Practical pathology

I. METHODS OF EXAMINATION.

1. Thoracic Cavity. As soon as the sternum is removed the anterior mediastinum and the pleural cavities are examined, noting first the position and relation of the thoracic organs, quantity and character of mediastinal fat, the contents of the pleural cavities, pleuritic adhesions, etc. Pleuritic exudates should be removed before they have become mixed with blood from the cut vessels or heart; and the pleural surfaces should be examined before their appearance has been changed by exposure to the air or to fluids. Pleuritic adhesions should be broken or cut, beginning with the left side and then on the right, and the entire surface of both lungs wholly freed.

2. Thymus. The thymus is then examined by means of transverse cuts; or, when large, is dissected from below upward, turned up onto the neck, and removed later in connection with the neck organs. When no traces of thymic tissue are visible to the naked eye the thymic fat should always be cut transversely and examined for the presence of small lymphoid nodules. In the case of hypertrophic thymus the question of pressure upon the trachea becomes of very great importance, and, to settle this, the trachea should be opened above the sternum before the thymus is removed; or the thymus may be taken out in connection with the trachea and both sectioned horizontally at the same time. In cases of sudden death, in which the thymus may be an etiologic factor, it is safest to examine the trachea from above the sternum before the thorax is opened, or to fix the whole body (infant’s or child’s) in formalin and then to remove thymus with trachea, and examine by means of transverse sections.

3. Pericardial Sac. This is next examined with respect to the degree of intrapericardial tension. Its anterior wall is then picked up at about its middle by the thumb and index finger of left hand, and the point of the long section-knife, with cutting edge outward, is pushed through the pericardium and a small slit made into the sac. The escape of gas or air should be noted at this time. A sterile pipette may now be introduced and the fluid contents of the sac secured for bacteriologic examination; or before the pericardial sac is opened the pericardium may be seared with a hot iron and a sterile pipette pushed through it into the cavity. The longitudinal incision through the pericardium is now extended upward to its attachment to the great vessels, and through the opening thus made the character and amount of the pericardial fluid are determined. The incision is then extended to the left at its lower end by cutting the sac-wall toward the apex of the heart. Through the three-cornered incision thus made the heart is lifted out of the sac and the surfaces of the parietal and visceral layers of the pericardium examined. Localized adhesions of the pericardium may be cut or torn, extensive or complete adhesions may be separated when this is possible; if this cannot be done, the pericardial layers are cut with the heart wall.

4. Section of the Heart. The heart may be examined either in the body or outside. The choice of several methods may be taken, and the one most convenient and easy of performance is advised, rather than a method based upon such considerations as the direction of the blood-current in the normal body. The chief essential is to expose completely the interior of the heart with the least possible disturbance of anatomic relationships, and to accomplish this in the simplest and easiest way. Such a method must leave the heart in such shape that it can be reconstructed for histologic study or utilized as a museum specimen. This can be accomplished by a modified Rokitansky method, as follows:

The heart is first carefully inspected as it lies in the pericardial sac. The apex is then lifted in the left hand and the posterior wall inspected. The heart is then drawn up over the right edge of the ribs, so that the left border of the heart presents uppermost as the line of greatest convexity. The point of the narrow brain-knife (amputation-knife), with cutting edge upward, is then inserted through the wall of the left ventricle at the apex, just to the left of the septum, and the knife pushed into the cavity until the point can be forced through the ventricular wall just below (ventricular side) the left auriculoventricular ring, and the ventricle-wall is then cut upward (as the heart is held) to the apex, in the line of greatest convexity, exposing the cavity of the left ventricle. The knife is laid aside and the ventricle is explored with the fingers of the right hand and the size of the mitral opening estimated. Before the fingers are introduced through the valvular openings the flaps should be carefully examined to see that no vegetations, thrombi, etc., are in danger of being loosened by them. With the opening of the heart-chambers the blood, if fluid, may pour out into the pericardial sac and flood the pleural cavity if not prevented by sponging or by removing it by means of a beaker. The knife is then introduced on the flat through the mitral opening into the left auricle in a line continuing the first incision with the junction of the left pulmonary veins. (See Fig. 38.) The knife is then turned with cutting-edge upward, the point thrust through the upper left pulmonary vein or between the left pulmonary veins, and the auricular wall is cut upward (downward anatomically) to meet the first incision below the mitral ring. The incision should pass between the mitral segments. The left auricle, mitral ring and flaps and the greater portion of the left ventricle are thus exposed and should be inspected.

The heart is then taken in the left hand and held by the anterior flap of the left ventricle, with the fingers inside the ventricle and the thumb on the outer surface of the anterior wall of the left ventricle, and lifted up vertically out of the pericardium. The brain-knife held perpendicularly, with cutting-edge to the right, is pushed through the right ventricular wall just to the right of the septum, carried across the cavity of the ventricle, to engage again in the ventricular wall in the line of greatest convexity, just below (anatomically) the right auriculoventricular ring, and the wall is then cut upward to the apex. The right ventricular cavity is thus opened, the fingers are introduced to explore the tricuspid ring, and the cavity and contents are inspected. The knife, held flat, is then carefully introduced through the tricuspid opening into the right auricle, the cutting edge outward, and its point thrust through the wall of the auricle midway between the superior and inferior venæ cavæ, and the auricular wall and tricuspid ring are cut upward toward the apex to meet the first incision into the right ventricle. If sufficient care is taken the incision will fall between the anterior and posterior cusps. Right auricle, tricuspid flaps and ring, and the right ventricle are thus exposed for inspection.

The heart is then drawn downward and allowed to lie flat in the pericardial sac, and the pulmonary artery is then explored with the fingers of the right hand. While the anterior wall of the right ventricle is held by the thumb and index-finger of the left hand the knife is then introduced, on the flat, along the right side of the septum, into the pulmonary artery; the edge is turned upward and the point pushed through the wall of the artery, about 3 cm. beyond the ring, and a cut made toward the apex through the anterior wall of the artery, pulmonary ring and anterior wall of right ventricle, just to the right of the septum. The pulmonary artery, ring, pulmonary flaps, and right side of auricular and ventricular septum are now inspected. In cutting the pulmonary ring care should be taken to make the incision between the two anterior cusps.

With the heart still lying flat in the pericardial sac, the aortic opening is explored by the index-finger of the right hand and the size of the ring estimated. The knife is then introduced on the flat, into the left ventricle, along the left side of the septum, through the aortic opening and as far as possible into the aorta. It is then turned, with the cutting edge upward, and the point pushed through the anterior wall of the aorta. The heart is then drawn downward and slightly raised by the left hand, holding it at the apex by the two flaps of the right ventricle. The knife is then drawn from above downward toward the apex, cutting in succession the anterior wall of the aorta, across the pulmonary artery, through the aortic ring, and the anterior wall of the left ventricle, just to the left side of the septum. By dissecting away the pulmonary artery from the aorta the incision through the former may be avoided. (See Fig. 41.) When desired this cut may be brought down through the septum instead, but if the bundle of His is to be studied in serial sections the cutting of the septum should be avoided. The enterotome or long straight shears may be used for all the incisions except the first ones made into the ventricles. For these the knife is necessary. The incision through the aortic ring usually cuts the anterior segment, but by making the cut more to the right the incision will pass between the anterior and the right posterior flaps.

Before the valvular orifices are cut it is often expedient to test the adequacy of the valves by means of water or air. The hydrostatic test is employed to the best advantage in the case of the pulmonary and aortic valves, either by pouring water into the vessels, or by immersing the heart in water and then lifting it up quickly. In the case of the auriculoventricular valves the air-test is carried out by inserting the nozzle of a bellows through an opening made in the ventricular wall and noting the effect of blowing and suction. Graduated cones or balls may be used for more accurate measurement of the orifices, or they may be measured after they have been cut.

If sufficient care is exercised in cutting the valvular rings the incision can be carried between the flaps without injury to the latter. This is often desirable in cases of valvular lesion, endocarditis, etc. In such cases the valvular rings may be left uncut, the line of incision being broken by the auriculoventricular ring, when the mitral and tricuspid valves are concerned. The pulmonary and aortic rings may also be left uncut; the incisions are stopped at the rings, and then begun again in the vessel-walls beyond the valves.

When bacteriologic examinations of the heart-contents are to be made the wall of the auricles or right ventricles can be seared with a cautery and a pipette introduced through the seared area; or the heart can be opened with a sterile knife, care being taken not to introduce the fingers into the opening or to permit the entrance of water.

Excellent preparations for the museum or for demonstration purposes can be made by distending the heart with alcohol or formalin. Blood and blood-clots should first be washed out. When fixed the heart may be sectioned in various planes, leaving the segments attached by the epicardium posteriorly, or openings may be cut in the walls. A very good picture of hypertrophy and dilatation is obtained by making a transverse cut through the ventricles midway between apex and base. Alterations in the form and position of the ventricular septum are best seen by this method.

After the opening of the heart and the inspection of the orifices, valves and auricular and ventricular septa, the coronary vessels should be examined by transverse cuts, or opened by fine probe-pointed scissors, beginning at their origin in the aorta. The auricular septum should be carefully examined for possible defects. While this is being done the wall should not be put on the stretch, but should be lax. The auricular appendages should be cut open from the auricles and examined for thrombi, which are of not infrequent occurrence in them. The mouths of the coronary veins and the veins of Thebesius should be examined also. The cardiac muscle is examined by parallel, vertical or horizontal incisions. The papillary muscles should be cut longitudinally from apex to base. The cardiac plexus and the ganglion of Wrisberg should be examined before the heart is removed.

When the heart is in a state of rigor mortis the contraction should be made to pass away by kneading or by the application of heat, before the organ is opened, or before any measurements are taken. After the heart has been opened it may be removed for weighing.

The heart may be removed first and then opened outside of the body. The organ is grasped in the left hand and lifted vertically and upward toward the head as far as possible, putting all of the attachments on the stretch. The vessels are then cut from below upward, first the inferior vena cava, then the pulmonary veins, the superior vena cava, pulmonary artery and lastly the aorta. (See Fig. 39.) The vessels should be cut as closely as possible to their exits through the pericardium, and care must be taken to get out the auricles entire.

After removal from the body the heart is placed upon the board with its anterior surface up, and the apex toward the operator. It may then be opened by the same method given above, by inserting the point of the brain-knife into the left ventricle just to the left of the septum, and cutting first the wall of the left ventricle along its left border as far as the mitral ring, exploring the mitral orifice, and then cutting it and the auricular wall into the upper left pulmonary vein with the long shears. The right ventricle, right auricle, pulmonary artery and finally the aorta are opened in succession, using the enterotome for all cuts except the first opening of the ventricle. The first incisions into the ventricles can be made very conveniently by holding the heart vertically with apex up, and the ventricle to be opened toward the prosector. The brain-knife is held vertically and its point inserted into the ventricle, just to the right or left of the septum, according to the ventricle to be opened, then carried across the cavity and pushed through the ventricular wall below the auriculoventricular ring, and the wall is then cut toward the apex. The remaining incisions are most easily made with the enterotome when the heart is held flat on the board with its anterior surface up. When the heart is opened outside of the body the Virchow method of opening in the direction of the blood-stream may also be used. (See below.)

Under certain conditions other methods must be employed for the examination of the heart. In cases of suspected aneurism, pulmonary embolism, patent ductus arteriosus, etc., the thoracic organs should be removed en masse and dissected on the table. They may be removed in connection with the neck-organs or alone. In the latter case the trachea is cut transversely above the sternum, the fingers of the left hand introduced into the trachea, and, while traction downward is being made with force, the œsophagus and cervical vessels are cut transversely, the trachea and vessels stripped down to the level of the clavicle, and the subclavian vessels cut on both sides. The thoracic organs are then stripped from the vertebræ down to the diaphragm and cut off just above the latter.

The pulmonary artery may be examined in situ before the heart is opened by thrusting a sharp-pointed scalpel through the wall of the artery just beyond the valves and cutting upward to the branches going to the right and left lungs. This incision may be extended downward through the pulmonary valve and the anterior wall of the right ventricle, and the right side of the heart first exposed.

5. Section of the Lungs. The general inspection of the pleural cavities and pleural surfaces is made as soon as the thoracic cavity is opened, as indicated above. If a pneumothorax is present the pleural cavity on the affected side is filled with water, the neck organs are exposed and a tube inserted into the trachea. When air is forced through this bubbles will escape from the perforation and the opening can be easily located. When extensive or complete pleural adhesions are present, so that they cannot be separated, it becomes necessary to remove the costal pleura in connection with the visceral layer. This is accomplished by loosening the costal pleura and subpleural fascia at the cut edge of the ribs with the blade of the knife, until the fingers and, finally the hand, can be worked in between the costal pleura and the chest-wall, gradually separating the two until the entire lung is freed with both layers of pleura adherent. Firm adhesions at the apex may have to be cut with the knife. Similar adhesions with the pericardium or diaphragm may make it necessary to cut out the adherent portion with scissors or knife and remove it in connection with the lung. When the pleural adhesions are very firm upon the right side the prosector may find it most convenient to stand at the left side of the cadaver and from this position separate the right costal pleura from the chest wall. An assistant may be of great service in pulling the thoracic wall outward. The edge of the ribs or cartilages may be covered with a towel or the skin may be drawn over it to protect the hands. In extreme cases it may be necessary to saw the ribs and remove them in connection with the lungs. Sometimes the adhesions may be separated more easily if the neck-organs are first removed down to the clavicle, and then, in connection with the lungs, are removed en masse, by means of powerful tugs, from above downward. The apical and posterior adhesions may be torn fairly easily in this way when ordinary manipulations in the thoracic cavity have no effect upon them.

When the pleural surfaces are free the left lung is lifted out of the cavity onto the right edge of the chest-wall, pulling it forcibly over to the right so that its posterior surface becomes uppermost. In this position the lung may be sectioned by one or more main incisions made with the long section-knife, cutting the organ from apex to base, down upon the ribs in the direction of the main bronchi and vessels. After the examination of the cut surfaces the organ may be returned to the cavity. It is better, however, to remove the lung, and section it outside the body. This is done by cutting the mediastinal pleura, pulmonary vessels and main bronchus with the cartilage-knife, while the lung is held upon the right edge of the thoracic opening, holding the knife so that its blade strikes the edge of the costal cartilages.

The lung, when free, is placed upon the board with its hilus downward and base toward the prosector. (See Fig. 42.) It is then held in the left hand, as shown in the illustration, the thumb holding the lower lobe, the index-finger between the lobes with its tip upon the main bronchus, the other fingers holding the upper lobe. With the long section-knife held slightly obliquely toward the anterior edge the main-incision is now made in one sweeping cut from apex to base, along the line of greatest convexity, down upon the main-bronchus and its chief branches and the large vessels. Care should be taken not to cut off the bronchi of the two lobes from the main bronchus. Incisions parallel to the main one may be made, if desired. Usually it suffices to go carefully over the remaining part of the lung, feeling it carefully for airless solid areas; if such are present they may be sectioned separately. The bronchi are then opened from the cut surface by means of the probe-pointed scissors, cutting as near to the pleura as possible. The sound or director may be used with advantage in opening up cavities from the bronchi. The position of the lung should be so changed that the bronchi always extend away from the prosector in a straight line. The portion of the lung containing the uncut bronchus should be left hanging over the left hand to put it on the stretch, thereby facilitating greatly the opening of the bronchus. The pulmonary vessels are opened with fine probe-pointed scissors from the cut surface. The bronchial lymphglands are then sectioned with the knife.

The right lung is then lifted up out of the thorax onto the right side of the thoracic opening, and is either sectioned in this position, or the mediastinal pleura, pulmonary vessels and bronchus are cut from below upward with the knife, its edge being directed against the ribs. When freed the lung is placed on the board, root downward and apex toward the prosector. (See Fig. 43.) The index-finger is put between the upper and lower lobes, the thumb holds the upper lobe, the other fingers are spread out over the surface of the lower lobe. The main-incision is then made in a sweeping cut, from base to apex, along the line of greatest convexity, the knife-blade being held slightly obliquely toward the anterior border (see Fig. 43), cutting down upon the main bronchus and its first division. Other parallel cuts may be made. The middle lobe is then sectioned by a sagittal incision on its anterior surface, directed toward its anterior border. The bronchi, pulmonary vessels and bronchial lymphnodes are then opened as in the case of the left lung.

Bacteriologic examinations may be made from smears or cultures made from the cut surfaces; or, to avoid contamination, the surface may be seared with a hot iron and the material obtained by means of a sterile pipette pushed through the seared surface into the lung-tissue.

When the neck-organs are not removed the section of the thorax closes with the examination of the aorta, oesophagus, thoracic duct and thoracic vertebrae. The blood-vessels and œsophagus are opened with the curved scissors, from above downward, the contents noted, and the walls examined. The thoracic duct is best dissected out from the right side, by cutting along the right side of the aorta and turning the latter over to the left. The duct is more easily recognized at its lower end. It may be inflated with the blow-pipe, or opened with a probe and fine probe-pointed scissors. Sometimes the duct can be most easily found by removing the left lung and then turning the right lung over into the left pleural cavity. The posterior mediastinal tissues are put on a stretch, so that the duct can be recognized through the pleura. For the examination of the left subclavian vein the left clavicle should be removed.

II. POINTS TO BE NOTED IN THE EXAMINATION OF THE THORAX.

1. Thoracic Cavity. Presence of gas or air (pneumothorax, infections with colon bacillus, gas-forming bacillus, proteus, etc.), relative degree of pressure, odor, etc. Measure contents of each pleural sac; note character of fluid (clear, turbid, bloody, chyliform, chylous, purulent, fibrino-purulent). Normally the pleuræ are moist-shining, smooth, grayish, transparent; only a few drops of fluid found in the cavities. In cases of slowly progressive cardiac insufficiency large amounts of clear fluid may collect in the cavities just before death. Non-inflammatory collections of fluid also occur in general œdema. In these conditions the pleuræ are not cloudy or dull, while in the case of inflammation the pleural surfaces are dry, cloudy, dull-shining, injected, rough or covered with fibrinous or purulent exudate. Examine pleural surfaces particularly for evidences of inflammation, recent and old tuberculosis, primary and secondary neoplasms (carcinoma).

2. Position of Thoracic Organs. Locate anterior borders of lungs, apex and borders of heart. The normal lung collapses after the removal of the sternum. How much of the pericardial sac is left uncovered by the lungs?

3. Anterior Mediastinum. Note character of connective-tissue, amount and color of fat-tissue, number and size of lymphnodes, occurrence of œdema or emphysema. An artificial œdema may be caused by the injection of large quantities of salt solution in the pectoral region just before death. An artificial emphysema may be produced by the removal of the sternum. The condition of the large veins in the upper portion of the mediastinum should be noted before the heart is removed. Are they lax, moderately full, or distended? Secondary tumors, hemorrhages, abscesses, œdema and emphysema are the most common pathologic conditions.

4. Thymus. The writer believes that the weights usually given for the thymus in the new-born are too high, and that 7-10 grms. represents the usual normal weight. A gland weighing 20 grms. or more must be regarded as enlarged. The organ reaches its fullest development at the end of the second year. Atrophy begins then, developing slowly up to the age of puberty, after that more rapidly. In adults the thymus normally consists of a mass of adipose tissue containing lymphoid nodules, in some of which corpuscles of Hassall persist to old age. Postmortem softening should not be mistaken for abscesses. The most important pathologic change is hypertrophy. Pressure of the enlarged gland upon the trachea, nerves or great vessels may cause thymic stridor, asthma, or thymic death (“lymphatic constitution”). Enlargement of the thymus may occur in “status lymphaticus,” exophthalmic goitre, cretinism, myxœdema, Addison’s disease, acromegaly, myasthenia gravis, epilepsy, scorbutus, rachitis, tonsillar hyperplasia, adenoids, congenital syphilis, Hodgkin’s disease, leukæmia, anencephaly, anæmia, acute infections, or it may exist as an independent affection. Oedema, congestion, inflammation, tuberculosis, neoplasms, etc., may also cause an enlargement. Absence of the thymus has been observed. Primary and secondary forms of atrophy in association with marasmus occur in children. Note relation of size of thymus to condition of child; atrophy of the organ is usually coincident with marasmus. Inflammation, tuberculosis, cysts, primary and secondary neoplasms, gummata, etc., are not common.

5. Pericardium. Note tension of sac, fluctuation, adhesions, thickness, character of inner surface, contents (amount, color, odor, presence of fibrin, blood or pus, gas). Normally there are about 5-10 c. c. of clear yellow fluid in the sac. Both peri- and epicardium normally are moist-shining, smooth, grayish and transparent. Large amounts of clear watery fluid may collect in the pericardial sac in slow death in cases of chronic valvular lesions, chronic nephritis, bronchitis and emphysema, but the surface of the peri- and epicardium remains smooth and shining. In inflammatory increase of the pericardial fluid the serous surfaces are dull, cloudy or dry, and may be covered with a layer of fibrin, the fluid is more or less cloudy and contains flakes or strings of fibrin, or may be purulent. The fibrinous exudate may be very extensive and from the movement of the heart be drawn out into bands, threads or villus-like prominences (cor hirsutum or villosum). Pericarditis is common in acute rheumatism, septicæmia, pyæmia, puerperal fever, osteomyelitis, pneumonia, and as a terminal infection in cardiac and renal disease. Tuberculosis is one of the most common causes of purulent, fibrinous and hemorrhagic pericarditis, particularly of the cor villosum. Examine surfaces for tubercles. The presence of blood in the pericardial exudate points usually to tuberculosis or malignant neoplasm, but in small amount may be found in various infections and intoxications. The age of the pericarditis may be judged by the amount of organization of the exudate, adhesions, thickenings, etc. “Milk spots,” “soldier’s spots,” “tendinous patches” or “friction scleroses” represent hyaline thickenings of the pericardium due to old pericarditis. Total synechia or atresia of the cavity may occur. As the result of calcification of an old pericarditic exudate the heart may be surrounded by a calcareous sheath (“stony heart,” “petrified heart”). Hæmopericardium results from the rupture of the heart, aorta, pulmonary artery or coronary vessel. Petechiæ of the peri- and epicardium are found in pyæmia, septicæmia, hæmophilia, scurvy, severe anæmia, leukæmia, chronic nephritis, and death from suffocation and various intoxications. Pneumopericardium may be due to perforating wounds, or to perforations from lungs, stomach or œsophagus, or to infections with gas-forming bacilli. Malformations are rare (diverticula, ectopia). Tuberculosis is usually secondary. Gummata are rare. Actinomycosis is usually secondary to actinomycosis of the neck or lungs. Primary neoplasms are rare. Secondary carcinoma and sarcoma (especially lymphosarcoma) are more frequent. Cysticercus, trichina and echinococcus are rare.

6. Heart. Note more carefully its position, whether displaced to right or left, location of apex, borders, etc. Relative size compared to cadaver’s right fist, which is usually a little smaller than the heart. Weight and measurements:—(The heart should be weighed after it has been opened, and its cavities freed from blood and clots.)

Average weight in adult male, about 300-350 grm.

Average weight in adult female, about 250 grm.

Normal limits, 200-350 grm.

Weight of heart to body-weight in adult male, 1:169; in the female, 1:162.

Circumference at base of ventricles 25.8 cm., length of ventricles 8-9 cm., breadth 8.5-10.5 cm., thickness 3-3.6 cm.; minimal measurements are for the female. Auricles are 5-6 cm. in length. Compare ventricles as to size.

Note form (long, cylindrical, pyramidal, broad, short, round, etc.) In hypertrophy of the left ventricle the heart is longer and more cylindrical; in hypertrophy of the right it is broader and more rounded. Normally the apex is formed by the left ventricle, the sulcus longitudinalis running to the apex and nearly dividing the heart into halves. In hypertrophy of the right ventricle the apex is formed by this ventricle, the sulcus longitudinalis passing to the left of the apex; in hypertrophy of the left ventricle the longitudinal sulcus runs to the right of the apex. What part of the heart lies anteriorly? (Normally a large part of the right ventricle.)

The consistence of the organ, particularly that of the ventricles, should be noted (firm, flabby, soft, etc.). Condition of the heart-chambers (empty, contracted, dilated, full). Rigor mortis should be removed by kneading or by the application of heat. The amount of subepicardial fat, its color, translucency, occurrence of serous atrophy, œdema, subepicardial hemorrhage, etc., are to be noted. In marasmus a serous or mucoid degeneration of the subepicardial fat is not uncommon. The subepicardial fat increases with age, and is normally most abundant along the grooves and blood-vessels, particularly the auriculoventricular grooves and on the right ventricle. Normally the color of the heart-muscle of the ventricles should be seen through the epicardium. The fat is increased in obesity, chronic alcoholism, chronic anæmia, tuberculosis, etc. When the fat-infiltration is so marked that the muscle cannot be seen the condition is known as adipositas or obesitas cordis, or in extreme cases as lipoma cordis capsulare.

7. Right Heart. Note amount of blood contained in right chambers (over-distended in death from asphyxiation, pneumonia, etc.), also its consistence (thick, thin, watery), color (light, dark, red, yellowish, chocolate, purplish), blood-clots (size, color, cruor, lardaceous clots, chicken-fat clots, pus-like clots, consistence, moisture), presence of free fat, gas or air, diffusion of hæmoglobin, presence of bile-pigment in blood. Note also amount and character of blood in venæ cavæ. The size of auricular and ventricular cavities should be estimated, noting condition of trabeculæ and papillary muscles (atrophic, flattened, hypertrophic, fatty, fibroid, calcification). The musculature of the ventricular walls is examined as to its thickness (normally the right ventricle wall is 4-5 mm. thick). Postmortem contraction should not be mistaken for hypertrophy. The color of the heart-muscle normally is pinkish in infants, flesh-red in adults, and brownish-red in old age and in atrophy following compensatory hypertrophy (brown atrophy). Under normal conditions the muscle is translucent. In cloudy swelling the heart-muscle appears cloudy and opaque as if cooked. Fatty degeneration appears as yellowish, opaque patches or streaks (“tiger-heart”), particularly in the papillary muscles and trabeculæ. In severe intoxications the process may be diffuse, and the entire musculature appear cream-colored or yellowish and opaque. The consistence may be firm, flabby, soft, putty-like; localized areas may be caseous. Infarcted areas are soft when fresh (myomalacia cordis). The consistence is increased in atrophy, fibroid heart, chronic interstitial myocarditis, syphilis, etc. Cloudy swelling and fatty degeneration make the heart muscle softer and more friable. In postmortem decomposition the heart as a whole becomes soft. Normally the endocardium should be gray, delicate, thin and transparent. The chordæ tendinæ are long, narrow and delicate. Note thickenings of endocardium and chordæ tendinæ, presence of thrombi (dry, brick-red, yellowish or gray, firmer than clots and adherent to the endocardium, often show simple softening, which should not be mistaken for pus; may be parietal, polypoid, valvular or free). The endocardium may be stained diffusely yellow (bile) or brown (methæmoglobin). Creamy or yellowish opacities of the intima are due to fatty degeneration.

8. Left Heart. Note same things in left side of heart as on right. In cardiac paralysis left ventricle is filled with blood if rigor mortis has not set in. Left ventricle wall is 10-15 mm. thick normally; may become 30 mm. thick in hypertrophy. Papillary muscles and trabeculæ may be markedly hypertrophic, but in the greatly dilated heart (aortic insufficiency) may be much flattened. The septum of the ventricles may share in the hypertrophy of either ventricle and when hypertrophic bulges into the cavity of the unaffected side. Examine wall of left ventricle, particularly near the apex, for infarcts, fibroid patches, aneurismal dilatation, rupture, fatty degeneration, thrombi, etc. Look particularly for pathologic conditions involving the atrioventricular bundle.

9. Orifices and Valves. Orifices should measure as follows:—Tricuspid (12-12.7 cm.), mitral (10.4-10.9 cm.), pulmonary (8.9-9.2 cm.), aorta (7.7-8 cm.). Rough measurements may be taken with the fingers, tricuspid admitting three, mitral two, pulmonary one and a half, aorta thumb. The orifices may be measured by graduated cones, or in the ordinary way after the heart is sectioned. Normally the edges of the valve-flaps should be delicate, smooth and thin. Examine for vegetations, thrombi, induration, thickening, contractions, ulcerations, tears, perforations, defects, calcification, atheroma, valvular aneurism, etc. Note thickening, contraction, adhesion, shortening, etc., of the chordæ tendinæ. When the tendons are long, narrow and thread-like, and without adhesions, the probabilities are that a lesion of the mitral orifice was not present.

10. Coronary Vessels. Walls should be uniformly delicate and thin, and the intima should be delicate, gray and transparent. Note contents of arteries and veins. Examine arteries especially for thrombi, emboli, arteriosclerosis, atheroma, calcification, obliteration of lumen, thickening of wall, loss of elasticity, opacity of intima and increased tortuosity of course.

The most important pathologic conditions of the heart are:—endocarditis (ulcerosa, maligna, verrucosa, simplex, chronica fibrosa, sclerosing), valvular insufficiency and stenosis, hypertrophy, dilatation, atrophy, fatty infiltration, fatty degeneration, cloudy swelling, anæmic infarction, calcification, acute and chronic myocarditis, abscess, fibroid heart, cardiac aneurism, rupture, thrombosis, embolism, malformations (septum defects, patent ductus arteriosus, stenosis or atresia of orifices), tuberculosis (not rare, in association with tuberculous pericarditis, or general miliary tuberculosis), syphilis (gumma not common, localized or diffuse interstitial myocarditis the most common manifestation), actinomycosis, cysticercus, echinococcus, trichina and neoplasms (primary rare, in part congenital, fibroma, lipoma, angioma, myxoma, rhabdomyoma; secondary sarcoma less rare than secondary carcinoma, most common forms are melanotic sarcoma and lymphosarcoma).

11. Left Lung. Weighs 350-500 grm. Size (voluminous, collapsed, compare lobes); form (edges rounded, sharp, nodular, saccular or cystic, contractions, depressions, emphysematous enlargements); pleura (examine again more closely. Circumscribed dull-shining or cloudy areas point to some pathologic condition of the lung beneath. Look for evidences of healed tuberculosis, particularly in the pleura of the apices. Secondary carcinoma of the pleura is very common. Primary tumors are rare; endothelioma and sarcoma are the most common forms. Small circumscribed areas of pigmentation usually represent old tubercles); color (depends upon degree of anthracosis, blood-content and condition of pleura, areas showing especial color should be examined closely; most common colors are pinkish-gray normally, grayish, slaty, black, red, brown, dark-red to black); size of air-cells (normally can be seen with naked eye, best seen at apex and borders, about size of pin-points, when larger than the head of a pin they are emphysematous); lobules can also be seen with naked eye, usually polygonal in shape, 2-3 mm. in diameter; consistence (estimate by going over entire lung, pressing the lung-substance between thumb and fingers; air-containing lung is soft, elastic and crepitates; airless areas are hard, firm and do not crepitate).

On the cut surface the following points should be noted: Blood-content (anæmia, hyperæmia, hypostatic congestion), color of cut-surface, air-content, exudate (serous, purulent), consistence (hard, soft, elastic, caseous, brittle, crumbling), character of surface (smooth, granular, nodular, cavities). Cavities should be described according to their position, size, shape, contents and character of their walls.

12. Right Lung. Weight 420-620 grms. Note size, form, color, surface, size of air-cells, lobules, consistence, blood-content, air-content, exudate, consistence and character of cut-surface, as in case of left lung.

Evidences of healed tuberculosis are found in practically all adult lungs in the form of localized thickenings or puckering of the pleura, especially at the apices, hyaline or anthracotic nodules, encapsulated, caseous or calcified tubercles. Old scars and indurations are firm, hard and usually black in color. Caseous areas are smooth, dry, white or grayish, and opaque. Very young tubercles are elevated, grayish and translucent. Atelectatic areas are depressed and bluish-red in color. Areas of hepatization are red or gray, elevated, granular, crumbling, moist in early stage, dry in caseous hepatization. In bronchopneumonia the areas of hepatization are usually sharply circumscribed. Metastatic abscesses lie usually beneath the pleura, are usually multiple and distributed over both lungs. Bronchopneumonic areas are usually found in the dependent portions, particularly in right lung. An abundance of foamy, watery fluid on the cut-surface indicates œdema; when very bloody there is usually a marked stasis or beginning hepatization present. In atelectasis and fibrinous hepatization the exudate from the surface is not foamy. Emphysematous areas are white or grayish-white and are most frequently found along the borders. Large air-spaces are often found along the interlobular septa (interstitial emphysema), particularly in children following trauma, croup, whooping-cough, etc. In chronic passive congestion the lung is firmer than normal, deep-red or brownish in color. Hemorrhagic infarcts lie usually beneath the pleura, are wedge-shaped, with base toward pleura, firm, smooth on section, or granular, and when fresh are nearly black; older ones are lighter and brownish. Cavities in the lung occur in tuberculosis, embolic and primary abscesses, actinomycosis, gangrene, bronchiectasis, primary and secondary tumors, etc. Gangrenous areas have diffuse borders, are gray or greenish in color, with central softened areas, with ragged borders and stinking smell. In bronchiectatic cavities the smooth mucosa of the bronchus passes directly into the wall of the cavity. Primary carcinomata of the lungs appear as cavities having a white medullary wall, or as medullary strands running along the bronchi. Tuberculous cavities have caseous walls, are more or less encapsulated, and usually show younger tubercles in the neighborhood of the wall. Antemortem hypostasis is usually darker and firmer than postmortem, and is usually associated with inflammation (hypostatic pneumonia).

The most important pathologic conditions of the lungs are:—Anomalies (anomalous lobes common, infradiaphragmatic accessory lungs, agenesia, congenital bronchiectasis), atelectasis (fœtal, compression, obstruction, paralytic, etc.), emphysema (acute, chronic, vicarious, senile, atrophic, hypertrophic, interstitial, gangrenous), hyperæmia, stasis, brown induration, hypostasis, œdema (universal, stasis, hypostatic, atelectatic, acute, chronic, terminal), hemorrhage, hemorrhagic infarction, thrombosis, embolism, fatty embolism, pneumonia (croupous, atypical, bronchopneumonia, acute and chronic interstitial), abscess, gangrene, tuberculosis (acute miliary, caseous pneumonia, peribronchial, tuberculous bronchopneumonia, indurative, fibroid, phthisis pulmonum), syphilis (gumma, white pneumonia), actinomycosis, neoplasms (primary adenoma, lipoma, papilloma, chondroma, osteoma, sarcoma, carcinoma and teratoma are rare; metastatic sarcoma and carcinoma are common; malignant chorio-epithelioma is not infrequent), parasites (echinococcus, cysticercus, hook-worm embryos, pentastomum and distomum pulmonale).

13. Bronchi. Note size, contents, thickness of wall, color and thickness of mucosa. Normally the bronchi are empty, and the mucosa grayish-red. In pulmonary œdema they contain clear, foamy fluid; in bronchitis they may contain a mucous, mucopurulent, purulent, fibrinous, hemorrhagic or putrid exudate. In acute bronchitis the mucosa is red; in chronic bronchitis the mucosa may be red or brownish, and thickened or folded. Material from the stomach may enter the bronchi postmortem and cause a postmortem digestion of the mucosa or wall.

The most important pathologic conditions of the bronchi are:—Inflammation (acute and chronic catarrhal bronchitis, fibrinous, putrid, atrophic, obliterans), bronchial asthma, tuberculosis, syphilis, stenosis, bronchiectasis, perforation (aneurisms, abscess, carcinoma, tubercles, etc.), bronchial calculi, foreign bodies, neoplasms (adenoma, papilloma, carcinoma, chondroma, osteoma), parasites (cysticercus, echinococcus, hook-worm embryos, distomum pulmonale, pentastomum).

14. Bronchial Glands. Note size, pigmentation (gray, dark-gray, black), consistence, character of cut-surface, caseation, fibroid induration, calcification, œdema, congestion, abscess, neoplasm. Tuberculosis and secondary neoplasms are the most common conditions. Lymphosarcoma is the most frequent primary tumor.

15. Pulmonary Vessels. Character of walls and contents. Normally the intima is smooth, grayish-white and translucent. Fatty degeneration of the intima is not rare (acute infections and intoxications); atheroma and aneurismal dilatation are infrequent. Occasionally parietal thrombi and thickening of the wall due to organization of a thrombus are seen. The pulmonary arteries are normally empty or contain soft cruor or agonal white clots. These are not adherent to the wall, do not fill the lumen and are soft and moist. Emboli fill the lumen as if forced into it (at the branchings of the artery they form “rider’s” emboli); they are more dry and brick-red, brownish or grayish in color. Occasionally they may be unrolled into long fibrinous strands. Older emboli may show more or less organization and adherence to the vessel-wall. In air-embolism the pulmonary arteries contain a mixture of blood and air looking like a stiff-beaten white of egg of red color. Large emboli of liver-tissue or liver-cells may be found in the pulmonary arteries after traumatic rupture of the liver. Fat-emboli of the smaller arteries can be recognized by the naked-eye. Thrombosis of both pulmonary arteries and veins is very common in chronic valvular lesions, pneumonia, terminal infections, burns of the skin, poisoning with hemolytic agents, etc.

16. Great Vessels of Thorax. Note size of lumen, condition of walls, particularly of intima, and the contents. Circumference of thoracic aorta 4.5-6.0 cm., thickness of wall 1.5-2 mm. Test elasticity of wall by stretching; note if it retracts and becomes shorter than the œsophagus, which was cut at the same level. Note consistence of wall (stiff and hard in sclerosis and calcification). Normally the intima of the aorta is smooth, grayish-white and semitranslucent; the wall is elastic. Fatty degeneration, sclerosis, atheroma and aneurismal dilatations are the most common pathologic findings. Fatty degeneration shows itself in yellowish spots or streaks, more opaque and slightly elevated. Sclerotic areas are hard, white and tendon-like. Atheromatous “plaques” and “ulcers” are white or yellowish, elevated, rough, scaly, with loss of substance, often more or less calcified. Thrombi are frequently formed upon such atheromatous patches. Hemorrhage into the intima may occur (aneurysma dissecans). Radiating or linear sclerotic folds and depressions in the intima, with or without dilatation of the lumen, usually result from syphilis (mesaortitis). A dirty brownish discoloration of the intima is due to an imbibition of diffuse hæmoglobin, usually postmortem. In chronic icterus the intima may be bile-stained. Thrombosis of the aorta is not common. Congenital or acquired stenosis at the isthmus is rare. Tuberculosis of the aorta-wall is also very rare.

17. Thoracic Portion of Oesophagus. Note size (stenosis, dilatation, diverticulum), contents (food, stomach-contents, blood, pus, foreign-body), thickness of wall, color of mucosa (normally grayish-white), neoplasms (carcinoma), perforations, erosions (aneurism, abscess, neoplasm), inflammation. Anomalies, tuberculosis, syphilis, actinomycosis and neoplasms (with the exception of carcinoma) are rare. The most common location of carcinoma is toward the cardia. Thrush is the most common parasite. Varices of the œsophageal veins are common, and from these fatal hemorrhages may occur. In the thoracic portion they are usually the result of collateral distention to offset a portal stasis (hepatic cirrhosis, Banti’s disease, thrombosis of splenic or portal veins). The passage of stomach-contents through the cardia into the œsophagus may cause a postmortem softening or perforation of the œsophageal wall.

18. Thoracic Duct. Note size, contents and character of wall. Tuberculosis, malignant neoplasms, obstruction, rupture and purulent inflammations are the most important pathologic conditions. In miliary tuberculosis the thoracic duct may be the primary focus or the avenue by which the bacilli enter the blood. The duct also plays an important part in the dissemination of malignant tumors and infections from the abdominal cavity and pelvis. Chylothorax and chylopericardium are usually caused by the blocking of the thoracic duct by malignant neoplasms (lymphosarcoma, carcinoma), or by rupture of the duct.

19. Thoracic Vertebrae. Note surfaces of vertebræ (normally smooth), curvatures, softening, erosions, exostoses, neoplasms, fractures, dislocations. Tuberculosis, curvatures and malignant tumors (secondary carcinoma, primary sarcoma, myeloma, chloroma) are the most common conditions. Aneurismal erosions are not rare.