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1 2 3

!^5^Ba(»»'

SYLLABUS

Post Mortem Methods

FOR THE USE OF

STUDENTS

IN THE

Montreal General Hospital

WYATT JOHNSTON, M.D.

Pathologist to the Hospital.

C. ASHFORD.

Montreal.

1890.

All medicl students should leave college prepared to per-
form an autopsy properly. This is especially necessary in a
country where, as yet, there exists no class of trained medico-
legal specialists, and where the youngest practitioner in the
district is usually the one called upon to perform autopsies for
the coroner.

The liest way for a student to learn to recognize pathological
changes in organs is by carefully studying normal organs
whenever opportunity offers.

By studying up the methods thoroughly before entering
the post-mortem room, students would derive far greater advan-
tage from the opportunities given them there. Comparatively
few students learn to dissect the brain and heart properly,
though the brains and hearts of animals can be bought at any
butcher's stall, and serve very well for practising the methods.
The method given here for the heart, though not a neat one,
is so simple as to require absolutely jio technical skill in carry-
ing it out. It is the one followed in the Munich Pathological
Institute.

The rest of the technique seems to be regarded as common
property in all text books. The diagrams were drawn by
Mr. A. Holdstock.

« J

DIRECTIONS

FOR

Performing Post Mortems.

1. By following a good method in mak-
ing poNt-mortenis every organ can be examined in
its turn without interfering with the examination of the
remaining organs ; the body is not disfigured and the
autopsy is completed in a reasonably short time. This
ensures much better results than when the examination
is conducted in a haphasard way, governed only by
the special clinical features the case may have pre-
sented. The method introduced by Virchow is readily
learned, and no great technical skill is required to
carry it out. '1 he one here described differs from it
only in unimportant details.

It will be seen that the autopsy begins with a care-
ful external examination of the body. Next the brain
is examined, though there is no serious objection in
most cases to doing this later on if preferred. Then
comes the opening and inspection of the abdomen,
followed by the opening, inspection and dissection of
the thorax ; lastly, the dissection of the abdomen.
The reason for making a preliminary inspection of

the great serous cavities as soon as they are opened,
is that their condition is Uable to be altered from
exposure to the air, entrance of blood, etc. Any
detailed examination of the extremities had l)etter be
deferred till the end of the autopsy. We examine in
sequence the different organs composing each system,
the examination of the urinary organs being finished
before that of the digestive organs is commenced, and
so on.

Virchow's n'.ethod is remarkably well suited for
medico-lcgal ca^es, though certain special prec. tions,
mentioned later on, have thtn to be observed. Other-
wise it will be found but seldom neccis;:r) to depart
materially from the routine here laid ccAvn. 'I'he
chief cases in which it is necessary to modify the
procedure, are those in whic:h the anatomical relations
of the parts are much altered, or whcie ihc organs are
matted together. In such cases it i^ l<esi lo examine
first such organs as are readily got at, remove the
more involved portions en /nasse and dissect tlitm
outside the body in the order found most convenient.

2. Ini^triiiiiciitH. A distinguished American
pathologist, wlio makes upwards of one thousand
autopsies yearly, found it convenient to limit his
outfit to a "vest pocket" })ost mortem case, contain-
ing merely a knife, a small saw and a needle. While
in the hands of skilful persons much can be done with
very few tools, beginners will do well to provide them-
selves with one of the well-filled cases sold by instru-
ment makers. These should contain a c ouple of large
" post-mo'-tem " knives, two or three dissecting scal-
pels, dissecting forceps, probe-pointed scissors, intes-
tine scissors, saw (with removable back), chisel, mallet,
(a very convenient form is that provided with a hook
at the end of the handle for wrenching off the skull-

cap) bone forceps, and probe, as well as needle and
thread for sewing up. For ordinary purposes no
special brain-knife is required.

In addition to these a measuring rule, weights and
graduated glasses are indispensable where scientific
accuracy is aimed at. Some watery solution of iodine
(1%) in iodide of ])otassium is needed to test for amy-
loid degeneration. Plenty of water, a sponge and
some towels are essensial to cleanliness.

A microscope with the usual accessories is neces-
sary for the proper investigation of many cases, and it
should be borne in mind that a very simple micro-
scopic examination of the fresh material, made at the
time of the autoi)sy, may often yield more valuable
information than can r.fterwards be obtained by even
the most elaborate study of the same material when
altered by harc'^ning processes. In hardening por-
tions of tissue, the pieces should not exceed half an
inch in thickness, and should be placed in twenty
times their bulk of the hardening fluid, which is to be
renewed several times.

3. DiNsectioii of boily. Learn from the
first to hold the knife properly. (}rasp it firmly in the
closed fist. Do not hold it with the fingers as in the
dissecting room. What is wanted is i. rapid survey of
the whole body ; not a minute dissection. In cutting
use the whole length of the blade, not the point alone.
Do not press the knife into the tissues, but draw it
through them rapidly ; this leaves the cut surface
smooth. Make the cuts free and sweeping, so as to
expose as large a surface as possible. "A free incision,
even when made in the wrong place and direction, is
preferable to several small cuts correctly made —
smooth though wrong incisions are better than jagged
ones which are correct." (Virchow).

Always put the tissues on the stretch before cut-
ting, either )iy pulling the neighbouring parts to one side
with the left hand, or in the case of elastic organs, by
supporting from below, l^y attending to these direc-
tions, the dissection can be made rapidly, and the
parts are exposed in good condition.

During the entire dissection, keep the fingers
constantly moist by dipping them fre(juently in clean
water, thus preventing any blood, etc., from drying on
them. It will then be but seldom necessary to do
anything beyond simply washing the hands at the close
of the autopsy in order to free them from all unpleasant
odour. In case this cannot be attended to, washing
with diluted Condy's fluid, will be found to remove
the odour promptly, though numerous other disinfect-
ants answer equally well.

4. Note taktni;. The notes of the autopsy
should be dictated at the time. When it is impossible
to do this, they should be written out in full immedi-
ately afterward. Describe each condition at the
time it is observed, nnd before proceeding with the
next step in the autopsy. Describe at length only
what is pathological. Notes concerning normal con-
ditions should be as brief as possible. It is usually
enough to state simj)ly that an organ is normal, but at
times it is better to state upon what grounds this
opinion has been formed. Make the description
entirely objective, stating only what is actually seen,
rather than the opinion formed of its nature. At the
close of the autoi)sy d:aw up a short summary
(anatomical diagnosis) of the conditions found. Ex-
clude all accounts of the technicjue from the report,
except where such details are necessary to make the
description intelligible. Observe the position and sur-
roundings of each organ before removing it ; the size,
external appearances, and any information obtained by

}

])alpaiion etc., before incising. Note the contents
aiul condition of tlic wall in hollow origans. Describe
with special care the appearance of the cut surface
after making an in( ision. The size, weight consis-
tency, texture, moisture, amount of blood present and
occurrence of any abnormal element, are points which
are easier to determine than alterations of color, beside
being more easily dc scribed, and less likely to mislead.
(Compare everything with the normal and judge it from
that standpoint.

5. An opinion as to the significance of the
changes found, and their relation to one another, can-
not be formed until the examination is completed,
as some condition found at a late stage may upset
any oi)ini'^n i)reniaturely formed. A positive opinion
as to the imihediate cause of death is often very dit^-
cult to aiiive at, indeed quite impossible in a certain
proportion ot cases, a fact not taken sufficiently into
account in legal medicine.

G. Preparation^^. The autopsy should not
under ordinary circumstances be performed earlier
than 10 to 24 hours after death; the body during this
time being kept in a cool place.

Place the body on its back upon the table or
board of convenient height, in a well-lighted spot.
Autopsies should not lie done by artificial light whe^e
this can be avoided.

Ascertain if possible the name, age and occupa-
tion of the deceased, the clinical history and the
symptoms attending death. Note the time which has
elapsed since death.

See that everything is in readiness before commenc-
ing, and have clearly in mind the special points to be
determined by the autopsy.

7. Inspection of body. Before beginning
the actual dissection of the hody, make a careful and
thorough external examination. 'I'his should on no
account be ])ostponed, as it cannot be done satisfac-
torily after the dissection has once been begun.

If the body is that of an unknown person, note
with special rare anything which may lead to its sub-
sequent identification.

Note the sex, apparent age, size, development,
and anything specially striking in its appearance.

Note the state of nutrition.

Note the signs of death : — rigor mortis, post
mortem lividity and any evidences of putrefaction.

Inspect in order the various regions of the body,
viz. : — Head, neck, chest, abdomen, back and extre-
mities, examining carefully the natural orifices,— mouth,
njse, ears, anus, genitals. Note any indications of
present or past disease, and any injury or foreign body.
If wounds are present, ascertain tiieir position, extent
and condition. In this examination the condition of
skin, hair, eyes and teeth, should be noted, but any
special disease of the skin is best described separately.

This completes the inspection.

8. Order in wliicli Uie organH Hboulil
be examined. The brain is usually examined first
of all, as otherwise it becomes anaemic through the
blood escaping from the veins on opening the heart.

The spinal cord may be examined either at the
beginning or the end of the autopsy.

The thorax and abdomen are next to be examined,
though in cases where the examination of the brain
is omitted, the dissection can be commenced here, in
the following orde^ : — (1) Open and inspect the

abdomen. (2) Open and inspect the thorax. (3) Re-
move and examine the heart, lungs and organs of neck.

Examine the abdominal organs in the following
order :

Omentum ; spleen ; left kidney and ureter ;
right kidney and ureter ; bladder and urethra ; geni-
tals ; rectum ; small and large intestine ; stomach and
oesophagus ; duodenum, bile ducts, portal vein, gall
bladder and liver ; pancreas ; supra renals, coeliac
ganglia, mesentery, retro-peritoneal glands, vena cavn,
aorta, thoracic duct, etc.

Last of all, if necessary examine the extremities,
bones, joints, peripheral vessels and nerves.

9. Opening tlie liead cavity. Place a
block of wood under the head to support it, and make
an incision commencing close behind one ear, passing
directly over the vertex (top of the head) and ending
close behind the other ear, cutting down to the bone
all the way. If the hair is long it must first be parted
in the line of the incision, and tied up out of the way.

Next reflect the tvvo halves of the scalp forward
and backward with a knife or chisel, till the orbital
ridges and the occipital protuberance are exposed,
taking care to keep the point of the instrument direct-
ed against the bone so as not to injure the scalp.
Tuck the hair under the folds of the scalp to keep it
from being soiled. Note carefully the condition of
scalp and skull cap.

Draw a line with the knife around the skull where
the bone is to be sawn through, cutting the temporal
muscles. This line should pass just above the frontal
eminences in front and through the occipital protuber-
ance behind. Instead of a single circular cut it is bet-
ter to saw in two planes, shewn as the dotted lines
FT and OT in figure 1, intersecting at the mastoid

"fym

!' ffl»^e i ffu^g|vy^^^ '

1-2

region on each side. The skull-cnp is then easier
to retain in position when the body is sewn up.

Fig. 1. — Diagram to illustrate the method of re-
moving the skull-cap. The hone is first
sawn through in the i)lane K T and after-
wards in the plane O T.

In sawing, steady the head with the left hand,
which should be [protected with a towel in case the saw
should slip. In most cases it is sufficient to saw
through the outer table only and crack the inner by
a few taps with a mallet and chisel at different
spots ; but in cases where fracture of the skull is
suspected, both tables must be sawn completely
through, even at the risk of wounding the brain, lest
a fracture be artificially produced. IVst the dei)th
of the cut from time to time with the j)oint of the
saw, remembering that the bone is much thinner in
the temi)oral region than elsewhere. As the thickness
of the skull may vary from nearly half an inch down
almost to that of stout writing paj)er, it is often im-
possible to avoid injuring the brain to some extent
but as the sensation imparted to the hand becomes
quite different as soon as the bone is completely cut
through, the mishap should be recognised at once.

Wrench off the skull cap with the chisel or with
a hook made specially for the purpose. Where the
dura is very firm'y attached to inner surface of the
bone, it may either be removed together with the
skull-cap after dividing the falx, or else the brain itself
may be comi)letely removed with the skull-cap, a more
difficult method Examine the calvariun. Examine
the external surface of the dura. Slit open and ex-
amine the longitudinal sinus.

Divide the dura along the line of the saw cut on
one side, draw it gently over to the opposite side and
examine its inner suface and corres|)onding surface of
the brain. Do the same on the other sic .. Pass a
scalpel carefully between the hemispheres and cut the
falx antericrly, reflect the dura backward, and examine
the pia and brain along the convexity, carefully com-
paring the two sides.

The nature and amount of any fluid which may
have escaped should be noticed. ,

10. To remove the braiiii, tilt the head
back and raise the frontal lobes. Support the hemis-
pheres with the left hand. Cut the optic nerves with
a sharp knife at their points of exit. Pass the knife
round the pituitary fossa, separating the pituitary body.
Divide both internal carotid arteries. Cut the third
nerves at their points of exit. Next pass the knife
along the sharp posterior border of the petrous bone,
dividing the tentorium together with the fourth and
fifth nerves, taking care not to wound the cerebellum
which lies immediately beneath. Divide the remain-
ing cerebral nerves at their points of exit. Finally
pass the knife deeply into the foramen magnum,
sever the medulla as far down as possible, cut the
vertebral arteries on each side and remove the brain,
separating it gently from the dura with the right hand.

11. Exaiiiiiiatioii of* brain. The method
to be followed must depend upon whether it is wished
to determine accurately the extent and relations of a
lesion in the substance of the brain or simply to see
whether any lesion is present at all, being satisfied
with a rough idea as to its extent and location.

In the former case the best method consists in
making a series of transverse sections through the whole
brain at definite levels. This can be done with the fresh
brain by using a long-bladed knife (an ordinary carv-
ing knife answers very well) but the best results are
obtained when the brair; has first been hardened in
a solution of bichromate of potassium, the s;iiue fluid
being injected into the arteries so as to reach the
deeper parts. This process is very tedious and trouble-
some, and is only to be reconmiended when a specially
careful investigation is to be made. For ordinary pur-
poses the following method (Virchow's) is preferable: —

12. Bissectioii of brain. Place the brain
base upwards and examine the base, noting the state
of the pia and vessels.

Turn the brain over and examine the state of
the convolutions and fissures, removing the pia if
necessary by pinching up a fold between the thumb
and forefinger and rolling the brain substance away
from it with the remaining fingers.

Next open the roof of the left lateral ventricle
by a shallow incision made with the point of the knife
dividing the corpus callosum slightly (J") to the left
of the median raphe, and extended into the anterior
and posterior corniia. In making this incision the
roof of the ventricle should be raised by drawing
the hemisphere gently outward with the left hand,
thus avoiding injury to the basal ganglia, which lie
immediately beneath.

mpwnm

Now make a deep incision into the white sub-
stance of the left hemisphere, cLirvinjjj outward so as to
pass just external to the great ganglia, and cutting; al-
most through the cortex all the way. Several similar
incisions external to this one, and parallel with it, will
exjiose the whole of the white substance of the left
hemisphere.

Make a similar dissection on the right side. (It
will be found convenient before doing this to turn the
brain end for end).

The lateral ventricles being now fully exposed,
note their size, contents, — including any fluid which
may have escaped in the process of opening, — and the
condition of the ependyma.

Expose the third ventricle by passing the blade
of the scalpel into the foramen of Munro and cutting
upwards. Reflect the posterior part forward with the
handle of the knife, and, after dividing the posterior
limb of the fornix on the right side, turn it over to
the left, exposing the choroid plexus, corpora
quadrigemina and pineal gland.

Next examine the fourth ventricle, exposing it by
cutting through the vermiform process of the cerebel-
lum, taking care to lift the left lobe slightly at the
same time so as to avoid injuring the floor of the ven-
tricle.

Now examine the basal ganglia by a series of
parallel transverse incisions, beginning anteriorly and
made about a quarter of an inch apart. In making
these incisions the knife should be held lightly
between the fingers and thumb and moved like a
fiddle bow, the blade being kept constantly wet and
the parts put upon the stretch by supporting the
temporal lobes from below, as otherwise the delicate
brain tissue will be torn. The incisions should pene-
trate to the cortex, exposing *he claustrum and the
convolutions of the island of k^il.

■ ■!

A more crude method of examininjj: the ginglia,
is by simply makini^ a couple of longiiiidina! incMsions
through the corpus striatum and oi)tic thalamus on
each hi ie, after o[)ening the lateral veiiiricles.

A few transverse cuts are now made into the cor-
poia (juadrigemina.

Examine the cerehellum by making a series of
deep incisions into each of the lateral lobes radiating
from the corpora (juadrigemina and exposing the sub-
stance of the cerebellum and cerebellar j)edunc!es.

Fold the hrain together and place it again with
the base upwards. Finish the dissection of the arter-
ies at the base and remove them.

Examine the crura cerebri, pons and medulla by
a series of parallel transverse incisions.

If the dissection has been i)roperly made, the
various parts of the brain will still be connected and
the whole organ can st'^ be folded together like a
loosely bound book, each part remaining in its normal
position, so that when hardened any ))ortion desired
can be examined micr()sc()[)ically. The points to be
attended to in examining a brain, are: (I) — to pre-
serve the relation of parts in the manner above des-
cribed, and (2) — by keeping the knife blade constantly
wet, to avoid tearing the brain tissue.

13. Bane ol'Hkull. After finishing the ex-
amination of the brain, examine the dura at the base
of the skull, slitting open the principal sinuses. Re-
move the dura by seizing the edge with a towel and
stripping it off. Fvxamine the bones at the base. By
chipping away the sphenoid bone, the course of the
carotid artery, cavernous sinus and jugular fossa can
be exposed.

14. Ear. The internal and middle ear can
be examined by simply breaking o[)en the petrous bone

mmm

(-
e

:in
ne

in the region of the semicircular canals with the ham-
mer or chisel, and removing the fragments with for-
ceps. This affords an excellent view of the tym-
panic cavity. When, however, a thorough examin-
ation is desired, it is better to reflect down the skin
and external ear by extending the scalp incision
a short distance down the neck, and dividing the
attachments of the auricular cartilages subcutane-
ously. The whole petrous bone can now be removed
by two saw cuts intersecting at the sella turcica.
Holding (he bone in a towel or placing it in a vise,
saw in a plane extending from the posterior border of
the external auditory meatus, to the anterior border of
the internal. The drum membrane is exposed intact,
and the tympanic cavity, mastoid antrum and anterior
mastoid cells are laid open.

15. Eye. To examine the eye, break in the
bony roof of the orbit and expose the posterior half
of the eye-ball at the entrance of the optic nerve.
Cut away the posterior part of the retina with a sharp
pair of scissors, keeping well behind the ciliary region
to avoid disfiguring the parts visible from the front,
and remove it with the nerve attached. A piece of
common cotton wadding placed in the orbit,can after-
wards be made to give the eye a very natural appearance.
The whole eyeball should not be removed without
si)ecial pei mission.

16. Fiici?. To examine the parotid gland and
bones of the face, extend the scalp incision behind
the ear to the angle of the jaw, and dissect down the
soft parts, taking care not to cut the skin. The re-
moval of portions of the skull or face should not, as a
rule, be attempted without special permission, as it is
almost certain to disfigure the features, though by
filling in the defect left with plaster of Paris, moulding

it to give the proper outline, and allowing it to
set before sewing up, a fairly natural appearance ran
be obtained. In no case must the skin of the face he
cut. (See Section 37.)

17. None. By chiseling out the ethmoid bone
a good view is obtained of the upper nasal passages
and frontal sinus. To examine the lower and anterior
parts of the nose, reflect up the upper lip, keeping the
knife close against the superior maxilla, sepnrating the
alae nasi subcutaneously and dividing the cartilaginous
septum.

18. Spinal cord. Place the body, flice down-
ward, with a block beneath the chest Make a deej)
incision from the naj^e of the neck to the sacrum,
passing close to the spines of the vertebrae the whole
way. Dis-^ect away the muscles on each side so as to
expose the laminae. Note anytiiing almormal about
the soft parts or bones.

Open the spinal canal by cutting through the
laminae near the articular i)rocesses. This can be
done with a saw, but it is better to use a rachitome
(chisel specially made for the i)ur|)ose), or simply a
pair of strong bone forceps.

Remove the laminae with bone forceps or hook,
and examine the j^osterior surfiTce of the sjjinal dura,
now lying exj)osed.

Slit open the dura along the posterior surface
with i)robe-i3ointed scissors, and examine the i)ia
mater and nerve roots.

Remove the cord by grasping the dura at the
posterior extremity, and cutting the spinal nerves in
succession at their points of exit. Divide the cord
obliquely near the medulla, or remove it entirely if the
brain has been previously removed. Slit up the dura
anteriorly and examine the pia in front.

■ i '■'•'^

o
m

Letting the cord rest lightly over the left fore-
finger, make a number of transverse incisions — one or
two bc^tween each pair of nerve roots. These should
l)e made with a very sharp knife, held lightly in the
right hand between thumb and fingers and moved in
a sawing manner.

Note carefully the ap])earance of both gray and
wliite matter on both cut surfaces, as eacli section is
made. As the macrosco])ical appearance of the cord
is vety deceptive, if any portion appears abnormal
it is advisable to snip out a minute fragment with
scissor^, s])rcad it out on a slide by gently pressing a
coverglass upon it, and examine it at u.ice micro-
scopically. A thorough microscopical examination
can only be made after t)ie cord has been hardened.

19. Vertebrae. When the examination of the
v'ertebrae is of special importance, the cord had better
be left alone till the thorax and abdomen have been
examined; the vertebral column can then be removed
and either sawn open by a median longitudinal
(sagittal) incision, or, if it is desired to examine the
cord as wtdl, the incision may be made sufficiently fiir
to one side.

A special set of chisels has been devised for the
puri)ose of removing the cord from in front, after the
removal of the thoracic and abdominal organs.

20. Kxaiiiiiialioii of the tliorax and
alHloiiieii. l-^irst o})en and inspect the abdomen,
then dissect the thorax ; finally return to the abdo-
men and finish dissecting it.

Place the body on its back with a block of wood
under the shoulders. Stand on the ri<j;ht side of the
body, hold the large knife firmly in the hand and make
a long straight incision from the episternal notch to
the pubis, passing to the left of the navel and cutting

completely through the skin. This cut should be made
rapidly and with firm i)ressure on the knife. Open the
peritoneum by a small incision in the epigastrium.
Note the escape of any gas. Extend this opening to
the pubis, retracting the right edge of the cut with the
left hand, to avoid injury to the intestines. Note the
character and amount of any tluid in the abdominal
cavity. (Irasp the side of the incision firmly in the left
hand, divide the upper end of recti muscles and dis-
sect off the pectoral muscles, exposing the costal
cartilages and intercostal muscles with a few sweeping
cuts, putting the tissues always forcibly on the stretch
before cutting.

Note the amount and appearance of the subcuta-
neous fat and the state of the muscles, ribs and
sternum. The mammary gland can be examined
by incising it deeply from the inner surface, leaving
the skin intact.

21. Inspect the ailMloiiiiiial cavity,

noting the position and color of the parts exposed,
the presence of abnormal substances in the peritoneal
cavity, etc. This inspection should be made systema-
tically, observing the position of liver, stomach and
intestines, including the vermiform appendix, the posi-
tion of the ])elvic organs, the state of pelvic cavitv,
flanks, and hypochondria. The examination is made
easier by first dividing the recti muscl's subcutane-
ously just above the pubis and turning the abdominal
walls outward. A crucial incision extending across
the abdomen into each flank is sometimes necessary.
If rupture or ])erforation of one of the abdominal
organs is suspected, this point should be settled if
possible before proceeding further with the autopsy ;
if this is neglected, and some such condition is after-
wards found, a doubt mny rennin as to whether it
may not hav^e been made accidentally during the
examination.

».i V >^Wi|1 ^ -i fl - 1Li »^ ■ a •■■

(

22. Find llie lovt'l of llic (liapliraKiii

by plncing the right hand within the abdomen, and
noting on each side tlie highest rii) or S[)ace at which
the finger tips of the left liand can l)e felt through the
chest wall in the nipple line. '1 his must of course be
done before the thorax has been opened. If pneumo-
thorax is susjucted, fill the angle between the chest
wall and the reflected skin with water and punc ture an
intercostal space below the surface, when, if air is jire-
sent, it will be recognized by bubbles rising.

23. Open the thorax by dividing the costal
cartilages just at their line of junction with the ribs.
Make the opening as roomy as i)ossible ; remember
that the cartilages of the lower ribs extend outward
nearly to the axillary line. Cut the cartilages by
pressing forcibly on the knife near the blade, holding
it parallel with the chest so as not to injure the lungs
with the point. If the ribs are calcified, divide them
with the .saw or bone forceps. The cartilage of the first
rib should be divided from bel^w about half an inch
farther out than the second, on account of the width
of the manubrium sterni. Open the sterno-clavicular
articulation on both sides, holding the knife perpen-
dicularly to the joint and carrying the cut round the
head of the clavicle to divide the sterno-clavicular
ligaments.

Raise the lower end of the sternum with the left
hand and cut away the attachments of the diaphragm
on each side, by thrusting the knife point through it
and cutting outward. Diseect off the tissue of the
mediastinum, keeping the point close against the
bone. Open the right sterno-clavicular joint from
below and cut round the upper end of the sternum,
following the upper border of the bone into the left
sterno-clavicular joint ; the sternum may then either
be completely removed, or allowed to remain attached

•)0

by the ligaments on the left side, being simply turned
over out of the way. In raising the sternum care
must be taken not to wound the great veins at the
root of the neck, as in that case the blood will escape
into the i)loural cavity. If the veins are wounded a
sponge should be placed over them to absorb the
blood.

Note the position of the thoracic organs. Ex-
amine the internal surface of the sternum. ICxamine
the anterior mediastinum and thymus or gland. Kx-
the pleural cavity on each side, noting the nature and
amount of any fluid which may be present.

Open the pericardium by pinching up a fold and
incising it with knife or scissors, extending the in-
cision "pward to the root of the vessels.

Note the nature and amount of any fluid in the
pericardial sac and t' e condition of parietal and vis-
ceral pericardium (epicardium.)

Note the position of the heart and the degree of
distention of its chambers. If it is wished to esti!:">ate
accurately the amount of blood in the heart cavities,
the heart should be incised i/i st'///, taking care to
make these incisions where the cavities are subse-
quently to be oj)ened. Feel the arch of the aorta to
ascertain if an aneurism be present, in which case the
aorta should be removed with the heart.

Remove the heart by grasping the ai)ex with
the left hand, lifting it outward and upward, and cuttiiiL;
across the vessels close to the pericardium. Cut
the aorta short enough for the valves to l)e seen, and
test their competency by pouring water into the vessel,
holding up the heart by the auricles. The compe-
tency of the tricuspid and mitral valves can be tested
by pouringwater through a tube passed into the pul-
monary artery and aorta, respectively. These tests are
not very reliable.

25. Open aiMl exiuiiiiie the eavltlcH of
the heart, following the order of the circulation —
right auricle; right ventricle; left auricle; left ven-
tricle. The incisions are best made with the large
probe-pointed scissors used for o[)ening the intestines.

I. Op(in the right auricle by cutting from the
superior to the inferior vena cava.

II. I^ass the probe-pointed scissors down the
[)ulm()nary artery and into the right ventricle and
open it by an incision, passing between the segments
of the pulmonary valve and extended to the apex,
kee|)ing just to the right of the septum. P^xamine
carefully the (Uivity of the ventricle and the valves
before proceeding further.

III. Pass the probe pointed blade of the scissors
through the trie i)id orifice, and cut across the face
of the tricuspid valve, extending the incision to the
apex of the right ventricle, along the right border of
the heart.

'I'he left chambers are examined in a correspond-
ing manner.

IV. Slit open the left auricle where the pul-
monary veins enter.

V. Pass the scissors down the aorta into the
left ventricle, drawing the pulmonary artery over to the
right so as not to wound it, and cut behind it along
the left side of the septum as far as the apex. As one
of the aortic cusps lies directly in the track of this
incision it is difficult to avoid injuring it. Examine
the interior of the ventricle and the valves before
making the next incision.

VI. Make an incision from the left auricle to the
apex of the left ventricle, passing the probe-pointed
blade of the scissors through the mitral orifice, and
cutting along the left border of the heart.

The method of opening the heart will be under-
stood better by referring to the diagrams.

Figure 1 is intended to shew the dissection neces-
sary for exposing the right chamhers of tlie heart.
The dotted hnes indicate the course of the incisions
and the arrows shew their (hrection. The numbers
I, II, III show the order in which the cuts are to L^e
made.

Figure 3 shews in a similar manner the incisions
for the left chamhers, the course of the incisions being
marked by dashes numbered IV, V and VI. The
pulmonary artery has been drawn over to the right.

In figure 4, the incisions for both sides are shewn
in the same diugram.

As each chamber is opened remove the blood
clot, observing its character, and the appearance of the
valves, endocardium and heart muscle, making incis-
ions into the muscle if necessary. Slit open the cor-
onary arteries and examine them.

Measure with a rule the circumference of the
different orifices after they are cut across, also the
average thickness of the ventricular walls. The dis-
tance from its apex to the base of the nearest sigmoid
cusp, is the best index of the si/.e of a ventricle.
Weigh the heart.

MEASUREMENT OF HEART.

5.V in 13 cm.

((

7.5

Tricuspid orifice

Mitral '* 4^

Pulmonary *' 3 J

Aortic " 3

Right ventricle length 3^ " 8

Left " " 3 " 7.5

Right '' thickness of wall J " 0.4

Left " " " " i " 1

20. I^uiigs. Remove each lung separately,
breaking down with the fingers any pleuritic adhesions
that may be present. If this cannot be done without
tearing the lung tissue, insert the fingers between the

«(

((

leces-

leart.

Iisions

mhcrs

to l}e

:isions

being

The

i,u;ht.

shewn

blood
) of the
l; incis-
he cor-

) of the
also the
The dis-
sigmoid
ventricle.

.13 cm.
.11 "
. 8 "
7.5 ''

. 8 "

T.r)

.0.4

. 1

eparately,
adhesions
e without
Aveen the

DIAGRAMS

TO ILLUSTRATE METHOD OF OPENING HEART.

Wig* 2* — The dotted lines represent the lines of incision for opening
the right chambers, .ind are numbered I, II and III,
corresponding to the order in which they should be made.

ao.

Fi|f . ;i.- The lines of dashes show the incisions for opening the left
chambers, the num!)ers IV, V and VI giving their order.

. ..o

^o.

pv.

In Figure 4 the incisions for hoihsides are shown in a
single diagram.

The lettering is the same in all the figures : R.a.,
right auricle; R.v., right ventricle; L.a , left auricle:
L.V., left ventricle ; P. a., jnilmonary artery; I'.v., pul-
monary veins ; S.c, superior cava ; I.e., inferior cava ;
A.o. , aorta.

. 'fr- .i- | lWM' » 'B » lg.«»»a»l3«llW.3g(B*^ ■» «^♦-«^.••«

costal pleura and chest wall, strip it off and remove it
with the lung. Pull the lung forward out of the chest
and cut across the bronchi, cutting close to the root of
the lung so as to avoid wounding the oesophagus.
Weigh the lung.

Note the api »earancc of the surface and the results
obtained by palpation. Make a long smooth incision
extending from apex to base along the posterior bor-
der, exposing as large a surface as possible. This
incision is easily made if the organ is balanced on the
left hand, or still better if a Sj)onge is placed beneath
it. The incision should not sever the large bronchi
and vessels. Subsequent incisions can be made
parallel to this one or transversely to it. P^xamine
the cut suface as to color, consistency, texture, amount
of blood, air. fluid, or solid exudation, etc. FAamine the
opposite lung in the same way. Slit up and examine
the bronchi and vessels.

27. Organs of neck. Extend the original
incision u])wards to the level of the hyoid bone, or,
if permissible, to a point one inch below the tip of
the chin. Free the skin and subcutaneous tissue from
the deeper parts as widely as j)ossible on each side.

Puncture the floor of the mouth just behind the
symphysis of the lower jaw, and sever the attachment
of the tongue to the inferior maxilla on each side by
l^assing the knife along the inner surface of the bone
as far back as the angle of the jaw. Draw down the
tongue through the floor of the mouth with the left
hand. Cut across the soft palate, divide the posterior
wall of the pharynx as near the base of the skull as
possible and carry the incision behind the tonsils on
each side. By drawing the tongue downward, the
pharynx and cesophagus can be dissected off from the
vertebra), with the cervical vessels and nerves attached.
At the root of the neck the vessels of the arm should

■ -Vfr.'i-^f^ertrrt^Ti^'^-^-t^ii^.-^m

be divided on each side, by cutting outward and back-
ward behind the head of the clavicle. 'I'he tesophagus
can either be divided above the bifurcation of the
trachea or just above the diaphragm. In some cases
it is convenient to ren ve the organs of the neck
together with the heart . iungs.

Examine the nerves aud vessels^ the tongue and
sub-maxillary glands and the thyroid gland.

With probe-{)ointed scissors cut across the soft
palate close to one of the tonsils and slit open the
pharynx and (oso|)hagus along the posterior wall.
Examine j)harynx and (esophagus, especially in the
region of the glottis. Slit up and examine the larynx
and trachea along the posterior wall, drawing the reso-
pifcagus slightly to one side. Examine the 'bronchial
glands.

28. I>iKHectioii of tibtloiiieii. Remove the
block from beneath the body and cut the diaphragm
on each side, this will cause the liver and stomach to
gravitate toward the thorax and so afford more s})ace
in the abdomen. Examine the peritoneum and omen-
tum, removing the latter. Draw forward the large
intestine, beginning at the sigmoid flexure, cutting
the peritoneum and the loose cellular tissue behind
it. After freeing the colon and coecum in this man-
ner, remove the ileum and jejunum, putting tlie mes-
entery on the stretch and separating it as near the gut as
possible by making sawing cuts across it with a sharp
knife. The duodenum is left to be examined later in
situ. The intestines may be simply turned out to the left
side of the body till the time comes for examining
them, or they may be completely removed by dividing
the commencement of the jejunum and cutting off
the rectum at the brim of the pelvis — first ligaturing
them if the contents arc fluid. It is well to remember
that the duodenum lies immediately under the ascend-

-*^^

Tf,

'\A

s
e

►ft

ing colon on the right side, when the small intestines
are turned over to the left, and the commencement
of the jejunum is found at the left side of the mesen-
tery by turning the small bowel over to the right.

20. Spleen. Remove the spleen, freeing it
with the fingers from any attachments which may exist,
and dividing the vessels at the hilus. Weigh the organ,
examine its surface, and expose the pulp by a single
incision along the convex surface, in the long axis.

30. Kiflneys. Remove the left kidney by
cutting the peritoneum in front and shelling it out
with the fingers from the loose connective tissue (fatty
capsule) surrounding it. (]ut the vessels at the hilus.
Divide the ureter at the brim of the pelvis, unless it
is desired to preserve the continuity of the whole
urinary tract.

\Veigh the kidney and examine the surface, after
incising the capsule and peeling it off. Make ah
incision along the convex border, extending the whole
length of the organ and deep enough to expose the
pelvis. In making this incision the kidney should be
held lightly in the left hand with the hilus toward the
palm. Examine the condition of cortex, medulla and
pelvis, and slit open the ureter. Examine the right
kidney in the same manner.

Make a small incision into the bladder and note
the character and amount of the urine.

31. Remove the eoiiteiits of* the pelvis

— first cutting through the i)eritoneum and cellular
tissue around the brim ; then, holding the bladder and
rectum in the left hand to put the tissues on the stretch,
pass the knife around the i)elvic wall close to the
bone, dividing all attachments; cut the rectum across
near the anus, and cut the urethra as (i\r forward as
possible under the pubic arch, depressing the handle
of the knife backward.

32. External genitaU orgaiiN. In foinalcs,
H" it is wished to remove the external genitals, together
with the pelvic organs, separate the legs widely and
make an elliptical incision i)assing from the pubis to
behind the anus on each side, including the pudenda
and the whole perineum. Bypassing the knife under
the pubic arch and separating the attachments to the
pubic bones, the whole of the external genitals, as
well as the j)erineum and anus, can be drawn into
the pelvis and removed.

In males, the penis can be removed by extending
the abdominal incision downward, dividing the penis
subcutaneously as far forward as may be necessary,
and drawing it under the pubis into the pelvis after
dividing the attachments. The testes can be removed
by enlarging the inguinal ring and pressing them out
from below, dissecting out the course of the vas defer-
ens if necessary. They can be returned to the scrotum
after examination.

i •

33. l>i8NCCtioii of pelvic or^aiiH. First
slit open the bladder and urethra along the anterior
surface and examine them.

In males, make transverse incisions in each lobe
of the prostate from behind. Examine the vesiculae
seminales, vas deferens and testicles.

In females, examine the external genitals. Slit
up vagina along the left side and examine. Dissect
the bladder free of the uterus on one side. 0[)en the
uterus by an incision anteriorly in the median line,
with lateral incisions into the cornua. ICxamine the
fallopian tubes, broad ligaments and ovaries, exposing
the ovaries by an incision along convex border.

Slit open and examine the rectum.

34. InteHliiien. Slit oi)en small and large
with the " intestine scissors " by inserting one blade

.^,:>^^smmMl^smsmmme'ii>*u0'^''*^-^

in the bowel and drawing the gut against the angle
formed by the other blade. The small intestine
should be opened along the mesenteric attachment ;
the large, along one of the longitudinal muscular
bands. Note the nature of the contents and examine
the mucosa. To prepare the mucosa for examination
after opening, draw the intestines between the first and
second fmgers of the left hand (which must be kept
wet), rinse in a pail of clean water and spread them
out on a tray or table.

Slit open the €liioclcnuiii along its anterior sur-
face. Note the contents and the state of the mucosa.
S(iueeze the gall bladder and see if bile flows from
the common gall duct.

Remove the Ntoinacli unopened, ligaturing the
upper part of the duodenum and the oesophagus, or
pinching the cut ends between the fingers. Cut the
oesophagus just above the diaphragm. Draw forward
the stomach and dissect off the attachments along
the lesser curvature. Cut the duodenum just beyond
the [)yloric ring. Ojicn with probe-pointed scissors
along the greater curvature, and examine the contents
and the state of the inner surface The stomach
{ .n be opened in situ by continuing the incision from
the duodenum along the greater curvature.

Raise the anterior edge of the liver and dissect
the bile ducts, hepatic artery and portal vein. Open
and examine j?all hlsulder.

35. The rciiiaiiiiiiiif alKloiiiiiial organs

may be conveniently examined in the following order.
Remove the liver by dividing the suspensory
Hgament and the lateral ligaments on each side. Weigh
the liver and examine the surface. Make a deep trans-
verse incision into the up{)er surface of the liver, cut-
ting deeply into both lobes.

Remove and examine the paiicreiiH, making a
longitudinal incision into it.

Examine the wiipra-rciiiilN, (whieh lie on either
side of the cceUac axis.)

Examine the mesentery.

SUt open tlie veiiat cava liift^rior.

Examine tlie semihmar gangha. (These are
found lying close to the coeliac axis after dissecting
up the vena cava.)

Examine the retro-peritoneal and retro-thoracic
glands.

Slit open the aortF

Examine the thoracic duct, (whi( h lies between
the aorta and oesophagus on the ri dit sidc; just above
the diaphragm.)

36. ICxaiiiliio llie extrcniitieH aiitl trunk

if necessary. The vessels are best examined by slitting
them up with prol)e-p()inted scissors after they have
been exposed. The incisions for the limbs should be
made in their long axis.

37. Ill ortler to saive time, when several
students are em[)lc)yed at once upon the same case ;
the following order will be adopted : —

1. Preliminary inspection.

2. Oi)ening of head cavity; opening of abdomen ;
removal of intestmes.

3. Opening of thorax ; dissection of brain.

4. Dissection of thorax ; examination of intes-
tines.

5. Dissection of abdomen ; removal of organs
of neck.

6. Dissection of organs of neck, and posterior
abdominal regions.

SCT

38. Sewlnjc up. At the close of the autopsy
the body cavities should he carefully si)onged dry, and
all organs not needed for subsecjuent examination
should be placed in them before sewing up. As it is
impossible to return the whole brain into the head
cavity after it has once been taken out, only return as
much as will readily go in and place the rest in the
abdcjmen. When the whole brain is retained it is
l)etter to place ])art of the liver in the cranial cavity to
make up the i)r()per weight of the head. All incisions
are to be carefully sewn up, making the stitches at
regular intervals, not more than half an inch apart,
taking care to pass the needle from within to without,
as the thread is then less visible. This is called the
glovers' stitch.

Try to restore the natural outlines as much as
possible, securing the skull cap in position by boring
a hole in the skull cap on each side in the temporal
region, and uiaking corresponding holes just below the
line of the saw cut. By passing copper wire through
each pair of holes and twisting it tight on the outside the
skull cap will be retained firmly in position. The
sternum can be brought into position in a similar
manner by wiring the ends of the costal cartilage^.
Where portions of bone have been removed the
natural appearance may be restored by filling the
vacancy with i)laster of paris, moulded so as to give
the natural outline, and allowing it to set before sew-
i ng up.

After sewing up the body, it should be carefully
washed before being dressed and laid out in the coffin,
and it should be seen that there is no blood oozing
from any of the incisions.

39. Aiitopnio^ in private lioiises. The

preparations should be as simple as possible, so as not
to annoy the inmates. At the close of the autopsy

VtfPm-

everything should be left exactly as it was fountl be-
fore comnicncing. A careful mental note should
therefore be made of the position of articles of furni-
ture, as well as clothini^, wreaths, etc., before they are
disturbed. Throughout the autopsy any noise, such
as hammering or sawing, should be avoided as far as
possible. The most scrujiulous cleanliness must be
observed throughout.

It is easier as a rule to remove the clothing from
the body and afterwards replace it, than to avoid soil-
ing it if it is left on. Shirts or gowns can be torn
down the middle 'I'he best plan is to secure the
presence of the undertaker and arrange that the body
shall not be put into the coflin till after the autopsy.
It is well to see also that no embalming lluid is
injected, as this alters the appearance of the tissues
materially.

The body should be placed in a good light. If
possible obtain a table or undertaker's trestle, but
when necessary the body can often be examined in the
coffin. Some newspapers or a sheet should be i)laced
beneath the body, to avoid soiling the clothing anil
floor. A jug of water, a couple of pails or basins, some
towels and a sponge, are also needed.

Before leaving sec personally that any blood-
stained or dirty water has been emptied out, and that
the room is well aired.

40. HfcMlico Ic^iil aiitop.sioH. As the

object here is to ascertain the cause of death with
special reference to the possibility of foul play, every-
thing bearing on this i)oint should receive s[)e(ial
attention. While any carefully performed autopsy
answers the requirements of the coroner's court fairly
well, there are certain special precautions not neces-
sary under ordinary circumstances, the neglect of
which renders the evidence worthless.

•WHItM'Tt-^'-

All details in the circumstances and surroundings
under which the body was found, which may have any
bearing on the case, sliould be carefully noted.

The body should be identilled before the exam-
ination is made. Where this is impossible note with
special care anything in its appearance, size, colour
of hair and eyes, condition and number of teeth, any
scars, tatoo marks, moles, etc., which may lead to
subsetiuent identification. A good photograph of the
body is of special value for this pur[)ose. A plaster
cast of any i)art may also be made and preserved.

The external examination of the body must be
made with extreme care, and if any wounds or injuries
are [)resent their exact nature and condition must be
stated. It is very im[)ortant, in medico legal cases, to
distinguish between discolorations of the skin due to
hemorrhages, and those due simply to one of the two
[)ost-mortem changes, gravitation of blood to depend-
ant parts, or from diffusion of the haemoglobin. In
h"i)ostasis the part becomes [)ale by simply pressing
on it ; in post-mortem staining it will readily be seen,
by making an incision, that the colouring mat< * has
simply stained the tissue about some small subcu-
taneous vessel. If on the other hand the discoloration
is due to the presence of extravasated blood, the
fluid blood or clot outside the vessels is easily recog-
nized. Doubtful spots should alivays be incised in for-
ensic cases.

The state of the i)Uj)ils should be noted. The
possible presence of any foreign body in the respira-
tory tract must always be borne in mind. WHien the
exact time of death is unknown, special importance
attaches to a minute account of the exact state of rigor
mortis or putrefaction present.

When the body is exhumed in an advanced state
of decomposition, it is better not to remove it from
the cotitin, in case it should fall to pieces. No amount

i:l

of decomposition is sufficient ground for declining to
perform an autopsy, as extensive injuries of the bones
and the presence of many poisons can still be
recogni/.'.^d.

Special attention should be paid to the examina-
tion of that part suspected of being immediately
concerned in causing death. This should be examined
as early as possible, but even when an apparently
satisfactory explanati n of the death is found, the
examination of the other parts should not be
omitted, and all the important organs should be
examined in every case.

The brain should always be examined first, unless
there is ground for supposing the cause of death to
lie elsewhere.

While a full and exact report of a medico legal
autopsy should always be made, it is usual to submit
only a brief abstract to the jury. In this . the
lesions found and the opinion formed are to be stated
in the simplest manner possible, avoiding as far as
possible the use of technical terms, and omitting from it
all extraneous matter likely to offer an opportunity for
raising side issues in case of a trial.

41. Ill caMeM Miiere poiHoiiiii)(: in hiih-

pected, it is well to be provided with a number
of large glass jars with ground glass stoppers. These
should be perfectly clean, and it is best to employ
new ones. If such jars cannot be obtained it must
be seen that no metal or rubber stoppers are used, as
these are liable to contain traces of arsenic. For the
same reason glazed earthenware should not i)e em-
ployed, though unglazed ware is free from this ob-
jection. In any case, one jar should be left unused,
to show that it is free from poisonous ingredients.

Care must be taken that the portions reserved
for chemical examination are not allowed to lie where

they may be contaminated, but are put at once into
the jar without having come into contact with any-
thing else.

The stomach and duodenum should be ligatured
at the beginning of the autopsy. They are afterwards
removed together, unopened. When they are open-
ed it must be done over a clean glass jar, and as soon as
the mucosa has been examined, placed in the jar,
together with the contents, and the jar sealed. In
some cases, however, it is better to send the stomach
unopened to the chemist. Half the liver and one of the
kidneys should be placed in another jar, and half the
brain in a separate jar. If urine is found in the bladder
it should also be preserved in the same manner.

The jars should be sealed in the presence of
witnesses, and a label attached stating their contents.
They should be given at once into the charge of the
coroner, who should lose no time in sending them to
a chemist.

As the existence of the hydrocyanic acid poison-
ing may be revealed by the characteristic odor, the
moment the abdomen is opened this sign should be
carefully looked for. In such a case the stomach
should immediately be placed in a jar, made air-tight
by covering the stopper with wetted parchment paper
or bladder.

42. :New-born children. In examining the
bodies of new-born children it is necessary to determine
(1) whether the child could have lived, and (2) whe-
ther it actually breathed, in addition to finding out the
cause of death. Special attention must therefore be
paid to the signs of maturity, noting the length of the
child and of the different limbs, the measurement of
the fontanelles, the state of development of the extre-
mities, eyes and internal parts, the amount and nature
of the hair, the presence of vernix caseosa, etc. The

centres of ossification present should be examined,
especially those of the lower epiphysis of the femur.

In detenninin,<^ whether the child has breathed,
the height of the diaphragm and the degree of
inflation of the lungs are significant. The trachea
should be ligatured before opening the thorax, and
the lungs and heart removed together. After care-
fully dissecting off the heart and examining it, the
lungs should be immersed in water to see if they float.
They are then cut into small pieces under water,
noting whether any portions float. The presence of
air in small tjuantities is revealed by small bubbles of
air rising. This test is open to too many fallacies to
be of much value in doubtful cases.

For the dissection the probe-pointed scissors will
be found most useful. Besides the examination of
the f<etus itself, the presence of any disease in the
umbilical cord and placenta should be looked for, if
they are attached, 'ihe condition of the fcetal orifices
should be noted in examining the heart. The ab-
dominal incision should be carried to each side of the
umbilicus, and the umbilical arteries and vein carefully
dissected. In some cases a congenital abnormality may
be found, sufficient to render life impossible. The
brain may be removed by cutting open the thin cranial
bones with strong scissors.

43. Dissection w<»iiiicls. All wounds re-
ceived in performing autopsies should be carefully
attended to. A trifling prick or scratch, which is not
noticed at the time, is more likely to cause trouble than
even a severe cut. l>eyond washing them well and
applying some antiseptic dressing, no treatment is
necessary. The a[)i)lication of caustics is more likely
to do harm than good. If it is necessary to continue
the autopsy, cover the part for the time with a strip
of rubber plaster after washing it thoroughly. Anthrax

and p;landers are specially dangerous, otherwise
the chief danger is from septic cases. Typhoid fever,
dii)htheria and tuberculosis, do not seein to be com-
municable in this manner.

44-. 'Hie following report of a case will give
an idea of how a report drawn up for clinical purposes
may be altered for medico legal use.

Ordinary report ot* autopsy:—

A. 1)., Aet 50. Died shortly after admission to
hospital.

Autopsy performed February 12th, 1890, 12 hours
after death.

Body that of a stout, heavily-built man. Post-
mortem lividity well marked on back ; slightly present
on face and neck. Rigor mortis well mnrked at all
joints.

Head examined first. No signs of injury to scalp
or skull-cap. A small reddish discoloration of the
skin is found on left temple ; tissues beneath it are
free from echymosis.

Pacchionian bodies large and numerous. Longi-
tudinal sinus contains a small blood clot. External
surface of dura normal. On removal of dura, vessels of
pia nearly empty. \ little bloody fluid lies beneath
the pia, chiefly in the sulci, less abundant over the
convexity than laterally ; the condition symmetrical on
both hemispheres.

On removal of brain, a large, soft, dark-red clot
is found covering the whole of the base. It lies princi-
pally beneath the pia, and extends a little way along
the sylvian fissure on each side. The clot is thickest
just anterior to the optic chiasm near the origin of the
anterior cerebral arteries. A large amount of extra-
vasated blood is found in the anterior part of the
longitudinal fissure. The frontal lobes are with diffi-
culty separated. A small aneurysmal dilatation, the

^^^ ^^ m i i jg ^tt i m y^* ,

'■<}

f 1

size of a cherry, is seen in the region of the anterior
communicating artery. This adheres closely to the
inner surface of the right frontal lobe, and shows a
small rent 5 mm. long, with ragged edges, through
which a clot protrudes.

On dissecting the brain, both the lateral ventricles
as well as the third and fourth ventricles, are distended
with smooth, dark-red clot. This forms a complete
cast of all the ventricles. The brain tissure lying be-
tween the aneurysm just described, and the head of
the right corpus striatum is lacerated and infiltrated
with soft dark clot, the head of the right corpus stri-
atum itself being also infiltrated, but to a less extent.
The rest of the brain presents nothing abnormal. The
brain substance is firm and somewhat pale.

On dissecting; the arteries at the base, some
fibrous thickening is noticed in the pia about the
aneurysm, most marked on the right side. The whole
of the anterior communicating artery is found to be
dilated. The sac contains recent clot only and opens
directly into the right and left communicating arteries.
The orifice in the It ft side is large and circular in form,
measuring 5 mm. in diameter, the orifice on the right
side is 2.5 mm. in diameter. .Ml the cerebral arteries
are large and thin walled, their intima appearing free
from atheroiLa. Examination of the base of the brain
shows nothing abnormal. The sinuses contain a little
fluid blood and d.irk clot.

In opening abdomen, subcutaneous fat 5 cm.
thick in most places. Omental fat abundant, peri-
toneum normal. Diaphragm on right side at 4th
space, on left side at r)th rib, in mammary line.

In thorax pleura normal. Pericardium normal ;
contains a teaspoonful of clear serum. Epicardial fat
not in excess. Right chambers of heart moderately
distended with blood ; left chambers empty. Organ
feels firm, muscle pale, valves normal. Weight, 500

enor
I the

vvs a
ough

rides

nded

iplete
g be-
ad of

trated ^

s stri-

xtent.

The

some

at the

whole

-»''^

I to be

■■{^1

opens

rteries.

1 form,

e right

irteries

ig free
e brain

I a little

5 cm.

t, peri-
at 4th

4^9

lormal ;

rdial fat

derately

Organ

rht, 500

grammes, wall of right ventricle averages 5 mm. in
thickness; of left ventricle, 2 cm.; length of right ven-
tricle, 8 cm.; of left 7.5 cm Circumference of aortic
orifice 7.5 cm.; of pulmonary, 8 cm.; of mitral, 10 em.;
of tricuspid, 13 cm.; coronary arteries normal.

Aorta elastic and not atheromatons.

Lungs — Left weighs 600 grammes, crepitant
throughout. Bases contain a good deal of blood.
Bronchial mucosa reddened Right lung weighs 680
grammes ; is in same condition.

Oesophagus, larynx and trachea normal, thyroid
gland normal.

Spleen weighs 215 grammes, pulp dark and soft.

Kidneys — Left weighs 150 grammes, capsule
readily removed, surface slightly granular, a few small
cysts in cortex. Right weighs 155 grammes, is in same
condition.

Su])ra-renals normal.

Bladder contains 400 cc clear urine. Mucosa
normal. Lateral lobes of prostate slightly enlarged.

Intestine normal ; contains ordinarv bile stained
faeces.

Duodenum normal ; gall ducts pervious.

Stomach contains a little li{[uid food.

Pancreas normal.

Liver — Weight 1680 grammes. A few dark bluish
spots on upper surface beneath capsule. A small
angioma the size of a pea in right lobe.

Gall bladder full of dark bile.

On microscopical examination, no sign of fatty
degeneration nor miliary aneurysms in the small
arteries of the brain.

Anatomical diagnosis: Rupture of aneurysm of
anterior communicating artery ; hemorrhage into
cerebral ventricles. Angioma of liver. Interstitial
nephritis. Hypertrophy of left ventricle.

'-*«««*»'i'««BSKe<»''

45. Report abrii^cil for coroner^i4 Jury.

Body identified as that of A. B.

Autopsy performed February 12th, 1890, at 2
p. m., 12 hours after death.

No sign of violence externally. Rigor mortis well
marked.

On examining the brain there was found an exten-
sive apoplexy arising from the bursting of a small blood
vessel in the brain. There was no evidence of this
having been caused by an injury. The kidneys showed
signs of chronic inflammation, and the heart muscle
was thicker than normal. The other organs showed
no changes of importance.

The autopsy shows that the deceased died a
natural death, from the bursting of a blood vessel in
the brain. This vessel was weakened from dilatation
of its walls, and the condition of the heart and kidneys
would tend to cause its rupture.

Signed,

AVERAGE WEIGHT OF NORMAL ORCiANS.

Brain 48 oz 1400 grammes.

Heart 12 " 300

Lung 20 " 600 "

Liver GO '' 1800

Spleen 6 " 170

Kidn. / 5 " 150

In temales the weight is about 5 or 10 per cent less.

fc^.*^plW7W,,

Jury.

0, at 2

rtis well

,n exten-
lU blood
: of this
; showed
t muscle
i showed

died a
vessel in
dilatation
d kidneys

)RGANS.

Ties.

cent less.