I. METHODS OF EXAMINATION.

1. Male Pelvis. When the removal of the external genitals is permitted the fundus of the bladder is taken in the left hand and pulled toward the head of the cadaver while the anterior wall is separated from the pubis. This can be done with the fingers of the right hand or the point of the knife. The loose connective-tissue is torn on both sides around the urethra and rectum until the hand can be passed beneath the rectum, completely encircling it and the prostate which must be freed as far as its anterior border. The legs of the cadaver are then separated, and an incision is made with the large section-knife, through the skin, beginning above at the root of the penis, at the termination of the main incision, and following the arch of the pubis around the external genitals down to the left, passing around the anus to the coccyx. A similar incision is then made on the right side of the external genitals to meet the first incision behind the anus. The outer genitals are then held in the left hand and pulled downward between the legs while they are dissected from the pubis, cutting the suspensory ligament of the penis, to the level of the posterior border of the symphysis. The knife is then run through into the pelvis just beneath the symphysis, and while traction is made upon the external genitals toward the right, a sweeping cut is made downward to the left along the pubic arch, severing the insertion of the cavernous portion of the penis on that side. A similar cut is then made on the right side. The penis thus freed is then pushed up beneath the symphysis into the pelvis and the scrotum pulled up after it, putting the perineum on the stretch and pulling up the anus so that it can be seen. While the external genitals are forcibly pulled upward in the pelvic cavity toward the head, the encircling incision behind the anus is deepened, cutting the fat-tissue, connective-tissue, and muscle around and behind the rectum, until the whole mass of genital organs and rectum is so loosened that it strips up easily to the brim of the pelvis, where any remaining attachments of peritoneum or blood-vessels are severed and the entire mass removed for examination on the board.

The mass is laid upon the board with rectum uppermost. The latter is then opened from the anus, using the intestinal shears, and scraping off the contents into a pail so as not to contaminate the other tissues. The rectum is then separated from the base of the bladder and prostate, guiding the incision along the outer muscular layer of the rectum, and stripping off the latter until the seminal vesicles are wholly exposed. These are then examined by means of transverse cuts, or are opened longitudinally with the knife or fine probe-pointed scissors. The prostate may also be sectioned from its posterior surface, if it is desired to preserve the urethral side intact. Cowper’s glands are also accessible from this incision. The organs are then turned over, the penis put on a stretch and the anterior wall of the urethra cut in the median line from the meatus to the bladder. A pair of strong, medium-sized probe-pointed scissors should be used. The incision is extended through the anterior wall of the bladder. The mouth of the ureters, ejaculatory ducts and ducts of Cowper’s glands are examined. If the prostate has not been examined from the rectal side it may now be examined by means of transverse incisions across the urethra and extending entirely through the gland. The section of the genitalia is then finished by the examination of the testicles. The latter are removed by enlarging the inguinal canal on each side, slipping the testicles up through them, and bisecting each gland so that the incision falls through the head of the epididymis. The testicles may also be examined by means of incisions made in the scrotum over the glands, which are forced through the incisions and then bisected. If the vasa deferentia are to be preserved they should be dissected out before the semicircular cuts on each side of the external genitals are made.

When the kidneys have been removed, and the ureters left uncut, to be examined in connection with bladder and external genitals, they are usually left lying on the thighs until the abdominal examination is finished. They are then laid in the abdomen until the pelvic organs have been separated up to the brim of the pelvis. At this point care should be taken to see that the ureters are not cut when the whole mass of pelvic organs, ureters and kidneys is removed. When placed upon the board the ureters are laid straight and the kidneys placed in their respective positions. The ureters are sounded from the bladder and when desired opened upward from the bladder to the kidneys. The section of the kidneys may then proceed according to the directions given in the last chapter.

When the external genitals cannot be removed, the testicles can be examined by enlarging the inguinal rings and canal, and forcing each testicle up from below, through the ring. The gland is then sectioned and, after examination, returned to the scrotum. The anterior wall of the bladder is then separated from the pubis and the tissues about rectum and prostate loosened until the hand can completely encircle the rectum and prostate. These organs and the bladder are then pulled up firmly toward the head of the cadaver, and with the cartilage-knife hugging the pubic bone the rectum is cut just above the internal sphincter, and the urethra just anteriorly to the prostate. When it is desired to get as much of the penis as possible, its attachments to the pubis are cut from the pelvic side, and the body of the penis pulled up into the pelvis, while the skin of the organ is loosened as far as the glans. The body of the penis may be severed from the glans or the glans may be freed from the prepuce and removed with the entire organ, leaving only the skin to be used for the restoration of the part. After the rectum and urethra are severed, the mass of pelvic organs is stripped up to the brim of the pelvis and removed, as given above. They are examined upon the board, opening first the rectum, then the seminal vesicles, prostatic urethra, bladder and prostate. The prostatic urethra and anterior bladder-wall are cut with the small probe-pointed shears, while the prostate is cut transversely with the long section-knife.

The bladder, prostate and seminal vesicles may be examined in situ, or separated from the rectum and examined outside of the body. The anterior wall of the bladder is freed from the pubis, and the lateral connections of the prostate separated. The bladder is then opened in its anterior wall by an incision from its fundus into the prostatic portion of the urethra. The prostate is then cut transversely at about its middle, the cut extending entirely through the organ. The fore-finger of the left hand is then hooked underneath the prostate, and the bladder stripped forcibly from the rectum, upward toward the pelvic brim. The base of the bladder is thus brought up into view, exposing the seminal vesicles, which are examined by transverse incisions.

In the employment of any one of these methods, the urine, if it is to be saved for examination, should first be drawn through a catheter. This is also the cleanest way of emptying the bladder, particularly when it is greatly distended. The employment of force to squeeze the urine out of the bladder through the urethra is not advisable when there is any disease of bladder or urethra present.

2. Female Pelvis. The contents of the pelvis and the external genitalia are removed from the female cadaver in the same way as in the male. The anterior wall of the bladder is first freed from the pubis and the tissues separated around and behind the rectum so that the hand can be carried around the vagina and rectum. When the external genitalia are to be removed with the internal organs, an encircling incision is made on both sides of the external genitals, beginning above at the termination of the main incision at the beginning of the anterior commissure, and meeting behind the anus. The external genitals are then dissected away from the arch of the pubis until the knife can be passed up beneath the symphysis and the attachments to the posterior border of the arch cut on both sides, so that the vulva can be pulled up beneath the pelvic arch, putting the perineum on the stretch. The posterior portion of the encircling incision is then deepened until the entire mass of external genitals and anus can be stripped up with the internal organs to the brim of the pelvis, where they are held up perpendicularly and any remaining attachments of peritoneum and blood-vessels cut, care being taken to cut outside of the ovaries and tubes. The mass thus removed is laid on the board with rectum uppermost and the latter opened first. The organs are then turned over, and the urethra and bladder opened in the anterior median line with the probe-pointed shears. The vagina and uterus are then opened in the anterior median line, bisecting the urethra and bladder. A heavy pair of shears having one blunt-pointed blade should be used. If it is desired to save the bladder and urethra, they can be dissected over to the right, or the vaginal wall can be cut on its left side. When the cervical canal will not admit the scissors the uterus may be cut in the median line with a knife. The horns may then be opened with the scissors. Additional cuts may be made into the uterine wall as desired (tumors, placental site, etc.). The tubes may be sounded from the abdominal extremity and then opened for their entire length with the fine probe-pointed shears, or they may be examined by means of transverse cuts. The ovaries are held with their flat surfaces between thumb and index-finger and then sectioned in the plane of greatest dimension from the convex border to the hilus. The broad ligaments, parametrium, parovarium and lymphnodes are examined by means of cuts made parallel with the sides of the uterus.

When the external genitals cannot be removed, the vagina and rectum, after they have been freed from the surrounding tissues, are put on the stretch toward the head of the body and cut through as close to the pubic outlet as possible. When this is carefully done it is possible to secure the inner labia and the urethra intact. The rectum is cut as close to the anus as possible. The organs are then stripped up to the brim of the pelvis, then held up perpendicularly while the remaining connections are severed. The organs thus removed are examined on the board in the same manner as given above. When the organs cannot be removed from the body, the bladder and urethra are examined by an anterior median incision after they have been freed from the symphysis. The uterus and vagina are then cut with the knife in the anterior median line, either through the bladder or after the latter has been dissected away. The ovaries, tubes and broad ligaments are then examined as directed above. The uterus and vagina may also be dissected from the rectum and opened by a posterior median incision. This method is used in medicolegal examinations.

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

I. MALE PELVIS. 1. Penis. Size, anomalies, condition, character of prepuce, evidence of circumcision, presence of smegma, character of meatus, discharge, wounds, scars (on and back of corona), evidence of syphilis, neoplasms, etc. Postmortem priapism occurs particularly in leukæmia. It may be caused also by traumatic or infective thrombosis and hæmorrhage, tumor-metastases, inflammatory infiltrations, and in death from hanging. The most important pathologic conditions of the penis are: inflammations (balanitis, posthitis, cavernitis, gonorrhœa, etc.), gangrene, phimosis, paraphimosis, præputial concretions, soft chancre, hard chancre, secondary syphilides, traumatic lesions (fracture, hæmorrhage, urine-infiltrations, etc.), anomalies (hypospadias, epispadias, etc.), tuberculosis (rare), condylomata, elephantiasis, cornu cutaneum, carcinoma, sarcoma (rare; melanotic sarcoma the most common form), secondary carcinoma (primary in prostate), lipoma, angioma and teratoma.

2. Scrotum. The most important pathologic conditions of the scrotum are: œdema, inflammation, gangrene, trauma, burns, elephantiasis, carcinoma, melanotic sarcoma, lipoma, fibroma, myofibroma, lymphangioma and teratoma.

3. Testis and Epididymis. Testis and epididymis weigh 15-30 grms. Note size, form and consistence. Normal color of cut-surface is grayish yellow; becomes brown in atrophy. Note character of tunics (color, lustre, smoothness, consistence, etc.), and contents of sacs (hydrocele, hæmatocele, empyema, etc.). The most important conditions affecting the testes are: inflammation (orchitis, epididymitis, vaginitis, abscess, hæmatogenous inflammations in pyemia, mumps, scarlet fever, typhoid fever, variola, chronic fibroid orchitis in syphilis, gonorrhœal epididymitis), tuberculosis, gonorrhœa, syphilis, actinomycosis, leprosy, leukæmic infiltrations, atrophy, compensatory hypertrophy, cryptorchidism, hydrocele, varicocele, spermatocele, cysts, malignant teratomata (syncytioma, cysts, cystocarcinoma, adenocarcinoma, adenoma, adenosarcoma, cystosarcoma, rhabdomyosarcoma, chondroma, osteoma, myxoma, etc.), carcinoma, sarcoma, lipoma, fibroma, etc., metastatic sarcoma and carcinoma, dermoid cysts, benign teratoma, parasites (echinococcus is rare). Tuberculosis is most common in the epididymis; syphilis more frequently affects the body of the testis. Torsion of the vas deferens may occur; atrophy of the testis may result. Twisting or thrombosis of the spermatic vessels may cause gangrene of the testicle.

4. Rectum. Note contents (amount, color, consistence, odor, etc.), color and character of mucosa (normally grayish red or reddish gray, smooth and translucent, solitary follicles just visible). Normally the rectum should contain formed brownish féces; in catarrh the contents are fluid and not formed, while the mucosa is covered with a thick glassy mucus. In obstruction of the gall-ducts the féces are gray (“clay-color”). In catarrhs and chronic passive congestion the mucosa is red. Decubital ulcers are often green from the imbibition of bile, and are surrounded by hæmorrhages. They are circular or correspond in shape to the fécal mass pressing upon them. Traumatic ulcers, hæmorrhages, diphtheritic inflammation, follicular ulcers, foreign bodies, stricture, fécal impaction, hæmorrhoids, fissures, fistulous tracts, tuberculosis, syphilis, adenomatous polyps and carcinoma are the most common pathologic conditions. The oxyuris vermicularis is the most common animal parasite. Gonorrhœa of the rectum is not uncommon. Stricture is most commonly caused by syphilis.

5. Prostate. Normal size is about that of a walnut or horse-chestnut. Weighs 19-25 grm. Average dimensions are 2.7 cm. long, 4.0 cm. broad, 2.0 cm. thick. Note form, consistence, color of cut-surface (smooth or granular), amount of secretion, corpora amylacea (color brown to black), size of gland-spaces, cysts, abscesses, tubercles, neoplasms. The most common pathologic conditions are: hyperplasia (usually inflammatory, the result of old gonorrhœal infection, less commonly due to chronic pyogenic infection), neoplasms (carcinoma is relatively common, usually developed in a prostate showing chronic inflammatory hyperplasia, adenoma, myoma, fibroma, myofibroma), cysts, acute inflammation (usually gonorrhœal), typhoid prostatitis, abscesses, tuberculosis, syphilis (rare) and atrophy. Thrombosis and the formation of phleboliths are very common in the prostatic veins; they are usually associated with gonorrhœal infection. The inflammatory hyperplasia may involve one or all three lobes of the prostate. In old men showing no evidences of prostatic inflammation the prostate may be atrophic.

6. Seminal Vesicles and Duct. Should be symmetrical. Note size, contents, character of wall, and appearance of lining membrane. They measure 3-5 cm. long, 1-2 cm. broad and 0.7-1.5 cm. thick. Gonorrhœal inflammations and tuberculosis are the most common conditions. In old men the vesicles contain a brownish-yellow mucoid substance. As a result of chronic inflammation the walls of the vesicles are thickened, often hyaline; the lumen is sometimes wholly obliterated. Calcification of the wall is not uncommon. Concretions are found in the vesicles following obstruction. Cystic dilatation may occur. Primary neoplasms (carcinoma and sarcoma) are rare.

7. Urethra. Mucosa should be grayish-red, smooth, shining and transparent. The most common and important pathologic condition is gonorrhœa (acute, chronic, anterior, posterior, erosions, ulcers, abscesses, perforation, stricture, periurethral abscess, cavernitis, etc.). Non-gonorrhœal urethritis is rare (colon- and influenza-bacillus, streptococcus, pneumococcus, etc.). Trauma (crushing, laceration, perforation, urine-infiltration, hæmorrhage, periurethral abscess, phlegmon, gangrene, stricture, urinary fistula, etc.), soft chancre, hard chancre, secondary and tertiary syphilitic lesions (gumma), tuberculosis (lupus), leprosy and neoplasms (rare: adenoma, carcinoma, melanotic and round-cell sarcomata [lymphosarcoma], fibroma, angioma) may occur. The most common anomalies are hypospadias and epispadias.

8. Bladder. Size, degree of distention, amount and character of contents, character and color of mucosa (normally gray-red, smooth and transparent), muscle-coats (hypertrophic, atrophic). The most common pathologic conditions are: anomalies (ectopia, ecstrophia, vesica bipartita, vesica bilocularis, diverticula), congestion, œdema, cystitis (acute and chronic catarrh, cystitis granulosa, cystica, purulent, phlegmonous, diphtheritic, emphysematous, interstitial, peri- and paracystitis, erosions, ulcers, gangrene, malakoplakia), tuberculosis, dilatation, trauma (rupture, perforation, fistula), neoplasms (papillary fibro-epithelioma, carcinoma, adenoma, myxoma, myoma, rhabdomyoma, angioma cavernosum, sarcoma, dermoids, secondary carcinoma [usually from prostate], and sarcoma [melanotic sarcoma]), concretions (urates, uric acid, oxalates, phosphates, carbonates, cystin and xanthin), and parasites (filaria sanguinis, distomum hæmatobium, echinococcus, trichomonas, ascaris and oxyuris).

II. FEMALE PELVIS. 1. Rectum. Note same things as given above for the examination of the rectum in the male. Gonorrhœa, stricture due to syphilis and traumatic fistula (due to child-birth) are more common in the female.

2. Vulva. The most important pathologic conditions are: congestion, œdema, hæmorrhage, hæmatoma, trauma (laceration), vulvitis (catarrhal, gonorrhœal, chronic, diphtheritic, gangrenous, phlegmonous, ulcerative, abscess), erythema, eczema, herpes, acne, furunculosis, pruritus, kraurosis vulvæ, leukoplakia, Bartholinitis, retention-cysts, cysts of the glands of Bartholin, hydrocele muliebris, syphilis (primary, secondary and tertiary lesions), tuberculosis (lupus), elephantiasis, condylomata, neoplasms (lipoma, fibroma, lymphangioma, papilloma, fibromyxoma, fibromyoma, chondroma, neuroma, carcinoma [usually very malignant in type], sarcoma [rare] and metastatic tumors [very rare]).

3. Urethra. Same conditions as noted above for the male. Small polypoid granulomata (caruncles) are very common; usually gonorrhœal in origin. Primary carcinoma is more common in the male.

4. Bladder. Note same conditions as given above. Rectovesical and vesicovaginal fistulas are not rare as the result of child-birth. Secondary carcinoma is more common than in the male (from uterus and cervix), primary carcinoma more rare. Ascaris and oxyuris may enter bladder from vagina through a rectal fistula.

5. Vagina. Note size (about 5-8 cm. long), contents (foreign bodies, pus, blood, etc.), color of membrane, condition of rugæ, hymen, etc. The color of the mucosa varies from a delicate rosy red to a bluish purple in the late stages of pregnancy. The most important conditions are: colpitis (acute and chronic, catarrhal, diphtheritic, gangrenous, emphysematous, granular, nodular, adhæsiva, exfoliativa, vetularum, ulcerative; gonorrhœa the chief cause; also caused by mercuric chloride and other poisons; occurs also in cholera, typhoid fever, variola, scarlatina, diphtheria and other infections), ulcers, abscesses, erosions, strictures, varices, prolapse, atresia, trauma (lacerations, rupture, hæmatoma, fistula), tuberculosis (rare), syphilis (primary less common than on vulva, secondary lesions common, gumma rare), thrush, cysts (retention, remains of Müllerian and Wolffian ducts, gas-cysts), neoplasms (papillary fibro-epithelioma, fibroma, myxoma, myoma, rhabdomyoma, rhabdomyosarcoma, myxosarcoma), carcinoma (primary rare, secondary relatively common, particularly of malignant chorio-epithelioma; primary ectopic chorio-epithelial tumors occur in vagina also), and parasites (trichomonas vaginalis, oxyuris vermicularis). Note particularly condition of hymen.

6. Uterus. The developed uterus weighs 33-41 grms. In women who have not borne children the dimensions are 7-8 cm. long, 4 cm. broad, 2.5 cm. thick; in women who have borne children the dimensions are 8-9 cm. long, 5-6 cm. broad, and 3 cm. thick. The dimensions of the postpartum uterus vary greatly, where normal contraction has taken place the length is 8-9 cm., breadth 5-6.1 cm., thickness 3.2-3.6 cm., and weight 102-120 grms. Note size, shape, character of peritoneal coat, consistence, character of cut-surface, size and contents of cavity. Length of uterine cavity 5.2-5.7 cm. Note relations between body of uterus and cervix. In adults the circumference of the body of the uterus is greater than that of the cervix; before the age of puberty it is less than that of the neck. In old age the entire organ contracts, but the body more than the cervix, so that the organ again assumes an infantile form. The external os in the virgin uterus is round or oval; in women who have borne children it appears as a transverse cleft. The most common conditions of the cervix are the so-called erosion and ectropion, cystic glands (ovula Nabothi), cervical catarrh, hyperplasia, ulcers, polypi, myofibroma and carcinoma. Note contents of cervical canal (normally glassy, tough mucus; in catarrh becomes thin, cloudy or purulent); length and shape of canal (elongations, dilatations, stenosis, etc.). Color of mucosa should be grayish-red; the folds should be distinct and symmetrical. Purulent and diphtheritic inflammations, lacerations, polypi, cysts, fibromyoma, carcinoma and tuberculosis are the most common conditions affecting the cervical canal.

The uterine cavity is normally empty; during menstruation or as the result of inflammation it may contain blood and bloody mucus; and the mucosa may be deep-red. The normal mucosa is gray-red and 0.5-1.0 mm. thick. In the puerperal uterus portions of the placenta, fœtal membrane, purulent or bloody lochial discharges are present. The placental site is shown by its uneven surface and presence of blood-clots. Gangrenous and purulent areas are greenish, gray, brownish-green, and black, with opaque and ragged surface. Gas-bubbles may be present. The normal consistence of the uterus is firm, diminished in the puerperal uterus, increased in chronic metritis. The cut-surface is smooth in the virgin uterus, rough in the uteri of women who have borne children and in chronic metritis. The most common pathologic conditions of the uterus are: abortion, hæmorrhage, apoplexia uteri, hæmatometra, hydrometra, pyometra, rupture, perforation, traumatic lesions, endometritis (acute, chronic, hæmorrhagic, interstitialis, glandularis, hyperplastica, cystica, polyposa, adenomatosa, infective, decidual, atrophic, etc.), foreign bodies, tuberculosis, syphilis, actinomycosis, hyperplasia, metritis (acute, chronic, hyperplastic, atrophic), perimetritis, parametritis, atrophy, neoplasms (myoma and myofibroma the most common; adenoma, adenomyoma, adenomatous polypi are very common; carcinoma [adenocarcinoma, cystocarcinoma, medullary, papillary, colloid, scirrhous, squamous-celled, malignant chorio-epithelioma] very common; sarcoma less common but it is not rare [myosarcoma the most common form; often represents a sarcomatous transformation of a myofibroma]; metastatic carcinoma and sarcoma are rare), and parasites (echinococcus).

7. Tubes. Note length, thickness, shape, character of peritoneum, patency, fimbriated extremities (swelling, redness, exudate, tubercles, hæmorrhage), contents, color and thickness of mucous membrane, thickness and consistence of entire wall. Tubes should be straight, not tortuous; in inflammation they are usually twisted, tortuous or bent. Hæmatosalpinx is usually caused by a tubal gestation. The most common pathologic conditions are: salpingitis (usually gonorrhœal, acute, chronic, catarrhal, purulent, pyosalpinx, hydrosalpinx, interstitial, perisalpingitis, tubo-ovarian abscesses and cysts), tuberculosis, actinomycosis (rare), syphilis (very rare), hæmatoma (ectopic gestation relatively frequent), neoplasms (rare: adenomyoma, fibromyoma, fibroma, myosarcoma, sarcoma, carcinoma, chorio-epithelioma and teratoma; secondary carcinoma from uterus, ovary and intestine).

8. Ovaries. Note size, form, consistence, color, character of cut-surface, number of Graafian follicles, corpus luteum, etc. Ovary at puberty weighs about 10 grm., measures 4-5.2 cm. long, 2-2.7 cm. broad, 1.0-1.1 cm. thick. The adult ovary weighs about 7 grm., and measures 2-4 cm. long, 1.4-1.6 cm. broad, 0.7-0.9 cm. thick. A corpus luteum is 1.0-2.0 cm. in diameter. Ovary is compared to an almond in size and shape. In young individuals the surface is grayish-white and smooth; with age the surface becomes more and more irregular, the organ smaller and its consistence firmer. The cut-surface in young individuals is normally very moist (this should not be regarded as œdema). The most important conditions are: inflammation (acute and chronic, hæmorrhagic, purulent, etc., oöphoritis, abscess), tuberculosis, cystic follicles, lutein-cysts, cystadenoma (multilocular, monolocular, surface papilloma, simplex, papillary), parovarian cysts, carcinoma, fibroma, sarcoma, dermoid cysts, teratomata, malignant teratomata, embryoma, parasites (echinococcus is very rare).

9. Uterine Ligaments, Vessels and Lymphatics. Peritoneum over the broad ligament should be moist-shining, delicate and transparent. Inflammatory processes are very common in the parametrium, particularly in puerperal cases. The peritoneum is cloudy, opaque, injected, or covered with fibrinous or purulent exudate. Great numbers of small cysts containing clear fluid are often found in the peritoneum of the broad ligament as the sequelæ of inflammation. Note contents of blood-vessels (thrombi, concretions, neoplasms), and character of walls. Parovarian cysts, myomata, adenomyomata (round ligament), secondary carcinoma, chronic inflammations, hæmatoma and tubercles are the most common pathologic conditions.