QZ K29p 1899 62141210R NLM D50abb5S 2 NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE LIBRARY. iNHE> Section, JVo. __J_ ________3—1639 NLM050866552 THE PATHOLOGIST'S HANDBOOK / THE PATHOLOGIST'S HANDBOOK: A MANUAL FOR THE POST-MORTEM ROOM / BY T. K KELYNACK, M.D., M.R.C.P. PATHOLOGIST, MANCHKS1ER ROYAL INFIRMARY; HONORARY PATHOLOGIST TO THE MANCHESTER CLINICAL HOSPITAL FOR WOMKN AM) CHILDREN I HONORARY PATHOLOGIST AND B ACTE RIOLOGI ST TO THE MAMHKS'I'ER EAR HOS- PITAL; DEMONSTRATOR IN MORBID ANATOMY, THE OWENS COLLEGE WITH ONE HUNDRED AND TWENTY SIX ILLUSTRATIONS J. & A. CHURCHILL 7, GREAT MARLBOROUGH STREET 1899 A - /d PRE PACE This little Handbook had its origin in a series of papers written for the (Manchester Royal Infirmary Students' Gazette.' Although considerably extended, the original form of the articles has, as far as possible, been retained. While fully recognising that post-mortem tech- nique can only be satisfactorily learnt in the post-mortem room, I have attempted, after many years' experience of teaching in the Pathological Department of the Manchester Royal Infirmary, to furnish a concise guide for Students acting as Clerks in the post-mortem room, and a suggestive manual for Junior Practitioners. My main object has been to indicate methods. Reference to special lesions has to a very great extent been omitted. For descriptions of these the Student will naturally refer to his text- books on Morbid Anatomy. VI PREFACE My best thanks are due to Dr Fothergill for several of the drawings from which figures have been prepared; and to Mr W. S. Kelynack for many of the photographs. A few illustrations have been reproduced from works already published by Messrs J. & A. Churchill, but where this is the case the source is clearly indicated, and I would here acknowledge my indebtedness, both to authors and publishers, for the use of the same. I have also to thank Messrs Weiss & Son for their courtesy in providing the blocks for the illustrations of the instruments. T. N. KELYNACK. 3, St. Peter's Square, Manchester ; September, 1899. TABLE OE CONTENTS Chapter I. Introduction . II. General Considerations III. Instruments . IV. External Examination V. Internal Examination VI. Examination of the Thorax and Xeek VII. Examination of the Abdomen VIII. Examination of the Head and Spine IX. Special Examinations X. Medico-legal Considerations XI. Miscellaneous Considerations Index LIST OF ILLUSTRATIONS Fig. 1. Ordinary post-mortem knife 2. Strong post-mortem knife 3. Cartilage knife 4. Long section knife 5. Brain knife 6. Scalpel 7. Do. 8. Do. 9. Do. 10. Probe-pointed curved bistoury 11. Trowel-shanked section knife . 12. Tiemann's double-bladed section knife 13. Straight sharp-pointed scissors 14. Fine curved scissors . 15. Scissors with angular blades 16. Bowel scissors . 17. Probe-pointed scissors 18. Strong saw 19. Saw . 20. Small hand-saw 21. Long metacarpal saw . 22. Spinal double saw or rachiotome 23. Butcher's saw . LIST OF ILLUST NATIONS IX Fig. 24. Cartilage shears or costotoine 25. Bone cutters . 20. j-sliapcd chisel 27. Spiked chisel . 28. Straight chisel 29. Curved spinal chisels . 30. Lion forceps . 31. Straight spinal chisel . 32. Iron hammer . 33. Hooks . 34. Dissecting forceps 35. Straight fine-pointed forceps 36. Curved fine-pointed forceps 37. Retractor 38. Curved blowpipe 39. Straight blowpipe 40. Injecting syringe 41. Cranium holder 42. Head-rest 43. Measuring callipers . 44. Graduated cone 45. Magnifying glass 46. Do. 47. Curved needles 48. Straight needle 49. Complete post-mortem set in case 50. Chest wall, indicating part to be removed for ex plor.ition of thorax (Virchow) 51. Superficial dissection of thorax and abdomen (Heath) 52. Transposition of viscera (Norman Moore) 53. Relations of heart and great vessels to chest wall (Luschka) . 5i. Pericardial haemorrhages 55. Secondary deposits of melanotic sarcoma into heart 56. Interior of light side of heart (Allen Thomson) 52 56 58 61 62 63 64 X LIST OF ILLUSTRATIONS Fig. PAGE 57. Interior of left side of heart (Allen Thomson) 65 58. Diagram showing method of holding heart in opening cavities of right side 67 59. Diagram illustrating method of holding heart in open ing cavities of left side 68 60. Aneurysm of mitral valve 70 61. Testing competency of aortic valves . 71 62. Scissors in position ready for division of right auri- culo-ventricular ring 72 63. Opening of right side of heart 73 64. Right side of heart opened . . 73 65. Opening of pulmonary artery 74 66. Diagram of incision into right ventricle 75 67. Incisions into heart according to Virchow 76 68. Diagram illustrating opening of aorta by cutting along septum and between two of the pulmonary cusps .... . 77 69. Opening of cavity of left ventricle by transfixion . 78 70. Hypertrophied heart from case of granular kidney . 79 71. Transverse sections of hypertrophied heart . 79 72. Aneurysm of left ventricle (Sieveking) . 80 73. Atheromatous aorta and orifice of saccular aneurysm 81 74. Aneurysm of arch of aorta (Sieveking) . 82 75. Method of holding lung in making section . 84 76. Method of incising lung 85 77. Vertical section through tuberculous lung 86 78. Section of tuberculous lung . 87 79. Bronchiectasis (Sieveking) 88 80. Impacted meat in larynx 89 81. Mediastinal growth invading lung 90 82. Subphrenic abscess (after Leyden) 93 83. Opening of intestines . 94 84. Ulcerative colitis 95 85. Ulcerative colitis 96 86. Dilated large intestine . 97 LIST OF ILLUSTRATIONS XI Fig. 87. Opening of bladder and urethra in position 88. Carcinoma of bladder (Norman Moore) 89. Haematocele (Curling) 90. Syphilitic testicle (Bowlby) . 91. Vertical section of female pelvis (Galabin) 92. Fibro-myoma of uterus (Norman Moore) 93. Uterus bicornis (Galabin) 94. Uterus septus (Galabin) 95. Double uterus and vagina (Galabin) 96. Uterine polypi (Galabin) 97. Fibro-myoma of uterus (Sieveking) . 98. Method of opening the kidney 99. Sarcoma of kidney . 100. Abscesses of kidney . 101. Divided kidney with supra-renal cyst 102. Horseshoe kidney (Norman Moore) . 103. Dilated stomach (Fagge) 104. Secondary growth of spleen . 105. Secondary sarcoma of spleen 106. Secondary melanotic sarcoma of liver (Norman Moore) .... 107. Secondary carcinoma of liver 108. Large cirrhotic liver . 109. Cirrhotic liver, transverse section 110. Biliary cirrhosis 111. Projecting right lobe of liver 112. Gall-bladder distended with gall-stones 113. Section of cranium . 114. Section of skull by V incision 115. Hydrocephalic skull (Sieveking) 116. Sinuses of the skull (from Hirschfeld and Leveille) 117. Sinuses of the skull and cranial nerves (Gray) 118. Base of the brain (from Hirschfeld and Leveille) 119. Secondary melanotic sarcoma of brain 120. Subarachnoid effusion (Sieveking) . PAGE 99 100 101 102 103 104 105 106 106 107 107 109, 110 111 112 112 114 116 117 Xll LIST OP ILLUSTRATIONS Fig. PAGE 121. Lateral ventricles of the brain (from Hirschfeld and Leveille) . . 138 122. Use of the vertebral chisel . . 139 123. Section of rachitic femur (Sieveking) . 144 124. Nulliparous and parous uterus (Galabin) . 147 125. Homicidal cut throat (Ogston) . 149 126. Suicidal cut throat (Ogston) . 149 CHAPTER I INTRODUCTION A thorough knowledge of morbid anatomy forms the surest basis for the practice of scien- tific medicine. Without it the practitioner be- comes little better than a mere empiric. Time and opportunity, unfortunately, limit the study of practical pathology for most to the brief period of student life. As Dr Goodhart has well expressed it, "the field of clinical obser- vation is always with us; but student life over, the opportunity of making any extensive ad- ditions to our knowledge of disease as it shows itself after death, is gone, and poor, indeed, to my thinking, is he who is not well-furnished in this respect." Valuable as are descriptions, illustrations, and museum preparations, they cannot set aside the necessity for personal observation of diseased structures as met with in post-mortem examina- tions. A recognition of the importance of morbid anatomy should prompt to an energetic and persistent studv of the same. The correct- 1 2 CHAPTER I ness and completeness of every ante-mortem diagnosis ought to be tested by a post-mortem inspection. Compliance with a doctrine of perfection is usually impossible, but every physician should feel it a duty which he owes to himself, as well as to the profession at large, to seek permission to make a post-mortem exa- mination where possible. Regular attendance in the post-mortem room is essential for a practical knowledge of disease. Morbid anatomy deals with fads. Theories as to the nature and causation of disease may come and go ; experimental pathology may establish or dispel particular views ; but a study of morbid anatomy is a necessity to each generation of students, and should be as much a subject of personal inquiry to the senior student as normal anatomy is supposed to be to the junior. Seeing, with most, is not only believing, but remembering, and, to a considerable extent, understanding. The atmosphere of the post- mortem room whets the appetite for investiga- tion into the problems of disease. The revela- tions of the pathological department not only indicate what disease can accomplish, but ex- plain clinical features, suggest lines for rational treatment, and oftentimes encourage a healthy and reasonable optimism by demonstrating the wonderful compensatory powers of nature. Pathological specimens are frequently exa- mined by students too much as though they INTRODUCTION 3 were mere curios, concerning which an inquisi- tive examiner might some day desire enlighten- ment. An intelligent inspection of pathological material should be something very different from this ; as Latham puts it, " so far as morbid anatomy contemplates the last or latest results of disease that are fixed and irremediable and unalterable its value is very small; but so far as morbid anatomy contemplates disease in pro- t/ress, and scrutinises and explains its organic processes, its value is very great." Every student should not only make it a rule to attend regularly in the post-mortem room, but also to actively participate in the conduct of examinations. It is necessary to be acquainted with the evidences of healthy and morbid processes in all their varying manifestations. And it is also desirable to be able to seleci the most suitable methods of investigation and demonstration. Until a student becomes qualified he can scarcely realise the importance of a practical acquaintance with pathology. As the law now stands, any practitioner may find himself sud- denly called upon to undertake most important pathological investigations, and be compelled to give opinions which will not only seriously affect his own credit, but may influence the highest interests of others, and lead to the most serious consequences. Neglect of morbid ana- tomy during student days must prove an almost 4 CHAPTER I irreparable loss, and may lead to much ignorant blundering in medico-legal cases, thereby bring- ing disgrace on self, defeating justice, and de- laying progress, both moral and scientific. In the pursuit of practical morbid anatomy there is the greatest necessity for system in in- specting, dissecting, and recording. While adopting some method of general application one must be ready to modify or adapt according to the requirements of special cases, and to meet the needs of special forms of inquiry. In the following chapters I shall endeavour to indicate the most convenient methods of con- ducting post-mortem examinations, and with directions, suggestions, and warnings, shall hope to present something which may be of service in the scientific investigation of disease in hospital and private cases, and in the un- ravelling of pathological cases in their medico- legal aspects.* * The following list of works dealing with post-mortem technique may be of service for purposes of reference : Blackburn, I. W. A Manual of Autopsies, designed for the use of Hospitals for the Insane and other Public Institutions. 1892. Caibd and Cathcart. A Surgical Handbook. 1896. 7th edition, p. 242. Chiari. Pathologisch-anatoinische Sectionstechnik. 1894. Clarke, J. Jackson. Post-mortem Examinations in Medico- legal and Ordinary Cases. 1896. Delafield and Prudden. Pathological Anatomy. 1896. Gannett. Post-mortem Examinations: Reference Hand- INTRODUCTION 5 book of the Medical Sciences. Vol. v, 1889, pp. 783— 791. Goubert. Manuel de l'Art des Autopsies, surtout dans ses applications lU'Anatomie pathologique. 1867. (Refer- ences given to many of the early works on the subject.) Hamilton. Text-book of Pathology. Vol. i, 18S9, pp. 1 — 42. Harris, Thomas. Post-mortem Handbook. 1887. Hektoen. Post-mortem Technique. 1894. Hudson. Article in ' Dictionary of Practical Medicine,' edited by J. K. Fowler, M.D. 1890, pp. 665—669. Mallort and Wright. Pathological Teclnvque. 1898, pp. 17—69. Nauwerck. Sectionstechnik. 1891. Newtii. A Manual of Necroscopy. 1878. Orth. Pathologisch-anatomische Diagnostik. 1894. Rolleston and Kanthack. Manual of Practical Morbid Anatomy, being a Handbook for the Post-mortem Room. 1894. Thomas, A. R. A Practical Guide for making Post-mortem Examinations and for the Study of Morbid Anatomy. 1873. Virchow. Post-mortem Examinations. (English translation by Dr. T. P. Smith.) 1880. Warthin. Practical Pathology for Students and Phy- sicians. 1897. Woodhead, (i. Sims. Practical Pathology. 1892, pp. 1— 29. Wynter and Wethered. A Manual of Clinical and Prac- tical Pathology. 1890, p. 2S5. CHAPTER II GENERAL CONSIDERATIONS Before proceeding to indicate the method of conducting a post-mortem examination, it may be well briefly to refer to certain general points of practical importance. Prevention of Post-mortem Wounds.—Tn the first place the pathologist, and students acting with him, should always be in thoroughlv good health. The dangers from infection are un- doubtedly much increased to a man " run down." Special care must be bestowed upon the hands and arms, and, generally speaking, no examination is to be undertaken if these be in any way damaged. It is a good rule to consider all matter met with in the post- mortem room as infective. It is important to explain the risk and indicate the appropriate treatment of cuts and pricks to the students and attendants, lest by negligence or ignorance they become seriously infected. Jackson Clarke* believes that by a simple * Clarke (J. Jackson), ' Post-mortem Examinations in Medico-legal and Ordinary Cases,' 1896. GENERAL CONSIDERATIONS / system of antiseptic precautions every danger may be removed from post-mortem work, and goes so far as to express an opinion that " there is not so much danger in performing any sur- gical operation immediately after making a post-mortem examination as there is in goinc from one surgical operation in which pus is encountered to another." Still, in spite of this view, the old impression has much in its favour, that post-mortem investigations should not be carried on by anyone actually engaged in sur- gical, gynaecological, or midwifery work. Should any injury be received during the course of a post-mortem, the affected part must at once be soaked in strong perchloride of mercury solution, which should always be at hand in suitable strengths for immediate use. If it is absolutely necessary to continue the examina- tion after a cut or scratch has been received, the affected part may sometimes be safely covered by painting it over with celloidin dissolved in alcohol and ether. Rubber cots are very useful for lame fingers, and a very satisfac- tory protection may be afforded by covering the affected digit with surgical tissue, the edges of which can be rendered adherent by chloro- form. Many protect the hands by wearing india-rubber gloves. Some strongly advise the use of photographer's gloves, made of " stockin- ette," covered with india rubber. Personally I generally prefer to work without this rather 8 CHAPTER II cumbersome and often doubtful protection. In such cases, however, as acute septic peritonitis, where infection of the hair-follicles may readily occur, good rubber gloves are undoubtedly useful. They should be made long in the wrist. It is a good plan in all cases to rub vaseline or a suitable ointment into the hands and arms before commencing work. It should be non- odorous, insoluble in the fluids of the body, and leave no stain on the hands. Some advise a stiff ointment, such as may be made by combin- ing beeswax and vaseline, or vaseline and some of the solid paraffins. Sometimes it may be well to insert soap under the ends of the nails. All infective matter should be dealt with promptly. The instruments, tables, and whole post-mortem room must be kept scrupulously clean. A plentiful supply of disinfectants and deodorants should always be kept ready for im- mediate use. Cleansing of the Hands.—After an autopsy the hands should be thoroughly cleansed with soap and hot water, soaked, if necessary, in some deodorant,* then placed in a solution of biniodide of mercury and potassium, or per- * After trying a number of different deodorants, I find " Jeyes' fluid " the most agreeable. " Izal" or other modern dis- infectant may be used with advantage. " Condy's fluid " has the disadvantage of staining when used in strong solution. Tur- pentine and " Sanitas " are also useful as deodorants. Some of the recently introduced antiseptic soaps are very convenient. Parke, Davis, and Co. supply a very useful " ethereal antiseptic GENERAL CONSIDERATIONS 9 chloride of mercury, and finally washed again with ordinary soap and water. Protection of the Operator.—The operator should be protected by a large apron and sleeves. The most convenient is made of stout washing material. Strong jaconet is occasionally em- ployed. The protecting gown or apron should be made so as practically to envelop the whole body. It should come up high in the neck, reach to just below the bottom of the trousers, and also thoroughly protect the back of the operator. Buttons should not be used, as they are soon broken in washing. The sleeves should be made separately. An elastic band at their ends will readily keep them in position over the rolled-up shirt sleeves. Any capable seamstress should be able to construct a serviceable garb. The post-mortem room should be supplied with a small mirror, so that the operator mav satisfy himself that no evidences of the character of his work are left upon him before appearing in public. Time and Place of Examination.—A post- mortem examination should never be made at night. Artificial light, if possible, is always to be avoided, particularly in coroners' cases. Justice and medical science would much benefit if the investigation of medico-legal soap," which will be found of service for rapidly and thoroughly cleaning the hands. 10 CHAPTER II cases could always be carried out in a well- lighted and suitably equipped post-mortem room, which, where possible, should be in con- nection with a medical school, or at all events in some central situation, and freely open to all students and practitioners. Permission for Autopsy. — In most English hospitals permission for a post-mortem examina- tion has to be obtained from the nearest re- lative of the deceased. Some institutions re- quire permission to be given in writing. It would be well if all hospitals could so frame their bye-laws as to allow of an examination being made as a matter of course. At the pre- sent time, doubtless, public opinion in many districts would be strongly against such an ar- rangement. In coroners' cases the body must not be touched without a formal order from the coroner himself. To prevent the possibility of any confusion, every body should have an enamelled plate bear- ing a number, corresponding to the mortuary register, fixed on the wrist before the body is removed to the post-mortem room. If what may be termed the aesthetic or senti- mental side of the question were more generally attended to, it is very probable the public would soon show less repugnance to the holding of pathological examinations. The care of a mor- tuary is a matter of real importance. Every GENERAL CONSIDERATIONS 11 hospital should have a mortuary chapel, with suitable arrangements for the viewing of the corpse by the friends. Clinical Abstract.—In every hospital case the pathologist should be furnished with an ab- stract giving the following data:—Name, age, occupation, residence, date of admission, death, operation (if any has been performed), name of physician or surgeon, and clinical diagnosis. Then should follow a brief outline of the history of the case, and with advantage there mav be added a list of the lesions expected to be found. Medico-legal Cases.—In all medico-legal in- vestigations the pathologist should enter upon the inquiry with a perfectly unbiassed mind. In all these cases accuracy and thoroughness are the great essentials. In many coroners' cases it is well not to start the examination until a police officer is present. In a medico-legal autopsy every medical man connected with the case should be granted the opportunity of being present. The giving of due notice as to time and place1 should be considered part of the duties of the police officer having charge of the case. Before commencing an examination the patho- logist should carefully select the necessary in- struments, and have everything needed for the full investigation of the case ready at hand. Rapidity of execution is often an important factor. 12 CHAPTER II It is well to dictate the notes of the case as the examination is proceeding. These should indicate pathological facts, give full descrip- tions of lesions observed, but no opinions or in- ferences should be expressed in a medico-legal report. In cases likely to lead to litigation I have generally found it wise to ask all the medical men present to sign the report in evidence of their agreement with the facts therein stated. Their opinion as to the cause, nature, and general bearing of the case is thereby not interfered with, and much of the quibbling as to facts which tend to make medi- cal men ridiculous in the eyes of the public may be avoided. On completing an examination the body should be so left as to show practically no evidence that it has been touched. This matter will be referred to later when dealing with the restitution of the body. Systematic Examination.—A complete inves- tigation must be systematic, and may oftentimes be a very lengthy affair. In many cases it does not close with the mere examination of the body. A complete post-mortem may necessitate reports on—(1) External appearances ; (2) Internal morbid anatomy; (3) Morbid histology; (4) Pathological chemistry; (5) Bacteriology. CHAPTER 111 INSTRUMENTS For the satisfactory conduct of a complete post-mortem examination only a comparatively small number of instruments are absolutely necessary. There are, however, a number of appliances which are very desirable, and usually provided in a well-equipped pathological de- partment. Still, it is wise to remember that should one be suddenly called upon to under- take a post-mortem investigation in an out-of^ the-way district, where suitable instruments are not available, the scientific investigation of an important case must not be allowed to pass, for difficult though it may be, a reliable and com- plete autopsy may be made by means of a strong, sharp clasp-knife, a carpenter's or butcher's saw, domestic scissors, and an ordinary chisel and mallet. I propose very briefly to indicate the chief instruments in general use. Any lengthy de- scription is rendered quite unnecessary by the accompanying illustrations. 14 CHAPTER III The actual methods of best employing these different instruments can, of course, only be learnt by actual work in the post-mortem room. Knives.—Several forms are in common use. Fig. 1.—Ordinary Fig. 2.—Strong Fig. 3.—Cartilage post-mortem knife. post-mortem knife. knife. The type usually spoken of as Virchow's jiost-mortem knife (Eig. 1) is by far the best for the major part of every examination. 14573�7373103030733� INSTRUMENTS 15 A stronger form, but of the same type, is used for cutting through the costal cartilages (Fig. 2). The most modern form is where the knife and handle are made from one piece of metal, thus adding to the strength and rendering perfect cleansing easy (Fig. 3). In many cases fitted in this country the old- fashioned English cartilage knife will be found, which, though good and effectual, is not so con- venient as the Continental forms. It will thus be seen that the most generally useful knife is constructed on the principle of a butcher's knife. The blade is large, with a deep belly and with a rounded end. It must be firmly fixed in the handle, which should be large enough to be comfortably grasped by the hand. It is well to have several of these knives, so that duplicates may always be avail- able when it is necessary for some to be sent to be re-sharpened. Long-blade J knives of the amputation type, are necessarv for the dissection of the brain, the separation of the intestines from their mesen- tery, and the section of large organs (Fig. 4). A large flat section or brain knife is often convenient (Fig. 5). Scalpels of different sizes and varying forms are useful for dissection (I'igs. G, 7, 8, 9). Short-bladed strong knives have been specially 16 CHAPTER III introduced for disarticulating at the sterno- clavicular joints. A myelotome is a knife with the blade set '/3 SCALK Fig. 4.—Long section knife. Fig. 5.—-Brain knife. Fig. 6.— Scalpel. almost at a right angle to the handle, and is used for cleanly and transversely cutting across the spinal cord low down when removing the brain. A curved probe-pointed bistoury is espe- INSTRUMENTS 17 daily useful for dividing the dura mater in removing the brain (Fig. 10). A trowel-shanked section knife is occasionally found convenient (Fig. 11). Fig. 8.—Scalpel. The double-bladed section knife is not now frequently used (Fig. 12). A liollow-ground razor is very useful for cutting thin slices of fresh tissues. 2 18 CHAPTER III Scissors.—An ordinary, strong, straight pair is the most generally useful (Fig. 13). Sorae- FULL SIZE 'J3 SCALE Fig. 9.— Fig. 10.—Probe-pointed Fig. 11.—Trowel-shanked Scalpel. curved bistoury. section knife. times scissors having a curved or angular form are exceedingly convenient (Figs. 14 and 10). INSTRUMENTS 19 The bowel scissors or enterotome (Fig. 16) is best for opening the intestines, and is also useful in completing the division of the 'J2 SCALE. Fig. 12.—Tiemann's double bladed section knife. heart after its removal from the body. One blade is usually provided with a hook-like pro- 20 CHAPTER III Fig. 14.—Fine curved scis Fig. 15.—Scissors with angular blades. INSTRUMENTS 21 cess, but when employed for opening the heart this may with advantage be dispensed with, and a pair used with the blade rounded off. Probe-pointed scissors are very useful for opening up ducts or laying bare vessels (Fig. Fig. 16.—Bowel scissors. Fig. 17.—Probe-pointed scissors. Scnrs.—A good strong saw is absolutely essen- tial. The best is one very much resembling a butcher's saw (Fig. 18). Indeed, some patholo- gists prefer an ordinary meat saw. The handle should be so shaped as to be comfortably 09 CHAPTER III t 13 SCALE Fig. 18.—Strong saw. 'J3SC&J.E Fig. 19.—Saw. 9999925 54521 INSTRUMENTS 23 grasped. Some of the pistol-shaped and some- what straight handles are inconvenient (Fig. 19). 'J3 SCALE Fig. 20.—Small hand- Fig. 21. —Long metacarpal saw. saw. A small hand-saw, somewhat of the type of Hey's, is occasionally convenient in opening up structures at the base of the skull (Fig. 20). 24 CHAPTER III The long metacarpal saw is also often of ser- vice (Fig. 21). The spinal double saw or rachiotome has been ■ 22.—Spinal double saw or rachiotome. devised to facilitate the removal of the spinal cord from the back (Fig. 22). �99998 INSTRUMENTS 25 Fig. 23.— Butcher's saw. A good saw must be strolls' and with well-set teeth. The blade should be long and with a 26 CHAPTER III rounded or curved end. Sometimes it is desir- able to use a saw with a moveable back. Fig. 24.—Cartilage shears or costotome. '(? SCALE Fig. 25.—Bone- cutters. 5441 INSTRUMENTS 27 Occasionally Butcher's saw proves verv useful (Fig. 23). A band-saw is sometimes handy, and a fine fret-saw is often of service in dissecting the bony structures of the ear. Shears.—Cartilage shears or a costotome may be needed for cutting through tough or calcified rib cartilages (Fig. 24). ft SCALE Fig. 26.—T-shaped chisel. % SCALE Fig. 27.—Chisel. Bone-cutters of strong construction are neces- sary for dividing calcified rib cartilages and 28 CHAPTER III bones (Fig. 25). Savage s vertebral forceps are useful for dividing the arches of the vertebras by snipping through the laminre. Chisels.—These are of different forms and are required for several purposes. The most gene- rally useful is that of a T shape (Fig. 26). Straight, guarded, and hatchet-shaped chisels are also used (Figs. 27 and 28). For opening the ver- Fig. 28.—Straight chisel. tebral canal by cutting through the pedicles and removing the bodies, large curved chisels have been introduced by Brunetti (Fig. 29). Special lion forceps are also needed to grasp the bodies of the vertebras during removal (Fig. 30). A straight form of the same type of chisel is some- times used in removing the cord from the back (Fig. 31). Hammers.—For general purposes I prefer a large wooden mallet. A soft iron hammer with wooden handle is also convenient. That usually supplied is made of steel, and has a wedge- shaped end (Fig. 32). Sometimes a blunt hook is formed at the tip of the handle, serving as a very convenient wrench for tearing off the skull-cap. Accessory Instruments.—HooJcs such as are INSTRUMENTS 29 Fig. 29.—Curved spinal chisels. 30 CHAPTER 111 Fig. 30.—Lion forceps. Fig. 31.—Straight spinal chisel. INSTRUMENTS 31 supplied in most dissecting-boxes are also some- times useful (Fig. 33). Forceps of the ordinary dissecting type are, 'k SCALE Fig. 32.—Iron hammer 'I3 SCALE. Fig. 33.—Hooks. of course, desirable where any careful dissection has to be undertaken (Figs. 34, 35, 36). Hooked retractors may also be of service (Fig. 37). Directors, grooved and probe-pointed, are CHAPTEi; III 1 o <=//«l IfN- ! 1s iS1 Fig. 34.—Forceps. Fig. 35.—Straight Fig. 30.—Curved line-pointed forceps, fine-pointed forceps. INSTRUMENTS 33 constantly needed. A metal blowpipe may sometimes be required (Figs. 38 and 39), and Fig. 37.— Fig. 38.— Fig. 39.— Fig. 40.— Hooked Curved Straight Injecting retractor. blowpipe. blowpipe. syringe. some form of injecting syringe should be at hand (Fig. 40). 34 CHAPTER III Some pathologists find a cranium holder or coronet an aid in the opening of the skull (Fig. 41). Fig. 41.—Cranium holder, crown, or coronet. ' A convenient form of head-rest is illustrated in Fig. 42. Measures.—These are absolutely essential, and should be of various kinds. Strong graduated glass vessels are necessary for fluids, while rigid and flexible measures are needed for estimating the size of organs. Graduated callipers are of great service (Fig. 43). A graduated cone is used for estimating the size of orifices (Fig. 44). A complete set of marked cones suitable for the measuring of various kinds of apertures will be found very useful. Some use balls of varying diameter. A strong magnifying glass (Figs. 45 and 46) INSTRUMENTS. 35 fitted in a suitable handle will often be of con- siderable assistance. Fici. 42.—Head-rest. Fig. 43.—Measuring callipers. Probes, needles (Figs. 47, 48), catheters, copper wire, and strong hempen thread should also be provided. CHAPTER III '/iSCALE FULL SIZE Fig. 44.—Graduated cone. Fig. 45.—Magnifying lens. 51154 INSTRUMENTS 37 FULL SIZE Fig. 4C—Magnifying lens. Fig. 47.—Curved needles. u PULL SIZE Fig. 48.—Straight post-mortem needle. 38 CHAPTER III Frequently hospitals are supplied with a complete post-mortem set fitted in a suitable case similar to that indicated in the accompany- ing figure (Fig. 49). INSTRUMENTS 39 In a thoroughly equipped pathological de- partment many other desirable appliances should be found. The table on which the body rests is usually made of stone or slate. If of wood it should be zinc-lined. A weighing table is an expensive luxury. A sloping metal table with raised edges, rounded corners, and so supported as to be readily rotated, is, perhaps, one of the most con- venient. It is usually made 6 feet long and 2 feet broad, and about 2 feet 9 inches in height. Thoroughly reliable scales, suitable for weigh - ing the different organs of the body, are of course necessary where post-mortems are made for scientific purposes. Blocks of wood of heavy and non-absorbent nature are convenient as supports. The one used for the head and neck should be excavated. A wedge-shaped block is necessary for the back when removing the cord according to Brunetti's method. Boards made of non-absorbent wood are also useful for placing instruments and organs on. Enamelled trays, similar in form to photo- graphic developing dishes, are very convenient receptacles for the organs as removed from the body. Scoops of different sizes are often of use in removing fluid from the thorax. 40 CHAPTER III A pair of bellows is of much service for in- flating organs like the stomach and intestines. A drill for making holes in bone is sometimes desired when it is necessary to wire fragments together. Amongst other desiderata may be mentioned tow, cotton wool, sawdust, sponges, twine, india- rubber tubing, pails, and plenty of disinfectants and deodorants. A supply of hot and cold water, and also suit- able means for disposing of all morbid dis- charges, will, of course, be always provided in a modern post-mortem room. Of the absolutely essential instruments, such as knives, scissors, and saw, it is well to have duplicates so that no inconvenience may be ex- perienced when sharpening is necessary. For examinations in private houses the in- struments may be best carried in an old and inconspicuous hand-bag; or a little ingenuity will readily devise a suitable " hold-all," made of such material as may be readily cleansed. In going to any case which may prove to be one of poisoning, it is well to carry a perfectly clean, stoppered glass bottle, into which the contents of the stomach may be placed. This should be carefully sealed before passing out of the care of the pathologist. CHAPTER IY EXTERNAL EXAMINATION. A thorough examination of all external characters should never be neglected. The in- spection must be minute and systematic. The same methods may be used in both scientific and medico-legal cases. In the former a detailed report is, of course, desirable, and in the latter it is of the greatest importance that nothing be overlooked. A hasty or cursory examination in medico-legal cases may lead to difficulties and discomfiture. Time of Examination.—It would be well if examinations could be made as soon after death as possible. Public opinion is against early internal inspection; in some countries at least twenty-four hours' interval is insisted on. There is, however, no reason why an early ex- ternal examination should not be made in most cases. Preservation of the Body.—It is very de- sirable that, prior to the making of the post- 42 CHAPTER IV mortem examination, all bodies should be kept in a specially constructed cold chamber.* It may be well to add here that in cases where no such refrigerating appliance is avail- able, and it is necessary to preserve the body from putrefactive changes until consent for the examination can be obtained, the corpse should be closely surrounded by ice. AYhere it is desir- able to preserve the cord in a fit state for micro- scopical examination, and the autopsy cannot be undertaken speedily, the body may with ad- vantage be kept in the prone position and ice applied along the back. Use of Photography.—Photography is a valu- able means of permanently recording external characters, and in medico-legal work especially it may be of the greatest service. The Body and its Environment.—An external investigation can be divided into two parts: 1. Examination of the body. 2. Examination of its environment. In many cases there is no opportunity for thoroughly investigating the relation of the body to its surroundings, and friends or law officials not infrequently remove the body before the medical man is summoned. In large towns and cities cases " found dead" are usually * For illustrations and description of the refrigerating apparatus in use at the London Asylums Laboratory at Clay- bury, in Essex, see ' Brit. Med. Journ.,' Feb. 18th, 1899. EXTERNAL EXAMINATION 43 brought direct to hospital or taken to a public mortuary. When summoned to examine a body as originally found, the pathologist should care- fully note all points of importance in connec- tion with the surroundings, and examine par- ticularly for the established signs of death. Remember the possibility of trance. When several bodies are found together it may be necessary to form an opinion as to which died first, and in what way they influenced each other in producing death. AY here possible measurements should be taken. The ground must be carefully examined for evidences of a struggle. Footprints must be inspected, and it may be desirable to direct that they be photographed or casts taken of them. The extent and direction of blood marks must be observed. A search should be made for weapons, or bottles which may have contained poison. The sense of smell must not be neglected. The posture and expression of the corpse may be suggestive. Preservation of Material.—It is always well to have a number of small bottles or well-corked glass tubes at hand, into which can be placed portions of dust, dirt, stains, or like matter which may be found on the clothes or about the body. The dirt taken from beneath the finger- nails has been known to afford important evi- dence in a medico-legal case. Portions of the 44 CHAPTER IV soil, if stained with blood or other discharges, should be preserved. Examination of the Hands.—These should be examined in all cases with special care. The character and position of rings or marks of such should be recorded. Oftentimes the hands afford valuable information respecting the occu- pation, social position, possible duration of ill- ness, and sometimes even the essential nature of the morbid processes leading to death. Inspection of Clothes.—The clothes should in all cases be carefully examined, as they often give important clues to the social position or occupation of the deceased. The contents of the pockets must be examined and handed over to an officer of the law, after noting such points as shall enable them to be readily recognised again in court if necessary. Any disordered condition of the clothes or presence of blood marks or other stains must be recorded. Taking of Notes.—Full notes must be taken at the time of examination. More than one medical man should always be present at a medico-legal inspection; and when two are exa- mining together it is much the most con- venient way for one to dictate the notes to the other, both of course agreeing with the in- dividual details of the report. History of the Case.—It is always well to know as much as possible about the history of the case before commencing the examination. Fre- EXTERNAL EXAMINATION 45 quently, however, the attendants and police have been directed to give no information. In any case the investigation must be undertaken in an impartial spirit and with an unbiassed mind. The whole examination must be made deliberately, in no hurry, and with the full de- termination that the notes shall be complete and minute, but expressing no opinions and innocent of any generalization. Divisions of the External Examination.—The external examination of the body may be divided into three parts: 1. Examination of normal characters. 2. Examination of morbid features. 3. Examination of post-mortem conditions. Examination of Normal Characters.—Details as to the normal characters are of importance chiefly for purposes of personal identification. The chief points to be noted relate to race, sex, age, stature, weight, girth, attitude, expres- sion, colour, and development. Generally one can form a fairly correct opinion as to the oc- cupation and social position of the deceased. In females the condition of the breasts and genitals should be examined, and the presence or absence of the hymen ascertained. Examination of Morbid Features.—The exa- mination for pathological characters is, of course, of extreme importance. Every deviation from the normal must be recognised. In medico-legal cases the lesion should be de- 46 CHAPTER IV scribed in simple and, as far as possible, non- technical language. Terms indicating processes are usually to be avoided. Opinions must not be allowed to replace facts in an official medico- legal report. The following are among the chief morbid features which should be looked for: —mal- developments either by excess, defect, or perver- sion; nutritional changes as evidenced by alter- ations in the quantity and colour of the hair, number of the teeth, " arcus senilis," corpulence or wasting; abnormal pigmentation and tattoo- ing ; scars and atrophic lines; hairy moles, mevi, growths, cutaneous eruptions, or special skin affections. The size and shape of the pupils should always be noted. Wounds, contusions, or other evidences of injury should also be care- fully looked for. Always examine the bones and joints for fractures and dislocations. The hands should particularly be examined. Cya- nosis, dropsy, or haemorrhage into the skin may suggest some important internal lesion or general disease. Hernia and enlarged glands must be noted if met with. The various orifices must be inspected for discharges or for foreign bodies. Morbid odours may sometimes lead to important conclusions. Do not forget to look for parasites, and if present, do not omit to mention them in the re- port. They may have important bearings in a medico-legal case. EXTERNAL EXAMINATION 47 In some instances it may be well to make "cover-glass" preparations of doubtful dis- charges. Sometimes it is most convenient to spread the same on microscopic slides. Blood, serum, and fluids should generally be collected and preserved for a time in sterilized pipettes. In the investigation of microbial diseases tubes containing suitable culture media should be at hand. Post-mortem Conditions.— Post-mortem con- ditions must always be clearly distinguished from ante-mortem lesions. In medico-legal in- vestigations this is of supreme importance. In every case the ordinary evidences of death should be looked for—cessation of the animal functions, alteration in the cornea, flaccid ity of the sclerotic, lowered temperature, pallor of skin, and the like. The question of post-mortem rigidity may sometimes afford valuable evidence as to the time of death, and should always be carefully recorded. It is well to make sure that the rigidity has not been broken down by the at- tendants in moving the body or removing the clothing. Much caution is necessarv in expressing any opinion as to the time that has elapsed since death. Consider well the conditions which hasten and delay the occurrence of rigor mortis, post-mortem lividity, and putrefaction. 48 CHAPTER IV The presence, size, shape, and situation of post- mortem lividities should always be recorded. Post-mortem staining must not be con- founded with contusions. Simple dirt has been mistaken for a bruise. Use sponge and water if there is any doubt. Cadaveric lividities must not be confused with areas of discoloration due to putrefaction; they occur before decomposition begins, and are due to stagnation and gravita- tion of the fluid blood in the capillaries and ves- sels, with loss of tone in the vessel walls. The chief distinctions between post-mortem stains and ante-mortem bruises may be briefly in- dicated in the following table: Occurrence Seat Shape Margin Colour Extent Post-mortem staining. 4—12 hours after death Dependent parts, ex- cept when pressed upon Irregular Ante-mortem contusion. Before death Anywhere ; at point of injury. Irregular, correspond- ing to agent inflicting injury. Ill-defined, zones of colour around edge. Variable : purple, vio- let, green, yellow, lemon. Usually more or less limited. More or less raised. Often injured. Effused blood into true skin and subcu- taneous tissues. Putrefaction may be evidenced by discolora- tion, distension of the abdomen or emphyse- Well-defined Dull red and purple May form large areas Elevation None Cuticle Unaffected Incision No effused blood. Blood in dilated vessels of rete mucosum EXTERNAL EXAMINATION 49 matous-like formations in the skin and sub- cutaneous tissues, and its seat, extent, and character should be indicated. The temperature of the chamber in which the body has been kept and the manner of its pro- tection should also be investigated. It is unnecessary to enter here into details concerning the above-mentioned points, as they are fully dealt with in most of the manuals of forensic medicine. 4 CHAPTER Y INTERNAL EXAMINATION General Considerations.—The internal exami- nation of the body must always be conducted in a systematic manner. While, however, adopt- ing a definite method of procedure, a patho- logist must ever be ready to modify, amplify, deviate from, or even altogether alter his usual plan, so as to meet the particular needs of any special case. History of the Case.—If possible the clinical history of the case should be ascertained before the examination is commenced, so that suitable precautions may be taken where ne- cessary. Thus in some instances it may be desirable to arrange for the collection and speedy examination of fluids, or the cultiva- tion of organisms. Cases of supposed pneumo- thorax or pneumo-peritoneum should be specially investigated before proceeding to open the cavities according to the usual methods. Oc- casionally, especially in examinations for scien- tific purposes in private houses, it may be de- INTERNAL EXAMINATION 51 sirable to draw off fluids from the pleural and peritoneal cavities by means of a trocar and cannula, or by an india-rubber tube, before opening these cavities. Post-mortem Conditions.—Special care must be taken not to confound post-mortem changes with true morbid conditions. The time since death should always be ascertained, and the temperature registered of the mortuary or place where the body has been kept. Medico-legal Cases.—Particularly in medico- legal cases the examination must be complete. In suspected poisoning not only must the stomach and its contents be preserved, but por- tions of other organs should be kept for analysis. Exhumation.—In cases of exhumation per- sons capable of identifying the body must be present. Photographs should be taken when possible. Disposal of Infectious Material.— Disinfect- ants and deodorants must never be used during the course of an autopsy. In all infectious cases such as typhoid, tuberculosis, and the like, precautions should be taken that all discharges and dejecta are suitably disposed of immediately after the examination is com- pleted. Order of Examination. — According to the routine method, the parts of the body are in- vestigated in the following order:—abdomen, thorax, neck, head, spine, and limbs. 52 CHAPTER V Not infrequently one has to be content with a limited examination. Permission is sometimes only granted for the opening up of an abdominal incision, but even in these cases the greater part of both thorax and abdomen may be explored. FiG. 50.—Sterno-clavicular articulation, ribs, and carti- lages, indicating part which must be removed to expose thorax. (Virchow.) In a large number of cases in this country the head is not opened, either because permis- INTERNAL EXAMINATION 53 sion is not obtained or no evidences of affection of the brain have been noted during life. When possible a thorough examination should always be made. In medico-legal cases it is well to remove the calvarium and examine the menin- ges before the body, as, if the heart be opened or the large vessels of the neck divided first, some of the blood may escape from the cranial cavity. Where the spinal cord is to be removed from the back, it is usually most convenient to per- form this part of the examination before proceeding to open the body. If the cord is taken out according to Brunetti's method, the viscera must be removed first. Preliminary Incisions.—The operator should always stand on the right side of the cadaver. The primary or long anterior incision starts at the lower border of the thyroid cartilage, and extends to the pubes. Sometimes it is allow- able to commence the incision below and behind the symphysis of the jaw. It should never be extended on to the chin. The knife must be firmly grasped, and so held that a clean cut is made with the belly of the blade. In the neck the cut is extended through to the sub- cutaneous tissue. Over the sternum the in- cision is carried down to the bone, but over the abdomen it reaches only to the muscular coats and the subperitoneal fat. The opening of the abdomen is made by pinch- ing up the peritoneum and subperitoneal tissue 54 CHAPTER V immediately below the ensiform cartilage, and making a small nick into the abdominal cavity. Note if air or fluid escapes. The small aperture is enlarged and the first and second fingers of the left hand introduced. Separating the fingers an incision is made between them and prolonged downwards, the traction on the abdominal wall made by the fingers together with the pressure of the back of the fingers on the underlying abdominal structures preventing any damage to the intestines. The attachment of the recti to the pubes is to be divided by carrying the knife outwards on each side at the lower end of the abdominal incision, but not extending through the skin. Occasionally a further incision is made into the rectus on either side, a little below the level of the umbilicus, taking care, of course, not to continue the cut into the skin. The thorax is now to be opened and a wider view given of the abdominal cavity. Hold the right abdominal flap firmly in the left hand and draw it forwards and outwards. With long sweeping cuts divide the attachments of the muscles to the lower ribs and cartilages. Ex- tend the cuts upwards, detaching pectoral muscles and removing all structures, so as to leave sternum, ribs, and cartilages cleanly ex- posed. Hold the left abdominal flap outwards and clear in similar manner. Now proceed to remove the " operculum." Disarticulate at the INTERNAL EXAMINATION .55 sterno-clavicular joints. Cut through the rib cartilages with a strong cartilage knife. Hold the blade a little obliquely and cut backwards and outwards near the costo-chondral junction. Generally the section of the rib cartilages is begun at the second. The disarticulation of the sterno-clavicular joints and division of the first ribs may be undertaken from the outside or started from the internal aspect as may seem most convenient. It is much better to always disarticulate the manubrium sterni rather than saw or break across the bone as is sometimes done. The first rib cartilage is often calcified, and has to be divided with bone forceps. Re- member the first costal cartilages must be divided further out than is necessary for the second rib. Cut through muscles and soft struc- tures. Carefully separate the attachment of diaphragm, cutting on to the bone and cartilage (Fig. 50). A consideration of the methods for opening the head may be best deferred until the exa- mination of the brain is described. Method of Investigation.—Before proceeding to consider the steps in the examination of the structures exposed, it may be well to remind the student of the words of Orth: " The chief re- quisite of every exact post-mortem examination is this, that no part shall be removed from its position until its relations to the surrounding parts are established, and that no part shall be Fig. 51.—Superficial inspection of thorax and abdomen. (Heath.) INTERNAL EXAMINATION ot taken out by whose removal the further ex- amination of other parts is affected." Inspection.—Before any parts are touched each cavity must be carefully inspected. Any alterations in the position, size, shape, and colour of the contained viscera are to be noted. The height of the diaphragm must be ascer- tained. Note the form and situation of growths if present. Observe also the relation of the lungs to the pericardium, and the degree of distension of the different parts of the gastro-intestinal tract. Note also the extent and colour of the fat in the omentum and mediastinum. Observe if any of the cavities are unduly distended, or if there be any accumulation of fluid (Fig. 51). Occasionally transposition of the viscera is met with (Fig. 52). Palpation.—Pass the fingers over the dia- phragm. Draw down the great omentum and pass the hand over and around the stomach. Let the whole of the intestinal tract be carefully handled. Palpate out the liver, spleen, pan- creas, and kidneys, noting alteration in size, shape, position, and mobility. Examine for ad- hesions. Let the pelvis be thoroughly explored. Carefully palpate the mediastinum and pleura?. Incisions.—Iu some cases it is desirable to make incisions into the organs before removing them from the body. This is particularly the case with the heart. Often the stomach and urinary bladder are opened in situ. The exact - ■■■■■ _ '■ Fig. 52.—Transposition of viscera. (Norman Moore.) INTERNAL EXAMINATION 59 methods by which this part of the examination may be best accomplished will be subsequently described when the examination of the respec- tive viscera is under consideration. Removal of Organs.—In order to satisfactorily investigate the various organs it is generally necessary to remove them from the body. This is often done separately. Not infrequently it is well to take them in association. Thus in con- nection with such lesions as mediastinal growth, intra-thoracic aneurysm, and oesophageal cancer, it is best to take the whole of the thoracic organs together, leaving their separation from each other until their exact relationship shall have been made out. Sometimes, especially in poisoning cases, it is well to take out the whole of the gastro-intestinal tract without separating it from the oesophagus. In many genito-urinary affections the parts are best removed together. CHAPTER VI EXAMINATION OF THORAX AND NECK General Considerations.—The thorax having been opened the investigation of the thoracic organs is to be proceeded with. A thorough examination by inspection and palpation must always precede any special dissection. Recent or slight adhesions may then be torn through, but if firm must be carefully divided with the knife, cutting in the case of pleural adhesions away from the lung towards the ribs and car- tilages. In some cases it may be best to strip off the parietal layer of the pleura from the ribs. In children under about two years of age the thymus will be distinctly seen. Before proceed- ing to remove any organ give particular atten- tion to the mediastinal structures, and thoroughly explore the root of each lung. In many cases it is best, as already indicated, to remove the whole of the thoracic organs together in one piece, and complete the dissection of the parts outside the body. Opening of the Pericardium.—Pick up the EXAMINATION OF THORAX AND NECK 61 wall of the pericardial sac with the thumb and forefinger of the left hand, and open by FlG. 53.—Diagram of the relations of the heart and great vessels to the wall of the thorax. The lungs are drawn aside. (From Luschka.) making a small snip with the scissors. Extend the incision vertically and make a second cut 1)2 CHAPTER VI outwards and downwards towards the apex of the heart. Examine the nature and measure the amount of any effusion present. Inspect the serous coat for evidences of pericarditis, localised fibrosis, adhesions or hemorrhages (Fig. 54). Fig. 54.— Heart from a case of purpura hemorrhagica, showing numerous small subepicardial haemorrhages. Anterior surface. "Milk patches" are frequently situated over the anterior and posterior surfaces of the right ventricle. When adhesions are universal, they may sometimes be broken down with care, but it may be necessary to cut through them in order to open the cavities of the heart. Often considerable subepicardial deposit of fat is pre- sent. When blood is found in the pericardial sac EXAMINATION OP THORAX AND NECK 63 search carefully for the source of the hemor- rhage before proceeding to remove the heart. Occasionally secondary nodules of growth are met with projecting from the visceral layer of the pericardium (Fig. 55). Pig. 55.—Heart, showing numerous secondary deposits of melanotic sarcoma. Examination of the Heart.—There are several methods by which the heart may be conveniently investigated. Some prefer always to open it in situ, while others only do so after removing it from the body. As a general rule, it is best to examine the cavities and orifices while the organ is in position (Figs. 56, 57). Order of Investigation.—A systematic investi- gation of the heart will necessitate—1. Inspec- 64 CHAPTER VI tion, palpation, and measurement in situ. 2. Opening of cavities and careful palpation of auricles, ventricles, and orifices. •>. Removal of the heart from the body. 4. Testing of valves. 5. Minute examination of valves, cavities, and walls. 6. Dissection of coronary arteries. Fig. 56.—Interior of right auricle and ventricle exposed by the removal of a part of their walls. (Allen Thomson.) EXAMINATION OP THORAX AND NECK 05 Fig. 57.—Interior of left auricle and ventricle, exposed by the removal of a part of their walls. (Allen Thomson.) Lines of Incision.—The opening of the heart in situ is best done by making an incision into each cavity separately. The different methods 66 CHAPTER VI by which this can be accomplished can only be satisfactorily learnt by actual demon- stration in the post-mortem room. The right auricle is opened by an incision extending from just above the auriculo-ventricular groove out- wards to a point midway between the entrance of the superior and inferior vena cava. The right ventricle is to be incised along its right border. The cut into the left auricle starts just above the coronary sinus, and extends to a point between the entrance of the left superior and inferior pulmonary veins. The left ven- tricle is opened along the left border of the heart. There are two principal ways in which this opening of the chambers of the heart in situ may be accomplished. 1. The best and easiest method is as follows : — Pick up the heart with the left hand, the fingers behind and the thumb in front of the apex. Draw the heart forwards and to the left, so that the left border rests against the cut edge of the rib cartilages and the border of the right ventricle ; the whole of the right auricle and points of entry of the vena; cava1 are thoroughly exposed (Fig. 58). Plunge the knife obliquely into the right auricle immediately above the auriculo-ventricular groove, and cut outwards between the superior and inferior vena cava. Then open the right ventricle along its right border, taking care to insert the knife obliquely EXAMINATION OF THORAX AND NECK 67 so as not to injure the septum. After investi- gating the contents of the cavities and the size of the auriculo-ventricular orifice, drop the organ back again into its normal position. Fig. 5S.—Method of holding the heart over the edge of the divided left costal cartilages. Dotted lines indi- cate situation of incisions into right auricle and right ventricle. Now pick up the organ in such a man- ner as to bulge out its left border. With thumb behind and fingers in front of the left ventricle draw the heart over the cut edge 68 CHAPTER VI of the right costal cartilages (Fig. 59). Open the left auricle by a cut extending from im- mediately above the auriculo-ventricular groove outwards between the entrance of two of the Fig. 59.—Method of holding the heart over the edge of the divided right costal cartilages. Dotted lines indi- cate situation of incisions into left auricle and left ventricle. pulmonary veins. Then incise the left ventricle along the prominent left border, inserting the blade obliquely so that the septum shall not be injured. EXAMINATION OP THORAX AND NECK 69 2. A less convenient method, and one usually at first perplexing to the student is as follows : — With the right hand rotate the heart so that its right border presents anteriorly. Slip the ex- tended fingers of the left hand beneath the heart, around the left border, until the fingers cover the anterior surface, and allow the thumb to rest on the posterior surface. Grasp the organ firmly. The right border, the only part un- covered, is thus made to bulge and project prominently forward. The incisions are then made into the right auricle and right ventricle. Now drop the heart back into position. To ex- pose the left side pick up the heart with the left hand, the first two or three fingers on the an- terior aspect of the heart and the thumb on the posterior surface. Grasp the organ firmly and pull it to the right side of the body. The left auricle is thus well exposed, and the left border of the left ventricle rendered prominent. Make incisions into the left auricle and left ventricle.* Not a few pathologists prefer to open the cavities of the heart after its removal from the body. In accomplishing this some use scissors, others use a knife. Both instruments may ad- vantageously be employed. In many cases the pulmonary artery should be slit open as far as its bifurcation before re- moving the heart from the thorax. Vnless this * For figures illustrating this method see ' Post-mortem Handbook,' by Dr. Thomas Harris, 1887, pis. iii and iv. 70 CHAPTER VI be done a thrombus may be readily overlooked or displaced. Examination of the Valves.—Whatever method be employed care must be taken not to injure the auriculo-ventricular valves or the septum. The size of the tricuspid and mitral orifices is Fig. 60.—Aneurysm of the mitral valve. often roughly estimated by inserting the finger tips, being careful not to detach any vegetations or inflict injury to the valve segments. The tricuspid orifice normally admits three finger tips of ordinary size, the mitral orifice two. EXAMINATION OF THORAX AND NECK 71 The examiner should be acquainted with the size of his fingers, measured separately and also together, so that he may have a fairly accurate and convenient gauge always at hand. .Measuring by means of graduated cones is to be preferred, as being far more accurate and scientific. ll< inoval of the Heart.—In removing the heart from the thorax hold the organ up by the septum and cut through the vessels close to the pericardium. All clots may now be removed and the organ weighed. Ftg. 61.—Illustrating method of testing competency of aortic valves by means of stream of water. Testing the Valves.—It is customary to test the competency of the pulmonary and aortic valves by means of the "water test," but this method is far from satisfactory (Fig. 61). 72 CHAPTER VI Some pathologists have advocated the testing of the competency of the cardiac valves by in- flation with air.* Dissection of the Heart.—After the heart has been removed from the body place it on the dis- secting slab, with the anterior surface upwards and the base towards the operator. Join the incisions in the right auricle and right ventricle by means of the " bowel scissors" (best con- structed for this purpose without the customary spike) (Figs. 62, 63, 64). Fig. 62.—The position of the scissor blades before the rig-lit auriculo-ventricular ring is divided. In the right ventricle a cut is to be made starting about the middle of the incision in the right border, passing above the insertion of the anterior papillary muscle and along the side of the septum into the pulmonary artery (Figs. * Hamilton, < Text-book of Pathology,' 1889, vol. i, p. 9. EXAMINATION OF THORAX AND NECK 7-*i Fig. 63.—Illustrating the method of joining the incisions in the right auricle and right ventricle by dividing the auriculo-ventricular ring by means of the " bowel scissors." Fig. 6-4.—The right side of the heart expDsed after the incisions into the right auricle and right ventricle have been joined by dividing the right auriculo-ventricular rinir with the bowel scissors. 74 CHAPTER VI 05, 00). The incision may usually be carried between two of the cusps of the pulmonary artery, if the division is made immediately behind a little ridge of fat which is generally present along its left side. The incisions in the left auricle and left ven- tricle are to be joined in a manner similar to those on the right side. This is most con- FlG. 65.—Opening of the pulmonary artery by means of the bowel scissors. veniently done by passing the blade of the bowel scissors into the left ventricle and through the mitral orifice into the left auricle. In cutting take care to preserve the valve segments as far as possible. EXAMINATION OF THORAX AND NECK 75 Where there is mitral stenosis it is best not to divide the valve. An incision may now be carried upwards along the anterior Avail of the left ventricle, keeping close to the septum, into the aorta. The line of section should be carried between two of the aortic cusps. This may easily be accomplished bj looking from above or vieAving from below, Fig. 66.—Dotted lines indicate incisions into right side of heart and across anterior wall of right ventricle into pulmonary artery. and arranging that the blade of the scissors or the edge of the knife be kept immediately be- tween two of the segments. If it is not necessary to preser\re the sigmoid 76 CHAPTER VI valves of the pulmonary artery, a convenient guide is obtained by cutting along the curved line of attachment of the pulmonary cusp Fig. 67.—Heart showing incision adopted by some pathologists in opening up pulmonary artery. (Virchow.) nearest to the septum and between tAvo of the pulmonary cusps into the aorta (Fig. 08). If this indication is followed, it Avill be found that the aortic valves have been opened out without injuring the individual segments. Occasionally it is convenient to open the ven- tricular caA'ities by transfixion (Fig. 09). The blade of a long and sharp-pointed knife is plunged into the posterior surface close to the septum, and brought out anteriorly near the septum. The cut is then made towards the EXAMINATION OE THORAX AND NECK 77 apex. This is, of course, done on both sides of the heart, so opening up each ventricle. Fig. 68.—Illustrating line of incision along anterior wall of left ventricle into aorta, cutting between two of the pulmonary cusps. In case of hypertrophy or considerable car- diac enlargement (Fig. 70) transverse sections of the ventricle form a very admirable Avay of indicating the variation in size and alteration in shape. Such sections are often useful for museum or teaching purposes (Fig. 71). 78 CHAPTER VI Iii certain conditions special methods of exa- mination may be necessary. In such lesions as thrombosis of the pulmonary artery or vena cava, aneurysm of the aorta or congenital mal- Fio. 69.—Opening of ventricle by transfixion with long-bladed knife. development of the heart and vessels, it may be well to dissect the parts in situ, or remove the thoracic contents in one piece before separating the individual parts. Fig. 70.—Hypertrophied heart, from a case of chronic interstitial nephritis. Fig. 71.—Transverse sections through the ventricles From a case of hypertrophy secondary to "granular" kidnev. 80 CHATTEL* VI In all subjects the interior of the heart must be submitted to a minute examination. Special attention must be given to the condition of the valves. The size and shape of the cavities and alterations in the consistency and appearance of the myocardium must be noted (Fig. 72). The orifices of the coronary arteries must be carefully observed, and the vessels slit up with Fig. 72.—Aneurysm of the left ventricle. (Sieveking.) probe-pointed scissors or a knife and fine grooved director or probe-pointed bistoury. Examination of the Thoracic Aorta.—The aorta must be exposed in its Avhole course. If in- voked by aneurysm or extensive atheroma, it is best to remove it in association with the heart. In such cases it should not be opened before being taken from the body. It can be readily slit EXAMINATION OF THORAX AND NECK 81 up on its posterior aspect by means of strong probe-pointed scissors. In all cases of aneu- rysm, and especially in the rare cases of dis- secting aneurysm, considerable care must be taken not to cut into the morbid parts until they Fig. 73. —Atheromatous aorta presenting orifice of aneu- rysm immediately above "intermediate" cusp of the aortic valve. are fully explored, and their exact relations clearly ascertained. Particular attention should ahA^A's be g-iven 6 82 CHAPTER VI to the first part of the aorta and the region of the arch (Fig. 73). Specially note the condition of the vessel in the neighbourhood of the orifices of the coronary arteries. Examination of the Pleural Cavities. — The pleurae Avill already have been thoroughly in- vestigated by palliation, and as far as is possible Fig. 74—Aneurysm of the arch of the aorta containing laminated clot. (Sieveking.) at present by inspection. In cases of supposed pneumothorax, before the thorax is opened a pouch should be made over the ribs by means of the skin flap and filled with water. On making a small aperture into the pleural cavity, EXAMINATION OP THORAX AND NECK 83 air, if present, will bubble up through the water. The amount of any fluid effusion should be carefully estimated. Adhesions Avhen tough must be cut. Note any areas of localised thick- ening. In all cases of death from respiratory obstruction, such as hanging, suffocation, and the like, examine for small petechial luemor- rhages. Miliary tubercles are often distinctly seen on the pleura. In cases of pneumothorax from rupture of the lung substance gently inflate the organ under Avater by means of a pair of bellows. The per- foration will then be easily detected. Examination of the Lungs.—This necessitates the following stages : —1. Inspection and palpa- tion in situ. 2. Removal from the body. 3. Making of sections. 4. Dissection of bronchi. 5. Special examination. Removal of the Lungs.—Generally it is best to remove the lungs together Avith the respiratory passages and often Avith the rest of the thoracic contents. When removed separately, the root is grasped by the left hand Avith the fingers astride the bronchus. Each organ is drawn for- wards and doAviiAvards, and the primary bron- chus cut through immediately behind the fingers. Incision of the Lungs.—The principal in- cision consists of a long, straight, deep cut from apex to base along the outer border, extending through the lung substance and leaving the 84 CHAPTER ATI halves hinged at the root (Figs. 75, 76). Other parallel cuts may be made as required. In examining the lungs, note particularly the size, shape, colour, Aveight, and consistency. Fig. 75.—Illustrating method of holding lung in making section into organ. In pneumonia, tuberculosis, gangrene, ab- scesses, and other special lesions of the lungs, EXAMINATION OP THORAX AND NECK 85 particular forms of examination will be neces- sary (Fig. 77). The medico-legal investigation of cases of atelectasis in still-born children necessitates such particular attention as is indicated in the text-books of forensic medicine. In many cases it is well to delay incising the lung until it has been hardened in formalin. Fig. 76. — Showing method of incising lung. This can be accomplished in a day or so, and satisfactorv secions can then be easily made (Fig. 78).' The bronchi are best divided by means of probe-pointed scissors (Fig. 79). The bronchial glands must be dissected out and incised. In cases of pulmonary tuberculosis where 86 CHAPTER VI an aneurysm has formed and ruptured, it is well to inject water into the pulmonary artery, Fig. 77.—Lung, seat of extensive tuberculosis with cavitation in upper lobe. From a young male adult. and then on section to notice from which branches of the bronchus it escapes. By this TA'AM [NATION OE THOL'AX AND NECK 87 means the ruptured sac may sometimes be readily localised. Fig. 78. —Section of tuberculous lung. ss CHAPTER VI In cases of pulmonary thrombosis and em- bolism do not omit to slit up the pulmonary artery and its branches. Fig. 79.—Bronchiectasis. (Sieveking.) Examination of Mediastinal Structures.—This can be most satisfactorily accomplished when the thoracic ATiscera have been removed in one piece. If possible, it is best to remove tongue, pharynx, oesophagus, larynx, and trachea, in con- nection with the lungs and heart. Pass a long- bladed knife up into the floor of the mouth immediately behind the symphysis of the jaw, and cut through the lateral attachments. Draw down the tongue. Cut through the soft palate at its junction with the hard, and then through the fauces. Divide the posterior wall of the pharynx. Draw all the soft structure of the EXAMINATION OF THORAX AND NECK 89 neck forwards and downwards. Divide the sub- clavian vessels behind the sternal end of the clavicles. Pull the contents of thorax forwards, and cut through oesophagus, aorta, and inferior vena caA'a. If there is anything in the stomach, ligature before making section. In poisoning cases take the gullet with the stomach. Azygos veins, thoracic duct, and sympathetic nerves may be dissected on the posterior AA'all of the thorax. After removal from the body lay the thoracic contents on the dissecting table, Avith their posterior surfaces upAvards. With a pair of "bowel scissors" slit up the pharynx and oeso- phagus in the posterior median line. Note the condition of the tonsils. Open up the larynx in the middle line posteriorly, and extend the incision along the trachea, pulling the oeso- FiG. 80.—Mass of meat blocking up entrance to larynx. From a subject "found dead." 90 CIIATTRi; VI phagus to one side. Do not omit to carefully examine the pharynx and larynx in medico- Fig. 81.—Malignant growth invading lung, compressing bronchus, and producing septic pneumonia. legal cases for foreign bodies (Fig. 80). Make sections into the thyroid gland. Examine the EXAMINATION OF THORAX AND NECK 91 thymus when present. Open up the thoracic aorta and dissect out the nerves. Inspect the mediastinal glands. In all cases of mediastinal growth and intra- thoracic aneurysm always remove the Avhole of the thoracic organs together, and dissect and study the relation of parts outside the chest (Fig. 81). CHAPTER VII EXAMINATION OF THE ABDOMEN The abdomen having been opened and thoroughly examined by inspection and pallia- tion, the further investigation may be proceeded Avith. General Considerations.—The order of the re- moval of the abdominal viscera varies Avith circumstances. When there are extensive ad- hesions, or in certain other lesions, it may be desirable to deviate from the the usual method. In private cases it is not always necessary to remove the intestines. llemember to palpate for mobility of the kidneys before the colon is removed. In cases of growth, extensive adhesions, and certain retro-peritoneal lesions it may be well to remove the abdominal viscera en bloc. In such conditions as subphrenic abscess it is often desirable to remove the parts in connec- tion with the thoracic organs (Fig. 82). It is well for the student to practise the different methods of procedure. Removal and Examination of the Intestines.— Always carefully palpate the whole of the in- EXAMINATION OF THE ABDOMEN 93 testinal tract before proceeding to remove any part. In this Avay any abnormalities such as Meckel's diverticulum or limited lesions are at Fig. 82.—Subphrenic abscess. (After Leyden.) 94 CHAPTER VII once detected. Generally it is best to commence the detailed examination of the abdominal viscera by removing both the small and the large intestine. Place a double ligature at the upper part of the rectum and at the commencement of the jeju- num, and remove the intervening portion. The Fig. 83.—Method of opening intestines. guts must be separated close to their mesenteric attachment. Scissors or the ordinary knife is best for detaching the large intestine. The small boAvel can most readily be removed by EXAMINATION OP THE ABDOMEN 95 Fig. 81.—Large intestine laid open, from case of ulcerative colitis. 96 CHAPTER VII cutting the mesentery Avith a long thin-bladed knife, using the same with a saAving or fiddle-bow moATement. After removal from the body the intestine is to be slit up Avith the bowel scissors (Fig. 83). The small gut must Fig. 85.—Ulcerative colitis, with extensive fatty deposit in subserous coat of the colon. be divided along the line of attachment of the mesentery. The vermiform appendix must also be opened up. After thorough cleans- ing examine for such lesions as enlargement of EXAMINATION OF THE ABDOMKN 97 lymphoid elements, ulceration, haemorrhages, congestion, and growths (Figs. 84, Ho, 86). Kig. 86.—Dilated caecum and colon laid open. Malignant stricture through which bougie is passed. Do not confuse post-mortem lividities Avith true engorgement. Portions of the intestines are frequently found to be bile-stained. "Agonic " intussusception is occasionally met with, especially in young subjects. 7 98 CHAPTER VII Examination of Urino-genital Organs.— Sometimes the removal of the kidneys and pelvic structures is left till almost the end of the examination of the abdomen. As a general rule it is best to proceed to their examination directly after the intestines have been taken out. Although the kidneys are often removed sepa- rately, this should never be done until the uri- nary passages are known to be normal. It is often Avise to open the bladder and slit up the ureters and pelvis of each kidney Avhile the parts are in situ. Frequently the whole of the urinary tract must be remoAred in one piece, and, in many instances, in association with the adjacent genital and other pelvic structures. Free the kidneys from their connections. Take care not to injure the adrenals. These may some- times conveniently be allowed to remain at- tached to the kidneys. Follow down the ureters. Let the kidneys and ureters hang over the groins while the pelvic structures are being separated. Examination of Male Genital Organs.—In the male continue the median incision along dor- sum of penis, and separate off the skin. Divide the penis transA^ersely behind its glans. Be careful in removing membranous and prostatic portions of urethra. Cut through symphysis, and separate or saw out symphysis and piece of pubic bones (Fig. 87). Now dissect back EXAMINATION OF THE ABDOMEN 99 penis, cut through attachments of crura, and separate tissues beneath prostate. The parts may then be removed en masse, and the dissection and examination completed outside the body. Some pathologists, instead of cutting through Fig. 87.—Method of opening bladder and urethra in posi- tion. Symphysis and portion of pubic bones have been removed, and piece is shown placed on left thigh. From an elderly male with gangrenous cystitis. Director in- dicates the necrotic bladder. 100 CHAPTER VII the pubic arch, free the penis, and then making an opening beneath the symphysis, push it through into the pelvic cavity, where, after freeing prostate, &c, the parts can be removed together. In many cases it is well to remove the testicles in association with the above parts. The bladder is usually best exposed by a median A^ertical incision (Fig. 88). Fig. 88.— Illustrating method of exposing interior of bladder. Carcinomatous growth springing from vesical walls. (Norman Moore.) The vesicalce seminalcs not infrequently are neglected. In all cases of genito-urinary disease, and especially in tuberculosis, they should be carefully dissected. They are best exposed by dissecting off the fascia at the base of the bladder immediately EXAMINATION OF THE ABDOMEN 101 above the prostate by means of a pair of scissors, and are most conveniently opened with a probe- pointed pair. It may be desirable to retain samples of the con- tents in the form of " coA^er-glass preparations," particularly in tubercular and gonorrhoeal cases. Fig. 89.—Hcematocele; much induration of tunica vaginalis. (Curling.) The prostate is best examined by means of a series of transA'erse sections. The testicles should be examined before the pelvic contents are removed. 102 CHAPTER VII Inspect the situation of the internal abdomi- nal rings. If a hernia is present the sac is to be remoA*ed Avith the cord and testicle in one piece. If no hernia exists trace back the vas deferens. Pull the testes up towards the abdo- men. Incise the rings if necessary. Separate the tunica vaginalis from the scrotum, taking FlG. 90.—Section of syphilitic testes, with guinmata of various sizes. (Bowlby.) care not to cut any invaginated skin. Open the sac anteriorly in the long axis of the tes- ticle (Fig. 89). The testis is best divided by a single incision passing through the globus major and gland doAvn to its hilum (Fig. 90). EXAMINATION OF THE ABDOMEN 103 Examination of Female Genital Organs.—In the examination of female cases, especially Avhere the condition of the genitals is of medico-legal importance, the investigation must be conducted with special care. fit;. 91.—Vertical section of female pelvis. (Galabin.) In many cases the internal genital organs in the female can be thoroughly examined without removal from the body. The ovaries should be sectioned and the uterus opened. In all cases, however, it is more convenient and satisfactory to remove the Avhole of the 104 CHAPTER VII pelvic structures together, and dissect them out- side the body. Separate the bladder from the pubes. Incise Fig. 92.—Fibro-myoma of uterus, illustrating method of section through greatest diameter of growth. (Norman Moore.) the peritoneum round the brim of the pelvis. Bring the rectum forward. Now cut through the rectum, vagina, and urethra. EXAMINATION OF THE ABDOMEN 1(J5 If it is necessary to remove the whole of the vagina and labia minora, insert the knife vertically immediately above the urethra. Cut through all the structures between the bladder and the pubes. Continue the incisions down- wards external to the labia minora, and divide the rectum just above the anus. The perineum is not to be divided. Lift the pelvic contents up by the left hand, and with a feAv touches of the knife free them from their connections. Fig. 93.—Uterus bicornis. (Galabin.) Noav proceed to expose the different parts. Slit up the rectum Avith the boAvel scissors. Open up the urethra and bladder with probe- pointed scissors. Usually the bladder is opened by a vertical incision while the viscus is in situ. Generally the ATagina is divided in the anterior median line, but if desirable it may be slit up 106 CHAl'TER VII Via. 94.—Uterus septus. (Galabin.) Fig. 95.—Double uterus and vagina. (Galabin.) EXAMINATION OF THE ABDOMEN 107 Fig. 96.—Uterus opened to show mucous polypi within cervical canal. (Galabin.) Fig. 97.—Fibro-inyoina projecting into cavity of uterus. (Sieveking.) 108 CHAl'TER VII along its posterior Avail or an incision can be made up each side into the lateral fornices. Examine the os, and then divide cervix and body of uterus by means of a stout scalpel or strong-bladed scissors in the anterior median line (Figs. 91—97). Extend the upper end of the incision into the uterus and outAvards to each Fallopian tube. In morbid conditions, Avhen it is necessary to open the canal, fine directors and fine probe-pointed scissors will be found of service. The broad ligaments and structures contained therein may need to be dissected. The OA-aries are best divided by means of a knife, cutting towards the hilum of the gland. Specially examine for corpora lutea. Separate Removal of the Kidneys.—Where there is no affection of the urinary passages or genital tract the kidneys can be removed separately. Cut through the peritoneum by a vertical incision outside the ascending and descending colon, first testing for any degree of mobility. Free the organs from their surrounding fat and pull each forward. The left is usually removed first. Place the fingers astride the vessels at the root of each organ, and cut behind them, and when free pull the ureter forwards Avith the kidney and divide it low down. It is well always to cut the ureter considerably longer in one kidney than the other, so that the organ EXAMINATION OF THE ABDOMEN 109 may be recognised at a glance. Remove the perinephritic fat, and measure and weigh each organ. Opening the Kidney.—The kidneys, however Fig. 98. —Showing method of holding the kidney and dividing it along its convex border. remoA-ed, are to be opened along the convex border by section with a large flat knife carried through so as to diA'ide each organ down to its pelATis. 110 CHAPTER VII This is best accomplished by grasping the kidney in the left hand, Avith the convex border pointing towards the operator, and drawing the blade of the knife from heel to toe, through the organ (Fig. 98). The pelvis and calices can be further explored by opening them up with scissors. Examine the parts systematically in the following order : —Capsule, surface, consistency, colour, cortex, medulla, pyramids, calyces, pelvis, and vessels (Figs. 98—101). Fig. 99.—Divided kidney, seat of sarcomatous infiltration. Particularly note the manner in Avhich the capsule strips. In many cases of granular EXAMINATION OP THE ABDOMEN 11] be -*3 01 0 s » -c a! 1^ 5 .2 be "%>„-<^, Fig. 101.—Divided kidney, showing cystic structure at upper end. Fig. 102.—Mal-dovelopment of kid- neys. "Horse-shoe" kidney (Nor- man Moore). EXAMINATION OF THE ABDOMEN 113 kidney and secondary inflammation of the organs it is more or less adherent to the surface. Abnormalities of the kidneys are fairly com- mon. The " horse-shoe" kidney is the usual form of " fusion " met with (Fig. l0'-2). Examination of Stomach and Duodenum. — These may be removed together, and often advan- tageously with the lower part of the oesophagus and pancreas attached. In cases of obstructive jaundice the common duct must be thoroughly investigated before the duodenum is removed, or the liver and gall-bladder must be removed in connection, and the parts dissected outside the body. As a routine method it is Avise after opening the duodenum to scpueeze the gall- bladder, and by forcing the bile through the papilla into the intestine demonstrate that no obstruction exists. Before removing any of these structures the foramen of Winslow and particularly the adjacent portal vein should be thoroughly examined. In poisoning cases the contents of the stomach and intestines must always be saATed. If un- prepared to collect the gastric juices in a suit- able vessel, the stomach must be used as a bottle for its own contents by ligaturing both ends. The stomach is usually opened along the greater curvature. DiAide the duodenum Avith the boAvel scissors, keeping along its convex border. Often the stomach and duodenum are opened in situ. Special attention must be giAen to the 8 114 CHAl'TER VII biliary papilla and the condition of the bile and pancreatic ducts. Fig. 103.— Dilated stomach almost tilling abdominal cavity. (Hilton Fagge.) Examination of the Pancreas.—The pancreas is generally most conveniently removed in con- nection Avith the stomach and duodenum. It can usually be freed from surrounding structures by a feAv strokes of the knife. Be- ware of injuring the left adrenal. EXAMINATION OP THE ABDOMEN 115 Although the organ is sometimes dissected while in the body, it is generally best to leave sectioning it until after its removal. It varies greatly in consistency, and is often much altered by post-mortem changes. Careful examination of the head of the gland for groAvth or fibrosis should always be made. The organ is best examined by making a series of thin transverse sections. The duct may be slit up with fine probe-pointed scissors. It is best found at the junction of the head with the body of the gland. It should be folloAved doaviiwards into the papilla and outwards into the tail. Sometimes calculi are present in the duct, or the canal may be dilated or present cystic formations. When hannorrhage is found, its exact situa- tion and extent should be carefully noted. In preserving portions for microscopic in- A-estigation osniic acid Avill frequently be found of service, especially in cases of so-called pan- creatitis. The splenic artery and vein should be laid open by means of fine pointed scissors. Examination of the Spleen.—The spleen is often the first organ removed from the abdomen. It is conA*enient sometimes to remove it in con- nection Avith the pancreas. It is usually incised in its greatest diamenter (Figs. 104, 105). Sec- tions carried transA7ersely to its long axis are 116 CHAPTER VII convenient, but whichever Avay the organ may be divided the slices should remain attached by the capsule. Frequently the spleen is so soft and friable as to need very careful handling to prevent tearing. Fig. 104.—Spleen divided, showing secondary growth. The capsule is in many cases wrinkled. When patches of lamellar fibrosis or depressions arc met with in the capsule, it is well to cut into them. Scars are often the evidences of old infarction. EXAMINATION OF THE ABDOMEN 117 In cases of lardaceous disease, the iodine test must be applied to a Avashed section of the organ. Fig. 105.—Spleen, sectioned and showing nodular masses of secondary sarcoma. Primary, round, and spindle- celled sarcoma in pelvic wall. Spleen weighed 21 oz., size 7i X 4£ in. From a middle-aged male. Not unfrequently accessory spleens, or sple- nules as they are usually termed, are met with 118 CHAPTEIl VII in the gastro-splenic omentum or in the great omentum. In certain blood conditions and infective diseases it is aatc11 to prepare cover-glass pre- parations from the fresh splenic pulp. Examination of the Adrenals.—The removal of the adrenals is generally left until the stomach, duodenum, and pancreas have been taken out. The left may readily be injured in removing the tail of the pancreas unless care is taken. The right should always lie examined before the liver is separated. Sometimes it is convenient to remove the adrenals in connection with the kidneys. Thev should always be sectioned transversely. In cases of Addison's disease the adrenals must be dissected out, together Avith the semilunar ganglia and solar plexus. Examination of Liver and Gall-bladder.— These are often removed early in ihe exami- nation. Sometimes this is convenient, as giv- ing more room for dissection. Generally they should be left till almost the end. The organ can readily be freed from all its attachments and lifted out. It may be divided by long sec- tions passing through its greatest diameter, al- though some prefer to make the cuts antero- posteriorly, parallel to the falciform ligament (Figs 100—110). EXAMINATION OK THK ABDOMEN 119 ■ •Msti,??^'-;^,., j-\- " !- Iff ;^ - Fig. 106.—Vertical section through liver with numerous secondary deposits of melanotic sarcoma (Norman Moore). 120 CHAPTER VII Do not forget to submit portions of the fresh liver in cases of pernicious amemia to a soaking in a 10 per cent, solution of potassium ferro- cyanide, and then washing well in weak hydro- chloric acid ('-2 per cent.), so as to develop the " prussian blue colour" indicative of the pre sence of iron. Fig. 107.—Antero-posterior section of liver, presenting numerous nodules of secondary carcinoma. Primary growth in rectum. From a middle-aged male. In so-called " emphysema" of the liver, squeeze portions of the organ under A\rater, when bubbles will escape.* The gall-bladder must be opened with scis- sors, and the cystic and bile ducts followed as far as possible (Fig. 112). * See ' Medical Chronicle,' June, 1896, p. 224. EXAMINATION OF THE ABDOMEN 121 Fig. 10S. — Large cirrhotic liver photographed in position. Fig. 109.—Cirrhotic liver, opened out by ti'ansverse incision. Fie. 110.—Section of the liver showing biliary cirrhosis Fig. 111.—Lingual process of right lobe of liver and distended gall-bladder. Fig. 112.—Gall-bladder laid open by longitudinal incision and showing aggregation of small gall-stones. EXAMINATION OF THE ABDOMEN 125 Examination of Mesentery and Structures form- ing Posterior Wall of Abdomen.—The viscera having now all been removed, the remaining structures are to be investigated. The mesentery will already ha\-e been exa- mined in part. The vessels and lymphatic glands may be still further explored. Particular attention should be given to the retro-peritoneal glands. Examine the thoracic duct and receptaculum chyli before removing the aorta. The solar plexus and sympathetic cords may also be dis- sected out. Slit up the aorta Avith scissors, and carry cuts into the iliac arteries. Examine the vena cava and pelvic veins. It is often well to do this before removing the pehdc organs. Dissect off the aorta and inspect the bodies of the vertebne. Cut into the psons muscles. If necessary exa- mine the sacro-iliac joints and bones forming the pelvis. CHAPTER VIII EXAMINATION OF THE HEAD AND SPINE The examination of these portions of the body is undertaken principally for the purpose of investigating lesions in connection Avith the brain and spinal cord, their membranes, and the organs of special sense. Superficial Examination. - Before proceeding to any dissection, careful examination of the external characters must be made according to the manner already indicated. Measurements should be taken where neces- sary. The graduated callipers are of particular service in taking the diameters of the head (Fig. 4^3). Casts of the head and face have sometimes to be prepared. The eyes should always be inspected with par- ticular care. The various orifices—ears, nose, and mouth- should be inspected for morbid discharges, foreign bodies, or evidences of injury. Scalp Incision.—The scalp is to be divided by an incision extending from one mastoid region EXAMINATION OP THE HEAD AND SPINE 127 to the other across the vertex, the cut berny carried through to the bone. This is best ac- complished by means of a small, short, narroAv- bladed scalpel, which, after the preliminary section into the scalp over the right mastoid has been made, is carried Avith its cutting edge directed outAvards to the skin. The tissues are thus divided from within, and the hair parted rather than cut. Strip the anterior flap for- Avards to the superciliary ridges ; the posterior backAvards to beloAv the occipital protuberance. If the hair be long, roll it up and protect be- neath the scalp flaps. A toAvel may be fixed tightly round the head and neck over the re- flected parts. If examination of the parotid gland is sub- sequently required, the coronal incision may be readily extended. Opening the Skull.—Before proceeding to saw through the skull turn down the temporal muscles and thoroughly detach the pericranium. Unless this be done the teeth of the saAv Avill readily become clogged, and saAving ren- dered very difficult. Tavo chief methods are employed in opening the skull: 1. In the circular method the skull is sawn through along a line corresponding anteriorly to the depression between the frontal eminences, posteriorly to the occipital protuberance, and laterally on a level Avith the helix of the ear Avhen the latter is draAvn upwards. 128 CHAl'TER VIII If two short shallow parallel saw cuts are made transversely at the vertex, strong twine can be caught in them after being passed through the temporal muscles, and thus the skull-cap can be easily retained in position (Fig. 113). Fig. 113.—Method of fixing skull-cap when the skull has been opened by a circular saw cut. In opening the skull by the circular method a crown or coronet is undoubtedly a useful guide, but the student should learn to make a clean saw cut without anv such assistance (Fig. 41). EXAMINATION OF THE HEAD AND SPINE 129 The most convenient form of saw for general use is indicated in Fig. IS. 2. The wedge-shaped incision is convenient in facilitating the restitution of the head. The anterior saw cut passes through the frontal eminences to a point just above and behind the pxternal auditory meatus. The posterior passes near the apex of the lambda, or about three inches above the external occipital protuberance. The two incisions join at an obtuse angle. In assisting to fix the skull it has been suggested that one of the saAv cuts should be so extended as to allow of the insertion of a thin bandage, which, after replacement of the calvarium, may be pinned over the vertex (Fig. 114). The bones are sometimes drilled and Avired. The skull must be sawn through carefully so that the dura is not injured. Sometimes the mallet and chisel may be employed to break through the inner table, but never in a medico- legal case. In some cases of posterior meningitis and hydrocephalus (Fig. 115), it may be advisable to remove the greater part of the occipital bone by a Y-shaped incision, the apex being at the foramen magnum. In infants the cranium can be conveniently laid open by diA'iding it along the lines of suture with a pair of strong scissors and bending the parts outwards. The blunt hook, which in many instances is 9 130 CHAPTER VIII supplied fixed at the handle-end of the hammer, often proves of great service in wrenching off the skull-cap. Fig. 114.—Method of fixing the skull-cap after opening the cranial cavity by a wedge-shaped incision. Fig. 115.—Hydrocephalic skull (Sieveking). EXAMINATION OF THE HEAD AND SPINE 131 The T-chisel is the best form for applying leverage after the skull cap has been sawn through all round (Fig. 20). Examination of the Dura Mater.—Not in- frequently the dura is adherent to the skull. This is normal in children. When firmly fixed to the bone it is best removed Avith it. The Fig. 116.—Sinuses of the skull (from Hirschfeld and Leveille). division is most conveniently accomplished by means of a probe-pointed curved bistoury (Fig. 10), or probe-pointed scissors (Fig. IT). After opening the superior longitudinal sinus incise the dura along lines corresponding to the saw cuts, separate the anterior attachment of 132 CHAPTER VIII the falx cerebri and turn the dura backwards. The other sinuses and parts at the base of the skull must be dissected after the removal of the brain (Figs. 110, 117) Removal of the Brain.—Lift up the frontal lobes with the left hand. Divide all the nerves Fig. 117.—Dissection of the sinuses of the skull and cranial nerves. The cavernous sinus dissected on the left side (Gray). and vessels at the base close to the bone. Cut along the attachment of the tentorium cerebelli on either side. Divide the vertebral arteries and spinal cord as low down as possible. EXAMINATION OP THE HEAD AND SPINE 133 A special knife, termed the myelotome, is sometimes used for this purpose. Examination of the Brain.—Place the brain with its base upwards and carefully investigate all the structures, especially following the middle cerebral arteries along the Sylvian fis- Fn;. 118.—The base of the brain (from Hirschfeld and Leveille). sures (Fig. 118). Aote particularly any lesions in connection with the pia and arachnoid or alterations in the convolutions (Figs. 119, 120). When blood is found about the base of the 134 CUAPTKK VIII brain it should be gently was lied away by a fine spray of Avater. After this a ruptured Fig. 119.—Brain, under surface. Numerous secondary deposits of melanotic sarcoma. Primary growth in skin of chest wall. From a man aged 40. aneurysm in connection with one of the cerebral arteries may often be detected with the greatest ease. EXAMINATION OF THE HEAD AND SPINE 135 The pituitary body should, whenever pos- sible, be removed Avith the brain. In cases of acromegaly, particular care must be taken in removing it. If left in the pituitary fossa it Fig. 120.—Subarachnoid effusion on the upper surface of the anterior lobe (Sieveking). should be dissected out when the structures at the base of the skull are examined. The surface of the whole brain must be exa- mined in detail before any incisions are made. Notice the extent, depth, and arrangement of the con\Tolutions. See if the membranes are readily attached. Do not confound Pacchionian bodies with tubercles. In most cases it will be found best to harden 136 CHAPTEK VIII the brain before dissecting it. In medico-legal cases it is, of course, necessary to section it at once. When time Avill allow it should, however, always be hardened first. After removing any small portions of the cortex necessary for special microscopic examination, the organ can be sus- pended in gauze in formalin solution of suitable strength. In this way the brain can be hardened in a very short time, and a much more satisfactory examination made than if the organ be dis- sected when fresh. The interior of the brain may be investigated in several ways. In determining Avhich pro- cedure to adopt remember Yirchow's postulate— " the individual peculiarities of the case must determine the method of examination." The plan followed should be the best suited for re- vealing the seat and extent of the lesion. The incisions should be so placed as not to inter- fere with the carrying out of an extensive microscopical investigation of the various por- tions of the brain if subsequently found neces- sary. In some conditions it may be Avell to arrange so that sections may be a\-ailable as permanent museum preparations. 1. Virchow's Method is perhaps the most generally useful. It has been described as a " fore-and-aft" section method. It may be variously modified according to the necessities of any individual case. Separate the hemi- EXAMINATION OF THE HEAD AND SPINE 137 spheres, slightly exposing the corpus callosum. Open into each lateral ventricle. Join the an- terior and posterior cornua by a crescentic in- cision outside the basal ganglia, carried outwards to the cortex and allowing the membranes to act as a hinge or binding. Cut through the fora- men of Monro and turn back the remains of the corpus callosum, fornix, and velum interpositum. Further incisions may be made into the cortex as required. Next divide the basal ganglia by a series of thin vertical sections. Then cut through the superior vermiform process of the cerebellum, exposing the fourth ventricle. Make radiating cuts into the lateral lobes of the cere- bellum. Now fold the brain up and turn it over, and make a series of thin sections through the crura, pons, and medulla. In some cases the crura cerebri may be cut through at an early stage in the examination, and the cerebellum Avith the corpora quadrigemina, pons, and medulla removed and examined separately. 2. In Pit res' Method six sections are made parallel to the fissure of Rolando. Various modifications of the perpendicular section method have been suggested. Noth- nagel separates the hemispheres and divides them by partial incisions. Hamilton* gives figures of vertical sections according to the plan he advises. Meynert has suggested a division Avhereby * • Text-book of Pathology,' vol. i, 1889, pp. 23—28. 138 CHAPTER VIII the different parts of the brain may be sepa- rated and their Aveight taken. Weigert recommends a combination of the methods of Yirchow and Meynert. In an old method, still sometimes useful, Fig. 121.—Lateral ventricles of brain as exposed by horizontal section (from Hirschfeld and Leveille). horizontal sections were made into the brain as it lay exposed in the skull after removal of the calvarium (Fig. 121). Removal of the Spinal Cord.—This may be accomplished in two ways: EXAMINATION OF THE HEAD AND SPINE 130 1. Posterior Method.—An incision is carried along the spinous processes from occiput to sacrum. Expose the lamina and open into the spinal canal by means of Luer's rachiotome (Fig. 22) or the ordinary saw with rounded ,"I Fig. 122.—Illustrating method of using vertebral chisel and mallet in removing spinal cord by the so-called Italian method. Also shows A-block over which the spine is stretched. end (Fig. 18). SaA7age's vertebral forceps may be employed with advantage. Cut across the dura at the lower end of the exposed spinal canal, and holding the membrane by means of dissect- ing forceps carefully cut through the nerve- 140 CHAPTER VIII roots. After removing the cord incise the dura longitudinally and make a lew transverse sec- tions, supporting the cord on the fingers. The spinal cord is then to be suspended in a cylindrical vessel containing Muller's fluid, formalin solution, or the special fixing and hardening agent it is desired to use. Remember in removing the cord by this method it is best to take out the brain first. 2. The Anterior Method was introduced by Brunetti.* The thoracic and abdominal viscera must first be removed. With the spine suitably stretched over a A"shaped block the pedicles of the vertebras are divided by means of specially constructed chisels (Figs. 29 and 122). The bodies are then removed and the cord exposed and separated.t Examination of Special Organs.—For the exami- * For detailed description of this method see article by Di Harris, ' Brit. Med. Journ.,' 1888, vol. i, p. 738. t For further particulars concerning the examination and preservation of the brain and spinal cord, I may refer students to the admirable and very practical little volume published by Dr Edwin Goodall ('Microscopical Examination of the Human Brain: a Manual of Methods,' 1894). For a thoroughly up-to- date handbook Pollack's work may be consulted (' Methods of Staining the Nervous System,' by Dr Bernhard Pollack, English translation from the second German edition by Dr W. R. Jack, 1899). Much assistance in technical details will be afforded by von Kahlden's well-known work (' Methods of Pathological Histology,' by C. von Kahlden, English translation by Dr H. Morley Fletcher, 1894). EXAMINATION OF THE HEAD AND SPINE 141 nation of the nasal fossa?, eye, and ear, special dissections are, of course, necessary. Harke has introduced a convenient method by which the skull may be divided into halves by means of a longitudinal incision.* The chief features of the nasal cavities may be exposed by removing the cribriform plate Avith a chisel and small saw. The meatuses of the nose may also be inspected by cutting through the hard palate by means of bone forceps. The antrum of Highmore may be opened by making an aperture in the canine fossae after everting the lip and incising the mucous mem- brane. The roof of the orbits is best cut through by means of the chisel. The eye is to be di Abided in the transverse meridian. The anterior part should be left in situ, but the posterior half may be examined carefully in water. The middle ear may be easily opened by chiselling aAvay the thin roof of the tympanum. It is usually better, hoAvever, to remove the temporal bone as a whole, and make sections by means of a fine saw. The most convenient line of division is one starting at the styloid process and extending to the carotid canal, and running * A good description is given by Mallory and Wright, in their recent work on ' Pathological Technique,' 1898, p. 64. 142 CHAPTER VIII parallel to the crest of the pyramidal portion of the petrous part of the temporal. The frontal sutures may be readily exposed by chipping aAvay the inner table of the frontal bone with bone forceps. CHAPTER IX SPECIAL EXAMINATIONS Examination of the Organs of Locomotion.— Usually it is only possible to subject the bones, joints, and muscles to a partial examination. It is manifestly undesirable to open every joint of the body, but only too often an exami- nation of all the joints is neglected. Examination of the Bones.—It is sometimes absolutely necessary, howeA'er, to inspect these parts in cases of injury or suspected disease. The condition of the bones, and particularly the state of the epiphyses, becomes of importance in ascertaining the age. In blood diseases, like pernicious aiigemia and leucocythaemia, portions of the long bones, as Avell as the medulla of the ribs and sternum, should be examined. Inflam- matory processes and neAV groAvths particularly call for investigation. In fractures careful dissection may be necessaiy to expose the injured parts. The medulla of the sternum can readily be exposed by making a vertical saAv cut partially 144 CHAPTER IX through the sternum and then forcibly bending the bone. Cover-glass preparations of the pulp should be taken from different bones in all blood diseases. The condition of the periosteum should always be carefully investigated. Long bones are best divided by a longitudinal saAv cut (Fig. 123). A saw Avith a moveable Fig. 123.— Section of a rachitic femur (Sieveking). back is not infrequently needed. A chain saw is also sometimes of service. When the bones are fractured, a careful dissection may be necessary to thoroughly expose the whole extent of the injury. SPECIAL EXAMINATIONS 145 Examination of Joints.—The joints may have to be opened in gout, osteo-arthritis, and rheu- matism, and also in certain local affections, especially those of an inflammatory nature. The examination must be so conducted as to produce little or no disfigurement. In some cases where it is necessary to subject a joint to special examination, it should be excised and the bones sectioned longitudinally by a coronal or sagittal saw cut. Examination of Muscles.—The muscles should be thoroughly investigated in conditions of mal- nutrition. In trichinosis careful exploration may be necessary to detect the parasites. Examinations in Private Houses. — A post- mortem may have to be conducted under con- siderable difficulties in a private house ; this is often undertaken for scientific purposes, and may then be of a limited character. When an exami- nation is made for medico-legal ends it must be thorough and absolutely complete, whatever dif- ficulties may be met with. Usually I prefer to make the examination with as little disturbance of the body as possible. It should be draAvn to one side of the bed. NeAvspapers are ex- tremely convenient, and very eifective Avhen suitably arranged around the body, in prevent- ing any soiling of the bed linen. The papers may subsequently be readily disposed of by burning. An assistant is of much service. 140 CHAl'TER IX 111 medico-legal investigations for the coroner, which, according to the present unsatisfactory custom, have often to be conducted in cottages or other unsuitable places, an intelligent con- stable may often be found Avilling and able to afford the pathologist considerable assistance. Sometimes the viscera may be opened and thoroughly investigated without removing them individually. Such organs as the lungs, kid- neys, spleen, liver, and uterus can be incised in the body. Never allow any carbolic powder or such-like deodorising agent to be added to the body during the performance of the autopsy. See that all sponges and material likely to con- vey infection are destroyed. The disagreeable odour remaining in a room after an examination may be covered by burning coffee on an iron shovel. It is convenient to keep a list of instruments and material needed in the examination of pri- vate cases ready at hand, so that if necessary they may be collected by an attendant at a moment's notice. A trocar and cannula or a long india-rubber tube is of much service in cases of ascites. Special Examination in Female Cases. — In cases of criminal abortion, rape, or suspected pregnancy, it may be necessary to particularly investigate the internal and external genital organs. Examine the labia majora for evi- SPECIAL EXAMINATIONS 147 deuces of injury or disease. Note presence or absence and character of hymen.* Collect any discharge for microscopical and bacteriological examination. Examine for usual signs of pregnancy or recent delivery (Fig. 124). Fig. 124.—Sections of nulliparous and parous uterus (Galabin). Always thoroughly examine the contents of the pelvis in situ before proceeding to make any incision. Search for evidences of old or recent inflammation or haemorrhage. The cervix * Illustrations given in the recently published * Atlas of Legal Medicine,' by Dr E. von Hoffmann, English edition edited by F. Peterson and A. O. J. Kelly, 1898. 148 CHAl'TER IX and upper part of the vagina must especially be examined for punctured wounds, but the Avliole of the genital tract is to be dissected and minutely inspected. The breasts should, be explored by means of one or more incisions made from the pectoral surface, and carried so as not to penetrate the skin. In some cases it may be well to collect in a pipette a little of the milk or other fluid found in the glands for subsequent examination. In the naked-eye examination of the breast according to Stiles' method,* slices of the affected organ are placed in a 5 per cent. watery solution of nitric acid, then washed in Avater. The connective tissue assumes a gela- tinous appearance, while the epithelial elements become differentiated as opaque white bands and areas. Special Forms of Death.—It is unnecessary here to dwell on the investigation of the diffe- rent causes or the varying mechanism of death. Those forms of death of medico-legal import- ance are fully dealt with in the ordinary text- books of forensic medicine. Cases of " sudden death " should always be completely examined. The cause is often unexpected, and not infre- quently such as might easily be overlooked un- less an entire examination be made. I have elsewhere referred to a number of such medico- * Stiles, * Edin. Med. Journ.,' June and July, 1892. SPECIAL EXAMINATIONS 149 Fig. 125. —Homicidal cut-throat (Ogston). Fig. 126.—Suicidal cut-throat (Ogston). 150 CHAPTER IX legal cases which I have recently investi- gated.*- In connection Avith exceptional forms of death, reference should be made to Brouardel's fascinating lectures.f Where possible, photographs should be taken of medico-legal cases. Remember in cases of all wounds the dis- section incisions should as far as possible avoid the affected regions until they have been fully described and drawn or photographed (Figs. 125, 126). Examination of New-born Infants and Children. —A knowledge of the special anatomical fea- tures of the child is a necessary foundation. J In a medico-legal case let the examination be thorough and complete. Be prepared to answer such questions as—What is the degree of ma- turity of the child ? Was it born alive ? If * " On the Examination of Cases found Dead," ' The Scalpel,' January, 1898; "A Note on Rupture of Intra-thoracic Aortic Aneurysms, based upon an Analysis of Thirty-two Cases," ' Lancet,' 1897, July 24th ; "Sudden Death in Aortic Stenosis," ' Medical Press and Circular,' May 11th, 1898; "Death from Impaction of Meat in the Pharynx," 'The Medical Press,' September 7th, 1898. t Brouardel, ' Death and Sudden Death,' English edition, 1897. J See admirable illustrations of frozen sections in ' The Topographical Anatomy of the Child,' by Johnson Symington, M.D., 1887. SPECIAL EXAMINATIONS 151 so, how long did it live ? Hoav long had it been dead at the time of inspection ? What was the cause and nature of the death ? Specially observe such points as—state of the umbilical cord, presence of \rernix caseosa, con- dition of fontanelles, state of nutrition, or signs of injury. Give particular attention to the vessels from the umbilicus. In the internal examination special attention must be devoted to the lungs, Avith the object of ascertaining if the child has breathed. Note the size and form of the thymus. The question of enlargement of the thymus gland as a cause of sudden death in children has recently received full consideration by Eolleston.* Inspect the stomach for the presence of milk. Particularly investigate all parts liable to mal-development. Remember the possibility of death from starvation or exposure.t Do not be misled by peculiarities in the * Rolleston, ' The Diseases and Primary Tumours of the Thymus (Hand,' 1898, p. 8. t Tables of weights and measurements of mature new-born infants are given in Casper's ' Handbook of the Practice of Forensic Medicine,' English translation by G. W. Balfour, M.D., vol. iii, pp. 19, 44, 58, 1864. Woodman and Tidy, 'Forensic Medicine and Toxicology,' also give tables for reference of standard weights of children at different ages. These are of much practical importance in connection with such prosecutions as are instituted by the National Society for the Prevention of Cruelty to Children. 152 CHAPTER IX anatomy of the child ; remember the changes which occur between birth and the period of full development. In considering the different stages of intra-uterine life it may be Avell to re- fresh the memory by a reference to works on human embryology. The dates of appearance of the points of ossification and the times of union of the different parts are of considerable importance in estimating age. CHAPTER X MEDICO-LEGAL CONSIDERATIONS A vkry considerable number of pathological examinations are undertaken primarily for medico-legal purposes. In this chapter I Avish to refer, A'ery briefly, and necessarily in a some- what fragmentary fashion, to some few points of practical importance in the im'estigation of these cases. Exhumation.—A body can only be disinterred by authority of the Home Secretary. Any medical man may be called upon to undertake the examination, although usually an expert is selected. He should see that all necessary ar- rangements are made Avhereby the investigation may be rendered thorough and expeditious. A relay of graA'e-diggers may be needed. Some- one capable of identifying the body must be present. It is avcII to be equipped Avith appli- ances for photographing. The examination should be undertaken early in the morning Avith a good light, and in summer before the heat of the sun is experienced. A 154 CHAPTER X table or board and trestles should be ready on Avhich the body can be placed. As it is generally for suspected poisoning that exhumation is performed, Avell-stoppered bottles of varying sizes should be proA'ided for pre- serving those tissues which it may be found necessary to retain for analysis. Portions of bone and samples of the soil should sometimes be preserved. It used to be customary to use chloride of lime during the course of the examination, but it will be sufficiently evident that no deodorant or disinfectant should be employed until the investigation is completed. The pathologist may judiciously arrange so that he can stand on the windward side of the body. If only the skeleton remains it may be necessary to pass the soil through a coarse sieve in collecting the small bones of the carpus and tarsus. Note the depth of the grave and the direction, situation, and any special features of the skeleton. If remains of any foreign material, such as rope, bullets, and the like be found, they should be carefully preserved. The fauna of dead bodies lias recently received attention. Mutilated remains.—Occasionally the patho- logist is called upon to examine portions of the body Avith a view to determine personal identity. MEDICO-LEGAL CONSIDERATIONS 155 ''' Parts " from a dissecting room have sometimes been submitted for medico-legal report. Many ingenious and elaborate methods have been employed for the concealment of remains. The practice of the disposal of the corpus delicti by dismemberment has been termed " Depechage."* Examination of Poisoning Cases.—In poison- ing cases see that the contents of the stomach and the organs to be submitted to analysis are placed in perfectly clean vessels, sealed, and immediately forwarded by special police mes- senger to the analytical chemist. Preserve any vomited material in a separate bottle. For further details, consult the ordinary manuals of forensic medicine, the special treatises on poisons, and Hoffmann's ' Atlas of Legal Medicine.' Certificates of Death.—In all cases of death, except those submitted to an inquest, a medical man is compelled to give a certificate. The form should be carefully considered, and the " primary " and " secondary " causes denoted with scientific precision. Difficulty is often ex- perienced in recording the " duration of the disease," and as a matter of fact it is generally not indicated or very indefinitely stated. Do not be misled by the common impression that * Griffiths : ' Mysteries of Police and Crime,' 1898, vol. i, p. 459. 156 CHAPTER X an inquest is unnecessary if death occurred at a date more than a year and a day after the receipt of the injury. All cases of death resulting from the effects of any injury must be reported to the coroner. No post-mortem exa- mination may be made on a coroner's case without his " order" or until after he has granted the certificate. Mr. Braxton Hicks' admirable little brochure should be consulted by all recently qualified men* When a post-mortem examination lias been made on an ordinary case it is Avell in filling up the certificate to state definitely that such has been performed. It may here be Avell to draw attention to the directions and suggestions published by the Registrar-General for the guidance of medical practitioners, together with the form of medical certificate used in this country. MEDICAL CERTIFICATE OF THE CAUSE OF DEATH. By section 20 of the Births and Deaths Registration Act, 1874 (37 & 38 Vict., c. 88), it is enacted that :— " In case of the death of any person who has been attended during his last illness by a registered medical practi- tioner, that practitioner shall sign and give to some * ' Hints to Medical Practitioners concerning the Granting of Certificates of Death/ by A. Braxton Hicks, 2nd edit, 1895. MEDICO-LEGAL CONSIDERATIONS 157 person required by this Act to give information con- cerning the death a certificate stating to the best of his knowledge and belief the cause of death, and such person shall upon giving information concerning the death, or giving notice of the death, deliver that certificate to the Registrar, and the cause of death as stated in that certificate shall be entered in the register, togetlier with the name of the certifying medical practitioner;" " Where an inquest is held on the body of any deceased person a medical certificate of the cause of death need not be given to the Registrar, but the certificate of the finding of the jury, furnished by the coroner, shall be sufficient j" " If any person to whom a medical certificate is given by a registered medical practitioner in pursuance of this section fails to deliver that certificate to the Regis- trar, he shall be liable to a penalty not exceeding forty shillings." And under section 39 of the same Act, every person who refuses or fails ■without reasonable excuse to give or send any certificate in accordance toith the provisions of the Act is liable to a penalty not exceeding forty shillings. It will be observed that in every case in which a registered medical practitioner has been in attendance during the last illness of the deceased, such practitioner is required to give a certificate of the cause of death. The certificate must be under the hand of such practitioner; and no other person is authorised by law to sign the certificate in his behalf. It is requested that the persons to whom the medical certifi- cates are given may be informed that they are to be delivered TO THE REGISTRAR when the death is registered, AND TO NO OTHER PERSON. These certificates, which are copied verbatim into the death register, together with the name of the certifying practitioner, are used for no other purpose, and are preserved as official documents by the local Registrars. V)S CHAl'TER X In order that the causes of death as certified by registered medical practitioners may be satisfactorily classified in the Statistical Department of the General Register Office, for publication in his weekly, quarterly, and annual reports, the Registrar-Geueral requests : — 1. That registered medical practitioners in filling up their certificates will adopt as far as possible the suggestions printed on the following page ; and 2. That the names of diseases in the certificates be written as legibly as possible in order that the Registrars may be enabled to copy them accurately into the death register. Suggestions to Medical Practitioners respecting Certificates of the Cause of Death. 1. State the causes of death in terms as precise and brief as possible, and use the names adopted in the nomenclature of the Royal College of Physicians, taking the English names in preference to the Latin or other foreign equivalents. Vague terms, such as decline, tabes, cachexia, Sec, should be avoided. So also hemorrhage should not be assigned as a cause of death without further specification of its probable origin and the organ affected. Tetanus again should be defined as idiopathic or traumatic, and if the latter the cause and nature of the injury should be added. 2. Write the causes of death, when there are more than one, under each other, in the order of their appearance, and not in the presumed order of their importance. 3. Medical practitioners should not content themselves with assigning, as is too often done, some prominent symptom as the cause of death; but should state, whenever possible, the disease to which the symptom was due. Sometimes, doubt- less, it will happen that the nature of the fatal disease cannot be ascertained with certainty; in such cases, and in such alone, a leading symptom should be assigned as the cause of death. " Dropsy " should not be returned as the cause of MEDICO-LEGAL CONSIDERATIONS 159 death without stating whether the dropsy ivas due to heart disease, or renal disease, or the like ; when " dropsy" alone is returned, it is assumed that the cause of this symptom was not ascertained. Similarly, when the immediate cause of death was dependent upon some general coudition, such, for instance, as the stru- mous, the syphilitic, or the rickety constitution, this remoter cause should be stated, as well as the more immediate cause. 4. In certifying deaths from any form of continued fever, stale the kind of fever, and, in so doing, be especially careful to adopt the nomenclature of the College of Physicians. Avoid all such ambiguous terms as low fever, miliary fever, brain fever, hectic fever, febrile attack, &c. Similarly avoid the term " typhoid pneumonia," which may mean either asthenic pneumonia with typhoid symptoms,, or enteric fever with secondary pneumonia, Do not use the term infantile remittent fever for enteric fever in children. 5. When the cause of death has been verified by a post- mortem examination, the letters P.M. should be added. 6. State in fatal cases of smallpox whether vaccination had been performed with effect and when, or whether the deceased was unvacciuated. If possible state the evidence of vaccina- tion, e.g. " two bad marks." The term " vaccinated " should be used in preference to "after vaccination." "Smallpox after vaccination, twenty-one days," is ambiguous, because the question arises whether the period (twenty-one days) refers to smallpox or to the vaccination ; the cause of death should be certified as "smallpox twenty-one days (vaccinated)." 7. Whenever child-birth has occurred within one month before death, this fact should invariably be certified, even though it may be believed that the child-birth had no connec- tion with the cause of death. 8. The duration of primary and secondary diseases in these certificates will always be considered to mean the time inter- vening between the first appearance of well-marked charac- teristic symptoms and death. 160 CHAl'TER X Smallpox, scarlet fever, measles, and other similar febrile diseases should, however, be dated from the rigors and first symptoms; not from the later appearance of the eruption. Ague, epilepsy, angina pectoris, and other maladies that occur in fits or paroxysm*, should be dated from the first attack, the duration of the last fit being added. The duration should bj stated in minutes or hours when the disease is fatal iu less than forty-eight hours; in days when the disease is of less than fifty days' duration; in months or years when the disease is of still longer duration. Examples:—(a) Scarlet fever . . 30 days. Anasarca . . 7 ,, Implies that the earliest symptoms of scarlet fever occurred thirty days before death, and that auasarci was first noticed seven days before death. (6) Epilepsy ... 5 years. Last fit . . .6 hours, Implies that the first epileptic fit occurred five years back, and that the fatal fit lasted six hours. (c) Excessive use of spirits — Delirium tremens . G days, Implies that the deceased had been for an unknowu time given to intemperance, and suffered from delirium tremens for six days before death. 9. SURGEONS in all case3 of operation should return (a) the primary disease or injury; (J) the kind of operation ; (c) the secondary diseases, such as erysipelas, purulent deposits, &c, and should state also the time from commencement of the primary disease, the time from the operation, and the time from the appearance of secondary disease, reckoning in each instance to the death. Examples:— Femoral- hernia .... 3 years. Strangulated .... 5 days. Operation . . . . . 2 „ Peritonitis . . . . .45 hours. 10. In every case of death from violence or suspected MEDICO-LEGAL CONSIDERATIONS 161 violence the medical practitioner should advise the friends of the deceased to bring the case to the knowledge of the Coroner in order that he may decide as to holding or not holding an inquest, inasmuch as the Coroner may otherwise feel it his duty, when the case comes to his knowledge, to order the body to be exhumed and inquiry instituted. N.B.—Xo medical practitioner is justified in giving a certi- ficate unless he was personally in attendance upon the deceased during the last illness. 11 Not to be used by any other than a Registered Medical Practitioner. v BIRTHS AND DEATHS REGISTRATION ACT, 1874. E,,";°r"""XSm MEDICAL CERTIFICATE of the CAUSE of DEATH. Hook of Deaths to be inserted here by the To be [riven by the Medical Attendant to the Person whose duty it is to give it, w ith inlurmatiim Rcistrar : of t lie Heath, to the Registrar of the Stb-Distku i m which t lie Oka in to >k place, ^ and TO NO OTHER PERSON. I I ; that I last saw h death was as hereunder written. on on I hekebt cektifv that I attended during the last illness ; that such Person's age was stated to be the " day of IS ; that he Died* the day of 18 , at and that to the best of my knowledge and belief the Cause of h * Should the Medical Attendant not feel justi- fied in taking upon himself the responsibility of cer- tifying the fact of Death, he' may here insert the words '• us I am informal." t The duration ot eacli form of Disease or Sym- ptom is reckoned from its commencement until death occurs. Witness my hand, this day of IS Signal lire Qualification as registered by Medical Council Residence N.H.—THIS CERTIFICATE IS INTENDED SOLELY FOR THE USE OF THE REGISTRAR, to whom it should be delivered by the Person giving information to bun of the particulars required by law to be registered concerning the Death. Penalty o/'£2 for nailed of Informant to •U/irer this Certificate to Ue.j'utrar. *»* The Registrar-General cautions all persons against accepting or using this certificate for any purpose whatever except that of delivering it to the Registrar. Cause of Death. Primary Secondary Duration of Disease in Year8- Month;'.' »»>»• i »««»•+ 1 ! MEDICO-LEGAL CONSIDERATIONS 163 The following persons are alone qualified to be informants for the registration of the death, and to whom only the certifi- cate should be given : 1. A relative of the deceased, present at the death. 2. A relative of the deceased, in attendance during the last illness. 3. A relative of the deceased dwelling or being in the sub- district in which the death occurred. 4. A person " present at the death." .">. The " occupier" of the house in which the death occurred. 6. An "inmate" of the house in which the death occurred. 7. The person "causing the body to be buried." By the 10th Section of the Births and Deaths Registration Act, 1874, the nearest relatives of deceased persons are required to be the informants of deaths, and they incur a penalty of £2 if they fail to comply with this law. The Registrar-General does not rigidly insist that the nearest relatives shall in all cases attend before the Registrar; but unless strong reasons for their non-attendance can be given it is the Registrar's duty to require that if there are in the sub-district any relatives of the deceased, either dwelling or being there for the time, some one of such relatives shall fulfil the legal obligation to sign the register book as informant. If no relative is available, as above referred to, then the register book may be signed by a person having one of the other legal qualifications. Informants must be prepared to state accurately to the Registrar the following particulars : (1) The date and place of death. (2) The full names and surname of deceased. (3) The correct age of deceased. (4) The rank, profession, or occupation of deceased. [If deceased is a child or an unmarried person without occupation or property, the full names and rank or profession of the father will be required (except in the case of illegitimate children); if a wife or widow, those of the husband or deceased husband.] 1(54 CHAPTER X Useful information respecting the registra- tion of births and deaths'will be found in Mr. (Jlenn's admirable ' Abstract of the Principal Laws affecting the Medical Profession/* Relations to the Coroner's Court.—Cases of violent or suspicious death have, in England, always to be submitted to the coroner. In Scotland the Procurator-Fiscal undertakes the duties of both coroner and jury. Every practitioner who may be called upon to make an investigation for the coroner should be acquainted with the sections of the Coroners Act of 1877, pertaining to the conduct of post- mortem examinations and the giving of medical evidence. Any medical man may be called upon to conduct the investigation at the coroner's dis- cretion, provided he is " a legally qualified medical practitioner in actual practice in or near the place where the death happened." Never commence the examination without the formal " order"' from the legally con- stituted authority. Occasionally the assistance and protection of the police may have to be sought in order to carry out the examination. In important medico-legal cases two medical men should be present. If any person is likely to be incriminated he should have the oppor- tunity of being medically represented at the autopsy. * ' The Medical Directory ' for 1899. Published by Messrs J. and A. Churchill. MEDICO-LEGAL CONSIDERATIONS 165 The pathologist must be prepared to give a definite opinion as to the connection between cause and effect, the morbid agent, and the ultimate consequences. Carefully distinguish between the effects of natural and adventitious causes. If possible, the autopsy should be conducted before putrefactive processes have commenced. Occasionally it may be necessary to examine a party connected with the death in question. If possible, ascertain the circumstances at- tending the death before commencing the exa- mination of the body. Clothes or foreign bodies found on the body should be retained in sealed vessels or so marked that they can be immediately identified in court. The following is the kind of form of order adopted by most coroners : Coroner's Inquest at upon the body of Bv virtue of this my Order as Coroner for the County Borough of , in the County of , you are required to appear before me and the Jury at in the said Borough, on the day of at o'clock in the noon, to give evidence touching the cause of death of and make a fost-mortem 166 CHAPTER X examination of the body with an analysis, and report thereon at the said Inquest. (iiven under my hand this day of 1899. To Coroner. In the interests of science and medico-legal medicine, it would be well if all medico-legal examinations, at least in cities with a medical school, could be conducted in some central institute, open to all duly qualified medical men and registered medical students. Where Cremation is to be carried out, special certificates are to be filled up in addition to the customary one presented to the Registrar of Deaths. It is very desirable that all bodies about to be cremated should be submitted to a thorough scientific examination, and it would be well if a medical report were made com- pulsory. CHAPTER XI MISCKLLANEOUS CONS 1 DERATIONS In conclusion, we may refer to some few re- maining points of importance to the practical pathologist. Restitution of the Body.—The aesthetics of an autopsy must on no account be lightly regarded. The body should be so left as to present no mani- fest evidences of the operation. No displace- ment or deformity must be visible. Cuts into con- spicuous parts are to be avoided. The face is always to be maintained intact. Special care must be taken in the replacement and fixation of the skull cap. It is often well to wire the bones together, or to fix them by means of double-pointed or U-shaped nails. In many eases it is well to arrange that the median in- cision should not appear above the level of the shroud. Blood and all fluids must be com- pletely removed from the cavities. A common scoop is useful for " bailing out." The brain is frequently placed in the body cavity. Gannett advises that the cranial cavity be filled with a sand-bag, easily made adaptable by spreading a 168 CHAPTER XI cotton cloth, eighteen inches square, heaping on it house sand, and then taking up the corners and tying with string.* The foramen magnum and apertures for the large vessels may be plugged with cotton wool or tow if necessary. Fine sawdust is exceedingly convenient in filling up the cranial and other cavities. Jt will be found that tow, when damp, can be readily moulded and packed so tightly as to make any part of firm consistency. Particular care must always be taken to prevent escape of blood or fluids from the mouth. When the pelvic organs have been removed plug the outlet with tow. The " operculum " may often with advantage be fixed in position. A rod may be necessary to stiffen the spine if a portion of the vertebral column has been removed. Sometimes plaster of Paris is used to stiffen parts. Tow or cotton wool is occasionally placed directly beneath the long antei'ior incision to prevent oozing. In some cases a strip of plaster is applied over the incision. The body is stitched up with stout thread introduced by means of a surgical needle (some prefer the curved form) from within outwards, starting at the pubes. * (lannett (\V. W.), "Post-mortem Examinations," article in ' Reference Handbook of the Medical Sciences,' vol. v, 1889, pp. 783—791. MISCELLANEOUS CONSIDERATIONS 169 The cadaver must be left scrupulously clean, particular care being taken to wash the hair free from all blood. The clothes must be re- placed, and the corpse and furniture left as it was arranged before the autopsy. Occasionally a medical man is called upon to advise regarding the process of embalming * Records.—A written report should be made on every case. This will vary somewhat in form and length, according as to whether the examination has been undertaken for medico- legal or purely scientific purposes. Generally it is well to have the notes taken down from dictation as the examination is proceeded with. In medico-legal cases all medical men present at the inspection should sign the report, which, of course, should only record facts, and be innocent of any suggestion of opinions. Many pathologists use special forms. Some recommended by asylum pathologists are rather too elaborate to be practicable for general cases.t In medico-legal reports all superfluous matter must be excluded. The report must be concise, definite, simple in form, and unmistakable in language. * See special article. Read (Julian, A.) ' Reference Hand- book of the Medical Sciences,' vol. ii, 1886, p. 666; also Thomas, A. R., ' A Practical Guide for making Post-mortem Examinations,' 1873, pp. 320—325. f See ' Index Pathologicus for the Registration of the Lesions recorded in Pathological Records or Case-books of Hospitals and Asylums,' by James C. Howden, M.D., 1894. 170 CHAPTER XI An interesting and suggestive, but now some- what out-of-date, manual was published many years since under the authority of the London Medical Society of Observation, in which certain forms were advised.* After describing the abnormal parts, a note that " the remaining organs were healthy " will often save time and prevent confusion. Virchow's 'Regulations for the Guidance of Medical Jurists in conducting Post-mortem ex- aminations for Legal purposes,' and his ex- amples of reports, may be studied with advan- tage.f Ogston gives specimens of the various forms of medico-legal reports as required in Scot- land. J Men about to practise in Scotland must make themselves acquainted with the details of their relationship to the Procurators-Fiscal.§ Frequently data respecting size and weight of different parts of the body in different sexes, * ' What to Observe at the Bedside and after Death in Medical Cases,' 1854. t ' A Description and Explanation of the Methods of per- forming Post-mortem Examinations in the Dead-house of the Berlin Charite Hospital, with especial reference to Medico- legal Practice,' by Professor Rudolph Virchow. English translation, by Dr T. P. Smith, 1880. X Ogston, 'Lectures on Medical Jurisprudence,' 1878. § See ' Regulations for Procurators-Fiscal in Criminal and other Investigations,' Crown Office, Edinburgh. MISCELLANEOUS CONSIDERATIONS 171 and at varying ages, are required, when re- ference may be made to Vierordt's well-known work.* Convenient charts engraved on slates have been designed for the marking in of lesions and life-size diagrams of the brain. These have been introduced so that accurate records of the size, shape, and extent of gross lesions can be readily prepared.f It is wise to have a blackboard marked with the names and average weights of the dif- ferent organs, and so arranged that the numbers ascertained in the case under examination ma}' be entered up directly the organ is weighed on removal from the body.J As far as possible, all organs and important parts of the body should be weighed and mea- sured. Every organ except the heart should be weighed before being cut. It is still custo- mary to express the weight in ounces in this country. It is to be regretted that the decimal system is not more generally used. The weights * Vierordt, ' Anatomische, Physiologische, und Physikalische Daten und Tabelleu zum Gebrauche fiir Mediciuer,' 1893. f Sold by John Bale, Sons, and Danielsson, 83—89, Great Titchfield Street, London, W. X A mounted and varnished table, for use in the post-mortem room, is published by Messrs. J. and A. Churchill. ' Table of the Average Weights of the Human Body, and of several of the Internal Organs, at Eighteen Periods of Life in both Sexes,' by Robert Boyd, M.D., 1882. 172 CHAPTER XI and measurements vary considerably according to sex, age, and size of the individual. The following merely indicates the rough average weight of normal adult male organs : Brain 11eart Lungs : (right) (left) Liver Spleen . Kidney . A useful table of the weights and measure- ments, taken from Nauwerck's ' Sectionstechnik,' is given by Mallory and Wright.* Data respecting the normal weight and di- mensions of the heart are given in several readily accessible text-books.t In hospitals the post-mortem reports are gene- rally entered in suitable books or on special forms. These should be numbered and indexed, both as regards the name of the subject and the pathological conditions found. It is well to have the cases indicated by a progressive number, * Mallory and Wright, ' Pathological Technique,' 1898, p. 36. t See Hamilton, 'Text-book of Pathology;' Jones, Sieve- king, and Payne, 'Manual of Pathological Anatomy,' 1875, pp. 334—337. 50 ounce 10 „ 20 50 MISCELLANEOUS CONSIDERATIONS 173 which will be found very convenient and time- saving when specimens have to be reserved for museum purposes or for more detailed in- vestigation, as the number can then be safely placed on the jars containing the preparation with the certainty that no confusion can subse- quently arise in identifying the same. At the head of the report the complete pathological diagnosis should be entered. Then follow par- ticulars as to name, age, occupation, residence, (kites of admission, death, and autopsy, name of physician or surgeon, clinical diagnosis, ope- ration, and outline of clinical history. After this comes the pathological report, which should be signed by the pathologist responsible for the conduct of the examination. Preparation of Museum Specimens.—The duty of assisting in the progress of medical science makes it incumbent on all pathologists to adopt the best means for the preparation and preser- vation of specimens suitable for museum pur- poses. The introduction of formalin has done much to further such efforts. It is, however, impossible here to do more than refer the student to readily accessible sources where full details may be obtained.* * Caird and Cathcart, ' A Surgical Handbook,' 8th edit., 1897, p. 293; Gibbes, 'Practical Pathology and Morbid His- tology,' 1S91; Hamilton, ' A Text-book of Pathology,' vol. i, 1889, p. 43; Rolleston and Kanthack, ' Manual of Practical 174 CHAPTER XI It is sometimes well to take casts of unusual displacements or exceptional deformities.* Preservation of Specimens for Microscopical Examination.— It is also part of the duty of anyone undertaking a post-mortem examination to select and suitably preserve tissues needing microscopic investigation. It does not come within the scope of these articles to enter on this large field, and indeed such is unnecessary, as full particulars are to be obtained in many readily accessible works.f Morbid Anatomy,' 1894, p. viii; Willett (E. W.)," Preservation of Specimens in Spirit," ' Lancet,' 1893, Nov. 25th, vol. ii, p. 1349; Wynter and Wetliered, ' A Manual of Clinical and Practical Pathoh gy,' 1890, p. 299. * For preparation of plaster and papier-mache casts, see Caird and Cathcard, 'A Surgical Handbook,' 1896, 7th edit., p. 237 ; for preparation of paraffin wax casts, see Peters, "A New and Original Method of making Casts," ' Brit. Med. Joum.,' 1898, vol. ii, p. 621. t Works dealing with the selection, preservation, and pre- paration of morbid histological specimens: — In several of the works already referred to in this manual particulars will be found regarding the investigation of morbid histological preparations. The following references will pro- bably be found of special service : Delafield and Pbudden. A Handbook of Pathological Anatomy and Histology. 5th edit. 1897. Gibbes. Practical Pathology and Morbid Histology. 1891. Goodall. The Microscopical Examination of the Human Brain. 1894. Fuiedlandee-Ebeeth. Microscopische Technik. 1895. MISCELLANEOUS CONSIDERATIONS 175 Remember it is well in many diseases to re- tain samples of the blood in the form of films.* Photography now lorins an almost essential adjunct to pathological investigation. Every post-mortem room should be equipped with ap- paratus suitably arranged for the photographing of the whole body or any of the organs. Hamilton. Text-book of Pathology. Vol. i, 1889. von Kahlden. Methods of Pathological Histology. Eng- lish edition translated by Morley Fletcher. 1894. Lee and HENNEGur. Traite des Methodes techniques de l'Anatomie microscopique. 1896. Lee (A. Bolles). The Microtomist's Vade Mecum. A Handbook of the Methods of Microscopic Anatomy 4th edit. 1896. Mallory and Wright. Pathological Technique. 1898. Pp. 204—383. Pollack. Methods of Staining the Nervous System. English translation by W. R. Jack, 1899. Ribbeiit. Lehrbuch der pathologischen Histologic 1896. Squire (P. W.). Methods and Formula} used in the Pre- paration of Animal and Vegetable Tissues, including the Staining of Bacteria for Microscopical Examina- tion. Wi:iciisi:lbaum. The Elements of Pathological Histology, with special reference to Practical Methods. English translation by W. R. Dawson, 1895. Wetheeed. Medical Microscopy. 1892. * For methods of collecting and preserving blood, see Cabot, 'The Clinical Examination of the Blood,' 1897; Coles (A. C), ' The Blood: how to Examine and Diagnose its Diseases,' 1898. Both give references to modern literature. 176 CHAPTER XI Photo-micrography has of recent years proved of great service in permanently record- ing minute details.* Preservation of Material for Bacteriological Investigation.—It is extremely important that the student should fully realise the importance of suitably collecting and fitly preserving dis- charges, blood, and tissues which it may be necessary to submit to a bacteriological exami- nation. The necessary steps are fully indicated in the many modern manuals now at his dis- posal. * Soc Pringle, 'Practical Photo-micrography,' 1893; and ordinary handbooks on photography. INDEX Abdomen, examination of, 92 Abdominal incision, 54 — rings, 102 Abortion, 146 Abscess, renal, 111 — subphrenic, 92 Abstract, clinical, 11 Accessory instruments, 28 — spleens, 117 Acromegaly, 135 Addisou's disease, 118 Adhesions, division of, 60 — examination of, 57 — pleural, 83 Adrenals, 118 ^Esthetic aspects, 10 Age, 45 Analysis, medico-legal, 51 Aneurysm, cerebral, 134 — heart, 80 Angular scissors, 20 Ante-mortem changes, 47 Antiseptic precautions, 7 Antrum of Highmore, 141 Aorta, openiug of, 75 Aortic valves, testing of, 71 Appliances, 13 Apron, 9 Arches of vertebra?, division of, 28 Arcus senilis, 46 Ascites, 146 Atelectasis, 85 Atheroma, 80 Attitude, 45 Auricle, left, 74 — right, 72 Auricles, opening of, 66 Auriculo - ventriculous groove, 66 Autopsies, works on, 4 Autopsy, instruments for, 113 Azygos veins, 89 Bacteriological investigations, 176 Balls, graduated, 34 Band-saw, 27 Base of skull, saw for, 23 Beeswax and vaseline ointment, 8 Bellows, 40 Bibliography — post-mortem technique, 4 12 178 INDEX Bibliography — morbid his- tology, 174 Biliary cirrhosis, 123 Biniodide of mercury, 9 Bistoury, 16 Bladder, female, 103 — growth, 100 — male, 100 — section of, 100 Blocks of wood, 39 Blood diseases, bone in, 113 Blowpipes, 33 Blunt hook, 28 Boards, 39 Bone-cutters, 27 Bone drill, 40 Bones, examination of, 143 Bottle for poisoning cases, 40, 155 Bowel scissors, 19 Brain, examination of, 133 — hardening of, 136 — horizontal sections, 138 — knife, 15 — removal of, 132 — secondary sarcoma, 134 — section of, 136 — vertical sections, 137 Breasts, 45, 148 Broad ligaments, 108 Bronchi, section of, 85 Bronchial glands, 85 Bronchiectasis, 88 Brunetti's chisels, 28 — method, 140 Butcher's knife, 15 Butcher's saw, 13 Calcified cartilages, 27 Calculi, pancreatic, 115 Callipers, 34 Calvarium, fixatiou of, 129 Canine fossa, 141 Cannula, 51 Carcinoma of liver, 120 Carpenter's saw, 13 Cartilage knife, 14 — shears, 27 Cartilages, cutting of, 15 Cases, medico-legal, 11 Casts, 126 Catheters, 35 Cavities, 57 Celloidin, 7 Cerebellum, 137 Cerebral arteries, 133 Certificates of death, 155 Cervix uteri, 108 Chapel, mortuary, 11 Children, examination of, 150 Chisels, 28 Clasp knife, 13 Cleansing of hands, 8 Clinical abstract, 11 — history, 50 Clothes, inspection of, 44 — investigation of, 165 Cold chamber, 42 Colitis, ulcerative, 95 Colon, affections of, 97 Colour, 45 Complete post-mortem set, 38 INDEX 179 Conditions, post mortem, 47 Cones, graduated, 34 Considerations, general, 6 Contusions, 46 Convolutions of brain, 133 Copper wire, 35 Cornea, 47 Coronal incision, 127 Coronary sinus, 66 — vessels, 80 Coroners' inquiries, 164 Coronet, 34 Corpora quadrigemina, 137 Corpse, preservation of, 42 Corpulence, 46 Corpus callosum, 137 Costotome, 27 Cotton wool, 40 Cover-glass preparations, 47,101 Cranium-holder, 34 Cremation, 166 Cribriform plate, 141 Criminal abortion, 146 Crown, 34 Culture media, 47 Curved bistoury, 16 — scissors, 20 — vertebral chisels, 28 Cut-throats, 149 Cyanosis, 46 Dangers, 6 Death, evidences of, 47 — forms of, 148 — time of, 47 Dejecta, disposal of, 51 Deodorants, 8 Depechage, 155 Development, general, 45 Diameters of head, 126 Diaphragm,estimation of weight. 57 — separation of, 55 Dictation of notes, 44 Directors, 31 Discharges, 46 Disinfectants, 8 Dissecting forceps, 31 — hooks, 31 Distinctions, stains and bruises, 48 Domestic scissors, 13 Double-bladed knife, 17 Double saw, 24 Drill, 40 Dropsy, 46 Duct, pancreatic, 114 — thoracic, 89 Ducts, bile, 114 — opening of, 21 Duodenum, 113 Dura mater, 131 ----bistoury for, 17 Ear, 141 Effusion, pericardial, 62 Embalming, 169 Embolism, pulmonary, 88 " Emphysema," hepatic, 120 Enamelled plates, 10 — trays, 39 English cartilage knife, 15 ISO INDEX Enterotome, 19 Environment, 12 Examination, abdominal, 92 — cardiac, 63 — head and spine, 126 — internal, 50 — systematic, 12 — thorax and neck, 60 Excavated head block, 39 Exhumation, 51, 153 Exposure, death from, 151 Expression, 45 External examination, 41 Eye, 141 Face casts, 126 Fallopian tubes, 108 Falx cerebri, 132 Fauna of dead bodies, 154 Female cases, 146 — genital organs, 103 Fingers, measuring by, 70 Flat knife, 15 Fluids, preservation of, 47 — scoop for removal of, 39 Fontanelles, 151 Footprints, 43 Forceps, dissecting, 31 Foreign bodies, 46, 90 Formalin, 85, 136 Fornix, 137 " Found dead" cases, 42 Fractures, 143 Fret-saw, 27 Frontal sinuses, 142 Gall-bladder, 120 Gall-stones, 124 Gastro-intestinal tract, 59 Genitals, female, 103 — male, 98 Genito-urinary organs, 59 Girth, 45 (Hands, bronchial, 85 — enlarged, 46 — mediastinal, 01 Glass, magnifying, 36 — measuring, 34 Globus major, 102 Gonorrhoea, 101 Gout, 145 Graduated cones, 71 Grooved directors, 31 Hamiopericardiuin, 62 Haemorrhages, 46 Hair, 127 Hake's method, 141 Hands, 44 Hand-saw, 23 Hanging, 83 Hammers, 28 Head, examination of, 126 Head-rest, 34 Heart, aneurysm, 80 — dissection of, 72 — hypertrophy of, 77 — lines of incision, 65 — methods of examining, 66 — opening of, 65 — removal of, 71 — transfixion, 76 — transverse sections of, 77 Hernia, 46, 102 Hey's saw, 23 High more, antrum of, 141 History of case, 11, 44, 50 Hollow-ground razor, 17 Hook, blunt, 28 Hooked retractors, 31 Hooks, dissecting, 31 Horse-shoe kidney, 112 Hydrocephalus, 129 Hymen, 45, 147 Ice as preservative, 42 Identification, 153 Iliac arteries, 125 Incisions into organs, 57 India-rubber gloves, 7 Infants, examination of, 150 Infectious cases, 51 Infective matter, disposal of, 8 Injecting springe, 33 Injuries in post-mortem work, 7 Inspection, examination by, 57 Instruments, 13 Internal examination, 50 Intestines, 92 Intussusception, " agonic," 97 Iodine test, 117 Jaconet, 9 Jaundice, 113 Jaw, 88 Joints, 145 Kidney, granular, 113 — "horse-shoe," 112 — opening of, 109 INDEX 2g] Kidney, pyaemic abscesses, 111 — removal of, 108 — sarcoma, 110 — systematic examination, 110 Knife, brain, 15 — clasp, 13 — double-bladed, 17 — flat, 15 — loug-bladed, 15 — short, 15 — trowel-shanked, 17 Labia, 105 Laminae, forceps for, 28 Larynx, 89 Lesions, list of, 11 Leucocythaemia, bone in, 143 Limited examinations, 52 Lingual process of liver, 124 i Lion forceps, 28 Liver, cirrhotic, 121 — "emphysema" of, 120 — examination of, 118 — melanotic sarcoma, 119 — secondary carcinoma, 120 Lividity, cadaveric, 48 Locomotion, organs of, 143 Long anterior incision, 53 Long-bladed knives, 15 Luer's rachiotome, 139 Lungs, aneurysm in, 86 — examination of, 83 — incision of, 83 — removal of, 83 Magnifying glass, 36 182 INDEX Maldevelopments, 46 Male genitals, 98 Mallet, 13 — wooden, 28 Measures, 34 Meckel's diverticulum, 93 Mediastinal growth, 90 Mediastinum, 57, 60, 88 Medico-legal cases, 11, 51 — considerations, 153 — notes, 44 — reports, 169 Mesentery, 125 Metacarpal saw, 23 Methods of investigation, 55 Microbial diseases, 47 Microscopical specimens, 174 Middle ear, 141 Mirror, 9 Mitral stenosis, 75 — valve, aneurysm of, 70 Mobility, testing for, 57 Moles, 46 Monro, foramen of, 137 Morbid anatomy, importance of, 3 — features, 45 Mortuary, care of, 10 — chapel, 11 — temperature of, 49 Mouth, 88 Moveable kidneys, 92 Miiller's fluid, 140 Muscles, 145 Museum specimens, 173 Mutilated remains, 154 Naevi, 46 Xasal cavities, 141 Neck, 89 Needles, 35 Nerves, sympathetic, 89 Non-absorbent boards, 39 Normal characters, 45 Nose, 141 Notes, dictation of, 12 Note-taking, 44, 169 Notice, attendance, 11 Nutritional changes, 46 Occupation, 45 Odours, 46 Ointment, 8 Omentum, gastro-splenic, 1 IS — great, 57 Opening of abdomen, 53 Operculum, removal of, 54 Orbits, 141 Order of coroner, 165 — of examination, 51 Organs in association, 59 Orifices, inspection of, 46 Osmic acid, 115 Ossification, centres of, 152 Osteo-arthritis, 145 Os uteri, 108 Ovaries, 108 Pacchionian bodies, 135 Pails, 40 Palate, 88 Palpation, examination by, 57 Pancreas, 114 INDEX 183 Papilla, biliary, 114 Parasites, 46 Parotid gland, 127 Pathology, importance of, 3 Pelvis, exploration of, 57 — veins of, 125 Penis, 98 Perchloride of mercury, 7 Pericardium, 62 Perineum, 105 Periosteum, 144 Peritoneum, 54 Permission for autopsy, 10 Pernicious anaemia, bones in, 143 ----liver in, 120 Pharynx, 88 Photographer's gloves, 7 Photography, 42, 51, 175 Pia-arachnoid, 133 Pigmentation, 46 Pipettes, 47 Pitres' method, 137 Pituitary body, 135 Place of examination, 9 Pleura?, 82 Pleural adhesions, 60 Pneumothorax, 50, 82 Poisoning cases, 40, 113, 155 Police, presence of, 11 Pons, 137 Portal vein, 113 — wounds, 6 Posterior meningitis, 129 Post-mortem technique, 4 Precautions, antiseptic, 7 Precautions in infectious cases, 51 Pregnancy, 146 Preliminary incisions, 53 Preservation of body, 41 — of material, 43 Prevention of post • mortem wounds, 6 Primary incision, 53 Private houses, examination in, 40, 145 Probe-pointed bistoury, 16 — directors, 31 — scissors, 21 Prostate, 101 Protection of pathologist, 9 Prussian blue reaction, 120 Psoas muscles, 125 Pulmonary artery, 69, 86 — thrombosis, 88 Pulp, bone, 144 Pupils, characters of, 46 Putrefaction, prevention of, 42 Putrefactive changes, 48 Pyaemic abscesses of kidney, 111 Race, 45 Kachiotome, 24, 139 Rape, 146 Razor, 17 Receptaculum chyli, 125 Records, 169 Recti muscles, 54 Rectum, 105 Refrigerating apparatus, 42 184 INDEX Remains, concealment of, 155 Removal of heart, 64 — of organs, 59 Restitution of body, 167 Retractors, 31 Retro-peritoneal glands, 125 — lesions, 92 Rheumatism, 145 Rib-cartilages, costotoine for, 27 — diseases of, 55 Rickety bone, 144 Rigidity, post-mortem, 47 Rolando, fissure of, 137 Root of lungs, 60 Rubber cots, 7 Sacro-iliac joints, 125 Sarcoma, melanotic, 119 — spleen, 117 Savage's vertebral forceps, 28 Saw, band, 27 — butcher's, 13 — fret, 27 — hand, 23 — Hey's, 23 — meat, 21 — metacarpal, 23 — moveable back, 26 — spinal double, 24 '■■'""' Sawdust, 40 Scales, weighing, 39 Scalp, incisions, 126 Scalpels, 15 Scissors, angular, 18 — bowel, 19 — curved, 18 Scissors, domestic, 13 — probe-pointed, 21 — straight, 18 Sclerotic, 47 Scoops, 39 Scrotum, 102 Section in situ, 57 Semilunar ganglia, 118 Sex, 45 Shears, 27 Sliort-bladed knives, 15 Sigmoid valves, 71 Signs of death, 43 Sinuses of skull, 131 Skeleton, 151 Skull, holder for, 34 — opening, circular method, 127 ----wedge method, 129 Skull-cap, fixation of, 128 —- wrench for, 28 Sleeves, 9 Soaps, 8 Social position, evidences, 45 Soil, preservation of, 44 Solar plexus, 118 Spinal cord, 138 — double saw, 24 Spine, 126 Spleen, removal of, 115 — secondary growths, 117 Splenules, 117 Sponges, 40 Staining, post-mortem, 48 Starvation, 151 Stature, 45 INDEX. 185 Sterilised pipettes, 47 Sterno-clavicular point, 55 Stiles' method, 148 Stockinette gloves, 7 Stomach, bellows for inflation, 40 — dilatation, 114 — examination of, 113 Straight scissors, 18 — vertebral chisel, 28 Sub-arachnoid, 135 Sub-epicardial deposits, 62 Subphrenic abscess, 93 Sudden death, 148 Suffocation, 83 Superior longitudinal sinus, 131 Sylvian fissure, 133 Sympathetic nerve, 89 Syringe, injecting, 33 Systematic examination, 12 Table, post-mortem, 39 Tattooing, 46 Temperature, 47 Tentorium cerebelli, 132 Testicles, 101 Thoracic aorta, aneurysm, 81 — atheroma, 80 — duct, 89, 125 — examination, 80 Thorax, opening of, 54 Thread, hempen, 35 Thrombus, pulmonary, 70, 88 Thymus, 60, 90, 151 Thyroid, 90 Tiemann's double-bladed knife, 19 Time of autopsy, 9, 41 Tissues, slices of fresh, 17 Tonsils, 89 Tow, 40 Trance, 43 Transposition of viscera, 57 Trays, 39 Trichinosis, 145 Tricuspid orifice, 70 Trocar, 51 Trowel-shanked knife, 17 Tuberculosis, pulmonary, 85 Tubing, 40 1 | Tunica vaginalis, 102 Twine, 40 Umbilical cord, 151 Urethra, female, 105 Urino-genital organs, 98 Uterus bicornis, 105 — double, 106 — fibro-myoma, 101, 107 — polypi, 107 — septus, 106 Vagina, 105 | — double, 106 | — wounds of, 148 ' Valves, auriculo-ventricular, 70 I — sigmoid, 71 Vas deferens, 102 Vegetations, endocardial, 70 Velum interpositum, 137 13 ion, 186 INDEX. Vena cava, 66 Ventricles, brain, 137 Vermiform appendix, 96 Vernix caseosa, 151 Vertebra?, 125 — lion forceps for, 28 Vertebral arteries, 132 — chisel, 139 — forceps, Savage's, 28 Vesiculse seminales, 100 Vessels, opening of, 21 Virchow's knife, 14 — method, 136 Viscera, inspection of, 57 — removal of abdominal, 92 Water-supply, 40 Water-test for valves, 71 Weapons, examination of, 43 Wedge-shaped block, 39 Weighing table, 39 Weights of organs, 171 Winslow, foramen of, 113 Wood blocks, 39 Wooden mallet, 28 Wounds, 46 PRINTED BY ADLARD AND SON, BARTHOLOMEW CLOSE, B.C., AND 20 HANOVER SQUAKK, "W. No. 1. London, 7, Great Marlborough Street, July, 1899. A SELECTION FROM J. & A, CHURCHILL'S CATALOGUE, COMPRISING MOST OP THE RECENT WOEKS PUBLISHED BY THEM. If.B.—J. & A. Churchill's larger Catalogue, which contains over 600 works with a Complete Index to their Subjects, will be sent on application. Human Anatomy : a Treatise by various Authors. Edited by Henry Morris, M.A., M.B. 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By Alexander Haig, M.D., F.R.C.P. Physician to the Metropolitan Hospital and the Royal Hospital for Children and Women. Fourth Edition. 8vo, with 65 Illustrations, 12s. 6d. Bronchial Asthma : its Pathology and Treat- ment. By J. B. Berkart, M.D., late Physician to the City of London Hospital for Diseases of the Chest. Second Edition, with 7 Plates (35 Figures). 8vo, 10s. 6d. Treatment of Some of the Forms of Valvular Disease of the Heart. By A. E. Sansom, M.D., F.R.C.P., Physician to the London Hospital. Second Edition. Fcap. 8vo, with 26 Engrav- ings, 4s. 6d. Medical Ophthalmoscopy: a Manual and Atlas. By Sir William R. Gowers, M.D., F.R.C.P., F.R.S. Third Edition. Edited with the assistance of Marcus Gunn, M.B., F.R.C.S., Surgeon to the Royal London Ophthalmic Hospital. With Coloured Plates and Woodcuts. 8vo, 16s. By the same Author. A Manual of Diseases of the Nervous System. Vol. I.—Nerves and Spinal Cord. Third Edition, by the Author and James Taylor, M.D., F.R.C. P. Roy. 8vo, with 192 Engravings, 15s. Vol. II.—Brain and Cranial Nerves : General and Functional Diseases of the Nervous System. Second Edition. Roy. 8vo, with 182 Engravings, 20s. Also. Clinical Lectures on Diseases of the Nervous System. 8vo 7s. 6d. Also. Diagnosis of Diseases of the Brain. Second Edition. 8vo, with Engravings, 7s. 6d. Also. Syphilis and the Nervous System: being a Revised Reprint of the Lettsomian Lectures for 1890. Delivered before the Medical Society of London. 8vo, 4s. The Nervous System, Diseases of. By J. A. Ormerod, M.D., F.R.C.P., Physician to the National Hospital for the Paralysed and Epileptic. With 66 Illustrations. Fcap. 8vo, 8s. 6d. 7, GREAT MARLBOROUGH STREET. 13 J. 8f A. Churchill's Recent Works. Text-Book of Nervous Diseases for Students and Practitioners of Medicine. By Charles L. Dana, M.D., Pro- fessor of Nervous and Mental Diseases in Bellevue Hospital Medical College, New York. Fourth Edition. With 246 Illustrations. 8vo,20s. Diseases of the Nervous System. Lectures delivered at Guy's Hospital. By Sir Samuel Wiles, Bart., M.D., F.R.S. Second Edition. 8vo, 18s. Handbook of the Diseases of the Nervous System. By James Ross, M.D., F.R.C.P., late Professor of Medicine in the Victoria University, and Physician to the Royal Infirmary, Manchester. Roy. 8vo, with 184 Engravings, 18s. By the same Author. Aphasia : being a Contribution to the Subject of the Dissolution of Speech from Cerebral Disease. 8vo, with En- gravings, 4s. 6d. Stammering : its Causes, Treatment, and Cure. By A. G. Bernard, M.R.C.S., L.R.C.P. Crown 8vo, 2s. Secondary Degenerations of the Spinal Cord (Gulstonian Lectures, 1889). By Howard H. Tooth, M.D., F.R.C.P., Assistant Physician to the National Hospital for the Paralysed and Epileptic. With Plates and Engravings. 8vo, 3s. 6d. Diseases of the Nervous System. Clinical Lectures. By Thomas Buzzard, M.D., F.R.C.P., Physician to the National Hospital for the Paralysed and Epileptic. With Engravings. 8vo, 15s. By the same Author. Some Forms of Paralysis from Peripheral Neuritis; of Gouty, Alcoholic, Diphtheritic, and other origin. Crown 8vo, 5s. A180. On the Simulation of Hysteria by Organic Disease of the Nervous System. Crown 8vo, 4s. 6d. Gout in its Clinical Aspects. By J. Mortimer Granville, M.D. Crown 8vo, 6s. Diseases of the Liver: with and without Jaundice. By George Harley, M.D., F.R.C.P., F.R.S. 8vo, with 2 Plates and 36 Engravings, 21s. Rheumatic Diseases (Differentiation in). By Hugh Lane, Surgeon to the Royal Mineral Water Hospital, Bath. Second Edition, much Enlarged, with 8 Plates. Crown 8vo, 3s. 6d. 7, GREAT MARLBOROUGH STREET. 14 J. 8f A. Churchill's Recent Works. Diseases of the Abdomen, comprising those of the Stomach and other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines, and Peritoneum. By S. O. Habershon, M.D., F.R.C.P. Fourth Edition. 8vo, with 5 Plates, 21s. On Gallstones, or Cholelithiasis. By E. M. Brockbank, M.D. Vict., M.R.C.P. Lond., late Resident Medical Officer at the Manchester Royal Infirmary and the Birmingham General Hospital. Crown 8vo, 7s. On the Relief of Excessive and Dangerous Tympanites by puncturing the Abdomen. By John W. Ogle, M.D., Consulting Physician to St. George's Hospital. 8vo, 5s. 6d. Headaches : their Nature, Causes, and Treat- ment. By W. H. Day, M.D., Physician to the Samaritan Hospital. Fourth Edition. Crown 8vo, with Engravings, 7s. 6d. A Handbook of Medical Climatology, embody- ing its Principles and Therapeutic Application, with Scientific Data of the chief Health Resorts of the World. By S. Edwin Solly, M.D., M.R.C.S., late President of the American Climatological Association. With Engravings and Coloured Plates. 8vo, 16s. The Mineral Waters of France, and its Wintering Stations (Medical Guide to). With a Special Map. By A. Vintras, M.D., Physician to the French Embassy, and to the French Hospital, London. Second Edition. Crown 8vo, 8s. Surgery: its Theory and Practice. By William J. Walsham, F.R.C.S., Senior Assistant Surgeon to, and Lecturer on Anatomy at, St. Bartholomew's Hospital. Sixth Edition. Crown 8vo, with 410 Engravings, 12s. 6d. A Synopsis of Surgery. By R. F. Tobin, Surgeon to St. Vincent's Hospital, Dublin. Crown 8vo, interleaved, leather binding, 6s. 6d. Surgical Emergencies : together with the Emergencies attendant on Parturition and the Treatment of Poison- ing. By Paul Swain, F.R.C.S., Surgeon to the South Devon and East Cornwall Hospital. Fifth Edition. Crown 8vo, with 149 Engravings, 6s. Illustrated Ambulance Lectures : (to which is added a Nursing Lecture) in accordance with the Regulations of the St. John's Ambulance Association for Male and Female Classes. By John M. H. Martin, M.D., F.R.C.S., Hon. Surgeon to the Blackburn Infirmary. Fourth Edition. Crown 8vo, with 60 Engravings, 2s. 7, GREAT MARLBOROUGH STREET. 16 J. fy A. Churchill's Recent Works. Operations on the Brain (a Guide to). By Alec Fraser, Professor of Anatomy, Royal College of Surgeons in Ireland. Illustrated by 42 life-size Plates in Autotype, and 2 Woodcuts in the text. Folio, 63s. Abdominal Surgery. By J. Greig Smith, M.A., F.R.S.E. Sixth Edition. Edited by James Swain, M.S., M.D. Lond., F.R.C.S. Eng., Assistant-Surgeon to the Bristol Royal Infirmary, Professor of Surgery, University College, Bristol. 2 vols., 8vo, with L'24 Engravings, 36s. The Physiology of Death from Traumatic Fever; a Study in Abdominal Surgery. By John D. Malcolm, M.B., CM., F.R.C.S.E., Surgeon to the Samaritan Free Hospital. Svo, 3s. 6d. The Surgery of the Alimentary Canal. By Alfred Ernest Maylard, M.B. Lond. and B.S., Surgeon to the Victoria Infirmary, Glasgow. With 27 Swantype Plates and 89 Figures in the Text, Svo, 25s. Surgery. By C. W. Mansell Moullin, M.A., M.D. Oxon., F.R.C.S., Surgeon and Lecturer on Physiology to the London Hospital. Large 8vo, with 497 Engravings, 34s. A Course of Operative Surgery. By Chris topher Heath, Surgeon to University College Hospital. Second Edition. With 20 Coloured Plates (180 figures) from Nature, by M. Leveille^ and several Woodcuts. Large 8vo, 30s. By the same Author. The Student's Guide to Surgical Diagnosis. Second Edition. Fcap. 8vo, 6s. 6d. Also. Manual of Minor Surgery and Bandaging. For the use of House-Surgeons, Dressers, and Junior Practitioners. Eleventh Edition. Fcap. 8vo, with 17*1 Engravings, 6s. Also. Injuries and Diseases of the Jaws. Fourth Edition. Edited by Henry Percy Dean, M.S., F.R.C.S., Assistant Surgeon to the London Hospital. 8vo, with 187 Wood Engravings, 14s. Also. Lectures on Certain Diseases of the Jaws. Delivered at the R.C.S., England, 1887. 8vo, with 64 Engravings, 2s. 6d. Als0 Clinical Lectures on Surgical Subjects. De- livered in University College Hospital. Second Edition, enlarged. Fcap. 8vo, with 27 Engravings, 6s. 7, GREAT MARLBOROUGH STREET. 16 J. 8f A. Churchill's Recent Works. The Practice of Surgery : a Manual. By Thomas Bryant, Consulting Surgeon to Guy's Hospital. Fourth Edition. 2 vols, crown 8vo, with 750 Engravings (many being * Coloured), and including 6 chromo plates, 32s. The Surgeon's Vade-Mecum : a Manual of Modern Surgery. By R. Druitt, F.R.C.S. Twelfth Edition. By Stanley Boyd, M.B., F.R.C.S., Assistant Surgeon and Pathologist to Charing Cross Hospital. Crown 8vo, with 373 Engravings, 16s. The Operations of Surgery : intended for use on the Dead and Living Subject alike. By W. H. A. Jacobson, M.A., M.B., M.Oh. Oxon., F.R.C.S., Assistant Surgeon to, and Lecturer on Anatomy at, Guy's Hospital. Third Edition. 8vo, with 401 Illustrations, 34s. Ovariotomy and Abdominal Surgery. By Harrison Cripps, F.R.C.S., Surgical Staff, St. Bartholomew's Hospital. With numerous Plates, royal 8vo, 25s. Diseases of Bones and Joints. By Charles Macnamara, F.R.C.S., Surgeon to, and Lecturer on Surgery at, the Westminster Hospital. 8vo, with Plates and Engravings, 12s. On Anchylosis. By Bernard E. Brodhurst, F.R.C.S., Surgeon to the Royal Orthopaedic Hospital. Fourth Edition. 8vo, with Engravings, 5s. By the same Author. Curvatures and Disease of the Spine. Fourth Edition. 8vo, with Engravings, 7s. 6d. Also. Talipes Equino-Varus or Club-Foot. 8vo, with Engravings, 3s. 6d. Also. Observations on Congenital Dislocation of the Hip. Third Edition. 8vo, 2s. 6d. Surgical Pathology and Morbid Anatomy. By Anthony A. Bowlby, F.R.C.S., Assistant Surgeon to St. Bartholomew's Hospital. Third Edition. Crown 8vo, with 183 Engravings, 10s. 6d. By the same Author. Injuries and Diseases of Nerves, and their Surgical Treatment. 8vo, with 20 Plates, 14s. 7, GREAT MARLBOROUGH STREET. 17 J. 8f A. Churchill's Recent Works. The Human Foot: its Form and Structure, Functions and Clothing. By Thomas S. Ellis, Consulting Surgeon to the Gloucester Infirmary. With 7 Plates and Engravings (5J Figures). 8vo, 7s. 6d. The Deformities of the Fingers and Toes. By William Anderson, F.R.C.S., Surgeon to St. Thomas's Hospital. Svo, with 18 engravings, 6s. Short Manual of Orthopaedy. By Heather Bigg, F.R.C.S. Ed., Part I. Deformities and Deficiencies of the Head and Neck. 8vo, 2s. 6d. Face and Foot Deformities. By Frederick Churchill, CM. 8vo, with Plates and Illustrations, 10s. 6d. Royal London Ophthalmic Hospital Reports. By the Medical and Surgical Staff. Vol. XIV., Part 2. 8vo, 5s. Ophthalmological Society of the United King- dom. Transactions. Vol. XVIII. 8vo, 12s. 6d. Manual of Ophthalmic Surgery and Medicine. By W. H. H. Jessop, M.A., F.R.C.S., Ophthalmic Surgeon to St. Bar- tholomew's Hospital. With 5 Coloured Plates and 110 Woodcuts. Crown 8vo, 9s. 6d. Nettleship's Diseases of the Eye. Sixth Edition. Revised and Edited by W. T. Holmes Spicer, M.B., F.R.C.S., Oph- thalmic Surgeon to the Metropolitan Hospital and the Victoria Hospital for Children. With 161 Engravings and a Coloured Plate illustrating Colour-Blindness. Crown 8vo, 8s. 6d. Diseases and Refraction of the Eye. By N. C. Macnamara, F.R.C.S., Surgeon to Westminster Hospital, and Gustavus Hartridge, F.R.C.S., Surgeon to the Royal Westminster Ophthalmic Hospital. Fifth Edition. Crown 8vo, with Plate, 156 Engravings, also Test-types, 10s. 6d. On Diseases and Injuries of the Eye: a Course of Systematic and Clinical Lectures to Students and Medical Practitioners. By J. R. Wolfe, M.D., F.R.C.S.E. With 10 Coloured Plates and 157 Wood Engravings. 8vo, 21s. Convergent Strabismus, and its Treatment, an Essay. By Edwin Holthouse, M.A., F.R.C.S., Surgeon to the Western Ophthalmic Hospital. 8vo, 6s. 7, GREAT MARLBOROUGH STREET 18 J. 8f A. Churchill's Recent Works. Normal and Pathological Histology of the Human Eye and Eyelids. By C. Fred. Pollock, M.D., F.R.C.S., and F.R.S.E., Surgeon for Diseases of the Eye to Anderson's College Dispensary, Glasgow. Crown 8vo, with 100 Plates (230 drawings), 15s. Atlas ot Ophthalmoscopy. Composed of 12 Chromo-lithographic Plates (59 Figures drawn from nature), and Explanatory Text. By Richard Liebreich, M.R.C.S Translated by H. Rosborough Swanzy, M.B. Third Edition, 4to, 40s. Refraction of the Eye: a Manual for Students. By Gustavus Hartridge, F.R.C.S., Surgeon to the Royal West- minster Ophthalmic Hospital. Ninth Edition. Crown 8vo, with 104 Illustrations, also Test-types, etc., 6s. By the same Author. The Ophthalmoscope : a Manual for Students. Third Edition. Crown 8vo, with 68 Illustrations and 4 Plates, 4s. 6d. Glaucoma : its Pathology and Treatment. By Priestley Smith, Ophthalmic Surgeon to the Queen's Hospital, Birmingham. 8vo, with 64 Engravings and 12 Zinco-photographs 7s. 6d. Hints on Ophthalmic Out-Patient Practice. By Charles Higgens, Ophthalmic Surgeon to Guy's Hospital. Third Edition. Fcap. 8vo, 3s. Methods of Operating for Cataract and Secondary Impairments of Vision, with the results of 500 cases. By Major G. H. Fink, H.M. Indian Medical Service. Crown 8vo, with 15 Engravings, 5s. Diseases of the Eye : a Practical Handbook for General Practitioners and Students. By Cecil Edward Shaw, M.D., M.Ch., Ophthalmic Surgeon to the Ulster Hospital for Children and Women, Belfast. With a Test-Card for Colour-Blindness. Crown 8vo, 3s. 6d. Eyestrain (commonly called Asthenopia). By Ernest Clarke, M.D., B.S. Lond., Surgeon to the Central London Ophthalmic Hospital, Surgeon and Ophthalmic Surgeon to the Miller' Hospital. Second Edition. 8vo, with 22 Illustrations, 5s. 7, GREAT MARLBOROUGH STREET. ' 19 J. 8f A. Churchill's Recent Works. Diseases and Injuries of the Ear. By Sir William B. Dalby, F.R.C.S., M.B., Consulting Aural Surgeon to St. George's Hospital. Fourth Edition. Crown 8vo, with 8 Coloured Plates and 38 Wood Engravings. 10s. 6d. By the same Author. Short Contributions to Aural Surgery, between 1875 and 1896. Third Edition. 8vo, with Engravings, 5s. Diseases of the Ear, including the Anatomy and Physiology of the Organ, together with the Treatment of the Affections of the Nose and Pharynx, which conduce to Aural Disease (a Treatise). By T. Mark Hovell, F.R.C.S.E., M.K.C.S.; Aural Surgeon to the London Hospital, and Lecturer on Diseases of the Throat in the College, etc. 8vo, with 122 Engravings, 18s. A System of Dental Surgery. By Sir John Tomes, F.R.S., and 0. S. Tomes, M.A., F.R.S. Fourth Edition. Post Svo,with 289 Engravings, 16s. Dental Anatomy, Human and Comparative: A Manual. By Charles S. Tomes, M.A., F.R.S. Fifth Edition. Post 8vo, with 263 Engravings, 14s. Dental Materia Medica, Pharmacology and Therapeutics. By Charles W. Glassington, M.R.C.S., L.D.S. Edin.; Senior Dental Surgeon, Westminster Hospital; Dental Sur- geon, National Dental Hospital, and Lecturer on Dental Materia Medica and Therapeutics to the College. Crown 8vo, 6s. Dental Medicine: a Manual of Dental Materia Medica and Therapeutics. By Ferdinand J. S. Gobgas, M.D., D.D.S., Professor of the Principles of Dental Science in the University of Maryland. Sixth Edition. 8vo, 18s. A Manual of Dental Metallurgy. By Ernest A. Smith, P.I.C., Assistant Instructor in Metallurgy, Royal College of Science, London. With 37 Illustrations, crown 8vo, 6s. 6d. A Manual of Nitrous Oxide Anaesthesia. By J. Frederick W. Silk, M.D. Lond., M.R.C.S., Assistant Anaesthetist to Guy's Hospital, Anaesthetist to the Dental School of Guy's Hospital, and to the Royal Free Hospital. 8vo, with 26 En- gravings, 5s. Practical Treatise on Mechanical Dentistry. By Joseph Richardson, M.D., D.D.S. Seventh Edition, revised and edited by George W. Warren, D.D.S. Royal 8vo, with 690 Engrav- ings, 22s. 7, GREAT MARLBOROUGH STREET. 30 J. Sf A. Churchill's Recent Works. A Handbook on Leprosy. By S. P. Impey, M.D., late Chief and Medical Superintendent, Robben Island Leper and Lunatic Asylums, Cape Colony. With 38 Plates, 8vo, 12s. Diseases of the Skin (Introduction to the Study of). By P. H. Pye-Smith, M.D., F.R.S., F.R.C.P., Physician to Guy's Hospital. Crown 8vo, with 26 Engravings, 7s. 6d. A Manual of Diseases of the Skin, with an Analysis of 20,000 Consecutive Cases and a Formulary. By Duncan E. Bulkley, M.D., New York. Fourth Edition, rojal 16mo, 6s. 6d. Diseases of the Skin : a Practical Treatise for Students and Practitioners. By J. N. Hyde, M.D., Professor of Skin and Venereal Diseases, Rush Medical College, Chicago. Second Edition. 8vo, with 2 Coloured Plates and 96 Engravings, 20s. Skin Diseases of Children. By Geo. H. Fox, M.D., Clinical Professor of Diseases of the Skin, College of Physicians and Surgeons, New York. With 12 Photogravure and Chromographic Plates and 60 Illustrations in the Text. Royal 8vo, 12s. 6d. Sarcoma and Carcinoma : their Pathology, Diagnosis, and Treatment. By Henry T. Butlin, F.R.C.S., Assistant Surgeon to St. Bartholomew's Hospital. 8vo, with 4 Plates, 8s. By the same Author. Malignant Disease of the Larynx (Sarcoma and Carcinoma). 8vo, with 5 Engravings, 5s. Also. Operative Surgery of Malignant Disease. 8vo,14s. Cancers and the Cancer Process: a Treatise, Practical and Theoretic. By Herbert L. Snow, M.D., Surgeon to the Cancer Hospital, Brompton. 8vo, with 15 Plates. 15s. By the same Author. The Re-appearance (Recurrence) of Cancer after apparent Extirpation. 8vo, 5s. 6d. Also. The Palliative Treatment of Incurable Cancer. Crown 8vo, 2s. 6d. Diagnosis and Treatment of Syphilis. By Tom Robinson, M.D. St. And., Physician to the Western Skin Hos- pital. Crown 8vo, 3s. 6d. By the same Author. Eczema: its Etiology, Pathqlogy, and Treat- ment. Crown 8vo, 3s. 6d. Also. Illustrations of Diseases of the Skin and Syphilis, with Remarks. Fasc. I. with 3 Plates. Imp. 4to, 5s. 7, GREAT MARLBOROUGH STREET. 21 J. 8f A. Churchill's Recent Works. Cancerous Affections of the Skin (Epithelioma and Rodent Ulcer). By George Thin, M.D. Post 8vo, with 8 Engrav- ings, 5s. By tf)e same Author: Pathology and Treatment of Ringworm. 8vo, with 21 Engravings, 5s. On Cancer : its Allies, and other Tumours: their Medical and Surgical Treatment. By F. A. Purcell, M.D., M.C, Surgeon to the Cancer Hospital, Brompton. 8vo, with 21 Engravings, 10s. 6d. Urinary and Renal Derangements and Calcu- lous Disorders. By Lionel S. Beale, F.R.C.P., F.R.S., Physician to King's College Hospital. 8vo, 5s. Chemistry of Urine : a Practical Guide to the Analytical Examination of Diabetic, Albuminous, and Gouty Urine. By Alfred H. Allen, F.I.C, F.C.S., Public Analyst for the West Riding of Yorkshire, &c. 8vo, with Engravings, 7s. 6d. Clinical Chemistry of Urine (Outlines of the). By C. A. MacMunn, M.A., M.D. 8vo, with 64 Engravings and Plate of Spectra, 9s. Diseases of the Male Organs of Generation. By W. H. A. Jacobson, M.Ch.Oxon., F.R.C.S., Assistant-Surgeon to Guy's Hospital. 8vo, with 88 Engravings, 22s. Atlas of Electric Cystoscopy. By Dr. Emil Burckhardt, late of the Surgical Clinique of the University of Bale, and E. Hurry Fenwick, F.R.C.S., Surgeon to the London Hospital and St. Peter's Hospital for Stone. Royal 8vo, with 34 Coloured Plates, embracing 83 Figures. 21s. Electric Illumination of the Bladder and Urethra, as a Means of Diagnosis of Obscure Vesico-Urethral Diseases By E. Hurry Fenwick, F.R.C.S., Surgeon to London Hospital and St. Peter's Hospital for Stone. Second Edition. 8vo, with 54 En- gravings, 6s 6d. By the Same Author. Tumours of the Urinary Bladder. The Jack- sonian Prize Essay of 18»7, rewritten with 200 additional cases. In four Fasciculi. Fas. I. Royal 8vo, 5s. Also. The Cardinal Symptoms of Urinary Disease : their Diagnostic Significance and Treatment. 8vo, with 36 Illustra- tions, 8s. 6d. 7, GREAT MARLBOROUGH STREET. 22 J. 8f A. Churchill's Recent Works. By SIR HENRY THOMPSON, BART., F.R.C.S. Diseases of the Urinary Organs. Clinical Lectures. Eighth Edition. 8vo, with 121 Engravings, 10s. 6d. Some Important Points connected with the Surgery of the Urinary Organs. Lectures delivered in the R.C.S. 8vo, with 44 Engravings. Student's Edition, 2s. 6d. Practical Lithotomy and Lithotrity; or, an Inquiry into the Best Modes of Removing Stone from the Bladder. Third Edition. 8vo, with 87 Engravings, 10s. The Preventive Treatment of Calculous Dis- ease, and the use of solvent Remedies. Third Edition. Cr. 8vo, 2s.6d. Tumours of the Bladder: their Nature, Sym- ptoms, and Surgical Treatment. 8vo, with numerous Illustrations, 5s. Stricture of the Urethra, and Urinary Fistulae : their Pathology and Treatment. Fourth Edition. 8vo, with 74 En- gravings, 6s. The Suprapubic Operation of Opening the Bladder for Stone and for Tumours. 8vo, with Engravings, 3s. 6d. Introduction to the Catalogue; being Notes of 1,000 Cases of Calculi of the Bladder removed by the Author, and now in the Museum of R.C.S. 8vo, 2s.6d. The Surgical Diseases of the Genito-Urinary Organs, including Syphilis. By E. L. Keyes, M.D., Professor of Genito-Urinary Surgery, Syphiology, and Dermatology in Bellevue Hospital Medical College, New York (a revision of Van Buren and Keyes' Text-book). Roy. 8vo, with 114 Engravings, 21s. Selected Papers on Stone, Prostate, and other Urinary Disorders. By Reginald Harrison, F.R.C.S., Surgeon to St. Peter's Hospital. Svo, with 15 Illustrations, 6s. Syphilis. By Alfred Cooper, F.R.C.S., Con- suiting Surgeon to the West London and the Lock Hospitals. Second Edition. Edited by Edward Cotterell, F.R.C.S., Surgeon (out- patients) to the London Lock Hospital. Svo, with 24 Full-page Plates (12 coloured), 18s. 7, GREAT MARLBOROUGH STREET, J. 8f A. Churchill's Recent Works. On Maternal Syphilis, including the presence and recognition of Syphilitic Pelvic Disease in Women. By John A. Shaw-Mackenzie, M.D. With Coloured Plates. 8vo, 10s. 6d. Diseases of the Rectum and Anus. By Alfred Cooper, F.R.C.S., Senior Surgeon to St. Mark's Hospital for Fistula; and F. Swinford Edwards, F.R.C.S., Senior Assistant Surgeon to St. Mark's Hospital. Second Edition, with Illustrations. 8vo, 12s. Diseases of the Rectum and Anus. By Harrison Cripps, F.R.C.S., Assistant Surgeon to St. Bartholomew's Hospital, etc. Second Edition. 8vo, with 13 Lithographic Plates and numerous Wood Engravings, 12s. 6d. By the same Author. Cancer of the Rectum. Especially considered with regard to its Surgical Treatment. Jacksonian Prize Essay. Third Edition. 8vo, with 13 Plates and several Wood Engravings, 6s. Also The Passage of Air and Faeces from the Urethra. 8vo, 3s. 6d. A Medical Vocabulary : an Explanation of all Terms and Phrases used in the various Departments of Medical Science and Practice, their Derivation, Meaning, Application, and Pronuncia- tion. By R. G. Mayne, M.D., LL.D. Sixth Edition, by W. W. Wagstaffe, B.A., F.R.C.S. Crown 8vo, 10s. 6d. A Short Dictionary of Medical Terms. Being an Abridgment of Mayne's Vocabulary. 64mo, 2s. 6d. Dunglison's Dictionary of Medical Science. Containing a full Explanation of its various Subjects and Terms, with their Pronunciation, Accentuation, and Derivation. Twenty- first Edition. By Richard J. Dunglison, A.M., M.D. Royal 8vo, 30s. Terminologia Medica Polyglotta : a Concise International Dictionary of Medical Terms (French, Latin, English, « S^S'J4*1^' £?ani8h' and Russian). By Theodore Maxwell, M.D., B.Sc, F.R.C.S. Edin. Royal 8vo, 16s. A German-English Dictionary of Medical Terms. By Frederick Treves, F.R.C.S., Surgeon to the London Hospital; and Hugo Lakg, B.A. Crown 8vo, half -Persian calf, 12s. 7, GREAT MARLBOROUGH STREET. J. Sf A. Churchill's Recent Works. A Manual of Chemistry, Theoretical and Prac- tical. By William A. Tilden, D.Sc, F.R.S., Professor of Chemistry in the Royal College of Science, London ; Examiner in Chemistry to the Department of Science and Art. With 2 Plates and 143 Woodcuts, crown 8vo, 10s. Chemistry, Inorganic and Organic. With Ex- periments. By Charles L. Bloxam. Eighth Edition, by John Millar Thomson, F.R.S., Professor of Chemistry in King's College, London, and Arthur G. Bloxam, Head of the Chemistry Depart- ment, the Goldsmiths' Institute, New Cross. 8vo, with 281 Engrav- ings, 18s. 6d. By the same Author. Laboratory Teaching; or, Progressive Exer- cises in Practical Chemistry. Sixth Edition, by Arthur G. Bloxam. Crown 8vo, with 80 Engravings, 6s. 6d. Watts' Organic Chemistry. Edited by William A. 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Arloing, Director of the Lyons Veterinary School, and Edited by George Fleming, C.B., LL.D., F.R.C.V.S., iate Principal Veteri- nary Surgeon of the British Army. Second English Edition. 8vo, with 585 Engravings, 31s. 6d. Human Nature, its Principles and the Principles of Physiognomy. By Physicist. Part I., Imp. l6mo, 2s. The Brain-Machine, its Power and Weakness. By Albert Wilson, M.D. Edin. With 37 Illustrations, 8vo, 4s. 6d. 7, GREAT MARLBOROUGH STREET. 28 Index to J. & A. Churchill's Catalogue. Allen's Chemistry of Urine, 22 ---— Commercial Organic Analy- sis, 26 Anderson on Fingers and Toes, 18 Armatage's Veterinary Pocket Re- membrancer, 28 Barnes' (R.) Obstetric Operations, 6 -------Diseases of Women, 6 Beale (L. S.) on Liver, 12 ------- Microscope in Medicine, 12 ---■—— Slight Ailments, 12 -------Urinary and Renal Derange- ments, 22 Beale (P. T. B.) on Elementary Biology, 3 Beasley's Book of Prescriptions, 8 ------- Druggists' General Receipt Book, 8 ------- Pharmaceutical Formu- lary, 8 Bell on Sterility, 6 Bellamy's Surgical Anatomy, 2 Bentley and Trimen's Medicinal Plants, 9 Bentley's Systematic Botany, 9 Berkart's Bronchial Asthma, 13 Bernard on Stammering, 14 Bigg's Short Manual of Orthopaedy, 18 Birch's Practical Physiology, 3 Bloxam's Chemistry, 25 ------- Laboratory Teaching, 25 Bousfleld's Photo-Micrography, 2S Bowlby's Injuries and Diseases of Nerves, 17 -------— Surgical Pathology and Morbid Anatomy, 17 Brockbank on Gallstones, 15 Brodhurst's Anchylosis, 17 ----------Curvatures of Spine, 17 ----------Dislocation of Hip, 17 ----------TalipesEquino-Varus,17 Brown's Midwifery, 6 Brown's Practical Chemistry, 26 Bryant's Practice of Surgery, 17 Buikley on Skin, 21 Burckhardt and Fenwick's Atlas of Electric Cystoscopy, 22 Burdett's Hospitals and Asylums of the World, 4 Butler-Smythe's Ovariotomies, 6 Butlin's Malignant Disease of the Larynx, 21 -------Operative Surgery of Malig- nant Disease, 21 Butlin's Sarcoma and Carcinoma, 21 Buzzard's Diseases of the Nervous System, 14 --------Peripheral Neuritis, 14 --------Simulation of Hysteria, 14 Cameron's Oils, Resins, and Var- nishes, 27 -------- Soaps and Candles, 27 Carpenter and Dallinger on the Mi- croscope, 28 Carpenter's Human Physiology, 3 Cautley on Feeding Infants, 7 Charteris' Practice of Medicine, 11 Chauveau's Comparative Anatomy, 28 Chevers' Diseases of India, 10 Churchill's Pace and Foot Deformi- ties, 18 Clarke's Eyestrain, 19 Clouston's Lectures on Mental Diseases, 4 Clowes and Coleman's Quantitative Analysis, 25 Clowes and Coleman's Elementary Practical Chemistry, 25 Clowes' Practical Chemistry, 25 Coles on Blood, 12 Cooley's Cyclopaedia of Practical Receipts, 27 Cooper's Syphilis, 23 Cooper and Edwards' Diseases of the Rectum, 24 Cripps' (H.) Ovariotomy and Ab- dominal Surgery, 17 -------- Diseases of the Rectum and Anus, 24 --------Cancer of Rectum, 24 --------Air and Faeces in Urethra, 24 Cripps' (R. A.) Galenic Pharmacy, 8 Cuff's Lectures to Nurses, 7 Cullingworth's Manual of Nursing.7 ------------Monthly Nurses, 7 Dalby's Diseases and Injuries of the Ear, 20 -------Short Contributions, 20 Dana on Nervous Diseases, 14 Day ou Diseases of Children, 7 ---on Headaches, 15 Domville's Manual for Nurses, 7 Doran's Gynaecological Operations, 6 Druitt's Surgeon's Vade-Mecum, 17 Duncan (A.) on Prevention of Dis- eases in Tropics, 10 [Continued on next page. 7, GREAT MARLBOROUGH STREET. Index to J. ft A. Ohurchill's Catalogue—continued. Ellis's (T. S.) Human Foot, 18 Fagge's Principles and Practice of Medicine, 10 Fayrer's Climate and Fevers of India, 10 -------Natural History, etc., of Cholera, 10 Fenwick (E. H.), Electric Illumina- tion of Bladder, 22 ------- Symptoms of Urinary Dis- ease, 22 ------ Tumours of Bladder, 22 Fenwick'B (S.) Medical Diagnosis, 12 --------Obscure Diseases of the Abdomen, 12 --------Out lines of Medical Treat- ment, 12 --------The Saliva as a Test, 12 Pink's Operating for Cataract, 19 Fowler's Dictionary of Practical Medicine, 11 Fox (G. H.) on Skin Dieeases of Children, 21 Fox (Wilson), Atlas of Pathological Anatomy of the Lungs, 11 ---Treatise on Diseases of the Lungs, 11 Frankland and Japp's Inorganic Chemistry, 26 Fraser's Operations on the Brain, 16 Fresenius' Qualitative Analysis, 25 --------Quantitative Analysis, 25 Galabin's Diseases of Women, 6 ------ Manual of Midwifery, 5 Gardner's Bleaching, Dyeing, and Calico Printing, 27 --------Brewing, Distilling, and Wine Manufacture, 27 Gimlette's Myxoedema, 12 Glassington's Dental Materia Medi- ca, 20 Godlee's Atlas of Human Anatomy, 1 Goodhart's Diseases of Children, 7 Gorgas' Dental Medicine, 20 Gowers' Diagnosis of Brain Disease, 13 -------Diseases of Nervous Sys- tem, 13 -------Medical Ophthalmoscopy, 13 ------Syphilis and the Nervous System, 13 Granville on Gout, 14 Green's Manual of Botany, 9 Greenish's Materia Medica, 8 Groves and Thorp's Chemical Tech- nology, 27 7, GREAT Guy's Hospital Reports, 11 Habershon's Diseases of the Abdo- men, 15 Haig's Uric Acid, 13 ----- Diet and Food, 4 Harley on Diseases of the Liver, 14 Harris's (V. D.) Diseases of Chest, 11 Harrison's Urinary Organs, 23 Hartridge's Refraction of the Eye, 19 ----------Ophthalmoscope, 19 Hawthorne's Galenical Prepara- tions, 8 Heath's Certain Diseases of the Jaws, 16 ------- Clinical Lectures on Sur- gical Subjects, 16 ------- Injuries and Diseases of the Jaws, 16 ------- Minor Surgery and Ban- daging, 16 ------- Operative Surgery, 16 ------- Practical Anatomy, 1 ------- Surgical Diagnosis, 16 Hellier's Notes on ..Gynaecological Nursing, 7 Hewlett's Bacteriology, 4 Higgens' Ophthalmic Out-patient Practice, 19 Hill on Cerebral Circulation, 2 Hirschfeld's Atlas of Central Ner- vous System, 2 Holden's Human Osteology, 1 ------- Landmarks, 1 Holthouse on Strabismus, 18 Hooper's Physicians' Vade Mecum, 10 Hovell's Diseases of the Ear, 20 Human Nature and Physiognomy, 28 Hyde's Diseases of the Skin, 21 Hyslop's Mental Physiology, 5 Impey on Leprosy, 21 Ireland's Mental Affections of Children, 5 Jacobson's Male Organs, 22 -------- Operations of Surgery, 17 Jellett's Midwifery, 5 Jessop's Ophthalmic Surgery and Medicine, 18 Johnson's (Sir G.) Asphyxia, 12 --------Medical Lectures and Es- says, 12 --------Cholera Controversy, 12 -------- (A. E.) Analyst's Com- panion, 26 [Continued on next page. STREET. Indrx to J. & A. Ohurchill's Catalogue—continued. Journal of Mental Science, 5 Kellogg on Mental Diseases, 5 Keyes' Genito-Urinary Organs and Syphilis, 23 Kohlrausch's Physical Measure- ments, 28 Lane's Rheumatic Diseases, 14 Langdon-Down's Mental Affections of Childhood, 5 Lazarus-Barlow's General Patho- logy, 2 Lee's Microtomists' Vade-Mecum, 28 Lescher's Recent Materia Medica, 9 Lewis (Bevan) on the Human Brain, 2 Liebreich's Atlas of Ophthalmo- scopy, 19 Lucas's Practical Pharmacy, 8 MacMunn's Clinical Chemistry of Urine, 22 Macnamara's Diseases and Refrac- tion of the Eye, 18 ---------- Diseases of Bones and Joints, 17 McNeill's Isolation Hospitals, 4 Malcolm's Physiology of Death, 16 Marcet on Respiration, 2 Martin's Ambulance Lectures, 15 Maxwell's Terminologia Medica Polyglotta, 24 Maylard's Surgery of Alimentary Canal, 16 Mayne's Medical Vocabulary, 24 Microscopical Journal, 27 Mills and Rowan's Fuel and its Applications, 27 Moore's (N.) Pathological Anatomy of Diseases, 2 Moore's(SirW. J.)Diseases of India.10 -------Family Medicine, etc., for India, 10 Morris's Human Anatomy, 1 -------Anatomy of Joints, 2 Moullin's (Mansell) Surgery, 16 Nettleship's Diseases of the Eye, 18 Notter and Firth's Hygiene, 3 Ogle on Tympanites, 15 Oliver's Abdominal Tumours, 6 -------Diseases of Women, 6 Ophthalmic (Royal London)Hospital Reports, 18 Ophthalmological Society's Trans- actions, 18 Ormerod's Diseases of the Nervous System, 13 Owen's (J.) Diseases of Women, 6 Parkes' (E.A.) Practical Hygiene, 3 Parkes' (L. C) Elements of Health, 4 Pavy's Carbohydrates, 12 Pereira's Selecta 6 Prescriptis, 9 Phillips' Materia Medica and Thera- peutics, 8 Pitt-Lewis's Insane and the Law, 4 Pollock's Histology of the Eye and Eyelids, 19 Proctor's Practical Pharmacy, 8 Purcell on Cancer, 22 Pye-Smith's Diseases of the Skin, 21 Ramsay's Elementary Systematic Chemistry, 26 --------Inorganic Chemistry, 26 Richardson's Mechanical Dentistry, 20 Richmond on Antiseptics, 7 Roberts' (D. Lloyd), Practice of Mid- wifery, 5 Robinson's (Tom) Eczema, 21 --------Illustrations of Skin Dis- eases, 21 --------Syphilis, 21 Ross's Aphasia, 14 -----Diseases of the Nervous Sys- tem, 14 St. Thomas's Hospital Reports, 11 Sansom's Valvular Disease of tne Heart, 13 Shaw's Diseases of the Eye, 19 Shaw-Mackenzie on Maternal Sy- philis, 21 Short Dictionary of Medical Terms, 24 Silk's Manual of Nitrous Oxide, 20 Smith's (Ernest), Dental Metallurgy, 20 -------(Eustace) Clinical Studies, 7 ■------Disease in Children, 7 -------Wasting Diseases of Infants and Children, 7 Smith's (J. Greig) Abdominal Sur- gery, 16 Smith's (Priestley) Glaucoma, 19 Snow's Cancers and the Cancer Process, 21 -----Palliative Treatment of Can- cer, 21 ----- Reappearance of Cancer, 21 Solly's Medical Climatology, 15 Southall's Organic Materia Medica, 9 Squire's (P.) Companion to the Pharmacopoeia, 8 [Continued on next page. 7, GREAT MARLBOROUGH STREET. Index to J. 4 A. Churchill's Catalogue—continued. Squire's (P.) London Hospitals Pharmacopoeias, 8 -------Methods and Formula; 27 Starling's Elements of Human Phy- siology, 3 Sternberg's Bacteriology, 11 Stevenson and Murphy's Hygiene, 4 Sutton's (F.) Volumetric Analysis, 26 Sutton's (J. B.) General Pathology, 2 Swain's Surgical Emergencies, 15 Swayne's Obstetric Aphorisms, 6 Taylor's (A. S.) Medical Jurispru- dence, 3 Taylor's (F.) Practice of Medicine, 10 Thin's Cancerous Affections of the Skin, 22 ----- Pathology and Treatment of Ringworm, 22 -----Psilosis or " Sprue," 10 Thomas's Diseases of Women, 6 Thompson's (Sir H.) Calculous Dis- eases, 23 ----------Diseases of the Urinary Organs, 23 ----------Introduction to Cata- logue, 23 ----------Lithotomy and Litho- trity, 23 ----------Stricture of the Ure- thra, 23 ----------Suprapubic Operation, 23 ----------Surgery of the Urinary Organs, 23 ----------Tumoursof theBladder, 23 Thome's Diseases of the Heart, 11 Thresh on Water Analysis, 4 Tilden's Chemistry, 25 Tobin's Synopsis of Surgery, 15 Tomes' (C S.) Dental Anatomy, 20 -----(J. & C. S.)Dental Surgery,20 Tooth's Spinal Cord, 14 Treves and Lang's German-English Dictionary, 24 Tuke's Dictionary of Psychological Medicine, 5 Tuson's Veterinary Pharmacopoeia, 28 Valentin and Hodgkinsen's Practical Chemistry, 26 Vintras on the Mineral Waters, etc., of France, 15 Wagner's Chemical Technology, 27 Walsham's Surgery: its Theory and Practice, 15 Waring's Indian Bazaar Medicines, 9 ------- Practical Therapeutics, 9 Watts' Organic Chemistry, 25 West's (S.) How to Examine the Chest, 11 Westminster Hospital Reports, 11 White's (Hale) Materia Medica, Pharmacy, etc., 7 Wilks' Diseases of the Nervous Sys- tem, 13 Wilson's (Albert) Brain-Machine, 28 Wilson's (Sir E.) Anatomist's Vade- Mecum, 1 Wilson's (G.) Handbook of Hygiene, Wolfe's Diseases and Injuries of the Eye, 18 Wynter and Wethered's Practical Pathology, 2 Year Book of Pharmacy, 9 Yeo's (G. F.) Manual of Physiology. 3 N.B.-J. & A. Churchill's larger Catalogue of about 600 works on Anatomy, Physiology, Hygiene, Midwifery, Materia Medica, Medicine, Surgery Chemistry, Botany, elc. etc., with a complete Index to their Subjects, for easy reference, will be forwarded post free on application. Amebica— J. & A. Churchill being in constant communication with various publishing houses in America are able to conduct negotiations favourable to English Authors. LONDON: 7, GREAT MARLBOROUGH STREET. QZ K29p 1899 62141210R NLH D50flbb55 E NATIONAL LIBRARY OF MEDICINE