/-; »C<%g.j;i^^%i:i;- ESX-^IEILirsirEXD .^STS 18 J >^ I • . . ICH. , THE ILLUSTRATED MEDICAL JOURNAL CO. MANUFACTURERS OF AND DEALERS IN SURGICAL INSTRUMENTS Dental Instruments, Batteries, Splints, MEDICAL BOOKS AND PERIODICALS AND PHYSICIANS' SUPPLIES. AH Orders MUST be accompanied witU tlie Casb. | We keep no book accounts See Prices on Third Cover Page. 1 i^fA/^- ' PoST-MoRTEMS; WHAT TO LOOK FOR HOW TO MAKE THEM WITH SECTIONS ON Iflfanticide, Poisons, Malformations, Etc. By A. H. NEWTH, M.D., LONDON. :K^^ EDITED, WITH NUMEROUS NOTES AND ADDITIONS, By F. W. OWEN, M.D., Demonstrator of Anatomy in the Detroit College of Medicine. published by The Illustrated Medical Journal Co., Detroit, Mich. COPyRIGHTED, 1885. v<.^^ MEDICAL HAND-BOOKS Published hy the Illustrated Medical Journal Co.f Detroit f Mich, Pocket Materia Medica and Therapeutics; by C. Henri Leonard, A. M., M. D. Cloth, 300 pages ; post- paid, $1.00. 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Bedside Clinic Leaves, for recording twice daily, the conditions of a patient. Price per tablet, 35 cts. Gynaecological Record Leaves; (Leonard). For recording diagnosis and all the physical symptoms in this class of cases. Price, per pad, 50 cts. Obstetric Record L-eaves. Price, per pad, 50 cts. Trichinae ; their microscopy, development and diagno- sis, and treatment of Trichinosis, by W. C. W. Glazier, M. D. ; 16 illustrations. Paper; price, 25 cts. Diseases of the Nose and Pharynx; from the German of Dr. Carl Michel, by Drs. Yemans and Shur- ly. 8vo, 112 pages. Price, 50 cts. K^^^Full descriptive Circulars on application. {All the above postpaid on receipt of price.) PREFACE. This Manual is intended to serve as a re- minder to the busy practitioner, and a guide to the student, of what is to be done and observed in making post-mortem examinations, and also to assist them in describing and understanding the various lesions which may be met with. It is not intended as a substitute for large pathological works, but as a supplement to them. Disputed points in pathology have been specially avoided, and the lesions are described as simply and concisely as possible. Very few notes have been made on the mi- croscopical appearances in disease, as they would have increased the size of the work too much, and also have exceeded its purpose. The principal works consulted here have been : Aitken — Science of Medicine ; Chue-ch- iLii — Diseases ofWomen; Manual of Midwifery ; Delafield — Post-mortem Examinxitions; Druit — Surgeon^ s Vade-mecum ; Goubert — Manual de VArt des Autopsies; Gray — Anatomy; Green — Pathological Anatomy; Guy and Ferrier — Forensic Medicine; Harley and Brown — Demonstrations of Microscopic Anat- omy; Jones and Sieveking — Pathological Anatomy; Orth — Diagnosis in Pathological Anatomy ; Yirchow — Post-mortem Examina- tions; WiLKS AND MoxoN — Lecturcs on Patho- logical Anatomy, The Authors. INTBODUCTORY. Before commencing a necroscop}^ {rSKpo^, death; (SKOTteiv, to examine) it is necessary to consider well the purpose of this examina- tion. In medico-legal examinations it is of course to assist in detecting crime, and hence to determine whether death was the result of disease or violence; and if the latter, whether the circumstances preclude the possibility of suicide or accident, In disease, where there is no doubt as to the cause of death, we have to consider from the lesions not merely the settlement of patho- logical questions, though these are import- ant, but the determination of how far the dis- ease might have been amenable to treatment. We have to search for the remote cause of the symptoms which had been observed during life. It is not pretended, in our present state of knowledge, that we shall as yet do much in this respect; we have to collect, observe, and collate facts, and then deduce results from them. The necessity, therefore, of most careful and extended necroscopies is obvious. Everything should be conducted.by method ; all that is likely to be required must be duly considered and prepared beforehand, for the want of one little detail or necessary instru- ment or appliance may vitiate the entire ex- amination. Notes must be carefully made at 6 INTRODUCTORY. the time; these may bo elaborated subse- quently, but the origiaal notes are to be pre- served. In describing the post-mortem le- sions, it is essential to give as much as possi- ble the actual appearances; and it is also necessary to remember that as there are dis- eases of which the lesions are as yet not found, so there are lesions which do not cor- respond to any known disease; and that most of the lesions observed after death are sec- ondary to the disease itself. This is import- ant, as many mistakes have arisen from re- garding the lesions as of primary significance. POST-MORTEMS: WHAT TO LOOK FOR AND HOW TO MAKE THEM. EXTERNAL EXAMINATION OF THE BODY, This is necessary in every case, but espec- ially in medico-legal enquiries, and must on no account be carelessly passed over; the omission of a slight detail may have very dis- astrous consequences. Surroundings, note objects lying near, as well as position and state of the body; contents of the hands, their condition, whether horny, delicate, stained, clubbed- lingered, &c. The nails often contain matter suggesting cause of death and place where it occurred, as grass, weeds, dirt, hair (may correspond with that of the murderer), bits of clothing, &c. The limbs may be fractured, dislocated, bruised, &c. The nostrils and mouth may contain for- eign bodies and dust, which also may show locality, &c. Skin, — Look for burns, birth-marks, tattoo marks, tj^phus spots, osdema, sordes at orifi- ces of mouth and nose, pale yellow tint of cancerous diathesis, bronzing, ulcers, &c. Where there are purple streaks along the courses of the superficial vessels, the lining of the internal vessels and heart will be deeply stained with blood pigment, as well as the various organs, as liver, spleen, &c. This state must not be mistaken for inflammation; it is a sign of decomposition, and masks other appearances. POST-MORTEMS. Wounds. — Cuts, punctures, scars, &c. Notice the shape of the wound, direction, size (measure carefully, but remember that contraction may have taken place), appear- ance, edges everted or not, contain coagula, contiguous effusion. Marks of strangulation, bleeding from eyes, ears, vagina, &c. Bruises may be produced immediately after death; if caused during life there is always extravasation; in post-mortem dis- coloration the vessels are simply distended or surrounded by serum stained with blood pigment. Serious injuries, as fractures, may be caused with- out external signs. An abrasion of the cuticle ap- pears dry and hard, whether produced before or after death. It is often difficult to tell whether wounds are inflicted before or immediately, or even some time after, death. If there are signs of inflam- mation, cicatrization, or suppuration, it is easy to say. If the wound is everted and coagula are near, then it must have been done shortly before death. If several are lying dead together, try to find which died first, from circumstan- ces, position, &c., as well as appearance of the bodies. Estimate the period since death, but do so guardedly; remember that the condition is affected by the state of the weather. The temperature of the body is not always a safe guide, for it often rises as putrefaction sets in, and varies according to the state before death and the atmospheric temperature. Hair. — Notice the appearance of the hair, it may give important evidence — color, con- dition, pediculi, long and lanky (in wasting disease), curly and crisp (in health) — pubic hair and whiskers especially; in phthisis much hair often grows on the chest (Wilks and Moxon). Rigor mortis, if present, is a sign of recent death. The amount of fat on abdo- men often shows the kind of life that has EXTERNAL EXAMINATION. been led — sedentary, addicted to beer drink- ing, &c. Examine the nianimse for milk ; abdomen, &c., for signs of pregnancy, recent or remote. In suspected rape, look for semen in or Dear vagina or on the clothes; put some on a slide with warm serum, and examine under the microscope. Cause of death. — Sometimes the exter- nal appearance will afford some clue as to the cause of death — thus, wasted in phthisis, and especially in diseases of the abdominal viscera, when there is often what is called the *' abdominal face." In pneumonia Hiqtq is generally an herpetic eruption on the lips. The abdomen is distended in ascites and peri- tonitis (but decomposition produces disten- sion). There may be the peculiar mulberry rash of typhus fever (enteric shows none); the skin is yellowish in pymmia, and the lym- phatics are often affected (swollen, &c.) The color of the skin will also show heart dis- ease; a livid color deuoies pulmonary affection. Anasarca of arms, face, scrotum, &c., shows heart disease or kidney disease; of abdomen, liver disease; of one or both legs, that there may be a thrombus in the femoral artery. In general anasarca the blood is at fault. In looking: for post-mortem lesions in particular affections it must be remembered that a disease or a poison (as alcohol) takes possession of a person's weakest or^an, and shows its effect mostly there; hence the differences of appearances from the same cause. SIGNS OF DEATH. It is very important to attend to these — firstly, because the person may not be actu- ally dead ; and secondly, because the question might be put by some sharp counsel to the medical man whether he was sure at the time of making the necroscopy that the person 10 POST-MORTEMS. was dead, and might request him to give proof of this. Vesalius was sadly troubled from having, as he fancied, noticed the heart beating after having opened a body. In the Pall Mall Gazette for June 24, 1874, there is reported the case of a little girl who was pronounced by the medical man as dead, and placed in a mortuary. In the evening, when a necro- scopy was about to be made, the heart was found to be beating. Cases of presumed trance, or other un- certainty as to death, may be easily settled by care- ful attention to the signs of death. ^Iisi^:^-'^^' The hand being held up in a strong light, and the fingers extended and closely approxi- mated, the points where the fingers touch will show pinkish tinge during life, but pale and yellowish in death. The Eyes. — Dull, flattened, sometimes wrinkled, soft, flabby, and covered with a viscid mucus. After sudden death, as apo- plexy, poisoning by carbonic dioxide, hydro- cyanic acid, &c., the eyes may remain bright and distended for some time. Cadaveric Rigidity.— Not always pres- ent, or only for a very short time; electric stimulus may cause movements in those re- cently dead. Skin, — Peculiar pallor, livid or lead-col- ored in parts; mucous membrane exsanguine at natural orifices: palms of hands and soles of feet yellow; green color in iliac fossae (this is very characteristic if present); loss of tran- sparency and of the naturally pink color in thin parts, as web of finger, &c. If during life the loba of the ear or a finger is con- stricted by a tight ligature, there is a redden- ing of the constricted part; this becomes darker and darker till it is converted into a bluish red: just round the ligature there is a narrow white ring. After death these changes do not take place, which are of course due to the return of blood from the part being hindered by compression of the EXTERNAL EXAMINATION. 11 veins. This is a certain sign of death, and is suggested by Dr. Magnus in Yirchow's *'Archiv." for 1873. The post-mortem change of color given here is sup- posed to be due to the action of sulphuretted hydro- gen on the albumin of the blood and tissues. Dr. Danis advises cutting down on an ar- tery — the temporal is the best — an empty state would show death. INFANTICIDE. — CHIEF MALFORMATIONS. Viability.— A child may live if born at the sixth month. The signs of having reached this age are: Length, from 8 to 13^ inches. Weight, 1 lb. to 2 lbs. 2 oz. Skin has some appearance of fibrous structure. Funis in- serted a little above the pubes. Limr of a dark red color. Points of ossification in the four divisions of the sternum. From this age the child increases in weight and length; the skin becomes more fibrous, and is covered with an unctuous matter, and fat appears in the subcutaneous tissue. 6 to 7 months, Length, 11 to 12 in. ; Weight, 2 lbs. 7 to 8 " *' 13 to 14 " " 3 to 4 lbs. 8 to 9 " '* 15 to 16 *' " 4 to 5 " 9 " " about 18 " '' 6 to 7 " Notice the measure from the vertex to the umbilicus, and from thence to the soles of the feet; state of the face (eyes, with or with- out membrana pupillaris), limbs (nails), gene- rative organs, position of testicles, points of ossification in the clavicle, maxillary hone, sa- crum, pubes, OS calcis, aster mim, stragalus, femur {lower end), &c. The point of ossification is easily obtained by ex- posing the end of the bone, and slicing the cartilage gradually till the o^sifla point is reached, which is of a deeper color than the cartilage. Shape of the liver, and comparative size of lobes; contents of gall bladder; length, color and quantity (lanugo) of hair should be noted. 12 POST-MORTEMS. Intra-uterine Maceration is distinctive. Body is shrunken, bones softened; the skin appears as if boiled or poulticed, is slimy, and readily comes off in patches; face and generative organs of a deep red color; the subcutaneous tissue looks like gooseberry jelly. The umbilical cord is straight and flaccid. Respiration Test.— The proof of respi- ration is a proof of life. But — 1, respira- tion may take place before delivery; 2, it may be so partial as to escape detection; 3, an artificially inflated lung may give the appear- ance of a respired lung. All Unrespired Lung is like a piece of liver, of a uniform bluish-red color, and sinks in water. It may float from putrefaction, but pressure will easily expel the gases so formed and cause it to sink. A Respired Lung is nearly always pinkish — mottled if respiration is imperfect; the lighter patches are groups of air cells, which under the microscope have a very characteristic ap- pearance. Hydrostatic Test. — Put both lungs in a ves- sel of water, then each separately; then cut up into about twenty pieces, and test each of the pieces Take the piece or pieces that float, put it, or them separately, in a strong cloth, and squeeze under a board; then put in the water again. If they sink, the lung is an unrespired or an uninflated lung. Examine the Stomach for food; the In- testines for meconium; the Bladder for urine. Notice state of umbilical cord. Other facts proving life.— Obliteration of the umbilical arteries and vein, of the duc- tus arteriosus and venosus; closure of the foramen ovale. The patency of any of these EXTERNAL EXAMINATION. IB is no proof of sUll-hirth, nor can any definite period of survival be formed. The Skin in a few days exfoliates as a fine dust; this exfoliation is a decided proof of life. The Umbilical Cord shrinks and withers and becomes flabby, with sometimes a circle of a distinct red color round its insertion; this takes place in a few hours; in one or more days it dries up, and about the fifth day falls off; the wound cicatrizes about the eleventh day. Violence. — Fontanelles may be punctur- ed; instruments passed up vagina, rectum, &c. Saffocation. — Notice marks of pressure. Stomach may contain matters causing the suffocation (as faeces, feathers, &c.) Strangu- lation. — The cord may be twisted round the neck during delivery; measure the length of the cord, notice its state, see if it corresponds with the marks on the neck. Look for finger marks on the neck, and judge which hand caused them. Fractures of the Skull may be caused accidentally; Contusions, too; contu- sions and fractures may be produced during labor. Notice if the cord hasbeen properly attended to; if not, if the body is exsanguine; if the child has been exposed ; if starved. 1. Large blood extravasations in the skin are always the result of external violence. 2. Effusions of blood in the muscles of the neck and in the course of the great vessels of the neck point clearly to attempted strangu- lation. 3. Haemorrhages between the liver and its capsule, and in the liver substance are always the result of external violence. In all these cases it is necessary to exclude difficult labors, operative measures and attempts at resus- citation. 14 POST-MORTEMS. 4. Lesions of the peritoneal membrane, and rupture of the liver, spleen and kidneys are due to violence ; they may be caused by the firm grasp of a hand round the child's body, and are not uncommon after attempts at artificial respiration. 5. Haemorrhages in the umbilical cord are very rarely caused during the act of birth, or during attempts at replacement in cases of prolapse of the cord. They are almost al- ways due to violence of some form, especially to tearing the cord. 6. Thick, circular, blood extravasations on the head or other parts of the body may be due to either diflicult labor or external vio- lence. 7. Hemorrhages in the lips, muscles of the tongue, palate or gullet, should raise a sus- picion of violence (either operative or crimi- nal); this will be confirmed if slight wounds of the mucous membranes of the parts affected are found. 8. Swelling of the lips — if not accounted for by the position of the face during partu- rition — must be considered a sign of the pres- sure of a hand on the child's mouth. 9. Hemorrhage into the external auditory meatus and external ear was not observed in any of the cases. This is always due to exter- nal violence. 10. Ecchymoses in the muscles, unless the result of difficult labor, etc., are always due to violence. 11. If asphyxia is caused by immersing the child in some fluid medium, or in dust, this will very frequently be found in the nose, mouth, throat, stomach or lungs. 12. Blood in the trachea, bronchi and alve- oli is usually due to aspiration from the ma- ternal passages or from the child's nose. EXTERNAL EXAMINATION. 15 If the ecchymoses of the muscles are due to ope- rative interference and not to criminal acts, we must remember that the presentation of the child will probably have been norma', and in this case the caput succedaneum will not be on the head but on some other part of the body; therefore, the presence of a caput succedaneum on the head, with signs of external violence, will make us suspect criminal in- terference. The cases of death from asphyxia have the following special feaiures : In all the serous membranes and in the different mucous mem- branes, blood extravasations were found in the greater number of cases, and almost with- out exception, sub-pericardial and sub-pleural hemorrhages were present. Extravasations were also often present in the spleen, kidneys, thymus gland, the connective tissue surrounding the pancreas, and under the scalp, epi- cranial aponeurosis and pericranium. In the middle ear and nasal fossae there was almost always a dark-red discoloration of the mucous membrane, and in many cases also, blood was exuded. Hemorrhages into the conjunctiva and retina, and in the form of small striations in the vocal cords were of frequent occurrence. Extravasation into the tissue of the lungs was very rare, and blood was never found in the alveoli or bronchi unless it had come from the nose of the child, or from the genital passages of the mother, through respiratory efforts. If death had not been brought about very rapidly, oedema of the lungs, larynx and nasal mucous membrane was found, and sometimes interstitial emphysema; the latter, however, being not uncommon even in cases of rapid asphyxia. In the bones and muscles there were no changes except great fulness of the blood ves- sels. The above report is founded on post-mortem exam- inations of 178 children born at the ninth month; 138 between the seventh and ninth, and 142 foetuses born alive between the fourth and seventh months, and is taken from Dr. Nobling's report in AerzJiches In- telligenzblatt. CHIEF MALFORMATIONS OF FCETUSES AND NEW-BORN CHILDREN. Absence of Organs, acephale (absence of head); anencephale (absence of braiu and spinal cord); congenital malformation (of idiots, cretins, &c.), congenital effusion of serum in the cerebral ventricles (with com- plete or incomplete development of the brain) or on the external surface; aprosopia (absence of face); absence of e3^es, eyelids, iris, mouth, lips, tongue, ear, epiglottis, penis, scrotum, testicles, vesiculse, ovaries, uterus, vagina, certain ribs or vertebrae, a part of a limb, hand, bladder, oesophagus, stomach, liver, heart, lungs, diaphragm, pan- creas, spleen, spinal cord(amyencephale), &c. Want of Union in Similar Parts.— Fissure in the median line, involving the cra- nium, the spinal column (spina bifida), the lips, the maxillary bones, tongue, roof of the palate, bladder, urethra, vagina, spleen, linea alba (with hernia). Inperforation of iris, eyelids, mouth, anus, urethra, vagina, uterus, intestines, oesophagus, valves of the heart, &c. Joining together of Organs.— Eyes (monopsia, cyclopsy); fusion of the lower limbs (symelia) or of the fingers (syndactyle). Atrophy, — Arrt^st of development in the limbs; feet or hands inserted on the trunk (phocomelia) ; incomplete limbs. Augmentation of Organs.— Double or- gans or increase in number (supernumerary limbs, &c.), &c. Heterogenesia. — Extra-uterine foetus; more than three feel uses at a time; foetus with change in the ordinary situations of the or- SIGNS OF DEATH FROM VIOLENCE, ETC. 17 gan; hernia of heart (lissure of sternum), of the abdominal viscera into the thorax, &c. Double Monsters.— By fusion together of some part of the body; developed equally, unequall}^ &c. ; contained in one another (foe- tal inclusion). 11. SIGISIS OF DEATH FROM VIOLENCE, POISONING, ETC. STARVATION, Emaciation in chronic cases is extreme, in acute cases less or even not at all. Stomach and Intestines empty, fauces dry; heart and bloodvessels generally empty; pu- trefaction is rapid and sets in early, and the body smells offensive. But disease may cause all these appearances. SUFFOCATION. Necroscopic signs not satisfactory. The Skin is generally of a uniform violet tint, with blackish ecchymotic spots. The Lungs fre- quently show punctiform ecchymoses and partial emphysema. The other organs are deeply congested. Suffocation, right side of the heart auricle and ventricle usually full of dark, clotted or fluid blood; left cavities empty; the conjunc- tiva may be congested or ecchymotic. The mouth often contains frothy blood and mucus. HANGING. Signs after death are those of suffocation. There is also the mark of the cord. This varies in position, depth, and appearance, accord- ing to the mode of hanging, struggles, weight of body, and material used. There may be only a depression, or the mark may be, after exposure, of a deep brown color. 18 rosT-xMOUTE.\rs. Examine the vertebrae lor fracture or dislo- cation, as of the odontoid process. The Tongue IS general!}^ swollen at the base, injected, and sometimes protruded. The penis is more or less erected, sometimes with emission; in females the genital organs are swollen and red. Faeces often expelled. DROWNING. Appearances vary very much, according to the mode of death; this may be from apnoea, exhaustion, syncope, apoplexy, shock, blow on the water from projection, cold, &c. , or any of these together. The Tonrjue is swollen at the base; the Skin is pale, with violet or rose-colored patches; Lungs, brain, kidneys, &c., congested; left side of Heart empty, right side full of blood. These are signs of apnoea. Special Signs of Drowning are— mud, sand, water-plants, &c., in the hands, nails, ears, nostrils, &c. ; fingers often excoriated. Water, &c., in the Lungs; this may, how- ever, enter after death ; water in the Stomach is a very strong presumptive evidence. Re- traction of the penis, cutis anserina, froth in the mouth and nostrils, ma}'' also be noticed. A chemical analysis of the water might at times afford valuable evidence. Submersion during Life or after Death. — Dr. Bougier, from experiments and autopsies at the morgue, formulates the fol- lowing conclusions: 1. The exterior aspect of the body is about the same in both cases. The appearance of moss on the body, weeds or sand grasped, in the hands would be of some diag- nostic value. 2. Water and foreign bodies penetrate into the air-passages and into the bronchial tubes of those submerged before, as well as those SIGNS OF nE.\Tir FROM VIOLENCE, ETC. 19 submerged after death ; hut in the latter the foreign bodies do not go beyond the fifth or sixth divisions of the bronchial tubes, and the liquid is arrested at the bronchi of medium size by the column of compressed air ; whereas, in the submerged during life, it penetrates doion to the small bronchial tubes. 3. The epiglottis is vertical in the sub- merged; it is only half open in the corpses immerged 4. Water penetrates in a pretty large quan- tity to the stomach of the former, but never to that of the latter (after death) ; and in making a comparative analysis of the liquid found in the bronchial tubes, one might arrive at a cer- tain diagnosis. 5. The same is the case with the middle ear. 0. The characteristic moss is found only in the submerged. 7. If the fluidity of the blood exists in cer- tain cases of poisoning by opium, it is easy by the aid of the spectroscope, and by analysis, to form the diagnosis. 8. In putrefied corpses, all the signs have nearly disappeared, and the medical jurist can only draw conclusions by presumptions. POWDER MARKS IN CASES OF DOUBTFUL SUICIDE. Dr. Fisk {Boston Medical Journal) concludes an able exposition of this perplexing subject thus: 1. From a great distance the entrance wound will usually be large and irregular; there loill be absence of any great degree of livid- ity of its edges, and absence of powder marks. The wound of exit, if one be present, will usually be larger than the loound of entrance. At any distance the edges of wounds of entrance wiU usuaUy be inverted, those of exit everted. 20 POST MORTEMS. 2. Prom a short distance the entrance and exit wounds will generally be nearly equal in size; the edges of the former will be blackened, and the powder grains will be im- bedded in the skin, but there will be absence of the scorchings and brandings of powder. 3. Close to the body the entrauce wound will general!}' be larger than the exit. There will often be, in addition to the tattoo- ing of the skin by un burnt grains of powder, a mark or brand made by the flame of the gases of the burning powder, by the soot of the partly burned powder and by the residue of ash of the wholly burned powder. As a rule this brand, which may consist of a burn- ing alone of the hair, the skin, or of the clothing, or of a burning and blackening of the skin or clothing, will appear at one side of the bullet hole. The position of the weapon is to be determined thus: When the brand appears upon the hair, the skin or clothing at one side of the bullet hole, hold the weapon with its muzzle to the bullet hole so that the line of its hammer and sight will meet a linedrawn from the centre of the bullet hole through the centre of the brand and it will show the exact position of the weapon when tired. Accidental Wounds are generally near wounds. When inflicted from a distance they cannot be distinguished from homicidal wounds. In shots fired near by, when a person is known to have been shot standing, an un- natural position of the weapon, as shown by the location of the brand, will tend to corrob- orate the claim of accidental shooting. So if one is knoicn to have shot himself an un- natural position of the weapon will show that the shot was probably accidental. The location of the wound and the course taken by the ball may also characterize the wound as acci- dental. SIGNS OF DEATH FROM VIOLENCE, ETC. 21 To distinguish Homicidal from Sui- cidal Wounds. — When the location of the brand, relative to the bullet hole, shows that the weapon has been held in a position of its hammer aud sight impossible or improbable for a suicide, it is probable that a murder has been committed. Certain relative locations of this brand may also indicate that the victim has been shot while in a re- clining position. Multiple toounds are usually homicidal, but may be either accidental or suicidal. Shots fired beyond the usual suicidal limit are prob- ably homicidal. It is said that the suicide rarely holds the muz- zle of his pistol more than eight inches from his body. Suicides generally fire at the side or front of the head, next to the heart; some- times at the back of the head. The distance from the body at which the weapon must be held to show the brand plainly is very nearly as follows: For small pistols and revolvers, not over four to six inches. For large weapons of this class, not over twelve or fourteen inches. POISONS. The necroscopic appearances in cases of poisoning are not always very decided, and great care must be taken to avoid drawing incorrect inferences. In some cases there are no post-mortem signs at all, and it is only when a strong corrosive poison has been taken that they are at all decided. The necroscopy in these cases must he per- formed loith extreme caution in the presence of om or 7)iore competent toitnesses. All instru- ments, vessels, and appliances of every kind must be scrupulously clean. The jars, bottles, or other vessels to con- POST-MORTEMS. tain the portions selected for chemical or other analysis should be washed out with water, then with strong sulphuric acid, again with water, and finally with distilled water. Stomacli. — Both ends of the stomach are to be securely tied up with double ligatures, se- cured by a pin to prevent slipping, and separ- ated by cutting between these. It is well, sometimes, to put it up whole in a jar for more leisurely examining it, or for a more competent person to do so ; it must be remem- bered, however, that the gastric juice may act on the coats and destroy them, it is therefore al- ways best to put the stomach and contents in separate vessels. If it is wished to examine it at once, put the contents in a clean jar; lay the organ on a clean flat surface, as a dish or piece of glass; open it along its smaller curvature. Look care- fully for leaves and seeds of plants, powders, &c. Tie both jars over with gutta-percha tissue, first putting a cork or stopper in if there is one, then a piece of white paper over this, and seal it so that they cannot possibly be re- moved without breaking the seal, and use a stamp that is not likely to be imitated; fasten a label to each jar or bottle, with the name of the contents, the date, and the signature of the necroscopist. The liver, kidneys, spleen, intestines and brain, or portions of these, should each be put in a separate vessel, and also carefully sealed and labelled. Where, however, the jars are taken straight to the analyst by the necroscopist, there is not so much w^ed to seal them, yet it is far better to do so in all cases. In making the necroscopy the intrusion of foreign bodies must be carefully guarded against, especially if they are of a metallic nature, as SIGNS OF DEATH FROM VIOLENCE, ETC. 23 pins, needles, nails, copper rings, bits of col- ored paper, pieces of sealing wax, &c. The accidental presence of any of these with the part to be analysed might spoil the whole analysis. 31^* Poisons may be introduced per rectum or per vaginam, or endermically and hypoder- mically. 2;^* Remember, Karcotics — as Opium, Belladonna, Ilyoscyamus, Camphor, &c. — give no satisfactory necroscopic appearances. Con- gestion of the brain has been met with, and a few other signs supposed to point to the cause of death. Belladonna, hyoscyamus, and camphor have each a peculiar smell, which may be more perceptible after gently warm- ing the contents of the stomach. The seeds of belladonna and hyoscyamus may be dis- covered. Alcohol, JEtlier, Chloroform, Hydrate of Chloral, c%c , produce inflammation of the stomach and bowels, and the characteristic odor of each will serve to distinguish them. Strychnia leaves no decided signs of its presence; the muscular spasm soon passes off, but the hands may remain clenched, &c. The Metallic Poisons show few post- mortem signs, nitrate of Silver is turned into chloride, which adheres to the mucous mem- brane in the form of curdy flakes, and the oesophagus and stomach are eroded. Copper causes inflammation, thickening, and sometimes ulceration of the mucous mem- brane, which is changed to a green color. The skin is often yellow. Antimony and Arsenic generally produce inflammation of the stomach and intestines, but not always. In arsenical poisoning the solid metallic oxide may be seen adhering in patches to the mucous membrane ; this often 24 POST-MOKTEMS. turns yellow, when decomposition sets in. by the formation of the sulphide. The contents of the stomach are generally of a brown color. Phosphorus. — This also produces patchy in- flammation, and particles of the substance may be found (as heads of matches, &c.) in contact. The skin is of a peculiar yellow tinge, and there is frequently extensive fatty degen- eration of the muscles, liver, &c. Various Salts of an irritant nature, when taken in large doses, may be poisonous, as Potassium Nitrate, Sulphate, Acid Tartrate, and Sulphide; Alum, Sodium Chloride, Chlor- inated Soda, Lime, Potash, &c. ; Barium Salts, also Iodine. These occasion inflamma- tion of the stomach and intestines, with secre- tion of a slimy mucus, thickening of the coats, hypersemia of the vessels; sometimes ulcera- tion. Potassium Sulphide deposits sulphur. Alkalies. — Sod. disease of the luDgs, pericarditis, &c. ; any of these may be a cause. In granular kidney the heart is almost constantly found enlarged. Atrophy. — Simple, with dilatation, some" times with contraction; in wasting diseases or as a congenital defect. Dilatation of the Heart, with atrophy, is most frequent on the right side, and chiefly affects the auricles; often a result of endo- carditis and disease of the muscular fibres. It is a serious disease. Dilatation with hypertrophy of the walls is not so serious; it shows a conservative ten- dency. The state of diastole may be mistaken for simple dilatation. Partial dilatation, or aneurism; contents of the pouches vary according to length of the ORGANS OF CIRCULATION. 33 disease; they may be blood, coagula, lami- nated fibrinous deposit, &c. The Coronary Vessels maybe congested or contain clots or purulent deposits; the walls may be atheromatous (cause of angina pec- toris), ossified, &c. Nerves of the Cardiac Plexus should be carefully examined. EXAMINATION OF ENDOCARDIUM. Open the heart by a V incision, with scis- sors which are inserted near the apex, one cut passing along the anterior groove, the other along the outer border, begin with the right ventricle. Examine the contents, and test the patency of the valves either with a stream of water or the fingers; aortic and pulmonary valves by a column of water in the vessels. Measure- ment of the orifices may be taken with a graduated cone or the fingers. Having examined the contents, state of the valves, &c., pass one blade of a long pair of scissors (enterotome) through the left ventricle up the infundibulum into the aorta, and di- vide where most convenient; the pulmonary artery may be opened in the same way through the right ventricle. Contents.— Clots. — Post-mortem are black or dark-colored, friable and humid, often covered with a fibro-albumlnous layer, not adherent to the parietes, with red corpuscles uniformly distributed through the clot. In the right ventricle and auricle the blood is buff anteriorly and red posteriorly: it is more fluid on the left side. Ante-mortem ('polypi ') are discolored, grey- ish or yellowish white, sometimes very white; have a fibrinous texture; are elastic, tenacious, resistent, more or less adherent to the walls, may be grooved by the passage of blood, 34 POST-MORTEMS. occasionally organised. Sometimes they are softened internally to a creamy consistence. The importance of clots in the heart is not very- great; ante-mortem generally show lingering death. Asphyxia is incompatible with the formation of ante- mortem clots. In sudden death the blood is gener- ally fluid. In apnoea the right side of the heart is gorged, the left nearly empty. Color of Endocardium. — When pink shows acute endocarditis and must not be confounded with post-mortem stainiog. Post- mortem redness, from deposition of blood pig- ment, is more diffuse ; there will be fluid blood in contact, and the coloring matter may be washed off or removed by maceration. Endocarditis. — Inflammatory redness (seldom seen post-mortem) is generally in patches, and remains permanent; there are also other pathological effects, as softening of the muscular structure, &c. Diffuse inflammation causes a silvery opacity from deposition oi fibrin. There may also be atheroma, shown by opaque cheesy patches or calcareous plates. The endocardium in the left auricle is nat- urally whitish, as it is thicker there. The results of endocaiditis are serious, as embol- ism, fibroid degeneration, and dilatation; inflamma- tion generally affects the valves. * Milky Patches' are signs of localised chronic inflammatory action, most probably of rheumatic origin, or from alcoholism. Granulations or Vegetations are formed by a tilting up of the superjacent endothelium from deposition of inflammatory products in the connective tissue; they may become cal- careous. Endocardial Ulcer.— Rare, always be- gins in a valve, may lead to perforation or aneurism, very rarely to gangrene. Is met with chiefly in cases of blood-poisoning, but whether secondary or primary is uncertain. State of the Walls.— Notice their thick- ness, size of the cavity, &c. Muscular struc- ORGANS OF CIRCULATION. 35 ture firm, friable, granular or lardaceous, fatty, &c. The muscular structure should be macerated in dilute acetic acid or alcohol, in order to examine it under the microscope; fibres being teased out by- needles and placed in glycerine. Tumours,— as lipoma, fibroma, carcinoma, cystic, tubercular, &c. — are sometimes met with, either embedded in the walls or project- ing into the cavity or from the surface. Fibroid Degeneration. — More common on the right side; substance is firm, leathery; cavity retains the form due to distension; most frequently associated with hypertrophy; it is generally a result of inflammation. Patty Deposition must not be con- founded with fatty degeneration. The latter is a serious affection; the former ('obesity of heart ') is not so serious, and is consecutive on general obesity; fatty deposition takes place on the surface of the heart and between the fas- ciculi, the muscular structure being histologi- cally unaltered, Patty Degeneration is always serious, the fat heing deposited within the muscular fas- ciculi — it is, in fact, a retrograde metamor- phosis of the normal structure, which is thus more or less destroyed. The patient may be thin, and yet have fatty heart. It is a cause of angina pectoris. This disease may be— 1. Oeneral; then usu- ally only slight. Muscular fibres paler, more flabby, break up easier, and leave a greasy stain on the knife. 2. Partial; the degeneration is more ad- vanced, but in patches, which cause a mottled appearance, the degenerated parts heing yellow or huff- colored, soft, Jiabhy, and rotten, with tendency to rupture or aneurism. Fatty degeneration occurs in alcoholism, some forms ^ of pleurisy and pericarditis, poisoning by phosphorus (in the latter case all form of muscular 36 POST-MORTEMS. structure may be lost, and its place taken by fat globules). Pigmentary Degeneration.— Muscular structure friable and of a brown color. This is a rare disease. Myocarditis (Inflammation of the Muscu- lar Structure).^MM^Q,\x\dkV fibres dark, soft, showing under the microscope at first num- erous leucocytes within and around the fasci- culi; in a later stage, pus. Generally results from pyaemia and infectious dis- eases, or from emboli in the coronary arteries. Chronic Myocarditis is more common, usu- ally as a result of rheumatism; it is often clearly traceable to syphilis, and leads to fibroid induration. The interior of the ven- tricle shows patches of a grey or pearly white color. In gummaceous myocarditis (tertiary syphilis) the majority of the muscuhir fibres are re- placed by fibrous tissue, with gummaceous tumours disseminated. These tumours are sometimes of a firm, yellow, cheeselike con- sistence, and may obtain the size of a pigeon's 'Cardiac Apoplexy.'— This term has been given to cases where haemorrhagic spots and extravasations of various sizes occur in the substance of the muscular tissue. Rupture of the 'H.Qd^rt.—Mod frequent on the left side, seldom at the apex ; generally the result of fatty or fibroid degeneration; sometimes caused by severe injury, as a blow on the chest. Gunshot wounds are not always immediately fatal; the patient may live for two or three weeks after. Cancer and other tumours are occasion- ally met with. VALVES. Auriculo-ventricular may be changed into an inextensible rins;, sometimes funnel- ORGANS OF CIRCULATION. 37 shaped, &c , contracted transversely, adherent to the walls, retroverted, &c. Structure may- be softer, atrophied, perforated (from ulcera- tion, then the orifice is surrounded with vege- tations); sometimes contains purulent matter or fatty substance; may be calcified, hyper- trophied, or granulated (vegetations); aneur- ism of the valves; hyematoma, met with in young children as small papilla containing blood. Contraction of the valves is generally caused by prolonged inflammation. There is a peculiar ten- dency for the valves to become calcified, as the result of long-continued disease. Aortic. — Adherent to the walls or one another, rolled up or thickened; free border, rugous, cartilaginous, or cretaceous; covered with warty vegetations (fibrinous or other deposits beneath the endothelium); pierced with small openings (fenestrated). Aortic valvular disease is infinitely more dangerous than mitral disease. Depositions of coagida on the valves may be mistaken for 'vegetations;' they may be dis- tinguished from them by being easily removed with care, leaving the valve whole; coagula often form on vegetations. AVERAGE SIZE OP THE ORIFICES. R. Auriculo-ventricular (tricuspid) =4:f inches, or 54*4 lines L. Auriculo-ventricular (mitral) ='^\h inches, or 44-3 lines Pulmonic =3^ ,, 40 Aortic . . =3| ,. 35-5 „ These dimensions vary considerably in dif- ferent individuals. SHAPE OP THE HEART. Globular— the right side larger than the left, met with in pulmonary obstruction, as emphysema or cirrhosis; also in mitral ob- struction, but then the left ventricle is hyper- trophied as well. 38 POST-MORTEMS. ' Bovine ' Heart— left ventricle much en- larged, seen in aortic obstruction. General Enlargement does not arise from valvular disease, but from obstruction in some remote vessels, as those of the kid- ney, &c. MALFORMATIONS. In rare cases there are only two chambers, in other cases three; origin of aorta and pul- monary artery from left ventricle; transpo- sition of vessels; absence of pulmonary artery; obliteration or destruction of aorta and per- sistence of ductus arteriosus) patency of the foramen ovale. None of these malformations has been proved to be the cause of cyanosis, which is still uncertain, though it may be associated with any of them. ARTERIES. The vessels should generally be slit up (small ones by means of a fine pair of scissors) and examined in- ternally, aorta sometimes as far as the iliacs. Before opening them, take the diameter either by the finger or a graduated cone. Lesions. — Hypertrophy, atrophy, dilata- tion (cylindrical, fusiform, or sacculated) or contraction of the aorta; arteritis; black or violet stains; atheromatous patches on the internal surface of aorta, or floating white cartilaginous plates in the arch ; aneurism of the aorta, which may burst into the trachea; sometimes the horizontal and vertical portions of the arch of the aorta are united; clots more or less obstructing the tube of any of the vessels, &c. Clots, when organized, should be carefully followed along the course of the vessels; in puerperal fever they often extend some distance. Narrowing of the Calibre of an artery may be congenital or from arteritis, pressure of a tumour, thickening of the tunics or car- tilaginous changes; it leads to gangrene of the part supplied. ORGANS OF CIRCULATION. 39 Narrowing of the calibre of an artery does not necessarily lead to gangrene of the part supplied by the vessel, unless it be a terminal branch. When the trunk of an artery is destroyed, the circulation is oftentimes restored through the anastomosing branches above and below the seat of injury. Arteritis, — {Hare), walls reddened, thick- ened, or sometimes thinned and friable, struc- ture being pulpy exudation of lymph blocking up the vessel (this may be purulent, albumin- ous, or fibrinous). Cavity narrowed, full of soft clots, &c. General arteritis is unknown. Chronic Arteritis or Atheroma. — Frequently associated with syphilis and as a result of old age. 1st stage, deposition of greyish translu- cent material in the intima; 2nd stage, fatty or calcareous degeneration. Sometimes fatty degeneration produces what is called an atheromatous abscess or ulcer. Aneurism. — 1. Dissecting, from rupture of inner and middle coats, due to atheroma. 2. Diffuse or general dilatation. 3. Saccular or true aneurism. Causes: ar- teritis, pressure, embolism, laceration. 4. Varicose, with or without a cyst. The contents of aneurisms should be care- fully observed; they may be soft clots or laminated fibrinous deposits. Intercranial Aneurisms. — Cause of convul- sions, apoplexy, paralysis, insanity, &c. Look for aneurism in all cases of large haemarrhage from mouth and nose ; note carefully condition of aorta. Arteries may rupture without dilatation, from fatty degeneration, atheroma, stenosis, etc. YEINS. Examined chiefly in cases of phlebitis, spontane- ous gangrene, varicose aneurisms ; they should also be examined in subjects affected with varicose veins, oedema, pulmonary embolism, purulent infection, &c. Search for varicosities, and see if they are in- flamed or softened ; examine the venous network at the upper part of the thigh; open the saphena. No- tice the uterine sinuses, isolate the utero-ovarian veins with the point of a knife, then open them ; do the same with the vascular plexus of the broad liga- ments and the ovarian veins. Soft and discoloured Phleboliths are sometimes found in the vessels here, attached to their walls by a thin pellicle; sometimes there is suppuration. 40 POST-MORTEMS. In Phlegmasia Alba Dolens there are clots or pus in the iliac or hypogastric veins, or in one of the principal trunks of the lower limbs. Phlebitis, Principal Alterations in.— Coagulation of the Blood. — This is often a cause, not a sign, of inflammation; there may be coagulation without inflammation. These Clots are various; wine color, grey or whit- ish, fibrinous, adherent to the walls or not; resistent or breaking down under pressure; containing pus (second period), grumous (later) ; pierced by a central canal. Walls reddened at first, afterwards white, swollen; cavity dilated; the vessel is some- times moniliform; adherent to surrounding cellular tissue, often with phlegmonous in- duration (the vessel then feels like a cord). Internal tunic may be red or white (accord- ing to degree of inflammation), rough, opaque, thickened, softened, friable, ulcera- ted, &c. Observed in pyaemia, poisoning (by dyes, &c.), injuries, &c. Thrombi from phlebitis, by forming emboli, are often a cause of ' metastatic ' abscess, as in the liver, kidneys, lungs, brain, &c. Pus in Veins. — Suppurative PJilebitis, from an abscess bursting into a vein; in cases of pyaemia, caries, bubo, &c. Primary suppura- tive phlebitis is rare. Adhesive Inflammation.— This may be primary, as in old people, or from the pres- sure of a tumour, but it is generally due to a thrombus. Phleboliths are calcareous particles which obstruct the veins; they are derived from degenerated coagula. Thrombosis is of importance. A clot ormed before death in situ is a thrombus; ORGANS OF CmCULATION. 41 may be distinguished from post-mortem clots by — 1, adhesion to the walls; 2, organization; 3, decolorisation ; 4, deposition of leucoc3^tes; 5, stratification. Met with in disease of the heart, cholera, leuksemia, Bright's disease; from pressure on a vein; varicosity; or en- trance of pus from an abscess into a vein (rare), &c. The thrombus becomes hghter in color, drier, firmer, and more adherent, by age. Embolism, — Obstruction of a vessel by particles of coagulated matter from a distant part. Originates from thrombi, ' vegetation ' from heart, portions of new growth, para- sites, pigment granules, &c., escaping into the circulation and being carried to some dis- tant part. Produces either necrosis or en- gorgement from obstructing the circulation. Plugging of the basilar or other artery of the brain causes paralysis and red softening of the brain; of the pulmonary, asphyxia; of the coronary, paralysis of the heart. Collateral circulation may be established; if it be not, then there is necrosis. The part which has been cut off is surrounded with a very characteristic zone of intense hyperaemia. Hsemorrhagic Infarcts may form from impaction of an embolus, escape of blood, and formation of a thrombus; often met with in the lungs, spleen, and kidneys. They are firm, wedge-shaped masses of a dark red color. LYMPHATICS. Inflammation.— Red line and swelling along the course of the vessel. This redness generally subsides after death. Walls thick- ened, opaque, less resistant; cavity dilated, may contain clots or even pus; abscesses sometimes form along the course of the ves- sels. Surrounding cellular tissue infiltrated with a sero-albuminous, half-concrete fluid. 42 POST-MORTEMS. It 18 never primary, but always follows some inflammation of the surrounding connective tissue, as from metritis, abscesses, poisoned wounds, &c. Chronic affections of the lymphatics are found in cancer, tubercle, scrofula, &c. Lymphatic Glands, — Morbid changes are nearly always secondary. Hj^pertrophied in phthisis, secondary and tertiary syphilis, typhoid fever, glanders, &c., mostly in the axillary, cervical, and thoracic regions; some- times soft, sometimes hard (syphilis). Tume- fied, red, soft and friable, or suppurated {Acute inflammation). Swollen, adherent to surrounding tissue, containing a caseous mass like raw potato; this sometimes softens and becomes like pus, or it may calcify {Tubercu- lar degeneration). Cancer. — Eare as a primary, but common as a secondary, affection. Syphilis.— Something like tubercular dis- ease, only the glands are not so enlarged. Other Changes.— Calcification, melanosis, epithelioma, amyloid degeneration, &c. Lymphsenoma. — Enlargement of the glands from hyperplasia of their elements; they ma}^ be soft or hard. When associated with anaemia and affections of the liver, spleen, &c., it constitutes Hodgkin's disease. The glands often retain pigments and poisons in- troduced from without. V RESPIRATORY SYSTEM. In penetrating wounds of the thorax note first the size , shape and direction of the wound in the skin and chest- wall ; second, the exact location of the wound; third, the in- ternal wound, structures injured; fourth, the RESPIRATORY SYSTEM. 43 general direction of the wound compared with the point of entrance; fifth, whether the wound is recent or inflicted some days prior to death. Before removing the Lungs, notice the form of the pleural cavity; if encroached on by the liver, stomach, &c. ; search for fistu- lous openings, especially in pneumothorax. If this was suspected before death, run a tro- car in before opening the thorax, and notice the rush of air . The amount of this can easily be measured by allowing it to escape into an inverted measure glass filled with water and standing in a basin or pail; press up the diaphragm to get as much air out as possible. If there is any fluid in the pleura, state its nature, quantity, and appearance. It may be measured by means of a glass tube with an elastic ball at the end ; by compressing this ball, and allowing it to expand, the smallest quantity of fluid may easily be removed, and if the tube is grad- uated it can be read off at once. Examine the mediastinum for cancer, haemorrhagic effasion (from bursting of an aneurism, &c.), acephalocystic tumours, ossi- flc plates, air (as general emphysema of infants), abscess of lung opening into the pericardium, &c. Feel carefully round the walls of the chest for fracture of the ribs (and compare the seat of these with disease of lung or pleura); look for osteophytes (old-standing pleurisies); abscesses; tumours (as cancer) in the inter- costal spaces, &c. Remove the Lungs thus :— Divide the tra- chea and oesophagus as high as possible; sep- arate all adhesions, drawing the lungs down- wards and forwards; then sever their connec- tion with the diaphragm. If the lungs are adherent to the walls, they must not be torn away, but the costal pleura is to be care- ully detached with them. 44 POST-MORTEMS. Notice the external shape, appearance, extent of hypersemia (post-mortem hypostasia will give evidence of the position of the body at and after death). Examine the edges, the base, and the apex; press with the fingers, in order to estimate the consistence, induration, elasticity, &c. Attach a blow-pipe to the trachea and inflate; see if the whole lung is permeable to air; then let the air escape; this will give an idea of the elasticity of the tissue. Inflation will also detect fistulous and other openings between the lung and the pleura, &c. When the lung is suspected of being per- forated, but no opening can be seen, put the whole lung under water and inflate; bubbles of air will escape from the injured part. Pass the long blade of a pair of scissors into a bronchus and follow the ramifications of the bronchi; this is better than simply incising the lung. LARYNX, TRACHEA, BRONCHI. Mucous Membrane.— Red and swollen, with much mucus {la7'i/}igitis, catarrhal, syphi- litic, &c.), greyish, thickened with muco-pus {chroniclaryngitis); oedematous {o&dema gloiti- dis, in children especially, also in Bright's dis- ease, &c.) (Edema is always less apparent after death than during life, and the only evidence of it may be a wrinkling of the mucous membrane. Suppuration (often secondary to erysipelas, &c.); plastic exudation in the larynx or trachea (croup, cynanche tracJiealis, diphtheria), in the bronchi (plastic bronchitis; this is a rare disease; the exudation may take a cast of the bifurcations in an arborescent form). Yellowish white, opaque and viscous or puru- lent mucus (chronic bronchitis); surface vel- vety or granular, bluish (a sign of suffocation), RESPIRATORY SYSTEM. 45 reddish, violet, slate-colored (different forms of bronchitis); thickened, thinned, softened, &c. Various Lesions. — Foreign bodies (with inflammation) ; ulcerations^ syphilitic — small, rounded, yellowish nodules with much fibroid formation, chiefly at the edges of the epiglot- tis; if severe, there may be a shaggy or floc- culent appearance ; tubercular — in early stage as small corpuscles, then ulcers which from coalescence of small ones become large and deep, chiefly near the glottis; typhoid — rare in this country, situated at the back of the larynx, generally a result of gangrene. There may be dilatation, this being either general or saccular; thinning; obliteration; perforation; or contraction (from pressure within or without); ossification of the carti- lages (senility). Various tumours, as mucoid, fibroid, chondroid, &c. Bronchial Glands.— May be red, black, tumefied, tuberculous, cretaceous, or cancer- ous. The Bronchi are opened by means of very fine scissors with unequal blades {proncho- tome), or by a director introduced into the tubes and a blade of an ordinary pair of scis- sors, or scalpel passed along it. In Dilatation search for the cause ; this is generally obstruction from cretaceous or scrofulous matter blocking up a bronchus, or from condensation of lung tissue; it is often met with in asthma. Parasites are never met with in the air passages of man as a disease; if found, they have been intro- duced accidentally since death. Bronchitis. — Redness of mucous mem- brane, from a bright red to a purple color; swelling. Secretion of viscid or purulent mucus, this oozes from the tubes on section. 46 POST-MORTEMS. In infants death may be from sudden effusion, causing suffocation. Always open the bronchi, and especially examine the smf. ler tubes, as these may contain purulent matter, &c. Chronic BroncMUs. — Mucous membrane may be deep red, violet or slate-colored; sometimes thickened, at other times thinned and reticulated. The bronchi are filled with thick mucus or muco-pus; in long-continued bronchitis this secretion may be offensive and of a dark color. It is often associated with emphysema and hypertrophy of the right side of the heart. PLEURA. Color. — Red (costal layer in acute pleurisy), citron, opaque (pneumonic layer in acute pleurisy), semi-opaque, yellow (chronic pleu- risy), greenish (last stage of phthisis). Contents. — Clear serum {chronic pleurisy)^ may cause carnification and atrophy of lung from pressure ; may be ascitic fluid (in general dropsy); thin layer of lymph, easily peeled off {eardy stage of pleurisy) \ thick layers are generally superimposed layers of varying con- sistence, sometimes it gets like cartilage {old- standing pleurisy)-, abscess — pus contained in a sac formed by lymph ; this may burst through the chest or into lung; adhesions — from or- ganization of lymph ; ossific deposits as true or false bone ; layer of fat (rare) ; cancer is always secondary, as hard, white, flat, and smooth scattered patches; blood — from fractured ribs, rupture of aneurism, purpuric state, &c. ; air — pneumothorax, from disease mostly, as burst- ing of a small abscess in, or injury to the lung, often the cause of sudden death; con- tents of stomach from perforating ulcer; tubercle (rare, always secondary), as miliary granulations, which may become confluent and cheesy by age. RESPIRATORY SYSTEM. 47 LUNGS. Hypertrophy ; this state is often uncertain when one lung is wasted or destroyed, its fel- low may become considerably hypertrophied ; atrophy (from pleurisy, &c.). Color. — The normal color is grey when the lung is deprived of its blood; in disease it may be greenish, bluish, livid, rose red (also in infancy), pale ^^ellow; slate color, from breathing air loaded with carbon, as coal dust; claret color; brown, from particles of hsematoidin in passive pulmonary congestion. Consistence. — Density and elasticity diminished or augmented. Condensation {atalectasis, a return to the foetal state) is either congenital or arises from pressure, or want of power to expand, dis- tinguished from hepatisation by the surface being depressed and not granular. Splenisation — lung substance softened, red- dened, serous. Hepatisation — red, solid, like liver, granillar on section, sinks in water; grey hepatisation, or carnification, color paler, more solid. Hypermmia — lung solid, brown sometimes, in long continued congestion, moister in more recent (not to be confounded with post-mor- tem hypostasia, which is darker and forms on dependent parts). Friable, softened, en- gorged; more crepitant than natural, as in emphysema. Emphysema — may be either interstitial (sur- face appears studded with beads) or vesicular (projections from surface that on section are like a sponge, met with in old-standing bron- chitis and phthisis). Induration or cirrhosis — from fibroid chan- ges, a result of chronic inflammation; fibroid induration, with cavities and 'tubercles' POST-MORTEMS. (sometimes called ' chronic pneumonic phthi- sis,' but it is properly chronic pneumonia); pigment induration — lung dark, dry, and firm, in some cases of heart disease; gangrene — lung broken up, fetid, fluid of a dirty green- ish color. Adherent to diaphragm, ribs, &c. Morbid Products. — Miliary granulations; cretaceous tubercles; tubercular or syphilitic cicatrisations (it is difficult to distinguish these from each other); gummata of tertiary syphilis are grey, cheesy, irregularly shaped ; ulceration, abscess (pysemic, phthisic, inflam- matory, &c.), perforations (from ulceration, injury, &c.); cavities; mdema — the lung is heavier, denser, and somewhat translucent, a frothy fluid escapes on section (in dropsy and Bright's disease); pigmentation, spurious melanosis or miner's phthisis — the lung tissue is quite black, either in patches or through- out, from deposit of carbon, probably from smoke or fine dust; the iung may also be in- filtrated with powdered glass (in glass work- ers), with metals (as in knife grinders), with silica, &c. Cancer, medullary (primary rare), epithelio- ma (secondary); sarcomata, osteo-sarcomata, enchondromata, lymphomata; hydatids (hav- ing escaped from the liver through a perfora- tion). Apoplexy of the Lung. — Hmmorrhagic infarction, — Blood is effused in the pulmonary parenchyma, coagulated, of a dark color; it sometimes produces inflammation. The part affected is of a globular or wedge shape, with the base towards the surface ^ varying in size from a pin's head to an orange, and consisting of a cavity bounded by comparatively healthy tissue. RESPIRATORY SYSTEM. 49 Endeavour to trace the burst bronchus ; the artery leading to the part will be found plugged by an em- bolus or a thrombus from an inflamed vein or from ^vegetations' (clots) detached from the valves of the heart. Emphysema. — Interstitial or Interiohular is rare, most frequently associated with gen- eral emphysema; it is also seen in children who have died of some long-standing bron- chial affection. The lung surface appears studded with beadlike bullae. This condition is not apparently of very great im- portance. Vesicular is the most common form. It is due to dilatation of the air vesicles. The lung feels somewhat doughy on pressure, does not col- lapse, and is dry and exsanguine. Bullae, or apparent projections of lung substance, are seen on the front surface of the lung; on section these parts are like a sponge. It is mostly associated with chronic bronchitis and dilatation of the right side of the heart. Phthisis, Lesions in.—Lung changes are found most and more advanced in the upper part of the organ. I. Lungs. Miliary Granulations. — First stage, isolated or joined together, grey and semi-transparent; 2d stage, yellowish white and opaque; 3d stage, 'Tubercles' (caseous matter), softened (with or without infiltration of the pulmonary parenchyma), suppurated or transformed into cretaceous, puriform, or greenish yellow, souplike matter (gangrene). Cavities (vomicae), more or less large, nearly empty, or filled with a white, j^ellow, grey, green, purulent, sanious, inodorous, or fetid liquid; their walls softened or indurated, regular or broken up, or beset with pseudo- membranous deposits ; with consecutive pneu- monia around them; fistulae, etc. II. Pleura. Concomitant Alterations. — Adhesions to the lungs by cellular, fibrous, or 50 POST-MORTEMS. cartilaginous bands; pleuro-pulmonary fis- tulse. Air passages in general. — Bronchi dila- ted either uniformly or limited to small areas. Ulcerated by tubercular granulations; bron- chioles are sometimes closed and form hard cords, traversing the vomicae. III. Digestive Organs. — Mouth, pharynx, and stomach inflamed; intestinal mucous membrane thickened, thinned, softened, or injected, covered with granulations (tubercu- lar, semi-cartilaginous). Biliary Organs — Liver fatty, hypertrophied, punctated v^ith red spots; bile pale, fetid. Bronchial and Mesenteric Glands, hypertrophied, softened, containing tuberculous granulations. Ner- vous Centres. — Miliary granulations dissemi- nated, or in layers, in the pia mater and en- cephalon; also surrounding the vessels, and in the choroid plexus. PNEUMONIA, Lesions in.— Croup- ous or Lobar Pneumonia. I. Stage (^71- gorgement). — Colour of the surface of the lung is violet, livid, or claret color. Floats on v^ater and is permeable to inflation, but it is more bulky, the density and weight are a little augmented, there is crepitation, but less than natural, and the elasticity is diminished, the finger can easily be forced into the paren- chyma (this distinguishes it from simple oedema). Its cut surface yields a liquid which may be serous, reddish, muddy, or spumous. II. Stage {Hepatisation). — Color of the surface of lung is a distinctly pronounced dull red, uniform or marbled (from absorption of blood or coloring matter). There is aug- mentation of volume, it does not float, cannot be inflated, and there is loss of crepitation, the lung substance is hardened, carnified, of a consistence like the liver, or the spleen (spleni- sation); it is friable. When cut. — Clean, dry, RESPIRATORY SYSTEM. 51 presenting red, hard, rounded, or flattened granulations (these being the plugs in the air vesicles). Liquid escaping from the Incisions (especially by pressure), is small in quantity, red, opaque, thick, and muddy. III. Stage {Grey Hepatisation). — Colour of the surface is grey or pale yellow; darker in old people, in children almost white. This last state is generally congenital, and is almost always due to syphilis. Sinks in water, impermeable to inflation; volume either augmented or decreased ; there is induration with very great friability, but less granular than in the last stage. Liquids escaping from Incisions. — Matter resembling pus; phlegmonous, reddish, inodorous, or fetid pus. Sometimes there is slight pleurisy with a layer of lymph. IV. Results. — Abscess, with an unbroken cavity, or irregular walls; simple or multiple (pysemic, phlebitic). Gangrene, either diffuse or circumscribed. Color in gangrene, vari- ous shades of green, brown, or black; sur- rounding parenchyma infiltrated with ill-con- ditioned pus. Texture softer and moister. Absorption. — Cells become granular and fatty, then absorbed or expectorated. This gives a purulent appearance to the sputa. The lung substance in this state is often so soft as to be broken up on removal. Y. Concomitant Alterations. — Pleurm almost always more or less inflamed. Bron- chi full of mucosities or dilated into pouches containing a purulent liquid. Bronchial Glands swollen, red, softened. Heart with fibrinous clots in the cavities (sign of s)ow death). Gastro-intestinal Mucous Membrane softened. There is nearly always some pre-existing chronic disease of one or more of the other organs in pneu- monia. The absence of chlorides in the urine may clear a doubtful case even post mortem. 52 POST-MORTEMS. Catarrhal or Broneho-pneuraonia {form of Inflammation of the Lungs in Chil- dren). — Inflammation is limited to single lobules, or groups of lobules; the lung is solidified only in patches; these have a ten- dency to become chronic and are then yellow- ish, dry, and crumbling, so that there is an appearance of spots varying in size from a pin's head to a pea, either yellow or puriform ; this is very characteristic. Often met with as a sequel of measles, especially in adults. There is a peculiar form of pneumonia caused by inhalation of particles of food which decompose and cause inflammation or gan- grene. This is chiefly met with in the insane, and especially in those who have been fed artificially. Interstitial or Chronic Pneumonia. {Cirrhosis), — There is an acute form of inter- stitial pneumonia, but it is very rare. Gener- ally unilateral. Lung is smaller, parenchyma dark grey or yellowish, smooth, dense, firm (almost cartilaginous), irregularly mottled with black pigment; bronchi dilated. The normal tissue is replaced by a dense fibrous growth. May lead to ulceration and exten- sive excavations, or gangrene. This was for- merly termed 'chronic pneumonic phthisis.' Generally a sequel of some affection of the bron- chi, or pleuritic, phthisic, or syphilitic inflammation of the lung. Typhoid Pneumonia.— There is hyperse- mia, and a spotted appearance of the lung, both externally and internally; chiefly at the posterior part, where there is also consolida- tion. Cheesy Pneumonia.— The lung passes through the three first stages of pneumonia, then the lobules are blocked up by ephithelial elements which undergo fatty degeneration DIGESTIVE APPARATUS. 53 or caseatioD. In an acute form this consti- tutes the so-called 'galloping consumption.' LUNGS IN NEW-BOKN CHILDREN. Not Respired. — Lungs like liver, of a uni- form colour; surface marked by slight fur- rows. Respired (or inflated). — Ah cells are a bright red colour if fresh and filled with blood; if they contain less blood, and are examined some time after death, they are of a lighter colour. Hydrostatic Test,— Q^oi entirely reliable, but still valuable). An unrespired lung sinks; but if decomposition has set in it may float from the contained gases. On the other hand, a respired lung may sink from disease; though some parts would float. Press the piece of lung firmly in a cloth, so as not to injure it; if it still sinks it has never been respired or inflated. Part of the lung ma}^ have respired. VL DIGESTIVE APPARATUS. MOUTH. Malformations, corrosions (poisoning by caustics, etc.), injuries, marks, etc. The mu- cous membrane is a dark purple colour in cases of suffocation, etc. InfLammation (stomatitis)— gums swollen in nodules, coated with thick tenacious mu- cus, papillae prominent. In chronic inflammation the gums waste and seem hard and polished; ulcerations; diphtheritic and croupous exudations. AphthouH ulceration due to a fungus (pidium albicans). 54 POST-MORTEMS. Small-pox pustules. Gangrene {cancrum oris or noma), a foul- smelling black patch, which becomes grey and sloughs. Tumours. — Fibromata, sarcamata, osse- ous, myeloid, angiomata, adenomata, papillo- mata (' epulis ' and * ranula ' are old, worn-out terms), epitheliomata, polypi (local hyper- trophy). Examine the roof of the mouth for fissures, ulcerations, tumours, etc., of the soft and hard palate. TONGUE. Hypertrophy {macroglossis), atrophy. Wounds caused by the teeth in spasms or convulsions may furnish important evidence as to the symptoms preceding death. In inflammatioa {glossitis), it is swollen with prominent papillae. Ulceration is either simple or syphilitic; the latter with condylomata or as deep superficial ulcers with hard walls. Cancer. — Scirrhous is nodulated; epithe- lial has ragged, everted edges. Hydatids are rare. Ranula is a cystic tumour caused by ob- struction of Wharton's duct and retention of the secretion of the submaxillary gland. PHARYNX. Inflammation {cynanche tonsillaris, ton- sils swollen); suppuration {quinsy). The tonsils become permanently enlarged after re- peated attacks of inflammation. Syptiilis. — Callous, well-defined, excava- ted ulcers with a greyish floor (' secondary '). Unsymmetrical, deep, more extended, with gummatous thickening of the neighboring tis- sue (* tertiary.') Croup. — Mucous membrane in the early stage is inflamed, then effusion of liquor san- DIGESTIVE APPARATUS. 55 guinis takes place, and afterwards a deposit of a fibrinous matter, which forms the ' false membrane ;' this often extends from the larynx to the bifurcation of the trachea. Diphtheria is not easily distinguished from croup, except by being more severe, sometimes causing sloughing, and by being deeper seated in the substance of the tissue, so that the false membrane cannot be removed. (ESOPHAGUS. Lesions are not frequent, it may be wounded from without or within. Dilatation — either partial and sacciform or general, sometimes like a second stomach. Contraction arises from pressure of tumours, cicatrisation of ulcers (syphilitic or others), poisoning by caustics or cancerous deposit in the walls. Inflammation — mucous membrane is swollen and granular, with uniform redness (rare as an idiopathic affection). The mucous membrane is normally a pale grey colour. Ulceration — generally in the form of clean cut, round ulcers sometimes with jagged edges; simple or syphilitic (in latter case with gummata). Perforation — often connected with an- eurism of aorta, which bursts into the oesopha- gus; sometimes joined to the trachea. Tumours. — Cancer — sometimes medulla- ry, rarely scirrhous, mostly epithelioma. This last appears as a circumscribed growth on one side, sometimes of a warty nature. Warty growths, cysts, myomata. The oesophagus may contain foreign bodies as a mass of food, bones, false teeth, etc., which may pierce the aorta. STOMACH. The size of the stomach varies consider- ably in health ; the following table is the mean of several measurements: 56 rOST MORTEMS. Inches. Transverse diameter 9 to lOX ) Vertical diameter 4 " 5 VDistended Anteroposterior 3 " 4 ) Inches. Transverse diameter 7 to 8 ) Vertical diameter 2^ " 3^ V Empty. Antero-posterior J^ " ^ ) Before opening i^lace a ligature at each end, preventing it slipping off by passing a pin through the coats; then inflate; notice the state of the walls. Put the contents in a bottle, if for medico- legal examination, and seal up at once, or put up the whole stomach without opening. Never open if poison is suspected, Leave opening for the chemist. Open the stomach along the les3er curva- ture, and spread it on a glass or porcelain plate for examination, then wash with a fine stream of water. Appearance of the Coats. -Color.— The, mucous membrane at death is pinkish white or ash-colored ; about five hours after death it becomes rose yellow. A hyperoemic state is frequently seen independently of the action of corrosive poisons, especiall}^ in heart dis- ease; during digestion or alcoholism; bluish white, grey, slaty or yellowish, from fatty degeneration of the epithelium {chronic gastri- tis); reddish brown, puckered {chronic gastri- tis, pellagra, etc.); rugae studded with red or brown spots in haemorrhagic elfusion and yellow fever. Mucous membrane ivan^iorva^iCL into detritus of a chocolate, black, or yellowish color {poi- soning by arsenic, etc.); mammillated (chronic gastritis, poisoning by a^mmonia.) Thickness and Con^istGn.QQ.~- Atrophy — post-mortem thinning must not be con- founded with disease. Inflamed — swollen, intensely red (rarely seen post mortem), sur- face covered with thick mucus. Catarrhal DIGESTIVE APPARATUS. 57 inflammation causes at first a slaty color, with swelling and softening; afterwards induration and hypertrophy. Morbid Productions.— Fungous vege- tations. Mucous polypi {sarcomata)', hyper- trophy of the villi round the glands, and of the glands themselves with hypertrophy of the muscular tissue. This state is often met with in drunkards. Plates or mammillse of a reddish brown or slaty grey color (chronie gastritis or catarrhal inflammation). Pus or blood injecting the mucous membrane in an arborescent form. Fibrinous exudation {croupous gastritis) rare, met with in croup, typhus, pyaemia, etc. Gangrenous patches nd infiltration with can- cerous or melanotic matter. Tubercle is ex- ceedingly rare. Cancer. — Scirrhus is the most frequent form of cancer, distinguished from simple induration (sarcomata or fibromata) — 1, by the nature of the cells and cell loculi; 2, by the submucous cellular tissue being increased in substance; 3, by affection of the lymphatic glands. Medullary is occasionally met with in the form of bleeding fungous excrescences. EpitTielioma only as extension from the oesophagus Colloid rarely. Various Alterations.— Ukers and scars, either simple, with perforation, or multiple; with adhesion to neighboring organs (cancer). HcBmorrliagic Effusion into the mucous mem- brane is very common, chiefly on the summit of the rugae in the form of clots, which are brighter or darker according to age. Softening is not so important as was for- merly thought, being generally post mortem from the action of the gastric juice; if pro- 58 POST-MORTEMS. duced during life it is seen chiefly where food is (cardiac extremity and fundus); when perforated during life, there are signs of in- flammation and gradual thinning round the hole (which is as if a piece had been punched out). Death after perforation is either from haemorrhage or peritonitis. Heematemesis may be from an exceedingly small perforating ulcer. Amyloid degeneration is occasionally met with. Notice the changes in relation to other organs; narrowing of orifices, etc. •There may also be distension by gas ; dilatation with or without "hypertrophy (chronic or rapid). Atrophy and retraction; bilocular stomach, or partial stran- gulation ; hernia through the umbilicus or diaphragm. Abnormal Contents.— 1. Intoxicating liquids; poisons; leaves of plants (as yew tree, which are needle-shaped). 2. Fathologic Liquids — mucus, thick, viscid, ropy or yellowish, more or less adherent to the mucous membrane; black liquid like soot (blood-clots); mixed with food or not; like coffee (plague); sanious or fetid (cancer, phos- phorus); lumbrici; foreign bodies, as sealing- wax, nails, buttons, pipe shanks, etc. Torula cerevisiw (yeast plant); aphthae; sarcina ventri- culi, etc. Corrosive Poisons. — Actioji of bichloride of mercury causes a slate color of the mucous membrane. Arsenic, a yellow color, portions of the poison may remain as a white powder. Orpiment and Scheele's green leave a green stain, etc. Mineral Acids. — Greenish, yellow, brown or black glutinous secretion, rugae softened; ulceration and perforation frequent. Sulphuric Acid often bleaches the mucous membrane, which then appears as if coated with white paint. DIGESTIVE APPAKATUS. 59 Nitric Acid changes the mucous membrane to yellow or green; perforation is less fre- quent than with sulphuric acid. Alkalies produce inflammation, abrasion, and ulceration ; and change the mucous mem- brane to a dark or tawny pulp; perforation rare. Oxilic Acid, mucous membrane pale, free from rugae, sometimes inflamed; vessels in- jected. Nitrate of Potash, inflammation and black patches. Alcohol, deep crimson or dusky red. Garholic Acid somewhat tans the mucous membrane. Post-mortera Softening and Perfora- tion. — Thinning, with arborescent black ves- sels running over the part alfected; there is usually a kind of water-mark limiting where the contents have acted on the coats. The opening is generally at the cardiac end; the liquid effused is chymous, and the organs in contact are softened without surrounding inflammation; the edges are thin, ragged, shreddy. Circumstances producing these changes uncertain. PERITONEUM. Inflation. — Sometimes it is necessary to inflate the lesser cavity of the peritoneum; this is done by introducing a blow-pipe through the foramen of Winslow thus: raise the liver, carry the finger from right to left to the neck of the gall bladder and follow this up Contents.— I. Liquids.— M^ij be trans parent or not; limpid; frothy; flocculent albumino-fibrous {chronic jperitordiis); of an oleaginous consistence; yellow-citron color greenish, etc. II. Liquids Mixed loith oilier Matters — faecal 60 POST-MORTEMS. stercoraceous {peritonitis by perforation m^ rup- ture). Bile, following wounds and rupture of the gall bladder. Urine, from rupture of the bladder. Pus, chronic peritonitis, or by bursting of an abscess of the liver, uterus, spleen, iliac fossae, bladder, etc. Blood, liquid or coagulated, mixed with serous effusion (haemorrhagic peritonitis, or from rupture of an aneurism, etc.). Oases, air more or less rich in oxygen, carbonic dioxide, or hydrogen sulphide. Foreign Bodies. — Pathologic. — Miliary tubercles as semi-transparent grey granula- tions diffused generally, but more abundant on the surface of the diaphragm and spleen. Cancerous Tuynors, encephaloid or colloid, may spread over the entire suiface. Fibrinous bands, joining various parts into one mass. Encysted abscess; blood cysts. SuperfcBtation may take place — 1, in the fallopian tubes; 2, in the ovaries; 3, in the walls of the uterus; 4, in the vagina; 5, in the peritoneal cavity. Hydatids may be loose or encysted. Biliary oi* urinary calculi, or intestinal worms, may escape through the walls of the abdominal organs into the peritoneum. Acci- dental — received from without, as projectiles, debris of instruments, etc., needles, etc., swallowed. Chief Alterations. — Mesentery and Peri- toneum. — Grey, slaty {chronic phlegmasia), red (with injection of mesenteric vessels), brown, blackish, bluish (certain forms of chronic peri- tonitis), light and whitish; infiltrated with serum, pus, blood, etc.; fatty; thickened, thinned, covered with plastic exudations; dis- seminated miliary granulations {tuberculosis)', DIGESTIVE APPARATUS. 01 charged with black matter {melanosis, but probably pigmentary remains of old inflam- mation) ; cancerous patches; ecchymosed spots {poisoning by phosphorus)-, pus, urine, etc. Hernia; shrivelled; cystic tumors; congeni- tal deformities. The Omenta. — Adhesions to neighboring organs, to abdominal walls, etc. ; red, violet, wine color (peritonitis from hernia, omentitis)', black, tumefied, thickened, infiltrated with plastic matters, blood, pus, etc. Gangrene. Surface villous or granulated (simple acute peritonitis). Hernise. Simple Acute "Bevitonitm,— Peritoneum may be dry, sticky, humid; injected, of a bright red color, especially along the intes- tinal folds; softening; plastic exudations causing adhesions, etc. Liquids effused (especially on the posterior walls), white, milky, yellow, green, muddy, flocculent, sero-purulent or purulent, mixed with bile, faecal matters or blood. Try to trace the cause of the inflammation, gener- ally it is from disease of some organ covered by the membrane. Puerperal. — Inflammation chiefly in the lesser pelvic cavity or around the uterus and its annexes. Tiie peritoneal and sub-perito- neal cellular tissue is red and infiltrated with pus. Liquids effused are muddy, flocculent, sanious, and fetid, nearly ahcays purulent. The peculiar odor is very distinctive. Search for the cause in the uterus, uterine sinuses, etc. ; may be pieces of decomposing membrane or placenta. Consecutive Peritonitis— following in- jury, etc. — redness less vivid. May be local, as over syphilitic affections of the liver, uter- us, etc., or over inflammations of the stomach, herniae, etc. Chronic Peritonitis— more often idio- pathic than the acute. There are formations 62 POSTMORTEMS. of false membranes (mostly on the surface of the liver); the peritoneum is thickened, often matted together, greyish, blackish, soft, fri- able. Liquids effused are sero-albuminous, white, opaque, semi purulent. Tubercular Peritonitis.— Not so fre- quent as was formerly supposed: it is gen^r- ally secondary, but sometimes primary. In the form of disseminated miliary tubercles which are found mostly under the diaphragm. Three forms — 1, with ascites; 2, with semi- organized lymphatic effusion; 8, with consid- erable adhesions to the intestines, and ulcer- ations. INTESTINES. Notice all abnormal relations and condi- tions carefully in situ. In cases of injury, or death from hernia, open the abdomen first at these parts. Begin the extraction with the duodenum ; sometimes it is advisL ble to leave the rectum. Tie up each end of the intestines, and let them fall, as they are removed, into a pail of water. When drawing tliem out to examine and open them, pass one end under the handle of the pail; this disentangles the intestines and lim- its the section. Some recommend filling the bowel with water before opening— this is useful wiiere perforation is suspected, as in dysentery, enteric fever, etc. — but it is not always well to do this, as it < isarranges the contents, and must certainly not be done in cases of suspected poisoning, nor where there may be ento- zoons, pus, blood, etc. The exterior must be first carefully ex- amined, and specially diseased parts removed. In opening use an enterotome, and do not cut along the free edge, as Peyer's patches are situated there, but cut along the insertion of the mesentery. Take care also not to rub the internal surface of the intestines. The normal color of the intestinal mu- DTGES nVE APPARATUS. 63 cous membrane is deep red in the jejunum, pale rose in the ileum, and dull white in the large intestines. Examine attentively for all causes of intesti- nal obstruction, etc. Thus, obstruction may be spasmodic, or from narrowing of the walls, etc. Where there is strangulation it is well some- times to inject the mesenteric artery, and then notice if the fluid penetrates freely into the branches above and below the strangu- lated part. It is important to state the cause of the obstruction — 1, foreign bodies; 2, alteration of the coats; 3, pressure from without (ovary, uterus, glands, etc.); 4, there may be internal obstruction, or diaphragmatic, mesenteric hernise, etc. Mucous Membrane. — Appearance — May be thickened, rugous, mammillated, or puffy, with hypertrophy of the muscular coat {hernia); granular (cholera) thinning, soften- ing; ulceration (in acute tuberculization, especially the mucous glands); gangrenous (malignant pustule, etc.). destroyed, dried up (peritonitis from hernia), friable, flabby (gan- grene from hernia, etc.), roughened, ecchy- mosed (malignant pustule, yellow fever); punctated, injected with blood, pus, etc. Cicatrices of typhoid fever; beset with small- pox pustules (doubtful). Color, — May be red (various forms of enter- itis, cholera, etc.), livid, slate color, grey, yellow (poisoning by ammonia, etc.), black (melanosis, yellow fever, pellagra), blackish brown (strangulated hernia), dead-leaf color (gangrene from hernia). Portions like wash- leather (amyloid degeneration), which turn brown after washing and the application of iodine; they are seen mostly in Peyer's patches. 64 POST-MORTEMS. Changes in the Csivity,— Follicles or Glands (duodenal or Brunner's, solitary or closed, agminate or Peyer's). — Swollen (scar- latina, typhoid fever, cholera, erysipelas, poisoning by ammonia, etc); orifices dilated; ulcerated (typhoid fever, sometimes in cholera); tuberculous; obliterated; seat of a confluent eruption (intractable diarrhoea). ValvuIcB Gomiuentes. — Augmented in volume; atrophied ; covered with ecchymosed patches. Foreign Bodies.— 1. Developed in the Canal. — Hard stercoraceous matter {entero- liths)-, ribbon-like concretions of glairy mucus. 3. Substances Accidentally Swallowed. — Vari- ous metallic plates, toy balls, marbles, knives, scissors, spoons (especially in jugglers, etc). 3. Liquids. — Bloody, puriform, deep brown (yellow fever, poisoning by phosphorus, etc.), bluish green (altered thickened mucus), yel- lowish serosity (strangulated hernia), glairy mucus (dysentery), white creamy matter (cholera), reddish mucus, blood more or less coagulated and mixed with excrementitious matters; meconium. It is important to take note of the appearances of the faecal matter, and this should be mixed with water in order to examine its composition. Lesions of the Walls.— Narrowing (cir cular or moniliform), strictures by syphilitic ulcerations, intestinal atresia; partial imper- meability; intestine terminated in a cul de sac or in a cord; dilatation; bends distended with gas or liquids; emphysema; pseudo-membran- ous pellicles, false membranes; haemorrhage and infiltrated blood (enterrhagia; in soften- ing and apoplexy of the brain, with embolism of the mesenteric arteries, etc.); ulcerations of various origins; perforations of a simple or multiple character, of a typhoid, dysen- teric, tubercular, and cancerous nature, and in gangrene from hernia; opening of the in- DIGESTIVE APPARATUS. 65 testine through the abdominal wall ; rupture (from accumulation of fa3cal matters, etc.). Pustular eruption; polypi and vegetations; lymphomata; scirrhus, colloid and medullary cancer, either affecting the structure or adher- ent to the external face; fatty tumors; hy- dated cysts adherent to the intestines; ento- zo5ns; diverticula of the intestines; oedema of the intestines. Invagination is beat shown by a perpen- dicular section. Notice the following in order from the outside to the inside: 1, the serous membrane of invaginating intestine; 2, the two mucous membranes in contact; 3, the two serous surfaces; 4, the mucous membrane of the invagiDated intestine. There may be double intussusception by another portion of intestine being forced into tlie first invagi- nation. There is always peritonitis, arising from congestion; this causes plastic effusion, tume- faction, going on to softening and gangrene. Volvulus is a twisting of the bowels, most frequent in the sigmoid flexure. Hernia. — Femoral, inguinal, umbilical, obturator, pudendal, ischiatic(into the notch), ventral, vaginal, rectal, diaphragmatic (rare), retro-perineal. This last is very rare, the intestine is forced down behind the inferior mesenteric artery into the meso- colon. When a strangulated bowel sloughs, it does so where it is strictured; if injured in taxis, it is at the most prominent part. Incarceration.— By the vermiform ap- pendix of the caecum, or by passing through a hole in the omentum, etc. Enteritis.— General (rare). Catarrhal — mucous membrane pink, cov- ered with semi opaque mucus; in fevers, croup, etc. ; chronic catarrhal — surface dark- ened. 66 POST-MOllTEMS. Local ioflammations — daodeniiis (after burns), ileitis, colitis, typhlitis (inflammation of caecum and the appendix), perityphlitis (inflammation of the cellular tissue surround- ing the caecum). These last may arise from foreign bodies in the appendix; bur, as Wilks and Moxon observe , hard dark concretions may form in this situation from chronic di'iease, and resemble date stones, etc. Colitis is often mistaken for dysentery. Lesions in Typhoid or Enteric Fever. — These are mostly situated at the end of the ileum, near the ileo-coecal valve, at the free or convex edge. Glands or Follicles. — (Agminated or Peyer's Patches). I. Stage — Softened or Reti- culated Patches. — Surface slightly raised; glazed, grained, mammillated; mucous mem- brane softened, of a brain-like consistence, rose red with grey points; submucous cellular tissue thickened and depressed. Surrounding mucous membrane exceedingly vascular. II. Sta,ge — Honeycomb Patches. — Patches raised more considerably, harder, with elastic resistance; submucous cellular tissue (in the whole extent of the patches) yellowish white, firm, dry, and brittle or friable, glistening. Solitary glan^to5 " The bones or ligaments may be softened or eroded; these parts may be injured during labor. Exostoses, either rachitic, scrofulous, or THE GENERATIVE ORGANS. 91 syphilitic ; false or cartilaginous exostoses ; oste- osarcomata may sometimes be met with. Lux- ations of the hip joint occasionally encroach on the cavity. Ligaments.— Round.— Lesions are: hy- pertrophy and lengthening; shortening and adhesion (cause of version and flexion). Broad. — May be altered in direction and connection. Is sometimes the seat of peri-uter- ine hcematocelCj which is generally consequent on ovarian haemorrhage or apoplexy, haemorrhage of the Fallopian tubes, or of the vessels of the broad ligament, rupture of an extra-uterine pregnancy, or retrograde migration or reflux of menstrual blood, etc. Inflammation and sup- puration may attack it. Cystic tumors of the broad ligament may be mistaken for ovarian cysts; these are frequently due to ecLarge- ment of the 'organ of Rosenmiiller' (parovarium), the remains of the Wolffian bodies, situated between the Fallopian tube and the ovary in the folds of the broad ligament. Fibrous, encephaloid, tubercular, and other tumors of the broad ligament, are sometimes met with, cholesteatoma, small cystic tumors containing scales of cholesterine, epithelium, etc. The veins are occasionally varicose or in- flamed, as in purulent infection. OVARIES. These organs should be carefully examined in every necroscopy. Notice, first of all, their situations and rela- tions to the surrounding parts (they may descend into the groin or labia). They are sel- dom wanting, though occasionally rudimentary ; there are never more than two. The normal average size of each ovary is about 1^^ inch in length, | in width, and i thick; average weight from 60 to 120 grains. They are covered in front by the broad liga- 92 POST MORTEMS. ments, and are connected to the uterus by special ligaments. They are of a whitish col- or, and the surface is either smooth or uneven. External Appearance. — They may be flattened, shriveled, globular, covered with filiform cel- lular excrescences {villous cancer) ^ pseudo-mem- branous flakes, or star-shaped excrescences, etc. A smooth ovary is evidence of menstruation not having commenced. At the catemenial period there is rupture of a Graafian vesicle ; the opening cicatrizes in about eight or ten days. They may be friable, softened, red, and con- gested (ovaritis), slaty or black, oedematous, covered with gangrenous patches (septicaemia), crepitant, etc. Internal Appearance. — The chief points to notice are the state of the Graafian follicles and the number of the corpora lutea, as these show the frequency of menstruation and impregna- tion. At the menstrual period the ovary is very hyperaemic, and also during pregnancy. False Corpora Lutea (after menstruation only) are small and angular, seldom present a cicatrix, have no cavity, are usually soft, and with only a thin layer of yellow matter or none at all. D'ue Corpora Lutea are large (often the size of a marble or mulberry), round, project from the surface of the ovary, have a triangular de- pression or cicatrix at their summit, and con- tain a small cavity, which becomes stellate towards the end of pregnancy ; they are vascu- lar, lobulated or puckered, firm and yellow. Two corpora lutea are formed when there have been twin pregnancies. The stroma of the ovary may hypertrophy, indurate, or soften. In Acute Ovaritis, which is almost al- ways puerperal, the organ is swollen, vascular, and red or wine-colored ; sometimes it is soft- ened, infiltrated with sanguinolent fluid or even pus, or converted into a grey and sanious pulpy THE GENERATIVE ORGANS. 93 matter. It may burst and produce fatal peri- tonitis. Chronic Ovaritis is much more frequent, and is characterized by a fibroid degeneration and thickening of the capsule or of the whole organ. Ovarian Cysts are the most frequent affec- tions ; these may be either — 1, simple or unilocu- lar; 2, tubo-ovarian ; 3, compound or muliilocular ; or 4 dermoid. Notice the adhesions and relations of the cysts, state of the Fallopian tubes (permeable or not), length ol ped- icle, etc. They may burst into the peritoneum. Contents of the Cysts. — Clear hyaline fluid, like water; citron or amber color (recent), milky (from fat globules) ; thick, mucilaginous, gelatiniform, flocculent, brownish, chocolate color (from blood or decomposition). The Dermoid or Pilferous Cysts contain skin, fatty tissue, hairs, glands, teeth, or bone (regular or irregular). Cancer of the ovary, either primary or sec- ondary, is generally intermediate between scir- rhous and medullary; a peculiar form called villous cancer is occasionally seen. Sarcomata, fibromata, angiomata, cartilaginous, bony, and other kinds of tumors are sometimes met with. FALLOPIAN TUBES. Disease of these is more frequent than is gen- erally thought. They may be adherent to the uterus or ovary (from chronic inflammation or old peritonitis) ; sometimes they are flexed, or they may be distended (by foetus, blood, etc.) Pass a fine wire through the tubes to see if they are permeable, or inflate them from the uterine extremity. Open them by passing a fine scissors (bron- chotome) along them from the fimbriform end. The mucous membrane may be red or swollen (inflammation — in pelvic cellulitis), or gray 94 POST MORTEMS. and discolored. Contents may be thick, wine- like, purulent, or whitish, or mixed with tuber- culous or cancerous matters (cylindrical cell- ules). Obliteration may be a cause of sterility. Fi- brinous tumors are occasionally met with in the tubes. Rupture sometimes occurs from over- distension by the catamenia, by serum, or by pus ; it may also be from tubal foetation, and then takes place about the third or fourth month of pregnancy. Acute inflammation is characterised by a swollen, reddened, and vas- cular state of the lining membrane, which is infiltrated with serum, lymph, or pus. Chronic inflammation may lead to fibroid thickening or to a large accumulation of pus. After impregnation it may be possible to find sperma- tozoa in the tubes. UTERUS. Notice its relations to surrounding parts be- fore removing it; cancerous and other adhe- sions ; versions and flexions ; loss of substance ; swelling of the various glands ; compression of the sacral plexus, sciatic nerve, iliac vein, etc. Examine also the state of the neighboring organs, as the rectum, bladder, etc. Absence of the uterus is very rare. If thought to be absent, search carefully for it or its remains in the recto-vesical pouch, amongst the muscles of the perineum, etc. ; rudimentary bodies may be found. The uterus may be bilocular and horned, or unicorn. Size. — This varies considerably, even in health ; sometimes the uterus continues unde- veloped even in adult life, this arrest of devel- opment must be carefully distinguished from premature atrophy. At puberty it is pear-shaped, weighs 8 to 10 drachms ; subsequently it is larger, more vascu- lar, of softer and darker substance ; during preg- THE GENERATIVE ORGANS. 95 nancy it enlarges immensely. After delivery it returns to nearly its normal size, and then weighs about two ounces ; the edges of the labia are fissured, its cavity is larger, and its muscu- lar structure is more apparent than in the vir- gin state. In old age it atrophies, becomes denser in texture, and the orifices are frequently closed. Usually six months elapse after delivery before it returns to normal size. The uterus is opened either by cutting it through from one side to the other, or by a T incision, the long arm of which opens the anterior wall half-way up, and the two shorter extend from the two Fallopian tubes to the first. Lesions. — Walls of the Uterus, — Pale, red, hypertrophied or turgescent (inflammation) ; black, shrivelled, friable, indurated, cartilagi- nous (chronic inflammation) ; ossiform (rare) ; flabby and spongy, softened, partially destroyed (inflammation) ; ulcerated, infiltrated with pus, fetid-sanious fluid (cancer) ; false membranes, fungous and polypus growths, gangrenous Veins and Sinuses. — Gaping, gorged with blood, containing clots, in those who have died at the puerperal period ; tilled with a puriform liquid (puerperal fever ?), gas (doubtful if ante or post mortem). Malformation, — Kudimentary, double, heart- shaped, bicornous, bifid, divided into partitions, unicornous, with occlusion of the orifices. Versions — ante-, retro-, latero-. Flexions — ante-, retro-, latero-. Falling down and prolapse into the vagina or vulva, with or without lengthening, with or without hypertrophy of the neck. Prolapse may be due either to laxity of the ligaments or to some change in the vagina. Inversion may have occurred during labor POST MORTEMS. or shortly after, either spontaneously or from too strong a traction on the cord, or from the presence of tumors. Hernise of the uterus. Wounds. — Traumatic or surgical (Caesarian section); pathologic rupture, perforation; it may also be injured by attempts to procure abortion. Various Lesions. — Inflammation {metritis), acute is shown by a swollen, softened, and red- dened state ; puerperal ; chronic has two stages — 1, infiltrated, hyperaemic ; 2, indurated, anae- mic; in endo-metritis or uterine catarrh the organ is congested and softened, and the mucous membrane red, or purple, or whitish; chronic endo-metritis (leucorrhoea) ; parametritis or in- flammation of the subperitoneal connective tis- sue ; false membranes in the cavity from croup- ous inflammation ; bag-like cysts {dysmenorrhoea membranacea) ; softening. Accumulation of fluid (hydrometra), of blood (haematometra), of pus (pyrometra), of air (physometra) ; the obstruc- tion in these cases may be either a tumor, cica- trix of the neck, or a swelling from chronic metritis. Cancer and cancroid (these begin to form at the cervix — scirrhus, epithelioma, sar- coma) ; ulcers (phagedaenic) ; moles, either fleshy, foetal, or hydatiform. Hyatids and other foreign bodies. Tumors. — Cystic, fibrocystic (myoma), fleshy (sarcoma) ; mucous polypi (myoxoma) ; glandular or follicular. The so- called fibroid tumors (myomata) are very com- mon, and often take the form of polypi. Gan- grene. Retention of the placenta. Metritis. — The most common form is endo- metritis or inflammation of the lining membrane or uterine catarrh, and is shown by the swollen, injected, and velvety appearance of the mucous membrane, which is sometimes detached; the surface is coated with a viscid, straw-colored or THE GENERATIVE ORGANS. 97 purulent discharge, which may be mixed with blood. Metritis, or inflamm'ation of the substance proper, is nearly always a result of pregnancy or traumatism ; the walls are reddened, softened, swollen, and contain much lymph. Sometimes suppuration takes place, and the matter may burst either into the cavity, or into the bladder, rectum, or abdominal cavity ; it may become absorbed. The inflammation may, though rarely, terminate in gangrene. Chronic metritis leads either to softening or induration. Cancer. — This is in the form of schirrhus chiefly, and is characterized by two stages. 1. Hardening ; the surface of the uterus is uneven, indented but smooth ; when cut into, the walls are of a whitish or greyish substance, of a fibroid structure, the meshes containing cancer- ous juice ; thin slices are semi-transparent. 2. Softening ; this takes place sooner or later, com- mencing at the cervix, and irregular ulcerations form, which may gradually eat away most of the uterus and vagina, sometimes perforating the bladder or the peritoneum, or the whole of neighboring organs and structures may be destroyed. Sometimes large masses of gristly substance, of a papillary nature, form in the ulcers, resembling a "cauliflower excrescence." Lesions of the Os Uteri.— The normal appearance of the os varies. It is generally a smooth oval slit, but it may sometimes be circu- lar or triangular, like a leech-bite. In disease it may be redder than normal (inflammation), granulated (granular inflammation), unequal and intented, friable, indurated (sequel of in- flammation) ; prominent and hypertrophied, atrophied, narrowed; softened and fungous; ulcerated (tubercular, or syphilitic, or simple) . cancerous encephaloid, scirrhous, hsematoid, alveolar, or colloid cancer) ; epithelioma ; cov- POST MORTEMS. ered with fleshy protuberances (papilloma or cauliflower excrescence — this is not cancer). A transverse opening, or os, is not a necessary sign of childbirth, as it has been seen in infants. Adherent to anterior or posterior walls of vagina; lengtheningr of the os, sometimes so much as to reach as far as the labia, etc. Show- ing products of pregnancy as adhesion of pla- centa, etc.; varicose veins, false membranes. Syphilitic ulcerations (chancre is rare), gum- matous tumors. Narrowing of the internal orifice ; occlusion of the os by a pediculated or sessile fibrous body, by a plastic plug organized during gestation. Rupture of the os is either spontaneous or traumatic from injury by instru- ments during accouchement, etc. Malformations. — Double, bifid, or multiple os ; congenital obliteration of orifice ; absence of os ; conical os (may prevent conception). The Uterus and its appendages should be espec- ially examined in the following cases : — Phlegmasia alba dolens ; abortion ; extra-uterine pregnancy ; purulent infection (pyaemia after labor, etc.); affections of the uterine annexes, as inflamma- tion of the ovaries, broad ligament, etc. ; ster- ility; menstrual irregularities; obstinate con- stipation ; uncontrollable vomitings of preg- nancy, and other obscure symptoms after con- finement. During Menstruation the uterus is con- gested, enlarged, and softened ; the mucous membrane is swollen, reddened, punctuated with bloody spots, and covered with menstrual fluid, which may be more or less watery. This state must not be mistaken for inflammation. Appearance of the Uterus after Parturition. — The organ is flaccid, softer than usual, nine to twelve inches long ; cavity may contain much clotted blood, pieces of pla- centa, decidua, etc. : generally there is a green- THJE GENERATIVE ORGANS. ish-red fluid covering the internal surface, and a soft, pulpy, raw spot where the placenta was attached, with semilunar openings on its sur- face. The mucous membrane of the os is gen- erally of an orange color after a recent delivery ; this is a very characteristic appearance if pres- ent. The Signs of the uterus having been pregnant are : — the organ is larger and the walls are thickened, the fundus is longer than the cervix ; in the virgin womb these are about equal, w^hile in children the neck is the longer ; the sinuses and vessels are enlarged, and the os is marked irregularly by cicatrices. Puerperal Fever. — There is inflamma- tion and extreme softness of the uterine walls, which may contain pus either in their substance or the cavity. The adjacent peritoneum is inflamed, and there is pelvic cellulitis. The uterine sinuses are often seen gaping, or blocked up with puriform matter or thrombi ; there is secondary affection of the lymphatics, and also of the liver, spleen, kidneys, etc., but, unlike general pyaemia, the lungs mostly escape Infection. VAGINA. Mucous Membrane. — Bright red (vaginitis), brownish, swollen, cedematous (effects of inflam- mation) ; covered with granulations due to fol- licular or papillary hypertrophy ; eroded super- ficially (effects of vaginitis), ulcerated, gangre- nous, etc. Vaginitis is usually gonorrhoeal. The liquid covering the mucous membrane may be greenish-yellow (vaginitis), sanious, diphtheric, fetid, purulent, sanguinolent, or mixed with clots. Various Lesions. — Vesical, urethral, or rectal fistulae; stricture following inflammation, etc.; presence of foreign bodies ; su])erficial or deep follicular cysts ; polypi, as fibrous, sarcomatous, 100 POST MORTEMS. or myomatous excrescences, pediculated or not ; cancer, encephaloid or cancroid. Syphilitic ulcerations : inversion of the vagina, in falling down of the uterus, and prolapse of the vulva; effusion of blood under the walls (vaginal haema- tocele). Projection into the vagina of various internal tumors, as vaginal herniae, vaginal cys- tocele (bladder prolapsing with vagina), rec- tocele (rectum prolapsing with vagina); abscess in the walls or the peri- vaginal tissues. Fibrous hypertrophy, vegetations. Various kinds of injury may be met with, as from forceps in delivery or instruments used to procure abor- tion. Poisons, as mercury or arsenic, may be feloniously or accidentally introduced per vagi- nam. Malformations. — Abnormal opening; congen- ital stricture; complete absence; obliteration and imperforation {atresia)^ impermeability, divided by a more or less complete partition, bifidity (with or without double uterus.). VULVA, PERITONEUM, ETC. Vulva. — May be wounded ; rupture of four- chette; tearing of the hymen, of the meatus (these injuries may arise either during labor from careless use of forceps and other instru- ments, or from attempted rape). Swelling from effusion of blood (thrombus) or hcematoma vulvae and oedema of vulva. Eczema, herpes, erythe- ma, erysipelas, etc. Gangrenous inflammation {noma of infants) this must not be mistaken for venereal disease ; it is of a deep, dusky red col- or, and the ulcers are greyish with a most fetid discharge ; it generally arises from a constantly dirty state of the parts. Abscess and vulvitis of little girls (simple, ulcerated, diphtheric, or gangrenous) are often met with. In examining for suspected rape on a child it must be remembered that diseases are fre- THE GENERATIVE ORGANS. 101 quently seen in children which may be easily mistaken for gonorrhoea. Eape on young chil- dren, which may be without penetration, is generally followed by inflammation; then , an abundant secretion takes place, at first of a sanious mucus, then of muco-pus of a yellowish- green color and glutinous consistence. Lesions. — Non-syphilitic ulcerations ; follicu- lar cysts (from obstruction of the sebaceous ducts), met with especially in the neighborhood of the urethra ; vulvar folliculitis (inflamma- tion of the mucous follicles). Warts {condylo- mata), sometimes forming by aggregation caul- iflower excrescences; "mucous patches,' V these are something of the nature of a wart, and are characteristic of syphilis; they appear as rose or purple-colored, circular or oval elevations, flat and covered with a very offensive ichorous secretion; they may coalesse and form liarger patches. Cancer, chiefly epithelioma. Fibrous and encysted tumors; hypertrophied lichen (mycosis). Oxyurides may escape from the rectum. Elephantiasis is an hypertrophy of the skin, and must not be mistaken for enl&.rge- ment from deposition of fat. Obliteration of the posterior commissure and separation of the labia majores by vaginal or uterine tumors. Vesico-labial hernise. Clitoris.— May be confounded with the labia split in two, absent, or developed in an extraordinary manner. Hypertrophy has no connection with excessive sexual indulgence. The meatus urinarius may be situated on the summit of an hypertrophied clitoris which might be easily mistaken for a penis. There is the case of a woman who was thought tp be a man, and married as such ; her real sex, was only discovered after death by the presence of a uterus. 102 POST MORTEMS. Perineum.— May be thinned and narrowed from disease; enlarged; absent (ei her from rnpture or as a congenital defect) ; contused, wounded (rupture and tearing) from labor, attempted rape, etc. Fistulae, excoriations, intertrigo, eczema, urinary tubercles ; perineal hernia and protusion of the perineum by vari- ous internal tumors, as bsematocele, cystocele, etc. MAMMiE. Before proceeding to open these, it is always well to make a physical examination first^ in order to estimate their hardness, softness, mo- bility, etc. ; by pressure milk or pus may escape. In order to open them, divide the skin by three or four lines radiating from the nipple to the circumference, and reflect the triangular pieces of skin ; or remove the breast entirely by one or two semi-elliptical incisions. Having ex- posed the organ, notice the state of the lacteal tubes, adhesions to neighboring parts, etc. Lesions, — Eczema, syphilitic induration and gummata ; abscesseSj these are termed ex^ra-mam- mary or superficial when situated between the skin and the breast, post or sub-mammary when behind the gland, true or intra-mammary when the glandular structure itself is afiected. Fis- tulae; partial or general hypertrophy (the breasts generally enlarge at the menstrual period). Tumors — adenoma or formed of gland structure; nodulated, elastic or hard (cystic sarcoma), these may be mistaken for cancer; cartilaginous (enchondroma), rare; fibroma (fibrous tumor) ; fatty (lipoma) ; mucous (myx- oma), rare; spindle-celled sarcoma (this was formerly mistaken for cancer, with which, in fact, it may be associated ; milk tumors or obstruction of the ducts with natural secretion (galactocele) ; cystic tumors (ecchinococus, hyd- atid, etc.) ; tubercle, rare ; calcareous deposits. THE NERVOUS SYSTEM. 103 probably from the retention of milk. Atrophy y in old age and wasting diseases. Cancer. — Most common form is scirrhus, which is a hard lobulated tumor at first, with affection of the neighboring parts and glands. It afterward ulcerates, and the sore has everted, raised, and puckered edges, with fetid secretion. Medullary cancer — brain-like in appearance — is met with in early life. Colloid has been very rarely seen. Adenoma of the breast (simple glandular tumor) is very often with great difficulty dis- tinguished from true cancer, especially in the early stage of ihe disease. In Man diseases of the breast may occasion- ally be met with, such as cancer and fibromata. In dropsical or fat men the breasts are often very large, but they have no gland structure. Cases are reported of men having true mam- mae which secreted milk, but they are doubtful. X. THE NERVOUS SYSTEM, HEAD. For the method of opening the head, see Chapter III. Before doing so the Scalp must be carefully examined. Notice the color and state of the hair. Look for fresh wounds and cicatrices, as cuts, bruises, abrasions ; echymoses with subcutaneous effusion or sanguineous swell- ings ; punctures through the fontanelles or tem- poral bones (these may be very minute) Var- icose aneurisms, oedema, pneumatocele (from communication with the frontal sinuses or mas- toid cells), diffuse inflammation of the cellular tissue ; erysipelas (see if there is a wound as well, and look for evidences of a debauch); pro- 104 POST MORTEMS. trusion of the brain through an opening in the skull, from a trephine wound or separation of the sutures (encephalocele). The head of a new-born child may be injured during labor by instruments or pressure, etc., or by a fall, as on to the ground accidentally. Sanguineous tumors on the heads of new-born children (cephalhsematoma) arise from pressure during labor. SKULL CAP. Fractures. — These must be carefully ex- amined, in order to judge the direction, extent, nature of the cause, etc. ; where they are indis- tinct or doubtful it is well to rub some ink in. The bone may be depressed or protruded, or radiated from the point of contact, etc. Always try to determine from the appearance if the injury is from a blow or a fall ; take some of the part injured and examine it carefully— microscopically, if necessary — it may retain some particles, as dirt, pieces of wood, metal, etc., which may afford important evi- dence. Perforations, as in infanticide, may be very small. Exostoses, osteophytes, and periostoses ; these may serve to explain some cases of paral- ysis; notice carefully their exact situation. Premature closure of the fontanelles may be a cause of epilepsy, cretinism, etc.; they may remain open longer than natural, as in hydro- cephalus. Irregular development of the skull ; not proportionate to the stature. Malforma- tion, as flattening (not traumatic); increase in the basal circumference, rotundity of the cra- nium (sometimes peculiar to idiotism or epilep- sy), general volume increased or decreased externally; take the measure by means of a pair of calipers. Remove the skull cap as directed in Chapter III; if there is a fracture, the greatest care must be taken in sawing through the bones, and it is well, if possible, to first remove the frac- tured part entire. Now examine the interior, and see if the abnormalities on the outer have any corresponding state on the inner surface, and also if lesions affect the dura mater as well. THE NERVOUS SYSTEM. 105 In suspected blows examine the side opposite to the presumed injury for fracture by contre coup, a^ at the base of the skull. The inner table of the skull may be exten^ sively fractured without any signs of much ex- ternal injury. If the blow has been from a light weapon sharply applied, the fracture is confined to the seat of the injury; if from a large body moving slowly, the injury is diffused. DURA MATER. Carefully examine the external surface' as far as it is exposed ; notice the adhesions, transpar- ency or opacity, redness, effusion of blood ; then judge whether it was produced before or after death, and look for corresponding injury to the bones and scalp, either near the seat of effusion or at some distant part. The effused blood may be more or less absorbed, some- times only a thin layer of decolorized fibrin remaining. The color of the dura mater is often of a rnpre or less deep yellow, as in jaundice or yellow fever and poisoning by crude carbolic acid. In syphilis there is frequently a peculiar yellow- ish grumous deposit either in the form of gran- ulations or as a pseudo-membrane. In deaths from prussic acid, or cyanide of potassium, or acute alcoholism, the odor of cyanogen or spirit is distinctly perceptible. The Pacchionian bodies may be en- larged, frequently forcing their way through the pia mater ; the nature of this enlargement is uncertain; or they may be disseminated and must not be mistaken for tubercles^ Divide the dura mater either along the edges of the sawn bones or across the vertex, or by a longitudinal incision a little to one side of the longitudinal sinus ; then divide the falx cerebri as near the crista galli as possible, and turn the membrane aside or back, or remove entirely. Lesions of the Dura Mater. — Dis- tended with serum (hydrocephalus), with blood. 106 POST MORTEMS. from rupture of a vessel, but see if this is ante or post mortem. Depressed, with wasting of the brain beneath ; adherent to the skull^ as in inflammation from injury or meningitis; in- flamed (nearly always from injury); vessels tur- gid, showing the mode of death, as poisoning by narcotics, apoplexy, etc. ; tubercular and syph- ilitic granulations, the former as miliary bodies, chiefly at the base, the latter as round, flatteaed, hard masses; fungoid growths; epithelial and fibrous tumors (notice the exact seat of these); dermoid cysts, containing hair, fat, etc. Patches of purulent matter, effusion of blood between its layers or true bony deposits ; cancerous tu- mors; hydatids. Defects are rare. Inflammation of the Dura Mater.— Acule.—Jn the early stage it is pinky and softer than normal ; then there is infiltration and sup- puration or effusion of lymph, giving: rise to adhesions and new formations. Chronic, — Characterized by the formation of a false meaibrane on the arachnoid surface, which becomes vascularized, and attached more or less in patches to the brain substance. Many of these false membranes are, no doubt, old blood effusions which have become organized. Syphilitic Inflammation is shown by a pink or red sarcomatous swelling, generally adherent to the brain, from one-third to half an inch thick and of a roundish flattened form. ARACHNOID AND PIA MATER. It is generally well to describe these two together, especially as modern physiologists regard the 'outer layer* of the arachnoid as the endothelium of the dura mater, and the 'visceral layer' as belonging to the pia mater; the pia is also the more important, as it is the vas- cular membrane of the brain. Lesions. — The membranes may be dry (from undue pressure of the brain), injected (acute inflammation), milky (chronic inflam- mation); distended with serum (inflammation), blood (if coagulated it is a sign of ante-mortem THE NERVOUS SYSTEM. 107 hsemorrhage ; if fluid it may have been effused post mortem) or pus (from injury, seldom or never from disease). In idiopathic inflammation of the arachnoid the eflfu- sion has been described as being between it and the pia mater; in traumatic inflammation it is between the arachnoid and the dura mater. The pia may be adherent to the dura mater or the brain, either generally or in large or small patches from inflammation ; this is often seen in general paralysis and other affections of the insane, etc. Thickened, softened, infiltrated with pus (chiefly along the course of the ves- sels), or covered with miliary granulations; these latter are nearly always confined to the base and the fissures ; if they are seen on the vertex, they have spread upwards from the base. Tumors of various kinds may be met with, as angioma, sarcoma, fibroma, papilloma, small epithelial growths, steatoma, hyatid cysts, pigmentary deposits, etc. Meningitis.— /S'lmpZe. — The first stage of active hyperaemia is seldom seen ; there is then greatly increased vascularity, more or less dif- fuse. Afterwards effusion takes place; this may be of various kinds, from a greenish watery fluid to an opaque milky deposit ; in rare cases pus has been found. Tubercular, — This is characterized by the deposit of grey, miliary granulations about the size of millet seeds, chiefly in the membranes at the base of the brain. They are met with most abundantly in the fissure of Sylvius, and are generally situated in the peri-vascular spaces ; they are always associated with inflammation, and nearly always with general tuberculosis. The disease is well shown by putting the membrane in a glass vessel of water over a dark surface, when the tubercles appear as white dots. Tubercular differs from simple meningitis not only by the presence of the tubercles, but also by the effusion being chiefly at the base, 108 POST MORTEMS. rarely or never at the vertex. The hemispheres of the brain are generally flattened from pres- sure ; the ventricles are distended with serum, and their walls are softened. VESSELS OF THE BRAIN. Sinus of the Dura Mater.— May be inflamed ; obstructed by clots, especially at the ^Torcular Herophili;' in cases of poisoning, suf- focation, etc., these clots are black and soft; in apoplexy, typhus, certain forms of insanity, etc., they are fibrinous, adherent, and of a yellow or brown color. In some cases of brain-softening, meningitis, otitis, etc., a thrombus may be found in the sinus. In death after erysipelas, pyaemia, etc., these vessels are sometimes affected with purulent deposits. Arteries. — May be dilated (aneurisms), im- permeable from atheroma or other changes or obstructed by clots ; they may be rigid, tortu- ous, sometimes calcareous. Affections of these arteries are met with mostly in old people, drunkards, rheumatic subjects, etc., and are fre- quently a cause of brain-softening or of apoplexy. Air in the Vessels. — This is generally a consequence of the manner in which the head has been opened, and then of course has no pathological significance; it may sometimes be due to post-mortem decomposition of the blood. Its presence, however, should be stated, and the cause for it determined if possible. Congestion of the Vessels is mostly a sign of the mode of death, and ought not to be considered as a cause; it is also often due to the position of the body at and after death. Ab- sence of congestion of the vessels of the brain would suggest the probability that death was not from asphyxia. Serous Apoplexy. — Sudden efiusion of serum has never been known to take place, and hence there is no such thing as serous apoplexy. Serous eflfusion is generally an accompaniment THE NERVOUS SYSTEM. 109 of brain- wasting, and is not always an inflam- matory product. URJEMIA. In cases of sudden death, with symptoms of brain disease, there may be no apparent lesion, death being due to ursemic poisoning; then look for disease of the kidneys, and test for urea in the blood and brain ; it is also important to do this in cases of suspected poisoning. Test for Urea. — 1 . In the Blood or Sm^um- — Acidulate with acetic acid ; evaporate to dry- ness over a water bath (small evaporating dish or watch glass in a large beaker of boiling wa- ter, with a piece of paper or wood so placed as to let the steam escape); dissolve the urea in boiling alcohol. Then evaporate again to dry- ness, add a little water, put it in a freezing mix- ture (or place on a piece of lint saturated in ether), add a few drops of nitric acid. If there is urea the nitrate will form, and can be distin- guished by its peculiar form of crystals. 2. In the Brain. — A good -sized piece of brain substance is to be cut up into small pieces, and placed in a convenient vessel. Ten ounces of boil- ing distilled water are put on them and allowed to stand for six or eight hours, the brain being frequently broken up with a glass rod during this time. The water is then carefully poured off into a clean vessel, and the brain is digested with another ten ounces of boiling water, al- lowed to stand the same length of time, and again poured off; this is repeated four times. The solutions are all mixed together, filtered, and evaporated to dryness. The dry residue 16 powdered and treated four times exactly as the brain was in the first instance, with a smaller quantity of water, however. The evaporated residue is dried in an oven, and then boiled in successive portions of ether. This ethereal ex- tract is evaporated to dryness, treated with a 110 POST MORTEMS. little tepid water, filtered, and again evaporated to dryness. The residue is to be put on a glass slide with a drop of nitric acid, covered with thin glass, allowed to stand awhile, and then examined under the microscope. Crystals of nitrate of urea will show themselves if urea is present (from Dr. Todd^s Clinical Lectures^ quoted in Aitken^s 'Practice of Medicine^), THE BRAIN. Notice all that can be seen as to the state of this organ while it is in situ; then remove it thus : — Having removed the dura mater, draw back the anterior lobes, divide the tentorium cerebelli from within outwards along the petrous bones, and cut the spinal cord as far down the canal as possible; then divide the various nerves and remove the brain, letting it fall into the left hand. Examine the base of the skull carefully; there may be fractures, caries, tu- mors, etc. Now weigh the whole brain en masse ; afterwards divisions of it may be taken and weighed separately. The normal brain weight is — males, 46 to 58 oz.; females, 41 to 47 oz. Now thoroughly and carefully examine the whole surface of the brain ; notice the state of vessels (the basilar and meningeal arteries, etc., for atheroma, emboli, etc.), adhesion of the lobes : look for tubercle or other deposit in the fissure of Sylvius. Notice the shape, symmetry, and depth of sulci, the flattening or prominence of the convolutions, etc.; estimate the consist- ence, fluctuation, softening, firmness, etc., of the brain substance. Sometimes small patches of eflfused blood will be seen at various parts of the brain; state exactly their situation, the same with tumors. It is of extreme importance in connection with the localisation of brain function to notice accurately the exact seat of pathologic states of the brain. THE NERVOUS SYSTEM. Ill The under surface of the base of the brain con- tains, in order from before backwards — 1, lami- nacinerea ; 2, olfactory nerves ; 3, anterior per- forated space; 4, optic commissure; 5, tuber cinerum; 6, infandibulum and pituitary body ; 7, corpora albicantia; 8, posterior perforated space; 9, crura cerebri, with the third nerves {motor oculi) on their inner sides, and the fourth nerves (trochlear) on the outer sides. Then comes the pons, with the fifth (trifacial) em- bedded in it; and behind this is the medulla, with the following nerves: — in front is the sixtJi {abducens oculi) ; at the side is the seventh, a double-nerve {portio dura, or motor of the face, and portio mollis, or auditory) ; farther back are the three separate nerves forming the eighth — the glosso-pharyngeal, the pneumogas- tric, and the spinal accessory ; and between the pyramidal and olivary bodies is the ninth or hypoglossal nerve. Remove the arachnoid and pia mater, noting any adhesions and their exact situation, as this shows localised inflammation; they may be so adherent as to drag out the brain substance on being stripped off, or they may be separated from the brain by effusion. Some of the vessels, carefully pulled out with the pia mater, may easily be examined microscopically, and often furnish important testimony as to disease of the brain. There are several methods of examin- ing the brain substance; the most gen- eral is to slice the brain in successive layers from the vertex to the base, cutting from within outwards, and leaving the slices partially at- tached on the outside, so as to preserve the nor- mal relations. But a better plan is to separate the two hemispheres, and cut from within out- wards and slightly downwards, just above the upper surface of the corpus callosum. This will expose the roof of the lateral ventricles. 112 POST MORTEMS. Before opening the ventricles examine the state of the grey and white substance^ the num- ber of the puncta sanguinea, both absolutely and relatively ; if very numerous and dark this may suggest the mode of death (asphyxia, etc.), the white part then often appears pink. The White Substance may be denser than usual, in patches or diffused (sclerosis) j or it may be softened, sometimes pulpy. Soften- ing {ramollissement) is either red, or yellow^ or white: the first is due to inflammation, embol- ism, or injury ; the second to fatty degenera- tion, and is frequently an evidence of syphilis ; white-softening is probably a post-mortem change. The brain substance is often more watery than usual [oedema), and serum runs from it on sec- tion ; this is probably a sign of brain atrophy, the serum being compensatory. The Grey Matter may be paler or darker than normal — sometimes almost black (melan- aemia) — firmer or softer, or the layers of vary- ing consistence; the layers may be more dis- tinct than usual ; and the whole grey matter may be wider or narrower. A good method of examining the grey matter is to cut as thin a slice as possible, place it between two pieces of glass, and hold it up to the light. Cerebral Hemorrhages, forming cyst- like cavities in the brain substance, are fre- quently met with in various situations, and arise either from injury, or disease of the ves- sels; in the former case they are generally found directly opposite the seat of injury; in the latter case they are chiefly in the basal ganglia. Their size varies from that of a pin's head to a large orange. In cases of cerebral hsemorrhage the blood-vessels should be exam- ined microscopically, as it is often due to dis- ease of the walls of the vessels. The effused THE NERVOUS SYSTEM. 113 blood may after a time be changed into a brown clot, or even into a decolorised fibrinous mass. Apoplexy is often associated with disease of the kidneys. Cerebritis is rarely met with as an acute affection ; the brain substance is redder and softer ; sometimes the white substance is indis- tinguishable from the grey. Chronic inflammation is generally attended with disease of the vessels, and is more local ; it often gives rise to sclerosis. Pvs may form from inflammation, and is met with either diffused through the substance, or as an encysted abscess, or as ragged ulcers on the surface. These ulcers are frequently multiple, of pysemic origin, and generally affect the grey matter. In old standing abscesses the pus is green. It gener- ally is very offensive and has an acid reaction. Lateral Ventricles. — In order to open the lateral ventricles a small incision is to be made in the roof, and the handle of a scal- pel passed into the ventricle as a guide for the knife for the further division of the roof ; the fornix is divided by passing the knife through the foramen of Monro and cutting upwards and forwards; the brain substance, including the roofs of the ventricles and the fornix, are now turned back, when the whole of the inte- rior will be exposed. Notice the state and relations of the various parts: the chief of these are — 1, the fifth ven- tricle ; 2, velum interpositum ; 3, the choroid plexus ; 4, the corpus striatum : 5, the optic thalamus; 6, the corpus fimbriatum; 7, the hippocampus major and minor; 8, the pineal gland ; 9, the corpora quadrigemina ; 10, the valve of Vieussens and the fourth ventricle. Divide the corpus striatum and the optic thalamus so as to expose their internal struct- 114 POST MORTEMS. ure. The remainder of the brain may be divided as is thought suitable; perhaps the better way is to cut it as much as possible in the direction of the fibres, that is, perpendicu- lar to the surface. The Ventricles in acute hydrocephalus and tubercular meningitis are distended with fluid, which is often turbid, and the walls of the ven- tricles are sometimes softened. The efibsion may cause atrophy of the hemispheres. Fre- quently the epithelium lining the cavities is granular, like sand ; this is considered a sign of chronic inflammation. Sometimes there are granulations which may be as large as hemp seeds. The ventricles are occasionally found full of blood; In this case the ruptured vessel should be sought for. Various tumors are also met with, as warty growths, carcinomata, earthy concretions, hy- datids, lipomata, enchondromata, etc. The Choroid Plexus is of a venous na- ture, and probably assists in regulating the central circulation ; it is often the seat of vari- ous lesions. It may be varicose, tumefied by serous eff'usion; the seat of hydatids, erectile (angioma), osseous, encephaloid, and other tumors; sometimes peculiar hard yellowish bodies are found in it of a concentric structure, varyiag from a microscopic size to that of a small pea or nut. They have been called cor- pora amylacea by Virchow, and concentric cor- puscles by H. Jones. Some give a brown, some- times bluish, tint with iodine ; others, however, do not show this reaction. Cysts, cystoid for- mations, and fatty tumors are also occasionally met with. The Fornix is very frequently softened: this may be from post-mortem change or dis- ease ; the latter must not be too hastily assumed. Tumors. — The most common form of tu- THE NERVOUS SYSTEM. 115 mors met with in the brain are the gliomatay which are composed of a soft, finelv granular material ; they are generally multiple and extremely vascular. Psammona is a tumor composed of lime saltSj and is of a sandy nature; Cholestama is of a pearly lustre, consisting of closely set, glisten- ing scales of cholestearin, Hyatid cysts often attain a large size, and- consist of a bag con- taining layers of a gelatinous membrane, on which appear a number of small white dots, presenting under the microscope the heads and hooklets of the echinococcus. To preserve the brain for microscopic section put it in spirit, colored brown with tinct- ure iodine, for four to six days, adding iodine occasionally; then keep in Miiller's fluid till hard. In studying the morbid anatomy of the brain it is useful and important to have a chart of the convolutions at hand for reference; in the mortuary there should be a cast of the brain, with the convolutions marked and named. The pathology as well as the physiology of the brain is still in a very unsatisfactory state, and one can only use general terms in describ- ing the lesions that are met with. It is of course unnecessary to say that affections of one side of the brain show themselves on the other side of the body. Injuries of the brain are always serious, but it must be remembered that even very severe injuries are not necessarily fatal. A case has been noticed where some brain matter escaped from the external meatus after fracture at the base of the skull, and recovery took place. For some^ years an editor of a paper in one of the Channel islands performed his duties with a bullet in his brain, and at his death one hemi- 116 POST MORTEMS. sphere was found to be completely destroyed. Injuries to the basal ganglia are more serious than affections of the vertex. Cases are on record where a small crow-bar and gas pipe have been driven through the head, yet the patient lived; pistol and rifle balls have passed through the head, the patient living. The Brain in Insanity.— Every possi- ble lesion has been observed in insanity, but none as yet has been found to distinguish it as a peculiar affection ; all those lesions that have been described as having been met with are also seen in health, or apparent health; but then, as Dr. Moxon observes, most people are suspected by their intimate friends of having some mental flaw. It is possible that, as the study of insanity becomes more exact and the localization of brain-function more definite, special lesions may be discovered. But it is probable, however, that we may have to look to other organs, especially those influencing the state of the blood, for the causes of insan- ity; and it is not at all unlikely that as the sympathetic nerve exercises a great influence on mental processes, so some affection of this will be found to be a potent factor in insanity. SPINAL CORD. In cases of locomotor ataxy, progressive muscular paralysis or atrophy, sclerosis, etc.. the whole extent of the spinal canal has to be opened; this is a diflBcult and tedious process. In order to remove this for examination the subject has to be laid on its face, an incision made in the median line, and the skin and sub- cutaneous tissue reflected. The muscles, fat, and tissue in the vertebral grooves have to be dissected out, so as to expose the spinal lami- nae ; these have then to be broken with a chisel, or sawn through either with an ordinary or with a special saw {rachitome)^ and the spinous processes of the vertebrae removed. The cord THE NERVOUS SYSTEM. 117 will now be seen lying in the vertebral canal, covered hj the dura mater, etc., which is not to be opened, but removed with the cord by division of the various spinal nerves. In ex- amining it to state its consistence, etc., remove the membranes jSrst, as a soft, swollen cord may seem hard in its resisting membranous covering. Lesions of the Spine.— Curvature.— - Either angular (kyphosis), from disease of the bodies of tne vertebrae; lateral {skoliods), the cause of which is obscure ; or forwards [lordosis). Fracture of the Spine.— When above the third cervical^ death is instantaneous ; in sudden death of children always look for dislo- cation or fracture of the odontoid process, and in other cases of sudden death from severe injuries a fracture in this part may pass unno- ticed unless carefully sought for. When fracture is high in the backy but below the third cervical, there is palsy of the arms, difficulty of breathing, and paralysis of the bladder and lower limbs ; the patient may live for two or three days, when death arises from some affection of the respiration. When the injury is in the dorsal region^ there is paralysis of the bladder and lower extremities; death is then generally due to pyaemia or uraemia from retention of urine, and may not take place for some weeks. Cancer affecting the bodies of the vertebrae has the remarkable effect of considerably short- ening the stature of the individual. Lesions of the Dura Mater.— The spinal dura mater is only an investing mem- brane, and not a periosteum, as is the cerebral dura mater, and therefore not so liable to dis- ease. It may be thickened, inflamed (acutely rare); seat of spina bifida or abscess (from 118 POST MORTEMS. injury, psoas abscess, bed sores, scrofulous dis- ease of vertebrae, etc); may contain morbid growths, as cancer, fatty tumor, etc. Arachnoid and Pia Mater Lesions. — Inflammation {spinal meningitis), a cause of convulsions in children, with eflusion of lymph or pus (this eflfusion gives an appearance of irregularity to the cord); haemorrhage (spinal apoplexy); tumors, bony plates (these are very common and have no particular importance; they might, however, be a cause of tetanus or convulsions, tubercle, etc. ; tubercular inflam- mation renders the membranes of the cord opaque from deposit). The Cord. — Atrophy, hypertrophy; hy- persemia (but this may be post-mortem hypos- tasia, from position of the body); inflammation {myelitis — rare) produces red, yellow, or white softening; sclerosis (general or local), from chronic inflammation. Tumors (cancer, tuber- cle, etc.); cysticerci, hydatids (rare). Hydrophobia and Chorea, — No defi- nite morbid appearance. Tetanus. — Generally the appearances are only microscopic, and then unsatisfactory ; there may be hyperaemia, enlargement of the central canal, proliferation of epithelial elements and leucocytes, etc. Sclerosis. — Cord looks like white of egg, of a grey color ; this is due to loss of the white sheath of the nerves. Two forms^ one as dis- seminated granular masses, the other extending ribbon-like through the tissue. Locomotor Ataxy. — Induration and dis- integration of the posterior columns of the cord, etc. Signs of Concussion {as after railway accident). — Haemorrhage in the dura mater, injury to the ligaments and cord itself; inflam- ORGANS OF SPECIAL SENSE. 119 mation, suppuration ; after a time, softening or sclerosis. NERVES. Atrophied ( after injur/, etc., or lesion of nerve-centre); hypertrophied ; inflamed (effu- sion into the sheath, etc.); neuroma — two kinds, one true nerve increase, the other a tumor (fibroma, myxoma, etc.) pressing on the nerve ; cancer (rare). Gliomata are tumors which often spring from the retina, especially in children. Skin diseases are sometimes associated with some affection of the sympathetic or cutaneous nerves. XL ORGANS OF SPECIAL SENSE, The most important changes in these are noticed in surgical works ; therefore only a few need be given here. EYE. To remove the eyeball and expose the orbit and con- tents, carefully break away the orbital plate. Eyelids. — Hordeolum (stye), ophthalmia tarsi, syphilitic ulcers; trichiasis— eyelashes growing inwards ; entropion— eyelids turning inwards ; ectropion — eyelids turning outwards ; ankyloblepharon — union of the lids to the globe. Tumors. — Naevi, hydatid cysts, tarsal tumor (enlarged Meibomian glands). Conjunctiva. — Inflammation ^— catarrhal, chronic, purulent, goQorrhoeal, scrofulous (with phlyctenulcej or small opaque pimples, at the margin of the cornea), granular (membrane roughened), pterygium (thick, red, elevated, triangular fleshy formation). Tumors. — Warts, enchondromata, fibromata, polypi, etc. 120 POST MORTEMS. Cornea. — Inflammation (keratitis) — syphi- litic (like ground glass), strumous with nodular elevations). Ulcers. — Leucoma, opaque cicatrix; onyx, suppuration between the layers of the cornea ; staphyloma, protrusion of iris, etc. Sclerotica. — Inflammation — rheumatic, syphilitic, etc. Tumors. Chambers. — Lining membranes inflamed; may contain blood, pus, hydatids, etc. Iris. — Inflammation (iritis) — syphilitic, with nodules of a reddish or dirty brown color along the margin; traumatic, from penetrating wounds ; rheumatic, dull and discolored with- out nodules; scrofulous. Cysts, melanomata, etc. Xjens. — Inflammation (very rare), opacity (cataract) with induration, softening, or a gela- tinous or fluid state. Glaucoma. — {Inflammation of Choroid). — Eyeball hard, cornea dull, iris slate-colored. Fluid contents of the orbit increased and tur- bid Hetina. — Inflammation — increased vascu- larity, exudation, dulness, sometimes extrava- sation of blood ; suppuration ; displacement by injuries, sub-retinal efl'usion, etc. Tumors — scrofulous and others ; glioma. Amaurosis may be due to an anaemic state of the retina, embolism of the central artery of the retina, detachment of the retina (from injury), inflammation of the optic nerve (shown by swelling and vascularity), tumors in the brain, syphilitic deposits, haemorrhage, abscess, atrophy, softening, etc. Cancer. — Scirrhus rare ; most frequent is colloid or melanotic. Glioma is not really cancer ; it is formed of round-celled sarcoma. ORGANS OF SPECIAL SENSE. 121 EAR. Auricle. — Hypertrophy, inflammaticn, tu- mors, etc, gouty deposit (urate of soda); haema- toma — effusion of blood (no doubt from injury), this may be absorbed, and then leaves the car- tilages in a wrinkled state. There is a peculiar fungus disease liable to affect the subcutaneous cellular tissue, from inoculation, and pro- duce extensive disorganization. Meatus, — Foreign bodies ; inflammation (lining membrane swollen and vascular); ab- scesses (follicular), sometimes they produce nec- rosis of the bone ; myxomata (polypi); eczema. Internal Ear, — Tn all cases of deafness the internal ear should be examined by break- ing away the roof with a chisel. There may be ankylosis of the stapes, disorganization from inflammation, caries, or various deposits; ob- struction of the Eustachian tube from thicken- ing of the mucous membrane, etc. NOSE. The interior of the nostrils may be easily exposed, without disfigurement, by raising the upper lip, sepa- rating the mucous membrane from the superior maxilla and dividing the fleshy part of the columna. Lesions. — Hypertrophy, inflammation, ul- ceration (syphilitic, etc.), lipomata, polypi and other tumors; worms or larvae sometimes get up the nose. In sudden unaccountable death look for for- eign bodies, as piece of tobacco pipe, etc., poked up the nose into the brain, through the eth- moid bone. SK5N. Hypertrophy. — Horny growths, corns, ichthyosis (thick and rough, like fish skin); elephantiasis (as of the scrotum, etc.) Atrophy in old age, syphilis and various cachexise (thin, dry appearance; surface chaffy or brawny, or greasy and lustrous) . Change of Color. — Addison's disease {melasma supra-renale), skin of a deep brown or 122 POST MORTEMS. greenisli brown hue. This disease is thought to be dependent on some affection of the sym- pathetic nerve. Skin Diseases. — Psoriasis (the red, scaly patches become pale after death); lichen; pity- riasis rubra, general redness with slight ap- pearance of excess of epidermic scales; pityri- asis versicolor (chloasma), buff-colored patches. Purpura, peiechice (small effusions of blood). Eczema, herpes, lupus, etc. Scleriasis (Fagge), formerly called Keloid, a swollen or brawny appearance of the skin, something like a cicatrix, for which it may be mistaken. Syphilitic Tubercles. — Solid swellings of the skin ; in size from a lentil to a hazel nut, and covered with epidermis. Condylomata. — Generally near the genital organs ; they are warts. Xanthelasma (Vitiligoidea). — Two forms — 1, X. Plana, as an opaque,~yellowish-white patch, not elevated, most on the palms of hands, scro- tum, ears, eyelids, etc. ; 2, X. Tuberosa, tuber- cle-like knots on the elbows, knuckles, etc. Associated with jaundice. Cancer. — Epithelioma, in form of warts ; epi- dermis thickened, opaque, yellow, cheesy and brittle ; it may be ulcerated, and then takes the form of- a deep irregular excavation sur- rounded by fungous warty growths. Desquamation of the skin takes place in more or less large patches in scarlatina, gangrene, from blisters, erysipelas, etc. Post-mortem separation from decomposition must not be mistaken for these pathologic effects ; there will in this case be other signs of decomposi- tion. THE BONES. The chief affections in which it is necessary to examine the bones are — injuries causing ORGANS OF SPECIAL SENSE. 123 inflammation, necrosis, nodes, fracture, etc. ; syphilis, scrofula, osteomalacia (mollities os- sium); rachitis (rickets); caries (of the bodies of the vertebrae produce spinal curyature). The most convenient bone to take for examination is the femur, the thigh being opened in the course of the vessels, that is, from the centre of Poupart's ligament to the middle third of the thigh. To find the centre of ossification, open th© knee joint, expose the end of the femur, and gradually pare down the cartilage, till a col- ored point is noticed; the size of this must be carefully measured. Periosteum. — May be red, swollen with effusion (acute periostitis); less red, more swol- len, denser, and generally adherent (chronic periostitis); pus under the periosteum; circum- scribed thickenings (nodes are signs of syphi- lis); a dense, hard, heavy tumor, like tendon, osteoid chondroma (or cancer), very malignant. Bone. — Bare, white or yellow ochre (color result of periostitis); necrosed, sequestrum en- closed in a shell of new bone, with or without cloacae; caries; indurated; more porous (rare- f active inflammation). InfLammation within the medullary canal (osteomyelitis), deep redness, small suppurating patches or abscesses (frequent cause of pyaemia). Thin scale of bone detached, surrounded by sinuous grooves formed of eroded bone (as on the skull in syphilis). Hypertrophy.— Either from deposit on the surface or condensation of tissue. Atrophy from inflammation, injury to nu- trient artery, want of use, etc. — Absorption and expansion of tissue, sometimes producing a porous state (osteoporosis); or there may be softening of the tissue by absorption of the min- eral matter and substitution of fatty or gelatin- matter (osteo-malacia). Fracture. — Callus is formed where bones do not meet evenly. This will give the prob- able age of the fracture. At first lymph is 124 POST MORTEMS. effused, which hardens; then bony spicules appear, and so a spongy mass is formed; the ossification commences about the third week; the "modeling" takes three or four months to complete. In deciding as to fracture of the neck of the femur regard must be had to the natural changes incident to old age. Tumors. — Exostoses, osteomata (growing from the bone), osteophytes (more superficial, not continuous with the bone, from which they differ in texture); enchondromata are lobulated cartilaginous tumors, non -malignant ; fibromata (rare, chiefly in the jaw); sarcomata, of a soft, fleshy, or tough consistence, may ossify and produce osteo-sarcomata. Endosteal sarcomata and myeloid tumors grow within the medullary canal ; they are generally of a deep crimson color, dry and soft ; myxomata (tumors like jelly); o/ngiomata (nature uncer- tain). Hcematoma (from effusion of blood). CephalhcBmatoma is a tumor met with on the heads of new-born children during labor. Cancer (rare), generally secondary as a soft tumor within the medullary canal; tubercle (doubtful); hydatid (rsire). JOINTS. Inflammation. — Simple Arthritis. — Red- ness (injected), effusion, often containing flakes of lymph, pus (in severe cases); pulpy degen- eration, the effusion having formed a soft thick tissue. Chronic Arthritis (Rheumatic), — Follows in- jury or rheumatic fever. In its early stage as a simple inflammation; after a time nodular masses form round the edge of the joint; then the cartilage is destroyed ; the surfaces of the bone are polished and gradually worn down. This disease is frequently mistaken for old- standing fracture or dislocation. Gouty Arthritis is shown by a white, chalk- SIZES OF THE DIFFERENT ORGANS. 125 like deposit of urate of soda in and around the joint. Phosphate of soda may also deposit in the same way. Loose Bodies often form in the joints, from a millet seed to a small almond in size ; they are composed of fibrous tissue ; their path- ologic import is undetermined. Rheumatisin. — Acute (morbid appearances have not been observed much). — Sometimes at first little change, at other times there is a pink color ; or there may be effusion, with flakes of lymph. Chronic. — Swollen condition of the membrane, otherwise not much change. Scrofulous Inflammation ( White Swell- ing). — In its early stage it has been seldom seen, but then as acute inflammation. Later Stage. — Synovial membrane is of a deep red color, eroded in parts; this increases till all of it is destroyed ; the pus is most offensive. Pysemic, sjonorrhoeal, puerperal, and scar- latinal "rheumatism'^ are all inflammations due to septicaemia. For the first few days the joint contains thin, dirty- colored pus ; then destruction of the synovial mem- brane takes'place. XII. VARIATIONS IN THE SIZES OF THE DIFFERENT ORGANS. Prof. Beneke has reached the following con- clusions, which have been published in a re- cent circular of the War Department : 1. Before puberty the aorta is smaller^ than the pulmonary artery; after this period the relation begins to be reversed, and in advanced life the aorta is always the largest. 2. The aorta and pulmonary artery are ab- solutely smaller in the female than in the male, but relatively to the length of the body there is scarcely any difference between the circum- 126 POST MORTEMS. ference of the arteries in the two sexes, while the heart in females is absolutely as well as rel- atively smaller than in males. 3. In adult males the volume of the lungs is greater than that of the liver ; in adult females the reverse seems to be true. 4. In men the volume of the two kidneys is nearly equal to that of the heart; in children it is greater. 5. Children have relatively larger intestinal canals than adults. 6. Sudden increase in the size of the heart occurs at the age of puberty. 7. The iliac arteries diminish in size during the first three months of life. 8. The cancerous diathesis is in the majority of cases associated with a large and powerful heart and capacious arteries, but a relatively small pulmonary artery, small lungs, well de- veloped bones and muscles, and tolerably abun- dant adipose tissue. Pulmonary tuberculosis is often associated with an unusually small heart. 10. In constitutional rachitis, the heart is generally large and well developed ; the arte- ries are also large. THE POST-MORTEM APPEARANCES IN NEW- BORN CHILDREN WHERE DEATH HAS BEEN CAUSED BY SUFFOCATION. Nobiling, in the Arizliches Intelligenzblaitj gives the following'summary as the results of his investigations : 1. Extensive hemorrhages into the skin are caused by external violence— difficult labor, operative procedures and endeavors to resusci- tate being excepted. 2. Hemorrhages into the muscles of the neck and along the great vessels always point to SIZES OF THE DIFFERENT ORGANS. 127 attempts at choking, with the same exception as in 1. 3. The following likewise always indicate external violence : Hemorrhages between the capsule and substance of the liver, or in the organ itself; tearing of the peritoneal covering or the parenchyma of the liver, spleen or kid- neys (not a rare occurrence when restoration to life has been attempted). Furthermore, hem- orrhages into the umbilical cord occur very rarely during labor or the performance of arti- ficial respiration ; they are caused, for the most part, by tearing or attempting to tear the cord. 4. Hemorrhages of great extent into the skin arise from difficult labor or external violence ; hemorrhages into the lips, tongue, gums or mouth are always suspicious. Swelling of the lips — apart from its occurrence in face presen- tations — is always to be considered an indi- cation of violence; so should be considered hemorrhages into the external auditory canal or auricle. 5. Effusions of blood into the muscles except the muscles of the heart, eye and tympanum, are always caused by external violence. The same exceptions are to be made here as in 1. 6. The substances, fluid or solid, through which suffocation has . ensued are usually to be found in the respiratory and digestive tracts, in the drum of the ear and the Eustachian tubes — indeed almost always in all of them. 7. Blood in the larynx, trachea, bronchi and alveoli has been sucked in by inspiration ; it has come from th« nose of the child or the par- turient canal. To a similar source is to be at- tributed blood found in the mouth, oesophagus or stomach. 128 POST MORTEMS. xrii. POST-MORTEM WOUNDS. It is hardly necessary to say that the utmost care must be taken during a necroscopy not to prick or scratch the skin, especially so if the subject has died of peritonitis, puerperal fever, erysipelas, scarlet fever, and other zymotic dis- eases ; also when the body is in a state of de- composition. If the skin is injured before commencing the examination, apply Friar's balsam, tincture of tolu, or collodion ; then cover with several lay- ers of sticking plaster, and grease or wax this well, so as to make it water-proof. If the skin is injured whilst performing the necroscopy, wash in cold water, suck well, and afterwards bathe or soak it in a mixture of dilute sulphurous and carbolic acid, as strong as can be borne. It must be remembered, how- ever, that strong carbolic acid will produce a painful sore, and that both these acids in dilute form, applied for some time, will destroy the epiderm; but this last effect is not of much consequence. The Editor has always used a pencil of nitrate of silver pressed well down into the wound. The painful inflammations which often arise from post-mortem wounds are relieved by paint- ing the part with strong perchloride of iron solution. If constitutional symptoms show themselves, as inflammation of the lymphatics these are best met with hyposulphites, of which the magnesic are the most efficacious; they should be taken very frequently, as every two hours. The sulphurous acid applied locally and the hyposulphites taken internally are so powerful in counteracting septicaemia that by their use blood-poisoning may be almost entirely pre- vented. INSTRUMENTS REQUIRED. 129 xiy. INSTRUMENTS BE QUIRED. The fewer instruments the better when the necroscopist has to carry them all with him, but in a well-appointed mortuary everything that can assist, even in minute details, should be provided. 1. Scalpels. — Three or more of moderate size, with rather broad blades, the cutting edge curved and the points blunted. Two or more of the usual kind for special purposes, and a large one for cutting the cartilage of the ribs. A long, thin, moderately wide-bladed knife, for slicing the brain, kidneys, etc. A Valen- tine's knife is very useful for making micro- scopical sections. 2. Saw. — This may be an ordinary meat or dove-tail saw, with or without a movable back ; a special saw or raehitome^ for opening the spine, is often required. 3. Scissors. — Straight and curved, also a pair for cutting the intestines, one blade hook- shaped (enterotome); it is useful also to have a a bronchotome, or narrow, unequal-bladed scis- sors, for opening the bronchi and blood-vessels. 4. Forceps.— These should be longer and stronger than the ordinary dissecting forceps. 5. Hooks. — Best mounted in handles ; those on chains are dangerous ; hooks may be extem- porized out of bent wire or pins with string attached. In fact, pliable copper wire will be found very serviceable for various purposes. 6. Mallet and Common Chisel.— A layer of leather or rubber on the striking part of the mallet serves to deaden the sound of the blows. 7. Tape Measure.— Made of stiff cloth. 8. Spring Balance — or beam scales— to weigh from a quarter of a pound up to ten 130 POST MORTEMS. pounds. In the mortuary a larger one should be provided for taking the weight of the entire body. 9. Needles. — These must be strong, curved and with cutting points 3 to 5 inches long. A few smaller ones are sometimes needed. 10. Cord. — Nothing answers better than the coarsest crochet cotton, or very even string, which should be well waxed before using. 11. Pins with and without guarded points. These last are serviceable for fastening up holes in the intestines, stomach, etc. 12. Bone Forceps.— Large and powerful, hawk's-beak shaped are best. 13. An Iron Ring, with three screws to fasten to the head to guide the saw, and with a handle to steady the head. 14. Several Blocks of Wood to sup- port the head; in the mortuary, however, a head-rest should be attached to the table with adjustable screw slide. A modificat/on of the iron ring and head-rest combined is very good. 15. Various Minor Necessaries. — Sponges, calico rollers, cloths, pieces of oiled silk or gutta-percha tissue (for taking away specimens), blow-pipe. India-rubber gloves, Coddington or Stanhope lens, hone, pots and jars for speoiciens, etc. In a well-appointed mortuary provision should be made for pho- tography. 16. Disinfecting Solutions. — Perman- ganate of Potash, or Condy's Fluid; Sir W. Bur- netCsy or Chloride of Zinc. — This latter solution is colorless, inodorous, and, diluted, preserves tissues almost for ever. Sulphurous Acid is the most valuable, remov- ing the cadaveric odor and preventing post- mortem sores ; this, combined with about a fourth part of carbolic acid to ten parts of water, is perhaps more efficacious. ORDER OF EXAMINATION. 131 Bond^s Terebene sprinkled over the body removes much of the unpleasant smell. Carbolate of Soda and dilute Carbolic Acid are very useful. The Illustrated Medical Journal Co., Instrument Dealers, Detroit, Michigan, offer the following compact Post- Mortem Case for 110.50. It contains: 1 Large Knife and Saw in one Handle; 1 Tenaculum ; 3 different sized Scalpels ; 1 An- eurism Needle; 1 Pair Forceps; 1 Pair Scis- sors ; 1 Set Chain Hooks ; 1 Blow Pipe ; 1 Post Mortem Needle ; 1 Chisiel. Knives, etc., have ebony handles. All in polished Mahogany Case, with Lock and Key. XV. OEDEB OF EXAMINATION AND TA- BLE FOB NECBOSCOPIC BECOBD. PRELIMINARY OBSERVATIONS. Place where necroscopygwas conducted — date — name of deceased — age — place where seen:— persons present — remarks on their behavior, etc. — state of locality — objects near. Measure- ments of distances to be accurately made. 132 POST MORTEMS. EXTERNAL EXAMINATION. Appearance of Body. —- Condition- position — clothing — height — weight — muscu- larity — proofs of death. Objects likely to have caused death, as knives, cords, bottles, etc., notice how and where they are placed. Pre- serve any vomited matters, also blood-stains. State of the Skin. — Clean or dirty, nat- ural or acquired color. Signs of decomposition. Marks of injury, disease, tattooing, naevi, warts, scars, etc. Condition of mammae ; silvery lines of preg- nancy on abdomen and breast. State of the Natural Orifices.— Eyes, ears, nostrils, mout>^, anus, urethra, vulva. Look for foreign bodies, signs of wounds, etc., in these. State of the Limbs.— Position ; rigor mortis. Size of hands and feet; delicately or coarsely formed, showing signs of handicraft. Special marks. Condition of the nails; con- tents (blood, dirt, grass, etc.) Features. — Relaxed or contracted ; eyelids closed or open ; condition of cornea and pupils. Mouth ; contents, position of tongue, state of the teeth. Carefully examine the Spine for disloca- tions, fractures, punctures, etc. INTERNAL EXAMINATION. Thorax uncovered (not opened), abdomen opened. Amount of fat or its absence on chest and abdomen. Wounds. State and position of the undisturbed abdominal contents, perito- neum, mesentery, etc. Foreign bodies ; disease. Position of the diaphragm. Thorax Opened. — Position of thoracic organs. Pericardium; mediastinum; pleura (undisturbed). ORDER OF EXAMINATION. 133 Heart. — Shape, appearance, weight. State of coronary vessels. Bulging of auricles and ventricles ; fat. Cavities. — Clots; muscular structure; valves. Vessels, — Aorta, pulmonary artery, vena cava, etc. Larynx, Trachea, Bronchi, etc.— Ab- normalities, foreign bodies, disease, etc. Lungs. — Pleura — adhesions, contents. Eight and left lungs — color, consistence, ap- pearance, weight, etc. ABDOMEN. Liver. — Form, weight, consistence. Gall Bladder. Pancreas. Spleen. Kidneys. — Bight and left; appearance of cortical and medullary substance ; weight. Supra-renal Capsules. Semi-lunar Ganglion. Stomach. — Size, appearance, contents. Tie up both the ends before removing ; and, if nec- essary, seal the whole up at once in ajar. Peritoneum, mesentery. Intestines. — Duodenum, ileum, ileo-csecal valve, appendix cseci, caecum, colon, sigmoid flexure, rectum. Appearance, position, con- tents, disease, etc. Bladder. — Full, empty, state of mucous membrane. Prostate ; urethra ; penis, testicles, etc. Uterus, vagina, etc., poisons may be intro- duced per vaginam ; ovaries, state of the Graa- fian vesicles, etc., Fallopian tubes, etc. HEAD. Scalp, bones, fontanelles. Brain. — Dura mater and arachnoid ; pia mater — superior surface, base, fissures. Grey matter, white; ventricles — 1st and 2nd, 3rd, 134 POST MORTEMS. 4tli and 5th. Corpus striatum, optic thalamus. Velum interpositum, choroid plexus, etc. Base of skull, fractures, caries, tumors, etc. Spinal Cord.— Marks of injury, disease, etc., in the vertebrae and in the cord itself. Dislocation of the atlas. OKGANS OF SPECIAL SENSE. Ear. — External meatus, disease, injury, for- eign bodies. Inner ear. Eustachian tubes. Nose. — Disease, foreign bodies, punctureS through the ethmoid bone. Eyes. — Eyelids, orbit, cornea, lens, cham- bers, retina, optic nerves. Bones. — Fractures, dislocations, shape, col- or, length, disease, etc. Centres of ossification in clavicle, maxillary bones, sacrum, pubes, os calcis, sternum, clavicle, femur. Examine the shape, size, etc. of the pelvis. INDEX. PAGE Air in Veins 108 Addison's Disease 79 Arachnoid 106 Asphyxia 15 Atrophy of Liver 73 Bladder 8) Body, External Examination 7, 25 Bones 122 Brain , HO Bright's Disease 82, 83 Bronchi 44 Cadaveric Rigidity 10 Cancer of Stomach 57 Cancer, Uterine 97 Cholera 68 Circulation, Organs of 30 Clitoris 101 Death, Signs of .....9-17 Digestive Tract 53 Disinfecting Solutions 130 Drowning 18 Dura Mater 105 Dysentery 68 Ear .....121 Embolism 41 Emphysema 49 Endocardium 33 Examination of Body 25, 131 Eye and Lids 119 Fallopian Tubes 93 Gall Bladder 75 Generative Organs, Male 86 " Female 90 Hanging 17 Head, Examination of 27, 103 Heart : 31 Hepatitis 72 Hernia 65 Hodgkin's Disease 77 Hydrocele 87 Infanticide 11 Injuries of Brain 115 Insanity 116 Instruments Required 129 Intestines 62 Invagination ." , 65 Joints 124 Kidneys 79 Lateral Ventricles 113 Larynx 44 Leuksemia 77 Ligaments, Uterine 91 Liver 70 Lungs 47 Lungs in Newly Born , , 53 Lymphatic 41 Malformations 11-16 Mammse 102 Meningitis 107 Menstruation 98 Mouth 53 Nerves 119 136 INDEX. PAGE Nervous System 103 Nose 121 CEsophagus 55 Orfices of Heart 37 Organs, Variations in Size 125 Ovaries ^. 91 Pacchionian Bodies 105 Pancreas 76 Parturition 98 Pelvis, Female 90 Penis 88 Pericardium 30 Perinseum 102 Peritoneum 59, 100 Pia Mater 106 Pharynx 54 Phlebitis 40 Phlegmasia Alba Dolens 40 Phthisis 49 Pleura 46 Pneumonia 50 Poisons, Signs of. 21 Poisons in Stomach 58 Portal System 70 Post-mortem Wounds 128 Powder Marks 19 Preservation of Tissues 28 Prostate Gland 88 Puerperal Fever 99 Eape 100 Respiration Test 12 Respiratory System 42 Rheumatism 125 Scrotum 86 Sewing up Body 29 Shape of Heart 37 Signs of Death 17 Skin 121 Skull cap 104 Solutions, Disinfecting 130 Spleen 76 Spermatic Cord 88 Spinal Cord 116 Starvation 17 Stomach 55 Suftocation 17-126 Supra-Renal Capsules 78 Suicide 19-17 Syphilis 73 Testicle 86 Tongue 54 Trachea 44 Typhoid Fever Lesions 66 Urjemia 109 Ureters 80 Urethra, Male 89 Urinary Organs 78 Uterus 94 Vagina 99 Valves of Heart 37 Veins 39 Viability H Vulva 100 Waxy Liver 74 Wounds, Post-mortem IS IXTSTRTTMENTS JSJT 50 PER CENT. DISCODNT. We Discount usual Catalogue Prices of SURGICAL or DEN- TAL INSTRUMENTS, BATTERIES and APPARATUS and BOOKS, from 15 to 50 Per Cent. Write us for LOW Prices on Instruments, etc., that you wish. Get your HIGH Prices elsewhere. . A FE^¥ OFFERS: BI^^Ii'rTINfl ffi^PR Leonard's "Ever Ready,'* $2. Contains l/iOOrjtlinU IfiiOriO lScalpel;lpr. Scissors; 1 pr. Forceps; 1 Tenaculum; 1 Cartilage Knife; 1 het of Chain Hooks; 1 Blow Pipe. Ail in Wood Case and sent post paid. DAPITFT TfiQl? Leonard's *'Multum in Parvo" Pocket Case, f UUilDl UaOlJ (20 instruments) $8. Contains 1 Scalpel ; 1 Tenac- ulum; 1 Gum Lancet; 1 Sharp-pointed, curved Bistoury ;1 Thumb Lancet; 1 Combined Spatula and Tongue Tie; 1 exploring Needle in Case; 1 Combined Male and Female Catheter and Caustic Holder; 1 Combined Torsion, Polypus, Artery and Needle Forceps;! Plam Artery Forceps; iPr. Probes; 1 Combined Director and Aneurism Needle; 3 Needles; 1 Tablet of Silk; 1 Probe-pointed Bistoury. All in a neat, two-fold, Silk and Velvet-lined Morocco Case. TUyPMAMIi'T'CPQ -A- warranted, accurate, self-registering, inde- inDRlttUlUEilEiriO structible index, latest pattern, in a hard rubber case, post paid, $1 00. TAATTI PAPri?!)^ Nickel-plated, octagonal joints, warranted. lUUifl lUIVvrirO Four pair for $5; three pair for $4; two pair for $2 70. All post paid. QTH'TUAQrABrQ Bi-aural, soft rubber tubes, postpaid $2 00 OiI!iinU0V;Uri:iO Camman's hi-aurcX " $1 75 "DAppr'PQ ElUotVs Obstetric, with Fcrew in handle, nickel-plated, iUilVjDrO postpaid, $5 00; Thomas', $4 50, post paid; Hodges', $4 50, post paid. Uterine, long dressing, $1 15, post paid. nVBAI\FPMTP QVPTMfU'Q In a neat case, with bottle and two nin/UDRlllll; OiiliilUDO gold-plated needles, screw-heads, fenestrated metal barrel, washers, etc., post paid, ^1 15. Uterine Applicators, post paid, 60c. Panquelin's Thermo-Cautery, 2 points Complete, in Case, 5^28. Stomach Pump, Aspirator and Syringe Combined, $12. THE ILLUSTRATE MEDICAL JOURNAL CO., Surgical Instrument Manufacturers and Dealers, Leonard B ock, i8 John R. St,, Detroit, Mich, All the abov^ *'offers'* post p lid on receipt of price.