A
PRACTICAL GUIDE
FOR MAKING
POST-MORTEM EXAMINATIONS,
AND FOR THE STUDY OF
MORBID ANATOMY,
WITH
DIRECTIONS FOR EMBALMING THE DEAD, AND FOR THE PRESERVATION OF SPECIMENS
OF MORBID ANATOMY.
BY
A. R. THOMAS, M. D.
Professor of Anatomy in the Hahnemann Medical College of Philadelphia;
Lecturer on Artistic Anatomy in the Pennsylvania Academy of Fine Arts,
and Philadelphia School of Design; Member of the American Institute of
Homœopathy; General Editor of American Journal of Homœopathic Materia
Medica, Etc., Etc.
FOR SALE BY
BOERICKE & TAFEL,
NEW YORK: | PHILADELPHIA:
NO. 145 GRAND STREET. | NO. 635 ARCH STREET.
1873.
Entered according to Act of Congress, in the year 1873, by
A. R. THOMAS, M. D.,
In the Office of the Librarian of Congress at Washington.
JAMES E. KRYDER,
PRINTER,
32 SOUTH SEVENTH STREET,
PHILADELPHIA.
PREFACE.
The following work has been prepared with a view of supplying a want,
the existence of which has long been felt by the author, both in his
private practice and public teaching. No pretension is made of offering
a complete work on Morbid Anatomy, the object having been, merely to
present the practitioner and student with a practical guide for making
post-mortem examinations, to give them hints as to what they are to look
for in such cases, and, finally, to aid them in recognizing the various
morbid appearances as they are exposed to view.
The work is divided into four parts. Parts I, II and III, corresponding
to the three great divisions of the body—the Head, Chest and Abdomen.
Part IV, is devoted to miscellaneous subjects, and contains chapters on
the Bones; Joints; Tumors; Effects of Poisons; Medico-Legal Autopsies;
On Embalming the Dead; and On the Preservation of Morbid Specimen.
A few illustrative cases have been introduced, and occasional reference
made to morbid specimens in the Museum of the Hahnemann College.
The following works have been consulted in the preparation of the book,
and as few references have been made, this general credit is felt to be
due the several sources of information: Rokitansky’s, Craigie’s, Jones
and Sievecking’s, and Green’s Pathological Anatomy; Rindfleish’s
Pathological Histology; Paget’s Surgical Histology; Raue’s Pathology;
Murchison, on the Liver; Hope, on the Heart; Brinton, on the Stomach;
Stewart, on the Kidney; Gross’ Surgery; Christison on Poisons; Casper
and Taylor’s Medical Jurisprudence.
Acknowledgment should here be made of the valuable assistance rendered
by Drs. W. H. Bigler and John N. Mitchell, in carrying the work through
the press; and of the kindness of Mr. J. H. Gemrig, in the loan of the
electrotype plates which embellish the preliminary chapter.
Conscious that the work is not without defects, it is still presented to
the profession, with the hope that it may be found to answer the purpose
for which it was designed.
A. R. THOMAS,
_937 Spruce Street_.
MARCH, 1873.
CONTENTS.
PAGE.
PREFACE, 15
INTRODUCTION, 17
PRELIMINARY CHAPTER.
Instruments and General Directions, 21
PART I.
THE HEAD AND SPINE.
CHAPTER I.
THE OPERATION.
On the Head and Spine, 27
CHAPTER II.
PATHOLOGICAL CONDITIONS.
SECTION I.—OF THE SKULL, 34
Fracture; Caries; Thinning; Increased Thickness, 35
SECTION II.—THE MEMBRANES OF THE BRAIN.
1. _The Dura Mater_, 36
Inflammation; Thickening; Fibrinous Clots, 37
Tubercular Deposits; Tumors, 38
2. _Arachnoid and Pia Mater._
Pacchionian Bodies; Inflammation; Serous Effusions;
Sanguineous Effusions, 38
SECTION III.—OF THE BRAIN.
What to notice; Inflammation; Softening; Abscess;
Hardening; Hypertrophy; Atrophy; Tumors of the Brain;
Adenoid Tumors; Scrofulous Tumors; Adipose Tumors;
Cholesteroma; Cartilaginous Tumors; Calcareous Deposits;
Encysted Tumors; Blood Cysts; Cancer; Melanosis;
Syphilitic Tumors; Obstruction of Arteries; Degeneration
and Calcification of Arteries, 47
SECTION IV.—OF THE SPINAL CORD.
1. _The Membranes._
Inflammation; Tubercular Deposits; Serous Effusion, 60
2. _Spinal Marrow._
Inflammation; Softening; Hardening; Atrophy; Morbid
Growths, 62
PART II.
THE NECK AND CHEST.
CHAPTER I.
OPERATION ON THE NECK AND CHEST.
CHAPTER II.
PATHOLOGICAL CONDITIONS OF THE ORGANS.
SECTION I.—OF THE TONGUE.
Cancer; Syphilitic Ulcer; Tumors; Ranula; Hypertrophy, 68
SECTION II.—OF THE LARYNX AND TRACHEA.
Inflammation; Ulceration; Œdema; Necrosis of Cartilages;
Abscess; Tumors; False Membranes, 69
SECTION III.—OF THE PHARYNX AND ŒSOPHAGUS.
Inflammation; Ulceration; Stricture; Dilatation; Tumors, 72
SECTION IV.—OF THE PERICARDIUM.
Inflammation; Adhesions; Effusions; Morbid Growths, 73
SECTION V.—OF THE HEART.
1. _Inflammatory Affection._
Pericarditis; Endocarditis, 76
2. _Valvular Affection._
Thickening; Calcification; Atrophy, 77
3. _Changes Affecting Size._
Hypertrophy; Dilatation; Atrophy, 79
4. _Morbid Condition of the Walls._
Fatty Degeneration, 82
5. _Morbid Growths._
Tumors; Cancer; Melanosis; Hydatids; Ossification of
Coronary Arteries; Abscess; Malformations; Aneurism;
Rupture, 84
6. _Displacements._
Ectopia Cordis; Transposition, 87
7. _Contents of Cavities._
Heart Clots, 88
SECTION VI.—THE AORTA AND ARTERIES GENERALLY.
Inflammation; Fatty Degeneration; Ossification; Aneurism;
Rupture, 98
SECTION VII.—OF THE PLEURA.
Inflammation; Plastic Effusion; Adhesions; Serous
Effusion; Sero-Purulent Effusions; Pneumothorax, 103
SECTION VIII.—OF THE LUNGS AND BRONCHIAL TUBES.
Pneumonia; Congestion; Red Hepatization; Gray
Hepatization; Suppuration and Abscess; Metastatic
Abscess; Gangrene; Pulmonary Hæmorrhage; Pulmonary
Apoplexy; Emphysema, 106
_Tubercular Disease of the Lungs_, 117
_Post-mortem Appearances in_, 118
_Morbid Growths._
Cancer; Melanosis; Hydatids, 120
_The Bronchial Tubes._
Bronchitis; Narrowing of; Dilatation of, 123
_The Mediastinum._
Inflammation; Abscess; Tumors, 126
PART III.
THE ABDOMEN AND PELVIS.
CHAPTER I.
THE OPERATION, 127
CHAPTER II.
PATHOLOGICAL CONDITIONS OF THE PERITONEUM AND ALIMENTARY TRACT.
SECTION I.—OF THE PERITONEUM.
Congestion; Inflammation; Fibrinous Exudations;
Suppuration; Gangrene; Ascites; Morbid Growths, 133
SECTION II.—OF THE STOMACH.
Post-mortem Changes; Gastritis; Effects of Poisons;
Gastric Ulcer; Hæmorrhagic Erosion; Softening;
Cirrhosis; Atrophy; Dilatation; Morbid Growths, 137
SECTION III.—THE INTESTINES.
Malformations; Inflammation; Ulceration; Dilatation;
Contraction; Displacements; Incarceration; Volvulus;
Intussusception; Rupture; Ulcer and Fissure of the Anus;
Fistulæ; Hæmorrhoids; Morbid Growths; Parasites, 149
SECTION IV.—THE PANCREAS.
Anomalies; Hypertrophy and Atrophy; Inflammation; Fatty
Degeneration; Dilatation of Ducts; Cancer, 160
SECTION V.—THE SPLEEN.
Congenital Anomalies; Hypertrophy and Atrophy;
Displacements; Rupture; Inflammation; Thickening of
Capsule; Degeneration; Morbid Growths, 162
SECTION VI.—OF THE LIVER.
Normal state of; Congestion; Hæmorrhagic Effusion;
Perihepatitis; Scar-like Marks; Hepatitis; Secondary,
Pyæmic or Metastatic Abscess; Degenerations of the
Liver; Waxy, Lardaceous or Amyloid Liver; Atrophy;
Simple Atrophy; Acute or Yellow Atrophy; Chronic
Atrophy; Cirrhosis, or Hob-nail Liver; Hypertrophy;
Morbid Growths; Parasites, 165
_Affections of the Gall-Bladder and Ducts._
Inflammation; Dilatation; Morbid Growths; Biliary Calculi, 189
CHAPTER II.
THE URINARY APPARATUS.
SECTION I.—THE KIDNEYS.
Congenital Anomalies; Congestion; Hæmorrhage; Nephritis;
Pyelitis; Abscesses; Inflammation of Capsule; Morbus
Brightii; Fatty Degeneration; Dislocated Kidney; Morbid
Growths; Parasites, 193
_The Ureters._
Dilatation; Inflammation; Morbid Growths, 205
_The Suprarenal Capsules._
Inflammation and Degeneration; Hæmorrhage; Morbid Growths, 207
SECTION II.—THE URINARY BLADDER.
Malformations; Dilatation; Hypertrophy; Contraction;
Inflammation; Morbid Growths; Parasites, 208
_Of the Urethra._
Malformations; Inflammation; Dilatation and Contraction;
Stricture; Rupture; Morbid Growths; Urinary Calculi, 212
CHAPTER III.
THE MALE GENERATIVE ORGANS.
SECTION I.—THE PENIS.
Congenital Anomalies; Hypertrophy and Atrophy; Fracture;
Paraphymosis; Balanitis; Herpes; Chancres; Morbid
Growths, 215
SECTION II.—OF THE SCROTUM.
Hypertrophy; Inflammatory Œdema; Morbid Growths, 218
SECTION III.—OF THE TESTICLES.
Congenital Anomalies; Hypertrophy and Atrophy;
Inflammation; Hydrocele; Hæmotocele; Varicocele; Morbid
Growths, 219
SECTION IV.—THE SEMINAL VESICLES AND PROSTATE.
Congenital Anomalies; Inflammation; Tubercular Deposits, 226
_The Prostate Gland._
Anomalies; Hypertrophy and Atrophy; Inflammation; Abscess;
Morbid Growths, 226
CHAPTER IV.
THE FEMALE GENERATIVE ORGANS.
SECTION I.—THE PUDENDA AND VAGINA.
1. _The Pudenda._
Congenital Anomalies; Hypertrophy; Inflammation; Morbid
Growths, 230
2. _The Vagina._
Anomalies; Occlusion; Dilatation; Laceration and Rupture;
Inflammation; Morbid Growths, 230
SECTION II.—THE UTERUS.
Anomalies; Hypertrophy and Atrophy; Hydrometra;
Malpositions; Hæmorrhages; Peri- or Retro-Uterine
Hæmotocele; Inflammation; Ulceration; Morbid Growths, 235
_Morbid Conditions following Parturition._
Rupture; Puerperal Inflammation, 241
_Extra-Uterine Pregnancy_, 244
SECTION III.—THE OVARIES AND FALLOPIAN TUBES.
1. _The Ovaries._
Malformations; Inflammation; Abscess; Morbid Growths, 247
2. _The Fallopian Tubes._
Anomalies; Inflammation; Morbid Growths, 251
SECTION IV.—THE MAMMÆ.
Anomalies; Hypertrophy; Atrophy; Inflammation and Abscess;
Morbid Growths, 252
_The Male Mammæ_, 257
PART IV.
MISCELLANEOUS SUBJECTS.
CHAPTER I.
OF THE PERIOSTEUM AND BONES.
SECTION I.—OF THE PERIOSTEUM.
Inflammation; Ulceration; Malignant Disease, 258
SECTION II.—OF THE BONES.
Inflammation and Abscess; Caries; Necrosis; Rachitis;
Mollities Ossium; Morbid Growths, 259
_The Medulla_, 267
CHAPTER II.
DISEASES OF THE JOINTS.
Malformations; Morbid Condition of Synovial Membranes;
Morbid Condition of Bursæ; Morbid Condition of
Cartilage; Ulceration of Cartilage; Chronic Rheumatic
Arthritis; Scrofulous Arthritis, 268
_Diseases of the Spinal Column_, 272
CHAPTER III.
OF TUMORS.
1. _Benign or Non-Malignant Tumors_, 274
2. _Malignant Tumors_, 286
CHAPTER IV.
POST-MORTEM APPEARANCES IN DEATH FROM UNNATURAL CAUSES.
1. _Death from Poisoning_, 294
2. _Death from Suffocation_, 300
3. _Death from Hanging or Strangling_, 301
4. _Death from Drowning_, 302
CHAPTER V.
MEDICO-LEGAL QUESTIONS.
1. _Method of Conducting a Medico-Legal Autopsy_, 304
2. _Questions Relating to New-Born Children_, 307
3. _Supposed Period of Death_, 312
4. _The Probable Cause of Death_, 317
CHAPTER VI.
ON EMBALMING THE DEAD, 320
CHAPTER VII.
PRESERVATION OF SPECIMENS OF MORBID ANATOMY, 326
INTRODUCTION
Before entering upon the study of any subject, it is of moment that the
student be thoroughly convinced of the importance of the knowledge which
he is about seeking to acquire, since his zeal in its pursuit will, in
most cases, be in proportion to this conviction. We will, therefore,
before entering upon the subject proper of this book, present in few
words, some considerations on the _importance of a study of morbid
anatomy as revealed by post-mortem examinations_.
The necessity of a study of anatomy and physiology by a medical student,
is now so universally recognized, that an attempt to prove its
importance would seem deserving only of ridicule; but the ignorance of
many practitioners on the subject of morbid anatomy, shows that this
study has yet to vindicate its claim as a necessary branch of a medical
education.
From a purely theoretical standpoint, the educated physician—one whose
motto is _Esse, non videri_—after combating a disease in vain, should
not feel content to remain in ignorance of its real nature, so far as
discoverable by anatomical changes, capable of being recognized after
death, even had he no prospect of adding thereby one jot to his
practical acquaintance with disease or to his power to combat it; yet
his scientific conscience (if we may be allowed the expression) ought
not to rest satisfied until, in all doubtful cases, his _ante-mortem_
diagnosis be confirmed or overthrown, and his conception of the case
completed in all its details by a _post-mortem_ examination.
Besides this purely individual scientific interest, there are weightier
practical reasons for an acquaintance with this branch of medical
science by the physician as practitioner.
Among the almost innumerable questions upon medical, theological, and
miscellaneous subjects which the American public feels at liberty to
propound to its medical advisers, none are of more frequent occurrence
and none are more justifiable than the two: “What is the matter with the
patient?” and “Will he, or can he, recover?” and to none is an answer
more imperatively demanded. The public very naturally, and with reason,
requires on the part of a physician the ability to make a diagnosis and
a prognosis. It will not be satisfied with being told that the name of
the disease is of no importance, that the doctor only wants to hear the
symptoms; that he does not cure _diseases_, but removes the symptoms of
disease, &c. Only an exceedingly well-trained public will accept these
truisms as an equivalent for diagnostic skill. Hence, it is the
physician’s interest, as well as his duty, as we shall see, to seek, in
all cases, to make a diagnosis, no matter how difficult the task may
prove to be. The question how far his treatment will be modified by his
diagnosis is a question of therapeutics, and does not belong here; but
certain it is, that a mere combatal of the symptoms as isolated
phenomena cannot be regarded as fulfilling the whole duty of a
conscientious physician.
The ability to make a diagnosis, and consequently prognosis, depends
upon a knowledge of pathology, with a knowledge of symptoms as signs of
pathological states and changes; and as such they must be critically
examined and their true import discovered, if possible. Thus treated, we
arrive, by various processes of reasoning, at a diagnosis, under which
the symptoms fall into their natural order of importance, and we run but
little risk of contending with remote subjective symptoms (of great
importance in differential therapeutics) to the neglect of more
important, though perhaps less prominent ones.
Besides this, we are, in a measure, prepared to foretell the probable
course of a disease, and can, therefore, in many cases, adopt
anticipatory measures, while in all we will be guarded against the
error, so often committed, of ascribing to the remedy used the so-called
“_aggravations_,” which are often only natural symptoms of the unchecked
and, perhaps, entirely uninfluenced morbid process. Such knowledge
serves thus, by purifying our experience, to guard us against
self-deception, and to prevent us from misleading others by reports of
cures of diseases existing only by virtue of a false diagnosis.
A knowledge of pathology, furthermore, places in our hands a thread
which can guide us through the labyrinth of our vast materia medica, and
which enables us, from the myriad of symptoms, to eliminate the
non-important ones. It shows us the “bearings” of the medicines and
their various specific ranges, thus materially facilitating the choice
of a remedy.
Again, medical science is virtually based upon pathology, and we see,
therefore, how important, nay, how absolutely necessary, to the progress
of the former is the study of the latter. The practice of medicine as an
art can never be advanced knowingly by those who neglect its cultivation
as a science. While each one may practice the art according to his own
convictions, true medical science stands above all the belittling,
bigoted prejudices of the schools. Here, every one claiming the name of
an educated physician can and ought to work.
The wild vagaries of former ages, when philosophy set up purely
theoretical views, under which observed phenomena were compelled to
arrange themselves, have warned the present age to be guided solely by
sober and exact observations and investigations; and it needs no proof
that, in the advancement of our knowledge of disease, these are best
accomplished by frequent post-mortem examinations, which thus become a
necessary adjunct to a proper study of pathology.
In all cases of interest, therefore, the physician should feel it a duty
which he owes to himself and the profession at large, to seek permission
to make a post-mortem examination; but in order that the fullest benefit
may be derived from the same, he must know how to look for what he is in
search of, and how to recognize it when found.
To furnish this knowledge is the object of the following pages, to which
we herewith introduce the reader.
PRELIMINARY CHAPTER.
INSTRUMENTS AND GENERAL DIRECTIONS.
=The Post-mortem Case=, as prepared by the instrument makers, will be
found to contain, usually, the following instruments:
[Illustration: [Scalpels]]
1. A set of ordinary dissecting scalpels, four or five in number, and of
graduated sizes, including one heavy cartilage knife.
[Illustration: [Knife]]
2. A brain knife with a long blade, for slicing the brain.
[Illustration: [Chisels]]
3. Chisels, of one or both the accompanying forms, for use in opening
the head or spine.
[Illustration: [Hammer]]
4. An iron mallet or hammer, with a hook on the end of the handle for
tearing off the culvarium.
[Illustration: [Enterotome]]
5. An enterotome, or scissors with blunt, hooked point, for splitting
open the intestinal canal.
[Illustration: [Saw]]
6. A saw with movable back; this arrangement permitting of a deeper cut,
in dividing large bones.
[Illustration: [Rachitome]]
7. The rachitome, a chisel-like instrument, to be used with the hammer
in opening the spinal canal.
[Illustration: [Saw]]
8. The double saw, used for dividing the laminæ of the vertebræ. A side
view of the instrument being given in the cut, one blade only is seen.
The two are attached to one handle, placed parallel with one another,
and about one and one-fourth inches apart. After the soft tissues have
been removed, this saw is used by passing the spinous processes between
the two blades, and thus dividing both laminæ at once.
[Illustration: [Clamp]]
9. A skull clamp, for steadying the head while removing the calvarium.
After the removal of the scalp, this instrument may be employed, and be
of much service for the above object. It is applied by placing the open
end of the instrument over the crown of the head, turning down the
screws, and thus fastening it just above the line of division of the
bone. The arched end of the instrument now serves as a handle for
turning or steadying the head.
10. Rib-shears, for dividing the ribs where that operation is found
desirable.
11. A tube for inflating the lungs, and an ordinary blowpipe.
12. Dissecting forceps, tenacula in handle and with chain, grooved
director, and assorted needles, straight and curved.
While a post-mortem case with all of the above instruments is very
convenient, and important even, where there is frequent occasion for its
use, still its absence should never deter the physician from making an
examination where the ordinary dissecting case may be had; and with the
country physician generally, this case is all that is absolutely
essential, as a common carpenter’s saw and chisel may at any time be
found, in cases where the head is to be opened; while for opening the
chest and abdomen, the dissecting case contains everything that is
essential.
Instruments used in post-mortem examinations should never be employed
for operating upon the living, without first being repolished by the
instrument maker, and the handles disinfected by careful cleaning in a
solution of permanganate of potash.
PRELIMINARY PREPARATIONS.
=The Preliminary Preparations= at the place of the operation should
consist in providing a sponge for absorbing fluids; newspapers and old
cloths for filling cavities or wrapping up any morbid specimen that it
may be desirable to preserve; a couple of quarts of clean sawdust or
wheaten bran for throwing into the cavities before closing them up, and
thus absorbing any excess of fluids; stout thread or twine for tying
intestines and closing the cavities; lard or sweet oil for oiling the
hands; a couple of empty slopbuckets for receiving the fluids, bloody
water, &c., and plenty of water, hot and cold, with towels and soap. If
the floor of the room is carpeted, to protect it from accident, a piece
of old carpet, or quilt, or oilcloth should be spread alongside the
table or box where the examination is made. Care should be observed to
have all these matters provided before the operation is commenced, when
the door should be fastened, that there may be no intrusion, by accident
or otherwise.
In preparing the body for examination, if the head is to be opened and
the body is in an ice-box, it will be absolutely necessary that it be
removed. Placing the cover of the box on the floor, the body may be
lifted out and placed on the same, when both may be again placed on the
top of the box or on a table, for the examination. If only the chest and
abdomen are to be examined, it will hardly be necessary to lift the body
from the box. In all cases, the sheet in which the body is placed, with
the underclothing, (the latter having been split down the centre,)
should be carefully turned aside, and care observed during the operation
to avoid as much as possible soiling them with blood-stains.
=Precautionary Measures.= That there is a certain amount of danger from
absorption of virus in case of cuts or scratches received while
conducting a post-mortem examination, cannot be denied; yet this danger
is by no means common to every case. In the great majority of instances,
probably no mischief whatever would follow such an accident, the danger
being confined almost wholly to cases of peritoneal inflammation,
erysipelas, and certain malignant forms of disease. In all cases,
however, it will be well to look for any scratch, cut, or abraded point
on the hands or fingers, and first touching them with nitrate of silver,
cover them finally with collodian. Smearing the hands well with lard or
olive oil will also aid much in preventing absorption.
Should an accidental cut be received during the operation, it will be
prudent, in all cases, to wash the hands at once, squeeze and suck the
part, to favor bleeding, and, finally, touch with a crystal of nitrate
of silver. Punctures with a needle or slight scratches which do not
bleed are, probably, more dangerous than a free cut; hence, in cases of
suspected danger, when a puncture has been received, it would be safer
to make a free incision with a knife, thus inducing bleeding, which will
favor the washing out of any virus, and finally, use the caustic.
=Time for Making the Examination.= As a rule, post-mortem examinations
should be made as soon after death as a due regard to the feelings of
friends will permit, say within twelve to twenty-four hours; a longer
delay would give time for such decomposition as not only to make the
examination extremely disagreeable, but, from change of structure in
tissues and organs, much less satisfactory. In cold weather, however, or
where the body has been placed in ice soon after death, as is the custom
in most cities, the examination may be postponed to any convenient time
before the burial.
=Notes.= In all important cases, notes should be taken down by an
assistant, on the spot, as dictated by the operator; heading these by
the name and age of the patient and a brief sketch of the disease. In
medico-legal cases, this is to be conducted with particular care, as
will be pointed out hereafter.
=Consent of Friends.= Much difficulty will sometimes be met in obtaining
the consent of friends for a post-mortem examination, the idea of the
mutilation of the body of the deceased striking many with particular
dread. With a little tact and management, however, consent may, in the
majority of instances, be obtained. Instead of speaking to a single
member of the family and leaving him or her to bring the subject before
others, in all doubtful cases it will be better for the physician to see
all the interested parties himself, either together or separately, and
endeavor to interest them in the case, by pointing out the peculiar
character of the disease, the satisfaction which the friends will
themselves derive from a verification of the diagnosis of their
physician, while, when too late, they may regret having withheld their
consent; also the scientific interest which attaches to the case, and
the benefit which will no doubt accrue to medical science through a
post-mortem examination, and the possibility that the lives of others
may depend upon a knowledge of the true state of this case. These, with
like considerations, adapted with ready tact to the class of persons to
be persuaded, will, in the majority of instances, be enough to overcome
all scruples, especially when joined to the assurance that the
examination will be so conducted as to leave no visible trace of the
operation with which to embitter the remembrance of the well-known
countenance.
PART I.
THE HEAD AND SPINE.
CHAPTER I.
THE OPERATION.
In opening the head for a post-mortem examination, let a thick block be
placed beneath the occiput, when, after having carefully parted and
turned aside the hair, an incision may be made through the scalp, over
the top of the head, from ear to ear. The back of the scalpel being
placed next the head, the point may be pushed in advance, thus dividing
the tissues without danger of injuring the edge of the instrument by
bringing it in contact with the bone.
From the loose connection of the tendon of the occipitofrontalis muscle
to the periosteum, by the use of the handle of the scalpel, the flaps of
the scalp may readily be turned aside, the anterior over the face, the
posterior on the back of the neck. The _skull clamp_ may now be applied,
which will be of great service in steadying the head while using the
saw. Instead of dividing the skull in a circular manner, as is usually
done in the dissecting-room, it will be better to start the saw above
the frontal eminences and run obliquely down towards the mastoid
process, meeting this line by another commencing at the occipital
protuberance and carried horizontally forwards, thus giving a wedged
form to the portion removed. The advantage of this method consists in
our being better able to hold the parts in position as they are
replaced, as in the old method, from the readiness with which the parts
move upon one another, the calvarium is liable to slide forwards or
backwards from its position, thus producing an unsightly ridge across
the forehead, which will more or less plainly show through the
integument. With young children, a strong pair of scissors may be used
instead of the saw in dividing the calvarium.
In using the saw, care should be observed not to injure the dura mater;
hence it will be better not to attempt to divide both tables with that
instrument, but rather depend upon the chisel or rachitome for breaking
away the inner table. To avoid the sound which would attend the use of
the iron hammer, which, if heard by members of the family, might excite
unpleasant feelings, a billet of wood or wooden mallet may be used; or,
these not being at hand, the head of the iron hammer may be muffled with
a towel, so as materially to deaden the sounds. The inner table having
been divided, the calvarium may be pried off with the chisel, or torn
away with the hook on the handle of the hammer. This, from the close
adhesion of the dura mater to the bones, will generally require
considerable force.
The calvarium having been removed, and the superior longitudinal sinus
opened, and the condition of its contents noted, the dura mater, after
its careful examination, may be cut through with the knife or scissors
in the line of the division of the bone. The membrane may now be lifted
up, when adhesions will be found between its under surface and the pia
mater, along either side of the falx cerebri. These should not be
mistaken for results of inflammation, as they sometimes are, they being
simply the points of entrance of the veins of the pia mater into the
superior longitudinal sinus. These having been divided, with the falx
near its attachment to the crista galli, the whole may be turned back,
exposing the brain.
To remove the latter, take away the block from beneath the head, and
lifting the anterior lobes of the brain, divide successively the several
pairs of nerves as they appear in sight, with also the tentorium on
either side, and as the brain falls back into the left hand, the knife
may be passed down into the foramen magnum, and the medulla oblongata
and vertebral arteries divided, when the whole may be lifted from its
position. More or less blood with the _cerebro-spinal fluid_ will
necessarily flow off during this operation, to secure which, a bucket
should be placed beneath the edge of the table, over which the head
should slightly project. In dropsy of the brain, although the fluid is
mainly in the ventricles, it may escape during the operation and be
caught in the same manner.
The external surface of the brain having been carefully examined, the
hemispheres may be sliced off to a level with the corpus callosum, when,
by removing the latter, the cavities of the lateral ventricles will be
exposed. After a careful inspection of the several objects seen here,
the fornix and velum interpositum may be removed, opening thus into the
third ventricle. Slices may now be taken off the corpora striata and
optic thalami, with deeper portions of the hemispheres, and sections
made of the crura cerebri cerebellum and medulla oblongata, thus giving
an opportunity of judging of the condition of all those parts.
After the removal and examination of the brain, attention should be
given to the _base of the skull_. The lateral and other sinuses should
be laid open, the dura mater, as far as possible, torn away, and the
bones examined for fractures, caries, abnormal growths, etc.
“_The simplest method for removing the ear_ for the sake of dissection
is, after the removal of the calvarium in the usual way, to take out
both the petrous bones together by means of two transverse vertical
sections, one in front of the two petrous bones and the other posterior
to them. The anterior of these sections should pass in a line a little
anterior to the anterior clinoid processes, and the posterior in a line
through the posterior third of each mastoid process. By means of these
two sections, the trumpet-shaped extremity of each Eustachian tube, a
portion of the mucous membrane of the fauces, and the whole of each
petrous bone, together with the mastoid processes, can be taken out.
“The disadvantage of this procedure is the disfigurement which is apt to
ensue from the falling in of the face. To avoid this disadvantage,
another mode of removing the ear may be resorted to. This consists in
taking out each petrous bone separately in the following manner: The
calvarium having been sawn off, an anterior section is to be made in
each side in the same line as in the above plan, but extending only as
far as the outer part of the body of the sphenoid bone; a posterior
section in each side is then to be made, as in the first plan, but not
extending farther inwards than the basilar process of the occipital
bone. These two sections are to be made with a saw or with a chisel and
hammer. The apex of each petrous bone is then to be separated from the
sphenoid and occipital bones, and each petrous bone (the outer ear and
integument being detached and reflected downwards) is to be drawn
outwards, taking care, by inserting the scalpel deeply, to remove as
much of the soft parts as possible.
“The organ of hearing having been removed, the dissection may be
conducted in the following manner: The auditory nerve in its meatus
should be first carefully examined, presuming that a previous inspection
has been made of the portion of the brain to which the portio mollis and
portio dura nerves are attached. The size of the external meatus having
been ascertained by allowing a strong light to fall into it, its
anterior wall is to be removed by the cutting forceps.
“The state of the epidermis, the ceruminous glands and secretion, the
dermis, periosteum and bone is to be noticed. The outer surface of the
membrani tympani is then to be examined; also the state of its
epidermoid and dermoid laminæ, its degree of tension, and the amount of
motion possessed by the malleus when pressed upon by a fine point. The
next step is to ascertain the condition of the guttural portion of the
Eustachian tube, to lay open the cartilaginous tube with the scissors,
and then to expose the cavity of the osseous portion by means of the
cutting forceps. In doing this, the tensor tympani muscle is exposed;
its structure should be examined, and if it has not a healthy
appearance, portions of it should be submitted to microscopic
inspection. The upper wall of the tympanum is next to be cut away by
means of the cutting forceps. In doing this, great care must be taken
not to disturb or disconnect the malleus and incus, which lie
immediately beneath it. After the tympanic cavity has been exposed, the
first step is to pull the tensor tympani muscle and ascertain how far it
causes a movement of the membrana tympani and ossicles. The incus and
stapes are now to be touched with a fine point, so as to ascertain their
degree of mobility; the tendon of the stapedius muscle is also to be
pressed upon. The condition of the mucous membrane of the tympanum and
of the mastoid cells is then to be ascertained, and any peculiarity of
the cavity, the existence of bands of adhesion, etc., to be noted.
“The most delicate parts of the dissection, viz., that of the internal
ear, must now be undertaken. The cavities of the vestibule and cochlea
are to be exposed by removing a small portion of the upper wall of each.
Before reaching the vestibule, the superior semi-circular canal will be
cut through and removed; the membranous canal should be drawn out and
inspected. As the cavities of the vestibule and cochlea are laid bare,
it is desirable to see that the quantity of perilymph is natural, as
well as its color and consistence. The outer surface of the membranous
labyrinth having been observed, it should be opened so as to expose the
endolymph and otoliths, portions of all which parts should be removed
for microscopic inspection. This having been effected, the remaining
membranous semi-circular canals are to be exposed, and the connection of
the base of the stapes to the fenestra ovalis carefully examined. The
last stage of the dissection consists in removing parts of the lamina
spiralis, in examining them microscopically, and in exposing from
within, by following the course of the scala tympani, the membrane of
the fenestra rotunda.
“The only part which now remains unexamined is the stapedius muscle; in
order to expose it, the course of the aquæductus Fallopii, beginning at
the stylo-mastoid foramen, should be followed until the base of the
pyramidal eminence containing the muscle is reached.”[1]
_The Eyes, with the optic nerves_, may be most conveniently removed for
examination, by breaking up the roof of the orbit with the hammer, and,
after the removal of the fragments of bone, dissecting away the fat and
muscles until the ball is exposed, when, with the scissors, the tunics
of the latter may be divided just behind the conjunctival attachment,
and the ball removed with the optic nerve. The front portion of the eye
being left in position, by filling the cavity behind with a little
cotton or paper, any flattening may be prevented, and thus any
appearance of loss of parts avoided.
The examination having been completed, the brain may be replaced, the
calvarium put in position, the scalp brought over the same and united
with stitches, the arranging of the hair effacing all traces of the
operation.
THE SPINAL CORD.
For the removal of the _spinal cord_, place the body in a prone
position, and make an incision the whole length of the back, over the
spinous processes of the vertebræ. Then raise up and turn aside all the
muscles with the integument, exposing the laminæ of the vertebræ. The
latter may now be divided with the single or double saw, the rachitome
or chisel being used to complete the operation, when the laminæ, with
the spinous processes, may be removed in one strip, exposing the cord
enclosed in its membranes.
The roots of the nerves may now be divided, and the cord, enclosed in
its sheath, removed; care being observed not to handle the parts roughly
while so doing. The dura mater may now be split open for the examination
of the cord. Should it be desired to preserve any portion for
microscopic examination, it may be suspended in a solution of bichromate
of potass, xx to xxx grs. to the ounce of water, and in a few days
transferred to a solution of chromic acid, ij grs. to the ounce of
water, where it should remain until sufficiently hardened to be cut into
thin sections.
The examination completed, the parts may be replaced and the incision
sewed up.
CHAPTER II.
PATHOLOGICAL CONDITIONS.
Section I. OF THE SKULL.
[=Notice= in examination, condition of _scalp_; cuts, bruises,
extravasation of blood, &c. _Cranium_—Color, smoothness or roughness
of exposed surface; fractures, their position and relation to injuries
of scalp. _Removal of Calvarium_—Adhesion of dura mater; inner surface
of; smooth or rough; seat of same; deposit of new bone; depression of
inner table; thickening or thinning of. State of fontanelles in
children; condition of frontal sinuses; condition of base of skull
noted after removal of brain; fractures; condition of petrous portions
of temporal bones, &c.]
=Fracture.= In a post-mortem examination of the head, after death from a
blow or fall upon that part, a fracture may be disclosed of which there
was no external trace. Owing to the greater thinness and brittleness of
the inner table, it is possible for this to be fractured without any
corresponding injury to the external; such fracture may possibly rupture
some of the branches of the meningeal arteries, which will be followed
by the formation of a clot between the bone and dura mater, the pressure
of which may be sufficient to produce death. Owing to the same
cause—greater brittleness of the inner table—when fracture of the outer
exists, that of the inner table will be likely to be more extensive,
accompanied perhaps with depression, of which there is no external
evidence.
Again, it will sometimes be discovered that fracture exists at a point
opposite to that upon which the blow was received, on the principle of
the “_contre coup_” of the French; thus, the blow having been received
on the occiput, the fracture may be found in the frontal region; or,
received on the top of the skull, fracture may result at the base. In
falls from a height, upon the top of the head, the weight of the body,
acting through the cervical vertebræ as a propelling force, is very
likely to produce fracture of the occipital bone.
=Caries= may affect any of the bones of the head, but in the majority of
cases it will be the result of syphilitic or mercurial poisoning.
Following an attack of periostitis, the inflammation extends to the bone
and gradually develops the carious ulceration. While the condition is
usually confined to, or at least, most strongly developed upon the outer
table, it may involve the entire thickness. In syphilitic ulceration of
the bones of the nasal cavity, the disease may destroy the cribriform
plate of the ethmoid bone, and thus extend to the membranes of the
brain.[2] So also, in caries of the petrous and mastoid portions of the
temporal bone, which sometimes results from scarlet fever, the disease
may extend to the inner surface, resulting in the accumulation of pus
within the cranial cavity.
Along either side of the central portion of the inner surface of the
calvarium may be usually seen, at least in the heads of aged persons, a
number of irregular, rough pits, varying in size and depth, which are
not to be mistaken for disease of the bone, they being simply
impressions of the _Pacchionian glands_.
=Thinning= of the bones of the head will always indicate _increased
pressure_ from within, induced by hypertrophy of the brain, or, as is
more frequent, hydrocephalus. In the latter case, not only thinning, but
complete absorption of the parietal and other bones may result.[3]
=Increased Thickness= will also sometimes be found. This condition
indicates _diminished pressure_ from within, as in atrophy of the brain.
The thickening results from a gradual remodeling of the inner table and
diploe, so that while the exterior of the skull may retain its normal
size and form, the inner table following the retiring and shrinking
brain, the interval between the two becomes filled with the thickened
diploe. It has been observed that this hypertrophy is greatest at those
parts of the bones where ossification first commences, as at the
parietal and frontal eminences. It is not confined to old persons,
though perhaps more frequent with them.[4]
Section II. THE MEMBRANES OF THE BRAIN.
1. The Dura Mater.
[=Notice= color and general character of surface; blood between it and
bone; position of; quantity; coagulated or not. Condition of
bone—necrosed or fractured; pus between dura mater and bone.
Tumors—their position, size, &c. Wounds—their position, extent, &c.
Open longitudinal sinus and note contents.]
This membrane, serving both as a periosteum to the inner surface of the
cranial bones and as a support to a serous membrane—the reflected layer
of the arachnoid—is subject to affections of a two-fold character, those
peculiar to the fibrous and serous portions.
=Inflammation= of this membrane, may involve either the outer fibrous,
or the inner serous layer. In the former case, the membrane appears
congested, red and more or less softened. The inflammatory process may
result in the formation of pus between the bone and dura mater, and even
in gangrene. The disease may also extend to the adjacent portions of the
pia mater and brain substance. External injuries, fractures of the bones
of the skull, inflammation of the periosteum, otitis, resulting in
caries of the temporal bone, may all be causes of inflammation of the
outer portion of the dura mater.
Inflammation of the inner surface of this membrane, is marked by the
presence of a net-work of delicate red vessels, while the surface is
covered by a soft, grayish or yellow semi-purulent matter, and may
attend cases of pyæmic poisoning, puerperal peritonitis, or some of the
exanthemata.
=Thickening= of the fibrous portion of the dura mater may be found as a
result of chronic inflammation, either spontaneous or as the result of
external injury. From the identity of structure between this and other
fibrous tissues of the body, it is not unlikely that this thickening is
often the result of a rheumatic form of inflammation.
External violence is, however, most commonly the cause of the change. In
one case, the patient fell down stairs in a state of intoxication,
striking the head on the steps. He continued in a state of insensibility
for nine days, when he began to show signs of returning consciousness,
taking food and drink, but memory, judgment, and all the mental
faculties were gone. Death ensued in about two years. The dura mater of
the left hemisphere was found greatly thickened. The pia mater
infiltrated with a large amount of serous fluid. The convolutions were
atrophied, and about four ounces of serous fluid found in the
ventricles. The _fornix_ was softened and the _septum lucidum_ entirely
destroyed.
=Fibrinous Clots, or Thrombi=, will be occasionally found within the
sinuses of the dura mater, where they may have given rise to congestion
of the brain, with apoplectic effusions, paralysis, convulsions, coma,
etc. They may originate from injuries of the head, inflammation of the
dura mater, pulmonary disease, etc.
=Tubercular Deposits= are also sometimes found in this membrane,
appearing, however, mainly upon the arachnoid surface. They present the
usual character of tubercle, having a whitish or grayish appearance,
with the consistence of cheese, and scattered in small particles upon
the surface. They are found in _tubercular meningitis_, (a disease
common with children but rare with adults,) and in most of those cases
of so-called acute hydrocephalus.
=Tumors= of various kinds are occasionally found in the dura mater,
including _cystic_, _fibrous_, _fatty_, _osseous_ and _cancerous_
growths. The latter may cause such absorption of the bones of the skull,
as to appear on the exterior of the head.
In one case which came into the dissecting-room some years ago, thin
_bony formations_ of the size of a silver quarter dollar were found in
the tentorium, and smaller ones in the falx cerebri. Nothing could be
learned of the previous history of the case.
2. Arachnoid and Pia Mater.
[=Notice= in examination, contents of cavity of arachnoid; serum or
blood; if former, amount, color, odor; if blood, situation, quantity,
fluid or coagulated; adhesion of surfaces of arachnoid; tubercles,
their position, &c.; color of membrane; vascularity, transparency, or
opacity. _Sub-arachnoid_ fluid—quantity, position, color, &c. _Pia
mater_—vascularity, in points and entire; serous effusion into
substance of; blood, &c.; position, size, &c., of clots; granulations,
(tubercles,) number, position, &c.; Tumors—size, position, and
character.]
As morbid conditions of the arachnoid membrane are more common with its
visceral layer, and as these conditions usually involve the pia mater,
the two membranes are here noticed together. They will be found
presenting various degrees of congestion after death, which will not
necessarily be a positive indication of the extent of congestion during
life.
=Pacchionian Bodies.= Along either side of the great fissure may be
noticed within the pia mater of adults, several small white bodies,
varying in number and size—the _Pacchionian bodies_. They may cause
absorption and perforation of the dura mater, and even of the bones of
the skull. Being looked upon as the result of mere senile changes, they
do not indicate the presence of disease, though repeated congestions of
the brain appear to favor their more rapid development.
=Inflammation= of these membranes, or _meningitis_, is a very common
affection, and is accompanied with an accumulation within its substance
or beneath its layers, of serum, lymph, or fibrine in various
proportions. It may be confined to circumscribed portions, or involve a
large portion of the membrane, and even extend to the spinal cord.
Adhesions between the two surfaces of the arachnoid sometimes result
from this form of inflammation.
Insanity in its various forms is most frequently accompanied with some
morbid condition of these membranes. In twenty-two cases of insane
persons whose brains were inspected by Dr. Marshall, in twenty-one,
serous fluid, varying in amount from one to twelve ounces, was found in
the ventricles, and in seventeen of these twenty-one cases, similar
effusion was found in the sub-arachnoid space, or within the substance
of the pia mater. While red injection of the membrane was found only in
four cases, yet other conditions—the effusions, &c.—were evidently the
result of previous inflammation. In nine cases were the arteries of the
brain opaque, thickened, steatomatous, or ossified; conditions highly
favorable for deranging the capillary circulation of the membranes or of
the brain.[5]
The following statement gives the principal morbid changes of these
membranes which have been found in cases of insanity:
1. Injection, more or less intense, of the _pia mater_, giving a red or
scarlet appearance; or, where infiltrated with serous fluid, presenting
a pale gray color and increased in thickness.
2. The arachnoid (the visceral layer) becomes opaque and thickened,
resembling the dura mater or macerated parchment.
3. The meningeal injection may terminate in serous effusion, either from
the free surface of the arachnoid into the sub-arachnoid tissue, (pia
mater,) or from the choroid plexus into the ventricles.
4. Albuminous exudations may be found upon the free surface of the
arachnoid of the _dura mater_, covering its whole extent, or confined to
definite portions.
5. Adhesions of the two surfaces of the arachnoid may rarely be found.
It is most common in the great fissure, and has been found in the
ventricles.
6. Blood may be effused upon the surface of the arachnoid or in the
substance of the pia mater.
=Serous Effusion.= As has been already intimated, this may be found
either in the cavity of the arachnoid—between the reflected and visceral
layers—or within the ventricles. In the former position, the quantity is
never large, while in the latter, it may amount to twelve or sixteen
ounces, and be present for many years. When in such large quantity,
there will be great distension of the ventricles and thinning of the
corpus callosum and fornix, with destruction of the septum lucidum, as
well as more or less separation of the cranial bones. It is only in
children and before the bones of the head have become united, that such
large accumulations are possible, as at a later period, from the
unyielding condition of the walls of the skull, the presence of a single
ounce, particularly if suddenly formed, would produce death. In all
cases, the danger to life will be in proportion to the rapidity of the
formation; a very slow and gradual accumulation permitting either of an
expansion of the cranial bones, or a gradual absorption of brain
substance, thus preserving an approximation to the normal pressure on
the brain tissue.
Serous effusions, like sanguineous, are generally the result of over
distension of the cerebral vessels, either from mechanical obstruction,
or a weakened condition of the coats of the vessels, with increased
force in the action of the heart. It generally attends tubercular
meningitis, and may be favored by an anæmic condition of the system. The
symptoms during life, attending a rapid effusion of serum, are not so
readily distinguished from those of sanguineous effusion, as to enable
us to pronounce with certainty in any given case as to the cause of the
cerebral pressure.
=Sanguineous Effusion—Apoplexy.= Effusions of blood may be found between
the bones and dura mater; between the two layers of the arachnoid;
within the substance of the pia mater; within the ventricles, or within
the brain substance. Blood clots will seldom be found between the bone
and dura mater, except as a result of mechanical injury, and in the
majority of cases as an attendant upon fracture. If a fragment of the
bone at the same time, be driven through the dura mater, then a clot may
be found in the arachnoid cavity. But in another class of cases, where
death has resulted from blows upon the head without producing fracture
of the bones, the whole surface of the brain in the region of the
injury, and not unfrequently in distant parts, after the removal of the
dura mater, is found covered with a layer of blood, which at first sight
appears to be outside of the membranes; but on close examination, it is
found that the blood is effused or infiltrated into the sub-arachnoid
tissue, and that it has escaped from the lacerated vessels in the pia
mater. The thickness of the layer varies. It is generally in greater
quantities at the sides and base of the brain, and the inferior lobes
and cerebellum may be covered by it. It is usually thickest over the
crura, the pons Varolii and medulla oblongata.
In the same class of cases the blood may be also effused into the
ventricles. These appearances are so uniformly the result of violence,
as to form a valuable piece of evidence in medico-legal inquiries, to
prove that such hæmorrhage and death could not be the result of internal
causes.
In the greater number of _still-born_ children, an examination of the
head will show a similar condition of things. The surface of the
cerebrum generally, with sometimes that of the cerebellum, will be found
covered with a layer of coagulated blood effused into the pia mater,
while the ventricles will often be filled with clots. Where the history
of the case is not known, it might at first be suspected that death was
the result of violence inflicted after birth. Violence has, to be sure,
been the cause of death, but it is such violence as attends a protracted
case of labor, with, perhaps, a large head, and a contracted pelvis of
the mother. The wonder is, that from the great pressure to which the
head is subjected during labor, that so few children are still-born or
do not die soon after birth, from rupture of the cerebral vessels.
Effusions into the ventricles, may also be frequently the result of
external violence. The pia mater, the vascular membrane of the brain, we
find carried into these cavities by means of the velum interpositum,
which forms the roof to the third ventricle, while its borders extend
into the lateral, forming the choroid plexuses. The effused blood may,
therefore, extend along this membrane into the cavity of the ventricles.
Again, blood may be effused in any portion of the _brain substance_,
constituting true sanguineous apoplexy. Certain parts are much more
frequently the seat of these effusions than others. They are more common
in the striated bodies or optic thalami—probably from the greater
vascularity of those parts—but may be found in the corpora quadrigemina,
the pons Varolii, the crura cerebri, or in the cerebral hemispheres, and
occasionally in the cerebellum. The symptoms during life will vary
according to the location of the effusion; when in the pia mater, or in
other words, outside of the brain, paralysis will seldom attend, though
the coma may be profound, with relaxation of the muscular system and
sometimes convulsions. When the hæmorrhage is in the optic bed or
striated body of one side, from the decussation of fibres in the medulla
oblongata, paralysis of the opposite side of the body will follow; while
if the effusion has taken place in both hemispheres, the palsy will be
double-sided, though probably more complete on one side than on the
other.
Effusions of blood into the corpora quadrigemina, will most frequently
be attended with muscular tremblings or convulsions, and probably
impaired sight, with some change in the pupil. When in the medulla
oblongata, convulsions, followed by palsy, deep coma, and early death;
greater fatality attending effusions at this point, probably, than at
any other. When the effusion takes place in the cerebellum, the loss of
consciousness will be very temporary; there may be relaxation of muscles
without palsy or loss of sensibility, and, it is said, frequent
vomiting.
The _amount_ of blood effused is subject to the greatest variation.
Clots may be found as large as a hen’s egg, or smaller than a pea.
Indeed, violent apoplectic attacks, ending in death, may occur, where
the most careful examination will fail to detect _any_ effused blood,
death being the result of extreme congestion of the membranes. On the
other hand, the presence of a clot is not necessarily fatal, evidence
being abundant that they may be so far reabsorbed as to be followed by
at least partial recovery.
The following cases will serve to illustrate these several conditions:
CASE I.—_Sudden Death from Cerebral Congestion._
Mr. M——, aged thirty-five years, had always enjoyed good health. For
some months previous to death, had been working very hard, with a good
deal of anxiety, in arranging the affairs of a company of which he was
secretary. On the evening previous to his attack, he retired at eleven
o’clock, well and in good spirits. At three o’clock A. M., his wife
was wakened by his heavy, stertorous breathing, attended with slight
convulsive movements of the limbs. In less than a half hour he was
dead. The post-mortem showed the heart, lungs, and abdominal organs to
be in a perfectly healthy condition, while the most careful
examination of every portion of the brain failed to expose the least
effusion of blood. The ventricles and sub-arachnoid space contained a
moderate amount of serum, while the vessels of the pia mater were
strongly engorged with blood.
CASE II.—_Apoplectic Attack, followed by Death in Three Days; Clot found
in Thalamus._
Mr. J——, aged sixty-one, a butcher, abstemious in his habits but
plethoric in temperament, was suddenly stricken down with an attack of
apoplexy, which left him with paralysis of the right side of the body,
with impaired speech and memory. He gradually and almost entirely
recovered. Ten months after, while in the street, he fell with another
attack. He partially recovered consciousness, but had complete palsy
of the _left_ side, and died in three days. Here, the post-mortem
revealed excessive congestion of the pia mater, and a large clot, the
size of a hickory nut, in the _right optic thalamus_. In the _left
thalamus_ was a distinct trace of a clot, (nearly absorbed, however,)
which had undoubtedly been effused in the attack ten months
previously.
CASE III.—_Apoplectic attack, followed by Hemiplegia, and Death in Five
Years._
Charles E. W——, at the age of forty-seven had a sudden apoplectic
stroke, in January, 1867, followed by partial paralysis of right side.
In May following, he had a second attack, which greatly increased the
hemiplegia, impaired the articulation, and weakened the memory and
intellect. His general health and strength gradually failing, he died
August, 1872, five years after the original attack.
Post-mortem revealed a greatly thinned and dilated condition of the
walls of the arteries of the base of the brain and the remnants of the
original clot imbedded in the left optic thalamus, the brain substance
around being of a dark color and much softened. From the appearance of
the dark, ragged remnant of the clot, it must have been originally of
about the size of a robin’s egg.
CASE IV.—_Death from Congestion, with Serous Effusion and Softening._
Mr. F. H——, aged thirty, had an attack of brain fever at twenty-three,
followed by attacks of severe pain in the head, recurring every few
days, weeks or months. These attacks were accompanied with slight
convulsive symptoms and delirium, the pain being of a most
excruciating character, and lasting from a few hours to two or three
days. The attacks were gradually increasing in severity, but without
any impairment of the faculties of the mind. On a Saturday night, he
was brought home with one of his worst attacks. When I first saw the
patient on Sunday evening, I found him in a half-delirious, stupid
condition, yet when roused up, giving satisfactory answers to
questions, but immediately sinking into his former condition, and
every one to five minutes starting suddenly up and, with staring eyes
and distorted face, uttering piercing shrieks and screams, and calling
to those around to shoot him, split open his head with a
hatchet—anything to release him from his sufferings. These paroxysms
would sometimes be followed by a convulsive action of the diaphragm
and abdominal muscles, ending in his sinking into the same dull,
stupid condition as before. In the interval of calm, the respiration
was remarkably slow and feeble, with a slow irregular pulse of forty
beats to the minute. These symptoms becoming gradually worse, he sank
into a comatose condition early Tuesday morning, expiring at daylight,
sixty hours after the commencement of the attack.
The post-mortem revealed greatly enlarged Pacchionian glands, with
extreme thinning of the skull over the same. The pia mater was
considerably congested. Upon turning the brain back for removal from
the base of the skull, there was a sudden gush of water from the
ventricles, sufficient of which was secured to show that the quantity
could not have been less than two ounces. Upon opening the lateral
ventricles, these cavities were found unusually large from distension
by the fluid, while the _septum lucidum_ and _fornix_ were found in a
soft, pulpy condition, the former being completely broken down and
detached from the corpus callosum above. The gray portions of the
corpora striata were also softer and more easily broken up than was
natural.
The appearance presented by a clot, as well as the brain substance
immediately around it, will vary according to the time the patient
survives the attack. When death follows in a few days, the clot will
have a soft, blackish appearance; after a month or six weeks, it becomes
firm, and assumes a deep brown color, and at a still later period, it
becomes still more firm, and of a pale red tint; lastly, it may become
entirely absorbed. Peculiar changes also take place in the brain
substance immediately around the clot, which vary according to the time
intervening between extravasation and death. The portion immediately in
contact with the clot is generally of a dark red or wine color, or, at a
later period, of a chocolate brown, and of a soft, pulpy consistency.
Exterior to this, the color is paler and of an orange tint, and still
further on, of a bluish-white or yellow. The change in _structure_ and
_consistence_ of the brain, immediately around the clot, constitutes one
form of softening soon to be noticed.
Section III. OF THE BRAIN.
[=Notice= _before removal_—size; form; symmetry; space between surface
of brain and calvarium. _After removal_—parts at base, their size,
symmetry, color on surface, infiltration with serum or blood. _Removal
of pia mater_—degree of adhesion; appearance of convolutions; color;
consistence; effect of stream of water. Ulcers—condition of brain
around. Sloughs—relation to membranes, condition of brain around.
Deposits; tumors, wounds, etc. _After section, notice_ breadth and
character of gray portions of convolutions; color, vascularity, etc.
_Consistency_—softened or hardened; of white substance; color.
_Blood-vessels_—number and size of red points in different portions.
_Extravasation of blood_—its situation; fluid or coagulated; amount or
size of coagulum; color, etc. Cavities in brain substance; their
number, shape and contents. Blood, purulent, or fluid; its quantity
and color. Condition of brain around; cicatrices; wounds; adventitious
substances, as tumors, calcareous masses, tubercle cancer, etc.
_Lateral ventricles_—note any difference in the two; contents; amount
of serum or blood. _Choroid plexus_—pale or congested; cysts;
calcareous bodies; their size and situation. _Lining membrane_ of
ventricles; its vascularity, roughness, opacity, etc. _Septum
lucidum_—entire or lacerated; consistence. _Fifth ventricle_—size,
contents, etc. _Third ventricle_; contents. Commissures—their
condition; middle, broken or double. _Optic thalami and corpora
striati_—size, symmetry; character of surface and interior; if
softened, extent; extravasation of blood, etc. Condition of _pineal
gland_; _corpora quadrigemina_; _valve of Vieussens_, _etc._ _Medulla
oblongata_—degree of adhesion of membranes; softening, exact locality
of; condition about origin of nerves; appearance upon section. _Fourth
ventricle_—contents; condition of floor, etc. _Cerebellum_—examine
with same care, and note same points as in cerebrum.]
=Inflammation.= Acute inflammation of the brain substance is a rare
disease, except as the result of mechanical injury. In such cases, the
disease is generally quite circumscribed, being confined to the
immediate region of the injury. The brain becomes very vascular,
acquiring a red color, which, at a later period, changes to a brown or
greenish hue, and becomes much softer than natural.
If a foreign body be lodged in the brain, as a piece of bone, or a
bullet, then the inflammation is likely to result in an _abscess_, which
will give rise to head-ache, delirium with intolerance of light,
succeeded by convulsions, coma and death.
_Subacute, or chronic_ inflammation of the brain, is much more common,
yet is accompanied with pathological changes similar to those of the
acute form. At first, the inflamed portion becomes red and congested,
the color gradually changing to a crimson, purple, brown, or claret
color, with more or less change of consistence.
The symptoms attending inflammation of the brain substance, or
_cerebritis_, are not readily distinguishable from those of meningitis;
indeed, in most instances the two diseases are, to a certain extent,
combined; as, from the vascular connection between the brain and pia
mater, there might be a ready extension of inflammation from one to the
other. When, however, there is any sudden perversion of the sense of
vision or hearing; or if there are convulsions, affecting mainly one
side of the body; or if coma succeeds the convulsions and is accompanied
by one-sided paralysis, we may expect to find evidence of inflammation
of the cerebral substance, with possibly that of the membranes also. It
is a fact to be borne in mind, however, that while in typhus and
typhoid, and perhaps some other forms of fever, we may have symptoms
strongly resembling those of idiopathic inflammation of the brain or its
membranes, still the post-mortem will reveal no trace of any such morbid
condition.
=Softening.= To be able to recognize readily any change in the
consistency of the brain, clear ideas must first be had of the normal
density of this organ. This may be obtained from an examination of the
brain of some of the lower animals—as the sheep or ox—that has been
killed in a state of health. We shall then find that the brain presents
sufficient firmness to permit of its being handled without rupture of
its substance, and to allow of its being sliced into thin sections which
will support their own weight. The gray portion is somewhat softer than
the white, yet the fibrous character of the latter, becomes apparent
only after hardening in alcohol. If put into pure water, it continues
unchanged for eight or ten hours, and without any portion becoming
dissolved, or rendering the water any degree turbid. The consistence of
the brain varies, normally, at different periods of life. In the fœtus
and at birth, its softness approaches to semi-fluidity. From this to the
fifteenth or twentieth year, it gradually acquires the firmness of the
brain of the adult.
=Softening=, one of the most common variations from the normal
condition, is generally a mere result of inflammation of a chronic or
sub-acute form, accompanied with a fatty degeneration of nerve
substance. Under the microscope, the change is seen to consist in a
disintegration of the nerve fibres, the medullary substance breaking up
into large masses, and undergoing fatty metamorphosis. It may take place
either on the _external surface_ of the organ, or in the _septum
lucidum_ and _fornix_, the _corpora striata_, or _optic thalami_ of the
ventricle, the central parts of the _hemispheres_, the _cerebellum_, or
the _crura cerebri_, in the order mentioned.
While this change is usually the result of inflammation, as already
mentioned, it may accompany or succeed the following morbid conditions
of the organ: 1. It may be the result of congestion of the vessels of
some portion of the brain. In this case, the softened portion is
reddish, crimson, or brown in color. 2. It may follow the effusion of
blood in apoplexy. The softened portion is then of a brownish color, or,
if considerable time has elapsed, it may be of a dirty ash color,
tending to green. 3. It may accompany or follow the process which
terminates in serous effusions. It is then of a milky-white color. 4. It
may take place in the brain substance immediately around tumors, when
its color may present a variety of tints.
Among the causes tending to induce this condition of the brain, may be
mentioned a diseased state of its blood vessels, or their obstruction by
fibrinous clots; constitutional syphilis; excessive mental labor, or
frequently repeated epileptic convulsions. The consistency will be found
to vary from a slight change from the normal condition, to that of a
soft, pulpy, or even cream-like condition.
The symptoms accompanying softening of the brain, present a considerable
variation. Among the more prominent, may be mentioned an unsteady or
tottering gait, partial palsy, thick and inarticulate speech, feeble
memory, disordered intellect, dull pain or heaviness in the head,
frequent drowsiness, formication, numbness or rigidity, or occasional
involuntary contraction of the muscles of the upper extremities.
=Abscess= of the brain, differs from softening, to which it may have
some points of resemblance, in the purulent matter being contained in an
irregular cavity, lined with a more or less distinct membranous cyst.
Flakes of lymph are frequently found in these abscesses, giving the
matter much the appearance of that contained in scrofulous abscesses,
and they are most commonly found in subjects who present the usual
symptoms of the strumous diathesis.
While these collections are unquestionably often the result of
inflammation, yet it has been claimed that they may result from previous
disease of a suppurative character in the lungs, and perhaps other
organs, the purulent matter being taken up by the veins and carried into
the general circulation, and finally deposited in the substance of the
brain. Abscesses may be found in any portion of the brain substance, or
the purulent accumulation may be found between the bone and dura mater,
or between the two layers of the arachnoid. In the latter cases, the
disease may generally be traced to caries of some of the bones of the
head, as of the petrous or mastoid portions of the temporal, or of the
bones of the nasal cavity, involving the cribriform portion of the
ethmoid.
Again, abscesses in the brain may result from external violence, as from
a blow or fall upon the head. It is remarkable, that in these cases,
some months may elapse between the date of the injury and death.
=Hardening.= Induration of the cerebral substance, is a condition not
readily distinguished during life from that of softening, the two states
being accompanied by symptoms of a similar character. Dr. Jones, who has
charge of the male department of the Pennsylvania Hospital for the
Insane, and has had many opportunities for examining the brains of
insane patients, tells me that he found hardening, nearly as frequently
as softening, in these cases, and never could tell beforehand, with
certainty, which condition might be present.
In hardening of this organ, its density may be increased to that of
boiled white of egg, or it may approach in consistence to that of a
brain that has been hardened in alcohol, losing much of the sticky,
adhesive character when broken up by the fingers, which marks the brain
substance when in its normal state. The cause of the change is not well
known, yet it is conjectured to be one of the results of inflammation,
inasmuch as it is generally found with its capillaries greatly loaded
with blood, while more or less fluid is found beneath the arachnoid and
in the ventricles. The induration may affect the greater part or even
the whole of the cerebral mass, or may be confined to particular
portions or regions.
In a case recently examined for Dr. Toothaker, of this city, where
insanity of some years’ duration, and finally death, had followed a
severe injury of the head, the brain was found so hard as to permit of
fracture in the direction of the fibres, thus readily tracing their
course.
The symptoms that have most frequently been observed to accompany this
change are, defect and gradual loss of memory, apathetic indifference,
slight difficulty of articulation, followed by loss of sexual desire,
partial palsy, fatuity, wasting and death.
Extreme induration is often found in the brains of idiots. The whole
organ may be found resembling in color and density boiled white of egg,
or even cheese. The cerebral substance is shrunken, dense, and
apparently quite void of vessels.
=Hypertrophy= of the brain, is a condition in which there is usually
increased hardness as well as increased volume, and is distinguished by
flattening of the convolutions, narrowing of the ventricles, and a
remarkable dryness of the whole organ with its membranes, the change
involving both the cerebrum and cerebellum, and accompanied with an
increase of weight, all indicating increased nutrition, or the deposit
of new matter in the tissue of the brain. Thinning of the cranial bones
may attend this condition, increased internal pressure resulting in
their partial absorption.
The causes of this form of disease are not generally understood. The
symptoms, though always present, are not uniform. Among them may be
mentioned intense head-aches, a weakened or perverted state of the
intellectual faculties, fits of giddiness, accompanied with stupor;
finally, convulsions, with perhaps loss of sensation and motion, the
patient being unexpectedly cut off by an epileptic attack. The disease
has not been observed in persons over fifty. In most cases, the patients
were between twenty and thirty. In one instance, however, it was
developed in a young girl of thirteen. Lead poisoning would seem to be
an exciting cause, it having, in several instances, been developed in
painters and manufacturers of white lead.
=Atrophy.= In this condition, there is found a general diminution of the
volume of the brain, and especially of the convolutions. The latter are
shrunk, narrow, and sometimes softened, while the sulci are large and
open, the brain receding from the skull, and the pia mater greatly
injected with serous fluid, giving the appearance of a jelly-like
investment to the whole brain.
The brain substance is at the same time soft, the ventricles enlarged
and filled with fluid, while a large amount of serum will flow from the
sub-arachnoid space at the base of the brain, and from the spinal canal.
While this condition of the brain might be looked upon as a result of
pressure from the accumulated serum, the absence of the usual symptoms
of hydrocephalus, with the known history of these cases, renders it
quite probable that the change commences as an actual loss of brain
substance, the place of the latter being supplied with serous fluid.
Resulting from atrophy of the brain, there will often be found an
increased thickness of the cranial bones, this being another
conservative effort of nature to preserve the normal support and
pressure upon the brain.
Atrophy of the brain is sometimes found in old age and in various
enfeebling diseases, where all the organs suffer more or less waste from
improper nutrition, but it is so frequently found with drunkards,
especially those who have died with _delirium tremens_, that this
condition may, in the large majority of cases, be considered as the
effect of intemperance.
Several forms of atrophy may also be observed. It may be confined to
some portion of the convoluted surface, or to one of the striated bodies
or optic beds. Atrophy of the optic tracts, or nerves of one or both
eyes, is not unfrequently associated with loss of sight from amaurosis.
Tumors of the Brain.
The brain, like other parts of the body, is subject to morbid growths of
a great variety of forms. The symptoms of tumors in the brain, in many
points, present such resemblances to other forms of disease, that it is
usually the post-mortem alone, that will determine the fact of their
presence or character. It may be said in general, however, that the
effects of morbid growths in the brain will vary according: 1. To the
changes in the surrounding cerebral substance; 2. To the size of the
growth; and 3. To the position of the brain in which it may be
developed.
1. The changes induced in the brain substance surrounding tumors are
usually, first, derangement of the circulation, and second, as a result
of this, effusion of serum, or finally, softening of a greater or lesser
amount of contiguous cerebral substance. Head-ache, with epileptic
attacks, loss of memory, irregular contraction of the muscles and
partial paralysis may accompany the vascular derangement, while as
softening or pulpy destruction supervenes, a general aggravation of all
the symptoms will follow, ending in death, either with coma or by a
sudden apoplectic attack.
2. Tumors of the brain of a _small size_, may be found after death from
other causes, that have evidently produced no symptoms during life; and
in other instances, they have induced no change until a few days before
death, in which cases, the convulsions, paralysis and coma which
precedes this result, must be attributed to the vascular disturbance in
the surrounding brain tissue.
3. The position of the tumor, will modify to some extent the character
of the symptoms manifested. When in the anterior lobes, loss or
impairment of speech is said to attend. While, when in the _corpus
striatum_, the motions of the legs and arms are disordered.
The following are the more commonly recognized tumors of the brain:
=Adenoid, or Glandular-like Tumors.= These are generally described as
resembling an enlarged lymphatic gland, both in color and density. They
may vary in size from a filbert to that of an orange. There may be a
single growth of this kind, or several, and they may be found in any
part of the brain.
=Tubercular or Scrofulous Tumors.= Under this head may be placed certain
bodies of a white or pale yellow color, firm, like soft cheese,
sometimes granular and friable, and consisting chiefly of a large
proportion of albuminous matter. They may be found first, as one or more
individual masses of considerable size; or second, sometimes as many
minute rounded bodies, distinct and separate from one another.
In examining the head of a hydrocephalic child of four years, with Dr.
von Tagan, we found attached to the underside of the middle lobe of the
left hemisphere, a body of a white cheesy consistence, and of the size
of half a hen’s egg. Connected with the cerebellum, was another tumor of
the same character, but smaller in size.[6]
Tubercular masses of this kind, may be found on the surface, or imbedded
in the substance of any portion of the cerebrum or cerebellum.
The second form of tubercular deposits, are confined almost wholly to
the gray matter of the surface. In one case, over two hundred of these
bodies were found scattered through the gray matter of the cerebrum and
cerebellum, of the size of a pea or bean, and of a pale yellow or bluish
color. When cut open, the interior of the bodies was found to resemble
boiled potatoes in consistency.
This form of disease is confined principally to children. Of thirty
cases collected by Dr. P. H. Green, of London, all were between the ages
of nineteen months and twelve years.
=Adipose Tumors.= Under this name, has been described a peculiar and
quite rare form of disease of the brain, in which either some portion of
the brain itself, or growths attached to or imbedded within the cerebral
substance, present a fatty appearance, which by some has been
denominated _lardaceous degeneration_. The exterior of the tumor is
smooth, of a yellow color, and the interior composed of adipose matter
of ash color, and semi-solid consistency.
=Cholesteroma.= This is another rare form of tumor of the brain,
consisting of white pearl-like, glistening bodies, varying in size from
that of a pea, to a walnut or small orange. They are found mostly at the
back of the brain, and in the sub-arachnoid tissue. When examined
chemically, the substance of these tumors is found to consist almost
wholly of cholesterin.
=Cartilaginous Tumors.= These are often spoken of as _scirrhus_ in their
nature. They may be described as irregular in shape, sometimes
lobulated, the interior yellowish in color, of a cartilaginous hardness,
and arranged sometimes in streaks or bands, in other cases, in rounded
masses. At a more advanced stage, from softening of the interior,
cavities begin to form, which are filled with a semi-fluid or jelly-like
substance. Death will generally ensue before this process is far
advanced.
=Calcareous or Bony Deposits.= _Osseous_ formations are not unfrequently
found connected with the membranes of the brain, but rarely, if ever,
with the brain substance. _Calcareous_ deposits, on the other hand, have
been found in almost every part of the brain. In the brain of an idiot
of sixteen, the pons Varolii, crura cerebri and cerebellum, contained so
much earthy matter, as to give difficulty in cutting with a knife (_Sir
E. Home_.) In the brain of a man who had long suffered from acute pain
in the head, a hard plaster-like concretion was found as large as a
filbert.
These bodies are, therefore, not to be looked upon as genuine bony
formations, but rather as an infiltration of chalky substance into the
brain tissue. Of the same nature, are the calcareous deposits found in
the pineal gland, which, although very constantly present after the age
of eight or ten years, can hardly be considered as normal products,
although it is well established that they exert no influence on the
functions of the brain.
=Encysted Tumors, Hydatids.= A variety of tumors of the encysted form
have been found in the brain by different observers, varying in size
from a pea, to that of an egg or orange. Their contents also, have
presented a great degree of variation. While some have been filled with
the cheesy substance of the ordinary steatome, others have contained
blood, a jelly-like, or even a limpid watery fluid.
It has been claimed by some, doubted by others, that the _animal
hydatid_, the _cysticercus_, has been found in the human brain. Having
unquestionably been observed in the eye, the heart, and other parts of
the body, it may also, possibly, sometimes be found in the brain. This
curious animal is now known to be but the larval form of one of the
cestoid entozoa, the _Tænia solium_. Its position in the brain, can only
be accounted for, by supposing that the embryo, which in its first stage
is very minute, by piercing the coats of the stomach, into which the egg
has been taken with the food, enters a blood-vessel, and being carried
into the brain, lodges in some of the capillaries, the walls of which it
penetrates. Entering thus the brain substance, it develops into the
second larval form, which consists of a small bag or cyst, filled with a
limpid fluid. Developed within the cyst, yet capable of being thrust
out, is the head, which presents four sucker-like processes, surrounded
by a circle of minute hooks, which give it the power of active migration
through the tissues. In the pig, the presence of these cysticerci
constitutes measly pork, which if taken into the stomach in a raw state,
the contained larvæ at once develop into the perfect worm, the _Tænia
solium_.
=Blood Cysts=, though not common, have been found in the brain. They
consist of a membranous cyst, which may be lobulated or contain smaller
cysts, the inner surfaces of which are lined with a vascular membrane,
from which escapes a bloody fluid.
=Cancerous Tumors= may be found in any portion of the brain, and may
present the several varieties of these malignant growths, including
_fungus hæmatodes_. While they are generally secondary with similar
tumors in other parts of the body, they may be primary in their origin.
They may acquire such a development as to cause absorption of both the
dura mater and skull, and thus appear upon the outside of the head. In
_fungus hæmatodes_, the enclosed substance consists of soft spongy
matter, of a brain-like consistency, divided into lobular masses, of a
reddish shining aspect. They are mainly found in young subjects,
sometimes in adults.
=Melanosis.= This form of morbid growth is occasionally found in the
human brain. The middle lobe of the left hemisphere of the brain of a
subject in the dissecting-room, was found to be attached to the dura
mater by a melanotic mass, resembling the dark bodies frequently found
around the bronchial tubes. Its attachments were such as to render it
doubtful whether it had its origin in the brain or in its membranes. The
gray substance of the brain of persons who have suffered malarial
diseases, is sometimes found presenting a blackish appearance from the
dark pigment within its substance, or within the pia mater.
=Syphilitic Tumors= are occasionally found in the brain, situated near
its surface. Their characters are not such as to permit of their ready
recognition, except when associated with syphilitic growths in other
parts of the body. They may vary in size from a pin’s head to a cherry.
They present a rounded or irregular form, a yellow color, and are
composed of spindle-shaped or round cells, which may undergo a cheesy
degeneration.
=Obstruction of Cerebral Arteries.= Patients suffering from endocardial
inflammations, or from aneurism of the arch of the aorta, or from any
cause having fibrinous deposits forming in the heart, are liable to have
the same washed along the carotids, and thus carried into the vessels of
the brain, thereby deranging the circulation through this organ. The
symptoms resulting, are generally those of apoplexy. Hemiplegia, with or
without loss of consciousness, follows. Softening of the cerebral
substance follows as a result of the accident, and it is not impossible
but that the presence of these bodies is the general cause of this
structural change of the brain.
The position of the embolus, in fatal cases, is usually in one of the
middle cerebral arteries; these vessels being in a more direct line with
the internal carotids. They may lodge, however, in the vertebrals or
basilar, yet through the circle of Willis, the several parts of the
brain will still receive a partial supply of blood.
=Atheromatous Degeneration, and Calcification of Cerebral Arteries.= The
coats of the arteries of the brain in old people, are liable to become
infiltrated with atheromatous and calcareous matter to such a degree, as
to render them rigid, and inelastic.
While the arteries of the base of the brain, as the basilar, the
cerebrals, or the communicating of the circle of Willis, are more liable
to this change, it may involve the smaller branches as well. The
increased thickness of the coats of the vessels, results in a diminution
of the calibre, while they are enlarged in external circumference.
Resulting from this state of the vessels, we shall have disturbed
circulation, followed by effusion, and in some cases by atrophy of the
brain. Attending this condition, are frequent attacks of stupor and
insensibility, lasting for several hours or even days.
Again, from the weakened condition of the coats of the vessels in these
cases, we may have an _aneurism_ resulting, the walls of which suddenly
giving away, death from hæmorrhage speedily follows.
Section IV. OF THE SPINAL CORD.
[=Notice= in examination. 1. _Vertebræ._—Condition of several parts;
caries, etc. 2. _Vertebral Canal._—Proportion to cord; contained
fluid; serum, pus or blood; amount, etc.; condition of spinal veins.
3. _Membranes of cord._—Bulging of any part; thickening; congestion;
morbid growths, etc.; fluids within; amount, color, etc. 4. _Spinal
cord._—Weight; size; condition of fissures; of interior, as seen on
section; softening; exact point of; roots of nerves; pressure upon,
etc.]
From the continuity and identity of structures, the spinal cord is
subject to essentially the same diseases as those of the brain.
1. The Membranes.
=Inflammation= of the latter may exist alone, or in connection with that
of the membranes of the brain, constituting _cerebro-spinal meningitis_.
Inflammation of the dura mater is an uncommon occurrence. The
inflammation in spinal meningitis is almost wholly confined to the pia
mater, this being the more vascular of the membranes. A pale reddish, or
sometimes purple color, with a bloody jelly-like infiltration,
characterizes the earlier stage, while at a later period the membrane
presents a greyish or dirty yellow appearance, from the presence of a
thick pus-like substance covering the surface. Such inflammations may be
either idiopathic, rheumatic or traumatic in their origin.
In _spotted fever_ the inflammation extends to the pia mater of the base
of the brain, and is remarkable from the epidemic form which it
sometimes assumes.
=Tubercular= deposits, as well as _tumors_ of various kinds, may be
found connected with the spinal membranes, so similar to those described
with the cerebral membranes, as not to require separate notice.
=Serous effusion= may be found in the spinal canal, in the same cases
when it exists in the cranial cavity, and may be either a diffusion of
fluid through the sub-arachnoid space, that has been effused in the
brain, or it may originate from the membranes of the cord itself. The
fluid may be either between the vertebræ and dura mater, or between the
latter and the pia mater.
A peculiar form of dropsy of the spine is sometimes found, congenital in
its nature, and accompanied with a deficiency in the spinal column, by
means of which a cleft remains in the arch of one or more of the
vertebræ; hence the name, _Spina bifida_, as applied to this disease.
The effusion in these cases, taking place before the vertebræ are fully
developed, the pressure from within prevents the final closure of the
canal posteriorly; when, from want of support at that point, the
membranes and covering tissues, yielding to the pressure from the
accumulating fluid, gradually protrude at that point, producing a
rounded fluctuating tumor. The disease is more frequently found in the
lumbar region, although it may occur in the dorsal or cervical, and in
some cases may involve the whole spinal column.
2. Spinal Marrow.
=Inflammation= of this structure, (_myelitis_,) presents the same
character, and may be followed by the same results as inflammation of
the brain. From the distension and engorgement of the capillaries of the
inflamed part, a bright red color may be presented, not only on the
surface, but in the substance of the cord when exposed by division.
Blood may also be found effused in the substance of the cord, or between
its membranes, or between the bony walls and the dura mater.
=Softening= of the spinal cord, may arise either spontaneously, or as a
consequence of injury. When spontaneously taking place, a large portion
of the cord may be involved. The appearance presented, is most usually
that of a soft pulpy mass, which easily breaks down upon the opening of
the membranes. When the result of injury, the softening is generally
confined to the portion involved in the original violence.
=Hardening= of the spinal marrow, (_sclerosis_,) may be one of the
results of inflammation, yet the accompanying symptoms may vary so
slightly from those of other forms of spinal disease, that the
post-mortem alone, will disclose the true nature of the difficulty. In
_locomotor ataxy_, the posterior columns of the cord are usually
affected with this change.
=Atrophy= of the spinal cord, differs from hardening, in the _shrinking_
which attends the progress of the disease, although there may be
increased density, as in the former case. The essential peculiarity of
atrophy, consists in an increased development of the fibrous elements of
the cord, which by pressure, gradually destroys the elementary nerve
constituents. This disease is confined chiefly to men of a middle age,
and is generally the result of venereal excesses; muscular
over-exertion, exposure to cold, &c., may also be exciting causes.
=Morbid Growths=, of various kinds, and closely resembling those found
in the brain, as well as _animal parasites_, are sometimes found in the
spinal cord.
PART II.
THE NECK AND CHEST.
CHAPTER I.
OPERATION ON THE NECK.
The parts which we may wish to examine in the region of the neck in a
post-mortem examination, include the tongue, the larynx, the trachea and
the œsophagus. These may be removed together, by first making a single,
straight incision from the chin, down the central line of the neck to
the sternum. Next turn aside the integument with the superficial
structures, separate the muscles of the tongue from their attachment to
the jaw, and divide the mucous membrane of the floor of the mouth on
either side of the tongue, when, with the tenaculum, the latter may be
drawn down beneath the jaw. The neck being well extended and the tongue
forcibly drawn down, the knife may be carried back on either side of
that organ, dividing the muscles and mucous membranes, including the
palatine arches and tonsils, when the tongue may be so drawn down as to
permit the knife to reach the posterior walls of the pharynx. This being
divided, from the slight adhesion to the spinal column, the whole may
now be drawn down and removed together, the trachea and œsophagus being
divided at the upper end of the sternum.
By the use of the enterotome, the pharynx, larynx and trachea may be
laid open from behind, which will fully expose their interior for
careful examination.
After the examination of the parts is completed, if it is desired to
preserve the specimen, the cavity remaining may be so filled with paper
or rags, as, upon the closing of the part, to leave little or no
evidence of the absence of any portion.
Through the mouth, the buccal cavity may be examined, when there may be
noted the condition of the teeth, gums, tonsils, palate, etc.; the
presence or absence of ulcers on any of these parts, or of food or other
foreign substances within the cavity.
OPERATION ON THE CHEST.
In opening the thoracic cavity for an examination of its contents, a
straight incision may be made along the central line, through the skin
and superficial tissues, from the upper end of the sternum, to near the
umbilicus. If it is desired to examine the abdomen at the same time, the
incision may be carried on to the pubis; otherwise, ending just above
the umbilicus, a transverse cut may be carried from its lower end, to
the border of the chest upon either side. These incisions being
carefully carried through the muscles and peritoneum, the flap thus
formed may be lifted and turned up upon the chest, and the peritoneum
divided along the cartilages of the ribs. The integument with the
pectoral muscles may now be dissected up together, and turned back as
far as the union of the cartilages with the ends of the ribs. With the
heavy cartilage knife, the former may now be divided near their union
with the ribs; care being observed not to permit the knife to pass into
the chest, and thus injure the lungs. In aged persons, and sometimes in
the middle aged, the cartilages will be found so ossified, as to require
the use of the saw or chisel in the place of the knife; this being more
frequently required with the first ribs, than with any other. The
ligaments uniting the clavicle with the sternum, having been divided,
the latter may be removed by commencing at the lower end, and separating
the diaphragm from its connections to the sternum and costal cartilages.
The sternum being now lifted from below, the mediastinum may be divided,
this forming the only bond of union to the parts beneath, except in
cases, where, from pleuritic inflammation, adhesions may exist between
the lungs and costal cartilages.
The sternum having thus been removed, the lungs will be found more or
less collapsed from atmospheric pressure, unless adhesions be so
extensive as to prevent.
The attention may now be given to the pericardium and heart. By making a
small opening into the cavity of the former, any dropsical fluid present
may be removed and measured. This may be accomplished, by introducing
the point of a syringe into the opening, and carefully drawing the fluid
into the same, and then forcing it into some vessel. Or, it may be
carefully absorbed by a sponge, and then squeezed out and measured.
The _heart_ may be removed for examination, by dividing the large
vessels springing from its base. In examining the cavities, valves, &c.,
the right auricles should first be opened, by an incision along its
base, another meeting this at right angles, thus making two angular
flaps, which may be turned aside, exposing the interior. In opening the
ventricle, let one incision be made parallel with, and about one-third
of an inch from the groove in the anterior surface dividing the right
from the left ventricle, commencing at the base and extending to the
apex; and another along the posterior groove, meeting the former at the
apex, thus making a triangular flap, which may be lifted, exposing the
interior of the cavity, without injury to the tendonous cords. The
semilunar valves of the pulmonary artery may readily be exposed, by
splitting open that vessel, and turning aside its walls. The left side
of the heart may be examined in the same manner.
The examination of the _lungs_ may often be made _in situ_. Deep
incisions may be made into their substance at various points, or
portions may be removed for examination. If a more careful inspection is
desired, or if we wish to examine the bronchial tubes or aorta, the
whole thoracic viscera may be removed together. To accomplish this,
divide the trachea and œsophagus, as they enter the chest, with also the
branches arising from the arch of the aorta. Carry the hands around
either lung, breaking up any adhesions which may be found, and then by
grasping the trachea and arch of aorta, and dragging down upon the same,
the posterior mediastinum may be divided from above downwards, the aorta
and œsophagus divided as they pass the diaphragm, and the whole of the
contents of the chest thus removed _en masse_. Placed upon a large tray,
they may now be examined in detail. The bronchial tubes may be best
inspected from behind, laying open the passages with the scissors at
their posterior walls. By means of deep incisions, extending from apex
to base upon the anterior surface, the condition of the interior of the
organs may be carefully noted.
The examination completed, all blood should be sponged from the cavity,
the organs replaced, and any remaining vacancy filled with bran or
sawdust. The sternum now being placed in position, the incision may be
sewed up.
CHAPTER II.
PATHOLOGICAL CONDITIONS.
Section I. OF THE TONGUE.
[=Notice= in examination: size; form; surface coated or clean;
furrowed or fissured; marks of bites, stains; color generally;
vesicles; ulcers; sloughs; tumors, wounds, etc.]
The diseases of the tongue, the appearance of which we may wish to
examine after death, include _cancer_, _syphilitic ulcers or tubercle_,
_tumors_, _hypertrophy_, _etc._
=Cancer= is the only disease of this organ likely to result in death. It
is said to occur more frequently in females than males. It may assume
the various forms of this disease, but is more frequently epithelial or
scirrhus, than medullary.
=Syphilitic Ulcers or Tubercle=, may be confounded with cancer, and in
some instances, only a previous knowledge of the history of the case,
assisted by a microscopic examination, would positively determine the
diagnosis.
=Tumors= of various kinds—encysted, fatty, fibrous and erectile—may be
found in the substance of the tongue, or underneath it in the floor of
the mouth.
=Ranula= is a peculiar form of tumor found under the tongue, often
attaining the size of a pigeon’s egg, and filled with a watery or
albuminous, or sometimes cretaceous matter. The tumor is usually
considered as arising from a dilatation of Wharton’s duct, but of this
there is doubt in some cases.
=Hypertrophy= of the tongue is sometimes found, where, from an increase
of the connective or areolar tissue, without any change in the muscular
fibres, the organ has become greatly enlarged, so as to cause deformity
of the mouth, or even of the whole lower part of the face. This
condition may involve the whole or a portion only of the tongue.