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Practical Pathology
A Manual of Autopsy and Laboratory
Technique
FOR
STUDENTS AND PHYSICIANS
BY
ALDRED SCOTT WARTHIN, Ph.D., M. D.
Professor of Pathology and Director of the Pathologic Laboratories
IN THE
UNIVERSITY OF MICHIGAN,
ANN ARBOR
SECOND EDITION
Rewritten and Enlarged
MORTUI VIVOS DOCENT
310 PAGES AND 55 FIGURES
ANN ARBOR
GEORGE WAHR, PUBLISHER
1911
Copyright 1897, by GEORGE WAHR
Copyright 1911, by GEORGE WAHR
ERRATA.
Page 155.—Thickness of gall-bladder wall 1-2 mm. instead of 1-2 cm.
Page 240.—Langhans’ for Langhan’s.
Page 264.—v. Kossa instead of Kossa.
Page 295.—v. Kölliker instead of Kölliker.
HERRN PROFESSOR ALEXANDER KOLISKO
Zur Erinnerung
an die ertragreichen, im Sektions-saale des
Wiener allgemeinen Krankenhauses
zugebrachten Sommertage
der Jahre
1893, 1894, 1895
gewidmet.
PREFACE TO THE SECOND EDITION.
The first edition of this book, in spite of numerous typographic
errors beyond the control of the writer, was very soon exhausted. An
apology is due the many, to whom, during the last ten years, a new
edition has been repeatedly promised. The writer’s only excuse for
the failure to fulfill these promises has been the pressure of other
work that has prevented such fulfillment. In the final accomplishment
of these promises the book has been practically rewritten and more
than doubled in size.
The autopsy method given in the main text is a composite one, made
up from the Rokitansky, Virchow, Chiari and Nauwerck methods,
according to the judgment of the writer as to what was the best in
these, and put together with modifications and additions arising
out of his own experience. The aim has been to offer a method by
which an autopsy can be performed with the greatest speed and ease,
and at the same time with the greatest completeness, the various
steps of the operation following in logical order in such a way that
nothing can be lost or destroyed, and thereby revealing a complete
picture of the pathologic conditions present. A choice of methods
is offered whenever the aims of the examination may be so varied as
to make variations in method advantageous. The general order of the
autopsy is the same as that given in the Protocol Blank-book, the
present book being designed as a guide and reference-book for that.
The points to be noted in the examination of each region are given
in connection with the method of examination of that region, and
represent the condensed special pathology of the latter. This should
be of great service to the beginner in autopsy work, as affording a
concise but complete guide to the most important conditions of each
region. A textbook on Special Pathology should be used as a reference
book in connection with these condensed statements of special
pathology.
The technical methods for microscopic examination given in Part
II have been brought up to date, and all recent methods of value
included. Original methods have been given in preference to
modifications; the latter, when of value, are also mentioned. As a
rule that method has been chosen which in the light of the writer’s
laboratory experience has yielded uniformly the best results. An
effort has been made to reduce the number of methods to the lowest
number as representing the best and most indispensable ones. During
the fourteen years of laboratory experience since the publication
of the first edition there has been plenty of time for changes
in points-of-view concerning laboratory methods. Then an ardent
exponent of celloidin-imbedding as a routine method, the writer has
now practically discarded it in favor of paraffin-imbedding and
the celloidin-sheet made by the dextrin-sugar or molasses method.
This combination method is so superior in every way to ordinary
celloidin-imbedding that the latter becomes obsolete except for a
limited number of conditions. A number of personal modifications of
various methods will also be found in this part of the book; indeed,
it is intended to be an expression of individual opinion concerning
laboratory methods.
The writer’s views concerning the value of teaching by
_unknowns_,—that is, giving the student preparations or case-material
for his own analysis and independent working-out to a diagnosis—are
stronger now than they were when the preface to the first edition
was written. Experiments with other methods of teaching have always
brought me back to this as yielding by far the best results. It
accomplishes two things—it not only teaches a knowledge of pathology,
but it develops objectivity and the faculties of diagnosis, and
accomplishes these with more marked success than any other method of
teaching pathology.
ALDRED SCOTT WARTHIN, Ph.D., M.D.
ANN ARBOR, MICHIGAN, May, 1911.
PREFACE TO THE FIRST EDITION.
Pathologic Histology deals with departures from the normal in the
various tissues of the body, which, occurring as the sequelæ of
disease-processes, or standing in the closest causal relationship to
the clinical symptoms and physical signs, constitute the foundation
of all diagnostic conclusions, and of all rational therapeutic
treatment. Without a definite knowledge of these abnormal changes, of
their various forms, of the manner in which they arise and progress,
no physician can deal intelligently with disease. The knowledge of
the _natural history_ of disease, based upon a knowledge of the
normal body, makes the wise and successful practitioner; and to such,
the autopsy, the microtome and the microscope must ever stand as
constant aids in the satisfying of his intellectual curiosity.
It is, therefore, essential that the student in his undergraduate
work should be so trained that, in addition to a broad conception of
General Pathology, he may acquire also such a technical knowledge
as to fit him to carry on his investigations after leaving the
laboratory. Not only in everyday practice in certain lines is a
knowledge of this technique necessary for diagnostic purposes, but
the true physician should so hold himself toward every problem of
diagnosis which presents itself to him, that with every opportunity,
he will, through excision, curettage or autopsy, make use of his
technical skill to further his knowledge of disease, and to aid his
science toward a solution of its great problems.
It is for these reasons, that in my laboratory courses in pathologic
histology, I wish to give each student a practical working knowledge
of the technique of pathologic investigations. That the student
become an expert as the result of such undergraduate courses is
neither possible nor desirable; it is only hoped that he may be
placed in a position to cope intelligently with the questions
awaiting him in the field of practice.
For the guidance of the student toward this end, I have compiled
this little book of laboratory methods, endeavoring to make it as
practical as possible, but yet thorough and complete. The methods
given are taken from the original papers, or from the compilations
of Friedländer and von Kahlden, but are modified in many instances
according to the writer’s own experience. The autopsy methods are,
in the main, those used by Kolisko of Vienna; but methods of Virchow,
Chiari, Nauwerck, and others, are also given.
It is from the study of the material itself, and not from the
textbook alone, that the student can obtain a proper knowledge of
pathologic changes. The most comprehensive textbook can give no
adequate idea of the infinite variety of these changes; there is no
absolute _type_, but an endless variety of appearances more or less
closely related. Only from a contemplation of this variety is it
possible for the student to build up a point-of-view, and to arrive
at an independent and unbiased conclusion.
The student who seeks in a preparation only the appearances described
in a textbook is not studying in a scientific way. He will constantly
accept the author, instead of using his own impressions for the
basis of deductions, guided by the experience of others. With an
unbiased mind the student should take each specimen for that alone,
which it, itself, presents; and upon this he should build his
conclusions. He should seek in the textbook the things he _finds_ in
the material; not _seek_ in the latter the things he _reads_ in the
former. Thus may he escape superficiality, avoid errors and hasty
judgments, and build up for himself a sure foundation of knowledge.
For these reasons the students in my laboratory course, having been
thoroughly prepared for such work by the study of normal tissues
in the histologic laboratory, are given the pathologic material as
_unknowns_, which under careful guidance, they are enabled to work
out for themselves to a satisfactory conclusion.
The student is further aided in the fixing of his impressions, and in
their expression, by means of the drawings and written descriptions
which he is required to make of the preparations. In this way the
faculties of observation and expression receive a training that is
not otherwise possible. It is true that such a course of instruction
is difficult for the student whose previous training has been
deficient in the cultivation of these most important faculties; for
this reason it is the more necessary that he should now apply himself
to work in the scientific method.
That this method of teaching takes much more of the instructor’s time
is true; that it takes too much time cannot be granted when measured
according to the results obtained. The frequent objection of the
student that he cannot draw only emphasizes the necessity of that
student’s receiving the necessary training to enable him to reproduce
his visual impressions.
A greater difficulty lies with the teacher. Not only must he select
his preparations with wisdom, so that in the necessarily limited
time of the course, the student may receive the greatest benefit; but
he must be tactful and patient in leading the student to work for
himself. It is easy to give a demonstration and then tell the student
to work; it is very much more difficult and nerve-consuming to make
the student _see_ and _demonstrate_ for himself. The relation of the
microscopic preparation to the gross anatomy must be shown, and,
when possible, demonstrated by macroscopic preparations; further,
the relation to the clinical symptoms and physical signs must be
made clear, so that the student receive not a narrow conception of
pathologic histology as something in itself separate and complete,
but as a foundation-stone to the broadest conception of diagnosis,
whereby the real unity of his studies will be revealed. Moreover, the
teacher must be fully awake to individual differences and needs, and
carefully shape his teaching influence upon each student accordingly.
The problem of the individual equation becomes especially difficult
in a course of this kind.
The laboratory course in histologic pathology, in the University
of Michigan, follows the general order given in the second part
of this book, beginning with the diseases of the blood and the
circulation, and finishing with the special pathology of the most
important organs. A preparatory training in general technique is
first given. About one hundred and seventy-five prepared specimens,
each illustrating some especial pathologic point, are given to the
class as unknowns for diagnosis. In addition each student is required
to prepare about fifty slides from fresh material, performing for
himself all of the necessary technical manipulations, according to
the methods given in this manual. To further the work in this course,
and to meet the needs of advanced students and of practitioners, this
book is primarily intended.
ALDRED S. WARTHIN, Ph.D., M.D.
ANN ARBOR, January, 1897.
CONTENTS
PART I.
THE SOURCES OF PATHOLOGIC MATERIAL AND THE
METHODS OF OBTAINING IT FOR EXAMINATION.
CHAPTER PAGE
_Introduction_ 1
I. The Autopsy: General Considerations 3
II. The Order of the Autopsy 24
III. The Protocol 33
IV. The External Examination 41
V. The Examination of the Spinal Cord 53
VI. The Examination of the Head 63
VII. The Main Incision: Thorax and Abdomen 96
VIII. The Examination of the Thorax 106
IX. The Examination of the Mouth and Neck 131
X. The Examination of the Abdomen 140
XI. The Examination of the Pelvic Organs 160
XII. Special Regional Examination 173
XIII. The Autopsy of the New-born 177
XIV. The Medicolegal Autopsy 187
XV. The Restoration of the Body 193
XVI. Other Sources of Pathologic Material 196
PART II.
THE TREATMENT OF THE MATERIAL.
_Introduction_ 199
XVII. The Laboratory Outfit 201
XVIII. The Examination of Fresh Material 208
XIX. The Preservation of Macroscopic Preparations 222
XX. The Fixation and Hardening of Tissues 225
XXI. Decalcification 232
XXII. Imbedding 234
XXIII. Section-cutting 238
XXIV. The Preparation of Mounted Sections 243
XXV. Staining and Staining Methods.—Nuclear and Protoplasmic
Stains 253
XXVI. Special Staining Methods for the Demonstration of
Pathologic Conditions in Cells or Tissues 262
XXVII. The Staining of Pathogenic Micro-organisms in Tissues 277
XXVIII. The Staining of Special Organs and Tissues 288
XXIX. Microscopic Examinations for Medicolegal Purposes 305
XXX. The Study of Mounted Preparations 309
LIST OF ILLUSTRATIONS
FIGURE PAGE
1. Large section, or cartilage knives 10
2. Scalpels 10
3. Long section knife 11
4. Myelotome 11
5. Autopsy scissors of various types 12
6. Enterotome 13
7. Costotome 13
8. Large autopsy saw 13
9. Small autopsy saw 14
10. Hey’s saw 14
11. Luer’s rhachiotome 14
12. T-chisel or skull-opener 14
13. Hatchet chisel 14
14. Straight bone chisel 14
15. Brunetti chisels 15
16. Steel hammer 15
17. Wooden mallet 15
18. Forceps 15
19. Bone-forceps 16
20. Bone-nippers 16
21. Probe 16
22. Blow-pipe 16
23. Hand bone-drill 17
24. Needles 18
25. Brass measuring-stick 18
26. Author’s method of removing skull-cap 65
27. Skull-cap after removal, showing interlocking joint 67
28. Method of examination of brain (after Nauwerck) 71
29. Section of brain. Ventricles opened (after Nauwerck) 72
30. Method of Pitres 75
31. Base of cranium after removal of brain (after Nauwerck) 79
32. Incisions for examination of orbit, ear and nose 80
33. Tympanic cavity after removal of tegmen (after Politzer) 81
34. Sagittal section through left middle ear, outer half (after
Politzer) 84
35. Sagittal section through left middle ear, inner half (after
Politzer) 84
36. The main incision completed (after Nauwerck) 97
37. Method of disarticulating sternoclavicular articulation
(after Nauwerck) 101
38. Section of left ventricle and auricle (after Nauwerck) 108
39. Removal of heart (after Nauwerck) 112
40. Section of right auricle and ventricle, Nauwerck method 114
41. Incision for opening of aortic ring (after Nauwerck) 115
42. Section of left lung (after Nauwerck) 118
43. Section of right lung (after Nauwerck) 119
44. Removal of neck organs (after Nauwerck) 132
45. Section of male pelvic organs (after Nauwerck) 162
46. Section of female pelvic organs (after Nauwerck) 164
47. Method of opening abdomen of new-born (after Nauwerck) 178
48. Section of pulmonary artery in new-born (after Nauwerck) 179
49. Method of demonstrating Béclard center (after Nauwerck) 180
50. A satisfactory microscope for the working laboratory 202
51. A good practical microtome 206
52. Cathcart freezing microtome 212
53. Carbonic-acid freezing microtome, Becker model 213
54. Bardeen freezing microtome 214
55. Knife for Bardeen freezing microtome 215
PART I.
SOURCES OF PATHOLOGIC MATERIAL AND METHODS OF OBTAINING IT FOR
EXAMINATION.
INTRODUCTION.
The chief sources of pathologic material are the autopsy, surgical
operation, diagnostic excision and curetting, the spontaneous
discharge of diseased tissue, and the experimental production of
pathologic conditions in animals. To these sources may be added the
blood and other body-fluids, as well as pathologic fluids, exudates,
effusions, cyst-contents, etc., particularly the cellular elements
found in the sediment of such fluids.
That an accurate pathologic diagnosis be secured, the material must
first be properly obtained, its gross characteristics carefully
noted, the portion to be examined microscopically chosen with
discrimination, and, finally, the microscopic examination itself
carried out along the various lines indicated. All of these
procedures require the knowledge of a certain amount of technique,
and the general principles of such technique should be familiar
to every student of medicine. While it is not possible that every
medical graduate can enter into the active practice of his profession
as an expert pathologist, yet the possession of the technical
knowledge necessary to perform an autopsy properly and to select
with discrimination the tissue for microscopic examination gives to
a physician a distinct practical advantage. This advantage becomes
the greater if to the possession of this knowledge there be added
also a practical working knowledge of the technique necessary for the
microscopic examination and diagnosis. Not that this knowledge should
be so extensive as to cover the great field of special methods; all
that is really essential is a knowledge of the general principles of
laboratory examinations; and a very large proportion of practical
work can be successfully carried out if the physician possesses
this foundation knowledge. In the first days of practice a young
physician so equipped often finds that his laboratory training comes
to be his chief source of income and opens the way to a successful
professional career. It constitutes a professional asset which the
older practitioner usually does not possess.
CHAPTER I.
THE AUTOPSY: GENERAL CONSIDERATIONS.
1. =AUTOPSY= (=Postmortem examination=, =necropsy=, =necroscopy=,
=obduction=, =mortopsy=, =section=; Latin, =sectio cadaveris=,
=sectio anatomica=, =autopsia cadaverica=, =sectio=, =obductio=;
French, =autopsie cadaverique=, =nécropsie=; German, =Leichenschau=,
=Section=, =Obduction=) is the term preferably applied to the
examination of the dead body, conducted for the purpose of
ascertaining the cause of death, for the study of the pathologic
conditions present with reference to their nature and cause, or
for the obtaining of anthropologic, anatomic or surgical data.
When carried out primarily with the view of obtaining evidence of
legal importance, as in the case of a suspected crime, accidental
death, the identification of a body, in damage suits for injuries
received, malpractice, insurance, etc., the autopsy is usually styled
=medicolegal=, or the German term =obduction= is not infrequently
applied. The terms =prosector= and =obducent=, although used
originally in a medicolegal sense, are now generally applied to the
person performing the autopsy whether medicolegal or not.
2. =IMPORTANCE OF THE AUTOPSY.= The opportunity of performing an
autopsy should be regarded by the physician and student as a very
great privilege. Even to the prosector with an experience of several
thousand autopsies to his credit, each new examination of a dead body
becomes a new revelation and extends still farther his intellectual
horizon. To the student and physician in practice each autopsy may,
if performed in the proper spirit, become in itself an educational
factor of the greatest value. In no other scientific procedure
is there such a demand made upon the faculties of observation,
judgment and interpretation, and in no other is there such intimate
correlation between methods of technique and the higher intellectual
processes. It is unnecessary to add that the ability to perform an
autopsy in the proper manner presupposes a foundation of accurate
anatomic and pathologic knowledge as well as a capacity for careful
work.
Primarily, the aim of the autopsy is to ascertain the cause of death
and to acquire knowledge of the changes produced in the tissues and
organs by the disease-process. If for no other purpose than that of
extending our knowledge of disease, the autopsy becomes the most
valuable factor in furthering the development of medical science.
We have but entered into the broad, rich fields of pathology; at
any time new facts may be discovered or observations of the most
far-reaching nature made. From year to year the statistics of the
most common diseases must be revised in the light of new conceptions
of disease. Through the autopsy there lies within the reach of every
practitioner the opportunity of contributing something worth while
to the general sum of medical knowledge. There is not a pathologic
condition in the medical category that does not call out for
illumination upon some point or other. The phenomena of malignant
tumors, the earliest stages of the so-called chronic affections, as
well as the majority of the infectious diseases, require further
autopsy observations for their elucidation. The autopsy establishment
of the diagnosis is also of the greatest importance in giving value
to vital statistics. Until we have a more universal confirmation of
the clinical diagnosis by the pathologic our vital statistics must of
necessity be imperfect.
To the practitioner the autopsy offers further a most valuable
control of subjectivity and a guide to methods of diagnosis and
treatment. Without such a control no one is so likely to get into
a dangerous rut as the practicing physician. The disclosures of
the autopsy will enable him to correct faulty methods, and should
effectually check any tendency to superficial diagnosis. Particularly
is this the case with regard to such diagnostic methods as palpation,
percussion and auscultation. Postmortem percussion offers a most
valuable means of acquiring precision in this important branch of
physical diagnosis. The percussion boundaries may be marked upon the
body by pencil, or long pins may be inserted, so that when the body
is opened the exact relation of the percussion area to the organ in
question may be noted. In the case of palpable tumors the results of
palpation before the body is opened should be carefully controlled by
the findings when the actual conditions are exposed. Even when the
cause of death seems obvious it is worth while to perform an autopsy
at every opportunity offered, both for the sake of controlling
technical methods and for the pictures of disease revealed. More
accurate knowledge of the nature of the processes of disease can
be obtained through one autopsy than through months of textbook
reading. To the surgeon the opportunity of examining cases dying
after surgical operation should be a source of great satisfaction.
The review of anatomic relationships offered by the autopsy is in
itself worth while, and in the case of healthy individuals killed
by accident the survey of the normal appearances of the organs and
tissues offers an opportunity for study too valuable to be neglected.
Further, it is justifiable to practice upon the cadaver any surgical
operation that does not disfigure it. Removal of the spleen,
transplantation of thyroid tissue into the spleen, decapsulation of
the kidney, transplantation of ovarian tissue, gastric and intestinal
operations, anastomosis of blood-vessels, operations upon the uterus
and cervix, prostate, vas deferens, thyroid, nose, ear, etc., and
many other surgical procedures may be practiced with profit upon
a cadaver during the course of an autopsy. The feasibility of a
new operative method or the improvement of an old one may thus be
demonstrated.
In the case of medicolegal autopsies the ends of justice as well
as the life, liberty or reputation of some individual may depend
upon the results of the postmortem examination. In all cases to
which there is any suspicion attached, or in which the cause or
manner of death is doubtful an autopsy should be legally required,
but unfortunately this is not yet done in this country. Physicians
individually should endeavor to create in the public mind a more
healthy attitude toward the autopsy and an appreciation of its
usefulness. As to his own share in the advantages derived from it,
it is safe to say that no physician can perform an autopsy properly
without having his experience widened, his knowledge of disease
increased, his diagnostic faculties sharpened and his tendency to
subjectivity controlled. Last, but far from being the least, should
be his gain in honesty and humility.
3. =LEGAL ASPECTS OF THE AUTOPSY.= The individual cannot dispose of
his dead body without the consent of his nearest heirs, except in
those States (New York) providing by statute that a person may direct
the disposition of his cadaver. The legal rights to the corpse are
vested first in the husband or wife of the deceased; if none, then
first in the father, then in the mother; after the parents, in the
brothers or sisters; after them in the next of kin, according to the
course of common law; and then to the remotest degree according to
the law of descent of personal property. An autopsy performed with
the consent of the relative having the body in custody cannot be
questioned, if it is properly performed. In the case of members of
societies requiring autopsies the membership cards or certificates
should be endorsed by the nearest heir.
A physician who performs an autopsy without the consent of the person
having the custody of the deceased does so at his own risk, except
in those cases in which the autopsy is in accordance with legal
statutes. In the majority of the States there are statutes providing
that the Coroner or Board of Health shall order an autopsy whenever a
person is found dead and the cause of his death is not apparent, and
cannot be ascertained from the evidence given, or from a superficial
examination of the body. In such cases no permit from the relatives
is necessary, and an autopsy performed under the direction of law is
never subject to legal punishment, if it has been performed according
to approved methods. Nevertheless, even in these cases it is a better
policy to secure the consent of the custodian of the body, when this
is possible.
When consent to an autopsy is withheld and the physician feels that
such an examination is necessary, he should turn the case over
to the Coroner or Board of Health, and act under such direction.
Conflicting decisions, however, have been made in different States.
The Supreme Court of Indiana (1909) held that a Coroner cannot order
an autopsy unless there was a reasonable supposition that death had
occurred from violence or casualty. A suit brought by an Indiana
physician to recover fee for an autopsy held on the order and under
the direction of a Coroner was set aside on the ground that there was
not the slightest suspicion of death from casualty or violence. Such
a decision is too narrow and not framed in accordance with the actual
needs of the times in so far as the protection or enlightenment of
the community is concerned. Under such a decision a Coroner or Board
of Health could not in safety order an autopsy in the case of a death
in which the diagnosis had not been established clinically, when no
suspicion of violence or casualty exists, although the establishment
of the diagnosis through an autopsy might be of the greatest
importance to the family or community.
On the other hand the Court of Appeals in Kentucky (1906) affirmed
judgment for the defendant in a suit for damages brought against a
physician for performing an unauthorized autopsy to secure a burial
permit, the court holding that, if the autopsy was made in good
faith for the purpose of ascertaining the cause of death in order
that a burial certificate might be granted, and if the autopsy was
made decently with due regard to the sex of the deceased and without
unnecessary incisions or mutilations, there could be no grounds for
damages. This is a reasonable and just decision and laws framed upon
it should be passed in all the States. Autopsies performed under
such conditions, however, should always be conducted in the presence
of several witnesses competent to testify as to the methods used.
In several States legal authority is given to the Board of Health to
order an autopsy whenever the health interests of the people demand
such an investigation. Autopsies performed under such orders against
the desire of the relatives should always be carried out with extreme
care and in the presence of proper witnesses.
State and charitable hospitals cannot be made liable for autopsy
performed by Coroner or Board of Health, when the consent of
the relatives is withheld. It is high time that all charitable
institutions in this country should require an autopsy from
all patients dying within their walls. The cards of admission
should contain a clause to this effect, and such cards should be
counter-signed by the nearest relatives.
Inasmuch as some life-insurance policies contain clauses requiring
the presence of a representative of the company at the autopsy or a
forfeiture of the claims, it is best to ascertain if such policies
exist in any given case, and to notify the company. The Supreme Court
of Missouri has decided that an autopsy made in ignorance of such an
insurance clause is no bar to recovery if the company be notified in
time for a re-examination of the body.
Supreme Court decisions also hold that consent for an autopsy implies
removal of organs and tissues for microscopic study, when such is
necessary to fulfill the object of the autopsy.
One of the great needs of this country is a uniform autopsy law
and the establishment of a proper medicolegal autopsy code, as in
Germany. As conditions exist at the present, crimes may be easily
concealed, the safety of the community endangered by failures
in diagnosis of communicable affections, and our morbidity and
mortality statistics become a shame and reproach to the nation.
The majority of our medicolegal autopsies are made by ignorant
and imperfectly trained coroners and coroners’ physicians, mostly
political appointees of inferior material. We need in our medical
schools a greater amount of attention paid to the teaching of
autopsy-technique and gross pathology. The community must also be
educated to a realization of the value of autopsies. It is the duty
of every physician and layman to work diligently for the improvement
of existing conditions. Had the ideas of a former Governor of the
State of Michigan been realized there would have been compulsory
autopsies upon the bodies of every person dying within the State,
and far-reaching results would have been attained. The economic
importance of tuberculosis and the venereal diseases would have been
made clear, the profession and laity alike educated, and the progress
of preventive medicine tremendously aided.
4. =PERMISSION FOR AUTOPSY.= It is a desirable and certainly a wise
precaution to obtain a written permit for the autopsy from the next
of kin or from the legal representative of the body, in case the
examination has not been ordered by law. Some of the legal decisions
quoted above offer sufficient grounds for this precaution. The
following form is in use in the University of Michigan Hospital.
NO........ ANN ARBOR, MICHIGAN..................., 19..
PROFESSOR OF PATHOLOGY........................
UNIVERSITY OF MICHIGAN.
Permission has been given by........................., who bears
the relationship of..................to........................, to
hold a postmortem upon the remains of...........................,
with the understanding that the object of such postmortem
is to ascertain the cause of death, and that you are to use
such means as you deem best to make a thorough examination
for the proper attainment of the object desired, excepting
that...............................................
...............................Superintendent.
There can be no doubt that the public in general is beginning to
appreciate the usefulness of autopsies, as it is much easier to
obtain them now than it was ten years ago. The proper display of
tact and a reasonable exposition of the object of the examination
will practically always meet the objections urged on sentimental
grounds. Aside from these the chief objection usually met with is the
fear of mutilation of the body. Emphatic assurance may be given in
this respect, not only as to the entire absence of any disfigurement
resulting from the examination, but also as to the marked improvement
in the general appearance and condition of the cadaver as the result
of the autopsy.
While it is obviously difficult to give any specific rules as to
the method to be pursued in seeking permission for an autopsy,
there are certain arguments that can be used to advantage. Natural
curiosity, the general good to humanity, the control of diagnostic
and therapeutic methods, new knowledge to be gained, the question of
inherited or infectious conditions, the strengthening of insurance
claims, etc., are some of the lines that may be followed in working
for an autopsy. Satisfaction is always expressed when definite light
is thrown upon the hereditary or infectious nature of the condition.
Religious scruples may often be overcome by an appeal to the pastor
or priest.
In a certain number of cases the matter is hopeless from the
beginning, but in the majority the autopsy may be secured by the
exercise of proper tact and patience. The laity should be educated
to ask for the autopsy; and even at the present time laymen often
show a greater willingness in this direction than some members of
the profession. That physicians and undertakers who discourage or
oppose autopsies should be avoided is a principle that should be
instilled into the minds of the public at large. Undertakers soon
come to recognize the aid given them by the autopsy in the matter
of embalming and preserving the body, and the prosecutor should
always show his readiness to allow the undertaker to profit by his
operations, and to render him such definite help as may be within his
power.
As a last resort the offer of a small amount of financial aid in
the burial expenses will secure sometimes a permission otherwise
refused. In extreme cases the physician may decline to sign the death
certificate, or the Coroner may be called in, or the case turned
over to the Board of Health. Under suspicious circumstances such
procedures are necessary, but threats to resort to these expedients
should not be made without good reasons.
With the request for the autopsy should be included the right to take
such portions of organs or tissues as is necessary for a microscopic
examination and for the complete diagnosis. It is, of course, never
necessary and certainly unwise in the majority of cases to make any
definite statements as to what or how much shall be taken away or
left. No specimens should be taken if this is absolutely forbidden;
and, while a half autopsy is better than none, the importance of the
microscopic examination should be urged, if necessary, as strongly as
the performance of the autopsy. The use of a written permission, such
as is given above, obviates the necessity of making a special request
for material and avoids the complications that such a request often
brings about. Moreover, the legal decision above quoted grants the
right to microscopic examination as included in the permit for the
autopsy when such an examination is necessary to complete the aims of
the autopsy.
5. =AUTOPSY INSTRUMENTS.= An autopsy can be properly performed with
very few instruments; indeed, a knife and a saw, with a needle to
close up the body, would suffice for the majority of cases. But
there are very great advantages in the use of certain instruments
adapted especially to autopsy needs, and these the physician should
gradually acquire for his work. It is not advisable to purchase the
so-called “postmortem sets” sold by the dealers, but far better
to start with two or three of the most necessary instruments and
gradually add to these. Surgical instruments as they become discarded
can often be made to do good service in the autopsy outfit. In
private practice the fewer instruments one can get along with the
better, as there is much less trouble in carrying them about and in
taking care of them, and it is better to make the performance of the
autopsy as inconspicuous as possible. In teaching institutions and in
hospitals the number and variety of instruments that can be utilized
in autopsy work are limited only by the financial means at disposal,
but even under the most favorable conditions in this respect it is
better to simplify as much as possible. The list given below will
meet all requirements.
[Illustration: FIG. 1—Large Section, or Cartilage Knives]
[Illustration: FIG. 2—Scalpels]
=Knives.= The _large section-_ or _cartilage-knife_ is the most
important cutting instrument used in autopsy work. It is a strong,
heavy knife 20-22 cms. long, with handle and blade of about equal
length. The blade has a heavy back, a bluntly rounded rather than
a sharp point (more blunt than appears in the illustration), and
bellies at its anterior third, narrowing toward the handle. In its
widest part the blade should measure about 1¾ cms. The handle is
heavy, 1½ cms. broad, and a little over 1 cm. in thickness toward the
blade, gradually diminishing to about ¾ cm. at the posterior third,
then increasing to 1 cm. toward the end. This variation in thickness
gives a gentle curve to the handle that is of great importance in
adapting the latter to the form of the closed hand, so that the knife
becomes practically a cutting extension of the fore-arm. With this
knife all the chief incisions are made, and it is rarely out of the
hands of the operator during the autopsy. The handle or blade may
be made shorter or longer according to preference, but the other
features of the instrument are most important.
=Scalpel.= (See Fig. 2.) A number of _dissecting scalpels_ of varying
sizes are needed for finer dissections. They should have a metal
handle, and are preferably of one-piece construction.
=Long Section- or Brain-Knife.= In place of the broad thin
brain-knife usually advised, an _amputation-knife_ can be used to
much better advantage in the section of the brain and in making the
chief incisions in the large organs. It should have a sharp point
rather than a blunt one.
[Illustration: FIG. 3—Long Section Knife]
=Myelotome.= This is used only for the purpose of cutting the spinal
cord squarely across in the removal of the brain. It has a slender
steel stalk with wooden handle, and a short, thin, narrow blade set
obliquely at the end of the stalk. This instrument is not absolutely
necessary, as the cord may be satisfactorily cut with the point of
the long section knife.
[Illustration: FIG. 4—Myelotome]
=Scissors.= (See Fig. 5.) A number of these are of service: one
large and strong pair with long handles and short stout blades,
another large pair curved or bent with the longer blade blunt- or
probe-pointed, a small pair with a narrow, probe-pointed blade for
opening small vessels or ducts.
=Enterotome.= (See Fig. 6.) For opening the intestine the enterotome
or intestinal scissors are used. These consist of one long
probe-pointed blade bluntly rounded at its end, and a shorter blade
with straight end fitting into the longer blade. Neither blade should
be sharp-pointed.
=Costotome.= (See Fig. 7.) The cartilage-shears have two short, thick
blades, the upper one with a broad belly, the lower one curved.
Between the strong handles a spring is placed, and the construction
should be such that when the blades are closed the ends of the
handles do not touch. The form in which the handles meet and are
secured with a catch is a dangerous autopsy instrument because of the
severe pinching that the operator’s hand is sure sooner or later to
receive.
=Saws.= (See Figs. 8, 9, 10.) A _small hand-saw_ (_bone-saw_) is
necessary for opening the skull, and the same saw may be used to
open the spinal canal. It is sometimes made with a rounded point
(_“fox-tail” saw_). For sawing vertically through the base of the
skull when exposing the nasal tract a larger _butcher’s saw_ with a
high frame may be used. For sawing the angles of the skull-cap _Hey’s
saw_ may be of service but is not essential. A _metacarpal saw_ may
be used for opening small bones or the long bones of an infant. _Band
saws_ are sometimes used in opening up the nasal tract.
[Illustration: FIG. 5—Autopsy Scissors of Various Types]
=Rhachiotome.= (See Fig. 11.) This instrument consists of two curved
saw blades placed parallel to each other in such a way that the
distance between them can be regulated by screws. There are two
handles, a horizontal one for the right hand, and an upright one for
the left hand attached to the fixed saw blade. It is used in opening
the spinal canal.
=Chisels.= (See Figs. 12, 13, 14.) A very convenient autopsy
instrument is the _T-chisel_ or _skull-opener_, used for springing
off the skull-cap and in detaching the periosteum. _Side-_
and _guarded-chisels_ may be used for the same purpose. The
_hatchet-chisel_ may also be used on the skull or spinal column.
_Straight_ and _curved bone-chisels_ are also necessary for the
examination of the bones and bone-marrow.
=Brunetti Chisels.= (See Fig. 15.) These are of great service in
opening the spinal canal, but require some practice for their proper
use. When used with skill they are preferable to the rhachiotome.
The chisels are rights and lefts, and have a long, heavy, curved
blade, broadening toward the cutting end, which has on its right or
left side a small blunt projection that is introduced into the spinal
canal after the removal of a portion of one of the vertebræ. This
projection serves as a director and lever, while the cutting edge
of the chisel is driven through the lateral portions of the bony
covering of the canal by means of blows from a wooden mallet received
upon the heavy handles.
[Illustration: FIG. 6—Enterotome]
=Hammer.= (See Fig. 16.) The steel hammer of the amputation- or
bone-sets is often of great service in autopsy work. The hook at the
end of the handle may be used to lift up the skull-cap after the
sawing is completed.
=Mallet.= (See Fig. 17.) A wooden mallet is necessary for the use of
the Brunetti chisels. It may be loaded with lead or the end may be
covered with felt to deaden the sound of the blows.
=Forceps.= (See Figs. 18, 19, 20.) _Dissecting forceps_ of various
types are useful in the finer dissections. _Cover-glass forceps_
should be at hand for use in the taking of smears. A pair of strong
_bone-forceps_ may be of occasional service in cutting ribs or small
bones. When the spinal canal is opened by means of the Brunetti
chisels or rhachiotome the loosened fragments of the vertebræ should
be jerked off by means of lion-forceps, or a strong pair of ordinary
nippers may be used for the same purpose.
[Illustration: FIG. 7—Costotome]
[Illustration: FIG. 8—Large Autopsy Saw]
=Miscellaneous Instruments.= (See Figs. 21, 22, 23, 24, 25.) Probes
of various sizes, grooved and curved directors, retractors,
catheters, both metal and flexible, injection-syringe, blow-pipe
with valve, trocar, cannulas, hand-drill for wiring bones, an
iron-vise, etc., all find a place of usefulness in autopsy technique.
In institution work motor band-saws, trephining or dental engines,
drills, etc., may greatly facilitate the progress of autopsies when
the daily number of these is great and when special examinations of
the ear or nose are required. The needles for sewing up the incisions
should be large, strong and slightly curved. A strong linen thread
should be used for stitching and for ligatures.
[Illustration: FIG. 9—Small Autopsy Saw]
[Illustration: FIG. 10—Hey’s Saw]
[Illustration: FIG. 11—Luer’s Rhachiotome]
[Illustration: FIG. 12 T-Chisel or Skull-Opener]
[Illustration: FIG. 13 Hatchet-Chisel]
[Illustration: FIG. 14 Straight Bone-Chisel]
Besides the instruments mentioned above there should be brass or
nickel measuring sticks, one 10 cms. long and one 30 cms. long, a
flexible metal measuring tape, graduated glass vessels for measuring
fluids, graduated glass cones for orifices, etc. Suitable scales
should also be provided. Rounded or triangular wooden blocks are
needed to elevate portions of the body. For the display of gross
specimens as they are removed from the body, agate dishes or wooden
trays that have been infiltrated with paraffin should be at hand.
The necessary outfit for the taking of material for bacteriologic
examinations should always be present. Likewise cover-glasses and
slides for smears, and reagents for the examination and preservation
of tissue should be at hand. Sponges, pails, towels, tow or excelsior
for filling up the body-cavities, disinfectants, etc., must be
supplied.
The autopsy outfit may be extended indefinitely to suit the
requirements of the conditions or the ideas of the pathologist. In
actual practice, however, the physician may confine his requirements
to the limits of a cartilage knife, dissecting scalpel, forceps,
one small probe-pointed pair of scissors, enterotome, saw, T-chisel,
needles, thread, sponge and specimen bottles. Five or six dollars
would cover the initial expense, and the set may be gradually
increased. It would seem unnecessary to decry the use of surgical
instruments for the autopsy. Once an instrument is used in an autopsy
it should be left in the autopsy set.
[Illustration: FIG. 15—Brunetti Chisels]
[Illustration: FIG. 16—Steel Hammer]
[Illustration: FIG. 17—Wooden Mallet]
[Illustration: FIG. 18—Forceps]
=CARE OF INSTRUMENTS.= The cutting instruments should always be kept
sharp and bright. Care should be taken that when the knives are
sharpened the blunt points and rounded bellies are not ground off.
After use the knives should be cleaned, disinfected and wiped dry. A
tight galvanized iron box containing wire trays and a bottom pan for
holding formalin is very practical in institution work. In private
practice the knives after cleaning and disinfection may be kept in a
holder made of Canton flannel or chamois skin having pockets fitted
to the instruments; the whole may be rolled up into a small and
compact bundle.
6. =PREPARATION FOR THE AUTOPSY.= Permission having been obtained,
the autopsy should be performed without delay. It is very important
that the examination should be carried out before the body has
become cold, if any thorough microscopic study of the tissues is to
be made. Changes in the finer structure of cells and nuclei quickly
take place, and certain tissues, such as parts of the nervous system,
the medullary portion of the adrenals, the pancreas, mucosa of
gastro-intestinal tract, etc., within an hour or so after death are
usually no longer fit for microscopic study. In all cases, therefore,
it is best to make the autopsy as soon as possible after death, that
is, as soon as positive signs of death appear. In the majority of
cases this takes place within an hour, and the most favorable time
for the performance of the autopsy falls within one to three hours
after death. Under certain circumstances it may be necessary to make
the examination sooner, but for various reasons the operation is very
repugnant when performed within the first half-hour after death. For
ordinary purposes an autopsy performed within twelve to twenty-four
hours is usually satisfactory. Occasionally it becomes necessary for
medicolegal purposes to examine a body some days, weeks, or even
months after death and burial.
[Illustration: FIG. 19 Bone-Forceps]
[Illustration: FIG. 20 Bone-Nippers]
[Illustration: FIG. 21 Probe]
[Illustration: FIG. 22 Blow-Pipe]
The body should not be frozen if microscopic studies are to be made.
When the autopsy is delayed cold storage just above the freezing
point produces less change in the gross pathologic picture, as
well as in the finer structure. No embalming fluids, injections,
punctures, etc., should be allowed, and undertakers should be
instructed not to do these things until after the question of
autopsy has been decided and the operation completed. If the use of
an embalming fluid becomes necessary, formalin, not stronger than a
ten per cent solution, should be advised, as it does not damage the
tissues and hinders but little the operations of the autopsy. Strong
solutions, as found in the usual embalming fluids, render the tissues
stiff and hard and cause color changes, while the strong vapors are
very unpleasant to the obducent. The use of arsenical embalming
fluids or preparations should be wholly discountenanced. When it
is desired to study the mucosa of the stomach or intestine, it may
be fixed soon after death by the introduction of a fixing fluid
into the stomach or intestine by means of a tube and pump. Finally,
instructions should be given that the body shall not be dressed for
burial until after the autopsy.
The necessity of making special preparations for an autopsy depends
upon its performance in a regularly appointed autopsy room or
under the conditions of private practice. In the former case the
autopsy room should be constructed to meet the demands of the
work. In teaching hospitals it should be a large, well-lighted and
properly-ventilated room with proper facilities for teaching-staff
and students, and should be so connected with the hospital wards
that the conveyal of bodies may be protected from observation. In the
same building there should be the pathological laboratory, library
and museum, a waiting-room, and under some conditions a chapel for
funeral services. The autopsy room itself should have a grooved
concrete floor sloping to a central drain, the furniture should be
of simple construction, and so built that the entire room may be
washed with a hose. The seats should be arranged in an amphitheatre
facing the northern side of the building, which should be constructed
practically wholly of glass, the lower sashes containing ground glass
or prisms. The northern half of the roof should likewise be of glass.
[Illustration: FIG. 23—Hand Bone-Drill]
In the pit, in the field of strongest illumination, should be placed
the autopsy table. This should be strongly built, of marble, slate,
soapstone, artificial stone, copper, zinc, etc., about seven feet
long, thirty inches wide, and thirty to thirty-six inches high. A
high table is much preferable to a low one. It should have a top
with grooves slanting toward a central perforated plate fixed in the
central hollow standard in such a way that the top may be freely
revolved. In the standard there should be a drain and ventilating
shaft connected with a fan revolving outward. The drain from the
table as well as the others from the laboratory should empty into a
large catch-basin where the contents may be sterilized before passing
into the main sewer. Above the table a combination gas and electric
light with hot and cold water-pipes should be arranged. A sheet of
blue glass of the proper tint may be used in connection with the
illuminating apparatus to give daylight effects.
Extra tables, weighing and measuring apparatus, sinks, lavatories,
bacteriologic outfit, sterilizer, instrument-case, etc., may be
supplied as needed. In the case of delayed permission, or when the
law requires that the bodies be kept a certain length of time before
the autopsy, it becomes necessary to provide a proper cold-storage
apparatus. The local conditions will suggest the most convenient and
appropriate construction. In routine autopsy service well-trained
assistants and attendants become a necessary factor in the
satisfactory performance of the work.
In private practice the autopsy is usually made in a private dwelling
or, more rarely, in an undertaker’s shop. Under such conditions much
depends upon the ability of the operator to make the best of things.
In place of a proper table, the cadaver must be examined upon the
bed, undertaker’s body-rest or shutter, in or upon the coffin, on
the coffin lid, box, door, shutter, table or board. It is always
advisable to move the body from the bed when anything else can be
found upon which it can be placed. The support should be put in front
of the window giving the best light and the cadaver placed upon this
with its left side toward the window. Care should, of course, be
always taken that the operation cannot be witnessed from without. A
piece of oil-cloth or several layers of newspapers should be placed
upon the floor beneath and around the support. When it is necessary
to make the autopsy on the bed or in the coffin an abundant supply
of old newspapers tucked under and around the cadaver will usually
prevent the escape of blood or fluids.
An abundance of cold water should be provided, also a slop-pail,
several basins, towels, old cloths, sponges, etc. Before the
operation is begun the instruments and utensils, specimen bottles,
needle and thread, etc., should be arranged. A stick of wood may
serve as a head-rest. Material for filling up the body and restoring
its form should be secured, according to the need for such. Hay,
bran, tow, excelsior, old cloths, paper, etc., may be used for this
purpose.
[Illustration: FIG. 24 Autopsy Needles]
[Illustration: FIG. 25—Brass Measuring-Stick]
When all is ready for the operation members of the family or of the
laity should be tactfully gotten out of the room. It is always well
to ask members of the family if they desire to be present, but this
invitation should be given in the expectation that it will not be
accepted. The effect of an autopsy upon the minds of the laity is
not always a pleasant one, and harm is sometimes done through the
misinterpretation of necessary procedures and the resulting gossip.
In private practice it is worth while, as a matter of courtesy, to
invite several of one’s colleagues to witness or take part in the
autopsy. An ideal way would be to have one of these perform the
operation in expectation of future reciprocation. In the interests of
objective observation a clinician should never perform the autopsies
of his own cases, but should turn them over to a trained pathologist
or to a colleague. The operator is usually in a better position to
know what to do than the onlookers, and while the suggestions of the
latter are usually futile they may be endured for the occasional
great help derived from them.
As far as the obducent himself is concerned he may prepare himself
simply by removing his coat and rolling up his sleeves, or he may
wear an autopsy coat or apron. While an autopsy can without doubt
be best performed with hands bared, the danger to the operator is
sufficiently great to lead him to sacrifice the undoubtedly greater
technical skill thus gained, to his own safety, by the use of some
protective. Rubber gloves of a medium weight, reaching half way to
the elbows, are a great protection when carefully cleaned, sterilized
and cared for. The sleeves of the coat may overlap the gloves and
be fastened to these by an elastic band. When gloves are not used
the hands may be covered with carbolized vaseline, or a six per cent
solution of guttapercha in benzin. Cuts, abrasions, hang-nails, etc.,
must be protected by surgeon’s-plaster, collodion, finger-cots,
etc. When these are used it may be necessary to remove them during
the course of the autopsy, as they are easily torn or become loose.
Frequent washing in flowing water lessens the danger of infection.
Blood and other fluids from the body should never be allowed to dry
upon the skin or upon anything used in connection with the autopsy.
Gloves should be thoroughly washed and scrubbed; and, when clean,
washed in four per cent formaldehyde and dried before they are
removed from the hands. They should be then dusted inside and out
with talcum powder and put away dry. When they are again used they
should be tested for holes by filling them with water. After having
been used several times they easily tear. If the autopsy has been
performed with unprotected hands, thorough disinfection of these,
particularly of the finger-nails, should be carried out. Unpleasant
odors may be removed from the hands by the use of mustard, dilute
tincture of benzoin, turpentine, etc., and then washing with tincture
of green soap. Rubbing with cornmeal is very effective in removing
discolorations of the skin, particularly the blood-stains fixed by
formaldehyde that occur so often in the course of autopsies on bodies
injected by the undertaker.
Postmortem infections should receive prompt surgical attention, as
the smallest one is dangerous and may develop in a few hours to such
an extent as to cause the most alarming constitutional symptoms.
In a way all autopsy work, like surgical operations, offers a
risk to the operator. This is particularly great in all cases of
pyogenic infection, tuberculosis, blastomycosis, syphilis and the
acute specific infectious diseases. Any of these infections may be
received through the unbroken skin by way of a hair-follicle; but
previous cuts, abrasions, hang-nails, etc., form a frequent avenue
of entrance for the infecting agent, as well as punctures, scratches
and cuts received during the autopsy from instruments, spicules of
bone, needles, etc. It is particularly dangerous to allow blood, pus
or exudates from the peritoneal or thoracic cavity to enter a glove
through a hole. A finger or hand so bathed is very likely to develop
hair-follicle infections. All wounds received during the autopsy
should be allowed to bleed freely, and then should be thoroughly
washed in sterile water, alcohol and ether and an antiseptic.
Tuberculous warts are very common on the hands of prosectors
having a large autopsy service and not using gloves. A generalized
tuberculosis may follow. These warts are easily removed by repeated
painting with fuming nitric acid, just sufficient to keep the skin
yellow. If this treatment fails such warts should be excised.
Syphilis has been reported only a few times as due to postmortem
infection; but observations tend to show that the spirochætes may
remain virulent for several hours (7-24) after death.
_7._ =AUTOPSY TECHNIQUE.= _The object of the autopsy is to examine
thoroughly, in as short a time as possible, and in the easiest and
most convenient method, all of the organs and tissues of the body,
with reference to the occurrence of disease-changes, in such a way
that nothing will be overlooked or obscured._ The preservation of
relationships becomes, therefore, a very important matter; and
nothing should be done to disturb these until a complete pathologic
picture has been obtained. All unnecessary handling and cutting must
be avoided. No hasty or ill-advised cuts should be made. Careful
deliberation is often necessary as to the proper course to be
pursued in order to obtain the proper result. Each autopsy is a law
unto itself in this regard. New complications constantly arise and
must be studied before the right way of revealing the solution of
the pathologic problem is found. _Above all things nothing should
be destroyed until its relationships have been fully determined._
False steps taken in an autopsy cannot be retraced, and the complete
investigation and the successful attainment of a diagnosis may be
made impossible by improper methods of technique. As in all other
technical matters there is a _best_ way of carrying out the different
steps of the autopsy; and as this best way must be altered to suit
the conditions as they arise, it follows that there is both a
_science_ and _art_ of autopsy-making. Some general rules can be laid
down that apply consistently to all autopsies, but strict adherence
to one method is impossible in all cases. As in everything else the
prosector should be master of his technique and not let it master him.
When everything is ready for the autopsy the operator should take
his place at the right side of the cadaver, unless he happens to
be left-handed, when it may be more convenient for him to stand at
the cadaver’s left. This position at the cadaver’s side he does not
leave, except when opening the cranium, when he stands behind the
head. When the spinal cord is removed posteriorly he still remains on
the same side of the table, although the cadaver, having been turned
over, presents its left side toward him. The instruments arranged
in proper order should be on a tray close at his right hand, either
on a neighboring table or placed on the autopsy table. As they are
used they should be washed and returned to their proper place and not
allowed to lie on the body or table.
The cutting technique employed in the autopsy is, as a rule, quite
different from that employed in surgical operations or in dissection.
For the large incisions the cartilage-knife is used. It should be
held in the palm of the hand so that when the arm is extended the
knife-blade becomes an extension of the axis of the arm, and used
with a free arm-movement, fingers and hand being firmly fixed to
the knife-handle. Long, sweeping cuts, adequate in pressure, and
giving smooth and even incisions, are made by moving chiefly from the
shoulder, with secondary movement from the elbow. The knife-blade
should not be pressed or pushed into the tissues, but should be drawn
through them rather quickly, cutting as it is drawn. The greater
the force used, the more swift the drawing-motion should be. All
cuts should be clean; if made in the wrong place they will do less
damage than ragged, uneven incisions. The toe of the cartilage knife
is used for the beginning and end of long incisions and for cutting
in hollow or depressed surfaces. For flat surfaces the belly of the
knife is employed. The heel of the blade can be used for cutting
cartilages. The incisions made in the body should be directed away
from the operator, especial care being taken to avoid injuring his
left hand or the hands or arms of anyone assisting in the operation.
When the knife is held as directed there is not much danger of a
slip except at the end of the incision when, the resistance being
overcome, the knife goes through with a rush. To avoid this, pressure
should always be slackened toward the end of the incision. The main
incisions in the organs should be made with the brain-knife or short
amputation knife, by a long, sweeping cut made from heel to toe of
the knife-blade and beginning at the part of the organ farthest
from the operator, drawing the blade through the organ toward the
operator. For finer dissections the smaller scalpels are to be
employed, and in such cases the dissection-technique of fixed arm and
free finger movement must be used. In many places within the body
the cutting-edge of the knife should be directed outward rather than
inward so that underlying structures may not be injured. Often the
fingers of the left hand are used in such cases to take the place
of a grooved director. The application of these and other points of
technique will be elucidated in the chapters following, whenever
it is of advantage to use some especial method. In general nothing
should be done to disturb relationships until these have been noted,
and cuts should be made into organs in such a way that they may be
reconstructed in their original shape and condition.
Order and cleanliness should characterize the autopsy. Abundance of
water should be at hand, and after every incision the knife should
be dipped into a vessel of water standing on the autopsy table.
Practically all cuts should be made with a _clean wet_ knife; only
in the case of the chief-incisions of the large organs is it of
advantage to cut with a _clean dry_ knife, when it is desirable to
obtain a judgment of the moistness or dryness of the cut surface.
Never cut with a dirty knife, as the cut-surface may be obscured.
A gentle scraping with the knife-blade often gives a more distinct
picture of the cut surface. The water-stream should not be used too
freely upon cut surfaces; it should be employed only when there is
so much blood or fluid that the surfaces are obscured, or when it
is desired to float up certain tissues or parts of organs. A better
picture of the cut-surface can sometimes be obtained by blotting it
with absorbent paper free from lint. Organs and tissues removed from
the cadaver should not be allowed to dry. Nor should they be left in
water. Both conditions will quickly ruin material in so far as its
after-use for microscopic study is concerned. They should be kept
covered with moist cloth or paper. As the organs are removed from
the body they may be quickly dipped into water and quickly rinsed,
but beyond this the use of water is not advisable.
Blood and fluids within the cavities of the body should be quickly
removed as soon as their character is determined. Stomach and
intestinal fluids in particular should not be allowed to escape
within the body-cavities. They should not be washed out, but removed
by the aid of beakers and sponges. Drops of blood or other fluids
upon the surface of the cadaver should be removed before they become
dry. All respect should be paid to the dead body. The face and hair
should be covered after they have been examined; and great care
should be taken to prevent any accidental cuts on the surface; and
the entire field of operation as well as the autopsy-table must be
kept clean. In private practice the external genitals should be kept
covered except for their examination. An abundance of large sponges
and a gently-flowing stream of water under low pressure permit a
clean and orderly autopsy. The use of a hose with water under high
pressure is dangerous because of the accidental spattering that
is sure to occur. Blood and fluids from a dead body should not be
spattered about because of the great danger of spreading infection.
When accidents do happen prompt cleaning up and disinfection should
be carried out. Particularly in private practice is it of the
greatest importance that no blood-stains be left behind.
The time required for an autopsy varies with the conditions of
the individual case. A complete and well-performed autopsy under
ordinary circumstances requires at least one hour, usually an hour
and a half. It is true that all the organs can be removed from the
body in a much shorter time, but the removal and inspection require
at least the time given above, if properly done. Some cases present
great difficulties and may require 4-12 hours for a satisfactory and
complete examination. For a medicolegal examination 2-3 hours is
usually necessary. No prosector should make more than two autopsies
in one day, and, if he is making them every day, one daily is quite
sufficient. The intellectual and nervous energy required for a
good autopsy is so great that it is impossible for anyone to do
justice to a large number made in quick succession. In many German
laboratories this fact is recognized and the autopsies are assigned
proportionately to members of the pathologic staff.
At the close of the autopsy the cadaver must be thoroughly cleaned
and restored, as far as possible, to its natural appearance.
Directions for the restoration and closure of the autopsied body will
be given in a later chapter.