleen, diseases of, 114 removal of, 113 weight and measures of, 277 Starvation, death by, 320 Statistics, morbidity and mortuary, 348 Stegomyia, 238 Stomach, 140 contents of, 139 hemorrhage of, 142 removal of, in cases of poisoning, 139 Stomatitis, 108 Stones of kidney, 150 Strangulation, 320 Suffocation, 320 Suggestions, medicolegal, xxvii Suprarenals, see Adrenals Surra, 243 Syphilis, 225' Syringomyelia, 191 Tabes dorsalis, 185 Taenia flavopunctata, 239 saginata, 239 solium, 239 Testes, syphilis of, 229 weight and measures of, 278 Testicles, diseases of, xiii Tetanus, 229 Thoracic cavity, examination of, vii. 64 inspection of, 65 duct, 144 Thrush, 229 Thymus gland, weight and measures of, 277 Thyroid gland, arsenic in, 331 examination of, 95 weight and measures of, 278 Tissues, preservation of, 244 Tongue, removal of, 95 Tonsils, removal of, 95 Toxicology, 325 Trachea, examination of, 95 Transudate, 59 Trichina spiralis, 240 Trichosis vesicae, 151 Trypanosoma, 243 Tuberculosis, 229 Tuberculous ulcers, 118 Typhoid fever, 237 ulcers, 118 Ulcers of intestine, typhoid, 118 tuberculous, 118 Uncinariasis, 240 Ureters, 130 situation of, 125 tying of, in operations, 130 Urethra, 134 Urine, collection of, 132 Use of post-mortem instruments, : Uterus, diseases of, xiii opening of, 133 weight and measures of, 279 Vagina, diseases of, xiii Valentine knife, 25 Vena cava, 144 Vesical calculi, 152 Viability, determination of, 312 W Wart, anatomical, 44, 237 Weights, xxv Wounds, treatment of post-mortem, 40 Yellow fever, 238 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