Practical pathology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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